A DICTIONARY OF PRACTICAL MEDICINE: COMPRISING GENERAL PATHOLOGY, THE NATURE AND TREATMENT OF DISEASES, MORBID STRUCTURES, AND THE DISORDERS ESPECIALLY INCIDENTAL TO CLIMATES, TO THE SEX, AND TO THE DIFFERENT EPOCHS OF LIFE. WITH NUMEROUS 4 PRESCRIPTIONS FOR THE MEDICINES RECOMMENDED; A CLASSIFICATION OF DISEASES AC- CORDING TO PATHOLOGICAL PRINCIPLES; A COPIOUS BIBLIOGRAPHY, WITH REFERENCES; AND AN Slppenbi* of .formulae: THE WHOLE FORMING A LIBRARY OF PATHOLOGY AND PRACTICAL MEDICINE AND A DIGEST OF MEDICAL LITERATURE. BY JAMES COPLAND, M.D„ F.R.S., FELLOW OF THE EOYAL COLLEGE OF PHYSICIANS f HONOR All Y MEMBER OF TIIE ROYAL ACADEMY OF SCIENCES OF SWEDEN ; OF THE AMERICAN PHILOSOPHICAL SOCIETY ; AND OF THE ROYAL ACADEMY OF MEDICINE OF BEL- GIUM ; LATELY PRESIDENT OF THE ROYAL MEDICAL AND CHIRERGICAL SOCIETY OF LONDON ; FOR- MERLY CONSULTING PHYSICIAN TO QUEEN CHARLOTTE'S LYING-IN HOSPITAL AND SENIOR PHYSICIAN TO TnE SOUTH LONDON DISPENSARY; CONSULTING, AND LATELY SENIOR, PHYSICIAN TO THE ROYAL INFIRMARY FOR DISEASES OF CHILDREN, ETC. EDITED, WITH ADDITIONS, BY CIIARLES A. LEE, A.M., M.D., PEOFESSOB OF MATEBIA MEDIOA AND OENEEAL PATHOLOGY IN GENEVA COLLEGE, ETC., ETC. “ (Glatili) tooltre lertte anti sla'Dlg tec$e.”—Chaucer. IN THREE VOLUMES. YOL. I. NEW YORK: HARPER & BROTHERS, PUBLISHERS, YEANKLIK SQUARE. 1859. “ '0 Blog (3pa\vg, y 8 k rkxvy /xcacprj, 6 8k tcaipog o£vs, y 8k irtlpa y 8k Kpimg xaXnrij. Au 8e ov povov ioiVTbv irapexuv ra 8kovra ttoikovra, a\\a kai rov voakovra kai tovq irapsovTag, icai rci ZfaOtv.” Hippocrates. “Man is born unto trouble as the sparks fly upward.” Job. “ Honour a physician with the honour due unto him, for the uses which ye may have of him: for the Lord hath created him. “ For of the most High cometh healing, and he shall receive honour of the king. “ The skill of the physician shall lift up his head: and in the sight of great men he shall be in ad- miration.” “ The Lord hath created medicines out of the earth; and he that is wise will not abhor them. “Then give place to the physician, for the Lord hath created him: let him not go from thee, for thou hast need of him. “ There is a time when in their hands there is good success.” Ecclesiasticus, chap, xxxviii., v. 1 et seq. “ Qua regio in terris nostri non plena laboris ?” Virgil. “Multorum disce exemplo, qua; facta sequaris, qua; fugias.” Cato. “ Mentem sanari, corpus ut segrum, Cernimus, et flecti medicina posse videmus.” Lucretius. “To ignorants obdurde, quhair wilfull errour lyis, Nor zit to curious folks, quhilks carping dois deject thee, Nor zit to learned men, quha thinks thame onelie wyis, But to the docile bairns of knowledge I direct thee.” James I. of Scotland. “Man is all svmmetrie, Full of proportion, one limbe to another, And all to all the world besides; Each part calls the furthest brother, For head with foot hath private amitie; And both with moons and tides.” George Herbert. Entered, according to Act of Congress, in the year one thousand eight hundred and forty-six, by HARPER & BROTHERS, in the Clerk’s Office of the District Court of the Southern District of New York. TO WILLIAM FOTHERGILL COOKE, ESQ., OAKLANDS, HANTS, TO PETER DICKSON, ESQ., UPPER BROOK STREET, TO HENRY JOHNSON, ESQ., CRUTCHED FRIARS, TO DANIEL LOUTTIT, ESQ., PULTENEY TOWN, CAITHNESS, • TO PATRICK PANTON, ESQ., EDENBANK, ROXBURGHSHIRE, AND TO THOMAS GODFREY SAMBROOKE, ESQ., EATON PLACE, BELGRAVIA, THE AUTHOR DEDICATES THIS WORK, wmi AFFECTION AND GRATITUDE, FOR THEIR DONG AND INTIMATE FRIENDSHIP. * Old Burlington Street, July, 1858. PREFACE. I. The Author deeply regrets the long period he has required to complete his undertaking; but circumstances which he could neither prevent nor control obliged him to bring out the early parts of it sooner than he desired, and delayed the subse- quent parts, which he was anxious to execute in a manner commensurate with the character and success of those which were published. A work requiring for its satisfactory performance an acquaintance with, and a frequent recourse to the best authorities, and a constant regard to the results of the Author’s observation and matured experience—to his written notes as well as to his repeated recollections—could not be completed in a few years. The frequent interruptions arising out of public and private medical practice ; the fatigue of body and mind which this practice involved; the calls required from him, the visits made, and the letters written to him by those in his profession who claimed his attentions; the anxieties resulting from the more intimate relations of life ; the disappointments and losses which often fall the most severely where they are most intensely felt— all have combined to delay the completion of an undertaking commenced with en- thusiasm, and, notwithstanding numerous discouraging and retarding circumstances, prosecuted with perseverance. During the many years the Author has devoted to this work, he has employed the time which his more active professional duties during the day allowed him in making notes, in referring to authorities, and in comparing the descriptions of the individual cases which had come under his care—of their histories, progress, course, complications, and treatment; while he has employed some of the hours usually giv- en to repose in digesting the results of his observations and studies into the follow- ing performance. Accustomed from early age to much endurance and application, endowed with a strong and a sound constitution, and enjoying through life uninter- ruptedly good health, for all which he cannot be sufficiently grateful to an almighty and gracious Providence, he has been enabled to pursue his avocations, notwith- standing the interruptions alluded to, with much less loss of time in the restoration of the powers of nature in sleep than is generally required. Thus endeavouring to economize and to regulate his time between the active du- ties of practice and the not less important duties of teaching, orally and by his writ- ings, the Author believes that he has succeeded in fulfilling the engagements he undertook in the Prospectus, which he offered to the Profession when he entered upon his undertaking.* * “Prospectus.—This work contains, in an abstract and condensed, yet comprehensive form, the opinions and practice of the most experienced writers, British and foreign, so digested and wrought up with the results of the Author’s practice that the student and young practitioner will not be bewildered in the diversity of the opinions and facts adduced for their instruction, but be guided in the difficult path on which they have entered, and enabled, with a due exercise of their powers of observation and discrimination, to arrive at just conclusions and successful practical results. To the experienced practitioner, also, the work will present a diversified range of opin- ions, methods of cure, and authorities, which his matured judgment will enable him to apply in an appropriate manner to particular cases. It also comprises the complications and modified states of disease, which are even more frequently met with in practice than those specific forms too often described by nosologists as constant and unvarying types, to which morbid actions, oc- curring under a great variety of circumstances, can never closely adhere. When discussing the methods of cure, the Author has attended to the various stages, states, and associations of dis- ease, to the regimen of the patient, and to the management of convalescence. He has given prescriptions for the medicines recommended in the mofet efficient states of combination. He has also added in an Appendix, and arranged in alphabetical order, upward of a thousand Form- ulae, selected from those most approved contained in the Pharmacopoeias of various hospitals and VI PREFACE. II. Occasion has been taken, in the course of the work, to notice topics belong- ing to Physiological Pathology, in as far as they may be considered introduc- tory to those which more strictly appertain to General Pathology. Reference may be made to the articles Absorption, Age, Asphyxy, Excretion and Excretions, Irritability and Irritation, Pulse, Shock, Sleep, Sympathy, Tremor, Vertigo, and some others, which may be classed Under the former head, although they also are intimately connected with the latter, and are, with it, more or less closely related to several practical matters—a relation which has never been overlooked by the Author. Viewing Physiological Pathology as a department only of General Pathology, its importance should not be thereby in any way lessened. The functional connections of morbid states, whether vital or structural, whether affecting the fluids or the solids, are of the utmost importance to the scientific and rational physician, and are never over- looked by him in his examinations of disease, however slight such disease may seem. A due recognition of these states, and of their relation to the several manifestations of life throughout the economy, is the true basis of all our practical indications of cure, and of the rational performance of all our professional duties. III. The doctrines of Disease are fully developed under several lieads, more espe- cially in the Articles Disease and Blood. In discussing fully and circumstantially the Causes of Disease, or Aetiology, and in specially considering Absorption, Arts and Employments, Climate and its Changes, Cold, Endemic Causes, Epidemic Injluences and Constitutions, Infections, Contagious and Poisonous Agents, as topics intimately con- nected with Aetiology, the Author has endeavoured to show their operation on the economy, and chiefly and more immediately on the vital force, as manifested by the organic nervous system; and through this medium principally, and through the blood also, and consecutively on the functions and on the organs of the frame. Viewing the primary operation of the causes of disease as now stated, he has de- scribed the procession of morbid phenomena, from the grand sources of disturbance pointed out under the designation of jEtiology, or the causation of disease, and from primary or early morbid vital states, described under the head of Pathogeny, until alterations of both fluids and structures are reached. The intimate connection of these states with their causes—predisposing, exciting and concurring, or determin- ing—induced the Author to comprise these important departments of General Pathology under one head, namely Disease, and to illustrate more fully his doc- trines in the Articles on changes of the Blood, and on those of Gout, Excretion, Con- tinued and Exanthematous Fevers, Pestilences, Rheumatism, and Morbid Sympathies, or Associations of Disease. He further exhibited, under the first of these heads, a sketch of those alterations of secretion, excretion, nutrition, and of structure, which supervene upon a longer or shorter continuance of the Pathogenic States previously foreign countries, and the writings of eminent practical physicians, and from the notes of his own practice. The work, moreover, contains a full exposition of the general principles of Pathology, a minute description of the numerous organic lesions of the human body, and a detailed account of those states of disorder incidental to the sex, the different periods of life, and to particular climates, with the peculiarities resulting from temperament and habit of body. It is prefaced by a classification of diseases according to pathological principles and in natural order, commencing with the simplest and most limited states of functional disorder, advancing through the more ex- tended and complicated diseases to those affecting the whole frame, and concluding with such as consist chiefly of morbid structure—the classification thus being a key to the systematic study of practical medicine as well as an arranged contents of the work. In order to facilitate refer- ence, as well as to avoid repetition, each article is methodically divided and headed, and the paragraphs numbered; and to each a copious Bibliography, with References, is added. “The Author, having since 1814 been in the habit of recording references to such medical works, memoirs, and subjects as he has found upon perusal deserving of notice, presents the ac- cumulated results to the reader. He has excluded from his Bibliography all inferior produc- tions, and nearly all inaugural dissertations; he has selected those works with whose character he is acquainted, and whose authors are distinguished; and he has brought down his record to the present day. He has likewise given copious references to such original papers and memoirs in the Transactions of societies and in medical journals as merit notice, believing them to consti- tute a most valuable part of medical literature and science. “In conclusion, the work contains the results of many years of laborious study and research, and upward of thirty years’ extensive and diversified experience, forming of itself a Library of Practical Medicine and copious Digest of Medical Literature.” PREFACE. VII described. This general view of the lesions of the circulating fluids of the secre- tions, and of the tissues, and also of the several metamorphoses, transitions, associa- tions, adventitious productions, and new formations, as consequences of antecedent morbid conditions, thus became an introduction to descriptions of the minute, as well as of the more gross and manifest alterations of structure. These descriptions are as fully given under the heads of the several organs, systems, and tissues of the body, as to comprise all the organic lesions usually described in recent works on Morbid Anatomy, with the addition of some others, of no small importance, which had not been previously noticed. The Author believes that he has thus furnished a complete view of the morbid changes observed in the more complex, as well as in the simpler tissues of the body, as they are disclosed to the unaided senses, and, as far as may be inferred, from discordant microscopic researches and descriptions. IV. A knowledge and a due estimate of symptoms, of their groupings and of their relations, are of the greatest importance to the physician, as furnishing his mind not merely with information requisite to the recognition of the seat and nature of the maladies which he is called upon to remove, but also with the relations subsist- ing between these maladies and the vital conditions and the individual functions of the frame. This department of General Pathology is treated as fully as the scope and character of the work could allow. However much certain signs and symp- toms of disease may be insisted upon by some medical writers, or new methods of investigation may be extolled by those who have introduced them, or made them the means of professional parade and notoriety, much more knowledge of the dis- tinctions, the characters, and the states of disease will be acquired by quiet, patient, and close observation, and by the experience gained thereby, than by modes of ex- amination, whereby a greater desire is evinced to impress the mind of the patient, than to ascertain the nature of the malady and the most appropriate means of cure. In the study of the signs and symptoms of disease, insufficient attention, or scarcely any attention, has been directed in medical writings to those symptoms which may be produced by large doses, or a too protracted use of powerful medi- cinal agents. Nor have the modifications, the mutations, and the suppression of the usual signs and symptoms of disease by these agents, when thus employed, re- ceived greater attention. The Author has noticed these topics in various parts of his work, and especially when describing the operation of those medicines which become poisonous when thus improperly prescribed, and in the Article on General Therapeutics. To the due consideration of Symptomatology, the discussion of Sympathy and of Sympathetic Phenomena, especially as associating and complicating disorder, appears to be a proper introduction; it is accordingly entered upon fully and comprehensively. In connection with a due consideration of sympathy, irritability and irritation can hardly be overlooked; for irritation, wherever it may be seated, will give rise, ac- cording to the grade or state of irritability and susceptibility by which the individ- ual frame may be endowed, to numerous symptoms, which are often traced with great difficulty to their primary seat. The Author has therefore attempted to con- sider the relations of irritability and the consequences of irritation as most intimate- ly connected with, and often the source of, sympathetic phenomena. V. In the Article on Symptomatology this important department of General Pa- thology is viewed more comprehensively than in other circumstances it may have been viewed; for the Author was obliged, by the scope and limits of his work, and with the object of preventing repetition, to consider, in connection with it, the sub- ordinate topics of Diagnosis and Prognosis. Indeed, inasmuch as these topics are in- timately related to General Pathology, they could not be disconnected from Semei- ology. Besides this, diagnosis and prognosis cannot be viewed with propriety or with precision separately from the symptoms indicating special morbid conditions— from the vital, the humoral, and the structural signs and symptoms of disease—to which they are intimately and practically related. In the usual descriptions of diagnostic symptoms, or of the differences existing between diseases affecting different parts, or manifesting different natures, condi- VIII PREFACE. tions, or characters, the most prevailing evil, and one which most impresses the mind of the physician as the field of his observation extends, is that differential signs and symptoms are described by writers as constantly existing, and as presenting lines of demarcation always, or at least very generally, observed; whereas in very nu- merous instances they are often either faintly seen or altogether absent, or so very imperfectly manifested as to suggest the gradual or insensible passage of one disor- der or morbid condition into another, thereby proving the necessity of studying the remoter relations and the more intimate connections of disease, as well as their dif- ferences in seat, character, nature, and form. Also, when enumerating symptoms, references to those which are indicative of danger, or even of a fatal issue, can not be overlooked, especially as they constitute the division of General Prognosis, com- prised by the more comprehensive department of Symptomatology ; Special Prognosis, or the prognosis of individual diseases, being discussed as a part of the pathology of these diseases, and in due connection with them. A full consideration of the states and manifestations of morbid actions cannot be limited to the discussion of Symptomatology and the sympathetic relations of disease. These subjects are merely the indications or outlines of general principles, which re- quire to be filled up and illustrated by the more precise descriptions of the forms, courses, and complications of diseases, as they are observed in practice, in different seasons and climates, in different epidemics, and in different races. The diagnosis and the alliance of morbid conditions, although furnishing opposite indications, also require to be duly estimated, in our endeavours to obtain precise and specific informa- tion as to the natures and tendencies of diseases. It is not only the features of dis- ease, but also the expressions of these features, which require to be studied in the investigation of the seats and vital relations of morbid action, and of the extent to which the blood and the tissues may have become contaminated and altered; and in our attempts to form a prognosis of disease, not only should these features and their expressions be duly studied, but also the extent to which they are affected, and the character of the change produced, by the means of cure which have been employed. During the course and treatment of disease, the very important diag- nosis between the changes which may be imputed to the natural procession of mor- bid phenomena, and those which result from, and are the actual effects of the medi- cinal agents which have been taken, is too frequently either neglected or altogether unknown; and the ignorance, more than the neglect, of this diagnosis has been the cause of more serious mischief than can well be credited, unless by those whose en- lightened experience and habits of close and unbiased observation enable them to form an opinion. To the diagnosis of the effects or symptoms produced by the usual causes of dis- eases, and by the action of medicines when given in excess, may be added the diag- nosis of the operation, or in other words, a due recognition of the modes of action of causes in developing morbid conditions. Thus, owing to numerous causes, more especially to original and acquired diathesis, to habits of life, and to modes of living, to indulgence in animal food beyond the wants of the economy, to the abuse of fer- mented and distilled fluids, to the many causes of debility and exhaustion, the organ- ic nervous force is lowered, digestion and assimilation are impaired, secretion and ex- cretion are diminished, nitrogenous and other excrcmentitious matters, the extreme products of animalization, accumulate in and contaminate the blood, occasion numer- ous diseases, especially gout, rheumatism, cutaneous eruptions, visceral inflammations, etc., and require for their removal and for their counteraction or prevention an ear- ly recognition and diagnosis of them; and, as shown by the Author in the early parts of his work (published 1832-7), a recourse to means which may increase the secretions and excretions, may depurate the blood, and promote the organic nervous force in all its functional manifestations. In the descriptions and discussions of the more important topics, comprised under Physiological Pathology, Pathological ology, Alterations of Structure, Symptomatology, etc., a strict regard has been di- rected, as in the instances just mentioned, to these their practical relations, and to the intentions and indications of cure which they may suggest, or which may be suggested as regards them. PREFACE. IX VI. The Principles of General Pathology—the due consideration of morbid conditions in their several relations—the causes of these conditions, their natures and char- acters, the signs and symptoms by which they are indicated, and by which their precise seats and issues are inferred—constitute the legitimate, and, indeed, the only true Introduc- tion to the practice of medicine—to Therapeutics, in the general and special ac- ceptation of the word. The importance of a due study of the principles of General Pathology has been acknowledged by all the educated members of the profession in modern times, and duly recognized in the very appropriate designation, “ Institutes of Medicine,” which has been bestowed, by many able writers, on this department of medical education. With this impression, strongly and permanently made on the mind of the Author, the Principles of Pathology have been fully discussed in this work. They are de- scribed succinctly, and in connection, under the head Disease, especially as respects the causation, the primary states, the consecutive and structural lesions, and the terminations of disease ; and they have been farther considered in the articles on the Sympathetic Relations of Morbid States, on Symptomatology, and in various other arti- cles referred to in the arranged contents. The intimate connection of these states with their causes induced the Author to comprise JEtiology and primary and consecutive Morbid Conditions in one Article, and to include farther a general view of alterations of structure consequent upon morbid action and nutrition—upon the pathogenic states previously described. This view of morbid conditions of vital manifestation, of the circulating fluids, of the se- cretions, and of the several metamorphoses, new formations, etc., thus became an in- troduction to the more minute description of the intimate, as well as of the more gross and manifest Alterations of Structure. These alterations are so fully described un- der the individual heads furnished by the several systems, organs, and tissues of the body, as to comprise all those contained in recent works on morbid anatomy, with the addition of several of no small importance, which had not previously been de- scribed, and of others, the nature of which had not been correctly estimated. The full exposition of structural lesions given under their respective heads may be read- ily inferred from the arranged contents, and requires therefore no farther notice at this place. But it may be remarked that pathological principles must necessarily be imperfect, or at least deficient, if the changes which the vital manifestation and the circulating and secreted fluids undergo, as far as they may be recognized, be not duly estimated, and viewed in connection with existing material or structural alter- ations. The dynamic states of morbid action have therefore received due attention, but not to the exclusion of other morbid conditions, which impart to diseases those specific and often dangerous perversions which constitute their natures and true es- sences, and with which dynamic states are also associated. The specific perversions or infections, for instance, characterizing small-pox, scarlet fever, etc., are associated either with an exalted or with an impaired state of vital force and of vascular action at different periods of these maladies. These perversions may be manifested by both the organic nervous system and the vascular systems and fluids, in various grades in different cases, and may be so great as to occasion danger or death, even inde- pendently of the dynamic states of action. In these cases it is not only the dynam- ic, but also the specifically perverted conditions—the latter more particularly—against which the physician must direct his agents, internal, external, and emotional, appro- priately to these conditions, endeavouring at the same time to counteract, to neutral- ize, and to remove those more material and manifest alterations which, while they are the results of these perversions, become the most influential agents of their in- creasing and exterminating effects. VII. General Therapeutics may be viewed as the capital of the column which the medical teacher has erected in honour of that science to the study of which he has devoted his life. It is attempted in this work to point out the several causes which combine to retard, if not to arrest the progress of therapeutical knowledge. The Principles of Therapeutics are next stated, and divided into the Fundamental, into the General, and into the Special; these being severally illustrated and enforced X PREFACE. by practical precepts and indications, having due reference to the states of vital force, of the circulating and secreted fluids, and of altered structures. The Author lias endeavoured to develop, under this head, the principles and intentions which should guide the student and the practitioner of medicine in the application of the knowl- edge they have acquired of other departments of science to the grand objects of cur- ing and of alleviating diseases. This most important subject is concluded by a classification of hygienic and therapeutical agents, according to their modes of ac- tion and to their effects — according to their physiological operation and to their curative influences. VIII. From the commencement of his lecturing on the Principles of Pathology and the Practice of Medicine, the Author adopted a Classification of diseases based on the Vital Force, as manifested by the several systems and organs of the body. He viewed disease, especially in its early states and stages, to be the result of causes af- fecting the conditions of this force in one or other of these systems and organs ; these conditions either passing into the healthy state, under the influence of this force, or extending to and deranging other allied systems and organs, thereby perpetuating or complicating disorder, until important changes supervene in the fluids or in the struc- tures, or in both fluids and structures. Conformably with this doctrine, and after a due consideration, 1st, of the causation of morbid conditions; 2d, of the nature and genesis of these conditions; 3d, of the changes they occasion ; and, 4th, of their mu- tations, metamorphoses, and terminations—subjects fully discussed under the heads, Disease, Blood, Crises, Excretion, Irritation, Sympathy, and Sympathetic As- sociations of Disease, and forming a system of General Pathology—the Author en- tered upon the study of the special forms of disease, commencing with those which are simple and primary—with the earliest, the mildest, and the most insidious departures from the healthy condition. Having thus commenced, he proceeded to describe the more severe and complex disorders and diseases; next, those which most frequently produce alterations of structure; and, lastly, organic lesions, which, as either consti- tuting the most advanced stages of disease, or terminating life, are demonstrable after death. An outline of this classification was published in 1822, and was adopted in the Lectures of the Author, commenced in the Session of 1824 and 1825. The chan- ges of structure thus produced by successive morbid conditions or actions were for the first time illustrated in these Lectures by colored drawings and engravings. IX. In the largest and most important portion of the work, namely, in that par- ticularly devoted to the Description of Diseases—in their special forms—the sev- eral species, forms, conditions, and complications of disease are delineated, and the treatment appropriate to each of these is fully stated and commented upon. The manner in which special diseases may be modified, and even changed in character, form, and issue, by the nature of their predisposing, exciting, and concurring causes — by sex, race, constitution, modes of living, and by endemic and epidemic influ- ences ; and the necessity of taking these causes severally and collectively into consid- eration during the treatment of these diseases are as fully noticed as the limits of the work could allow. Until the appearance of the early parts of this undertaking, spe- cial diseases had been described as they appear in their most usual and unvarying forms. Neither their vital nor their material modifications and alterations, nor their complications — their vital and structural alliances and associations—as they occur in medical practice, had received due attention. No attempts, even, had been made to develop this very important and strictly practical view of morbid actions, and to extend it to the pathology and treatment of these actions as they appear in the dark races of our species, until they were made in the present work; and however imper- fect these attempts may be considered, it is hoped that a fuller exposition of these and other practical topics will follow from the examples hereby furnished to future inquirers. In the descriptions of Special diseases—of the simple, the complicated, the inflam- matory, the febrile, and the malignant, or pestilential—the Author has endeavoured to exhibit the changes which successively take place in the vital manifestations, in PREFACE. XI the constitution of the circulating and secreted fluids, and in the organization of the structures during the progress of these diseases. A due estimate of these, made with the acumen, the perspicacity, and the science which can be directed to them by the physician, constitutes the essence of pathological knowledge ; and an experienced— an unhesitating recourse to remedial indications and means, appropriately to existing pathological conditions, can alone insure successful results, as far as success can pos- sibly be achieved. Under the heads Blood, Disease, Fevers, Dysentery, Infection, Pestilences, Puerperal Maladies, etc., the succession of changes—dynamic, specific, or pervert- ed—are fully exhibited and illustrated, as they are manifested from the first impres- sion of these causes—from the earliest sense of sinking at the epigastrium and gene- ral malaise, or from the depression of the organic, nervous, or vital force throughout the frame, until the secretions, the circulating fluids, the excretions, and the struc- tures become contaminated and organically altered, and capable, as respects certain specific maladies, of communicating the same morbid actions to healthy but predis- posed and susceptible persons, exposed to the emanations proceeding from them. In our examinations of the sources and causes of several of the maladies which are often most prevalent, and which prove most destructive to the human race, their connection with epidemics, or epizooties, in the lower animals has been too generally overlooked. That diseases, originating and becoming prevalent and fatal in the low- er animals, often extend to or infect the human species, and that they may be recog- nized in this species by appearances and symptoms as nearly allied as the different circumstances of man and the lower animals are capable of manifesting, have been satisfactorily demonstrated in respect of more than one of the exanthematous dis- eases. Established facts of this nature suggest farther researches into the concur- rent causes and the phenomena not only of these, but also of other infectious and contagious diseases, and more especially where such a connection may be presumed to exist; for if disease may thus originate on any occasion, it may on others, and thus the evil may be multiplied, or even perpetuated. X. The descriptions of diseases are based chiefly on the Author’s own observation. His experience had demonstrated to him, what others had either overlooked or not ventured upon, that the very different conditions and manifestations of morbid ac- tion, and the diversified characters of local and specific diseases, caused by circum- stances not always manifest or even recognizable, but exerting, nevertheless, a more or less powerful influence on the state, course, and issue of these diseases, required due consideration in respect both of their pathological relations and of their treat- ment ; he therefore has endeavoured not only to describe the more usual forms and courses of diseases, but also to notice and to distinguish these modifications and dif- ferences, to assign them to their specific or influential causes, and to point out the means of cure most appropriate to each. The nature of the predisposing and exciting causes ; original constitution, temper- ament, and diathesis; endemic and epidemic influences, climates, and states of sea- son and weather; secret habits and vices; the emotions and passions; the deficien- cy, superabundance, and the nature of food ; overcrowded places of resort; a foul and too frequently respired air; infection and contagion in their various modes of transmission ; peculiarity of race and varieties of the species, and the prevailing ep- idemic constitution, are severally, and in their diversified combinations, considered by the Author, with reference to the forms, states, the course, and issue of diseases. These circumstances, modifying, diversifying, or altogether changing the characters and states of local or even of specific maladies, he has extended his descriptions scf as to comprise the different forms thus produced, whether simple or complicated, and he has considered them with reference to their modifying and appropriate causes as fully as his limits would admit. * Having viewed diseases as they are influenced, modified, or altogether changed by the above causes, or by their various combinations acting on the organic, nervous, or vital force, and consecutively on the secretions, excretions, and circulating fluids, the Author has farther described or more slightly noticed these extensions, associations, XII PREFACE. or complications of morbid action, proceeding either from these agencies, from su- peradded influences, or from the consecutive changes just referred to, and as more fully set forth in the articles on Disease, on Fever, on Irritation, and on the Sympa- thetic Association of Disorder, or Morbid Sympathies. The causes of disease primarily impress and influence vital conditions according as their natures and combinations are related to or affect the vital force manifested by individual systems or organs; and according as they influence not only one sys- tem or organ, but also two or more, either simultaneously or in succession, they often produce associated or complicated disease. In practice, simple or uncompli- cated disease is thus less frequently observed than the complicated, even in its ear- ly stages, and still less frequently in its advanced course. In lectures and in sys- tematic writings, diseases have hitherto been generally described as presenting un- varying forms or types, and as systematically and precisely as the genera and spe- cies of the organized productions of nature. But diseases seldom present such un- varying types, seats, or conditions, or such specific differences, or such uncomplica- ted forms; for, commencing as disturbances of vital forces and manifestations, and proceeding, thus characterized, to more extended and more serious alterations, not merely of vital conditions, but also of organization, they are, even when individually different, constantly changing, often approximating in character and form, not un- frequently lapsing the one into the other, even when apparently the most simple and specific, and still more frequently changing when they are complicated and severe. These diverse and varying states — these mutations, extensions, and associations — are the obvious results of existing conditions of vital power at the time of exposure to the causes of disease, of the nature and operation of these causes, of their action on the vital conditions and manifestations, and of the changes effected by these con- ditions on the depurating and secreting organs, on the circulating fluids, and ulti- mately on the organization. Conformably with these views, or rather pathological principles, the Author has, from the commencement of his attempts to teach, either orally or by his writings, followed his descriptions of the more simple states of disease by some account of the more frequent complications presented in practice by these diseases, viewing these latter, as well as the uncomplicated states, with reference to varied forms, to altered vital conditions, and to their final results. While he has endeavoured not to over- look the descriptions of disease, whether simple or complicated, furnished by the best modern authorities, he has relied chiefly on his own observation, and has sta- ted the results, derived from a long series of years, and from different sources and fields of experience, more especially as they have been influenced by season, climate, epidemic constitutions and causes, and by the various circumstances, fully set forth under the articles on Disease, on Endemic and Epidemic Influences, on Infec- tion, on Fevers, Pestilences, on Sympathetic Association of Disorders, etc. To describe disease with originality and accuracy, especially with reference to its various phases, modifications, differences, and mutations, arising out of the causes and circumstances alluded to, is attended by no slight difficulty; and this difficulty is greatly augmented by the desire of conveying accurate views in concise, appropri- ate, and forcible language, without unnecessary amplification or repetition. Our perceptions of diseased actions may be distinct and accurate, and our conceptions of their causes and tendencies may be lively, or even forcible in our own minds ; but to convey these with equal accuracy and force to the minds of others; to place them before the mental vision of the reader, as we have seen and considered them; and to render them objects of that amount of interest which their importance and ten- dencies demand, can not always be accomplished, so as to fully satisfy the mind of the describer, and the wants of those whom he endeavours to instruct. To fail in accomplishing an object of so great difficulty — a difficulty of which an idea can be formed only by making an attempt to overcome it — may not attach to it greater blame than may be imputed to all attempts which, from the nature of the object, preclude perfect success. But, although this has not been reached by the Author, yet he can not divest himself of the hope that his efforts have not altogether failed, and that close observers and candid judges will allow that he has endeavoured to de- PREFACE. XIII scribe faithfully what he has carefully observed, and to elucidate, neither irration- ally, nor unprofitably to the reader, the sources, the natures, and the issues of the numerous maladies which his undertaking comprised. XI. The pathology and treatment of Fevers and Pestilences are fully enter- tained. The Author has endeavoured to adduce all that has appeared to him de- serving of description and elucidation, and to remove much error of long existence as to their nature and treatment. He has fully considered their causes, both those which primarily influence the vital force and its several manifestations, and those which affect the constitution of the circulating fluids. Certain of these causes, especially specific infections, have been supposed to act primarily on the blood ; but the long periods often existing between the impression made by the causes and the manifestation of their effects, as well as the character, course, and issue of these effects, render it more probable that the morbid impression is directly and primarily made upon the organic nervous systefti, the vital force of which is changed con- formably with the nature of this impression ; the consecutive changes being a series of effects more or less slowly evolved, until, after various periods, these changes break out into more or less acute disorder implicating the whole organization. If the phenomena of all infectious fevers—the typhoid, the exanthematous, the malig- nant, and the pestilential—be closely considered, it will be found that the infectious agent may instantly and sensibly impress the body so as to produce a feeling of sinking at the epigastrium, often followed by nausea, vomiting, or retching, by manifest disorder of the organs supplied with the organic or ganglial nervous sys- tem, and by changes of the secretions, the excretions, the circulating fluids, espe- cially the blood, and ultimately of the vital cohesion and physical conditions of the several structures. That the morbid impression is primarily made upon that portion of the organization especially devoted to secretion, assimilation, and the growth, nutrition, and development of the body, is shown by the permanence of certain of its effects—by the circumstance of the constitution being rendered insus- ceptible of the impression of the same morbid agent for ever after, and by the rapid waste and emaciation of the tissues which are always most liable to experience those changes when the vital force exerted by the ganglial nervous system is im- paired. If the infectious agent acted primarily, or even chiefly, on the blood, and as a leaven producing a specific change on this fluid, no reasons could be assigned for the future immunity from the morbid action of the same specific agent, inasmuch as the constant metamorphosis and waste of the blood, and the continued renewal of this fluid by the assimilation of the chyle and lymph, would render it susceptible of repeated infections after certain intervals. In those states of general disease depending upon the absorption or passage of contaminating agents into the blood— these agents thus acting primarily or directly upon the blood—no such immunity is observed, the contamination of this fluid and its consequences resulting again and again, provided that recovery takes place from the earlier attacks. When discussing fevers—continued, exanthematous, malignant, pestilential, and puerperal—the Author has endeavoured to connect these with their causes, to describe the changes, both functional and organic, which successively occur in the fluids, general systems, and structures. He has divided the fevers which assume a continued type into the forms and varieties which most frequently appear in temperate climates and as he has observed them. But he has contended that no precise line of demarcation can be drawn between several of them, one form passing, in individual cases, into the other the most nearly allied to it, according to the exciting cause, to the concurrence of other causes and determining influences, and to the existing epidemic constitution ; certain forms thus prevailing or predomi- nating. As regards the three great modern Pestilences, the Author has, from a firm con- viction of the nature of their sources, and of the causes of their dissemination, entered fully into the discussion of these important subjects. He has endeavoured also to show, under the. head Prevention of Pestilence, how they may be prevented, their effects counteracted, and their extension limited. Sufficient evidence that his XIV PREFACE. endeavours have not been altogether without beneficial results has been adduced by others, who have stated that he has contributed to the means which have been found most successful in their prevention and treatment.* It may not be necessary to refer to the views adopted by the Author in respect of particular maladies or classes of disease. These can be correctly observed only by perusing them under their respective heads; but he would direct attention to Apo- plexy, Dysentery, Erysipelas, Fevers, Scarlet Fever, Inflammations, Diseases of the Heart, those of the Lungs, Tubercidar Consumption, Dropsies, and Puerperal and other Diseases of Females, as furnishing illustrations of the various modifications, important differ- ences, and not less important complications they present in practice, arising out of existing states of vital power, of the circulating and secreted fluids, &c., influenced and caused by numerous circumstances which have been fully recognized and illus- trated. XII. The diseases which are most prevalent in warm climates, especially among the white races who visit or remain in these climates, hate received a due share of atten- tion in this work; their nature and treatment are fully described, chiefly from the Author’s own observations, and with references to the experience of the best writers on these diseases. He may direct the attention of the reader, with some satisfac- tion, to his description of the pathology and treatment of Dysentery, of Intermittent, Remittent, and Malignant Fevers, of llamagastric Pestilence, of Diseases of the Liver, of the Spleen, &c.; and he hopes—as indeed he has received much valued evidence— that his full exposition of these maladies has been found most advantageous to medical practitioners residing in, and proceeding to, intertropical countries and unhealthy climates. Nor has the Author neglected the states and forms of these and other diseases, as they occur in the dark races and aborigines of these countries, and the treatment and different means of cure which they require when they are afflicted with them. XIII. Having been for twenty-five years Consulting Physician to a Lying-in Hospital, the Author had acquired considerable experience of the Diseases of the Puerperal States, and of the treatment most appropriate to the different circum- stances in which they occur, and to the causes and influences which modify their course and determine their issues. To these, as well as to the other disorders and dangerous maladies to which females are liable, much attention is devoted by him in this work, and a full exposition of their pathology and treatment is given, both from his own observation of these diseases, and from the more recently published works of eminent writers, who are more especially engaged in this department of medical practice. In respect of these diseases, the Author has not been influenced by any * The Author may be excused for giving the following extract from a letter addressed to him by Dr. Archibald Smith, who has had an experience of more than thirty years’ residence in an intertropical country. The Author should state that Dr. A. Smith was quite unknown to him until he did him the honour and kindness of addressing to him the letter from which the follow- ing is quoted: “I have often consulted with you in the pages of your valuable practical works, and never have I had occasion to do so with more interest than recently in Peru, when the yel- low fever for the first time broke out in that part of the world. Your treatise on this subject, in your ‘Dictionary of Practical Medicine,’ was really the only work which seemed to guide our practice in the any way hopeful or successful treatment of that dreadful malady. We were there, doctors of Germany, France, Italy, Spain, and England, in co-operation with the native practi- tioners ; and it surely is no small thing to say that more relief was procured to the sick from the application of your principles of practice in this disease than from the joint medical knowledge of all of us put together. I think you must be gratified by knowing that at least to one forlorn class of sick—the Indian race—your turpentine treatment was signally successful; and that to all the different races, whether brown or white, your general treatment to prevent the patient from ever sinking to the stage of black vomit, or irrecoverable prostration, was peculiarly fortunate above that of all other writers, English or Continental, as far as I know. Your work, in conse- quence, was by the whole profession in Lima sought after eagerly, and your name mentioned with the respect due to the prophet—though not in his own country.” Dr. A. Smith has very kindly allowed the Author to publish the above extract from his very encouraging letter. Kef- erence may also be made to a most interesting account of the Yellow or Haemagastric Fever as it appeared in Peru in 1852, published by Dr. A. Smith in the 82d vol. of the Edinburgh Medical and Surgical Journal. of the prejudices, or one-sided views, which have engaged the minds of too many members of his profession. He has been guided only by a desire to ascertain the truth, and by a sense of duty to the numerous readers of this work; and having succeeded, as he believed, in his endeavours, he has imparted the results in his descriptions of the nature and treatment of the organic and other diseases of females, respecting which any deferences of opinion had arisen among physicians. PREFACE. XV XIV. Numerous and important diseases, peculiar to infants and children, and others not less important and prevalent in the early epochs of life, are not more distin- guished by danger and fatality than by the difficulty of ascertaining their existence and diagnosis, especially during the earlier stages of these diseases. Having been for many years Physician to the Royal Infirmary for Diseases of Children, and having acquired, in that Institution and in private practice, much experience of these diseases, the exposition of the pathology and treatment of them in this work may be reasonably allowed to deserve some share of attention and reliance. The importance of studying the maladies to which children are liable cannot be over- rated, in respect both of the obligation imposed on the conscientious physician to ascertain the nature and the most successful treatment of these maladies, and of the habits of close observation and investigation thereby acquired by him, especially during the early periods of his practice. XV. In the course of the exposition of the treatment of diseases, numerous pre- scriptions and formulce are given, showing the modes of combining and of exhibiting the medicines advised for the several states and stages of disease for which they were found most beneficial. Most of these prescriptions had been employed in practice by the Author, as well as very many of those which are given as an Appendix to the work. • Some of the formulas contained in this Appendix had received the sanction of very eminent observers, and all of them are deserving the notice of physicians. The successful employment, however, of these medicines, as well as of all others, depends entirely on their adaptation to the existing states of individual cases—upon the acumen, the perspicacity, and the pathological knowl- edge of the physician. These prescriptions and formulae may be expected to prove of no mean service to young and inexperienced medical practitioners, and even the oldest may derive some benefit by adopting them, while few will fail to receive use- ful suggestions by referring to them. XVI. When treating of individual diseases, especially of those which are endemic and epidemic, of fevers, &c., the prevailing general constitution, or character and complexion of diseases, as insisted upon by Sydenham, has been noticed. The pro- priety of attending to this general constitution has been proved by the Author’s experience. For many years, and up to the year 1828, or about that time, these and other maladies, especially those most prevalent, presented more or less of a sthenic diathesis, and agues and other malarious diseases were comparatively rare; while, since the above date, these maladies have been more or less asthenic; and while blood-letting and other lowering means were required during the preceding number of years, these means have been rarely beneficial during subsequent years. It is not improbable that this change in the character or constitution of disease has been owing to the mean annual fall of rain during these periods, a greater fall having occurred annually since than before the above date, and consequently tellurial miasms have been more freely generated. XVII. Some of the disorders described by the Author in separate articles may be viewed as symptomatic of some primary or latent irritation, or as an exaggerated or prominent symptom of an obscure or totally unrecognized visceral lesion, and hence not deserving of the same amount of interest as should be attached to an idiopathic or primary malady. But it is not easy, or even possible, to determine, in every case, the primary or the consecutive nature of a complaint; and when the former cannot be ascertained at once, means should be used to mitigate the symptomatic XVI disorder, which, by its severity, may mask the original lesion. Disorders also referred to the same seat may be either primary or symptomatic, and hence should be practically viewed and treated as either condition is inferred. Moreover, the complaint, although obviously symptomatic, may attach to itself the importance and the means of cure which a primary disease would suggest. Many also of the disorders usually denominated as symptomatic are, from their severity and patho- logical relations, complications rather than prominent symptoms ; they are, on this account, and owing often to their severity, practically viewed by the Author with all the interest which is attached to idiopathic diseases. PREFACE. XVIII. At the present day the practice has grown up (and prospered as a trade) of viewing diseases, both those which are chiefly internal, and those more external or local, and of exhibiting them to the public as being better understood from being specially professed. But man, although furnishing the most wise, the most com- plex, and the most wonderful of all machinery, is not an inanimate machine, but is endowed with vital force distributed to, and actuating numerous systems, organs, and parts, and evincing functions and offices duly connected with and influencing each other, so that the conditions of each are manifested by all, in various modes of action, of existence, and of change. Hence the state of one organ or part cannot be considered in practice, either correctly or safely, disconnectedly from the rest of the economy; and hence an interference with a single organ may, without due reference to the state of the whole body, endanger the life of the individual. Who- ever attempts to cure an external sore, an eruption, or even certain internal or local affections, without considering the relations of these affections to visceral disorder, may either, by effecting what he professes, occasion a most severe or fatal malady, or he may fail in his attempts, or even aggravate the disease by an incompetence to estimate correctly the sympathetic and the symptomatic relations of the affected organ, and of the disease of which it is the seat. All parts of the frame are bound together by the vitality which endows them ; and the meddling or ignorant inter- ference with one part, without duly considering the existing conditions and rela- tions of the others, and the contingencies which may arise from such interference, is more likely to extend or to perpetuate, than permanently to remove disease. The medical or the surgical specialist may err, not only by suppressing a dis- charge, or by healing an eruption or a sore, which have become safety-valves to a morbid constitution, or have warded off* a disease to which an internal organ is predisposed ; but he may err still further by his ignorance of the operation of medi- cines which, when given in excessive doses or too long continued, may produce effects much more serious or even dangerous than the affection for which his vaunted treatment was employed; and, moreover, he may be, as he often is, most comforta- bly unconscious of the evil he has occasioned, by his being completely ignorant of the symptoms by which these bad effects are indicated, and of his having been the cause of the fatal issue which often ultimately supervenes. Have certain specialists of the present day any precise knowledge of the effects of several dangerous sub- stances when prescribed in large doses or continued for too long a time ? Are they sufficiently, informed as to the operation of arsenical and other poisonous prepara- tions, and of the changes, they undergo in the body when thus employed ? Can they recognize, and, recognizing, accurately describe the phenomena which result from these preparations when thus exhibited, and when combined with other dele- terious, or at least most energetic substances ? The Author believes that they can- not, not only because these phenomena are most varied, complicated, and even different, according to the peculiarities of individual cases, to the constitution of the patient, and to the medicinal and dietetic combinations in which these prepara- tions have been given, but more especially because they have been persisted in with a manifest ignorance of the operation of these medicines, until the most serious results have been produced. Within six months from writing this the Author has been called, in consultation with other physicians and surgeons, to four cases for which arsenic had been given in large doses and for prolonged periods, and which had been continued until most dangerous, and in one case fatal, effects were pro- PREFACE. XVII duced. Has it never entered into the minds of these specialists who thus wield the most dangerous weapons of their profession, the poisonous class of medicines, that they accumulate in the system, and are eliminated from it slowly and imperfectly; that they combine with and remain in the tissues and organs long after they have been taken; that, consequently, they must have passed through absorbent vessels and glands and into the circulating fluids, and that they may possibly irritate and inflame, or organically change, the vessels and the glands through which they pass, and in a similar manner, or otherwise, seriously affect the heart and nervous masses, as well as the organs by which they are eliminated from the economy ? XIX. The causes, the early approaches, the advanced forms, and the treatment of Insanity and Suicide are described as circumstantially and fully as the powers of the Author have allowed. A general view of the manifestations of mind by the instrumentality of the brain is exhibited as a suitable introduction to the study of this important department of medical science. This view is commenced with a notice of the lowest and the most general states of mind—of the instinctive feel- ings—observed in the animal creation, and is followed by an exposition of the highest—of the intellectual and reflective powers and moral sentiments—as evinced by the most civilized of the human species* To this arrangement -of the mental emotions and powers, and to the full description of the causes of disorders of these- powers, the Author is desirous of directing the attention of the reader. The increasing prevalence of insanity, and of those alterations of structure with which insanity is either remotely allied, or more intimately connected and even complicated—alliances fully described under that head—is to be assigned to more than one cause ; but there is no cause half so influential in occasioning this calamity as that secret vice, which has been denounced in several parts of this work, from a knowledge of its great prevalence among young persons of both sexes, and of its most injurious influence on the healthy conditions of both mind and body. The infirmity of mind and the extreme credulity which it induces, before- it complelely prostrates the faculties, render those addicted to self-pollution, those of the male sex more especially, the weak and drivelling victims of a class of unqualified, un- feeling, and imposing pretenders, from whose misrepresentations the laws furnish no protection, and upon whom no restrictions are imposed. The great importance of guarding against this most vile and degrading vice has not been sufficiently recognized by medical writers, especially systematic writers ; but, as it can be shown that a large proportion, if not the majority of cases, of chronic diseases, and of the infirmities of mind and body in both sexes, arises from this vice, practiced at a period when the structures of the body are advancing to or are assuming their full development, a due regard should be directed to means of preventing it, inas- much as it has become a most prevailing, a most debasing, and a most destructive physical and moral evil. XX. Poisons have been ably investigated by modern medico-legal writers, chiefly, however, as regards the lesions they produce, and the methods of detecting them in the digestive canal and structures of the body. The chemical and the medico-legal investigations of poisoning are not entertained, because they do not come within the scope of this work. But poisons are individually considered as respects their acute, and their chronic or slow operations and effects, each poison producing, according to its nature, specific effects, and therefore requiring an appropriate treatment. The chapters on the nature, operation, and treatment of individual poisons are prefaced by an account of the modes in which poisons are used, and the varied circumstances in which they are had recourse to. Without this inform- ation, the* accidental or the felonious use of them may be mistaken for the course and issue of natural diseases or even of puerperal maladies. The exhibition of * “Far as creation’s ample range extends, The scale of sensual mental powers ascends ; Mark how it mounts to man’s imperial race From the green myriads in the peopled grass.”—Pope. XVIII PREFACE. poisons also during disease, either singly or added to the medicines which the patient has been taking, lias often not been sufficiently recognized or even suspected by the medical adviser, and hence there is reason to believe that many persons have been destroyed without the cause having been recognized, and the effects of acute as well as of chronic or slow poisoning have been mistaken for the course and issue of natural disease. In order that this view of poisoning should not be overlooked, that the symptoms may be more clearly determined, and that the treat- ment should be both suitable and successful, the Author has fully considered the modus operandi or the physiological action of individual poisons, and has arranged them according to the more prominent characters by which their operation is mani- fested. The treatment advised for each poison has been as fully described as the limits qf this undertaking could admit, both as respects the employment of antidotes, and as regards the selection of means for the removal of the injurious effects they may have produced. The serious effects, as well those of acute as of chronic poisoning, and their diag- nosis from natural maladies, have been fully described, and the Author is desirous of directing attention especially to what he has stated respecting the effects of Antimonials, of Arsenic, and its preparations, of Digitalis, of Mercurial prepara- tions, of Lead, of the various modes of using Tobacco, of the preparations of Opium and Morphia, of Food-poisons, and of the Poisons imbibed during the dissection of recently dead bodies and from putrid animal matters. He has, as respects these and other poisons, considered not only their more immediate effects, but also- their more remote consequences, and has discussed fully the treatment most suitable to each, as regards both its. acute and its chronic or slow operation. This has ap- peared the more necessary inasmuch as he has been frequently consulted by medi- cal men respecting dangerous cases which have appeared to have been caused by the prolonged or excessive use of arsenical and other poisonous medicines. XXL In the course of the work, Hygienic Measures are not overlooked, par- ticularly in regard to those more important occasions which demand them, as well as to those less frequent and especial occurrences which due attention to them may require. A full exposition of the causes of disease and of their modes of operation on the human frame forms of itself an important part of a Hygienic system, inas- much as the avoidance of these causes is the chief object of all hygienic measures. When discussing special diseases their causes have been fully considered, and under the head JEtiology (see art. Disease) these causes have been arranged and viewed in connection; while those which are most influential and noxious, and hence most important, have been separately noticed in due connection with the effects they produce and with the means of prevention. In the exposition of Endemic and Epi- demic Influences', of the effects of Arts and Employments, of Infection, of Climate, due attention has been directed to the means of preventing and of counteracting most important agencies in the production of disease, and to other Hygienic considera- tions connected with these subjects. In the article on Protection from Pestilences (vol. iii., p. 282, et seq.), as well as on the Sources and Causes of Pestilences, the Author has given a full exposition, not only of those sources, but also of Fevers and of all malignant and dangerous diseases, and of the most successful means of pre- venting their appearance, their introduction, and dissemination. Not the least important of the measures here advised are those means of protection which enable the constitution to resist infection and injurious emanations : these measures have been described as consisting, 1st, “ of Medicinal Prophylactics,”* and, 2d, “ of * The Author believes it to be a duty he owes himself to state the following: A friend, with his family, being about to proceed to the Havana, and thence to several parts of intertropieal America, applied to him in 1820 for instructions to enable them4:o escape the endemic and epi- demic diseases of these parts. He furnished this gentleman with such instructions as he believed to be most conducive to the attainment of this object. The chief of these were to avoid all sources of malaria and situations which attract it, and the night and morning air, in these situa- tions and after falls of rain; and, if these could not be avoided, and when circumstances re- quiring precautions occurred, or when exposure was inevitable, to have recourse to a prescribed PREFACE. XIX Dietetic, Regiminal, and Moral Prophylactics.” These topics, hitherto neglected by modern writers, have received adequate attention from the Author, not only in the present work, but also in other publications, the first of which appeared as early as 1821. XXII. No attempt has been made in this work to discuss the Statistics of Disease, nor has the “numerical method” of exhibiting the symptoms, &c., of disease and of the effects of remedies been noticed. Of the former, an approximation only, and that loose and inaccurate, can be expected; for, unlike other subjects respecting which statistics are often of use, disease varies with age, sex, season, weather, climate, and the numerous domestic, social, and Hygienic circumstances, by which the health of communities is influenced, and which are in constant states of muta- tion. The same causes and circumstances also affect the phenomena, symptoms, course, character, or nature and termination of all disorders and maladies; and, while remedies and plans of treatment prescribed appropriately to these effects are hence obviously required, these remedies must, in order to be successful, or even not detrimental, be so combined or modified as peculiarities of constitution, causes, and influences suggest, and, indeed, demand. When, therefore, we observe, as may have been recently observed, a laudation of the numerical method—a method de- serving notice only from the few eminent names who have had recourse to it, we must infer either that they have been ignorant of the varying or even different natures, characters, and symptoms of the same diseases under the varying causes, circumstances, &c., which influence or altogether change them, or they have alto- gether overlooked those differences. Besides, many of the symptoms of a disease, and those even by which the experienced physician will be chiefly guided in his practice, cannot be assigned or enumerated so correctly as to direct his indications of cure. Let Pneumonia be taken as an instance. The physician, in assigning the symptoms of this disease, numerically, requires to do so with strict reference to the sthenic, asthenic, and gouty forms, to the gradations and to the complications— Broncho-pneumonia, Pleuro-pneumonia, &c.—of the malady. Then, following out his boasted method, he endeavours to give the numerical results obtained from dose of medicine, consisting of about three grains each of camphor and capsicum, with either a drachm of powdered cinchona or an ounce of the decoction, or one or two drachms of the com- pound tincture of cinchona. This dose was to be taken at night and upon getting up in the morning, before exposure to the morning air. If circumstances prevented this prophylactic to be 'taken, a cup of strong coffee, night and morning, was substituted. This gentleman (Mr. Bullock, the then well known naturalist), on his return to Europe, published his travels in Mexico, &e., and with them the Author’s instructions, which were stated by him to have proved so successful, that, notwithstanding much exposure, a due regard to them had preserved him and the members of his family from disease during their residence and travels in that country. Soon after the appearance of Mr. Bullock’s work, the Author’s instructions contained in it were published separately by a bookseller in the city. At the time when these instructions were written, the sulphate of quinine had not been discovered, or at least was not'then introduced into this country. When the Niger Expedition was about to leave England in 1839, two physicians who accom- panied the expedition called on the Author with an introduction from his esteemed friend, II. C. Kendrick, Esq., late of the War Office. After representing to them the extreme risk they were about to encounter, and the very probable results of the expedition—results which took place exactly as they were predicted from the Author’s observation and experience of Western Africa—and after listening to and stating reasons against their sanguine expectations, he wrote the following prescription for them to have recourse to when they came within the influence of the African malaria, stating to them that, as soon as this should take place, their sanguine anticipations would undergo a very marked change: Quince di-Sulphatis; Pulveris Capsid, Camphorce, aa, gr. iij. ad gr. v.: Misce. This medicine, commencing with the smaller, and increasing it to the larger dose, was to be taken night and morning, in any manner or vehicle convenient and suitable; the larger dose when the exposure was the greatest, when also, as well as on other occasions, a cup of strong coffee was to be taken at night, and in the morning before exposure to the air. On the return of this ill-fated expedition to England these two gentlemen called upon the Author to thank him for their successful recourse to the prophylactic he had prescribed for them—how many besides these returned from that expedition need not be stated. Since these occurrences, and since their publication on several occasions, and since the recommendation of the above prophylactics in the early parts of this work, they have been often adopted with success in several quarters of the globe where remittents and agues arc endemic. XX PREFACE. bleeding, from tartarized antimony, from camphor, liquor ammonia? acetatis, &c., and from leaving the case to nature; and the consequences are, that, having treated the disease according to the name he has given it, and not according to the features and nature resulting from its causes and modifying influences, he finds that those means which are most heroic, especially bleeding and antimony, are the least suc- cessful, inasmuch as they have been prescribed for many cases and in various cir- cumstances for which they were inappropriate or injurious; and he observes that camphor and the acetate of ammonia are more successful than these, because, while they are suitable in certain forms of the malady, they do not produce the injurious effects of the first-mentioned means in these forms. Hence we cannot be surprised if this method should furnish results which may be adduced as evidence of the injurious effects of all modes of treatment, and of no treatment at all being more successful than any one method prescribed, without discrimination, for all forms, and states, and stages of the disease. Such results, however, should be rationally expected; for the empirical or ignorant treatment of all cases of a disease by its name, and by the same remedy or plan, and without reference to itg very different forms and states, must be injurious to as many at least as it benefits, and hence no treatment, or the vital resistance which nature furnishes to the extension of disease, will prove the most successful. A substance is remedial only by its appropriate employment—appropriate as to its dose, combinations, and continuance—appro- priate as to the states and stages, and to the various causes, influences, &c., which modify and favour' the course and terminations of disease. XXIII. The Bibliography and References appended to each article require a very brief notice. These are, to some extent, historical, and are enumerated with some, but no constant relation to the course of time and to the progress of knowl- edge. They might have been made much more copious than they are; but there are several works on Medical Bibliography to which the learned reader may refer if the literature of any one subject become an object of interest to him, and where the imperfections of this department of the Author’s labours may be supplied. It must, however, be confessed, that the very circumstance of a very large proportion of the references to original papers, memoirs, and researches having been made in the manner he has stated in the original Prospectus of his work (see p. iii.), is an indi- cation of omissions which it was out of his power to supply; and even if he had been enabled to perfect this department to the full extent of his wishes, the benefits thereby conferred might not have compensated the labour. If it be objected that the opinions and writings of the older medical authors are undeserving of the notices which have been taken of them, it may be answered that the practical knowledge of disease at the present day is not so far advanced above that of some ages past as those believe who are acquainted with the former only. Practical medieine is essentially a science of observation and close comparison ; and the ability of observing closely has not been limited to a single epoch, nor can it be appropriated exclusively by the observers of the present day, although doubtless the materials and the powers of correct observation have increased. Besides, the single observer should not suppose that the whole sphere of correct medical inform- ation can be embraced by himself, or that his own extent of acquirement should constitute a sufficient amount of knowledge. It is unnecessary to allude further to particular departments of this work, or to subjects which have received especial attention and development. It is desired, and, indeed, most ardently desired, that every part of this difficult undertaking should be closely but candidly scrutinized; for, although the Author has been a student during his life, he is not too old to learn and to derive advantage from judicious criticism. XXIV. The Author may be permitted to state the incentives to his undertaking, and the sources of the hopes he has entertained of being enabled to accomplish it. When he entered upon the study of these departments of science, which are the bases of practical medicine, he felt the want of a work which would supply students PREFACE. XXI and practitioners of medicine with that amount of knowledge which the due and conscientious discharge of their duties required. He had had the advantages, at that time too seldom enjoyed by medical students, of having pursued, during four years at the University of Edinburgh, those studies which form the best introduc- tion to the attainment of medical knowledge, and not only of having assiduously attended the lectures, but also of having possessed the acquaintance, and he may say the friendship of men whose names will long live in the annals of literature, science, and philosophy—of Dunbar, Ritchie, Leslie, Playfair, Stewart, Jamie- son, Hope, Niell, and Fleming—names he now recalls with all the happiness connected with the best of his early reminiscences. After having devoted eight years to preliminary and professional education, he closely observed, during two years, the diseases which prevailed in Franfe and Germany soon after the peace of 1815. He subsequently extended his field of observation and experience to the most unhealthy intertropical countries ; and on his return to England, he was re- quired, from the commencement of his practice, to exert his powers of observation and discrimination in the treatment of diseases of difficulty and danger, and in examining critically the merits of those medical writings which were produced in this country and on the Continent of Europe. Having been engaged in writing on scientific and medical subjects from 1819 until the present day, and in lecturing on Pathology and Practical Medicine from 1824 until 1842; having from the earliest of these dates enjoyed as extensive opportunities in public and private practice as he could use with advantage to his patients and to the advancement of his own knowledge ; and being fully impressed by the truths which extensive fields of observation and mature experience had dis- closed, he has ventured to state his opinions with the confidence inspired by a firm belief of their accuracy. To hesitate in conveying instruction and in employing remedial means betrays insufficient knowledge, and has never been rewarded by more than accidental success; but a firm conviction and expression of the truth of what is stated or advised will generally produce belief in the mind of the reader or hearer. Hesitation rejects, where it fails in suggesting, further investigation; confidence commands belief, even when further research is required, and obtains success as its reward. By the plan of his work the Author attempts, at least, to fulfil the great func- tions of medical writing—to arrest the attention, to engage it with an unflagging interest, to infix what is important or undisputed in the memory, and to carry on the mind, by an enlightened induction, to a due recognition of pathological princi- ples and of therapeutical intentions and precepts. He is unfeignedly conscious that his powers are inadequate to the full attainment of these ends, but he hopes that his attempt will not be without a share of success as respects both the advancement and diffusion of rational medical knowledge and the health of the community. Having been engaged in discussing medical doctrines and practice from an early period of life, and having promulgated opinions, formed after close observation and due consideration, different from many received or confided in, the Author has lived to see these opinions adopted either very generally, or by many of the best authori- ties in the profession; and he therefore hopes that his past experience in medical literature will justify his present undertaking. Whatever defects may exist in this work—and no one is more conscious of them than the Author himself—he believes them to be those of omission rather than of commission. Much may have been overlooked, but much has been duly recorded, and nothing deserving of notice has been willingly omitted. The Author has referred to the opinions of other medical writers—both of contemporaries and of those who have preceded him—as copiously as the plan of the work could allow. It would have been quite impossible to state these opinions otherwise than in the abstract, and he has done this as succinctly and as correctly as he could. He has been anxious to state the sources from whence he has derived his information, and he has, he believes, not failed to do so. He has referred chiefly to the names and the views of original writers and observers, and he has not in any instance inter- rupted the current of his histories of opinions by either eulogy or reprehension. Of XXII PREFACE. those who have contributed to the science to which he has devoted himself he has recorded the labours impartially, and he has thus evinced his estimation of their value—a value which eulogistic expletives could not have increased. When he has noticed opinions that required examination, in order that truth might be elicited, he has treated no one with disrespect. Although he hopes that his labours have not been without avail, yet he is too deeply impressed by his own deficiencies —he has had too often reason inwardly to regret the imperfect state of his own knowledge of many subjects, particularly in respect of the desired extent of knowl- edge, to judge harshly of others. He has considered it better to pass over alto- gether what he distrusted or considered injurious, than to occupy his pages by adducing it for the purpose either of exposure or reprehension. He has not adopted this resolution from a desire ©f his own ease, but from a conviction that he would be occupying valuable space, and still more valuable time, without ade- quate, if indeed any advantage. Although few can be more sensible of the imperfections of his work than the Author himself, yet he hopes the reader who attentively studies his pages will allow him the merit of industrious study of the best medical authors, and attentive observation of the causes, course, and consequences of disease, and of the effects of remedies. His labours, which have been incessant for many years, have been per- sisted in, under circumstances and contingencies which few could have endured. He has received no assistance in furtherance of his undertaking, nor with his knowledge of human nature would he have accepted any. Some inaccuracies are inevitable in a work so extensive and laborious as this is, but the Author believes that they are not many or important, inasmuch as every line of it was written by his own hand, and all the proofs were carefully read and corrected by himself. Of the manner in which he has conveyed his ideas, his doctrines, his descriptions, and his instructions, it does not become the Author to venture a confident opinion. He has endeavoured only to be clear, forcible, and condensed. He has avoided a parade of scientific and technical terms and of foreign words and phrases, and has preferred English expressions wherever they were admissible, and the instances were rare in which they were not only appropriate, but even preferable. Thirty years of his life have been devoted to this work by its Author. He has laboured on it alone and unassisted. He has, however, been encouraged to perse- vere to its completion by the friends to whom in gratitude he has dedicated it, and by the indulgence and liberality of his Publishers. He feels with becoming thank- fulness the kindness of many in the profession throughout the three kingdoms who have confided in his medical knowledge, and have thereby enabled him to provide for the day which was passing over him, and for those dear and nearly related to him, whom misfortune and death have left to his care. And he expresses his heartfelt thanks, not only to those friends, but also to others, who, quite unknown to him as the authors, have been favoui'able, kind, and considerate reviewers of the parts of the work as they successively, although tardily, appeared. Entertaining no mean opinion of the legitimate exercise of the healing art,* viewing his profession in the light in which it was held in ancient, and even in more modern times, and estimating his work according to the experience and the research, to the time he has devoted to it, and to the amount of labour and the sacrifices it has cost him, he feels assured that he has not laboured in vain; and he cannot doubt that it will be of essential service to many—that suffering humanity will be benefited, and rational, learned, and scientific medical practice advanced by it. “ For his name and memory, he leaves them to men’s charitable speeches and to foreign nations, and to the next age.” * Bacon vindicated the dignity of the healing art by appealing to the example of Christ, and reminded men that the Great Physician of the soul did not disdain to be also the physician of the body. “ Nusquam enim legimus miraculum aliquod ab eo patratum circa honores, aut pecunias, sed tantum circa corpus liumanum, aut conservandum, aut sustentandum, aut persanandum.” De Augmentis, Sfc., lib. iv., ch. ii. PREFACE OF THE AMERICAN EDITOR. The Editor of “The Dictionary of Practical Medicine” congratulates himself and the American Medical Profession that the great work which is now presented entire to the American public has at length been brought to a successful comple- tion. Commenced in the year 1840, its Numbers appeared at very unequal and irregular periods; each Number, however, commanding the increasing admiration of the profession every where at the comprehensive range of the author’s learning, his extensive practical experience, and his admirable power of condensing and arranging his vast materials. So valuable, indeed, was the work every where con- sidered that two or three different publishers undertook, at different times, its republication; but, after issuing a few Numbers, abandoned the enterprise, on the ground of its delay and the supposed uncertainty of its completion. In the year 1844 the well-known medical publisher H. G. Langley, of New York, undertook to bring out the work, under the superintendence of the undersigned, and faithfully carried out the promise contained in his Prospectus, until his failure in business in 1850, when it passed into the hands of its present publishers. The Editor deems it due to himself to quote the following remarks from the “ Notice” which he pub- lished on assuming the superintendence of the work, in regard to his views and intentions as to the manner in which he should aim in discharging the task in- trusted to his care: “ Regarding this work as decidedly the leading medical production of the age, both as regards the philosophy it inculcates, the vast accumulation of facts it pre- sents, as well as the systematic order in which they are arranged, the Editor will not feel himself justified in altering, in the slightest degree, the original text. He, therefore, pledges himself to preserve the different articles in their integrity, neither mutilating by omissions, nor qualifying by alterations and modifications. Indeed, so highly elaborated and finished are the different articles that they form very complete monographs on the subjects of which they treat; and no one could expect, unless prompted by a high degree of arrogance and self-conceit, to be able to im- prove upon the labours of the accomplished Author. But it is to be borne in mind at the same time that, as medicine is a rapidly-progressive science, additions are constantly being made to our knowledge in its various departments. Moreover, the medical literature of our country is but little known across the Atlantic, and the works of American physicians have heretofore not perhaps received that degree of attention abroad to which they are justly entitled. These omissions and defi- ciencies, so far as they exist, it is the design of the publisher to have supplied; and it will, therefore, be the aim of the Editor to keep this object especially in view. “ It is a fact, also, universally acknowledged, that, in consequence of the diversified range of our climate and its extreme vicissitudes, we have diseases which are not XXIV PREFACE OF THE AMERICAN EDITOR. only unknown to the milder and more uniform climate of Great Britain, as yellow fever, cholera infantum, &c., but many of our diseases assume a type and malignancy never witnessed in that country; and hence they require important modifications with regard to their treatment. These facts will not be lost sight of in editing the work ; and in whatever additions may be made, practical utility will be constantly kept in view. Such additions will be included in brackets [ ].” Such were the views and pledges of the Editor on assuming his responsible task, and he confidently appeals to the readers of the work whether he has not faithfully carried them out. He has constantly laboured to render the “ Dictionary” still more acceptable to the American public; and he uses this term designedly, inas- much as its pages are equally calculated to interest, enlighten, and instruct the other professions and the general reader, as those more especially connected with the study aifd practice of the Healing Art. To the earlier Numbers, which had been issued in England several years before their republication here, nearly one fourth of new and original matter has been added, while the later Numbers have been so brought up to the existing state of our knowledge and of the science, and have done such full justice to American Avriters on the particular subjects brought under review, that the Editor has found his task comparatively light, and has, therefore, not sought to gild refined gold. lie has, moreover, the high satisfaction of knowing, from the assurance of the accomplished Author in person, that the annotations and additions have met his kind approbation. The “Dictionary of Practical Medicine” has now a Avorld-wide celebrity, and needs no commendation at our hands. Its articles have been justly characterized by the “ Edinburgh Medical and Surgical Journal" as “ unrivalled for extent and ac- curacy of information, methodic arrangement, and the condensed form in which they are composed.” Sir John Forbes, late Editor of the 11 British and Foreign Medical Review,” thus speaks of it: “ The information amassed in these volumes is literally enormous, and, contemplated simply as an accumulation, it must excite astonishment as the production of an individual; but when it is further considered that the whole of the materials have been most carefully selected from all existing sources, most particularly studied, valued, winnowed, digested, elaborated, and arranged into compact and simple forms, easily accessible and readily available in practice, it is not easy to point out, in the whole of medical literature, any work by a single hand so much calculated to excite admiration of the industry and talents of the Author. In every article contained in the volumes, the reader cannot fail to be struck with the writer’s most extensive learning, which has enabled him to collect knowledge from all authorities, ancient and modern, foreign and domestic; and he will, at the same time, be no less surprised than gratified at the singular power Avhich has arranged the Avhole so lucidly and in such systematic order. As there is no medical practitioner in this country, old or young, high or low, who will not derive great pleasure and great profit by consulting them, so we think there is no one who should not add them to his library.” The London Medical Gazette charac- terizes the work as “ a miracle of industry, and bearing internal evidence of having been the object of years of labour and investigation directed to the end in view. Not the least praise we have to bestow upon the execution is the just keeping observed in respect to the length of the articles; those which relate to the diseases PREFACE OF THE AMERICAN EDITOR. XXV of moment, being fully discussed in well-digested essays, while no attempt is made to give consequence to those which are unimportant.” The Medical Quarterly lleview speaks of it as a work, “ so condensed in style, and so excellent in execution, that analysis is impossible, and criticism very difficult.” Elliotson, in his able work on “ Physiology,” describes it as “ a work displaying such extraordinary extent of reading and such deep and comprehensive reflection, as to demand a place in the library of every medical man.” The Medico-Chirurgical Review remarks that “ the immense quantity of matter which is here compressed into a small space must render the work a very popular one, more especially for those practitioners who reside in the country, or travel abroad, on account of the facility of reference, and the portability of the Dictionary. The labour is immense, and will stamp the Author as a man of great research and sound judgment.” The medical journals of our own country have been equally lavish in their com- mendations of the work. But one only, however, and that standing at the head of American periodical medical literature will be quoted, viz., “ The American Journal of the Medical Sciences.” “ This work,” says the Editor, “ has thus far been executed in so masterly a manner as to have obtained general commendation, and, when completed, will be a work which the extensive and laborious research which it displays, the ability with which the materials are digested and condensed, the deep reflection and excel- lent judgment conspicuously manifested, render an extraordinary monument of individual industry. The American Editor seems disposed to rival the Author in industry, his additions to the part befofe us being very numerous, and adding greatly to its value, particularly by supplying the observations and experience of American physicians which have been overlooked in the original, and enriching the bibliography with references to our own literature,” &c. Such are some of the opinions of the medical press in regard to the merits of the work now presented to the public. Many more, equally laudatory, might be given, but these will suffice. The work will speak for itself. In conclusion, the Editor would beg the kind indulgence of the reader for any seeming omissions on his part; he has aimed to render impartial justice to all the medical writers of our country deserving of especial notice, whether their labours have appeared in the pages of periodicals, or in separate works or monographs. If any have been omitted, it has been from inadvertence or lack of information, not from design. “ Non omnia possumus omnes.” Charles A. Lee. New York, November 1st, 1858. CLASSIFIED CONTENTS. Preliminary Remarks. —An Arranged Contents of his work is attempted by the Author with the object of enabling the student of medicine and the medical prac- titioner to peruse what he has advanced as the results of his observation, of his practical experience, and of his reading, with the most advantage, and in the most suggestive manner. Information is useful not only as respects its amount, but also as regards what it may suggest to the mind of the reader calculated to lead to further investigation and illustration, than the limits allotted by the Author to the many subjects and topics which have come under his consideration could allow. He has endeavoured to arrange these subjects, both pathological and practical, in such an order as may enable the information first afforded, or successively obtained, to contribute to the elucidation, and to the more complete comprehension, it is hoped, of what is subsequently discussed. It may be necessary to premise that the Classification of diseases here attempted is, as far as the Author is concerned, altogether original, although it was first pub- lished in the u London Medical Repository” in 1822. Notwithstanding that this attempt was made at so early a period of his practice, he had then enjoyed exten- sive opportunities of observation in this country, on the Continent of Europe, and within the tropics. This classification and the pathological principles here stated are the same as were then published. Comprehensive and close observations, the sources of true experience, which he believes himself to have possessed, as well as to have exerted, have confirmed him in the belief that his arrangement is the most use- ful, practically or therapeutically, inasmuch as it is founded upon, and has constant reference to, the conditions of vital force—to that power which actuates the whole human organization, and to which a continued regard must necessarily be had, and a constant reliance placed in our efforts to alleviate or to remove disease. During the many years in which the Author was engaged in lecturing on the Principles of Pathology and on Practical Medicine, he adopted this classification, and he believes that it was then conducive to the acquisition of practical knowledge by his pupils. This arrangement being thus based upon the states of vital force, and upon the unquestionable facts that disease, especially in its slightest and earliest deviations from health, is a deranged manifestation of life in some tissue, organ, or system ; that this deviation is followed by a succession of changes, until alterations of the fluids, secretions, and structures supervene; that the existing change has been induced by that which preceded it, often aided by the persistence of the exciting cause or causes, and by the concurrence of additional influences; and that it will itself occasion still further changes, if not arrested by science or art, or by the efforts of nature, or, in other words, by the resistance which the vital force or power may be enabled to oppose to successive or unfavourable changes, it follows that a due recognition of the simplest and earliest manifestations of disorder, a correct estimate of existing changes, and an accurate view of future contingent alterations and results are of the utmost importance, not merely as respects the places assigned to them in the classification, but still more as regards the adoption of indications of alleviation or of cure, and the selection of means by which these indications may be fulfilled. Of the essence of life itself we know nothing further than that it is associated with, and manifested by structure, the simplest and lowest structures displaying its simplest, but yet its most generally diffused functions or properties, the more complex organizations its higher manifestations, the highest and most perfect of created beings alone possessing its highest faculties. XXVIII CLASSIFIED CONTENTS. The lowest formations which evince vitality possess organic nervous corpuscles and digestive and circulating systems; and as we ascend the scale of animal crea- tion, the organic nervous system rises, from rudimental, through more perfect developments, to the most complex and complete, as displayed in the highest order of animals. Over the two latter systems—the assimilating and the circulating— the organically sensitive presides, each of these reciprocally aiding and contributing its functions to the others, and thereby supporting and increasing the vital force, while this force itself preserves the organic elements in which it is associated, and develops them into specific forms, more particularly when subjected to the influences which excite it into activity. Thus it will be seen that these three prime factors of life, viz., the organic nervous globules and their conformation into ganglia and ganglial nerves, the circulating systems, and the digestive apparatus, which is more especially subsidiary to the others, have certain organs—respiratory, assimilating, secreting, excreting, &c.—which are subservient to the life of the individual—to the maintenance of vital force or power; other organs, as those of voluntary motion, of sense, and of the intellectual and moral powers, for holding communication with the rest of the species and of creation ; and superadded organs, intended to per- petuate the species. CLASSIFIED CONTENTS. GENERAL PATHOLOGY. I. Physiological Pathology : Absorption, § 1, et seq i. 27 Age, its physiological and patho- logical relations —46-57 Asphyxia, § 1, et seq — 168 Asphyxia of new-born infants — 175 Asthma, physiological relations of. $ 3-6 . — 177 Blood, physiological pathology of, l) 1-25 .. — 211 Blue disease — 251 Climate, physiological and patho- logical effects of, § 17-42 — 404 Cold, physiological and morbid ef- fects of, 1-15 — 409 Crises, nature and origin of — 513 Excretion and Excretions, the phys- iological and pathological rela- tions of, § 1-14 — 975 Mind, instinctive affections and in- tellectual manifestations of, ar- ranged and noticed, § 66, et seq. ii. 512 Insanity, physiological pathology of, t) 327-384 — 573 Irritability, physiological and path- ological relations of, § 1-20 — 690 Irritation, the physiological and morbid relations of, § 1-25 — 696 Menstruation, physio-pathological states of, l) 4-18 — 959 Pollutions, remarks respecting, 1, ct seq., i. 197; § 103 — 669 Tabes, &c., 1) 1, et seq iii. 1100 f. Venous congestions, Art. Con- gestion of Blood, § 1, et seq . i. 467 g. Asthenic Haemorrhage’s, 12 ii. 74 h. Impaired vital cohesion, and flac- cidity of the tissues—Soften- ing of Tissues, § 1, ct seq.... iii. 922 i. Diminished vital resistance to contaminating agents, § I, et seq ibid. See more fully the pathology of the Art. Debility, § 1, et seq.. — 547 Bibliography and References to Arts. Debility, i., 560 ; and to* Softening of Structure.... — 925 B. Alterations proceeding from irreg- ularly distributed or increased Organic Nervous or Vital Force. a. Vascular plethora, <$ 13-23 i. 214 b. Generally increased vascular action, § 82-86 —663-5 c. Local determinations of blood and vascular erythism, 6 25- 33 — 217 d. Increased exhalation and secre- tion, $ 95-102 — 667 e. Sthenic Hemorrhages ii. 74 /. Sthenic Inflammations — 426 C. Alterations caused by Perverted or by Exhausted Organic Nervous or Vital Force. a. Alterations affecting chiefly the Blood, $ 78-160 -227-49 (a) Alterations of the blood in disease, proved and insist- ed upon, $ 78-137 -227-44 (i) Changes as respects the CONTENTS—Pathogeny. chief constituents of the blood, § 81-91 i. 227-30 (c) Vitiations of the blood by the fluids which supply its waste and which form it, $ 111-114 — 237 (d) Imperfect performance of the functions of depura- tion a chief cause of the vitiation of the blood, § 115-124 — 238 Illustrations, § 125- 131 — 240 (e) Contamination of the blood by putrid or by septic mat- ters applied to the tissues, $ 125-134 — ibid. (/) Contamination by causes affecting the nerves sup- plying the vascular sys- tem, $ 134-142 — 243 (g) The absorption or passage of morbid matters into the blood from the veins— Lymphatics, § 143-145... — 246 (A) Phenomena depending up- on a vitiated state of the blood, § 145-151 — 246 (i) Connexion of morbid action and of organic lesion with states of the blood, § 148 — 247 Bibliography and Referen- ces to alterations of the Blood — 250 b. Alterations of the secretions and excretions, § 93-109 ....—666-70 (a) The simpler alterations of exhalation and secretion, $ 94-103 — 667 (5) Preternatural exhalation and secretion, § 104-109.. — 669 (c) Secretions and productions adventitious to the situa- tion, § 108 — 670 and to the economy, § 125-136 — 674 c. Adventitious productions ow- ing to constitutional taint and perverted action, &c., 141 — 678 Scrofulous and tubercular de- posits, &c iii. 797-837 Atheromatous, suetty, fatty, os- sific, &.c., deposits, or trans- formations, &c i. 133 d. Destruction of organized parts, § 147 — 679 e. Connexion of morbid ac- tions and organic lesions with states of the blood, $ 148-151. — 680 Urinary deposits and calcu- lous formations iii. 1314-53 c. Alterations chiefly of sensation and motion, see Art. Paral- ysis, (j 3, et seq — 12 (a) Alterations of sensibility, § 6-14 ibid. (b) Pains, &c., of various kinds — (c) Loss of sensation, &c — 13 (d) Impaired or lost*motion... — 13 (e) Irregular motions—Paral- ysis agitans — Tremor— Spasmodic motions, &c... — 25 CONTENTS—Structural Lesions. XXXI d. Alterations of the fluids, and of sensitive and irritable parts affecting more or less the functions and tissues of the economy, § 145, et seq i. 246-8 See, also, Fevers, Pestilences, and other Diseases arising from miasmata and specific in- fections, &c. (a) The procession of morbid phenomena, § 152-154 — 681 (J) Grades of morbid actions, § 154 — ibid. (c) Of the types and forms of disease — Periodic — Con- tinued, § 155-157 — 682 (d) Duration of morbid actions —the terms acute, sub- acute, chronic, § 158, 159. — ibid. (e) Of crises and of critical days — 513 (/) Of the terminations and is- sues of disease, § 160-162 — 683 (g) Of the relations, succes- sions, and complications of disease, § 163-171 —684-6 (A) The metastasis, or change, migration, &c., of disease, $ 172 — 686 (0 Circumstances modifying the form, complications, dura- tion, and termination of disease, § 177 — 687 Bibliography and Referen- ces to Art. Disease — 688 IV. Lesions of Structure generally proceeding from one or more of the Morbid States already adduced. i. Alterations usually termed In- flammatory, or Consequences of Inflammation—See Art. In- flammation, t) 1, et seq ii. 426 A. The Phenomena constituting Sthen- ic Inflammation, their Course and Terminations, § 4—50 —426-38 a. Acute sthenic inflammation, § 5-29 -426-33 b. Sub-acute and chronic inflam- mations, i) 30-35 — 434 c. Complications of sthenic in- flammations, § 36-38 — 435 d. Terminations and consequen- ces of inflammation : exuda- tions, effusions, suppuration, ulceration, thickening, indu- ration, § 39-50 —435-8 B. Adhesions, Morbid and Reparative, t) 1, et seq i. 40-4 a. Between cellular and serous tissues, § 11 — 42 b. Between mucous surfaces, t) 15 — 43 c. Bibliography and References... — 44 C. Abscesses, Description of, t) 1-53. —15-24 a. Encysted, diffusive, chronic, § 3-20 — 15 b. Symptomatic, consecutive, t) 20 -29 — 18 c. Course and terminations of, § 30-53 — 20 d. Pus, descriptions of iii. 610 e. Bibliography and References., i. 26 D. Modifications and Varieties of In- flammation, § 51-70 ii. 438 a. Modifications as to activity and grade, § 51-53 — 438 b. Modifications owing to impair- ed vital force and morbid states of the blood—Asthenic inflammations, &c., $ 54-67.—439-42 , c. Asthenic inflammations, their progress, complications, and consequences —Disorganiza- tions—Ichorous and sanious exudations — Ulceration — Sphacelation, § 68-77 — 442 d. Softening of structures, inflam- matory, § 43 — 437 Softening, different states and forms of, Art. Softening, § 1, el seq iii. 922 c. Consecutive inflammations, va- rying with the states of vi- tal power and of the blood, § 112 ii. 453 /. Secondary inflammations, ow- ing to the passage or absorp- tion of morbid matters, &c., § 114-120 — ibid. g. Opinions as to the nature or the pathology of inflamma- tions, $ 135-171 — 457 h. Gangrene caused by inflamma- tions. See Art. Gangrene, $ 6-15 — 9 i. Reparation of the consequences of inflammation, § 172-176.. — 469 k. Bibliography and References.. —487-9 ii. Alterations, occurring gener- ally INDEPENDENTLY OF IN- FLAMMATION, or owing to Mor- bid States of Secretion and Nutrition, § HO, et seq i. 671 A. Atrophies, Nature, ) Lesions of the appendix caeci, § 27-33 — 334 p. Lesions of the colon — 449 q. Alterations of the rectum and anus iii. 642-63 {a) Malformations of the, § 5... —• 643 {b) Foreign bodies in, and lac- erations of the, § 7 — ibid. CONTENTS—Organic Lesions of Organs. (c) Inflammatory lesions of the, § 27 iii. 646 (d) Abscess of the, § 47 — 650 (e) Ulceration of the, § 56 — 652 (/) Fistula in ano, § 61 — ibid. (g) Fissures of the anus, § 70. — 654 (A) Prolapsus of the rectum, § 76 — 655 (i) Excrescences and polypi of the anus and rectum, §88 — 657 (k) Contractions and strictures of the rectum and anus, § 92 — 658 (0 Cancer of the rectum and anus, § 109 — 661 {in) Bibliography and Referen- ces —• 663 ii. Structural Alterations of the Biliary Apparatus. A. Lesions of the Liver ii. 839-78 a. Congestions of the liver, san- guineous and biliary, § 66-84 — 839 {a) Sanguineous congestions, § 66-77 — ibid. {b) Biliary congestion, $ 78-84 — 841 b. Haemorrhage of the liver, § 89 -93.. — 843 c. Alterations consequent upon acute and chronic inflamma- tions of the liver, § 124 — 849 {a) Abscess of the liver, § 128. — ibid. And § 206-210 — 867 (£) Softening, gangrene, and other lesions, § 205, 211.. —866-7 (c) Enlargement of the liver, § 212,213 — 867 (d) Induration, atrophy, &c., § 214 — 869 (e) Cirrhosis, &c., § 215, 217. — ibid. d. Lesions from impaired vital power and nutrition, § 218... — 870 (a) Fatty and oily deposits, &c., § 219 — ibid. (b) Tubercular and cancerous formations, § 222-230.... — ibid. (c) Simple cysts and acephalo- cysts. &c., § 231 — 872 e. Bibliography and References.. — 877 B. Alterations of the Bile, Gall-blad- der, and Ducts ii. 1 ; and i. 458 a. Alterations of the bile, § 1-7... ii. 1 b. Biliary concretions, &c., § 1, et seq i. 458 c. Bibliography and References.. — 463 d. Changes consecutive of inflam- mation of the gall-bladder, 6 26 ... ii. 6 e. Changes in the biliary ducts, § 28 — 7 d. Bibliography and References to — 8 C. Morbid appearances most frequent- ly seen in connexion with Jaun- dice, § 18-25 — 344 Bibliography and References... — 358 iii. Lesions of the Spleen, § 27, 76 -97 iii. 980 a. Those consisting of congestion and inflammation, &c., § 27. — 981 b. Organic lesions of the spleen, § 76-84 — 990 c. Enlargements and tumours, § 85-89 — 991 CONTENTS—Organic Lesions of Organs. d. Morbid formations, 9 90-96.... iii. 992 e. Haemorrhage into the spleen, 9 97 — 993 /. Bibliography and References.. — 995 iv. Lesions of the Pancreas — 4 a. Alterations consequent upon in- flammation, 9 12-19 — 5 b. Those not necessarily depend- ing upon inflammation, 9 23 -36 — 7 4 c. Bibliography and References.. — 11 v. Organic Lesions of the Mesen- tery and Mesenteric Glands, 9 1, et seq ii. 983-9 a. Alterations of the mesentery consequent on inflammation, 9 6 — 983 b. Lesions of the mesenteric glands, 9 8-12 — ibid. c. Scrofulous and other lesions of these glands, 9 24, 36 — 986 d. Bibliography and References.. — 991 vi. Structural Changes of the Urinary Apparatus. A. Alterations of the Kidneys, 9 25, et seq — 725 a. Changes consequent upon in- flammations, 9 26-38 —725-8 b. Lesions consequent upon gouty, rheumatic, asthenic, and con- secutive nephritis, 9 49, 51, 54, 56, 59 -730-2 c. Appearances after death from cachectic nephritis, or gran- ular disease of kidneys, 9 99- 109 -741-3 d. Lesions consequent upon in- flammation of the pelvis and calices of the kidney, 9 174, et seq —758-63 e. Alterations of the tissues sur- rounding the kidneys, 9 202 -207 — 763 d. Alterations of the supra-renal bodies, 9 1, ct seq iii. 1565 /. Congestion, hyperaemia, and anaemia of, and haemorrhage from, the kidneys, 9 219-226 ii. 765 g. Atrophy, hypertrophy, soften- ing, and induration, 9 227- 230 — 766 h. Morbid secretions and forma- tions in the substance of the kidneys, 9 231-241 — 767 i. Hydatids, acephalocysts, and worms in the kidneys, 9 243 -244 — 768 k. Changes in the calices, pelvis, and ureters, 9 245, 246 — 770 l. Alterations of the blood-vessels and nerves of the kidneys, 9 247-249 — ibid. Concretions or calculi in the kidneys, 9 122, et seq. iii. 1339 to. Absence and mal-positions of the kidneys, 9 251-253 ii. 770 n. Bibliography and References.. — 771 B. Alterations of the Urinary Bladder, 9 62-110 iii. 1304-13 a. Changes consequent upon in- flammation, 9 63-78 —1304-6 b. Malignant and other forma- tions, 9 104-106 iii. 1312 c. Abnormities of the bladder,§ 110 — 1313 d. Calculi in the urinary bladder, 9 122, et seq — 1339 e. Bibliography and References.. — 1313 C. Lesions of the Prostate Gland, 9 20, et seq — 509 a. Enlargement and induration, 9 20-22 — ibid. b. Tubercular deposits and ulcera- tion, 9 23-28 — 510 c. Hamnorrhage from, 9 29 — ibid. d. Malignant deposits in the, 9 30 -32 — 511 e. Calculi in, and concretions of the veins of, 9 33-38 — ibid. f. Bibliography and References.. — 512 vii. Alterations of the Sexual Or- gans of the Female. 1st. Of the Mammae, 9 17-70 ii. 930-8 A. Lesions caused by Inflammation, 9 17-35 — 930 a. Lesions consequent upon in- flammation of the nipple, § 17 — ibid. b. From acute inflammation of the mammae, 9 20 — 931 c. Abscess of the mammae, 9 21-25 — ibid. d. Swelling from chronic inflam- mation of the lactiferous tubes, 9 32 — 932 B. Organic Lesions of the Mammas, occurring independently of In- flammation, § 35 — 933 a. Haemorrhagic congestion, <$36 — ibid. b. Atrophy and hypertrophy, 9 38, 40 — ibid. c. Scrofulous and adipose tu- mours, 9 42-44 — 934 d. Chronic mammary tumour, 9 46-48 — ibid. c. Irritable tumour, &c., 9 52-55 — 935 /. Cartilaginous and ossific tu- mour, 9 60 — 936 g. Cystic and hydatidic tumour, 9 61-63 — ibid. h. Malignant disease of the mam- mae, 9 70 — 938 Bibliography and References.. — ibid. 2d. Alterations of the Uterus and its Appendages. A. Lesions of the Ovaria, 9 4, et seq. iii. 1061 a. Changes consequent upon in- flammation, 9 12-16 — 1063 b. Organic lesions independent of inflammation, 9 21-42 — 1064 Bibliography and References.. — 1067 B. Abscess and other Lesions of the Fallopian Tubes, 9 72-80 — 1375 Gonorrhoeal lesions of the uterine appendages, 9 122 — 1264 C. Alterations of the Uterus, 9 l, et seq — 1361 a. Changes consequent on inflam- mation of the neck and mouth of the uterus, 9 21-48 —1365-70 b. Lesions from inflammations of the body of the uterus, &c., 9 49-68 -1371-3 c. Enlargement of the uterus, 9 69-72 — 1374 d. Syphilitic and gonorrhoeal al- XXXV XXXVI terations of the cervix uteri, § 123 .. iii. 1387 e. Displacements of the uterus, § 126 — ibid. (a) Descent of the uterus, § 128 — ibid. (b) Flexions and other devia- tions, § 139 — 1390 f. Inversion of the uterus, § 151. — 1394 g. Of polypi of the uterus, § 158. — 1396 h. Of fibrous and other tumours of the uterus, § 164 — ibid. i. Tubercular and fatty degenera- tion of the uterus, § 187 — 1402 k. Cancerous or malignant dis- eases of the womb, § 190-198—1402-5 Bibliography and References.. — 1412 3d. Alterations of the Vagina and Vulva, § 1, et seq — 1428 A. Lesions consequent upon Inflam- mation of the Vagina, § 8 — 1429 a. Specific inflammations, ulcera- tions, abscess, &c., of the va- gina, &c., § 12-16 —1430-1 b. Various organic lesions, § 17,18 — 1431 B. Alterations of the Vulva caused by Inflammation, § 21-46 —1431-5 ft. Specific inflammations, ulcera- tions, and abscess of the vul- va, § 38-48 —1434-6 b. Other organic changes, § 49... — 1436 Bibliography and References to Arts. Vagina and Vulva.... — ibid. viii. Alterations of the Peritone- um, § 3, et seq — 73 A. Lesions consequent upon acute sthenic peritonitis, § 5, et seq., 81 —73,84 B. Partial peritonitis with reference to its seats, § 12-18 — 74 C. Omental peritonitis, or omentitis, § 16-18 • — 75 D. General peritonitis, forms and le- sions caused by, § 19-35 — ibid. E. Chronic peritonitis, simple and tu- bercular, § 37-57, 111 -78-89 F. Peritonitis in children, § 58-70... — 82 a. The early changes consequent on sthenic peritonitis, § 81.. — 84 b. Plastic exudations and false formations, § 82-90 — 85 c. Lesions consequent on asthen- ic peritonitis, § 97 — 87 d. Alterations produced by chron- ic peritonitis, § 99 — ibid. e. Chronic tubercular peritonitis, primary and consecutive, § 111-115 — 89 /. Effusions and various forma- tions in the peritoneum, § 116 — 90 g. Other organic lesions of the peritoneum, § 164-181 — 100 h. Bibliography and References.. — 105 ix. Lesions of Serous and Synovi- al Membranes, § 1, et seq — 858 A. Certain consecutive changes of their lesions, §1 — ibid'. B. Alterations of synovial mem- branes, § 3 — ibid. C. Bibliography and References — 859 x. Alterations of the Respirato- ry Organs. CONTENTS—Organic Lesions of Organs. 1st. Lesions of the Larynx and Tra- chea, § 80, et seq : ii. 792 a. Alterations consequent upon inflammation, § 80-83 — ibid. (a) Lesions of the epiglottis, &c., § 76 — 791 (b) (Edema, puriform infiltra- tion, ulceration, ossifica- tion of the cartilages, ne- crosis, fistulffi, &c., of the larynx and trachea, &c., § 81-84 — 792 b. Foreign bodies lodged in the larynx, &c., § 112 — 803 c. Tumours, &c., compressing the windpipe, § 124 — 806 d. Bibliography and References.. — 807 2d. Alterations of the Bronchi, § 2-25 i. 296 a. Alterations of the mucous mem- brane, § 3-8 — ibid. b. Alterations of the secretions of the air-tubes, § 9-14 — 298 c. Lesions of the cellular, fibrous, and cartilaginous tissues of the air-tubes, § 15-17 — 299 d. Alterations of the calibre of the air-vessels, § 18-20 — 300 (a) Dilatation of the bronchi, § 19, 106 — ibid. (b) Diminished calibre, § 18... — ibid, c. Ulceration of the bronchi, § 108 — 321 f. Bibliography and References.. — 323 3d. Lesions of the Lungs, § 3, 27, et seq ii. 878 a. Alterations consequent on sthenic inflammation, § 3, 27 -38 — 881 b. Lesions following asthenic in- flammations, § 67-69 — 887 c. Changes following associated or complicated pneumonia, § 69, 73-79 — ibid. d. Emphysematous lesions of the lungs, § 137, 155-159 — 900 e. (Edema of the lungs, § 166, 167 — 905 /. Atrophy and hypertrophy, &c., § 170, 171 — 906 g. Abscess and gangrene, § 172, 173 — 907 h. Tubercles in the lungs, § 176, ii. 910; and § 1-7, et seq iii. 1188 i. Malignant formations in the, § 177-181 ii. 910 k. Hemorrhage into the lungs, &c., § 186-192 — 911 l. Bibliography and References.. — 912 4th. Lesions of the Pleura, § 112, et seq iii. 318 A. Forms and seats of pleurisy, § 41, et seq — 304 B. Partial pleurisy with adhesions, l) 51 — 307 C. Pleurisy with affusion, § 52 — ibid. D. Pulmonary, costal, diaphragmatic, and mediastinal pleurisies, § 54 — ibid. E. Pleurisy connected with pneumo- nia—Pleuro-pneumonia, § 148 -152 — 326 F. Double pleurisy, §61 — 308 G. Chronic pleurisy and empyema, § 63 — ibid. H. The early changes consequent upon pleuritis, § 112-115 — 318 I. Consecutive products of pleuritis, § 115 iii. 319 a. Plastic organizable exudations, 116, 117 — ibid. b. Purulent or empyemic affusion, 118, 119 — 320 c. Tubercular pleuritic products, $ 120, 124 -320-333 d. Sanguineous and gaseous prod- ucts, (} 121, 206, 207 -321-337 e. Organization or pleuritic exu- dations and adhesions of op- posite surfaces, &c., 123... — 321 /. Fatty degeneration of bands of adhesions, and other altera- tions in the pleura, § 100,210—316, 338 g. Ulcerations, perforations, and gangrene, § 201-203 — 336 h. Watery and other affusions into its cavity, 204 — 337 i. Cartilaginous and osseous for- mations in the, § 208 — ibid. k. Malignant or cancerous degen- erations, § 212 — 338 l. Bibliography and References.. — 340 xi. Lesions of the Mediastinum, § 7, et seq ii. 952 a. Alterations consequent upon inflammation, § 7, 8 — ibid. b. Abscess of the mediastinum, § 9 — ibid. c. Thickening and other organic changes, § 15, 16 — 953 d. Bibliography and References.. — ibid. xii. Alterations of the Diaphragm, § 12, et seq i. 600 a. Lesions produced by inflamma- tion, § 12 — ibid. b. Perforations of the diaphragm, f) 17 — 601 c. Other lesions of, § 20 — ibid. d. Spasm, ruptures, &c., § 19, 21 —601-2 c. Bibliography and References.. — 602 xiii. Alterations of the Heart and Pericardium ii. 193 A. Lesions consequent upon Inflam- mation, f) 65 — 209 a. Inflammatory lesions of the en- docardium and valves, § 65- 67 -209-10 b. Lesions of the valves and ori- fices caused by chronic in- flammation, 67, 68 — 210 c. Lesions of the pericardium caused by acute inflammation, t) 85-88 — 214 d. Lesions by chronic inflamma- tion, t) 89-94 — 215 e. False membranes and adhe- sions, § 107 — 220 f. Inflammatory lesions of the substance of the heart, § 111 -120 -220-3 g. Inflammatory lesions of the heart and pericardium of chil- dren, f) 150 — 233 Bibliography and References to Inflammation of heart and pericardium — 234 B. Structural Changes of the Heart and Pericardium not necessarily caused by Inflammation, l) 154- 276 -235-262 CONTENTS—Organic Lesions of Organs. a. Hypertrophy of the heart, § 156 ii. 235 (a) Simple hypertrophy, 157 — 236 (b) Hypertrophy with dilata- tion, § 158 — ibid. (c) Concentric hypertrophy, § 159 — ibid. b. Complicated hypertrophy, 167 — 238 c. Consequences of hypertrophy of the heart, $ 169-173 -239-43 d. Dilatation of the chambers of the heart, § 187 — 244 e. Dilatation of the orifices, § 191 — ibid. f. Atrophy of the heart, § 206.... — 248 g. Contractions of the cavities and orifices, § 202 — 249 h. Alterations of the consistence and colour of the heart, <5 215 — ibid. i. Serous and sanguineous infil- tration, § 222 — 250 k. Fatty degeneration and obesity of the heart, § 224 •— ibid. l. Adventitious formations in the heart and pericardium, § 231 — 252 m. Malignant formations, &c., 6 238 — 253 n. Polypous concretions in the cav- ities of the heart, § 243 — 254 o. Ruptures of the heart, § 251... — 257 p. Alterations of the blood-vessels of the heart, 266 — 260 q. Communications between the sides of the heart, § 267 — ibid. r. Displacement and preternatu- ral positions, § 273 — 262 Bibliography and References to structural lesions of the heart —262-7 xiv. Alterations of the Brain and of its Membranes, § 1-223..i. 253-295 A. Morbid states of the membranes of the brain, § 3-46 — 254 a. Of the dura mater, § 4-10 — ibid. b. Of the arachnoid of the dura mater, § 11-20 — 255 c. Changes of the arachnoid and pia mater, § 21-32 — 257 d. Of the choroid plexus, pia ma- ter, &c., § 33-36 — 259 B. Lesions of the sinuses of the dura mater and of the vessels of th« brain, $ 37-46 — 260 C. Alterations of the substance of the brain, § 47 — 261 a. Lesions consequent upon in- flammation, § 48 — ibid. b. Suppuration and abscess, 50 -84 — 262 c. Ulcerations and sphacelation of the brain, § 65-67 — 265 D. Softening of the brain, § 68-83... — ibid. E. Hsemorrhage into the brain, § 84 — 268 F. Hypertrophy and atrophy of the brain, § 86-102 — 269 G. Induration of the brain, § 102-109 — 271 H. Morbid growths in the brain, § 110-128 — 273 a. Tubercular formations, § 111- 115 — ibid. b. Other tumours and cysts, § 116 -123 — 274 c. Hydatids, &c., § 124 — 276 d. Malignant or cancerous tu- mours, § 125-128 — ibid. XXXVII XXXVIII I. Rupture and laceration of the brain, § 129-131 i. 277 K. Ecchymoses and alterations of col- our, § 132,133 — 277 Bibliography and References — 295 xv. Alterations of the Spinal Cord and of its Membranes, § 120 iii. 956 A. Lesions consequent upon inflam- mation of the membranes of the spinal cord, § 137, et seq., and 178 —958, 966 B. Alterations caused by inflamma- tion affecting the tissues of the cord, § 154 and 181 —961, 966 C. Organic lesions of the spinal cord, § 182 — 967 a. Softening and induration of the tissues of the cord, § 185 — — ibid. b. Hemorrhage into or from the spinal cord—Apoplexy of the cord, § 190 — 968 c. Tumours of various kinds in qr near the spinal cord, § 199... — 969 d. Malignant or cancerous forma- tions, § 202 — ibid. D. Bibliography and References — 973 VII. Sympathies and Sympathetic Association of Disorder— Morbid Sympathies. Definitions of Sympathies with Re- marks, Sec., § 1-13 —1027-8 Preliminary Anatomical and Phys- iological Observations, § 17-20 — 1030 A. The great extent and importance of the ganglial or the organic nervous system, § 20-23 — ibid. B. Division of the nerves into, 1st. The organic or ganglial; 2d. Those of special sensation; and, 3d. Those of volition or motion, § 24 — ibid. C. The connexions subsisting be- tween the organic and cerebro- spinal nervous systems, § 24-29 — ibid. i. Inquiry into the Media by which Sympathetic and Symptomatic Phenomena are evolved, and Morbid Conditions are asso- ciated, § 36-43 — 1033 1st. Direct or immediate Sympathies, §36 — ibid. A. Direct communications by means of ganglial nerves, § 37 — 1034 B. Influence of ganglia on different organs or parts, § 37 — ibid. C. By direct communications by means of the cerebro-spinal nerves of sense and motion, § 37 — ibid. D. By continuity of surface or tissue, §37...... — ibid. E. By contiguity of organs and struc- ture, § 37 — ibid. 2d. Indirect or mediate Sympathies, § 38 — ibid. A. By vascular communications, § 38 — ibid. B. By states of the circulating fluids, § 39 — ibid. a. The chyle and other absorbed fluids, § 39 — ibid. b. The blood, § 39 — ibid. C. Owing to the conditions of the se- cretions and excretions, § 39... — ibid. CONTENTS—Morbid Sympathies. a. By the various secretions, § 39 iii. 1034 b. By the excretions, § 39 :.. — ibid. 3d. Reflected Sympathies, § 40 — ibid. A. Reflected from nervous ganglia, often attended by spasm and al- tered sensibility of involuntary parts, <5> 40 — ibid. B. Reflected through the media of.the ganglionated roots of the spinal nerves, and affecting the move- ments of voluntary parts, $ 41. — ibid. C. Reflected through the medium of the spinal cord, and inducing morbid sensations or motions, or both, § 42 — ibid. D. Reflected through either the me- dulla oblongata or the brain, or both, and causing various dis- orders of sensation, of percep- tion, and voluntary action, &c., § 43 — ibid. ii. Circumstances influencing the Character, Number, and In- tensity of Sympathetic Phe- nomena, § 44 — 1035 a. Race and temperament, § 45 — ibid. b. Habit of body, § 47 — ibid. c. Sex, § 48 ; — ibid. d. Age, §49 — ibid. e. Physical power, § 50 — ibid. f. Occupations, &c., §51 — ibid. iii. Special Consideration of Sym- pathies AND OF ASSOCIATED Morbid Phenomena, § 52 — 1036 1st. Associated Sympathies or Affec- tions of the Digestive and Assim- ilative Organs, § 53-62 — 1036 A. The sympathy between the digest- ive organs and the functions of the heart and lungs, § 63-69...—1038-9 B. The sympathies between the di- gestive organs and the brain, and organs of sense, § 70 — 1040 C. Between the organs of motion and the digestive organs, § 72 — ibid. D. The sympathies of the reproduc- tive organs with the functions of digestion, § 73 — ibid. 2d. The Sympathetic and Symptomat- ic Phenomena resulting from the states of the Circulating and Res- piratory Organs, § 74 — ibid. a. The organization of the blood considered, § 76-82 —1041-2 b. Sources of the contamination of the blood, § 83-88 —1042-3 c. Sympathies resulting from the states of the blood, § 92 — 1044 d. The sympathetic association of disorder owing to the quality of the blood, § 93-100 — ibid. e. Importance of observing morbid conditions of the blood in con- nexion with states of the or- ganic functions, § 97-100.... — 1045 f. The importance of considering the quantity of the blood in relation to the area of the blood-vessels, §101 — 1046 g. The sympathetic association of disorder arising from the quantity of the blood, or from CONTENTS—Symptomatology. XXXIX the want of correspondence between the mass of blood and the area of the blood-ves- sels, and the state of vital force, § 101-107 iii. 1046-7 h. The several sources and condi- tions from which alterations of the vascular system and blood proceed, causing mor- bid sympathies and associa- ted diseases, § 107-113 — 1047 i. Maladies evincing these sources, morbid conditions, and asso- ciations, § 114-125 —1048-9 k Sympathetic complications of disease from organic lesions of the heart, § 126-128 — 1050 l. Sympathies between the states of the circulation and the di- gestive organs, § 128 — ibid. m. Sympathies between the cardi- ac and pulmonary circulation and the brain, § 130 — 1051 n. Between the circulating, nerv- ous, and muscular systems, § 133 — 1052 3d. Sympathies of Sensation and asso- ciated states of Morbid Sensibil- ity and Motion, § 134—136 — ibid a. Associated states of morbid sen- sation, § 134 — ibid. b. Sympathetic disorders of ani- mal motion, § 137 — 1053 4 th. Sympathies and associated Dis- orders evolved by the Reproduc- tive Organs, § 139 — ibid. Bibliography and References— — 1055 VIII. Semeiology or Symptomatolo- gy, comprising General Di- agnosis and Prognosis, § 1— 220 -1056-1099 Preliminary remarks respecting Symp- tomatology, or Semeiology, com- prising General Diagnosis and Prognosis, § 1-4 — 1056 i. Signs and Symptoms appertaining to the Attitude and Appearances of the Body, and of the Animal Functions, § 4-41 —1057-65 A. Of the attitude and general appear- ance of the body, § 4-7 — 1057 B. The expression of the face and state of the features, § 7-16 .... — ibid. C. The external examination of the chest, § 1-9 i. 365 a. Of deformities of the chest, § 1 -12 — 367 b. Of auscultation of the chest, § 1-41 —199-207 D. The external examination of the abdomen, § 1-26 — 1-5 E. The states of the general surface of the body, § 16-25 iii. 1059 F. The perspiratory functions, § 25- 36 — 1062 G. The state of nutrition of the body, § 36-41 — 1064 H. The functions and organs of vol- untary motion, § 41-55 — 1065 ii. The Signs and Symptoms furnish- ed by the Senses and Nervous System of Animal Life, § 55-95—1067-75 A. The signs presented by the eyes, § 57-74 .. iii. 1068 B. The signs furnished by the sense and organs of hearing, <) 74-76 — 1071 C. By the sense of smelling, § 76-78 — ibid. D. By the sense of taste, § 78-80.... — ibid. E. By the sense of touch, § 80, 81... — 1072 F. The signs furnished by sensation and sensibility, § 81-88 — ibid. a. Diminished and exalted sensa- tion, § 81-84 — ibid. b. Perverted sensibility, §‘84-87. — ibid,. c. Pain and its various modifica- tions, § 88-94 — 1074 G. The signs evinced by the mental manifestations, &c., § 95 — 1075 iii. The Signs and Symptoms of the Digestive Functions and Organs, § 96-147 — 1075 A. Of the mouth, teeth, and gums, § 97-101 — ibid. B. The signs furnished by the tongue, § 101-116 — ibid. C. Bjfcthe salivary secretions, § 116— 118 — 1078 D. By the throat and fauces, § 118- 121 — ibid. E. By deglutition, &c., § 121-123... — 1079 F. By the desire of food and drink, § 123-129 — ibid. G. The symptoms connected with the stomach, § 129-132 —1080-1 a. Of flatulence, eructations, &c. b. Retchings and vomitings — 1505 H. Furnished by the intestinal func- tions and evacuations, § 132- 147 -1081-4 I. By the state and appearances of the alvine evacuations, § 147-152.. — 1084 a. As respects the biliary secretion and excretion, § 154 — 1085 b. As regards the intestinal secre- tions and excretions, § 156- 158 — ibid. c. Excretion and excretions, § 1.. i. 975 K. Crises and critical days, described — 513 Bibliography and References to.. — 519 iv. The Signs and Symptoms connect- ed with the Circulating Systems, § 159-170 iii. 1086 A. The physical signs and symptoms related to the heart, &c., § 160 — ibid. B. Auscultation of the heart and per- icardium, § 25, ct seq i. 204 C. Congestion of the cavities of the heart, § 162 iii. 1087 D. Signs and symptoms connected with the arterial system, § 163. — ibid. E. Semeiological notices of the pulse, § 16-37 — 599 a. As to the development of the pulse, § 17-23 — 600 b. As to the rhythm and frequency of the pulse, § 24-36 — 601 F. Signs connected with the venous system, § 166 — 1088 G. Signs furnished by the lymphatic vessels and glands, § 169 — ibid. v. Signs and Symptoms of the Respi- ratory Function, § 170-208 — ibid. A. Of the signs furnished by the va- rious states of respiration, § 170 -185 — 1089 XL B. Of the states, temperature, and odour of the expired air, § 186 -188 iii. 1092 C. Of auscultation, of respiration and voice, l) 16-24 i. 200 D. Signs furnished by the states of expectoration, <$ 189-208 iii. 1092-6 a. Mucus, muco-purulcnt,pus, and ichorous matters, &c., t) 190 -196 -1092-3 b. Blood in various states and as- sociations, t) 197-200 —1093-4 c. Fibrinous, membraneous, and tubular exudations, § 200.... — 1094 d. Earthy or calcareous concre- tions, <) 201 — ibid. e. States of expectoration in spe- cial diseases, § 202-205 — ibid. f. The act and manner of expec- torating, f) 205 — 1095 g. Yawning, sighing, sneezing, laughing, &c., as signs of disease, t) 206-208 — ibid. vi. Signs and Symptoms furnished by the Urinary and Sexual Organs, $ 209-218 — 1096 A. Signs furnished by the states of the urine, 210 — ibid. B. Signs furnished by the excretion of the urine, t) 210-218 — ibid. C. Signs furnished by deposits and other states of the urine. See Urine, § 1, et seq —1314-55 D. Signs furnished by the sexual or- gans, tj 219, et seq — 1097 E. Bibliography and References to Symptomatology — 1099 and to Abdomen, Ausculta- tion, Chest, Pulse, Urine. Symptomatology and Diagno- sis are farther elucidated by an account of the Several Dis- eases which may be Feigned, and of the Means of their De- tection. (See Art. Feigning Disease, &c.) i. 1029 Feigning Disease — ibid. 1. Pretended; 2. Artificially excited; 3. Exaggerated; and, 4. Artifi- cially increased, diseases, § 1-5... — ibid. Abdominal Tumours, Abortion, Absti- nence, i) 6-8 — 1030 Blindness, Cachexia, Cancer, Catalep- sy, Concretions, &c., § 9-13 — ibid. Deafness, Deaf-dumbness, Delivery, Dropsy, Dysentery, rnd Chronic Diarrhoea, § 14-17 — 1031 Epilepsy, Faeces, incontinence of, Fainting, Fevers, &c., § 19-22 — ibid. Gastric Affections, Haemorrhoids, Hae- morrhages from the Stomach or from the Lungs, l) 23-25 — 1032 Heart Affections, Hepatic Disorders, Hernia, Hydrocele, Hysteria, § 26 -29 — ibid. Jaundice, Insanity, Lameness, Neu- ralgia and Rheumatism, Ophthal- mia, $ 30-38 — 1033 Palsies, Polypi, Pregnancy, Pulmo- nary Diseases, Affections of the Rectum, § 39-43 — 1035 Rheumatism and Lumbago, Sight, dc- CONTENTS—General Therapeutics. fects of, Somnolency and Sopor, § 44-46 i. 1036 Tympanitic and Emphysematous Af- fections, Tumefied Leg, &c., §47,48 — ibid. Ulcers, Urine, incontinence of, Bloody Urine, Urinary Calculi, and Gravel, $ 49-52 _ 1037 Uterine Diseases, Varicose Veins, Wounds, &c., § 53-55 — ibid. Bibliography and References — 1038 GENERAL THERAPEUTICS, § 1, et seq iii. 1128-35 i. Circumstances retarding the ar- rival at Just Principles in Therapeutics, § 4-12 —1129-31 A. Limited views in pathology, &c., $4 — 1129 B. The neglect of the states of vital endowment, § 5 — ibid. C. Undue importance attached to novel views, &c., § 6 — ibid. D. Wrong estimates of particular medicines and agents, (j 7 — 1130 E. The license allowed to imposture, § 8 — ibid. F. The selfish policy of members of the profession, <5 9 — ibid. G. The neglect of the physiological action of medicines, § 10 — 1131 H. The prejudices of patients, &c., § 11 — ibid. I. Medical jealousies and contentions, &c., 12.... — ibid. ii. Therapeutical Principles, &c., t) 13-69 —1131-44 1st. The fundamental Principles of Therapeutics, § 13-24 —1131-3 A. To endeavour to interpret aright the operations of nature, § 14.. — 1131 B. To ascertain the causes, the acces- sion, the course, and the circum- stances influencing the progress of the disease, &c., § 15-22 .... — ibid. C. To determine the pathogeny of disease, &c., § 23 — 1133 D. To remove all predisposing, ex- citing, and concurring causes, § 24 — ibid. 2d. General Therapeutical Principles and Precepts, § 25-36 —1133-5 A. Of indications and contra-indica- tions in the treatment of dis- ease, <$ 25 — 1133 B. To employ the most suitable means for the fulfilment of intentions of cure, § 26 — ibid. C. To observe closely the states of vital power and of vital manifes- tations, &c., $ 27 — 1134 D. To estimate the influence of tem- perament, diathesis, and other circumstances of the patient, &c., § 28 — ibid. E. To select the means of cure with strict reference to their modes of action, &c., $ 29-36 —1134-5 3d. Special Therapeutical Principles, &c., $ 37 — 1135 A. The restoration of nervous and vi- tal power when primarily de- pressed, &c., § 38-41 —1135-7 B The promotion of the several se- creting and excreting functions of the depurating processes, § 42-48.. iii. 1137-8 C To equalize the vital and vascular actions throughout the frame, $ 49 — 1139 D. To moderate or restrain excessive secretion and excretion, &c., § 50 — ibid. E. To moderate or allay nervous ex- citement, unnatural function, or irregular actions, § 52 — ibid. F. To allay or remove vascular dis- order, § 53 — 1140 G. To prevent, correct, and counter- act morbid states of the blood, 55-7 — ibid. H To allay morbid irritation, &c., § 58 — 1141 I. To alter or correct diseased states of individual structures, &c., § 59 — ibid. K. To prevent or remove exhaustion in its various forms, &c., § 60. — 1142 L. To remove congestions of blood, &c., § 61 — ibid. M. To support vital resistance to the extension of disease, and to en- able it to throw off parasitical formations, &c., () 62-4 — ibid. N. To restore impaired or lost func- tions, § 65 — ibid. O. To palliate urgent or distressing symptoms, &c., § 67 — 1143 P. To excite and direct the mental emotions, to the prevention and removal of disease, § 68 — ibid. iii. The Principal Classes of Hygien- ic and Therapeutical Agents—1144-8 (See, in connexion with these, General Hygiene.) 1st. Psychical or Mental Remedial In- fluences — 1144 A. Those furnished through the media of the senses — ibid. a. Affections of mind induced by pleasant odours and tastes.. — ibid. b. States of mind caused by vis- ion . — ibid. c. Affections of mind from sounds, voice, speech, &c... — ibid. d. States induced by the sense of touch — ibid. B. Influences produced by the in- tellectual powers — ibid. C. Influences arising from the mor- al affections of mind — ibid. 2d. Hygienic Agents and Influences.. — ibid. A. Food and drink — ibid. B. Air and locality — ibid. C. Modes of exercise, &c — ibid. D. Climate and change of climate. — ibid. 3d. Medicinal Agents.—Medicines ap- plied to the Frame —1144-8 A. Modes in which medicines are employed, &c — 1144 B. The action of medicines — ibid. C. The modes in which, and the channels through which, medicines act — ibid. D. The general effects of medicines — 1145 Classification of Medicines ac- CONTENTS—Arrangement of Therapeutical Agents. XLI CORDING TO THEIR SPECIAL Operations iii. 1145-8 Class I.—Abstracting the Animal Heat, or depressing the Cal- orific Process — Refriger- ants _ 1145 A. External refrigerants — jbid. B. Internal refrigerants-. — ibid. Class II —Depressing, Suppress- ing, &c., Involuntary" and Voluntary Motions—Seda- tives, &c _ ibid. A. Mental sedatives — ibid. B. Physical or medicinal sedatives — ibid. Class III.—Softening or Liquefy- ing Agents—Dissolvants... — ibid. Class IV.—Astringing the Tissues AND INCREASING THE VlTAI. Cohesion of the Structures —Astringents and Tonics.. — ibid. A. Vegetable astringents, &c — ibid. B. Bitter tonics — ibid. C. Astringent and bitter tonics.... — ibid. D. Aromatic tonics — ibid. E. Acid tonics — ibid. F. Alkaloid tonics — ibid. G. Metallic tonics — ibid, Class V.—Irritating the Struc- tures— Irritants—Corro- dants — ibid. A. Mineral irritants and corrodants — ibid. B. Vegetable irritants and corro- dants — ibid. C. Animal irritants — ibid. D. Physical and mechanical irri- tants — ibid. Class VI.—Relaxing the Tissues AND LOWERING IRRITABILITY Demulcents—Emollients ... — ibid. A. Aqueous emollients — ibid. B. Mucilaginous emollients — ibid. C. Amylaceous emollients — ibid. D. Saccharine emollients — ibid. E. Albuminous emollients — ibid. F. Gelatinous demulcents — ibid. G. Oleaginous emollients — 1146 Class VII.—Stimulating or excit- ing the Vital Manifesta- tions — Stimulants — Excit- ants — ibid. A. Condimental and aromatic stim- ulants — ibid. B. Resinous and balsamic stimu- lants — ibid. C. Gum resins — ibid. D. Camphoraceous stimulants — ibid. E. Ammoniacal and other stimu- lants — ibid. F. Alcoholic stimulants — ibid. G. Calorific and electrical stimu- lants — ibid. Class VIII.—Augmenting the Se- cretions and Excretions— Evacuants—Depurants — ibid. A. Increasing the secretion from the nares—Errhines — ibid. B. Augmenting the salivary secre- tions—Sialagogues — ibid. C. Provoking the discharge of the contents of the stomach— Emetics, vomits — ibid. XLII CONTENTS—Special Pathology and Therapeutics. D. Producing alvine evacuations— Purgatives—Cathartics iii. 1146 a. Laxatives, or mild and gentle aperients — ibid. b. Cooling or saline purgatives.. — ibid. c. Mild purgatives — ibid. d. Chologogue or alterative purg- atives — ibid. e. Drastic or acrid purgatives ... — ibid. E. Promoting the excretion of urine —Diuretics — ibid. a. Acid and saline diuretics — ibid. b. Irritant diuretics — ibid. c. Sedative or depressing diuret- ics — ibid. d. Stimulant diuretics — ibid. F. Increasing cutaneous transpira- tion—Diaphoretics — ibid. a. Diluent or aqueous diapho- retics — ibid. b. Saline, antimonial, or cooling diaphoretics — ibid. c. Opiate diaphoretics — ibid. d. Warm or stimulating diapho- retics — ibid. G. Promoting the discharge from the bronchi and trachea — 1147 H. Exciting the catamenial dis- charge—Emmenagogues — ibid. a. Purgative emmenagogues — ibid. b. Diuretic and stimulating em- menagogues — ibid. c. Uterine emmenagogues — ibid. Class IX.—Exciting the Cerebro- Spinal Nervous System — Nervous and Muscular Ex- citants — ibid. Class X.—Irritating and Depress- ing Medicines—Acro-Seda- tives — ibid. A. Mineral acro-sedatives — ibid. B. Vegetable acro-sedatives — ibid. Class XI.—Irritating and Alter- ative—Acro-Alterants — ibid. A. Mineral acro-alterants — ibid. B. Vegetable acro-alterants — ibid. Class XII.—Altering Vital Ac- tions — Alterants — Deob- struents — ibid. A. Mineral deobstruents — ibid. B. Vegetable deobstruents — ibid. C. Animal alterants and dcobstru- ents — ibid. Class XIII.—Stupefying or Nar- cotizing the Nervous Sys- tem—Narcotics—Hypnotics —Anaesthetics — ibid. A. Inhaled gases and vapours — ibid. B. Vegetable narcotics — ibid. Class XIV.—Affecting the Blood and Capillary Vessels — Hhlmato • Cathartica — IL®- mapharmaca — ibid. A. Altering the appearance and condition of the blood — Blood-medicines — ibid. B. Constringing the capillaries and altering the blood circulating in them — ibid. Class XV. — Inducing Contrac- TIONS OF THE UTERUS PAR- TURIENTS—Parturifacients, iii. 1148 Class XVI. — Expelling Worms, AND PREVENTING THEIR FOR- MATION—Anthelmintics — ibid. A. Mechanical anthelmintics — ibid. B. True anthelmintics—Medicines poisonous to worms — ibid. C. Purgative anthelmintics — ibid. D. Medicines preventing the gen- eration of worms — ibid. Class XVII.—Preventing a Solu- tion of the Vital Cohesion of the Tissues — Antisep- tics ; also, Class IV — ibid. A. Mineral antiseptics — ibid. B. Vegetable antiseptics — ilid. Class XVIII.—Neutralizing Acid- ity—Removing and prevent- ing Fermentation—Sorbefa- cients — ibid. A. Direct Antacids or anti-fer- ments — ibid. B. Indirect Antacids or anti-fer- ments — ibid. Class XIX.—Destroying, Remov- ing, or Counteracting In- fections, Miasms, &c.—Dis- infectants — ibid. A. Destructive disinfectants — ibid. B. Also, Classes IV., VII., and XVII., by their direct and in- direct influences — ibid. Remarks on the classification, &c — ibid. Bibliography and References—1149-50 SPECIAL PATHOLOGY AND THERAPEU- TICS, OR THE SYMPTOMS, NATURE, AND TREATMENT OF SPECIAL DIS- EASES. First Class.—Disorders consisting chiefly of Impairment of Vi- tal Force.* Order I.—Impaired Function of the Digestive Organs. Genus 1st. Impaired Function chiefly of the Stomach. Spec. 1st. Relaxation of the uvula and palate—Definition — 1 Symptoms and causes... — ibid. Treatment — ibid. Spec. 2d. Indigestion or dyspepsia, definition of. ii. 377 Description of symptoms and relations and con- sequences of — 378 Causes and pathology of — 383 Treatment of — 388 Various means of cure advised for — 390 Diet and regimen for.... — 393 Bibliography and Refer- ences — 398 Spec. 3d. Gastric flatulence and * Vital force, vital power, vital energy, are used as sy- nonymous terms ; and organic nervous force, p iwer, and energy imply the display of vital force by means of the organic or ganglial nervous system. Vital functions are the manifestations of vital force by the organs or struc- tures of the body, the discharge of the offices which are destined to be performed by the organs and tissues of the frame. fermentation, defini- tion and description of i. 1234 Primary and symptomat- ic forms of — ibid. Causes, pathology, and treatment of — 1235 Bibliography and Refer- ences of — 1238 Spec. 4th. Rumination and regur- gitation of food, defini- tion of. iii. 716 History and symptoms of — ibid. Causes and treatment of — 719 Bibliography and Refer- ences to — ibid. Spec. 5th. Pyrosis, definition and symptoms of — 615 Diagnosis, causes and treatment of — 616 Bibliography and Refer- ences — 618 Spec. 6th. Apepsia, or complete loss of appetite and of digestive power, symp- tomatic of many dis- eases — 1080 Genus 2d. Disorder of the Intestinal Function arising chief- ly from depressed vital power. Spec. 1st. Duodenal indigestion, or impaired function of the duodenum i. 702 Pathology of — ibid. Treatment of — 793 Spec. 2d. Costiveness and Consti- pation, definition, &c., of — 471 Causes and pathology of — 472 Consequences and ter- minations — 474 Treatment and remedies for — 475 Bibliography and Refer- ences — 479 Spec. 3d. Inaction or imperfect vi- tal function of the cae- cum, described — 329 Pathology of — ibid. Symptoms of. — 330 Treatment of. — 331 Spec. 4th. Torpor or atony of the colon, definition, &c., of — 449 Pathology of. — ibid. Causes and consequen- ces of — 450 Treatment of. — 451 Spec. 5th. Colic, or flatulent colic, definition, &c., of. — 426 The variety and states of, described — ibid. a. Colic from flatulent disten- tion — 427 b. Colic from injurious ingesta — ibid. c. Colic from bilious or other morbid secretions — 428 d. Colic from the poison of lead — 430 Symptoms and pathology and symptomatic relations of these varieties —426-36 Treatment of these varieties—436-42 CONTENTS—Special Pathology and Therapeutics. Bibliography and Referen- ces i. 448 Spec. 6th. Tympanites — Flatulent distention of the di- gestive tube — Syno- nymes—Definition.... iii. 1289 Pathology and causes of — ibid. The signs and symptoms of — 1291 The treatment, indica- tions, &c — ibid. Means for removing the distention — ibid. Treatment of the patho- logical states produc- ing it — 1292 Bibliography and Refer- ences — ibid. Spec. 7th. Inaction of the rectum, definition and symp- toms of . — 645 Causes, complications, and treatment of — ibid. Genus 3d. The Formation of Concre- tions in the Intestines —Alvine Concretions, &c., definition of i. 463 Spec. 1st. Earthy, phosphatic, and other concretions, de- scribed, &c — ibid. Their causes and effects — 465 Their symptoms, &c — ibid. Treatment of — 466 Spec. 2d. Fatty and unctuous and heterogeneous concre- tions — ibid. Sources and nature of... •— 467 Bibliography and Refer- ences — ibid. Genus Ath. Depressed or exhausted Vi- tal Function of the Bil- iary Apparatus, inde- pendently of previous Organic Lesions. Spec. 1st. Torpor of the liver, or diminished secretion of bile, definition and symptoms ii. 835 Causes of torpid liver... — 830 Treatment of torpor of liver — 836 Spec. 2d. Inaction of the gall-blad- der and ducts—Accu- mulation of bile in the gall-bladder and ducts from local asthenia, definition and symp- toms — 2 Causes and complica- tions — 3 Treatment of. — 4 Consequences of — ibid. a. Excessive distention of the gall-bladder — ibid. Symptoms and diagnosis of — 5 Treatment of — 6 b. Formation of gall-stones in the ducts and gall-bladder —Biliary concretions, def- inition and description.... i. 458 Symptoms of — 459 Consequences and causes of — 460 Treatment of. — 462 XLIII XLIV Bibliography and Referen- ces i. 463 Spec. 3d. Accumulation of the ele- ments of bile in the blood—False or pseu- do-jaundice, descrip- tion of ii. 348 Treatment of — 355 Spec. 4th. Jaundice from suspend- ed or impaired func- tion of the biliary or- gans — 347 Treatment of. — 353 Spec. 5th. Infantile jaundice, de- scription of. — 350 Treatment of — 355 Remedies advised for the different states of functional jaundice... — 356 Bibliography and Refer- ences to jaundice — 359 Spec. 6th. Asthenic congestions of the liver, sanguineous and biliary, definition — 839 Var. a. Partial sanguineous con- gestion — ibid. (a) Hepatic venous con- gestion — 840 (b) Portal congestion... — ibid. Var. b. General sanguineous congestion — ibid. Var. c. Biliary congestion — 841 Causes, symptoms, and complications of as- thenic congestions of the liver — ibid. Treatment of hepatic congestions — 843 See Bibliography and References to Arts. Liver, Gall-blad- der and Ducts, and Jaundice. Genus 5th. Impaired Function of the Pancreas iii. 4 Causes and treatment of — ibid. Genus 6 th. Asthenic Congestion of the Spleen -— 980 Causes and symptoms of — ibid. Treatment of — 981 Order II.—Impaired Vital Function of the Urinary and Sexual Organs. Genus 1st. Imperfect Function mani- fested chiefly by the Urinary Organs, of- ten arising from im- pairment of the di- gestive and assimila- tive functions. Spec. 1st. Enuresis, or secretion of urine in excess i. 583 ; iii. 1097, 1293 Spec. 2d. A chylous state of urine iii. 1337 Spec. 3d. Diabetic urine—Diabe- tes — definition and description of, symp- toms and complica- tions of. i. 583 Duration and termina- tions of — 586 CONTENTS—Special Pathology and Therapeutics. Causes and pathology of i. 588 Treatment and means recommended for — 592 Treatment advised by the author — 595 Bibliography and Refer- ences — 598 Spec. 4th. Paralysis, or inaction of the urinary bladder— definition iii. 1297 History and causes of.. — ibid. Description of. — 1354 Treatment of — 1355 Various affections of the Urinary Organs, Symptomatic of dis- eases of the Nervous Centres, of the Kid- neys, Bladder, &c., see Arts. Urinary Bladder, Urine and Urinary Deposits, and Urinary Cal- culi. Genus 2d. Impaired Vital Function of the Male Organs of Generation. Spec. 1st. Involuntary pollutions— Spermatorrhoea, &c.. — 488 Symptoms and conse- quences of — 489 Treatment of — ibid. Bibliography and Refer- ences — 497 Spec. 2d. Impotency, &c., causes and pathology of. ii. 370 Complications and rela- tions of — ibid. Treatment of — 374 Bibliography and Refer- ences — 376 Genus 3d. Impaired or lost Function of the Female Genera- tive Organs. Spec. 1st. Chlorosis, definition of., i. 371 Causes and history of... — ibid. Symptoms and diagno- sis of. — 372 Treatment of — 374 Bibliography and Refer- ences to — 374 Spec. 2d. Absent, suspended, or suppressed menstrua- tion, definition of. ii. 963 Var. a. Simple functional ame- norrhoea — 964 Causes, pathology, and treatment — ibid. Var. b. From congenital confor- mation — 966 States and causes of.... — 967 Treatment of — ibid. Var. c. Suppression of the men- ses — 968 Definitiont description, and diagnosis, &c., of — ibid. Treatment of — 969 Var. d. Complicated amenor- rhcea —* 970 Spec. 3d. Difficult menstruation, definition and descrip- tion of. — 972 Causes and diagnosis of — ibid. CONTENTS—Special Pathology and Therapeutics. Pathology and compli- cations of. ii. 974 Treatment of. — ibid. Spec. 4th. Passive, atonic, or as- thenic menorrhagia.. — 977 Treatment of asthenic., iii. 979 Irregularities, complica- tions, &c.,of menstru- ation — 980 Bibliography and Refer- ences — 982 Spec. 5th. Leucorrhcea asthenica —Chronic leuchor- rhoea — 818 Treatment of — 819 Spec. 6th. Impotence and sterility of the female — 373 Causes and description of. — ibid. Treatment of — 374 Bibliography and Refer- ences — 376 Order III.—Impaired Vital Force MANIFESTED BY THE CIRCULAT- ING and Respiratory Organs. Genus ls£. Depressed action of the Heart, from lowered Organic Nervous Power. Spec. 1st. Irregular action of the Heart, independent of any organic lesion, definition, &c., § 39.. ii. 203 Description of enfeebled and irregular action of the heart — ibid. Treatment of — 204 Spec. 2d. Fainting, or full syn- cope, definition and description i. 1024 Causes and pathology of — 1025 Treatment of. — 1027 Bibliography and Refers ences — 1028 Spec. 3d. Depression and sinking from physical and mental shock and mental emotions, defi- nition and phenomena iii. 858 Var. a. Physical shock from in- juries, &c — 860 Var. b. Moral shock — 861 Diagnosis and progno- sis of — ibid. Treatment of — 862 Bibliography and Refer- ences — 863 Spec. 4th. Faintness from inani- tion, &c i. 32 From ansemia — 221 From losses of blood,&c. — 224 Spec. 5th. Faintness from breath- ing foul air, the odours of flowers, or vapours, &c — 137 Spec. 6th. Symptomatic faintness —the derivation of or- ganic nervous force from the heart to some other part, as in im- pregnation and preg- nancy, &c iii. 503 Genus 2d. Deficient Vital Power of the Respiratory Or- gans. Spec. 1st. Asphyxia of new-born and debilitated chil- dren, owing to imper- fect vital expansion or collapse of the lungs, i. 175-6 Spec. 2d. Dyspnoea and Apnoea generally symptomat- ic of disease of the lungs, heart, dropsi- cal effusions, oedema of the lungs, bronchial disease, bronchorrhoea — 187 Spec. 3d. Dyspnoea from impaired vital expansion of the lungs, in debilitated and ill-nourished chil- dren — 175 Spec. 4th. Dyspnoea of aged, phleg- matic, and hypochon- driacal persons, owing to deficient vital pow- er of the lungs — 321 Var. a. Attended by relaxation of the bronchial exha- lants—Bronchorrhoea — ibid. Var. b. With general cachexia.. — ibid. Diagnostic symptoms... — ibid. Treatment of — 322 Spec. 5th. Deformities of the tho- rax, forms and states of — 367 (a) Lateral depression of the chest — ibid. (i) Depression of the sternum with lat- eral prominence of ribs., — ibid. Description and causes. — ibid. Treatment of — 368 Order IV.—Deficient Vital Force of the Organic Nervous Sys- tem ACTUATING THE CEREBRO- SPINAL Organs and their Nerv- ous Productions—the Nerv- ous System of Relation—and INFLUENCING MORE OR LESS THE VascularCirculationofthf.se Organs. Genus lsf. ImpairedOrganic Nervous Energy of the Brain. Spec. 1st. Impaired organic nerv- ous force, with exalt- ed morbid sensations —Morbid conscious- ness —Hypochondria- sis — Synonymes — Definition ii- 301 Grades and complica- tions — ibid. Duration and termina- tions — 303 Lesions of structure and diagnosis of. — ibid. Causes, predisposing and exciting — 305 Pathology and progno- sis of — 306 Indications of treatment — 308 Means advised com- mented on — — 309 XLV XLVI Remedies advised by authors ii. 312 Bibliography and Refer- ences — 313 Spec. 2d. Impaired nervous force, with disordered states of mind—Insanity — 500 Definition, and arrange- ment of its forms, &c. — ibul. A review of the indica- tions, signs, and symp- toms of insanity — 502 Classification of mental disorders adopted by writers — 510 Classification of the manifestation and af- fections of mind by the Author — 512 Arrangement of the spe- cial forms of insanity followed by the Au- thor — 513 Yar. 1st. Partial insanity, or the simpler forms of in- sanity — ibid. a. Moral insanity, forms and states of. — ibid. b. Partial disorder of the understanding — 519 c. A general view of par- tial insanity — ibid. d. Hypochondriac mono- mania — 520 e. Melancholic monomania —xMelancholia — ibid. f. Several varieties of par- tial insanity described — 524 Var. 2d. Mania, or madness, characterized, &c — 526 a. Acute mania, symptoms of — ibid. b. Course and symptoms of chronic mania — 528 Causes, diagnosis, and prognosis — 529 Var. 3d. Amentia, or imbecility —Chronic insanity... — 530 Definition and descrip- tion of. — ibid. a. First grade, or loss of memory — 531 b. Second grade, or irra- tionality — ibid. c. Third degree, or incom- prehension — ibid. d. Fourth degree, or loss of instinct and volition.. — ibid. e. Fifth grade, or fatuity, or annihilation of mental power — 532 Spec. 3d. A. Causes and diagnosis of imbecility — ibid. B. Complications of insan- ity — 533 Insanity complicated with general paraly- sis — 534 Complicated with ver- tigo — 535 Insanity complicated with epilepsy, or con- vulsions — ibid. CONTENTS—Special Pathology and Therapeutics. Complicated with apo- plexy ii. 536 Complicated with other nervous and physical disorders — ibid. C. Terminations and dura- tion of insanity — 537 D. Prognosis of insanity... — 541 E. Relapses and recurren- ces of insanity — 542 F. Fatal termination, its pathological causes... — 543 G. The alterations of struc- ture connected with insanity — 549 (a) Morbid appear- ances in the head — ibid, (b) Alterations in the thoracic viscera... — 553 (c) Alterations in the abdominal viscera — 554 H. Causes of insanity — 555 (a) Predisposing causes, fully re- viewed and con- sidered — ibid. (b) Exciting or effi- cient causes — 561 Certain moral emo- tions — 562 Physical causes of insanity — 566 a. Social and political caus- es of insanity — 572 b. Of the physiological pa- thology of insanity... — 573 (a) Remarks on mind and organization.. — ibid. (b) On modern ma- terialism — 576 (c) Of phrenology, in relation to insan- ity — 578 I. Of the connexion of the mind with the nervous systems — 584 K. Treatment of insanity... — 590 a. Introductory re- marks on — ibid. b. Seclusion or sep- aration of the in- sane — 591 c. Clothing, regi- men, and diet of the insane — 594 d. Management of convalescents — ibid. e. Means of prevent- ing attacks, relap- ses, or returns of insanity — 595 L. Treatment of special forms of insanity — ibid. (a) Of partial insan- ity — ibid. (b) Treatment of mo- ral insanity — ibid. (c) Of melancholic monomania ■— 596 (d) Of other partial states of insanity. — 599 M. Treatment of general in- sanity — ibid. a. Of maniacal insanity ii. 599 b. Treatment of demen- tia and fatuity, chronic states of in- sanity — 602 N. Treatment of the com- plicated states of in- sanity — 603 O. Review of the remedies for insanity, with re- marks on the individ- ual means and plans advised ? — ibid. a. The moral treatment of insanity — 619 b. Of the classification of patients and arrange- ment of institutions, &c — 625 Spec. 4th. Connate or puerile in- sanity, defined and de- scribed — ibid. (a) Deficiency of intel- lect — ibid. (J) Complete privation of mental facul- ties—Idiotcy — 626 Complications and caus- es of imbecility and idiotcy — 627 Treatment of imbecility and idiotcy — 628 Spec. 5th. Puerperal insanity, de- fined — ibid. Description of. — ibid. a. Insanity during.preg- nancy — ibid. b. Insanity after deliv- ery — 629 c. Insanity during or after lactation •— 630 Diagnosis and prognosis of. — ibid. Causes of puerperal in- sanity — 631 Pathological states and relations of. — 633 Treatment of puerperal insanity, with refer- ence to the period of its occurrence — 634 Diet, regimen, and mor- al management — 635 Spec. 6th. Suicidal insanity—Sui- cide—Definition — 636 Occasions or causes of suicide — ibid. Predisponent circum- stances and causes... — 643 Pathology of suicidal insanity — 649 Physiological consider- ations as to suicidal insanity — ibid. Prognosis, &c — 651 Treatment — avoidance of the occasions, &c. — 652 Surveillance and re- straint — 653 Prevention and repres- sion — 654 Bibliography and Refer- ences to insanity — 655 CONTENTS—Special Pathology and Therapeutics. Spec. 7th. Cretinism — definition and description i. 511 Treatment — 511 Bibliography and Refer- ences — 513 Spec 8th. Asthenic, weak or se- rous apoplexy—Apo- plexy from lowered organic vital force.... — 102 Description, termina- tions, morbid appear- ances — ibid. Pathological states of, $ 115 — 108 Treatment of, § 148-152 — 114 Spec. 9th. Cerebral syncope, $ 7... — 1025 Causes and pathology of — ibid. Diagnosis and treatment — 1027 Bibliography and Refer- ences — 1028 Spec. 10th. Nervous Headache,* § 10 ii. 169 Causes and description of — ibid. Treatment and means advised, § 39 — 175 Genus 2d. Deficient Vital Function of the Organs of Sense. Spec. 1st. Amaurosis, or loss of sight from impaired function of the optic or ophthalmic nerves, or retina, &c., owing to capillary or venous congestion, &c., defi- nition, &c., § 1 i. 57 Causes and pathological states, § 9 — 58 Symptoms, grades, and forms, § 20 — 60 Diagnosis and prognosis — 65 Treatment, &c., <$ 70 ... — 66 Bibliography — 70 Spec. 2d. Functional diminution or abolition of the faculty of hearing — Nervous deafness ii. 187 Symptoms and pathol- ogy of. — ibid. Treatment of. — 188 Spec. 3d. Loss of the sense of smell iii. 12 Spec. 4th. Impaired or lost sense of taste — ibid. Spec. 5th. Anaesthesia, or loss of feeling — 13 Symptoms and pathol- ogy of. • — ibid. Treatment of paralysis of, t) 205 — 45 Genus 3d. Lowered Vital Power of the Spinal Column... — 934 Spec. 1st. Flexures of the spine, § 29 ih- 938 Forms, causes, and con- sequences of. —• ibid. Treatment of — 940 XLVII * Headache is ascribed to altered sensibility, or to pain arising from changes of the organic nervous endowment of the brain or its membranes, caused either by impaired capillary circulation, or by vascular congestion or excite- ment, or by organic lesion, &c. See art. Headache. XLVIII Treatment advised by the Author, § 48 iii. 942 Spec. 2d. Venous congestion of the spinal cord, its membranes, &c., with or without increased serous effusion — 936 Spec. 3d. Rachialgia, or nervous and painful affections of the Spinal Column, $ 58 — 944 Definition, description, and varieties of — ibid. Causes and nature of... — 947 Treatment of — 948 Bibliography and Refer- ences — 973 Spec. 4th. Tabes dorsalis from ex- haustion — 1100 Genus 4th. Impaired Vital Power of the Nerves of Sensa- tion or Motion, asso- ciated with altered, generally exalted, Sen- sibility. Spec. 1st. Neuralgic affections, evincing no sign of inflammation or of organic lesion ii. 1006 Varieties and states of. — 1008 Causes and associations of — 1015 Terminations and prog- nosis of. — 1018 Pathology of. — 1019 Treatment of — 1021 Various plans and means of cure — 1022 Bibliography and Refer- ences — 1029 Spec. 2d. Barbiers, definition and symptoms i. 208 Treatment — ibid. Spec. 3d. Beriberi, definition, symptoms, and diag- nosis — ibid. Causes and pathology of— 209 Treatment of. — 210 Bibliography — 211 Order V.—Impaired Organic Nerv- ous or Vital Force mani- fested by the Blood and by the Vascular and Absorbent Systems, with more or less Cachexia. Genus ls<. Alterations of the Quan- tity and Quality of the Blood — 219 Spec. 1st. Morbid deficiency of blood—ansemia—defi- nition — ibid. Symptoms and pathol- ogy of. — ibid. Complicated states of... — 221 Causes and treatment of —. ibid. Bibliography and Refer- ences.., — 222 Spec. 2d. Deficiency from losses of blood — ibid. Morbid effects produced by, on persons in health — ibid. CONTENTS—Special Pathology and Therapeutics. By large losses of blood i. 222 The insidious effects from repeated losses of blood — 224 Of excessive loss of blood in diseases of excitement — ibid. Of the mode by which excessive loss may be prevented or coun- teracted — ibid. Of loss of blood in states of depressed vital power — 225 Treatment of the effects of large loss of blood — 226 Treatment of reaction after large loss of blood — ibid. Treatment of consecu- tive exhaustion — ibid. Of the treatment of the serious effects of de- pletion in certain dis- eases — ibid. Spec. 3d. Chlorosis—Definition... — 371 Causes, predisposing and exciting — ibid. History and symptoms of..... — 372 Diagnosis and prognosis — ibid. Morbid appearances and nature of the disease — 373 Treatment, remedies, &c — 37 4 Bibliography and Refer- ences — 375 Spec. 4th. Congestion of blood— Definition — 467 Nature and relations of — ibid. The seats, causes, and symptoms of. — 468 Appearances and ter- minations — 469 The treatment of — 470 Bibliography and Refer- ences — 471 Spec. 5th. Alterations of the blood in disease — 227 A. The causes of these al- terations shown — ibid. B. Changes in the chief constituents of the blood — ibid. C. Alterations referable chiefly to states of vital force — 230 D. Alterations referable to depressed vital force. — ibid. E. Proofs of changes in the healthy states of the blood — 231 a. The vitiation of the blood by the fluids which supply and nourish it — 237 b. “ By the imperfect per- formance of the func- tions of depuration’’’* — 238 * A very recent writer (Brit, and For. Medico-Chirurg. Review, July, 1858, p. 68) states “ that Dr. Watson has assigned a prominent position to the remarks of Dr. Gold- ing Bird on the treatment of acute rheumatism by the CONTENTS—Special Pathology and Therapeutics. XLIX c. By the other causes enumerated in the department of pathol- ogy i. 239 d. Phenomena depending upon a vitiated state of the blood, and in- dicating its existence — 246 F. Therapeutical indica- tions and measures for diseased states of the blood — 248 a. Treatment of blood abounding with fibri- nous and albuminous constituents — ibid. b. Treatment of blood with a loose coagulum, &c. — ibid. c. Treatment of other mor- bid states of the blood — ibid. G. Prophylaxis, or preven- tion of morbid states of the blood — 250 Bibliography and Refer- ences — ibid. Genus 2d. General Cachexia with or without emaciation. Spec. 1st. The scrofulous or stru- mous taint or diathe- sis—Latent scrofula —Characters of. iii. 797 Indications and descrip- tion — 798 Causes referable to the parents — 800 Causes acting chiefly during early life — 803 Pathological relations of — 819 Treatment—Indications and means of cure ... — 829 Bibliography and Refer- ences iii. 837 Spec. 2d. Cachexia from improper or insufficient food... i. 326 After weaning or dur- ing dentition — 48 Treatment of — 49 Spec. 3d. African cachexia, de- scription of — 327 Causes and treatment of — 328 Genus 3d. Cachexia with increased bulk of a ■part, or greater part, of the body. Spec. 1st. Obesity, definition and characters of...... ii. 1035 Causes and pathology of — 1036 Treatment of — 1038 Bibliography and Refer- ences — 1039 Spec. 2d. Leucophlegmasia or chronic asthenic an- asarca, and oedema... i. 727 States and relations of. — ibid. Treatment, &c — 730 Bibliography and Refer- ences — 731 Spec. 3d. Cachexia with alteration of the form or ap- pearance of the body. See also Class IV., Order IV. (a) Rachitis — Rickets —first stage of.... iii. 702 (b) Scorbutus—Scurvy —first grade of... — 841 (c) Purpura, early state of — 605 Order VI. General Chronic Debil- ity, or Impaired Vital Force, MANIFESTED THROUGHOUT THE frame.—See Art. Debility. Genus lsf. Simple general Debility, without any manifest Inflammatory or Or- ganic Change—Defi- nition i. 547 Spec. 1st. Primary debility — 548 Causes of. — ibid. Treatment of — 556 Spec. 2d. Consecutive debility .... — 550 Causes and pathology of — ibid. Treatment of — 558 Manifestations of debil- ity — 551 Complications of debil- ity — 555 Pathological relations of — ibid. Treatment of the sev- eral forms and states of debility — 556 Treatment of its various associations — 559 Of convalescence — ibid. Moral and physical regi- men, and other means — 560 Bibliography and Refer- ences — ibid. Spec. 3d. Climacteric decay—Def- inition — 396 Symptoms — ibid. Causes — 397 salts of potash, &c. Dr. Bird’s views on blood depura- tion, and on the existence of a peculiar class of remedies, the renal depurants, are in our opinion eminently sound, and in the highest degree worthy the attention of all physicians.” (Loc. tit., p. G8.) The author is happy to quote this opinion in behalf of a doctrine fully set forth by him in the article on the Blood, the class of blood-depu- rants (the terms depurants and depuration actually em- ployed by him) being also there enumerated. This ar- ticle, a3 well as others, in which depuration of the blood by the action of the several emunctories, and of the kid- neys especially, is insisted upon, was published in 1S32, and the several articles in which these substances are pre- scribed from the experience of the author and of other au- thorities appeared in the parts of this work published from 1832 to 1837. The depurants recommended by the author are not only those adopted by Dr. G. Bird, but others also, even of greater importance, are enumerated from an ample experience of their efficacy. The first edition of Dr, G. Bird’s work appeared in 1844; and that contain- ing the chapter on depuration of the blood by the‘kidneys was published in 1853. “ Dr. Fuller’s important Expe- rience of Alkaline Remedies in the Treatment of Rheuma- tism" (op. cit., p. 69) was published in 1852. The article on that disease in this work appeared several years pre- viously to 1852 ; and in that article alkalies were insisted upon by the author, conformably with his views of the pathology of the malady, as being among the chief reme- dies for its cure; magnesia, its citrates, the citrates and the acetates of the alkalies, being also considered not the less efficacious—indeed, most efficacious, especially when judiciously prescribed and combined with other medicines. In addition to these, the bihorate of soda is there men- tioned; and here the author may remark that he has found this medicine of marked benefit, both in preventing the deposition of lymph on the valves in cases of rheumat- ic endo-carditis, and in removing it at an early stage of its formation, as proved to him by several cases, one of which being the son of a late eminent physician in Nor- wich. L CONTENTS—Special Pathology and Therapeutics. Treatment i. 397 Bibliography and Refer- ences — 398 Genus 2d. General Debility, asso- ciated with Hydatidic and Verminous For- mations and Develop- ments Spec. 1st. Hydatids — Synonymes —Definition ii. 292 Description of. — 293 Pseudo-hydatids, or sim- ple cysts — 295 Remote and immediate causes of hydatids — 296 Symptoms and treat- ment — 297 Bibliography and Refer- ences ■— ibid. Spec. 2d. Worms — Intestinal Worms — Vermina- tion—Entozoa—Def- inition iii. 1514 A. The origin of animal parasites —1515-16 The emigrations and immigrations of. — 1516 B. The classification of in- testinal worms — 1519 a. Infusoria — Description of the trichomonas and the denticola hominis —1519-20 b. Helmintha—Vermes— General description of — 1520 Their general pathology — ibid. The general prognosis of. — ibid. The principles of treat- ment of — ibid. C. Description of the 1st Order, Platyelmia; of the 2d Class, Hel- mintha —■ 1521 Generation, metamor- phosis, and growth of tape-worms — 1521 The development of cestoidea, or cestode worms — 1526 a. Description of the bo- thriocephalus latus... — ibid. b. Description of tainia so- lium — 1527 c. Description of tsenia mediocannellata —1529-30 Symptoms and diag- nosis of the mature cestoidea occurring in the human intestines — 1531 Description of imma- ture tainife found in the human body ex- ternally to the intes- tines — ibid. a. Of cysticercus tenuicol- lis — ibid. b. Of echinococcus scoli- cipariens, and of E. altricipariens —1531-2 The diagnosis, progno- sis, and etiology of...—1533-4 D. Description of trema- toidea, monostoma, and distoma iii. 1534-5 Seats, diagnosis, and alterations produced by —1535-7 E. Description of nematel- mia — Nematoidea — Thread-worms — Round worms — 1537 a. Of tricocephalus dispar —Trichina spiralis...—1537-8 b. Of oxyuris vermicularis — Locality — Symp- toms and diagnosis —1539-40 c. Of Strongyli gigas — Locality and Symp- toms —1540-1 d. Of ancylostomum duo- denale—Pathology of — 1541 F. Symptoms and altera- tions observed after death from —1541-2 a. Of filaria medinensis— Synonymes and diag- nosis —1542-3 b. Of ascaris lumbricoides —Symptoms and di- agnosis —1544-5 G. A general view of the symptoms produced by worms in the di- gestive canal — 1546 H. The causes of worms... — 1547 I. The treatment of worms — ibid. a. The prevention of the ingestion of their ova — ibid. b. The prevention of the development of the ova when ingested ...—1547-8 K. The direct and curative treatment of worms.. — 1548 a. The treatment of tape- worms — ibid. The several methods recommended ........—1549-55 b. Treatment of distoma, oxyuris vermicularis, of Strongylus gigas, the ancylostomum du- odenale —1556-7 c. Treatment of filaria me- dinensis and ascaris lumbricoides —1557-9 L. The after-treatment of worms, &c — 1560 Bibliography and Refer- ences —1561-3 Second Class.—Diseases consist- ing of a Morbid Increase of Fonction of an Organ or Part arising chiefly from Local Irritation or Excite- ment, or from Causes pro- ducing an Irregular Distri- bution of Vital Force, espe- cially IN DELICATE AND IRRI- TABLE Subjects. Irritation, defined to be an exalta- tion of the vital actions of a tis- sue or organ, relatively to the vital states of other parts ii. 696 CONTENTS—Special Pathology and Therapeutics. Relations of irritation to diseases, more especially to this class ii. 697 Pathological relations of irritation — ibid. Relations of irritation tfo the cere- bro-spinal nervous system — 698 Physiological relations of irritation s— 699 Irritation through the media of the organic nerves, productive of spasmodic, convulsive, and pain- ful complaints — 700 Productive of numerous sympa- thies and sympathetic associa- tions of disease — 701 Pathological relations of — ibid. Relations to inflammatory states... — 702 Relations to haemorrhages and se- rous effusion — ibid. Relations to morbid nutrition and to the states of the blood — ibid. Of the propagation, reflection, re- action, and other phenomena of irritation — 703 The constitutional effects of irrita- tion — 706 The continuity, periodicity, dura- tion, and effects of irritation — ibid. Of the influence of the causes on the states and characters of irri- tation — 707 Treatment of irritation with refer- ence to removing, subduing, and counteracting the causes — 710 Various indications and means of cure — 711 Diet, regimen, change of air, min- eral waters, &c — 716 Bibliography and References — ibid. Order I.—Disorders consisting op simple Increase op the Vital Force or Functions of an Or- • gan or Part. Genus 1st. Increased Vital Action of the Digestive Or- gans. Spec. 1st. Difficult dentition—Def- inition i. 580 Pathology of. — ibid. Treatment of — 581 bibliography and Refer- ences — 583 Spec. 2d. Chiefly of the stomach —Morbid appetite— Defined — 120 a. Insatiable or excessive appetite—Bulimia.... — ibid. States and causes of.... — ibid. Treatment of —. 122 b. Vitiated appetite, defini- tion of. — 123 Description of — ibid. Treatment of. — 124 Bibliography and Refer- ences — ibid. Spec. 3d. Increased action of the intestines — 602 a. Feculent diarrhoea — 603 b. Bilious diarrhoea ■— ibid. c. Diarrhoea with vascular excitement — 604 d. Puerperal diarrhoea — 605 e. Diarrhoea in infancy and childhood — 606 Other states and asso- ciations of. i. 606 Pathology, prognosis, &c — 607 Treatment and remedies advised — 609 Notices ofvarious means — 616 Bibliography and Refer- ences — 618 Spec. 4th. Gastro-enteric irritation or disease ii. 29 Pathological relations of — 30 Therapeutical relations of. — 34 Bibliography and Refer- ences — ibid. Spec. 5th. Bilious Cholera—Chol- era biliosa—Definition i. 375 Causes, symptoms, &c., of — ibid. Treatment of — 380 Genus 2d. Nervous Palpitations of the Heart or Arteries. Spec. 1st. Excited action of the Heart—Palpitations of, $ 43 — 204 Causes and course of... —- ibid. Diagnosis, &c — 205 Treatment of — ibid. Treatment of hysterical and other states of... — 206 Bibliography and Refer- ences... — ibid. Spec. 2d. Palpitations of the Aorta — 79 Nervous pulsations of the abdominal aorta described — ibid. Treatment of — 80 Genus 3d. Increased activity of the Generative Organs. Spec. 1st. Self-pollution, or manu- stupratio iii. 485 Symptoms and signs of masturbation — 486 Evil consequences of this vice to the indi- vidual, and to his off- spring, if any — 487 Treatment of — 489 Bibliography and Refer- ences — 497 Spec. 2d. Erotomania—Nympho- mania ii. 516 Treatment of — 595 Spec. 3d. Satyriasis — ibid. Genus Ath. Excited Organic or Vi- tal Force, affecting the Circulation in the Brain, or in parts of the Brain. Spec. 1st. Irritation, mental or physical, of the or- ganic nervous system of the brain, causing increased vascular de- termination, with or without cephalalgia., i. 278 Spec. 2d. Acute or active conges- tion of the brain — ibid. Symptoms, causes, and pathology — ibid. Treatment of — 279 LI Spec. 3d. Excited vital action in parts of the brain, causing a morbid in- crease of certain emo- tions and passions. See Partial Insan- ity and Acute Ma- nia— I. Class—Or- der IV ii. 519 Spec. 4th. Tremor*—Definition.... iii. 1185 Description 1... — ibid. Causes and states of.... — ibid. Diagnosis and progno- sis — 1187 Treatment — ibid. Bibliography and Refer- ences — 1188 Spec. 5th. Delirium with tremor, with excited vascular action—Definition.... i. 571 Symptoms, modifica- tions, and diagnosis — 573 Causes, pathology, and prognosis — 575 Treatment, &c — 576 Bibliography and Refer- ences — 580 Spec. 6th. Vertigo*—Definition... iii. 1495 Description of. — ibid. Causes and forms of.... — ibid. Diagnosis and morbid relations of — 1497 Prognosis and treatment of — ibid. Bibliography and Refer- ences — 1498 Order II.—Irritation or Vascular Excitement occasioning or followed by Haemorrhage, CHIEFLY FROM MUCOUS AND other Surfaces—Definition... ii. 72 A. Of the state of organic, nervous, or vital force in haemorrhage. — 73 » B. Of changes in the seats of haem- orrhage — 74 C. Of changes in the circulating or- gans and vessels producing haemorrhage — ibid. D. Of the states of the blood in haemorrhage — 75 E. Remote causes of haemorrhage .. — 77 F. Symptoms, diagnosis, and prog- nosis — 78 G. Classification of haemorrhages.... — 79 H. Treatment of haemorrhages — 80 I. Remedies for, adduced and com- mented upon — 83 K. Regimen and prophylaxis — 85 L. Bibliography and References — 87 M. Haemorrhages considered with respect to their seats — ibid. N. Bibliography and References — 88 Genus 1st. Hcemorrhages from the Digestive Canal. Spec. 1st. Haemorrhage from the mouth and throat — 94 LII CONTENTS—Special Pathology and Therapeutics. Description of seats and states of haemorrhage ii. 94 Diagnosis and causes of — ibid. Treatment of. — 95 Bibliography and Refer- ences — ibid. Spec. 2d. Haemorrhage from the (Esophagus — 1049 (Rarely occurs un- less from mechan- ical injury and organic lesions, Class IV.) — ibid. Treatment, &c — 1050 Spec. 3d. Haemorrhage from the stomach — 108 Primary or simple — 109 Vicarious haematemesis — 110 Haemorrhage from dis- ease of associated viscera — ibid. Haematemesis from or- ganic lesions of the stomach or of its ves- sels — 111 Vomiting of black mat- ter — ibid. Causes and symptoms.. — ibid. Morbid appearances and pathological inferen- ces — 113 Diagnosis and prognosis — 114 Treatment during the attack — 115 Treatment subsequently to the attack — 116 Bibliography and Refer- ences — 118 Spoc. 4th. Haemorrhage from the intestines and melae- na — ibid. Definition and descrip- tion of — ibid. Pathology and causes of — 119 Diagnosis and prognosis of — 121 * Treatment of — ibid. Bibliography and Refer- ences — 122 Spec. 5th. Haemorrhage freftn the haemorrhoidal vessels —Haemorrhoids — 144 Definition and patholog- ical history — ibid. General character and description — 145 Varieties of the haemor- rboidal tumours — ibid. Character, returns, amount, and nature of the discharge — 147 The consequences and complications ofhaem- orrhoids — 148 Diagnosis, causes, and prognosis — 150 Treatment, constitution- al and pathological re- lations of — 152 Treatment of the haem- orrhoidal discharges.. — ibid. Treatment of the haem- orrhoidal tumours .... — 153 * Many cases of vertigo may tie referred to debility or even to anasmia of the brain ; others to congestion or to active determination of blood to the brain, and others to organic lesion. The same remarks apply to Tremor, which also may proceed from very opposite states of cir- culation in the brain, or even from structural change. See Class IV., Order Ilf. CONTENTS—Special Pathology and Therapeutics. LIII Treatment of the con- sequences and com- • plications ii. 156 Re - establishment of suppressed haemor- rhoids — 158 Bibliography and Refer- ences — ibid. Genus 2d. Haemorrhage from the Respiratory Surfaces. Spec. 1st. Haemorrhage from the nose — Epistaxis — Definition of — 88 Phenomena and causes of. — ibid. Treatment and means advised — 90 After-treatment of...... — 92 Bibliography and Refer- ences — 93 Spec. 2d. Haemorrhage from the bronchi — Haemopty- sis—Definition — 95 Symptoms and progress — 96 Appearances after death from — 97 Causes and pathological relations of — 98 Diagnosis and prognosis — 101 Treatment, history of... — 102 Treatment, and means of, commented on — 105 Inhalation, regimen, &c. — 107 Bibliography and Refer- ences — ibid. Genus 3c?. Haemorrhage from the Urinary and Sexual Organs. Spec. 1st. Haemorrhage from the urinary organs — Haematuria — Defini- tion — 122 Description—1st, as re- spects the appearances of the urine and blood contained in it — 123 And, 2d, of the symp- toms observed — ibid. Seats and sources of the haemorrhage — ibid. Pathological states giv- ing rise to haematuria — 124 Diagnosis and prognosis — 125 Treatment of the more acute states — ibid. Of the passive and oth- er states — 126 Bibliography and Refer- ences... — 127 Spec. 2d. Haemorrhage from the uterus—Menorrhagia —Definitions and dis- tinctions — ibid. Var. a. Non-puerperal menor- rhagia — ibid. Causes, predisposing and exciting — 128 Symptoms and progress — 129 Var. b. Haemorrhage at or after the cessation of the catamenia — ibid. Var. c. Puerperal uterine haem- orrhage — 130 Periods, forms, and states of ii. 131 Prognosis, with refer- ence to these forms and states — 132 Treatment, in connex- ion with the indica- tions of cure — 133 Treatment of the sever- al periods, forms, and states — 134 The means advised for uterine haemorrhage, commented on — 138 Bibliography and Refer- ences — 141 Genus ith. Haemorrhage into serous and short cavities. (Generally conse- quent upon or- ganic lesions of the adjoining or- gans. See Class IV.) When occurring pri- marily or idiopathic- ally, states producing ‘ it — 142 Seats, cavities, and membranes affected.. — ibid. Bibliography and Refer- ences — 143 Genus 5th. Haemorrhage into the Ar- eolar Tissue, or into the Parenchyma of Organs — ibid (Generally occasion- ed by organic le- sions. See Class IV) Morbid states causing haemorrhage into these structures — ibid. Order III.—Spasmodic and Painful Diseases resulting from in- ordinate Action of Muscular Fibres, caused chiefly by Ir- ritation seated in or affect- ing some Part of the Organ- ic Nervous System. Definition of spasm iii. 926 a. Varieties and arrangement of. •— ibid. b. Spasm of involuntary structure an element of several diseases — 927 c. Spasm of voluntary muscles or parts, relations of. — ibid. d. Spasm may extend from one order of parts to others — 928 e. Causes of spasm — ibid. f. Diagnosis and prognosis of. — 929 g. Treatment with reference to the pathological relations of spasm . — 930 h. Bibliography and References — 933 Genus 1st. Spasmodic Affections of the Digestive Canal, with diminished Se- cretion from the Vil- lous Surface. Spec. 1st. Spasm of the CEso- phagus — Spasmodic stricture of the (Eso- phagus ii. 1050 LIV CONTENTS—Special Pathology and Therapeutics. Definition, causes, and symptoms ii. 1050 Treatment and means of cure — 1051 Bibliography and Refer- ences — 1052 Spec. 2d. Spasm of the stomach— Gastrodynia, cramp of the Stomach — Synonymes and defi- nition of iii. 997 Causes and symptoms.. — 998 Diagnosis and prognosis — ibid. Treatment and means advised — 999 Spec. 3d. Spasm of the intestinal canal — Colic and Ileus i. 426 (The several forms of colic and ileus have been classed in the First and Fourth Classes; but many cases of the following varieties may be viewed as chiefly spasmodic, the spasm being caus- ed by irritation of, or lesions im- plicating, the or- ganic nerves, and attended by ac- cessions of great pain.) Var. a. Colic with flatulence, &c — 427 b. Colic from injurious in- gesta — ibid. c. Colic with suppression of the secretions — Dry belly-ache — 428 d. Colic from lead—Lead colic — 430 e. Colic with complete ob- struction—Ileus—Or- ganic lesions, &c — 432 f. Various sympathetic forms of colic — 434 Causes, symptoms, and - morbid appearances in colic and ileus —435-44 General remarks on the pathology of colic and ileus — 435 Diagnosis and prognosis — 436 Treatment of the sev- eral varieties of colic and ileus —436-45 Of lead colic — 439 Of convalescence from . — 442 Treatment of ileus I*— ibid. Remedies and means prescribed — 442-6 Bibliography and Refer- ences — 448 Spec. 4th. Spasm of the rectum and sigmoid flexure of the colon iii. 658 Treatment of — ibid. (Spasm of these parts, occasioning tenesmus, &c., of- ten attends irrita- tion and organic lesions, either seated in them or in their vicinity. See Arts. Dysen- tery, Rectum and Anus, &c.) Gams 2d. Spasmodic Affections of the Digestive Canal, with increased Secre- tion from the Villous Surface. Spec. 1st. Spasm of the stomach, with eructations of watery fluid—Pyro- sis iii. 615 (The disorder usu- ally termed pyro- sis is character- ized, in some cas- es, chiefly by pain- ful spasm previ- ously to the aque- ous discharge ; and in others by indigestion, with no pain and little or no spasm, the fluid being merely regurgitated from the stomach.) Diagnosis, causes, and nature of — 616 Treatment and Bibliog- raphy.. —617-18 Spec. 2d. Spasmodic and painful action of the stomach, duodenum, and intes- tines, with copious evacuations and spasms of the ex- tremities—Cholera* —Definition i. 375 History and symptoms. — ibid. Var. a. Bilious cholera — ibid. b. Flatulent cholera — 377 c. Spasmodic cholera — 378 Diagnosis, causes, and pathological states.... — 375-9 Treatment and remedies prescribed — 380 Bibliography and Refer- ences — 382 Genus 3d. Spasmodic Affections of the TJrinary and Sex- ual Organs. Spec. 1st. Irritable urinary blad- der iii. 1293 Diagnosis of. — 1294 Treatment of — ibid. Spec. 2d. Spasm of the urinary bladder—Definition... — 1296 * The phenomena characterizing Cholera vary much with the seat of spasm and pain, with the severity of the irritation of the organic nerves, and with the degree of affection of the duodenum. When the spasmodic action of this part is great, the ducts are implicated, and the discharge of bile is arrested. The irritation of the organ- ic nerves, being propagated to the roots of the spinal nerves, occasions spasms of the voluntary muscles, as stated in the first part of the work, published September, 1832. Diagnosis of iii. 1297 Treatment of — ibid. Spec. 3d. Irritation of the uterus and appendages, with more or less morbid sensibility of these organs— Synonymes —Definition — 1361 Local and general symp- toms — ibid. Diagnosis and prognosis — 1362 Causes and nature of ir- ritable uterus — ibid. Treatment of — 1364 Genus 4th. Spasmodic Affections im- plicating chiefly the Respiratory Organs. Spec. 1st. Affecting chiefly the dia- phragm — Hiccough — Singultus — Syno- nymes—Definition.... ii. 271 Causes—Various sour- ces of irritation, &c., generally symptomat- ic — ibid. Diagnosis and progno- sis — 272 Spec. 2d. Cough or irritation re- flected chiefly on the respiratory muscles generally—A symp- tomatic affection pro- duced by various sources of irritation .. i. 596 Causes, sources, and forms of — ibid. Treatment of, and means of cure — 507 Bibliography and Refer- ences — 508 Spec. 3d. Simple catarrh — Spe- cific irritation of the Schneiderian mem- brane and adjoining surfaces, often with a watery discharge, and slight sympto- matic fever towards night—Definition — 349 Causes, predisposing and exciting — 350 Diagnosis, prognosis, &c — 351 Complications and na- ture of — 352 Treatment and prescrip- tions for — ibid. Bibliography and Refer- ences — 354 Spec. 4th. Hooping-cough — Per- tussis — Synonymes and definition ii. 273 Description, commence- ment, and course — 274 Complicated pertussis.. — 275 Appearance seen in fa- tal cases — 278 Nature and seat of per- tussis — 279 Diagnosis, prognosis, and causes — 282 Treatment of the sim- ple form — 284 CONTENTS—Special Pathology and Therapeutics. Treatment of complica- ted hooping-cough ... ii. 285 Review of remedies ad- vised — 286 Bibliography and Refer- ences — 291 Spec. 5th. Spasmodic croup i. 524 (A variety of Croup characterized more by spasmodic ac- cessions than by inflammation, and caused by irritation or inflammation of adjoining or re- mote parts, may be included in this CLASS.) Appearances observed after death — 525 Nature of the disease... — 532 Treatment of spasmodic croup — 538 See, also, Class III., Order I., Gen. 8. Spec. 6th. Spasm of the Larynx in children — Spasm of the glottis—Syno- nymes and definition, ii. 777 Symptoms, diagnosis, and causes of. — ibid. Nature and pathological relations — 778 Diagnosis and prognosis of — ibid. Treatment, intentions, and means of cure, &c — 782 Spec. 7th. Suffocative laryngeal af- fection in adults — 783 Generally symptomatic of antecedent disease — ibid. Consequent upon irrita- tion of the sexual or- gans or spinal nerves — ibid. Treatment with refer- ence to the patholog- ical causes — 784 Of the hysterical forms. — ibid. Spec.8th. Asthma—Spasmodic and Humoral Asth- ma—Synonymes and definition i- 176 Physiological pathology of — 177 Symptoms and history of — 178 a. Of spasmodic asthma... — ibid. b. Of humoral asthma — 179 Terminations and ap- pearances after death — 180 Varieties of asthma, and of their pathology — — ibid. Diagnosis and progno- sis — 184 Predisposing and excit- ing causes — 185 Complications of asthma — 187 Proximate cause and re- lations of — 188 Treatment of the parox- ysm — ibid. Intentions and remedies LV LVI CONTENTS—Special Pathology and Therapeutics. prescribed for the at- tack i. 189 Treatment during the intervals — 193 Treatment of the sever- er symptoms and com- plications of. — 195 Of regimen, diet, miner- al waters — ibid. Change of air and cli- mate for — 196 Bibliography and Refer- ences — ibid. Spec. 9th. Rabies — Hydrophobia — Synonymes—Defi- nition iii. 618 Description of its sev- eral stages — 619 Symptoms of, in the canine race — 623 Appearances after death —most marked in the medulla oblongata— in the respiratory passages and in the blood — 623 Diagnosis and progno- sis . -625-7 Cause, and animals com- municating the mal- ady — 628 Nature of rabies con- sidered — 630 Pathological inferences and remarks — 632 Symptoms of rabies in the dog — 633 Prophylactic treatment of — ibid. Curative treatment! and means which may be tried, when the mal- ady has appeared — 637 Bibliography and Refer- ences — 640-2 Genus 5th. Convulsive and Spasmod- ic Diseases caused by Irritation of the Brain, Spinal Cord, or their Membranes.—See, al- so, Class III., Order I., and Class IV., Order III. Spec. 1st. Epilepsy — Synonymes and definition of. i. 904 Description and pre- monitory symptoms.. — ibid. Phenomena during and after the convulsive attack — 905 Of the intervals between the fits — 907 Consequences and ter- minations — ibid. Predisposing and excit- ing causes — 908 Several grades and forms of epilepsy — 910 Simple cerebral forms of — 911 Sympathetic forms of epilepsy — 912 Complications of epi- lepsy — 914 Appearances after death from i. 915 Nature of epilepsy — 917 Diagnosis and prognosis — 919 Treatment of the epi- leptic fit — 920 Treatment in the inter- vals with reference to the several forms, states, and causes of epilepsy — 921 Treatment of the com- plicated states — 925 The means advised for epilepsy, with com- ments on — 927 The means employed externally — 936 Regimen, diet, change of air, travelling, Ac. — 937 Bibliography and Refer- ences .. — 940 Spec. 2d. Convulsive and spas- modic affections—Ir- regular and partial convulsions — Syno- nymes and definition. — 479 Forms of convulsions described — 481 Var. a. Partial or local convul- sions — 482 Varieties and seats of.. — ibid. b. General convulsions'— Tonic and clonic — Sthenic and asthenic — 483 c. Infantile convulsions, symptoms and forms of — 484 Eclampsia and other varieties of. — 485 Convulsions in the puer- peral states — 486 d. Premonitory symptoms and complete seizure — ibid. e. Convulsions sympathet- ic of several diseases. — 488 Diagnosis, consequen- ces, and prognosis of convulsions — 489 Remote and efficient causes — 490 General view of the treatment — 492 The means during the attack — ibid. The prevention of the seizure — 495 External means, regi- men, &c — 497 Treatment of convul- sions in infants and children — 498 Treatment of puerperal convulsions — 502 Means required to ter- minate the seizure ... — ibid. Of the epileptic attack in the puerperal state — 504 Of the attack when caused by losses of blood — ibid. Of the prevention of convulsions — ibid. Bibliography and Refer- ences i. 505 Spec. 3d. Tetanus and trismus— Synonymes, defini- tion, &c iii. 1101 Description of the sev- eral forms of trismus and tetanus — ibid. a. Of trismus — 1102 b. Of acute tetanus — ibid. c. Of sub-acute and other states of — 1105 Duration and termina- tion of tetanus — ibid. Appearances in fatal casds — 1106 Diagnosis of. — 1108 d. Tetanus infantum, or trismus of new-born infants — 1109 Causes and appearances after death — 1110 Relations and alliances of trismus and tetanus to other diseases — ibid. The effects of muscular contractions on the circulation — 1111 Influence of the states of the blood on mus- cular contractions .... — 1112 Predisposing and excit- ing causes — ibid. The formative or incu- bative period of teta- nus — 1114 The prognosis, &c — ibid. Pathological inferences and remarks — 1115 Remarks on the treat- ment of — 1116 The local treatment of.. — 1117 The external means ad- vised — 1118 Constitutional and inter- nal means — 1119 Successive and com- bined measures — 1124 The prevention of teta- nus or trismus — 1126 Treatment of convales- cence — ibid. Bibliography and Refer- ences —1126-8 Spec. 4th. Chorea—Chorea Sancti Viti — Synonymes and definition i. 386 (Chorea, tremor, shaking palsy, and various other af- fections charac- terized by twitch- ings of the mus- cles, and usually viewed as states of chronic or as- thenic spasm, may be considered as the results of im- paired or sup- pressed nervous influence endow- ing the muscles, CONTENTS—Special Pathology and Therapeutics. LVII and as not legiti- mately belonging to this order.) Symptoms, duration, and complications.... i. 387 Terminations and ap- pearances after death — 388 Diagnosis and progno- sis . — ibid. Predisposing and excit- ing causes — 389 Nature of the disease... — ibid. Of nervous diseases re- sembling chorea — 390 Conspectus of the treat- ment of chorea — 392 Treatment recommend- ed by the Author — 393 Prescriptions advised... — 395 Treatment of the com- plicated and irregular states of chorea •— ibid. Bibliography and Refer- ences — 396 Spec. 5th. Catalepsy—Synonymes —Definition — 344 Symptoms and relations of. — ibid. Diagnosis and causes of — 347 Treatment of — 348 Spec. 6th. Cataleptic ecstasy — Definition — 346 Description and termin- tion — 347 Causes and nature of... — 348 Treatment of —• ibid. Bibliography and Refer- ences — 349 Genus 6th. Spasmodic and Convul- sive Affections owing to Irritation of the Fe- male Sexual Organs, extending thence to the Spinal Cord, and oft- en to the Brain. Spec. 1st. Hysterical spasms, pains, and convul- sions — Hysterical Affections — Syno- nymes and definition, ii. 314 a. The milder and more regular forms of — ibid. b. The severer forms of... — 315 c. The irregular and ano- malous states of hys- teria described — 317 Complications of hyste- ria — 323 Duration and termina- tions — ibid. Diagnosis, &c — 324 Causes, predisposingand exciting — 325 Pathological remarks, &c — 327 Circumstances to be considered in the treatment of hysteria — 330 Treatment of an hyster- ical attack — 331 General treatment in the intervals — ibid. LVIII CONTENTS—Special Pathology and Therapeutics. Treatment of the prom- inent symptoms and anomalous forms ii. 333 Treatment of hysterical mental disorders — 337 Of the prophylactic treatment of hysteria — 338 Baths, mineral waters, exercise, diet, and regimen — ibid. Bibliography and Refer- ences' — 340 Spec. 2d. Convulsions in the puer- peral states i. 486 Puerperal periods and character of the at- tack — ibid. Premonitory symptoms, &c.: Complete seizure — 487 Modifications, &c — ibid. See, also, Genus ddh. Spec. 3d. Spasm of the uterus after parturition — ibid. Third Class.—Diseases consisting, at some Period of their Course, of Excitement or Re- action of the Organic Nerv- ous or Vital Force, mani- fested either by one or more Organs especially, or throughout the Body. In this class of diseases the efficient cause generally depresses or ir- ritates the seat of disease, vital excitement or reaction common- ly supervening and opposing or removing the depression, unless the depression be so extreme as to overwhelm the vital resist- ance. Order I. — Diseases characterized BY AN UNNATURAL STATE OF Irritation and of Vascular Reaction of an Organ or Part, generally followed by Morbid Exudations, by Chang- es of Vital Power and ©f the Organization of the affected Part. The Doctrine of Inflammation, and an Inquiry into its Con- stitutional and Local States. Inflammation—Definition, fic., of ... ii. 426 A. The phenomena constituting sthenic inflammation — ibid. a. Of acute sthenic inflammation. •— ibid. Of the local appearances after death — 430 The constitutional symptoms and effects of sthenic inflam- mations — ibid. The changes in the blood — 431 b. Chronic inflammation described — 433 Progress and duration of sthen- ic inflammations — ibid. c. Complications of sthenic in- flammation — 435 Terminations and consequences — ibid. Exudations, softening, thicken- ing, &c _ 436 Suppuration and purulent mat- ter.... ii. 437 Pus, microscopic appearances of. iii. 438 B. Abscess, pathological charac- ters of. i. 15 Forms of, described — 16 Symptomatic abscesses de- scribed — 18 Consecutive abscesses, pathol- ogy of. — 19 Progress and terminations of abscesses — 20 The diagnostic signs of abscess — 22 The prognosis of — 23 The .medical treatment of ab- scesses — 24 Of opening abscesses ■— 25 Bibliography and References.. — 26 Ulceration and other changes consequent upon inflamma- tion ii. 438 C. Different forms and states of inflammation depending upon constitutional and patholog- ical causes — ibid. a. Asthenic or diffusive inflam- mation — 439 Local characters described — ibid. Constitutional symptoms of.... — 440 Progress, duration, and compli- cations — 442 Consequences and terminations — 443 b. Modifications of inflammation by structure — 445 Diagnosis of inflammations — ibid. Causes, constitutional and pre- disposing — 448 The exciting causes — 450 c. Consecutive inflammations, na- ture, &c., of — 453 d. Secondary inflammations, de- scription of. i —- ibid. Progress of inflammations — 455 D. Theory or nature of inflamma- tion — 456 a. Opinions as to the nature of inflammation — 457 b. Pathology of the several forms of inflammation — 462 E. Of reparation of the conse- quences of inflammation — 469 F. Considerations which should guide the treatment of in- flammations — 470 a. Treatment of acute sthenic in- flammation — ibid. Local, derivative, and other means — 477 b. Treatment of asthenic inflam- mation — 482 Constitutional means calcula- ted to promote vital force and resistance — 483 Means directed to remove prominent or urgent symp- toms, &c — 484 c. Treatment of states between the sthenic and asthenic — 485 d. Treatment of specific inflam- mations — 486 e. Diet, regimen, &c.... — 486 Bibliography and References... — 487 See, also, Ar/s. Abscess, Gan- grene, Induration, Soft- ening, &c.. Genus 1st. Inflammations of the Di- gestive Canal. Spec. 1st. Inflammation of the mouth—Stomatitis — Synonymes and defi- nition iii. 1018 a. Simple, or erythematic. — ibid. Simple stomatitis — ibid. Treatment of — 1019 b. Pseudo - membraneous stomatitis — ibid. Causes and treatment.. — 1020 c. Mercurial stomatitis. See Poisons, § 562- 594 — 453-9 d. Ulcerated stomatitis .... — 1021 Treatment of — ibid. e. Phagedenic stomatitis — Cancrum oris — Symptoms of — 1022 Diagnosis and causes of — 1023 Treatment, &c — ibid. Bibliography and Refer- ences — 1024 Spec. 2d. Inflammation of the tongue — Glossitis — Definition, &c — 1176 a. Acuteglossitisdescribed — 1177 Course and consequen- ces of...? — ibid. Abscess of the tongue.. — ibid. b. Asthenic acute glossitis, course and termina- tion — ibid. Causes of acute glos- sitis — 1178 c. Superficial and partial glossitis — ibid. d. Chronic superficial glos- sitis — ibid. Prognosis of inflamma- tion of the tongue.... — 1179 Treatment of acute glos- sitis — ibid. Treatment of chronic glossitis — 1181 Symptomatic and com- plicated glossitis, treatment of — ibid. Treatment of partial and of chronic glossitis... — ibid. Bibliography and Refer- ences — 1184 Spec. 3d. Inflammation of the ton- sils — Tonsillitis — Synonymes and def- inition — 1150 Symptoms and causes of... — 1151 Course and duration of. — ibid. Abscess, enlargement, &c., of — 1152 Treatment of acute sthenic tonsillitis — 1160 Treatment of asthenic tonsillitis — 1161 Treatment of abscess of the tonsils — 1162 Spec. 4th. Inflammation of the pal- ate and fauces—Isth- CONTENTS—Special Pathology and Therapeujics. mitis—Angina—Syn- onyines and definition iii. 1 Symptoms and compli- cations of — 2 Chronic and ulcerated sore-throat — ibid. Treatment of acute, chronic, and compli- cated sore-throat — 3 Bibliography and Refer- ences — ibid. Spec. 5th. Inflammation of the fauces and pharynx — Pharyngitis — See Art. Throat.—Syno- nymes and definition of. — 1153 Causes and description of. — ibid. a. Mild, acute, and catar- rhal — 1154 Forms, their complica- tions, and termina- tions.... — ibid. b. Chronic pharyngitis.... — 1155 c. Pharyngitis with plastic exudation —Diphthe- ritis—Angina—mem- branacea — ibid. Description, and spe- cial and constitution- al symptoms of — ibid. Terminations and prog- nosis of — 1156 Appearances after death — 1157 d. Diffusive inflammation of the throat — As- thenic angina—Syn- onymes—Definition.. — ibid. Causes and symptoms... — ibid. Duration, termination, and prognosis — 1158 Complications, &c — 1159 Treatment of angina pharyngea. See Ton- sillitis — 1162 Treatment of angina membranacea — ibid. Treatment of diffusive angina — ibid. Treatment of the com- plications of angina.. — 1163 Diet and regimen — ibid. Bibliography and Refer- ences — 1166 Spec. 6th. Aphthous inflammation of the mouth, fauces, and pharynx—Thrush — Aphthae — Syno- nymes and definition. — 1167 Symptoms and charac- teristic features — ibid. Nature of aphthae — 1168 Treatment—local, hygi- enic, and medicinal... — 1169 Bibliography and Refer- ences — 1171 Spec. 7th. Inflammation of the oesophagus — (Eso- phagitis—Synonymes and definition ii. 1042 a. Causes and symptoms of acute — 1043 LIX LX Terminations and ap- pearances in fatal cases ii. 1044 b. Sub-acute and chronic oesophagitis — 1045 Consequences or lesions produced by — ibid. Stricture, ulceration, and their symptoms — ibul. Prognosis of chronic oesophagitis and of its consequences — 1047 Treatment of acute oeso- phagitis — 1048 Treatment of sub-acute and chronic, and of their consequences and complications.... — 1049 Bibliography and Refer- ences — 1052 Spec. 8th. Inflammations of the stomach—Gastritis— Synonymes, defini- tion, &c iii. 1000 Causes, predisposing and exciting — ibid. Description of the forms and states of. — 1001 a. The milder states of gastritis — 1002 b. Sub-acute gastritis — 1003 c. Acute or severe gas- tritis — ibid. Chronic gastritis — 1005 Appearances observed after death. — ibid. Diagnosis and prognosis of gastritis — 1006 Treatment of the milder states of — 1007 Treatment of the more » severe forms of. — ibid. Of the chronic states of gastritis — 1008 Treatment when asso- ciated with spasm.... — ibid. Spec. 9th. Inflammation of the du- odenum—Duodenitis — Synonymes and definition i. 793 Sub-acute and chronic duodenitis — ibid. Symptoms of acute duo- denitis — 794 Consequences and com- plications of duode- nitis — 795 Treatment of the slight- er and more chronic states of — 796 Treatment of the more acute, and of its con- sequences and com- plications — ibid. Bibliography and Refer- ences — 797 Spec. 10th. Inflammation of the small and large in- testines —Enteritis— Synonymes and def- inition ii. 658 A, Symptoms of inflamma- tion of the mucous CONTENTS—Special Pathology and Therapeutics. surface of small in- testines ii. 659 States, progress, and complications of, in adults and children... — 660 B. Symptoms of inflamma- tion of the follicular glands of the small intestines — 661 States, progress, and complications of fol- licular enteritis in adults and children.. — 662 C. Inflammation implicat- ing all the coats of the small intestines —Phlegmonous ente- ritis — 664 a. Symptoms of the acute form — ibid. b. Symptoms of sub-acute — 665 D. Inflammation of the large intestine—Co- litis—Definition — ibid. a. Symptoms of acute co- litis — 666 b. Symptoms of chronic colitis — ibid. E. Inflammation of both small and large in- testines — Ileo-colitis — Definition, &c ■— 667 a. Symptoms of acute ileo- colitis •— ibid. b. Ileo-colitis in hot coun- tries — ibid. c. Sub-acute and chronic ileo-colitis — 668 F. Pseudo - membraneous enteritis, forms and symptoms of. — 669 Associations or compli- cations of enteritis in adults and children... — 670 Diagnostic signs, symp- toms, and circum- stances of enteritis .. — 671 Diagnosis of the com- plications of — 673 Consequences, termina- tions, and prognosis.. — ibid. Appearances after death — 676 Causes, predisposing and exciting, of in- flammation of the in- testines — ibid. a. Treatment of acute and chronic mu co-enteri- tis and of muco-en- tero-colitis in adults and children — 679 b. Treatment of acute fol- licular enteritis and entero-colitis. — 681 c. Treatment of chronic follicular enteritis .... — 682 d. Treatment of phlegmo- noid or sero-enteritis. — 683 e. Treatment of enteritis with tubular or mem- braneous exudations. — ibid. Bibliography and Refer- ences — 689 CONTENTS—Special Pathology and Therapeutics. Spec. 11th. Inflammations of the CEecum and of its ap- pendix i. 331 Causes and history of... — 332 a. Symptoms of inflamma- tion of the mucous surface of — ibid. b. Acute inflammation of the coats of the c®- cum — ibid. c. Inflammation of the ap- pendix cffici — ibid. d. Inflammation of the pe- ricaecal tissue — 333 e. Chronic inflammation of the caecum — ibid. Consequences, compli- cations, and progno- sis of inflammation of the caecum — 334 Treatment of the sever- al states of inflamma- tion of the caecum, its appendix, &c — 335 Treatment of inflamma- tion of the pericaecal tissues and the com- plications — 336 Bibliography and Refer- ences — ibid. Spec. 12th. Inflammation of the rectum and anus — Proctitis—Definition, iii. 646 Remarks on the states and associations of... — ibid. a. Symptoms of acute sthenic proctitis — ibid. b. Symptoms of sub-acute and chronic procti- tis — 647 c. Asthenic acute proctitis — ibid. Consequences and ter- minations of the sev- eral states of procti- tis — ibid. Complications with co- litis and adjoining parts — 648 Causes and treatment of the several states of proctitis — ibid. Treatment of the conse- quences and compli- cations in adults and children — 649 d. Itching and mucous dis- charges from the anus, consequent upon irri- tation or inflamma- tion of the mucous surface — 649 Treatment of these af- fections — 650 e. Abscess of the rectum and anus — ibid. f. Several other conse- quences of proctitis described — 652 Treatment of abscess and other consequen- ces — 653 Bibliography and Refer- ences r. — 663 Genus 2d. Inflammation of the Bil- iary Organs. Spec. 1st. Inflammation of the liv- er —Hepatitis — Syn- onymes and definition . of. ii. 844 Remarks on the seats, states, and relations of hepatitis — ibid. A. Acute and sub-acute hepatitis described... — 845 a. When affecting chiefly the substance of liver — ibid. b. When seated chiefly in a part of the surface. — 847 B. Chronic inflammation of the substance and surfaces of the liver.. — 848 Consequences and ter- minations of hepati- tis — 849 C. Suppuration or abscess in the liver — ibid. Progress, course, and constitutional symp- toms of hepatic ab- scess — 850 Situations in which ab- scess generally opens— 851 Indications, signs, and symptoms of the pointing of hepatic abscess — ibid. D. Chronic enlargement of the liver — 852 Complications of hepati- tis—with periodic fe- vers—with dysentery —with gastritis, &c.. — 853 Prognosis of the several states of hepatitis — 854 E. Treatment of acute .and sub-acute hepatitis ... — 855 a. The means of cure re- viewed and comment- ed on — ibid. b. Of the use of mercurials in hepatitis — ibid. c. The treatment of hepa- titis in Europeans in warm climates — 859 d. Treatment of the com- plications of acute hepatitis — 860 e. Treatment of abscess of the liver — 861 f. The external opening of abscess of the liver... — 863 g. Treatment of chronic hepatitis — 864 Bibliography and Refer- ences — 877 Spec. 2d. Inflammation of the gall- bladder and ducts— Definition, &c., of.... — 6 Symptoms and consecu- tive changes — ibid. Pathological observa- tions — ibid. Treatment, constitution- al and local — 8 Bibliography and Refer- ences — ibid. LXI CONTENTS—Special Pathology and Therapeutics. LXII Genus 3d. Inflammation of the Pan- creas. Pancreatis — Definition, &c iii. 5 • Symptoms, progress, di- agnosis, and difficul- ties of — ibid. Complications, conse- quences, and termin- ations — 5, 6 Causes, treatment, &c.. — 6, 7 Genus ith. Inflammation of the Spleen —Splenitis. Synonymes and defini- tion of. — 981 Causes and history of splenitis — ibid. a. Acute splenitis, descrip- tion of. — 982 Appearances after death from — ibid. Abscess and other ter- minations of acute splenitis — ibid. b. Asthenic acute spleni- tis, generally consec- utive and complica- ted — 983 c. Chronic splenitis, symp- toms and consequen- ces of, in adults and in children — ibid. Diagnosis and prognosis of splenitis, and of its complications — 985 Treatment of acute sple- nitis — 986 Treatment of sub-acute and chronic splenitis. — 987 Treatment of the conse- quences and compli- cations ■— ibid. Means advised by au- thors .'. — 988 Bibliography and Refer- ences — 995 Genus 5th. Inflammation of the Urin- ary Organs. Spec. 1st. Inflammation of the kid- neys — Nephritis — Synonymes and defi- nition ii. 722 Var. a. Inflammation of the vascular and tubular structure of the kid- neys. Nephritis propria— Causes, &c — ibid. Description of its sever- al forms and states... — 723 Symptoms of acute and sub-acute nephritis... — ibid. Symptoms of chronic nephritis — 725 Consequences and ter- minations — ibid. Appearances observed after death — 727 Diagnosis of simple states of nephritis .... — 728 b. Modified states of ne- phritis — (a) Gouty nephritis — 729 (b) Rheumatic nephri- tis—Symptoms ii. 730 (c) Consecutive or as- thenic nephritis — ibid. Of the influence of ne- phritis in producing other maladies — 732 Complications and prog- nosis of nephritis — 733 Treatment of the pri- mary and simple forms — 734 Treatment of the modi- fied and consecutive states — 735 Spec. 2d. Cachectic nephritis — Granular disease of the kidneys—Albu- minous nephritis — Inflammation of the Malpighian corpus- cles—Synonymes and definitions — 736 Description—Symptoms and terminations of acute albuminous ne- phritis — ibid. Symptoms of chronic cachectic nephritis... — 737 Appearances of the sev- eral stages of the dis- ease after death — 741 Diagnosis of acute and chronic cachectic ne- phritis ; — 744 Complications and rela- tions of cachectic ne- phritis ibid. Nature of cachectic or albuminous nephritis — 750 Prognosis, circumstan- ces connected with... — 751 Causes, predisposing and exciting — 752 Treatment of the acute and sub-acute forms and early stages — 753 Treatment of the chron- ic states — 754 Treatment of the com- plications and rela- tions, individually considered — 755 Spec. 3d. Inflammation of the pel- vis and calices of kid- neys—Pyelitis—Def- inition of. — 757 Symptoms, with refer- ence to the severity and causes of the dis- ease... — ibid. Diagnosis of pyelitis — 759 • Complications and prog- nosis — 761 Complications with cal- culi and other diseas- es of the urinary or- gans, &c — ibid. Pyelo-nephritis, or in- flammation of the pelvis, * calices, and substance of the kid- neys — 762 Peri-nephritis —inflam- mation extending to * the fibrous, cellular, and adipose tissues .. ii. 763 Treatment of pyelitis— of the acute and early states — ibid. Of the states depending on renal calculi — 764 Of the chronic states of pyelitis — ibid. Bibliography and Refer- ences — 771 Spec. 4th. Inflammation of the uri- nary bladder—Cysti- tis—Synonymes and definition iii. 1300 Tissues and parts chief- ly affected — ibid. Var. a. Acute inflammation of the mucous surface of — ibid. Consequences and ter- minations of — 1301 Chronic inflammation of the mucous coat — ibid. b. Acute inflammation, comprising the coats of the urinary bladder —True cystitis — 1302 Consequences and ter- minations of. — ibid. Chronic cystitis—Dura- tion and consequence — 1304 Complications of cystitis— 1305 Appearances after death — 1306 Diagnosis and prognosis of — ibid. Causes, predisposing and exciting — 1307 Treatment of acute mu- co-cystitis — 1308 of chronic muco- cystitis — 1309 of acute uro-cysti- tis — 1310 of chronic uro-cys- titis —• 1311 when the perito- neal coat is implica- ted — ibid. Bibliography and Refer- ences — 1313 Spec. 5th. Inflammation of the prostate gland—Pro- statitis — Definition, &c — 506 Causes and description of — ibid. Symptoms of acute pro- statitis — 507 . Symptoms of chronic prostatitis — ibid. Alterations observed, di- agnosis and progno- sis — 508 Complications and treat- ment of a’cute and chronic prostatitis and their consequen- ces — 509 Bibliography and Refer- ences — 512 CONTENTS—Special Pathology and Therapeutics. Genus 6th. Inflammation of the Fe- male Sexual Organs. Spec. 1st. Inflammation of the ova- ria—Ovaritis. Synonymes and defini- tion ii. 1061 Causes, predisposing and exciting — 1062 Symptoms of the sev- eral states of ovaritis — ibid. Consequences and ter- minations — 1063 Treatment of the sev- eral states of. — ibid. Bibliography and Refer- ences — 1067 Spec. 2d. Inflammation of the ute- rus and appendages —Definition iii. 1365 Var. a. Of the neck and mouth of the uterus.. — ibid. Causes and symptoms of. — 1366 Appearances and con- sequences of. — ibid. b. Inflammation of the body of the uterus— Metritis — 1371 (a) Internal metritis — Endo-metritis — Symptoms, progress, and terminations — ibid. (i) Acute metritis—Seat, symptoms, termina- tions, &c — ibid. Diagnosis, prognosis, and appearances after death — 1373 (c) Sub-acute and chron- ic metritis — ibid. Local and constitution- al symptoms — ibid. Progress, terminations, and diagnosis — 1374 Enlargement of the body of the uterus—Signs, symptoms, &c — ibid. c. Inflammation and ab- scess of the Fallopian tubes and cellular tis- sue — 1375 (a) Causes, symptoms, and progress of — 1376 (b) Terminations and prognosis of — ibid. d. Associations or compli- cations of metritis — 1377 e. Treatment of inflamma- tion of the uterus and appendages — 1379 (a) Of inflammation of the cervix and its con- sequences — ibid. (b) Treatment of hyper- trophy and induration of cervix — 1383 (c) Of acute inflamma- tion of the internal surface and body of the uterus — 1384 (d) Treatment of chron- ic metritis and en- larged uterus — 1385 LXIII LXIV CONTENTS—Special Pathology and Therapeutics. (e) Of inflammation and abscess of the uterine appendages iii. 1386 f. Inflammation of the ute- rus and appendix of a specific nature — ibid. (a) Gonorrhoeal inflam- mation of these parts — ibid. (/>) Syphilitic ulceration of the cervix uteri.... — 1387 (c) Treatment of spe- cific inflammations of these parts — ibid. Bibliography and Refer- ences — 1410 Spec. 3d. Inflammation of the ute- rus and appendages in the puerperal states —Puerperal metritis and ovaritis — 565 A. Symptoms of puerperal metritis — Acute and sub-acute — ibid. Course and terminations of — 566 Appearances on dissec- tion — ibid. B. Symptoms of inflamma- tion of the ovaria and Fallopian tubes — 567 Course and terminations of. — ibid. Diagnosis of puerperal inflammation of the uterus and append- ages — 581 Treatment of puerperal metritis and ovaritis.. — 585 Genus 7th. Inflammation of the Peri- toneum, affecting more or less some portion of its expansion—Par- tial or general Peri- tonitis. Spec. 1st. Non-puergeral peritoni- tis—Peritonitis inde- pendently of the puer- peral states — Syno- nymes and definition of — 73 A. Symptoms of acute sthenic peritonitis.... — ibid. a. Partial states of acute sthenic peritonitis.... — ibid. b. Peritonitis omentalis — Omental peritonitis .. — 75 B. Acute general perito- nitis, symptoms and course of — ibid. C. Asthenic general perito- nitis—Dififusive peri- tonitis — 76 Forms and states of, de- scribed — ibid. Consequences and ter- minations of acute general peritonitis — 77 D. Chronic peritonitis, lit- erary history of. — 78 a. Primary chronic perito- nitis, symptoms of... — 80 b. Consecutive chronic pe- ritonitis. — 81 E. Acute, sub-acute, and chronic peritonitis in children iij. 82 Chronic tubercular peri- • tonitis in children.... — 83 F. Complications of peri- tonitis, reviewed and commented on — ibid. G. Appearances on dissec- tion—(a) after acute sthenic peritonitis.... — 84 (b) After acute asthenic peritonitis — 87 (c) The lesions observed after chronic perito- nitis — ibid. Diagnosis between pe- ritonitis and visceral diseases — 91 Prognosis of the several states of peritonitis... — 93 Causes, predisposing and exciting — ibid. Treatment—(a) of acute sthenic peritonitis.... — 95 (b) of acute asthen- ic peritonitis — 97 (c) of chronic peri- tonitis — 98 (d) of the compli- cations of peritonitis. — ibid. (c) of peritonitis in children — 100 (/) of convales- cence from peritoni- tis — ibid. Bibliography and Refer- ences — 105 Spec. 2d. Peritonitis in the puer- peral states—Puerpe- ral peritonitis — 564 Symptoms, course, and terminations of. — ibid. Diagnosis and prognosis of -581-3 Treatment of —• 585 Genus 8th. Inflammation of the Mes- entery and. of its Glands. Difficulties connected with the diagnosis of diseases of these parts ii. 983 Spec. 1st. Inflammation of the mesentery—Mesente- ritis—Definition, &c.. — ibid. Great difficulty attend- ing the diagnosis of.. — ibid. Symptoms and history of its several states... — ibid. Consequences and treat- ment of — ibid. Spec. 2d. Inflammation of the mesenteric glands.... — 984 Difficulty of its diagno- sis — ibid. Recognised chiefly by its effects, &c. See Class IV., Order I. Genus 9th. Inflammation of the 0?- gans of Respiration. Spec. 1st. Inflammation of the dia- phragm — Diaphrag- mitis—Definition, &c. i. 599 Seats and causes of dia- phragmitis i. 599 Symptoms and compli- cations of. — 600 Causes and termina- tions, and prognosis of — ibid. Treatment of —■ 601 Bibliography and Refer- ences — 602 Spec. 2d. Inflammation of the pleura — pleuritis — Synonymes and defi- nitions iii. 297 Causes, predisposing, exciting, and patho- logical of — 298 Description of the changes constituting pleurisy — 299 The physical signs and symptoms — (a) of sthenic acute pleuri- sy — 300 Consecutive effects and terminations of acute sthenic pleurisy —• 304 (i) Of dry pleurisy — ibid. (c) Of asthenic pleurisy — Cachectic pleurisy — 306 (d) Of partial pleurisy ■— Diaphragmatic — Mediastinal, &c — 307 (e) Of double pleurisy.. — 308 (/) Of chronic pleurisy —Empyema — ibid. Signs of absorption of the effusion — 311 Persistent empyema, &c — 313 Terminations of chron- ic pleurisy — 314 Complications of pleuri- sy — ibid. Pleurisy in infants and children — 316 The state of the blood in pleurisy — 317 The pathological states and alterations, &c... — 318 The diagnosis of pleuri- sy — 323 Prognosis, with refer- ence to the forms and states — 325 Pleuro - pneumonia, or pleurisy associated with pneumonia — 326 Different states and as- sociations of pleuro- pneumonia — ibid. a. History of the treatment of pleurisy — 327 b. Means advised by the Author — 329 c. Treatment for acute pleurisy — ibid. d. Of the asthenic and la- tent states — 330 e. Of partial and double pleurisy — 331 /. Of chronic pleurisy and empyema — ibid. CONTENTS—Special Pathology and Therapeutics. LXV g. Of paracentesis thoracis in chronic pleurisy... iii. 332 h. Treatment of the com- plications of pleurisy. — 335 Of pleuro - pneumonia, &c — ibid. i. Treatment of pleurisy in the dark races — ibid. k. Treatment of pleurisy in infants and chil- dren — 336 l. Diet and regimen dur- ing and in convales- cence — ibid. Bibliography and Refer- ences — 340 Spec. 3d. Inflammation of the lungs—Pneumonia— Pneumonitis— Syno- nymes and definition. ii. 878 A. Primary acute pneumo- nia, its seat, &c — 879 The usual symptoms and course of the sthenic form — ibid. Structural changes marking the stages of pneumonia — 881 Diagnosis of the stages and consequences of simple pneumonitis.. — 883 B. Varieties and complica- tions of pneumonia... — 886 a. Asthenic, congestive, or nervous pneumonia.. — ibid. b. Complications — Broncho - pneumonia —Pleuro-pneumonia, &c — 887 Tubercular, haemorrhag- ic, consecutive, and other complicated states — 889 Causes, predisposing, exciting, endemic, and epidemic — 890 Duration, terminations, and prognosis of pneumonia — 892 Treatment of the stages of sthenic pneumonia — 893 Treatment of asthenic or congestive pneu- monia — 896 Treatment of complica- ted pneumonia — 897 Treatment of pneumo- nia in infants and children — 898 Treatment of pneumo- nia in the dark races. — 899 Diet and regimen in pneumonia — ibid. C. Chronic pneumonia, pri- mary and consecutive, description of. — 900 Treatment of — ibid. Spec. 4th. Inflammation of the bronchi — Bronchitis — Synonymes and definition of i. 302 A. Symptoms of acute bronchitis — 303 LXVI a. Of catarrhal bronchitis . i. 303 b. Of true or sthenic bron- chitis — ibid. c. Of asthenic bronchitis.. — 304 Duration and termina- tions of acute bron- chitis — 305 Complications in chil- dren and adults — 306 B. Symptoms of sub-acute and chronic bronchi- tis — 307 Appearances in fatal cases of acute and chronic bronchitis — 308 Diagnosis of the several forms and states — ibid. Prognosis of the acute and chronic states.... — 310 Predisposing and ex- citing causes — 311 Treatment of the sever- al states and stages of acute bronchitis ... — ibid. Treatment of their com- plications — 315 Treatment of sub-acute and chronic bronchi- tis — 316 Of inhalations, &c., for. — 319 Treatment of the com- plications of chronic bronchitis — 320 The regimenal ' treat- ment of bronchitis — ibid. Bibliography and Refer- ences — 323 Spec. 5th. Inflammation of the larynx and trachea— Laryngitis —- Trachi- tis—Laryngo-trachei- tis—Synonymes and definition ii. 786 (Inflammation may be seated chiefly in the larynx or in the trach- ea, but most frequent- ly it extends from the one to the other, and not unfrequently from the pharynx to the la- rynx ; and sometimes also to the trachea and larger bronchi, especially in angina membranacea.) A. Symptoms of catarrhal laryngitis •— ibid. B. Acute laryngitis, forms and stages of — ibid. C. Consecutive and com- plicated acute laryn- gitis •— 788 D. Asthenic acute laryngi- tis — 789 E. Consecutive and com- plicated asthenic — ibid. F. Chronic laryngitis, sim- ple, consecutive, and complicated — 790 Syphilitic chronic laryn- gitis — 791 Appearances after death CONTENTS—Special Pathology and Therapeutics. from sthenic, asthen- ic, and chronic laryn- gitis ii. 792 Diagnosis of acute, com- plicated (laryngo-tra- cheitis), and chronic laryngitis — 793 Prognosis of the several forms, &c — 795 Causes of the forms, states, and complica- tions — ibid. Treatment of acute sthenic laryngitis — 796 Ofthe complicated states of the disease — 798 Treatment of acute as- thenic laryngitis — 799 Of chronic laryngitis — ibid. Local and constitutional means advised for la- ryngitis — 801 Bibliography and Refer- ences — 807 Genus 10th. Inflammation of the Mediastinum—Syno- nymes—Definition. Symptoms, causes, com- plications — 951 Terminations in abscess, &c — 952 Treatment of inflamma- tion and abscess of the mediastinum — ibid. Bibliography and Refer- ences — 953 Genus 11th. Inflammation of the Heart and Pericar- dium—Definition. Division of, and remarks on, this subject — 208 Spec. 1st. Inflammation of the en- docardium—Endocar- ditis — Synonymes and definition — 209 History of, and appear- ances after death — ibid. Symptoms and diagno- sis of the several stages — 211 Symptoms of lesions of the different valves... — 212 Spec. 2d. Inflammation of the pe- ricardium — 214 Structural lesions in the acute stage — ibid. Symptoms and diagno- sis of pericarditis and of its consequences.. — 216 Spec. 3d. Inflammation of the structure of the heart —True carditis—Sy- nonymes and defini- tion — 220 Structural lesions in true carditis — ibid. The symptoms and diag- nosis of — 223 The predisposing and exciting causes of in- flammation of the heart and pericar- dium — 224 CONTENTS—Special Pathology and Therapeutics. LXVII Remarks on the patho- logical states of ii. 225 The diagnosis of inflam- mations of the heart and pericardium, and of their complications — 227 The prognosis, duration, and terminations of inflammations of the heart, &c — 228 The prognosis of the above species — ibid. The treatment of in- flammations of the heart and pericardi- um — 229 Of the more acute states of — ibid. Of the sub-acute and chronic states of. — 230 Treatment of other states, complications, and relapses — ibid. Causes, symptoms, and treatment of carditis and pericarditis in children — 234 Bibliography and Refer- ences — ibid. Genus 12th. Inflammation of the Cir- culating' Systems. Spec. 1st. Inflammation of arteries — Artereitis — Syno- nymes and definition, i. 126 Pathology, causes, and lesions of artereitis... — ibid. Symptoms of acute ar- tereitis — 128 Of chronic artereitis, and of the complica- tions — 129 Diagnosis and prognosis of — 130 The treatment of acute and chronic artereitis and their complica- tions — 135 Bibliography and Refer- ences — 136 Spec. 2d. Inflammation of veins — Phlebitis — Syno- nymes and definition, iii. 1437 The causes of phlebitis. — 1438 The local and constitu- tional symptoms of... — ibid. The different patholog- ical states of phlebi- tis — 1439 Seats of phlebitis — Symptoms and con- sequences — 1441 Diagnosis, prognosis, and pathological in- ferences — 1442 Treatment of phlebitis.. — ibid. Review of the treatment previously employed. — 1443 Treatment advised by the Author — 1444 In the first or local pe- riod of phlebitis — 1445 In the second or con- taminating stage — 1446 Bibliography and Refer- ences iii. 1452-3 Spec. 3d. Inflammation of the lymphatic vessels — Lymphangeitis — Sy- nonymes and defini- tion ii. 918 Causes, predisposing and exciting — 919 Description and diagno- sis of acute and chron- ic lymphangeitis *— ibid. Terminations, progno- sis, and morbid ap- pearances — 920 Treatment—indications and means of cure ... — 921 Spec. 4th. Inflammation of lym- phatic glands—Lym- phadenitis — Defini- tion — 923 Symptoms of acute, chronic, and specific lymphadenitis — ibid. Causes, local and con- stitutional — 924 Treatment of acute, chronic, and specific lymphadenitis — 925 Bibliography and Refer- ences — 928 Genus 13th. Inflammation of the Structures requisite to the Mental and Ani- mal Manifestations. Spec. 1st. Inflammation of the membranes and sub- stance of the brain— Definition i. 279 Pathological observa- tions, &c — ibid. ~Vox.A. Inflammation of the membranes — Menin- gitis—Definition — 280 Symptoms of acute me- ningitis — ibid. Symptoms and lesions of chronic meningitis — 281 B. Inflammation of the sub- stance of the brain— Cerebritis — Cephali- tis—Definition — 282 Precursory and mediate symptoms- of general and partial cephalitis. — 282-3 C. Inflammation of both the membranes and substance of the brain — Phrenitis — Ence- phalitis—Definition .. — 283 Seat and symptoms of the stages of. — 284 Predisposing and excit- ing causes — 285 Diagnosis of encephali- tis — ibid. States, forms, and com- plications — 286 Terminations and prog- nosis — ibid. D. Treatment of idiopathic and simple encephali- tis — 287 LXVIII Treatment of the com- plicated states of. i. 289 Of the more unfavoura- ble and anomalous states — 290 Treatment of the sub- acute and chronic states, particularly in children — 291 Treatment of the se- quela} of encephalitis — 292 Regimen, &c., during the disease — ibid. Bibliography and Refer- ences — 295 Spec. 2d. Inflammations of the membranes and sub- stance of the spinal cord—Rachialgitis— Definitions iii. 956 Pathological observa- tions — ibid. A. Inflammation of the membranes of the spi- nal cord — Meningi- tis spinalis — Defini- tion — 957 Symptoms of acute spi- nal meningitis — 958 Association of spinal meningitis with cere- bral meningitis — ibid. Symptoms of chronic spinal meningitis — 959 B. Inflammation of the structures of the spi- nal cord—Myelitis ... — 961 Symptoms of acute my- elitis — ibid. Symptoms of chronic myelitis — 962 Diagnosis and compli- cations of inflamma- tions of the mem- branes and substance of the spinal cord — 963 Prognosis of the several states and associa- tions of. — ibid. Treatment of acute and chronic spinal menin- gitis, and their com- plications — 964 Treatment of acute and chronic myelitis — 965 Bibliography and Refer- ences — 973-6 Genus 14th. Inflammations of the Or- gans of Sense. Spec. 1st. Inflammations of the eye —Ophthalmia—Defi- nition i. 985 Predisposing and excit- ing causes, and their modes of operation... — ibid. A. Inflammation of the ex- ternal tissues of the eye — 986 (a) Mild inflammation of the conjunctive — 987 Treatment of. — ibid. (£) Symptoms of severe inflammation of the CONTENTS—Special Pathology and Therapeutics. conjunctive — Puru- lent ophthalmia i. 988 Of purulent ophthalmia in infants — ibid. Causes, symptoms, and progress of — ibid. Terminations and prog- nosis — 989 Treatment and means of cure — 990 Purulent ophthalmia in adults — 991 Causes and contagion of. — 992 Symptoms, diagnosis, prognosis, and conse- quences of — 994 Local and general treat- ment of the states and grades of — 996 (c) Gonorrhoeal ophthal- mia, progress and con- sequences of — 1002 Diagnosis, prognosis, and causes of. — ibid. Treatment of — 1003 (d) Pustular and scrofu- lous ophthalmia, caus- es, symptoms, and course — 1005 Diagnosis, consequen- ’ ces, &c — 1007 Treatment, regimen, &c. — ibid. (e) Exanthematous oph- thalmia, forms, ap- pearances, &c., of.... — 1009 Treatment of. — ibid. B. Inflammation of the proper coats of the eye—Definition — 1010 (a) Symptoms, course, and effects of. — ibid. Diagnosis and prognosis of — 1011 Treatment of the acute states, general and local — ibid. Of the sub-acute and chronic states — 1012 (&) Rheumatic, catarrho- rheumatic, and ar- thritic ophthalmia — Symptoms and course of. — ibid. Treatment of — 1013 (c) Inflammation, acute, sub - acute, chronic, and scrofulous, of the cornea—Corneitis.... — ibid. Treatment of these states of corneitis — 1014 C. Inflammation of the in- ternal parts of the eye — 1015 (a) Inflammation of the anterior chamber — ibid. Treatment, &c., of — 1016 (J) Inflammation of the iris—Iritis — ibid. Causes, symptoms, and grades of iritis — ibid. Diagnosis, prognosis, and consequences — 1017 Treatment of ■— 1018* j CONTENTS—Special Pathology and Therapeutics. LXIX The pathology, connex- ions, and treatment of sympathetic iritis i. 1018 D. Inflammations of the in- ternal coats of the eye — Internal ophthal- mia — 1019 (a) Inflammation of the re- tina, acute and chron- ic — Symptoms and course of. — ibid. Treatment of — 1020 (b) Inflammation of the choroid coat, its symp- toms and treatment... — ibid. (c) Arthritic, and other forms of inflamma- tion — ibid. Treatment of. —1021-2 E. Inflammation of the whole eye — Defini- tion — 1022 Symptoms, diagnosis, course, and conse- quences of — ibid. Treatment of its stages and forms — ibid. Bibliography and Refer- ences — 1023 Spec. 2d. Inflammation of the ear —Otitis—Definition.. — 847 a. Symptoms of external and internal acute otitis — ibid. Consequences and le- sions — 848 b. Symptoms of chronic otitis—Otorrhoea — 849 Consequences and le- sions... — ibid. Prognosis and causes... — 850 c. Treatment of acute ex- ternal and internal otitis —» 851 Treatment of chronic otitis and otorrhoea... — 852 Bibliography and Refer- ences — 853 Genus 15th. Inflammation of Muscu- lar and Fibrous Struc- tures. Spec. 1st. Inflammation of muscu- lar structure—Myosi- tis—Definition ii. 995 Causes, symptoms, and consequences — ibid. Suppuration, gangrene, induration — ibid. Treatment of myositis.. — 996 Bibliography and Refer- • ences — 998 Spec. 2d. Inflammation and sup- puration of the psoae muscles — Psoitis — Definitions iii. 516-19 Causes, symptoms, and diagnosis of. — 516 Diagnosis of psose ab- scess and prognosis.. — 517 Treatment of psoitis and of psoae abscess — ibid. Bibliography and Refer- ences — 519 Spec. 3d. Inflammation of fibrous tissues i. 1230 Causes, states, and con- sequence — 1231 Alterations produced by — ibid Inflammation of fibrous tissues of joints — 1233 Bibliography and Refer- ences — ibid [See, also, Gout, Rheu- matism, &c.] Genus 16th. Inflammation of the Pe- riosteum and Bones. Spec. 1st. Inflammation of the pe- riosteum —Periostitis —Definition iii. 69 Symptoms of acute and sub-acute periostitis.. — ibid. Symptoms of chronic periostitis — 70 Associations, conse- quences, and lesions. — ibid. Diagnosis and causes... — 71 Treatment of the acute and early stages — 72 Of the chronic, suppura- tive, and other states — ibid. Bibliography and Refer- ences — ibid. Spec. 2d. Inflammation of bones — Osteitis — Defini- tion ii. 1053 Causes, seat, and ana- tomical characters— — ibid. Symptoms, progress, consequences, and terminations — 1054 Suppuration, caries, and necrosis — 1055 Causes and symptoms of necrosis — ibid. Of the formation of new bone — 1056 Treatment of osteitis.... — ibid. Treatment of scrofulous and syphilitic ostei- tis — 1057 Treatment of necrosis... — ibid. Bibliography and Refer- ences — 1060 Genus 17th. Specific Inflammations capable of affecting various parts—Vene- real diseases—Syno- nymes and definition. iii. 1454 (Arising from a spe- cific contagion.) Spec. 1st. Inflammation of the ure- thra — Gonorrhoea — Definition — ibid. Symptoms in the female and in the male — 1455 Secondary effects and complications — ibid. [See, also, Gonorrhoeal Ophthalmia and Gon- orrhoeal Rheumatism.] Treatment of gonorrhoea in the female and in the male — ibid. Treatment of the ad- vanced stages and consequences —1457-8 LXX Spec. 2d. Syphilis—Lues venerea —History of. iii. 1459 Question as to its ori- gin, and period of its appearance in Europe — ibid. a. Description of primary syphilis, and of the forms of chancre — 1464 Diagnosis of primary chancre — 1465 b. Syphilitic bubo, diagno- sis of — 1466 c. Secondary syphilis, the various affections of, described — ibid. Diagnosis of secondary eruptions — 1468 Secondary affection of the scalp — ibid. d. Secondary affections of mucous surfaces — 1469 e. Tertiary syphilitic dis- eases described — ibid. Course and forms of.... — 1470 Syphilitic affections of the testes, periosteum, bones, and joints — 1471 The syphilitic cachexia, symptoms and diag- nosis of — ibid. f. Syphilis in the foetus, infants, and children. — 1472 g. Varieties or modifica tions of syphilis — syphiloid diseases.... — 1473 (a) Syphilis iEthiopica —Yaws—described.. ■— ibid. (b) Sibbens, or sivvens, description of. — 1474 (c) Pian, or epian — Yaws of the West. Indies — 1475 (d) Other appearances and modifications — ibid. h. Diagnosis of primary, secondary, and tertia- ry syphilis —1476-7 i. Prognosis of syphilis, local and constitu- tional — 1477 k. The efficient cause of syphilis, and the cir- cumstances aiding its operation — 1478 Of the infection of the foetus — Congenital syphilis — 1480 l. Inferences as to origin, and pathology of sy- philis — 1481 m. Treatment, history of... — 1482 Of primary syphilis and gangrenous chancre.. — 1485 Of the non - mercurial treatment of primary syphilis — ibid. Treatment of constitu- tional or secondary syphilis — 1486 Of tertiary syphilis, and means advised — 1488 Of the inoculation of syphilis, or of syphi- CONTENTS—Special Patholog/ and Therapeutics. lization as a cure and a prevention iii. 1489 History of, and modes of inoculation —1489-91 Bibliography and Refer- ences —1492-4 Genus 18th. Ciseases resulting from morbid diathesis or states of the constitu- tion —from impaired organic nervous power, and from morbid states of the blood owing to impaired or suppressed depurating function, and not confined to any organ or part. Spec. 1st. Gout—Arthritis—Syno- nymes—Definition ii. 37 A. History of acute gout... — 38 Of the local and consti- tutional symptoms of the fit — ibid. The sequelae of acute gout — 40 B. Chronic gout, local and constitutional symp- toms — ibid. Concomitants and con- sequences of — 41 C. Irregular gout, described — ibid. a. Retrocedent or displaced gout — 42 b. Disguised or lurking gout — 43 Diagnosis and prognosis of gout — 44 Causes, predisposing and exciting — 46-8 The pathological condi- tions of gout — 48 The states of the blood, and of the depurating functions — 49 D. Treatment, the opinions of the ancients as to the — 52 a. Treatment of the parox- ysm of acute gout.... — 54 Treatment by renal and other depurants of the blood — 56 Local treatment of the paroxysm — 58 Of diet and regimen, and of convalescence — 59 The empirical treatment of acute gout — 60 b. Treatment of chronic gout — 61 The local treatment of.. — 62 c. Treatment of irregular gout — 63 Of retrocedent gout — ibid. Of misplaced gout — 64 Of mineral and thermal waters in gout — 66 The prevention of gout. — 67 Bibliography and Refer- ences — 70 Spec. 2d. Rheumatism — Syno- nymes—Definition... iii. 663 A. Description—a. of acute CONTENTS—Special Pathology and Therapeutics. and sub-acute rheu- matism iii. 664 b. Of chronic rheumatism. — 666 Chronic, of the joints... — 667 Of the seats of acute and chronic rheuma- tism — 669 c. Gonorrhoeal rheumatism — 672 Of the complications, extensions, or metas- tasis of rheumatism .. — 673 Of the states of the blood and excretions in rheumatism — 675 Diagnosis and progno- sis — 677 Remote causes, predis- posing and exciting.. — 678 B. The nature and pathol- ogy of rheumatism... — 680 a. Treatment of acute and sub - acute rheuma- tism — 684 Means advised by writ- ers — ibid. Treatment advised by the Author — 688 b. Treatment of the chron- ic states of rheuma- tism — 689 Review of remedies for, with comments — ibid. Review of various means recommended for the several forms — 692 Of several external means — 693 Of mineral waters and baths, and physical training — 694 c. Treatment of the com- plications of rheuma- tism — 696 d. Of gonorrhoeal rheuma- tism — 698 Regimen, diet, and change of air — 700 Bibliography and Refer- ences ,, — 700-2 Sub-Order.—Inflammatory Diseases of the Integuments. Genus lsi. Dermatites simplices — Eczemata — Defini- tion — 889 Spec. 1st. Erythema—Synonymes —Definition, and va- rieties of, described .. i. 971 Causes and diagnosis of — 973 Treatment of its varie- ties — ibid. Bibliography and Refer- ences — 974 Spec. 2d. Rose-rash — Roseola— Synonymes and defi- nition of iii. 712 Description of its varie- ties — ibid. Diagnosis and causes... >— 713 Treatment and Bibliog- raphy — 714 Spec. 3d. Nettle-rash — Urticaria — Synonymes and definition iii. 1358 Description of its varie- ties — ibid. Associations, diagnosis, and prognosis — 1359 Causes, treatment, and Bibliography — 1380 Spec. 4th. Lichen — Lichenous- rashes — Synonymes —Definition ii. 826 Description of its varie- ties... _ ibid. Diagnosis, treatment, and Bibliography — 828 Spec. 5th. Prurigo—Synonymes— Definition iii. 512 Description of its varie- ties.... — ibid. Diagnosis, prognosis, and causes of. — 513 Treatment of its varie- ties and Bibliography — 514 Spec. 6th. Eczema — Synonymes —Definition i. 856 Description of its states and varieties — ibid. Diagnosis, prognosis, and causes of. — 858 Treatment of its varie- ties and Bibliography, &c —858-60 Spec. 7th. Herpes—Herpetic erup- tions—Synonymes—• Definition ii. 267 Description of its varie- ties — ibid. Causes and diagnosis of — 269 Treatment and Bibliog- raphy, &c — 270-1 Genus 2d. Dermatites Squamosa. Synonymes—Definition iii. 870 Spec. 1st. Pityriasis—Synonymes —Definition — 291 Description of its varie- ties — ibid. Diagnosis, prognosis, causes, and complica- tions — 294 Treatment, Bibliogra- phy, &c — 295-6 Spec. 2d. Psoriasis and lepriasis — Synonymes and definition — 519 Causes, predisposing and exciting — ibid. A. Description of the vari- eties of psoriasis — 521 B. Description of the vari- eties of lepriasis — 523 C. Of syphilitic psoriasis and lepriasis — 524 Diagnosis and prognosis — 525 The pathology of scaly eruptions — 526 Treatment and thera- peutical intentions ... — ibid. Remedies advised and commented on — 527 Mineral waters, regi- men, and diet — 530 Bibliography and Refer- ences — 531 LXXI LXXII CONTENTS—Special Pathology and Therapeutics. Genus 3d. Pustular and Vesicular Eruptions. Synonymes—Definition iii. 611 Remarks on the erup- tions comprised as pustular — ibid. Spec. 1st. Ecthyma — Synonymes —Definition i. 853 Description of its varie- ties — ibid. Diagnosis and causes of — 854 Treatment and Bibliog- raphy, &c — 855 Spec. 2d. Impetigo — Impetigin- ous affections—Syno- nymes and definition, ii. 363 Description of its varie- ties — 364 Complications, diagno- sis, prognosis, and causes — 365 Treatment of the varie- ties, Bibliography, &c. — 367-9 Spec. 3d. Itch — Psora — Syno- nymes—Definition ... — 716 Description of its forms and varieties — 717 Complications of. — ibid. Diagnosis and causes... — 718 Treatment and Bibliog- raphy — 719-21 Spec. 4th. Malignant pustule — Contagious carbuncle —Synonymes—Defi- nition iii. 612 Causes — ibid. Description of its forms and terminations — C13 Appearances in fatal cases —613-14 Diagnosis and progno- sis — 614 Treatment and Bibliog- raphy —614-15 Genus 4th. Bailee — Blains — Syno- nymes—Definition.... i. 326 (Is chiefly symptom- atic.) Spec. 1st. Pemphigus — Syno- nymes — Definition.. iii. 64 Description of the acute — ibid. Description of the chron- ic — 66 Diagnosis and progno- sis — 67 Treatment of acute and chronic — 68 Bibliography and Refer- ences — 69 Spec. 2d. Rupia — Synonymes — Definition — 720 Diagnosis, prognosis, and causes of. — ibid. Treatment, &c — 721 For other diseases of the skin, see Class Fourth, and the mala- dies of which affections of the skin are symptomatic. Also, see Art. Skin, Functional and Structural Lesions of, and the Classification of the Dis- eases OF OR AFFECTING THE Skin in that article. Order II.—Diseases arising from Depressing Causes, charac- terized at their Commence- ment by Impaired Vital or Organic Nervous Force, but generally followed by more or less Reaction throughout the Frame, but often more PROMINENTLY EXPRESSED IN ONE or more Organs — Fevers — Definition i. 1039 General observations and view of fever — ibid. Characters of fever, with remarks on each — 1040 General description of idiopathic fe- ver — 1041 Of symptomatic fever — 1044 The diagnosis of fever — ibid. The general course of. — 1045 The stages of fever described — ibid. Arrangement of the types and forms of fever — 1048 The terminations of fever — 1049 The appearances after death by fever — 1050 The prognosis of fevers — 1051 The remote causes of fever — 1053 History of opinions as to the nature of fever — ibid. Pathological states and early changes in fever — 1060 Existing opinions as to the nature of fever — 1061 Author’s opinion of the operation of the causes of, and of the early changes in fever — 1064 Of the consecutive pat hological states — 1067 Of the development of complications of fever — ibid. The general treatment of fevers — 1069 The prophylaxis of fevers, and the means for, advised — ibid. Of the arrest of the morbid impres- sion by the causes of. — 1070 The curative treatment of fevers, and the indications which should direct it — 1071 Review, with comments, on the sev- eral means advised for fevers — 1072 Of the regimen, food, drink, and management of patients in fever... — 1082 Of the treatment of convalescence and relapses — 1083 Bibliography and References —1083-5 Genus 1st. Periodic Fevers — Inter- mittent and Remittent Fevers. Spec. 1st. Intermittents or agues —Definition — 1085 The arrangement of agues noticed — ibid. A. Simple, mild, and un- complicated ague — ibid. The types and intermis- sions of — 1086 B. Inflammatory ague, or ague with inflamma- tory reaction — ibid. C. Ague, with oppression of vital power—Con- gestive ague — ibid. D. Complicated or malig- nant ague — 1087 LXXIII E. Masked or anomalous ague i. 1088 Consequences and ter- minations — ibid. Appearances in fatal cases — 1089 Prognosis and diagno- sis of agues — ibid. Remote causes and na- ture of intermittents. — ibid. Treatment of the sev- eral forms of inter- mittents during the paroxysm — 1093 Treatment in the inter- missions — 1094 Remedies to prevent the return of the fit — 1096 Treatment of masked ague, and of the se- quel® — 1098 Of convalescence, regi- men, diet, &c — 1099 Bibliography and Refer- ences — ibid. Spec. 2d. Remittent or exacerba- ting fever—Definition — 1100 Predisposing and excit- ing causes of — ibid. A. Description of mild re- mittent — 1101 B. Of inflammatory remit- tent — ibid. C. Of bilio - inflammatory remittent — 1102 D. Of the adynamic or ma- lignant — ibid. E. Complicated remittents — 1103 Terminations and ap- pearances after death — ibid. The diagnosis of remit- tents, and distinctions between the yellow remittent and heema- gastric fever —1104-5 Treatment of the sever- al varieties of remit- tent — 1106 Treatment of the com- plicated states of — 1108 Notices of means for various states of the disease., — 1109 F. Of chronic, obscure, or relapsing remittents.. — 1113 Symptoms and course of. — 1114 Treatment of, and regi- men, and change of air for — 1115 Spec. 3d. Remittent fever of chil- dren 0... — ibid. Description of the acute, adynamic, and chron- ic forms of — 1116 Diagnosis, terminations, and prognosis of. — 1117 Treatment and regimen of the several varie- ties of — 1118 Bibliography and Refer- ences to remittent fe- vers — 1121 CONTENTS—Special Pathology and Therapeutics. Spec. 4th. Hectic fever — Syno- nymes and definition, i. 1122 Description of the early symptoms of — 1123 Causes, pathological, &c — 1124 Prognosis, pathology, post-mortem appear- ances, and nature of. — 1125 Treatment of the sever- al forms — 1127 Diet, regimen, &c — 1128 Bibliography and Refer- ences — ibid. Genus 2d. Continued Fevers—Syno- nymes—Definition of— ibid. Remarks on the division of continued fever .... — ibid. Review of the prognos- tic symptoms of. — 1132 Sub-Gen. 1st. Non-infeclious Contin- ued Fevers. Spec. 1st. Ardent fevers—charac- ters of. — 1136 A. Ephemeral fever — Symptoms and diag- nosis of — ibid. Treatment and Bibliog- raphy of — 1137 B. Inflammatory fever — Synonymes and defi- nition of — ibid. a. Mild inflammatory fe- ver, symptoms and history of. — ibid. Complicated states of... — 1138 b. Severe inflammatory fe- ver — 1139 Complications, termina- tions, and diagnosis of — 1141 Prognosis, duration, and post-mortem appear- ances of — 1142 Causes, predisposing and exciting — ibid. Of the nature of inflam- matory fever — 1143 C. Treatment during the stage of excitement.. — 1146 Treatment in the stage of exhaustion or col- lapse — 1147 Bibliography and Refer- ences — 1150 Spec. 2d. Bilio-gastric fever—Sy- nonymes and defini- tion — ibid. Description of its usual course — ibid. Of its modifications and complifications — 1151 Duration, terminations, and diagnosis — 1152 Prognosis and causes of — 1153 The indications and means of cure — ibid. Bibliography and Refer- ences — 1155 Spec. 3d, Mucous or pituitous fe- ver — Synonymes — Definition — 1156 LXXIV Symptoms and diagno- sis of i. 1156 Duration, terminations, and prognosis — 1157 Appearances on dissec- tion, and causes of.. — ibid. Treatment and inten- tions of cure — ibid. Bibliography and Refer- ences — 1158 Spec. 4th. Influenza — Catarrhal fever—Synonymes— Definition ii. 489 History of its epidemic appearances — ibid. Symptoms and compli- cations of — 492 Progress, duration, se- quelaj, &c., of — 495 Diagnosis and appear- ances in fatal cases .. — ibid. Remote causes and na- ture of influenza — 496 Treatment of simple and complicated — 498 Bibliography and Refer- ences — 499 Sub-Gen. 2d. Continued Fevers which are Infectious, when circumstances favour Infection. Spec. 1st. Sweating fever—Syno- nymes—Definition... i. 1158 History of its occur- rences and epidemic prevalence — ibid. Symptoms of its mild, severe, and compli- cated or* malignant forms — 1159 Alterations of structure, diagnosis, prognosis, and causes — 1160 Treatment of its several forms — 1161 Bibliography and Refer- ences — 1162 Spec. 2d. Common continued fe- ver—Synochoid fever — Synochus—Defini- tion — ibid. A. Description of simple continued fever — synochus mitior — ibid. Stages and terminations of. — ibid. B. Severe or complicated— synochus gravior — 1163 a. With predominant af- fection of the bron- chi and lungs — ibid. b. With predominant cere- bral affection — 1164 c. With predominant af- fection of the digest- ive mucous surface... — 1165 d. Other complications no- ticed — 1166 Remote causes — Pre- disposihg causes — ibid. Exciting causes, and determining influen- ces — 1167 CONTENTS—Special Pathology and Thep.apf.utics. Spec. 3d. Typhoid fever—Asthen- ic or adynamic fever — Sy nony mes—Defi- nition i. 1168 A. Mild typhoid fever—Sy- nonymes of — 1169 Description and diagno- sis of — ibid. B. Complicated typhoid, or low nervous fever.... — 1170 a. With prominent affec- tion of the respiratory organs — ibid. b. With prominent affec- tion of the digestive mucous surface — Adynamic fever, &c. — ibid. c. With prominent affec- tion of the cerebro- spinal nervous sys- tem — ibid d. With severe affection of several vital organs —Typhus gravior — ibid. e. Other modifications and prominent affections of low nervous fever. — 1171 C. Relapses and sequelae of typhoid fevers — 1172 D. Of petechias and exan- thematous eruptions in typhoid fevers — ibid. Spec. 4th. Putro-adynamic fever— Typhoid fever with putro-adynamic char- acters — Synonymes ■—Definition — 1173 Description of its inva- sion and course — ibid. Modifications, compli- cations, and sequelae of..... _ 1174 Diagnosis—the chang- es which more espe- cially constitute ma- lignancy or putro- adynamia — 1176 The immediate causes of septic or putrid changes in fever — 1176 Spec. 5th. Typhus— True typhus — Exanthematic ty- phus —Synonymes— Characters — 1181 A. Remarks on malignancy in relation to this and other continued fevers — ibid. B. Of the exanthematous eruption in typhus... — 1182 C. Description of the sev- eral stages of typhus. — ibid. • Modifications and com- plications — 1183 D. Causes, predisposing, exciting, and efficient, of synochoid and ty- phoid fevers — 1185 Prognosis, terminations, and mortality in syn- ochoid and typhoid fevers — ibid. E. The organic lesions ob- served in these fevers — 1188 CONTENTS—Special Pathology and Therapeutics. LXXV Pathological conclusions as to them i. 1190 F. Treatment of synochoid and typhoid fevers ... — 1202 a. Of synochoid fevers — — ibid. Of their complications.. — 1203 b. Of typhoid fevers, his- tory of — 1204 Treatment appropriate to the stages of — 1207 Of the varieties and complications of ty- phoid fevers — 1208 c. Of the treatment of pu- tro-adynamic fevers.. — 1212 Of the primary and con- secutive states of — ibid. Of the modifications and complications of. — 1213 G. Of the treatment of true or exanthematic ty- phus — 1214 Of the several stages and forms of. — ibid. Of the irregular and complicated states ... — ibid. H. Comments on the medi- cines advised for the treatment of typhoid fevers — 1215 a. On antiphlogistic medi- cines — 1216 b. On stimulant remedies. — 1217 c. On preparations of cin- chona and other ton- ics — ibid. d. On chlorides and chlo- rates, and hydro-chlo- rates, &c — 1218 e. On alkalies, and their carbonates and salts . — 1220 f. On opium, opiates, and other narcotics — 1222 g. On the use of wine, and indications requiring it — ibid. h. The kinds and quantity of wine and ferment- ed liquors, and fer- ments — 1223 i. On spirits of turpentine, phosphoric acid, cam- phor, capsicum, tar- water, green tea, and other stimulants — 1224 k. On several external means — ibid. l. Diet, regimen, and air in the several stages, and during convales- cence — ibid. Bibliography and Refer- ences —1228-30 Genus 3d. Exanthematic Fevers — Exanthematous Dis- eases— Eruptive Fe- vers—Definition — 974 Remarks on the classi- fication of eruptive fevers, and on the diseases which may be comprised under this head — ibid. Circumstances which should be recollect- ed in the treatment of the exanthemata.. i. 975 Spec. 1st. Erysipelas—The rose— Synonymes — Defini- tion — Infectious in circumstances favour- ing infection — 944 General description of., — ibid. Particular description of the forms and states of. — 945 Division of the forms... — 947 Simple erysipelas — ibid. Complicated erysipelas, states and grades of.. — 948 Lesions observed in fa- tal cases — 952 Diagnosis and progno- sis — ibid. Causes, predisposing and exciting — 653 Epidemic erysipelas — mostly adynamic and infectious — 954 Erysipelas of infants — 958 Treatment of simple or mild erysipelas — 959 Treatment of the sever- al associated and com- plicated states of ery- sipelas — 960 Of the constitutional treatment of.. — ibid. Of the local treatment of. — 964 Treatment of erysipelas in infants — 966 The regimen, diet, and treatment of conva- lescence — 970 Bibliography and Refer- ences — 970-1 Spec. 2d. Glanders—Definition... ii. 34 Description of simple acute glanders in the human subject — ibid. Appearances after death — 35 Description of acute farcy glanders — ibid. The chronic forms of glanders — ibid. Nature of the disease... — 36 The prognosis of acute and chronic glanders — ibid. Treatment and Bibliog- raphy of — 37 Sub-Genus. The Exanthemata which generally infect the hu- man frame only once, and destroy the sus- ceptibility of the or- ganic nervous system to be again affected by their respective causes i. 974 (It may be considered that true or exanthe- matic typhus should be comprised under this head, on account both of the eruption characterizing it, and LXXVI CONTENTS—Special Pathology and Therapeutics of the infrequency of its occurrence oftener than once in the same person. It, however, furnishes a link in the chain which connects the several species of fever—continued and eruptive, mild and malignant, or pesti- lential — with each other.) Spec. 1st. Measles—.Morbilli—Sy- nonymes and defini- tion ii. 938 Description of the sev- eral stages of the reg- ular form — 939 Modifications, complica- tions, and irregulari- ties of measles — 940 The terminations and sequelae of measles... — 943 Appearances observed in fatal cases — 945 Pathology, diagnosis, and prognosis — 946 The specific and predis- posing causes, and origin of measles — 948 The treatment and indi- cations — 949 of the modifica- tions, complications, and irregularities — 950 Bibliography and Refer- ences — 951 Spec. 2d. Scarlet fever — Scarla- tina — Synonymes — Definition iii. 725 Historical remarks — ibid. A. Description of the stages of regular scarlatina.. — 726 B. Of the types and irregu- lar forms of — 727 a. Of the appearances of the eruption of — 728 b. The forms of scarlatina depending upon the states of vital power, &c — 729 (a) Mild or simple scar- let fever — ibid. (ib) Inflammatory or an- ginous scarlatina — ibid. (c) Malignant scarlet fever — 730 (d) Scarlatina without the eruption — 731 (e) Latent or suppressed scarlet fever — 732 C. Complications or promi- nent affections of scar- let fever — 733 D. Sequelae of scarlet fever described — 737 State of the blood and urine in scarlatina.... — 741 Appearances in fatal cases 742 Diagnosis and prognosis — 744 The specific and predis- posing causes — 746 Of susceptibility and im- munity, and period of incubation iii. 750 Pathological inferences — 751 E. Treatment — Preserva- tive measures — 753 Curative treatment of simple or mild scar- latina — 755 Of inflammatory or an- ginous scarlatina — 756 Of malignant scarlet fe- ver — 758 Of scarlet fever without the eruption — 759 Of latent, suppressed, or masked scarlatina. — ibid. Treatment of the sever- al complications or prominent affections. — 760 F. Treatment of the se- quelae of scarlet fever — 762 Remarks on the reme- dies recommended for — 763 Regimen, diet, &c — 767 Bibliography and Refer- ences — 767-8 Spec. 3d. Scarlatina rheumatica— Synonymes and defi- nition — 721 Remarks respecting, and symptoms of its sta- ges — ibid. Modifications and differ- ences — 723 Causes and nature of... — ibid. Treatment in theEastern and Western hemi- spheres — 724 Bibliography and Refer- ences — ibid. Spec. 4th. Rubeola—Morbilli scar- latinosi—Synonymes and definition — 714 Remarks respecting the hybrid characters of the disease — ibid. Description of its course and terminations — 715 Nature—shown to be a connecting link be- tween measles and scarlatina — ibid. Treatment and Bibliog- raphy — 716 Spec. 5th. Chicken-pox'—Varicel- la — Synonymes — Definition i. 369 Remarks on the rela- tions of. — ibid. Var. a. Lenticular chicken-pox described — 370 b. Globular varicella — ibid. c. Conoidal varicella — ibid. Diagnosis, &c — ibid. Treatment and Bibliog- raphy — 371 Spec. 6th. Small-pox — Variola — Synonymes — Defini- tion iii. 883 Historical sketch — ibid. A. Description of natural small-pox — 885 CONTENTS—Special Pathology and Therapeutics. Of the stages of discrete or benign variola iii. 885 Modifications of discrete or benign variola — 889 The symptoms of conflu- ent small-pox — ibid. Of variola after vaccina- tion — 890 The complications or prominent affections of variola — 891 The coexistence of va- riola with another ex- anthematous malady. — 895 Yariola in the puerpe- ral states and in the foetus — ibid. Of the characters of the local affections and of the fever — 896 Appearances in fatal cases — 897 The diagnosis and prog- nosis of small-pox — ibid. The causes of death from small-pox — 900 The efficient and pre- disposing causes of variola — 901 Of epidemic visitations of variola, and the re- sults — 904 B. Of the inoculation of small-pox — 905 The circumstances con- nected with, and the course of the disease after inoculation — 906 C. Treatment of small-pox in its successive stages— 910 Treatment of confluent variola — 914 Of the several complica- tions, and in the puer- peral states — 915 External means to give relief and prevent pit- ting — 916 Bibliography and Refer- ences — 920-2 Spec. 7th. Vaccinia — Cow-pox — Variola vaccinia — Vaccination—Defini- tion — 1414 History of, and discov- ery of, by Dr. Jenner. — ibid. Of vaccinia in the cow. — 1417 Regular inoculated cow- pox — ibid. Irregular or anomalous vaccinia — 1418 Recurrent cow-pox — 1419 Nature of vaccinia, its identity with variola. — 1420 Of the protective influ- ence of cow-pox — 1421 Circumstances impair- ing this influence — 1422 Small-pox after vaccina- tion — 1424 Operative measures as to vaccinia — 1425 Of revaccination, and LXXVII conclusions respect- ing it iii. 1425-7 Bibliography and Refer- ences —1427-8 Order III.—Pestilential Maladies — Pestilences — Propagated by Infection. Circumstances, physical and moral, originating and spreading pesti- lence — 107 Genus lsi. Pestilences appearing epidemically, and gen- erally after long inter- vals. Spec. 1st. Choleric pestilence — Synonymes — Defini- tions — ibid. Introductory remarks... — ibid. Progress and mortality since 1827 — 109 Description of pestilen- tial cholera — 111 Symptoms of its suc- cessive stages — ibid. Prognostic symptoms of — 114 Morbid appearances in fatal cases — ibid. Diagnostic characters of — 116 Causes and nature of pestilential cholera... — 118 Infectious nature of, de- monstrated — ibid. Arguments of the non- infectionists — 131 Conclusions as to the causation and propa- gation of this pesti- lence — ibid. Effects of the exciting cause on the vital force and on the blood — 134 Treatment of the grades and stages of the mal- ady — 137 Notice of various modes employed in different countries — 139 Treatment chiefly con- fided in by the Au- thor — 142 Of the severer grades of the malady — 145 Treatment in the stage of collapse — 148 Treatment during con- valescence — ibid. Bibliography and Refer- ences — 151 Spec. 2d. Hsemagastric pestilence — SynonymeS and definition — 152 Introductory remarks... — ibid. Description of hsemagas- tric or continued yel- low fever — 154 Of the several forms of the disease — ibid. Of the stages of the malady — 158 * Appearances after death — 160 Diagnosis of the forms of. — 162 CONTENTS—Special Pathology and Therapeutics. LXXVIII Prognosis and mortality of iii. 165 Predisposing and deter- mining causes — 168 Infectious nature of this disease demonstrated — 169 This pestilence is differ- ent from remittent yellow fever — 185 This malady attacks the same person only once — 187 Observations on the propagation, origin, and nature of this disease — 195 Questions proposed as to the sources and nature of it — ibid. Pathological inferences deducible from the above — 200 Treatment of the grades and forms of hsema- gastric pestilence — 203 Treatment of the stages — 204 Remarks on various methods and means of cure — 207 Of the use of spirits of turpentine, camphor, capsicum, &c — 209 External remedies and treatment of convales- cence.. •— 210 Bibliography and Refer- ences —215-17 Spec. 3d. Septic or glandular pes- tilence — Plague — Synonymes — Defini- tions — 217 Introductory remarks... — 218 Description of its symp- toms and grades — 221 Of its stages and states of plague — 223 Appearances after death — 225 Diagnosis and progno- sis — 226 Causes of plague •— 228 Is plague caused and propagated by infec- tion 1 — ibid. That it is thus propa- gated appears demon- strated — 230 Proofs of its infectious nature — 231 Opinions of contempo- rary writers referred to — 235 Of the origin of plague. — 241 Arguments of anti-infec- tionists disproved — 244 Circumstances favour- ing and determining infection — 248 Of insect life as a cause of pestilence — 251 Conclusions as to the causes and propaga- tion of plague — 252 The nature of plague... — 254 Treatment of plague .... iii. 255 The local treatment of.. — 259 The diet, regimen, and management of con- valescence — ibid. Bibliography and Refer- ences : — 260-1 Spec. 4th. Dysentery* — Inflam- matory dysentery — Synonymes — Defini- tions i. 797 Seat and forms of — ibid. Description of acute sthenic, or inflamma- tory dysentery — 799 Hyperacute, or dysen- tery of Europeans re- moved to hot climates — 801 Complications of inflam- matory dysentery — 810 Sub-acute and chronic dysentery — 813 Complications of chron- ic dysentery — 814 Terminations and prog- nosis — ibid. Appearances in fatal cases — 816 Diagnosis of. — 817 Pathological inferences. — 819 Hepatic complications considered — 821 Of relapses, &c •— 823 Treatment of acute sthe- nic dysentery — ibid. Of Europeans in hot climates — 825 Treatment of complica- ted — 827 Of the sub-acute and chronic — 829 Treatment of certain contingent states — 831 Review of remedies ad- vised by authors — 833 Diet, regimen, and pro- phylactic means — 843 Bibliography and Refer- ences — 843—4 Spec. 5th. Asthenic dysentery — Epidemic dysentery — Malignant dysen- tery — Infectious — Definition.. — 802 Causes, predisposing and exciting — 802-5 Forms and symptoms of — 805 Dysentery in the dark races — 807 Epidemic dysentery — 806-9 Types and course of the disease — 809 Intermittent, remittent, or continued types, according to the caus- es — 810 Complications of as- thenic dysentery — ibid. Complicated with scur- vy — 812 * Dysentery, its asthenic or adynamic form especially, and in the dark races, or when epidemic, often assumes an infectious and pestilential character. CONTENTS—Special Pathology and Therapeutics. Prognosis of. i. 814 Diagnosis of asthenic, and its complications — 817 Appearances of fatal cases — ibid. Pathological conditions — 819 Treatment of the as- thenic forms — 825 In the dark races — 827 Complicated with scur- vy, treatment of. — 828 Treatment of other com- plicated states, and contingent conse- quences —828-32 Notices of remedies ad- vised by authors, with comments and pre- scriptions — 833 Regimen and diet — 843 Prophylactic measures . — ibid. Bibliography and Refer- ences — 843-4 Order IV. — Puerperal Diseases — Maladies connected with Pregnancy and Parturition. Genus 1st. Disorders contingent upon Pregnancy. Spec. 1st. Various disorders inci- dental to pregnancy., iii. 497 A. (Edema of the labia vulvse — 498 Treatment of. — ibid. B. Pruritus vulvae — ibid. Treatment of. — ibid. C. Leucorrhcea — ibid. Treatment of. — ibid. D. Menstruation during pregnancy — ibid. Treatment of. — 499 E. Watery discharge from the vagina — ibid. Treatment of — ibid. F. Rheumatism and spasm of the uterus — ibid. Symptoms and progno- sis of — ibid. Treatment of — 500 G. Inflammation of the pregnant uterus — ibid. Causes and symptoms of. — ibid. Treatment of. — ibid. H. Sympathetic affections during pregnancy .... — 501 (a) Salivation and mor- bid appetite — ibid. (b) Nausea and vomit- ing — ibid Causes and diagno- sis of — ibid. Treatment of. — ibid. (c) Heartburn, pyrosis, spasmodic and col- icky pains — 502 (d) Constipation — ibid. Treatment of. — ibid. (e) Diarrhoea — ibid. Treatment of. — ibid. (/) Jaundice — ibid. (g) Palpitation of the heart — 503 (A) Cough and dyspnoea iii. 503 (i) Hsemoptysis — ibid. I. Disorders of the nervous system during preg- nancy — ibid. (a) Headaches, causes and treatment — ibid. (A) Sleeplessness, caus- q es and treatment... — 504 (c) Despondency and hypochondriasis ... — ibid. Treatment of — ibid. (d) Convulsions, &c. ... — ibid. (e) Painful affections of the mammae — ibid. Treatment of.... ibid. (/) Various other disor- ders — ibid. K. Influence of pregnancy on the course, ter- minations, and treat- ment of chronic and pre-existent disease.. — 505 L. Influence of pregnancy on the production, course, and treat- ment of acute mala- dies — ibid. Treatment of acute dis- eases during preg- nancy — 506 Bibliography and Refer- ences — ibid. Spec. 2d. Abortion—Synonymes —Definition i. 5 Causes, predisposing and exciting — 6 Symptoms, diagnosis, and prognosis of. — 8-10 Treatment, preservative — 10 Palliative and remedial means — 11 Bibliography and Refer- ences — 15 Spec. 3d. After-pains—Definition — 45 Symptoms and diagno- sis — ibid. Treatment and Bibliog- raphy — 46 Spec. 4th. Disorders incidental to lactation ii. 772 a. The slighter disorders of lactation — ibid. b. Milk-fever — 773 Treatment of — 774 c. Excessive secretion of milk — ibid. Treatment of — ibid. d. Undue or improper lac- tation — ibid. Duration, symptoms, and treatment — ibid. e. Suppression of the milk — 775 Primary, consecutive, partial, or total — ibid. Treatment of — ibid. f. Termination of the pe- riod, weaning — 776 Bibliography and Refer- ences — ibid. Genus 2d. The milder forms of Puer- peral Fever. Spec. 1st. Ephemeral fever — Pu- LXXIX LXXX erperal ephemera — Definition iii. 548 Causes and symptoms of. — ibid. Diagnosis and treatment — ibid. Spec. 2d. Gastric or intestinal fe- ver—Definition — ibid. Causes and symptoms.. •— ibid. Diagnosis and tjpatment — 549 Spec. 3d. Miliary puerperql fever — ibid. See, also, Miliary Erup- tions ii. 992 Genus 3d. Severe and Malignant Puerperal Fevers — Synonymes — Defini- tions iii. 549 Literary notices of pu- erperal fevers — 550 Arrangement of the forms and states of... — 552 Causes, predisposing and exciting — 554 Of the infectious nature of puerperal fevers, and proofs adduced... — 556 Inferences and precau- tions against — 561 Connexions between puerperal fevers and other prevailing dis- eases — ibid. General description of puerperal fevers — 562 Spec. 1st. Inflammatory puerperal fever — 564 Var. a. Puerperal peritonitis, causes and symptoms of. — ibid. Terminations and prog- nosis — 565 b. Puerperal metritis, symptoms of its mild and severe forms — ibid. Terminations and prog- nosis — 566 Appearances in fatal cases — ibid. c. Inflammation of the ute- rine appendages — ibid. Symptoms and termina- tions of. — ibid. Spec. 2d. Congestive or synochoid puerperal fever — 567 Symptoms with refer- ence to its origin or seat, or prominent af- fection — ibid. Symptoms and course of uterine phlebitis... — 569 Consecutive affections upon uterine phlebi- tis — 570 Spec. 3d. Malignant or putro-ady- namic puerperal fever — ibid. Periods of its occurrence and symptoms — ibid. Complications of. — 572 Of symptoms marking the forms and com- plications — 573 The appearances of the blood in malignant puerperal fever — 575 CONTENTS—Special Pathology and Therapeutics. Appearances after death iii. 575 Results of post-mortem researches by others . — 578 A. Pathological inquiries respecting the sever- al species of puerpe- ral fevers — 579 Diagnosis of these spe- cies — 581 Prognosis of these spe- cies — 583 Pathological inferences — 584 B. Treatment of puerperal fevers — 585 a. Of the inflammatory states — ibid. b. Of the congestive or synochoid forms — 586 Means of cure advised.. — ibid. c. Treatment of malignant or putro - adynamic puerperal fever — 588 Means employed by the Author — 589 Remarks on several means of cure — 590 Prophylactic measures. — 593 Bibliography and Refer- ences — 594 Class IV. — Organic Lesions not ADMITTING OF ARRANGEMENT UNDER THE PRECEDING CLASSES, ALTHOUGH CONSEQUENCES OF THE Diseased Conditions charac- terizing these Classes.—The Three former Classes com- prise Primary Diseases, this Class embraces Structural Changes.* Order I.—Organic Lesions of the Digestive Organs. i. Structural Changes of the Ali- mentary Canal. 1st. Of the mouth and throat. The causes and symp- toms of lesions of the mouth — 1163 Treatment of them — 1165 ; 2d. Organic lesions of the tongue described — 1181 • Symptoms and diagnosis — 1182 Treatment and Bibliog- raphy —1182-4 3d. Structural changes of the tonsils and throat described — 1163 Treatment and Bibliog- raphy — 1166 4th. Structural changes of the oesophagus de- scribed ii. 1041 Symptoms and diagno- sis of — 1044 Treatment — 1049 Bibliography and Refer- ences — 1052 * These lesions are enumerated fully in that part of the Classified Contents which refers to the description of Morbid Structures; therefore a brief reference to their causes, their symptoms, and to their treatment, can only be admitted under this class. CONTENTS—Special Pathology and Therapeutics. LXXXI 5th. Organic lesions of the stomach, comprising the cardia and pylo- rus, described iii. 1008 Symptoms of ulceration, &c — 1009 Treatment of. — 1010 Symptoms of softening and other lesions of its coats — ibid. Treatment of — 1011 Symptoms and causes of malignant disease of. — 1013 Treatment of — 1014 Other organic lesions, their symptoms and treatment — 1016 6th. Structural changes of the duodenum de- scribed i. 795 Treatment for — 796 7th. Several organic lesions of the intestines — Causes and symp- toms of. ii. 687 Treatment of — 687-9 (See, farther, Arts. Co- lic and Ileus ; Co- lon, Digestive Ca- nal, and Dysen- tery.) 8th. Organic lesions of the rectum and anus.... iii. 650-63 Description of each le- sion, and the causes and symptoms of each—651-63 Treatment of the sever- al alterations of struc- ture — ibid. ii. Alterations of Structure of the Biliary Apparatus. 1st. Organic lesions of the liver ii. 866 A. Lesions consequent up- on inflammation — ibid. B. Alterations not arising from this cause — 870 Diagnosis of structural changes of the liver.. — 873 Treatment of organic lesions of liver — 875 Mineral waters, regi- men, diet, &c.—Bib- liography — 876-7 2d. Alterations of the gall- bladder and ducts.... — 6 Description, treatment, and Bibliography — 6-8 3d. Lesions of the biliary apparatus attended by jaundice — Defini- tion — 341 Description of its states and symptoms — ibid. Remote causes and mor- bid appearances — 343 The pathological rela- tions and forms of jaundice individually described — 346 Prognosis and proxi- mate causes of — 352 Treatment, remarks on the ii. 353 The indications and means of cure in the several states of — ibid. Comments on the reme- dies advised by Au- thor for — 356 Mineral waters — Regi- men —j- 66 Bibliography and Refer- ences — 70 (See, also, Biliary Con- cretions. Class I.) 4th. Organic lesions of the pancreas iii. 7 Description and symp- toms of. — 8 Treatment and Bibliog- raphy of — 11 5th. Organic changes of the spleen — 990 Causes and description of — ibid. Treatment and Bibliog- raphy of — 994-6 6th. Organic disease of the mesenteric glands — Definition ii. 983 Causes, symptoms, and diagnosis of. — 984 Complications and ap- pearances after death — 986 Nature and prognosis... — ibid. Treatment, indications, and means of cure.... — 989 Regimen and prevention of — 991 Bibliography and Refer- ences — ibid. Order II.—Alterations of Struc- ture in the Urinary and Sexual Organs. i. Alterations of Structure in the Uri- nary Organs. 1st. The several alterations of the. kidneys de- scribed — 765 The alterations in the calices, pelvis, and ureters described — 770 Symptoms and treat- ment — 771 2d. Organic and malignant changes in the uri- nary bladder iii. 1312 Symptoms and treat- ment of. —1312-14 3d. Organic changes in the prostate gland de- scribed — 509 Calculi in the prostate . — 511 Treatment of, and Bib- liography — 512 4th. Urine and its deposits, pathological relations of — 1314 Of the formation and examination of. — 1321 Pathological and thera- peutical indications of deposits in the urine. — 1324 LXXXII CONTENTS—Special Pathology and Therapeutics. Gravel or gravelly de- posits iii. 1339 Concretions or calculi formed by — ibid. Classification of calculi formed in the urinary organs — 1340 Urinary calculi de- scribed — ibid. Causes and origin of calculi — 1345 Symptoms and diagno- sis of urinary calculi. — 1349 Treatment of urinary calculi — 1352 Diseased excretion and suppression of urine. — 1353 Bibliography and Refer- ences —1355-7 Haemorrhage from the urinary organs con- sequent upon organic alterations. SeeAiA Haemorrhage, <) 204, Class II., Order II. ii. Alterations of the Sexual Organs. 1st. Organic changes of the uterus and append- ages — 1385 A. Alterations consequent upon inflammation described, and how treated — ibid. Alterations of a specific nature — 1386 B. Alterations independent of inflammation — 1387 Displacements and de- viations of the uterus described — ibid. Inversions of the, de- scribed, and how treated — 1394 Polypi of, described, and how treated — 1396 Tumours, &c., described, and how treated — 1398 Cancer of, its forms and symptoms — 1402 Treatment of cancer of the — 1407 Bibliography and Refer- ences —1410-13 2d. Alterations of the vagi- na and vulva — 1428 Alterations of the vagi- na, and treatment....—1430-1 Lesions of the vulva de- scribed — 1433 Treatment of, and Bib- liography —1435-6 (Haemorrhages from the sexual organs con- sequent upon organ- ic lesions. See Art. Haemorrhage, <) 220, Class II., Order II.) 3d. Organic lesions of the mammae ii. 933 Description of the sev- eral alterations........ —933-8 Causes and diagnosis of. — ibid. Treatment of ii. 934-8 (See, also, Structural Alterations of.) 4th. Organic changes of the ovaria — 1064 Description and symp- toms of. — ibid. Treatment of — 1065 iii. Lesions of the Peritoneum, Mes- entery, and Omentum. 1st. Alterations of the peri- toneum iii. 84-100 A. Lesionsconsequentupon acute and chronic in- flammation — 84, 93 Treatment of. — 98 B. Organic lesions not pro- ceeding from inflam- mation — 100 Description and symp- toms of — 100-3 Causes and treatment of — 104 2d. Alterations of the mes- entery ii. 988 Treatment of — 989 3d. Alterations of the omen- tum. See Perito- neum. 4th. Effusions into the peri- toneal cavity. See Order IV. Order III. — Organic or Consecu- tive Lesions of the Respi- ratory and Circulating Or- gans. (The lesions consequent upon in- flammation of these organs are described as such in the sec- tions of the respective articles in which inflammations, their consequences, and their treat- ment are described.) i. Structural Changes of the Respi- ratory Passages and Organs. 1st. Lesions of the mucous surface of the nostrils —Ozaena—Definition of.... — 1067 Ulceration of the nasal mucous membrane ... — ibid. Description and progno- sis — ibid. Treatment and Bibliog- raphy — ibid. 2d. Lesions of the larynx and trachea — 790 Treatment of — 800 Foreign bodies in the... —. 803 Diagnosis, prognosis, &c., of the — 804-6 Treatment of — 806 Of tumours external to and compressing the larynx or trachea — ibid. 3d. Structural alterations of the bronchi i. 296 Alterations of the mu- cous membrane of the — ibid. False membranes formed on — 298 CONTENTS—Special Pathology and Therapeutics. Alterations of the other structures of the air- tubes i. 299 Alterations of the cali- bre of the tubes — 300 Dilatations of the bron- chi — 321 Treatment, &c — ibid. Ulceration of the bron- chi — ibid. Treatment of — ibid. 4th. Organic lesions of the lungs ii. 900 Emphysema of the lungs — ibid. Symptoms and diagno- sis — 902 Progress and prognosis — 903 Treatment of emphyse- ma — 905 CEdema of the lungs ... — ibid. Symptoms and treat- ment — 906 Hypertrophy and atro- phy of the lungs — ibid. Abscesses and gangrene of, symptoms of — 907 Treatment of gangrene. — 909 Tubercles and malignant diseases — 910 Melanosis of the — ibid. 5th. Structural changes of the pleura, not nec- essarily arising from inflammation iii. 336 Description of — ibid. Symptoms and signs of — 338 Treatment of organic lesions of. — 339 Structural Changes of the Heart and Pericardium — Definition ii. 235 1st. Hypertrophy of the heart, description — ibid. The causes and nature of — 237 Complications and con- sequences of. — 238 Symptoms, signs, and diagnosis of. — 240 Treatment of. — 242 2d. Dilatation of the cham- bers and orifices of the heart — 244 Description of — ibid. Remote and patholog- ical causes — ibid. Signs and symptoms of — 245 Progress and termina- tions — 246 Treatment of dilatations of the cavities and orifices — ibid. 3d. Atrophy of the heart, description of — 248 Causes, signs, and symp- toms of. — ibid. Treatment of — ibid. 4th. Contractions of the cavi- ties and orifices of the heart described — 249 Treatment of. — ibid. 5th. Alterations of the con- sistence and colour of the heart — ibid. The signs and symp- toms of ii. 249 Treatment of — 250 6th. Serous and sanguineous infiltrations of the heart — ibid. 7th. Fatty degenerations and obesity of the heart.. — ibid. Description, and signs and symptoms of. — 251 Treatment of. — 252 8th. Adventitious formations in the heart and peri- cardium described.... — ibid. Signs and symptoms of — ibid. 9th. Polypous concretions in the cavities of the heart described — 254 The signs and symp- toms of — 256 Prognosis and treatment of. — ibid. 10th. Ruptures of the heart... — 257 Seat and history of. — ibid. Pathological causes and descriptions of. — 259 Symptoms and diagno- sis of — 260 11th. Alterations of the blood- vessels of the heart described — ibid. 12th. Ossific deposits, or other changes in the arte- • ries, with softening, fatty degeneration, or atrophy, of the struc- ture of the heart — Angina Pectoris—Sy- nonymes—Definition i. 71 Symptoms and causes of. — ibid. Diagnosis, prognosis, &c. — 72 Opinions as to its prox- imate cause — 73 Treatment during the attack — 75 Treatment during the intervals — 76 Review of means rec- ommended — 76-8 Bibliography and Refer- ences — 78 13th. Communications be- tween the sides of the heart ii. 260 Signs and symptoms of — 261 Blue disease—Cyanosis —Definition i. 251 The pathology of. — ibid. Symptoms, progress, and terminations — ibid. Causes — 253 Treatment and Bibliog- raphy — ibid. 14th. Displacements, &c., of the heart ii. 262 Bibliography and Refer- ences — 262-7 iii. Structural Alterations of Circu- lating Vessels. 1st. Morbid structure of ar- teries i. 130 LXXXIII LXXXIV CONTENTS—Special Pathology and Therapeutics. Lesions of the coats of. i. 130 Aneurisms described ... — 132 Narrowing and oblitera- tion of — ibid. Other alterations de- scribed — 133 Treatment of morbid structures of., — 136 2d. Organic lesions of the aorta — 81 Dilatation of the, and aneurism of, described — ibid. Lesions connected with aneurism of. — 83 Consequences and ter- minations of. — ibid. The causes, signs, and diagnosis of. — 84 Treatment of — 86 Rupture of the aorta.... — 87 Constriction and obliter- ation of — 88 3d. Structural alterations of veins iii. 1447 Description and patho- logical relations of..—1447-52 4th. Structural changes of lymphatics and lym- phatic glands ii. 921 Description of changes in the lymphatic sys- tem — ibid. Alterations of lymphatic glands described — 925 Lesions produced by.... — 927 Bibliography and Refer- ences — 928 iv. Non-malignant Growths or Tu- mours not depending on Morbid Taint. 1st. Bronchocele — Syno- nymes—Definition... i. 323 Causes and morbid rela- tions — ibid. Diagnosis — 324 Treatment and Bibliog- raphy — 324-5 2d. Inflammatory and or- ganic enlargements of the parotid gland., iii. 58 Causes and history of... — ibid. Treatment of. — ibid. 3d. Enlargement and indu- ration of the prostate gland — 508 Causes, &c., of — ibid. Treatment of — 509 4th. Various morbid and fat- ty growths described — 779-82 Treatment of — 792-5 Diet and regimen — 795 Bibliography and Refer- ences — 796 Order IV.—Organic Lesions, with Hemorrhagic or Serous Ef- fusions. Sub-Order I.—Organic Lesions caus- ing Hemorrhagic Exudations or Effusions. i. Consecutive or Structural Lesions of the Digestive Or- gans, sometimes caus- ing the Effusion of Blood. Arrangement of organic lesions causing hem- orrhages ii. 80 1st. From changes in the mouth and throat — 94 Treatment of — 95 2d. Hemorrhage from the oesophagus — 1049 Treatment of — 1050 3d. Organic lesions causing hemorrhage from the stomach — 110 Appearances on dissec- tion — 113 Diagnosis and progno- sis — 114 Treatment of, and Bib- liography —115-18 4th. Lesions causing hemor- rhage from the intes- tines and melena — 119 Appearances on dissec- tion — 121 Treatment, &c — ibid. 5th. Structural changes pro- ducing hemorrhoids.. — 146-9 Diagnosis of. — 150 Treatment, constitution- al and local — 152-6 ii. Structural Alterations of the Uri- nary and Sexual Or- gans often causing Exudations of Blood. 1st. From the urinary or- gans—Hematuria.... — 123 The blood being retained in the bladder — 124 Diagnosis of. — 125 Treatment — ibid. 2d. Alterations of the ute- rus and appendages causing hemorrhages iii. 1378 Treatment of — 1379 A. Polypi uteri producing hemorrhage — 1396 Treatment of —1397-8 B. Hemorrhage caused by tumours of the ute- rus — 1400 Treatment of.... — 1401 C. Hemorrhage from can- cer, &c — 1402 Treatment of. — 1407 iii. Organic Lesions of the Circula- ting Organs some- times causing Effu- sion of Blood. 1st. Obstructive disease ofthe heart causing hemor- rhage ii. 96 A. Producing hemoptysis, or pulmonary apo- plexy —100, 911 B. Causing apoplexy and paralysis. See the pathology and treat- ment of these diseases i. 107 Relations and complica- tions of. ii. 100 Treatment of. — 102 CONTENTS—Special Pathology and Therapeutics. LXXXV 2d. Alterations of the heart and pericardium, caus- ing effusion of blood into the latter ii. 257 Causes, symptoms, and diagnosis of — 259 Bibliography and Refer- ences — 262 3d. Structural changes of arteries causing effu- sion of blood i. 130 Aneurisms, ruptures of, atheromatous, fatty, and ossific deposits in, arteries — 132 Treatment of. — 135 4th. Lesions of veins some- times causing haem- orrhage iii. 1451 Treatment, as in the above states — ibid. iv. Organic or Consecutive Lesions of the Respiratory Or- gans, occasionally fol- lowed by Effusion of Blood. 1st. From and into the bron- chi and lungs—Pul- monary Apoplexy .... ii. 911 Terminations, &c — 912 Treatment of — ibid. 2d. Haemorrhage into the plural cavity—Hsema- thorax iii. 337 Symptoms of — 339 Treatment of. — ibid. v. Organic Alterations of the Brain, Spinal Cord, and thin Membranes, sometimes followed by Effusion of Blood. 1st. See the forms of Cere- bral Apoplexy and of Paralysis, attended by effusion of blood.. i. 90,268 iii. 13, 16 2d. Spinal Apoplexy—Symp- toms of — 968 Treatment of — 969 Bibliography and Refer- ences — 973 Sub-Order II.— Organic Lesions causing Serous or Dropsical Effusions. i. General View of Dropsical Effu- i sions i. 689 A. Pathology of dropsy — ibid. a. Historical sketch of opinions of — ibid. b. The causes of dropsies — 691 c. Appearances observed on dissection — ibid. d. The chief pathological states causing dropsy — 693 {a) Acute or sthenic in- flammatory dropsy ... — 694 (b) Asthenic or passive dropsy — 696 (c) Consecutive or symp- tomatic dropsy — 697 B. Principal lesions, caus- ing consecutive, chronic, or passive dropsies i. 697 a. Dropsy from obstructive lesions of the heart... — ibid. b. From disease of the veins and lymphatics — ibid. c. Connected with the lungs and pleura — 699 d. Dropsy from organic disease of the liver... — ibid. e. Dropsy from disease of the kidneys — 700 f. From disease of the kidneys and heart.... — ibid. g. From disease of the ovaria and uterus — 701 C. Of the state of the urine in dropsies — ibid. D. Treatment of dropsies.. — ibid. a. Of acute dropsy — 702 b. Of sub-acute — ibid. c. Of asthenic or passive.. — 703 E. Treatment of consecu- tive dropsies — ibid. a. When consecutive of cardiac disease — ibid. b. When owing to disease of the veins or absorb- ents — 704 c. Connected with pulmo- nary or pleuritic dis- ease — ibid. d. WThen owing to disease of the liver or spleen — ibid. e. When caused by disease of the kidneys — 705 f. When caused by ovari- an or uterine disease — 706 F. Indications of treat- ment, and means rec- ommended for drop- sies — ibid. a. To remove the irrita- tion or vascular ac- tion causingdropsy— Means, &c — ibid. An enumeration of the various means ad- vised — ibid. b. To remove obstructions to the circulation, and to promote absorption — 709 A review, with com- ments, of the numer- ous medicines, purga- tives, diuretics, and depurants, recom- mended : — ibid. Bibliography and Refer- ences — 715 ii. Dropsy of the abdomen—Organic lesions producing —- 716 A. Synonymes, definition, and causes — ibid. Pre-existing diseases, or pathological states, producing — ibid. Forms and complica- tions of. — • 717 Appearances in fatal cases — 718 Diagnosis and progno- sis — 719 LXXXVI Treatment of acute and sub-acute states i. 720 Of the asthenic or pass- ive — ibid. Treatment of the con- secutive and compli- cated — 721 Of paracentesis abdomi- nis — ibid. B. Puerperal ascites, pa- thology of — 722 Treatment of, accord- ing to the puerperal states — 723 Bibliography and Refer- ences — 724 iii. Encysted dropsies—Synonymes —Definition — 743 Causes, remote and proximate — ibid. Prognosis, treatment, and seats of — 744 Var. A. Dropsy of the ovarium.. — 745 Definition and patholo- gy of. — ibid. Causes, symptoms, and progress — 746 Diagnosis and progno- sis — 747 Treatment, general and local — ibid. Var. B. Dropsy of the Fallopian tubes — 749 Var. C. Encysted dropsy of the uterus — ibid. Var. D. Encysted dropsy of the peritoneum — ibid. Treatment of — 750 Var. E. Encysted dropsy of the liver — ibid. Diagnosis and treatment — ibid. Var. F. Encysted dropsy of the kidney—of the omen- tum, &c. — ibid. Bibliography and Refer- ences — 751 iv. Dropsy of the amnion—Defini- tion — 724 Pathology, diagnosis, &c — ibid. Treatment, &c — ibid. v. Dropsy of the pleural cavities— ITydrothorax —Syno- nymes—Definition.... — 736 a. Acute and sub-acute hy- drothorax — ibid. Appearances on* dissec- tion — 737 b. Passive or complicated — ibid. Diagnosis of hydrotho- rax — ibid. Prognosis and treatment — 738 Means of cure, and pre- scriptions for — 739 Bibliography and Refer- ences — ibid. vi. Dropsy of the pericardium—Hy- dro - pericardium — Definition, &c — 732 Pathology and diagnosis of. — ibid. Causes and prognosis... — 734 Treatment, &c — ibid. CONTENTS—Special Pathology and Therapeutics. Bibliography and Refer- ences i. 735 vii. Dropsy of the cellular tissue — Anasarca — Syno- nyrnes—Definition ... — 734 A. Partial cellular dropsy —(Edema — Hid. B. General cellular drop- sy — 725 Description and diagno- sis of acute and sub- acute anasarca — Hid. Passive or consecutive anasarca described ... — 726 Symptomatic of diseases of the heart, kidneys, lungs — 727 Treatment of partial — 728 Of the several forms of general, consecutive, or symptomatic — 729 Bibliography and Refer- ences — 731 viii. Dropsy in the head—Hydroce- phalus— Synonymes —Definition — 752 A. Definition and descrip- tion of acute hydro- cephalus — ibid. Forms and stages of.... — 753 Appearances on dissec- tion — 756 B. Hyper-acute and sub- acute hydrocephalus described — Hid. Appearances on dissec- tion — 757 Diagnosis and remarks respecting acute — ibid. Prognosis and causes, predisposing and ex- citing — 759 Pathological inferences, &c — 761 Treatment, literary his- tory of. — 763 Indications and means of cure — 764 Review of, with re- marks on the methods usually employed — ibid. Treatment of the hyper- acute form — 768 Regimen and prophy- lactic treatment — ibid. C. Chronic dropsy of the head — Chronic hy- 4 drocephalus —Defini- tion — 771 Causes, varieties, and symptoms — ibid. Duration and appear- ances on dissection... — 773 Prognosis and inten- tions of cure — 774 The means of treatment described — 775 Local and operative treatment — 776 Regimen and prophy- lactic means — 780 Bibliography and Refer- ences — 780-2 CONTENTS—Special Pathology and Therapeutics. LXXXVII ix. Congenital dropsies — Definition of i. 740 A. Congenital hydrocepha- lus — ibid. B. Congenital dropsy of the spine—Spina bi- fida — Synonymes — Definition — ibid. Description of. — 741 C. Congenital dropsies of the large cavities — 742 Causes of congenital dropsies — ibid. Treatment of. — ibid. Bibliography and Refer- ences — 743 x. Acute dropsy of the thigh and leg*—Phlegmasia al- ba dolens — Syno- nymes—Definitions.. iii. 279 A. History,description,and symptoms — 280 Terminations and ap- pearances after death — 283 Causes, predisposing and exciting — 284 B. Phlegmasia dolens un- connected with the puerperal states — 285 Nature of the disease... — 286 Pathological inferences and prognosis — 287 C. Treatment recommend- ed by others — ibid. Treatment advised by the Author — 289 Local treatment — ibid. Bibliography and Refer- ences.... — 291 Order V.—Organic or Consecutive Alterations of the Nervous System of Animal Relation. See Chap. VI., Structural Changes of Special Organs, Sections xiv. and xv. (The nervous system of animal re- lation—the brain, spinal cord, and their nerves—is here viewed (as in my publications in 1822, ’24, and ’29 on this subject) as being distinct from the ganglial or the organic nervous system; this latter supplying and endowing the former with its own peculiar nervous organization and force, the nerves of both systems free- ly and mutually communicating with each other, and with their respective ganglia or centres.) Genus i. Softening of the Brain and Spinal Cord. 1st. Softening of the struc- ture of the brain i. 292 Symptoms, direct and indirect — 292-3 Treatment of — 294 Bibliography and Refer- ences — 295 2d. Softening and other le- sions of the spinal cord iii. 968 Doubtful diagnosis of... — 971 Treatment of — ibid. Bibliography and Refer- ences.. — 973 Genus ii. Apoplectic and Paralytic Maladies. 1st. Apoplexy — Synonymes —Definitions i. 88 A. Description of the states of. — ibid. a. The premonitory signs of. — 89 b. The symptoms consti- tuting the attack — ibid. c. Simple and primary apo- plexy — 90 Appearances on dissec- tion — ibid. d. Gradually increasing or ingravescent apoplexy — 91 Appearances after death — ibid. e. Apoplexy complicated with, or followed by, paralysis — 93 Morbid appearances, &c. — 94 /. Apoplexy commencing with, or following, paralysis — 95 Morbidappearances,&c. — 96 B. The phenomena of apo- plexy not depending , upon its separate forms — 97 C. The relations of the symptoms to certain parts of the brain, &c. — 98 D. Diagnosis and progno- sis — 99 E. The causes, predispos- ing and exciting — 101 The modus operandi of the causes — 103 Consecutive and compli- cated apoplexy — 104 F. The pathological states constituting — 107 Inferences respecting... — 109 G. Treatment of apoplexy — ibid. a. Means intended to pre- vent the attack — 110 b. Treatment of the attack — 111 c. Of depressed states of the seizure — 114 d. Remedies admissible in the sthenic or asthen- ic states — 115 c. Treatment of the con- secutive and compli- cated states — 116 f. Treatment subsequently to the attack, or dur- ing convalescence.... — 117 Bibliography and Refer- ences — H8 Apoplexy of new-born infants described — 119 Treatment advised — ibid. 2d. Paralysis—Palsy —Sy- nonymes—Definition iii. 12 A. Paralysis of sensation.. — ibid. * Phlegmasia alba dolens may be viewed as acute drop- sy of the extremity, or as serous effusion into the limb, owing to inflammatory obstruction of the vein3 and lym- phatics. See the Pathology of the disease. LXXXVIII a. Loss of the individual senses iii. 12 (a) Loss of sight — Amaurosis in the se- quel i. 57 (b) Defect or loss of feeling — Anasthesia iii. 13 B. Paralysis of motion — ibid. a. The local or partial states of palsy — ibid. b. Hemiplegia, modes of occurrence, &c — 16 c. Paraplegia, description of. — 17 C. General paralysis — 20 a. Pathological relations of — ibid. b. Symptoms and compli- cations — 23 D. Paralysis in new-born infants and children.. — 24 E. Shaking palsy described — 25 F. Paralysis from poisons. — 26 a. From lead — ibid. b. From arsenic, mercury, monkshood, &c — 27 G. General history of the various disorders at- tending palsy — ibid. The associations or com- plications of — 29 a. With apoplexy — ibid. b. With epilepsy, inflam- mations of the brain, &c — ibid. c. With insanity, &c — 30 d. With disease of the heart and other mor- bid states — 31 Diagnosis of the lesions causing palsy — 32 Consequences, termina- tions, and prognosis.. — 33 Causes, predisposing and exciting — 34 Of certain points in the pathology of palsy ... — 36 Of reflected actions, &c — 40 On the forms and modes of sensibility — 41 The mechanism and functions of the spi- nal cord — 43 F. Treatment of palsy — 45 a. Of paralysis of sensa- tion — ibid. b. Of palsy of motion, lo- cal and hemiplegic... — ibid. c. Treatment of paraple- gia — 46 d. Of paralysis of infants and children — 48 e. Of shaking palsy — ibid. f. Of palsy caused by poi- sons — ibid. g. Of the complications of palsy * — ibid. G. Appreciation and appro- priation of remedies for palsy — 50 a. Of internal medicines... — ibid. b. Of external means — 52 c. Of regimen and diet — 53 CONTENTS—Special Pathology and Therapeutics. Bibliography and Refer- ences iii. 54 3d. Amaurosis—Synonymes —Definition i. 59 A. Seats of amaurosis — ibid. B. Causes, predisposing and exciting — 58 Efficient or pathological causes — 59 C. Symptoms, progress, &c — 60 D. Stages, grades, and forms — 62 E. Diagnosis and progno- sis — 65 F. Treatment—a. Of func- tional amaurosis — 66 b. Of congestive amauro- sis — 68 c. Of the inflammatory states of the internal parts of the eye — 69 d. Of amaurosis from le- sions of the optic nerve, brain, &c — ibid. Bibliography and Refer- ences — 70 4th. Hearing, impaired or lost — Deafness ii. 182 A. Deafness from disease of the external ear ... — ibid. a. Diseases of the auditory passage and tympa- num — ibid. b. Treatment of these — 183 B. From diseases of the Eustachian tube and cavity of the tympa- num — 185 Treatment of these — 186 C. Deafness from affec- tions of the auditory nerves.. — 187 a. From compression of the auditory nerves... — 188 b. From palsy of the acous- tic nerves — ibid. c. Treatment of nervous deafness — ibid. D. Deafness from plethora or congestion — 189 Treatment of — ibid. E. Of deafness and dumb- ness — 190 F. Remedies advised for deafness — ibid. a. Constitutional means... — ibid. b. Local and external rem- edies — ibid. Bibliography and Refer- ences — 192 Genus iii. Affections of the Brain fre- quently, although not necessarily, caused by Organic Changes. 1st. Several states of Mania and of Insanity. See Class I., Oroer IV. 2d. Many cases of Epilepsy, of Convulsions, Ver- tigo, Tremor, &c. See Class II., Or- der I. CONTENTS—Special Pathology and Therapeutics. LXXXIX Genus iv. Affections arising from the States of the Circula- tion, and of the Blood in the Brain, more fre- quently than from Or- ganic Lesions, and generally Symptomat- ic, or Consequences of antecedent Disease. 1st. Delirium—Definition ... i. 565 Phenomena character- izing it — 566 Diagnosis of. — 567 Pathological relations of — 568 Lesions observed after death — ibid. Prognosis of. — 569 Treatment of its several forms — ibid. Remedies advised by authors — 570 Bibliography and Refer- ences — 571 2d. Coma and lethargy — Synonymes—Defini- tion — 453 A. Varieties and symptoms — ibid. Duration, termination, and diagnosis — 454 B. Primary or idiopathic coma — ibid. C. Symptomatic coma — 455 Prognosis and pathology — ibid. D. Treatment of the sever- al states or varieties.. — 457 Bibliography and Refer- ences — 458 Order VI. — Diseases of a Disor- ganizing or Malignant Na- ture. Sub-Order I.—Maladies which are NOT MALIGNANT, BUT WHICH AF- FECT the Fluids and disor- ganize the Structures more or less remarkably. Genus i. Scurvy—Scorbutus—Syno- nymes—Definition iii. 839 Historical sketch — ibid. Description of its stages — 841 Chemical analysis of the blood and urine in.... — 843 Appearances after death —- ibid. Complications with dys- entery, rheumatism, &c — 844 Diagnosis and progno- sis — ibid. Predisposing causes .... — 845 Exciting and chief caus- es — 848 The nature of scurvy... — 850 The prevention of scur- vy — ibid. Means of prevention commented on — 851 Treatment of the dis- ease — 854 Of complications and severe states — 855 Bibliography and Refer- ences — 856-8 Genus ii. Purpura — Synonymes — Definitions iii. 604 Relations, &c. — De- scription — ibid. Var. a. Purpura simplex — 605 b. Purpura haemorrhagica — ibid. c. Purpura urticans — 606 d. Purpura senilis — ibid. Complications of pur- pura — ibid. Appearances on dissec- tion — 607 Diagnosis and prognosis of purpura — ibid. Treatment with refer- ence to its pathology and forms — 609 Bibliography and Refer- ences — 610 Genus iii. Gangrene—Definition ii. 9 A. Pathological relations of — ibid. a. Gangrene consequent upon inflammation ... — ibid. b. In respect of particular tissues — 10 c. Gangrene from exhaus- tion of organic nerv- ous power — 12 d. Gangrene from obstruct- ed circulation — ibid. e. From the lesion of nerves — 15 /. From physical agents.. — ibid, g. Gangrene from poisons — 17 (a) From diseased grain — ibid. (b) From diseased or decomposed animal matters or emana- tions — ibid. (c) Of hospital gangrene — 18 B. The constitutional symp- toms of gangrene — 19 C. Prognosis of. — 21 D. Treatment of gangrene — 22 (a) With reference to the pathological states — 23 (b) With regard to the causes — ibid. (c) Of hospital gan- grene — 24 (id) Local treatment of.. — 26 Bibliography and Refer- ences — .28 Secondary and tertiary syphilis, the syphilitic cachexia, and the several forms of this disease de- scribed under the head Syphilis, may also be classed here. See Class III., Order I. Sub-Order II.—Structural Diseases CAUSED BY A CONSTITUTIONAL Taint or Diathesis. Genus i. Not Malignant. 1st. Scrofula and tubercles— Synonymes and defi- nition of iii. 797 A. The scrofulous diathe- sis, or taint, described — ibid. B. The causes of the stru- mous taint, and of external and internal tuberculosis — 799 XC a. Causes appertaining to the parents iii. 800 b. Causes acting during early life — 803 c. Aiding or determining causes — 810 C. The pathology of scrof- ula and tubercles — 811 a. The structure of tuber- cular and scrofulous matter — ibid. b. Structure of tubercles displayed by the mi- croscope — 815 c. The chemical composi- tion of. — 816 d. The pathogenesis of scrofula and tubercu- losis — 817 e. The identity of scrofula and tubercles — 820 /. The relations of the scrofulous taint with other diseases — 821 g. The complications of scrofula and tubercles — 823 h. The comparative mani- festations of tubercu- losis — 824 D. The prevention of scrof- ula and tuberculosis.. — 826 E. The medicinal treatment of. — 828 ft. Of the scrofulous taint, devoid of local lesion — ibid. b. Of the more developed states of tuberculosis — ibid. c. The means advised for scrofula and tubercu- losis — 830 d. Change of air, mineral waters, local means, regimen, &c — 835 Bibliography and Refer- ences — 837-9 2d. Tubercular consumption — Phthisis — Syno- nymes and definitions — 1188 Origin, &c., of. — 1190 A. Description of tubercu- lar phthisis — 1191 a. Of the more usual form of. — ibid. (ft) Of the signs and symptoms of the first stage — ibid. (b) Of the second stage — 1194 (c) Of the third stage.. — 1196 b. Signs and symptoms di- agnostic of phthisis .. — 1197 c. The forms or modifica- tions of phthisis — 1203 (ft) The latent form of... — ibid. (b) Primary acute, or rapid phthisis — 1204 (c) Consecutively acute — 1206 (d) Protracted phthisis . — ibid. (e) Phthisis in infants and children — 1207 (/) Phthisis in the dark races — 1208 d. The states of the blood in phthisis — 1209 CONTENTS—Special Pathology and Therapeutics. B. Complications of tuber- cular phthisis iii. 1211 a. With haemoptysis — ibid. b. With bronchial irrita- tion and inflammation — ibid. c. With disease of the larynx and trachea... — 1212 d. With partial inflamma- tion of the lungs — ibid. e. With inflammation of the pleura — 1213 f. With various abdominal lesions — ibid. C. The pathological anato- my of pulmonary tu- bercles — 1215 a. The seat and distribu- tion of tubercles in the lungs — ibid. b. The lesions of the lungs associated with tuber- cles — ibid. c. Softened or liquefied tu- bercles — 1217 d. Tubercular cavities and vomicae described — 1218 e. The absorption and heal- ing processes of, de- scribed — 1219 D. Tuberculosis of the bron- chial glands — 1221 E. Duration and prognosis of phthisis — 1222 F. The causes of tubercu- lar phthisis — 1223 Classification of the causes of tubercular consumption — 1224 a. Causes appertaining to the parents — 1225 b. Causes acting during infancy and child- hood — 1228 c. Causes acting during and subsequently to puberty — 1229 d. Contingent or concur- ring and aiding influ- ences, &c — 1230 e. Pathological causes of phthisis -— 1238 f. The modes of operation of the causes — 1240 G. The treatment of tuber- cular consumption ... — ibid, a. Historical sketch of the treatment recommend- ed by authors — ibid. (a) Means advised by the ancients — 1241 (b) By physicians in the 15th, 16th, and 17th centuries — 1242 (c) By authors of the 18th century — 1244 (d) By writers of the 19th century — 1246 H. The prevention of tu- bercular phthisis — 1250 I. The treatment when phthisis is threatened — 1282 K. Treatment of the usual form of phthisis — ibid. CONTENTS—Special Pathology and Therapeutics. XCI a. Of the first stage of iii. 1282 b. Of the second stage of.. — 1257 c. Of the third stage of.... — 1260 L. Treatment of the latent form of phthisis — 1261 M. Of the primary acute, or rapid form of — 1262 N. Of the consecutively acute form — ibid. O. Of protracted phthisis.. — 1263 jP. Of phthisis in children and in the dark races — ibid. Q. Treatment of complica- ted phthisis — ibid. R. Remarks on the means advised for tubercular phthisis — 1267 Of mineral waters for phthisis — 1274 Of inhalations and fumi- gations — 1275 External means for — 1276 Of states of the air, voy- aging, and climates for phthisis — 1277 Countries, &c., advised for -1278-83 Diet and beverages — 1284 Bibliography and Refer- ences —1285-9 Genus ii. Cancerous and other Ma- lignant Diseases. (Maladies not amenable to treatment, and ter- minating in general contamination of the frame.) 1st. Cancer—Scirrho-cancer—Car- cinoma—Definition... i. 336 A. Scirrhous stage—Occult cancer — 337 Definitions and descrip- tion of. iii. 769 Minute anatomy of scir- rho-cancer — 778 B. Carcinomatous stage, or open and ulcerated cancer i. 338 Diagnosis of — ibid. Proximate analysis of... iii. 778 C. Causes, remote and proximate i. 339 D. Treatment at an early stage — 390 At an advanced stage... — ibid. Medicines advised for... — 341 Extirpation, regimen, mineral waters, &c... — 343 Bibliography and Refer- ences — 344 2d. Fungoid disease — Fungus hsematodes — Syno- nymes—Definition ... — 1243 Description of — ibid. Progress and duration.. — 1245 Diagnosis and compli- cations —■ ibid. Causes, origin, and prog- nosis — 1246 Treatment and Bibliog- raphy, &c —1248-9 3d. Melanosis — 8ynonymes — Definition ii. 955 A. True melanosis, its seat ii. 955 The forms of — ibid. The anatomical rela- tions of — 956 Physical and chemical constitution and prog- ress — 957 Symptoms anddiagnosis — ibid. Remote causes, origin, and nature of. — ibid. Treatment of — 958 B. Spurious melanosis — action of chemical agents on — ibid. Origin of — ibid. Bibliography and Refer- ences — 959 4th. Colloid, or gum-cancer — Glue-cancer iii. 779 Description and micro- scopic characters of.. — ibid. 5th. Lupus—Synonymes—Defini- tion — ii. 913 A. Description of superfi- cial lupus — 914 a. Non-tubercular — ibid. b. Superficial tubercular... — ibid. B. Phagedenic lupus — L. exedens — ibid. C. Lupus with thickening — ibid. Diagnosis,. &c — 915 Prognosis and causes... — 916 Treatment, constitution- al and local — ibid. Bibliography and Refer- ences — 917 6th. A view of malignant and non-malignant mor- bid growths or tu- mours iii. 769 A. Description of their ele- ments and microscop- ic structures — 770 B. Anatomy of these struc- tures, individually— — 778 C. Pathological relations of these morbid growths or tumours — 784 a. Diagnosis of each — 789 b. Prognosis individually.. — 791 D. Treatment of morbid growths — 792 a. Of malignant growths i. 340 iii. 793 b. Of non-malignant — 795 Bibliography and Refer- ences — 796 7tli. Pellagra—Synonymes—Defi- nitions — 59 Symptoms, &c — ibid. Appearances on dissec- tion — 61 The Asturian pellagra.. — ibid. Diagnosis and progno- sis — 62 Causes, endemic and hereditary — ibid. Treatment and Bibliog- raphy — 63-4 8th. Elephantiasis Arabum—Sy- nonymes—Definition i. 860 Causes, &c — ibid. Symptoms and progress — 861 XCII CONTENTS—Poisoning, Diagnosis and General Treatment of. Pathology and diagno- sis i. 861 Treatment — 863 Bibliography, &c — ibid. 9th. Leprosy — Leprosy of the Middle Ages—Syno- nymes—Definition ... ii. 807 A. Description of tubercu- lar leprosy — 808 Terminations and ap- pearances on dissec- tion — 809 B. Maladies allied to tuber- cular leprosy — ibid. a. Lepra taurica — ibid. b. Lepra amesthesiaca — ibid. c. Jewish leprosy •— 810 d. The radesyge, allied to pellagra — 811 Diagnosis of leprosy.... — ibid. Causes — 812 Treatment — 813 Bibliography and Refer- ences — 815 POISONS—POISONING—POISON- ED, SYMPTOMS AND TREAT. MENT OF, $ 1 iii. 346-483 Synopsis or Arrangement of the Sub- jects and Topics herein comprised — 346 I. The Modes in which Poisoning TAKES PLACE, $ 2-10 347 The several ways in which poi- sons may be exhibited or em- ployed — 347-9 II. Of the Action of Poisons, $ 11 — 349 i. Of the local and primary action of poisons, $ 12-15 — ibid. ii. Of the remote or consecutive ac- tion of poisons, $ 16 — ibid. III. Of the Media or Channels by which Poisons act, $ 18... — 350 i. The nature of the local and pri- mary action of poisons, $ 19- 23 -. — ibid. ii. The sympathetic operation of poisons considered, $ 24 — 351 iii. The organic action of poisons, $ 25 — ibid. iv. Their chemical action noticed, $ 27 — ibid. IV. The general or usual Effects of Poisons, $ 28 — 352 i. Depressing or sedative effects, $ 28-30 — ibid. ii. Exciting or stimulating effects, $ 31 — ibid. iii. Exhausting organic nervous force, and sensory and motive functions, $ 32 — ibid. iv. Perverted or morbid actions of poisons, $ 33 — 353 V. The special Operation of Poi- sons, $ 34 — ibid. i. Depressing or refrigerating ac- tion, $ 35 — ibid. ii. Benumbing or destroying sensi- bility, $ 36 — ibid. iii. Impairing the irritability and paralyzing voluntary actions, $ 37 _ 354 iv. Diminishing vital cohesion, and producing a septic action, $ 39 iii. 354 v. Exciting ganglial, spinal, and sensory nerves, &c., $ 41-44.. — ibid. vi. Astringing and irritating the tis- sues, $ 45 — 356 vii. Affecting and perverting the ir- ritability of contractile tissues, § 46 — ibid. viii. Acting on the secretions and excretions, § 47 — ibid. ix. Substances irritating, altering, &c., the parts, $ 49 — ibid. VI. The Circumstances which modi- fy the Effects of Poisons, $ 51 — 357 i. The states of the poisonous sub- stances, &c., $ 52 — ibid. ii. Combinations, admixture, and chemical conditions, $ 53-55 — ibid. iii. The nature of the parts to which they are applied, $ 55-57 — ibid. iv. Habitual use, idiosyncrasy, and moral and physical states of the recipient, $ 58-60 — 358 VII. Circumstances which should suggest Suspicions of be- ing Poisoned, $61 — ibid. i. The sudden occurrence of se- vere symptoms, especially aft- er taking any substance, &c., $ 61-64 — ibid. ii. The state of the patient’s spir- its and feelings, &c., $ 65 — 359 VIII. Matters requiring Attention when Suspicions are exci- ted, $ 66 — ibid. IX. The Symptoms caused by Poi- sons, $ 67 — 360 i. The characteristic symptoms, &c., $ 68 — ibid. ii. The duration of the symptoms, $70 ....« — 361 a. Acute or rapid poisoning, $ 71... — ibid. b. Chronic or slow poisoning-, $ 72 — ibid. X. The general Diagnosis of Poi- soning, $ 73-90 — 361-5 i. The general diagnosis of poison- ing during life, $ 73-77 — 361 ii. The diagnosis furnished by post-mortem examination, $ 78-87 — 362 iii. By chemical analysis and moral circumstances, $ 88-90 — 364 XI. The Diagnosis of Poisoning during Disease, $ 91-97 — 365 i. General review of, and remarks respecting, $ 91 — ibid. ii. Diseases and states of disease in which poisoning may re- sult from ignorance and heroic practice, $ 92-5 — ibid. iii. Felonious poisoning during dis- ease, and the puerperal states, $ 93 — 366 XII. The general Principles of Treatment for Poisoning, $ 98-105 — ibid. i. The prevention of the action of poisons, $ 99-102 — 367 CONTENTS—Poisons, their Special Effects and Treatment. XCIII ii. The counteraction of the opera- tion of the poison, § 103 iii. 367 iii. Removal of the progressive ef- fects of poison, and opposing the tendency to death, § 105.. — 368 XIII. Classification of Poisons, $ 106 — ibid. i. Arrangements proposed by writ- ers, $ 106 — ibid. ii. Arrangement adopted by the Author — 369 XIV. Of the Special Effects and Treatment of Poisons, § 108 — ibid. Class I. — Acrid and Corrosive Poisons, $ 109 — ibid. i. Symptoms and diagnosis of corrosive poisoning, $ 109.. — ibid. ii. Acids.—A. Acetic acid, con- centrated, $ 125.. — 373 B. The mineral acids, the hydrochloric, the nitric and sulphuric acids, $ 132 — ibid. C. Oxalic acid, § 159 — 378 iii. Alkalies and their carbonates, $ 167 — 380 iv. Antimony, chloride of, $ 175. — 382 v. Iodine and bromine, $ 179.... — ibid. vi. Lime, unslaked, $ 189 — 383 vii. Phosphorus, $ 192 — ibid. viii. Salts—Alkaline corrosive, $ 196 — 384 A. Bichromate of potash, $ 197 — ibid. B. Binoxalate of potash, $.198 — ibid. ix. SaltsMetallic corrosive, $ 199 _ ibid. A. Of antimony, $ 200 — ibid. B. Bismuth, trisnitrate of, § 201 — ibid. C. Copper, preparations of, $ 205 — 385 D. Gold, chloride and iodide of, $ 211 — ibid. E. Mercury, bichloride of, $ 216 _ 386 Nitrates, bicyanide and some other prepara- tions of, $ 226 — 388 F. Silver, nitrate of, $ 229... — ibid. G. Tin, the chlorides of, $ 231 — ibid. H. Zinc, chloride and sulphate of, $ 232 — ibid. x. Vegetable acrids, $ 234 — ibid. a. Anemone, the poisonous species of, $ 235 — ibid. b. Arum maculatum and A. dracunculus, $ 236 — 389 c. Brionia dioica, $ 237 — ibid. d. Caltha palustris, $ 238.... — ibid. e. Chilidonium majus, and other species, $ 239 — ibid. f. Croton tiglium, $ 240 — ibid. g. Cucumiscolocynthis, $242 — ibid. h. Cyclamen Europseum, § 244 _ 390 i. Daphne gnidium and D. mezereum, $ 245 — ibid. fc. Delphinium staphysagria, $ 246 _ ibid. 1. Euphorbia officinarium, and other species, $ 247. — ibid. m. Gratiola officinalis, $ 249 iii. 390 n. Hippomane mancinella, § 250 — ibid. o. Iotropha curcas, $251 — ibid. p. Juniperus Sabina, $ 252.. — ibid. q. Momordica elaterium, $ 253 _ 391 r. Narcissus pseudo-narcis- sus, $ 254 — ibid. s. Ranunculus, several spe- cies of, $ 255 — ibid. t. Rhus toxicodendron, $ 256 — ibid. u. Stalagmitis cambogioides, $ 257 — ibid. v. Other acrid and corrosive plants, $ 258 — ibid. Class II.—Depressing and Para- lyzing Poisons — Sedative Poi- sons, $ 261 — 392 A. Acetic acid, in frequent doses, and diluted, $ 262 — ibid. B. Acids, the mineral, fre- quent doses of the di- lute, $ 263 — ibid. C. Alkalies and their carbon- ates, prolonged use of, $ 264 — 393 D. Cold or abstraction of ani- mal heat, $ 265 — ibid. E. Digitalis purpurea, $ 266 — ibid. F. Lead, preparations of, $ 275 — 395 G. Prussic or hydrocyanic acid, and its compounds, $ 289 — 398 H. Zinc, oxyde of, § 321 — 405 I. Vapours of ether and al- cohol, $ 322 — ibid. Class III. •— Excitants — Stimu- lants— Exciting and exhaust- ing Poisons, $ 323 — ibid. i. Alcohol, $ 324 — ibid. ii. Ethers, $ 336 — 407 iii. Camphor, $ 341 — 408 iv. Chelidonium majus and C. glaucium, $ 352 — 409 v. Heat, in various forms, $ 353.. — ibid. vi. Ipecacuanha, $ 358 — 410 Class IV.—Exciting and Constring- ing Poisons—Nervous and Mus- cular Excitants, $ 361 — ibid. i. Alum, § 363 — 411 ii. Nux vomica and Strychnia, $ 364 — ibid. Various plants containing Strychnia, $ 370 — 412 iii. Brucia antidysenterica, &c., $ 378 — 414 iv. Cocculus Indicus, $ 379 — ibid. v. Coriaria Myrtifolia, § 381 — ibid. Class V.—Irritating and depress- ing Poisons — Irritating and Paralyzing Poisons—Acro-Sed- atives, $ 382 — 415 i. Aconite : varieties of A. napel- lus, $ 383 — ibid. ii. Arsenic and its compounds, $ 393 — 417 iii. Colchicum autumnale, $ 419... — 423 iv. Hellebore and its species, $ 423 — 425 v. Food poisons, $ 427 — ibid. A. Poisonous fish, $ 428 — ibid. XCIV B. Poisonous meats, $ 434 .... iii. 427 C. Diseased animal substances, fluids, secretions, &c., $ 444 — 429 vi. Mineral and saline acro-seda- tives, $ 451 — 431 A. The antimonial compounds —Tartar emetic, &c., $ 452 — ibid. B. Baryta and its salts, $ 458 — 432 C. Cupreous preparations and compounds, $ 464 — 433 D. Salts of potash, $ 475 — 434 E. Sulphurets, $ 481 — 436 F. Tartaric acid, $ 485 — ibid. vii. The necroscopic poison—Poi- son imbibed from recently- dead bodies, $ 487 — 437 viii. Putrid animal matters, $ 519.. — 444 ix. Tobacco—Indian and Virgin- ian, $ 523 — 445 A. Tobacco-smoking, $ 527... — 446 B. Tobacco-chewing, $ 528 ... — ibid. x. Other vegetable acro-sedatives, $ 534 — 447 A. Castor seeds, $ 534 — ibid. B. Iatropha manihot, $ 535... — ibid. Class VI.—Irritant and alterant Poisons — Acro-alterant Poi- sons, $ 536 — ibid. i. Belladonna, $ 537 •— 448 ii. Cantharides, $ 546 — 450 iii. Chlorine and the chlorides, $ 553 — 451 A. Chlorine gas, $ 553 •— ibid. B. Chlorate of potash, $ 556.. — 452 C. The chlorides and hypo- chlorides, $ 557 — ibid. iv. Iodine and its compounds, $ 558 — ibid. v. Mercurv, the preparations of, $ 562" — 453 A. Mercurial vapours, $ 564.. — ibid. B. Mercurial salivation, &c., $ 568 — ibid. C. Mercurial diseases, $ 570.. — 454 vi. Thorn-apple, $ 594 — 459 Class VII.—Narcotics or Stupe- fying Poisons—Hypnotics, $ 598 — 460 i. Carbonic acid gas, $ 600 — 461 ii. Carbonic oxyde gas, $ 610 — 463 iii. Carbureted hydrogen gas — Coal gas, &c., $ 611 — ibid. iv. Chloroform and the ethers, $ 615 — 464 v. Cicuta virosa—water hemlock, $ 617 — 465 vi. Conium—Hemlock, $ 619 — ibid. vii. Henbane—Hyoscyamus, $ 624 — 466 viii. Opium, and its preparations, $ 630 — 467 a. Opium-eating, $ 637 — 468 b. Opium-smoking, $ 641 — ibid. c. Morphia, and its salts, $ 650 — 470 ix. Sulphureted hydrogen gas, $ 661 — 473 Class VIII.—Narcotic and irri- tant Poisons •—Acro-Narcotics — Narcotico-Acrid Poisons, $ 667 — 474 i. Empyreumatic oils, $ 668 ' — ibid. CONTENTS—The Prevention of Disease. ii. Fool’s parsley, $ 669 iii. 474 iii. Fungi—poisonous mushrooms, $ 670 — ibid. iv. Hemlock dropwort, $ 680 — 476 v. Grain, diseased, $ 681 — ibid. vi. Laburnum, $ 683 — ibid. vii. Leguminous seeds, $ 684 — ibid. viii. Lolium Temulentum, $ 685.... — 477 ix. Yew-tree, $ 686 — ibid. Ci.ass IX.—Septic and Disorgan- izing Poisons, $ 687 — ibid. i. Remarks on various septic poi- sons, $ 688 — ibid. ii. The bites of various poisonous serpents, $ 690 — 478 iii. The stings of insects, &c., $ 702 — 481 Bibliography and References.. •—483-5 HYGIENE, OR THE PREVENTION OF DISEASE. i. Remarks respecting the preven- tion of the diseases to which the several epochs of life are most liable, in the Art. Age., i. 46 Bibliography and References.... — 57 ii. The causes of, and the means of averting, the maladies re- sulting from Arts and Em- ployments — 161 Bibliography and References ... — 168 iii. The influence of Climate in causing, in preventing, and in curing disease — 404 Bibliography and References ... — 418 iv. The means of preventing and of counteracting the bad effects of Cold — 423 Bibliography and References ... — 425 v. Description of the causes of dis- ease, and of their avoidance and prophylaxis—See Dis- ease, $ 7-62 — 644 vi. Of preventing the production of Endemic Causes of disease, and of counteracting their ef- fects — 874 Bibliography and References ... — 877 vii. Causes of Epidemics, and infer- ences respecting them — 880 Bibliography and References ... •— 895 viii. The prevention and counterac- tion of the causes of Fever, $ 117-122 — 1069 ix. The sources of Infection, their modes of communication and operation, their effects ; and the means which protect from Infection, and counteract its impression and operation ii. 404 Separation of the infected, dis- infection, &c — 417 Precautions against infection ... — 420 Treatment of the early symptoms of infection — 422 Bibliography and References ... —423-6 x. Protection from Pestilences, and from other dangerous dis- eases iii. 261 Sources of pestilential and other diseases referred to, their ef- fects stated, and their removal insisted on — 106,263 CONTENTS—The Prevention of Disease. A. The protection of the com- munity iii. 263 The prevention of animal ex- cretions and remains from accumulating — 264 The prevention of other do- mestic causes by sanitary measures, &c... — 265 Protection from foreign pes- tilences and infections— Quarantine — 267 B. The arrest of pestilential diseases, when introduced or prevailing — 271 a. When they appear in a pop- ulous city or town — ibid. b. Measures advised when such diseases are introduced into armies or garrisons... — 272 c. When introduced into ships, transports, and ships of war, &c — 273 C. Protection of individuals, families, or classes from prevailing pestilences or other infectious maladies.. — 274 a. Departure from the sphere of infection, or strict se- clusion, &c — 275 b. Restrictions imposed on those departing from an infected locality, and on their clothes — ibid. D. Protection by means which enable the constitution or vital force to resist infection — 276 a. Various medicines, &c., ad- vised with this object — ibid. b. Regimen and diet recom- mended with this intention — ibid. Bibliography and References ... iii. 279 xi. Of Vaccination as a protection from small-pox — 1290 Of revaccination, and of the evi- dence in its favour — 1293' Bibliography and References ... — 1294 xii. Prevention of Tubercular Con- sumption — 1250 a. The efficient prevention — 1251 b. The conditional prevention °£ — ibid. xiii. The prevention of Scrofula and Tuberculosis — 826 xiv. The prevention of Scurvy — 850 a. By vegetables, fruits, and lime-juice — ibid. b. By tar-water and various fer- mented liquors — 852 c. By spruce-beer and vegetable acids — ibid. d. By fresh meat, — 853 xv. Hygienic Therapeutics — 1131 A. The removal of all predis- posing, exciting, and ac- cessory causes — ibid. B. To excite and direct the men- tal emotions to resist the causes of disease — 1143 C. Hygienic agents and influ- ences enumerated — 1144 (The preventive or hygienic treatment of the most im- portant diseases is gener- ally considered when treat- ing of these diseases ; and the avoidance and counter- acting of the causes con- stitutes prophylactic or hygienic indications for all diseases.) XCV CONTENTS OF THE FIRST VOLUME. 4BDOMEN—External Examination of, in Disease . ABORTION 5 ABSCESS 15 ABSORPTION—In Relation to the Causation, Con- tinuance, and Removal of Disease . . . .27 ABSTINENCE—Its Morbid Effects . . . .30 ACNE 34 , ACRODYNIA 39 ADHESIONS—Reparative and Morbid . . .40 ADIPOSE TISSUE—Its Morbid States . . .44 AFTER PAINS 45 AGE—Considered with Relation to the Nature and Treatment of Diseases 46 AMAUROSIS 57 ANGINA PECTORIS 71 ANTIPATHY 78 AORTA—Nervous Pulsation of the, etc. . . .79 APOPLEXY—Forms of 88 OF NEW-BORN INFANTS . .119 APPETITE, MORBID 120 , VITIATED 123 ARTERIES—Diseases of 124 ARTS AND EMPLOYMENTS—In Relation to Dis- eases, etc 137 ASPHYXY 168 OF NEW-BORN INFANTS . . .175 ASTHMA 177 ATROPHY 197 AUSCULTATION 199 BARBIERS 208 BERIBERI 209 BLOOD 211 BLUE DISEASE 251 BRAIN and MEMBRANES—Diseases of . . . 253 BRONCHI—Diseases of the 296 BRONCHIAL FLUX 321 BRONCHOCELE 323 BULLiE 326 CACHEXY ib. CCECUM—Its Diseases, etc. 329 CANCER 337 CATALEPSY and CATALEPTIC ECSTASY . . 345 CATARRH 349 CELLULAR TISSUE 354 CHEST—Diseases of 365 CHICKEN POX 369 CHLOROSIS 371 CHOLERA 375 CHOLERIC FEVER OF INFANTS . . . .382 CHOREA 3S6 and RELATED AFFECTIONS . . 390 CLIMACTERIC DECAY 396 CLIMATE 398 COLD . 419 COLIC 426 fiige COLIC, BILIOUS 428 and ILEUS 432 COLON 449 COMA and LETHARGY 453 CONCRETIONS, BILIARY 458 , INTESTINAL . .463 CONGESTION OF BLOOD . . 467 CONSTIPATION 471 CONVULSIONS 479 , INFANTILE 485 COUGH 506 CRANIUM—Morbid Changes in 509 CRETINISM 511 CRISIS 513 CRITICAL DAYS 518 CROUP 519 DEBILITY 547 DEGLUTITION—Difficult 561 DELIRIUM .565 WITH TREMOUR 571 DENTITION—Difficult 581 DIABETES 583 DIAPHRAGM 599 DIARRHCEA 603 DIGESTIVE CANAL 619 DISEASE ... 643 DROPSY . . . 689 OF THE ABDOMEN .... 716 OF THE CELLULAR TISSUE . . 724 OF THE CHEST 731 , CONGENITAL 741 , ENCYSTED 743 IN THE HEAD 752 DRUNKENNESS 782 DUODENUM 792 DYSENTERY 797 EAR—Nervous Affections of, etc. .... 844 ECTHYMA 853 ECZEMA 857 EDUCATION, PHYSICAI 860 ELEPHANTIASIS 860 EMPHYSEMA 863 ENDEMIC INFLUENCE and DISEASES . . 867 EPHELIS 878 EPIDEMICS and EPIDEMIC CONSTITUTIONS . 880 EPIGASTRIUM 897 EPILEPSY 904 ERECTILE TISSUE 942 ERETHISM ib. ERGOTISM ........ 943 ERYSIPELAS 944 ERYTHEMA 97} EXANTHEMATOUS DISEASES . . . .974 EXCRETION 975 EXPECTORATION 082 CONTENTS. Page EYE 984 FAINTING 1024 FEIGNING DISEASE 1029 FEVER 1038 , INTERMITTENT . 1085 , REMITTENT 1100 , REMITTENT, OF CHILDREN . .1115 .HECTIC 1123 , CONTINUED 1129 —, EPHEMERAL 1136 , INFLAMMATORY 1137 , BILIO-GASTRIC 1150 , MUCOUS . ... 1156 FEVER, SWEATING 1158 , SYNOCHOID 1162 .TYPHOID 1168 , WITH PUTRO-ADYNAMIA . . .1173 , SPOTTED, of New-England . . . 1176 .TYPHUS . ... .1181 .TYPHOID. ..... .1185 , TYPHOID and TYPHUS . . . .1191 FIBROUS TISSUE 1231 FLATULENCY 1235 FCETUS 1238 FUNGOID DISEASE . .... 1243 FURUNCULAR ERUPTIONS 1250 A DICTIONARY OF PRACTICAL MEDICINE. ABDOMEN. Syn. Ventre, Fr. Unterleib, Bauch, Ger. Ventre, Panda, Ital. Belly, Eng. External Examination of tiie Abdomen in Disease. Classification.—Pathology. Semeiology, or Symptomatology; Diagnosis. 1. The abdomen may be considered as the fundamental part of the frame, inasmuch as it is never wanting in monstrous foetuses ; and as it contains parts which are the first formed in the embryo, and are the centres and sources of or- ganic life. The number and importance of the viscera contained in its cavity ; the number, the diversity, the extreme frequency and complica- tion, of the maladies to which these viscera are liable, are circumstances which pressing! y urge upon the practitioner a careful examination of the parietes of this cavity, in order to ascertain the nature and extent of disease. Much, how- ever, will depend upon the manner in which the examination is made, in respect both of acqui- ring information as to the existing state of disease, and of drawing inferences as to its origin, and the best means of removing it. 2. Pathologists have generally divided the ab- domen into certain Regions, with the view of describing with more accuracy the seat of morbid actions. These regions are marked out by means of imaginary lines, drawn in horizontal and ver- tical directions. The horizontal lines, four in number, divide this cavity into three zones. The highest of these lines pass over the xiphoid carti- lage ; the second, by the margin of the tenth rib ; the third, by the anterior and superior spine of the ilia ; and the fourth, by the superior margin of the pubis; thus giving three zones, the epigastric, the umbilical, and the hypogastric. 3. For the sake of additional precision, each of these zones is divided into segments by vertical lines, also four in number, drawn from the acro- mial extremity of the right and left clavicles to the insertion of the ligaments of Poupart; and from the posterior margins of the axillae, over the most exterior part of the crests of the ilia, to the large trochanters. The spinous processes of the vertebrae may likewise be considered as forming a fifth line of demarcation; as we cannot overlook the posterior parts of the body in our investigation of many of the diseases affecting the abdominal organs. The vertical lines now enumerated, di- viding the horizontal lines very nearly at right angles, give us nine regions on the anterior and lateral aspects of the abdomen, and six posterior regions. The anterior regions are the epigastric, umbilical, hypogastric, and right and left inguinal; the lateral regions are the right and left hypo- chondriac, and right and left iliac ; the dorsal regions are the inferior dorsal—right and left, the right and left lumbar, and the right and left glu- teal regions. 4. It does not belong to the scope of this work to enumerate the anatomical boundaries of the abdomen ; the parts forming its parietes ; or the viscera contained in each region. These are matters which are, or ought to be, familiar to all who peruse this work. But it is necessary to remind the reader, that organs which, in the healthy state, are always situate in a particular region, will be so changed in form and bulk by disease as frequently to extend to adjoining regions, where they will often be detected upon a careful examination; or they will be altogether displaced, either by the specific gravity of their contents, or by tumours developed in their structure. The former phenomenon is often remarked in respect of the liver, spleen, kidneys, ovarium, uterus, &c.; the latter, in the stomach, pylorus, gall-bladder, colon, &c. 5. This change of the position of the abdominal viscera is chiefly observed in the more chronic kinds of organic diseases, and is pointed out in the articles in which they are described: it is gen- erally more manifest in one posture of the body than in others ; and is to be ascertained, with the other maladies to which these viscera are liable, by the modes of examining the abdomen about to be explained, assisted by other rational or infer- ential symptoms. These modes may be made the source of much information as to all the relations of abdominal diseases; but attention, repeated observations, and much natural discernment, are required to obtain from them all the knowledge they are capable of conveying. I shall discuss this subject in the brief manner to which I am necessarily driven, by noticing—I. Inspection ; II. Manual examination ; III. Percussion; and, IV. Auscultation of the abdomen. 6. I. Inspection by the sense of sight merely, although the best mode of acquiring an idea of the form, size, and motions of the abdomen, is chiefly valuable as a means of investigating the diseases of its viscera in conjunction with the other modes just enumerated; yet simple inspection furnishes us with the most important information in many diseases, particularly in those of infancy and childhood, as well as in many acute and chronic maladies occurring in adults. The form of the abdomen, although necessarily in some measure changed by marked variation of its bulk, may. nevertheless, be much altered without any decided difference in its size. Thus, it is somewhat changec 2 ABDOMEN.—Investigation of, in Disease. in severe diseases of the respiratory passages, when the entrance of air into the lungs is obstructed ; the epigastrium and hypochondria being then pressed inwards and upwards: whilst in some morbid states of the liver and gall-bladder, of the spleen, and of the ovaria, an unusual prominence in their respective regions is frequently observed. But the most remarkable changes in the form of the abdomen is met with when the size of the ca- vity is also altered. It is scarcely necessary to allude to examples ; but, in all those diseases at- tended with enlargement or diminution of the bulk of this important part of the body, either in one of its regions, in several of them, or in all, inspection should always be performed: it gives greater pre- cision to manual examination; enables us to com- pare the bulk of a region with the corresponding region on the other side, and with others in its vicinity: and impresses upon the memory the changes which the part may experience during the progress of disease. It should, therefore, never be neglected in all the forms of abdominal dropsy ; in peritonitis, chronic or acute; in in- flammation of the stomach, liver, spleen, and bowels : in the different kinds of colic, in fevers, in uterine and ovarian diseases : in affections of the kidneys and urinary organs ; in all disorders accompanied with obstruction to the excretions ; and, in short, in all chronic maladies. It ought never to be overlooked in the diseases of infancy and childhood, of whatever nature they may be. 7. Besides, however, attending in those diseases to the form and size of the abdomen merely, the motions which it presents ought not to be neglect- ed When rightly interpreted, they often furnish important diagnostic and therapeutic hints. But they require to be viewed in connection with the motions of the thorax, and state of the heart’s ac- tion. In diaphragmitis, peritonitis, gastritis, enter- itis, and certain states of hepatitis, the motions of the abdomen are slight or obscure, whilst the ac- tions of the thraox are increased. On the other hand, in several severe diseases of the respiratory organs, particularly in croup, laryngitis, bronchi- tis, several varieties of asthma, pleuritis, pneu- monia, &c., the parietes of the chest are nearly motionless; whilst the movements of the abdomen, especially at the epigastrium, in croup and asthma, are remarkably increased, or laborious. The motions of the abdomen, also, are often not lim- ited to those caused by respiration ; but in some eases, particularly in organic changes of the heart, pericardium, aorta, &c., and even in certain nerv- ous disorders implicating these organs, comprise those occasioned by the action of the heart, in- creased by the state of the large abdominal vessels, and by the emaciation or other morbid conditions of the patient. 8. II. Manual Examination of the abdo- men is one of the most important means of dia- gnosis we possess : but it furnishes information in proportion to the perfection of manner in which it is made. In this very requisite mode of inves- tigation, the temperature of the hand of the prac- titioner at the time of making it should be attended to, in the great majority of diseases; both as a moderate warmth of the hand is necessary to the greatest delicacy and accuracy of touch, and as its application to the surface of the abdomen will not in that state occasion any disturbance or con- traction of the muscular parietes. In entering upon the examination, care should be taken not to excite the alarm of the patient. The hand ought to be applied at first in the gentlest manner pos- sible. By observing this, three very important objects will bo best obtained; namely, a know- ledge of the form, of the temperature, and of the sensibility of the surface of the abdomen. 9. As much more information than this is required from manual examination, the patient should be directed to place himself in a favour- able position for a more general and complete investigation. He should be placed on his back, with the head and shoulders slightly and com- fortably elevated, and the thighs drawn nearly to a right angle with the trunk. If the bladder be lull, it should be emptied. When proceeding to examine, the patient should be told to relax all the muscles, particularly the abdominal muscles Commencing, therefore, with the utmost gentle- ness, and passing the hand slightly over the ab- domen, we should slowly increase the pressure, with the view of ascertaining the following con- ditions . 1 st, Its temperature; 2d, Its form and size ; 3d, Its sensibility ; 4th, Its degree of ten- sion and firmness ; 5th, The existence of enlarge- ments, tumours, &c.; 6th, The presence of effused fluids; 7th, The probable existence of accumu- lated secretions and fecal matters ; 8th Hernial protrusions and displacements. On each of these I proceed to offer a few remarks. 10. 1st, The temperature of the abdomen fur- nishes most important indications as to the nature of disease. It is generally always higher than natural in diseases of increased action ; and is also often higher when the patient is actually com- plaining of cold, particularly at the commence- ment of fevers. In many fevers and inflammations of the abdominal viscera, particularly those of a dangerous or malignant character, the increased temperature is accompanied with a peculiar acrid pungency to the sensation of the examiner; a phenomenon which indicates the utmost risk of rapidly supervening disorganization. Diminished temperature of the abdomen is met with in the period of depression, or cold stage at the com- mencement of fevers, but very seldom at their termination, even in death, unless in the most malignant or liquescent forms. It is also met with after injuries of the abdomen, particularly blows on the epigastrium, in anaemia, chlorosis, and other disorders of debility. 11. 2d, The form and size of the abdomen are frequently altered, as already noticed (§ 6, 7.); but, in order to ascertain the nature of the alter- ation, various means of investigation are generally required, particularly those which remain to be considered. When proceeding with the manual examination of the abdomen, it is necessary very gently to increase the pressure, and, when acute pain is not complained of, to make it in various directions,—laterally, downwards, upwards, and backwards to the spine,—so that if altered sensi- bility of any of the contained viscera exist, it may not escape detection, but be accurately ascer- tained and estimated ; and the examination should always be made with a careful observation of its effects upon the expression of the countenance of the patient. It will also often be requisite to per- form the manual examination, now with the points of several fingers, now with the whole of one, or even of both hands; and occasionally, at the same time that a full inspiration is being made. But it should always be performed with attention to the sensations of the patient, particularly as expressed by the countenance, and to the feelings ABDOMEN.—Investigation of, in Disease. 3 and ideas it may excite in our own minds. Even the state of action in which the abdominal muscles ire often thrown by the examination ; the degree of pressure occasioning such action ; and the cir- cumstance of tension of those muscles preceding I he examination, or being excited by it; as well as the continuance of their contractions, and the periods and occasions of their relaxation, are all important matters in our estimate of the state of the viscera underneath,—more particularly in the various states of inflammation seated in the peri- toneum, in the alimentary canal, &c. 12. 3d, The sensibility of the parietes of the abdomen is most intimately associated with that of the contained organs, both in health and dis- ease. The sensibility of the epigastric region varies most widely in different persons. It is fre- quently, even in tolerable health, very great in delicate and thin females. It is always so in inflammation of the viscera, more particularly when the serous membranes are affected ; and the more superficial the inflammation, the more tender is the surface. In order to obtain an ac- curate idea of the state of the sensibility of the abdomen, pressure should be commenced in the gentlest manner, and with the fingers and palm of the open hand. When the patient cannot endure the slightest touch, the disease is then commonly in the parietes, or in the serous mem- brane reflected over them. When the cause exists more deeply, the tenderness is less acute, and the muscles are almost instinctively brought into action, even before pressure is made, in order to protect the diseased viscera from it. 13. When superficial tenderness is absent, the examination may be made with increased pres- sure, in order to ascertain the presence of tender- ness, pain, or soreness, in any degree or at any part. But caution in thus increasing the pressure is always necessary when the parenchyma of an organ, particularly of the liver or spleen, is enlarg- ed or otherwise affected ; for many such affections may be very serious, and yet the sensibility of the diseased part not much increased. I have known rupture of an enlarged and softened spleen occa- sioned by the rudeness of the examination ; and writers have mentioned similar accidents to have occurred to the liver. 14. 4th, The tension and firmness of the abdo- men require attention, and due estimation of their actual amount; and in connection with the other diagnostic indications furnished by the examin- ation. Thus, when the tension is associated with increased temperature and sensibility, inflamma- tion of one or more organs underneath, particular- ly of the peritoneum, may be predicated. The tu- mefaction, degree of sensibility, position of the patient, &e. will further prove the accuracy of the diagnosis. Tension and firmness are always present in the different forms of peritonitis and inflammations of the subjacent viscera, but not uniformly throughout all their stages. Even in the worst or most malignant forms of perotinitis, as those met with in puerperal females, these symptoms are often either almost altogether want- ing, or they exist for a short time only. When effusion of a serous or sero-purulent matter occurs in peritonitis, or when suppuration has followed inflammation of the enveloped viscera, tension as well as firmness disappear. They are generally, however, both present, even when the sensibility of the parietes is not much greater than natural, in chronic peritonitis with the formation of false membranes, or the agglutination of the opposing surfaces of the viscera. 15. 5th, The presence of tumours or other mor- bid growths, or the fact of their absence, has also to be ascertained by manual examination. This information can be obtained only by this mode of investigation, carefully conducted. If we detect any degree of unusual tumefaction or hardness, we should endeavor to ascertain its exact site ; its form, size, connections ; its consistence, degree of sensibility; and whether it is fixed or moveable, soft and yielding, or hard ; pulsatile or not. The situation of the tumor; its size, form, and degree of fixedness, will enable us to form an idea of the part affected: whilst the absence or presence of morbid sensibility in it, of fluctuation and pulsa- tion, and the manner in which the nearest parts of the abdominal parietes are affected by it, will furnish important indications of its nature. When tumours or unusual circumscribed indurations are detected in any part of the abdomen, we should bear in mind that their sources and kinds are nu- merous ; that they may be formed in the liver, pancreas, spleen, stomach, pylorus, mesentery, omentum, caecum, kidneys, uterine organs, &e.; that their nature may be extremely various ; and that they may consist either of accumulations of some fluid contained in a cyst, or infiltrated in the substance of an organ, or enclosed in its natural cavity, the outlet of which has been obstructed; or of a deposition of some morbid structure, the nature of which can only be known by a com- parison of numerous symptoms, and the history of the disease. Care should be also taken that the accumulations of faecal matters occasionally formed in the caecum, and in various parts of the colon, or that an unusual anterior protuberance or curvature of the inferior dorsal or lumbar ver- tebrae, be not mistaken, as have sometimes hap- pened, for morbid growths; and that unusually large collections of the natural secretions in their cysts, as of the bile and urine, owing to temporary obstruction to their discharge, be not treated as morbid formations of a very different kind. I have known cases in which distension of the gall-blad- der, from great accumulation of the cystic bile, was mistaken for abscess of the liver ; and an enormously distended urinary bladder was viewed as dropsy. 16. 6th, The presence of fluids effused into the peritoneal sac is best ascertained by placing the patient in the erect posture. If this cannot be done, and if he cannot even sit up, the shoulders and limbs should be placed low ; and, whether in the erect or recumbent posture, the palm of one hand laid with a gentle pressure upon one side of the abdomen, whilst we tap, somewhat smartly, with the other hand, on the opposite side. The impulse occasioned by the stroke will occasion, if fluid be effused, a vibra- tory undulation or shock which will be felt by the other hand, and which constitutes the diagnostic symptom in diseases of the abdomen attended with effusion. 17. 7th, Accumulation of faecal matters in the bowels are not infrequently mistaken for tumours. These matters usually collect and harden in the CEecum, or in some part of the colon. They sel- dom accumulate in the small intestines, unless they consist of certain kinds of intestinal concre- tions (see the art.) ; which are with difficulty dis- 4 ABDOMEN.—Investigation of, in Disease. tinguished from tumours seated in some one of the abdominal viscera. It is indispensably requi- site to examine the abdomen carefully in all cases of habitual or occasional constipation, particular- ly in the region of the ctecum and course of the colon ; as, when conducted with an experienced tact and discrimination, these collections will gen- erally be ascertained: and when the history of the case, and numerous contingent rational symptoms, are taken into account, little risk will be run of confounding them with morbid growths. The accumulation of secretions in the gall-blad- der, and in the urinary bladder, are chiefly, par- ticularly the latter, ascertained by manual ex- amination. The diagnosis of those disorders is fully pointed out in another place. 18. 8th, Protrusion of some part of the abdom- inal contents, giving rise to any either of the more common kinds of Hernia, or of those which are unusual, should never be overlooked. Ingu- inal, femoral, and umbilical hernias are so fre- quent, and, when either incarcerated or strangu- lated, occasion so serious effects, that in all cases where severe symptoms are referred to any of the viscera contained in the abdominal cavity, or in its vicinity, or when the functions of the bow- eis are obstructed, this source of mischief should be particularly inquired into. 19. I may observe generally, in respect of manual examination of the abdomen, that it fur- nishes valuable means of diagnosis in very many diseases, particularly when estimated in due con- nection with those derived from other sources • but I should add,—what I shall often have to prove hereafter,—that it does not always give us exactly the same kind of information that is sta- ted in several, and even in some very recent, works. Thus it is said to be the most certain means of ascertaining the presence of enlarged mesenteric glands, and by actually feeling these glands enlarged. Now this is not the case, and I state it from an experience of many hundred cases: for there are comparatively but few in- stances in which these enlarged glands can be satisfactorily detected, by the most careful man- ual examination. But this mode of investigation furnishes certain indications of their presence of a different kind from that which writers have laid down. It may also be remarked, that a manual examination of the abdomen is generally much more successfully made in lean subjects, in fe- males than in males, and in children than in adults ; whilst in muscular men, and in fat per- sons, it furnishes much less information, owing to the muscularity and thickness of the abdom- inal parietes. 20. III. Percussion has been employed as a means of diagnosis in diseases of the abdomen, from a very early period of medical knowledge, but chiefly with a view of recognising tympani- tic affections, or unusual accumulations of air, and dropsical effusions ; and it was not until very lately that attention was directed to it as a means of investigation in a very large proportion of other diseases of the abdominal viscera. Percussion of the abdomen, as well as of the thorax, is either direct or mediate : the former is that which was first ably insisted on by Avenbrugger, and brought into notice by Corvisart, chiefly in the investigation of thoracic diseases ; the latter, both in its application to abdominal and thoracic affec- tions, is the invention of M. Piorrv -rho has paid great attention to its perfection, and has written ably on it as a means of diagnosis. 21. Direct percussion consists of simply striking the parts, somewhat smartly with the points of two or more fingers united and brought to the same plane, and attending to the sounds elicited Mediate percussion is performing the same with a thin plate of ivory, box-wood, or any other hard elastic body, placed over the part to be thus examined, and striking upon it. The advantages derived from having such a body interposed be- tween the surface and the fingers are, 1st, The part is protected in a great measure from the stroke, which, although slight, yet is frequently unpleasant to delicate and sensitive persons ; 2d, It assists in the production of the sound for the obtaining which percussion is employed. (See art. Percussion.) The body on which the per- cussion is thus made usually consists of a small ivory plate of about 2J or 3 inches in diameter; M. Pioury calls it the pleximeter, or measure of percussion. In all cases in which we wish to examine the abdomen by percussion, it will be necessary to use the pleximeter. The informa- tion it conveys varies according to the state of the parts underneath. If we place it over the liver, percussion gives out a dull sound ; from the cir- cumstance of a dense body lying beneath that part of the abdominal parietes: if it be moved in the course of the stomach and colon, a sound will be elicited clear in proportion to the quantity of air contained in these viscera. 22. During our investigation of the abdominal contents with the aid of mediate percussion, it will be necessary to attend to certain facts:—1st, That the pleximeter will furnish, in the same person, a sound varying from dull to tympanitic as the parts over which it may be placed differ in density and the quantity of air they may enclose ; 2d, That in situations of the abdomen where, owing to the quantity of air usually contained in the bowels, mediate percussion generally gives a tympanitic sound when the plate is placed lightly on the surface, it will give a much duller, or even a dead sound, when pressed inwards so as to dis- place the air froin underneath it, and to approach nearer to some solid body, or to bring the parts nearer to that condition by the pressure; 3d, I hat the stomach and whole tract of the intes- tinal canal always contain a certain quantity of air or gaseous fluid, particularly the large bowels : and that they approach more nearly to the ab- dominal parietes in proportion to their distension, whether with air, or with fluid, or more or less solid contents and, 4th, The quantity of air contained in the digestive tube, especially the sto- mach and large bowels, is great in proportion to the deficiency of its vital energy, and the decree of inflammatory action affecting it. 23. These facts being attended to in our inves- tigations of abdominal diseases by means of per- cussion, mediate or direct, the extent of the liver may be distinctly traced by its means ; and the degree of inflation of the bowels, or stomach, may be ascertained with tolerable certainty When the stomach is nearly empty (for it always contains some air secreted from its internal sur- face,) it retracts backwards, and recedes from the abdominal parietes towards the centre of the trunk; having then the colon more or less dis- tended with gas, placed before it. As it becomes filled with air or the ordinary ingesta, it extends ABORTION—Causes of. 5 to the left hypochondrium, and approaches the left and anterior parietes of the upper zone of the abdomen. In proportion to the quantity of air it contains, percussion gives out a clear sound, which is dull or dead as it is filled with fluid or solid ingesta, and as the air is displaced. When vve know that the stomach must be empty of food, and yet find that a dull sound is emitted, on percussion, we should always suspect organic dis- ease. In these cases air is often secreted with great rapidity from its internal surface, but is im- mediately expelled, owing to the irritable state of its muscular coats, without being retained, and before any very material distension of the viscus is occasioned by it. 24. The small intestines generally contain air; although, I believe, much less than is usually found in the large bowels. In a state of health, particularly a few hours after a meal, when the chymous matter is passing along them, percussion over them,—that is, over the umbilical region, and the immediately adjoining parts of the surround- ing regions,—generally yields a dull sound; which becomes clear in proportion to the quantity of air they contain, excepting in very fat persons. In a great majority of abdominal diseases, the quantity of air contained in the small intestines is increased much beyond what exists in health; this is parti- cularly the case in several diseases of debility, as chlorosis, indigestions, colicky affections, torpid states of the liver, constipation, certain states of fever, hysteria, &c.; and still more so in inflam- matory states of portions of the digestive tube, in peritonitis, in puerperal fevers, &c. 25. When the mucous surface of the bowels or of the stomach is irritated or inflamed, the quantity of air secreted is often very great; but, excepting in the slighter states of such diseases, it is seldom retained within the sphere of the in- flammation so as to occasion that degree of dis- tension which may be detected by percussion, although it is often retained in adjoining parts of the tube, occasioning distension, great pain, tor- mina, &c. This disposition to expel the morbid collection of air arises from the irratibility of the muscular fibres of that part of the intestines, the mucous surface of which is in a state of irritation ; the morbid action of these fibres propelling it either upwards or downwards, where it may accu- mulate or be evacuated, but most commonly into the large bowels, or into the duodenum and stom- ach, where it may be detected by percussion. In diseases which paralyse the contractile actions of the muscular coats of the bowels, as the malig- nant puerperal peritonitis, the last stages of ente- ritis, rabies canina, and the advanced states of adynamic fevers, the quantity of air which is scereted and accumulated in the whole digestive tube, and the consequent distension, are often enormous. The sound on percussion, in these cases, generally becomes quite tympanitic long before death, indicating the cause, as well as the lost tone of the muscular coat of the canal. 26. The phenomena now noticed to occur in respect of the small intestines affect, in a still more marked manner, the large bowels; flatulent distension of these being readily traced by mediate, or even direct percussion, particularly in the course of the colon, even when the small intes- tines are comparatively free from it. 27. It is not merely the presence of accumu- lated air in the different parts of the digestive tube, and the important oathological and therapeutic indications to which the knowledge of this fact naturally leads, that render percussion of the ab- domen a valuable means of investigation but it is also the information it conveys of the existence of more solid formations—of fluid collections, and morbid productions. Unusual distension of the bladder; all the forms of abdominal dropsy; ovarian diseases; purulent collections in, or enlargements of, the liver; tumours of every kind, particularly when they reach a considerable size ; enlarge- ments of the spleen or kidneys, &c.; are more readily and earlier detected by means of mediate percussion than without this aid : and, in all these, the sound emitted is dead over the diseased part, and becomes clear as the boundary of dis- ease is passed, and when the plate is placed over the hollow viscera. 28. IV. Auscultation, mediate or direct, par- ticularly the former, is often necessary in abdo- minal diseases, particularly in ascertaining whether or not the large vessels are affected ; and even in tracing disease of the right side of the heart and of the pericardium. It may also be useful in those diseases of the liver which extend to the lungs through the diaphragm, particularly abscess or hydatidic cysts of the liver breaking into the lungs. Auscultation of the abdomen has been resorted to by M. Kergaradec to ascertain the existence of pregnancy; and by M. Lisfranc, to determine the presence of stone in the bladder, when the sound is imperfectly heard to strike against it. Bibliography.—Baglivi, Prax. Med. lib. iv. c. 9.— Double, Seineiologie Generate, t. i. p. 383.—Cruveilhier, Dictionnaire de Med. et Chirarg. Prat. t. i.—Piorry, De la Percussion Mediate, Paris, 1828 ; et Precede Operatoire dans l’Exploration des Organes par la Percussion Mediate, Paris, 1830.—Forbes, Cyclop, of Pract. Med. vol. i. p. 1. ABORTION. Syn. Abortus, Aborsus, Affluxio Auitpdopct, Errpiofia, Arist. Aptt\opa, Hip. Avortement, Fr. Aborto, Ital. Falche Geburt, Fehlgeburt, Ger. Mis- carriage, Eng. Classif.—5. Class, Diseases of the Sexual Function; 3. Order, Affecting Impreg- nation (Good). I. Class ; V. Order {Author, see Preface). 1. Defin. The expulsion of an embryo or foetus which is either already dead, or is at a too early period of foetal existence to live. 2. This definition will distinguish abortion from premature labour, which latter is applicable to delivery after the sixth month, when the foetus may live ; and from false delivery, which signi- fies the expulsion of a mole, or false germ, instead of an embryo. Under this term I also include expulsion of the ovum before the sixth week, commonly called miscarriage. [Frequency.—Dr. Collins met with 293 pre- mature cases in 16,414. Dr. Beatty met with 21 premature cases in 1,200. Dr. Churchill records 65 cases of abortion in 1,705 deliveries. Madame Laciiapelle 116 cases in 21,960 cases of pregnan- cy. Mr. Duebel 35, in 420 ; making in all 530 premature cases in 41,699 deliveries, or 1 in 98$ —Churchill’s Midwifery—p. 167.] 3. I. Causes.—These may be divided into such as act primarily upon the mother, or depend upon her; and into those which are connected with the product of conception, and are owing to diseases of the fetus and its appendages (Duges.) Or they may be divided into the pre- disposing, exciting, and efficient causes. It will 6 bs necessary to consider the causes with some relation to these distinctions. 4. i. Predisposing causes.—The disposition to abortion is, in some females, so strong that the slightest exciting cause will produce it; in other females the most serious injuries, and the most violent mental and moral impressions, are insuffi- cient to occasion it Some of the predisposing causes are referable to the mother, others to the foetus and its appendages. 5. A. The predisposing causes referable to the mother are numerous, and consist of certain states of the uterus, and particular conditions of the habit and constitution, influencing either the uterus or the embryo itself. 6. The conditions of the uterus favoring abor- tion are great rigidity of its fibres, and an un- yielding state of its parietes, opposing too great a resistance to the dilatation which the organ must necessarily experience ; too great sensibility and contractility of the uterus, in the former of which states the other organs of generation often also participate; too great a flow of blood to the uterus and ovaria, either proceeding constitution- ally, or from causes which excite the nerves of these organs or parts adjoining; feebleness and relaxation of the neck of the uterus—a condition of the parts which M. Desormeaux states he has frequently ascertained to exist in females subject to abortion; and atony of the uterus itself, either from original constitution or long-continued leu- corrhoea, or from a severe or protracted labour, a cause which may be conjoined with the one pre- ceding it. The foregoing causes are chiefly pro- ductive of those abortions which occur at the same period of pregnancy, and which have been called periodic by some authors. 7. To the above may be added as strictly re- ferable, a condition of the organ called by Peu immoderate heat of the uterus, which is attribut- able to an excited condition of the nerves of the organ, and a chronic inflammatory or irritative state of its vessels; also scirrhus, fibrous, fleshy, steatomatous tumours of the uterus; polypus, dropsy, the presence of several children, and the too rapid or too great dilation of the organ thereby occasioned; tumours of, and fluid effusions into, the substance of the ovaria ; and inflammation of the ovaria and parts adjoining. 8. The causes chiefly referable to the consti- tution and habit of the mother are certain states of the atmosphere, to which only can be attributed those frequent abortions sometimes observed, which have even assumed an epidemic form and of which Hippocrates, Fischer, Tessier, Desor- meaux. and others, have made mention ; the san- guine and irritable temperament; plethoric habit ; a constitutional disposition to haemorrhage inde- pendently of, or connected with, the foregoing states ; habitual menorrhagia; irregular menstru- ation ; great debility of body; excessive sensibil- ity, susceptibility, and mobility of the nervous and muscular systems; hysterical states of the nervous system; the syphilitic and the mercurial poisons; a cachectic condition of the frame ; pain- ful and chronic diseases; addiction to masturb- ation in early life; curvatures of the spine ; mal- formations of the spine and pelvis ; hereditary disposition; an acquired disposition arising from previous abortions caused by accidental circum- stances ; marriage or impregnation late in life; deficient or improper nourishment ; too close cinctures of the body ; worms in the intestinal ABORTION—causes of. canal; conception at a too early period after delivery, or after a previous abortion; the atonic state of plethora generated by luxurious indul- gences, by sleeping in soft and too warm beds, by indolence, a too full diet, &c.; local plethora, or excitement of the uterine organs, occasioned and kept up by sensual gratifications; and the constitu- tional and local commotion occasioned by infectious exanthematous, pestilential, and febrile diseases.. [According to Madame Boivin, morbid changes in the uterine appendages, are one of the most frequent and least known causes of abortion. She describes cases, where, after abortion, she found the broad ligaments, the fallopian tubes, and the ovaries agglutinated together, and adherent to the posterior surface of the uterus, the adhesion being so close as to require recourse to the scalpel to se- parate it. In such a condition of the parts, abor- tion would be very apt to occur, as the uterus and its appendages would not be able to expand to the increasing size of the ovum, and their re- sistance would excite uterine contraction suffi- cient to produce the expulsion of the foetus. — Re- cherches Sur I’avortement.] 10. B. The causes which depend upon the foetus are referable either to the foetus itself or to its appendages. They operate either by favouring the death of the foetus, which acts then as a foreign body in the uterus, exciting the organ to expel it; or by impeding its growth, so that it does not consume, or does not afford a ready circula- tion to, the blood sent to the uterus; thus occa- sioning an accumulation of this fluid in the uterine vessels, and consequently congestion, terminating in hremorrhage and the expulsion of the embryo. Owing to these circumstances, abortion is favoured by debility, or imperfect development of the foetus; by monstrous conformation, and disease affecting it at some period of its early growth; by the imperfect adhesion of the placenta to the surface of the womb, or its implantation over the neck of the organ; by disease of the placenta, as inflammation, apoplectic haemorrhage into its substance, calcareous deposits, fatty degenera- tion, scirrhous or cartilaginous induration; the formation of serous cysts, of hydatids, aneurism, or varices of this organ ; by atrophy, hypertrophy, or disproportionate size of the placenta ; by a too short or a too long umbilical cord; by twisting of the chord around the neck or one of the limbs of the foetus ; by diseased structure of the chord itself, as extreme tensity or softness, the formation of tumours or hydatids in it, by knots or adhe- sions preventing or impeding the circulation through it; great tenderness of the membranes of the ovum; inflammation, thickening, opacity, and irregularity of the membranes; the presence of too much or too little amniotic fluid, and collec- tions of serum, or of a sanguineous fluid, be- tween the chorion and amnion; adhesions formed between the placenta and parts of the surface of the foetus; and, in the most advanced pe- riods of gestation, constitutional diseases, particu- larly eruptive and infectious diseases, or continued fevers, extending from the mother to the embryo. 10. ii. The occasional exciting causes are ex- tremely numerous. It may be even said that there is scarcely an* occurrence in life which may not be occasionally concerned in producing abortion. (Desormeaux.) The chief causes of this class are acute diseases; such as fevers, scarlatina, measles, small-pox, and inflammations, particu- larly of the uterus, ovaria, pelvic peritoneum. ABORTION—Causes of. 7 colon, Ac.; the irritation of adjoining viscera; diarrhoea, dysentery, tenesmus, colic, constipation, haemorrhoids; hysterical and epilectic convul- sions ; syphilis; violent pain; disappointment and anxiety of mind; anger, fright, excessive joy; the impression of various odours; threatened as- phyxia, particularly from the vapour of carbon ; violent exertions and fatigue ; dancing ; riding on horseback, or in an uneasy carriage, or on a roughly paved road; excessive venereal indul- gence ; severe coughs; hiccup; immoderate laugh- ter : vomitings ; sea-sickness ; injuries on the loins or abdomen; any sudden shock, even the extraction of a tooth; the use of irritating or drastic purgatives, or of emmenagogues; pedi- luvia ; hot-baths; large blood-lettings, particularly from the feet; convulsive movements of the foetus; [Pressure exercised on the uterus by the blad- der and rectum, when these organs are distended ;] rupture of the umbilical cord or of the mem- branes ; adhesions formed between the serous sur- face of the fundus of the uterus and the adjoining viscera, preventing the dilatation or the ascent of the womb, and occasioning its reaction on its contents. [The influence of habit in inducing abortion, is a fact familiarly known, if not susceptible of sat- isfactory explanation. Each occurrence serves to predispose to a repetition of the accident at about the same period, and after it has happened sev- eral times, it is extremely difficult for the pregnant female to go safely beyond that period. Dr. Young of Edinburgh states that he had a patient who miscarried thirteen times in succession, and Dr. Schutze, one to whom the same accident happened twenty two times, at or about the same period of gestation, namely, the third month. Dr. Churchill (Midwifery, p. 168,) states that he was consulted by a lady who had miscarried ten or twelve times during the second month of ges- tation, and he observes, that “ it is remarkable, that these patients seem to have as great an apt- itude for conceiving as for miscarrying.” Dr. Francis, (Denman's Midwifery, p 543) states that he has known a case, where miscarriage took place eleven times in succession, at the begin- ning of the third month; and another, where the female aborted at irregular periods of ges- tation, between the 5th week and the fourth month, for the period of 16 years, though she af- terwards proved pregnant and went her full time. I have known one instance, where a female abort- ed eighteen times in the course of ten years, at about the fourth month, and another where mis- carriage occurred thirteen times in twelve years, at the third or fourth month, and at length the woman died in parturition, the last child having survived to the full time of gestation. Is it not highly probable, that besides the force of habit, in these cases, there is often something to prevent the distension of the uterus beyond a certain size, as suggested by Madame Boivin? What would seem to render such a supposition highly probable, is the fact, that many ova, after their expulsion, appear to be decayed and withered, as if they had ceased to grow for some time previous to their expulsion.] 11. The foregoing causes act variously in pro- ducing abortion. Some of them may produce directly a separation of the placenta from the sur- face of the uterus, particularly when the placen- tal mass is very considerable ; but this is a rare occurrence, and can only be inferred to exist when uterine, haemorrhage follows immediately upon the application of the exciting cause. A violent shock, injury, fall, compression of the uterine re- gion, riding, dancing, coition, Ac. may have the immediate effect, or they may occasion rupture of the cord or of the membranes; but more fre- quently these, and in a still more particular man- ner, the other exciting causes, produce certain intermediate effects, as congestion of the vessels of the womb, which is soon followed by haemorr- hage and by separation of the placenta; or they occasion contractions of the uterus, owing to the excitement and irritation of its nerves, or of the nerves of adjoining or sympathising parts, the separation of the placenta, and expulsion of the foetus. 12. Klein and many other authors have re- marked that the causes of abortion generally have a more marked effect at the period at which the menses would have returned in the unimpregnated state. The molimen, or tendency to congestion in, and haemorrhage from, the uterus, which then may be supposed to exist, renders it more suscep- tible of being injuriously impressed by the occa- sional causes of the disease; and, where other predisposing causes are already in existence, has a direct influence in separating the placenta, and inducing uterine contraction and abortion ; several of the causes produce spasmodic or convulsive actions, which are sympathetically transmitted to the uterus, whilst others seem to act primarily on the foetus. The direct action of certain of the exciting causes on the foetus may be doubted ; but every experienced and observing practitioner must have remarked the very frequent and immediate effect of strong passions of the mind of the mo- ther upon the motions of the foetus, inducing con- vulsive actions, painfully and distinctly felt, and sometimes followed by its death. Amongst the most common exciting causes of abortion are those means which, from their occasional action in this way, have been called abortives, and which the practitioner should be acquainted with, so as to enable him the better to counteract their effects. 13. The production of abortion is a felonious act, and one which the practitioner never will re- sort to, except in the case of irreducible retrover- sion of the uterus, [or such a degree of malforma- tion, as to render parturition impossible, and thus oblige the practitioner to have recourse to the Cesarian section, in order to extract the child.] The means usually resorted to by females them- selves, or by persons who criminally usurp the medical character, and employ feloniously the little empirical knowledge they may have acquired, either surreptitiously or otherwise, are, large bleeding from the feet; pediluvia; violent emetics; drastic purgatives, particularly those which act upon the colon and rectum; active emmenagogues, as savine, ergot of rye, juniper, hellebore, Ac.; and stimulating injections into the vagina: also various mechanical means employed to break the membranes, or to procure the discharge of the amniotic fluid. Many of the foregoing, or all of them excepting the last, will often fail of producing the desired effect. They frequently also succeed, and sometimes they occasion the death of both mother and fcotus. Mauriceau, De la Motte, Boer, Desormeaux, Duges, Borns, Hamilton, Ryan, Ac., have satisfactorily shown the uncertainty of those means, and have met with numerous instances in which they had been carried to the utmost extent 8 ABORTION—Symptoms of. serious haemorrhage. In other cases the action of the cause is instantly followed by a large ef- fusion of blood, which continues until after the expulsion of the foetus and its appendages. Fre- quent lancinating pains dart through the abdo- men, chiefly in the direction of the umbilicus and vulva ; the uterus makes efforts at expulsion, and the foetus is expelled. The more advanced the term of pregnancy, the nearer do the symptoms approach to those of delivery at the full time ; and the nearer also do its consequences assimi- late to those following upon a natural confine- ment, as the lochial discharge, after pains, milk- fever, &.C. [In some instances, the dead foetus is retained in the uterus an extraordinary length of time. A case occurred in our own practice, where a fe- male, carried a dead foetus, which perished about the 6th month of pregnancy, eight months, and it was then expelled, very much shrunken and shrivelled, but entire, and without any signs of decomposition. A similar case is related in the Amcr, Jour. Med. Sciences, (vol. xvii, p. 347,) by Dr. J. G. Porter of New London, where a foetus perished at the fourth or fifth month of pregnan- cy, and was retained in the uterus five months af- terwards, without decomposition, or any evidence ef putrefaction.] 17. It is sometimes observed, even up to the middle period of utero-gestation, that the foetus is expelled enveloped in its membranes. But it sometimes also occurs in the first months, that, after the rupture of the membranes, the foetus and placenta are retained, decomposed and discharged in the form of a brown foetid sanies. In other cases the placenta is not expelled until several weeks after the fostus, either in the state now de- scribed, or in that of a putrid mass. It occa- sionally is observed that the placenta continues attached to the uterus, and is nourished, increas- ing in size, and assuming the appearance of a fleshy mass, in which are sometimes found simple cysts, or cysts containing hydatids. This latter occurrence takes place either when the foetus had been expelled, or had died at an early period of its formation ; and, whilst it was yet small and nearly gelatinous, being dissolved during the pro- cess of decay in the amniotic fluid, or preserved in it. 18. This change in the placenta forms what has been called by Desormeaux and others the mole of generation ; the chief character of which is that it possesses a cavity lined with a smooth membrane, the remains of the amnion. Fre- quently, at the more advanced periods at which abortion takes place, the foetus is expelled alive ; but the duration of its life subsequently depends upon its age, and the circumstances attending its abortion. It sometimes also is dead before it is expelled, occasionally for a considerable time ; al- though it may have reached the age of several months. Its death does not necessarily lead, al- though it does generally, to its expulsion. In some cases it is retained even up to the full period of utero-gestation, and is then thrown out in a state of peculiar softening and maceration, but without putrefaction: this only occurs when the mem- branes have remained entire, and air been ex- cluded from the interior of the uterus. [Where abortion is threatened from morbid changes in the uterine appendages, according to Madame Boivin, diagnosis is difficult,—but the following symptoms are generally indicative of their existence: severe without acting in the way desired; but had occa- sioned enteritis, dysentery, perotinitis, metritis, and other dangerous diseases. Many cases are also on record where attempts had been made to produce abortion by puncturing the membranes ; and the uterus itself had been penetrated, and the death of the mother thereby occasioned. It is a matter of the utmost difficulty, even to the most expert surgeon, to puncture the membranes at that period of pregnancy when it is usually at- tempted by ignorant persons; the only persons indeed, who would make the attempt. 14. II. The Symptoms of abortion vary re- markably with the period of pregnancy at which it takes place ; also with the cause producing it. They do not, therefore, admit of being divided into precursory and essential symptoms : the for- mer being frequently wanting. In the two first months of pregnancy the ovum, which is then small, is sometimes expelled without any remark- able pain or haemorrhage; but more frequently there are pains, accompanied with coagula, in which the ovum is generally enveloped, and where it often escapes observation. This is particularly the case when, the membranes being broken, the embryo escapes without the placenta. At this early period females often suppose that they have been the subject merely of an interruption of the menses, followed by a more abundant and painful return of them than usual, instead of a true abor- tion or miscarriage. 15. As the period of utero-gestation advances, and the size of the foetus increases, the pains and haemorrhage accompanying abortion are augment- ed; the haemorrhage being generally more consider- able than that attending delivery at the regular period. The abortions which proceed from chronic dis- eases, or from causes acting slowly, and particu- larly those which are occasioned by morbid states of the embryo, or of its membranes, are generally P’ eceded by horripilations or rigors, followed by febrile movements, by heat, want of appetite, nausea, thirst, pain in the loins, lassitude, leipo- thymia, syncope, coldness of the extremities, pal- pitations, lowness of the spirits, paleness of coun- tenance, tumefaction or lividity of the eyelids, deficient brightness of the eyes, foetor of the breath ; a feeling of weakness in the abdomen, or of cold about the pubis; of weight about the anus and vagina ; flaccidity and diminished size of the breasts, sometimes with a slight discharge of se- rum ; a flow of a sanious, then of a sanguineous, fluid, and afterwards of blood, either in a fluid or grumous state, from the vulva ; diminished mo- tion of the child, soon afterwards followed by per- fect cessation of motion ; lessened bulk of the abdomen or of the hypogastrium ; uterine pains, which become more and more frequent and se- vere ; progressive dilation of the uterine orifice, and prominence of the membranes ; and, lastly, expulsion of the amniotic fluid and foetus, followed, at an indefinite time, by the placenta. Most fre- quently the discharge of blood does not cease until the placenta is expelled. (Desormf.aux.) 16. Abortion proceeding from the more ener- getic exciting causes is sometimes preceded by pains, and an unusual sense of weight in the loins and at the lower part of the vagina; by horripilations or rigors, by general uneasiness, and cardialgia or nausea. From the first there is often an appearance of blood, followed by the discharge of a sanguineous serum, which soon passes into pain and suffering during the menstrual period, continual bearing down, and sense of dragging during the menstrual flow, and also during the evacuation of the bladder and rectum, acute or dull pain in one or both groins, extending up- wards to the loins and downwards to the limbs, and more or less of leucorrheal discharge.] In other instances it is converted into a substance resem- bling adipocere, or the fatty substance generated during the decomposition of animal matter. In rarer cases the foetus and envelopes become hard- ened, and even converted into a bony or petrous state, and retained till the natural death of the mother; or in the course of some months, or even years, occasion inflammation of the uterus, and suppuration. Sometimes, in cases of this latter description, a portion of the uterus forms adhesions to the parts opposite ; the abscess which is formed extending in that direction, and opening on the surface of the abdomen, or in the interior of the intestinal canal, or into the vagina, and giving issue to purulent matter, mixed with a foetid sanies, and portions of bones arising from the decomposi- tion of the textures of the embryo. But these latter consequences of abortion are rarely met with unless in cases of rupture of the womb, or extra-uterine impregnation. 19. In some cases of abortion the haemorrhage from the uterus continues to a serious extent for several days. This may be the case at various epochs of pregnancy; and may result from the detachment, partial or general, of the placenta, and its retention along with the foetus in the ute- rine cavity, owing to imperfect action of the ute- rus to eject it. It may also proceed from the ex- pulsion of the foetus, and the retention of the pla- centa, either altogether or partly separated from the uterus. In some cases the presence of the placenta, or of a portion of the membranes in the womb, or in the os uteri and upper part of the vagina, by the irritation thereby occasioned, may have the effect of keeping up a constant and ex- hausting haemorrhage. In a case of abortion to which I was recently called, the practitioner in attendance stated the foetus to have come away two or three days previously. Upon inquir- ing as to the discharge of the appendages, I was led to recommend an examination per vaginam; when they were found lodged partly in the vagina and os uteri. After their removal the patient ra- pidly recovered. 20. III. Diagnosis.—The diagnosis of abortion should be directed to three objects: 1st, its cause ; 2dly, to the possibility of preventing its occur- rence ; and, 3dly, to ascertaining the stage or development of the process. The causes of abor- tion are generally readily recognised, and admit of an easy explanation. There are two, however, to which Professor Desormeaux has particularly directed attention: namely, rigidity of the fibres of the fundus and body of the uterus, and laxity of its neck. The former of those is generally con- nected with a similar state of the whole system, and accompanied with scanty or painful men- struation. In the first impregnations abortion takes piece at an early period; but in subsequent ini j< itions the period of gestation approaches more nearly the natural epoch, the female at last bearing children to the full time. When the abortion is referable chiefly to laxity of the neck of the uterus, a result contrary to the foregoing takes place; the period of abortion approaching ABORTION—Diagnosis of. 9 nearer, in successive conceptions, to the time of impregnation. Examination per vaginam dis- closes this state of the cervix uteri, which some- times permits the escape of the ovum without much pain. The presumed existence of either of the foregoing states, particularly, if any of the symptoms enumerated as characterising abortion be present, should lead us to suspect its approach- ing occurrence. And it may be considered as commenced if pains occur at regular intervals, which become of shorter duration, and are di- rected from the umbilicus to the os coccygis; if the os uteri dilates, if the membrames become, prominent during the pains, and if the amniotic fluid escape. M. Desormeaux, however, has de- tailed instances where, notwithstanding the above phenomena, the patient was not delivered for sev- eral weeks afterwards; but these are extremely rare. 21. In cases where more than one child is contained in the uterus, or where this organ is double, one of the foetuses may be expelled in the course of gestation, and the other may still remain and arrive at the full period of foetal life. The eminent author whom I have now quoted mentions the case of a female, pregnant for the first time at the age of forty years, who expe- rienced abortion at two months and a half; the symptoms of pregnancy, however, continued, and the motions of the foetus were felt at the usual time. At the seventh month, a severe fright was immediately followed by symptoms indicating the death of the child; however, the motions of the child were still felt in the uterus: at last, after two months, and at the usual period of gestation, this female was delivered of a dead child, and of another which had arrived at the full period, and was living and healthy. M. Rousset has also related a similar case (Traite de VHysterotokie.') [A similar case is recorded by Dr. S. Jackson in the Am. Journal Med. Sci. (Vol. 22, p. 237), where a female aborted at the third month of pregnancy, which was attended with considerable haemorrhage, and six months afterwards was deliv- ered of a child that had arrived at the full period. A similar case is stated in the same article to have occurred in the practice of Dr. Joseph G Nancrede, of Philadelphia. Burns, (Princip. of Mid. Ed. 2d. p. 195) remarks that “ cases have occurred of twins, one of which has been ex pelled while the other remained, and gestation was still maintained to the proper period.” Dr. Dewees expresses his belief also, that “ the uterus may expel a foettis prematurely, and then become passive, until a twin is matured, or in a condition to be expelled with advantage to itself.” (On Fe- males, p. 333.) Puzos (Mem. de VAcad, de Chi- rur. Vol. 1. p. 20.3), declares that neither pain nor hmmorrhage necessarily produces abortion ; and, La Motte (Obs. 305) gives an instance where a pregnant female went her full time, after the orifice of uterus was considerably dilated. See also a case of twins in the London Lancet, (Oct. 30 1841), in which one of the children was born alive at the full term of pregnancy, while the other had been retained in the uterus six months after its death, without having undergone decomposition.] When abortion occurs during the first two months, we can often only distinguish it from exces- sive menstruation by the coagulating of the blood. Cases, however, sometimes are met with where coagula form during menstruation, but seldom or 10 never during healthy menstruation. Abortion is most frequent during the three first months of pregnancy. 22. IV. Prognosis.—Abortion has been con- sidered of more serious import than delivery at the full time, by Hippocrates, AStius, Mauriceau, and others. The prognosis will, however, entirely depend upon the nature of the causes producing abortion ; the period of gestation at which it takes place; and the symptoms accompanying it. It may be stated generally, that the danger increases in proportion as it approaches the full period of gestation; inasmuch as the haemorrhage is greater, the expulsion of the fetus and appendages more difficult, and the milk-fever more violent, the longer the period of utero-gestation. The abor- tion which occurs from accidental, or active ex- citing causes, is generally more dangerous than that which follows the predisposing causes; this is more particularly the case, the more violent the cause, the more prompt its effects, and when it acts upon females not predisposed to abortion. The most dangerous abortions are those which are procured by substances of an irritating nature taken internally, and by attempts to excite the uterus, or to puncture the membranes per vaginam. 23. On the other hand, when abortion takes place spontaneously, and without any very mani- fest or sufficient cause, it is often unattended by pain or difficulty, leaving behind it scarcely any unpleasant consequences; but this form of abor- tion is most liable to recur ; and its repeated occurrence often gives origin to a number of ail- ments, some of them of serious moment, such as irregular menstruation, chronic metritis, organic lesions of the uterus and ovaria, irritable uterus, hysteria, and a debilitated and cachectic habit of body. 24. Abortion is chiefly dangerous from the hcemorrhage attending it; and hence the risk is proportionate to the extent of this effusion. Abor- tion, accompanied by convulsions, diarrhoea, dy- sentery, or supervening in the course of fevers, inflammations, or of eruptive diseases, are seldom devoid of danger, which under certain circum- stances, is even great. Inflammation of the womb of great severity, endangering the life of the pa- tient, or causing adhesions of the Fallopian tubes or of the ovaria to the serous surface of the uterus, and consequent sterility, is not an infrequent con- sequence of abortion. 25. On the other hand it may be productive of certain advantages, according to Mauriceau, Desormeaux, and some others, who have, in rare cases, observed abortion occurring before the third month to be followed by a more regular state of the catamenia, in those who had been irregular previously, and by an improved state of health; even fecundity taking the place of former sterility. 26. V. Treatment.—The treatment of abortion is divided into, 1st, the preservative; 2d, the pal- liative ; and 3d, the remedial. On each of these I shall offer a few remarks. 27. i. The Preservative treatment comprises the following objects; viz. to remove the predisposing causes as far as this may be accomplished; to repress all undue action whenever it may appear; and to prevent, as well as to counteract, the effects of the exciting causes. These ends are to be kept in view, and applied to individual cases, appro- priately to the causes and circumstances by which they are characterised. Where plethora, general ABORTION—Treatment of. or local, exists,’ it should be reduced by general or local depletion, in very moderate quantity, and repeated at short intervals ; but more preferably by a low and antiphlogistic diet and regimen, acidulous and cooling beverages, the recumbent posture, and tranquillity of mind. In cases cha- racterised by relaxation of the system, and of the reproductive organs, an opposite, or a tonic and invigorating regimen is required. In every in- stance the preservative treatment must be based upon our views respecting the pathological state of the uterus, and of the whole frame at the time of prescribing it. 28. When the horizontal posture is considered necessary, the patient will be more benefited by reclining on a mattress, than on a soft, hot bed. Her apartment should be cheerful, large, and airy; the bed-clothes light; and all anxiety of mind respecting the issue, and depression of spirits, prevented; a confiding and cheerful state of feel- ing will materially conduce to a favourable result. The diet, under ordinary circumstances, ought to be light and digestible, and varied according to the particular circumstances of the case. The beverage should be mild, and, in cases of local or general plethora or excitement, rather cooling than otherwise, and such as may promote, rather than retard, the natural actions of the bowels. Lemonade, imperial, barley-water, toast-water, &c., are amongst the best in this class of cases. 29. Much will depend upon the perseverance with which this plan may be followed, particu- larly in cases of habitual or precedent abortions ; where it ought to be rigorously enforced and con- tinued for months, or at least, for a long time after the period of gestation at which the former abortion occurred. If the threatened abortion be accompanied with pains, or by any degree of discharge, an opiate should be given at bed-time ; and, in every case where we have conceived it requisite to abstract blood, either generally or locally, even as a preventive measure, the oper- ation should be followed by a dose of opium. 30. Attention to the bowels is indispensable ; but great discrimination is necessary in the choice of laxatives when the bowels are constipated. These should be of the most cooling and gentle description. The soluble tartar, and cream of tar- tar in the form of electuary, or with confection of senna, particularly in cases of plethora, are very eligible. Castor oil, with a very few drops of laudanum, which will not retard its operation; or small doses of the bi-sulphate of potash, are also suitable laxatives. 31. When, from our knowledge of the state of the ovum, in previous abortion, we suspect a repetition of it, we may endeavor to prevent it, by using those means which are most successful in imparting energy to the constitution, and, through it, to the generative functions ; so that the process of fetation may proceed to a successful issue. This is, perhaps, best accomplished by change of air; the use of the tonic mineral waters, both internally and in the form of baths ; by the mineral acids given in the infusions of bit- ter tonics, or with the solutions of the salts of iron: as the tinctura ferri sesquichloridi; the tinctura ferri cetherea (see Appendix'); by the sulphate of zinc, with the compound infusion ot roses; by the exhibition of the various balsamic and terebinth- inate medicines, combined with the pulvis cin- chonce, or the pulvis rhei, and the carbonates of the alkalies, or magnesia; and by attention to the state of the bowels, to diet, and gentle but regular exercise. The balsams most serviceable in cases of this description, as well as in all those charac- terised by weak and imperfect uterine function, are the balsams of Peru, of Canada, of Chio, and of copaiba; the terebinthina vulgaris, and T. Veneta. Siebold recommends the balsamum vitae Hoffmanni (F. 317.), a medicine which en- joys great reputation on the Continent in many diseases of debility. The loins may be rubbed night and morning, for some time, with the lini- mentum saponis et camphor® comp. (F. 306.), the linimentum terebinthin® compositum (F. 311.), or the liniment, anodynum (F. 298.). The appli- cation of the emplastrum cumini, the emplastrum picis compositum, or the emplastrum roborans (F. 118.), to the loins will also prove of service. 32. When diarrhcea occurs during the period of utero-gestation, and more especially if it be accompanied with tenesmus, in delicate females, or in those who have experienced previous abor- tions, it should be immediately checked or lessened. In these cases disorder is chiefly confined to the colon and rectum, which should be soothed by small emollient and anodyne enemata, or by the use of suppositories of lead plaster, and opium. Whilst, however, we thus prevent the irritation from being extended from the large bowels to the uterus, we should take care to prevent the reten- tion of hardened f®ces in the cells of the colon, by which irritation will be perpetuated; and to remove them, when we suspect their presence, by the use of gentle laxatives, and emollient and aperient injections, avoiding the use of saline purgatives and cathartics. 33. In cases of threatened abortion in debili- tated constitutions, the mineral acids, particularly the sulphuric, either with or without small doses of laudanum, or combined with small doses of colchicum, or of digitalis, are extremely useful. Where the circumstances' of the case permit the horizontal posture to be dispensed with, the pa- tient may be allowed very gentle exercise, for short periods, in the open air, avoiding all exer- tion and local excitement. She should live ab- stemiously, yet not too low. In many cases of this description a glass or two of light wine may be allowed daily, and in several a still more tonic treatment is required. When this is the case, the infusion of calumba, or of quassia, with the car- bonate of soda, and tincture of hyoscyamus, has seemed to me very serviceable; and the patient has been allowed the occasional use of the swing, or a gentle ride in a carriage. The tepid and cold hip-bath, particularly with sea-water, are often of use in cases of this description, as well as the treatment recommended in a preceding pa- ragraph. The necessity of abstaining from sexual intercourse in all cases of threatened abortion, is most evident. 34. In cases accompanied with incipient dis- charge, either the cold hip-bath, or sponging the hips, thighs, and lower parts of the trunk with cold water and vinegar ; or by squeezing a large sponge filled with cold water, so that its contents may fall in a scattered stream from some height upon the hips and pelvis; will sometimes be ser- viceable. Injections of cold or iced water, or cold astringent solutions per vaginam, or a lavement of cold water, will sometimes arrest the accession of h*morrhage. 35. It will occasionably be observed that weak, nervous, and delicate females are often irritable ABORTION—Treatment of. and dispirited from a tedious confinement, during gestation, and even abort owing to this cause ; obviously, in many cases, from the effect produced upon the uterus, and upon the nutrition and health of the embryo. This should be anticipated and prevented by a timely relaxation of the plan, and by allowing the patient as much exercise, amuse- ment, &.C., and by adopting as much of the treat- ment recommended above (§ 33.), as may be con- sistent with the accomplishment of our end. When, in these cases the nervous symptoms predominate, the use of antispasmodics, with anodynes, and their combination with vegetable bitters, chaly- beates, &c., are often required. The diet should also be nutritious, but easy of digestion, and not too heating and stimulating. 36. The foregoing plan will often succeed in preserving the infant, unless the discharge con- tinues or becomes more copious ; the uterine pains, with the other symptoms of commencing abortion, still persist or increase ; and the woman be advanced in pregnancy; when little advan- tage will be obtained, particularly if the orifice of the womb dilate. When this is the case, attempts at'preservation will entirely fail, and we must adopt the second intention. 37. ii. The palliative measures now required consist, in addition to those recommended ( § 34.,) of cold applications to the genital fissure and in- sides of the thighs, and the tampon, or plug, as recommended by a number of authors, and sanc- tioned by Denman, Hamilton, Burns, Merriman, Dewees, Ryan, &c. These are especially requisite where the haemorrhage is great, particularly when the abortion takes place between the third and sixth month. Opium, with the acetate of lead, given in a very large dose at the first, and repeat- ed according to circumstances, should also be ex- hibited. Opium, as well as plugging the vagina, are chiefly serviceable where the haemorrhage continues after the expulsion of the embryo. The plug recommended by Dr. Dewees is a sponge squeezed out of vinegar. Dr. Ryan advises either old linen or a sponge to be wetted with a saturat- ed solution of alum, and smeared with some ole- aginous matter, to be passed up the vagina, so as completely to fill it. Dr. Blundell directs a scruple of alum, dissolved in a pint of water, to be injected into the uterine cavity. 38. The practitioner should in every instance be satisfied as to the expulsion of the embryo and the whole of its appendages, for he may be de- ceived in this matter (§ 19.); a small remnant of the placenta or of the membranes, when still left in the cavity of the uterus, or even lodged in its orifice, being often sufficient to keep up an ex- hausting or even dangerous discharge. When the embryo only is expelled, the appendages being still retained, or when the haemorrhage is great, the entire ovum still remaining in the uterus, the ergot of rye will often prove of inestimable ser- vice ; and when given in the form of decoction, with as much borax as it will dissolve, will seldom disappoint our expectations. When a portion of the appendages remain at the orifice of the womb, it may be drawn down by the finger, or by a curv- ed dressing forceps. [In these cases Dr. Dewees recommends the use of a crochet, consisting of a piece of steel of the thickness of a small quill at its handle, and gradually tapered off to its other extremity, which is bent to a hook of small size. It is only in case of flooding, after the ovum has been broken and 11 its contents expelled, that Dr. D. recommends the use of this instrument. In early abortion this is quite a frequent occurrence, and the flooding is often alarming. When then a portion of the in- volucrum, or the placenta, insinuates itself into the neck of the uterus, thus preventing the de- gree of contraction necessary to check the hajmorrhage, (which condition may generally be ascertained upon examination,) the crotchet will be found highly useful. The mode of using it is as follows—The fore-finger of the right hand is placed within or at the edge of the os tincce ; with the left we conduct the hooked extremity along this finger, until it is within the uterus; it is gen- tly carried up to the fundus, and then slowly drawn downwards, its curved point fixing in the placenta; when thus engaged it is gradually withdrawn, and the placenta with it. “ In every case,” says Dr. Dewees, “ in which I have used it, the discharge has instantly ceased.” This instrument of Dr. Dewees, has not proved as useful in the hands of others, as it seems to have done in his own, and therefore other me- thods have been invented for the purpose of ex- tracting the placenta. Levret’s “abortion forceps,” (pince a faux germe) can only be used when a portion of the placenta projects through the os uteri into the vagina, and therefore will be found inapplicable in a large majority of cases. The tampon is doubtless the most generally available means, but even this is attended with uncertainty, and most physicians therefore depend on cold applications, and the internal use of the ergot. Drs. Denman and Burns give no directions as to instrumental means in such cases, but very full advice as to the medicinal treatment and regimen. There is an instrument called “ Burton’s Forceps,” which has been employed for this purpose, but the same objections apply to it, as to those of Levret’s. Professor Hodge of the University of Pennsylvania has also invented an abortion for- ceps, on the principle of Everett’s bullet forceps. This instrument consists of two blades, which re- volve on each other at a joint, so that they may be laid together like two spoons ; when thus ad- justed it is introduced into the uterus, on one side of the placenta, when the moveable blade is re- volved so as to be placed on the opposite side of the placenta. This instrument could hardly be applied with safety, except where the os uteri is much relaxed and dilated, which is not often the case. Those who are aware of the great prone- ness which the os uteri has to take on diseased action, from irritating causes, will resort with great hesitation, to instrumental aid. Dr. Meigs of Philadelphia employs the Polypus forceps in these cases, with as is stated, “ satisfactory success ; ” it might however be unsafe in less skilful hands. Dr. Henry Bond of Philadelphia, has recently in- vented a placental forceps, which seems to pos- sess some advantages over most of the others. It consists of two blades, about ten inches in length, curved laterally on a radius of about twelve inches, and the blades are about an inch and a half longer than the handles, the extremi- ties of the blades spread out with an oval expan- sion about half an inch wide and the handles and blades, including the edges of the oval portion are rounded off so as to preclude all possibility of wounding or pinching any of the surrounding soft parts. The inner part of the oval expansion is made concave and rough, so as to maintain a se- cure grip upon the body embraced. The instru- 12 ABORTION—Treatment of. ment may be easily guided by the finger to the os uteri, into which, if sufficiently expanded, it is intro- duced, and if necessary, it may be rotated so as to detach the placenta, in order to its extraction. —Amer. Jour. Med. Sciences, for April 1844.] In cases of great haemorrhage in the early months of pregnancy, the ovum being retained, Dr. Burns advises the use of smart clysters, and plug- ging the vagina. In every case of hcemorrhage from abortion, as well as after delivery at the full period, but particularly when the haemorrhage proceeds from inefficient contraction of the uterus, and retention of the ovum, or some portion of the appendages of the embryo, I have prescribed, with complete success, an enema, with from one to two ounces of the oleum terebinthinae in a pint of water-gruel. 39. The injection of water into the rectum, or a solution of acetate of lead and opium, has been advised by Dr. Dewees and Dr. Conquest When the haemorrhage occurs in robust and ple- thoric females, and the discharge has not produced much exhaustion, vensesection may be tried. In cases of this description, tincture of digitalis, in lialf-drachm doses, has been recommended: but, owing to the loss of blood, the effect, although not produced with the necessary celerity, will often be too violent and unmanageable, and will so en- danger the patient as not to justify its use unless under very peculiar circumstances. I once pre- scribed colchicum in large doses in a case of hae- moptysis, with violent paroxysms of cough and threatened abortion, occurring in a plethoric lady at the fourth month of pregnancy. Full venae- section was performed, chiefly on account of the severity of the pulmonary disease ; the colchicum was directed with an anodyne; and the patient left under the care of the family practitioner Abortion took place, and was attributed chiefly to the sickness, retching, and depression occasioned by the colchicum; it having been unremittingly administered until my next visit, on the third day from that on which it had been prescribed, not- withstanding the discretionary power with which the practitioner had been invested. (See also on this subject, the Treatment of Haemorrhage from the Uterus.) 40. iii. The remedial treatment of abortions is next to be considered. It occasionally happens that the retention of the ovum, or of a portion of the appendages of the embryo, produces much constitutional disturbance, particularly nervous symptoms and irritative fever, which sometimes assume serious features, with disorder of the bow- els, typhoid or ataxic signs, and an offensive va- ginal discharge. The decoction of cinchona and hydrochloric acid, or this decoction with the liquor of the acetate of ammonia, or the following will prove extremely serviceable:— No. 1. fit Mist. Camphor® 5 j-; Liq. Ammon. Acet 3 ijss.; Acidi Acetici Pyrolignei Til xxv.; Syrup. Z.ingi beris. 3 ss. M. Fiat Haustus ter quaterve in die su, mendus. No. 2. fit Camphorse rasse gr. ij.—iij.; Extr. Cinchon Kesin. gr. iij.—v.; Conserv. Ros. q. s. ut fiant Pilulse ij ter die capiendae. In cases of this description a turpentine enema, administered every second or third day, is ex- tremely beneficial: and advantage will be derived from injections of a solution of the chloruret of lime, or of Labarraque’s liquor, per vaginam. No. 3. fit Liq. Sod® Chlorinate f jss.; Mist. Cam phor®, ? vijss. M. Fiat Injectio. 41. When troublesome diarrhoea is present, in cases of this description, the chloruret of lime, either in the form of pill or solution, is extremely efficacious. I have prescribed it as follows:— No. 4. ft Chlorureti Calcis gr. viij.—xvij.; Pulv. Traga- canth. Comp. 3 jss. Syrup, q. s. M. Fiant Pilulae xxiv., quarum capiat binas ter quaterve in die. No. 5. It Chlorureti Calcis gr. vj.—xij.; Tinct. Calum- bffi 3 iij.; Aq. Menth. Virid., vel Aq. Carui, vel Aq. An- ethi, 3 vj.— | vijss. Fiat. Mist., cujus sumat coch j. vel ij. larga ter quaterve quotidie. The chloruret of lime may also be administered in water gruel, as an enema, in doses of viij. to xij. grains, once or twice daily. 42. The debility occasioned by abortions requires the use of tonics, with mineral acids, nourishing but light diet, a wholesome air, gentle exercise, and the tepid or cold salt water bath :—the min- eral waters of Bath, Bareges, or Tunbridge; those of Ems, Spa, Pyrmont, and Geilnau ; or the artificial mineral waters of the last-named place, are also beneficial. When nervous or hys- terical symptoms supervene, the exhibition of an- ti-spasmodics, with gentle tonics, and the occa- sional use of cooling aperients, are required. The treatment of the effects of abortion is, in every respect, the same as that recommended in the articles on Haemorrhage from the Uterus, in the unimpregnated and puerperal states. [Abortion in a Medico-legal point of view, has bearings at ’ relations too extensive for full consideration in this place ; for a complete discus- sion of the subject, the reader may consult Beck’s “ Medical Jurisprudence,” or Guy’s “ Forensic Medicine” (Am. Edition). The first point to be determined in these cases of suspected violence, is, has abortion really taken place ? This involves the necessity of examining the substances which may have been discharged from the womb, and nothing short of the discovery of the ovum must be deemed satisfactory. The length and size of the foetus must be accurately noted ; for if it has arrived at the sixth or seventh month, when it is capable of maintaining an independent existence, any questions that may arise belong rather to infanticide than to abortion. During the early periods of pregnancy it will often be difficult to distinguish the ovum from other substances, as moles, false membranes, clots of blood, &c., that may be expelled from the uterus. In all such cases, as already observed, no substance is to be admitted as the product of conception, in which distinct traces of an ovum cannot be recognised. The age of the ovum is to be ascertained by com- paring it with the description of the growth and development of the embryo and foetus, as con- tained in the works above mentioned. The next thing to be attended to is an examination of the woman. It is obvious that the value of such an examination will greatly depend on its being made at an early period, as well also, as the period of utero-gestation, at which the abortion has taken place—as the parts soon assume their natu- ral condition, our enquiries will be altogether un- satisfactory, unless made soon after the abortion is said to have occurred; if not made at an early period, the fact of abortion will have to be prov- , ed by circumstantial evidence alone. We are also to bear in mind, that the same derangement of parts will be caused by the expulsion of moles, hydatids, &c., as by the passage of a foetus through them. If we are satisfied that abortion has taken place, it will be expedient to enquire whether there was not such a predisposition to abortion, as to account for its having taken place, without attri- ABORTION—Medico-legal. buting any great efficacy to the means employed. To determine this question, we must enquire into the general health of the female before the abor- tion took place, and especially whether she has had previous abortions, and if so, whether they occurred about the same period of gestation. If the female died from the means employed, we should carefully examine the condition of the uterus, as well as the adjacent parts. It should not be forgotten that abortion from natural causes is of frequent occurrence in the early months, and more frequent as the period of utero-gestation is earlier. The next point to be determined is, was the abortion produced by violent means, or was it the effect of natural causes ? Collateral circumstan- ces, must here be allowed their full weight, as whether the pregnancy had been concealed, whe- ther abortive medicines had been procured, or used, &c. The criminal means which are resorted to with the view of destroying the foetus, may be divided into two classes, general and local, or those which act through the constitution of the mother, and those which act by immediate appli- cation to the abdomen or uterus of the mother To the first class belong blood-letting, Emetics, Cathartics, and Emmenagogues, and to the lat- ter, mechanical violence to the abdomen or uterus. Abortives.—A few remarks on abortives, may not therefore, be inappropriate to this place—and of the constitutional means, blood-letting first claims our attention. We can trace back the popular confidence in this remedy to the writings of Hippocrates. But so far from its being founded in truth, it is one of those popular errors, which time and experience have not been able to set aside. So far from venesection predisposing to abortion, unless carried to great extent, it is known to be one of the best preventive measures against it. Mauriceau states that the wife of one of his colleagues was delivered at the full period, of a well-developed infant, after having been bled 80 times during her pregnancy. Jamot tells us that his own wife bore a living infant at full time, after being bled 48 times; and according to De La Motte, a female was bled 87 times in the last five months of her pregnancy. (Velpeau, Ars des Ac- couchmens.) Ur. Rush, also (Med. Ob. & Inq. v. 3. p. 309,) states that not one pregnant woman whom he bled during the yellow fever of 1783, died, or suffered abortion ; and he gives an ac- count of one female whom he bled 11 times in 7 days, during her pregnancy, of another who was bled 13 times, and of a third who was bled 16 times, while in the same condition. All these women recovered, and were delivered of living and healthy children. Dr. Dewees (Cyclop, of Med. Vol. 1. p. 92), tells us that in cases of threatened abortion, “ blood-letting can rarely be dispensed with, in habits disposed to be plethoric, and is often of singular benefit in opposite temperaments, when artificial action is roused beyond the healthy bounds.” It is a very prevalent opinion among the com- mon people, that bleeding from the foot is a cer- tain means of bringing on abortion, and accord- ingly it is often resorted to for this purpose. But like the former, it is nothing more than a vulgar error, wholly unsustained by reason or observation. In France, and sometimes in this country, leeches are applied to the anus or vulva with a view to bring on abortion; but the practice is no more successful than general blood-letting. 13 Emetics.—These can by no means be considered as exerting any peculiar action on the uterus, although such as produce a powerful impression on the general system, as antimony, are unsafe in the advanced stages of pregnancy. Abortion may follow their administration, as it follows any violent shock given to the system ; but it is well established that emetics exert no specific influence over the uterus, for nothing is more common than severe vomiting during the earlier periods of preg- nancy, and sometimes throughout the entire du- ration of it, and yet without producing abortion. Velpeau relates a case in which fifteen grains of Tartarized Antimony were given with a view of procuring abortion, and although it caused violent vomiting, it did not bring on miscarriage. Cathartics, have also been employed for the destruction of the fetus, but with the same un- certainty.—Dr. Rush (Med. Ob. e (Duncan's Annals of Med., vol. iii.). 34. Arsenic, in the form of Fowler’s solution, had been recommended in this disease by Dr. Alexander (Med. Comment., vol. xv. p. 373.), at a period antecedent to the introduction of the nitrate of silver into practice, as an internal medicine; and subsequently by Sir G. Blane, who gave it with advantage, combined with digitalis and mercury (Med. Chir. Trans., vol iv. p. 136.). 35. Besides these, preparations of bark and other vegetable tonics have been recommended, either alone, or in combination with antispasmo- dics and anodines. The hydrosulphuret of am- monia, in gradually increased doses (from eight drops to thirty) twice or thrice daily. The dif- ferent preparations of valerian, the ammonio- sulphate of copper, and sulphate of quinine, have likewise been employed, and occasionally with decided advantage: from the last of these, combined with an anodyne, particularly with opium and camphor, I have observed much ben- efit to be derived. The following formula; may be employed. No. 18. fy. Infusi Rosas Co. 3xj.; Quinin* Sulph. gr. j. ~ij.; Acidi Sulph. Arom. Ilf x.; Spirit. .'Ether. Sulph. eoinp. 3j.; Tinct. Opii. Ilf xij. M. Fiat Haustus bis in dieyapiendus. Or, No. 19. 5s Extracti Anthemid. 3ij.; Quininse Sulph. XIJ. ; Mass® Pilul. Galban. Comp. 3j.; Camphor® teupactffi, gr. xv.; Syrup. Papaveris, q. s. Misce bene et divide in Pilulas xxiv., quarum capiat unam ad Binas vel tres bis terve quotide Having derived much advantage from the in- ternal use of the bi-borate of soda in dispeptic irritability of the alimentary canal, I was induced to employ it in a case of this disease which occur- red to me a few years since, in doses of from twenty to thirty grains, given in the decoction of althaea. It produced seme relief; but the case was of the greatest severity, and little benefit, at least of a permanent description, was derived from any means which were adopted, excepting from the prussic acid. 36. Mercurials have received the sanction of Brera. I have employed them in three cases, at first as an alterative ; five grains of blue pill hav- ing been directed occasionally at bed-time, and subsequently so as to affect the mouth. In one of these the alterative dose had a beneficial effect upon the state of the stomach and bowels ; but this was of short duration. When, however pushed further, so as to affect the gums, great irritability of the system, fever, restlessness, and increased pain, anxiety, and sinking, were occa- sioned by it. In the other case, evidently con- nected with hepatic disorder, the blue pill was also at first given as an alterative on alternate nights. It affected the gums after a few doses, and afforded relief. It was now pushed with the intention of inducing salivation ; and a somewhat violent effect was produced on the mouth, which was relieved upon exciting the salivary glands. Decided advantage was now procured; the bow- els were kept open by means of a stomachic aperient, an issue inserted in one of the thighs, and ANGINA PECTORIS—Treatment change of air recommended. This patient per- fectly recovered. 37. Where plethora exists, blood-letting in the intervals will be serviceable, with a light abstemi- ous diet. When the paroxysms are apt to occur during the night, I have found an opiate given at bed-time, as recommended by Dr. Heberdf.n, of great service. In one case of this description I gave the acetate of morphine, in the dose of an eighth of a grain, but it occasioned such distressing feelings of sinking, and general depression of the powers of life, that stimulants were required ; yet the same patient had experienced relief from opium combined with camphor. On one occasion I tried the effects of iodine in the form of the tincture; but although its use was adopted with great cau- tion, seven drops only having been given three times a day, it occasioned an increase of all the symptoms, apparently owing to its irritating effects on the digestive mucous surface, and the idiosyn- crasy of the patient. I may here notice the prac- tice recommended by Schlesinger (Hufeland’s Journ., vol., 1. p. 57.), consisting in the exhibition, every two hours, of the extract of the lactvca virosa, in doses of two grains, with half a grain of digitalis. What effect may we expect from the use of colchicum ? Where the disease seems to originate in gout, the colchicum might be tried; but its use would require great circum- spection. In my opinion, it should only be given in combination with stimulants, or antispasmo- dics and tonics, the tinctura colchici composita being the most promising preparation of it in such a case. 38. Although the patient labouring under this disease is generally incapable of any, excepting the most gentle, exercise ; yet this should be taken under favorable circumstances ; and change of air, particularly to healthy, dry, and elevated situations, should not be overlooked. It will generally be observed, that persons labouring un- der the worst form of the disease, incapable even of walking or sitting upright for any time, will bear well, and even be benefited by, rapid travel- ling in a carriage. This was first evinced to me by the case of a gentleman of great scientific and literary attainments, residing for a time at Paris, where I was called to him in the summer of 1829 He was anxious to return to England, from a dread of dying abroad. He undertook the jour- ney with me, and was better during it than either previously or subsequently. He has since taken long journeys, with similar advantage. 39. Secondly, Much benefit will be often re- ceived from topical means. Under this head ru- befacients, issues and setons deserve particular notice. The latter have been employed on the insides of the thighs by Macbride and Darwin, Kreigelstein and Wolff also have observed advantage to be derived from them, when inserted either in this or in other situations. I have resorted to a peculiar form of issue in several cases of this disease, and, upon the whole, with much benefit. In one case, however, it failed of having the least good effect. 40. The form of issue to which I allude, and for the knowledge of which I am indebted to my learned friend Dr. Hutchinson, is the bark of me- zereon root, deprived of its external cuticle, and, after having been soaked for some time in a little water, placed upon the surface of the part from which we wish to procure a discharge. This bark should be confined to its place by means of 77 78 adhesive plaster, spread on paper of larger dimen- sions than the part covered by the mezereon bark. The bark may be renewed every night, until it procures a copious discharge. In some cases the effect is produced in a single night, or in twenty- four hours. When the discharge becomes copious the bark may be renewed less frequently. The adhesive plaster serves both to keep the mezereon in its situation, and to retain the discharge, so as to preserve it from soiling the clothes. When it is abundant the plaster may be renewed, and the secretion removed, as its occasional acrimony often tends to heighten and to extend the irrita- tion. In a severe and chronic case of this dis- ease* which occurred to me ip 1830, I employed this form of issue, and kept a surface of about four inches square over the left small ribs discharg- ing as long as the patient would endure this treat- ment. The disease disappeared, and up to this time it has not returned The advantages of this issue are, that the patient can manage it from the beginning with great ease ; and it may readily be increased to any extent, and the discharge augmented according to the exigencies of the case. 41. Artificial eruptions, from the ointment or plaster of the potassio-tartrate of antimony, have now usurped the place of setons and issues; but, from a very extensive experience of the for- mer, both previous and subsequent to the publica- tion of an article on them in the London Medical Repository for April 1822, I consider them of in- ferior efficacy in some diseases, and particularly in this, to the pea-issue, or the issue now described. It is singular that the advantages to be derived from the production of artificial pustulation, in the treatment of various disorders, were so little known or appreciated until the appearance of Dr. Jen- ner’s pamphlet on the subject, since the practice had been recommended long previously in the Lectures of the second and third Monros on Morbid Anatomy, as being frequent preferable to the use of blisters; and had been found service- able by Goodwin, Autenrieth, and Kreigel- stein, in this affection, in which it had been em- ployed by them at the end of the last century. Liniments with croton oil, are equally serviceable and more immediate in their effects. 42. Blisters, either frequently repeated, or kept discharging for a longer or shorter period, have received the sanction of Percival and many others. But little benefit will be derived from them, unless they be used in the way now named. Thilenius recommends (Med. und Chir. Bemer- kungen, i. p. 183.) repeated blisters applied be- tween the shoulders. I agree with him in the selec- tion of this place in preference to others for their application, as well as in the propriety of repeat- ing them frequently. M. Laennec states that he has derived great advantage from magnetism, used in the following manner, both in alleviating the paroxysm, and in preventing its accession :— He applies “two strongly magnetised steel plates, of a line in thickness, of an oval shape, and bent so as to fit the part,—one to the left pnecordial region, and the other exactly opposite, on the back, in such a manner that the magnetic current shall traverse the affected part.” (Diseases of the chest, p. 705.) 43. When the affection is complicated with other diseases, particularly with organic lesions of the heart, or enlargement of the liver, the treat- ment should be modified accordingly. In order to ascertain the nature of such complications, aus- ANTIPATHY cultation may be resorted to; for, although it gives us no information respecting the simple dis- ease, it often enables us to detect the lesions with which it is sometimes associated, and to direct our means of cure more appropriately, and with hap- pier results than we could otherwise do. When the substance of the heart is weakened or attenu- ated (§ 23.) tonics, particularly sulphate of qui- nine, sulphate of zinc, and the various prepara tions of iron, given in decided doses, are particu- larly indicated. In other cases, as well as when the liver is affected, issues are generally service- able. When the disease is connected with en- largement, &c. of the liver, mercury is almost in- dispensable. In all cases, whether simple or complicated, attention to diet and regimen, a pure air, amusement without excitement, and an equa- ble and contented state of mind, are not only re- quisite to recovery, but are also necessary to ren- der it permanent. Bibliography.—Sauvages, Nosologia Methodica, tom iv. p. 120. edit. 8vo.—Heberden, Medical Transactions of the College of Physicians, vol. ii. p. 59.1768.— Eisner, Ab- hanlung iiber die Braustbraune. Koenisb. 1778.—Schaffer, Dissertat. de Angina Pectoris. Gotting. 1787.—Butler, Treatise on the Disease commonly called Angina Pectoris. Lond. 1791.—Schmidt, Dissert, de Angina Pectoris. Gott. 1793.—Parry, An Inquiry into the Symptoms and Causes of the Syncope Anginosa. Lond. 1799.—Hesse, De Angina Pectoris. Halle, 1800.—Darwin, Zoonomia, vol. iv. p- 42. 1800.—Stoeller, Journ. der Pract. Heilkunde von Huffe- land, 17 b. 1803.—Jahn, Ueber die Syncope Anginosa, (Hufeland’s N. Journ. 1806.—Beaumes, Traite Elemen- taire de Nosologie. 1806.—Dcsportes, Traite de l’Angine de Poitrine. 1811.—Blackal, Observations on the Nature and Cure of Dropsies, &c. Lond. 1813.—Kreysig, Die Krankheiten des Herzens. 8vo. Berl.—Zechinelli, Sulla Angina di Petto Pad. 1813.—Jurine, Memoire sur l’An- gine de Poitrine, couronne par la Socidtb de Medicine de Paris, 1815.—Lacnnec, Traite de P Auscultation Mediate. Paris, 1826.—Chapman, American Journal of Medical Sciences, vol. vii. Phil. 1831.—Jolly, in Dictionnaire de Medicine et Chirug. Pratiques, &c., tom. ii. Paris, 1829. —.7. Hope, On Diseases of the Heart. Lond. 8vo. 1832. p. Ali.—Bouilland, Traite Clinique des Maladies de Cceur. Paris, 8vo. 1835, tom. ii. p. 491. [Hosack. (David,) Remarks on Sternalgia or Angina Pectoris.—Essays on various subjects of Med. Science, ii. 288. New York, 1824.—Chapman, Notes of cases of An- gina Pectoris, with some remarks. Am. Journ. Med. Sci. vii. 67. Phil. 1830 —Warren, (John C.,) Remarks on An- gina Pectoris, New Eng. Jour, of Med. and Surg. i. 1. Boston 1812.—Bogart, (Henry,) On Angina Pectoris, Thesis, N. York, 1813-1 ANIMATION SUSPENDED. See Asphyxy. ANTIPATHY. Syn. ’Avniradits, Gr. Antipathia, Lat. Der Widerwille, die Antipathie, Ger. Antipathia, Fr. Antipatia Avversione, Ital. Antipathia Sensilis, et A Insensilis, Good. Classif.—4. Class; 4. Order (Good). I. Class ; IV. Order (Author.) 1. Defin. Internal horror and distress on th( perception of particular objects, with great rest lessness, or with fainting. 2. This singular affection has merely been men- tioned by Cullen : it has, however, received more attention from Sauvages Linnteus, Vogel, Ploucquet, Passament, and Good. The last named writer has needlessly divided it into two species—sensile and insensile antipathy ; the for- mer arising from objects or subjects which strike some one of the senses; the latter from the pres- ence of an object, as soon as it comes within the sphere of some unknown influence, although un- perceived by any of the senses. There are numerous instances of singular an- tipathy on record ; and most persons of observa- tion have met with others in the course of their experience. The vulgar explain them generally by considering that the mother had experienced AORTA—Nervous Pulsation of. 79 a fright from the objects of antipathy during the early months of pregnancy—and there are, no doubt, some facts, which countenance the suppo- sition. Thus, James the First could not endure the sight of a drawn sword: Rizio was killed at the feet of Queen Mary when pregnant with him ; and many other instances are mentioned by writers ; but more frequently the persons them- selves, who are thus affected, have experienced frights during the early months of infancy, or have had their minds early and indelibly im- pressed by certain subjects. Peter the Great had a fall from a bridge into the water when an infant, and he could not afterwards endure to hear the rattling of a carriage passing over a bridge. Persons often retain the antipathy to the sight of crabs, lobsters, &c., which had been oc- casioned by fright from them in infancy or child- hood. A man-servant in the author’s family, ad- vanced in life, had so great an antipathy to the sight of a mouse, that he would fly as fast as he was able from the place where one was seen ; and become quite frantic at the sight. He stated that his mother, who likewise had an antipathy to mice, had been distressed by one thrown upon her when pregnant of him. Some persons cannot endure certain odours, from the faintness, or sick- ness, or sense of anxiety and distress they occa- sion. This appears to proceed from peculiar idiosyncrasy. I have likewise seen persons who could not touch certain smooth objects without feeling a peculiar shudder or horror, followed by faintness in some. This appears to arise from associations excited in susceptible or sensitive minds. 4. The most singular instances of antipathy are those which occur at the presence of objects unperceived by any of the senses, forming the insensile antipathy of Dr. Good. Thus, a cat concealed in a room has been known to produce a most indescribable distress or horror in a person who has not perceived it by any one sense, and has been, in no other way, informed of its pres- ence. Some singular idiosyncrasy, doubtless, exists in such cases. Sauvages conceives that an effluvium proceeds from the animal, which, com- bining with that emanating from the person thus affected, occasions the unpleasant sensations upon this peculiar organisation or idiosyncrasy. This is perhaps the only opinion that can be formed on the subject. 5. The Treatment to be adopted for the re- moval of antipathies consists chiefly of resolute endeavors to overcome the morbid impression, by gradually accustoming the mind to its influence. Indeed, this is the only remedy that can be re- sorted to. Its adoption, successfully, or other- wise, will entirely depend upon the mental energy of the patient. But there cannot be a doubt, that all impressions, however unpleasant or distressing may be ultimately overcome by repetition, and a firm resolution either to endure, or not to be affected by them. The following works will furnish some curious information on this sub- ject, with much trifling, silly hypothesis, and irrel- evant matter. Bibliography.—Lipsius, Diss. Antipathic Singulares, Acc. Jen. 1678.—S. Rattray, Ailitus Novas ad Occult* Sympathi*et AntipathicCausas. Glasg. 1658.—K. Digby, Theatr. Sympathet., p. 138.—Rudolph, De Antipathia Humana. Basil, 1700.—■Schurig, Chylologia, p. 96. et 163. et seq.—JYtentx, Disser. Antipathic Phys. Phienom. ad suas Causas Revocata. Lips. 1708.—Du Voisin, De Antipathia Humana. Basil, 1701.—Qwinger, De Anti- pathia Humana, Eascic. Dissert. Select., n. 1.—Sckwim- mer, De Antipathia. Jense, 1669.—Uermstaedt, Wun- derbare Kriifte der Natur durch die Syrnp. und Anti- pathie. Rotenb. 1776, 8vo.—Passament, Essai sur les Antipathies, Paris, 1811.—M. Good, Study of Med. by Cooper, vol. iii. p. 366. ANUS. See Rectum. AORTA. Syn. Arteria Magna. Aorte, Fr Aorta, die grosse Schlagader, Haupstamm alter Korperpulsardern, Ger. Its Diseases. 1. This most important vessel is liable to all the lesions which have been noticed under the article Arteries. Some of them, however, when seated in this artery, are so important, particularly as re- spects their effects upon adjoining viscera, and their extremely dangerous consequences generally, that I propose to give a succinct account of them in this place. In doing this, I shall so far depart from the alphabetical arrangement, in respect of the subordinate heads of the subject, as may be requisite to the consideration of it in strict patho- logical order. Functional disorder, therefore, of this vessel will be first considered ; next, inflam- mation ; and, lastly, those lesions which usually result from inflammation, &c., as aneurism, con- striction, obliteration of the vessel, &c. 2. I. Nervous Pulsation of the Abdominal Aorta.—Classif. II. Class : I. Order. This is not an infrequent affection in weak, emaciated, and delicate persons, and particularly hysterical females. It is often associated with collections of air in the colon or stomach ; and with accu- mulations of faecal matters or morbid secretions in the caecum. It is also not infrequently conse- quent upon neglected dyspepsia. 3. i. The Symptoms are generally very charac- teristic of the nature of the complaint, and suffi- ciently serve to distinguish it from organic lesion of the vessel. The morbid pulsation is generally associated with nervous or hysterical symptoms, and is of a variable character. It is increased and diminished, sometimes without any evident cause, but more frequently by mental or moral affection and emotions, or by constitutional causes. Disorders of the stomach, and irregularity of the uterine functions, also sometimes occasion or reproduce it; and I have observed it to follow upon the paroxysms of sinking or leipothymia, to which very delicate females are occasionally liable. [Dr. Hope has shown that pulsation of the ab- dominal aorta generally arises from an anaemic or watery condition of the blood, while, nervous- ness, whether pre-existent or consequent, co-ope- rates by accelerating the circulation. Laennec supposed the phenomenon was produced by ner- vous and hysterical irritability with spasm of the aorta. It has often been mistaken for aneurism of the abdominal aorta.] 4. Upon pressing the stethoscope firmly over the aorta, the pulsation will be generally felt limited in extent, in its tranverse or lateral direc- tion, but it will be very perceptible in the course of the vessel from the bifurcation to the epigas- trium. Instead of the gradual, steady, and strong motion or impulse attending aneurism, there is felt a vigorous and smart jerk ; and the sound is either merely a slight whizzing, or is scarcely to be heard.* [* See an excellent paper on “ Pulsation in Epigastrio” in the first volume of the Physico-Med. Transactions of N. York, (1817,) by Dr. Y. Mott. Dr. Mott states that this pulsation may arise from the following causes :—I. Aneu rism of the aorta, coeliac, or superior mesenteric artery. II. Enlargement or disease of the pancreas. III. Scirrus 80 [Dr. Graves of Dublin has shown that the im- pulse may sometimes be excited by the horizontal position, when, from hydrostatic pressure, it does not exist in the erect. Inorganic murmurs and thrill, with a jerking pulse in the carotid and sub- clavian arteries, and venous murmurs in the jugular veins, generally co-exist with aortic pulsation, and serve to corroborate the diagnosis.—Hope.] 5. ii. The Treatment of nervous pulsation of the aorta will entirely depend upon the peculiar circumstances of the case in which it occurs. If the paroxysm is severe, the preparations of sether, assafeetida, valerian, and ammonia, should be ex- hibited. I have seen much benefit afforded by strong coffee and green tea in these cases. The dependence of the affection on mental emotions indicates the propriety of advising a tranquil state of mind and a mild diet, with attention to the reg- ular functions of the bowels. In cases evincing much irritability mental or corporeal, hyoscyamus, conium, or the acetate or sulphate of morphine, in very small doses, particularly hyoscyamus com- bined with camphor, will be found useful. The preparations of morphine, however, should be cautiously administered in this affection. In a case which occurred to me some time ago, the sixteenth part of a grain only of the acetate of morphine, was followed by unpleasant depression. Upon the whole, more advantage will accrue from the antispasmodics than from the sedatives just named; but in cases characterised by atten- dant irritability, the combination of substances be- longing to both these classes of remedies will be of great service. 6. In all cases of this affection occurring in females,—and the great majority of them do oc- cur in this sex,—the state of the menstrual dis- charge should receive the utmost attention. When the more distressing state of the affection subsides, a more tonic regimen and plan of cure may be adopted. The bitter infusions and decoctions, particularly those of calumba, cinchona, casca- rilla, and chamomile, with the alkaline prepara- tions, &c., and subsequently the preparations of iron, the shower bath, cold salt water bathing, chalybeates, regular exercise in the open air, and light nutritious diet, are the means chiefly to be depended on. When associated with other ail- ments, it is generally symptomatic of them, and therefore in such cases the treatment must be di- rected to the primary complaint. 7. II. Inflammation of the Aorta.—Syn. Aortitis. Aortite, Fr. Die Aortenentzundung, Ger. Classif. II. Class ; II. Order.—Inflamma- AORTA—Inflammation of. tion of the aorta occasionally takes place, but more frequently in a chronic than an acute form, and commonly consecutively of inflammation of the internal surface of the heart, and during the course of certain states of fever. The internal membrane of the vessel is sometimes alone in- flamed, particularly when the disease takes place during fevers, or extends to it from the internal surface of the heart’s cavities ; but, in several cases, the subjacent cellular tissue, or both it and the internal membrane are chiefly affected. Aortitis seldom originates in the exterior coats of the vessel. 8. i. The Causes of aortitis are,—1st, External injuries, as blows, contusions, falls, &c.; 2d, Vio- lent, or too long-continued exertion ; 3d, The use of hot, stimulating and acrid ingesta, spirituous liquors, and the introduction, by absorption or other- wise, of irritating poisons and morbid secretions. &c. into the circulation ; 4th, The extension of in flammation from the heart, lungs, pleura, and pericardium, and the suppression of the eruption in eruptive fevers ;—M. Portal states {Anal Med., t. iii. p. 127.) that he has met with it in cases of this description ;—and, 5th, The causes which are productive of diseases of the heart. 9. ii. The Symptoms can scarcely be stated with any hopes of enabling the practitioner to distinguish this disease, which is generally met with in conjunction with other maladies ; particu- larly fevers, and inflammations of the heart, lungs, pericardium, and pleura, and disclosed to us only bv post mortem, examination.—a. When inflam- mation more or less acute extends along the de- scending aorta, the patient generally complains of a smarting and painful sensation in the direc- tion of the.spine, with a violent feeling of pulsa- tion of the aorta ; extending to the iliacs, without any appearance of enlargement or tumour; and unaccompanied by smallness of pulse in the re- moter arteries, particularly those of the superior parts and extremities of the body. In the more acute cases, a sensation of heat is felt in the re- gion of the vessel, sometimes with oppressive anx- iety, leipothymia, or tendency to fainting, and al- ways increased force and vivacity of the pulsa- sations of the vessel. 10. b. The chronic states of this disease admit not of recognition until they have produced some one of those organic lesions, which occasioned marked obstruction of the circulation, or aneuris- mal dilatations. Dyspnoea upon slight exertion, emaciation, a pale, yellowish tint of countenance, palpitations, hypertrophy and dilatation of the heart’s cavities, oedema of the extremities, &. are then the usual symptoms ; and, although they fur- nish no certain evidence of the existence of the disease, yet when they are present, without the signs of narrowing of, or obstruction in, the ori- fices of the heart’s cavities, and of the origin of the aorta, chronic disease of the aorta may he presumed to exist. 11. c. Aortitis, particularly in its chronic states is occasionally complicated with hypertrophy of the left ventricle ; the hypertrophy either causing the inflammation of the aorta, or the latter occa- sioning the former, particularly when the canal of the vessel is narrowed or obstructed by the effects of the inflammation. The other complications have been already noticed (§ 7—9.). It is chiefly owing to the more frequent occurrence of the disease in a complicated, than in a simple form, that it is so commonly overlooked, and so difficult of the stomach, and particularly its lower or pyloric ori- fice. IV. Tumours at the footof the mesentery. V. Ner- vous irritation. VI. Enlargement of the vena cava infe- rior. VII. Increased solidity of the lungs. VIII. En- largement of the heart, particularly a dilatation of its right side. IX. Adhesion of the pericardium to the heart. “ Every pulsation in the vicinity of a large artery,” says Dr. Mott, “and particularly if it is accompanied with a tumour, gives rise to the suspicion of an aneurism, In the extremities, very little difficulty can attend ; an accu- rate diagnosis, for the most part, can be arrived at. Aneu- risms of the large arteries of the trunk are, however, not easily detected; first in consequence of the adhesions which they contract with the surrounding viscera, and secondly from the diseases of many other organs with which they are apt to be associated ; the latter of which alone will produce many of the characters of aneurism.” If the pulsation in the epigastrium is strong, we may in- fer that it is not aneurismal, but produced by one of the other causes. The perfect correspondence between the pulsation of the epigastrium, and the action of the heart, is a circumstance strongly diagnostic of the aneurismatic state of the aorta, coeliac or superior mesenteric artery.” —hoc. Cit.] AORTA—Aneurism of. 81 to be ascertained, even when its existence is sus- pected. 12. iii. The Prognosis of this disease, when its existence is presumed, is always unfavorable ; on account both of our ignorance of much that is important respecting its symptoms, complications, and consequences, and of the fatal nature, sooner or later, of a great part of the effects to which it gives rise. 13. iv. The Lesions produced by inflammation of the aorta are nearly the same as those I have enumerated in the article on the lesions of arteries. But as these changes, when affecting this impor- tant vessel, are often the first step to the formation of aneurism in it, I shall here briefly allude to them as they actually appear upon examination. Aortitis, whether occurring simply, or with dis- ease of the heart or other related viscera, presents the results of various grades of activity. In the more acute cases, the internal surface of the ves- sel is of a deep or dark red, sometimes approaching to purple; and both the internal membrane and the middle coat are easily torn. The connecting cellular structure and the fibrous coat are much more injected with blood than natural; and co- agula, more or less firm, and of a fibrous character, sometimes adhere to the internal surface of the inflamed part: but this is not often observed in the aorta, as the current of the circulation through it seems to wash away the fluid as soon as it is ef- fused, and before it coagulates on the surface which produced it. Obliteration of the aorta (see § 53.) may, however, arise either from exter- nal pressure, or from false membranes formed in its internal surface, so as to obstruct the current of the circulation in it; or from depositions of lymph between its coats, sufficient to produce the same effect, the obliteration being thus a remote consequence of the obstruction. 14. The results of chronic aortitis, are more fre- quently met with than those of the acute. These are yellow spots, or yellow curdy matter deposited under the inner membrane, which may burst from the distension and the friability occasioned by the inflammatory state ; the curdy matter projecting like a tubercle into the canal of the vessel ; bony deposits, which are also just formed under the in- ternal membrane, and in like manner become ex- posed and washed by the current of the blood in the vessel; thickening and induration of the coats of the aorta; friability and softening of one or more of them; ulceration commencing in the lining membrane, and extending more or less through the exterior tunics, till at last dilatation of the external coats in the form of a pouch, or fatal haemorrhage, ensues ; and cracking, and lacera- tion or dilatation, which, with the former lesions, generally originate the different forms of aneurism to which this vessel is liable (see § 18.). In a case which occurred to Dr. J. Wilson in the Mid- dlesex Hospital, the internal surface of the ascend- ing aorta and the arch was extensively ulcerated, without dilatation. 15. Dilatation of the coats of the aorta may first occur, and then the inner or middle coats give way when it has reached a certain pitch : or the laceration of the inner coats, with or without previous ulceration, may take place previous to the dilatation. But either state of disease—dilatation or laceration—especially the latter, seems to pro- ceed from a nearly similar pre-existing change of the internal tunics, one evidently connected with slow inflammatory action. Even dilatation, which has been attributed to debility of structure, is more frequently a result of inflammation, which in fact occasions here, as it does every where else, debility of structure; defective vital cohesion of the texture being a general result of inflammation. 16. v. Treatment. Aortitis requires the same treatment as other acute inflammations. General and local blood-letting, perfect repose, both moral and physical, and the rest of the antiphlogistic re ■ gimen are indispensable. The preparations of di gitalis in order to quiet the heart’s action, cooling aperients to remove faecal accumulations, and counter-irritants to elicit a determination of the fluids to external parts, are amongst the most ef- ficacious means. In resorting to counter-irritation, care should be had not to employ substances cal- culated to excite general irritation by their use in this way. The ointments or liniments of the potas- sio-tartrate of antimony (see F. 305. 749.) are the only means of this description ; excepting is- sues, which should be used in this disease. 17. When those symptoms appear which have been stated to result from chronic aortitis, or its effects, local depletions,—particularly when signs of congestion of either the heart, lungs, or head, appear—a restricted diet and regimen, perfect re- pose of body and mind, attention to the abdominal functions, and the use of the tartarised antimonial ointment, or setons or issues, are the chief means that can be called to our aid. Other remedies may, however, be employed, with the view of al- leviating or removing the contingent symptoms and ailments that may supervene. 18. Ill Aneurism of the Aorta,—Aorteu- rysma.—Die Aortenweitung, Ger.—Classif. IV. Class ; II. Order.—i. Aneurism of the aorta is a not infrequent consequence of inflammation, particularly of its more chronic forms. The changes in the parietes of the vessel, constituting aneurism of it, are the following:—1st, Simple dilatation of the whole circumference of the ves- sel ; 2d, Dilatation of one side only, in a succulated form, without rupture of its coats, or true aneu- rism; 3d, Dilatation of the external or cellular coat of the vessel, occasioned by rupture or ulce- ration of the internal and middle coats, or conse- cutive or false aneurism ; and, 4th, Ulceration or rupture of the internal coats taking place after their dilatation, and occasioning the still further di- latation of the cellular coat, constituting mixed or compound aneurism. 19. A. Simple dilatation of the whole circum- ference of the aorta may occur to a greater or less extent along the vessel; it may be limited to a small portion only ; or it may occur in several parts, giving the vessel an irregular shape, and forming several oval expansions of it. The se- cond of these is the most common. The dilatation is various in extent: it is frequently as great as twice or thrice the natural calibre of the vessel, or even greater. It is usually more evident in one side than in an another, and is attended with some one or more of the organic changes de- scribed as consequent upon chronic inflammation of the aorta (see § 13—15., and Arteries, Pa- thology of ), particularly thinning and thickening of the coats, thereby resembling passive and ac- tive aneurisms of the cavities of the heart. The situations in which this change of diameter of the vessel occurs most frequently, are the ascend- ing portion and arch; but it is not infrequent in the descending aorta. Dilatation of the pulmo 82 nary artery is very rare. The simplest form of aneurism, although frequently accompanied with various morbid depositions in the coats of the ves- sel, never contains laminated coagula, unless the lateral dilatations very nearly approach the state of sacs or pouches, constituting the next variety. In some cases of this form of aortic aneurism, similar changes are also met with in some of the large arterial trunks, as the subclavian, coeliac, and iliac arteries. 20. B. True aneurism, or extensive dilatation of a portion of the circumference of the aorta, frequently has a neck of less diameter than the body of the sac. It seems to arise from a loss of elasticity and vital resistance of the portion of the vessel thus affected, in consequence of chro- nic inflammation and its effects. Owing to this cause the dilated portion of the vessel often pre- sents many of the lesions described as consecutive of the inflammatory state, particularly reddened spots, minute fissures, atheromatous, cartilagin- ous, or ossific deposits, &c. This variety most commonly affects the ascending portion and arch of the aorta, and shoots out from its anterior or lateral parts. It often attains a considerable size, being sometimes as large or larger than the foetal heart, and generally inclines towards the right side of the chest. The dilated coats of the vessel are generally thicker, and but very rarely thinner than natural, unless in parts of the aneurismal pouch. When it arises from the root of the aorta, and the inner and middle coats burst, fatal extra- vasation takes place within the pericardium; no false aneurism taking place in this situation, ow- ing to this part of the vessel being destitute of the cellular coat. Coagula do not frequently form in true aneurism as long as the current of blood in the sac continues to be not much ob- structed ; but when, owing to the narrowness of its mouth, or to retardation of the current of cir- culation in it, a partial stagnation takes place, coagula then form, frequently in an irregular or confused state, but sometimes in regular layers. 21. C. Aneurism with ulceration of the inter- nal coats, or false aneurism. This variety arises, 1st, from rupture or fissures of the internal coats, owing to a loss of their vital cohesion, and to friability consequent upon chronic inflammation, associated with fungous, calcareous, and steato- matous deposits ; and is often occasioned by acci- dents, or violent or sudden extension of the vessel; 2d, from ulceration following scrofulous and chro- nic inflammations, and the detachment of various depositions formed in the internal membrane. Cases have been recorded by Laknnec and Guthrie, wherein fissures of the internal coats of the vessel, instead of producing aneurismal dilata- tion of the external coat, had dissected it from the fibrous tunic along the greater part of the length of the vessel; but such occurrences are very rare. This variety of aneurism cannot be formed at the commencement of the aorta: it is most frequently met with in the descending aorta, and the part opposite to the tumour or sac is generally not in the least dilated. Numerous instances of this va- riety of aneurism are recorded by modern authors. [Several cases of dissecting aneurism, have been recorded; one by Laennec, in which the separation of the coats extended from the heart down to the iliac arteries; two by Mr. Guthrie, in his work on the diseases of arteries ; one by Mr. Shekelton, in the 3d. vol. of the Dublin Hospital Reports, where the blood, after passing AORTA—Aneurism of. through a fissure penetrating the two internal coats, again re-entered the canal of the artery by a rent through the same tissues ; one by Nichols, (the case of George II.); one by Hodgson, (on Diseases of Arteries, p. 63.); two by Morgagni, (Epist. 26. Art. 15—21st.); two by Dr. Pennock, of Phil. (Hope on Dis. of the Heart, Am. Ed. p. 402.), in which the appearances on dissection, led him to conclude that the lesion consisted in a separation of the lamina of the middle coat, by blood driven by the propulsive force of the heart through a rent, caused by a laceration of the serous coat and a partial rupture of the layers of the middle coat {Am. Journ. Med. Sciences, vol 23.); one by Dr. Paul B. Goddard, of Phil., {Ibid, Nov. 1838, p. 20.) ; and one by Dr. J. A. Wash- ington, of New York. In both these latter also, the lamina of the middle coat of the artery were separated, and the blood was effused into the pe- ricardial sac. In Dr. W’s. case we are told that “ it was found, that the laceration which had at first been confined to the inner and middle coat, had ultimately extended through the whole thick- ness of the aorta, opening into the pericardial sac. The rupture began very near the sigmoid valves, and extended spirally, so as very nearly to encircle the aorta—the two ends of the spiral la- ceration being about an inch from each other. The laminated character of the middle coat of the aorta was seen along this rupture ; a thin lamina of this coat being partially separated from that portion of it which was adherent to the inner coat. Through this spiral rupture, blood had been driven by the heart, between two layers of the middle coat of the aorta down to the bifurca- tion, into the common iliacs, separating them in the posterior semi-circumference of the artery— at the point of separation of the lamina of the middle coat from each other, fibres of either layer stood out distinctly, crossing each other as tena- cula holding the two layers together. That the rupture along the extent of the aorta was not be- tween the centre and middle coat, but between the two layers of the middle coat, the one ad- hering to the inner, and the other to the outer coat, was very evident from careful dissection of the part, as well as from the tenacula formed out of the very substance of the middle coat, and which have been represented as apparently hold- ing the two layers together along the line where the separation had ceased. The inner coat of the artery, at, and near the place of rupture, was dotted over with aethcromatous spots, but no ossification existed ; the aorta itself was enlarged, but not aneurismal near its origin ; the valves were pretty sound, and the whole heart slightly dilated; the pericardium was gorged with blood, the opening into it from the aorta being about the diameter of a quill.”] 22. D. Mixed or compound aneurism. After all the coats of the vessel have been dilated to a certain extent, forming either simple expansion or true aneurism, but, owing to the less extensi- ble properties of the internal coats, conjoined with the effects of previous or existing inflammatory action, rupture or ulceration of them takes place, the impulse of the current of the circulation di- lates still further the yielding cellular coat of the vessel, and a sac or cyst is thus not infrequently formed of this coat surmounting the primary aneurism. In this case the perforated internal coats form the neck of the cyst, which is always narrower than the cyst itself. When the ruptured AORTA—Aneurism of. part of the internal coats is considerable, so that the impulse from the current of blood prevents its coagulation in this cyst; or, when in this, as in the other varieties of aneurism, coagulable lymph is not formed, so as to give rise to layers of fibrin- ous coagula within the sac calculated to support it, rupture of the sac will sometimes occur, and a diffused form of aneurism be the result. 23. E. Of certain changes connected with aneurism of the aorta. In some rare instances an aneurism of this vessel has been observed by Haller, Dubois, Dupuytren, and Laennec, con- sisting of hernia of the inner coat through the ruptured fibrous coat. But it is obvious that aneurism, or tumours of this description, can sel- dom reach any considerable size without being either ruptured, owing to the more friable nature of the internal membrane, or confined by granu- lations and adhesions on its external surface, as shown by the experiments of Hunter, Scarpa, and Home. Solid small tumours of the size of nuts, and closely attached to the aorta, have been described by Corvisart and Hodgson ; the latter of whom supposes, with Laennec and Bertin, that they are the remains of spontaneously cured aneurisms, their sacs having been filled with co- agula, and their size afterwards diminished by ab- sorption. The deficiency of the coats of the ves- sel, at their points of union with it, seems to con- firm this opinion. 24. a. One of the most important changes connected with this disease is the deposition of fibrine and the formation of coagula on the in- ternal surface of the sac. This process generally appears to proceed by progressive steps : and the deposition thus presents successive layers. The most central of these generally consist of blood only, more or less firmly coagulated ; and each layer becomes firmer, drier, and paler, and more and more fibrinous, until the parietes of the sac is reached. In many cases, the most external layers chiefly consist of a whitish or greyish yellow fibrine, more or less opaque and friable. Some- times they nearly resemble dried paste. The more recently formed coagula are soft, loose, and often only partially adherent to the layer next it. In some cases blood seems infiltrated between the layers. Those next the vessel are generally united to it by a fine cellular-like tissue, furnishing ap- pearances of a partial organisation. These depo- sitions evidently proceed from the effusion of co- agulable lymph from the internal surface of the aneurismal sac, and the partial stagnation or retardation of the blood, favoured by the narrow- ness of the neck of the sac, and the inflamed, un- even, or ragged state of its internal surface. When neither of these states exists, as is often the case in respect of the first two varieties of the dis- ease, and particularly when the neck of the pouch is wide, neither coagula nor layers of fibrinous de- posits are formed. When, however, inflammation of the internal surface of the dilated vessel or of the sac exists, and when a morbid secretion takes piace from it, this will originate coagulation of a portion of the blood which comes in contact with it, and form, at the same time a bond of union between the coagulum and the internal surface of the dilated coats of the vessel. The thick- ness and compactness of the coagula in aortic aneurisms are often remarkably great, and are chiefly to be imputed to this mode of origin. (See art. Blood.) 25. b. As the aneurismal tumour enlarges, it generally occasions important changes both in itself and in adjoining parts. Those which re- spect the sac itself are chiefly thickening of the dilated coats, or thinning of them ; and, in some instances, of both these changes in the same case. When the extension of the sac is considerable, or when moderate, if opposed by a firm substance, as cartilage or bone, ulceration or absorption of the parietes of the sac, inflammation of its more ex- terior parts and adhesions to adjoining structures ; and, ultimately, as the tumour increases, perfo- ration or rupture of the more prominent part, fol- lowed by fatal haemorrhage, take place. The mode in which the aneurism bursts is different, according to its situation and the structure which it compresses and destroys; thus it not infre- quently breaks by ulceration and perforation of a limited part of the sac. In some cases, particu- larly when it opens into a serous cavity, distinct laceration of the more exterior covering occurs; when it reaches a mucous surface or the skin, a slough is formed on its most prominent part, which is soon detached, and fatal haemorrhage is the result. In the majority of such cases, the proper coats of the vessel may have been long previously destroyed at one part or other of the sac. But, if the aneurism form at the root of the aorta, rup- ture or ulceration of the proper coats of the vessel is followed by instant effusion of blood into the pericardium. Rupture of the aneurismal tumour, as respects the coats of the vessel, whether burst- ing into a hollow cavity or upon a surface, or forming a diffused aneurism, is generally trans- verse ; but it is, in some cases, longitudinal, when it implicates all the coats ef the vessel; or the rup- ture of the internal coats is transverse, and that of the external coat longitudinal; the former be- ing almost universally transverse. The effects of aneurism upon adjoining parts require particu- lar notice. 26. F. Of the effects of aortal aneurisms on adjoining parts, and the situations in which they break. The effects of aneurisms on adjoining parts necessarily depend upon their volume, firm- ness, and position. The heart, lungs, trachea, large bronchi, (Esophagus, pulmonary artery, large veins, thoracic duct, and various organs contained in the abdominal cavity, may be displaced, atro- phied, or partially destroyed, by the compression occasioned by them. 27. a. The vena cava is not infrequently more or less obstructed by the pressure of aortal aneu- risms. M. Reynaud (Journ. Hebdom. t. ii. p. 109.) met with a case in which this vessel was very nearly obliterated by an aortal aneurism, and M. Bouillaud mentions a case in which the superior vena cava was so much compressed by an aneu- rism at the arch of the aorta, that apoplexy was caused by it (Diet, de Med., et Chir. Prat., t. iii. p. 403.); and Corvisart (Journ. de Med. par MM. Corvisart, &c., t.. iii. p. 85.) and Bertin, relate similar instances. The thoracic duct has also been destroyed by it, as was observed by M. Laennec. Mr. Hodgson and Sir A. Cooper met with cases in which the common carotid, and subclavian arteries were completely obliterated by the pressure of aortal aneurism. 28. b. When the pressure of an aortal aneur- ism destroys an adjoining viscus or structure, the ulcerative inflammation is often extended from the parietes of the sac to them, followed by the ad hesion and absorption or ulceration of the parts most compressed, until the tumour bursts, in one 83 AORTA—Aneurism of. of the modes now stated (§25.), into one or other of the following situations:—Aneurism of the ascending or pericardial aorta generally opens into the pericardium: in three cases it bursts into the pulmonary artery, recorded by Dr. Wells (Trans, of Society for Impr. of Med. and Chirurg. Knowledge, vol. iii. p. 85.), M. Sue (Journ. de Med. Gordin., t. xxiv. p. 124), and MM. Payen and Zeink (Bui. de Fac. de Med., No. 3. 1819.). Aneurism of the arch of the aorta may break into the trachea, ossophagus, pleural cavity, or into the pericardium. That of the descending aorta generally bursts into the pleura, oesophagus, pos- terior mediastinum, or into the lungs. Aneurisms of the pectoral aorta most frequently burst into the left pleura ; they have, however, been known, but in two instances only,—recorded by M. La- ennec and Mr. Chandleb,—to open into the spinal canal, having destroyed the bodies of the vertebrm, which are generally more or less injured in cases of aortal aneurism of considerable size. When seated in the ascending aorta, they often destroy the sternum ; in both cases causing inter- stitial absorption of the bone, and often of the parietes of the sac and fibrinous layers of coagula in contact with it, so that the blood washes the bone itself. The cartilages usually resist the pressure of aneurisms, either altogether, or much longer than the bones ; and when the periosteum is inflamed by the pressure of the aneurism, an ossific deposit is not infrequently formed around the tumour. 29. c. Aneurism of the aorta may, however, destroy life, even without breaking in any of the above directions; either by impeding the action of the heart and displacing it, or by compressing the organs of respiration, or by occasioning con- gestion, infiltration, and hepatization of the lungs ; or by compressing the oesophagus, or injuring some of the thoracic ganglia ; or it may destroy or compress the thoracic duct and large veins, as stated above (§ 27.), to a fatal extent. 30. d. The bursting of an aneurism of the aorta is not necessarily followed by instant death, as has been shown by MM. Laennec and Mab- jolin, and very recently by Mr. S. Cooper. In a case read by this very able surgeon, at the Me- dico-Chirurgical Society, where the aortal aneu- rism had pointed under the left shoulder-blade, but subsequently broke ipto the oesophagus, several pounds of blood were discharged by vomiting and stool, yet the patient lived for many months after- wards, and pursued a laborious occupation; a second haemorrhage at last proving fatal. When the sac of an aortal aneurism bursts, and the blood flows into a cavity or viscus, from which it is readily discharged, death usually is soon pro- duced. But when the opening in the sac is so situated that the blood is effused into the cellular structure, and what was before a true or encysted abscess becomes a diffused one, life may be pro- longed for some days or weeks, or even longer. This, however, will depend upon the situation in which the rupture takes place, and the nature of the parts into or upon which the blood is effused. When the sac of an aneurism is ruptured, the laceration is generally in the same axis, or nearly so, with the opening into the sac, owing to the impulse being greatest in this direction, unless a divergence is occasioned by the unyielding nature of the parts in this situation, and by the slight resistance opposed by parts immediately adjoining. 84 31. G. Of the causes of aneurism of the aorta. Diseases of arteries, and consequently aneurism, are much more frequent in men than in women. Mr. Hodgson states, that of sixty-three cases of aneurism, external as well as internal, seen by him, only seven were in females. But the pro- proportion of cases of aortal aneurism met with in females is certainly much larger than this. I have seen three cases of aortal aneurism in females; but I have certainly not seen nearly twenty-four cases in males, which is the proportion here indi- cated. Syphilis and the use of mercury have been considered predisposing causes of aortal aneurism, but upon no just grounds. I am in- clined to believe, with Mr. Guthrie, that the habitual use of ardent spirits has a more marked predisposing effect than any other cause with which we are acquainted. A more immediate state of disposition is created in the vessel itself by inflammatory irritation of its parietes, and the consequent diminution of its elasticity and vital cohesion, or power of resistance opposed to the casually augmented impulses of the heart, espe- cially during mental excitement and corporeal exertion. Hypertrophy of the left ventricle, par- ticularly if consequent upon chronic inflamma- tion of the vessel, and influenced by moral and physical causes, will tend to produce dilatation or rupture of the coats of the aorta. The most fre- quent exciting causes undoubtedly, are excessive mental emotions, and violent exertion, particu- larly of the trunk of the body, and when suddenly made ; but it seems evident that a morbid state of the vessel has existed previously, at least in the majority of such cases. 32, ii. Of the symptoms and diagnosis of aortal aneurism. These naturally divide themselves into,—1st, the rational or general signs ; and, 2d, those which are detected by auscultation. a The rational symptoms of aneurism of the aorta, whilst the tumour still remains concealed in the large cavities, are very equivocal.* The effects produced by it also proceed from various other diseases. Those symptoms even when con- sidered collectively, are extremely fallacious ; but when viewed in connection with those which are detected by auscultation, they are very important aids to diagnosis. 1st, Aneurism of the pectoral aorta occasions a sense of oppression or infraction in the chest; but this is felt in varous diseases of the thoracic viscera. Dissimilarity of the pulse in both wrists is sometimes present; but this is also met with from diseases of the subclavian artery, from tumours pressing upon it, or from an irregu- larity in the distribution of the brachial or radial arteries. A purring tremor, as pointed out by Corvisart, is sometimes perceptible when the hand is placed upon the middle and upper part of the sternum: when distinctly felt, it indicates aneurism of the ascending aorta: it is also fell above the clavicles in aneurism of the arch, and [* “ When an anuerism is buried deep in the chest, and not capable of being detected by the sight and touch, it does not present a single general sign which is peculia r to itself and therefore pathognomonic of its existence There are even cases in which it occasions no functional derangement,—no inconvenience whatever ; and the first circumstance that unveils the truth, is the sudden deatli of the patient while apparently in the enjoyment of per- fect health. I have met with six or seven instances in which large aneurisms have existed without awakening even a suspicion in the mind of the medical attendant. One in particular, eluded the penetration of a distinguished foreign auscultator, though he explored the lungs with eminent success.”—Hope on Dis. of the Heart, American Ed., p. 413.1 is one of the surest symptoms of the first and se- cond varieties of the disease ; but it is often indis- tinct when the aneurism is sacculated and con- tains layers of coagula. This tremor, however, sometimes proceeds from other causes than aneu- rism, more particularly from the mucous rattle seated in the large bronchi ; but, in this case, the purring tremor is not so constant or continued as in aneurism. 33. Pressure from this disease on the trachea and large bronchi occasions a wheezing or sibil- lous respiration, which is generally permanent, referable to the lowest part of the throat, and sometimes with a whispering or croaking voice ; the breathing is also anxious and laborious. Pres- sure of the tumour on the resophagus renders de- glution of solids difficult and acutely painful or lancinating, and sometimes even impracticable. But these effects upon the function of respiration will be produced by various diseases of the larynx, and by frequent accumulations of viscid mucus in the upper part of the trachea. The attentive observer will, however, readily ascertain the ex- istence of these affections. Other tumours may also exist and occasion similar symptoms both of respiration and of deglution; but, in such cases, the diagnosis is often impossible. 34. When the aneurism has eroded any of the bodies of the vertebra, a gnawing or boring pain is felt in the spine ; and, when the tumour affects the brachial plexus of nerves, an aching of the left shoulder, extending to the neck and scapula, with impaired power, formication, and numbness of the arm, is complained of. Rheumatism of the shoulder-joint, or parts adjoining, and severe spinal disease, are often attended with similar sensations; and the symptoms referred to the shoulder and arm are frequently presented in pericarditis, organic diseases of the heart, and angina pectoris, from the ramification of branches of nerves from the cardiac ganglia to the brachial plexus. 35. Pulsation felt beneath the sternum, or ribs, at the upper part of the thorax, is amongst the most certain signs of this disease : but we should recollect that it will also be occasioned by any tumour interposed between the thoracic parietes and the aorta, and in contact with the latter; by adhesions of the pericardium to the heart and ef- fusions of fluid into the former, and by consider- able enlargement or dilatation of the heart itself. Pulsation above the clavicles, although a frequent symptom of aneurism of the ascending aorta or of its arch, may likewise proceed from other causes, as enlarged glands, or various kinds of tu- lours, receiving the impulse of the subclavian .rteries; from subclavian aneurism, and aneu- risms of the innominata and common carotid, be- tween which and aortal aneurism the diagnosis is most difficult, as Burns, Cooper, Monro, and Hodgson have pointed out. Violent pulsations of the carotids have been adduced as a sign of aortal aneurism ; but they may arise from ner- vous affection of the heart, hypertrophy of the left ventricle, or from obstruction of the flow of blood in the descending aorta, or in the subclavian arteries. 36. When aneurism of the ascending aorta at- tains a certain size, a tumour is usually formed about the fifth and sixth ribs of the right side: when seated in the anterior part of the arch, it appears at the third and fourth ribs of the same side, at their sternal extremeties: when in the AORTA—Aneurism of. upper part of the arch, the tumour rises above the sternum and sternal ends of the clavicles. When aneurism is seated in the descending thoracic aorta, and in the lower part contained in the tho- rax, it often points, after destroying the ribs and bodies of the vertebra;, under the left shoulder- blade, and pushes out this part. The strong pul- sations always present in the tumour indicate its nature. Notwithstanding, it may subside, or alto- gether disappear for a time under an appropriate treatment. Previous to the appearance of the tumour, the symptoms are, as already shown ex- tremely fallacious. 37. In the advanced stages of aneurism of the thoracic aorta there are generally coughs with mucous or bloody expectoration, dyspnoea, and even orthopnoea, dysphagia, attacks of spasmodic suffocation, pain in the left shoulder, axilla, inner side of the arm, and ascending up the left side of the neck, with pricking pains in the tumour, and sometimes with a sense of whizzing or rushing at the top of, or under the sternum, and occasionally sensible to the hand. A dragging downwards of the larynx is sometimes complained of. All fe- brile symptoms are generally absent. Although these are the rational symptoms which are most to be depended upon, they must be viewed with those reservations which I have particularised in the preceding paragraphs. 38. 2d, When the aneurism is seated in the abdominal aorta, acute pain is complained of in the lumbar region, occasionally shooting into either hypochondria, and downwards into the thighs and scrotum. It is generally constant, but is also sometimes intermittent. It is often exacerbated into violent paroxysms, being dull and fixed in the intervals. It is aggravated by constipation, change of position, or pressure on the loins, and is unattended by any sense of heat in the part. In some cases there is also numb- ness of the lower limbs, as in that recorded by Mr. Mayo (Med. Gaz., April, 1829), where the aneurism was situated between the crura of the diaphragm and the dorsal pains were excruci- ating. The patient often complains of severe fits of colic, accompanied with spasms of the abdominal muscles, and occasionally there are nausea and irritation of the stomach, but with little loss of appetite. Constipation is always present. Decubitus on the left side or back often produces great distress, and occasions palpitation, which generally subsides upon turning on the face or right side. Coldness, formication, pricking, and numbness of the lower extremities, are not infrequent; and in some cases paraplegia has oc- curred, with involuntary evacuations of the urine and feces. 39. The tumour may not become perceptible externally ; but as it increases it will press inju- riously upon, and sometimes displace, one or other of the abdominal viscera, particularly the stomach, liver, and even the heart. When the tumour can be detected externally, it has gene- rally been on the left side, nearly on a level with the last dorsal vertebra. When large, it often impedes the action of the diaphragm, and thus deranges the respiration. In some cases it has pressed upon the pericardium, and thus had the double pulsation of the heart communicated to it. (See Cases by Drs. Graves and Stokes, Dub. Hosp. Reports, vol. v. p. 24.) 40. b. Signs furnished by auscultation.—Dul- ness of sound upon percussion of the upper ster 85 86 nal portion of the chest and cartilages of the right ribs, although present in aneurism of the pectoral aorta, also occurs in other lesions of the thoracic viscera. Dr. Elliotson states, that a thrilling sensation given to the hand only, or chiefly, when applied above, or to the right of the cardiac region, and a bellows-sound heard in the same situation, may justly give a strong suspicion of the disease. But that neither the bellows-sound nor the thrill, always occurs. In four cases out of seven he found both wanting. Laennec never observed the thrill before the tumour became visible externally. He considers that the chief diagnostic of aortal aneurism is a strong and single pulsation, discernible by the ear in the situation of the aneurism, synchronous with the pulse at the wrist, stronger and louder than the action of the ventricles, and unaccompanied by the sound of the auricles. When, however, the aneurism comes in contact with the pericardium, a double instead of a single pulsation of the heart is com- municated to the tumour. This was remarked in the cases recorded by M. Cruveilheir, and Drs. Graves and Stokes. 41. Dr. Hope observes, that it is unimportant whether the pulsations be single or double ; for, though the latter, may be distinguished from the beating of the heart by unequivocal criteria, viz.:—“1st. The first aneurismal sound coinci- ding with the pulse, is invariably louder than the healthy ventricular sound, and, generally, than the most considerable bellows-murmurs of the ventricles.—2d. On exploring the aneurismal sound from its source towards the region of the heart, it is found to decrease progressively, until it either becomes totally inaudible, or is lost in the predo- minance of the ventricular sound. Now, if the sound emanated from the heart alone, instead of decreasing it would increase on approximating towards the prsecordial region.—3d. The second sound actually does sustain this progressive aug- mentation on advancing towards the heart; and as its nature and rhythm are found to be precisely similar to those of the ventricular diastole heard in the preecordial region, it is distinctly identified as the diastolic sound.* The second sound, there- fore, corroborates rather than invalidates the evi- dence of aneurism afforded by the first; for, if both sounds proceeded from the heart, both would, on approximating towards it, or receding from, sustain the same progressive changes of inten- sity.” (Diseases of the Heart and Great Vessels, p. 425.) Besides these views, with which I con- cur, the sound of the aneurismal pulsation is deep, hoarse, and of short duration, commencing and terminating abruptly, louder than the loudest bel- lows-murmurs of the heart, and of a rasping or grating character. 42. The sound of aortal aneurisms is generally audible in the back ; and when the descending aorta is the seat, it is louder in this situation than on the breast. If it presents the abrupt, rasping character, when heard on the back, the evidence of aneurism is complete; for, as Dr. Hope ob- serves, the loudest sounds of the heart, when heard in this situation, are so softened and sub- dued by the distance as totally to lose their harsh- ness. This is in accordance with the opinion of M. Bertin, who very correctly observes, that when the stethoscope is applied upon the sternum AORTA—Treatment. in aneurism of the substernal aorta, and on the back, near the pectoral spine in aneurism of the descending aorta, the disease may be recognised, before any external tumour is seen, by a strong single sound, of greater intensity than that of the heart. The pulsations of aneurismal tumours of large arteries are indeed so intense, hoarse, sharp, and peculiar, as to be readily recognised by a person who has once examined them with the stethoscope, although the sounds they furnish can- not be readily described. 43. The purring tremor, already noticed as felt by the hand, may also be ascertained by the aid of the stethoscope. It is chiefly found above the clavicles, in cases of simple dilatation of the ascending aorta and arch and sacculated aneurism in the same situations. In old and large aneu- risms, containing layers of coagula, it is generally absent, and is more intense the more unequal and rugged the interior of the diseased portion of vessel, particularly when it is is studded with osseous or cretaceous deposits. Dr. Elliotson states, that when the aneurism is large, a single, and more frequently a double, bellows-sound is often heard in the seat of aneurism, distinct from the beating of the heart: when the sound is double, the first is heard along with the pulse, the latter often the louder of the two, afterwards. The bellows-sound in these cases may be ascribed to the passage of the blood from the dilated aneu- rism into the narrower commencement of the healthy vessel; and, when the sound is double, the second may proceed from the reaciion of the dilated part of the vessel impelling a portion of the blood into the narrow and healthy vessel after the action of the left ventricle. 44. 2d. Aneurism of the abdominal aorta is more easily detected by auscultation than aneu- rism seated within the chest. A constant and powerful pulsation is felt by the hand, and still more remarkably by the ear resting on the stethoscope, accompanied with a brief, loud, and abrupt bellows-sound; but not so hoarse as that of aneurisms in the chest. The pulsation is single, unless the tumour comes in contact with the diaphragm and pericardium ; and it is either inaudible or very indistinctly heard in the back. By pressing the instrument in various directions, so as to bring it as close as possible to the tumour, its seat and dimensions will be ascertained. 45. iii. Treatment.—The method of cure first recommended by Valsalva has been since very generally adopted, not only in aneurisms of the aorta, but also in similar diseases of arterial trunks. I believe, however, that it has been often carried to a very hurtful length. I have seen cases in which anuerismal tumours had existed for a long time without any increase, as long as the patient avoided any marked vascular excitement, and continued his wonted diet; but when repeated depletions and vegetable or low diet were adopted, great augmentation of the tumour and fatal results soon followed. In three cases which occurred in my own practice, and in which the method I am about to recommend was employed, a marked amendment was the conse- quence. 46. In order to devise a rational method of treating this formidable lesion we should con- sider, in the first place, the process adopted by nature to remedy it; and having correctly inter- preted this process, we should endeavour to assist nature in accomplishing it. We have seen that * See art. Auscultation and Heart, as to the sounds of this organ. AORTA—Rupture of. 87 aneurismal dilatation, &c. of arteries, particularly of the aorta, (§§ 14, 15.,) commences in slow in- flammatory action, and that as the coats dilate or rupture, lymph is thrown out, which coagulates the blood, entangling its fibrine and red globules, and thus a fibrinous eoagulum, attached to the inner surface of the vessel, is formed, and by its aid the inflamed and otherwise diseased coats of the vessel are strengthened, particularly as the fibrinous layer of eoagulum becomes more and more consolidated or organised. Now, what are the circumstances proper to the circulation and state of the constitution calculated to promote this change on the one hand, or to counteract it on the other; for whatever advances it, or assists nature in its completion, will tend to remedy the disease ; whilst whatever counteracts it, will lead to fatal results? I shall first consider the mea- sures calculated to counteract the process which nature adopts to remedy the disease. 47. a. I believe that there is no position in pathology more firmly established, since it was insisted upon by John Hunter, than that what- ever greatly lowers the vital energies will impede the formation of cOagulable lymph and fibrinous coagula, especially in diseased vessels ; and that increased rapidity of the circulation, throbbing of the arteries, abstraction of the fibrine and red globules of the blood, by repeated or large de- pletions, and the absorption of serous, watery, or unassimilated materials into the current of the circulation, in order to supply the place of the portion of blood abstracted, will, with other effects, inevitably tend to prevent those changes from taking place which we wish to bring about. That large depletions produce increased quick- ness of the pulse, reaction of the heart, throbbing of the arteries, and all the effects now instanced, must be evident to every thinking and experi- enced observer; and that these effects are actually those which counteract the changes which nature produces, in order to remedy disease of the cir- culating system, must be equally manifest. That these results will be still further promoted by undue, or too great abstinence, is no less obvious ; and yet, how frequently do we find both inor- dinate depletion and unreasonable abstinence re- commended, in the very teeth of their fatal con- sequences on numerous occasions, for the cure of aneurisms. 48. b. But what are the means which are cal- culated to advance the process which nature uniformly adopts in order to restore as nearly as possible the vessel to a healthy state ? These may be stated, in a few words, to be whatever restrains or retards the action of the heart, with- out reducing the vital energies of the frame, and the preservative influence they exert, both on the coats of the vessel, and on the surrounding structures. Conformably with this view, strict quietude of body and mind, a light digestible diet, the careful avoidance of spirituous and malt liquors, and the adoption of moderate general or local depletions, only if the state of the circulation unequivocally requires them, are chiefly to be relied upon; and, as far as my own observation, and the careful study of the cases recorded by various writers have enabled me to judge, they are the only means which deserve any share of confidence. Whilst change of air is generally beneficial, exercise on foot, or on horseback, especially the latter, must be avoided, and the utmost attention should be always directed to the digestive, secreting, and excreting functions. 49. When, in consequence of the energetic action of the heart, or the plethoric state of the circulation, or excessive action of the tumour, we determine on depletion, it ought to be performed in the recumbent posture; and the quantity as well as the mauner of abstracting it should be such as to prevent any risk from too great depres- sion, and its consequent reaction, whether of the heart or of the arteries. When the disease is attended with paroxysms of palpitation, depletion will be seldom of any use, and should therefore be cautiously employed in such cases. Local de- pletions may be resorted to when local pains are complained of; but, if the tumour has nearly reached any of the surfaces, they are seldom productive of benefit. 50. Digitalis has been generally recommended ; it may be of some service when exhibited cau- tiously, and in moderate doses, but its full effects must be guarded against. The same remarks apply to colchicuin. The superacetate of lead, combined with the acetic acid, and small doses of opium, is preferable to digitalis; and any hurtful effect that would arise from it will be prevented by an occasional dose of castor oil. In cases attended with palpitation of the heart, or inordinate pulsation of the tumour, I have pre- scribed the sulphate of zinc, and the sulphate of alumina, generally combined with small doses of camphor and hyoscyamus, with considerable bene- fit as palliatives. The acetate of lead may also be exhibited in a similar state of combination. 51. The application of ice to the tumour has been advised by Continental physicians; but it is often productive of much distress. A lotion or repeated sponging, and occasionally the con- tinued application of epithems may be employed : and either of those recommended in F. 157. 332. 336. may be adopted. Perfect repose, however, morally and physically, with careful prevention of plethora and sur-action of the heart, is indis- pensable ; other means will be useful, chiefly in as far as they conduce to these states. By en- deavouring in this manner to bring about the spontaneous cure of aortal aneurism, it may be supposed that we risk inducing the obliteration of the vessel; but I believe that this is not so likely to occur in the aorta as in smaller arteries; and even were it to occur, the result does not appear so hazardous as the continued increase of the aneurismal tumours ; as sufficient evidence is on record of the possibility of a collateral circulation being established. 52. IV. Rupture of all the coats of the Aorta, without aneurismal dilatation of the ves- sel, is a very rare occurrence, and has been met with only after violent external injuries, such as falls, or leaping from a great height, and from mental excitement, when the vessel has been previously diseased. In the Ephemerides Phy- sico-Medicae Naturae Curiosorum {Dec. iii. Ann. ii. Obs. 70.), a case is recorded, in which it was ruptured by a blow on the hypochondrium. Mr. James has recorded an instance of rupture and instant death in an active seaman, previ- ously in good health, from jumping out of his ham- mock (Lond. Med. and Phys. Journ., vol. xviii.); and Mr. Arnott has given a similar case, pro- duced by a violent concussion of the body, from falling from a scaffold {Ibid., vol. lviii. p. 19.) 88 APOPLEXY. The most instructive case, however, of rupture of the aorta without aneurism has been minutely detailed by Mr. Rose {Lond. Med. and Phys. Journ., vol. lviii. 4to. p. 15.). In this case, as in the others, the coats of the aorta were all ruptured. They were more readily lacerated than usual, and the inner coat had a thickened stortomatous ap- pearance. A case is given by Dr. Hume (Glas- gow Med. Journ., vol. iv. p. 148.), in which rupture of the aorta took place in a strong man upon get- ting into bed, followed by death in a few hours. An aperture, the size of a quill, was found in the ves- sel about two inches above its bifurcation. No account is given of the state of its coats. 53. V. Constriction and Obliteration of the Aorta have been observed by several pa- thologists. Stoerck {Annales M6d. ii. p. 262), Meckel {Memoirs de Berlin, 1756), Sandifort {Observat. Anatom. Path. iv. No. 10.), and Dr. Graham (Trans. Med. Chir. Soc., vol. v. p. 287.), with other recent authors, have recorded cases of extreme constriction of the aorta; whilst M. Desault {Journ. de Chirurg. 1792,) M. Bras- dor {Recueil Periodique de la Soc de med a Paris, t. iii. No. 18.), Dr. A. Monro {On Aneurisms of the Abd. Aorta, p. 5.), Dr. Good- ison {Dub. Hosp. Rep., vol. ii. p. 193,), M. Velpeau, {Revue Med., t. iii. 1825., p. 326)., and M. Reynaud {Journ. Hebdum. de Med., t. i. p. 161.), have adduced cases wherein this vessel was entirely obliterated, the circulation having been preserved by the anastomosis and enlarge- ment of the arteries sent off above and below the seat of obliteration. 54. With respect to the origin of this lesion, it may be referred primarily to inflammation of the vessel. But various intermediate changes will necessarily have taken place, from the more im- mediate effects of inflammation to the complete obliteration of the vessel. It is probable that, in some rare instances, as in large arterial trunks, the transverse rupture of the internal membrane of the vessel, with the consequent effusion of lymph, and formation of fibrinous coagula, may so obstruct its canal as to give rise to its partial or total obliteration, without any aneurismal tumour having formed ; and it is not improbable that obliteration or constriction of the canal may have proceeded in other cases, from the advanced stages of the spontaneous cure of aneurism; the deposition of fibrinous coagula, and the subse- quent changes which had taken place in them, and the diseased coats of the vessel, having ended in obliteration, and the establishment of a col- lateral circulation. Bibliography.—Morgagni, De Sed. et Caus. Morb. epist. xvii. et xviii.—Nichols, Philos. Trans, vol. xxxv. p. 443. et vol. Iii. p. 269.—Haller, De Aorta; Vemeque Cava; Gravior. quibusdem Morbis. Goet. 1749.—Burns, On Diseases of the Heart, &c. p. 206.—Cruveilheir, Sur 1’Anatom. Patholog. Paris, 1816, t. ii. p. 60.—Hodgson, On Diseases of Arteries, &c. p. 127.—Corvisart, Sur les Maladies du Cceur, &c. p. 313.—Scarpa, Riflessioni ed Osservazioni suit’ Aneurisma. Pavia, 1804.—Krcysig, Die Krankheiten des Herzens. Berl. 1814-16.— Testa, Delle Malattie del Cuore, &c. Nap. 1826.—Proudfoot, Edin. Med. and Surg. Journ. vol. xxii.—Lacnncc, De l’Auscultation Mediate, &c. 2d ed. Paris, 1826.—Noverre, Sur les Aneurysmes de l’Aorte. Paris, 1820.—Andral, Clinique Medicale, &c. t. iii. Paris, 1825.—Bouillard, Sur le Diagnostique des Aneurysmes de l’Aorte. Paris, 1823. —Mollison, in Trans, of the Medico-Chirurg. Soc. of Edin. vol. iii.— Guthrie, On the Diseases and Injuries of Ar- teries. Lond. 1830.—Berlin, et Bouillaud, Traite de Malad. du Cceur et des Gros Vaisseaux. Paris, 1824.— Graves, Stokes, and Btatty, in Dub. Ilospit. Rep. vol. v. —Elliotson, On the Diagnosis of Diseases of the Heart. &c., fol. Lond. 1831.—Hope, On Diseases of the Heart and Great Vessels, &c. 8vo. Lond. 1831; and Medical Gazette volumes, vol. iv. passim.—Stokes, in Dublin Med. Journ. vol. v. p. 400.—Green, in Ibid. vol. vii. p. 231.—Geddings, in Amer. Cyc. of Pract. Med. part. vii. p. 152.—See also a number of detached instances of dis- ease of the Aorta adduced by Ploucquet, in his Medicina Digesta, from various authors, to whom I have not thought it necessary to refer. [New York Med. Repository, vii. 24.—Am. Med. Re- cord., xiv. 239.—Phil. Journ. Med. and Phys. Sci., xi. 414. xiii. 180. 318.; x. 88.—Am. Journ. Med. Sci., i. 200. ; ii. 202. 451; v. 145. 487; vii. 494. 556. 229.; iv. 345. ; vi. 243.; xii. 355.; (Mott’s case of Aneurism,) xv. 223. (Aneurism of the Aorta simulating Lanyngral Phthisis.—Ibid, Ossi- fication of Aorta mistaken for Aneurism, xix. 52. 329; xxv. 241.—(Compression of Aorta to arrest other haemor- rhages,) xxvi. 488. 212.; xviii. 481. 482.—New York Med. Gazette, i. 33.] APHONIA. See Voice, Morbid States of. APHTHAE. See Thrush. APOPLEXY. Deriv. and Synon, Apoplexia, from d-xoTr\fioP. M. Roget, in Cyclop, of Pract. Med. vol. i. p. 167.—C. H. Marc, Nouv. Recherches sur les Secours a donner aux Noyes, &c., 8vo. Paris, 1835.—Lancet, No. 629. p. 806. R. Dunglison, art. Asphyxia, in Amer. Cycl. of Pract. Med. vol. ii. p. 465. (A most able treatise.) 1. ASPHYXY of New-born Infants is fre- quently met with, particularly in those who are naturally feeble, or weakened by rupture of the chord or laceration of the placenta in consequence of sudden delivery, or of the operation of turning, especially when required by uterine haemorrhage. It is also occasioned by compression of the chord, and a protracted parturition. 2. Besides the absence of respiration and of muscular motion upon delivery, the surface is pale ; the flesh and limbs are soft and flaccid ; the heat of the body is rapidly diminished, but the circulation still continues, at least for some time. Several cases which are viewed as asphyxy more properly belong to syncope or loss of blood, or participate in those states as well as in privation of the respiratory actions. This privation may depend upon imperfect circulation in the pul- monary arteries, and through the lungs ; or upon inactivity of the respiratory muscles, and torpor of the nerves which supply them, owing to im- perfect circulation in the brain ; or upon these causes conjointly. Care should be taken to dis- tinguish these cases from apoplexy ; as the states of the vascular system, and of circulation in the brain, and consequently the treatment which is required in each, are very different. 3. The treatment of these cases consists of de- ferring the ligature of the chord for some time ; of taking care that no blood is lost from dividing it; of enveloping the infant in warm flannel; of holding it near a warm fire, or plunging it in a warm bath, rendered exciting by means of salt or mustard ; of removing all obstruction to the pas- sage of air into the lungs from about the throat and mouth ; warm frictions of the surface of the chest, with gentle succussation with the palm of the hand on the shoulders ; tickling or irritating the nostrils and arm-pits with a feather ; dropping a little diluted aromatic, or ammoniated spirit upon the lips ; and most particularly inflation of the lungs by the breath of the medical attendant, either blown directly into the mouth, the nostrils being closed, and the trachea gently pressed back- wards ; or through a curved tube introduced into the larynx, as recommended by Ciiaussier, and employed by him at the “ Maison d’Accouche- mens” in Paris. This latter method is certainly preferable. Insufflation is to be managed in the same manner, in other respects, as described in the foregoing article. But I think that the breath of the attendant is better suited to infants, than cold air thrown into the lungs by a bellows. ASPHYXY—In New-born Infants. carefully and assiduously employed, and places more dependence upon means calculated to ex- cite the respiratory muscles to contract. For this purpose he recommends a species of spirit douche, and directs the practitioner to take a mouthful of brandy, and dash it forcibly against the anterior parietes of the chest. He states that this is sel- dom required oftener than twice or thrice. Me- chanical irritation of the nostrils, or exciting powders applied to the pituitary membrane, may be cautiously tried ; a stimulating clyster may also be thrown up. Galvanism or electricity may likewise be resorted to when within our reach. We should not relinquish our endeavours at resuscitation under two or three hours, or even longer ; and, if we ultimately succeed, the state of the infant should be carefully watched for two or three days. [As Dr. Doherty has suggested, (Dublin Jour, of Med. Sci., March 1844, p. 68,) it may well admit of doubt whether the term asphyxy, is properly applied to infants, born in a pulseless, and apparently inanimate state, as the word in its proper, pathological signification, only implies a condition, the consequence of a cause, which di- rectly arrests the supply of pure air, that should enter the chest. “ But in the foetus at birth” says this writer “ no such cause exists under ordinary circumstances. The child is then surrounded by an atmosphere of healthy quality, whose ingress is prevented by no mechanical impediment, and breathing, if it remain unaccomplished, is so, not from any fault in the lungs and its appendages, but from a defect in the stimulus of nervous in- fluence, upon which the muscular actions consti- tuting respiration, depends. This consideration would seem to suggest other measures of resus- citation, rather than artificial inflation in the first instance. There is this difference between a child still-born, and a person of more advanced age who has fallen into asphyxy, namely, that the latter has been accustomed to the circulation of arterialized blood, while in the former that fluid has never, as yet, been perfectly decarbonized. In the adult, the chain of events, by which death is induced, may be stated to be: firstly, a suspension of the respiratory function, while the heart’s ac- tion continues ; 2ndly, (the circulation being thus maintained) the contact of venous blood with the nervous centres, by the deleterious qualities of which, their sensibility is depressed ; and 3dly, a stagnation in the lungs, through which such blood soon ceases to be transmitted. It is evident, under these circumstances, life may often be pre- served, if we reverse these conditions by substitu- ting for natural inspiration an artificial current of air by which there may be effected in the pulmo- nary tissues, those changes in the blood necessary to enable it to traverse them, and by which it may be purified of the noxious constituents that are acting as a poison on the system. By thus tem- porizing, an opportunity, which speedy dissolution would otherwise deny, is afforded for the employ- ment of remedies capable of removing the coma- tose condition, and in this way, the vital principle may be resuscitated and sustained. But in the child that has never breathed, things are differ- ently circumstanced. In it, the nervous appara- tus has not yet been supplied with blood which has undergone the process of aeration; for al- though some alteration is produced in it by the ac- tion of the placenta, and foetal liver, and per- haps the thymus gland, duiing intra-uterine exist- 175 4. M. Desormeaux complains of his wamt of success from inflation of the lungs, even when 176 ASTHMA. ence, it preserves throughout those characters, which are denominated venous, and “ both in the arteries and veins, differs in no perceptible respect from the venous blood of the adult.” In the child still-born, therefore, it is not necessary to take in- to consideration, as an element in the production of a fatal event, the destructive effects of black blood, if conveyed by arterial vessels, so apparent in after-life (otherwise there could never be such an occurrence as the unaided revival of an in- fant, 24 hours after being laid aside for dead ;) and on that account, the circumstances are not so urgent as to require us to immediately adopt mea- sures for its purgation (or oxygenation,) by begin- ning our efforts for restoration at the lungs, but they should be directed rather to the brain and its peripheral extremities, whose blunted sensibilities is the cause of non-performance of respiration. Then, indeed, it may be useful, if breathing be de- layed, to blow into the lungs, as experiment has proved that expansion and contraction of the chest, and the vital actions consequent thereon, directly aid in the circulation of the blood—(Loc. cit.) Dr. Marshal Hall in his late work, on the diseases and derangements of the nervous system, observes that “ respiration is an excited function; that it belongs to the excito-motory sub-division ; and that consequently in cases of asphyxy of new-born infants, we must instantly use all our efforts to excite respiration. The excitors of res- piration are the trifacial, the pneumogastric, and the spinal nerves. The trifacial nerves must be excited by forcibly blowing or dashing cold water on the face, by stimulating the nostrils by ammonia, snuff, pepper, or the point of a needle. The spinal nerves must be excited by forcibly dashing cold water on the thorax, the thighs ; by tickling, or stimulating the sides, the soles of the feet, the verge of the anus. What the pneumogastric is, as the excitory nerve of respiration, under ordinary circumstan- ces, the trifacial and the spinal nerves are, in cases of asphyxy, or suspended respiration. The means recommended for exciting respiration through these excitors, frequently induce a sud- den act of inspiration, which proves the first of a series so essential to animal life. The important point to be mentioned, is, that it is not the mere application of cold, but the sudden application of cold to a warm surface, which is the effectual means of exciting respira- tion. It is the sudden alternation. To apply cold to a cold surface would only be to sink the gene- ral powers of life. The infant should be kept warm; the warm bath may be required; and then cold water must be applied, in moderate quantity, but with force. But if these attempts to excite respiration through the trifacial and spinal nerves fail, we must imitate this function, by artificially distend- ing the lungs, in the hope that eventually, it may be excited through its wonted channel the pneu- mogastric. To effect this the practitioner’s lips are to be applied to those of the infant, interposing a fold of linen, and he is to propel the air from his chest, slowly and gradually, into that of the infant, closing its nostrils, and gently pressing the trachea on the esophaguss. The chest is then to be pressed, to induce a full expiration, and allowed to expand, so as if possible to effect a degree of in- inspiration. But it is important in doing this, that the prac- titioner himself, should previously make several deep and rapid respirations, and finally a full in- spiration. In this manner, the air expelled from his lungs into those of the little patient, will con- tain more oxygen and less carbonic acid, and consequently be more capable of exciting the dying embers of life. If all these plans should be tried in vain, I would strongly advise galvanic or electric shocks, to be passed from the side of the neck to the pit of the stomach, or in the course of any of the motor respiratory nerves, and their appropriate muscles. No time should be lost in sending for a proper apparatus: but should the lapse of an hour, or even more, take place before it can be obtained, still it should be sent for and tried. When respiration is established, the face must still be freely exposed to the air, whilst the tem perature of the limbs and body is carefully sus- tained. In the midst of these efforts, it should, in the next place, be the office of two other individuals to maintain or restore the temperature of the in- fant, by gently but constantly pressing and rub- bing its limbs between their warm hands, passing them upwards, in the direction of the venous circulation. An enema of gruel, at 98° or 100°, or higher, with a little brandy, should be administered. As soon as possible a little warm liquid, as barley- water, at blood-heat, should be given by means of the proper bottle, furnished with leather or soft parchment—a tea-spoon must not be used for fear of choaking. If the infant draws the liquid through its own lips, by its own efforts, there is no danger. Lastly, these various means should be continued or repeated in the most persevering manner.” {Med. Chir. Rev., Oct. 1841, p. 319.) Notwithstanding the above opinion of Dr. Hall, it may well be doubted, whether the surface should not be kept at a moderate temperature, say of 60, or 70, rather than one of 90, or 100 degrees. The experiments of Dr. Edwards, of Paris, and Dr. Scholer, of Berlin, are decidedly in favour of such a conclusion.] Bibliography.—Burns, Principles of Midwifery, &c. 8th edit. p. 593.—Gardien, Traite Complet. d’Accouche- mens, Ac. t. iii. p. 135.—Desormeaux, art. Nouveaux-nes, Diet, de MddOcine, t. iii. p. 153.— Wilson, in Glasgow Med. Journ. vol. ii. p. 237.—See Dublin Med. Journ. for July, 1836, passim. ASTHMA. Deriv. and Synon. ’A08pa, an- helatio ; from aw, I breathe: dodyaiw, I breathe with difficulty. Suspirium, Celsus, Seneca. Dyspnoea Spastica, Auct. Var. Myspathica Spastica, Ploucquet. Asthma Chronicum, J. P. Frank. Asthma Convul- sivum, Baglivi, Alberti, Hoffmann, Sauvages. Asthma Spasticum, Juncker. Pneusis Asthma, Young. Asinia, Bolsaggine, Ital. Pousse, Asthme, Fr. Die Engbrustigheit, das Keu- chen, Ger. Classif. 54. G. Asthma; 3. Order, Spas- mi; 2. Class, Neuroses (Cullen). 4. G. Asthma; 2. Order; 2. Class (Good). 37. G. Asthme Convulsif; 4. Order; 4. Class (Pinel). II. Class, III. Order (Author, see Preface.) 1. Defin. Great Difficulty of breathing, re- ASTHMA—Pathology of. turnng in paroxysms, accompanied with a wheez- ing sound, sense of constriction in the thorax, anxiety, and a difficult cough, terminating in mucous expectoration. 2. There are few diseases, the nature of which nas been a subject of greater doubt and difference of opinion than asthma. Until the writings of Floyer, Willis, Hoffmann, Alberti, and Juncker, directed particular attention to its pa- thology, it was generally confounded with dysp- noea, being usually denominated intermittent or remittent dyspnoea. By these writers, and more recently by Salvages, Cullen, Pinel, and Georgf.t, asthma was considered as essentially nervous in its nature ; and the lesions found upon the dissection of fatal cases viewed as its conse- quences, and not as its causes. More recently, and even at the present day, among many, it has been considered as a symptom of organic change of either the heart, large blood vessels, or of the lungs, air-tubes, Ac. But this doctrine, although generally accurate in respect of Dyspnoea, is quite erroneous as applied to asthma. 3. Physiology of Asthma.—The dependence of dyspnoea, not only upon organic lesions of the organs seated within the chest, but upon the form of the thorax, upon diseases of adjoining viscera, and upon the state of the air-passages, is suffi- ciently obvious. The difficulty of breathing pro- ceeding from these sources may be either con- tinued or remittent; but it never is, whilst the causes on which it depends are in existence, characterised by intervals of perfect ease. True asthma, however, presents intervals of healthy respiration ; and although repeated returns of the attack will generally induce some change in the organisation of either the lungs or the principal organs of circulation, yet this is not uniformly the case ; and moreover, an attentive examination of the thoracic viscera, in recent attacks, fails of detecting in them any appreciable change, par- ticularly during the intervals between the parox- ysms. The disease has even proved rapidly fatal during the attack, and yet no alteration adequate to account for the symptoms could be detected on dissection. Instances of this description have been adduced by Wichmann (Hufeland’s Journ. b. i. p. 18.), Parry, Georget, Andral, Laen- nec, and Guersent, and justify the opinions of those who have referred the disease chiefly to the nervous system. In some cases, after repeated returns of the attack, and when they have in- duced organic change, the intervals are less dis- tinctly marked, consist of remissions merely, and the disease may, at last, pass into confirmed dyspnoea. 4. A. The structure of the air-passages and bronchi evidently shows that these parts are sus- ceptible of preternatural or spasmodic constriction. During 182 L and 1822, when engaged in some researches into the pathology of diseases affecting the trachea and bronchi, I was enabled distinctly to trace muscular fibres throughout those parts, both in man and in the lower animals. The dis- position of those fibres, in many of the lower animals, and the mode of their connection with the cartilaginous rings, are peculiar, and beau- tifully adapted to guard against the contingencies to which they are liable from varying positions and habits of life. Upon those, however, I can- not here enter. About the same time that my attention was directed to this subject (Land. Med. Repository, vol. xxii. p. 418.), the researches of Resseissen of Berlin, and of Laennec and Cru- veilheir of Paris, appeared; and the results, in respect of the structure of the bronchi and larger ramifications of the trachea, upon the whole, agree with what I had observed. It had been denied that the membranous, or any other part of the air-passages contain muscular fibres. But this was asserted chiefly by those who cannot believe that a part is muscular, unless the fibres are the same in appearance as those which enter into the composition of the muscles of voluntary motion. Other anatomists, who take a more comprehen- sive view of the conformation and functions of the muscular system, consider, with greater justice, that the muscles which are acted upon by the will, form an order by themselves ; and that there is another and a very important order of muscular parts, which are not directly influenced by vo- lition, but which contract from stimuli acting on them, either immediately or mediately, and which present certain peculiarities in respect of the ap- pearances of their fibres, of the mode of then- distribution, and of the manner of their connec- tion with internal tissues and organs. Now, the fibres which are discovered in the trachea, and traced to the smaller ramifications of the bronchi, are in every respect similar to other involuntary muscular fibres, in their organisation; in their connection with a mucous surface, forming, in many respects, a tunic concentrically with the mucous coat; in being disposed in circular fibres, surrounding hollow tubes; and in being supplied entirely by ganglial or involuntary nerves. The disposition of the fibres, therefore, which are de- tected in the air-passages, being altogether similar to that which obtains in other canals, the mus- cular structure of which is not disputed, as in the alimentary tube and urinary bladder ; the organ- isation of the fibres being also similar; their con- nection to a mucous surface, and the circum- stance of their being supplied with the same order of nerves, being at the same time considered : are we therefore to be surprised that agents affecting either the mucous surfaces thus related to them, or the nerves supplying them, should be followed with analogous effects to those which we observe after the action of agents directed to the mucous surface or nerves of the alimentary canal ? 5. B. The lungs possess a vital power of expan- sion.—The structure of the air-passages, then, would lead us, independently of the results of ob- servation, to infer that the circular fibres are liable to experience, with all other involuntary muscular fibres, a spasmodic constriction; and it evinces, particularly in the confirmation of the cartilagi- nous rings with which the trachea and larger ramifications of the bronchi are provided, a marked provision against an inordinate continuance or degree of this constriction; the rings, by their permanent elasticity, acting as antagonists to the circular fibres, preventing extreme constriction, and at last overcoming long-continued spasms, particularly in those larger branches, the inordi- nate constriction of which might have the effect of excluding the air from a very large portion of the lungs. In the larger ramifications of the bronchi, the muscular fibres connecting the ex- tremities of the cartilaginous rings are thus an- tagonised by these rings; but, in the smaller ramifications, where the rings cease to be de- tected even in the imperfect forms in which they there exist, and where the fibres are perfectly 177 178 circular, the only provision which can prevent an inordinate constriction of those fibres, is in the structure of the lungs themselves, which must necessarily , undergo a change in bulk, and be- come more condensed by this constriction, in those parts, at least, to which the spasm extends ; unless we believe that the lungs, like various other organs, are endowed with an expansive power,— a power which physiologists and pathologists have too much overlooked in their exposition of the healthy and morbid actions of the animal economy.* 6. The mechanism of the expansive power is so little understood, and generally so insufficient for the explanation of this phenomenon, that we must refer chiefly to the vital actions of the part, which must necessarily depend on the energies of the body generally. The expansile action of the penis, nipple, heart, uterus, &c., cannot be ex- plained by their organisation only: it is mani- fested to us only during life, and the perfection as well as imperfection of this action are always ac- cordant with the degree of vital energy with which these organs are endowed. 7. I have long since had occasion to remark that the motions and functions of the lungs (Phy- siological Notes, .. vii. p. 139.; et Rathke, in Ibid. t. vii. p. 481 .— Walter, Museum Anatom. Berol. 1803, p. 275.—Osiander, In Gotting. Gelchst. Anzeiger, 1812, No. cxxxix.—Beclard, Bulletin de la Faculti6 de Mdd. t. iii. p. 292.—Jlutenrieth, in Tubinger Bliittern vol. ii. p. 273 .— Paletta, Exercitationes Pathologies! t. i. p. 127.—Ehrmann, in Repertoire Gen. d’Anat. &c. Phys. Pathol, t. iv. p. 25.—Martini, in Repertorio Medico-Chirurgico di Torino, No. lix.—Otto, in Selt. Beobach. part ii. p. 157.—Billard, Traite des Maladies des Enfans Nouveau-nes, &c. 8vo. Paris, 1828.—Mcryc, in Archives G6n. de Med. Jul. 1827.—Gcoffroy St. Hi- laire, in Ibid. July, 1827.; et Philosophic Anatomique. Paris, 1822.—Meckel, in Pathol. Anatom, vol. i. p. 292.; et Archiv. f. d. Physiol, b. vii. p. 99.—Earle, in Medico Chirurg. Soc. Trans, vol. vii. p. 427.—Stanley, in Ibid, vol. viii. p. 12.— Thompson, in Lond. Med. Repos. Nov. 1824.— Workman, in Ibid. vol. iii. No. xviii.—Spalding, in New. Eng. Journ. of Med. and Surgery. Jan. 1820. xii. Laceration.—Arnemann, Versuche iiber das Ge- hirn und Ruchenmark. Got. 1787.—Burdach, Vom Baue und Leben des Gehirns, b. iii. p. 501.—Copland Hutchison, Practical Observat. on Surgery, Treat. 4.—Brodic, in Med. Chirurg. Trans, vol. xiv. Lond. 1828.—Otto, Verzeichn. No. 2891. xiii. Alterations of Colour.—Stoll, Ratio Medendi vol. iii. p. 11.—Lallemand, Recherches Anat. Patholog. sur l’Encdphale et ses Depend. Paris. 1824-29.—Billard in Archives G6n. de Med. t. ix. Dec. 1825, p. 492.— Bright, Medical Reports, vol. ii. part. ii. p. 670. [American Bibliog. and Refer.—Cowper, (James,) case of extensive and deep seated injury of the Brain, un- attended by any disturbance of the intellect, terminating favorably; Am. Journ. Med. Sci. vol. xviii. p. 533.—Fisher, (J. D.,) On Bellows-Sound of the Brain; Am. Journ. Med. Sci. vol. xiii. p.289.—Ibid. Cerebral Auscultation, vol. xxii. p. 259.— Thurston, (J.,) case of very serious injury of the Cranium and Brain; N. England Journal of Medicine and Surgery, vol. ix, p. 220. In this case the patient recovered after the loss of a considerable portion of cerebral sub- stance.—Jeffries, (John,) case of Organic Disease of the Brain terminating fatally, in which extraordinary conges tion of all the vessels existed; N. Eng. Journ. of Med. and Surgery, vol. xv. p. 351.—Griswo’d, (M. R.,) Va., Se- vere injury of Brain, in which a portion sloughed away, with no appreciable impairment of the intellectual facul- ties ; Am. Journ. Med. Sci. vol. xx. p. 85.—Buck, (G.,) In- juries of Head, New York Journ. of Med. vol. iii. p. 333; Hernia of the Brain, vol. ii. p. 484.—Post, (A. C.,) Injury of Head, N. Y. Journ. Med. and Surgery, vol. ii. p. 214 ; Hemiplegia;, Ibid, vol. i. p. 213.—Morris, (G. W.,) cases of Injuries of the Head, treated at the Pennsylvania Hos- pital, Am. Jour. Med. Sci. vol. ix. p. 314.— White, (J. E.,) of Savannah, case of Diseased Brain, N. Y. Med. Repos- itory, vol. viii. p. 229.1805.—Stuart, (J. B.,) examination ot the Brain after death from spotted fever, N. Y. Med. Re pository, vol. iii. p. 23.—Bartlett, (J.,) and Wilson, (J.,) ap- pearances of the Brain after death from spotted fever, N. York Med. Rep. vol. iii. p. 40.] BRONCHI, Diseases of the. — Syn. Bybvsoi, Gr. Bronchus, Bronchia, Lat. Bronche, Fr. Die Luftriihrenaste, Ger. Bronchi, Ital. Air- passages, Air-lubes, Eng. 1. Bronchi and Air-tubes.—their Alterations Under this head, the alterations of structure usually found in the air-tubes, from the larynx to the smallest subdivisions of the bronchi will be first considered, and subsequently the history of such of them as are more immediately seated in the bronchi, and are not treated under distinct heads, where some of them are placed, owing to their specific nature, and their relations to other parts. 2. I. Alterations of Structure in the Bronchi.—As the same lesions are found in the larynx and trachea, as in the bronchi, although certain of them are more frequent in one part than in another, no particular distinction depend ing on locality merely will be made, in order that repetitions may be avoided. 3. i. Alterations of the Mucous Membrane of the Air-passages.—These are the same in kind from the glottis to the air-cells, whether the vascularity, the structure, or the secretions of this membrane, be individually or collectively changed. A. Passive or simple congestion of this surface is not unfrequently found after death ; and there is every reason to believe that it may take place during life, or at the moment of death, or even be a post mortem change. When occurring during life, it is most frequently met with in the debilitated, and when the return of blood to the left side of the heart has been impeded. Simple congestion of this membrane may be either partial or general. When general, and at the same time suddenly and intensely formed, it may terminate life with all the symptoms of asphyxy. (See Congestion of the Bronchi.) In a slighter form it accompanies various diseases, particularly the febrile exanthemata; but it is seldom found in a chronic form. Congestion of this membrane pre- sents various depths of shade, varying from a dirty pale red, or a brick red, to a brownish or purplish hue ; being sometimes equally deep throughout, in others of a different shade in dif- ferent situations. 4. B. Inflammatory injection, or active con- gestion of the bronchial surface is generally par- tial, or affects one part of the air-passages more than another. It is also of a livelier colour, and is usually attended with some of the changes hereafter to be noticed. Partial or inflammatory redness of the mucous membrane is very much more common than general congestion. It may be limited to the trachea and larynx, whilst the bronchi are pale ; and in this case it may be con- fined to one side of the tube. M. Andral has seen it cease abruptly at the median line, particu- larly when one lung was affected; and then the inflamed side of the trachea has corresponded with the diseased lung. The redness may also be confined to the large bronchi, the mucous sur- face of the passages above and below its seat being pale; or it may be limited to the smaller bronchi, where it often occasions great dyspnoea and fever, with little or no cough. According to M. Broussais, the bronchi of the upper lobes are most frequently congested and inflamed. Conges- tion and inflammatory injection of the bronchial mucous membrane, although very often connected with diseases of the substance of the lungs, are not necessarily dependent on any of them; for this membrane may be pale from the glottis down- wards in cases of acute, and still more in chronic, pneumonia. The same obtains in respect of tubercles, previously to their softening. In many cases, however, where tubercles exist in the lungs, the surfaces of the smaller bronchi are more or less inflamed or congested ; and when the tuber- cles have advanced to softening, the bronchi near- est them are almost always red. Where tuber- cular excavations exist, the redness is still more marked and extensive, sometimes proceeding along the trachea to the larynx: bronchitis thus super- vening to tubercular phthisis. In these and vari- ous other diseases, the inflammatory state of the mucous surface commences in the smaller ramifi- cations, and spreads upwards to the glottis. But in other maladies, particularly those which first affect the Schneiderian membrane, throat, fauces, pharynx, &c., the injection of the bronchial sur- face is chiefly an extension of these ; inflammatory action more frequently originating in some one of these situations, and extending itself more or less rapidly, according to the state of the patient, along the surface of the larynx, trachea, and large bronchi successively, until it at last reaches the minute bronchi, or even the air-cells and structure of the lungs. This is the usual direction in which BRONCHI AND AIR-PASSAGES—Alterations of the. inflammation of the mucous membrane of the air- passages commences and extends itself; but most frequently without reaching the smaller bronchial ramifications, and pulmonary parenchyma. 5. C. Thickening of the mucous membrane of the air-passages is a very common lesion, arising, 1st, from its conjested or injected state ; and, 2d, from its increased nutrition or hypertrophy.—a. The former is most frequently observed in the larynx and small bronchi: it is sometimes found in children about the margin of the glottis, giving rise to a form of croup.—b. True thickening, or hypertrophy of this membrane, occurs in various situations, occasioning very different phenomena accordingly, particularly in those who had been affected with chronic coughs. This form of thick- ening may extend throughout the larynx, or may be limited to the epiglottis, to the entrance of the glottis, to the chordae vocales, or to the ventricles. In the trachea it may occasion no marked symp- tom ; but in the bronchi, particularly the smaller, it gives rise to sensible alterations of the sound of the pulmonary expansion. It may, when exten- sive, very materially impede the changes produced by respiration on the blood. Hypertrophy of this membrane may also be confined to a circumscribed point, forming thus a tumour rising above the sur- rounding surface. This form of thickening may assume a nearly cauliflower appearance, from its exuberance. These excrescences have been found in the larynx by MM. Andral and Ferrus. 6. The mucous follicles may be enlarged inde- pendently of the membrane in which they are seated. When this is the case, a number of round granular bodies, of either a white, red, or dark- brown colour, are found on the internal surface of the membrane, surrounded by two coloured circles—one round the centre, the other round the base. M. Andral thinks that they have often been mistaken for tubercles, and for the variolous eruption. 7. C. Other alterations of structure in the respi- ratory mucous membrane.—a. Atrophy is said by Andral sometimes to be observed in this mem- brane.—b. Softening is much more frequent; and is most common in the larynx, especially in the situation of the chord® vocales and ventricles, where it is sometimes very rematkable, and has been the1 only change of these parts observed in persons who had either lost their voice or been hoarse long before death.—c. Ulceration is not infrequently found in this membrane. Ulcers may be seated in any part of the air-passages, but are more common in the larynx than in the trachea or bronchi. They rarely, however, occur in the larynx, without tubercular ulceration existing also in the substance of the lungs. They occasion various modifications of the voice, according to the parts of the larynx in which they are situated; being found in every point of its internal surface. Their size and number vary exceedingly. Some- times only one very small ulcer is found, the rest of the larynx being in all other respects quite natural. In other cases, this part is nearly de- stroyed by numerous ulcers of various shapes and sizes; and in some cases, one large ulcer extends over one half or more of the larynx. Ulcers, when seated in the trachea, are chiefly found in its posterior or membranous part. M. Andral states, that in some cases they are confined to one side of the trachea, which invariably corresponds to the diseased lung ; or, if both lungs be diseased, 297 to that which is most affected. Ulcers are not so frequent in the bronchi as in the larynx, but more so than in the trachea. 8. Ulcers in the internal surface of the air- passages sometimes extend no deeper than the cellular tissue connecting the mucous membrane to the subjacent parts. In this case the connect- ing tissue is much thickened at the bottom of the ulcer. But they frequently proceed deeper, de- stroying successively the different tissues, until the parietes of the tube are at last perforated, and a fistulous opening is formed between it and some neighbouring organ or part, as the (Esophagus, aorta, parenchyma of the lungs, large blood-vessels, the pleural cavity, &c., or even the external sur- face ; forming, in this last case, a direct commu- nication between its interior and the external air. When a fistulous opening extends into an exca- vation in the parenchyma of the lungs, it is diffi- cult to determine whether it produced, or was itself occasioned by, the excavation. When it is connected with a cavity arising from the liquefac- tion of tubercular masses, there can seldom be much difficulty in determining the precedency; but every cavity found in the lungs has not this origin. There can be no doubt that ulcers perfo- rating a bronchial tube may excite inflammation of the substance of the lungs, and occasion either small abscesses, or ulcerations, which enlarge into considerable excavations. But, in the majority of cases, excavations communicating with the bronchi arise from the softening of tubercles ; the bronchi being perforated from without inwards, instead of from within outwards, as in the case of ulceration commencing in their mucous surface. The bronchi or trachea may be also perforated from without inwards, by aneurisms, &c. of the aorta, and not infrequently by ulceration com- mencing in the oesophagus and extending through the membranous part of the trachea ; an instance of which I lately had an opportunity of seeing in a patient of my friend, Mr. Byam. Suppurated bronchial glands may also perforate the bronchi which they surround, and pour their contents into them. A similar result may likewise occur from purulent collections, hydatid formations, &c. of adjoining parts, as of the thyroid gland ; instances of which are recorded by Portal and Andral. 9. D. Alterations of the secretions of the Air- tubes.—M. Andral has very justly stated that alterations may occur, 1st, in the gaseous secre- tion ; 2d, in the perspiratoiy exhalation; and, 3d, in the mucous secretion.—a. Changes of the gaseous exhalations are but little understood, and are more matters of inference than of demonstra- tion. There can be no doubt, however, that not only in various diseases, but also in certain states of the system and of the atmosphere, a very ma- terial alteration occurs in the proportions of the different gases naturally exhaled by the mucous surface of the lungs. That the successive changes in the system, certain conditions of temperature and of the air, different states of vital energy, and the constitutional differences in the various races of our species, modify very materially the quantity of carbonic acid gas and of azote exhaled from the lungs, may be considered amongst the surest established facts in physiology. (See my Notes, (f-c. p. 626.) Such being the case, it may rea- sonably be inferred that marked alterations of the gaseous exhalations also take place in disease. 10. b. The perspiratory exhalations evidently undergo changes in disease; but their nature and 298 BRONCHI AND AIR-PASSAGES—Alterations of the. extent are but little known. The vapour exhaled from the respiratory mucous surface very probably may, when excessive, be condensed into a liquid state, and increase the watery fluid sometimes discharged from the lungs. M. Alibert states that he has seen, in certain diseases of the skin in which the cutaneous transpiration is suppressed, the pulmonary vapour issuing like steam from the chest, and descending again like an abundant dew. M. Andral adduces, in his Clinique Me- dicale, the case of a person who suddenly dis- charged, whilst suffering from hydrothorax, an enormous quantity of a serous fluid from the bronchi, at the same time that the fluid which had been effused in the chest was absorbed. 11. c. Alterations of the mucous secretion of the bronchi have been successfully studied by a number of modern pathologists, but more particu- larly by M. Andral. This secretion is modified both in its quantity and quality. It is often very greatly increased in acute and chronic affections, particularly those immediately affecting the respi- ratory passages; under which heads the principal changes of this secretion, with the different states and stages of disease, are described. The quan- tity of the mucous secretion may be so excessive as to nearly fill up the bronchi, trachea, and larynx, and to suffocate the patient. This some- times occurs in adults; but, I believe, still more frequently in children, forming in one of its states a species of croup intermediate between true croup and bronchitis; and, in another state, the disease hereafter described as asthenic bronchitis. M. Blaud considers the former, or that seated chiefly in the large bronchi, in which the secretion is consistent and glairy, a “form of croup, and calls it croup myxagene.” This excessive secre- tion of mucus is sometimes unattended by any alteration of the air-passages. The mucous se- cretion may become so viscid as to adhere to the sides of the bronchi; where it may accumulate so as to occasion a fatal dyspnoea, by preventing the passage of the air. In other cases, the mucus is transformed into a puriform fluid; sometimes, without any trace of ulceration, or even of red- ness, in any of the bronchi; the alteration of the secretion being independent of any perceptible change of structure. More commonly, however, patches, streaks, or points of inflammatory injec- tion of the mucous membrane accompany this state of secretion. 12. <1. Meml/runiform concretions, or false mem- branes, form more frequently upon the internal surface of the air-passages than in any other mu- cous canal. Some pathologists have supposed them to be consequent on the most intense states of inflammatory action in mucous membranes; but this is evidently not the case : they are rather a result of a certain state of the system, pro- bably connected with excess of the albuminous constituent in the blood, together with a disposition in the inflamed vessels to secrete it. (see art. Croup). These membranes are generally unor- ganised, and vary in thickness and consistence in different parts as well as in different cases. Ac- cording to Schwilgue, they consist of albumen, with a small portion of carbonate of soda and sulphate of lime. M. Bretonneau has detected fibrine in them. They may exist in patches, or in continuous layers, or in perfect tubes ; and extend from the larynx, where they usually com- mence, to the minute divisions of the bronchi. They rarely originate in this latter situation, and advance upwards; but they often commence in the pharynx, fauces, &c., and extend through the glottis, and down the trachea and bronchi. They are most frequently met with in children from two years of age to puberty ; and are not confined to, although most frequent in, acute diseases. In some cases they assume, in children, a chronic character, but only when confined to the trachea ; whilst a chronic state is most common in adults, when they are usually formed in the bronchi. When, however, they occur in the larynx, the tumefaction of the subjacent membrane, the spasms of the muscles, and their own thickness, often give rise to an acute or fatal disease. When seated in many of the small bronchi, they may occasion asphyxy by interrupting the changes produced by the air on the blood. It is probable that fibrinous or polypous concretions may some- times form in the bronchi, from the coagulation of a portion of blood exhaled from its mucous surface. Laennec has described (Rev. M6d. 1824, t. i. p. 384.) a case which appears to be of this description. Such formations differ from the albuminous exudations, in their containing much fibrine, and being of a darker colour than the latter. 13. e. Earthy or calcareous concretions occa- sionally are found in the air-passages, and are sometimes coughed up. They consist chiefly of phosphate of lime ; and are formed either in the substance of the lungs, and escape into the bronchi, or in the latter; but more probably in the air-cells. They have also been found impacted in the ven- tricles of the larynx. The cause of their for- mation is not well understood. They have been ascribed to chronic irritation of the small bronchi and air-cells ; but this source is by no means well established. I have met with them in gouty per- sons, by whom particularly they are often expec- torated during life, recovery generally taking place. Hydatids have also been found in the air- tubes. In some cases they may have been de- veloped in this situation ; but they much oftener escape into it from contiguous parts. 14. /. Hcemorrhage from the respiratory sur- faces is amongst the most frequent changes to which it is subject. In the greatest number of cases of hcemoptysis, the blood is exuded without any ulceration or breach of surface : a slight red- ness of the mucous membrane being the only change that can be detected. When the haemor- rhage occurs in the smaller bronchi, the blood sometimes accumulates and coagulates in them; imparting a blackish or brownish black appearance to the lobules, and constituting the pulmonary apoplexy of Laennec. The occurrence of hae- morrhage into the parenchyma of the lungs is, however, more strictly deserving of this appella- tion. The extravasation and coagulation of blood in the small bronchi, giving to portions of the lung a blackish and indurated appearance, are most commonly, but not always, found in persons who have expectorated blood, or died from an attack of haemoptysis ; and are most frequent in those cases which supervene in the progress of diseases of the heart. M. Andral considers, however, that the haemoptysis is not from those sources which have been called apopleptic; but from a larger extent of mucous surface, and from larger tubes. (See art. Lungs,—Alterations of, and Hcemorrhage from.) t 15. ii. Alterations of the other Structures composing the Air-tubes.—A. The fibrous and BRONCHI AND AIR-PASSAGES—Alterations of the. muscular tissues of the air-passages experience various ohanges.—a. The fibrous structure of the bronchi is sometimes found either softened or hypertrophied. The thyro-arytenoid ligament is occasionally softened. It has ihen lost its brilliant colour, become opaque, or even changed into a cellular-like tissue, or an unorganised pulpy sub- stance, leaving the thyro-arytenoid muscle ex- posed. In this case the voice is remarkably altered. When the fibrous tissue is hypertrophied, increase of thickness is the chief appearance (An- dral.—b. The muscular structure, as it exists in the trachea, &c., may be either atrophied or hy- pertrophied ; it may also be softened and destroyed partially or in points by ulceration (§7, 8.). But it is chiefly where this structure assumes a differ- ent state and function, as in the larynx, that it undergoes marked alterations, giving rise to the most formidable and fatal diseases. The muscles of the larynx are, in some of those cases, softened, more or less atrophied, or even altogether de- stroyed ; and, in others, infiltrated with either purulent or tubercular matter (Bouillaud, An- dral, and others).—M. Andral states, that he has more than once observed, on examining the larynx of persons who had been long completely without voice, the thyro-arytenoid muscle either remarkably atrophied, or its fibres infiltrated by different morbid secretions ; this being the only lesion that could be detected. 16. B. The cartilaginous structures of the air- ■passages are most frequently diseased in the lar- ynx. The cartilage of the epiglottis sometimes loses its natural form: it is scarcely ever ossified ; but it is occasionally somewhat indurated, so that it imperfectly protects the opening of the larynx. It is not infrequently destroyed altogether by ul- ceration, commencing either in itself, or in the tissues enveloping it. Similar changes to these sometimes take place in the other cartilages of the larynx. Ulceration of these cartilages may be superficial only; or it may destroy more or less of their structure. It generally commences in the soft parts covering them; but in some cases, particularly of constitutional taint, there is reason to suppose that it originates in inflammation of the cartilages themselves, terminating in the ulcer- ative process, and the formation of purulent mat- ter in the soft parts adjoining, which escapes by a fistulous opening, generally through the mucous surface into the larynx, and rarely externally. Ulceration may also commence in the articula- tions of the cartilages; filling them with pus, and destroying their ligaments and articulating sur- faces. The thyroid and cricoid cartilages are naturally ossified in old age ; and in consequence of disease, in earlier life. M. Andral states, that the arytenoid cartilages have never been ossified. The rings of the trachea are sometimes ossified, but seldom or ever otherwise altered. The car- tilages of the bronchi are often hypertrophied, becoming more apparent, and forming more com- plete rings, than natural. They are also sometimes ossified. MM. Reynaud and Andral found the ultimate ramifications of the bronchi changed into osseous spiculas, with minute canals (the cavities of Jhe bronchi) running through them, in very old subjects. M. Andral states, that the bronchial cartilages may become so brittle from disease, as to break into fragments, project into the canal of the bronchi, or become altogether detached, and be ultimately expectorated. 17. C. The cellular tissue connecting the 299 BRONCHI AND AIR-PASSAGES—Alterations of the. 300 above structures is often the seat of disease. In the larynx, it is very frequently the seat of in- flammation and congestion ; and, in consequence of a chronic state of inflammatory action, it some- times becomes indurated and thickened ; diminish- ing remarkably the calibre of the glottis, impeding the action of the muscles, and affecting the form and movements of the epiglottis. This tissue, in the situation of the larynx and epiglottis, is occa- sionally infiltrated with serum, which, when con- siderable, constitutes the adema of the glottis, first accurately described by Bayle. The infil- tration may distend the folds of mucous membrane, surrounding the rima of the glottis, so as to ob- struct more or less the passage through it. This change is generally consecutive of inflammation of the mucous membrane of the larynx, or of chronic affections of this organ. In some cases it is very chronic; in others very acute, quickly producing asphyxy. Instances of this latter form are to be found in the sixth volume of the Archives Generates de Medicine, and twenty-second volume of the London Medical Repository. Purulent matter is sometimes found in the cellular tissue of the air-vessels, either in the state of small ab- scesses, or infiltrating it to a greater or less extent; and either in the ventricles of the larynx, or in any other situation in the course of the air-passages. Tubercular matter has also been found in various parts of this tissue. Different kinds of tumours occasionally compress the nerves supplying the air-vessels, and give rise to symptoms similar to those caused by disease of their parietes. They are sometimes formed in the larynx, or in its im- mediate vicinity, occasioning more or less com- plete occlusion of the glottis. M. Ferrus has recorded a case where this result followed the developement of two fungous tumours in the larynx (.Archives Gener. Aohl, 1824.) Several writers have made mention of a varicose state of the veins of the air-passages amongst the causes of hsemop- tysis; but M. Andral states that he has never met with this appearance in his numerous post mortem inspections. 18. iii. Alterations of the Size or Calibre of the Air-vessels.—The changes already de- scribed very often cause marked change in the air-tubes, either diminishing or increasing their calibre.—A. Diminution of their canals are occa- sioned,—a. by the formation of false membranes, chiefly in the larynx and trachea of children, and in the bronchi of adults ;—b. by thickening of the mucous membrane; occurring principally in the glottis and bronchi;—c. by infiltrations of fluids into the sub-mucous cellular tissue, chiefly in the larynx and vicinity;—d. by various substances formed in some part of these tubes, such as hyda- tids, coagula of blood, concrete mucus, &c. e. by compression by some tumour situated externally to some portion of them, as by the thyroid gland, an aneurismal tumour, or enlarged bronchial glands.—f. Lastly, there is every reason to con- clude, that diminution or constriction of some part of these passages very often arises, although seldom in so permanent a manner as to be ob- served after death, from spastic contraction of the fibres or muscles belonging to them ; particu- larly when foreign bodies escape into the tracnea, or when it, the larynx, and even the bronchi, are irritated by morbid productions—the larynx more especially. 19. B. Dilatation of the bronchi was first de- scribed by Laennec, and afterwards illustrated by Andral and others. It is most frequently observed in the smaller ramifications; and may be so great as to be mistaken for tuberculous ex- cavations.—a. In some cases, the bronchi may be uniformly dilated throughout one or more of their ramifications, some of those which could not na- turally receive a fine probe, having attained the size of a goose-quill; and, in some instances, even admitting the finger. These dilated branches are sometimes visible on the surface of the lung, where they terminate abruptly. They occasionally also terminate, particularly near the top of the lung, in an indurated black portion of its substance, or in a cartilaginous mass, or in a calcareous concre- tion, either exterior or interior to the dilated bronchi. [This sacular expansion of the termi- nal branches of the bronchi, forms a peculiar sub- division. We often meet with them, distended in the form of thin membranous vesicles, filled with air, either singly, or in groups, and generally at the apex of the superior lobes of the lungs, or in the vicinity of cicatrices, the remnants of former tubercular cavities. These vesicular ex- pansions are very apt to form, where a bronchial tube has become compressed by, or nearly oblite- rated in passing through the portion of lung, which is rendered nearly impermiable by tubercular de- posits, or other morbid changes, obstructing the free admission of air. Dilatation of the bronchi affects especially the smaller tubes, as those of the third or fourth order, and is rarely met with in those of the larger trunks.]—b. In other cases, the dilatation is limited to a particular point of the tube, and has the appearance of an excavated cavity in the substance of the lung, for which it may be mistaken, especially when it is met with in the upper lobe. The size of cavities arising from this species of dilatation varies from that of a hemp-seed to that of an egg. Several of these may co-exist. When they are placed near each other, they folm, by their communication, a com- plicated sinus filled with puriform mucus, and closely resemble some kinds of tuberculous exca- vations.—c. Occasionally they present a third form, consisting of a succession of dilatations, between each of which the bronchus recovers its natural diameter, the walls of the dilated portion being generally thin and transparent. One lung may contain a number of these dilatations.— d. The parietes of the dilated bronchi are, in some cases, hypertrophied, or more fully developed than in the natural state; in other cases they are re- duced to a delicate membrane, presenting neither fibrous nor cartilaginous tissue. (Andral.) The dilated portions generally contain much mucus, or a puriform mucus. 20. These changes of the bronchi are seldom found, unless in persons who had suffered attacks of chronic bronchitis. They are most common in persons of middle or advanced age. But they are also sometimes met with in children who had died of hooping-cough, particularly in its more chronic states, and when complicated with bron- chitis. I have occasionally found them in this class of subjects; but only consequent upon this disease. Dilatations of the bronchi, unless when very considerable, seldom occasion any change of the parenchyma of the lungs, beyond compressing and condensing it: they are frequently associated with either grey or dark induration of the adjoin- ing pulmonary substance. (See Chronic Bron- chitis, § 52. 61.) [Chronic Catarrh is very apt to occasion this hypertrophied and thickened condition of the walls of the bronchi, especially the lining mucous membrane, which we find swollen, spongy, softened, and of various shades of a dark red colour. Often the walls of the bronchi are rigid, and expanded when laid open, the white fibrous sheaths or parietes, contrasting strongly with the internal red, and swollen mucous membrane, from which a thick yellow purulent matter is seen to exude. Sometimes we find the walls in a state of relaxation and emaciation, especially in the sae- cular form of the disease ; while the mucous membrane is but little reddened, or even paler than natural, its texture but slightly, if at all softened, and resembling very much a serous membrane. In this condition we find the cavities containing a thin, puriform, pale yellow, or almost colourless glassy mucus.—Dilatation of the bronchi is sup- posed by Laennec, and most pathologists, to be produced in a mechanical way, by catarrhal se- cretions blocking up certain portions of the tubes, aided by powerful inspirations during paroxysms of coughing. The dilatation of the bronchi be- ing the primary affection, and the condensation of the parenchyma consequent upon it. Dr. Cor- rigan, however, believes the disease to be analo- gous to scirrhous of the liver, and calls it there- fore, scirrhous of the lungs. He supposes that the atrophy and obliteration of the pulmonary tissue is the primitive affection, and the dilatation a se- condary result, or consequence of this: arising not only from an attempt to fill'up the space left vacant in the contracting lung, by the forcible ex- pansion of the bronchi during the act of inspira- tion, but also by the mechanical dragging apart of the walls of the tubes from the shrinking of the pulmonary tissue itself. The great extent to which the pulmonary tissue around the affected bronchus is atrophied, the nature and degree of this change, and the fact that it is not equally developed around the dilated tube ; all these circumstances combine to give plausibility to Dr. Corrigan’s theory. Rokitansky* supposes that in the first variety, atony and paralysis of the contractile and irritable tissues of the tubes are present, occasioned by inflammation and blenorrhoea, occasioning an easy dilation of their walls, by the inspirations and concussions in paroxysms of coughing, which are often violent and forcible, in order to throw out the accumulated secretions ; the process also be- ing aided by many of the smaller bronchi being filled with catarrhal mucus. This variety arises only in that portion of the bronchial system which forms the seat of the catarrh. The saecular dilatation of the bronchi, the same pathologist supposes to arise, not in the catarrhal section of the bronchial system, but beyond it; being a consequence of a bronchitis in the termi- nal branches of the air tubes, causing first obstruc- tion of them by accumulation of secretion and swelling of their mucous membrane, and finally entire obliteration of them. The more laboured and the more protracted the single inspirations, so much the more readily does the inspired air which is obstructed in its passage through the tubes, tend to produce dilatation. He supposes that the ex- pansion takes place toward the perfectly imper- meable portion of the bronchus, for the paren- BRONCHI—Congestion of the. chyma and air-cells which were supplied with air by it have now collapsed and become atrophied, thus giving rise to a space to be occupied by the dilating bronchus, which lies in the midst of a collapsed* and apparently compressed pulmonary parenchyma ; hence this last appears the exciting cause, the dilatation the result. Rokitansky thus makes the obliteration of the terminal tubes the first step; the obliteration of the parenchyma which they supplied, the second; the dilatation of the air-tubes in order to supply the vacuum, the third. The primitive affection, according to Corrigan is not bronchitis, but a disease of the parenchyma of the lung; not so much an inflammation of the interstitial tissue, as a peculiar pneumonic cellular process, which slowly extends from one lobule to another, depositing a product which becomes indu- rated, and unites closely with the pulmonary tis- sue itself, while the air-cells become atrophied, obliterated and transformed into the same sub' stance—a larger or smaller portion of the lungs thus becomes contracted and obsolete in proportion to the extent of the bronchial affection; and when all, or most of the bronchi of a lung are dilated, its entire parenchyma will be found atro- phied, and contracted to a small portion of its normal volume, and drawn up towards the roots of the bronchi, as if in consequence of external pressure from an effusion into the pleura; thus occasioning the cavity of the chest to become smaller than usual, and its walls to sink in, over the contracting lung. Bronchial dilatation, when extensive, owing to the atrophy of a large portion of the lungs which attends it, causes obstruction of the circulation, active dilatation of the right ventricle, congestion of the whole venous system, cyanosis, excessive developement, and vicarious action of the per- meable portions of the lungs, and is not nnfre- quently followed by bronchial and pulmonary hae- morrhage. If it attain a very high degree of developement, it causes debility, emaciation, ge- neral cachetic appearance, dropsy, and finally, total exhaustion. (Rokitansky.)] II. Congestion of the Bronchi.—Classif. I. Class, III. Order (Author.) 21. Defin. Urgent continued dyspnoea; little or no cough, and no expectoration; with an anx- ious, pale, or livid countenance.—This affection is not often seen in a primary, severe, and general form; but it is very common in more slight and partial states, and as an attendant on typhoid, malignant, and pestilential diseases, and on exan- thematous fevers, especially measles, scarlatina, and small pox, either shortly before the breaking out, or upon the premature disappearance of the eruption, when it often assumes a very general and severe form; and it not infrequently in slighter grades, ushers in other diseases of the bronchi, particularly haemorrhage, bronchitis, humoral asthma, &c. General idiopathic congestion of the bronchi, to such an extent and degree as to destroy life, although rare, is sometimes met with. Several cases have been recorded of persons who, without any apparent cause, were seized with urgent dyspnoea, increasing until it terminated in death; and, on dissection, the only morbid ap- pearance observed was general congestion of blood in the capillary vessels of the mucous and sub-mucous respiratory tissues. (See § 3. for a description of its anatomical characters.) 22 i. The symptoms of this affection have not 301 r* A Treatise on Pathological Anatomy, by C. Roki- tansky, M.D., Vienna. Translated from the German by Dr. John C. Peters, New York, 1845. Part. I.] 302 BRONCHI—Inflammation of the. been sufficiently investigated; but they may be stated to consist of continued dyspnoea, more or less urgent; sometimes fever, little or no cough, and no expectoration; the sibillous or sonorous rhonchus in the large tubes, and absence of the respiratory murmur over the chest; diminished resonance on percussion ; anxious, pale, bloated, or slightly livid countenance ; purplish tint of the lips and nails of the fingers; anhelation, &c. When the congestion takes place in the course of febrile or exanthematous diseases, in addition to these, the pulse becomes very quick, small, irre- gular, or intermittent, and the oppression at the chest extreme. 23. ii. The Causes of these congestions are not well known. They appear, however, to be most frequently occasioned by the inhalation of poi- sonous gases or effluvia ; by close, overheated, and crowded apartments ; by the ingestion of sedative or narcotic substances, or indigestible or poisonous animal or vegetable matters; by in- ordinate distension or oppletion of the stomach; and by the transition or metastasis of other dis- eases, or by their determination to the bronchial surface in a more especial manner, as in the in- stances above referred to (§ 21.). When this affection proceeds from poisonous or indigestible substances, and not infrequently also when it arises from other causes, it is evidently associated with more or less congestion of the substance of the lungs. It often precedes other pulmo- nary complaints, as haemorrhage, and that mo- dification of asthma, called dry catarrh, by Laennec. Congestion of the bronchi sometimes also occurs in the progress of several diseases of the heart attended with obstructed or impeded circulation through its cavities, particularly those of its left side ; and is often one of those changes which supervene in the advanced stages of several acute diseases, especially the exanthemata, and to which death is more immediately owing (see §21.). . 24. iii. The Treatment must depend upon the state of the vital energies at the time, upon the nature of the cause to which the congestion is owing, and on the evidence of existing general plethora. The state of the pulse, in respect of frequency and fulness, will indicate the degree of activity characterising the attack ; but generally, when the congestion is considerable, the changes which take place in the lungs during respiration being impeded, the vital energies become propor- tionately reduced, and the pulse weak, quick, and small. In the majority of cases, it will be neces- sary, notwithstanding, to abstract blood either by venesection or cupping; and if the depression of vital power be urgent, to exhibit simultaneously stimulants by the mouth, and in enemata ; to em- ploy frictions with irritating liniments (see F. 305. 308. 311.), and revulsants, such as sinapisms, blisters, mustard pediluvia, &c.; and to inhale, at brief intervals, and for a very short time, stimu- lating vapours, particularly those of ammonia, camphor, aromatic vinegar, &c., with the view of exciting the nerves of the bronchi, and thereby removing the distension of the capillaries, and accelerating the circulation through them. YVhen, however, the patient, in addition to the symptoms indicating congestion, complains of a sense of heat, trickling, &c. in the course of the trachea, or under the sternum; and if the pulse retains its volume, and still more especially if it be > ; up, full, or rebounding; we should infer that the fulness of the bronchial vessels is of an active description and most probably amounts to deter- mination of blood; and, possibly, constitutes the early stage of hcemorrhage or of inflammation. In cases of this description, full blood-letting, either generally or locally, or both; and after- wards, counter-irritation and revulsion, irritating cathartic injections, the strict avoidance of inter- nal stimuli, and the antiphlogistic regimen ; must be prescribed. 25. In every case a strict reference should be had to the cause, associated circumstances, and the complications of the attack, and the treat- ment should be varied accordingly. When it seems to have been induced, or aggravated, by hurtful substances taken into the stomach, the exhibition of emetics, particularly No. 402, in the Appendix, ought not to be omitted; and, if they fail of operating, the stomach-pump should be used. The bronchial congestion preceding, ac- companying, or consequent on the eruptive fevers, is to be combated by cupping rovulsants, rubefa- cients, stimulating frictions of the surface, and by emetics. III. Haemorrhage from the Bronchi.—Hwder, and the same of antimonial powder, given at bed-time, will often procure a quiet sleep. Children wrho are kept within doors for months succeeding their birth, are extremely liable to this disease ; for the susceptibility to bronchial irrita- tion is generally proportioned to the care with which they are excluded from the external at- mosphere. Here we find the child fretful, with, perhaps, a swollen and livid face; hurried and wheezing respiration ; anxious countenance ; hot skin; and full and strong pulse; with more or less derangement of the digestive organs, and in- ability to nurso, caused by the extreme dyspnoea. In such cases, I have found blood-letting, general and local, the most important remedy. The phy- sical signs of bronchitis will generally be dis- tinctly heard immediately after the operation ; the breathing becoming easier, the face less swelled, the skin cooler, and the pulse moderated. In the 312 place of antimony, which is highly recommended by Dr. Stokes and others, we are in the habit of using ipecacuanha, as its use is not attended with danger, and it exerts as powerful a control over the disease. Antimony is altogether too violent an agent to be resorted to in the diseases of young children, and especially of infants. For blisters we would substitute, in all cases of bronchitis during early childhood, warm fomentations and poultices. Small doses of calomel, in combina- tion with the ipecacuanha, are often extremely serviceable. An emetic, followed by cathartic doses of calomel, aided by other laxatives, will often give entire relief in simple bronchitis. Free vomiting by antimony, as recommended by M. Girard, is altogether too hazardous, and should not be ventured upon.] 72. b. The choice of diaphoretics in this disease is deserving of notice. Early in the first and second varieties I have usually preferred the potassio-tar- tate of antimony, generally in solution, and con- joined with the vin. ipecacuanhas, or with the spirit aether, nit., small doses of camphor, &c. But in infants or very young children, in the aged, and in the third or asthenic form of the disease, ipe- cacuanha seems preferable,—in the latter class of subjects particularly, combined with camphor. In the more catarrhal, or less acute, forms of the complaint, ipecacuanha, combined with nitrate of potash and opium, and, in the more sthenic states of the disease, the same medicines, in larger doses, will often prove equally serviceable as the preceding. While febrile excitement continues much increased, diaphoretics or diuretics are often exhibited with little advantage, as the restoration of the cutaneous and urinary secretions is rather the consequence, than the cause, of diminished or exhausted febrile commotion. The object there- fore, should be, first to lessen the excitement by depletion, alvine evacuations, and sedatives; and then to employ those diaphoretics which produce a lowering and refrigerant effect, until the strength of pulse and heat of skin are reduced. Hence the propriety of adopting the medicines already re- commended, and combining them with the nitrate of potash and with each other. 73. c. Emetics are amongst the most beneficial remedies we can resort to in certain states of bronchitis, particularly in the third variety ; and, in the second, after blood-letting: in children they are often remarkably useful. They have the effect of unloading the bronchi of the mucus accumu- lated in them, of relaxing the surface, and after- wards of promoting perspiration. For children, ipecacuanha should be preferred; and for aged persons, and the third variety of the disease, the sulphate of zinc. In the second form, and in all other subjects, the potassio-tartrate of antimony is the best emetic that can be prescribed, as it ope- rates both by vomiting, by lowering the vascular action, and promoting perspiration. Emetics are more particularly required when the expectoration is difficult or suppressed, the cough severe and suf- focating, and when the disorder depends upon the inhalation of irritating particles. They moreover tend to promote the operation of purgatives, which are generally much required in this disease. In cases of extreme depression, with suppressed excretion of the secretion, the stimulating eme- tics in the Appendix (F. 402, 403.) should be se- lected. 74. d. Purgatives and cathartics have been considered by several writers as of doubtful effi- f* There is often great fear of sanguineous depletion, in bronchitis, in consequence of the debility, or a sensa- tion of sinking, which often attends the disease. These symptoms, however, are merely owing to a deficient oxygenation of the blood; an incipient asphyxia, which is relieved by the abstraction of blood. When the in- flammation is seated in the larger bronchi, the patient Will bear the loss of a greater quantity of blood, than when it is located in the smaller ramifications. I)rs. Bright and Addison suppose that inflammation in the bronchial mucous membrane has a certain course to run, and that the period for active depletion is very short,— our experience does not agree with these statements.] cacy in pulmonary inflammations; and, when expectoration is established, as being even pre- judicial. Such appears also to be partly the opinion of an able reviewer in the Medico-Chi- rurgical Review for Dec. 1820. But it is not quite in accordance with my experience, which, at the Infirmary for Children alone, must have amounted to some thousand cases of the differ- ent forms of the disease. It should be kept in recollection, that the expectoration in bronchitis is not a salutary discharge from the lungs, the pro- motion of which is a beneficial indication of cure ; but that it is the product of a morbid state, of the nature of which it is an index; and that this state is generally inflammatory, and always attended with determination of the circulating fluids, thereby keeping up the discharge. It is obvious, that whatever tends to increase the morbid determi- nation to the bronchial surface will increase the disease, and, consequently, the expectoration ; and that whatever derives from this situation will pro- portionally diminish both. That purgatives or cathartics, judiciously combined, have the effect of deriving from the lungs, by increasing the se- cretions of the liver and digestive mucous surface, must be evident; and I have accordingly found them serviceable when thus prescribed. Severe attacks of bronchitis, moreover, are favoured by congestions and accumulations of bile in the biliary organs, and by sordes retained on the mucous surface of the bowels. In all those cases more especially—wherein the stools are gene- rally very offensive—and at the commencement of all the forms of the disease, these medicines ought to be exhibited, with the view not only of pro- moting the abdominal secretions, and of removing faecal matters and sordes, but also of deriving the circulation from the seat of disease; and the bowels should be kept very freely open through- out the treatment. It is, of course, understood that we are not to prescribe cathartics to the ex- tent of depressing the energies of the frame too low, especially when they are already weak. In- deed, purgatives may be as much required, and as beneficially employed, in asthenic cases, as in others of a more phlogistic description, particularly if the bowels have been neglected; effects of a very different nature from that of mere evacuation arising from a judicious choice and combination of them. Thus, when prescribed with bitters, tonics, stimulants, or antispasmodics (F. 266. 471. 572. 880, 881. 887.), in the asthenic or suffo- cative states of the disease, not only will full alvine evacuations be procured, but also a tonic effect on the digestive organs ; and, consecutively, a more moderate secretion in the bronchi, with an easier expectoration, will be produced. I have observed that the combination of purgatives, espe- cially calomel, or those of the resinous class, with camphor, antimony, and hyoscyamus, according to the circumstances of the case, is particularly serviceable in bronchial diseases. 75. e. Expectorants have been much abused in inflammations of the bronchi; chiefly from the cir- cumstance of the expectoration being too generally viewed as a salutary discharge which ought to be promoted, instead of its being a product of the in- flammatory state, or of active determination to the surface of the air-vessels. I consider them quite inadmissible when there is much fever, or heat of skin, or when the sputum is abundant and fluid, the patient having sufficient strength to bring it up; and generally in the second variety of the BRONCHI—Acute Inflammation of the—Treatment. disease. On the other hand, in the third variety, or when the expectoration is arrested evidently from want of power to throw it off, or to exdrete it, or from its great viscidity, expectorants will be of much service. In such cases, ammonia and camphor should be first tried, as being generally least detrimental in doubtful cases, and most quickly beneficial. Where the admissibility of expectorants is evident, especially in the asthenic form of the disease, and in aged persons, squills, (t m- moniacum, galbanum, or senega, may be directed; with the precautions, and in the forms, recom- mended when treating of them with reference to humoral asthma (see Asthma, § 89. 103.; and ft No. 41—46.). When expectoration is rendered difficult, and the cough suffocative, from the tenacity and consistence of the sputum, as is sometimes the case, attenuants and alteratives, as the fixed alkalies combined with ipecacuanha, &c., or as prescribed in the article on Asthma (§ 103. If No. 50, 51.), and exhibited with camphor or ammonia, will be found of much service. In nearly all states of bronchitis, camphor is a most valuable medicine. Its virtues have been singu- larly overlooked by the writers on this disease ; but, when combined with colchicum, or with anti- mony, nitrate of potash, ipecacuanha, &c\, and given in small doses, in the more inflammatory and febrile states of the disease ; or when prescribed in progressively larger quantities, with diuretics, the spirit, aether, nit., opium., &c., as the vascular excitement subsides, and febrile heat disappears ; and in large doses (from five to ten grains), with ammonia, ammoniacum, senega, opium, &c.,when exhaustion and difficulty of expectoration from deficient power are urgent; it is one of the most valuable remedies we possess in this, as well as in several other diseases. [The Polygala Senega is one of the most use- ful of the expectorant remedies in this affection ; and the formula recommended by Dr. Stokes is one of the best. Decoct. Polygalse. 1 v.: Syrup. Tolut. § ss.: Tinct. Op. Camph. Tinct. Scillffi aa. 3 ij.: Carb. Ammonias gr. xv. vel. xx. M. This preparation will generally diminish the expectora- tion without increasing the dyspnoea; rendering the pulse slow and fuller ; and the respiration freer.] 76. f. The inhalation of emollient and medi- cated vapours is occasionally of much benefit in the sthenic form of the disease, but chiefly in its first and second stages. The vapour arising from a decoction of marsh mallows, or from linseed tea, or from simple warm water, is the best suited to this state ; and should be employed from time to time, the temperature of the apartment being duly regulated through the treatment, and constantly preserved from about 66° of Fahr. to 75°. Dr Paris recommends, during the dry easterly winds of spring, (when the disease is so prevalent), the vapour of warm water to be diffused in the pa- tient’s apartment. In the early stage it may be of advantage. In the case of the son of an emi- nent medical writer, attended by Dr. Gordon, Mr. Annesley, and myself, this was tried in the state of the air alluded to, but with no benefit The case terminated fatally, from extension of the disease to the air-cells and substance of the lungs. When the expectoration becomes whitish, opaque, and thick, the vapour may be rendered somewhat more resolvent by adding a solution of camphor in vinegar, and extract of conium or hyoscyamus to the hot water, or to the emollient infusions now 313 mentioned; and in the asthenic variety, particu- larly when the difficulty of expectoration, and the fits of dyspnoea, are distressing, or when the excretion of the morbid matter is impeded or suppressed from want of power, the medicated vapours and gases recommended in the chronic state of the disease (§ 98.); and in humoral Asthma (§ 88.) may be tried. [Inhalation is not always safe in bronchitis ; es- pecially the inhalation of stimulating substances, such as gum ammonias, myrrh, and squill. Cases have occurred where this mode of treatment has given rise to acute inflammation, and even fatal pneumonia, especially where turpentine has been inhaled.] 77. g. There are various medicines which are occasionally useful, when exhibited in appropriate states and periods of the disease. Amongst these, narcotics and sedatives deserve an especial notice. Opium should not be exhibited alone, as long as febrile action is great; but, in combination with antimony, or ipecacuanha, and nitre, it is often a most valuable medicine. It is best given in small or moderate doses, in conjunction with camphor and expectorants, where vital power is reduced and expectoration difficult (§ 37.). In general, when the skin becomes cool, the bowels are well evacuated, and the air-tubes remain irritable, opium, or some other narcotic or anodyne, is in- dispensable. Opium, and others of this class of me- dicines, particularly when judiciously prescribed, are then of sendee, not only in diminishing the irri- tability of the system and of the air-passages, and in lessening the cough, the frequency or severity of which often aggravates the inflammatory irritation of, and determination to, the bronchial surface, but also in equalizing the circulation, in determining to the skin, and promoting perspiration. In the more phlogistic states of the disease, and at its com- mencement, colchicum or digitalis will be often of advantage, in diminishing vascular action, lo- cal determination, and morbid irritability. They ought, however, seldom to be used at the same time. In the more sthenic cases, digitalis is very beneficially associated with the preparations of antimony. When the sputum is thick and opaque, colchicum is generally less beneficial than at an earlier period, excepting in conjunc- tion with diuretics and camphor. When the skin has become cool, it is no longer of use. In the third variety, it is seldom indicated, unless at the commencement of the disease, or when combined with ammonia and camphor. Upon the whole, both colchicum and digitalis are less to be de- pended upon in acute bronchitis, than a judicious combination of antimonials with anodynes, &c. Hyoscyamus, conium, and the extracts of poppy and of lettuce, are also very generally serviceable in the different forms of bronchitis. But with them, likewise, the amount of advantage will entirely depend upon the manner in which they are pre- scribed. In the sthenic and febrile states of the disease, and at its commencement, they should be associated with antimonials, ipecacuanha, refrige- rants, demulcents, and emollients (F. 24. 208. 427. 554.); with diaphoretics (F. 394. 568. 809.) ; and with diuretics (F. 818. 865. 893.); or in other similar forms, of which there are several in the Appendix. When the disorder assumes an asthenic state, or when expectoration is diffi mlt, the cough distressing, and the skin cool, any of the sedatives particularised may be conjoined with either ammonia, camphor, or the fixed alkalies, 314 BRONCHI—Acute Inflammation of the—Treatment. or with other attenuants (F. 835.), and with ex- pectorants, &c. (F. 356. 555. 558. 811. 895.) ac- cording to circumstances. 78. h. When the acute form of the complaint seems to be about lapsing into the chronic, the combination of gentle tonics with emollients and diaphoretics is often of service, as was first pointed out by M. Broussais, who allowed also red wines, much diluted with water, in this state. The in- fusion or decoction of cinchona, or the infusion of uva ursi, may be thus prescribed:— No. 69. If Decocti vel Infusi Cinchonae 5 iijss.; Liq Ammon. Acet. 5jss-! Mucilag. Acaciae Jss.; Spirit Aither. Nit. 3 ijss.; Tinct. Camphor® Comp. | ss.; Extr. Conii gr. xx.; Syrupi Tolutani 5 ss. M. Capiat Cochleare unum amplum secunda vel tertia quaque hortl, vel Coch. ij. quintis vel sextis horis. 79. i. External measures ought not to be over- looked during the Course of the disease. In re- spect of local or general depletions, nothing need be added to what has been already stated. The former of these should always be preferred when doubts are entertained as to the propriety of taking any considerable quantity of blood ; and, in the sthenic form of the disease, may be resorted to at an advanced stage, particularly when the change in the expectoration, and other symp- toms f§ 35.), indicate a return or exacerbation of the inflammatory action. Blisters are not admissible in the early stages of sthenic bron- chitis. But, in the asthenic disease, or when in- flammatory action and febrile heat have been subdued by depletions, &c., blisters are of much service, and may be applied either between the shoulders or on the breast; and, in some severe cases, re-applied or kept discharging for some time. In young children, and in adult or aged persons, when the secretion of the bronchial surface is profuse, and the powers of life much exhausted, I have derived more permanent advantage from the use of the rubefacient liniments in the Appendix (F. 295,296. 311.), rubbed assiduously twice a day over the chest or back, than from blisters. When blisters are employed, much benefit will some- times arise from removing them as soon as slight redness of the skin is produced, and covering the part with a large warm bread and water poultice, which ought to be frequently renewed ; or by applying a succession of warm fomentations. In some extreme cases of this description, I have seen much advantage derived from applying over the epigastrium and lower part of the chest, a flannel wrung out of hot water, and immedi- ately afterwards soaked with the spir. terebinth., and allowing it to remain until severe burning heat of the skin is produced by it. If suffocation be threatened either by the profuseness of the secretion, by its difficult expectoration, or by ex- haustion of the vital energy ; and if we be, as we then unfortunately are, at a loss for any proba- ble means of success ; this will sometimes have a remarkable effect, and save the life of the patient, particularly when assisted by the internal use of camphor, ammonia, &c. At the time of my writing this, a case occurred, attended by Mr. Faxon and myself, where immediate relief and a speedy recovery followed this almost dernier re- sort. And I have often witnessed a similar re- sult, in other most dangerous cases of this descrip- tion, from the internal as well as the external use of this most valuable remedy, particularly at the Infirmary for Children, where I have for many years had recourse to it in cases of danger. 80. The tepid bath, or semicupium, will oftej be of service early in the disease; and in its course sponging the surface of the chest, or of the whole trunk, with warm water and vinegar, and afterwards with the warm nitro-muriatic acid lotion (F. 834.), particularly towards the decline of the disease, when we dread its lapsing into the chronic, and in the asthenic variety, will often prove of essential service. The common beverage of the patient during the treatment should be regulated according to the state of febrile action, and its compatibility with the treat- ment directed. Barley water, with any of the vegetable acids, tamarind water, or any of the formulae or drinks (vide Potus), contained in the Appendix, may be directed. 81. B. Of the complicated states.—a. Bron- chitis is not infrequently associated, particularly at its commencement, with sore throat; inflamma- tion existing not only in the fauces, but extend- ing to the pharynx, and through the larynx down the trachea and bronchi. This state of disorder sometimes obtains in scarlet fever, forming a com- plication of remarkable danger. I have also ob- served it, in a very severe form, affect six members of one family, and three of another, both living in the vicinity of the metropolis, in a low damp situ- ation, all of whom had long previously had scar- latina. In some of these cases the danger was great, and all were severe and of the asthenic type. Purgatives, first consisting of calomel and James’s powder, and subsequently combined with stimulants and tonics, were actively exhibited. De- mulcent linctuses (see Linctus, in the Appendix), or astringent, cooling, and antiseptic gargles; external revulsants, and rubefacients; the inter- nal exhibition of camphor, combined with anti- monials, hyoscyamus, diuretics, and afterwards with ammonia, mild attenuants, expectorants, and tonics ; the liquor ammonia acetatis, with inifus. cinchona, spirit, sether. nit., or spirit, am- mon. arom., &c. formed also the chief means of cure. All the cases terminated favourably. 82. b. When the disease is complicated with scarlet fever, the treatment will altogether de- pend upon the character of the prevailing epi- demic, and the circumstances of the case. Early in the complication, local depletions are some- times required; and afterwards, full doses of camphor or ammonia, or of both,—particularly if the eruption prematurely disappear, or present a dark tint, or if the anginous affection assume an ash-colour, or a dark red, or brownish hue,— are amongst the chief remedies to be depended on. I have met with severe cases in which the bronchial disease either preceded, or followed, the efflorescence and decline of the eruption in scarlet fever; and in the course of this association most violent cerebral symptoms have supervened ; thus forming a double complication. These cases, al- though extremely dangerous, are not necessarily fatal. Local depletion, sometimes to a very con- siderable extent, may be practised, chiefly by leeches applied over the sternum, behind the ears, or below the occiput, or by cupping on the nape of the neck; and calomel, antimony, revulsants, purgatives, camphor, ammonia, &c., according to the circumstances of the case, should be pre- scribed. Counter-irritation by rubefacient lini- ments is particularly required in complications of the disease with scarlatina or measles. For- mulae No. 299. and 300. may be used for this purpose, or the following:— ' BRONCHI—Complicated Inflammations of the—Treatment. No. 70. IJt Camphora; 3 j.; Pulv. Capsici 3ss.; Olei Macis 1H xxx.; Olei Oliva; 5jss.; Liq. Ammon. 3vj. Misce. Fiat Linimentum. 83. c. The appearance of the disease with measles, either previous to, in the course of, or subsequently to, the eruption; or even its acces- sion during convalescence, is a very frequent oc- currence. This association was very common in the winter and spring seasons of 1829, 1830, 1831, and 1832; during which epoch, blood-let- ting was not so generally indicated, nor so well borne, as in former years, the bronchial affection being more frequently of the asthenic stype. In general, however, local depletions are required early in the disease, and, in some cases, may be carried to a considerable extent; often much fur- ther than in its association with scarlatina. I have sometimes found it necessary to deplete locally in both these states of complication, at the very time when I judged it proper to exhibit camphor or ammonia in considerable doses. But in many instances, particularly during the years above specified, patients have recovered as rea- dily when no sanguineous depletion has been employed, as where it has. Bronchitis occurring either in the course of scarlatina, measles, or small pox, requires active counter-irritation and revulsion; and the means recommended for this purpose (§ 79.) to be decidedly enforced. The observations I have already made respecting the use of inhalation (§ 76.) also apply to such cases. When these exanthemata commence with bron- chial symptoms, emetics .ire then of decided ad- vantage. And, if they be accompanied with sore throat, purgatives ought to be given in de- cided doses, the bowels freely acted upon through- out, and enemata occasionally thrown up, parti- cularly F. 140. 149. 794. 84. d. When bronchitis occurs in the course of continued fevers, the same general principles of treatment are required, as have been specified in respect of scarlatina and measles. In all these states of complication, this disease should be viewed as a marked manifestation, in a particular organ, of the morbid state prevailing more or less throughout the frame; and it should be kept in recollection, that this affection always, in some measure, impedes the changes effected by respi- ration on the blood, thereby increasing the mor- bid condition of this fluid existing more or less in all severe cases of exanthematous fevers, and at least the disposition to it that obtains even in sim- ple continued fever. The extent to which deple- tion should be carried in this complication, or the propriety of employing it at all must depend upon the character of the fever, of the prevailing epi- demics, and the particular symptoms and circum- stances of the case. I have seen a strong, and regular-living man, with fever thus complicated, very dangerously depressed by a single small de- pletion. Purgatives are, however, better borne, particularly when combined with camphor on ammonia; and occasional large doses of calomel combined with camphor, and followed in a few hours by a cathartic draught, will be found of much service in promoting the functions of the liver, and enabling it to remove those elements from the blood, which so readily accumulate in it to a hurtful extent, when their elimination by the lungs is impeded. Much advantage will also arise from the use of blisters applied for a few hours, and often repeated; from the use of the 315 316 rubefacient liniments above specified; and from the inhalation of the vapour of warm water, with a solution of camphor in vinegar added to it. 85. d. The association of the sthenic form of bronchitis with tracheitis and laryngitis, either affection preceding the other, requires full deple- tion, general or local, or both ; large and repeated doses of calomel, with antimony; the tepid or warm bath, or semicupium ; internal and external revulsion, by cathartics, purgative enemata, &c.; emetics, particularly when the paroxysms of suf- focation and stridulous respiration are urgent; the inhalation of watery, emollient, and anodyne vapours; and a free use of diluents, emollients, &c., with the carbonate of soda, the sulphuret of potassium, small doses of the sulphuret of am- monia, or of the sulphuret of copper, in extreme cases, until nausea or vomiting is occasioned, &c. Blisters are seldom of much service in this state of disease, particularly whilst the symptoms of croup are present. They ought never to be ap- plied over the throat, as occasionally directed, and, in some cases, not without mischief; al- though recovery has taken place in others, not- withstanding the risk they occasioned of increas- ing the local irritation. 86. e. One of the most frequent complications presented to us in practice is that of bronchitis with hooping cough. In some cases, this com- plication commences with the usual symptoms of catarrh, on which those of bronchitis supervene ; the characteristic signs of hooping cough, par- ticularly the convulsive fits of coughing, with the inspiratory whoop, and vomitings, not appearing for some days subsequently. In other cases—and those, perhaps the most numerous,—the inflam- matory affection has not appeared until after the invasion of pertussis. When thus associated, bronchitis may be either sthenic or asthenic; the one or the other being more generally prevalent in some seasons than in others. During the years specified above (§ 83.), the asthenic state was most common ; and I have seen several cases in which sanguineous depletion had been inju- diciously practised, particularly as respects quan- tity. Cerebral symptoms are apt to occur during this complication, and also infiltration or hepa- tisation of a part of the substance of the lungs. These unfavourable terminations should be anti- cipated and prevented by small local depletions, —by leeches applied behind the ears; by the ex- hibition of camphor combined with ipecacuanha or antimonials, and narcotics, particularly conium or hyoscyamus; by diaphoretics with diuretics; ' and more especially by the use of the liniments J and revulsants already recommended (§ 79.). (See Hooping Cough.) 87. /. The simultaneous occurrence of inflam- matory action in both the digestive and respiratory mucous surfaces is not infrequent, particularly in children; and means calculated to benefit the j one, generally aggravates the other, or risks the ! accession of cerebral disease. I have found small local depletions, followed by the pulv. ipe- cacuanhoe comp., combined with small doses of calomel, or hydrarg. cum creta and camphor; the warm bath and frictions, with the stimulating liniments already specified (§ 79.) ; the applica- tion of blisters for a few hours only, and often re-i peated ; the liq. ammonifB acet., with spirit, aether, nit., camphor mixture, diuretics, &c., constitute the principal means of cure. 88. g. The association of hepatic disorder with BRONCHI—Complicated Inflammamion of thf.—Treatment. bronchitis is not rare. But the affection of the biliary organs does not always precede the bron- chial disease: it often occurs in its progress ; an increased, as well as a morbid, secretion of bile supervening, probably in consequence of the vica- rious increase of function of the liver, and its irritation by, and elimination of, the morbid ele- ments accumulated in the blood owing to the impeded function of the lungs. This complica- tion requires the use of mercurial purges com- bined with camphor and antimony, particularly James’s or kermes powder (F. 637.); external irritants and revulsants, cathartic enemata (F. 151.), &c. A similar treatment is indicated when the disease is connected with the translation of erysipelas, gout, or rheumatism. 89. h. If the inflammation extend to the sub- stance of the lungs or pleura, the antiphlogistic treatment should be rigorously enforced: the so- lution of the potassio-tartrate of antimony ought to be given in frequent doses, and carried as far as circumstances will permit; internal and ex- ternal revulsants resorted to at the same time ; and diaphoretics and diuretics suited to individual cases prescribed. In some instances, either col- chicum or digitalis, or both, may be substituted for the antimony; but they answer better, par- ticularly the digitalis, after this medicine has pre- viously been used. If we have reason to suppose that effusion of serum has taken place in the thoracic cavities, diuretics, and, amongst others, digitalis, should be employed; recollecting, how- ever, that the accumulative and sinking effects of either digitalis or colchicum sometimes appear very rapidly, and in an alarming degree, when they are given either at the same time or after the exhibition of the potassio-tartrate of anti- mony. Disease of the brain or its membranes supervening in the course of bronchitis has been considered in the article Brain (§ 186.). 90. The sub-acute form of bronchitis requires in all respects the same treatment as the acute uncomplicated disease, but not carried so far ; the activity of the means should have due relation to the acuteness of the attack, and the effects they produce. [Dr. Stokes lays down the following points of doctrine, as bearing most directly on the treat- ment of pulmonary disease:— First. That in some cases an antiphlogistic treatment may cut short the disease in its first stage ; but that, in most instances, particularly in the affections of mucous membranes, its effect is to bring on the occurrence of the second stage. Second. That the principal circumstance on which the success of stimulants depends, is their having been preceded by antiphlogistic treatment. Third. That in many cases disease will con- tinue for a great length of time, and yet (as shown by the result of treatment) be in its first stage. Although chronic as to its period of du- ration, it is still acute when tested by the effect of treatment. Fourth. That this result is most frequently seen under the following circumstances:— 1. Cases of local disease, with but little injury to the general health. 2. Diseases of tissues, where there is but little relief by secretion. 3. Diseases of organs which have been neg- lected, or exasperated by too early stimulation. Fifth. That in many cases, where the disease has been neglected, or exasperated, it will be ne- BRONCHI—Chronic Inflammation of the—Treatment. 317 cessary to precede all stimulants by an anti- phlogistic treatment, either general or local.— Stokes on the Chest, Am. ed. p. 119.] 91. 2d. Of Chronic Bronchitis.—M. Brous- sais has very justly stated the indications of cure in chronic bronchitis to be, 1st, to diminish the general excitability, and to keep the circulation quiet; 2d, to solicit the excitement and the fluids to other organs, particularly towards the skin; and, to these I would add a 3d, namely, to re- store the healthy tone and functions of the bron- chial surface, by means which seem to have this effect either directly or indirectly. It is obvious, however, that the accomplishment of the first and second intentions have an indirect influence in bringing about the third. 92. a. General blood-letting is inadmissible in this state of the disease ; and even local bleedings should in many cases be employed with caution. Cupping, however, to a moderate extent, is very frequently required ; and it is evidently more ad- vantageous to repeat the operation to a small extent, than to abstract a large quantity at once. When the disease has existed long, and is at- tended with a copious discharge, much general debility, and absence of pain upon full inspiration, even local depletion cannot be ventured on. Next in importance to depletion is counter-irritation ; and for this purpose several means are presented to us. When there is a tendency to acute action, or when the cough is at all painful, and the spu- tum puriform, either the tartarised antimonial ointment, or a large issue or seton in the side, is preferable : but when there is very marked relax- ation of the bronchial mucous surfaces, blisters, and rubefacients, or a succession of them, seem more appropriate. I have, however, found, in a number of cases, the liniments, No. 296, 297. 311. in the Appendix, productive of much greater advantage, and more generally applicable, than either blisters or the ointments. They may be employed once or twice daily. The vapour arising from them, and diffusing itself around, has also a direct and beneficial effect, by being inhaled, upon the diseased mucous membrane. M. Broussais is very favourable to the use of setons and issues ; and I have seen several instances of marked benefit from them, particularly in the obstinate state of the disease which simulates tubercular phthisis. He also recommends warm cataplasms to the chest, made rubefacient by the addition of mustard. I have seen advantage produced by warm bread and water poultices applied over blistered surfaces, and the seats of issues formed by the mezereon bark, and by the same kind of poultices, to each of which one or two table- spoonsful of the nitro-hydrochloric lotion (F. 834.) had been added. But it is chiefly early in the chronic disease, or when it has recently passed into this state from the acute, that issues and se- tons prove successful. They exhaust the ener- gies of the system too much to be of service in the latter stages, or when the discharge from the lungs is profuse, and the vital energies much de- pressed. 93. b. Expectorants have been much em- ployed in this state of disease ; and though more appropriate in it, than in the acute, they are often hurtful from their too exciting operation on the vessels of the bronchial surface. This is especi- ally the case with squills, ammoniacum, and se- nega, which ought to be used with much caution, and never whilst the sputum is purulent, and pain or soreness complained of in the chest, with fever, heat of skin, &,c. The best expectorants are those which are also astringent, or at least not very heating: amongst these, the sulphate oi oxide of zinc, with small doses of myrrh or gal- banum, and extract of conium; or small doses of sulphate of quinine, or of the sulphate of iron, with ipecacuanha and opium ; or the sulphuret of po- tassium, and the balsamum sulphuris (F. 21, 22.), are the most eligible, when the state of the ex- pectoration, of the skin, and pulse, indicates the propriety of having recourse to tonic expectorants. Opium has been too much reprobated in cases of this description, as well as in acute bronchitis, owing to the dogma that it suppresses expectora- tion. I believe, however, that, when judiciously combined, particularly with ipecacuanha, with the chloride of calcium, or either of the sulphates of potash, of alumina, or of zinc; or with the nitrate of potash ; or with camphor, with kermes mineral, or the compound powder of antimony, according to the circumstances of the case, it is a valuable medecine ; and that the diminution of the expectoration produced by it, and which has been unacountably dreaded, is, when it occurs, a consequence of its changing the morbid state of the vessels forming the excreted matter. If it be the object—as necessarily follows from the doc- trine of some writers—to preserve a copious and free expectoration in this disease, how can it ever be cured ? Frequently have I seen this end pur- sued, as if it constituted all that was required, and squills, ammoniacum, senega, &c. given accord- ingly ; and the «more abundant and easy the ex- pectoration thereby produced, the more rapidly did the powers of life give way, or complete hec- tic, with all its attendants, manifest itself. The following have proved serviceable when the pulse was soft, and not remarkably frequent; the skin cool and moist; the sputum very abundant, and consisting chiefly of mucus ; and the weakness and emaciation considerable :— No. 71. Pc Pulv. Ipecacuanha: gr. j.; Camphors: rasa? gr. ss.—j.; Extr. Conii gr. iv.—vj.; Mucil. Acacia; q. s. M. Fiant Pil. ij. ter die capiendo:. No. 72. R Zinci Sulphatis gr. vj.; Mass® Pilul. Gal- ban. Co. 3j.; Extr. Conii 3 ss.: Syrupi q. s. M. Fiant Pilul® xij., quarum capiat unam tertiis horis. No. 73. R Pulv. Ipecacuan. Comp. gr. xxv.; Quinime Sulphatis gr. vj.; Pulv. Acaci® 3j.; Extr. Lactuc® 3j.; Syrupi Papaveris q. s. M. Fiant Pilul® xviij., quarum capiat binas ter quotidie. No. 74. R Quinin® Sulphatis gr. vj.; Pulv. Ipeca- cuanha gr. iv.; Camphor® rasa: gr. iv.; Opii Puri gr. vj.; Pulv. Itad. Glycyrrh. (vel Extr.) 3 ss.; Mucilag. Acaci® q. s. Misce bene, et fiant Pilui® xx., quarum capiat duas ter quaterve quotidie. No. 75. R Balsami Sulphuris 3 ss.; Pulv. Ipecac, gr. vj.; Extr. Conii 3ij.; Pulv. et Mucilag. Acaci® q. s. M. Fiant, secundum artem, Pil. xx., quarum capiat binas quarta quaque hora. No. 76. R Solut. Chloridi Calcii Til xx.—xxxv.; Mist. Camphors 3 x.; Tinct. Opii Comp. (F. 729.) Til x.—xx.: (vel Tinct. Camphor® Comp. 3 jss.) M. Fiat Haustus ter die capiendus. 94. c. In cases of this description, any of the formula; given under the head Balsams, in the Appendix, may be employed. Dr. Armstrong strongly recommended the balsam of copaiva in chronic bronchitis; but it is seldom beneficial, and is certainly inferior to the other balsams and terebinthinates in this affection. (F. 486, 487 538. 571.). In the more advanced stages of chronic bronchitis, particularly when colliquative sweats or diarrhoea occur, the most essential ben- efit has been derived from the following mixture ; but even where the bowels are regular, I have found it by no means productive of costiveness BRONCHI—Chronic Inflammation of the—Treatment. 318 At the time that I was giving this medicine to the third patient on whom I had tried it, a case showing the success of a nearly similar treatment, was published by Dr. Hastings (Midland Med. Repos, vol. ii. p. 376.),—a coincidence fully evin- cing the propriety of the practice. No. 77. Mist. Cret® ?vjss.; Vini Ipecac. 3 jss.; Tinct. Opii 3j.; (vel Tinct. Camphor® Comp. 3 vj.); Syrupi Tolutani 3 iij. M. Capiat Cochlearia duo larga ter quaterve in die. The cretaceous mixture will often be of service when used alone, or with a little of the chloride of calcium, or with the addition of mucilage, or of hyoscyamus, or conium, or extr. lactucee, or the extr. papaveris, according to circumstances. In this state of the disease, also, I have seen sulphur given with advantage in mucilaginous electuaries. Dr. L. Kerckhoffs states, that he has adminis- tered it with success, in conjunction with the powder of the white willow bark. M. Broussais relies chiefly upon mucilages and demulcents, combined with ipecacuanha and opium, and cer- tainly with great justice. (See F. 284, et seq.). The extr. lactucae, as recommended by Dr. Dun- can, may occasionally be substituted for the opium. The decoctions of Iceland moss, and the infusions of conium, or marrubium, of the uva ursi, or of the melissa (F. 230. 237, 238. 245. 267.), with mucilages, anodynes, and ipecacuanha, are also very serviceable. I have given the pre- parations of iodine in a few cases, in small doses; and in some instances, especially when there was little or no febrile action, nor much emaciation, benefit appeared to be derived from them. 95. d. When the disease is attended with dys- pnoea, and profuse or difficult expectoration, emetics are of great, although often of temporary ad- vantage, particularly in aged persons. Ipecacu- anha, or sulphate of zinc, with the addition of diffusive stimulants, (F. 402.), are the most appro- priate in the majority of cases.. After their ope- ration, and if the strength be not very much re- duced, the digitalis or colchicum may be pre- scribed in conjunction with diuretics and gentle astringents (F. 203.). These active medicines are chiefly suited to the more febrile states of the dis- ease, or when soreness or slight pain of chest are complained of, with a puriform expectoration; and are best combined with small doses of blue pill, camphor, and opium,—with pectoral infu- sions and mixtures (see App. F. 244. 426. 497.) with demulcents (F. 389.), and with diuretics (F. 194, 195. 236, 237.). Dr. Hastings recommends a combination of digitalis and colchicum ; but I have seen more harm than benefit occasioned by it in some cases of chronic bronchitis,—a result which might, d priori, be expected from the as- sociated operation of two most depressing medi- cines, given in a state of disease characterised by irritative, rather than by acute, vascular action. I have found them most beneficial when exhibited singly with diuretics, or diaphoretics, in the chronic form of bronchitis consecutive of exanthe- matous fevers (§ 54.) ; sometimes resorting also to the warm bath, followed by frictions of the sur- face with the liniments F. 297. or 311. The com- bination of colchicum and digitalis, in small or moderate doses, has proved more serviceable, in my practice, in tubercular disease of the lungs, or when bronchitis has been complicated with tubercles, or with pneumonia. In cases where the propriety of giving these medicines is doubt- ful, a combination of them with the alkalies, or their carbonates, and with tonic infusions or de- coctions, or F. 515—517., or the following, may be prescribed:— No. 78. ft Pulv. Colchici (vel Pulv. Digitalis) gr. j.—ij.; Mass® Pilul. Hydrarg. gr. ij.; Mass® Pilul. Galbani Comp. gr. v.; Extr. Opii gr. ss.; Syrupi q. s. M. Fiant Pil. ij. bis terve quotidie sumend®. No. 79. ijt Infusi Uv® Ursi 3 xij.; Acidi Sulph. Dil ill xx.; Tinct. Digitalis 1TI x.—xv.; Tinci. Camphor® Comp. 3 j.; Syrupi Papaveris 3 ss. M. Fiat Haustus, bis terve in die sumend us. No. 80. Ijt Sod® Carbon, (vel. Liq. Potass®) 3 j.; In- fusi Calumb® (vel Decocti Cinchon®) 5 vj.; Tinct. Se- min. Colchici 3 j.—- 3 jss.; Tinct. Digitalis HI xxx. M. Capiat Coch. ij. larga ter in die. No. 81. II. Mist. Diosm® Crenat® (F. 39G.) ? vss. ; Tinct. Digitalis Til xxxv. (vel Tinct. Semin. Colchici 3j. — 3 ij.) ; Extr. Conii gr. xxvj. (vel Extr. Lactuc® 3 ss.); Syrupi Tolutani ? ss. M. Fiat Mist., cujus sumat Coch. ij. larga ter quaterve in die. No. 82. ij Pulv. Acaci® 3 ij.; Mist. Amygdal. Dulc. et Mist. Camphor® aa § iijss.; Acidi Hydrocyanici fltxj.— xviij.; Spir. /Ether. Sulph. Comp. 3 ij.—iij.; Oxymellis Scill® 5 ss. M. Coch. ij. vel iij. larga ter in die. 96. Hydrocyanic acid is often of much service in the chronic forms of bronchitis, especially in their complications with disorder of the digestive organs, and may be exhibited with demulcents, gentle tonics, astringents, or expectorants, or as prescribed in the Appendix (F. 344. 858.). When the disease is associated with derangement of the hepatic functions, or even of the stomach and bowels, it will be necessary to give small doses of blue pill, or of the hydrarg. cum creta, with de- obstruents and gentle tonics ; and, on some oc- casions, full doses of calomel from time to time, either alone, or in suitable forms of combination, followed by a purgative. No. 83. Ijk Pilul. Hydrarg. gr. vj. (vel Hydr. cum Creta gr. xviij.) ; Pulv. Ipecacuanh® gr. viij.; Extr. Sarzffi et Ext. Taraxaci aa 3 j.; Gum. Assafcetid® et Saponis Castil. aa 3 j. M. Fiant Pilul® xlviij., quarum capiat binas, ter quaterve in die. No. 84. ft Hydrarg. Chloridi gr. vj.; Kermes Mineral, gr. xij.; Camphor® ras® gr. xij.; Extr. Taraxaci 3 ijss.; Extr. Humuli 3 jss. M. Divide in Pilulas lxiv., quarum capiat ij. vel iij. ter quaterve in die. 97. The treatment which has been already recommended for Humoral Asthma (see particu- larly § 100, et omn. seq.), and the tonics and as- tringents, especially the sulphates of zinc, iron, or quinine, already noticed (§ 93.), are applicable, with but little variation, to the more chronic and humoral states of the disease, particularly in per- sons advanced in life, and in children, when it has assumed a chronic form after hooping-cough and the exanthemata. I have also occasionally seen benefit derived, in these states of chronic bronchitis, from the chlorate of potash, given to adults, in from two to six grains, three or four times a day. This medicine was often prescribed by myself and one of my colleagues, at the In- firmary for Children, during the years 1826—1828, and subsequently, in the more chronic forms of bronchitis, and in various disorders of debility: in which latter it was generally beneficial: but little advantage was frequently derived from it in this disease, unless in those forms of it now men- tioned, where it was often of great use, particu- larly when the morbid action seemed connected with deficient tone of the bronchial vessels, and of the system generally. Mr. Murray, in a re- cent publication, states, that he has employed it successfully in consumption,—a name which has usually comprised most of the cases of this form of bronchitis. 98. e. Inhalations of medicated or tar vapours have been recommened by Crichton, Pagenste- CHER, HuFELAND, FoRBES, HASTINGS, ELLIOTSON, Gannal, and others noticed in the article on Asthma, and been disapproved of by some. I be- lieve that they have frequently been used in too concentrated a state ; or too much of the vapour has been diffused in the respired air, occasioning irritation of the bronchial membrane, instead of a gently tonic and healing effect. Whenever any of the vapours advised in this disease produce an increase of the cough, either its use should be left off, or its strength greatly reduced. The man- ner of having recourse to such vapours, as well as the choice of substances emitting them, have not, in my opinion, always been judicious. The tar vapour is occasionally of service, chiefly from the quantity of turpentine it contains ; while the acrid empyreumatic fumes which it also emits, counteract whatever good effect the former con- stituent might produce. Would it not, therefore, be preferable to try the effects of the substance from which the advantage is obviously derived ? I have done so in a few cases of this disease, and seen marked benefit result from it: and there- fore recommend it to the notice of other prac- titioners. In former times, medication by fumiga- tions and vapours was much resorted to ; and it is probable, that the early use of incense and vari- ous balsamic and aromatic fumes in religious rites had some relation to their prophylactic effect against disease, or even to their curative influence, the more especially, as the priests of antiquity also exercised the healing art. In several of the pro- ductions attributed to Hippocrates, the inhalation of vapours and fumes of various resinous and balsamic substances is recommended; and a num- ber of writers in the 16th, 17th, and 18th centu- ries, have advised a nearly similar method, and employed camphor, benzoin, amber, frankin- cense, myrrh, storax, assafoetida, sulphur, cloves, the balsams, &c. for this purpose. This practice was employed by Benedict (see his Theatrum Tabidorum) in consumptive diseases : and Boer- haave gives several formula in his Materia Medi- ca, for fumigations with the above substances. Mead, in his Monita et Precepta, offers several judicious remarks on this subject. He observes —“ that fumigation with balsamics, &c. is of vast service in some cases: which is to be done by throwing the ingredients on red coals, and receiv- ing the fumes through a proper tube directed to the wind-pipe.” After noticing the undeserved neglect of this practice, and the propriety of thus applying medicinal substances directly to the seat of disease, he states, that the smoke of the balsam of Tolu conveyed into the lungs, or the smoking this substance like tobacco, is of signal service in diseases of this organ (p. 58.). It appears from the writings of Fracastori that the fumes of cir.naba• vrere much employed by inhalation in the treating:.t of the constitutional forms of syphilis, at an early period of the history of that disease, when it assumed a pestilential form. 99. Notwithstanding the unsuccessful attempts of Beddoes to revive the practice, by employing the elementary and permanently elastic gases, but according to views too exclusively chemical, the practice of inhalation has long been neg- lected or undeservedly fallen into the hands of empirics. Very recently, however, it has been brought again into notice by M. Gannal, Mr. Murray, and Sir C. Scudamore ; and chlorine eras, and fumes of iodine, and watery vapour holding in solution various narcotics, have been BRONCHI—Chronic Inflammation of the—'Treatment. recommended to be inhaled. I have tried those substances in a few cases of chronic bronchitis; but in not more than two or three cases of tuber- cular phthisis. The chlorine was used in so di- luted a state as not to excite irritation or cough. The sulphuret of iodine, and the liquor potassii iodidi concentratus (F. 328.) were also employed ; one or two drachms of the latter being added to about a pint of water, at the temperature of 130°, and the fumes inhaled for ten or twelve minutes, twice or thrice daily. The tinctures or extracts of hyoscyamus and conium, with camphor, added to water at about the above temperature, were likewise made trial of; and, although the cases have been few in which these substances have been thus used by me, yet sufficient evidence of advantage has been furnished to warrant the re- commendation of them in this state of the disease. 100. Inhalations also of the fumes of the bal- sams, of the terebinthinates, of the odoriferous resins, &c. are evidently, from what I have seen of their effects, of much service in the chronic forms of bronchitis: and I believe that they have fallen into disuse, from having been inhaled as they arise in a column or current from the sub- stances yielding them, and before they have been sufficiently diffused in the air. When thus em- ployed, they not only occasion too great excite- ment of the bronchial surface, but also intercept an equal portion of respirable air, and thereby interfere with the already sufficiently impeded function of respiration. M. Nysten has shown (Diet, des Scien. Med. t. xvii. p. 143.) that ain- moniacal and other stimulating fumes, when in- haled into the lungs in too concentrated a state, produce most acute inflammation of the air-tubes, generally terminating in death ; and has referred to a case in which he observed this result from an incautious trial of this practice. 1 conceive, therefore, that the vapours emitted by the more fluid balsams, terebinthinates, the resins, camphor, vinegar, &c., and from chlorine and the pre- parations of iodine, should be more diluted by admixture with the atmosphere, previously to being inhaled, than they usually are. According to this view, I have directed them to be diffused in tne air of the patient’s apartment, regulating the quantity of the fumes, the continuance of the process, and the frequency of its repetition, by the effects produced on the cough, on the quan- tity and state of the sputa, and on the respiration. The objects had in view have been gradually to diminish the quantity of the sputum, by changing the action of the vessels secreting it; without exciting cough, or increasing the tightness of the chest, or otherwise disordering respiration. From this it will appear, that the prolonged respira- tion of air containing a weak dose of medicated fumes or vapours, is to be preferred to a short inhalation of them in their more concentrated states. The want of success which Dr. Has- tings and others have experienced, evidently has been partly owing to the mode of adminis- tering them, and partly to having prescribed them inappropriately. When the patient com- plains of acute pain in any part of the chest, as in some of Dr. Hasting’s cases, they are as likely to be mischievous as beneficial. Where benefit has been obtained, it will be found that it was when the fumes of the more stimulating of those substances were diffused, in moderate quan- tity, in the air of the patient’s apartments; or when he passed, at several periods daily, some 319 time in a room moderately charged with the vapour or fumes of the substance or substances selected for use. (See the remarks on Inhalation in Humoral Asthma. § 88., for an account of va- rious medicines that may be employed in this manner.) 101. f. Sponging the surface of the chest, and trunk of the body, first with tepid and afterwards with cold lotions, has often been practised by me with advantage in several states of this disease. When the expectoration has been profuse, the debility great, and little or no febrile heat pre- sent, I have preferred for this purpose the nitro- hydrochloric acid lotion (F. 834.), in a warm or tepid state, night or morning, or both. When the disease is more active, the habit of body being, nevertheless, relaxed and debilitated, a solution of common salt in water, or the lotion, Bs 54., seems preferable; and the directions given re- specting this treatment in the article Asthma (§116, 117.) should be strictly followed. I have observed much benefit derived from the appli- cation, for a considerable time, of one of the plasters, F. 111. 115. 118. 119., between the shoulders; whilst cold sponging the anterior of the trunk with the lotions referred to has also been directed. 102. g. The Complications of chronic bronchitis require generally no particular modification of treatment from that now detailed: indeed, some of them have been already noticed. I may, how- ever, add, that, in the chronic asthenic states of the disease frequently met with in aged persons, and often occurring in children after exanthema- tous diseases, hooping-cough, and bowel com- plaints, the flowers of sulphur, the preparations of zi«c,thetrisnitrateof bismuth, and the chlorates of potash and of lime, have severally been of great service, especially when combined with narcotics —with opium in the aged, and conium in the young,—their constipating effects upon the bowels being duly obviated by the occasional exhibition of purgatives. The chronic bronchitis compli- cated with, or consecutive of, hooping-cough, the characteristic cough of the latter either still con- tinuing, or having altogether disappeared, is fre- quently attended with dilatation of the bronchi. In these cases, balsams, inhalation, the use of tonics, particularly the sulphate of iron, quinine, the linaments already noticed, frequent doses of sulphur, or moderate doses of the chlorate of pot- ash, are required. If the child be not very young, either of these latter may be combined with belladonna, or with conium, and given in honey or syrup of squills; or with simple syrup, sugar, powdered liquorice-root, or with the com- pound tragacanth powder. When the disease is associated with chronic irritation of the mucous surface of the bowels, the chlorate of lime will be of much service, and will soon restrain the latter affection ; the use of the liniments already recom- mended (F. 296. 311.), in addition, generally con- tributing to cure the bronchial disease. Either of these linaments has often been sufficient of itself to remove all disorder, both in the consecutive states, and in the different complications noticed at this place ; and, when bronchitis seems to have a tendency to terminate, or has actually termi- nated, in effusion, they have powerfully assisted the treatment. When, however, dropsies super- vene, in addition to them, colchicum or digitalis, with astringent tonics ; squills, with blue pill, ta- raxacum, or extract of sarsaparilla; the preoara- 320 BRONCHI—Chronic Inflammation of tiie—Treatment. tions of iodine, alone or with narcotics; bi-tar trate of potash, with the bi-borate of soda, parti- cularly this last; and various other diuretic and deobstruent medicines in different forms of com- bination—of which numerous examples are given in the Appendix—and the general plan of treat- ment recommended in the article Dropsy ; should be employed. 103. C. The regimenal treatment of bronchitis requires strict attention.—a. In the sthenic acute disease it should be strictly antiphlogistic ; and, at the commencement of convalescence, a farina- ceous diet adopted, until out-of-door exercise may be taken, or shortly before. In the asthenic states of acute bronchitis, this regimen is chiefly appli- cable to the commencement of the disease: sub- sequently, nourishment in small quantities, suited, in kind and frequency of partaking of it, to the state of the symptoms, the powers of the digestive organs, and feelings of the patient, should be permitted; and even animal food of a digestible nature, in moderate quantity, may in some cases, particularly in the aged, be permitted once a day. The decoction of Iceland moss, jellies, mucilagi- nous and emollient soups ; shell-fish ; the different kinds of white fish, dressed either with sweet oil or the oil obtained by boiling their fresh livers: the lighter kinds of animal food; and, in the case of infants, attention to the milk of the mother, or a healthy wet-nurse ; are all occasionally of ser- vice during early convalescence from the acute forms of bronchitis, and in the progress of the more febrile states of the chronic disea'se. In the more asthenic cases of this latter, or when the expec- toration is profuse, the skin cool and moist, and the habit of body lymphatic, relaxed, or wasted, ani- mal food, especially fresh beef or mutton, under- done, and in moderate quantity; new-laid raw eggs; or a due proportion of digestible and sti- mulating food ; will be found most serviceable. In nearly all the chronic states of the disease, particularly in their advanced stages, a light nu- tritious diet is necessary. 104. b. The patient’s beverage should receive particular attention. Lemonade, imperial, barley- water, and the cooling and aperient drinks pre- scribed in the Appendix (F. 588—595. 916.), should be employed in the sthenic form of the acute disease. In the asthenic and chronic states, the red Bourdeaux wines, or the wines of Bur- gundy—the former generally reduced by one- third or one-half water; or beer or ale, also reduced, to which a little of the liquor potass®, or of Brandish’s alkaline solution, has been added, may also be tried at meals ; and either of these, or of the more cooling beverages, adopted, that may be found to agree best with the patient. If the disease evince a disposition to terminate in dropsy, the imperial drink, with the addition of a little bi-borate of soda, or F. 590, 591., will be most serviceable. In the advanced period of chronic, or during convalescence from acute, bron- chitis, the sulphureous mineral waters will often be beneficial. Those of Harrowgate, Leamington, or Moffat, may be tried ; or of Enghein, Bonnes, Bareges, or Cauterets (Roche) ; or the artificial waters of Ems or Carlsbad. 105. c. Few diseases are more benefited than chronic bronchitis by change of air. A resi- dence on the southern coast, particularly at Tor- quay, and in various other parts of Devonshire, during the winter and spring months, guarding against vicissitudes of climate,—which, how- ever, is milder and less variable in this part of the island than any where else ; wearing flannel next the skin, especially during winter and spring; gentle exercise on horseback, or the use of the swing ; and constant attention to the state of the bowels ; are severally of great importance. During the progress of convalescence, as well as in the earlier stages of disease, particularly if the secre- tion from the bronchi continue, it will be neces- sary to resort occasionally to an emetic; and in a day or two subsequently, notwithstanding the bowels may be freely open, to an active cathartic. In these cases, the addition of a vegetable bitter or tonic to a purgative medicine,—as the sul- phate of quinine to aloes, or the infusion or ex- tract of gentian to senna,—will have a decidedly cathartic operation, without lowering the energies of the frame. There are few diseases more bene- fited, either in their progress or decline, than those now discussed, by active purging; but it will often be requisite to combine the purgatives with stimulants or tonics, m order that an active or continued operation on the bowels may not ex- haust the patient. During convalescence, the free use of purgatives requires a liberal and in- vigorating diet. 106. V. Dilatation of the Bronchi.—i. The anatomical characters and physical signs of this change of the bronchi have been already de- scribed (§ 19.). It is almost entirely a conse- quence of, or an attendant upon, the more chronic cases of bronchitis, or of hooping-cough compli- cated with bronchitis. The expectoration, be- sides being copious and puriform, is often foetid, —a diagnostic symptom of this alteration, with- out which, M. Louis, and other pathologists, who have devoted much attention to pulmonary diseases, have sometimes failed of distinguishing it from phthisis. 107. ii. The Treatment of this alteration is nearly the same as that which has been recom- mended in the more chronic states of bronchitis. The means which are especially indicated consist of the inhalation of balsamic and terebinthinate fumes; of those of crbasote, chlorine, iodine, &c. (§ 99,100,) ; the internal use of balsams, tonics, and bitters, particularly the sulphates of quinine, or of zinc, or iron; and other preparations of cinchona or steel; with the use of the liniments already noticed (§ 102.); or the nitro-hydrochloric acid lotion on the chest. The chlorate of potash, or of lime, seems indicated in this form of the disease. An open state of the bowels, an occasional ca- thartic, nutritious diet, and change of air, are also evidently required. In other respects, the treat- ment already detailed (§ 101. et. seq.) may be fol- lowed ; or modified according to the peculiarities of the case. 108. VI. Ulceration of the Bronchi (see § 7, 8.) is another alteration which is produced by, or is attendant on the advanced stages of, chronic bronchitis; most frequently, however, when complicated with tubercular phthisis. It is not infrequently met with, particularly after bronchitis occasioned by the mechanical irritation of mineral, vegetable, or animal molecules. The existence of ulceration, when seated in the bronchi, is not indicated by any sign in addition to those which accompany the most chronic states of bron- chitis, or tubercular disease, when it arises from, or is complicated with, this change. When affect- ing the Larynx or Trachea (see these articles), it may frequently be suspected, or occasionally BRONCHIAL FLUX—Diagnosis. prognosticated. In a case which occurred in the trachea, a prognosis to this effect was given by me long before death. 109. The Treatment of this lesion, even could its existence be ascertained during life, can- not be different from that required in some other states of chronic bronchitis. That ulceration may take place in the bronchi, and heal, as evinced by the appearance of cicatrices, has been ascertained by M. Laennec, and other patholo- gists. In addition to the means of cure already described, the establishment of local drains of the most active kind is obviously required. Blisters and issues applied to a distant part have not been found of use by M. Laennec.' He pre- fers the repeated application of small moxas as near the seat of disease as possible, and the pre- servation of absolute rest and silence. The in- halation of emollient, anodyne and balsamic va- pours and fumes may likewise be tried ; and, if the disease be devoid of marked febrile excite- ment, the expectoration abundant, and the powers of life consequently reduced, the treatment ad- vised for dilatation of the bronchi (§ 19.) may be employed in all its parts. (For the treatment of other organic changes of the air-passages, see arts. Croup, Larynx, Lungs—Hemorrhage from, and Trachea.) VII. Bronchial Flux.—Bronchorrhcea (from Bp6yx°s and /5scj.) — Syn. Bronchorrhee (Roche) ; Catarrhe Pituiteux (Laennec); Mucous Flux. Classif. I. Class, III. Order {Author). 110. Defin. A flux of watery mucus, or phlegm, from the chest, with more or less cough, but without fever; frequently occasioning ex- haustion. 111. This affection varies considerably. It is often a variety of chronic bronchitis ; being con- secutive of it in persons advanced in life, or those of a relaxed and phlegmatic or pituistous habit of body. In other cases it appears from the com- mencement, or consecutively of slight catarrh, as intermediate between chronic bronchitis and hu- moral asthma. This appellation, may, upon the whole, therefore, be viewed as applicable to those cases which are attended with a more abundant fluid, and transparent expectoration, than is ob- served in chronic bronchitis, and are devoid of fever and all other signs of inflammatory action, whilst they are equally without the severe dyspnoea, the paroxsymsof suffocation and cough, and the intermissions, characterising humid asthma. 112. i. Bronchorrhcea proceeds generally from similar causes to those which produce common catarrh, or bronchitis, even although it be not consecutive of some one of the forms of bronchial inflammation. It is very frequently, either at its commencement, or recurrence, connected with cold and moist states of the atmosphere, or occa- sioned by exposure to cold in some one or other of its forms. When it occurs as a sequela of bronchitis, it may be viewed as arising from lost tone of the vessels and of the bronchial surface, the flux or determination to this part still con- tinuing, from peculiarity of habit or some other cause, after all inflammatory and febrile symp- toms have been removed. Thus, it is very fre- quent in aged persons of relaxed fibres, who have experienced repeated attacks of pulmonary catarrh. 113. ii. Diagnostic Symptoms.—Bronchorrhcea 321 may be distinguished from chronic bronchitis, tubercular phthisis, and humoral asthma, by the following characters:—The quantity of fluid ex- pectorated is very great; being in some cases, as much as four or five pounds in the twenty-four hours. The sputum is colourless, ropy, transpa- rent, slightly frothy on the surface, and resem- bling the white of egg mixed with water. It is without the thickened sputa generally accom- panying chronic bronchitis. There is considerable dyspnoea, but the chest sounds well throughout upon percussion; and the cough is slight compa- ratively to the quantity of the expectoration, being evidently no more than is occasioned by the discharge of the secreted fluid. The pulse and temperature of the skin are natural, and there are no night sweats. The appetite is gene- rally unimpaired ; and emaciation is not remark- ably, or not at all observed, unless the quantity of the sputum be extremely great. M. Nauche states, that the expectoration in this state of dis- ease is always more or less acid, and reddens lit- mus paper, whilst that proceeding from inflam- matory action restores the blue tint to this paper after being reddened by acids. On auscultation, the respiratory murmur is commonly weak, but is very rarely suspended. The sibilous rhonchus is heard more or less distinctly, and often mixed with the sonorous, and occasionally with the mu- cous rhonchus, the bubbles of which seem to burst upon the surface of a fluid of less consistence than in bronchitis. 114. Bronchorrhcea usually commences with catarrhal symptoms, and frequently without fever. In other cases, after bronchitis has continued chronic for a longer or shorter period, the ex- pectoration becomes less consistent and less opaque, more abundant, and similar to that de- scribed ; and the affection becomes established, —aggravated at times by disorder of the stomach or bowels, or by changes of the air, especially by cold and moisture, or by arrest of the cutaneous transpiration from any cause,—and ameliorated at other times by a warm dry air, an open state of the bowels, and light nourishing diet, taken in moderate quantity. Vacillating in this manner, the disease may continue for years if it be not se- vere, without materially affecting the strength. But more frequently the discharge increases, after irregularly prolonged, and more or less slight intervals ; the patient loses his flesh, and becomes paler ; his strength is impaired; dys- pnoea increases ; and, in some cases, the affection either runs into humoral asthma, or the quantity of expectoration is augmented so as to exhaust his energies, and to occasion suffocating parox- ysms of cough. In rarer cases the quantity of the bronchial discharge has been so great as to occasion the exhaustion and death of the patient. M. Andral has detailed two cases of this de- scription, wherein, upon dissection, no evidence of inflammation or congestion could be found in the air-tubes. M. Roche, has described, what he has designated an acute form of this affection, which other French pathologists have named catarrhe suffocant; but it differs in no respects from the more humoral states of asthma, de- scribed in its more appropriate place, and pre- senting all the symptoms of spasm of the aic- passages, with a copious viscid expectoration ; the spasm and other symptoms subsiding r.ite' the bronchi and trachea are unloaded of me 322 BRONCHIAL FLUX—Treatment. cretion accumulated in them. Bronchorrhoea has in rare instances, been the means of removing other diseases. M. Andral states that he lias seen hydrothorax disappear after the establish- ment of a copious bronchial flux. 115. iii. Treatment.—After the full exposition that has been given of the means of cure in the different states of chronic bronchitis, to some of which bronchorrhoea is closely allied, it will be sufficient to enumerate succintly the various means which are applicable to this affection. As the disease essentially consists of an increased se- cretion and exhalation from the respiratorv mu- cous membrane, with a determination of the cir- culation to that quarter, and deficient tone of the vessels distributed to it; the obvious indications are, to increase the secretions from other sur- faces and organs, thereby to derive from the lungs, and to restore the lost tone of this mem- brane and its vessels. In some cases accord- ingly, it will be advantageous to commence with an ipecacuanha or sulphate of zinc emetic, and afterwards to act freely upon the secretions and alvine excretions by purgatives. I have never seen a case of the disease which has not been much relieved by purgatives ; taking care, how- ever, that they should not lower the energies of the constitution, by combining them with tonics, bitters or stimulants, and allowing sufficient light nourishment to admit of this mode of derivation being satisfactorily employed. In the intervals between the exhibition of purgatives, diuretics and diaphoretics may be exhibited, and the cu- taneous functions promoted by wearing flannel next the skin during the winter and spring months. 116. Expectorants are very much employed in this affection ; but some of this class of medicines are seldom of benefit in it, unless combined with opium. The balsams and terebinthinates (F. 484—487. 489.) ; the sulphate of zinc, with myrrh, or the compound galbanum pill; and either of these, with camphor and opium are often of service. In addition to these, inhalations, as recommended in another part (§ 99, 100.), may be employed. Although astringents and inhala- tions are often required, yet we should be cau- tious in using them when the disease has been of very long continuance, particularly in persons ad- vanced in age, or when there is any irregularity of the action of the heart, or physical sign of or- ganic change about this organ, complicated with it ; inasmuch as the arrest of an habitual discharge will, in such circumstances, risk the supervention of effusion in the cavities of the thorax. It will be more judicious, in these cases, to confide in purgatives combined with bitter tonics; in diuretics, and in diaphoretics, so as to moderate the discharge, and prevent its increase, or its exhausting effects upon the system. At the same time the vital energies should be pro moted by a light nutritious diet, moderate exer- cise, and change of air, with the sulphureous or gently tonic mineral waters. In other cases where the age of the patient, the regular oi healthy state of the heart’s action, the absence of leucophlegmasia, and the circumstances of the case altogether, are ouch as to preclude dread of the consequences of or.pp/ossing this discharge, cold sponging the surface of the bony by the nitro- hyurochioric lotion, &c. (§ 10L), and the lini- ments already noticed (F. 28d. 311.), with the internal use of the more tonics, parti- BRONCHOCELE—Causes and Morbid Relations. curs during the early epochs of life, most fre- quently about the period of puberty, in persons of a weak and lax fibre, and generally in fe- males ; it very seldom being observed in Great Britain in males: but the comparative frequency of it in the latter sex is greater in Switzerland, and other parts where it is very prevalent, and is connected with cretinism. In a considerable number of cases which have come before me in females, I have never met with any before the period of commencing puberty,—not even at the Infirmary for Children; although the menses have often been delayed for a year or two, or even longer, when the tumour has appeared at this epoch; and I have seldom observed an in- stance in this sex unconnected with some kind of irregularity of the menstrual discharge, or dis- order of the uterine functions. In two cases, oc- curring in married females, who were under my care, unhealthy or irregular menstruation had existed during the continuance of the goitre ; in one case for eight years, in the other for five: upon its disappearance, pregnancy took place in both. Suppression of the menses has sometimes caused its sudden appearance and rapid develope- ment; and it more rarely has originated during pregnancy and the puerperal states. Authors have adduced conclusive proofs of its occurrence hereditarily, independently of endemic influence. 3. Dr. Good has attributed the disease, in a great measure, to poverty, and the nature of the food: the rich being exempt from it. This is, however, very far from being the case. I have seen several cases of bronchocele in the richest of this metropolis. He is also wrong in attri- buting it to the use, in Derbyshire, of oaten cakes. In Scotland, where this article of diet is in gen- eral use, bronchocele is rare. 4. That it chiefly depends upon certain phy- sical causes is shown by its prevalence in certain districts in preference to others, and by the cir- cumstance of its disappearance when persons affected by it endemically have changed their residence. M. Alibert mentions his having seen it disappear after a residence in Paris. It has been very generally imputed to the water used by those affected. Since the time of Pliny, it has been attributed to the use of snow water. But it prevails in several places where this cause does not exist, as in Sumatra, and several parts of South America. The Swiss who drink snow water are free from the disease, while those who use hard spring water are most commonly af- fected. Captain Franklin states, that at a part in his journey to the Polar Sea, where bronchocele prevails, it is coufined to those who drink river water, and that those who use melted snow es- cape. Mr. Bally ascribes its frequency, in a district in Switzerland, to the use of spring water impregnated with calcareous or mineral sub- stances ; and he states that those who use not this water are free from both goitre and cretinism. Dr. Coindet observed that the inhabitants of Ge - neva, who drink the hard pump waters, are those most liable to bronchocele. Its prevalence in Nottingham is ascribed by Dr. Manson to the same cause; which also seems to occasion it in Sussex and Hampshire, in the valleys of which counties it is frequently met with. 5. That this is, however, not the only cause, may be inferred from other physical circum- stances connected with its endemical prevalence. Its great frequency in low, moist, marshy, and 323 cularly the sulphate of iron or of quinine, in ad- dition to the measures already recommended, may also be practised. Biblioo. and Refer.—Morhof, Princeps Medicus, 4to. Rost. 1665.—Rccderer, Disser. de Catarrho Phthisin Men- tiente, 4to. Goet. 1758.—Richter, On Mucous Consump- tion, in Med. and Surgical Observations. Edinburgh, 1794.—Beddoes, On the Medicinal Use of Factitious Airs, fee. Brist. 1795.—Englehart, De Catarrho Inflammatorio, 4to. Lund. 1799.—La Roche, Essai sur le Catarrhe Pul- rnonaire Aigu, 8vo. Paris, 1802.—Bertrand, Sur la Dis- tinction du Catarrhe, de la Pleurisie, et Peripneum. &c. 4to. Paris, 1804.—Cabanis, Observ. sur les Affect. Catarrh. 8vo. Paris, VdOl.—Badham, On the Inflammatory Affec- tions of the Mucous Memb. of the Bronchi*, 8vo. Lond. 1810.—J. P. Frank, Interp. Clinic, p. U0. Tub. 1812. J. Frank, Praxis Medica, &c. p art ii. vol. vi. p. 3o9.—Fer- riar, On the Effects of Pneumatic Medicine, Medica.1 His- tories, &c. vol. ii. p. 261. Lond. 1810.—Broussais, Histoire des Phlegmasies, ou Inflammations Chroniques, &c. t. i. p. 09. 3d edit. Paris, 1822,—Gheyne, On the Pathol, ot the Larynx and Bronchia. Edinb. 1809. Alard, Du Siege et de la Nature des Maladies, 2 t. Paris, 1821. Villerme, Diet, des Scien. Med. t. xxxii. p. 208.—Hastings, On In- flam. of the Mucous Membrane of the Lungs, &c. 8vo. Lond. 1820.; and Midland Medical Reporter, vol. ii. p. 397.—Roche et Sanson, Nouveaux Siemens de Pathol. Medico-Chirurgicale, t. i. p. 560.; et Diet, de Med. et Chir. Prat. t. iv. p. 258.—Armstrong, On Scarlet Fever, Measles, and Consumption, 2d edit. Lond. 1818. Bouillaud, in •fount. Complement, de Diet, des Sciences Med. t. xix. p. 5.—Duncan, Observations on Pulmonary Consump- tion, 2d edit. p. 162.—Latnnec, Traite de F Auscultation Mediate et des Maladies des Poumons, &c. 2d edit. Paris, 1825.; et Rev. Med. t. i. p. 384. 1824.—Andral, Clinique Medicale, &c. t. ii. p. 1.; et Anatomie Patho- logique, t. ii. p. 465.; et Archives G6n6r. de Medecine, t. iv. p. 314.—Royer-Collard, Nouv. Biblioth. Med. t. i. p. 198. 1826.—Sarin, Rev. Mddicale, t. ii. p. 520. 1826.— Mills, Account of Morbid Appearances front Disorders of the Lungs and Heart, 8vo. Lond. 1830.—Alcock, On In- flammation of the Mucous Memb. of the Organs of Re- spiration, Medical Intelligencer, Nos. vii. and viii. p. 151. —R. Harrison, in Medical and Physical Journ. July, 1820.—Johnson's Medico-Chirurg. Review, Dec. 1820. p. 341.—Chomel, Diet, de M6d. t. iv. p. 417. (art. Catarrhe Pulmonaire.)—Hildenbrand, Institut. Practico-Medicte, t. iii. p. 470.— Pagenstecher, in Hufeland's Journ. der Pract. Heilk. Nov. 1827.—Crichton, On the Treatment of several Varieties of Pulmonary Consumption, and on the Vapour of Tar in that Disease, 8vo. Lond. 1823.—Elliot- son, Lond. Medical Gazette, vol. viii. p. 289.; and Lancet, vol. xvii. p. 467.—Bayle. Recherches sur la Phthisie {in some cases of chronic bronchitis found the bronchial sur- face pale, and without change), obs. xlix. p. 392. Paris, 1810.—Abercrombie, in Edin. Medical and Surgical Jour- nal, vol. xvii. p. 39. (Ulceration of the bronchi.)—J. Forbes, On Tar Vapour in Diseases of the Lungs, &c. in Medical and Physical Journ. vol. xlviii. p. 281.— Wil- liams, On the Physical Signs of Diseases of the Lungs. Sec. p. 60. 8vo. Lond. 1829.—Forbes, Original Cases, illus- trating the Use of the Stethoscope and Percussion, 8vo. Lond. 1824.—Gendrin, Histoire Anatom, des Inflamma- tions, &c. t. i. p. 545. Paris, 1826.—Bright, Reports of Medical Cases, &c. p. 127. 4to. Lond. 1827.—Graves, in Renshaw's Med. and Surg. Journ. vol. vii. p. 193. BRONCHOCELE (from, BAvr,c, throat, and Ka\n, a swelling). Syn. Hernia Gutturalis, Gossum, Luftrohrenbruch, Kropf, Ger. Goitre, Fr. Broncocele, Gozzo, Ital. Thyrophraxia, Alibert. Cynanche Thyroidea, Conradi. Goitre, “ Derbyshire Neck.” Classif. 4. Class, Local Diseases ; 6. Order, Tumours {Cullen). 6. Class, Excernent Function ; 1. Order, Affecting the Paren- chyma {Good). IV. Class, IV. Order {Author, see Preface). 1. Defin. Chronic enlargement of the thyroid gland, sometimes with change in the surrounding parts, generally increasing slowly, often continu- ing for years, and depending upon constitu- tional causes. 2. I. Causes, and Morbid Relations.—This disease is endemical in Derbyshire, and some other parts of this country ; but most remarkably so in Switzerland, various adjoining districts, and in some places in South America. It usually oc- 324 BRONCHOCELE—Diagnosis—Treatment. warm valleys, and the exemption of the inhabit- ants of dry and elevated situations, have been shown by Larry, Fodere, Saussure, Reeves, Clark, Valentin, Postiglione, and J. Johnson, as respects various districts in Switzerland, the Tyrol, Carinthia, the Vallais, and the north of Italy. Similar facts have been adduced by Dr. Gibson, and Humboldt, in regard to the United States, and South America. It is most probable, however, that the exhalations from the soil of those localities are not the only, but a concurrent cause, co-operating with others possessing equal influence in the production of the disease, and particularly with the nature of the water. But it as certainly sometimes appears where neither of those causes can be traced, as in London ; dis- order of some kind in the uterine functions being the most frequent morbid relation it has presented, as far as my experience has gone. Its connection with cretinism in the districts on the Continent above alluded to, and the occasional appearance of the disease at very early periods of life—it being even sometimes congenital, in these coun- tries, as well as being more common there in the male sex than in this country—are matters of some interest, and not readily admitting of ex- planation ; since poverty, close, confined, and ill- ventilated apartments, are not the chief causes of those phenomena, as shown by their absence in the poorest classes in this metropolis. Dr. Parry has seen goitre follow diseases of the heart, and epilepsy. Flajani has noticed the common occurrence of palpitations and affections of the lungs from the disorder it has occasioned of the respiratory function. When the tumour is very large, or hard, or when it has increased sud- denly, it not infrequently occasions most urgent symptoms, by its pressure on the trachea, oeso- phagus, and jugular veins. 6. As respects the external and interval ap- pearances of this tumour, I may briefly observe that it affects generally the whole gland; but is also sometimes confined to the lateral or to the middle lobes: it is more rarely large on one side than another. At first it is commonly compact, rounded and equal; but, as it increases, it is either soft and flabby to the touch, or unequal, irregular, hard, and obscurely lobulated. It is usually free from pain, and is not discoloured. When it is greatly increased in size, and is soft, it appears pendulous, chiefly owing to its lower parts being most enlarged. When the tumour is divided, the cells of the gland are found, accord- ing to Hunter, Baillie, and B. Bell, filled with a more or less viscid fluid; and are of various sizes, generally from that of a pea downwards, not only in different cases, but even in the same gland. In the older, harder, and more irregular forms of the tumour, melicerous, steatomatous, cartilaginous, and ossific deposits have been met with in parts of it, by Celsus, De Haen, Frey- TAG, Giraud, Hedenus, and others. The usual state in which this disease presents itself, ob- viously, is that of an increased secretion into the cells of the gland, distending them more or less; the other changes sometimes observed, being con- sequences of obscure irritation induced in parts of it during its continuance or growth. 7. II. Diagnosis.—It is necessary to be aware that other diseases of either a more acute or ma- lignant character may affect the thyroid gland and its vicinity, and be mistaken for bronchocele. 1st, The gland may be either healthy, or but little enlarged ; the tumour consisting chiefly of thick- ened surrounding cellular tissue, sometimes con- taining cysts filled either with a serous, albumin- ous, or purulent matter. Large encysted tumours may also form in the course of the trachea. But these may be readily distinguished by their situ- ation, form, and fluctuation. 2d, The gland itself may be the seat of chronic or acute inflammation. In this case the swelling increases more rapidly, but seldom attains a large size ; and is generally attended by redness of its surface, and increased temperature. It is also painful, particularly on pressure, and is very hard. I lately saw a case of this description, in a married female of about thirty, who was also seen by Mr. Lloyd, where the inflammation had proceeded to suppuration, and had terminated in an external opening. I believe that inflammation of the gland never oc- curs but in scrofulous habits. 3d, The gland may also be the seat of scirrhus, which may ul- timately go on to carcinomatous ulceration ; but this is a rare occurrence. In this case the gland is very hard, seldom large, sometimes scarcely increased in bulk, and is the seat of sharp darting pains. It is only met with in persons advanced in age. Alibert states, that he has observed a case of goitre pass into cancer; but I doubt the fact; cancer having a very wide and indeter- minate signification with this writer. The dis- ease can scarcely be mistaken for aneurism of any of the thyroidal arteries, if any share of at- tention be directed to the subject. Bronchocele has been considered in the light of a strumous disease—as a form of scrofula. Dr. Postiglione, however, contends that no connection exists be- tween these diseases. As respects the state of morbid action in the gland, the concomitant phe- nomena, and the respective terminations of both diseases, there is certainly no intimate relation between them. 8. III. Treatment.—Previous to the use of iodine in the cure of bronchocele, numerous re- medial means were recommended by writers. Of these, the most common were frictions with various liniments; dry rubbing; stimulating and astringent lotions; cold bathing, and cold douches; mercurial applications; plasters with cicuta and ammoniacum, or with ammoniacum and hy- drarg.; repeated blistering; leeches applied to the tumour; electricity and galvanism; moxas, issues, and setons; ligature of the arteries sup- plying the gland ; and extirpation of the gland itself. Amongst the internal remedies recom- mended, I may notice the various preparations of mercury; digitalis combined with camphor (Os- siander) ; sulphuret of potassium; chloride of barium (Postiglione) ; cicuta or belladonna, ei- ther alone, or with the chloride of barium ; the chloride of calcium ; preparations of potash and soda; various mineral springs; the use of sea water, and of distilled water; the ammonio- chloride of iron ; burnt sponge, given either alone, or with mercury; and the ashes of the fucus vesiculosus (Russell). 9. Of all these, the most celebrated was burnt sponge; and, after the discovery of iodine, this substance, which, having been found by Dr. Straub, of Berne, to be contained in officinal sponge, was recommended by him in 1829, and adopted by Dr. Coindet, of Geneva: and so sue cessful has this medicine proved in the trealmen, of bronchocele, that, of a hundred and twenty cases treated with it by Dr. M anson, of Not ting- ham, seventy-nine were cured, eleven greatly relieved, and two only were not benefited by it. Of several cases of the disease which have come before me since the introduction of this remedy into practice, there has not been one which has not either been cured or remarkably improved by it. I believe, however, that although it has been found the most certainly beneficial of any medi- cine ever employed in bronchocele, some other practitioners have not derived an equally uniform advantage from its use. I can account for this only by considering that it has been given in too large and irritating doses, or in an improper form ; and without due attention having been paid to certain morbid and constitutional relations of the disease during the treatment. The cases of two females who were lately completely cured by the remedy confirm this inference. They had both had the tumour for several years, one for nine years; and had, on former occasions, gone through long courses of iodine, prescribed by judicious and eminent practitioners, but without advantage. When this medicine was ordered by me, it was, therefore, with great difficulty that they were induced to have recourse to it again. It was ordered in very small doses, often repeated, and strict attention was paid to the state of the secretions, and to the uterine functions. In the course of a fortnight an improvement was mani- fest ; and of a few weeks longer, a great decrease of the tumours had taken place. One of these females, a married woman, who had been once pregnant nine years before, upon the disappear- ance of the tumour came with child; soon after which it somewhat suddenly reappeared, but the resumption of the iodine again dispersed it. The preparations given in the Appendix (F. 204. 277, 278. 302. 323, 324.) are those which an exten- sive experience of its effects in various diseases, as well as in this, has led me to adopt. 10. In respect of the use of iodine in bron- chocele, the weaker preparations should be at first preferred; and care should be taken never to exhibit them to the extent of irritating the sto- mach or bowels : when this effect is produced, lit- tle or no benefit will be derived from them. The success which Dr. Manson and M. Lugol have derived from this valuable medicine, I know from experience to be chiefly owing to the small and soluble doses in which they exhibited it. In some of the more obstinate cases, it will be often requi- site to assist the operation of iodine by other means. Sometimes the occasional use of ein- menagogue aperients will be of much service ; and when the uterine functions evince disorder, as they very frequently do in cases occurring in females, I have usually directed either the bi- borate of soda, or milk of sulphur, to be taken, in the form of electuary, every night (F. 89. 281.). A calomel purge will also be sometimes of ser- vice. I have generally preferred the internal to the external use of the medicine in this disease. In some more obstinate cases, they may be both employed; but its external application should be of the mildest kind. In some cases, a moderate blood-letting may be premised ; and some writers recommend that leeches should be applied to the tumour itself. Nearly all the cases which I have seen, having occurred in females, in whom it appeared requisite either to promote the men- strual discharge or to subdue uterine irritation, I have usually directed the bleeding, when prac- BRONCHOCELE—Treatment. tised, to be performed in the feet, or leeches to be applied to the groins. Dr. Coster has adduced a case in which galvanism materially assisted the iodine in removing bronchocele. 11. Dr. Kolley has stated, that iodine should not be exhibited where there is a disposition to congestion in the head and internal viscera ; when febrile and inflammatory symptoms are present ' when gastric, hepatic, or intestinal disorder exists and when there is a disposition either to hydro- cephalus or to pulmonary consumption. This is in some respects just; but after depletions, and when the more marked symptoms of these dis- orders are subdued, iodine may, notwithstanding, be exhibited, if its effects be carefully watched, and if the mildest and weakest preparations be selected, and these be combined with anodynes and narcotics. I have observed that a continued course of iodine has sometimes had the effect, particularly during cold weather, of producing pains in the limbs or joints resembling rheuma- tism, which have continued to increase if the medicine was not for a time relinquished. This effect has never appeared during a course of less than six weeks. It has generally soon disappeared after an aperient operation from sulphur, and one or two warm baths. A change to warm weather has also removed it. 12. If iodine fail of reducing the tumour, and if its pressure occasion urgent symptoms, recourse must be had to surgical aid. For a full exposi- tion of this part of the treatment, I must refer the reader to Mr. Cooper’s Surgical Dictionary, and limit myself to a brief enumeration of this class of measures. The first and most important of these is the insertion of setons in the tumour This practice was recommended by Dr. Quadrj, of Naples ; and practised first in this country by Mr. Copland Hutchison, and with success. According, however, to the experience of Mr James, Mr. Cooper, and Mr. Gunning, this prac- tice is liable to occasion dangerous hsemorrhage, sloughing of the tumour, and irritation and in- flammation of the trachea or larynx. Mr. Ly- ford has, however, employed setons successfully ; whilst Hedenus states, that he has seen tetanus occasioned by their introduction. It has been re- commended to cut off the supply of blood to the gland by tying its arteries; and the advice has been followed by Blizard, Walther, Coates, Brodie, and Earle. The cases thus treated by Blizard, Coates, and Brodie, terminated unfa- vourably ; whilst those by Walther and Earle succeeded. Lastly, the tumour has been altoge- ther removed by excision. Dessault first per- formed this operation successfully; Gooch at- tempted it in two cases, but failed; Dupuytren and Klein also failed; whilst Vogel, Theden, and Graeffe, performed it with success ; and Hedenus, of Dresden, succeeded in six cases in which he resorted to this operation. Bibliog. and Refer.—Pliny, lib. ii. cap. 37,—Celsus, lib. vii. cap. xiii.—De Haen, Ratio Medendi, pars vii. p. 385.—Rush, Medical and Physical Journ. vol. xvi. p. 208.—Fod'erk, Traite sur le Goitre et le Crdtinisine, 8vo. Paris, An. 8.—Flagani, Collez. d’Osservazioni e Refless. de Chirurg. t. iii. p. 270. Roma, 1800 —Baillie, Morbid Anatomy, 8vo. p. 87.—Larrey, MOmoires de Chirurg. Milit. t. i. p. 123.—Bally, in Diction, des Sciences Med. t. viii.— Wenzel, Ueb. den Cretinismus. Wien. 1802.— Wylie, in Hufeland's Journ. 1809, 2d. st. Febr. p. 118.—Maas, Diss. sistens Gland. Thyroideoideam tam Sanam tam Morbosam. Wire. 1810, 8vo.—Postiglione, Mem. Patholog. Practica sulla Natura di Gozzo Flor 325 BULIMIA—BULLAE—CACHEXY. 1811.—Alibert, Nosologic Naturelle, t. i. p. 464. fol. Paris, 1817.—Straub, in Naturwissenchaftlicher Aux. der All- gemeiner Schweiz. Gesell. &c. von Fr. Meisner, 4to. Bern. 1820.—Coindet, Decouverte d’un Nouveau Jlembde contre le Goitre, in Bibl. Univers. Juil. 1820, p. 190.; et Feb. 1821, p. 140.—Carro, in Ibid. Mai, 1821.—Brera, Saggio Clinico sull’ Iodio, &c. Pad. 1822.—Quadri, in Medico-Chirurgical Society’s Transact, vol. x. p. 16.— Coates, in Ibid. vol. x. p. 312.—A. C. Hutchison, in Ibid, vol. xi. p. 235.—Roots, in Ibid. vol. xii. p. 310.—Kennedy, in Bond. Medical Repos, vol. xvii. p. 177.—Humboldt, in Magendie, Journ. de Physiol. Expdr. t. iv. p. 109.—He- aenus, Tractat. de Gland. Thyroid. &c. Lips. 1822.—Cos- ter, Archives Gdndr. de Medicine, Juillet, 1823.—Gaird- ner, On the Effects of Iodine, &c. 8vo. Lond. 1824.—Kol- ley, Medico-Chirurgical Review, vol. vi. p. 229.— Tael, Journ. Complement des Sciences Med. t. xxiii. Nov. 1825. —Peschier, Biblioth. Univers. Oct. 1824, p. 146.—Manson, Medical Researches on the Effects of Iodine in Broncho- cele, &c. 8vo. 1825.—Georgiani, De Prsecipuis Thyro- phraxiam Curandi Methodis, 8vo. Pavia, 1825.—Kriigel- stein. Die Kunst d. Krankh. d. Schilddriise u. d. Kropf zu Heilen, &c. Gotha. 8vo. 1826.—Earle, in Lond. Med. and Phys. Journ. Sept. 1826.—Lawrence, Lectures by, Medical Gazette, vol. vi. p. 719.—J. Johnson, On Change of Air, &c.—J. Bramley, in Edin. Med. and Surg. Journ. vol. xliv. p. 448.—Barker, in Med. Gaz. vol. xv. p. 230. BULIMIA. See Appetite. BULLiE. Blains. Syn. \eypa, mucus, and vpev, a membrane), Hildenbrand. Catarrhe, Rhume, Fluxion, Fr Fin Fluss, Schnupfen, Katarrh, Ger. Catarro, Reuma, Ital. A Defluxion, a Cold. Classif. 1. Class, Fevers ; Order, Fluxes {Cullen). 3. Class, Sanguineous Func- tion ; 2. Order, Inflammations {Good). II. Class, I. Order {Author, see Pre- face) 1. Defin. Sneezing, watery discharge from the nostrils; lachrymose state of the eyes ; slight gravative headache, chillness, evening fever, sometimes accompanied with sore throat, hoarse- ness and cough. Path. Defin. Specific irritation of the mucous surface of the nostrils, extending to the frontal sinuses and eyes, in one direction; to the posterior nares, fauces, and throat, in another; and occa- sionally also to the pharynx, (esophagus, glottis, and trachea, thus terminating in catarrhal bron- chitis. 2. Although the most common of all diseases, there are few which are less understood, or have called forth a greater diversity of opinion, than catarrh. This uncertainty is chiefly owing to its varying characters, arising from the limitation or extension of its seat, the temperament and habit of body of the patient, the causes which occasion it, and the severity of the attack. If the affec- tion be not extended much beyond the Schneide- rian membrane, it very generally receives the name of coryza, or catarrhal coryza; if it be seated in the frontal sinuses, it is called gravedo, or catarrhal cephalalgia; if in both these sit- uations, a cold in the head; if the fauces be its principal seat, catarrhal cynanche, or catarrhal sore throat; if the glottis and pharynx, catarrhal cough and hoarseness; if it advance to the tra- chea and bronchi, catarrhal bronchitis ; and if the eyes be primarily affected, catarrhal opthalmia. It may thus be limited to any one of those situa- tions, or be extended to two, or more, or even all of them, according to the predisposition of the parts and of the person affected. It may even proceed further, as to the air-passages on the one hand, or to the oesophagus and digestive organs on the other, after having subsided in, or disap- peared from, its primary seat; and it may even be coexistent in several, or even all of these situations. 3. If we consider the origin and phenomena of catarrhal affections, we shall observe many characters warranting an analogy between them and rheumatism on the one side, and erysipelas on the other. Catarrh is a disorder proper to mu- cous membranes, and is not limited to the parts of this tissue above specified. The same causes which occasion it in them, will sometimes, al- though much less frequently, excite it in other parts of this system according to morbid predis- position of the organs. Rheumatism is an affec- tion of the fibrous, sero-fibrous, and aponeurotic structures, and generally proceeds from the same or very similar causes to those which produce ca- tarrh ; they are both also often present at the same time, and in the same person, and the epi- demic prevalence of both is not uncommon. Ery- sipelas is an affection of the skin, also often de- pending upon similar causes to those which pro- duce catarrh and rheumatism, particularly those connected with the states of the atmosphere ; and all of them are benefited more or less by a nearly similar treatment. Neither of these diseases is the same as true inflammation, although present- ing more or less of the inflammatory characters, but also some which are proper to each. On this account, therefore, should they be viewed, even when approaching the nearest to inflammation, as essentially specific diseases; possessing, how- ever, certain symptoms in common with one ano- ther, and with inflammation; the same causes acting on a certain number of individuals, pro- ducing catarrh in many, rheumatism in some, ery- sipelas in a few, and true inflammation in others, according to the diathesis, habit of body, state of the abdominal functions, previous disorder, &c. of the affected. 4. I Causes.—A. The predisposing causes of jatarrh are referrible chiefly to original confor- mation and diathesis, and to previous disorder, particularly as respects the state of the digestive and assimilating organs. It most frequently af- fects persons of a phlegmatic temperament, re- laxed habit of body, and delicate constitution, or who are weakened by any cause, particularly by morbidly increased secretions and discharges ; also those with long necks and narrow chests, or who indulge in warm apartments and beds, who rise late, and take little exercise in the open air. It is very common among the inhabitants of cold, moist, and changeable climates, more particu- larly during spring and autumn, and in variable or wet seasons; and in persons whose digestive organs are deranged, the functions of the liver torpid, and whose biliary organs and alimentary canal are loaded by morbid or accumulated se- cretions. 5. B. The exciting causes of catarrh are most commonly cold and moisture, or other states of 350 CATARRH—Causes. the air, which eith r are or are not perceptible to the senses, but wh.ch impede or check the insen- sible cutaneous perspiration, and change the functions of those parts of the mucous surfaces most obnoxious to their first impression. That there is something in the air, often producing ca- tarrh, beyond what is perceived by our senses, is shown by the very general or even epidemic prevalence of the affection during states of the weather and of the air, in which nothing peculiar can be observed. Its great frequency, particularly in certain localities and seasons, has induced some authors, amongst whom Dr. Maccullocii is pre-eminent, to impute it to a diluted or generally diffused malaria proceeding from the usual sources of this active agent of disease. 6. Change of locality, whilst it will often re- move a cold, will also frequently occasion it, especially in some constitutions : and a current of air, particularly if it come directly on the face, is a very common cause. The occurrence of ca- tarrh on travelling and visiting places at a dis- tance has been attributed to malaria ; and this may very possibly be the case in many instances. Whenever I have gone any distance into Essex, I have returned with catarrh. It is very com- monly believed by unprofessional persons, that the disease is infectious ; from the circumstance of its commencing in one member of a family, and attacking others successively. This spread of the ailment, however, may be in a great measure owing to the diffusion of the same cause in the atmosphere, whether it be a much diluted or weak local malaria, or a more widely spreading epi- demic influence. Still I believe that there are some grounds for the popular belief. Although these causes will explain much of what is im- puted to infection ; still, it may, either of itself oc- casion the disease, or, when superadded to them, induce an attack in those whom the states of the air, without such aid, might have spared. When catarrh is occasioned by local or generally dif- fused influences, it may not only thereby assume an infectious character, but really possess it; thus countenancing the opinion of Dr. Cullen, that the epidemic prevalence of the disease only is in- fectious ; yet, still, I question if this limitation be just. There can be no doubt, however, that when it arises from epidemic, malarial, or infectious sources, it is usually febrile and severe, and very prone to extend along the air-passages on the one hand, and to the digestive mucous surface on the other, particularly the former ; while catarrh, aris- ing from the more common causes of cold and moisture merely, in any case of the many ways in which these causes are applied to, and affect either the whole or parts only of the frame, is more commonly seated in the cephalic mucous surfaces, assuming the form of cold in the head, coryza, or sore throat, and quickly subsiding. It should not be overlooked, also, that sudden change from a low to a high temperature, or from a very dry to a very moist air ; and even the being more than commonly over-heated, without any very apparent chill, or exposure to cold in any form subsequently; will often produce catarrh. This is especially the case, if the exposure to warmth be sudden, after an impression of cold of some continuance, as the coming into an over- heated apartment out of a cold and moist atmos- phere,—the instantaneous transition from a raw air of about 32° to a dry air of upwards of 70°. 7. II. Symptoms.—Owing to the circumstances CATARRH—Symptoms—Prognosis. 351 already alluded to (§ 2.), catarrh manifests itself in various forms ; but most commonly in the fol- lowing manner:—A. Its slighter states. At a period generally varying from a day or two, to six or seven, but occasionally after even a shorter or longer time, from exposure to the cause, this af- fection commences with a sense of chilliness or coldness, lassitude, and heaviness of the head, fol- lowed by dryness, fulness or stuffing of the nasal passages, frequent sneezing, a dull pain and sense of weight in the forehead, and stiffness, or rather uneasiness, in the eyes. To these is more or less quickly added a distillation of a watery fluid from the nose and eyes, with slight redness and tume- faction of the mucous surfaces of these parts. Occasionally the above symptoms appear nearly simultaneously. The deduction is generally somewhat acrid and saline, producing slight ex- coriation of the parts over which it passes. These phenomena constitute the gravedo of Celsus, and the coryza or defluxion of various authors. They maybe the only ailment, and not proceed further, or they may have others rapidly superadded to them, depending upon greater constitutional dis- turbance, and the extension of the affection to a larger surface. In the former case, the general lassitude and chilliness ushering in the complaint are often so slight as to be overlooked ; but, in the latter case, and in the severer states of the disease about to be noticed, they are commonly more marked from the commencement, and amount even to slight shiverings, followed by white tongue, acceleration of pulse, and increase of heat in the evening. The posterior nares and fauces, as well as the nose and eyes, are affected ; and the patient complains of a sense of roughness or soreness of the throat; loss of the sense of smell ; sometimes of dulness of hearing, with soreness or pain extending along the Eustachian cube to the ear, with slight redness of the fauces and mouth, hoarseness, frequent tickling cough and efforts to excrete a mucous fluid abundantly secreted from the posterior nares, fauces, pharynx, and trachea; and sometimes with a loss or sup- pression of voice, from slight cedematous fulness about the glottis. To the foregoing are very commonly added pains resembling those of rheu- matism in various parts of the body, particularly about the neck, head, and limbs, loss of appetite, costive bowels, and slight thirst. 8. B. Its severe forms.—The above symptoms constitute the usual form of simple catarrh, which frequently subsides in from three, to seven or eight days ; the fluid secreted becoming gra- dually less copious, more opaque and coloured, and, at last, thick, small in quantity, and yellow- ish white, or yellowish green ; all disorder quickly disappearing. But in very many other instances as the coryza and watering of the eyes subside, straitness, oppression, and uneasiness in the chest, supervene: with fits of coughing, and all the symptoms described under the catarrhal form of Bronchitis. In other cases, the symptoms indi- cate, from the beginning, a more severe affection, and a more evident constitutional disturbance, approaching more nearly to a state of inflamma- tory irritation of the mucous membrane of the cephalic passages, than the preceding form. In this case, the coryza and watering of the eyes are attended by much soreness and heat of the eyes, nostrils, fauces, and throat; by frequent sneezing; and by the secretion of a very copious, watery, and colourless fluid, excoriating the parts over which it passes. The fauces are red ; the tonsils somewhat inflamed and enlarged; and there is a short, dry, tickling cough. The fever, which, in the slighter state of disease, was scarcely noticed, is much more evident in this, particularly towards evening ; and is ushered in by chills, or shiverings, the chills often continuing throughout, and pre- ceding the evening febrile exacerbations; catar- rhal fever usually thus assuming a remittent type. The pains felt in different parts of the body, and the general lassitude, cough, anorexia, sluggish- ness of the bowels, and thirst, are also greater in this, than in the preceding state of the affection. 9. Throughout the disorder, the patient is un- usually susceptible of the impression of cold, even although the skin be warmer than natural. He is also inordinately disposed to experience an ac- cession of, or to contract a fresh cold, upon the slightest exposure to its causes, or even to the least depression of temperature. Owing to this circumstance, catarrhs are often very much pro- longed, and either assume a chronic form, or in- duce chronic bronchitis, and other serious affec- tions of the air-passages and lungs. 10. C. Progress and terminations.—This form of catarrh either disappears as in the slighter states of the disorder, with a diminished and thickened secretion, less frequent and less severe fits of coughing, and subsidence of fever, in from four, to seven or nine days ; or it affects, in a much shorter period,—sometimes almost from its commencement,—the pharynx, trachea, and large bronchi, producing slight or severe bronchitis ; or it terminates in this disease, or in pneumonia, or even in pleuritis. But most commonly, under proper management, it is attended merely by a moderate catarrhal affection of the trachea and bronchi; with fits of coughing, increased mucous expectoration, &c., consituting catarrhal bron- chitis. It also sometimes extends down the oesophagus, and affects slightly the stomach, in- ducing numerous dyspeptic symptoms; and, in persons with an irritable state of the digestive tube, occasionally passing off at last with mucous or serous diarrhoea. 11. III. Prognosis.—In general, catarrh is a very slight ailment, and attended with no danger as respects itself. But, in aged persons, in those disposed to pectoral diseases, particularly those who may have tubercles already formed in the lungs, who have had haemoptysis, or who are asthmatic, or have experienced attacks of bron- chitis, pneumonia, or pleuritis, catarrhal affec- tions require strict attention, as they very often quickly produce, or terminate in, these maladies. In many persons, also, they are very prone to be- come chronic, either in the form of a chronic coryza, with continued irritation, and slight red- ness of the posterior nares and fauces, and an abundant muco-puriform discharge ; or in some one of the states of chronic In the aged, and in those of a phlegmatic temperament, or lax habit of body, catarrh often passes into a chronic bronchial flux, when it has been neglected, or renewed by incautious exposures during the treatment. Children of a lymphatic and flaccid habit of body are very liable to catarrh in the form of coryza ; and in them it very frequently assumes a chronic form ; the thick muco-purulent secretion filling up the nares, and, in infants, pre- venting them from taking the breast, and ren- dering them irritable, each attempt at sucking disordering the pulmonary and cerebral circuia- CATARRH—Complications—Treatment. 352 tion in such a manner as even to occasion con- vulsions. In children also, the coryza, when al- lowed to become chronic, sometimes degenerates into ozcena, with ulceration. 12. IV. Complications.—Catarrh very com- monly ushers in the febrile exanthemata, particu- larly measles; and even accompanies them through their course, especially in the form of bronchitis. It is also very liable to appear during convalescence from them. Its connection with rheumatism has already been noticed (§ 3.), both disorders evidently springing from the same causes. Continued fevers, as well as some epi- demic visitations of fever, are not infrequently complicated with catarrhal affections. The asso- ciation of catarrh with biliary and gastric derange- ments is very common, sometimes in consequence of the disposition to be affected by its causes dur- ing biliary disturbance, and occasionally owing to the circumstance of simultaneous disorder of the digestive, cephalic, and respiratory mucous sur- faces, having arisen from the impression of the same exciting causes. These complications have especially characterised the various occurrences of epidemic catarrh, which have been observed. (See art. Influenza.) 13. V. The Nature of Catarrh is deserving of some notice. Many pathologists, particularly those of the modem Parisian school,—the fol- lowers of Laennec and Broussais,—consider it as ordinary inflammation of the cephalic mucous membranes, or parts of this tissue which it usually affects. Other pathologists, more especially Richter and Hildenbrand, view it, with stricter propriety, as an inflammation of a specific kind. I believe, although it very often terminates in true inflammation when it extends to the bron- chial tubes, that it chiefly consists of a specific irritation of that portion of the mucous surface primarily affected by it, nearly allied to inflam- mation, and soon followed by, or accompanied with, great increase of the secreting functions of the part; or, in other words, that it is not pure inflammation, but an irritation of a specific or peculiar kind, attended by slightly increased vas- cularity, afflux of the circulating fluids, and aug- mented secretion. Since the time that Van Hel- mont ridiculed, in his Catarrhi. Deliramenta, the opinions then entertained respecting catarrh, en- quiries into its nature have been more rational, although, up to the present time, ideas have still continued very vague as to the extent of surface affected by it, many even of modern writers comprising under catarrh, not only bronchitis, but even all affection of mucous surfaces, at- tended with a copious serous or sero-mucous dis- charge. 14. One of the most interesting questions con- nected with this subject, and one which has been agitated by J. P. F rank and others, is, whether the defluxion is a consequence of the suppression of the cutaneous perspiration, arising out of the irritation which the secretion retained in the cir- culation produces upon the cephalic and pulmonic mucous surfaces ; or of the specific irritation and morbid impression of those parts by the exciting causes of the disease. The former opinion was very generally received by the followers of the hu- moral pathology; and the latter by Hoffman, and subsequently by Cullen, Pinel, and other dis- ciples of his school. Pinel considered the febrile phenomena merely as symptomatic of the in- flamed mucous membrane, discarding the plaus- ible opinion advanced by Botal, that whatevei of inflammation exists is caused by the acrimony of the catarrhal discharge, and that the local ail- ment is consecutive of the constitutional dis- turbance,—a doctrine which is in strict accord- ance with the description of the disease given by Richter, and with the more usual succession of its phenomena. In some cases, however, it is very difficult to determine the priority of the general disturbance, the local ailment being equally early. Upon the whole, I believe it is not proved that the constitutional affection is the con- sequence of the local, although the former is generally increased in proportion to the severity of the latter; nor does it appear that the deflux- ion is caused by the suppression of the cutaneous perspiration, even granting that suppression is ac- tually produced,—a position by no means esta- blished. I would thence infer that the causes of catarrh affect primarily the organic nerves sup- plying the surface principally disordered, and through them, the system generally ; and that, owing to this change, the secreting functions and circulating actions of the part primarily or spe- cifically impressed, are altered, and the disease fully developed; its chief modifications arising out of the degree to which the constitutional actions are disturbed, of the extent of surface affected, and of the grade of irritation produced in the capilla- ries of the part. 15. VI. Treatment.—The treatment varies much according to the symptoms and periods of the disease. Immediately upon the approach of catarrh, before febrile exacerbation has appeared, and whilst ailment is limited to the cephalic mu- cous surfaces, very opposite means to those re- quired when fever is present, or when the affec- tion has extended to the trachea, and threatens to produce bronchitis, are generally most serviceable. Under the former circumstances, a judicious ex- hibition of stimulants of any kind, but especially stimulating diaphoretics, will either cut short the disorder, or render it much shorter and more mild ; whilst, in the latter state, particularly when any pectoral symptoms have appeared, considerable risk will be incurred in some constitutions, although either little or none in others, of inducing inflam- matory action by the same measures.* [* The catarrh as above described, is rarely uncomplica- ted with bronchial affection; See Art. Bronchitis. The late Dr. Dewees treated the ordinary catarrh of children as well as adults, (catarrhal bronchitis) with local and ge- neral bleeding, and moderate purging, followed by the free use of expectorants, especially the compound syrup of squills, or as it is very generally called, Coxe's Dine Syrup. In acute cases, previous to depletion, this prepa- ration may prove too stimulating, although this effect is controlled in a degree by the antimony it contains, and to which it chiefly owes its emetic properties. If there is not much arterial excitement, Dr. D. recommends to com- mence the treatment by emetic and expectorant doses of this article. (For the mode of preparing, see U. S. Dis- pensatory.) We have, however, found this preparation very uncertain in its effects, sometimes operating with great violence, and then almost inert. In infants and very young children, moreover, antimony is always an extremely hazardous remedy, and may with advantage give place to other substances, equally efficacious and far safer. Much mischief is done by the exhibition of opiates in this form of the complaint, for the purpose of alleviating the cough, especially when the skin is hot and the pulse active, and the expectoration thin, or scanty, with con siderable oppression. In one instance, we have known death speedily follow the exhibition of a full dose of morphine in an adult female of delicate constitution, the expectoration having" been suddenly checked, and suffo- cation ensued from engorgement of the air-cells of the lungs. C AT A R RII—' Fit atm ent. 16. Early in the disease, therefore, and while a copious defluxion has not come on, the patient, may inhale through the nostrils the vapour of warm water, of any emollient and anodyne de- coction or infusion: if the ailment is no more than a coryza, or cold in the head, febrile action not having appeared, he may take, upon going to bed, an active stimulating draught, consisting chiefly of ammonia, camphor, spirit, cether. ni- trici, &c., with or without a narcotic. Either of the following will be used with advantage as long as febrile action, or any acute affection of the bronchi, has not appeared:— No. 96. ft Spirit. /Ether. Nit. 3 j.—3 iij.; Tinct. Cam- phor® Comp. 3 j.— 3 ij.; Mucilag. Acaci® 3 ij.; Spirit. Anisi. 3 j.— 3 ij.; Liq. Ammon. Acet. 3 ij.; Mist. Cam- phor® ?i.; Syrupi Tolutani 3j. M. Fiat Haustus, hora somni sumendus. No. 97. If Camphor® ras®, gr. iij.—vj.; Ammon. Sesqui-carbon gr. vj.—x.; Pulv. Ipecac, gr. j.; Extr. Hy- oscyami gr. vj.; Conserv. Ros. q. s. ut fiat Bolus, h. s. s. 17. The above draught will often arrest the dis- ease, when given sufficiently early. In some cases I have directed the bolus to be taken with it, either the hyoseyamus or the tinct. camph. co. being omitted. On the following morning, a sto- machic aperient may be taken ; but nothing more is necessary, not even diluents, as, at this period, they will have little further effect than to increase the defluxion. When the pulse becomes acceler- ated, and somewhat fuller or harder than natural, with other signs of febrile action ; or when the throat is more or less affected, and particularly if there be irritation about the glottis and trachea; a different practice is required. Diluents will now be of service, particularly in conjunction with emollients, diaphoretics, &c. Any of the medicines of this description in the Appendix (F. 238. 244.), or those denominated pectoral (F. 389. 426.), will be of service; or the following may be used. Richter states, that the first of these has generally been employed by him early in catarrh. No. 98. If Calomel gr. j. Extr. Hyoscyami gr. ij.; Gum. Acaci® Pulv., Sacchari Albi, aa gr. xv. Misce et fiat Pulvis. Dispens. tales quatuor. Sumat Eger tertia quaque bora unum. No. 99. If Mucilag. Acaci® 3 j.; Mist. Camphor® et Mist. Amygdal. Dulc. aa 5SS-! Liquor. Ainmon. Acet. 3 iij.; Tinct. Camphor® Co., Spir. /Ether. Nit., aa 3 ss.; Syrupi Tolutani 3 ss. M. Fiat Haustus, quarta vel quinta quaque hora capiendus. 18. Whenever we deem it requisite to act moderately on the bowels, either in the course or at the decline of the complaint, a full dose of the flour of sulphur, either with, or without cream of tartar, will be found to act most beneficially, both on the catarrh and on the abdominal functions. When febrile action becomes more fully developed, or if the disease assumes an inflammatory cha- racter, with headache, flushed countenance, or hard cough, a suitable quantity, either of the liquor antimon. potassio-tartratis, or, of the viuum ipecacuanha;, may be added to the above draught; and either of the following given at bed time :— No. 100. If Pulv. Ipecacuanha gr. ij.; Hydrarg. Chlo- ridi gr. iij.; Pulv. Opii Puri gr. j.; Mucilag. Acacise q. s. ut fiant Pilul® ij. No. 101. If Pulv. Jacobi Veri gr. iij.—v.; Hydrarg. Chloridi gr. iij.; Opii Puri gr. j. (vel Extr. Hyoscyaini gr. v.); Syrupi q. s. M. Fiant Pilul® ij. 19. When ailment begins to subside, or when it seems likely to degenerate into a chronic state, with more or less affection of the bronchi, the treatment recommended in Catarrhal bronchitis, or in the slighter chronic states of the disease, should be prescribed. (See Bronchitis, § 69.) Hufeland recommends a decoction of the un- toasted coffee-berries, or the carduus benedictus, in those cases. Joerdens advises the oleum cam- phoratuin (F. 449.) on sugar ; Lentin, the oleum terebinthinae rubbed on the loins ; and Kortum, camphor, with hydrochlorate of ammonia. The decoction of Iceland moss, with ipecacuanha, or spiritus Esther, nit. and syrup of poppies, may also be used, or either of the following:— No 102. If Zinci Oxydi gr. j. (vel Sulphatis gr. ss./; Pulv. Ipecacuan. gr. ss.; Extract Hyoscyami (vel Conii) gr. iij.; Extr. Glycyrrh. gr. ij. Fiant Pilul® ij. ter qua- terve in die sumend®. No. 103. If Extr. Papaveris Albi gr. iij.; Mucilag. Aca- cia; 3j.; Tinct. Camphor® Comp. 3 ss.; Spirit. A nisi 3 j.; Decocti Alth®® et Aq. Sambuci aa 5 ss.; Spirit. rEther. Nit. Ilf xx.; Syrupi Tolutani 3 j. M. Fiat Haustus, ter quaterve quotidie capiendus. 20. When catarrh is connected with biliary disorder, or with accumulated sordes in the priina via, an ipecacuanha or antimonial emetic at the commencement of the treatment will often be of much service ; especially when followed by a dose of calomel and an aperient draught, or stomachic purgative, in order to evacuate whatever morbid secretions or fsecal matters may have been col- lected If it be complicated with rheumatism, calomel, combined with antimony and opium, and subsequently with camphor, ipecacuanha, and opium, will be found of service; biliary collec- tions, &c. being carried off by the exhibition, every day or alternate days, of a stomachic pur- gative. If catarrh bo accompanied with symp- toms of debility, or with those of a nervous cha- racter, forming what some German pathologists have termed nervous catarrh, the liquor ammonia; acetatis, with larger doses of camphor than under the preceding circumstances, or with the spirit, ammon. arom. or tinct. ammon. comp., or the spirit, aetheris sulphur, comp., and any of the ano- dynes in common use, are appropriate medicines, When the disease becomes chronic, change of air is most beneficial. During the treatment, the patient should avoid exposures to atmospheric vicissitudes, and partake only of light bland diet, observing the injunctions laid down for the ma- nagement of convalescence from bronchitis. (See Bronchitis and Influenza.) [The late Dr. D. Hosack made two distinct va- rieties of catarrh ; the one, arising from cold and the usual causes of inflammatory pulmonary af- fections, and requiring venaesection and other active antiphlogistic means ; the other depending on a specific contagion ; in which the nervous system is more profoundly affected, preceded by a chill, and attended with delirium, great sensi- bility of the eyes to light, severe pains, moist tongue, and extreme weakness of pulse, with general depression of the powers of life. In this form of the disease, the treatment should be cor- 353 The regimen should be strictly antiphlogistic during the whole treatment of acute bronchial catarrh. Dr. Dewees and other writers recommend plentiful dilution, keeping the temperature of the room at about 60, and avoiding all sudden transitions of temperature. Dr. Williams, however, recommends an entire abstinence from fluids of every kind, and states that a total disuse of them for twenty-four or forty-eight hours, will gene- rally extinguish the disease, by cutting off the supplies which keep up the serous exhalation. My own experi- ence has most fully verified this statement. The vapour bath judiciously employed will be found one of the most beneficial remedies in the treatment of catarrhal bronchi- tis, especially after the force of the disease has been somewhat abated by the usual antiphlogistic measures.] 354 CELLULAR TISSUE—Alterations of. dial and mildly stimulant; avoiding blood-letting, and active cathartics, though gentle emetics are often useful in the commencement of the disease. Dover’s powder, with a decoction of the Virginia or Seneka snake root, with small quantities of am- monia or camphor in wine whey, will be found very useful, especially where the vital powers are materially depressed. It is this latter form of the complaint, that usually goes under the name of Influenza, and which often prevails epidemically, and demanding a cautious, supporting course of treatment, with an avoidance of all debilitating measures. In the influenza that prevailed epi- demically in the United States in 1782, 1790, and 1791, Dr. Hosack states that bleeding was attended with very unfavourable results. The same was noticed by us during the prevalence of the disease in 1831, 1832, and in 1843: it being characterised by a strong typhoid tendency. Mild stimulating diaphoretics, with the inhalation of the vapour of vinegar and water, or hops and vinegar, were generally attended with beneficial effects. Calomel and ipecac, in doses sufficient to excite gentle vomiting, followed by mild laxatives were often singularly efficacious in palliating the more violent symptoms, and breaking the force of the disease.] Bibliog. and Refer.—Celsus, de Medicina, iv. 2. p. 375.—Botal, Comment, de Catarrho. Lugd. 1565, 160. —Schneider, De Catarrhis, libri vi. 4to. Witeb. 1660.— Rolfink, De Catarrho Narium. Jen. 1690; et De Catarrho ad Nares, ad Fauces, et Pulmones. Jena1, 1672.—Juncker, De Congestionibus, vulgo Catarrhis et Rheumatismis. Hala;, 1748.—Chandler, Treatise on the Disease called a Cold, 8vo. Lond. 1761.—Stoll, Rat. Medendi, t. iii. p. 39., t. iv. p. 223.— Wallich, De Frequenti Catarrhorum e Pri- mis Viis Origine. Goet. 1777.—.7. P. Prank, De Curand. Morbis, lib. v. pars i. p. 108.—Kelson, On the Nature aud Cure of Colds, 8vo. Lond. 1797.—Cullen, First Lines of the Pract. of Med., vol. ii. p. 83. 4th ed.—Haartmann, De JKtiolo-. Catarrhi, Abo. 1802.—Kortum, in Hufeland und Himly, Journ. der Pract. Heilk. July, 1810, p. 48.—Hufe- land, N. Annalen, b. i. p. 173.—Lcntin, Beytriige, ii. ob- ser. 16.—Jocrdms, Hufeland's Journal d. Pr. Arzn. b. vi. p. 429.—Parr, Med. Diet. vol. i. p. 369.—Richter, Tharapie Specielle, b. ii. p. 84.—Hildenlrrand, Institutiones Practi- co Medico:, t. iii. p. 459.—Dugcs, Sur l’Etat. Catarrhal. Rev. Med. t. iii. p. 210. 1825.—Macculloch, On the Pro- duction and Propagation of Malaria, and the Diseases occasioned by it. 8vo. Lond. 1827. [S. Forry, On Epidemic Influences, with special refer- ence to the now prevailing Epidemic Catarrhal Fever. New York Journal of Medicine, vol. i. p. 64.—D. Hosack, Lectures on the Theory and Practice of Physic. New York, 1838.] CELLULAR TISSUE. Syn. Tela cellulosa, Corpus cribrosum, Tela mucosa, Auct Var. Tissu Cellulaire, Fr. Tissv Muqueux, Bordeu. Corps Cribleux, Fouquet. Reticular Mem- brane, W. Hunter. Filamentous Tissue. Cel- lulo-fllamentous Substance. Its Diseases. Alterations of the. Classif. Special Pathology.—Morbid Structures. 1. A. The quantity of the cellular tissue varies greatly in different constitutions, a large propor- tion of the soft solids consisting of this structure, particularly in persons of a lax fibre and rounded fleshy form. It is relatively more abundant in the female than in the male ; in the young than in the aged; in the sanguine, phlegmatic, or lymphatic temperaments, than in the melan- cholic ; and in those who are fair, than in the dark complexioned and swarthy. It may be diminished, in parts, from pressure ; or throughout the body from disease, or inanition. Long-continued and laborious exertions will also apparently lessen it; or at least diminish its bulk, by causing the ab- sorption of the serous and fatty matters deposited in its areolae or interstices. It is remarkably in- creased by full and rich living, and by indolence but its bulk is then evidently, in a great measure, owing to the general fulness of its minute vessels, and to the greater proportion of fluid contained in its interstices. Partial, increase of this tissue is also observed, but chiefly in consequence of dis- ease. It forms, in such cases, the basis of various morbid growth particularly encysted, scrofulous, sarcomatous, and scirrhous tumours. 2. B. The consistence of the cellular tissue also varies greatly. In some persons it is unusually lax and extensible ; in others, it is uncommonly dense and tenacious. The slighter changes of consistence are the result of original conformation, and of age. It is usually more lax in females than males, in the phlegmatic and lymphatic tem- peraments than in the melancholic and bilious; and in very young persons, than in those of ma- ture or advanced age. The state of vital energy also influences its consistence ; for as the powers of life are reduced by disease, &c. its cohesion is proportionately lessened, and it becomes more lax and inelastic. Changes of consistence occur- ring in parts are chiefly the consequences of in- flammatory action. Continued pressure has the effect of condensing it, and changing it from a nearly semifluid state, into a fibrous, lamellated, and firm structure. 3. C. Inflammation of this tissue gives rise to the most varied and important changes, according to the vital energies of the frame, the state of constitution, and habit of body, the nature of the exciting causes, and the intensity of the disease. In a previously healthy state of the system, and when the exciting cause is not of a septic or poi- sonous nature, the inflammation is usually of the phlogistic or phlegmonous character, and its ex- tension is limited by the formation of coagulable lymph around the centre of the part inflamed ; and which, becoming condensed with the cellular tissue exterior to it, forms a cyst for the enclosure of the purulent matter which is usually formed within the part, when the inflammation has pro- ceeded to a certain height. (See Abscess, § 5.) 4. When the inflammation arises from septic or poisonous animal secretions, or from the more common causes of irritation, or of local injury act- ing on an unhealthy habit of body, or during un- wholesome or epidemic states pf the air, it as- sumes a spreading or diffusive character. The disease, however, may be spreading, without being primarily diffusive ; for it sometimes commences in a point or circumscribed spot, as in phlegmo- nous inflammation ; and from the influence of certain causes, hereafter to be noticed, coagulable lymph is not formed so as to limit its extent, as in that form of the disease, and it consequently spreads more or less rapidly ; the part soon losing its vitality, and the secretion from the affected vessels infiltrating and contaminating the portions adjoining it, until extensive destruction and sphace- lation of this tissue takes place. The inflamma- tion may, on the other hand, owing to nearly the same causes, attack, almost coetaneously, a con- siderable extent of structure, and terminate either in the same way, or in a manner nearly resem- bling it. Spreading inflammation of the cellular tissue is generally the consequence of external ex- citing causes, particularly punctures, abrasions, wounds, fractures, &c. acting upon a predisposed system, and more commonly gives rise to a foul serous or sanious secretion, and terminates in sphacelation or gangrene; whilst diffusive inflam- CELLULAR TISSUE—Diffuse Inflammation of—Causes. 355 mation is more usually produced by internal causes, or such as affect the nervous or constitu- tional powers previously to the developement of the disease in the cellular tissue; the secretion which is formed in the part approaching more nearly than that of the foregoing to a puriform matter, and extending in various directions in the course of this structure, under the integuments, &c. which it but little affects. The former is often connected with hospital gangrene, or is nearly allied to it, as well as to various forms of foul spreading ulceration ; the latter is frequently an attendant upon erysipelas, without, however, constituting any of the states of that disease ; and upon the inoculation of animal poisons, as in the dissection of bodies recently dead of diseases in which the blood and soft solids are more or less vitiated. (See Cellular Tissue—Diffusive In- flammation of.) 5. Cellular tissue is also often the seat of chro- nic inflammation, generally in circumscribed parts, giving rise to cold or chronic abscess (see Ab- scess, § 19.); or to certain manifestations of scrofulous disease. In this state of inflammatory action, gelatinous or albuminous fluids are com- monly effused into the interstices of a greater or less extent of this tissue ; imparting to it a swollen or hardened appearance ; as in rheumatism, gout, imperfectly cured erysipelas, pelagra, elephanti- asis, and probably that peculiar affection denomi- nated the induration of the cellular tissue of new- born infants. Otto comprises also phlegmasia dolens under the class of lesions of this tissue, which arises from chronic inflammation: but we have not sufficient evidence of this origin. In- deed, facts, as far as they have been ascertained regarding it, very conclusively show, that other structures besides this are affected at a very early period of the progress of the disease. 6. D. Infiltrations, or effusions of fluids from the circulating vessels, frequently take place in this tissue, and constitute the prominent pheno- mena of various diseases. Haemorrhage some- times occurs in it, either from external injuries, or from internal causes affecting the vitality of the system and the states of the capillaries and circu- lating fluids. When it originates in the latter source, the effused blood is usually infiltrated into the interstices of the structure in circumscribed spots, forming ecchymoses, and sugillations, as in scurvy and purpura haemorrhagica, &c. When the haemorrhage is extensive, it is commonly ow- ing to the rupture of an aneurismal vessel or varix. The infiltration of serous fluids is very common, either in circumscribed parts (oedema), or more or less generally, although in different degrees, in the greater part or the whole of the body (anasarca). This preternatural increase of the serosity usually moistening the cellular tissue is owing to various causes, explained in the arti- cle Dropsy ; and chiefly to increased exhalation, either from augmented determination of the cir- culation, or deficient tone of the exhalants, or both,—to impeded absorption, either from ob- structed circulation in the veins or inactivity of the absorbents,—and to oppletion of the vascular system by the serous or watery parts of the blood, from obstructed elimination by the kidneys or by the respiratory and digestive mucous surfaces, and by the skin. A general state of very slight oedema, or an unusual fullness, softness, and flac- cidity of the cellular tissue,—a condition obvi- ously depending upon its laxity or deficient cohe- sion, conjoined with the presence of a greater pro portion of watery fluid than in the healthy state, —not infrequently also is observed, particularly in phlegmatic and lymphatic constitutions. This has usually been termed leucophlegmasia; and al- though it may not amount to actual disease, yet it undoubtedly forms the first stage of several slowly formed maladies, and is usually attended with that state of the frame described in the ar- ticle Cachexy. It is of importance to attend to the chief pathological relations of this state of the cellular tissue, as they furnish useful indications respecting the nature and treatment of various diseases with which it is often connected. It com- monly proceeds from an originally weak conforma- tion, subsequently heightened by diminished vital power of the system in general, and defective co- hesion of this tissue in particular. 7. The urinary secretion sometimes escape® into the cellular structure, which it violently in- flames ; the part thus infiltrated being usually affected by the spreading form of the disease, and the constitution thereby suffering most severely, as in other cases of this state of inflammation. This tissue is sometimes also infiltrated by aeri- form fluids, constituting the emphysema or pneu- matosis of authors. This species of infiltration arises either from the escape of air into the cel- lular substance, owing to laceration of some part of the respiratory mucous membrane ; or from a morbid secretion by the vessels in certain advanced stages of disease, as in the last period of some forms of inflammation. (See art. Emphysema.) 8. E. The cellular tissue is also very frequently the seat of a great variety of morbid growths, and formations of a specific and malignant kind. Amongst these, the most important are simple se- rous cysts, hydatids, tubercles, melanosis, earthy and bony concretions, the vascular sarcoma of Abernethy, &c. These adventitious produc- tions very often commence in some part or other of this tissue, even when they are found in other structures ; the matrix, or medium of connection furnished by it to other textures and organs, being most frequently their point of origin. Certain parasitic animals, especially the larva) of the oestrus, filariw, and cysticerci, are also occasion- ally met with in the cellular membrane. Changes of colour are not unusual, most commonly in con- sequence of biliary obstruction, giving rise to jaundice ; and of certain malignant fevers, when it is either yellowish or yellowish green, and defi- cient in its vital cohesion. Cellular Tissue—Diffusive Inflammation OF THE. ClASSIF. III. CLASS, I. OllDER {Author). 9. Defin.—Severe constitutional disturbance, either preceding or following intense pain and diffuse swelling of some part of the cellular tis- sue, with rapid pulse and depressed vital power. 10. The parts of the cellular tissue chiefly af- fected, according to Mr. Hunter and Dr. Craigib, are those in which the adipose substance is most abundant. In respect, however, of its seat and nature, this important malady has been much misunderstood, owing to the circumstance of its most commonly occurring as a complication with diseases of those structures, whose anatomical connection with this tissue is extremely intimate. Dr. Duncan, to whom we are indebted for the most comprehensive account of it which has hi- therto appeared, has erred in considering other maladies, thus contingently related to it, as form- 356 CELLULAR TISSUE—Diffuse Inflammation of—Symptoms. ing varieties of it, rather than as being occasional complications with it. It is true, that, while dif- fusive inflammation of the cellular structure arises primarily, constituting the only or principal complaint, it is also associated (generally in a se- condary form, or in consequence of the extension of inflammation from immediately adjoining tis- sues) with inflammations of absorbing vessels and glands, with phlebitis, with inflammation of the fasciae, and most commonly with erysipelas ; these generally proceeding from the same causes, and from similar states of constitution and vital energy of the patient, as occasion it; and one or other of these diseases often appearing simultaneously with it. But, when thus associated, it may con- stitute either the least, or the most remarkable part of the malady ; and, therefore, in such cases at least, can only be viewed as a more or less im- portant part of a complicated disease. 11. I. Causes.—A. The predisposing causes, as far as they are ascertained, are epidemic states of the atmosphere; impure conditions of the air originating in local sources, particularly the foul air of crowded or imperfectly ventilated hospitals and apartments ; morbid accumulations of bile in the gall bladder and ducts, and of sordes, &c. in the prima via ; lowered vital power, from whatever cause ; the use of unwholesome food, a cachectic habit of body, and deranged state of the digestive functions, or of the secretions. B. The exciting causes are chiefly local inju- ries and sprains, especially punctures and abra- sions ; venaesection and the ligature of veins ; the inoculation of various animal poisons, generally of a septic tendency ; acrid substances, or vegetable or animal matters in a state of disease or decom- position, applied to the cellular tissue ; and even the simple contact of morbid secretions and fluids with any part of the body. The numerous in- stances which occurred a few years since in Ply- mouth Dock, and described by Dr. Butter and Mr. Tripe, were chiefly referrible to epidemic or endemic states of the air; were generally excited by local injury ; and were complicated with ery- sipelas. 12. II. Symptoms.—A. The local symptoms are variously modified, according to the causes by which the disease is produced.—a. In some cases it proceeds with very severe lesion of the part to which the cause is applied, as when the fluids and secretions of a diseased animal come in contact with the skin, and give rise to the disease called “pustule maligne” by the French, or malignant anthrax. In this case the morbid matter pro- duces a vesicle, from its effects on the rete muco- sum, followed by a tubercle, arising from the ex- tension of the inflammation to the true skin, whence it penetrates to the subjacent cellular tis- sue. Its progress then is very rapid and alarming. A considerable swelling now extends to some dis- tance, presenting a peculiar character. The sur- face of the skin is shining, and the swelling is elastic, diffused, and resisting, with a throbbing pain and sense of heat, followed by a feeling of torpor, tightness, and weight of the part. This morbid state extends in all directions ; and, upon examination, excites a sensation between the softness of oedema and the elasticity of emphy- sema, to which the terms boggy or doughy, have been applied. The central parts generally soon become entirely deprived of life, and the mortifi- cation glides below the skin, and destroys the cel- lular tissue all around; the constitution being most seriously affected. A nearly similar state of the part primarily injured not infrequently fol- lows the application of various acrid matters, ani- mal or vegetable, directly to the cellular tissue^it- self. Punctures, also, which penetrate as far as this tissue, or mere abrasions of the cuticle, may also occasion it; the chief difference being in respect of the extent to which the skin is af- fected. In some of such cases, particularly when punctures are the cause, either with or without the application of morbid matter, the skin is very slightly diseased, although the cellular tissue is very extensively destroyed ; whereas, in other in- stances, especially when the cuticle is abraded, or when acrid matter is applied externally to the skin, this structure is very manifestly inflamed at the same time, and the malady presents the cha- racters of erysipelas, complicated with this affec- tion of the cellular membrane. 13. b. When the disease arises from punctures, mechanical injuries, chemical irritants, and some- times from wounds received in dissection, the constitutional disease is, as in the foregoing in- stances (§ 12.), preceded by the local affection. The mischief commences in the seat of injury, and extends from thence to the trunk of the body, and sometimes also in an opposite direction, with- out leaving any interval apparently sound. The progress of this variety differs greatly in different cases; being in some confined to the limb, or part of the limb, to which the cause is applied, and in others proceeding rapidly to the trunk, and termi- nating fatally. In a few of the instances follow- ing venesection, the puncture heals as usual, and either remains permanently united, or opens again, and gives vent to some purulent matter ; but more commonly union does not take place ; the lips of the incision remaining slightly swollen, red and everted. Some ichorous or puriform discharge appears, and disease extends continuously from the wound to the shoulder or breast. 14. c. In the most dangerous form of the ma- lady, as that consequent upon the inoculation of a virus or morbid matter, a vesicle or pustule forms in the part to which the poison is applied, with very remarkable constitutional disturbance, followed by severe diffusive inflammation of some part of the cellular texture, generally on the same side with that on which inoculation of the dis- ease took place, but at a distance from it, and not continuously with the primary pustule. In such cases, the manner in which the malady is propa- gated from the local injury,—which is most com- monly in the fingers,—to the seat of the diffusive inflammation, which is usually in some part of the trunk, has not been satisfactorily shown. It has been supposed to pass along the absorbents, and, arriv- ing at the axillary glands, to excite inflammation in them, extending to the surrounding cellular tissue ; others have thought that the process takes place along the veins; but the accuracy of either of those views has not been demonstrated by dis- section, both these sets of vessels having been found free from disease in cases of this descrip- tion. The history of this most dangerous malady, and the nature of the cause which excites it, ren- der it more probable tlrat the morbid impression is made upon the organic nerves of the part, and that the frame is soon generally affected, owing to the anatomical and functional relations of this system of nerves; the intimate connection of which with the blood-vessels disposing the consec- utive diffuse inflammation to appear on the same CELLULAR TISSUE—Inflammation of—Terminations. side with that on which the morbid impression was first made. The primary pustule is usually of very little extent or severity, often heals before the consecutive inflammation takes place, and is evidently the local effect of the virus upon the capillaries of the part to which it was applied. But it is quite insufficient to account for the rapid and violent constitutional disturbance which fol- lows, and which can only be explained by refer- ring it to the change produced by the morbid mat- ter in the organic system of nerves primarily, and consecutively in the vascular system, and in the blood itself. 15. The chief and not infrequent illustration of this form of the disease is furnished us in the cases which follow punctures received on open- ing recent subjects. In the course of ten or twelve hours from the time of sustaining the in- jury in the finger, or not until after five or seven days, the patient complains of rigors, remarkable debility, and frequency of pulse, with sickness at stomach, retchings, &c. A pustule appears in the part, but not always ; and generally no con- nection can be traced between it, even when it is formed, and the diffusive inflammation which takes place during the progress of the constitu- tional affection. In some cases, a few red lines may be traced, or swelling of the surrounding part is observed; but neither advances any dis- tance, the parts above being perfectly sound. In the course of the violent fever induced by the in- oculation in the hand, the consecutive inflamma- tion usually appears in the axilla, and extends towards the sternum, along the neck, down to the loins or haunch, or even to the thigh of the same side. In some instances, it terminates at the mesial line ; in others it passes continuously to the other side. It occasionally is translated from one side or part to the other, by a kind of metas- tasis, as in gout or erysipelas. 16. The inflammation of the cellular tissue of the trunk, whether arising from a continuous ex- tension of the disease from the arm, or part ori- ginally affected, as in certain states of the disease (§ 12, 13.), or in the course of the constitutional commotion (§ 14.) excited by the inoculation of a morbid virus, always possesses peculiar cha- racteristics : it is diffuse or extensive, without the smallest tendency to point; being flatly elevated above the sound parts, usually by a raised or defined margin. It is smooth and equal, without central hardness, and with all the characters already noticed (§ 12.). In general, no chords, which can be supposed to be diseased lymphatics, veins, or arteries, can be traced under the surface, and the glands are either very slightly or not at all enlarged. The diffused swelling commonly fur- nishes an obscure sense of fluctuation; but, fre- quently, when punctures have been made into it, little or no discharge has been procured. 17. The pain of the swollen part is most acute in every instance, whether the swelling be in an extremity, or extend along it to the trunk, or cc mmence in the trunk itself; and it is quite in- dependent of whatever affection of the skin may accompany the malady. In some cases, the in- teguments present not the least redness, although the cellular tissue has extensively suppurated, or even sphacelated ; but the skin is commonly more or less affected, although in a secondary manner, in consequence of the extension of disease from the cellular tissue to it, and generally subse- quently to the manifestation of acute pain. In the advanced stages, the skin has often a reddish or pink coloured blush, and occasionally a mot- tled or livid hue. In some cases, at a still further advanced period, solitary vesicles form over the diseased cellular tissue, and contain a serous, or sero-sanguineous, or ichorous fluid. The tem- perature of the part is sometimes much below natural. 18. B. The febrile commotion, whether appear- ing consecutively of the diffuse inflammation, directly produced in the part primarily injured, or previously to the affection of the trunk, is of a typhoid or adynamic type,' and is accompanied with the most marked disorder of the nervous sys- tem, with anxious collapsed countenance, and fre- quency of pulse ; more particularly when excited by the inoculation of a morbid matter, as by wounds from dissecting recent subjects, and when preceding the disease of the cellular tissue of the trunk. The fever sometimes commences insidi- ously, but more frequently in a very evident or tumultuous manner. The pulse soon becomes very quick, sharp, broad, soft, or compressible. The patient lies in the supine posture, with de- pressed shoulders, and without turning to either side. Delirium is common, but it is generally intermittent; and profound coma is rare. The respiration always is quick, laborious, and painful, partly owing to the inflammation of the cellular tissue of the side of the thorax, and its extension to the costal pleura. As the disease advances, the peculiar cadaverous fcetor emitted by the pa- tient, the yellowish or lurid hue of the surface, the offensive and sometimes coloured sweat, which in rare instances, proves critical, and the tendency to ulceration in the parts pressed by the weight, of the body, show that the blood, the secretions, and the soft solids, are more or less contaminated. Towards a fatal close, the raving delirium is often accompanied with muttering, and starting of the tendons ; and alternated with stupor; the breathing becoming panting, labori- ous, or interrupted. 19. The Terminations of the disease vary with the exciting cause, the state of the patient’s constitution, and the part primarily affected. When it arises from mechanical causes, as after veniEsection, simple puncture, &c., it may termi- nate with spreading suppuration, which may or may not be attended by sloughing of the cellular structure : and this result may occur both in cases which end fatally and in those that recover; a* partial regeneration of this tissue taking place in some of the latter. In the milder cases, the in- flammatory action changes its character, and shows a tendency to stop ; the disease terminating in phlegmonic suppuration and granulation. If the cellular substance adjoining a serous mem- brane become affected, this latter participates, and the inflammation spreads rapidly over it. generally producing an effusion of sanguineous serum; but sometimes, also, adhesion of the opposite surfaces. Occasionally the adjoining periosteum becomes diseased, and even the car- tilages and bones denuded. A fatal termination occurs either rapidly from the intensity of the disease, or more slowly from some one of its sequel®: and usually takes place, in the first instance, in fr an four to fourteen days; in the second, not till after two or more weeks, or even longer; but the common period is from the sixth to the tenth day. 20. III. Appearances on Dissection.—Dr. 357 CELLULAR TISSUE—Inflammation of—Diagnosis. 358 Duncan has given a very minute and accurate account of the successive changes that take place in the diseased structure. As the malady often attacks progressively various parts, it is some- times found after death, in all its stages, in the same subject. In the part last affected, which is frequently the space between the last ribs and the os ilium, the cellular substance is merely osdcmatous, with increased vascularity ; the infil- trated fluid being either limpid or tinged with red, and readily flowing from the divided tissue. In a more advanced stage, the effused matter is less fluid, often higher coloured, but not yet puriform. The diseased structure is next found gorged with a white semifluid matter, which greatly augments its thickness, separating the particles of fat at a distance from each other, but does not flow from the incision. In a subsequent stage, this matter is opaque, whitish, or reddish, or greenish, but is now so fluid that it flows from the incision. It is still, however, contained in the cells of the tissue; and it is only in the last stage, and after the texture of the part is entirely broken down, that this puriform matter is met with in collections, mixed with portions of the sloughy tissue. At this last stage the matter is not circumscribed by any cyst, or defined cavity, but is gradually lost in the adjoining cellular substance, without any line of demarcation. (See art. Abscess, §15.) 21. The cellular tissue itself is usually gray or ash coloured. It is detached extensively from the textures it connects, or adheres to them and the skin in sloughy shreds ; and long sinuous ca- vities are found between the tendons or muscles. The muscular structures adjoining are generally more or less diseased, the inflammation extending to their interfibrous cellular tissue ; which, how- ever, does not appear to be alone affected, the muscular fibres having their colour altered, and being more easily torn than in health. As re- peats the blood-vessels, the number of visible red arteries is increased, and the veins are enlarged, and turgid with black blood. Mr. J. Hunter states that he found, “ in all violent inflamma- tions of the cellular membrane, whether sponta- neous or the consequence of accident, that the coats of the larger veins passing through the in- flamed parts became also considerably inflamed ; and that their inner surfaces take on the adhesive, suppurative, and ulcerative inflammations ; for in such inflammations, I have found in many places of the veins adhesion, in others matter, and in others ulceration.” (Trans, of Soc.for Improve- ment of Med. Knowledge, 8vo. Lond. 1793, p. 18.) 22. The lymphatic vessels have not been suffi- ciently examined. The axillary glands have, however, been observed somewhat enlarged, and embedded in the diseased cellular tissue. Dr. Duncan states, that, although a tender and swelled axillary gland has been frequently men- tioned as one of the first symptoms observed, he has never found them so much changed as at all to support the idea that their affection was the primary cause of the alteration of the sur- rounding parts. The state of the fascice has been very generally overlooked in dissections of fatal cases of this malady, as well, indeed, as that of the blood-vessels and lymphatics ; but the fascice, tendinous expansions, sheaths of tendons, &c., are not always unchanged, although they appear not to have suffered in some instances. The skin is often severely affected, but not essentially or pri- marily, in the idiopathic form of diffuse inflamma- tion of the cellular texture. 23. IV. Diagnosis and Complications.—a. Dif- fuse inflammation is readily distinguished from phlegmonous inflammation of the cellular tissue, by the circumscribed hardness of the latter, by the elevation of the tumour, and its pointing and becoming soft in the centre ; and especially by the phlogistic character of the attendant fever, which will also indicate the nature of the disease, when phlegmonous inflammation is seated be- neath fascise. In the less severe cases of the diffuse disease, particularly when it is principally seated in those parts to which the exciting cause has been directly applied, and when it has been judiciously treated in the early stages, a disposition to pass into the phlegmonous state, by the form- ation of coagulable lymph, and the limitation thereby put to its extension, are very generally observed. Indeed, this change of character con- stitutes the favourable termination of the disease ; although it may also occur as a complication in unfavourable or even fatal cases, especially when veins or fasci® are also affected. 24. b. Diffuse inflammation of the cellular tissue is often consequent upon erysipelas, or complicated with it, particularly the erysipelas phlegmonodes; the difference between them con- sisting in the circumstance of this tissue being primarily and mainly affected in the former ; and consecutively of the inflammation of the skin, in the latter. 25. c. Inflamed veins may be distinguished from this disease, when they can be felt stretching like chords in the direction of the swelling, and when the pain and tenderness on pressure are chiefly limited to the same line. There is usually, also, little or no affection of the skin, even secondarily, and the disease is generally more confined to a limb ; fullness of the pectoral, cervical, and late- ral muscles and surface being commonly want- ing. (See Veins—Inflammation oj.) When the tumefaction is very great, it is extremely difficult to determine respecting the affection or non-affec- tion of the veins: the consecutive inflammation of these vessels, however, and its complication with this disease, is very common, as Mr. Hunter has so accurately stated, and -more recent re- searches have confirmed. 26. d. The diagnosis between this malady and inflamed lymphatics is also extremely diffi- cult, owing chiefly to the same cause, namely, to the oedema and congestion of the surrounding and distant cellular tissue consequent upon the obstruction of these vessels in the inflamed state. The existence of superficial red streaks, not con- nected with veins, running along an extremity from the part where the exciting cause is sup- posed to have been applied, and swelling of the lymphatic glands to which they lead, are the only proofs we usually possess of the lymphatics being diseased; and the absence of their appear- ance is the chief evidence of their being unaf- fected. But, as in cases of inflamed veins, dif- fuse inflammation of the cellular substance very generally follows inflammation of the absorbents, as satisfactorily shown by Abernethy, James, Duncan, and Breschet. The difficulty of diag- nosis, however, in a great proportion of cases, excepting at their commencement, must be evi- dently owing to the very sufficient reason of their co-existence. 27. e. The same circumstance also explains the difficulty sometimes found of distinguishing the disease from inflammation of the fascia; for in the majority of instances, the affection com- mences in the cellular tissue, and extends to the fascia, this latter structure being very rarely in- flamed primarily, unless after it has experienced some external injury. Even when the fascia is primarily inflamed, it will not be possible, on some occasions, to form an accurate diagnosis; as dis- ease commonly extends thence to the cellular tissue on each side of it. When the fascia is affected, either primarily or consecutively, con- traction of the limb is generally occasioned : but this is insufficient evidence of inflammation of the fascia, as inflammation and distention of the parts enclosed by it will produce this effect. When the disease commences in the cellular tissue, and ex- tends to that portion enclosed by fascia, or to this structure itself, the skin is often unaltered even colour. In a most severe case, attended by Mr. Parker and myself, the whole leg and thigh, to far above the hip, were affected, and the limb contracted, and yet the skin was natural. The inflammation may, however, originate in the skin, extend to the subjacent cellular tissue, thence to the fascia, and, ultimately, to the cel- lular tissue beneath it; forming an important va- riety of erysipelas, well described by Mr. Cop- land Hutchison, and constituting the triple com- plication of diffuse inflammation of the cellular substance with that of the skin on the one side, and with that of the fascia on the other, the first oeing most extensively and destructively diseased. The local and constitutional suffering in such cases chiefly arises from the pressure made by the fascia upon the inflamed and tumid cellular tissue underneath it. 28. /. Whilst it is important to distinguish be- tween injury or inflammation of a nerve, and this malady, it must not be overlooked that the one is often associated with the other ; priority of affec- tion in respect of either being the chief object of diagnosis. When, after a puncture or other local cause, very acute pain is complained of, particu- larly in the situation and the course of a nerve, with severe or obstinate symptoms of great ner- vous irritation, convulsions, &c. accompanying it, we may conclude that the disorder has originated in a nerve ; and, if to those symptoms are added the diffuse, boggy swelling, &c. already described (§ 12.), we may likewise infer that diffuse inflam- mation has subsequently attacked the cellular tissue. 29. g. I have met with some instances of dif- fuse inflammation of the cellular tissue as a com- plication and termination of several severe or fatal states of disease in the puerperal state, both with and without affection of the skin ; but only in the wards of a lying-in hospital. They have appeared in two forms: 1st, In the advanced progress of asthenic inflammation of the uterus, attended with an excoriating and foetid discharge, which has first irritated the skin about the nates,—the cellular tissue underneath becoming diffusely inflamed to a great extent, and destroyed ; and 2d, After cases of inflammation of the uterine veins, evidently in consequence of the vitiation of the circulating fluid Dr. Otto, Dr. Duncan, and Dr. Craigie, refer phlegmasia dolens to diffuse inflammation of the cellular substance. But, I think, on insuffi- cient evidence. If this tissue be really inflamed in that disease, other structures participate ; and CELLULAR TISSUE—Inflammation of—Pathological Inferences. it certainly is not the part first affected. In the cases which I have seen examined after death, —only three in all,—the nerves and veins were the parts to which the symptoms of disorder were first referred; the veins being obstructed in all the cases. (See Phlegmasia Dolens.) 30. h. The cellular tissue of the side of the neck and throat is sometimes diffusely inflamed, apparently from an extension of disease, in an- gina maligna, and worst form of scarlet fever, the patient sinking from it rapidly. I have, however, met with one case of this description, where re- covery ultimately took place. This disease also rarely occurs near the anus, or about the buttock and perinffium, in the course of fevers, dysentery, &c. But it is more disposed, on these occasions, to limit itself, and to terminate in suppurating ab- scesses. When it occurs in aged persons, from the escape of urine into this tissue, it generally extends rapidly and terminates fatally; and a nearly similar result follows its appearance after important surgical operations, as after lithotomy, amputations, and the ligatures of veins and arte- ries for aneurismal dilatations of them. 31. Y. Pathological Inferences.—a. Con- formably with recently accumulated facts con- nected with diffusive inflammation of the cellular tissue, it may be concluded that it presents various morbid associations and grades of intensity, as well as distinct relations to the attendant constitutional disturbance, according to the diversified causes which occasion it:—1st, That depressed vital power, or a previously disordered state of the chylopoietie viscera, or general cachexy, is often requisite to its occurrence: 2d, That abrasions, the irritation of acrid secretions or decomposed animal or vegetable matter, simple punctures, in- juries received during the dissection of subjects in a state of incipient decay, and the contact of mor- bid fluids, most commonly produce the disease pri- marily in the part in which the injury is sustained, the mischief spreading continuously from thence ; although occasionally appearing afterwards in other parts, without any continuous connection, when the circulation has become contaminated by the primary affection : 3d, That, when originating and spreading as now stated, sometimes the skin, at other times the veins, occasionally the lym- phatics, on some occasions the thecse or fasciae, and more rarely the voluntary nerves, or any two or more of these, participate more or less in the disease; 4th, There appear to be other causes, which, acting in the manner of specific poisons produce comparatively but little effect on the part to which they are directly applied; but which affect the system universally, chiefly by depres- ing and otherwise changing the organic, nervous, and circulating functions, the alteration of the cel- lular tissue appearing subsequently: 5th, That the local affection in this form of disease, which may be denominated consecutive diffusive inflam- mation of the cellular tissue, is often of very small extent compared with the severity of the consti- tutional disturbance ; and, very frequently, ap- pearances of contamination of the frame present themselves before the cellular tissue is affected, and even then the affection may be trifling, or even not recognisable (see Poisons—Animal): 6th, That the malady originating in the inocu- lation of a poison or virus, particularly during the examination of recently dead bodies, cannot be ascribed to inflammation of veins, or of lymph- atics, or of nerves, or of fasciae, or even of the 359 360 cellular tissue itself; and that, although this last most frequently exhibits morbid appearances, yet are these appearances obviously contingent upon general disease of the frame, interesting in a spe- cial manner its various vital manifestations. (See Author, in Lond. Med. Repos, yol. xx. p. 24. 1823.) 32. b. As respects the association of the local and constitutional affection, all the cases of this disease may be divided into two classes:—1st, Those in which the constitutional disturbance is mainly owing to the primary local lesion, or its extension, whether it be inflammation of the cel- lular tissue alone, or of this tissue associated with inflammation either of veins, lymphatics, theca}, aponeuroses, or of the skin ; the relation subsist- ing between the intensity of the primary local affection, and the constitutional disorder, being more or less apparent and co-ordinate (§ 12, 13.): 2d, Those in which the local lesion is obviously the least important change that has been induced, either directly by the exciting cause, or consecu- tively by the constitutional affection ; and, even when it becomes the most serious, is manifestly the result of the constitutional affection (§ 14.), and disproportioned to it. Thus the local and the general symptoms are presented to us in a differ- ent order in these two forms of the disease. In the first, also, the febrile action is more inflamma- tory than in the second, but still partaking of the irritative character, as has been very justly in- sisted upon by Mr. Travers. In the second, it is more asthenic ; the nervous system is much more disordered ; the anxiety, distress, and men- tal and physical depression, are greater than in the first; and all the organic functions more gravely affected ; the blood, the secretions, and soft solids, becoming at last very evidently altered.* (See Blood, § 139. et seq.) 33. VI. Prognosis.—The danger of this dis- ease is much less when it is accompanied with in- flammatory, than with adynamic or highly irrita- tive fever, and morbidly excited sensibility. In general, the rapid extension of the disease from the arm to the trunk; great tumefaction of the region of the pectoral muscles; the first appear- ance of the inflammation in this situation, or in any part of the trunk, from causes which first occasioned serious constitutional disturbance ; re- markable frequency of pulse following rigors, with anxious collapsed countenance, ferrety eyes, delirium, difficult respiration, depression of mind, the accession of fresh rigors, extreme debility, and stupor ; are all indications of great danger. The nature of the cause, also, should influence the prognosis. When it proceeds from the liga- ture of a vein, vensesection, and particularly from wounds in dissecting recent subjects, the danger is great. There is, however, less risk when the CELLULAR TISSUE—Inflammation of—Treatment. disease arises in the part to which the cause has been applied, and when the skin becomes much affected with a disposition of the inflammation to limit itself, and form healthy pus, than when it appears consecutively of a pustule merely in the part inoculated, and of fever with extreme de- pression. 34. VII. Treatment.—A. Prophylaxis. Pre- cautions are absolutely requisite when punctures are received in post mortem examinations, or when the cuticle about the nails and hands of the examiner is abraded. Some constitutions are more liable to be inoculated in this way than others, particularly persons who are out of health at the time, or whose vital energies are depressed Wearing gloves during a morbid dissection may be of use in such circumstances. Dr. Duncan suggests the anointing of the hands with cam- phorated oil, or with simple axunge, before hand- ling the viscera. Abrasions about the fingers should be protected by adhesive plaster. If, not- withstanding, punctures are received, or if an abraded or punctured part come in contact with any of the fluids or soft solids of a recently dead body, with animal or vegetable matter in a state of decomposition, with acrid or morbid secretions, suction or perfect ablution of the part ought in- stantly to be performed ; a pledget of lint, wet with either a strong solution, or the oil of camphor (F. 449.), or with turpentine, applied to it, and the application covered so as to prevent its quick evaporation. On the several occasions of the employment of these means, in the persons both of myself and of my medical friends, no dis turbance has accrued from these accidents. Two partial exceptions, however, have occurred, but in such a way as to confirm the propriety of this practice, and illustrate the nature of one form of the disease. The punctures, in these two cases, were received when examining the bodies of fe males who had, but a few hours previously, died of malignant puerperal fever; and the applica- tion was not resorted to until after leaving the apartment where the inspection was made. In one of those cases,—that of a pupil,—camphor was used ; in the other,—that of my friend, Mr. Churchill,—ammonia was employed. Both these gentlemen experienced, within twenty-four hours afterwards, considerable general disturbance, with sickness at the stomach, and nervous depres- sion and debility. All disorder, however, disap- peared in a day or two after the exhibition of warm diaphoretics and stimulants ; but in neither case was the least irritation observed in the part punctured. The morbid impression was evidently made upon the organic nervous sys- tem, as evinced by disorder of the functions more immediately dependent on it; but was not so intense, relatively to the state of predisposition, as to occasion further disease. As to the use of ligatures, &c., I must refer the reader to what I have stated respecting them in the article on Ani- mal Poisons. 35. B. Curative treatment.—a. It will be evi- dent, from the history of diffusive inflammation of the cellular tissue, that local means are chiefly applicable to certain of its states and complica- tions. When the primary local affection is at- tended by much pain, both cold and warm ap- plications have been recommended by different writers. The choice, however, between them, may be determined by the sensations of the patient but warm fomentations, unremittingly * It may be stated at this place, that the disease which has been observed to follow inoculation of an animal poi- son during the examination of recent subjects is obviously distinct from diffuse inflammation of the cellular tissue, although this local affection, or some modification of it, often takes place in the advanced stage of that disease, which has accordingly been referred to in this article as one of the chief causes of the lesion now under consider- ation. The subject is, however, considered more fully in the article on Poisons. In justice to myself, I should state, that I published, in the London Medical Repository for July, 18-23, p. 24—27., some remarks on the nature of the malady infected by inoculation from recent subjects, and the operation of animal poisons on the economy ; and I request the favour of the reader who is interested in these important subjects to refer to these remarks, and to the conclusions to which Mr. Travers has come, in his work on Constitutional Irritation, p. 413. Lond. 1826 CELLULAR TISSUE—Inflammation of—Treatment. 361 employed, appear to me the safest, particularly when inflammation is externally apparent. When the local affection is limited chiefly to the part to which the cause was applied, or its vicinity, the detraction of blood from it by leeches or scarifica- tions, and incisions through the integuments, ought not to be neglected. The latter of these two modes of local evacuation, as first recom- mended by Mr. Copland Hutchison, is evidently the most beneficial, not merely by procuring a more decided and rapid discharge, but also by giving an external outlet to the matter which otherwise would infiltrate the cellular tissue, and extend the mischief. Even in cases of great vital depression, and when the cellular tissue is con- secutively diseased, incisions should not be neg- lected ; they being compatible equally with an energetic, tonic, or stimulating treatment, as with its opposite ; and they are not the less necessary in the early stages than at later periods, and when fluid is diffused through the cellular struc- ture. When the part affected is deeply seated, they should be deep and large, so as fully to reach it; their number being proportionately diminished. But the great object is to make a free passage for whatever fluid matter may have formed, or that will form subsequently. This practice has re- ceived the approbation of Dr. Duncan, and the best recent writers on this disease ; and its pro- priety has satisfactorily been shown in those cases which have fallen under my own observation. 34. b. The general means of cure are usually directed with the intention of subduing the local affection, and more especially the state of high nervous sensibility and vascular irritability which exists, whether this state be consequent upon the primary lesion produced by the exciting cause, or whether it be the immediate effect of that cause, and the antecedent of any affection of the cellular tissue, as in cases of inoculation by mor- bid matters or animal poisons. But, although this intention is generally kept in view, very different, and even opposite, measures have been recom- mended for fulfilling it. ' It is evident that the same measures are not suitable to all states and periods of the disease ; and possibly to this cause may be imputed the great diversity of means which have been advised, and the partial success attributed to very opposite methods. Much also is owing, more generally than has been admitted, to the constitutional powers of the patient. A number of practitioners and writers advocate general blood-letting, and trust chiefly to it for the fulfilment of the above intentions, without adverting to the fact, that the morbid states form- ing the essential characters of the disease are, in their severest and most deadly forms, independent of sthenic action, and cannot be either limited or subdued by venaesection, although it may bo re- quired to a moderate extent; particularly when the local affection arises primarily q,nd directly from the exciting cause, implicates any of the parts which I have noticed as being involved in its complicated forms, and is chiefly antecedent of the grave constitutional disturbance character- ising the advanced stages of disease. But even in such cases, the depletion shoidd be prac- tised early, and confined chiefly to young, ple- thoric, or robust persons; the local evacuation con- sequent upon free incisions being sufficient in most cases. In other respects, the treatment in this form of the disease may be similar to that recom- mended in inflammation of the veins; for the principle acted upon by Mr. John Hunter in re- spect of that malady, and which is founded in accurate observation, is equally applicable to this —namely, to impart energy to the system, so as to enable the vessels to form coagulable lymph, by which the extension of the morbid action may be limited, and a diffusive or spreading inflamma- tion may be converted into the phlegmonous state. This practice is still more imperatively re- quired in the other form of the disease, or that in which the affection of the cellular tissue is con- secutive of a constitutional disturbance, excited by a morbid virus or animal poison. 35. The frequent inefficacy of depletions and the antiphlogistic treatment, and even their inju- rious effects as shown by the rapid sinking con- sequent upon them, are fully demonstrated by the history, given by Dr. Butter, of the disease which occurred in Plymouth Dock, and by the cases after wounds in dissection recorded by va- rious writers. The instances of recovery after this practice cannot be brought as evidence of its efficacy ; inasmuch as the smallness of their number: the tonic treatment, which, in several of them, followed vascular depletions; and constitutional energy ; may be adduced to disprove it. After studying the cases which have been published by Dr. Duncan, Dr. Colles, Mr. Travers, Dr. Dease, Dr. Butter, &c., and re- flecting on my own limited experience, I would strenuously recommend the following measures, in addition to those already advised:—As to the question of blood-letting, that is already disposed of; but I may further add respecting it, that, however great the severity of the pain, or the senso- rial excitement; or however frequent, open, sharp, or bounding the pulse ; these symptoms should be arguments against, rather than in fa- vour of vensesection. But if the pulse be not re- markably frequent, or if it be firm and constricted, then this operation ought to be performed. Yet I should expect little or no advantage from this practice, in those cases of the disease which pro- ceed from the inoculation of putrid or morbid ani- mal matters or poisons, whatever the character of the pulse may be. It is, however, seldom such as can warrant depletion in these cases; being generally of the former description, and rarely of the latter. The object which we should propose to accomplish, next to that already stated, is to rouse and support the energies of life, and thus to oppose to the extension of the disease an augmented vital resistance. This can be done only by a stimulating and tonic treatment, and by the expulsion from the frame of such imt uri- ties and morbid matters as may tend to impede the natural functions, and depress their energies. The means which we should employ with these views, if judiciously selected, will be more effica- cious than any other for the fulfilment of the in- tention proposed above (§ 34.). The agents which I have found most successful in attaining them, are large doses of camphor, with opium, sometimes also with calomel, and the occasional exhibition of spirits of turpentine, either alone or with castor oil, and of one of the enemata (F. 148, 149.) contained in the Appendix. The plan I have followed in several cases of this disease, mostly of a more or less complicated nature, which I have treated, has been to give the fol- lowing bolus, or the pills first prescribed; and a CELLULAR TISSUE—Induration of. 362 few hours afterwards the draught, which, in three or four hours, should be followed by an enema (F. 151.): No. 104. ft Camphor® ras® gr. x.—xv.; Hydrarg. Chloridi gr. x.—xx.; Opii Puri gr. jss.—ij.; Pulv. Capsici gr. iv.; Conserv. Rosar. q. s. ut fiat Bolus, statim sumen- dus, et horas post tres vel quatuor repetendus. No. 105. ft Camphor® ras® gr. vij.—xij.; Ammon. Sesqui-earbon. gr. xv.; Hydrarg. Chloridi gr. xx.; Pulv. Capsici Annui gr. viij.; Opii Puri gr. iij.; Mucilag. Aca- ciffi q. s. ut Fiant Pilul® xij., quarum capiat duas omni hor;l vel bihorio. No. 106. ft Olei Terebinthin® 5 ss.—? j- (vel etiam Olei Ricini 5 ss.) i Olei Cajuputi tH,vj.; Lactis Recentis % ij. Fiat Haustus. 36. If a free evacuation of the bowels be pro- cured, the bolus and draught should not be re- peated more than once; if the evacuation be scanty, they may be given a third time, having prolonged the period between the second and third doses ; in the intervals between which, as well as subsequently, the following pills and draughts may be taken:— No. 107. ft Camphor® ras® gr. iij.—v.; Ammon. Ses- qui-carbon. gr. iv.; Pulv. Capsici gr. j.; Mucilag. Acaci® q. s. M. Fiant Pilul® ij., secundd, tertia, vel quarti quaque hora sumend®, cum Ilaustu sequente. No. 108. ft Mist Camphor® ?j.; Liq. Ammon. Acet. 3jss.; Spirit. ASther. Sulphurici Comp. 3 j.; Tinct. Cap- sici Annui TIlx.; Syrupi Aurantii 3 ss.; M. Fiat Haustus, cum Pil. supra pr®scriptis capiendus ; vel. No. 109. ft Infusi Cinchon® § j.; Liq. Ammon. Acet. 3 ij.; Spirit. Ammon. Arom 3 ss.; Tinct. Capsici ITj xij. Olei Cajuputi ITJ, vj. M. Fiat Haustus, ut supra sumen- dus. 37. In the slighter cases, less active means will be found sufficient; but when the disease assumes a serious form, and particularly if the constitu- tional symptoms manifest themselves before the affection of the cellular tissue has commenced or made any sensible progress, the above or simi- larly active remedies must be energetically pre- scribed. 38. During the course of the more adynamic states of the malady, after aivine evacuations have been procured, I have seen the best effects follow the liberal use of wine, and large doses of bark with the aromatic spices. If the tongue and mouth be parched, the pills or bolus, and the tur- pentine draught, prescribed above, should precede the exhibition of the wine, bark, or sulphate of quinine. The irritability of the stomach and de- lirium, often accompanying the advanced stage of the worst states of the disease, being more rea- dily allayed by powerful stimuli, as camphor, cap- sicum, ammonia, ether, spirits of turpentine, cajuput and other essential oils, wine, bark, sul- phate of quinine, brisk bottled ale and stout, very small doses of opium', brandy, &c., than by me- dicines of any other description, it will be neces- sary to administer these, in forms of combination suited to the circumstances of the case; chiefly with the view of rousing and supporting the ener- gies of life, changing the state of morbid action, and thereby preventing the extension of the local mischief, and the tendency to contamination of the fluids and solids of the frame. The regimen during the treatment should be in accordance with these intentions, and the patient should be allowed what he may crave for; as desire in such cases for articles of food, or for particular beve- rages, is the instinctive expression of the wants of the economy. Bibliog. and Refer.—Morand, Hist, de l’Acedbmie Roy.des Sciences, An. 1766.—J. Hunter, Med. and Philos. Comment, vol. ii. p. 430. 8vo. ed. 1775.; and Trans, of Soc. for Improvement of Med. Knowledge Lond. 1793.— Wilson and Wells, Ibid. vol. iii. pp. 360. 367.—C. Smyth, Med. Communications, &c. vol. ii. p. 190. Lond. 1790 —Colics, On Wounds received in Dissection, Dublin Hosp. Reports, vol. iii. p. 200.; et Ibid. vol. iv. p. 240.— Uease, in Edin. Med. and Surg. Journ. July, 1826.— Wise- man, in Ibid. July, 1825.—Duncan, Trans, of Med. and Chirurg. Soc. of Edin. vol. i. p. 470.—Herisse, in Journ. de M6d. fee. t. xii. p. 417. Paris, 1806.—Home, Philos. Trans, for 1810, p. 75.—James, On the Nature and Treatment of lnflam. &c. 8vo. Lond. 1821.—Jt. C. Hutchison, Trans, of Med. and Chirurg. Soc. vol. v. p. 280.— Travers, On Con- stitutional Irritation, 2d ed. 8vo. Lond. 1827.; in Lond. Med. and Phys. Journ. Feb. 1823, p. 176.—Barlow, in Ibid. Aug. 1823, p. 177.—Rust's Magazin fur die Ge- sammte Heilk. b. xiv. p. 100.— Wansborough, in Lond. Med. Repos. May, 1823, p. 353.—Jluthor, Ibid. vol. xx. p. 24.—Shaw, in Med. and Phys. Journ. A]). 1825, and Feb. 1827.—Nelson, in Ibid. Aug. 1823.— Thomson, in Ibid. Ap. 1825.—Forbes, in Ibid. July, 1826— Earle, in Ibid. Jan. 1827.—Butter, On Irritative Fever, &c. 8vo. 1825.—Craigie, Gen. and Path. Anatomy, 8vo. p. 34. Cellular Tissue—Induration of. Syn. (Edematie concrete, Billard. Sclereme, Chaussier. Squirrho-Sarque. Beaumes Skin-bound. Classif. III. Class, I. Order {Author). 1. Defjn. A wax-like consistence of the skin and sub-cutaneous cellular tissue, commencing in the hands, face, and lower extremities—the parts most remote from the centre of the circulation ; often extending to the trunk, the parts being cold, often pale, yellowish, or rose-coloured, frequently mottled, or livid, with weak pulse and respira- tion, terminating in congestion of the lungs and asphyxy. 2. This affection was first described, in 1718, by J. A. Uzembezius, physician to the hospital at Ulm, and afterwards more fully investigated by Doublet, Andry, Auvity, Hulme, Denman, and Underwood, as well as by several contemporary writers. It is very prevalent and fatal in some of the lying-in and foundling hospitals on the Continent, but is comparatively rare in this coun- try, especially during recent times. Its nature and seat have been much discussed by foreign medical writers ; and even at present, various points connected with its pathology are not fully established. It is, however, evident that the dis- ease assumes various forms, and exhibits different morbid relations, which may be referred to the two following varieties. Var. i. (Edematous Hardening of the Cellular Tissue; Sclereme cedemateux, Ciiaussier and Duges. 3. In this form of the disease, the sub-cuta neous cellular tissue is infiltrated with a yellowish coagulable albuminous serum; the limbs of the infant are more or less tumefied as well as hard, are somewhat rigid, and the skin assumes a vio- let tint, owing to the pulmonary congestion ac- companying it; with weak oppressed respiration, and feeble irregular pulse. In some cases, it commences with simple oedema, particularly when it arises from exposure to cold. If the cold have acted upon the greater part or whole of the sur- face of the body, the affection is sometimes more or less universal, but usually most remarkable in the limbs. It rarely attacks the abdomen, chest, and neck. The parts diseased are cold, tumid, discoloured, insensible, hard, and receiving and preserving the impression of the finger when very firmly applied. During the progress of the affec- tion, the cry becomes very weak and peculiar; dyspnoea increases; the thorax is dull on percus- sion ; and the impulse of the heart and the re- spiratory murmur, are found weak on ausculta- tion. Death often follows in from four to eight days, without any convulsion, but generally pre- CELLULAR TISSUE—Induration of—Pathology. 363 ceded by a lethargic somnolency ; and spasmodic attacks resembling slight trismus, and opisthotonos sometimes occur in the advanced stage. The in- durated parts occasionally assume an erysipela- tous appearance, and, in rare instances, pass into sphacelation. In favourable cases, or after an early and judicious treatment, the affection sub- sides ; the hardness, and afterwards the oedema, disappearing in the course of two or three weeks. M. Gardien states, that he observed suppuration of the affected part to occur in one case only. Var. ii. Induration affecting chiefly the Adi- pose Tissue; Sclereme concret, Ciiaussier, Duges ; Skin-bound, of English authors. 4. This variety generally depends upon the sudden impression of severe cold ; is compara- tively rare, and is chiefly met with in lying-in and foundling hospitals. The cheeks, limbs, fore- arms, thighs, back, abdomen, chest, and neck, successively, or two or more of them simultane- ously, assume a remarkable hardness, which yields not to the pressure of the finger. The temperature and sensibility of the surface are much depressed ; and with difficulty raised. The skin is pale or yellowish and wax-like ; sometimes livid or mottled. Trismus and opisthotonos are more common in this than in the preceding va- riety. There is little or no tumefaction or oedema ; the skin being fixed and immovable upon the subjacent parts. In some instances, the extre- mities and back are somewhat emaciated, dry, and even rigid, particularly in the advanced stage ; and the cheeks and temples are collapsed. At the commencement, the appetite and digestion are often not much affected ; but during the pro- gress, and towards the close of the disease, the bowels become more or less disordered. Dr. Den- man and Dr. Underwood seldom met with it but accompanied with some bowel complaint. Tne infant soon becomes too feeble to draw the breast ; it utters a peculiar moaning noise, or feeble whining cry ; and has the appearance, even early in the complaint, of dying; and, at last, sinks apparently asphyxied. In favourable cases, the skin and extremities lose their hardness and rigidity, and the infant recovers gradually, if pulmonic inflammation does not come on, and carry it off. Inflammation of the indurated parts seldom or never appears in the course of this variety. 5. I. Pathology.—M. Gardien states, that he has sometimes remarked a slight increase of heat precede the insensibility, coldness, and hardness of the parts affected ; but without any general febrile symptoms. The only indications of dis- order he has observed to usher in either variety, are difficulty of respiration, and a peculiar feeble- ness of the pulse and of the voice. Somnolency or lethargy is very usual during the course of the disease, and, as M. Doublet observes, increases towards a fatal termination. The affection, par- ticularly the latter variety, is rarely congenital. M. Dupargue has detailed two cases in which the infant upon delivery was so hard and rigid as to resemble a mummy, the vessels of the umbili- cal chord being diseased. 6. A. Causes.— The different states of this disease have been attributed to a syphilitic taint. It is, however, most commonly owing to the influence of cold upon new-born infants, and generally occurs from the second to the four- teenth day after birth. Imperfect or unwhole- some nourishment, and the influence of a vitiated atmosphere, particularly the air of crowded hos- pitals, upon the imperfectly developed respiratory functions, are, in my opinion, amongst its most energetic causes. It is very apt to occur in pre- maturely born infants, in those of a feeble con- stitution, and who are deprived of the mother’s or nurse’s milk. M. Palletta remarks, that out of sixty-five cases, forty were prematurely born. M. Ratjer states, that its dependence upon at- mospheric cold is shown by the greater number of cases at the Hospice des Enfans Trouves, when winter sets in. But as a free ventilation, and dissipation of the foul air of an hospital ward, are in some measure prevented during cold wea- ther, the prevalence of the disease at this season may be equally owing to this circumstance. M. Bjllard has shown that the number of cases in the warm months is usually not much less than in the cold, in the above-named hospital. Dr. Bigeschi, however, states a fact, in his report of the Lying-in Hospital at Florence, which shows the great influence of cold in causing this affec- tion. He observed the disease very prevalent during the winter season, especially if rigorous ; and he consequently ordered the infant to be kept in the mother’s bed, as warm as possible ; and from that time no case of it occurred. M. Sou- ville has met with the disease frequently in the northern departments of France, and also attri- butes it chiefly to cold, the influence of which is likewise admitted by Palletta. It sometimes, also, occurs in the course of the bowel complaints incidental to infants, particularly when improper- ly nourished ; and it is frequently complicated with the jaundice of this epoch. M. Billard states that, in seventy-seven cases with (edema- tous induration, thirty were jaundiced. 7. B. Appearances in fatal cases.—In the first or most common variety, the cellular tissue is found loaded by a thick albuminous serum, which coagulates by heat, and which, according to M. Leger and M. Billard, partly escapes upon dividiug it. Dr. Palletta, however, states that, upon division, it remains firm and concrete, the infiltrated matter not escaping. In the second or more rare form of the affection, the cellular and adipose tissues are hard, concrete, and frequently of a deep yellow colour. The adipose tissue of- ten presents a number of small dark yellow grains dispersed through it. The lymphatic glands, as well as the mesenteric glands, are enlarged ; and slight serous or sero-albuminous deposition into the cellular tissue is observed throughout the body, with sanguineous or sero-sanguineous infil- tration of parts of it; and effusion into the shut cavities. The vessels of the brain are usually congested. The cavities of the heart are loaded with blood ; the foramen ovale is sometimes more open than it should be; the pericardium contains some sanguineous serum ; the lungs are often congested or hepatised ; and the larynx and epiglottis cedematous. The liver is frequently large and congested ; the gall bladder and he- patic ducts full of bile ; and the gastro-intestina’ mucous surface more or less inflamed. The mos constant morbid appearances are the engorgement of the venous system ; the dark or black state of the blood; the accumulation of a thick, deep- coloured, viscid, or coagulated fluid in the adipose and cellular tissues, imparting to them a condensed or firm appearance ; and the congestion of the tho- racic viscera: but these latter are commonly not otherwise diseased. 364 CELLULAR TISSUE—I.nduramix of—Treatment. 8. C. Proximate Cause.—The first variety of this affection may be considered as a form of oede- ma ; the peculiarity resulting chiefly from the thick, coagulable nature of the effused fluid, and the deficient developement of animal heat in parts far removed from the centre of the circulation ; in consequence of which the adipose matter either is secreted in a morbid state, or cannot be pre- served in its natural semifluidity. The second or more rare form of the affection is chiefly to be attributed to this change of the adipose substance, which, owing to defective vital manifestation in the part, and the depressed grade of animal warmth, assumes the condition which it usually presents soon after death. M. Denis supposes that the disease is connected with the gastro- intestinal irritation so frequently found upon dis- section. Dr. Holme and, more recently, Dr. Palletta viewed it as consecutive of, and occa- sioned by, the congestion of the lungs and the difficulty of the pulmonary circulation ; whilst M. Baron, physician to the Parisian Hospital, in which from two to three hundred cases occur every year, considers that the internal congestion takes place subsequently to the appearance of the disease. I believe that this is the more cor- rect view; for M. Billard found unusual con- gestion or hepatisation of the lungs in less than one half the cases he examined. There can be no doubt, however, that as the affection of the cellular tissue proceeds, and as the circulation in this tissue and in the extremities is more and more retarded, congestion of the internal viscera comes on, but not always in the same organ; the encephalon, cavities of the heart, liver, and spleen, also experiencing this change ; sometimes with serous or sero-sanguineous effusion into the ad- joining shut cavities. The frequent complication of the disease with jaundice would seem to in- dicate that the biliary organs are more or less affected ; and such may be the case in respect of their functions : but M. Billard found, in ninety cases, twenty only of organic lesion of the liver, the icteric appearance being evidently dependant upon the morbid state of the serum of the blood, and the deficient vital endowment of the cutaneous capillaries. M. Breschet had found the foramen ovale more than commonly open in many cases, and inferred that the affec- tion was caused by this circumstance. M. Bil- lard states that his numerous examinations do not countenance this inference, but admits that they are often coincident changes. This writer, Who has paid much attention to the subject, concludes, that general debility, congenital ple- thora of the vascular system, congestion of venous blood in the tissues, and unusual dryness of the skin previous to the exfoliation of the epidermis, are its chief predisposing causes; and that vas- cular plenitude, an engorged state of the cellular and adipose tissues, and the influence of external agents interrupting cutaneous transpiration, are its more immediate causes ; the coldness of the extremities and affected parts resulting from the slowness of the circulation and the depression of the vital powers. 9. Diagnosis and Prognosis.—A. This affec- tion is obviously more or less intimately related to oedema on the one hand ; and, in some in- stances, to erysipelas on the other : — to the former, by the effusion of fluid in the cellular tissue ; but differing from it chiefly in the persist- ent, firm, wax-like, and coagulated state of the infiltrated part, and in the reddish yellow, livid, or mottled appearance of the skin ;—to the latter, by its frequently dark red, or livid colour; but differing still more widely from it, in the principal affection of the cellular tissue, in the remarkable coldness of the part, languor of the circulation, and general absence of any change in the skin itself. And it is distinguishable from both, by the peculiar cry of the infant; the weak, moaning, and sibilant respiration, the dyspnoea, the feeble irregular action of the heart; the leipothymia and lethargy, and the frequent complication with tris- mus and tetantic spasm ; as well as with the pecu- liar jaundice of infants. It may be also mistaken for erythema nodosum; but the knotted sensation, upon passing the fingers over the skin, furnished by this affection, is sufficient, of itself, to distin- guish it from the smooth, cold, and diffused hard- ness of the present disease. • 10. B. The Prognosis should be always re- served or cautious. A large proportion of those attacked die, particularly in hospitals, even under the most judicious management; sometimes, in two, three, or four days, in the most severe cases, and in prematurely born children that have been exposed, soon after birth, to cold. But, generally, the disease does not terminate either way in less than from six or eight days to twenty or thirty. It may even be more prolonged ; and, when re- covery is advancing, inflammation of the lungs or digestive canal, or effusion of the brain, may occur, and either cut off the patient, or put his life in the utmost jeopardy. 11. II. Treatment.—The intentions of cure will vary with the particular form of the disease. In the first, or oedematous variety, in which vas- cular plethora is generally present, depletion is often of service ; particularly if the circulation in the extremities and affected part be at the same time excited by means of frictions with warm sti- mulating liniments. MM. Baron and Billard prefer frictions to the use of the vapour bath, re- commended by MM. Duges, Peligot, and others. In the second variety, in which there is less mde- ma, and greater induration, and, according to se- veral recent writers, a coagulated state of both the adipose substance and the fluid effused into the cellular tissue, blood-letting may not bo admissible. MM. Chambon, Palletta, and Gardien, how- ever, consider that, in this variety also, depletion should be practised, in order to relieve the cere- bral congestion attending it; and therefore re- commend two small leeches to be applied behind the ears. In this practice I have generally con- curred, but have adopted it with much caution in prematurely born or weakly infants ; directing, also, for all the states of the disease, calomel or hydrarg. cum creta, with soda, and small doses of ammonia ; the compound decoction of sarsaparilla with liquor potassae ; the warm bath, followed by repeated frictions of the surface with stimulating liniments; and the nourishment of Nature intend- ed for the infant. Although a very common and fatal disease in France, it is seldom observed in this country, and even at the Infirmary for Chil- dren, cases of it have very rarely presented them- selves. I have not met with an instance of it in the Queen’s Lying-in Hospital. 12. After the above means have been perse- vered in for a time, a few drops of spirits of tur- pentine and sweet spirits of nitre may be given occasionally in sugared dill-water; and the infant enveloped in very soft flannel or wash-leather, which ought to be covered over with oiled silk, in order to prevent the dissipation of the animal heat. Dr. Palletta states that he treated, with uncommon success, the very numerous cases that occurred in the Lying-in Hospital at Milan, with half a grain of the kermes mineral (F. 637.) given three or four times a day, and warm bran or warm flour applied to the parts affected. An- dry and Gardien advise the use of blisters;— the former to the affected parts; the latter to the nape of the neck, with the view of preventing the occurrence of cerebral congestion;—but I have had no experience of their use in this disease; and consider them less efficacious than frictions with stimulating liniments, several formula) for which are given in the Appendix. During treat- ment, a pure warm air, and the natural food of the infant, furnished by a healthy nurse, will be found extremely conducive to recovery. [Induration of the skin is a very rare disease in this country, but few cases having come under our observation during a practice of near twenty years. Dr. Condie states, (“ Diseases of Chil- dren”), that although connected as physician, for 18 years, with one of the largest medical chari- ties, perhaps, in this country, he has met with but twelve cases of the disease during that period. In the Foundling Hospital of Pans, 645 cases oc- curred between the years 1808 and 1811, of which number, 567 terminated fatally ; and in 1826, there occurred in the same institution 240 cases, of which 50 died.—(Billard.) In most of the cases, where the disease has come under our notice, it occurred in new-born infants, of a deli- cate habit, where the mother was in ill health, or of intemperate habits.—The condition of the skin should always be regarded as of less importance than that of the system generally, as death usually results from derangement of the internal organs, and not from the state of the integuments. The treatment should therefore be general, rather than local. Such as small doses of calomel in combi- nation with ipecac, three or four times a day, with the occasional use of castor oil, the vapour bath, or a leech or two to the epigastrium, if there are symptoms of acute, or sub-acute inflamma- tion of the gastro-intestinal mucous membrane.] Biblioo. and Refer.— Uiembeiius, in Ephem. Nat. Curios, cap. ix. ob. 30. p. 62. 1718.—Doublet, in Journ. de Med. Avr. 1785, p. 447.—Beaumes, Fondemens de la Science Method, des Maladies, t. i. p. 314.— Underwood, On the Diseases of Children, 8th edit. 8vo. p. 256.—Gar- dien, Traite Comp. d’Accouchemens et des Malad. des Filles, des Fein, et des Enfans, t. iv. p. 91. Paris, 1826. —Palletta, in Archives G6n. de Medecine, t. v. p. 105., et Ibid. t. ix. p. 276.—Llgcr, in Ibid. t. vii. p. 16.—Du- pareque, Nouv. Bibliotheq. M6d. Sept. 1828, p. 333.— Ratter, Archives Gendr. de Medecine, t. xvii. p. 42.— Billard, in Ibid. t. xiii. p. 204., et Traite des Maladies des Enfans, &c. 8vo. Paris, 1828, p. 169.—Dupes, Manuel d'Obstetrique, &c. Paris, 1830, p. 437.—Condie, On Dis- eases of Children, p. 517. CEPHALITIS. See Brain, Inflammation of. CHEST. Syn. Thorax, Fr. Der Brustkasten, Ger. Torace, Ital. The Thorax. External Examination of, in the course of Disease—Classif. General Pathology— Semeiology. 1. Regions of the Chest.—It is necessary to divide the chest into different regions, in order to give precision to our diagnostic researches. This is done by drawing horizontal and vertical lines from certain conspicuous parts of the body. The first horizontal or transverse line extends anteriorly from the humoral extremities of each clavicle, CHEST—External Examination of, in Disease. across the junction of the clavicles A7ith the iippei part of the sternum, posteriorly passing over the last cervical vertebra ; the second, around the middle of the chest, anteriorly passing over the nipples, and posteriorly passing between the spine of the scapulae and their inferior margins; the third passes around the lowest part of the chest, from the zyphoid cartilage, and over the hypochondria. The first, vertical line extends from the upper to the lower extremity of the sternum ; the second and third, from each acro- mial extremity of the clavicles to the external rami of the pubes ; the fourth and fifth, from each posterior margin of the axillae to the crests of the ilia ; the sixth and seventh, from the clavi- cular transverse line along the posterior border of each scapula, or a little exterior to it, to the middle horizontal line ; and the eighth, along the spinous processes of the dorsal and cervical vertebra). To these lines may be added one drawn on each side, from the last cervical vertebra, around the lower part of the neck, and sloping downwards to the upper part of the sternum. Thus the chest will be divided into sixteen regions, viz. two superior, or humoral regions ; four anterior,—the subclavian and submammary ; four lateral,—the axillary and subaxillaxy ; and six posterior,—the scapular, subscapular, and interscapular. 2. The viscera lodged beneath each of the different regions of the chest and the nature of its parietes, are too well known to require any notice. I therefore proceed to point out the va- rious methods which are employed to investigate the diseases of the thoracic organs. These con- sist of inspection, mensuration and manual ex- amination, percussion, succussion, and auscul- tation. 3. A. Inspection.—It is important for the physician to take into consideration the form and size of the chest, in estimating the causes, nature, and tendencies of disease. Vigour of constitution is generally incompatible with a small or ill formed thorax; this conformation not only dis- posing to various affections of the viscera con- tained in this cavity, but also aggravating their severity. Every change from the due proportions of the chest ought to be considered of importance. This cavity is generally artificially modified in its form in females. Its capacity is reduced in a transverse direction, by the lateral compression to which it is subjected ; and, owing to the same cause, the superior abdominal viscera are pushed upwards, and it is thereby further diminished in a vertical direction. But the compression thus exercised not only reduces the absolute capacity of the chest, but it also prevents the elevation of the ribs, and the descent of the diaphragm during respiration, rendering each inspiration of small amount, and insufficient for the developement and wants of the frame. It moreover presses the lower ribs downwards and inwards upon the more important viscera contained in the abdomen; prevents the ascent of the contents of the ciecum : and favours lateral curvature of the spine, wfiich, in its turn, tends remarkably to diminish the ca pacity of the chest. 4. During inspection of the thorax, there are other circumstances, besides its form and size, which should fix attention. The actions of its parietes, the equality of the motions of each side, and their connection with the movements of the abdomen, are of the utmost importance. In pleuritis, the motions of the ribs of the affected 365 366 side are greatly impeded; and if both sides be affected, the costal parietes are but little moved during respiration, this function being chiefly per- formed by the diaphragm and abdominal muscles. On the other hand, when the diaphragm, or either of its serous surfaces, are inflamed, or when intense inflammation affects any of the superior abdominal viscera, respiration is chiefly performed by the costal parietes. In the first case the re- spiration is said to be abdominal, in the second thoracic. 5. It is chiefly by actual inspection of the chest that we can ascertain the existence of mdema of its surface: the distance between the ribs, the prominence of the spaces between each, the existence or non-existence of partial contrac- tions, and bulgings or prominences of its walls, —are all important facts in our diagnosis of dis- eases seated in this cavity. Thus, in phthisis, when the pulmonary tissue is tuberculated, shrunk, or contracted, &c., a falling in of the ribs, par- ticularly of the subclavian region of one or both sides, is observed; whilst in asthma and em- physema of the lungs, the ribs are full and ex- panded. This state, however, of the ribs may exist only on one side ; as in cases of pleurisy of one side, terminating in effusion, in empyema, and in pneumothorax, we often observe the af- fected side expanded, and the intercostal spaces prominent, whilst the other is natural. In other instances of organic disease, one side may be un- commonly contracted; as after cures of old, or chronic, or circumscribed pleurisy, in partial or general destruction of one lung, and in lateral curvature of the spine. In many of these, the opposite or sound side is fully developed, owing to a slight hypertrophy of the sound lung; in cases of curvature, one side is always prominent in pro- portion to the depression of the other. The pro- minence of the sternum, and lateral depression of the ribs, which is so common in children; and the falling in of the sternum, and prominence of the ribs ; are ascertained by inspection. 6. B. Manual examination and mensuration.— It is of importance to ascertain the existence of tenderness on pressure in various parts of the chest, particularly when the patient complains of pain, or difficult respiration. This can only be done by manual examination. Extreme sensi- bility of the external surface indicates either irri- tation of the membranes of the spine, or rheuma- tism affecting the parietes of the chest. When pressure in the intercostal spaces is required to develope the pain, disease is usually seated in the pleura, or parts beneath it, or in the pericardium. It is seldom, however, that we can occasion pain by pressing between the ribs in cases of organic disease of the substance of the lungs, or even of the pulmonic pleura, unless this latter has formed adhesions to the costal pleura. During manual examination, attention should be paid to the ex- istence, the kind, and the extent of moisture on the surface of the chest; to its temperature, which is generally more or less increased in in- flammations ; and to the palpitations or impulse of the heart. It is evident that the existence of oedema or emphysema of the surface of the chest is chiefly to be ascertained by manual examina- tion of it. 7. Mensuration of the chest may be sometimes required, in order to ascertain either the degree of prominence of one side, or of the contraction of the other. In both cases a piece of tape is CHEST—External Examination of, in Disease. used; the measurement being made from the spinous processes of the vertebrae to the central line of the sternum, and from the top of the shoulder to the lowest rib. The admeasurement should be taken during a full inspiration and expiration, and the progressive increase or de- crease noted. It will often happen that no dif- ference between either side exists during a state of tranquil respiration; and yet, upon forced re- spiration, the difference is very manifest. 8. Mr. Abernethy proposed, many years ago, —and the proposition has been recently revived on the Continent,—to ascertain the capacity of the lungs, by measuring the quantity of air they are capable of containing, as an indication of the ex- tent of disease by which they are affected. The recommendation was rational, and deserving of greater attention in several affections of this organ than it has received, particularly when the evi- dence furnished by the measure is duly estimated in conjunction with other signs. The method simply consists of the patient taking as deep an inspiration as he is able, and then expiring through a tube, one end of which is passed under a glass jar, containing, and inverted over, water. The quantity of water displaced is the measure of the capacity of the lungs. A person, full grown and in health, usually displaces from six to eight pints. If the amount be much less than this, it may be inferred that the lungs are obstructed by disease of their substance, or by tumours, effu- sions of fluid in the pleura, or other causes press- ing upon them externally. Although muscular de- bility, or spasm, may diminish the quantity of air inspired, yet there can be no doubt that the method is calculated to furnish very useful infor- mation. 9. Some years since, it was proposed by a physician on the Continent, to test the capacity and soundness of the lungs by causing the patient to take as full an inspiration as possible, and to count from one upwards, in a deliberate manner, during the following expiration, and whilst ex- piring as slowly as he can. The number that will lie reached, either during the expiration or whilst the breath is retained, or before a new in- spiration is entered upon, will be an index of the soundness of this organ. Dr. Lyons, who has more recently recommended a modification of this method, advises that me period should be noted by the seconds hand of a watch. He states that a healthy individual will not continue count- ing above thirty-five seconds; and that, in con- firmed phthisis, the period never exceeds eight, and seldom six seconds. I have practised this method during the last five years, and have sel- dom found a healthy person who could proceed beyond thirty-five seconds, and scarcely one who could go beyond forty ; but I have met several cases of pulmonary consumption, where, up to a very advanced stage of the disease, twelve, fif- teen, and in one case, twenty seconds were reached ; and even in the last stage, eight or ten seconds are not uncommon ; although the num- ber mentioned by Dr. Lyons is much more fre- quent. Percussion, succussion, and auscultation of the chest are comprised in the articles Auscultation and Percussion. Biblioo. and Refer.—Avenbrugger, in Journ. de M6decine, t. xxxii. p. 81.—Double, in Journ. G6n£r. de M6d. t. xxix. p. 241.—l.acnnec, De l’Auscultation Medi- ate, &c. 2d edit. 8vo. t. i. Par 1826 —Abernethy, Physio- logical Essays, part ii. p. 157.—Lyons, Edin. Med. Journ. vol. xxviii. p. 453.—Dupuytren, Archives G6n. de Med. t. xvi. p. 556,—Piorry, Procede Operatoire, &c. dans l’Ex- ploration des Organes, 8vo. Paris, 1831. Deformities of the Chest.—Glassif. I. Class, III. Order (Author). 1. I. Lateral Depression of the Chest.— Depression of the lateral parietes of the chest had escaped the attention of authors, although of very frequent occurrence, until M. Dupuytren wrote a memoir on the subject (Repertoire Gen. cl’Ana- tomie, <$pc. t. v. p. 110.). A few scattered remarks on the subject may be found in the writings of Van Swieten, J. L. Petit, Levaciier, and others, who have attributed it to rickets and other affections, and have evidently been unacquainted with its nature, causes, effects, and method of treatment. Not a week passes without cases of this contraction being presented at the Infirmary for Children ; and, although sometimes a congeni- tal deformity, it has appeared to me very fre- quently to be greatly increased, if not altogether occasioned, subsequently to birth, by the very common practice among nurses of lifting the child by pressing the palms of the hand on the sides of the chest, immediately under the armpits. This deformity consists of a greater or less depression of both sides of the thorax, with a proportionate protuberance of the sternum and abdomen for- wards, and of the vertebral column backwards. 2. It is most commonly found in infants born of debilitated, lymphatic, scrofulous, and rickety pa- rents,—particularly those inhabiting low, cold, and moist situations, or who live in small ill-ventilated apartments,—and amongst children who are badly clothed and nourished. In many cases the de- formity does not consist of merely a level depres- sion of the lateral parietes ; but the ribs are actually bent inwards, the sternum and spine forming a curve outwards. In some, the lower or upper parts of the sternum are the most promi- nent. This extreme grade of depression is seldom or ever met with at the moment of birth ; M. Du- puytren thinks differently. My experience leads me to state that it generally comes on gradually after birth, owing to deficient inflation and deve- lopement of the lungs, arising from the weakness of the muscles of inspiration, and flexibility of the ribs at the time of birth. In cases of this descrip- tion, the vital energy of the lungs is insufficient for their healthy actions, and the respiratory me- chanism is unable to accomplish their full expan- sion, or to sustain the continued pressure of the atmosphere, before which the soft and imperfectly formed thoracic parietes gradually yield. The manner in which nurses frequently lift infants, as already stated, tends further to increase the mis- chief, particularly in those who are originally weak and ill-nourished. The effects of this co- arctation of the thorax upon the functions, and ultimately on the structure of the lungs and heart, soon become very evident. We usually find the pulse quick, and the breathing oppressed ; with a weak voice, occasional anxiety, and inca- pability of speaking or reading for any time, or of uttering many words without frequent pauses. In the newly born infant, there is great difficulty of suckling, from its inability to raise the ribs with sufficient power to perform this process. It is seized with suffocation when at the mother’s breast, which it often quits with fits of crying. As it advances in age, the disorder of respiration CHEST—Depression of the. and circulation is still more remarkable, particu- larly upon ascending acclivities. The pulse be- comes quick, irregular, or intermittent; and is accelerated upon the slightest cause, whether phy- sical or mental. 3. In children whose chest is thus compressed, the tonsils generally, or rather constantly, become tumid,—so much so, as frequently to increase the disorder of the respiratory actions ; and all the structures and organs of the body are impaired both in function and in developement, owing to the derangement which the depression occasions to respiration and circulation. In many cases which have come before me, rapid emaciation, great debility, defective assimilation and sangui- faction, an atrophied and flaccid state of the mus- cles, softening of the bones, frequently asthenic or chronic bronchitis, and swelling of the glands, have followed the deformity and terminated the life of the patient. 4. Organic lesions.—In these cases the ap- pearances observed on dissection are such as the original and consecutive ailments lead us to ex- pect. These consist in retarded developement ol the skeleton; want of union between the bones composing the cranium ; enlargement of the heads of the long bones, sometimes with softening and flexures of their bodies. Dentition is also re- tarded ; and, if it have proceeded, the crowns of the teeth are eroded. The voluntary muscles are atrophied, soft, pale, and exhibiting a fish-like structure. The lungs are compressed towards the vertebral column, and present a corresponding depression to that of the lateral parietes of the chest, with the marks of the ribs indented in their posterior and lateral surfaces. This organ is often studded with tubercles of various sizes; portions of it are frequently inflamed or hepatised; and, in some cases, attended with bronchitis, the bronchi are more or less loaded with mucus, or muco- purulent matter. The substance of the heart is commonly pale and flaccid ; and, in young in- fants, the foramen ovale is sometimes widely open ; and in older children but imperfectly closed. The mucous follicles of the intestinal canal are often tumefied, but rarely ulcerated, excepting when a chronic diarrhoea has attended the latter stages of the thoracic compression. The mesenteric glands are also occasionally much enlarged. 5. II. Depression of the Sternum, with late- ral prominence of the ribs.—This deformity is the reverse of the former: the sternum is pressed in- wards, either at its middle or lower part, or along its whole extent; the ribs are very much bent, and prominent laterally ; the chest being broad, but compressed anteriorly, the shoulders high, and the spine either straight or but little altered from its natural form. This change has also been much overlooked by authors. Mr. Coulson, how- ever, has lately noticed it in an instructive article on deformities of the chest. It is by no means uncommon both in young and grown up subjects, although not so frequent as the lateral depression. In cases of depression of the sternum, the lungs and heart are compressed anteriorly ; their func- tions much altered, and ultimately their structures. This deformity is very seldom congenital, being the consequence of weakness, or of a scrofulous or tubercular diathesis. I have met with two in- stances of it out of six members of one family who died of consumption soon after puberty. It is in some cases antecedent of any apparent disease of 367 368 CHEST—Deformities of the—Treatment. the lungs : in other instances, it is consecutive of pulmonary disease ; and in others, of external pressure and stooping occupations. [Dr. Graves has noticed a remarkable mobility of the sternum, in the person of a medial student, 19 years of age, who had often been attacked by violent pectoral inflammation. The sternum could be pushed in towards the spine with the hand, so as to convert the anterior part of the chest into an extensive cavity, at the bottom of which was the sternum. The portion of the chest which yielded in this singular manner to pressure, comprised the sternum from within two inches of its superior edge, and seemed below this point to be limited laterally by the lines answer- ing to the junctions of the cartilaginous with the osseous portions of the ribs, so that the whole space capable of being pressed inwards was near- ly triangular in shape, and very extensive. When the pressure was carried to the farthest point, the sternum was pushed in about two inches, and the action of the heart, as well as that of the subja- cent lung, appeared to be notably diminished, and in consequence of this, the pulse was weakened. No other portion of the osseous system exhibited the least trace of softening.—Stokes & Graves’ “ Clinical Lectures,” Am. Ed. p. 179.] 6. It is not uncommon to find females with the chest of a cylindrical or oval form instead of being a truncated cone ; entirely in consequence of the inordinate pressure to which its lower part has been long subjected from tight lacing of the stays. In some of these cases, the sternum, particularly its lower part, is pressed inwards. The effects, however, of this habit, and of the deformities which it occasions, have been alluded to in an- other part. (See Chest—Examination of the, §3.) 7. III. Treatment.—A. The cure of the lateral depression of the chest is by no means so hopeless as it may appear, particularly if it be attempted at an early period, and before serious organic mis- chief has been produced. Invigorating medicines and nourishing diet are requisite, particularly in conjunction with various external and mechanical means. 8. a. The external treatment which I have found the most successful, consists of warm or tepid salt water bathing in infants; and in directing the mother to make pressure very frequently through the day upon the protuberant spine and sternum, by placing one hand on the former, and the other on the latter. But this pressure must oe so managed as to be made only at the moment of expiration, and entirely suspended during the moment of inspiration, so that no impediment may be in the way of the free dilatation of the parietes of the chest. The practitioner should take care to instruct the mother in the manner of employ- ing the pressure upon the sternum and spine, with the view of throwing outwards the depressed lateral walls of the chest. The more frequently this pressure can be employed, the better ; and its benefits will be considerably promoted by ap- plying the following liniment, night and morn- ing, along the spine, or even upon both the sternum and spine. I have employed this and similar liniments, in these situations, with the greatest advantage, in this and several other dis- eases connected with debility, particularly in young subjects. No. 110. ft Linimenti Camphor® Comp. Linim. Sa- ponis Comp., aa Jj. • Olei Terebinthin® 3vj.; Benzoini 3 ij.; Styraeis Balsami 3 jss.; Olei Cajuputi, Olei Limo- nis, aa 3 ss. M. et fiat Linimentum. 9. In public practice, I have usually substi- tuted for the above, either equal parts of the com- pound camphor and turpentine liniments ; or these, with the addition of the soap liniment, or their equal quantities of olive oil and turpen- tine, with a little soft soap. In conjunction with these means, the artificial salt water bath, with a very large proportion of salt, at a tem- perature suited to the peculiarities of the case, will be found extremely serviceable. As soon as children affected by this depression of the walls of the chest can be brought to employ the muscles of the upper part of the body in a determinate manner, this mode of treatment should also be employed. Perhaps the best mode of overcoming the depression, by developing muscular action and power, is to cause the child to raise weights, by means of ropes and pulleys placed at a consider- able height over its head ; so that, by taking hold of the rope with both hands raised above the head, and pulling it downwards, the muscles may be brought into action, and the parietes of the chest thereby dilated. But moderate and duly regulated exercise, particularly of the muscles of the arm and trunk of the body, accompanied with invigorating medicines and regimen, will be pro- ductive of benefit. 10. b. Internal treatment should always be conjoined with the means stated above. The digestive functions generally require regulation, and tonic or permanent excitement. After having evacuated morbid secretions and faecal accumu- lations from the bowels, by means of the usual purgatives, of which rhubarb, or senna combined with a tonic bitter is among the most suitable, Brandish’s alkaline solution, or the solution of potash,- or other preparations of this substance, may be given, either in some gruel or mutton broth, or in a tonic infusion, or combined with the preparations of iron. The following powders may also be taken once, twice, or thrice daily :— No. 111. ft Ferri Sulphatis exsic. gr. ij.—vj.; Potass® Sulphatis gr. xij.—xx.; Pulv. Cascarill® 3 j.— 3 jss. Misce bene, et divide in Chartulas xij. ®quales, quarum capiat unam bis terve quotidie. No. 112. If Potass® Carbon, gr. j.—iv.; Ferri Sesqui- oxidi gr. iij.; Pulv. Rhei gr. iv.—ix.; Pulv. Cascarill® (vel Calumb®) gr. v.—xij. Misce. Fiat Pulvis. No. 113. If Ferri Potassio-Tartratis gr. iij.—xvj.; Pulv Calumb® gr. vj.—xij.; Pulv. Zingib. gr. ij. M. Fial Pulvis. 11. Instead of these, the tincture of the am- inonio-chloride of iron; mixtures containing sul- phate of quinine ; or the tincture of iodine, in doses of one to three drops, twice or thrice daily, may be employed advantageously. In every other res- pect the treatment is the same as that recom- mended for Rickets. But whatever mode of cure be adopted, change of air, or at least a wholesome pure air, with regular exercise, is requisite to its success. In this deformity, the various exercises resorted to with the view of imparting strength and agility to the frame, will be useful, if judiciously directed. 12. B. The treatment of the other deformities of the chest must be conducted very nearly on tlie same principles ; the pressure, in cases where it may be proper to have recourse to it, being made in an opposite direction to that recommend- ed above, when the anterior parietes are depress- ed. But this deformity is very seldom met with so early in life as to admit of any expectation of advantage from the use of pressure. The other CHICKEN-POX—Description of. 369 means, as long as the pathological states of the thoracic viscera do not contra-indicate them, are the most applicable. Bibltoo. and Refer.—Dupuytren, in Repertoire Ge- nerate d’Anatoniie et Pathologie, &c. t. v. p. 128.—Coul- son, in London Medical Gazette, vol. iv. p. 69.; and on Deformities, &c. 8vo. Lond. 1835. CHICKEN-POX. Syn. Varicella, Crystalli, Va- riola Spuria, Variola Lymphatica, Variola Vo- latica, Auct. Var. Variola Pusilla, Heberden. Exanthema Varicella, Parr. Synochus Vari- cella, Young. Emphlysis Varicella, Good. Verole Volante, Fr. Die Unachten Kindspoc- ken, Ger. Ravaglione, Ital. Water-jags, Water-pox. Classie. 1. Class, 3. Order (Cullen). 3. Class, 3. Order (Good). III. Class, III. Order {Author). 1. Defin. An eruption over the body, of semi- transparent glabrous vesicles, with red margins, accompanying a slight attack of fever, seldom passing into suppuration ; but, on the third day, bursting at their tips, concreting into small puck- ered scabs, and leaving no cicatrices. 2. Under the name chicken-pox, or varicella, have generally been comprised certain eruptions, which closely agree in many features with each other, and which in some respects resemble small- pox. It is from this latter circumstance that they claim a very particular notice, as they are generally of so slight a nature as to require but little medical treatment. They were formerly very generally confounded with sinall-pox; but the difference between them was remarked as early as the beginning of the sixteenth century by Vidus Vidius and Ingrassis. (Sennert and Riveri, professors at Wurtemberg and Montpel- lier at the commencement of the seventeenth century, and Diemerbroek, state that the dis- tinction was well known in Germany, France, and Italy, to the vulgar, who had a separate ap- pellation for this eruption. Morton, was the first in this country to mark the difference, and to des- cribe this disease under the name “ chicken-pox,” by which it appears to have been commonly known before he wrote. Since then it has been noticed by Fuller, and accurately defined as a distinct disease by Heberden. He, however, continued to designate it by the term variola pusilla; whilst his contemporaries, Vogel, Bur- serius, and Sauvages, also applied to it the generic term variola, with the specific desig- nation of volatica, spuria, and lymphatica. But, as Dr. Bateman has remarked, this circumstance cannot be considered evidence of their consider- ing it as generically the same with small-pox. The entirely distinct nature of chickeu-pox was very generally believed in, since Dr. Heberden pointed out the difference between it and the small-pox, until recently questioned by Dr. John Thomson, by whom the opinion of the earlier physicians, that they are merely varieties of the same disease, has been revived. This learned physician, and M. Berard, urge in favour of this opinion the circumstance of variola and vari- cella appearing from the same exciting causes, whether those affected have been vaccinated or not; and affirm that persons exposed to the in- fection of chicken-pox have caught small-pox, and that the former appears only in those whose constitutions have been modified by the influence of either small-pox or cow-pox. On this subject MM. Schedel and Cazenave remark, that in those epidemics which they have had opportu- nities of noticing in Paris, the several eruptions might be classed under three heads: 1st, Variola properly so called ; 2dly, the malady termed vari- loide, or variola modified; 3dly, An eruption purely vesicular, offering every appearance of varicella. The same cause, namely, variolous infection, seemed to develope these several eruptions, which were observed in the same quarters, in the same streets, in the same houses. When the disease made its appearance among a numerous family, some had small-pox, some modified small-pox, and others chicken-pox. One circumstance was striking to every one, namely, the mildness of the disease in those persons who had been vacci- nated, and in the majority of those who had al- ready had variola. 3. These facts certainly favour the opinion of Dr. Thomson ; but, as the above writers have stated, many cogent arguments have been urged against it, especially by Abercrombie, Bryce, Luders, &c. :—1st, It is very difficult to deter- mine, during a small-pox epidemic, whether the occurrence of that disease among individuals coming in contact with persons infected with chicken-pox is rather the result of this commu- nication, than of the variolous infection which at that moment developes the malady on all sides: 2d, Vesicular varicella properly so called, is not transmitted by inoculation, and never produces variola: 3d, Those persons who consider chicken- pox as contagious, have confounded it with modi- fied small pox: 4th, Varicella appears in persons who have not been vaccinated, and who have never had the variola; consequently, in such cases, it cannot be regarded as a variola modified by the prior existence, either of this disease or of vaccination: 5th, Vaccination practised shortly after the disappearance of varicella pursues its course in the most regular manner, which never happens when vaccination follows variola: 6th, The progress of varicella is uniformally the same whether it occurs before or after vaccination, or after variola: 7th, Variola sometimes reigns epi- demically, without being accompanied by vari- cella ; and, on the other hand, the latter may be- come epidemic without being attended by the for- mer. In fact, the characters of the eruption, and the symptoms of varicella, differ essentially from those of variola. 4. I. Description.—A. Of the eruption. Un- der the name chicken-pox are included different varieties of eruption, generally characterised by very slight and brief antecedent fever, consisting of vesicles or very imperfect pustules which ma- turate and decline in three, four, or five days, oc- curring chiefly during infancy and childhood, but also at adult age, and occasionally prevailing epi- demically. The generic term, chicken pox, com- prises three species or rather varieties, which have been distinguished from each other for very many years in different parts of this country, by the popular names of chicken-pox, swine-pox, and hives. These Willan and Bateman distin- guished, according to the form of their vesicles, into, 1st, Varicella Lentiformis ; 2d. V. Conifor- mis; and, 3d, V. Globularis. Dr. Good has adopted these names and distirictions, but has added a. fourth, the V. Corytnbosa, the clustering or confluent chicken pox ; which, if considered at 370 CHICHEN-POX—Diagnosis. all as a distinct variety, is not of frequent occur- rence ; but has occasionally been observed by Bateman, Ring, and myself. Var. i. Lenticular Chicken-pox, Varicella Lentiformis; V. Lymphatica, Plenck. 5. This variety appears on the first day of erup- tion, in the form of small red protuberances, of an irregularly circular, or rather tending to an ob- long figure, with a nearly flat and shining sur- face, in the centre of which a transparent vesicle is very soon formed. On the second day of the eruption the vesicle is filled with a whitish lymph, and is about the tenth of an inch in diameter. On the third day the lymph is straw-coloured; and, on the fourth, the vesicles which have not been broken subside, and are puckered at their margins. Few of them are entire on the fifth day; but the orifices of several which have broken are closed or adhere, so as to confine a lit- tle opaque lymph within the puckered margins: on the sixth day, small brown scabs appear in place of the vesicles; and become yellowish on the seventh and eighth days, gradually drying from the circumference to the centre. On the ninth and tenth days they fall off, and leave for a time red marks on the skin, without depression. The disease may, however, be longer than now stated, owing to fresh vesicles appearing during two or three successive days, and going through the same states as the first. The eruption is usually distinct, is general over the body, and comes out first on the back and breast. The ves- icles, even when they suppurate, leave no ci- catrices. The pustules of small-pox break out first on the face, neck and breast, and always leave depressions. Far. ii. Conoidal Chicken-pox, Varicella Coniformis; Varicella Verrucosa, Pienck ; Variola Lymphatica, Sauvages; Pemphigus Variolodes, Frank ; Verolette, Fr.; Rava.g- lio, Ital.; Swine-pox. 6. The vesicles of this variety arise suddenly, have a somewhat hard and inflamed base, and are on the first day acuminated, containing a transparent lymph. On the second day they are a little more turgid, their bases more inflamed, and the lymph in many of them is of a light straw-colour. On the third day, the vesicles are shrivelled, and those which are broken have their lymph concreted into slight gummy scabs. Such of them as remain entire, and have their bases much inflamed, contain, on this day, a whitish puriform fluid ; every vesicle of this kind leaving, after scabbing, a durable cicatrix. On the fourth day, thin dark brown scabs are seen intermixed with others, which are rounded, yellowish, and semi-transparent. These scabs gradually dry, separate, and fall off in four or five days. 7. A fresh eruption of vesicles usually takes place on the second or third day, and has a simi- lar course to the preceding; the whole duration of the eruptive stage being thus six days in this variety of varicella. In some instances minute red tubercles appear, and subside without forming vesicles. The scales last formed are generally not separated till the eleventh or twelfth day. In some cases, when the febrile symptoms have been severe, slight ulceration takes place in the vesicles from which the scabs have fallen off, leaving depressions or cicatrices, but only in parts subjected to pressure. Far. iii. Globular Chicken-pox, Varicella Globularis; Hives. 8. The vesicles of this variety are large and globular, but their base is not quite circular. Tney are surrounded by inflammation, and contain a transparent lymph, which is slightly turbid, and resembles milk-whey, on the second day of the eruption. On the third day they subside, become shrivelled as in the former varieties, and appear yellowish from the admixture of a small quantity of puriform matter with the lymph; some of them remaining in the same state till the follow- lowing morning ; but before the conclusion of the fourth day, the cuticle separates, and thin dark scabs cover the basis of the vesicles. The scabs dry, and fall off in four or five days afterwards. 9. B. Of the constitutional affection.—All these varieties of chicken-pox may attack the same individual at different epochs, and offer the same symptoms, whether before or after small- pox or vaccination. They are frequently associ- ated with the epidemic prevalence of small-pox. They appear principally in the early months of the year, and the spring ; seize chiefly young persons, and adults sometimes ; and each of them, with a few exceptions, affects a person only once in their lives. Varicella is preceded, for twenty- four or forty-eight hours, by chills, depression, anorexia, costiveness, and thirst, with heat of skin, flushed countenance, accelerated pulse, ten- dency to perspiration, and other febrile symptoms. Sometimes there is nausea, or even vomiting, with pain at the epigastrium and through the limbs. In some cases, tbe fever is so very slight as to be overlooked ; and, in infants, is often indicated only by heat of skin and fretfulness. The erup- tion usually commences on the back and breast; appearing next on the face, neck, and scalp ; and lastly on the extremities. It is sometimes preceded, for a few hours, by a general erythematous rash ; and the vesicles are usually most abundant in the conoidal form ; they being sometimes coherent, or seated close together, but seldom confluent. When thus coherent or clustering, they form the fourth variety of Dr. Good (§ 4.). Owing to the itching which accompanies them, children often break the vesicles by scratching, whence proceeds an increased inflammation, forming a yellow pus, more or less consistent. This happens particu- larly on the face. The crusts which replace these pustules remain much longer, and leave small cicatrices. As the vesicles appear successively during two or three days, we may perceive the eruption exhibiting its several stages at the same period, in the same individual. 10. II. Diagnosis.—The vesicle full of se- rum on the top of the pock, on the first day of the eruption,—the early abrasion of many of the vesicles,—their irregular and oblong form,—the shrivelled state of those that remain entire on the third and fourth day, and the radiating furrows of others which have had their ruptured apices closed by a slight incrustration,—the general ap- pearance of the small scabs on the fifth day, at which time the small-pox pustules are not at the height of their suppuration,—sufficiently distin- guish chicken-pox from small-pox. Dr. Willan has pointed out the characteristic ciscumstance, that variolous pustules are, on the first and se- cond day, small, hard, globular, red, and painful; imparting the sensation, when the finger is passed over them, similar to that which one might con- ceive would be excited by the pressure of small round seeds under the cuticle. In varicella, al- most every vesicle has, on the first day, a hard in flamed margin; but the sensation communicated to the finger is like that from a round seed flat- tened by pressure. As the pustules of small-pox, moreover, become gradually developed, they con- tain a white thick matter ; the formation of which precedes suppuration, as shown by Dr. Ashburner. When the globular vesicles or hives appear, as is sometimes the case, intermixed with the lenticular or conoidal eruption, they afford a ready distinc- tion from the small pox, to the pustules of which they bear little resemblance. 11. It is not, however, so easy to distinguish varicella from modified small-pox. The symptoms precursory of the latter are usually intense, which is never the case with the former. In modified variola, the eruption is pustulent, and the pustules are small, circular, and generally depressed in the centre. After the scaly crusts drop off, tubercles are frequently seen, which disappear but slowly. In varicella, the vesicles, which are at first trans- parent, contain a fluid which becomes sero-puru- lent; and they are never followed by tubercles, as in modified variola. To this I must add, that varicella is not infectious; whereas modified va- riola may be transmitted by inoculation, and may even in some cases, occasion a very severe attack of true small-pox. }2. III. The Treatment of varicella is very simple : the patient should remain in bed, in a temperate atmosphere ; ought to be placed on low diet, and abstain from animal food for a few days ; should have the bowels duly regulated, and par- take freely of lukewarm diluents. Bibliog. and Refer.— Vidas Vidius, De Chrystallis. —Ingrassias, De Tumor. Prat. Nat. 1. i. c. i.—Scnncr- tus, Med. Pract. 1. iv. cap. 12.—Riverius, Prax. Med. cap. ii.—Diemerbroeck, De Variolis et Morbis, cap. ii.— Morton, Pyrotologia, &c. p. 38.—Fuller, Exanthemato- logia, p. 161. 1730.—Ilsberden, in Trans, of the Coll, ot Phys. vol. i. art. xvii.; et Comment, de Morbis, cap. <16.— Vogel, De Cognosce ml. et cur. Horn. Morb. § 128. 1772. -Burserius, Inst. Med. t. ii. cap. 9. § 305— Sauvages, class iii. gen. ii. sp. 1 .— Wilson, On Eruptive Fevers, 4th edit. p. 321.—Ring, Med. and Phys. Journ. vol. xiv. p. 141.— Thompson, On Varioloid Diseases, 8vo.—Raycr, Traite de Maladies de la Peau, 8vo. t. i.p.340— Cazenave, et Schedel, Abrege Pratique de Mai. de la Peau. 8vo. p. 61.—./. Green, On Diseases of the Skin, 8vo. Lond. 1834. p. 116.—G.Gregory, Cyclop. Pract. Med. vol. i. p.377. CHLOROSIS. Der. and Syn. From paleness, yellowish green. Pallidus Morbus ; Foedus Virginum Color; Pallor Virginum; Morbus Virgineus; Fcedi Colores; Icterus albus; Icteritia alba ; Cachexia Virginum vel Muliebrum; Febris Amatoria ; Chlorosma, Ac. Auct. Var. Chlorose ; Pales Couleurs, Fr. Die Bleichsucht, Ger. Green Sickness, Eng. Classif. 2. Class. Nervous Diseases ; 2. Order, From Defect of Vital Energy {Cullen). 5. Class, Diseases of the Sexual Function; 2. Order, Affecting the Or- gasm {Good). I. Class, II. Order {Au- thor, in Preface). 1. Deein.—Pale yellowish green complexion, languor, debility ; depraved appetite, with occa- sional nausea or sickness, and disorder of the sexual secretions; generally occurring, about pu- berty, or soon afterwards. 2. Chlorosis has been very generally consid- ered as a variety merely of amenorrhcea, parti- cularly by Cullen, Pinel, and Frank, although they have classed it as a distinct disease. As to its occurrence independently of retained or sup- pressed menstruation, there can be no doubt, al- though it is frequently connected with such dis- CHLOROSIS—Causes. oriler. It is also similarly related to dyspepsia, and to anaemia; Dr. Young classing it with the former disease. Sauvages includes, as a variety of chlorosis, the cases of anaemia which occur in infants and children, denominating them the chlorosis infantum. But although several such cases are met with in practice, they seldom pre- sent the yellowish green tinge of this disease, be- ing usually of a white or exsanguineous paleness, unless when complicated with jaundice, which is but rarely remarked. They are entirely referrible, in respect of their pathological relations and ter- minations, to anaemia (see Blood—Deficiency oj); and are sometimes, owing to the exhaustion at- tendant upon their last stages, mistaken for hydro- cephalus. Sydenham considered chlorosis as a variety merely of hysteria, connected with a cacochymia,—its frequent complication with that disease being evidently the source of this fallacy ; and lastly, Van Swieten viewed it as a form of cachexy. These opinions serve to show the pro- priety of considering it as a distinct disease, but more or less intimately related to those com- plaints, owing to the circumstance of them all originating in a nearly similar state of vital energy, particularly as manifested in the organic nervous system; specific differences between them con- sisting in the particular viscus or part more es- pecially affected, and in the grade and mode of such affection. 3. Dr. Good divides chlorosis into two species, the atonic and entonic ; but this is an unnecessary refinement, no phenomena which warrant such a distinction presenting themselves in practice. Indeed, the entonic only consists of a state re- latively of less deficiency of vital power than the atonic, and is, in many cases, merely the first stage of the disease ; particularly when it occurs in tolerably strong females, and whilst the torpid function has not as yet extended much furthei than the sexual organs, in which it originated, the digestive, assimilating, and vascular orgai i not having sustained much disorder. Dr. Good, has likewise made mention of an acute chlorosis, occurring chiefly in married women. But the state of disease thus designated by this physician, is simply that chronic disorder, often attended with slight irritative fever, following large losses of blood, which are not readily supplied by the di- gestive and assimilating functions ; and is in all respects a state of anaemia. (See Blood, § 34. et seq.) 4. I. Causes.—A. Predisposing causes. Chlo- rosis is most frequent in girls about the age of puberty ; either previously to the appearance of the menses, or when they are retained, or occur irregularly, or with difficulty. But married wo- men, particularly widows and those who have not borne children, are not exempt. In them it is generally connected with suppression ol the menses. It is even met with in males, although rarely, about the period of puberty ; as remarked by Hamilton, Blane, Desormeaux, Roche, and myself in two or three cases. When observed in this sex, it is apparently connected with protracted evolution of the sexual organs; and one or two of the young females of the same family are sometimes also affected. The lymphatic and me- lancholic temperaments ; feeble and delicate con- stitutions ; residence in cold, moist, and miasma! localities and climates ; insufficient, unwholesome, innutritious, and watery vegetable food : inatten- tion to the digestive functions, particularly those 371 372 CHLOROSIS—Diagnosis of the bowels; the abuse of diluents, of acid weak wines, or of spirituous liquors, early in life ; too great indulgence in warm bathing ; prolonged sleep; tight lacing at an early age; and what- ever debilitates and relaxes the system ; predispose to this disease. The most frequent causes are se- dentary occupations in crowded and ill-ventilated manufactories and towns, especially those em- ployments which require a stooping position, and are prosecuted by females at a very early age, or before the frame is developed. 5. B. The more common exciting causes, are longings after objects of desire ; depressing pas- sions and affections, especially unrequited love, or unfortunate or imprudent attachments; long entertained feelings of sadness or anxiety, parti- cularly when caused by removal from friends, and the scenes of recent happiness and affection. According to MM. Desormf.aux and Roche, pri- vation of the physical gratification of love is a very frequent cause. Retention, difficult and im- perfect occurrence of the menses, have very ge- nerally been enumerated amongst its causes, but the uterine disorder is rather a coincident effect of the same pathological state that produces chlo- rosis (§ 12.). Suppression of the menses, exces- sive menstruation, and manustupration, are some- times concerned in its appearance; the latter acting chiefly by debilitating the frame generally, by exhausting the energy of the sexual organs, and thereby assisting the operation of other causes, par- ticularly when the functions of the stomach and bowels are torpid, or otherwise disordered. The influence of constipation, and fecal collections in the caecum and colon, in occasioning the disease, cannot be questioned, although somewhat exclu- sively insisted upon by Dr. Hamilton ; in oppo- sition to the opinion of Dr. Cullen, who referred it chiefly to an inactive state of the ovaria. It seems, however, quite as evident that the torpor of the digestive organs, especially of the lower bowels, and the inactivity of the uterine organs, depend upon the state of the organic system of nerves, which supply not only those viscera, but also those concerned in assimilation and circula- tion,—all those functions presenting more or less disorder in the course of the disease. 6. II. History and Symptoms.—Chlorosis pre- sents two stages; the incipient, and the fully developed or confirmed. It also manifests various morbid associations or complications. A. The incipient stage commences insidiously, and almost insensibly. The patient is at first languid, listless, weak ; loses her complexion ; has no disposition to amusement, if it require mental or physical exer- tion ; is often without appetite, or craves for par- ticular, and sometimes unwholesome, kinds of food ; the bowels are costive ; bodily exertion soon occasions shortness of breath, and fatigue ; the breath is offensive; the tongue is white or pasty, sleep is disturbed or unrefreshing, and op- pressive in the morning; she often complains of intermittent headach, pain of the left side, and palpitations, which are induced by the slightest cause ; the pulse is quick, weak, and small; and the catamenia are either retained, or are scanty, and of a pale colour; all these symptoms gradually increase, and the countenance becomes more and more pale, and assumes a greenish yel- low tint. 7. B. The fully developed disease presents its characteristic complexion—the pale greenish yel- low of an etiolated plant. The lips, gums, and in- sides of the cheeks, are pale; the eyelids ara livid, sometimes cedematous, particularly in the morning; the conjunctiva are remarkably white ; the soft solids flaccid; the extremities cold ; and the ankles (edematous. The tongue is usually pale, soft, flabby, and indented at the edges by the teeth ; sometimes it is smooth, glossy, and fis- sured. The appetite is more and more capricious and morbid; sometimes with pica, or a desire for pickles and acids ; ail'd nausea and vomiting, es- pecially in the morning, and cardialgia or gastro- dynia alter meals, not infrequently occur. If the menses have already appeared, they become gradually more difficult, and scanty ; are attended with syncope or pain; are of short continuance, pale, or watery ; recur at longer periods, and at last disappear. The patient is often sad; enter- tains depressing and minister ideas; prefers soli- tude, and is capricious. In the more advanced or inveterate cases, the finger nails are brittle, dry, and split or break oft*; the hair is weak, falls out, is lank, dry, and splits at its extremities. The abdomen is often tense, distended, and slightly painful. A constant pain is complained of under the left breast, sometimes with a slight cough; the constipation alternates with diarrhoea; some degree of emaciation takes place ; the oedema ex- tends, or assumes the form of anasarca or asci- tes ; various irregular states of hysteria occasion- ally appear during the course of the disease; and some one or two symptoms become promi- nent, occasionally deceiving both the patient and medical attendant by their severity. Thus the headach, pain of the side, palpitations, cough, &c. occasionally lead to the apprehension of in- flammatory states of the brain, or of the pleura, of disease of the heart, or of phthisis. 8. C. Terminations and complications.—When the disease becomes inveterate from neglect, in- efficient treatment, or the continued operation of its causes, &c., it often assumes diversified forms, owing to morbid associations. The continued disorder and debility of the digestive organs, and the consequent insufficient supply of healthv chyle to the blood, as well as the imperfect san- guifaction of what is supplied to it, sooner or later gives rise to anaemia, which, in its slighter grades, owing to the causes hereafter to be noticed (§ 12.), even accompanies the early stage of chlorosis. In females who have been married, or in those who, previously to the appearance of the disease, had the uterine functions and discharges regu- larly and fully established : hysteria, in some one or more of its numerous states, is commonly ob- served. Chlorosis is sometimes also complicated with swellings of the glands, or with chronic cu- taneous eruptions, or with hoematemesis and ma- lm ; and occasionally terminates in dropsy of either the thoracic or abdominal cavities. Mania and delirium rarely ensue in the course of its ad- vanced stages and inveterate forms. 9. III. Diagnosis.—Chlorosis is most intimately related in its symptoms, and the nature of the changes which constitute it, to anaemia. Indeed, the advanced stage of the former is often identical with the latter; the chief differences consisting in the pale, greenish, or greenish yellow tint of the countenance, the torpor or disorder of the uterine functions, and affection of the stomach in chlorosis. It also often resembles other chronic diseases, particularly those seated in the stomach, and tuberculous affections; but not so closely as to be mistaken for them. Neither the nervous headach, nor the hysterical pains, particularly those complained of in the left side and under the left breast, nor the palpitations of the heart, can with due attention be confounded with inflamma- tion or organic change in these situations: yet have I seen these mistakes made and nearly fatal consequences ensue,—the practitioner having been deceived by the frequency of the pulse in such cases. In this, as well as in other diseases, much advantage will accrue from recollecting that the most acute pain is generally owing to a pathological state the reverse of inflammato- ry ; and that the most frequent pulse is very far from indicating a necessity for blood-letting, which if practised in such cases, will increase the morbid sensibility and the vascular irritabili- ty, even when it does not hasten a fatal termina- tion. 10. IV. Prognosis.—Chlorosis is always chro- nic ; is generally cured, particularly in its simple form; but sometimes also terminates fatally, ow- ing to the associated lesion of various functions and organs. Recovery may be confidently ex- pected, when it is incipient or uncomplicated, and none of the internal viscera betray marked dis- ease ; especially if it have not continued longer than two or three months, and the menses have not appeared. If it occur in married women, sterility is often the consequence ; or, if children are borne, they are generally feeble and unhealthy. Chlorosis should be viewed in a serious light, if it have been of long duration ; if the catamenia, after having appeared, are gradually suppressed ; more particularly if the signs of anaemia to a con- siderable degree be present ; if emaciation be rapid, with quick respiration and cough ; if the cedema of the extremities extend ; if symptoms of effusion of serum into the cavities supervene ; if haematemesis or malaena occur ; and if it have resisted, in its early stage, a judicious treatment. In the advanced progress of the disease, especially when it is complicated, death sometimes takes place unexpectedly, but seldom without evidence of excessive depression of the organic nervous in- fluence, and of great deficiency of the circulating fluid. (See Blood. § 42. et seq.) 11. V. Pathology.—A. Morbid appearances. The adipose substance is sometimes not much di- minished ; but the rest of the soft solids is flaccid and pale, from a deficiency of the red blood. Effusion of serous fluid is commonly met with in the large cavities, particularly those of the pleura, pericardium, and peritoneum, and occasionally also in the ventricles of the brain. The lungs are frequently (Edematous, or studded with tu- bercles ; the liver is often enlarged, and some- times pale or tuberculated ; the stomach small, pale, and contracted; the mesenteric glands slightly enlarged ; the ovaria and uterus, in some instances, are imperfectly developed, or contain small tumours; the cavities of the heart are oc- casionally somewhat enlarged, and their parietes are generally flaccid and pale, or slightly atro- phied ; the blood is commonly pale, aqueous, and deficie it in coagula,—those which are found in the large veins and auricles of the heart being of a very light colour, and small. These are the most common lesions; but others are sometimes noticed, both in the organs now mentioned, and in different parts, as in the spleen, pancreas, gall- bladder, kidneys, &c. In some cases but little change beyond the exsanguineous state of the va- CHLOROSIS—Prognosis—Patholofy. rious structures are observed, as in those recorded by Lieutaud. 12. B. Nature of the disease. It has been considered by many writers, and amongst others by Wedel, Korte, Cullen, Desormeaux, and Roche, that chlorosis is chiefly dependent upon debility or torpor of the nervous influence deve- loping and actuating the ovaria and uterus. Hoffmann, Darwin, and Saunders connect it more immediately with obstructed function of the liver. Hamilton refers : t chiefly to torpor of, with accumulated sordes in, the digestive organs, par- ticularly the lower bowels ; and Andral, to the deficient and morbid state of the blood. If we reflect upon the character of the associated phe- nomena constituting the disease, in relation to their causes, on the one hand, and to their conse- quences and terminations on the other, we must necessarily arrive at the inference, that all the organic functions—those of digestion, assimila- tion, sanguifaction, nutrition, and generation,— are inadequately performed; and, as the organs devoted to these offices are intimately connected one with the other, and actuated by the organic nervous system, that consequently the vital energy of this system is insufficient for the purposes it is destined to perform. We know that the evolution of the sexual organs is owing to the state of vital power ; and that, by a reciprocal influence, the activity cf those organs increases all the other functions of the frame. Therefore, as we com- monly observe this disease at the period of puberty, and associated with imperfectly developed or per- formed function of the sexual organs, we must necessarily infer, that the defective energy of the organic nervous system delays or arrests their developement, and weakens their functions ; the whole frame being thereby deprived of the stimu- lus they impart to it. Consequently, if the causes continue to operate, or if this system experience no salutary or natural excitement, all the organic functions languish more and more ; the chyle is imperfectly prepared; and sanguifaction and as- similation are inadequately performed ; all the phenomena of an advanced state of the disease being the result. [Dr. Cullen regarded chlorosis as the effect of suppression of the menstrual secretion, hence oc- casioning a general loss of tone in the system. Cragie and others however, state (“ Practice,” vol. 2. p. 697.), that this disease is not confined to females, and we know that the menses are often suppressed without any symptoms of chlorosis. It does not occur in women who have lost an ovary, or in whom it has not been developed, though the sexual peculiarities are indistinct. The retention of the menstrual evacuation would rather seem to be the effect, and not the cause of the general languor, and derangement of the secretory organs so characteristic of this affection. Andral has pointed out an impaired condition of the blood, as constituting the most essential feature in chlorosis ; (Anatomie Pathologique t. i. p. 87.) the red globules being diminished in quan- tity, and the serum much increased in proportion to the clot. To this cause must be attributed the diminished temperature of the surface, the pallor and waxy appearance, as will as the want of colour in the catamenia, and the pale stain which the blood leaves upon a white cloth. Wherever we meet with a great deficiency of red globules, according to Andral, there will be much prostra- 373 374 tion of the muscular powers, general debility, grave disturbance of the nervous system, manifested by different disorders of the intelligence, sensation, and motion ; as well as of the functions of digestion, circulation and respiration—hence it is that we meet so often with dyspepsia, dyspnea, and palpi- tations of the heart in ancemic subjects—Andral has also noticed the fact that the blood of chlorotic patients is often buffed, showing that while it has lost some of its red globules, it has retained its usual proportion of fibrine, thus causing an excess of the latter in proportion to the former. Dr. Babington of London, has published the results of an examination of the blood in two cases of chlorosis, and found it contained 871 and 852 parts of water in 1000, instead of 780 the healthy proportion ; and the colouring particles amounted to 48,7 and 52 respectively, instead of 127. The albumen and salts being in the usual proportion— (Art. “ Blood” Cycl. Anat. and Physiology.) Another fact worthy of notice in chlorotic and anaemic cases, is the distinct bellows sound heard, by auscultation, over the heart and large blood vessels.—This sound is not heard where there is simply a diminution of the fibrine, or of the albu- men. The results which M. Andral has obtained on this subject are as follows. 1. When the globules are so much diminished as to be below 80, (the mean of healthy blood, being 140) the bruit de souffle exists in the arteries as a constant condition. 2. When the globules remain above 80, this sounds may still show itself, but it is no longer constant; it is often heard when the globules oscillate between 80 and 100 ; but rarely heard when they reach above 100, and never when they are above the physiological mean. In 22 case of chlorosis, an intermittent bellows sound occurred in 8 cases, the globules ranging from 97 to 117, and a continuous souffle was met with 14 times, the globules varying from 28 to 113. This bruit de diable* is heard most frequently along the carotid and subclavian, and sometimes in the crural arteries; generally on one side only. Raciborsky states that he did not find it wanting in a single chlorotic case that occurre din the clinical wards of Bouillaud, during a year and a half of his attendance.] 13. VI. Treatment.—A. In its first stage, this affection is generally soon removed, 1st, by a due attention to the causes,—particularly the mental or moral causes,—and by removing or counter- acting them as far as possible; 2d, by eva- cuating all morbid and accumulated sordes from the alimentary mucous surfaces, and regulating the alvine secretions and excretions ; and, 3d, by imparting vigour to the digestive and organic functions, and exciting at the same time the torpid or imperfect actions and secretions of the uterus. It will generally be necessary to ascertain the causes of the affection, or to direct the attention of the friends of the patient to their nature, ten- dencies, and the best means of counteracting them. The medical treatment may be commenced with a moderate dose of calomel or blue pill, and a few grains of powdered ginger, given at bed-time ; and the following morning the secretions should be more fully promoted and evacuated by a dose of castor oil, or of the compound decoction of aloes. After the bowels have been freely eva- puated, the following pills, or F. 877. should be taken daily, either during or after dinner:— LnuOROSIS—Treatment. No. 115. R. Aloes Socot., Ferri Sulphatis, aa gr. ij.; Gum. Mastich. gr. j.; Pulv. Capsici gr. ij.; Syrupi Simp vel Olei Caryoph. q. s. M. Fiant pilul® du®.* During the use of these, it will generally be requisite to promote the functions of the li-ver, and excite the bowels, by the occasional repetition of the calomel and ginger at bed-time, and the purgative draught the following morning. In some cases, the operation of the medicine may be very advantageously promoted by an enema. In many instances, nothing beyond what is now re- commended will be necessary; but, in addition, a course of chalybeate mineral waters may be directed; and, under every circumstance, exer- ciso in the open air, particularly on horseback change of air to the sea coast, a light nutritious diet, and warm clothing, especially of the lower extremities, should be recommended. Flannel drawers will be found of service in winter. 14. B. In its second stage, or in the more ob- stinate cases, or when the affection is attended with difficult or scanty menstruation, the tinct. ferri ammonio-chloridi, or the tinctura guaiaci composita, and the phosphate of iron or the io- dide of iron, are preferable to the sulphate of iron,—the compound aloetie decoction being the most suitable aperient. When pains of the head, or of the left side, or other symptoms of hysteria, or palpitations, are complained of, these medicines will be advantageously associated with camphor and hyoscyamus. When the torpor of the uterine system is evident, conium will, however, be pre- ferable in such cases to hyoscyamus, and may be given either with these medicines, or with any of the ammoniated spirits. In a few obstinate cases of the disease, I have prescribed, with marked ad- vantage, small doses -of the extract of nux vomica and the strychnine, as in Formulae 542. 565, and 907. 15. If the disease still persist, if the ankles swell, or if dropsical symptoms come on, and the menstrual evacuations continue suppressed, ad- vantage will sometimes accrue from the iodide of iron, and from rubbing the loins assiduously every' night with either of the liniments, F. 296. and 311., and acting gently on the bowels by means of the following pills:— No. 116. R. Pilul. Aloes cum Myrrha 3 j.; Saponis Castil. 3 ss.; Olei Crotonis Tiglii III iij. Contunde bene simul, et divide in Pilulas xxiv., quarum omni nocte capiat unam, duas, vel tres. 16. In the course of practice, I have seen three cases of the disease complicated with swelling of the parotid and submaxillary glands. In order to remove these tumours, I prescribed iodine in- ternally, in small and frequent doses, giving also at bed-time the aloes and myrrh pill. In these instances, the menses gradually came on, and all * [The most valuable preparations of iron are those which have the deutoxide for their base, as in the mine ral waters, and the following formula R Ferri Sulphat. 3 ij.— 3 iij.; Acidi Nitrici, 3 iij.; Aqua Dist. 1 jss.—These are to be rubbed together gradu- ally in a glass mortar, till the iron is dissolved ; then fil- ter.—Dose, 5 to 15 drops in water, two or three times a day. Here the oxygen of the nitric acid uniting with the sulphate of iron, forms a persulphate ; at the same time the iron is converted into red oxide. It is far superior to the Tinct. Ferri Mur., and it never precipitates the oxide of iron. Patients do not well bear above ten or twelve drops to a dose; and when given with small doses of sulphate of magnesia it equals the purgative mineral waters. The Bitartrate, the Potassio-Tartrate, the Am- monio-Tartrate, and the Liquor Ferri Bin iodidi are also very valuable preparations of iron : when given in solu- tion, this agent is far more efficacious than when given in the form of pill.] * Diable—Humming-top of children CHOLERA—History and Symptoms. 375 disorder vanished. I have on other occasions observed a very marked emmenagogue, as well as tonic effect, produced by the preparations of Iodine; and from these effects, as well as from their efficacy in the above cases, I consider them calculated to prove of use in certain states of obstinate chlorosis. On some occasions, par- ticularly when chronic eruptions appear in the course of the disease, sulphur will be found the best aperient, and the following pills will be pro- ductive of benefit; but, in addition to those al- ready particularised, several recipes will be found jn the Appendix suited to the different forms and complications of this affection, as well as of other derangements of the uterine functions. No. 117. ft Sod® Bi-boratis 3 ij.; Sulphuris Praecip. 3j.; Mucilag. Acaci® q. s. Fiant Pilul® xxiv., quarum capiat tres, ter quotidie. (See also F. 519.) No. 118. ft Sod® Bi-boratis 3ij.; Pulv. Capsici Annui 3j.; Pilul. Aloes cam Myrrha 3j.; Olei Sabin® q. s. M. Fiant Pilul® xxx., quarum capiat binas ter die. No. 119. ft Ferri Sesquioxidi 3 j.; Sulphuris Depur. 3 j.; Myrrh®, Aloes Soc., Fellis Tauri Insp., aa 3 ss. Con- tunde bene simul, et divide in Pil. gr. iv., quarum sumat binas vel tres, bis terve in die. 17. Electricity and galvanism have been ad- vised by Renaud and Sigaud la Fond for this disease ; and the ammonio-sulphate of copper, by Bianchi. The preparations of iron have very pro- perly been directed, in conjunction with the alka- lies and myrrh, by Willan, with stimulants and bitters, by Schaeffer, with assafaetida, by Hir- schel, and with cinchona and rhubarb, by Ranoe. Marriage has been suggested as a remedy for chlorosis, by Wedel, Le Blanc, Korte, and several others. Cold bathing has been recom- mended by Brandis, and condemned by Darwin ; and purgatives have been chiefly depended upon by Hamilton. The use of mineral waters is cer- tainly of much service in chlorotic cases. Those of Driburg, Pyrmont, Spa, Carlsbad, &c. on the Continent, have been much praised by Brandis’ Marcard, and Kressig ; and the chalybeate springs in this country, by most practitioners. But equal advantage will sometimes accrue, in the inveterate forms of the disease, from the sul- phureous and saline waters, in addition to a ju- dicious course of medicine ; and from the Bath and Buxton warm springs, used in the form of baths. The warm hip-bath, some salt and a little mustard having been added to the water, is also beneficial. (See Menstruation.) Bibliog. and Refer.—Hippocrates, De Morb. Mul. sect. v. p. 125.—Ballonius, De Morb. Mul. Opera, vol. iv. pp. 66. 129.—Le Blanc, Ergo Venus Amantium Ictero. Paris, 1616.—Hoffmann, De Genuina Chlorosis Indole, v. Opera, Supp. ii. part ii. p. 389.— Wedel, De Chlorosi seu Fcedis Virginium Coloribus. Jen®, 1681.; et De Ve- nere Medica et Morbosa, p. 23.—Korte, De Pallore Vir- ginum, Venerem indicante. Hal. 1759.—RanOe, in Acta Reg. Soc Med. Haun. vol. iv. p. 114.—Richter, Die Spe- cieile Therapie, &c. b. iii. p. 752.—Darwin, Zoonomia, vol. iii. p. 157. 8vo ed.—Brandis, Ueber die Wirkung der Eis- enmittel und, &c. p. 113.—Schaffer in Hufeland's Journ. der Pract. Arzneyk. b. vi. p. 267.—Bianchi, in Brera, Com- ment. Med. dec. i. t. ii. n. 2.—Cullen Works by Thom- son, vol. ii. pp. 293.384.—Hamilton, Observ. on Purgative Med. &c. ch. iv.—Gagnion, Sur la Pubertb de la Femme, et surle Chlorosis. Paris, 1809.—Frank, Efemeridi Fisico- Medici, 1805.—Horn, Archiv fur Pract. Med. b. v. st. 1. p. 90.—Desormeaux, Diction, de Med. t. v. pu 166.— Roche, Diet, de Mbd. et Chir. Prat. t. v. p. 230. CHOLERA. Syn. Cholora Morbus, Passio Cho- lerica, Diarrhoea Cholerica, Auct. Lat. Cho- leree. Cholerragie, Trousse-galant, Fr. Die Gallenruhr, Brechruhr, Ger. Diarrhoea Cho- lera, Young. Classif. 2. Class, Nervous Diseases; 3. Order, Spasmodic Affections (Cullen). 1. Class, Diseases of the Digestive Func- tions ; 1. Order, Affecting the Alimentary Canal (Good). II. Class, III. Order (Author, in Preface). 1. Defin. Griping pains, followed by vomiting and purging, very rarely with flatulent eructa- tions and dejections, and always with spasms of the extremities, particularly the inferior, and anxiety. 2. I. History and Symptoms.—The term Cholera has been in use since the time of Hip- pocrates, who admitted two species of the dis- ease,—one humid, the other dry,—x°^Pa fypv, Xo\£oa frpa. According to Celsus, it is derived from and pea, signifying literally bile-flux. Trallian, however, derives it from %oX«f and pecj, intestinal flux. Galen, adopting the dis- tinction established by Hippocrates, attributed the humid cholera to the presence of acrid hu- mours generated by the corruption of the food; and the dry cholera, to an acrid flatus. With very slight modifications, this doctrine was re- ceived by Fenrel, Baillou, Sydenham, F. Hoff- mann, Bianchi, Sauvages, and Vogel, the differ- ence chiefly consisting in the part they ascribed to the bile, and to the state of this secretion, in the production of the disease. Cullen directed atten- tion, more accurately than his predecessors, to its nervous and spasmodic characters. Pinf.l was, however, the first who made any considerable in- novation on the opinion of the Ancients as to its nature. He classed it as a species of the genus •of fevers, to which he applied the term of Menin- go-gastric. M. Geoffroy (Diet. des. Scien. Med. t. v.) subsequently attributed to it an inflam- matory character; and MM. Broussais and Gravier afterwards contended that it consists of inflammation of the mucous surface of the diges- tive tube commencing with nervous symptoms. 3. This diversity of opinions will be fully ac- counted for in the sequel; but I may at present remark, that they may be in many respects re- conciled, inasmuch as the particular form of dis- order, for which each exclusively contends, fre- quently exists as a part of the morbid condition constituting the disease. After having paid con- siderable attention to the literature of cholera, and had much experience of all its forms—of two of them in my own person—I consider that it ad- mits of division into the following distinct va- rieties :—1st, The Cholera Biliosa, or bilious cho- lera ; 2d, Cholera Flatulenta, flatulent cholera; 3d, Cholera Spasmodica, the spasmodic cholera, or Mort de Chien. As I believe the disease which has appeared in recent times, and has received numerous appellations, among which that of epidemic cholera has been most commonly used, to be a different malady from the other forms of cholera,* I have treated of it in a distinct article. (See Pestilence.) i. Cholera Biliosa, Bilious Cholera; %oXtpa hype, Gr.; Cholera Ilumida, Lat.; Choler- ragie, Fr.; Die Gallenruhr, Ger. 4. Defin. Copious and frequent vomiting and purging, at first of the alimentary and faecal matters, with a redundancy of bile, and spasms of the legs and thighs. 5. Causes, States, considered a mere prolongation of the Eastern continent, whilst the Northern lands of the latter, elevated from 3000 to 5000 feet, become a great reservoir of ice and snow, which diminish the temperature of adjoining regions. Moreover, the western coast of both continents has a higher temperature than the eastern, in corresponding latitudes ; and this arises from the steady prevalence of westerly winds, between the parallels of 30° and which sweep from the ocean a humid atmos- phere, which, in its passage over the land, has a constant tendency to establish an equilibrium of temperature, and as its vapour is gradually con- densed, it also evolves its latent heat.t Philadel- phia and Pekin, each on the eastern coast of its respective continent, and nearly in latitude 40°, have the same mean annual temperature, whilst on the western coast of the old and the new world, the same annual temperature is found about the 48th parallel- The climate of the new world, viewed in its general features, is, contrary to com- mon opinion, more mild and uniform than that of the old. Taking, for example, the annual tem- perature of 53° 60', the eastern coast of Asia shows a difference of 55° 80', in the mean tern- perature of summer and winter, whilst the eastern coast of America exhibits a difference only of 43° 60'; and on the other hand, the western coasts of Europe and America present respectively a dif- ference of 28° 30' and 23°. Hence the fallacy of the opinion, which ascribes the mild climate of Europe to the influence of agricultural improve ment, becomes at once apparent, when it is con sidered that the region of Oregon, lying west of the Rocky Mountains, which continues in a state of nature, has a climate less contrasted than tha‘ of Europe in similar latitudes, and that, conse quently it is in a proportionate degree milder thai the climate of our own region, in which the labors of man in a few ages have almost wrought mira- cles, as well as that of the eastern coast of Asia, which has been under cultivation for several thou- sand years. Dr. FoRRy has made three General Divisions of the U, States, embracing three systems of cli- mate ; namely, I. The Northern ; II. The Middle; and III. The Southern. The 1st extends on the Atlantic coast, from Eastport, Me., to the harbour of New York ; the 2d from Delaware Bay to Savannah ; the 3d the whole region, south and west to Texas and the Rocky Mountains. The Northern Division exhibits the greatest di- versity of physical character, as well as the most marked variety of climate. On the sea coast of New England, the influence of the ocean modifies the range of the thermometer and the mean tem- perature of the seasons; advancing into the in- terior, the extreme range of temperature increases, and the seasons are violently contrasted. Having come within the influence of the great lakes, a climate like that of the sea-board is found, and proceeding into the region beyond the modifying agency of these inland seas an excessive climate is again exhibited. The variations of the isotheral, and isocheimal curves,—the lines of equal winter and summer temperature—thus afford a happy illustration of the equalizing tendency of largo bodies of water. The chain of vast lakes or inland seas, lying in the course of the St. Lawrence, it is estimated, embraces an area of 93,000 square miles, some of the largest of them having a mean depth of* 1000 feet, and altogether containing, as has been computed, 11,300 cubic miles of water—a quan- tity supposed to exceed more than half of all the fresh water on the face of the globe. The influ- ence of these lakes is to render the winters milder within their influence, and the summers cooler, than the same latitudes situated beyond their in- fluence, and there is an equally striking difference in their effects upon the weather, as respects cloudy and fair. Remote from the lakes, we have 216 fair days, 73 cloudy, 46 rain; 29 snow; in their vicinity we have 119 fair days, 132 cloudy; 67 rain; 47 snow. Localities under the influence of the ocean or inland seas, do not exhibit great extremes of temperature, but the air is moist, and the changes of season are slow, uncertain and variable. On the other hand, the climate of localities, removed from such equalizing influences, is characterized by a great range of the thermometer, and a corresponding dryness of the atmosphere ; the mean temperature of winter and summer is strongly contrasted, and the sea- sons change in constant and rapid succession. Conformably to these general laws, it is found that the climatic features of the coast of New England, and of the region of the great lakes, * At Fort Vancouver, in the Oregon Territory, in a pa- ra'llel 5° north of the city of New York, Mr. Ball tells us that he commenced plowing in January of the year 1833. “ The vegetables of the preceding season” he says. “ were still standing in gardens, untouched by the frost. New grass had sprung up sufficiently for excellent pasture. Though the latitude is nearly that of Montreal, mowing and curing hay are unnecessary, for cattle graze on fresh- growing grass through the winter. Garden vegetables, such as turnips and carrots, are not destroyed, but no trees blossom till March, except willows, alders, &c. 404 exhibit a striking- resemblance ; the temperature being milder and more uniform than that of the intervening tract, as well as the region beyond the lakes, the climate of which may be said to be excessive, or rigorous.—As the mean annual tem- perature, however, is nearly the same, the dif- ference of climate is owing to the unequal distri- bution of heat among the seasons. We possess io exact measurement of the relative quantity of rain that falls in our different systems of climate, and as no observations have been made upon the hydrometer, their relative degree of humidity can- not be determined. In the Middle Division of our climates, the extremes of temperature are much more modified than in the northern division, being characterized by great variableness, whilst in the latter, a com- paritively steady temperature predominates. As we proceed south the seasons become, as a gene- ral rule, more uniform in proportion as the mean annual temperature increases. The climate of the region of the great lakes on our northern frontier, is not more contrasted in the opposite seasons than that of Philadelphia—an inference long since deduced from the fact, that similar vegetable productions are found in each, while the same plants will not flourish in the interior of New York, Vermont, and New Hampshire. The region of Pennsylvania, as though it were the battle ground on which Boreas and Auster strug- gle for mastery, experiences, indeed, the extremes of heat and cold. But as we proceed south along the Atlantic plain, climate soon undergoes a striking modification, of which the Potomac river forms the line of demarcation. Beyond this point, the sledge is no more seen in the farmer’s barn-yard. The table-lands of Kentucky and Tennessee, on the other hand, carry, several de- grees farther south, a mild and temperate cli- mate. The Southern Division is characterised by the predominance of high temperature. Proceed- ing south from Canada to Florida, the seasons be- come more uniform in proportion as their annual temperature increases, and they glide imperceptibly into each other, exhibiting no great extremes. Compared with the other regions of the United States, the peninsula of Florida has a climate wholly peculiar. The lime, the orange, and the fig, find there a genial temperature; the course of vegetable life is unceasing; culinary vegeta- bles are cultivated, and wild flowers spring up and flourish in the month of January ; and so little is the temperature of the lakes and rivers dimin- ished during the winter months, that one may al- most at any time bathe in their waters. The cli- mate is so exceedingly mild and uniform that be- sides the vegetable productions of the southern states generally, many of a tropical character are produced. The palmetto or cabbage palm, the live-oak, the deciduous cypress, and some varie- ties of the pine, are common farther north; but the lignum-vitse, mahogany, log-wood, mangrove, cocoa-nut, etc., are oniy found in the southern portion of the peninsula. Here also in common with our southern borders, the fig, date, orange, lemon, citron, pomegranite, banana, olive, tama- rind, papaw, guava, as well as cotton, rice, su- gar-cane, indigo, tobacco, maize, etc., find a genial climate. “ In contemplating,” says Dr. Forry the scenery of East Florida in the month of January, the northern man is apt to forget that it is a winter landscape. To him, all nature is CLIMATE—Its Influence on Man. changed; even the birds of the air,—the pelican and flamingo, indicate to him a climate entirely new. The writer being attached, in January 1838, to a boat expedition, the double object of which was to operate against the Seminoles, and to explore the sources of the St. John’s, found in the midst of winter, the high cane-grass, which covers its banks, intertwined with a variety of blooming morning-glory (convolvulus). The thermometer, at mid-day, in the shade, stood at 84° Fah., and in the sun rose to 100° ; and at night we pitched no tents, but lay beneath the canopy of heaven, with a screen perhaps over the face as a protection against the heavy dews. Nothwithstanding the day attains such a high temperature, the mercury just before day-light often sinks to 45°, causing a very uncomfortable sensation of cold. Along the south-eastern coast, at Key Biscayno, for example, frost is never known, nor is it ever so cold as to require the use of fire. In this system of climate, the rigors of climate are unknown, and smiling verdure never ceases to reign.”] 1G. II. Influence of Climate on the Hu- man Constitution.—From what has been already adduced, the action of climate on the human frame must be admitted to be extremely com- plex ; the ultimate result arising chiefly from the combined operation of heat, light, electricity, atmospheric pressure, the various emanations arising from the soil, and the productions, vege- table and animal, constituting the food of man. I he human species is, in many respects, moral as well as physical, moulded by the climate and soil which he inhabits; and, by this pliability of his functions, ur.der the influence of atmospheric and other vicissitudes, is the only animal that is truly cosmopolite. liv considering the influence of cli- mate on man, it will be advantageous to view it, first, with reference to extensive communities and races of the species ; secondly, as respects the na- ture of the food which different climates provide for the uses of man, ana its co-operation with the climate in modifying the human frame, and coun- teracting the effects of rigorous seasons, and the unfavourable influences to which it is exposed in arctic and tropical regions; and, thirdly, as re- gards the changes produced in individual consti- tutions after migrating from one climate to another. Neither the limits nor the scope of this work will permit me to consider these subjects in all their relations; I must, therefore, confine myself to such topics as have an evident and important bearing upon practical medicine—in respect either of the causation and nature of disease or of rational methods of cure. 17. i. Climate in relation to the Varieties of the Species and their prevailing Diseases. —Although man is more readily assimilated with particular climates than any other animal, yet this faculty is not equally possessed by all the varieties of the species and the natives of every latitude. It is more particularly manifested bv the inhabitants of temperate climates; probably owing to their greater vital energy, and to their habitual exposure to alternate extremes of tem- perature and of season. The natives of polar regions on the one hand, and of tropical countries on the other, possess it in a much less remarkable degree ; and not only are they speedily cut ofFby removal from the one climate to the other, but they often suffer greatly from a residence in tem- perate countries. It should not, however, be overlooked, that man, like many of the individ- uals below him in the scale of creation, often de- rives advantage from a change of locality ; pro- vided that the change is not made to opposite climates, but to districts of equal or greater salu- brity. 18. It has long been a matter of dispute whether the differences, intellectual and physical, presented by the various races of man, have arisen from the continued, slow, and imperceptible oper- ation of climate ; or have been originally impressed upon the species. The evidence and arguments connected with this subject fall not within my province. But it is of importance to the practical physician to note what those peculiarities are, that characterise the different races of men; and whether they be the result of climatorial influ- ence or of original conformation, to consider them in connection with the climates to which we find them more particularly appropriated in our survey of man in his distribution over the globe. However cursory this survey may be, there are certain facts of the utmost practical importance to every one who entertains philosophic ideas in medicine, which should not be overlooked; namely, that the slow and continued operation of a particular climate actually changes the human frame in many respects to that state which its indigenous inhabitants present; and that the con- stitution, thus assimilated, is necessarily the best suited to the external influences to which it is ex- posed, and the food furnished by the soil of which it is the native. There are, however, certain cha- racteristics, especially those which distinguish the and Mongolian varieties, that a succes- sion of ages has not been sufficient to impart to different races which had migrated to the climates they inhabit; and which must, therefore, bo im- puted to original conformation. 19. A. The effects of great cold, and of the privation of solar light, during nearly two-thirds of the year upon the human frame, are observable in the stunted growth and the weak muscular power of the Samoi'ed, the Ostiaks, the Esquimaux, the Greenlander, and the Laplander, compared with the inhabitant of temperate climates. In the arctic regions, the human body, like many of the lower animals, and the productions of the vegeta- ble kingdom, rarely reaches that state of develope- ment it presents in temperate countries: the fea- tures and stature retain an appearance of boyhood or youth, almost until marks of age appear; the complexion is greyish; the head flat, the face broad, the eyes far apart, and the whole figure squat and unattractive. Female pubescence, however, according to the accounts given by Lin- naeus, Humboldt, Lyon, Parry, and Franklin, as indicated by the accession of the catamenia, is not delayed beyond the period usual in temperate countries—most probably owing to the premature excitement of the generative organs in the unre- strained intercourse of the sexes, that takes place at an early age. To this cause, also, is to be im- puted the circumstance of their females being less prolific than those of temperate climes; whilst, in these races, the instinctive feelings which tend to the preservation of the individual and of the species are sufficiently strong, the intellectual en- dowments and moral sentiments are remarkably torpid. The benumbing influence of cold, and of the privation of solar light, is also manifested in the functions of the nervous and sanguiferous sys- tems. Diseases generally assume among them an CLIMATE—Its Influence on Man. asthenic form ; fevers being of a low type, and sthenic inflammations of rare occurrence. As long as the natives of arctic regions remain in their own countries, they are exposed to but few causes of disease besides cold, the scarcity of pro- visions, occasional excessive repletion, and various contagions. The soil being almost constantly frozen, even during summer, at the depth of a very few feet, deleterious emanations seldom or never issue from it; but infectious maladies, when once introduced, become extremely destructive, and several of them often very prevalent, owing to their low, small, and unventilated dwellings, and their want of personal and domestic clean - liness. When, however, they migrate to more temperate and southerly regions, they are very liable to febrile and sub-inflammatory diseases, arising from increased temperature, the vicissi- tudes of season, and other novel causes to which they become exposed ; whilst their maladies sel- dom require, their constitutional powers can but ill tolerate, a lowering treatment, or large san- guineous depletions. 20. B. Although extreme and continued de- pression of temperature produces the above effects, more moderate cold, particularly when alternating with a temperate summer heat, promotes the de- velopment of both the body and mind. Countries situate between 45° and 63° of northern latitude are inhabited by the most robust and enduring of our species, in respect of both physical and in- tellectual powers. It may be stated in general of the northern temperate zone, that the inhabit- ants of its more southerly countries have made the earliest advances in civilization, and that those of its middle and more northerly climates have carried the useful arts and sciences to the highest perfection. Within the range of this zone, man presents the greatest diversity of tempera- ment, of constitution, and mental endowment. Muscular frames, plethoric habits of body, and the sanguine temperament, predominate among the natives of the more northerly of temperate climates, particularly as regards Europe and its western countries. Affections of the chest and respiratory organs, inflammations, fevers compli- cated with inflammations of the lungs or of the brain, and rheumatism, are the most prevalent diseases. Epidemics assume most frequently amongst them a phlogistic character: and vas- cular depletions are more required, and better borne, in the treatment of their maladies. Cli- mates which are the most variable, as to both the commemcement and the course of the dif- ferent seasons, are, notwithstanding the many disadvantages imputed to them, the most favour- able to the advancement of the various bodily and mental powers. The rapid and frequent vicissitudes of weather preclude, as respects the community generally, the regular adoption of means to guard the body against their operation : consequently the frame becomes habituated to their operation, and thereby fortified against the injurious impressions which would be otherwise made by them. That countries thus circum- stanced are benefited rather than injured by this state of weather and season, is shown by the ro- bust frames, the mental activity, and the longe- vity of their inhabitants. The physical and moral history of the British Isles, Denmark, Sweden, and the more continental districts of western Europe, demonstrate this fact. In the eastern countries of this quarter of the globe, as well as 405 406 CLIMATE—Its Influence on Man. in central Asia and in North America, the seasons being much more regular in their advent and in their course, measures are more regularly and uniformly adopted to moderate the extremes of temperature and the vicissitudes of weather ; and these have, in many instances, the effect of ener- vating the frame, of promoting the extension or prevalence of disease, and of thereby diminishing the mean duration of human life. Of this de- scription is the use of excessively warm clothing and of stoves, which overheat the air of the apartments, without renewing it so rapidly as is often requisite to the wants of the economy. Hence, whilst the external atmosphere is cold, dry, and invigorating to the healthy frame in a state of activity, the air in-doors is close, warm, and depressing; the frequent alternation from the one to the other, or the constant residence in the latter, being injurious even to those in health, and causing diseases of the thoracic and abdo- minal viscera. 21. While the natives of northerly inland coun- tries suffer more especially from the extremes of temperature and of season, and .the circumstances which arise out of them, they are less exposed to emanations, arising chiefly from the decomposition of vegetable and animal matter—to those ende- mic sources of disease that produce so much suf- fering and mortality in low or level districts, and in more southerly climates, where the atmosphere is moist and warm. The inhabitants of temperate countries, considerably elevated above the level of the sea, and of mountainous places, are generally of a spare, firm, and muscular habit of body, and strongly formed ; chiefly owing to their active and industrious modes of life, and the pure and light state of the air they breathe. The irritable, sanguine, and nervous temperaments, and quick, irritable, and generous dispositions, predominate among them. Inflammatory, haemorrhagic, and spasmodic diseases, particularly haemoptysis, bron- chitis, consumption, asthma, inflammations of the lungs and pleura, rheumatism, and disorders of the circulatory organs, are most common. Their females are more virtuous and prolific, and the mean duration of human life longer than amongst the natives of lower districts and warmer climates. 22. C. There are certain peculiarities in the na- tives of temperate countries, particularly of Euro- pean countries, that must strike the pathologist as intimately connected with the nature and treat- ment of their diseases. These are chiefly the complexion of the skin, the large developement of the respiratory, biliary, nervous, and circulating organs, compared with those of the natives of in- tertropical countries. The skin of the dark races is not only different in colour, but is also con- siderably modified in texture, so as to enable it to perform a greater extent of function than the more delicately formed skin of the white variety of the species. The thick and dark rete mucosum of the former is evidently more suited to the warm, moist, and miasmal climates of the tropics, than that with which the latter variety is provided. The skin of the negro is a much more active organ of depuration than that of the white. It not merely exhales a larger proportion of aqueous fluid and carbonic acid from the blood, but it also elaborates a more unctuous secretion, which, by its abundance and sensible properties, evidently possesses a very considerable influence in counter- acting the heating effects of the sun’s rays upon the body, and in carrying off the superabundant caloric. Whilst the active functions, aided by the colour of the skin, thus tend to diminish the heat of the body, and to prevent its excessive increase by the temperature of the climate, those mate- rials that require removal from the blood are eli-J ruinated by this surface, which, in the negro espe- cially, performs excreting functions very evidently in aid of those of respiration and of biliary secre- tion. In the white variety of the species, on the other hand, the functions of the lungs and liver are much more active than in the darker races, changes to a greater extent being performed by respiration in the former than in the latter, as I have proved by experiment. The liver is also larger, and its secretions more copious in the European than in the negro or Mongol. 23. In the inhabitants of northern climates, and elevated or cold countries, the functions of the lungs and kidneys are extremely prominent, and those of the skin and liver much less so; eliminating or depurating actions on the blood being performed chiefly by the former organs. But, in the natives of intertropical climates, the skin assumes, as shown above (§ 22.), a more ex- tensive function, and, by its activity, compensates for the diminished operation of the lungs, liver, and kidneys, generally observed among them, aided, no doubt, by the secretions from the in- testinal mucous surface. In temperate countries, the various emunctories of the frame present a degree of activity in strict keeping with this gen- eral connection of climate with the development and activity of these functions. In the warmer districts of temperate climates, and especially in those which are subjected to a dense, moist, and miasmal atmosphere, the changes produced by respiration are diminished, and those effected by the cutaneous and intestinal mucous surfaces are increased. If the natives of such districts belong to the white variety of the species, their cutaneous surface not being constituted so as to enable it to perform the compensating action for which the skin of the darker races is destined, a different or- gan performs this office, and the liver assumes an increased action, combining and eliminating se- veral of the effete constituents or elements as they accumulate in the circulation, and thereby giving rise to an increased and modified biliary secretion. 24. D. If we compare the organisation and functions of the negro (and I may add of the Mongol) with those of the European, the follow- ing general results will appear, and, together with what has been now advanced, will serve as the source of very important pathological and thera- peutical inductions:—The circulating organs, the lungs, the liver, the middle and anterior lobes, and convolutions of the brain, the muscles, and the bones, excepting those of the head and face, are very evidently smaller, and their functions less prominent in the former than in the latter variety ; whilst, on the other hand, the skin and its functions are much more developed. With the activity of function, conjoined with fre- quent exposure to the action of numerous ex- citants, the disposition to, and occurrence of, dis- order increase ; and, accordingly, diseases of the lungs and circulating organs, of the liver, and of the nervous system, predominate in the white races of man; and chronic affections of the skin, and those acute maladies which chiefly attack this surface and the intestinal mucous membrane, in the dark varieties of the species. Amongst the latter, fevers are not common ; and when they occur, they are usually slight, terminate speedily, seldom assume an inflammatory or continued type, often pass off with critical discharges from the skin or bowels, and not infrequently lapse into a state of low or chronic dysentery. The exanthematous diseases generally assume in them a severe and asthenic form, and rapidly spread by infection. Verminous disorders are very common in them ; but affections of the brain and its membranes, and of the teeth, are extremely rare; the cranial contents seldom suffering ma- terially in the course of febrile attacks. The remarkable thickness of the bones of the head, in nearly all these races, protect the membranes and brain from the causes of disorder to which they are liable ; and the continued exposure of the head to the action of the sun and air, the absence of mental culture, and their modes of life, by no means dispose these parts to disease. Inflamma tions, particularly those of a sthenic character, very rare ; and, if vascular excitement attend the early stage of these maladies, it soon exhausts itself and passes into the opposite extreme. Dis- orders, which consist chiefly of morbidly in- creased discharges, from deficient tone of the extreme vessels, and those of a spasmodic form, are not uncommon. 25. E. The organisation of the dark races of man, chiefly as respects the state of vascular ac- tion and tone, the developement of the viscera al- ready referred to (§22—24.), their food, modes of life, excessive addiction to venereal indulgence, the continued influence of a moist and .miasmal atmosphere, and the characteristic features that their diseases consequently assume, generally preclude the employment of large vascular de- pletions. During the progress of febrile and ex- anthematous maladies, critical evacuations from the skin and intestinal mucous surface frequently occur, the latter of which are very apt to assume a colliquative or chronic state, and, if not judi- ciously controlled, to carry off the patient. Hence the propriety of employing free evacuations of the prima via, with warm diaphoretics, at the com- mencement of their diseases, and of supporting the energies of life in the advanced stages. The circumstances now referred to as modifying the the constitution and diseases of the dark races of our species, should never be overlooked when de- vising plans for treating them. Nor should the fact be neglected, that worms, especially lumbrici, in the intestinal canal, are very frequently con- nected with the origin of many maladies of re- mote but related organs. Affections of the sto- mach, diarrhoea, colicky pains, leucorrhoea, various spasmodic, and convulsive disorders, chronic dys- entery*; &c., very often arise from this cause ; and no more than the cause itself, will ever be perma- nently removed, in these races, especially by eva- cuations alone, but by combining them with sti- mulants, tonics, and antiseptics. Although both the habits and modes of living of the dark races, and the constitution of their digestive organs, re- quire the occasional use of active purgatives, in order to remove the saburra and colluvies which so rapidly collect on the intestinal mucous sur- face, yet those medicines should generally be com- bined or alternated with substances which exert a cordial and tonic influence, as their vital energies soon sink under frequent evacuations when de- CLIMATE—In relation to the Food of Man. prived of an accustomed or requisite stimulus. (See Art. Disease.) 26. ii. Of the Food of Man in Relation to Climate and the Constitution of the Varie- ties of the Species.—The intimate relation which subsists between the food of man, and the nature of the soil and climate which he inhabits, and the combined operation of both upon his con- stitution and the character of his diseases, have seldom been considered in a manner deserving of the subject. Man, although in some measure in- dependent of the nature of the soil or climate in which he lives, is yet, in several points of view, the creature of both. His manifestations both moral and physical, are moulded by both influ- ences, like the animals which are below him in the scale of creation, although generally in a much less degree. It is the soil that furnishes him food, and the air which he respires derives much of what is noxious to his frame from that source. Whenever, therefore, the natural history and diseases of man come under consideration, they should be viewed in relation to those productions of the soil on which he subsists—with which, in many respects, he may be considered as a fellow product, but holding a superior station, and by which are often caused many of his ailments. As it is beyond the scope of this work to enter fully into the very interesting considerations which this subject involves, I can only point to its more general connections ; and I do this more with a view of directing the attention of others to the subject, than of satisfying my own wishes as to its discussions. 27. As the physical and intellectual powers of man enable him to occupy the whole surface of the globe, it follows that he cannot be restricted to any particular kind of food—in other words, he must be naturally omnivorous, as a consequence of his ubiquity. If the wastes of Lapland, the shores of the icy sea, the frozen coasts of Green- land, and the deserts of Terra del Fuego, were destined by nature for the habitations of man, then is he not an herbivorous animal; nor is even a mixed diet necessary for his support. It would be impossible to procure vegetable productions where the earth’s surface is almost constantly either frozen or covered with snow. The conti- nual use of animal food is as natural and whole- some to the Esquimaux, as a mixed diet is to an Englishman. The Russians who winter in Nova Zembla, according to Dr. Aiken, imitate the Sa- moieds, and eat raw flesh and drink the blood of the rein-deer, in order to preserve their health in these arctic regions. The Greenlander devours with good appetite, the raw flesh of the whale, or the half frozen and half putrid flesh of seals ; and drinks the blood of these latter animals, or regales on dry fish and whale-oil. 28. Within the tropics, man is subjected to the continued operation of a high temperature, which excites the nervous functions and vascular action, notwithstanding the provision with which nature has furnished his integuments, in order to mode- rate the animal heat. This provision, as we have seen, consists chiefly of the dark colour of the rete mucosum, which speedily gives off the su- perfluous heat of the body, and of the great acti- vity of the perspiratory functions (§ 22.). Inter- tropical countries, particularly such as are low or swampy, while they abound with the produc- tions of the vegetable kingdoms, and with nume- rous swarms of insects and reptiles, maintain 407 408 CLIMATE—In Relation to the Food of Man. very few of those gregarious animals which serve as food; and thus we perceive that their inha- bitants, unless in elevated and cool situations, as in Abyssinia, Mexico, &c., are obliged, by the scarcity of these animals, to subsist on vegetable productions, and to adopt a system of religion, which, while it tends to prevent the entire destruc- tion of the more useful species, is sufficient to re- strain their numbers within their appropriate means of subsistence, and without encroaching on or impairing the supply of food with which the vegetable creation furnishes man. Hence, in many places of intertropical Africa, the lower animals, whose numbers are few, are occasionally made sacred by the priests for a time ; and in other places of this continent animal food is very rarely enjoyed. In Hindostan, the natives are almost debarred from the use of flesh meat; and the cow is made sacred, evidently to prevent the destruction of a species, whose milk furnishes man with one of the chief articles of diet. 29. But nature provides a more suitable ali- ment to the inhabitants of those climates. The date, the palm-tree, the cocoa-nut, the sago-tree the plantain, the sugar-cane, and the banana ; the yam, cassava, ground-pea, and other roots; a great variety of refreshing fruits; and, more particularly, the very abundant production of nutritious grains, especially the Indian corn and rice, richly supply the natives of these climates with wholesome food. The general and neces- sary adoption of a vegetable diet within the tropics, from the exuberance of the vegetable creation and the comparative scarcity of those grega- rious animals chiefly destined for the use of man in cold and temperate regions, is necessary to the existence of the human species in the higher ranges of temperature, and in the more unhealthy districts in hot climates. The adoption of animal diet exclusively, or of loo large a proportion of it, disposes the human frame, when exposed to the influence of tropical heat, to those diseases which arise from endemic causes,—viz. the decay of ve- getable and animal matters, the exhalations of marshy and absorbent soils, and other emanations accumulated in moist and close situations ; and to those which affect the alimentary canal and other abdominal viscera. Various epidemic diseases also often produce their greatest havoc, and as- sume pestilential characters, amongst those who, to the predisposition occasioned by a high range of temperature, have superadded that arising from a too full animal diet. It appears to be a salutary law of nature, that, in those climates, where ani- mal food would be detrimental to the human race, there the animals usually destined for the purpose are few in number, and stunted in growth. The localities, indeed, which are the most destructive to man, are also the most inimical to these ani- mals, which, if they were chosen as the chief article of food, would both dispose to disease and increase its fatality. Thus it appears that the distribution of the classes of animals over the sur- face of the globe is so apportioned, and certain of their orders and genera so restricted to particular latitudes and climes, as to be subservient to the wants of man, without becoming hurtful, or en- dangering his existence in countries in many re- spects unfavourable to his bodily and mental de- velopement. 30. While the vegetable diet, which the hottest and most unhealthy climates furnish, is the least liable to excite the nervous system, or to overload the circulating and secreting organs, or to irritate and inflame the excreting viscera, it serves to pro- mote endurance, and, with the hot spices which grow spontaneously in th same localities, to counteract the contaminating changes produced in the body by the vegeto-animal effluvia to which it is frequently exposed. In both Indies, and in intertropical Africa, the inhabitants of low and moist situations live almost exclusively on rice and maize ; with these they consume, as a condiment, a very large quantity of the hottest spices, the stimulating and tonic qualities of which preserve them from the effects of the diminished tempera- ture and terrestrial emanations, during, and after, the rainy seasons, and monsoons, and in soma measure from intestinal worms ond other parasi- tic animals. To these spices even the feathered creation, and the lower animals occasionally re- sort, especially during the unhealthy seasons. Were the inhabitants to live chiefly on animal food, and use the strong fermented liquors, made in colder climates, the nervous and vascular sys- tems would be inordinately excited, irritability be- ing thereby soon exhausted, and they would be as much disposed to, and affected by disease, as un- seasoned Europeans who, partly owing to these causes, so soon become its victims, after having removed to low, moist, and hot situations between the tropics. Nature adapts her productions in every climate, to the necessities of man ; and appropriates them to his real, but not his imagined, wants,—to his state of constitution, as modified by the operation of soil, air, and temperature ; and nowhere is this provision more manifest than in warm countries. There, if the causes of disease be most energetic, as they most indisputably are, she has chiefly restricted them to those which proceed directly from the soil and the climate, while she has confined those arising from the nature and the abuse of food within narrow limits; as there man is destined, by the circum- stances already alluded to, to live chiefly on a vegetable diet, and is liable only to occasional deficiency of its supply. But even the inflictions which nature thus imposes on the inhabitants of these climates are accompanied by abundant means of preventing their invasion, or arresting their progress. The most unhealthy situations not only abound with suitable means of sub- sistence, but also present spontaneously the most efficacious prophylactic and curative agents for the diseases that are endemic in them. Thus rice, the banana, the plantain, the juice of the cocoa-nut and of the palm, the oil of the palm- nut, &c., are the most wholesome articles of food in the districts wherein they are most abundant. The low grounds on which these are produced abound with deleterious miasms; and the stag- nant water, which there often serves for the ne- cessities of life, contains the ova of insects and animalcules. While the former occasion agues and remittents, the latter gives rise to diseases of the digestive canal, and to the generation of worms; and both causes combine to produce fevers, diarrhoea, dysentery, cholera, visceral ob- struction, &c. In the above localities grow the different species of the capsicum.,—the principal condiments employed by the natives ; and these are also the chief prophylactics and remedies for their constitutions against the diseases now alluded to. By the side of the palms and the cocoa-nut grow the different species of the tamarind and the croton, which are, respectively, the mildest and CLIMATE—Effects of Change of, on Man. most cooling aperient, and the most, active cathartic. Thus nature provides an antidote to the bane which is imposed on the inhabitants of unhealthy warm climates, and, by adopting the indications she presents, they are enabled to exist without suffering much more from disease than the natives of temperate countries, or having the allotted span of human existence much abridged. It is in no small measure owing to his persisting in the diet, beverages, clothing, and modes of living, suited to a cold or temperate climate, and to which he had become accustomed, that the European is liable to disease when he has re- moved to a hot country. When travelling in the most unhealthy parts of intertropical Africa, in 1817, I met with an Englishman, who had lived there between thirty and forty years, and was then in the enjoyment of health. The circum- stance was singular; and, in answer to my in- quiries as to his habits, he informed me, that soon after his removal to that pestilential climate his health had continued to suffer, when, after trying various methods without benefit, he had pursued as closely as possible the modes of life of the natives, adopting both their diet and beverages, and from that time he had experienced no serious illness. 31. In countries approaching the poles, where the continued low temperature, and the want of solar light during two-thirds of the year, tend to diminish nervous and vascular energy and tone, and to lower the whole circle of vital actions, nature has furnished man with those articles of food which are the best calculated to nourish, to stimulate, and impart vitality to the frame, and thus to enable it to bear up 'against the rigour of the seasons, and the injurious influence of the climate. Without such food, the inhabitants of arctic regions would fall a prey to diseases of de- bility, and the higher latitudes would soon become entirely depopulated. In these, as well as in northerly and elevated parts of temperate coun- tries, nature spontaneously provides man with those substances which are the most energetic, both as preventives and as remedies of those diseases which arise from the influence of climate. The various species of pine abound in the cold- est regions, and furnish, in numerous forms, the most efficacious internal and external medicines, and even the most wholesome beverages in these maladies. Hoemorrhagic diseases, low fevers, asthenic inflammations, scorbutic and cachectic affections, the extreme effects of cold upon the extremities, &c., are most successfully prevented or treated by the judicious use of terebinthi- nate preparations. This observation is also applica- ble to the arnica montana, and other alpine plants.* 32. The temperate zone, whilst it furnishes in its wide range the greatest diversity of climate— in some localities that of the tropics, in others that of arctic regions—provides man with the greatest abundance of animal and vegetable food: thus enabling him to combine both, or to adopt more or less of either, according to the nature of the seasons, of the climate, and the particular circumstances in which he may be placed. Na- ture is always provident: she takes sufficient care that each particular district or country shall have within itself, or be capable of producing by re- quisite labour, those articles of food which are most appropriate to the climate, and thereby the most wholesome to its inhabitants. When com- merce or manufactures increase the population of a district beyond the means of sustenance deriv- able from the soil, and lower animals, in the vicinity, the food which is obtained from a simi- lar climate is generally the most wholesome. Various disorders originate from the introduction, from remote countries, of unsuitable articles of luxury into diet; and not a few arise from the improper mode of preparing food, which would otherwise be wholesome. Thus, the hot spices and the high seasoned dishes, which, during the tropical rains, would be beneficial to the natives of those climates, who live chiefly on vegetable diet, frequently are productive of disease amongst those who partake too freely of animal food, or the high-feeding inhabitants of commercial cities. The adoption, also, of highly seasoned dishes, with an undue quantity of flesh meat,—undue, because exceeding the wants of the economy, and the circumstances of the climate,—and the use of spirituous and fermented liquors, are fer- tile sources of disease, particularly fevers, and affections of the abdominal viscera, among Eu- ropeans residing in warm places or during warm seasons. 33. jFrom these and other considerations the following corollaries may be drawn:—That the climate of a country should, in a great measure, guide man in the selection of food ; those pro- ductions which are most abundant around him being most appropriate to the circumstances in which he is placed: and that the nature of his food thus conspires with the climate to modify his constitution, whilst it serves to counteract the ri- gours of season, and the unwholesome influences to which he is constantly exposed in very hot as in very cold countries. 34. iii. Of the Effects produced on the Human Constitution by Change from one Climate to another of a very different or opposite Description.—By referring to what has been already advanced respecting the physical re- lations of climate, and the circumstances more immediately connected with cold and warm countries respectively, and by connecting these with the peculiarities characterising the races of man inhabiting both, we shall readily perceive that a most important revolution will take place in the animal frame from the change, in whichever di- rection it may be made ; and that such revolution will be great in proportion to the suddenness and greatness of the change; it being in either case attended with more or less febrile commotion or other diseased action. 35. 1st. Of change from a cold or temperate to a warm climate.—A. Keeping in view the following characteristics of a cold and temperate climate— viz. its low temperature, the alternations of sea- son, the pureness of the atmosphere, the more nutritious, invigorating, and stimulating nature of the food, and the effects of warm clothing—and 409 [* According to Liebig, the large amount of carbon taken in the food by the inhabitants of the Polar Regions, is burnt in the lungs, by which the animal temperature is supported, and without which life could not be main- tained. Of the fact of the necessity of large quan- tities of animal food in cold climates, there can be no doubt, and Liebig's explanation has been adopted by many of our most distinguished physiologists. Sir John Ross remarks, “he who is well fed resists cold better than the man who is stinted, while the starvation from cold follows but too soon a starvation in food. This, doubtless, explains in a great measure the resisting pow- ers of the natives of these frozen climates; their con- sumption of food, it is familiar, being enormous, and often Incredible.” (“ Narrative,” &c., p. 200 :1835.)J 410 CLIMATE—Effects of Change of, on Man. connecting these with the vascular plethora, the active functions of the brain, lungs, liver, and kidneys of its inhabitants, the disturbances which will result when they are subjected to a continued high range of temperature, and to an atmosphere loaded with moisture, and frequently with vegeto- animal effluvia, may be anticipated. It is now fully ascertained that the effects of a high range of temperature, and of moist miasmal air, on the European constitution, are a diminution of the changes effected by respiration on the blood, an increase of the secreting anfl excreting functions of the liver and skin, and a decrease of the urin- ary excretion. When, therefore, the pletiioric European migrates to an iutertropical country, the functions of the lungs and the pulmonary exhalation become diminished ; the requisite changes are not effected on the blood ; notwith- standing the excitement of the nervous and vas- cular systems by the increased temperature ; and the already active and developed liver is irritated and has its functions augmented by the increase of those elements in the blood, that the lungs and skin cannot remove from it. Hence proceed fe- brile attacks, particularly when excited by their appropriate causes; inordinate activity, with a relative frequency of the diseases of the liver ; the secretion of acrid bile; and the disorders es- pecially affecting the alimentary canal and ex- creting organs. The general adoption of too rich and nourishing food and beverages by those who remove from cold to hot climates, tends greatly to increase these evils as already explained (§ 30,) ; and the influence of high temperature and of a vertical sun upon the Europoan head is productive of diseases both of it and of the liver. To the§e effects, the mental cultivation and ac- tivity of Europeans somewhat predispose them ; whilst their heads are not so well guarded from external influences by the constitution of its in- teguments and hair, and the thickness of the cra- nial bones, as those of the Negro and Mongol varieties of our species. 36. The obvious indications resulting from these facts are, that natives of cold countries mi- grating to warm climates should, particularly if the change has been made abruptly, live abste- miously, and promote the functions of those or- gans which perform the most essential part in ex- creting effete or injurious elements from the circu- lation. The head should be kept cool, and pro- tected from the rays of- the sun ; the surface of the trunk and lower extremities ought to be pre- served in a freely perspirable state, so as to take off the load of circulation, and derive from the ex- cited liver. In order to promote the secreting and depurating functions generally, active exer- cises, short of fatigue, should be taken, without exposure to the causes of disease, particularly those which are endemic. As the maladies which most frequently supervene on change from a cold to a warm climate proceed neither from the increased temperature alone, nor from greater moisture of the air, but from these conjoined with malaria, and not infrequently also with wide ranges of temperature during the twenty-four hours, especially in high and inland localities— with hot days, and cold, raw, and dewy nights, and with a too full and exciting diet and regimen, causing fevers, dysentery, and diseases of the biliary organs—care ought to be taken to avoid those causes as well as whatever may tend to as- sist their operation on the frame, and to protect the system against the sudden daily changes by warm clothing at night, &c. 37. B. The consideration of the effects pro- duced by migration during a state of disease, from a cold to a warm and moist climate, is of the utmost importance. Keeping in mind its in- fluence upon the healthy frame—chiefly in ex- citing the functions of the skin and liver, and di- minishing those of the lungs—we are led to pre- scribe it in the treatment of various diseases. In hcemoptysis, this change is obviously beneficial, especially as a warm and moist atmosphere, by this mode of operation, lessens the activity of the pulmonic circulation and the disposition to san- guineous exudation from the surfaces of the bronchi. Bronchitis aud tubercular phthisis are also often benefited, and the progress of the lat- ter much delayed, by this state of atmosphere, especially when adopted early.* Chronic rheuma- tism is sometimes cured by this change, seem- ingly owing to its influence in promoting the biliary and cutaneous functions. Dropsies, par- ticularly anasarca and hydrothorax, have been, in a few instances, removed by a change to a warm climate ; but wfliilst a moist state of the air is most, serviceable in pulmonary and hoemorrha- gic diseases, dry warmth seems more beneficial in dropsies, dyspeptic affections, and hypochondria- sis, evidently from its effects in augmenting the insensible perspiration and the pulmonary exhala- tion, and imparting tone to the capillary circula- tion. Besides these, gout in its early stages, dys- menorrhcea, and scrofula in nearly all its forms, are benefited by a change to a warm, or even a mild and dry atmosphere. 38. 2d. Of migration from a warm to a cold or temperate climate.—This subject should be viewed in relation, first, to the change as it affects the dark races of man ; and, secondly, as it re- spects those belonging to the Caucasian variety, who have either been born or acclimated in warm countries.—A. If change from a cold to a warm climate is productive of disease and great morta- lity in the white constitution, the migration of the dark races to a cold or temperate country is not less fatal to them; and whilst the change pro- duces, in the former case, fevers, diseases of the biliary organs, and of the alimentary canal, it oc- casions, in the latter, tubercular phthisis, and other tubercular affections, with diseases of the bronchi, &c. When the dark races, particularly the negro, aud those of the Mongol variety who are natives of iutertropical and low countries, migrate to places subjected to a low range of tem- [* From a careful study and observation of the effects of a change of climate, from cold to hot, in tubercular phthisis, we are satisfied that instead of proving benefi- cial, it almost invariably hastens the death of the patient. A sudden transition from the temperate, bracing climate of our northern and middle states, to the hot, moist, and sultry climate of the West Indies, produces a very debil- itating effect upon the sick, who is thereby, as well as by the excessive heat of the day, prevented from taking any active exercise in the open air ; the appetite accordingly languishes ; colliquative sweats increase; diarrhoea, if present, is aggravated ; the tubercular deposits undergo a more rapid process of softening ; and death rapidly closes the scene. When to all this are added the discomforts of travelling, the want of necessary attendance, and the absence of those conveniences, essential to the welfare and comfort of the invalid, in countries where little pro- vision is made for the accommodation of the sick, we should hesitate before sending patients away from their own fire-sides and families to meet a speedier fate in a foreign land. Simple bronchitis, however, is often bene fited by such a change.] CLIMATE—As a Therapeutical Agent. 411 perature during a great part of the year, the de- pressing influence of cold upon the nervous sys- tem and vital actions of the lungs and skin gives rise not only to tubercular formations, but also to increased secretion from the internal mucous sur- faces, and they are, in the great majority of cases cut off, in a few months or years, by diseases of the lungs, kidneys, and bowels. Those, however, who change the climate progressively, or who are born in countries of an intermediate temperature, and who are provided with warm clothing, and animal or nutritious diet, suffer much less than those who migrate in a more direct manner, even although possessed of these latter advantages. The native African who removes immediately to Europe seldom lives over two winters in it; whilst the negro, who has been brought to the West In- dies, and subsequently to the southern states of North America, previously to his arrival in more northern countries, and enjoys necessary food and clothing, will often not suffer materially from the change. B. Those who have been born of European parents or being seasoned in warm climates, not infrequently suffer after removal to temperate or cold countries. Even although the change may have become necessary from chronic affections of the liver or bowels, yet may it for a while aggra- vate or render more acute hepatic disorder, or su- peradd to it disease of the lungs ; and many who have experienced only functional disorders of the stomach or liver, or who acquired merely a tendency to them during their residence within the tropics, have been attacked by active disease soon after their return to Europe. Others, also, who have suffered more seriously, have had their complaints aggravated after a short residence in England, although they were benefitted during their voyage home. This result of change to a colder climate proceeds not, however, altogether from the temperature or the state of the seasons, but in a great measure from the imprudence of the patient. Frequently, however, a colder atmos- phere is prejudicial for a time, by constricting the vessels on the external surface, and determining an increased flow of blood to the large internal viscera, and thereby occasioning congestion and obstruction of (hose organs which have been weakened by previous disease or the influence of climate. Another frequent consequence of change from a warm to a cold country is a diminution of all the secretions, particularly those of the skin and liver; originating vascular plethora and vis- ceral engorgement. In this state of the vascular system, if the cutaneous or pulmonary surface be subjected to cold, particularly cold combined with moisture, after the circulation has been deter- mined to these parts by hot rooms and crowded assemblies, or if reaction rapidly follow the im- pression of cold, the gTeat mass of blood is thrown upon the internal viscera, which, if not relieved by a free secretion, become the seat either of congestion or of inflammation. Hence it is that hepatitis or dysentery, so frequently follows changes from a high to a low temperature. The remarkable liability to diseases of the respiratory organs, observed in those who have returned to Europe after a long residence in warm countries, is evidently owing, in many instances, to pre-ex- isting disorder of the liver, which has extended thence to the lungs, owing either to the increased action cf this latter organ upon removal to a colder climate, or to imprudent exposures to cold, or to breathing a very warm and close air imme- diately upon coming out of a cold and dry atmos- phere. 40. In order to counteract these effects of change, warm clothing, particularly of the lower extremities, with the use of flannel next the skin, should be adopted; and exposures to cold and moisture, and the night air be avoided. The diet ought to be light, and of moderate quantity : the strong wines imported into this country abstained from ; and, above all, the functions of the bowels and abdominal viscera carefully watched and pro- moted whenever they seem to flag. It may be of importance to know the most suitable period of the year to arrive in this country, after the frame has become assimilated, by a long residence, to a warm climate. If an invalid return in winter, the sudden transition from a warm to a cold country may be detrimental; if early in the spring, he is liable to feel the effects of a variable season for some time. The least objectionable period extends from May to September; and if the cold of the winter months be found too severe in the more easterly counties, or in the metropolis, the climate of Devonshire or of Bath may be tried with as great advantage as that of most of the southern parts of continental Europe. Old residents in a warm climate will experience much advantage from residing some time in the more southerly parts of Europe, before passing to Eng- land or other countries of the north, more par- ticularly if they use a course of the warm min- eral waters of Yichi, Carlsbad, or Ems, in their way. 41. The children born of white parents resi- dent in the more unhealthy countries within the tropics, very generally die at an early age if they be not removed to a colder climate. They com- monly sink from the choleric form of fever de- scribed in a separate article as incidental to infants ; or from diarrhoea, dysentery, or diseases of the abdominal secreting viscera, often assum- ing a remittent form. When, therefore, either of these appears in this class of patients, removal to a temperate climate should be advised when it can be effected; taking care to guard them, by warm clothing, &c., from vicissitudes of temper- ature for a considerable time after the change, and attending to the first indication of pulmonary or tubercular disease, or disorder of the liver and bowels. 42. III. Of the particular Localities which ARE BENEFICIAL IN DISEASE, OR OF CLIMATE AS a Therapeutical Agent.—In this part of the subject, I shall consider, first, the different parts of Great Britain which may be suitable places of residence for invalids; secondly, those in the south of Europe and the Mediterranean ; and, thirdly, those in the Atlantic and West Indies. 43. i. Climate of certain places in England.— The chief difficulty in this country is to find a mild and sheltered climate for invalids from pul- monary disease ; and it is almost exclusively to the south and south-west parts of the island, in the immediate vicinity of the sea, that we must direct our inquiries. The general use of coal fires in all the large towns in Great Britain, owing to the quantity of sulphur this mineral contains, and of sulphuric acid fumes and fuliginous matter generated, renders the air more irritating to the lungs, and increases the risk of a winter residence in these places, to all those who suffer from, or are even liable to, diseases of the respiratory or- gans. This, together with other considerations— especially the results of observation—renders it imperative on the medical attendant to recom- mend removal to a more salubrious locality. The mild situations I shall notice are in the south, the south-west, and the west of the island. 44. A. The south coast is much milder and more moist than the east and inland parts of the island, during the months of November, Decem- ber, January, February, and March ; but from April till October the temperature of the latter is greater. On this part of the coast, Undercliff, in the Isle of Wight, Hastings and Brighton, have been recommended as winter residences for inva- lids. a. Undercliff is the most sheltered and mild of these places in winter, and its air softer and more humid in summer than either, b. Hast- ings is sheltered during the winter and spring months, from the north and north-east winds ; and, of the various places on this part of the coast, ranks next to UnderclifF as a residence for invalids with pulmonary affections, c. Brighton is more exposed than the foregoing to the north and north-east winds, and its air is drier, and hence more bracing. It is therefore more suitable than they to the nervous, the simply debilitated and relaxed, to the dyspeptic, to those affected with chronic bronchitis and asthma, attended by greatly increased secretion. Dr. Clark very pro- perly suggests that invalids, who select the south coast as their winter residence, should pass the autumn at Brighton, and the winter at Hastings; the climate of the former being mild to the end of December. 45. B. The south-west coast of the island is very mild in several situations during the winter, and has, therefore, been very generally recom- mended in diseases of the respiratory organs. Sir J. Clark estimates the temperature of its more sheltered localities as being 5° higher than that of London, during the winter months; and the temperature of the south coast as only 2° higher. But I conceive that there are, at least, 6° and 3°, respectively, of difference between these and London and its vicinity. Besides, it is not only the range of temperature that should be considered, but its greater equality and less rapid vicissitudes, and the increased humidity, and more soothing influence of the air.—a. The places on the coast of Devonshire most in repute as residences for the consumptive, are Torquay, Dawlish, Sidmouth, Exmouth, and Salcomb. Of these Torquay is the best; and, according to the reports of Sir J. Clark, Dr. Foote, and of my friend Dr. W. Hutchinson, who has resided in it, superior to all other places in our island in pul- monary cases. 46. b. Penzance is the principal place in Corn- wall recommended for invalids. Its peninsular situation, and south-west position, give it a re- markably soft, humid, and mild atmosphere ; and the equality of its temperature, not only through- out the year, but also during the day and night, renders its climate in many respects superior to that of most places in the south of Europe and brings it next to Madeira. The quantity of rain that falls annually at Penzance is nearly double that which falls in London ; the number of rainy days is much greater; and the temperature of the air at night at least 7° higher during the win- ter months. This mildness, equality, and humid- ity of climate is, however, somewhat impaired CLIMATE—As a Therapeutical Agent. by its exposed situation, and its liability to high winds. 47. Both the Land’s End and the coast of Devonshire, owing to the predominating character of softness, humidity, and equality of climate, exert, along with a soothing, an evidently relax- ing effect. Hence this coast is best suited to the irritable and inflammatory states of disorders • of the respiratory organs, and such as are charac- terised by irritation, but little expectoration, and dryness of skin. In cases attended with a co- pious expectoration, great relaxation of the mu- cous surfaces and soft solids, and in nervous de- bilitated persons, this climate will prove injurious. Even in those cases where it is evidently indi- cated, and actually proves of service, removal will be necessary to a somewhat drier air during the summer; and this should not be deferred longer than June, or undertaken before April or May ; the patient generally deriving much be- nefit by returning the succeeding winter. The observations now made upon the climate of the south-west coast apply to that of Jersey and Guernsey, to which islands invalids sometimes repair, and occasionally with advantage. South- west winds generally prevail in them during au- tumn and winter, and cold north-east winds often continue long in the spring. The summer cli- mate of these isles is excellent. Of the two that of Jersey is preferable. 48. C. The West of England.—The mean temperature of this part of the island is a little lower than the southern coast, but in March and April it rises somewhat above it. Bath and Bristol are about 3° warmer than London during the months of November and December; but this difference is reduced more than one-half during January, February* and March. In this part of the country the vale of Bristol is the most sheltered and mildest. The climate during the winter is rendered more mild by the vicinity of the ocean, whilst the groups of surrounding mountains attract the clouds and diminish the fall of rain below the current to which its western po- sition would otherwise subject it. Bristol Hot- wells, and the lower parts of Clifton, are the most sheltered spots, and the best suited to con- sumptive patients; whilst other invalids will find most advantage in the more elevated situations which the latter presents. In general, the cli- mate of this place is perhaps the mildest and driest in the west of England ; and, therefore, one of the best winter residences for invalids. It is drier and more bracing than that of the south- west coast, and therefore not so well suited to con- sumptive cases, and to those affected by irritative action in the respiratory passages and bronchi. For these the more soft and humid air of Tor- quay and Penzance is preferable ; but, with the return of summer, the consumptive invalid will relinquish the latter for the former with benefit. Clifton and Bath are certainly preferable places of residence to the south-west coast, in cases of protracted dyspepsia, gout, and scrofula, particu- larly the last occurring in young persons, and re- laxed habits. In these affections, the waters of Bristol Hot-well will, with regular exercise on horseback or on foot, prove extremely benefi- cial. 49. The more inland districts of this part of England furnish various places which are salutary to invalids during the summer. Malvern, and the surrounding country, with the Malvern wa- ters, are very serviceable in scrofulous and dyspep- tic cases ; and, for the consumptive and other in- valids, various places in Wales, as Abergavenny, Aberystwith, Tenby, Barmouth, &c., will be visited during the season with advantage. Where a course of goat’s whey may be considered of advantage, a summer residence in Wales will be preferred. There are various other places, which besides their mineral waters, furnish excellent summer residences for the invalid. Buxton, Mat- lock, Leamington, Cheltenham, Tunbridge Wells, &c., independently of the use of their respective mineral waters, prove excellent places of resi- dence for those who are debilitated or exhausted, whose mucous surfaces are relaxed, or whose di- gestive, secreting, and assimilating functions are imperfectly performed, and any of the abdominal viscera congested or obstructed. In these latter circumstances of disease, especially, the appro- priate use of the waters of those places, assisted by regular horseback or walking exercise, by sui- table medical treatment, and by mental relaxa- tion and amusement, will often prove of great service. In prescribing the mineral waters of any of those places, due reference should be had to the nature of the climate ; and, on the other hand, when directing change of climate, some attention should be paid to the waters which the place may afford; as the appropriate use of the one, whilst the patient is experiencing the influ- ence of the other, will materially promote the end in view. 50. In a very great proportion of cases, where the state of the patient admits of change of lo- cality, much advantage will accrue from passing the autumn on the south coast of the island, as at Brighton, Hastings, or Undercliff, after having passed the summer at the foregoing watering- places. In general, when the digestive and ge- nerative organs are disordered, frequent change of air, and travelling by .easy and short journies, with gentle exercise, particularly on horseback, agreeable amusement, and regular habits, will prove of marked advantage, and greatly aid me- dical treatment. 51. ii. Of the climate of certain parts in France.—A. The West and South-west of France furnishes several places, the climate of which possesses the softness and humidity which are requisite in pulmonary diseases. The mean an- nual temperature of the south-west of France is stated by Sir J. Clark to be 4° higher than that of the south-west of England ; and the climate of both generally agree or disagree with the same diseases.—a. That of the south coast of Britanny is mild during the winter, and temperate in sum- mer, the mean temperature of this province being about 56£°. Its climate is soft and relaxing ; and it is hence suited to dry bronchial irritations, to haemoptysis, and tubercular cases. Laennec found it very favourable to consumptive patients, and states that the proportion of such in this part of France is very small. In scaly eruptions on the skin, dysmenorrhoea, and in irritable habits of body, this climate will be often of service. 52. b. Pau, situated at the base of the Pyren- ees, from the account of it given by Dr. Clark and Dr. Playfair, appears to be the best place in the south-west of France for invalids ; and yet, in no respects is it superior to the south-west of England in consumptive cases. Its air is still and,mild in winter and spring; the chief advan- CLIMATE—As a Therapeutical Agent. tage it offers being the great mildness of its spring Dr. Clark gives the following comparison :—its mean annual temperature is higher than that of London, and about 3° higher than that of Pen- zance ; it is about 5° lower than that of Marseilles, Nice, and Rome ; and 10° lower than that of Madeira. In winter, it is 2° warmer than Lon- don, 3° colder than Penzance, 6° colder than Nice and Rome, and 18° colder than Madeira. But in the spring, Pau is 6° warmer than Lon- don, and 5° warmer than Penzance ; only colder than Marseilles and Rome, and 7° colder than Madeira. The range of temperature be- tween the warmest and coldest months at Pau is 32° ; this at London, and likewise at Rome, is 26° ; at Penzance it is only 18°, and at Madeira 14°. The daily range of temperature at Pau is 7£° ; at Penzance it is 6£° ; at Nice, and at Rome 11°. Pau is drier and warmer than the south part of England in the spring, and northerly winds are less injurious. One of its chief advan- tages is its vicinity to the watering-places among the higher Pyrenees, which are often beneficial places of summer residence to those who have passed their winter and spring at Pau. 53. B. The South-east of France. — The climate of the tract of country extending along the shores of the Mediterranean, from Naibonne and Montpellier to the Var, is warmer and drier, but more exciting than that of the south-west. It is subject to sudden vicissitudes of temperature and to cold winds, especially the north-west, or Mistral. It is decidedly prejudicial to consump- tive patients, especially when the disease has made some progress, and to irritative affections of the stomach, trachea, or larynx ; and is ser- viceable chiefly in diseases of debility and relaxa- tion unattended by inflammatory or hsemorrhagi action. 54. Sir J. Clark ranks the principal places on the coast of Provence in the following order, as residences for invalids:—Ilyeres, Toulon, Mar- seilles, Montpellier, Aix, Nismes, Avignon.— a. Hyeres possesses the mildest climate on this part of the coast, being sheltered from the north winds by a range of hills; and its inhabitants being comparatively exempt from pulmonary affections. h. At Marseilles the climate is dry, variable, and subject to cold irritating winds. It is therefore injurious to consumptive patients; and is one of the places in France where pulmonary diseases are most prevalent. Invalids requiring a dry air, and capable of bearing cold winds, may be bene- fited by residing here for some time. c. Montpel- lier has obtained a reputation for salubrity to which it has no claims. According to MM. Four- nier and Murat, more than a third of the deaths that occur in the hospital of this city are from pulmonary consumption. The prevalence in this part of the country of northerly winds during winter and spring, both accounts for the frequency of pulmonary diseases and points out its unfitness as a residence for patients thus affected, d. Aix is still more exposed than Montpellier to the Mis- tral and north winds, and pulmonary complaints 'are very prevalent among its inhabitants. 55. C. Nice, although situate on the same line of coast as Provence, enjoys a much milder climate than any part of that province. It is protected by a lofty range of mountains from the north winds ; and the daily range of temper- ature is there less than at almost any part of the south of Europe. During winter the weather ia 413 414 settled, and the atmosphere clear, the thermome- ter seldom sinking to the freezing point, excepting at night. At this season, however, as well as in the spring, cold dry winds are not infrequent; and the climate is, upon tho whole, dry and excit- ing. Hence it is not favorable to pulmonary con- sumption,—the very disease for which it was formerly very improperly recommended. It is likewise'unfavorable to irritable or inflammatory states of the larynx, trachea, and bronchi, attend- ed with scanty expectoration, or haemoptysis. But chronic bronchitis, bronchorrhoea, and humoral asthma, are generally very much benefited by the climate of Nice. It is also serviceable in all cases of debility, torpor, and relaxation of the mucous surfaces ; in chronic rheumatism, gout, external scrofula, dyspepsia, and hypochondriasis. 56. iii. Of the Climate of Italy and Mediter- ranean.—A. Genoa is not favorably noticed by Dr. Clark as a residence for invalids; but Dr. Johnson, on the authority of Dr. Mojon, speaks of it in more favourable terms. It is best suited to those affected by chronic bronchitis, and dys- peptic and gouty complaints; and to persons of relaxed and phlegmatic habits of body. Pisa, Rome, and Naples are the other places in Italy most frequented by invalids. The climate of Pisa nearly resembles that of Rome, the latter being somewhat warmer and drier in winter. Dr. Clark considers the climate of Rome as one of the best in Italy for consumption, unattended by haemop- tysis. For those, however, who cannot take ex- ercise in the open air, and must confine themselves to sheltered situations, the Lung Arno, in Pisa, is the best place of residence to be found in Italy. The climate of Naples is considered by this writer, as well as by M. Lasnyer, more exciting than that of the two foregoing places; and it is more subject to high winds. The diseases which a re- sidence in either of these three cities will benefit, are those above enumerated. Persons who re- main in Italy during the summer, will find Lucca, Sienna, and the vicinity of Naples, the coolest situations. 57. D. There are various other places on the shores and islands of the Mediterranean, the cli- mates of which are suitable to invalids ; but we possess little or no accurate information respecting them. Malaga in the south of Spain, Cagliari in Sardinia, and some parts on the coast of Sicily, afford a mild winter climate, but the difficulty of reaching them, and of obtaining in them many necessary comforts and conveniences, almost precludes invalids from the northern parts of Eu- rope from visiting them. Malta is not open to these objections ; but, according to Dr. HenneN, the quantity of dust raised from its arid soil, and suspended in the air, during dry weather, renders it an unsuitable climate for consumptive pa- tients. A considerable number, also, of the in- habitants die of pulmonary diseases. In his work on the medical topography of the islands of the Mediterranean, Dr. Hennen states a fact, which is perfectly in accordance with my observ- ation in warm climates, although doubted by Dr. Clark, viz. that those of the Ionian Islands, which are decidedly most malarious and remark- able for remittents, have had fewest pulmonary affections amongst the British troops. In res- pect of the health of the troops stationed in these islands, this writer states, that, from an average of seven years, phthisis has borne a proportion to othei complaints of 1 to 198-J only. At Malta, CLIMATE—As a Therapeutical Agent. on an average of eight years, consumption has occurred in the proportion to other maladies of 1 to 93J. Including all pulmonic complaints whatever, the proportion to others, as regards the Ionian Isles, has been 1 to 20f ; and, as respects Malta, 1 to 14. Taking into calculation the whole Mediterranean islands, the proportion of pulmonic, to other diseases, has been I to in the British army. 58. iv. Climate of the Northern Atlantic.— Under this head the climates of Lisbon, Cadiz, Madeira, the Canaries, the Azores, Bermudas, and the Bahamas, may be arranged ; all of which have been recommended to persons requiring a soft and equable climate, during the winter and spring. 59. A. Madeira is, of all these places, indis- putably the best, as respects both the climate, and the comforts and conveniences within the reach of the invalid. The frequency and excellency, also, of the means of conveyance to and from the island are no small recommendations. From the minute account furnished of the climate of this island, by Drs. Gourlay, Heineken, and Ren- ton, after a long residence in it, and from the effects I have observed in several persons who have resorted to it as a winter’s residence, it may be justly concluded, that it is superior to any part of the south of Europe for consumptive cases. Its central ridge of mountains gives it, in summer, a cool land wind; and the north trade winds, at this season, render it temperate, and salubrious. During winter and spring, Funchal, and parts near the sea-shore, are the best places of resi- dence ; and during summer the more elevated situations in the interior are cool and agreeable. The mean annual temperature of Madeira is about 6° higher than the south-east of France and Italy; and the heat throughout the year is much more equably distributed. The winter of the former is 12° warmer than that of the latter, and the summer 5° cooler. At Madeira the ex- treme annual range is only 14°, whilst it is double this amount at Pisa, Rome, and Naples. In re- spect also of the progression and steadiness of its temperature, it excels those places. Rain falls at Madeira on 73 days of the year, and at Rome on 117 days, and chiefly during the autumn in the former. The air is also more soft than at Rome. 60. B. The Canaries possess the next best climate to Madeira. The mean annual tempera- ture, however, of Santa Cruz, the capital of the former, is 71° ; whilst that of Funchal, the capital of the latter, is only 65°. The summer temperature of Santa Cruz is 7° warmer than that of Funchal, and the winter temperature 5° warmer. Hence the mean annual range of tem- perature is greater in the Canaries than in Madeira; which possesses, in other respects, advantages suf- ficient to recommend it in preference to the form- er in pulmonary diseases. 61. C. The Western Islands, or Azores, enjoy a climate nearly approaching to that of Madeira. They are, however, more subject to high raw winds, particularly those from the north and north-west, which are often very cold and harsh ; and the temperature of winter is lower, and that of summer higher, than in Madeira. The air is also more humid. From a very short visit I made to Madeira and the Azores,—to the former in the spring, and to the latter in winter,—I should con- clude the Azores to be much inferior to Madeira as a residence for invalids, chiefly because of the CLIMATE—As a Therapeutical Agent. absence of many necessary comforts and conve- niences, of their stormy winters, and the infre- quency and ineligibility of the opportunities of transport between them and this country. The climate of the Bermudas and Bahamas presents no advantages sufficient to obtain for them a pre- ference to those already noticed. They are liable to storms, and to harsh northerly winds in winter, from the American coast, whilst their summers are very hot. 62. v. Climate of the West Indies.—The mean annual temperature of the West Indies, at the level of the sea, is 79°, 80°, and 81° ; and during the winter months, in some places, about 3°, and in others only 2° lower. The extreme annual range is 20°, and the mean daily range about 6°. This continued high temperature exhausts the energies of invalids; and the clearness of the skies, and great power of the sun, prevent suitable exercise in the open air. A visit to the West Indies of a few months’ duration, made either to some of the most healthy islands, or passed chiefly aboard ship, will, however, prove of service in several chronic affections, particularly those referred to above (§ 37.), excepting consumption in its more advan- ced stages. Persons much disposed to this disease, either hereditarily or by the conformation of the chest, &c., or who are threatened by its early stages, will find a removal to the West Indies one of the prophylactic measures most to be depended upon. When residing some time in an extremely malarious place within the tropics, I observed that the most healthy persons in it were those who were constitutionally disposed to pulmonary dis- ease. But I believe, that the observation often made, is perfectly correct, that removal to an in- tertropical country, when phthisis is far advanced, will only accelerate its progress. It may also be stated, that severe and protracted catarrhs are very common upon entering between the tropics. In gout, chronic rheumatism, scrofula, and cal- culous affections, a residence in the West Indies is often productive of advantage. [As the West Indies are becoming more and more the resort of invalids from the United States, a few additional details on their climate, &c., may be useful. The mean temperature of the seasons in the W. I., at the level of the sea, is as follows: —winter, 76°, 7'—spring, 79°—summer 81° :— autumn, 80°. The mean daily range in summer, is from 80° to 86° ; the temperature in the shade often rising higher in northern latitudes than in the West Indies. It is the duration of heat, rather than its intensity, which characterizes the climate of the tropics, and it is owing to this circumstance, that it exerts so injurious an influence on the health of those accustomed to reside in northern latitudes. The winter, and early part of the spring, are in general dry, and the weather fine: the wind being more northerly than usual. The summer is dry and hot; and autumn the season of the heavy rains ; but there is seen little of that con- tinuous rain which occurs in temperate climates; the annual fall of rain is about 65 inches ; but the quantity varies much in the different islands, in those of a mountainous character, the fall being much greater than in the low islands. The great- est fall of rain place in October. In No- vember the weather generally begins to clear up, the north-easterly winds resume their regularity, and from the beginning of December till the ver- nal rains of April and May, the weather is settled, and comparatively cool. Thu dew point is much higher than in northern latitudes, and this exerts an important influence upon the health. From the small size of the greater number of the West India Islands, there do not occur the regular alternations of land and sea-breezes which prevail generally in tropical climates, but the same circumstance admits of the influence of the easterly, or trade wind, without intermission; which prevails with great regularity for nine months of the year. During August, September, and October, the trade winds are much mors irregular, but still the prevailing wind is decidedly the east. “ It is chiefly owing to the full influ- ence of the Trade Wind,” says Dr. Clark, “ that the climate of the West Indies, is not only toler- able, but infinitely more agreeable than Europeans, who have never visited them, can possibly imagine, when the temperature, as indicated by the ther- mometer, is alone considered.” It is now pretty fully established that a mista- ken impression has generally prevailed among physicians with respect to the influence of a tropical climate on disease, especially pulmonary affections. It appears from the British Army Reports, that nearly twice as many cases of con- sumption originate among the troops in the West Indies, as in Great Britain, twelve per thousand being the ratio attacked in the former, and but six and a half in the latter. “ If we have found cause,” says Dr. Clark, “ to condemn Italy, as a summer residence for consumptive patients, there seems no just reason, why we should commend the West Indies, even in winter, the temperature of which is above the summer temperature of any place in the South of Europe.” Again—he very justly remarks, “ every thing that we know re- garding the nature of consumption, and the influ- ence of a high temperature on it, supported by our practical experience of the climate now under consideration, bear us out in laying it down as a general rule, that the climate of the West Indies is an improper one for patients with tuberculous disease of the lungs.” Dr. Hunter, speaking of Jamaica, observes: “ Pulmonary consumptions rarely originate in the island, but those who come from England with that complaint already begun, are not benefitted by the warmth of the climate; on the contrary, the disease is precipitated, and proves sooner fatal than it would have done in a more temperate air. Of this we had repeated examples among the soldiers, several of whom arrived in the island with beginning consumptions, and were all quickly carried off by that disease.” Drs. Musgrave and Arnold, agree in this opinion, and Dr Chis- holm states, that catarrh, pulmonic-inflammation, and phthisis pulmonalis, are very frequent in the West Indies; that these diseases are very rapid in their progress; that when phthisis is fully es- tablished, there is no safety in remaining in the climate ; and that a sea voyage, and a temperate, or even cool climate, presents then the only, or at least, best chance of life. The opinions of Dr. Ferguson, Sir Alexander Dickson, and Dr. McArthur, all of whom, as well as those above quoted, resided many years in the West Indies, and had peculiar opportunities of observing the effect of climate on a large scale, are equally strong on this subject. It was formerly customary in the British Navy to send seamen, laboring un- derchronic pulmonary diseases, to the West Indies, but their progress to a fatal termination was so 415 416 CLIMATE—As a Therapeutical Agent. rapid, and so uniformly hastened, that on a repre- sentation to this effect, having been made to the Head of the Naval Medical Department, by Dr. McArthur and others, the practice has long since been discontinued. Medical opinion however, is decidedly in favour of the beneficial influence of this climate on persons predisposed to consumption, as a prophylactic means. Physicians in New England, especially in Bos- ton, have been much in the habit, during past years, of sending pulmonary invalids to Cuba; there to remain till the last of April, then to em- bark for Georgia, South Carolina, or Florida, and to return slowly by land so as to reach New Eng- land about the last of June. Of late Santa Cruz has been much recom- mended, as a winter residence in such cases; but the want of suitable accommodations for in- valids, and the high rate of living, are serious ob- jections to this island as a place of resort. Dr. Clark thinks that Orotava, a town situated on the north-western side of the island, 25 miles from Santa Cruz, possesses many advantages, both as respects accommodations, climate, roads, and beauty of country. As Dr. Clark remarks, in respect to the effects of a tropical climate in pulmonary diseases, much will depend on the nature of the constitution— whether it is such as is calculated to bear a tro- pical climate well, or likely to sink under the irri- tating and exhausting effects of heat—as a pro- phylactic even, it is not safe to recommended it in all cases, for, as this author truly observes, when the morbid condition of the system, which gives reason to fear the approach of phthisis, de- pends chiefly on hereditary predisposition, and occurs in early life, especially in feeble irritable constitutions, the climate of the West Indies will rarely agree. But at a more advanced period of life, and in constitutions free from much disorder of the nervous system, and of the digestive organs, the climate may prove useful. Chronic affections of the bronchial membrane, occurring in persons of a tolerably sound constitu- tion are often benefitted by a residence in the West Indies. In Asthma the climate is generally injurious: also, in all diseases of the digestive organs, the extreme heat causes an irritable con- dition of the mucous membrane of the stomach and bowels, combined with a state of relaxation which greatly predisposes to dyspepsia, dysentery, and other disorders of the abdominal viscera, fevers, &c. If the general health is unimpaired, chronic rheumatism is often relieved by a resi- dence within the tropics ; but if the health is de- teriorated, the powers of the digestive organs much weakened, or the disease attended with pro- fuse perspirations, such a climate proves very in- jurious, and Dr. McArthur, declares that no- thing but a return to a cooler climate can save the patient. (Clark “ The Sanative Influence of Climate,” &c., 3d edition, London 1841, p. 310.) The climate also proves injurious to per- sons of weak irritable constitutions, or with irri- table oowels, or deranged digestive organs gener- ally, or with an irritable skin, or subject to cuta- neous eruptions of an irritable character, and too copious perspirations. Persons subject to severe headaches, or who have any predisposition to cerebral disease, or to insanity, and plethoric peo- ple generally, should avoid the tropics. Persons intending to visit the West Indies for the benefit of their health, should leave here in October or beginning of November, and expect to remain within the tropics till April. Such individuals, on approaching a warmer climate, should live more abstemiously than usual, and upon less exciting food; cutting off all wines and fermented drinks, as well as distilled liquors, and avoiding exposure to the rays of the sun, exercise in the middle of the day, and as well as to currents of air, while in a state of perspiration, using cool water freely over the whole body every day. Flannel is the safest and best covering next the skin ; for it is to be recollected, that although the general tempera- ture of the winter is high, yet dry, cool winds fre- quently occur, and give rise to catarrhal and other inflammatory affections of the lungs, for contrary to what is generally supposed, these diseases are very common in the torrid zone, and Often prove fatal. In returning again to the north, the invalid must guard against the effects of a change of cli- mate, and provide for it by suitable clothing, and avoid exposing himself on deck to damp, cold winds. Strict attention must also be paid to diet. The complaints most likely to attack persons re- turning from a hot to a cold or temperate climate, are diarrhoea, catarrh, and rheumatism.] [Climate of the United States.—Penin- sula of Florida.—We have already spoken of the mildness of the climate of this region of the United States. It appears to possess an insular temperature not less equable and salubrious in winter, than that afforded by the south of Europe, and is therefore well adapted to those forms of pulmonary disease, as bronchitis, and incipient phthisis, as are benefitted by a mild climate. Mildness and uniformity are the two distinguishing characteristics of the climate of the Florida penin- sula. At Key West, for example, the mean tempe- rature of winter is 70° 05', and of summer 81° 39' —and in six years’ observation at this place, the thermometer was never known to rise above 90°. If we compare the jclimate of East Florida, with the most favoured situations on the continent of Europe, and the islands held in highest estima- tion for mildness and equability of temperature, in regard to the mean temperature of winter and summer, that of the warmest and coldest months, and that of successive months and seasons, we shall find the results generally in favour of the former. Thus the mean difference of successive months, stands thus :—Pisa, 5° 75', Naples, 4° 28', Nice, 4° 74', Rome, 4° 39', Fort King, interior of Florida, 4° 28', St. Augustine, 3° 68', Fort Brooke, on the western coast of Florida, 3° 09', Penzance, Eng., 3° 05', Key West, 2° 44', Madeira, 2° 41' The mean annual range thus:—Fort King, 78°, Naples, 64°, Rome, 62°, Nice, 60°, Montpelier, France, 59°, Fort Brooke, 57°, St. Augustine, 53°, Penzance, 49°, Key West, 37°, and Ma- deira, 23°.—Thus it is easily demonstrated that invalids requiring a mild winter residence, have gone to foreign lands in search of what might be found at home, “ an evergreen land in which wild flowers never cease to unfold their petals.” (For ry). The air of Florida is of course far more humid than in our northern regions, causing that general relaxation and lassitude, consequent on this at- mospheric condition. In winter, however, the atmosphere is comparatively dry and serene, ow- ing to the circumstance that th® rains generally fail at a particular season; thus, although the mean annual quantity of rain is 31.40 inches, yet the proportion during the six months intervening between November and May, is only 8.84 in Phere are also, notwithstanding this exces- sive quantity of rain, a greater number of fair days in Florida, than in the northern states. Thus, whilst on the northern lakes, the annual ratio of fair days is only 117, on the coast of Flo- rida it is 250, and at Fort King, in the interior, 309. St. Augustine, situated on the eastern coast, and Key West, belonging to the Archipel- ago, south of Cape Sable, are the principal places in Florida to which invalids have hitherto resorted for a winter residence, and they are the only ones which afford the conveniences required by the wants of the invalid. The frequency and se- verity, however, of the winds at St Augustine, constitute a considerable drawback on the benefits of the climate ; an objection which does not lie against parts in the interior, or even Key Bis- cayno, on the south-eastern coast, or Tampa Bay, on the Gulf of Mexico. It is to be recol- lected, that the influence of temperature on the living body, more especially as regards winds, is often indicated more accurately by our sensations than by the thermometer; and consequently the advantages of climate, as regards its fitness upon the pulmonic, not unfrequently depend on the mere circumstance of exposure to, or shelter from cold winds. Invalids, who spend the winter months at St. Augustine are often prevented from venturing into the open air, by the chilly north east blast, surcharged by fogs and saline vapours, which sweeps down the coast, from the northern latitudes. These winds are particularly injurious to patients labouring under an irritable state of the bronchial membrane, and in such cases Fort King is preferable as a residence to St. Augustine, or even Fort Brooke. For some years past, we have been in the habit of sending such pulmonary cases, as we supposed would be bene- fitted by a northern climate, into the interior of Florida and Georgia, in the pine region, where the dry air, and the mild and uniform tempera- ture, in connection with the aroma of the pine, seemed to exert a highly favourable influence. In our judgment, the climate of no part ot the West Indies can compare, in point of salubrity in such cases, with those above mentioned. Dr. Forry was in the habit of recommending pul- monary invalids to embark about the middle of October for Tampa Bay; and having spent the winter months there, to proceed, early in March, to St. Augustine, by way of Dade’s battle- ground, and the old Seminole agency, and return- ing home in June. And he confidently predicted, from a long residence in Florida, attached to the U. S. army, that when the period of the red man’s departure shall have passed, the climate of this land of flowers, would acquire a celebrity as a winter residence, not inferior to that of Italy, Madeira, or Southern France.] 63. vi. Of residence on the sea shore and voyaging-—There are certain topics connected with change of climate often discussed during the course of practice, viz. whether are inland situa- tions, or places on the sea-shore, whose climates are physically alike, most serviceable in pulmonary diseases? and whether or not sea-voyages pos- sesses any advantage over a land residence in these complaints.—a. In respect of the first question, it may be stated, that places on the sea-shore are generally more humid than those inland, and oftener, on this account, preferable in the dry and the haemorrhagic pulmonary affections; whilst a situation somewhat inland, or not removed above CLIMATE—As a Therapeutical Agent. a few miles from the coast, seems somewhat more serviceable in those cases of consumption which are otherwise characterised. But the question has not been satisfactorily determined, and, indeed, is not easy of solution. [Sir James Clark observes that from all he has been enabled to learn and observe, “ consumption is cceteris paribus, more frequent on the sea-coast than in the interior”—and Dr. Morton, of Phi- ladelphia, {Illustrations of Pulmanary Consump- tion”) remarks, that “experience has amply proved that a mixture of sea and land air, such as exists on all our maratine situations, is unfa- vourable to delicate lungs ; and especially where there is phthisis, or even a predisposition to it.” Dr. Forry, however, maintains, that the statis- tics of the U. S. army, demonstrate clearly the fact that catarrhal diseases are scarcely half as prevalent on the moist and variable coast of New England, or the great lakes, as in the dry and less changeable regions of the same latitude ; and that as regards a permanent residence, the for- mer is less injurious. Dr. F., however, admits that as regards tubercular consumption, the opi- nion of Dr. Morton may be correct; but he is very positive that it is not in any form of pulmo- nary disease, which has its origin in mere inflam- mation : and he observes that “ a winter resi- dence on our sea-board, exposed to the prevailing north-east wind, is any thing but advantageous to the consumptive.” Such is, indeed, our own experience.—Pulmo- nary cases are always benefitted by a removal from the sea-coast into the interior, although it be into a much colder climate. Our north-east and easterly winds, are often saturated with saline va- pours, which are extremely irritating to the dis- eased bronchial membrane ; thus aggravating the cough, and adding greatly to the discomfort of the patient. Besides, as these winds, contain a large proportion of moisture, they excite a greater sensation of chillness in the invalid, by their pro- perty of conducting caloric more rapidly from the body, and this also tends to increase the inflam- matory action which already exists. We have often known a bad cough got rid of, by removing from this city, to some place in the interior, 150 or 200 miles from the ocean, and in several in- stances, life has evidently been prolonged by such a change of climate. The late Dr. P. of this city was subject to a cough for several years before he died, but, whenever he visited his friends in the upper part of Vermont, he was in- variably relieved of it, so that during the latter years of his life, whenever it became very trou- blesome, he was in the habit of retiring to the country for relief, which he always found, and which could not be had on the sea-board. He at length died of pulmonary phthisis, to which he was hereditarily predisposed. There is something, doubtless, in the admixture of land and sea air, apart from the saline particles, which proves dele- terious in these cases. “ Every seaman,” says Dr. Chapman, “ knows the fact, and so sensibly is the impression felt, that the approach to a coast is predicted from it, and most generally he acquires what is called the land cough. That the sea- board is every where more liable to consumption than the interior, seems sufficiently demonstated, and is conspicuously illustrated in relation to our own country.” (Thoracic and Abdominal Dis- eases, p. 86.)] 64. 6. With reference to the second question, 418 CLIMATE—As a Therapeutical Agent. it may be stated more confidently, that sea-voy- aging, in a suitable climate, is preferable to land residence in the early stages of phthisis, and par- ticularly when it is attended by haemoptysis. This advantage is evidently to be attributed to the influence of the ship’s motion on the sangui- neous and nervous systems. This opinion was argued for by Dr. Gregory, in his excellent thesis, De Morbis Cceli Mutatione Medendis, and has been generally admitted. Cruising in a warm or even temperate latitude, particularly in the Atlantic, is preferable to voyaging, because of its longer duration. Whilst the sun is north of the oquator the climate between the 30th and 50th degree of latitude ; and while the sun is south of the equator, that from the 20th to the 35th or 40th degree of north latitude, will be found the most salutary. During winter, voy- ages between Madeira and the West Indies ; and, in summer, between Madeira and this country, in the vessels constantly trading between Eng- land and the West Indies, and which generally touch at Madeira, might be undertaken with ad- vantage. These vessels furnish tolerable accom- modations, which may be easily improved or adapted to the state of the invalid. [Considerable benefit is undoubtedly often de- rived from a sea-voyage in some forms and stages of pulmonary disease ; and yet in many cases it also proves injurious. We may expect in a majority of cases, that it will make a prettv de- cided impression upon the system; whether for good or evil will depend much on circumstances connected with the peculiarities of the individual. Where there is great debility, or derangement of the digestive organs, especially nausea, or irrita- bility of the stomach, a sea-voyage is very cer- tain to exert a deleterious influence, and may cause a fatal degree of exhaustion. But where the digestive powers are unimpaired, and relaxa- tion is indicated, we may confidently anticipate that a sea-voyage, if undertaken at a propitious season, and with suitable accomodations will prove advantageous. As a general rule the month of June is the most proper month to un- dertake a voyage ; and a trip to Europe, in one of our commodious packet ships, to return after the autumnal equinox, promises perhaps more bene- fit, than can be derived from any other excursion of this kind.] 65. A. When the winter has been passed in any of the warmer situations noticed above, attention ought to be paid to the time of returning to this country. This should not be earlier than the first, or later than the last week in June. If the in- valid have passed the winter in the south of France or in Italy, these places may be left early in May, and he may travel cautiously through Switzerland, avoiding exposure to the evening and morning air. During the journey, warm clothing should bo resorted to as soon as the tem- perature falls so low as to become sensibly cold ; and a free circulation in the skin and extremities ought to be carefully preserved. 66. B. With respect to the diseases which are benefitled by change of climate, it is unnecessary to add any thing at this place, as the climates which seem most serviceable are noticed when discussing the treatment of those diseases in which most advantage is derived from removal to particular climates. The affections for which this treatment may be employed, are scrofula, tuber- cular disease of the lungs, haemorrhage from the lungs, cumstance of the medicine, which is most to be depended upon in relieving some of the most urgent symptoms, and enabling the liver to throw oft' the load of morbid secretions which oppress it, having the effect, in some constitutions espe- cially, of increasing the exhaustion of nervous power, and the tremors and paralysis attendant on the worst forms of the complaint. Calomel, in a large dose, either alone or with opium, has an excellent effect in allaying the distressing irri- tability of stomach, and carrying the biliary and other morbid secretions downwards: but if it be repeated in such quantity oftener than once, or if free evacuations be not procured soon after its administration, it is apt to affect the mouth, and to prolong the period of convalescence. I have therefore endeavoured to procure from it a soothing effect on the stomach, along with its chologogue operation, guarding against its se- condary action on the system ; and have pre- scribed from ten to twenty grains in a bolus, with about ten grains of camphor, and sometimes with two of opium. This will generally allay the retchings, and enable the stomach to retain the medicine next to be given. About three or four hours after the above has been taken, a draught, consisting of half an ounce each of castor oil and oil of turpentine, with one or two drops of croton oil, on the surface of aqua pimentce, is admin- istered, and its operation on the bowels promoted by a clyster composed of about four ounces of olive oil, or two of castor oil, one of turpentine, half an ounce of sulphate of magnesia, and from ten to twenty ounces of the decoction of linseed, or of marshmallows. This enema should be steadily thrown up by the improved apparatus. Whilst this treatment is proceeding, a liniment may be assiduously rubbed on the abdomen, and on the limbs, if much pain be felt in them ; or a piece of flannel, charged with one of these liniments (F. 297, 307., &c.), may be closely applied over the belly. If these means procure evacuations, recovery will soon follow ; but if the draught be thrown off the stomach, or the injection be returned without effect, they should nevertheless be repeated. If the abdomen be much distended, and painful on pressure, the hot turpentine fo- mentation ought to be applied, as long as the patient can endure it, instead of the liniment. These measures will seldom fail of procuring most copious evacuations, which should be promoted by sulphate of magnesia and spiritus eether. sulph. comp, in the compound infusion of roses ; and by oleaginous clysters with camphor or assa- fcetida, and oil of linseed. After two or three doses of sulphate of magnesia have been given, the following draught may be exhibited, and re- peated frequently ; the action of the bowels being promoted by the enema. No. 137. ft Camphor® rasa; gr. iij.—vj.; tere cum Mu- cilag. Acaci® | ss., et Aq. Pimento l j.; Sulph. Alumina pulver. 3 ss.; Spirit, Anlsi 3j.; Syrupi Croai 3ss. Misce. Fiat Haustus, quarto vel quinta qu&que hora sumendus, prius agitata phiala. No. 138. ft Terebinth. Venet. vel Commun. 3 vj.— J j.: 441 442 COLIC AND ILEUS—Treatment of. Tinct. Assafoetida; 5 ss. (vel Ol. Anisi § j.) ; Olei Oliva: l iij.; tere cum Vitel. Ovi, et adde Decocti Malvse 5 xvj.; in quo prius soluta erat Sulphatis Magnesia; 5 ss.— f j., et fiat Enema. 67. i. The treatment of convalescence from lead colic is of much importance, particularly when attended with tremors, epilepsy, severe ce- phalalgia, or paralysis. At first the alum and cam- phor should be given for two or three days ; and the action of the bowels promoted by oleaginous enemata ; the loins and abdomen being rubbed night and morning, with one of the liniments al- ready recommended. As there is a great ten- dency of the disease to return, particularly when the patient follows the occupation which occasion- ed it, the strictest attention should always be paid to the state of the bowels, and the sulphates of magnesia and alumina, with compound infusion of roses, and some aromatic spirit, be taken fre- quently ; and, upon the first indication of obstruc- tion, recourse should be had to oleaginous clysters. 68. k. In order to remove the sequela of the disease, particularly the paralysis, the patient should be allowed a generous diet, with exercise in the open air; and strychnine, or the extract of nux vomica, with the aloes and myrrh pill, or F. 541. 565. may be taken twice or thrice daily. The palsy arising from the poison of lead is much benefited by this active medicine, as well as by frictions with stimulating substances, by electricity, and the use of splints along the fore- arm and hand, as recommended by Dr. Pember- ton. The Bath waters are very serviceable in promoting perfect recovery, and preventing a relapse : with these views, the balsams, particu- larly the Canadian and Peruvian, may also be taken, with the sulphates of alumina and quinine, or with tonic extracts, camphor, &c.: and, under every circumstance, the digestive organs should be strengthened and the action of the bowels promoted by tonics combined with aperients and antispasmodics. I have obtained marked advan- tage from strychnine thus combined, as well as from several of the gum resins, as ammoniacum, myrrh, assafoetida, and galbanum, particularly when, besides the reduced nervous and muscular power, the digestive functions still continue to suf- fer. (For the prophylactic treatment of this disease, see the article Arts and Employments, § 17—30.) 69. ii. Treatment of Colic caused chiefly by Change of Structure or Position.—A. Of colic from constrictioy, of the bowels. This state of disease will not be benefited by purgatives or carminatives; but a judicious choice and com- bination of aperients will often be of service. In all cases of this description, due examination per anum should be instituted ; and as stricture fre- quently occurs at the upper part of the rectum and lower part of the sigmoid flexure of the colon, a very long flexible bougie should be carefully introduced, as recommended by Dr. Willan. When we have reason to suspect the existence of stricture in any part of the colon, the use of mucilaginous, saponaceous, or oleaginous enemata should be long persisted in ; but the patient ought to be very careful not to employ any oil that is not perfectly sweet. At the same time, the ac- tion of the bowels may be promoted by an elec- tuary composed of equal parts of the bi-tartrate of potash and bi-borate of soda, with confection of senna and common treacle, or either the in- spissated juice of the sambucus or simple syrup. I have seen advantage derived from a plaster, consisting of the emplastrum picis comp., the em- plast. ammoniaci cum hydrargyro, and either the extract, belladonnas or the extr. conii kept long applied over the abdomen. When the stricture ap- pears to be low in the colon, and yet beyond the reach of a bougie, suppositories, with either of these extracts and the lead plaster, will be pro- ductive of some relief; and when it can be reached by a bougie, the occasional introduction of one will often permanently remedy the disease. 70. Most of the cases of this complaint that I have seen, have occurred in persons who had long been in the habit of having recourse to purgatives, consisting chiefly of calomel and colocynth, or the compound extract of the latter—substances which have a remarkable effect in irritating the internal surface of the colon and rectum, and constricting their muscular tunics. It is obvious that a frequent repetition of these medicines, unless their effects be counteracted by emollient clysters, will at last give rise to inflammatory thickening of the parietes of the bowel, and con- striction of its canal. In most of these cases, also, there exists inflammatory action of the in- ternal surface of the constricted part, and of its vicinity. Hence the advantage usually derived from a cooling regimen, a spare or farinaceous diet, and cooling gentle laxatives, assisted by soothing and demulcent clysters, as the fol- lowing :— No. 139. Ijt Semin. Fcenicul. dulc., Semin Anisi aa contus. 5 ss.! Fol. Malvffi et Flor, Anthem, aa 3 vj.; Aquas O jss. Coque ad O j. ; dein exprime et adde liq. expresso Olei Oliva;, vel Ol. Lini. § iij.; Potassa; Tartar, et Bi- boratis Soda; aa 3 j.— 3 ij. Misce et fiat Enema, pro re nata injiciendum. No. 140. If Extr. Hyoscyami 3 ij. ; Camphor,t rasa; prr. vj.—v. ; Soda; Sesqui-carbon. vel Bi-boratis 3 jss.— 3 ijss. Potassa: Nitratis ? ss.; tere cum Mucilag. Acacise 1 vji, et adde Decocti Papaveris § x.—xx. Misce et fiat Enema. No. 141. ft Extr. Belladonna; gr. iij.—vi., tere cum Decocti Cydonia; (vel Decocti Althaea;, vel Dec. Hordei Comp.) ?xij.—xvj.; et adde Potass® Carbon. 3 j. ; Potas- sae Nitratis 3j. Misce pro Enemate. 71. B. Treatment of Ileus.—The importance of ascertaining, previously to the adoption of a plan of treatment in this state of the disease, the existence of hernia, has been already noticed ; but the young practitioner should be aware that hernia may exist without the patient being aware of it; and the real state of the case may be mis- taken, owing to the absence of any tumour, so very small a portion of the side of the bowel being strangulated as not even to obstruct its canal. I have twice or thrice—once in one of my servants—met with such cases, in consult- ation with eminent surgeons, where the exact state of parts was inferred, and a successful treatment pursued. There are certain forms of the disease which may be briefly characterised, as they require a very different treatment:—1st, Great distention of the abdomen, with diffuse, but not acute, tenderness; obstinate costiveness ; retchings, particularly when substances are taken into the stomach ; anxiety, and general uneasi- ness : 2d, The above symptoms, with fixed and severe pain, and great tenderness, felt in a defined part of the abdomen, often about the region of the csecum: 3d, Violent attacks of tormina, oc- curring in paroxysms, like the strong impulse downwards from the action of a drastic purge,— the action proceeding to a certain point—there stopping, and becoming inverted,—followed by vomiting, which soon becomes feculent (Aber- crombie) : and, 4th, Where the symptoms of the third state are accompanied with tenesmus, and the discharge of a small quantity of bloody water or mucus, sometimes with indistinct or elongated tumour, and the other signs already described (§ 40.) as indicating invagination of the bowels. 72. In the first of these the bowels are evi- dently distended and inactive ;—in the second, they are probably in a similar state owing to ob- struction, stricture, or strangulation, with inflam- mation, most frequently in the vicinity of the csecum and its appendix ;—in the third, there are more evident signs of stricture or strangula- tion ; but this may also be an advanced stage of the second;—and in the fourth, the symptoms are more strictly referrible to invagination ; al- though this may also exist in the third of these states. 73. a. It is evident that the first of these states will very frequently be much benefited by purgatives, particularly by a large dose of calo- mel (from 10 to 20 grains), which will, either alone or with camphor and hyoscyamus, allay the morbid action of the stomach, and move the bowels, particularly if it be assisted by the hot turpentine fomentation or epithem (§ 54.), and by enemata (§ 57. 66. 70.). In cases where a full dose of calomel only has been given, a dose of castor oil, with ten or fifteen drops of laudanum, may follow it in one or two hours; and an injection with three times the quantity of the same medi- cines may afterwards be thrown up. In some instances equal quantities of castor oil and tur- pentine may be given soon after the calomel. After the irritability of the stomach has subsided, the action of the bowels may be promoted by small doses, frequently repeated, of the purified extract of aloes, with hyoscyamus, and a small quantity of extract of gentian, which will promote its action. Gallesky states that he has found recently expressed linseed oil, in the dose of a large spoonful, with a few drops of the oil of an- iseed, given every hour or two hours, extremely beneficial. If the first dose of calomel neither opens the bowels nor allays the action of the stomach, it may be combined with from one and a half to three grains of pure opium. This will, in most instances, settle the stomach and open the bowels, particularly if it be soon followed by the fomentation and enema already advised. 74. b. The tendency of colic to lapse into a latent or obscure state of inflammation has al- ready been noticed (§ 54.); and this tendency is the greater, the more nearly the disease ap- proaches to ileus from its commencement. As colic in every form is more especially an affec- tion of the muscular coats of the bowel, and as inflammation, when it supervenes, as it so fre- quently does, upon colic, seems to attack this part especially, and to terminate then more ra- pidly in gangrene than when it originates in either the mucous or peritoneal coats, so it be- comes necessary to have a prompt recourse to blood-letting, particularly when rigors have oc- curred, and the pulse is oppressed or constricted, and the habit of body plethoric or muscular. In such cases, blood-letting should be full and de- cided, and, if necessary, repeated ; but it ought not to be trusted to alone, or even mainly ; for if carried too far, or employed too largely, or even at all in some cases and states of constitution, or too late in the disease, it may hasten a fatal termina- tion. It is beneficial chiefly in the second and third states of the malady, especially when re- COLIC AND ILEUS—Treatment of. sorted to early, and followed by local depletion, by calomel and opium, the warm turpentine fo- mentation on the abdomen, and subsequently by clysters (F. 144. 146, 147.). I believe, however, that in many cases, particularly those commenc- ing as flatulent colic, blood-letting carried to the utmost extent will not of itself prevent either gangrene from taking place, or fseculent vomiting from coming on. For in these, and in the first state above specified, the muscular and other coats seem to lose their vitality, without almost any other mark of pre-existing inflammation, that I could observe in some cases on dissection, than change of colour. And yet, when duly employed, particularly early in the other states of the disease, blood-letting will often give de- cided and immediate relief, and be quickly fol- lowed by free evacuations and speedy recovery. 75. c. Opiates and other anodynes are most important remedies in nearly all the states of the disease, but especially in the second and third particularised. The propriety of premising gene- ral or local blood-letting, or both when it is clearly indicated, and the advantages of com- bining opium or hyoscyamus, at first with a large dose of calomel, or camphor, or both, have been adverted to. These remedies will often of them- selves produce free evacuations : but in the states of the ileus now mentioned, purgatives given by the mouth, unless of the mildest kind, or com- bined as above (§ 52.), and exhibited subsequently to the above remedies, are seldom of service Appropriate enemata, however, should not be omitted. 76. d. The tobacco injection is one of the most generally adopted remedies in this disease, and one which has received the warm sanction o! Dr. Abercrombie. This able physician recom- mends it with judicious caution, and directs at first only fifteen grains of the tobacco to be in- fused for ten minutes in six ounces of boiling wa- ter ; the quantity to be increased to twenty grains, and repeated after an hour, if no effect be pro- duced. I believe that, when thus employed, early in the disease, and in persons previously of sound vital power, this will often be of service, or at least not detrimental. But I have seen seve- ral cases wherein this powerful substance, even when no more than half a drachm had been in- fused for fiteen minutes in a pint of water, pro- duced the most distressing effects ; and in one case, where it was given in opposition to my opi- nion, which was in favour of a terebinthinate in- jection, death followed its administration before three minutes had expired,—evidently from its se- dative operation in an advanced state of the dis- ease. I have seen many cases in which it had been administered, and, unless under the circum- stances in which I have stated it to bo admissable, or when stimuli are given at the same time by the mouth, I believe that it favours a fatal termi- nation, by exhausting the vital power of the ali- mentary canal, and disposing inflammatory action to terminate in gangrene. The introduction of tobacco smoke into the large bowels appears a much safer and more efficacious practice, and to be appropriate to a greater number of the many morbid states of which ileus is an effect. 77. e. Various other kinds of injection have been recommended; and some of them are more deserving of confidence in the treatment of ileus than almost any other remedy. I have already mentioned several (§ 66. 70.), and referred to 443 COLIC AND ILEUS—Treatment of. 444 others in the Appendix (F. 140, 141. 150.) on which very considerable reliance may be placed. Dr. Maxwell has found large injections of warm linseed oil—from two to four pints—steadily and slowly thrown up, regurgitation being prevented by pressing the guard of the pipe against the anus, remarkably successful, after faeculent vo- miting had come on, and the usual means had failed. He recommends, in such cases, the pa- tient to be placed on the right side, with the pel- vis elevated above the rest of the body, the pre- mature return of the injection being prevented by firmly pressing a ball of linen against the anus. He directs this clyster to be repeated every three or four hours, until relief is obtained ; and, when much exhaustion is present, with the addition of laudanum. This physician and Dr. Wood like- wise advise, in cases where the existence of intus- susception is suspected, the inflation of the intes- tines by air, and adduces cases in which it was followed by copious evacuations; but it seems doubtful whether or not invagination existed in any of them. This practice, first recommended by Hippocrates, afterwards insisted on by Al- exander of Tralles, Zacutes Lusitanus, and Riverius, and mentioned by Sagar, and some other systematic writers, is certainly deserving of trial where we have reason to suspect invagina- tion or internal strangulation. In most cases, however, inflation with tobacco smoke appears preferable; but, as Quarin remarks, it should be frequently repeated, and its effects carefully watched. Although the infusion of tobacco has been chosen for injection by Vicat, Fowler, Campet, Conradi, Hufeland, and Abercrom- bie, yet I agree with Sydenham, De Haen, Sagar, Quarin, and many others, in considering the smoke superior to the infusion; the former being adopted by some merely on account of the greater facility of conveying it into the bowels, and without reference to the very different ope- ration of these two modes of employing this pow- erful medicine. But in cases where inflation by air or tobacco smoke is adopted, purgative injec- tions should speedily follow, as directed by Hip- pocrates, if evacuations have not taken place; for the smoke may even pass out by the mouth, and yet copious motions may not otherwise be produced. Besides these means, yeast has been administered as an injection in warm small beer, wTith the intention of evolving its fixed air in the bowels, and thereby extracting any unnatural convolution or slight invagination that may have been formed. Sulphuric (Ether has likewise been thrown into the large bowels, with the expec- tation that its fumes would operate in a similar manner. Antimonial wine, and the powder or infusion of ipecacuanha have been prescribed in enemata, with a view of relaxing spasm, in cases where it is presumed to be the chief cause of ob- struction : whilst the infusion of poppies and of chamomile flowers, various anodyne, saponaceous, laxative, and oleaginous injections (§ 57. 66.), have also been directed with the views already stated. 78. /. Baths, tyc.—Tepid or warm baths are sometimes useful adjuvants in the early stages of the disease, and are generally recommended. Cold fluids taken into the stomach, and thrown into the large bowels, in considerable quantities, and cold epithems constantly applied on the abdo- men, have been prescribed by Bureau*, Maret, Range, Steidele, Darwin, Conradi, Bald- inger, Smith, and Abercrombie. The dashing of cold water over the lower extremities and ab- domen of the patient, whilst he is kept in a stand- ing posture, has likewise been directed by several physicians; but this practice, although occasion- ally of service, seems less successful than the judicious application of cold to the surface of the abdomen itself. When this cavity is distended, tense, painful on pressure, particularly in a cir- cumscribed portion, with increased temperature of its surface, the cold douche, or the applica- iton of cloths moistened with vinegar and water, will often prove of advantage. Dr. Brandis, of Copenhagen, states that he has employed iced drinks, and cloths wetted with iced water to the abdomen, in ten cases with success: and that in some instances the practice requires to be perse- vered in for a long time, and assisted by anti- spasmodic and laxative enemata, and by opiates with stimulants and tonics taken internally. 79. g. When signs of depression of the vital energy manifest themselves in the advanced stage of the disease, stimulants are required, and, if ju- diciously selected and combined, their exhibition will sometimes be rapidly followed by amendment. Wherever the lowering measures already noticed are followed by increase of the symptoms, particu- larly vomiting and restlessness, or by sinking of the nervous power or of animal heat on the surface of the trunk, antispasmodic stimulants and tonics should be conjoined, according to circumstances, with certain of the measures described above. Purgative tinctures are sometimes of service in this state, particularly the tinctures of aloes, with liquor potassse, and tinct. hyoscyami; and the compound tincture of senna, with tinct. ammon. comp, and spirit, anisi, in large or often repeated doses. Notwithstanding constant or even fseculent vomiting in this stage, advantage will sometimes be derived from a full dose of unrect.ified oil of turpentine (from 1 iv.—x.), taken on the surface of aqua pimentae, to which either spirit, anisi, tinct. cardamom, co., or tinct. capsici, has been added. 1 have seen the vomiting cease, and the distension of the abdomen rapidly subside, im- mediately after this draught, which should be repeated if the former has been thrown off. A full dose of common oil of turpentine, taken by the mouth, has a singular effect in constricting, and, as it were, drawing the small intestines close tc the root of the mesentery; so that in cases where I have given it, and in which hernia had chanced to exist, the hernial sac has become quite empty soon after its exhibition. May not the advantage obtained by it occasionally arise from the disentanglement of a constricted or im- prisoned portion of intestine by this mode of operation, as well as from its influence in restor- ing the action of the paralysed and dilated coats of the bowel in other cases? In many states of inflammatory action, particularly those attended with exhausted tone of the capillaries and de- pressed vital power, it is one of the most active means we possess of preventing gangrene or effusion, and of restoring the natural action of the vessels. 80. h. In some cases, after depletions have been carried far, or in nervous and irritable habits, the inverted action of the stomach and * Mr. Bureau recommends the use, and gives a plate descriptive, of a simple hydraulic apparatus for injections, the same in all respects as one lately introduced into this country from France, under the name of clysmaduct, but which is suited only to the injection of water. COLIC AND ILEUS—Treatment OF, FROM INTUS-SUSCEPTION. npper part of the alimentary canal appears to continue in consequence of the vital exhaustion and irritability of parts; but if these states were put a stop to for a while, and the powers of life supported, the natural action of the bowels—re- specting the immediate restoration of which the patient is often injuriously harassed—would ge- nerally at last return. Under such circumstances, pills consisting of the trisnitrate of bismuth, cam- phor, and opium, frequently repeated ; or of the first of these, and extract of hop, or of henbane, or the hydrocyanic acid, in the recent oleum amygdal. dulcis, or oleum olivee, in moderate but rather frequent doses, and occasionally with an aromatic spirit or distilled water; will often prove of service, particularly when aided by the external means about to be recommended. When thus exhibited, the hydrocyanic acid has a restorative effect; and it is still further beneficial when associated with suitable stimulants, as camphor, Eother, &c. In a few instances I have inferred from the situation of the pain, and other symp- toms, that the disorder originated in the duodenum or jejunum ; and in these especially, the trisnitrate of bismuth and the hydrocyanic acid have been of considerable benefit. The compound tincture of guaiacum, with paregoric elixir, in full doses, and given in milk, or in the recent oil of almonds or of olives, or in linseed oil, has also occasionally proved of advantage, The acetate of morphia is sometimes of service in allaying the distress, anxiety, and irritability of the stomach and dia- phragm ; but it should be prescribed in an aromatic spirit, and in a dose which will secure its anodyne effect without sinking the vital energies. I have used the following with marked advantage, repeat- ing the dose every two hours until an effect was produced :— No. 142. IJ. Acetatis Morphia; gr. iv.; Spirit. Myristicae et Spirit. Pimento aa s j.; Spirit. Camphors; et Tine. Benzoini Comp, aa 5 ss. Soiv. Capiat 3 j. and 3 ij. in Saccnaro vel Syrupo vel Oteis supra memoratis. 81. i. The ingestion of crude mercury, or of globules of lead, to the extent of one or two pounds, has been recommended in ileus by seve- ral authors, particularly in that state of the malady which presents the symptoms indicating invagi- nation of a portion of intestine. Sydenham Sciienck, Belloste, Pare, Panzani, Hoffmann, Sagar, Quarin, Vevinson, Darwin, Abercrom- bie, and many others, have noticed this practice • some of them, as Sydenham and QOarin, in doubtful terms—others more favourably. M. Holland has detailed the history of a case, wherein, other means having failed, he gave about 10 ounces of crude mercury, which, after a short time, occasioned a sensation of change in the position of some part within the abdomen, in- stantly followed by relief. Similar instances have been recorded by Dr. Uwins and Dr. Belluci. I have never tried this metal; but, many years ago, I saw a patient—a female between twenty and thirty,—relieved from all the characteristic symp- toms of this state of the disease by the ingestion of about two pounds of common shot, which has also been recommended in volvulus, by many of the best medical writers of the three last centuries, and by some of them in preference to quicksilver. Large blood-lettings, the tepid bath, and various other means (§ 54. 77.), should generally precede the ingestion of lead or quicksilver. [Two such cases have fallen under our care, where we felt authorized in administering crude quicksilver; in the one case, with the effect of producing speedy relief; in the other, an old lady of 60, without any beneficial result.] 82. k. Various external means besides those already noticed, have been recommended in ileus. Sagar* states, that he was cured of volvulus, by having the abdomen, at the commencement of the attack, kneaded like dough, with oiled hands,—a plan instituted evidently with the view of disen- tangling a displaced portion of bowel. Aret/eus, and Paul of JEgina, directed cupping on the ab- domen. Celsus advises dry cupping on both the loins and abdomen ; but little advantage can bo expected from this latter measure, unless it be performed by one capacious vessel, as is, I be- lieve, occasionally done in some northern con- tinental countries. Quarin states, that in an extreme case, all other means having failed, and the pulse being small and irregular, the extremi- ties cold, the countenance sunk, with hiccup, &c., he had recourse to dry cupping, using for the purpose porcelain bowls. Relief soon followed, and the bowels were copiously evacuated, their action having been assisted by enemata of infu- sion of chamomile flowers and the potassio-tartate of soda. 83. 1. Dr. Abercrombie expresses himself in favour of large blisters on the abdomen ; but much more certain and immediate relief—often within ten minutes after its application—is derived from the hot spirit of turpentine fomentation placed over the whole abdomen. Where there is little or no tenderness of this cavity, I have, however, preferred inunction of its surface with one of the liniments above directed (§ 51.), keeping subsequently a cold turpentine epithem applied. Forbes, Wilmer, and Baldinger also advocate the use of blisters on the abdomen; but Meier prefers placing them on the insides of the thighs. The recommendation of Sydenham, to keep a young dog constantly applied to the ab- domen, will appear to many a singular remedy ; but the views with which he prescribes it are by no means devoid of reason. 84. m. Numerous writers antecedent to the time of Quarin, and subsequently, have recom- mended an incision to be made through the parietes of the abdomen, and the internally stran- gulated, or the invaginated, portion of bowel ex- tricated through it. Nuck has recorded a case where this operation was performed with success. Van Swieten objects to it, the uncertainty of the existence of volvulus or internal strangulation. But in several cases of invagination which I have seen, and in a great many I have perused—almost all those, the history of which has been fully de- tailed—the symptoms described (§ 40.) as charac- terising this state were present, particularly the tormina, followed by desire of evacuation, and tenesmus, with the discharge of a little bloody mucus or water; the oblong tumour, in a part of the abdomen, admitting of being recognised at some period of the disease ; have been superadded to the other symptoms of ileus, and pointed out its precise nature. In two cases I felt inclined to have had the operation performed ; and, indeed, suggested it. The diagnosis was found correct 445 * “ Olim Crisii incidi in hunc morbum (volvulum) ego; Ilungarus Sartor accitus me restituit intra tres horas methodo sequenti: impositmn me supinum prato, in- unctisve oleo olivarum manibus suis depsabat prout pis- tores pastam panis subtiliter incipiens successive seinpei fortius totum abdomen meura.” (p. 320.) 446 on examination after death. A case is given by Dr. Fubohius, in Hufeland’s Journal for Febru- ary, 1825, almost identical with one of these, and characterised by the above diagnostic symptoms, in which he resorted to this operation over the place to which the patient referred the sensation of obstruction, and where an obscure oblong tu- mour, in the situation of the ascending colon, was detected. An invagination of the colon was re- moved, and the patient perfectly recovered. The reader need not be informed that ileus very com- monly proceeds from strangulated hernia, and sometimes persists from adhesions, &c., after the displaced bowel has been returned. The propriety of having an early recourse to the operation after we fail in returning the protruded intestine is here very obvious.* 85. n. During and subsequent to convales- cence from ileus, the patient should wear flannel next the skin, and promote the functions of the COLIC—Treatment of its Sympathetic States. stomach and bowels by vegetable bitters combined with gentle aperients, and the carbonates of the alkalies. The bulky and flatulent vegetables ought to be avoided, and the extremities and sur- face of the abdomen and loins kept equally warm. The utmost attention should be paid to diet; all indigestible substances, and acid or acerb bever- ages being carefully avoided. 86. iii. Treatment of Symptomatic or Com- plicated Colic.—A. The means of cure in most cases of this description should be directed to the diseased viscus, by which the functions of the ali- mentary canal are affected.—a. Those colicky symptoms which are produced by irritation, or the passage of gall-stones, through the common bile-duct, and by the obstruction occasioned by concretions in the intestines, will generally bo re- lieved by nearly the same treatment as that re- commended in this article ; but whatever differ- ence should exist, is detailed in the article on Concretions.—b. The colic which is symptom- atic of worms in the intestines requires, if the at- tack be severe, the internal and external means already recommended to allay the urgent symp- toms ; but after this is accomplished, the reme- dies resorted to for the cure of verminous disor- ders should be employed. (See art. Worms.) 87. B. The occurrence of colic from affections of the kidneys, particularly from calculi in their pelvis or ureters, should not be overlooked by the practitioner; nor should he forget that it is some- times consequent upon aneurism of the abdominal aorta, and of tumours formed in the mesentery, or in the omentum.—a. In the first of these pa- thological states, much relief will be afforded by the alkaline carbonates, with opiates, or sedatives, and followed by oleaginous purgatives and ene- mata, in addition to whatever depletory or other measures the circumstances of the case will point out. The use of liniments with camphor, soap, and opium, rubbed on the abdomen and loins, will also give much relief.—b. In colie depending upon the latter organic changes, little beyond palliating the urgent symptoms by the remedies now men- tioned, can be expected. 88. C. Flatulent colic, generally of a pro- longed description, and often not easily removed, at least in a permanent manner, sometimes occurs in the course of asthma and bronchorrh&a, owing apparently to the interrupted functions of the mucous surface of the lungs ; the evolution of gaseous fluids from the blood being impeded on this surface, but supervening vicariously on that of the alimentary canal. In such cases, after the bowels have been freely evacuated, carminatives combined with ipecacuanha and hyoscyamus ; the infusion of valerian, with hydrocyanic acid, and spirit, anisi ; powders of magnesia, trisnitrate of bismuth or oxide of zinc, and ipecacuanha ; sul- phate of zinc, with myrrh, camphor, and opium or hyoscyamus ; and camphor mixture, with extract of belladonna, spiritus aetheris sulphur, comp, and spirit, menthoe ; are among the means which will afford the greatest relief. 89. D. There are few more common complica- tions than hysteria and colic; but the treatment varies not materially from that now stated.—a. In such cases, the functions of the uterus requires strict attention; for morbid sensibility, and even vascular excitement, both of this viscus and of the ovaria, are often present. The treatment too commonly adopted in this state of complication, although it may give immediate but temporary f * M. Amussat, of Paris, has endeavoured in several in- stances, in cases of obstinate and unyielding constipation, diseases of the rectum, &c., to afford relief by making an artificial anus in the loins, and in July 1844, he operated in the following case. A woman 53 years of age, and hitherto of a robust constitution, began to be annoyed in April preceding, with a gradually increasing constipation of the boweis, and occasional attacks of sharp colicky pains. These attacks became more frequent and severe, and the fecal matters, evacuated after the use of enemata, were found to be small, flattened, and smeared with a sanguinolent mucus. From the 12th of June, there was no intestinal evacuation either of feces or of wind; and all means that were tried to move the bowels, utterly failed. No obstacle could be detected by an examination per anum. On the 1st July, M. Amussat made an open- ing into the descending colon, without dividing the peri- toneum. After exposing the intestine by an incision carried through the integuments and muscles in this part, he passed a tenaculum into it in order to secure it in its position, and then made a vertical opening in it with a pair of scissors. When this opening was sufficiently enlarged, the cut edges of the gut were fixed to the wound in the integument's, at the anterior angle of the wound by means of three stitches. Injections of tepid water facilitated the evacuation of the fecal matters. No inflammatory or febrile reaction supervened; and by the 30th of the month, the patient was recovered. The artificial anus perfectly fulfilled its functions, the bowels acting very regularly; during the intervals be- tween each evacuation, the wound was kept closed by a wax bougie. Such an operation can rarely be considered justifiable, except in cases of a chronic kind, where the obstruction is complete, and where death must inevitably result if left to nature or the ordinary means. An operation of gastrotomy is reported in the Archiv Gen, for 1838, by M. Monad, one of the surgeons of the Hospital Cochin, at Paris, in a chronic case, marked by constipation, fecal vomiting, hiccup &c., after making an opening, a portion of small intestine, red and tumefied, was laid open to the extent of an inch and a half, a ligature applied through the mesentery of the divided intestine, and retained at the edge of the wound by means of strips of adhesive plaster ; light dressings were applied, and the patient felt much relieved. On the next day the loop of intestine was found to have retracted inwards; but it was easily found, and then fixed more securely than before, by means of two sutures. The patient, however, rapidly grew worse and died on the following day. On dissection it was found that the obstruction was seated at thr point of junction of the cttcum, with the as- cending colon, the intestinal tube being contracted, so as scarcely to admit the point of the little finger. The ileum had been opened eight inches above the caput coli; a very trifling adhesion had taken place at the seat of the artificial anus, and the abdominal cavity contained con- siderable sero-purulent fluid.* A late number of the Boston Med. and Surg. Journal, contained an account of a successful operation of gastrotomy, in a case of violent ileus, caused by introsusception. The late Attorney General of the U. S., H. S. Legare. died of ileus, result- ing from displacement of the colon, which produced stran- gulation of the intestine and unyielding obstruction.] * For further remarks on this subject see Art. “ Consti- pation." COLIC—Treatment of its Sympathetic States. relief, not unfrequently perpetuates the patholo- gical state, of which both hysteria and colic are merely symptoms. Instead of employing medi- cines which excite both the digestive mucous sur- face and the generative organs, in these cases, cooling and soothing remedies are much more ap- propriate to them, such as those above enumerated (§ 87.); local depletions, nitrate of potash, car- bonate of soda, extract of hop, cooling aperients, vegetable tonics, exercise in the open air, &c.— b. When the complaint is symptomatic of diffi- cult menstruation (§ 43.), general or local blood- letting may be resorted to in the plethoric sub- ject : but in the weak or hysterical, camphor, ammonia, soda, &c. with hyoscyamus; or the acetate of morphia or laudanum given in some aromatic spirit, the compound tincture of guaia- cum in linseed tea, the preparations of rue and of juniper, and the treatment detailed in the article on the Disorders of Menstruation, will generally give speedy relief.—c. Colicky pains sometimes occur during pregnancy; in such cases, cooling aperients, with antispasmodics and opiates, or other anodynes, and preceded by sanguineous depletion, if congestion or plethora exist, will remove all disorder.—d. Severe at- tacks of colic are not uncommon upon suppres- sion of the menses or of the lochia. If a tendency to inflammatory action manifests itself, and espe- cially if the patient be plethoric or robust, general or local depletion should be practised; a dose of a mixture composed of a decoction of the radix rubise, tincture and syrup of saffron, and as much biborate of soda as it will dissolve, should be given every two hours; the volatile liniment with camphor and opium ought to be rubbed on the abdomen; and afterwards, a fomentation with the decoction of poppy-heads, &c. applied to the same situation. Schmidt- mann advises a cataplasm, consisting of marsh- mallows, henbane, bruised linseed, and poppy- heads, to be placed warm on the abdomen ; and the steam of hot water to be conveyed to the pudenda.—e. If colic proceed from congestion or inflammatory irritation of the uterus or ovaria, local depletions; diaphoretics, and refrigerants, combined with sedatives ; aperients, with cooling emollient enemata, and low diet, are the most appropriate remedies. 90. E. Colicky complaints are not infre- quently referrible to congestion and irregular vascular action in the liver, pancreas, or spleen; or, if not arising from such disorders, are asso- ciated with them, owing to deficient energy of the organic nervous system ; and, consequently, to imperfect performance of the abdominal func- tions generally.—a. In cases of this kind, local depletions, followed by purgatives, exerting a chologogue and deobstruent action, external irritation, and subsequently, by vegetable tonics, laxatives, regular exercise, and a course of the Leamington, Harrogate, Buxton, or Chelten- ham, mineral waters, or the artificial waters of Carlsbad, Spa, Ems, &c., according to the circumstances of the case, will generally re- move all disorder. Impeded circulation through the portal system is more or less concerned in the causation of colic pains in these cases ; the return of blood through the mesenteric and haemorrhoidal veins deranging the contractile actions of the intestines, and giving rise, in many cases, particularly those in which this patholo- gical state obtains, to the additional association of hsemorrhoidal affections, which, if neglected, may terminate in anal fist nine.—b. It is not un- common to find a severe attack of colic usher in hcemorrhoidal discharges: the impeded circu- lation through the portal vessels, and the conse- quent fits of colic, being both relieved by the consecutive haemorrhage from the hsemorrhoidal veins and mucous surface of the rectum. In almost all such cases, in addition to the conges- tion and associated disorder of the assistant chylopoietic viscera, there are more or less vascu- lar plethora, impeded secretion generally, and de- ficient energy of the organic nervous system,—a complicated state of disorder evidently requiring local depletions from the region of the liver, or, as Continental practitioners very reasonably prefer, from the vicinity of the anus, with the remedies above stated, and assisted by regular exercise, gentle tonics, aperients, and a regulated diet and regimen. From this it will not appear singular that very dangerous attacks of colic, or even of ileus, will sometimes occur after the operation for haemorrhoids or anal fistulas, or other morbid states of the rectum, when performed, as they some- times are, without previous medical treatment of a kind appropriate to the state of internal disease. —c. The complication of colic with either acute or chronic jaundice is evidently referable, either to the passage of gall-stones (§ 86.), or to the pa- thological state of the liver now noticed, or to in- flammatory action in the duodenum or biliary ducts, or, lastly, to congestion of bile in the he- patic ducts, or in the gall-bladder. When symp- toms of local plethora or congestion can be de- tected, cupping, and the rest of the treatment now directed, will be serviceable. (See Jaundice —Treatment of.) 91. F. When the colic arises from atonic, misplaced, or erratic gout, large doses of the carbonates of the alkalies, or magnesia, with cam- phor or ammonia, are required, followed by blood- letting, if the pulse, habit of body, and strength of the patient admit of it; by calomel, with cam- phor and hyoscyamus, or opium, at bed-time : by active cathartics, conjoined with stimulants and restoratives, as long as the alvine evacuations indicate the propriety of their exhibition ; by purgative and antispasmodic injections, and by rubefacients and sinapisms to the lower extre- mities. After morbid secretions and retained faeces are evacuated, colchicum may then be given with ammonia, or with camphor and mag- nesia. But arthritic colic occurs most frequently in aged persons, or in those with exhausted con- stitutions, in whom, instead of evacuations, be- yond the expulsion of morbid secretions, active stimulants,—as large doses of camphor and am- monia, or of guaiacum and ammonia,—with warm spices, Cayenne pepper, and sometimes combined with opium or aconitum, and assisted by sin- apisms, are indispensably requisite. 92. G. If colic supervene on the disappear- ance or suppression of rheumatism from the joints or aponeuroses, or on the repulsion of chronic eruptions, local depletions, followed by camphor- ated liniments and fomentations ; warm turpen- tine epithems applied on the abdomen ; calomel, with antimonial preparations, or with ipecacuanha and opium ; warm vapour and fumigating baths; the carbonates of the alkalies, sulphur, the com- pound decoction of sarsaparilla, or the decoction of dulcamara; blisters, plasters, or ointments, with the potassio-tartrate of antimony, saponace- 447 448 ous and oleaginous enemata ; and sinapisms to tho extremities or parts primarily affected ; con- stitute the chief means of cure. The frequency, and, in two of the forms of the disease especially, the danger, of the complaint now discussed, have induced me to be more circumstantial in the account of its pathology and treatment than may appear requisite to many: but I am convinced that the experienced practitioner will not be of the number; but will find cause to regret, with myself, upon reviewing his knowledge, that his information on the subject is not greater than his means of observation have yet afforded him, or my labours can possibly assist him in obtaining. Bibliog. and Refer.—A. Common Forms of Colic.— Plini, Hist. Nat. 1. xxvi. cap. i.—Celsus, De Medicina, 1. iv. sect. 13, 14.—Alexander Trallianus, 1. iii. ch. 44.— Bullion, Consult, vol. i. p. 5.—Schenck, 1. iii. pp. 173.179. and 274.— Willis, Opera Omnia, de Anim. Brut., par. ii. cap. 15. p. 202.—Bond, Sepulchretum, Sec., 1. iii. sect, xiv. obser. 1. 5.; et Mercurius Compitalitius, p. 115. ct seg.— Riverius, Observ. cent. i. ob. 12. 13. 59. &c, ; cent. ii. ob. 12. 38. &c. ; cent. iii. ob. 22. 48.—Rolfink, De Doloro Colico, Jenae, 1660.—Alberti, Da Coiica Hffiinorhoidali. Hal®,1718.—Hoffmann, De Intestinorurn Doloribus, Opera, vol. ii. p. 294.; et Consult, cent. ii. n. 16.—Huxham, in Philos. Trans. No. 422.—Harris De Morb. Inf. p. 31.— Katmpfer, Amcen. Exot. p. 588.—Juncker, De Morbis Colicam consequentibus, 4to. Hal®, 1749.—Agricola, Comment, in Poppium, De Sulphure, p. 416. 462.— Sauvages, Nosologic Methodique, &c. t. ii. p. 510.—Stoll, Ratio Med. par. ii. p. 135. 138., par. iii. p. 65.—Rosen. De Dolor. Spastico-flatulentis Prim Viar. 8vo. Lond. 1771.— Burserii Institut. Med. Pract. vol. iv. ed. Lips. p. 358. ct seq.—Bang, in Act. Reg. Soc. Med. Havn. vol. i. p. 235. et seq., et vol. iii. p. 115. et 141. et seq.—Ranoe, in Ibid. p. 349., et vol. iv. p. 113.—Kunig, De Remed. Indigenis— Tode, Biblioth. i. 3. 148.— Tonrnay, Ergo Colico Dolori Opium, 4to. Nanceii, 1784.—Baudry, Sur la Colique Ner- vo-gastrique. Paris, 1805.—Eberle, De Coiica Infantum. Arq. 1784 —Barker, in N. Y. Med. Repository, vol. v. No. iii. art. 3.—Conradi in Hufeland's Journ. der Pract. Arz- neyk. vi. b. p. 414.—Rave, in Ibid. vii. b. p. 168.—Fromm, De Oleo Ricini, ejusque in variis Col Spec, effectu praes- tant., 4to. 1806.—Michaelis in Loder's Journ. fur die Chirurg. iii. b. p. 633.— Thomann, Annalen, ad 1800, p. 271.—Odier, in Journ. de Med. t. xlix. p. 337.—Hosack. in Lond. Med. Repository, vol. xviii. p. 77 —Chomel, Diet, de Medicine, vol. v. p. 448.—Schmidtmann, Sunnna Obser- vat. Medicar. vol. iv. p. 373. et seq. B. West Indian and Madrid Colic.—Hernandez, Trattato del Dolor Colico, 4to. Madriti, 1750.—Hunter On Diseases of Jamaica, &c.—Lind, On the Diseases of Hot Climates, p. 254.—Luzuriaga, Dissertation Medica sobre el Colico de Madrid. Mad. 1796.—Chisholm, On the Diseases of Hot Climates, See. 8vo. Lond. 1822. p. 92— Larrey, Mem. de Chirurg. Milit. t. iii.—Aulagnier, Re- cherches sur la Colique de Madrid, Paris, 1811.—Libron, in Collect, des Theses souten. a l’Ecolede M6d.de Paris. 1809, No. 82.—Jacob, Ibid., 1815, No. 86.— Thomson, Edin. Med. and surg. Journ., Nov. 1818. p. 614.—Musgrave, in Lond. Med. Repository, by Copland, Nov. 1825.—Pascal in Journ. des Progres des Scien. Med. t. ii. p. 240.—Mar- quand, in Journ. Complement des Scien. Med. t. xxiii. p. 97.—Quiei, Account of the Bilious Colic, or Dry Belly-Ache, 8vo. Lond. 1778, {extremely valuable). C. Lead Colic.—Rcidlin, Lin. Med. 1695. p. 162.— Calmette Riverius Renovatus, vol. i. Lyon. 1704.—Van Swietcn, Comment, vol. iii. p. 347.— Tronchin, De Coiica Pictonum, 8vc.. Geneva;, 1757.—Grashuis, De Coiica Pictonum, Amst. 1755.—De Haen, De Coiica Pictonum, Hag®, 1745.— Warren, in Med. Transac. of Col. of Phys. of Lond vol. ii. No. 7.—Eyerel, Sylloge, obs. iv.—Astruc, in Haller, Collect. Diss. Tract, vol. iii. No. 84.—Stoll, Rat. Med. ii. p. 270., iv. p. 75„ vi. p. 333.. vii. p. 307. et seq.— G. Baker, Medical Tracts republished by his Son, 8vo. 1813, p. 1. and HQ.—Dubois, An Colicis figulis Vense- sectio ! (neq.) Paris, 1757.—Dufresne, Ergo non Colicis figulis Venesectio. Paris, 1777.—Harrison, On the Cure of the Dry Belly-Ache. Lond. 1786.—Adair, in Edin. Med. Comment, vol. x. p. 233.: et Mem. of Med. Soc. of Lond. vol. ii. p. 236.—Merat, Sur la Colique Mdtallique. Paris, 1804.—Lcntin, Beytriige, p. 336.; et Memorab. &c. p. 113.; et in Blumenbach, Med. Biblioth. ii. p. 149.— Hahnemann, in Ibid. iii. b. p. 546.—Ranque, in Journ, des Progres des Scienc. Med. t. ii. p. 242.— Wolff, in Formay, Eplieiner. von Berlin, i. b. 2 st. p. 83.—Quarin, Animad- versiones, p. 187— Lindt, De Aluminis Virtute Medica. Got. 1784.—Hardy, of the Colic of Poitou and Devon- shire, 8vo. Lond. 1779.—Garnett, in Mem. of Med. Soc. of Lond. vol. v. p. 123.—Percival, in Edin. Med. Comment. COLIC—Bibliog. and Refer. vol. ii. p. 239.—Alcock, The Endemic Colic of Devonshire, not caused by a Solution of Lead in the Cider; with Re marks on Dr. Baker's Essay. Plymouth, 1769.—Fischer, Bemerkungen iiber London, &c.p,173.—Burger, in Horn's N. Archiv. ii. b. p. 342.—Oendrin, in RCcueil Periodique de la Soc. de Sante a Paris, No. 5., et t. ii. p. 338.—Cheyne, in Edin. Med. and Surg. Journ. vol. iv. p. 314.—Sommer, in Hufeland's Journ. der Pract. Arzneyk. vii. b. p. 83.— Michaiilis, in Ibid. xii. 4 st. p. 31.—Oebel, in Hufeland's Journ. der Heilk, i. b. p. 195., et xvii. b. 3 st. p. 108.— Bateman, Art. Colic, in Rees's Cyclopedia.—Roberts, in Transact, of Lond. Coll, of Phys. vol, v. p. 15.—Pem- berton, On the Abdom. Viscera, &c. p. 150.—Andral, Clinique Medicale, t. iv. Paris, 1827.—Pariset, in Diet, des Sciences Med. t. vi. p. 9.—Orfilu, Toxicologie Gen6- rale, i. p. 637.—Fricse, in Archiv. der Pract. Heilk. fur Schlesien, iv. b. 1st. n. 6.—Andral, in Revue Med. t. ii. 1824, p. 203.—Kapeler, Archives GCner. de Medecine. t. xviii. p. 370.—Graves, Dublin Hospital Reports, vol. iv. p. 45.—Gregory, Practice of Phys. 3d. edit, p.524.—Chris- tison, On Poisons, p. 493.—J. Copland, in Lond. Med. and Surg. Journ. vol. i. p. 147. ; and in Lond. Med. Repository, vol. xviii. p. 322.—Fournier, in Journ. Hebdomad, de M6di t. vii. Paris, 1830 .—Gcndrin, Transact. Medicales, Jan. 1832.— Uwins, Med. and Phys. Journ., v. xxx. p. 441. D. Ileus and Volvulus .—Hippocrates, Ilcpt vovoiov, iii. Opera, p, 491. ; llcpi raOoov, Op.p. 52.—Scribonius Largus. De Compos. Med. ch. 28.—Aretceus, Curat. Acut.i. ii. c.5.— Paulus JEgineta, l.iii. c. 44.—Bartholinus,Epist. iii. p.284.; Historia. Anatom, cent. v. hist. 23.; et De Usu Nivis Me - dico, p. 145.—Sydenham, Opdra, p. 267.—Zacutus Lusi- tanus, Pract. Adinirab. 1. ii. obser. 29.—Bonet, Sepul- chretum, 1. iii. sect. 14. obs. 7. 24., et 1. iv. sect. i. ob. 23.— Morgagni, Epist. xxxiv. No. 11. 12. 18—Vicat. Delect. Observat. Pract. App. p. 31.—Hoffmann, De Passione Iliaca, Opera, Supp. ii. n. 2.—Sugar, Systema Mor- borum, Sec. p. 321. Vien. 1757.— Quarin, De Cur. Feb. et Inflam. p. 384 Vien. 1781,—Monro, primus, Observ. en Intus-suceptio, in Edin. Med. and Phys. Essays, vol, ii. art. 27. ; Ibid. vol. iii. p. 387.—Simson, in Ibid. vol. v. par. ii. p. 664.—De Haen, Rat. Med. par. i. p. 113., par. viii. c. 5., par. ix. c. 5., and par. xi. c. 3.—Monro, tertius, Morbid Anat.,of the Gullet, Stomach, and Intes- tines, 8vo. 2d. edit. p. 59.— Whately, in Philos. Transac. vol. lxxvi.—Fowler, Med. Reports of Tobacco, Lond. 1785.—Barthez, Observat. sur les Coliques Iliaques essen- tieilement Nerveuses, in Mem. de la Society Med. d’Emu- lation, t. iii. p. 401 .—Darwin, Zoonomia, vol. ii. p. 533.— Ludwig, Dc Causis Obstruct. Alvin®, p. 32.—Howship, in Med. and Surg. Journ. vol.viii.p. 129.—Hufeland, in Journ. der Pract. Arzneyk. ii. b. p. 309.; et in Journ. der Pract. Heilk. Nov. 1809. p. 133.—Schaffer, in Ibid. Dec. 1810. p. 30.—Conradi in Hufeland's Journ. der Pract. Arz- neyk, vi. b. p. 495.—Forbes, in Edin. Med. Comment, vol. ix. p. 266.—Scott, in Ibid. vol. v. 183.—Nee hi son. On Crude Mercury in Obstructions of the Bowels, Lond. 1788.—Baillie, Series of Engravings, fasc. iv. tab. i.— Sims, Observations on Epidemic Disorders, Sec. p. 27.— Gadolla, De Vomita Intestinor, sive Volvulo. Vien. 1771. —Hartmann, Do Ileo Cognoscendo et Curand. 1780.— Gallcsky, Vom Miserere, etc. p. 70.—Salgues, in Journ. de Medicine, t. xxxvi. p. 515.— Wolff, in Hufeland's Journ. der Pract. Heilk. xvii. b. p. 189.—Bureau, in Mem. of Med. Soc. of. Lond. vol. ii. p. 227.—Baldinger, N. Magazin, viii. b. p. 77.—Vogel, Methode de Ileus, &c., Loder's Journ. fur Chirurg. i. b. p. 511.—Monfalcon, in Diet, des Sciences M6d. t. xxiii. p. 541.—Raige Dolorme, in Diet, de Medicine, vol. xxi. p. 402.—Richter, Die Specielle The- rapie, iv. b. p. 171—226.—Rayer, Archives G6n6r. de Med. t. v. p. 68.—Lebidois, Ibid. t. xiii. p. 230.—Louis. Ibid. t. xiv. p. 185.—Rcgnault, Journ. Univers. des Scien. M6d. t. iv.—Mortier, Journ. Complement des Scienc. Med. t. iii.—Faget, Journ. Gener. de M6d. t. xi.—Dance, Sur les Invaginations des Intestins, in Report. Gener. d’Anatom, et Patholog. &c. t. i. p. 441.—Smith, in Edin. Med. and Surg. Journ. vol. ix, p. 287.—Maxwell, in Ibid, vol. xxi. p. 72.—Rolland, Archives Gdner. de Medicine, t. v. p. 220.—Fuschius, in Ibid. t. ix. p. 116.—M. Bunt, in Ibid. p. 230.—Bclluci, in Ibid. t. xviii. p. 290.—Ha- zard, in Trans, of Med.-Chirurg. Soc. vol. i. No. 14.— Baud, in Journ. Gen. de Med. t. xxiv. p. 20.—Brandis, in Nouv.Journ.de Med. t.v. p. 89.— Willan, Miscellaneous Works, by Smith, Lond. 1820, p. 285.—Abercrombie, On Diseases of the Abdominal Viscera, &c. Edin. 1828, p. 104. —Beilby, Alison, Sec., in Edin. Med. and Surg. Journ., vol. xliv. p. 280, et scq.— Wood, in Bost. Med. and Surg. Journ. 1835. Those who wish to be acquainted more fully with the opinions of the writers of the fifteenth, sixteenth, and seventeenth centuries, as to Ileus and Colic, will find them detailed at considerable length in Bonet’s Polyalthes, Sec. fol. vol. i. p.500. et scq.: in his Mercurius, fol. p. 115.; and in Manget’s Bibliothica Medica Practica, fol. vol. i. p. 575. Although I have-not availed myself of these collections in any way, owing to my circumscribed limits, and desire ! to give more precise information of a later date, and more fn accordance with my experience, than that which they furnish, yet will they be found to contain much of what has been considered of much more modern date, and, when sifted from the refuse, of no mean value. The Bibliography of these diseases in Ploucqet’s Med. Digesta, is brought down to the commencement of this century ; but many of the references are inaccurate ; that by Young is very scanty, and not select. The list appended to the art. Ileus, in the great French Dictionary, is entirely a catalogue of Theses on the subject, of no value; instead of consisting, as it ought, of references to the experience of the best practical writers. COLON.—Syn. KtoXov. Der Grimmdarm, Ger. The Large Bowel. 1. The colon is very often the seat of disease, the rest of the alimentary canal being but lightly affected. In some complaints, as constipation, colic, and dysentery, it is the part principally disordered ; and in others, as indigestion, diar- rhoea, ileus, peritonitis, &c., it participates in the disease with the rest of the digestive organs. The investigation, therefore, of these maladies neces- sarily includes the consideration of the chief mor- bid states of this viscus. But there are other derangements which require a brief notice at this place, and which do not belong to these diseases, or to those changes of structure that are common to it and the rest of the alimentary canal, and are considered in the article on the Pathology of the Digestive Canal. 1. Torpor or Atony of the Colon, and its Consequences. — Classif. — I. Class. I. Order (Author). 2. Defin. General debility, with indigestion; slow or irregular state of the bowels ; distension, borborygmi, or stridulous noises, in the course of the colon ; frequently pain or uneasiness, some- times with tumours in some part of this viscus. 3. Its Pathology.—Atony and distension of the colon may be variously associated with other disorders. They obtain more or less in all cases oi' constipation and colic which depend not upon inflammation, or upon diminution or constriction of the canal of the intestines; and they are also often complicated with torpor of the liver, and deficient secretion from the internal surface of the colon. Distension is usually occasioned by flatus or fecal matters ; and it may produce little or no inconvenience, beyond constipation, until it reaches a great extent; but it frequently gives rise to flatulent and stercoraceous colic, and even to ileus. The gases found in the colon are azote, carbouic acid gas, and carburetted hydro- gen, in varying proportions; and when they accu- mulate largely, they always produce borborygmi, or an unpleasant or painful sense of distension, and constipation or colic. A. Flatulent disten- sion of the colon (see Flatulence) is commonly dependent upon want of vital tone of the diges- tive organs generally, and of this viscus particu- larly. In irritation or inflammation of the bowels, flatus is also generated in great quantity ; but it is usually expelled quickly, especially when they are unobstructed, owing to reaction of their mus- cular coats. Much doubt exists as to the source whence this flatus proceeds. The circumstance of its rapid reproduction after its evacuation, when the bowels contain no substances which could give rise to it, and various physiological considerations, lead me to infer that it is in great measure exhaled from the digestive mucous sur- face ; the gases consisting chiefly of those which pass into, or are formed by, the blood ; and which, in health, are afterwards given out from it, on the mucous surface of the lungs. Persons who often COLON—Torpid States of, See expel the flatus from the lower bowels, where it evidently is destined to perform useful purposes in the economy, are most subject to an atonic state of the colon, and to a continued as well as an increased generation of the intestinal gases: and, when circumstances prevent the accustomed frequency of their discharge, are most liable to experience the effects of their accumulation. Atonic distension of the colon by flatus is also a common attendant upon congestion of some one or more of the abdominal viscera, and even upon general vascular plethora, particularly when it oppresses the circulating energies. It also often accompanies hysteria : and, owing to the increased sensibility of the organic nerves, as well as to the morbid irritability and irregular action of the mus- cular fibres of the bowels, gives rise to various painful sensations in their course, and to anoma- lous states of disorder. 4. B. When an atonic and flatulent state of the colon is associated with morbid irritability of the muscular coat, painful sensations in some part of the course of this viscus are frequently complained of, particularly by females ; are by them often referred to its left arch and descending portion; and are attended by loud croaking or stridulous noises, especially upon full respiration and mental emo- tion. The bowels are usually constipated, and attempts at evacuation are accompanied with slight tenesmus, the stools being discoloured, hard, slimy, or in lumps. The abdomen is tumid ; and tenderness, often shifting its place, and varying in degree or duration, is sometimes felt. The whole digestive organs necessarily participate in this state of disorder, and perform their functions imperfectly. The nervous system of organic life acquires increased sensibility; the cerebro-spina! system becomes morbidly susceptible of im- pressions, particularly in females; the counte- nance is pale, slightly discoloured, and often covered by an oily moisture ; the tongue is loaded, flabby, sometimes large, presenting fissures on its surface, and the impressions of the teeth on its edges; the pulse is weak and soft; and a sense of distension and oppression follows a full meal. This state of disorder is very frequent in young females, who take not sufficient exercise; and, when neglected, is often the forerunner of more serious ailments, both of the bowels and of the generative organs. 6. C. Deficient vital energy of the colon also gives rise to relaxation or irregular action of its coats, to constipation, and to collections of fecal matters, generally with more or less flatulence. Fcecal accumulations to a great amount is most commonly met with in aged females, or persons far advanced in life, who have injured the tone of the bowel by the frequent use of cathartics, and have passed a sedentary and luxurious exist- ence. They also occur, but to a much less ex- tent, in children and young persons, especially females from the ninth to the eighteenth year of age, and even upwards. Sometimes they occa- sion large tumours, particularly in the caecum and sigmoid flexure, but occasionally also in the transverse arch and other parts of the colon. When distension proceeds from retained fecal matters, in addition to the local signs observed on careful examination and percussion of the abdo- men in the course of this bowel, numerous symp- tomatic ailments are complained of. These vary but little from those described above (§ 4.), and in the article treating of accumulations in the 449 450 Cmcwui (§ 11.). The countenance and skin are o-enerally foul, unhealthy, and devoid of anima- tion ; the perspiration is thick, clammy, foetid, and oleaginous ; the breath very offensive ; the tongue loaded or furred; the lips and gums are pale; muscular energy is much diminished; the appetite imperfect or capricious; digestion diffi- cult ; headach or vertigo is often present; the abdomen is tumid, doughy, and inelastic; the urine is loaded; the bowels are either constipated or irregular, or, if daily evacuations take place, the motions are slimy, very dark, or otherwise dis- coloured, scanty, and offensive; and the pulse soft, weak, often slow, but afterwards accelerated. In many cases, pains in the loins, abdomen, and limbs are complained of, with mental inactivity, general lassitude, oedema of the lower extremities, flabby inelastic state of the soft solids, leipo- thymia, or fainting, upon quickly assuming the erect posture, and occasional fits of sinking, espe- cially in females. 6. Although torpor of the colon is most fre- j quently followed by faecal accumulations and distension, yet these are neither constant nor ne- cessary results of this state, at least to any very manifest extent; for sordes and faecal collections may be very injurious to the mucous surface, without proving so from their bulk or mechanical effects only. Indeed they are often noxious from their acrimony, without occasioning remarkable distension, or any degree of obstruction, par- ticularly when the vital energies are depressed. Their presence, therefore, should be inferred rather from various remote symptoms than from those which are referable to the colon itself. But whenever disorder of remote organs leads us to suspect torpor of this bowel, the practitioner should make an accurate examination of all the abdominal regions, commencing with that of the caecum, following the course of the colon be- tween the ilium and right ribs, below the epi- gastrium and under both hypochondria, to the left side and iliac fossa, and to the hypogastrium. If a sensation of doughy fulness be felt by the examiner, in any part of its course, the internal surface of the bowel is probably lined with sordes and accumulated secretions which its vital energy has not been sufficient to throw off. If hardness be felt, with more or less tumour, fascal col- lections are most likely formed. But the evi- dence furnished by this examination should not satisfy us: we should inquire after the symptoms stated above, particularly the foul or clammy tongue, fcetor of the breath, unnatural state of the countenance, and cutaneous surface, and the of- fensive and morbid evacuations usually attendant upon this ailment. A belief is too generally entertained, that fiscal matters and sordes will not accumulate in the colon, unless the patient has been constipated. But they may collect in its cells, the more central part of the canal allow- ing daily evacuations ; and they may even remain there for a considerable period, producing much irritation, and even a relaxed state of the bowels; thereby misleading the judgment of the prac- titioner as to the pathological state constituting the disorder. How, therefore, is he to form an accurate opinion? By a careful examination of the abdomen in the course of the colon, of the urine, of the stools, and of all the organic and animal functions, and by ascertaining the presence or absence of the symptoms enumerated above (§ 4, 5.). In many cases, when the morbid collections COLON—Torpor of. have become acrimonious, an irritative diarrhtea continues for some time, or recurs at intervals, before the morbid matters are fully thrown off, owing to spasmodic constrictions of parts of the bowel. On these occasions, the stools are watery or fluid, and are apparently composed of discoloured faeces, broken down and mixed in a liquid ; at other times they are dark green, muddy, putrid, &lc. ; very frequently they are slimy, con- taining lumps of hardened faeces, very offensive, and of a dark green or brownish black hue ; and their evacuation is preceded by griping, tenesmus, or a scalding sensation of the anus. 7. D. Imperfect action of the colon is evidently dependent chiefly upon deficient vital energy of the frame, owing either to original conformation, or to various causes of exhaustion, acting chiefly on the digestive canal and associated viscera, with more or less torpor of the biliary functions. When allowed to continue, it perpetuates and augments the morbid condition in which itself originated: drawing other organs within the sphere of disease, particularly those of mental manifestation, and of generative function, in the female. In young persons it often occasions, or is complicated with, curvatures of the spine, chorea, chlorosis, retention or suppression of the menses, nervous tremors and convulsions, &c., and when the distension of the colon is great, dyspnoea or shortness of breathing, palpitations of the heart, &c.; these affections appearing oftener, perhaps, along with it, as associated effects of depressed vital power, than as consequences of this particu- lar lesion of function. 8. E. The more remote causes of torpor and distension of the colon are, confinement in close and crowded apartments during the greater part of the day, and sleeping in chambers similarly circumstanced; constrained and sedentary posi- tions, in which the abdominal muscles remain nearly inactive; premature and excessive cul- tivation of the mental, to the neglect of the phy- sical powers,—the discipline of modern board- ing schools; the inappropriate combination and use of purgative medicines; indolent and luxu- rious habits; occupations which prevent bodily activity ; and particularly those performed by the assistance of machinery, and in hot foul air, stagnant in crowded manufactories ; pre-existing debility of the stomach and digestive canal, or of the frame generally ; paraplegia, or hemiplegia ; disease of the spinal column, its membranes, or chord ; neglect of the first intimation to alvine evacuations; venereal excesses; the disgusting habit of expelling the flatus from the bowels; and whatever weakens, either directly or indirectly, the vital manifestations of the alimentary canal, or disorders the general health. 9. Local and constitutional effects produced by torpor of the colon.—A. Owing to the course and connections of the colon, to the remote causes above enumerated, and to the depression of di- gestive and vital energy they occasion, the matters discharged into this bowel from the small intes- tines, and the secretions from its own internal sur- face, are liable to be retained for a long time. Fcecal accumulations and obstructions have been now shown necessarily to follow such retention. It may be next requisite to point out certain of the most important and frequent consequences of these states:—a. One of the most immediate is the retention of the mucous secretion within the follicular glands, as well as in the ducts leading from them ; causing distension, and subsequently inflammation and ulceration of them.—6. The retention of fecal matter in the colon is often followed by absorption of much that otherwise would have been excrementitious, both into the general current of the circulation, and, at first, at least, into the blood which flows into the portal veins, where it often excites and irritates the liver, and either is partially removed by this viscus, giving rise to increased or vitiated biliary secre- tion, or contaminates the whole circuiting and secreted fluids.—c. The bile also may, particu- larly in warm countries, and in persons in whom it is habitually secreted in excessive quantity, be rapidly conveyed along the small intestines with the chyme, and yet be retained too long in the ccecum and colon, whence it may be absorbed, with a portion of excrementitious matters, into the circulation, and give a lurid or unhealthy aspect to the countenance, and occasion various constitutional ailments, characterised chiefly by lassitude, debility, irregular action of the bowels, loaded urine, and a foul tongue.—d. Faecal ac- cumulations, when allowed to remain too long in the colon, and thereby to give rise to gaseous and noxious formations, not only impede many of its functions, but also favour changes in the vascular action and structure of its coats, particularly of its mucous, sub-mucous, and muscular tunics,—the first and second becoming irritated, inflamed, or even ulcerated; the third over distended, and thereby deprived of its power of salutary reaction. —e. Among the most common consequences, also, of torpor and fecal infarction of the colon, are haemorrhage from it and the rectum, and hte- morrhoidal tumours, arising immediately from the foregoing changes, and from interrupted circula- tion through the luemorrhoidal veins. 10. B. The effects of over-distension of the colon upon the other abdominal viscera, owing to the extensive connections subsisting between them and this bowel, may be readily inferred.—a. The distended caecum and sigmoid flexure of the colon press injuriously upon the femoral nerves and blood-vessels, the ureters, and the internal iliac veins; producing numbness, cramps, pains, and, owing to the impeded return of blood, more or less oedema, of the lower ex- tremities. The ascending and descending por- tions of the colon press upon the kidneys and adjoining vessels, occasioning disorder of the urinary secretion, with a sense of weight, or dull aching pain in the loins. Distension of the right and left flexures, and transverse arch, deranges the functions of the biliary organs, the duodenum, stomach, and spleen.—b. If the colon be dis- tended to the utmost, not only are all those consecutive disorders much increased, but the descent of the diaphragm is also much impeded, and the actions of the heart and lungs materially affected; occasioning palpitations, intermissions, and irregularity of the pulse, dyspnoea, and a short and rapid respiration. Owing to this effect upon the circulating and respiratory organs, the return of the blood from the head is retarded ; various nervous ailments, and headach, are occa- sioned ; and determination of blood to, and con- gestions and effusions of serum on the brain and its membranes, supervene as the more remote effects.—c. Faecal or flatulent accumulations in the colon affect, in a very evident manner, the functions of the small intestines and stomach, or increase disorder in these viscera, when it pre- COLON—Treatment. 451 viously exists,—a circumstance of frequent oc- currence, the function of digestion being equally impeded with that of defecation, and owing to the same primary pathological state, namely, imperfect manifestation of vital power through- out the organic nervous system. Hence the in- digestion, the acrid and flatulent eructations, and the imperfect chylifaction and nutrition, so fre- quently associated with torpid function of the large bowels.—d. In children and young per- sons, the mucous sordes, morbid secretions, and excrementitious matters, that collect as a conse- quence of this state, become not only a nidus for worms—remarkably favouring their generation ; but also a cause of irritation to the mucous sur- face, to the absorbing vessels, and to the mesen- teric glands, owing to their partial absorption, either alone, or with whatever chyle may be formed. That diseases of the intestinal mucous sur- face, and that obstruction and enlargement of these glands, with the consequent marasmus, &c., often arise from the morbid impression and irritation caused by these retained excretions, an extensive experience in the diseases of children has fully convinced me ; and that dysentery and diarrhoea, among this class of patients, as well as in adults, frequently proceed from this cause, more espe- cially in warm and unhealthy climates, will be acknowledged by every experienced practitioner. —e. Even many of the diseases that affect the skin, and chronic ulcers of the lower extremities, arise from the absorption from the large bowels of excrementitious matters, that irritate and in- flame, in the course of their elimination from the blood by the cutaneous function, the delicate vascular tissue subjacent to the cuticle. This is particularly the case in warm countries and sea- sons, in which the quantity of these matters always passing out of the circulation by the skin is much greater than is usually supposed. What- ever opinion may be formed as to the origin of such affections, there can be no doubt that the treatment based upon this doctrine is the most successful in removing them.—/. Among other consequences of faecal accumulations in the colon, elongations and displacements of this bowel may be ranked ; and when these changes take place, they increase the disorder which occasioned them. It has often been remarked, particularly by Es- quirol, Hinze, and others, that displacement of the colon is one of the most common morbid ap- pearances found in the bodies of hypochondriacal and melancholic persons. Torpor or atony of this viscus favouring faecal accumulations in it, is an important characteristic of these affections, and is manifestly connected with the causation of dis- placement of the large bowel. (See art. Hypo- chondriasis, &c.) 11. ii. Treatment.—The indications of cure in cases of torpid function of the colon, consist— 1st, of evacuating whatever faecal or acrimonious matters may have collected in it; and, 2nd, of restoring the energy of the digestive organs, and directing such regimen as may prevent a return of this disorder.—A. Many practitioners, deceived by the reports of the patient, or misled by the appearances of the stools procured by the first purgatives prescribed, stop far short of the point to which these medicines should be carried. It is not sufficient to order two or three doses of purgatives, or even of active cathartics ; but they ought to be repeated, or continued so as to secure their full effect, and be combined with COLON—Unnatural Position of. 452 such other medicines as will promote their opera- tion without weakening the parts which they stimulate, and will prevent the patient from being debilitated by them. In all affections of the colon, purgatives that procure full, bulky, and not frequent or watery evacuations, should be selected. The preparations of aloes (F. 181. 454.), those of senna combined with gentian (F. 266. 430.), castor oil, rhubarb and mag- nesia, precipitated sulphur (F. 45. 82. 96.), the compound jalap powder, &c. (F. 635, 636. 652.), operate in this manner ; and, particularly when we wish to promote the secretions from the in- testinal surface, may be exhibited after a dose of calomel or blue pill taken at bed-time ; or the compound extract of colocynth, or the aloes and myrrh pill, or jalap, may be combined with one of these mercurial preparations, and the extract of hyoscyamus, (seo F. 462. 471. 881.). When it is necessary to continue the exhibition of purgatives, they should be either alternated with tonics, or combined with vegetable bitters, which will both promote their action, and increase the strength of the patient, (see F. 562. 572.). When the motions are morbid, great advantage will be derived from resorting to the use of clys- inata, as recommended in the article Colic {§ 57. 66. 77.). If faecal collections to a great extent have formed, they are indispensable remedies; and if symptoms of obstruction, or of irritation, or chronic inflammation, are manifest, they should be assisted, by the external means there advised (§ 66.83). Under every circumstance, the exhibition of purgatives by the mouth, and of enemata, should be persisted in until the stools as. suine a natural appearance. (See also the Treat, merit of diseases of the cm and of Constipation.) 12. In cases where retained matters in the colon have occasioned irritation, such clysters as will promote the full evacuation of its contents, and at the same time allay irritation, ought to be resorted to from time to time. These will relax irregular constrictions of the bowel, promote the operation of purgatives given by the mouth, dis- solve hardened faeces, and loosen the adhesion of tenacious secretions lodged in its cells. In cases of this description, the soap injection, with, or without, the addition of castor or olive oil, the compound decoction of barley with common salt, Or the potassio-tartrate of soda; the infusion of linseed, with the biborate, or the carbonate of soda and assafostida ; the decoction of marsh-mallows, with the infusion of camomile-flowers and linseed oil ; and the turpentines, triturated with white of egg or mucilage ; will have a most beneficial ef- fect, particularly when assisted by appropriate laxatives taken by the mouth * When the irrita- tion of the bowel appears to be accompanied by spasmodic constriction, the aperients should be combined with either camphor, ammonia, ipeca- cuanha, hyoscyamus, the compound galbanum pill, &c. (F. 463. 890.) according to existing cir- cumstances. In cases of this kind, much debility is often present, and the functions of the stomach require the aid of light nutritious food and gentle tonics; the purgatives being exhibited either at bed-time or early in the morning, so as not to dis- order the functions of the stomach. Such ecco- protic or alterative laxatives as are slow in their operation (F. 503. 892.) should be taken at night, and purgatives or cathartics that are quick in their action early in the morning, so that they may not interfere either with necessary food or with re- quisite avocations. 13. When the fecal accumulations cannot bo removed by the above means, others of a more powerful nature, as the elaterium or croton oil, assisted by colocynth or terebinthinate injections; and the purgatives advised in the more obstinate cases of colic and constipation, assisted by shocks of electricity and galvanism passed through the ab- domen ; should be resorted to. When the bowels are acted upon with great difficulty, the stools being very black and offensive, we may generally infer that not only is the colon torpid, but the fol- licles are loaded or obstructed, and their secre- tion morbid. In these cases, galvanism, as shown in an instructive case by Mr. Clarkson, prom- ises to be of much service. In several instances, when the pulse has been weak, and the skin cool, I have added the extract of nux vomica to the purgative, with much advantage, and combined a portion of this active substance with the liniment (F. 306.) which has been rubbed on the abdomen. 14. B. In order to prevent the re-accumulation of morbid matters in the colon, and give tone to the digestive organs generally, the patient should daily attend to the first intimations of evacuation, and promote the functions of digestion and defe- cation, by resorting, whenever they flag, to aperi- ents or laxatives, combined with tonics. Blue pill, with the aloes or myrrh pill, or F. 470., may be occasionally taken at night, and the tonic and aperient medicine (F. 266.) the following morn- ing. The diet and regimen should be carefully regulated, and exercise be taken in the open air, either on foot or horseback. After health has been in a great measure restored, chalybeate mineral waters, and the artificial waters of Ems and Pyrmont, will be productive of much benefit; but frequently it will be more advantageous to commence with the Harrogate or Leamington waters, or the artificial waters of Seidschutz, Eger, or Carlsbad, and have recourse subsequently to the chalybeates of Cheltenham or Tunbridge* In many cases, the warm or tepid salt water douche over the abdomen, sea-bathing, frictions of the surface of the body, and of the belly espe- cially, night and morning, with either a hard towel or brush, will prove of much service. 15. II. Unnatural Positions of the Colon, &c.—This viscus is not infrequently found mis- placed, and forming singular flexures, in those who have suffered from constipation, fecal re- tention, dysentery, hypocondriasis, or melancho- lia. But there are no constant symptoms by which such changes can be inferred with much certainty during the life of the patient. M. Es- quirol found out of 168 dissections of melancho- lic patients, the colon displaced in 33. This change had previously been remarked by Mor- gagni (De Sed. et Caus. Morb. epist. iv. art. 16. et seq), Hallf.r (Elem. Physiol. 1. xxiv. sec. 13. et seq.), Soemmering {De Corp. Hum. Fabrica, t. iv. p. 313.), and Wells, but unconnected with mental disorder. In many cases, the bowel is '* The successful use of enemata in these cases de- pends much upon passing the injection high up in the colon, by means of a long tube, as recommended by Dr O’Beirne ; and the quantity of fluid administered should be several quarts. Common enemas given in the ordinary way will seldom succeed in affording relief. The fluid must reach the fecal accumulations, so as to act upon them mechanically, and this can only be done by pro- ceeding ia the manner above mentioned.] [* The sulpher waters of Virginia have proved very useful in these cases.] COMA AND LETHARGY. ot only displaced, but is also elongated, without Deing divided, as in its natural state, into cells by partial partitions, and the tonic action of its longi- tudinal bands. These changes seem to be fa- voured by relaxation of the mesocolon, and by complete atony of those bands. An elongated and displaced state of the colon is common in cases of old hernia; and in these is often con- nected with a stretched appearance of the mesen- tery, but without any organic change of the coats of the bowel: but sometimes the unuatural flexure or duplicature is adherent at its opposite sides, forming a large loop ; particularly when it has been consecutive of acute or inflammatory dysentery. Displacement may take place in any part of the bowel, but it is most common in the transverse arch and sigmoid flexure ; the former part hanging down towards the pubis, generally in an unadhering, but occasionally in an adher- ing, loop ; and the latter part crossing over to the right side of the abdomen, or passing behind the pubis. Duplicatures of the colon may also form at the right or left parts of its arch ; the op- posite peritoneal surfaces being more frequently, in such cases, adherent to a considerable extent by coagulable lymph. Several plates are given by Mr. Annesley, illustrative of this change ; which is not infrequently observed in fatal cases of chronic dysentery, particularly in warm cli- mates. That these unnatural flexures are also often caused by faecal collections, and obstructions to the faecal discharges situated either in the rec- tum or in the sigmoid flexure of the colon, appears very probable; but they may also arise from a naturally elongated formation of the bowel. That, when once produced, they favour such collections, with their consequences, particularly severe dys- peptic and hypochondriacal ailments, dysentery se- vere colic, or even ileus, and great distension or in- flammation of the colon or small intestines, cannot be doubted ; but that they will occasion insanity or melancholy, as Esquirol and Hinze suppose, seems not to be made out. Dr. Y elloly states, that Mr. Lawrence and Mr. Dalrymple, who have examined many bodies of insane persons, have very seldom observed in them any deviation from the natural course of the colon. 16. As we have no certain or even probable means of ascertaining the existence of these changes during life, it is unnecessary to offer any remarks on their treatment. But this is a matter of but little importance, as the disorders which they produce are in ail respects the same as those already noticed ; and even if their nature were recognised, they can be remedied or alleviated only by the means described above, particularly by laxative and solvent enemata; and by what- ever will, whether taken by the mouth, or injected per anum, preserve a fluid state of the stools, or reduce them to a softened condition, and promote the healthy secretions and regular functions of the large bowels, and of the digestive organs in gen- eral. (See F. 82. 98. 144.)—See art. Digestive Canal, for the organic lesions of the colon ; and arts. Diarrhoea, Dysentery, and Intestines, for its other diseases.) Bibliog. and Refer.—Severinus, De Recond. Absc. Nat. 1. iv. cap. 35 (Greatly distended, <$-c.)—Adolphi, De Intestino Colo, mult. Morbor. Nido, &c. Lipsue, 1718.— Vater, De Situ Natur. et. Prseternaturali Intest. Coli. Witeb. 1737.—Fischer, De Morbis Intest. Coli, &c. Erf. 1728.—Hamberger, Observat. Clinic. Jena?, 1754, p. 10. {Great distension.)—Stoerck, Annus Med. t. i. p. 126., et t. ii. p. 268. {Flutulent and f cecal distension, and laceration of the longitudinal bands.)—Leusingk, De Morbis a Situ lntestin. Crassor. pendentibus. Goet. 1756.—Van Roye-n De Intest. Crasis, multorum Morb. Causa et Sede. Lugd Bat. 1752, 8vo.— White, Cases in Surgery, p. 13.—Hamil- ton, On the Utility of Purgative Medicines, 8th ed. 8vo. 1826.—Abemethy, On the Constitutional Origin of Local Diseases 8vo.—Roth, Pathoiog. latest. Coli. Erlang. 1802.— Wells, inTransac. of Society for promoting Med. and Chirurg. Knowledge, vol. iii. p. 158.—Esquirol in Diction, des Sciences M6d. t. xxxii. p. 172.; et Journ. Gbner. de Med. Fran, et Etrang. Mai et Juin, 1818.— Geoghegan, Transac. of the College of Physicians of Dub- lin, vol i. p. 104. (Great distension of the colon.)—Stoker, in [bill. vol. ii. p. 6. (Rupture from, distension, without ulceration.)—Hinze, Archives Cener. de Med. t. iii. p. 125. (Displacement of colon)—Yelloly, in Edin. Med. and Surg. Journ. vol. xvi. p. 476. (Displacement of colon.)—Clarkson, in Ibid. p. 475.—Annesley, Researches on the diseases of India, &c. vol. ii. p, 50. et seq. COMA.—Syn. and Deriv. Kd>ya, Profound sleep (from Ku, I lie down). Carus, Sau- vages, Good. Cataphora, J. Frank. Lethar- gie, Assoupissement, Fr. die Schlafsucht, Schlaffieher, Ger. Sopore, Somnolenza, Ital. Classif. 2. Class, Nervous Diseases; and 1. Order of this Class {Cullen). 4. Class, 4. Order (Good.). IV. Class, III. Order {Author, in Preface). 1. Defin. Preternatural sleep, with physical torpitude, and suppression of the mental poivers. 2. I. Varieties and Symptoms.—There are various modifications of coma, each of which have received different appellations, as Lethargus, Ca- taphora, Agrypnia, Carus, &c.; these names being also used generically by some authors, but more frequently specifically, as I shall apply them on this occasion. They are all most commonly symptomatic of pre-existing disease ; but they are also occasionally primary affections. I shall, therefore, after describing very succinctly each variety of coma, and its more constant symptoms, notice it first as a primary affection, and next as an important phenomenon in other acute diseases, particularly of their severe forms or advanced stages; afterwards the different pathological states causing this affection, the signs which dis- tinguish them, and, lastly, the means best adapted to relieve them, will be briefly stated. 3. i. Coma Vigil—Agrypnia, Ktopa iypvirvij>&ss (Hippocrates), Typhomania, Sopor cum Agryp- nia—is characterised by a constant disposition to sleep, without falling into quiet, sound, or natural sleep ; by low muttering delirium, or unconnected talk ; unnatural action of the hands and fingers, sometimes also of the feet; pale sunk counten- ance ; a natural or but slightly increased temper- ature of the head ; by the patient opening the eyes and staring about upon the slightest disturb- ance, or starting up as if frightened by strange sights, and again attempting to lie down; and sometimes by difficulty of speech and of swallow- ings liquids. 4. ii. Lethargy—Lethargus* (from AijOn, Lethe, et aoyos, celer), Veternus, Lat.—is charac- terised by slight but constant somnoloncy, or mental and corporeal torpor, evidently depending upon a morbid condition of the brain; when addressed, the patient answers forgetfully, and afterwards sinks into the same state as before. 453 * I have, conformably with the received acceptation of lethargy in this country, made it the slightest form of soporose coma; although the ancients, our countryman Willis, who has written ably on this affection, the greater number of writers of the sixteenth and seven- teenth centuries, and many modern German authors, have defined it nearly as follows:—“ Profound sopor, or preternatural sleep, with fever and deliriumthus ap plying the term to the more profound state of febrile coma 454 This is a slighter grade of the following varieties, and may pass into them. 5. iii- Coma Somnolentum—Cataphora is cha- racterised- by sopor or profound sleep, without the power of wakening spontaneously; the pa- tient, when roused, slowly opening the eyelids, and answering either rationally, forgetfully, or in- coherently, but immediately afterwards falling into the same state of profound sopor ; and fre- quently by relaxation of the muscles of the lower jaw, it thereby differing from apoplexy and carus. 6. iv. Coma profundum—Carus, KApos—is cha- racterised by its more or less sudden invasion ; by the profound sopor, the eyes being shut as in a deep sleep, and the patient being generally de- prived of motion and sensation. Sometimes, however, upon being called to loudly, he opens his eyes, but immediately shuts them, without answering any question ; and occasionally when pinched he draws away the part, indicating re- maining sensibility ; the breathing is undisturbed or irregular, sometimes laboured, but without stertor: there is seldom much febrile heat, and the evacuations are passed without consciousness. 6. A. Review of the chief symptoms.—a. The pulse varies greatly in each of the above states of coma. It is generally slow, full, and soft; but it is also often small and quick in coma vigil, or in any of the varieties, when accompanying the last stages of fever; and small, hard, and some- times irregular, in the coma attendant upon in- flammatory action of the brain or its membranes. It is also frequently unequal, intermittent, and generally slow, but sometimes also quick, in the coma produced by injury of the brain, and by haemorrhage or effusion of fluid within it.—b. The respiration is often natural, as in coma vigil; sometimes accompanied by sighs, or laboured, as in coma profundum ; frequently slow, and very seldom stertorous, unless in the coma of apo- plexy.—c. The pupils of the eyes are generally more or less dilated, and sluggish in their mo- tions, or altogether insensible to light; but they are sometimes, in the most unfavourable cases, much contracted, or one contracted and the other dilated.—d. The countenance is usually tumid, and without expression; sometimes pale or bloated, or red or injected ; the eyes are pro- minent or suffused; and the head somewhat warmer than natural, or of the healthy tempera- ture, the beat of the carotids being full or strong: in the coma consequent upon fever, and in coma vigil, the features are commonly pale, sunk, and cool; the action of the carotids being weak and soft in some cases, and hard and oppressed in others.—e. The mental powers are commonly suppressed ; but upon being momentarily excited, they sometimes appear more or less disordered, particularly in any of the states of coma super- vening upon fever, or inflammation of the brain or its membranes; low delirium and febrile heat then being also present.—f. The surface of the body is often natural, sometimes cold or clammy ; but when the affection is caused by fever or in- flammation, the temperature may be somewhat elevated, and the skin dry.—g. The extremities are frequently natural at first, but they are also often cold or clammy, or become so.—h. The posi- tion is commonly supine, without attempts at motion, in profound coma; and, in the worst cases, the patient slips down in bed.—i. The tongue is natural, or merely much loaded, in some instances ; but in coma symptomatic of in- COMA AND LETHARGY—Somnolentum—Idiopathic. flamniation or fever, it is usually furred, dry, and brown, hard, and constricted.—k. The alvine ex- cretions are either retained, or passed without consciousness. 8. B. Duration and termination.—a. Any one of the forms of coma may be sudden in its attack, and terminate speedily in death ; or it may come on gradually, and be of short duration, sense and voluntary motion as slowly returning. The seizure may be repeated frequently, or it may be periodic, particularly when attendant upon epi- lepsy, or remittent fever of a bad form. When its accession is slow, it often commences with drowsiness or headach.—b. Its duration is very various ; the lethargic and slighter varieties being occasionally of long continuance—sometimes last- ing many weeks, and spontaneously passing off! The more profound states of coma frequently end fatally in a few hours, and seldom continue longer than a few days. I however attended a case of profound coma with Mr. Bushell, that continued several weeks, and yet terminated in recovery.—c. It may terminate in either recover)' or death, or in some other disease with which it is more or less closely related,—as apoplexy, para- lysis, insanity, or malancholia, epilepsy, and epi- leptic or other forms of convulsions, with which it occasionally alternates; and in inflammation of the brain or its membranes. 9. C. Diagnostic remarks.—The states or grades of disease described above may pass one into the other, or into some other malady, whether they appear primarily or consecutively. They are often very nearly allied to, or rather are less degrees of apoplexy ; and apparently consist of a somewhat similar condition of the organic ner- vous power and vascular action within the brain, to that which obtains in a great proportion of the attacks of that disease (§ 62. et seq.), particularly those which do not immediately depend upon haemorrhage.—a. The close resemblance of many cases of coma vigil to ecstacy, and of the other states of coma to catalepsy, not only as to the grouping of the sensible phenomena which res- pectively constitute them, but also as to their pre- sumed proximate causes, indicate that catalepsy and cataleptic ecstacy are merely unusual modi- fications of the state of cerebral disease now under consideration.—b. The absence of stertor consti- tutes the chief difference between the most pro- found state of coma, cams, and apoplexy.—c. The fulness and strength of the pulse, particularly in the carotids, and the natural or strong state of the respiration, are sufficient to distinguish coma from syncope, in which latter the action of the heart is greatly diminished primarily, the functions of the brain failing consecutively —d. Coma dif- fers from asphyxy in the circumstance of the res- piratory functions being first suppressed, and sub- sequently the action of the heart in the latter; the consequent coma arising from congestion of venous blood in the brain, produced by the abolished respiration, and obstructed circulation through the lungs and cavities of the heart. 10. II. Of Primary or Idiopathic Coma.— Either of the varieties described above may occur as a primary affection arising from states of the organic nervous power and circulation within the brain, which will be noticed in the sequel (§ 13.), and which are commonly produced by the fol- lowing agents:—Causes.—The continued or in- tense action of cold upon the nervous system and circulation; the influence of narcotics, par- ticularly in some constitutions; indulgence in spirituous or intoxicating liquors, either carried too far or continued too long; venereal excesses ; insolation; fatigue or prolonged watching; the influence of particular odours, condiments, or kinds of food in some temperaments ; inanition or exhaustion of vital power, by whatever cause, especially in the aged of the male sex ; immoder- ate evacuations or discharges; mephitic or car- bonaceous fumes or gases; sadness, anxiety, fright, terror, anger, and other violent mental affections; the inappropriate use of either warm or cold baths; the exhaustion of vital or nervous power by excessive or long-continued pain ; con- cussions and injuries of the brain ; erratic, atonic, or retrocedent gout; pregnancy or child-bearing; and suppression of the menses or lochia; are the causes which produce, in a primary form, any of the states of coma described above. 11. III. Symptomatic Coma.—Either of the varieties of coma may supervene in the advanced course, more rarely on the invasion, or inter- mittent, remittent, or continued fevers, particu- larly typhus; of inflammations of the brain and its membranes ; and of insanity and melancholia. Simple determinations of blood to, or congestion of, the encephalon, will frequently be sufficient to induce the slighter states of coma; whilst its more severe or profound conditions are common con- sequences of effusions of blood or serum, and of numerous organic changes occurring within the head. (See Brain—Organic Lesions of its Mem- branes and Substance, § 21—84.). It is one of the most important symptoms that appear in the course of erysipelas of the face or head, and of exanthematous fevers ; it may likewise supervene, particularly coma vigil, in the advanced stages of several acute maladies evincing exhaustion of the vital energy of the brain and nervous system, and in those in which the circulating fluid and secretions become vitiated or contaminated. The coma, which is usually consecutive of epileptic or convulsive attacks, consists of the slighter varieties denominated lethargic and somnolent, forming a part or consequence of these diseases. Coma is sometimes, also, a symptom of severe hysteria, particularly in plethoric persons with interrupted catamenial discharge; and, in rare instances, of worms, but by no means so frequently as stated by some writers. The occasional occurrence of any of the varieties of coma from suppression or retention of urine, from metastasis of gout and rheumatism, from the suppression of accustomed discharges, and more rarely from the retrocession of eruptions, and the drying up of old ulcers, should not be overlooked, particularly as such morbid relations require a peculiar and appropri- ate treatment. 12. IV. The Prognosis in most cases of coma is unfavourable; for, although many will recover —even the great majority—the slighter cases will often present sudden changes. A much more favourable opinion may be entertained of coma when it is produced by narcotics and spirituous liquors, than when it comes on in the course of febrile or malignant diseases, particularly after the absorption of morbid matters into the blood. The occurrence of epistaxis, of swellings of the parotids; the accession of the catamenia, or the hiemorrhoids ; a faeculent diarrhoea; copious gen- eral perspiration ; abundant discharge of urine depositing a sediment; erysipelas, eruptions, boils, gout, or rheumatism, appearing in external parts, COMA AND LETHARGY—Prognosis—Pathology. particularly the lower extremities; and the re- turn of sound natural sleep during a state of coma vigil, or typhomania, are very favourable —indeed, critical symptoms. The persistence of the affection; scanty secretion or retention of urine ; subsultus ; spastic contractions of one or more limbs; loss of speech, and total insensibil- ity; distortion of the eyes; vomiting or retching; a previous breaking up of the constitution ; pre- existing cachexy, and old age ; bleeding from the ear, when it has been caused by external injury, as in concussion ; constant supine posture, and slipping low down in the bed ; coldness of the head, with sunk countenance, and cold, clammy surface ; loss of the faculty of deglutition, or re- turn of matters put in the mouth ; are very un favourable signs. 13. V. Pathology.—A. Primary and symp- tomatic coma may be resolved into the following pathological states, either of which may exist singly, or in conjunction with one another:—1st, Exhaustion of the organic nervous influence sup- plying the brain, or torpor or suppression of it, inducing a state which may be called paralytic— a paralysis of all the cerebral functions: this condition is produced chiefly by directly or indi- rectly sedative causes, and by whatever depresses or exhausts the vital energy generally, or the nervous power in particular: it may be attended by anannia of the brain ; and then the coma will be preceded by, or accompanied with, convul- sions, or alternate with them ; but it is more frequently productive of some one of the states about to be noticed, especially congestion, and occasionally effusion within the head: it may go on to dissolution, or it may be followed by reac- tion and active congestion or acute inflamma- tion ; the comatose states sometimes observed at the invasion of dangerous forms of fever, and of certatn.apoplectic seizures, and the coma of the early stage of concussion of the brain, being of this description.—2d, Congestion of the capil- laries, veins, or sinuses of the brain, is, perhaps, the most common morbid condition that obtains in coma, as respects the vascular system: but this state can scarcely arise, unless the organic nervous influence with which these vessels are supplied has been exhausted or depressed, excepting in those cases where the congestion proceeds from obstructed return of blood by the sinuses, or by the large veins coming from the head: in many cases, therefore, the existence of this state pre- supposes that first described, at least to some ex- tent ; and whether thus originating, or proceeding from impeded or obstructed return of blood, will equally occasion pressure of the organic nervous and cerebral tissues, and suppression of their functions ; congestion of the blood-vessels within the head may, moreover, be associated with some other morbid states, as with contamination of the circulating fluid ; as in the coma that occurs in the advanced stage of typhus, and when morbid secre- tions are absorbed into the blood.—3d, Active determination of blood to the head will seldom occasion more than lethargy or coma vigil,— states which are frequently produced in this way in the advanced stages of various acute diseases, and sometimes by the use of anodynes, which, in some constitutions, disorder the nervous functions and excite the cerebral circulation.—4th, Inflammation of the brain or membranes, owing to the tume- faction consequent on it, &c., will often be accom- panied with coma; and still more frequently 455 456 COMA AND LETHARGY—Pathology of. terminate in it,—as shown in the article on that disease : and, as we have seen that coma will thus proceed from very different or even opposite states of organic nervous power, and of vascular action, it becomes a matter of the utmost practi- cal importance to distinguish them with accuracy: but not only may those pathological conditions exist in different cases, they may obtain at differ- ent stages of the same case: thus the coma of concussion, in which the first of those conditions exists, may successively pass into congestion and inflammatory action, forming the three stages which Mr. Abernethy has very accurately pointed out in concussion of the brain; coma, accompanied with very different symptoms, and modified in degree, being present throughout.— 5th, The circulating fluid itself may be more or less changed ; it either being of a darker colour, and in a less decarbonised state, than in health ; or having entirely lost the power of coagulating, or presenting a coagulum of a weak or dissolved texture. (See Blood, § 94.) In addition to this state of the circulating fluid, congestion of the cerebral vessels and increased action of the heart may exist, as in the advanced stages of malignant, exanthematous, and febrile diseases ; these associated lesions may be also preceded by, or coexistent with, depressed vital or organic nervous energy of the encephalon.—6th, Effusion of blood or serous fluid within the brain will give rise to profound coma, generally as a conse- quence of either the first, second, third, or fourth preceding states, occurring either primarily, or in the advanced progress of febrile diseases. 14. B. It must be evident that a successful treatment of coma, under the numerous circum- stances and diversified forms in which it presents itself in practice, must be based upon a recogni- tion of the pathological states that occasion it. But bow are these states to be ascertained ? The difficulty even of an approximation to this know- ledge is doubtless great; but the practical results, to which the information leads, are of the utmost importance, as respects both the issue, and the reputation of the physician. I shall therefore offer a few remarks, with the view of facilitating the investigation of this subject, and placing our intentions of cure upon a rational basis.—a. In the first of the above pathological states, the pulse is weak, soft, unequal, or intermitting; the pulsation of the carotids is smaller, weaker, and softer than natural; the breathing is soft, slow, or laboured, but without stertor ; the limbs and muscles are relaxed, and deprived of sensibility ; the surface is pale, cool, moist or clammy, par- ticularly the extremities; the head is cool, or at least not above, frequently below, the natural temperature; the countenance is pale or sunk; the eyes open, without suffusion, and the pupils dilated ; the tongue is soft, flabby, and broad, unless in the last stages of fever, when it is covered by a brown or dark fur ; and the skin is dry or harsh. The feebleness and intermissions of the pulse, the depression of animal heat, and the loss of sensibility and voluntary motion, are generally in proportion to the exhaustion of vital power in the brain, and therefore important guides in the treatment of coma.—b. The second pathological condition, or that of congestion, will vary in differ- ent cases, or even in different stages of the same case, from the depressed state of vascular action and animal heat, described above, to that now to be noticed. The pulse is oppressed, or full, slow, irregular, occasionally nearly natural,—in the carotids somewhat fuller, stronger, or more labour- ing, than in health, or in other parts where it can be felt; the respiration is either natural, or slow, labourious or irregular ; the countenance is slightly tumid, bloated, or livid; the eyes are somewhat suffused and prominent, the pupils dilated and insensible ; the temperature of the head is occa- sionally natural, but more frequently slightly increased, and the face and scalp moist; the appearance of the tongue, as in the foregoing state, varies according as the coma is a primary or consecutive state of disease ; the evacuations are either retained or passed insensibly ; and sensi- bility, voluntary motion, and mental manifesta- tion, are abolished in proportion to the extent of depression of the organic nervous influence of the brain, and of vascular congestion. This state may supervene on the former with more or less rapidity, and terminate either in a return to healthy action, or in the third and fourth states referred to.—c. The third and fourth patho- logical states are different grades of vascular action, often arising out of the preceding: that consisting of active congestion or increased deter- mination of blood through the cerebral vessels may present nearly the same symptoms as those characterising congestion, but in a much slighter degree ; sensation and voluntary motion not being quite abolished ; the coma being in its slighter grades,—as lethargy and coma vigil, very rarely coma somnalentum. The pulse and respiration may not be materially affected, or it may be merely accelerated ; the temperature, even of the head, may also be natural, or but slightly increased, ihat of the extremeties being depressed ; the countenance may not be materially changed ; in some cases it may be even sunk or depressed ; but the carotids generally beat more fully and strongly than in health ; and the mental mani- festations are not merely more or less suppressed, but sometimes also disordered. The state of inflam- matory action, and its consequences, give, rise to phenomena of greater intensity than those now noticed, and which have been very fully described in another place. (See Brain, § 180.)—d. The fifth state which I have referred to, as obtain- ing in some cases of coma, seldom occurs alone, but is associated with one or two of the prece- ding, particularly the first, second, or even the third conditions. It is characterised chiefly by a. lurid, foul, dirty, or cachetic appearance of the surface ; a sunk or sallow countenance ; a fre- quent, soft, small, or broad and open pulse: by low delirium or typhomania; starting of the ten- dons, and picking of the bed-clothes ; preceding and associated febrile, exanthematous, or malig- nant diseases ; and by fcetor of the secretions and excretions. In some cases, when this state has come on rapidly, the tongue is merely broad, flabby, marked by the teeth at the edges, and covered by a creamy sordes; but in the last stage of acute diseases, it is deeply furred, or coated with a thick mucous sordes of a dark brown colour, often extending to the gums, and even to the lips.—e. The sixth and last state, that of effusion, may be consequent upon any of the preceding, and be caused by one or more of them. If the effusion be sanguineous, the attack is often sudden ; the respiration is generally ster- torous, irregular, &c.; and signs of local para- lysis may often be detected. (See Apoplexy.) If serum be effused, the coma is as profound as that caused by sanguineous effusion ; but slower in its accession, and less frequently attended by stertorous breathing, and local paralysis ; it is also more commonly preceded by signs of inflamma- tion, active determination, or congestion of blood, within the head. (See Dropsy of the Ence- phalon.) 15. VI. Treatment.—The foregoing patho- logical states will often insensibly lapse into one another, as in concussion and inflammation of the brain, giving rise to distinct stages of these dis- eases, and requiring a different treatment for each ; and, according as they may thus vary, so will their symptoms be modified; the principal pheno- mena connected with the cerebral functions, the pulse, the respiration, the animal temperature, the state of the head and carotids, &c., being the practitioner’s guides in the direction and com- bination of his means of cure. These means will now require no further notice than a bare enumeration, as they are more fully discussed in the articles on the diseases in which coma, in one or other of its forms, most commonly presents itself. 16. A. The first pathological state (§ 13,14. a.) requires stimulants and counter-irritants ; but these remedies must be exhibited with much caution; as an excessive or inappropriate use of them might produce, even in the slighter cases of cere- bral exhaustion, determination of blood to the head, and convert congestion into inflammation,— consequences which will frequently supervene, at least in a slight degree, as in concussion, not- withstanding the utmost care to avoid them. The preparations of ammonia, musk, and cam- phor, internally and externally employed ; ene- mata, containing the same medicines, or the infu- sion of valerian, castor, assafoetida, or the tere- binthinates ; wine and cordials, given frequently and in small quantity ; irritating or vesicating embrocations; cataplasms, sinapisms (Celsus, Paulus JEgineta), to the head, and plasters, as well as moxas, and the cautery (Zacutus Lusitanus, Rhodius, and Severinus) applied to various parts, or even to the head itself; blisters to the nape of the neck, behind the ears, or to the head (Bonet, Lanzani, Syden- ham) ; volatile substances held to the nostrils or applied to the temples ; errhines (Genius Aure- lianus, &c.) ; urtication Selti) ; galvanism and electricity (Hufeland, &c.) ; the affusion of warm, tepid, or, in some, cold water on the head; active and stimulating emetics (Riviere, Rigal, &c.) ; purgatives combined with stimulants, antispasmodics, and tonics ; cathartic clysters, conjoined with similar sub- stances ; the use of coffee and green tea, particu- larly when this state of disease has followed the ingestion of sedative or narcotic poisons, and after the stomach has been evacuated by emetics and the stomach pump, and washed out by the injection of warm water; are severally of use in this state of coma, and may be resorted to in various combinations, according to the circum- stances and severity of the case. All these mea- sures are, however, not equally applicable to every case where this pathological state may be presumed to exist; but the judgment and expe- rience of the practitioner can alone enable him to employ them in an appropriate manner; the shades of difference in particular cases requiring certain means, or peculiar combinations of them, COMA AND LETHARGY—Treatment of. scarcely admitting of description, at least within the limits to which I am necessarily confined. 17. B. The second pathological state (§ 13, 14. b.), when closely verging, as it occasionally does, upon the first, will require several of the means enumerated with respect to it; whilst, when fully formed, and approaching that of active determi- nation or congestion, hut few of them are applica- ble. Much, however, will manifestly depend upon the habits, and the constitution of the patient ; upon the nature and duration of the disease of which coma is an advanced phenomenon; and upon the state of the pulse, the temperature of the head, and the character of the countenance. The first state is injured by blood-letting in any form, it being even not an infrequent consequence of inanition, or even of ansemia of the brain ; but this second state will generally be benefited by depletion, and in proportion to its approximation to the third and fourth states described above (§ 13, 14. c.). The question chiefly is as to what extent it may be carried, and the manner in which it may be performed. In the majority of cases, local depletions by cupping between the shoulders and nape of the neck, or by leeches ap- plied behind the ears or on the neck and occiput; by simple scarifications by a lancet in the last- named situation, in some cases ; in others, bleed- ing from the feet whilst they are placed in warm water, and cold or tepid water is being poured in a stream upon the head ; and in certain in- stances the application of a number of leeches on the inside of the tops of the thighs, or about the anus ; are the preferable modes of having recourse to depletion in this state of disease : but the ex- tent to which the evacuation should be carried must entirely depend upon the symptoms and cir- cumstances of the case, and the effects produced by it. In addition to this important means, pur- gatives ought to be given by the mouth, and their action increased by cathartic clysters, in which either assafoetida, valerian, camphor, the terebin- thinates, or other antispasmodics and stimulants, may be also exhibited. Counter-irritants and de- rivatives should be applied, but at a distance from the head ; and, while a frequent operation of the bowels is procured, the functions of the skin and kidneys should be promoted by diaphoretics and diuretics, the extremities being kept warm, the head cool, its haircut off, and the shoulders highly elevated. In many instances of this state, even local depletion should be cautiously employed; and in these, as well as in others, much advantage will often accrue from having recourse to resto- rative means. It is in this pathological condition of coma, and in those about to be noticed, that oil of turpentine, in large doses, so as to act freely on the bowels, has proved so beneficial in my prac- tice. This state very generally obtains in coma from narcotics and spirituous liqours ; and is then, especially, very remarkably benefited by the cold affusion on the head, and the preparations of am- monia. 18. C. The third said fourth states (§ 13, 14, c.) require nearly the same treatment as the second, but carried much further; general and local depletion, cold affusion on the head, or the appli- cation of ice, or evaporating lotions ; the most active cathartics, clysters, and derivants or coun- ter-irritants, and the other measures, as fully pointed out in the article on Inflammation of the Brain (§ 174). When these states have gone 457 458 on to effusion either of blood or of serum,—the sixth pathological condition adduced,—the treat- ment recommended in Apoplexy and in Dropsy of the Encephalon (see these articles) should be employed. 19. D. The fifth pathological state obviously requires stimulants, tonics, and antiseptics, par- ticularly camphor, in considerable doses; the chlorides of sodium, potassium, &c. ; wine, with cordials, spices, &c.; bark, with camphor; pur- gatives conjoined with stimulants, so as to excite the eliminating or depuratory functions ; carthar- tic, tonic, and antiseptic clysters ; calomel, com- bined with camphor and ammonia, or musk ; the turpentines given by the mouth, and in enemata, with capsicum and aromatics; external deriva- tion and counter-irritation ; the various balsams, with the chlorides, &c.; quinine, with the aromatic sulphuric acid ; the preparations of cinchona or cascarilla with soda, or with the hydrochloric acid, or hydrochloric aether ; Cayenne pepper in- ternally, as well as externally in camphorated embrocations, &c. When coma is consequent upon the retrocession of gout, rheumatism, ery- sipelas, or cutaneous eruptions, the propriety of having recourse to sinapisms, rubefacient pedilu- via, and other derivatives, in addition to such other means as the symptoms of the case may suggest, must be obvious. If it follow suppressed dis- charges, we should endeavour to restore these, or produce one supplemental of them. (See the treatment of the diseases of which coma is most frequently an important symptom.) Bibi.iog. and Refer.—Hippocrates, Ilrpi vovacov, iii. Opp. p. 488.—Galen, Lib. de Comate, cap. ii. t. vii. p. 195. —Celsus, 1. iii, cap. 20.—Arcteeus, Cur. Acut. 1. i. c. 2.— Paulas JEgeneta, 1. iii. cap. 9. et 10.—Oribasius, Synop. 1. viii. c. i.—Avicenna, Canon. 1. iii. fen. i. tract, iii. c. 7. &c.—Zacutus Lusitanus, Pr. Hist. 1. vii. obs. 4. (The actual cautery behind the ears.)—Rhodius, 1. i. obs. 36. (The cautery to the neck.)—Severinus, De Efficac. Med. p. 213.—Ballonius, Consult. 1. i. 45, 1. iii. 32.— Willis, De Anim. Brut. Path. cap. 3, 4, 5.—Riverius, Prax- Med. t. i. cap. i.—Sydenham, Opera, p. 281.—Bonet, Sepul- chretum, 1. i. sect. iii. obs. 5. 13. 18.—Risen, De Comate Somnalento. Basil, 1674.—Heinz, De Affectibus Soporosis. Argent. 1677.—Morgagni, Epist. v. art. 13. 23. 29—36.— Bellini, De Morliis Capitis, p. 455.—Hoffmann, De Af- fect. Soporosis, obs. 5. Opp. iii. p. 216.—Boerhaave, De Morbis Nervorum, p. 640.—Cartheuser, De Typhomania. Francf. 1750.—Kruger, De Somno, Morborum Matre et Filio. Helms. 1754.—Haller, Observat. Med. Pract. Goet. 1750.—Sauvages, v. iii. class, vi.—xxix. 7.—Bang, in Acta Reg. Soc. Med. Hafn. vol. iii. p. 127.—Vogel, Beo- bachtungen, No. 9.—Hinze, in Stark's Archiv. b. vi. p. 178.—Behrends, in Hufeland's Journ. der. Pr. Heilk. b. xi. 2 st. p. 1.; Ibid. b. xx. 4th st. p. 5. (Galvanism rec- ommended in.)—Rigal, in Mem. de Toulouse, 1788.— Portal,Cours d’Anatomie Med. t. i. p. 21. (An instance of coma from narrowing of the carotid arteries.)—Selti, in Brugnatelli, Bibliotheca Fisica, v. ii.—Brewster, Edin. Philos. Trans, for 1817. (Idiopath. coma from congestion.) — Cooke, Treatise on Nervous Diseases, v.. i. p. 372. (Idiopath. lethargy.)—J. Frank, Praxeos Med. Univ. proe- cepta, par. ii. vol. i sect. i. p. 367.—Bahn, in Encyclopad. Worterbuch der Med. Wlssenschaften, b. viii. p. 107.— (Bonet's Thesaurus Med. Scrip, t. i. p. 715., and his Mer- curius, &c. p. 616.; also Manget's Bibliotheca Med. Script., art. Carus, and Ploucquet's Medicina Digesta, art. Coma, may be consulted by the curious; but little information of importance will be obtained.) CONCRETIONS, Biliary.—Syn. Calculi or Lapilli Cystici; Calculi Fellei; C. Bilieres, C. Biliarii; Cholelithi; Hepatalgia Calcu- losa; Var. Auct. Concrementa Biliaria, Soem- merring. Chololithus, Good. Calculs Bilia- res, Fr. Die Gallenstein, Ger. Gall-stones. Classif. 1, Class, Cceliaca; 2. Order, Splanchnica, Gen. iii. (Good). I. Class, II. Order (Author.) CONCRETIONS, BILIARY—Pathology of. 1. Defix. Concretions formed in the bile-pas- sages, and occasioning in many instances more or less disturbance, with paroxysms of pain com- monly referred to the right epigastrium and liy- pochondrium, reaching to the back, nis Cas- til. gr. x. ; Pulv. Ipecacuanh® gr. vj. ; Extr. Hyoscyami 3 ss. Contunde bene simul et fiant Pilul® xviij., quaruni capiat binas hora somni quotidie. No. 147. ft Hecocti Aloes Comp. § ivss. ; Liquoris Potass® (vel Carb. Sod®) 3j. ; Vini Aloes 3 vj. ; Extr. Taraxaci 3 iij.; Spirit. Pimento 1 ss. M. Capiat tertiam vel quartam partem pro dose, et repetatur pro re nata. No. 148. ft Magnes. Snlphatis 3 j. (vel Potass® Sul- phatis 3 ss.) ; Infusi Ros® Comp., Infusi Gentian® Comp, aa 3 vj.; Acidi Sulphurici Arom. Ill x. ; Tinct. Senn® Comp, (vel Tinct. Aurantii) 3 j.— 3 ij. M. Fiat Haustus, omni meridie capiendus. In most instances of constipation depending upon torpor of the small intestines, and deficient biliary secretion, a full dose of blue pill or of calomel should be exhibited at bed-time, and a common black draught the following morning, at the com- mencement of the treatment, with the view of promoting the secreting functions of both the liver and the mucous follicles of the bowels*; and a moderate action ought to be kept up for some time subsequently by the remedies now adduced. 17. b. In those cases in which the large bowels are chiefly in fault, the preparation of aloes va- riously combined, the means already mentioned, particularly & 146, 147., or those recommended in the articles on the Colon, and on Colic, will be generally found appropriate. In some instances, however, it will be requisite to have recourse to more powerful cathartics than I have yet mention- ed—particularly when irritability of the stomach, or of the system generally, does not exist, and to promote their action by enemata. The following, or F. 140, 141. in the Appendix, may be employed: No. 149. ft Pulv. Jalap, gr. xij.; Pulv. Scammoni® gr. v.; Potass® Sulphatis 3 j.; Olei Caryoph., et 01. Ca rui, aa til iij. Tere bene simul, et fiat Pulvis in quovis vehiculo idoneo sumendus. No. 150. ft Magnes. Sulphatis 3 vj.; Infusi Senn® Comp. 1 ij,; Tinct. Jalap. 3 j.; Tinct. Opii tlf vj.—x. (vel Tinct. Hyoscyami 3 ss.) ; Tinct. Castorei, Spirit. Pi- mento, aa 3 j. M. Fiat Haustus. No. 151. ft Extr. Colocynth. Comp. 3 ij.; Saponis Castil. gr. xij.; Olei Crotonis gtt. iij. (vel Extr. Nucius Vo- mic® gr. iij.) M. Fiant Pilul® xii. Capiat duas hora. decubitus. No. 152. ft Manns J j.; Infusi Anthemidis 5 xij-: solve, et adde Olei Oliv® § ijss.; Magnesia Sulphatis 1 jss. Sit Enema. 18. c. In cases apparently depending upon deficient tone of the muscular coat of the large bowels, and imperfect propelling power of the upper part of the rectum. I have seen benefit derived from combining the spirituous extract of nux vomica or strychnine with the pilula aloes cum myrrha, or with the compound extract of colocynth, as directed above in & 151., in place of the croton oil. When this state is connected with deficient secretion from the intestinal mucous surface (§ 7. b.), small doses of the croton oil, from 475 476 one sixth to one half of a drop, combined with some other purgative, and repeated daily, or on alternate days, will remove obstructions from, and restore the secretions of, the mucous follicles. In cases also where the internal surface of the intes- tines are loaded with a viscid mucous sordes (§ 7. g.), it acts more efficiently than any other medicine, particularly when combined as above (ft 151), or with calomel or blue pill, and restores more permanently the functions of the intestines. I have recently met with several cases of con- stipation consequent upon attacks of pestilential cholera, and in nearly all of these I have inferred the existence of not only imperfect peristaltic action of the bowels, but also an accumulation of viscid mucous, or albuminous sordes on their internal surface,—an inference confirmed by the state of the evacuations. The combination of purgatives now alluded to has proved more effi- cacious in removing this morbid condition, than any other I have employed. 19. d. In children and young females, consti- pation is generally attended, even if it be not caused, by deficient secretion from the mucous follicles, and by an accumulation of mucous sordes (the Saburra intestinalis of the older writers, and the Embarras Sabural and Embarras intestinal of French authors) on the internal surface of the bowels. In these cases, a dose of calomel, with either jalap or scammony, and tri- turated with sugar, and followed by castor oil, or the infusion of senna with salts, or by the decoc- tion of aloes, &c., according to the circumstances of the cases, will generally procure full evacua- tions. But in many such cases, the repeated ex- hibition of these will be required before the col- lected sordes can be removed ; and even when the evacuations have assumed a healthy appearance, it will be requisite to resort occasionally to purga- tives combined with tonics and resolvents—such as senna, aloes, or rhubarb, with gentian, cascarilla, cinchona, or calumba; and with potass, soda, &c., before the functions of the bowels will be al- together restored. 20. e. When the fecal retention assumes the form of obstipation, and is attended with difficult or imperfect evacuation ; or with frequent desire, and tenesmus ; and with hard, rounded, scybalous discharges ; we may infer the existence of rigidity of the longitudinal bands of the colon (§ 7. e.); and should combine anodynes and antispasmodics with purgatives. I have commonly derived most advantage from small doses of castor or olive oil, exhibited frequently, in some carminative or aro- matic water, with a little tincture of hyoscyamus and ipecacuanha wine; and from demulcent, anodyne, and oleaginous clysters (F. 143, 144. 795.) Electuaries, also, consisting of the confec- tion of senna, with cream of tartar, magnesia, extract of hyoscyamus, &c. (see F. 96. 98.), will generally prove more serviceable, in these cases, than very active medicines. When the retained, scybalous feces produce irritation of the colon, the frequent calls to stool, and the scanty, mu- cous, and watery evacuations, may lead the prac- titioner to suppose, if he rely upon the account of the patient only, that diarrhoea, instead of constipation, actually exists, and hence to adopt an improper treatment. In these cases, the warm or tepid bath, the addition of ipecacuanha, or hy- oscyamus, or both, to the purgatives given by the mouth, and the use of clysters with infusions of ipecacuanha and linseed, and with olive, linseed, CONSTIPATION—Treatment. or almond oil, will generally procure the evacua- tion of scybalous faeces. When the bowels are distended by flatus, the operation of aperients will be most assisted by gentle friction of the abdo- men ; and confidence to persist in the use of it will be given by directing the friction to be em- ployed with some liniment (F. 298. 306.), or with ft 157, subjoined. No. 153. ft Olei Ricini recentis 3 j.— 3 ij.; tere cum VI- tello O vi unius, et adde terendo, Vini Ipecacuanha: 111 x.; Tinct. Hyoscyami Til xv.; Tinct. Castorei Til xx.; Aqua: Pimentos 3 xj. M. Fiat Haustus, 4ta vel 5ta quaque hora sumendus. No. 154. ft Potass® Bitart, in Pulv. ? j-; Sods carbon, exsic. (vel Magnesia1 Calcinate) 3 iij.; Confectionis Sen- na 1 jss.; Confectionis Rute 3 ijss.; Extr. Hyoscyami gr. xij. ; Pulv. Ipecacuanhae gr. ij.—iij.; Tinct. Capsici 3 ss. ; Syrup. Zingiberis q. s. ut fiat Electuarium, cujus capiat partem quartam 4tis vel 5tis horis donee plene dejecerit alvus. No. 155. ft Soda: Sulphatis, Manna: Opt., aa | j., solve leni cum calore in Aqua: Mentha; Virid. 5 vjss., et adde Tinct. Senna: Comp. ?j.; Vini Ipecacuanhas 3j.; Tinct. Capsici 3 ss.; Spirit. Carui 3 ij. M. Capiat Coch. larga quatuor tertiis vel quartis horis. No. 156. ft Olei Amygdala: Olei Ricini, Manna: Opt., aa 3 jss.; Aq. Pimento: 3xj. M. Fiat Haustus, 4tis, 5tis. vel 6tis horis sumendus. No. 157. ft Unguenti Cetacei 3 jss.; Olei Carui et Tinct. Opii, aa 3 jss. Misce, et fiat Linimentuin, cum quo illinatur abdomen, urgente flatu. 21. B. a. In the more obstinate or prolonged cases of constipation, which have resisted the above, or any other means usually employed to procure evacuations, we should endeavour to as- certain, by enquiring into the previous state of the patient’s digestive and intestinal functions, and by examining the abdomen, rectum, and parts in the vicinity, the probable cause of obstruction. The account which may be furnished of the ap- pearance of the evacuations heretofore, and of the facility with which they had been evacuated, as well as of the sensations felt before or at the time of evacuation, will very materially guide the judgment of the practitioner in concluding re- specting the existence of organic disease of the colon or rectum, or in the vicinity of the latter. Frequent attacks of diarrhoea, tenesmus, or dy- sentery, previously to the occurrence of constipa- tion, or of pain in the course of the colon, or along the sacrum, should always lead us to suspect nar- rowing, or thickening, or both, in some part of the colon or rectum (§ 9.). In such cases, we should endeavour to solicit faecal discharges by oleaginous and saponaceous clysters, and frictions of the abdomen, rather than by purgatives taken by the mouth; and we ought not to be too offi- cious in the use of these ; but, should so study the feelings of the patient, as to prevent irritation and febrile disturbance—the harbingers of inflam- mation—from coming on. In these cases parti- cularly, examination of the state of the rectum, and the lower part of the colon, by the introduc- tion of the long flexible bougie, as recommended by Dr. Wiixan, should not be omitted ; and if any stricture exist within the reach of this instru- ment, its gradual dilatation should be attempted. If a stricture be reached, it may be of service to use a hollow bougie, along which enemata may be thrown up so as to pass beyond the seat of ob- struction, which might otherwise not be overcome by them. Instances have been met with, in which stricture and organic disease of the colon have apparently existed for some time without con- stipation having been complained of; and yet the exhibition, when constipation did take place, of acrid purgatives in large and repeated doses, has CONSTIPATION—Treatment. 477 been soon followed by an unfavourable issue, which, however, might not have been much longer deferred by any treatment whatever. Cases illus- trative of this occurrence have been recorded by Home, Sterry, Annesley, &c. (See refer- ences.) 22. b. In almost every instance in which the bowels still remain obstinately costive after two or three doses of purgative medicine have been given, but without any urgent symptom being complained of, it will be more advantageous to use gentle means, to trust chiefly to enemata, and to wait patiently the result, than to prescribe med- icines which will irritate and invert the action of the upper part of the digestive tube without reaching the seat of obstruction. If, notwith- standing, symptoms of inflammatory action begin to appear ; or if the stomach become irritable ; or if the pulse be oppressed, hard or constricted ; or if the patient be plethoric and of a sanguine or irritable temperament, venesection, or the appli- cation of leeches to the abdomen, or both, should be resorted to, and hot poultices and fomentations or the warm turpentine epithem, or a blister, be afterwards placed upon the belly. The patient may then be left quiet for several hours, in ex- pectation of the action of the purgatives previ- ously given ; or, if the stomach be irritable, sooth- ing and anti-emetic remedies (F. 178, 179. 357.) only, or a full dose of calomel with opium or hy- oscyamus, should be taken, and after a few hours the enema may be repeated. In cases of obsti- nate constipation, unconnected with contraction of the colon or rectum, a large dose of calomel, either alone, or with opium or hyoscyamus, may be exhibited, and repeated once or twice, at dis- tant intervals; each dose being followed either by castor oil, or by the common black draught, or by half an ounce of turpentine with an equal quantity of castor oil in any suitable vehicle. But where inflammatory disease, or lesions con- sequent upon inflammation, are suspected to ex- ist in either the colon or rectum, calomel, or even a full dose of blue pill, will often aggravate the mischief, unless emollient enemata be frequently thrown up. Indeed, I believe, from the experi- ments and observations I have made respecting the action of calomel on the alimentary canal— from remarking its effects in irritating and in- flaming the inner surface of the colon and rectum when taken in large doses—and from the history of the previous ailments, and treatment of many of those who have had stricture of the rectum or colon —that a very large proportion of such cases has been brought on by the frequent use of calomel as a purgative. 23. c. When we believe that constipation is owing to a torpid or paralysed state of the mus- cular coats of the large bowels, and the accumu- lation of hardened fasces consequent thereon (§ 9. a.), oleaginous purgatives given by the mouth; in some cases, a full dose of calomel fol- lowed by a turpentine and castor oil draught; and, subsequently, oleaginous, saponaceous, and terebinthinate enemata; are generally the most appropriate means. If, however, these fail, then small but repeated doses of castor, olive, or almond oil ; frequent demulcent enemata; the aspersion of cold water over the abdomen or lower ex- tremities ; or injections of cold water, may be tried. (See § 26.) If there be great inflation or faecal distension of the colon, friction with the carminative liniment prescribed above (& 157.), may also be employed, with various other internal and external means recommended in the articles on Colic and Colon. In aged females especially, hardened feces sometimes collect to such an ex- tent, and are lodged so firmly in the rectum and lower part of the colon, as to require removal by mechanical means. Cases of this kind have been detailed by Schurig, Petit, Bishoprick, Se- cheverel, White, &c., and have occurred in my own practice, as well as in that of many others. They require the careful introduction of a mar- row-spoon, or some similar instrument into the rectum, to break down the feces; and subse- quently the means just stated, particularly olea ginous and terebinthinate injections thrown up by the pump apparatus now in general use, which should be provided with a large and very long pipe, or with a long, hollow, and flexible bougie, which ought to be passed as far as possible up the rectum. 24. d. If alvine obstruction be apparently owing to organic, malignant, or other diseases about the uterus, its appendages, the vagina, or rectum (§ 10.); or to spasmodic constriction of the sphincter ani excited by inflammatory irritation in its vicinity, or by haemorrhoids, the warm bath, semicupium, or the hip-bath; the vapour of hot water and narcotic decoctions directed to the anus; anodyne and relaxing injections; and the extract of conium or hyoscyamus, made into either a suppository or an ointment, with the addition of a little of the extract of belladonna; may be prescribed, along with such other mea- sures as the circumstances of the case may require. 25. e. When constipation is dependent upon or associated with, disease of the spine, or in- flammatory irritation of the membranes and en- velopes of the chord, leeches should be applied near the place where pain is complained of; oi the patient may be cupped in the vicinity, kept quiet, and in the horizontal position ; and the action of the bowels promoted by the means stated above (§ 16, 17.), and by terebinthinate injections. If inflation of the bowels exist, the carminative liniment may be employed; and i, tenderness, tension, or pain of the abdomen be complained of, leeches, followed by fomentations, &c. as already advised (§ 22.), should be re- sorted to. 26. C. Besides the above, other means have been recommended by authors in various states of the disease, and found of much service when appropriately prescribed. Joerdens advises the frequent administration of assafeetida in enemata, and, in cases of deficient secretion and healthy action of the colon, it is certainly of essential use, either alone or in conjunction with purga- tive medicines. Starke recommends the in- spissated ox-gall, both in the form of pills and in clysters. In the latter form, it is calculated to prove an excellent adjuvant of other means; and when combined with aloes, taraxacum, soap, ex- tract of gentian, &c. (F. 559. 562.), it is very serviceable in restoring the healthy functions of the bowels, and digestive organs generally. Wendt directs repeated clysters of the decoction of gratiola to be thrown up. Numerous writers have advocated the application of cold, in cases of obstinate constipation. Schenk, A. Fonseca, Blankard, and Laison advise the patient to walk or stand upon a marble pavement or slab; and Brassavolus states that Savanarola cured 478 CONSTIPATION—'Treatment. the Duke of Ferrara, by making him walk bare- footed over a cold wet marble floor. Steven- son, Falconer, Percival, and Spence direct the affusion of cold water over the lower and upper extremities, and adduce cases wherein the practice had been successful after other measures had failed. Kite, Bartram, Sancassini, and Schmidtmann recommend cold epithems, and the affusion or aspersion of cold water, over the abdomen; and Kaehler, Korb, and Brandis advocate the administration of cold clysmata, in addition to the employment of cold externally. The cold and tepid shower hath, the cold plunge bath, and warm and tepid bathing, have severally been resorted to in aid of other measures, and are frequently of use,—the former particularly in habitual constipation, the latter in cases at- tended by difficult and imperfect evacuation, and seemingly dependent upon rigidity of the longi- tudinal bands of the colon. Electricity and galvanism have been employed successfully by Kite, Sigaud la Fond, Grapengiesser, and Clarkson ; and the injection of tobacco smoke, and of a weak infusion of the leaves of tobacco, has been advised by Von Mertens, Vogel, and other authors referred to, when discussing the treatment of Colic and Ileus (which see). The decoction of barberry ; powdered charcoal (Mit- chell and Daniel), in the dose of one, two, or three table-spoonsful given every hour in milk or lime water; frictions of the abdomen (Quel- malz) ; inunction of it with linseed or olive oil (Riedlin, &c) ; fomentations consisting of senna leaves made hot and moist by boiling water, and placed over the abdomen (Petit) ; purgative ex- tracts ; tinctures, and infusions, applied to this situation, either in the form of ointment or foment- ation (Schenck, Alibert, &c.) ; and enemata con- taining the potassio-tartrate of antimony (Elias), have also been employed. The exhibition of eme- tics was advised by Hippocrates, Praxagorus, C/elius Aurelianus, and Alexander Tralles ; and of ipecacuanha or antimonial emetics by Stoll, Sims, Sumeire, Deplace, and Hosack. I have seen benefit derived from inunction of the abdomen with an admixture of castor and linseed oils, to which three or four drops of croton oil had been added. In a great proportion of the cases of constipation which have occurred tome since 1817, when I first adopted the practice, very certain and immediate advantage has been derived from a full dose of calomel (either with or without opium or hyoscyamus), followed in a few hours by half an ounce of oil of turpentine, and an equal or some- what larger quantity of castor oil, taken either in a cup of milk, or in a glass of some aromatic water. The action of these has usually been promoted by an injection containing castor, olive, ir almond oil; and, if the operation has not beeu sufficiently copious, another dose of castor nil has been given, and the enema repeated.* 27. ii. The prevention of a recurrence of the disease should be strictly guarded against, par- ticularly after active cathartics have been given to remove it. Purgatives, aperients, or laxatives, combined with stomachic bitters and tonics (F. 187. 266. 872.), ought to be taken daily, and afterwards on alternate days, until the functions of the bowels are fully restored. The patient’s diet should be light and nutritious ; all astringent and indigestible substances avoided: and, if the abdominal secretions be deficient, an occasional dose of blue pill, or hydrarg. cum creta, and a course of taraxacum, with deobstruent laxatives and tonics (F. 390. 510. 873.), prescribed. Sub- sequently a course of Leamington or Cheltenham mineral waters, or the artificial Seidschutz, Marienbad, and Carlsbad* waters, and in some cases the Pyrmont and Spa waters, will prove of much benefit. The shower bath, upon getting out of bed, or the cold salt-water bath, will further tend to promote the digestive and defsecat- ing processes. Costive persons, with a large or pendulous abdomen, should wear a broad belt or bandage around it, which will serve to promote the functions of the bowels. The patient should carefully avoid the remote causes of constipation, attend daily to the first intimations to stool, and have an early recourse to medicine when such intimations are delayed beyond the usual time. When the bowels require the assistance of med- icine to preserve them in a regular state, aloes may be combined with mastich and Cayenne pepper, or with a bitter extract, myrrh, and assafoetida, and taken daily about two hours before dinner. [There are numerous mineral waters in the United States which may be usefully employed in cases of habitual constipation. The Congress water of Saratoga possesses valuable laxative, combined with tonic and alterative properties; but its cathartic powers require, in many cases, to be aided by the addition of an extra quantity of some of the salines. It has been suggested that where there are objections to swallowing such a large quantity of fluid, from the dis- turbance created in the system in irritable cases, the water might be concentrated by evaporation, so that a few ounces might produce the desired effect. This is practised at the mineral springs in England and on the Continent of Europe with manifest advantage. Persons of plethoric habits should be cautious how they use the Saratoga to those that are acrid; and give them with antispasmo- dics and sedatives. 4. When it arises from torpid peri- staltic action and lessened secretion, conjoin tonics, gum resins, and bitters, with purgatives and aperients; myrrh, assafoetida, galbanmn, &c„ with aloes; sulphate of qui- nine, or ext. of gentian with aloes ; the alkaline solutions, with tonic infusions; use friction with stimulating lini- ments to the abdomen, or along the spine ; resort to the cold salt-water bath or shower bath, and the tonic and aperient mineral waters of Cheltenham, Leamington, Vichy, and Carlsbad. 5. When it is attended by ac- cumulations of hardened fieces in the colon, have recourse to copious soapy or oily clysters—to the introduction of a marrow-spoon to break down the fieces—to the injec- tions of cold water, &c., by the valve-apparatus, with a long bougie attached to the pipe—to the aspersion of cold water on the abdomen, or the application of cold to the lower extremities, &c. 6. If it proceed from organic change of the large bowels, or of parts affecting them, solicit evacuation by emollient and relaxant enemata, and suppositories: soothe local and constitutional irritation, preserve the functions of the stomach, and give the al- kaline solutions with conium, belladonna, &c.—(From the Author's short JVotes of his Lectures delivered from 1824 to 1829.) * The following synopsis exhibits a succinct view of the treatment .—1. If the pulse be hard or constricted, and if there be pain, increased on pressure, bleed generally or locally, or both—apply blisters or hot fomentations, or the cold affusion, or cold epithems, &c., on the abdomen; afterwards exhibit purgatives, enemata, &c. 2. If con- stipation seems to arise from diminished secretion and exhalation, give calomel or blue pill, carbonates of the alkalies, jalap, the purgative oils, senna, camboge, ela- terium, croton oil, &c„ according to circumstances. 3. If it depend upon a rigid fibre and habit of body, combine purgatives with relaxants and nauseants—with ipecac- uanha, antimony, colchicum, soda, hyoscyamus, &c.; prescribe emollient and relaxant medicines in preference CONVULSIONS—Pathology of. waters, for unless previous depletion be practised or the bowels be kept in a soluble condition by the aid of other laxatives, apoplectic or other serious symptoms may follow. The sulphurous waters of the United States are also extremely useful in constipation, abounding as they do in saline constituents. Of these, the white and red sulphur springs of Virginia are perhaps the most frequented. The action of the salts is supposed to be mainly upon the stomach and small intes- tines, while the sulphur increases the peristaltic motion of the large intestines, as well as stimu- lates the entire mucous membrane. The sulphur waters of Avon and Sharon, in the State of JJew York, have been found very beneficial in cases of constipation of the bowels. Those at Shannondale, Virginia, also enjoy a merited celebrity in such cases, attended with hepatic derangement, as well as of the digestive organs generally. The water acts as a powerful diuretic, alterative, and laxative, but must be used in con- siderable quantities to produce the desired effects. Much may be done in preventing constipation of the bowels by proper attention to diet and exercise. Although laxative and purgative re- medies are often indispensable in the manage- ment of these cases, yet we attach far less importance to them than to those general hy- gienic means, which tend to prevent the ne- cessity of having recourse to more active medi- cation. A diet of stale bread of unbolted flour, rye or Indian mush with molasses, a liberal use of the laxative fruits, as figs, prunes, preserves, apple-sauce, with a simple enema daily, will, in a large majority of cases, preserve the bowels in a soluble state, and better promote the comfort of the patient, thafi the ordinary medicines of a cathartic kind. To such a system of diet should be conjoined regular exercise in the open air, with the shower bath or cold sponging, and the flesh brush daily. As constipation depends, to a great extent, on a torpor in the organic system of nerves, supplying the intestinal tract, thus rendering its mucous and muscular coats less sensible to the stimulus of its contents, it is highly probable that galvano-magnetism might prove a valuable agent in restoring its normal impressibility.] Bibi.ioo. and Refer.—Hippocrates, Ilspi vovatov, iii. Opp.v. p. 491.—CiBliusAurclianus,Opp. pp. 243.529.—Alex- ander Tralles, lib. ii. cap. 44.—Ballonius, Opp. i. p. 40.— Schenk, Observat. 1. iii. n. 285.—Salmuth, cent, i.obs. 24., cent. ii. obs. 65. 98., cent. iii. obs. 26. 45.—Blankard, Col- lect. Metl. et Phys. cent. vi. No. 68.—Panarolus, Ja- trolog. Pentecost, i. obs. i.—Smetius, Miscellan. p. 561.— Bonet, Sepulchret, 1. iii. s. xiii. obs. 11. p. 589.— Tricen, Observ. Med. p. 25. and 56.—Morgagni, Epist. xxxii. de Alvi Adstrictione.—Callisen, in Act. Soc. Med. Havn. i. and ii. p. 329.—Aaskow. in Ibid. ii. p. 9.—Brendel, Observ. Anat. Med. dec. i. n. 20.—A. F. Walther, De Intest. Angustia. Lips. 1731.— Quelmalz, De Frictione Abdominis, &c. Lips. 1749.—Lieutaud, Hist. Anat. Med. 1. i. obs. 292. 293. 301.—A. Fonseca, De Tuenda Va- leted.—Sancassani, in Haller, Bibl. Med. Pract. vol. iii. p. 601.—C. G. Ludwig, De Causis Obstructionis Alvina;, 4to. Lips. 1770.— Petit, Traite de Malad. Chirurg. t. ii. p. 101., et t. iii. p. 47. 103., et M6rn. de l’Acad. de Chirurg. i. p. 239.—Saunages, t. ii. p. 363 —Devilliers, in Journ. de Med. t. iv. p. 257.—Marteau de Grandvilliers, in Ibid, t. xiii. p. 226.—Laison, in Ibid. t. Ixxxvii. p. 354.—Cullen, Materia Medica. vol. ii. p. 496.—Roeschlaub, Magazin. b. iv. No. 7. — Erhard, De Praeternat. et rara Obstipat. Alvi Causa, &c. Erf. 1790.—Stoerck, Annus Med. vol. i. p. 125.—Block. Med. Bemerkung. p. 124.—Stoll, Rat. Med. par. ii. p. 135.vol.vii. p. 154.— Weikard. VermischteSeriften, b. ii. p. 52 —Starke, Klin. Instit. p. Yl\.—Baillie, in Trans, of Soc. for the Improvement of Med. and Chirurg. Know- ledge, vol. ii. No. 14. p. 174.—Meckel, N. Archiv. b. i. No. 3., et Acad, de Berlin, &c. 1759, p. 39.—Stevenson, Edin. Med. Essays, &c. vol. v. p. 803.—Lorry, Hist, de Soc. de Med. vol. ii.—Burggrave, Medicin. Fiille, p. 232.— Cruickshanks, Anat. or Absorb. Vessels, p. 119.—Reil, Mernorab. Clin. vol. i. fasc. 1. No. X—Theden, N. Be merkung, b. iii. p. 76.—Ford, in Lond. Med. and Physic Journ. vol. iv. p. 390.—Kite, in Ibid. vol. viii. p. 164.— Leske, Auserl. Abhandl. b. i. p. 61 ,— Wedel, Stark's At chiv. b. vi. p. 673.—Riedlin, Millenarius, No. 301. et 536 —Sims, Observ. p. 20.—Sumeire, Journ. de Med. t. lxi p. 369.—Odier, Manuel de Med. Pratique, p. 207— Moeller in Batdinger, N. Magazin. b. xx. p. 178.—Osiander, N Denkwiirdigkeiten, b. i. st. 2. p. 130.—Falconer, in Mem of Med. Soc. of Lond. vol. ii. p. 72.—Sherwen, in Ibid vol. ii. p. 9.—Kaehler, in Stark's Archiv. b. ii. st. 2. No. 2.—Grapengeisser, Versuche, &c. p. 100.—Mibert, in Mem. de la Soc. Med. d’Emulation, t. i. p. 182. 443.— Wiliam, Miscel. Works by A. Smith, &c. Lond. 1821. p 446.—Daniels, in Philadelph. Med. Journ. vol. v. p. 119.— Wendt, in Annalen des Klin. Institut. 1 heft.—Secheverel, in Journ. Gdner. de Med. &c. t. xix. p. 6,—Hufcland. in his and Himly's Journ. der Pract. Ileilk. Nov. 1809, p. 130.—Portal, in Mem. de l’Institut. Nat. de France! 1807, — Pomma, in Journ. de Med. Contin. July. 1810, p. 74 —Spence, Med. Trans, of Coll, of Phys. vol. iii p. 99.—Gerard, in Duncan's Edin. Med. Comment, vol. x. p. 44.— Warren,, in ibid. p. 255. Dels ham, in Ibid, vol. xiii. p. 282.—Bishoprick, in Ibid. vol. xx. p. 340 — Hosack, in Duncan's Ann. of Med. 1796, p. 310; and Lond Med. Rep. t. xvii. p. 77,—Mossman, in Ibid. 1797, p. 307 —Clarke, Trans, of Irish Acad. vol. vi. p. 3. — E. Home, Trans, of Soc. for Med. and Chirurg. Improvement vol. ii. p 182.—Bader, Observ. 39, — Korh, in Richter's Chir. Bibl. b. viii. p. 120. — Mursinna, Beobach. b. i p. 141.—Bateman, Art. Constipation and Costivencss, in Rees's Cyclopedia.—Joerdens, in Hufeland's Journ. (let Pract. Heilk. b. xvii. st. 2. p. 87.—Elias, in Ibid. b. x. st. 1 p. 140.—Mitchell, N. Y. Med. Repos. 1800.—Sterry, in Lond. Med. Repos. May, 1823.—Crampton, Dub. Hosp Reports, vol. iv. p. 385.—Hoioship, On Dis. of the Lovvei Intestines and Costiveness, &c. 8vo. Lond. 1820.—Recce On Regulating the Stomach and Bowels, &c. 8vo. 2d edit 1827.—Green, Edin. Med. and Surg. Journ. vol. ix. p. 166 — Oudnay, vol. xvi. p. 383.—Clarkson, in Ibid. vol. xvi p. 475.—Annesley, and Author, in Researches on Diseas of India, &c. vol. ii. p. 50„ei seq.—Valentin, in Bull, des Ann. des Scien. Med. t. x. p. 74 —Bompard, Traite des Malad. des Voies Digestives, &c. 8vo. Paris, 1829, p. 280 —Staniland, Lond. Med. Gazette, vol. xi. p. 245. CONSUMPTION. See Pulmonary Con- sumption, and Mesknteric Consumption. CONTAGION. See Infection. CONVULSIONS.—Syn. snasyos, Gr. Spasmi, Clonici, Motus Convulsivi, Distensiones Nervo- rum, Conductiones, Auct. Var. Convulsion, Spasme, Fr. Zuckungen, Ger. Convulsioni, Ital. Convulsion Fits. Classif. 4. Class, Nervous Diseases; 3. Order, Spasmodic Affections {Cullen). 4. Class, Affecting the Nervous Func- tion : 4. Order, Affecting the Sensorial Powers {Good). II. Class, III. Order {Author, in Preface). 1. Defin. Violent and involuntary contrac- tions of a part, or of the whole of the body, sometimes with rigidity and tension (tonic con- vulsions) ; but more frequently with tumultuous agitations, consisting of alternating shocks (clonic convulsions); that come on suddenly either in recurring or in distant paroxysms, and after irregular and uncertain intervals. 2. Convulsions have attracted a due share of attention from the medical writers of all ages. Hippocrates states, that “ convulsions arise either from repletion or evacuation” {Aphor. sect. vi. § 39.); and Galen, whilst he admitted the propriety of referring them to these two mor- bid states, argued for a third, namely, irritation occasioned by a morbid humour. jEtius adhered to a similar arrangement, but considered that the third of these pathological conditions per- formed the principal part. Subsequent writers, chiefly copiers or commentators on Galen, adopted his views. Zacutus Lusitanus imputed much importance to the second morbid state of 479 480 CONVULSIONS—Pathology or. Galen, viz. excessive evacuation; and consid- ered that a positive or relative dryness of the nervous and muscular system was occasioned by it. The writings of Willis and Sylvius Dele- boe made some alterations in the received doc- trine of the origin of convulsions, by referring more than their predecessors had done to the nervous system and animal spirits, and less to the influence of morbid humours. It was not, however, until the appearance of the writings of F. Hoffmann, that a spirit of accurate inves- tigation was manifested in this department of medical inquiry. This writer, to whom our science still continues under great obligations, regarded convulsions as a consequence chiefly of a morbid state of the spinal chord and its mem- branes,—an opinion which has been adopted by many, and which numerous facts seem to sup- port, in respect of* several manifestations of these complaints, although it cannot so frequently be shown that this part of the voluntary nervous system is that primarily affected. 3. The opinions respecting the nature and relations of convulsions, entertained during the last century, and what has passed of the present, have been so numerous and vague, that the advantages resulting from a review of them could by no means compensate for the limits they would occupy. Such of them as deserve notice will be referred to hereafter. It may, however, be remarked respect- ing; them, generally, that no two writers of repu- tation agree as to either the import of the word, the diseases coming within this denomination, or the manner of arranging and considering them. Under such circumstances, the systematic and eclectic writer might be placed in much difficulty, if he had not extensive and diversified experience to guide him. Upon this, however, my chief reliance is placed, even while I endeavour to pro- fit by the labours of my predecessors,—some of them my followers in the adoption of important curative means in these affections. [Since this work was written, Dr. Marshall Hall has thrown much light on diseases of the nervous system, especially those of a spasmodic kind, by his various publications. He has, indeed, fully established the physiological principle, that the contractions of all the sphincters, of the oeso- phagus, the glottis, the iris, the eye-lid, and the regular action of the muscles of respiration, are sustained, independently of the will, by a nervous influence conveyed by afferent nerves from the respective parts or surfaces to the spinal marrow, and reflected from it through the efferent nerves to the muscles connected with these parts. The increase of this involuntary excito-motory power, is instanced in the spasm of the throat, and some- times of the sphincters, in hydrophobia, tetanus, and some hysterical affections. The humid respi- ration, the convulsive cough, violent retching and hiccup, which are occasionally presented in these and other nervous diseases, may also in part be traced to an undue influence of the excito-motory nerves of organic life. These actions are some- times excited by sensations, as the breathing, by feeling of want of breath, cough, by tickling in the air-passages, retching, by nausea, &c.; but where there are no such sensations, or where they bear no proportion to the violence of the actions, we are warranted in concluding that the excito-motory function is itself exalted. A similar exaltation of the excito-motory function, independent of sensa- tion and volition, is exemplified in the voluntary muscles, when they are deprived of sensation and voluntary motion by disease in the brain itself, or cutting off communication between the brain and spinal chord, without materially injuring the cord itself: as in paraplegia from an injury to the upper part of the spine, or, as occurs in the symptom of “ fidgets,” caused by irritation reflected from the lower part of the intestinal canal, or from the uterus (Williams). Convulsive disorders, then, according to Dr. Hall, are to be referred to an irritation of the true spinal system : and this irritation may be centric, as in epileptic and apoplectic convulsions from dis- ease in the head, and those from loss of blood ; in which cases, the medulla oblongata and spinal chord being excited, the excito-motory influence radiates to the limbs and muscles generally ; or it may be eccentric, commencing with irritation of the extremities of some afferent nerve, which transmits it to the spinal centre, whence it is again reflected generally or partially. Such are the convulsions arising from teething, uterine, intestinal, and renal irritation; and a slighter degree is exemplified in the rigour caused by the sudden impression of cold on the surface, or by passing a bougie into the urethra of a nervous person. Partial spasms caused by reflected irrita- tion, are exemplified in cramp in the legs, from acrid matter in the colon, in diarrhoea, and cholera: retraction of the testicle from calculus or inflam- mation of the kidney: spasm of the glottis, from teething, gastric irritation ; sneezing, from irrita- ting the nares, &c. We have also instances of reflected irritation in involuntary muscles, as palpitation of the heart from irritating matters in the stomach or intestines, kidneys, or other vis- cera. The same organ is excited to inordinate action by irritation set up in any part of the system, as in fever, or local inflammation. Spas- modic action of the bronchial tubes, occasioning what is called spasmodic asthma, is also pro- duced by gastric and intestinal irritation, trans- mitted to the spinal chord, and hence reflected upon the affected organs. Dr. Hall supposes that when the phenomena of inordinate reflex actions are general or extensive, as in convulsions, tetanus, and paraplegia, they are to be referred to an un- due excitement or erethism of the spinal and pro- longed medulla; but that the more partial exam- ples may arise from similar excitement of a small portion of it only, or of the incident (afferent) nerve of the part which occasions the phenomenon, or of the excito-motory (efferent) nerve of the part which exhibits the phenomenon. Dr. Williams (Principles of Pathology, p. 107,) thinks that the causes of this excitement may be sometimes referred to an increased flow of blood through the spinal marrow or its nerves, or the branches of the sympathetic nerve. Thus we have convulsions, or spasms, in the early stage of inflammation of the spinal chord, or its sheath. He also thinks that the convulsions in epilepsy and apoplexy are, in part, owing to the flow of blood through the medulla, being increased in pro- portion as that through the brain is impeded. But in many cases the excitement is of a more direct nature, as in the tetanic spasm caused by strych- nine, or the convulsive motions produced by me- chanical irritation of the spinal marrow or of its nerves. Here we have immediate effects which can scarcely be attributed to a flow of Wood to the spinal chord. The same writer thinks that another cause for increase of the involuntary ex- CONVULSIONS—Forms of. 481 cito-motory property, is accumulation by rest; causing its augmentation in the medulla in nar- cotism, and in injuries of the spine, which suspend the exhausting influence of volition on the whole or part of the marrow, in which the nervous energy therefore accumulates, and becomes un- usually abundant. It is highly probable, as Dr. W. suggests, that sedentary habits and too much indulgence of sleep, may cause an accumulation and morbid excess of nervous power, and thus develop convulsive and spasmodic symptoms, which are the results of its overflow. (Loc. cit.) Muller (Elements of Physiology, Phil., 1844,) states that the cause of convulsions may be seated in the nerves themselves, in the brain, or in the spina! chord. When in the nerves, the convulsions are caused by the reflection on motor nerves, by the spinal chord and brain, of an influence com- municated to them, either from local diseases of nerves, as tumours or neuralgic affections ; from any strong impression on sensitive nerves, or, in children, from any local disease. When convul- sions arise from disease of the spinal chord, or of the brain, they observe the same laws as paraly- sis from cerebral disease. It is, however, to be remarked, that lesions of the cerebral hemispheres, the cerebellum, and the pons varolii, are more prone to cause paralysis ; lesions of the corporal quadrigemina and medulla oblongata, to cause both paralysis and convulsions, p. 637.] 4. If, in defining convulsions, we state it to be “ an abnormal action of muscular or fibrous parts,” we at once make it synonymous with spasm, and embrace a most numerous class of dis- eases, viz. those forming Dr. Cullen’s order, Spasmodic Diseases, as well as many of those in which spasm is merely a part of the morbid state. If we define it to be “ an irregular or abnormal action of voluntary muscles,” we shall comprise all those maladies which usually put on nearly a regular form of type, owing to certain pecu- liarities of the spasmodic action and concomitant phenomena, as tetanus, epilepsy, &c. But if we adopt the more confined and precise definition given above, we shall include those disorders only which assume no regular type ; but which, whilst they approach, on the one hand, those of a regular form, often pursue, on the other, very eccentric courses, and even anomalous states. It is impos- sible to consider the diseases of the frame in a woy true to nature, and at the same time as abstract entities—as species perfect and distinct of themselves. They are individually, in truth, merely certain morbid states, lapsing on the one side insensibly into others, to which, although most intimately allied in every respect, different names have been but too arbitrarily assigned; and passing on the other side into affections other- wise denominated, although not materially differ- ing in their natures. Thus, if we make spasm the essential character of one great family of diseases, we may divide it into subordinate orders, genera, and species, according to the parts affected, and the functions concomitantly disordered, and the permanency, the rigidity, the relaxations, and the frequency of recurrence of the spastic action. But still the essence of disorder will be very gen- erally the same ; and each of these subdivisions each of the manifestations of the particular morbid states made the basis of distinction—will so insensibly glide into each other, as to defy the possibility of drawing lines of demarcation be- tween them. The practitioner will be unable, on many occasions, to detect in practice the specific differences assumed ; and will continually meet, as I have in many hundreds of instances, with cases which he cannot refer to one species more than to another, and which are as much eclamp- sia as epilepsy, or as much what are usually called convulsions as either the one or the other. If we take the character of the spasm, in respect of permanency, rigidity, relaxation, and recur- rence, as a basis of arrangement of all the dis- eases attended by abnormal action of voluntary muscles, we shall have every grade, passing im- perceptibly from the most acute form of tetanus through cramp, epilepsy, eclampsia, convulsions, &c., down to the most atonic states of chorea and tremor. Also, if we consider the affections called convulsions, and which are usually irregu- lar in their forms, with reference to the character of the abnormal contraction of the muscles, we shall perceive it in some cases of the most violent and spastic nature, frequently of some contink- ance, the relaxations being of brief duration, or scarcely observable ; and in others nearly or alto- gether approaching to tetanic. These constitute the more tonic form of convulsions, from which there is every possible grade, down to the atonic or most clonic observed in chorea or tremor Thus, then, abnormal actions of muscular parts, like all other morbid actions, may, in respect of grade, be either above or below the healthy stand- ard—tonic and clonic marking each respectively ; but between which there exists every possible degree ; these terms being therefore entirely rela- tive, and conveying no definite and unchanging meaning. But, besides varying remarkably as to grade, the abnormal actions of voluntary mucles may be attended by numerous phenomena giving them specific characters. Thus, when accom- panied with complete insensibility, or any other superadded morbid condition, they have been de- nominated epileptic, hysterical, &c. ; and, from this circumstance, they assume certain types, but of no very constant or immutable kind. When, however, they are not so associated, they consti- tute a simpler state of disease, and put on less regular forms, affecting either the whole of the voluntary mucles, or a greater or less number of them. 5. I. Forms.—From this, therefore, it is to be inferred that, although Dr. Cullen, and many others, have considered convulsions as character- ised by the clonic nature of the spasms—by the alternation of contraction and relaxation without the control of the will—yet this does not univer- sally obtain, they sometimes assuming states ap- proaching to tetanic, and every degree of violence, as well as length of duration. The more regular and specific forms of convulsion, as epilepsy, hysteric fits, raphania, hiccup, tetanus, rabidity, &c., are discussed in separate articles ; I shall, therefore, consider at this place only those simple and irregular states of convulsion which do not fall within its more specific manifestations. 6. Simple convulsions present great diversity of character. They have been already shown to differ widely in violence and degree ; and they vary as greatly in duration, modes of accession, and recurrence, as well as in the number of parts affected by them. Hence, they may be acute or chronic—most frequently the former ; partial or general; continued, recurrent, or intermittent; uncertain, in their accession, or periodic; and they may, moreover, attack a number oi purls 482 in succession. The circumstances and causes which originate them will also impart to them certain characters, which, although frequently difficult of detection, should not be overlooked. Thus, they are either idiopathic or symptomatic, most frequently the latter, even when the primary lesion elludes observation. But these diversities of form, although most deserving of attention, can only partially serve as a basis for the prac- tical consideration of convulsions. I shall there- fore view them, 1st, In respect of their partial or local occurrence ; 2d, As to their general mani- festations ; 3d, As they affect infants and children ; and, 4th, As we observe them in connection with the puerperal states: I shall also notice them as associated with, or consequent upon, other acute diseases. 7. i. Partial or Local Convulsions :—Many of the disorders which have been imputed to con- vulsion of individual parts, fall more appropriately under the denomination of spasm. I shall there- fore briefly notice only such as, from the alterna- tion of relaxation and contraction, appear to ap- proximate to the convulsive state. A. Involuntary contractile parts are more subject to spasmodic ac- tion, than to that which may be said to be really convulsive. Whether or not certain of the pheno- mena presented in various diseases of the aliment- ary canal, as gastrodynia, pyrosis, rumination, retchings, colic, borborygmi, ileus, the tormina of dysentery, &c., are more properly convulsive or spasmodic, must be entirely a matter of opinion, to which but little practical importance should be attached, as they are both modifications merely of the same proximate condition. This remark ap- plies equally to the abnormal actions sometimes presented by the urinary bladder and uterus; and it is probable that palpitations of the heart, and angina pectoris, are chiefly manifestations of convulsive contractions of this viscus. (See An- gina Pectoris, and Heart—Palpitations of.) That hiccup is altogether owing to convulsive actions of the diaphragm, cannot be doubted. (See Hiccup.) 8. B. Voluntary muscles and parts present the most unequivocal appearance of partial or local convulsions; although several local affections, denominated convulsive by some writers, are, more strictly speaking, spasm or cramp of particu- lar muscles.—a. The muscles of the eye-lids, owing either to the contraction of an ill habit, or to irritation of the ophthalmic branch of the fifth pair of nerves, are sometimes clonically convulsed —forming the nictitatio of;' authors.—b. The muscles of the eye-balls are also not infrequently similarly affected, particularly in infants and children—occasioning, particularly during sleep, rolling of the eyes. This state of local convulsion is common during dentition, and disorders of the stomach and bowels. Either a more severe state of convulsion of these muscles, approaching to spasmodic contraction of one or more of them, or a paralysis of their antagonists, will occasion distortion of the eyes, or strabismus, with or without irregular oscillations of the iris, dilated pupil, &c. ; as in inflammatory and organic affections within the cranium, and in verminous disorders.—c. Twitching convulsions of the mus- cles of the face, or those inserted into the lips ; retraction of the angles of the mouth, giving rise to what has been called the risus sardonicus; are often observed, but generally as a symptom of the invasion or actual existence of most danger- CONVULSIONS—Local. ous diseases ; as inflammation of the encephalon, or of the diaphragm, and various organic changes affecting the substance of the brain. Twitchings of the muscles of the face, however, sometimes occur in persons of a nervous and irritable tem- perament, or with an excited brain, without any apparent disease.—d. Convulsive movements of the tongue are seldom observed unconnected with irregular movements of other parts, unless in the diseases now named and in apoplexy.—e. Slight convulsive actions of the muscles of the lower jaw, giving rise to grinding of the teeth in sleep, are very common occurrences in persons with worms, or other diseases of the alimentary canal ; or ex- cited circulation of the encephalon. I have seen a case of clonic convulsion of the muscles of the lower jaw, this part being in a state of constant motion, alternately to either side, owing to the contractions of one side taking place when relax- ation occurred in the other.—/. Trismus, or spas- modic contraction of these muscles in infants, arises from disorders of the prima via, the impres- sion of cold, or irritation of the umbilicus, but does not strictly fail under the head of convul- sions.—g. A clonically convulsed state of the muscles of the neck is sometimes, but rarely, observed, producing convulsive tremor, or shaking palsy of the head, which is aggravated on certain occasions of mental perturbation, and nervous or vascular excitement. (See Palsy, Shaking, and Tremor.)—h. The abnormal actions which ap- proximate more closely to the permanent or spas- tic contractions, and affect one or more of the cervical and adjoining muscles, are much more common, and are often induced by a current of cold air, by over-straining, or by inflammatory irritation about the bodies, or intervertebral sub- stance of the upper cervical vertebrse ; or from disease about the medulla oblongata or base of the brain ; or from irritation of remote parts—as of the genital organs of the uterus or ovaria ; or from strangulated hernia,—an instance of which last has been observed by myself. In all such cases, the head is drawn more or less to one side, or backwards, or forwards ; but similar flexures of the neck often are occasioned by the paralysis of muscles on the side from which the head is bent, the tonic or natural action of the unaffected muscles drawing the head from the paralysed side. In the one case, however, the muscles are rigid and strung like a cord on the contracted side, and more or less pain is complained of either in them or in the vicinity, particularly on attempts to bend or turn the head or neck in an opposite direction ; whilst, in the other case, these symp- toms are wanting. These are more properly cases of spasm than of local convulsion, as the contraction seldom alternates with relaxation, but is commonly more or less permanent. However, cases sometimes occur, which are intermediate between permanent spasm and convulsion, espe- cially as a symptom of the diseases last referred to—i. Convulsive movements in the pharynx and ossophagus, impeding or preventing deglu- tition, are frequent in hysteria, and in the last stage of several fatal diseases.—k. They also affect the muscles of the larynx, the diaphragm, and other respiratory muscles, either separately, in rapid succession, or nearly simultaneously. Some of these affections are transient, and the result of slight causes ; as in sneezing, coughing, sighing, sobbing, &c.: others are extremely dan- gerous, owing to the nature of the parts affected, CONVULSION S—General. 483 the severity and continuance of the convulsive movements, and the circumstances in which they supervene ; as in spasm of the glottis, spasmodic croup, certain states of asthma, with severe fits of coughing, singultus, &c.—1. Convulsive actions also occur in the muscles of the abdomen ; as in hysteria, common and lead colic, and in conse- quence of intestinal worms. The most remarka- ble instances of true convulsions of the abdominal muscles merely, that I have observed, have oc- curred in adult persons infested by the large round worm.—m. The muscles of the spine sometimes experience convulsive actions, but more frequently spastic contractions, occasioned by hysteria, dis- ease of the bodies of the vertebra; or membranes of the spinal chord, injuries of adjoining parts, strangulated hernia, acute rheumatism, the pas- sage of biliary or renal calculi along the ducts, and inflammatory irritation of the uterus or ovaria. —n. Either one or both of the upper extremities are occasionally affected by convulsions, more commonly both. The fingers are generally clenched around the thumb, which is drawn upon the palm ; the arm being either extended forcibly, and the hand turned as in pronation, or the fore- arm bent upon the arm, or both these occurring in rapid alternation. Such are the more tonic convulsions of the upper extremities ; but their muscles also experience slight and extremely clonic contractions ; as the subsultus tendinum often observed towards the close of fevers and diseases of the brain ; the more tonic or spastic convulsions, particularly when affecting one arm only, also arising from lesions of some part of the encephalon, or of the upper portion of the spinal chord.—o. Convulsions of the lower extremities are characterised by analogous movements, and chiefly affect the flexor and extensor muscles. The toes are bent downwards, and the legs and thighs either drawn upwards or extended, or both the one and the other alternately. 9. Convulsions of voluntary muscles may oc- cur as now described, or in two or more situations, or even in different or opposite parts, either simul- taneously or in succession. They may affect one side of the body only, the other being in its na- tural state, or paralysed. They much less fre- quently attack either half tranversely. 10. ii. General Convulsions.—General con- vulsions observe no certain mode of accession. On some occasions they attack suddenly ; but they are much more frequently preceded by pre- monitory signs, especially in children and chronic cases,—a knowledge of, and attention to, which may be made available in preventing their oc- currence. They are also sometimes recurrent, or succeed each other, with more or less rapidity. 11. A. The premonitory signs are vertigo and dizziness, irritability of temper ; flushings, or al- ternate flushing and paleness of the face ; lumi- nous or other spectra floating before the eyes ; va- rious noises in the ears; partial loss of sight or hearing ; restless or unsound sleep, or uncommon weight or drowsiness; fulness or prominence, and rolling of the eyes ; clenching or grinding of the teeth, clenching of the hands, &c. during sleep ; a tumid appearance of the countenance and hands; coldness or cramps of the extremities; slight tremors, shivering, horripilation, shudderings or horrors ; nausea, retching or vomiting; or pain and distension of stomach and left hypochondrium ; unusual flatulence of the stomach and bowels, or other dyspeptic symptoms ; pains in the loins or back ; frequent sighing or sobbing; numbness of various parts ; stammering or impeded utterance, loss of memory, and absence of mind; palpita- tions, or slowness and irregularity of pulse ; slow, laborious, or irregular respiration ; and sometimes a copious discharge of limpid urine. In some in- stances, leipothymia, or threatened syncope, pre- cedes the general convulsions. 12. B. a. The more tonic seizure.—The con- vulsive movements constituting the paroxysm generally follow rapidly upon one or more of the above signs, and very remarkably as to violence and duration. During their continuance, the countenance is very much distorted ; the eye-balb are prominent, full, wild, staring, and rolled in all directions; the eyelids are either open, or rapidly shut and opened ; the patient grinds and gnashes his teeth, and sometimes foams at the mouth, or protrudes the tongue. The alternate contractions and relaxations of the whole voluntary muscles, and contractions and extensions of all the limbs, are performed with the utmost irregularity, ra- pidity, and with so great force, as often to require the united strength of several persons to prevent the patient from injuring himself. In these strug- gles, the teeth, or even the bones of the extremi- ties, have been known, in some instances, broken. The respiration is laborious, interrupted, and sometimes accompanied by a hissing noise. The countenance, and indeed the whole scalp, are sometimes tumid, bloated, or red, and often leaden or livid towards the close of the fit, par- ticularly in plethoric persons, when the respira- tory actions are much impeded, and the affection originates in cerebral disease. In other cases, the face is pale, and the pulse weak, or small and constricted. The urine and faeces are occasion- ally voided with violence duriug the paroxysm: occasionally large quantities of limpid urine are passed. In these, the pulse is generally full, strong, and commonly slow or irregular. In many instances, the general sensibility and conscious- ness are but very slightly impaired, particularly in the more simple cases, and when the proximate cause is not seated in the encephalon ; but in proportion as this part is affected, primarily or consecutively, and the neck and face tumid and livid, the cerebral functions are obscured, and the convulsions attended by stupor, delirium, &c., or rapidly pass into, or are followed by, these states. 13. b. The more clonic convulsions.—Such are the common manifestations, of convulsions, when they are not occasioned by inanition ; the paroxysms, however, varying greatly in violence, duration, and frequency of recurrence, according to the degree of vital energy, and numerous other circumstances. But when they arise from, or are associated with, exhaustion, excessive dis- charges, and evacuations of the vascular system, they assume a somewhat modified character. They are then not attended by sopor ; the general sensibility and cerebral functions being but little, or not at all affected The pulse is frequent, small, weak, broad, or open; the features are but slightly distorted; the countenance is pale and collapsed; and the limbs and extremities cold, and much less rigidly convulsed than in the tonic or more spastic seizures. In many cases, the convulsive movements resemble a succession of general shocks, succussions, or shudderings, sometimes of great violence, and often of con- siderable continuance, occasioning the bod or 484 room to shake, and terminating the life of the patient: in others, they consist of constant tossings of the limbs and trunk. 14. C. Duration and recurrence.—The pa- roxysm may cease in a few moments or minutes, or continue for some, or even many, hours. It generally subsides rapidly, the patient experien- cing, at its termination, fatigue, headach, or stu- por ; but he is usually restored in a short time to the same state as before th6 seizure, which is liable to recur in a person once affected, but at uncertain intervals, i After repeated attacks, the fits sometimes become periodic (the convulsio re- currens of authors.) In adult females, they com- monly accompany the menstrual period When they arise from organic disease within the cra- nium, each successive interval is generally short- ened, until their recurrence is so frequent that the patient is scarcely recovered from the languor or other symptoms, consequent on one seizure, until he has another, which at last either ends in pro- found coma, or terminates life. 15. D. The modifications of convulsion are ex- tremely numerous. In some cases, the respira- tory muscles are much affected, and the fit is ac- companied with yelling and shrieks, evidently not proceeding from pain (the convulsio ejulans, or shrieking convulsion.) In other instances, the abnormal movements shift from one part to ano- ther, or attack various muscles in succession. In these the seizure is comparatively slight, and the cerebral functions not remarkably disturbed ; the convulsio erratica of Dr. Good. In rarer cases, the seizure assumes the form of convulsive tremor, as remarked by Dr. Prichard ; is attended with a hot, perspiring state of the head, vertigo, and slight stupor, and continues one, two, or three hours. 16. a. Besides these, various other forms of convulsion occur, particularly in persons under the influence of a morbidly excited imagination, or religious enthusiasm ; and in females endowed with the nervous and irritable temperaments, with great mobility of the muscular system, and who are affected by nervous or vascular excitement of the generative organs. On many occasions these seizures have been propagated to a number of persons by sympathy. The convulsions which became almost epidemic in the west of Scotland, in 1742, and were occasioned by religious enthu- siasm, are not only instances of a peculiar form of this affection, but also among the most striking on record of the influence of imagination, and of sympathy, or of imitation, in disordering the functions of the body. A number of persons were attacked nearly at the same time, when hearing the addresses directed to the imaginations and passions of their hearers by the followers of Whitfield ; and always when impressed by the denunciations of vengeance and hopes of sal- vation which they set forth. The mental agony which was thereby induced, gave rise, in many, to the most violent tremblings and agitations of the body, which were frequently preceded by faintings, and followed by convulsions, and sub- sequently by sobbing, weeping, and crying aloud. In some cases the convulsions produced epistaxis, which generally terminated the seizure. Such appears to have been the usual course of the paroxysm, according to the meagre accounts which have been furnished of it. (See Edin. Med. and Surg. Journ. vol. iii. p. 442.), The con- vulsions described by Mr. Cornish as having been CONVULSIONS—Infantile prevalent in Cornwall in 1813 and 1814, owing to the same causes, hardly differed in any respect from the above. 17. b. The convulsions which were prevalent in some of the Zetland Isles during the middle and towards the close of the last century, but which have seldom occurred there since that period, seem to have had some resemblance to the foregoing as well as to hysteria. Dr. Whytt has referred to the frequency of convulsions in these islands ; and has adduced the extreme fa- cility with which they were propagated among young women, as a proof of the existence of a wonderful sympathy between the nervous sys- tems of different individuals. The convulsions now alluded to, commonly attacked adult females when at church; but men and young girls were not altogether exempted from them. They are described very nearly as follows, by gentlemen who had frequently witnessed them :—Persons affected, generally fall down in apparent fainting or swooning fits, and soon afterwards utter wild cries and shrieks, the sound of which puts all who are subject to the disorder in the same situ- ation. Their limbs and bodies are tossed about, the most frightful screams being uttered by them all the while. Their heads are also thrown from one side to the other, and their eyes are fixed and staring. In this manner they roar and struggle for five or ten minutes, and then rise up without recollecting a single circumstance that happened to them, or being in the least fatigued by the exertions made in the fit. Females are most commonly attacked in a crowded church, and on occasions of public diversion and merriment. 18. Similar instances of the spread of convul- sions, by the infection of sympathy or imitation, have been recorded by writers, and cases of it have occurred within the observation of the au- thor. Dr. Haygartii has adduced a remarkable occurrence of this description.—Twenty-three females, from 10 to 25 years of age, and one lad of 17, who had all intercourse with each other, were seized, in 1796, in Anglesea, with slight pain of the head, or of the stomach and left side, followed by twitchings or convulsions of the upper extremities, continuing with little intermission, and with much violence, for a considerable time. The disorder was not so violent in bed; but it continued in some cases during sleep. The pulse was moderate, the bowels costive, and the gen- eral health not much impaired. There was usually hiccup ; and, when the convulsions were most violent, giddiness, with loss of hearing and recollection. During convalescence, the least fright or sudden alarm brought on a slight pa- roxysm. (See Chorea and Related Affec- tions, &c.) 19. iii. Infantile Convulsions.—Convulsions often attack infants of a delicate and irritable frame, and those who are seized by severe internal or constitutional disease, or are suffering some concealed visceral irritation. They occur most frequently in children under four or five years of age, and particularly during dentition. They de- cline in frequency from this epoch to the com- mencement of the second dentition, or about the seventh year, when they again are often met with. Mr. North doubts that any increase takes place at the seventh year. The above is the re- sult of my experience, which in great measure agrees with that of Beaumes, Tissot, and others As infantile convulsions present various peculiari* ties in their causes, phenomena, complications, and consequences, and are besides among the most important morbid conditions which come be- fore the practitioner, I shall consider them apart. 20. A. Premonitory signs often usher in the attack, but occasionally no such symptoms are observed. I suspect, however, that they are more commonly altogether overlooked, than entirely absent. They consist chiefly of manifestations of generally increased irritability. This is shown by the temper, if the child be a few months old or upwards; by want of sleep at night, and heaviness in the day, or by perfect insomnia ; by a lighter and shorter sleep than usual, the child starting up on the slightest noises, or as from a frightful dream, with fits of screaming with- out evident or sufficient cause; by alternately flushed and pale countenance or unwonted ani- mation of the face and eyes, followed by languor and heaviness ; by a half closed or open state of the eyelids during slumber, with startings and tw’itchings; by fixed, vacant, staring eyes, the pupils being either contracted or dilated, or fre- quent oscillations of the iris, without being in- fluenced by the admission of light, or contraction of one pupil while the other is dilated ; by stretch- ings or rigid extensions of the limbs ; by hiccup, or irregularity of breathing, or short gasps, fol- lowed by long laborious inspirations ; by twitch- ings of the fingers, or clenching of the hands, or pressure of the thumb upon the palm, the fingers being extended and separated from each other, or frequently moved about; by the sudden relin- quishing of the breast soon after having sought it. eagerly, and the throwing back the head, with an expression of anxiety, and an appearance of dif- ficult deglutition ; and by fulness of the upper lip, with a pinched nose and countenance, and slight blueness below the eyes and about the mouth. Many of these symptoms, designated by the vulgar, “ inward fits,'” may with justice be attributed to inflammatory irritation of the arachnoid, as indeed contended for by Parent, Martinet, Lallemand, &c. ; and, in my opin- ion, especially of the arachnoid of the base and internal surfaces of the brain. Bracket and North have enumerated them as premonitory of convulsions, which they doubtless most frequently precede ; but in a great many cases convulsions hold the same relation to inflammatory and febrile attacks in infants, as rigors do to the same dis- eases occurring in adults ; and hence these signs must often be common to both, and also to some other infantile diseases. This is shown by their frequency in remittent fever, and other inflam- matory irritations of the gastro-intestinal mucous surface of children. 21. B. The paroxysm of convulsions in chil- dren is similar to that occurring in adults. In the most severe cases, there is a violent, involuntary, and alternating or convulsive action of all the voluntary muscles extending to some internal or involuntary parts ; in which, indeed, the affection often seems to originate, or which appear to be those first affected. In plethoric infants, the face and scalp are tumid, reddened, and subsequently livid ; the eyes are distorted and staring, or turned up beneath the upper eyelid, leaving only the schlerotie visible ; the respiration is impeded and laborious, but very rarely attended by foaming at the mouth and protrusion of the tongue, unless the paroxysm be epileptic. The whole surface often becomes slightly violet-coloured towards CONVULSIONS, INFANTILE—Symptoms and History of. the close of the fit, and the hands tumid. In many instances, paritcularly in weak or exhausted children, the seizure is much less violent, the countenance being pale and collapsed, and the convulsions more clonic. There are sometimes only twitchings of the muscles of the face, and alternate contractions and relaxations, or rapid shocks, of a few parts, or of only one half of the body, or of various parts in succession, with slight blueness about the eyes and mouth ; but more fre- quently the whole body is convulsed, and the countenance distorted and haggard. In some cases, the thumbs are drawn into the palms, and the great toes towards the soles. The mental faculties, and general sensibility, in the slight or clonic convulsions, are generally not interrupted. They are also, however, frequently obscured, but only during the height of the paroxysm; and sometimes even entirely abolished in the severe recurrent convulsions attending cerebral disease —the eclampsia of some authors (§ 24.). 22. C. The utmost diversity exists as to the duration and recurrence of the fit. In some cases it is only momentary or of a very few minutes’ duration. In other instances it continues for several hours, with frequent remissions. It may likewise cease, and shortly afterwards re- turn, and thus subside and recur at short but irre- gular intervals for several times, and at last cease altogether, or terminate life. Or the first seizure may be so severe as to be fatal. These recurring fits are often at last attended by insensibility, which is not altogether, or even not at all, re- covered from in the intervals. This form of the malady is more common in children than in adults, excepting as it occurs in the puerperal states, or towards the termination of tumours and abscesses in the brain. As the convulsive move- ments constituting the fit become less and less violent and constant, and respiration fuller and freer, the natural appearance of the surface re- turns, and the child is enabled to cry ; it after- wards falls either into a refreshing sleep, or, if the convulsions have a cerebral origin, into a stupid or lethargic state of various duration. 23. D. There is a species of spastic or tonic convulsion, which is but rarely met with, affect- ing chiefly the extremities. It seems more nearly allied to spasm than convulsion, into which, how- ever, it sometimes passes ; and occurs, chiefly, in very young children, and in those approaching to puberty, particularly those who are nervous and irritable. I have seen but few instances of it; but it has more frequently been seen by MM. J a delot and Tonnelle. It consists of rigid con- traction of the upper and lower extremities, of the former only, but more frequently of both. The hands are slightly bent on the forearm, and the feet are stretched in the same axis with the leg. The spastic action of the muscles continues for several horn's, or even days, then ceases, and returns, and often thus recurs frequently at short intervals. The intellectual faculties, the general sensibility, and the muscles of the trunk, are not affected; and the pulse and natural func- tions not materially disturbed. The cases of it which have occurred in my practice, have all been evidently owing to the irritation of worms, or morbid matters in the alimentary canal, or to dentition. 24. E. Another form of convulsions is much more frequently met with in children, to which the name of Eclampsia has been given by Rosen, 485 486 Sauvages, Brachet, and others, and which has been considered as infantile epilepsy by some, and, with more justice, by others, as convulsions occurring in the more robust children as a conse- quence of cerebral congestion of an active form. But it differs from epilepsy, in the absence of foaming at the mouth, by the irregular and fre- quent recurrence of the attack, by its longer du- ration in most cases, and by its uniform connec- tion with evident signs of fulness of blood, or acute disease in the brain. This form is seldom pre- ceded by precursory symptoms of any continu- ance. The child cries, its face and scalp be- come red and tumid, it loses consciousness, and is seized with violent convulsions, or with tremor and rigidity, or a succession of spastic shocks of the limbs. In a few seconds, or minutes, or even hours, the seizure subsides ; but is generally re- newed at short intervals; the head remaining hot and pained after each return of the fit, which never terminates by a critical sleep of short con- tinuance, and in restoration of the healthy func- tions, as in epilepsy, unless assisted by active treatment, but is frequently followed by profound stupor or complete insensibility. From the fore- going it will be evident that eclampsia is merely a more severe form of convulsion, differing from others only in respect of the severity or tonicity of the muscular contractions, the more complete abolition of sensibility and of the cerebral func- tions, and its more uniform dependence upon congestion of the brain and its consequences (§ 21.). The eclampsia of children is in every respect similar to the convulsions of the puerperal states (§ 29.). 25. F. There are certain phenomena con- nected with the accession and the course of the convulsive fit that require attentive observation, as they furnish indications of the pathological state occasioning the seizure, and, indeed, form the basis for rational indications of cure. These have intimate relation to the origin of the parox- ysm either in repletion or inanition—in congestion or in anaemia of the cerebro-spinal masses; in which latter the convulsions of children not in- frequently originate, as shown by Dr. M. Hall and Dr. Gooch, and subsequently by others, and as I have had frequent opportunities of remarking for many years. When the convulsion is at- tended with a congested state of the circulation in the head, it wifi generally be readily recog- nised, both from the history of the case, and from the premonitory and concomitant symptoms. The warm, tumid scalp and face; the flushed coun- tenance ; the contracted pupils and suffused con- junctiva ; quick, full, or hard pulse, particularly of the carotids ; are evident signs of an excited circulation in the brain, not infrequently either accompanied with, or running into inflammatory action. When the countenance and scalp are swollen, full, dark, or livid ; the fontanelle elevated and tense; the eyes distorted, prominent, vacant, and stupid; the pupils dilated; the veins of the head and neck large and dark ; the pulse slow, irregular, or oppressed ; the respiration laborious ; the vessels within the cranium are evidently con- gested. Dr. John Clarke, and many other writers, impute the convulsions of children to ir- ritation or organic change, either directly or indi- rectly, induced in the brain or its membranes, particularly in the arachnoid, according to M. Brachet. It wifi be seen, when treating of the proximate cause of convulsions, that, although CONVULSIONS, PUERPERAL—Description of. this may be most frequently the case, it is by no means universally so. For we occasionally meet with convulsions consequent upon exhaustion, and even anaemia, as in the last stages of chronic di- arrhoea, or other diseases ; and after large or re- peated depletions, where there is no evidence of irritation of the arachnoid or of organic change. In many such cases there may occur notwith- standing, especially during the height of the pa- roxysm, temporary and slight congestion of the head, as shown in the article Blood, (§ 54—61.); but, still, evidence of aneemia of the brain, and, indeed, of the general system, will be furnished in the depressed and relaxed fontanelle; in the pale, collapsed, and pinched features; in the re- tention of consciousness and unimpaired general sensibility ; in the bloodless and dull appearance of the conjunctiva and cornea; in the state of the pulse in the carotids, and the low temperature of the head, and in the pale, shrunk, wasted, and often bloodless condition of the whole sur- face. 26. There is a disease to which infants are liable, that consists of a spasmodic contraction of the muscles of the larynx and of the extremities, and which has been confounded with convulsions, or with spasmodic croup, and variously denomi- nated. As the muscles of the larynx are chiefly affected, and as the disorder consists of spastic rather than convulsive action, it is treated of in a separate article. (See Larynx, Spasm of.) 27. iv. Puerperal Convulsions. — Convul- sions may come on (a) during the latter months of pregnancy ; (6) during parturition; and (c) during the first forthnight after delivery. They may be partial or general, most commonly the latter; and they may assume various shades of tonicity, from a state of tetanic violence to the more clonic form, characterised by alternating contraction and relaxation ; but they usually pre- sent very nearly the same phenomena as eclamp- sia—being attended by loss of consciousness, and recurring paroxysms, between which sensation is not restored. 28. A. Premonitory symptoms commonly usher in the seizure ; but, in some cases, they are cither absent, or so brief in duration, or so slight, as to evade detection. Chaussjer thinks that they are scarcely ever wanting altogether. The patient usually complains shortly—sometimes for several days—before the attack, of lassitude, depression, and a feeling of indisposition which she cannot well describe ; frequently of disorder of the sto- mach ; often of weight or pain in the head, or of drowsiness, vertigo, and sparks, or various dark or bright objects floating before the eyes. These symptoms are renewed at intervals during a day or two, and are occasionally attended by embar- rassment of speech. To these usually are super- added, shortly or just before the seizure, a change in the expression of the countenance ; partial or occasional failure of sight, or loss of sight; some- times loss of hearing; haggard, vacant, and fixed state of the eyes, with a dilated pupil; ring- ing or other noises in the ears; sometimes most acute and splitting pains in the head, with a flushed neck and face ; generally sickness, pain, oppression, and anxiety, at the stomach ; thirst; a full and quick pulse ; subsequently a slower pulse ; and swelling of the neck and countenance; tetanic stiffness of the wrists ; cramps in particu- lar muscles or parts; twitchings of the muscles of the face; shocks or shudderings through the CONVULSIONS, PUERPERAL—Description of. trame ; altered respiration ; loss of consciousness ; and all the phenomena constituting the developed seizure. Dr. J. F. Osiander states that he has seldom observed a tumid state of the face and hands wanting as a premonitory symptom. If the convulsions occur during parturition, the pains often become feeble and frequent before the seizure. 29. B. The complete seizure.—To these suc- ceed involuntary contractions of the muscles of the face and jaw, instantly followed by spasmodic succussions, or general convulsions of a violent or tonic character; sometimes approaching to tetanic, but commonly closely resembling eclampsia; or the universal convulsions of the epileptic or hys- terical paroxysm. The respiration is laborious, imperfect, sonorous, aud hissing,—frequently with foaming at the mouth,—and the tongue is often protruded ; the eyes are injected, prominent, fix- ed, staring, or rolling; the countenance and head tumid, red, or livid ; the limbs are strongly con- vulsed, and tossed about; the heart beats strongly; and sensibility and consciousness are entirely abol- ished. After a short time the convulsion subsides ; respiration becomes less laborious, and the coun- tenance less livid ; but the comatose stupor con- tinues, sometimes with slightly stertorous breath- ing; when, after an indefinite, but generally a short, interval, the spasmodic succussions and general convulsions return as before, or with slightly modified severity or duration, and subside into stupor as before. Thus they may recur two or three times—more frequently, several or many times—when the patient either quickly awakes, unconscious of what has passed, as if from a slum- ber ; or passes into a more comatose state ; or recovers partially ; sight and hearing, or speech, or both, being lost for a time. Or she may expe- rience some one of the unfavourable terminations hereafter to be noticed. 30. It may be generally remarked, that, upon the accession of puerperal convulsions, a flux of blood takes place to the head and superior ex- tremities ; the veins of the lower limbs becoming proportionately empty, and the pulsation of their arteries being comparatively small and weak. The worst forms of the attack are often attended by a firm spasmodic constriction of the cervix uteri, preventing the expulsion of the fetus. M. Menard states, that, in the majority of cases of death by convulsions previous to delivery, the child has been found dead, the contraction of the features and extremities denoting that it had par- ticipated in the affection of the mother: this, however, wants confirmation. In some instances, the child has been unexpectedly born during the violence of the convulsions, as if expelled by them with unwonted celerity. [“ Women are far more liable,” says Dr. Den- man, “ to convulsions in first, than in subsequent, labours ; and then, it is said, more frequently when the child is dead than when it is living. But when women have convulsions, the death of the child ought generally to be esteemed rather an effect than a cause, as they have often been delivered of living children when they wore in convulsions, or of dead, and even putrid, children, without any tendency to convulsions.” Of 19 cases of puerperal convulsions recorded by Dr. Joseph Clarke, 16 were first children. Of 48 related by Dr. Merriman, there were 36 instances in which it was the patient’s first labour. Of 30 cases which occurred to Dr. Collins, 29 were in women with their first children; 14 of the 32 children were born alive. In 18 of the 30, the convulsions subsided after delivery ; in 10 the fits occurred both before and after: and in 2 the attack did not come on till after delivery. In 15 of the 30, the patients were delivered by the natural efforts; in 6 delivery was effected by the forceps ; in 8, by the perforator and crotchet, and in 1 the feet presented. Two of the children were born putrid. Five of the women died. In 6 of the 48 cases related by Dr. Merriman, the convulsions did not occur till after delivery. Five of these patients recovered: the other, after the epileptic attack, became maniacal, but appeared to be gradually recovering, when, at the end of three weeks from the first seizure, she was attack- ed with another fit and died. All the children were alive. In three cases the women were pregnant with twins. In 2 of these cases, the attack of convulsions occurred in the interval be- tween the births of the two children. All the wo- men were delivered without artificial assistance : two of them recovered, and three of the children were born alive ! In 11 cases, the delivery was effected by the forceps. All these women recovered, and three of the children were born alive. In nine cases the perforator was employed. Seven of the women recovered. In four cases, the operation of turning was resorted to: two of the women recovered ; all the children were dead bom. In one case the woman died undelivered. In 14 cases, the children were born without extraordi- nary assistance: 10 of these women recovered, and 5 of the children were born alive. Thus 37 women recovered and 11 died ; 19 children were born alive (including the 6 bom before the mothers were attacked with convulsions) ; 34 were born dead. Dr. Ramsbotham has related the histories of 26 cases; of which 10 proved fatal: 13 occurred before delivery, 10 during labour, and 4 after. Dr. Ingleby relates 35 cases ; of which 4 were fatal ; 19 during labour, 11 of which ended fatally ; and 16 after delivery, of which 5 were fatal. (Robert Lee.) Puerperal convulsions are not of frequent occur- rence. Out of 96,903 recorded cases of labour, according to Churchill, there were but 159 cases of convulsion, or 1 in about 609. On the whole, the mortality is considerable, but far less than it formerly was. Jacob states, that in his time scarcely any survived. Dr. Parr, in his Med. Diet., remarks, that 6 or 7 out of 10 die. Dr. Hunter, that the greater proportion were lost. Out of 152 cases, collected from Clarke, Churchill, Merriman, &c., 42 mothers were lost, or more than one-fourth.] 31. C. Modifications.—In persons of a nervous temperament, local pain or irritation, or even ex- haustion alone, may induce that state of cerebral affection upon which convulsions are consequent, without the supervention of plethora, and active congestion of, and determination of blood to, the brain, characterising the great majority of cases. In these persons, the seizure is sometimes preceded by sinking, leipothymia, or fainting; the counte- nance is neither tumid nor livid ; the eyes and face are unsuffused, but wild—often sparkling, staring, or rolled irregularly ; the pulse is small, hard, or constricted; the urine is frequently copious and pale ; and the agitations and tossings of the limbs greater, but less rigid or spastic, than in the mixed epileptic and apoplectic forms described above. In these cases, there is evi- 487 488 dently cerebral irritation, or erethysm ; and, during the paroxysm, abolition of consciousness ; but the patient generally either partially recovers her sensibility between its exacerbations or recur- rences ; or awakens out of this state entirely restored, and without experiencing any of those sequela? which are left by the more congestive attacks. In other instances, seizures occur, pre- senting characters intermediate between these ; but the first described state is by far the most common. From this it may be inferred that convulsions, in any of the three periods con- nected with child-bearing, will evince modified phenomena, according to the constitution, tem- perament, habit of body, predisposition, and pre- vious ailments of the patient. In the plethoric, epileptic, irritable, sanguine, and robust, it will present the characters of eclampsia or epilepsy —the most common—or of apoplexy or coma ; and in the hysterical, the nervous, the delicate, &c., it will assume these now noticed, which ap- proach those of a severe hysterical attack. The convulsions which come on in the puerperal states, from large losses of blood, are either of this kind, or of one closely resembling it, or intermediate between it and the epileptic. 32. v. Convulsions associated with other Manifestations of Disease.—Convulsions may occur on the invasion, during the course, and at the crisis or decline, of a great number of acute diseases, particularly in children under eight years, about the period of puberty, and in females of a nervous and susceptible constitution. Their connection with irritations, &c., in the prima via, and with organic diseases in, or affecting the large nervous masses, is considered at another part (§ 37. 44, 45.) ; but their association with some other maladies require a more especial notice in a prac- tical point of view. a. The invasion of various acute distempers is often attended by convulsions. Indeed, in some of the severe diseases to which young children are liable, particularly the exan- thematous fevers and inflammations, convulsions usurp the place of the cold stage or rigors which usher in these diseases in adults, and are gener- ally preceded by coldness of the surface. When occurring in this manner, they should be regarded as indicating one of three things, viz. a morbid susceptibility of the nervous system, and predis- position to disease in the cerebro-spinal axis ; or an approaching dovelopement of febrile reaction and of eruption, if the patient be of a sound con- stitution ; or else an imperfect evolution of both, with a disposition to visceral irritation, inflamma- tion, or effusion, particularly of the brain or abdo- minal viscera, if the habit of body be in fault, or if there exist any hereditary disposition, or vice remaining after previous disease. 33. b. The course of various diseases sometimes becomes associated with occasional or recurring convulsive seizures ; often of a partial, or of an irregular, peculiar, or anomalous character ; but frequently, also, such as those described under general convulsions (§ 12, 13.). Children, and females about the period of puberty, are most liable to these complications. We observe these seizures in hooping cough and croup; in the remitting fevers of infants ; in mania, and febrile insanity ; in inflammatory and numerous organic diseases of the brain (§ 37, 44, 45.) and spinal chord ; in verminous complaints, and other disorders of the alimentary canal ; in organic lesions and calculi of the kidneys and urinary bladder ; CONVULSIONS—Complications of. and in states of nervous and vascular excite- ment or irritation of the female organs. In all these complications, either active congestion or determination of blood to the head, or irrita- tion of the cerebro-spinal axis and membranes, or both these states, may be presumed to exist ; active congestion being occasioned by impeded return from, with increased impetus of the cir- culation to, the brain and medulla oblongata ; irritation of these parts being generally propa- gated thither from some portion of the organic nervous circle, and through the medium of this circle, in which it had been primarily excited. We not infrequently observe convulsions attended or followed by mania and insanity, or even supervene in the course of these mental dis- orders. When this is the case, the convulsive seizure is commonly of a tonic and acute form, and approaches nearly to eclampsia and epilepsy, constituting the maniacal convulsions of authors. The convulsions which occasionally are observed in females, in connection with irritation of the sexual organs, are evidently owing to the propa- gation of disorder, through the medium of the organic or ganglial, to the spinal nerves, or to the chord itself, or even to the brain ; as well as to the extent to which these various parts of the cerebro- spinal system are thereby influenced ; and the various forms which the convulsions thus origi- nating commonly assume, are to be imputed to the existing state of local or general plethora, or to the degree of determination of blood to the head with which the superinduced irritation is attended. When we reflect upon the connection of the organic nerves with the spinal, and especially on the mode of that connection with the brain itself and the rest of the cerebro-spinal system, we shall not be surprised that irritation of the extremities of the organic nerves, either in some one of the female organs, or in some part of the jrrima via, excites in one person, according to peculiarity of temperament, hereditary predisposition, habit of body, or state of vascular plethora, convulsions of a spastic or tonic character in the limbs and trunk, the cerebral functions being undisturbed; in another person, convulsions either of a clonic or irregular form, consciousness also being retained ; or either of these forms, or both of them variously or singularly mixed, with partial or complete deprivation of sense and mental manifestation, or with a comatose or maniacal delirium superadded. Nor should it be a matter of wonder that irritation thus originating gives rise to various other abnormal nervous and mus- cular phenomena, such as catalepsy, ecstasy, hys- teria, &c. 34. c. Convulsions sometimes .also usher in the crises of fevers and other acute diseases. This occurs most frequently in delicate or hyste- rical females, the abnormal contractions assum- ing a variety of forms, and often an hysterical character ; but it also not infrequently is observed in the male sex, especially in young and delicate persons. This association of convulsions is gener- ally dependent upon a severe affection of the brain in these fevers, and attended by either coma or delirium ; and although they may indicate a favourable change, particularly when accom- panied with, or immediately followed by, other critical phenomena, or when they put on the true hysterical form, yet they may be the outward signs of an exasperation of the cerebral or cerebro- spinal affection, particularly when the mental faculties and general sensibility are not soon afterwards restored. Other morbid associations, as with worms, diseases of the brain and spinal chord, &c., may be considered as causes of con- vulsions rather than complications. 35. II. Diagnosis.—Simple convulsions may with difficulty be distinguished from epilepsy and hysteria. They cannot readily be mistaken for tetanus or rabidity. There are many cases, which the nature of the exciting cause, and the history of the case, show to be different from true epilepsy, and yet they cannot easily be distin- guished from it during the height of the parox- ysm ; and the remark applies equally to the hysteric fit. In fact, convulsions present so many and so slight grades of difference, as to the spastic contraction of the muscles, and the fre- quency and rapidity of its alternation with relaxa- tion,—as to the presence of, or immunity from, cerebral disorder, as well as to the nature and extent of such disorder, — are so intimately allied in respect of their causes, of the particular system of the frame upon and by which these causes produce their sensible effects, and of the nature of these effects as far as they become symptoms or signs of the particular lesion which occasioned them, that the difficulty of diagnosis is very great in many instances, excepting to the acute and experienced observer, whilst it is suffi- ciently easy in others.—a. Generally, however, simple convulsions will be readily distinguishd from epilepsy, by the retention of consciousness and general sensibility in the former, excepting in the height of the paroxysm in the severer or more plethoric cases, as in eclampsia and puer- peral convulsions, in which both are lost ; by the general absence of the consecutive sleep or sopor of epilepsy ; by the irregular and frequently recurring form of the seizure ; by what is known of its origin and connection with obvious causes, and by the mode of its attack and of recovery from it. There are also various symptoms which, although common to eclampsia, puerperal con- vulsions, and epilepsy, arq yet peculiarly cha- racteristic of this last; and we find, in addition, other phenomena which simple convulsions sel- dom present, particularly the frightful scream on the accession of the epileptic fit, the ante- cedent aura or peculiar premonitory signs, the very sudden and unexpected seizure when the aura is wanting, the expulsion of the seminal and prostatic secretions, as well as of the alvine excretions; the more frequent occurrence of foaming at the mouth, and severer affection of the respiratory muscles ; the more leaden appear- ance of the countenance, and the more common recurrence of the paroxysm at a stated time, than in convulsions, particularly after the first sleep, or when the patient awakens or is rising in the morning. (See Epilepsy—Diagnosis.)—ft. Con- vulsions are readily distinguished from hysteria, by the antecedent copious discharge of pale urine, the globus hystericus, and the borborygmi; and by the alternate crying and laughing attend- ing the seizure of the latter. Some instances of simple convulsion, arising from irritation of the female organs, will, however, very nearly ap- proach, if not altogether run into, the hysterical character ; as we also see many cases of puer- peral convulsion differing but little from epi- lepsy, excepting in the frequent recurrence of the paroxysm in the former before the patient has recovered from the sopor consequent upon CONVULSIONS—Diagnosis—Terminations the antecedent fit, and in one or two of the diagnostic signs noticed above.—y. The continued or permanent nature of the spasms in all the forms of tetanus, and the absence of any tendency to obscuration of the general sensibility and men- tal faculties, during the whole unremitting dura- tion of this dreadful disease, are sufficient diag- nostics between it and convulsions.—d. Rabidity cannot be mistaken for this affection, if the history of the case, the uncommonly increased sensibility of the whole frame, the dread of fluids, and unimpaired cerebral functions, characterising rabies, be attended to ; for, although convulsive seizures occur frequently in it, they are produced by so slight external or mental causes—by every attempt at swallowing liquids—that their nature and origin cannot be for a moment doubted. (See Rabidity.) 36. III. Terminations or Consequences, and Prognosis.—A. Convulsions, in any of the forms now placed before the reader, may terminate, (a) in health; (b) in some other disease; or (c) in immediate dissolution, a. Their termination in health may be marked by no peculiar phenome- non, beyond the non-recurrence of the seizure. In other cases they are followed by critical evac- uations, particularly haemorrhage from the nose, mouth, or ears, after which they may never re- cur, or which may produce an immunity from them for a time. Vomiting and diarrhoea, or the accession of the catamenia, may likewise prove critical. 37. b. They often axe followed by other diseases; or rather the original disorder or change of struc- ture, of which convulsions are merely a part of the sensible and outward signs, may, from its increase, or extension to adjoining parts, occasion other or additional phenomena more or less inti- mately allied to convulsion, as palsy, apoplexy, coma, loss of speech, or of sight, or hearing, chorea, or mania, delirium, idiotcy, &c., each of which may pass into the other, or be variously associated with one another. Thus, loss of sight, hearing, speech, and idiotcy, may be the con- sequences in the same case. Also, either of these consecutive phenomena may arise from the cere- bral congestion, and its effects, produced by the frequent recurrence or by the severity of the fit, particularly when the respiratory functions are much impeded in it, and the system is plethoric and relaxed. My limits will not admit of illus- trations of these facts, either from my own ex- perience, or from the other sources which are referred to at the end of the article; but they are of common occurrence, and may, after con- tinuing for a longer or shorter time—in some cases for many years—in others for a very short period—either be recovered from, or terminate existence. In some cases, convulsions are fol- lowed by a state of leipothymia, trance, or complete syncope, which, when profound and continued, may be mistaken for dissolution, and endanger premature interment. There is reason to suppose that, in some countries where inter- ment usually follows death at a much shorter period than in Great Britain, this dreadful fate has overtaken the patient. In other instances, lethargy, or torpor, terminates the paroxysm, which, in rare instances, has been of long dura- tion, and also may be mistaken for death. Whilst the convulsions of childhood more commonly give rise to, or terminate in, loss of one or more of the functions of sense, in chorea, in idiotcy. 489 or in hydrocephaius; those attacking adults are more disposed to pass into either apoplexy, coma, palsy, or mania; and whilst the convulsions of the former class of subjects are more frequently the consequence of irritations affecting the ab- dominal viscera, those of the latter, excepting in females, are more generally the result of disease within the cranium or spinal column, often at a certain stage of its progress. 38. c. Their termination in death takes place either through the intervention of one or more of the diseases noticed above as their consequences, or, more directly, from the extension of convulsion or spasm to the respiratory muscles, inducing asphyxy, or from an overwhelming congestion or effusion of blood in the brain. This sudden un- favourable change more commonly occurs in puerperal convulsions than in other forms, ex- cepting when they proceed from abscesses or tumours within the cranium. Death may also occur from accidental suffocation during the paroxysm. 39. B. The Prognosis of convulsions depends chiefly on what is known of their causes, on the antecedent and consecutive phenomena, on the history of the case, and the degree in which the functions of the brain and nervous system are affected during and after the fit. a. If the convulsions occur in children, without fever or any primary or cerebral disturbance, and ap- parently from worms, disorder of the prima via, &c., a favourable opinion may be entertained. But when they are preceded by head-affection, by fever, followed by strabismus, stupor, or loss of one or more of the functions of sense ; when they are prolonged or recurrent; or are followed by signs of any of the unfavourable terminations noticed above, much danger should be appre- hended. Indeed, all cases depending upon cere- bral disease are attended by more or less danger, which, in some instances, become most imminent, particularly when the symptoms of hpdrocephalus are present.—b. In adult persons the prognosis is equally unfavourable, when the affection is evidently the result of cerebral disease, or of organic changes—and when the fits become more and more frequent, or severe, with more marked cerebral disturbance, either attending upon, or following them. On the other hand, when they are symptomatic of disorders of the prima via, or of the generative organs, a favour- able opinion may be entertained.—c. Puerperal convulsions, however, should never be considered devoid of danger, more especially when they oc- cur after delivery ; or in consequence of great exhaustion of vital power, or of uterine haem- orrhage. When they are slight, are unattended by stertorous breathing, or by paralytic or apo- plectic symptoms, and when parturition is so far advanced as to readily admit of its completion by art, less danger may be feared. But the prog- nosis of convulsions generally must be inferred from a careful review of the diversified circum- stances of individual cases, especially in respect of their remote and efficient causes, and of their disposition to terminate in either of the ways pointed out. 40. IV. Appearances on Dissection of fatal Cases. (See Brain, § 4—-133.), Epilepsy, and Spinal Chord. [The pathological appearances after death, from infantile convulsions, are extremely various. A collection of numerous cases on record gives 490 CONVULSIONS—Prognosis—Appearance—Causes of. us the general result of autopsies, extensive con- gestion of the brain, and spinal marrow ; serous or gelatinous effusion upon the surface, and at the base of the brain, in the ventricles, and in the sheath of the vertebral canal; in a few in- stances, an effusion of blood has been observed upon the hemispheres of the brain, or within the spinal canal, or indications of meningeal inflam- mation, circumscribed softening of the brain, and abscesses. These appearances are, however, more often the effect than the cause of infantile convulsions. After death from puerperal convulsions, the pathological appearances throw but little light on the nature of the disease. In some cases there has been observed an unusual degree of redness and softening of the cerebral substance, great congestion of the sinuses and smaller veins and arteries of the brain ; effusion of blood or serum into the ventricles, and lymph covering the ven- tricles. In other cases there has been no morbid appearances whatever to account for the symp- toms. Dr. Ramsbotham concludes, from his dis- sections and other circumstances, that “the whole train of symptoms in puerperal convulsions evin- ces considerable derangement of the functions of the brain and nervous system; yet, after death, correspondent marks of organic mischief within the head are seldom met with.” (Vol. ii. p. 248.) Dr. Robert Lee observes, {Theory and Practice of Midwifery, Phil., 1844, p. 398), “ The different anatomical inquiries at. which I have been present have not disclosed such regular appearances as to sanction the uniform deduction that the brain was the principal seat of the disease. I suspect that, in many instances, that important organ is no otherwise implicated than through the medium of sympathetic irritation.” Dr. Collins also re- marks, “ I conceive we are quite ignorant, as yet, of what the cause may be ; nor could I ever find, on dissection, any appearance to enable me to even hazard an opinion on the subject.” M. Cru- veilhier examined a case in which not the slight- est state of congestion of the vessels of the brain could be detected ; and M. Boutilleaux relates another case of a similar kind.] 41. V. Remote and efficient Causes.— i. The remote causes of convulsions are numer- ous ; but they often require a certain original or acquired predisposition of system to insure their operation; and various influences which may only predispose to them in some persons, may even excite them in others. A. Predisposing. There is every reason to suppose that the off- spring may derive constitutional predisposition to convulsions from the parents. Persons of a ner- vous and irritable temperament,—of a delicate frame, and largely developed head (Desf.ssartz), —of a relaxed and soft fibre, and plethoric vascu- lar system,—children whose fontanelles are very late in closing,—those who are naturally of a quick, sensitive, and unstable disposition, and whose physical and moral constitutions are readily impressed,—are predisposed by original conformation. Those infants who have experienced injury of the cranium during parturition (Smel- lie) ; persons who have early, prematurely, or inordinately indulged in venereal pleasures— who have placed no restraint on their passions, particularly anger,—who have become debili- tated by any cause (Autenrieth),—who have had their cerebral organs unduly and too early excited, and before the process of developement CONVULSIONS—Causes of. 491 was sufficiently far advanced ; the present state of civilization and precocious mental improve- ment ; the greater irritability of the system ac- companying the epochs of dentition ; the irritable and plethoric states attendant upon pregnancy; habitual determination of blood to the head; previous attacks of convulsion, either before or after puberty, or in a former pregnancy; at- tempts to conceal pregnancy, and the mental distress and shame attending it in unmarried women ; exhaustion of nervous or vital power by increased discharges, long-continued pain, or want of sieep ; all luxurious indulgences; too much sleep ; inanition and want; prolonged lac- tation ; fluor albus, &c.; and certain electrical states of the air, by which the nervous system is influenced, and rendered more susceptible of im- pressions and excitement; are the chief causes which generate a predisposition in the frame. It has been remarked by Dr. Ramsbotham, and other writers, that puerperal convulsions were most frequently produced during warm electrical states of the atmosphere. 42. B. The exciting causes of the various forms of convulsion are very numerous; and they act in different ways in producing their effects. I have already stated, that irritation of a part of the or- ganic or ganglial nervous system will be trans- mitted by the communicating branches to the spinal nerves, and produce convulsive actions of the muscles they supply, without the brain expe- riencing any evident lesion ; whilst, in other cases, the irritation may be conveyed to the brain, either directly by the organic nerves, or through the medium of the spinal chord, the cerebral func- tions suffering accordingly. But irritation or organic change of any of the parts contained within the cranium will also occasion convulsions, the general sensibility and mental manifestations being then more or less obscured or perverted during the paroxysm or subsequently. These facts, which might be illustrated by numerous cases, the history and results of which I have attentively observed, naturally point to a division of the causes, first, into those which act upon some portion of the organic nervous circle, or the viscera which it supplies ; and, secondly, upon the cerebro-spinal system itself. But, although it is useful to make this distinction, particularly for practical purposes, yet it should not be over- looked, that irritations affecting the former would rarely be followed by convulsions, unless the latter possessed a marked disposition to disease, as far as regards increased susceptibility and proneness to experience alterations from the healthy condition of its circulation. 43. a. The exciting causes which act more immediately upon the organic nervous system, and through it upon the spinal nerves or brain, or both, are the following:—a. In infants and children, the retention of the meconium ; a mor- bid state of the umbilical chord ; unwholesome milk, or improper feeding ; acid or acrid sordes, and various diseases of the alimentary canal; an overloaded stomach; suppression or retention of the urine; accumulated flatus, or morbid secre- tions, and the presence of worms, occasioning irritation of the bowels ; the ingestion of acrid substances—as very irritating purgatives (Gohl and Lentilius), or emetics (Riedlin),—acrid enemata ; noxious or indigestible substances taken as food; acidity of the prima via; dentition at either of its epochs, particularly cutting the eye and molar teeth; the irritation of pained or carious teeth; and calculi in the urinary organs, &c. /3. In persons about, or subsequently to, puberty; and occasionally in children, organic diseases of the stomach, bowels, or collatitious viscera; af- fections or lesions of the heart; constipation, colic, ileus, and intus-susception ; incarcerated or stran- gulated hernia (Graaf and myself); organic change of the kidneys, and suppression of urine ; manustupratio or inordinate sexual intercourse; and nervous and vascular excitement, or other dis- eases of the female organs, particularly the ovaria and uterus.—y. In puerperal females, a loaded stomach or disorder of this organ brought on by indigestible or unsuitable articles of diet, particu- larly shell-fish (Clarke) ; rapid or premature distension of the uterus during pregnancy; long continued and exhausting labour ; excessive, fre- quent, and inefficient pains; distension of the urinary bladder, during or after parturition; a loaded state of the bowels, excessive depletion or flooding ; venereal indulgences during the last two months of utero-gestation. 44. b. The causes which act more directly on the cerebrospinal nervous system are—a. the improper exhibition of narcotics, and of spirits and various quack medicines, by the lower classes, to infants and children; the admission of a strong light, or the impression of loud noises on very young infants; the continuance or excess of pain; in- juries received on the head during, or subsequently to birth ; fear, and sudden fright, or fearful dreams. —B. In adults more especially, and in children also, the most common causes of this description are, the influence of imagination and imitation; the action of the sun’s rays on the head; exces- sive mental labour or anxiety; extreme bodily sufferings, or long watching; injuries of the brain, spinal chord, or nerves; irritation of nerves by tumours, abscesses, or by ligatures in operations, or injuries of them by wounds and accidents; in- cipient curvatures of the spine (Wichmann, Bo- net) ; the impression of excessive or long con- tinued cold, or of a cold bath; the influence of particular odours on some constitutions; the abuse of spirituous liquors; the influence of various poisonous substances on the nervous system, be- longing to the animal, vegetable, and mineral kingdoms, as nux vomica, and nearly all the class of narcotics ; deleterious gases, and metallic fumes, as the nitrous oxide, sulphuretted hydrogen, &c., the vapours of mercury and lead; and the irri- tating and inflammatory operation of many mineral preparations and acrid vegetables (see Poisons) ; all emotions of the mind which excite the nervous power, and determine the blood to the head, as joy, anger, religious enthusiasm, excessive desire, «fcc.; or those which greatly depress the nervous influence, as well as diminish and derange the actions of the heart, as fear, terror, anxiety, sadness, distressing intelligence, frightful dreams, &c.; nu- merous lesions of the encephalon or its membranes, particularly effusions of fluid, abscesses, tumours, ossific deposits, and various other adventitious formations—indeed, nearly all the organic changes described in the articles on the Brain, Epilepsy, and Spinal Chord; also exhaustion from pre- vious disease, particularly by large losses of blood (Schroeder) ; inanition and want (Amatus Lusi- tanus) ; the erect position suddenly assumed ; lightning (Grapengiesser) ; abscesses about the neck ; the suppression of eruptions and discharges, particularly on the head or from the ears; the 492 syphilitic poison; and repulsion of gout or rheu- matism.—y. In puerperal females, many of the causes now mentioned are especially productive of convulsions, particularly anxiety or distress of mind in unmarried females; violent straining during labour; and sudden changes from the hori- zontal to the sitting or erect postures. 45. ii. The efficient causes have been partially alluded to. Their nature may be in some mea- sure inferred from what has been stated above. It seems evident, from a careful consideration of the exciting causes, of the character and progress of the symptoms, and the lesions usually detected on dissection, that convulsions arise from several pathological states, the grosser or more palpable parts of which only we are enabled to recognise by the senses; and that, in addition to these, a certain susceptibility of the nervous system, par- ticularly of the cerebro-spinal centres, is requisite, nevertheless, to the full developement of the seizure. It is extremely probable that convul- sions frequently arise from some considerable change in the state of the circulation within the cranium, and that such change may be either active cerebral congestion,—in some cases con- nected with general plethora, but in others not thus associated, and, even in a few, accompanied with marked deficiency of blood,—or local or general anaemia. Moreover, it may be presumed that the seizure very often is accompanied with but little disturbance of the cerebral circulation or func- tions at its commencement; and that it chiefly de- pends upon irritation, in some manner induced in the organic nerves, and, through them, in the spinal nerves, either partially or generally. We have no proof of the circulation of even the spinal chord or its membranes being disordered in these cases, al- though it may be affected in convulsions, either primarily or consecutively. In cases which more manifestly proceed from disease within the cra- nium, and that of an organic kind, as from tumours, abscesses, aqueous effusion, &c., it by no means follows that the circulation in the brain is gene- rally, or even at all, either accelerated or con- gested, although these lesions may safely be as- sumed in many instances. In some cases even of organic change, the general amount of circulation in the head seems, as far as we can judge from symptoms, much below the natural standard, and yet convulsions will supervene ; whilst in others, signs of inflammatory action of the membranes are apparent. In many cases, moreover, judging from the states of pre-existing disease, from what is known of the operation of various causes, and from the symptoms connected with the head,—the weak and small pulsation of the carotids, the antecedent fainting or leipothymia, the low temperature of the scalp, and pale, sunk, and pinched features,—it may be inferred that the vital endowment and the circulation of the brain are momentarily deficient, both in activity and in quantity. 46. Therefore, while I subscribe to the justice of the aphorism of Hippocrates, that convulsions arise from repletion or inanition as respects the circulation within the cranium, I would qualify it, and add, that they often originate thus, but that either of these states forms a part only of the changes that produce them, even when most irre- fragably present,—that in many cases the circu- lation in the brain is not materially disturbed, whilst the spinal nerves are affected either by ir- ritation conveyed to them from the organic ner- vous system, or from the spinal chord itself, more CONVULSIONS—Treatment. frequently the former,—that even when the brain is disordered, general convulsions will arise only when the disorder extends to, or influences the parts more immediately related to, the locomotive actions of the body, as the spinal chord or its mem- branes,—and that we cannot contemplate the origin of convulsions in any wav, and leave out of view changes primarily induced in the organic nervous or ganglial system—which changes will more readily produce, than be produced by, dis- ordered circulation in the cerebro-spinal organs. We know that the movements of the foetus in utero are automatic—are the consequence of irritations affecting the organic nerves, extending to the spinal nerves, and through them, inducing motions of the limbs. To the production of these, any change in the brain or spinal chord is not required; and a great many cases of convulsion have a similar origin, the difference being only as to the grade of irri- tation relatively to the susceptibility of the patient, and to the effect produced. As to the opinion entertained by the older humoral pathologists, from Galen to Willis, that a morbid state of the fluids also occasions convulsions, some im- portance may be attached to it. We do not, how- ever, find convulsions much more prevalent when the blood is manifestly morbid, unless in those cases where a previous, and at least an equal, change has been produced upon either the organic, or the cerebro-spinal nervous systems. The convul- sive movements that occur in common and pesti- lential cholera, in malignant fevers, in rabidity, and in organic lesions of the kidneys,‘with suppression of urine, are proofs of this position. That, however, a morbid state of the blood sometimes constitutes a concurrent proximate cause of certain diseases, in which convulsions either incidentally occur, or form a part of the circle of advanced phenomena or effects, may be admitted, in the absence of suf- ficient evidence to the contrary ; for, when the blood itself is primarily changed, we may with reason infer that convulsions will sometimes mani- fest themselves as a part of the effects thereby pro- duced upon the nervous system ; but I believe that convulsions seldom arise from this cause only. 47. VI. Treatment. — i. Of Convulsions generally. The means of cure in all cases of convulsions are directed with the view, 1st, of subduing the fit, when called to a patient labour- ing under it: and 2nd, of preventing its return. A. To subdue the paroxysm, it is necessary to have prompt recourse to active measures: but these should not be employed indiscriminately, and without taking quick cognisance of the cause, and the existing pathological states as far as they may be readily ascertained. The circumstances principally to be observed by the practitioner, are the presence or absence of active cerebral congestion and sopor, the existence of general vascular plethora, the temperature of the head and lower extremities, the pulsation of the carotids, and the character of the countenance and of the convulsive motions. These may be ascer- tained in a very few moments, and at the same time that inquiry is being made into the cause of the seizure, and the peculiarities of the case, as respects the age, constitution, and habits of the patient. 48. a. A person in convulsions ought to be placed so as to breathe an open coot air, and to facilitate the restoration of one of the earliest functions disordered ; and no more attendants be permitted than are absolutely necessary. Those susceptible of, and liable to, nervous affections, should not be allowed to remain in the same room, or even in the same house, with the patient while in the fit.—b. When the habit of body and the cerebral symptoms, &c., present no contra- indication, general or local blood-letting, or both, should be resorted to, and carried as far as cir- cumstances may warrant. When the cerebral congestion is very active and extreme, the jugular vein may be opened; but the depletion should never be pushed too far, with an expectation of stopping the convulsions; nor should it ever be carried to deliquium, for the system may be thereby injured, and a return or immediate recur- rence of the seizure be favoured by it. Revulsive bleedings, as from the feet while they are held in warm water, may be preferred, if the seizure be connected with difficult or suppressed menstru- ation. Local depletions, in other instances, are best practised by cupping behind the ears, par- ticularly in children, and upon the nape of the neck, and between the shoulders. In other in- stances, when the brain is not affected,—when the head is cool, and the carotids are pulsating neither more fully nor more strongly than natural, —the state of the spinal column should be care- fully enquired after, by pressing a warm sponge along and between the vertebra; and the abdo- minal regions and the evacuations ought to be daily examined. If signs of inflammatory action exist in either of these quarters, particularly if they be connected with plethora, general and local depletion—preferably the latter, when plethora is wanting—should be resorted to. But there are maaiy eases, especially those produced by copious evacuations, by inanition, and the exhaustion of painfui and protracted disease, where depletion would be most injurious; and there are inter- mediate grades, in some of which local blood- letting might be either beneficial or of no advan- tage, according as the case approaches nearer to the one extreme than the other. When the con- vulsions are partial, then local depletions are to be preferred. 49. c. There are certain states of convulsion, in which it at first seems difficult to determine as to the propriety of resorting to blood-letting in any way. One of the most common of these, is that characterised by a pale and somewhat sunk countenance, and by tonic convulsions. This appearance may mislead the practitioner, if he do not examine carefully into other symptoms. If, in addition to those, the carotids pulsate strongly, the temperature of the head be increased, the pupils contracted, and the brows knit, we should suspect inflammatory irritation of the arachnoid —notwithstanding the absence of all plethoric or asthenic signs—and resort to depletions, and the means about to be noticed. (See also Brain — Treatment of Inflammation of its Membranes.) Another state sometimes occurs, with very violent general convulsions, a broad, open, throbbing, and frequent pulse; pale countenance and surface, often with sopor or delirium, or both. These symptoms may mislead the inexperienced, and depletions—occasionally the very cause of the mischief—may be improperly employed to re- lieve it. But when the history and symptoms of the case are more minutely examined, we shall find precisely that state which is described in the article Blood (§ 53—60.), and that, instead of congestion, there is general anaemia, with cerebral irritation, combining with the physical condition CON VULSIONS—Treatment. of the brain, to determine to it the greater part of the blood in the system. In other cases, there is apparently anaemia of the brain, at least at the commencement of the fit, and either conscious- ness is retained, or it is lost from the state of the cerebral circulation. These forms of seizure may be called ancemial; inasmuch as they arise either from a general deficiency of blood, or from anaemia of the brain, although the vessels of this organ soon become partially congested from the impeded respiration, and interrupted circulation through the lungs and heart, at the commence- ment of the paroxysm'. In these, a very opposite treatment to depletion is required. The ob- servations of Latham, Hali., Gooch, North, and the author, on this important practical topic, have, however, induced the practitioners of the present day to resort to blood-letting in convul- sions in a much more discriminating manner than formerly. 50. d. Next in importance is the judicious em- ployment of cold and heat—of cold in the form of cold affusion on the head and spine, and of heat in that of warm bath or semicupium. An appropriate use of these is more generally service- able, and often less dangerous, than depletions. The cold affusion to the head, and, in cases where there seems to be irritation of the spinal envelopes, along the vertebrae ; and cold, in the form of epithems, evaporating lotions, pounded ice to the head, when convulsions are produced by inflammatory action in the brain or spinal chord ; are among the chief forms in which this agent is admissible. The cold bath, although advised by Currie, Loeffler, Beaumes, Baynard, and others, is, in my opinion, a hazardous experiment during the paroxysm, and sometimes even in the interval. The warm bath, or semicupium, is fre- quently of much service, and particularly when there is either high nervous irritation ; a dry- harsh skin, or cold surface or extremities; and my experience accords with that of Heilbronn, Henrischen, Doerner, and Stutz, respecting the propriety of adding a quantity of the fixed al- kalies, or their carbonates, to the water. When the head is much affected, either by inflamma- tory irritation of the membranes or active con- gestion, cold affusion, or cold epithems or lo- tions, may be employed whilst the patient is in the warm bath, or is using the semicupium or pediluvium. In slight cases of convulsion, the aspersion merely of cold water over the face, head, or neck, is often of service. Largo draughts of cold water were recommended by Hoffmann ; and they, as well as water ices, and cold clysters, have been several times employed by myself with much benefit. Cold injections are praised by Langiians and Marx. Cold affu- sion, cold aspersion, and cold epithems, have been prescribed by Currie, Dufont, Doemling, and others; but the two former were usually directed by them to the surface generally, in- stead of to the head,—a circumstance which ac- counts for the disuse into which it had fallen, when the practice was revived some years since by the author. 51. e. If the patient can swallow, and the muscles of the jaw are not much affected, cathartic medicines should be given by the mouth ; but in most instances it will be prefer- able to delay them until after the seizure. But I have under no circumstances been prevented from directing a cathartic and anlispasmodie 493 CONVULSION S—Treatmrnt. 494 enema to be thrown up. Either of F. 131— 136. may be employed and repeated if it be not retained, as is frequently the case. When purgatives can be taken, a full dose of calomel, either alone or with jalap, followed soon after- wards by an active cathartic draught or mix- ture, consisting of senna, tincture of jalap, carmi- natives, and antispasmodics, particularly the pre- parations of ammonia and camphor, is, upon the whole, the most appropriate. But under every circumstance the operation of these should be promoted by enemata. When we wish to produce an active derivation from the head and spine, as well as alvine evacuations, the croton oil, elaterium, ol. terebinthinee, &.C., may be em- ployed. But, where the object is chiefly to bring away offending secretions, and other causes of irritation, and at the same time to allay disordered action in the prima via, calomel, jalap, rhubarb, and senna, are, perhaps, the best purgatives we can employ. Their action will, in all instances, be much 'increased, and a marked change be often produced in the disease, by an occasional dose of the ol. terebinth, and ol. ricini, assisted by the enemata already recommended. If con- vulsions arise from worms in the intestines, anthel- mintic purgatives, during both the paroxysms and interval, should not be omitted. Calomel may generally, with due address, be exhibited during the fit, and subsequently other anthelmintics may be given. Bergius and Barton prefer the Spige- lia Marylandica in such cases; but the other means adopted in verminous disorders may be employed according to circumstances. Rmetics are sometimes of service, when exhibited upon the first intimation of the seizure, particularly if there be indications of gastric irritation from offending or noxious ingesta, and acid sordes, or it the par- oxysms assume a periodic form. Schenck, SchjEFFer, Rigel, Conradi, and Smith, advise them chiefly in such cases. Thom recommends them to be exhibited to the nurse, when convulsions attack infants. 52. f. Antispasmodics are sometimes produc- tive of instant relief, when employed in large doses, early in or upon the first intimation of the fit, particularly when it arises from debility, or ir- ritation in the prima via, or morbid nervous sus- ceptibility ; but they seldom can be taken in the paroxysm, unless it be slight, or arise from ex- hausting causes, and then they7 are often of great service, especially if they be combined with resto- ratives and opium, conium, or hyoscyamus. The aethers, camphor, musk, assafoetida, valerian, the preparations of ammonia, bismuth, zinc, &c., are amongst the most efficacious in these cases. When inflammatory irritation seems to exist in the membranes of the brain, they are obviously contra-indicated ; but congestion of a passive na- ture, especially when the pulsations of the ca- rotids are not strong or hard, and the temperature of the head is not increased, should be no reason for omitting them. An extensive experience, however, of the effects of the spirit of turpentine in convulsive diseases, has convinced me that it is the most efficacious and the safest antispas- modic that can be employed for their removal. If it be given in doses so large as to act as a purgative, and seldom or rarely repeated, it is re- markably beneficial in the cases which arise from cerebral congestion or irritation ; but when the seizure is connected with anemia, or exhausted vital power of the brain, or general debility, it ought to be exhibited in small doses, often re peated, and be combined with restoratives and aromatics. Michaelis, Schmalz, Albers, Har- gens, Conradi, Heilbronn, and Wiedemann, streunously advise, in all convulsive affections, large doses of the fixed alkalies, either alone or alternated with opium. Of the antispasmodic action of these substances, as well as of their soothing operation on the digestive mucous sur- face, there can be no doubt. If the convulsions arise not primarily from organic disease within the head, I believe that opium thus combined will often be of great service, and particularly when they proceed from the nervous susceptibility and muscular irritability often connected with de- bility, exhaustion, and excessive evacuations. The good effects of alkalies in disorders of the di- gestive functions, and the frequent origin of con- vulsions in these disorders, or their connection with them, must be admitted. Moreover, the al- kalies, combined with opium, or hyoscyamus, co- nium, or belladonna, and ipecacuanha, &c., are among the surest means we possess of al- laying irritations affecting the nervous system. Stutz, Bruningiiausen, Doerner, and Henris- chen, employ them also in fomentations to the abdomen, in baths, and in enemata ; they using an ounce of the caustic alkali to about a quart of water for the fomentation. I have prescribed the alkalies frequently and largely in the convul- sions of children with much benefit. Other an- tispasmodics, and different modes of applying those in common use, have been adopted by vari- ous writers ; but as these are better suited to ful- fil the second intention of cure, I will notice them hereafter. 53. g. Anodynes and narcotics are often of the most essential benefit when appropriately prescribed and combined, or preceded iy other suitable remedies. They are seldom of service in the convulsions proceeding from active congestion and organic disease within the head; but when the affection is connected with irritation in other parts, or when the disorder of the brain or its membranes consists chiefly of irritation, they should not be omitted. They are seldom of use, —sometimes even injurious, in puerperal convul- sions, and ought to be given with caution to very young children. In cases where the pro- priety of exhibiting them is doubtful, any unpleas- ant operation will be prevented by combining them with camphor, or with aromatic tinctures or spirits. I have derived great advantage from employing them externally, selecting for this purpose opium or belladonna, in the form of em- brocation or plaster —generally the former —ap- plied during the paroxysm over the epigastrium and abdomen, and combining them with rubefa- cient and stimulating substances, as camphor, ammonia, Cayenne pepper, &c., or with any of the liniments or plasters in the Pharmacopoeias, or in the Appendix, suited to the case (F. 108. 297. 307.). The practitioner should, however, be cautious in the employment of the more active of these narcotics, even externally, as very dan- gerous effects have resulted from them. Dr. Thackeray found that tobacco steeped in brandy, and placed over the epigastrium, produced a most dangerous state of vital depression. 54. h. Revulsants and counter-irritants are of great service in all states of the disease accompa- nied with cerebral congestion, or irritation of the membranes of the brain or spinal chord. Sina- pi sms to the extremities; rubefacient liniments (F. 299. 305.),. and embrocations, particularly those with Cayenne pepper, horse-radish, &c.; the tur- pentine fomentation ; the immersion of the hands and feet, or the lower extremities, in a salt and mustard bath; dry cupping on the nape of the neck, occiput, between the shoulders, or along the spine ; are the preferable means of this de- scription. These will often, of themselves, shorten the seizure ; but if they fail of having this effect, after slight redness of the skin has been produced, advantage will frequently arise from placing over it a liniment or embrocation containing opium, or the acetate or hydrochlorate of mor- phia, or any of the other anodynes in use, either of which may also be employed in the form of plaster combined with antispasmodics, &c. 55. i. Convulsions arising from exhaustion, ha- morrhagy, inanition, &c., require restoratives, stimulants, &.C., in small quantity, and frequently exhibited, with strict attention to the tem- perature of the head, which should be low- ered whenever it rises above natural, by cold applications. (See Abstinence—Treatment of; and Blood—Deficiency of, § 48, 49.) The com- bination of hyoscyamus with gentle tonics ; the preparations of opium, conium, or hop, with those of ammonia and camphor ; the preparations of valerian or assafeetida with the carbonates of the alkalies ; the hydrochlorate or acetate of morphia, with the aromatic spirits and tonic tinctures; and emollient and antispasmodic enemata, are most appropriate to those cases. In these, as well as in the more clonic forms of convulsions, the preparations of iron, particularly the ammo- nio-tartrate of iron,* alone, or combined with hyoscyamus, will be of much service. The oc- currence of these affections towards the close of febrile or acute diseases (§13. 33.), particularly when they manifest signs of greatly depressed vital power, requires nearly similar remedies, or such as exert a still more stimulant and antispas- modic operation. The sulphate of quinine, with hyoscyamus and camphor ; the decoction of cin- chona, or infusion of arnica or serpentaria, with liquor ammonite acetatis and aether ; warm negus, with aromatics ; and stimulating embroca- tions or liniments over the epigastrium, may be resorted to in these cases. If convulsions occur in the course, or towards the crisis of fevers, the treatment must altogether depend upon the state of the cerebral functions, and the disposition that may be evinced towards spontaneous or critical evacuations, to the promotion of which our means should be directed ; taking care, at the same time, to guard the head from mischief, by employing local depletions, cold affusion, cold epithems, and internal and external revulsants, if it exhibit appearances of congestion or in- flammatory irritation; and warm diaphoretics, gentle tonics, and antispasmodics, and other means of supporting the manifestations of vital power in the nervous systems, and of promoting the secreting and excreting functions. 56. k. When convulsions are produced by nar- cotic or acro-narcotic poisons, the immediate eva- cuation of the noxious substance by the stomach pump, or by emetics, the cold affusion on the CON VULSIONS—Treatment. head, followed by stimulants and antispasinodics, green tea, or coffee, stimulating enemata, and frictions of the surface, are chiefly to be depended upon. If they proceed from the fumes of lead or mercury, antispasmodics, tonics, stimulants, strychnine, or nux vomica, with purgatives, are most serviceable, particularly when assisted by the warm bath, and by frictions of the surface af- terwards with stimulating liniments. Serpentaria, the arnica montana, and camphor, are often ben- eficial remedies in those cases. 57. 1. Convulsions either of a partial, a general, or irregular and anomalous form, arising from irritation of the female organs, require local de- pletions, cooling aperients, and antispasmodics ; the internal use of soda and nitre ; cold clysters: the cold affusion or aspersion ; the tepid bath ; or the shower bath, while standing in warm water ; and draughts of cold water. In a case of general convulsions arising from inflammatory irritatiou about the neck of the uterus, with leucorrhcea, I directed the patient to take a lemon ice, or to drink as much as she could of cold spring water upon the intimation of the seizure ; and she has hitherto done so with uni- form benefit. Having seen her during the parox- ysm, and perceiving that she retained her con- sciousness, cold water was given, and swallowed with some difficulty. The benefit was almost in- stantaneous. If the convulsions be connected with difficult, or suppressed menstruation, gene- ral or local depletions, and afterwards the warm general or hip bath, full doses of the preparations of assafostida and ammonia, particularly the tinct. ammon. comp., the spir. ammon. foetid., or the tinct. guaiaci composita, also camphor, and the boracic acid, or the biborate of soda, have proved the most effectual remedies in my prac- tice. But the means already advised to prevent congestion or irritation within the cranium, should be resorted to upon the first intimation of the fit. Bleeding by leeches from the inside tops of the thighs are indicated in these cases ; but it can be practised only in the interval. 58. B. The prevention of the paroxysms is to be attempted, with due attention to the remote and proximate causes, the former of which should be removed as completely as possible, and the latter energetically but cautiously combated ; rec- ollecting always that convulsions are the out- ward manifestations of certain lesions of the ner- vous, acting on the muscular, functions ; and that our knowledge of such lesions extends not beyond the inference that they consist of depression or exhaustion of vital power, or of irritation, or of congestion, and occasionally, of two or all these slates conjoined, some one of them predomina- ting over the others, and being associated with ad- ditional and even opposite changes. Many of the means already noticed are requisite in the inter- vals, as well as in the paroxysm, especially when judiciously modified to the circumstances of the case. a. Vascular depletion is often required, and in similar states of disease to those already pointed out; but it should be directed with great circumspection, and to a moderate extent, unless the signs of active cerebral congestion, or of in- flammatory irritation, or of general plethora, be unequivocal. If, however, opposite states obtain, viz. exhaustion, and deficiency of blood, very dif- ferent means must be employed. In most in- stances of convulsions, the quantity of the cir- culating fluid is not so frequently either much 495 * A most valuable and beautiful preparation very lately introduced by Mr. Aikkn ; and from its very pleas- ant sweet taste—resembling that of liquorice—extremely well adapted for children. Dose from half a grain to five or six grains. 496 above or much below the usual proportion, as the influence,—vital or nervous, or by whatever name it maybe called,—by which the distribution of blood throughout the frame is regulated, is dis- turbed so as to determine or attract a larger pro- portion to one part than to another. In no pe- culiarity of constitution is the old doctrine, “ ubi irritatio, ibi Jluxus,” more frequently illustrated than in that in which convulsive complaints are most commonly observed ; and, in these diseases, we are continually finding fluxion one of the earliest censequences of irritation. I have long thought, and on several occasions contended, that, in the common routine of practice, blood- letting is too indiscriminately employed to remove such determinations or irregular distribution of the circulating mass; and that, although it some- times succeeds, owing to its being associated with other and more appropriate means, it often fails, or even augments the mischief, by increasing the debility and susceptibility of impressions from ex- citing or irritating causes, that generally charac- terise the nervous system of persons subject to convulsive seizures. Therefore, when the ab- straction of blood is really necessary, it should be performed in such a manner, and be accompanied with, or followed by, such medicines as are most likely to equalise the circulation; and it is chiefly in this way that many of those about to be noticed are productive of any service in the disease. Local depletions, in moderate quantity, repeated according to circumstances,—from the nape of the neck or occiput, when the head is af- fected, and along the spine, if irritation of the membranes of the chord is suspected^—and as- sisted by such other means as the case may re- quire, are more generally applicable in the inter- vals than large venaesections. 59. b. There are few remedies more beneficial in convulsions than mild purgatives, or aperients, taken daily, and conjoined with tonics and anti- spasmodics. Active purgation, if long persisted in, will lower the vital energy, and thereby fa- vour the return of the fits; but the more deobstru- ent and eccoprotic medicines of this class, parti- cularly when thus combined, may be given, so as to procure two or three faccident evacuations daily. Thus prescribed, purgatives will increase the patient’s strength, and often procure a pro- longed immunity from the seizures. Aloes, with quinine or iron, and camphor ; or with myrrh, as- safoetida, the tonic extracts, &c., and occasionally with blue pill, or with extract of hop, hyoscya- mus, or conium (F. 450—471.); senna, with gen- tian or bark, the preparations of ammonia, aether, &c. (F. 266. 872.) ; and either of these with the liquor potassee, or the alkaline carbonates, are most to be relied on. But advantage will accrue from changing the forms and mode of combina- tion and exhibition of purgatives from time to time, and from assisting them with such other re- medies as the special characters of the case may require. A full dose of calomel, followed by the turpentine draught (§ 51.), may occasionally be resorted to; and enemata will also be of service. In every instance, the appearance and quantity of the discharges, intestinal and urinary, should be examined ; and when the sensibility of the bowels seems to be increased, oleaginous or mild purgatives, with alkalies and hyoscyamus, ought to be preferred. Morgagni recommended, as an aperient, two ounces of the ol. amygdal. dulc. to be taken every night,—a medicine well suited to CONVULSIONS—Treatment. cases of this description; but the ol. olivee, oh lini, or the oh ricini, and 6ven the cod or tusk liver oil, may also be thus used. Where we find the tongue much loaded or furred, active purgatives, particularly full doses of calomel, with cathartic extracts, &c,, are especially required in the first instance ; and mild laxatives, with tonics and an- tispasmodics, subsequently. 60. c. In many cases, particularly when the convulsions proceed from inflammatory irritation of the membranes of the brain or spinal chord, bleeding and purgatives will be advantageously followed by an alterative course of mercury, pushed as far as to affect the gums, and by low diet. Much tact is, however, required in deter- mining as to the cases and period of treatment, in which this practice should be adopted. It is admissible only when the disease proceeds from the pathological state just mentioned, or is con- nected with a syphilitic taint, or has originated in the abuse of spirituous liquors, &c., and the too great indulgence of the appetite for food ; and it will be injurious in cases of exhaustion, unless combined with active tonics and nutritious diet. Plummer’s pill, the hydrarg. cum creta, or the blue pill, may be given, in small and frequently repeated doses (from half a grain to a grain of the last, thrice a day), with anodynes, as conium, hyoscyamus, ext. humuli, and small quantities of camphor. In more doubtful cases, or when we suspect that effusion of fluid has supervened upon disease of the membranes, the bichloride of mer- cury may be prescribed, either in the compound tincture of cinchona, or with the compound de- coction of sarsaparilla, or diuretic infusions or spirits, according to the symptoms and circum- stances of the case. 61. d. Various antispasmodics and tonics, be- sides those already adduced, have been directed chiefly in the intervals ; and others in more com- mon use have been employed in novel forms. The cupri ammonio-sulphas has been prescribed by Home, Duncan, and Bianchi ; the nitrate of silver, by Powell and Hall ; the animal oil of dippel, by Herz ; the oil of rue, by Abraiiam- son ; cajuput oil, by Thunberg ; the mislctoe, by Colbatch and Home ; and the preparations of zinc, by Goodsir, Bell, Beaumes, Duguid, White, and many more. Krebs has advised the trunk of the body to be enveloped in cam- phorated cloths, if we suspect convulsions to arise from intestinal worms. Warburg has rec- ommended mush in large doses, combined with nitre; and Sidren and Frankfurter the inter- nal use of nux vomica, apparently upon the principle of Hahnemann, that similes similibus curantur. Cazals directed about half a drachm of trisnitrate of bismuth to be taken in the twenty-four hours, with castor. Vogel thought that benefit has been derived from the flowers of the white lily; and Baker, Pallas, Thom, and Home, entertained a similar opinion as to the effect of the cardamine and anemone pratensis, artc- misia, and the radix pceonicz. Digitalis was employed by Siiaal; emollients, by Kortum; ipecacuanha, by Plenk ; and various narcotics by the majority of authors, chiefly in combination with stimulating antispasmodics, in order to in- sure their effect. Of the substances now enu- merated, the most deserving of notice seem to be the preparations of zinc, bismuth, musk, and the misletoe. Of the former of these I have had much experience ; but, upon the whole, they are CONVULSIONS—Treatment. 497 inferior to camphor, valerian, assafcetida, am- monia, and the (ethers, judiciously combined and assisted by other remedies, particularly when taken upon the first intimation of the seizure. If the disease be the result of exhaustion, or inani- tion, and particularly if it assume a periodic form, the preparations of cinchona, the sulphate of qui- nine, iron (Buechner, Reidlin, Loeffler, Hutchinson, Elliotson, &c.), especially the sesquis-oxide in large doses, or the ammonio-tar- trate, and the arsenical solution with potash, are the most appropriate remedies, either alone, or with aperients, or antispasmodics, or anodynes and narcotics, according to the peculiarities of the case. I have, for many years, employed the in- fusion of green tea, if the convulsions arise not from inflammatory action within the head, and generally with great success. The good effects of the medicines now mentioned, when they pro- duce any, are to be imputed chiefly to their influ- ence in overcoming the susceptibility of the ner- vous system, giving tone and energy to the mov- ing fibres, and increasing the secreting and ex- creting functions. In order to insure their effects, they should be varied and changed from time to time, and differently combined with one another. 62. e. There is scarcely any anodyne or varcot- ic substance, that has not been employed in con- vulsions. The preparations of opium, of poppy, of belladonna, (Stoll, Bergius, &fi.), of conium (Stoerck, &c.), of hyoscyamus, stramonium (Stoerck, Sidren, WadenBerg, &c.), and to- bacco, (Riverius, Currie,Thackeray, Haygarth, &c.), have been prescribed in various modes and states of combination—with aperients, or stimu- lants, or tonics, &c.—internally and externally— in enemata, and in suppositories. The most suc- cessful modes of exhibiting either of these sub- stances in convulsions, are internally with cam- phor, assafcetida, or the carbonates of the alkalies ; and externally, either in the form of liniment, embrocation or plaster on the epigastrium, or along the spine, combined with the substances just mentioned, or with any of the liniments or plasters in the Pharmacopoeias, or in the Ap- pendix. 63. /. Various derivatives or revulsants have been used in the intervals, as well as in the par- oxysm. Blisters may be employed; but they are pot so- generally appropriate as the produc- tion of a number of pustules by means of the tartar-emetic ointment or solution (F. 749.), or of the croton oil, rubbed upon the inside of the thighs, or on the epigastrium, or along the spine. Sev- eral writers have directed blisters to the head ; but the pathological states admitting of their applica- tion in this situation are comparatively rare, and require the most intimate knowledge of disease, and appreciation of symptoms for their recogni- tion. It is only when the vital energy of the brain is profoundly sunk or exhausted, and not suppressed by congestion, or active determination of blood, or the pressure of effused fluids, or ad- ventitious formations, that a blister on the scalp can be of any service. When applied to the nape of the neck, or behind the ears, or between the shoulders, they are seldom of much use, un- less kept open for some time. The pea or meze- reon issue in the insides of the thighs, and anti- spasmodic liniments or plasters along the spine, or over the epigastrium, are sometimes useful aux- iliaries. 64. g Electricity and galvanism have been proposed in convulsions; but agree with Gra- pengiesser in thinking them hazardous, h. Cold bathing has been very commonly recommended ; but it requires discrimination. It will benefit chiefly those cases which are unconnected with organic lesion, and which depend upon general debility and susceptibility of the nervous system. In these the salt water bath should be preferred, and its use commenced in the tepid state, the temperature of successive baths being gradually reduced. The cold shower bath is more generally applicable, particularly upon getting out of bed; and when it cannot be resorted to, the patient ought to sponge or bathe the whole head with cold water every morning. The strictest atten- tion should, at the same time, be paid to the state of the digestive functions, and of the alvine evac- uations. Cutaneous excretion also ought to be promoted; for, not only are all the other func- tions thereby improved, but contingent disturb- ance of any of them, and the irregular distribution of blood, in which convulsions often originate, are less likely to take place whilst the circulation in the surfaces is uninterrupted. It is probably from this mode of operation, as much as from their antispasmodic action, that service has been obtained from several diaphoretics, particularly the kermes mineral, and other antimonials, rec- ommended by Unzer, Gulbrand, Struve, and Harder, i. Warm baths, hip baths, semicupium, &c., when any advantage is derived from them in the intervals, act chiefly in this manner. But I believe that they will seldom be productive of much benefit, unless in cases connected with sup- pressed eruptions, or the exanthemata, or with irregular or difficult menstruation, and with dis- orders of the digestive canal in children ; and in these the effects of warm baths will be much enhanced by stimulating or irritating frictions of the surface immediately upon coming out of them. 65. k. The almost epidemic prevalence of con- vulsions during states of religious enthusiasm and mental excitement, as shown by the occurrences already referred to (§ 16—18.), and by the seizures that affected many of the Jansenists who made pilgrimages to the grave of Deacon Paris, during the persecution of this sect in 1724, as well as by the convulsions at one time so uncommonly fre- quent in the Methodist meetings in various parts of Cornwall, as described by Mr. Cornish, should lead the physician to recommend such moral regimen as the circumstances of particular cases may seem to require. The above facts, as well as the circumstances recorded by Boek- haave, of almost all the girls and boys in the hospital of llaerlem being seized by convulsions from their seeing a girl who had been frightened into them, will alone show the importance of separating the affected from females or other susceptible persons. There can be no doubt that simple hysterical or epileptic convulsions occur- ring in one among a crowd of females will often occasion convulsive seizures in others, particu- larly in those of a delicate frame and nervous temperament, although they may have never previously been similarly disordered. I have met with such an occurrence more than once. In- deed, the number of these attacks on the public occasions referred to, is a sufficient proof both of the influence of the mind in producing them, and of the propriety of the immediate separation of a person thus seized, as was judiciously and suc- 498 CONVULSIONS OF CHILDREN—Treatment. cessfully practised by Dr. Haygarth. The pro- pensity to become affected by convulsions from seeing one in a fit appears to have been well known to the Romans, and from its frequency on occasions of public assembly, as much as from other considerations, they obtained the name of Morbus Comitialis, which has been understood as applying only to epilepsy, but which I be- lieve had a much wider signification, and com- prised all convulsive seizures. That fear or terror will not only occasion convulsions, but also remove them, or at least often prevent their accession, might be inferred a priori, even if it were not proved by experience. The actual cautery employed by Boerhaave soon put a stop to them in the hospital at Haerlem ; and their prevalence in certain of the Zetland Isles was said to have been arrested by the uncere- monious ducking inflicted upon two or three of those affected; the fear of being treated in the Same way having effectually prevented others from being attacked. 66. 1. Regimen.—The circumstance of those convulsions which arise in crowded assemblies from mental excitement and religious impressions being often ushered in by faintings and signs of congestion of the cavities of the heart, of the large vessels, of the lungs, &c., should suggest the avoidance, by susceptible persons, of warm and crowded assemblies, where the foul and moist air conspires with moral emotions in depressing the nervous power, and in favouring congestions of the heart’s cavities and large vessels ; as well as the propriety of removal to the open air, and of having recourse to antispasmodic stimulants upon the approach of the sinking and oppression at the epigastrium and prsecordia, which often usher in the fit. The importance of adminis- tering to the mental affections and emotions—of relieving as much as possible anxiety or de- spondency—ought to be pointed out to those con- cerned, and the patient encouraged strenuously to resist the invasion of the paroxysm. Per- sons subject to convulsions should never receive indulgence on account of them, but be made to know that they may be warded off, by not yield- ing to the feelings which often favour or produce them. Regular hours of rest, of recreation, and of eating, should be adopted ; sedentary habits avoided ; exercise in the open air taken daily, and both the mind and body duly occupied with- out fatiguing either the one or the other. In some cases, depending upon disease of the brain or its membranes, the appetite is morbidly in- creased, and much more food is taken than is re- quisite to the wants of the frame. Others are connected with indulgence in spirituous liquors. It is almost unnecessary to add, that unless these excesses be guarded against, and the diet and regimen duly regulated, medical treatment will not be efficacious. 67. ii. Treatment of Convulsions in Infants and Children.—A. Many of the measures al- ready recommended in the paroxysm may be also employed in this class of patients ; but in a suita- ble form and with strict reference to existing pa- thological states. Where we observe the indica- tions of cerebral irritation and congestion (§21.24.), cupping on the nape of the neck, behind the ears or occiput; the warm bath or semicupium, with cold affusion; cold epithems, &c., on the head, the hair having been removed or cut close; a dose of calomel, or of calomel and scammony, if the child can swallow, and a cathartic and anti- spasmodic injection; are suitable remedies. The jugular vein may be opened in robust or well- grown children ; but care should be taken not to bleed them to syncope, as a return of the con- vulsions may be thereby occasioned. Children ought to be blooded with great caution during a fit; for, although I cannot go so far as to say, with Harris, that it is dangerous to bleed in the paroxysm, yet I believe that the convulsions will occasion a hurtful quantity of blood to flow without any immediate effect, if the evacuation be pushed with the view either of subduing them, or inducing syncope. It is as improper as it is futile to lay down any rules as to the extent to which depletion may be carried. It is obvious, that when the child is plethoric, the head large and hot, the eyes suffused and prominent, the ca- rotids throbbing, &c., it may be practised freely, even in the fit, without risk. 68. a. Compulsions sometimes proceed from the nature of the ingesta. If this be the case, and if the abdomen be distended, an emetic should be exhibited without delay. Seizures not infrequently arise during the period of dentition from indigestible or irritating substances in the prima via, and in such cases often commence in simple flatulent colic. After an emetic has been exhibited, or even independently of it, a purga- tive, if it can be taken, should be prescribed, along with carminatives or antispasmodics, and a clyster thrown up. In cases of this description, I have found a dose of calomel, with soda or pot- ash, or the hydrarg. cum creta, followed by ei- ther of the following mixtures, a carminative enema, and friction with an antispasmodic lini- ment on the abdomen or spine, the most suc- cessful means. No. 158. & Magnesi® Calcit-.ate 3 ss.; Sacchari Albi 3 j.; Olei A nisi HI v.; tere bene simul, et adde Aqu® Fu- niculi Dul. ? jss.; Spirit. Ammon Foetid. HI xv • Pulv. Rhei gr. xvj.; Syrup. Papaveris 3 Ij. Fiat Mist.’ cujus capiat coch. unurn, vel duo minima, tertiis vel quartis horis. No. 159. R Olei Ricini 3 iij.— 1 ss., Olei Terebinth. 3j.— 3 ij.; tere cum Vitel. Ovi, et adde Aq. Foeniculi 5 ss — 1 j.; Syrup. Papaveris et Syrup. Rosa; aa 3 ij. M. Fiat Mist., cujus sumat partem quartern vel tertiam ter tiis vel quartis horis. 69. b. Clysters, containing valerian, assafcetida, or a terebinthinate substance, triturated with the yolk of egg, and any of the carminative waters, to which oieum ricini or ol. olivas may be some- times added, are the most appropriate to those cases. Much discrimination is required as to the choice and continuance of cold applications to the head, particularly if the warm bath or semicupium be simultaneously resorted to. These combined means should never be left to the dis- cretion of a nurse, at least without the personal superintendence of the practitioner in the first instance. In general, as soon as the temperature is reduced, and the features become pale and shrunk, or the fontanelle (if unclosed) level, or at all depressed, whether the convulsions, or sopor, when present, disappear or not, the application of cold to the head, in any form, should be left off, to be again resumed when the symptoms requir- ing it recur. 70. c. During dentition, or even before the teeth approach the margin of the gums, free scarifications ought to be practised, and repeated as soon as the scarified parts cicatrise, otherwise the obstacle to the passage of the teeth will be thereby increased. If general or cerebral pie- CONVULSIONS OF CHILDREN—Treatment. 499 thora be ndt present, or has been removed and the bowels have been fully evacuated, any of the alkaline or earthy carbonates, with aqua foe- niculi, or aq. pimentae, aether, camphor, &c., with the extract of conium or hyoscyamus, or the syrup of poppies, or small doses of laudanum, may be prescribed with the view of soothing the susceptibility and irritability of the frame at this period. Form. 347. 442. 865. have been ordered by me very generally in such cases, at the infirmary for children. In very young in- fants, convulsions may be occasioned solely by the retention and accumulation of acid and acrid sordes in the prima via. These are readily re- moved by a dose of calomel, followed by olea- ginous or other purgatives, the semicupium, and clysters. Tissot and Sharp state that they have been produced by the retention of the meconium, owing to spasmodic stricture of the sphincter ani. This is, however, a rare occurrence. Emollients, oleaginous laxatives, the semicupium, clysters, and anodyne liniments, are appropriate to such cases. It has been repeatedly contended for by most of the older, although denied by many mod- em writers, that the anxieties, the more violent passions, and the irregularities of the nurse, may change her milk so as to disorder the digestive organs, and thereby give rise to convulsions in delicate infants. This fact is established by re- peated observation. I perfectly agree with Mr. North, who has taken a very judicious view of this subject, that it should never be overlooked. The ‘obvious remedy in such cases is to change the nurse ; and, if this cannot be done, to remove as far as may be the cause of disorder; to promote her digestive and excreting functions; to tran- quillise or subdue any mental disturbance or febrile action that may affect the state of the milk, and to prescribe for the infant aperients with soda or ammonia, or other antacids and antispasmodics. I have often employed the oxide of zinc or trisnitrate of bismuth with soda, or the pulvis creta? compos., and either the pulvis ipe- cacuanha? comp., or small doses of conium or hyoscyamus, with much advantage in these cases or simply the bi-borate of soda in camphor mix- ture, or aq. fceniculi. 71. d. The cold bath is a very doubtful rem- edy in the seizure: it is much less efficacious than the cold affusion on the head; and when the child retains its consciousness, it even some- times aggravates the mischief. Of the recom- mendation of Dr. Bronn, to employ gradually increased pressure on the epigastrium during the fit, I have had no experience: it, however, de- serves a trial. 72. e. Of the use of blisters in convulsions, as well as of alkaline rubefacients, as the liquor am- monias, no favourable idea should be entertained, as they require the utmost discrimination, and are far from being unattended by risk: for, al- though they will often cut short the paroxysm, yet they will also occasionally produce so violent irri- tation and inflammation as to be rapidly followed by sphacelation of the integuments. This is liable to happen particularly in ill or insufficiently fed, in delicate and irritable children ; in those of a gross or fat habit of body, who have been al- lowed to feed upon the richer sorts of animal food too exclusively; in the slate of vital ex- haustion observed in the latter stages of dis- ease, as well as in the early periods when the pulse is very quick, irritable, or sharp, the skin dry and burning, and the cerebral organa much excited or oppressed ;—under such circumstances, I have usually directed a liniment composed of equal quantities of the liniment, saponis et opis {Ed. Phar.), and of the liniment, terebinthinee, or either of F. 308. 311. to be rubbed on the epigastrium and abdomen, or along the spine. Thunberg advises the cajuput oil to be applied to the epigastric region during the fit; Her?. directs the animal oil of dippel to the same region, and Abrahamson the oil of rue. Either of these will frequently cut short the paroxysm, but I can assert, from a very extensive experience, that the liniments I have recommended are the safest and most efficacious. 73. /. When convulsions occur in the invasion of any of the exanthematous fevers, or upon the retrocession of the eruption, the treatment must depend, in a great measure, on the habit and strength of body, and the extent to which the brain is affected. If cerebral congestion or irri- tation, with general heat of surface exist, local depletions, the cold affusion on the head, whilst the patient is plunged in a warm bath, to which some vegetable or mineral alkali has been added, cooling aperients, cathartic injections, the tartar- emetic ointment and solution F. 749. rubbed on the spine, and diaphoretics, are generally most service- able. After the bowels have been freely evacuated, the carbonate of soda and nitrate of potash, given in mucilaginous vehicles ; the spirit, cetheris nitrici, with the liquor ammonia? acetatis in camphor julep, &c., may be prescribed. If the skin be cool, and the pulse weak, or if the fit have occurred after the disappearance of the eruption, salt and mustard may be put in the bath ; and if the coun- tenance be pale and collapsed, and the cerebral functions not materially disturbed, warm and cor- dial diaphoretics, as the preparations of ammonia, camphor, serpentaria, See., exhibited from time to time. Frictions of the surface, immediately after the prttient is taken out of the bath, will generally promote its good effects. 74. g. If convulsions occur in the course.of hoop- ing cough or croup, we may conclude that conges- tion, or inflammatory irritation of the membranes of the brain, has supervened, and should direct local depletions, the cold affusion on the head, semicupium, and the carbonates of the fixed al- kalies, with opium, hyoscyamus, or belladonna, in minute doses, unless the patient is already much reduced by repeated or large evacuations, when we may infer that the convulsive seizures are connected with anaemia, and should prescribe the treatment already described in relation to this state (§ 55.). 75. h. The convulsions which occur so fre- quently as a consequence of chronic or severe bowel complaints, and of exhaustion from other diseases, and which have been too frequently imputed to dropsical effusion in the ventricles, require cordial antispasmodics, tonics, and light nutritious diet. Although sometimes attended by more or less effusion, arising from the phy- sical condition of the cranium and its contents, and serving to prevent any vacuum from being occasioned by the deficiency of blood in the cerebral vessels, yet the convulsions should not be viewed as proceeding from the effused fluid, but rather from the irregular and imperfect supply of blood to the cerebral structure. 76. i. The seizures that follow great losses of blood in children are generally characterised by too CONVULSIONS OF CHILDREN—Treatment. 500 active determination of this fluid to the cerebral structure ; and require the head to be kept cool and elevated, the bowels to be acted upon, and restoratives, antispasmodics, cordials, and tonics to be administered with the extract of poppies, conium, or hyoscyamus, according to the pecu- liarities of the case. 77. k. If convulsions follow the disappearance or repulsion of chronic eruptions, we should dread the existence of inflammatory irritation of the membranes of the brain or medulla oblongata or spinalis, with a tendency to serous effusion. Local depletions, the warm bath, frictions of the surface, particularly of the part whence the eruption had disappeared, with irritating lini- ments, the use of sinapisms, and deobstruent purgatives, as calomel, &c., are chiefly to be con- fided in. 78. 1. When the seizures have recurred several times, particularly in infants, and are attended by dilated pupil, squinting, slow pulse, &c., their connection with hydrocephalus may be inferred. In such cases, even local depletions should be employed with caution: but in many instances they may still be resorted to, in small quantity; and followed by alterative doses of calomel or hyd. cum creta, diuretics, small doses of digitalis with spirit, eether. nit. and the use of the liniment (F. 311.) to the head and loins both in the fit and in the interval. [Dr. Tripler, of the U. S. Army, recommends mustard internally in the convulsions of children in preference to all other remedies, and states, that it often promptly succeeds in arresting the paroxysm when other means fail; and that its efficacy has no relation to its emetic properties. In one instance that had lasted five hours, and resisted the usual remedies, it immediately ar- rested the spasms without vomiting the patient till some time afterwards. (New York Jour. Med. and Surg., vol. ii., p. 385.) Dr. N. Morrell, of this city, has published an excellent paper on convulsions in the New York Jour, of Med. and Surg., in which he maintains, that in every kind of convulsion, the respiratory system is the first to suffer; that the lungs become primarily, and the brain secondarily con- gested ; and that the first object in treatment is, to restore the free action of the respiratory ap- paratus, inasmuch as a few deep inspirations are sufficient to relieve the brain, which is an effect that can not occur as long as the lungs are con- gested. The treatment is founded on this pa- thology : one or both temporal arteries are to be opened, by which the left side of the heart is emptied, blood not perfectly depurated is poured in, the irritability of the ventricle diminishes, and the lungs are emptied. The lungs are now capable of expansion, and through the reflex function, thus stimulated to action, the glottis opens; the child takes three or four deep in- spirations, each inspiration diminishing cerebral pressure by returning the blood from the head, the force of arterial action subsides, and the con- vulsion ceases. To prevent the return of the convulsions other indications are now presented, viz., to maintain the glottis open, to unload the portal system, and to restore the suspended secretions. For the first indication, Dr. M. gives from one to five drops of cajuput oil; for the second, a large enema of salt and water; for the third, a dose of calomel. If the convulsions return, the oil of cajuput is to be repeated, and sometimes the bleeding, together with the enema, and, in addition, a tea-spoonful of the following mixture every four hours: muri- ate of ammonia and nitrate of potash, each 3j.; nitric ether, 5 j.; water, 5 iij. In some cases this treatment is to be followed by tonics, as quinine Fifteen cases of convulsions are reported in illustration of the efficacy of the above mode of treatment.] 79. B. The preventive treatment,—a, in ple- thoric, fat, and gross-living children, should chiefly consist of a proper regulation of diet, as advised by Beaumes. Farinaceous food ought to be adopted, with only an occasional indulgence of the less stimulating meats. No rational plan of treatment, however, can be attempted with the view of prevention, without strict reference to the remote and proximate causes of the affection; the former of which should be carefully avoided, and the latter removed by suitable treatment. When we detect cerebral irritation, or determina- tion of blood to the brain, or active congestion, cupping, as already directed ; the daily affusion of cold water on, and a constantly cool state of, the head; a moderate, but continued, action on all the secreting and excreting organs; tranquil- lity, and the abstraction of all excitement of the mind and senses ; a bland and low diet; the use of revulsants, and warm clothing on the lower ex- tremities ; are the most appropriate remedies. 80. b. In very delicate children, where no evident inflammatory irritation within the head exists, a tonic treatment is obviously requisite. The sesquioxide or aiumonio-tartrate of iron mav be given, either alone, or with other antispas- modics, or any of the other preparations of this metal. The sulphate of quinine, or the prepara- tions of cinchona, with liq. ammonias acetatis, and a little of any of the compound spirits of am- monia ; suitable diet, attention to the state of the bowels, and change of air, will also be of service. Calomel, in frequently repeated doses, either alone or with purgatives or anodynes, has been most injuriously resorted to by practitioners, upon the mistaken notion that convulsions are always connected with irritation within the cranium, and that this medicine alone can remove this state; whereas, if calomel be prescribed in small and frequently repeated doses, it will actually increase the susceptibility and irritability of the body generally. When, however, it is given in full doses at distant intervals, or only occasion- ally, and either combined with jalap or some more active purgative, or followed by cathartics and enemata, it is a valuable remedy. Where the bowels are thus judiciously acted upon from time to time, and particularly if this be accom- plished by a terebinthinated draught, tonics, com- bined with antispasmodics and anodynes, will be of the greatest benefit, especially if there be no disorder of the cerebral functions to forbid their exhibition. The sulphate or oxide of zinc, or the sulphate of quinine, or the oil or other preparations of valerian, or assafoetida, musk, &c., with either coniurn, hyoscyamus, or the extract of poppy ; the tonic decoctions and infusions, with the alkalies ; and various other remedies already recommended in the intervals (§ 61. 75.), may be severally employed, according to circumstances, after pur- gatives have been duly prescribed, and the stools have become natural. [Compression of the carotids has been prac- tised successfully in some cases of convulsions as CONVULSIONS OF CHILDREN—Treatment. 501 a means of shortening the paroxysm, and arti- ficial respiration has also been resorted to with decidedly beneficial effects in some instances, where all other means had failed. When the attack is evidently not owing to the irritation of teething, we have been generally in the habit of administering a mild emetic of ipecac., and often with the happiest effect. Not unfrequently, a solid cheesy mass has been ejected from the stomach, caused by the coagulation of the milk by the acid present in that organ, when the convulsion has instantly ceased. In one desperate case, this succeeded after all other measures had failed. A stream of cold water upon the head is another remedy on which we place great reliance. Where an emetic has been employed, it will be useful to follow it with calomel and oil, and small doses of the extract of hyoscyamus, rubbed up with calcined magnesia in a little anise or peppermint water. It is very important, after the paroxysm, to keep the bowels regular and promote a healthy state of the secre- tions, which is best done by minute doses of calomel combined with ipecac, or magnesia. The diet also should be very light, and of easy di- gestion, and given only in moderate quantities. Animal food, as a general rule, should be pro- hibited. Cases occasionally occur where con- vulsions are owing to excessive evacuations, as from loss of blood, or from diarrhoea; here, gentle stimulants, combined with some narcotic, will be useful; as wine whey, or the carbonate of ammonia with hyoscyamus or eonium. We have known more than one instance where a con- vulsion has been brought on in an infant from a sudden paroxysm of anger in the mother, by which the milk has suddenly acquired irritating properties. These cases show us the importance of a due regulation of the temper and feelings on the part of the nursing mother, and the ne- cessity of instantly removing the child from the breast when the milk is liable to be affected by such a cause. In this city, one of the most fre- quent causes of convulsions in children is the use of the milk of cows fed on distillery slops ; in- quiry should, therefore, always be made as to the kind of milk used, and none but that of the purest kind employed for the nourishment of the young.] 81. c. When we have reason to infer that the convulsions proceed from intestinal worms, calomel with camphor, and the other cathartics noticed above ; the occasional exhibition of an active terebinthinate draught, followed by ene- mata, containing aloes, assafoetida, camphor, &c., and subsequently, by the preparations of iron, as well as any other of the remedies and modes of combining them described in the article Worms, may be directed. It is generally remarked by the German writers, that worms never form in the alimentary canal previously to weaning, if the milk be healthy ; and the observa- tion is confirmed by my experience. It is there- fore, after this period, that convulsions can be referred to this cause. 82. d. The marked hereditary and constitu- tional tendency to convulsions in the same family of children, and the very frequent connection of this affection with cerebral irritation, or with dropsical effusion in the ventricles, or between the membranes, in such cases, have presented difficulties to every practitioner. I believe that the disease, when occurring in this manner, has been too frequently ascribed to inflammatory action, and a too lowering treatment adopted. Mr. Hill recommends the arsenical solution, with musk, in these cases; and I doubt not their utility, if carefully employed; but other tonics and antispasmodics, particularly the weaker prep- arations of bark or calumba, with the liquor potass®, and small doses of eonium, or syrup, papav., or opium, if the child be not too young, and if the watchfulness or erethysm of the brain be present, will be found still more serviceable, especially if the head be kept cool, the secretions and excretions carefully promoted, and the kidneys occasionally excited by the addition of diuretics to the tonics, as the spir. ®ther. nit., digitalis, syrup, scill®, &c., or by the application of a suitable liniment (F. 311.) to the loins. In several cases of this description, I have directed, after other means had failed, and while tonics, as now prescribed, were given, the hair to be cut off, and the liniment to be rubbed upon the head immediately after the cold affusion. In cases connected with inflammatory irritation of the membranes, local depletions, the cold affusion, &c. (§ 67.) should precede the above treatment. 83. e. The diet and regimen of children that have once experienced a seizure of convulsions, ought to be carefully attended to. The stomach ought never to be overloaded, either by the mother’s milk, or by its ordinary food, which should be always recently prepared, and easy of digestion. As crying often brings back the seizures in infants and young children, it should be prevented as much as possible. When the bowels have been sufficiently evacuated by the medicines suggested, from one to three grains of the hydrargyrum cum creta, either alone, or with the carbonates of the fixed alkalies may be given at first every night and morning, and afterwards every night, or every other or third night. The head should be always ele- vated ; and whilst in bed or indoors, it ought to have no other covering upon it than that with which Nature has provided it. On no occasion', should the warm fur or beaver hats, which are very improperly worn by children, be used; nor ought the mental powers to be prematurely or inordinately excited. In a word, the head should be kept always cool, the mind tranquil, the lower limbs warm, and the bowels open. A free, tem- perate, and healthy atmosphere, with occasional change of air, is also as necessary as medical treatment. [As a preventive measure, nothing is more bene- ficial than a removal of the child from the impure air of cities to the fresh and pure air of the country. By such a change the vital powers are invigorated, nervous excitability diminished, and the system rendered less susceptible to the impression of the ordinary exciting causes of convulsions. That convulsive diseases among children are far more frequent in the city than the country will apper from the following state- ments :—In Philadelphia, the number of deaths from convulsions in children under ten years of age, during the 35 years preceding 1842, was 7,297, or an average of 208.5 per annum; in infants under one year of age, 5,325; between one and two, 994 ; two and five, 726 ; five and ten, 252. The deaths in the city of New York in children during the 16 years from Jan. 1, 1819, to Jan. 1, 1835, inclusive, were 5,461; and of these a very large proportion occurred under the age of one year. In 1834, the number of deaths 502 CONVULSIONS, PUERPERAL—Treatment. the neck.] Simultaneously with the flow of blood, or immediately after it, the affusion of cold water or the application of a bladder of pounded ice on the head, and the exhibition of ten grains of calomel, and from five to ten grains of camphor, previously reduced to a powder by a few drops of spirit, with or without an equal quantity of musk, and shortly afterwards of two or three drops of croton oil, should never be omitted. These med- icines may readily be administered, by mixing them in sweet butter, and introducing a portion from time to time over the root of the tongue, upon the end of an ivory letter-folder, or upon the handle of a spoon. A cathartic and antispasmodic enema (F. 141. 149.) should also be thrown up without delay ; and immediately repeated, if it be returned. The combined effects of these will sel- dom fail of producing a solution of the paroxysm. My experience of the excellent effects of cam- phor is fully confirmed by Dr. Hamilton, although Ciiaussier expresses an unfavourable opinion of it, and of all heating antispasmodics; and the re- cently published observations of Mr. Michell are strongly in favour of musk, which he gives in doses of from one to two scruples. Depletion may be carried further in those states of the dis- ease which assume the characters of eclampsia, or which are attended by great fulness about the head, or stertorous breathing, than in almost any other malady. Chaussier advises, after general depletion has been practised, local bleeding from the nape of the neck and occiput, or from the epigastric region. 86. p. As to the propriety of prescribing opium in puerperal convulsions, very opposite opinions have been given. Petit, Hamilton, Merriman, and Dewees consider it most injurious; Man- ning and Bland recommend it, and Leake and Burns, with a judicious discrimination, state, that when the disease is not accompanied with fulness of the vessels of the head, it may be exhibited with advantage after blood-letting. In this de- cision I concur, and add, that it should always be given either with camphor, as directed by Stoerck, or with the carbonates of the alkalies, as advised by Stutz and Bruninghausen, or with both ; more particularly when the convul- sions occur from excessive irritability, or previously to the period of full gestation, or after delivery, or when they assume chiefly the characters of hysteria. Rinck applies it to the abdomen, and Hufeland to the soles of the feet. 87. y. Some difference of opinion exists as to the propriety of exhibiting emetics in this disease. Denman is in favour of them, but Mauriceau, Ciiaussier, and Hamilton condemn them, unless after blood-letting, and when the seizure has been excited by improper ingesta,—the only circum- stances under which, in my opinion, they should be given, and in which Dr. Blundell also rec- ommends them. Of the good effects of active cathartics there cannot be the least doubt. I have always observed, as Dr. Merriman has stated, that the stools procured by them are mor- bid and offensive. 88. <5. The next practical point of importance is, whether or not the patient should be immedi- ately delivered; and on this the sentiments of the most eminent accoucheurs are at apparent, rather than actual variance. No person will deny that the state of the uterus is connected with the cause of the seizure; therefore it would obviously seem requisite to remove that from this disease was 770. Dr. Condie remarks, that those forms of convulsive disease in chil- dren, depending upon atmosphere or climate, such as prevail in the West Indies, or in crowded hospitals, ill ventilated suburban dis- tricts, or the narrow streets, courts, and alleys of large cities, often exhibit peculiar phenomena, marking them, in a certain sense, as specific dis- eases ; like all affections that owe their existence, in a great measure, to atmospheric causes, they assume often peculiar types and characteristics, and prove, generally, more fatal in their ten- dencies. Under this head may be classed the epidemic convulsions which occurred at Paris (Claubey), the epilepsy that occurred at Copen- hagen, and destroyed in 13 years nearly 13,000 children; the trismus nascentium of the West Indies, and the infantile convulsions which, pre- vious to the year 1792, destroyed every sixth child born in the Dublin Lying-in Hospital. (Clarke.)] 84. iii. Treatment of Puerperal Convul- sions.—The more frequent occurrence of convul- sions iu a first pregnancy, during a protracted labour in those who have experienced them pre- viously ; the period of the puerperal state, and the progress of the labour and state of the os uteri when they do occur; the characters they assume— whether those of eclampsia, of epilepsy, of hys- teria, or of simple clonic convulsion ; the causes which induce them, the circumstances connected with them, and the fact that they, more than any of the other forms of convulsion, are the result of active determination of the blood to the head— which, however, is merely the effect of irritation primarily seated in the abdominal viscera; are all to be taken into consideration in the treatment of them. The intentions of cure are the same in this as in the foregoing states of convulsion ; and they should be promptly fulfilled. 85. A. In order to cut short the seizure,—a. After having resorted to suitable means to pro- tect the tongue, as the introduction of a cork be- tween the teeth, &c., blood-letting from the arm, but preferably from the jugular vein, when it can be easily performed, should be employed, and carried at once to a decided extent relatively to the vigour and habit of body of the patient; and it should be repeated after a short interval, if the convulsions recur, and there be no circumstances to forbid it. [It is well known, however, that profuse blood-letting will not invariably control the disease, and Dr. Robert Lee states that the sudden abstraction of fifty or more ounces of blood from the arm of some individuals, instead of arresting the disease, would destroy life. This writer recommends, after thirty or thirty-five ounces of blood have been drawn from the arm, to trust to local bleeding, and especially to the application of cupping-glasses to the temples and nape of the neck. When the constitution has been previously exhausted by some chronic dis- ease, or haemorrhage; or without these, if it is peculiarly delicate, nervous, and irritable, and has been weakened by grief, and other depressing passions, and the pulse is very rapid and feeble, he thinks it better to trust entirely to the local abstraction of blood and other remedies, and ab- stain altogether from general bleeding. On ex- amining the tables given by this author, we find that some women died who were bled profusely, and that others recovered where a small quantity was drawn from the arm, or where it was entirely drawn by cupping from the temples and nape of state. But the objectors reply, that convulsions also occur after delivery, when this state of uterus no longer exists: I have, however, never met with any, of several eases of convulsions after delivery for which I have prescribed, that did not arise from analogous causes of irritation, viz. an over-distended urinary bladder, the re- tention of the placenta or of coagula in the uterus, or the accumulation of fecal or irritating matters in the bowels. I therefore would adhere to the opinion I have often given, namely, if the above means have failed, and if the labour be so far advanced as to enable the accoucheur to de- liver immediately without force or injurious in- terference, then let it be done. If the labour be not so far advanced as to enable the accoucheur to deliver immediately without force or injurious interference, then let it be done. If the labour be not so far advanced, but yet the os uteri is considerably dilated, then the membranes may be ruptured, particularly if they be very tumid,— if, indeed, they have not been already ruptured, which is often the case, and either full doses of the biborate of soda (3j. to 3 ss.j given, or the ergot of rye. If the os uteri be rigid, or undi- lated, the former of these will be preferable. If, however, the labour has not proceeded far, then any interference, excepting by the exhibition of medicinal substances, may be more injurious than beneficial. La Motte, Osborne, Leake, Ha- milton, Dubois, Ashwell, Nauche, Miguel, Burns, Osianders, father and son, Duges, and Ramsbotham, are favourable to as early delivery as possible without violence ; whilst Bland, Gartiis- iiore, Baudelocciue, Hull, Gardien, Denman, and Blundell, are against forcible dilatation of the os uteri, and attempts at delivery in the early stage of labour. After all, the difference is more :n words than in intention ; for the general object e to hasten delivery, without injurious interfer- ence, if the labour be so far advanced as to render ie attempt prudent; and those who have es- poused either side have stated their opinions with such exceptions and limitations, and with so little precision, as to leave the subject nearly where they found it, and to render it no easy matter to ascer- tain under what circumstances they would either have recourse to art, or trust to nature. When the treatment already recommended fails, or is followed by an exasperation of the convulsions,— which will very seldom occur if it have been judiciously directed,—then I eonceive that the active interference of art should be called to our aid. There is, perhaps, no subject on which opinions are stated to be so much at variance as on this,—each succeeding writer placing those of his predecessors in opposition, even where no real difference exists, and thereby bewildering the in- experienced, in order that he may have the credit of giving a decision respecting it. 89. £. Chaussier recommends, in rigidity of the uterine orifice, the application of a pomade con- taining belladonna, with a view of relaxing the •oastic contraction, which, he states, is not limited u this part, but extends to the whole of the organ. I believe, however, that the body of the womb is generally free from spasmodic contraction. This preparation consists of two drachms of the extract of this narcotic, softened with an equal quantity of water, and triturated with about an ounce of prepared lard. A piece, the size of a small nut, is to be introduced into a female syringe, open at the extremity, and conveyed to the os uteri, where CONVULSIONS, PUERPERAL—Treatment. 503 it is to be applied by pushing onwards the piston. In about half an hour the rigidity subsides, and the labour proceeds. Of this practice I have no experience. M. Chaussier discourages any other attempt at dilatation of the os uteri, as irritating the parts, and inducing a recurrence of the con- vulsions. 90. £. I have never omitted, in any case treated by me since 1819, to employ tho affusion of a stream of cold water on the head, and the injection of turpentine clysters, sometimes with camphor, assafcetida, or valerian, and the results have been most satisfactory,—a much less quan- tity of blood having been detracted than is usually required in such cases. I am not aware that either of these two remedies had ever been em- ployed in puerperal convulsions, until long after I had given publicity to the practice,—a prac- tice which I know to have been recommended very recently by those who, at that time, ridi- culed it. In the more rare states of the disease, which are attended by a weak quick pulse, pale features, and hysterical symptoms, enemata con- taining valerian, assafcetida, or camphor* are very serviceable. In those which assume the comatose or apoplectic characters, blisters applied to the nape of the neck, and sinapisms to the ankles and calves of the legs, are useful adjuvants of the measures already recommended. 91. ih In all cases occurring previously to, during, or after parturition, the state of the blad- der, and of the bowels, ought to be carefully enquired into. Early in 1823, I was called to the Queen’s Lying-in Hospital, by the house pupil, to a patient who had been seized with puerperal fever on the second day after delivery, but was convalescent from it, when she was at- tacked by convulsions, brought on by a distended urinary bladder. I found that the urine had been drawn off, and that she had been blooded once largely. The case was one of extreme severity and danger ; the convulsions were unre- mitting, and attended by profound coma and asphyxy. The vein was re-opened, and, while the blood flowed, a stream of cold water was kept playing upon the vertex, and, at the same time, a clyster with turpentine and camphor was thrown up. Thus, the three most powerful—the almost only, remedies to be confided in, were simultaneously in operation. The patient rapidly recovered. Purgatives were given by the mouth, upon the solution of the convulsions ; deglutition having been entirely abolished during the whole seizure. This was one of the earliest cases in which I had ventured upon the simultaneous employment of these powerful agents, the use of them in succession having been generally adopted by me previously. I allude more particularly to this case, because of its uncommon severity ; of its occurrence soon after a most dangerous dis- ease, as late as nine days after delivery, in a pub- lic institution, and at a time when my public recommendation of the practice apparently re- ceived but little attention ; although it will not now be looked on with scepticism. 92. 6. Of other remedies but little maybe said, as they should be viewed as auxiliaries merely. I have already expressed myself favourably of camphor (§ 85.). Burns condemns it; but, when exhibited after depletion, and at the same time with the cold affusion on the head, and cathartic and antispasmodic clysters, it is a valuable med- icine. Unc. 'r the same circumstances, musk, 504 CONVULSIONS, PUERPERAL—Treatment. centa should be removed, and the existence of internal haemorrhage enquired after—if at a later period, the state of the urinary bladder and bowels, as well as of the womb, demands atten- tion. In all such cases, active purgatives and cathartic clysters are especially required, but the choice of them should be made with due reference to the state of constitutional power, and to the presence or absence of cerebral congestion, or of exhaustion and nervous susceptibility. 95. A. When the. convulsions attack epileptic females, they generally have all the characters of epilepsy or eclampsia, generally with unremitting sopor and stertorous breathing passing almost into asphyxy ; and they require the treatment described above. When they occur in hysterical females, they may also assume the same forms, and de- mand the same method of cure ; or they may pre- sent the features of simple hysteria, particularly borborygmi, quick pulse, &c., with very slight cere- bral affection. In these latter cases, the nervine remedies mentioned in the next paragraph will be adopted with advantage, especially after the cold affusion on the head. Cold enemata may be also thrown up, as advised in Hysteria. In the ma- jority of these seizures, neither bleeding nor arti- ficial delivery is required, unless cerebral conges- tion supervene, or the patient be strong or plethoric. 96. jx. Convulsions in the puerperal states may occur from great exhaustion, from want and inanition, and losses of blood. In these, the prac- titioner should trust chiefly to the cold affusion, performed only momentarily ; to the keeping of the head cool and elevated ; to sinapisms on the lower extremities ; to the exhibition of camphor, ammonia, the vegetable alkalies, and musk, with small doses of opium, or of the aethers with hy- oscyamus or conium ; to the administration of valerian, assafoetida, or turpentine clysters ; to the warm bath ; to anodyne frictions of the abdomen ; and to as early delivery as may be safely at- tempted ; the vital energies being supported by gentle cordials during the remissions. If the seizure be complicated with haemorrhage from the uterus, or hsematemesis, prompt artificial delivery, the turpentine clyster in the first instance, and turpentine draught in the second, are the most certain means. 97. B. The prevention of puerperal convulsions is of great importance The means calculated to attain this object can be put in practice only when the premonitory symptoms (§ 28.) manifest themselves.—a. If these indicate fulness of the vessels of the head, bleeding from the arm, or cupping on the nape of the neck, will be neces- sary ; and in every instance the bowels are to be freely evacuated. There are few cases of the disease, at whatever period it may occur, entirely unconnected with fecal accumulations ; and al- though this state of the bowels may not excite the attack, it certainly remarkably disposes to it. Cathartics should therefore be given by the mouth, and their action promoted by clysters. Dr. Blundell advises an ipecacuanha emetic to be taken in the first instance ; and where there is a loaded or disordered stomach, this practice may be adopted. In addition to these, the warm bath may be used ; and if, notwithstanding, signs of active determination continue, the cold affusion on the head, or cold applications, should be also resorted to, either previously, or at the same time with, or subsequently to, the warm bath. Dr assafeetida, and the other antispasmodics, will also be of use ; for all risk of their injurious action on the brain is prevented by the cold affusion, whilst they co-operate with the terebinthinate in- jections to excite the contractions of the body of the uterus, and remove spastic constriction of its neck. Of the ergot of rye, my experience is limited. I have given it only in one case of this disease, and then it was combined with biborate of soda,—a medicine undeservedly fallen ,into dis- repute—but which I have prescribed for many years. The labour in that case proceeded rapidly, and the patient recovered. Much difference of opinion exists as to the effects of, and propriety of giving, the ergot in convulsions. If the os uteri be dilated, and the external parts free from rigidity, blood-letting, the cold affusion, and cathartic injections, having been actively but unsucess- fully employed, there can be no doubt of the pro- priety of exhibiting it. Opinions will always be at variance as to the benefits derived from sub- stances recently introduced into practice ; for, as all medicines are remedies only from their appro- priate use, experience of their operation is required to ascertain the circumstances in which they are truly of service. In a case of puerperal convul- sions—I believe the first in which the ergot was exhibited—Dr. Brinckle gave it after the means usually adopted had failed. Twenty minutes after the first dose had been taken, uterine action came on, and the patient recovered. It is strongly recommended by Dr. Waterhouse, of Philadel- phia, and by Mr. Michell. 93. t. In cases of unyielding rigidity or callo- sity of the os uteri, Van Swieten advised an in- cision to be made through its margin. Dubosc, and, subsequently, Lauverjat, Bodin, and Cou- touly, who considered it perfectly justifiable after blood-letting, the warm bath, and other means usually employed, had failed, have had recourse to this operation. M. Coutouly has recorded four cases (two of which are quoted by M. Mi- guel) in which it was resorted to ; three of these recovered. The death of the fourth he imputed to the circumstance of it having been too long de- layed. M. Nauche also favours this operation in the above circumstances, especially if emollient and narcotic injections into the vagina have failed to relax the rigidity. 94. k. The warm hath, and emollient fomenta- tions, followed by the use of an anodyne liniment on the abdomen, have been recommended by Denman and Nauche ; and the tepid bath by Capuron, after bleeding has been practised. Much advantage will accrue from assiduous fric- tions of the abdomen, more particularly if they be performed with an anodyne and antispasmodic liniment (§ ,53, 54.), independently of the use' of a warm or tepid bath ; for either of these can seldom be used with advantage in the circum- stances of puerperal patients. In every case the hair should be cut closely off. This may be done in a very few minutes ; but shaving the head is merely a loss of time. Burns, Ryan, and Clarke advise the application of a blister on the head ; but I believe that it will be required only in ex- treme cases; it certainly ought to be ventured upon only in such, where the coma is profound, and the pulse weak, and the patient sinking. The advantages stated to have been derived by Dr. Clarke from acrid cathartics, and clysters, are confirmed by my own experience. If the convul- sions occur immediately after delivery, the pla- CONVULSIONS—Bibliog. and Refer. 505 Home and Dr. Blundell favour the exhibition of digitalis in such circumstances. 98. b. If the premonitory symptoms be charac- terised by leipothymia or sinking, rapid weak pulse, particularly of the carotids ; coolness of head, sunk features, &c.,—the internal use of camphor, or musk, ammonia, assafoetida, the (ethers, the warm bath, with small doses of opium, purga- tives, sinapisms, blisters, and the turpentine fomen- tation applied on the abdomen, are the most ap- proved means of prevention. [Puzas lays great stress on the importance of prompt and vigorous measures in the acute con- vulsions which precede or accompany labour, and especially of paying particular attention to the first symptoms which announce convulsions. For example, a female will, all at once, complain of dazzling of the eyes, weight in the forehead, or posterior part of the head, and sudden loss of vision ; symptoms which announce that an attack of convulsion is at hand. He remarks that he has often seen women suddenly seized with fright- ful convulsions during labour, because attention had not been paid them when they complained of pain in the head ! The true plan, in such cases, is to bleed very freely, on the first appearance of the symptoms that threaten convulsions, and in this way only will they generally be prevented.] 99. c. If the patient have had two or three attacks at some former period, and if the above preventive treatment have not rendered the ac- cession of the disease less probable, Dr. Blundell advises the membranes to be punctured. 100. C. During convalescence, the states of the urinary bladder and of the bowels should be care- fully watched, and evacuated ; the diet regulated ; and both body and mind kept tranquil. If cere- bral symptoms continue for some time afterwards, the head should be preserved cool, and sponged with cold water night and morning, and a blister applied to the nape of the neck, and kept open for some time, whilst a course of eccoprotic and deobstruent purgatives is continued for several days. Bibliog. and Refer.—i. Convulsions in General. Hippocrates, Aphor. sec. vi. § 39. vol. i. p. 101. edit. Vander Linden.—Galen, De Locis Affect. 1. iii. c. 6.—Oribasius, Synop. l.viii. c. 16.—Paulus JEgineta, 1. iii. c. 19.—Zacutus Lusitanus, Prax. Hist. 1. i. cap. 11., 1. v. cap. 2.— Willis, De Pathologia Cerebri, cap. i. 4.—Baillou, Op. omnia, vol. iv. p. 134.—Amatus Lusitanus, cent. vii. cur. 11. (Inanition.)—Bonet, Sepulch. 1. i. cent. xiii. observ. 26.— Morgagni, De Sed. et Caus. Morb. ep. x. art. 21 .—Hoff- mann, De Convulsionibus, in Oper. vol. iii. p. 31., et Supp. vol. ii. p. 2.—Collbatch, Sur le Gui de Chene, in Malad. Convuls. Paris, 1719.—Baynard, On Hot and Cold Baths, &c. Lond. 1722.—J. Juncker, De Morb. Spasmodico-Convulsivis, &c. Hal®, 1739.—Monro, in Edin. Essays and Observ. vol. iii. p. 551.—Schroeder, De Convulsion, ex Hremorrhagia nimia oriundis. Marb. 1752.—Marx, De Motibus Convulsivis, &c., 4to. Hal®, 1765.—Stoll, Rat. Med. par. iii. p. 412.—Stoerck, Do Strainonio, Hyoscyamo, Ac. Vien. 1762; et Ann. Med. vol. i. p. 15.— Wedenberg, De Stramonii TJsu in Morb. Convuls. Ups. 1772.—Sidren, De Stramonii Usu in Malis Convuls. Ups. 1773 ; et in Act. Med. Suec. t. i.— Whytt, Works, 4to. p. 582.—Home, Clin. Exp. Hist, and Diss. &c. 8vo. p. 153.—Evans, in Med. Observ. and Inquiries, vol. i. art. 11.—Gulbrand, in Act. Reg. Med. Hann. b. i. p. 26.— Bell, in Edin. Med. Comment, vol. i. p. 120.—Goodsir, in Ibid. vol. i. p. 467.— Warburg, Medic. Beobachtung. No. 10. —Clarke, in Med. Facts and Observ. vol. viii. p. 275.—Pal- las, Reisen durch Russland, ii. p. 387.— Unzer, in Hainb. Mag. b. viii. p. 369.—Bergius, Mat. Med. p. 121.—Arnot, Edin. Med. Essays, &c. vol. vi. p. 634.—J. Smith, Ed. Med. Comment, vol. iii. p. 316.—P. Dugud, in Ibid. vol. v. p. 84. — White, in Ibid. vol. vi. p. 330.—Armstrong, in Ibid. vol. ix. p. 307.—Albers, Edin. Annals of Med. vol. vii. p. 406. (From abscess of the ear) ; et Horn's Archiv. b. i. p. 329. —Conradi, in Hufeland's Journ. der Pract. Heilk. b. vii. st. 2. p. 6.—Hargens, in Ibid. b. vii. st. 1. p. 114.—Doer- ner, in Ibid. b. xv. st. 4. p. 94.—Henrischen, in Ibid b. xv. st. 4. p. 79.—Michaelis, in Ibid. b. iii. p. 344.— Wiedemann, in Ibid. b. Vi. p. 418.—Struve, in IbiJ. b. xxiii. st. 4. p. 8.—Schmalz, in Ibid. b. xi. st. 4. p. 169. —Heilbronn, in Hufeland und Harles N. Journ. del Ausl. Med. Chir. Lit. b. ii. st. 1. p. 187.—Powel, in Trans, of College of Pbys. of Lond. voi. iv. art. 8.—Latham, in Ibid. vol. vi. p. 248.—Cornish, in Lond. Med. and Physi- cal Journ. vol. xxxi. p. 373.—Loeffler, in Richter’s Chir. Biblioth. b. viii. p. 732.—Krebs, Medicin. Beobachtun- gen, b. ii. heft 2d.—Sumeire, in Journ. de Med. t. xxi. p. 224.—Dupont, in Ibid. t. xxxii. p. 130.—Parry, Mem. of Med. Soc. of Lond. vol. iii. art. 8. (Compression of the carotids—Bianchi, in Brera's Comment. Medici, dec. i. t. ii. art. 5.—Grapengiesser, Versuche, p. 98.—Plenk, in Abhandl. der Joseph-Acad. b. i. p. 318. {Ipecacuanha.)— Thunberg, De Oieo Cajeputi. Ups. 1797.—Herz, Briefe, st. 1. art. 1 .—Jlbrahamson, in Meckel's N. Archiv. b. i. st. 3. art. 21.— Hufeland, Bemerkung. iiber Blattern, &c. p. 349.—Frankfurter, Med. Wochenbl. b. v. p. 229.— Savary, in Diet, des Sciences Med. t. vi. par. ii. p. 197.— P. Jolly, in Diet, de Med. et Chirurg. Prat. t. v. p. 473.— Naumann, in Encyclopad. Worterbuch der Med. Wis- sensch. b. viii. p. 341.— Thackeray, in Med. and Phys. Journ. vol. x. p. 410., and vol. xii. p. 508.—Barton, in Ibid, vol. viii. p. 428.; Edin. Med. and Surg. Journ. vol. iii. p. 441. —Clarke, in Ibid. vol. v. p. 268.—Hill, in Ibid. vol. v. p. 318. — Thomson, in Ibid. vol. xiv. p. 614. {Dissections in.)— Haygarth, Of Imagination as a Cause or Cure of Dis- orders. Bath, 1800.—Portal, Anatomie Medicale, t. iv. p. 69. et seq. {Results of Dissections in.)—Dessesartz, in Journ. de Med. t. xlvii. p. 114.—Rinck, in Stark's Archiv. b. v. p. 389.—Kortum, in Hufeland's Journ. der Pract. Arzneyk, b. iv. p. 381.—Cazals, in Journ. Gener. de Med. Dec. 1810, p. 371. {Bismuth.)—Schaeffer, in Hufeland’s Journ. der Pract. fleilk. Feb. 1810, p. 105.—Gebel, in Ibid, b. xvii. st. 3. p. 103. {Musk in large doses.)—Berge, in Med. Chir. Rev. vol. xxv. p. in Ibid. vol. xxvii. p. 485.—Lee, in Lond. Med. Gaz. vol. xxi. p. 11. ii. Convulsions of Children.—Harris, De Morbis Infantum, p. 102.—Rosen, Traite de Malad. des Enfans, 8vo.—Beaumes, Traite des Convulsions dans l’Enfance, 8vo. Paris, 1805.—Capuron, Des Maladies des Enfans, 8vo. Paris, 1813, p. 407.—Gardieu, Traite de Malad. des Enfans, t. iv. ; D’Accouchemens, 3d edit. p. 239.—J. Clarke, Commentaries on the Diseases of Children, 8vo. p. 80. (Too exclusively referred to cerebral irritation.)—Jacques, in Journ. Gbner. de Med. t. xxix. p. 280,—Bronn, in Ibid. t. xxxi. p. 457.—Piorry, De l’lrritation Encephal. des Enfans. Paris, 1823.— Underwood, On Diseases oi Children, by Merriman. Lond. 1827, p. 233.—Bracket, Sur les Convulsions des Enfans, 8vo. Paris, 1824. (A good book, with too partial a leaning to cerebral irritation.)—• J. North, Practical Observat. on the Convulsions of In- fants, 8vo. Lond. 1826. {An able and judicious work.) iii. Puerperal Convulsions.—J. Leake, On the Acute Diseases of Females, &c. 6th edit. p. 338. {Convul. from Inemorrh. and inanition well treated of)—Manning, On Female Diseases. Lond. 1775, p. 357 — Denmanf In- trod. to Practice of Midwifery, 5th ed. p. 569.—Hamilton, Edin. Ann of Med. vol. v. p. 318.—Coutouly, in Journ. Gener. de M6d. t. xxxii. p. 157.—Fritz, De Convuls. Gravid, et Parturientium. Wirceb. 1810.—Michaelis, in Siebold's Lucina, b. vi. p. 37.—Bruchmann, in Horn's Archiv. Jan. 1811, p. 10.—Gasc, Memoires sur divers Points d’Accouchemens. Paris, 1810.—Gardien, Traite Compiet d’Accouchem. t. ii. p. 418.—Stutz, Michaelis, Wiedemann, and Bruninghausen, in Hufeland’s Journ. &c. b. x. No. 4. ; and in Lon/l- Med. and Phys. Journ. vol. v. p. 473. and 557.—J. F. Osiander, Deutsche Zeit. schrift f. Geburtskiinde, b. ii. st. 3 p. 538.—J. L. Boer, Abhandl. und Versuche Geburtshuf. Inhalts, &c. &c. 1791, b. iii. p. 192.—Hufeland, Journ. der. Pract. Heilk. Dec 1816.— Wagner, De Eclampsia Exquisita in Partu Morb. 1817.—J. Clarke, in Trans, of Irish College of Phys. t. i. p. 381.—Merriman, On Difficult Parturition with Remarks on the Managem. of Labours, 8vo. Lone! 1820, p. 135.—Dewees, in Amer. Med. Record, No. iii and in Johnson’s Med.-Chirurg. Rev. June, 1820, p. 128 —Brinckle, Philadelphia Med. Journ. vol. vi. p. 126.- Goupil, in Journ. des Progres des Scien. Med. t. iii. p. 161 —Duges, in Rbv. Med. t. i. 1826, p. 378. ; et Manuel Ob stet. Paris, 1830, p. 275.; et Diet, de M6d. Prat. t. vi. p. 537 —Chaussier, Sur les Convulsions qui attaq. les Femmes Enceintes. Paris, 1824.—Miguel, De Convulsions chez les Femmes Enceintes, en Travail, &c. 8vo. Paris. 1824. —Blundell, Lectures, in Lancet, vol. xiv. p. 484. et 513.—• Burns, Principles of Midwifery, 6th ed. p. 484.—Ryan, Manual of Midwifery, 2d ed. p. 285.—Michell, On Dif- ficult Parturition, and the Use of Ergot of Rye, &c. 8vo. 1828— Nauche, Des Maladies prop, auxFemmes,&c.8vo. Paris. 1829, p. 449. [ W. Ley, Use of Indian Hemp in some Convulsive Disorders. — Braithwaite’s Retrospect, 1843. — Dr. O. Shaughnessy, On Indian Hemp, as an Anti-Convulsive. Ibid. p. 30,—J. Stewart, A Practical Treatise on Diseases COUGH—Causes. 506 of Children.— W. P- Dewees, On the Diseases of Chil- dren. Robert Lee, Theory and Practice of Midwifery, Am. ed. 1844.—D. F. Condie, A Practical Treatise on the Diseases of Children, 1844.—D. Hosack, Appendix to Thomas's Practice of Medicine.—Marshall Hall, Dis- eases and Derangements of the Nervous System.—C. J. B. IVilliams, Principles of Medicine, Phil., 1844.—Alison, Pathology and Practice of Medicine, 1844.—Cope, Artifi- cial Respiration during Convulsive Fits of Children. Am. Journ. Med. Sciences, vol. xxi. p. 4911.—Evory Kennedy, Convulsions of New-born Infants. Dublin Journ. of Medicine, Jan. 1837.] CORPULENCY. See Obesity. COUGH.—Syn. B»/f, Gr. Tussis, Lat. Bex, Good. Pneusis Tussis, Young. Der Hasten, Germ. Toux, Fr. Tossa, Ital. Classif.—2. Class, Diseases of the Respi- ratory Function ; 2. Order, Affecting the Lungs (Good). II. Class, III. Order (Author). 1. Defin. Violent and sonorous expulsion of air from the lungs, preceded, rapidly followed by, or alternating with, quick inspiration. 2. I. Pathology.—Dr. Cullen and several other nosologists have considered cough as chiefly a symptom, which undoubtedly it is most fre- quently ; but I agree with Dr. Young and Dr. M. Good in believing that it is entitled to be viewed, on some occasions, as an idiopathic affec- tion. Dr. Good, however, has ranked it as a genus, and comprised under it various affections, which are either merely slight forms of Bronchi- tis, or the results of organic changes in the Lungs, and which I have treated of in these articles, and in those on Bronchorrhcea, Ca- tarrh, and Influenza. He has, moreover, sub- divided it into more varieties than can easily be recognised in practice, and has viewed Hooping- cough as a species of the genus, instead of a distinct disease. 3. Causes.—Cough, in either of the forms about to be particularised, commonly attends dis- orders of the air-passages, and of parts in their vicinity, particularly of the larynx ; also those of the lungs, and their membranous coverings ; and sometimes diseases of other organs by which the respiratory functions are affected sympathetically —or rather, from continuity of tissue or nervous communication. It is thus occasioned by affec- tions about the fauces, tonsils, pharynx, and neck ; by the irritation of dentition ; by diseases of the oesophagus, particularly when inflammation and ulceration of this part extends to, or penetrates, the membranous part of the trachea (Kappel- hout, Mr. Byam, and myself); diseases of the spine and its contents (Wichmann) ; by creta- ceous or calcareous formations in the ramifica- tions of the bronchi (Morgagni, Bonet, Baillie, Portal, and myself in several cases, two of which occurred in gouty subjects) ; by all or- ganic changes of the thoracic viscera; by the accidental passage of foreign substances, solid or fluid, into the air-passages; by the lodgment of the eggs or larvae of insects in the same situation (Vogel and Percival, &e.) ; by the irritability of parts attendant upon the nervous temperament and debility ; by the influence of irritation and imagination,—a cause which did not escape the observation of the acute Montaigne ; irregular or misplaced gout; the irritability of the parts con- tinuing some time after measles, or inflammations of the air-passages or lungs ; disorders of the di- gestive organs, particularly the stomach and liver, Sec. (Winther, Stein, Percival, &c.) ; by ac- cumulations of bile in its receptacle ; by the irri- tatiou of worms ; by the repulsion of cutaneous eruptions, and the healing of old sores, and sup- pression of chronic or accustomed discharges. From this enumeration it is evident that cough is chiefly a symptom of numerous pathological states, which will be found very fully described under different heads, as indicated above. The epidemic cough noticed by some writers falls under the article Influenza. In the act of coughing, the lungs are passive ; and in the idiopathic states of the disorder they are not organically affected ; the disorder being chiefly seated in the trachea, larynx, and vicinity. In very many cases, the irritation occasioning the cough exists chiefly in the poste- rior fauces and pharynx, and extends no further than the epiglottis and rima glottidis. 4. i. A. Dry Cough occasionally occurs in an idiopathic form.—a. From exposure to cold in any form ; the attendant symptoms not amounting to complete Catarrh ; and it may, or may not, in a very short time terminate with slight mucous expectoration. When, however, it arises from this cause, it usually runs the course described in that article.—b. It is occasionally produced by acrid or acid fumes and gases, or by various foreign substances inhaled, or accidentally passed, into the trachea, and from several of the other causes enumerated above (§ 3.).—c. It also, in some cases,—first noticed by Montaigne, and well described by Whytt,—presents a strictly nervous character, particularly in nervous, hys- terical, and irritable persons.—d. In those espe- cially, and also in feeble or delicate constitutions, a short, frequent, and dry cough is sometimes met with, without any disease of the lungs, air- passages, or other organs ; and the only change that can be detected is slight redness at the mar- gin of the soft palate, or in the posterior fau- ces ; sometimes only in the pharynx; and oc- casionally near the tonsils; but this is not uni- formly, although frequently, observed. Here it is obvious that the irritation of these parts ex- tends to the glottis, or to the epiglottis only ; and that it is either strictly local, or connected with slight derangement of the stomach and prima via. In the former case it is idiopathic, in the latter symptomatic, or at least a complicated ail- ment. 5. B. Dry cough is more frequently symptom- atic—a. Of the first stage of diseases of the larynx, trachea, and lungs; of organic changes of the large blood-vessels of the chest; and sometimes of complaints of the more superior of the abdominal viscera.—b. It is frequently occa- sioned by elongation of the uvula, and the ir- ritation this part produces about the root of the tongue and epiglottis. But when the uvula is elongated, there usually is also more or less co- existing irritation about the posterior fauces and pharynx, extending to the glottis or epiglottis. And it should be, moreover, kept in view, that these ailments are principally dependent upon, even although they may not be always produced by, disorder of the stomach and digestive organs generally.—c. In many instances, also, it will be found that the cough is owing to irritation of the mucous surface of the stomach and oesopha- gus, although it may not extend so far as to be apparent in the pharynx or be so severe as to oc- casion redness of this part.—d. Cough is often produced by diseases of the liver, and by collec- tions of bile in the gall-bladder and hepatic ducts In many of such cases, the cough is severe ana COUGH—Treatment. 507 spasmodic, often very obstinate and of long dura- tion ; the symptoms of hepatic disorder being sometimes so slight as to escape detection, unless the attention of the practitioner is awakened to the connection ; the chief indications of its exist- ence being the loaded or furred tongue, pains about the diaphragm, fulness at the epigastrium, and indigestion.—e. Lastly, dry cough is often occasioned in young and delicate patients by the irritation of worms in the prima via. The more particular consideration of these associations will be found in the articles on the diseases of which the cough is merely a symptom. 6. ii. Humid Cough,—a. may follow upon the preceding; or it may occur primarily from the usual causes of catarrh. In such cases, it is merely a slight form of that affection, the matter expectorated being mucous or serous, and the cough unattended by manifest febrile or constitu- tional disturbance. This form of cough is very liable to recur, or become chronic, in delicate persons during the winter (winter-cough); or from vicissitudes of season and weather; and, like the former variety, the irritation exciting it may be chiefly seated in the pharynx and vicinity, or in the larynx and trachea. Tn many cases the serous, or sero-mucous secretion, following the cough, entirely proceeds from the fauces and vicinity.—h. In old persons, however, it is se- creted chiefly by the bronchial surface, and is then, particularly in its more severe forms, the affection described under the name of Bronchor- rhcea.—c. Humid cough is generally less frequent, but more prolonged, and recurs in severe par- oxysms. It is sometimes complicated with rheu- matism and gout. It also presents the same pathological relations as described in connection with the dry variety; but it is not so often symp- tomatic of diseases of the abdominal viscera, as the foregoing.—d. In the old and weak, humid cough is usually very severe, owing chiefly to the want of vital power of the respiratory organs, and of the system generally, to throw off the mucus secreted in the air-passages ; and which is either very abundant, from the relaxation of the ex- treme vessels ; or very tenacious, from absorption of its more fluid parts, during its retention on the surface that secreted it, or from both conjoined. In such cases, the paroxysms of coughing are very severe and prolonged ; and the affection is liable to be exasperated upon every change of season and weather.—e. In other cases of humid cough, the exacerbations are also very severe, particularly in the morning; but the excretion is thin and frothy. This is observed most fre- quently in persons addicted to intoxicating bev- erages ; and in those debilitated by sexual in- dulgences. When humid cough depends upon hepatic disease, it often assumes this form. 7. II. Treatment.—i. A. The idiopathic states of drrj cough require demulcents, emollients, with diaphoretics and narcotics, or anodynes (see F. 238.244. 389. 426., and R 98. and 99. at p. 353.). The Conium, hyoscyamus, solanum, oenanthe, and phellandrium aquaticum (Theussink and Frank), may severally be employed, and the functions of the abdominal viscera improved by suitable means. But the pathological states, as well as their causes, on which this form of cough depends, should be investigated, and the treat- ment modified accordingly.—a. If it follow the mpression of cold in any form, the treatment 'escribed in the article Catarrh (§ 15.) will be appropriate.—b. If it be produced by the inhala- tion of irritating fumes, or the molecules of either mineral, vegetable, or animal matters float- ing in the air, the removal of the cause, and the use of demulcents, emollients, and emetics, and subsequently narcotics, are most to be depended upon.—c. When it assumes a nervous character, particularly in hysterical and delicate females, the state of the uterine functions, and the existence of irritation in some part of the digestive tube, or in the sexual organs, or spinal chord, should be enquired after, and the treatment directed accord- ing to the information acquired. In many such cases, the exhibition of a gentle purgative, and afterwards small doses of camphor, ipecacuanha, ammonia, oxide of zinc and trinsitrate of bis- muth, hyoscyamus, extract of hop or poppy, the carbonate of soda, &c., variously combined, will be of service. If there be evident debility, and the cough assumes a periodic form, the preparations of bark or of iron, the sulphate of quinine, or gentle tonics, with anodynes and nar- cotics, will be required. The cold bath, which has been much recommended by Wiiytt, will also prove beneficial.—d. When it proceeds from irritation of the fauces or pharynx, demulcents, emollients, &c., with ipecacuanha, or with dia- phoretics and anodynes, will be required. But the greatest advantage will be derived from the use of cooling and astringent gargles, and stoma- chic purgatives (F. 266.). [When cough proceeds from elongation of the uvula, it should be removed by the scissors or knife. Cough is often kept up by a chronic in- flammation of the mucous membrane of the fauces and larynx, which, if not removed, is apt to extend down the trachea, and at length terminate in bronchitis. This is speedily relieved by sponging the parts with the nitrate of silver in solution, (20 to 40 grains to the ounce of water,) and if there is reason to believe that the inflammation involves the larynx, the swab, which should be of soft fine sponge, at- tached to a piece of whalebone bent at the end to an angle of 45 degrees, should be carried below the rima-glottidis, after the manner recom- mended by Trousseau and Belloc, (p. 125. Phil. Edition, 1843.). These writers recommend the nitrate of silver to be used, in the strength of from half a drachm to a drachm of the nitrate to two drachms of water. They report numer- ous cases of laryngeal cough cured by this treat- ment alone.] 8. B. The symptomatic occurrence of cough must be treated as pointed out in the articles on the primary affections occasioning it.—a. If it be referred to the respiratory organs, the means ap- propriate to their diseases must not be departed from.—b. When we observe elongation of the uvula, either with or without signs of irritation of the pharynx, disorder of the digestive functions may be inferred; and, after having had recourse to purgatives, cooling and astringent gargles, prussic acid, and mild stomachics will be useful. —c. The dependence of cough upon diseases of the biliary organs, whilst it suggests a treatment chiefly directed to these diseases, will also indi- cate the propriety of ascertaining, with as much precision as possible, their nature. If indications of accumulated bile in the gall-bladder and he- patic ducts are detected, calomel or blue pill, with, or followed by, purgatives, and a course of alteratives, taraxacum, &c. will be requisite. Ic 508 COW-POX—CRAMP—CRANIUM. order to carry off collections of morbid bile, and other vitiated secretions; and afterwards the med- icines now enumerated, or the preparations of ammonia or camphor, combined with colchicum, will generally afford marked relief. The depend- ence of this variety upon the diseases already noticed as occasioning the other form of cough, requires the several measures pointed out with reference to each of them (§8.).—d. If the cough be very severe, in old and exhausted persons, and in those who have injured their constitutions by venereal indulgences, a tonic and stimulant treatment, and the remedies instanced in this paragraph in increased doses, will be requisite. It will be found in these, as well as broken-down drunkards, that the cough will be aggravated by remedies which in any way depress the vital energies. In these last, the cough is frequently connected with hepatic disease, the treatment of which will depend upon its nature ; but, although depletion may be occasionally required for the primary malady, the powers of life must be at the same time supported. 11. In this variety, generally, the mild expec- torants, with demulcents ; the jelly of sub-acid fruits; the inhalation of emollient, stimulating, or astringent vapours (see Bronchitis, § 76. 98.) ; the use of acid beverages; warm, rubefacient, sti- mulant, and tonic plasters ; the warm bath, made gently stimulating by salt and mustard ; a light, demulcent, and nutritious diet, with strict atten- tion to the functions of the stomach and bowels ; change of climate or of air, and a judicious choice of residence according to season, with gentle but regular exercise and warm clothing; are severally of advantage, and some of them of the utmost importance. (See Bronchi, § 104). fiiBLioo. and Refer.—Ferncl, Consil. xxiv.—Forest, xvi. n. 1—6.—Horst, Opera, vol. Ii. p. 128.— Willis, Phar macop. Ration, par. ii. sect. i. cap. 4.—Montaigne, Essais. 1. i- cap. 20.—Bond, Sepukhret. Anat. 1. ii. s. iii. obs. 11. —Morgagni, De Sed. et Caus. Morb. epist. xv. art. 22, 23. —Stein, Be Tussi Stomachali Humida. Argent. 1749.— Winther, De Tussi Stomachali, &c. Marb. 1719.—Hal- ler, De Tussi. Goet. 1749.— Whyt, Works, 4to, p. 432. —Buchner, De Tussi Ilumida, &c. Hal®, 1763.—Finck, De eo, quod Tussi proprium est et Cominuni. Bamb. 1779. — Kappelhout, Sectiones Cadaverum Pathologic®, p. 5. — Vogel, Beobachtungen, &c. No. 7.—Portal, Anat. Med. t. v. p. 43.—Percival, Essays, &c., vol. i. p. 272.; and Med. and Phys. Journ. vol. iv. p. 65.—Mudge, On Coughs, &c., 8vo. London, 1789.—Doubleday, Med. Observ. and Inquir. vol. v. — Douglas, in Ibid. vol. vi. p. 163. — Bell, Duncan's Med. Comment, vol. xiv. p. 307.—Frank, In- stitut. Clinica Vilnensis, ann. ii. p. 27. — Wichmann, in Lodcr's Journ. b. ii. st. 1. p. 31. — Young, Introduce to Med. Literature, 8vo. p. 187.—Stanger, Trans, of Med. and Chirurg. Soc. vol. i. p. 13.—M. Good, Study of Med. by Cooper, 3d edit. vol. i. p. 580. — Brooke, On Liver Cough, Trans, of Irish College of Phys. vol. iii. p. 245. COW-POX. See Vaccination. CRAMP. See Convulsions (§ 4), Spasm, and Tetanus. CRANIUM. — Syn. Kpaviov (from spavos, a helmet, as defending the brain from injury). Die Hirnschale, Ger. Le Crane, Fr. Cranio, Ital. The Skull. Classif. Pathology. — Special Pathology —Morbid Anatomy. 1. The cranium and its envelopes, the scalp and the pericranium, are often the seat of diseases which are of much moment, not only as respects these parts themselves, but also as regards the important organs and membranes which they contain. 2. 1. Diseased Appearances of the Envel- some cases, a gentle dose of either of these cholo- gogues will produce copious discharges of morbid bile, and the immediate disappearance of a con- stant, severe, dry, and harsh cough, of which alone the patient has complained. In others, re- peated and large doses will be required to ac- complish this object. In all these, purgatives should be exhibited until the tongue becomes clean. If tenderness or pain exist in the region of the liver, with febrile symptoms towards even- ing, or restlessness through the night, blood-let- ting, general or local, ought to precede other measures; and the hepatic disease should be treated with reference to the form it presents, and as described in the article on Diseases of the Liver.—d. When the cough is attended by a tumid abdomen, and other signs of worms, the treatment recommended in such cases, accord- ing to their numerous modifications, must be em- ployed. 9. In almost all the idiopathic and symptoma- tic forms of dry cough, more advantage will be obtained from demulcents than from heating or stimulating expectorants, which should always be laid aside when there is evident vascular ex- citement of a sthenic or tonic kind. Those ex- pectorants, however, which are of a mild nature, or which act chiefly by exciting slight nausea, will generally be of service, particularly when combined with emollients, diaphoretics, and nar- cotics ; and there are few conditions, in which the preparations of antimony or ipecacuanha, with liquor ammonise acetatis, and the warm bath, will not be extremely beneficial. In this vari- ety of cough, also, appropriate medicines, exhib- ited in such a manner as will favour a prolonged impression on the palate and pharynx—as in the form of lozenge or linctus—will thereby have their effects manifestly promoted ; and advantage will also accrue from wearing warm, antispasmo- dic, or rubefacient plasters between the shoul- ders, both in this and the humid variety of the affection. No. 160. R Confect. Ros. Canin. et Confect. Rosa: Gal. aa 1 j.; Olei Amygdal. Dulc. 3 vj.; Syrupi Papaveris Albi §ss.; Spirit. /Ether. Nit. 3 ij.; Acidi Sulphur, dil. 3jss.; Pulv. Ipecacuanha: gr. ij. M. Fiat Linctus, de quo sumatur pauxillum subinde. No. 161. R Emplast. Picis Comp. part. ij.; Emplast. Ammoniaci (vel Emp. Ammon, cum Hydrarg.) et Em- plast. Opii aa part. i. M. Fiat Emplastrum perlargum inter scapulas imponendum. 10. Humid cough, when it presents the char- acters of slight catarrh, requires the treatment described in that article.—a. If it frequently re- cur, or become chronic, or assume the form of winter cough, the more tonic demulcents, as the decoction of Iceland moss, or of the sea moss, with lemon and candy,—the mistura ferri com- pos, with a decoction of liquoric root,—attention to the digestive and excreting functions,—warm clothing,—and careful avoidance of exposures to the vicissitudes of season or weather,—are most to be depended upon.—b. When the cough occurs in old persons, with increased secretion obviously from the bronchi, gentle tonics, and ex- pectorants, as myrrh, galbanum, assafaetida, ben- zoin, the oxide or sulphate of zinc, the lerrebin- thinates, camphor, ammonia, the balsams, and, indeed, the whole of the treatment described in the articles on Chronic Bronchitis (§ 91.) and Bronciiorrhcea are most appropriate.—c. When it is complicated with gout or rheumatism, pur- gatives, combined with tonics or stimulants, in opes of the Cranium. — These are princi- pally the same as are observed in analogous structures in other parts of the body. Nearly the same changes are remarked in the scalp, and subjacent cellular tissue, as in the integumental coverings of other parts ; and in the pericranium, as in other parts of the periosteum. These struc- tures, forming the envelopes of the cranium, will, therefore, require but little remark. 3. A. The scalp is subject to the same inflam- matory states as other parts of the body; and these require the attention of the physician, from their occasional extension to the bones of the cranium and membranes of the brain. Inflam- mations of the scalp vary in character with the condition of the vital energies and digestive and biliary organs. Sometimes this structure is the seat of active phlegmonous inflammation, but more generally of the erysipelatous. When ery- sipelas attacks the scalp, a copious exudation of a serous or sero-albuminous fluid takes place in its subjacent cellular tissue. Occasionally this tissue is affected by inflammatory action'of an unhealthy kind, but limited in extent, and closely resem- bling carbuncle, and of which I have met with some cases in children. The scalp is also par- ticularly liable to certain specific inflammations of a chronic kind, especially to pityriasis, porrigo, sycosis, lepra, psoriasis, eczema, rupia, and syphilitic ulceration. Tumours, generally en- cysted, sometimes form beneath the scalp, most frequently between it and the tendinous expan- sions of the occipito-frontalis, and other muscles attached to the pericranium. These expansions, and the muscular structure attached to them, and perhaps occasionally the pericranium also, are often the seat of rheumatism and rheumatic inflammation. They are not infrequently, also, affected by common inflammation and its con- sequences, particularly after external injuries. Dropsy of the cellular tissue beneath the scalp, independently of inflammation, is very rare. It has, however, been observed in young subjects, and received the appellation of hydrocephalus ex- ternus, and oedema capitis. 4. B. The Pericranium is subject to the same changes as the periosteum in other parts of the body ; amongst these are chronic and specific inflammations, giving rise to thickening of the membrane; to nodes, frequently terminating in suppuration and exfoliation of the subjacent part of the bone; and, in cases still more chronic and slight, to unnatural deposits of bone upon the external surface of the skull. (See Periosteum —Inflammation of.) Inflammations of an acute or sub-acute character sometimes, also, attack this structure, and, when not arrested in their progress, give rise to its separation from the bone ; and not infrequently, owing to the exten- sion of the morbid action through the tables of the cranial bones, to a corresponding separation of the dura mater from the diseased part of the skull. It seems probable that morbid action of any kind is seldom continued long in the peri- cranium, without the dura mater, which performs the office of an internal periosteum, suffering in a corresponding degree, and ultimately trans- mitting the disease to the subjacent membranes, and even to the brain itself. Specific inflamma- tion also of this structure, of a most painful and dangerous kind, occasioning death of the portions of bone beneath the parts chiefly affected, is CRANIUM—Morbid Changes in. 509 produced by syphilis and the inordinate and pro- longed use of mercury. 5. II. Morbid Changes in the Cranium.— The bones of the cranium are subject to various diseased appearances, many of them having a close reference to the state of the system, and its morbid dispositions, and still more so to those slowly formed lesions which frequently affect the brain and its membranes.—A. Enlargement, or rather distension, of the bones of the cranium, is frequently an attendant upon chronic hydro- cephalus, and the hypertrophy of the brain some- times accompanying rickets. When the accu- mulation of fluid is great, and has taken place before ossification is far advanced, this process frequently commences at several more distinct points than in the healthy state, thus generating as many distinct bones. In the majority of these cases, although the surface of the cranial bones is greatly extended, there is a general deficiency of the ossific deposit, rendering the skull more than usually thin. The Museum of Guy’s Hos- pital contains the cranium of an hydrocephalic man, who lived to the age of 29 years. Its cir- cumference is 33 J inches. There is also in the Museum of St. Thomas’s, the skull of a child of two years, that measures 29 inches. 6. B. Deficient deposit of hone, as now re- marked, is often connected with the foregoing lesion ; in which case it is commonly general, the whole cranium being more or less thin as well as enlarged; but the thinness may also, although less frequently, accompany a natural-sized skull. The deficient deposit, or thinness of bone, may also be partial. In this case, partial or cir- cumscribed accumulations of serum, or tumours, generally exist beneath the part of the cranium thus changed ; and we have reason to believe that it is to the pressure exerted by these that the unusual thinness is to be imputed. It should, however, be kept in recollection that the cranial bones vary exceedingly in thickness, without having seemingly diverged from the healthy state. 7. C. Imperfect ossification is chiefly a lesion of early age, being merely a slow or impeded developement of the bones, arising from one or both of the following causes:—a. From deficient powers of the constitution, in which the process of ossification either generally or locally in re- spect of the cranium participates; h. From the distension arising from the accumulation of fluid. The imperfect ossification in such cases may con- tinue to the age of three, four, or five years, and generally consists merely of a more than usual openness of the sutures, or a deficient deposit of bone at the parts most remote from the centres from which the ossific process proceeds. In some cases, however, the imperfection exists in about the middle of one of the bones ; a patch of membrane, or a narrow stripe being surrounded by bone. When these patches or clefts in the bone are considerable, or remain for any time unfilled up, a portion of the membranes often protrude, forming large watery tumours, owing to the pressure of fluid effused between or under- neath the membranes, — a circumstance which occasionally obtains. -An interesting case of this description, successfully treated by ligature, has been recorded by Mr. E. Thompson. The ma- jority of these cases are congenital, but the pro- trusion is often not noticed until long subsequent 510 to birth. Sometimes a portion of the brain itself protrudes, forming a congenital hernia cerebri. 8. D- The bones of the cranium may be insuf- ficiently evolved. In this case they are generally formed with more than sufficient rapidity, and their sutures are closed prematurely, so that they cannot give way before the growing brain, which thus becomes, with the case enclosing it, imper- fectly evolved. The cranium may thus appear unnaturally small, as is sometimes observed in idiots and epileptics; but this state may arise not only from early closing of the sutures, but also from imperfect developement of the brain itself. Microcephalia was considered by Hippocrates as a cause of idiotcy; and facts, showing that great diminution of the size of the head is very generally connected with weakness or privation of intellect, have been adduced by Greding, Gall, Sporzheim, Georget, and many others not believers in the doctrine of Gall. 9. E. The shape of the cranium is often some- what changed by these and other causes. When the cranium is much deformed, it is more com- monly a congenital vice arising either from the pressure in utero of a deformed pelvis, pelvic tumours, &c.; or from deficient developement, early disease of the embryo, and monstrosity ; or from congenital change of the structures which it contains. But deformity of the cranium may also take place after birth, from deficient or ir- regular developement of the brain, or from the effusion of fluids in the cranial cavity. The early closing, also, of some sutures, and the protracted closing of others, whereby the yielding of the bones is prevented in one part, and facilitated in others, are often productive of deformity. Rickets, dropsy of the brain, softening of some of the bones, particularly of the base, whereby it is thrust up into the cavity (Otto), cretinism, &c., are all often productive of deformity. A species of deformity has several times come be- fore me, and generally attended by epilepsy, and idiotcy, which I have seldom seen noticed. This consists of obliquity in the halves of the cranium ; one half being much more depressed, both at the top and base of the skull, than the other. This deformity is sometimes thus simple, consisting only of comparative elevation and depression of the sides of the cranium. But I have observed it more commonly connected with an equal obliquity posteriorly and anteriorly; the elevated or depressed half either receding or advancing much more than the other. In cases of this de- scription, the cranium has also presented a certain angular form, so that I have been led to de- nominate the appearance, the diamond-shaped obliquity or deformity of the skull. 10. F. Hypertrophy, thickening or enlarge- ment of the bones, assumes two principal forms. 1st, That of a superabundant deposit of the ossific matter, giving rise to uncommon density, and to the disappearance of the diploe, and converting both tables of the skull into one dense bone, resembling, but much harder than, ivory. This appearance of the cranial bones is almost nat- ural to the negro. It is observed, also, in per- sons advanced in life, who have been subjected to laborious employments, physical and mental; and it is often seen in epileptics, in maniacal epi- leptics, and in some who have been long insane. It may or may not be accompanied with increased thickness of the bone. Greding found the skull too thick in 151 out of 196 insane persons; CRANIUM—Morbid Changes in. and Georget observed it one-twentieth and up- wards too thick in 480 out of 500, belonging to the same class of patients. The second form of enlargement is rather the result of a loose or spongy formation of the bones, in which, although most remarkable in the diploe, both tables of the bone often participate more or less. In this form, the actual quantity of bony matter is not much augmented. Increased thickness of the bone generally obtains here, and sometimes reaches an enormous extent, and closely resembles in ap- pearance a piece of pumice stone. 11. G. Irregular deposits of ossific matter are very frequently observed on both the internal and external surfaces of the cranial bones, particuarly the former. Th£y are often found adjoining the sutures, sometimes with a mammilated ap- pearance on the external surface. On the internal surface, they frequently assume an irregular bo- tryoidal form; sometimes they present large masses, particularly on the frontal bone, and encroach considerably upon the cavity. Not infrequently these deposits are prolonged into the form of irregular processes ; occasionally the pro- longation is in the seat of particular parts or pro- cesses, as in the clinoid process. These exostoses are sometimes very prominent and acute. In some instances they encroach upon the foramina through which the nerves and vessels pass. In these cases, symptoms of pressure or of irritation are present, and vary according to the seat, form, and extent of the ossific deposit. Epilepsy, in- sanity, irregular convulsions, spasmodic contrac- tions, and neuralgia, are amongst the most prom- inent effects of these productions. 12. H. Vascular engorgement is sometimes observed in the cancellated structure forming the diploe, in cases where great congestion, or very active inflammation, has existed in the head, membranes, or pericranium; the vessels passing from or into the bone being congested, and the diploe of a deep or purplish red colour. 13. I. A softened state of the diploe is not in- frequently observed in cases where active inflam- mation has affected the pericranium, or dura mater, and extended to the bone. In these cases the tables of the bone are more friable than natural. A similar appearance is also observed when the system has been much contaminated by carcinomatous disease. 14. K. Ulceration of the cranial bones is also not uncommon ; and is generally attended with more or less absorption, exfoliation, and the de- posit of irregular bony spiculce. Ulceration and absorption result very frequently from lupus, and the formation of bony spiculte generally attends upon osteosarcoma. 15. L. Caries, or death of the hone, is not in- frequently observed to follow upon inflammation extending from the pericranium, or dura mater, to the bony structure. It is a very common consequence of inflammation of the ear long neg- lected, or imperfectly treated. It may be limited to either of the plates, or it may extend to the whole thickness of the bone. In either case, the dead part is detached from the iiving by the ab- sorption which takes place around it, and in the surrounding inflamed and ulcerated parts. Ow- ing to this process, a distinct line of separation is frequently formed, and the dead portion is completely exfoliated. While the dead bone is being removed in this manner, or after its re- moval, if the dura mater, which acts as the periosteum of the internal table, is not destroyed, new bone is deposited, and thus the mischief is often repaired. I have met with two such cases in children. 16. M. Fungus cranii, or medullary sarcoma of the bones of the skull, is occasionally ob- served. It has been described as occurring on the top of the cranium by Crell, Sandifort, VVishart, Abercrombie, Landmann, and Otto. A distinct tumour is often produced by it on the internal as well as the external surface of the skull,—the part forming a spongy growth. It is more rarely met with about the base of the cranium. It may originate in the bones, or their internal or external periosteum ; but, in whichever of these it may commence, it soon in- volves them all. When originating in the bones, it usually assumes the characters of os- teosarcoma, and those of fungus when it com- mences in the pericranium or the dura mater. 17. N. Perforations of the cranial bones are also observed, generally as a consequence of the pressure of internal tumours, of an encysted, scrofulous, or fungoid description, attached to the membranes underneath, or of aneurisms, &c. Cases of this description are recorded by Pal- letta, Le Clerc, Richter, Pelletan, and Otto. After artificial perforations of the skull, as after trejJhining, and fractures, with loss of bone, osseous matter is sometimes regenerated, radiating from the surrounding divided surface of bone. The exuberant formation of ossific matter after fractures of the cranium is sometimes pro- ductive of serious effects. (See § 11.) 18. O. Depressions and fractures require little notice further than that they are the most fre- quent causes of inflammation, and its consequen- ces in the surrounding membranes, and con- tained organs, and of irregular bony depositions. Depression of the superior and lateral bones of the skull may take place in early age to a very great extent, and remain through life, without affecting the mental manifestations. Several instances of this have come before me, in some of which the depression was fully larger and deeper than the bowl of a large table-spoon. One of my earliest and most talented friends has a depression to this extent in one of the pa- rietal bones, from an accident in childhood. ISibi.ioo. and Refer.—Le Clerc, in Haller's Biblioth. Cliirurg. t. i. p. 469.—Kaufmann, De Tuinore Capitis Fungo-so, &c. Helinst. 1743.—Sandifort's Exercitat. Acad. 1. ii. t. 3.—Siebold, in Arnemann's Magazin fur die Wundarzneiwiss. Got. 1797, vol. i. part iv. p. 389.— Cheston Browne, in Philosoph. Transac. vol. lxx. p. 323. —Home, Trans, for Improvement of Med. and Surg. Knowledge, vol. iii.—Sandifort, Observ. Anatom. Pa- thol. 1. iii. cap. 9. t. 9., et 1. iv. cap. 10 ; et Museum Anatom, vol. ii. t. 61, 62.—Blamenbach, De Anomalis et Vitiosis quibusdam nisus formativi Aberrationibus Com- ment. p. 17.—Esquirol, in Diet, des Scien M6d. t. xxiii. p. 521.—Georget, De la Folie, &c. Paris, 1820, p. 478.— Landmann, Comment. Patholog. Anatom. &c. 4to. Dips. 1820.—Find, Sur les Vices de Conformation du Crane des Altenes; in Bullet, de la Societ. Philomath. Ann. t. iv. p. 103—109.— Wenzel, Ueber den Cretenismus. Wien. 1802.—Baillie. Engravings, &c. fasc. x.—,T. P. Frank, Opuscula Posthuma, p. 102. t. 4—6. 8vo. Vien. 1824.—Krcbel, De Anatomia Patholog. Ossium Capitis, 8vo. Hnlae, 1823.—Otto, Verzeichniss der Breslaner Anat. Priiparatensamiung, No. 163. 165 210. 3057. 3068. 8048. &c.—Palletta, Exercitat. Patholog. voi. i. p. 127.— Abercrombie, Path, and Pract. Researches on Diseases of the Brain. &c. Edin. 1828.—Bright, Medical Reports, &c. t. ii. p. fedi, &c.—Cruveilhier, Anatomie Pathologique. Devr. 8vo. Paris, 1830, fol.—BallingaU and Russel, in Transact of Med. and Chirurg. Soc. of Edin. vol. i. p. 68. 74.—E. Thompson, in Lond. Med. Repos, vol. xxii. p. 353. (Very interesting.)—(See also Art. Cranium, in Plane- CRETINISM—Description. quet's Med. Digesta; and in Otto's Lehrbuch der Pathol Anat. des Menschen, &c Berl. 1830.) CRETINISM.—Syn. Cagots, Struma Tyro- lensium,Gautier. Cretin, Cretinisme, Fr. Classif.—6. Class, 1. Order (Good). I. Class, IV. Order (Author). 1. Defin.—Imperfect formation or develope- ment of the cranium, and the whole of the Itody, tvith mental imbecility, and physical imperfection, varying chiefly in degree. 2. This state of imperfect physical and men- tal developement, rather than of diseased action, was first noticed by Plater among the poor of Carinthia and the Valais, where, and in the val- leys of the lower Alps and Switzerland, it is en- demic. But it is not peculiar to these places ; for it has been observed in the valleys of the Pyre- nees by Raymond, in some parts of Salzbourg by Knolz, and in various other localities in the cen- tral and southern countries of Europe, as well as in Chinese Tartary, according to Sir G. Staunton M. De Saussure, Ackermann, Fodere, Ifhof, Erhard, the Wenzels, and Knolz, have given us the best description of this state of mental and boddy deformity, in respect both of its nature and causes. The brief account of it by Dr. Good is both imperfect and erroneous, and must have been written in perfect ignorance of the de- scriptions of the above eminent observers, as well as of others deserving of perusal. He very inaccurately associates it with bronchocele on the one hand, and with rachitis on the other, with the former of which it is not necessarily, although very frequently, connected, and from the latter it is to- tally distinct. 3. I. Description.—Cretinism presents va- rious modifications in kind, and every interme- diate grade between that extreme degree of physical and mental debasement which is char- acterised by the utmost deformity and entire absence of mental manifestation, the organic or vegetative functions only being performed, and that condition which may be considered as very nearly approaching the healthy constitution of man. There are certain circumstances which distinguish cretins from other idiots, viz. a. They present certain bodily deformities, which are sel- dom or never observed in other idiots ; and, b. Their physical and mental infirmities are always the result of endemic causes. 4. In general, some degree of goitre is attend- ant on cretinism, but not invariably. Professor Knolz states, that it is sometimes absent, and occasionally slight, the thyroid gland being en- larged in no greater proportion than several other glands are in the same subject. The stature is seldom above four feet and a half, often much less ; the cranium is deformed and has a conical shape—the forehead being thrown backwards, narrowed, and flattened, and the occiput being nearly on a line with the neck; the flesh is soft and flaccid; the skin wrinkled, yellowish, or pale and cadaverous, dirty, and covered by chronic eruptions ; the tongue is thick, and hang- ing out of the mouth, which is open, large, and slavering ; the lower jaw is elongated and promi- nent ; the eyelids are thick, the eyes red, small, but prominent, watery, and frequently squinting; the nose is flat; and the whole coun- tenance is idiotic or expressive only of lascivious- ness. The belly is large and pendulous; the neck either short and thick, or long and thin ; the limbs crooked, short, distorted, &cc.; and the 511 512 CRETINISM—Causes—Treatment. eyes; the female cretin having enormously large and pendulous breasts. The less debased among them marry rarely with one another, but do not propagate cretinism, the predisposition only to it being derived by the offspring from the parents. Malacarne (Mem. de l’Acad, de Turin) attrib- utes the mental debasement to the contraction of the bones of the cranium, which prevents the cerebral organs from acquiring their natural di- mensions and functions; and Ackeiimann es- pouses a nearly similar opinion. The conforma- tion of the body is generally stated not to be congenital, although, at birth, the cretin may ap- pear weak, puny, or sickly. It usually comes on gradually from birth ; and M. De Saussure states, that children who, living in the localities where it is endemic, and are not affected at eight or ten years, generally escape it; and that infants who are brought into these districts at a very early age, are equally subject to it with those who are born in them. 6. II. Causes.—The principal, if not the only, cause of cretinism is dwelling, during infancy and childhood, in deep, narrow, moist, and malarious valleys, situated at a lower level than 3000 feet above the ocean, where the air is stagnant, and the solar beams intercepted by the mountains. MM. Ferrus, Georget, and the authors already referred to, state, that cretins beconTe numerous in proportion as the valleys sink below this ele- vation. In addition to those causes, may be added the poverty, ill-feeding, drunkenness, indolence, dirtiness, sensuality, and low debauchery of the parents,—circumstances tending to the produc- tion of an infirm and deformed offspring; the In- activity and filth into which children who begin to evince signs of cretinism are allowed to sink, and the influence of water holding calcareous and other mineral substances in solution. MM. De Saussure and Fodere, however, deny that the water is concerned in the production of this in- firmity ; but MM. Bally and Rambuteau show that much is owing to it in the causation of cre- tinism, as well as Bronchocele (see that article). The last named authority states that the offspring of the natives of Valais, who intermarry with persons from the Italian side of the Alps, are more subject to cretinism than those born of na- tive parents; that females who have husbands from the higher Alps seldom have children af- fected by this infirmity ; that wherever cretins are seen, goitre is also prevalent; but that the latter is found in places where the former does not exist; and, consequently, that the same causes that occasion goitre, when present in an intense degree, also produce cretinism. 7. III. The Treatment of this infirmity is necessarily preventive rather than curative, and consists of the amelioration of the physical and moral condition of the parents; of the removal of infants, as soon as signs of the malady manifest themselves, to more elevated and open localities, and to mountainous districts, to enjoy a purer air and stronger light; of obliging them to exert themselves in some useful and suitable employ- ment, and to pay attention to personal cleanli- ness; of frequent ablutions, followed by active and stimulating frictions of the whole surface of the body; of the use of stimulating tonics (Er- hard) ; and of allowing them a stimulating and strengthening diet, with a large proportion of ani- mal food. Josias Simler, who wrote in 1574, states that the malformation, constituting the gait imperfect and waddling. The senses are more or less defective, or altogether abolished; the cretin being often deaf and dumb, and those who possess the faculty of speech expressing themselves imperfectly and with difficulty. The intellectual functions are either entirely absent or imperfectly developed, whilst the organic or vegetative functions are in a state of increased activity: cretins being voracious, lascivious, and addicted to masturbation. They appear to have no other enjoyment than eating and sleeping; and their insensibility is often so great that they obey not the calls of nature. In some instances, the bodily deformity is not so remarkable as that now described ; imbecility, flaccidity of the soft solids, with bronchocele, constituting the extent of infirmity.* 5. The cretin, like most idiots, seldom attains an advanced age ; indeed, few of them reach up- wards of thirty years. Clayton remarks, that although they die early, they soon present the appearance of age. They are usually of the lymphatic temperament, with light hair and grey * The following account of tbe “ Fexesor cretins of Salzbourg, is abridged from that given by Professor Knoi.z The whole body is stunted, its height not ex- ceeding four feet. There is a total want of due proportion between its different parts: the height of the head, with reference to the rest of the body, being l-4th or l-5th, in- stead of l-8th, the natural proportion. The neck is strong, and bent downwards. The mammae are very voluminous and pendent; the upper limbs reach below the knees; the arm is shorter than the fore-arm; the chest narrow ; the abdomen hemispherical, and of a length not exceed- ing the height of the head; the penis and scrotum come down to the knees ; the thighs are, with the haunches, of a greater width than the shoulders, and are shorter than the legs, the calves being almost wanting ; the foot is small, and the toes partly distorted; the lower ex- tremities are shorter than the upper half of the body. In the head, the masticating organs, the lower jaw, and the nose, preponderate considerably over the or gans of sense and intelligence. The skull is depressed, and forms a lengthened and angular ellipsis ; the re- ceding ferehead presents, internally, large frontal sinuses, to which the brain has yielded a part of its place ; the top of the head is not vaulted, but flat- tened ; the occiput projects but slightly, and runs almost even with the nape of the neck, as in ruminating ani- mals. The face is neither oval nor round, but spread out in width ; the parts of which it is composed being wide and short, and the maxillary bones projecting greatly. The forehead is narrow, flattened, and low ; the eyes are usually far apart, diverge slightly, and are small, and seated deep in the orbit; the pupil is contracted, and not very sensitive to light; their external angles are situated higher than the internal ; the eyelids, unless when drop- sically swollen, are flaccid and pendent; the look is a fixed stare without expression, and turns with indiffer- ence from all that is not eatable. The root of the nose is widened and depressed, the bones of the nose square; the zygomatic bones are wide, and extremely projecting: the external ear is large, stands out from the head, and hearing is very defective. The elon- gated form of the lower jaw of the cretins, and their thick and padded lips, make them resemble rumina- ting creatures more nearly than man. The tongue is thick, and rather cylindrical than flat; the saliva is continually running from the angles of the mouth. Enlargement of the thyroid gland is recognised as one of the signs of cretinism; but its size is no sure guide to the extent of the existing infirmity. The throat presents, also, other obstructed glands. The thorax is generally narrow and flat; the abdomen is usually distended with gases, and largely developed towards the chest; the flesh of the extremities is flabby; the knee of an irregular shape, and usually bent; the fin- gers are very long and lank, and the nails very small. The upper part of the vertebral column being directed more or less forward, and the lower part, with the ba- sin, being pushed backward, the sacrum assumes a more horizontal, and the other pelvic bones a more vertical position than in the healthy formation. Besides the masticating and digestive organs, those of generation are also strongly developed, especially in the male. (Jle- dccin. Jar bucket des k. k. JFsterr. Staatcs, b. i. st. 1. 1829, p. 86' CRISIS—Prognosis. physical infirmity, is sometimes congenital; and probably it is so occasionally. In such cases, it is not likely that much advantage will accrue from any means. M. Rambuteau, however, states that it is scarcely ever congenital; but it is not unlikely that experienced observers may predi- cate, from the appearance of the newly born in- fant, whether or not it is likely to become the subject of this dreadful infirmity—may observe that state of developement and formation, which, if not actually the incipient malady, is predispo- nent to its occurrence. Bibi.iog. and Refer.—Storr, Alpeureise Vorborei- tung, par. Iv.—Be Saussure, Voyage dans les Alpes. Genev. 1786.—Clayton, in Mem. of the Lit. and Philos. Soc. of Manchester, 1790, vol. viii. art. 13.— dckermann, Ueber die Kretinen, &c. Gotha, 1790, 8vo.— Fodere, Sur le Goitre et le Cretinisme, 8vo. Turin, 1792.—Erhard, in Hufeland's Journ. der I’ract. Heilk. b. xiv. st. 2. p. 80.— J. et C. Wenzel, Ueber den Cretinismus. Vien. 1802.— Iphof, De Cretenismo. Viteb. 1804.—Michaelis, in Bla- me rihach's Biblioth. b. 3. p. 640.—Virey, in Diet. Scienc. Med. t. vii. p. 343.—Georget, Diet, de Medecine, t. vii. p. 184.—Rambuteau, in Ibid. t. vi. p. 186.—F. Sensburg, Der Cretinismus, 8vo. Wiirzbourg, 1825.—C. Londe, Diet, de Med. Prat. t. v. p. 550.—./. J. Knolz, in Bulletin des Scien. Med. t. xxi. 1830, p. 390.—J. Johnson, Change of Air, or the Pursuit of Health; being an Excursion through France, Switzerland, and Italy, &c. 8vo. Lond. 1831, p. 56. CRISIS.—Syn. Kptoif, a judgment or decision (from Kpivto, I judge or determine). Judicium, Judicatio, Lat. Entscheidung der Krankheit, Ger. Crise, Fr. Crisi, Ital. Classif.—Prognosis. 1. Crisis may be defined a sudden change du- ring the height of a disease, tending either to re- covery or to death. Critical changes have been much regarded in the prognosis and treatment of diseases, from the time of Hippocrates, who first mentioned them, and the days on which they occur, down to the present period. Asclepiades, and the methodists, however, denied their influ- ence, and disputed the existence of critical days. Galen and his followers attached great impor- tance to them. It is recorded, that, having been called to a patient—a young man—with two dis- ciples of Themison, Galen prognosticated a fa- vourable change by a critical hcemorrhage. The opinion was ridiculed by the two methodists, who advised blood-letting ; but it was soon verified, for the patient had a copious epistaxis, after which he recovered. It is unnecessary to allude to the writers who have contended for the importance of this subject: they comprise most of the emi- nent names in medicine, from Hippocrates to Cullen, Pinel, Frank, Hildenbrand, and Kreyssig. The titles of many hundred volumes that have been written upon it might be adduced in proof of the consideration attached to it: and although much more has been imputed to critical evacuations, and days, particularly by the hu- moral pathologists, than legitimately belongs to them, and granting that too devoted an attention to them has induced many to adopt injudicious indica- tions, and weak measures of cure, yet some reputa- tion will be acquired from the prognosis which an acquaintance with them will enable the physi- cian to give ; and much benefit will result to the patient from the treatment which this knowledge will suggest. 2. Since the overturn of the humoral pathology, the doctrine of critical evacuations has undeserv- edly fallen into disrepute, although the eminent writers who contributed most to the overthrow are amongst its most rational and warm espousers. In our own country, at the present time, too little attention is paid to these evacuations, and still less to the periods at which they occur. There can be no doubt that the former is the most im- portant ; but the latter part of the subject should not be disregarded. After all that has been urged in favour of, or in opposition to, the doctrine, I may conclude that, in temperate climates, a num- ber of diseases, particularly fevers, run on for cer- tain periods with regularity, and, after an exas- peration of the symptoms, or some violent per- turbation of the economy, terminate by evacua- tions of different kinds, which tend to remove the train of morbid actions, and to restore the healthy functions. In other cases, the exasperation of disorder is followed by imperfect evacuations, oc- curring in an irregular manner ; whilst in some it gives rise to additional phenomena of a danger- ous or fatal character: hence crises have been denominated salutary and complete, imperfect and fatal. It was considered by the older writers requisite to a salutary crisis, that the evacuations constituting it should be attended by favourable symptoms, and be copious and manifest; and not only appropriate to the disease, but also consist- ent with the state of the patient. An imperfect crisis was considered better or ivorse: the better slate alleviating the malady ; the worse render- ing it more severe and dangerous, from the super- vention of metastases and complications. Having described the phenomena which are critical, I shall next notice the periods of disease at which they are most frequently observed. 3. I. Crises manifest themselves,— 1st. On the skin : A. by sweats ; B. by acute or chronic eruptions. 2d. In the cellular tissue : A. by swellings in various parts ; B. by boils and car- buncles ; C. by gangrene; and D. by purulent collections. 3d. In the glands: A. by buboes; B. by swelling of the parotids ; C. by salivation : D. by a flux of urine. 4th. On the mucous sur- faces: A. by increased excretion—a. from the nose ; b. from the bronchi, &c.; c. from the sto- mach (vomiting) ; d. from the bowels (diarrhoea); B. by sanguineous exhalation—a. by flux—a. the htemorrhoidal; p. the menstrual; b. by hsemor- rhagv; a. from the nose (epistaxis); p. from the bronchi (haemoptysis); y. from the stomach (haernatemesis); <5. from the intestines; c. from the uterus (menorrhagia); (. from the urinary organs (hsematuria). 4. 1st. A. Sweats are salutary crises in con- tinued and bilious fevers, in inflammations of the lungs and liver, in bronchitis, and less frequently in rheumatism. Fracastori describes an epi- demic putrid fever which.generally terminated fa- vourably in this manner. Acute dropsy, particu- larly anasarca, when caused by interrupted per- spiration, sometimes disappears after copious sweats. This evacuation is usually preceded and indicated by a soft, full, open pulse ; by a dimi- nution of the alvine evacuations ; by softness, and occasionally slight itching of the skin ; and by in- creased colour of the cheeks. A salutary sweat should be distinguished from such as are limited to the forehead or face, and the neck or breast, whilst the rest of the body is dry ; or those which cover only the lower extremities: these consti- tute merely partial or incomplete crises, and merely diminish the violence of disease. 5. B. Eruptions.—Miliary and vesicular erup- tions only are critical: the others are merely symptomatic, or even form a part of the disease; 513 514 as erysipelas, purpura, petechia;, &c. A miliary eruption is favourable, if the symptoms subside, if the patient feels an itching or pricking, if they be general, and do not appear before the seventh day: if they be unattended by fulness of the sur- face ; and if their subsidence be followed by vom- itings, hiccup, or convulsions, they indicate a fa- tal termination (Landre-Beauvais). Sometimes a miliary eruption comes out at different periods, and prolongs the disease, when partial relief fol- lows it, each appearance being an incomplete cri- sis. Many chronic eruptions may not only be complications of visceral disease, but occasionally imperfect crises,—they alleviating the internal malady. They are more rarely completely salu- tary. 6. 2d. A. Swellings of various parts, as of the face or neck, the hands, the lower extremities, &.C., have been considered as partial crises in ataxic and gastric fevers, and in exanthematous diseases. B. Boils are critical in some complaints, particularly towards the termination of acute dis- eases, especially small-pox.—C. Gangrenous pus- tules or anthrax occur in malignant or pestilen- tial fevers ; gangrenous eschars also are met with in similar cases, as well as in typhoid or ady- namic fevers ; particularly about the sacrum, and in places which have been blistered, or pressed upon. If, in such cases, the febrile symptoms subside upon the sphacelation, and if the gangre- nous change be rapidly and distinctly circum- scribed, it may be favourably critical ; but if the symptoms continue, and the pulse becomes more frequent, weak, small, and soft, the local mischief is entirely symptomatic, and indicative of an un- favourable termination.—D. Purulent collections are indicated by the continuance of the disease without any considerable evacuation, or exhaus- tion ; by a sense of chill, horripilation or rigor, oc- curring at intervals, without any manifest cause ; by the discharge of much clear urine ; by partial sweats ; by a softness of the pulse ; by a remit- tent or hectic fever, and by flabbiness of the soft solids. The favourable changes of this nature oc- cur in the extremities, and suppurate easily and rapidly. Those that are unfavourable take place in some internal viscus. 7. 3d. A. Buboes chiefly belong to pestilential fevers ; but they are occasionally observed in the adynamic fevers of temperate climates. They indicate a favourable or fatal crisis in the manner stated with respect to gangrenous eschars.—B. Swellings of the parotids occur in low or malig- nant fevers; and appear either alone, or with other critical changes. They are commonly pre- ceded by a slight rigor ; by severe headache, stu- por, noises in the ears, and deafness, with pale- ness, swelling, and sometimes redness of the coun- tenance. This occurrence is rarely critical, and, of itself, furnishes no sure indication of the issue : if accompanied with favourable changes, it be- comes an additional sign of returning health ; but if the swelling is slow, or disappears in a very short time, the other symptoms still continuing, it is a dangerons circumstance.—C. Salivation was noticed by Sydenham as a principal critical evacu- ation in the fevers of 1667 and 1668 ; and it oc- curred in the epidemic that prevailed at Breslaw in 1700. It occasionally supervenes in some forms of cynanche, and in bilious and gastric fe- vers.—D. The urine is sometimes discharged co- piously at the height of febrile and inflammatory diseases; and is to be viewed as a favourable oc- CRISES—Description of. currence. It is usually clear when recently evar, uated, but deposits soon afterwards a whitish or rose-coloured sediment. The symptoms indicating this discharge are very obscure. Some authors have noticed the “pulsus myurus,” which con- sists of every three or four successive pulsations being progressively diminished. A sense of weight below the hypochondria; of gravative tension in the hypogastrium, and of heat in the urinary organs, is stated by M. Landre-Beauvais to pre- cede this evacuation. 8. 4th. A. a. Coryza, or sero-mucous excretion from the nose, is sometimes critical in continued fevers; but little importance is to be. attached to it.—b. Mucous excretion from the bronchi is fre- quently a partial crisis in several fevers, and in inflammations of the thoracic viscera (see Bron- chi and Lungs).—c. Vomitings are rarely indica- tions of a perfect crisis ; they occasionally, how- ever, favour the developement of those changes which precede a favourable termination of dis- ease. They are sometimes ushered in by a bit- ter taste in the mouth, yellowish fur on the tongue, suborbitar pain, and headache, nausea, salivation, coldness of the extremities ; and frequency, and occasionally intermissions, of the pulse.—d. Diar- rhoea and copious alvine evacuations are favour- able crises in nearly all acute, and even in some chronic diseases. But it is necessary that they should be feculent or bilious, and homogeneous— not watery or flocculent: if they approach to a natural, or have a yellowish brown colour, and are followed by abatement of fever, &c., a favour- able crisis may be confidently looked for. The chronic diseases, in which they indicate a change tending to health, are congestions and inflamma- tions of the liver and spleen, hypochondriasis and melancholy, slight or incipient dropsies, rheuma- tism, and gout. They are usually preceded by borborygmi, with slight flatulent distension of the abdomen ; flatulence and eructation ; a sense of tension and uneasiness in the lumbar region ; fly- ing pains in the extremities ; and a developed but unequal pulse, occasionally with irregular inter- missions. 9. B. Sanguineous exhalations are often criti- cal in the more inflammatory states of fever, and in the phlegmasiae. According to Hoffmann and Landre-Beauvais, discharges of blood from the nose, the hremorrhoidal vessels, or the uterus, are equally salutary in ardent fevers. In general, these haemorrhages are preceded by depression of the morbid temperature, and erethism of the skin ; by slight horripilations of the limbs ; by a more open and rebounding pulse ; and a sense of heat, pruritus, and tickling, in the part whence the evacuation is about to proceed.—a. The menstrual flux is sometimes a rapid crisis in fevers and phlegmasiae. It is indicated by dull heavy pains in the loins, groins, and tops of the thighs ; by tension in the hypogastrium ; heat and pruritus of the genitals ; pallor of the face, and a dark circle round the eyes ; swelling of the breasts ; pale, scanty urine ; horripilation, and erethism of the skin ; and by a quick, sharp, and unequal pulse. Very frequently the menses appear at the regular period, or a little earlier, or later, in fevers and inflammations, without affording any, or but imperfect relief. In these cases, they should not paralyse the activity of the treatment. When they occur at or before the usual time, are abundant, and are attended by evident benefit, they should be considered as critical: but if they are delayed, or are difficult or scanty, they are imperfect crises, and should not interfere with the measures which the circumstances of the case may require.—b. The kcemorrhoidal flux is often critical in inflammatory fever, pneumonia, hepa- titis, and other phlegmasise. Stahl states that a return of this discharge is sometimes favourable in inflammations of the brain, and particularly in hepatitis, nephritis, melancholia, hypochondriasis, and mania. The observation is certainly correct. This evacuation is indicated by pains in the loins and the groins; by a sense of uneasiness and pressure towards the anus and perineum ; by fre- quent desire to pass the urine and go to stool ; by flatulence and borborygmi, slight pallor of the face, and fulness of the hypochondria; and by fulness and inequality of the pulse as to strength.—c. Critical epistaxis Was considered of great importance by the older physicians, who paid much attention to the symptoms indicating its accession : these are, redness, with slight tu- mefaction of the face and eyes ; reddish or brilliant objects floating before the eyes ; the involuntary shedding of tears ; weight of the temples, and beating of their arteries ; deafness, or noises in the ears; slight delirium, or vertigo; a sense of tension in the neck, with distension of its veins ; a dull pain in the forehead, and at the root of the nose, or an itching and tickling in the nostrils ; a quick, hard, full, and an unequal pulse ; fre- quent and slightly laborious respiration ; some- times with tension or oppression, without pain, at the prsecordia. Occasionally, pallor, and con- striction of the whole surface, coldness of the lower extremities, and horripilations, also precede a critical epistaxis. This crisis is most common in young persons, and adults whose vital energies have been previously unimpaired, and who have been subject to this evacuation. It occurs most frequently in summer and autumn ; in the more inflammatory states of fever; in the acute phleg- masiae affecting the super-diaphragmatic organs ; and rarely in hepatitis. If the discharge consists of a few drops only, it is an alarming symptom ; and although it be copious, if not soon followed by amendment, it is unfavourable. When ex- cessive, and attended by syncope, convulsions, loss of power, partial or cold sweats, and cold ex- tremities, it is a fatal sign. A syncope, however, which terminates the epistaxis, is often followed by recovery (Landre-Beauvais). 10. d. Haemoptysis, haematemesis, hcematuria, and intestinal haemorrhagy, are always false or unfavourable crises. They are generally preceded by tension and tenderness of the hypochondria ; and supervene most frequently in adynamic, malig- nant, and pestilential fevers ; in confluent small- pox, scarlatina maligna, and in scurvy : they oc- cur less frequently in females than in males. 11. A. The above are the phenomena which have usually been considered critical by the older, and which are admitted by the best modern, medical writers ; as well as the symptoms which indicate their accession. There are, however, still some circumstances connected with them de- serving of notice.—a. The haemorrhagic evacua- tions occur most frequently in the spring, or in dry summers, in persons from 15 to 35 years of aorary authors ; and is common in the epidemic visitations of this dis- ease, or of anginous scarlatina ; the greater num- ber of fatal cases exhibiting soft fragments of false membranes, of a greyish or ash colour, covering the larynx and trachea, and a livid appearance of parts of the subjacent mucous membrane. This is one of the most dangerous complications of the disease. The affection of the air-passages is here consecutive, and the difficulty of swallow- ing usually precedes the characteristic symptoms of croup, which are generally accompanied with great fcetor of the breath.—a. In many instances of the malignant sore throat, the exudation thrown out from the inflamed surface forms a pellicle co- extensive with the spread of the inflammatory process from the fauces to the pharynx and air- passages. In some cases, ulceration, and slight apparent sloughing, occur in the central parts, and those first affected ; whilst the surrounding surface, and parts subsequently diseased, become covered by a soft and easily lacerated exudation. In rare cases the inflammation commences in the pharynx (Cynanche Pharyngea), and spreads to the fauces on the one side, and down the larynx, trachea, and oesophagus on the other. In these, the pellicular exudation formed on the inflamed surface very nearly approaches that of croup; oftener, however, it is of a darker and dirtier colour, softer, and not so continuous; whilst in some cases it is formed in patches, is similar to thin sloughs, and is interrupted in parts by a dark, foul, but not concrete secretion; the subjacent mucous surface being of a dark, livid, or brick- red colour, or ulcerated, or even partially sloughed. Sloughing, however, or even ulceration, although mentioned by several writers, is comparatively rare; the more frequent commencement of the faucial or pharyngeal complication of croup be- ing attended by the pellicular or concreted exu- dation now mentioned, without sloughing. The 526 CROUP—Complications of. jection of the pharynx, epiglottis, and larynx, which were covered by a cream-like exudation, their mucous membrane being softened. The trachea and bronchi contained some flocculent viscid mucus ; and the digestive villous surface, particularly in the upper part of the oesophagus, stomach, and portions of the small intestines, was softened and inflamed. In all the foregoing com- plications, the affection of the larynx and epiglot- tis is generally more remarkable than that of the trachea. 18. C. With the exanthematous fevers.—a. Croup sometimes comes on during the eruptive fever, or efflorescence of measles; when it occa- sionally assumes more of the remitting and spas- modic character, and is seldom very severe or dangerous. In this case it generally subsides as the eruption becomes abundant. But it also su- pervenes upon the extinction of the eruption ; or it does not appear until during or after desquama- tion ; and, in some instances, not until advanced convalescence. When this occurs, the inflam- matory fever soon passes into an adynamic state, and the disease assumes a severe form, with spasms of the larynx, often terminating with con- vulsions and suffocation. In one instance of this kind that occurred in my practice, much swelling and oedema of the throat appeared externally, and aggravated the symptoms ; recovery, how- ever, unexpectedly took place, with a free dis- charge of glairy mucus, and concrete fragments of membrane. In another instance, emphysema of the throat occurred, and gradually extended over the neck, chest, and face. Permission was not obtained to examine the body, so that the channel through which the air had passed from the respiratory passages into the cellular tissue could not be exactly ascertained.—b. The com- plication with smalt-pox has been very particu- larly noticed by Pjnel, Albers, Vieusseux, and Royer-Collard, and is not uncommon. It usu- ally occurs in the more severe cases, particularly when the disease is confluent* and generally comes on slowly in the suppurative stage. In the more malignant cases, the difficulty of respiration is ex- cessive ; the voice very hoarse or suppressed ; the paroxysms of suffocation are extreme ; the cough dry, or giving issue merely to a small quantity of dirty serum, or muco-sanguineous or dark sanguin- eous matter ; and the attendant fever adynamic. On dissection, a membranous substance is seldom found in the larynx or trachea, but merely portions of a semi-concrete matter, with spots of intense in- flammation in these parts, the epiglottis, and large bronchi.—c. The complication with scarlet fever is never met with excepting this disease be asso- ciated with sore throat, especially when malig- nant or epidemic (§ 16.) ; and it is then a fre- quent cause of death.—d. The association, or rather the supervention of croup on erysipelas, particularly of the head and face, occurring in adults, has been observed by Forestus, {Opera, 1. xv. obs. 20.), Latour, Stevenson, and Gibson {Trans, of Med. Chirurg. Soc. of Edin. vol. ii. p. 95.), and in several instances by the author. In those cases, the inflammation and character- istic exudation spread from the fauces to the air- passage. 19. D. With other diseases.—a. Croup is some- times associated with acute bronchitis; and when it terminates fatally, it is often in consequence of extension of the inflammation to the bronchi, and thence to the substance of the lungs, pneumonia abovs changes are most remarkable in the pha- rynx, and are slighter in the larynx and trachea; the exudation being there somewhat paler, and from its colour and appearance very generally mistaken, both while adherent to, and whilst be- ing detached from, the inflamed surface, for spha- celated sloughs, particularly as observed in the throat, and described as such. The complication, v/ith croup, of various states of angina or sore tnroat—malignant, or epidemic—whether com- mencing in the pharynx, or in the fauces, and extending to the pharynx, is not uncommon. Epi- demic visitations of it have occurred in very mod- ern times, and have been described by Hamilton, Deslandes, Bourgeois, Bretonneau, Trous- seau, Moronval, Emangard, Schmidtmann, and others.—/?. In some cases the affection originates in the tonsils {Cynanche Tonsillaris, &c.), and extends to the adjoining parts. In the croup epi- demic in Buckinghamshire in 1793, and described by Mr. Rumsey, the croupal symptoms were stated to have been coeval with “inflammation and swelling of the tonsils, uvula, and velatum pendu- lum palati; and large films of a white substance were formed on the tonsils.” Similar appear- ances have likewise been noticed by Ferriar, Hosack, Mackenzie, Robertson, and Bourgeois and by myself: the pellicular exudation extend- ing over the fauces, down into the pharynx and larynx. The croup which has been described by Louis, Hufeland, and others, as occurring in adults, was thus complicated. The complication with the malignant throat has been observed by me both in its simple form and in its associa- tion with scarlet fever. Some years since, I at- tended, early in the winter, some of the children of a numerous family residing a few miles from town, in a low and damp situation. They had had scarlatina, with very severe sore throat, two or three years previously. On this occasion, one of the oldest was seized with malignant angina, ex- tending to the pharynx, and along the Eustachian tube to the ear, with foetid respiration, and irrita- tion of the larynx, producing a constant tickling cough. A similar affection spread to four of the younger children, and in two of them it was com- plicated with croup; the symptoms of which were severe, continued, and well marked in one, and more spasmodic and intermittent in the other. In these, ash-coloured exudations covered the greater part of the fauces and tonsils, and extended down into the. pharynx. They recovered with difficulty, by the means hereafter to be noticed. 17. B. Croup may be also complicated with Thrush.—Cases of this description are rare. I have seen only two of which I have taken any account. This association has also been observed by Jurine, Double, Pinel, and Royer-Collard, who notice the adynamic or ataxic character of the fever accompanying it; the adynamic state being the consequence chiefly of this associated disorder, supervening upon pre-existing disease, generally of the digestive mucous surface, and often, moreover, in a weak and cachectic sys- tem. The patches of pellicular exudation in the mouth and throat characteristic of thrush, had extended down the pharynx, larynx, and part of the oesophagus, in these cases ; death having been occasioned by the consequent irritation, and fre- quent recurrence of spasm of the larynx. In the only one I had an opportunity of examining after death, there was little or no inflammation in the trachea; but there was considerable vascular in- thus also supervening. But the croup may also, although much more rarely, be consequent upon bronchitis. — h. It may occur in the course of pertussis, and it then usually assumes the re- mittent and spasmodic or the bronchial forms.— c. Lastly, it may be associated with (esophagitis ; but when this is the case, the inflammation with albuminous exudation usually commences in the pharynx, and extends down the oesophagus, and to the larynx. This is not an infrequent occur- rence in children under two or three years of age ; as, indeed, M. Guersent has remarked; the larynx and epiglottis being the only parts of the air-passages affected; and these chiefly with spasm, from the irritation of the portions of false membrane covering or coming in contact with them. 20. II. Terminations and Prognosis.—Croup may terminate—1st, in recovery ; 2d, it may pass into or excite some other disease,—a return to health, or a fatal issue, taking place mediately through it; 3d, in death, either from exhaustion of the vital energies, or from suffocation. A. A return to health is indicated by the mild form of the disease; by the quiet respiration whilst the cough is absent; by the moderate excitement and frequency of the pulse ; by a looser cough and a more natural state of voice, followed by expec- toration of viscid mucus, and membranous frag- ments ; by a copious and general perspiration on the third day, the symptoms being moderate ; by epistaxis on the second, third, fourth, or fifth days; by the absence or subsidence of violent attacks of spasm of the glottis, and suffocation ; by the simple and uncomplicated state of the disease ; and the absence of exhaustion, or of great frequency or irregularity of pulse, and of other signs of adynamia. 21. B. It may excite additional disease, or pass into some other malady,—a circumstance which, although not necessarily fatal, may greatly in- crease the danger. The morbid state of the system, and general depression of vital power accompanying most of the complications now noticed; the more constant affection, and dispo- sition to spasmodic action of the larynx, in all of them; the interruption caused to the respira- tory processes, and the attendant or consequent congestion of the lungs, as well as the marked disposition they create to consecutive disturb- ance ; greatly augment their danger generally. The disorders consequent upon the simple and complicated states of croup are both direct and indirect. The direct are—a. Extension of inflam- matory action to the bronchi and substance of the lungs,—generally an unfavourable event, and indicated chiefly by the unremitting persistence of the symptoms, hy deep suffocating paroxysms of cough, great frequency of pulse, lividity or leaden hue of the countenance, by the dark tinge of the lips and tongue, cold clammy per- spirations, somnolency, and all the characters of asthenic Bronchitis (§ 37.). When the bronchial affection does not appear until during convalescence, it is more slight, unless the causes have been energetic, and it presents more of the usual characters and states of that disease. The consecutive occurrence of either pneumonia or any of the forms of bronchitis should be carefully enquired after, by observing the symptoms, and examining the chest by auscultation.—b. Exten- sion of disease to the sub-mucous and follicular structures, occasioning inflammation and ulcer- CROUP—Terminations and Prognosis—Diagnosis. 527 ation of these tissues, with symptoms of laryngea. or tracheal consumption upon the subsidence of croup, is a much more rare occurrence than the preceding; but, when it takes place, a muco- puriform expectoration accompanies and follows the characteristic discharge and signs of croup, with pain and irritation in the larynx and trachea, recurring exacerbations of suffocating cough, and difficulty of breathing, chiefly of a spasmodic description, particularly when the inflammatory irritation is seated in the larynx or epiglottis, and the usual symptoms of hectic. The very marked tendency, also, of the disease to relapse, is in a great measure owing to the persistence ot a slight degree of inflammatory action in the large bronchi, or in the trachea and larynx, for some time after the membranous exudation on the diseased surface has been thrown off; the dis- order being readily aggravated upon exposure to the exciting causes. This disposition of the dis- ease to return diminishes with the length of time that has elapsed from the subsidence of the ori- ginal attack, but does not altogether disappear for many weeks, or even for months, especially in some constitutions, and in the last and first months of the year; and even more than one relapse may take place in weak, irritable, and nervous frames, but generally in a more spasmodic form.—c. Besides producing these, it may occa- sion, although very rarely, abscess in the vicinity of the larynx or trachea. I believe that dilata tion of the bronchi is a much more frequent re- sult.—d. Of the more indirect terminations and consequences of this disease, congestions of the encephalon, giving rise to convulsions and effusion of serum in the ventricles, or between the mem- branes, are the most important. In many cases, particularly in delicate and nervous children, the convulsive movements seem to commence with the spasmodic actions of the laryngeal muscles, and the strangulation thereby occasioned; the head and neck being thrown back, and all the limbs convulsed. Life is in some cases thus ter- minated by asphyxy. Jurine, Vieusseux, and myself, have met with cases of hydrocephalus following the disease ; but they are not common. 22. C. Danger is to be dreaded, when fever is very high early in the disease, and when respira- tion is permanently audible, cooing, and labo- rious, or as described above (§ 7.). When the disease goes on to the third stage, notwithstand- ing the treatment; when it presents any of the complications (§ 16.) and consecutive affections (§ 21.) already noticed; when the discharge of the characteristic exudation does not take place, or when the expectoration of fragments of it is not followed by any relief; when the counte- nance becomes livid or leaden, the eyes sunk, the lips and tongue dark, and the pulse very fre- quent, small, weak, and irregular; and the other symptoms of vital exhaustion appear; great danger exists. A fatal issue is to be expected when the patient presents the appearance de- scribed as characterising the third stage, particu- larly those noticed as marking its close (§ 8.). 23. III. Diagnosis.—The hoarseness, and the loud, sonorous, and ringing cough ; the forcible and difficult inspirations; flushed face; injected and watery eyes; the frequent and hard pulse, with thirst and inflammatory fever, the heaving of the thorax and motion of the trachea, in the developed stage ; and the husky choking cough, the whispering voice, and wheezing respiration, 528 &c., of the third stage; sufficiently distinguish this disease from any other. When it is uncomplicated, nothing beyond a slight redness is ever observed m the throat; and there is little or no pain upon deglutition, unless the larynx be much affected. —a. Croup can scarcely ever be mistaken for Cynanche maligna, or C. Pharyngea, or any other form of sore throat, as long as these affections do not extend to the larynx; as the great difficulty of deglutition, and the but little disturbed state of respiration, independently of the obvious af- fection of the throat, &c., are sufficient to distin- guish between them. When, however, portions of the concreted exudations in these affections irritate the glottis, they occasion a short, tickling, dry cough ; and even excite, in some cases, stran- gulating spasms of the larynx, nearly resembling croup, particularly when it is complicated with these maladies. If, however, it be thus associated, the croupal characters, in addition to the appear- ances in the throat and pharynx, will be too evi- dent to be misunderstood ; the descriptions already given of these complications being sufficient to point them out.—b. During the eruptive fever of measles, the tracheal affection is often so great as to simulate croup; and in many cases it even amounts, as already stated, to a slighter form of the complaint, which usually disappears as the eruption becomes matured; but attention to the symptoms will readily show the nature of the disorder, and how far the affection of the larynx and trachea should be viewed as a symptom, or as an important complication of the exanthema- tous disease. — c. Croup may readily be distin- guished from bronchitis, by its sudden and severe attack; its occurrence in the evening and at night; its remissions; the hoarseness, and the ringing, dry, and frequent cough; the difficult inspirations, and impeded respiration ; the altered voice and speech ; the sensations and symptoms referrible to the trachea in the former, and to the sternum and chest in the latter; and by the absence of expectoration until late in the disease, when it is membranous or tubular, and not mucous and muco-puriform, as in bronchitis, until after the discharge of the membranous exudations. These characters will also serve to indicate the supervention of croup on bronchitis,—an occur- rence which is sometimes observed, although much more rarely than that of bronchitis on croup.—d. Laryngitis is with greater difficulty distinguished from croup than the foregoing, and in many respects there is little or no difference. The practical importance of the diagnosis may not appear great, but it is sufficiently so to war- rant an accurate distinction. 1st. True laryngitis occurs in adults ; seldom, in children, in any other form than associated with either the simple or complicated states of croup. 2d. It is a purely inflammatory disease, attended by a fixed burning pain in the larynx, increased on pressure and examination; and, when attacking adults, never gives rise to a false membrane, unless it be superinduced in the specific and epidemic forms of cynanche, and then it assumes modified charac- ters. 3d. It more frequently terminates in the manner characterising acute inflammations, viz. ulceration and suppuration, than when the larynx is affected in croup. 4th. It is more acutely and constantly inflammatory, *he symptoms are more continued, and it is more benefited by a purely antiphlogistic treatment, than croup. 5th. It much oftener passes into tfcs chronic CROUP—Causes of. form, than the latter disease. (See Larynx— Inflammations of.)—e. Chronic laryngeal and tracheal inflammation—the laryngeal and tra- cheal consumption of some writers—resemble croup, in the hoarse voice, harsh dry cough, and the difficulty of respiration ; but their progress is much slower, and less acute than croup; they do not present the violent paroxysms towards night; they seldom or never are observed in children ; and ulceration of these parts of the air- passages is always found in fatal cases.—/. Croup may also be confounded with the diffusive inflammation which sometimes attacks, either primarily or consecutively, the cellular tissue about the throat, or with abscesses in the same situation : either of which may involve the larynx and mem- branous part of the trachea, or so affect them as to give rise to croupal symptoms; but the ex- ternal appearances, the difficult deglutition, the state of the throat, and the history of the case, will at once show the differences existing beween them.— g. Pertussis and croup can hardly be mistaken for each other; the invasion, charac ters, and progress of both diseases being so very different. The prolonged whoop, the unchanged voice, and the occurrence of the cough in con- vulsive paroxysms after a meal, terminating in vomiting and a copious discharge of a clear and glairy fluid; the complete intermissions, respira- tion, voice and speech remaining unaffected ; the almost entire absence of fever, and the much more slight and chronic form of the latter disease in its uncomplicated state ; are sufficient distinc- tions. Croup may, however, occur in the course of hooping cough ; but then its characteristic symptoms will make it apparent to the attentive observer, and point out the nature of the resulting association.—h. The effects following substances that have escaped into the trachea often resemble croup; but may be distinguished from it by the sudden occurrence of pain and suffocation ; by the frequent change of the exact seat of uneasiness with the change of the situation of the foreign body ; the dryness of the cough, and the violence of the strangulation; and by the irregularity, the completeness, and sometimes the long coutinuance of the intermissions. When a foreign substance passes into the glottis, and is retained there, suffo- cation is generally occasioned either from the size of the substance, or from the spasmodic constric- tion of the muscles of the larynx occasioned by it. — i. Hysteria may also simulate croup: but the age of the patient, the history of the case, and the local and general symptoms, if attentively ob- served, will indicate the nature of the affection.— k The spasmodic states of croup closely approach to convulsive spasm of the larynx; but the absence of cough and fever, the brief fits of strangulation, the complete intermissions, the spasm of the thumbs and toes, the purplish countenance, and the general convulsions, will distinguish that af- fection from any form of croup. (See Larynx— Convulsive Spasm of.) 24. IV. Causes.—A. a. Croup is more fre- quent in cold and moist climates than in those which are warm. Rapid arid frequent vicissitudes of season, weather, and temperature, have con- siderable influence in producing it. Hence its prevalence in the valleys of Switzerland and Sa- voy, in this country, particularly on its eastern side ; in the other north-west countries of Europe ; and in North America. But the middle, and even the south of Europe, are not exempt from it. M. CROUP—Causes of. 529 Valentin has shown its frequency in the middle and southern provinces of France, Goelis in Vi- enna, and Ghisi in the north of Italy. Sir James M’Grigor notices its prevalence—probably in a complicated form, from its occurrence also in adults (§ 25.)—at Bombay, in 1800. According to the information given by Jurine, Lentin, Cheyne, and others, we might be led to infer that it has been more common in very modern times than formerly: the difference may, however, be owing to its having been mistaken for some other affection. [M. Marx observes that “ this disease, which only a few years past was the terror of all pa- rents, when viewed in reference to its peculiar in- tensity and frequency, may be regarded as a prod- uct of recent times—a bad result of our social condition, and the physical education of our youth. The employment of emetics early in the disease has proved how it can be checked with perfect success; and consequently it can no longer be considered as one of the ominous satel- lites of our times, whatever may be its origin or nature. The men of civilized nations, as they feed better, are more subject to pure inflamma- tion than those of uncivilized, because they are more plethoric and excitable, and in the main undergo greater toils and perils.”—(On the “ In- fluence of Civilization on Diseases,’’ 1844.)] I believe that it has not been so frequently met with during the preceding five years, as it was about twenty or thirty years ago. M. Jurine re- marks, that, although the table he has given of the number of cases from 1760 to 1807, shows a nearly progressive increase, yet he has observed, at Geneva, no increase during the last eighteen years preceding the date of his work. The following evidence, nevertheless, would render it evident, that, in some countries at least, croup is more prevalent now than for- merly. According to the information given by Dr. Cookson, a practitioner of forty years’ expe- rience in Lancaster had never seen it until 1760. Dr. Friedlander (Journ. de Montpellier, No. IX. p. 276.), states, that it has become yearly more prevalent in Vienna; and that the physician to the Hospital for Children, who had treated, from 1774 to 1817, nearly 60,000 children, did not meet with a single case in the three first years of his practice, saw it but rarely during the next six years, and yet treated 1665 cases of it in the last five years of this period. Similar facts are also furnished by Dr. Goelis. Although croup occurs at all seasons of the year, it is most preva- lent in those which are cold and moist, or when the alternations of temperatnre are sudden and re- markable. I have observed it more frequently in the months of January, February, March, April, November, and December, especially if east or north-east winds prevail after heavy or continued falls of rain. I believe that the above results are nearly in accordance with those furnished by Jurine, Crawford, Michaelis, Double, and Bricheteau. 25. b. The great susceptibility of early age, and the narrowness of the larynx previously to puberty, have generally been supposed to favour the occurrence of croup. M. Blaud, however, denies that this latter circumstance has any in- fluence in causing it. This is doubtless the case in respect of the production of the disease, but not as regards its severity and danger, both of which it evidently increases. It is rare to meet with croup until after the child has been weaned: I have, however, seen it in children at the breast, as early as three, four, five, and six months of age ; but much more frequently at this age in those who have been brought up by hand ; aud in a still greater number of ihstances, at from seven months to upwards of a twelvemonth, in those which have been recently weaned. M. Duges states, that he met with an instance of it in an infant of a few days old. The age at which the disease is most common is, according to my experience, from one year to nine. But it not infrequently occurs at both an earlier and a later period. Van Bergen states, that it is often observed from the age of two to five years inclu- sive : Home assigns from fifteen months to twelve years: Crawford mentions some cases from fif- teen months to two years, but gives the age of from two to eight as the most common: Cheyne, from sixteen months to twelve years ; Salomon, from two to five years inclusive ; Miciiaelis, from fifteen months to ten years; Zobel, from the latter months of suckling to nine years; Vieusseux, from seven months to ten years ; Ber- nard, from one to six years ; Barthez, from two to ten; Rumsey, till fourteen; and Caillau, from eighteen months to eleven years. [Dr. Dewef.s remarks that this complaint is almost altogether confined to the period of child- hood, and is most frequent in infancy, on or be- fore the fifth or sixth year : although he has met with it in its most formidable shape in children at the breast, as well as witnessed death from it in the adult. In Philadelphia, during the eight years preceding 1840, 286 deaths are reported from croup, in infants under one year of age; 275 between two and five years; 171 between one and two years; 67 between five and ten years ; and twenty-one over ten years of age. Home states that the earlier the children are weaned, the more liable they are to the disease.] The foregoing applies only to the simple and uncomplicated disease. When it occurs in a complicated form, or consecutively upon anginous affections, particularly upon inflammation of the pharynx, tonsils, or fauces, or on the exanthema- tous diseases, it may, and, indeed, occasionally does, occur in adult subjects, and in infants of a more tender age. The cases published by M. Louis, and denominated by him croup in the adult, were instances of the anginous complica- tion. Although the occurrence of uncomplicated croup in adults is very rare, cases have been observed by Hosack, Mitchell, Mills, and Latour. 26. c. M. Blaud and Dr. Albers observe, that boys more frequently contract the disease than girls, owing to the greater exposure of the former to its exciting causes. This opinion has been opposed by MM. Double aud Royer- Collard ; whilst Dr. Jurine states, that of ninety-one cases he treated up to 1808, fifty-four were boys, and thirty-seven girls; and of twenty- eight cases which occurred in 1808, eighteen were boys, and According to his ob- servation, also, the greater number of cases oc- curred at the age of two, three, and four years; and next at one, five, and seven. This accords with my own experience, which is further sup- ported by that of Goelis, who, from 1797 to 1808, treated 252 cases of the disease, of which number 144 were boys, and 108 girls. 27. d. The nervous and sanguine temper amenUi CROUP—Pathology of. 530 or a mixture of the two—the spasmodic charac- ters predominating in the former, the inflamma- tory in the latter—with a tendency to a fulness of habit, seem to predispose to croup. That it will, however, often come on independently of plethora, cannot be disputed. I have seen it in infants of about four months old, brought up by hand ; and even in these, soon after having lost much blood in the treatment of other diseases, especially when cold easterly winds occur in the spring or autumn, after heavy falls of rain. Cheyne, and some others, conceive that an hered- itary tendency exists in croup. But this is not made out: for, as M. Desruelles has judiciously remarked, the only proof that can be brought in support of it, is the circumstance of two or more children being seized with it in the same family ; an occurrence which may be explained by the susceptibility of age and temperament, being often necessarily the same in several of them ; and by their being exposed to the.same agents, and placed under similar circumstances. 28. e. The localities in which this disease seems most prevalent are those which are low and moist, near the sea, on the banks of large rivers or lakes, or near marshes, in the depths of low valleys, or at the bases of precipitous mount- ains. Hence the endemic character, which some writers have imposed on it, but which is not strictly applicable; for, although it is more fre- quently observed in the above situations, yet it is also often met with in places very oppositely cir- cumstanced ; and it cannot, therefore, strictly be said to be an endemic disease. 29. /. The epidemic prevalence of croup has been contended for, and denied, by writers. Some consider it as entirely sporadic and acci- dental ; others suppose that it may become epi- demic consecutively upon catarrhal epidemics, and that it has no other claims to such a charac- ter ; whilst many believe that it occasionally ap- pears in an epidemic form. That it has so oocur- red in former times appears evident. Baillou manifestly observed in it an epidemic form, in Paris, in 157G; Gmsi, at Cremona, in 1747; Starr, in Cornwall, in 1748; Rosenstein, in Upsal, &c., in 1762 ; Van Bergen, in Frank- fort, in 1764; Wahlbom and Baeck, in some parts of Sweden, in 1768 and 1772 ; Barker and Most, in some places in the United States ; Au- tenrieth, at Stutgardt, in 1807 ; Albers and others, in parts of Saxony, in 1807 and 1808; Schmidtmann, in 1311 ; and various other writers during the last fifty years. My own observation would lead me to infer, that although croup is generally a sporadic disease, occurring occasion- ally at all seasons, 3Tet it sometimes assumes epi- demic features, both in respect of its simple state, and its complications with other species of angina, particularly at periods when they or catarrhal affections prevail—the seasons favourable to the production of these diseases most frequently oc- casioning this malady also. This opinion derives support from the numerous facts furnished by Rumsey, Pinel, Jurine, Goelis, Albers, Royer- Collard, Bricheteau, Bretonneau, and other writers referred to at the end of this article. 30. g. Several authors, particularly Wichmann, Boeiimer, Field, Rosen, Goelis, Lobstein, Guersent, Louis, Shultz, and G. Gregory, have adduced facts to show that the disease may occasionally prove infectious. The two early Swedish writers contemporary with Home, j namely, IIalen and Wahlbom, assert its in- j fectious nature. On the other hand, this prop- erty is denied by Chalmers, Michaelis, Thile- nius, Double, and Albers. It has most indu- bitably manifested this property when it has pre- vailed epidemically, and when associated with cynanche maligna, and some other exanthema- tous or anginous affections. On several occasions, however, of its occurrence within a short time, in two or more members of the same family, it has evidently proceeded from the same causes acting upon similar states of susceptibility and disposi- tion. But even the simple form of the disease j has appeared in children who have slept in the j same bed with another affected by it. Two or j three such cases have occurred under my own observation ; and others are recorded by Goelis, and some other authors now mentioned. Wheth- er or not it was produced in these cases by inhaling the air respired by the affected child, or by the causes above stated, may be disputed. Yet it is probable that the air which has been respired by the affected may sometimes be a l concurrent or determining cause of it in others. 31. B. Although the foregoing may be consid- ered as predisposing causes merely, yet they are very commonly the only exciting causes which can be detected. There is no doubt, however, that the causes which occasion common catarrh and bronchitis sometimes also give rise to croup. It is also not infrequently excited by, or at least consecutive of, bronchitis, hooping cough, the va- rious forms of cynanche, measles, erysipelas, and scarlet fever; and it occasionally also appears during advanced convalescance from these, espe- cially the latter: and, indeed, from other acute diseases. Also running against the wind, crying, and exertions of the voice; cold acting in any manner, or upon any part of the body, particu- larly under the neck and throat; having the hair cut short during cold or windy weather; habitual exposure, and the laying aside the accustomed covering of the neck and chest; and even acci- dental attempts at swallowing substances of an acrid nature, or of a very high temperature ; have sometimes produced croup. The retrocession of the above eruptive diseases, and the suppression of other eruptions, or of discharges, secretions, and excretions, are amongst its most frequent causes. 32. V. Pathology of Croup.—i. Lesions ob- served in fatal cases. A precise idea of the organic changes which take place in the course of the disease is necessary to enable us to devise, at the commencement, appropriate means, both for their prevention, and for their removal when prevention is unattainable. The lesions observed in fatal cases, and present in all, to a greater or less extent, may be referred to two heads.— 1st. Inflammation with tumefaction, redness, in- jection of the blood-vessels, and slight softening of the mucous membrane of the air-passages. 2d. An albuminous exudation in the form of a false membrane, or a thick, glutinous, and stringy mucus, or both. (See Bronchi and Air-Pas- sages—Lesions of, § 12.) A. The former of these is usually observed, varying, however, in respect both of intensity, and extent of surface affected. In some cases, they are limited to the upper part of the trachea ; in others, they extend to the larynx, or to both the larynx and first divisions of the bronchi, or to the latter merely; and, in complicated cases particularly, or when the dis- CROUP—Pathology of. either partially or altogether detached from it by a puriform mucus. 34. The state of the exudation varies with the stage of the disease, the intensity of the inflam- mation, and the treatment which has been adopted. Thus, when a child dies very early in the malady, instead of the albuminous coating above described, a tenacious, or reddish, frothy mucus is only found. In this comparatively rare case, the spasm of the air-passages attending the inflam- mation, together with the obstruction occasioned by this mucus, has produced asphyxia. It seems that this glutinous exudation becomes more con- densed, and moulded into a false membrane, or partially assumes this state, as the disease advan- ces. (See Bronchi and Air-Passages.) • : 35. C. In many cases, instead of a mem- branous exudation, a viscous, muco-puriforrri matter lines the trachea only, or both the trachea and larynx, as remarked by Frank, Vieusseux, Valentin, Double, Desruelles, Bbiciieteau, Blaud, and Odier. This substance is whitish, greyish, or yellowish grey, and occasionally floc- culent. It is not infrequently formed in con- siderable quantity in the more acutely inflamma- tory cases (§ 12.), and particularly in those which terminate fatally in some hours. It seems as if the quantity of thick viscous matter thrown out on the inflamed surface, together with the spasm of the trachea and larynx, occasioned suf- focation before it could be condensed into a membranous substance. Cases of this description have been particularly noticed by M. Royer- Collard, and have occasionally come before me in practice. I have sometimes also observed a thick, stringy, and adhesive matter, of a greyish white colour, in the superior and posterior part of the trachea and larynx, obstructing the passage, the mucous membrane underneath being nearly altogether exempt from redness and tumefaction. In some instances, this matter has presented a muco-puriform character, varying in its shade of colour, but extremely thick and adhesive. A similar appearance has been remarked by Des- ruelles, Double, Blaud, and Bricheteau. Owing to the absence of the usual marks of inflammation in the situation where this accumu- lation has been met with, it may be presumed that the inflammatory marks had partly dis- appeared after the discharge of this matter; its secretion promoting the resolution of the inflam- matory action, the remaining signs of which had vanished after death the accumulated secretion which had been instrumental in occasioning disso- lution alone presenting itself, the powers of life having been insufficient for its excretion. I have suspected, from observing the progress of other cases, that the inflammatory action sometimes had commenced in the bronchi, and extended upwards along the trachea, and that the secretion now noticed had been chiefly furnished from the larger bronchial ramifications, and had become so thick and adhesive when it arrived at the upper part of the trachea and larynx, as not to have been expelled by the cough, but to have excited spasm of the glottis, and thereby produced suffoca- tion. In some instances of this description, more decidedly inflammatory appearances were ob- served in the larger bronchi than in the trachea. It is probable in these, that the secretion found in the latter situation proceeded chiefly from the former, and that the injection of the vessels in the 531 ease assumes a seemingly epidemic, or even in- fectious character, the inflammatory states now enumerated, with the characteristic secretion, ex- ist also in the pharynx and fauces, and advance downwards to the ramifications of the bronchi. In the most acute forms of the disease, the mu- cous surface of the trachea and larynx assumes the above inflammatory appearances in the course of a few hours. In the second stage of the dis- ease, it becomes streaked, or partially covered by an albuminous, and sometimes a sanguinolent exudation ; and in the last stage, this exudation has concreted to a more or less complete mem- brane ; the inflammatory states of the surface un- derneath still remaining, but in a less distinct manner, and occasionally in patches or streaks only. In some cases, the injection of the vessels, and tumefaction of the surface, are but slight, yet the exudation of a thick concrete membrane ex- ists to a considerable extent; in others it is thin and scanty, or almost entirely consists of a thick tenacious mucus. 33. B- The morbid exudation varies much in consistence, in quantity, and the extent of surface covered by it. In some complicated or consecutive cases, already alluded to, a false membrane has formed from the fauces to the last ramifications of the bronchi. MM. Bretonneau and Briciieteau have observed it without any breach of continuity throughout the whole of this extent. I have never met with an instance where it was so extensive, without interruptions, particularly in the bronchi and about the larynx. In the greater number of the pure uncomplicated cases of the disease, the concretion exists princi- pally in the upper part of the trachea. In the more acutely inflammatory, it extends to the larynx and epiglottis ; in others, to the first rami- fications of the bronchi; and in a few, in both directions. In the complicated cases, and in those of an apparently epidemic and infectious nature, the throat is equally affected, constituting the Diphtherite, or the Inflammation pelliculaire of M. Bretonneau. This false membrane is whitish, greyish white, or passing to a greyish yellow. Its thickness varies considerably. Micu- aelis and Bard consider a line and a half, or two lines, to be its utmost thickness. I have certainly seen portions quite as thick, but not thicker, and sometimes evidently consisting of two or more distinct layers. It is thickest in the posterior and superior part of the trachea, and thinnest about the larynx and epiglottis, when it extends thither, and in the lowest and anterior part of the trachea. Its consistence and tenacity also vary extremely, not only in different, but also in the same case. It is almost universally softest where it approaches the bronchi, where it generally passes into a thick glutinous mucus. The more consistent and firm it is, the more per- fectly is it moulded upon the surface from which it was secreted. But when the consistence is slight, it forms merely membranous shreds, or soft polypous concretions, intermingled with a thick glutinous mucus. The interior of those exudations is generally covered with a whitish tenacious mucus ; and their exterior, or the surface which has been in contact with the inflamed mucous membrane, is sometimes dotted with minute specks of blood. In some cases, these concretions are found still adhering to the surface on which they are formed ; in others, they are 532 CROUP—Pathology of. mucous lining of the trachea had disappeared after death. 36. D. Any very remarkable lesion of the tissues subjacent to the mucous surface has not been found, unless the disease has terminated in tracheal consumption. It has been a question whether or not the false membrane formed in croup is capable of becoming organised, and united to the surface that has produced it. We have no conclusive evidence of such an occurrence, al- though Soemmerring, Albers, and Bricheteau are inclined to believe it possible. The other morbid appearances are chiefly the consequences of the interrupted functions of respiration and circulation through the lungs ; such as con- gestion of this organ and of the brain ; hepatisation of parts of the lung ; emphysema of this viscus ; and, in very young children, enlargement of the thymus gland. The lesions observed in the com- plications of the disease, as far as they have not been already noticed, more strictly belong to the particular maladies with which it is occasionally thus associated; where they are described, and in the article Membrane. 37. ii. Nature of the Disease.—Different opin- ions have been entertained as to its inflammatory nature in all cases, the exact character of the inflammation, and the extent to which spasm of the upper parts of the air-passages may contribute to its production. The very slight inflammatory signs sometimes found in the part covered by the false membrane ; the absence of these as well as of any fluid or concrete exudation, in other cases ; the circumstances under which the disease has sometimes made its appearance, and the ab- sence of phlogistic symptoms in its course, an albuminous exudation either forming notwith- standing, or not at all; have induced several writers to consider it as not merely an inflamma- tion of the upper part of the air-passage, but a disease of a peculiar nature, more or less con- nected with the state of the system, although prin- cipally affecting the trachea and frequently the larynx, and large bronchi also. The opinion of Rogery, Hare.es, Hecker, and many others, amount to this merely ; and they seem not far from the truth. I have remarked, that, although croup assumes the more unequivocally inflamma- tory form in strong and plethoric children, it does not most frequently affect them, unless they be of the sanguine or irritable temperament; that it presents every shade or modification from this, to the least phlogistic and most manifestly spasmodic form ; that even its most inflammatory state may assume a spasmodic or nervous char- acter after large depletions, which, while they diminish, as under every other circumstance of disease, the phlogistic diathesis and symptoms, increase the nervous and spasmodic ; and that even when the first seizure has been of the inflam- matory form, yet the relapses, or subsequent attacks, which are sometimes repeated several times at irregular intervals, have generally pos- sessed more of the spasmodic character. 38. Another fact, which I have uniformly ob- served, appears important ; namely, that the quantity of fibrine and crassamentum in the blood taken from the patient, and of albumen in the urine, have been great in proportion to the in- flammatory type of the disease, and the disposition to form a false membrane ; whilst in the more spasmodic varieties, in which an albuminous exudation is seldom found, or at least but sparingly, and the urine is more copious and limpid, and less, or not at all albuminous, the blood has presented a smaller or less firm crassa- mentum. These facts evidently show, not only that the state of the blood is different in these forms of the disease, but that the condition of the organic nervous or vital power, upon which tho appearances and constitution of the circulating fluid so closely depend, is also different ; and, moreover, that the manifestations of both the one and the other will vary in the different modi- fications of croup, conformably with these results. The combined and reciprocative operation of the nervous influence, and the condition of the circu- lating fluid, will give rise, according to the state of the frame, and the nature and combination of the exciting causes, to constitutional as well as local phenomena ; to a state of febrile action, which will be inflammatory in, generally, the majority of cases, nervous in others, and present more or less of gastric, or even of adynamic symptoms in some, particularly when the disease occurs in a complicated or epidemic form. The imporatance of attending, during the treatment of particular cases, and of their different, stages, to the charac- ters of the constitutional disturbance—to the at- tendant fever, will be evident, as indicating not only the means to be also the nature of the local mischief. Thus, in the cases at- tended by inflammatory fever, the exudation is abundant and rapidly formed ; in that manifesting the nervous form, it is either scanty, imperfect, or consists of a little glairy fluid,—the spasmodic character predominating, and cerebral symptoms sometimes supervening ; and in that presenting the adynamic and gastric form it is spreading,— seldom limited to the trachea and larynx, but often extending to the pharynx, fauces, tho mouth and even to the nostrils on the one hand, and down the oesophagus and bronchi on the other. It is in this last form that the disease pre- sents itself when it is epidemic or infectious ; and although the adynamic (or the malignant charac- ter, according to J. P. Frank) often manifests itself early, yet the antecedent febrile symptoms very evidently evince high action. *39. There is one important point not sufficiently adverted to by authors, viz. the very early period at which the tracheal exudation is often poured out, in the inflammatory states of tho disease ; the symptoms making the first or premonitory period being those indicating the local developement of the malady. Thus, a healthy child has evinced no disorder for several days, or the disorder has been so slight as to escape observation—it may even be more than usually lively and alert on the day preceding the night on which it is most se- verely attacked ; and yet, if an emetic be that in- stant exhibited, a large quantity of the thick, glairy, sanguineous and gelatinous matter will be brought away from the air-passages ; showing that, in many instances, the early advances of the inflammatory action is slow and insidious; that the characteristic seizure often does not occur until the exudation has accumulated to a consid- erable extent in the trachea, or the inflamma- tion has extended to the larynx ; and that it is partly owing to the retention of this matter— which is evidently thrown out in a fluid form,— that it concretes into a false membrane, each successive discharge sometimes forming a dis- tinct layer. MM. Gendrin, Andral, and other pathologists, have remarked, that the inflamma- lory action which gives rise to the albuminous ex- udation on the surface of mucous membranes is of a sub-acute, rather than of an acute kind. I believe that this is the case in respect of the inflammation of the trachea and larynx, in croup; and that the formation of a false membrane is the result not so much of the sthenic or acute char- acter of the local action, as of the abundance of albumen and fibrine in the blood,—a circum- stance which partly accounts for the frequency of relapses in some children (§ 41. o.), and jus- tifies Harles, Hecker, and others, in considering the disease to consist of a peculiar form of inflam- mation. Some writers, however, suppose that the very acute symptoms, and rapid termination of many cases, militate against these opinions ; but it should be recollected that, even in the most severe cases, the inflammatory action, when it commences in the trachea, often exists for several days, in the manner already noticed, until it has either extended to the larynx, or produced such a quantity of albuminous exudation as will obstruct respiration, or induce, by its irritation, spasm of the air-passages,—these effects being the chief causes of the severity and rapid termination of the disease. This will become more evident, when we consider the consequences of inter- rupted respiration upon the frame—whether the interruption proceed from the mechanical ob- struction occasioned by the exudation and false membrane, or the frequent recurrence or con- tinuance of spasm of the larynx and trachea ; or from inflammatory action, and its consecutive axudation extending down the bronchi; or from '.wo or all of these combined. These corise- juences are, in fact, the third stage of the dis- ease ; the symptoms of which are the usual phe- nomena resulting from obstructed respiration, interrupted circulation, and congestion of the lungs; imperfect action of the air upon the blood, and the circulation of this fluid in a nearly venous state, with congestion of the cavities of the heart, and impeded return of blood from the head. The circulation, moreover, of imperfectly arterialised blood to the nervous systems occasions lethargy, with sinking of the vital powers, and increases the disposition to spasmodic action of involuntary parts, and to convulsive movements of voluntary organs ; all which (the former espe- cially) become so prominent a character of the malady in its advanced stages, and often termi- nate existence. Thus it will appear manifest, —and the fact is of great practical importance,— that the severity, rapidity, and danger of croup, are not the immediate consequences of the ac- tivity or acuteness of the inflammatory action ; but of the exudation to which it gives rise, and of the conformation and functions of the parts which it affects. 40. Duval, Jurine, Albers, and Schmidt, have considered it worth ascertaining, in how far the disease could be artificially produced in the lower animals; and whether or not, when thus produced, inflammation exists to the extent of accounting for the phenomena, or gives rise to a false membrane. They injected into the tra- chea of fowls, dogs, cats, sheep, wolves, &,c., various irritating substances, as the bichloride or peroxide of mercury (Schmidt) dissolved in spirits of turpentine, and solutions of iodine, and nitrate of silver ; they moreover made these animals in- hale the fumes of sulphuric and hydrochloric acids; and the results were just what might have been CROUP—Pathology of. anticipated, viz. that in some cases, inflamma- tion without any exudation was produced: in others, a fluid, or more or less concrete exudation was found in various quantity ; and in all, the matter in the air-passages was not sufficient en- tirely to obstruct the access of air to the lungs ; thus confirming the opinion justly contended foi by Cullen and others, that a great part of the phenomena and consequences of the disease is to be attributed to spasm of the larynx and tra- chea. Schmidt succeeded in producing a false membrane only in young animals,—a fact in accordance with the spontaneous occurrence of the disease previously to puberty, and to be referred to the more albuminous state of the blood often observed at this period. It may be of importance to know that croup—identical in its phenomena and organic changes with the dis- ease in the human subject—occurs also in sev- eral of the lower animals, especially before they are fully grown. Its occurrence in chickens is well known by the name of “Pip.” Dupuy, Rush, Valentin, Youatt, and others, have ob- served it in horses and dogs ; Double, in lambs and cats ; and Ghibi and Gohier, in cows. In some of these animals it has even occurred as an epidemic. 41. Pathological Conclusions.—Another point, of greater importance than it may at first seem, is whether or not the matter concreted and moulded on the inflamed mucous surface be exuded by this tissue itself, or secreted by the follicular glands with which it is so abundantly supplied. M. Grimaud has adopted the latter alternative. From particular attention I have paid to this subject, some of the results of which have been stated in the article Bronchi (§11, 12.), I would draw the following inferences relative to it, and to the pathology of croup gen- erally :—(a) That the mucous membrane itself is the seat of the inflammation of croup; and that its vessels exude the albuminous or char- acteristic discharge, which, from its plasticity and the effects of temperature and the contin- ued passage of air over it, becomes concreted into a false membrane;—(6) That the occa- sional appearance of blood-vessels in it arises from the presence of red globules in the fluid when first exuded from the inflamed vessels, as may be ascertained by the exhibition, upon the approach of the symptoms, of a powerful emetic, which will bring away this fluid before it has concreted into a membrane ; these globules gen- erally attracting each other, and appearing like blood-vessels, as the albuminous matter coagulates on the inflamed surface;—(c) That the mem- branous substance is detached in the advanced stages of the disease, by the secretion, from the excited mucous follicles, of a more fluid and a less coagulable matter, which is poured out be- tween it and the mucous coat; and, as this se- cretion of the mucous crypt® becomes more and more copious, the albuminous membrane is the more fully separated, and ultimately excreted if the vital powers of the respiratory organ and of the system be sufficient to accomplish it;— (d) That sub-acute or slight inflammatory action may be inferred as having existed, in connec- tion with an increased proportion of fibro-albu- minous matter in the blood, whenever we find the croupal productions in the air-passages ; but that these are not the only morbid conditions constitu- ting the disease ;—(e) That, in conjunction with 533 534 CROUP—Treatment of its common Forms. the foregoing,—sometimes only with the former of these in a slight degree,—there is always present, chiefly in the developed and advanced stages, much spasmodic action of the muscles of the lar- ynx, and of the transverse fibres of the mem- branous part of the trachea, which, whilst it tends to loosen the attachment of the false mem- brane, diminishes, or momentarily shuts, the ca- nal (of the larynx) through which the air presses into the lungs ;—(/) That inflammatory action may exist in the trachea, and the exudation of albuminous matter may be going on, for a con- siderable time before they are suspected,—the accession of the spasmodic symptoms being often the first intimation of the disease ; and these, with the effects of the pre-existing inflamma- tion, give rise to the phenomena characterising the sudden seizure ;—(g) That the modifications of croup may be referred to the varying degree and activity of the inflammatory action ; the quantity, the fluidity, or plasticity of the exuded matter ; the severity of spasmodic action ; and to the predominance of either of these over the others in particular cases, owing to the habit of body, temperament, and treatment, of the patient, &c. ;—(A) That the muco-purulent secretion, which often accompanies or follows the detach- ment and discharge of the concrete or mem- branous matters, is the product of the consecu- tively excited, and slightly inflamed, state of the mucous follicles, the secretion of which acts so beneficially in detaching the false membrane ; —(i) That a fatal issue is not caused merely by the quantity of the croupal productions accu- mulated in the larynx and trachea; but by the spasm, and the necessary results of inter- rupted respiration, and circulation through the lungs ;—(A) That the partial detachment of fragments of membrane, particularly when they become entangled in the larynx, may excite se- vere, dangerous, or even fatal spasm of this part, according to its intensity relatively to the vital powers of the patient; and that this occur- rence is most to be apprehended in the com- plicated states of the malady, where the inflam- matory action, with its characteristic exudation, spreads from the fauces and pharynx to the larynx and trachea; the larynx being often chiefly affected in such cases ; and from its irri- tability and conformation giving rise to a more spasmodic and dangerous form of the disease (l) That the danger attending the complica- tions of croup is to be ascribed not only to this cir- cumstance, but also to the depression of vital power, and the characteristic state of fever ac- companying most of them, particularly in their advanced stages ;—(m) That irritation from par- tially detached membranous exudations in the pharynx, or in the vicinity of the larynx or epiglottis, may produce croupal symptoms in weak, exhausted, or nervous children, without the lar- ynx or trachea being themselves materially dis- eased ; and that even the sympathetic irritation of teething may occasion the spasmodic form of croup, without much inflammatory irritation of the air-passages, particularly when the pri- ma via is disordered, and the membranes about the base of the brain are in an excited state ;— (n) That the predominance in particular cases of some one of the pathological states noticed above (g), as constituting the disease, and giving rise to the various modifications it presents, from tfie most inflammatory to the most spasmodic, may be manifested in the same case at differ- ent stages of the malady, particularly in its simple forms, and in the relapses which may subsequently take place ; the inflammatory char- acter predominating in the early stages, and either the mucous or the spasmodic, or an asso- ciation of both, in the subsequent periods ;—(») That the relapses, which so frequently occui after intervals of various duration, and which sometimes amount to seven or eight, or are even still more numerous, may each present differ- ent states or forms of the disease from the others; the first attack being generally the most inflammatory and severe, and the relapses of a slighter and more spasmodic kind ; but in some cases this order is not observed, the sec- ond or third, or some subsequent seizure, being more severe than the rest, or even fatal, either from the inflammation and extent of exudation, or from the intensity and persistence of the spas- modic symptoms,—most frequently from this latter circumstance. The above inferences, how- ever minute or trite they may seem, should not be overlooked, as they furnish the safest and most successful indications of cure, and are the beacons by which we are to be guided in the treat- ment of the disease. 42. VI. Treatment.—i. The curative Treat- ment of Crout. I shall first state the method of cure on which I would chiefly rely in the different modifications of the disease ; and after- wards notice some of the remedies which have been recommended by various writers. Several of these are of great benefit in certain circum- stances of the disease ; but we can seldom de- pend upon any one of them ; it is on a judi- cious combination and sequence of means that we should chiefly rely ; and upon the adapta- tion and co-ordination of these in particular cases. The intentions of cure are—1st, to diminish in- flammatory and febrile action, when present: and to prevent, in these cases, the formation of a false membrane, or the accumulation of albuminous matters in the air-passages;—2d, when the time for attempting this has passed, or when it cannot be attained, to procure the discharge of these matters ;—3d, to subdue spas- modic symptoms as soon as they appear ; and 4th, to support the powers of life in the latter stages, so as to prevent the recurrence of spasms, and to enable the system to throw off'the matters exuded in the trachea. 43. A. Treatment of the common and inflam- matory Croup.—a. If the practitioner see the patient in the first stage (§ 6.), particularly if hoarseness, or a rough cough, with other catarrhal symptoms, be present, it will be proper to give an active antimonial emetic, with the view of ful- filling the first of the above intentions.* This will often bring away a considerable quantity of a thick, glairy, and sometimes slightly sanguineous matter from the trachea, and will give immedi- ate, although generally only temporary, relief. If * [It should be borne in mind that tartar emetic is a hazardous remedy in very young children, infants, and in those of a debilitated constitution, owing to the severe prostration it is apt to produce. In several instances we have known it produce fatal effects, and therefore we prefer, in such cases, the ipecacuanha, or the combi- nation of ipecac, with the oxymel of squills, in doses of a tea-spoonful of a mixture, composed of one ounce of the oxymel of squills, and half an ounce of the wine of ipeeac, every fifteen minutes until vomiting is pro- duced. To very young infants the ipecac, alone, or com- bined with calomel, should be given.] the matter discharged from the air-passages pre- sent the above appearances ; if the child be pletho- ric, the pulse at all excited, and the countenance flushed ; we should not be deceived by the calm following the full operation of the emetic, but should have recourse to blood-letting. In the ma- jority of instances, cupping between the shoul- ders or on the nape of the neck, or the application of leeches on the sternum, to an extent which the age, habit of body, and strength of the patient may warrant, will be preferable to venesection. Under these circumstances, particularly when the nausea occasioned by the emetic has hardly sub- sided, the abstraction of little more than an ounce, or an ounce and a half, of blood, for every year that the child may have completed, will be borne. In town practice, the local is preferable to general blood-letting; but the latter will be adopted, with advantage in the country, amongst plethoric and robust children. The advantages of depletion and antimonials are attributable to their influence in arresting the inflammatory ac- tion, and, from the consecutively accelerated ab- sorption of fluids into the circulation, to the rela- tive diminution of the albuminous constituents of the blood. I have in several cases directed, af- ter a moderate depletion, and after the operation of an emetic, a piece of folded flannel to be wrung out of hot water, and freely sprinkled with oil of turpentine, or with either of the liniments (F. 296. 311), and applied around the neck and thoat. This application has given in- stant relief. [Where free vomiting is early induced in croup, blood-letting will rarely be found necessary; but where febrile symptoms are prominent, it is a remedy which cannot safely be neglected. But it will rarely be necessary to bleed to syncope, as recommended by Bayley, Ferriar, Dick, Chap- man, and others. Dr. Eberle very properly rec- ommends copious bleeding in cases of violent in- flammatory action, indicated by an active, firm, tense pulse, and general fever. Dr. Hosack, al- though in favour of free bleeding in croup, does not approve of its being carried so far as to pro- duce fainting, having repeatedly observed very serious and permanent evils arise from the exces- sive loss of blood. Dr. Stewart observes that this opinion is sustained by his experience ; “ for although prompt, decisive, and repeated bleeding is necessary, yet the constitution will often suffer from the loss of blood, carried to the extent in- sisted on by many writers, where the nervous system feels the effects of this remedy, as at this early age, its consequences continuing for a long time after.” The opinion of Mr. Copland with respect to the advantages of local blood-letting, is not fully sustained by the experience of American practitioners. Prof. Dewees strongly opposes the use of leeches to the throat under any circum- stances, having never seen them productive of any benefit; but on the contrary, from the length of time necessary to obtain the requisite quantity of blood, the exposure of the throat du- ring their application, and the coldness of the leeches, the symptoms of croup have increased during their application. Where it is necessary to use local depletion, Dr. D. recommends cups applied between the shoulders, but never around the throat. I believe it will rarely be found ne- cessary to resort to local bleeding in the treat- ment of croup, if a proper impression be made on CROUP—Treatment of its common Forms. the circulation by general blood-letting, and the impression sustained by other appropriate rem- dies, as emetics, the warm bath, diaphoretics, &c.] 44. Immediately after depletion, and an emetic, the best internal medicine undoubtedly is calomel and James’s powder—from three to five grains of the former, and two or three of the latter being given. This powder may be repeated every sec- ond, third, or fourth hour, until two or three doses have been taken. After the first dose, the child should be put in a tepid bath, and be allowed as much tepid diluents as the stomach will bear, in which carbonate of soda may be dissolved, and which maybe rendered agreeable with syrup.* If the powders, given to the extent now mentioned, have not acted upon the bowels, castor oil, or some other purgative, assisted by an emetic, should be administered. These means, aided by the turpentine epithem applied around the neck, will seldom fail of cutting short the disease. If, however, it still proceed, the means to be em- ployed in the next stage should be adopted ac- cording to the circumstance of the case. 45. 6. The second or developed stage is that in which medical aid is most frequently resorted to; and at this period, conformably with what has been stated (§ 39.), the disease is actually further advanced than the symptoms indicate. At its commencement, however, the first inten- tion of cure should be attempted ; but the most decided means will be now requisite to attain its fulfilment. These should bo put in practice, even although the treatment already recommended may have been employed in the preceding stage. An active antimonial emetic should be instantly exhibited, so as to produce full vomiting ; and immediately upon the conclusion of its operation, blood-letting, general or local, must be resorted to. The abstraction of a greater quantity than that indicated above (§ 43.) will seldom be more beneficial, nor, indeed, will it be borne without producing syncope, which, in children especially, should be avoided, as favouring the supervention of convulsions or reaction. But it may be requi- site, particularly when the patient has not lost any blood during the preceding stage, to repeat the depletion. On this, or on any future occasion of repeating it, local blood-letting, in the situa- tions and mode already mentioned (§(43.), is now to be preferred. If they have not been prescribed previously, the calomel and James’s powder should be given every two or three hours, until three or four doses are taken; and the adju- vants directed to accompany and to follow this medicine in the first stage, should also be em- ployed in this. 46. Having thus carried depletion as far as seems prudent, and fully evacuated the prima via, if a very obvious improvement have not taken place, or if the suffocating seizures recur notwithstanding, dry cupping may be resorted to, and afterwards either a blister should be applied between the shoulders, on the nape of the neck, or on the epigastrium, but never on the throat, or the turpentine epithem (§ 43.) ought to be applied around the neck. If symptoms of febrile excite- ment still attend the seizures, an emetic should be given, so as to excite vomiting again, and be repeated until it has this effect fully. If the ur- gent symptoms and fever still continue, vomiting may be excited a third or fourth time at intervals of two or three hours. The tartar emetic is, 535 536 CROUP—Treatment of Its common Forms. upon the whole, the best medicine for the purpose in the early or inflammatory states of the dis- ease, and may be given in doses of half a grain, in simple solution, to a child two or three years old, as advised by Dr. Cheyne, and repeated at about half an hour, or sooner, if vomiting be not induced. M. Guersent prefers ipecacuanha, and advises blood-letting to precede the exhibition of emetics. Where the inflammatory action is con- siderable, this method may be adopted; but where we may expect to bring away the exuded matter by means of an emetic, before it has con- creted into a membrane, it will be as well to ex- hibit one without delay, and to keep up a con*- slant nausea by the same medicines given in fre- quent and small doses. But I have seen the tar- tar emetic not only fail in producing vomiting, but also prove injurious by causing dangerous vi- tal depression. 47. If the symptoms continue notwithstanding the judicious use of the above means, we should infer the formation of a false membrane, unless the exacerbation be altogether spasmodic—the breathing and voice becoming natural, or nearly so, in the intervals. The measures to be em- ployed now should have reference to the separa- tion and discharge of the concrete exudation, and the removal of spasmodic symptoms—to the ful- filment of the second and third intentions pro- posed. Bleeding, even if the state of the patient would admit of it, would not promote these in- tentions ; and the exhibition of calomel or mer- curials, excepting with the view of promoting all the abdominal secretions and excretions, and thereby to derive from the diseased organ, would not materially assist our views, inasmuch as it is impossible thereby to affect the system of children so as to prevent the formation of coagulable lymph. In this case, we should assist the opera- tions of nature in detaching the false membrane. It has been stated, that this is accomplished by the effusion, by the excited follicles, of a fluid matter between the concrete substance and the mucous coat; therefore those medicines which have usually the effect of increasing and render- ing more fluid the mucous secretion of the air- passages, should now be prescribed. But care should be taken not to exhibit these or any other expectorants, too early, or until depletion has been carried sufficiently far. They are most ser- viceable about the termination of the second, and the commencement of the third stage. The medicines best calculated to act as expectorants in this disease are, the preparations of squills, of ammoniacum, of senega, the carbonates, and the sulphurets of the alkalies, and camphor. The oxyinel or syrup of squills may be given, either alone, or with some one of the sulphurets, or with senega, and generally to the extent of keeping up a slight nausea, unless the exacerba- tions of cough and suffocation be severe, when full vomiting should be produced by their means. I prefer the emetic effect at this period to be ob- tained by squills; as antimony lowers too quickly the vital power, which ought now to be sup- ported, so as to enable the diseased organ to throw off the morbid matter formed upon its sur- face. A mixture, consisting of decoction of sen- ega, with vinum ipecacuanhas and oxymel of squills, may also be adopted with equal advan- tage. When the medicines fail of exciting vom- iting, the pharynx should be irritated by a fea- ther. I have seen very much benefit derived from this simple means; and have considered it more beneficial than any other, in the third stage, in promoting the discharge of matters from the trachea. Jurine also places great reliance on it. When severe exacerbations, with spasm and threatened suffocation, occur, it is always most advantageous to produce instant vomiting. The sulphate of zinc has been advised by M. Guer- SEnt, and the sulphate of copper by Dr. Hoff- mann, for this purpose. In this state of the dis- ease, I have applied the warm turpentine epi- thern mentioned above (§ 43.), around the neck, with almost instant benefit. [Vitriolic emetics have acquired considerable reputation, for the expulsion of the membranous formation in croup, where all other means have failed in affording relief. Of these, the sulphates of zinc and copper have been used to a consider- able extent. The former by Dr. J. W. Francis, of* New York, in three cases, with complete suc- cess, where all hopes of recovery had been previ- ously abandoned. (N. Y. Med. and Phys. Journ., v. iii., p. 54.) A strong solution, consisting of two drachms of sulphate of zinc, to an ounce of wa- ter, was made, of which a large tea-spoonful was administered every twenty minutes to a child of two years, for about two hours, without effect. A solution of the sulphate of copper of the same strength was prepared, and after twice giving it, a portion of the membrane was detached; the white vitriol was then again resorted to, with the effect of dislodging a large quantity of similar membranous substance. Dr. F., to whom the profession is indebted for the introduction of this remedy, remarks, that vitriolic emetics may be given with more safety than is generally sup- posed, in those cases where inflammatory action has been subdued.—(Stewart), On the Use of Sulphate of Copper in Croup. See American Journ. of Med. Sciences, vol. xviii., p 231.] 48. During this and the preceding stages, the inhalation of watery and medicated vapours may be resorted to. At the commencement of the disease, vapours of an emollient kind are most beneficial; but when we wish to promote ex- pectoration, camphor may be added to the sub- stance used iu this way. Home, Crawford, Pearson, Rosen, Pixel, and Goelis, have ap- proved of this practice. When spasmodic symp- toms manifest themselves, inhalation, assisted by the tepid or warm bath, is often of use; but an- tispasmodics should also be prescribed with the other medicines, or in enemata. I have never seen any permanent advantage derived from nar- cotics given by the mouth, except from opium or syrup of poppies, combined with antispasmodics; probably owing to their lowering the vital ener- gies, which are always much depressed when nervous symptoms appear. Great care should be always taken in exhibiting opiates in clysters to children: in very young children the practice is attended by much risk. Opiates are given to greatest advantage with ipecacuhana, as in Do- ver’s powder, or with camphor, or calomel, or with both. I have likewise found camphor, with James’s powder, and hyoscyamus, of much benefit in some cases in which I have prescribed it. The hydrosulphuret of ammonia may like- wise be tried in both this and the next stage of the disease. 49. In many cases the judicious use of blood- letting, calomel, antimony, &c., will cut short the disease, even although the patient may not have been treated until this period has been far ad- vanced ; and in others, the active use of these means may give rise to very alarming depression of the vital energies, even when they may have succeeded in removing the cause of obstruction and irritation in the air-passages. In these, stim- ulants, antispasmodics, and restoratives must be immediately resorted to, but with great caution, lest the inflammatory action may be reproduced by their means.* CROUP—Treatment of its common Forms. 537 50. c. The treatment of the third stage, either when the patient has not been earlier seen, or when previous measures have failed, should be directed with the view of fulfilling the second and third indications of cure, and at the same time with due reference to the fourth—the preservation of the exhausted nervous and vital powers. The chances of recovery are now very few; but these few should not be neglected. Many of the reme- dies, already mentioned, especially expectorants, should also be exhibited in this stage; and these ought occasionally—particularly when the symp- toms become very urgent—to be given so as to exert a speedy emetic action; and be combined with antispasmodics—with either camphor, am- monia, aether, musk, valerian, assafoetida, the oxide of zinc or trisnitrate of bismuth, the sulphurets of the alkalies, &c.; and the same medicines, or the infusion of valerian, may also be prescribed in enemata, especially when spasmodic or nervous symptoms are predominant. When emetics are exhibited in this stage, those substances which are required in smaller doses in the remissions, in order to act as nauseants or expectorants, are amongst the most eligible—particularly squills, senega, the sulphate of zinc. The inhalation of the vapour of ammonia, camphor, or aether, in that of warm water, or of the fumes of warm vinegar, either alone, or with camphor; is sometimes productive of benefit in this period. Some advantage may also be derived from sternutatories blown into the nostrils, as advised by Lentin, and Thilenios. I have seen, in two or three instances, the sneezing occasioned by them favour remarkably the discharge of the false membranes from the trachea ; common Scotch snufF having been used for this purpose. 51. The tepid hath may be resorted to both in this and the preceding stage, once or twice daily, or according to circumstances ; and either the sul- phuret of potassium, or the carbonates of potash or soda may be put in the water; and, if a tendency to collapse becomes apparent, the bath should be warm, and some mustard may also be added. Blisters between the shoulders, or on the sternum, may likewise be tried; but they always require great discrimination and care, in order to avoid un- pleasant consequences from them. They should not, in this stage, remain on longer than from four to eight hours. Home and Thilenius advise them to be applied to the neck; Lentin and Goelis, to the neck and sternum; and Royer- Collard, between the shoulders or on the arms ; Maercker states, that he has derived but little benefit from them. Olbers and Royer-Collard speak favourably of sinapisms placed on the lower extremities. I have, however, seen more advan- tage accrue from rubefacient liniments (F. 299. 304.) or epithems, applied on the epigastrium and chest, or between the shoulders. During this, as well as the preceding stage, a cathartic action should be exerted upon the bowels, unless the medicines previously exhibited occasion diarrhoea, * The following case will illustrate the above observa- tion, a id may prove instructive to the less experienced reader. I have extracted it verbatim from my note- book, with the remarks suggested at the time appended to it:— William Hodson, aged five years and a half, was seized, on the 17th of Nov., 1821, with hoarseness, fever, and a ringing, dry cough. The mother opened its bowels with salts, and gave it some antimonial wine. The following day, in the evening (18th), I saw it. There was much fever, with flushed countenance, and a constant, hard, and ringing cough, with a sibilous noise on respiration. Pulse frequent and hard ; skin harsh and dry ; great restlessness, tossing, dyspnoea, with hoarseness, and the characteristic breathing of croup. I directed blood-let- ting from a vein in the arm ; and the blood was allowed to flow in a full stream till approaching syncope was in- dicated, seven ounces being abstracted; and the follow- ing powders were directed to be taken every ten minutes, till full vomiting was induced; and subsequently every three hours : — No. 162. It Hydrarg. Submur. gr. xxx.; Antimon. Pot.- Tart. gr. iij.; Pulv. Ipecacuhanai gr. vj. Misce bene, et divide in Pulv. viij. Early in the morning of the 19th I again saw the child. The powders had been given, as above, until full vomit- ing had been produced ; and one powder had been taken subsequently. The sense of suffocation had disappeared after the vomiting. The matters ejected contained much thick ropy mucus, with memhranous shreds of firm co- agulated lymph floating in it. The cough and croupy symptoms had disappeared ; the voice was clear, and the respiration easy; but now the child complained of distressing sickness, with frequent vomiting and purging: the stools were first bilious, offensive, copious, and fiecu- lent: but they had now become watery. The pulse was extremely frequent, so as scarcely to be counted; and so small and thready as hardly to be felt at the wrist. The countenance was pale and sunk; the skin cool and moist; and all the symptoms of sinking of the powers of life, very manifest. The powders were discontinued, and the following mixture directed :— No. 163. ft Aq. Cinnam. ? iijss.; Spirit. Ammon. Arom. 3jss.; Tinct.Opiiin.xv.; Syrupi Scillie Z iij. M. Two tea-spoonsful of this were to be taken every ten or fifteen minutes, until a decided effect from it was evident. After four or five doses, the stools and sickness were restrained, and the child fell into an easy and sound sleep. A blister was now applied to the sternum, which was to be removed at the end of four hours, and poulticed with a bread-and-water poultice. The semicupium to be employed afterwards, and at bed-time. Three grains of calomel, with one of James’s powder, to be taken at night, and the mist, camphorce, with liq. ammon. acet., vinum ipecacuhante, and syrupus papaveris, every three hours. Linseed tea or barley water, with sugar-candy or liquorice for common drink. 20th.—All the symptoms of croup had disappeared; but there was still some cough and fever, with occasional paroxysms of difficult breathing. The bowels had been open this morning; pulse 120, and small. Antimonial wine was added to the mixture; and an injection di- rected, with assafoetida, spiritus terebinthinae, oleum ri- cini, and camphor. In the evening.—He had had no return of the paroxysms since the injection, which was retained above an hour, ami had procured two evacuations. Pulse 116; cough less frequent; skin more natural. The blistered surface had risen in some parts, and was inflamed in all. From this time he continued to recover: diaphoretics, demulcents, aperients, and the semicupium, being em- ployed until convalescence was complete. Remarks.—It is by no means unusual to find a recur- rence of the inflammatory and local symptoms after they have been apparently most completely subdued by means similar to those employed in the foregoing case; and even after the powers of life, and all local inflammation and febrile action, had been equally depressed. This recur- rence of the acute symptoms seems owing to either an over active use of stimulants, or an injudicious choice of them in the collapse occasionally following the decided use of blood-letting and antimony. Sometimes it arises from exposure to cold, or a current of cold dry air; and then generally a distinct chilliness of rigor is previously felt. Occasionally I have traced it to too early recourse to food, or articles of a too stimulating and indigestible de- scription. Inattention to the state of the bowels will also dispose to it; and even a blister applied too near upon the seat of disease has evidently produced such an ef- fect, especially in thin irritable children. In no case would I permit a blister to be placed upon the throat, so firmly am I persuaded that mischief is occasioned from it in this situation. CROUP—Treatment of the Spasmodic Form. 538 or dysenteric symptoms. Medicines of this de- scription are beneficial, as active derivatives from the seat of disease, and as evacuants of morbid secretions. Calomel, with jalap, may be given, either alone, with musk, or some other antispas- modic medicine; but, in every instance, the oc- casional exhibition of an enema should not be neglected. Olbers, Albers, and Jurine, strenu- ously advise large doses of musk to be exhibited; and Kendrick and Royer-Collard, assafoetida to be administered in clysters. The affusion of cold water on the head has been sometimes resorted to by Harders, Schmidt, and myself, when the preceding means have failed, particu- larly if congestion or other cerebral symptoms have supervened, and the exacerbations have assumed chiefly a spasmodic form. 52. IS. Treatment of the humid and spasmodic forms of croup.—a. In the humid or bronchial form of the disease, the intentions of cure are,— 1st, to subdue inflammatory action ; 2d, to remove the matters exuded from the air-passages; 3d, to calm spasmodic action; and, 4lh, to support vital power. These can be attained only by bleeding, general or local, as already advised, but never from the throat itself; in the early stages by antimonial emetics, and subsequently by those consisting of ipecacuanha or sulphate of zinc ; by calomel, with James’s powder, as prescribed above ; and afterwards with other purgatives, as scam- mony or jalap; by cathartic eneinata ; by exter- nal derivatives; and, lastly, by antispasmodics and diffusible stimulants. Of these, individually, little need be added to what has been already ad- vanced. More advantage seems to be derived from purgatives, in this, than in any other form of the disease. I have sometimes seen them bring away a thick, gelatinous, glairy secretion, similar to that discharged from the air-passages in the advanced stages. Their operation should be promoted by the administration of purgatives in antispasmodic clysters, as extract of colocynth with assafcetida, valerian, or camphor; and if spasmodic symp- toms become urgent, the sulphurets or carbon- ates of the alkalies, and either of the various antispasmodics already mentioned, may also be taken by the mouth, particularly camphor, with James’s powder, or Kermes mineral, or ipecac- uanha, with spirits of nitre, aether, or other diaphoretics. The medicated tepid or moderately warm bath, blisters, the turpentine epithem ap- plied around the neck and throat, rubefacient liniments, the inhalation of simple or medicated vapours, may also be resorted to in the manner de- tailed above. In the last stage, when the powers of life indicate exhaustion, ammoniacum, senega, oxymel of squills; and camphor, assafcetida, musk, ammonia, the tethers, &c., in full doses; and rube- facient and stimulating frictions, liniments, and baths, with the rest of the treatment already rec- ommended at this period; are the chief means in which we can confide. 53. b. In the spasmodic form of the malady the indications of cure are very nearly the same as now stated; but the treatment will neces- sarily vary with the extent to which inflammatory irritation may be supposed to exist either in or about the larynx, particularly soon after the ap- pearance of the disease; or about the medulla oblongata, in its more advanced course. In that state of constitution in which this form is most frequent, bleeding is seldom required beyond that procured by a few leeches applied to the nape of the neck, when we infer the presence of inflam- matory irritation in the above situations. In this modification, whether occurring primarily, or in relapses, antispasmodics, given both by the mouth and by clysters, are indispensable ; but emetics, and afterwards cathartics, medicated tepid or warm baths, and inhalations, the turpentine epithem applied around the neck, blisters, or rubefacient frictions and liniments along the spine and over the epigastrium, and the cold affusion on the head, also constitue important parts of the treatment. The antispasmodics most to be confided in are, the sulphurets and carbonates of the alkalies, va- lerian, assafcetida, ammonia, camphor, musk, the preparations of aether, the oxide of zinc and trisni- trate of bismuth, and the liquor ammonite acetatis, with excess of ammonia. Mr. Kimbell states, that he has derived most advantage from the internal use of arsenic, or sulphuret of potassium, aided by regular attention to the bowels, the shower bath, and by blisters or anodyne frictions on the spine. Of arsenic I have had no experience in this affection ; but I have given the preparations of bark, and used the other remedies he has men- tioned, with advantage. If the above means do not soon remove the disease, irritation about the base of the brain or medulla oblongata should be suspected, and leeches ought to be applied on the neck ; and calomel, with aperients, or with musk or camphor, exhibited once or twice daily, injec- tions being also employed: cerebral symptoms should be always enquired after, and energetically treated when detected. [During a paroxysm of laryngismus stridulus, thymic asthma, or spasmodic croup, the child should be placed in an upright position, exposed to cool fresh air, while cold water is dashed over the face. All compression is to be removed from the cervical vessels, and brisk friction applied over the spine, while the feet and legs are im- mersed in a hot mustard pediluvium; or the patient may be immersed in a warm bath, while cold water is sprinkled over the face. Dr. John- son recommends the application of ammonia to the nostrils, and irritating the pharynx with a feather for the purpose of inducing vomiting. If it is a case of simple spasm of the glottis, these means will often prove entirely successful. An enema of turpentine or assafcetida will often prove useful; and in extreme cases, Maksii and Potter recommend tracheotomy. Where there is evident determination of blood to the head, a few leeches should be applied behind the ears, and after the bleeding is stopped cold lotions to the scalp. As this affection is so apt to occur during den- tition, the gums should always be examined, and if swollen, freely lanced; Dr. Hall recommends free incision of the gums, if they are not swollen, and even if the teeth have all appeared, for the pur- pose of correcting a state of the blood-vessels and nerves of the gums, which, though physiological, partakes of a pathological character, and the operation, he thinks, should be repeated for several successive days. The condition of the food, also, and the state of the stomach and bowels, should be examined, and the proper measures taken to cause a healthy supply of nourishment, suitable to the age of the child, if improper food, par- ticularly of an artificial kind, has been used. The bowels also should be daily evacuated by such mild aperients as are calculated to neutral- ize any acid in the stomach, should costiveness CROUP—Treatment of its Complicated Forms. 539 exist. The clothing is to be properly regulated, all causes of irritation removed, and if there are present symptoms of cerebral congestion, blood- letting will be manifestly proper. As this spas- modic form of the disease may possibly originate in an enlargement of the cervical glands, particular attention should be directed to this cause; and should the affection appear to originate in this way, leeches, followed by iodine internally and externally to the part affected, will be proper. Great care is necessary that the child be not suddenly frightened or alarmed, as mental emo- tion often brings on a paroxysm. The tepid salt water bath, with a pure, dry, fresh atmosphere, are highly useful in the way of prevention as well as of cure.] 54. C. Treatment of complicated and con- secutive Croup.—The treatment of the various complications of the disease must be directed ac- cording to the general principles now sketched; and with strict reference to the nature of the associated malady, to the period of the primary disease at which it appeared, to the characters of the attendant constitutional disturbance, and of the prevailing epidemic, and to the well-ascer- tained fact that local inflammations supervening in the course of continued or eruptive fevers, although they require depletions, do not admit of them to the same extent as those which occur primarily. 55. «. The association of croup with inflam- mation of the throat, and exudation of lymph in this situation, whether originating in the pharynx, which is rarely the case, or extending thither and to the air-passages from the fauces and tonsils, is one of the most frequent forms in which the disease presents itself, particularly when epidemic or infectious, and is, therefore, deserving of particular notice. But the treat- ment must, in great measure, depend upon the degree in which either sthenic or asthenic in- flammatory action and fever may be considered to exist. Although great increase of vascular action is present at the onset, in the majority of such cases; yet it is often attended by deficient vital power, and exhaustion soon takes place. Even in the most sthenic cases, the treatment which would have been of service at first is soon no longer admissible: whilst in other cases, and in some epidemics, very marked adynamia is manifested from the commencement. Much de- pends on the precision with which the exact nature of the case and the state of vital power are ascertained, and on having early recourse to judicious measures. As to the predominance of either of the states of morbid action alluded to, the frequency and tone of the pulse, the colour of the exudation in the throat, and of the parts sur- rounding it, and the continuance of the disease, are the chief guides. If the inflammation and exudation commence in the tonsils and spread downwards, if the exudation be of a light colour, and the inflamed parts of a lively hue, the pulse being strong, full, and not very quick, depletions, general or local, the use of emetics and nauseants, and the rest of the antiphlogistic treatment, are required; but the further the disease departs from these character, the darker and dirtier the exudations appear, ..more livid and deeper the colour of the infla' - parts, the quicker, soft." , and weaker, tb Jlse, the more should anti- phlogistic measuico be relinquished, unless in some cases to a moderate extent, and at the very commencement of the complaint; and the more ought we to have recourse to camphor, ammonia, the decoction of senega, ammoniacum, &c. 56. b. The nearer the complicated disease, in its local and constitutional manifestations, approaches to the malignant form, the more extreme is the danger, and the greater necessity is there for the exhibition of tonics and stimulants. In such cases, the decoction of senega, the infusion of serpentaria, or mixture of ammoniacum, may be prescribed, with camphor, and any of the compound spirits of ammonia: or the decoction of bark, with liq. amnion, acetatis and tincture of capsicum ; or the sulphate of quinine, with infusion of roses and the aethers ; or either the chlorate of potassa, or the hy- drochlorate or sesqui-carbonate of ammonia, with camphor, musk, myrrh, assafoetida, &c., in suitable vehicles. When the paroxysms of suffocation be- come urgent, senega, preparations of squills, or F 402., may be given in doses sufficient to produce vomiting, and repeated according to circumstances; and active stimulant and antispasmodic clysters be thrown up. The vapour of camphor and warm vinegar may also be employed, and various stimu- lating and aromatic fumigations resorted to. The mouth and throat should be frequently gargled, or washed, by means of a sponge fixed to the end of a piece of whalebone, with a solution of the chloru- rets, or of the bi-borate of soda in camphor mix- ture ; or with a weak solution of nitrate of silver,— a scruple to an ounce of distilled water,—as first advised by Mr. Mackenzie ; or with Goulard water, as suggested by Dr. Hamilton ; or with the chloric acid or chlorine in decoction of bark, or other stimulating detergents; and sinapisms or embrocations with Cayenne pepper, or rubefacient liniments (F. 300. et cet.), may be applied on the nape of the neck, or on the lower part of the chest, and on the epigastrium. In the complications oi the disease with angina maligna, observed by Loeffler and Bretonneau, powdered alum was directed by them to be blown into the throat; and various other astringent and antiseptic powders maybe employed in the same manner. When the characteristic eruption of scarlatina accompanies the affection of the throat and air-passages, the treatment must be directed according to the same principles. In all cases of angina, attended with membranous exudation, whether the attendant constitutional disturbance present sthenic or asthenic characters, the local treatment advised by Mr. Mackenzie should be adopted upon the appearance of the exudation on the tonsils or fauces, and a large blister should be applied early, as being the most efficacious means of preventing the extension of this form of inflammation to the pharynx, air-passages, or (Esophagus. 57. c. The treatment of the complications with aphtha, or with any of the eruptive fevers, will depend, as much as the foregoing, upon the state of vital power characterising the constitutional affection. The appearance of croupal symptoms in the course of small-pox—particularly confluent small-pox—will require nearly the same medicines as have now been recommended (§ 56.) ; and the washes advised to be applied to the mouth and throat will be equally serviceable in the aphthous, as iu the variolous complication. When croup is consequent upon either measles, or hooping cough, vascular depletion is more frequently required than in almost any other complication, excepting CROUP—Remarks on various Remedies employed in. 540 that with inflammation of the throat of a sthenic kind, whether attended by albuminous exudation or not. 58. D. The affections consequent upon croup— or the states of disease which it excites, or into which it passes—require not only appropriate rem- edies, bbt also the application of them with strict reference to the primary malady, and the means by which it was combated. When it runs on to bronchitis, the latter affection commonly assumes the asthenic form, generally terminates fatally, and requires the treatment described in the art. Bronchitis (§ 70. et seq.). Its passage into pneu- monia is attended with similar results ; and deple- tions, unless they have been previously neglected, are not well borne. When diarrhoea or dysen- teric symptoms are produced, in the latter stages, by the means used to remove the disease, we shall generally find the preparations of opium, and the warm bath, as hereafter to be noticed, of much benefit. A considerable number of cases, particularly those complicated with sore throat, terminate in sinking or exhaustion of vital power, and not by suffocation. This circumstance should be kept in view in the treatment of the last stage ; and its earlier indications be met with suitable stimulants and tonics (§ 56.). In cases present- ing imminent suffocation, the question of trache- otomy should be entertained ; but at the same time, with the recollection that either exhausted vital power, the extension of disease to the bronchi, and the accumulation of viscid or concrete exuda- tions in them, or inflammatory action, or emphy- sema of the lungs themselves, may tend, individu- ally or in combination, to prevent the success of the operation, independently of the immediate contingencies to which it is liable. (See § 74.)* 59. Remarks on various Remedies advised, and on the Opinions of Authors respecting them.—a. Nauseants and emetics. In the first stage of the disease, and in the commencement of the second, I have sometimes found that tartar emetic, given so as to produce and prolong a state of nausea, has so completely relieved the croupal symptoms as to prevent altogether the necessity of having recourse to blood-letting : and that in other and more severe cases, the same medicine, ex- hibited so as to produce vomiting, and to continue the nauseating effect for some time afterwards, and thereby to prevent reaction supervening upon the emetic operation, has been followed by a similar result. Emetics have been much recom- mended after blood-letting, and the inhalation of vapour, and when the exudation is presumed to begin to loosen, by Home, Lentin, Darwin, Maercker, Portal, Smith, Hecker, Vieusseux, Rumsey, &c. When the patient has not been visited sufficiently early, this plan is certainly judicious. But when he is seen in the first stage, it will be better to attempt to prevent the forma- tion of the false membrane, by exhibiting nause- ants or emetics instantly, as now advised, and, unless the inflammatory symptoms are very se- vere, before having recourse to blood-letting. This early exhibition of emetics is sanctioned by Crawford, Cheyne, Pinel, Hosack, Thompson, Hufeland, Albers, Schwilque, &c. Dr. Gais- ler prescribes, on the invasion ,pf the disease, tartarised antimony and oxymel of colchicum. Whilst vascular excitement continues, either this combination, or the antimony only, in repeated doses, as suggested by Cheyne and Michaelis., is the best emetic ; hut when we wish to detach the membranous exudation, the preparations of squiils, alone, or with ipecacuanha, are preferable. In the more spasmodic form of the disease, ipecacu- anha, as Gof.lis remarks, is as suitable an emetic as can be adopted: but when it is found neces- sary to exhibit such a medicine in the last stage of the disease, or when it is associated with an- gina maligna, or attended by symptoms of de- pressed vital power, senega, squills, or the sulphate of zinc, given with stimulants and antispasmodics, or F. 402., or the sulphate of copper (Encyclog. t. xxii. E. p. 10.), are to be preferred. Goelis recommends emetics in the first stage of the least inflammatory forms, and generally in the third stage ; but he prohibits them in the second or in- flammatory stage, and when suffocation is threat- ened towards the close of the disease. When, however, potassio-tartrate of antimony is em- ployed, and nausea is kept up in the intervals between the emetic operation, as I have recom- mended above, bleeding being also employed, the reaction dreaded by this experienced writer will not come on. His objections to an emetic in the paroxysms of suffocation occurring towards the close of the malady may be well founded, were antimony or even ipecacuanha to be then pre- scribed ; but, when zinc, squills, and senega, are conjoined with stimulants and antispasmodics, and their operation accelerated by irritating the pharynx, I have seen the air-passages thereby freed from the substances obstructing them, and the patient saved. 60. /?. Bleeding, general or local, or both, although indispensably requisite in the great ma- jority of cases, is not always of service. Rumsey and Huggins- remarked its injurious effects in the complicated cases they treated ; and the more nearly the disease approaches to the spasmodic, and the febrile symptoms to the adynamic char- acter, particularly in the complications, the more likely is it to be of little benefit, or even injurious. * I may here adduce a summary of the practice adopted by the most experienced physician in France in this dis- ease—the senior physician to the Hospital for Children in Paris. It will be seen how closely it agrees with my own, in a similar institution in London: — M. J adelot considers croup as a kind of angina of the air-passage: presenting more violent symptoms, and having true paroxysms, separated by well-marked inter- missions of a special character. He admits different degrees of the disease, without changing its nature. Bleeding by leeches, and emetics, are the agents he most frequently employs in its treatment. Emetics alone have often sufficed to stop the disease, especially in weak, pale, or bloated subjects ; but, in opposite cases, he insists on the application of leeches, and allows the blood to flow until the child becomes pale, and the pulse loses its strength. After the bleeding, he causes vomiting, several times in succession, at intervals of two or three hours ; and the practice is attended by the greatest success, re- lief being very apparent after each vomit. When the croup has arrived at the second period, with- out having been opposed, and the presence of a false membrane is suspected, M. J. directs leeches to be ap- plied ; but, the moment they fall off, he hastens to pro- duce vomiting: and it is in this case that he employs, by spoonsful, every ten minutes or quarter of an hour, the mixture called anticroupal*, until full vomiting is pro- duced. He insists, also, upon the use of errhines, and of derivatives applied to the skin and intestinal canal. When the disease is very rapid, it has been a question whether or not we should commence by bleeding, or by an emetic. M. J.’s opinion is, that we should first bleed, if the child be robust, and if it present signs of congestion towards the superior parts ; on the contrary, he would commence by vomiting, when the subject is pale and ex- hausted, and there is little heat or fever. (Ratier’s Medical Guide, 34.— Schaffer, in Ibid. July, 1811, p. 155. ; et in Hufeland's Journ. d. Pr. Heilk. Nov. 1810, p. 80.— Double, Traite du Croup, Svo. Paris, 1801.—Chaussier, in Journ. de M6d. Contin. May, 1811, p. 74., et Dec. p. 455.— Leeson, in Med. and Phys. Journ. Nov. 1801.— Wainwright, in Ibid. April, 1800.— W'dlan, Reports on Dis. of London. Lond. 1801, 8vo.— Latour, Manuel sur le Croup. Paris, 8vo—Chamerlat, Journ. de Med. &c. t. xx vii.—Royer-Collard, in Diction, des Sciences Med. t. vii. p. 412.—Chevalier, in Transac. of Med.-Chirurg. Soc. vol. vi. p. 151.—Mercicr, in Journ. Univers. des Sc. Med. &c. t. xiv. p. 225.—J. A. Albers, Comment, de Trachei- tide Infantum, &c. 4to. Lips. 1816. (Obtained the prize given by Napoleon.)—L. A.Goclis, Tract, de Rite Cogno- scenda et Sananda Angina Membranacea, Svo. Vien. 1813.—Grimaud, in Journ. Complem. des Diet, des Scien. Med. Jan. 1822.—Author, in Lond. Med. Repository, vol. xix. p. 46.—Schmidt, Journ. des Progres des Scien. Med. t. ix. p. 244.— Lobstein, in Memoir, de la Soc. Med. d’Emulation, t. viii. p. 500.—Louis, Memoires Anatomico- Pathologiques, Svo. Paris, 1826, p. 203.: et in Archives Gener. de Med. t. iv. p. 5. et 369. (In the adult.)—Red- delin, in Philadelph. Journ. of Med. Science, vol. v. p. 201. (Snuff in.)—Hoffmann, in Ibid. vol. vi. p. 409. (Sulph. cupri.)—Valentin and IVigard, in Lond. Med. Repos, vol. i. p. 122. 285. 48.—Serf, in Ibid. vol. iv. p. 143. 464. (Potassce sulphur.)—Schmidtmann, Observ. Med. vol. ii. p. 24.—Editor of Quarterly Journ. of For. Med. vol. v. p. 618.—./. B. Lacroix, D’Une Epidemic de Croup, &c. 8vo. Paris, 1822.; et in Nouv. Journ. de Med. t. xiv. p. 176. Godman, in Journ. de Progres des Scien M6d. t. xiv. p. 340.—Bland. Nouv. Rech. sur la Laryngo-Trach6ite, &c. 8vo. Paris, 1823; et in Nouv. Biblioth. M£d. t. iv. p. 40.—Hillard, in Archives Gener. de M6d. t. xii. p. 544., et t. xx. p. 491.—Ouvrard, in Ibid. t. xii. p .631.—i.Epidemic.) —Guersent, in Ibid. t. xvii. p. 493.—Bretonneau, in Ibid, t. xiii. p. 5, el t xxiii. p. 387. 519. (Comp, with ang. pha- ryngea.)—Villeneuve, in Ibid. t. xviii. p. 308. (With ang. pharyng.)—Horteloup, in Ibid. t. xviii. p. 57.— Bourgeois, inlbd. t. xix. p. 134.—(Comp, with ang. fauc.) Giraudet, in Ibid. p. 586.— Trousseau, in Ibid. t. xxi. p. 541. (Comp, with Scarlatina.)—Emangard, Amer. Journ. of Med. Sciences, vol. vi. p. 181.— Vanderburgh and Godman, in Ibid. vol. ii. p. 480.—S. Jackson, in Ibid, vol. iv. p. 361.—Hosack,, On Croup, in Essays on var. Subjects of Med. Science, vol. ii. p. 133. N. Y. 1824. 8vo. —Ballard, in Journ. Hebdom. t. iii. p. 113.—Deslandes, in lourn. des Progres des Scien Med. t. i. p. 152.—Monro- »lal et Lavie z, in Rev. Mtld. t. ii. 1825, p. lit .—Macken- zie, in Edin. Med. and Surg. Journ. voi. xxiii. p. 294.— Robertson, in Ibid. vol. xxv. p. 279.—Pretty and Sym, in Med. and Physical Journ. for Jan. 1826.—G. Gregory, in Ibid. Oct. 1825.—J. Hamilton, Edin. Journ. of Med. Sci- ences for October, 1826.—Matins, De Cynanche Trache- alia, 8vo. Edin. 1830.—Guersent, in Diet, de Medecine, t. vi. p. 211.—H. M. J. Desruelles, TraittS Theoriq. et Pra- tique du Croup, &c. 8vo. Paris, 1821.—T. Guibert, Re- cherches Nouvelles sur la Croup, et sur la Coqueluche, &c. 8vo. Paris, 1824.—P. Bretonneau, eur la Diphthfi- rite. on Inflam. Pelliculaire connue sous le Nom de Croup d’Angine Maligne. &c. 8vo. Paris, 1826.— W. H. Porter, On the Surgical Pathol, of the Larynx and Tra- chea, with relation to the Operation of Bronchotomy, &c. 8vo. Dublin, 1820.—Kimbell, in Lancet, vol. xvii. p. 160.—Bricheteau, Precis Anal, du Croup, et de l’Angine Couenneuse, &e., et Rap. sur les M&moir. env. au Con- cours sur le Croup, &c., par Royer- Co'lard, &c. 8vo. Paris, 1826.—Jurine, in Rapport du Royer Collard, in Ibid. Mills, On the Morbid Appear, of the Trachea, &c. 8vo. Dub. 1829.— Wood, in Transac. of Med. and Chirurg. Society, vol. xvii. p. 169.—Bow, in Brit, and For. Med. Rev. vol. iv. p. 243.— Hatin, in Ibid. vol. vi. p. 530. (Archer, John, On the Use of the Radix Sendee (Poly- gala Seneka. Linn.) in the Cure of Croup, N. Y. Med. Repository, vol. ii. p. 24.—,7. Archer, An Inaugural Dis- sertation on Cynanche Trachealis, commonly called Croup or Hive3, Phil., 1798, 8vo., p. 46.—J. V. Brower, A case of croup, wiUi remarks, &c., N. Y. Med. Reposit., vol. xii., p. 247.—J. C. Bliss, A case of croup, in an adult, in which tracheotomy was performed, Ibid., New Series, vol. ii., p. 377. —C. Rokitansky, A Treatise on Patho- logical Anatomy, Part I., translated from the German by John C.Peters, N.Y.,8vo., p. 164— Samuel Bard, Inquiries into the Nature, &c., of Ang. SufFoe., 1771, N. Y. J.D. Hunter, N. Y. Med. and Surg. Journ., vol. i., p. 311.— B. Beck, N. Y. Med. and Phys. Jour. vol. i.—David Hosack, Lectures on the Practice of Physic, N. York, 8vo., p. 514.—S. Bard, Med. and Phys. Journ. vol. iii., p 5g.—jg. Rush, Med. Inquiries and Observations, vol. ii., p. 376.—John W. Francis, N. Y. Med. and Phys. Journ., vol. iii., p. 56.—James Jackson, N. Eng. Journ., vol. i., p. 385.—Dick, Supplement to Dr. Burton’s Med. and Phys. Journ., May, 1809, p. 242.—Dewees, Stewart, Condie, Eberle, On Children.—Chapman, On Croup, Phil. Journ. Med. Sci., vol. i., p. 308.—John Stearns, Coxe’s Med. Museum, vol. v., p. 185 —Billard, (Stewart’s Trans- lation), p. 427.—S. D. Townsend, Case of Croup cured by calomel and Dover’s powder, with a blister to the throat, Boston Med. and Surg. Jour. 1831.—J. Stearns, A Dissertation on Cynanche Trachealis, or Croup, Am. Med. and Phil. Register, vol. iii., p. 257.—Riellet and Barthez, On Diseases of Children, art. Croup, 1844.— C. J. B. Williams, A Practical Treatise on the Diseases of the Respiratory Organs, including Diseases of the Larynx, Trachea, Lungs, and Pleura, with notes by M. Clyiner, M. D., Phil., 1845.—Ryland, On the Larynx, 1843.J CYANOSIS. See Blue Disease. CYNANTHE MALIGNA. See Scarlet Fe- ver ; and Pharynx, Inflammations of CYNANCHE PAROTIDiEA. See Parotid, Inflammation of. CYNANCHE PHARYNGEA. See Pharynx, Inflammations of. CYNANCHE TONSILLARIS. See Tonsils, Inflammations of. CYNANCHE TRACHEALIS. See Croup. CYSTITIS. See Urinary Bladder, Inflamma- tions of. DEAFNESS. See Ear. Diseases of; and Hearing, Disorders of. DEBILITY.—Syn. Adynamia, Asthenia, Ato- DEBILITY—Divisions of. nia, Debilitas, Lat. Die Schwasche, Schwasch- heit, Ger. Debilite, Asthinie,Fr. Debolezza, Ital. Vital Depression, Diminished Vital Power or Energy. Classif.—General Patholoy ; Pathogeny. —Special Pathology. I. Class. 1. Defjn.—That departure from the healthy condition of the frame, which consists of a di- minution of its vital energies—of an enfeebling of its powers, manifested in numerous conditions and grades throughout the whole frame, or more or less remarkably in particular systems or or- gans. 2. Debility is a state of vital manifestation in- timately connected with the nature of disease ; and in whatever acceptation it has been under- stood, it has been admitted by every physician who has looked beyond the grosser and more pal- pable changes superinduced in the economy, as not only a most important pathological condition, but as often constituting what is, in the common language of medicine, disease itself. It often performs a principal part in the commencement, and towards the close, of the most severe mala- dies ; and its modifications are amongst the most difficult in pathology to detect and to interpret aright. Several of the appellations it has re- ceived have been more or less restricted to certain of its conditions ;■ as adynamia, to want of mus- cular or animal power; atonia, to deficient vital tension and tone of circulating and exhaling ves- sels ; asthenia, to depressed energy of organs essentially vital, &c.; but as the distinctions be- tween them have never been made with suffi- cient precision, aud have seldom been preserved, and as they have all been used synonymously by the best modern writers, they will be thus received at this place. 3. It might appear interesting to ascertain the varieties and grades of debility ; but this is a matter of no easy accomplishment, if not entirely beyond the reach of our powers. Debility is, besides, a relative term; and of its extent or de- gree of departure from that condition of vital power requisite to the perfect performance and continuance of the functions, we can form no very precise idea, even were we agreed upon the standard of power by which the comparison should be made. Of its numerous grades and manifestations, from the slightest departure from health to the utmost consistent with existence, there can be no question; and therefore they cannot be otherwise than arbitrarily appreciated. This will appear obvious to any one who wifi refer to the numerous varieties into which Vogel and Sauvages have divided asthenia. 4. Divisions of.—It will be preferable, there- fore, to consider debility in respect merely of its principal conditions relatively to the operation of the chief causes which induce it; and in order to elucidate its morbid relations, and its influence in producing and perpetuating further disease, to enquire into its manifestations and effects on the various general systems and organs of the body. The majority of pathological writers have found great difficulty in considering this subject, and scarcely any two have agreed as to the manner of discussing it, or as to its nature. Some have viewed it as the negative of excitation, or a mi- nor degree of that state of excitement induced in the system by the agents surrounding and acting upon it,—by privation, or change of the factors of life (Hartmann). This opinion, which may 547 DEBILITY—Conditions of. be traced to the Strictum and Laxum of Tiiemi- son ; but which was first insisted on, in a manner at all accordant with the doctrine of solidism, by Brown, and variously modified and illustrated by his contemporaries and followers; led to the division of this grand pathological state into two forms,—direct and indirect debility. This divi- sion was adopted by Darwin ; and Rush fol- lowed the same track, denominating the former debility from abstraction, the latter debility from action. Rasori and Tommasini hardly even modified the doctrine of Brown, when they di- vided it into primary and secondary; the former arising from contra-stimulating, the latter from stimulating, impressions. Broussais followed a similar arrangement, but considered that it is primary in very few instances, and only from the abstraction of stimuli. The simplicity of these divisions is their chief recommendation ; but it is carried so far as to be inconsistent with the com- plexity of those derangements to which the hu- man frame is subject. This feeling seems to have induced Boisskau to impute it to three sources : 1. To a complete or prolonged abstrac- tion of the accustomed stimulus; 2. A diminu- tion of the reciprocal stimulating influence of the organs; and 3. To the inordinate excita- tion of a part, rendering the others incapable of acting with energy. M. Bracket, adopting sim- ilar views to my own, but several years after mine were published, both in the London Medi- cal Repository, and in my Physiological Notes, refers debility either to diminution of the action of the cerebro-spinal system, enfeebling the func- tions over which it presides, or to depression of the functions dependent upon the influence of the organic or ganglial nerves ; the weakness of the nervous system arising, as he thinks, either from deleterious states of the blood, or diminution of its quantity. Hufeland divides it into true, and apparent or false ; the one from change of the nervous sensibility, the other from oppression of the vital powers. Dr. Geddings, the most recent writer on the subject, considers debility, 1st, as direct, when arising from the abstraction of stimuli, or the operation of contra-stimuli, or such substances as “ directly enfeeble the organ- isation ;” 2dly, as indirect, or that resulting from exhaustion, and “ from deterioration of the nutritive molecules of the blood;” and, 3dly, as metastatic, or that form proceeding from inordi- nate irritation of one organ leaving the others in a minor state of excitation. [Dr. Hodge, of Philadelphia, (Am. Journ. Med. Sciences, vol. x., p. 92.), has attempted to make a distinction be- tween “ sedation ” and debility ; understanding by the former, morbid depression, the phenomena of life being depressed below their healthy standard; and by the latter, a real diminution, or loss of strength. Defining vital strength or power, to be the capability of resisting injurious causes, or enduring healthy or diseased actions, and excitement, or irritation, to be an increased manifestation of the phenomena of life, or increased action, which may exist with much or little power, he thinks that the strength of power of any tissue should be distinguished from irritation, and that power and action are very different conditions. Hence he thinks it important to distinguish be- tween debility, or the diminution of power, and sedation, or the depression of action: and this distinction he applies to the several parts or tis- sues of the body, as well as the entire organism. This appears to us to be complicating the sub- ject, without throwing any additional light upon it. For all practical purposes, these conditions may be regarded as essentially the same, and re- quiring similar treatment. The causes of seda- tion, moreover, as laid down by Dr. H-, as ab- straction of accustomed stimuli, sedatives, me- chanical causes, irritations, &c., are those which produce debility, according to his own definition of this term. (See loc. cit.)] It is impossible to examine the conditions of debility with any de- gree of precision abstractedly from their principal causes. I shall, therefore, with due regard to this connection, consider, 1st, The primary or direct states of debility ; 2dly, Its consecutive oi secondary conditions; and, 3dly, Those forms, consisting not only of depressed, but of otherwise morbid or vitiated, vital manifestation—or com- plicated debility. After having discussed these topics, with reference to general debility, the more special or partial states of debility, and its consequences, will be brought into view ; and the subject pursued in its relation to general and spe- cial pathology. 5. I. Conditions of Debility.—i. Prijiary Debility (Direct, Brown; True, Hufeland; from Abstraction of Stimuli, Rush and Bois- seau). This state of debility is not so frequent as is commonly supposed, although by no means so rare as Broussais and his followers contend. Many of the cases commonly imputed to it strictly belong to the other conditions specified above (§ 4.). Primary debility may be, (a) Original, or congenital ; and (h) Acquired.—A. The former of these is observed in the children of exhausted, dissipated, or aged parents,—especially the male parent,—and is familiar to every common ob- server. It also presents itself in the infants of those who are of a strumous diathesis, although generally in a slighter grade, and more frequently obscured by concurrent disease of particular or- gans. This form of debility seldom continues long without being followed by some specific mal- ady, which it either remarkably favours, or even more directly produces,—causes, which are in- nocuous as respects infants of originally sound stamina, variously affecting, and ultimately blight- ing the debilitated offspring. 6. B. Acquired debility presents itself to our notice in every stage of life. If it supervene in infancy and childhood, it may be, to a certain extent, perpetuated in the constitution through life. But, in whatever period it may occur, it is most frequently the consequence of the abstrac- tion of stimuli necessary to the excitation and per- petuation of the vital manifestations to a requisite extent.—(a) The infant that is not sufficiently, or is injudiciously, or unnaturally nourished, if it escape any of the maladies to which it is thereby disposed, becomes pale, languid, soft, and en- feebled, or altogether diseased: it wastes; its flesh is flabby ; its growth is impeded ; and it at last is the subject of anaemia, or of tubercles, or of worms, or of disease of the digestive canal, of the mesenteric and other glands, or of the joints and bones. But insufficient or inappropriate nourishment affects all periods of life in nearly a similar manner. A fish diet through life gives rise to a weaker conformation of body than food of a mixed kind. This was proved by Peron in respect of the natives of Van Dieman’s Land. Similar effects follow an exclusively vegetable diet, although not to so manifest a degree. Il DEB ILITY—Primary. 549 should, however, be admitted that those who are obliged to live on one kind of food alone are more liable to experience insufficient sup- plies of it.—(6) The abstraction of the animal warmth is another cause, occasioning a modified, and, as it were, an acute form of debility, fol- lowed by peculiar effects, which are fully de- scribed in the article Cold.—(c) The privation of solar light has a marked influence on the vege- table creation ; plants being pale, sickly, and im- perfectly developed, and their proper juices scant- ily and insufficiently elaborated. An analogous effect is produced by the same cause on the ani- mal creation, and particularly on man—the body becoming pale, sickly, and etiolated ; the senses remarkably acute ; the general sensibility and muscular irritability much heightened ; the or- ganic actions readily influenced by the slightest external agents ;* and the circulating fluids thin, watery, and deficient in albuminous constituents, and red globules, and in quantity. Facts illus- trative of this occurrence are adduced in the article on anaemia, which is thereby produced. (See Blood, Deficiency of, § 41.) The phys- ical and mental debility resulting from confine- ment in dungeons and dark cells is to be attribu- ted to the exclusion of light, restricted diet, want of exercise and of free air, and to moral causes combining with these in depressing the vital powers, and ultimately producing disease of a low and dangerous form.—(d) Intimately con- nected with this cause and its effects is the pri- vation of fresh air and exercise. When muscular action cannot be performed under favourable cir- cumstances, particularly as respects the requisite renewal of air, the circulation languishes, and suffers deterioration; the developement of the locomotive organs is either impeded or pre- vented, and they are no longer in a fit state for the execution of the acts of volition. By a want, also, of a requisite renewal of air, the stimulating constituent of it becomes diminished, and re- placed by directly sedative gases, and by vapours loaded with the effluvia of the system that respires it, or of those which may respire it in the same place ; the extent of the stagnation or confine- ment of air, and of the causes of deterioration, proportionately heightening and accelerating the depressing effects thereby produced upon the frame.—(e) It is extremely probable, that what- ever, in its passage through the digestive canal, or circulation through the body, abstracts oxygen from the system, will be also, to a certain extent, a cause of debility, as supposed by Humboldt. The causes of scurvy may be partly of this de- scription ; as well as those of several other dis- eases.—(/) A not uncommon cause of depressed vital power is the young sleeping with the aged. This fact, however explained, has been long remarked, and is well known to every un- prejudiced observer. But it has been most un- accountably overlooked in medicine. I have, on several occasions, met with the counterpart of the following case:—I was, a few years since, consulted about a pale, sickly, and thin boy of about five or six years of age. He ap- peared to have no specific ailment; but there was a slow and remarkable decline of flesh and strength, and of the energy of all the functions —what his mother very aptly termed a gradual blight. After enquiry into the history of the case, it came out that he had been a very robust and plethoric child up to his third year, when his grandmother, a very aged person, took him to sleep with her; that he soon afterwards lost his good looks ; and that he had continued to decline progressively ever since, notwithstanding medical treatment. I directed him to sleep apart from his aged parent; and prescribed gentle tonics, change of air, &c. The recovery was rapid. But it is not in children only that debility is induced by this mode of abstracting vita! power. Young females married to very old men suffer in a similar manner, although seldom to so great an extent ; and instances have come to my knowledge where they have suspected the cause of their debilitated state. These facts are often well known to the aged themselves, who consider the indulgence favourable to longevity, and thereby often illustrate the selfishness which, in some persons, increases with their years.—(g) It is extremely possible that whatever conducts the electricity of the body from it will occasion direct * The remarkable and authentic history of Casper Hacser, by the President Von Feherbuch, furnishes striking illustrations of the above. The accounts which have been recently published of this person should be attentively perused by every pathologist and philoso- pher, as being most singular and instructive. Casper Hauser was kept, from infancy until he was eighteen years of age, in a perfectly dark cage, without leaving it; and where he neither saw a living creature, nor heard the voice of man. He was restricted from using his limbs, his voice, his hands, or senses; and his food consisted of bread and water only, which he found placed by him when wakening from sleep. When ex- posed in Nuremberg, in 1828, he was consequently, at eighteen years, as if just come into the world; and as incapable of walking, discerning objects, or conveying his impressions, as a newly born infant. These faculties he, however, soon acquired; and he was placed under an able instructor, who has recorded his history. Dark- ness had been to him twilight. The light of day at first was insupportable, inflamed his eyes, and brought on spasms. Substances, the odour of which could not be jierceived by others, produced severe effects in him. The smell of a glass of wine, even at a distance, occasion- ed headache ; of fresh meat, sickness, &c.; and of flow- ers, painful sensations. Passing by a churchyard with Dr. Daumer, the smell of the dead bodifes, although alto- gether imperceptible to Dr. D., affected him so powerfully as to occasion shudderings, followed by a feverish heat, terminating in a violent perspiration. He retained a great aversion, owing to their disagreeable taste and smell, to all kinds of food excepting bread and water. When the north pole of a small magnet was held to- wards him, he described a drawing sensation proceeding outwards from the epigastrium, and as if a current of air went from him. The south pole affected him less; and he said it blew upon him. Professors Daumer and Herrmann made several experiments of this kind, and calculated to deceive him; and, even although the mag- net was held at a considerable distance from him, his feelings always told him very correctly. These experi- ments always occasioned perspiration, and a feeling of indisposition. He could detect metals placed under oil- cloths, paper, &c., by the sensations they occasioned. He described these sensations as a drawing, accompanied with a chill, which ascended, according to the metal, more or less up the arm; and were attended with other distinctive feelings, the veins of the hand exposed to the metal becoming visibly swollen. The variety and multi- tude of objects which at once came rushing upon his attention when he thus suddenly came into existence —the unaccustomed impressions of light, free air, and of sense—and his anxiety to comprehend them—were too much for his weak frame and acute senses; he be- came dejected and enfeebled, and his nervous system morbidly elevated. He was subject to spasms and tre- mors ; so that a partial exclusion from external excite- ments became for a time requisite. After he had learned regularly to eat meat, his mental activity was dimin- ished : his eyes lost their brilliancy and expression ; the intense application and activity of his mind gave way to absence and indifference ; and the quickness of ap- prehension became diminished. Whether this change proceeded from the change of diet, or from the painful excess of excitement which preceded it, may be ques- tioned. My limits admit not of my adding more. The whole account is most important—the more so, as the physiological facts stated in it may be relied on. 550 DEBILITY—Consecutive. debility. With this view I have long been in the habit of causing females who used steel sup- ports to their stays to lay them altogether aside. The experiments on Casper Hauser confirm this supposition. [That electricity is rapidly drawn from the body, is proved by the simple experi- ment of placing the finger, moistened, upon one of the metallic parts of the armature of an elec- tro-magnetic apparatus, the number of revolu- tions of the machine being instantly increased, and in many instances apparently doubled. This shows that the amount of the electric fluid de- veloped in the system approximates to that gen- erated by a machine of sufficient power for all medical electro-magnetic purposes.]—(h) Inti- mately related to the causes consisting of ab- straction of requisite stimuli, and to the effects resulting therefrom, seem to be the privation of those excitants to which the frame has been long habituated ; although these, as well as their effects, may be considered as falling more strictly under a different section of this subject. The privation, by whatever cause, of those states of electrical tension which exist in healthy conditions of the body, and fright, or prolonged fear, may also oc- casion primary debility. 7. C. But the vital power is enfeebled by another class of causes — by agents which seem directly to depress it below its healthy standard. These agents have been called contra-stimulants by the Italian physicians of the school of Rasori.—(a) Several of those, however, when employed in sufficiently small quantities, actually excite the parts to which they are applied; and it is only when they are used in large doses that an oppo- site effect—violent depression and even annihi- lation of life—is produced. A minute quantity of prussic acid, or of tobacco, excites the organic functions ; a large quantity instantly destroys life: and the remark applies, to a certain extent, to nearly all the more energetic narcotics; although many of them, as well as several other agents, whilst they depress the vital manifestations gener- ally, also excite or irritate particular organs or tissues. Tartar emetic, acetate of lead, oxalic acid, colchicum, stramonium, belladonna, &c., furnish illustrations of this fact.—(b) The primary effects of terrestrial effluvia or malaria, and of the infectious emanations proceeding from the diseased, as from those affected by plague, yellow fever, typhus, and pestilential cholera, are evidently most acutely debilitating, even although these causes may also, and at the same time, act by irritating certain organs or tissues. — (c) Various mental emotions are also very powerful depriments of vital power, such as fear, anxiety, grief, longings after objects of affection, nostalgia, &c., particularly if they be of long continuance: they retard all the organic func- tions, and at last wither the whole organisation. —(ri) Whatever impedes respiration, owing to the effects of this function upon the circulation, and on the blood itself, and consecutively upon the organic and cerebro-spinal nervous systems, also depresses the vital power in a very remark- able manner. Among the causes of primary debility, Dr. Geddings has included anaemia. There can be no doubt of the existence of de- bility, when the blood is deficient or impure ; but, instead of being the cause, anaemia is the effect of debility.* 8. ii. Consecutive or Secondary Debiliti may arise in two ways: (a) from increased ex- citation of an organ, occasioning proportionate diminution of the energy of others—sympathetic debility, or debility from an irregular distribution of the vital endowment; and (b) from the exhaus- tion occasioned by previous excitement.—A. Sym- pathetic Debility (Debilitas Spuria, Hufeland ; Metastatic Debility, Dr. Geddings.) When it is considered that the organic or ganglial nerves alone supply the blood-vessels, and the secreting organs and surfaces; that they communicate very freely with each other, and with their chief centre, the semilunar ganglion; that they are formed into numerous plexuses, rendering thereby the con- nection between them still more close; and that they are intimatety related to the cerebro-spinal system, through the medium of communicating nerves ; the mutual dependence of action between the various organs of the body may be easily explained. If, moreover, it be granted, as I have endeavoured to prove in another work, that the most important vital phenomena,—as digestion, assimilation, circulation, secretion, ani- mal heat, generation, &c. — in short, that life itself, with all those manifestations of it now par- ticularised, and which have usually been called organic—result from the influence exerted by the ganglial nervous system, through the instru- mentality of the vessels and structures upon the circulating fluid they contain, and reciprocally by this fluid upon the nerves ramified in the parietes of the vessels, and upon the ganglia themselves, through which it must necessarily circulate,—the agency of this system in the pro- duction of the numerous phenomena of debility must be evident. From this view of the subject, and taking into account the various functions of dissimilar textures, and, under certain circum- stances, the combined influence and reaction of the cerebro-spinal system and sensorium, the numerous relations of disordered actions, as re- spects the manifestations not merely of debility, but of disease generally, may be more satisfactorily traced. 9. When one organ or general system is simply excited, without being otherwise diseased, the functions of other organs, with which it is more or less intimately related by means of the ganglial nerves, undergo a relative degree of change ; for as we exalt the vital manifestations in one or more parts of the series, we diminish them in equal pro- portion throughout the remainder. These views were first stated in the London Medical Repository, for May, 1822, and fully illustrated in my Phys- iological Notes, published in 1824; and have since been adopted by Boisseau and Geddings. A due application of them is of the utmost im- portance in pathology and therapeutics, as well as in ascertaining a large proportion of the forms of debility, particularly those presented to us in the course of many acute and chronic diseases; thus irritation of the mucous surface of the stom- ach or bowels enfeebles the rest of the frame; and inordinate excitation of any other secreting organ diminishes the nutritive and animal func- tions in an equal degree, and so on as respects often the result of scanty or poor food, especially that which contains little animal matter or gluten, and also of excessive loss of blood, as well as profuse evacuations of other fluids which contain much of the animal parts of the blood; and though these are the primary, the vitiation and impoverishment of the blood are the exciting causes of that state of the system.] f* That anwmia, however, is often indirectly the cause of debility, is very evident when we consider that it is various other viscera and structures, as more fully explained when describing the states of vital energy connected with the nature of disease. (See art. Disease.) 10. B. The Debility of Exhaustion, or from exitement of a part, or of the body generally (In- direct Debility, of Brown).—This form of debility arises from all agents, mental or physical, which excite the actions of a part, or of the system, above its normal state. Many of these causes act with great rapidity and intensity, others very slowly and insidiously; and whilst some simply change the grade of vital action, others seem to alter it in kind. Their effects vary remarkably with the sus- ceptibility of the organ and constitution on which they act, and the frequency of their repetition ; each successive application being generally less efficient than the preceding, if it be delayed until the ac- tion of the previous one has terminated. The circumstance of stimuli being productive of ex- haustion, or indirect depression of vital power, to as great extent below the standard of health, as the previous excitement rises above it, as fully shown by Brown, Darwin, and Rush ; and that stimuli must be repeated in larger quantity to produce the same effects, although presenting certain exceptions, are important facts as respects this pathological condition in particular, and disease in general: as long, also, as the repetition of the stimulus follows so quickly and regularly as to an- ticipate the appearance of the consecutive debility, the unavoidable consequences of its abstraction will not appear, at least for a very long time. But they ultimately will supervene in a most severe, and often dangerous, form, when such an event takes place; and if it does not occur soon, the prolonged excitement will ultimately terminate in organic change. Drunkards and opium-eaters often furnish proofs of the latter fact; and persons who indulge in an occasional debauch only, or who undergo great physical or mental exertions, feel the truth of the preceding positions. There is one cause, however, which requires to be particularised on account of its mode of operation and consequences: this is excessive sexual indul- gence. It occasions a loss of vital power through the medium of the discharges, independently of the exhaustion consequent upon the previous nervous excitement. Its depressing effects are, moreover, experienced by all the organs, but es- pecially in the ganglial and cerebro-spinal nervous systems; and are often followed by the most serious results in both male and female. 11. iii. Complicated Debility. — I have con- tended, in the article Disease, that the vital manifestations of an organ, or of the frame gener- ally, may be modified, not only in grade, but also in kind. If this be admitted, it follows that de- bility, originating in either of the ways now shown, may be either simple, or associated with an other- wise morbid state of vital action. Upon a review of practical facts, we shall find that the more simple states of debility most frequently occur either primarily—especially from agents abstract- ing vital power—or indirectly, from causes which over-excite the nervous influence, or which ab- stract as well as exhaust vital power; such as the one last adduced (§ 10.). But the condition now under consideration is more generally the result of causes which either irritate in a slow and con- tinued manner some particular tissue or viscus, or modify the sensibility of an organ, or change its secreting or nutritive actions, or even vitiate DEBILITY—Complicated—Special Manifestations and Effects. the condition of the circulating fluids. Whilst the preceding forms of debility are mostly met with in the commencement of diseases, or constitute the early stages of those ailments consisting almost entirely of simple asthenia, but which are often mistaken for structural maladies, this condition is observed chiefly in the progress, or towards the close, of many acute and chronic complaints, some of which are of a specific or malignant character; and it may arise out of either of the foregoing varieties of debility, especially when much pro- longed. That which becomes so remarkable in the course of typhus, or yellow fever, of plague, or of syphilis, cancer, scrofula, &c., consists not of a simple depression or exhaustion of vital power merely; for this power is also specifically modi- fied even from the commencement of these dis- eases ;—the sensibility and organic contractility are changed; the secretions and nutrition are interrupted, or much affected; and although the debility may be the same as to grade in several or all of them at certain of their stages, yet is the vital endowment otherwise modified in each, and in such a manner as to present specific characters whereby they may be severally known and dis- tinguished, without taking the grade of vital mani- festations into the account. It is this form of debility which may be imputed to what has been called, in general terms, by Brera, the evolution of matters injurious to life: and it very often arises from causes, which, by the nature of their impression upon the living frame, not merely de- press, but also otherwise vitiate, the conditions of life in all the systems and organs of the body, as shown by the effects produced by the morbid effluvia of typhus, yellow fever, and other malig- nant diseases. 12. II. The special Manifestations and Ef- fects of Debility.—I have hitherto been con- sidering asthenia in its general conditions; I have now to view it in its specific ox partial states. In doing this, I shall only attempt an imperfect out- line of its relations to the principal general systems and organs of the body, and endeavour to show that one or more of them may manifest this state in a greater degree than the rest, or in a modified form ; and that in this manner much of the varied phenomena of disease may arise ; but that neither of them can experience it to a great extent, or for a long time, without either a similar state of dis- ease extending more generally, or some other morbid condition springing out of it,—conse- quences which must necessarily result from the intimate union of the different organs by the organic nervous and vascular systems, as well as from the mutual dependence of their functions, and the reciprocity of vital influence. 13. i. Debility of the general Systems.—A. The close connection of the organic, or ganglial nervous system with the manifestations of life has been in several places insisted upon; and con- formably with this opinion, and with intimate views of the origin and nature of morbid actions, debility cannot exist in a marked degree without this system being primarily affected. But of the extent of this affection we can form no estimate, excepting from the effects upon the functions of those organs which it influences. I have long considered, and on various occasions endeavoured to show, that the ganglial and the vascular systems, by their resulting and reciprocal actions, are the factors of life; and that the part which the former consequently and necessarily performs in the DEBILITY—Special Manifestations and Effects. 552 causation and removal of morbid phenomena is most immediate and important. If we examine closely the manner in which causes invade the frame, we shall find, a great proportion of those which produce any of the states of vital depression already noticed make their impression in such a manner as to leave no doubt of their action being primarily exerted upon this system, thereby prov- ing its very close connection with life. It is, how- ever, evident that the impression made in this quarter will not remain for any time limited to it; hut will extend in the first instance to those parts which are most intimately associated with it, and dependent upon it for the regular performance of their functions. This a priori inference is actually demonstrated by observation ; for we find the cir- culating, the digestive, and the assimilative func- tions, immediately enfeebled by causes which can operate in no other way, and through no other channel than the nervous system of organic life. Such of those causes as are of an intense kind and are most injurious to life,—which modify while they depress its manifestations,—have their impression rapidly propagated throughout this system, and to the structures and organs which it actuates ; whilst those of a slighter kind, or slower operation, may exert their effects in parts of it only, or chiefly, and more or less partially, in other viscera. Viewing this system, therefore, as that upon which the greater number of causes depressing their vital manifestations first exert their action, and consequently as the point whence the depressing effects proceed, I shall briefly consider these effects in each of the principal functions, organs, and structures. 14. B. The circulating systems and fluids are affected according to the intensity of the depress- ing causes relatively to the energy of the system at the time; and the ultimate results vary with the successive changes that supervene hi it and the associated nervous systems, and secreting and eliminating organs.—(a) In simple debility, the heart's action is languid, or slow' ; but readily ex- cited by stimuli. If the debility be chronic, the parietes of its cavities may ultimately become wasted or thinned, or even softened, and the cavities themselves dilated. In the advanced stages of acute or complicated debility, the heart’s action is generally very quick, soft, weak, small, and unequal or irregular; and in chronic cases, its substance softened, flaccid, or even dilated.— (b) The arterial vessels lose some portion of their tone ; but excepting in as far as they react on the impulse of the heart on the blood, they are not otherwise affected until debility arrives at an advanced stage, or is acute or complicated. When this occurs, arterial action may even become very much increased, particularly as respects the frequency of the pulsation communi- cated by the heart’s contractions, whilst the vital power of the system generally is remarkably depressed. In such cases, the pulsations are broad, open, quick, and very easily compressed ; or they are small, weak, soft, and thready. Acute and complicated debility, thus presenting the ap- parent incongruity of great depression of vital power, with morbidly excited vascular action, is not infrequently observed in the advanced stages of those diseases in which the circulating fluid becomes contaminated by injurious matters in- troduced into it from without, or generated in it, in the manner explained in the article Blood (§ 110—144) In these, although the general manifestations of life are enfeebled to the utmost, yet the action of the heart and arterial system is excited by the irritation produced by the con- taminated blood circulating through them, and the low grade of vitality still existing is thereby soon exhausted.—(c) The manifestations of debility on the blood itself,—in occasioning plethora when the vital depression is so slight as not to diminish digestion and assimilation,—in favour- ing irregular distributions, or determination of blood, in its more chronic states,—in producing anremia, when its grade is still lower, or when it is more prolonged, and the assimilative functions especially affected—and in giving rise to con- tamination of this fluid, when it impedes the secreting, eliminating, or excreting functions,— will be found discussed in that article.— (d) De- bility seldom exists long, or in a marked form, without the venous circulation becoming thereby affected. The depressing agents, indeed, which act most severely upon the frame, give rise to impeded circulation or congestions of blood through the veins as one of their more imme- diate effects upon the economy, as shown in the article Congestion or Blood.—(e) The lymphatic and absorbent vessels even escape not the con- sequences of debility, particularly when it arises from original conformation, or deficient and un- wholesome food. This is shown by scrofulous diseases of the glands, in the mesenteric consump- tion of children, and some states of dropsy. (See Lymphatic System.) 15. ii. Debility of the Functions of associated Organs.—The functions about to be particularised are depressed by, (a) Causes which lower the vital actions of the foregoing systems in a general and severe manner; and (6) by such as operate immediately upon these organs themselves. The former, being more general, and more intense in their operation, are immediately followed by arrest or remarkable disturbance of the functions in question; whilst the latter causes usually, but not always, over-excite and thereby exhaust these functions, and, by the frequency of their repetition rather than by their intensity, produce their effects more slowly and partially. A. The digestive and secreting organs are amongst the first to experience debility, however induced. This may arise from the evident dependence of their functions upon the ganglial system of nerves. But they may be especially affected, and may continue so for some time, without other parts of the frame evincing much disorder, particularly when the debility has been slowly and indirectly produced. The more special manifestations of debility in the stomach, the liver, the duodenum, and bowels, usually begin in this way ; and they have severally obtained, according to the forms they assume, the names of indigestion, torpor of the liver, flatulence, constipation, colic, &c.— these being the more common effects, although several others may be adduced. When debility, either of an acute or chronic form, affects chiefly the digestive organs, the abdominal secretions and excretions are more or less disordered—are usually in smaller quantity and vitiated quality. But this is not the only result; they are generally re- tained on the surfaces and situations where they are secreted, until they undergo various changes, and acquire irritating properties. This is well illustrated by many of the functional diseases of the liver and bowels. (See Caecum, Colon, Con- cretions, Constipation, Liver, Worms, &c.) DEBILITY—Manifestations of. 553 16. B. The respiratory and assimilating func- tions manifest debility in various ways; the res- piratory by frequency, shortness, and quickness of action, and diminution of the changes usually produced upon the blood and air respired; the assimilating function by the thin and watery state of the blood, by the deficiency of its quantity, or of its red particles, as in anaemia, and, in slighter cases, by the milky or oleaginous condition of the serum. When debility is slight or recent, or when it has been gradually induced by stimulating agents, nutrition is not very materially affected ; it may even be partially increased, owing to im- peded or imperfect secretion and assimilation, the consequent abundance of fatty matter in the circulation, and its deposition in the adipose struc- ture, thereby increasing the bulk of the body. But when the vital energies are more remarkably depressed, either in acute, chronic, or complicated cases, the nutrition of all the structures and organs, particularly of adipose, cellular, and muscular parts, is more or less arrested. 17. C. The vital manifestations of the cerebro- spinal nervous system, and organs of sense, may be remarkably enfeebled, without the rest of the frame being materially affected: but they may also be uncommonly active, although all the other functions of the body are debilitated. Idiotcy and certain states of insanity are often met with unconnected with any marked depres- sion of the physical powers; and, on the other hand, particularly in chronic debility attended by emaciation and quickened circulation, the powers of mind are frequently very acute. The slightest change in the freedom, activity, or quickness of the circulation in the brain and spinal chord, and in the purity of the blood, will materially affect the character of the phenomena associated with debility of these organs, or of the body generally. As long as the circulation is unimpeded, and the blood sufficiently purified by the emunctories, debility will be attended by great activity of all the senses, and increased irritability of all the muscles. Hence arise various of its forms, fa- miliar to every observer of disease,—that with increased sensibility (the Debilitas ad Sensum of some writers), and that with augmented irrita- bility (the Irritable Debility of Hufeland and other German authors,—the “ Mobility” of Dr. Cullen) ; both which forms constitute increased susceptibility, or excitability, of the cerebro-spinal system, and of the organs they influence. When, however, retarded circulation occurs in this sys- tem, or if the blood itself be rendered inappro- priate to its state and functions, by the super- abundance of unassimilated materials, or if it be insufficiently purified by the emunctories, debility, whether thus limited or universal, will be attended by a proportionate degree of torpor (the Torpid Debility of Hufeland), as well as by adynamia of all the organs dependent upon this system ; instances of which are sufficiently common in many acute diseases. In this way the various manifestations of debility in the mental faculties, the general sensibility, and the mobility of the frame, in different cases and complications of disease, may be explained,—particularly if the various organic changes which so often supervene or become associated with this state of vital power, and with either of the conditions of the cerebral and general circulation now alluded to, bo called into aid. The causes also, the nature of their impression, and their mode of operation, will remarkably modify the state and duration of cerebral asthenia. These are chiefly, (a) Such as act immediately on this system,—as inordinate mental exertions, the depressing passions and emotions, excessive fatigue, and narcotic poisons. (b) Those which act indirectly or mediately,—as the intense or prolonged impression of cold on the surfaces, terrestrial and infectious miasms, the actions of various sedative or contra-stimulant agents, and the abuse of the sexual organs; all which occasion modified or even different effects. The organs of sense, as well as other parts im- mediately controlled by the cerebro-spinal system, have their functions enfeebled and impaired in proportion to the debility it experiences. But they may also be individually affected, and in various degrees, without this system being mate- rially disordered. Such occurrences generally arise from the operation of local causes,—as over- excitement of the organ, and exhaustion of its sensibility by its peculiar stimuli; as weakness or loss of sight from over-exertion, or the intense or prolonged action of light; and loss of hearing from great noises, &c. 18. D. The muscular structures, from their connection with the ganglial and cerebro-spinal systems, necessarily experience the effects of de- pression of the energies of these systems, varying, according to its acute and chronic form, its degree, its simple or complicated state, and the progress it has made. But debility seldom originates in, or is limited to, these structures. Its earliest and simplest manifestations in them are diminished tone, flaccidity, wasting, particularly of voluntary muscles; lowered, or in some cases, morbidly increased irritability, according as the nervous systems experience a diminution or increase of their susceptibility () The recurrence of the 561 * [According to Muller, there are three acts in deglu- tition: in the first, the parts of the food collected to a mass, glide between the surface of the tongue and the palatine arch till they have passed the anterior arch ot the fauces; in the second act, the food is carried past the constrictors of the pharynx; and in the third, it reaches the stomach through the oesophagus. These three acts tollow each other with extreme rapidity; the first is per- formed voluntarily by the muscles of the tongue, under the influence of the hypoglossal and glosso-pharyngeal nerves. The second also is effected with the aid of muscles which are in part endued with voluntary mo- tion, such as the superior and inferior muscles of the soft palate; but it is, nevertheless, an involuntary act, for it takes place without our being able to prevent it, as soon as a morsel of food, drink, or saliva is carried back- wards to a certain point of the tongue’s surface. The third act is executed independently of the will, by mus- cles, of which the contractions are always involuntary. According to Marshall Hall, the second and third acts of deglutition are always excited, or reflex movements; and when they seem to be performed voluntarily, although there is no food to swallow, saliva constitute! the neces- sary stimulus. According to Dr. Reid, (Ed. Med. and Surg. Journal, vol. li. p. 273), the nerves which convey to the medulla oblongata the impression which excites the movements of deglutition, are the glosso-pharyngeal, those branches of the 5th that are distributed to the fauces, and probably those branches of the superior laryn- geal nerve which reach the pharynx; while the motor influence transmitted from the medulla is conveyed by the pharyngeal branches of the vagus ; by tlje branches of the hypoglossal nerve, distributed to the tongue, thy- ro-hyoid, sterno-hyoid, and sterno thyroid muscles ; by the motor filaments of the recurrents ramifying in the muscles of the larynx ; by some branches of the 5th sup- plying the elevator muscles of the lower jaw; by the branches of the portio dura which ramify in the digastric and stylo-hoid muscles and muscles of the lower part of the face ; and probably by some branches of the cervical plexus which unite with the descendens noni; all the muscles supplied by the nerves here enumerated being engaged in the function of deglutition.) 562 affection will be prevented by the internal use of vegetable bitters and tonics, with the alkaline carbonates ; by narcotics or antispasmodics com- bined with ipecacuanha ; and by a free action kept up for some time on the lower bowels, by means of the resinous or other purgatives con- joined with vegetable bitters, and promoted by clysters. The other means, mentioned hereafter (§ 16,) will also prove useful adjuvants. II. Symptomatic and complicated Dysphagy. Classif.—General Pathology ; Therapeu- tics, &c. 5. Difficult or obstructed deglutition is an occa- sional or constant attendant upon a variety of functional disorders, and of organic changes. 1st. It is often symptomatic of hysterical, hypochon- driacal, flatulent, and asthmatic affections. 2d. It is constantly attendant upon tetanus and rabidity. 3d. It is sometimes produced by organic change seated in parts about the base of the brain or cra- nium, the medulla oblongata, or upper part of the spinal chord. In all these symptomatic states, the parts immediately concerned in the function of deglutition are seldom, and not necessarily, affected organically: but in the following there always exists either inflammatory action, or its consequences, or some structural change, in the parts by which food is conveyed into the stomach, or in their immediate vicinity. The preceding may be called symptomatic forms of dysphagy ; those which are to follow, complicated states of this affection. Under this latter may be ar- ranged, 1st, Dysphagy from congenital malfor- mations; 2dly, From inflammation or structural lesions of the mouth, tongue, fauces, pharynx, or tonsils; 3dly, From diseases of the epiglottis or larynx ; 4thly, From inflammations or structural lesions of the oesophagus, or of the cardiac orifice of the stomach ; 5thiy, From tumours pressing upon the pharynx or on the oesophagus. On each of these I shall add but few remarks. 6. i. Symptomatic or Sympathetic Dys- phagy.—A. of spasmodic or flatulent diseases. Difficulty of swallowing occasioned by hysteria, hypochondriasis, spasmodic asthma, dyspepsia, and even rabidity, is in a great measure to be ascribed to a flatulent distension of a portion of the oesophagus, with spasmodic constriction of other parts of this tube, and disposition to convul- sive or spasmodic action of the muscles of the pharynx, either upon certain occasions of their being excited by the mind, as in hydrophobia, or upon attempts at performing their usual func- tions. In many instances, particularly those connected with asthma, indigestion, or flatulence of the digestive canal, the difficulty is attributa- ble rather to the ascent of flatus in the oeso- phagus, preventing the transmission of food into the stomach, than to spasmodic action of the muscular parts concerned in the process. In these cases, the patient feels much pain, with a sense of distension or pressure under the sternum, and in the course of the oesophagus after swal- lowing. 7. B. Dysphagy may be occasioned by struc- tural lesion about the base of the brain or cervical portion of the spinal chord, or about the base of the cranium. In such cases the paralysis may be more or less complete ; and it may be limited to the muscles of the pharynx and upper part of the oesophagus (Bonet, Portal, Baldinger, and myself,) or it may have extended to them from other parts. Numerous cases illustrating these DEGLUTITION, DIFFICULT—Pathology. positions have been recorded. The participation of the muscles of deglutition in either general or partial paralysis is very commonly observed in apoplexy, &c.; and the occurrence of this form of dysphagy, independently of organic change, or rather from congestion about the base of the brain, is shown by its occasional accession in the advanced stages of fever. Paralysis of the mus- cles concerned in this function may also be pro- duced by wounds of the nerves of the face (Palletti), by lightning (Paterson), and bj( severe cold (Bleuland). It is, however, most frequently caused by the slow developement of tumours, or cysts, or other structural changes about the base of the cranium, whereby either the nerves supplying these muscles are compressed at their origin or in their course, or a portion of the brain or of the upper part of the spinal chord is injured. 8. ii. Complicated Dvasphagy, or difficult deglutition from structural change affecting the parts immediately concerned in this function, comprises a great variety of lesions. I shall merely enumerate them with reference to their seat; their nature, morbid relations, and treat- ment, being fully discussed under more appropriate heads. 9. A. Dysphagy from congenital malformation. —Extreme smallness, or enlargement of the tongue ; the termination of the pharynx, or of the cesophagus, in a cul-de-sac, or obliteration of the (Esophagus ; the division of this part into two canals, and its communication with the trachea ; are the chief malformations which interrupt deglutition ; and are of a very rare occurrence in otherwise well-formed infants. Cases, however, have been recorded by Blaes, Van Cuych, Mi- chel, Billard, Martin, A. Cooper, and An- dral. In these, death, necessarily resulting from inanition, took place in from three to nine days. A slight interruption to deglutition very frequently arises from congenital fissures of the soft and hard palates. 10. D. From diseases of the mouth and throat.— (a) Inflammation or chronic enlargement of the tongue; ranula; sublingual calculus (Guenther) ; and aphthce, ulceration, tumours, and excres- cences about the base of the organ (Reidlin, Van Swieten, Tode, and Inglis) ; are not infre- quent causes of dysphagy. Cases of chronic en- largement of the tongue, impeding deglutition, unconnected with malignant disease, and con- tinuing for many years, are recorded by several writers. I have seen an instance of this kind, that had existed from infancy to nearly middle age. These and other affections, with the treat- ment appropriate to them, are particularly no- ticed in the article upon the Diseases of, and the Indications furnished by, the Tongue.—(b) The fauces and tonsils not uncommonly occasion dys- phagy. Inflammation, suppuration, ulceration, or destruction of the soft palate, or of the uvula ; great relaxation of the latter part; inflammalion, abscess, chronic enlargement, and ulceration, of the tonsils; fungous and other tumours and polypi of the maxillary sinus, or posterior nares ; various tumours or excrescences attached to the palate or tonsils (Schmidt, Thilenius, &c.) ; and the severe effects of mercury, or the sudden arrest of salivation; are generally attended by more or less of dysphagy.—(c) When the pharynx is the seat of inflammation or of its consequences, or of the lesions now enumerated, or of malignant DEGLUTITION, DIFFICULT—Diagnosis—Treatment. 563 disease (Kergaradec, and myself), deglutition is commonly much more impeded than when only the fauces are affected; and in some in- stances it is extremely difficult or nearly impos- sible. In such cases, the epiglottis and larynx are more or less irritated, and, by the conse- quent disorder of the respiratory actions, the dys- phagy is still further increased. Foreign, and particularly pointed or sharp, bodies lodged in the pharynx, are also sometimes causes of dys- phagy. 11. C. Dysphagy from disease of the epiglottis and larynx.—(a) Inflammation, ulceration, and entire destruction of the epiglottis, or induration, incurvation, and the removal of it by wounds, will occasion difficult deglutition, as in the cases recorded by Maynwaring, Schurig, Bonet, Desgranges, Tonanni, and Larrey.—(6) Also inflammation and ulceration of the larynx, ossi- fication of its ligaments, and displacement of the os hyoides, are generally attended by dysphagy. The possibility of the occurrence of this last cause, although observed by Valsalva, and Mol- linelli, has been doubted; but the instance of it noticed by Sir C. Bell (Surg. Observ. p. 160.), and the case wherein it was caused by swallow- ing a large hard substance, recorded by Dr. Mugna (Annali Univers. di Med. Nov. 1328.), put the matter at rest. Fracture of this bone by external violence has produced not only an im- possibility of deglutition, but even more serious consequences, as shown in the cases published by Dr. Marcinkowski and M. Lalesque (Journ. Hebdorn. tf-c.).—(See Larynx—Diseases of.) 12. D. Diseases of the oesophagus, and cardiac orifice of the stomach, will impede or altogether obstruct deglutition. Inflammations and their consequences, as softening and ulceration, indura- tion, thickening, stricture, and purulent collections between the coats of these parts ; also partial dilatations, sacs, and diverticula, or even large pouches, either with or without thickening and stricture of the part of the oesophagus immediately below the dilatation (Blasius, Haller, Meckel, Monro, Ludlow, C. Bell, Odier) ; polypous or fungous excrescences or tumours of various kinds in some portion of this canal, or in the cardiac orifice of the stomach; or scrofulous, callous, cartilaginous, osseous, carcinomatous, or scirrhous degeneration of these parts ; or merely enlargement or ulceration of their mucous glands; and spasm, rupture, or perforation of the oeso- phagus, or the lodgment of foreign bodies in it, are severally causes of dysphagy ; and are fully described in the articles on the Pathological An- atomy of the Digestive Canal ; and on the Dis- eases of the (Esophagus, as well as in those of the Stomach. 13. E. Tumours pressing upon the pharynx, or upon the oesophagus,—as bronchocele, or other tumours or abscesses near the throat and in the neck ; tumefaction of the lymphatic and secreting glands below the jaw, and at the top of the sternum ; aneurism of the subclavian or carotid arteries, or of the aorta before it passes into the abdomen ; enlarged bronchial glands, tumours of various kinds, and abscesses in the posterior mediastinum ; exostoses or other diseases of the cervical vertebrae, and purulent collections be- tween them and the oesophagus (Carmichael, myself, and others); also abscesses formed be- tween, or involving, the trachea and oesophagus (Hay and myself); dropsy of the pericardium (Bang) ; and enlargement of the liver, have severally been observed to occasion dysphagy. 14. iii. The Diagnosis of dysphagy requires a few observations merely.—(a) In idiopathic, as well as in the sympathetic dysphagy, the difficulty takes place suddenly, disappears as suddenly, re- mits or intermits, and is generally attended either by convulsive efforts, by choking sensations, or by flatulence, dyspepsy, or various nervous symptoms, particularly when it is connected with hysteria, hypochrondriasis, &c.—(b) In cases of atonic, or paralytic dysphagy, solids are more easily swallowed than liquids ; but the process is often very slow, and the difficulty great.—(c) When it proceeds from disease of the fauces, the cause is obvious to the sight; and frequently also when it is induced by the state of the pharynx. In this latter case, as well as in dysphagy from lesions of the epiglottis and larynx, or from tumours or fun- gous excrescences developed in, or pressing upon, the pharynx, or from inflammatory diseases of it, or of the upper part of the oesophagus, substances are often forcibly ejected into or through the nostrils, upon attempts at deglutition, owing to the spasmodic action of the muscles of the pharynx. —{d) When dysphagy is caused by a diminution of the canal of the oesophagus, either from thick- ness of its parietes, or from tumours pressing upon it, See., difficulty of swallowing solids is first felt, and this at least is followed by a dif- ficulty of swallowing fluids; the interruption to this function proceeding gradually and slowly. When the obstruction is seated low in this tube, or about the cardiac orifice of the stomach, pain is usually fell underthe sternum afterswallowing: and the matters are afterwards regurgitated into the mouth, owing either to a sudden reaction of the parietes of the canal, or more commonly to their inverted peristaltic action. (See art. (Eso- phagus—Diseases of.) 15. iv. Treatment.—It must be evident that the treatment of sympathetic and complicated dysphagy should be conducted strictly according to the pathological state on which it depends, as far as that may be ascertained. Hence a tolerable knowledge of the means applicable to it, in every circumstance in which it presents itself, is to be acquired only by a reference to the articles where the various lesions occasioning it are described, in respect of their nature and cure. 16. A. Sympathetic dysphagy—(a) of spas- modic or flatulent disorders, requires very nearly the same treatment as already recommended in the idiopathic form of the disease. If it accom- pany hysteria, swallowing, slowly, cold or iced fluids, and cold applications to the neck, will soon afford relief; but it will afterwards be necessary to have recourse to tonics and cooling aperients, with other means suited to the peculiarities of the case. The instances in which Tode and Wich- mann found quassia so beneficial, were probably of this kind, or the idiopathic form already no- ticed.—(b) When dysphagy is connected with flatulent dysphagy, or with asthma, or palpita- tions of the heart, relief will generally be obtained from anodynes or antispasmodics combined with refrigerants, or from vegetable tonics with alkaline carbonates and aperients. Blisters, or rube- facient plasters, or either of the ammoniacal, the compound galbanum, or the cummin plasters, with opium or the extract of belladonna, applied over the sternum or throat, will also materially assist the internal remedies. Heinecken advised 564 DEGLUTITION, DIFFICULT—Treatment. the preparations of zinc, which, as well as the trisnitrate of bismuth, may be tried in this form of dysphagy. He also recommends the distilled water of the lauroccrasus, for which the hy- drocyanic acid may be substituted with advantage. Besides these, the cupri ammonio-sulphas, the preparations of camphor, with those of henbane or couium, may also be exhibited. In every form of dysphagia not depending upon organic change, purgatives, and cathartic and antispasmodic en- emata, will be productive of more or less benefit. 17. (c) Dysphagy, from paralysis or atony of the muscles of deglutition, should be treated j according to the principles stated in the article j Palsy. If it be occasioned by congestion about ; the base of the brain or spinal chord, general or | local bleedings, active cathartics, and external j derivatives, must be employed. Congestion having \ been removed, large doses of camphor, as advised by Hoffmann ; stimulating linctuses and gargles ; sialagogues ; electricity and galvanism ; exciting liniments or blisters to the neck or throat, as suggested by Loefflf.r ; as well as moxas and issues ; may be severally employed. Dr. Barton recommends the zanthoxylum in cases of this de- scription. Thunberg and Baldinger advise the cajuput oil to be rubbed on the neck ; Gardanne, sinapisms to be applied on the same part; and Franck, the actual cautery. 18. B. Dysphagy from organic change of the parts directly concerned in the function of deglu- tition requires means the most diversified, ac- cording to the nature of the lesions to which it is attributable.—(a) When it is congenital, but little can be done excepting in the slighter forms occasioned by cleft palate, or by adhesion of parts within the mouth. In these, the expert surgeon •nay afford complete relief.—(6) Difficult deglu- tition from diseases of the tongue, fauces, tonsils, or larynx, is of itself of minor importance ; but as respects the primary lesion, of the utmost mo- ment, requiring the most energetic measures pointed out in their treatment. (See these arti- cles.)—(c) Dysphagy from inflammations, or their usual consequences, whether seated in the pharynx, the oesophagus, or the cardiac orifice of the stomach, should be treated according to the sthenic or asthenic form they may assume. After general or local depletions, especially cupping between the shoulders or over the sternum, emollient, cooling, and febrifuge linctuses ought to be taken at short intervals. I have prescribed, with advantage in such cases, especially when ulceration has been suspected to exist, linctuses containing the nitrate of potash, or the hydro- chlorate of ammonia, or the biborate of soda, or the carbonates of the fixed alkalies with the nitrate of potash and ipecacuanha, in addition to the other means described in the articles on the dis- eases of these organs. When foreign bodies are lodged in the pharynx or oesophagus, appropriate measures should be resorted to, either for extract- ing them, or for pushing them onwards into the stomach.—(d) When dysphagy is occasioned by tumours developed in, or pressing upon, the oesophagus or cardia, it is not always that their nature, or even their existence, can be fully as- certained. If their presence be inferred, or when they are developed in external parts, or if the diathesis be scrofulous, then iodine may be pre- scribed internally as well as externally, with pot- ash, conium, &c.* If abscesses have formed between the upper part of the oesophagus and cervical vertebra1, or between the former and the trachea, or about the pharynx, an unfavourable issue might possibly be averted by incisions made into them. If aneurisms press upon the gullet, the treatment recommended when discussing Diseases of the Arteries should be put in prac- tice.—(e) When thickening of the parietes of a portion of the oesophagus, with more or less of stricture or scirrhus of this canal, or of the cardia of the stomach, is the cause of dysphagy, cupping, or leeches applied over the sternum T issues and moxas in the game situation, or in each side of the neck; the linctuses recommended above (§ 18. c.) ; mercurial and other alteratives, with conium, hyoscyamus, camphor, &e.; the iodide of mercury, or the iodide of potassium, internally and externally; the carbonates of the alkalies, or the liquor potassae in emollients, &c., with various other means noticed in the article on the (Esophagus, may be employed. If these fail, a careful trial may be made of the bougie ; but the utmost attention should be paid not only to the manner of using it, but to the effects pro- duced by ; for if the stricture be connected with sacs, pouches, or diverticula, or hernia of the inner coats through the muscular, or even with simple ulceration,—changes which not infrequently take place in the part immediately above the strictures —much mischief may result from even a cautious introduction of a bougie. The frequent and ob- vious connection of dysphagy with scrofula shows the propriety of prescribing the medicines founu most serviceable in that disease, particularly whe; occurring in the scrofulous diathesis: and in sucl cases, the chloride of calcium or of barium, conium liquor potassae, and especially the preparations o iodine, should be fully tried. 19. C. The treatment advised by the best writers on this and its related affections consists of much that has been now stated ; in addition to which, however, I may briefly add, that, the chloride of barium has been recommended by Kerksig ; cold and iced fluids, by Tode and Montat ; conium, by WlCHMANN, Coi,LOMB, IiuFELAND, and JoiIN- ston j hyoscyamus, by Withering ; opiates, by Ferrein and Conrali ; the liquor potassa, by Haller ; emetics, by Ferrein ; and local bleed- ings, by Franck and Bang. Calomel and some other preparations of mercury have been pre- scribed by Sequira, Stevekson, Engelhard, Brandis, and others,—to the extent of producing salivation, by Kramp, Munckley, Brisbane, and Farquharson—in the form of mercurial ointment, either alone or with the volatile liniment, rubbed over the sternum and throat, by Dobson, Patten, Kerksig, and Watiien—internally, with anti- mony, by Van Geun—and with aloes and camphor, by Haller, Patten, Bang, and Bran- dis, who contend strenuously for the occasional origin of dysphagy in suppressed rheumatism and repelled eruptions, and also recommend born in India, but who had resided some years in Lon don. The glands in the neck, and underneath the sternal ends of the clavicle and sterno-mastoid muscles (as well as in various other parts of the body), were so greatly en larged as to impede deglutition and respiration. She had been treated by several eminent practitioners ; but the tumours had increased. In consultation with Mr. An nesley, who had requested me to see her, a course of iodine was recommended : and the iodine of potassium was employed, chiefly internally, for eight or nine months, with occasional intervals not exceeding a fornight each. The glandular enlargements gradually subsided, the cat- amenia appeared, and she perfectly recovered. She is now well, and married. * f was consulted, in 1826, in the case of a young lady external derivatives and irritants, as sinapisms, issues, setons, blisters, repeated or kept open, &c. The surgical measures to be resorted to in various circumstances of the disease are fully discussed in the writings of J. Hunter (Trans, of a Soc. for the Imp. of Med. and Chirurg. Knowledge, vol. i. art. 10.), Desault, (Surgical Works, cj-c.), Richter, (Chirurg. Biblioth. b. xii. p. 11.), C. Bell (Surg. Observ. , I understand), Auct. var. Paracope, Swediaur. Irvereden, Aberwitz, Germ. Delire, Fr. De- lirio, Ital. Classif.—Pathology ; Symptomatology. 1. Delirium has been defined :—Disorder of the intellectual powers, with or without derangement of the moral sentiments. But this definition is too' extended and vague, and embraces the whole circle of mental diseases. J. Franck, and some other pathologists, have restricted it by adding— this disorder assuming an acute form. Several writers, retaining the preceding extended defi- nition, have divided delirium into the acute, and the chronic ; the former consisting of various mor- bid states of the brain, attended by mental dis- turbance and fever—the latter of mental aliena- tion, unattended by fever or active bodily disorder. Chronic delirium, therefore, comprises all those states of disordered mental manifestation treated of in the article Insanity. Acute, or febrile de- lirium refers to those morbid affections of mind supervening in the course of febrile, inflammatory , and some chronic diseases, and which have been denominated symptomatic, or sympathetic, delir- ium; and those which are produced by acute diseases, or injuries of the brain or its membranes, and by intoxicating or narcotic substances, and which have been termed idiopathic delirium by some writers. The common acceptation of the word delirium, and that in which it has been used by the best authors, accords with the acute form as occurring in the manner now stated ; and in this light I shall also view it. But it is more doubtful in how far it is ever an idiopathic affec- tion. Indeed, in many of the diseases in which it is admitted by all to be a symptomatic or sym- pathetic disorder, its more immediate dependence upon a morbid state of vital endowment and cir- culation in the encephalon is as manifest as in some of those which have been viewed as idio- pathic. The distinction, therefore, cannot be maintained, especially as it appears to have been founded upon a mistaken idea, viz., upon the sup- posed existence, in the reputedly idiopathic form, of inflammatory irritation or action of the brain or its membranes; which action does not obtain 565 566 in the other That delirium is most frequently occasioned by such a pathological state, cannot be doubted; but it is equally certain that it some- times also proceeds from a different condition ; and that either of them—either inflammatory action, or simple disturbance of the cerebral functions without inflammation—may exist in each of the divisions thus distinguished,—in the idiopathic as well as in the sympathetic form. If the dis- tinction in question be still retained, it would be more accordant with the generally admitted ac- ceptation of the word idiopathic, to consider, as J. Franck has done, all the manifestations of delirium as symptomatic, excepting when it is occasioned by intoxicating and narcotic substances: but, when it proceeds from inflammation of the brain or its membranes, whether primarily or consec- utively induced, to view it merely as a symptom, but by no means a constant, although a very general symptom, of this state of disease. 2. Delirium, as well as other cerebral affec- tions, has been too generally imputed to inflam- matory action; and the state of the ganglial or organic nervous power, which evidently influences both the functions and the circulation of the brain, has been entirely overlooked, particularly as respects this affection. There can be no doubt of the difficulty of appreciating correctly the na- ture or extent of the disorder which this part of the system experiences. But this circumstance surely does not preclude us from tracing ulti- mate phenomena to their true origin, instead of stopping at intermediate effects; nor from in- ferring, from the nature of these phenomena, and of the causes which increase or remove them— from the juvantia and laidantia—certain general conclusions respecting the condition of that power whence morbid conditions primarily emanate; each successive effect being the cause of further change, until organic lesion, and ultimately death, result. Believing, therefore, on physiological grounds, that delirium is often the consequence of changes in the state of organic nervous power —of the functions of that part of the organic or ganglial system supplying the encephalic organs— influencing, in some cases, one or more of the mental manifestations, without any appreciable ehange of vascular action or of structure; in others, both function and circulation ; and in many, not only function and circulation, but organization also ; and that our knowledge of these changes, of their signs, and of their various related circum- stances, are too imperfect to enable us to come to accurate conclusions; but that we should pro- ceed nevertheless with the aid of the dawn of knowledge now opening upon us; I shall briefly consider, first, the phenomena and diagnosis of delirium—afterwards its pathology and treatment conformably to the doctrine now alluded to. 3. i. Phenomena.—A. The invasion of delirium is generally preceded by sleeplessness, headache, vertigo, heaviness of the head, noises in the ears, change of voice, absence of mind, forgetfulness of pain, by an air of surprise, and acuteness of the senses; the eyes are brilliant and intolerant of light; the head is often hot, the face flushed, and the circulation of the brain more or less increased. In some cases, however, these symptoms are either altogether absent, or inappreciable; and in others the countenance is collapsed, pale, and cool, and the eyes sunk. To the foregoing phenomena suc- ceed those which constitute delirium, and which vary remarkably in character and intensity. In DELIRIUM—Phenomena. many cases, particularly when there are few or no signs of augmented determination of blood to the head, a simple agitation or merely absence of the mind, or reverie, or wandering from the ob- jects before it, or a slight incoherence in the ideas, is all that is observed; but from this slight state of affection, we meet with every grade and form of mental disorder—sometimes with fright, visions or illusions, often connected with present objects; occasionally with hallucinations, or the reproduction, in confused or unconnected forms, of previous impressions;—in certain cases, with the most furious mental and physical agitation; in others, with the greatest depression and the most sombre taciturnity ;—in one case, with tears and signs of great mental distress; in another, with a lively but incongruous current of ideas, or even with laughter and gaiety. 4. B. Delirium is frequently present at first only during the intermediate states between sleeping and waking, which patients in acute diseases ex- perience ; the mind still perceiving objects, but imperfectly. In this state the patient appears to dream aloud; and when fully awakened, returns rational answers to questions put to him ; but he soon lapses into a state of dreamy incoherence, or into that of more complete delirium. This con- dition nearly approaches that of coma vigil, into which it often passes. In some instances, this state is characterised by a loss of recollection of all objects observed, and of all ideas with which the mind had been stored during the greater period of life, and by the recovery of the memory of languages and of ideas acquired at a very early age, and long forgotten. Thus old persons, when delirious, although their minds are blanks as respects every thing present, or which have be- come known to them from youth or manhood, will talk of matters which had interested them previously to such periods, and sometimes in a language which they had then spoken, but of whicli objects and language they had no recollection long before their delirium, nor retained any after their recovery. Here, again, the remarkable similarity between several manifestations of de- lirium and dreams is strongly evinced ; the objects and ideas about which the unconscious mind is engaged in the states of both delirium and dreaming being frequently those which had made a vivid impression in youth, which had become erased by the cares and employments of life, but which are recalled during certain conditions of the brain. The production of these in incongruous forms, and the giving utterance to the morbid conceptions formed of them, constitute hallu- cinations; whilst, owing to the nearly inconscious state of the mind, the imperfect and erroneous impressions made by surrounding objects on the senses of the patient, give rise to inconclusive and unconnected conceptions, in consequence of the morbid condition of the brain, and occasion the illusions characterising the delirious affection. 5. In addition to disorder of the mental powers, the organs of locomotion are remarkably affected. In the low or quiet delirium, and in the less dangerous states, in which the brain is only functionally deranged, the muscles are either somewhat agitated, or very much enfeebled, and the voice is very weak or nearly lost. In more severe cases, the voice and the muscular force are greatly increased; the patient, however, sinking into a state of profound collapse after a few violent efforts. In the most dangerous form of delirium, particularly when it proceeds from organic disease of the brain or its mem- branes, it is attended, but more frequently fol- lowed, by general convulsions, by spastic con- tractions of one or more of the voluntary muscles, by entire loss of consciousness and sensibility, or by paralysis. 6. C. Delirium, as M Georget has remarked, may be continued or intermittent, even in the continued affections of the brain. When it is intermittent, it usually returns with the exacer- bation of fever that takes place in the evening and night. When the patient recovers his rea- son, he is generally weak and exhausted; his senses are readily and painfully impressed by their respective stimuli; and he complains of thirst, and pains of the head and limbs. If the delirium has been slight, and consciousness has not been entirely abolished, he retains more or less recollection of what had passed during its continuance. But when it has been intense, or of some duration, he has no knowledge of what has occurred. The epidemic appearance of de- lirium mentioned by Quelmalz (De Epidem. Mentis Alienatione. Lips. 1752.) and Michaelis (Med. Pract. Bihlioth. b. i. st. 1.) is to be imputed to the prevalence of those diseases in which delirium is apt to supervene, and espe- cially in that form on which it is most fre- quently an attendant. The duration of the paroxysm of intermittent delirium varies from one to several hours; but the continued form, particularly when occasioned by disease within the head, may last several days, or even many weeks. Sometimes, as in the more severe ce- rebral cases, it alternates with profound coma. When it terminates fatally, it generally passes into coma; but in some instances the patient recovers his reason for a few hours before dis- solution.* 7. ii. Diagnosis.— It is of the utmost im- portance that delirium should not be mistaken for insanity, and especially that the delirious patient should not be removed to an asylum for the insane. On two occasions I have seen such D ELI RIU M—Diagnosis. a mistake made, and about to be acted upon, when my opinion was requested. But these cases recovered perfectly: to one of them — a professional man — the removal to an asylum, or the supposition even of being insane, might have been ruinous. There can be no doubt that delirium often passes into insanity, especially when it has been caused by inflammatory states of the brain, and by fevers with determination to the part; or when it occurs in persons hered- itarily predisposed to insanity; but until it has assumed the features of that form of mental dis- order, it certainly in no respect should be viewed and treated as such. 8. The causes and circumstances originating delirium are often of themselves sufficient to show its difference from insanity. Its occur- rence in the advanced stages of acute diseases, or of chronic maladies when the powers of life have become exhausted and febrile action of an acute kind has supervened, is especially char- acteristic of delirium. The insane patient has all his senses, as well as his digestive, assimila- tive, and locomotive powers, but little or not at all impaired. His mental faculties and intel- ligence are also but partially deranged. M. Georget has very justly remarked, that the mental disorder of the insane is often confined to a single faculty; and even in the most extended, or maniacal affections, the faculties are rathei perverted, or insulated, and without the bond of association, rather than extinguished. The most maniacally insane person wills and reasons, and is not always absurd in his actions. But in the delirious, all the cerebral functions are severely affected. His sensations arc imperfect and in- correct, his ideas unconnected, his passions dis- ordered, his voluntary motions irregular, feeble, and defective; his intelligence and recollection nearly abolished; and he is impassive to all that surrounds him. W hilst the delirious patient presents many of the physical signs of exhausted vital energy, or of the gravest state of disease, the insane has all the appearances of unimpaired health, particularly in the early stages of insanity, and before consecutive organic change has taken place. In the former, the sensations and percep- tions are more or less abolished ; in the latter, they are but little or not at all impaired,— the judgment only, or conviction of the under- standing respecting them, being erroneous. The false conviction of the insane is too strong to be removed by the evidence of the senses: the sensations and perceptions of the delirious are always too weak, even when consciousness is partially present, to become the basis of sound conclusions. Hence the insane person cannot be convinced by objects seen, heard, and understood by him, in opposition to his perverted judgment respecting them; and the delirious patient per- ceives objects so faintly, if he perceives them at all, as to be unable to distinguish between such as are in any respect similar, or to recognise one person from another. Besides the circum- stance, also, of delirium being generally an acute, and insanity a chronic affection, it may be re- marked, that in the former, when occurring from inflammatory states of the encephajon, or from fevers complicated with such states, the return to the healthy function is often so slow as to occa- sion fears of the supervention of the latter. In some instances, however, the restoration from febrile delirium has been quick, and the mental 567 * [Delirium is a very frequent symptom in the typhoid (or continued), the typhus, and the remittent fevers of this country. In mild cases, there is an impatient and irritable, or a listless and indifferent state of mind; or the patient may be extremely timid, and apprehensive of danger. There is also a loss of memory and of control over the thoughts, an inability of fixing the attention upon any one subject, and such a condition of mind may exist through the whole course of the disease if it be not one of marked severity. In the latter case, we have, as a general rule, a degree of delirium proportioned to the severity and danger of the disease; occasionally a case of fever terminates fatally without delirium, but this occurs very seldom. It may come on during any period of the disease ; sometimes it is observed at the com- mencement, but rarely till the second week of the fever, but its early appearance denotes a severe and dangerous form of the malady. Where the fever terminates fatally, the delirium is usually persistent, and of a low and mut- tering kind. Occasionally, the patient is wild and agi- tated, in constant motion, picking at the bed-clothes, affected with subsultus, and incoherence of speech. Monomaniacal delirium is rarely met with in fevers, though in some instances it is observed. The late Dr. Nathan Smith, of New Haven, believed that in some cases, the moral principle was affected after recovery from fever, for he states, that he had known some indi- viduals left with an almost irresistible propensity to steal. On the other hand, Louis states, that in 300 cases of typhoid fever treated by him, there was but a single instance where there was any morbid condition of the mind remaining after the establishment of convalescence. In children, Rillikt remarks, that delirium rarely shows itself before the 15th day of the disease (See Bartlett on Fever, p. 245.)] DELIRIUM—Pathology. 568 manifestations have become even more active than previously to the seizure. 9. iii. Pathology.—It is of the utmost prac- tical importance to distinguish the different forms of delirium, particularly in respect of the grade of vascular excitement and vital power, and the existence or non-existence of inflammatory ac- tion, for, without such a step is previously taken, no rational method of cure can be adopted. I shall therefore attempt to make this distinction. ! 10. A. Delirium attended by exhausted ner- oous and vital influence is sometimes occasioned J by excessive haemorrhages or venoesection, by in- anition, prolonged lactation, and profuse seminal ■ or other discharges, by old age, hysteria, fear, &.c. It also occasionally supervenes from ex- j haustion in the last stages of some acute and chronic diseases, or from whatever directly or in- directly depresses the powers of life, as shown in the article Debility. In many such cases, how- ever, although the vital energies are sunk, yet she brain is more or less excited relatively to the other parts of the body; and in some, the state of delirium is connected with an impure or con- taminated condition of the circulating fluids, par- ticularly when it occurs in the advanced course of malignant diseases. The delirium, also, which is caused by excessive pain, by capital operations, by the suppression of the appearances of pain or suffering, or by the apprehension of the conse- quences of operations, and which M. Dupuytren lias very appropriately denominated nervous de- lirium, chiefly falls under this form of the affec- tion ; and to if may be added many of the in- stances of delirium caused by excessive irritation in remote but related organs or parts, as con- sumption, ulcerations of the bowels, worms, &e. Although it is often obvious that a relatively in- creased determination of blood to the head exists iu some cases of this form of delirium, yet it may j be inferred, with equal justice, that a deficient supply of blood to the brain obtains in others. This conclusion may be legitimately drawn from i the pale, cool, shrunk features, sunk eyes, the j weak and small pulsation of the carotids, the ef- fects of various kinds of treatment, and the ab- sence of increased or even common vascularity j of the brain upon examination after death, in j some cases of this form of delirium. The opinion has been supported by M. Georget and several other pathologists, without having been imputed by them to its obvious source, viz. exhausted power of the organic nerves supplying the vessels of the brain. 11. B. Delirium characterised by depressed or exhausted vital power, and morbidly excited vascular action, is by far the most common forfn ; and is very frequently observed in the advanced progress of continued, remittent, intermittent, malignant, and exanthematous fevers ; of acute inflammations; and of several chronic diseases, particularly when they pass into the acute form. It may also be occasioned by any of the nar- cotic or acro-narcotic poisons, or from their ex- hibition in enemata; and in some temperaments and constitutions, by a small quantity of those in common use,—as by opium, stramonium, bella- donna, &c. . I have more than once seen it pro- duced even by the preparations of hop and hyos- cyamus taken in moderate doses. Its occurrence from the medicinal exhibition of various narcotic and poisonous substances is noticed by various writers;—from cicuta, by Wepfer and Smetius (Miscell. p. 569.); from belladonna, by Pelar- gus and Valentini (De Maniacis ab Usu Bellad. tf-c.); and even by the superacetate of lead, by Stoll (Rat. Med. par. vii. p. 317.) and Knight (Land. Med. and Phys. Journ. vol. iv. p. 286.).— Dioscorides (Mat. Med. 1. iv. cap. 63.).—West- phal (Pathol. Dcemoniaca, p. 33—36.), and Horn (Archiv. Nov. 1811, p. 540.), have noticed the occurrence of delirium from hyoscyamus ex- hibited in clysters. Poisoning by various sub- stances, as the Lolium temulentum, and some of the narcotics just mentioned, generally occasions delirium. It may also arise from indigestible substances taken into the stomach. In all these cases, in addition to the states of the system connected with the appearance of this affection, there is generally increased excitement of the circulation in the brain, relatively to that in the rest of the body; and not infrequently an impure or altered state of the circulating fluid. The delirium occasioned by the protracted use, and the sudden disuse, of narcotics or spirituous liquors, by erysipelas, and retrocedent exanthemata, is of this kind, between which and delirium tremens there is often a close resemblance. 13. C. Delirium occasioned by inflammatory action of the brain or its membranes, when the inflammation takes place primarily, is seldom attended by very manifest exhaustion of vital power, at least to the extent of the preceding forms. When, however, the inflammatory action is very general throughout the brain or its mem- branes, or when it supervenes on continued fevers or erysipelas, and is attended with serous effusion, vital depression is more apparent, and its termination in, *or alternation with, coma, more common. This state of delirium, particu- larly when it proceeds from concussion or ex- ternal injuries, is often phrenitic or maniacal— the Delirium ferox of authors—as respects the exaltation of muscular force. It is occasioned by all the causes stated to produce inflammation of the brain, particularly suppression of critical or accustomed evacuations, eruptions, or discharges ; auger; the exciting passions ; metastasis of specific inflammations ; the ingestion of spirituous liquors, &c. Whilst the protracted use of intoxicating beverages, &.c. occasions delirium tremens, unac- customed intoxication sometimes produces the delirium now being noticed, by inflaming the brain. This form of the affection is often com- plicated with convulsions, contractions of the limbs, paralysis, &c., particularly when the sub- stance of the brain is organically changed ; and is, when thus attended, very much more danger- ous. (See Brain—Inflammations of, § 164.) 13. iv. Lesions observed in fatal Cases.— In the first form of this affection, scarcely any, or no evident change, is found in the brain or its membranes, beyond either a somewhat increased or diminished vascularity, occasionally with a slight increase of the consistence of the cerebral substance, or of the fluid in the ventricles. In many cases, all the parts within the cranium are apparently sound. In the second variety, and wherever delirium is unattended by marked dis- order of the muscular actions—when it is without extreme prostration, or convulsions, or paralysis—the chief changes are, increase of the consistence of the brain, and of the fluid contained in the ventricles, injection of the pia mater, sometimes with infiltration of serosity, and occasionally a somewhat deeper shade of colour in parts or the whole of the cerebral substance. M. Georget remarks that pathological investi- gations do not confirm the opinions of some authors, who impute the cause of delirium and convulsions to inflammation of the arachnoid; and that even epileptics and the insane seldom present the appearances usually caused by arachnitis. They have probably confounded in- flammation of the membranes and periphery of the brain with the usual manifestations of de- lirium ; and thus imputed the changes observed in the former to the latter In the third form of this affection, or when it is attended by the lesions of muscular action noticed above, the appear- ances observed are more completely those usually found after inflammation. Indeed, delirium fre- quently occurs, but not uniformly, or even gen- erally, in nearly all the inflammatory diseases of the brain or of its membranes, and occasionally in the advanced stages of the organic changes limited to parts of this organ. (See art. Brain.) 14. v. Prognosis.—The great diversity of the results furnished by post mortem investigations will show the difficulty of appreciating aright the conditions of the brain in delirium, and of coming to a correct conclusion as to its issue. When it is sympathetic of disease of remote organs, the worst opinion should be formed of the result. Delirium occurring in the advanced stages of diseases of the lungs, stomach, or bowels, is a most dangerous symptom ; and when it super- venes in slow and consumptive maladies, it rarely remits, and death is not far distant. It seldom appears as a sympathetic affection, until the powers of life are greatly depressed, and the pulse is very much increased in frequency and dimin- ished in tone. Dr. Gilbert (Krankheiten der Franzos. Arm. p. 48.) observes, that delirium prevailed in the fevers which accompanied the French wars in Germany, in proportion to the frequency and weakness of the pulse,—a fact fully supporting the inference at which I had long ago arrived. On the other hand, when it appears in an intermittent or slight form, or from the operation of the less intense causes upon del- icate and nervous constitutions, and without other grave symptoms, although evincing the severity of affection, it is not, in itself, a dangerous occur- rence. When it follows capital operations, or severe injuries of any kind, it very often indicates the developement of inflammatory action of the brain of a most dangerous or rapidly fatal form. Delirium is most frequent in females, in the nervous temperament, and in young persons above the age of eight or ten years; but it is, in such cases, a less unfavourable symptom. It is seldom observed previously to the fourth or fifth year,—convulsions usurping its place at an earlier age: but, when it occurs thus early in life, it is a sign of great febrile excitement, with either de- termination to, or acute inflammation of, the membranes or periphery of the brain. If it be continued, or alternate with coma ; or if it be complicated, with extreme prostration of muscular power, or with convulsions, spastic contractions, paralysis; the existence of inflammation of the brain, to the extent of producing organic change and extreme danger, may be inferred. Pererius, Piso, and many other writers, have contended that furious and sad or fretful delirium is more unfavourable than that which is tranquil or lively; and the observation seems to be nearly correct. The prognosis of sympathetic delirium should, DELIRIUM—Prognosis—Treatment. however, not be fouhded so much upon its form, and the other symptoms referrible to the cerebro- spinal system, as upon the nature of the primary malady ; for it is not the delirium which is in itself dangerous, but the disease upon which it supervenes; the circumstance of its occurrence evincing the very sinking condition of vital power. M. Georget truly states, that the sudden cessa- tion of delirium and agitation, attended by want of recollection of the previous state, by great debility, irregularity of the action of the heart, and loss of temperature in the extremities, nose, and ears, is a most unfavourable omen ; and often accompanies the termination, by gangrene, of in- flammation of some important organ, always indicating approaching dissolution. When deliri- um accompanies fevers, particularly those with determination of blood to the encephalon, or in- flammations of the brain or of its membranes, it often yields favourably to epistaxis, copious alvine discharges, and other critical evacuations. (See art. Crises.) 15. vi. Treatment.—When the inexperienced practitioner, in his endeavours to obtain informa- tion as to the treatment of this affection, finds remedies of the most opposite kind very con- fidently recommended by writers,—vensesection by one, bark and stimulants by another, emetics or purgatives by a third, and digitalis, antimo- nials, &c. by a fourth,—he is at a loss how to act; and arrives at the conclusion, that if one be right, the others must necessarily be wrong. The fact, however, is, that all of them are partly right, but also partly wrong. The circumstance of this affection having been hitherto viewed without reference to the very different states or grades of vital energy with which it is often associated, or to the condition of circulation in the brain, and its division into idiopathic and symptomatic,— either of these divisions presenting the different forms I have endeavoured to distinguish,—has led to, and perpetuated, the empirical manner in which it has been treated. It is necessary to ascertain not only the origin and morbid relations of this affection, but the phenomena attendant upon it at the time of investigation ; more espe- cially the condition of the secretions and excre- tions, the temperature of the head, the state of the pulse in the carotids and temples, the appear- ance of the countenance, and the state of muscu- lar power and motion. These will at once indicate to the observing practitioner the existing pathological condition causing the affection,—will enable him to assign it to one or other of the forms above distinguished, and thereby to prescribe for it appropriate remedies. 16. A. The first form of this affection (§ 10.) will be most benefited by quietude, gentle restora- tives, and nourishment; by a moderately cool, pure, and frequently renewed air; by the tepid affusion on, or cooling applications to, the head, if there be any increase of its temperature ; by warm pediluvia ; by camphor conjoined with re- frigerants and cardiacs, or with sedatives ; and, if the vital depression be very great, the head cool, and the carotids pulsating weakly, by the preparations of quinine or bark, of assafoetida, va- lerian, musk, camphor in large doses, with those of ammonia, opium, &e., exhibited bv the mouth, and in clysters: or by small quantities of mulled wine or negus. In the more purely nervous de- lirium, or when it occurs from operations, anx- iety, fear, and injuries of parts at a distance from 569 DELIRIUM—Treatment. 570 the head, opium, given by the mouth, or in ene- mata, as recommended by M. Dupuytren, will be most beneficial. If it be attended by much agitation, narcotics—as opium or hyoscyamus— in full doses, either alone, or with camphor, assa- foetida, soda, or ammonia, &c.; the acetate or hydrochlorate of morphia, with aromatics and cardiacs ; quietude, in a cool, well-ventilated, and darkened apartment; the tepid affusion on, or cold-sponging, the head, if its temperature be in- creased ; and warmth to the lower extremities, are the chief remedies. 17. B. In the second form, of this affection (§ 11.), if there exist signs of determination of blood to, or of congestion in, the head, bleeding by cupping, or leeches applied behind the ears and below the occiput, the affusion of a stream of cold water on the vertex, and purging, are amongst the most efficient means that can be employed. If the delirium be attended by stupor, or tendency to coma, or by subsultus tendinum, picking of the bed-clothes, &c., blisters to the nape of the neck, and the treatment advised in the article Coma, will be requisite. If the deliri- ous stupor be not removed by the more usual remedies, and if it have arisen from erysipelas of the head, incisions of the scalp of the occiput, as recommended by Copland Hutchison, may be practised. When there is no very considerable heat of the head, or when the extremities are cool, and the morbid secretions have been purged off, full doses of camphor (F. 494. 496. 903. 906.) may be exhibited. If the pulse be very weak, and the prostration of strength very great, the preparations of quinine or of bark, or of ammo- nia, camphor, assafoetida, valerian, musk, &c., with aromatics and cardiacs, or even wine in the form of negus, should be resorted to. When, with the vital depression and increased vascular action characterising this form of delirium, there are appearances of a morbid state of the circu- lating fluid, we should endeavour to rouse the vital energies at the same time that we excite the secreting and depurating organs, by exhibit- ing camphor with the chlorates (the oxymuriates) of the alkalies (see F. 439. 845. 847. 928.), and the resinous purgatives with bitter tonics and stimulants (F. 492. 504. 572.). In such cases, the treatment recommended in the articles Blood (§ 156. et seq.) and Fever, will also be appro- priate. As soon as stupor and a tendency to coma appear, in addition to the medicines now suggested, cathartic and stimulant enemata (F. 139. 149.), or an active purgative draught (F. 216.), should be exhibited, and repeated ac- cording to circumstances ; and if these fail, blis- ters, sinapisms, rubefacient cataplasms or lini- ments, may be resorted to. The terebinthinates have been employed by me since 1819, with great benefit, in this and some other forms of febrile delirium. The practice has lately been favoura- bly noticed by Dr. Graves (Med. and Surg. Journ. vol. ii. p. 782). If the head be cool, and the pulse, particularly in the carotids, be weak, small, and very frequent, either in this or the pre- ceding form, all revulsants from the head, even the keeping it elevated, or warm pediluvia, will be injurious ; and may convert, as Dr. E. Gil- christ (Edin. Med. Essays and Ohserv. vol. iv. p. 358. et seq.) long ago remarked, a tranquil, into a most violent, delirium, which may soon terminate in fatal exhaustion. In both the first and seebnd forms of this affection, the practi- tioner should not be induced to resort to lowering measures, merely because the muscular force is momentarily increased, and the patient is violent, restless, and agitated. If, with this state, the pulse is very frequent, small, weak, or irregular, and the head not very hot, a restorative and sooth- ing treatment will be more beneficial. I have repeatedly observed, that this form of the affec- tion, when supervening on protracted and ex- hausting disease, has been almost immediately subdued by small quantities of warm spiced negus; by camphor, with capsicum and opium or hyos- cyamus; and by frequently sponging the head with cold or tepid water, when its temperature has been increased, or by the tepid affusion. 18. C. The third or inflammatory form of de- lirium should be treated in every respect as de- scribed when discussing inflammation of the brain or its membranes. (See art. Brain.) General and local bleedings, cold affusions and applica- tions to the head, &c., are indispensable in it. If the delirium be complicated with stupor, or coma, convulsions, contractions or paralysis of muscles, &c., vascular depletions and active alvine evacu- ations should be followed by external derivatives of a permanent kind ; by incisions of the scalp ; by issues, open blisters, moxas, the use of the tar- tar emetic ointment, dry-cupping, &c.; whilst the secretions, &c. should be promoted by mer- curial and other alteratives, and the bowels fully evacuated from time to time by a cathartic draught (F. 216.), and enema (F. 149.). In every form of the affection, the patient should be irritated as little as possible by opposition, but in- dulged as much as is consistent with safety. 19. D. I shall conclude by noticing the treat- ment. recommended by some authors.—(a) The topical application of cold has been advised by every writer on this affection, particularly since Bartholinus so strenuously recommended it (De Usu Nivis Medico, cap. 25.). It may be pre- scribed in the form of cold affusion, pounded ice, cold epitheins, evaporating lotions on the head, or simple sponging. If, however, it be continued too long, or after the morbid heat has been sub- dued, and the features have shrunk, it will be in- jurious, by depressing the nervous energies too low, and favouring the supervention of coma, or violent agitations, terminating in fatal exhaustion. It is required chiefly in the third form of the dis- ease ; but in the Jirst and second forms, when the temperature of the head is increased, it should be cautiously employed, or the tepid affusion substi- tuted for it. In these, however, I have preferred that the scalp should be sponged with a tepid and very weak solution of the nitro-hydrochloric acid. —(b) Camphor has been nearly as universally prescribed. Buchner (De Prastantia Camphoric in Deliriis. Halse, 1763.), and Tode (in Soc. Med. Hann. Coll. ii. No. 34.) especially recom- mended it,—the latter with mineral acids. It is a most excellent remedy when judiciously exhib- ited. If given at all in the third form of the af- fection, it should be in small doses, with nitre and antimony, or with digitalis. In the first form, it may be prescribed in larger quantity; and in the second, especially if there be stupor or coma, or a morbid state of the blood, in still larger doses, with tonics, antiseptics, aromatics, and cordials.—(c) Opium or hyoscyamus is noticed by Percival (Lond. Med. and Phys. Journ. vol. i. p. 443.), Goubier {Journ. de Med. t. Ixxxv. p. 244.), Du- puytren, and Kortum (Beytrdge zur Pract. Arzneywiss. No. 9.). In some states of the first and second forms of the affection, when it is purely nervous, or is attended by much agitation, watchfulness, &c., either of these medicines may be employed. In the more doubtful cases, either of them may be safely exhibited with camphor and James’s powder. In the third form, particu- larly when it assumes a maniacal or violent char- acter, and after depletions have been carried as far as may be thought prudent, and the bowels have been freely evacuated, I have repeatedly seen a full dose of opium or hyoscyamus, given either alone, or with antimony, or James’s pow- der, and camphor, produce the happiest effect. Any unpleasant symptom that may result either from too large doses of these narcotics, or from their inappropriate use, will readily be removed by the cold or tepid affusion on the head The acetate or hydrochlorate of morphia, taken in a full dose of the spirits of pimenta, or in any other aromatic spirit, has proved equally beneficial with opium, in my practice. [Dr. Graves, of Dublin, recommends opium in combination with tartar emetic, in the delirium of typhus; Dr. Hudson also (Dublin Journal, July, 1837,) states that he has used, with great success, the same combi- nation, in similar cases. He states that it is best adapted to that restless kind of delirium resem- bling delirium tremens, in which the patient can- not be restrained from attempting to leave his bed and walk about the ward, when every muscle is tremulous, the eye red from want of sleep, the tongue dry, and the patient presenting that kind of spurious excitement, which might induce the attendant to order the local abstraction of blood, by leeching the temples, or opening the temporal artery. In prescribing this medicine, Dr. H. thinks it advisable to use caution in two ways: 1st, Not to give it after it has produced sleep ; 2d, To follow it up by the prompt and frequent exhibition of wine, and such nourishment or cor- dials as the more or less advanced stage of the disease, and debility of the patient, may require ; as there is increased risk of the patient sinking, unless timely supported after sleep thus induced.] The external employment of opium has been found very successful in delirium, by V. Chi- arurgi (SulV Uso Esterno delV Opio, 8vo. Flor. 1797.), Ward (Lond. Med. and Phys. Journ. vol. i. p. 441.), and Percival (Ibid. p. 444.), who have used it in the form of liniment (3 j. triturated with 5j. of adip. praep.), either with or without cam- phor.—(d) Purgatives have been justly praised by all writers on this affection. The ancients prescribed them in very large doses, and prefer- red the hellebores, which, with calomel and those I have already particularised, should be actively exhibited, according to the strength of the patient. When the debility is great, they must be asso- ciated with a tonic and stimulant treatment.—(e) Emetics have been mentioned by several writers ; and when delirium proceeds from the ingestion of narcotic, indigestible, irritating, or poisonous substances, or is connected with the accumulation of saburrse in the upper portions of the digestive tube, they are then requisite.—(/) Antispas- modics and cordials, particularly valerian (War- burg, Med. Beobacht. No. 16.), assafcetida (Wan- ters, Journ. de Med. t. lvi. p. 115.), musk (Kor- tum, loc. cit.), warm negus, and similar medicines, have been recommended ; and are often of ser- vice, when the powers of life are much depressed. —(g) Blisters have been applied to the head DELIRIUM WITH TREMOR. much too indiscriminately: I have seen them prove most injurious in this situation. Dr. E. Gil- christ, one of the best writers of his time, directs them both to the head and to the insides of the legs. I believe that they will prove beneficial in the former situation, only when the powers of life are sinking fast, and the delirium is attended by stupor, a cool head, and sunk or collapsed fea- tures, as in cases of low or adynamic fevers. W hen this affection is consequent upon febrile de- termination of blood to the head, blisters on the insides of the legs, &c. may be useful derivatives; but they often occasion so much pain and irrita- tion in this situation, as to thereby counteract, particularly in the turbulent state of delirium, any good they might otherwise produce.—(h) Of the sedatives or contra-stimulants prescribed by writers, the preparations of antimony, particu- larly James’s powder—digitalis, and the nitrate of potash, are the most deserving of notice. Whenever the delirium is connected with in- creased vascular action in, or determination to, the head, these medicines are of more or less ser- vice when judiciously combined with other appro- priate remedies. Withering (On Digitalis, p. 33.) and Patterson (Med. and Phys. Journ. vol. v. p. 442.) strenuously advise the preparations of digitalis ; but they, as well as those of antimony, require much caution, if ventured upon in the delirium attendant on low or malignant fevers. It is chiefly in the maniacal or third form of this affection that they are most beneficial, and in it they should be exhibited in a decided manner ; but in the first and second, particularly in the delirium of typhus, they are generally injurious. —(/') The actual cautery on the nape of the neck, and moxas, have been advised by M. Va- lentin (Med. and Phys. Journ. vol. xix. p. 432.), and several other Continental writers.—(k) Dr. Grant (On Fevers, 8vo. 1771.) recommends the patient to be allowed to dress and sit up when he feels anxious to do so ; but this, and several ju- dicious observations of this writer, are more fully adverted to in the article on Fever. The obser- vations made on convalescence from Inflamma- tions of the Brain, and from Fever, are per- lectly applicable to the management of conva- lescence from delirium. (See these articles.) Bibliog. and Refer.—P. M. De Heredia, De Nat Delirn, ejusque Causis, Oper. t. iii. p. 278.—Vchr, De De liriis ex Ventriculo. Fr. 1662.—Boerhaave, Institut. ft 566, et cet.—Stubbs, in Philos. Trans. No. 56.— Van Swieten Comment, vol. ii. § 700.—Pererii, Ciuajst. Med. xii.—- Teichmeyer, De Deliriantium Furore et Dementia, 4to. Jena;, HM.—Quelmalz, De Epidemica Mentis Alienatione. Lips. 1752; et De Delirio ex Lactatu. Lips. 1754.—Buch- ner. De Deliriis, Vitam et Mortem prasagientibus. Hal. 1757; et De flecticorum Deliriis Malo Omine oriundis. Halae, 1765.—J. Cnobloch, De Paraphrosyne, et Different, suis, in Haller's Biblioth. Med. Pract. vol. ii. p. 124.— Baumer, De Delirio Hysterico. Erf. 1763— J\Tunn, De Delir. Hysterico. Erf. 1762.—Plieninger, De Precipuis Deliriorum Causis. Stuttg. I119.—Gilibert, Adversar. Med. Pract. p. 256. (From inanition.)—Parry, in Mem. of Med. Soc. of Lond. vol. iii. p. 11.—Bang, in Act. Reg. Soc. Med. Haun. vol. ii. p. 76., vol. iii. p. 127. (From mental emotions.)—Ranoe. in Ibid. vol. ii. p. 13.-Esqui- rol, in Diet, des Scien. M6d. t. viii.art. Delire.—J. Frank, Praxeos Med. &c. par. ii. vol. i. sect. i. p. 654.—Georget, in Diet, de Medecine, t. vi. p. 395. DELIRIUM WITH TREMOR. —Syn. De- lirium Tremens, Sutton. Brain Fever, Pear- son. Brain Fever of Drunkards, Armstrong. Mania a Temulentia, Klapp. Mania d Potu, Snowden and Carter. Delirium Ebriositatis, Blake. Idiopathic Delirium; Delirium treme- 571 572 faciens, Author. La Folie des Ivrognes, De- lire Tremblant, Fr. Classif.—4. Class, Nervous Diseases: 1. Order, Affecting the Intellect (Good). I. Class, IV. Order (Author). 1. Defin.—Delirious illusions, with constant tremor of the hands and limbs, watchfulness, and great frequency of pulse. 5. I. Distinctions.—This form of delirium is variously modified, according to the causes in which it originates, and the habits and constitution of the patient. Although it is here divided into two species ; the one being evidently connected with inflammatory irritation of the arachnoid, or with excited vascular action in the membranes of the brain, and associated with great irritability— the other consisting chiefly of this last state, at- tended by exhausted nervous energy ; yet it often presents intermediate forms or modifications, which cannot be referred to the one species more than to the other. Nevertheless a distinction should be made, inasmuch as the predominance of the characters of either species will indicate the propriety of employing more or less of that treat- ment which is appropriate to it; for owing to the want of such a distinction, the delirium which arises chiefly from intoxicating liquors has been too generally treated after one fashion, and in too empirical a manner, merely because it has presented one or two characteristic symptoms, —its numerous other phenomena being entirely overlooked. Thus, when the disease arises, as it commonly does, from the abuse of intoxicating liquors, it may assume more or less of the features of either species, according as it is directly or indirectly produced by this cause ; but if it be viewed as a consequence of inflammatory action only, or as proceeding from nervous exhaustion exclusively, the conclusion will in either case be only partially correct, and the practice founded upon it frequently injurious. 3. i. Delirium with Tremor and excited Vascular Action in the Membranes of the Brain (Encephalitis Trcmefaciens of J. Frank). 4. Defin.—With great terror and irritability of temper, and violence upon being opposed ; a frequent, full, or hard pulse ; countenance often wild or flushed, and the head hot. 5. This species of delirium forms the connect- ing link between that which is purely nervous, and that depending upon inflammatory action of the membranes and periphery of the encephalon. 1 hat it may run into, or form a slight grade, or modification, of inflammation of these parts, in some cases, I will not dispute ; but that it always is strictly inflammatory, is opposed by the fact that it will often subside spontaneously, in a short time after its cause has ceased to act. The “ Delirium E brio sum” of Darwin and some other writers, or the delirious affection which is immediately consequent upon intoxication, is an example of this; it sometimes subsiding in a few hours, or in a day or two, when not injudiciously interfered with: but this is only an occasional occurrence, and cannot be trusted to. This state of delirium, when directly produced, as it com- monly is, by intoxication, is not always charac- terised by tremors at the commencement; but, when thus accompanied, it is often mistaken for the true form of delirium tremens, into which, however, it not infrequently passes, chiefly owing to the cause in which it had originated. It is generally attended by extreme irritability, often DELIRIUM WITH TREMOR—Distinctions—Cause.. by great violence, and sometimes by general spasms and constant vomiting. The head is usually hot, and the face flushed. This species of idiopathic, or primary delirium, is caused, not only by the use of intoxicating liquors, opium, &c., but also by the excitement of the cerebral organs by intense or prolonged study, particularly when prosecuted under the influence of depress- ing causes. Dr. J. Johnson states, that he has seen delirium tremens in young ladies, whose mental powers had been exhausted by this cause : and most probably it was this species of disease that he had observed, as the treatment which he found successful in it, is essentially the same as that which is most beneficial in this affection. Delirium with tremors is also, in some rare in- stances, chiefly occasioned by excessive venereal indulgences, or masturbation ; most probably, however, assisted by various concurrent causes. 6. ii. Delirium with Tremor from exhausted Nervous Power (the true Delirium tremens of modern writers, and D. Traumaticum, or D. Ner- vosum, Dupuytren). 7. Defin.—With a morbid recurrence of the patient’s ideas to his avocations; a frequent, weak, or small pulse ; cool, humid, or perspiring surface ; and loaded, but moist tongue. 8. This disease was very generally confounded with phrenitis, until Dr. Sutton ' directed at- tention to it as a specific affection, requiring a peculiar treatment. As Dr. Ryan has remarked, it most probably constituted a large proportion of the cases named “ Demonomania” by the writers of the 16th and 17th centuries. It had not, how- ever, altogether escaped attention, previously to the notice taken of it by Dr. Sutton. Dr. Pearson, of Newcastle, had written, for private circulation, a small tract respecting it j and cases illustrative of its nature and appropriate treat- ment had been shortly before published by Dr M'Wiiirter (Med. and Phys. Journ. vol. xviii p. 153.): Dr. Saunders had also mentioned it in his lectures delivered at Guy’s Hospital, about the close of the last century ; and that manifesta- tion of it observed after external injuries is stated by Dr. Blake to have been noticed in Dr. Colles’s Lectures on Surgery, with an accu- rate reference to its chief, although apparently the predisposing cause, and to the means of cure which repeated observation has shown to be most successful. 9. II. Causes, Ac.—Whilst the former state of delirium is often directly occasioned by drunk- enness, this is as frequently indirectly produced by the same cause ; the one being immediately consequent upon or accompanying intoxication, the other commonly resulting from the abstraction of the accustomed stimulus, after an habitual or continued indulgence in it, or after a protracted fit of ebriety. A slight form of it, or merely tre- mors of the hands or limbs, with deficient nervous power, and occasional illusions, will sometimes appear after habitual tippling, without intoxication having once been produced. The use of intoxi- cating liquors, and the neglect of sufficient food ; a protracted debauch followed by sudden priva- tion, or by depressing causes ; large or repeated depletions employed to Mmove the headaches or stupor of drunkards, or the first species of this delirium : the treatment indicated by the diseases with which such persons may be affected; the debility caused by the diarrhoea or cholera some- times consequent on intemperance; the shock DELIRIUM WITH TREMOR—Symptoms. 573 arising out of severe injuries, particularly frac- tures ; exposure to cold, a course of mercury, and the puerperal state,* are principally concerned in the production of this affection. That the delirium which has been called “ D. Trauma- ticum” by British writers, and “ D. Nervosum” by Dupuytren, is in every respect the same as that now being considered, is proved by the fact of its appearance chiefly in persons of intemperate habits, by identity of phenomena, and by the ef- fects of various modes of treatment upon both be- ing alike. 10. Although the chief cause of delirium tre- mens is evidently the abuse of intoxicating, espe- cially spirituous liquors, yet this is not the only cause. It may also be occasioned by the drug- ged beverages prepared in Eastern countries, particularly in the East Indies, when too freely indulged in ; and by the excessive use of opium. But it is chiefly when sobriety has followed a protracted debauch; and when, during the first days of the abstraction of the accustomed stimu- lus, the additional causes mentioned above, come in aid of the efficient cause,—when the habits and indulgences of the patient have produced that state of the nervous system which readily passes into serious disease upon its being influ- enced by depressing agents, that true delirium tremens takes place. Inattention to this fact, by nearly all the writers on the disease, excepting Dr. Blake, has led to serious misapprehensions. Practitioners have too generally concluded that the delirium of drunkards is always of the same kind; and have overlooked differences very gen- erally subsisting between that immediately pro- duced by intoxication—the first species of this affection; and that indirectly occasioned by it— the second species, or true delirium tremens. An occasional, or even a single indulgence in intoxicating liquors to excess will sometimes give rise to the former; a repeated, habitual, or pro- tracted indulgence is requisite to the appearance of the latter. The frequency of this affection, particularly in the lower classes, justifies the at- tention recently paid to it; and I believe that it is more common now than formerly, owing to the cheapness, and facilities of procuring spiritu- ous liquors. Between 1820 and 1832, I treated 21 cases, about two-thirds of which were in con- sultation with Mr. Houlton, Mr. Barnwell, Mr. Winstone, Dr. Riding, and Mr. Painter ; the others in dispensary and private practice. In some manufacturing and trading towns, it is of frequent occurrence. In the United States of America, it is, however, much more common than in this country. Dr. S. Jackson states, that he has treated upwards of 200 cases; Dr. Carter, of Philadelphia, mentions nearly the same number ; Dr. Ware says, that he has seen more than 100 ; and Dr. Wright, that he has received, in the institution at Baltimore, from 60 to 70 cases an- nually. But it is evident, from the details they have furnished, in the works referred to at the end of this article, that they have included under the same head delirious affections immediately consequent upon intoxication; and that, owing to this circumstance, has arisen much of the contrariety of opinion respecting the nature and treatment of the disease, which is as remarkable amongst physicians on the other, as on this, side of the Atlantic 11. III. Symptoms.—The phenomena of de- lirium tremens vary remarkably, from the slight- est forms of nervous tremor with spectra! illusions, and accelerated pulse, to the most alarming state of vital depression, muscular agitatiyn, and men- tal alienation about to be noticed. Dr. Blake has marked out three stages into which the dis- ease may with propriety be divided. It should, however, be recollected, that they are not always obvious or clearly defined ; that they exist only in those cases which supervene on the abstrac- tion of the intoxicating stimulus ; that the first stage is wanting in those that more immediately follow intoxication, and consequently in most, if not all, the first species here described; and that, in the species now being considered, it is but seldom brought under the cognizance of the physician,—medical aid being seldom required until the second period is developed. As the treatment may be more precisely stated when the disease admits of a division into stages, I shall adopt that suggested by Dr. Blake, and which differs but little from that which has been fol- lowed by Dr. Lyon, Dr. Ryan, and Dr. Bark- IIAUSEN. 12. The first stage of true delirium tremens frequently appears from two to eight or nine days after a protracted debauch, or a prolonged fit of intoxication ; and is commonly attended by slight febrile action, and gastric derangement, often aggravated by some accidental cause, ex- ternal injury, or contingent ailment (§ 9.), gen- erally the immediate effect of excesses ; but the length of time which elapses between the ab- straction of the accustomed stimulus, and the commencement of the symptoms, is often uncer- tain. The first indications of the disease are, according to Dr. Blake, a peculiar slowness of the pulse, coldness and clamminess of the hands and feet, general debility, and diminution of the animal temperature. In addition to these, nausea and occasional vomiting, particularly in the morning ; much diminution of appetite, and aversion from animal food ; excessive perspiration from trivial exertion; frightful dreams; vertigo, and sometimes cramps of the extremities, are complained of. The bowels are often constipated, but sometimes open, or even relaxed, and the tongue is tremulous, furred, and moist. In most cases, the peculiar tremor of the hands is present in this stage ; but in a few it is not remarked un- til the next. The spirits are much depressed ; the patient sighs frequently ; his countenance is anx- ious and dejected ; he complains of oppression of the praecordia ; is anxious about his affairs ; and is either restless and watchful, or has short and broken slumbers. This state seldom continues longer than a few days. It is generally of longer duration in the old or worn-out drunkard, than in the younger and more robust, in whom it may be followed by increased’vascular action in one or two days. 13. The second stage commences with rest- lessness, a peculiar wildness of the countenance, and a hurried anxious manner; marked suscepti- bility of the nervous system, and irritability of the muscular system ; great excitability of temper, acceleration and smallness of the pulse, and various mental illusions and alienations. The heat of the surface of the trunk increases, but the hands and feet retain the same coldness and * I have seen three cases in females, and these were habitual drunkards ; the disease appeared in two of them a few days after delivery. 574 clamminess already noticed. The mental de- lusion becomes more constant as this stage is developed, and is generally of a low or melan- cholic kind, with continued reference to the patient’s ruling passions and occupations, and anxiety respecting them. He sees objects where their presence is physically impossible; is con- tinually haunted by frightful creatures, or oc- cupied with most extravagant ideas, and is constantly endeavouring to avoid them. He now becomes altogether deprived of sleep; the restlessness and quickness of manner increase; the countenance is more anxious; the tongue is more deeply furred; the tremor of the hands and tongue continue, without remission; the bowels are either constipated, or, if relaxed, the evacuations are very dark and offensive; the urine is scanty; the pulse is soft, or small, and ranges between 100 and 120; the pupils are con- tracted, but the eyes are not intolerant of light; and the patient is talkative, constantly occupied with the objects of his delusions; he cannot be kept in one place ; and, when opposed, is violent and noisy. This stage usually continues from one to three or four days; when it terminates, either in a general mitigation of symptoms, or in more profound collapse of the vital powers, thereby constituting the third stage. 14. The third period, in the slighter or more favourable cases, is ushered in with mitigation of the foregoing symptoms ; yawning, drowsiness, and profound sleep, which generally terminate the disease ; but in the more dangerous cases, the preceding phenomena become more severe, and accompanied by more complete depression of vital power, and increased irritability of mind. The patient makes violent and excessive struggles, which are attended by very copious perspiration. As the malady advances, and the energies sink, the coldness and clamminess of the hands and feet, which had been extending upwards during the second stage, spread over the whole surface ; and the pulse becomes still more frequent, small, weak, or thready, and sometimes can hardly be counted; the tremor increases in the hands, and often invades the whole frame; and is rather a constant trembling, more nearly resembling that occasioned by severe cold, than the sub- suit us tendinum of typhus, or the nervous rigors of some other affections. The perspiration be- comes more and more cold, and exhales a pecu- liar smell, which is, as Dr. Hodgskin has re- marked, between a vinous and alliaceous odour. The countenance is commonly pale and anxious; the pupils very contracted; the tongue loaded, furred, and often brownish at the centre and root, and occasionally red at the point and edges; the patient talks incessantly, and with great rapidity; the delirium increases in violence; and the mind is excessively irritable, and continues so until shortly before death, when a calm takes place. In some cases, instead of this calm occur- ring, the patient is carried off in a convulsion. [Dr. Ray has very truly observed (Medical Jurisprudence of Insanity, p. 417), that the character of the delirium in this disease is pecu- liar, bearing a stronger resemblance to dreaming than any other form of mental derangement, as if the dreams which disturb and harass the mind during the imperfect sleep that precedes the explosion of the disease, continue to occupy it when awake, being then viewed as realities in- stead of dreams. One of the most common hal- DEL1R1UM WITH TREMOR—Diagnosis. lucinations is, to be constantly seeing spiders, snakes, worms, devils, and all manner of unclean things around and about him, and filling every part of his room; and it is the extreme terror which these delusions inspire that gives such an unutterable expression of anguish to the counte- nance, and prompts the sufferer to constant efforts to escape from their presence. Under the influ- ence of these false apprehensions, patients have, in some instances, killed their wives or children, believing that they were enemies, and trying to injure them. Dr. Ray’s work, above quoted, con- tains several such cases, and he observes, that “ so complete and obvious is the mental derange- ment in this disease, so entirely are the thoughts and actions governed by the most unfounded and absurd delusions, that if any form of insanity absolves from criminal responsibility, this, cer- tainly, must have that effect.”] 15. Modifications, p, and other Ameri- can writers, prescribe tartar emetic in frequent doses, in those cases which are referrible to the present species of affection, until it either has an emetic action, or nauseates and purges the pa- tient ; and Dr. Blake confirms the result of my experience, as now stated, in recommending emetics of sulphate of zinc, assisted by the ad- ministration of anlispasmodics and stimulants, such as Bather, camphor mixture, coffee, &c., with the application of cold to hie head, while the surface of the body and extremities are sponged with tepid water ; apu", in some cases, bleeding, without being pushed so far as to increase de- bility. This treatment is, however, most appro- priate when the affection is the direct result of intoxication ; but when it arises from other causes (§ 5.), vascular depletions, purgatives, cold appli- cations to the head, and a more sparing use of stimulants, are most appropriate. 23. B. Treatment of the second species, or true delirium tremens.—a. During the first stage we should endeavour to cut short the disease, by ex- hibiting, every hour, very small doses of laudanum .n effervescing draughts, with the sesquicarbonate of ammonia, in camphor mixture ; or the opium with full doses of camphor and ammonia; and by administering clysters, with assafcetida, cam- phor, and tinct. opii. Dr. Carter, of Philadelphia, advises the mistura assafcetidce with tinctura opii to be taken every hour or two. Dr. Blake recommends the accustomed stimulus in moderate quantity, and at short intervals: but it may oc- casion a too violent reaction, unless the head be guarded by having frequent recourse to the tepid or cold affusion on it. In some cases, however, warm spiced negus or punch may be allowed, especially in exhausted and old drunkards. This i3 the only period in which blisters should be em- ployed—if employed at all. The nape of the neck, or the epigastrium, is the preferable place on which to apply them. Anodyne and stimu- lating liniments (F. 297. 308.) rubbed over the epigastrium are, however, more efficacious. In some cases, a warm bath will precede the use of liniments with marked benefit. 24. Of all the cases of the disease I have seen, there has not been one that has not indicated the propriety of prescribing cathartics, in order to remove accumulated secretions. From the quan- tity of very dark, offensive, bilious evacuations which they have procured,—often not until after their repeated exhibition, and even in cases where the bowels had been opened or relaxed,—I have concluded that collections of vitiated bile in the gall-bladder and hepatic ducts have favoured the supervention of this peculiar affection. Under this conviction, I have always exhibited, as early as circumstances would permit, an active cholo- gogue purgative, generally a bolus consisting of about ten grains of calomel, with as much cam- phor, and a grain of opium, in conserve of roses ; and, in a few hours afterwards, a warm stomachic and aperient draught, followed in an hour or two by an enema (F. 135.). The advantages arising from conjoining camphor, or large doses of am- monia, or capsicum, or other stimulants, with pur- gatives in this disease, are manifest; for by these, or similar means, we shall succeed either in ar- resting its progress, or in preventing the depres- sion which might follow copious evacuations— fears of which have paralysed the treatment of it. In all cases, but especially in diseases accom- panied by low or melancholic delirium, accumu- lations of vitiated bile or other secretions should be suspected and be removed: nor should we in- fer, from having at first failed in procuring their discharge, that no such disorder exists ; for the most active, and even the most judiciously se- lected, cathartics may long fail in evacuating the thickened and morbid contents of the gall-blad- der and hepatic ducts, particularly when their excitability has become exhausted by spirituous potations. 25. b. In the second stage—if it supervene notwithstanding the above means, or if the pa- tient be not seen until it has appeared—the treatment should be commenced by the exhibi- tion of the calomel, camphor, &c., as prescribed above (§ 24.), if they have not been already ex- hibited, or if they have not procured copious, dark, and offensive stools ; and evacuations ought to be promoted by warm and stimulating aperient draughts, and by purgative enemata containing assafcetida, camphor, &c., or consisting of F. 130. 149. The greater number of the cases I have seen had been treated by able practitioners, ac- DELIRIUM WITH TREMOR—Treatment. cording to the plan advised by the best writers, but without success—although purgatives had been given where the bowels had not been suffi- ciently open. In all these, this treatment was immediately put in practice, and assisted by cor- dial draughts containing some one of the ammo- niated spirits, and tethers, &c., and by the ene- mata already alluded to. As soon as alvine evacuations were procured by these means, opium, either alone, or with ammonia or cam- phor, or with both, was prescribed in full doses, and repeated according to its effects ; and al- though they were all severe cases, one only ter- minated fatally. 26. At this period of the disease, the warm bath, at a temperature of about 90°, will assist materially in tranquillising the patient, and pro- moting the effects of opium. Dr. Wright, of Baltimore, strongly recommends it; but it is not a new practice in delirium tremens, as he sup- poses ; and he is favourable to the use of Dover’s powder, which, however, is more suitable to the preceding species. Although opium should bi given in full or decided doses, combined as stated above,—(in from one to three or four grains—the smaller quantity being repeated twice or thrice, the larger not oftener than once, and after a longer interval),—it should not be persisted in. unless sufficient time be allowed to elapse aftei each dose; for, as Dr. Pearson has observed, if it does not succeed after its exhibition at first in a decided manner, it increases the intellectual con- fusion and danger. Some of the American phy- sicians have recommended enormous doses of this medicine. Dr. S. Brown gives from 3 j. to ?ss., or even more, of laudanum for a dose. Dr. S Jackson prescribes from ten to fifteen or even twenty grains of solid opium every two hours ; and states, that four ounces of good laudanum having been given in twelve hours, partly by mistake, a sound sleep of twenty-four hours duration, and perfect recovery, were the result. I only am surprised that the sleep was nol that of death. These are not solitary instances of the extravagance, if not rashness, of some Amer- ican practitioners ; nor, indeed, has the practice of giving excessive doses of laudanum in this af- fection been limited to them. When we find thirty or forty leeches ordered to be applied to the throat of a child five or six years old in croup, and repeated oftener even than once, and the bleed- ing promoted, should we wonder that death en- sues? Feats of hardihood in medicine are ton often the consequence of clerical and practical ignorance; and they may be allowed to meet their own reward, as long as they are not ob- truded into the annals of our science, and thereby set forth to the inexperienced as examples to be followed. But when this distinction is conferred on them, it becomes the duty of those who record the progress of medicine, to note also, and to oppose, its backslidings by the severest reprehen- sions. 27. I believe that large and frequently re- peated doses of opium in this disease, as Dr. Wright, of Baltimore, has remarked, favour the supervention of coma, convulsions, or paralysis ; and that the effects of an excessive quantity of this drug very nearly resemble the phenomena of the last stage of the disease, particularly towards its fatal close. This fact should not be over- looked, and should lead us to distinguish between the consequences of an injudicious treatment, 577 DELIRIUM WITH TREMOR—Treatment. 578 and the worst features of the malady. It is the abuse of opium that is here argued against; its truly medicinal exhibition that is contended for,— given in a quantity which sound sense will dic- tate, and after accumulated and morbid secretions and excretions have been removed, the discharge of which might be impeded, or interfered with by the immediate employment of this valuable rem- edy. I consider opium as necessary to the cure of this disease, as bark and analogous medicines are to the cure of ague ; but, as in their case, the morbid colluvies, which has at least disposed the system to be affected, and aggravated the malady, should be removed, in order that recovery may be ensured and be permanent. 28. In this stage of the disease, particularly when the delirium is attended by much agitation or violence, it is necessary to obtain an influence over the patient’s mind by moral means. All irritating contentions, however, should be avoided ; and the patient’s wishes, when not likely to prove injurious to him, be indulged. By thus granting what is less material, he will more readily submit to what is important; but he ought not to be left a moment without an attendant. Coercive measures will generally be found unnecessary, if soothing and indulgent but firm treatment be adopted, and the warm bath be occasionally re- sorted to. In a majority of instances, the above means will be followed by a remission of the symptoms, and a disposition to sleep will manifest Itself,—sometimes, however, accompanied by nervous rigors. Opium should now be left off, or its dose mnch diminished; and the patient kept as quiet as possible. His first slumbers are often short, broken or interrupted by startings, or ter- minated by fright. If he awaken alarmed, his distress should be soothed, and a moderate dose of opium with warm spiced negus or punch may be given him ; these will generally secure a sound sleep, from which he will awaken in a rational state of mind. Afterwards it will only be necessary to support the strength by light and nutritious diet, and gradually diminish the quan- tities of the restoratives that have been pre- scribed. 29. In cases characterised by much vital de- pression, very frequent pulse and cold surface occurring in old and habitual drunkards and broken constitutions, a liberal use of cordials, and even a moderate quantity of the accustomed stimulus, in addition to the opium, should be ad- ministered from time to time ; particularly if the head be cool, the face pale, and the action of the carotids not strong. On the other hand, in those cases which were described (§ 15.) as approaching the first species of the disease, cupping, or the application of leeches on the occiput, or nape of the neck, or behind the ears, will be requisite early in this stage ; and full doses of calomel, and the rest of the purgative treatment, with cold applications, or tepid affusions on the head, should be more actively employed, and precede the ex- hibition of opium. In this state of the disease, opium often aggravates the symptoms, unless it follow a judicious use of these remedies; and other excitants are equally injurious. In these cases, James’s powder, or antimony, either pre- viously to, or conjoined with, camphor and opium, will also be productive of much benefit. 30. That state of the disease which comes on after external injuries or operations (§ 9.), I have imputed chiefly to the previously intemperate habits of the patient. It requires the same treat- ment as the more nervous or vitally depressed cases now alluded to (§ 29.); and, as well as these, will be remarkably benefited by small clysters containing' moderate doses of laudanum, administered after the bowels have been suffi- ciently evacuated, and repeated according to cir- cumstances. This treatment has been much relied upon by M. Dupuytren : but if it remove not the disorder, after sufficient time has been allowed for its operation, camphor may be added to it; and ammonia, musk, aether, See. be given in suitable vehicles ; or a moderate quantity of the patient’s favourite beverage allowed him, as suggested by Dr. Colles. Of two cases recently reported {Med. Gazette, vol. vii. p. 287.), which confirm the view I have taken of the origin of traumatic delirium in that state of constitution which intemperance induces, opium failed in one; and hydrocyanic acid, which was tried in the other, was equally unsuccessful. 31. c. If the third stage appear notwithstanding the above treatment, little hope of recovery can be entertained, as most likely serous effusion has become superadded to exhausted vital and ner- vous influence. Nevertheless, medical aid should not be withheld, especially if the patient have not received it in the earlier periods, or have been treated injudiciously. The hair should be re- moved from the head, and either a blister applied, or one of the liniments (F. 299. 308.) rubbed upon it. A blister, sinapism, or other rubefacient, should also be applied over the epigastrium ; and camphor, ammonia, musk, capsicum, Sec. liber- ally administered; restoratives and stimulants being also exhibited in clysters. Mercurial lini- ments containing camphor may likewise be rub- bed upon the inside of the thighs, and the warn* bath resorted to. 32. d. Certain modes of practice have been em- ployed, to which a brief reference may be made. Dr. Klapp, and some other physicians of the United States, have recommended tartar emetic in frequent - doses, until it nauseates and purges the patient; but this treatment is more appro- priate in the first species, or in such cases of the second as approach it most nearly (§ 15.). Dr. Speranza, of Parma (Bullet. des Scien. Med. Sept. 1830.), directs leeches to the head and anus, applies ice to the scalp, and gives calomel and jalap, and subsequently hydrocyanic acid. This method is obviously suited only to the first species, and would be injurious in most instances of the second. From the preference he has given to the appellation adopted by J. Frank,—-2?/iee- phalis tremefaciens,—I would infer that he ha3 never prescribed it in the true delirium tremens. Dr. A. L. Pierson (N. Eng. Journ. of Med. and Surg. vol. ix. No. 2. Ap. 1820.) states, that he gave very large doses of digitalis (sixty drops every three hours) after bleeding, and the patient recovered; but this was evidently a case of this first form of the disease. Dr. Pauli informs us that he has prescribed from three to six drachms of fresh ox-gall, in aromatic water, half a glass of brandy each morning, and two grains of the watery extract of opium at night, in forty-three cases, and has lost only one {Med. Gazette, vol. ix. p. 776.). The propriety of having recourse to moderate quantities of the stimulus to which the patient has habituated himself, in the depressed periods of the disease, and especially in those cases which present the more marked signs of 57t exhausted nervous and vital power, has been in- sisted on by Dr. Blake, Dr. Ryan, &c., and admitted above, as well as by others ; and quinine, capsicum, the preparations of hop, and various aromatics and cordials, may be also used as ad- juvants of opium. [There is no disease which has occasioned a greater diversity of opiniou, both as to its pa- thology and treatment, than that of delirium tremens. And this has doubtless arisen from con- founding different forms and stages of the disease, and not marking those well-defined varieties so lucidly described by our author. American phy- sicians have thrown more light upon it than all the European writers combined ; perhaps, because it may be said it is a disease of more frequent occurrence in this country than in any other, and we have therefore more frequent opportunities of observing and treating it. So far as we have ob- served, the treatment of this disease among us is, as it should be, eclectic. To say that the opium treatment, or the stimulating treatment, is the only proper course to pursue, is in the highest degree absurd. Fortunately, it is a complaint that is not apt to terminate fatally, except when complicated with cerebral inflammation, or is treated badly: a large majority of cases recover- ing, if left solely to the recuperative efforts of nature. From a pretty extensive experience in dispensary practice, we are certain hat the opium practice is the most fatal of all, and be- tween the expectant and the stimulant treatment, we should be inclined to give the preference to the former. On this point, therefore, we agree with Dr. Ware, of Boston, who has published a Very excellent paper on the subject, in the Boston Medical and Surgical Journal. It appears that eight cases were treated with large doses of >pium, given with the intention of bringing about i termination of the paroxysm by sleep. The juautity administered varied, in different cases, from 24 to 72 grains, and it was usually given in the course of forty-eight hours. Four of these cases proved fatal—one died after sleep had been procured, the patient never awaking after the full effect of the remedy had been produced, but expiring in a state of coma. The other three died without having slept. Seven cases were treated by small doses of opium, or opium given in such manner and quantity as not to have a distinct and powerful influence in the procuring of sleep, the quantity not exceeding two or three grains in twenty-four hours. Two of these pa- tients d.ed, both without having slept. Twelve cases were treated principally by repeated and continued vomiting by tartar emetic, according to the mode of practice recommended by Dr. Klapp, of Fniladelphia. Of these one only died. In twenty-nine cases the mode of treatment was expectant, and one died. To sum up, of fifteen cases treated by opium, six died ; of forty-fire in which it was not used, two died. “ This differ- ence,” says Dr. W., “ in the results of treatment, would seein altogethor too great to be attributed to accident, and goes far to establish the truth of the opinion, that opium given in large doses is actually injurious to patients labouring under de- lirium tremens. But even admitting it as possible that the great proportion of fatal cases, occurring where opium was used, was accidental, it cer- tainly, I think, will not be contended that the favourable termination of the cases not treated by opium was also owing to accident. And it DELIRIUM WITH TREMOR—Treatment. will certainly follow, that opium, if not absolutely injurious to these patients, is at least useless, and that our success in this disease will be sufficiently satisfactory without it.” We believe that delirium tremens will rarely prove fatal, unless some other affection is present, which endangers life apart from the influence of the former. Of the eleven fatal cases described by Dr. Ware, it appears that eight were of this character. It is certain that such complications often exist, which are not detected during life, owing to the difficulty of diagnosis from the de- lirium that is present. It is generally supposed that the patient is safe if sleep can but once be induced, and yet we sometimes see cases termi- nate fatally after sleep has occurred. General blood-letting, though not often indicated, is by no means inadmissible in this disease. We formerly bled nearly one half of all cases treated, and yet we rarely lost a patient. Other means, however, were employed at the same time, as gentle cor- dials, stimulating diaphoretics, and in some in- stances anodynes, and alcoholic potations, accord- ing to the particular circumstances of the case— not unfrequently, cups, or leeches to the epi- gastrium or the temples, were indicated, and a stream of cold water turned upon the head from a considerable height, has, in repeated instances, restored the patient to a calm and tranquil condi- tion. The ordinary antispasmodics, as valerian, musk, castor, and assafoetida, have rarely proved beneficial; often, indeed, they have seemed to aggravate all the symptoms, and we believe they possess no specific power whatever over the dis- ease, as has been claimed for them by soma writers. There is often present great irritability of the stomach, which is best allayed by swal- lowing small bits of ice, or ice water; having previously applied a mustard poultice over the stomach. In short, the treatment of this disease, like most others, must be eclectic, in order to be successful, although we are aware that great suc- cess has been lately claimed for the stimulant plan of treatment, as practised by Dr. Gerhard in the Philadelphia Hospital. Of 162 cases of the dis- ease, this physician claims to have cured 160, and that “the disease terminates favourably in every instance, when treated according to the method recommended.” Siroiiar success, how- ever, has attended a directly opposite mode of treatment, and Dr. Dunglison states (Cyclopedia of Prac. Med., art. Delirium Tremens) that du- ring the years 1841-42, in the Women’s Lunatic Asylum of Philadelphia, eighty-four cases of deliri- um tremens were treated without a drop of alco- holic liquor, and with the loss of only one patient, w ho died the morning after her admission, and was not seen by him. Moreover, it appears that of the fifty-one cases treated by Dr. Klapp, by emetics, without a drop of alcoholic drink, or a particle of opium, all but one recovered. So that it is by no means settled, as yet, that the stimu- lant treatment is preferable to all others. In favour of the opium treatment, see papers by Joseph Klapp, Medical Recorder, vol. i. Ec- lectic Repertory, vol. vii. John Hale, Med. Re- corder, vol. ii. Joseph G. Nancrede. Ibid. Daniel Drake, Ibid., and Gilbert Flagler, Ibid. Wal- ter Channing, New Eng. Journal of Med. voL viii. advocates the opium treatment. W. D. Brin- kle, N. Am. Med. and Surg. Journal. B. F. Coates, Ibid., for July and Oct. 1828. Dr. C. -maintains that tha disease consists in a heightened 580 activity of the sensorium, and that this appears to arise from the generation, in that organ, of an unusual vital power, which is not, as is common, exhausted by the narcotic poisons habitually used ; that it is apt to be complicated with other dis- eases, the symptoms of which it observes, or ren- ders imperceptible ; that it is accompanied, as all vital excitements are, with an unusual amount of blood in the organ affected ; and is from this cause sensibly influenced by cups, blisters, and emetics, but is not so far checked by emetics as to render them advisable as a leading means of cure ; that it is not sufficiently under the control of the gen- eral circulation as to be cured by venassection ; or to be sensibly relieved by it, without such an ex- haustion as is highly dangerous to life; that it is entirely and absolutely under the control of opium, although the fever and other diseases which are liable to accompany it may be by no means so ; that it admits of very large doses of opium, which are not productive, either at the time, or subse- quently, of any injurious consequences, provided they are not repeated, after a tendency to sleep is evinced ; that the patient must sleep or die ; but that the physician should closely watch the effects of the opium, which may be administered without delay and without regard to the different stages of the disease ; that purgatives are of no use, but to prevent costiveness, after the admin- istration of the opium, although they may be in- dicated for diseases that exist at the same time, but in these cases, should be postponed till after sleep has been procured ; and, finally, that gentle stimulants are frequently useful during conva- lescence ; but that they should not resemble ardent spirits, nor should these latter be given during the paroxysm : that an excellent and suffi- cient one is capsicum. One of the best essays published in this country, on Delirium Tremens, is by Drs Jesse Carter, of Philadelphia, (Am. Journ. Med. Sciences, vol. vi. p. 321.), from whom Dr. Copland has freely borrowed in the preceding article. Dr. C. relies chiefly on opium and the tincture of hops, combined with the free use of the patient’s accustomed stimulus. Where gastritis, hepatitis, pneumonitis, or cerebritis is present, the exhibition of opium would only hasten the fatal termination. Dr. C. states very truly, that where there ia active determination of blood to the head, as evinced by the excitement of the mind, heated state of the scalp, flushed face ahd injected eye, sleep cannot be produced by the ex- clusive use of opium. The system is exhausted by excessive exertion, the eye retains its restless- ness and watchfulness, the voice becomes more enfeebled, symptoms of stupor and insensibility, with stertorous breathing, supervene, and the pa., tient expires in a fit of apoplexy, or else lingers' for several days, and then dies of effusion on the brain. But if depletory measures are first resorted to, as bleeding, cathartics, cold to the head, leech- es, &e., then the administration of opium would be followed by the happiest effects, in calming the excitement and producing sleep.] 33. e. During the treatment, little or no nourish- ment is desired, or even required : arrow-root and ■feago, with a little brandy or white wine, may, however, be given from time to time, particularly if the patient wish it. When he becomes con- valescent, the diet should be very light, but nu- tritious ; and a suitable beverage, in moderate quantity, be allowed. During recovery, the state of the digestive functions ought.to be attended to, DENTITION, DIFFICULT—Pathology of. and promoted by tonics, and by aperients when ever the bowels are torpid- I have never known or heard of an instance wherein the state from which the patient has escaped, or the representa- tions of the medical attendant or friends, has effected a reformation of the habits which pro- duced the disease. However, the physician should discharge his duty, by stating to him the conse- quences that will accrue from persisting in them. Bibliog. and Refer.—S. B. Pearson, Observ. on Brain Fever. Newcastle, 1801.—M'Whirter, in Med. and Phys. Journ. vol. xviii. p. 153.— T. Sutton, Tracts on Delir. Tremens, &c. &c. 8vo. Lond. 1813.—Arm- strong-, On Brain Fever from Intoxication, in Ed in Med. and Surg. Journ. vol. ix. p. 58. 146.—Jficol, in Ibid. June, 1831.—A. L. Pierson, in N. Eng. Journ. of Med. and Surg. vol. ix. 1820.—S. Brown, in Airier. Med. Re corder, April, 1822.—Klapp, in Ibid. vol. i.; and Eclect. Repert. vol. vii. p. 252.—Snowden, in Ibid, vol v.—Play- fair, On Del. Trent., in Transac. of Med. and Phys. Soc of Calcutta, vol. i. p. 124.—Coates, in North Amer. Med. and Surg. Journ. vol. iv.; and in Johnson's Med.-Chirurg. Rev. vol. viii. N. S. p. 457.—Clutterbuck, Lectures in Lancet, vol. xi. p. 376.—Barkhauscn, in N. A. Med. and Surg. Journ. vol. vii.—Leveille, Mein, sur la Folie des lvrognes, in Mem. de l’Acad. Roy. de Med. tom. i. 4to. Paris, 1828, p. 181.—Ryan, in Lond. Med. and Surg. Journ. vol. iii. p. 227.—Hells, in Archives G6n. de Med. t xv. p. 430.—A. Blake, Pract. Treat, on Delirium Tre- mens, &c.8vo. 1830.; and in Edin. Med. and Surg. Journ. Oct. 1823, p. 501.— T. H. Wright, in Amer. Journ. of Med. Sciences,vol. vi. p. 17.—S. Jackson, in Ibid. vol. vii. p. 361 —J. Carter, On Mania a Potu, in Ibid. vol. vi. 321.— Ware, On the IJistory and Treatment of Delir. Trem. 8vo. Host. U. S.1831.—Bright, Medical Reports, vol. ii part i. p. 15, ct seq.—Hingeston, in Lond. Med. Gaz. vol. xi. p. 7.—F.Uiotson, in Ibid. p. 466.—J. Johnson reported in Lancet for March 23, 1833. DENTITION, DIFFICULT.—Syn, Dentitio difficilis, Odontio Dentitionis, Good. Dys odontiasis, Ploucquet. Difficult Teething. Classif. — 1. Class, 1. Order (Good) II. Class, I. Order (Author'). 1. Defin.—Slow or delayed evolution of tlu. teeth, with signs of local irritation, and con stitutional disturbance, often with disorder man ifested especially in the digestive organs and nervous systems, occurring chiefly in weak or over-fed children. 2. A general view of the pathological relations of dentition was exhibited in the article Age (§ 10.) ; and, therefore, only that morbid con- dition of the process which is unattended by dis- ease of an important organ, and is referrible chiefly to this process itself, although often caus- ing disease, or being accidentally associated with it, will be here noticed. 3. i. Dentition, in the most favourable cases, is preceded by slight salivation, by heat and fulness of the gums, occasional flushings, increased thirst, restlessness or fretfulness, and frequent endeav- ours to thrust things into the mouth, evidently to allay irritation or itching. These symptoms gen- erally appear about the third or fourth month, and precede the appearance of the teeth sometimes by several weeks ; and occasionally subside, and re- appear shortly before the tooth makes its way through the surface. These signs of disturbance are merely the necessary attendants on the for- mative processes going on in the gum. But very commonly in children of deficient vital power, and occasionally in those which are apparently robust, or rather plethoric from overfeeding, den- tition is either delayed, or is attended by more serious disorder, particularly while the canine teeth are being protruded. In delicate children, particularly those living in crowded towns, and low and ill-ventilated localities, this process is DENTITION, DIFFICULT—Treatment. both late and slow in taking place, and is often attended by signs of increased irritation, as red- ness or tumefaction of the gums; by various cutaneous eruptions ; by greater fretfulness, some- times sickness and feverishness towards night, with restlessness, fits of crying, and sudden start- ings from sleep. These may be the only ailments, which may subside either partially or altogether as soon as the tooth has passed the surface, and return shortly before others come in sight; but not infrequently, particularly in this class of pa- tients, disorders of the prima via, particularly chronic diarrhoea, slight dysenteric affections, or slow remitting forms of fever, obstruction or en- largement of the mesenteric glands, obstinate and recurring coughs, tubercular degeneration in the lungs or digestive tube, marasmus, &c., super- vene more or less rapidly. 4. ii. In children who are of a plethoric rather than of a robust habit of body, and which Dr. J. Clarke has, with much justice, ascribed to over- feeding, the gums are often swollen and painful, the face flushed, the head hot and pained; and all the symptoms of inflammation of the mem- branes of the brain, or of inflammatory fever with determination to the encephalon, frequently supervene. In them, the symptomatic fever is generally high, and attended by great thirst, nausea, vomitings, constipation, and occasionally by drowsiness or stupor, or by great irritability and restlessness, or by both states of disorder al- ternately ; sometimes by short broken slumbers, from which the child awakens in a state of alarm, or in a fit of crying; or by convulsions, dimin- ished secretion of urine, and other signs of cere- bral affection. These are the usual concomitants and symptoms, or consequences, of difficult den- tition ; but they do not always stop here; for they often run on into more serious disease,— such disease, however, occasionally appearing more abruptly and without these precursory ail- ments, at least in such degree or duration, as to become objects of attention to the attendants, or to lead them to resort to medical aid. These maladies, although often occasioned either partly or chiefly by dentition, when occurring in children at that epoch ; and whether affecting the cerebral, the thoracic, or the abdominal organs, or the skin ; are still more frequently independent of this pro- cess, and therefore cannot be further alluded to in connection with it, than they have already been in another place (see Age, § 10.);—and, indeed, in most instances in which a close con- nection between them and difficult or morbid dentition is observed, it is that of concurrent ef- fects of constitutional predisposition and of an- terior changes in the organic functions ; the local irritation and sympathetic febrile disturbance either exciting morbid action in such organs or tissues as, from hereditary conformation or vice, are disposed to it; or aggravating previously ex- isting disorder, and rendering evident what was before latent, or unobserved. In these cases, therefore, dentition is to be looked upon either as a principal, or as a concurrent exciting cause of many of those diseases which occur at the period of dentition—but a cause most frequently con- current with improper feeding and clothing. 5. iii. A natural or slightly difficult dentition may be converted into serious disease, by the not uncommon habit of giving the infant food when- ever it cries from the irritation attending upon the process, and thereby overloading and further dis- ordering the digestive processes, which are already disordered by the febrile disturbance generally accompanying it; whilst determination of the cir- culation to the head is favoured by the practice of covering the head in-doors or when asleep, and by wearing thick felt hats during mild or warm weather. Brandis believes that difficult den- tition is the consequence of obstruction of the salivation which accompanies, and is salutary in. this process : Hecker, that it results from a mor- bid state of this secretion: Mylius, that it is the effect of disorder sympathetically induced in the liver: Thom, that dentition often occasions an acrimony of the abdominal secretions, which react upon the original seat of disorder, and upon the system generally; thereby rendering it difficult or morbid : Wigand, that the affections attending, delaying, and otherwise disordering, this process, are accidental complications merely ; and John Clarke, that all such disorders are commonly the consequences of plethora arising from over- feeding. Now, in all these opinions, there is much truth ; and one or other, or several of them obtain in many instances, more, however, as con- tingent and related effects of the local irritation, than as causes of the difficulty of the process,— which irritation is the chief or concurrent cause of febrile disturbance, of disordered function, and at last of more palpable disease, according to the condition of particular organs at the time, and constitutional or acquired predisposition. 6. iv The irruption of the second or perma- nent teeth may also be delayed or attended by sympathetic disorders, particularly in persons whose maxillae are insufficiently developed, and when the dentes sapientes, and the canine teeth, are appearing. In delicate, nervous, and irritable subjects, swelling of the parotid and sub-maxil- lary glands, painful and sometimes periodic affec- tions of the ear or face, slight or recurring op- thalmia, irregular convulsions, or epilepsy, and chorea, have, in some instances, been excited by this cause ; and have disappeared upon the erup- tion of the teeth, or the removal of the local irri- tation. 7. v. The Treatment of difficult dentition should be directed with the intention—1st, of re- moving the local irritation; and, 2d, of subduing the sympathetic disorders associated with it.—A. The local irritation requires scarification of the gums whenever they are at all swollen or red; and particularly in the second stage of the process, when the tooth has reached the surface, whether there be redness and swelling or not. The pro- priety of this operation has been, however, called in question, particularly by Sternberg, Storch, Thom, and Brandis, on the plea of its inutility, of its occasioning ulceration or disease of the cap- sules of the teeth, and of the cicatrix which is soon afterwards formed being absorbed with greater difficulty than the other parts. But these are by no means valid objections—for its utility has been proved by the experience of Harris, Cowper (.Anat. of the Hum. Body, Bromfield (Ob- servations, tj-o. vol. ii. p. 17.), Berdmore (Treatise on the Teeth, tf-c., 8vo. Lond. 1770.), Hurlock, Riedlin, Wedekind, Kennedy, Marley, myself, and most modern writers of experience: and, as to the contingent ulceration of the gums, it seldom or never occurs when the operation is judiciously performed; when the lancet is clean, not carried too deep into the gum, if lancing be performed early in the process; and when its edge is directed 581 DENTITK, DIFFICULT—Treatment. 582 rather outwards, as recommended by Mr. Mar- ley. That the cicatrix may oppose the passage of the tooth is certainly not proved ; but this, if it did, is no objection, as a repetition of the opera- tion is often necessary, and generally beneficial. M. Brouzet (Sur VEducat. Medic, des Enfans, t. i. p. 234.) advises the surface of the gum to be divided, from time to time, by the point of the nail,—a practice which possesses the advantage of not alarming the child, of being easily and readily performed, and of delaying the closing of the divided part. But care should be taken not to perform it until the nails have been well cleaned. 8. The propriety of allowing the infant to rub the gums with hard substances has been ques- tioned by Auzebi, Marley, and others, from an idea that they will hereby become more callous, and absorbed with greater difficulty. But the truth of this is questionable. I believe that sub- stances pressed frequently between the gums, materially lessen the irritation and distressing itching felt in them, and promote the flow of saliva,—results of no mean importance in pre- venting the supervention of sympathetic disturb- ance. These results will be ensured, in cases of existing irritation, by frequently moistening what- ever substance is thus employed with biborate of soda mixed in a little syrup of senna. 9. Besides the above, various other means have been recommended in order to subdue the local irritation : the chief of these are—a preservation of a lax state of the secretions and bowels: leeches, particularly behind the ears (Syden- ham, Kortum, Stoll, Leroy, Journ. de Paris, 1784); internal emollients (Paulus iE gin at us, i. i. cap. 9., and Bekker, Hermet, Rediviv. p. 705.) ; various derivatives (Hufeland) ; calo- mel (Mylius, and others); the alkalies (Hecker) ; cold applied to the face (Wig and), opium (Wedekind) ; and active purging (Vandermonde and Portal, Anat. Medicate, t. i. p. 211.). The best means of promoting the secretions and al- vine evacuations are, small doses of hydrarg. cum creta, conjoined with the dried carbonate of soda, and, if the state of the bowels requires it, with the pulv. jalap®, given every night. Leeches behind the ears, and cold applied to the head, should never be neglected whenever the temperature of this part is increased, and other signs of determination of the circulation to it are observed. In such cases, active cathar- tics, calomel with James’s powder, and the rest of the treatment recommended for cerebral dis- eases, are necessary. Blisters applied also be- hind the ears are the best external derivatives; but they should be removed as soon as redness is produced. Opium is very seldom admissible; but, if much irritation exist, the tepid bath, and syrup of poppies with small doses of the bibo- rate or the carbonate of soda, may be prescribed. If the gums become ulcerated, biborate of soda or sulphate of alumina, or the boracic acid, in honey or syrup of roses, should be employed. 10. B. The sympathetic disorders should be subdued as soon as they appear.—(a) If the head indicate vascular excitement, the means already specified (§ 6.8.) should be directed; and if the symptomatic fever, with or without deter- mination to this quarter, be considerable, cooling aperients, and saline and antiphlogistic diapho- retics, are requisite, with the cold affusion on the head, the tepid bath, &c.—(b) Constipation, or colicky affections, which are not infrequent during this epoch, should receive immediate attention: and aperients, emollient laxatives,— as castor oil with two or three drops of oleum anisi, hydrarg. cum creta with carbonate of soda, —and, if requisite, purgative and antispasmodic enemata, ought to be prescribed.—(c) Care ought to be taken not to check a slight diarrhoea; but if it passes beyond this, emollients, demul- cents, refrigerants, diaphoretics, alteratives, ton- ics, absorbents, &c., should be prescribed, ac- cording to the circumstances of the case, and be assisted by the semicupium, warm clothing on the lower part of the body, and occasional doses of rhubarb with magnesia and hydrarg. cum creta.—(d) In some cases, both vomiting and purging, or a slight form of cholera, or of choleric fever, supervene; the stools being greenish, spinach-like, and offensive, sometimes terminating in a gelatiniform softening of the mucous surface of the stomach and bowels, as described by M. Cruveilhier ; but more fre- quently without such disorganization, as M Guersent has remarked. The classes of remedies just now particularised are also admissible in this affection. (See Choleric Fever of Infants, and Diarriicea.)—(e) Watchfulness, irritability, frequent starting from sleep, with crying, &c., should always be dreaded, especially when the canine or anterior molar teeth are about to ap- pear, as not infrequently being the precursors of convulsions, and indicating much sympathetic ir- ritation of the nervous system with disorder, of the digestive organs, and excited circulation in the encephalon. On the other hand, somnolency, particularly in plethoric children, evinces con- gestion within the head, which may be readily converted into inflammatory action; or it may terminate in effusion of serum: and either con- dition may usher in convulsive spasm of the. larynx, the nature and morbid relations of which have been so little understood. In all these varying states and relations of disease, leeches applied behind the ears, lancing the gums, pur- gatives, emollients, refrigerants, a cautious exhi- bition of narcotics, laxative and antispasmodic enemata, the tepid bath, cold or tepid affusion on the head, rubefacient and anodyne liniments (F. 298. 308. 311.) rubbed along the spine, and, in delicate children, gentle tonics, are requisite, and should be modified according to the habit of body, and the particular features of the case. (See Convulsions in Children; and Larynx— Convulsive Spasm of.)—(/) The occurrence of obstinate coughs at this period should suggest attention to the state of the gums, with the use of demulcents and emollients, conjoined with laxatives, external derivatives, and diaphoretics. Leeches, also, ought to be resorted to, if the cough be attended by heat of skin, quick pulse, accelerated respiration, or if the child be ple- thoric.—(g) Eruptions, also, on the head, be- hind the ears, or on any part of the surface, ought not to be suppressed by external applications ; but the functions of the abdominal and depura- tory organs ought to be promoted by alteratives and gentle aperients, and the utmost cleanliness of the skin preserved. [We have been in the habit, for some years past, of healing up eruptions on the head and other parts of the body, which have been caused by the irritation of teething, and we have wit- nessed no unpleasant consequences from the DIABETES. 583 practice. We, however, at the same time, pre- scribe laxatives, as syrup of rhubarb, or small doses of calomel, administered daily, and direct the child to be kept exclusively upon the mother’s milk, if nursing; and if weaned, or brought up by the bottle, to lessen the quantity of food, as well as reduce somewhat its quality. With these precautions, eruptions may speedily and safely be healed, by the use of the calomel ointment, or almost any of the mercurial preparations, and without endangering the health of the child. During the 16 years, extending from 1819 to 1834 inclusive, the number of deaths from teeth- ing in the city of New York, according to the City Inspector’s Report, was 1163. But this in- cludes but a very small proportion of the number, as inflammation of the brain, hydrocephalus, chol- era infantum, and other forms of disease are of- ten induced by the same cause.] 11. C.—(«) During dentition, the head should be washed with cold water night and morning; and no other covering than that with which nature has provided this part should be put upon it when within doors or asleep; and on no occa- sion should warm felt hats be worn, thin straw or white hats being lighter and cooler.—(6) The diet should be carefully attended to, and that only allowed which is easily digested ; and even it ought to be taken in moderate quantity. The child ought also to be much in the open air; and, if the process threaten much constitutional or lo- cal disease, an entire change of air will often be advantageous. Biblioo. and Refer.—Hippocrates, ITept oSovTtnpviris, Opera, cura Vender Linden, vol. i. p. 590.—Aetius, Te- trab. i. ser. iv. cap. 9.—Avicenna, Canon. 1. iii. fen. 7. tract, i. cap. 16.—De Castrillo, De Dentitione, Valadol. 1557.; in Haller's Bibl. Med. Pract. vol. ii. p. 119.—Pa- ricus, Opp. Chirurg. 1. xxiii. cap. 67.—Riedlin, Lin. Med. 1695, p. 406.—Ortlob, De Dentitione Puer. DifficUi. Lips. 1694.—Sydenham, Opp. p. 248.—Harris, De Morbis Acutis Infantum, p. 28.—Beurlin, De Dentitione Diffi- cili. Altd. 1720.—.7. Hurlock, Practical Treatise upon Dentition. Lond. 1742, 8vo.—Juncker, De Dentitione Ditiicili. Hal. 1745.— Vandermonde, An Infant, a Den- tit. Convulsionibus vel Soporibus repetitas Catharticorum Hsus. Paris, 1757.—Stoll, Pradect. i. p. 247., ii. p. 414.— IFigand, Heitriige, heft. ii. p. 141.—.7 Hunter, The Nat. iiist. of the Human Teeth, &c. pp. 132. 234.—R. Blake, On the Struct, and Form of the Teeth, &c. Dub. 1801. — Wichmann, Ideen zur Diagnostik, b. ii. p. 3.— Wagner, De Dentitione Diff. a dubiis Cl. Wichmanni Vindicata. Jen. 1798.— Thom, Erfahrungen und Bemerk. p. 21.— Starch, Kinderkrankheiten, t. ii. — Brandis, Versuch ueber die Metastasen, p. 210.—Ludwig, De Dent. Diff. Lips. 1800.— Wedekind, in Hufeland’s Journ. der Pract. Heilk. b. ix. st. 1. p. 34.—Mylius, in Ibid. b. xxvi. st. 2. p. 183.—Hecker, in Magazin fur Pathol. Anat. und Phys. b. i.—Hufeland, Bemerk. ueber Blattern. &c. p. 341.— Fox. On the Diseases which affect Children in the first Dentition, in Nat. History of the Teeth. Lond. 1803, 8vo. —Bichat, Anat, Oencrale, t. iii. p. 88.—Beaumes, Traite de la Premiere Dentition, et de Malad. qui en dependent. Paris, 1805, 8vo.—Gardien, Sur les Mai. des Enfans, &c. —Jit. Good, Study of Med. vol. i. p. 50.—.7. Kennedy, On the Management of Children in Health and Disease, 8vo. Lond. 1825, p. 297.—X. Palmer’s Popular Illustrations of Medicine, 8vo. Lond. 1829, p. 127.— T. C Haden, Observ. on the Management and Diseases of Children, 8vo. Lond. 1827, p. 132.—Darwall, On the Management and Disorders of Infants and Children, &c. 8vo. Lond. 1830, p. 79.—Marley, On the Nature and Treatment of the Diseases of Children, 8vo. Lond. 1830, p. 90.—Evanson and Maunsell, On the Management and Diseases of Chil- dren, 8vo. Dublin, 1836, p. 196. [See Stewart, Dewees, Condie, and Eberle, On the “ Dis- eases of Children,” art. Dentition. Also art. “Denti- tion,” in the Cyclopedia of Practical Medicine, edited by Prof. Dunglison. Phil. 1844. For a case of Third Denti- tion, see Eclectic Journal of Medicine, vol. iv. p. 142. For similar cases, see also Jehler, Progr. de dentitione tertia. Lip. 1786.—Haller, vol. viii. p. 22.—Med. and Phil. Comment, vol. iii. and viii .—Simmons, in Med. Ob- servation and Inquir. vol. iii. p. 148.—James Jackson, Re- marks on the Morbid Effects of Dentition, New Eng. Journal, vol. i. pp. 12. 113. 22!).] DIABETES. Excessive Secretion of Urine.— Syn. Aia/ifijrijj (a siphon ; or from iiaPaivw, transeo). Lienteria Urinalis, Tabes Urinalis Diarrhoea Urinosa, Hydrops ad Matulam, Profluvium vel Nimia Profusio Urince, Cito Ernissio Rerrnn quce bibuntur, Auct. Vet. Polyuria, Seidel. Diabetes Anglicus, Mead and Sauvages. Phthisuria Saccharina, Dia- betes Saccharina, Nicolas, Gueudeville, Hufe- land. Diabetes Mellitus, Cullen and Sagar. Dipsacus, Hecker. Phthysuria, Reil. Meli- turia, R. Willis. Harnfiuss, Honigartige Harnruhr, Germ. Urinflod, Dan. Diabete, Fr. Flosso d’Orina, Ital. Urine-Flux. Classic.—2. Class, Nervous Diseases; 3. Or- der, Spasmodic Disorders {Cullen). 6. Class, Disease of the Excreting Func- tion ; 2. Order, Affecting Internal Sur- faces {Good). I. Class, II. Order {Au- thor in Preface). 1. Defin.—Urine secreted of a sweet taste and violet smell, generally in large quantity, with great thirst, dryness of skin, debility, and emaciation. 2. This disease was but slightly alluded to by Celsus. Aret.lus gave a tolerably complete history of it, which the majority of his followers merely copied. Alexander of Tralles added nothing to either its pathology or treatment, ex- cepting the drawing of a comparison between it and lientery ; and Aetius, taking up the same idea, states, that the one affection differs from the other in as far as that the undigested aliments pass off, in the former by the urine, in the latter by the stools ; an opinion which was afterwards adopted by Fernel, Duret, Zacutus-Lusita- nus, and others. But Willis was the first who advanced a rational theory of the disease. Since his time, opinions as to its pathology have been various, and the remedies recommended still more diversified. 3. Even up to the present day, the term dia- betes has been applied to various states of dis- ease :—1st. To that consisting chiefly of diuresis, or morbidly increased flow of urine, without ref- erence to its quality; 2d. To that in which the urine is voided not only more frequently, and in larger quantity than natural, but also of changed quality, as respects certain of its constituents, viz. albumen and urea, either of which may be in excess ; and, 3d, to that in which a saccharine matter is either superadded to the other ingredi- ents contained in the urine, or in part replaces them. To the last of these morbid states I shall limit the term diabetes, conformably with the views of Dr. Prout and M. Renauldin. The other morbid conditions of the urine will be no- ticed when treating of the pathology of this secre- tion. (See Urine.) Restricting, therefore, the term diabetes to that state of the urine character- ised by the presence of saccharine matter, I have defined it accordingly. In consequence of the very vague ideas which have but too generally been entertained both as to the phenomena re- quisite to constitute this malady, and as to its various morbid relations, diabetes has generally been considered with reference to the quantity of the fluid secreted, without regard to the cir- cumstance alluded to by Dr. Parr and others, and judiciously insisted on by Dr. Prout, that the disease may exist for a long time, and the urine 584 DIABETES—Symptoms. of which indicates the amount of saccharine mat- ter in the urine. [According to Berzelius, when the urine is evaporated and treated with alcohol, the sugar and extractive matter, soluble in alcohol, are dissolved. After sufficient evaporation, the sugar crystallises from this solution in small granular crystals like sugar of grapes. Sometimes, how- ever, merely a sweet syrup is obtained, which does not yield crystals. It has not yet been as- certained whether there exists an uncryslalli- sable variety of diabetic sugar, or whether it is caused by containing so much deliquescent ex- tractive matter that its water prevents the crys- tallisation of the sugar. This may easily be de- termined, by destroying the sugar by fermenta- tion, and evaporating the fermented fluid, where- by the extractive matter is separately obtained. Prout has already proved that it is the same sugar that in vegetable chemistry is called grope sugar, for it agrees with it in all its chemical prop- erties, as well as its composition. Peligot and Erdmann, and other chemists, have also arrived at the same conclusion. Its Formula is C12 H'2 CH2, or simply C6 H6 O®.—In order to separate the sugar in its pure state, Berzelius advises to evaporate the urine in a water-bath to the consist- ence of honey, and treat the remainder with alco- hol of 0-833 as long as any substances are dis- solved by it, then evaporate the alcoholic solution to the consistence of a syrup, which is to be put in a cool place for crystallisation, where generally in a few days, sometimes not before a week or ten days, it is converted into a granular mass. This mass is then put in a cool place, after it has been laid on folds of bibulous paper, and covered by a glass receiver, in which a moistened sponge is sus- pended. The extractive matters deliquesce, and are absorbed by the paper, which, with the exception of the sheet on which the sugar is lying, may be occasionally changed. When the paper absorbs no more, the mass is to be crumbled, pressed be- tween fresh bibulous paper, and left for a few days in a warm place under the receiver with the moistened sponge. Finally, the sugar should be powdered and washed with anhydrous alcohol. It is then to be dissolved in water and crystallised. The sugar may also be obtained more speedily and more colourless, by precipitating the solution in alcohol of 0-833, with subacetate of lead added in small portions as long as any separation oc- curs, shaking the liquor well after each addition of the subacetate. Then filter the mixture and wash the precipitate with a little alcohol, treat the spirituous solution with sulphuretted hydrogen, filter from the precipitated sulphuret of lead, and then evaporate to the consistence of honey. When the sugar has been separated by crystalli- sation, the urea, acetic acids, and other substances which it retains are extracted by anhydrous alcohol. It is important to the physician to be able to detect sugar in urine supposed to be diabetic. The easiest way is, to add two tea-spoonsful of ferment or yeast to three or four ounces of urine, and place the mixture in a temperature of about 70° F. If there is sugar present, fermentation will soon take place. Or a few drops of the sus- pected liquid may be placed on a saucer and held over the mouth of a tea-kettle containing boiling water; as soon as it is dried, add a few drops of dilute sulphuric acid, consisting of one part of acid to 6 or 8 of water, and then heat gently for a few minutes. If the urine contains sugar, tha be extremely saccharine, without much, or even any, increase of its quantity 4 aud, when the uri- nary discharge is augmented much beyond natu- ral, that it is much easier to reduce it even to the usual quantity, than to restore it altogether to its natural quality. 4. I. Symptoms.—A. The urine of diabetic pa- tients is generally of a pale straw or greenish yel- low colour ; of a faint and peculiar odour, some- limes resembling that of hay or of sweet whey or milk, or of violets. Its taste is always more or less saccharine ; and its specific gravity usually varies from 1-025 to 1-052. The quantity of urea is seldom much diminished in diabetic urine: Dr. Prout and Dr. Henry have never observed it al- together absent; and Mr. Kane and Mr. M’Gregor have found it in greater relative pro- portion than in healthy urine, but masked by the sugar or saccharine matter held in solution: there is little or no lithic acid. The usual saline ingredients in healthy urine exist in the urine of diabetes, but in diminished quantity, whilst their relative proportions continue nearly the same. Dr. Watt has found a little blood in it; but this is a rare occurrence: it much more frequently contains albuminous matter analogous to that of chyle. Dr. Henry has given a useful table show- ing the quantity of solid extract in a wine pint of urine of different specific gravities from 1-020 to 1-050. The following abstract of this table will enable the reader to ascertain the quantity of solid matter diabetic urine may contain :— Specific gravity com- pared with 1000 parts of water at 60“ Quantity of solid extract in a wine pint. Quantity of solid extract in a wine pint, in grains. oz. dr. scr grs. 1020 382-4 0 6 i 2 1021 401-6 0 6 2 1 1122 420-8 0 7 0 0 1023 410-0 0 7 1 0 1024 459-2 0 7 1 19 1025 478-4 0 7 2 18 1026 497-6 l 0 0 17 1027 516-8 l 0 1 16 1028 536 0 l 0 2 16 1029 555-2 l 1 0 15 1030 574-4 i 1 1 14 1031 593-6 l 1 O 13 1032 612-8 i 2 0 12 1033 632-0 l 2 1 12 1034 651-2 l 2 2 11 1035 670-4 l 3 0 10 1036 689-6 i 3 1 9 1037 708-8 l 3 2 8 1038 728-0 l 4 0 8 1039 747-2 i 4 1 7 1040 766-4 l 4 2 6 1041 785-6 l 5 0 5 1042 804-8 l 5 1 4 1043 824-0 l 5 2 3 1044 843-2 l 6 0 3 1045 862-4 l 6 1 2 1046 881-6 l 6 2 1 1047 900-8 i 7 0 0 1048 920-0 i 7 1 0 1049 939-2 l 7 1 19 1050 958-4 l 7 2 18 This table enables us to ascertain with consider- able precision the quantity of solid matter voided by a diabetic patient in a given time. Thus, suppose 10 pints are passed in 24 hours, of the average specific gravity 1-040, it is evident that this will contain 10 X 1 .. 4 .. 2 .. 6—15 .. 7 .. 2, or upwards of a pound and a quarter of solid extract. Diabetic urine, in a moderate temperature, be- comes sour, smells like turned milk, and some- times ferments. With the addition of a little yeast, it readily undergoes the vinous fermenta- tion, yielding alcohol by distillation, the quantity DIABETES—Symptoms. spot soon turns black ; otherwise it has an orange colour. This action is so delicate that when one part of sugar is dissolved in 1000 parts of healthy urine, the spot is blackened; and with one part of sugar to 2000 of urine it becomes sufficiently dark to yield a distinct proof of the presence of sugar.—(Range.) Lehmann has discovered hip- puric acid in diabetic urine, but this is to be re- garded, says Berzelius, as an accidental, not a constant ingredient. See Berzelius On the Kid- neys and Urine, translated by M. H. Boye and F. Leaming, M. D., Phil. 1843, pp. 120, etc.] 5. Besides the saccharine condition of the urine, the next most striking and constant symptom is its increased quantity. Sometimes the quantity voided is enormous. P. Frank details a case in which 52 lbs. were passed in twenty-four hours ; and instances are by no means uncommon of from twenty-five to thirty-five pints having been discharged in the same time for weeks, or even months together. In some cases the urine has been said to have been nearly double the quantity of the whole ingesta,—a circumstance which has puzzled physiologists to explain, and has induced some to believe that, in addition to the colliqua- tion of the solids of the body, absorption of mois- ture from the air actually takes place during the disease in some cases, either through the medium of the respiratory organs or cutaneous surface, or both. I believe, however, that so great a differ- ence between the quantity of the ingesta and urine, as here stated, is extremely rare; although a considerable excess has been proved by Dr. Bardsley ; and the experiments of modern physiologists have shown that the lungs may ab- sorb moisture from the atmosphere, although the skin may be incapable of doing so. 6. B. The constitutional symptoms are often ushered in by weariness and aversion from any exertion ; by dryness and disagreeable taste in the mouth, the saliva becoming white and frothy ; and by a sense of weight, heat, or pain, in the epigastrium, accompanied with alternate chills and flushings, or burnings of the palms of the hands and soles of the feet. To these supervene dryness of the skin, much thirst, costiveness ; a saccharine state of the urine, with, and some- times without, an increased secretion of it; a craving appetite, and all the symptoms constitu- ting the disease. In many cases, the urine has evidently been saccharine, without much in- crease in its quantity, long before the attention of either the patient or practitioner had been directed to this secretion. In other cases, the disease at- tacks more suddenly, generally with dryness of the month and throat; dry skin; a feeling of heat and pain in the epigastrium, occasionally with headache, commonly with aching of the back and loins, and pain in the course of the uri- nary passages; sometimes, as mentioned by Bal- lonius, a sense of cold in the loins is complained of. The urine generally, now much increased in quantity, presents the appearances already de- scribed, and deposits no sediment. The breath- ing is short, sometimes difficult or oppressed, with a short tickling cough ; sometimes muco-puriform expectoration, and flying pains through the chest. The desire for drink and food increases ; the skin becomes rough or scaly ; the tongue either loaded with a dark-coloured fur, particularly at its base, or unnaturally clean, and of a dark red, or pur- plish red hue ; the mouth foul, dry, and clammy ; the bowels constipated, the evacuations being dif- ficult, painful, dry, and often without their nat- ural odour. A hay-scent sometimes issues from the body, as first noticed by Dr. Latham, and a similar halitus occasionally from the lungs. As the secretion of urine increases, the thirst and hunger become intolerant, and, in some cases, the latter amounts to complete pica, as stated by Sprengel. The sense of heat and burning at the epigastrium is exasperated, and extends in the direction of the urinary passages, frequently with phymosis, and some degree of uneasiness or inflammation about the external orifice of the urethra. The secretion of the pros- tate—but not the semen, as loosely stated by some writers—is sometimes voided after the dis- charge of urine ; and the patient loses his sexual propensities and powers. To these symptoms are generally added, chilliness, and great sensibility of cold; cold extremities, often alternating with burning of the soles of the feet, and slight oedema ; acid eructations, flatulence ; painful muddy eyes ; indistinct vision ; headache or vertigo ; dyspnoea or cough, and weariness on the least exertion ; a sense of sinking at the epigastrium; weight and tenderness about the prsecordia ; frequent sigh- ing ; listlessness; a weak, forgetful, distrusting, anxious, wavering, and peevish state of mind ; and great depression of spirits. As the dis- ease advances, the debility and emaciation in- crease. The skin becomes rugous and scaly, par- ticularly over the abdomen ; and the veins large and distended. The fauces and tongue now as- sume a dark red tint, and are unnaturally clean; the gums spongy or partially absorbed ; the teeth loose, and the breath foetid. In some cases, aph- thoe appear in the mouth, and the gums ulcerate. Patients sometimes complain of a sweetish or mawkish taste ; and the saliva has been found to ferment briskly when a little yeast was added to it. The pulse is at first but little affected; oc- casionally it is somewhat hard or frequent, partic- ularly after a meal, or during the febrile exacer- bations which usually occur in the advanced state of the malady. In the last stages, the pulse is often quick, sharp; or weak, small, and com- pressible. It is, however, very variable in differ- ent cases, or even in the same case. [Diabetes often comes on in so insidious a man- ner as to render it difficult, if not impossible, to de- termine its commencement. If we, however, en- quire as to the period when the urine was last ob- served to be turbid, we may trace diabetic attacks very nearly to their origin. According to Prout, this can generally be ascertained, for patients will usually state that at some former period the con- tinued turbidity of the urine was such as to attract their observation ; and on being questioned as to the supposed cause of such turbidity, some ascribe it to exposure to cold; others to an attack of rheumatism ; others to mental anxiety, &c. In many instances the cessation of this turbidity is not accurately noticed; in a few, the termina- tion is observed to take place rather abruptly ; and the urine, on becoming clear, becomes increased in quantity. Observation proves that when the urine begins to become clear, the saccharine con- dition commences, or at least becomes confirmed, though, in general, the increased flow of urine is not so great as to attract the patient’s attention for several weeks, sometimes for several months after this period. Now in proportion as the urine becomes clear and copious, the symptoms above noticed by our author begin to appear; the 585 DIABETES—Duration—Organic Changes. 586 mouth becomes clammy, the tongue loaded with a white frothy mucus, and the thirst increases; the appetite, nevertheless, remains unimpaired ; or is even better than ordinary, although the patient daily loses flesh and strength, finds himself less adequate to his former exertions, both bodily and mentally. Then follow the other constitutional symptoms already pointed out.] 7. C. The blood taken in the progress of the disease generally separates into a loose, dark crassameutum, containing a smaller proportion of fibrine than the clot of healthy blood ; and a whitish or light-coloured serum, resembling whey. Its analysis has been made by several eminent chemists, with the view of detecting saccharine matter in it. Nicolas and Gueudeville consid- ered it less animalised, and to contain a smaller quantity of fibrine, than healthy blood ; but they found no saccharine matter. Wollaston, Mar- cet, Henry, and Prout, also failed in finding any of this matter in the serum ; whilst Richter conceived that he could detect it by the taste, and, with many other pathologists, believed that it exists in small quantity in the blood, from which it is so constantly eliminated by the action of the kidneys, as never to accumulate to the ex- tent of being detected by chemical agents ; or that it is concealed by its combination or admix- ture with albumen. More recently it has been actually detected in the blood, first by Ambrosiani, and more recently by Mr. C. Maitland and Mr. M’Gregor. [Dr. G. O. Rees has given a process (Guy’s Hospital Reports for Oct. 1838) by which he has obtained sugar of considerable purity from the serum of a diabetic patient. The process is as follows:—The mass of blood is to be evapo- rated to dryness, over a water-bath; the dried mass to be comminuted and digested for several hours in boiling water; the aqueous solution is to be filtered off", evaporated to dryness, and the dried residuum digested in alcohol of sp. gr. 0.825 ; the alcohol solution thus formed is to be filtered, or carefully poured off, evaporated to dryness, and the dry mass treated several times with rec- tified ether, which dissolves out urea, and also some fatty matter, leaving behind the sugar, in admixture with osmazome and chloride of so- dium ; this mass, on being dissolved in alcohol, and the solution allowed to evaporate spontane- ously in a flat glass dish, affords mixed crystals of alkaline chloride and diabetic sugar; which are easily distinguishable from each other, and allow of being separated mechanically, by shaking them up in alcohol, when the chloride sinks ; and the sugar, being principally collected above, may be removed for examination by the careful use of the spatula ; the alcohol must not, of course, be allowed to remain long in contact with the crys- tals, as it would redissolve them. The following is the analysis of 1000 grs. of diabetic serum ob- tained for Dr. Rees by Dr. Bright. The sp. gr. of this patient’s urine was 1048 ; and the con- tents of the serum as follows: water, 90-850 ; al- bumen, 80-35; fatty matters, 0-95; diabetic sugar, 1-80 ; animal extractive, soluble in alco- hol, urea, 2-20 ; albuminate of soda, 0 80 ; al- kaline chlorides, &c.,4-40—Loss 1-60 ; total 1000. If we compare this analysis with that of the serum of healthy blood, we perceive that we have here a great excess of matters soluble in alcohol, while the albuminate of soda is rather less than in health. The alkaline salts are also very small in proportion, being only 4-40 grs. in 1000 grs. of serum, while in health they amount to from 7 to 8 grs. per 1000.] 8. i. Complications.—I have scarcely met with a case of this disease which was entirely uncomplicated with pulmonic symptyms ; and a similar remark has been made by Dr. Bardsley. On this account I conceive that the appellation given to the disease by Nicolas and Gueude- ville, of Phlhisurie Sucree to be extremely ap- propriate. It should, however, be conceded, that, in many cases, other organs participate in func- tional, and even in organic disease, particularly the digestive mucous sufaces, and the liver. In- deed, it may be often looked upon as a result of a breaking down of the system, often in conse- quence of intemperance and illicit indulgences, and exhaustion of the vital energies and assimi- lative functions, whereby several, or even all, of the organs concerned in the perpetuation of life suffer more or less. 9. ii. Terminations.—If unchecked by treat- ment, the debility increases, and pulmonic symp- toms, with hectic fever, if they have not already existed, seldom fail of appearing. Occasionally the disease passes into incurable dropsy. Not in- frequently the discharge is much diminished, and more urinous, for a short time before death ; and, in some instances, the patient is suddenly cut off either by apoplexy, or, as observed by Dr. Prout, by a peculiar affection of the stomach occasioned by improper food, or by over-distension of this vis- cus from the excessive quantity of solid and fluid ingesta. 10. iii. Duration.—Diabetes generally contin- ues for an indefinite time, according to the sud- denness or acuteness of the attack, the previous health of the patient, the nature of the exciting cause, the form of the complication, the diet and regimen prescribed, and the means of cure em- ployed. It is always exasperated during cold and moist weather. Frank states, that it is also worse in autumn. Hecker, Thenard, Dupuytren, and the author, have known it to continue, with inter- vals of improvement, for many years ; and Oos- terdyck states that he treated a case that ter- minated unfavourably in a few days. [In a case that fell under the care of Dr. Chapman, the dis- ease proved fatal in the course of 36 hours, and during its continuance many gallons of fluid were evacuated. Roche and Sanson (vol. xi. p. 121.) state that two hundred pounds have been evacu- ated in 24 hours, or 25 gallons.] When the is- sue is fatal, it commonly runs its course in a few months, and is seldom of shorter duration than several weeks. I believe that the disease not in- frequently exists, for a considerable time at least, without any very sensible increase of the quan- tity of the urinary discharge, and that it is hence often far advanced before it comes before the phy- sician ; and that many cases which have been believed or stated to have been cured, have ex- perienced merely a temporary benefit,—the mal- ady returning in all its severity from the slightest exposure to its more common exciting causes, or the least want of attention to the requisite diet and regimen. 11. iv. Organic Changes are by no means constantly observed after diabetes, even in the urinary organs; and, when present in them, are not such as may account for the disease ; but, as Hecker has justly contended, are rather its ef- fects than its causes. Rutherford, Home, Du- DIABETES—Prognosis and Diagnosis. 587 puytren, Segalas, and Dezeimeris, have found the kidneys somewhat enlarged and vascular. Bonet, Morgagni, Monro, IIertzog, Cawley, Desault, and Hecker, have observed them only more flaccid than natural: and Cruickshanks, Reil, Rutherford, Duncan, and Baillie, have remarked merely a more turgid state of their blood-vessels; which Frank and Vetter have stated to have been more lacerable than in the healthy state. In rarer instances, one or even both kidneys have been observed much smaller than usual (P. Frank, Muller). Hydatids have been found, by Beer, filling and distending them enormously; and calculi have been detected in their pelvis by Baillou. Ruyscii and Hecker met with cartilaginous induration of their envel- opes and cortical substance ; and Brodie found their structure hard and gristly. Muller men- tions enlargement of their nerves ; and Duncan records a case in which the splanchnic nerves were all enlarged to three or four times their natu- ral size. Conradi observed the pelvis of the kid- neys enlarged so as to contain a small orange; and Ruysch, Rutherford, Reil, Hecker, and Clarke, remarked considerable dilatation of the ureters. Increased size of either the pelvis of the kidneys, or of the ureters, or urinary bladder, or even of them all, is not infrequent. In some instances, the bladder is thickened, or contracted, and slightly inflamed, and the prostate enlarged. All the urinary organs, however, have been found as frequently natural, even by the authors now mentioned, as presenting the above changes. 12. Next in frequency to enlargement and flaccidity of the kidneys, the mesenteric glands have presented morbid appearances. Mascagni, Juncker, Himly, Reil, Home, Cawley, and Hecker, have found them enlarged, obstructed, and otherwise changed; but they also have been met with perfectly natural, by the same authors, as well as by others. Rutherford and Monro have observed enlargement, softening, and in- creased vascularity of the absorbent glands gen- erally. The thoracic duct has, in a few instances, been found greatly enlarged and dilated. The Inngs are, perhaps, as frequently diseased as any other organ. I have never seen a case exam- ined in which they were perfectly healthy. Lu- roth, Sf.galas, Dupuytren, and Horn, have severally observed tubercles in every stage of their progress; ulcerations, tubercular excava- tions, hepatisations, and purulent collections or disseminated vomicce, in the lungs, as well as in- flammation of the pleura, and its consequences— adhesions of the pleura, &c., of the pericardium and pleura, serous effusion into the pleural cavity, &c. M. Luroth detected, in addition to hepat- isation of, and excavations in, the lungs, aneu- rism of the pulmonary artery, the kidneys being sound. Similar states of the pulmonary artery, lungs, and kidneys, were found in a case recorded by M. Lobstein ; the lungs being extensively tu- berculated, hepatised, and adherent to the tho- rax, without any manifest thoracic symptoms du- ring life. The digestive organs have been next most frequently diseased. Dupuytren and Sega- las have observed a more vascular state than natural of the digestive mucous surface, but with- out any organic change of the stomach, or intes- tines, beyond dilatation of the former, and of the duodenum. Rutherford and Baillie always found the stomach healthy. The liver is more frequently diseased. Mead states that it was al- ways altered in structure ; whilst Cullen, Frank, and Home, generally observed it natural. Caw- ley and Hecker have commonly detected or- ganic change of this viscus. The spleen and pancreas have seldom presented any lesion. Micii- aelis, Conradi, and Hecker, detected chyle im- perfectly mixed with the blood in the large ves- sels and cavities of the heart; and the same authors, and Marshall, remarked a chocolate appearance of the blood in all the vessels. Dr. Rutherford states that the blood was black and fluid in all the cases he inspected. In the cases I have seen examined, the mucous surface of the stomach, and of the upper parts of the small in- testines, was rugous and vascular. The lungs were congested or hepatised, or tuberculated and excavated, or their pleurae adherent. The heart was flaccid, soft, and small; the blood dark and semi-fluid; the kidneys congested with dark blood, and somewhat large ; the super-renal cap- sules somewhat indurated ; and the renal ganglia more than usually large. But these changes are not uniformly observed ; several of them were wanting; and in one or two instances, no deci- dedly morbid change was detected, beyond the absence of the usual cadaverous and peculiar odour generally perceived upon opening the cavi- ties. Upon the whole, therefore, post mortem research has thrown but little light on the nature of diabeles, further than showing that it is the result of a morbid condition of several, if not all, of the digestive, assimilating, and excreting vis- cera, and not of any one of them. 13. II. Prognosis and Diagnosis.—A. Al- though patients whose constitutional powers are not greatly reduced, may sometimes live for many years, under judicious treatment, in this disease, yet should the prognosis be upon the whole very unfavourable: a cure may, however, be effected by appropriate means adopted early ; but this re- sult is comparatively rare, and should never be considered as perfect, unless the healthy quality, as well as quantity, of the urine be altogether re- covered, and the strength and bulk of the body be restored. Partial, or even very great, relief is often afforded ; but the malady after a while re- turns, and may proceed without admitting of re- lief to a fatal issue, or be again and again checked by treatment. Much depends upon the patients themselves, and the strictness with which the prescribed regimen is followed ; for, as the disease often originates in excesses, a return to them upon partial, or tolerable, recovery, will bring back the disease. When we find it complicated, as it most commonly is, with organic disease of the lungs, liver, or lymphatic system, a favourable issue cannot be expected. Out of from twelve to fif- teen cases I have treated, I know of two only at the present time that have perfectly recovered. One of these, a married woman, who had previ- ously been attended by an eminent writer on the disease, has continued perfectly well for six or seven years ; but although not yet thirty-five, the catamenia, which had disappeared before the de- velopement of diabetes, has not returned. The chances may, perhaps, be estimated at about five or six, or even higher, against the patient; but much will depend upon the quantity and quality of the urine, the progress of the disease, the age, visceral complications, constitutional powers, the state and functions of the skin, the degree of ema- ciation, and circumstances and character of the patient. I believe that the prognosis should be DIABETES—Causes. much more unfavourable where the urine is mel- litic, than when it is not so changed, however abundant it may be. 14. B. The Diagnosis of diabetes mellitus is very readily formed from the sensible properties of the urine. (See the Symptoms, §4. 7.; and art. Urine.) 15. III. Causes.—A. Predisposing. Heredi- tary predisposition to this disease has been re- marked by several authors. Dr. Prout has ob- served it in four instances. Isenflamm states that he knew of seven of the descendants of a diabetic patient, who died of the malady. Mor- ton, Brisbane, Rollo, Blumenbach, Frank, Storer, and Clarke, also furnish similar facts. Diabetes is more frequently met with in the male, than in the female sex ; and in persons who either are past the period of puberty, or are advanced in years. [It is more common in individuals of a sanguine temperament, with light or reddish hair, than in other; next in those of the melan- cholic temperament. It is more common also in strumous individuals, with dark hair and eyes, fair skin, &c., and in those it is very generally unmanageable and fatal.] The true diabetes mellitus is rare in children, whilst albuminous urine and enuresis are frequent complaints in them. It is much more common in cold and moist countries, particularly those in which the inhabitants live chiefly on rye, or any other veg- etable food, or are imperfectly nourished, than in warm or dry climates: and is hence oftener met with in Great Britain, Ireland, Holland, Den- mark, and Sweden, than in France and Ger- many ; and in the western, than in the eastern side of this island. J. Frank states that he saw a greater number of cases of it in Italy, than in any part of Germany. Dr. Christie observed it more frequently amongst the inhabitants of Cey- lon, than in any part of continental India ; and imputes it to the moist state of the atmosphere, and their poor vegetable diet. The scrofulous diathesis also predisposes to it. [Diabetes usually occurs in persons of spare and feeble habits, though not always. Dr. Prout mentions (On Stomach and Renal Diseases, Phil, ed., 1844, p. 48,) that he has met with it in severa linstances, in unusually fat and powerful individuals, and in both sexes. One was a mid- dle-aged gentleman, who had spent many years in India, but who had returned in consequence of bad health. At this time he weighed 27 stone, or nearly 350 pounds. When he consulted Mr. P. a few months afterwards he weighed 23 stone. At this time, he laboured under well-marked symp- toms of diabetes ; the urine was large in quantity and very saccharine, thirst urgent, with severe phymosis, &c. He recovered entirely under Mr. P.’s treatment. For similar cases (see loc. cit. p. 49.)] 16. B. The Exciting Causes are not so pre- cisely ascertained as the predisposing, and their connection with the origin of the disease not so obvious as could be desired; but the following, acting either individually or in conjunction, par- ticularly in the latter mode, may be considered as most commonly productive of diabetes, where a predisposition to it exists, either hereditarily, or from visceral disease :—Continued or repeated ex- posure to cold and moisture; drinking cold fluids when the body is over-heated ; suppression of an habitual perspiration, by whatever means ; acid- ulous or fermented liquors, particularly in malt 588 liquors, cider, &c.; the exhaustion arising from excessive evacuations and morbid discharges, or from undue sexual intercourse ; great bodily and mental exertions; the depressing passions, such as anxiety, disappointment, &c.; and whatever occasions great exhaustion of the powers of life, and of assimilation, is sometimes productive of this malady. Besides these, authors have ad- duced others as its occasional causes. Auten- rieth mentions the use of acids and acidulous fluids ; Boerhaave, Lister, Stedman, and Frank, the abuse of diuretics and diluents; Syden- ham and Senac, excessive horse exercise ; Ruyscii, Cheselden, and Latham, the existence of chron- ic abscesses and carbuncles ; Frank, the car- rying of heavy weights; Bennewitz (Os- sann’s Jahresbericht, led. Comment, vol. ix. p. 349.—Cruickshanks, On the Lacteals and Lymphatics, p. 69.—./. P. Frank, De Curand. Horn. Morbis, t. v. p. 39. Man. 1792.; et Interpret. Clinic, vol. i. p. 347.—Baillic, Trans, of Soc. for Improvement of Medical Knowledge, vol. ii. art. 5.— Ijatham, Facts and Opinions concerning Diabetes, 8vo. Lond. 1811.—Desault, Journ. de Chirurgie, t. i. No. 3.— DIAPHRAGM—Inflammation of. Satterley, Med. Transact, vol. v. art. 1.— Warren, in Ibid. vol. iv. p. 188.—Shee, in Duncan's Med. Annals, vol. i. p. 343.—Jarrold, in Ibid. vol. vi. p. 390.—Soem- merring, De Morb. Vasor. Abiorbentium, p. 157.—Fahner, Beytrilge zur Pract. Arzneyk. b. i. art. 4.—Rollo, On Diabetes Mellitus. Lond. 1797, 8vo.—Hcrtiog, in Hufe- land's Journ. der Pract. Arzneyk. b. vii. st. 2, p. 155.— A. G. Richter, Die Specielle Therapie, b. iv. p. 443.— Bardsley. Medical Reports and Exper. &c. 8vo. Lond. 1807.— Trinka, De Diabete. Vindob. 8vo. 1778.— Weber, Observat. Med. fasc. i.—Plenciz, Acta et Observat. Med. p. 153.—Marabelli, Mem. sulle Differenze dell’ Orina in Diab. 8vo. Pavia, 1792.— Tonmasini, Storia ragionata di un Diab. 8vo. Parma, 1794.—Bang, in Acta Regia; Soc. Med. Haun. vol. ii. p. 291.—C. Darwin, in Med. and Physical Journal, vol. xxvi. p. 465.—Girdlestonc, On Diabetes. Yarmouth, 1799.—Red/earn, in Lond. Med. and Phys. Journ vol. i. p. 218.—Gilby, in Ibid. vol. iv. p. 205.—Marcet, in Ibid. vol. ii. p. 207.— Lubbock, in Ibid, vol. v. p. 56.—Stoeller, Beobachtungen, obs. 1.; et in Hufeland's Journ. der Pract. Arzneyk. b. vi. p. 64.— Richter, Med. and Chirurg. Bemerkung. p. 76.—Home, Clinical Experiments, p. 296.—Roebcr, in Museum der Heilk. b. iv. p. 298.— Watt, Cases of Diabetes, &c. Glasgow, 1803.—Ritter, in Hufeland's Journ. der Pract. Heilk. b. xx. st. 3. p. 145.—Schutz, in Ibid. b. xii. st. 2. p. 12S.—Michaelis, in Ibid. b. xiv. st. 3. p. 44.—Hufeland, in Ibid. h. xlvii. s. 117.— Wolff, in Ibid. Jun. 1810, p. 120. —Cullen. Practice of Med., by Thomson, vol. i. p. 313.; vol. ii. p. 491.—Ferriar, Medical Histories and Reflections, vol. iv. p. 46.—Blumenbach, Med. Biblioth. b. ii. p. 127. —JWonro and Duncan, in Annals of Med. vol. viii. p. 388. —Nicolas et Gueudeville, Recherches et Experiences Medicales sur la Diabete Sucree, ou la Phthisurie Sucrtie, Paris, 1803.—Place, De vera Diabetes Causa in Defectu Assimilationis quaerenda. Goet. 1784.—-Metz, Diabetis Observatio, in Disput. Med. Pract. Haller, t. iv.— Henry, Ann. of Philosophy, vol. i. p. 27.; et. Trans, of Med. and Ch'rurg. Soc. vol. ii. p. 119.— Wollaston and Marcet, Philos. Trans, vol. ci. 1811, p. 96.—Du- puytrcn et Thenard, in Journ. de Med. Contin. vol xii. p. 83.—Clarke, in Edin. Med. and Surg. Journ. 1810.— Bostock, Mem. of Med. Soc. of Lond. vol. vi. p. 237.; et Transac. of Med. and Chirurg. Society, vol. iii. p. 107.— Money, in Ibid. vol. v. p. 236.—Mynster, in Acta Regia; Soc. Mediae Hafniensis, vol. v. 1818.—Krimer, in Horn’s Archiv. 1819. — Autenreith, Physiol. §813.—Dezcimeris, in Miimoires de la Soc. M6d. d’Emulation, t. ix. p. 211.— Duncan, in Transact, of Med. and Chirurg. Society of Edin. vol. i. p. 474.—Fraser, in Edin. Med. and Surg. Journ. vol. i. p. 16.—Alley, in Ibid. vol. iv. p. 35.—Chris- tie, in Ibid. vol. vii. p 285.—Renauldin. in Diet, des Sciences Med. t. ix. p. 125.— Henry et Soubeiran, in Journ. des Progres des Scien. Mbd. t. i. p. 250.—Hufe- land, in Ibid. vol. ii. 2nd series, p. 43.—Marsh, Dublin Hospital Reports, vol. iii. p. 480.—MM. Vauquelin et Se- galas, in Migendie’s Journ. de Physiologie, t. iv. p. 356. Paris, 1825.— W. Prout, Inquiry into the Nature and Treatment of Diabetes, Calculus, &c. 2d edit. Lond. 1825.—Rochoux, Diction, de M6d. vol. vi.— Heineken, in Lond. Med. Repos, vol. xix. p. 265.—Carter, in Ibid, vol. xx. p. 390.—D. Barry, see Lancet, No. 238. p. 926. —R. Venables, On Diab., &c. 8vo. Lond. 1825.— Vauque- lin et Segalas d’Etchepare. in Archives Gener. de Mede- cine, t. vi. p. 625.—Lobstein, in Ibid. vol. xviii. p. 432.; et in R6pert. Gen6r. d’Anat. et Phys. vol. ii. p. 356.— Sharkey, in Transac. of Irish College of I’hys. vol. iv. p. 379.—Bouillaud, Diction, de Med. et Chir. Prat, vol. vi. p. 249.—M. Good, Study of Med. by Cooper, vol. v. p. 494.—Berndt, Encyclop. Worterb. de Med. Wissensch. art. Diabetes.—Ambrosiani, in Annali Univer. di Med. Apr. 1835. — Maitland, in Lond. Med. Gaz. vol. xvii. p. 909.—MGregor, in Lond. Med. Gaz. vol. xx. May 13 and 20, 1837.—R. Willis, Urinary Diseases and their Treatment, 8vo. Lond. 1833 p. 196. DIAGNOSIS. See Symptomatology. DIAPHRAGM (from Siatppdjom, I separate).— Syn. Aristotle. A.tatppayya, ipeucs. Sep- tum transversum, Lat. Der Zwergmuskel, Ger. Diaphragme, IT. Midriff, Eng. 1. When we consider the musculo-tendinous structure, and varied connections of the dia- phragm,—that it is situated between three serous membranes, and attached to the vetebral column, the ribs and their cartilages,—that it is traversed by the most remarkable nerves and blood-vessels of the body, and itself provided with important vessels and nerves, that it is in more or less direct contact with the lungs, the heart, the liver, stomach, pancreas, kidneys, and spleen: and intimately associated by its nerves, its ves- sels, and its functions, not only with the mucous surface of the respiratory organs, as well as with these organs themselves, but also with the diges- tive and large secreting viscera,—its importance in a pathological point of view must bo appa- rent. The extent of its organic and functional relations are such, that agents acting on either the external or internal surfaces of the body must necessarily influence its actions. It. cannot, therefore, be a matter of surprise to find it frequently subject to disorder; but I am at a loss to conceive the reason for the very genera! neglect with which even its most serious diseases have been treated. This can be owing only to the circumstance of their being imperfectly un- derstood, or referred to some one of the adjoining organs, and viewed as merely symptomatic or sec- ondary affections. 1. Inflammation of the Diaphragm.—Syn. Diaphragmitis (Hildenbrand, J. Frank, &c.); Paraphrenitis, P araphrosynis (Rufus Ephe- sius, et Auct. Vet.) ; Diaphragmite, Para- phrenesie, Fr. ; Zwergmuskell-Entzun- dung, Ger. Classif. III. Class, I. Order (Author). 2. Defin.—Acute pain and constriction oj the lower part of the thorax, extending to the back and loins, increased upon respiration and raising the body erect, with singultus, convulsive dis- tortion of the angles of the mouth, and very acute inflammatory fever. 3. i. Seat.—Inflammation of only the mus- culo-tendinous structure of the diaphragm is a very rare disease, particularly in its primary form ; and I believe is very seldom met with, excepting upon the disappearance of rheumatism from some ex- ternal part, or after penetrating wounds and other external injuries. As a consecutive or secondary affection, and especially in conjunction with in- flammation of one or more of its serous mem- branes, it frequently occurs, although often either entirely overlooked, or mistaken for inflammation of some one of the adjoining viscera. The advan- tages of being able to distinguish it in practice are not diminished on this account; and it often be- comes of great importance to ascertain its exist- ence, whether as a primary or as a consecutive disease. 4. I believe that inflammation may originate in the cellular tissue connecting the serous mem- branes reflected over the diaphragm to its musculo- tendinous structure, in which case the disease will extend chiefly to either one or both of those surfaces; but that, in the more frequent states of diaphragmitis,—particularly its consecutive form,—the inflammation commences in one of the serous surfaces, and extends thence, through the medium of the sub-serous cellular tissue, more or less to the other structures of the organ. 5. ii. The Causes of daphragmitis, particularly in its consecutive forms, are generally those which are productive of pleurisy, pneumonia, hepatitis, or peritonitis. In addition to those, I may adduce others, which have a more evident influence in producing this disease, viz. punctured and other wounds ; external injuries and fractures of the lower ribs; concussions of the trunk, particularly from missing steps on descending stairs, or from falling upon the hips ; immoderate laughter ; vio- lent retchings ; continued crying and weeping; obstinate singultus; currents of cold air, when the body is perspiring ; the incautious use of cold 599 drinks, ices, Ac.; the suppression of painful emo- tions ; violent efforts of any description ; the re- pression or metastasis of rheumatism ; the stop- page of accustomed discharges; and the drying up of old eruptions or ulcers by external applica- tions. Instances of the occurrence of inflamma- tion of the diaphragm from the repression of rheu- matism have been recorded by Paterson (Mem. of Med. Society of London, vol. V. No. 32.) and Portal (Aruit. Med. t. ii. p. 444.) ; and from healing up old sores, suppressing gout, Ac., by Aaskow Act. Reg. Sue. Med. Hafn. t. i. p. 205.), Boisseau (Nosographie Organ, t. xi. p. 620.), Wendt, Selle, and others. Hildenrrand con- siders the habit of wearing tightly laced corsets a cause of the disease. I doubt not that it is, at least, a predisposing cause. 6. iii. Symptoms, Complications, Ac.—A. Either after rigors, chills, horripilations, Ac., or consequent upon disease of some one of the ab- dominal or thoracic viscera, the patient experi- ences violent, sharp, burning pain, tension, and cord like constriction, at the lown 1 an of the thorax, particularly beneath the ste uu.u and hy- pochondria, and stretching to the loins,—increased and descending lower during inspiration—dimin- ished and ascending during expiration,—aug- mented by coughing, sneezing, fulness of stomach, and pressure on the abdomen ; likewise by vomit- ing, by the expulsion of the faeces or urine, and by bending the trunk of the body in any direc- tion. The breathing is short, frequent, anxious, small, and performed entirely by the intercostal muscles, the abdomen being nearly motionless. The hypochondria fall inwards, or are retracted, and, with the prtecordia, are sensible to pressure. There are frequently painful and difficult degluti- tion, referrible to the lower part of the oesophagus and cardia ; great anxiety, with occasional inter- rupted sighs ; singultus, particularly towards the close of the disease, involuntary retraction of the angles of the mouth, or risus sardonicus ; delirium, which is sometimes furious ; spasms, or great fee- bleness of the muscles of the abdomen and ex- tremities ; irritable, porraeeous vomiting; leipo- thymia or sinking, Ac. The pulse is always fre- quent—at first strong and hard, afterwards small, more quick, wiry, Ac. The bowels are consti- pated and urine in small quantity; thirst is at first urgent, afterwards not felt; and restlessness, particularly as the disease advances, is extreme. 7. B. Complicated Forms.—a. The symptoms vary considerably with the surface of the organ chiefly affected, and according as inflammation of an adjoining viscus may have preceded, accom- panied, or followed that of the diaphragm. When inflammation implicates the diaphragmatic pleura, or extends to the lungs, mediastinum, or pericar- dium, we must expect to observe many of the symptoms of those diseases ; particularly those consisting of lesion of the function of respiration. Percussion will give out a somewhat duller sound than natural; cough will be more or less com- plained of, and be frequently attended with a watery mucous expectoration. 8. When the inferior surface of the diaphragm is inflamed, the stomach and liver seldom escape participation in the disease. In this case the pain and sensibility of the hypochondria are increased, and the stomach is more severely disordered. When the muscular or tendinous structures are chiefly implicated, the complaint assumes its most violent forms; and, owing to the nerves of the or- 600 DIAPHRAGM—Symptoms, Complications—Prognosis. gan being then more seriously affected, the sym- pathetic effects of the disease, as delirium, the sardonic spasm of the muscles of the countenance, singultus, dysphagia, anxiety, retraction of the hypochondria, spasm of the abdominal muscles, Ac. are more constant and severe. 9. Diaphragmitis is sometimes complicated with, at other times consequent upon, acute rheu- matism ; and I believe that it may be associated both with inflammation of the convex and posterior part of the liver, and with acute rheumatism, in the same case and at the same time. I am at present attending a patient, in whom there is every reason to infer the existence of this very complicated malady; and am of opinion that similar associations of the disease would have been more frequently remarked in practice, if the severity of the rheumatic pains, and of the remote symptoms caused by inflammation of the dia- phragm, had not masked those more directly con- nected with the affected organ, and thereby mis- led the practitioner. 10. There are several symptoms which have been adduced by authors as pathognomonic of this malady, but which are not uniformly observed: thus Stoll, Aaskow, and Boisseau have found delirium frequently wanting altogether: and, in several cases in which I have seen the disease complicated with hepatitis and pleuritis,—particu- larly the former,—neither delirium, nor the cynic spasm, was present. I agree, however, with J. P. Frank (Dc Curand. Morb. Horn. t. ii. p. 193.), in considering these symptoms as being more fre- quently met with in this disease, than in any other affecting the viscera of the large cavitiee, and particularly when the tendinous part of the organ is affected. 11. C. Course and Termination.—The course and progress of this disease are generally acute If it terminate not in resolution within a few days, it produces either adhesion to the adjoining viscera, or disorganisation, followed rapidly by death. When adhesions form, signs of chronic disease of this and the adjoining viscera continue after the subsidence of the acute symptoms: but when disorganisation and gangrene supervene, the patient experiences, after a very few days, a sense of suffocation, sinking with singultus, extreme frequency and smallness of pulse, faintings, Ac., speedily followed by dissolution. 12. D. The morbid appearances most fre- quently found after diaphragmitis are, effusions of coagulable lymph, or of sero-albuminous fluid, or of both, on either of the surfaces of the organ, generally with adhesions, more or less extensive, to the adjoining viscera; increased redness and vascularity, or deepness of colour, of one or more of the different structures composing the organ ; false membranes upon its Surfaces ; portions of it ulcer- ated, or of a dark colour, softened, and nearly disorganised; and, more rarely, sphacelated in parts, infiltrated with pus, or containing one or more distinct purulent collections. 13. iv. Prognosis.—Recovery from this mal- ady should be considered as very doubtful, until we have very unequivocal symptoms of resolution, without any sign of the extension of disease to the organs situated on either side of the diaphragm. —a. The circumstance of diaphragmitis arising from external injury, or the extension of inflam- mation from the pleura and pericardium ; the early accession of urgent anxiety, followed by delirium; singultus, and sobbing; deoressed. col- lapsed, and anxious countenance, with spasms of the muscles of the face ; irregularity, intermission, and smallness of pulse ; coldness of the extremi- ties ; leipothymia ; difficult deglutition ; frequent and irritable vomiting, and restlessness ; absence of thirst; convulsions ; convulsive, frequent, and laborious respirations, &c. ; are very unfavourable symptoms.—b. The subsidence of the urgent symptoms; an improved state of the pulse, and appearauce of the countenance ; the occurrence of any of the critical evacuations, or restoration of the suspended secretions, or a sound and re- freshing sleep ; a more natural respiration, and the absence of serious disease of the collatitious viscera ; are the most favourable circumstances. 14. vi. Treatment.—The intentions of cure are the same in this as in other acute inflamma- tions. The antiphlogistic treatment promises us the principal aid; but to be successful, it must be employed early in a decided manner. Full blood- letting from the arm, the patient being in a semi- recumbent posture, until a decided effect ensues— until syncope approaches, but is not induced—as recommended in another place (see Blood, § 54.;; afterwards cupping on the loins and back, on each side of the spine; leeches applied near the anterior insertion of the diaphragm ; purgatives; refrigerating diaphoretics; febrifuge diluents; external fomentations and cataplasms; tepid baths ; purgative, and subsequently emollient ene- mata, with complete stillness and silence ; should be employed according to the exigencies of the case. The practitioner ought not to be deceived by the presence of singultus, and the great de- pression of the powers of life so frequently at- tendant on the disease ; and thus be led to the exhibition of antispasmodics and stimulants, when opposite measures are requisite. Nor should he be induced by the state of the stomach, and of the matters discharged from it, to exhibit emetics. When vomiting is present, it should be allayed ; and, for this purpose, as well as to prevent the formation of coaguiable lymph and adhesion be- tween the surfaces of the organ and the adjoining viscera, large doses of calomel and opium—from ten or twenty grains of the former, am. from one to three of the latter, either with oi witimut from one to three grains of camphor—f ..o...iJ be ex- hibited, and repeated at intervals of six or seven hours ; the first dose being given immediately af- ter the first blood-letting. The danger of the dis- ease requires prompt and powerful agents ; and, after depletions, the combination of calomel, opium, and camphor, is particularly serviceable. 15. When the disease is associated with inflam- mation in the adjoining viscera, the calomel should be carried so far asto affect the mouth ; and if the pleura or pericardium be also diseased, antimoni- als and diuretics ought to be added. If the con- vex or posterior parts of the liver and peritoneum be also inflamed, the use of mercurials is also required, and with nearly the same intentions, viz. to prevent adhesions, and procure the absorption of effused fluids. If the disease be associated with rheumatism or gout, then, after local depletions, active mercurial cathartics, and derivatives ap- plied to the joints, colchicum, with large doses of soda or potash, or with magnesia, ammonia, or camphor, may be exhibited. 16. It often happens, that after the inflamma- tion in this organ and its collatitious viscera is subdued, considerable irritability, evinced by the occurrence of singultus upon taking substances DIAPHRAGM—Treatment—Organic Lesions of. into the stomach, continues for some time. To remove this, the use of gentle tonics, combined with anodynes and antispasmodics, as the infu- sion of calumba, with opium, carbonate of soda, hyoscyamus, or camphor, is generally required, or of the infusion of valerian, or of the oxide of zinc, or the tris-nitrate of bismuth, or musk, &c. Convalescence, aud the regimen of the patient are to be managed precisely as in other inflam- matory diseases. 17. II. Diaphragm, Organic Lesions of.— i. Perforation of the diaphragm is not an un- common consequence of abscess of the liver, pointing up towards the thorax'. In the great majority of such cases, adhesion of the adjoining surfaces of the liver and diaphragm has preceded the perforation ; and when this has been accom- plished by the disorganising process following the inflammation excited in the diaphragm, the con- tents of the abscess pass either into the cavity of the thorax, or adhesion of the inflamed diaphragm to the lungs having also taken place, into the lungs, whence it may be expectorated, and the patient even recover. (See Liver—Abscess of the.) Instances have even occurred of the ab- scess having thus traversed the diaphragm, and opened into the pericardium. 18. Perforation of the diaphragm has likewise taken place from abscess of the spleen, and from ulcerations of the stomach, which had adhered to the diaphragm. It has very seldom been ob- served that the perforation of this organ has oc- curred in an opposite direction, namely, from the thorax downwards. But Portal (Anal. Med.) met with a case in which an imposthume of the lungs opened through the diaphragm, and burst into the abdominal cavity. The diaphragm may likewise be perforated in this direction by aneurism of the aorta. Meckel also found ulceration of the diaphragm, apparently resulting from chronic inflammation, in the dissection of a maniacal patient. 19. ii. Rupture of the diaphragm sometimes occurs from falls ; violent succussions of the trunk ; vomiting, or severe retchings ; blows on the abdomen, back, hypoehondrium, or epigas- trium ; suppressed efforts, and sudden muscular exertions. M. Percy states, that a young female, suppressing the pains of child-birth, uttered a plaintive cry, had her mouth hideously distorted, and shortly afterwards expired, giving birth to a child. On dissection, the diaphragm was torn obliquely in the fleshy part of the left side. Two thirds of the stomach, with a portion of the omen- tum and colon, had passed through the rupture into the thorax. On another occasion, M. Percy found, after a fall, the ribs of the patient very prominent; the abdomen, at its upper part, sunk inwards; and the countenance presenting the risus sardonicus. He prognosticated a rupture of the diaphragm which was found after death. (Percy, Diet, des Scien. Med. t. ix. p. 214.) Rupture of the diaphragm is not necessarily im- mediately fatal. Boisseau (Nosog. Organ, t. ii. p. 623.) mentions a case where a patient lived six months, and followed his occupations, after the occurrence. A person having taken an emetic, died soon afterwards with convulsions, the cynic spasm of the muscles of the face, &c. On ex- amination, the tendinous part of the diaphragm was found tom near the part where the intercostal nerve passes through it. 20. iii. Various Morbid Productions have 601 602 been found more or less intimately connected with the diaphragm, in persons who had experi- enced disorder of the respiratory function. These have consisted of tumours of various descriptions, encysted or unencysted ; cartilaginous or osseous formations, and earthy concretions in its surfaces (Sciireiber, Leveille, Voigtel) ; fleshy tu- mours ; and large fibrous cysts containing hyda- tids (Portal), or merely an aqueous or serous fluid. It is not infrequently found partially dis- placed in aneurism of the heart and aorta. Cases of this description are recorded by Vetter and Blancard. It js also pressed high into the tho- rax by enlarged or suppurated liver. 21. iv. Spasmodic Actions.—The diaphragm contracts forcibly in crying, coughing, vomiting, during the expulsion of the excretions, child-birth, and tenesmus. It contracts slowly, but forcibly, and is rapidly followed by relaxation, in sighing. It contracts for a longer time, and is relaxed more quickly in yawning. The contraction is more rapid, forcible, and interrupted by qlosure of the glottis, in hiccup, sobbing, &c.; and sneez- ing is owing to convulsive contraction of the dia- phragm, followed soon afterwards by convulsive action of the expiratory muscles. In all these, the other inspiratory muscles co-operate more or less energetically. 22. The motion of the diaphragm is generally more frequent, irregular, and unequal, than natu- j ral in convulsive diseases, particularly when the irritation is propagated to this part, or influences the functions of the par vagum, by being extended to the top of the spinal chord, &c. This is evinced in epilepsy, hysteria, pertussis, &c. The con- tractions of the organ are still more disordered in tetanus, they being nearly permanent about the fatal close of the disease. Death is occasioned by this, rather than by any other circumstance ; the permanent spasm of the diaphragm and other respiratory muscles preventing the expulsion of the inspired air, and consequently producing a variety of asphyxy. (See art. Hiccup.) 23. v. Paralysis of the diaphragm is incom- patible with the duration of life, and can occur only during the last moments of existence. It may be induced by the inhalation of noxious gases into the lungs, and from virulent poisons, thus con- stituting another form of asphyxy: and it is pro- duced by injuries of the medulla oblongata, or in its vicinity, or by whatever may interrupt the functions, or injure the. par vagum. I have met with a case where it followed, at a remote period, fracture by muscular action of the dentated cer- vical vertebra, as verified on dissection by Profes- sor R. Quain and myself. Bibliog. and Refer.—Galen, De Locis Affect. 1. v- cap. 4.— Bonet, Sepulch. Anat. 1. i. sec. 1. obs. 1.—Mor- gagni, Epist. vii. art. 14.—Roth, Diss. de Inflammat. Septi transversi. Lips. 1748.—Schulze, Diss. de Paraphreni- tide. Hal. 1742.—Schneider, De Inflam. Diaphragrnatis. Witteb. 1665.—Meckel, in Mem. de l’Acad. de Berlin, 1764, p. 88.—Schroeder, De Inflam. Diaph. Goet. 1772. —Stoll, Ratio Med. t. ii. p 385.—De Haen, Ratio Med. par. i. p. 84., par. ix. p. 17.—L. A. Ebeling, Diss. de In- flammatione Diaphragmitis. Goet. 1771.—G. M. Gatten- hof, Spec. Sist. Paraphrenitidis Rationem el Curationem. Heid. 1791. — Isenfiamm, Prakt. Aum. liber die Mus- keln. $ 162.—Aaslcow, in Act. Hafn. vol. i. p. 205.— Sandifort, Exercit. Acad. 1. ii. p. 88.—Portal, Anat. Medical, t. iv. p. 233.—Hempel, De Diaph. Sano et Mor- boso. Goet. 1808.— J. P. Frank, De Cur. Horn. Morb. t. ii.—Roy, Traitb sur le Rire. Paris, 1814.—Sawici, De Diaphragmitide. Wila, 1819.—Hildenbrand, Insti- tutiones Medic®, t. iii. p. 267.—J. Frank, Praxeos Med. Pr®cep. Univ. par. 2. vol. ii. sect. 2. p. 2.—Boisseau, Nosographie Organique, t. ii. p. 617.—Voigtels, Pathol. Anat. t. ii. p. 201. DIARRHCEA—Symptoms and Varieties of. ; DIARRHOEA. — Syn. (Aiappota, from Siappiat, I flow through, <5ia and piu>). Diarrhoea Ca- catoria, Rheuma Gastros, Galen. Rheumatis- mus, Alexander of Tralles. Dejluxio, Cffilius Aurelius. Alvi Fluxus, Ventris Profluvium, Auet. Lat. Cours de Ventre, Devoyement, Fr. Der Durchfall, Bauchfluss, Durchlau.f, Germ. Diarrea, Ital. A Purging, Looseness, <$pc. Classif.—2. Class, Nervous Diseases; 3. Order, Spasmodic Affections (Cullen). • 1. Class, Diseases of the Digestive Func- tion ; 1. Order, Affecting the Digestive Canal (Good). 1. Defjn.—Frequent, loose, or fluid alvine evac- uations, vnthout tormina or tenesmus. 2. Although diarrhoea may occur as an inde- pendent or unassociated complaint, yet may it supervene as an occasional or even common symptom, in several maladies. Dr. Cullen, whilst he admitted diarrhoea as a specific disease, yet viewed it as always symptomatic of other pa- thological states. That it is so in most cases, can- not be doubted ; but that it also is, in some in- stances, an idiopathic disorder, in respect both of its primary manifestation, and of its independence of inflammatory action of the intestinal mucous surface, or of disease of immediately related or- gans, is equally certain ; and fully demonstrated by its causes and progress,—by the effects of treat- ment, and the appearances observed in fatal cases. 3. I. Symptoms and Varieties of Diarrhoea. —This disease is usually preceded by various dyspeptic symptoms, sometimes by slight nausea, frequently by uneasiness in different parts of the abdomen, by flatulence, and by pain, particularly before an evacuation takes place. In severe cases, the abdomen is somewhat distended and tender to the touch, and its temperature increased; and occasionally the stools are preceded by much pain in the tract of the intestines, and accompanied with “vomiting, or with fainting, or leipothymia; they are always without effort, but are rarely in- voluntary. Each evacuation relieves for a time the patient’s uneasiness, which, however, soon returns. The discharges are usually copious, offensive, and feculent at first; but they soon be- come more scanty, watery, or mucous—often in proportion to the frequency of the calls to evacua- tion, after each of which the patient feels more and more weakened. Their number varies from three or four, to twenty or thirty in the twenty-four hours, but they are not so often voided in the night as in the day. At the commencement of the attack, and in slight cases, the pulse is gen- erally not materially affected ; but when vomit- ing or much griping pain is present, it is often increased in frequency. At an advanced period it is usually small, weak, and somewhat acceler- ated ; the countenance being pale, the body somewhat emaciated, the strength diminished, and the skin dry and very sensible of cold. The tongue is often loaded from the commencement in the middle and at the root, and sometimes is red at the point and edges. The urine is generally scanty throughout the complaint. The evacua- tions vary remarkably as to the nature of the matters composing them, their colour, consistence, smell, and other appearances, not only in different cases, but even in the same case, at different periods. Nosologists have generally divided the disease into varieties or species, founded on the different states of the discharges. But this is not a satisfactory basis of classification, as the appear- DIARRHCEA—Idiopathic—Symptomatic. 603 ances of the evacuations do not depend upon defi- nite pathological conditions, although furnishing important indications of the seat and state of dis- ease. The most common of these appearances are, the feculent, which usually precedes the others ; the bilious ; the mucous ; the serous ; the chylous; or white ; and the lienteric. But every practitioner must have observed that not only will these discharges present themselves during dif- ferent periods of the disease, but that two or more of them may co-exist; thus the evacuations are not infrequently, at the same time bilious, mucous, and serous ; or feculent, bilious, and mucous ; or watery and bilious. i. I DIOPATHIC DlARRHtEA. ClASSIF. II. CLASS, I. Order (Author). 4. Defin.—Copious, feculent, and frequent evacuations, sometimes preceded by griping, and unattended by fever. 5. A. Diarrhoea of Irritation.—This form of the disease comprises most of the cases denomi-' nated feculent by authors, and termed D. Ster- corea by Sauvages, D. Crapulosa, by Cullen, and D. Fusa, by Good.—(a) It is usually caused by any stimulating or irritating substance re- ceived into the stomach ; by too great a variety or quantity of food or drink, or even by a small quantity of that which is unwholesome, or which may disagree with the patient’s diathesis, or with the existing state of the digestive organs; by in- digestible vegetables, particularly cucumbers, mel- ons, salads, &,c.; by various acid fruits, particu- larly plums, piue-apples, &c.; by acidities gen- erated in the priiria via, and the quality of the nurse’s milk; and by deutition in infants. [Ac- cordingto Dr. Stokes (Bell and Stokes' Practice, vol. i. p. 201,) every variety of diarrhoea may be referred to a single cause, irritation; although they may arise under different circumstances. It is very evident that irritation of the gastrointes- tinal memorane may originate, not only from in- digestible food, but from exposure to wet and cold, or the transfer of profuse perspiration in hectic, &c. It certainly is more often depending on irritation than any other pathological state of the mucous surfaces: it is, however, a mooted point, whether in all instances such be the correct pathology of the disease.]—(b) The symptoms in this variety are frequently nausea ; severe griping pains before each evacuation ; foul, or ioaded tongue ; copious feculent stools, afterwards be- coming frothy, watery, or mucous, and exhaling an offensive, or sour odour ; the pulse and tem- perature of the surface being but little affected.— (c) This form generally ceases spontaneously, owing to the evacuation of the offending sub- stances ; and the digestive functions are soon af- terwards restored, if its cause be subsequently avoided. It may, however, excite some of the other pathological states to which this disease has been ascribed, and be thereby prolonged ; or it may terminate in organic change. 6. B. Diarrhoea of Relaxation associated with Irritation (Diarrhoea a Cibis corruptis, Sennert) —(a) may be caused by whatever relaxes the tone of the intestinal mucous surface, or of its vessels, by its septic influence, whilst it excites the peristaltic actions of the tube, as stale fish, high game, or any animal food approaching to putridity, over-ripe, or decayed fruit, stale vege- tables, yos, a discourse. Causes act primarily on the vital endowment. —I have already stated, that although the vari- ous textures and organs of the body display the finest combinations of mechanism, and the most beautiful principles of action presented by the physical world, yet they are entirely under the dominion of life, by which only they are actu- ated, and on which they entirely depend for the functions they present. It is not upon the tex- tures or organs themselves that the causes of dis- ease generally make their first impression ; and even when they are brought in immediate relation to a particular organ or structure of the body, we have no evidence to furnish that they derange these parts by primarily affecting the machinery of which they are composed ; but, on the con- trary, from the gradual manner in which derange- ment is produced, from the nature and effects of the disorder which follows, and numerous other considerations, it may be inferred that they make their first impression upon the vital endowment of the organ, disordering the functions which it per- forms under the dominion of life; and the func- tional disorder either leads on to the production of further disease, or indirectly to a return to the healthy condition. No doubt, some causes affect at once the organisation of the part, such as many chemical, physical, and mechanical agents; but the majority modify the vital manifestations of the frame, either in one organ or structure, or in several simultaneously; and by impeding or modifying, deranging or altogether changing these manifestations, thereby induces effects, which be- come themselves causes of further disease, until life itself is terminated, or a healthy condition of function re-established. Of the justness of this inference satisfactory evidence will be furnished in the sequel. § A3., et seq.) 8. The causes of disease have been variously arranged and named by pathologists. For the better understanding the subject, and writers on disease, the different arrangements and distinc- tions which this subject has received may be briefly alluded to. Causes have been denomi- nated extenal or extrinsic, and internal or intrin- sic, according as they operate upon the body from without or within. They have also been called principal and accessory or concurrent; disease proceeding chiefly from the former with the as- sistance of the latter. They have also been named positive and negative, from the manner in which they act upon the body ; and by some they have been divided into physical, chemical, and physiological, according to their nature. The division, however, which has been most gen- erally adopted is into remote, and proximate or im- mediate, according to their relation to the disease occasioned by them : the remote being the first in the chain of causation, the proximate or immedi- ate those early changes which they effect in the oecotiomy, and which constitute the primary con- dition of the disease, or, in other words, the pa- thological states arising directly from the opera- tion of the remote agents. The remote causes have been divided into predisposing and exciting or occasional causes; the predisposing being those which influence the conditions of the living func- tions so as to favour the operation of those occa- sional or exciting causes whence disease more directly springs. To these two classes I would add a third, viz., determining or consecutive causes, which, being posterior to the others in point of time, determine or call into action the exciting causes, or rather come in aid of, and fol- low up, the impression made by the latter; and which, without such aid, might have been in- sufficient to produce actual disease, or would have induced it only in a slight degree. 9. It must be obvious that all causes, as well as the effects they produce, must have an intimate relation to the condition of the living frame ; and that those which may be quite inefficient on one person will be powerfully active on another ; or which are without effect on an individual at one season, will be very influential at another, owing to the state of vital energy at the time, to the concurrence of other causes, or to exposure soon afterwards to such as will determine, or otherwise aid, those which preceded it, and which, although the principal or exciting causes, were insufficient, until thus reinforced, fully to produce the disease. Owing, also, to the condition of the frame, no ef- fect will sometimes follow one, two, or even three exciting causes ; and until a greater number are brought into operation, no mischief will often re- sult. The effects produced by various animal and vegetable exhalations on different individuals, or upon the same person at distinct periods, under different states of mind and predisposition ; and by the action of numerous concurrent, accessory, and determining causes; fully illustrate this posi- tion. It is chiefly owing to a want of knowledge of the doctrine of causation, that so much error and difference of opinion prevail respecting infec- tious and non-infectious diseases. On the other hand, persons may be so very easily affected, that causes of the slightest nature, and such as are determining or accessory in the majority of cases, DISEASE—Predisposition to—zEtioi.ogv. are principal in respect of them ; and influences which are usually predisposing are often, in such persons, the exciting causes of disease. Also those which are remote in their operation on some constitutions, are direct or immediate in respect of others. Examples of this are found in the dis- eases of the lungs, liver, stomach, and bowels. In .considering the agents which affect either the functions, or the organisation, I shall first notice those which generally predispose the system to disease: next those which excite disease in a di- rect or immediate manner; afterwards such as are specific, or produce determinate results ; the ef- fects of their operation on the living frame being obvious, and often admitting of being foreseen ; and lastly those circumstances which sometimes determine, reinforce, or call into action, exciting or specific agents. 10. i. Of the Predisposing Causes of Dis- ease.—These may be classed—1st, into such as are proper or peculiar to individuals, and the cir- cumstances iu which they are placed ; 2d, into such as are not proper or peculiar to individuals, but which may affect various persons, and even numbers of persons, but individually and occa- sionally ; and, 3d, into such as are general, and affect more or less all who are exposed to them. —A. Those which are peculiar to the individual, and to the circumstance in which he is placed, and which may be called the individual predis- posing causes, are—1st, original conformation and hereditary predisposition, age, sex; tempera- ments, original and acquired; habit and constitu- tion ; trades, professions, and circumstances of life, &c.; and, 2d, the various external and inter- nal agents, and circumstances modifying the state of the functions,—as previous functional dis- order, and convalescence from disease; and the pregnant and puerperal states. 11. a. Original conformation and hereditary predisposition.—It is generally observed, that the constitutions, temperaments, and diathesis of the offspring closely resemble the parent; and that whatever disposition to disorder, whether of func- tion or of structure, the latter may have possessed, is liable to evince itself in the former. From this circumstance having been very generally re- marked in respect of certain maladies, they have been termed hereditary. But it must not be sup- posed that children are actually born with the diseases of their parents. This is but seldom re- marked ; although, in rare instances, I have ob- served the commencement of tubercles in the lungs of a new-born infant by a consumptive mother ; and small-pox and syphilis are some- times communicated to the foetus in utero, occa- sioning in some instances its premature birth, and even its death, either previously to or about the natural termination of utero-gestation. Hydro- cephalus, cataract, and various imperfections of the organ of hearing, and, indeed, of other or- gans of sense, are not infrequently congenital, or examples of disease from original conformation; but, in such cases, it is rare that the parent is similarly affected at the time, although the hered- itary predisposition, as about to be explained, ex- ists nevertheless; and, as respects the first of these, a tendency merely to the disease could have existed at an early age in the parents. It should be kept in recollection, therefore, that the foetus in utero may be affected by several ca- chectic, inflammatory, or even febrile diseases, communicated by the parents, or supervening 645 DISEASE—Predisposition to—2Etiology. 646 accidentally: but, of those which are thus com- municated, even the majority are not, properly speaking, hereditary ; and those which are acci- dental do not depend upon the constitution of the parents, or the ailments experienced by the mo- ther during the period of gestation. Congenital diseases are consequently divisible into—1st, Those which occur in the foetus, without any par- ticipation on the part of the parents,—as imper- fect developsment of organs, inflammations, effu- sions of fluid in various parts, &c.; 2d, Diseases in which the foetus participates with the mother, owing to their contaminating influence, or their extension throughout her organisation,—as syphi- lis, small-pox, fevers, &c.; 3dly, Those that af- fect the foetus from a constitutional liability in one or both parents,—as hydrocephalus, cataract, tubercles, &c. 12. Most commonly, however, the child is bom free from disease; but, inheriting the con- stitution and diathesis of the parent, has that con- dition of function and organisation which renders it more susceptible of impressions produced by the exciting causes of certain maladies. Examples of this may be contemplated daily in respect of diseases of the lungs and brain ; the constitution and functions of these viscera disposing them or rendering them more prone to experience those derangements by which the parent or parents had been affected. In some instances this pre- disposition may be more strongly marked in the child than in the parent, and in other cases the predisposition may be extremely slight, and only brought to light by the operation of the more en- ergetic agents. 13. The predisposition of the offspring gen- erally evinces itself more strongly at certain ages than at others, according to the kind of morbid constitution or predisposition which it may inherit, the causes to which it is exposed, and the nature of the malady which results. Thus, the disposi- tion to hydrocephalus, convulsions, idiotcy, rick- ets, scrofula, cataract, &c. is most apparent soon after birth, and at early epochs of life ; to epi- lepsy, haemorrhage, and pulmonary consumption, about the age of puberty, or previously, or soon after; to gout, asthma, and angina pectoris, in adult and mature age ; to insanity, apoplexy, and paralysis, during the mature or advanced stages of life ; and to various nervous disorders, at more irregular periods. But these diseases do not ne- cessarily supervene, although one or both parents have been affected by them : and several usually appear in alternate generations. Some occur more uniformly than others. When the predis- position to them is derived from only one parent, they very frequently never make their appear- ance, unless as the effect of very active exciting agents. But even when the predisposition is de- rived from both parents, and when it may be con- sidered as being thereby heightened, exciting causes are generally required to develope the dis- order. 14. b. Age.—Each of the different epochs of existence is more liable to certain diseases than to others. During the earlier periods, there is generally a predisposition to particular disorders, even when no hereditary taint exists. This is partly owing—(a) to the changes going on in the frame; (6) to the state of vital manifestation ; and (c) to irritations in the alimentary canal. Amongst the changes proceeding in the frame, that either readily suffer derangement or lead to it, the most important are the processes of ossifi- cation and developeinont of the contents of the cranium. These processes are more or less under the dominion of the vital influence ; and they are more or less disturbed as this influence is affected, in respect either of the system generally, or of particular organs. Hence, rickets, hydrocepha- lus, inflammations of the brain or its membranes, readily occur. The quantity of blood sent to the brain in early life is another predisposing cause of cerebral affections ; and the readiness with which the functions and even the circulation of tho brain are disturbed by impressions from without or by irritations from within, becomes, especially when assisted by other causes, a frequent source of disease. (See Age, § 10.; and Dentition.) 15. After the first dentition, and during growth, the powers of life are energetic, as shown by the reaction of the vital functions upon the depress- ing causes of disease; and are eminently con- servative, particularly in resisting hurtful agents. The predisposition is chiefly to inflammatory ail- ments and acute attacks of fever, especially in those who breathe a wholesome air and are suffi- ciently nourished. But the susceptibility to im- pressions, both moral and physical, is energetic ; and irritations, from whatever cause, are gen- erally followed by augmented vascular action, with which the whole frame, owing to the sus- ceptibility of the nervous systems, promptly sym- pathises. Hence febrile attacks, eruptive fevers, inflammations, cerebral affections, disorders of the air passages, of the alimentary canal, and lym- phatic glands, usually appear. At this period, also, all specific causes readily take effect, par- ticularly of those diseases which are incidental to childhood ; their full operation, however, destroy- ing the susceptibility to be again affected by them. About the time of puberty and adolescence vari- ous complaints first show themselves, especially some that are inflammatory, and to which there is an hereditary tendency,—as pulmonary con- sumption, haemorrhage from the lungs, epistaxis, plethora ; and as soon as the body has ceased to grow in height., or the vessels to extend them- selves in the direction of their axis, those disor- ders are still more readily produced by exciting causes. In manhood and mature age, the sus- ceptibility to impressions gradually diminishes, and generally continues to decrease as age advances. During the former of these periods, hypochondri- aisis, melancholy, insanity, hoemorrhoidal affec- tions, asthma, rheumatisms, and the majority of organic diseases, with the exception of such as are scrofulous, commonly make their appearance. Towards the decline of life, gout, softening of the brain, apoplexy, paralysis, scirrhus, cancer, changes in the coats of the blood-vessels, diseases of the organs of sense, affections of the urinary passages, &c. usually supervene. (See Age, and Climacteric Decay.) 16. c. Sex.—There are a great many diseases to which both sexes are equally liable. Fevers, inflammations, organic diseases, and many others, attack both. But it has been observed, during the prevalence of epidemics, and in unhealthy countries, that the female sex suffers much less than the male. This, no doubt, arises from the more reg- ular habits of females, and their less exposure to the determining or concurring causes: something may also, perhaps, be attributed to their peri- odical discharges, which tend to diminish plethora and to purify the circulating fluid—circumstances DISEASE—Predisposition to—^Etiology. 647 calculated to impart a partial exemption from several diseases, particularly those which are epi- demic and endemic, although they may dispose to others. But the conformation and tempera- ment of females, the sympathy existing between their generative organs and the state of the circu- lation in the brain, the marked susceptibility of their nervous system, and great mobility of their muscular organs, dispose them—especially those in cities and populous towns—to diseases usually denominated nervous. The natural vicissitudes, also, of female life are accompanied with a ten- dency to particular maladies, especially the peri- ods at which the menstrual discharge commences and ceases ; at the former of which, nervous and cachectic complaints—at the latter, diseases of the organs of generation, or of those closely al- lied to them in function or situation—very fre- quently appear ;—chorea, chlorosis, irregular con- vulsions, hysteric or painful affections, difficult, suppressed, or irregular catamenia, occurring about the former epoch; and chronic inflamma- tions, seirrhus, cancer, and other organic lesions of the womb, disease of the breast, and disorders of the colon or rectum, about the latter period. 17. d. Temperament and diathesis.—The san- guine and irritable temperaments dispose to ple- thora, inflammations, haemorrhages, pneumonia, and to inflammatory fevers. The bilious tem- perament most readily experiences biliary de- rangements, bilious fevers, affections of the stom- ach and bowels, hypochondriasis, mental disor- der, chronic cutaneous eruptions, and various or- ganic derangements of the abdominal viscera. Persons of the lymphatic or phlegmatic temper- aments are predisposed to catarrhal attacks, slow fevers, chronic discharges, dropsies, scrofulous and scorbutic affections, diseases of the joints and glands, and to tuberculous and other chronic dis- eases. In persons thus constituted, the powers of life are languid, the preservative influence and vital resistance feeble, and reaction upon noxious causes or agents seldom developed or energetic. The nervous temperament disposes chiefly to con- vulsive diseases, especially to hysteria in the fe- male sex; to mania and insanity, or other de- rangements of the mental manifestations, as hy- pochondriasis, melancholia, &c.; to nervous and typhoid fevers, &c. This temperament often modifies the progress of various acute diseases, and imposes upon them a nervous character. When the temperaments are mixed, an accord- ant predisposition may often be remarked ; as, in the sanguineo-bilious, a disposition to bilious in- flammatory fevers, to hepatitis, to inflammations of the alimentary canal, of the brain, and of the serous surfaces, &c., is often manifested. 18. e. Of constitution and habit of body, it may be remarked, that a robust constitution generally successfully, opposes the impressions of many ex- citing causes ; but when once a morbid impression is produced, disease assumes a more active or acute character, and is attended with higher vas- cular action, the powers of life and reaction being great. On the other hand, weak constitutions, and those of a scrofulous taint, are most disposed to disorder, more readily affected by its causes upon the first impression ; and disease in them assumes a more chronic and low form. When persons thus constituted have become habituated to the impression of certain morbid agents, they frequently cease to be affected by them in the usual manner; as observed in respect of marsh or terrestrial emanations, which seldom give rise to regular attacks of fever in such subjects, but induce organic disease, and sinking of the powers of life. . 19. Habits of life and profession are amongst the most influential predisposing causes of disease. Whatever profession or occupation requires an active exertion of the powers of the mind, and continuation of that exertion to the neglect of sufficient relaxation and exercise, occasions de- termination of blood to the head, and favours the production of inflammation of the brain or of its membranes ; especially if such persons live fully or luxuriously ; and, if fever attack them, the head, the liver, and stomach, become severely and dangerously affected ; and, unless the disease be actively treated at its commencement, death may supervene in consequence of serous effusion from the membranes, or of softening of the texture of the brain, rupture of its vessels, or of organic change in the liver, or digestive canal. Those who take active exercise in the open air are gen- erally more disposed to inflammatory attacks of an acute character, to pneumonia, and to rheumatism, than to other complaints ; although in them the predisposition to disease is much less than in other persons. Those who indulge the appetites beyond what the economy requires,—especially the desire for food, and for vinous and spirituous liquors,— are liable to disorders of the stomach, liver, and intestinal canal; and, if attacked by fevers, these organs generally are the most seriously affected : such indulgences also dispose to plethora, apo- plexy, paralysis, gout, dropsy ; and in many cases directly excite those maladies. Inordinate sexual intercourse is also a frequent predisposing cause of many diseases, and often immediately induces disorder. Pulmonary disease, affections of the heart, epilepsy, mania, and the other disordered manifestations of mind, frequently take place in consequence of the predisposition to them gener- ated in the system by the excessive indulgence of this appetite. It also leads to other maladies, by lowering the vital energies of the frame, and thereby rendering them more assailable by the common exciting causes of disease. 20. g. The circumstances of life in which per- sons are placed have a marked influence in favour- ing or counteracting the operation of exciting causes. It has been determined, by exact ob- servations and calculations, that those who enjoy easy or comfortable circumstances are much less subject to disease than the poor, the insufficiently clothed, and ill-fed. This arises not only from the former class being less exposed to its exciting causes, but also from the good effects of sufficient nourishment in supporting the energies of life, and thereby warding off the impressions of injuri- ous agents and influences. Much, also, is owing to personal and domestic cleauliness, to proper clothing, and to living in airy apartments in healthy localities. Yet, while full living thus wards off many diseases, especially those arising from debility, as low or adynamic fevers, scorbutic disorders, scrofula, dysentery, and various others, it disposes to gout, dyspeptic and nervous affec- tions, particularly to apoplexy and paralysis. (See Arts and Employments.) 21. h. Debility, previous disorder and con- valescence from other diseases, often favour the operation of exciting causes ; particularly when the powers of life are much depressed or ex- hausted. In respect of the predisposition occa- 648 DISEASE—Predisposition to—.Etiology sioned by already existing disorder, some doubt may be entertained by those who may have adopted the hastily formed and incorrect dogma that two disorders cannot co-exist in the economy. This may be true in respect of certain febrile diseases, especially those of a specific or exan- thematous kind : but in nearly all beside, so very numerous are the exceptions, that the principle becomes quite untenable ; and, in many cases, even an opposite doctrine may be enforced, par- ticularly in respect of bilious and nervous dis- orders. Thus, when the functions of the stomach are weakened, or those of the liver obstructed, various affections of different organs related to these, either in function or anatomical connection, are apt to supervene, more especially febrile dis- eases, disorders of the bowels, brain, and lungs. The exhaustion of the powers of life partially continuing during convalescence, also disposes the frame to the invasion of the exciting causes. On this account convalescence ought always to be watched by the ordinary medical attendant, who, if not allowed to continue his aid for this purpose, should state his reasons for proffering it; and, if it should be declined, the patient will then have himself only to blame. (See Debility, &c.) 22. i. Amongst the other individual predis- posing causes of disease, I may mention the preg- nant and puerperal stales. These states favour, in a very marked manner, the occurrence of several maladies, which, owing to this connection, have been denominated puerperal, &c. Although these diseases arise chiefly from the predisposition cre- ated by the conditions of the female organs and constitution during these states, yet a great differ- ence exists between them as to their necessary dependence upon these conditions; for, whilst these states predispose to the invasion of exciting causes developing disease in other circumstances, the maladies that result may be either such as are peculiar to them, as adynamic puerperal fever, &c ; or such as are not necessarily de- pendent upon, although remarkably favoured by, them, as inflammations of the uterus and perito- neum, uterine htemorrhage, convulsions, mania, &c. During the puerperal state, also, although the predisposition to fevers, inflammations, con- sumption, various nervous affections, rheumatism, &c., is less strong than it is to the preceding dis- eases, yet it is greater at this period than at any other. 23. B. Amongst those predisposing causes which are not peculiar to the individual, hut which affect persons individually and occasional- ly, certain states of the mind deserve the first place.—(a) When the mental energies are de- pressed by grief, anxiety, disappointment, fear, &c., the powers of life are less able to oppose the debilitating causes of disease which invade them from without, and of which nature all the ex- citing causes of fevers, particularly those which are specific or contagious and miasmal, generally partake in a most marked manner. On the other hand, when the mind is elevated by success, by hope, by confidence, and the other exciting pas- sions, the depressing causes make little or no im- pression upon the constitution; and individuals thus circumstanced almost always escape from diseases which readily invade the fearful, the de- jected, and the disappointed. There is, perhaps, no circumstance which more certainly disposes the system to the operation of the exciting causes of fever, than the fear of being attacked by it; whilst nothing fortifies the constitution more surely than a full confidence that the causes of disease will not take effect. 24. (b) Next in importance to mental depres- sions, is whatever lowers the vital energies, or ex- hausts and debilitates the body. Under this head, low diet, fatigue, previous illness, excessive se- cretions and discharges, want of sleep, and vene- real excesses may be classed. (See art. De- bility.) 25. (c) Dress, even, has a very evident in- fluence in creating a predisposition to disease. Too little clothing, particularly in females, favours the occurrence of difficult and suppressed men- struation, pulmonary disease, and disorders of the bowels. It was remarked, during the French revolution, when it was the fashion to dress clas- sically,—which was almost a state of semi-nudity, and more appropriate to the warmer climates of Athens and Rome than to those of the north of France and this country,—that pulmonary dis- eases, rheumatism, suppressed menstruation, bow- el complaints, catarrhs ; and amongst the children, who were exposed with naked busts and thin clothing, croup, and other diseases of the air- passages and lungs, were uncommonly prevalent. On the other hand, too warm clothing is a source of disease, sometimes even of the same diseases which originate in exposure to cold ; and often renders the frame more susceptible of impressions of cold, especially of cold air taken into the lungs. The remarks now offered may be applied to overheated sitting and sleeping apartments, and to warm soft beds and bed clothing. These relax and weaken the frame, dispose to disorders of th« kidneys, urinary and sexual organs, and render the system much more susceptible of injurious impressions from without. A predisposition is thus produced, not only to catarrhs, inflamma- tions, affections of the lungs, and rheumatism, but to irregularity in the menstrual discharge. It has been remarked, that the females in Holland, who generally use very warm clothing, warm apart- ments, and warm beds, are very subject to ex- cessive menstruation and fluor albus. Females, also, become disposed to various diseases, particu- larly those affecting the pulmonary organs and heart, from wearing very tight-laced and un- yielding corsets. Indeed, those dressed in this manner can scarcely call the intercostal muscles into action, and can breathe only by means of the diaphragm. The mechanism of respiration being thus impeded, the requisite changes are not fully produced upon the circulating fluid ; and conges- tion supervenes in the lungs, right side of the heart, and parts situated below the seat of pres- sure. This cause is especially injurious to females during growth and pregnancy; for the chest should be fully and freely expanded, especially at these periods, in order that the circulation through the lungs and heart may be unimpeded ; and that the blood should experience those changes with- out interruption, that are required for the devel- opement of the body and of the foetus. The functions, not only of the lungs and heart, but of the liver, stomach, and bowels, are materially in- terrupted, and even these organs themselves are removed from their natural positions in respect of each other, by this cause. This is more remark- ably the case as regards the colon, which, by the squeezing together of the hypochondria and lateral regions of the abdomen, is thrown into unnatural duplicatures; the passage of the fecal matter along it being thereby impeded, and habitual cos- tiveuess, with all its consequences, produced. 26. (d) Amongst the most frequent predisposing causes to disease, is intemperance in food and drink. Too much and too great a variety, par- ticularly of animal food, high seasoned dishes and soups, rich sauces, the too liberal use of vinous, spirituous, or other exciting liquors, overload, over- dislend, and over-excite the stomach ; dispose it, the liver, and bowels to inflammations aud func- tional and organic disease ; directly induce ple- thora: and when this state is produced, inflam- matory complaints in early life, and gout, apo- plexy, paralysis, &c. at a more mature age, frequently follow. On the other hand, an un- wholeshome, poor, innutritious diet, or food of a fluid or watery consistence, predisposes to diseases of debility, by diminishing the powers of life, par- ticularly in the digestive organs, and lessening the vital resistance to depressing causes. Typhoid or adynamic fevers, dysentery, cutaneous com- plaints, verminous diseases, tubercles, scrofula, scurvy, scorbutic dysentery, enlargements and affections of the joints, are common under such circumstances. 27. (e) Excessive secretions and evacuations, although in some instances a disease of them- selves, frequently predispose to further disease. The abuse of remedies which have an evacuant operation, excessive perspiration, fluor albus, too long suckling, and venereal excesses, weaken the powers of life, and expose them to the invasion of exciting causes. 28. (/) Indolence and too great exertion, both predispose to and occasion disease ; whilst moder- ate exercise, especially in the open air, increases the energies of the frame. Fatigue generally favours the impression of causes which produce acute affections, as fevers and inflammations ; whilst indolence and sedentary occupations dis- pose to chronic maladies, as congestions of the liver and abdominal organs, to corpulency, apo- plexy, haemorrhoidal affections, and derangements characterised by diminished tone of the nervous and vascular systems. 29. (g) Sleep.—The want of this restorer of the vital energies favours the invasion of fevers, inflammations of the brain, and disordered mani- festations of mind ; whilst too much sleep, and the horizontal posture too long retained, or too fre- quently assumed, predispose to apoplexy, paraly- sis, softening of the brain, inflammation of the cerebrum or of its coverings, and affections of the kidneys. Many, also, of the causes of acute dis- eases make their impression during sleep, when the body is relaxed, and thereby exposed to their invasion. On the other hand, early rising pro- motes both mental and corporeal energy. It has been remarked by the actuaries of Life Insurance Companies, that early rising is, of all habits, the most conducive to longevity ; all long livers being early risers. 30. (A) Due regulation of the temper, the passions, and desires, and a proper conduct of the imagination, are also necessary to resist exciting causes. Indulgence of temper and passion no*, only predispose to disease, but also frequently di ■ rectly excite it, particularly in nervous, irritable, and sanguine temperaments. Diseases of the heart, brain, liver, stomach, and bowels, often originate in these sources. Uncontrolled passions of every description occasion numerous functional and structural changes, seated chiefly in the DISEASE—Predisposition to—Aetiology. viscera of the large cavities. Moderation in eat ing and drinking, in sleep, in the indulgence of those appetites, feelings, passions, and desires which have been implanted in our natures by a wise Providence for our advantage, gratification, social improvement, and happiness ; an equable state of the mind, with confidence in our powers; and the pleasant excitement accompanying a well-regulated course of application to business or study ; are the best means of resisting the impres- sions of injurious agents. 31. C. General predisposing Causes.—Of these, the most universal in their operation are certain constitutions of the atmosphere. Besides the variations in the temperature and dryness of the air, its electrical conditions also vary extremely ; but as yet we are not possessed of sufficient data to enable us to state with precision how far these conditions may predispose to, or directly excite, disease, or what particular change in our bodies result from certain electrical states of the atmo- sphere. But that the electrical conditions, 1o- gether with a more or less humid state of the air, are connected, in the relation of cause and effect, with the prevalence of disease, is extremely prob- able, although not satisfactorily demonstrated. Those conditions which predispose to disease are —1st, temperature ; 2d, humidity; 3d, these two states conjoined ; and 4th, electrical conditions of this fluid. Two very important subjects, very intimately allied to these, and which act both as predisposing, exciting, and specific causes, viz. endemic and epidemic influences, are considered in separate articles. 32. (a) Temperature has a considerable influ- ence in generating a predisposition to certain dis- eases. Thus, in low-states of atmospheric tem- perature the functions of respiration are fully and actively performed, especially as respects the blood; and the diseases observed in such circum- stances are of an inflammatory nature, are seated chiefly in the respiratory organs, and are charac- terised, unless when the reduction of temperature is remarkably great, or the air very moist, by reaction of the powers of life on the causes which excite them. Very warm states of the air im- pede the changes which the blood undergoes in the lungs; and, by thereby furnishing abundant materials for the formation of bile, occasion an in- creased secretion of this fluid. Hence bilious diseases are most prevalent during high atmo- spheric temperatuite. This effect upon the blood is still more marked, if warmth be conjoined with moisture (§ 34). Under those circumstances, bilious fevers, hepatic diseases, dysentery, diar- rhoea, and cholera prevail. 33. (b) Moisture.—In dry states of the air, changes are fully effected on the blood by respira- tion ; its watery portions are more freely carried off from the exhaling surfaces; its purity is in- creased, its congestion and excessive fulness pre- vented ; and consequently, the vital energies are promoted; and the depressing causes of disease, as infectious animal effluvia, and terrestrial ex- halations, make much less impression on the sys- tem. Disorders occurring in this state of air as- sume chiefly a phlogistic or sthenic character, and affect most frequently the organs of respira- tion and the nervous system. A very moist state of atmosphere causes opposite effects. It fails of producing to the full extent the requisite changes in the blood, and of carrying off the fluids exhaled from the surfaces, especially of the lungs; there- 649 650 by rendering the powers of life more languid, and the system consequently more open to the inva- sion of the exciting causes. Less moisture also being exhaled, the elements of biliary secretion, and the watery portion of the blood become re- dundant in the vascular system. Hence an abundant secretion of bile, fevers, affections of the liver, and determination of fluids to the intes- tinal canal, &c. are promoted. (See art. Cli- mate.) 34. (c) Temperature and moisture conjoined. —That warm and humid states of air are indi- vidually active as predisponents of disorder, has been shown ; but it is when they are conjoined, that they are especially injurious. A warm and humid atmosphere dissolves and accumulates the specific causes, such as animal and vegetable ef- fluvia ; assists their operation; and favours a rapid transfer of electricity from the earth’s sur- face, and the change in the condition and the ac- cumulation of it in the air resulting therefrom. It has been shown by the experiments of Prout, Fyfe, Allen, and Pepys, in an artificially in- creased temperature, and by those I made in an intertropical atmosphere, that heat remarkably- diminishes the changes effected by respiration on the blood ; and these changes are further dimin- ished by warmth associated with moisture, which, moreover, promotes the passage of positive elec- tricity from the body. And as the researches of Ritter show that the electricity of the positive pole heightens, whilst that of the negative de- presses, tfl'e actions of life, the ultimate effect of humid, atmospheric warmth, as respects both the state of the circulating fluid and the locomotive electricity of the body, will be to lower the whole circle of vital manifestations, and to dispose to, or even to induce, diseases of a low character— to occasion adynamic, continued, and remittent fevers, or agues of a pernicious and congestive kind, or dysentery, cholera, chronic asthma, diar- rhoea, and affections of the liver and spleen. A moist and warm air may, therefore, be stated to be doubly injurious, inasmuch as it is of itself au extremely active predisposing and exciting cause, and as it is the means of dissolving vegetable and animal miasms,—of marsh, infectious, and pestiferous emanations,—and the vehicle or medium in which they act injuriously on the frame. 35. (d) A moderately cold and a dry air in- creases the respiratory actions, and the energies of the system ; proving what is commonly called a bracing atmosphere. Diseases usually assume an acute, sthenic, or phlogistic form; and the respiratory organs are liable to suffer.—In cold and moist states of air, rheumatism, gout, ner- vous affections, scrofula, and glandular diseases, intermittent and adynamic fevers, erysipelas, dropsies, anasarca, and chronic disorders and congestions, often prevail, especially in low, ill- ventilated, and marshy places. The positive electricity being rapidly carried off by induction from the body, a salutary stimulus, and one which experiments have shown to be productive of in- creased activity of all the animal functions, may be supposed to be lost. But when the air is very dry, the transit of electricity from the surface of the earth and from the body is impeded; this fluid accumulating until a moister state of air diminishes its quantity, and changes the relation subsisting between the electrical condition of the frame and that of the atmosphere. In very dry DISEASE—Predisposition to—Aetiology. and warm states of air diseases less frequently prevail than when it is both warm and moist; and are more frequently characterised by increased vascular action. Inflammatory fevers, inflamma- tions of the brain, liver, and stomach, are then most prevalent. 36. (e) Sol-lunar influence.—Considerable im- portance has been attached to the influence of the sun and moon in creating1 a morbid predis- position. Close observation of the relation sub- sisting between the prevalence of fever and dysen- tery, and the full and change of the moon, has apparently established some degree of connection between them in warm climates, particularly in the eastern hemisphere ; but the manner of ex- plaining this circumstance has been by no means satisfactory. Some impute it to a direct lunar influence ; and adduce in support of their opinion the fact, that dead animal matter, when ex- posed to the moon’s rays, more speedily suffers decomposition than when protected from them. Others, who favour sol-lunar influence, argue that it proceeds from the height of the tides, at full and change of the moon, occasioning the rivers on the coasts to inundate their banks, and to de- posit vegeto-animal matter, which is rapidly de- composed, when the water retires and leaves the low ground exposed to the sun’s influence. But if the relation subsisting between the prevalence of disease and the moon’s changes were owing to this circumstance, it could hold only in respect of parts situated in the low alluvial countries on the coast, and not in districts inland and much elevated above the level of the sea. This, how- ever, is not the case ; for observation has shown the influence, whatever it may be, to be as pow- erful in high and inland countries as in districts on the sea-shore. 37. (/) Light and sunshine.—That the power of the sun’s directed and refracted rays, in the production and removal of disease, is by no means inconsiderable, is proved by their influence on the vegetable and animal kingdoms; and by the effects which ensue in the economy when they are en- tirely excluded. These effects have been described in the articles on the Blood (§ 47.), and De- bility (§ 6. c.). The vital depression attended by increased sensibility, mobility, and suscepti- bility to impressions, and the anaemia and general cachexy, which ultimately result from the pro- tracted exclusion of light, are sufficient proofs of the beneficial influence of the sun’s rays upon the frame. But additional and more direct evi- dence is furnished in the greater activity of the vital functions in spring; and in the genial ex- citement of the frame of the aged and debilitated, and indeed of both the minds and the bodies of all, by sunshine ; light, as ordained and regulated by nature, being a salutary stimulus, and neces- sary to the energetic and healthy performance of all the functions. The exciting and depressing effects of the excess and absence of light respect- ively prove its influence over all the organic and mental manifestations, and consequently its power in predisposing to, and even exciting, disease— the intense oc continued action of light inordi- nately exciting the nervous and vascular systems, and producing disorders of this kind ; its abstrac- tion weakening all the mental and bodily func- tions, and favouring the occurrence of diseases of debility. It is obvious from this, that light, es- pecially sunshine—and even its abstraction—may be made subservient to the removal of disease. DISEASE—Exciting Causes of—Etiology. 651 either, in its individual capacity, or in association with a pure, dry, and temperate, or warm air, as- sisted by suitable exercise, and change ol ocality ; and that the partial abstraction of one or both of these requisites to the due or energetic performance of the functions, must be ultimately followed by dis- ease, however remote the effect, or numerous the intermediate links in the chain of causation. [To these general predisposing causes may be added, atmospheric pressure. The mean pres- sure of the atmosphere on the surface of the human body, supposing it to be about 15 square feet in extent, is about 40,000 lbs.; and the dif- ference of pressure at different times, supposing the range of the thermometer to be about three inches, amounts to about 4,000 lbs. It is reason- able to imagine, that this immense difference cannot take place, as it sometimes does very suddenly, without producing a very sensible effect upon the functions of the body, and physicians have, therefore, attributed the increased alacrity and strength of body, and energy of mind, that are generally experienced in a clear cold day, to the greater density of the atmosphere, and the listlessness and depression so commonly felt upon a close hot day, to its greater rarity. But as Fletcher very justly observes {Elements of General Pathology, p. 59), it appears very ques- tionable, whether what is commonly attributed to increased and diminished density of the atmo- sphere, should not rather be ascribed to the less and greater degree of heat of which that increased or diminished density are merely concomitants. “ It is well known,” he remarks, “ that no in- crease of alacrity is felt in a diving-bell in great depths under the water, where the density of the air may be presumed to be at its maximum. On the contrary, a great increase of alacrity is ex- perienced on ascending in an air-balloon, or in ele- vated situations, where the pressure of the atmo- sphere is the least; an ascent of even 500 feet, it is computed, producing a diminution of pressure of about 600 pounds. In these latter cases, then, we have no difficulty in referring the peculiar state of both body and mind to the cold ex- perienced by persons in these situations; but as cold, at the ordinary elevation, is accompanied by an increase, not a diminution, of the density of the atmosphere, we commonly ascribe to this increase of density what is really attributable to the cold ; and the same doctrine may be applied to the opposite state of the body, commonly referred to diminished density of the atmosphere, but really referrible to the heat which accom- panies it. However this may be, it is not easy to attribute the occurrence of any particular dis- eases to the difference in the density of the atmosphere alone, unless, perhaps, hajmoptysis, asthma, and some other diseases of the lungs, owing to the greater or less expansion which the same quantity of air undergoes in this organ in proportion to its greater or less density, and the consequently unequal stimulus with which it acts upon it.” Dr. Prout observes [Bridgewater Treatise, Am. Ed., p. 197), that at the time the cholera first appeared in England there was a positive increase in the weight of the atmosphere similar to what might be supposed to be produced by the diffusion of a heavy gaseous principle through the lower regions of the air. Hence, he inferred, that the cause of cholera was a poison analogous to malaria, whose high specific gravity and feeble diffusive powers kept it near the earth’s surface, along which it insensibly crept, especially in low and damp situations. At an elevation of 15,640 feet, the atmosphere is said to be one-half rarer than at the level of the ocean, and yet there are inhabited villages on the Himala Mountains, equally elevated, where the inhabitants enjoy good health. The town of Potosi, in Bolivia, is 13,265 feet above the ocean, and formerly contained a population of 160,000 inhabitants, and yet, we are told, that no inconvenience is experienced except by new settlers, and that in a short time the different organs become accustomed to their external re- lations. From an account in the 1st vol. of the N. Y. Jour, of Med. by Dr. Df.tmold, of the effects of condensed air in a coal-mine in France, where the density is equal to that of three atmospheres, we find the following as the most remarkable:— When the men first entered the condensed air, they experienced more or less pain in the ears, which ceased as soon as an equilibrium was es- tablished between the condensed air and the air contained in the interior of the ear: the men were unable to whistle in the condensed air; every body spoke through the nose, as it is called; the workmen, in ascending the shaft, filled with condensed air, did not lose their breath, nor become short of breath to the same degree as when making a similar ascent in the open air; and, lastly, one man, who had been deaf for several years, heard better in the condensed air than any of the other miners who were not deal —(loc. cit.) (See Dunglison on Human Health, Phil. 1844.)] 38. ii. The exciting Causes.—These have been called occasional by some writers, and direct by others, determining by several, and principal by a few writers. I shall divide this class of causes into—(a) those which are occasional in their operation ; and (h) those which are specific, or whose influence is followed by specific and de- terminate results. The causes already described dispose the body to the action of those about U. be noticed; either by impeding, modifying, or in- terrupting some one or more of the vital functions or by changing the constitution or organisation o? the tissues or organs which are the instruments of the functions under the dominion of life. But the predisposing causes may, either by their ac- tivity, or by their acting in combination or in close succession, of themselves, produce disease, without the aid of any of those which are usually termed exciting ; the predisposing being, in such cases, the true and only exciting causes. Thus the indulgence of the appetites, fatigue, the de- pressing passions, moist states of the air, &e.— either alone, or associated with age, or constitu- tion, or habit of body, &c.—are often the only causes to which disease can be traced. On the other hand, the exciting causes frequently produce their effects without the previous operation, as far as we have the means of knowing, of the predis- posing causes ; and many of them merely predis- pose the system to the action of others following in close succession. 39. 1st. The occasional exciting causes act either—(a) upon the vital functions, or the mani- festations of life in the various organs and struc- tures ; or (6) upon the organisation of the part to which they are applied. 40. A. Of the causes which primarily influence the functions.—These will be considered in rela- 652 tion to the organs on which they immediately and chiefly act:—1st, Those which are applied to, and disorder or obstruct the functions of the external parts of the body; 2d, Those which make their morbid impression upon the respiratory organs; 3d, Those which act simultaneously upon both the cutaneous and pulmonary surfaces; 4th, Those which act primarily upon the digestive organs ; 5th, Those which affect the organs of sense; 6th, and lastly, Those which excite the feelings, passions, and moral emotions, and there- by modify the manifestations of mind, or the func- tions and organisation of the body. 41. (a) The causes which injuriously affect the external parts of the frame, either disorder the perspiratory and eliminating functions of the cu- taneous surface, or modify the sensibility, or ob- struct the actions, of external parts.—a. The per- spiratory offices of the skin are disordered by the diversified modes in which its temperature is af- fected. Heat increases the organic actions of this surface—by exciting the nervous influence, expanding and relaxing the capillaries and exhal- ing pores, and, indeed, all the tegumentary tis- sues, by determining thither an augmented circu- lation, and thereby increasing the vital turgescence and excretory functions,—and cold diminishes or entirely arrests all these actions (as shown in the art. Cold); the excessive increase or diminution of the cutaneous functions in a part or in the whole of the surface, by disordering the balance between those performed throughout the frame, exciting diseases which assume varied forms and grades, according to the predisposition of different organs, the state of the system, and the causes which may co-operate with the change of temperature. Whilst insolation and unusual warmth in any form —as warm baths, vapour baths, currents of heat- ed air, frictions, &c.—are powerful agents in the production or in the removal of disease, according to the circumstances in which they are employed, considerable or prolonged cold is equally efficient in both capacities. But it is more owing to the vicissitudes of temperature—to their rapid alter- nations—than to any excessive grade of either, that the supervention of disorder is to be imputed. The sudden suppression of a copious perspiration ; the partial exposure, also, of certain parts, and the superfluous coverings of others ; or the action of currents of cold air upon one part, and of ra- diant heat on another, as when seated near large fires; and wearing unnecessary coverings on the head whilst the circulation is determined to it by position ; are also no mean agents in the produc- tion of rheumatic and nervous affections, and in- flammations, by deranging both the perspiratory functions, and the sensibility of the parts thus oppositely acted upon. The influence of too much clothing around the hips and thighs of females, and of too soft and warm beds and couches, in favouring uterine and vaginal discharges, and haemorrhoids ; and of too little clothing on the same parts, in obstructing the catamenia ; is gen- erally admitted. The want of personal and do- mestic cleanliness, by allowing the accumulation of sordes upon the cutaneous surface, and the continued irritation of hurtful matters which may have come in contact with it, is a frequent cause, of disorder of both its functions and its sensibility, and a common origin of many of the eruptions to which it is liable. 42. 0. Obstructions to the free actions of volun- tary parts are often occasioned by the kind or DISEASE—Exciting Causes of—yEtiology. fashion of the coverings which protect them ; and, not infrequently, injurious pressure of parts is superadded. Very thick and unyielding shoes prevent the developeineut of the muscles of the lower limbs, particularly the gastrocnemii, weak- en the ankle, joints, and occasion a shuffling gait. Strait, confiued clothes, on young and growing persons, cinctures of any part, and too close or straitly braced breeches, sometimes produce dis- eases of the organs of generation, varicose state of the veins, varicocele, flexures of the spine ; and wastings, painful affections, and organic changes of the testes. All impediments to free motion and the exercise of our organs are more or less injurious. 43. (b) The respiratory surfaces are affected by several of the causes which act upon the cu- taneous surface. The operation of a warm and moist, or of a cold and humid, air on the lungs, and through them, upon the whole frame, has already been pointed out. (See § 32-35., and art. Cold.) The specific gravity, also, of the atmo- sphere has some influence in disease; the dimi- nution of it occasionally producing haemorrhages from mucous surfaces. Exertions of voice or speech, long and loud speaking, running against the wind, and foreign substauces floating in the air (as shown in the article on Arts and Employ- ments), are common causes of bronchial and pul- monary affections. The polien or the odour of vegetables, grass, and flowers, the effluvium of new hay, &c., sometimes give rise to severe at- tacks of asthma, or that form of it which has recently been termed hay fever. The animal effluvia floating in the warm, moist, and often stagnant air of assemblies, theatres, camps, ships, hospitals, and crowded gaols, independently of the admixture of any of the specific miasms here- after to be noticed, change the condition of the organic nervous influence, disorder the secreting functions, contaminate the circulating fluid, and, in this manner, produce effects which are injuri- ous in proportion to their concentration or inten- sity—generally low or adynamic fevers. Chemical fumes sometimes excite bronchitis; and various simple or compound gases, the air of mines, the exhalations of privies and sewers, and even of new-painted rooms, are productive of syncope, asphyxy, or even apoplexy, convulsions and paral- ysis. In such cases, the diminution of oxygen in the respired air, or the impression made by the foreign fumes or gases upon the nerves of the respiratory organs, or both conjoined, impede, ob- struct, or arrest the changes produced upon the blood in the lungs, and ultimately terminate in death, preceded by one or more of the above af- fections. 44. (c) Several of the exciting causes act upon both the external and respiratory surfaces; espe- cially vicissitudes of season, of temperature, and of dryness of the atmosphere, suddenly passing from a cold to a warm air, prevailing winds (see Climate, § 11, 12.), the night or morning air; and numerous circumstances connected with the habitation or locality—especially the existence of the endemic sources of disease in its vicinity— ventilation, temperature, and dryness. The in- fluence of north-east winds in reproducing attacks of ague and rheumatism ; of the night and morn- ing air, in causing disorders of the mucous sur- faces, and of low, damp, ill-ventilated, and crowd- ed habitations, in giving rise to fevers, is well known. DISEASE—Exciting Causes of—./Etiology. 45. (d) On the digestive surfaces and organs. •—a. Mode of operation.—The numerous and di- versified substances which are either commonly, occasionally, or accidentally received into these organs, produce their effects in different ways. Those which are injurious from their specific ten- dency, or from excess, as numerous poisonous and medicinal substances, and those which disagree, from idiosyncrasy, mode of preparation, or injudi- cious admixture with others, as various articles of food, drink, and condiment; act in some one of the following modes:—1st, By irritating the villous surface, or altering its organic actions from the standard of health. 2d, By exciting, depress- ing, or otherwise modifying the nervous power of these organs; the morbid impression being propa- gated, in a greater or less degree, to other related organs. 3d, By both these modes of action con- joined. 4th, By the absorption of these substances into the circulating fluids, and by their exciting, depressing, or changing the vital actions, through this channel; the manifestations of life in the or- ganic nervous system, or in the blood itself, or in the cerebro-spinal system, or in secreting and ex- creting organs, being individually or conjointly affected in one or other of these ways. And, 5th, Both by their primary morbid impression on the digestive villous surface and nerves, and their consecutive influence, as stated in the 1st, 2d, and 3d heads ; and by their absorption and action, in the manner now assigned.* (See, also, art. Poisons.) 46. (3. Food and drink.—The full discussion of these topics would comprise the subject of Die- tetics ; upon which, however, the scope of this work will not allow me to enter further than very briefly in connection with the causation of disease. They have already received some attention in relation to climate and season (see Climate, § 26.) ; and to the habits of individuals as to their use (§ 19.). It must be obvious that any arti- cle. of diet will occasionally be found difficult of digestion, or even injurious, in certain latent and open states of disorder. When obstructions of any of the viscera, or accumulations of secretions in the biliary organs or in the prima via, already exist, owing to weak action or torpor of any of these parts, very slight aberrations from an ac- customed diet, or substances not usually hurtful, may occasion very serious disease. It is also evident that the privation of food and drink; ex- cesses in either, or in both ; and, in this climate, too large a proportion, or the exclusive use, of either animal or vegetable diet; will be produc- tive of correlative ill effects. The excessive use of animal food, particularly pork, gives rise to plethora, scrofula, and gout; and the want of vegetables, herbs, and fruits, in sufficient propor- tion to the salted provisions consumed, or an in- nutritious diet, is productive of scurvy, purpura haemorrhagica, of an intermediate disorder, which may be called land scurvy, and chronic diarrhoea and dysentery. Both flesh and fish are some- times productive of disorder, owing to their being diseased at the time of being killed, to their be- coming tainted subsequently, and to unwhole- some ways of preserving them. A poisonous prod- uct is occasionally evolved in smoked and dried meats ; and shell-fish, chiefly from being imper- fectly boiled, and long kept by the retailers, is often extremely injurious. The plan very {gener- ally adopted by the fishmongers of London, of preserving fish—especially turbot, salmon, and, indeed, all the fish that is not sold before even- ing—by means-of ice; a large proportion being lrozen, thawed, and frozen and thawed again, as alternately exposed in the day on their stalls, and lodged in the evening and night in the ice- pits, until the cohesion of the fibres is lost, and the flavour dissipated; is most prejudicial to health, particularly during summer and autumn ; and is one ot the most frequent causes, in Lon- don, of disorders of the stomach and bowels, although overlooked by writers on this class of diseases. Nor does the evil end here ; for all the salmon that becomes tainted from this mode of keeping, is either pickled or smoke-dried, and sold for that prepared in these modes from the fresh state. Independently, however, of these circumstances, all kinds of fish—some more fre- quently than others—may occasionally disagree, particularly with certain idiosyncrasies, and with weak digestive organs; as lobsters, muscles, &c. Some kinds are even poisonous, especially in warm climates; and others produce disorder Irom being out of season, as salmon, trout, &c. The injurious action of fish is exerted chiefly upon the stomach and bowels; generally in the form of cholera, attended by extreme vital de- pression ; and sometimes by an eruption on the skin. That the poisonous elements are partially absorbed into, and act partly through, the cir- culation, may be inferred from their effects, and from their peculiar odour being afterwards de- tected in the cutaneous secretions. The means of preventing and counteracting the ill effects of fish are stated in the article Poisons. Vegeta- bles, even, will also disorder the digestive organs if they be allowed to run to seed, or grow too far, or if kept too long after they have been removed from the soil. 47. y. Cookery and condiments.—Animal sub- stances become indigestible by being either too much or too little cooked ; and vegetable sub- stances, chiefly, by being too little. Fried and baked meats are less digestible than roasted and broiled. Stewed dishes, meats prepared a second time, and very highly seasoned articles, are all prejudicial. Fish often disagrees with the stom- ach, from the manner of cooking, and the sauces taken with it; and, of these, butter is one of the worst ingredients. Vinegar, lemon-juice, and salt are the most wholesome condiments ; and, if the fish be rich and fat, Cayenne or black spice may be added,—these being amongst the best antidotes to any ill effects it may produce. The livers of fish are generally productive of disorders in weak digestive organs; for, during boiling, all the oil—which is extremely wholesome, and even medicinal, and which might advantageously enter into the composition of the sauce instead of but- ter—is extracted, and, swimming on the surface of the water in which the fish is boiled, is thrown away with it; the part remaining being that only which is generally, but improperly, used. Con- diments, excepting by those who have been long habituated to them, are hurtful, unless taken in very small, or at least moderate, quantity. Salt, vinegar, and lemon-juice are the most wholesome under all circumstances. The fact, that salt is 653 * The above classification is in accordance with that published by me in the London Medical Repository for May, 1822, p. 380.; and was the first that was based upon the absorption of substances into the circulation, and up- on their relative action on the organic nervous, and cere- bro-spinal systems. 654 DISEASE—Exciting Causes of—.Etiology. necessary to health at all periods of existence, is not easily reconciled with the equally well-estab- lished fact, that the protracted use of salted pro- visions is a principal cause of scurvy, scorbutic dysentery, external sores, ulcers, as well as an evident predisposing cause of fevers, inflamma- tions, &c. But it may be presumed that the combination of salt with the animal fibre decom- poses it or modifies its effects upon the living system. Besides, salted meat, particularly when it has been long preserved, becomes less nutri- tious, and more difficult of digestion ; the ill effects being equally attributable to the deficiency of vegetables, frequently conjoined with bad water, and the depressing passions. 48. <5. Baked pastes, and pies, tarts, <$-c., and the boiled dough of puddings, are difficult of di- gestion, especially the former; and should never be taken by dyspeptics. Fruit, when in season, is much more wholesome. But if it be used either previously to being fully ripe, or when it has become over-ripe or stale, and particularly if it be uncooked, disorders of the stomach and bow- els are frequently produced by it. New cheese is very injurious when partaken of largely ; and nuts, cucumbers, and melons are always indi- gestible, however ripe they may be. A variety of fruits, immediately after a full meal* is also pro- ductive of disorder; the most wholesome being ripe oranges, grapes, strawberries, &c. All pre- served and stimulating articles of dessert merely load the stomach, occasion thirst, and lead to the ingestion of a greater quantity of fluid, and of wine, than is consistent with easy digestion, and with the regular performance of the functions. 49. c. Drink and beverages are also common sources of disease, either from being of improper kind, or used in excessive quantity. The most wholesome wines are port and sherry, after hav- ing been six or eight years in bottle, and the finest and highest flavoured French and Rhenish wines. The constant use, however, of even the best port and sherry occasions vascular plethora, and its consequent ills, unless very active exer- cise be taken. Delicate persons should dilute them with an equal, or one half the quantity of water. Champagne often excites gout: I have observed two or three glasses of it bring on an attack the following day. Malt liquors, although both tonic and nourishing, owing to the hop and extract of malt contained in them, occasion dis- ease when constantly used, from these very cir- cumstances ; a plethoric state of the system, obesity, and various contingent diseases, being the result. The most wholesome of this kind of beverage is brisk small beer. Cider and perry are sometimes productive of colicky affections, gastrodynia, indigestion, and diarrhoea, especially if they be taken while the body is perspiring, or in very hot weather. Spruce beer is much more wholesome. Spirituous liquors, particularly those n common use, are most injurious to the frame ; and, in the lower classes, are the most frequent causes of, first, functional, and afterwards organic, diseases of the stomach, liver, bowels, and brain, as well as of some other viscera, and of insanity. Coffee and tea, although, upon the whole, whole- some beverages, may be, in some constitutions and states of the system, productive of disorder. A strong infusion of coffee, taken soon after the principal meal, promotes digestion, and counter- acts whatever ill effects the cold and poor wines used on the Continent might otherwise produce. But it is sometimes injurious, from its stimulant properties, in cases of cerebral irritation, or ex- citement ; and, when taken late in the evening, prevents sleep. The infusions of black or green tea are gently tonic and narcotic ; the latter act- ing more energetically upon the cerebro-spinal system than the former. Green tea usually ex- cites the nervous power; and, like coffee, in- creases the activity of the cerebral functions. But, when morbid, vascular, or nervous excite- ment exists, it generally proves an excellent tonic and sedative ; procuring sleep, and diminishing both nervous and vascular disorder. In cases of asthenic vascular action, attended Dy coma or lethargy, I have found it a most valuable restora- tive of both vital and cerebral power. In addi- tion to the above, the use of hard or unwholesome water, and either a high or a very low tempera- ture of the ingesta, are often productive of disease. 50. £. The effects of accidental or designed in- gestion of poisonous substances, as well as the means of counteracting and removing them, are considered at another place ; and, although in- judicious uses of remedial means are but too fre- quently causes of disease, and of its aggravation, especially the inappropriate use of mercurial prep- arations, of emetics and irritating purgatives, of vascular depletions ; of stimulating and heating substances, exhibited with the view of restoring nervous power, or of promoting expectoration, instead of allaying increased vascular action, and of secret remedies of every description; the na- ture of the subject precludes further allusion to it at this place. The influence of morbid secretions poured into the digestive tube, and the effects of arresting accustomed or salutary evacuations, as increased discharges from the uterine organs, haemorrhoids, &c., or vicarious secretions, with- out having opened an artificial outlet, or pro- duced artificial irritation and discharge, in ex- tending, perpetuating, and aggravating disease, rather than originating it—for morbid states of secretion imply existing disorder—are sufficiently obvious. 51. (e) The causes which act on the organs of sense consist chiefly of the abstraction of the natural stimuli or impressions, and the applica- tion of them in unusually intense forms ; the mental phenomena excited through the medium of the senses not falling under this head.— a. Sight may be weakened by prolonged dark- ness, and consequent inaction of the organ ; but it is much more commonly injured by the un- usual impression of light, which may so intensely excite and exhaust its sensibility as to destroy its functions. The rays of the sun, and lightning, have produced this effect almost instantaneously; and the light reflected from snow in northern countries, and from the sands of the arid districts of intertropical climates, has frequently occasioned it in a slower but not less effectual manner. Per- sons employed in glass-works, forges, foundries, &c., who frequently subject their eyes to an in- tense light and radiant heat; and those who are occupied on small, very near, or minute objects : are often affected by amaurosis, cataract, and other chronic disorders of the organ. When the sensibility of the eyes is increased by protracted darkness, the admission of even a moderate light often becomes painful and injurious, if it take place suddenly. Of the various colours reflected by the rays of light, white and red are most fatiguing to the sight.—/?. Hearing is injured by DISEASE—Exciting Causes of—^Etiology. 655 very loud noises, or detonations, near to the or- gan ; and persons of weak or nervous constitu- tions may even lose this sense by such causes; or experience convulsive seizures, syncope, vio- lent palpitations, or disorder of the digestive and circulating organs. Loud noises are extremely injurious in all cases of cerebral and vascular excitement; and in cases of external injury, as well as of internal inflammation. M. Percy states, that he observed the wounded often very sensibly affected by the report of cannon during sieges and battles.—y. The sense of touch, and the sensibility of external parts, are acted on by many of the causes already noticed ; but often in an imperceptible manner. Numerous external irritants; extremes of temperature, either of the air, or artificially excited, as extensive vesications and burns ; violent or protracted excitement of the senses of sight and hearing ; or irritations or injuries of nerves; frequently affect sympathet- ically the whole frame ; and even occasion con- vulsions, spasms, inflammation of the brain and spinal chord, or of their membranes; and, when extremely intense in relation to the vital resist- ance of the sufferer, great depression, and even fatal sinking, of the powers of life.—<5. The sense of smell may be impaired by over-excite- ment ; or by causes acting in this, or in any other way. It is also partly through this sense that various agents invade the system, especially those of a depressing kind, as iufectious effluvia. KiSee art. Infection.) Odours sometimes, also, produce syncope, nausea, vomiting, and nervous affections through this medium.—e. The sense of taste is the least frequently the channel through which exciting causes act: the impression, how- ever, made upon the palate by certain articles are sometimes productive of severe disorder of the digestive organs; and, in the case of the more active narcotics, &c., of dangerous disease of the nervous system. 52. In the foregoing review, those causes which act externally upon, or through the medium of, the organs of sense have been noticed. But there are numerous changes, which are intrinsic, or take place in the organic, nervous, and circulating systems, as well as in the brain and secreting viscera, and which affect these organs in a very remarkable manner. These, however, are rather secondary or pathological causes—or the effects of agents acting primarily upon those or other parts of the frame, which effects become contin- gent or necessary causes of disorders of the or- gans of sense—from altering their condition, or the state of parts necessary to the perfect per- formance of their functions. Thus the senses may be disordered, or altogether abolished by disease of the bruin, or of their nerves, or by af- fections of the digestive and assimilating viscera. This influence of disease of one viscus or system, upon those anatomically or physiologically re- lated to it, also subsists more or less evidently throughout the frame; the primary affection giving rise to a variety of sympathetic and sec- ondary disorders, according to the progress it has made, to the circumstances that have influenced it in its course, and the predisposition of the indi- vidual (§ 21.). 53. (/) On the sentiments and passions.—The circulation of the brain, the action of the heart, and the functions of the digestive and generative organs, are frequently disturbed by causes affect- ing the manifestations of mind.—a. Excessive mental employment; long protracted attention, especially to one subject; over-exertion of indi- vidual powers, without the requisite repose, and the relaxation resulting from an agreeable diver- sity of pursuit; the distraction also occasioned by a number of pressing or abstract topics; can seldom be very long persisted in, without ex- hausting the mental energies, exciting or other- wise disturbing the circulation through the brain, and ultimately inducing either acute or chronic cerebral disease, as phrenitis, delirium, insanity, apoplexy, paralysis, epilepsy, &e.; especially if other circumstances concur to excite or overload the vascular system, and determine the circula- tion to the head, or if the requisite nightly repose be abridged or interrupted.—/?. Certrain trains of feelings, and particular desires or passions, as re- ligious sentiments, affection, love, hatred, reyenge, avarice, pride, vanity, &c., may all be carried to that pitch, by being constantly and exclusively entertained, as insensibly to pass into monomania, or other forms of insanity ; or to occasion ecstasy, catalepsy, convulsions, or some one of the diseases mentioned above (a).—y. Various circumstances occasioning solicitude, anxiety, distress of mind, sadness, fear, shame, penitence, disappointments, and losses of all kinds, the indulgence of grief, and anxious or constant longings after objects of desire or of affection, may not only disorder the mental manifestations in a partial or general manner, but also disturb the functions of the heart, as well as those of digestion and assimila- tion. All the depressing emotions of mind have an especial effect upon the circulation, upon the nutrition of the frame, and indeed upon all the functions dependent upon the organic nervous system ; and favour chronic and asthenic diseases of the heart, particularly passive dilatation and enlargement of its cavities, indigestion, and con- stipation ; also chlorosis, pulmonary consumption, hysteria, and tubercles, early in life ; and hypo- chondriasis, melancholia, chronic diseases of the liver, spleen, and pancreas, and cancerous or other malignant diseases, at mature or advanced ages.—<5. Surprise, fright, terror, anger, and in- dignation, are not infrequently productive of apoplexy, paralysis, epilepsy, convulsions, syn- cope, violent palpitations, painful or acute affec- tions of the heart, disorders of the stomach, liver, and bowels, hysteria, abortions, derangement of the uterine functions, and of the manifestations of mind.—s. Great mental excitement, unlooked- for success, the sudden accession of fortune, ex- treme joy, and all the pleasurable emotions car- ried to excess, are not infrequent causes of insanity, of phrenitis, epileptic convulsions, hys- teria, and catalepsy.—£. An improper conduct, and an insufficient control, not only of the senti- ments and emotions, but also of the imagination, are amongst the most common causes of disorder in the manifestations of mind, as well as of the other maladies enumerated above (a, /?).—n- In- ordinate indulgence of the sexual appetite occa- sions epilepsy, loss of memory, and mental and corporeal debility, impotency, diseases of the testes, prostate gland, and urinary bladder, and affections of the heart and lungs in males; and in females, inflammation of the ovaria and uterus, fluor albus, hysteria, chlorosis, melancholy, ir- regular convulsions, organic or scirrhous changes in the uterus, diseases of the ovaria, and sterility, &c. (See art. Age, § 24.)—0. Persons who have been habituated to excessive sexual indulgence, 656 and become altogether continent, are liable to nocturnal emissions, to impotency, convulsive and other nervous diseases, and to disordered mental manifestations.—i. Numerous acts of volition in- judiciously attempted or directed may be produc- tive of the most dangerous injuries and disease; as violent muscular efforts, of sprains, aneurisms, haemorrhages, inflammation and caries of the vertebrae, or inflammation of the intervertebral substances. Positions with the head low, or on the back, and especially such as are uneasy or unnatural, too long retained, or too frequently assumed, give rise to cerebral disorder and curva- tures of the spine ; and encumbered, obstructed, or too rapid and protracted movements, produce injurious acceleration of the circulation, exhaus- tion, with other ill effects. 54. *B. The chemical and mechanical causes of disease require little notice here ; the former of these having received attention in the articles on Asphyxy, and Poisons ; and the latter on that of Arts and Employments, as Causes of Disease. —(a) Chemical agents are injurious—1st, by their influence on the functions of the part with which they come in contact, their effects varying with their individual properties; 2d, by the change they produce in the structure itself, either in combining with it, or otherwise changing its con- stitution, so as to render it incapable of its healthy offices; and, 3d, by totally destroying the nervous and vital influence, and intimate or- ganisation of the part.—(b) Of mechanical causes and positions impeding, upon physical principles, the flux or reflux of the circulation and secreted fluids, continued pressure of various grades, and unnatural ligatures of parts, are the most com- mon, and act slowly, and often insensibly and un- remittingly. Shocks or concussions of a part or of the whole of the body, or other kinds of exter- nal violence, not only occasion the division, frac- ture, dislocation, bruise, and comminution of ex- ternal parts, but also the rupture, laceration, haemorrh