UNITED STATES OF AMERICA WASHINGTON, D. C. GPO 16—67244-1 " DUPLICATE From the Public LjUiy of the City of Boston SlTF.RIN-TENDF.NT. PUBLIC LIBRARY or THl CITY OF BOSTON ABBREVIATED REGULATIONS. One volume can be taken at a time from the Lower Hall, and one from the Bates Hall. Books can be kept out 14 days. A fine of 2 cents for each volume will be incurred for each day a book is detained more than 14 days. Any book detained more than a week be- yond the time limited, will be sent for at the expense of the delinquent. No book is to be lent out of the household of the borrower. The Library hours for the delivery and re- turn of books are from 10 o'clock, A. M., to 8 o'clock, P. M., in the Lower Hall; and from 10 o'clock, A. M., until one half hour before sunset in the Bates Hall. Every book must, under penalty of one dol- lar, be returned to the Library at such time in August as shall be publicly announced. The card must be presented whenever a book is returned. For renewing a book the card must be presented, together with the book, or with the shelf-numbers of the book. PRESENTED TO THE loUta£// -A^^vC-jn . w; ifoUfci $£ •farr/rr./ tJlaA,*/*, /£. IJ.S-6' 'r./^S!: DICTIONARY ■ f OP PRACTICAL. MEDICINE: COMPRISING GENERAL PATHOLOGY, THE NATURE AND TREATMENT OF DISEASES, MORBID STRUCTURES, AND THE DISORDERS ESPECIALLY INCIDENTAL TO CLIMATES, TO THE SEX, AND TO THE DIFFERENT EPOCHS OF LIFE; WITH NUMEROUS PRESCRIPTIONS FOR THE MEDICINES RECOMMENDED A CLASSIFICATION OF DISEASES ACCORDING TO PATHOLOGICAL PRIN- CIPLES, A COPIOUS BIBLIOGRAPHY, WITH REFERENCES; AND AN frppexCHiv ot ^pprofoefc iFormulae: THE WHOLE FORMING A LIBRARY OF PATHOLOGY AND PRACTICAL MEDICINE, AND A DIGEST OF MEDICAL LITERATURE. BY JAMES COPLAND, M.D. Consulting Physician to Queen Charlotte's Lying-in Hospital; Senior Physician to the Royal Infirmary for Diseases of Children; Member of the Royal College of Physicians, London; Member of the Medical and Chirurgical Societies of London and Berlin, etc EDITED, WITH ADDITIONS, BY CHARLES A. LEE, M.D. '£P()33£Tt NEW-YORK: ^ HARPER & BROTHERS, PUBLISHERS, 82 CLIFF STREET. 18 45. V YJ"B C7S"4-d l$£9c, v. 4. Entered, according to Act of Congress, in the year 1846, by Harper & Brothers, In the Clerk's Office of the Southern District of New-York. CONTENTS. HEARING—Deafness from Diseases of the Eustachian Tube, &c. - - 185 Remedies for .... 191 Bibliography and References - 192 HEART AND PERICARDIUM—Dis- eases of......193 General View of - - - - 197 Nervous or Functional Affections - 203 Neuralgic Affections of the - - 207 Inflammations of - - - - 208 Inflammation of the Endocardium - 209 ----------------Pericardium - 214 Symptoms and Diagnosis - - 218 Inflammation of the Structure of the Heart.....220 Treatment of - 229 Bibliography and References - 234 Structural Lesions of the Heart, &c. 235 Hypertrophy.....237 Dilatation of its Chambers - - 244 Atrophy of.....248 Ruptures of.....257 Bibliography and References - 262 HERPETIC ERUPTIONS - - - 267 Treatment.....270 HICCOUGH—Description, Causes, &c. 271 HOOPING-COUGH—Description - 273 Nature and Seat of 279 Prognosis, Causes, and Treatment 283 HYDATIDS—Description, &c. - - 293 Symptoms and Treatment - - 297 HYPERTROPHY—General Pathology, &c........298 HYPOCHONDRIASIS — Description, &c........301 Duration—Lesions of Structure, &c. 303 Causes, Pathology, &c. - - 305 Treatment.....308 HYSTERIA—Various Forms of - - 314 Duration and Termination - - 323 Causes—Pathology - - - 325 General Treatment ... 330 Bibliography and References - 340 JAUNDICE—Pathology—Symptoms - 341 Causes—Morbid Appearances - 343 Treatment.....353 Bibliography and References - 359 ICHTHYOSIS—Diagnosis - 361 IMPETIGINOUS AFFECTIONS—De- scription ----.. 363 Prognosis—Causes—Treatment - 367 IMPOTENCE AND STERILITY - 369 In the Male.....370 -----Female - - - - 373 Treatment.....374 Bibliography and References - 376 INDIGESTION—Pathology - - 377 Causes of, and Symptoms - - 380 Treatment - 388 Diet and Regimen ... 393 Bibliography and References - 398 INDURATION—Treatment - - 400 INFECTION — Pathology—Classifica- tion .......401 Sources of.....404 Media of.....409 Symptoms of - - - - 413 Protection from - - - - 417 Bibliography and References - 423 INFLAMMATION—Phenomena of - 426 Colour of the Blood, &c. - - 431 Terminations and Consequences - 436 Various Modifications ... 438 Diagnosis.....447 Exciting Causes - 450 Prognosis.....455 Opinions concerning - - - 457 Pathology.....462 Treatment.....472 Bibliography and References - 487 INFLUENZA—History of - - - 489 Symptoms of .... 492 Progress—Diagnosis - 495 Causes......496 Treatment.....498 Bibliography and References - 499 INSANITY—Definition - - - 500 Symptoms of .... 502 Classifications .... 510 Melancholic Monomania - - 521 Dementia.....530 Complications of - - - - 534 Terminations of - - - - 537 Predisposing Causes - 555 Physiological Pathology of - - 573 Treatment.....590 HEARING—Deafness from Disease of the Eustachian Tube. 185 not necessarily weaken the hearing." Now this is not altogether just; for M. Itard con- tends that, when the opening is small, the hear- ing in some cases is not materially impaired, although in the great majority it is more or less so ; but that when it is considerable, or when a large portion of the membrane is de- stroyed or detached, hearing is always very much injured. Although perforation of the membrane causes deafness, yet there are states of the ear, and even of the membrane itself, in which artificial perforation of it maybe attended by some benefit. Such states are, however, few, and the instances of success from the op- eration have been rare or equivocal. 15. Artificial perforation of the membrane was first performed by Sir A. Cooper many years since; but the circumstances requiring the operation were not fully understood until explained by Deleau and Kramer. The latter of these writers remarks that Sir A. Cooper supposed perforation of the membrane to be in- dicated chiefly in cases of obstruction of the Eustachian tube, and in extravasation of blood in the cavity of the tympanum ; but, as he ap- pears to have been unacquainted with cathe- terism of this tube, his diagnosis of the closure of it was altogether uncertain. Even suppo- sing these morbid states actually to exist, they may lie treated more efficiently by introducing the catheter into the tube itself than by perfo- rating the membrane. Itard contends that the operation is admissible only when there is in- vincible obstruction in the tube ; Saissy advi- ses it only in thickening and hardening of the membrane ; and Deleau recommends it also in this case, as well as in obstruction or oblitera- tion of the Eustachian tube, and in obstruction of the cavity of the tympanum. Dr. Kramer has recourse to the operation only when the membruna tympani is much thickened, quite in- sensible to the probe, hard as cartilage, and if the hearing is very much impaired ; but even in this case it should be performed only when both ears are affected with considerable deaf- ness, and when the ear to be operated upon does not suffer from any other disease by which the result might be rendered abortive. [Pilcher (loc. cit.) thinks that this operation is justifiable only in cases of invincible stricture of the Eustachian tube. It was first suggested by Riolanus. When the operation is indica- ted, it may readily be performed by directing a strong light upon the membrane, which is then to be perforated at the lower part, anterior to the inferior extremity of the manubrium of the malleus, by a small perforator having a sharp- ened point extending two or three lines be- yond the shoulder. On account of the readi- ness with which the wound heals, Mr. Buchan- an recommends a quadrangular perforator, which makes a larger opening ; and Henly has introduced a small punch which cuts out a small piece. The same instrument has been recom- mended by Dr. Gibson, of Philadelphia. One serious inconvenience attending this operation is the liability to haemorrhage into the tympanal cavity, the blood becoming organized, and thus causing deafness.] 16. II. Deafness from Disease of the Eus- tachian Tube and Cavity of the Tympanum.— i. Affections of the tube.—The Eustachian tube may be obstructed, 1st. By the pressure of tu- II 24 mours in its vicinity ; 2d. By inflammation causing tumefaction of the mucous membrane, effusion, &c. ; and, 3d. By the more remote consequences of inflammation, namely, con- striction or obliteration of a portion, or of the whole of the canal. Before, however, any of these can be accurately ascertained, it is ne- cessary to have recourse to means of explora- tion similar to those employed in obstructions of some other canals. The introduction of tubes or catheters into the canal, in order to ascertain the nature of, and to remedy various affections both of it and of the cavity of the tympanum, has been resorted to by Sabatier, Wathen, Douglas, Saissy, Itard, and others. Through this tube lukewarm water was some- times injected by these writers, in order to judge of the state of the middle ear, according to the sensations produced by it, or by the total ab- sence ol sensation. Deleau and Kramer, how- ever, rejected the use of water as an injection, and adopted the suggestion of Cleland, to em- ploy air instead of water in the investigation and treatment of diseases of the tube and cav- ity of the tympanum.' Dr. Kramer recommends the usual sUver inflexible catheters to be used ; and air, compressed in an apparatus, he de- scribes to be injected through it in the follow- ing manner : " After the catheter has been in- troduced into the tube, and fixed by means of a frontlet, the patient is placed close to a table, on which he leans his elbow, holding with the hand of that side the pipe of the air-press filled with compressed air. The operator then in- troduces the metal beak of the pipe into the funnel-shaped dilatation of the catheter, applies his ear close to that which is being examined, opens the cock of the machine, and listens to the sound caused by the air rushing into the cavity of the drum. When the tube and cavity are free the air strikes with an audible shock against the membrane of the tympanum. When the shock is over, or is slight, a blowing or rustling in the ear of the patient is heard, caus- ed by the streaming of the air." All variations from this sound are morbid, and furnish more or less distinct indications of diseased changes in the organ. If the air-douche does not pen- etrate to the membrana tympani, Dr. Kramer advises catgut bougies to be used for opening the passage in the tube. [The accidents which sometimes occur in consequence of catheterism of the Eustachian tube, and injections of air into the middle ear, are described by M. Deleau under the follow- ing heads : 1. Inflammation of the throat, and catarrh of the tympanum ; 2. Emphysema ; 3. Rupture of the membrana tympani. Emphy- sema has occurred to Dei.eau six or seven times. Several deaths have- been recorded in the London medical journals within a year or two past from the pumping of air from a press into the Eustachian tube. It has been sug- gested by Pilcher (loc. cit) that this happened from the passage of air into the larynx by the catheter taking a wrong direction, and not hav- ing penetrated at all into the tube. See " Clin- ical Observations, by Mr. Wharton Jones, on the Use of the Air-douche in the Diagnosis and Treat- ment of Discuses of the Ear," Lond. Med. Gaz., 1839, and Am. Ed. of Pilcher, on the Ear, p. 260. Mr. Wharton Jones recommends the in- jection of the vapours of acetic aether, or ethe- 186 HEARING—Deafness from Disease of the Eustachian Tube. real vapour, into the Eustachian tube, as well calculated to benefit cases of deafness owing, according to Kramer, to nervous deafness, but which he believes to depend frequently on some change in the membrane lining the tympanum. The fact is, that we are as yet but little ac- quainted with the diseases of the labyrinth, and it will be safer to employ, either before or in addition to local treatment, purgatives, leeches, blistering, or whatever other more general rem- edies may be indicated. Mr. Kramer remarks, that out of 300 cases of diseases of the ear of all kinds, 200 require the air-douche to assist the diagnosis; but that a*)out 30 only are cu- rable by it; of the remaining 170, about 30 are put down as cured, and about 50 as relieved by the injection of vapours of acetic aether ; this treatment having been continued for months, of the remainder, 80 were considered as incu- rable from the first, and not treated; the rest remained unaffected by treatment. Deafness is, in some cases, relieved by forcible expira- tions with the nose and mouth closed, which drives the air into the internal ear through the Eustachian tube, and a case of cure is related int he " Mem. of the Med. Soc. of London," of over a year's standing, by this procedure.] 17. A. Inflammation of the mucous membrane of the Eustachian lube occasions modified or dif- ferent results, according to the intensity of the morbid action, and the degree in which adjoin- ing parts participate in the disease.— a. Ca- tarrhal inflammation, or irritation of the tube, with accumulation of mucus obstructing it, is a not infrequent attendant upon catarrhal com- plaints, upon inflammations of the throat or fauces, and upon eruptive fevers, the deafness sometimes accompanying these diseases ari- sing from this affection of the tube. It is most common in moist, cold localities and climates, near the seacoast, and in foggy weather. The Treatment should be directed to the removal of the primary disorder, especially the affection of the throat. If the deafness still continue, astringent gargles containing the biborate of soda, or the nitrate of potash, or the hydro- cldorate of ammonia, or gargles with the de- coction and tincture of bark and hydrochloric acid, or the internal use of iodine, may be of service. Aqueous injections into the guttural orifice of the Eustachian tube have been advi- sed by Saissy, Itard, and others ; but Dei.eau and Kramer prefer the air-douche just descri- bed, notwithstanding the good effects of these. 18. b. Deafn ess font inflammation of the mu- cous membrane of the tube may proceed from disease of the throat, or of the proper mem- brane of the drum, and be complicated with either, or with both these diseases. In the case of its connexion with lesion in the cavity of the tympanum, it is either associated with, or has followed acute otitis or otorrhaea; but when the inflammation is confined to the gut- tural part of the canal, deafness is neither great nor attended by pain in the interior of the ear. The patient hears well at times, but only mo- mentarily. He hears his own voice even worse than that of others, and occasionally has a crackling, gurgling, or detonating sensation in the throat leading to the ear. The diagno- sis is still more to be depended upon if pain or inflammation exists in the throat or fauces, and if the former be increased on gaping or masti- cation. The chronic states of this d»e*fe..°f the tube are generally connected with sypm > or with the scrofulous diathesis. cfatPs 19. c. The Treatment of the more acute states of inflammation of the tube should be entirely antiphlogistic. Local vascular depletions ac- tive purgatives, especially calome uithan - mony ; fooling and detergent gargles particu- larly those wUh the biborate of soda, or nitre, or hydrochlorate of ammonia, external deriva- tives, or the warm or vapour bath and diapho- retics, are generally required. After vascular depletion, an emetic is sometimes of service ; but, as this disease most frequently is conse- quent upon, or complicated with an affection of the throat or ear, or occurs in the course of exanthematous fevers, the treatment of it must necessarily depend very much upon the nature and state of the primary or associated malady. When the disease of the tube is chronic, or consequent upon venereal affections of the throat, mercurials, especially the bichloride of mercury, gargles containing this substance, or the internal use of iodide of mercury, should be resorted to. In the scrofulous diathesis, the preparations of iodine may be tried. In pro- tracted or severe cases, especially when con- nected with ulceration in the throat, or syphilis, or scrofula, treatment is seldom successful, as they have very frequently gone on to the states next to be noticed. 20. d. When the inflammation, either from its protracted continuance, or from its exten- sion to the connecting submucous cellular tis- sue of the tube, gives rise to thickening of the mucous membrane, or to ulceration, more or less complete occlusion, or stricture, or even oblitera- tion of the canal, may result, especially when an ulcer is seated near the orifice of the tube, and afterward cicatrizes, as in cases of malig- nant angina, or of venereal ulceration of the throat. It is important to distinguish these lesions from those states of disease which ad- mit of satisfactory treatment. This is to be done chiefly by ascertaining the history of the case. If the deafness have followed severe affections of the throat, especially that occur- ring in connexion with malignant eruptive dis- eases, with syphilis, or with scrofula ; if it have continued long, been constant and unin- terrupted ; and if it have followed severe otitis or purulent otorrhaea (see art. Ear, $ 10, 18), it may be inferred that one or other of the lesions just specified exists. If there be any doubt entertained, recourse to the means of explora- tion advised by Itard, namely, by forcing water into the tube, or to that employed by Deleau and Kramer, and described above ($ 16), will establish the diagnosis. 21. Perforation of the membrane of the tym- panum has been resorted to by Itard in cases of this kind, but with very equivocal success. Dr. Kramer states that he has found them in- curable, and that this operation has been of no use in them, as the mucous membrane of the cavity of the tympanum is also diseased The introduction of catgut bougies into the Eusta- cnian tube has not been productive of any per- manent benefit. If obliteration of the canal be complete, the cavity of the drum is always in- volved in the disease; and d fortiori, perfora Hon of the membrana tympani, advised bv w™ writers, can be of no avail. ' e HEARING—Deafness from Affections of the Auditory Nerves. 187 [Many cases of what have been generally regarded as incurable strictures of the Eusta- chian tube will, according to Pilcher (loc. cit), yield to cautious and regular dilatation. When Sir Asti.ey Cooper introduced his operation of puncturing the membrane of the tympanum, he was not aware of this procedure ; and Pil- cher observes, that " no doubt can exist that, in many instances in which the membrane was punctured, and in several which this distin- guished surgeon has related, the obstruction might have been removed, and particularly in cases where there is a collection of mucus or blood in the cavity, which may be more easily syringed out with warm water through the tube than removed through an artificial opening in the membrane." Catheterism of the tube is useful, 1st. As an important means of investigating its condition of health or disease, and that of the tympanum; 2d. To remove mucus or blood from the tympanal cavity ; 3d. To dilate a stricture of the tube ; and, 4th. To stimulate the nervous system of the ear in ca- ses of diminished function] 22. c. Deafness may depend upon the occlusion of the Eustachian tube by tumours pressing upon its guttural extremity.—Enlarged tonsils are the most common cause of this form of deafness ; but polypous or fungous excrescences, and en- larged parotids also, not infrequently produce it. In either case, the diagnosis is very easy, and the indications of cure sufficiently manifest. Polypi must be removed by excision or liga- ture whenever either can be performed. When the tonsils are enlarged, scarifications, astrin- gent and detergent gargles, stomachic purga- tives and tonics, the preparations of iodine, and the other means of cure directed for en- largement of the Tonsils (see the article), should be prescribed. If the tonsils contain matter, the puncture or incision of them ought not to be delayed. Enlarged parotids, if the affection be chronic, may be treated with io- dine, &c. [Our author has, perhaps, not dwelt suffi- ciently on the importance of constitutional treatment in cases of chronic inflammation of the Eustachian tube. We often find, in con- nexion with these cases, a relaxed uvula, en- larged tonsils, a red tongue, enlargement of the glands of the neck, thickening of the lining membrane of the Eustachian tube, an irritable state of the lining membrane of the nostrils, and of the mucous membranes generally; in short, all the symptoms that characterize the strumous habit. Local treatment will not alone prove sufficient here .- we must have recourse to blue pill, the iodides, sarsaparilla, soda, with rhubarb, gentian, columbo, and other tonics. We must endeavour, in other words, by con- stitutional treatment, to impart new energy and a healthy action to the entire mucous system.] 23. B. Inflammation of the cavity of the Tym- panum.—The inflammation may affect only the mucous membrane lining this cavity, or it may extend to the submucous cellular tissue, and even to the periosteum. It is generally either acute or chronic, and, in cither case, is a se- vere and often dangerous disease. The symp- toms, consequent lesions, and the treatment of this disease in its various forms, are fully described in the article Ear (see Y 14, et. seq.). As deafness resulting from purulent olorrhxa, with perforation of the membrane of the tym- panum, or from disjunction or loss of the small bones of the ear, or from caries of the osseous structure, belong to the more chronic states of otitis, and is discussed in the article just refer- red to (art. Ear, $ 19, et seq., and 28, et seq.), it is unnecessary to recur to the subject at this place. 24. C. Deafness may arise from extravasation of blood in the cavity of the drum.—This lesion is usually the result of external injury, of vio- lent attacks of sneezing, or of constriction of the neck, but it is chiefly caused by the first of these. In cases of this kind, Sir A. Cooper advised perforation of the membrane ; but the extravasated fluid will either pass off by the Eustachian tube, or be absorbed. Moreover, the deafness and other unfavourable symptoms existing in these cases are not so much de- pendant upon the extravasation in the cavity of the ear as upon the injury other parts of the organ, or even the brain and its membranes, may have sustained. When, however, blood is effused in the drum, inflammatory action not infrequently supervenes. 25. III. Deafness from Affections of the Auditory Nerves — Nervous Deafness. — We can seldom arrive at just conclusions respect- ing deafness from this cause derived from di- rect phenomena. We can infer it only from the absence of those deviations from the healthy state that have already passed under consider- ation. When, in connexion with the absence of these lesions, ascertained by a minute ex- amination, and by having recourse to the air- douche, there are indications of disease within the cranium, or of some other malady with which the organ of hearing may be presumed to sympathize, then the existence of deafness from an affection of the auditory nerves may be considered as probable. In such cases there is impaired or lost hearing, without any organic deviation in the ear, the lesion being either in the nerves, in their expansions in the labyrinth, or in their course thither, or in the brain at oi near their origins. It is always difficult, fre- quently impossible, to determine the situation of the lesion, and still more so to ascertain whether the lesion consist of simply impaired or lost function of the nerves, or of interrupted action, owing to extraneous influences or mor- bid productions in their vicinity. In all cases, however, the absence of organic change in the ear itself should be previously made out. Dr. Kramer states that most writers on the dis- eases of the ear—that Saunders, Swan, Len- tin, Beck, Vering, J. Frank, and Saissy— have been incapable of determining this pre- liminary part of the investigation ; that Curtis, Stevenson, and Wright are still worse au- thorities, and that Itard and Deleau are alone deserving of any confidence. Having consult- ed with M. Itard, and frequently referred to his writings, I can bear testimony to his sci- ence and candour, and to the great value of his contributions to this department of medical knowledge. 26. Dr. Kramer, with much of the spirit of the craft, but also with the science of the phy- sician, severely criticises the writings of his contemporaries ; rejects the distinctions of Itard, which, however, appear to be more sci- entific and correct than his own j and proposes 189 HEARING—Deafness from Affections of the Auditory Nerves. a novel division of nervous deafness, and a new mode of treatment. He divides it into two forms, the one attended by excitement or ere- thism, the other by torpor. Noise in the ears is always present in the former, but never in the latter. This symptom is often, however, attendant on very different diseases of the ear, but in a very indeterminate and inconstant manner. To determine, therefore, whether deafness, with noises in the ear, proceeds from disease in the organ, or from nervous affection merely, minute investigation, and the means of diagnosis already mentioned, must be had recourse to. But these are also requisite in the torpid form of nervous deafness. Mr. Swan believes that many cases usually imputed to palsy of the auditory nerve are occasioned by chronic thickening of the membrane lining the cavity of the tympanum, involving the small branches of nerves in this situation. This is not improbable; and, admitting it to obtain, Dr. Kramer's mode of diagnosis will not always succeed, nor determine the existence or ab- sence of true nervous deafness. On this sub- ject, the views of M. Itard are more patholo- gical, and less empirical than those of Dr. Kramer ; and therefore, in the few observa- tions I have still to offer, I shall chiefly follow him. 27. A. Deafness may proceed from compression of the auditory nerve.—In most instances, how- ever, this source of the affection cannot be ac- curately determined. A tumour may be devel- oped, or purulent formations or extravasated blood may exist in the course, or in the vicin- ity, or near the origin of the seventh pair of nerves, interrupting the passage of impressions made on the organ to the sensorium; but this condition often can be only surmised. Duver- ney and Sandifort found these nerves pressed upon by tumours, and Severinus observed them surrounded by serum and effused blood. If the tumour or morbid collection be considera- ble, then the extension of paralysis to the nerves of vision and of smell may favour the conjecture. Bonet mentions a case in which hearing and sight were lost, and on dissection a tumour was found pressing on the nerves of these senses. Thomann records a similar in- stance to this. Itard found in a man who had lost the hearing in the left ear small tu- mours lying on the corresponding side of the cerebellum, and nearly two ounces of a thick fluid in the ventricle of the same side. In ca- ses adduced by Lieutaud, in several detailed by Lallemand, and in some seen by myself, an abscess had formed in the part of the brain adjoining the ear, and, by pressure or conse- quent disorganization, had destroyed the func- tions of the auditory nerve. (See article Ear, § 21, et seq.) 28. a. The Symptoms of deafness from com- pression of the nerve of hearing are, severe and nearly constant headache, vertigo, noise in the ears, impaired sight, and weakness of the mental faculties, especially of the memory. The progress of this affection is generally very slow, although the internal disease producing it is ultimately fatal. In several instances mentioned by Itard, it continued some years without materially affecting the general health In two instances the above symptoms contin- ued upward of fifteen years. I also have known cases nearly as long protracted as these. The case is most protracted when it P^efds JjJ1 a tumour or morbid growt.within.thecranum^ 29 R Deafness from Palsy of the Acoustic Ne'rle.^lTnTs^oses th{t this nerve may be paralyzed (a) by a severe shock or commo- tion, (A) by convulsions, (c) by apoplexj, (d) by fever, and (e) from sympathy with some other organ. Without denying the possibility of these causes giving rise to palsy of the nerves of hearing, and even admitting that apoplexy or convulsions and fever will some- times occasion it, yet the others may seem problematical.—a. It is probable that very loud noises, as a clap of thunder, or the explosions of artillery, may paralyze these nerves, espe- cially as deafness from these and similar caus- es can be explained only after this manner, when symptoms of inflammation or of conges- tion of the ear, or of the brain cannot be de- tected. M. Itard believes that the shock oc- casioned by falls in the lower parts of the body, or the counter-stroke occasioned in this and other ways, also may paralyze the audito- ry nerves; but this cause seems more doubt- ful than the preceding. When deafness has been occasioned by loud noises, hearing often returns spontaneously in a few days or weeks; but if the deafness persists for some months, it is rarely removed by treatment. 30. b. Deafness sometimes follows convul- sions. This is most frequently observed in children under four or five years of age. Many of the cases of deaf-dumbness originate in the convulsions occurring during the first denti- tion. But the deafness may not be the result of the convulsions, both the one and the other more probably being produced by some lesion at the origin of the acoustic nerves, or by effu- sion into the fourth ventricle, or by some change at the base of the brain, or about the medulla oblongata. When the loss of hearing is complicated with palsy of one side, or of one limb, the nature of the affection may be inferred; but when this is not the case, and when hearing in both ears is lost, the exact nature or seat of lesion can seldom be deter- mined, or even surmised. M. Itard considers deafness occurring in this manner as quite in- curable. 31. c. Deafness from apoplexy is a frequent occurrence, and may exist in one or both ears. When hemiplegia has followed the apoplectic attack, the deafness is generally on the same side, and is then incurable -, but when the pa- tient is not far advanced in years, and when there has been no consecutive palsy, the af- fection of hearing may be somewhat ameliora- ted by the sole efforts of nature, or by the means about to be mentioned; but more fre- quently, especially in old persons, no advan- tage accrues to the hearing from treatment. When deafness occurs early in typhoid and in- fectious fevers, it frequently continues after re- covery from them. If a judicious application of remedies do not succeed in a reasonable time, and if the affection have been of long continu- ance, hearing is very rarely recovered. 32. B. Treatment—When the deafness fol- lowing these diseases is incomplete, and oc- curs in young persons, then blisters applied be- hind the ears, or moxas in the same situation • the vapour of aether, or of camphor; the in' HEARING—Deafness from Affections of the Auditory Nerves. 189 ternal use of stimulants, when there is no ten- dency to cerebral plethora; and the use of stomachic purgatives and alteratives, to pro- mote the secreting and excreting functions, may be resorted to ; but recovery of hearing, in these cases, may proceed as much from spontaneous changes in the circulation within the head, and in the state of nervous power, as from the remedies prescribed. (See, also, $37.) 33. d. Deafness is sometimes symptomatic of, or associated with disorders of the digestive or- gans.—In these cases, the affection is general- ly slight; but it is sometimes very considera- ble and difficult of removal. Impaired and dis- ordered digestion, deranged biliary secretion and excretion, a foul or loaded tongue, tumid abdomen, a morbid state of the evacuations, and an unhealthy aspect of the countenance and of the general surface, generally charac- terize this form of deafness. The treatment consists chiefly in the exhibition of emetics, followed by stomachic purgatives, and in at- tention to diet and regimen. The purgatives should be often repeated, and sometimes even the emetics ought to be given from time to time. After the secretions and excretions have somewhat improved, tonics and deobstru- ents, and the preparations of iron may be pre- scribed, and be aided by blisters, or moxas ap- plied behind the ears. The disorder of the di- gestive organs, associated with deafness, is sometimes also connected with difficult denti- tion, as justly remarked by Nuck, Hesse, and Itard ; and occasionally the impaired digestive, assimilating, and excreting functions, of which deafness is symptomatic, gives also rise to the pioduction of intestinal worms. In these cir- cumstances, the indications of cure are mani- fest. (See Dentition—Difficult; and Worms —Intestinal.) 34. e. Idiopathic Paralysis of the Acoustic Nerves.—This affection has been defined by Itard to be a want of excitability in these nerves—a loss of their sensibility, independ- ently of the circumstances or causes already passed in review. Its existence has been un- justly doubted by Dr. Kramer. M. Itard be- lieves, however, that it may be congenital, or supervene at any period of life; but that it most frequently occurs after forty. It is often accompanied with headache, noise in the ears, and mental inaction. Numbness, or want of sensation in the external ear, is sometimes present. M. Itard has seen the organic sen- sibility of this part entirely lost in two instan- ces. In old persons, this symptom is often ob- served in slighter degrees, and is attended by dryness of the meatus. This variety of deaf- ness is generally ameliorated by warm or mild weather, and by loud noises ; but, as soon as these cease, the affection returns to its former state. It is caused, as well as aggravated by mental exertion and fatigue ; by masturbation, venereal excesses, and other depressants; by exposure to cold, currents of air, and humid- ity, and by the depressing passions. Its ac- cession is imperceptible, and its progress very slow. Sometimes it continues long station- ary ; but it is little influenced by treatment. If the patient, however, be not far advanced in life, some advantage may be derived from blis- ters applied behind the ears, or from moxas, rubefacients, or stimulants around the organ, and repeated from time to time ; from the va- pour of aether, or of camphor conveyed into the meatus or into the Eustachian tube ; from tonics, with serpentaria, or arnica, and from the preparations of iron. Electricity and gal- vanism have been employed in this variety, but with little or no permanent benefit. 35. /. Deafness, in its more complete states, may also proceed from organic changes in the acoustic nerves. Sylvius found them, on dissec- tion, remarkably atrophied : a state probably con- sequent upon prolonged inaction. Ackermann observed them indurated ; and Morgagni states that, in one case, they were entirely wanting. [Mr. Yearsley maintains* that nervous deaf- ness is a very rare disease ; that is to say, that the loss of hearing, from torpor or inactivity of the auditory nerve, unconnected with organic disease in the different parts of the external, middle, and internal ear, is extremely unfre- quent, and that a large majority of cases, usu- ally called nervous deafness, are, in reality, de- pendant on a diseased state of the mucous membrane of the internal ear. He states that, in 120 cases of dissections of deaf cases, the aural mucous membrane was diseased in no less than 91 cases, or upward of three fourths of the number examined. Mr. Y. dwells em- phatically on the frequency with which inflam- mation extends along the nasal cavities, the tonsils, fauces, and throat, through the Eusta- chian tube, to the internal ear, thus giving rise to a thickened slate of its mucous lining mem- brane, and, consequently, to deafness, as in ep- idemic catarrh, the exanthematous affections, &c. ; and hence he directs attention to the im- portance of removing the tonsils, when en- larged, and correcting the morbid condition of the mucous membrane of the throat and fau- ces by local applications as well as general treatment.—(Loc. city] 36. C. Deafness from Plethora.—a. Conges- tion of the vessels of the head or of the ear is not infrequently productive of deafness; and this congestion may either be purely local, or connected with a state of general plethora. In cases of this kind, the patient complains of headache, vertigo, throbbing noises in the ears or head, or momentary unconsciousness, which are increased by warmth, by a stimulating re- gimen, and the horizontal position. This form of affection is most common early in life, and again at middle age, or soon after; and espe- cially in those who are subject to haemor- rhoids unattended by discharge, and in females who have experienced an interruption of the catamenia, or in whom this evacuation has ceased. The strictly local state of the affec- tion may follow suppressed evacuations of va- rious kinds, or repelled eruptions, or even ret- rocedent gout; and modifications of it are oc- casionally met with in connexion with second- ary syphilis, and with herpetic or other chronic eruptions. 37. b. The Treatment should, in great meas- ure, depend upon the existence of local pleth- ora or congestion only, or upon this state being associated with general plethora. The pathol- ogist will generally decide correctly in these * {Deafness successfully Treated through the Passages leading from the Throat to the Ear, &c, by James Years- ley, M.R.C.S., 3d ed. London, 1841, 12mo.] 190 HEARING—impaired or Lost—Remedies recommended for. cess detailed by M. Itard, in an instructi chapter on the subject oMIiknukd 39. V. Of certain Remedies j^0.^ a de. for Impaired or Lost Hearing. sire of restoring the a^JJ^fSm whom the care of the regular practitioner•' f the nretensions and advertising assiduities 01 me pretensions rt,lu „ntirplv removed them, I empirics have almost entirely rerm shall next take a brief ^ry^ofthe principal T^168 eTTher^^erarkn\;aVn,onSe SSSiin^aJcS men, P'—ther branches of practice, should undertake the management of these disorders ; for they only are capable of ascertaining the various patho- logical conditions of which deafness is either an immediate, or a remote and indirect conse- quence, and of appropriately prescribing means of cure—of employing these means without risk of injury to the function, or to the organ, or even to the brain, with which the organ is so intimately connected. 40. A. Constitutional Means.—a. Vascular de- pletions, general or local, are necessary when inflammatory action, or general or local pleth- ora is present. In other circumstances they are inadmissible.—b. Purgatives are required in similar states ; and when deafness is associa- ted with disorder of any of the digestive or- gans, and with costiveness. They were much praised by Diemerbroeck, Hoffmann, and Fa- der. They are injurious in purely nervous deafness, unless conjoined with stomachics and tonics.—c. Emetics have been recommended by Stoll, Lavaud, and Kennedy, and are some- times of service when the hearing is impaired by inflammation of the ear, or by collections of mucus in the guttural extremity of the Eu- stachian tube, or when the affection is con- nected with deficient action of the biliary ap- paratus. In nervous deafness they are use- less, and, when congestion of the brain is pres- ent, they may be injurious.—d. Tonics and stimulants, especially the preparations of cin- chona, of cascarilla, of iron, of serpentaria, of arnica, of camphor, of ammonia, the aethers, &c, have been very generally resorted to in nervous deafness, and sometimes with benefit, when judiciously employed.—e. Alteratives and deobstruents, especially mercurials and iodine, or a combination of them, may be severally pre- scribed when the deafness is dependant upon secondary syphilis, or upon constitutional vice, or is connected with chronic cutaneous erup- tions. They may also be tried when thick- ening of the membranes of the ear, or of the Eustachian tube, or obstructions of the latter by mucus are supposed to exist.—/. Salivation was recommended by Desault and Ettmul- ler, but is requisite only when the affection proceeds from venereal ulceration in the vi- cinity of the organ.—g. The preparations of squills internally have been advised by Lange, when the Eustachian tube is obstructed by mucus ; and a course of dulcamara by Car- rere, when deafness is associated with her- petic eruptions. Sulphur and the balsam of sulphur may be prescribed, as directed by Ru- land, in these or similar circumstances. 41. B. Of Local Re medics.—a. Of these the cases ; but when the affection has followed the disappearance of accustomed sanguineous or other discharges or evacuations, spontane- ous or artificial; and when the pulse, habit of body, and temperament indicate vascular ful- ness, then general blood-letting, repeated ac- cording to circumstances, local depletions, pur- gatives, and external derivatives, low diet, and regular exercise will generally restore the hear- ing, if they be decidedly prescribed and rigor- ously pursued. Deafness, however, from local plethora, and especially from congestion of the vessels of the organ, is not so easily remedied ; and, when remedied, is liable to return. Local depictions, either from the vicinity of the or- gan, or from the anus, when there is a tenden- cy to haemorrhoids; blisters applied on the nape, and kept long open, or preferably issues or setons ; deobstruent purgatives or aperients, regularly and long persisted in ; the warm or vapour bath, and other means calculated to promote the cutaneous functions, and prevent them from being interrupted, will be most ser- viceable for this form of the affection. If it have followed the suppression or disappear- ance of some eruption, discharge, or external affection, derivatives to the extremities, &c, sinapisms, blisters, &c., should be resorted to. If it have occurred in connexion with second- ary syphilis, a mercurial course will remove it, unless organic lesion of the Eustachian tube, or in the cavity of the tympanum, &c, have taken place. When it is associated with her- petic or other chronic eruptions on the skin, the same internal and external means which succeed in removing these will also generally improve the hearing, especially alteratives, purgatives, diaphoretics, sulphureous, fumiga- ting, and other medicated baths, and strict at- tention to diet, and to appropriate means for improving the digestive, the assimilating, and the excreting functions. 38. IV. Deafness and Dumbness most com- monly proceed from acute or chronic otitis in early infancy, giving rise to organic changes in the delicate and complex structure of the ear, especially in the labyrinth, and in the acoustic nerves; or from diseased changes near the origin, or in the course of these nerves. When deafness is congenital, one or other of these le- sions may be inferred to have taken place in the foetus ; or the organ, or nerves of hearing, may be considered as having been imperfectly developed in some of their parts. Deafness and dumbness are very seldom remedied, and never if the deafness has been congenital. If the affection has arisen in infancy from dis- ease of the ear, then the treatment may be carefully directed to the removal of the morbid conditions which that disease may be presumed to have occasioned ; but the utmost attention must be paid to the history of the case, to the existing state of the organ, and of the consti- tution, and especially to the phenomena con- nected witli the brain and digestive organs. Cases of this kind are rarely treated with suc- cess ; but, for this very reason, they should be placed under the care of a scientific medical practitioner, and be treated according to gen- eral principles directed to the particular lesions of the organ, and to the pathological states of the system. That these cases ought not to be despaired of, is proved by the instances of sue- most vaunted are electricity, galvanism, and min- eral magnetism, but chiefly by those who are adepts in these departments of quackery. The HEARING—Impaired or Lost—Remedies recommended for. 191 inutility of, and even occasional risk from these means have been shown by Haller, De Haen, Zetzel, Freese, and Treviranus. Dr. Kra- mer has examined the proofs as to the efficacy of electricity in deafness, furnished by the most respectable of those who have written upon the subject; and has shown that not one case can be said to have been cured, although many have been made worse by it. The opinions of Itard and Deleau nearly coincide with those of Dr. Kramer. Many cases have been pub- lished as cures by galvanism and mineral mag- netism, but the improvement said to have oc- curred has continued only as long as the ex- citement occasioned by the employment of these agents. In most cases, however, no benefit has been derived from them, or it has been apparent only, or has existed merely in the patient's imagination. In two or three in- stances, patients have conceived their hearing to have been somewhat improved by galvanism ; but I have observed that this sense has never- theless become more and more impaired.* 42. b. Moxas have been praised by Paroisse, Loder, and Itard. Dr. Kramer is not favour- able to them; but the testimony of a person who has a favourite remedy of his own, and finds fault with nearly all other means, should be received with reservation. M. Itard, whose experience and opinion are equal to those of Dr. Kramer, is in favour of them, in the cases in which they have been prescribed above.—c. Issues and setons have been employed by Zacu- tus Lusitanus, Ettmuller, Itard, and others, as derivative means. They should be inserted in the nape, or in the arm, in those states of the affection for which they have been already recommended. They will often prove ineffica- cious, or even injurious, if resorted to inappro- priately ; and especially in cases of idiopathic palsy of the acoustic nerves, or in old, enfee- bled persons; or when the deafness has been caused by exhausting or depressing causes.— d. Blisters, applied behind and below the ears, and often repeated or kept open, have been praised by Riedlin, Lavaud, Stoerck, Wendt, Itard, and others. Dr. Kramer considers that they, as well as the tartar emetic, ointment, are indicated only in circumscribed inflammation of the auditory passage and membrana tympa- ni. He prefers the ointment, which he rubs below the mastoid process, to avoid injuring this part. These means, however, admit of a more general application than he has allowed. 43. C.—a. Masticatones were prescribed in deafness by Wepfer, Diemerbroeck, Stahl, and Morgagni ; but they are now entirely neg- * [Mr. Dukton, in his late work (The Nature and Treat- ment of Deafness and Diseases of the Ear, London, 1641), remarks as follows in relation to this remedy : " The author is much indebted to his friend, Mr. Pil- cher, for frequent opportunities of witnessing the treatment of torpid nervous deafness by electricity, and can bear tes- timony to its utility in many cases. The failure of elec- tricity, as a remedy, may in many rases be attributed to the want of a proper selection in the person thus treated. Itard relates several cases in which much benefit was de- rived, from the use of electricity ; he, however, makes the followiug observation: 'et de nos jours cettc melhode de traitemeut a ete abandonne couime impuissanle.' Yet, notwithstanding this observation, the author has seen sev- eral cases benefited by the use of electricity." We have employed galvanism in several instances, and continued its use for some tune, but havo observed no marked benefit from its application. Unless employed with great care, it is calculated to do injury rather than good. The testimony in relation both to galvanism and electricity, in the treat- ment of deafness, is exceedingly discrepant..! Iected. Sfeveral states, however, of this affec- tion admit of a trial being safely given to them. —b. Gargles are among the most useful means that can be resorted to in those states of the affection which originate in acute or chronic diseases of the throat. And when it is consid- ered how very often inflammations of the ear and deafness are caused by lesions of the Eu- stachian tube, proceeding from the throat and posterior nares, especially during the various forms of cynanche, and in the course of erup- tive fevers, the importance of these means can- not be overrated. These applications should be suited to the nature of the affection of the throat; in the more sthenic states of inflam- matory action, they should be refrigerant, and contain the nitrate of potash, or hydrochlorate of ammonia, or biborate of soda; in the more asthenic forms of affection, they may be astrin- gent, tonic, and stimulant, and may also con- tain either of these, or some other detergent substances. When the occlusion of the gut- tural extremity of the Eustachian tube with mucus is suspected, these salts, especially the last, will be of service ; and, when the deafness is in great measure nervous, the tincture of capsicum may be added to these, or to any other form of gargle that may be preferred. In deafness connected with secondary syphilis (§ 20), the bichloride of mercury will be em- ployed, in the form of gargle, with advantage. 44. D. Drops and Injections, especially those of a spirituous, irritating, or acrid nature, into the auditory passage, are justly considered by Itard and Kramer to be injurious. But vari- ous stimulating or rubefacient applications about or below the ear, as garlic, onions, rue, &c, have, according to Hoffmann, Muller, and others, sometimes been resorted to with advantage in nervous deafness. Dr. Turnbull recommends ointments with either veratria, delphinea, or aconitine, to be rubbed around the ear daily ; or four or five drops of a spirituous solution of either of these (gr. ij.-iv. to jss. of spirit) to be dropped into the ear. Of perfora- tion of the membrane of the drum, notice has been already taken. Its want of utility, and the circumstance of its readily cicatrizing, have been pointed out by Hufeland, Naas>e, Mau- noir, Itard, and Kramer. Douches of vapour or of water were formerly used in several af- fections of the ear. Bartholin, Hoffmann, and Michaelis advised warm vapours, con- taining various stimulating substances, as cam- phor, aether, &c, to be directed into the mea- tus. These, however, require much caution and discrimination ; but they may sometimes be of service, especially in catarrhal affections of the ear, and in idiopathic nervous deafness. Dr. Kramer undervalues these and other means, in order to enhance his own remedy ($ 45). 45. E. Injections into the Eustachian Tube were first recommended by Guizot ; but Cle- land, in 1731, first proposed them in a practi- cable mode, namely, by the nose ; and Wathen long afterward proved that a favourable result might be obtained from the practice. The in- jection of fluids into the tube was advised by Busson and others, to be performed by filling the mouth with the fluid; and, having firmly closed the lips and nose, by forcing it into the tube. Air has also been directed to be forced into the tube, by Cleland and Sims, in the 192 HEARING—Impaired or Lost—Bibliography and References. same way, in order to remove obstructions of it; and the smoke of tobacco has been similar- ly used, with the intention both of removing obstruction and of exciting the organ in ner- vous deafness, but with very equivocal results ; I know one instance in which it proved deci- dedly injurious. Injections of medicated flu- ids, of vapour, and of air into the Eustachian tube, by means of a suitable apparatus, have been severally resorted to by Itard, Deleau, and Kramer. Besides injecting air as a means of diagnosis, Dr. Kramer throws into the tube, through a catheter introduced into it, the va- pour of acetous cether, generated, in a proper apparatus, at a summer temperature ; but con- fines the practice to cases of nervous deafness characterized by torpor, or those unattended by noises in the ear. He also aids the local means by remedies intended to improve the constitution, and the digestive and other func- tions. [The method of introducing the vapour of aether into the ear, as laid down by Kramer, is to adapt a cork accurately to a glass jar, passing two metal tubes through the cork, one of which is furnished with a funnel and stop- cock for introducing the fluid, the other with an elastic tube and stop-cock. The jar being half filled with warm water, a small quantity of the acetous aether is introduced through the funnel, which is immediately closed by the stop-cock; the elastic tube being then fitted to the cathe- ter previously introduced into the Eustachian tube, and then opened, the aether, vaporized, rushes through the tube into the tympanum ; or a wide-mouthed bottle may be procured, through the cork of which a metal pipe is pass- ed in an air-tight manner, which pipe is fur- nished with an elastic tube and stop-cock. The bottle being half filled with warm water, about half a drachm of acetous aether may be poured into it, and the mouth immediately clo- sed. The apparatus is very portable, and the elastic tube, with its stop-cock, is easily at- tached to the catheter, which should be pre- viously introduced into the Eustachian tube. Should the aether not be readily volatilized, the bottle may be placed in a vessel of hot water, when it will be readily converted into vapour. This vapour may be applied two or three times at a sitting, and may be repeated daily, or eve- ry two or three days, according to the effect produced.—(See Pilcher, loc. cit.) As the diagnosis of obstructions of the Eusta- chian tube, as well as of muculent accumula- tions in the middle ear, can only be accurately made out by the use of the catheter, a few di- rections for performing it may not be inappro- priate. The catheter should be of silver and inflexible, about six inches long, and of a cali- ber ranging from the size of a crowquill to that of a large goosequill. The extremity should be well rounded, and should have a curve of about five lines from the farther end, which should correspond with the lateral situa- tion of the mouth of the Eustachian tube. It should also be graduated by inch and half inch divisions, as these will facilitate its introduc- tion. In passing the catheter, the instrument should be warmed and oiled, and passed along the floor of the nostril with the convexity up- ward and the concavity downward. It should then be gently turned just before it reaches the pharynx, so that the point sha be warded a little upward, as the mouth, of U* Eustachian tube is above the level of thes floor of the nose. The operator will readily leel when the catheter slips into the orifice of the "Se catheter is,»*^useful in di=ti- rnegarS.Toe £#? " .or vapours into the middle ear; but also to dilate stricture of the tube, or of removing blood which may have accumulated in the tympanal cavity] 46. F. Russian Vapour Baths have been much recommended in deafness, especially when it has been supposed to originate in exposure to cold ; and warm, or fumigating, or sulphur baths, have likewise been employed in these and oth- er circumstances of the affection. They may all prove injurious in cases connected with congestion in the head or ears, or with general plethora. They are most serviceable when constitutional complaints, especially chronic cutaneous eruptions, or an obstinately harsh and unperspirable state of the general surface, are associated with the deafness; this latter probably depending in part upon a somewhat similar state of the ears to that of the skin and general system. In these cases they should be cautiously employed, vascular determinations to the head or to the ears having been previ- ously removed, and morbid secretions and ex- cretions freely evacuated.* Bibliog. and Refer.— Celsus, 1. vi., c. 7 ; 1. vii., c. 8. —Severinus, De Recond. Abscess. Nat., 1. iv., c. 36.—Syl- vius, Prax. Med., 1. ii., c. 8.—Zacutus Lusitanus, Prax. Ad- mirab , I. i., obs. 70.—Valsalva, De Aure Humana, 4to. Venet., 1740.—Ettmullrr, Opera, t. ii., p. 738.—Diemer- broeck, Anat., 1. iii., c. 18.—Ruland, Curat. Empir., cent. viii., c. 55.—Bonet, Sepulchretum, l- «v., st. ,v., p. 168.-/. M. Alard, Essai sur le Catarrhe de l'Oreille, 8vo. Par.. 1807. P/&,nr,n'n JTn- de M*d- Co',tin- '• *■• P * <*- Pfcngsten, Bemerkung. und Beobachtung. ueber Geh6r, * [Mr. Yearsley reports, as admitted~aTthe "London InshtuUonfor Curing Diseases of the Ear," for 183SJ9 a total of 203 patients. Of these wire cured 81 improved 24 incurable 58, unknown result 34, remaining-6, wTch is J rat o „f more than i cured h ., ^ B juoW f™„ "Mistical results, that, under judicious treatment * , one half of all the cases of deafness, not hhSSMl .«V are susceptible of greater or leas relief-J K aged» HEART AND PERICARDIUM—Diseases of. 193 Geftlhl, Taubhcit, &c. Altona, 8vo, 1811.—/. C. Saunders, TIih Anat. and Diseases of the Ear, 2d ed., 8vo. Lond., 1817.—Monfaicon, Deslongchamp, et Marquis, in Diet, des Sciences Med., t. xxxviii. Paris, 1819.—Itard, Traite des Mai. de l'Oreille, 2 tomes, 8vo. Paris, 1821.-7. Frank, Prax. Med. Universal Pracepla, t. iii., p. 880.—M. Deleau, Mem. sur la Perfor. de la Memo, du Tynipan., 8vo. Paris, 1822.—L. Meiner, Die Krankh. des Ohres und Gehors, 8vo. Leips., 1823.—/. A. Saissy, Essai sur les Mai. de l'Oreille Interne, 8vo. Paris, 1827.—Hufeland, in Nouv. Jouru.de Med., t. xiv., p. Z.—M. Pinel, Archiv. Gen. de Med., t. vi., ?. 247.—/. H. Beck, Krankheiten d. Gehororgans, 8vo. leidelb., 1827.—jlf. Deleau, Mem. sur le Catheritisme de la Trompe d'Eustache., 8vo. Paris, 1827.—/. Burnc, in Cyclop, of Pract. Med., vol. iii.—IV. Kramer, Die Erkennt- niss und Heilung der Ohrenkrankheiten, 8vo. Berlin, 1836. —Rev. in Brit, and For. Med. Rev., No. v., p. 79.—A. Turn- bull, Treat, on Painful and Nervous Dis., and on those of the Eye and Ear, 8vo. Lond., 1837.—(See, also, Bibliog. and Refer, of art. Ear.) iGeorge Pilcher, A Treatise on the Structure, Economy, and Diseases of the Ear; being the Essay for which the Fothergillian Gold Medal was awared by the Medical So- ciety of London, 1st Am. Ed. Phil., 1843.—Robert B. Todd, The Cyclopedia of Anatomy and Physiology. Lond., 1839, part xv.—T. Wharton Jones, Organ of Hearing, in Ibid.— Joseph Toynbee, Second Series of Observations on the Pa- thology of the Ear, based on 120 Dissections of that Organ, in Med. Chir. Trans,, 2d ser., vol. viii., 8vo, p. 425. Lond., 1843 (Mr. T. holds that the most prevalent cause of deaf- ness is chronic inflammation of the mucous membrane which lines the tympanic cavity, and that by far the greater ma- jority of cases commonly called nervous deafness ought more properly to be attributed to this cause).—Joseph Will- iams, Treatise on the Ear, tion, and not the rule, as M. Piorry "°™™* them to do. It should also be kept in, mind that the morbid sounds may be pr?d"^?Dy ' refluent, as well as by an onward motion ol the blood, as M. Filhos has contended. 14 M Bouillaud considers that the bellows sound may proceed from, 1. Narrowing of the orifices, with induration of the valves; 2. Small- ness of the aortic orifice, although the valves are quite healthy ; 3. Polypous exudations, re- sulting from acute inflammation of the endo- cardium ; 4. Irregularity or roughness of the surface of the valves, or vegetations, or calca- reous incrustations on them; 5. Infiltration of the valves from inflammation ; 6. Adhesions of the auriculo-ventricular valves to the adja- cent parietes ; 7. Dilatation of one or more of the heart's orifices, with consequent inefficien- cy of the valves ; 8. Hypertrophy, with dilata- tion of the left ventricles, although unattended by narrowing of the orifices ; 9. Chlorosis, anaemia, and nervous affections of the heart, in some instances; 10. Extreme debjjjty from haemorrhage, or other depressing causes. It has been supposed that the bellows sound, which is not constant, or is only occasional, in the last three circumstances may arise from spasm. M. Bouillaud believes it to depend in these on a narrowing of the orifices, to adapt themselves to the diminished quantity of blood circulating through them. He farther consid- ers that all the above cases are reducible to one common principle, namely, increased fric- tion produced in some of them by the direct, in others by the refluent, current of the blood; but most frequently from the former cause. From this it is evident—and most experienced practitioners must have arrived at the same conclusions, from their own observations—that it is impossible to decide, from the bellows sound alone, in which of the orifices, if in any, the lesion is seated. The co-existence of this sound with the systole or diastole, and the sit- uation in which it is loudest, may assist the observer, but still no accurate conclusion can be formed as to its precise cause. When the sawing or rasping sound is heard, the alteration may be considered to partake more or less of an osseous nature. [We have already referred (art. Ausculta- tion) to the late researches of Andral, by which it appears that an abnormal sound of the heart often exists independently of organic structure, and caused solely by modifications in the composition of the vital fluid—in other words, to changes in the relative proportion of the elements of the blood. Considering the proportion of red globules in healthy blood to be as 127 m 1000 parts, he has shown that the following modifications are caDable of produ- cing the bruit de soufflct. or bellows sound. bust When the globules have diminished suf- ficiently to be below the cipher 80, this sound always exists in the heart and large arter- wLn fhf The ^ellows sound may °e heard when the amount of globules ranges from 80 to inn S occasio,nally whe* it reaches above mean m^T ^ V^T ^ Penological mean 127. Andral has observed this sound under these circumstances, in putrid and emo- tive fevers, pneumonia, rheumatism anrl in numerous chronic diseases. Also, ii fs me" HEART—Diseases of—General View of. 197 with often in pregnant women, in whom there is generally found to be a deficiency in the globular element of the blood. (Hamatolog., Am. Ed., Phil., 1844.)] 15. C. The sounds produced occasionally by the surfaces of the pericardium in a state of dis- ease were overlooked by Laennec, and have only recently received attention. It is chiefly to Collin, Reynaud, Honore, Stokes, Will- iams, Mayne, and Bouillaud that we are in- debted for observations respecting them. M. Bouillaud divides these sounds into three va- rieties : 1st. The rubbing sound resembles that caused by rubbing together two pieces of silk, or of parchment. It is to be distinguished from a similar sound produced by the pleura, by its being double and synchronous with the heart's action. It is most obvious in the systole, and is diffused over a considerable surface. 2d. The creaking sound is altogether similar to the creaking of leather, or of shoes, or of a saddle. M. Bouillaud remarked it once; M. Andral only once; and Dr. Williams in three cases. M. Collin and others have also heard it. I have met with it in two instances : one of them a boy, about ten years of age ; the other a young lady of about twenty, who, in 1833, came from Brompton to consult me. She had, several months previously, experienced an at- tack of acute pericarditis ; and, while descri- bing her symptoms to me, she herself likened the morbid sound she heard in the praecordial region to the creaking of new shoes. I heard it distinctly with the unassisted ear. 3d. The scraping sound is such as may be expected to be produced by rubbing a rough and hard car- tilaginous or osseous body against the pericar- dium. Its synchronism with the motions of the heart distinguishes it from similar morbid sounds originating in the pleura. M. Bouil- laud states that the first two sounds occur only in aeute pericarditis. In the two instan- ces I met with there had existed the acute form of this disease ; but it had long before subsided, leaving after it organic lesion, or, at most, a chronic state of inflammation. The friction or rubbing sound, in its faintest states, occurs in the early stages of acute pericarditis, and while the membrane is dry. The creaking or leathery sound seems to arise from thicken- ing or condensation of the sub-serous and se- rous tissues of the pericardium, especially of the portion reflected over the heart; and the formation of a dense and elastic false mem- brane, with, perhaps, more or less adhesion of the opposite surfaces. The scraping or grating sound is caused by lesions which occur only in the more protracted cases of chronic pericardi- tis. When the bellows sound is heard in peri- carditis, it does not necessarily depend upon this disease, but rather upon the co-existence of inflammatory action in the internal mem- brane of the heart, or the extension of it to the fibrous structure of the orifices or of the valves, and the consequent contraction or other lesions thereby occasioned. 16. v. Percussion of the Cardiac Region is best performed with the index finger of the unemployed hand as the medium, or plessime- ter. In the healthy state, the extent of the dull sound generally varies from an inch and a half to two inches square, which answers pre- cisely to the extent to which the heart is dis- engaged from the lungs. The extent of the dulness increases very much in hypertrophy eft the organ with or without dilatation of the cav- ities, in simple dilatations, and in congestions of them occurring in various diseases. It is not unusual to find the dulness, in these cir- cumstances, extending to five or six inches square. (See art. Auscultation.) Biblioo. and REFER.— IV. Harvey, De Motu Cordis et Sang. Ciiculatione, 4to. Frank., 1628. — J. Smith, King Solomon's Portraiture of Old Age, 8vo. Lond., 1666.—R. Lower, Tractat. de Corde, item de Motu et Colore Sangui- nis, 8vo. Lond., 1669.—R. de Vieussens, Nouvelles Decou- vertes sur le Cceur, 12mo. Toulouse, 1706; et Traite Nouv. de la Structure du Cceur, 4to. Toul., 1715.— W. Wood, A Mechanical Essay on the Heart, 4to. London, 1729.—P. Chirac, De Motu Cordis Adversaria Analytica, 12mo. Pans, 1744. — Author, in Lond. Med. Repos. for May, 1822; and Notes and App. to Richerand's Elements of Phys., &c, p. 611, et seq. Lond., 1824 and 1829.—Vaust, in Journ. Univers. des Sciences Med., t. xxvii., p. 164.— Gendrin, Archives Gener. de Med., t. xvi„ p. 123.— W. Stokes, in Dubl. Journ. of Med. Sciences, vol. iii., p. 50; vol. iv., p. 29.—Turner, Trans, of Med. and Chirurg. Soc. of Edin., vol. iii., p. 205.—Spittal, in Edin. Med. and Surg. Journ., July, 1826, p. 122—Corrigan, Trans, of King's and Queen's Coll. of Phys. Dubl., vol. i., N. S., p. 151.—D. Williams, in Edin. Med. and Surg. Journ., Oct., 1829.— Pigeaux, Archives Gener. de Med., Juil. et Nov., 1832.— Magendie, Lect. in Lancet, Feb., 1835.—Bryan, in Ibid., Sept., 1833.—Rouanet, Journ. Hebdom., No. 97. —Bouillaud, in Ibid., 1834.—T. Davics, Lect. on Dis. of the Lungs and Heart, p. 369.—Carlile. Dubl. Journ. of Med. Science, vol. iv., p. 84.—C. I. B. Williams, The Pathology and Diagno- sis of Dis. of the Chest, &c, 3d edit. Lond., 1835, p. 163. —Report of the Dublin Committee on the Motions and Sounds of the Heart, in Dubl. Journ. of Med. Scien., Sept., 1825, and Med. Gazette, vol. xvi., p. 777.—Corrigan, in Dubl. Journ. of Med. Science, vol. ix., p. 173.—P. M. La- tham, Lectures on Subjects connected with Clinical Medi- cine. Lond., 8vo, 1836 (An interesting work).—/. Bouil- laud, Traite Clinique des Mai. du Cceur, 8vo. Paris, 1835, reviewed in British and For. Review, No. 2, p. 425.—(See, also, Biblioo. and Refer, of art. Auscultation.) [Am. Biblioo. and Refer.—/. A. Swett, Review of Hope, On Diseases of the Heart, in New-York Journ. of Med., vol. ii., p. 417.—C. W. Pennack and E. M. Moore, Report of Experiments on the Action of the Heart. Phila- delphia, 1840, and in Am Ed. of Hope, On the Heart.— Meredith Clymer, Am. Ed. of Williams, On Diseases of the Respiratory Organs. Phil., 1845.—T. Stewardscn, Am. Edition of Elliolson's Principles and Practice of Medicine. Phil., 1844.—Medical Examiner, No. 44.] II. A general View of Diseases of the Heart. —Syn. Kapdiac voaoi, Gr. ; Cordis Morbi, Lat. ; Herzkrankheilcn, Germ. ; Maladies du Cceur, Fr.; Malattie del Cuore, Ital.; Diseas- es of the Heart, Heart Diseases. 17. As the various maladies of the heart fre- quently proceed from the same causes, often are met with in similar states of complication or association, admit often of the same prog- nosis, and even frequently require the same modes of treatment, I shall, in order chiefly to prevent repetitions, take a general view of them before I proceed to consider their specific forms. 18. i. The Causes of Diseases of the Heart are even more diversified than was supposed by Corvisart and some other writers.—A. The Predisposing Causes are nearly the same as those concerned in producing inflammatory and nervous diseases in other organs ; but the un- ceasing actions and the intimate sympathies of this viscus not only increase the general pre- disposition, but also serve to impart a peculiar character to the effects more immediately pro- duced on it by numerous physical agents and moral influences. The irritable, nervous, and sanguineous temperaments ; a plethoric habit of body ; the rheumatic and gouty diathesis ; depression of mind ; and the puerperal states, favour more or less the occurrence of diseases 198 of the heart. Lancisi, Albertini, Senac.Mor- gagni, Corvisart, Bouillaud, and others have remarked an hereditary predisposition to these diseases, independently even of either of the diathesis just particularized. Besides these, susceptibility of the nervous system, whether original or acquired; and pre-existent disorder, especially debility in its various forms ; impair- ed digestive, excreting, and assimilating pow- ers ; morbid states of the blood, affections of the lungs and liver, and irritations of the ute- rus and spinal chord, predispose more or less to these maladies. 19 B The Exciting Causes may be arranged into, 1st The Mechanical and Traumatic ; 2d. The Physical; 3d. The Moral; and, 4th. The Pathological.—a. Under the first of these may be arranged blows, falls, wounds, and external inju- ries directly or mediately affecting the organ ; compression of the ribs or sternum, or of the hypochondria, by resting against a desk, and by strait lacing ; and over-distention of the stom- ach by food or drink.—b. Among the physical causes may be enumerated, great muscular ex- ertion, especially while the breath is retained ; long journeys on foot, and fatigue; running against the wind, or ascending eminences or stairs ; reading or speaking aloud, and singing, especially if long continued, or when impas- sioned ; blowing wind instruments ; straining at stool; advanced pregnancy; excessive ve- nereal indulgences ; the abuse of spirituous or fermented liquors ; arsenical preparations in poisonous doses, or employed too long or in too large doses as a medicine ; the injudicious use of other acrid substances ;. exposure to cold, or to cold and humidity conjoined, and to currents of cold air; wearing damp linen or clothes, or sleeping in damp beds or sheets ; and drinking cold fluids or eating ices when the body is perspiring.—c. The moral causes comprise all the depressing and exciting affec- tions of mind, especially when excessive, but more particularly the former. Sudden shocks, fright, terror, violent fits of anger, anxiety, grief, sadness, nostalgia, amorous affections—all not merely affect the functions of the heart in a very remarkable manner, but sometimes, also, alter its structure. 20. d. The pathological causes are still more influential than the causes already enumerated, and act in different ways. 1st. Some of them embarrass the actions of the heart, by impeding the functions of the diaphragm and lungs; a flatulent distention of the stomach or colon, en- largement of the liver or of the spleen, and ef- fusions of fluid in the large cavities. 2. Others obstruct the circulation through the lungs, and consequently cause congestion or distention of the heart's cavities ; as asthma, hooping-cough, pneumonia, bronchitis, convulsions, &c. 3d. Certain pathological states extend to the heart or pericardium from other parts, owing either to proximity of situation, or to their structure being of the same kind as that of the parts pre- viously affected. Thus, inflammation of the external or internal membrane, or other dis- eases of the heart, appear in the course, or af- ter the subsidence of pneumonia, of pleuritis, of rheumatism, &c. 4th. Some of these causes are connected with excessive vascular pletho- ra, with or without a morbid condition of the circulating fluids ; as the suppression of erup- HE\RT—Diseases of—General View of That the bloode££?t jj =...ier to the imp> similation and the injurious nature of the m ded'action of any of the, principal -J^g and excreting organs. That the woo ' come morbid, owing either to the "JPertect ^ nd the injurious nature ot tne in- gesta, or to the accumulation in it oTbe u ti- mate products and effete principles of assimila- S rePqu7nng to be eliminated bv'the energe ic action of the emunctones; and that this state of the blood may excite disease in some part of the heart's internal surface, seem more than probable. The changes in the circulating fluids, moreover, taking place in the course of fevers, or in connexion with the exanthemata, erysipelas, gout, &c, may also occasion dis- ease of this organ ; and it is not unreasonable to infer that, when this connexion is observed, as much is often owing to the morbid condition of the blood as to that of the living solids. 5th. In cases of suppression of gout or rheumatism, or the retropulsion of the exanthemata and of other acute cutaneous eruptions, it may be ad- mitted that, while the constitutional disturb- ance upon which the local or external affec- tion depends remains unabated, the suppression of the latter will very probably be followed by some prominent affection or localization of morbid action in an internal organ, especially if the powers of life are inadequate to throw it off upon some external part; and as, in these diseases, the circulating fluids are more or less altered, and the actions of the heart already much disturbed, one or other of the tissues or compartments of this organ will be quite as likely to become the seat of the superinduced malady as any other internal part; and even more so, as respects the rheumatism, owing to the predisposition arising out of identity or sim- ilarity of structure. 6th. One affection of the heart, functional or structural, may occasion another, or an additional lesion. Thus, vio- lent palpitations sometimes rupture a muscu- lar column, or tendon of the valves, or even the parietes of the heart itself; and narrowing of an orifice occasions dilatation of the cavity behind it, &c. 21. While Corvisart and Schina have at- tached the greatest share of importance to mor- al causes in the production of cardiac diseas- es, and undervalued the influence of physical agents, M. Bouillaud has over-estimated the latter at the expense of the former; and they, as well as all other writers, have either entire- ly overlooked, or have scarcely adverted to several of the antecedent changes or pathologi- cal states to which I have imputed so much in the causation of these maladies. 22. ii. Of the Seat and Anatomical Characters of Diseases of the Heart.—A. It is extremely rare, as M. Bouillaud remarks, to find the heart altogether diseased : most commonly a compartment only, or a portion of it merely, or even one of the tissues constituting it, is af- fected. Sometimes one or more valves or ori- fices are primarily altered ; and in other cases, either the internal or external membrane or the muscular structure is changed. In one in- stance, a cavity is dilated and its walls thin- ned ; in another, it is of natural capacity, but its parietes are remarkably thickened ; and in others, the compartments individually'present various lesions, as softening, hardening; &c 23. B. The intimate nature of the heart's le- HEART—Diseases of—Characters and Diagnosis. 199 Sions is not always evident, even on the most minute examination. That they are frequent- ly inflammatory, or of that kind usually so de- nominated, cannot admit of a doubt; and that they still more frequently are the consequen- ces of inflammation in some one or other of its grades, modified, however, by the tissue in which it is seated, by the state of vital power attending it, and by the condition of the circu- lating fluids, is no less true, although less man- ifest than the former proposition. Inflamma- tion affecting a serous surface gives rise to re- sults varying with its intensity, and with the state of the constitution, in respect both of or- ganic nervous energy and of vascular tone. When the latter remain unimpaired, the pro- duction of coagulable lymph is a common re- sult ; but the lymph, being secreted in a fluid state, will often, when the internal membrane of the heart is inflamed, be washed into the current of the circulation before it can be coag- ulated, and no very manifest evidence of the disease may be detected after death, although it has existed in its most intense form, or even has been the cause of death. When the in- flammatory action is co-existent with depress- ed vital power and a morbid state of the blood, the fluid secreted by the inflamed surface is in- capable of coagulating, and it readily mixes with and contaminates the vital current; the seat of disease presenting, after death, but lit- tle change beyond dark discoloration and soft- ening. In respect both of the internal surface and of the substance of the heart, lesion of the capillary action and tone, as well as of vital co- hesion, may have existed during life, and yet escape detection after death; and certain of the changes sometimes observed—especially alterations of colour, fibrinous coagula attach- ed to the valves, &c, and slight effusion into the pericardium—have either taken place short- ly before, or at the period of dissolution, or even soon after this issue. 24. Although most of the affections and le- sions of the heart are to be imputed chiefly to inflammatory action and its consequences, va- ried by the conditions alluded to, yet they are not altogether of this nature, or do not always originate in this way. We have seen above (Y 5) that this organ derives its energies chief- ly from the ganglial nervous system : it must, therefore, follow that extreme depression or exhaustion of this system must be attended by a marked alteration of the functions of the heart; indeed, the evident imperfection of the actions of the latter is one of the principal in- dications we possess of the exhaustion of the former. And if this alteration or imperfection of action continues long, or returns frequently, lesion of structure, especially dilatation, soften- ing, thinning, atrophy, &c, of the parietes of one or more of the compartments of the organ, &c, must ultimately take place. Nor is this the only mischief; for, along with it, alteration of the circulating fluid often exists—this latter still farther impairing nervous or vital power— and, in connexion with both these pathological conditions, inflammatory action, or an altered state of vascular action, constituting one of the morbid conditions usually so denominated, oc- casionally, also, takes place in the internal sur- face of the heart, or in some other of its con- stituent tissues, giving rise to the farther chan- ges already alluded to in general terms, and hereafter to be more particularly noticed. 25. iii. The general Characters and Diagnosis of Diseases »/ the Heart naturally divide them- selves into, 1st. The Local Signs; and, 2d. The General Symptoms, or sympathetic phenomena. The former have been generally termed phys- ical ; the latter, physiological and rational; but the one class should always be considered in connexion with the other in the course of prac- tice.—A. The local signs are ascertained by auscultation, percussion, inspection, and palpita- tion. Of the former of these means sufficient notice has been taken. (See arts. Ausculta- tion and Chest.) The latter requires equal care with the former ; and the sensations com- municated to the hand of the examiner, as well as those excited in the patient by the examina- tion, should be attentively ascertained and es- timated. The indications furnished by these means are diversified according to the nature of the diseases which furnish them ; but they can be known only by listening to the extent, seat, and nature of the sounds given out by the organ or elicited by percussion ; by ob- serving the form and motions of the precordial and adjoining regions ; by feeling the motions, tremours, or thrills often existing in these situ- ations ; and by ascertaining the sensations of the patient upon pressing between the ribs, or on the praecordia, or upward upon the dia- phragm, and under the anterior margin of the left floating ribs. 26. B. The general symptoms, or sympathet- ic phenomena, are ascertained from attentive observation of the several related functions. The very intimate relation of the heart to all the principal viscera, but especially to the blood and circulating vessels, to the organic or gan- glial nervous system, and to the respiratory or- gans, and the influence which these exert upon this organ, and which it exerts upon them, sev- erally and conjointly, require to be kept in view. The manner, also, in which the brain, the liv- er, and other digestive organs are often affect- ed by diseases of the heart, may likewise be made a source of information. Most of the con- nexions which have been traced between affec- tions of distant organs and the heart have been imputed to augmented or impaired actions of the latter — most frequently to hypertrophy. But there is sufficient evidence to prove that interrupted circulation, caused by alterations of the valves or of the orifices, is much more con- cerned in the production of sympathetic dis- turbance, and even of structural lesion, of re- mote as well as associated parts, than hyper- trophy or excited action. An impeded passage of blood from the auricles occasions congestion of the venous system ; serous effusion into shut cavities, and cellular or parenchymatous struc- tures ; haemorrhages from mucous surfaces or into the substance of organs; and not infre- quently congestions or enlargements of the liver or spleen. When hypertrophy exists, it is generally caused by the increased action re- quired to overcome an obstacle situated at the outlet from the hypertrophied compartment; yet still the obstacle is but imperfectly over- come, and the force of the current of blood be- yond the seat of obstruction is even less than in health. The necessity, therefore, of ascer- taining the pathological states of remote as 200 HEART—Diseases of—their Nature and Arrangement. well as of collatitious parts, in connexion with the actions and sounds of the heart, in order to arrive at correct conclusions as to the diseases of the latter, is manifest. The relations of morbid actions must be duly estimated, with- out assigning a preponderating or an exclusive share to one or two conditions, and overlook- ing all the rest. No partial or empirical views should be entertained; and far less ought a charlatan parade of examination be pursued and acted upon, to the neglect of physiological inquiry and of rational deductions. There is as much empiricism at the present day in the modes of investigating and observing diseases as in those of curing them; but there is this difference, that the empiricism of the former kind is much more ad captandum than the lat- ter, and generally more fussy, and often more offensive. 27. iv. Of the Nature and Arrangement of Dis- eases of the Heart—A. The nature of these dis- eases has been partially noticed when viewing the alterations of structure attending or conse- quent upon them (y 23, 24). Of the intimate nature of these maladies we know nothing more than is intimated by function or action, or is made apparent on close inspection.—a. When disordered action is suddenly excited by men- tal emotions, or by affections of related parts, and as suddenly ceases, leaving the organ in the integrity of its functions, we infer that the disturbance is seated in, or extends to that part of the organic nervous system which ac- tuates it; and this view is confirmed by the juvantia and lozdentia, and often by the appear- ances observed after death in persons who had been thus affected, and who had died of other diseases. In these cases, the disorder must, in the present state of our knowledge, be view- ed as purely functional, or nervous, or dynamico- vital, as termed by various writers ; and it may, without much stretch of ingenuity, be chiefly referred either to impaired action or to excessive action. In these affections, the ner- vous system of organic life—particularly that part of it supplying the heart—is primarily dis- ordered, and continues the only or chief seat of the disturbance for some time. But if either affection be excessive or enduring, then alter- ation of structure may result, and assume one or other of the forms about to be noticed. 28. b. Diseases of a most serious nature often attack the heart, in which, conjointly with more or less disturbance of the organic nervous influence, the vessels supplying one or more of the constituent tissues of the organ exert a morbid action, and give rise to various changes of structure, according to the grade of vital power, and to the state of the blood. These diseases frequently take place less obviously, or much more insidiously, than the foregoing, although often, also, in a severe and acute form; and they are always dangerous. The rapidity of their course, as well as the chan- ges they produce, depends upon the intensity of the morbid vascular action, and the consti- tutional states just mentioned. From the cir- cumstance of this action being attended by injection and development of the vessels, par- ticularly of the capillaries, and giving rise to changes usually observed to follow inflamma- tion in other parts similarly constituted, it has been denominated inflammatory. By this term, • . i a tr, hp implied that however, it is not intended *° «* ' F consists the morbid vascular action_a togetw either of diminution or of augmcnw vital properties of the vessels; but^tnai, as have contended in the ^^^Zlnl and I-Lu„t.moN, J w rather ^.^ perversion of these'J™?*™ d ^ inflammation, and not a cndnBc , j j , this change, whatever direction it.may take forming only one of the elements of the morbid state. Beyond this, we can hardly advance ,n our analysis of the nature of inflammatory dis- eases of the heart; but we may infer, with some truth, that, when the organic nervous or vital powers are unimpaired, and the blood un- contaminated, the morbid vascular action will partake more or less of the excited or sthenic condition, will exert a formative process, and will most probably form lymph, which will co- agulate if allowed to remain for any time in contact with the part which produced it; or occasion thickening, or a condensation of the affected parts; or give rise to other changes varying with the grades of action ; and we may farther conclude, with equal justice, that, when the vital powers are depressed or ex- hausted, or the blood altered or contaminated, the local morbid action will be asthenic, will be incapable of developing the changes just specified, and, in their place, will produce, ac- cording to its seat, a sanious or sero-sanguine- ous fluid from the surfaces, that will farther contaminate the blood, if the internal membrane be implicated, or give rise to softening, discol- oration, &o, of the substance of the organ, if this part become affected. 29. c. Under the above two heads may be comprised those affections of the heart which may be said to be primary, as respects this or- gan, although they are often associated with, or even preceded by disorder of other viscera, as well as by alteration of vital power and of the circulating fluids. But there is another class of cardiac diseases which present differ- ent characters, and consist, in a great degree, of change of structure, often associated, how- ever, with disorder of the organic nervous in- fluence, and sometimes, also, with more or less marked alteration of vascular action in one or more of the constituent tissues, or com- partments, of the heart. They may be said to proceed from the morbid conditions already discussed, especially when these exist in sub- acute, or in slight or chronic forms. That this is the case, will become apparent when 1 come to describe them individually. It will then be fully shown that impaired or irregu- larly exerted nervous influence, and morbid vascular action, in one or more of the constitu- ent structures of the organ, have, together or singly, altered their nutrition, or impaired the vital cohesion of the molecules of which they are formed ; and that the consequences of al- tered nutrition and impaired vital cohesion chiefly consist of the increased or diminished an? P?,.Va".d deuS,ty' the augmented redness &c nJ.hiClty- the SOftnesS' the «i>atations, tn'lthe_pa,;ieties of the cavit.es ; and of the fungous or polypous excrescences, 'the oartila. ginous and osseous formations, and the difflS ent morbid productions, &c, found in the heart and pericardium. nearl 30. B. Conformably with the above view of HEART—Diseases of—their Complications—Prognosis. 201 the nature of affections of the heart, I shall divide them into, 1st. Disorders which are mere- ly nervous, or functional, and chiefly dependant upon the state or distribution of the ganglial ner- vous influence, particularly in respect of this or- gan ; and under this head will be comprised, (a) Impaired and irregular actions of the heart; and, (b) Excessive action of the heart. 2d. Diseases in which, conjointly with more or less disturbance of the organic nervous influence distributed to this organ, the blood-vessels of one or more of its constituent tissues manifest a per- verted or morbid action. Under this division will be considered, (a) Inflammation of the endo- cardium or internal membrane of the heart; (b) Inflammation of the pericardium ; and, (c) In- flammation of the substance of the heart, or car- ditis. 3d. Organic or consecutive lesions of the heart, resulting from, and often associated with one or more of the above pathological conditions. Under this head will be discussed, (a) Atrophy of the heart; (b) CEdcma of the organ; (c) Softening and hardening of the structure; (d) Adventitious productions in the heart; (e) Changes of the di- mensions of the orifices and valves ; (/) Changes in the dimensions of the cavities of the heart; (g) Hypertrophy of one or more of the compartments ; (h) Rupture and wounds of the heart, &c, &c. 31. v. Of the Course, Termination, and Dura- tion of Cardiac Disease.—Affections of the heart may be acute, sub-acute, or chronic.—A. Those which are nervous or functional are most fre- quently chronic, remittent, or even periodic; yet they are sometimes acute, and of very short duration, as in cases of cardiac syncope, &c. ; and frequently terminate without any le- sion of structure, although they occasionally induce it.—B. Inflammations of one or more of the constituent tissues of the heart may as- sume any grade of intensity, and pursue, ac- cordingly, an acute or chronic course, or even any of the intermediate or sub-acute states. The chronic form may be consequent upon the acute ; or it, as well as the sub-acute, may ap- pear primarily, especially when the inflamma- tory action is limited in extent, or is confined to a single constituent tissue of the organ. Although they may terminate in resolution, yet they most commonly give rise to organic changes, among which must be ranked the ef- fusions of fluid, &o, frequently met with in the pericardium. The more intense states of in- flammation of either of the surfaces, or of the substance of the organ, may terminate fatally in two or three days, while the less severe or chronic states may continue months, or even years ; but when they become thus prolonged, it is generally owing to their having passed into organic change, or to a temporary subsi- dence of the morbid action, and to returns or exacerbations of it, under moral or physical influences.—C. Organic lesions of the heart are extremely uncertain as respects their course, duration, and termination. Even when most manifest and extensive, their symptoms and progress are by no means uniform; the most distressing phenomena, as in inflammations of the organ, often varying, disappearing, return- ing, or pursuing very different courses in sep- arate cases, or even in the same person at different periods. They frequently, also, pre- sent more or less evident remissions and exa- II 26 cerbations, or even a marked periodicity. This circumstance probably induced Corvisart, and especially Rostan, to refer many cases of ner- vous asthma to organic disease of the heart. But this circumstance is explained by the fact already adverted to—that change of structure, even when most prominent, is only one of the elements of the cardiac malady, the organic nervous energy of the organ being also always more or less affected ; and we know that in- termittence, or periodicity, is characteristic of affections of the nervous system. The exa- cerbations or violent paroxysms which patients with organic lesions of the heart experience, is not, however, altogether owing to periodicity of the morbid action, but is often excited by mental emotions, by errors in diet, by over- distention of the stomach or colon, by neglect of the excreting functions, and by exposure to atmospheric vicissitudes. 32. vi. The Complications of Diseases of the Heart are important objects of consideration, in respect both of the associations of these dis- eases with one another, and of their connexion with other maladies.—A. Nervous affections of the heart are often attendant upon disorders of the digestive organs, on flatulency, on con- gestions of the liver, and on disorder of the respiratory functions. They are frequently, also, observed in the course of chlorosis, hys- teria, and anaemia; and are often excited by affections of the womb, and by the puerperal states. Indeed, the numerous pathological causes (§ 20) of cardiac diseases form, also, complications with them.—B. Acute or chronic inflammation of the internal membrane of the heart sometimes extends to the pericardium ; and inflammation commencing in the latter surface very frequently reaches the former. This association ,of inflammation of both sur- faces, or extension of the morbid action from the one to the other, especially from the exter- nal to the internal membrane, is to be explain- ed by the proximity of the one to the other in certain parts of the organ, and by the circum- stance of the connecting cellular substance being frequently implicated, especially when the pericardium is inflamed. This fact, which is much insisted upon by Bouillaud, has been taught in my lectures since 1825.—C. Inflam- mations of these membranes are also often complicated with, or consequent upon acute articular rheumatism, or inflammation of the pleura or lungs. This association is met with in a very large proportion of cases of these diseases.—D. The complication of organic le- sions of the heart with those of the large ves- sels, and particularly those of the aorta, are well known ; and of softening, dilatation, &c, with adynamic fevers, scurvy, purpura, &c., has been often remarked. The connexion ex- isting between obstructions at the orifices of the heart, and commencement of the large ves- sels, and hypertrophy ; and between these and diseases in the lungs and brain, especially apo- plexy, palsy, pulmonary haemorrhage, effusion into the cavities of the chest, anasarca, &c, will be more fully shown in the sequel. 33. vii. The Prognosis of Cardiac Diseases.— Senac and Corvisart entertained the most un- favourable opinion as to the result in diseases of the heart. The latter writer even affixed the epigraph, " Haret lateri lethalis arundo," to 202 HEART—Diseases of—thei the title-page of his work. At the present day, more favourable ideas are entertained on this subject, although the opinion of Corvisart will still hold with respect to some of the organic changes of the organ.—a. The nervous affections of the heart will frequently yield to treatment, unless they be very violent, when an unfavour- able, or, at least, a guarded prognosis should be given.—b. Inflammations of the membranes, and even of the substance of the heart, if they come early under treatment, will often terminate fa- vourably ; yet they ought, nevertheless, to be viewed as very dangerous maladies, as re- spects both the organic lesions they may cause, and the contingency of an immediate or sudden dissolution.—c. Most of the organic lesions of the organ are incurable; and yet the patient may live many years, when judiciously man- aged. Of this kind are, induration of the valves, narrowing of the orifices, chronic pericarditis, hypertrophy, &c. The unceasing functions of the heart, and their extreme importance to the economy, however, render diseases of it more dangerous than those of almost any other or- gan. But the advances that have been recent- ly made in their diagnosis have given greater precision to the treatment, and have, conse- quently, afforded a greater degree of success than formerly. 34. viii. The Treatment of Cardiac Affections.— A. The nervous affections of the heart, especial- ly those associated with disorder of the digest- ive and assimilative organs, or characterized by irregular or excessive action, have been too generally, and most injuriously treated by vas- cular depletions and purgatives. I have seen even the complication of palpitation with chlo- rosis treated by depletions, and a complete state of anaemia result. In cases of this kind, a judicious selection of tonics, chalybeates, an- odynes, and stomachic aperients, appropriately to the peculiarities of each, aided by light, nu- tritious diet, by gentle exercise in an open dry air, and sometimes by tonic and alterative min- eral waters, will generally remove the com- plaint. 35. B. The inflammatory diseases of the heart require more or less copious and repeated de- pletions ; in the acute stage, the most decided adoption of them, as well as of other antiphlogis- tic means. M. Bouillaud has strongly insist- ed upon the propriety of prescribing repeated blood-lettings ; but although the depletions he recommends are considered large in France, they are not larger than those usually directed in this country for the same diseases. The exhibition of calomel and opium, or of calomel, antimony, and opium, in repeated doses, to pro- mote the resolution of the inflammatory action, or to prevent it from passing into the chronic state, or from terminating in effusion, or to limit the effusion of lymph, or to prevent the organization of what may have been effused, and promote its absorption, is the next most important means, and should always follow im- mediately after a decided vascular depletion, in the manner described in the article Blood (§ 64-68). This practice, somewhat modified from that adopted by British medical practi- tioners in warm climates, was first brought into use in this country by Dr. Hamilton, of Lynn Regis (Medical Commentaries, &c, vol. ix., p. 191. Lond., 1785). His paper on this r Prognosis and Treatment. subject-the most valuable in n*0^™ "^cal literature-contains all the modifications that have been attempted in this practice oy ur. Armstrong and other more recent writers, with the view of appearing original, u nas been erroneously stated, by several who have adopted this treatment, that Dr. Hamilton al- ways prescribed these medicines until the gums were affected by them; and it has been claim- ed as a point of originality that they have em- ployed the same means, so as not to produce, or short of producing this effect. In some complaints, however, and even in some of those under consideration, this effect is neces- sary to the successful operation of these sub- stances. That Dr. Hamilton, however, thought it unnecessary to employ them, in certain dis- eases, as rheumatism, &o, so as to affect the mouth, is shown by his remarks respecting their operation (Opus citat, p. 200). He there states that, when they act upon the skin or bowels, re- lief will accrue from them without the mouth becoming affected ; and that, when the skin is dry, hot, or contracted, emetic tartar should be added to the calomel and opium, in order to determine to this surface. 36. When inflammations of the heart come under treatment at a more advanced stage, or when they have assumed a more chronic form, vascular depletions must be prescribed with greater caution, and the calomel and opium should be given until either the gums become affected or a slight ptyalism be produced. If the action of the heart be irregular or excited, a small quantity of camphor may be added to each dose of these medicines ; and if the pulse be hard and regular, a repetition of the blood- letting, and a combination of James's powder, or of tartar emetic, or of ipecacuanha, with the calomel and opium, will act beneficially, both upon the circulation and upon the emunctories. The bowels should be kept freely open, and the action of aperients promoted by enemata. 37. Although it is necessary to have recourse to copious depletions in the acute or early stage of inflammations of the heart, yet their effects should be carefully watched; and they ought to be still more cautiously employed in chronic or advanced cases ; for there are very few in- flammatory diseases in which they may prove more beneficial than in these, if they be resort- ed to at the proper time, and in sufficient quan- tity ; or in which they may be more injurious, if too long delayed, or too sparingly employed, or carried too far. When prescribed in a tim- id manner, and if a decided use of calomel and opiurn, sometimes with antimony, colchicum, or other adjuvants, be not adopted, an acute inflammation, which would otherwise have en- tirely subsided, either passes into a chronic state, or gives rise to organic changes imbit- tenngthe shortened period of future existence. npvi k tha,S PromPted to decision, it must namL,6 over!ooked> ^at in most cases of in- n™?* ° affeCting this viscus- ^e organic reffularlef,ne/gy 1S T™ ^J688 imPa"ed or ir- mfasurl7, v,ermrt; arVd that the most de«sive Srutmn«r UW' therffore' £ directed with whichSch~sPect,on.. The other means wnicn. may be brought in aid of those alrpadv noticed are comparatively of so littL im™/ tance, and require to be so varied aSJrffi» the forms and stages of the disease, that no nfen° HEART—Functional Disorders of the. 203 tion need be made of them until the specific af- fections of the organ come under consideration. 38. C. The organic lesions of the heart re- quire a much more prudent recourse to deple- tions than the diseases just dismissed, inas- much as the nervous influence, especially that actuating the organ, is much more impaired in the former maladies than in the latter. In cases of dilatation of one or more of the cavi- ties, even a moderate depletion may be followed by a fatal result; and when there is hypertrophy the heart requires all the energy it possesses to overcome the obstacle in the way of the cir- culation. The small but repeated depletions, and the antiphlogistic regimen recommended by Valsalva and Albertini, and so generally adopted in organic diseases of the heart, may be carried too far, as Corvisart has judicious- ly shown. They may be even most injurious. There are few means which are universally or even generally applicable to these lesions, ex- cepting mental and physical quietude, and at- tention to the digestive and excreting functions. Vital energy seldom admits, in them, of being lowered ; and whatever acts in this manner should be employed with discrimination, or ap- propriately to those states which seem special- ly to require it. In them, also, moral training, attention to diet, living in an equable tempera- ment, and in a healthy and airy situation, a gently open state of the bowels, and a due se- cretion of bile, and the careful avoidance of whatever excites or aggravates the disorder of the heart, are among the most generally appli- cable means of treatment. Numerous other measures may be employed, but they are ap- plicable only to particular lesions, and there- fore will be mentioned where the treatment of these lesions is particularly discussed. Biblioo. and Refer.—Galen, De Locis Affect., 1. v., c. 2.—Actius, Tetrab. 1., sect, iv., c. 77.—Avicenna, Canon., tract, iii., fen. ii., tract, i., c. 2.—B. Montagnana, Cons, de JEgritoa. Cordis, in Op. Sel., fol. Ven., 1497.—C. Vega, De Cord, et Thoracis Affect., in Arte Med., fol. Lugd. Bat., 1564.—C. Bruno, De Corde et ejus Vitiis., 4lo. Bas., 1580. —E. Rudius, De Nat. et Morbosa Cord. Constitutione, 4lo. Venet., 1600.—A. Albertini, De Affect. Cordis Libri Tres., 4to. Venet., 1618.—C. Tardy, Traite de la Monarchie du Cceur en rHomme., 4to. Paris, 1656.—A. Bulgetius, De Affect. Cordis., 4to. Pat., 1657.—Sennertus, Praxis, 1. ii., par. iii., c. 3.—A. Kramer, Diss, de Morbis qui Cor et Res- pirat. Organa infestant., 4lo. Vien., 1716.—Af. Martinez, Observat. Rarse de Corde, 4to. Madr., 1723.-7. Af. Lan- cisi, De Motu Cordis et Aneurismatibus, fol. Rom a?, 1728. —Af. Berbeyrac, Nouv. Dissert, sur les Maladies de la Poi- trine et du Caeur, 12mo. Amst., 1741.—J. Senac, Trait* de la Structure de Caeur, et de ses Maladies, 2 tomes, 4to. Paris, 1749.— J. F. Meckel, Sur les Mai. du Cceur, in Mem. de l'Acad. de Berlin, 4to. Berl., 1759.— A. Matanus, Do Aneurismaticis Priecordiorum Morbis, 4to. Liburn., 1761. —H. Mason, Lectures upon the Heart, &c, 8vo. Read., 1763.—C. F. Juncker, Diss. Cordis Morb. proprios in Tabu- la exhibens, 4to. Halae, 1763.—A. le Camus, Maladies du District du Cceur, 12mo. Paris, 1772.—Spaventi. Diss, de Frequentioribus Cordis Morbis, 4to. Vien., 1772.—/. J. Neifeld, Ratio Medendi Morbns Circuli Sanguinei, 8vo. Breslau, 1773.—F. Petraglia, De Cordis Affeclionibus Syn- tagma, 8vo. Romaj, 1778.—C. F. Michaclis, Aneurism. Cord. Disq., in Dotting, Tract., vol. i.—J. G. Walther, in Nouv. Mem. de l'Acad. des Sc. a Berlin, 4to. Berlin, 1785. —Odier, Manuel de Medecine Pratique, p. 151, 336.—J. C. Reil, Dissert. Anal, ad Hist. Cordis Pathologicam, 4to. Halae, 1790.—A. Portal, Anatomie Medicale, t. iii., 8vo. Paris, 1804.—Cabirau-Cabannes, Apercu sur quelques Af- fect. Organiques du Caeur, &c, 8vo. Paris, 1805.—J. .V. Corvisart, Essai sur les Maladies du Cceur et des gros Vais- ieaux, 8vo. Paris, 1806, 3d ed., 1818, translated by Heb, 8vo. Lond., 1613.—M. A. Pert*, Essai sur la Medecine du Caeur, 8vo. Lyon., 1806.—Contelle, Essais sur quelques Causes de Mai. du Ca?ur, 8vo. Paris, 1808.—A. Burns, Observations on some of the most frequent Diseases of the Heart, 8vo. Edin., 1809.—P. /. Pelletan,in Clinique Chi- rurg., Svo. Paris, 1810. — .4. Testa, Delle Malattie del Cuore, 3 vols., 8vo. Bologn., 1811.—/. Gates, On Diseases of the Heart, 8vo. Philadelphia, 1812.—Le Gallois et Afe- rat, in Diet, des Sciences Med., t. v., 8vo. Paris, 1813.— F. L. Kreysig, Die Krankheiten des Herzens, &c, 4 bde., Svo. Berlin, 1814-17.—L. P. Lukomski, De Statu Militum Morbis Cordis gignendis Idonea. Wien., 1815. — /. H. James, in Trans, of Med. and Chirurg. Society, vol. viii., p. 434.—/. C. Wctzler, Ueber Krankh. des Herzens, in Bey- trage zur Medicin, b. i.—H. Reeder, A Pract. Treatise on Dis. of the Heart, Svo. Lond., 1821 .—Beclard et Chomel, Diet, de Med., t. v., 8vo. Paris, 1822. —Af. Fodere, in Journ. Complement, du Diet, des Sc. Med., t. xxxii. et xxxiv.; et J. Johnson's Med. Chirurg. Rev., vol. ii., p. 417. —Hufeland, in Nouv. Journ. de Med., t. xiv., p. 204.—J. Johnson, in Trans, of Med. and Chirurg. Soc, vol. xiii., p. 212 ; and Med..-Chirurg. Rev., Nos. 38, 39, No. 43, p. 231. —/. Abercrombie, Trans, of Med.-Chirurg. Soc. of Edin., vol. i., part i. Edin., 1824.— Wishart, in Ibid., vol. ui., p. 195.—JR. J. Bertin, Traite des Maladies du Caeur, 8vo. Paris, 1824.—//. Burger, Diagnost. der Hertzkrankheiten, 8vo. Berlin, lb'25.—C. H. Parry, Collect, from his unpubl. Writings, »•> P- 62 (Draught* Ann. viii., Mediate, ur ia Nature ioin f,ment de P'usieurs Maladies, t. iv., p. 173. Paris, ' -Merat, in Diet, des Sciences Medicales, t. xxxix., 370; 8vo. -1 ii., pars ii.i secT ^ »™.-rtToZ%%&*2fi& Med vol. ,v.( p. 232.-/. Bouillaud, Trait* ClinuauVsu les Mai. du Cceur, t. ii., p. 486. *-»mque sur in. Painful or Neuralgic Affections of thk of cold water for palp.).-Brugnatelli, Giornale, Am . i., n. 8 (Nitre with tonics).—Laennec, Auscult. M . ik, p 227. Paris, 1829.-.1. Portal, Mem. sur la ! loin wment de P,us'eurs Maladies, t. iv., p 173. n iV rr"!\in r>,ict;.des Scie»ces Medicales, t. x* p. U4.—J. Johnson's Med.-Chirurg. Rev. vol iv n ' »ol. v. p. 217.-Andral, Diet, de Medecine tx'vf'" Pans, 1826.-/. Frank, Praxeos Medic* UniveVsi Prace HEART—Neuralgic Affections or—Diagnosis—Treatment. 207 Heart.—Classif. II. Class, I. Order (Au- thor). 53. Charact.—Sudden attacks of anguishing pain in the cardiac region, returning at intervals; the actions and sounds of the heart and respira- tion being but little affected. 54. In the same category with the disorders just considered may be arranged those painful affections which have been considered as neu- ralgia of the heart. They might be viewed as modifications of Angina Pectoris, and arran- ged with it, if there were sufficient evidence to prove that they are actually seated in the nerves of this organ. But, as Bouillaud ob- serves, although the functions of the heart may be disordered in connexion with them, the nerves of the adjoining viscera and structures are probably as much affected as those of the heart. A case of this complaint has been de- scribed by Dr. Elliotson, and is altogether similar to some that have occurred in my prac- tice. Indeed, neuralgia of the cardiac and com- municating nerves, or affections intermediate between it and angina pectoris, are by no means rare. A case of this affection came under my care in 1821 ; and since then I have treated six similar cases : two in females between the ages of twenty-five and thirty, three in gen- tlemen somewhat upward of fifty, and a sixth in a physician of about thirty-five years of age. 55. A. Diagnosis.—According to the phenom- ena observed in these cases, this complaint is characterized as follows : A most acute, lancinating, and anguishing pain is felt to the left of the sternum, darting through the region of the heart, often from under the left nipple backward to the spine or left shoulder-blade. Sometimes it is confined to this organ ; and occasionally it extends to the left brachial plex^ us, and up the left side of the neck, or left arm, or to other parts in the vicinity of the heart. This complaint is generally intermittent, or re- mittent, or even periodic in its character ; the paroxysms are sudden or almost instantaneous in their accession, and their duration is very variable. They leave the patient intervals of comparative ease, when the pain is dull or aching, and confined to the region of the heart. They return at various intervals, sometimes once or twice in the day, and occasionally not for several days. They are attended by the utmost agony and distress. The actions of the heart are somewhat accelerated during the fit, and sometimes more or less irregular or tur- bulent ; but they are also in other instances nearly natural. There is no morbid sound, be- yond a slight bellows sound in a few cases, heard on auscultation, and the breathing is tranquil. The paroxysm may take place at any period, and when the patient is perfectly quiet, mentally and physically, and without the occurrence of any cause sufficient to account for the seizure. This affection does not ap- pear to be aggravated, or its attack to be fa- voured, by exercise, or by motion or position ; but, on the contrary, it seems to be benefited by gentle exercise in the open air. Debility and loss of flesh generally are induced by the excessive suffering ; but the appetite is not materially impaired. The powers of digestion are, however, weakened, and the bowels are more or less sluggish. This complaint is gen- erally of long duration. The shortest period in my cases was six or seven months; and in one, where the intervals between the attacks were very considerable, it was as many years. 56. B. Causes.—Of the six cases above re- ferred to, two were females. They were both unmarried; but the catamenia were perfectly regular; and neither of them had ever com- plained of any hysterical symptom, or had ex- perienced pain in the spine. Of the four males, the two most advanced in life had formerly had gout; and in one of them, who was under the care of Dr. Roots and myself, the cardiac neuralgia was induced by grief. The other two were medical practitioners: one of them had been engaged in a laborious practice in the country; the other had experienced family contrarieties and disappointments, and was endowed with the utmost susceptibility and ir- ritability. The recurrence of the attack seems to be favoured by cold, especially by cold east winds; and there is reason to believe that malaria is concerned in causing it. In a vio- lent case, recorded by M. Andral, no trace of organic lesion was observed on dissection. 57. C. Treatment — The means of cure in this affection are not materially different from those advised for Angina Pectoris, to which it is an intimately allied affection. As in that complaint, so in this, and in Palpitations (6 50), the indications are, 1st. To shorten the attack; 2d. To prevent the recurrence of it. — a. The remedies I have found most efficacious in fulfilling the first intention are, camphor in large doses with opium, or acetate of morphia ; the hydrocyanic acid, with camphor, or ammo- nia^ or other stimulating antispasmodics, or warm carminatives and tonics; a full dose of calomel, with camphor, capsicum, and opium, or the hydrochlorate of morphia ; the prepara- tions of colchicum conjoined with ammonia, camphor, the carbonate of soda, &c.; a mus- tard poultice applied as hot as it can be endured over the epigastric region ; and a plaster, con- sisting chiefly of extract of belladonna and cam- phor, placed over the praecordia. I have tried various narcotics besides these just named ; but less certain advantage has been derived from them than from those. The extract or tincture of aconilum, or of stramonium; or the powdered root or leaves, or the extract of bel- ladonna are, however, often of service, espe- cially when the medicines just mentioned have failed. 58. b. The second intention has been best answered by purgatives, by mild and chiefly farinaceous food, by abstinence from stimula- ting liquors, by tonics conjoined with absorbents and stimulants, and by external drains or deriv- atives long persisted in. The sesqui-oxyde of iron, in large doses, the bowels being kept freely open, has been sometimes of service. Dr. Elliotson found benefit from it in one in- stance ; but it has failed in other cases; and equal advantage has been derived from a com- bination of sulphate of quinine, camphor, and as much purified extract of aloes as acted freely on the bowels. In one of the female cases al- luded to, the nitrate of silver, given with a nar- cotic extract, was extremely serviceable. In the other, pills, containing as much croton oil as procured at least three or four stools daily, [ were regularly continued for a considerable I time, and a large issue was kept long dis- 208 HEART AND PERICARDIUM—Inflammations or. charging. Complete recovery took place in both instances. In one case, change of air, travelling, attention to diet, and issues in the side effected a cure, the patient being a physi- cian of great learning and extensive medical knowledge. In another case, the symptoms were aggravated by depressants and abstinence; and recovery took place during a recourse to tomrs conjoined with anodynes; to a generous and light diet, the patient being allowed from four to six glasses of old wine, or even more, daily; and to change of air, and the amuse- ments and distractions of watering-places. In one instance, great benefit appeared to follow the persevering use of croton oil as an external derivative ; and eruption over the epigastrium having been kept long out by its means. In the case of a medical practitioner from Devon- shire, who very recently consulted me, all these, as well as other means, altogether fail- ed. At last, an ointment containing aconitine was directed to be rubbed over the sternum; but of the effect of this I am yet ignorant. In another instance, no benefit followed the appli- cation of an ointment containing veratria. 59. Besides the substances already mention- ed, I have tried many others. Digitalis has been of no service. Some benefit, however, has followed the internal use of turpentine giv- en in drachm doses until it affected the urinary organs; and from the iodide of potassium, or iodide of iron, conjoined with narcotics : I tried creasote in one case without any advantage. I think that the disease may wear itself out, in some instances, without being much relieved by medicine, if attention be paid to diet and regimen, and to the state of the stomach and bowels, and if the energies of life be supported or promoted by suitable means. At present, I am attending a gentleman who has been for many years afflicted with this complaint, the paroxysms of which, however, come on after considerable intervals. He was formerly sub- ject to gout, which I have attempted to excite in the lower extremities without avail. He has consulted many physicians in London and on the Continent, and has even given homoe- opathy a lengthened trial. On no occasion had he experienced any material relief. I was re- quested to see him six or seven years ago, and have since continued to prescribe for him oc- casionally, excepting while he had recourse to means prescribed by Dr. Turnbull, from which he derived no benefit. The attacks are short- ened and relieved by the medicines mentioned above (y 57); but they still recur, although not so frequently as before ; attention to diet, an open state of the bowels, and gentle exercise in the open air, being found most efficacious in deferring their visitations. [Cardialgia will often be promptly relieved by the administration of a gentle emetic, con- sisting of a few grains of the sulphate of zinc and ipecacuanha, given in a single dose. We have known a patient labouring under this af- fection, with most distressing palpitations, ef- fectually relieved by this combination, even be- fore vomiting took place. Immersing the feet and hands in hot water, containing salt or mus- tard, will frequently tend to abate the pain, and cut short the paroxysm. Mental tranquillity is cf the first importance in warding off attacks of this disease. Pure air, a regulated diet, and gentle exercise, are also essential to recov- *'J , „ »i.,i r«says on Fever, BtBLIOO. and *■«»■-■* *^&«rt&c* 8vo. Lond. Inflam. Rheumatism Dis. *')£ J „"Neuralgic Di. diseases. 1828 ,P-™\-T-P-Tftfr*)Wotson, Opus eft., p. &c, 8vo. Lond , 829, p. « .a Johnaon;s Med. 33 ; and in Lancet, 1830-31, voui., . m Qnd and Chirurg. Rev. vol. x p. £ t|<,, 3i4__A xrv., p. 33(1. - ^^'p^X, and Nervous Affections, Ac, internally and externally)- IV. Inflammations of the Heart and Peri- cardium.-Syn. Carditis, Auct. ; C. Span, tonea, Sauvages; Cauma Carditis, Young; Empresma Carditis, Good. Classif.—1. Class, Febrile Diseases; 2. Order, Inflammations (Cullen). 3. Class, Diseases of the Sanguineous Function; 2. Order, Inflammations (Good). III. Class, I. Order (Author, in Preface). 60. Defin.—Continued pain or anxiety in the region of the heart, palpitations, a tendency to syn- cope or faintness, dyspnoea, acceleration and irreg- ularity of the pulse, with symptomatic inflammato- ry fever. 61. Inflammations of the heart were first de- scribed by Rondelet, and afterward by Salius Diversus and Forestus. More recently, they have received attention from many systematic writers ; but, until the appearance of the works of Burns, Corvisart, Kreysig, Testa, Hil- denbrand, and Laennec, their pathology and treatment were deficient in precision and accu- racy. J. P. Frank first directed attention to inflammation of the endocardium, or internal membrane of the heart, especially in connexion with inflammation of the internal surface of the blood-vessels. Hildenbrand considered that inflammation might affect either the peri- cardium reflected over the heart, or the sub- stance of the organ, or the membrane covering the valves and internal surface of the compartments; but that it was seldom confined to any one of these situations. Of still more recent writers, some have entirely overlooked inflammation of the internal membrane, while others have very properly insisted upon its frequency and impor- tance, in its various grades, and in respect of its diversified results. It is somewhat surpri- sing that Laennec and Hope should have neg- lected this form of carditis, after attention had been directed to it by Frank, Hildenbrand, Lobstein, and Kreysig. M. Bouillaud has considered it much more fully than any former writer ; but he is mistaken in thinking that he is the earliest writer upon it; for, in addition to the names just mentioned, Bertin, Barbier, Littre, P. M. Latham, Elliotson, and Wat- son, wrote upon it before the appearance of his excellent work. Hildenbrand expressly refers the lesions of the internal surface of the organ, and of the valves, to inflammation ; these le- sions having a more or less strict reference to the intensity and duration of the inflammatory action. (Institutiones, t. iii., p. 263.) Since 1824 I have described internal carditis in my lectures, and have pointed out the alterations of structure induced by it; and, in treating of inflammations and organic changes of the heart, t have always described it first, considering it as one of the most frequent forms of carditis, and, m its various grades, as the cause of most ol the alterations observed in the structure of the organ. On the present occasion, I shall HEART—Inflammation of the Endocardium. 209 consider, first, internal carditis, or endocardi- tis ; secondly, external carditis, or pericarditis ; and, thirdly, carditis proper, or muscular cardi- tis, with the lesions which are more immedi- ately linduced hy them, individually and con- jointly. Although it is necessary thus separ- ately to discuss these diseases, inasmuch as each may exist fn a primary and distinct form, yet, as this is comparatively rare, I shall also consider their associations with each other, and with other maladies. i. Inflammation of the Endocardium.—Syn. Carditis Interna, Author ; Endocarditis, Bar- bier, Littre, Bouillaud; Inflammatio Super- ficici interna Cordis, Hildenbrand; Internal Carditis, Inflam. of the Internal Membrane of the Heart. 62. Charact.—Oppression and anxiety at the Pracordia, with frequent faintnesses ; dyspnoea; increased action, remarkable acceleration, and ir- regularity of the heart; and morbid sounds heard on auscultation; the pulse being weak, small, ir- regular, or indistinct. 63. A. History.—The serous membrane li- ning the cavities and valves of the heart is oc- casionally found intensely red in one or hoth sides of the organ. This change has even ex- tended to the aorta and pulmonary artery. Since it was first noticed by J. P. Frank, it has attracted much attention. The redness can- not be removed by washing, and hardly even by maceration. It has been ascribed to the im- bibition of the colouring matter of the blood ; but frequently no blood is found in contact with the coloured part. It evidently does not arise from congestion of the cavities of the heart previously to death, because it has been observ- ed where no such occurrence has taken place farther than is always attendant upon dissolu- tion. It certainly is not owing to decomposi- tion, either incipient or advanced, as no signs of this change have been detected in connexion with it. That it is essentially dependant upon inflammation is shown by its being very often attended, 1st, by slight thickening and soften- ing of the membrane itself; 2d, by that change in the connecting cellular tissue which permits this membrane to be more readily detached from the adjoining textures than in health ; and 3d, by the presence of the usual products of in- flammation affecting serous surfaces. The circumstance of these products being frequent- ly not found on the reddened or injected inter- nal surface of this organ is readily explained by the fact that the lymph, the usual product of inflammation of serous membranes, being effused in a fluid state, is commonly carried away by the current of the circulation before it can coagulate on the inflamed surface. Be- sides, internal carditis very often takes place in connexion with that state of constitutional power which John Hunter very ably proved to be incapable of forming coagulable lymph. But this disease is not unfrequently met with in a form which does not admit of doubt; and to that, more especially, I have now to direct attention ; its more disputed states, also, com- ing under consideration in the sequel. 64. Kreysig (Ueber die Krankh. des Herzens, 2d th., p. 125) was the first to give a detailed description of internal carditis, but M. Bouillaud has very recently entered upon the subject much more fully than any of his predecessors. 27 The frequency of the disease, especially in connexion with articular rheumatism, will en- able the practitioner to investigate its nature and the phenomena it occasions in relation to the structural lesions which have been produ- ced. This has been ably done by M. Bouil- laud, who, although he is not the first, is cer- tainly the best writer on the subject. Since 1820 my attention has been directed to inter- nal carditis, in consequence of having then met with a remarkable case of it. (See Lond. Med. Repos., vol, xv., p. 26, 1821.) In 1821 I was requested to see another case, which termina- ted fatally much more rapidly than the former. To both these I was called in consultation with other practitioners ; and in both, as well as in a third that occurred the following year, post- mortem examinations were made. I have since frequently observed this form of carditis ; and my experience warrants the assertion that a large proportion of the more obscure—or what were formerly considered the more obscure— affections of children, particularly those occur- ring in connexion with affections of the joints, are either internal carditis, or this complaint associated with pericarditis. 65. «. The alterations of the internal membrane of the heart, caused by inflammation of it, vary with the intensity and duration of the morbid action, (a) At an early stage, 1. Redness is one of the most common appearances. It varies from a scarlet tint to a reddish brown or violet hue, and may be limited to the valves, or extended to all the cavities, or even to the large vessels. The inflammatory nature of this redness has been disputed; but when it is at- tended by one or more of the following lesions, its nature then admits of no doubt. 2. Thick- ening of the internal membrane, or endocardi- um, is a common attendant on inflammatory redness, when it has continued a few days, es- pecially of that part reflected over the valves. 3. Softening also sometimes is observed in this stage, but most frequently in the next; this change generally extending to the connecting cellular tissue. 4. Ulceration is met with only in rare cases at this period ; but instances of its occurrence are recorded by Bouillaud and others. 5. A puriform or albuminous exudation also takes place; but rarely in such a manner as will admit of its demonstration. So great is the force and rapidity of the current of blood through the compartments of the heart, and so rapid the motions of their parietes, that the prod- ucts of inflammation of their internal surface are swept away and mixed in the circulating mass. Nevertheless, portions of these secre- tions are occasionally found after acute endo- carditis. Puriform matter has sometimes been seen enclosed in a coagulum, or concealed in the meshes of the muscular columns. Coagu- lated or albuminous lymph has been found in similar situations; but more frequently adhe- rent to the valves, or to their margins, or ten- dons. Occasionally it appears like granulations on these parts. 6. Gangrene has been sup- posed hardly ever to occur from carditis ; but M. Bouillaud considers that the appearances observed in some of his cases warrant the in- ference that it may take place, although rarely, in consequence of acute endocarditis ; and I believe that it will supervene only when inter- nal carditis attacks a cachectic habit of body, 210 HEART—Inflammation of the Endocardium. or when there is a septic tendency induced in the system by a depraved state of the circula- ting fluids, and by impaired vital power. 7. The blood is more or less affected by acute en- docarditis. When the disease attacks a per- son whose blood has not been already material- ly vitiated, or whose soft solids have not been materially affected, then it occasions a greater or less disposition of this fluid to coagulate, and gives rise to fibrinous concretions resembling those found in the blood-vessels after inflam- mations of their internal surfaces. These con- cretions, when formed in the heart, are colour- less, elastic, glutinous, and adherent to the in- ternal surfaces of the cavities, or interlaced between the fleshy columns and tendons of the valves, and resemble the buffy coat of the blood. They are manifestly produced by the lymph exuded by the inflamed internal surface of the organ, which, towards the close of life, forms the nucleus around which the fibrinous portions of the blood collect and concrete. If, however, in- ternal carditis occurs when the blood is already vitiated, and vital power is either much im- paired or deteriorated, the fluid effused from the inflamed part will be incapable of coagula- ting itself, or of causing the coagulation of the blood—will be of a watery or sanious kind—and will instantly mix with the mass of blood, and farther vitiate it; death soon taking place, with all the symptoms of adynamic or putro-adynam- ic fever. 66. b. The second stage, or the period inter- vening between the fifteenth and thirtieth day of the disease, is attended by other alterations. 1. The inflamed membrane is more thickened, this change often extending to the connecting cellular tissue, and even to the fibrous textures, especially of the valves. 2. The albuminous or fibrous exudations now pass from the amor- phous to the organized state, and assume the appearances of excrescences, vegetations, granu- lations, cellulo-fibrinous adhesions, and of sero- albuminous false membranes. M. Bouillaud observes that the excrescences or granulations are most frequent on the valves, especially their free edges. He divides them into the globular or albuminous, and the warty. The former are soft, of a whitish, yellowish, or reddish hue, and easily detached, and originate in the or- ganization of adherent coagulable lymph, as ob- served to take place on the surface of other serous membranes. The warty excrescences are of a cartilaginous consistency and firmly at- tached. They are either distinct, or aggregated into groups presenting a cauliflower appear- ance, and vary in size from that of a millet- seed to that of a pea. Both these kinds of vege- tations seldom exist alone, either on the valves r»r on the internal surface of the cavities ; but are commonly attended by fibro-cartilaginous or calcareous induration of the valves ; and when they are large, numerous, or aggregated, they necessarily occasion narrowing of the or- ifices, and an impediment to the action of the valves. 3. Adhesions of the opposed surfaces of the internal membrane were first described by M. Bouillaud, who has adduced six cases in which he met with them. They are, howev- er, rarely observed ; for the force of the blood's circulation, and the movement of the parietes of the cavities and of the valves, prevent their formation, excepting at those places where „o=t n« between the these obstacles are the least-a a *nd tne op- less moveable parts of the; valves ancMhe j. posite surfaces of the .^'Recirculation, hesions disturb the regularity ot ">e o , by preventing the if^^TaZ^n sing the orifices. Ano\h? *^00„ thP nrmositfl is iometimes observed between the opposite is s^et™f« ""j;'7„Certain cases of nar- margins of the, ralves m c mentioried heTle1Z0?P*"d false membranes are also occasionallyiund covering a_ greater or less extent of the internal surface of the heart; and M. Bouillaud states that he has seen these membranes consist of several supenm- posed layers. In place of these, small colour- less patches, of from four to six lines in diam- eter, sometimes form on the endocardium, and may be removed, leaving it more opaque than natural. In many cases, the supposed thick- ening of this tissue has been entirely owing to organized false membranes ; but as often the endocardium is itself thickened, opaque, and its free surface unequal, somewhat wrinkled, and villous ; this change extending, as stated above, to the connecting cellular tissue. 67. c. In the third or chronic stage of internal carditis, the cellulo-fibrous, the fibrous or fibro- cartilaginous alterations or formations observ- ed in the former stage are converted into the cartilaginous, osseous, or calcareous state. 1. These latter productions sometimes consist of circumscribed points—occasionally of thin patches of the size of the finger-nail, or even larger—or more rarely of rounded masses. The valves may be almost entirely changed into a cartilaginous or osseous structure ; but the fibrous zone of the orifices, and the points of the valves, most frequently undergo this al- teration. Between these morbid patches or in- crustations, the spaces are either natural or simply thickened. The osseous formations often reach a very considerable size, and assume very irregular shapes, and sometimes even pen- etrate deeply into the substance of the heart. 2. The cartilaginous or osseous valves are variously altered. As long as these changes consist of simple points or laminae of small ex- tent, the thickened and more rigid valves may still perform their offices; but when these al- terations become more extensive and complete, the valves can no longer fulfil their functions. In this stage they present various lesions, as to form. Sometimes, as shown by Laennec, Ber- ttn, and others, their margins, especially those of the aortic valves, are folded in, so as to give an inverted appearance ; and occasionally they are folded back, forming what has been descri- bed by Dr. Hodgkin and others under the name of retroversion. They may also be too short, or too unyielding, or too small, to close their re- spective orifices ; and the orifices, on the other hand, may be too large for the valves. In either case these latter will be insufficient fox their purposes. The diseased valves are occa- sionally perforated, or torn or ruptured in dif- ferent directions ; and those of the aorta have been found so completely torn as to be nearly detached. Sometimes one set of valves only is affected ; but more frequently, when one set is very severely altered, another is opaque, „™ enfd'~r otherwise changed in some de- f™ .uContractwn of the heart's orifices is among the most common and most serious HEART—Inflammation of the Endocardium. 211 consequences of the changes now being con- sidered. It may be so extreme as not to admit the point of the little finger, or even a quill. The thickened and hardened valves sometimes adhere at their opposite margins, leaving a per- manent opening of a roundish, oval, crescent. or slit-like form ; which, in the case of the au- riculo-ventricular valve, resembles the glottis or the os tincae, owing to the thickening of the margins, and projection into the cavity of the ventricle. The thickening and induration oc- casionally extend to the tendons, or even to the muscular columns. The semilunar valves also often stand firm and convex, or rigid. These changes have been well described by Mr. Adams and M. Bouillaud. Dr. Elliotson remarks that the valves of the pulmonary artery sometimes grow up so as to leave only a small round or triangular opening in their middle. 68. d. The inflammatory origin of the changes now described has been doubted by several pa- thologists, and even by Laennec ; but it has been advocated by Frank, Kreysig, Hilden- brand, Andral, Elliotson, Bouillaud, La- tham, Watson, and others. Osseous forma- tions in the heart have been supposed to occur only in advanced age. Bouillaud states, that of 44 cases, 33 occured in persons under fifty, and 19 out of these were observed in persons under thirty: one being only ten years, another seven, and a third ten months. I have met with this formation in two children, one of sev- en, the other of ten years; and in both the symptoms and associated lesions observed on dissection were obviously inflammatory. In- deed, the matter is put beyond dispute. The narrowing of the orifices of the heart by chronic inflammation is, as remarked by a recent writer, very analogous to what takes place in other organs from this cause—as in the urethra, and lachrymal and biliary ducts, the pylorus, the rectum, &c.; and the hypertrophy of the heart which succeeds, may be compared to the thick- ening of the muscular coats of the bladder, stomach, and other hollow viscera, arising in such circumstances from the difficulty of expel- ling their contents, owing to the obstruction. When inflammation attacks the internal surface of the heart, the parts of it about the boundaries of the cavities, and near the orifices, or cover- ing them and the valves, are most liable to be affected, as commonly observed about the boundaries of other cavities and canals. Bi- chat had noticed the greater frequency of the lesions just mentioned in the left than in the right side of the heart. The fact is undoubted. M. Bertin considered that inflammation and its consequences are more likely to be occa- sioned and maintained by the exciting proper- ties of arterial blood, than by the inert venous blood returned to the right side of the heart. This, however, is not sufficient to explain the circumstance ; for inflammations are more fre- quent in veins than in arteries. 69. B. Symptoms of Internal Carditis.—a. In the first or acute stage, actual pain is seldom felt, unless the disease be associated with per- icarditis or with pleuritis ; but uneasiness, op- pression, or anxiety in the praecordia, with faint- ness, is always complained of. The physical signs require the closest attention. 1. The praecordia region, in simple endocarditis, is shaken by the violence of the heart's action, ] the hand being forcibly resisted by the impulse when applied over this region. The pulsations are felt over a greater extent than natural, owing to the turgescence of the organ in an in- flamed state; and a vibratory tremour, more or less marked, is also sometimes felt. 2. Per- cussion furnishes a dull sound over a greater extent of surface than natural, from four to nine or twelve square inches. But, in order to distinguish this sound from that attending ef- fusion into the pericardium, it is necessary to observe that it coexists with a superficial, visible, and sensible pulsation of the heart; the beat being profound, and hardly visible or sen- sible in cases of pericarditis with effusion. 3. Auscultation detects a bellows sound, which masks the two normal sounds, or one of them only. This sound is the louder, the stronger the action of the heart; and is also rougher, the greater the swelling of the valves, and the more abundant or concrete the exudation of lymph from the inflamed surface. Sometimes when the palpitations are violent, a metallic sound isochronous with the systole of the ven- tricle is also heard. 4. The force of the heart's contractions is changed both to the eye and to the touch, and the frequency equally affected, the pulse rising sometimes as high as 140 and 160, or even higher, in a minute, and becoming irregular, unequal, or intermittent. 5. Animal heat is generally also increased, but not usually in proportion to the augmentation of the circu- lation. The arterial pulsations represent only the frequency, but not the strength of the heart's action in this disease; for, while the contrac- tions of the. heart are energetic, the pulse is generally small, soft, and indistinct. This is owing to the obstacle opposed to the circulation by the swelling of the valves or orifices, or both ; or by the fibrinous exudations formed around them ; a smaller column of blood being thrown into the arterial trunks; hence, prob- ably, arise the pallor, anxiety, jactitation, faint- ness, leipothymia, want of consciousness, &c, frequently also observed. 70. In general, the venous circulation is not materially disturbed in this stage of internal carditis; but when the above obstacles to the circulation through the orifices become consid- erable, dyspnoea, a bloated or livid appearance of the face, slight oedema of the extremities, and pulmonary, or even cerebral congestion often supervene. In this case, the patient ex- periences the most distressing oppression, can- not lie down in bed, is watchful, restless, and subject to a constant jactitation. In the simple form of endocarditis, delirium seldom occurs ; but temporary wandering of the mind, and sud- den terror or unconsciousness, are occasionally present when the dyspnoea is extreme. The digestive functions, the secretions and excre- tions, are also more or less impaired; and in the more extreme states, cold sweats often break out. 71. The above symptoms appertain especial- ly to the acute form of endocarditis, particularly when it is general. But when it is partial, or sub-acute, or chronic, the symptoms are not so prominently grouped ; and it is, consequently, recognised with greater difficulty. An atten- tive observer, however, will seldom mistake it for any other disease, excepting pericarditis, with which it is very liable to be confounded, 212 HEART—Inflammation of the Endocardium. even by the most experienced. But the error is not material; for both diseases very often coexist, and the means of cure are the same in each. When pericarditis is attended by ef- fusion, then it is readily distinguished from endocarditis by the circumstance mentioned above (y 69); but when it gives rise merely to a pseudo-membranous exudation, a diagnosis is formed between them with very great diffi- culty ; the sounds, however, in this state of pericarditis will be a tolerable guide to a cor- rect inference. 72. b. The symptoms of the second and third, or chronic stages of internal carditis have refer- ence chiefly to the structural changes that have been induced. The disease may have termi- nated in resolution before advancing into these changes, the foregoing symptoms having disap- peared. But when it has been mistaken, or neglected, or imperfectly treated, it passes into these sub-acute and chronic states or stages; the inflammatory action gradually subsiding as to intensity, or passing into that slow or chronic form observed to produce similar changes in serous tissues to those which have been descri- bed (!) 66, 67). Of all the organic lesions con- sequent upon endocarditis, the different forms of induration of the valves and contraction of the heart's orifices are the most permanent; often continuing after the inflammatory action which produced them has disappeared, whether this action has been acute, sub-acute, or chronic. 73. c. The symptoms of induration of the valves and narrowing of the orifices are gener- ally such as lead to the detection of these chan- ges, as well as of the consecutive hypertrophy and dilatation. 1. Inspection shows merely the extent, force, and rhythm of the pulsations. 2. The hand applied on the prcecordial region discov- ers a vibratory or purring tremour, with irregu- larity, inequality, or intermissions of the heart's action, or a treble or quadruple movement, as well as the increased force and extent of the contractions. 3. Percussion furnishes a dull sound to a greater extent than in health. 4. Auscultation detects, during the contractions of the heart, a morbid sound, which is blowing, filing, grating, rasping, or sawing, as to its char- acter, according to the resistance furnished by the diseased valves, to the degree of contrac- tion of the orifices, to the capacity of the cavi- ties, and to the strength of their parietes. Each of these sounds may be either double or single : the former completely masking or replacing both the natural sounds; the latter, only one of them. The morbid sound varies in duration and intensity: it is sometimes sudden, short, abrupt, and jerk-like ; in others it is slow, pro- longed, or drawn out. It is occasionally so loud as to be heard even at a short distance from the chest; and, in some cases, it is so slight as to be detected with difficulty. In a few instances of induration of the valves, the bellows sound assumes a sibilous character. 5. Pain seldom attends the above lesion ; but the patient complains of weight, or of uneasiness or embarrassment at the praecordia ; of palpi- tations, of sinking, or of faintness. The palpi- tations are excited by the least exertion or mental emotion, and are characterized by the increased force, and the remarkable frequency of the pulsations, which may reach 160 beats or upward in the minute. 74. When, therefore, either of the morfjd sounds just mentioned is present f™?™ cordial region, with a vibratory or P"J™8 °£ mour, palpitations, an irregular• umuItuous o intermttent action of the ^eaT,\''-n nf th highest degree probable that induration of the valves, andg *^^Ti£*toL*5 orifices, exist, particularly u ««= » some months' or years' duration Phis infer- ence amounts to certainty, when, with the above local signs, the following general or sym- pathetic phenomena are present, especially a small, weak, or vibratory pulse, which contrasts remarkably with the energetic actions of the heart; dilatation of the superficial veins, par- ticularly of those near the heart, as the jugu- lars, &c. ; sallowness or lividity of the counte- nance ; symptoms of congestion of the lungs, brain, liver, and mucous surfaces; passive haem- orrhages from the lungs and mucous mem- branes ; dyspnoea, shortness of breath, or sense of oppression or stuffing in the chest, increased on slight exertion ; effusions of fluid into serous cavities, or into cellular parts, &c.; and cerebral derangement, as restlessness, watchfulness, frightful dreams, jactitation, laborious breath- ing, &c. Pulsations of the jugular veins, syn- chronous with the pulse, are observed when a reflux of a portion of the blood takes place from* the right auricle during the contraction of the right ventricle, owing to insufficiency of the tricuspid valve, either from alterations in itself, or from dilatation of the auriculo-ventricular orifice. 75. d. The diagnostic symptoms of lesions of the different valves, and of narrowing of the differ- ent orifices of the heart, have been stated with more confidence than truth by some who have made the stethoscope an instrument of parade and charlatanry. In answer to the question, Can this diagnosis be established? M. Bouil- laud justly answers that it is more curious than useful. There is no doubt of the morbid sound being loudest at a point the nearest to the diseased orifice ; and upon this much of the diagnostic evidence rests. But farther proof is requisite. When the pulse is examin- ed in connexion with the action of the heart, it is generally more irregular, unequal, intermit- tent, and smaller, in narrowing of the aortic ori- fice, than in that of the left auriculo-ventricular orifice ; and the vibratory tremour of the pulse in the large arteries, first noticed by Corvisart, is most remarkable in the former case. The maximum also of the intensity of the purring tremour in the praecord wl region, as well as the maximum intensity of the morbid sound, cor- responds with the contracted orifice. M. Bou- illaud considers that synchronism of the mor- bid sound with the ventricular systole or dias- tole signifies nothing ; but in this he is incor- rect, his opinion being the consequence of his views respecting the source of the natural sounds of the heart. Narrowing of the orifices rll ell ,side 1S infinitely less frequent than that of the left orifices ; and is indicated by the correspondence of the maximum of the morbid s S»IT and°f the purring tremour with the anrt nT °t hGSr ?nfi,ces' and *>? the distention !Sj5SSSn ge veins' esPeciall^of 76 Dr. Williams (see Medical Gazette vol xxvi., p. 601) has divided structural Sns of HEART—Inflammation of the Endocardium. 213 the valves and orifices of the heart into two kinds, the obstructive and regurgitant; accord- ing as they impede the current of blood in its proper direction, or permit its reflux. But some alterations are both obstructive and regurgi- tant, as they impair both the opening and the closing of the valves.—a. Obstruction at the aortic orifice is attended by a bellows sound, which is superficial, and occasionally sibilous, about the middle or top of the sternum, or about the cartilages of the fifth and sixth left ribs, and which masks or replaces the first nat- ural sound, and occasionally extends to the carotids. The second natural sound is either weak or indistinct, when the aortic valves are much diseased, the pulse being remarkably small and weak. Obstruction of this orifice generally causes enlargement of the heart. When lesions of the aortic valves render them insufficient, and occasion a reflux current into the ventricle, a short whiffing sound replaces the second natural sound at the middle of the sternum, the second natural sound in the pul- monary valves still remaining audible to the right of the sternum. Insufficiency of the aortic valves gives rise to dilatation, with hy- pertrophy of the left ventricle. 77. b. Obstruction at the left auriculo-ventricular orifice, or obstructive disease of the mitral valve, may be attended by a morbid sound or murmur at the time of the second natural sound, owing to the resistance to the current during the re- filling of the ventricle ; the morbid sound, how- ever, not replacing the second normal sound, as the action of the semilunar valves may still be perfect, but merely attending it, or masking it, when loud. This lesion is accompanied by a small, but strong or hard pulse. It usually occasions hypertrophy of the left ventricle, sometimes with diminution of its cavity, and dilatation of the left auricle. Insufficiency of the mitral valves produces a morbid sound at the time of the first natural sound, that is most distinct at the left margin of the sternum, be- tween the third or fourth ribs, or rather more to the left, or as far as the left nipple, or a little below it; and that does not extend to the ar- teries. The pulse is always irregular or inter- mittent This lesion commonly gives rise to hypertrophy of the left ventricle, with dilatation of the auricle. 78. c. Lesions of the semilunar pulmonary valves are very rarely observed. Obstruction in this situation occasions a morbid sound at the mid- dle of the sternum, more superficial and whiz- zing than that caused by disease of the aortic valves (Hope). The circumstances of the mor- bid sound being inaudible over the great arter- ies, as Dr. Williams observes, of its not affect- ing the pulse, and of its causing more marked signs of venous congestion and disease of the right side of the heart, are more to be depend- ed upon than the mere situation of the morbid sound in the diagnosis of this alteration. 79. d. Lesions of the tricuspid valve, and of the right auriculo-ventricular orifice, are more com- mon than those of the pulmonary valves, but less so than those of the mitral valve. They give rise to a deep blowing or filing sound, most distinct under the sternum at the juncture of the fourth rib. If the lesion obstruct the cur- rent of blood, the morbid sound will replace the second natural sound ; but if it allow regurgita- tion into the auricle, the morbid sound will ac- company the first sound; the regurgitation giv- ing rise to pulsation in the jugular veins, and to dilatation of the right auricle or ventricle, or of both. 80. e. Adhesion of the auriculo-ventricular valves to the parietes of the heart, according to M. Bou- illaud, are attended by the symptoms of nar- rowing or contraction of the orifices, especially palpitations, the bellows sound, the purring tre- mour, dyspnoea, and venous congestions, with passive effusions; but are distinguished, 1st, by the more broad, less dry, and less rasping sound than in narrowing; 2d, by the less irreg- ular, less unequal, and less intermittent pulsa- tions of the heart; the purring tremour being more diffused, and less distinct than in nar- rowing of the orifices ; 3d, by the pulse being less small, and the oppression at the praecordia, the venous congestions, and their consequen- ces, being less remarkable than in the latter lesion. 81. /. The diagnosis of thickening of the inter- nal membrane of the heart, whether this change depends upon a true hypertrophy of this tissue, or upon the organization of a false membrane lining its surface, is frequently impossible. When the thickening extends to the valves, without any other lesion of them or of the ori- fices, a remarkable increase in the loudness of the sounds is produced, especially if the mitral valve is affected. When the valves, or the ori- fices, or the parietes of the compartments are otherwise altered, as they most frequently are contemporaneously with this change, the signs will have a particular reference to such altera- tions. 82. It is justly remarked by Dr. Williams, that when two or more of the preceding lesions are associated, the signs become complicated, and the obscurity of the case increased; for, unless the character and locality of the morbid sound be distinct, the more prominent may mask the others. When the sounds are dif- ferent, one being filing or grating, and the other blowing, the difficulty is less, and the nature and position of each affection may be exact- ly indicated. Rasping or sawing sounds are very rarely produced by mere contractions or by soft depositions, unless for a short time du- ring increased action of the heart. When these sounds are permanent, they may be re- ferred to cartilaginous or osseous deposites in or about some of the valves. Hypertrophy and dilatation often make the signs of diseased valves more evident, by augmenting the force of the current through the cavities, and ren- dering more distinct the place and order of the sounds. [Endocarditis, though frequently a primitive affection, is perhaps no less often associated with acute articular rheumatism than pericar- ditis ; and, according to some pathologists, it is a far more frequent complication. It also occurs as a sequel of pneumonia, pleurisy, and inflammation of the serous tissues. Its pres- ence may generally be presumed if a patient be suddenly attacked with three signs: 1st. Fever. 2d. Violent action of the heart. 3d. A valvular murmur which did not previously ex- ist, provided the murmur be well distinguished from an attrition murmur, as the latter indi- cates pericarditis. The evidence is still strong- 214 HEART—Inflammation of the Pericardium. er if the signs occur in connexion with acute rheumatism. Most cases of the disease termi- nate in recovery, although it often lays the foundation of organic changes of the valves, which may ultimately produce the most serious consequences.] ii. Inflammation of the Pericardium.—Syn. Carditis externa, Author ; Pericarditis, Auct. var.; Exocarditis, Barbier ; Carditis, Sauva- ges, Vogel, &c. ; Inflammatio Cordis et Peri- cardii, Senac; Hertzbeutelenzungdung, Germ.; Piricardite, Fr. ; Inflammazion del Pericardio, Ital. ; External Carditis; Inflammation of the Envelope of the Heart. 83. Char act.—Pain under the sternum, in- clining to the left side and to the epigastrium, with tenderness on firm pressure in the latter sit- uations ; dyspnoea; anxiety, oppression, constric- tion, or tightness at the pracordia; great rapid- ity and irregularity of the heart's action, and of the pulse ; inflammatory fever; and morbid sounds detected by percussion and auscultation. 84. A. History, &c.—Pericarditis was first mentioned by Avenzoar, who was himself at- tacked by it, and was cured by blood-letting ; but, excepting the cursory notice taken of it byRoNDELET, Salius Diversus, and Forestus, little attention was directed to it until Bonet, Hildanus, Berger, Morgagni, and others re- corded cases illustrative of its morbid rela- tions. Still more recently, our knowledge of its nature and treatment has been much ad- vanced by the writings of Corvisart, Burns, Kreysig, Laennec, Testa, Bertin, Elliot- son, Stokes, and others ; and by numerous memoirs which have appeared in the transac- tions of medical societies and in periodical works, and to many of which references are subjoined. 85. B. Structural Lesions.—a. In the acute stage of pericarditis.—a. The earliest change is redness of the pericardium, from capillary in- jection. In some cases, particularly when death has taken place rapidly, the redness is not remarkable, probably owing to the reces- sion of the blood from the capillaries after death. The increased vascularity is principally seated in the subjacent or connecting cellular tissue ; and the redness is sometimes increased by the infiltration of minute quantities of blood into this tissue, or into the serous membrane itself, so as to give rise to ecchymoses, or red points, spots or patches, or streaks. The thick- ness, transparency, and consistence of the per- icardium seldom undergo great changes at an early period of the disease, yet this membrane is often thicker and more opaque than in the healthy state. It is generally detached with greater ease from the surface of the heart, and its removal shows the injection and redness, or infiltration of the connecting cellular tissue. The natural exhalation from the surface of the pericardium is either increased in quantity or remarkably altered in kind, or both ; the accu- mulated effusion which thus results constituting a principal part of the changes produced by the disease. 86. (3. The effusion into the pericardium pre- sents various states, and undergoes changes of much importance as respects the subsequent course of the disease: 1st. The effused fluid usually coagulates or separates into a turbid or flocculent serum and a concrete or fibrinous false membrane, which is organizable and commonly covers the free surface of the car- diac envelope. In some instances the coagu- lation is more irregular, or presents a curdled appearance, without being disposed in a mem- branous form over the external surface of the organ The more fluid part of the effusion is generally serous, but it is sometimes san- guineous or tinged by the escape of a portion of the colouring substance of the blood. Oc- casionally the effused matter consists chiefly of coagulable lymph disposed in the form of false membrane ; but more frequently the membranous depositions are accompanied by a quantity of fluid varying from a few oun- ces to several pounds. M. Louis adduces a case in which it amounted to four pounds; and Corvisart another, in which the pericardium contained a still larger quantity of a sero-puri- form fluid. 2d. In some cases of pericarditis, the effused matter consists of a homogeneous, inodorous, and well-digested pus of the con- sistence of cream, and of a grayish, yellowish, or greenish-white hue. The quantity of this matter varies as much as that of the former, or sero-pseudo-membraneous effusion. Cases of pericarditis, giving rise to a purulent effu- sion, have been recorded by P. Frank, Hasen- oehrl, Monro, Stoerck, Stoll, Lieutaud, Senac, Baillie, Corvisart, Louis, Bouillaud, and several recent writers. Instances in which the present fluid presents a sero-puriform char- acter are frequent. 87. y. The coagulated ox fibrinous lymph form- ed in acute pericarditis is sometimes found in amorphous masses; but it is most frequently disposed in a membranous form, covering the greater part, or even the whole, of the free sur- face of the pericardium, especially of that part reflected over the heart. This false membrane varies in thickness from a fraction of a line to several lines. The appearance of the free sur- face of this membranous exudation is gen- erally peculiar. Corvisart compared it to the internal surface of the second stomach of a calf. Sometimes it resembles the surface of a pineapple. Dr. Hope remarks that, when the layer is thin, its free surface is often pitted with small depressions at regular intervals, presenting the aspect of a fine reticulation; and that, when it is thick, the surface is divi- ded into more spacious cells, often as large as a pea, and separated by coarser partitions. In most of the cases which I have examined the surface either was shaggy, or hanging in nu- merous short shreds—the " Cor hirsulum, vii- losum, tomentosum" of the older writers; or presented an appearance similar to that pro- duced by pressing soft grease between two smooth plates and by forcibly separating them. In some preparations of my late colleague Dr. Sweatman, these appearances are beautifully preserved, the membranous exudation in these having surrounded the whole of the heart. M. Cruveilhier and Dr. Hope have delineated these changes in their pathological works. In some instances the effused lymph is arranged in transverse undulations, or it presents an in- dented or wrinkled form. It occasionally ac- quires a deeper hue the older it becomes, or presents a deep brown or reddish-brown col- our, most probably derived from the colouring matter of the blood which the effused fluid con- HEART—Inflammation of the Pewcardit/m. 215 tained. The more recent the membranous exudation, the more feeble is its cohesion; and the older it becomes, the greater is its tenacity and elasticity. 88. or valves, or in both orders of parts, similar to those already alluded to ($ 66,67), are generally also observed; and a fatal termination is seldom long deferred. 95. C. Symptoms and Diagnosis of Pericardi- tis, and of its Consequences.—Inflammation of the pericardium was considered by Laennec and several recent writers as the most difficult of the diseases of the heart to detect. This arose from too little attention having been paid to the rational symptoms attending it, and from the sounds occasioned by it having been imper- fectly ascertained. The difficulty has been much exaggerated; for, of the numerous cases in which I have been consulted since 1818, some of which were published as early as 1821, the disease was detected during life in all but one, which I saw with Dr. Duffin. This case was complicated with other lesions, and termi- nated fatally a few hours afterward, the con- stant vomiting and affection of the diaphragm having masked the symptoms indicative of per- icarditis. That this disease is often overlooked, or confounded with inflammations of the pleu- ra, lungs, diaphragm, &c, with which it is often complicated, cannot be doubted; and that it is, in its various grades of intensity and states of association, a much more common malady than has been supposed, is shown by the fact of M. Louis having found it in the proportion of one case in twenty in all the dissections he has made. This is still farther proved by the cir- cumstance of my having seen as many as four cases of the disease in one day, three of them in children under ten years of age, who were brought to my house, and who were examined, also, by Mr. H. Barker, the present house- surgeon to the North London Hospital, and then one of my pupils. On two occasions, I have met with the disease in two children of the same parents, and once in two brothers at the same time. Although auscultation and percus- sion furnish some of the most important signs of pericarditis, and of its consequences, yet they must not be depended upon without care- fully ascertaining the rational symptoms, local and general, and cautiously comparing and es- timating all the phenomena observed. 96. a. Symptoms of the acute or first stage.— (a) The local signs of acute pericarditis consist, 1st, of altered sensibility; 2d, of disordered ac- tion ; 3d, of change in form; 4th, of morbid sounds heard on percussion and auscultation.— a. Paint more or less acute, is very frequently complained of under the left nipple, extending to the lower extremity of the sternum, occu- pying sometimes the whole praecordia, irradia- ting thence to the left axilla, or arm, or to the diaphragm and epigastrium, or to the left hy- pochondrium. The pain is pungent, lancina- HEART—Pericarditis—Symptoms and Diagnosis. 217 ting, tearing, or violent; is often attended by a sense of compression and constriction, and by anxiety ; and is increased on percussion, on a full respiration, on coughing, on holding the chest erect, and on lying on the left side. In many cases, however, the pain is dull, or so slight as to be little or not at all complained of; but if pressure be made upon the intercostal spaces, or upward from the epigastrium towards the pericardium, more or less internal pain will be excited. Cases, also, occasionally occur in which no pain is felt at the praecordia, and, consequently, where the existence of pain on pressure in these situations has been neither inquired after nor ascertained; and instances are not uncommon where the pain of pericar- ditis is masked by an associated acute pleuritis or severe articular rheumatism. I agree with Dr. Elliotson and Mr. Mayne in considering pain or tenderness circumscribed in extent, and confined chiefly to the left side of the epi- gastrium, and felt most when pressure is di- rected upward on the diaphragm and under the anterior margins of the left false ribs, as one of the most constant symptoms of pericarditis. M. Bouillaud observes that the more simple the disease, the more frequently is it latent, and in this he agrees with Laennec ; that the same holds, also, in respect of rheumatismal pericar- ditis, which is often attended by little pain, when the adjoining pleura is unaffected; and that the pain is most severe when the costal pleura in the vicinity, and especially when the diaphragmatic pleura is implicated. 97. (3. The pulsations of the heart are stronger and more frequent than natural; sometimes regular, at other times irregular, tumultuous, unequal, or intermittent, with exacerbations of the palpitations. The impulse is then readily felt by the hand, and perceived on inspection. But frequently it can be detected by neither, when copious effusion has taken place into the pericardium, and the palpitations present at the commencement then disappear. In these ca- ses, the actions of the heart are either really or apparently feebler than natural. M. Bouillaud states that when the inflammation is passing into the formative action—when organization is commencing in the effused lymph—the sec- ond movement of the heart seems double, or imparts a crepitating or crackling sensation to the hand. 98. y. A more or less evident prominence of the praecordia, or of the cartilages of the left ribs, mentioned by M. Louis, is often observed, especially when the disease affects children. It depends either upon effusion into the peri- cardium and vascular swelling of the affected tissues, or upon inordinate action and con- secutive hypertrophy. The concomitant signs, especially the states of pulsation and impulse, will readily disclose the cause of this appear- ance. 99. 6. Percussion furnishes a dull sound to an extent in proportion to the effusion, and at a period of the disease varying with the com- mencement and progress of this lesion. At first, or in that form of pericarditis called dry, but little effusion, or merely a thin membra- nous exudation of lymph takes place, and the dulness on percussion is not much increased. Hence it is only when effusion is considerable that this means of investigation is of much as-1 II 28 sistance in this disease. When the fluid is not abundant, the position of the patient will also modify the extent or situation of the dull sound, or even prevent it from being remarked, owing to the gravitation of the liquid to the more de- pending part of the pericardium. 100. e. Auscultation affords no sign that can be alone depended upon in the acute stage of pericarditis. The sound resembling the creak- ing of new leather is rarely heard in this period, but more frequently in the next. It was first noticed by M. Collin, and afterward mentioned by me in the article Auscultation (() 41), where I attempted to explain its occurrence. Dr. W. Stokes next treated of it in an able paper on this disease. I have already alluded to cases in which I have met with it, and one in which it was distinctly heard by the patient herself ($ 15). In its true form, it rarely, or only tem- porarily occurs. But a friction sound, which has been noticed by Stokes, Mayne, Watson, myself, and others, is frequently heard in this stage, or when little or no effusion exists, and closely resembles the friction, rubbing, or to- and-fro sound in pleuritis. In some cases, the rubbing sound resembles the rasping, grating, or sawing sound in induration of the valves, from which it must be distinguished, as well as from the bellows or blowing sound, which is also often heard in pericarditis. When the rubbing sound assumes a grating or rasping character, and is thus liable to be mistaken for similar sounds caused by valvular disease, it will generally be found to arise from the rough surfaces of false membranes covering the sur- face of the pericardium.* In these cases, also, M. Bouillaud likens the friction sound to the rubbing together of taffeta or of parchment. This kind of rubbing sound is to be distinguish- ed from the rasping or sawing sound caused by disease of the valves, by its being double, and more superficial and diffused than it. The bel- lows sound, also, may be confounded with the more superficial and diffused rubbing or crush- ing sound; but a slight attention will detect the difference between them, arising from the circumstances just stated. This sound, in its different modifications of a filing, sawing, or rasping sound, is always single—is a rnsh, or whiz, as Dr. Watson remarks, and is synchro- nous with the systole of the ventricles, and deep-seated; the rubbing or friction sound, in its different states, is a double sound, and sug- * [The practitioner will do well to bear in mind the fol- lowing conclusions of Dr. Hope, in studying the diagnosis of cardiac affections : 1. The ventricular systolic currents, through contracted orifices, from being stronger than the diastolic, produce louder murmurs. 2. Considerable con- tractions of a rough, salient configuration, whether osseous or not, produce the rough murmurs of sawiiig, filing, or rasping, provided the current be that of the ventricular sys- tole, its diastolic currents being too feeble. 3. The pitch, or key, of murmurs is higher in proportion as they are gen- erated nearer the surface, and the currents producing them are stronger, and vice versa. Also, the key is lowered by distance, independent of depth, from reverberation through the chest. 4. Musical murmurs indicate nothing more than ordinary murmurs. 5. Rough murmurs, and even loud and permanent bellows murmurs, indicate organic disease. 6. Permanent murmurs from regurgitation necessarily indi- cate organic lesions. 7. Continuous murmurs in the heart will probably be found to iudicate, sometimes organic dis- ease attended with regurgitation out of the aorta into the right ventricle or pulmonary artery, sometimes churning of a little serum between layers of rough lymph on the per- icardium, and sometimes, probably, dilatation of the pul- monary artery and compression of the vena innominata.— (Loc. cit.)} 818 HEART—Pericarditis—Symptoms and Diagnosis. gests the idea of the rubbing together of the opposite surfaces of the pericardium, roughen- ed by the exudation of lymph ; it ceases when a copious effusion of serum takes place, or when the surfaces become adherent. Both these sounds are sometimes coexistent, espe- cially when the internal and external mem- branes of the heart are inflamed at the same time; and they may be then severally ascer- tained by an experienced and careful observer.* I have detected a bellows sound in the larger proportion of cases of pericarditis that I have seen in children. The rubbing or friction (Stokes, Mayne, Bouillaud), the lo-and-fro (Watson), the crushing (Bouillaud), and the ascending and descending (Laennec and Rey- naud) sounds, are either the same, or slight modifications of the same phenomenon ;t are heard chiefly in acute pericarditis ; are double sounds, although louder during the systole than during the diastole of the ventricles ; are caus- ed by changes affecting the pericardium ; are not heard in all cases, and only in certain sta- ges or states of the disease, and depend upon different lesions from those which occasion the bellows, rasping, or sawing sounds. These latter proceed from alterations within the heart, the former from changes external to it. The creaking or leather sound, according to my ob- servation, occurs chiefly in the chronic stage of the disease ; is a different sound from that of rubbing or friction ; does not depend upon that cause, but upon thickening and induration of the pericardium reflecting over the heart and of the connecting cellular tissue, or upon the existence of a dense or an elastic false mem- brane, as stated above (§ 15). 101. When copious effusion has taken place into the pericardium, the natural sounds of the heart, as well as the morbid sounds arising from changes about the valves or in the orifices of the organ, will be heard more obscurely, or * [Dr. Pennock remarks (Am. Ed. of Hope on the Heart, Phil., 1842, p. 177), that " the friction sounds in well-mark- ed pericarditis are almost always double, and frequently may be even triple, or more ; for when effused lymph is at- tached to the pericardial surfaces, each division of the heart, during its systole, moves so as to cause a friction upon the opposed surface of the pericardial sac ; and during its dias- tole a similar rubbing may exist, although in an opposite direction. Now, since the auricular movements are inde- pendent of those of the ventricles, their movements, also, are double ; so that, if friction exist both upon the auricular and ventricular surfaces, the attrition sounds will be quad- ruple, or double with the auricles, and double with the ventricles. The friction sound generally ceases in a few days, for the lymph is absorbed, or it is converted into a false membrane, which connects the heart with the peri- cardium. When mucous or crepitant ronchi exist over the precordial space, the crackling sound often bears some re- semblance to that of friction, rendering it doubtful whether the morbid sound occurs during respiration, or whether it is caused by attrition. This doubt may be resolved by re- questing the patient to hold the breath for a short time, and examining the prncordium at that moment; if it be found that the sound has then ceased, it has evidently been generated in the lungs; but if it continues, it is friction sound."] + (Dr. Watson (Lectures on the Principles and Practice of Physic, Phil., 1844) describes this as a lo-and-/ro sound, or " one conveying to the ear the notion of the rubbing of two rough surfaces backward and forward upon each oth- er. It seems near to the ear, and, therefore, near to the surface of the patient's body. Like all the other morbid sounds heard within the chest, it is capable of much variety in tone and degree. Sometimes it very closely resembles the noise made by a saw in cutting through a board. Some- times it is more like that occasioned by the action of a file, or of a rasp, or of a nutmeg-grater. But its essential char- acter is that of alternate rubbing: it is a s indicated by a few symptoms, which, when duly weighed in connexion with the previous history of the case, may lead the acute physi- cian to presume its existence with some truth. These symptoms, however, taken by them- selves, often attend other diseases character- ized by extreme asthenia, and even the asthenic functional disorders of this organ (y 39). But when, after more or less acute or sub-acute symptoms referrible to the praecordia, especial- ly if attended by any of the morbid sounds, or other physical signs observed in external or internal carditis, or after dyspnoea, &e, the impulse of the heart at the praecordia, and the pulse at the wrist, become obscure, weak, and irregular, the latter being small or indistinct, the face livid or tumid, and the extremities oedematous, the dyspnoea increased or more constant, and when fainting or syncope occur frequently, or from very slight causes, then softening of the muscular structure of the heart may be presumed. Still, all these symptoma may depend upon effusion into the pericardium, which, however, is often associated with soft- ening of the organ. But a careful examination of the chest by percussion and auscultation, and the diagnostic symptoms adduced in the article on Dropsy of the Pericardium (§ 151), will often lead to a just conclusion. The soft- ening of the heart, which, in a slighter degree, may be presumed to exist during convalescence from low or malignant fevers, is generally at- tended by a small and quick pulse, by a very weak and limited impulse, and by frequent re- turns of faintness or syncope. In the soften- ing observed in very old people, the pulse is often slow, feeble, indistinct, or intermittent, or irregular; and dyspnoea, with many of the symptoms just mentioned, is generally present. 126. iv. Of the Causes and Development of Inflammations of the Heart and Pericardium.— Inflammations of the surfaces and substance of the heart arise from the same predisposing and exciting causes. When either of these forms of carditis proceeds directly from these causes, or independently of a pre-existing malady, it has been denominated primary or idiopathic; but when it has followed another disease, and when a connexion can be traced between both, it has been called consecutive or symptomatic. The causes already adduced under the heads of pre- disposing (y 18) and exciting (Y 19) are princi- pally concerned in the production of the pri- mary states of these inflammations. Some of those which have been termed pathological (y 20) chiefly occasion the consecutive forms of carditis. 127. A. Of the predisposing causes (v 18) al- ready stated, plethora, the rheumatic and ar- thritic diathesis, the irritable and sanguineous temperaments, hereditary constitution, mental emotions, and early age, seem to be most con- cerned in producing inflammations of the heart and pericardium. Although these diseases may occur at any age, yet they are most frequently HEART AND PERICARDIUM—Inflammations of—Causes, etc 225 met with between the ages of six and thirty- | five. M. Bouillaud assigns the period between ten and thirty as that of their most common occurrence. I have, however, observed a large proportion of cases between five and ten years of age, and after thirty. I agree with him in considering them most frequent at those sea- sons when the vicissitudes of temperature and season are the greatest, and, I may add, du- ring spring, when northeast winds are most prevalent. 128. B. The exciting causes (y 19) comprise nearly all those just referred to, especially the mechanical, the traumatic, the physical, and the moral exciting causes. Of the physical causes, the most common are, exposure to cold when the body is perspiring, or after it has been much overheated or excited, and wearing damp clothes, or sleeping in damp sheets or beds. The impression of cold after the copious transpiration and exhaustion caused by bodily or mental exertion, or by both conjoined, is very apt not only to produce inflammation of either of the surfaces of the heart, but also to occasion pneumonia or pleuritis to be associa- ted with it. A young man of talent, after ad- dressing a meeting under great mental excite- ment for upward of an hour, exposed himself immediately to a cold easterly wind in the month of March, and was soon afterward seized with pericarditis, complicated with pleu- ritis of the left side. A middle-aged man, after great muscular exertion and fatigue, allowed himself to be suddenly chilled : he was after- ward attacked by internal carditis, which soon became associated with pericarditis. The dan- gerous and often fatal consequences of violent or prolonged exertions in working the pumps of leaky or sinking vessels are generally ow- ing to the production of this malady in its most acute form. Of the truth of this, the author had, many years ago, a painful opportunity of assuring himself. The moral causes enumera- ted above (v 19 (c)), and in the article Disease (y 53), sometimes either induce, or concur with other causes in occasioning one or other of the forms of carditis. 129. C. The pathological states which have been adduced ($ 20) are by much the most common causes of inflammation of the internal and external surfaces of the heart; and of these the most frequently observed is rheumatism, particularly the acute articular form of that dis- ease. Internal or external carditis may be connected with rheumatism in three modes : 1st. The cardiac inflammation may follow the disappearance or suppression of the rheumatic affection, and may thus appear as a metastasis, or translation of this affection; 2d. It may take place before the rheumatic disorder has ceased in an extremity or external part of the body ; and co-exist with this disorder in one or more joints, or in these situations, the external affection being, however, much less severe after the development of the cardiac malady ; 3d. Rheumatism may extend itself to the heart or pericardium without abatement in its exter- nal seat, or may affect, almost simultaneously, one or more joints, and the heart; or a very acute arthritic rheumatism may mask a sub- acute internal or external carditis. Of these three modes of connexion, the first and second are the most frequent; but the third is by no ' « 29 I means rare. I believe that the more acute the rheumatic complaint, and the more it affects the joints, the greater is the risk of its occa- sioning carditis or pericarditis ; the risk being also greater, the younger the patient: and I am moreover of opinion that this connexion between inflammations of the heart and rheu- matism is much more frequent at the present day than twenty years ago.* Twenty-five years since, when I published a dissertation on rheu- matism, and had my attention as alive to this circumstance as now, and with equal opportu- nities of meeting with it in public institutions, it was much less frequently observed. The modes of ascertaining it have certainly been improved since then ; but nearly as much now is often lost by inattention to the physiological or rational symptoms as is gained by ascer- taining the physical signs. Besides, as I have always resorted to auscultation and percussion since 1819, when I frequently accompanied Laennec in his rounds, the disease was almost as likely to have been detected by me then as now. [Dr. Latham states (" Lectures on Subjects connected with Clinical Medicine, comprising Dis- eases of the Heart," 2 vols., Lond., 1845) that between the years 1836 and 1840, there oc- curred under his care, at St. Bartholomew's Hospital, 136 cases of acute rheumatism; of which 75 were males and 61 females: and of the 75 males, the heart was affected in 47, and unaffected in 28. Of the 47, the seat of the disease was the endocardium alone in 30, the pericardium alone in 3, and both the endocar- dium and pericardium in 7 ; and while the heart was undoubtedly affected in 7 others, the exact seat of the disease was uncertain. Of the whole number of males in whom the heart was thus variously affected, 3 died; and in these 3 the pericardium and the endocardium were both inflamed. Of the 61 females, the heart, was affected in 43, and unaffected in 18. Of the 43, the seat of disease was the endo- cardium alone in 33, the pericardium alone in 4, and both the endocardium and pericardium in 4 ; and the exact seat of the cardiac disease doubtful in 2. Of the whole number of females in whom the heart was thus variously affect- ed, none died. The account of males and fe- males taken together will stand thus : Cases of acute rheumatism .... 136 Heart exempt in.......46 Heart affected in......90 Seat of disease in the heart: Endocardium alone in.....63 Pericardium alone in.....7 Endocardium and pericardium in . 11 Doubtful in........9 Deaths 3 ; in all of whom both endocardium and pericardium were affected. Of the 63 pa- * [" One law respecting the connexion between the car- diac and the arthritic symptoms," says Dr. Watson, " may be stated with confidence ; namely, that the younger the patient is who suffers acute rheumatism (and 1 have seen it so early as the third or fourth yeaT), the more likely will he be to have rheumatic carditis. The chance of the com- bination appears to diminish after puberty, as life advances. I have known only two persons pass through acute rheuma- tism with an untouched heart prior to the age of puberty ; and in those two, I am by no means certain that the articu- lar disease was genuine rheumatism. In each of them the large joints became painful, and swelled, for a day-or two only, towards the close of scarlet fever—a circumstance not, | 1 believe, unusual. I was dreadfully apprehensive of car- i ditis, but it did not occur."—(Loc. cit.)] 226 HEART AND PERICARDIUM—Inflammations or—Causks, etc. tients wha suffered simple endocarditis in the course of acute rheumatism, 30 were males and 33 females, of Whom none died ; but aus- cultation showed that of these the membrane recovered its complete integrity of structure only in 17, and that it remained permanently injured in 46. Of the 30 males, the subjects of rheumatic endocarditis, the endocardial mur- mur ceased entirely in only 8; while it re- mained after they were convalescent, and as long as they continued under observation, in 22. And of the 33 females, the endocardial murmur ceased entirely only in 9, while it re- mained in 24. This denotes a most fearful disease in regard to its distant results, showing that the probability is as great as 4 to 1, that inflammation befalling the endocardium will become the rudiment of disorganization to the entire heart. The results of simple rheumatic pericarditis were that, of the 7 who suffered simple pericarditis in acute rheumatism, 3 were males and 4 females, of whom none died, and no exocardial murmur remained after conva- lescence, to denote a change of structure in the pericardium, although adhesion might exist and escape this as well as all other known methods of diagnosis. Of the 11 in whom endocarditis and pericar- ditis were combined, 7 were males and 4 fe- males ; out of these, inflammation was arrest- ed and life saved in 8 ; and 3 died. Of the 8, who were convalescent from this double dis- ease, the endocardium underwent perfect rep- aration in 2, for the endocardial murmur en- tirely ceased; and imperfect reparation in 6, for the endocardial murmur continued. As to the pericardium, although the exocardial mur- mur ceased in all, Dr. L. thinks it doubtful whether its reparation was perfect in any, there probably remaining a greater or less ex- tent of permanent adhesion. Thus, of these 8 cases involving both the investing and lining membranes of the heart, it is not certain, or perhaps probable, that the organ recovered a perfectly healthy condition in a single instance. The appearances on dissection in the fatal ca- ses corresponded with those giyen by Mr. Cop- land. Of 136 cases of acute rheumatism. Mr. L. also found that while the heart was inflamed in 90, or in two thirds of the whole, the lungs were inflamed only in 24, or one in 5£. These 24 cases were made of 4 of bronchitis, 18 of pneumonia, and 2 of pleurisy. Of the 46 cases of acute rheumatism in which the heart was unaffected, the Kings were inflamed in 5, a ra- tio of 1 to 9 ; and of the 90 cases in which the heart was inflamed, the lungs were also in- flamed in 19, a ratio of more than 1 in 5. Of the 63 cases of endocarditis, the lungs were inflamed in 7. a ratio of 1 to 9. Of the 7 cases of pericarditis, the lungs were inflamed in 4, a proportion of more than one half. Of the 11 cases of endocarditis and pericarditis simulta- neously, the lungs were inflamed in 8, a ratio of two thirds. Thus showing that, while in acute rheumatism inflammation of the lungs does not occur more frequently when the en- docardium is inflamed than when the heart is entirely exempt from disease, yet that wheti this membrane and the pericardium are both involved, inflammation of the lungs is a fre- quent complication. The pulmonary affection consisted either in the existence of single m double pneumonia, single or double pleurisy, or bronchitis of one or both lungs. Dr. Charles Hooker states (Bost. Med. and Surg. Journ., vol. ii,p. 33fl) that a remarkable change of diathesis was observed in the city of New-Haven and vicinity in the year 1830-1; and that rheumatism, complicated with pericar- ditis, pWMitis, Ac, became very prevalent, For this, he *ays, the Actca racemosa proved a most prompt and efficacious remedy. "In the commencement of a severe case," he re- marks, "a full dose of calomel was commonly administered, and this was followed by a mix- ture of Tinct. Actcea, yfy, and Tinct. Opii, jij., in doses of forty or sixty drops every two or four hours. Scarcely any other medication was required, whether a case was pneumonitis, pleu- ritis, pericarditis, or phrenitis, all of which were of a rheumatic character*; and with this plan the severest cases were almost sure to come to a favourable resolution within four or six days." During the following year, the disease was also very rife, but wanting the usual acute symptoms of the affection. There was a strong predisposition to serous effusion into the peri- cardial sac ; post-mortem examination revealed copious liquid effusion into the cavities of the pleura, of a straw colour, with an admixture of yellowish, albuminous flocculi. The lungs were largely infiltrated with pus and serum, with such a preponderance of the serum as to occa- sion an unusually pale appearance, and the de- gree of softening was such that the lungs could hardly be handled without breaking into a thin, pultaceous mass. The pericardium was dis- tended with a liquid similar to that within the pleura, and in most cases the inner membrane was coated, so as to have a pale, buttery appear- ance. The muscular substance of the heart was remarkably softened, and in most cases paler than natural. Dr. H. remarks that the prominent feature of the disease was a tenden- cy to a separation of the serum and fibrin, with effusion of serum ; and that the principal dan- ger to be apprehended was from serous effu- sion into the pericardium, the lungs, the brain, and the spinal canal. The remedies employed were, therefore, aimed to prevent effusion and promote absorption ; for which purpose, after a full dose of calomel, one of the following pills was given every one, two, or four hours, ac- cording to the circumstances of the case: & Eialeni, gr. j.; Calomel, gr. xv. ; Putv. Digitalis, 3j. ; Pulv. Scilice, 3j. ; Pah. Canlharid,, gr. v.; Muc. G. Arabic, q. s. Ft. pill, No. 40. These were continued until eight or ten copious liquid evacuations were produced, after which they were so given as to procure two or three evac- uations daily. This plan, with blisters to the precordial region and sinapisms to the extrem- ities, was the only medication ordinarily requi- red. In many cases, eonjoined with this treat- ment a mixture of Ol. Terebinth., with muci- lage of gum Arabic, was advantageously used; W. also, were infusions of Senega, Asclepias tyriaca, and bac. Juniper. This treatment, how- yrer is not recommended as adequate to the iur-JlJZir,caJdltis and carditis, but was found SUC,enSST "nder the c,rcui"stances indicated. conrfLT u"eXt mos}- fre(*uent Pathological carditis ^avhenCe Ca,rdlt,S' specially extereal carditis, may proceed, are pleurisy and pleura- HEART—Inflammations or—Diagnosis, etc. 227 pntumony. The former disease may occur in consequence of the extension of the latter, or they may both appear almost simultaneously. I have even seen pericarditis give rise to, or followed by pleuritis. Inflammations of the heart, thus associated, are most commonly caused by some one of the numerous modes in which cold is applied to the surface—or, rather, in which the animal caloric is carried off—when the body is perspiring, especially after exertion or fatigue, ami in the rheumatic diathesis. Gout is also sometimes a cause of carditis, and, I think, of the internal form of the disease, in preference to pericarditis. Internal carditis occasionally appears at an advanced stage of, or during convalescence from either of the eruptive fevers. It, as well as other forms of the disease, may also follow other fevers, and the complaints mentioned above (Y 20). 131. v. The Diagnosis of Inflammations of the Heart may be inferred from the description I have given of the symptoms attending each of the varieties ; but as these varieties are often associated with each other, or in some measure pass into one another, as the inflammatory ac- tion predominates more or less in one of the constituent tissues of the organ, so the symp. toms will vary in different cases, and even in different periods of the same case. Attention, however, to the following circumstances, and groups of morbid phenomena, will generally enable the practitioner to arrive at a tolerably just conclusion as to the nature of the disease: 1st. The situation of the pain, in the more acute cases, and the tenderness, soreness, or pain on pressure felt in the left and upper part of the epigastrium, and in the left anterior in- tercostal spaces ; 2d. The increase of pain on stretching upward or backward, and the inabil- ity to lie on the left side; 3d. The frequent extension of pain to the left axilla, shoulder, or arm, and the occasional numbness of the latter; 4th. The greatness of the anxiety in proportion to the cough ; the anxious, haggard, or peculiar expression of countenance ; and the bloated or livid appearance of the face at a more advanced stage; 5th. The state of the pulse at the wrist examined in connexion with the actions and impulse of the heart; the great frequency and irregularity of the latter, and the smallness, weakness, &c, of the former ; 6th. The palpitations and tendency to syncope, or the alternation of these symptoms, and their connexion with pain, anxiety, dyspnoea, rest- lessness, or jactitation ; 7th. The signs on percussion and auscultation, especially the single bellows or blowing sound, with all its mod- ifications ; and the double friction, rubbing and creaking sounds : the former having reference to changes within the heart, the latter to alter- ations within the pericardium. 132 vi. The Complications of Inflammations of the Heart have been already noticed in gen- eral terms (y 32). Inflammation of the internal membrane, whether acute, sub acute, or chronic, is often associated with, or gives rise to, peri- carditis, at an early period of its progress ; but this latter is much more frequently complicated with, or occasions the former. Signs of endo- carditis are more commonly and more early detected in the course of pericarditis, than those of pericarditis are in the course of endo- carditis ; and both may be farther associated with inflammation of the cellular tissue or substance of the heart, or true carditis, in vari- ous degrees, or to a greater or less extent, as respects the different compartments of the or- gan. A. Internal carditis is much more com- monly observed in a complicated than in a simple state, especially when it is at all ad- vanced. It presents itself in connexion with the following diseases, and probably in a ratio of frequency approaching the order in which I am about to enumerate them : 1st. With peri- carditis and articular rheumatism; 2d. With pericarditis only ; 3d. With rheumatism only ; 4th. With pneumonia, pertussis, and pleuritis ; 5th. With inflammation of the blood-vessels, especially phlebitis ; 6th. With eruptive or adynamic fevers; 7th. With purulent collec- tions or caries in distant parts. Internal car- ditis, when associated with rheumatism or with pulmonary or pleuritic diseases, is generally also connected with pericarditis ; but when it supervenes in the course of phlebitis, or of fe- ver, or from some cause which contaminates the circulating fluids, then it is generally un- connected with pericarditis, although the sob- stance of the heart may be more or less impli- cated, or even softened. 133. B. Pericarditis is also much more fre- quently met, even in its early stages, in a com- plicated than in a simple form—generally in connexion, 1st. With internal carditis, either acute or chronic ; 2d. With articular rheuma- tism ; 3d. With both internal carditis and rheu- matism, this being oftenest observed; 4th. With pleuritis. either pulmonary, diaphragm- atic, or costal; 5th. With pleuro-pneumony; 6th. With inflammation of the diaphragm or mediastinum; 7th. With true carditis ; 8th. With peritonitis; 9th. With inflammation of some one of the abdominal viscera; and, 10th. With eruptive fevers. Two or more even of these complications may exist in the same case, especially internal and external carditis, pleuritis, and articular rheumatism ; pericardi- tis, diaphragmitis, and pneumonia, &c. A body was lately brought into the dissecting-room of the Middlesex Hospital medical school, in which the liver was found inflamed and en- larged. It had formed adhesions with the dia- phragm on one side, and with the adjoining viscera on the other. Between these viscera and the concave surface of the liver the adhe- sions formed a large sac containing a turbid serum. The pericardium and diaphragm were inflamed, as well as the pleura on both sides. The pericardium and pleural cavities contained much turbid, thick serum. When pericarditis is associated with peritonitis, or with inflam- mation of some of the abdominal viscera, the additional complication of pleuritis, especially diaphragmatic pleuritis of the same side, is not infrequent. Bouillaud adduces an instance of splenitis, diaphragmatic pleuritis of the left side, and pericarditis in the same patient. The opinion of Corvisart, that acute pericar- ditis rarely or never exists without being com- plicated, in some period or other of its course, is very nearly if not altogether true.—C. Of the complication of true carditis little farther need be added. It can hardly exist without more or less inflammation of one or both surfaces of the heart; and in the few cases of it thai have been observed, several were also coil. 228 HEART—Inflammations of— nected with rheumatism, with pleuro-pneumo- ny, with eruptive and other fevers, with phle- bitis, and with purulent or sanious matters ab- sorbed into the circulation. 134. vii. Of the Progress, Duration, and Ter- minations of Inflammations of the Heart.—A.— a. Internal carditis may be acute, sub-acute, or chronic, and all the intermediate degrees. The most acute form may. especially from the ef- fects of treatment, assume a mild and very chronic state ; and this latter state may acquire greater activity, and become much more severe or acute. This latter change is, however, less frequent than the former. Where an amelior- ation has taken place, a recurrence or exas- peration of the acute symptoms is very apt to occur. The most acute cases, M. Bouillaud observed, arose from sudden chills while the body was perspiring, chiefly in persons of the lymphatico - sanguine temperament, and em- ployed in laborious occupations; hot stimula- ting liquors, taken with the view of recalling the perspiration to the surface, having assisted in developing the disease. When the less se- vere cases appear in connexion with rheuma- tism, as they often do, in one or other of the modes above stated (v 129), a stimulating treatment of the latter disease renders much more acute the cardiac affection. 135. b. The duration of endocarditis is most indefinite, and altogether dependant upon the severity of the disease, the habit of body, age, strength, and constitution of the patient, the nature of the complication, the mode of treat- ment, and the period of recourse to it. Acute endocarditis may terminate fatally in two or three days; and in this case death is caused chiefly by the formation of fibrinous concre- tions, or coagula, in the cavities of the heart. When complicated with pericarditis, or with pleuro-pneumony, its duration will generally accord with that observed in these diseases. The slighter or more chronic forms of internal carditis are of long duration, the more conceal- ed states being prolonged indefinitely, or even for years; and organic lesions, especially of the valves and orifices of the organ, are usually the result at more or less early periods of their course. The inflammatory action either sub- sides or entirely ceases, after having produced these lesions, or it still continues in an obscure form. In the former case, especially when the amelioration proceeds from judicious treatment and regimen, the disease may remain, even for years, either stationary or more or less miti- gated ; but, in the latter, it generally advances with varying degrees of rapidity, until the func- tions of the organ and of the adjoining viscera are more or less impeded, or altogether inter- rupted ; or until fatal congestions take place in vital parts, or dangerous effusions of blood or of serum supervene in important organs, or from mucous or serous surfaces. 136. B.—a. The progress and duration of per- icarditis also vary with the causes which occa- sion the attack, with the age, temperament, and habit of body of the patient, and with the morbid connexions and treatment of the dis- ease. The most acute form may terminate fa- tally with great rapidity. M. Andral records a case which was fatal in twenty-seven hours. The celebrated Mirabeau was carried off by it so raDidly as to lead to the suspicion of his hav- Progress, etc.—Prognosis. i„g been poisoned : he wjj-onlyr improperly treated although gj^™*^ ^ gener. time in France. s"™ ™;th internal carditis, ally complicated, either with nitr - ,33>. The ™« "^.^SS^h teenth But there are exceptions to this, the ighter and more chronic ^esof^^ may continue for some months ; and the conse- quences, particularly adhesions, connecting the pericardium, partially or generally, to the sur- face of the heart, may remain much longer, or for years; and, in some cases, especially when these lesions are slight, without materially dis- turbing the health. These adhesions are fre- quently attended by increased redness of the membrane, and by a little turbid serum, unless when they have obliterated all remains of the cavity. Bertin, Elliotson, and Bouillaud be- lieve that they do not occasion, even when gen- eral, any inconvenience beyond what proceeds from other coexistent lesions. But this is too favourable a view. They assist in developing, if they be not already associated with, still more serious alterations of the heart; and these latter frequently occasion other changes, either in collatitious or remote organs, more especially serous or sanguineous effusions; and thereby greatly abridge the period of existence. 137. viii. The Prognosis of Inflammation of the Heart ought to be given with caution, gen- erally with reservations, even when the most favourable circumstances are present.—A. In endocarditis in its most severe states there is always more or less danger; and the danger becomes extreme when the anxiety is very great, when the pulse is very frequent and ir- regular, and when swoonings or cold perspira- tions supervene. The slighter or more chronic states of the disease might be amenable to treatment, if it were possible to ascertain their presence before they produce lesions which are but little under the control of medicine. But where these exist in a manifest degree, the prognosis becomes unfavourable in proportion as they oppose the circulation through the com- partments of the heart; death being the ulti- mate result, although it may be long deferred, and various intermediate changes may occur. 138. B. Pericarditis is always a dangerous malady ; yet a considerable proportion of the cases will recover if their nature be early rec- ognised, and if an appropriate treatment be prescribed. M. Louis considers that perfect or partial recovery—partial, inasmuch as or- ganic change of some kind remains, particularly adhesions of the pericardium to the heart- occurs in five cases out of six. If, however, the disease, whether acute, sub-acute, or chron- ic, has given rise to effusion, an unfavourable opinion ought to be entertained of it, and espe- cially if the patient be far advanced in life, or of a cachectic habit of body. Whether the effusion be puriform, or sero-sanguineous, or pseudo-membranous, or sero-albuminous, the question is chiefly as to the length of time that may elapse before a fatal issue takes place; much depending upon the symptoms and signs indicative of the amount of effusion, upon the states of the pulse and of the respiration, and HEART—Inflammations of—Treatment. 229 upon the age and vital energies of the patient. When the effusion follows rapidly upon an acute attack, especially if there has been great fre- quency of pulse, and depressed constitutional powers, the danger becomes much more im- pending than when effusion takes place more slowly and to a less amount. If pericarditis be associated with endocarditis, as indicated by the hellows sound, or by any of its modifica- tions, or with pleuritis, pleuro-pneumony, or diaphragmitis, the danger is thereby increased very greatly—and increased in proportion to the intensity or extent of these inflammations. When the sub-acute or chronic disease has given rise, at more advanced periods, to adhe- sions, or to false membranes (y 107), the actions of the heart and diaphragm may be much dis- ordered, and the functions of respiration, and of circulation in related or remote parts, greatly disturbed; but these consequences are not al- ways observed. Patients have lived for years without much disorder being complained of; although more frequently these functions, par- ticularly the latter, are more or less deranged, impeded circulation, or effusion into some cavi- ty or organ, sooner or later taking place. 139. C. Of the prognosis of true carditis it is unnecessary to speak. If it be presumed to exist, the opinion of the result should be unfa- vourable, inasmuch as a degree of inflammation of the substance of the heart so intense as to be recognisable generally induces the most se- rious changes either on one of the surfaces, or in the structure of the organ. If the symptoms of softening of the heart (y 125) be such as to admit of recognition, with any degree of confi- dence, the prognosis is extremely unfavoura- ble, unless this lesion have taken place in fever, when a more favourable opinion may be enter- tained ; recovery sometimes taking place during an energetic recourse to tonics, chalybeates, change of air, &c. The other consequences of carditis need not be noticed at this place, as they rarely admit of recognition during the life of the patient. 140. ix. Treatment of Inflammations of the Heart.—The different forms of carditis require very nearly the same means of cure, the chief modifications consisting in the extent to which vascular depletions should be carried in the various circumstances that usually present themselves, and in the choice of additional agents for averting the more serious changes which are apt to take place.—A. Blood-letting is necessary in the three varieties of carditis, and especially when either of them is associ- ated with pleuritis, or pleuro-pneumony ; but the utmost discrimination should be exercised as to its amount and repetitions. In all cases, it should be employed early in the disease, and the quantity of blood taken away ought to be in due relation to the violence of the attack, to the age and constitution of the patient, and to the effects produced. In general, vascular de- pletion may be carried farther in pericarditis than in internal carditis, and in the complicated, than in the simple disease. The practitioner ought not to be deterred from bleeding by the weakness and smallness, or irregularity of the pulse, or by the faintness complained of; nor induced to carry it too far by the palpitations and inordinate impulse of the heart, and by the cupped and buffed state of the blood. If car- ditis be connected with rheumatism, this state of the coagulum will continue, although deple- tion be carried to inanition. I have seen it greatest in the blood last taken, where I was confident that the depletion had been carried to a very dangerous length. In these cases, the disease is partly in the blood itself; there is a redundancy of fibrin and albumen, and an in- creased disposition to their coagulation. 141. B. Internal carditis, unless when asso- ciated with pericarditis, is not so much bene- fited by very large blood-lettings as may be supposed, although decided depletion, especial- ly early in the disease, is required. M. Bouil- laud thinks that this treatment should be car- ried farther in endocarditis than in pericarditis : but I differ from him in this; for the danger which he endeavours to avert by repeated ven- aesections—and by them chiefly, if not solely— may be more certainly and safely prevented by the means about to be noticed, when prescribed after more moderate or less frequent depletions than he recommends. Besides, internal car- ditis sometimes occurs in cases where blood- letting had been previously, and even copiously practised; as well as in others where it must be very cautiously and moderately resorted to. In all the forms of carditis, and particularly in pericarditis, it is often necessary to repeat the venaesection oftener than once; but as often, after one moderate or copious venassection, cupping will be the best mode of abstracting blood. Indeed, a sufficient quantity may be taken away by this mode from the first, if the operation be properly performed. When the symptoms are severe, and the disease fully de- veloped, the depletion should be prompt, copi- ous, and repeated, according to circumstances ; but care ought to be taken not to defer the rep- etition of it until the recurring inflammation proceeds far : the least indication of unsubdued action, or the earliest sign of a return of the disease, requires that this means should be again cautiously resorted to, aided, however, by the remedies about to be noticed. In the circumstances under consideration, nervous ex- citement, or irritation, may be mistaken for un- subdued inflammatory action. This may be- come a dangerous, if not a fatal error; and acute observation and enlightened experience can alone guard against it. 142. C. After blood-letting, the rapid induc- tion of the mercurial action is of the greatest importance. With this intention, calomel should be given, every four or six hours, with opium and small doses of the potassio-tartrate of anti- mony, or James's powder, or with colchicum or digitalis. These medicines act beneficially, not only by abating the morbid action of the heart, but also by inducing more rapidly the specific effects of the mercury. In the rheumatic forms of carditis, colchicum is extremely useful. It may be prescribed either with calomel, or with saline medicines, especially the alkaline carbon- ates. I agree with Dr. Roots in his recom- mendation that patients should be kept long under the mercurial influence, and that a local depletion should be resorted to whenever the symptoms become aggravated. When palpita- tions or nervous symptoms follow depletions and the production of the mercurial action, cam- phor (F. 373, 375, 555), or asafaetida (F. 905), or the decoction of senega (F. 74), in moderate do- 230 HEART—Inflammations of—Treatment. ses, will be found extremely useful in reducing the irregularity and the frequency of the heart's action. If the irritability of the heart still con- tinue, these medicines may be given with digi- talis (F. 574), or with hyoscyamus (F. 460), or With opium (F. 493), or with the hydrochlorate or acetate of morphia (F. 537), or with the hy- drocyanic acid. This last has been strongly recommended by Dr. Elliotson in such cases ; and I have found it extremely useful. The ex- tract or tincture of hop, either alone or conjoin- ed with camphor, or with asafcetida, or with the compound galbanum pill, will also be found of service. Where it is still necessary to keep up the mercurial influence, the blue pill may be added to either of these. Anodyne plasters (F. 108, 117) may also be applied over the ster- num .- those containing camphor and extract of belladonna (F. 112, 113) will be found most beneficial. Anodyne liniments (F. 297, 313) will likewise be useful, particularly when pain or irritability continues after the mercurial action is induced. 143. D. In the more chronic or sub-acute states of inflammation of either of the constituent tis- sues of the heart, the means already recom- mended should be prescribed according to the severity and peculiarities of the case. If effu- sion have taken place into the pericardium, or if excrescences or other alterations about the valves or orifices be presumed to exist, exter- nal derivatives, by blisters, repeated or kept open ; by moxas, setons, or issues ; by the tar- tarized antimonial ointment, or by croton oil, may be tried. These derivatives are most service- able when directed to a part at a little distance from the region of the heart. The praecordia will thus remain free for the application of ei- ther of the plasters, or of the liniments recom- mended above (y 142), or of mercurial ointment with camphor. When, in these states of car- ditis, the action of the heart becomes inordinate, M. Bouillaud and some French physicians ad- vise eight or ten grains of powdered digitalis to be sprinkled over the blistered surface. I have had no experience of this mode of em- ploying digitalis. When, in addition to the ir- regular and excited action, there is more or less pain—a perverted state of sensibility fol- lowing the morbid vascular action—ointments or embrocations containing the narcotic alka- loids, especially veratria, delphinaa, or aconitine, may be then tried, in the manner advised by Dr. Turnbull. I have prescribed the first of" these substances in two or three cases of this kind ; but, although it was not devoid of a cer- tain degree of efficacy, it was not so beneficial as was anticipated from the praises bestowed upon it. In neuralgic affection of the heart, and in angina pectoris, the external use of these substances is sometimes productive of relief * * Dr. Turnbull prescribes veratria nnd delphinaa in similar formula and in the same doses. He directs half a drachm of the alkaloid to be dissolved in a drachm of sweet oil, and made into an ointment with an ounce of prepared lard; or a scruple of the alkaloid to be dissolved in two ounces of rectified spirit, for an embrocation; or one grain in twelve pills, with extract of hyoscyamus, &c, one of which is to be taken every three hours. A small portion of the ointment, or of the embrocation, is to be robbed over the preoordia, for ten or fifteen minutes, twice a day. He prescribes aconitine in similar formula to the foregoing ; but he directs only sixteen grains, and eight grains of it to the same quantity of ointment and spirit respectively. Of the tincture of aconite (prepared from one pound of coarsely -pondered aconite root macerated in two pounds of rectified 144 E When the inflammatory affections of the heart are connected with arthritic-or acute rheumatism-™ these espec.ally. but also ifi oth- er cases of carditis-a superab und ance offibnn or of albumen in the blood should be expected, and the disposition to its coagulation on the in- flamed surface ought to be prevented as much as possible. The only means which I know capable of fulfilling this intention are, mercu- rials, combined as above advised, particularly with colchicum or antimony ; the spirits of tur- pentine, given in drachm doses three times a day, until the kidneys become affected ; the bi- borate or the carbonate of soda or of the other alkalies ; and the iodide of potassium. These, after vascular depletion has been employed suf- ficiently, will often be of service, especially if they be judiciously combined with sedatives or narcotics, and aided by external derivatives; substances of an acid nature being, at the same time, avoided. Blood-letting will rarely, of it- self, remove altogether this or any other form of carditis, or change the morbid state of the blood, unless it be assisted by other means, more especially by those already mentioned. 145. F. When either of the forms of carditis supervenes in the course of eruptive or continu- ed fevers, after having a cautious recourse to general or local depletion, the milder prepara- tions of mercury in frequent doses, until the mouth becomes affected, the alkaline carbo- nates, spirits of turpentine internally, or exter- nally in the form of stupe or embrocation, mer- curial liniments or ointments with camphor, &c, and external derivatives, are most to be depended upon. The action of the kidneys should also be promoted by conjoining these with anodynes, nitre, or the sweet spirits of nitre, digitalis, camphor, opium, &o, according to the peculiarities of the case ; or by assidu- ously rubbing a stimulating liniment (F. 297, 311) over the loins. If the inflammation affect chiefly the internal membranes of the heart in the course of exanthematous or low fevers, or if it seem to have been induced by morbid or irritating matters in the circulation, vascular depletions must be employed with caution; in the latter of these circumstances they will oft- en be more injurious than beneficial. The oth- er means, however, just recommended, partic- ularly camphor, nitre, the alkaline carbonates, and opium, should not be neglected. 146. G. Relapses of carditis, especially of per- icarditis, are very common, particularly when the patient relinquishes medical and moral treatment before the morbid condition is en- tirely removed and the functions of the organ entirely restored, or when the inflammation has left more or less alteration of structure, or when the mercurial influence has been imper- fect, of too short duration, or suddenly termi- nated. This influence should therefore be ex- erted fully, continued for some time—not less than two or three weeks—and allowed gradu- ally to subside. In cases of relapse, the large depletions, often required in a first attack, are frequently hazardous. Local bleedings and a moderate use of mercury are generally suffi- cient. Relapses are usually of a sub-acute or chronic form, and are often merely exacerba- tions of unsubdued disorder, or inflammatory spirit for seven days), he gives four or fi*> drops three timi » day, and employs it also externally. HEART—Inflammations of—Treatment. 231 action superinduced in parts already altered in structure as well as impaired in function. Hence these remedies should be prescribed with more precaution and restriction than in first attacks. 147. External derivatives, employed so as to produce a permanent effect, are usually of ser- vice in relapses, as in the chronic states of the disease. Blisters should be repeated, or kept open ; but they should not be applied immedi- ately over or too near the heart, nor longer than to produce redness or incipient vesication. The part ought then to be covered by a warm bread- and-water poultice, which ought to be several times renewed. The irritating effects produ- ced on the circulation by the absorption of the cantharides will thus be in some measure pre- vented. Other means of derivation are often preferable to blisters, especially tartarized anti- monial ointments or plasters ; or warm turpen- tine stupes, embrocations, or liniments ; but the former of these, as well as setons and is- Bues, should be directed at some distance from the inflamed organ. If these occasion consti- tutional irritation or debility, they should be re- linquished ; or anodynes may be given, with gentle tonics, as the tincture or extract of hop, with camphor or asafoetida, or the medicines of this kind already advised (y 142), may be prescribed, in combinations according to cir- cumstances. The diet should be light, and moderately nutritious. 148. H. In the different states of carditis, the bowels must be kept moderately open by mild and tooling purgatives, but severe purging ought to be avoided. The functions of the oth- er excreting organs should also be promoted. The urine especially ought to receive atten- tion, both as to quantity and quality. If it abound with acid, as generally observed in the rheumatic complications, the alkalies, or the biborate of soda, may be given in large doses, with colchicum, camphor, digitalis, or hyoscya- mus, &c. The states of the stomach and liver require careful regulation ; and the redundancy of excrementitious matters in the blood must be prevented by promoting the free action of all the emunctories. 149. I. The diet and regimen should be strict- ly antiphlogistic in the more acute states of the disease. As these pass away, or lapse into more chronic forms, bland, mucilaginous, or farinaceous articles of food, according to the circumstances of the case, may be allowed; but even these ought to be given sparingly un- til convalescence is established. In the more chronic cases, or after relapses, the diet may be more nutritious, light animal food and broths being allowed in moderate quantity. Still, the principal part of the diet ought to be chiefly farinaceous ; and all exciting or heating bever- ages must be avoided. During the different forms and complications of carditis, perfect re- pose, mental and physical, ought to be preserv- ed. The patient's drink, in acute or first at- tacks especially, should be emollient and cool- ing. A weak decoction of marsh mallows, or of barley, or of liquorice root, or mucilaginous fluids containing small quantities of the nitrate of potash, and the subcarbonate of soda, or the biborate of soda, will be found generally appro- priate. Beverages containing an acid should be avoided. [Great obscurity has hitherto rested upon the pathology of cardiac affections, and especially upon the causes through which, in acute rheu- matism, disease is set up in the heart. An- imal chemistry, in the hands of Andral, Lie- big, Golding Biro, Benck Jones, and others, has at length shed some light upon these dis- eases, and furnished a clew, which, if faithfully followed out, may lead to still more important and successful results. Neither an accurate description of symptoms (and none has been more accurate and true to nature than that of Aret^us), nor pathological anatomy, served to aid us much either in the diagnosis or treat- ment of these obscure affections, until at length auscultation and percussion disclosed new di- agnostic signs, and gave significance to those not previously understood or correctly inter- preted. Then pathological chemistry came to our aid, and by its steady rays illuminated a path hitherto devious and shaded in twilight; so that at the present moment we stand in ad- vance of our predecessors, and, if we mistake not, are destined to make still more important acquisitions in this field of discovery. We have already alluded (art. Blood) to the evi- dences of an acid diathesis in acute rheuma- tism, aa manifested by the state of the secre- tions, especially the perspiration, caused by the retention of lithic acid in the blood,* from im- paired function of the kidneys; thus causing the vital fluid to prove morbidly stimulant to the heart and arterial system, as well as the synovial tissues. But, besides this, we have, according to Andral, an increase of fibrin from 2-5 to 4 (in healthy blood), to 8 or 10 in 1000 parts, or more than triple its natural quan- tity ; and these two morbid states of the blood undoubtedly tend to excite inflammatory action in the serous membrane lining and investing the heart. " The subversion of the alkaline state of the blood," says Dr. Furnivall, " could not but prove highly exciting to the endocar- dium, thus causing hypertrophy and inflamma- tion ; while the superabundance of the fibrin tends to favour the formation of depositee within the fine interstices of the cardiac valves and parts adjacent, leading to an embarrass- ment of their action, until the valves can no longer preserve their natural functions. Be- sides, we know that rheumatic inflammation generally attacks the fibrous and fibro-serous textures, and as these textures abound in and about the heart, we have thus another cause powerfully determining morbid action to this organ." Dr. Furnivall states that, since 1830, he has employed alkalies, especially the liquor, or car- bonus potassa, very extensively in acute rheu- matism, and that during that period not a sin- gle case of heart disease has occurred in his practice complicating the former affection, al- " [It has been objected to this hypothesis that the blood is an electro-negative body, and will not allow free aci«Tis its composition. But it is not necessary that the acid should be a free acid : on the contrary, it may exist under some other form, or only its elements may abound in the blond ia greater proportion. Dr. Simon has recently discovered lith- ic or uric acid in purulent secretion ; and it has frequently been recognised in the fluid of rheumatic ulcerations ; and the saliva, it is well known, has an acid reaction. The time is not distant when chemical analysis will be so far per- fected as to detect these minute changes in the composi- tion of the blood ; a process of exceeding difficulty, owing to the chemical transformations that occur at the time the analysis is going on ] 232 HEART—Inflammations of—Treatment. though more than fifty cases have come under treatment, without including any cases of chron- ic or sub-acute rheumatism.* Dr. F. supposes that alkalies act in these cases in a fourfold way: 1st. As neutralizers of the acid predom- inant in the system, and as restorers of the alkaline condition of the blood ; 2d. That they serve to dilute the fibrin superabounding in the blood, and thus restore its normal fluidity ; 3d. As sedatives, indirectly, by the first two modes of action; and, 4th. As diuretics, thus helping to carry off the morbid elements of the blood. We have been in the habit of prescribing al- kalies in rheumatism for nearly twenty years, and with constantly increasing evidence of their prophylactic efficacy in preventing inflam- mation fastening upon the heart, or its invest- ing or lining membrane. Indeed, there is no class of medicines which produces more deci- ded effects upon the blood than alkalies, and none which can be depended upon with more certainty, either to dilute or thin the fibrin of the blood, or reduce the plethora which at- tends on hypertrophy. We frequently find this condition resisting the use of the lancet, which, indeed, is but comparatively transitory in its effects, the very loss of blood often seeming to induce a more active formation of it, besides the injurious reaction which so frequently fol- lows. But by the use of the fiydrochlorate of ammonia, liquor potasses, the nitras potassa, and the alkaline subcarbonates, we may in a short time reduce the amount of red globules, and obviate that condition of the vital fluid on which plastic inflammation depends. We cannot, in this connexion, avoid enter- ing our protest against the use of an article which is frequently employed in acute cardiac affections for the purpose of moderating the action of the heart; we mean digitalis. This agent not only excites a very considerable de- gree of nausea and gastric irritation, which, by- the-way, always prevent any sedative or diu- retic effect, but it manifestly enfeebles the ac- tion of the heart and retards the circulation of the blood, consequently promoting its stagna- tion ; a state of things which it is highly desi- rable to avoid. In all cases of heart affections, attended with much debility of the organ, there is greater or less danger of polypous formations, and in acute endocarditis there is, as we have seen, great liability to vegetations of lymph be- coming attached to the valves and lining mem- brane of the different cavities, an accident which digitalis is likely to favour. Although there may not be in endocarditis any positive debility of the cardiac muscular fibres, there nevertheless is, after a few days at least, a la- boured action of the organ, showing an inabili- ty to propel the thickened blood. In these ca- ses, alkalies, with aconite or hydrocyanic acid, are far preferable, and by their combined use we may avoid the necessity of excessive blood- lettings. Dr. Furkivall recommends aconite, indeed, as one of the most important remedies in the treatment of endocarditis, especially as a sedative, which he regards as superior to any other. It appears to possess a decided action on the organic nerves; reduces the action of * [" The Diagnosis, Prevention, and Treatment of Dis- eases of the Heart and of Aneurism, with Observations on Rheumatism," by J. J. Furnivall, M.D., Lond., 1845.] the heart speedily and in a very sensible de- gree ; possesses considerable power as an an- nphlogistic, and is neither apt to excite nausea, nor does it prove dangerously cumulative, like digitalis. In all cases, then, of cardiac affec tion in debilitated subjects, where there is grea excitement of the circulation, aconite is well worthy of trial. We often meet with these ca- ses of heart disease where there is considera- ble excitement, with inflammatory tendency, combined with a general want of power, and where we are afraid to use the lancet. Here we are disposed to believe that the aconite will prove a valuable remedy, as it has fre- quently been known to reduce the pulsations, in 48 hours, 20 or more in a minute. It is a rem- edy, moreover, well adapted to hypertrophy; to inflammatory complications ; and especially to prevent palpitations as well as to remove them, inducing, as it does, a permanent diminution of the heart's action and of its irritability, wheth- er the habit be debilitated or not; neither low- ering the strength nor causing nausea, yet ef- fectually quelling inordinate action. The an- tiphlogistic action of this article is fully proved by the fact that it speedily removes that con- dition of the blood on which its buffy coat de- pends. To ensure its activity, great care is, however, necessary, not only in its preparation, but also in preserving it from the action of heat, light, and atmospheric air. The extract of asparagus has recently been recommended by Mr. Furnivall and others as an important remedy in the treatment of these affections ; reducing the number of pulsations from 120 to 90 in about 30 hours. We have known it employed with apparent benefit in these cases, and deem it well worthy of farther trials. General and acute pericarditis is, at the same time, one of the most dangerous as well as the most difficult to treat of all diseases, its danger arising from the vital importance of the organ affected, and its liability to organic chan- ges before adequate remedial measures are entered upon. Patients, it is true, generally apparently recover from pericarditis and endo- carditis, but if we examine them carefully af- terward, we shall, in a large number of cases, discover a distinct bellows sound, or other evi. dence of some organic change, which alters the healthy proportion of the cavities and their outlets, or which interferes with the natural play of the heart. Time reveals the mischief that has been done, and when the patient dies, we find disease of the valves, hypertrophy, dil- atation, or an adherent pericardium, life hav- ing been a tedious scene of protracted suffer- ing. Dr. Copland, as well as Dr. Hope, differ from Bouillaud in the extent to which they would carry blood-letting in these affections, espe- cially in acute pericarditis. Dr. Watson tells us that Bouillaud's practice has failed in Great Britain ; that although early and copious bleeding may arrest the disease before the sound of attrition is heard, yet that afterward the consequences of inflammation will be un- affected by this remedy. There is undoubtedly much risk in bleeding to syncope in this dis- ease, as in rheumatic cases, at least, endocar- ditis is generally present, and there is a ten- dency towards a deposition of the fibrin of HEART—Inflammations of—Treatment. 233 the blood, in the shape of minute vegetations, upon the inflamed valves, which is favoured by a retarded movement of the blood over them, and particularly by its stagnation, as in fainting. Bleeding should, therefore, not be carried to such an extent as to endanger such a result, but it should be free, and repeated according to circumstances. Cups and leeches to the precordial region will, in general, if carried to a sufficient extent, be found preferable to gen- eral blood-letting. Too much importance can scarcely be attached to the use of mercury in this affection; and we are always to bear in mind the remark of Dr. Latham, that " in acute pericarditis there is no medium between com- plete cure and certain death." Our treatment in these cases has been simi- lar to that recommended by Hope. The patient is bled in an erect position, and from a large incision, to the verge of syncope ; and the ear- lier the better. From thirty to fifty leeches are then applied immediately, or as soon as reac- tion appears, over the precordial region ; and if the pain is not entirely relieved by these means, together with cathartics, a stimulating enema, and strong revulsives to the extremities, we repeat the bleeding, or the leeching, or both, as the case may require, and this two, three, or more times, according to the circumstances of the patient. Such active treatment as this, however, we have rarely found necessary. Du- ring a dispensary practice of over four years, in which time several thousand patients with various diseases came under our treatment, we recollect only some ten or twelve cases of pericarditis that required very active treat- ment. In a large number of instances the dis- ease was promptly arrested by one very copious blood-letting, followed by free leeching, and an active cathartic. In the aged, the debilitated, or the very young, cupping was found prefera- ble, both to general bleeding and to leeching ; and this is the proper remedy where, from per- sistance of pain and other symptoms, the dis- ease appears to have been not thoroughly erad- icated, and yet the condition of the patient scarcely seems to warrant the farther abstrac- tion of blood. Dr. Hope thinks that where mercury is employed to such an extent in the early stage of the disease as to produce its constitutional effects, the total quantity of blood necessary to be lost will rarely be considera- ble. But the difficulty is to affect the system with mercury sufficiently early to prevent the necessity of sanguineous depletion. We are to bear in mind that our object is to prostrate the action of the heart in an expe- ditious manner, and prevent the establishment of reaction. Our experience coincides with that of Dr. Hope, that if this object can be ac- complished after the first 20, 30, or 40 hours, the disease frequently does not rally, but re- mains perfectly under the control of reme- dies. And we also agree with him in the opin- ion that a degree of activity in the first in- stance, which to some may appear excessive, is an ultimate source of economy to the strength of the patient, as the disease is sub- dued at once, and the protracted continuance of depletory measures, the most exhausting to the constitution, is rendered unnecessary. In addition to these measures, diluting, cooling 30 drinks of the super-tartrate of potash (9iv. to one quart of water), or of nitrate of potash (9ij. to one quart) should be drank freely, and nausea- ting doses of antimony administered every two or three hours, the diet consisting of barley or rice water, gruel, or thin arrow-root. The ad- ministration of mercurials should commence at an early period of the disease, and, in most cases, carried to a sufficient extent to pro- duce a tender state of the gums, which should be maintained for a week or ten days, or even longer, unless the symptoms yield before the expiration of this period. A succession of small blisters over the praecordial region will prove highly useful, where pain continues in the ad- vanced stages of the malady, and also where effusion has taken place into the pericardial sac, as already mentioned. The practitioner should ever bear in mind the importance of closely watching the cardiac symptoms in all cases of acute rheumatism, that he may be able to discover and to check the very first invasion of disease in this most vital organ. Auscultation should be practised, if possible, several times in the 24 hours, for often, where there is no pain, no excess of im- pulse, no irregular action, some unusual sound may be detected in the heart, showing that something wrong is going on there. It may be a simple prolongation or harshness of the sys- tolic sound, without any distinct bellows mur- mur ; and those accustomed to diagnosticate cardial affections will be able to discover these minute and, to many, inappreciable changes, before they have gone to that extent as to be obvious to the uncultivated ear. Where the central organ of the circulation is suddenly in- vaded with inflammatory action, we generally find pain in the praecordial region, with irregu- lar or fluttering action of the heart; but in many instances the approaches of disease are so insidious that no objective symptoms are presented, and we must trust to the delicate and feeble impressions made upon our organs of hearing. We agree with Dr. Latham, that where any endocardial or exocardial murmur is heard in acute rheumatism, we shall be justi- fied in resorting at once to blood-letting and other antiphlogistic measures, and that we should do wrong in waiting until a distinct bellows murmur is heard. In these cases, not only the ear, but the eye, and every sense and faculty are to be employed in ascertaining what is going on within. With respect to the extent to which mercu- ry should be employed in acute diseases of this kind, our rule is to give it in such a way as speedily to produce its constitutional effects, without, however, inducing salivation ; and this may often be done in 48 hours, if combined with such a proportion of opium as to prevent its escape by the bowels. Experience has abun- dantly proved that we have no remedy, except blood-letting, which so effectually controls in- flammatory action as this mineral; it must, however, be employed conjointly with other means, as so ably pointed out by Mr. Copland in various parts of this work.] 150. x. Of Inflammations of the Heart in Children.—A. Internal Carditis is sometimes met with in children, most frequently after smallpox, scarlatina, pneumonia, hooping- cough, and measles ; but it occasionally, also, 234 HEART—Bibliography and Referbncks. appears as a primary affection. It is often con- nected with articuiar rheumatism, or compli- cated with pneumonia or pertussis. I have ob- served it to attend, in its more acute states, the secondary fever of smallpox, but it more commonly appears during convalescence from these eruptive diseases. It is generally insid- ious in its attack and early progress. The pulse becomes quick, irritable, small, and irreg- ular. Cough, without expectoration, or in- crease of pain, is sometimes present. The sounds of the heart are extended, and the pul- sations are indistinct or tumultuous, or run into one another. Breathing is short or hur- ried, especially on any exertion. A heavy pain or aching, or soreness is felt under the sternum, and to the left side. The jugular veins often pulsate; the face is anxious ; the hands become hot in the evening, and the child cannot preserve the horizontal posture in bed. Still it walks about, appears only much out of health, is short-breathed, irritable, and very delicate. On auscultation, a blowing or bel- lows sound is generally heard more or less dis- tinctly. At last hypertrophy, with dilatation of the heart, becomes manifest, and all its con- sequences. 151. B. Pericarditis is a much more common disease in children than is generally supposed. I have met with it often, both in its simple and complicated forms, and at all the epochs of childhood, from three or four years and up- ward. It is frequently associated with endo- carditis and true carditis, and with pleuritis or pleuro-pneumony. In the latter complications it often proceeds to a fatal issue, without hav- ing been recognised during life, it having been masked with the pulmonary affection. Most commonly, however, it is connected with acute arthritic rheumatism; and in this case there may exist also internal carditis, and diaphrag- matic or pulmonary pleuritis. 152. C. The Causes of pericarditis in chil- dren are nearly the same as in adults. I have observed the disease chiefly in children who live in low cellars, and in ground floors, and are much exposed to cold and humidity, es- pecially if they be imperfectly clothed and ill- fed. It is from these causes principally that articular rheumatism, with which the different forms of carditis are generally associated in children, also arises. Pericarditis is often oc- casioned by exanthematous fevers, and by in- flammations of the lungs or pleura; or it fol- lows these diseases, most probably, in conse- quence of exposure to cold, or to vicissitudes of temperature during convalescence from them. It is extremely rare to meet with articular rheumatism in persons under puberty, and es- pecially in children, unconnected with external or internal carditis, or even with both. The Symptoms of pericarditis in children, and the structural lesions produced by it, as well as those consequent upon endocarditis, differ in no respect from the history given of them in adults. 153. D. The Treatment of inflammation of the heart in children should be strictly and ac- tively antiphlogistic at an early stage. Deci- ded local depletions, the exhibition of calomel or other mercurials with colchicum, or antimo- nials. or other anodynes ; mild purgatives, ex-' ternal derivatives, perfect repose, and a bland,! low diet, with the emollient and alkaline drink, already prescribed, are the chief means of cure.* b.bl.oo. and refer.-i, c*™T\'-ZR£fUl%?!: thod. Curand. Morb., cap. «., P- "S- Wd- f*■? '57»- If. Andru, Remarques sur la Sa.*nee, la Purgation, *c, i-„ ■£'„.,1700 — A. Pasta, Epist. de Cordis Polypo ia D^um^'voca'r- BeV,•1™-=°''*"'^fT^S dis Vera., 8vo. Jen*. 17*58.--/. Pasta, De Sang, et Sang. Concretiombu. per Anat. i«Iny»tis, -fc«. Berg.. 1 s Wlv- Borsieri, Inst.t. Wd. Pract., t.£.. ♦ t**'9.^-** "«*, Selecta Diarii, Ac. Annis 1-83, 1785, et 1786. pasnm.- A. Portal, Cours d'Anat. Med., t. in., j>. i9.-Marcus, Ent- wurf einer Speciellen Therapie, b. ii-. p. WS.-Kntjtl. stein, in Hufeland's Journ. der Pract. He.lk.,b. xix. st. iv., p. 119.-ScAenck, in Ibid., b. xxvn., St. i., p. 68-Gartner, De PolypoCoidis in Specie Infant. Wursb., mi.-Merat, Diet, des Sciences Med., t. iv., p. iA.-J.F. Davis, Inqui- ry into the Symptoms and Treatment of Carditis, &c.,8vo. Bath, 1808.—Huber, De Carditide quas epidennce grassata est inter Milites. An. 1814, in Obsid. Cast. Delfzyl. Grdu., 1819— E. Stanley, Trans, of Med. and Chirurg. Soc. o( Lond., vol. vii., p. 3\9—James, in Ibid., vol. viii., p. 434.— Folchi, Riflesstoni sulla Diagnosi della Carditide h Pencar- ditide, 8vo. Rome, 1829.—F. L. Roux, De Carditide Ex- udations ; cum Tab., 4to. Leips., 1820.—Author, in Lond. Med. Repos., vol. xv., p. 25, 1821.—/. F. Meckel, Fab. Anat. Path. Fasc, i. Leips., 1817.—Laennec, De 1'Auscul- tat. Mediate, ou Traite du Diagnostic des Mai. des Pou- mons et du Cceur, t. ii. Paris. 1819, 2d ed., 1826.—Ghs, Ueber Herzbeutziind., 8vo. Wiirzb., 1826— Hildenbrand, lustitut. Med. Pract., vol. iii., t) 571.—Broussais, Exarnen des Doctrines Medicales Gen. adopt., j.; Sod. carbon 3J (vel Sodf b.-borati, jM., . Spiri,. J^theri. N.t.3js..; Tinct. Digitalis m«.-iw.; Sirupl Papaveris 3J. M. Fiat Mist., cujus capiat Cuq». ii., minima! vel i medium quater in die. «J-» mmimt, vel. j. HEART—Hypertrophy or—Description. 235 Burse Mucosa-, Ac, p. 41 —Stnae, De Corde, 1. iv., c. 2— I Stoerck, Ann. Med., vol. ii.. p. 232, 2fi4.—Stoll, Rat. Med., ' pars n., p. 385— Watson, Phil. Trans., 1777, at 31.—IAeu- taud. Hist. Anat. Med., 1. ii., obs. 672, et seq—J. G. Wal- j ttr, in Nouv. Mem. de l'Acad. des Sciences a Berlin, 1785, t. iv., p. 57; Observ. Anat., p. 63 ; et Mus. Anat., vol. i., p. 148-297.—Caldani, Mem. di Fisica della Soc. Ital. a Mode- na, t. xii., p. 2.—/. P. Frank, De Cur. Horn. Morb., 1. ii., p. 173.—Biermayer, Mus. Anat. Pathol., No. 434.—Portal, M6m. sur. Plusieurs Malad., t iv., p. i. ; et Cours d'Anat. Med., t. iii., p. 24.—Prost, Med. cclairee par 1'Ouverture des Corps, vol. i., p. 140..—Andral, Mem. de la Soc. Med. d'Emulation, t. ix., p. 380.—Tacheron, Recherches Anat. Path., t. in., p. 226. Paris, 1825.—/. Abercrombie, Trans. of Med. Chirurg. Soc. of Edin., vol. i.—J. Frank, Rat. In- stit. Clin. Ticin..cap. ix., et Prax. Med. Univers. Precepta, par. ii., vol. ii., sect, ii., p. 190, et seq.—Milller, De Con- cret. Morb. Cordis cum Pericard. Casibus aliquot illustrata, 8vo. Bon., 1825.—Rayer, in Archiv. Gener. de Med., t. i., p. 521.—Timlmouche, in Ibid., t. xviii., p. 593.—Louis, in Revue Med., t. i., p. 30, 1826; et Mem. et Recherches sur J'Anat. Path., 8vo. Paris, 1826, p. 253.—/. P. Latham, Lond. Med. Gaz., vol. iii., p. 209.—Adams, Dub. Hosp. Rep., vol. iv., art. ]9.—BUuland, It-ones Anat. Pathol., 4to. Tab., 1, 2. Traj. ad Rh., 1836.—Hrissault, Essai sur la Pericar- dite, consid. dans son Etat Aigu et Chr., 8vo. Strasb., 1826.—Stiebtl, Monog. Cardit. et Pericardii Acuta, &c, 4to. Franc, ad Mcen., 1828.—R. Mayne, in Dublin Journ. of Med. Science, vol. vii., p. 255.—SeidHtz. in Hecker's An- nalen., b. ii., Heft. 2. Bert., 1835. —Hughes, in Guy's Hosp. Reports, No. 1, p. 175.— Stroud, in Johnson's Med. Chirurg. Rev., No. 46, p. 441.—/. Watson, Med. Gaz., July 30, 1836, p. 701.—Roots, St. Thomas's Hosp. Reports, No. 4, June, 1836; and Med. Gaz., Nov. 12, 1836, p. 222- R. W. Smith, in Dublin Journ. of Med. Science, vol. ix., p. 418. (See, also, Biblioo. and Refer, to Diseases of the Heart generally.) iii. Ulceration, Suppuration, Softening, Partial Aneurism, and Gangrene of the Heart.—Benivenius, Observ., rap. 42.—Schenck, Observ., &c, 1. ii., obs. 202- 207.—Columbus, De Re Anat., 1. xv., p. 489.—Bontt, Se- pulchre!., 1. iv., sect. i„ obs. 2 ; sect, x., obs. 1.—Morand, in Mem. de l'Acad. des Sc. de Paris, 1732, p. 594.—G. Ga- leati, De Bonon. Scien. et Art. Instituto atque Acad. Com- ment., t. iv., p. 26, 1757.—Morgagni, Epist. xxv., 17-25 ; Ep. xvii., 5, 8.— Stoerck, Ann. Med., vol. ii., p. 262.—Lieu- taud. Op. cit., vol. ii., obs. 510-543.—M. Akenside.m Phil- os. Trans., vol. liii., p. 353.—Crvikshanks, The Anat. of the Absorb. Vessels, Ac. Lond., 1786. — Sandifort, Observ. Anat. Path., 1. iv., sect, x., p. 109.—Penada, Saggi di Pa- dova, t. iii., par. ii., p. 59.— Walter, Nouv. Mem. de l'Acad. des Scien. i Berlin, 1785.—Vering, in Den Abhandl. der Josephsakad., vol. ii., p. 345.—Johnstone, Mem. of Med. Soc. of Lond., vol. i., and in Med. Essays. Evesham, 1795. —Desault, Cours de Clinique Externe, p. 117. Paris, 1804. —M. Baillie, Morbid Anat., <&c, ed. 5th, p. 5.—Corvisart, Op. cit., obs. 42, et p. 253.—Biermayer, Mus. Anat. Path., No. 374.—Portal, Op. cit., t. iii., p. 79, er passim ; et Mem. sur Plusieurs Malad., t. iv., p. 17-62.—Testa, Op. cit., p. 233-245.—Gaulay, Mem. sur la Gangrene du Cceur, 8vo. Paris, 1807.—Bogota, in Brera's Giorn. di Med. Practica, t. iii.. par. ix.—G. Jager, in Harles's Rhein. Jahrb., b. ii., p. 146.—Jostphi, Neuen Archiv. fiir Aerzte, b. iii., n. 4.— Fitzpatrick, in Lond. Med. Repos., vol. xvii., p. 295.—Au- thor, in Ibid., vol. xvii., p. 298.—Laennec, Op. cit., t. ii., p. 286, 305.—//. Cloquet, Bullet, de la Faculte de Med. de Paris, 1822, p. 219.—/. Kennedy, in Lond. Med. Repos., vol. xxi., p. 124.— Scoutetten, in Journ. Universelie des Scien. Med., t. xxiii., p. 236.—Maruejouls, Journ. du Pro- gres des Sc. Med., dec, t. xvii., p. 253.— Rullier et Andral, in Revue Medicale, t. ii., 1824, p. 306.—Kreysig, Op. cit., b. iii., p. 165.—Neuhert, in Hufeland's Journ., dec, Nov., 1823, p. 91.—Berard, Diss, sur quelques Points d'Anat. Path, et de Path. Paris, 1826; et Archives Gen. de Med., t. x., p. 364.— Biett, in Ibid., t. xiii., p. 110; et Repert. Gen. d'Anat. et de Physiol., 1st Trim., 4to, 1827 (The case of Talma).—R. Adams, in Dublin Hospital Reports, vol. iv., p. 353.—Breschet, in Rep. Gen. d'Anat. et de Phys., Sec, t. iii., p. 183.—Reynaud, Journ. Hebd. de Med., t. ii., p. 363.—Marcchal, in Ibid., t. ii., p. 494.—Bignardt. Aunali Iniversali di Med., Jan., 1829; et Arch. Gen. de Med., t. xix., p. 438.—Dezeimeris, in Ibid., t. xxi.. p. 343.—Ollivier, in Diet, de Med., 2d ed., art. Cam-.—Andral, Anat. Path., t. ii., p. 324. (See, also, Ploucqutt's Med. Digesta, art. Cordis Apostema, Arrosio, Exulceratio, and Ulcus, and the References to the other chapters.) iv. Induration, Ossification, &c. — Hollerius, De Morbis Internis, 1. i., cap. 50.— Veslingius, Observ. Anat. et Epist. Med., xv.—Bartholinus, Hist. Anat., cent, i., 50 ; cent, ii., 45.— Gemma, in Halter's Biblioth. Med. Pract., vol. ii., p. 198.— Garengeot, in Mem. de l'Acad. des Scien- ces, 1726.— Botrhaave, Pnelect. ad Instit., I) 478 (The sep- tum ossified).—Aurivillius, Nova Acta Soc. Upsal., vol. i., n. 15.— Albertini, in Comment. Bonon., vol. i., 1731.—Mor- gagni. De Sed. et Caus. Morb., Ep. xxvii., art. 17, et seq.; el Ep. xxviii., 16.— Senac, Op. cit., c. i.—Gutst, in Lond. Med. Mus., vol. iii., p. 165.—Stoll, Rat. Med., par. i., p. 252.—De Haen, Rat. Med., par. vi., c. 4.—Sckaarschmidt, Medic, und Chir. Nachrichten Juhrg., b. iii., p. 245.—Lieu- taud, t. ii., obs. 556. 571.—Simmons and Watson, in Med. Communicat., vol. i., art 18, 19. — Bordenavc, Mtm. de l'Acad. des Scien., Ac, 1786, p. 53.—Beauchamp, in Sedil- lot's Rec. Period., t. v., p. 292.—Haller, Elem. Phys., vol. viii., par. ii., p. 78.—Michailis, Medicin. Pract. Biblioth., b. i., st. i.; et in Hufeland's Journ. der Pract. Heilk., b. xviii., st. iii., p. 6.—Thomann, Ann. Institut. Med. Clin. Wurceb., vol. i, p. 118.—Reuss, Repert. Comment., vol. x., p. 94.—.1/. Baillie, Series of Engravings. &c, Fasc. i., pi. 5.—Renauldin, in Coroisart's Journ de Med., vol. xi., p. 259.—Crowfoot, in Edin. Med. and Surg. Journ., vol. v., part xix— Ploucquet, Med. Digesta, art. Cor, Ossificatio ejus.—Prost, Med. eclairee par. l'Observat. et l'Ouvert. des Corps, t. i., p. 140.—Weber, in Salzb. Med. Chir. Zei- tung, part ii., p. 80 (Two bony plates as large as oyster shells).—A. Burns, Op. cit., p. 146.—Kreysig, Op. cit., b. iii., p. 268.—Laennec, Op. cit., t. ii., p. 402.—Cruveilhier, Sur l'Ana*. Pathol., t. ii., p. 22, 77.— Rudolphi, Grund. d. Physiol., Ii. ii., par. ii., p. 290.—Boeck, De Statu quodara Cordis Abnormi., 8vo. Ber., 1818, p. 25. — Mayer, Oes- treich. Med. Jahrb., b. v., par. iii., p. bO (Nearly the whole upper surface oss.).—A. W. Otto, Selt. Beol)., part i., p. 99, and Comp. of Hain. and Comp. Pathol. Anat., trar.s. by South, p. 286.—Tacheron, Recherches sur I'Auat. Path., t. iii., p. 257, 261.-Archives Gen. de Med., t. i., p. 521.— Bertin, Traite des Mai. du Cceur. p. 262.—Louis, Mem. ou Rech. Anat. Path., p. 298.—Abercrombie, in Trans, of Med. Chirurg. Soc. of Ed., vol. i., p. I.—Adams, in Dub. Hosp. Rep., vol. iv., art. 19.—Rose, in Lond. Med. Repos.. vol. xix., p. 29, and in Med. and Phys. Journ., Dec, 1823.—R. W. Smith, in Dub. Journ. of Med. Sc, vol. ix., p. 418. (See, also, the BiBLtuo. and Refer, to the chapter on Structural Lesions of the Heart.) V.—Of Structural Lesions of the Heart and Pericardium. Classif.—IV. Class, II. Order (Author in Preface). 154. Defin.—Alterations of one or more of the constituent tissues or compartments of the heart, generally arising from previous local or constitu- tional disease, and occasioning more or less obvious lesions of related organs. 155. This class of disease of the heart might, according to the definition just given, have com- prised several alterations of structure which have been already considered ; but as these alterations more immediately proceed from in- flammatory action, they have been noticed un- der the head of inflammations of this organ. The lesions, however, which remain to be de- scribed do not depend alone upon either of the chief pathological states already discussed. They are no more the consequences of inflam- mation than they are of altered nervous pow- er. Indeed, they may even occur without any evidence of either morbid condition having ex- isted, although they often more remotely result from certain combinations or forms of these conditions. The only inference that can be drawn from a minute examination of a large proportion of them is, that the organic nervous influence, and, consequently, that the states of vascular action and of the circulating fluids have been altered in such a manner as to have af- fected the nutrition of one or more of the con- stituent structures of the heart, or to have giv- en rise to preternatural and adventitious pro- ductions in that organ. (See art. Disease, $ 93, et seq.) In the consideration of the struc- tural lesions of the heart, I shall notice, in the first place, those which seem to be the simplest in their nature, and in respect of the morbid conditions out of which they arise ; and subse- quently those which depend upon more com- plicated pathological states. i. Hypertrophy of the Heart.—Increase of the Muscular Tissue of the Heart. 156. Defin.—Augmentation of the muscular 236 HEART—Hypertrophy of. substance of the organ, resulting from increased nutrition, and this from excited action. 157. A. Description. — Although Diemer- Broeck, Bartholin, Lancisi, Mokgagni, Se- nac, Borsieri, Corvisart, and others had de- scribed, more or less fully, hypertrophy with dil- atation, and had even noticed the simple form of hypertrophy, or that without dilatation, yet it was not until 1811 that the different vari- eties of the lesion under consideration were fully investigated. In that year M. Bertin described the several forms of hypertrophy with an accuracy fully confirmed by the subse- quent researches of Laennec, Elliotson, Hope, and Bouillaud. M. Bertin considered hyper- trophy nearly as follows : 1st. Simple hypertro- phy ; the parietes of the compartments being thickened, the cavities retaining their natural dimensions; 2d. Hypertrophy with dilatation; the cavities being increased in capacity, and their parietes either of natural or of augmented thickness ; the Active Aneurism of Corvisart, and the Eccentric or Aneurismal Hypertrophy of Bertin; 3d. Hypertrophy with diminution of the cavities ; the Concentric Hypertrophy of Bertin. 158. The second of these, or hypertrophy with dilatation, is the most common. It presents two varieties : (a) That in which the walls of one or more compartments are thickened, and the cavity dilated; (b) That with the walls of natural thickness and the cavity dilated, or hy- pertrophy with increased extent of the walls (Hope). In this latter variety there must necessarily be augmentation of the muscular structure, other- wise the dilatation would be attended by thin- ning of the parietes. The third of the above forms of hypertrophy is the next in frequency, and theirs* is the least common. For twenty cases of the second form of this lesion, not more than one is observed of the first. A thick parietes and a small cavity of either of the ven- tricles do not of themselves constitute concen- tric hypertrophy; for a violent contraction at the time of death may have produced this state. But in this case the bulk of the part would be proportionately lessened. To constitute, there- fore, this form of hypertrophy, the parietes should not only be thickened, and the cavity be diminished, but the bulk should either be natu- ral, or greater than natural. In this and the simple hypertrophy of the left ventricle, the thickness is sometimes double, or even triple what is natural. Bouillaud thinks that the concentric hypertrophy is more frequent and greater in the right than in the left ventricle; and adduces a case from Bertin, where the parietes of the right ventricle were increased to sixteen lines ; a thickness never observed in concentric hypertrophy of the left, although a less degree of thickening is oftener observed in the latter. 159. M. Bouillaud adduces several instan- ces of hypertrophy with extreme dilatation. In one, the left ventricle could contain the closed hand. In another, the right ventricle could ad- mit a goose's egg, while the left could contain the closed hand of a female. In a third, the right auricle of a child of seven years was filled ] with a coagulum as large as the hand of an J adult. In concentric hypertrophy the cavities of the ventricles, especially of the right, may be diminished so as hardly to admit the thumb, or a pigeon's egg. Louis and Bouillaud have ob- served the cavity of the right ventricle even less than this. The columns; carneae generally par- ticipate in this form of hypertrophy, and there- by tend to diminish the cavity. In this ventri- cle, especially, they are often remarkably thick- ened and interlaced, and they may even subdi- vide the cavity, or traverse it, or be so hyper- trophied as nearly to fill it (Bertin, Bouillaud, and Hope).* 160. Hypertrophy may be limited to a single compartment, or it may extend to two or more, and even, although rarely, to the whole organ. It is, in all its forms, more frequently observed in the ventricles than in the auricles, as the former are most obnoxious to the exciting caus- es ($ 165). In some instances one cavity is thickened, while another is attenuated. When hypertrophy with dilatation extends to all the compartments, the heart is often enlarged to three or four times its natural size. It then usually assumes a globular form, the apex be- ing nearly effaced, and it lies transversely in the thorax, the diaphragm turning it in this po- sition, and considerably to the left. It also ari- ses high in the chest, and pushes up, and press- es upon the lung of the left side. The situa- tion of the greatest thickening is usually above the middle of the ventricles, where the fleshy columns take their origin ; but an irregular form of hypertrophy is occasionally seen. The in- terventricular septum is not so often thickened as the external parietes. Hypertrophy may be confined not only to a single ventricle, but even to a part of it, as the base, the apex, the fleshy columns, or the external walls, the rest of the compartments being either natural or thinned. A ventricle may also be contracted in one part and dilated in another; but these latter alter- ations are comparatively rare. It is obvious that the heart will vary in its external form, ac- cording as the hypertrophy is confined to one compartment, or is extended to two or more, or as either form of this lesion predominates. When there is great dilatation, the fleshy col- umns are often stretched, flattened, or attenu- ated. 161. Hypertrophy of the auricles is generally attended by dilatation, the simple and concen- tric forms being very rarely observed in them— so rarely that Laennec does not appear to have * [In order to form a correct opinion whether there is hypertrophy of the heart or not, it will be useful to call to mind the natural size of this organ. According to Laennec, the heart, comprising the auricles, ought to have a sin equal to, a little less, or a very little larger than the first of the subject. The walls of the left ventricle ought to have a thickness a little more than double that of the walls of the right; they ought not to collapse when an incision ia made into the cavity. The right ventricle, a little larger than the left, and having larger columns carneae, notwith- standing the inferior thickness of its walls, ought to col- lapse after an incision has been made into it. In an adult of a medium height and well built, the mean weight of the heart is from eight to nine ounces ; the mean circumference of the organ at its base ii from eight to nine inches; the me»n'longitudinal and transverse diameters are three and a half inches (the transverse diameter, in general, rather exceeds the longitudinal); the mean anteroposterior diam- eter is about two inches. The mean thickness of the walll ot the left ventricle at the base is from six to seven lines. 1 he mean thickness of the walls of the right ventricle el the base is two and a half lines. The mean thickness of the walls of the left auricle is one and a half lines. The mean thickness of the walls of the right auricle is one line. I he ventricular cavity, on an average, will contain a hen's £5/ riv i ,Ca7oy °f the ri(fht vent"cle a little exceeds hat of the left (BouiLLAUD.)_See Buot's Researches on Am. Ed. of Hope on the Heart, Phil., 1844.)] HEART—Hypertrophy of—Nature and Causes. 237 met with these forms in this situation. The musculi pectinati are more enlarged than any other parts of the parietes of the auricles, and sometimes they alone are hypertrophied. Dr. Hope remarks that, as the musculi pectinati are larger and more numerous in the right than in the left auricle, it is in the former that the thickening proceeds to the greatest extent, the right auricle being thereby rendered nearly as thick as the right ventricle (y 9). 162. B. The Nature and Causes of Hypertro- phy.—The hypertrophied muscular tissue of the heart is generally of a livelier red hue than the natural structure, and at the same time firmer and more elastic. This circumstance, in con- nexion with that of hypertrophy, sometimes fol- lowing inflammation of the external and inter- nal membranes, and being even occasionally as- sociated with inflammation of the internal sur- face of the aorta, has induced some patholo- gists—especially Bertin, Bouillaud, Andral, and Elliotson—to refer this lesion to inflam- matory action; and they have considered the accompanying pain and sense of heat in the cardiac region occasionally complained of, the absence of any obstacle to the circulation in some cases, and the not infrequent complica- tion of it with more or less recent inflamma- tory products on one or other of the surfaces, or with increased vascular injection, as proofs of this origin. M. Bertin quotes, in support of this view, the experiments of M. Chevalier, who found, on comparing a hypertrophied ven- tricle with a healthy specimen under the mi- croscope, that the fibres of the former were much redder than those of the latter, and that, on steeping a portion of each in separate quan- tities of distilled water, the hypertrophied por- tion reddened the water more than the other, and when taken out was still the redder of the two. On being put in boiling alcohol, it was found to contain less fatty matter. On this point, which is one of some importance as re- gards the treatment, the writers just named contend, that although it may be considered that this lesion is most frequently produced by ob- struction in the opening leading from the hy- pertrophied cavity, and depends upon increased muscular efforts to carry on the circulation through it, occasioning an increased circulation in the nutrient vessels, and hence augmented nutrition of the part; and although this undoubt- edly obtains to a great extent, and amounts very nearly to one form of inflammation—to inflammation with a development of the for- mative process, yet hypertrophy does not al- ways depend upon such obstruction ; and even when it does, it may be considered not the less inflammatory, inasmuch as the obstruction, whether in the valves or in the state of the or- ifices, is almost always a result of, or an at- tendant upon inflammation, the obstruction, as well as the hypertrophy, proceeding from the presence or continuance of increased vascular action, especially of the nutrient vessels. 163. Notwithstanding these arguments, hy- pertrophy of the muscular tissue does not ap- pear to be the immediate result of inflammato- ry action, although it is generally consequent upon the changes produced by this state of ac- tion, and is often associated with it in the other constituent tissues of the heart. Indeed, it is not unusual for inflammation to occur in these tissues in the course of hypertropny. Admit- ting that the obstruction to the circulation, pro- ductive of enlargement of one or more of the compartments, is not always seated at their openings, yet the inordinate action either caus- ed by nervous excitement long continued, and by inflammatory irritation of the internal mem- brane, or required to overcome the impediments occasioned by false membranes and by adhe- sions of the pericardium, may so develop the muscular structure of a part, or the whole of the organ, as to constitute a very remarkable degree of hypertrophy, although the orifices are unobstructed. If the opinion I have contended for above (§ 6), that the heart possesses a pow- er of active dilatation, as well as of active con- traction, be admitted, the circumstance of caus- es which impede the dilatation of one or more of the cavities being attended by hypertrophy will be readily explained, and one of the argu- ments in favour of the opposite doctrine dis- posed of. When this lesion is seated in the ventricles, especially in the right, it is occa- sioned, perhaps, as frequently by these causes as by any obstacle to the onward current of the circulation. The increased firmness and elasticity of the hypertrophied structure is an additional evidence that this lesion is not in it- self inflammatory, for it presents neither the friability and softening, nor the induration and morbid colour observed to follow inflammation. 164. Viewing, therefore, hypertrophy of the heart as the result of augmented nutrition con- sequent upon increased exercise of the muscu- lar structure, the increased exertion requiring, and hence inducing a more active state of the circulation in this structure, it follows that whatever occasions this increase will, if long continued, give rise to this lesion, in some one or other of its forms, especially in young, san- guine, or plethoric persons, or while the pow- ers of life are unimpaired. Whatever excites the nervous influence of the heart so as to pro- duce long-continued palpitation, or demands from the organ a greater power, either of con- traction or of dilatation, will produce it, partic- ularly in the compartments having a more di- rect relation to such exciting cause. The more remote causes, therefore, of hypertrophy may be divided into, 1st. Those which act directly upon the nervous influence of the heart; 2d. Those which impede the onward current of the blood, and thereby occasion reaction of the muscular structure, in order to overcome the distend- ing or opposing fluid ; and, 3d. Those which encumber the muscular actions of the organ, and render either the contractions or the dila- tations of its cavities more difficult, and require a more energetic exertion of these actions than natural. It must not, however, be supposed that the causes belonging to either of these or- ders produce the effect singly. Two or more of them, although belonging to different orders, often act in unison in producing this lesion. 165. a. The exciting causes which act prima- rily upon the nervous influence of the organ are, all the moral emotions, the other causes shown above to produce palpitation ($ 45, 46), and the physical agents which occasion increased cir- culation. Protracted muscular exertion, by re- turning the blood to the heart with great rapid- ity or force ; a stimulating and rich diet, by ex- citing the heart, and, at the same time, loading 238 HEART—Hypertrophy or—Complications, etc. it with a rich blood ; and the abuse of spirit- uous and intoxicating liquors, are often more or less directly concerned in the production of this lesion, although other causes frequently co-operate with them.—b. The causes which produce reaction by obstructing the circulation are chiefly mechanical, as the alterations in the orifices and valves already described ($ 66,67) j contractions, dilatations, and aneurisms at the commencement of the arterial trunks, espe- cially the aorta ; congestion of the lungs, or in- terrupted circulation through them, from dis- eases of their substance, or of the bronchial tubes, or of the pleura, or from emphysema, and from the accumulation of fluids in the pleu- ral cavities ; the frequent recurrence of spas- modic and convulsive affections, particularly asthma and hooping-cough, and whatever im- pedes the circulation in the aorta, vena cava, and principal vessels immediately connected with them, as wearing strait corsets, the gravid uterus, and large tumours. Under this head, also, may be mentioned insufficiency of auric- ulo-ventricular valves, either from atrophy or contraction of them, or from dilatation of the orifices. Contractions of these orifices, or ob- structions caused by adhesions of, or excres- cences upon the valves, will occasion hyper- trophy not only of the auricles, but also of the ventricles—of the auricles, from the obstruction at their outlets, and the consequent distention of their cavities ; of the ventricles, from the augmented force of dilatation required to fill them ; the concentric form of hypertrophy de- pending chiefly upon this latter cause. Of the other causes of hypertrophy it is unnecessary to make particular mention, as they are of less frequent occurrence, and do not differ materi- ally from those already noticed in connexion with excited action ($ 19,45) and inflammations ($ 126) of the heart. 166. It may be stated, in general terms, that the same causes and lesions of structure which occasion thickening of the parietes of a com- partment, or thickening with dilatation, will pro- duce in other persons simple dilatation, or dila- tation with attenuation of the parietes. The al- terations of the thickness of the walls, as well as of the capacities of the cavities, seem to de- pend very much upon the states of vital energy and resistance, and of nutrition. In young and robust persons thickening of the walls, with or without dilatation of the cavities, of one or more of the compartments, will most likely occur; whereas in the delicate, the lymphatic, or leu- cophlegmatic, in the ill-fed, and in those either advanced in life, or exhausted by previous dis- ease, dilatation, or dilatation with attenuation of the parietes, of one or more of the chambers, will most probably lake place ; but much, also, will depend upon the nature of the obstruction or cause out of which the hypertrophy or dila- tation arises. Where the obstruction to be overcome is relatively greater than the power of the organ to overcome it, dilatation of the cavity more frequently takes place than thick- ening of the walls of that cavity ; and where the obstruction is before the hypertrophied cav- ity, more or less dilatation is usually observed, the degree of thickening or of attenuation of the parietes depending upon the states of vital power and of nutrition, as just stated. Where, however, the obstruction is behind the hyper- trophied compartment, thickening of its walls, with or without diminution of its cavity, is the common attendant. When the cause of hyper- trophy is regurgitation of blood mto the cavity, owing to insufficiency of the valves at the out- let, there is generally more or less dilatation; but there may be either thickening or attenua- tion of the walls, according to the states of vi- tal energy and nutrition. Where there is actu- al thickening of the muscular substance, the coronary arteries are found proportionally en- larged, indicating a greater activity of the vital and nutritive actions of the organ. Dr. Hopk considers that when hypertrophy is connected with an obstruction behind it, the alteration is owing to the retarded circulation in the veins, which is propagated through the capilraries to the arterial system, and ultimately to the heart. He thus explains the occurrence of hypertro- phy of the left ventricle when the mitral orifice is contracted. But the active efforts made to fill the ventricle seem to me to be the cause of this association of hypertrophy ($ 165), for it is often observed where the extreme venous con- gestions, to which Dr Hope's mode of account- ing for it would necessarily give rise, are ntt met with.* 167. C. The Complications of Hypertrophy of the Heart are principally those morbid condi- tions of which the enlargement is a frequent consequence, particularly those just mentioned (4 165), and chronic inflammations of the inter- nal and external surfaces of the organ. These latter lesions, as well as disease of the orifices and valves, not only give rise to hypertrophy, but also often complicate it during its future course. When inflammatory irritation is in- duced in the internal membrane of the cavities, excited action of the muscular structure is the usual consequence ; and when this is long kept up, hypertrophy will follow to a greater or less extent. When pericarditis is followed by ad- hesions or by false membranes, thickening of the walls of the compartments will also some- times result ; the increased action required, in this encumbered state of the organ, in order to keep up the circulation, developing and aug- menting the muscular structure of one or more of the compartments. In these cases, addi- tional lesions are often observed, particularly of the valves and orifices ; and adhesions of the pericardium to the pleura, or other alterations of the collatitious viscera, frequently also exist. 168. Nothing is so common as to find one or more of the above changes of the internal and external surfaces of the heart complicated with hypertrophy. M. Bouillaud remarks that whei inflammation of the external, and especially of the internal sere-fibrous tissue of the organ has become chronic, hypertrophy of the muscular structure is sure to follow. Of thirty-three cases which he records of pericarditis and en- docarditis that terminated in thickening and [We are not, as yet, prepared to admit, with Mr. Cop- land, the doctrine of active expansion of the ventricles, es- pecially as a cause of hypertrophy. It seems to ui much more rational to attribute the enlargement to the excitemeftl and increased action of the whole heart, caused by distea- "°n of ''* other cavities, thus leading to increased growth of the ventricle also. It hardly seems possible that the same nures wb>ch encircle both ventricles can be excited in one and not in the other; or that the left ventricle, which « naturally the strongest and most active, should not be exci- ted by sympathy or continuity of irritRimn, and this leads to a diminution of its cavity by the thickening of its walls.] HEART—Hypertrophy of—its Influence. 239 induration, there was not one in which there was not also hypertrophy. Indeed, this latter lesion may be associated with any of the alter- ations to which the. pericardium and heart are liable, or even with several of them; and it may be, moreover, complicated with various changes of the arterial system, especially car- tilaginous, osseous, and albuminous produc- tions (see arts. Apoplexy. $ 96, and Arteries, A 38, et seq.), aneurisms, &c.; or with conges- tions of related organs, particularly of the lungs, the brain, and the liver; or with effu- sion of serum into shut cavities, or into the cellular tissue ; or with haemorrhages from mu- cous surfaces, or into the substance of the lar- ger organs, as the brains, lungs, liver, &c. [The combinations of hypertrophy and dila- tation are of frequent occurrence in proportion as they are higher in the following scale : 1. Hypertrophy, with dilatation of the left ventricle, and a less degree of the same in the right. 2. Simple dilatation of both ventricles. 3. Simple hypertrophy of the left. 4. Dilatation, with alteration of the left. 6. Hypertrophy, with contraction of the left. 6. Hypertrophy, with contraction of the right. Of the Auricles. 1. Distention, particularly of the right, from congestion during the period of dissolution 2. Dilatation, with hypertrophy. 3. Simple hypertrophy. 4. Hypertrophy, with contraction, which is almost unknown] 169. D. Of the Influence of Hypertrophy, «fc, of the Heart upon Cerebral and Pulmonary Haem- orrhage.—It is unnecessary to add much to the remarks already offered on this subject in the articles Apoplexy ($ 96) and Hemorrhage ($ 30, 107, 115); but certain points connected with it require to be considered at this place.— a. Cerebral hemorrhage is probably a more fre- quent consequence of cardiac disease than pul- monary haemorrhage, but facts are wanting to determine to what extent it is so. That it is more common is shown by Bertin and Bouil- laud ; and it may partly be accounted for by the fact of disease of the pulmonary arteries being much less common than alterations of the cerebral vessels. That an intimate con- nexion often exists between the occurrence of apoplexy and palsy, and antecedent disease of the heart, is now fully established, although doubts are still entertained by some as to the nature of the connexion. As long ago as 1822 and 1823,1 discussed this question (Lond. Med. Repos , vol xviii., p. 149, and xix., p. 17), and in the article Apoplexy (published Sept., 1832) the results of my inquiries were again stated. The occasional dependance of cerebral haemor- rhage on disease of the heart was first remark- ed by Baglivi, who observed it in the case of Malpighi, who died apoplectic after palpita- tions caused by structural change of the heart. It was only incidentally mentioned by Mor- gagni and Lieutaud, and not insisted on in the relation of cause or effect until M. Richerand treated-af it in his account of the case of Ca- bana, in whom this complication was found. Portal, T«sta, and Sprengel soon afterward expressed the same opinions as Richktiand ; and Robh met with this association of disease in the case of the cwwn prince of Sweden. The frequent connexion between cerebral haem- orrhage and disease of the heart has been shown in this country by Hutchinson, Aber- crombie, Craioie, Johnson, Hope, Watson, and myself; and in France by Bricheteau, Lal- lemaSd, Bertin, Cruveilhier, Brouissais, An- dral, and Bouillaud ; and the effect upon the brain has been too exclusively limited to haem- orrhage, and too generally imputed to hyper- trophy of the left ventricle. There is, how- ever, every reason to believe that softening of the brain, congestions of the veins and sinu- ses, and serous effusions into the ventricles or between the membranes, occasionally, also, proceed from cardiac disease, especially when it causes obstructed circulation through the right side of the heart; and that cerebral haem- orrhage may sometimes depend upon the le- sions in this situation, as suggested in the articles referred to. 170. M. Bricheteau has very recently in- vestigated this subject at some length ; but he has insisted chiefly upon the influence of hyper- trophy of the left ventricle in the production of haemorrhage in the brain. He has, howev- er, remarked that other changes within the head besides this may result from this cause, especially determination of blood to the brain, mental disorder, serous effusion, brain fevers, &c. He observes that when hypertrophy is accompanied with other lesions of the heart, particularly with such as impede the free egress of the blood from the left ventricle, as disease of the aortic orifice, the symptoms of cerebral disorder are then much less conspicuous ; and that dyspnoea, tendency to syncope, and drop- sical effusions are more marked. M. Bouil- laud found, out of fifty-four cases of hypertro- phy, in some of which the right ventricle only was affected, and the left one not at all, or very little so, that there were eleven with cer- ebral disease, six with apoplexy, and five with softening of the brain. In five of these eleven the cerebral arteries were ossified or cretace- ous at one or more points. In six of these cases the hypertrophy of the left ventricle was eccentric, in three it was concentric, and in two simple. 171. Dr. Watson (Lond. Med. Gaz., April 6, 1835) has made some very judicious remarks upon this subject; but in all the material points, particularly in the explanation of the connexion between diseases of the heart and brain, he has been anticipated by the observations I have offered, both in the papers referred to above, and in the article Apoplexy ($ 96), where I have succinctly given the results of my own investigations. The views there entertained, as Dr. J. Johnson has done me the justice of stating (Med. Chirurg. Review, April, 1836, p. 512), in an able inquiry into this subject, are fully confirmed by his own experience, and by the more recently published researches of MM. Bouillaud, Bricheteau, and others. As the paragraph referred to in the article Apoplexy has so fully and completely anticipated the re- sults at which subsequent writers on this sub- ject have arrived, I have only to request the reader to turn to it, especially as I have no- thing farther to add to it.*__________ * [Dr. Hope proves, from the statistics of St. Mary Le Bone Infirmary, that in fatal cases of apoplexy, hypertrophy of the left ventricle of the heart exists in more than three fourths of the casts.] 240 HEART—Hypertrophy op—Symptoms and Diagnosis. 172. b. The influence of cardiac disease on pul- monary hemorrhage has also been adverted to in the article Hemorrhage ($ 30, 115). M. Bouillaud found this form of ha;morrhage less frequently to arise from lesions of the heart than that just noticed. He has adduced only three instances in which it seemed to depend upon hypertrophy of the right ventricle. And M. Bertin, while he admits the occasional connexion between pulmonary apoplexy and hypertrophy in this situation, considers it not common. A more intimate and more frequent dependance of the former on the latter has re- cently been contended for by M. Bricheteau. A different view of the connexion between pul- monary haemorrhage and cardiac disease has been lately entertained by Dr. Wilson and Dr. Watson, particularly the latter. The depend- ance of dropsical effusions within the chest upon organic lesions in the left side of the heart has been long known ; but the connexion between haemorrhage from the respiratory sur- faces and these lesions had been entirely over- looked. Mr. A. Burns seems to have been the first who took a judicious view of the subject. He observes that the pulmonic vessels, by the congestion occasioned by cardiac disease, and the continued vis d tergo, are ruptured, the blood being forced into the" air-cells, or into the cel- lular structure of the lungs, until this organ appears like liver, or sinks in water. Dr. Wat- son has very fully shown that the pulmonary haemorrhage rarely depends upon hypertrophy of the right ventricle, but chiefly upon narrow- ing of the left auriculo-ventricular orifice, or rigidity of the mitral valve. Indeed, hypertro- phy of the right ventriole seldom exists with- out disease at the origin of the pulmonary artery sufficient to counteract the increased action of the ventricle. It is, therefore, the obstructed return of blood from the lungs, ow- ing either to narrowing or to dilatation of the left auriculo-ventricular orifice, or to insuffi- ciency of the mitral valve, and but rarely the increased impetus occasioned by the hypertro- phied right ventricle, that causes any of the forms of pulmonary Hemorrhage ($ 107, 115). M. Bertin admits the influence of narrowing of the left auriculo-ventricular orifice in the production of haemorrhage into the lungs, and considers the haemorrhage thus caused to be of a more gradual and passive kind than that produced by hypertrophy of the right ventricle. Dr. Townsend (Cyclop, of Pract. Med., vol. i., p. 138) states that, of twenty-two cases of pul- monary apoplexy examined by him, more than two thirds occurred in persons whose hearts were diseased, and in two only of these was the haemorrhage connected with tubercles; but he has* neglected to assign the particular lesions of the heart observed in these cases. The very frequent dependance of pulmonary apo- plexy on cardiac disease has been insisted upon, also, by Chomel, Andral, Cruveilhier, Bouil- laud, Hope, and others, but with a great want of precision as respects the seat and nature of the primary malady. That cases sometimes occur in which hypertrophy of the right ven- tricle is associated with narrowing of the left auriculo-ventricular orifice in the production of pulmonary haemorrhage is shown by an inter- esting case recorded by Dr. Law (Cyclop, of Pract. Med., vol. ii., p. 403). A young lady had repeated haemoptysis, with palpitations, which were more frequent and profuse until death. Both lungs were found engorged with blood, &c The right ventricle was hypertrophied and dilated ; the left auricle dilated and thick- ened ; the left auriculo-ventricular orifice con- tracted so as hardly to admit a quill; and the left ventricle contracted. The pulmonary ar- tery was dilated and thickened ; the aorta was smaller than natural. In this case, the con- gestion of the lungs, consequent upon obstruct- ed circulation through the left side of the heart, had not only caused haemorrhage, but also by- pertrophy of the right ventricle. 173. It is, moreover, very probable, as I have stated in the article Hemorrhage ($ 115), that when the more powerful moral emotions are productive of haemoptysis, this effect is owing as often to their impeding the circulation through the left side of the heart as to their exciting the action of the right ventricle; and that, when the same emotions occasion apo- plexy, palsy, or any other cerebral disease, they act as frequently by interrupting the cur- rent through the right side, as by inducing in- ordinate action, or hypertrophy, of the left ven- tricle. It is, however, to be presumed that the opposite passions produce opposite effects upon the heart, and that, while terror, fear, grief, anxiety, and other depressing passions impede, the circulation through this organ, and cause congestion of its cavities, thereby favouring the occurrence of haemorrhagie or serous effu- sions either in the head or in the chest, the exciting passions, as anger, desire, revenge, &c, accelerate and increase the force of the circulation, by exciting the actions of the ven- tricles. From this it will appear that the same class of emotions may induce effusion into either the brain or lungs, according to the pre- disposition or previous state, functional or structural, of these organs, and to the side of the heart chiefly affected by them; and that, while the depressing passions act by interrupt- ing the circulation through the heart, and, con- sequently, by impeding the return of blood from these parts, the exciting emotions operate by increasing the frequency and power of the ven- tricular contractions, and by propelling the blood with greater force into these organs. 174. E. Symptoms and Diagnosis of Hypertro- phy of the Heart. — a. The local signs consist chiefly of a permanent increase of the force of the heart's contractions, of the sphere within which they are perceived, and of the double sounds attending them. These signs—the per- manently increased force, extent, and sounds of the heart's actions—are always present; but they vary considerably, and are attended by other phenomena—commonly by an increased extent of dulness on percussion in the cardiac region, and often by some degree of prominence of this part, particularly in young persons. W here hypertrophy is considerable, the move- ments of the heart are visible in a large extent of the left side of the chest and towards the pit of the stomach, and often through the clothes. I he apex of the heart is felt more to the left, and generally at the sixth, seventh, or eighth intercostal space, while the base corresponds with the third, or even the second intercostal space. On applying the hand upon the cardiac region, a stronger, a more extensive, and long- HEART—Hypertrophy of—Symptoms and Diagnosis. 241 er enduring impulse or shock is felt, consisting not only in the striking of the apex, but also in the pushing of the ventricle against the ribs, as the latter swells in each contraction. In these cases, the head, or stethoscope, on auscultation, is raised by the force of the impulse. The first sound is generally prolonged and duller than nat- ural, and the more so the greater the hypertro- phy or thickening of the ventricle. But when the thickening is moderate, and the cavity is somewhat dilated, the sounds are stronger and clearer than natural, and heard over a more extended sphere. When the thickening is very great, and the cavity diminished, the sounds become nearly or altogether imperceptible. In simple hypertrophy, the sounds are not usually otherwise morbid ; but when there is disease of the valves, then the sounds characteristic of this disease are heard. 175. In proportion as dilatation is great, the impulse is slighter, brisker, and lower than nat- ural ; and the first sound is louder, clearer, and of shorter duration. The greater the thicken- ing of the walls, the duller are the sounds, com- pared with the force of the shock or impulse ; and the greater the dilatation of the ventricular cavities and attenuation of their parietes, the clearer, louder, and shorter are the sounds, in relation to the force of the impulse ; which, in cases of great dilatation, is much less than nat- ural. Where the enlargement consists chiefly of dilatation, as well as where thickening pre- dominates, the sounds will be otherwise alter- ed, according to associated disease of the valves or orifices of the organ. In hypertrophy with slight dilatation, as Dr. Williams remarks, there is a strong heaving impulse, with an ab- rupt collapse or back stroke, and a prolonged, diffused, but not clear sound. In dilatation with slight hypertrophy, the sound is loud, commen- cing abruptly, and heard over a large space; while the impulse is unnaturally great only when the heart is excited, as in palpitation, when it produces hard, abrupt, and circumscri- bed blows, without heaving. The palpitations attending hypertrophy will be violent and heav- ing when the thickening predominates; but noi- sy, fluttering, and accompanied with a feeling of faintness when dilatation is the chief lesion. 176. Cardiac hypertrophy is seldom accom- panied with pain; but when it is considerable, or very great, a sensation of uneasiness, of weight, or of anxiety is often felt in the prae- cordia or at the epigastrium. Dulness on per- cussion is in relation to the extent of hypertro- phy and dilatation, and is observed to extend downward and towards the left :-ide, owing to the explanations given above ($ 160), unless when the heart is confined by adhesions. Prom- inence of the cardiac region is not uncommon when the hypertrophy is great. Bouillaud has directed particular attention to this sign; but it has been incidentally noticed by others. 177. b. The general or rational symptoms vary much with the form of hypertrophy, and with the other lesions of the heart with which this is associated. The pulse, in simple and eccen- tric hypertrophy, is generally strong, large, full, vibrating, and free ; but it is small or oppressed in the concentric variety. When there is also disease of the left orifices and valves, the pulse is weak, small, or otherwise affected. Where the hypertrophy is simple, the face and general H 31 surface are animated, the animal heat is devel- oped, and a tendency to active haemorrhage sometimes observed. The venous circulation is also unimpeded, and neither sanguineous nor serous congestions or effusions take place. But when the hypertrophy is complicated with le- sions, interrupting the passage of the blood through the heart, the pulse is weak, small, and irregular; congestions or effusions of blood, and dropsical infiltrations and collections, being common results. Respiration is but little dis- turbed as long as the hypertrophy is moderate and simple. But when it is excessive, it then encroaches on the lungs, and causes dyspnoea ; and, as this state is usually a consequence of impeded passage of blood in the heart, causing congestion of the lungs or serous infiltration of their substance, the dyspnoea is principally owing to these circumstances. Indeed, the majority of sympathetic phenomena observed in connexion with hypertrophy are no farther dependant upon this lesion than that they re- sult from the same alterations as it. Cough is seldom present in the early stages, especially when the hypertrophy is confined to the left ventricle ; but when sanguineous or serous congestion supervenes in the lungs, this symp- tom is commonly observed. OZdema occurs when the hypertrophy is very considerable, and is attended by dilatation. It often appears first in the eyelids and face ; and, as the obstruc- tion to the circulation through the heart increas- es, the serous infiltration augments, and be- comes more general. In simple hypertrophy, the countenance retains its complexion, or is more than usually florid ; but when there is dil- atation, and in proportion as the enlargement is complicated with obstructed circulation, and as the obstruction extends to the lungs, the lips, cheeks, and even the nose present more and more of a purplish tint, and the general surface assumes a sallow and cachectic hue. Apoplec- tic, paralytic, or convulsive attacks, and -pulmona- ry haemorrhage, have been already noticed as consequences of hypertrophy, particularly of its more complicated states. Epislaxis some- times occurs, and prevents or defers the occur- rence of either of these, or of some other se- rious symptomatic malady. 178. c. The signs and symptoms of Hypertro- phy of the individual compartments require some notice, those just mentioned having reference to this change of the ventricles generally. The physical signs of hypertrophy of the auricles cannot be stated with any precision in our pres- ent knowledge ; but, as this change is usually associated with hypertrophy of the ventricles, the distinction between them is not material. Hypertrophy of the left ventricle may be recog- nised by the following signs : The impulse of the heart is greatest under the cartilages of the fifth, sixth, seventh, and eighth left ribs ; and in this situation there is the most dulness on percussion, and prominence of the thorax. The pulse, if there is no obstruction at the aortic or- ifice, is strong, tense, full, vibrating, or hard ; the face is flushed, and the patient experiences throbbing headaches, giddiness, and sometimes even epistaxis. Hypertrophy of the right ventri- cle is attended by a palpitation, or an impulse, which is strongest under the lower part of the sternum, where, also, is the greatest dulness on percussion, especially if this lesion be not 242 HEART—Hypertrophy of—Terminations—Prognosis—Treatment. associated with hypertrophy of the left ventri- cle ; and the pulse possesses neither the force nor tension observed in this latter alteration There are commonly more or less dyspnoea, short breathing, cough, and, subsequently, ex- pectoration and lividity of the face ; but, as I have shown above(§ 172). these symptoms are still greater, and more frequently attended by haemoptysis when the lungs are congested in consequence of interrupted circulation through the left side of the heart, with which, however, this form of hypertrophy is occasionally associ- ated. Turgescence, pulsation, or undulation of the jugular veins, was noticed as a symptom of this alteration by Lancisi ; was rejected by Corvisart ; but admitted by Laennec and Hope. Bertin and Bouillaud consider that it is present chiefly in hypertrophy with dilata- tion, extending to the auricle, and when the right auriculo-ventricular orifice is imperfectly shut during the systole. 179. F. Terminations and Prognosis.—a. As long as hypertrophy continues simple and mod- erate in degree, the patient may experience but little inconvenience from it beyond slight dysp- noea and palpitations, particularly on exertion. But if intemperate living be indulged in, or great corporeal exertion be resorted to, the disease will increase rapidly, and will lead to farther change either of the heart or of the more im- mediately related organs, especially of the brain and lungs. The progress of the malady will consequently vary with the peculiarities and complications of the case, and with the habits, occupations, and treatment of the patient. The terminations of hypertrophy depend, also, very much upon the same circumstances. In its simple states, apoplexy and active haemorrha- ges are its occasional consequences ($ 169); but, if these result not from it, the patient may live many years. When hypertrophy is attend- ed by much dilatation, the symptoms are more severe, and its course more rapid. It does not so frequently cause apoplexy as the foregoing state, but it is generally accompanied with greater disorder of the respiratory functions. Dr. Hope remarks that, when this form of the disease demands, owing to the palpitations and dyspnoea, periodical bleedings at short intervals, it hurries, with an uninterrupted course, to its fatal termination. In the majority of such ca- ses, however, bleedings are not the appropriate means of alleviation. 180. Both the progress and termination of the malady, and consequently the prognosis, more especially depend upon the pathological causes and complications of it. When these consist of diseased valves or contracted orifi- ces, the hypertrophy and dilatation usually pro- ceed to a greater extent, and the balance of the circulation is more disturbed than in the simple form of the complaint. In such cases, congestions, and even effusions of blood, or of serum, generally supervene, either in the sub- stance of important viscera, or on venous or serous surfaces, and occasion various consec- utive maladies, according to the particular le- sion of the heart, and to the consequent seat of congestion, effusion, or infiltration of paren- chymatous structures. Hence result pulmona- ry haemorrhage, &c , oedema, or effusion into the bronchi, or into the pleural cavities, &o, followed by asphyxy. Abolition of the func- tions of the lungs causes stupor, or acceler- ates the alterations which often take place in the brain, especially congestion and sanguine- ous or serous effusions ; or these latter are the first to occur, especially when the primary lesion is in the right side of the heart (J, 169) 181. b. The prognosis, it is evident from the foregoing, is generally unfavourable, especially in the more complicated cases, in proportion to the extent of lesion of the orifices and valves, and where hvpertrophy is accompanied with adhesion of the pericardium. Debility, age, a cachectic habit of body, and disease of the lungs also increase the danger, or, rather, ren- der it more imminent. In the simple states and early stages of the malady, when the con- stitution is not impaired, and when the patient can be subjected to appropriate treatment, and is so circumstanced as to pursue it, the prog- nosis is much more favourable; and, although the alteration already existing may not be di- minished, its progress may be arrested. 182. G. Treatment.—The circumstances which influence the terminations of hypertrophy and the prognosis of it should also control the treatment. The simple form of the malady, particularly in young and otherwise sound per- sons, requires very different means from the complicated, especially when occurring in bro- ken-down constitutions : in the former, vascu- lar depletions may be employed, and repeated from time to time; in the latter, they require great caution and discrimination, or they may be injurious. Laennec and Bouillaud advise blood-letting and other reducing and tranquilli- zing means, in the manner recommended by Albertini and Valsalva, and to a decided ex- tent. But I agree with Dr. Hope in consider- ing these measures hazardous, and often inju- rious, when pushed as far as these writers di- rect. M. Laennec, especially, insists upon co- pious depletion at the commencement of the complaint—upon a repetition of it every two, four, or eight days, until the palpitations cease, and the heart gives only a moderate impulse— upon spare diet, with very little or no animal food—and upon physical and mental repose. If the treatment is not commenced until hyper- trophy has occasioned dyspnoea, dropsical effu- sions, oedema of the lungs, &c., he still advises bleeding and abstinence ; and, in all cases, a perseverance in this plan, especially in absti- nence, for many months ; and he has no confi- dence in a cure until the expiration of a year (if the patient live as long) of complete absence of all the symptoms and physical signs of hy- pertrophy. As to blood-letting, the opinion of M. Bouillaud is not materially different from that of Laennec. He prescribes, for an adult of medium strength, and for a medium degree of the complaint, three or four bleedings at the arm, each consisting of twelve or sixteen oun- ces, followed by one or two cuppings on the pra;cordia of eight or twelve ounces each, in the course of the treatment. He considers di- gitalis as the next most important remedy—as the true opiate of the heart; and employs it both internally and endennically. He applies a blister on the praecordia ; and he sprinkles the blistered surface with from six to fifteen grains of powdered digitalis, directing, at the same time, and long afterward, mental and bodily repose, and a very restricted diet. HEART—Hypertrophy of—Treatment. 243 183. a. Respecting blood-letting in this mala- dy, my experience and opinions are in accord- ance with those of Dr. Hope; and I consider, with him, sparing abstractions of blood, at in- tervals of two or three weeks or more, to be the most beneficial. More copious depletions have given temporary relief, but the symptoms have soon returned with increased violence and carried off the patient, especially in cases where there were also dilatation and lesions of the valves or orifices of the heart. As I have shown in the article Blood (y 58), large deple- tions increase the frequency of the heart's ac- tion ; and this effect is more readily produced by them when this organ is in a state of en- largement. I perfectly agree with the above writer in considering that the indications of treatment should be to diminish the quantity, without deteriorating the quality of the blood, and without producing reaction, or permanent- ly enfeebling the action of the heart and the energies of the constitution ; that from four to eight ounces of blood, taken every two, three, four, or six weeks, according to the circum- stances of the case, will be sufficient to fulfil this indication, to keep down inordinate ac- tion, and to relieve the dyspnoea ; that the diet should be spare, and consist of white ani- mal food, and liquids in small quantity, and that everything heating or stimulating, or cal- culated to accelerate the circulation, ought to be avoided. [In the treatment of this affection, our first aim should be to remove any exciting cause of the malady, as violent exercise, intemperance in food or drinks, mental excitement, &c.; and as it consists in an increased power and action of the heart, a reducing and tranquil- lizing treatment will be appropriate. The plan, however, of rapid depletion by general blood- letting, so strongly urged by Valsalva and Al- bertini, and more lately by Laennec, has at present hut few followers among judicious practitioners. We formerly tried the plan rec- ommended by Laennec in several instances, abstracting blood as copiously as the patient could bear without falling into a state of sink- ing, repeating the operation every few days until the palpitation ceased, and the heart gave but a moderale impulse under the stethoscope, at the same time diminishing, by one half, the quantity of aliment which the patient usually took. In the early stages of hypertrophy, spa- ring abstractions of blood at intervals of two or three weeks or more, we have found very useful; but, in the latter periods of the disease, bleeding has generally exasperated all the symptoms, especially the dropsy, and parox- ysms of dyspnoea. Repeated blood-letting inevitably brings on a state of anamia, characterized by a diminished proportion of fibrin and red globules, and al- ways attended with a quick, jerking beat of the heart and arteries, palpitation and breath- lessness on exertion or excitement, and that disposition to serous infiltration usually called dropsy from debility.] 184. b. Much benefit will result from a judi- cious selection of internal medicines. Of these, digitalis, colchicum, the sub-borate of soda, mer- curial alteratives, hydriodate of potass, refrige- rants, and diuretics are most deserving of notice. The secretions and excretions should be freely promoted by a mercurial alterative taken at bedtime, and a mild purgative in the morning. Equal parts of infusion of digitalis and cam- phor mixture may be also given twice or thrice a day with five or six grains of the sub-borate of soda ; or small doses of colchicum, with an alkaline subcarbonate, may be prescribed in an infusion of tilea Europea, or decoction of marsh-mallows. Diuretics are also of service, especially the super-tartrate of potash with the sub-borate of soda, in the compound decoction of broom-tops, or in a weak infusion of senega, or in camphor julap, or in the decoction of ta- raxacum—the nitrate of potash or soda, with spirits of nitric aether—and the acetate of pot- ash, with small doses of squill, or the infusion or spirit of juniper. When dropsical effusions take place, these, varied according to the peculiari- ties of the case, and aided by hydrogogue pur- gatives, are required ; and one or other of the liniments prescribed in the Appendix (F. 297, 311), with the addition of a little of the hydrio- date of potash, may be rubbed or applied over the thorax daily. When the breathing be- comes much affected, camphor, with small do- ses of ipecacuanha, and with hyoscyamus or belladonna, &o, may be tried ; and when de- bility or irritability is urgent, camphor, con- joined with hydrocyanic acid, or with digitalis and the extract of hop, or with gentle tonics and other narcotics, as the acetate of mor- phia, will be very serviceable. Digitalis was much praised by Ferriar in palpitations from organic lesions; and, when hypertrophy is at- tended with excessive action and distressing irritability, the following will be found use- ful: No. 256. R Infus. Digitalis Jvijss. ; Potassae Nitratis 3ij.; Acidi Hydrocyaniri 1H,xiv. i Sirup. Aurantii 31J.; Misce. Capiat aeger Coch. i., amplum secumla quaque hnra. 185. c. When diseases of the valves and orifices of the heart have been concerned in the pro- duction of hypertrophy, the treatment is not ma- terially, if indeed at all different from what is here advised. The fixed alkalies, especially the liquor potassae, may be given in suitable combinations, as with digitalis, camphor, and various diuretics. The internal exhibition of the hydriodate of potash has been tried by me in several cases, but the results have not al- ways led me to persist in the use of it in car- diac hypertrophy from this cause. It may, how- ever, be given in small doses with liquor po- tassae ; it will then not be injurious. 186. d. External derivatives, especially setons or issues, inserted near the margins of the false ribs, or below them, have been prescribed by me in several cases, and in some with marked advantage. In every instance the treat- ment should be assiduously persisted in, and a most, abstemious diet and regimen rigidly ob- served. Repose of mind and body, and resi- dence in a dry and pure air, are also most ben- eficial. As the features of the disease vary, so should the treatment be modified, care being taken not to reduce the vital energies too low. As soon as exhaustion appears, it ought to he met by restorative means. Where a free dis- charge is procured by setons or issues—which are especially indicated when the hypertrophy has been consecutive of rheumatic disease of the. heart—a gently tonic treatment will be often requisite ; and if any preparation of col- 244 HEART—Dilatation of its Chambers and Orifices. chicum be exhibited, it should be given with camphor or ammonia, or even with stomachic or gentle tonics. ii. Of Dilatation of the Chambers and Ori- fices of the Heart. — Syn. Cordis Aneu- risma, Ballonius, Baglivi; Passive Aneurism of the Heart, Corvisart; Cardieurysma. Car- diectasis, Auct. ; Expansion of the Heart's Cavities. 187. Charact.—Slight palpitations, with dysp- noea and cough; the impulse of the heart being weak and diffused ; the sounds being louder, clear- er, shorter, and heard over a larger extent of the chest than natural; and the pulse being weak, small, or irregular. 188. A. Description.—Dilatation (a) may af- fect equally the whole parietes of one or more of the cavities; or (6) it may be so confined to a portion of the parietes of a chamber as to form an aneurismal pouch.—a. The first of these va- rieties usually presents itself in three forms: 1st. With thickening of the walls of the com- partments. 2d. With a natural state of the walls; and, 3d. With attenuation of the walls. The first of these has been considered in connexion with hypertrophy, and most of the remarks made with respect to it also apply to the sec- ond of these forms. It is chiefly, therefore, to the third, or to dilatation with attenuation of the parietes of the chambers, that attention is now directed. The muscular substance of the heart is often healthy, although dilated ; but it more frequently is soft, flaccid, or even re- markably softened, especially when the atten- uation, as well as dilatation, is great. Some- times its structure is readily broken down by the pressure of the finger, and is of a deeper or darker red, or of a paler or more fawn-col- our than natural. The more remarkable states of softening observed in connexion with dila- tation have been consecutive of inflammation of one or other of the surfaces, probably ex- tending, in some degree, to the substance of the heart, and occurring in debilitated, pre- viously diseased, or cachectic constitutions. 189. This lesion of the heart is much rarer than dilatation with thickening, or with a nat- ural state of the parietes of the cavities ; and the instances recorded of it are not numerous. Lancisi, Morgagni, Corvisart, Bertin, Krey- sig, J. Frank, Laennec, Louis, and Hope have described but few cases of it. Burns and Laennec believed that rupture might proceed from dilatation; and Dr. Hope and Dr. Will- iams have met with this occurrence, which is most likely to take place in aged persons. Dil- atation with attenuation seldom affects one ventricle without the other; but it is more common, or greater in the right than in the left ventricle. It more rarely is seated in all the chambers of the organ. The attenuation exists in various degrees. It may be so ex- treme that the walls of the ventricles hardly are equal to two lines at the thickest parts (Hope and Chomel). The fleshy columns are usually stretched and spread out. The inter- ventricular septum is proportionately less at- tenuated than the other parts. The dilatation is more in the tranverse than in the longitudi- nal direction of the ventricles, the heart there- by assuming a spherical form, and the apex being nearly effaced. When both the ventri- cle and auricle of the same side are much di- lated, the intermediate orifice J* generally also widened, and the valve insufficient to close it. As in cases of hypertrophy, the pos.uon of the organ is somewhat altered when the dilatation is great, it being more or less transverse, and towards the left. A very slight attention is sufficient to distinguish the distention that takes place during the last moments of life from morbid dilatation. The former is slight, presents the appearance of tension, and the muscular substance is healthy, the organ often resuming its natural size when emptied. The latter consists not only of distention, but also of flaccidity, thinning, and softening of the parietes. 190. b. Partial dilatation of one of the heart'i cavities is but rarely met with. M. Bertin states that he has seen one portion of a cavity dilated, and another in its natural state, or even thickened, especially in the right ventricle, near the pulmonary artery. This is evidently a slighter grade of that lesion which has at- tracted, more recently, considerable attention under the appellation of "false consecutive aneu- rism" (Breschet), "■sacculated aneurism," and " true aneurism of the heart" (Ollivier). This alteration has been observed by Galeati, Butt- ner, Corvisart, Baillie, Zannini, Berard, Rostan, Cruveilhier, Breschet, J. Johnson, Elliotson, Adams, Dance, Reynaud, &c. It was found in the heart of Talma, the celebra- ted French tragedian. It is exactly similar to the aneurism of large arteries, and has been met with only in the arterial side of the heart; and, excepting in a single case recorded by Dr. Elliotson, where it existed in the left auricle, always in the left ventricle. In many of the cases it was found at the apex ; in some at the base, or at the middle of the ventricle ; and in others at the front or side. In this last situa- tion it was detected in Talma. In the instan- ces which occurred to Reynaud and Elliot- son two aneurisms were found in the same ventricle. This form of aneurismal tumour varies in size from that of a filbert to that of the heart itself. The larger tumours usually contain layers of dense coagula, similar to those which fill the cavities of arterial aneu- risms. They communicate with the ventricle by a more or less narrow opening, which, with the whole of their interior surfaces, is gener- ally lined with a membrane continuous with that of the ventricles. Like other aneurisms, they are most common in adult males. 191. c. Dilatation of the orifices of the heart \s not less frequent than expansion of the cavi- ties, and often coexists with it. The orifices may be dilated in various degrees, as already shown ($ 189); but generally, when the change is very considerable, the valves become in- sufficient for their purposes, and the expan- sion, owing to the regurgitation into the auri- cles, extends to them. The auriculo-ventric- ular orifices are most frequently dilated, but in very lare instances the arterial orifices have experienced this alteration in a slight degree. 192. B. Causes.—a. Most of the causes, re- mote and immediate, of hypertrophy are also those of dilatation of the chambers and orifices of the heart. As Dr. Hope observes, dilatation is merely a mechanical effect of over-disten- tion. Blood accumulated within the cavities, owing to an interruption to its exit from them, HEART—Dilatation of i will dilate and attenuate their parietes, in pro- portion to the resistance opposed, and to the force exerted by the muscular structure, in or- der to overcome it. When that force is weak, or insufficient to overcome the resistance, the parietes yield, and the cavities undergo dilata- tion with a rapidity depending upon the weak- ness of the walls and the extent of interrup- tion. It necessarily follows that the cavity immediately behind the seat of obstruction will be the first to undergo dilatation, and will experience it to the greatest extent. The compartment, also, having the weakest pari- etes, is, cazteris paribus, the most frequently di- lated. Permanent dilatation is the result of prolonged or repeated causes, as contractions of an orifice, disease of the valves, and fre- quent returns of nervous palpitations. The depressing passions and emotions, as anxiety, fear, &c. ($ 19), and whatever tends to weak- en the power of the heart, may occasion this alteration. The walls of the cavities may also be unusually weak or thin, congenitally and hereditarily. Lancisi observed this lesion in four successive generations ; and Albertini saw a female die of dilatation, five of her broth- ers having been cut off by the same malady. It is most common in persons of a tall, thin, delicate, feeble, and nervous or lymphatic con- formation and lax fibres. Age has also great influence on its production. It is not uncom- mon in young children, but it is most frequent in the aged. It rarely occurs in young adults, unless it has been induced by masturbation, or by fevers and diseases of the respiratory or- gans. In general, all obstructions to the cir- culation, whether situated in the orifices of the heart, or in the aortic or pulmonary sys- tem, will produce it as well as hypertrophy, the supervention of the former being the result chiefly of debility of the organic nerves sup- plying the organ, and of impaired tone or defi- cient nutrition of the muscular structure ; of antecedent disease, characterized by debility or cachexia, or by both. 193. b. When the auricles are protected by a natural state of their valves, and of the auric- ulo-ventricular orifices, the ventricles may be dilated without the former being materially af- fected ; but when the auricular valves are dis- eased, so as to occasion interruption to the pas- sage of the blood from the auricles, or when the auriculo-ventricular openings are dilated, so as to permit regurgitation from the ventricles, then the auricles become dilated, although rare- ly without some increase in the thickness of their parietes. 194. c. The diseases of which dilatation is most frequently consecutive are, inflammations of the heart, and the lesions of the valves and orifices caused by them ; rheumatism extending or translated to this organ ; tubercular consump- tion ; asthma and emphysema of the lungs ; sec- ondary syphilis, especially when treated by ex- cessive quantities of mercury (Albertini) ; adynamic, typhoid, and exanthematous fevers ; scurvy, and carcinomatous and haemato-en- cephaloid maladies. M. Bertin contends that dilatation is generally consequent upon some ob- stacle to the course of the blood ; and that the obstacle, at the same time that it gives rise to this lesion of the heart, produces other phenom- ena, as engorgement of the vessels, serous ef- rs Chambers and Orifices. 245 fusions, passive haemorrhages ; these phenom- ena, as well as the dilatation, being the result of the same proximate cause. Dr. Hope justly observes that the change in the capacity of the cavities may result not only from obstacles to the circulation, but also from debility. There can be no doubt of deficient tone of the muscu- lar parietes, and of the softening and asthenia of the organ, shown to follow adynamic fevers, and of protracted nervous palpitations, particu- larly when connected with chlorosis, anaemia, &e, being sufficient to cause dilatation of one or more of the chambers of the heart, inde- pendently of any appreciable obstacle to the cir- culation. Curvatures of the spine, and what- ever diminishes the cavity of the chest, or presses inordinately upon the large vessels, may also occasion this alteration. 195. d. The same causes and pathological con- ditions which occasion the expansion of a whole compartment or of an orifice may give rise to the dilatation of a portion of it only in the form of an aneurismal cavity, especially whatever opposes the transmission of blood from the heart, as laborious occupations, the more vio- lent mental motions, as hatred, revenge, jeal- ousy, anger, &c. This—the only lesion of the heart which ought to be called aneurismal— may be produced independently of inflammato- ry action, owing to great muscular efforts, or obstacles to the circulation. Where the inter- nal membrane is not destroyed nor thickened, and where the muscular fibres are stretched, separated, or ruptured, antecedent inflamma- tion may not have existed ; but where there is thickening of the internal membrane, or ulcera- tion, or adhesion of the external surface of the dilated part to the pericardium, this lesion may be considered to be a more or less remote con- sequence of chronic inflammation, affecting a portion of the parietes of the ventricle, the di- lated part having lost its elasticity and contrac- tile power. In connexion with this, some ob- stacle to the circulation, or to the passage of blood from the left ventricle, has frequently also been present; the increased lateral pres- sure arising from impeded circulation dilating or extruding the most softened, weakened, or yielding portion of the ventricle. In the unique case of aneurism of the left auricle recorded by Dr. Elliotson, there were extreme cohesion and ossification of the mitral valve, and con- sequent reduction of the auriculo-ventricular opening, changes always consequent upon in- flammatory action, as above insisted upon ($ 68). The sinus of the auricle formed a large aneurism, containing dense and thick layers of fibrin; the interior of the tumour being lined with the smooth membrane of the cavities, as in aneurism of the ventricle. 196. C. The Signs and Symptomatic Effects of Dilatation have been partly noticed under the head of hypertrophy with dilatation (y 175); but those which more especially indicate dila- tation with attenuation remain to be detailed. —a. When the affection is considerable, and extends to both ventricles in uniform expan- sion of the parietes, the heart acquires a round- ed shape, and the degree of contraction is less- ened ; and, as the apex is consequently less forcibly impelled against the ribs, the impulse is slight, brisk, and low in the praecordia. The first sound of the heart is shorter, louder, and 246 HEART—Dilatation of its Chambers and Orifices.—Treatment. clearer than usual, and is heard over a larger extent than would be expected from the weak- ness of the impulse. When the dilatation is considerable, the first sound resembles in short- ness and flapping character the second, and is to be distinguished from it only by its synchro- nism with the pulse of the carotids (Laennec, Hope, Williams). When the dilatation is de- pendant upon disease of the valves and nar- rowing of the origins of the arterial trunks, the sounds will assume a morbid character accord- ingly (y 76). The pulse, in dilatation of the ventricles, is necessarily feeble, and often small; and various symptomatic lesions are observed, which, however, are referrible rather to the al- teration that has produced the dilatation than to the dilatation itself. In expansion of the left ventricle, the physical signs are most appa- rent to the left of the sternum, between the fifth and eighth ribs ; and the symptomatic phe- nomena consist chiefly of dyspnoea, oppression in the praecordia, and dropsical effusions in the chest, &.c. In expansion of the right ventricle, the physical signs are most evident under the sternum, and are accompanied with a pulsating swelling of the jugulars, especially if the dila- tation extend to the auriculo-ventricular open- ing ; the sympathetic changes being principally serous effusions within the cranium, or in the cellular tissue, ascites, oedema of the extremi- ties, short breathing, and various signs of gen- eral cachexia. 197. b. The symptoms of partial dilatation (y 190) of the cavities are extremely obscure. Those stated by Dr. Baillie are common to all cardiac diseases. Auscultation renders us lit- tle or no assistance in ascertaining its exist- ence. It rarely attains a large size—never so large as to produce an external tumour. The cases recorded by M. Reynaud and Dr. J. John- bon terminated in rupture of the aneurism without any previous suspicion of its existence. Dr. Elliotson's and M. Cruveilhier's cases presented symptoms which merely led to a be- lief in the existence of organic disease of the heart. In one of the two cases mentioned in the catalogue of the preparations belonging to the medical department of the army, the pa- tient had complained of cough, dyspnoea, pain in the chest, and haemoptysis ; in the other, the symptoms were not ascertained. Talma died of stricture, amounting nearly to obliteration of the rectum. The aneurism of the left ven- tricle was small, and filled with concentric lay- ers of fibrin. It was remembered that long previously, after having enacted the part of Orestes, in the play of Andromache, Talma felt himself strangely agitated, anxious, and rest- less for some time ; but these symptoms grad- ually subsided. It was supposed that the in- ternal membrane, or some of the fibres of the muscular structure, had then given way, the consequent effusion of coagulable lymph pro- ducing a partial and temporary cure. Others of the cases upon record have been equally ob- scure, while some have been attended by pal- pitations, urgent dyspnoea, cough, and short breathing; anxiety, pain, and constriction at the praecordia ; weak, irregular, or intermit- tent pulse; inability to lie otherwise than on the back ; sudden starting up from sleep, oede- ma of the extremities, &c. 198. c Dilatation of the orifices gives rise to : no indications of its existence, unless it is so considerable as to permit a reflux of the cur- rent of blood, and even then the signs are I equivocal This reflux is one of the causes of the bellows sound, and of the purring tremour, I When it takes place through the right auriculo- ventricular orifice, it causes a venous pulsa- I tion, particularly in the jugulars. 199 D. Progress, Termination, and Prognosis of Expansion of the Heart-The progress of dil- atation entirely depends upon the nature of the pathological condition, or antecedent disease, of which it is a more or less immediate conse- quence. A slight degree of expansion, depend- ing chiefly on original conformation, and ac- companied with a delicate constitution and thin muscles, may subsist long, or remain station- ary for years, without occasioning much disor- der beyond dyspnoea, shortness of breath, and palpitations on exertion, or slight asthmatic dis- order ; but when dilatation is consequent upon a permanent or increasing obstacle to the cir- culation, or is associated with adhesions of the pericardium, the symptoms are more severe, more rapid in their progress, and attended with evidence of general cachexia. When dyspnoea becomes urgent, or oedema or dropsical effu- sions take place, or when pulsation of the jugu- lars is observed, the disease is generally rapid in its progress, especially if exasperated by ex- ertion, mental disquiet, or attacks of fever, &c.; although judicious treatment, by repeatedly pro- curing the removal of effusions, will often pro- long life a considerable time. Much, however, will depend upon the age, strength, constitu- tion, and previous state of the patient. Upon the above considerations the prognosis must entirely depend.* 200. E. Treatment of Dilatations of the Cav- ities and Orifices, with Attenuation of their Pari- etes.—The first object is to ascertain the exci- ting or pathological cause of the dilatation, and to remove it as much as possible. When the cause consists of disease of the valves or ori- fices impeding the circulation, it is difficult, if not impossible, to effect this object, yet it ought not to be left unattempted; but when the cause is of a less permanent kind, as peripneumony, spinal curvatures, pertussis, asthma, bronchitis, hydrothorax, emphysema of the lungs, &c.; or when the dilatation has been produced by labo- rious occupations, constrained postures, strait lacing, playing on wind instruments, &c, this intention ought never to be overlooked ; for, if the expansion have not proceeded so far as to * [The signs and diagnosis of dilatation of the heart are most ably pointed out in Dr. Pennock's Am. Edition of Hope on " the Diseases of the Heart and great Vessels," which the reader should consult. In addition to the symp- toms above mentioned may be enumerated discoloration of the face, congestion of the brain, injection of the mucous membrane, passive hemorrhage, congestion and enlargement of the liver, and angina of the heai t. Mitral regurgitation, from dilatation of the left ventricle, is occasionally met with, which we have had an opportunity of observing this day, July 9th, 1845, in a patient of Dr. North's, at Saratoga springs. A lady of about thirty years of age, labouring un- der general debility and cachexia from extreme cardiac dil- atation, from some unknown cause swooned away, or faint- ed, and, on reviving, there was found to exist the most vio- lent and rapid palpitation that I have ever witnessed. The wnole left side of the chest was thrown into violent commo- tion, and the pulsation iu the carotids was a tremulous wave, advancing and receding with astonishing rapidity, the num- ber of pulsations that could be counted amounting to over -WU in a minute. These symptoms contmued nearly two hours, and were at length relieved by vomiting, induced by a few grains of sulphate of zinc and ipecacuanha.] HEART—Dilatation of its Chambers and Orifices.—Treatment. 247 deprive the muscular structure of the organ of its resiliency, a more or less complete restora- tion of the dilated cavity may be effected. Even when it is impossible to restore the organ to its healthy state, an increase of the dilatation may be prevented, and the patient's life may be pro- longed to the usual limits. 201. The greatest attention should be paid to diet and regimen, as well as to the selection of medicinal agents; and both classes of means ought to be directed to the support of vital power. With this view, vegetable and min- eral tonics may be prescribed, with aromatics, antispasmodics, and anodynes, according to circumstances. Small doses of quinine may be given with camphor and hyoscyamus, or of the sulphate of iron, or of the sulphate of zinc, with the extract of hop. Valerian, asafoetida, the compound galbanum pill, or the compound iron pill, may also be exhibited in similar forms of combination ; or either of the alkaline solutions in use may be given with chalybeates, or with tonic infusions or decoctions. Where there is any obstacle to the circulation, referrible either to a morbid state of the lungs, or to diseased valves, the fixed alkalies, or the sub-borate of soda, with tonics, will be found of much ser- vice. If there exist pulmonary congestion, with copious and difficult expectoration, the decoc- tion of senega root, with an aromatic water, and small doses of camphor, will'be productive of benefit. If attacks of dyspnoea or of asthma take place, and if the dilatation be complicated with emphysema or with oedema of the lungs, this combination will be of use; or camphor, ammonia, asafoetida, ammoniacum, the aethers, &c., may be exhibited in forms which the pe- culiarities of the case will indicate. At the same time, the surface of the body should be kept warm, and derivatives applied to the ex- tremities, fresh air being freely admitted into the patient's apartment. [These cases of dyspnoea will often be most promptly relieved by the administration of a few grainsof sulphate of zinc or ipecacuanha, or both combined; and the result may be explained either by the counter-impression thus made upon the mucous membrane of the stomach, or by the removal of some irritating cause in this organ, to which the impeded respiration is owing.] 202. The utmost attention ought always to be paid to the state of the digestive organs. The secretions and excretions should be pro- moted ; those of the liver and bowels being freely evacuated by an occasional dose of the blue pill at night, and of a stomachic aperient the following morning. Flatulent distention of the stomach and bowels, and acidity, should be especially guarded against, and removed by the means suggested in the article Flatulency (y 15, et seq.); for these states of disorder re- markably aggravate both functional and organ- ic affections of the heart, as shown in the arti- cle just referred to (§ 8). The circulation ought to be kept tranquil by moral and physical quietude, and by a light, nutritious, but not heating diet. In order to preserve a free state of the cutaneous function, and to prevent ca- tarrhal affections, flannel should be worn next the skin, and the feet kept warm by woollen stockings. Febrile and inflammatory affec- tions, and particularly inflammations of the lungs and bronchi, as Dr. Hope very properly advises, should be sedulously guarded against, by adopting these and other means, and prompt- ly treated when they occur. But even in these circumstances, I would add, blood-letting ought to be resorted to with extreme caution, and rarely or never by venaesection. In all cases of expansion of the cavities of the heart, the organ is unable to accommodate itself to large or sudden losses of blood, and hence a fatal collapse may be the result of the abstraction of this fluid. If the contingent pulmonary con- gestion should render vascular depletion an ap- propriate remedy, a small quantity only ought to be taken away, and always when the patient is in the recumbent posture, restoratives and external derivatives being also resorted to. 203. If the expansion has followed low or adynamic fevers, or has been caused by vene- real excesses or masturbation, or by non-in- flammatory softening or relaxation of the mus- cular structure of the organ, as in cachectic, chlorotic, or scorbutic constitutions, tonics are especially requisite ; particularly the prepara- tions of iron, the tincture of the muriate of iron, and chalybeate mineral springs ; residence in a pure and dry air, and light, nourishing food. The vegetable tonics with the alkaline subcarbonates, or preferably with the vegetable or mineral acids, especially the muriatic, the nitro-muriatic, and the acetic, will also be of service, according to the state of antecedent and concomitant constitutional disease. 204. When disease of the valves and orifices of the heart, or any other obstacle to the cir- culation, of which dilatation is a consequence, has proceeded so far as to have also occasion- ed dropsical effusions, treatment is seldom pro- ductive of more than temporary benefit. The means which promise the greatest advantage, especially when effusion has taken place, are so fully stated in the article Dropsy (y 45- 47), that I need not particularize them at this place. If permanent dyspnoea, emphysema of the lungs, increased exudation into the bron- chial tubes, and difficult expectoration, be as- sociated with this state of cardiac disease, ex- pectorants, especially the decoction of senega, the balsams, camphor, ammoniacum, &c, with opium, will be of service. 205. In addition to strict attention to diet and regimen—the former consisting chiefly of light animal food, in moderate quantity, and the more farinaceous vegetable substances, the latter of mental and bodily quietude—the pa- tient should reside in a dry, bracing, temperate, and equable climate, and in large, well-ventila- ted apartments. He should observe early hours, and, as his health improves, take very gentle exercise in the open air. The cold or salt water bath, or the shower-bath, will also be of service, if directed with caution and dis- crimination. In this, as well as in all other af- fections of the heart, bulky, flatulent, and aces- cent vegetables should be avoided, and that kind of food preferred which is found to be most easy of digestion. Recourse may be had to chalybeate or other strengthening mineral wa- ters as convalescence advances. Admitting it possible that partial dilatation or aneurism of the cavities, and that dilatation of the orifices of the heart may be detected during life—a circum- stance not likely to occur, in respect of the 248 HEART—Atrophy of. former lesion especially—the treatment will not vary from that which has been now recom- mended. iii. Atrophy of the Heart. — Cardiac Con- sumption. 206. Charact.—Diminished size or wasting of the heart, the actions of the organ being feeble, lim- ited in extent, and attended by a weak and confined impulse, and by little or no dulness on percussion in the prazcordia. 207. A. The heart may be unusually small, from original conformation or from disease.—a. Many of the instances of extreme smallness of this organ on record are referrible to the for- mer cause. Those adduced by Morgagni (Ep. lxx., 5), Lieutaud (vol. ii., obs. 453), Burns (Op. cit., p. 110X Kreysig (b. ii., p. 468), Otto (Compend. of Comp. Anat, p. 264), and others, are of this kind. The majority of those refer- red to by Lieutaud and Ploucquet (Med. Di- gest., art. Cor—parvum), are stated so loosely by their respective authors as to be almost de- void of interest. Otto thinks that a dispropor- tionate size of the heart to the whole body is sometimes hereditary; and that, when it is congenital, it is often connected with other vicious formations of the organ, or with general weakness and imperfect development. If a really small heart be fleshy, firm, and red, and its compartments in due proportion to one an- other, it may be considered as a vice of confor- mation. 208. b. True atrophy, or diminution of the heart from disease, is rarely observed in a re- markable degree. Slight grades of it are, however, not uncommon, especially in wasting diseases, as phthisis, mesenteric obstructions, and chorea, although the atrophy of this organ is not so considerable nor so rapid as in other muscles. Otto attributes this to the want of cellular tissue between the muscular fasciculi. Portal, Testa, and Kreysig suggest that the seeming diminution caused by the violent con- traction of the organ at the time of death should not be confounded with atrophy of it. True atrophy is accompanied with attenuation, softness, or paleness, or hardening of the struc- ture, or with a shrivelled or wrinkled appear- ance of the surface of the viscus. It may be so considerable as to reduce the organ to one half or one third its natural weight. M. Cho- mel found the heart not larger than a hen's egg in a man who died in the hospital La Cha- riti. As respects its form : 1st. One or more of the compartments are attenuated without any change in their capacities, the heart being but slightly diminished in bulk ; 2d. With at- tenuation there is much more rarely diminution of the capacities of the chambers, the organ being very much lessened in size; and, 3d. With diminution of the cavities, the parietes may be of the natural thickness, or even above it; this is the most frequent form of atrophy. 209. B. The Causes of atrophy of the heart are, 1st. Local; 2d. Moral; and, 3d. Constitu- tional.—a. Of the first, the most common are compression, arising from the pressure of mat- ters effused into the pericardium, or from tu- mours developed in the mediastinum, and con- striction or other changes of the coronary ar- teries, especially ossific deposites in their coats, &.c. I doubt, however, the influence of com- pression from these causes, as the heart is very rarely found atrophied where the greatest amount of effusion has existed in the pericar- dium. In the case referred to below, where there obviously is extreme atrophy from local causes, the previous effusion never seemed to have been very great.*—b. The moral causes consist of mental anxiety, and all the depress- ing passions, particularly when their action has been prolonged —r. The general causes are, whatever arrests the nutrition of muscular structures ; and yet the heart seldom partici- pates in the change of these parts, or only in a slight degree. In the diseases just mentioned (y 208) more or less atrophy is sometimes met with, but it seldom bears any relation to the wasting of the voluntary muscles. In a case of tubercular consumption, in which death oc- curred instantaneously, before ulceration had commenced, and before emaciation had become considerable, the heart was small and flabby, and the parietes of the ventricles somewhat at- tenuated. The most marked cases of atrophy which I have seen were in persons who had died after attacks of chorea and chlorosis, and after hypochondriasis and distress of mind. 210. C. The Symptoms are seldom such as to indicate, with tolerable certainty, the exist- ence of atrophy of the heart, unless it be very considerable. In this case, the impulse is weak, limited or small; the sounds are indistinct oi faint, in proportion as the cavities are dimin- ished in capacity; and there is little or no dul- ness on percussion. The pulse is small, thready, and often frequent; and there is com- monly marasmus, and loss of colour. Yet emaciation can hardly be reckoned as a sign of atrophy, as it not infrequently accompanies hy- pertrophy of this organ. 211. D. The Treatment of this lesion should be directed, 1st, to the removal of the causes, as far as it can be accomplished ; and, 2dly, to the restoration of the healthy nutrition of the organ. The latter of these intentions will be best accomplished by attention to the digestive and assimilative functions, and by the use of chalybeate medicines and mineral waters, with suitable exercise in a dry and temperate air; and the other means recommended for function- * The following case is singular: A girl, at the age of seven years, was attacked with rheumatism of the joints of the upper extremities, with extension of the disease to the pericardium, the former affection subsiding partially as pericarditis was developed. The treatment mentioned in the note to par. 153 was prescribed, and the disease nearly disappeared. But the pericarditis returned on two subse- quent occasions at considerable and irregular intervals; and, in the second and third attacks, the cartilages of the left ribs were pushed outward by the effusion into the pericar- dium. A mercurial treatment was prolonged; recovery seemed more complete, and the case was dismissed. About eight or nine months afterward, this child was brought to me with the lower half of the sternum and the cartilages of the left ribs, which were formerly protuberant, drawing backward towards the spine, so as to form a deep and large depression in this situation, and scarcely to leave sufficient space for an atrophied heart to lie between the spine and the depression. The epigastrium was drawn inward and upward on each contraction of the ventricles. In this case, which was seen also by some of my colleagues at the Mid- dlesex Hospital, the repeated attacks of pericarditis had given rise to adhesions of the pericardium to the heart, and probably also to the pleura ; to this atrophy had succeed- ed ; and the sternum had been drawn inward with the wasted heart. This child was, even in this state, much re- covered. She could take gentle exercise. The heart did not present any morbid sound at this period ; but there was well-marked epigastric pulsation of a confused kind, proba- bly owing to the pressure of the heart on the aorta She was alive and able to be about when this was written HEART—Alterations of Colour and Consistence of. 249 al disorders (y 50 53), for softening (y 221), and for dilatation (y 200) of the heart. 212. iv. Contractions of the Cavities and Orifices of the Heart.—A. Diminution of one or more of the cavities arises, 1st. From concentric hypertrophy of the parieties (y 158); 2d. From atrophy of the heart (y 208); 3d. From the pressure of tumours, or of effused fluids on one or more of the compartments of the organ; and, 4th. From concretions of lymph or of fibrin, recent or organized. The first, second, and third of these morbid states have received attention at the places referred to ; the fourth will be fully considered hereaf- ter. From whatever of these causes the di- minished capacity of the cavities arises, it is evi- dent that very serious phenomena will result as soon as this lesion becomes so great as to ma- terially derange the circulation, especially ve- nous congestions, and serous effusions and in- filtrations. When the cavity of the left ven- tricle is diminished, the pulse is small, as in narrowing of the aortic orifice. 213. B. Contraction of the orifices of the heart may proceed from the same changes as produce diminution of the cavities; but it most frequent- ly is a more or less immediate result of inter- nal carditis, and attendant upon induration of the valves. As such it has already been con- sidered, when treating of the chronic states of endocarditis (y 66, 67). 214. C. The Treatment of diminished capa- city of the cavities is rarely followed by any benefit. The changes producing it manifestly are beyond our resources. This remark is nearly applicable to contraction of the orifi- ces. The means, however, which may be em- ployed, should depend upon the cardiac lesions and the symptomatic changes consequent upon this alteration of the orifices and valves. If hypertrophy have become associated with it, the treatment advised in the chapter on this lesion (y 182), according to the form it may assume, will be appropriate. If expansion of the cavi- ties have taken place, the means prescribed un- der that head will be requisite (v 200). 215. v. Of Alterations of the Colour and Consistence of the Heart.—A. The colour of the heart may vary, or be irregular, both on its surfaces and in its substance. One or more white specks, or patches, of different sizes, are often found. They are produced by a slight inflammation, causing thickening and opacity of the membrane, and are seated in either the internal or external surfaces. The structure and external surface of the organ are often paler than natural in cachectic, dropsical, and leucophlegmatic habits; and are sometimes of a pale yellow in these habits of body, and in hearts which are preternaturally fat. In in- flammation, and in hypertrophy, this organ is redder than usual. In softening, suppuration, mortification, and other organic lesions, it is often spotted, of a grayish, light, or dark brown. Sometimes the internal surface, in one or all the cavities, is reddened throughout by the im- bibition of the colouring matter of the blood ; and a similar discoloration of the external surface has been observed to follow from the transudation of blood, and from haemorrhage into the pericardium. Otto found the heart tinged with green in a case of poisoning with stramonium seeds. 216. B. Alterations of consistence have already been partially noticed (y 113-115), but chiefly as consequences of inflammation.—a. Softening of the heart is not infrequently found in per- sons who have died of low fevers and malig- nant diseases, and it then occurs in the ad- vanced stages of these maladies ; but it is also met with under other circumstances. It pre- sents two forms ; one the result of inflamma- tion (y 113), generally with asthenic charac- ters ; the other seemingly in no way arising from inflammatory action, but rather from im- paired organic nervous or vital power, and in- sufficient nutrition of the organ. In the for- mer the softening is most commonly attended by a deeper tinge of colour or discoloration ; and the substance of the heart is not wasted, or is even more bulky than natural; signs of antecedent inflammation being usually present either in the internal or in the external sur- face, or even in the substance of the organ itself. In the latter form the heart is paler, as well as softer than usual—is easily broken down—and frequently the cavities are some- what dilated ; but there is rarely any other distinct vice of structure. In a few extreme cases, the muscular fibres present a sort offish- like structure, especially in young chlorotic and leucophlegmatic persons. 217. The non-inflammatory form of soften- ing is met with chiefly under the circumstances just mentioned, and in fatal cases of scurvy, purpura, chorea, dropsy, and anaemia. In all these I have seen it, as well as in mesenteric decline and tubercular consumption. It is oc- casionally associated with an inordinate depo- sition of fat around the organ ; this latter be- ing generally attended by a relaxed, pale, soft- ened, or atrophied state of the muscular struc- ture of the heart. In persons who have died suddenly, and without any distinct cause, the heart is sometimes soft, flabby, and even blood- less. Cases of this kind are recorded by Mr. Chavalier, and by my friend Mr. Worthing- ton (Lond. Med. Reposit, vol. xvii., p. 361). An instance also recently occurred in my own practice. In the softened state of the heart found in low fevers, and in other contaminating diseases, there is also observed more or less dark discoloration of it. Violent exertion di- minishes the vital cohesion of this organ, as well as of other muscles, deepens its colour, and causes it to be easily broken down. Senac and Otto found it very soft in hunted deer. This alteration is probably increased by the ef- fect which an inordinate acceleration of the circulation produces upon the fibrin of the blood, as shown by Haller and others. (See art. Blood, v 134.) 218. b. The Symptoms of softening entirely depend upon the proximate cause. If it arise from inflammation, then it is generally attend- ed by the signs and symptoms of an associated endocarditis or pericarditis. If it be accompanied with dilatation, more or less of the phenomena attendant upon that lesion may be expected. In its simple or non-inflammatory states, there are generally great langour and debility ; a soft, quick, weak, feeble, and small pulse; frequent faintings ; a sallow, pale, faded, or tallowy complexion; passive oedema of the extremi- ties, and sometimes of the countenance ; the sounds of the organ being dull and obscure, and 32 250 HEART—Fatty Degenerations and Obesity of. the impulse weak or nearly gone. As this le- sion is often attended by effusion into the per- icardium, the sounds and impulse will be far- ther obscured by this circumstance, and the sphere of dulness on percussion extended ac- cordingly. Wrhen it is not thus associated, the faint sounds and impulse of the heart will not be attended by greater dulness on percussion than natural. (See, also, the sections on In- flammations (v 121) and on Dilatation (y 196).) 219. c. Induration of the heart is generally a remote consequence of inflammatory action (y 119), and is more rarely observed than the op- posite lesion. It is often simulated by an un- usual contraction at the moment of dissolution. In hypertrophy, also, the heart is firmer than natural, but not to amount to a morbid indura- tion, so as to afford great resistance to the scalpel, or to cause a crepitation on dividing it. Induration may occupy the whole of a ventricle, or only part of it; and it may accompany other lesions, or alterations of the organ as to size. It is evidently the consequence of altered nu- trition, and is different from the firmness ob- served in hypertrophy, as well as from the car- tilaginous and osseous hardening of portions of the organ sometimes consequent upon inflam- matory action (y 120). 220. d. Of the Signs and Symptoms of this lesion, nothing positive is known. Laennec supposed that, in its slighter grades, the im- pulse of the heart was increased ; and Corvi- sart thought that, beyond a certain point, it rendered the contractions of the ventricles more difficult, and their movements more con- fined. 221. e. The Treatment of alterations of the consistence of the heart should be directed ac- cording to the evidence of these changes that may exist, and to the associated cardiac and symptomatic changes. In softening, we must depend chiefly upon the exhibition of tonics, especially quinine, cinchona, mineral acids, &c, or upon the tincture of the muriate, or the sulphate, or the other preparations of iron, pure air, and the means recommended for dilatation (y 200). If it were possible to ascertain the presence of induration of the heart, but little could be hoped from medical means. Those advised for hypertrophy (y 182) are, perhaps, the most appropriate. [Perfect tranquillity of body and mind, with as much animal nutriment as the stomach can bear, are essential to the proper management of cardiac softening. Pure air is of no less impor- tance ; for we cannot look for the cessation of palpitation till anaemia is removed. We must employ such means as are calculated to restore the general tone of the muscular system, for, by so doing, we restore tone and elasticity to the heart. If dropsy has already set in, we should use tonics with our diuretics, as casca- rilla, quinine, gentian, &o, and where there is a failure of the circulation, with a tendency to sinking, the diffusible stimulants, as wine, bran- dy, and aether, will be useful] 222. vi. Of Serous and Sanguineous Infil- trations of the Heart.—A. Infiltration of Se- rum into the Cellular Tissue of the Organ— QZdcma of the Heart, Bouillaud—is very rarely seen. This writer, however, describes it as follows: The cellulo-adipose tissue enveloping the viscus presents the form of a tremulous, gelatiniform mass; from which exudes, upon pressure, a liquid, transparent serum, which is sometimes colourless, and occasionally of a yellowish °reen tint. The cellular tissue which is thus infiltrated is of a dull white, or opaline hue, as if macerated by the contained fluid. This alteration may accompany other dropsical maladies, or cachectic states of the system; but it is referred by M. Bouillaud chiefly to a varicose state of the coronary veins, consequent on the difficult passage of the blood from them into the right auricle. Obliteration of some of the cardiac veins will occasion this lesion ; but it has hitherto not been described. 223. B. The Exudation or Infiltration of Blood into the cellular tissue of the heart—Cardiac Hemorrhage—has been also met with, but very rarely, and chiefly in the form of petechia, or small ecchymoses. One or two instances of a more copious haemorrhage into the substance of the organ, so as to form a distinct haemor- rhagic cavity—Apoplexy of the Heart—have been recorded. Petechia and ecchymoses, principally on either of the surfaces of the organ, have been noticed by Stoll, Fairbairn, and Otto. I met with this alteration in a case of purpura haemorrhagica, and in another of scurvy. In these diseases, and in the putro-adynamic states of fever, I believe that it is not very un- common. Otto (Comp. of Path. Anat, y 177, p. 278) states that he met with effusions of blood, in various parts of the heart, in a case of petechial fever; also in a person killed by fire-damp, and in a child who died of hooping- cough. In a case of violent inflammation of the heart, he found small extravasations of blood under the outer membrane. Dr. Fair- bairn (Trans, of Med. and Chirurg. Soc. of Edin., vol. ii., p. 157) observed effusions of blood under the inner membrane of the heart in a case of purpura; and Cruveilhier (Anat. Path., livr. xxii., pi. 3) saw the same lesion in the substance of the left ventricle. The exu- dation and effusion of blood into the pericardi- um has received attention in the article Hem- orrhage (y 276).* 224. vii. Of Fatty Degenerations and Obesity of the Heart.—The fatty degeneration of the structure of the organ is not to be con- founded with an excessive deposition of fat be- tween the pericardiac covering and the sub- stance of the heart, frequently met with in cor- pulent persons.—a. Excess of fat in this viscus is often accompanied with a flabby, softened, and attenuated state of the parietes. In these cases the adipose substance often penetrates to some depth between the muscular fibres. The symptoms attending this state of the organ cannot be referred so much to the accumula- tion of fat—to the obesity of the organ—as to the change in the muscular parietes attending it; both alterations being results of weakened or- ganic nervous energy, and of, consequently, impaired assimilation. 225. b. The true greasy degeneration is a trans- [Petechia: and ecchymoses on the outer surface of ths heart, as also sanguineous infiltrations in its substance, have been observed by Dr. Francis in several bodies dead bf drinking cold water when over-heated, during the ardent heat of summer, in New-York, in the season of 1824 and a .1T ,1 aS "' 5xubs*1uent yars. In a case of sudden death by l.ghtnmg, Dr. F. found the heart surcharged with blood under its outer covering, with exudation of blood and serum within the pericardium.! HEART—Fatty Degenerations and Obesity of. 251 formation of the muscular substance of the or- gan into a fatty matter similar to that first de- scribed by Haller and Vicq d'Azyr as occur- ring in the muscles. This lesion is generally confined to a portion of the parietes. Laennec and Andral met with it only at the apex. Dr. Hope found the greater part of both ventricles thus degenerated, the colour being that of withered leaves. More rarely, the substance of the heart has the appearance of lard, as re- marked by Corvisart, Burns, Duncan, Cheyne, Luchett, and Chomel ; the less altered por- tions in these cases are not only soft and flab- by, but they also have an oily aspect. 226. c. Both these forms of fatty degenera- tion sometimes nearly approximate. M. An- Pral remarks that most frequently the mus- cular fibres are not really converted into fat, but are only atrophied by the excessive depo- sition of fat between them ; yet, in some cases, they seem to have undergone this change, as they grease both paper and the scalpel, owing to an oily matter infiltrating them. That the atrophy of the muscular substance is not a mere consequence of the accumulation of fat, as Andral and others suppose, and that both changes are joint consequences of impaired vital power and imperfect assimilation, are sat- isfactorily shown by the circumstances under which they occur, by their being met with only where these primary pathological conditions exist, especially in aged persons, and by their having been found in connexion with an excess- ive quantity of oil in the blood ; the increase of this fluid in the circulation being a manifest result of impaired assimilation. Mr. Smith {Dub. Journ. of Med. Science, vol. ix., p. 412) has detailed two cases in which this connexion was observed ; and one recently fell under my own observation. In Mr. Smith's cases, glob- ules of limpid oil floated on the surface of the blood ; in my case, the serum was remarkably milky, from the quantity of fat it contained. From the history, and the alterations found on dissection, of two cases detailed by Dr. Duncan {Edin. Med. and Surg. Journ., vol. xii., p. 65), and by Dr. Simeons (Heidi. Kinisch. Ann., t. iii.), it appears that inflammation of the heart may tenninate in the true fatty degeneration of the muscular substance of the organ.* * It may be interesting to subjoin the particulars of a few of the cases of this lesion which have been put upon record. I. A young married woman was seized, ten days before coming under Dr. Duncan's care, with rigours, followed by great anguish and pain under the sternum, with jactitation, want of sleep, rheumatism of the joints, pleuritic pains in the chest, cough, expectoration, dyspnopa, inability to lie down, followed by oedema of the extremities, the pulse hav- ing become weak, soft, and small. The treatment was an- tiphlogistic for some time after her admission into the hos- pital (on the eleventh day of the disease), and subsequent- ly palliative. She died six weeks after the attack. On dissection, the pericardium was found universally inflamed, and firmly adherent to the heart. The lungs were agglu- tinated to the pericardium and to the costal pleura. The heart was enlarged and thickly covered with coagulated lymph, by which the pericardium adhered to it. Under this lymph, about two thirds of the structure of the heart was changed into condensed fat, which melted, stained pa- per, and swam in water; the remaining third had almost lost its muscular appearance. The column* carneae in both the ventricles were larger than natural. Ossific de- posites were found in the aortic and mitral valves. 2. A gentleman aged sixty, who had experienced attacks of gout, and had lived fully, was struck with apoplexy, for which he was treated, by Dr. Cheyne, in the usual man- ner. His pulse, however, continued extremely unequal and ifregular; dropsy supervened; and he died, some weeks afterward, of a recurrence of the apoplectic seizure with 227. d. Of the Signs of Obesity and Fatty Degeneration of the Heart little can be stated with confidence. Many writers suppose that the accumulation of fat, together with the soft- ening of the muscular substance, embarrasses the organ, and ultimately arrests its action. Boerhaave thus accounted for the sudden death of a person whose heart was found load- ed with fat. Portal (Anat. Med., t. iii., p. 75) believed that obesity of the heart produces pal- pitations, dyspnoea, asthmatic affections, and even sudden dissolution ; and Bonet, Senac, and Fothergill entertained similar opinions. It has been also supposed that the softening and attenuation of the muscular substance at- tending the excessive deposition of fat in this organ dispose to perforation or rupture of it. Morgagni and Bouillaud have recorded cases which favour this view. In one of the two in- teresting instances adduced by Mr. Smith, the sudden death was owing to rupture of the left ventricle. Kreysig remarks that, more com- monly, obesity of the heart gives rise to no symptoms by which its existence can be infer- red during life. M. Chomel, however, thinks that it often occasions dyspnoea and palpita- tions, and very probably faintings or sinking; an irregular, weak, soft, small, and slow pulse ; and anasarca, or oedema of the extremities, may also be produced by it. [Dr. Hope supposes that an accumulation of fat about the heart leads to, 1st, diminution of the sounds ; 2d, irregular pulse, without val- vular disease ; and, 3d, oppression, or even pain in the praecordial region, with general signs of a retarded circulation, producing cere- bral, hepatic, and other congestions.] hemiplegia. On dissection, the heart was found greatly hypertrophied. The lower part of the right ventricle was converted into a soft, fatty substance ; the upper part was remarkably thin, and gradually degenerated into this sub- stance. The whole substance of the left ventricle, with the exception of the internal reticulated structure and column* carneae, was converted into fat, the cavity being greatly en- larged. The valves were sound. The aorta was studded with steatomatous and earthy concretions. The principal peculiarity in the symptoms was the state of the respiration, which was irregular, and often suspended for a quarter of a minute.—(Dublin Hosp. Reports, vol. ii., p. 216.) 3. Mr. Adams (Ibid.,\o\. iv.,p. 396) has detailed the case of a man, aged sixty-eight, of a full habit of body, who was subject to cough, and frequent attacks of an apoplectic na- ture. His breathing was irregular, and his pulse about thirty in a minute. He died from an apoplectic attack. On dissection, the right auricle was much dilated. The right ventricle seemed composed of fat, of a deep yellow colour through most of its substance. The reticulated lining of the ventricle, which, here and there, allowed the fat to ap- pear between its fibres, alone presented any appearance of muscular structure. The left ventricle was very thin, and its whole surface was covered with a layer of fat. Beneath this the muscular structure was not a line in thickness, and was soft, easily torn, and like liver. The septum of the ventricles presented the same appearance. In both ventri- cles, even in the lining fibres, yellow spots were seen, where fat had occupied the place of muscular structure. The whole organ was very light. The valves of the aorta were partially ossified. 4. A girl, during arthritic rheumatism, complained of va- rious symptoms, many of which were referrible to the heart. Internal heal, with coldness of the surface, suppressed men- struation, cold perspirations, very feeble action of the heart, were complained of. Death took place after ten months. On dissection, the lungs were found adherent to the peri- cardium and costal pleura. Yellowish white filamentous adhesions existed between the heart and pericardium. Two thirds of the muscular substance of the organ were converted into a grayish yellow mass of fat. (Dr. Simeon's Op. cit., Heidi., 1827.)—See, also, Dr. Elliotson On Diseases of the Heart (p. 32), and the two cases recorded by Mr Smith, in which free oil was seen in the blood ; and in one of which, also, softening and rupture of the left ventricle were ob- served. 252 HEART AND PERICARDIUM—Adventitious Formations in. 228. e. An excessive deposition of fat under the pericardium, according to M. Bizot, is much more frequent in females than in males. He found, in 35 of the latter, the heart very much loaded with fat in 4; but, in 42 of the former, it was equally charged in 23 cases. That the accumulation of fat around the heart is not necessarily connected with, nor depend- ant upon general obesity, is shown by the cir- cumstance of 29 of the female cases having been thin or emaciated, and yet of these there were 14 instances of obesity of the heart. Of 13 females of a full habit, 9 presented an accu- mulation of fat around this organ. In 25 phthisical females, M. Bizot found a maximum deposition of fat in this situation in 11 cases, a medium quantity in 11, and complete absence of it in 3. In 11 phthisical men, this deposite was wanting in 6, and very scanty in 5. (Mem. de la Soc. Med. d'Observat, t. i., p. 351.) I have observed an unusual accumulation of fat around the heart most frequently in habitual drunkards. 229. /. A morbid deposition of fat has likewise been observed on the external surface, and be- tween the layers of the pericardium; sometimes to the extent of producing an injurious pressure upon the heart and great vessels, and even sud- den death. Instances of this change have been noticed by Bonet, Senac, Godart, Morgagni, Meckel, Testa, Parry, Black, Kreysig, and Horn. That this deposition is entirely inde- pendent of general obesity is confirmed by the remark of Otto, who states that he has met with it, although there was meagerness of other parts of the body. Fatty deposites on the pericardium have been incorrectly consid- ered as causes of angina pectoris by Fother- gill, Wall, and Schramm ; they are only con- tingently associated with it, or with neuralgia of the heart, in rare instances. 230. g. The Treatment of this lesion, in ca- ses where the above indications, conjoined with a leucophlegmatic and corpulent state of the frame, render its existence probable, consists in whatever will improve the digestive and as- similative functions and the organic nervous energy. Tonics, chalybeate preparations ; io- dine, or iodine with iron ; stomachic aperients; regular exercise in a dry, open air ; and absti- nence from fat, oily, or rich articles of diet, and from stimulating beverages, especially spiritu- ous and fermented liquors, constitute the chief means of cure, if, indeed, a cure be practicable. 231. viii. Of Adventitious Formations in the Heart and Pericardium.—A. Of Earthy and Ossific Deposition^, little remains to be add- ed to what has been already advanced, when considering them as occasional terminations of chronic inflammation (y 119, 120). But calca- reous phosphates are sometimes deposited in circumstances which are by no means conclu- sive of the presence of inflammatory action, particularly in aged persons, and when other consequences of this action are not observed. __a In many cases, a whitish patch appears, either in the fine cellular tissue uniting the en- veloping membrane to the heart, or between the reflections of the internal membrane com- posing the valves, increases in thickness, and assumes more and more the characters of car- tilage, especially in the latter situation. The morbid secretion giving rise to this patch ulti- mately becomes the seat of osseous or earthy deposites. M. Andral divides the ossiform formations found in the heart into three species, as they are seated in the cellular, fibrous, or muscular tissue—(a) That in the cellular tissue is the most common, the portion of it uniting the reflections of the internal membrane to the fibrous structure of the orifices and valves be- ing most frequently thus altered. The calca- reous phosphates are deposited in the cellular tissue in minute grains, or in considerable masses, separating and compressing the sur- rounding textures. They are more rarely met with in the tissue connecting the muscular fibres ; and they there form either isolated masses, or are connected with the deposites formed around the orifices.—(b) The fibrous tis- sue frequently also becomes the seat of the os- seous deposite, and chiefly in three points: 1st, In the tendinous zone encircling the left auric- ulo-ventricular orifice; 2d. In the fibrous struc- ture of the valves ; and, 3d. In the tendons of the mitral valve.—-(c) The third species is the most rare. Indeed, it is doubtful whether the muscular fibre ever becomes the seat of this al- teration. It seems more probable that the de- posites in the connecting cellular tissue, by their bulk, compress or partially destroy the muscular structure, than that this structure is converted into bone. The rare instances on record, especially those adduced by Burns, Remauldin, and others above referred to(Y 119), are most probably merely proofs of the partial destruction of the muscular tissue in the seats of the excessive osseous or calcareous forma- tions. 232. b. The pericardium very rarely presents patches of the cartilaginous and osseous trans- formations. Instances, however, of the former have been recorded by Boerhaave, Riolan, Hautesierk, Morgagni, Saviard, Otto, and Testa ; and of the latter have been observed by Aurivillius, Saviard, Walter, Haller, Pasta, Senac, Prost, Rayer, Laennec, and Abercrombie, in the fibrous or in the serous layer. Fibro-cartilaginous and osseous concre- tions are still more rarely found loose in the cavity of the pericardium. They have been detected only by Lanzoni and Otto, and have probably had their origin in peduncular tumours which had subsequently been broken off. 233. c. Signs.—Laennec supposed that car- tilaginous or osseous formations in the sub- stance of the heart may be recognised, when very considerable, by an augmentation and mod- ification of the sound. That a morbid sound will be heard when the orifices and valves are im- plicated, cannot be disputed ; but the phenom- ena consequent upon these changes, when con- fined to the body of the organ, have not been observed with any precision. In a case noticed by M. Andral, the suppositions of Laennec were not confirmed. It is unnecessary to add that these lesions are altogether beyond the reach of treatment. 234. B. Tubercular Formations have been very rarely found in the muscular structure of the heart. M. Laennec met with only three or four cases, but Otto and Bouillaud never saw one. M. Andral remarks that the heart is one of the organs in which tuberculous de- posites are most rarely observed. Instances, however, are recorded by Hildanus, Bonet, Morgagni, Portal, Autenrieth, Spens, Law- HEART AND PERICARDIUM—Adventitious Formations in. 253 bence, Bayle, Macmichael, and Elliotson, at the places referred to below. In a man aged thirty-four, who complained of pain in the chest, cough, inability to remain in the recumbent pos- ture, and subsequently of irregularity of pulse and palpitations, hypertrophy of the left ventri- cle and tubercular formations in the muscular structure were found after death. (Cat. of Prepar. in Museum Fort Pitt, &c, p. 38.) In an aged man, who died of pulmonary consump- tion (Dub. Med. Journ., 1836), a tubercular mass was found in the parietes of the left auri- cle obstructing the trunks of the pulmonary veins. M. Sauzier detected, in a man who died of tubercular disease of the lungs, pan- creas, &c, tubercles in a crude state in the walls of the auricle, the pericardium being ad- herent in the situation where they existed. Most of the cases of this lesion on record have occurred in persons who were labouring under extensive tubercular disease of the lungs and other organs : many of them have not been ob- served with any degree of precision, and the anatomical descriptions have generally been very loosely given. Tuberculous productions have been found also in the internal surface of the pericardium by Musgrave, Haller, Voigh- tel, Baillie, Otto, and others. 235. C. Watery Cysts and Hydatids have been detected both in the substance and on either of the surfaces of the heart.—a. Simple cysts have not infrequently been confounded with hydatids, the former having been descri- bed as instances of the latter formation, espe- cially some of those mentioned by Bonet, Rut- ty, Morgagni, Huermann, Salzmann, Clossius, and others. Portal found several hydatids on the base of the heart; Meckel and Bernhardi, large hydatid sacs on the left ventricle ; Price, a. large single hydatid in the muscular sub- stance, in a boy who died suddenly ; Aber- crombie, a bag containing two ounces of albu- minous fluid on the left auricle ; and Trotter, two hydatids within the right ventricle. It is, however, doubtful whether these were really cases of hydatids. From the imperfect account given of the most even of these, it may be in- ferred that some of them, at least, were merely instances of serous cysts. M. Andral remarks that these cysts vary from the size of a pea to that of a large hen's egg. They are most fre- quently found between the external surface of the heart and pericardium ; but they are some- times seen on the internal surface of one of the chambers. In other cases, they are not visible on either surface, and it is only on dividing the muscular structure that they are detected. M. Dupuytren saw a number of these cysts im- bedded in the walls of the right auricle, and protruding a considerable way into its cavity. M. Andral found a cyst as large as a walnut in the walls of the left ventricle, which were slightly hypertrophied. In another case, he detected one on the free surface of the lining membrane of the right ventricle, attached to it by a delicate pedicle of the same texture as this membrane. Dr. Elliotson mentions a case in which a number of globular cysts, con- taining a bloody fluid, were attached by pedi- cles to the fleshy columns. 236. b. Instead of simple cysts, true hyda- tids have been found in the heart, but in ex- tremely rare instances in the human subject ; they are more frequently met with in this or- gan in the lower animals. M. Andral has oft- en seen them in the hearts of measly pigs, and only once in the human heart. Otto saw them protruding into the right auricle in one case ; I and in a man who died of diseased testes, he detected " a heap of hydatids on the Eustachian valve, hanging by several threads into the right ventricle." These, however, were probably only a cluster of simple cysts. Mr. South states that at St. Thomas's Hospital, there is a heart with a cyst on its apex as large as a hen's egg, which was filled with hydatids. Watery cysts and hydatids have been found not only under that part of the pericardium reflected over the heart, but also either attached to the inner sur- face of the bag of the pericardium itself, or lodged between its layers. 237. D. Tumours of various kinds are noticed by the older writers as having been found in the substance of the heart; but, owing to their de- ficient anatomico-pathological knowledge, and to loose or defective descriptions, the exact na- ture of these is unknown. To these belong the cases recorded by Rhodius, Schenr., Columbus, and Bonet, and those collected by Lieutaud. Tumours of a steatomatous nature have been ob- served by Penada, Fleisch, Sprengel, and Otto ; and others, of nmelicerous and gritty kind, by Morgagni, Walter, Arndt, and Cruveil- hier. Otto states that he has seen a fat, grit- ty tumour in the substance of the right ventri- cle of an old woman, and five or six encysted tumours, the size of hazelnuts, in the left ven- tricle of a young man. In an officer, who was the subject of chronic hepatitis, dropsy, &c, the slightest exertion producing severe palpita- tion, hurried and oppressed breathing, and a sharp, irregular pulse, the heart was enlarged, and presented a large encysted tumour on the right auricle, the aorta being ossified at sever- al points. (Catal. of Prepar. in Mus. Fort Pitt, &c, p. 36.) 238. E. Sarcomatous Formations, and Medul- lary Sarcoma or Encephaloid Productions, have also been found in both the heart and pericar- dium. Otto remarks that sarcoma occurs, 1st, as single, little roundish knots, deposited be- tween the layers of the valves ; 2dly, as white condylomatous growths on the inner surface, and especially on the valves ; and, 3dly, as spheroidal, smooth, tolerably large, and solid growths, or true sarcoms. The first is com- mon ; and instances of the second are recorded by Lancisi, Bonet, Morgagni, Sandifort, Tes- ta, Laennec, Desruelles, &C. Corvisart, Scarpa, and some others, consider them of a syphilitic nature, while Bertin and Bouillaud controvert this opinion. Otto states that he has met with them large, grape-like, or in the form of a cock's comb or cauliflower, both in syphilitic and in other persons. Bouillaud views these formations as the consequences of modi.red states of chronic inflammatory action. The third variety is most rare. It has been ob- served in either surface, and in the substance of the heart, by Forlani, Blancard, Soemmer- ring, Otto, Rigacci, Nasse, and others. Meck- el found fifteen of these productions, from the size of a pin's head to that of a hazelnut, partly within and partly without the heart. Testa found them in the heart of a person long afflict- ed with syphilis. Mr. South stales that, at St. 254 HEART—Polypous Concretions in its Cavities. Thomas's Hospital, on the interior of the right auricle of the heart of a man, who had a sar- comatous growth in the nostrils, there were two similar productions, one as large as a bean, the other as a pea. 239. F. Medullary Sarcoma, or Fungoid Dis- ease, in modified forms, may implicate the heart or pericardium, or both. As in the case of tu- berculous deposites, it is observed principally in cases where this disease had previously ap- peared in other parts of the body. Bartzky found it on the anterior and upper part of the heart; Segalas d'Etchpare, in a boy; Cru- veilhier, in an old man ; Ollivier, and sever- al authors quoted by Otto, in persons advan- ced in life. In all these there were similar tu- mours in other parts, and the muscular struc- ture of the heart was chiefly affected. When this disease is seated in either the posterior or the anterior mediastinum, the pericardium may be penetrated by it, and the heart itself impli- cated. This was observed in the case of a woman whose arm had been amputated on ac- count of this malady (Gerson and Julius, Mugaz. der Ausl. Liter, d. q. Heilk., September, 1823, p. 199). The pericardium was involved in it. in a case which lately fell under my ob- servation. The disease was seated in the me- diastinum, and extended not only to the peri- cardium, but also to the sternum and ribs, its nature being recognised during life. In a case published by M. Velpeau, encephaloid tumours were found in the substance of the heart, in the lungs, between the pleura and ribs, in the bron- chial glands, under the mucous membrane of the stomach, in the duodenum, in the pancreas and right kidney, in the liver to the number of some hundreds, between the tunics of the gall- bladder, in different parts of the peritoneum, on the upper surface of the brain, in the thyroid gland, and under the skin, and in the muscles of the right thigh. The aorta also was com- pletely obstructed by fungoid masses. 240. M. Andral twice saw this disease in the right side of the heart. In the first case the patient presented signs of hypertrophy of the left ventricle. In addition to this, almost the whole of the right ventricle and auricle were converted into a firm, dirty while sub- stance, traversed by a number of reddish lines, and possessing all the characters of the enceph- aloid substance. The second case was that of a man of middle age, who had enjoyed good health till two years previously, when he be- came slightly asthmatic. He continue I in this state for five or six months, when he was sud- denly seized with the most, excruciating pain, confined at first to the region of the heart, but soon extending over the left side of the thorax. His dyspnoea increased, and lie had violent pal- pitations and vomiting The pain ah .ted alter an hour, and the next day lie was as usual During the following year the dyspn ea increas- ed, and the pain returned seven or eight times. He afterward became much emaciated, had a peculiar sallow tinge, and evening exacerba- tions of fever. The attacks of violent pain were now frequent, but of short continuance. He had also occasional attacks of palpitation, but there was no stethoscopic evidence of dis- ease either in the heart or lungs. After some time he became cedematous, and died sudden- ly. The wall of the right ventricle was occu- pied by a large knotted tumour, extending from the apex to the base, projecting very much ex- ternally, and protruding internally into the ven- tricle. The encephaloid substance composing it was firm in some points, and soft and difflu- ent in others. (Anat Path., t. n., p. 347.) 241. G. True Scirrus and Carcinoma of the heart are, according to Otto, still doubtful. Where the evidence of either has been most conclusive, there has also been scirrus or car- cinoma of other parts. Open carcinoma of the heart can hardly exist, as death will take place before.the disease can proceed to this stage. Most writers, especially foreign pathologists, have confounded true carcinoma with fungoid or encephaloid disease; and cases have been recorded as examples of the former, when they were really instances of the latter. Of this kind are the cases adduced by Laennec, Vel- peau, Andral, Cruveilhier, Ollivier, &c. Bayle and Cayol never met with an instance of scirrus of the heart. I have seen scirrus in the lungs and pericardium in one case, and in the pleura and pericardium in another, scir- rous and carcinomatous disease have long pre- viously existed in other parts of the body. M. Billard found in an infant three days old, three tumours imbedded in the heart, possessing the characters of scirrus. I doubt, however, their being actually scirrus. M. Recamibr observed the heart partially converted into a substance resembling the skin of bacon in a person who also had cancerous tumours in the lungs. Cases of a more doubtful description are recorded by Carcassone and Duchateau. Rullier states that he found cancer in the heart of a person who had this malady in other organs ; and a similar instance is recorded in the Revue Medicale (t. i., 1824, p. 272). 242. H. Melanosis has also been found in the heart and pericardium ; but in all the instances of this kind on record this production has ex- isted also in other parts. As to the Treatment of adventitious productions in the heart, it is unnecessary to offer any remarks. 243. ix. Of Polypous Concretions in tub Cavities of the Heart. — Bartoletti and Pisini were the first to impose the name of pol- ypi on those concretions of lymph and fibnn which are sometimes found in the cavities of the h>art and large vessels after death. Kkr- krinu first contended that these concretions wore different, in their nature and mode ol" for- mation, fro.n polypi of the uterus and nasal fissae, to which Bartoletti and Pisini had li- kened them. But with Kerkring originated the distinction of them into false and true polypi, the former consisting of a post-mortem coagu- lation of the fibrinous part of the blood, the lat- ter presenting a consistent ce.hilar or organized appearance, and being formed durinji the life of the patient This distinction was "first ques- tioned by Morjaoni, who denied the existence oi true polypi of the heart, and in this opinion he was followed by I.ikutaud, Pasta, and oth- ers. On the other hand, Manget, Malpighi, Pkuhlin. Pbykr, F. Hoffmann, and Fani-osi maintained that the polypous concretions found m the cavities of the heart were to be regarded as the more immediate cause of death, and not as having been formed at the time of death. 1 he opinions of pathologists, however, remain- ed long divided on this point, until Corvisart, HEART—Polypous Concretions in its Cavities. 255 Testa, Burns, Bertin, Kreysig, Laennec, and others investigated it somewhat more closely, and ascertained that, although these concre- tions occasionally form about the time of death. or immediately afterward, there are others of a different kind, which are produced during the life of the patient, and occasion very severe symptoms referrible to the heart, but not of a kind which generally admit of a precise diag- nosis. 244. A. Of the Formation and Kinds of Cardi- tc Polypi.—Polypous concretions are most fre- quently observed in the right cavities of the heart, and oftener in the auricles than in the ventricles. This is explained by the circum- stances which favour their production, espe- cially the stasis of the blood in the auricles, the state of the blood when it reaches the right au- ricle, and the extension of inflammatory action from the venous trunks. These three princi- pal causes are especially concerned in the pro- duction of three kinds of concretions. In the heart as well as in the veins, and even in the arteries, the fibrinous parts of the blood may concrete, 1st, from a condition purely mechan- ical ; 2dly, from an altered state of the blood itself, especially from the passage of morbid matter into it: and, 3dly, from inflammatory action. Each of these, as being especially con- cerned in the production of three varieties of cardiac polypi, requires a detailed considera- tion 245. a. Simple fibrinous concretions—the false polypi of former writers—are frequently found in the right cavities of the heart, and sometimes extend into the vena cava and pulmonary ar- tery. They are occasionally entangled in the columnae carneae ; but they have no organized or intimate connexion with any part of the in- ternal surface of the heart with which they are in contact. They consist of an unorganized accretion of the fibrinous and albuminous parts of the blood ; are of a uniform colour, easily torn, and generally met with in patients who have died of chronic diseases, characterized fre- quently by a deficiency of the red particles of the blood, or, in cases of marasmus, great de- bility or cachexy, and which have been accom- panied by obstacles to the circulation, as from disease of the valves and orifices of the heart. These concretions may commence during the last moments of existence, or immediately upon dissolution. In cases of mechanical obstacle to the circulation through either the heart or lungs, the fibrinous parts of the blood may con- crete in the right side of the heart so as to pre- vent the continuance of its action. The sam« result may also follow the reninra or stas s of blood in the right auricle and vena cava, con- sequent upon extreme depression of the powers of life.or upon prolonged syncope. &c, the con- cretion thus formed preventing the restoration of the heart's contractions. Under such cir- cumstances, this va i ty of concretion may be the proximate cause of death, although formed 60 shortly before, especially in diseases of the heart, and during extreme vital prostration. 246. b Fibrinous concretions from the passage of mirrhid secretions into the blood. During lan- guid states-of the circulation, or when the fibrin- ous parts of the blood are disposed to coagu- late, the passage of pus, or of the more consist- ent morbid secretions into the veins, occasion- ally determines or gives occasion to this act, the morbid matter carried into the circulation being the nucleus around which the fibrin con- cretes, especially in the situations, as the right side of the heart most favourable to this occur- rence. When a partial coagulation of fibrin is thus occasioned during the venous circula- tion, the concretions, at first small, often be- come entangled in the fleshy columns of the right side of the heart, and undergo changes arising, 1st, from the concentric deposition of additional layers of fibrin, as in the cavities of aneurisms ; 2dly, from their age or duration ; and, 3dly, from the effects they produce on the parts with which they are in contact.—(a) Upon dividing these concretions, the appearance of concentric layers of fibrin becomes manifest, and in the centre, either pus, or tuberculous matter, or a substance resembling a minute co- agulum is observed.—(b) The colour and con- sistence of these concretions depend chiefly upon their age. In the more recent cases, they nearly resemble those already described, and are soft or easily torn Those of longer dura- tion are more evidently disposed into concen- tric layers, more firm and fibrous, and generally of a paler tint, but varying from a grayish col- our to a grayish red or flesh-colour.—(c) When they are of considerable size, or of long dura- tion, they appear to have compressed the fleshy columns in which they are entangled, and ulti- mately they become adherent, in one or more points, to the internal surface of the heart in more immediate contact with them. This ad- hesion is manifestly owing to the irritation they have occasioned in this surface, and at these points, and to the consequent exudation of lymph, by which they become agglutinated and more or less closely adherent.—(d) In this va- riety of concretion there are neither blood-ves- sels nor vascular connexions with the surface to which they become ;:dherent: circumstan- ces readily explained by the modes of their pro- duction and of their consecutive agglutination. At the same time, such adhesions are merely contingencies, and very frequently do not oc- cur, especially in the more recent concretions. The form and size of these concretions also vary remarkably. 247. c. Polypous Concretions consequent upon Internal Carditis—While the two preceding varieties of concretion are generally observed in the right side of the heart, that about to be considered is most frequently met with in the left, inflammation attacking this side of the organ oftener than the right (y 65, 68) This variety varies much in size and in firmness. It may not much exceed the granulations or ex- crescences described above (y 66), or it may be so large as to nearly fill one of the cavities. In its more recent state, it is generally amorphous, resembling concrete lymph, or the buffy coat of the blood, glutinous, and slightly adherent to some part of the internal surface, or of the fleshy columns or tendons of the valves. But, when it has been of considerable duration, it is more firm, fibrous, or cellulo-fibrous, in its structure, and more firmly adherent to the in- ternal membrane, with which it seems as if continuous. In some cases, blood-vessels may he traced through this variety of concretion, and their communication with those of the ! heart's internal surface may be demonstrated. 256 HEART—Polypous Concretions in its Cavities. When this form of concretion is of considera- ble size, there is every reason to suppose that it is not altogether, or even chiefly, formed of the lymph exuded from the inflamed internal surface, as the quantity of lymph thus effused cannot be more than will give rise to the gran- ulations, excrescences, or vegetations already noticed (y 66). But the lymph thus exuded, during a languid circulation, or states of the blood favouring coagulation, attracts and dis- poses the fibrin to concrete around it; and pol- ypi of great size, sometimes disposed in layers, as the second variety, may thus be formed. The firmness and cohesion of these polypi vary considerably, but their cohesion has no refer- ence to the intimate nature of their connexion with the heart's surface; for in some cases, where the polypus was very soft, vessels could easily be traced from the heart into it, and these so large as to admit of injection (Rigacci, in Bullet, des Scien. Med., Sept., 1828; Bertin, Traite des Mai. du Caur, &o, p. 448); while in other instances the polypus has been firm, in- timately adherent to, and apparently forming a continuous structure with the surface of the heart, and yet the existence of blood-vessels was not apparent. That this variety of concre- tion originates in inflammatory irritation of some part of the internal surface of the heart, is proved by the history of the cases in which it has been met with, and by the appearances exhibited upon dissection. From the foregoing division and description of these productions, the diversity of opinions which has long existed as to their formation will be readily accounted for. 248. B. Of the Signs of Cardiac Polypi.— About the end of the last century, polypi of the heart were considered a frequent occurrence, and many of the disorders of respiration and circulation were attributed to them. J. J. Rous- seau took a journey to Montpellier to be treated for this disease, and, according to M. Bouil- laud, upon foot, which he could not, of course, have done if he had been the subject of it. It is evident that the symptoms will vary accord- ing to the situation, size, and origin of these formations—to the degree to which they ex- tend into or fill up the cavities of either side of the organ. Malpighi, Senac, Sauvages, and Bursieri have entered very fully into the diag- nosis of these concretions, but no reliance can be placed upon what they have adduced respect- ing it. Even the more recent observations of Laennec, Harty, and others have not much advanced our knowledge. M. Bouillaud re- marks that it is necessary for them to have at- tained so great a size as to notably impede the circulation before they can be possibly recog- nised during life. They do not, however, equal- ly impede the flow of blood through the cavi- ties in all the situations in which they may be placed. The concretions which are attached to the valves, or to their tendons, the other cir- cumstances being the same, cause the greatest interruption of the circulation. When they occupy the right cavities, as most frequently is the case, the blood is sent in diminished quan- tity to the lungs, and accumulates in the venous trunks, causing congestion of the liver, brain, abdominal viscera, &c. ; effusions into shut cavities and cellular parts; and asphyxy from leficient aerification of the blood, if the supply of blood to the lungs be much lessened. When they form in the left side of the heart, the phe- nomena are, in some respects, the same ; but congestion of the lungs is a necessary conse- quence, with dyspnoea, effusions into the bron- chi, or substance of the lungs, &c. 249. According to Laennec, the sudden su- pervention of an anomalous, confused, and ob- scure pulsation, in a patient who previously had presented a regular action of the heart, should lead to the suspicion of a polypous concretion ; and if this disturbance takes place on one side only, this indication is almost certain. M. Bouillaud considers that the concretions con- sequent upon internal or external carditis are indicated by tumultuous pulsations of the heart, with a dulness or obscurity of the attendant sounds, or with a simple, or hissing bellows sound ; by oppression, dyspnoea, or orthopnea, and extreme anxiety, followed by venous con- gestions, and leipothymia; and by coma, ster- torous breathing, convulsive movements, an indistinct and very small pulse, and coldness of the extremities. When these phenomena are manifested in the course of an acute disease of the heart, particularly during internal cardi- tis, in which there had previously been but little irregularity, and oppression of the respiration and circulation, the existence of a polypous concretion is very probable, and especially if the sounds of one or more of the cavities are much diminished or obscure. In chronic dis- eases of the heart, attended by habitual dysp- noea, the occurrence of an insupportable or- thopnoea and anxiety, with obscuration of the sounds, restlessness, coldness, and lividity of the face and extremities, and occasionally vom- iting, also indicate the formation of concretions, especially if these symptoms have supervened without an obvious cause ; and in this case it is very probable that the concretions exist in the right cavities. 250. C. The Prognosis and Treatment of polypous concretions require but few remarks: the former is always extremely unfavourable. Indeed, it is doubtful whether recovery ever takes place from them, at least when the in- dications of their existence are tolerably con- clusive. M. Bouillaud, however, takes a more favourable view of the issue of such cases, and thinks that the more recent, and those which are not of large size, may be dissolved. This writer and M. Legroux suppose that attempts should be made to prevent the formation of these concretions in diseases of the heart, both in those which consist chiefly of interrupted circulation and in inflammatory action. With this view they recommend small blood-lettings from time to time, and diluents. It is proba- ble that the disposition of the fibrinous por- tions of the blood to concrete may be counter- acted by the exhibition of mercurials, by the liquor potassae, and the subcarbonates of the alkalies, and particularly by the sub-borate of soda. This last substance I have found the most certain in preventing the coagulation of fibrin, and in dissolving lymph ; and it may, therefore, be prescribed with advantage, not only in the inflammatory diseases of the heart, but also where there is reason to suspect the formation of polypous concretions. [We believe, with Dr. Hope, that excessive biood-letting, as well as the exhibition of digi- HEART—Ruptures op. 257 talis and nauseants, have a powerful tendency, in advanced stages of organic disease of the heart, to favour the formation of polypous con- cretions in the cardiac cavities. Bouillaud and others have recommended frequent venae- section as one of the best means of preventing the formation of polypi; but no fact is better established than that, in dilatation of the heart, in softening, and in advanced stages of valvu- lar disease, blood-letting will not only fail to prevent polypi, but will actually induce them, besides favouring the supervention of dropsy, exhausting the vital powers, and hastening the case to a fatal termination. If wre wish to pre- vent polypus in advanced stages of cardiac dis- ease, we should direct the patient to be kept perfectly tranquil and in the easiest position, so that the circulation may not become embar- rassed from being hurried ; to avoid nauseants and digitalis, and everything calculated to de- range the stomach and destroy the appetite ; we should, in particular, pay attention to the diet, which should be of easy digestion, and in very moderate quantities ; the bowels are to be regulated by enemata, and the mind pre- served in as cheerful a condition as possible. Our curative means are extremely limited. Warm fomentations to the surface and the ex- tremities, to diffuse the circulation, and pre- vent congestion in the heart and great vessels ; the free admission of fresh air ; stimulants, as ether, carb. ammonia, wine, &c.; and if parox- ysms of congestion of the heart come on, indi- cated by a confused, irregular action of that organ, with a small, weak, irregular pulse, and suffocative dyspnoea, immersing the feet and legs in a hot mustard bath ; these means, em- ployed and repeated according to circumstan- ces, embrace nearly everything of importance that can be brought to oppose this malady.] 251. x. Of Ruptures of the Heart.—A. Seat and History of, &c.—Rupture of the heart was first observed by Harvey. Lancisi and Morgagni showed that instances of sudden death were frequently owing to this cause. As examinations after death became more fre- quent, cases of this occurrence were more commonly met with ; and at the present epoch of pathological research they are by no means rare. Morgagni (Epist. xxvii., 10) remarked that rupture of the left ventricle is more com- mon than that of the right; and that this lat- ter is more frequent than rupture of the auri- cles : this is confirmed by the particulars of the cases which have been since recorded. M. Ollivier states that, out of 49 instances, the rupture was seated in the left ventricle in 34; in the right ventricle in 8 ; in the left auricle in 2 ; and in the right auricle in 3 ; and that, in 2 cases, both ventricles presented several ruptures The results are, however, different in respect of ruptures occasioned by external violence. In 11 instances of this description, the right cavities were torn in 8 ; and the left in 3. In these 11 cases the auricles were torn in 6. 252. In the above 49 instances of sponta- neous rupture the apex was found to be its seat in 9, this lesion in the others being near- er the base of the organ. The directions of the lacerations were various ; in some the lacera- tion was transverse or oblique ; in others it was longitudinal, or in the direction of the fibres, or of the axis of the organ. In certain II 33 cases it was extensive on the external surface, and very small internally. In other instances the reverse was observed. The laceration may occur obliquely through the parietes, and resemble a sinus, as remarked by Morgagni. It may even be incomplete, some of the stretch- ed fibres still remaining and concreting the op- posite edges (Rostan). It may also resemble the perforation made by a bullet. It may, more- over, involve only one or two of the muscular layers, without penetrating into the cavity; and it may be limited to a few fasciculi of fibres, or to the fleshy columns, or even to the valves. When there is no apparent alteration of the tissue at the place of rupture, it is difficult to determine whether or not it has taken place from within outward, or in the opposite direc- tion. The most singular circumstance in the history of this lesion is the occasional occur- rence of two or more lacerations, in different degrees, in the same heart. M. Ollivier, upon examining into the particulars of the most au- thentic cases, found eight in which there were several ruptures, either in the same ventricle or in both. M. Rostan detected two lacera- tions in the left ventricle ; Morgagni, three in the same situation ; Portal, the same num- ber in the same place ; Dr. Ashburner, two in the left ventricle, and one in the right. M. Blaud found two penetrating the ventricles, two involving only the superficial layer of the left, and one the external layer of the right ventricle ; and M. Andral observed five in the left ventricle, and a perforation of the stomach in the same patient. Frequently, when the substance of the organ is torn, some of the fleshy columns corresponding to the rupture are also torn. In some instances the fleshy columns are alone torn, the parietes of the ven- tricles remaining entire. In this case the de- rangement of the circulation becomes extreme, especially if the tendinous cords attached to the free margin of the valves are ruptured (Ollivier). Instances of this kind are record- ed by Corvisart, Laennec, Bertin, Adams, and others. Ruptures of the heart have been arranged as follows by Dezeimeris : 1st. Rup- ture from external violence. 2d. Spontaneous rupture without previous lesion of the tissues of the organ. 3d. Ruptures consequent upon dilatation. 4th. Ruptures with probable, but not with demonstrable lesion. 5th. Ruptures ow- ing to softening of the heart. 6th. Ruptures from abscess ; and, 7th. Ruptures caused by ulceration or perforation of the heart. M. Ol- livier has adopted a somewhat similar plan to the foregoing in his treatise on this subject. 253. a. Rupture of the Heart without previous Lesion, or without demonstrable lesion, is com- paratively rare. In the cases recorded by Ploucquet and Fischer the rupture was pre- ceded by severe pain, continued or remittent, in the left shoulder and about the margin of the left shoulder-blade, and shooting down the arm and left side of the thorax, and attended by a sense of laceration, pressure, and anxiety at the praecordia and epigastrium, sometimes with numbness and prickings in the shoulder and arm. In other instances, as in those published by Portal, Baron, and Andral, death has oc- curred without any previous ailment excepting dyspnoea, which was observed only in the case recorded by Portal. 258 HEART—Ruptures or. [Spontaneous rupture of the heart is so rare that neither Corvisart, Laennec, Bertin, nor Senac met with a single case of it, although their experience in cardiac diseases was very great. About sixty cases of it have, however, been recorded, of which thirty-four have been collected, in various publications by Dr. Hal- lowell* In most of these instances, it is sta- ted that the patients had been affected, for a greater or less length of time, with palpitations, and had experienced frequent attacks of lypo- thymia, or pain beneath the sternum, and tight- ness and weight about the chest. Death gen- erally took place very suddenly, although Ros- tan relates a case where the patient is said to have lived fifteen years after the accident, and died at last of rupture in another part of the organ (section 265, note). In a few instances, several hours elapsed between the occurrence of the rupture and the death of the patient. When death occurs instantaneously, as it gen- erally does, it is in consequence, not of the amount of blood effused, for this frequently does not exceed ten or twelve ounces, but of the pressure exercised upon the organ by the surrounding mass of blood, thus arresting its action, and stopping the supply of blood to the various parts of the system.] 254. b. Rupture consequent upon Narrowing of the Orifices, with or without hypertrophy or dil- atation of the cavities of the heart, is a more frequent occurrence than the foregoing. Mor- gagni has adduced several instances in which the laceration was consecutive of alterations at the origin of the aorta. Haller has cited a similar case ; and others have been recorded by Portal, Rostan, and Dezeimeris. In a case published by Chaussier, in which death occurred during a dispute, the aorta was found constricted at its origin by a cartilaginous tu- mour which surrounded it. There can be no doubt that an obstacle to the circulation at the heart's orifices will favour rupture of the cavity behind it; and that laceration may occur, al- though the parietes of the cavity are hypertro- phied. Instances of this latter occurrence have been published by Morgagni, Rostan, and oth- ers. Morgagni supposed that, when the rup- ture is connected with hypertrophy, it takes place in that portion of the parietes which is the least thickened and resistant. But this is not always the case : for the rupture has been observed in the most hypertrophied part. M. Chomel supposes that, when this has occurred, the ventricle has been almost equally thickened and resistant throughout, and that the part torn, although the most hypertrophied, has been ac- tually the weakest. If the sole cause of rup- ture were a distending force, or even the re- sistance furnished by the contents of the cavi- ty to the contraction of its parietes in forcing the contents onward, then might the laceration take place in the weakest part; but the rupture does not always occur in this way ; for it is reasonable to infer that the same circumstan- ces as occasion increased action and conse- quent hypertrophy will sometimes produce la- ceration, when their increase is rapid, or the obstacle to the circulation through the cavities of the heart insurmountable ; and that hence the muscular structure is torn by its own ex- * [Am. Jour. Med. Sciences, vol. xvui , p. 74.] cessive action at the very part where the con- traction is most energetic. 255. c. Dilatation of the cavities might at first appear more frequently connected with rupture than hypertrophy has been found to be, lacera- tion of the parietes following the extreme or sudden dilatation of them ; but this connexion has been even less frequently observed than the preceding. Instances of it have, howev- er, been adduced by Morgagni, Martini, and Sch^ffer. Local or partial dilatation might also appear frequently to terminate in rupture of the dilated part; but this is also a rare ter- mination, as the adhesion of the part to the pericardium, or the formation of fibrinous lay- ers in the interior of the sac, prevents it from being so easily torn as it otherwise would be. M. Ollivier remarks that, of nineteen instan- ces of local dilatation, rupture occurred only in the three cases recorded by Galeati, Penada, and Bignardi. 256. d. That Rupture should be favoured or occasioned by partial or general Softening of the Substance of the Heart will be readily conceded, and several cases are recorded in illustration of the occurrence. In all these the softening was great, although varied in its characters: in some it has been denominated gangrenous, particularly by the older writers ; in others ap- oplectic, by Cruveilhier (Anat. Path., fasc. iv.); and in others gelatiniform, or senile, by Blaud. Of the second of these varieties, instances have been adduced by Tengmalm, Corvisart, and Rochoux. M. Ollivier states that the thesis of this last writer contains several cases of this kind of rupture. Instances of the third variety of softening terminating in laceration are pub- lished, in the places referred to below, by Ha- zon and others. In a case by S. Frank, this alteration appears to have arisen from lesion of the nervi vagi; and in one by Hodgson, the softening and atrophy seem to have followed obliteration of the coronary arteries. Rupture has also been occasioned by the softening at- tendant upon fatty degeneration of the heart (y 224). Morgagni, Schmucker, and Adams have recorded cases in which this form of soft- ening had terminated in laceration. [Dr. Hallowell describes a case of rupture from fatty degeneration of the heart (Am. Jour. Med. Sci., vol. xvii., p. 86) in a woman 76 years of age. On opening the thorax, the pericardi- um was seen greatly distended, and presenting a black appearance. An incision being made into it, the heart was displayed surrounded by an enormous clot of black blood, weighing about 5-xii. Where the rupture took place, in the an- terior face of the left ventricle, one fourth its length from the apex, there were two small linear openings, three or four lines in length, separated by an interval of three lines, and communicating with the cavity of the ventricle by a single opening. The thickness of the wall of the ventricle was but slightly diminished, rather less red than natural, and presenting a peculiar marbled appearance, exhibiting yellow streaks whose direction was parallel with that of the fleshy fibres of the heart. The substance of the heart, owing to fatty degeneration, ex- hibited a friability, when cut into thin slices, comparable to that of liver.—(Loc cit.)} 257. e. Abscess in, or Ulceration of the Mus- cular Structure of the Heart has also been found HEART—Ruptures op. 259 to have terminated in Rupture.—In cases record- ed by Morgagni, Portal, Brera, Langlade, and H. Cloquet, ulceration had partially pene- trated the parietes of one of the cavities, the remaining layer being torn by the distention or resistance of the contents of the cavity. In- stances of abscess of the structure of the organ recorded by Erdmann and Mott, and quoted by Dezeimeris, terminated in a similar manner to the foregoing, the termination admitting of the same explanation. 258. /. The Rupture may be partial, or confined to one or more Layers, or muscular Fasciculi, or tendinous Cords of one or more Cavities, as sta- ted above, and as shown by Corvisart, and confirmed by Laennec, Bertin, Adams, and others. In the three cases recorded by Corvi- sart, the rupture appeared to have been occa- sioned by violent physical efforts. Bertin de- tected rupture of one of the fleshy columns of the right ventricle, and attributed it to violent fits of cough. Laennec found one of the ten- dinous cords attached to the free margin of the mitral valve torn across ; and Dr. Cheyne met with another instance of rupture of one of these cords in a person affected with dilatation and hypertrophy of the left ventricle. Cases in which rupture of the fleshy columns and tendi- nous cords have occurred have likewise been ob- served by Bouillaud, Townsend, and others. [Dr. Maclagan relates a case of death, in a recent number of the Edinburgh Journal, caused by rupture of some of the superficial fibres of the heart. The patient, aged seventy-five, while Beated with her family in the middle of the day, was observed to hecome suddenly pale, and, before assistance could be given, fell from her chair. She was seen in about a quarter of an hour; the features were pale and sharpened; the extremities cold and pulseless; she was, however, sensible, and able to articulate cor- rectly. She swallowed, also, without difficulty, though with disinclination ; but there was no restoration of the pulse or of the natural tem- perature of the extremities. She continued in a state of restlessness and occasional jactita- tion, but without apparent pain, and expired in about an hour from the period of the seizure, the breathing throughout having been nearly natural. The body was examined forty-six hours af- ter death. On exposing the pericardium, it was found to be much distended with fluid ; on opening it, eight ounces of fluid blood and fiv. of coagula were removed. Two lacerations were found in the walls of the heart; one close to the septum cordis, upon the anterior aspect of the left, ventricle, about an inch and a half above the apex of the heart; the other, which was smaller, was situated higher up, and was so shallow as to appear to be merely a fissure of the serous membrane. The larger lacera- tion communicated with one of the coronary veins, and this appeared to be the source of the haemorrhage, as it did not reach into the ven- tricle. The patient's death appeared to be ow- ing rather to the mechanical obstruction to the heart's action than to loss of blood. The heart itself was above the normal size, without be- ing hypertrophied ; it was loaded with fat, and its substance was apparently slightly softened. —(Med. Times, July 2, 1845 )] 259. g. Ruptures of the Valves are not infre- quently met with as a consequence of fragility arising from induration and ossincation, or from softening caused by inflammatory action ; but previous disease is not always necessary to the production of this rupture, especially when it is produced by external violence, or by sudden and violent physical efforts. When, however, it is consequent upon slighter grades of these causes, or upon mental emotions, previous dis- ease of the valves, or of the orifices, or of the internal surface of the heart may be inferred ; otherwise they would have been inadequate to its production. If the rupture of the valve be partial, the patient may live a considerable time afterward ; but extensive chronic disease will be the result, owing to the local irritation, and to the imperfect function of the valve, particu- larly farther structural change of the ruptured valve, dilatation, or dilatation with hypertrophy of the chambers of the heart, &c. When the rupture is extensive, and has been favoured by existing structural change, death either follows almost instantly, or takes place in a short time. When the rupture is partial, the patient may live for a considerable time, with the symptoms of insufficiency of the valves (y 76, 198). 260. F. Rupture of the Heart from external Vi- olence is not a rare occurrence. Contrary to what is observed in respect of spontaneous rup- ture, the laceration occasioned by external force is more frequently seated in the right than in the left side of the organ, and much more commonly in the auricles than in the ven- tricles. As M. Dezeimeris has argued, it is very probable that the mode in which the rup- ture is produced by external injury depends much upon the nature and seat of the injury. When the region of the heart, or the thorax, is the seat of the external violence, the rupture takes place in the cavities possessed of* the weakest parietes, and in ^he most yielding points of these ; but when the injury is of a kind to prevent the heart from evacuating its contents, as in the case of a carriage-wheel passing over the trunk, or of any heavy body pressing upon the aorta, the muscular efforts of the ventricles to expel their contents may occasion either a partial or complete rupture of them, or of the vessel at some point between the heart and the part pressed upon. 261. B. The Causes of Rupture of the Heart, especially the most material, and those con- nected with the pathological states of the organ, have been already stated and explained under distinct categories. There are, however, va- rious other causes which determine aid, or ac- celerate these in their operation. Violent men- tal emotions, particularly anger, fright, terror, unexpected disappointments, distressing intel- ligence suddenly communicated, anxiety, &c.; sudden and violent muscular efforts, and labo- rious or prolonged physical exertions of any kind, particularly in constrained positions. The act of coition and straining at stool have often occasioned rupture, a very large proportion of the cases of it on record having been attributed to these causes. M. Ollivier states that rup- ture of the heart occurs more frequently in men than in women; but this is not satisfac- torily determined. It is certainly more com- mon in persons far advanced in life than in the young. M. Blaud considers the rupture that takes place in old age as generally the conse- 260 HEART—Alterations or the Blood-vessels in. quence of softening of the heart. Several cases recorded by him and by other writers confirm this; and those adduced by Cruveil- hier and Smith farther show that softening terminating in rupture of the left ventricle is often accompanied, in old persons, with great accumulation of fat on the surface of the organ. [It has been stated that, with the exception of several cases in children not well authenti- cated, all the subjects who died of this disease were over 58 years of age. Of 23 cases col- lected by Dr. Hallowell, in which the age is stated, 9 were between 70 and 80 ; 6 between 60 and 70; 5 between 50 and 60; 2 between 40 and 50, and 1 between 20 and 30 ; and of 34 cases, 16 were males, and 18 females.—(Loc. city] 262. C. Symptoms and Diagnosis.—a. The cases hitherto recorded throw but little light on the diagnosis of this lesion. Some of these have furnished proofs of disease of the heart for a longer or shorter time ; while others, up to the hour of death, had complained of no symptom indicative of any affection of the heart or large vessels. In the instances recorded by Plouc- quet, Olmi, Charpentier, and Fischer, the pa- tients complained, for a short time before death, of a violent pain in the left shoulder, extending to the arm, and occasionally to the whole side ; attended, especially at last, with more or less numbness, and characterized by exacerbations and slight remissions. In some cases, inex- pressible anxiety and pain have been felt in the praecordia and epigastrium, with cold extremi- ties and cramps, shortly before dissolution. In the majority, rupture has produced instant death ; but in some this has not been the case. In the instance adduced by J. Frank, life was prolonged twelve hours, probably from a coagu- lum filling up the laceration for a time. In a case recorded by Rust, the rupture was pro- duced by the passage of a carriage-wheel over the chest, and was seated in the right auricle ; yet the patient survived fourteen hours. 263. In most of the cases in which the rup- ture is preceded by violent pain, M. Ollivier thinks that it is produced gradually, from the successive laceration of several layers or fas- ciculi of muscular fibres, and that the pericar- dium becomes only gradually distended by the effused blood. Where the laceration and aper- ture are at once large, a copious effusion in- stantly occurs, fills the pericardium, and abol- ishes the contractions of the organ. 264. b. When the rupture is seated in the par- titions between the auricles or ventricles, a fatal result may not very rapidly occur. In this case, the venous may be mixed with the arterial blood, although this may take place only to a small extent.—c. In the three cases of rupture of the fleshy columns detailed by Corvisart, a sudden oppression and sense of impending suf- focation were the first symptom complained of. The pulse became unequal, irregular, and inter- mittent, and the pulsations of the heart con- fused. This state of distress and anxiety may coptinue for some days before it terminates in death; or it may endure much longer, and be accompanied with various signs of organic dis- ease of the heart.—d. Rupture of the valves will necessarily be attended by much irregularity or disprder of the circulation, and by a simple, or hissing, or musical bellows sound (BouillaCd, Farrall). . , 265. As the diagnosis of rupture of the fleshy columns and valves of the heart, in the present state of our knowledge, is very imperfect, and as the signs of rupture of the parietes of one of the cavities are equivocal, nothing can be adduced as to the Treatment of these lesions. Indeed, in most instances, medical interference will be quite unavailing, and even as much mis- chief as benefit may result from it.* [When rupture of the heart occurs, it is, for the most part, in the left ventricle, in its ante- rior wall near its middle. In 31 cases collect- ed by Dr. Hallowell, there were 3 ruptures of the right auricle, none of the left, 2 of the right ventricle, and the remaining 26 of the left ven- tricle.] 266. xi. Alterations of the Blood-vessels of the Heart. The coronary vessels are more or less enlarged in hypertrophy of the heart, and diminished in atrophy. Some writers have supposed that the smallness of the vessels in the latter lesion is actually the cause of it; but the state of the vessels is solely dependant upon the nutrition of the organ. Portal (Anat. Med., t. iii., p. 74) found the coronary veins di- lated and varicose ; and the larger trunks have contained polypous concretions (Kreysig). The coronary trunks, both veins and arteries, are always very much, and progressively enlarged with the accession of age, as shown by M. Bi- zot. The most common alterations, however, of the cardiac vessels are cartilaginous and os- sific formations in the arteries. These, espe- cially the ossific deposition, may consist merely of small isolated patches, or they may nearly or altogether surround the vessel. Ossification may extend along the greater part of an artery, or to two or more. Generally, the canal of the vessels is uninterrupted, although the parietes have become quite inert. Cases, however, have occurred in which the canal has been ob- literated. Instances of extensive ossification of the cardiac arteries have been recorded by Parry, Ring, Portal, Hodgson, and others, and have been usually found associated with softening, flaccidity, or some other change in the nutrition of the organ. Angina pectoris has been supposed to depend upon this change; but numerous instances of ossification of the coronary arteries have been met with without this complaint, or, indeed, any symptoms re- ferrible to the heart having existed. 267. xii. Communication between the Sides of the Heart.—This lesion is most frequently congenital, or the result of malformation, or * The only instance on record showing the possibility of recovery, more or less partial, from rupture of the heart, has been published by Rostan ; but some mistake may have existed as to the morbid appearances. Tho case is, however, very interesting. A woman had experienced, fifteen years previously todeath, a violent pain in the Procar- dia and epigastrium, extending to the back, anil returning at intervals. She was afterwarl subject to palpitations, followed by syncope. Her death was sudden. The peri- cardium contained blood effused in its posterior part, but was adherent to the heart anteriorly by several albuminous layers. On removing it, an irregular rupture, an fneh said a half in length, and quite recent, was found ; but, to the left of this, ;ind at a distance of six lines, the substance of the organ was destroyed, and replaced by a fibrinous con- cretion, entirely similar to those found in aneurismal sacs, and intimately connected with the structure of the heart. The ventricle was thinned in this situation. The latter [ appearance was attributed to a rupture which had taken I place at a long bygone period. HEART—Communication between the Sides of. 261 imperfect development of the organ. It occa- sionally increases suddenly about the period of puberty. M. Bertin (p. 436) and M. Bouil- laud (t. ii., p. 564), however, believe that it is not unfrequently a consequence of ulcerative perforation; while M. Louis maintains that it very rarely arises from this latter cause. The communication may exist through the inter- auricular, or through the interventricular par- tition, or through both at the same time. Bouillaud remarks that, in many cases, the opening in the inter auricular partition is a per- sistent state of the foramen ovale; but, in others, that it is consequent upon ulceration, particu- larly when it occupies a situation different from that in which the oval foramen is always found, and when there are more than one perforation. The communication in this situation is gener- ally by a rounded opening, with smooth, some- times thick and tendinous margins, commonly of from four to six lines in diameter, but some- times of nearly double this size. The perfora- tion of the interventricular partition is found in va- rious situations, but most frequently at the junction with the partition of the auricles, and towards the insertions of the pulmonary artery and of the aorta. The form of the openings is commonly round, and the diameter is the same as those of the interauricular partition, the margins presenting the same polished and fibrous appearance. 268. The state of the valves and orifices of the heart, in cases of communication between the opposite cavities, is important. Of fifteen cases detailed by Bouillaud, the valves were indurated, thickened, corroded, or perforated in twelve ; and in ten of these twelve, the orifices to which these valves belonged were more or less contracted. In eight of the twelve cases, these lesions affected the right; in three, the left valves and orifices. In five of the eight cases they were seated in the pulmonary valves ; in two, in the tricuspid valve; and in one in both the pulmonary and tricuspid. Of fifty-three cases of cyanosis noticed by M. Gin- trac, similar lesions to the above were found in twenty-seven; and in all these latter they were seated in the right side of the organ ; twenty-six being at the orifice of the pulmonary artery, and one only in the auriculo-ventricular orifice. The contractions of the orifices and lesions of the valves, in these cases, did not differ from those described above (y 67, 213). The greater frequency of the narrowing of the right orifices, particularly that of the pulmonary artery, in cases of communication between the opposite cavities, is deserving notice. This lesion M. Louis considers to be congenital. M. Bouillaud believes it to be, in some cases, caused by inflammatory action. 269. In eleven of the fifteen cases given by M. Bouillaud, the heart was enlarged, dilata- tion, with hypertrophy, having existed in the right side. Dilatation of the right auricle was observed in ten cases ; and in most of these the parietes of the auricle were also thickened. Hypertrophy of the right ventricle was met with in ten cases ; and in four of these the hy- pertrophy was concentric. The left side of the heart presented nothing abnormal, excepting the induration of the valves and narrowing of the orifices, in the three already noticed (y 268). In the twenty cases reported by M. Louis, near- ly the same appearances as in those of M. Bouillaud were observed. Dilatation of the right auricle existed in nineteen, six times with hypertrophy, and twice with thinning of its parietes. Dilatation of the right ventricle was observed in ten, hypertrophy in eleven, and both dilatation and hypertrophy in five in- stances ; while, on the left side, dilatation of the auricle occurred thrice, that of the ventri- cle four times ; and hypertrophy of the former twice, and that of the latter thrice only. (See Blue Disease, y 8.) 270. In some instances, communication be- tween the opposite sides of the heart is associ- ated with other lesions of malformation; as the connexion of the aorta with the right ventricle (Ribes), or with both ventricles (Louis), the persistence of the arterial canal, &c. (See Blue Disease, y 8.) The state of the pericar- dium has been noticed in a few only of the cases of this description ; and in these, altera- tions depending upon chronic pericarditis, and effusion of a serous fluid, were chiefly observed. 271. The symptoms of the lesion under con- sideration are generally equivocal; for, as it is generally associated with disease of the valves and orifices, and with dilatation and hypertro- phy of the corresponding chambers of the or- gan, it becomes difficult to separate the phe- nomena actually depending upon these lesions from those arising from the communication be- tween the opposite cavities. The palpitations, dulness on percussion of the praecordial region, the purring tremour, the bellows or saw sound, the faintings, sinkings, oppression, &c, the irregularity and smallness of the pulse, the ve- nous and serous congestions, &o, observed in these cases, are manifestly owing to these as- sociated lesions. That more or less admixture of the venous and arterial blood results in con- sequence of the communication, must be ad- mitted. M. Louis thinks that it takes place chiefly on the entrance of the blood into the communicating cavities, and on the departure of the blood from these cavities, when the nat- ural orifice is more or less constricted. 272. Blue discoloration of the skin (see Blue Disease) has been attributed to this communi- cation ; but it is not always observed, and it is rarely universal. Sometimes it is not remark- ed, even in the countenance, till the last period of the patient's life. This change of colour is to be attributed as much to the obstacle to the circulation of the venous blood, as to the com- munication between the opposite sides of the organ ; and this communication has generally existed aconsiderable time before the health has been very remarkably affected. The symptoms assigned to this alteration, particularly blue discoloration, leipothymia, great sensibility to cold, oppression and suffocation in the thorax, are chiefly an aggravation of those observed in other diseases of the heart, and are often want- ing in this. According to M. Louis, the symp- tom most to be depended upon is, a sense of suffocation, occurring sometimes periodically, but always frequently, accompanied or followed by leipothymia, and with or without blueness of" the skin, and occasioned by the slightest causes. Admixture of the red and dark blood, even to a considerable extent, at least in ap- pearance, seems not incompatible with a toler- ably prolonged existence, nor with development 262 HEART—Displacement and preternatural Positions or. of the intellectual faculties. It has no manifest effect upon intercurrent diseases. The exist- ence of a communication between both sides of the heart, even when it becomes somewhat manifest, is not so dangerous as the blue dis- ease. The former may not give rise to serious phenomena ; the latter indicates that the com- munication is accompanied with a dangerous interruption of the circulation through the right side of the heart, or some equally dangerous lesion. As to the treatment of this alteration, I cannot add anything to what I have stated in the article Blue Disease (y 12). [Corvisart was one of the first to call atten- tion to the fact, now well established, that cy- anosis, though often found associated with an open state of the foramen ovale, may yet exist without this imperfection ; the blue colour be- ing often manifested in early life, while no com- munication has been traced between the oppo- site sides of the heart. Crampton has also related cases where there was a free opening between both auricles and ventricles, which must have subsisted for years, and yet in which there was no cyanosis. M. Ribes gives an in- stance of a man, 60 years of age, in whom the auricles communicated without there being any change in the colour of the skin. Dr. Francis very properly alludes to the blueness of the skin in cholera asphyxia, death from lightning, drinking cold water, inebriation, &c, as illus- trating the influence of obstructed circulation in the lungs, and through the heart, on the vascular system (Appendix to Stewart's Billard, p. 703). "All these examples," he observes, " may be cited to demonstrate a cyanose state influencing a stagnation in the capillary system. In short, in the advanced stage of various af- fections, accompanied with a disordered circu- lation, we may often become the observers of this cerulean discoloration."] 273. VI. Displacement and preternatural Positions of the Heart—The situation of the heart is sometimes anormal, owing to malfor- mation ; but my limits will not admit of an ac- count of the various alterations of the position, and of the form of the organ, observed as a con- genital vice. Those who are desirous of obtain- ing information on this subject will find it in the works of Haller, Meckel, Otto, Breschet, Bouillaud, and others, referred to at the end of this article. The position of the heart may be anormal in several ways, from malforma- tion ; it may be placed externally to the tho- racic parietes, or internally in the abdominal cavity, below the diaphragm, or in the right side of the thorax; and the vice in situation may be associated with other anomalies, either in the circulating system, or in the position and form of the adjoining viscera, or in both. These, however, are matters calculated rather to excite curious speculation than to lead to practical inferences. But with true displace- ments of the heart, or alterations of position after birth, the case is different. These displace- ments arise from diseases, or injury of the organ itself, or of adjoining parts ; and the extent of the alteration, and the manner or mode of its occurrence, in such cases, are matters of real practical importance. 274. a. The apex of the heart may be turned altogether to the left side, without farther al- teration of position, or it may be raised at the same time somewhat higher in the thorax by excessive hypertrophy of the organ—A. The heart may be pushed downward by an aneurism of the arch of the aorta, or by some other tu- mour pressing upon it. Cases of this kind have been recorded by Lancisi, Moroagni, and Otto. —c. True prolapse, or dragging down of the organ, from increased weight and weakness of the parts supporting it, is very rare ; but it has been noticed by Leidenfrost, Senac, Zuliani, Pachioni, Otto, and Testa. In this form of displacement, the diaphragm is carried before the heart, a convex tumour thereby invading the abdomen.—d. The heart may be pressed unusually high in the thorax, or towards the neck, by enlargement of the abdominal viscera, by large hydatid cysts, by inordinate distention of the stomach or colon, by excessive dropsical effusion into the peritoneum, by tumours of the spleen, liver, or other parts, and by aneurism of the descending aorta. Instances of these occurrences have been adduced by the writers referred to hereafter. One of the most com- mon causes of this displacement is aneurism of the descending thoracic, or of the abdominal aorta. In such cases, a double pulsation is felt in the aneurismal tumour, as in those recorded by Drs. Graves and Stokes. 275. «. The heart is not unfrequently pushed over to the right side by various alterations in adjoining viscera. It must, however, be recol- lected that this organ may be situated towards the right side, owing to original conformation, or to transposition of some or of the whole of the viscera. Instances of this are, however, very rare ; but several have been adduced by the writers mentioned above (y 273,274). The alterations causing the displacement of the heart to the right side are, destruction or con- densation of the right, and hypertrophy of the left lung, as in the case recorded by Dr. Aber- crombie ; dropsical effusion into, or encysted dropsy of the left thorax; pneuma-thorax of the left side ; collections of pus or of blood in the left pleural cavity ; tumours of various kinds; diaphragmatic herniae; and curvatures of the spine. Dr. Stokes mentions a case in which the heart was thrust by a blow of a wheel to the right side, where it continued long after- ward to pulsate. 276. Several instances of displacement of the heart to the right thorax have been observ- ed by me. In all these it arose from the effu- sion of fluids of various kinds in the left pleu- ral cavity: in one case, from the effusion of blood from external injury, with fracture of the ribs; in three, from pleuritis of the left side, terminating in serous effusion; in two, from empyema; and in two, from pneumothorax. In one of these latter, consequent upon tuber- cles, the patient had not been long ailing. The passage of air into the left pleural cavity was sudden and rapid. I saw him within two hours from the commencement of the distress conse- quent upon it, and immediately detected the pulsation of the heart on the right side. n^,0Gn.A"D »«"•-*■ HVPERTROPHY of the i«h 1%'l4%7,BQr£oh'""'J1'**?*' Anat-' ««■ i- Hist. xxxn., 50.—Haller, Opusc. Pathol. Obs., 21 — Morea«*i atr'IZ- 21 ;PHVi,i^8i !T' 9:~™4 in AbSidL ™ S, ,\M.ed; ^I'n1-' No- ™~ Chamber!, io tar Art ru' ■ Ju,V8I0'rP- 6-Piquet, RepW x n 92 vol rTTw *'%*■: Re»"rt"r- Comment., VoL x., p. 92, vol. *»., p. 304.-*>tf«, in Horn's Archive, t. BIBLIOGRAPHY AND REFERENCES. 263 Prakt. Medic, vol. iii., p. 298. — Boeck, de Statu Quodam Cordis abnormi., 8vo. Berol., 1818.— Vetter, Aphorismen aus der Pathol. Anatomie, p. 99. — Bertin — Legallois, in Bulletin de la Faeulte de Med. de Paris, ann. xiii., p. 69. — Lallemand, in Arch. Gener. de Medic, Aug., 1824. — Bouillaud, in Arch, gener. de Med., vol. v., p. 373. — Pult- ney, m Philos. Transac, vol. Ii., 2. — /. Copland, Influence of Hypert. of the Heart on Apoplexy ; in Lond. Med. Repos., vol. xr., p. 17, 1822.—J.Johnson, in Med. and Chirurg. Re- view, No. 48, p. 407. — Rousseau, in Rccueil de Memoires de Med. Chir. et Pharm. milit., par Fournier, vol. x., p. 366. —Andral, Anat. Pathol., vol. ii., p. 284, 285.—Lecheverel, in Recueil Period., vol. xii., p. 41. — Balme, in Journ. de Med., vol. xlii., p. 410. — Conradi, in Arnemann Magazin., b. i., p. 86 —Walter, in Nouveaux Memoires de l'Academie A Berlin, 1785, p. 59.—Seiler, in Horn. N. Archiv., b. ii., p. 211.—Hufeland, Jouru.de Pract. Heilkunde, h. xiii., st. iii., p. 74; and xviii. b., iii. St., p. 88. —John, in Hufeland Journ. der pr. Heilkunde, b. xxiii., st. iii., p. 81. ii. Dilatation of the Heart. — Lancisius,De Motu Cordis et Aueurysmatibus, fol. Rom., 1728.—Meckel, in Mem. de l'Academie de Berlin, 1750, p. 163; et 1756, p. 46. —Senac, Traite du Cceur., in Lond. Med. and Phys. Journ., No. 95, vol. xvii., p. 9.—Ritter, in Hufeland's Journ., vol. xx., p. 117.— Lucas, De Depositionibus Cretaceis intra Cordis Valvula- rum Arteriarumque Substantiam, 4to. Marbourg, 1815.— Aldis, in Edinb. Med. and Surg. Journ., vol. v., part xx., No. 5. —Baillie's Engravings, Fasc. i., fig. I, 2, 3, 5.—Hodg- son, Engravings to illustrate Diseases of Arteries. Lond., 1815, tab. i. ; and Dis. of the Art. and Veins, p. 50.—Meckel, Tab. Anat. Path., fasc. i., tab. v.. tig. 1-8.—Albers, in Salzb. Med. Chir. Zeitung, 1815, No. 25, p. 416.— Faber, in Hufe- land's Journ. d. P. Heilk., Aug., 1827, p. 79— Louyer-Vil- Urmay, in Bulletin de la Fac de Med. de Paris, 1816, No 1. —Burns, Op. cit., p. 34, 157.—Jurine, Mem. sur l'Angine de Poitrine, 8vo. Par., 1815.—Howship, Op. cit., p. 64.— Schramm, Com. Path, de Angina Pect., p. 17. Lips., 1822. xiv. Communication between both Sides of the Heart.— Blankard, Collect. Med. Phys., cent, iii., No. 52. —Bartholin, in Acta Hafniensis, vol. i., p. 100.—Schroder, Obs. Ann. Med., dec. i., obs. iv., p. 65— Morgagni, Epist. xvii., 12.—Brendel, Ephein. N. C, cent. iv.. obs. 166.— San- difort, Obs. Anat, Path., 1. iv., c. 6.—Hagstrom, in N. Schwed. Abhandl., b. vii.—Senac, Op. cit., t. ii., p. 404.— Spry, in Memoirs of the Medical Society of London, vol. vi., p. 137.—Hunter, Med. Observ. and Inquiries, vol. vi., p. 291.—Pelletan, Clinique Chirurg., vol. iii. Par., 1810.— Tabarrani, in Atti di Siena, iii., Append., p. 41.—Tupper, in Med. and Phys. Journ., vol. iii., p. 497.—Tacconi, in Comment. Bonon., vol. vi.— Corvisart, Op. cit., p. 276, 290, 293.—Farre, Pathol. Researches, fcc, p. 27-30.—Gallois, in Bullet, de la Faeulte de Med. de Paris, An. 1809, p. 133. —Caillot, in Ibid., An. 1807, p. 21.—Thibert, in Ibid., An. 1819, p. 355.—Ribes, in Ibid., An. 1815, p. 421.—/. J. Mo- reau de la Sarlhe, Fragm. pour servir a l'Histoire de la Med., . Grafe's and v. Wulther's Journ. der Chir., vol. x., p. 44, pi. 2, fig. l.—Knup, in Har- less, Rhein-Westphal. Jahrb. d. Med. und Chir., vol. iv., part, i., No. 8. Archives Gen. de Med., Sept., 1827.—Ce- rutti, Rarior. Monstri. Descript. Anat.,4to. Lips., 1827.— Staupa, Anweisung zu Gerichtl. und Pathol. Untersuch- ungen Menschl. Leichname, p. 164, note 20. Wien., 1827. —Cogoreux, in Revue Med. Franc, et etrang., vol. i. and ii , 1827. — Wittcke, Hufeland's and Osann's Journ. d. Prakt. Heilk., April, 1828.-Basedow, in Ibid., July, 1828, p. 78.—R. K. Hoffmann, in New-York Med. and Phys. Journ., vol. vi., p. 250.—Alibert, Nosol. Naturelle, t. i., p. 344.—Otto, in Selt. Beob., vol. i., p. 16, 64 ; vol. ii.. No. 21, p. 49, 102.—Legallois, vol. xii., p. 122, v. Bulletin de la Soc. de Medec, 1809, p. 99.—ReiVs Archiv. 11., and MeckeVs Descript. Monstror. nonnullor., p. 50.—R. Knox, in Edinb. Med. and Surg. Journ., 1815, vol. ii., p. 57.— Holmes, in Trans, of Med. and Chirurg. Society of Edinb., vol. i.—C. J. B. Williams, in Cyclop, of Pract. Med., vol. iii., p. 63.—Miguel, in Archiv. General de Med., vol., xvii., p. 430.—Wittcke, in Ibid., vol. xviii., p. 83.—P. C.A.Louis, in Ibid., vol. iii., p. 325, 485 ; et Mem. on Recherches Ana- tomico-Pathol., 8vo. Paris, 1826, p. 301.—Bonnissent et Pinel, Revue Med., t. vi., p. 175.—Cruveilhier, Anat. Pa- thol., 1., pi. 6. xv. Displacements of the Heart.—Sennert, Prac, 1. ii., pt. ii., cap. xv., p. 703. Lugd. Bat., 1650.—f. Plater, Obs., 1. iii., p. 636.— Lancisi, Do Mort. Subit., p. 136, et de Aneurismatibus, 1. ii., prop. 52.—Mobius, Fujidam. Med. 266 BIBLIOGRAPHY AND REFERENCES. Physiol., c. x.—Fabricius Hildanus, Cent, ii., obs. 33 — Boerhaave, Opera Omnia. Hagae. Com., 1738., p. 3.—Bar- tholinus, Histor. Anat., 1747, cent, ii., hist. 25.—Meckel, in Mem. do l'Acad. de Berlin, 1759, p. 44, 45, and 86.—Meck- el, de Conditione Cord. Abnorm., p. 6.— Morgagni, Ep. Anat.. xv., n. 53 ; and xvii., p. 25.—E. Jager, De Hepati- tide et Phthisi., y$, Ivyvbc, Hippocra- tes. Singultus, Pliny, Sauvages, Vogel, Sa- gar. Lygmus, Swediaur. Pneusis singultus, Young. Clonus singultus, Good. Hoquet, Fr. Glucksen, Schluckcn. Germ. Stnghiozzo, Ital. Hiccough, hocket, hickup. Classif.—4. Class. 3. Order (Good). II. Class, III Order (Author). 1. Defin.—An uneasy sensation at the pracor- dia, followed by a rapid contraction of the dia- phragm, of momentary duration, causing an audi- ble inspiration, iterated at short intervals. 2. i. Description.—Although hiccough is fre- quently symptomatic of dangerous maladies, and is even a fatal sign in these, yet it is occasionally the chief and primary disorder. When it is thus idiopathic, it is generally a slight and evanescent affection. It consists of a sudden and rapid contraction of the respira- tory muscles, of the diaphragm especially, in- stantly followed by relaxation, thereby causing as rapid an inspiration, which is audible from its suddenness and force. These convulsive movements return at short intervals, and are attended by painful uneasiness at the praecor- dia and epigastrium, increasing with the fre- quency of the convulsive contractions and con- tinuance of the disease. 3. ii. Causes.—Hiccough occurs frequently in infants and young children. It is not un- common in aged persons ; and, at these epochs, is generally symptomatic of irritation of the stomach or duodenum, or produced by a too precipitate deglutition, the movements which accomplish this process often taking place in an irritable or spastic manner in persons at the two extremes of existence. The arrest of the alimentary bolus in the oesophagus ; an insuf- ficiently masticated or dry state of the bolus ; an irregular or precipitate performance of deg- lutition, especially when the stomach is empty or debilitated; the ingestion of highly season- ed or stimulating food or drink, or of cold fluids ; laughter, particularly in hysterical fe- males ; long fasting and emptiness of the stom- ach ; irritating or poisonous substances in this organ; worms in the digestive canal ; and wearing strait-laced corsets, are the most com- mon exciting causes of the less important and idiopathic cases of this affection. 4. Hiccough may be one of the forms in which hysteria manifests itself, particularly when hysterical patients have been subjected to mental emotions, as after crying or laugh- ing. It may also follow a fit of cough or vom- iting ; or it may be produced by sudden frights. But in all these, debility, especially of the di- gestive organs, is a predisposing cause. It is often a symptom of irritation or inflammation of an adjoining viscus, particularly of the con- vex surface of the liver and of the stomach, especially at its cardiac orifice. It may arise from the passage of biliary calculi along the ducts, or from calculi in the kidneys, or in their passage into the ureters. Strangulation of in- ternal parts, irritating matters in the colon, ex- ternal injuries and fractures of the ribs, the va- rious stages of pregnancy, and the suppression of accustomed discharges and eruptions, have severally produced it. Besides, singultus oc- curs in a great number of acute diseases and fevers, particularly towards the close of life. ft usually attends fatal cases of inflammation of the abdominal viscera, and is generally pres- ent when hepatitis of the upper or posterior parts of the liver extends to the diaphragmatic peritoneum, or when abscess of this organ points upon the diaphragm. 5. When singultus occurs after a too full meal, or after the ingestion of cold or irrita- ting fluids, which is very common, it is com- paratively of little import, farther than that it 272 HICCOUGH—Causes. evinces a debilitated state of the stomach and increased irritability. But when it follows a meal either frequently or habitually, chronic inflammation of the stomach, especially about the cardiac orifice, or even of the oesophagus or duodenum, should be suspected ; or irrita- tion of the pancreas or biliary ducts, or worms in the alimentary canal may exist. When de- pending upon this latter cause, it sometimes alternates with sneezing and pruritus of the nostrils. 6. Authors have recorded numerous instan- ces of hiccough continuing from two to three days to many months, or even longer, in some cases without any other very prominent symp- tom of disease ; in others, alternating with sneezing, syncope, or hysteria. Various anom- alous cases of this affection have been record- ed by Poterius, Schenck, Bartholin, Alber- ti, Lanzoni, Hoffmann, Bauer, Parr, and oth- ers. Most of these have arisen from some permanent source of irritation, as biliary or urinary calculi; or have been one of the many manifestations of hysteria. The only instan- ces of persistent hiccough that I have observed were referable to these sources, or to uterine irritation. 7. iii. The lesions of structure most frequently observed in those who have experienced this affection in a remarkable manner have been chiefly the following: The usual appearances and results of inflammation of the peritoneum, pleura, diaphragm, liver, stomach, or other ad- joining viscera; encysted or other tumours connected with, or pressing upon the diaphragm or its crura; scirrus of the cardiac orifice of the stomach, or of the pancreas ; morbid struc- tures developed about the root of the mesen- tery ; calculi, and abscesses in the kidneys, or calculi in the gall ducts ; tumours pressing upon the eighth pair of nerves ; and albuminous or other fluids effused into the sacs of the pleura, or into the peritoneum. 8. iv. Of the diagnosis and prognosis of sin- gultus it is unnecessary to make any specific mention. The former is obvious ; the latter may be inferred from what has been already stated. When hiccough is the primary disor- der, and quite independent of internal inflam- mations, or of fever, a favourable result will generally follow, although it may be more than usually severe or frequent in its attacks. But when it is a symptom of these maladies, and appears at a far-advanced stage of acute or chronic diseases, it is generally a fatal indica- tion. Cases, however, will occur in which the experience and pathological discrimination of the practitioner will be severely tried in giving an opinion as to the result. 9. v. Treatment.—The means of cure in this complaint should be selected with strict refer- ence to the causes and pathological dependency of it.—A. In the primary or idiopathic forms of it, the administration of opium with ether, or of other anodynes and diffusible stimulants, and of refreshing alkaline beverages, will generally give relief. Various antispasmodics, volatile nervines, and sedatives, especially camphor, ammonia, hyoscyamus, hydrocyanic acid, either taken into the stomach, or inhaled into the lungs with warm vapour, will often remove the complaint. Idiopathic hiccough also may cease spontaneously; or it may be arrested by exci- ting some powerful mental emotion, as surprise, fright, &c, or by powerfully exciting the dia- phragm by sternutatories or emetics; or by taking any substance in quantity into the stomach. When its continuance or severity requires med- ical interference, the pathological knowledge and diagnostic acumen of the physician are oft- en put to the test, as either the absence of other symptoms, or their equivocal nature, ren- ders it doubtful to what cause it should be as- signed. In those cases the chest and abdomen ought to be minutely examined before any opin- ion is formed. 10. In obscure or doubtful cases, camphor, with or without the nitrate of potash; the spiritus atheris nitrici, or the spiritus atheris sulphurici comp., or the tinctura camphor a composita may be given with demulcents. The alkaline sub- carbonates may also be exhibited with hyoscya- mus, or with colchicum, opium; or the hydrocyan- ic acid may be given in an aromatic or gently tonic infusion. If there be reason to refer the affection to irritation in the kidneys, or in the biliary ducts, demulcents with camphor, and the sub-carbonates of soda, &c, will generally be of service. If it appear to depend upon worms, the treatment should be directed accordingly. When it is referrible to inflammatory action in the stomach or duodenum, full doses of calomel, with opium and small quantities of camphor, general or local depletions, according to circum- stances, and cathartic enemata, are chiefly to be depended upon. Even in the more obscure and non-febrile cases which may resist sooth- ing and antispasmodic remedies, cupping over the hypochondria, or along the vertebral col- umn, as recommended by J. P. Frank, followed by blisters, sinapisms, moxas, the warm turpen- tine epithem, or other counter-irritants, in the same situation, may be prescribed. In cases where vascular depletion seems inadmissible, advantage may be derived from dry-cupping, as advised by Riedlin, Cleghorn, and Hufeland. Besides these, the tincture of nux vomica has been employed by Ranoe, and the cajeput oil by Vogel. 11. When this affection is merely a form of hysteria, or is connected with uterine irritation, cold aspersions of the surface ; refrigerants with camphor, and the other means usually employ- ed in that complaint are indicated. When it assumes a periodic character, the sulphate of quinine, and other preparations of bark, may be prescribed, with sulphuric acid, and sulphuric ffither. Repeated doses of magnesia with am- monia and aromatics; the carbonates of iron, and other preparations of this metal; the sub- nitrate of bismuth; the various preparations of zinc; and, lastly, electricity or galvanism in the direction of the spine or diaphragm, have sev- erally been recommended. 12. When hiccough is a distressing symp- tom about the fatal termination of disease, large doses of camphor, of ammonia, or of musk, and opiate frictions, &c, have generally been pre- scribed ; but these can only palliate, and very frequently they are inadequate to accomplish this intention. Bibliog. and Refer.- Oribasius, Synopsis, 1. vi., c. U—Attius, Tetrab. in., serm. i., c. 5.—Avicenna, Cnnun, 1. m., fen. xin., tract., v., c 19.- Rigaud, Ergo Solvunt siugultum Vomitus et Sternutalio. Pans, 1601 — Zacutus \iU"if"T: Med-,Pract- "j«-J(• "•' P- 690—Hollerius, Ue Morbis Internis, 1. i., c. 32—Bartholmus, Hist. Anat ceut HOOPING-COUG H—Description. 273 ii., hist. 4. — Riedlin, Lin. Med., 1696, p. 276, et cent, i., obs. 15.— Hoffmann, Opera, vol. iii., p. 127.—Alberti, Ca- sus Singultus Chronici viginti quatuor Annorum. Hals, 1743.—Bonet, Sepulchretum, I. iii., s. v., obs. 1, 2.—Cleg- horn, Diseases of Minorca, p. 211. — Z. Vogel, Medic u. Chirurg. Beobacht., p. 214.—Morgagni, De Sed. et Caus. Morb., epist. xxix., 3.— Ranoe, in Acta Reg. Soc. Med. Havn., vol. i., p. 460.—.V. Stoll, Praelect., vol. ii, p. 153.— Darwin, Zoonomia, iv., i., 1, 7. — Renauldin, in Diet, des Sc. Med., 1. xxi. — Raige-Delorme, Diet, de Med., t. xi.— Ashe, Cyclop, of Pract. Med., vol. ii., p. 424.—Jolly, Diet. de Med. et Chir. Pract., t. x. HOOPING-COUGH. —Synon. Pertussis, Syd- enham, Huxham, Cullen, Darwin. Tussis Ferina, Hoffmann. Tussis Convulsiva, Sau- vages. Tussis Quinta, Schenck. Tussis Clangosa, Bourdelin. Tussis Dclassans, T. suffocans, T. Amphimerina, T. Tussiculosa, T. Stomachalis, T. Spasmodica, Auct. var. Pneu- sis Pertussis, Young. Bex convulsiva, Good. Bronchitis Epidemica, Marcus. Bronchitis Convulsiva, Prunel. Bronchocephalitis, Des- ruelles. Coqueluche, Maladie Cuculaire, Toux Quinteuse,Tr. Keichhusten,Kikhusten,Krampf- husten, Germ. Kikhosta, Swed. Pertosse, Ital. Hooping-cough, Chin-cough, Kin-cough, Kinkhost. Classif.—2. Class, 3. Order (Cullen). 2. Class, 2. Order (Good). II. Class, III. Order (Author in Preface). 1. Defin.—Convulsive and suffocative cough, accompanied with a reiterated hoop, or consisting of many successive short expirations followed by one deep and loud inspiration, and these alterna- ting for several times; occurring in paroxysms, ending with the expectoration of tough phlegm, and frequently with vomiting; infectious, and often epidemic, appearing but once during life. 2. M. Guersent defines hooping-cough to be a catarrhal affection of the air-passages, char- acterized by sonorous inspirations with immi- nent suffocation. The origin of this disease is obscure; for, if the ancients have at all ob- served it, they have not described it so as to enable us to recognise it. Doubtless new mal- adies may develop themselves in the progress of the refinements of society, and of the chan- ges which the physical and moral world have undergone during a lapse of ages. This cannot be denied in respect of some of the exanthe- mata, or of diseases propagated by a specific virus, as smallpox. But, excepting these, it is difficult to admit that those maladies, the spread of which very much depends upon atmospheric vicissitudes, and epidemic constitutions, and upon general susceptibility of the species, can have been of modern occurrence entirely. It is not easy to conceive why a disease should not have, at least, occasionally appeared, since the circumstances favouring, and causes indu- cing it must have been in existence from the earliest ages. It may be said of hooping-cough, as of some other diseases, that, although the more exact observations and descriptions of modern observers have made it known only in comparatively recent periods, yet it may have existed nevertheless, and have been unknown from having been confounded with other mala- dies resembling it. 3. The passages in Hippocrates that maybe referred to this disease are equally applicable to several other catarrhal affections or disor- ders of the respiratory organs. Some of the older writers take notice of epidemics, which have been considered to have been hooping- II 35 cough, especially those of 1239 and 1311 ; but they may have been severe catarrhal epidem- ics or influenza. Rosen thinks that pertussis passed from the East Indies and Africa into Europe, but of this he has furnished no satis- factory proof. According to MezeSay, it first appeared in France in 1414; and he has been generally considered as having given the earli- est account or description of the disease ; but, upon referring to this writer (Abregt Chron. ou Extrait de I'Hist, de France, t. iv., p. 65), there is nothing but the name Coqueluche that is ap- plicable to it. Indeed, his account would have been quite applicable to the influenza of Janu- ary, 1837. The epidemics noticed by De Thou and Pasquier, to which the same name was given, and which occurred in 1510 and 1557, were evidently influenza, and not hooping- cough ; and the same remark is applicable to most of the supposed epidemics of this latter disease during the sixteenth and seventeenth centuries. 4. Willis was the first who accurately de- scribed hooping-cough under the name of " Tussis puerorum convulsiva, sue suffocativa, et nostro idiomate chin-cough vulgo dicta" (Ope- ra Omnia. Amst., 1682, vol. ii., p. 169), and it is only from his time that we have any account of the disease that can be relied upon. It was afterward noticed by Sydenham (Op. Universa. Lugd. Bat., 1726, p. 311), and by both it was treated of as a common disease. It is extreme- ly doubtful that the epidemics of the fifteenth and sixteenth centuries, which proved so very fatal, were actually this complaint. The im- perfect notices made of them convey nothing really proving that they were it. Rosen con- fesses that he cannot determine when pertus- sis first appeared in Sweden; and, as respects this country, there is no account earlier than that of Willis which can be received. 5. I. Description.—Hooping-cough, whether in an epidemic or sporadic form, presents near- ly the same phenomena, particularly when it is simple or uncomplicated ; but it is modified, in many respects, by the season, climate, consti- tution or habit of body of the patient, and by the complications which take place in its early stages. I shall, therefore, describe, first, ita simple or uncomplicated form, and, secondly, the complications which it frequently presents. 6. i. Simple Hooping-cough—Pertussis has been divided into two stages by some writers, viz., the catarrhal and the convulsive; and into three by others, the second stage being divided by the latter into the periods of convulsion and of decline.—A. The stage of development, or the catarrhal period, is generally announced by some slight rigours or chills, turgescence of the face, slight redness of the conjunctiva, wa- tering of the eyes, and the signs of simple cor- yza. There is scarcely any fever, sometimes only for twenty-four or thirty-six hours ; but in some cases the fever is more marked, and it occasionally assumes a quotidian or tertian type. The cough is more or less frequent, comes on in fits, and may at this time be taken for common catarrh, or catarrhal affection of the trachea and bronchi. However, a slight shade of difference may be detected in the tone of the voice, which experienced observers will recognise as characteristic of the disease. The cough is more sonorous and more acute 274 HOOPING-COUGH—Description. than in bronchitis; expectoration is scanty, even with adults, and the matter brought up is limpid, as at the commencement of catarrhal affections. The anterior part of the neck is sometimes uneasy, or even painful, but in other respects there is little complaint, except- ing a slight depression of spirits, moroseness, heaviness, diminished appetite, and sluggish bowels. This period generally continues from five to twelve days, and seldom more than fif- teen. [In fifteen cases of hooping-cough, Dr. Trous- seau found the initial catarrh absent but twice; and in sixteen cases recorded by Valliex, catarrh was noticed in fourteen, these being all in which the early symptoms were particularly observed. There is a difference of opinion among pathologists as to the duration of this stage, some making it last from four to six days, while others assign it a much longer du- ration. Lombard states that, in an epidemic that occurred at Geneva, it lasted from one month to six weeks. In twelve cases observ- ed by MM. Rilliet and Barthez, the hoop ap- peared on the first day once ; the catarrh last- ed six days in one case; seven days once; eleven days twice ; fifteen days five times ; thirty days once ; and forty-five days once. In this country, the catarrhal stage averages about two weeks, the transition to the second stage occupying from four to eight days.] 7. B. In the Convulsive, Spasmodic, or Ner- vous Stage, the patients complain frequently of uneasiness or pain under the sternum ; the fits of cough are longer, more frequent, particularly at night, and commence with unpleasant titilla- tion at the larynx, during which the expiratory and inspiratory movements are irregular and in- complete, chiefly in very young children, who evince considerable dread of the attack. This state is attended with anxiety and a slight mu- cous rattle. On the accession of the fit, infants grasp persons or objects that are near them, or, upon awakening from sleep, start up. Each accession consists of a very dry, sonorous, spasmodic cough ; the contractions of the res- piratory muscles being so quick, and succeed- ing each other so rapidly, and attended with so much constriction of the larynx, that the patient cannot breathe, and seems almost suffocated. The face and neck are swollen, injected, and violet-coloured ; the jugular veins are gorged ; the eyes prominent, injected, watering, and the paroxysm terminates with one or two long, incomplete inspirations, attended with that pe- culiar noise from which the disease has gen- erally derived its designation. Sometimes the fit of cough is interrupted during one or several minutes, and is resumed, but does not cease entirely until the patient rejects, by a sort of regurgitation, a ropy and limpid fluid, which comes partly from the bronchi, and partly from the stomach, as shown by the presence of por- tions of ingesta, and of bronchial mucus.* In some cases, when vomiting does not accom- * iThe termination of the cough in vomiting is merely the result of the violence of the action which produces the cough : as soon as the muscular efforts have compressed the chest as far as it will yield, their force falls on the stomach ; and in proportion as the cardiac orifice yields is the completeness of the act of vomiting. This disposition is increased by habit, and. consequently, as the disease ad- vances the fits of cough often terminate, more frequently and speedily, by vomiting or retching.] pany the paroxysm, this particular fluid pro- ceeds chiefly from the air-passages ; in others, particularly in those accompanied with vomit- ing, it is chiefly from the stomach. It is some- times sanguineous, either in streaks or specks; and when the paroxysms are severe, blood sometimes escapes from the nostrils, and even, in rare cases, from the ears and eyelids. The termination of the paroxysms is often attend- ed by a watery secretion from the eyes. Cry- ing, mental irritation, or opposition frequently brings on a fit -, and even the sight of another in the paroxysm will induce it in those affected by the disease. The fits are generally much more severe after a meal, or after running, or other very active exercise. Their number varies with the severity of the disease, from five or six in the twenty-four hours, to one ev- ery ten or fifteen minutes ; they are generally severer and more frequent during the night than in the day. [According to Rilliet and Barthez, the paroxysms lasted from one fourth to three fourths of a minute, and even two minutes ; and there were often twenty parox- ysms in the twenty-four hours, sometimes less, sometimes as many as forty-eight, and in one case seventy-two. Dr. Trousseau states that, in the first two or three weeks, the paroxysms go on increasing to a period corresponding to the twenty-ninth or thirty-eight day ; they then remain stationary for a certain number of days, and then rapidly decline in frequency, being generally most frequent during the evening and night.] On applying the stethoscope or the ear to the chest, on the accession of the par- oxysms, a mucous rattle may sometimes be heard; but frequently no unnatural noise can be detected, unless the disease is complicated with bronchitis. During the paroxysm the res- piration is so far suspended as not to be heard in any part of the lungs ; but at the moment of inspiration the air is precipitated by a loud, hissing sound, as far as the bifurcation of the bronchi, where it seems to encounter some ob- stacle, as it does not pass farther for one or two seconds. This stage usually continues from fifteen days to a month, or even longer. During its course, the fever, which had been either scarcely perceptible or but slight, but had been suspended after the invasion of the disease, is, in some cases, rekindled with more force, assuming the continued or intermitting type. It is chiefly during the early part of this stage that pertussis becomes complicated with, or excites bronchitis or other disease of the lungs. Yet such complications occur at vari- ous intervals from the attack, and sometimes even accompany the first stage. But it is gen- erally during this period that affections of the head, or of the abdominal viscera, supervene, which, with lesions of the lungs, occasion un- favourable terminations. However, when the disease is slight and uncomplicated, it is with- out fever, the patients preserving their usual health and appetite, which may be even more craving than usual. 8. C. The Stage of Decline is of indetermi- nate duration, occurring from three to five weeks after the invasion of the disease, and continuing from twelve days to two or three months. It may be said to commence from the time of the paroxysms being more distant and shorter than in the preceding period, and by HOOPING-COUGH—Complications of. 275 their termination, in the excretion of an opaque and thickish matter, as in the last stages of ca- tarrh, and in the vomiting of alimentary mat- ters. The fits become insensibly feebler during this stage ; the cough gradually loses the char- acteristic hoop, and approximates nearer that attending the last stages of catarrhal affections. Sometimes the patient will remain for a day or two, or even longer, without cough ; but on exposure to cold, change of temperature or weather, or after errors of diet, it returns with similar characters. In some seasons especial- ly, as during autumn, and at other seasons on the occurrence of easterly winds, I have seen the paroxysms of cough return, with the same characters, after a fortnight, a month, or even two or three months, of perfect and apparent recovery. [According to Dr. Lombard, the average du- ration of hooping-cough, as observed by him, was from fifteen to sixty-five days; the aver- age thirty to forty days. The disorder among us lasts from one to five, and even twelve months, the average being about three ; its du- ration being extremely variable, and depending much, we believe, on the mode of treatment pursued. Much also depends on the season of the year, it being always of longer duration in winter. The popular notion is, that it is six weeks in reaching its height, continuing for some time with little abatement, then declining and going off in six weeks more.] 9. ii. Complicated Pertussis —Hooping- cough is frequently accompanied with, or occa- sions, in its severer forms, or in predisposed subjects, most serious affections. It may even attack patients already suffering or convales- cent from disease ; and although occurring un- der such unfavourable ciicumstances, may not be severe, and may terminate favourably, al- though in other cases it will often aggravate the pre-existing or accompanying malady—so much so as even to lead to a fatal termination. The complications of hooping-cough vary ex- tremely, according to the season of the year, the state of the weather and atmospherical vi- cissitudes, the character of the prevailing epi- demic, and the habit and temperament of the patient. They constitute the most important features of the disease, inasmuch as the danger depends entirely upon the particular form of complication present. The success, also, of the practitioner will mainly depend on the ce- lerity and accuracy with which he may detect existing or incipient stales of superadded or contingent disease, and the decision with which he may treat them. The importance of attend- ing closely to the progress of hooping-cough, even in apparently favourable cases, must be apparent to those who have had occasion to observe how insidiously diseases of the sub- stance of the lungs or of the brain have su- pervened and advanced even to an irremedia- ble degree, masked by the cough, so as to have failed of attracting the attention of parents or those around the patient; or, if they have at- tracted notice, to have been mistaken for a symptom merely of the simple and less danger- ous affection. I have frequently been called to children dangerously affected with disease of the lungs or brain, which had been in exist- ence for many days before attention had been excited by it. Considering the complications of pertussis most important, I shall treat of them somewhat in detail. 10. Pertussis, in either an epidemic or spo- radic form, particularly the former, sometimes follows rapidly upon measles. Occasionally it appears during convalescence from that com- plaint. In such cases, disease of the lungs, par- ticularly bronchitis, pneumonia, pleurisy, tuber- cles, &c, often steals on without being sus- pected until it has made a formidable progress, or passed beyond the reach of aid. The pre- vious disease, and the treatment employed for it, have often induced that state of the system which does not evince the complication by many of the usual symptoms which character- ize it in the idiopathic or primary form ; and it is chiefly by attentive observation of the pulse and respiration, in the intervals between the paroxysms, and of the expectorated matter, and by examining the state of the lungs by means of percussion and the stethoscope, that we can detect the complication or judge of its nature and extent. In infants with a narrow or mal- formed chest, there are often great dyspnoea, frequency of pulse and of respiration, some- times even without much serious disease of the lungs, beyond slight bronchial irritation. The most common complications of hooping- cough, especially from two or three months old to seven or eight years, or later, are, croup, bronchitis, pneumonia, pleurisy, pneumo-thorax, adema of the lungs, hydrothorax. In all these the respiration is difficult, frequent, and em- barrassed ; the countenance and extremities are turgid; and there is continued frequency of pulse. The expectoration terminating the paroxysms varies according as either of the above lesions is present. It is generally much diminished, and in proportion to the severity of the organic disease and of the accompanying fever. But the extent and nature of the com- plication should be carefully determined by the stethoscope and by percussion. In somewhat older children, and in those advancing nearer to puberty, who are of a scrofulous habit, and hereditarily disposed to phthisis, haemoptysis, sometimes to a considerable extent, takes place, and in these subjects particularly tubercular disease of the lungs is not infrequently devel- oped, either with or without haemoptoe. 11. B. In infants and young children, the functions of the brain, and the symptoms indi- cating disturbance of this organ, should be care- fully watched for, particularly those indicating cerebral congestion, hydrocephalus,. meningitis, or cerebritis; and if any of these symptoms occur, and especially if attended by continued fever, by screaming, or by rolling of the head, or con- vulsions indicating meningitis or hydrocepha- lus ; or by somnolency, falling of the eyelids, cool state of the skin, inability or disinclination to move or be moved, with dilated pupil, &c, indicating cerebritis, decisive treatment should be adopted, as recommended for these mal- adies. 12. C. Diseases of the Abdominal Viscera are much more rarely complicated with hooping- cough than those already mentioned ; however, diarrhoea, chronic irritation of the stomach and bowels, remittent fever, inflammation of the mucous surface of these organs, are not infrequent at- tendants upon it. Sometimes, even, inflamma- I tion of the peritoneum and mesentery will occur, 276 HOOPING-COUGH—Complications op. during the advanced stages of hooping-cough, and I have occasionally, also, met with inflam- mation of the caecum and colon, and pericarditis. These complications, particularly those of the digestive mucous surface, may superinduce otH- ers, as enlargement of the mesenteric glands, and affections of the cerebral organs, rapidly terminating in effusion. 13. With respect to all these complications, it may be generally remarked that they are at- tended by more or less fever of a continued or remittent type, and with paroxysms of cough more or less dry and severe. Sometimes the febrile exacerbations and remissions are well marked, especially when the complication is in the abdominal cavity. The expectoration ter- minating the fits generally diminishes as the complication increases in severity, and the vomitings often disappear. The paroxysms also are followed by more sensible prostration of strength. Having thus taken a general view of complicated pertussis, I shall next more par- ticularly notice those complications which most commonly occur, and which frequently super- induce farther disease, especially in connected or associated structures. 14. D. Pertussis associated with Bronchitis is extremely frequent during spring and winter, and in this climate, especially in the months of February, March, and April, owing to the prev- alence of easterly winds at that season. 1. It may precede hooping-cough; 2. It may be coe- val with it ; and, 3. It may supervene in the course of the disease. The last is most com- mon. Whenever bronchitis appears, there are always decidedly febrile symptoms during the intervals between the paroxysms of cough. The breathing is also much accelerated, and, when examined by auscultation, is accompanied by the mucous rattle, and occasional temporary suspension of the respiratory sound in parts of the lungs, owing to the accumulation of the mucous secretion for a while in one or more of the bronchial tubes conveying air to those parts of the organ. The expectoration, also, from being clear, whitish, and ropy, becomes more opaque, less fluid, gelatinous, and less abundant. The paroxysms of cough are much more frequent, and often accompanied with a feeling of oppression in the chest, and are less constantly followed, or even not at all, by rejec- tion of the contents of the stomach. The chest sounds well upon percussion, and the patient lies on the side most affected, or, in slighter cases, on either side. When the bronchi of both lungs are generally affected, he is unable to lie on either side, or is incapable of lying down at all. 15. This complication often terminates fatal- ly, either from obstruction of the air tubes by the accumulation of tenacious mucus, togeth- er with spasm about the larynx, occasioned by the nervous character of the disease, and the irritation of the glutinous secretion, the patient dying asphyxied ; or from congestion of the ves- sels of the head, owing to the paroxysms of cough, the obstruction produced by the mucus in the air-passages, and the difficult circulation through the lungs; or from the inflammatory action having extended to the trachea and larynx, or to the minute bronchi and substance of the lungs terminating in condensation, &c, of the structure of the organ, dec. In some cases, owing to the treatment employed and constitution of the patient, the acute form of the bronchial affection gradually subsides until it arrives at a milder state ; when, owing to the incapability of the vessels to assume the healthy state, a chronic form of disease continues long afterward, which may be removed, in some cases, by judicious management; but which terminates in ulceration of the mucous mem- brane, or gives rise to tubercles, to chronic pleuritis, or other lesions in the thoracic cavi- ty. This complication is frequent from six or seven months upward, and especially during the second, third, and fourth years of age. [Rilliet and Barthez deny the constant presence of bronchitis in hooping-cough, and state that they found it alone or in connexion with pneumonia in only one half of the cases that proved fatal. The inflammation rarely consisted in redness of the mucous membrane alone, and it was most generally accompanied with continuous dilatation of the smaller air tubes. The existence and intensity of the bronchitis were in relation to the period at which the patient died. If death occurred on the 15th, 18th, 26th, and 27th days, there was no bronchitis; but it was constantly present when the malady was more prolonged. The same holds good in pneumonia ; it was con- stantly found in those dying beyond the 27th day at the second stage, and sometimes the second and third stages. The two phlegma- sia* coincided, and it was difficult, during life, to indicate precisely the exact period of the in- vasion of the pneumonia. It was generally partial and lobular. MM. Rilliet and Bar- thez met with only one case of lobular pneu- monia in a child that recovered; it occupied the summit of the left lung, and was developed at the end of three weeks.] 16. E. Hooping-cough associated with pneumo- nia and pleuritis is very frequent in the spring during easterly or northerly winds, particular- ly when these follow heavy falls of rain and open weather. It is more common in some epidemics than in others, and is met with at all ages, but most frequently from one to six or seven years or upward; and in children of a full habit of body, sanguine temperament, and strumous diathesis it may be nearly coeval with the pertussis ; but it more commonly su- pervenes in the course of the disease, the in- flammation commencing often as bronchitis, and extending in parts along the smaller rami- fications of the bronchi, to the air-cells and sub- stance of the lungs. In some cases, pleuritis supervenes to the pneumonia, and in others a portion of a whole lobe of the organ, and the pleura covering it, seem as simultaneously af- fected. It is very difficult to ascertain the ex- istence of this complication in infants and very young children, but auscultation and percussion furnish considerable aid to the diagnosis. 17. The Symptoms of this complication vary according as the inflammation of the lungs and hooping-cough are coeval affections, or as the one may supervene to the other. When the affection of the lungs or pleura is present from the commencement, the cough occurs frequent- ly, in short paroxysms, and is seldom followed by the rejection of the contents of the stomach. The pulse and respiration are quick, hard, full, and hurried; the alse nasi and diaphragm la- HOOPING-COUGH—Complications or. 277 bour much during the respiratory motions, and the cough is without the attendant hoop, and does not terminate in vomiting, as the compli- cation becomes developed. When it has been consequent upon the bronchial complication, wheezing and difficult expectoration are gener- ally present; and the sputa become thick, opaque, glutinous, puriform, or streaked with blood. The prostration of strength is also great. There is a dull sound given out upon percussion of the thorax, over the seat of the disease. On examining the chest with the stethoscope, the signs enumerated in the pneumonia of children are more or less manifest (see art. Lungs—Inflammation of). When the pleura is implicated the cough is more suppressed, and pain is complained of in some part or other of the thorax; yet this latter symptom is not al- ways prominent. In addition to the other stethoscopic signs, the metallic tinkling is often present. In the worst cases of this complica- tion, as in those of the preceding, the lips as- sume a livid hue, and the extremities become cold, or even of a leaden colour. This com- plication often terminates unfavourably in a short time. During its continuance the hooping- cough presents characters much less distinct, but which become more pronounced as the in- flammation is subdued. [MM. Rilliet and Barthez deny the fre- quency of emphysema in pertussis, and they explain its rare occurrence by the mechanism of the paroxysms. Each spell consists of a series of expirations, followed by a single, long, whistling inspiration. This series of expira- tions empties the lungs, and thus acts in an in- verse direction to the mechanical cause of emphysema. The long and whistling back- draught occurs during a spasmodic constriction of the larynx, trachea, and bronchi, which does not permit the air to go beyond the principal bronchial ramifications. The expulsion of air, and the incomplete access of air into the air cells during the paroxysm, are then the two phenomena which explain the absence of em- physema. In complicated cases it exists, but then to a less degree than when bronchitis and pneumonia occur alone ; so that hooping-cough, so far from producing emphysema, tends to di- minish the intensity of this lesion in the dis- eases which frequently give rise to it. Inflam- mation, according to these authors, is the sole cause of dilatation of the smaller bronchi; the phenomena of the paroxysm occur during ex- piration, and the strong inspiration admits air only into the large bronchi. (Clymer, in Am. Ed. of " Williams on the Diseases of the Respira- tory Organs," Phil., 1845.)] 18. F. Complications with tubercular Phthisis, hydrothorax, or pneumo-thorax are rarely or nev- er met with, unless as the consequences of one or other of the foregoing, or in the far-ad- vanced stages of pertussis ; and are therefore unfavourable terminations rather than compli- cations of the disease, arising out of neglect or inappropriate treatment, or constitutional pre- disposition. The state of the expectoration and hectic symptoms, and the signs furnished by auscultation and percussion, will enable the practitioner to detect either of these termina- tions. 19. Pertussis associated with inflammatory ir- ritation of the Membranes or Substance of the brain, or occasioning Hydrocephalus, is very com- mon, particularly in infants about the period of dentition, or from six months to two or three years of age. In these, convulsions in various forms, spasm of the glottis, screaming, &c, are of frequent occurrence, and indicative of this complication, which is often more preva- lent in some epidemics than in others. Con- gestion of the brain, owing to interruptions to the return of blood from it during the parox- ysms of this disease, often terminates in effu- sion, capillary reaction, or even softening of parts of the organ. The spasms and convul- sions which generally attend these affections of the brain in infants and young children rarely carry off the patient. They are rather the indications of that state of disease of the substance or membranes of the brain which terminates in softening of the central parts, and in serous effusion into the ventricles. When- ever the paroxysm of cough is increased in violence, the characteristic hoop disappearing, the face becoming very livid, and the thumbs drawn into the palms, cerebral congestion, with its attendants and consequences, should be an- ticipated. In some cases, but by no means frequently, the swelling on the tops of the fin- gers and toes, noticed by Dr. Kellie, and the crowing inspirations indicating spasm of the larynx (see Larynx) and threatening suffoca- tion, are observed, generally at early stages of this complication. When the convulsions af- fect one side of the body more than the other, and especially if one side or limb be paralyzed, softening of some of the more central parts of the brain and serous effusion may be inferred. [This complication was met with by MM. Rilliet and Barthez five times in twenty-. nine cases, being more frequent in very young children. The eldest of these cases was five years old ; the disease was severe in all. The hooping had been established from sixteen to thirty-one days ; of seven cases, five succumb- ed, death immediately following the convul- sions] 20. In all cases of pertussis, when chills, followed by burning heat of the surface; pains of the head, with obscure redness of the con- junctiva ; a fixed, brilliant, dry, and peculiar appearance of the eye; unusual redness or pallor of the face; very torpid bowels, with morbid excretions ; irritability of stomach in- dependently of the fits of cough ; aversion from light or noise; heaviness or drowsiness and languor; grinding of the teeth; or sudden starting or shocks of the body in sleep; rolling or tossing back the head, and piercing screams are observed, then irritation of the brain or its membranes, which will soon pass into organic change and effusion, is manifestly present, whether there be convulsions or not. When stupor or unconsciousness has come on, with one arm waving in the air, or tossed over the head, while the other is paralyzed, a farther advanced state of disease than mere inflamma- tory irritation, as softening or effusion, may be inferred. 21. H. Pertussis associated with Disorder of the Bowels, or with infantile remittent Fever, is not infrequently observed. In these cases the abdomen is tumid, the evacuations offensive and unnatural, the breath is fetid, the tongue loaded, and the appetite is impaired. The 278 HOOPING COUGH—Complications or. complexion is lost, and the eyes more sunk and heavy than in health. At last febrile ex- acerbations and remissions are observed, gen- erally twice in the twenty-four hours; pickings of the nostrils and lips ; the cough returns more frequently, and ceases to terminate in vomiting; the breathing is oppressed, hurried, and short; the expectoration, at the termination of the fits, is more scanty, but without the signs of bronchitis or of pneumonia ; and emaciation proceeds. If this state of disorder continue, effusion in the ventricles of the brain may take place, or the mesenteric glands may become diseased. This complication steals on imper- ceptibly, and generally in the second or third stage of pertussis. 22. iii. The Appearances observed in fatal ca- ses of Pertussis show the nature and extent of the complications, rather than of the disease itself. The accounts furnished us of the fatal epidemics in former ages, contain no details of the appearances after death; and even the more recent researches of Watt, Marcus, Waterton, Guibert, Desruelles, Guersent, and others, have thrown little light upon the nature of the malady, although they have illus- trated the changes which often supervene in its course. The lesions which are most con- stantly observed, are more or less redness of the mucous surface of the trachea and bronchi, with considerable tumefaction of the glands at the bifurcation of the latter. These tubes con- tain a considerable quantity of a ropy or more or less thick mucus. In the bronchitic compli- cation these changes are still more marked, and in infants the thymus gland is often unu- sually large. Inflammations of the lungs or of the pleura, or of both, in all their phases and stages, and effusions into the pleural cavities, with or without adhesions or false membranes, are not unusual, but are observed only in cases of the pulmonary complications described above. They are generally associated with muco-puri- form matter accumulated in the bronchi, and splenification or condensation of several lob- ules or portions of the lungs. 23. When the disease induces chronic bron- chitis or tubercular consumption, whether hae- moptoe has occurred or not, the mucous mem- brane of the bronchi has been found thickened, softened, rarely ulcerated in some points and injected, and tubercles have been observed in all stages of development and softening, and accompanied with ulcerated excavations. Tu- bercular changes are, however, not very com- mon in young children. Dilatation of the bron- chi is sometimes observed; but I have not met with it so often as Laennec believes it to oc- cur. It is to be looked upon as a remote con- sequence of the disease in prolonged cases. M. Breschet observed, in two instances, injec- tion of the pneumo-gastric nerves ; but Mar- cus, Guersent, and myself have not found these nerves materially changed. 24. The morbid appearance found within the cranium have been chiefly consequent upon the cerebral complications, and have consisted of softening of the central parts of the cerebrum; effusion into the ventricles, or between and be- neath the membranes ; congestion of the ves- sels, &c. As far as my dissections have gone, inflammatory appearances have been observed in the medulla oblongata, or in its membranes, even when no other remarkable lesion was present within the cranium. Whether this change be a consequence of the disease or not, is difficult to determine ; but there can be little doubt that those found in the brain are merely' remotely consecutive lesions. 25. The stomach usually presents no partic- ular lesion ; but I have observed inflammatory appearances in the oesophagus, and the same have been remarked by Ozanam in his numer- ous dissections in the Foundling Hospital at Milan. I have likewise found the mucous sur- face of the pharynx and epiglottis, particularly the latter, more or less inflamed, and the sub- jacent cellular tissue, especially at the base of the epiglottis, infiltrated and cedematous. The mucous membrane of the intestines, particular- ly of the caecum and colon, has been in some instances ulcerated, and the mesenteric glands engorged; but only in protracted cases passing into infantile remittent fever. From the nu- merous post-mortem examinations I have made, I am warranted in stating that most of the le- sions observed by writers in this disease are merely effects of the complications of, and dis- eases excited by this complaint; and that the parts most constantly found altered are the mucous covering of the epiglottis, trachea, and bronchi; and of the pharynx and oesophagus; and, as respects the nervous system, the me- dulla oblongata and its membranes. [According to Billard,* post-mortem exami- nation has not revealed anything uniform in this disease, except bronchial catarrh in various stages of advancement, almost always accom- panied with a considerable quantity of mu- cosity accumulated in the bronchi, which are sometimes sensibly dilated, and exhibit a vivid red colour. Among the concomitant lesions of the catarrh, Billard often met with inflam- mation of the lymphatic ganglia in the vicinity of the bronchi, and a dilatation of the termina- tion of the bronchi, first noticed by Laennec. Sometimes he observed the bronchi unequally dilated, as in emphysema, and small vesicles at their extremities, filled with a creamy, inodor- ous pus. This able writer speaks of the dis- ease as complicated with pneumonia, pleurisy, pulmonary tubercles, chronic enteritis, mesen- teritis, meningitis, and hydrocephalus. Dr. Mackintosht states that he has examin- ed the bodies of those who have died of this disease in fifty instances, and found the appear- ances very uniform, according to the period of the disease at which death took place. In or- dinary cases, where death took place during the 2d, 3d, or 4th week, marks of vascularity and of venous turgescence were discovered in the head, and sometimes effusion of serum in the ventricles and between the membranes, but these were far from being invariable appearan- ces. Other marks of sanguineous congestion were found in different parts of the brain. Tra- ces of disease were invariably found in the thorax. In a few cases the lungs were some- what collapsed, but in general they completely filled their respective cavities. In a few in- stances the pleura costalis was covered with lated hy James Stewart, M.D., New-York 'l83» ] t I" Principles of Pathology and Practice of Medicine," hy John Mackintosh, 4th Am. Edition, with Notes bi Samuel Georqe Morton, M.D., 8vo, Phil 1644 ] HOOPING-COUGH—Nature and Seat of. 279 lymph-like and unctuous secretion. Once or twice the lungs adhered to the walls of the chest by an intermediate deposition of soft co- agulating lymph. The anterior surface of the lungs, in almost all cases, presented spots of a whitish appearauce, as if coated over with lymph ; but this was found, upon closer exam- ination, to depend on emphysema, air being ef- fused beneath the pleura, from the rupture or enlargement of the air-cells ; considerable por- tions were observed gorged with blood. Some- times the substance of the lungs was in a state of oedema, and occasionally portions were ob- served inflamed. In persons who were not cut off till the 8th or 10th week, tubercles in vari- ous states were frequently observed; some- times vesicular or crude, large and solitary, sometimes softened, and partly discharged by expectoration. Once or twice one lung was found infiltrated with a soft caseous matter. The bronchial glands were found enlarged if the patient did not die before the 3d or 4th week. The mucous membrane throughout the air passages always displayed more or less vascularity, which increased towards the ram- ifications, and the tubes were found filled with matter which had more or less resemblance to pus. This was also sometimes in the trachea and larynx. Occasionally flakes of coagula- ble lymph were observed, and ulcerations about the glottis, in the larynx and trachea, but more particularly at the great bifurcation (loc. cit.). The late Mr. Alcock, of London, states that he has repeatedly ascertained, by dissections of patients who have died of hooping-cough, that the larynx invariably exhibited signs of inflam- mation, often to so great an extent as, by its swelling, to close mechanically the glottis ; oft- en the exudation of coagulable lymph near the larynx, the mucous membrane of the trachea and bronchi much increased in vascularity, and the cavities of the latter filled with fluid more or less mixed with air; the appearance of the fluid varying from thin mucus to perfectly form- ed pus.—(Med. Intell.)] 26. iv. Of the Nature and Seat of Pertussis.— Sydenham imputed hooping-cough to the pres- ence of a subtile and irritating vapour in the blood, affecting the lungs and exciting the par- oxysms. Boehme (Cur-Methode der Wichtig- stcn, Brust krankheiten, Leip., 1788) conceived that it proceeded from a peculiar miasma act- ing chiefly on the nerves. Linnaeus had pre- viously referred it to the presence of minute in- sects in the air (Dissert. Exanthemata Viva., Upsal, 1757); an opinion which was partially adopted by Rosenstein, who, however, believed that it was propagated by a morbific principle emanating from the affected, and passing into the system of those exposed to its influence by the respiratory organs and stomach ; and hence the affection of those viscera, and the irrita- tion of the mucous glands, occasioning an in- ordinate secretion of phlegm. 27. Waldschmidt (Institut Medicina Ration- alis, 12mo, Marb., 1688), Stoll (Ratio Medendi, pars ii., p. 180), Danz (Versuch einer Allgemeinen Geschichte des Keichhustens, &c, Morb., 1791), Lentin (Memorabilia, p. 38), Friboro and Brou- zkt (Sur I'Education des Enfans, t. ii., p. 25) as- cribed the disease chiefly to gastric disorder and saburra, while they admitted, particularly Danz and Lentin, that the lungs are also much affected, but in a sympathetic manner, and that the other symptomatic disorders accompanying it vary exceedingly, while the respiratory func- tions are more constantly disturbed. Chambon (Des Maladies des Enfans, t. ii., 8vo, Paris, 1799) and Tourtelle (El'emens de Med. Th'eo- rique et Pratique, t. ii.) considered pertussis as a species of catarrh. The former located it in the stomach, and supposed that it is of an as- thenic nature, the cough and other nervous symptoms being occasioned by the affection of this organ. The latter extended the gastric disorder to the lungs, and regarded the disease as a pituitous pneumo-gastric affection. A similar opinion was entertained, also, hy Dr. Styi (Hufeland, Journ. d. Pr. Arzneyk., b. vii., st. iv., p. 177). Gardien (Traite des Mai. des Enfans, p. 391) nearly coincided with Tour- telle in referring it to a nervous irritation, sui generis, causing a pituitous or increased mu- cous secretion from the bronchi and stomach, with convulsive action of the glottis and dia- phragm, and believed that it differs from ca- tarrh chiefly in its cause and the periodicity of its character. The opinion of Millot was not materially different from the foregoing. He referred the disease to a spasmodic irritation of the stomach primarily, and of the lungs symptomatically, and he imputed the cough chiefly to the convulsive action of the dia- phragm ; but he contended that the throat and bronchi are also implicated. M. Broussais has also argued that the source of the disease is in the stomach ; but he considers that it consists of inflammatory irritation, producing an in- creased secretion of mucus, and that the ter- mination of the fits in vomiting disembarrasses the affected surfaces and assuages for a time the irritation. He, however, admits that this affection of the stomach is not of itself suffi- cient to constitute the disease, but that it is al- ways extended to the bronchi.—(Ann. de la Med. Physiol., Mai, 1824.) 28. Besides those who have thus considered pertussis either catarrhal in its nature or allied to this state, others have conceived that it is chiefly of a nervous character. While the for- mer have placed the most stress upon the ca- tarrhal symptoms, particularly the discharge of a clear, ropy mucus, and the acceleration of the pulse in many cases, the latter have been more engaged with the convulsive features of the dis- ease, especially the cough, its occurrence in fits, as in other nervous affections; and with the perfect, or nearly perfect, slate of the func-, tions during the intervals in the simple form of the disease. The opinions of Hoffman (Opera, Suppl. ii., pars x., p. 244) and of Hufeland (Bemerk. ueber Blattern, &c, p. 421) in this very nearly coincide. They both impute hooping- cough to irritation of the nerves supplying the larynx, air passages, diaphragm, and stomach; to an affection chiefly of the pneumo-gastric nerves. Hufeland supposes that the irrita- tion of the nerves supplying the larynx and air passages is extended to the diaphragm by the intimate sympathy existing between these parts; that this muscle is thereby thrown into convulsive action; and that, owing to its ac- tion on the cardia, and the irritation extending to the stomach through the medium of the eighth pair of nervss, this organ undergoes en- ergetic contraction, and evacuates its contents • 280 HOOPING-COUGH—Nature and Seat. the vomiting thus occasioned removing the ir- ritation of the respiratory organs, and thereby terminating the paroxysm. Thus, the vomit- ing is the antagonist of the spasmodic state of the organs of respiration ; and, as observed in practice, a salutary occurrence. Very nearly allied to this opinion is that proposed by Jahn (UeberdenKeichhusten. Rudolstadt, 1808). He considers hooping-cough to be an affection of the phrenic nerves, occasioned by a peculiar miasm, too subtle to be recognised. Loben- stein-Lobel (Ueber die Ang. Membr. den Keich- husten, &c, 1811) contends that this disease originates in a peculiar affection of the nerves of the diaphragm ; that in its second stage the phrenic nerves are in a state of irritation ; and that in its third the irritation is expanded throughout the system; it thus commencing with a morbid affection of the diaphragm, which extends itself, by nervous connexion, to the rest of the respiratory apparatus and stomach, and sympathetically to the whole economy. 28.* According to Paldame (Der Stikhausten. Halle, 1805), hooping disease depends on ex- alted irritability of the lungs, and of the organs most closely sympathizing with them, particu- larly the diaphragm and stomach. Nearly alli- ed with the foregoing opinions is that which has been proposed by Wendt (Die Kinderkrankh. System., &c., 8vo, Breslaw, 1822). He arran- ges hooping-cough with nervous diseases ; ar- gues against the production of a secretion pe- culiar to it, yet imputes it to a certain miasm engendered by the nature of the season and constitution of the atmosphere, and thus pre- vailing generally in an epidemic form. The nerves which he considers chiefly affected are the branches of the intercostals, the eighth pair, and the recurrent nerve ; the solar plexus he views as being consecutively affected. He con- tends that the disease is not a variety of bron- chitis, as believed by many ; and that the bron- chi are only sympathetically irritated, and chief- ly from the increased secretion of mucus and aqueous fluid poured into them during the par- oxysm. He admits that it is generally accom- panied with a phlogistic diathesis of the bron- chi and substance of the lungs, but that there is no developed state of inflammation ; this di- athesis admitting, however, of inflammation be- ing speedily kindled up from exposure to its ex- citing causes, and during certain epidemics; but when it exists, that it is merely a contin- gent complication. 29. M. Guibert (Recherches Nouv. sur le Croup et sur la Coqueluche. Paris, 1824) views pertussis as essentially nervous. He consid- ers that a common cough may pass into this affection, by having the spasmodic state of the muscles of the larynx and of the diaphragm su- peradded to it; and, therefore, that spasm su- peradded to cough constitutes the disease, the state of spasm resulting from the high nervous susceptibility and particular disposition to it existing in children, and from individual idio- syncrasy. He supposes that, while the spas- modic state constituting the disease affects the muscles of the larynx and the diaphragm, in some cases this state is extended to the mus- cles of the head and whole body, occasioning general convulsions. The increased secretion of mucus he refers to an excited state of the mucous membrane of the air passages, and of the pharynx, oesophagus, and stomach, existing independently of any inflammatory action ; and considers that the paroxysms of cough proceed from obstruction of the bronchi by the accumu- lation of this secretion ; the nervous symptoms being the result of the spasm, which he con- siders the chief agent of the morbid phenome- na. But this theory leaves unexplained the precise cause and origin of the spasm, which doubtless affects the parts to which he refers it. 30. According to M. Guersent (Diet, de Mid., t. vi., p. 6), hooping-cough is a catarrhal affec- tion, seated in the trachea and bronchi, con- sisting of a specific inflammation, accompanied with spasm of the trachea and glottis. To this opinion may be objected, that the causes of the disease are not always of a specific character; that, although it evidently is often propagated by infection, yet it frequently occurs sporadi- cally, and then it cannot be traced to any spe- cific cause. When, also, inflammatory appear- ances are observed in the air passages of some cases which have terminated fatally, these dif- fer not materially from the changes occasioned by common inflammation. 31. Dr. Watt (Treatise on the History, Nature, and Treatment of Chin-cough. Glasg., 1812) con- siders the disease to be inflammatory, and seat- ed in the bronchi. Dr. Badham and Marcus, of Bamberg, entertain the same view as Dr. Watt. Albers, of Bremen, denies hooping- cough to be essentially inflammatory. He just- ly states that it is never so rapidly developed as bronchitis; that it is an affection of the nerves of the chest, frequently occurring epi- demically, and generally admitting of cure with- out the assistance of art, unless when appear- ing in a complicated state, or when inflamma- tory action supervenes in its progress: a ter- mination which would but seldom occur if it were essentially inflammatory, and which sel- dom is observed to follow bronchitis or pneu- monia when left entirely to nature. Thus, while Albers considers hooping-cough to be an affection of the nerves of the thorax, with which bronchitis is frequently complicated, Watt and Marcus conceive that it is a catar- rhal bronchitis from its commencement. Near- ly similar to the opinion of these two authors seems to be that of M. Fourcade-Prunet, who views it as a variety of bronchitis, without, however, stating in what the difference con- sists. The convulsive paroxysms of cough he attributes to the morbid sensibility of the mu- cous membrane of the air passages in their in- flamed state, and to the irritation occasioned by the respired air and the secretion formed on this membrane. M. Boisseau (Diet, abrig'e des Scien. Medicales, t. v.) entertains a similar opin- ion to that of M. Fourcade-Prunet; and Dr. Dewees (.4 Treatise on the Physical and Medical Management of Children, 8vo. Phil., 1825) con- tends that it is a catarrhal inflammation of the respiratory mucous membrane, with an aug- mented secretion of mucus. Dr. Dawson (No- sol. Pract. of Physic, 8vo. Lond., 1824) also be- lieves in the inflammatory nature of the dis- ease, but confines its primary seat to the mu- cous membrane of the glottis. Laennec re- gards it as a variety of pulmonary catarrh, hold- ing an intermediate grade between the pituitous and the mucous catarrh; and he denominates it, from the convulsive character of the cough, HOOPING-COUGH—Nature and Seat. 281 convulsive catarrh. The expectoration he con- siders to be, at the commencement, pituitous, and towards its close nearly mucous. The ab- sence of respiratory sounds during the parox- ysms he explains by supposing either a mo- mentary congestion from blood or serum, giv- ing rise to a tumefaction of the mucous mem- brane sufficient to obstruct the bronchi, or to a spasmodic constriction of these tubes. 32. Dr. Webster (Med. and Phys. Journal, Dec, 1822) contends that the symptoms, when closely viewed, warrant the conviction that hooping-cough depends upon inflammatory ir- ritation of the brain, or of its membranes, or of both. A somewhat similar opinion had been given by A. Leroy (Med. Maternelle, 8vo, Par- is, 1803). Boisseau, Otto (Nye Hygaa, August, 1824), and Begin (Traite de Therapeutique, &c, t. ii., 8vo, Paris, 1825) had admitted the fre- quency of the association of cerebral affection with hooping-cough, even from the commence- ment ; while they oppose the inference that the latter is dependant upon the former. Dr. Web- ster is, however, the first writer who fully ap- preciated the influence of cerebral irritation on the respiratory organs in this disease, and ex- cited attention to an important and early com- plication of it. 33. M. Desruelles states that hooping- cough is an inflammation of the bronchi, giv- ing rise, at an early period of its course, to cerebral irritation ; that, as long as the bron- chitis is simple, the cough is not attended by the characteristic hoop; but that, when the cerebral irritation commences, the diaphragm and muscles of the larynx, &e, become subject to convulsive actions, which impress the cough with its peculiar features. The arguments al- ready adduced against the inflammatory origin of the disease are equally applicable to this view ; and the constant existence of cerebral irritation is by no means proved, the occasion- al supervention of this irritation being all that is fully ascertained. 34. From my researches into the pathology and treatment of hooping-cough, during some years previously to 1823,1 was led to consider the medulla oblongata or its membranes very early implicated in this disease, evidences of inflammatory irritation of these parts having been very generally observed in the post-mortem inspections I had made. I conceived that the morbid impression or irritation occasioned by the exciting cause in the upper parts of the re- spiratory surfaces, particularly the glottis and its vicinity, affects the respiratory nerves, es- pecially the pneumogastric ; and that the irrita- tion is extended to the origins of these nerves, where it aggravates and perpetuates the prima- ry affection. Where no predisposing, concur- rent, or consecutive causes or influences fa- vourable to the development of inflammatory action, either in the respiratory organs or in the brain, exist, the morbid action does not proceed beyond an irritative state, and the disease pre- serves a simple form. But when such causes are in operation, the irritation passes into in- flammatory action in either of these situations ; in some cases extending from the epiglottis and pharynx to the bronchi and lungs, and in oth- ers from the medulla oblongata to the brain or its membranes. As the irritation increases or extends downward along the respiratory surfa- 36 ces on the one hand, or to the pharynx and gas- tric mucous surface on the other, and as it pre- dominates in the one above the other, so does the disease assume more of a bronchitic or of a gastric character, the latter form being the most favourable, as tending to disembarrass the bronchi, and to prevent the extension of disease in that direction. When the disorder implicates the lungs, the gastric affection either does not appear, or is thereby superseded; and when the brain becomes affected, either the gastric symptoms are not observed, or they assume different characters, appearing in the intervals between the fits of cough, instead of termina- ting the fits, and the cough loses its convulsive or nervous form. It does not, however, follow that the stomach is materially affected, even when the vomiting is the most remarkable. In these cases the irritation seldom extends much beyond the pharynx ; the irritation of this part and of the epiglottis, and the convulsive nature of the cough, being the principal causes of the vomiting. The copious discharge of ropy mu- cus terminating the fit partly proceeds from the pharynx and vicinity, even when there is no vomiting. Attentive observation subse- quently to the adoption of these views, and ex- tensive experience of the treatment founded on them, have confirmed my confidence in their accuracy in the principal points. 35. I believe that the disease is chiefly ner- vous in the simple cases ; that it preserves this character more or less throughout, even when inflammatory complications ensue ; and that, in the uncomplicated state, the nervous affec- tion never proceeds beyond irritation. The im- pression made by the causes is followed by functional lesion of the respiratory nerves, par- ticularly the nervus vagus; and, owing to this lesion, the mucous surfaces they supply fre- quently experience consecutive changes, as re- spects the state of circulation, exhalation, and secretion. Hence result increased vascular de- termination and augmented secretion, attend- ed by irritation of the glottis, epiglottis, pha- rynx, and air tubes, inducing convulsive action, which supervenes the more readily, as the dis- ease is essentially nervous in its nature, but often becoming, consecutively, irritative or in- flammatory ; this last characteristic being only an occasional complication, occurring from pre- disposition, habit of body, epidemic influence, or fortuitous causes favourable to its develop- ment. The inflammatory appearances in the medulla oblongata and base of the brain may be owing to the functional relation of these parts to the respiratory order of nerves, which receive the first impression of disease, and whose functions are so manifestly disordered throughout, as noticed above (§ 7); or these, as well as the consecutive cerebral complica- tions, may be induced by the disposition to dis- ordered circulation, occasioned by the change in the state of nervous influence, and perhaps still more by the impeded return of blood from the brain during the paroxysms. The vomit- ing so generally terminating the fit has been, as I have shown, imputed by many primarily to the stomach. But this symptom is often attendant upon severe fits of cough, whenever the epiglottis suffers unusual irritation. As it does not occur during the first days of the com- plaint, it seems to be owing to irritation of this 282 HOOPING-COUGH—Diagnosis. part, which has been gradually coming on with the progress of the disease, until it reaches a pitch occasioning increased convulsive action of the respiratory muscles, extending to the di- aphragm, the abdominal muscles, and stomach, the irritation of the morbidly sensible epiglottis by the cough increasing the paroxysm until vomiting is produced. [In reference to these different views, Dr. Williams (.4 Practical Treatise on the Diseases of the Respiratory Organs. Phil., 1845) thinks that, in many instances, they do not sufficiently regard the physiological character of those morbid motions which form the chief feature of hooping-cough. "Thus," he remarks, "we find much ascribed to the phrenic nerve and diaphragm, when it is obvious that these agents of inspiration are little, if at all concerned in the motions which constitute the cough. We regard hooping-cough as originating in a spe- cific irritation (almost always inflammatory at first) of the lining membrane of the upper por- tion of the air passages. This irritation is, in the first stage, constant, and accompanied with cough and expectoration, like those of common inflammatory catarrh ; but in the second stage it peculiarly increases the irritability of the laryngeal, constrictor, and bronchial muscles, and of the nerves which excite the contractions of these as well as of the expiratory muscles, which are sympathetically associated with them; those, in fact, which are concerned in the act of coughing" (p. 492). We are not aware that any new light has been thrown upon the true pathology of hoop- ing-cough in this country, and undoubtedly as great diversity of views exists in relation to it here as among the European faculty. Dr. De- wees, as Dr. Copland observes, regarded the disease as consisting in " an inflammation of the mucous membrane of the organs of respi- ration, occasioning an increased secretion of fluid, which, accumulating, acts as an extra- neous substance, and brings on the cough for its expulsion." Dr. Stewart regards the disease " as inflam- matory in its first stage; or, perhaps, a com- plication of inflammation with some inexplica- ble action of the nervous system, which mod- ifies the simple bronchitis," but "in the last stage purely spasmodic" (A Practical Treatise on Diseases of Children. New-York, 1841). Dr. Condie supposes the essential symptoms of hooping-cough to be the result of a spasmodic closure of the glottis ; but whether this is ow- ing to an irritation seated in the larynx and trachea, or in the brain, he thinks it difficult to determine. " In the greater number of cases," he remarks, "the disease commences as a simple, and often very mild bronchitis; and it is not until after the bronchial irritation or in- flammation has existed for some time that the irritation is transmitted to the laryngeal nerves, and the convulsive cough and difficulty of res- piration occur" (On Diseases of Children. Phil, 8vo, 1844). Dr. Gerhard considers this an af- fection of the nervous system, accompanied by bronchitis, in which sometimes the one, some- times the other predominates ; the affection of the nervous system being, in some cases, very 6evere, with but little cough, whereas the cough is frequently very bad, with compara- tively slight nervous symptoms" (Lectures on the Diagnosis, Pathology, and Treatment of the Diseases of the Chest. Phil., 1842). The late Dr. Hosack regarded hooping-cough as essen- tially an inflammatory affection, and his treat- ment, which was decidedly antiphlogistic, was founded on this pathology. It is believed that few practical observers regard the disease as a pure neurosis, or as purely inflammatory, al- though the phenomena observed during life might lead to the former, and the organic chan- ges noticed after death to the latter opinion. The cultivation of morbid anatomy has led to a modification of views once entertained in re- lation to the pathology of this, as well as nu- merous other diseases ; for few, perhaps, with Hufeland, Jahn, and Cullen, notwithstanding the convulsive nature of the symptoms, will at-r tribute the disease to an irritation of the eighth pair and the phrenic nerves, while positive marks of inflammation, to a greater or less ex- tent, invariably exist in the lungs and air passa- ges. When to this we add the well-known fact that symptoms of catarrh, or inflammatory dis- ease, precede, for some time, the characteristic cough, and that, both during this period and afterward, in the intervals of the fits of con- vulsive coughing, the mucous wheeze, and oc- casionally the other rhonchi which distinguish pulmonary catarrh, are perceptible, we shall no longer hesitate to adopt those views as to its pathology which are held by a large major- ity of the medical world, namely, that it is a nervous affection, generally complicated with bronchitis or pneumonia, although, in some in- stances, it may exist without them.] 36. II. Diagnosis.—The existence of this complaint, particularly at an early stage, is not always readily ascertained. During the first period it is not easily distinguished from a common cold. In most instances, however, the more paroxysmal nature of the cough, and the absence of fever, will indicate the affec- tion, although the characteristic hoop is want- ing. Occasionally this sign is absent altogeth- er in the slightest cases, although the disease is prevalent in a family, and yet there may be little doubt of the nature of the cough. Its more or less convulsive form, the perfect inter- vals, the evidence of congestion towards the head during the fit, and, as the complaint ad- vances, the copious discharge of ropy mucus, are quite distinctive, although there is no com- plete hoop. When this latter sign is present, or when the paroxysms of cough terminate in vomiting, there can be no doubt as to the dis- ease. [We do not regard the hoop as characteristic of this disease, neither its absence disproving the existence of the affection, nor its presence absolutely proving it. We frequently meet with the hoop in ordinary catarrh, especially in children who are teething; and MM. Rilliet and Barthez point out (vol. ii., p. 224, et seq.) two diseases of very different, characters, each of which may be, and often is, confounded with hooping-cough. Acute bronchitis, attended with cough recurring in paroxysms, is one of these diseases ; the other is tubercular degen- eration of the bronchial glands. The former of these affections may be distinguished from hooping-cough by the general absence of a ca- tarrhal stage introducing the paroxysms of cough; by those paroxysms being usually HOOPING-COUGH—Prognosis—Causes. 283 shorter, less intense, often unattended with hoop, or, at any rate, accompanied with a very rare and indistinct hoop, and without expecto- ration or vomiting. It is associated, from the commencement, with intense fever and accel- erated respiration, a small pulse, anxious coun- tenance, and extreme dyspnoea, and tends rap- idly to a fatal termination. Tubercle of the bronchial glands may be distinguished by the paroxysms of cough being usually very short, and unattended either with hoop or with mu- cous expectoration, or with vomiting. In its course, too, attacks of asthma often occur, which alternate with the paroxysms of cough. It is frequently attended with alterations in the character of the voice, and is associated with hectic fever and night sweats, and may be far- ther recognised by the physical signs of tuber- cular disease.] 37. III. Prognosis.—When the complaint is simple, the prognosis is favourable • but it may, at first, assume this form, and afterward be- come complicated, and consequently more or less dangerous, owing to injudicious'manage- ment, to various influences, and to its continu- ance ; therefore a cautious or reserved opinion should be given as to the result in all the early stages. The complaint is, generally speaking, more dangerous the younger the child ; but the period of dentition aggravates the risk. When, however, the infant has a healthy nurse, and is itself of a good constitution ; if it have not re- cently suffered from any infantile complaint, or been lately weaned ; if the attack commences in summer or spring, or in a mild, dry season ; if the intervals be complete, and of considera- ble duration ; and if the paroxysms be attended by vomiting and a free excretion of mucus, a favourable prognosis may be entertained. If the lungs or the head, the latter especially, be- tray disorder; if the child belong to consump- tive, scrofulous, or old, asthmatic parents; if there be tendency to cerebral diseases in the family, a cautious or an unfavourable opinion should be given. All the symptoms indicative of the more serious complications (y 10,11) are signs of danger. Upon the whole, the com- plaint is more favourable in adults than in in- fants, or even than in children; yet there is great risk, even in them, of the occurrence of pneu- monia, bronchitis, or pleuritis; and, in young adults of a scrofulous diathesis, of phthisis, or of haemoptysis. It may cause abortion in preg- nant females ; and in those who are hysterical the cough may ultimately pass into an obsti- nate form of that complaint, and be removed with difficulty, especially if the circumstance be overlooked. The occurrence of the com- plaint during convalescence from measles or scarlatina is unfavourable, inasmuch as bron- chitis and the other pulmonary complications are apt to ensue. The presence of cerebral symptoms, or of fever or a quick respiration in the intervals, and a scanty excretion of mucus after the fits, indicate danger. 38. IV. Causes, &c. — Of the causes and modes of propagation of hooping-cough we have no very positive knowledge. The disease oc- curs either epidemically or sporadically, and often during seasons and under circumstances wherein catarrhal and pulmonary affections prevail. When it commences in autumn or winter it is always of longer duration than at other seasons ; and, like other catarrhal com- plaints, it is often prevalent in spring and sum- mer. It generally affects several or many at the same time, particularly infants from two or three weeks old and upward, and children till after the second dentition. It sometimes oc- curs in adults, and but rarely in the aged. Among adults, females are oftener attacked than males: those of the latter who are ner- vous, irritable, or approach the nearest to the female constitution, being the most suscepti- ble of it. It affects persons only once, but rare instances of second attacks have been observed. [" I have known pertussis to occur," says Dr. Francis, " within the first week of infant life and prove fatal; and I have been made ac- quainted with three instances of the disease occurring in male subjects of advanced age. In one, aged 86 years, the disorder, strikingly characteristic in its symptoms, terminated life after about ten days' duration. In the second case, the patient, aged 60 years, had suffered repeatedly from bilious remittent fever. When hooping-cough set in, the patient had been for some twelve months exempt from febrile an- noyance. The paroxysms of the hooping- cough after the first few days became exceed- ingly severe, and were accompanied with great cerebral irritation ; the disorder finally termi- nated in congestion of the brain and paralysis of the right extremities, with loss of speech, coma, and death. The third case was that of a female aged about 62 years. Like small- pox, measles, and scarlet fever, its occurrence in some individuals a second time is occasion- ally to be met with."] 39. Hooping-cough, independently of its epi- demical appearance, seems to possess infectious properties, which, although admitted by the majority of authors, have been disputed by a few. It is always quickly propagated through a family, and its extension, when sporadic, may be prevented by removing the unaffected chil- dren. Mothers, nurses, and even fathers, who have not had the disease, will often contract it from their children ; and I have known moth- ers who had had it in their childhood affected a second time by a child at the breast, or by its prevalence among the other children. Its infectious properties are farther shown by a child having caught it from others, at school or at nurse, and, when removed under the disease to a distant part of the country, and into a fam- ily where it did not exist, communicating it readily to those who had not had it. Like all infectious maladies, it is much more rapidly propagated during certain constitutions of the air, particularly those in which catarrhal com- plaints are frequent, or when measles prevail, than in others. In its epidemic form, its infec- tious property appears to be most fully marked, from the circumstance, probably, of the concur- ring causes, whatever they are, being then more active, as well as from the predisposition these epidemic states occasion. Pertussis has also been frequently observed to follow epidem- ically upon epidemic morbilli. When it occurs sporadically, and during healthy states of the at- mosphere, it often fails to be propagated, un- less to those most predisposed. Moveover, it is often necessary to infection that the breath of the affected subject should be inspired by the unaffected, and that the disease should, at 284 HOOPING-COUGH—Treatment. the time, be fully developed. The infectious property seems to diminish as the disease de- clines. Dr. Cullen and many others believed that it disappeared in from four to six weeks; but, as Dr. Elliotson remarks, the period can- not be fixed with any precision. It is general- ly from five to seven or nine days, or even longer, after exposure to infection, that the cough commences. [During the sixteen years from Jan., 1819, to Jan , 1835, there were 1400 deaths in the city of New-York from hooping-cough, being to the whole number of deaths in the ratio of 1 to 64 4. In the city of Philadelphia, during the six years preceding 1840, of the 24,738 deaths among children under 15 years of age, 606 were of bronchitis, 617 of croup, 800 of pneu- monia, and 511 of hooping-cough. Of the lat- ter, 242 were under 1 year, 135 between 1 and 2, 112 between 2 and 5, 21 between 5 and 10, and 1 between 10 and 15 years. Dr. Dewees is inclined to believe that the hooping-cough depends on causes of a more general and per- vading influence than contagion, in other words, that it is meteoratious ; and mentions the fact that the disease suddenly broke out on Block Island, and prevailed extensively without the inhabitants of the place having had any inter- course with an infected source. " It is a rule," says Dr. D., " with few or no exceptions, that where a disease can be traced to atmospheri- cal influence, it does not prove contagious. Nature, indeed, can hardly employ two such opposite causes to produce the same effect."] 40. V. Treatment.—There are few maladies against which a greater array and variety of means, both medicinal and regimenal, have been recommended than against hooping-cough. Vascular depletion, emetics, purgatives, diaph- oretics, antispasmodics, excitants, internal and external irritants, &c., have been severally prescribed as unfailing agents, and combined in infinite forms in the treatment of this com- plaint. Although these may be extremely ben- eficial, they may be also most mischievous, success entirely depending upon their applica- tion appropriately to the peculiarities of indi- vidual cases. As the disease is variously mod- ified and complicated, so it cannot be removed by a particular class of remedies, or by a spe- cific form of treatment. Means inappropriate- ly employed may convert a simple and slight case into one both complicated and dangerous. There are certain considerations requisite to a successful treatment of this complaint; and these should always be kept in view, not only in it, but also in all other epidemic maladies. I refer especially to the constitution and habit Of body of the patient, to the character of the prevailing epidemic, to the nature of existing complications, and to the period and progress of the disease. It is owing to these circum- stances that the means which are beneficial in one case, or in one season, are often injurious in others Thus the epidemics of spring or winter more frequently require vascular deple- tion than those of summer and autumn, while these latter derive more benefit from emetics than the former. So important are the compli- cations of pertussis, that the treatment should be mainly directed to their prevention or re- moval ; and whatever they may be—whether bronchitis, pneumonia, congestion or inflam- mation of the brain, &c.—it should be recol- lected that they are much more dangerous than when occurring primarily or in a state of pre- vious health, unattended by the aggravating circumstances of this complaint. 41. i. Treatment of Simple Hooping-cough.— In the slighter cases little more is required than attention to diet, regimen, and the excre- tions, unless the child be plethoric, when addi- tional means will be necessary.—a. In the first stage, a dose of rhubarb with hydrarg. cum creta or calomel, and a little ipecacuanha, may be giv- en every night, occasionally interposing an emetic. The diet should be farinaceous, with milk. The child ought to be confined to a mild, equable temperature, and wear flannel next the skin in winter, spring, or autumn. If the pa- tient be plethoric, it will be proper, as a pre- caution, to apply leeches, according to his age, either behind the ears or over the sternum, as the head or respiratory organs may indicate a disposition to be affected. In the more se- vere attacks, also, this measure should never be neglected ; and diaphoretics, with small doses of antimony, or of ipecacuanha, ought to be giv- en every four or five hours ; the secretions and excretions being duly promoted by calomel and rhubarb every night, and a stomachic purgative, or an emetic, each second or third morning, according to circumstances. 42. b. In the second stage of simple pertussis, an anodyne may be added to the diaphoretic mixture, and taken every four hours. If no sign of cerebral or pulmonary affection appear, the hydrarg. cum creta may be substituted for calomel in the night powder. It is in this pe- riod that the treatment recommended by Dr. Pearson is most serviceable. This consists of an antimonial emetic, followed by a draught con- taining a drop of tincture of opium, five drops of ipecacuanha wine, and two grains of carbonate of soda, for a child of one or two years of age. This draught is to be repeated every four or five hours for several days, the bowels being kept open by rhubarb and calomel. As the cough declines, he lessens the opiate, and gives myrrh in place of the ipecacuanha wine. This treatment is excellent for children of three or four years of age or upward; but, until they reach two or three years, opium ought not to be given. For those of the age mentioned by Dr. Pearson, I consider the extract or sirup of poppy, or conium, or henbane, to be preferable. The liquor potassa, also, will be often advan- tageously substituted for the soda. The decoc- turn senega, or the infusum Valeriana, may be given in this and the next stage with some aro- matic water, and an antispasmodic. It will be sometimes of service, even in this stage, to ex- hibit an emetic, if the fits do not terminate in vomiting; and, unless the attack is slight, the same diet and regimen as directed in the first stage should be continued in this. A principal indication in both is to watch the first sign of visceral disease, and to oppose its accession by leeches applied in either of the situations just named, and by emetics. In both periods, also, advantage will accrue from the warm semicupi- um or pediluvium at bedtime ; but, unless the case become severe, it will only be occasional- ly required. The excretions should always be promoted by mild and stomachic purgatives. 43. c. In the third stage the chief indications HOOPING-COUGH—Complicated—Treatment. 285 are to strengthen the system, and to supersede the convulsive character of the affection by giving tonics with antispasmodics and anodynes. The gentler tonics may be first employed, and successively those which are more energetic, in conjunction with preparations of poppy, or with paregoric, or with conium, hyoscyamus, lau- rel water, &c. There are numerous medicines belonging to these classes that may be given with great advantage in this stage, but they will be noticed hereafter. Tonics, as well as antispasmodics or anodynes, will be advanta- geously exhibited with the alkaline subcarbonates, or with liquor potassa, or Brandish's alkaline solution, and purgatives beneficially conjoined with vegetable bitters or other tonics. If the disease assume a periodic or intermittent type, the preparations of bark or quinine should be prescribed. It is principally in this stage that change of air proves so serviceable. It should not be neglected, paiticularly when this period and convalescence are protracted. In both this and the preceding stage embrocations or lin- iments of a rubefacient and antispasmodic kind (see Append., F. 295, et seq.), applied to or rub- bed upon the spine, will prove very serviceable. Sinapisms will also sometimes be of use, espe- cially in threatened bronchitis ; and, in young, delicate, or irritable children, are preferable to blisters and the tartarized antimonial oint- ment, from which I have seen dangerous con- sequences accrue in patients of this descrip- tion. 44. ii. Complicated Hooping-cough. — A. The most common-complication is with inflamma- tion of the bronchial mucous membrane. But this may not be the only associated inflammation ; for pneumonia, or pleuritis, or even both, may be superadded to it: a contingency to which the^practitioner should be always alive. If simple bronchitis (y 6) be alone present, local de- pletions, in addition to the treatment already directed, must be prescribed; and antimonial wine, with the solution of the acetate of ammo- nia and camphor julap, should be taken every third or fourth hour. In young children, how- ever, ipecacuanha wine should be preferred to antimony. A small dose of calomel, with or without ipecacuanha, rhubarb, or julap, may be given every night, or night and morning, ac- cording to circumstances ; guarding, however, against too great an action on the bowels. After depletions have been sufficiently em- ployed, sinapisms or blisters applied for a few hours, or until erubescence of the surface is produced, and then followed by warm poulti- ces, will be very serviceable. The warm semi- cupium may also be resorted to at bedtime. An ipecacuanha emetic, when expectoration is dif- ficult, or twice or thrice a week, will also be beneficial. After the inflammatory symptoms are removed, any of the anodynes recommend- ed above may be added to the diaphoretic mix- ture, an embrocation or liniment (F. 297, 300, 311) applied along the spine, and the complaint treated, in the second and third stages especially, as advised for the simple disease. 45. B. In the complication with pneumonia or pleuritis, or with both (y 14-18), more deci- ded depletion will generally be requisite than in the bronchitic form. But it must not be over- looked that these inflammations are seldom , present in pertussis without more or less bronchitis. In this, as in the other pulmonic complications, cupping over the sternum, or be- tween the shoulders, is a preferable mode of depletion to the application of leeches ; and, in a far advanced stage of these inflammations, either after blood has been freely abstracted, or when excessive secretion into, or accumu- lation of viscid fluid in the bronchi threatens suffocation, dry cupping between the shoulders is the next efficient means to a stimulating emetic. A purplish hue of the lips or cheeks, and dilatations of the nostrils, should not pre- vent depletion if it is otherwise indicated, par- ticularly in plethoric children, if it have not al- ready been practised, and if the skin be hot and the pulse not much reduced in strength. When the substance of the lungs or pleura becomes inflamed, calomel, with or without ipecacuanha, should be given in larger and more frequent doses than when the bronchi only are implica- ted, and the diaphoretic mixture should con- tain an antimonial preparation. This last, however, ought to be given with caution in in- fants or young children, for I have seen most serious effects produced in them by large doses of tartarized antimony, particularly when too often exhibited or too long persisted in. In this complication, sinapisms and blisters, pre- scribed as above (Y 16), are beneficial after vas- cular depletion has been pushed sufficiently far; but, in many cases, much greater benefit will accrue from the application of the warm turpentine epithem on the chest or between the shoulders, or from one of the liniments (F. 297, 300, 311) already noticed, employed in the form of an embrocation. Having removed the ex- isting complication, the subsequent treatment must entirely depend upon the peculiarities of the case. The diet and regimen should be strictly enforced, and the patient kept in a mild and equable temperature. The semicupium, or warm bath, gentle diaphoretics with diuretics and anodynes, and, as the disease declines, mild tonics, with sedatives and antispasmodics, will also be of great service. The excretions should be kept free, and change of air advised as soon as it can be safely attempted. 46. C. The complication with cerebral affection must be promptly met by the application of leeches behind the ears or to the occiput, or by cupping in this situation or on the nape, ac- cording to the age of the patient and the se- verity of the complication. Whenever the sim- ple form of pertussis has presented such severi- ty as to render the occurrence of pulmonic or cerebral affection at all probable, and more es- pecially if the child have been plethoric, I have always directed leeches to be applied behind the ears or to the occiput, influenced by the views as to the pathology of the complaint already stated; and I have had the greatest reason to strongly recommend this practice. When hoop ing-cough is aggravated by teething, the cere- bral complication should be dreaded, although neither convulsions nor any other very promi- nent symptom of it may have appeared. In these cases the gums ought to be attentively examined, and scarified as they may require it. If the infant be at the breast, the nurse's milk and health should receive attention. The se- cretions and excretions of the patient must be most actively promoted by full doses of James's powder, by purgatives, and cathartic enemata. 286 HOOPING-COUGH—Specific Modes of Treatment. The temperature of the head should be reduced by the cold affusion on it, or by cold sponging whenever either becomes necessary, and the means advised for Inflammations of the Brain (y 191), and for Acute Hydrocephalus (see Drop- by of the Head, y 260), ought to be employed, according to the circumstances insisted upon at these places. The objects are to remove in- cipient mischief, and to prevent thereby the accession of a formidable malady by a prompt application of efficient means. To wait until the coming evil has fully declared itself is to sacrifice the principal chances of success ; for all cerebral affections that supervene during pertussis are much more dangerous than those which occur primarily. As soon as the com- plicated affection is removed, change of air should be recommended. Nothing is so ad- vantageous as a complete change of air for children treated in London, or in other large towns. 47. D. Infantile remittent fever generally does not appear in connexion with pertussis until an advanced stage of the latter. Other associated affections, as chronic pulmonary disease, curva- tures of the spine, rickets, affections of the joints, enlargement of the mesenteric or of the absorbent glands, &c, are sometimes also met with in protracted cases of hooping-cough, or in the stage of decline, particularly when the disease has been neglected, or when the morbid affec- tion has been perpetuated by habit, or by the neglect of such means as are calculated to break the chain of disordered action. They often also may be traced to constitutional vice or predisposition, and to neglect of the excre- ting functions. Under whatever circumstance, either these or the remittent fever may occur in the advanced course of hooping-cough, de- bility is a principal element of the complicated malady. The functions of digestion and respi- ration, and, consequently, assimilation and nu- trition, having been more or less impaired du- ring the early stage of the primary disease, in- herent vice, or an existing disposition to dis- order, the more readily manifests itself. As constitutional power sinks, maladies, which most commonly arise from debility, make their appearance, the particular malady being deter- mined in its occurrence by hereditary taint or by previous disorder. In many cases the su- perinduced affection is merely a sequela of per- tussis ; but, in others, the characteristic symp- toms of the primary disorder still continue in a very pertinacious manner. 48. The remittent febrile disorder depends, in several instances, upon chronic irritation of the digestive mucous surface ; in others, upon the state of the season or weather, and the in- fluence of exhalations from a humid soil, or upon a moist and cold atmosphere : and in some, upon both conjoined. But whatever may be the source, it cannot be doubted that debil- ity is an important part of the disorder, and that the alvine secretions and excretions are much disordered. At the same time, there- fore, that a treatment appropriate to the affec- tion of the digestive canal is requisite, the state ef constitutional power must receive attention. Purgatives are generally necessary in this com- plication, especially at an early period of it ; but they ought to be of a stomachic kind, or combined with tonics, and neither be too irrita- ting, nor too pertinaciously directed. The com- pound infusions of gentian and ol senna, with sulphate of potash ; rhubarb with this latter, in an aromatic water; hydrargyrum cum creta, or blue bill, with ipecacuanha at bedtime ; ei- ther of the preceding, or castor oil, being ta- ken in the morning, are among the most suit- able purgatives, and they should be repeated according to the state of the stools. If the bowels be irritable or dysenteric, a full dose of calomel or hydrarg. cum creta, with the compound ipecacuanha powder, should be first given, having in some cases premised an ipe- cacuanha emetic. Some hours afterward a dose of castor oil ought to be taken, and its operation promoted by an emollient injection. After the intestinal canal is evacuated, irrita- tion should be allayed by mild tonics, conjoined with aromatics, absorbents, sedatives, or an- tispasmodics, according to the peculiarities of the case. Preparations of cinchona, quinine, chalybeates, dec, will subsequently be of ser- vice. The decoction of bark, or any tonic in- fusion, will be advantageously given with li- quor potassae, or Brandish's alkaline solution; and afterward the ammonio-chloride or potas- sio-tartrate of iron, and change of air will gen- erally prove most beneficial. 49. Although this treatment is recommend- ed chiefly with the view of preventing hoop- ing-cough from lapsing into, or becoming as- sociated with infantile remittent, and of re- moving this complication, yet it will be equally serviceable in the prevention of the other se- quela of the complaint mentioned above (y47). When affections of the joints, rickets, or mesen- teric disorder either supervene upon, or follow an advanced stage of pertussis, the prepara- tions of iodine, and other means directed for these complaints, should be resorted to. Af- fections of the spine are generally owing to weakness of the muscles and ligaments of the vertebral column, induced by this disease, or to scrofulous inflammation of some portion of the column itself. When the disorder is at- tributable chiefly to.the former of these causes, then the tonics already recommended, salt wa- ter bathing, sea air, and frictions with stimula- ting liniments along the spine will be very ser- viceable ; and when the more solid structure of the column is implicated, then the prepara- tions of iodine, Brandish's alkaline solution, or the liquor potassa, and change of air, should be severally prescribed, as circumstances will suggest. 50. iii. Of the more Specific Modes of Treat- ment advised for Hooping-cough, and the Circum- stances in which they are admissible or appropri- ate.—Willis and Sydenham directed blood-let- ting in the plethoric and inflammatory cases, emetics of the oxymel of squills, purgatives, and blisters to the nape of the neck or between the shoulders. Willis also prescribed tonics du- ring the decline of the complaint. He partic- ularly notices the Muscus pyxidatus, or M. Pyx- ioides, the Lichen pyxidatus of Tournefort, or cup-moss, as a very popular remedy in hoop- ing-cough. Gerarde remarks that "the pow- der of this mosse, given for certaine daies to- gether, is a most certaine remedy for that perillous malady the chin-cough." Dilenius praised the powder of it when frequently given, and supported his opinion by the authority of HOOPING-COUGH—Specific Modes of Treatment. 287 Willis and Gerarde. Other writers have prescribed it in the form of decoction in milk. Van Woensel (Hist, de la Soc. Roy. de la Med., t. ii., p. 294) recommended it in decoction, sweetened with sirup of mint. Baglivi em- ployed, also, the Muscus arboreus and M. quer- neus in pertussis, in the form of decoction; and a sirup prepared from the decoction exists in the Pharmacopoeia Wittembcrgcnsis, to facili- tate its exhibition to children. Stoll (Rat. Med., vol. vi., p. 6) found these mosses or li- chens, particularly that growing on the oak, very serviceable in the hooping-cough which was epidemic in Vienna in the spring of 1775. Frank also praises it. 51. De Haen, in a letter written in 1747 to Van Swieten, describes a very prevalent and fatal epidemic hooping-cough. Children from a few weeks to ten years of age were chiefly affected, but adults were occasionally also seiz- ed. When one child was attacked in a family, none escaped who had not had the disease pre- viously. It was often protracted to three, four, or even six months. He states that vascular depletion in the plethoric, purgatives, ipecacu- anha, anodyne emulsions, opiates, oxymel of squills, nitre, &c, were severally employed, but with no marked success. He subsequent- ly, with his colleagues, Ouwens, Westerhoff, and Velsen, was induced to prescribe the Ker- mcs mineral, by the benefit derived from it in spasmodic asthma. To a child of six months, he commenced with one grain in the 24 hours, given in sugar and divided into three powders ; to a child of one year, two grains in the same pe- riod ; and to a child of three years, three grains, increasing the dose gradually and cautiously. The success of this medicine he describes as most astonishing. In another letter similarly addressed, in 1751, De Haen remarks, that al- though he had found the Kermes mineral of very great service in the hooping-cough of that au- tumn, it was less so than in the epidemic of 1747: and he adds, •' Plenque vero curantur Limacum* lacte coctarum largo atque prctracto USU." (A. De Haen, Opusc quad, inedita, &c. Cur. J. Eyerel, P. i. Vind , 1705, p. 42, 173.) In another work (Rat. Med, t. iv., p. 121) he notices a case in which the fit of cough termi- nated in suffocation ; but the means usually re- sorted to in suspended animation having been employed, restoration and recovery took place 52. Stoll states that he never saw sporadic cases of pertussis in Vienna up to the year 1777. The disease had previously appeared only in epidemic forms, and generally with modified characters. At some seasons the stomach, at others the head, and sometimes the lungs, were especially deranged Occasionally it was at- tended by a miliary, and in some instances hy a scarlet eruption In a few cases urticaria and erysipelas occurred. In Vienna and Hun- gary it generally evinced a stomachic origin. The epidemic of 1775 frequently affected adults. The paroxysms were most seveie on the alter- nate days, and during the night; and penpneu- * Appended to a case treated hy Stoll, the history of which 18 given by EYEKEL (Op. cit., t. ii . p. 164), is the j following note : Decocium limacum, in epiilemiia tussi con- vulsiva egregiuru et unicuin s*pe fun reinediiiin, teste IIaEmo. qui a loininn rustica Hagie Ualavorum id d'dicit. Adluere all* epidemic uln ml juvit.sed uln Kermes ininer- alis et opium onineni absolvit pagiuam—Decoctum hoc li- rxacuiu per octo dies repetatur. monia was a frequent complication. He states that blood-letting, emetics, purgatives, emoll- ients, and opiates, especially these last, were prescribed without benefit. Blistering, howev- er, between the shoulders, and bleeding, were beneficial when the disease was about to pass into pneumonia. He observed the injurious effects of stimulating expectorants in favouring the development of pneumonia, with which per- tussis is so apt to become complicated. Tonics were generally required as early as debility became apparent ; and, even after the dis- ease was removed, they were often necessary. When the bowels were not freely open, they were conjoined with aperients. In the epidem- ic of 1779, all the cases in which the fits ter- minated in vomiting recovered. Stoll found ammonia, gum ammoniacum, and Venetian soap, given in simple oxymel, or oxymel of squills, of service. Decoctions of emollient herbs and roots, and of the flowers of arnica, were also beneficial. Opiates were productive of mischief in many cases, and even of fatal ef- fects in some, a glutinous effusion having been found in the bronchi of such cases. During the epidemic in Copenhagen in 1784, Bang made trial of the cicuia, after the exhibition of emetics; but with temporary advantage only. Towards the decline of the disease, musk was found of service. 53. Dr. Huxham introduced the use of mer- curial purges. After their operation he prescri- bed the Peruvian bark. Dr. Bisset commenced the treatment with an emetic of oxymel of squills, followed by rhubarb, manna, &e. As soon as the severity of the complaint began to subside, and the intervals between the fits to be prolonged, he gave the bark. The propriety of having recourse to emetics was advocated by Hoffmann, Forbes, Aaskow, Navier, Amstein, H"feland, and others. The substances usual- ly employed as emetics were ipecacuanha, tar- tar emetic, Kermes mineral, and oxymel of squills. They were generally exhibited at the commencement of the treatment, and occasion- ally in the course of the complaint. Lafossk and Remer gave them only at the commence- ment. Ipecacuanha was preferred by Linnaeus, Aaskow, Thilenius, Weber, and many others; and oxymel of squills by M lzer. Stoll con- sidered emetics to be especially serviceable in hooping-cough during summer or autumn. Struvk directed them in the evening, and Sims after blood-letting. Lkttsom believed them to be useless, and Jonks and Niemann to be abso- lutely injurious. Burton was among the first to condemn them, and he no less objected to blood-letting and cathartics, unless in inflam- matory cases, in their stead he prescribed a mixture, the most active ingredient of which was tincture of cantharides There can be lit- tle doubt of emetics having been occasionally abused by inappropriate exhibition ; but expe- rience has proved them to be most serviceable iu this complaint, when judiciously employed. At the present day, the means advised by Bor- sieri are the most geneially applicable, and therefore the best, as far as it goes, that can be adopted. He presciibed a smaller or larger emission of blood early in the disease ; a gen- tle emetic, occasionally repeated, where there is no symptom forbidding it; aperients of calo- mel, rhubarb, or manna, and external irritants. 888 HOOPING-COUGH—Specific modes of Tbeatment. The only fault that can be found with this treat- ment is the neglect of demulcents, anodynes, and antispasmodics, which are very generally beneficial in an advanced stage of the com- plaint. 54. Dr. Darwin insisted upon the frequent occurrence of peripneumonia during hooping- cough ; and he therefore directed leeches, to prevent as well as to remove this complica- tion. After evacuating the bowels and giving diluents, and when the complaint had reached the second stage, he prescribed, for a child of about three years, a sixth of a grain of calomel, a sixth of a grain of opium, and two grains of rhubarb, twice a day. The only objection to this treatment is the too general use of opium, and the amount of the dose of it, for a child : in combination, however, with calomel, it is much less injurious than when given alone. He likewise employed antimonial emetics, mild cathartics, cool air, repeated blisters, or the tincture of cantharides internally, warm bath- ing, the inhalation of the steam of warm water containing a little vinegar, opiates in small doses, and digitalis. He prescribed digitalis whenever a tendency to inflammation, or to ef- fusion, or to pulmonary consumption, appear- ed. He considered, with much justice, diuret- ics to be more or less useful in this, as in other disorders implicating the respiratory organs. Dr. Elliotson has very properly contended, that, wherever there is oppression of breath- ing, with violent spasmodic attacks of cough, accelerated pulse, and sonorous or crepitous rattle, inflammation of the respiratory organs is present, and should be treated by bleeding, by emetics, and by calomel. In such cases, sedatives and antispasmodics ought not to be resorted to until inflammatory action is remo- ved, and the secretions and excretions are free- ly evacuated. It is unnecessary to allude far- ther to the various modifications of treatment adopted by other experienced physicians. I shall, therefore, only notice some of the princi- pal remedies prescribed for this complaint. 55. iv. a. Blood-letting was directed early in hooping-cough by the great majority of writers, since the time of Sydenham to the present day; and frequently even in slight and simple cases, as a precautionary measure, particularly in plethoric habits. Lettsom has justly remark- ed that, if it be not resorted to early in the complaint, it is seldom of service at an advan- ced period; but cases in which inflammatory affections of the lungs or brain arise at this pe- riod furnish exceptions to this rule. Stoll prescribed depletion chiefly when the lungs be- came affected. Hufeland directed leeches to the chest; and Webster to the temples, in most cases. I have seldom omitted to apply them behind the ears, or between the nape and occiput, or to prescribe cupping in this situa- tion, at an early stage, influenced by the rea- sons stated above (y 35). Of emetics mention has already been made (41, 44). Purgatives have been employed chiefly with the view of evacuating accumulations of faeces, and of pro- moting the secretions and excretions. Calo- mel has been very generally recommended, both as an aperient and as an alterative. Fischer and Hargens gave it alone ; but it has been more generally conjoined with rhubarb or some other purgative ; and, in the inflammatory com- plications, with James's powder, ipecacuanha, &c. Darwin and Stroem prescribed it with rhubarb and opium ; in which combination it is often beneficial at an advanced stage, and in patients above four or five years of age. The frequent use of laxatives or mild purgatives has been much insisted upon by Michaelis and Kortum. Cathartic or irritating enemata have been resorted to by Holdefreund and Hufe- land. 56. b. Diaphoretics and expectorants have been generally employed through the course of the complaint; the former at the earlier, the lat- ter at more advanced periods. Some of these medicines promote both perspiration and ex- pectoration, and are hence the more servicea- ble in severe or complicated states of the com- plaint. Antimonials, in small doses, were prais- ed by Fothergill, Weber, and many others. The solution of tartar emetic was employed by Hirschel ; the golden sulphuret of antimony was preferred by Closius and Hannes. Van de Sande and Unzer gave it after having pre- mised emetics, and Holdefreund conjoined it with sugar of milk. The Kermes mineral was prescribed by De Haen, Hargens, Kortum, Hinze, and Styx. Quarin gave it with the flour of sulphur, gum Arabic, and extract of liquorice; but, although formerly in great re- pute in febrile and pulmonary diseases, it is now seldom employed. The following powder was once much used on the Continent for the cure of this complaint .- No. 257. R Kermes Mineralis, Pulv. Ipecacuanha;, S3 gr. j.; Ocul. Cancror. pulv. et Pulv. Acaciae, aa 3j. Tere bene, et divide in Cartulas vj., quarum capiat unam sextis horis. 57. This dose was prescribed for a child of one or two years. Much of the virtues of these powders was clearly attributable to the ipecacu- anha, which is one of the most serviceable med- icines employed for hooping-cough. Henninos and Keutsch relied chiefly upon it, and gave it in minute and frequent doses. Hargens or- dered it in considerable quantities; Krebs, in the form of infusion ; Vogler, with opium, magnesia, gum Arabic, and sugar; and Pear- son, with opium and soda. Ammoniacum and squills have been used as expectorants; but they require much caution, for, in the more in- flammatory states of the complaint, they may aggravate the disorder, or even favour the oc- currence of inflammatory action in plethoric habits, or when the phlogistic diathesis is pres- ent. The oxymel of squills was frequently em- ployed as'an emetic, and often with benefit. Hufeland and Sulzer gave it with cinchona and extract of hyoscyamus, in the advanced stages of the complaint. 58. c. Numerous antispasmodics have been prescribed in the second and third stages, on ac- count of the convulsive character of the affec- tion. Asafatida was recommended by Millar ; but was considered useless by Hufeland. Cas- tor was given by Morris and Horn ; musk, by Conradi, Gesner, Wolff, Von Berger, Hufb- land, and Horn. Marcus conjoined musk with the sulphuret of antimony and magnesia. The oxide of zinc was praised by Crell, Percival, and Hart. Scheidemantel very judiciously employed it after evacuations. Winckler and Tode gave it with cinchona, and Starke with cream of tartar; but from this combination tartrate of zinc must have been formed. Har- HOOPING-COUGH—Specific modes of Treatment. 289 oens, however, considered it inefficacious. I have but little experience of its effects in this complaint. Camphor, in very small doses, with diaphoretics, at an early period ; and in larger quantities, with anodynes, other antispasmod- ics, or tonics, is often of great service, particu- larly after moderate depletion and alvine evac- uations. The subcarbonates of the alkalies were given by Hinze, Mkmminger, Pearson, and Keutsch, and are often important adjuvants, in conjunction with hyoscyamus or other narcot- ics, and with rhubarb or other aperients, in the treatment of the second and third stages. I have, however, often preferred the liquor potas- sa, or Brandish's alkaline solution, especially in the scrofulous diathesis, and in cachectic habits. The subcarbonate of ammonia, in small doses, and other preparations of ammonia, are frequently beneficial in cases of debility at an advanced period, or when the complaint is pro- tracted. Muriate of ammonia was recommend- ed by Stoll at an early stage, with oxymel. I have found it an excellent refrigerant anti- spasmodic and tonic in several instances. 59. d. The most energetic narcotics and ano- dynes have been prescribed, with a view of al- laying spasmodic action, and generally in con- junction with some one of the antispasmodics or diaphoretics already noticed. Opiates were given by De Haen, with camphor and musk; by Hufeland, in the form of Dover's powder ; by Jocob, with pectoral elixirs and spirits of nitric aether; by Ruling, similarly combined, after four or five emetics ; and by Lefosse and Lettsom, in the second and third stages, with cinchona. Willan employed a watery extract of opium ; and Brera used it externally, in fric- tions or in liniments. Of the various prepara- tions and combinations of opium, the paregoric elixir is indisputably the best in hooping-cough, especially when given with an alkaline subcar- bonate, in almond or mucilaginous emulsions. The extract of the lactuca virosa was praised for this complaint by Dr. Gumprecht and oth- ers, and it has been much employed by some practitioners. Conium was first prescribed for hooping-cough hy Dr. Stoerck and Dr. Butter. It was afterward used by Ranoe, Schneider, and Hufeland. Lettsom and Hargens con- sidered it devoid of efficacy. I have prescribed it in numerous cases, and believe it beneficial when its virtues are not injured by preparation or age. It should not be given in the first stage. Hyoscyamus was recommended by Wolff, Wi- gand, and Joerdens ; and by Fischer, with ve- getable bitters. It is nearly as beneficial as co- nium ; but in some patients it is more liable to affect the head. 60. Belladonna has been extensively tried by Continental physicians in pertussis, and the powder of its root was most commonly employ- ed, particularly by Ranoe, Buchhaave, Frank, Meglin, and Etmuller ; and by Laennec after the operation of emetics. Schaeffer and Wide- mann gave it in large doses, and considered that it was quite a specific, particularly when admin- istered in enemata. This is, however, a some- what dangerous mode of prescribing it. The minute doses recommended by Wezler and Hufeland are much more judicious. The ex- tract of tobacco has likewise been prescribed by Gesner, Thilimus, and Hufeland ; but it also requires much caution, and ought not to be tri- ll 37 ed with young children. The tincture of Lo- belia inflata has been employed by Dr. Andrews with benefit. When the convulsive cough is aggravated by the accumulation of viscid mu- cus in the bronchi, the exhibition of this medi- cine, until it produces vomiting, will be of great service. Colchicum was praised by Haden and Alcock : and, when cautiously given in con- junction with magnesia, or the alkaline carbon- ates, or with either of the antispasmodics no- ticed above (y 58), it is of service in the inflam- matory complications ; but it may be very inju- rious in other circumstances, and particularly in very young patients. The same remarks ap- ply to digitalis, as prescribed by Drake and Darwin. Hydrocyanic acid has also been rec- ommended by Dr. Granville and Dr. Elliot- son. I have seen much benefit derived from it in the advanced stages of the complaint, par- ticularly when given in conjunction with cam- phor, or with gentle tonics or demulcents. It should be most cautiously tried, if tried at all, with young children. Dr. Elliotson, howev- er, remarks that a minim may be added to an ounce or two of almond emulsion, and a tea- spoonful of this given them three or four times a day. Laurel water was much employed in hooping-cough by Continental physicians, and is still preferred by many to prussic acid. 61. e. Among stimulants, the tincture of can- tharides has been most frequently employed. It was praised by Forbes, Schaeffer, and Plouc- quet ; and was prescribed with camphor and extract of bark by Burton ; with antispasmod- ics and anodynes by Wolff, Widemann, and Hufeland ; with preparations of cinchona by Chalmers ; and with these and paregoric by Lettsom and Graves. I have prescribed it in a number of cases, and have found it diminish the frequency and severity of the fits in the nervous states of the complaint, particularly when it occasioned irritation of the urinary or- gans. The extract of nux vomica was recom- mended by Michaelis and Hufeland, conjoin- ed with the extract of Carduus benedictus. I have tried it, with manifest advantage, in cir- cumstances similar to those in which canthar- ides was employed. But neither the one nor the other ought to be resorted to in the first stage, or in the inflammatory complications. Guaiacum has been prescribed for pertussis, chiefly- by Hufeland and Veizhans ; and saf- fron with castor, after due evacuations, by Theussink and Hargens. Castor was itself much employed by Sauvages, Morris, and Horn ; and a decoction of unroasted coffee was given by Hufeland. The muriate of barytes. has also been noticed with commendation by the writers just named. 62. /. The propriety of having recourse to tonics in the second and third stages, particu- larly the latter, cannot be disputed; but they ought not to be prematurely prescribed, espe- cially in the second stage, and while a phlogis- tic diathesis is present even in the slightest de- gree. Of the various tonics, the preparations of cinchona are certainly the best. The infu- sion may be first given, conjoined with the so- lution of the acetate of ammonia, and subse- quently the decoction with liquor potassae or the subcarbonate of soda. The extract of co- nium or hyoscyamus, or paregoric elixir, may be added to either of these. Bark was strong- 290 HOOPING-COUGH—Specific Modes of Treatment. ly recommended by Quarin, Courbette, and Holdefrec.ni). Hannes gave it with the sul- phuret of antimony, and administered it in ene- mata ; and Sauvages and Morris, with castor; Bisset, Stoll, Aaskow, Weber, and Michaelis very judiciously premised sanguineous deple- tions, emetics, and purgatives before they ven- tured upon it. Murray and Hufeland gave it with cantharides in the latter stages. It is much more beneficial in some epidemics than in others. When the complaint is protracted, and assumes an intermittent or periodic type, particularly a tertian form, quinine or cinchona ought never to be omitted. The arsenical solu- tion has also been employed in circumstances requiring the bark. It was much recommend- ed by Ferriar and Simmons, and is undoubted- ly of service in these ; but it is not superior to cinchona; and, in children especially, it is a much more hazardous substance. I have giv- en the sulphate of zinc with great benefit in some cases ; and the nitrate of silver, triturated with extract of hop or of hyoscyamus, with equal advantage, in others. The sulphate of iron was very favourably noticed by Dr. Stanger, and is an excellent medicine in the third stage, or purely nervous state of the complaint; but it is not superior to the other preparations of iron, particularly the ammonio-chloridc and the potas- sio-tartratc. 63. g. There are various other medicines which have been employed internally against hooping-cough; but these require only a sim- ple enumeration. Of the Lichen pyxidatus mention has already been made (y 50). The Lichen coccifcrus was recommended by Forbes and Von Woenzel ; and the L. Islandicus by Weber. The Ledum palustre, Tilca Europaa, and Althaa officinalis were prescribed by Wahl- bom, Linn.eus, Walter, and Wahlin ; the Gcum urbanum, by Keck and Buchhaave ; Phel- landrium aquaticum, by Van der Bosch ; an in- fusion or extract of the Narcissus pseudonarcis- sus, by Dufresnoy ; an extract of the Mesem- bryanthemum, by Wendt ; and an extract of the Cardamine pratensis, by Comhaire and Veille- cheze. Isinglass was used in this complaint by Heineken and Gautieri ; acetate of lead, in small doses, by Forbes ; oxyde of zinc, with ci- cuta or belladonna, by Guersent ; diluted ace- tic acid, with sugar, by Hannes ; sulphur, by Sydenham, Quarin, and Unzer ; and the sul- phuret of potass by several Continental physi- cians. 64. h. There are few complaints in which ex- ternal medication has been so extensively or so beneficially employed as in this. Although the inhalation of simple or medicated watery va- pours does not strictly come under this head, I may here state that it has been advised by Pearson, Darwin, and others. The observa- tions as to this practice, in the article on In- flammations of the Bronchi (see that article), and as to the medicines that may be used in this manner, entirely apply to hooping-cough. In the early stage, the vapour to be inhaled should be either simple or merely emollient. In the latter stages it may be slightly impregnated with camphor, or with some narcotic ; but this practice can seldom be adopted for young chil- dren. The inhalation, in early or inflammato- ry states of the complaint, of stimulating va- pours is always injurious. 65. i. External irritants of various kinds have been prescribed. Blisters were applied to the chest, and between the shoulders, by De Meza, Paldamus, Quarin, and others ; but the precau- tions stated above (y 44) should be observed, particularly in cases of infants and young chil- dren. Knebel directed rubefacients to the nape of the neck ; Pelargus and Hufeland, to the lower extremities ; Henning and Hecker, to the epigastrium ; and Durr, to the soles of the feet. Various substances have been employed as external irritants. Henning recommended a cataplasm containing scraped horseradish; Struve, a liniment with tincture of cantharides and tartar emetic; and Zadig, the tincture of ginger applied to the epigastrium. Autenrieth prescribed an ointment containing tartar emet- ic to be rubbed upon the chest, or between the shoulders, or upon the epigastrium; and this practice was adopted by Kelch, Merrem, Nolde, and Michaelis ; but Horn and Schnei- der found it productive of little or no benefit. Autenrieth has received the credit of being the first to employ tartar emetic as an exter- nal irritant; but it was thus recommended long previously by the older Monro. I have seen the incautious use of this ointment productive of dangerous, and even of fatal sloughing, in debilitated or cachectic children and infants. Loebenstein-Loebel advised a liniment con- taining a solution of phosphorus, in oil of cum- min and camphor, to be applied on the epigas- tric region. From an extensive experience of external irritants in the treatment of pertussis, I prefer the semicupium or pediluvium, mustard and salt having been put into the water; the occasional application of a mustard poultice to the chest or epigastrium ; dry cupping on the nape of the neck or between the shoulders ; or friction with the following liniment along the spine, or the application of a piece of flannel moistened with it on the sternum or epigastric region, according to the peculiarities and com- plications of the case : No. 258. H: Linimenti Camphor* Comp., Linimenti Tere- binthinse, 8a f j.; Tinct. Capsici 3j. ; Olei Caojuputi 3SJ. vel. 3j. Misce. Fiat Linimentum, vel Embrocatio. 66. Since the introduction of vaccination, it has been proposed by Okes, Cleeve, and Mou- tain- to inoculate with the vaccine matter as a preventive and as a cure of hooping-cough. This subject has been recently agitated, but without any conclusive evidence of benefit hav- ing been derived from the practice.* 67. k. In the second, but especially in the third stage of the disease, change of air, partic- ularly to the seaside, as recommended by Gregory and Hufeland, and sea voyaging, are of the utmost advantage. For patients resi- ding on the seacoast, frequent excursions on the water will be highly beneficial, especially if nau- sea or vomiting be thereby produced. Salt- water bathing, commencing with the warm or tepid bath, and passing gradually to the cold bath or shower bath, will be found very ser- viceable, if no complication forbid it. The diet * [It is well ascertained, by recent and repeated experi- ments, that vaccination exerts no control over the progress of pertussis. Ten children labouring under this disease, who had never been vaccinated, were admitted into the hospital for children, in Paris, in 1S35, of which nine were vaccinated. Pustules were regularlv developed, but the hooping-cough was in no respect modified by the vaccine disease.—(Bull. Gen. de Therap., July 30, 1636.)] HOOPIXG-COUGH—Bibliography and References. 291 of the patient, in the first stage, should be anti- phlogistic ; and in the second and third it ought to be very light, chiefly farinaceous, and mod- erate in quantity. Over-distention of the stom- ach aggravates the fits and favours cerebral congestions. Exposure to cold, or to vicissi- tudes of weather or temperature, running, &c, also, may induce inflammatory complications. Young children ought to be carefully watched at night, and be raised up as soon as the fit is threatened. Whenever the phlegm obstructs the fauces, it should be removed by a small, thin piece of whalebone, bent in the form of a tongue-scraper, or by the finger of the nurse. [The treatment of hooping-cough in our coun- try is generally very simple ; for, unless com- plicated with other affections, it usually runs its course with safety, seldom requiring the in- terference of art, much less the employment of active measures. The opinion very generally prevails that the disease cannot be arrested, and that all we should aim to accomplish is to palliate the symptoms and assist nature in the means which she has pointed out for its relief, as by the administration of emetics, which tend to promote the bronchial secretion as well as favour its removal. In this as in all other com- plaints, our treatment is, of course, to be reg- ulated by the stage of the disease, the violence of lhe attack, its simple or complicated charac- ter, and the age and vigour of the patient, and the judicious directions laid down by our au- thor will prove an ample guide to the practi- tioner under the different circumstances in which he may be called to prescribe. From considerable experience, we are indu- ced to believe that this disease may be greatly modified, if not arrested in its course, by a somewhat active treatment in its commence- ment, especially when it attacks with any con- siderable degree of violence ; and, accordingly, we have for some time past been in the habit of treating it, in its first stage, as a simple bronchitis, with general or local bleeding, pur- ging, emetics, and the usual antiphlogistic meas- ures. In many instances the disease will be of too mild a character to require anything more than gentle emetics and expectorants with an occasional cathartic; but we have so often seen its violence and duration so obviously aba- ted by Wood-letting, and especially by cups to the chest, that we cannot hesitate to resort to these means, rejecting as we do the hypothesis that the affection is a simple neurosis, and has a certain prescribed period to run. We rarely, if ever, prescribe antimony to children under two years of age, on account of the violence with which it frequently operates; after that period it may be cautiously administered with great benefit in this disease, as it is supposed to meet the double indication of bronchial in- flammation and spasm consequent on neurosis, over both of which it exerts a manifest influence. The ipecacuanha, in combination with sulphur, we have found well adapted to these cases, and where the cough is urgent, a small quantity of hyoscyamus may be combined with it. If the catarrhal symptoms are severe, calomel purges will prove highly beneficial, to be followed by an emetic of ipecacuanha, or the same medi- cine in expectorant doses. Alkalies are useful in every stage of the affection. Of the class of antispasmodics tha belladonna, j and asafoetida are in most repute in the treat- ment of this disease among American practi- tioners, although the hydrocyanic acid has some warm eulogists. The hyoscyamus is also an admirable remedy in the latter stages of the affection, and a very good form of administer- ing this, as well as the belladonna, is to com- bine it with the sirup or wine of ipecacuanha and subcarbonate of potassa. We need not add that these narcotics should be given to children with great caution ; we, however, place more reliance on change of air and travelling in the chronic stage of hooping-cough, when severe, than on all other remedies.] Bibliog. and Refer..—Amatus Lusitanus, Cent, vi., 90. — Willis, Pathol. Cerebr., cap. 12; et De Medicament. Operat., par. i., sect, i., cap. vi., p. 169.—Syden/iam, Epist. i., Respons. Opera., Lugd. Bat., 8vo., 1726, p. 311. — H. Shane, Voyage to Madeira and Jamaica, fol. Lond., 1707. —F. Hoffmann, De Tussi Convulsiva, Opp. Suppl. ii., De Tussi, iii. Halae, 1732.—Alberti, De Tussi Infantum Epi- demica. Halae, 1728.—Huxham, Opp. i., p. 98. De Morbis Epid., vol. ii., p. 75.—Brendel, Progr. de Tussi Convulsiva. Goett., 1747 ; v., Opp. i., p. 159. — L. C. Bourdelin, J. B. Basseville, Ergo Tussi Clangoss Emesis. Par., 1752.— Haller, D. ad M., i. — Nayler, Dissertation sur plusieurs Maladies qui ont rcgne a Chalons sur Marne, - Guersent, in Encyclographie, vol. xi., J., p. 261,369 ; and vol. xiv., J., p. 367, and L., p. 221 .—Naumann, Handb. der Medicinisch. Klinik., b. i., p. 321. — Berndt, Clinical Com- munication in Brit, and For. Med. Rev., July, 1836, p. 178. — R. T. Evanson and H. Maunsell, Pract. Treat, on the Management and Dis. of Children, 8vo. Lond., 1836, p. 363.— Whilmore, in Lancet, Oct., 1837, p. 97 and 129.— Jadelot, in Lancet, Sep., 1837, p. 909.—.V. G. Andral, Cours de Pathologte Interne, *c, livr. troisieme. Paris, 1837. tAM. Biblioo. and Rbfer.—Waterhouse, Treatise on Hooping-cough.—D. F. Condie, A Practical Treatise on the Diseases of Children. Phil., 1844, and Am. Ed. of Evan- son and Maunsell on the Management and Diseases of Chil- dren.— W. W. Gerhard, Lectures on the Diagnosis, Pathol- ogy, and Treatment of the Diseases of the Chest. Phil., 1842.—James Stewart, A Practical Treatise on the Diseases of Children, 2d ed., 1 vol., 8vo. N. York, 1844 ; also Trans- lation of Billard, On Dis. of Children.—John Bell, Am. Ed. of Underwood on Diseases of Children, and Lectures on the Theo. and Prac. of Physic. — G. Ackerley, On the Management of Children in Sickness and in Health.—W. P.Dewees, A Treatise on the Medical and Moral Manage- ment of Children, 1 vol., 8vo. Phil.—/. Eberle, A Treatise on the Diseases and Physical Education of Children, 1 vol., 8vo. Phil.—J. Thatcher, American Modern Practice, Hist> P- 27- "09 - G. J. Du Ph 1^'T" ilV V?l-JJ-.P-58T^ *»*?"•«» *«"*«, Hist p. 74. -C. N. Le Cat, Philos. Trans.. 1741, p. 712.- [■^rnegan, in Ibid., 1745, p. 305. —W. Graham, in Ibid., J/41, p. ,08.-17. Watson, in Ibid., 1741, p. 711. — H. D. *P»ring, Svenska Vetusk. Acad. Handl., 1743, s. 306 ; and fcchwedische Akad. Abhandl., 1743, s. 246. — Morgagni, Caus. et Sed., &c, epist. xxxviii., 36, 45. — A. P. Kiilpin, bchnften der Berliner Gesellsch. Naturf. Freunde, b. i., s. 348. — W. Scott, Med. and Philos. Comment, by a Soc. in Edinburgh, vol. v., p. 183. —A. P. Nahuys, Verhandel. van hot. Genootsch. te Vlissingen, deel. 3, bl. 453.-7. Collet, Med. Transact., vol. ii.. p. 486.— V. Menghinus, Commen- taru Bonomenses, vol. ii., P. j., c, p. U2. — Durand, An- nates de la Soc. de Medec. de Montpellier, vol. xxii., p. 366 and 357.— Lamorier, Mem. de Montpellier, vol. ii., p. 62.— J. Paisley, Med. Essays and Observat. by a Society in Ed- inburgh, vol. v., part ii., p. 766.—Guattani, Mem. de l'Acad. des Sc, tion; 1. Order, Affecting the Intellect; (Good). I. Class, IV. Order (Author in Preface). 1. Defin.—Chronic indigestion, with languor, flatulency, dejection of mind and fear, arising from inadequate causes ; general exaltation of sen- sibility ; a rapid succession of morbid phenomena, simulating numerous diseases, or otherwise a real, but variable state of suffering, exaggerated by the morbid sensibility and fears of the patient, with unsteadiness or variability of purpose, and dis- tressing anxiety respecting his complaints. 2. Hypochondriasis has been very differently arranged by nosological writers. Vogel placed it among spasmodic diseases, and Cullen, much more correctly, in that order of nervous complaints which depend upon defective vital power. Sauvages, Linnaeus, Pinel, and Good have included it in the class of mental affec- tions, and viewed it as nearly allied to insanity. I agree with Dr. Prichard in considering the arrangement of these latter writers not to be justified by the history of the disease, and for reasons that will be stated under the head of Diagnosis. 3. I. Description and History.—A. The first, or slightest degree, or stage of this malady is generally confined to disorder of the digest- ive organs, its invasion and progress being commonly slow. However, in a very few in- stances, its attack is sudden, and its course more rapid. The disorder of the digestive or- gans is always real, although more or less ex- aggerated, and attended by a sentiment of general uneasiness or distress, referrible to an increased susceptibility, or morbid sensibility, especially of the organic nervous system. The appetite is sometimes not affected, but it is oc- casionally variable or deficient, or even exces- sive. Digestion is slow and difficult, and the patient complains of pain, oppression, or dis- tention in the stomach, or hypochondres after a meal. These sensations are attended and aggravated by flatulency and borborygmi, and sometimes by acid or acrid eructations. Occa- sionally the abdomen feels hard from flatulent distention, and various symptoms characteristic of chronic indigestion, as cardialgia, sense of heat in the course of the oesophagus, nausea, hemicrania, twisting or griping pains in the abdomen, &c, are complained of In a few instances the appetite is perverted, particularly in hypochondriacal females, or during preg- nancy, a morbid desire for indigestive or the most improper substances being present. Thirst is seldom much complained of. The tongue is commonly loaded or covered, towards the root and middle especially, and particularly before breakfast, with a mucous coating. The mouth is clammy, and the taste somewhat perverted. The breath is generally offensive. The nausea is sometimes attended with a vomiting of mu- cous fluid, or of an acid matter, with half-di- gested food, and sometimes with a sort of sal- ivation. The flatulence of the digestive canal excites, or is accompanied by sympathetic pains in various situations, which are alleviated by eructations, and especially by the expulsion of the air downward, but these pains usually re- turn, although not always in the same place, or with the same characters. The bowels are generally costive, but they are occasionally irregular ; constipation, with colicky pains, sometimes alternating with diarrhoea. The relaxation of the bowels seldom affords relief; and when it is prolonged, it often increases the anxiety, depression, and nervousness of the patient. The urine is occasionally natural, but it has frequently been observed by Sydenham, Hoffmann, and Cheyne more than usually limpid and abundant. It is sometimes loaded, or deposites a copious sediment, as in dyspep- tic cases. Palpitations in the heart and in the epigastric region are sometimes felt, and excite great uneasiness in the patient's mind. 4. B. The second degree or stage of the com- plaint is even still more diversified than the preceding. The symptoms already detailed continue undiminished, are often aggravated, and are accompanied by others, referrible to the brain and organs of sense, and sometimes, also, to the thoracic viscera. Yet, notwith- standing the severe train of symptoms and dis- tressing feelings of the patient, he frequently presents the appearance of sound, or even ro- bust health. He often complains of violent pains in the temples, forehead, or occiput, or of general headache, with dimness of sight, and noises in the ears ; or of a sense of weight or pressure, more intolerable than pain, at the vertex, with giddiness or confusion of mind ; and sometimes of a constriction, or tightness in the head or temples, or of a morbid sensibil- ity of the scalp and roots of the hair. Occa- sionally the senses are morbidly acute and in- tolerant of light and noise. Pains resembling rheumatism, or those of syphilis, are felt in various situations, occasionally with a feeling of burning or heat, and sometimes with cold- ness, horripilations, numbness, cramps, feeble- ness, or threatened paralysis of one or other of the extremities. Weakness of the limbs, unsteadiness in walking, or feebleness of the joints (in some instances with neuralgic pains), and great susceptibility to cold and heat, are not unfrequently also complained of. The morbid sensibility of the hypochondriac is gen- erally increased by a cold and humid state of the atmosphere, by easterly winds, and by very warm seasons. His mind is incapable of exer- tion or prolonged attention, although, when aroused, he may be lively and acute ; but he soon becomes engaged with his own feelings and sufferings. To these he frequently recurs in conversation, whenever he has an opportu- nity of doing so, although he seems to suspect that the subject is unpleasant to those who listen to him, and therefore suppresses a part of his complainings. In some cases there is dyspnoea, constriction of the chest, with a dry, short, or spasmodic cough, and occasionally a sense of suffocation or constriction is felt in the throat, with flatulence and various other symptoms resembling those attendant on hys- teria. These phenomena have induced sev- eral writers to consider the disease closely allied to hysteria, and the severe palpitations, or irregular action of the heart, frequently also complained of, have farther countenanced the idea; while they have excited the anxiety of the patient, and induced him to believe himself the subject of irremediable disease of the heart. Sleep is sometimes not materially disturbed, and occasionally the hour of repose is ardently looked for ; but in other cases it is dreaded as aggravating the distress. Generally, as the dis- 37 302 HYPOCHONDRIASIS—Description of—Complications. ease advances, unquiet and distressing dreams, restlessness or insomnia, incubus and nervous agitations are more or less complained of. 5. C. The third or confirmed grade of this malady presents nearly the same phenomena as have been detailed, but in a somewhat heightened and chronic form. The complaints of the patient have been varied, and a succes- sion of most of those enumerated have been ex- perienced. The patient is often tortured with the most distressing feelings, which are greatly aggravated by his fears. He dreads impending dissolution, from the symptoms referred to the head, heart, or chest. His ideas are concen- trated on himself and his feelings, and he is incapable of attention or mental exertion, un- less aroused by circumstances of unusual in- terest or moment. This mental incapacity is increased by an idea that his faculties are im- paired, and by his dread to exert them. Oc- casionally vertigo, dimness of vision, or intol- erance of light and noise, are so great as to justify his fears ; and the pains in the head, or the sensations of pressure on the head and temples, are so severe that the eyes feel as if starting from their sockets. At the same time, the organic sensibility of the digestive canal is so acute that the progress and operation of a dose of medicine are traced by him through the different compartments, and made objects of comment. Palpitation is felt at the epigas- trium and about the coeliac axis, and is some- times attended with sensations of throbbing, extending to the extremities. Disorder of the digestive functions still continues more or less marked, and the tongue is either loaded or covered with a mucous coating, or is flabby at its edges. The pulse is seldom very mate- rially affected, unless the patient be subject to palpitations or irregular action of the heart. In this advanced or prolonged state of the dis- ease, the countenance of the patient often pre- sents an air of distress or suffering. In some cases it becomes sallow, but in others his ap- pearance has no relation to the intensity of the sufferings he expresses. While most of the faculties of the mind are more or less weaken- ed, the imagination is morbidly active, and is constantly engaged with the consequences or results of the disease of which he believes himself the subject. His desire and hopes of recovery, however, prevent him from being weary of life, or from entertaining an idea of terminating it. On the contrary, he is most anxious to obtain relief, hut is frequently un- steady in the use of means calculated to afford it. He has recourse to a variety of opinions, and is more ready to adopt what is recommend- ed for his restoration than to persevere in its employment, or to continue under the direction of the physician whom he has consulted. 6. II. Associations or Complications.— Ju- dicious observers who have studied the course of this malady will agree in believing that the symptoms characterizing it are by no means imaginary. They evidently depend upon phys- ical disease, in connexion with a morbidly ex- alted state of sensibility. This physical dis- ease commences in the digestive organs, at- tended with morbid organic sensibility, which extends to the cerebro-spinal nervous system, thereby aggravating and multiplying the morbid phenomena. The lesions, therefore, observed in the course of the malady, whether function- al or structural, can hardly be denominated complications. They are rather integral or ne- cessary parts of the malady, rendered more prominent, however, by the distressing feelings which they excite, or with which they are as- sociated. In addition to the functional disor- der of the stomach, and other chylopoietic vis- cera characterizing this complaint, the digest- ive canal often presents evidence of marked ir- ritation, amounting, in some cases, to asthenic inflammatory action, or even to structural le- sion of the mucous surface. The secreting function of the liver is also often disordered, and symptoms of congestion or engorgement of this organ, or even of inflammatory action, may occasionally be detected ; and in these affections the gall-bladder and ducts not unfre- quently participate. The spleen is sometimes enlarged, and occasionally in connexion with disorder in the biliary apparatus. Hypochon- driacs often are subject to hamorrkoids, owing to local or general plethora, or to costiveness, or to the use of irritating cathartics. This con- nexion has been noticed by Hippocrates, Ga- len, Stahl, Hoffmann, Alberti, Highmore, and others, and has been considered as being salutary in plethoric hypochondriacs, and when the haemorrhoidal flux has not been excessive or debilitating. Some writers, particularly Koch and Buchner, have viewed the haemor- rhoids as the cause of the hypochondriasis ; and I have met with cases which countenance the opinion, as well as with others which mili- tate against it, and show that the removal of the former has increased the latter, by aug- menting plethora, and disposing to affections of the brain. I was very recently consulted by a gentleman, who had been subject to haemor- rhoids and hypochondriasis in its slighter form, the discharge from the former always relieving the latter for a time. The haemorrhoidal affec- tion was cured by surgical treatment; but the hypochondriasis was afterward remarkably ag- gravated, and was followed by painful spasm and irritation about the sphincter. He consult- ed another eminent surgeon, who divided the sphincter ; but the operation was succeeded by inflammation of the rectum, extending along the colon, with the usual dysenteric symptoms, fever, and the utmost distress. These having been subdued, the complaint in the rectum con- tinued unmitigated, and the patient's hypochon- driacal sufferings increased to the utmost. In this case the local treatment, which was ob- viously injudicious, remarkably aggravated the disease. 7. Hypochondriasis either seldom occurs in females, or occurs only in a slight degree, as long as the catamenia continue regular; but when they are suppressed or diminished, or dis- appear at the natural period, it occasionally commences, or is aggravated. It may also oc- cur in a slight form during pregnancy, and sub- side or disappear after delivery. Of this I have seen more than one instance. Pregnancy may also relieve this complaint when the patient has been labouring under it for some time pre- viously. Organic disease, or irritation of the uterus, is one of the most frequent associations of hypochondriasis in this class of patients ; and it may, moreover, not be the only one in the same case. HYPOCHONDRIASIS—Lesions of Structure. 303 8. The symptoms referrible to the head are not always dependant alone upon altered or ex- alted sensibility. In addition to this state there is often also congestion, or deranged circula- tion in the brain ; but the cerebral affection is generally consecutive upon disorder of the di- gestive functions, and upon increased sensibil- ity of the organic or ganglial nervous system, even although the chief cause of the hypochon- driasis has acted primarily upon the mind. 9. Hypochondriasis may be excited in the course of some organic malady, by the patient's attention being suddenly directed to the seat of disease, although his feelings and spirits had not been previously affected. This is not un- usually the case with organic affections of the heart. I have seen more than one instance where the detection of disease about the valves, or a particular examination of the heart by aus- cultation and percussion, led the patient to sus- pect what really existed ; and the suspicion soon amounted in his mind to certainty—his fears and distresses becoming even painful to the observer. The connexion of hypochondri- asis with the gouty diathesis has seldom been adverted to by writers ; yet I have met with several cases where the former has come on after the suppression or disappearance of gout. In such cases, disorder of the abdominal vis- cera is more or less marked, and is sometimes associated with deranged circulation in the brain. Indeed, this may be said to be one of the forms of misplaced gout: hypochondriasis, when prolonged or neglected, or aggravated by injudicious treatment, may pass into melancholy, or even into insanity; but this is much more rare than is supposed. In these instances, mel- ancholic ideas, or some single delusion, is en- tertained, while the primary disorder either continues unchanged or is partially absorbed in the superinduced malady. 10. III. Duration and Terminations. — a. The duration and progress of hypochondriasis are most indefinite. The accession of it is gen- erally gradual and imperceptible, unless when caused by some overpowering impression or mental emotion. When judiciously treated in its slighter forms, or during early periods, this complaint may be removed after a cdhiparative- ly short time ; but, otherwise, it may continue for years, with various mutations, and with in- definite periods of relief or exacerbation, de- pending partly upon the permanence of the causes, on the state of the season, or the oc- cupations and amusements of the patient, or upon whatever may affect his general health and constitutional powers. It may even spon- taneously cease for a time, and return again and again ; or it may continue through life, without apparently shortening its duration; but, more frequently, the functional, or struc- tural lesion producing it gradually increases, until visceral disease of a very obvious kind is developed, and shortens existence, under the care of some practitioner who, most probably, had not witnessed the earlier progress of the malady. ^ ■11. b. The terminations of hypochondriasis are, 1st, in the restoration of health by medical treatment; 2dly, by critical evacuations and I spontaneous recovery; 3dly, in the develop- ment or supervention of organic or fatal vis- I ceral disease.—a. The first of these can be ac-1 complished only slowly, and by judicious re- course to medicine, regimen, and moral disci- pline.— b. Critical evacuations are rarely ob- served. Diarrhoea, particularly when caused by a copious secretion of bile, and followed by a resolution of hepatic engorgement or biliary obstruction, occasionally affords some relief; but it rarely removes the complaint unless it be aided by additional means. The same remark applies equally to hamorrhagic discharges. They furnish, however, indications of what should constitute, at least, a portion of the treatment in many cases. The spontaneous appearance of cutaneous eruptions has been noticed by Bo ekhaave, Lorry, Van Swieten, Heim, and Reil, as favourable occurrences ; and enlargement of the external glands had also been consider- ed critical by Stoll, Klein, and others. 12. c. Organic, or fatal visceral disease, is more liable to occur in hypochondriacs than in other persons, or than is commonly supposed. The parts most frequently undergoing structural le- sion, are the stomach, liver, and biliary appara- tus, the brain and membranes, the large bow- els, the heart and large vessels, the spleen, pancreas, uterus, and kidneys. Functional dis- order of some one of these, in connexion with derangement of its circulation, and with exalt- ed organic sensibility and nervous susceptibili- ty, most probably gives origin to most of the pa- tient's sufferings ; and as these disorders pro- ceed onward to organic lesion, the malady ad- vances, until this lesion is expressed by signs much less equivocal than those attending the earlier stages of the hypochondriacal affection. Insane delusions, melancholy, palsy, or epilep- sy, may thus supervene from progressive struc- tural change ; but the former of these are by no means so common as is generally believed. Palsy is not a frequent, and epilepsy is a com- paratively rare termination of this malady. Or- ganic lesions of the heart and pericardium, as well as of the large bowels and urinary organs, are, however, oftener observed than has been supposed. The structural changes met with in advanced or old cases of hypochondriasis are chiefly the following : 13. IV. Lesions of Structure.—Various changes have been observed in the digestive mu- cous surface, the most important of which have been congestion, partial softening, discoloured spots, and slight ecchymoses. Thickening of the coats and induration, or an incipient state of scirrus of the pylorus, or cardiac orifice of the stomach (Bonet, &c.), have been more rare- ly met with. The liver has presented various lesions, the chief of which have been conges- tion, enlargement of the organ, and dilatation and engorgement of the vena portae (Lieutaud). I have found the hepatic ducts and gall-bladder distended, enlarged, and filled with dark inspis- sated bile. Gall-stones have also been found in the bladder and ducts. Alterations of the spleen have been observed by Bonet and oth- ers, and of the pancreas by Brandis. The large bowels, especially the sigmoid flexure of the co- lon, the cacum and rectum, frequently present changes similar to those noticed with reference to the digestive mucous surface generally, or are thickened, or somewhat contracted, and the colour is sometimes displaced. Heemor- rhoidal tumours are often met with. A pleth- oric, engorged, or congested state of the abdom- 304 HYPOCHONDRIASIS—Diagnosis. inal viscera generally, has been remarked by Theden, Burggrau, and Leuthner. I have found calculi in the kidneys in one instance, and enlargement of the prostate gland and disease of the bladder in another. Alterations of the ute- rus have been noticed by some writers; and I believe that they are not rare in connexion with hypochondriasis, especially after the change of life. 14. Organic disease of the heart and large blood-vessels is not unfrequent in hypochondri- acs ; but instances in which the structure and orifices and valves of this organ have been ac- curately examined after their death are remark- ably rare. It is not improbable that some of the changes observed as a consequence of in- ternal carditis, and of chronic inflammation of the large vessels, would be detected in some cases if a careful inspection after death were instituted in persons who had been subject to this complaint. A plethoric state of the vas- cular system generally has been remarked by Winneke, and a very dark and altered state of the blood by Thilenius and Burggrau. Va- rious lesions have been found in the brain and its membranes, particularly in cases wherein the patient's chief suffering had been referred to the head; but these lesions have either been very different in different cases, or very imper- fectly described; while, in some, little or no alteration has been detected. In short, the bodies of hypochondriacs have presented le- sions as diversified as the complaints made du- ring life ; but these lesions have been very fre- quently overlooked, or no inquiry after them has been made, owing to the circumstance of the complaints of this class of patients having been very generally viewed as entirely imaginative. 15. V. Diagnosis.—The diagnosis of hypo- chondriasis is most difficult; for the complaints of the patient are so distressing, and his suf- ferings apparently so extreme, that the inexpe- rienced practitioner may be deceived by them, and believe them to proceed from dangerous states of disease, and to require the most ener- getic remedies. This simulation of organic and serious maladies, if it be not detected, may lead to a mischievous treatment. On the other hand, when a patient is known to be the sub- ject of hypochondriasis, the circumstance ought not to induce us to overlook, or to treat care- lessly, his sufferings, which are generally not only real, but also often depending upon struc- tural changes, although these changes are ei- ther too obscure or too minute to be readily or easily detected. The versatility and mutations of the hypochondriac's sufferings, and the in- consistency observable between his complaints and his appearance, and between the local and general, or constitutional symptoms, will read- ily suggest the nature of the disease. Yet the symptoms sometimes continue without change; and the patient often makes the same com- plaint. In such cases, there is reason to be- lieve that real disease exists, although exag- gerated by his morbid sensibility and fears, by his imagination having long been engaged with his sensations in the seat of disorder. The want of relation between his feelings and con- stitutional symptoms ought, also, not to be too much relied upon ; for, in hypochondriacs, the vascular system is not readily excited to feb- rile commotion, although the sensibility is ea- sily deranged and altered in a variety of situa- tions, either successively or simultaneously. In every instance there is the utmost necessity for patient investigation, and for the exertion of practical acumen. When the hypochondri- ac's sufferings are seated in the digestive or- gans, then a careful examination of the abdom- inal regions, and of the excretions, will gener- ally indicate the extent of mischief, and show how much may be attributed to the patient's susceptibility or morbid sensibility; but when the complaints are referred to the head or heart, then the difficulty is greater ; for we know that in these situations structural changes may be slowly advancing without inducing those phys- ical signs and disorders of the functions of these organs usually attendant upon more rap- idly developed organic lesions. 16. The sufferings referred to the digestive organs have been imputed by Broussais and his followers to gastro-enteritis; and I believe that, in many cases, the circulation in the digestive mucous surface is more or less deranged; but this derangement is not identical with true in- flammatory action. The organic sensibility and state of nervous influence in these parts are not the same in these complaints. In hyp- ochondriasis the patient can bear firm and prolonged pressure, although he may wince from a momentary or slight pressure, owing to his fears and morbid feelings. He generally has an unimpaired, or even a ravenous appe- tite ; is capable of using exercise, or even of undergoing fatigue, and is benefited by them. His bowels are usually costive, and his appear- ance is not materially, if at all, affected ; and febrile symptoms are not observed. Whereas, in gastro-enteritis, firm pressure is generally not endured, the appetite is impaired, as well as the looks, strength, flesh, and general health; and the bowels are loose and irritable, although the converse of this is sometimes observed. The spongy condition of the gums, the falling of them from the teeth, and the flabby state of the sides of the tongue, frequently observed in hyp- ochondriasis, indicate rather a deficiency of tone and of vital cohesion of the digestive mu- cous surface than inflammatory action. 17. The«symptoms referrible to the head are often such as to rouse the anxiety of the prac- titioner, especially when they are attended by disorder of any of the functions of sense. Yet I believe that these symptoms more frequently depend upon disordered circulation, as well as altered sensibility, than is supposed. In this complaint the state of the cerebral circulation is too often neglected, or not inquired into, and the sufferings of the patient believed to be ei- ther exaggerated or imagined. When his strength and healthy appearance are unimpair- ed, and the functions of the senses are unin- jured ; and when the temperature of the scalp and the action of the carotids are not material- ly affected, we may safely conclude that the morbid feelings in the head do not indicate that danger which the fears of the patient would imply ; and this inference will be the more con- clusive if the patient have never experienced any apoplectic, paralytic, or epileptic seizure, and if he has been known to be subject to ner- vousness, low spirits, or hypochondriacal feel- ings. In many cases, however, of this malady, particularly in the second or third grades of it, HYPOCHONDF increased action of the carotids, heat of the Bcalp, flushing of the countenance, suffusion of the eyes, &c, indicate cerebral plethora, or ac- tive congestion within the head, and sufficient- ly show that, although the sensations in this quarter may be exaggerated, they are by no means unreal. 18. The disorders referred to the heart and lungs are to be distinguished from such as are unequivocally organic by attention to the phys- ical signs. The palpitations and anxiety at the praecordia often complained of are certainly chiefly nervous in their nature ; but of this we have only negative proof. During the palpita- tion, a bellows-sound may be present, although it cannot be detected in the intervals. Yet I have known instances where it was at first heard only during the paroxysm of palpitation ; but, after the lapse of a long period, it was heard more constantly. I believe that those distressing symptoms, although strictly ner- vous at early periods of the disease, either slowly or imperceptibly induce, or are attended from the beginning with a slight and gradually increasing kind of organic lesion. Morbid states of the heart, as slow grades of inflammatory irritation, may exist, especially in the lining membrane of the cavities and large vessels, and occasion the distressing feelings complain- ed of, although they may not be manifested by physical signs. When cough and difficult or oppressed breathing are present, their nervous or sympathetic nature may be readily deter- mined by attention to their characters, by the absence or the appearance of expectoration, and by the signs furnished by auscultation and percussion. 19. Hypochondriasis has been often con- founded with, or viewed as a variety of insan- ity. It is important to discriminate between them. Dr. Prichard's remarks on this subject evince the correct judgment of this able writer. He observes that a hypochondriac is in full possession of his reason, though his sufferings are not so dangerous or so severe as he suppo- ses them to be; but if he declares that his head or his nose has become too large to pass through a doorway, or displays any other hal- lucination, he has become a lunatic; his dis- order has changed its nature ; and this conver- sion takes place occasionally, though by no means so frequently as supposed. Hypochon- driacs, however low-spirited or dejected, also suffer differently from persons affected with melancholy. The apprehensions of the former are confined to their own feelings and bodily health. On other subjects they converse cheer- fully, rationally, and justly. But melancholies view all things through a gloomy medium. • They despond on all subjects, and are mentally miserable, and independently of any severe bodily suffering. The affections and sentiments of the hypochondriac, especially to his former friends, or to his connexions, are not in the unnatural or perverted state observed in all the forms of insanity. 20. VI. Causes.—i. Predisposing circumstan- ces.—Hypochondriasis may commence at any age; from 21 to 55 in males, and from 30 to 60 in females. It is more frequent and more severe in the former than in the latter sex. It seldom occurs in females until after 30 or 35, hysteria being the form which nervous af- II 39 UASIS—Causes. 305 fections usually assume in them in early life j but it often commences about or soon after the cessation of the menstrual discharge, although rarely in so severe a form as in the other sex. It affects every temperament or habit of body ; but somewhat oftener the nervous, the melan- cholic, the sanguine, and the bilious; and per- sons who are subject to haemorrhoids, to con- stipation of the bowels, and to disorder of the digestive functions, and who are of a sallow complexion. Hereditary influence, or peculi- arity of constitution transmitted from the pa- rents, has, perhaps, some influence in predis- posing to it, as Willis, Hoffmann, and others have contended, although not in so remarkable a manner as in some other nervous complaints. Employments which are sedentary, or prevent due exercise in the open air, and which, at the same time, admit of activity of mind, also pre- dispose to this complaint. Hence the frequen- cy of hypochondriasis in shoemakers and tai- lors. Mental exertion and fatigue, or prolong- ed or overstrained attention and devotion to a particular subject, especially in connexion with full living relatively to the exercise taken in the open air, may be said to be the chief sour- ces of predisposition among the educated class- es.* Owing to these circumstances, this has been termed the disorder of literary men ; but whoever is engaged in active mental pursuits, or in departments of business requiring great intellectual exertion, or occasioning anxiety of mind, is equally liable to it. Dr. Prichard ob- serves that agricultural labourers, who spend a great portion of their time in solitary em- ployment in the country, are frequently the subjects of this complaint. Although solitary employment is likely to dispose the mind to brood over the evils that afflict it, yet much is probably, also, owing to the diet of field labour- ers, and to the influence of humidity and exha- lations from the soil to which they are exposed, particularly in the reparation of ditches and hedges. The effect of climate in predisposing to hypochondriasis is not very manifest; but situations which are humid, and productive of terrestrial emanations, are apparently not without some influence in the production of it. 21. ii. The exciting causes may be divided into (a) those which act more immediately upon the mind, and consecutively, or through the medium of the mind, upon the organic func tions; and (b) those which affect primarily those functions, and secondarily the mental energies.—a. Whatever exhausts or directly depresses cerebral power, as intense applica- tion of the mind to difficult or abstract sub- jects, anxieties respecting schemes, specula- tions, or objects of ambition ; disappointments, sorrow, fright, or sudden alarm; the depress- ing passions, severe losses of fortune or friends, indulgence of sombre or sad feelings; devotion to music and the fine arts, reading medical books, &c, and whatever favours congestion * [We are acquainted with several clergymen labouring under the most aggravated form of this disease, brought on by high living, close application, and want of bodily exer- cise. They have tried every form of quackery, including hydropathy and homoeopathy, under a mistaken impression that their complaint is under the control of drugs. Few, if any of them, have ever been induced to pursue a systematic course of exercise, with early rising, cold sponging, and a regulated diet; means which would undoubtedly suffice, in nine cases out of ten, to remove every vestige of the mal- ady.] 306 HYPOCHONDRIA of the brain, as indulgences in bed, the use of narcotics, particularly opium, &c., may occa- sion this complaint. 22. b. The causes which act primarily upon the organic nervous system and functions of the organic viscera are very diversified. What- ever impairs the energy of the system, as the too frequent or too liberal use of calomel as a purgative, or of other mercurials ; poor or in- nutritious diet, or the excessive use of tea and slops; a humid, close, impure, or miasmatous air, &c, may produce hypochondriasis. Mer- curial purgatives, although often serviceable by promoting the discharge of bile, and giving relief for a time, yet often increase the nervous depression and morbid sensibility, when fre- quently resorted to, and induce or aggravate this complaint. Of the origin of hypochondri- asis in an improper recourse to calomel, I have seen several instances. Whatever inordinate- ly excites or directly relaxes the digestive mucous surface, as acrid cathartics, often ex- hibited, &c. ; whatever occasions or perpet- uates indigestion, or impedes the functions of secretion and excretion; and whatever occa- sions plethora of the vascular system general- ly, or of the portal or cerebral vessels in partic- ular, especially overloading the digestive or- gans by too large meals, or by too rich or full living, the inordinate use of animal food, of malt liquors, wine, &c.; insufficient exercise, and inattention to the several excreting func- tions, may give rise to hypochondriasis. What- ever induces torpor or perpetuates inaction of the depurating organs, while the organs of sup- ply are stimulated to increased activity, will occasion redundancy of noxious elements, or of the ultimate products of animalization in the hlood, and will, sooner or later, especially in -connexion with vascular plethora, give rise to this complaint, or to some other, depending, equally with it, upon oppletion of the vascular system. Persons who have been accustomed to active occupation, both physical and mental, or to much exercise in the open air, upon re- tiring from business with a competency, and when hoping to enjoy the fruits of industry, are often overtaken by this complaint, particu- larly if they live fully, and in a comparative state of ease and indolence. The vascular system, which was formerly preserved in a state of fulness, in due relation to nervous power, by the healthy action of the different emunctories, now becomes overloaded, partic- ularly the portal vessels. The cerebral circu- lation also becomes oppressed, and the mental energy impaired. 23. c. Some of the causes act by weakening both the organic nervous influence and the mind. The most injurious of these are prema- ture and excessive sexual indulgences, partic- ularly masturbation. Whenever hypochondri- asis appears early in life, this should be dreaded as having been the chief cause. Many of the depressing passions, and anxiety of mind, act in a smilar manner. As the early addiction to vicious habits, as well as several others of the exciting causes, is more or less frequent in all classes of the community, it cannot be said that the effect is confined to any particular class. Indeed, hypochondriasis is often met -with in the lower orders, although not so fre- quently as in those whose minds are most .SIS.—Patmologv. highly cultivated, whose sensibilities are there- by rendered acute, and who are either preclu- ded from, or not obliged to take that exercise which is necessary to prevent general, local, or excrementitious plethora. 24. VII. Pathology.—The ancients appear to have observed this complaint chiefly among philosophers, poets, and others endowed with the most acute sensibility and the most vivid imagination, and to have either confounded it with, or viewed it as a variety of melancholy. Aristotle says that all the great men of his time were melancholic, that is, hypochondriac. Hippocrates, Aret^eus, and others attribute the complaint to an excess of black bile. Di ocles refers it to the stomach, and Galen con siders it as a variety of melancholy, haying its origin in this organ. However much the an- cients and older writers differ as to whether it should be considered as a dyspeptic or as a mental affection, they appear not to view it as connected with hysteria. Sydenham, howev- er, describes hypochondriasis and hysteria as the same affection, without taking into account the chronic inflammations, obstructions, or le- sions of structure so often associated with the former, and refers them to deficiency or irreg- ularity of the animal spirits—of the cerebro- spinal nervous influence, in the language of modern pathology. Willis considers it as a nervous complaint seated in the brain; and Zacutus Lusitanus, as an affection of the stom- ach and liver, depending upon coldness of the former and increased heat of the latter. Boer- haave thinks that it depends upon a viscid mat- ter engorging the vessels of the organs seated in the hypochondria, as the liver, the spleen, stomach, pancreas, and the mesentery. Stahl and his followers suppose it to arise from ef- forts to establish a critical haemorrhage ; Low- er, from a morbid disposition in the mass of blood ; and Hoffmann, from too great a ten- sion of the nervous system, sometimes in con- nection with inflammation of the digestive mu- cous membrane. From the time of Hoffmann until that of Cullen, various modifications and absurd combinations of the preceding opinions have been advanced. Cullen observes that this disorder occurs chiefly in persons of a mel- ancholic temperament; that it consists of an affection of the mind, conjoined with dyspep- sia, and is the result of a weak and mobile state of the nervous power. The opinions of Crich- ton and Good are deficient in precision and ac- curacy ; they have confounded with hypochon- driasis affections entirely distinct from it and from one another. Louyer-Villermay has formed more correct views of its nature and relations than most modern authors. He con- cludes that it is seated in the abdominal visce- ra, particularly in the stomach, and that these are affected in their nervous system or their vital properties, and especially in their organic sensibility. He conceives the disorder to con- sist in an alteration of the vital properties of the nerves of digestion, and an exalted state of organic sensibility, of which these nerves are the special conductors and receptacles. At the same time, he admits that the general sen- sibility and the cerebral functions become con- secutively affected. This opinion is essential- ly the same as that of Bichat ; and it has been adopted by the author, and, more recently, by M. HYPOCHONDRIASIS—Prognosis. 307 Bracket and Dr. Gully. M. Broussais con- tends that hypochondriasis is not merely a ner- vous affection, but that it is a result of chronic inflammation of the digestive mucous mem- brane, the morbid sensibility distinguishing it arising from the peculiar condition of this membrane, as respects its vascularity; and that the various ailments of which the hypo- chondriac complains proceed from sympathy with this part of the digestive canal. 25. M. Georget argues, on the contrary, that the disease is primarily seated in the brain; that it is characterized by disorder of the func- tions of this part, unaccompanied by fever, or convulsive motion, or any manifest derange- ment of reason or judgment; and he adduces the following circumstances in support of his argument: 1. That the chief exciting causes of the disease exert their influence directly on the functions of the brain. 2. That the charac- teristic symptoms are referrible to the head. 3. That other symptoms observed in the com- plaint are not constant, some belonging to one organ and others to another, while the digest- ive functions are occasionally not disordered. 4. That moral treatment is the most efficacious in the complaint. There are several fallacies in the above inferences; it by no means follows that, because certain occurrences make their first impression on the mind, the brain should be either principally or primarily affected by them. The depressing passions, however ex- cited, produce a much more remarkable effect upon the functions, and even upon the organi- sation of the heart, the stomach, the liver, &c, than upon the brain itself, unless, indeed, this last organ has previously been in a state of disease. The early symptoms, also, of hyp- ochondriasis are certainly not so referrible to the brain as to the digestive and other organs supplied by the ganglial class of nerves ; and moral treatment is not always the most suc- cessful, or that which should be alone put in practice ; it more generally constitutes only a part of a general plan. 26. Dr. Prichard observes that, when we take into consideration the mental dejection of hypochondriacs, the habitual state of their spirits, and the trains of morbid or painful sen- sations which torment them, we must admit that some deviation from the healthy state of the cerebral functions lies at the foundation of their ailments, though it is remote from organ- ic disease, and of a kind of which we can form no conception. Many of the phenomena, he allows, would lead to the opinion that the prin- cipal deviation from the natural state of func- tions is seated in the nervous system of phys- ical or organic life; but phenomena involving consciousness and affections of mind can hard- ly be confined to this part of the nervous sys- tem. Dr. Prichard, however, overlooks the fact that the brain itself is as much supplied with the organic nervous system as any other internal organ, and, consequently, that it will manifest disorder whenever this part of the nervous system is seriously affected; and that this disorder will present similar characters as to kind—as to depression, perversion, activity, or exaltation—to those displayed by other or- gans influenced by this system. The complaint, it is admitted, commences, or is first manifest- ed in the digestive viscera; and it is not until the organic nervous system evinces great de- pression throughout the abdominal organs that the functions of the brain become also mani- festly depressed or impaired, and then the de- pression observed in the energies of these func- tions is similar in kind to that remarked in the digestive, secreting, and excreting actions : these latter are performed slowly and imper- fectly ; intellectual power, attention, and appli- cation are also weakened. The sensibility of the organic nervous system is morbidly acute in all or several of the viscera; the cerebro- spinal system, and the dependant organs of sense and volition, are also morbidly suscepti- ble, and incapable of the energetic exercise of their functions. The organic actions are per- formed with obscure sensations of distress, dif- ficulty, or anxiety; the mental operations are attended by fear, distrust, and anxious bodings. The vital manifestations throughout the econo- my are languid and relaxed, and the resistance opposed by life to morbid impressions remarka- bly weakened; the faculties of the mind are equally languid, and the tone of the cerebro- spinal nervous system altogether depressed. Dr. Prichard supposes that the occasional sus- pension of the complaint, for longer or shorter intervals of time, militates against the opinion that the disease is owing to the state of the or- ganic, nervous, and digestive functions; but this part of the nervous system is as likely to experience remissions and exacerbations of disorder as the brain and its dependencies. At the commencement, the affection of the organ- ic or ganglial nervous system is confined chief- ly to the digestive and excreting organs; but at a more advanced stage it is extended to the brain, where it occasions the dejection of spir- its, the fears, and the anxieties connected with the patient's feelings and ailments, characteri- zing the fully-developed complaint. 27. My views will be partly apparent from what has been now advanced. But, although the organic nervous system is evidently prima- rily and chiefly affected in hypochondriasis, and although the brain thus becomes consecutively implicated, other morbid conditions are also su- perinduced, and are more or less concerned in the aggravation or perpetuation of the patient's feelings and sufferings. Imperfect excretion, compared with the supply of nourishment, in- duces either absolute or relative plethora, as well as a morbid condition of the circulating fluids, owing to the accumulation of noxious matters—alimentary, saline, and animal—prod- ucts of animalization which have not been eliminated from the blood. The chief vital or- gans thus become loaded and oppressed; and the nervous system and brain are rendered morbidly susceptible by the quality of the blood circulating in them. From considerable expe- rience and close observation of the circumstan- ces connected with the pathology and treat- ment of this complaint, I am firmly persuaded that these views constitute the only basis of a successful method of cure. 28. VIII. Prognosis.—It is often extremely difficult to form an opinion as to the presence of danger in this complaint. Even where the sufferings have been most distressing, the pa- tient's life has apparently not been materially shortened thereby; and where they have been much slighter, death has occurred unexpected- 308 HYPOCHONDRIASIS—Treatment. ly, and while the symptoms did not seem to in- dicate its approach. This may have been ow- ing in part to the want of discrimination on the part of the practitioner, in not detecting organ- ic lesion in the heart, brain, or other viscera. There can be no doubt that many cases of ob- scure structural change in either of these or- gans, or in any other part, were formerly con- sidered as hypochondriasis, and most injudi- ciously treated as such. Many of these would have been detected by the improved diagnosis of the present day, and thus the number of in- stances of the disease would have been dimin- ished. Yet, nevertheless, the existence of this complaint, or, in other words, of an affection of the functions and sensibility of the organic and cerebro-spinal nervous systems, sometimes associated with and heightened by structural lesions, cannot be doubted; although M. Fo- ville has contended that it should not be con- sidered as anything else than organic change in persons of acute sensibility ; that both it, hysteria, irregular gout, and disorders of the flu- ids belong to the same category; and that to one or other of these the ignorant part of the profession refer those complaints, the true seats and nature of which they are unable to detect; that, in short, they are names under which all others but the morbid anatomists conceal their ignorance. Now it may be stated, without much fear of injustice, that those who see no- thing in disease but what is demonstrable after death, and who believe in nothing pathological which is not material and palpable, will very often arrive at wrong conclusions as to the or- igin, nature, course, and treatment of the most important maladies of our species. 29. The Prognosis, however, relates more to the probable recovery of the patient than to any danger more or less immediately attending it. Of the existence of danger, the signs of organ- ic change will be the chief harbingers, and upon the detection of these, and upon the inferences formed as to the seat and nature of existing le- sion, the opinion will necessarily depend.—a. The circumstances which may be considered as unfavourable to the patient's complete recov- ery are not always very manifest or readily as- certained ; but, if the causes are not remova- ble, or chiefly of a moral kind ; if the disease is confirmed, or if the patient has had repeated attacks ; if it has supervened upon the suppres- sion of the haemorrhoidal flux, and is not re- moved by the restoration of this evacuation, or upon the disappearance of the catamenia at the usual period; if sleep is not obtained without recourse to narcotics; if the imagination is powerfully affected, and constantly influenced by moral causes, the physical indications of dis- ease being slight; if the nervous affection is associated with serious disorder, or with signs of structural change of some important viscus or with some mental delusion; and if the pa- tient indicates much suffering in his appear- ance, or the melancholic temperament, or a ca- chectic habit of body, we may expect to allevi- ate, but we can hardly hope to remove the mal- ady, although the removal of it may be accom- plished. b. A more favourable opinion may be enter- tained if the chief ascertained causes are remo- vable ; if the disease is recent, or only in the first or second stage ; if the patient is of a san- guine temperament; if the circumstances or profession of the patient admit of exercise, or salutary employment of mind or body, and of travelling, or repeated change of air during the treatment; if he enjoys his nightly repose, and possesses his usual or natural looks; if the test of Baglivi—" In chronicis morbis si fades nat- uralis sit, ac boni coloris, nunquam credo ades- se obstructiones, aliaque vitia in visceribua"— is applicable, and if the unfavourable circum- stances enumerated above are not present. Hypochondriasis has been removed by the su- pervention of other diseases, as diarrhoea, dys- entery, fever, jaundice, dropsy, &c. 30. IX. Treatment.—Hypochondriasis would be more frequently cured if stricter attention were paid to the removal of the circumstances in which it originated, and to the combination of physical and moral treatment appropriately to the pathological states just considered. But the disease is generally advanced or confirmed before proper medical advice is resorted to ; the patient has been for some time exciting his imagination and aggravating his morbid sensa- tions by reading medical works, which might mystify, but could not instruct him as to his ail- ments, and dabbling in physic, which might con- firm, but could rarely relieve his complaints; he fails in his own efforts, and then, if he have recourse to a duly qualified adviser, he expects, and is impatient if he does not derive immedi- ate benefit. Many hypochondriacs also adopt neither the restricted diet nor the regimen pre- scribed for them ; and thus the treatment fails more from the fault of the patient than from the means employed. 31. i. The first indication, in the treatment of hypochondriasis, is to remove the remote causes, the habits, circumstances, and moral influences to which the patient has been or is subjected. The diet should be restricted, and regulated with ref- erence to the patient's habits, occupations, and daily amount of exercise ; and he ought to be engaged, as much as possible, with objects cal- culated to interest, but not to fatigue the mind. With the affluent this is a matter of difficulty, and is often only to be accomplished by travel- ling. In the good old monkish days, pilgrim- ages to the shrines of saints were recommend- ed for the benefit both of soul and body; but in modern times, since these have become di- vided cures, saintly interference has been but little confided in, and the purifying operation of mineral springs has alone been considered efficacious. And certainly the good effects re- sulting from faith in either, or in both these agents, have neither been few nor equivocal. The shrewd practitioner who plants himself by the side of a saline or chalybeate mineral spring, or any other spring possessing deobs-truent and tonic properties, and situated in a dry and sa- lubrious air, if he succeed in attracting hypo- chondriacs to his Hygeian temple by the usual direct or indirect means, will generally relieve many of the more faithful of his worshippers. The lawyer, the merchant, the stock-broker, and others who have weakened their digestive or- gans, exhausted their nervous systems, and over-excited or tortured their brains by appli- cation to business, by the vicissitudes of affairs, and the anxieties which are consequent there- on, when induced to visit a watering-place, will frequently derive benefit from the moral HYPOCHONDRIA and physical changes thereby occasioned. In- stead of over-exciting or distracting the mind with business, of overloading, and, perhaps, over-stimulating the digestive organs, of allow- ing the liver and bowels to become torpid, of neglecting due exercise in the open air, and of respiring the impure atmosphere of a crowded city or manufacturing town, the hypochondriac is properly directed to relinquish the anxieties of affairs, to conform to a limited diet, to keep his bowels very freely open, to walk and ride a certain number of miles daily at prescribed times, and to drink the waters, whether aperi- ent, deobstruent, or chalybeate. The result cannot be doubtful in many cases. The entire removal of the causes of disorder, the exercise, the change to a purer air—the thorough alter- ation of habits, of circumstances, and of atmo- sphere—all combine to produce benefit; and the physician, as well as the spring, obtains a credit, to which the amount of merit really pos- sessed by either by no means entitles them, and which is often heightened by the circumstance of advice previously given to the patient— while he is immersed in business and distract- ed by anxieties, when precluded from exercise and amusement, and when constantly subject- ed to the combined operation of the causes of the malady — having failed in accomplishing what was probably most judiciously attempted, but which he was counteracting in the most efficient manner in his power. 32. The best means of fulfilling this indica- tion is by travelling, and by due attention to the diet, and to the excreting functions. Continued residence at a single watering-place is not near- ly so beneficial as travelling, unless much ex- ercise be daily taken. Travelling, aided by mineral waters suited to the peculiarities of the case, has the best effect; and, next to this plan, judicious medical treatment, pursued at the same time with change of air and scene. The very incidents connected with travelling, as Dr. Prichard remarks, abstract the patient's at- tention from his feelings and sufferings; and even the temporary disorders that may occur, as rheumatism, cold, and diarrhoea, produce this effect in a still more remarkable manner. When mineral waters are resorted to, either alone or in connexion with travelling, those which are aperient and deobstruent should be first used, as the waters of Seidschutz, or Pull- na, or Cheltenham, or Harrowgate [or the Con- gress at Saratoga], &c. ; and subsequently those of Bath, Carlsbad, or Marienbad, Pyrmont, or Tunbridge, &c. The springs of Schwalbach and Pyrmont were much extolled by Hoffmann ; those of Eger and Marienbad, by Heister and Hufeland ; and the waters of Pyrmont and Selt- zer, by Marcard. The baths of Wiesbaden have also been praised by Ritter and others. Du- ring a course of chalybeate waters [as the Pa- vilion, High Rock, or Iodine at Saratoga], the bowels ought to be kept moderately open, ei- ther by aperient medicines, or by the more ape- rient or purgative waters. Exercise of all kinds is more or less beneficial; but that on horseback, or on foot, or both, is perhaps pref- erable. The former was much praised by Syd- enham and Fuller ; but, whatever kind of ex- ercise be adopted, it is necessary to regulate the bowels, to promote the functions of the emunctories, to remove the patient from the .SIS—Treatment. 309 pursuits, anxieties, and circumstances which induced the complaint, or to change his habits, and to amuse and interest his mind. 33. ii. The second indication is to evacuate mor- bid secretions and accumulated excretions, to cor- rect the morbid states of the digestive canal, and of the organs immediately connected with it, and to relieve the more distressing feelings of the patient. It is indispensable to the obtaining of the con- fidence of the patient, and, consequently, to the successful management of his case, that his va- rious ailments should be attentively heard and patiently investigated; that they should be al- together viewed as real, and that the treatment should be prescribed for him with clearness and with decision. However much the practitioner may doubt as to the origin or nature of the complaint, and however much he may despair of the efficacy of the means prescribed, he should conceal his doubts, treat the sufferings and feelings of the patient with sympathy, and arrange and combine the means of cure into a method at once consistent and appropriate, which is to be faithfully pursued in all its parts. Confidence will be thus inspired, without which he will neither derive benefit nor continue un- der treatment. 34. a. The propriety of having recourse to mild or stomachic purgatives, when the bowels are sluggish or torpid, or the stools offensive", cannot be questioned. Yet, in some cases, the gastro-intestinal mucous surface may be in such a state of irritation or of chronic inflammation as to require these to be prescribed with cau- tion and selected with judgment. When this state of the digestive mucous surface is present, leeches should be applied to the abdomen, or to the anus; refrigerants shorM also be given with mucilaginous or emollient medicines (F. 355, 431, 436, 821, 837, 865), and the functions of the skin promoted by the warm or vapour bath. If the patient be plethoric, a moderate venasection or cupping on the nape of the neck, or a repe- tition of leeches to the epigastrium or anus, will be of service. Although irritating purgatives are hurtful in this description of cases, yet those of a mild or of a cooling kind ought not to be withheld; and their operation may be promoted by enemata. The tartrate or sul- phate of potash, the carbonate of soda or mag- nesia with rhubarb, either in powder or infu- sion ; or the phosphate of soda, or the tartrate of potash and soda, may be given with other substances (F. 440, 441, 868), according to the peculiarities of the case. The diet should be restricted chiefly to mucilaginous or farina- ceous articles, and the beverages consist of simple saline or cooling fluids. 35. In other cases, particularly where the di- gestive mucous surface is deficient in tone, and when the states of the epigastrium, of the pulse, and of the tongue do not indicate inflammatory irritation, purgatives or aperients of a warmer or more stomachic kind than the above may be prescribed. The infusion of senna, or that of rhubarb, may be given with the infusion of gen- tian or of columba, or of cinchona, or of casca- rilla, and an aromatic or carminative tincture and a neutral salt; or the aperients directed above (§ 34) may be taken in mint-water. In many cases the compound galbanum pill, or as- afbztida, may be conjoined with the purified ex- tract of aloes, or with rhubarb, and the inspissa- 310 HYPOCHONDRIASIS—Treatment. ted ox-gall (see F. 547, 548, 558-563, 572-576), either at night, or daily with dinner. I have found the following excellent in hypochondria- sis with a torpid state of the large bowels : No. 259. K Pulv. Rhei 3ss.; Pulv. Ipecacuanha, Pulv. Capsici, 55 gr. vj.; Extr. Aloes purif. 3j.; Extr. Fellis Tauri 3ss. ; Saponis duri, gr. xij.; Olei Carui, q. s. Con- tunde bene, et divide in Pilulas xxx., quarum capiat unam vel duas quotidie cum prandio. No. 260. K Extr. Fellis Tauri, Massae Pilul. Galb. Comp., 55 Jss.; Extr. Aloes purif. 3j. ; Saponis duri, gr. x.; Pulv. Ipecacuanha, gr. viij. M. FiantPiluHe xxx., Capiat unam vel duas, ut supra. 36. The use of laxatives in hypochondriasis was much insisted on by Renouart and Legier, and various substances belonging to this class were recommended ; but they require no very particular remark at this place. Magnesia, es- pecially the calcined, is well deserving of adop- tion when the complaint is attended by a co- pious deposite of salts in the urine, or by a gouty diathesis. It also relieves the flatulence and distention of the epigastrium and hypo- chondria more certainly than any other aperi- ent. When there is no gastro-intestinal irrita- tion, or if this be slight only, it may be given in mint-water, or in any tonic, stomachic, or aro- matic vehicle. Precipitated sulphur was much praised by Bisset, and is certainly an appropri- ate laxative, particularly as the use of it for some time increases all the excretions, and es- pecially those from the skin, bowels, and liver. 37. b. Many of the distressing feelings of the patient are referrible to irritation in some part of the digestive mucous membrane. This ir- ritation may exist in the rectum in connexion with haemorrhoids, or in the cacum, or in any other part of the canal; but these two are among its most common seats. In such cases it is propagated by the communicating ramifi- cations of the ganglial nerves to the roots of the spinal nerves, or to the spinal chorai, and sensibly expressed in some remote part by re- flex sympathy, as stated in my notes to Riche- rand's Elements of Physiology (p. 34, London, ] 824, 2d ed., 1829). The hamorrhoidal discharge has been considered favourable in hypochondri- asis by Alberti, Grant, and others; but, as already stated (§ 6), it indicates either general or local plethora, when it has not been induced by costiveness or by acrid purgatives, and points to restricted diet. When the haemor- rhoids are not attended by any discharge, they furnish the same indications, and show that, in addition to low diet, general or local blood-let- ting should be prescribed. Without these, the removal of the haemorrhoidal affection may not be entirely devoid of risk to the hypochondriac, especially if regular exercise in the open air be not taken. 38. c. Simple lavements or enemata have been too generally neglected in the treatment of this complaint. The researches of Pinel, Annes- ley, and of the author, show that the large bowels are not only disordered in their func- tions, but also often altered in structure, or even displaced in the more severe and chronic cases. The depressed state of organic nervous energy, occasioning hypochondriasis, permits faecal and flatulent accumulations to form in the cacum, colon, and rectum (see these articles), causing inordinate distentions of portions of the canal with spasmodic constriction of ad- joining parts. Owing to the faecal collections, to the efforts of one part of the bowel to propel its contents through a torpid or an obstructed portion, and to the frequent recurrence of these states, displacement of portions of the colon, and even partially of the caecum, are not rare. Inordinate dilatation of the latter viscus is also sometimes observed. But I have remark- ed, in several cases of hypochondriasis compli- cated with haemorrhoids, or with spasmodic stricture of the sphincter ani, or with- fissure or some other source of irritation in the anus, a remarkable dilatation of the rectum within the sphincter. In these instances the dilatation amounted to a sacculated state. This had ev- idently proceeded from inordinate accumula- tion of faeces, owing to the obstacle to their discharge, caused by internal haemorrhoids or by spasm of the sphincter. One of these had been treated for stricture of the rectum, and a bougie frequently passed ; but it seldom found its way into the portion of the bowel above the dilatation. The intestine was injured by this officious interference ; peritonitis supervened; and near the fatal termination of the case I was consulted. Inspection after death furnish- ed a striking example of this dilated state of the rectum, as well as of the effects of a spe- cies of interference generally quite unnecessa- ry, although so frequently practised at the pres- ent day by a few surgeons, as to render it dis- gusting, particularly as it is warranted neither by the history and nature of the case nor by sound therapeutical views. 39. In the early stages of hypochondriasis, especially, and as a means of preventing cos- tiveness and the above, as well as other conse- quences of this state, enemata of various kinds, according to the peculiarities of the case, ought to be frequently employed. Simple water, te- pid or cold, emollient, oleaginous, or sapona- ceous fluids, and various saline solutions, will be thus administered with benefit, and will not only promote the action of the aperients just mentioned, but, when daily used, will establish a regular state of faecal excretion. (See the Formula for Enemata in the Appendix.) 40. d. Whenever the complaint is connected with vascular plethora, or is consequent upon the suppression or disappearance of some ac- customed evacuation, and when it has been fully developed, an oppressed or congested state of brain may exist. But whatever may be the state of circulation in the capillaries or sinuses of this organ, there can be no doubt of the pro- priety of a moderate depletion, by cupping on the nape of the neck, in these cases. I have pre- scribed it in several instances with marked ben- efit, and in one gentleman I carried the deple- tion to thirty ounces at a single operation with the greatest advantage. Many of the patient's distressing feelings depend upon the superin- duced disorder of the circulation in the brain, particularly those which are referred to the head, and to the organs of sense and volition. In some cases, however, of this description, blood should be abstracted with caution, and it will sometimes be necessary to promote ner- vous energy and tone, even while we have re- course to depletions and evacuations. When- ever the hypochondriac has increased heat of scalp with a firm pulse, these latter may be safely prescribed in moderation, and may be aided by cold-sponging the head night and morn- ing, or by daily recourse to the cold douche or HYPOCHONDRIASIS—Treatment. 311 shower-bath. The extremities, especially the feet, of this class of patients are generally cold ; this circumstance should receive due attention. When the sufferings are referrible to the brain it will be useless, and indeed sometimes inju- rious, to attempt to alleviate or suppress them by powerful narcotics. Even when these give temporary relief, more permanent mischief is often occasioned. The means already noticed, both regimenal and medicinal, will be much more efficacious ; and, if these fail, when push- ed sufficiently far, organic lesions probably ex- ist, for which setons, issues, &o, may be tried, although with but slight prospect of advantage. 41. e. If the complaint is associated with pal- pitations or irregular action of the heart, or with a dry, nervous cough, much benefit will result from camphor, conjoined with narcotics, and sometimes, also, with refrigerants and demul- cents. A weak decoction of Senega, with or- ange flower water, or with any other aromat- ic and demulcent fluid, and with small doses of prussic acid, or of some other anodyne, will often, also, be of service. If the liver be con- gested or otherwise disordered, the treatment should be modified accordingly. The majority of cases of this kind, particularly if the patient have lived fully or taken little exercise, will bear depletion, especially cupping on the right hypochondrium, or below the right shoulder, or the application of leeches to the anus. A dose of calomel, or of Plummer's pill, or of blue pill, may also be prescribed; but it should either be conjoined with an aromatic, or some purgative, or be followed, in a few hours, by a stomachic aperient. Hypochondriacs are generally very susceptible of the specific action of mercurials, and their mental depression and nervous sen- sibility are much increased by them ; yet, with due caution, and if not often resorted to, they are beneficial when the functions of the liver are impaired. The super-tartrate of potash, the preparation of taraxacum, and the carbonates of the alkalies, with stomachic purgatives, are also of great service in a torpid state of this organ. When, in connexion with this, or with a morbid state of the biliary and other abdom- inal secretions, the hypochondriac complains much of colicky pains, with costiveness, flatu- lence, distention, &e., these, and the mild pur- gatives already mentioned, calcined magnesia, with antispasmodics or carminatives, or with small doses of ipecacuanha and hyoscyamus, should be steadily employed for some time, and be aided by emollient diluents, by demulcents, and by saponaceous or oleaginous enemata. Cas- tile soap may also be conjoined with the other substances, given in the form of pill. 42. iii. The third intention is to restore the en- ergy and healthy functions of the organic, nervous, and cerebral organs.—Tonics have been too com- monly prescribed prematurely in hypochondri- asis, or when the digestive mucous surface, or the brain, or the liver, has not been in a state to derive benefit from them. They are even prejudicial in most of the circumstances which have now been considered, unless in combina- tion with purgatives, especially when these parts are in a state of irritation or congestion, and, until this be removed, they may even ag- gravate the complaint. But when the excre- tions have been duly promoted, appropriate evacuations procured, and visceral congestion removed, a judicious recourse to them is often of great service. During a course of tonics, the bowels should be kept regularly open, and local irritation or determination of blood pre- vented or removed, should either appear. The chalybeate mineral springs, already mentioned (n, although it sometimes appears a few we^ks after delivery. Its frequent connexion vith irritation of the spinal cord, with function- al disorder of the heart, &c., has been already alluded to ; and it is often associated with hyp- ochondriasis. It is often, also, consequent upon derangements of the digestive organs, especial- ly those in which the gastro-intestinal mucous surface is in a state of irritation. It is not in- frequently connected with disorder of the uri- nary organs, the urinary secretion and excre- tion being affected in various ways besides that which more usually characterizes the hysteric seizure. When hysteria appears in the course of other maladies, it is generally owing to the temperament and constitution of the patient, and to debility or exhaustion of nervous pow- er, from disease or from treatment. Hence its occurrence after excessive or inappropriate de- pletions, after haemorrhages, after parturition, and after fevers. 42. When hysteria is complicated with these or other diseases, or when these affect hyster- ical females, a prolongation of disease, or far- ther complications, and a protraction of con- valescence, are frequently produced. Dr. Con- olly justly remarks that, in the course of a long hysterical disorder, and yet more readily in the course of fever in an hysterical patient, inflammatory action may take place at the ori- gin of previously irritated nerves, or in the brain, or other organs ; tenderness of the spine may become excessive; and disordered sensa- tion and impaired power of motion may indi- cate the existence of something more than mere irritation. These symptoms may disappear as the patient gains strength ; but they sometimes become more intense and constant, and assume a more serious form than the shifting, evanes- cent, or local tenderness and pain, affecting va- rious parts as described above (y 14). 43. VI. Duration and Terminations.—a. The duration of the paroxysm of hysteria varies from a few minutes to many hours; but the continuance of the complaint is very uncertain. Hysteria may not again recur after a single seizure, especially if it have been induced by the more powerful causes; but this is seldom the case, for when it has once appeared, there is a predisposition to its return, in one or other of its various forms, upon the recurrence of any of the predisposing or exciting causes. Much, however, will depend upon the general health and circumstances of the patient. It may thus reappear after intervals of various duration ; or it may hardly ever be completely absent, in some one or other of its numerous modes, during the greater part of the period between puberty, or the age of twenty, and the complete cessation of the catamenia. It sel- dom occurs, even in those subject to it, after this latter epoch ; yet I have seen instances of it, induced by mental emotion, at a much later period of life. A very large proportion of the ailments of females during the period of ute- rine activity, however diversified their charac- ters may be, are really hysterical. Hence many females enjoy much better health after this change has been quite completed than they did previously, although about the period of change their complaints are often aggravated. 44. b. The terminations of hysteria are, 1st. In a more or less complete restoration of health. 2d. In some other complaint, into which it may altogether merge and disappear, or with which it may become associated. It rarely or never terminates in death, unless from neglect or im- proper treatment.—(a) Restoration of health de- pends very much upon the attention paid during treatment to the removal of the causes, to the state of the general health, to the uterine func- tions, and to associated disorder.—(b) Hysteria may pass into epilepsy, or assume various con- vulsive forms. It may terminate in mania, and more rarely in confirmed insanity, or in mental imbecility. Females who have been subject to hysteria in the unmarried state, especially if it have assumed the fully developed or convul- sive form, are more disposed than others to puerperal convulsions and to puerperal mania; although marriage sometimes entirely removes or ameliorates the complaint. It may also ter- minate in inflammation of the membranes of the brain, or of the spinal cord; but this does not occur so frequently as some suppose. It occasionally gives rise to inflammation of the 324 HYSTERIA—Diagnosis. uterus, or of the ovaria ; but in these cases the irritation or congestion of these parts, and dis- order of the uterine functions, upon which the hysteria depended or was associated, are only more fully developed, or converted into the in- flammatory state by it. Although it often de- ranges the functions of the heart and lungs, it seldom occasions serious diseases of these or- gans ; but it often aggravates pre-existent dis- order of them, as well as of the several digest- ive viscera. 45. VII. Diagn&sis.—It is generally easy to distinguish the more fully developed states of hysteria from other affections ; yet this is occa- sionly very difficult; and it is particularly so to distinguish several of the more irregular forms of the complaint from those diseases which they so closely simulate. Of the diagnosis of these forms I have made sufficient mention in my descriptions of them.—a. Fully formed hys- teria may be mistaken for epilepsy, and the mis- take is the more likely to occur, as the former may pass into the latter, particularly when af- fecting plethoric persons, or when neglected ; but it then usually assumes the uterine form of epilepsy. Pinel, Villermay, and Conolly have properly insisted on the importance of forming a correct diagnosis between these two maladies, and especially of not imputing epi- lepsy to a female who is merely hysterical. " It is important to humanity, and to the peace and happiness of families," adds M. Villermay " that these complaints should be correctly dis- tinguished." Epilepsy is an hereditary crwjease, is incurable in the majority of instances, «nd generally weakens the intellects and the under. standing—circumstances which cannot be im- puted to hysteria. Sydenham, Tissot, and Villermay advise that not only should the symptoms and mode of attack in both be inqui- red into, but also the causes which occasioned the seizure ; yet too much reliance should not be placed upon these in the formation of a di- agnosis. The most frequent causes of hysteria are, the emotions of love and jealousy, volun- tary or compelled continence, longings after ardently-desired objects, or unsated desire, dis- orders of menstruation, &c. (y 54); those of epilepsy, on the other hand, are hereditary pre- disposition, fright, terror, &c. (see art. Epilep- sy, v 19-24). 46. In epilepsy, the seizure is sudden or in- stantaneous ; the patient often utters a loud cry, falls violently to the ground, froths at the mouth, protrudes the tongue, which is general- ly injured by the teeth, and is altogether un- conscious. The eyes are distorted, the mus- cles of the face violently convulsed, and the pupils are insensible to light. There are gen- erally no precursory symptoms, and there is no sensation of globus hystericus. The epileptic attack terminates in sopor, or a heavy sleep, from which the patient awakens exhausted, complaining of headache and depression. In hysteria, on the other hand, the seizure is more gradual; is generally preceded or attended by the globus; neither frothing at the mouth, nor protrusion of the tongue, nor distortions oif the face and eyes characterizing it. The hysteric patient retains her consciousness, or remem- bers what has passed during the paroxysm; and although she laughs and weeps alternately, the muscles of the face are not otherwise con- vulsed. At the termination of the fit there w often a tendency to sleep, or, rather, a desire to remain quiet; but there is no sopor or heavy sleep, unless in the comparatively rare form of hysterical coma. There are always borboryg- mi, pain in the left side, and a copious flow of urine. M. Georget attaches most importance to the absence of the precursory symptoms ob- served in hysteria, the complete loss of con- sciousness, and the distortion of the mouth, protrusion of the tongue, and state of the eyes, in determining the existence of epilepsy. When hysteria is about to pa3S into epilepsy, distor- tion of the eyes and of the muscles of the face is the surest indication of the transition; and when to this, frothing at the mouth, injury of the tongue, and complete loss of consciousness are added, the epileptic character is fully de- veloped. Numerous other circumstances con- nected with the history of the case, and the occurrence of the attack, already stated in the description of both diseases, will assist the di- agnosis. When a convulsive paroxysm occurs in males, there can be rarely any doubt as to its nature; but when it appears in females, an attentive inquiry into its peculiarities, and into the state of the uterine functions, is especially requisite ; for, although it may be hysterical, it may pass into the epileptic form, or it may pre- sent a mixed character, but attention to the pathognomonic symptoms just stated will read- ily determine the nature of the seizure. 47. b. Although hypochondriasis and hysteria are distinct diseases, yet they frequently ap- proximate each other, or are even associated in females; indeed, most hysterical females may be said to be hypochondriacal, especially if hysteria, has become habitual or confirmed. Dr. Cullen remarks that the two diseases have some symptoms in common, but they are, for the most pan, considerably different. Spas- modic disoHer is rare in the one, but frequent unto a great 6«gree in the other. Persons lia- ble to hysteria *re sotnetimes affected at the same time with dyspepsia-, they are often, how- ever, entirely free from h; but this never happens to those subject to hypochondriasis. These complaints occur mostly hv different tem- peraments, ages, and sexes.; a circumstance requiring no illustration. The association of them in the female, and perhaps in rare instan- ces in the male, as in the cases above abided to (y 40), is of too much importance to be over- looked. Considering how much the several parts of the body are connected, and how much the several functions depend upon each other, we cannot wonder that their morbid affections should often be mixed, or insensibly pass the one into the other; the effect of this is, indeed, that there are no universal distinctions, and that in a few cases only are there exact limits between analogous or similar diseases. Accu- rate observation and precise description do much in extricating us from this confusion; but in some cases, still, we must remain in doubt and in difficulty. Yet even in these it will mat- ter but little as to what name we may use, so long as we recognise and estimate with accu- racy the nature, extent, and relations of the morbid condition.* * M. Brachet, in distinguishing between hysteria and hypochondriasis, says that the former is a spasmodic affec- tion of the cerebral nervous system, to which he has given the HYSTERIA tDr. Ashwell has very judiciously directed the attention of the practitioner to the hysteric diathesis, as a knowledge of its existence serves as a most important guide in the treatment of female complaints. " It is difficult," says Dr. A., " exactly to describe the nature of a perva- ding hysteria, and yet there are few observant practitioners who do not ascertain and appre- ciate its existence. Its diagnosis may not ad- mit of easy explanation, but ar conviction of its presence rests on the mind. In such instan- ces, pain, which would lead an ignorant physi- cian to bleed and give mercury, suggests to one better informed the propriety of abstaining from both : if asked the grounds of his opinion, he will refer to a certain something pervading the whole series of symptoms very different from severe inflammation. The pain may be acute, the pulse quick, the skin hot, and the entire system highly excited, still it is evident that there is something associated with all these indications of a transient and functional kind; an affection, indeed, of the nervous system, ir- ritability, and not inflammation. If he acts upon this conviction, and does not bleed and purge, but soothes and supports by narcotics and bland nourishment, the truth of his opinion becomes apparent, and the result proves that hysteria is very rarely either an active or dan- gerous malady." (Goddard's Am. Ed. of Ash- well on "Diseases peculiar to Women," Phil., 1845.) But, although hysteria possesses such a truly proteiform character, simulating almost every disease to which the female constitution is ever exposed, we are not to forget to be constantly on our guard, lest we mistake diseases depend- ant on congestion, or on changes more deci- dedly organic, for hysteric or functional mala- dies only. We have known cases to be regard- ed and treated as hysterical which proved to be of the latter kind, requiring, of course, a di- rectly opposite mode of treatment. Dr. Con- olly has truly observed that any function may, in the hysterical constitution, be readily disordered, as the respiration, the circulation, the digestion of food; any part may be affected with pain, and the usual symptoms of confirm- ed disease, and, at length, the parts thus affect- ed may really become the seat of inflammation or other disorder, and undergo a change of structure. This fact, so often noticed by every clinical observer, should teach every practition- er caution, and lead him to investigate this class of diseases with more than usual care and minuteness. It will be useful, in studying the diagnosis of hysteria, to bear in mind the following table of the parts, obviously under the dominion of the true spinal marrow, as given by Marshall Hall as affected in this multiform disease: name of cerebral neurospasm (neurospasmie cerebrate), and that the latter is a disorder, a vitiation, an aberration of the two nervous systems, which he denominates a cerebro-gan- Clial neurotaxy (neurotoxic ctrebro-ganglionaire). Thence e infers that there can be no identity as to seat or affec- tion between these two diseases ; for the one is a spasmodic affection of the cerebral system only, and the other is an ataxy of the two nervous system*. He, moreover, states that there is no farther analogy between them than the partici- pation of the cerebral nervous system in the two maladies ; but that, in hypochondriasis, the ganglial system is equally compromised. Hence, 1st. They are not identical affec- tion* ; 2d. They differ in their seat and nature ; the phe- nomena in the one being spasmodic ; in the other, vitiation t function. .—Causes. 325 1. The larynx: imitation of croup; apparent- ly imminent suffocation. 2. The pharynx : dysphagia. 3. The respiratory organs: dyspnoea, cough, hiccough, retching, vomiting, &c. 4. The cervix vesica : dysuria, retention. 5. The muscular: trismus, tetanus, contract- ed hand, distorted foot, &c. The rest relates to emotion, which is the "magna pars of hys- teria."] 48. VIII. Causes.—i. Predisposing.—Hyste- ria may be said to be almost peculiar to the fe- male sex; for the instances of its appearance in the male are so rare, and so problematical, as respects its fully developed and conclusive states, as hardly to be taken into account.—a. The age at which females are most liable to it is from fifteen to fifty; and especially from twenty to thirty, and again from forty-two to forty-eight. It sometimes does not occur until the latter epoch ; but it rarely recurs at a later period of life. Hysteria is very seldom observ- ed before puberty; but considering that men- struation commences in some cases, particular- ly in young ladies in boarding-schools, as early as the tenth and eleventh years, the appearance of this complaint, in some one or other of its forms equally early, cannot be a matter of sur- prise. Temperament and diathesis evidently pre- dispose to hysteria; nervous, sanguineo-ner- vous, and irritable temperaments, and persons of a lax, weak, or delicate, impressible, and soft habit of body are most subject to it. As this state of constitution is derived from the parents, the opinion of Hoffmann, Frank, and others, as to its occasional dependance on hereditary pre- disposition, cannot be disputed. The children of debilitated, exhausted, or aged parents, and those who are of an impaired constitution, ei- ther originally or from early management and education, are most likely to be subject to this disorder. A plethoric habit of body, joined to relaxation or deficient tone, predisposes to the more developed or convulsive states; and a thin or spare habit, associated with delicacy of con- formation and susceptibility of the nervous sys- tem, to the more irregular forms. 49. b. There is perhaps no other malady which depends so much as this upon the man- agement of childhood, and on the moral and physical education of early life. A luxurious and delicate mode of living and of rearing; a neglect of whatever promotes the powers of the constitution, especially of suitable exercise in the open air, and of early hours as to sleep- ing and rising; an over-refined mode of educa- tion, and the excitement of the imagination and of the emotions, to the neglect of the in- tellectual powers and moral sentiments; too great devotion to music, and the perusal of ex- citing novels ; the various means by which the feelings are awakened and acute sensibility is promoted, while every manifestation of either is carefully concealed ; and studied endeavours to dissemble desires which struggle to be ex- pressed, all serve, especially at a period when the powers of mind and the conformation of the body are approaching development, to pro- duce that state of the nervous system of which hysteria is one of the most frequent indications. About the period of puberty in females, various circumstances connected with their education tend to weaken their constitution, to excite A—Causes. 326 HYSTERI their emotions and desires, and to cultivate their imaginative and more artificial faculties at the expense of their reasoning and moral powers. Whenever numbers associate previ- ous to, or about the period of puberty, and es- pecially where several use the same sleeping apartment, and are submitted to a luxurious and over-refined mode of education, some will manifest a precocious development of both mind and body ; but in proportion to precocity will tone and energy be deficient, and suscepti- bility and sensibility increased. In these cir- cumstances, also, organic sensibility, particu- larly as relates to the uterine system, often as- sumes a predominance powerfully predisposing to hysterical affections. There can be no ques- tion, although the subject has been but rarely approached by British medical writers, that in- dulgence in solitary vices and sexual excite- ments is not an infrequent cause of this, as well as of other disorders. Numerous writers have insisted upon the propriety of giving due consideration to this source of mischief, as well as to the ennui and chagrin attending celibacy and continence. I agree with Dr. Conolly in believing that English practitioners pay, per- haps, too little attention to these and other re- lated circumstances; and that, in a country where the passions and emotions are so care- fully suppressed or concealed, they sometimes seem to forget their silent operation on the frame, and charge the medical writers of other countries with being somewhat fanciful and ex- travagant. 50. c. Besides the above, there are various circumstances connected with the social state that tend to develop these conditions of the uterine organs and nervous system, in which hysterical disorder originates. M. Georget remarks that the progressive steps of life, as youth passes away, are sources of painful mor- al affections, especially to the frivolous, the vain, and the unmarried of the sex. These affections increase the susceptibility of the ner- vous system, and, with numerous other circum- stances yet to be mentioned, dispose to the nervous disorders of the more advanced epochs of life. There can be no doubt that pampered modes of living; an early or habitual indul- gence of temper, or of the emotions and de- sires ; the use of wines and liquors, even with- in what may appear the bounds of moderation ; late hours, and late rising; insufficient modes of exercise, or the want of it, and of pure air ; neglect of the requisite exposure to light and sunshine ; and sedentary occupations, particu- larly in over-heated and crowded apartments or factories, more or less predispose the fe- male constitution to this affection. Some wri- ters believe that the use of tea and coffee has a similar effect; it is possible that the former, especially green tea, taken too frequently or in excess, will weaken the nervous system, and that the latter will sometimes excite the uter- ine organs. The influence of climate is not very manifest; temperate and changeable re- gions certainly furnish more numerous instan- ces of nervous disorder in females than very warm or very cold countries; but as much is probably owing to the state of manners and so- ciety in the former as to climate. Even dress has some effect in the production of hysteria; inordinate compression of the waist by stays not only weakens and displaces the digestive or- gans, but favours local determinations and con- gestions, and deranges the uterine functions. - 51. d. Previous disorder more frequently pre- disposes to hysteria than other circumstances, for many of those already noticed induce other complaints before hysteria, in any of its forms, is manifested ; and these complaints constitute merely that state of predisposition which only requires the occasion or exciting cause of its appearance. The various disorders of Men- struation (see that article), determination of blood to or congestion, or irritation of any of the uterine organs may exist, and yet no hys- terical affection take place. The nervous sys- tem also, both ganglial and cerebro-spinal, may be susceptible and morbidly sensible, and yet none of the phenomena constituting hysteria may appear. These, as well as some other morbid states, frequently constitute only the predisposition, which, however, will readily burst into open disease when one or more of the exciting causes come into operation. What- ever exhausts organic nervous power will in- crease susceptibility and irritability, and thus constitute that mobility of the system, and dis- position to local determinations and conges- tions, justly insisted upon by Dr. Cullen as being connected with the pathology of the com- plaint. The susceptibility arising from ex- haustion by acute disease favours the appear- ance of hysteria, especially during early con- valescence. The approach and presence of the catamenia have also some influence, both as a predisposing and an exciting cause. 52. Gastro-intestinal disorder, or irritation, has been justly viewed by numerous writers as a predisposing cause of hysteria, and particularly insisted upon by Broussais and his followers. Although this writer has doubtless exaggerated the influence of this morbid condition, and im- puted to it phenomena depending chiefly on de- bility and augmented organic nervous sensibili- ty, yet it is nevertheless often present, associa- ted, however, with other morbid states, as those just named, and with impaired action and flatu- lent distention of the digestive canal. In some cases, also, the gastro-intestinal disorder is al- most coeval with, and purely a complication of the hysterical affection. But it is much more frequently observed that numerous circumstan- ces tending to disorder the digestive mucous surface, especially errors in diet, as respects both food and drink, and various symptoms in- dicating impaired or disordered digestion and faecation, have preceded, for a longer or shorter period, the development of the hysterical dis- order. Still, it must be admitted that the symp- toms referred to the alimentary canal, espe- cially impaired function, flatulent distention and borborygmi, and altered sensibility, are greater indications of debility of the organic nervous system than of inflammatory irritation of the gastro-intestinal mucous membrane. Nor should it be overlooked that disorder of the uterine organs, seated not merely in the nerves, but affecting also vascular action in these organs, may exist without exciting painful sensations, and yet sympathetically disturb the digestive canal. Thus we perceive the changes produ- ced in the uterine system by impregnation dis- played chiefly in the digestive organs and ner- vous system. Even the errors of diet, and the HYSTERIA- desire for various improper or indigestible ar- ticles of food and drink, which has been attrib- uted to disorder of the alimentary canal, may be actually occasioned by changes originating in the uterine organs. These substances, however, by increasing the disorder of the digestive tube, will aggravate or perpetuate the primary af- fection of the sexual organs. There can be no doubt, that whatever weakens organic nervous power, as all disorders of the gastro-intestinal viscera necessarily do, will both dispose to and increase hysterical complaints. 53. It has been supposed by some writers that the females of gouty parents are more prone than others to hysteria. This may be partly accounted for by deficiency of constitutional energy derived from the parent, and greater susceptibility of the nervous system, as well as by the circumstances alluded to above (y 49). 54. ii. Exciting Causes.—Certain of the pre- disposing causes may of themselves occasion the complaint, when more than usually active, especially disorder of the uterine organs, or of the digestive canal. Excitement of the nerves of the uterus or ovaria, or irritation of them, particularly in connexion with any irregularity of menstruation ; inflammatory action, of an acute, sub-acute, or chronic nature, of the vagi- na, or of these organs; congestion, structural lesion, tumours, polypi, &c, of the uteras, and leucorrhcea, not infrequently occasion hysteria. Although this disorder is very often connected with excitement, or even with inflammatory irritation in the ovaria, yet it is seldom symp- tomatic of fully developed ovarian dropsy. It is not improbable that this latter malady pro- ceeds from a state of impaired tone, or is as- sociated with a condition of the organic actions in these parts, incompatible with the production of the hysterical paroxysm. Irritation of the gastro-intestinal mucous membrane, by stimu- lating or acrid ingesta, particularly such as act npon the colon and rectum, as large doses of aloes, colocynth, &c.; morbid secretions, mu- cous sordes, and faecal collections in the large bowels ; the irritation of worms, especially of ascarides, in the rectum—the Hysteria vermi- nosa of Sauvages ; the use of stimulating or acrid glysters, and haemorrhoids, sometimes excite one or other of the forms of the com- plaint. Excessive discharges and hasmorrha- ges, particularly prolonged leucorrhcea, diar- rhoea, abortions, uterine haemorrhage, and pro- tracted suckling, on the one hand; and on the other, the suppression of discharges, as of the catamenia, of the lochia, and of leucorrhcea ; long or extreme suffering from pain ; mental or bodily fatigue ; and even irritation of remote parts, as that connected with cutting the wis- dom teeth, occasionally induce a seizure. 55. Mental affections and excitements, es- pecially those which act upon the uterine sys- tem in particular, disappointments in love, un- returned and spurned affections, jealousy, an- ger, and other violent emotions ; protracted ex- pectation, longings after objects of desire, tra- gic representations, frights, the sight of objects disgusting or distressing, or disagreeable from peculiar mental diathesis, and intelligence of a distressing or of an exciting nature, suddenly communicated, are the most common occasions of hysteria, as respects both its first appear- ance and its subsequent recurrences. Several -Pathology. 327 of these emotions affect the uterine organs, the affection being afterward reflected upon the nervous system generally. Premature or phys- ically incongruous marriages ; excited, but un- satisfied desires ; celibacy, and veneris deside- rium inane, are also not infrequent causes of the complaint. Frank remarks that " Ccelibem vitam plures sine noxa ducere possunt fceminae, sed vix unan illarum invenies, quae prope mari- tum impotentem impune decumbere possit. Idem de uxoribus, a maritis neglectis, valet." There is no doubt that the sight of others in the fit will sometimes produce an hysterical seizure. I have myself witnessed this on two or three occasions, and in one of these, two females were attacked from this circumstance. This phenomenon has been imputed to imita- tion ; but it may with equal propriety be as- signed to sympathy, to fear, &c. Probably more than one of these feelings are concerned in producing it. Severe mental distresses, or extreme joy, may also occasion some one or oth- er of the forms of the complaint. Immoderate fits of laughing produced by humorous or ridic- ulous occurrences, or crying caused by vexa- tion or contrarieties, may also pass into the hysterical paroxysm.* I have no doubt of the fit being often renewed at pleasure, almost as readily as tears may be shed, by recalling or adverting to various feelings, emotions, or cir- cumstances ; and I have even seen instances which have convinced me of thefact. Electri- cal and warm states of the air, and sudden vi- cissitudes of temperature, have been supposed sufficient to produce a seizure. The influence of spirituous or vinous potations, of stimulating diuretics, and of substances which excite or irritate the urinary bladder in the production of the complaint, is much less doubtful than that of atmospheric temperature ; but the close, warm, and impure air of crowded rooms and assemblies, particularly in connexion with ex- cited feelings or contrarieties, very often occa- sions an attack, especially in those who have previously experienced it. A similar effect is, in rarer instances, produced by various odours, especially in peculiar idiosyncrasies. High- more states that the fit has been often induced by the odour of musk. 56. IX. Pathology.—The nature of hysteria may be in a great measure inferred from what has already been stated respecting its symp- toms and causes ; yet something more explicit * [The reader will not fail to call to mind, in connexion with this subject, the dancing mania described by Hecker, in his " Epidemics of the Middle Ages," an imitative hys- terical disease which extended over the whole of Germany in 1734. The preaching of the celebrated John Wesley was frequently followed by convulsive movements in his hearers, and even by cataleptic and epileptic symptoms, &c. That hysterical laughter is not always confined to females, will appear from the following ludicrous description from Wesley's Journal: "Friday, 9th, 1740.. I was a little surprised at some who were buffeted of Satan in an unusu- al manner by such a spirit of laughter as they could in no way resist, though it was pain and grief unto them. I could scarcely believe the account they gave me, had I not known the same thing ten or eleven years ago. Part of Sunday my brother and I then used to spend in walking in the meadows and singing psalms. But one day, just as we were beginning to sing, he burst out into loud laugh- ter. I asked him if he was distracted, and began to be very angry, and presently after to laugh as loud as he. Nor could we possibly refrain, though we were ready to tear ourselves in pieces, but we were forced to go home without singing another line." Perhaps this incident may throw some light on the question whether males are ever subject to hysteria.] 328 HYSTERIA—Pathologt. still must be advanced on this subject. As simple and pure hysteria is rarely or almost never fatal, and as we therefore have hardly ever an opportunity of examining the state of the principal viscera of patients who had been subject to this complaint, unless they have died of some intercurrent or associated malady, so proofs have been wanting in support of any of the doctrines proposed as to its nature, and a very wide scope allowed for vague hypothesis. The ancients and many of the moderns referred hysteria to the womb, and hence the origin of the name. The ancients, however, ascribed properties, powers, functions, and motions to the uterus which modern knowledge has shown to be erroneous ; yet I am disposed to believe that this organ, influenced as it most probably is by the nervous and vascular states of the ovaria, performs a very important part in the economy ; and that this is not confined to al- terations merely of its organic sensibility, but that it extends frequently to its contractility, and to several related organs. [It may, perhaps, subserve other purposes than the gratification of curiosity to quote some of the opinions of ancient writers on the nature of this singular affection. Paulus ^Egineta describes the disease under the term of " uterine suffocation," or the " hys- terical convulsion," and says " it is a rising up of the uterus, affecting sympathetically the most important parts, as the carotid arteries, the heart, and the membranes of the brain." As the paroxysm subsides, he represents the uterus as gradually relaxing, " and thus they recover their understanding and senses. The disease comes on periodically like epilepsy, and is occasioned by the uterus being gorged, or from semen or some other matter having be- come putrid in it." He describes the disease as attacking most frequently in winter and au- tumn, " especially young women who are prone to venery, the barren particularly, if their ste- rility be brought on by medicines, and others of a cold nature." According to Hippocrates, this complaint generally attacks antiquated virgins or young widows. " If the womb," he says, " ascend to the liver, the patient sudden- ly becomes speechless, her teeth are fixed, and her colour becomes pale." Galen explains with great particularity how the uterus is re- tracted upward and to the sides by its ligaments in this complaint; and when it does take place, he says, there is a loss of sense and motion, a small, feeble pulse, and sometimes asphyxy. Areteus represents the uterus to be, as it were, an animal within an animal, wandering up- ward, downward, and to either side, being at- tracted by fragrant things, and flying from fe- tid ; and that, when it ascends upward, it oc- casions compression of the liver, diaphragm, lungs, or heart, and sympathetically with the last, also, of the carotids, being accompanied with heaviness of the head and loss of sensi- bility. Acteus says the disease is occasioned by flatulent refrigeration; while Plato says that the womb is an animal desirous of generation : if it become unfruitful for a long time, it turns indignant, and, wandering all over the body, stops the passages of the spirits and the res- piration, and occasions the most extreme anx- iety, and all sorts of diseases. (See Adams's Com. in Paulus Mgineta, Sydenham Edition. London, 1844.)] 57. Some recent writers have ascribed hys- teria to irritation in the uterus, in the intestines, in the brain, or even in other internal viscera occurring in delicate, nervous, or susceptible persons. Dr. Conolly remarks that in all ca- ses of hysteria there is a disordered state of some part, or the whole of the nervous system, and that, although this state may he, and very frequently is induced by uterine irritation, it no less evidently arises, in other cases, from caus- es productive of irritation in other parts of the body, and also from causes acting directly upon the mind. That more or less susceptibility, original or acquired, characterizes the state of the nervous system in hysterical persons will not be disputed; yet even in such persons, the usual exciting causes, or irritations of differ- ent viscera, will not occasion true hysterical symptoms unless they previously affect the state of organic nervous influence or of circu- lation in the sexual organs. 58. Willis ascribed hysteria to disorder of the brain, and M. Georget has recently adopt- ed the same view, which has been most ably and satisfactorily overthrown by M. Foville. Still more recently, Mr. Tate has contended that hysteria arises from a morbid state of the spinal cord, connected with disorder of the womb ; but, as I have already remarked, this "morbid state" is but a vague generic term, and that, most probably, even when it is most prominent, more of altered sensibility than of vascular or structural lesion of this part of the nervous system constitutes its essence. How- ever this may be, attentive observation of the morbid phenomena, especially at their com- mencement, will show that the spinal affection is merely a consecutive and contingent disor- der, and one by no means generally, or even very frequently observed. This want of pre- cision in the use of terms, and in the ideas re- lating to the pathology of hysteria, has been sur- passed by M. Andral, when he says, "As to my opinion respecting the seat of hysteria, I repeat that it is a nervous complaint, and that its seat is the nervous system !" 59. Although the uterus and its appendages have been viewed as the chief source of hys- teria, both by the ancients and by most of the moderns, yet some difference of opinion exists as to the nature of this primary affection. Pi- nel, Villermay, Lobstein, and Foville con- sider that it is entirely nervous, or is an exci- ted state of the nerves supplying the organs of generation. Other writers, as Addison, &c, who have adopted the term uterine irritation, seem to ascribe to this term a similar meaning to that which the above authors have wished to convey; although they contend that, in con- nexion with this state, the uterine functions are very often disordered. M. Pujol, on the other hand, infers the existence of chronic in- flammatory action of the uterus as the imme- diate cause of the complaint. Inflammatory action in its various grades, from simple ere- thysm upward to the most acute vascular change, may sometimes be a complication or cause of hysteria; but there is no necessary dependance of the one upon the other; for we often meet with metritis without hysterical symptoms, and still more frequently with fully developed hysteria, without any evidence of metritis. Yet it should not be overlooked that HYSTERIA- the former is often symptomatic of, or compli- cated with the latter. 60. When we consider the number and im- portance of the nerves of the female organs of generation, the connexions existing between them and the nerves supplying the kidneys, the urinary bladder, and the intestinal canal on the one hand, and the spinal and sacral nerves on the other ; and the fact that these nerves are small and apparently few in girls, large and nu- merous during the epoch of uterine activity, and very small in old women, the sympathetic effects of irritation, excitement, or of erethysm of them will be more readily recognised, and the relation of these sympathies to their source made more obvious. Attentive observation of the causes of hysteria, and of their more imme- diate effects upon the generative system, and a knowledge of the sensations of the patient with reference to the origin and course of this ailment, will prove that the old opinion as to its source is correct. That the primary affec- tion is seated in the nerves of the generative organs, and that it consists chiefly of excite- ment, erethysm, or irritation, sometimes, how- ever, associated with congestion or vascular determination to the uterus, or with disorder of the catamenia, are shown by the circum- stances in which it is observed, and the fact that it never appears until these nerves have approached their full development, nor after their principal functions have ceased. Geor- get, however, contends, in opposition to this opinion, that organic lesions of the uterine or- gans are very common in females who have never had hysteria ; and that the more serious changes, as cancer uteri, uterine polypi, ovarian dropsy, &c., are seldom accompanied with this complaint. But the most of these maladies do not appear during the epoch in which hysteria is most common. As long as the uterine func- tions and sympathies are active hysteria will occur. Hence its not infrequent connexion with metritis and other uterine diseases during the prime of life ; but when these functions and sympathies are exhausted or greatly enfeebled, as in most of the dangerous maladies and or- ganic lesions of the uterus and ovaria, as well as in advanced life, hysteria will not be devel- oped. The generative nerves have then be- come incapable of experiencing that state, and of exerting that influence upon the nerves rela- ted to them, which are requisite to the production of hysterical phenomena. As M. Foville has justly observed, we do not find sexual ardour among the symptoms of malignant alterations of the testes, or of hydatids in the spermatic cord, &c. Hysteria does not occur in aged females, for the very same reason that menstruation and pregnancy do not take place in them. The belief that hysteria may affect males has been adduced against its uterine origin ; but the fact of true or unequivocal hysteria having been met with in males needs farther confirmation, or, rather, the nervous affections, resembling some states of hysteria noticed in this sex, require a closer observation than they have hitherto received. I will not, however, deny, that irritation of the male sexual organs will not occasionally pro- duce disorder in many respects similar to that observed in females in like circumstances, par- ticularly in susceptible and nervous persons. CI. My views, therefore, as to the pathology 42 -Pathology. 329 of hysteria are as follows: a. That hysteria arises from the state of the organic nervous influence endowing the generative organs of the female, and that a similar state of the sex- ual organs of the male very rarely occasions it, and then only in peculiar circumstances ; b. That this state of nervous influence nearly ap- proaches to, or consists of excitement, nervous erethysm or irritation, or is of an active or sthenic kind, as respects the functions of these organs; c. That this is generally attended by vital turgescence of the vessels of the uterine system; and these states, consequently, occur chiefly during the prime of life, or while the nerves of generation and the uterine circula- tion possess their functional energies ; d. That these conditions of nervous influence and cir- culation in these organs are generally insuffi- cient of themselves to occasion the fully devel- oped complaint; and that, in addition, there are increased sensibility and irritability of the sentient and motive systems, and, consequent- ly, augmented susceptibility of impressions, from mental or physical causes, arising either from original conformation or from acquired habit or diathesis ; e. That when these states of the generative organs are excited by mental emotions or by other circumstances, the affec- tion is propagated by direct or immediate sym- pathy—by the organic nerves—to the digestive tube and urinary organs on the one hand, and to the cerebro-spinal nervous system on the other; and thus the phenomena constituting the hysterical seizure are developed; /. That the hysterical phenomena, proceeding from di- rect sympathy with the uterine organs, consist chiefly of those referred to the bowels — the borborygmi, globus, &c, and to the urinary or- gans, as the increased secretion of urine, &c.; g. That the extension of the disorder of the uterine nerves, by means of the ganglial sys- tem and its communicating branches to the roots of the spinal nerves, gives rise to the symptoms depending upon reflex sympathy,* es- pecially the convulsions, pains, &c, and the af- fections of the respiratory organs, throat, head, &c.; h. That the phenomena of the developed states of the disease and of its irregular forms are principally sympathetic, and of the kind which I was the first to denominate the reflex (see Notes and Appendix to Richerand's Ele- ments of Physiology, p. 34 and 546); and the same views and pathological explanations giv- en in the articles Chorea and Related Affec- tions (y 15-17), Convulsions (v 46), Epilepsy (y 51), apply to the different varieties of Hys- teria : i. That, although hysteria is often con- nected with deficient or irregular menstruation, yet this function is sometimes excessive, or is occasionally regular, in every respect, in hys- terical persons. [Dr. S. Jackson regards the brain, or, rather, the medulla oblongata, as the seat of hysteria, * in my Appendix to M. Richerand's Elements of Physiology, published in 1824 and in 1829, I have divided the sympathies into, 1st. The Reflex, or those which take place in consequence of irritations conveyed by the nerves to the cerebro-spinal centres, and thence reflected upon mo- tive or sentient parts; and, 2dly. The Direct, or those which proceed more immediately from the seat of primary excitement to other parts, by means chiefly of nervous com- munication, continuity of membrane, structure, &c. These views as to sympathy, which are certainly original, were applied to the explanation of the pathology of Chorea, and its related disorders of Convulsions, Epilepsy, &c. 330 HYSTERIA- and thinks that those who are subject to fre- quent attacks of hysteria have this portion of cerebral structure in a permanent state of irri- tation of feeble grade, and which is increased by any sudden and strong impression, an un- expected noise, sight, or intelligence, becoming in them an exciting cause of the hysteric par- oxysm. He supposes that the stomach and uterus are the organs from which the irritation that causes the paroxysms most frequently proceeds, and is most commonly transmitted through the great sympathetic, which anasto- moses with the par vagum that has its origin in the medulla oblongata. Hence the varieties observable in the disease will depend, 1st. On the intensity and extent of the cerebral irrita- tion ; 2d. On the local visceral irritation by which it is excited ; 3d. The organ that is the seat of the primary irritation.—(Treatise on Dis- eases of Females, by W. P. Dewees. Phil., 1833, p. 550.)] 62. X. Treatment.—There are few diseases less under the control of medical treatment than hysteria ; and various circumstances con- nected with it often occur to render the man- agement of it not only unsatisfactory, but also unpleasant. Patients themselves, or their friends, readily suppose that relief should quick- ly follow a recourse to medicine, and conclude that the proper means have not been employed when relief is not obtained. They do not con- sider—and the fact is generally not sufficiently explained in the proper quarter and at the prop- er time—that the complaint arises from causes which are mostly permanent in their action, or which continue during the treatment, and that in every case the difficulty of removing an ef- fect, while the causes are in operation, is very great. The candid physician also readily ad- mits that the complaint in its various forms is devoid of danger, and this circumstance is be- lieved by many to imply a speedy cure. Sev- eral varieties of it, also, are calculated to ex- cite alarm ; and, if they be not soon removed, the knowledge or ability of the physician un- der whose care they may have come is im- peached ; and some other advice is asked, and often in quarters noted neither for honesty nor ability. If the patient should thus fall into the hands of either the qualified or the unqualified charlatan, the complaint is misrepresented or exaggerated, and alarm is excited. The effect, however, is often beneficial, although it was as little intended as its source was unsuspected. The impression of fear on the niind may put a stop to some of the causes, or may interrupt the succession of morbid sympathies. The pa- tient, moreover, after she has passed from the care of the scientific practitioner, may be sub- jected to influences of a powerful nature, moral or physical, or both, and experience temporary or some permanent advantages from them ; but from whatever source they proceed, or by whomsoever administered — whether by the medical empiric or by the spiritual comforter, the modern worker of miracles — the results are often equally annoying to the duly qualified practitioner. The regular professor of medi- cine is expected to administer benefit in all cases, and without, regard to circumstances. If he fail, and the patient, under very different circumstances and influenced by very different feelings, receive benefit from the manipulations -Treatment. of a charlatan, whose means are more striking or imposing, or more suited to the moral con- dition of the patient than those previously em- ployed, the occurrence is made a matter of no- toriety, and equally to the disadvantage of the one as to the credit of the other. The former is expected by the public to cure, and it is con- sidered discreditable for him to fail; the latter is viewed as having made a wonderful discov- ery if he succeed but in a single case, and his knowledge is supposed to have come by inspi- ration, as it could not have been derived from any other source. Another circumstance far- ther serves to counteract the treatment advised by scientific men, particularly in large towns. The patient is capricious, and her friends are often equally unstable. If benefit is not re- ceived in a very short time, the advice of some one else is obtained, and before he can be of any service he also is dismissed, and a third is called in. Thus, from twenty to thirty practi- tioners may be consulted without one of them having had a sufficient opportunity of fulfilling a single intention of cure. Now what is the consequence 1 The patient resorts to some noted or fashionable empiric, who is informed of her long sufferings, and the want of success of the greatest physicians in her case. He is shrewd enough to see at once the state of mat- ters, and to turn them both to his pecuniary advantage and to his credit. He exaggerates the risk, the difficulty, and the consequences of the disease; refuses to undertake the case unless at his own terms, which he takes care to secure ; and he thus also secures the con- tinuance of the patient under his care, and even her confidence, although he should fail in all beside. 63. From the dishonest acts of charlatans useful lessons may, however, be honestly learn- ed. When a physician is called to a nervous patient who has been under the care of other physicians, instead of prescribing at once, and without reference to this circumstance, he should acquaint her or her friends that proba- bly a sufficient opportunity of affording relief had not been allowed to those who had prece- ded him; that, as a member of an honourable profession, he expects to be honourably dealt with, and that he will not compromise his rep- utation by prescribing for the case unless he be allowed time and opportunity—fully and cir- cumstantially—for its proper treatment. Un- less these be conceded, and in a spirit which will promise to secure their due performance, it will be infinitely better to relinquish the case altogether than to enter upon the treatment of it with the probability of disappointment. When it is found that the physician thus re- gards his own reputation, respect and confi- dence will be accorded to him by the patient and her friends. 64. There are various circumstances in the pathology of hysteria which require strict at- tention in the treatment. 1st. The particular form of the hysterical seizure, whether regular, irregular, or anomalous ; 2d. The condition of the nervous system, particularly with reference to increased sensibility and irritability ; 3d. The excitement, erethysm, vital turgescence, or oth- er disorder of the uterine system, and their in- fluence by direct and reflex sympathy; 4th. The states of the vascular system in connexion with HYSTERIA—Ge neral Treatment. 331 these, especially in respect of plethora, general or local, or of deficiency of blood; and, 5th. The functional or other disorder of the digest- ive canal. Of all these, the most important is the state of uterine function ; for unless the symptoms connected with the generative or- gans be carefully ascertained, as far as is prop- er to inquire, and the disorder in this quarter be carefully inferred, the treatment will often be unsuccessful; and, even with the utmost exercise of professional acumen, we may fail, more or less, owing to the permanence of the moral and physical causes of the complaint. 65. i. Treatment in the Seizure.—A. If the paroxysm be attended by severe convulsions, the principal intention is, to preserve the patient from injuring herself; the next is, to shorten its duration.—a. Although her struggles are se- vere, she generally retains sufficient conscious- ness, and even volition, to avoid danger. There- fore little effort should be made to restrain them, and especially as they have, upon the whole, a beneficial effect, particularly in equal- izing the circulation. If, however, the fit as- sumes an epileptic character, this object should be carefully attended to, and a folded napkin placed between the teeth, if it be required. In all cases, the patient should be removed to an airy apartment, and the clothes losened around the waist, chest, and neck.—b. In order to shorten the Jit, various means have been recom- mended, and found more or less serviceable. If the patient is able to swallow fluids, a large cupful of cold or iced water may be given and repeated. If the seizure be more severe, or be attended by general or cerebral plethora, the affusion of cold water on the head and neck should be resorted to, or cloths wet with it, or with an evaporating lotion, should be placed around the head. If the severity of the spasms* particularly of the muscles of the face and jaws, and of the strangulating sensation arising from the globus, prevents deglutition, enemata will be found of great service. The substances which I have found most efficacious, when thus em- ployed, are, the spirits of turpentine alone, or with castor or olive oil, asafatida, and camphor. An enema of the coldest spring water also puts an instant stop to the convulsions. The spirit of turpentine was recommended by me in 1821 (Med. and Phys. Journ., vol. xlvi., p. 107, 185) in these cases. From half an ounce to an ounce and a half of it may be thus administer- ed, with either of the oils just named, in any vehicle, as gruel, milk, broth, &c. As the pa- tient's consciousness is seldom lost in the seizure, the influence of fear in arresting it has been often resorted to, and frequently with complete success. Even mention of the affu- sion of cold water has put a stop to the fit. Yet instances have occurred in timid persons of great nervous susceptibility where fear has aggravated the convulsions. 66. B. Where there is neither cerebral pleth- ora nor difficult deglutition, the internal use of diffusible stimulants, as the preparations of ather, of ammonia, of valerian, of asafatida, &c., have been very generally recommended, and are oft- en useful, combined, according to, circumstan- ces, with one another, or with anodynes, as laudanum, henbane, hydrocyanic acid, &c. ; the smoke of burned feathers, and the odour of asafoetida, of mint, of the volatile alkali, of aromatic vinegar, &c, are the common domes- tic means for the removal and prevention of a seizure. Much, however, particularly as re- spects the prevention of the fit, depends upon the patient herself. Most females subject to the complaint give way to the current of their feelings until the paroxysm is developed, al- though a determined resolution to prevent or suppress it would often prove successful. Dif- fusible stimulants are not so generally useful in preventing as in shortening the attack. The former of these objects is more certainly attained by a draught of cold water, or by an enema of the same, or by cold applications to the head, than by other means. Dr. Conolly states that he has found half a drachm of ipe- cacuanha prevent the seizure. Any of the oth- er substances already recommended to be used in enemata for the purpose of shortening the fit will generally also prevent it. 67. C. The more severe or alarming states of the fit, as the comatose, the cataleptic, &c, are most benefited by the affusion of cold wa- ter on the head, or by the application of cold lotions in this quarter. Vascular depletions are seldom necessary during the fit, even in these cases, unless the attack has followed the sup- pression of accustomed discharges ; or the tem- perature of the head and the action of the ca- rotids show the propriety of prescribing them, and even then a moderate blood-letting, or cup- ping on the nape of the neck, will be sufficient. Warm and rubefacient pediluvia, and other de- rivatives from the head, may also be employed in these cases. The means which may be far- ther resorted to will be stated hereafter (y 71, 75, 97). 68. ii. General Treatment, particularly in the Intervals.—A. With reference to the state of the uterine system.—The female organs of generation may be subject to that state of excitement, erethysm, turgescence, or irrita- tion which, in susceptible and nervous persons, seems intimately connected with hysteria, with out the catamenia being in any way disorder ed. More commonly, however, this discharge is scanty, difficult, painful, or irregular as to time^ quantity, and character. In a few instan- ces it is suppressed, or nearly so ; in others it takes place at intervals of two or three months ; in some it is too profuse, or much too frequent, and in many it is pale and branniform, or it presents appearances more fully described in the article Menstruation. But all these states are usually accompanied by more or less of al- tered sensibility, referrible to the uterus or ovaria: there is often pain behind or above the pubis, in the lower part of the sacrum, or in the loins, or in the hips or tops of the thighs; the excretion of urine is disturbed, or too fre- quent, or attended by slight scalding, &c. ; and there is sometimes leucorrhcea, with tender- ness of the os uteri on examination, and occa- sionally an unpleasant sense of heat in the va- gina. All these indicate the propriety of having recourse to local depletions; yet, unless the patient be plethoric, or the discharge has been scanty or suppressed, a very copious vascular depletion is often injurious. A moderate cup- ping on the sacrum, or the application of ten or twelve leeches to the groins, two or three days before the expected return of each month- ly evacuation, or to the hypogastrium, will gen- 332 HYSTERIA—General Treatment. erally suffice. If the depletion be more liberal, the employment of tonics and of other means to improve the general health must not be neg- lected. 69. All the symptoms just noticed as indica- ting irritation of the uterus are often present, even in the severest form, where there is great constitutional debility, and, in a few instances, where the colour of the surface and of the lips, and the states of the pulse and of the veins, in- dicate more or less anaemia. In these even local depletions maybe hurtful. The chief de- pendance must therefore be placed in prevent- ing local excitement or irritation, in the use of cooling tonics, sometimes in conjunction with anodynes and sedatives, and in improving the digestive functions and general health by suit- able diet and regimen. The sulphates of iron, of zinc, and of quinine, are severally of use, in combination with small doses of camphor, or of ipecacuanha, and with extract of henbane, or of hop. If these should occasion headache, or in- crease the tenderness in the vicinity of the uterus, the infusion or decoction of cinchona, or the infusion of valerian with nitrate of potash, or hydrochlorate of ammonia, or carbonate of soda, may be prescribed. When the bowels require to be opened, the cooling aperients, as the bi- tartrate of potash, with the nitrate, and the confection of senna, should be preferred. Mor- al and physical quietude, frequent reclining on a couch, and a digestible and cooling diet, ought also to be enforced. In more plethoric persons these means are still more requisite than in the preceding ; and, instead of chalyb- eates and tonics, cooling diaphoretics, particu- larly weak camphor mixture, with solution of the acetate of ammonia, nitrate of potash, and spirits of nitric aether, will be often taken with benefit. Wherever uterine turgescence or erethysm is inferred, the treatment must be di- rected with reference to the states of general or local plethora, and of nervous power, as hereafter insisted upon ; and hot spices, exci- ting articles of food, and stimulating bevera- ges, should be avoided. Heating purgatives and irritating injections ought not to be em- ployed. A separate sleeping apartment should be suggested. 70. When the catamenia are disordered, the treatment should be directed with strict reference to the state of disorder, as explained in the article Menstruation. If they be exces- sive or too frequent, tonics and astringents, with refrigerants, and anodynes or narcotics, are gen- erally requisite ; but the predominant use of either of these classes of remedies should de- pend upon the peculiarities of the case. In these cases, especially, advantage will accrue from cold sponging the loins, abdomen, and hips every morning with an astringent lotion, as with equal parts of rose-water, solution of the acetate of ammonia, and vinegar ; from the occasional recourse to an enema of cold water, particularly when a seizure is threatened, or to emollient and anodyne enemata on other occa- sions ; and from rest in the horizontal posture. The cold plunge or salt-water bath, or shower bath, will often, also, be of service. In the other states of disordered menstruation, the treatment should be directed according to the principles stated above (y 68, 69). 71. B. With reference to the state of nervous susceptibility and tone.—The increased suscep- tibility of the nervous system generally charac- teristic of hysteria is frequently associated with more or less debility, and increased irrita- bility of the moving fibre, or, in other words, with mobility of the muscular system ; and to this state, whatever may be other morbid con- ditions, should the treatment be in some meas- ure directed. Yet the means which are the best calculated to correct this state are by no means obvious ; for if it be associated with vascular turgescence of the uterine system, or with general plethora, antispasmodics, chalyb- eates, and other heating tonics may increase the complaint, although they will generally be of service in an opposite state of the vascular system. In general, therefore, the condition of the sensibility and irritability should be com- bated chiefly by frequent and regular exercise in the open air, by early rising, by sleeping in large, airy apartments, by cold or salt-water bathing or the shower bath, by cold sponging the surface of the body, by a proper conduct and employment of the mind, and by a correct management of the passions. 72. Dr. Cullen very justly remarks that tonics may be of service when the disease de- pends upon general debility; but as a plethoric state, especially of the uterus, is more or less joined with hysteria, the frequent or long-con- tinued use of them may do harm. They should be confined to cases of pure mobility, particu- larly with a periodical recurrence of the seiz- ure ; and then the selection of them ought to be determined by the peculiarities of the case. In many such, the preparations of cinchona or of valerian, with the nitrate of potash, or car- bonate of soda ; the sulphate of quinine or of zinc, with small doses of camphor; the infusion of bark, or of roses, with one of the mineral acids, and the tincture of the sesquichloride of iron, will be most serviceable. In some cases, the addition to either of these medicines of an antispasmodic, as of the compound spirit of sul- phuric ather, the tincture of valerian, &c.; and of an anodyne, as henbane, hydrocyanic acid, &c, according to the other substances select- ed, will be farther advantageous. When hys- teria affects plethoric habits, and is connected with manifest signs of turgescence of the gen- erative organs, opium is injurious. But in oth- er circumstances it is often of service, particu- larly when conjoined with camphor, aromatics, or with some of the substances just named, but even then it should only be occasionally employed. When narcotics have not been previously resorted to, the preparations of hop will be found useful, if general plethora be not present. 73. C. With reference to the states of the vascu- lar system.—The connexion of hysteria with vascular plethora, general or local, is often obvious, and has been very judiciously viewed by Dr. Cullen. The usual practice of remo- ving this state by blood-letting, he remarks, is often precarious; for sometimes, instead of preventing, it will indirectly induce or increase vascular fulness. Besides, if depletion be car- ried too far, the complaint may be thereby in- creased. " Venaesection, therefore, may either increase the plethora or induce inanition ; and it is only to be used in recent cases, and where there is manifestly a full habit." A spare diet HYSTERIA—Treatment of Irr: EGULAR AND COMPLICATED STATES. 333 and regular exercise, particularly in the open air and in the light of day, early rising, and cooling aperients, are the means upon which the chief reliance ought to be placed in removing this state, and especially as they tend also to strengthen the nervous system, and prevent local turgescence and irritation. The frequent association, also, of dyspepsia, and of gastro-in- testinal disorder with hysteria, renders this regimen still more necessary. When deple- tion, however, is indicated by the turgescence, or chronic inflammatory state of the uterine organs, or by impaired or obstructed menstru- ation, it should be practised in the manner al- ready advised (y 68). 74. When the vascular system is deficient, rather than too full of blood, and when this fluid seems thin or poor (the Hysteria chlorot- ica of Sauvages), then tonics, especially the preparations of iron and chalybeate mineral springs, will be most beneficial; but they should be aided by air and exercise, and the other means already advised for improving nervous energy (y 71). The sulphate of iron with the extract of hop, or with the compound galbanum, or with the compound aloetic pill, according to the states of the bowels and of the catamenia ; the compound mixture of iron, &c. ; and a moderately nutritious or milk diet, will be emi- nently beneficial in these cases. If the patient complain of weakness in the loins and limbs, a large plaster of the red oxyde of iron, or the aromatic plaster, should be worn on the lum- bar region, in addition to the employment of the other means already recommended. 75. D. With reference to the state of the digestive organs.—Irritation of the digestive mucous surface, in connexion with hysteria (y 52), is often most successfully treated by a mild, spare diet and moderate exercise in the open air. If the patient be plethoric, or complains of pain or soreness, or of" tenderness in the epigastrium, abdomen, or hypogastrium, local depictions, par- ticularly the application of leeches on the abdo- men, and cooling diaphoretics, with external de- rivatives, will be appropriate, as respects both the digestive and the hysterical disorder. If the bowels be costive, the cooling aperients (F. 96, 790), or the preparations of rhubarb with ipe- cacuanha, calcined magnesia, or castor oil, will be useful. If they be relaxed, the hydrargyrum cum creta, with rhubarb and ipecacuanha, or this last with the extract of hop, or of poppy; and refrigerants, conjoined with demulcents, will be serviceable. In cases of hysterical colic, and of irregularity of the bowels in hysterical persons, a frequent recourse to enemata—to those con- sisting of cold or of emollient fluids, and some- times of cooling aperients—will generally prove of great benefit. When the catamenia are at the same time disordered, clysters containing the spirit of turpentine are frequently very use- ful. The state of the digestive organs often requires tonics and stomachics; but these reme- dies may prove too stimulating, unless they be given with refrigerants and antacids, as with the nitrate of potash, and the carbonate of soda. Aloetic and heating or acrid purgatives, partic- ularly those which excite the rectum and large bowels, are sometimes injurious. The propri- ety of exhibiting them, even when hysteria is associated with scanty or obstructed catame- nia, is occasionally even doubtful, particularly when general or local plethora or excitement is present, unless these have been removed by suitable depletions ; and then the compound de- coction of aloes, with a little of the solution of potash, may be preferred. When flatulence is distressing, as it often is, the treatment should altogether depend upon its connexion with gas- tro-intestinal irritation, or with uterine excite- ment or turgescence. In the former case, the means just stated should be prescribed, aided by the application of a large rubefacient plaster, or the Compound galbanum or pitch plaster, on the stomach or abdomen. Mint water, with calcined magnesia, and an aromatic or carmin- ative, or the infusion of calumba or of chyrita, with the carbonate of soda and compound tinc- ture of cardamoms, will generally also be ser- viceable. 76. iii. Treatment of the Irregular and Complicated States.—The intentions of cure in these states of hysteria are, 1st. To remove ex- isting disorder in the uterine and digestive organs, or in the cerebro-spinal centres j 2dly. To allay the local affection by means appropriate to its pe- culiar characters; and, 3dly. To make a forcible impression, mentally and physically, on the nervous system, so as to allay the primary nervous af- fection, and to break the chain of nervous sympathy. These intentions are severally more or less applicable to all the nervous states about to be noticed; but a great difference will be shown to exist in the modes or means of their fulfilment, and in the dependance to be placed upon them individually. 77. A. The painful affections depending upon this complaint, or arising from irritation or tur- gescence of the uterine organs, influencing sympathetically (y 13) related or distant parts, require means, in some cases at least, different from, or additional to those already mentioned. —a. The treatment of Hysterical headache is ful- ly stated in the article Headache (y 40). 78. b. Pain in the left side of the thorax, simu- lating pleuritis, or pericarditis (y 15), is difficult to remove, especially if there be tenderness in the dorsal portion of the spine, and disorder of the uterine functions. If the catamenia are scanty, and especially if there be more or less vascular plethora, cupping on the loins or sa- crum, or the repeated application of leeches to the loins, and cooling or mild purgatives, will be necessary. In other circumstances, and in such cases, after these means have been em- ployed, the effects of antispasmodics and of nar- cotics may be tried, especially of camphor or ammonia, with valerian or asafoetida and hen- bane, &c. If the pain be attended by palpita- tions of the heart, &e, the decoction of senega may be prescribed w;th mint or orange-flower water, carbonate of soda, and tincture of hen- bane ; or camphor may be given in a mucila- ginous mixture with hydrocyanic acid. Imme- diate relief is often obtained by applying on the pained part a piece of flannel wrung out of hot water, and sprinkled with spirit of turpentine, or with the following liniment: No. 261. ft Linimenti Camphors Comp., Linimenti Ter- ebinthina Comp., 5a f j.; Olei Cajuputi et Olei Limonis, &S 3j. M. Fiat Linirnentum vel Embrocatio. These embrocations should be covered by a dry cloth, or by wash-leather, to prevent evapora- tion, and be kept applied to the affected part until they occasion redness and burning heat of 334 HYSTERIA—Treatment of Irregular and Complicated States. the integuments. I have seen the pain removed also by the inner bark of the mezereon, pre- viously moistened and softened, and kept ap- plied to the part until a superficial sore was produced. If pain or tenderness in the spine be also complained of, the means about to be noticed (y 85, 86) may be prescribed. 79. c. Hysterical pain in the regions of the stom- ach and spleen (y 17) often resists medicine, and disappears spontaneously, especially after mar- riage, or from changes in the states of the uter- ine system. It is sometimes relieved by cam- phor, conjoined with hydrocyanic acid or with the acetate of morphia, or by the other anti- spasmodics and anodynes mentioned above (y 78). The warm epithem and embrocation just recommended has, however, proved most successful in my practice. Large doses of the subcarbonate of soda, with a carminative mix- ture or spirit, and tincture of henbane or of opium, often afford relief. An enema, contain- ing either the spirit of turpentine and castor oil, or asafoetida and confection of rue, gener- ally proves very serviceable. 80. d. When pain is severe in the region of the descending colon and left iliac region (y 18), or in other parts of the abdomen, with flatulent disten- tion, increased sensibility, and other symptoms resembling peritonitis (y 21), the above treat- ment is more to be depended upon than any other. The warm epithem or embrocation should never be omitted. The enema just pre- scribed will seldom fail of emptying the large bowels, and of expelling the flatus, which is a chief cause of the more painful symptoms. When the complaint assumes the form of hys- terical colic, the bowels being costive, these means are usually eminently successful. They may require, however, to be repeated. If pal- pitations be present in these cases, they depend upon, or are aggravated by the flatus, which often rises up into the oesophagus, and, by distending a portion of this canal, embarrasses the auri- cles of the heart. Hence the benefit which re- sults from the means which are most effica- cious in expelling the flatus, particularly from those just named ; and from calcined magnesia, prescribed with antispasmodics and carmina- tives, or warm purgative tinctures. For pain in the region of the liver (y 30) the treatment here advised will be appropriate. In all these states of the complaint, the bowels should be kept moderately open by mild or stomachic pur- gatives. 81. e. When pain is seated behind, or just above the pubis (y 20), and particularly when it extends to the sacrum, to the os coccygis, or when it implicates the urinary bladder, or its functions, irritation, or vascular turgescence, or conges- tion of the uterus may be inferred. Local de- pletions ought then to precede other means ; and the mode, amount, or repetition of deple- tion should depend entirely on the habit of body of the patient, and the state of the cata- menia. After these have been prescribed, the bowels must be evacuated by mild or stomachic purgatives, and the circulation equalized by cooling diaphoretics and anodynes. Camphor mixture, almond emulsion, solution of acetate of ammonia with nitrate of potash, spirits of nitric aether and tincture of henbane, are gen- erally useful in these cases. But if the pain still continue, the external means above ad- vised, and the enemata (y 78, 79), should be resorted to. 82. /. Pain in one or both mamma (y 29) is sympathetic of irritation or turgescence of the uterus or the ovaria; but it is sometimes as- sociated with tenderness of one or two of the dorsal vertebrae. It is often removed by the treatment now prescribed. If there be scanty menstruation, leeches may be applied to the mamma?; but the tops of the thighs and hypo- gastrium are preferable situations. I have found cooling diaphoretics with narcotics, as the solution of the acetate of ammonia, and camphor julep, with the acetate of morphia and an aromatic spirit, very serviceable in this state of disorder. In a case of this kind, where there were remarkable tenderness and hardness of the left mamma, evidently depending upon uter- ine irritation and turgescence, and for which I was consulted by another practitioner, com- plete recovery followed a short course of the solution of the iodide of potassium in camphor mixture, to which the solution of potash and henbane were added. If tenderness exist in any of the dorsal vertebrae, the treatment ad- vised for this complication ($ 85) should also be pursued. 83. g. In the more acutely painful or neuralgic affections connected with uterine disorder, the effect of a plaster, with the extract of belladonna and camphor, may be tried. But when they are associated, as sometimes observed, with pain or tenderness in some portion of the spine, then the other local means about to be noticed may be also employed. I have seen the most marked benefit result, in these more acute cases, from half an ounce each of spirits of tur- pentine and castor oil, taken on the surface of milk, and repeated once or twice after the in- tervals of a day or two ; or from a full dose of the former medicine, followed by the enema al- ready mentioned (y 79), or by any suitable pur- gative. Repeated doses of turpentine, until either the kidneys are affected, or the bowels are entirely evacuated, and enemata containing a considerable quantity of this substance, will be found the most efficacious, when painful af- fections, connected with hysteria, are seated in, or extend to the lower extremities. 84. h. Pain in the region of the kidneys, and in the course of the ureters (y 22), is evidently an extension of irritation from the uterus to these organs by direct sympathy, a considerable por- tion of the nerves of the generative and urinary organs belonging to the same ganglia. The treatment should, therefore, be chiefly directed to the state of the uterine system. Local de- pletions will sometimes be requisite, especially if there are general or local plethora, and scanty menstruation. The fixed alkalies or the alka- line subcarbonates, with anodynes and the spirits of nitric aether or the compound spirits of juniper, will occasionally be of service, es- pecially when the urine deposites a sediment of uric acid in the form of sand. When the urine is higher coloured, or deposites a pink or amor- phous sediment, consisting chiefly of the lithate of ammonia, the infusion or decoction of cin- chona with hydrochloric acid, or the balsams, taken in the form of pills, with magnesia, will be found beneficial. The digestive functions should receive due attention. A rubefacient, stimulating, or roborant plaster applied on the LEGULAR AND COMPLICATED STATES. 335 HYSTERIA—Treatment of Irr loins, as the aromatic, cummin, pitch, or am- moniacum plaster, will often also afford some relief. 85. i. Pain in the spine (y 23) is rather a com- plication than a form of hysteria, and is not to be viewed as altogether, or always, depend- ing upon inflammatory action or irritation ; but rather upon excited sensibility. There is no doubt that vascular excitement or congestion often exists in these cases, especially where there is much tenderness or prominence of one, two, or more of the spinal processes, or puffi- ness around them. In these cases, especially, there is more or less continued disorder of the uterine, or of the digestive, or of the respira- tory functions, or even of all of these, accord- ing to the seat and extent of the spinal affec- tion ; and occasionally the cerebral circulation becomes also deranged. To this affection, Darwell, Teale, Tate, Brown, and Griffin have directed particular attention, under the name of Spinal Irritation, or, more properly, ir- ritation of the spine, and have recommended for it local depletions and external irritants, &c. But whoever confides in these alone, or even principally, will find himself disappointed in many, if not in the majority of cases. They often, however, are important parts of the treat- ment, especially if plethora, general or local, or scanty menstruation exists. In cases of this description, the digestive functions should re- ceive strict attention, the bowels being kept regularly open. In the majority, and partic- ularly if there is debility or deficiency of blood, or too frequent or too copious menstruation, the sulphate of quinine, with camphor and ex- tract of hop, or extract of hyoscyamus ; the preparations of cinchona, with the alkaline sub- carbonates, or with the mineral acids, according to circumstances, and the preparations of iron, will prove of great service if appropriately ad- ministered. In some instances of the associ- ation of hysterical affection with tenderness of the spine, and with neuralgic pains in the cor- responding nerves, I have found, after local de- pletions and alvine evacuations, pills containing full doses of the sulphate of quinine and sul- phate of irop, with camphor and extract of hy- oscyamus, very beneficial, and have added the purified extract of aloes to them with advan- tage, when the bowels were costive, or the cat- amenia deficient. Where the powers of the constitution are not impaired, or where there is excited action, an occasional recourse to the draught with spirits of turpentine and castor oil, or to the enema containing the same sub- stances, will be of essential service. 86. External means of various kinds have been applied to the spine in these cases, often without benefit, sometimes with detriment, par- ticularly when the increased sensibility depend- ed upon sympathy with other parts, and upon great nervous debility. When there is suffi- cient evidence to infer that inflammatory irri- tation and turgescence have been excited in the membranes or investing structures of the spinal cord, then certain of these applications, as leeches, scarification and cupping, the tar- tarized antimonial ointment, or issues, will be more or less beneficial; but in other circum- stances they will be of no service. The relief which has followed the application of blisters, or of rubefacient and stimulating plasters, is no proof that the morbid sensibility of the spine depended in these instances upon inflammatory excitement or vascular turgescence ; for, if these morbid states had existed in any degree of sthenic activity, these applications were more likely to have aggravated than to have removed them. Where they have actually giv- en relief, there is reason to infer that the mor- bid condition was one of deficient vascular and nervous energy, rather than the reverse, and one for which general restoratives or tonics, as well as local excitants, were required. Much attention to the states of the various functions, particularly of those of the abdominal and pel- vic viscera, and great discrimination, are ne- cessary in these cases, to determine aright as to the local means appropriate to the various conditions of this class of affections. There are some applications which will not be inju- rious under any circumstance, but will be ser- viceable in many. The chief of these are the warm terebinthinate epithem and embrocation already noticed (y 78), applied over that part of the spine, chiefly, where pain is felt. Plas- ters, also, consisting chiefly of ammoniacum, compound pitch, or of red oxyde of iron, &c, will subsequently prove useful. Where signs of inflammatory action of the ligamentous or other structures of the spine are present, the above liniment, epithem, or embrocation, ap- plied to the affected part, and setons, issues, or open blisters, some distance below it, so as to produce a derivation from the seat of morbid action, will frequently afford great relief. 87. k. Pain in the sacrum and os coccygis is generally not to be imputed to the same mor- bid states as that referred to the spine. It fre- quently depends upon the condition of the uterus, particularly about the os and cervix uteri, and requires the same treatment as that advi- sed for pain behind or above the pubis (y 81). Whether proceeding from this source, or from disorder near the origins of the jierves, or from disease of the structures of the spine, or of ad- joining parts, the means just recommended, constitutional as well as local wi}l be useful when judiciously employed. 88. I. Hysterical affections of the hip or other joints (y 26) are very difficult to manage, and require, for their removal, not merely an im- provement of the general health, but also strong impressions upon the mind and nervous system. The intentions of cure above stated (y 76) should be fully followed out, and the particular means already described fairly tried. The medicines which I have found the most successful are, the spirits of turpentine,* prescribed in various modes, internally and externally, and adminis- tered in enemata; the preparations of iodine, alone, or with narcotics; and camphor. These, however, should be associated with suitable adjuvants ; among which, the several narcotics and antispasmodics are the most important. The warm or vapour bath, simple or variously medicated; mental excitement, and exercise * The spirit of turpentine was first recommended by the author for these states of hysteria, and for neuralgic and similar affections. It has recently been advised for the same complaints by some French physicians. The origi- nality of the practice may be known by referring to A Me- moir on the Employment of Terebinthinous Remedies in Disease, by James Copland, M.D., us, 1. ii., Q. 11.—Galenus, De Loc. Affect., 1. vi., c. 5.—Paul- us JEgin, 1. iii., c. 71.—P. Touret, Ergo Hystericis Venus, Paris, 1570.—Denizot, Ergo Hystericis Ven;esectio. Paris, 1573.—BallOnius, De Morb. Mul., v., Opp. iv., p. 147.—B. Rouseus, De Hominis Primordiis Hystericisque Affectibus, &c. Lugd. Bat., 8vo. 1594.—Sydendam, Opusc., p. 407.— A. Laurentius, De Hystericis Affectionibus Infantilibusque Morbis. Lion., 8vo, 1595.—Primerosius, De Morb. Mul., 1. ii., c. 5.—E. Jorden, Briefe Discourse of a Disease called the Suffocation of the Mother. Lond., 4to, 1603.—Bouvard, Ergo Mulieri Praefocata; Vir Succulentus. Paris. 1612.— Horstius, Opp., ii., p. 274,285, 294.—Mercurialis, De Morb. Mul., 1. iv., c. 22.—N. Highmore, Exercitationes du*, qua- rum prior de Passione Hysterica. Oxon., 12mo, 1660; et Epistola ad Thomam Willis, de Passione Hysterica. Lon- don, 4to, 1670.—Ruland, Cur. Emp., cent, ii., cur. 83.-7*. Willis, Affectionum qua dicuntur Hysterics, &c, Patho- logia vindicata. Lond., 4to, 1670 ; et Affectionum qua di- cuntur Hystericse et Hypochondriacae Pathologia Spasmodi- ca Vindicata. Lond., 12mo, 1678.—Dacquet, Ergo Venus Hystericarum Medela. Paris, 1674.—Riedlin, Ltn. Med., 1700, p. 199.—J. Purcell, A Treatise of Vapours or Hyster- ic Fits. Lond., 8vo, 1701. — Slahl, De Hypochondriaco- Hysterico Malo. Hal., 1703.—Cruger, De Magnetismo Re- rum, et de Uteri Ascensione. Zittau, 1712.—P. Hunauli, Dissertations sur les Vapeurs, et les Pertes du Sang. Par., 12ino, 1716.—R. Blackmore, A Treatise on the Spleen and Vapours, oc, Galen. Lepra Squa- mosa, Auct. var. Herpes, Phlyctana, Lichen, &c, Auct. Phlysis Impetigo, Young. Ecpy- esis Impetigo, Good. Dartre, Dartre crouteuse, Fr. Zittermal, Ringworm, Germ. Impetigine, Ital. Tetter, Humid or Running Tetter. Classif.—3. Class, 3. Order (Cullen). 6. Class', 3. Order (Good). 5. Order, Pus- tular Eruptions (Willan). III. Class, I. Order (Author). 1. Defin.—An eruption of one or more crops of small, yellow, itching pustules, disseminated or collected in clusters, the contents of which dry up in a short time, and assume the form of yellowish, rough, or prominent incrustations; generally un- accompanied by fever, and not contagious. [This affection may be said to consist in a state of active inflammation of the cutis, on which minute vesicles are speedily formed, the contents of which are at first transparent, but which become shortly after opaque; when the skin is broken, and the fluid escapes, it dries on the part, and forms scabs or scales of a yel- lowish-brown hue, varying in thickness and ad- hesiveness according to the quantity of the flu- id discharged. So that impetigo, in different cases and their stages, exhibits vesicles, pus- tules, and regularly formed scales, somewhat resembling those of psoriasis. Scabies and ec- zema are also characterized by vesicles and pustules.] 2. I. Description.—Impetigo may attack ev- ery part of the body. It may be simple or com- plicated. Willan, Bateman, and Biett enu- merate five species of the disease. I agree, however, with Dr. A. T. Thomson, in limiting them to two, three of those proposed by Wil- lan being merely varieties of simple impetigo. The first species, or simple impetigo, according to this view, is unattended with fever, and comprises the figured, scattered, and scabid varieties. The second, or complicated, or ery- sipelatous species is attended with fever, ow- ing, probably, to the extension of the inflam- matory action to the more deeply-seated integ- umental tissues. ECTIONS—Description. 364 IMPETIGINOUS AFF: 3. i. Simple Impetigo—Impetigo simplex—usu- ally occurs without any premonitory symptoms or derangement of health. It is met with most frequently in children at the period of dentition, in young persons of either sex, and in those of a sanguineous and lymphatic temperament, with a fine, susceptible skin and florid complex- ion. It most commonly appears in the spring, at which season several have been periodically attacked by it during many successive years. This species occurs principally under two vari- eties. The pustules may be collected in circu- lar or oval groups, occupying a surface of great- er or less extent, but pretty exactly circumscri- bed ; this variety constitutes the Impetigo figu- rata of Willan. Or the pustules may be scat- tered far apart, assuming no particular form, but disseminated over a surface of variable ex- tent : this variety has been called Impetigo spar- sa. To these a third division has been added, by the name of Impetigo scabida; but this is merely a more severe form of impetigo sparsa. Many intermediate degrees exist between these varieties ; but the characters they present are sufficiently distinct to give scope to the gener- al study of the disease. At the same time, each variety may bo acute or chronic, according as it consists of a single crop, or of successive eruptions of pustules. > 4. A. Impetigo figurata~Dartre crustacie fla- vescente of M. Alibert—is the most common of these affections. It may occur in any part of the body, on the neck, trunk, and extremi- ties, particularly the hands; but it generally occupies the face, appearing most frequently on the middle of the cheeks, from whence it extends, in a circular or oval direction, over a considerable extent of surface. Sometimes it is confined to the eyelids, when it is commonly complicated with ophthalmia; and occasionally it appears on the chin, the ala nasi, and imme- diately below the margin of the septum of the nose. Although this variety usually occurs without very manifest disease of the general system, yet it not unfrequently follows anxiety or other depressing affections of the mind. In this case it is ushered in by a feeling of lassi- tude, by disorder of the digestive functions, by weakness and uneasiness, accompanied by pain in the epigastric region, and sometimes by cephalalgia. The eruption, as it first appears on the face, commences by one or more small, red, and very superficial blotches, which itch considerably, and gradually enlarge, becoming covered with small, yellowish, psydracious pustules, placed so close to each other as to be almost confluent, and surrounded by a red, inflamed border. The pustules are but slightly elevated, and are the seat and source of much heat and stinging pain. These clus- ters, which are usually of a circular or oval form, and of various dimensions, may continue isolated, or extend still farther by the develop- ment of fresh pustules at their circumference ; and the eruption may be so extensive that both cheeks, and even the whole chin, may be cov- ered with it at once. The pustules, however, do not remain long in this state ; but in the course of thirty-six or forty-eight hours, or, at most, three days, they burst, and discharge an ichorous fluid, which dries quickly, and is con- verted into a yellowish crust of greater or less thickness, very friable, slightly furrowed, semi- transparent, and resembling portions of candied honey, or the concrete, gummy exudations on a cherry-tree. At the same time the discharge continues under these crusts, thereby increas- ing their thickness, and causing them to extend considerably beyond the limits of the original pustules; and it is usually at this stage of the disease that the patient is seen by the prac- titioner. The skin in the circumference of these incrustations is of a red colour; and if the scabs fall or are rubbed off, the integuments under them appear likewise red and excoria- ted, exhibiting, at the same time, minute pores, from which a purulent discharge exudes, which greatly augments the heat and smarting. To- wards the edges of these diseased patches may be still seen some unbroken psydracious pus- tules, and others over which the liquid has flowed when it is scarcely coagulated. If the disease be of great extent, the features can hardly be recognised. 5. Impetigo figurata continues in its crusta- ceous state from two to four weeks, when it is not protracted by successive eruptions: the itching and heat then abate, as well as the morbid secretion ; the incrustations become drier, and fall off irregularly, leaving one or more red spots or marks, which remain visible for more than a month. The cuticle, at the same time, is so thin as to be liable to excoria- tion from the slightest friction, and a very tri- fling exciting cause often brings back the dis- ease. More frequently, however, the ichorous discharge is reproduced, accompanied with fresh crops of psydracious pustules ; the erup- tion is frequently renewed after running its usual course, and thus continues for many months, sometimes for years. In this manner it becomes a chronic disease, although the suc- cessive inflammations keep it always in an active state. In these cases the inflammation does not spread superficially, but penetrates the whole thickness of the skin, and sometimes affects the subcutaneous cellular tissue. When the disease yields either spontaneously or to medical treatment, the amendment commences in the centre of the patches ; and even when this occurs, not infrequently the edges retain their diseased character, and fresh pustules are produced; these, however, as the treatment proves successful, also gradually disappear, and the skin regains its natural colour slowly in these parts. 6. Impetigo figurata may appear on the limbs, and even on the body. When it affects the lower extremities, the patches are usually large, and of an irregular oval, whereas they are smaller and rounder on the upper limbs. Some- times the patches enlarge by successive margi- nal crops : this has been observed on the legs, which have thus been gradually covered from above the knee to the ankle. The disease often becomes chronic, and the time of its du- ration varies. In such cases we do not ob- serve successive and abundant crops of pus- tules, or these large inflamed patches, but merely a few occasionally. Frequently, how- ever, no pustules are found; but the peculiar form of the patches and crusts, with the partial eruption from time to time, suffice to charac- terize it. In some instances the pustules are intermixed with transparent vesicles, as in some of the varieties of herpes. When this in- IMPETIGINOUS AFFECTIONS—Description. 365 termixture occurs, the disease is much more troublesome from the extreme irritation, itch- ing, smarting, and heat which accompany it, and is much more difficult of cure. When these vesicles break, they discharge a fluid much more acrimonious than that of the pus- tules, which, wherever it touches the sound skin, produces a vesicular inflammation and a pustular eruption. This variety of the affec- tion appears principally on the hand, about the metacarpal bones, or on the wrist. The vesi- cles appear in slow succession at a little dis- tance from each other and from the pustules ; when broken, they are little disposed to heal, and the cuticle ultimately becomes thickened and inflamed, and covered with the rising erup- tions, small humid ulcers, and chaps or fissures. The sensation of burning and intense itching is extremely distressing, especially on the first rising of the vesicles ; and every remedial ap- plication which is employed becomes a source of irritation, and increases the evil. 7. B. Impetigo sparsa differs from the prece- ding variety merely in the irregular and scat- tered distribution of the eruption. Its nature and progress are the same ; but, instead of be- ing arranged in circumscribed groups, its pus- tules are dispersed without any regular order over the extremities, neck, face, shoulders, and external ears. This variety is most prev- lent in autumn, continuing obstinately through- out the winter, and disappearing only at the approach of summer. It has a greater tenden- cy to pass into the chronic state than the last variety. Although it may develop itself on any part of the body, yet it affects more particular- ly the extremities, manifesting an especial pre- dilection for the legs, and in that situation be- coming extremely troublesome and obstinate. Sometimes it confines itself to one spot alone; at others it covers a whole limb, or even more than one, at the same time. 8. The pustules in impetigo sparsa aie devel- oped in the same manner as in impetigo figura- ta ; but here, instead of being collected togethc r, they are scattered irregularly over the diseased surface, and accompanied with insupportable itching. The incrustations, also, which follow the bursting of the pustules are thicker and more friable, and are not formed into so large plates as in impetigo figurata: the attendant in- flammation is, however, more extensive ; and as they fall off and disappear the surface of the limb becomes studded with ulcerations and fissures. 03dema is not an infrequent attend- ant or consequence of this variety of the disease. 9. In some cases, and especially in persons of advanced age, with enfeebled constitutions, the crusts attain a great thickness: they are of a yellowish brown colour, variously divided by deep fissures. They have been compared to the bark of a tree by Willan, who calls this variety Impetigo scabida. It is, however, no- thing more than a severer form of the last va- riety. Sometimes these crusts cover a whole limb till it is cased with them, the motion of it becoming both difficult and painful ; at the same time considerable heat and a tormenting itching exist. After a while these crusts split; and, when a portion of them is detached, a co- pious discharge exudes from the excoriated surface, quickly concretes, and fills up the va- cuity. When this variety affects the lower extremities, and is very severe, it sometimes occasions cedematous infiltration and ulcera- tion, and even extends to the toes and secre- ting matrices of the nails—Onychia Impetigi- nodes. The oedema and ulceration commonly appear about the ankles, particularly in aged, weakly, or broken-down constitutions. The ulcers are uneven, and either discharge, a sero- purulent fluid, or are covered by yellowish crusts, their edges being irregular, purplish, or livid, and often crowned with small sanguino- lent pustules. When this variety occurs in the upper extremities it does not differ from that already described, but it is much less severe, and its chronic form more rarely associated with oedema and ulceration than that observed in the lower extremities. Acute impetigo spar- sa of the face usually presents greenish yellow incrustations, dispersed over the cheeks, or adhering to the beard in the adult. In children the inflammation often extends to the nose, which swells, and is sometimes plugged up, the disease then frequently becoming chronic. 10. C. Impetigo Favosa. — This variety is merely impetigo sparsa affecting the neck, ears, and hairy scalp—the Porrigo favosa of Willan and Tinea granulata of Alibert—especially of children, and occasionally of adults. It occurs most frequently in the back parts of the head, but the entire scalp may be implicated ; and it appears as yellowish white pustules, irregular- ly scattered over the hairy scalp, and attended by inflammation and pruritus, their centres be- ing traversed by hairs. In from two to four days the pustules pour out a fluid, which agglu- tinates the hair, and dries into small brownish or grayish, rough, and irregular crusts or masses like candied sugar. These become friable and detached from the surface, but adhere to the hair, which often seems filled with them; a faint, sickly, or unpleasant smell being exhaled from the head when cleanliness is neglected. Pediculi multiply rapidly, and swarm in the hair, which is not lost, but is often agglutina- ted or matted by the discharge. Impetigo of the hairy scalp is not contagious, and does not implicate the piliferous bulbs, like favus or true porrigo. It seldom lasts longer than some months; and it commonly is removed in the course of a few weeks, with proper treatment. When it becomes chronic, the inflammation often extends to the cellular tissue underneath, giving rise to small, circumscribed abscesses. The lymphatic glands of the neck are frequent- ly enlarged and painful. Rayer and Green consider that this affection of the scalp is strictly % form of Impetigo sparsa, and not a variety of the disease, to which Willan has applied the term Porrigo, and I am of the same opinion. 11. ii. Complicated Impetigo. — A. Impetigo Eczematosa.—Impetigo is sometimes associa- ted with Eczema—Eczema Impetiginodes. (See art. Eczema, $ 5.) The eruption so frequent in infants during suckling and teething, com- monly called Crusla Lactea, or Milk Scall, is evidently an association of this kind, chiefly affecting the face, and extending partially to the scalp ; the characters of eczema predomi- nating in some infants, and those of impetigo in others. Occasionally it assumes nearly the appearance of impetigo figurata. It has been variously arranged by writers on diseases of 366 IMPETIGINOUS AFFECTIONS—Diagnosis. the skin, who have, even to the present day, been more desirous to point out, and even to feign distinctions, than to trace the changes which these diseases undergo and the con- nexions which subsist between them, or to show how frequently the one runs into the other; and has been termed Impetigo larvalis, Impetigo mucosa, Tinea la.ctea (Sauvages), Tinea benigna, Tinea muciftua (Alibert), Porrigo lac- tea, Porrigo larvalis (Willan. Bateman), Lac- tumen, Eczema lactea, &c, according as it was supposed to be allied to Impetigo, Porrigo, or Eczema. This of itself is sufficient to show the very intimate relation of these affections to each other, and to point out the necessity of considering them in their natural conditions, and in connexion with their particular seats, and with the states of vital action; and not merely with reference to certain artificial dis- tinctions, which often cannot be ascertained, and which sometimes do not exist. The dif- ferences between vesicles and pustules, so much insisted on in the classifications usually adopt- ed at the present time, often do not exist, or exist not in such a manner as to become avail- able to the practitioner. These, and numerous others so implicitly received as matters of be- lief, may be useful as a part of the craft of the adept, but they are of very minor importance in the estimation of the truly philosophic ob- server, and are valued by him for just as much as they may he worth, in the particular cases in which they are manifest. An eruption may be vesicular to-day and pustular to-morrow; or, in other words, the former, owing to chan- ges in the vital actions of the part affected, and in the morbid secretion, may pass into the lat- ter ; or both kinds of eruption may be co-exist- ent or coetaneous, either in the same or in different situations of the same case. Instan- ces will also occur in which the most acute observers will be puzzled to determine whether the primary eruption is vesicular or pustular ; for it may be intermediate as respects the ap- pearances both of the contained fluid and of the containing and surrounding tissues. To whatever genus this eruption may be referred —whether it be dignified in being described as a genus of itself, or be viewed as merely a spe- cies, or be debased to the rank merely of a mongrel variety—it is consolatory to know that, in its intenser states and more extended forms, as well as in slighter grades, and how- ever great the attendant pruritus and pain may be, or however deep the chaps or fissures may seem, no permanent marks or cicatrices are produced by them. * 12. B. Impetigo Erysipelatodes is easily dis- tinguished by presenting, at its commencement, the ordinary symptoms of erysipelas. The other varieties of the eruption are in general unattended by any febrile disturbance, although the digestive organs may be more or less dis- ordered. But this is ushered in by decided symptoms of constitutional commotion. Its premonitory stage is characterized by pertur- bation of the system, fever, much burning and smarting heat, an cedematous 6tate of the eye- lids, and a redness and puffy swelling on the upper part of the face. This state of things continues for two or three days ; when, on run- ning the finger over it, the surface, instead of the smoothness of erysipelas, is found to ex- hibit a slight inequality; and on minute exam- ination it seems papular. In a day or two more it is covered with numerous psydracious pustules, which first appear below the eyes, but soon cover the greater part of the face, and sometimes extend to the neck and breast. The itching, smarting, and sense of heat which ac- company these pustules are very distressing. When they break, a hot, acrid fluid exudes, which irritates, and often excoriates the sound surface on which it flows. The face remains in this painful condition for ten or fourteen days, when the discharge diminishes, and con- cretes into thin, yellowish scabs, in the inter- stices between which fresh pustules arise at intervals with renewed heat and pain, and run the same course as the former. The disease may continue thus severe and troublesome for two or three months. The period of its dura- tion, however, is uncertain; and when it dis- appears it leaves the cuticle in the same dry, red, and brittle state which characterizes the departure of the other varieties of impetigo. During the progress of this disease, the health of the patient is not very much disordered, and the constitutional disturbance is much less than in erysipelas. This form of the disease is oc- casionally confounded with eczema impetigi- nodes. In the advanced stage, however, the distinction is easily recognised. 13. Besides the above varieties of impetigo, Willan and Bateman mention another under the title of Impetigo rodens. It is, however, of very rare occurrence, and cannot with proprie- ty be called an impetiginous disease, being more of a malignant ulcer, complicated with psydracia. It is said to be uniformly fatal, and to have been benefited by no remedies, either external or internal, which have been employed for its relief. 14. II. Diagnosis.—The varieties of impeti- go are liable to be confounded with other pus- tular eruptions, especially porrigo, ecthyma, and scabies, and with eczema; but a careful inspec- tion of the pustules and of the incrustations, as either may present themselves, will show the differences between them.—a. The clusters of impetigo are distinguished from the circles of porrigo in not continuing to pour forth a puru- lent and glutinous discharge, but after the first eruption an ichorous humour, and in not form- ing those thick, soft, and copious scabs which characterize the latter disease. The pustules of impetigo discharge, while those of porrigo, seated more deeply, are quickly changed into dry, yellowish-coloured, cup-shaped scabs. The crusts of the former are brown or of a dull gray, and not broad, thick, nor continuous, as in por- rigo scutulata. Impetigo of the hairy scalp is not likely to be mistaken for porrigo Ivpinosa; it does not implicate the piliferoiis bulbs like this and the other varieties of porrigo. It is distinguished, however, with greater difficulty from eczema impetiginodes affecting this part, the principal difference being in the appearance of the incrustations; but, as already insist'd on, these latter are very nearly related erup- tions.—b. The diagnosis between impetigo and scabies depends on the distribution of the erup- tion in patches ; the copious exudation of ichor«; and the reddened, rough, and fissured cuticle; and the heat and smarting which ac- company the itching in the former. In the IMPETIGINOUS AFFECTIONS- Btrictly purulent scabies, the pustules rise to a much greater elevation and magnitude than in this complaint, and are filled with a thick yel- low pus, and are more inflamed around their base. Porrigo and scabies are contagious ; but none of the varieties of impetigo possess this property.—c. In its more advanced stage, im- petigo may be mistaken for psoriasis or lepra; but in these there are no laminated concretions of ichorous matter or lymph, the squama? con- sisting of exfoliations of morbid cuticla These scaly diseases emit no fluid ; and the existence of pustules and of a discharge, however slight, are sufficient to determine the impetiginous eruption.—d. The pustules of psycosis are larger and not so yellow, and are more isolated and more prominent than those of impetigo ; which are always much crowded, and secrete abun- dantly. The scabs of the former are drier and of a deeper colour than the crusts of the latter, and are reproduced only after a fresh eruption of pustules. The crusts in impetigo are green- ish yellow, thick, semitransparent, and repro- duced without any renewal of the pustules. In psycosis, also, the pustules do not break till the fifth, sixth, or seventh day; while in im- petigo they burst on the third or fourth. More- over, tubercles and indurations are observed in the former, but not in the latter.—e. Impetigo is more likely to be confounded with syphilitic eruptions on the face ; but the peculiar charac- ter of venereal desquamations, or the firmly adherent scabs, concealing ulcers and leaving indelible cicatrices, sufficiently distinguish the latter from the former. Some of the forms of eczema may be mistaken for impetigo, but the diagnosis has been fully stated in the article Eczema (§ 13). The most superficial observa- tion will detect the very marked difference be- tween acne rosacea and this complaint. Mr. Dendy states that the internal use of the deuto- ioduret of mercury often produces vesicles, fol- lowed by yellow or yellowish green scaly crusts, which may be easily mistaken for those of im- petigo and porrigo. 15. III. Prognosis.—This is more favoura- ble in impetigo than in lichen, lepra, psoriasis, eczema, and many other cutaneous eruptions. In whatever part of the body the disease, in its acute state, be situated, it generally yields to medicine in two or three weeks. Its duration in the chronic form cannot be stated with pre- cision, as this necessarily depends on the con- stitution of the individual, the number of the eruptions, and the existence of other particular conditions, such as scrofula, pregnancy, ame- norrhcea, the change of life, &c. When chron- ic impetigo occurs on the head, on the upper lip, or any other region covered with hair, it often proves a very obstinate and troublesome disorder ; especially if the patient be of advan- ced age, of a scrofulous diathesis, or a shatter- ed constitution. But under no circumstances can it be regarded as attended by danger. The sudden suppression of the more severe forms of the eruption, particularly those affecting the face and scalp of children, may, however, be productive of most serious disease. 16. IV. Causes.—Impetigo is not communi- cated by infection. It is most frequently ob- served among the poor, ill-lodged, badly fed, and filthily disposed classes. Its exciting caus- es are, however, sometimes obscure. Individ- -Prognosis—Causes—Treatment. 367 uals of a sanguineous, or sanguineo-melancholic, or lymphatic temperament, and scrofulous con- stitution, with a thin, soft skin, are most liable to it. In them it is occasionally excited by violent exercise, by intemperance of any kind, or by the depressing passions of the mind, as grief, disappointment, fear, &c. It is very oft- en preceded by headache, languor, and disorder of the alimentary canal, and cannot be traced to any other exciting cause than this disorder. Infants at the breast, and children during teeth- ing, particularly the lymphatic and scrofulous, are most liable to the varieties affecting the face and scalp. Young persons with fine skins are sometimes attacked with that of the face on exposure to a hot sun. ^Females, on the appearance and on the cessation of the catame- nia, are also apt to be affected with this com- plaint. Several external causes may, however, excite pustules of impetigo by acting directly on the skin. Persons who handle irritating substances, as raw sugar, lime, or metallic dust, often have impetiginous eruptions on the hands. Bateman regards the pustules caused by the ointment of tartarized antimony, as a species of this disease ; but they are of an entirely dif- ferent character, and cannot be classed among any of its varieties. I believe that disorder of the digestive organs, and accumulations of mucous sordes and other secretions in the pri- ma via, more commonly occasion impetigo than is generally supposed. I scarcely have seen a cas-e in which this derangement was not mani- fest either before, or in the course of treatment, and in which this eruption was not evidently symptomatic of it. In this opinion I am sup- ported by Mr. Dendy, my late colleague at the Infirmary for Children, where cases of this kind came frequently before us. 17. V. Treatment.—i. Whatever be the va- riety of simple impetigo, one mode of treatment is indicated. In the commencement of the dis- ease, Willan and Bateman recommend the internal administration of sulphur, but not in sufficient quantity to produce purging; and if there is much inflammatory irritation of the cuticle, soda, nitre, or the bitartrate of potash, with which some of the vegetable acids, as citric acid or lime juice, may be advantageously com- bined. The indiscriminate employment of sul- phur has, however, sometimes aggravated the symptoms and favoured the reappearance of the eruption. I have prescribed, with marked benefit, the sub-borate of soda in emollient vehi- cles, either with or without small doses of ni- tre, or of the bitartrate of potash. Blood-lettings, either general or local, have been proposed in extensive attacks of impetigo figurata, and in plethoric individuals may be of advantage ; but in general they are not productive of benefit, and in persons of a weak and scrofulous habit of body are detrimental. If the eruption is at- tended by much fever, calomel and antimonials, or other mild mercurials, cooling saline solu- tions, and diaphoretics with diuretics, will be of service. 18. Locally, emollient fomentations, such as the decoction of mallows, digitalis, poppy heads, &c, and ablution with tepid water, are of the most essential service in the incipient stage of this disease, especially if the common saline mixture, with conium, be given at the same time. At a later period, saturnine or alkaline ECTIONS—Treatment. 368 IMPETIGINOUS AFF: lotions, and the application of the ointment of the acetate of lead or oxyde of zinc, will accelerate the cure, and will be often sufficient to effect it. 19. ii. When this affection occurs in children at the period of dentition, simple cleanliness is frequently all that is required. Here the erup- tion is occasionally accompanied by a manifest improvement in the constitution, and it would be highly imprudent and even injurious to check or repel it. If it occurs on the hairy scalp or face (§ 10), the hair must be removed and emoll- ient applications resorted to. Where there is much local inflammation, or in plethoric chil- dren, leeches ought to be applied behind the ears. Saline purgatives, as the sulphate of soda, sul- phate of magnesia, or tartrate of potash and soda, may be given with advantage in these cases, in doses of from two drachms to half an ounce daily. If the disease, wherever occur- ring, proves obstinate, it has been usually treat- ed by an alterative mercurial course, particular- ly Plummer's pill, or the hydrargyrum cum creta, with the decoction of sarsaparilla or cinchona; but a more beneficial effect has been derived from the exhibition of five or six grains of calo- mel at bedtime, followed by a brisk cathartic the next morning, and a moderate dose of the liquor arsenicalis, taken three times a day in the de- coction of elm bark. 20. iii. As to local means, almost every vari- ety has been tried in this disease. In some in- stances the patient cannot bear the most sooth- ing and emollient applications, while in others the most stimulant have been employed with advantage. Where the irritation is insupport- able, the use of the hydrocyanic acid has been suggested by Dr. A. T. Thomson, in the propor- tion of one fluid drachm to four fluid ounces of water, combined with one drachm of alcohol, and six or eight grains of acetate of lead; and subsequent experience has shown the value of this application. It soothes the irritation, and disposes the skin to regain its healthy action ; but it must not be applied without caution, as cases have been recorded where it became ab- sorbed into the system, and produced depress- ing effects on the constitution, with consider- able intermission of the pulse. These unpleas- ant symptoms, however, ceased on discontinu- ing it. It is useless to apply any local remedies until the thick incrustations which occur in im- petigo scabida are removed by emollient poulti- ces, or by a weak decoction of poppies, or by exposing the surfaces to the vapour of hot water, &c. Any of the mild ointments before mentioned may afterward be applied, and the surface should be covered with pledgets of soft lint, or the whole should be touched with a so- lution of nitrate of silver ; or if the skin is not very irritable, and the attendant inflammation but slight, while at the same time the disease has become chronic, the baths of Harrowgate, or artificial fumigations of sulphur, the hot air and vapour baths, and the alkaline and sulphureo- gelatinous baths will frequently both procure the removal and prevent the recurrence of the eruption. But in the more inflammatory cases, and in plethoric persons, blood-letting should precede a course of these baths. With the same intention, the baths of Bareges, Lojesche, Cauterets, Enghien, and many other Continent- al springs have been recommended. Great benefit has also been derived from the warm sea-water bath, especially when followed by a course of sea bathing; it should, however, be remembered that salt water is injurious during any actual inflammation. But great discrimi- nation is always required in the treatment of this eruption. Where there are much inflam- mation and irritability of surface, the internal remedies should be of a cooling and sedative nature, and the external applications emoll- ient and palliative; in an opposite state, the arsenical solution may be given; and slightly stimulant ointments, such as the ointment of nitrate of mercury diluted with six or seven parts of simple ointment, or an ointment of trisnitrate of bismuth may be applied. In all cases the diet of the patient should be restricted, and animal food taken in very moderate quan- tity : milk and farinaceous food are the most appropriate. Fermented liquors, spirits, and wine ought to be strictly forbidden. 21. iv. In impetigo erysipelatodes antiphlogis- tic means must be early adopted. Purgative medicines, especially the infusion of senna with full doses of the alkaline carbonates, and the neutral salts with antimonials and nitre, will ma- terially alleviate the fever; but when the dis- charge is copious, and incrustations begin to be formed, the greatest benefit will be derived from the decoction of cinchona with hydrochloric or dilute sulphuric acid. If the disease becomes chronic, a slight alterative course of mercury and of sarsaparilla generally proves beneficial. The solution of potash and the alkaline carbonates are also serviceable, when taken in tonic infu- sions. The local remedies, which were recom- mended in the other forms of the disease, namely, emollient fomentations and tepid ablu- tions, mild ointments applied to the excoriated surfaces, and sea bathing, or sulphureous fumi- gation on the decline of the eruption, will also be required in this variety. [The treatment of impetigo rarely comes un- der the eye of the physician at its first com- mencement, when the fluid which the vesicles contain is transparent (lymph), instead of opaque and purulent. We are inclined to be- lieve, from what we have observed, that if the diseased secretion was frequently removed by ablution with warm water, while, at the same time, saline cathartics were administered, a cooling regimen enjoined, and all greasy irrita- ting applications withheld, the disease would generally be effectually subdued within a very short time. The part should be kept moisten- ed with cold water, or a weak solution of the acetate cf lead, and covered with oiled silk to prevent evaporation. It is customary with some practitioners to resort, at an early period, to the use of sulphureous preparations, believing that they exert a specihc influence in control- ling the disease. There can be no doubt, how- ever, that the attack is often aggravated and prolonged by their injudicious and indiscrimi- nate employment in the early stages of the dis- ease. As a general rule, they should not be employed in the commencement, and where the affection is of limited extent; all that is neces- sary is to confine the patient to cooling drinks, and relieve the local irritation by emollient lo- tions of poppy heads, decoction of mallows, flaxseed, tepid milk, or scalded bran. If the af- fection is attended with much inflammation, general or local bleeding will be useful, with IMPOTENCE AND STERILITY. 369 cathartics and emollient lotions, and an infu- sion of the succory or chiccory, with half an ounce of soda to the pint; general tepid ba- thing (the baths being made alkaline by soda or potash) and douches of vapour to the part will also prove beneficial, where the disease is ob- stinate, by changing the action of the skin. In severe cases, purging with calomel and Epsom salts will often be followed by complete suc- cess, especially if preceded by general bleed- ing. Mr. Plumbe recommends, under the same circumstances, acidulated drinks, made by add- ing from half a drachm to a drachm of sulphu- ric acid to a pint of water. He also recom- mends alkaline, alternated with acidulous lo- tions, to the part affected, after clearing the diseased surfaces as much as possible from the scabs that cover them. We have found the me- dicinal hydrocyanic acid very effectual, in the proportion of fjij. to half a pint of pure water, with the addition of half an ounce of rectified alcohol. After the disease has become chron- ic, the sulphurous preparations will prove high- ly advantageous, especially the natural sulphur waters of Sharon, Avon, and the Virginia Springs. A new spring, strongly impregnated with sulphuretted hydrogen, and containing only, according to our analysis, fifteen grains of saline and earthy matters to the gallon, will undoubtedly be found useful in the treatment of this and other cutaneous affections.* The water should be used both internally and exter- nally : where the natural waters cannot be had, an artificial sulphur bath may be prepared, by adding from two to four ounces of sulphuret of potash to a bath. The same preparation may be used internally and as a lotion. Where-the vapour douche is employed—and it should never be omitted in chronic cases—it should be ap- plied for the space of from ten to twenty min- utes each time. In some obstinate cases of limited extent, we have used an ointment of ioduret of sulphur, sufficiently strong to produce a cauterizing effect, with complete success. It should be made, for this purpose, in the propor- tion of twenty or thirty grains to the ounce of lard. A weak solution of the nitrate of silver, applied with a camel's hair brush, will also ar- rest the disease, as will the ointment of the proto-nitrate of mercury (3i. to ?j. lard). When all other means fail, we shall be justified in re- sorting to the arsenical preparations. The iodides should not be omitted in chronic cases. Dr. Hendric has related some instances (" Phil. Jour, of the Med. and Phys. Sciences," p. 400) where obstinate cases of impetigo were cured by means of the expressed juice of the Sangui- naria canadensis, which possesses acrid and stimulating properties. Benefit might also be derived from employing the juice of others of our indigenous acrid vegetables.] Biblioo. and Refer. — Celsus, L. v., c. 28, n. 17.— Aitius, Tetrab., Serm. iv., cap. 130.—Avicenna, Canon., 1. iv., fen. 7, tract 3, cap 1. —Paulus JEginus, L. iv., c. 3. — Riverius, Observ. Commun., p. 661.—Lossius, Concil.,n. 42. — /. P. Frank, De Cur. Horn. Morb., 1. iv., p. 11.— Fo- restus, Observ. et Curat., lib. xxviii. — Callisen, Chirurg. Hodiern., sect. 612.— Willan, Practical Treatise on Impeti- go, &c, 4to. Lond., 1814.—Marcolini, Sopra alcune Im- petigini Memoria. Venezia, 1820.—S. Plumbe, On Dis. of the Skin, eea taken. 20. That the time required for the stomachic digestion depends upon the quantity and kind of food, and upon the state of the stomach ; that the time required for the dispo- sal of a moderate meal, in a healthy'state of the organ, va- ries from three hours to three hours and a half or four hours; and that in states of indigestion the process is de- layed much longer than this, particularly as respects the more indigestible substances. 21. That a diminution of the temperature of the stomach below 98° impedes digestion ; and that the temperature of the organ is not necessarily elevated by the process. 22. That whatever promotes organic nervous power with- out exhausting it favours digestion, as breathing a dry, pure air, hilarity of mind, moderate laughter, &c. 23. That the organic or ganglial nervous influence is more concerned in the process of digestion than the influ- ence conveyed to the stomach by the eighth pair of nerves ; and that the circulating, absorbing, and especially the se- creting functions of the organ, are under the dominion of the former, while the sensibility and muscular contraction! are directed by the latter. 24. That the inferences drawn by Dr. W. Philip from his experiments as to digestion depending upon the influ- ence of the eighth pair of nerves, and as to galvanism being capable of supplying the place of this influence, are unphil- osophical, as they are formed without due consideration of all the circumstances, and as they leave out of the account the shock given to the system by the violent operations per- formed in these experiments. M—Treatment. 388 INDIGESTIOI [Every close observer of disease must ac- knowledge that dyspepsia is symptomatic of two opposite conditions of the stomach: one of congestion, or inflammatory irritation ; the other of anaemia, or, rather, of deranged ner- vous sensibility. The latter form of indiges- tion, consisting in a purely morbid state of the sensibility of the gastric nerves, has been well described by Dr. James Johnson, in his work on the Morbid Sensibility of the Stomach and Bowels, to which the reader is referred. Now it is obvious that, for the successful treatment of this disease, we should be able to determine with some certainty whether the symptoms are dependant on nervous or vascular irritation— whether the gastric mucous membrane be in a state of active congestion, or the nervous sen- sibility of the organ only be deranged. By at- tending to the following directions, chiefly from Jolly, we shall be materially aided in arriving at a correct diagnosis. In a purely nervous af- fection of the stomach we have pain of an acute, tearing, intermittent kind, diminished by pressure, and by taking food; more fre- quently occurring in the morning. In inflam- matory affections of the stomach we have pain of a dull, obscure, constant kind, augmented by pressure and by food, increasing towards the evening. In the former (the nervous) we have the tongue sometimes coated, broad, and clean ; in the latter, almost always red, contracted, thickly coated. In the former the appetite is morbidly increased, depraved, and there is a craving for high-seasoned dishes and alcoholic drinks; in the latter the appetite is wanting, never depraved, and there is an aversion to high-seasoned food and alcoholic stimulants. In nervous affections of the stomach the taste is metallic, or acid, and there is a vomiting of mucous secretions ; in the inflammatory affec- tions the taste is bitter or clammy, and the food is rejected. In the former the thirst is not increased, and there is a desire for warm or cold drinks indiscriminately ; in the latter there is morbid thirst, and a constant wish for cold drinks. In the former there is frequent constipation, while the stools are often natural, and not offensive; in the latter there is frequent diarrhoea, with bilious, mucous, bloody, or of- fensive stools. In the former there is frequent- ly pulsation in epigastrio, intermittent, and not synchronous with those of the heart; in the latter the pulsations in the epigastrium are natural, continuous, and synchronous with the cardiac pulsations. In the former there is ei- ther no fever, or it is of an intermittent kind ; in the latter there is fever, which is continuous. In the former there is an increase of the dis- ease early in the day, the urine is clear and abundant, and the heat of skin natural; in the latter there is apt to be an exacerbation in the evening, the urine is high-coloured and scanty, and the temperature of the surface is augment- ed. In the former there is no progressive ema- ciation, the physiognomy is natural, the temper morose, melancholy, or irritable ; in the latter there is a gradual wasting of flesh, the features are pale, sallow, sunken, or anxious, and the disposition but little altered. In the former the diagnosis is often obscure, the prognosis less dangerous, and the anatomical characters equivocal or altogether wanting ; in the latter the diagnosis is usually more clear, the prog- nosis more unfavourable, and the anatomical characters constant, but more or less varied. Occasionally, however, the symptoms of vas- cular and nervous irritation of the stomach are so similar that the most experienced practition- er is at a loss to decide upon their precise path- ological character, and we are guided in our diagnosis chiefly by the results of treatment. And there can be no doubt, moreover, that ca- ses of a complicated character often occur in which there is a blending of the symptoms above detailed, indicating a union of gastritis with exalted gastric sensibility.] 38. IV. Treatment.—There are few diseas- es which require greater attention to its causes and to its various states during treatment than this. The objects of the practitioner are, 1. To ascertain the predisposing and exciting causes; 2. To draw a rational inference as to the path- ological states on which the complaint depends ; and, 3. To examine into its associations, and to attend to the nature and relations of its com- plications, whether primary or consecutive. Guided by these general intentions, the more special indications are, I. To avoid the causes ; 2. To give immediate relief to the more urgent symptoms, as acidity, cardialgia, flatulence, pain, costiveness, &c. ; 3. To remove the path- ological states and their consequences ; and, 4. To prevent a return of the disorder. These in- dications require to be fulfilled by means appro- priate to the particular form of the complaint; 39. i. Treatment of the Asthenic Form of Dys- pepsia.—A. In the more acute states, it is some- times necessary to remove the load by which the stomach is oppressed, or the substance by which it is irritated, by an emetic. But, unless when it is obvious that the disorder depends upon this cause, emetics are injurious, partic- ularly a repetition of them. In such circum- stances, the effect is soon produced by irrita- ting the fauces by a feather, or with the finger ; by a warm infusion of chamomile flowers ; by tepid water, with common salt, or with an ape- rient salt, and by ipecacuanha. When pallor of the countenance, nausea, oppression, and the sense of a load at the epigastrium, and rancid or bitter eructations are present, emetics are indicated ; and these are the most suitable means. But after the organ is evacuated, its functions should he restored by repose, and by small quantities of Seltzer water, of iced water, or a cooling aromatic water, as spearmint, &c. Food should not be given till the appetite re- turns, when the lighter and more palatable ar- ticles may be taken. The bowels afterward require to be evacuated, either by stomachic aperients, as rhubarb, with magnesia or soda, in an aromatic water, or aloes with an alkali, as in the compound decoction, or by enemata. Most of the means recommended in the article Constipation (§ 15, et seq.), and in several of the Formulae of the Appendix, will likewise be appropriate in these circumstances. 40. When nausea continues after the stom- ach and bowels have been evacuated, or when the vomiting is protracted after offending mat- ters are removed, medicines to relieve these symptoms should be prescribed, especially the hydrocyanic acid, in camphor julep, with a little compound spirit of lavender, or tincture of car- damoms, or a drop or two of creosote, in the form of a pill, with powdered liquorice root. INDIGESTION—Treatment. 389 Effervescing draughts, with citric acid and am- monia, this last being somewhat in excess ; or the liquor ammoniae acetatis, with camphor mixture, or with spearmint water; or calcined magnesia, in this or in any other aromatic wa- ter, will also be serviceable. If these fail of affording relief, active purgative enemata will generally be efficacious, the symptoms disap- pearing as soon as a free action of the bowels is procured. 41. Heartburn is best treated by medicines which act upon the secretions and move the bowels. Rhubarb, with magnesia, and sesqui- carbonate of ammonia, in an aromatic water ; a blue pill, with Castile soap; and alkaline so- lutions in bitter tonic infusions, or in lime-wa- teT, are commonly employed, and are most use- ful when this symptom is connected with acid- ity. But when heartburn is attended by ran- cid, septic, or insipid eructations, the mineral acids, as the nitric, the hydrochloric, and the aromatic sulphuric acids, given in simple cam- phor, or aromatic water, or in suitable tonic in- fusions, will be most serviceable. Dr. Pem- berton advises lemon juice in these cases, and Dr. Todd the phosphoric acid. When there is a liability to heartburn, wine, spirits, and par- ticularly malt liquors, should be avoided. Hock or old sherry may, however, be taken in great moderation in Seltzer water. [Ipecacuanha, in small doses, often proves a very efficacious remedy for heartburn ; and the following pill may be taken three times a day with decided benefit: R Pulv. Ipecac, gr. xii.; Pulv. Rhei, Sapon., aa, jss. M .Ft. mass, in pill. xviii. divide ; where nausea is present, a small quantity of aromatic powder, ammonia, or qui- nine, will often afford relief. The latter, com- bined with ipecacuanha, forms a very effica- cious remedy, as does also the ipecacuanha and ammonia. The sulphuret of potassa and the natural sulphur waters have formerly enjoyed a high reputation in the treatment of this affec- tion. The former may be advantageously com- bined with the extract of gentian or hop, or with rhubarb or aloes. Dr. Dick (On the Di- gestive Organs, p. 128, Phil, edit.) recommends gunpowder in cases of heartburn with eructa- tions, as tending to relieve the morbid sensa- tions, correct the secretions, preserve the bow- els in a soluble state, and to exercise a very favourable action upon the skin, kidneys, and lungs.] 42. Pain, or the slighter states of morbid sen- sibility, will be best removed by the trisnitrate of bismuth, conjoined with extract of hop, or ex- tract of hyoscyamus; by hydrocyanic acid or cre- asote, as directed above* ($ 40) -, by other ano- * [The hydrocyanic acid is an admirable remedy in this form of dyspepsia, attended with pain and cardialgia, and prepares the stomach for the reception of tonics and oth- er remedies which otherwise would be inadmissible. It has been used to a considerable extent in this country by some practitioners ; but the difficulty of preserving it of a suitable and uniform strength, the danger from differences in formulae, and its alleged uncertainty, have all tended to prevent its general introduction into practice. But these drawbacks may be guarded against by using that prepared according to the last United States Pharmacopeia (1842), which contains 2 per cent, of pure anhydrous acid, and keeping it carefully protected from the light. For the re- lief of gastralgia, even when complicated with gastritis, we know no remedy comparable with it; and between the pe- riods of its administration we may give the carbonate of iron, or quinine with ipecacuanha, or strychnine (which is an admirable remedy in many cases of dyspepsia), with the best effect.] dynes, given with aromatics and antispasmod- ics ; by the compound or foetid spirit of ammo- nia, in suitable vehicles ; by the compound gal- banum pill, or the compound rhubarb pill, with henbane and ipecacuanha; by draughts of warm water, either alone, or with an alkali, or with magnesia. If pain be severe, and if vomiting have come on spontaneously, and continued af- ter morbid matters are removed, a full dose of opium, with an aromatic, or of the acetate or hydrochlorate of morphia, similarly combined, should be prescribed. But the propriety and frequency of repeating it will depend upon the circumstances of the case. Ifflatulence is troub- lesome, the means already advised may be pre- scribed, or those recommended in that article (§ 15) may be employed. Friction over the ep- igastrium, especially with a stimulating lini- ment, will also give immediate relief from both pain and flatulence. When headache is present, the treatment proposed for Dyspeptic Headache (§ 46) should be directed. For the costiveness so generally attendant upon this form of indi- gestion, the medicines already noticed, or those about to be prescribed, or a combination of mild aperients with tonics, deobstruents and altera- tives being given occasionally at night, will prove of great service. [Some writers have recommended the oil of turpentine in this form of dyspepsia, when of long duration, and the patient is exhausted by its violence, in doses of a drachm every hour or two, mixed with mucilage. We have known it employed with much benefit under such cir- cumstances, as we have also the arsenical solu- tion (Fowler's) and the nitrate of silver, in do- ses of a sixth of a grain, gradually increased to three or four grains, three times a day, in the form of pills. We consider it important, to en- sure the full effects of this remedy, that no chlo- ride of soda or common salt should be taken either immediately before or after taking the pills. Where gastrodynia assumes a periodical character, a watery infusion of bark, or even qui- nine, will often afford relief, but alcoholic tinc- tures should be entirely proscribed. Besides the danger of creating an appetite for stimulants of this kind, they almost invariably exasperate the disease, although they often afford tempo- rary relief. In these cases, attended with cardialgia ow- ing to acidity, the following formula is recom- mended by Dr. Chapman : # Carbonat. Sodas, vel. Carb. Potass., 3ii.; Gum Arabic, 31J.; Sp. Lavend. Comp., 3L ; Tinct. Theh, gtt. xx.; Aq. font., fiv. M. Where the stomach has lost its tone, as in the case of drunkards, the following preparation will succeed better than any other: # Aq. Ammo, pur., 3J.; Magnes. Calcin., 31J. ; Aquae Cinnam., fij. ; Aq. font., ;vj. M. Where much muriatic acid already exists in the stom- ach, ammonia is supposed to be objectionable, from its liability to form a muriate of ammo- nia, which would prove a source of irritation. Under these circumstances, the ensuing mix- ture will answer: # Liquor Potassae pur., 3J.; Magnes. Calc, 31J.; Aq. Cinnamom., fij. ; Aq. font., s-vj. The dose of this and the preceding mixtures is about fss., repeated pro re nata.] 43. After an acute attack of dyspepsia, par- ticularly when occasioned by errors of diet, it is necessary to enjoin abstinence, and thus af- ford the stomach time for repose, until its or* 390 INDIGESTION—Treatment. ganic sensibility and functions begin to return. After a while, a cupful of mutton or veal broth, or of green tea, or of coffee without milk, may be given and repeated ; or a wine-glassful of Port-wine negus may, in some cases, be allow- ed. But care should be taken in returning to a full diet; and the injunctions as to diet about to be stated ought to receive attention. In gen- eral, tonics and stomachics should not be pre- scribed until the functions of the stomach are returning. 44. B. Having removed the more acute at- tack of asthenic dyspepsia, with its urgent symptoms, the remaining disorder is in all re- spects the same as the more slight and chronic states of the complaint, and requires a similar treatment to them. The third intention of cure ($ 38) should now be carried into effect; and the organic nervous energy, the secretions, and the muscular tone of the stomach be improved. This intention is to be effected chiefly by the diet and regimen hereafter to be noticed ; but a judicious recourse to medicine will also prove of great benefit. The infusion of cinchona, of columba, of gentian, chamomile, cusparia, cas- carilla, will be severally useful, with the alka- line carbonates, and small doses of stomachic tinctures. Afterward the metallic tonics, as the tincture of the sesquichloride of iron, the sul- phate of iron, the sulphate of zinc, the trisni- trate of bismuth, and the mineral acids, will generally be of service. Several of these may be given with the extract or tincture of hop, or of hyoscyamus. Lime-water may be taken with aromatics, particularly when the bowels are much relaxed ; and the aerated or alkaline chalybeate waters may be used. When there is no complication contra-indicating cold bath- ing or the shower bath, it will be advantageous to resort to them frequently ; and when unea- siness at the epigastrium is often felt, a warm plaster will be worn in this situation with ben- efit. 45. The most active or varied means employ- ed to restore the functions of the stomach will be frequently inefficacious if the offices of the collatitious viscera be imperfectly performed. The biliary secretion should therefore be promo- ted or corrected by occasional doses of blue pill, or Plummer's pill with soap ; and the bow- els preserved moderately open by mild purga- tives, or by a combination of them with bitters and tonics. With this view, rhubarb may be eonjoined with aloes, guaiacum, and ipecacu- anha, or with magnesia ; the infusion of senna, with the infusion of gentian; the compound decoction of aloes, with the decoction or ex- tract of taraxacum ; the sulphate of potash with rhubarb ; the purified extract of aloes with Castile soap, &c. These and other mild purgatives may be taken in other combinations, as draughts, mixtures, or pills, as prescribed in numerous and various forms in the Appendix, and in the article Constipation. A judicious combination of bitters with mild purgatives, as of sulphate of quinine, or inspissated ox-gall with aloes (F. 562, 575); the infusion of senna with any of the bitter infusions (F, 266); and the decoction of aloes with soda and infusion of columba, will generally be extremely useful in this state of the complaint. 46. When chronic asthenic dyspepsia is at- tended, not only by a torpid state of the liver, but also by incipient cachexia, or has given rise to cutaneous eruptions, &c, much benefit will result from the simple preparations of sarsa, with liquor potassae or Brandish'* alkaline so- lution, and extract of taraxacum. If it have occasioned difficult or impaired menstruation, or a state of incipient chlorosis, as often ob- served in females in London, the preparations of iron, particularly the mistura ferri composi- ta, the decoction of aloes being taken so as to act freely on the bowels ; or the pilula ferri composita, conjoined either with the pil. aloes cum myrrha or the pil. aloes composita, will generally remove all disorder, if sufficiently persisted in, and aided by change of air, diet, and exercise. 47. In this form of dyspepsia, the restoration of the digestive functions much depends upon a healthy state of the other excreting organs, as well as of the bowels. The functions of the kidneys and of the skin should be duly promo- ted and corrected. The temperature of the general surface and the exhalations from it ought to be preserved, and the urine duly ex- amined, in order to ascertain, not only its ap- pearance, but the general character of its chem- ical constituents. As these vary, or as cer- tain of them predominate, so should some of the most efficacious medicines prescribed in the complaint be varied or altogether changed; so should tonics be conjoined with alkalies or acids; and aperients and alteratives be given with absorbents or deobstruents. [In this form of dyspepsia, unattended with gastric irritation, we have found the chalybeate waters of Saratoga very beneficial, taken in moderate quantities, and at regular intervals. A tepid bath of 70°, or a shower bath of the same temperature, or colder if the impression is agreeable, should be used night and morn- ing while drinking the waters, and as much ex- ercise taken on foot as possible short of pro- ducing much fatigue. This, with a diet con- sisting of tender beefsteak or mutton chop, plain-boiled rice, stale wheat bread (or that made of the unbolted meal if the bowels are costive), and these taken in very moderate quantities, at an interval of at least six hours, will, in a large majority of cases, afford deci- ded relief, if not effect a permanent cure. Ir the treatment of this disease, in those who have been accustomed to much intellectual exertion, it is absolutely necessary to enjoin a suspen- sion of all mental labour ; for, as this is one of the most efficient causes of indigestion in this country, so its entire suspension is essential to the removal of the malady.] 48. ii. The irritative variety of dyspepsia re- quires very different means of cure from those just advised ; but the removal of the exciting causes is as necessary in the treatment of it as in that of the foregoing.—a. In the more acute states of this variety, when pain, tenderness, heat, or soreness is felt in the epigastrium, al- though the vascular disorder of the villous sur- face may not amount, it nearly approaches to inflammation; and erethism, or vascular con- gestion, at leastK exists. The application of leeches to the epigastrium then becomes neces- sary. In plethoric persons, a bleeding from the arm should be preferred. In those who have suffered from haemorrhoids, or obstructions of the liver, cupping on the hypochondria, and in INDIGESTION—Treatment. 391 females whose catamenia are deficient, leeches to the groins, may he prescribed. Afterward a large rubefacient plaster, formed either of equal parts of the compound pitch and ammoniacal plasters, or of seven parts of the former with one of the cantharides plaster, should be appli- ed over the epigastrium. The blue pill, or hy- drarg. cum creta, should be taken at bedtime, and a mild aperient in the morning. Fresh cas- tor oil, assisted by cathartic enemata, will be useful in this variety. In some of the more acute cases, a full dose of calomel, either alone or with a little James's powder, will be of ser- vice. Although calomel, when frequently ex- hibited, weakens the nervous energy, yet an occasional dose diminishes vascular action in the villous coat of the stomach, and excites the actions of the lower bowels. It should be fol- lowed by mild purgatives and active enemata ; for by increasing the organic actions of the lower portion, the morbid states of the upper parts of the digestive tube will the more readi- ly subside. When this variety of dyspepsia is attended by an erythematic rednessxor soreness of the fauces and pharynx, as it frequently is, sometimes extending down along the oesopha- gus, calomel, taken in the form of powder, aid- ed by mild aperients and active enemata, will be of essential service, not only in acting in the manner just stated, but also in promoting the secretions of the liver and intestinal canal. 49. The other urgent symptoms, noticed with reference to the former variety, are generally much more severe in this, and require a some- what modified treatment. But irritation, ere- thism, congestion, or even inflammatory action of the villous coat are not the only pathological states characterizing cases of this kind. Or- ganic nervous power, the secretion of the gas- tric juices, and the tone of the coats of the stomach, are more or less weakened or disor- dered, and require to be strengthened as well as corrected. At first, cooling medicines and diaphoretics are required, in order to remove irritation or vascular excitement; but they should afterward be conjoined with mild tonics or gentle restoratives, and aided by a light far- inaeeous diet {$ 72). If nausea or vomiting oc- cur in this variety, the means already prescri- bed ($ 40, 41) will generally remove them. If they proceed from irritating ingesta, the gentle measures noticed above (§ 39) will procure their expulsion. Afterward, small doses of the ni- trate of potash, and of the solution of the ace- tate of ammonia, may be taken in camphor wa- ter. When this variety is caused by intemper- ance, these medicines, aided by abstinence, will prove particularly serviceable. If pain or in- ternal heat is complained of, or if vomiting con- tinues after offending matters are removed, or after vascular depletion has been practised, the warm turpentine epithem, or a mustard poul- tice, may be applied over the region of the stomach, or one of the liniments above refer- red to may be used as an embrocation in the same situation. The anodynes advised for the asthenic variety may also be taken, and ca- thartic enemata administered, until the bowels are freely evacuated. The medicines already recommended for heartburn, and for other un- pleasant symptoms, will also be appropriate after having had recourse to the means just advised. [Some cases of indigestion are attended with vomiting and diarrhoea. Under such circum- stances we should aim to allay the irritability of the mucous surfaces by mild opiates and antacid or absorbent remedies: the hyd. cum creta, gr. ij., with one grain of Dover's powder, may be given two or three times a day; or, if acidity be present, the carbonate of soda with morphia, or a grain or two of rhubarb with the same anodyne. The hydrocyanic acid is also a valuable remedy in these cases, combined with the chalk mixture; and we have derived great benefit from applying a few leeches over the epi- gastrium, and then a small blister, which should be dressed with a cerate containing three or four grains of morphia to the ounce. The diet, of course, should be chiefly farinaceous.] 50. b. In the chronic states of irritative dys- pepsia, local depletions are requisite only when there is evidence of plethora, or of increased action, or when natural secretions or accustom- ed evacuations are suppressed. Small doses of mild mercurials at bedtime, the simple prep- arations of sarsa, either alone or with liquor potassae, and external derivatives, are here ex- tremely beneficial. After the secretions have been improved by these, and the excreting func- tions restored, the milder tonics, conjoined with refrigerants and diaphoretics or anodynes, will be of great service. The decoction of Ice- land moss, and various other demulcents, may be taken with hydrocyanic acid ; and a plaster, consisting of either the ammoniacal, the com- pound pitch, or the compound galbanum plas- ter, may be worn on the epigastrium. I have generally preferred a plaster consisting of equal parts of the compound pitch and of the ammo- niaeo-mereurial plasters, and prescribed the fol- lowing : No. 262. ft Potasss Nitratis 3ss,; Liquor. Ammonias Acetatis fi.; Infusi vel Decocti Cinchona fiii. M. Capiat Coch. ii., veL iiii., larga bis terve in die. No. 263. it Potassie Nitratis ,3i. ; Liquoris Ammonia Acetatis jf i.; Aquae Flor. et Infusi. Aurantii Comp. aa Jiiss. Misce. Capiat tertiam partem, ter in die. No 264. ft Acidi Hydrocyanici, M. ii., Mist. Amygdalae Duleis ; Aqua Flor. Aurantii, et Mistur. Camphor, aa fss. M. Fiat Ilaustus ter in die sumendus. No. 265. ft Infusi Lupuli, Jivss.; Acidi Hydrocyanici, M. viii.; Tinct. Aurantii et Tinct. Gentians Comp. aa 3ii. M. Capiat quartam partem bis terve in die. No. 266. R Liquoris Potassae, 3i#s.; Decocti Sarzae, f vii.; Extracti Sarzae, 3iss. ; Tinctur. Hyoscyami, 3i. ; Tinct. Aurantii, 3iii.; Sirup. Sarzae, 3ii. M. Fiat Mistura, cu- jus capiat partem quartam ter quaterve in die. No. 267. ft Infusi Valerianae, 3x.; Acidi Hydrocyanici fllii.; Sodae Carbonatis, gr. x. ; Tinct. Cardamom. Comp., 3i.; Spirit. Lavand. Comp., 3ss. M. Fiat Haustus ter in die sumendus. [In cases of indigestion attended with pain and constipation, Mr. Langston Parker (The Stomach in its Morbid States, &c, Phil., 1841) recommends the following formulae as afford- ing much relief: # Pulv. Rhei, gr. iv.; Mor- phia? MUriatis, gr. yL M. Ft. pill, ter die su- mend. Cum Cochlear., iij., larg. Misturae se- quent. # Infus. Cascarillse, fvii.; Magnes. Sulphatis, ?ss. ; Magnes. Carb., 3Jss.; Tinct. A[oes, fss. ; Acidi Hydrocyanici, gtt. xv. ; Tinct. Humuli, 31J. M. Cap. Cochlear., iij., larg. ter die. These preparations are said to act freely on the bowels, without occasioning pain. After constipation has been obviated, the following preparation will be found very useful: #. Magnes. Carb., 3J.; Bismuth Sub- nit., gr. v.; Morphiae Muriatis, gr. i. M. Ft. pulv. ter die sumendus. The indications un- 392 INDIGESTION—Treatment. der this form of the malady are to remove pain and obviate constipation, by which it is always aggravated, to subdue concomitant inflamma- tory action, and to enable the stomach, when these intentions have been accomplished, to fulfil its offices again properly. As laxatives, in the treatment of indigestion attended with constipation, we have derived great benefit from the use of the following preparations: R- Pulv. Rhei, 31J.; Pulv. Ipecac, gr. x. ; 01. Carui, gtt. x. ; Sirup Commun., q. s. Ft. mass, et div. in pilul. xl.; or, R Gum Mastic, Pulv. Aloes, aa. 3J.; Pulv. Ipecac, gr. x.; 01. Carui, gtt. x. ; Muc Gum Arabic, q. s. Ft. mass. ; div. in pilul. xx. Rhubarb, aloes, ipe- cacuanha, and soap make a very good prepara- tion ; as does also the following: R Pulv. Rhei, 3ij. ; Pulv. Gentian., 3J.; Sodae Carbon., 31J.; Aq. font., Oj. M. Ft. infus.] 51. iii. Treatment of the earlier consequences of dyspepsia.—The treatment of several of these is fully discussed in the articles Duodenum, Flatulence, Headache, Hypochondriasis, Pyrosis, and Stomach—Painful Affections of. It will therefore be unnecessary to advance much under this head.—a. When dyspepsia, in either of its forms, causes frequent attacks of relaxation and soreness of the throat and fau- ces, or inflammatory redness of these parts with cough, the diet of the patient should be strictly regulated, and mild purgatives, aided by cathartic enemata, prescribed. These at- tacks should not be neglected in persons pre- senting any tendency to bronchitis, or to pec- toral disease. Some of the severest states of laryngitis and tracheitis have originated in ir- ritative dyspepsia, the symptomatic irritation of the pharynx and fauces extending to the larynx, and exposure to cold, to currents of air, or to other causes, heightening the affection of the respiratory passages. A predisposition to affections of the respiratory organs, or tu- bercles in a latent state, are then often called into activity by neglected dyspepsia, owing ei- ther to symptomatic irritation or to consequent debility. In females, excessive menstruation, as to either the frequency or quantity of the discharge, is often the more immediate conse- quence, or intervenes between the dyspeptic disorder and the pulmonary affection. In such cases the treatment should be directed both to the original disorder and to the consequent af- fections ; and, fortunately, much of the means, both medicinal and dietetical is appropriate to both, the more astringent and refrigerant ton- ics, and mild or cooling aperients, benefiting the disorder of the stomach as well as the su- perinduced complaints. To these medicines, ipecacuanha, camphor, and narcotics will be added with advantage. 52. b. The symptomatic disorder of the heart, consequent upon one or other of the varieties of dyspepsia, requires chiefly attention to the original complaint. When palpitation is fre- quent, or the pulse intermittent, after the bow- els have been freely evacuated and the secre- tions improved, camphor and ipecacuanha with hyoscyamus ; the sulphate of iron with extract of hop; the decoction of senega with orange- flower water, or infusion of orange peel and hydrocyanic acid; the infusion of valerian sim- ilarly combined; the nitrate of silver triturated with the extract of henbane, or of hop, will severally afford relief. In the irritative states of dyspepsia, particularly if signs of congestion, erethism, or inflammatory irritation of the vil- lous coat be present, the treatment advised above for this state ought to be premised. At the same time, some one of the warm plasters already prescribed may be applied to the epi- gastrium. In 1820 I first employed the nitrate of silver, combined with narcotics, for a case of dyspeptic palpitation, commencing with half a grain thrice daily, and increasing the dose to one grain. This patient, and others similarly affected, for whom I have ordered this medi- cine, perfectly recovered. Dr. J. Johnson has strongly recommended the nitrate of silver in dyspepsia; and, certainly, few medicines are more deserving adoption, when the patient is not alarmed at its use. It should, however, be very cautiously employed. This writer also insists much upon the use of the sulphate of quinine in most dyspeptic cases. In small doses, with sulphuric acid, in infusion of roses, it is an excellent medicine at that stage of the treatment when active tonics should be pre- scribed, especially when much debility is com- plained of. In order to prevent its constipating effects, it may be given with small doses of the purified extract of aloes, or with the aloes and myrrh pill; and when palpitations and other nervous symptoms exist, camphor and hyoscy- amus will be added to them with great benefit. In females who have long laboured under dys- pepsia, the quinine, taken in solution, is very serviceable when the catamenia are too abun- dant ; but in other circumstances, particularly when a chlorotic state of the system, and im- paired or obstructed menstruation have super- vened, the sulphate of iron with the aloetic prep- arations should be preferred. 53. c. Of all the consequences of protracted and irritative dyspepsia, disorder of the biliary functions and disease of the liver are the most common. When evidence of congestion, or fulness, or tenderness in the region of the liver exists, then the treatment should be commen- ced with general or local depletions, with cup- ping on the hypochondrium or near the right shoulder blade, or with the application of a number of leeches near the epigastrium, or around the anus. Small doses of blue pill, or of calomel, ought to be taken occasionally at bedtime, and to be followed by saline aperients in the morning. Alterative medicines, consist- ing chiefly of the alkaline carbonates, or of the liquor potassae, should be given daily, with ta- raxacum, sarsa, and such of the other remedies above recommended as may be appropriate to the case ; but the treatment of this complica- tion is fully discussed in the arlicles Gall- bladder and Ducts, Jaundice, and Liver. 54. d. Cutaneous eruptions, both acute and chronic, frequently are associated with the more protracted states of dyspepsia, and arer often consequences of these states. Yet they are seldom referred to these sources, or to these conditions of the villous surface of the stomach, of the digestive mucous surface gen- erally, and of the biliary and other excreting functions with which they are so intimately connected. In numerous instances, heating, stimulating, and irritating medicines are pre- scribed, either prematurely, or at a time or stage of the treatment of these eruptions when INDIGESTION—Of local or general depletions, refrigerants, evacu- ants, alteratives, and a low, cooling diet ought to have been employed. This remark is ap- plicable also to those early indications of biliary disorder, of affections of the kidneys and uri- nary bladder, and especially of gout, which so often appear in the course of chronic indiges- tion. [To these most comprehensive and judicious directions of our author but little remains to be added. From a somewhat extended experience in the treatment of the different forms of indi- gestion, we are inclined to believe that far too little attention is generally paid to restoring and maintaining the healthy functions of the skin. We can call to mind several most ob- stinate cases which had resisted the whole routine of remedies usually employed for this affection, and which readily yielded to the daily employment of the vapour bath, friction with the hair glove and the flesh brush, and other means to restore cutaneous action. We be- lieve, therefore, with Professor Chapman, who has laid down most admirable precepts on the management of dyspeptic maladies (Lectures on the more important Diseases of the Thoracic and Abdominal Viscera, Phil., 1844), that it is, for the most part, well to let the stomach alone, or, forbearing the use of every sort of internal medicament, and particularly of any activity, to endeavour to abate and draw away the irri- tation to the exterior surface by a combination of depletory and revellent means, as local bleed- ing, rubefacients, sinapisms, vesicatories, the vapour, tepid, and warm baths, or the Croton oil, so as to induce pustulation. When the latter is employed, if the irritation seems to be seated in the ganglionic nerves, it is preferable to make the application to the epigastrium, but over the spine when the irritation seems to proceed from the rachidian axis. Dr. C. rec- ommends to cup the spine and counter-irritate the epigastrium. " By this simple plan," says he, " aided by the regimen hereafter to be pointed out, I have met with no difficulty in arresting the progress of the disease, and am persuaded, from ample experience, that it is the one which only will be found productive of apy uniformity of success. As corroborative of the correctness of this view, in theory and practice, it may be remarked, that whenever a metastasis of the irritation takes place to the surface, as an efflorescence or any other form of eruption, relief is ordinarily afforded. Nor to the other and rarer form of the disease, depend- ant principally on a want of muscular contrac- tility alone, from imperfect innervation, have I found this plan less applicable. It might, in- deed, be affirmed to be more prompt and effec- tual under such circumstances. Cases without number have I known with a permanently dis- tended stomach, and the indescribable wretch- edness of this state, which, after refusing to yield to every variety of internal remedy, were very speedily cured by the topical applications to the exterior already enumerated."—(Loc. cit., p. 224.)] 55. Of the Diet and Regimen in Dyspep- sia.—Unless the diet of the dyspeptic be duly regulated, medical means will be employed in vain. On the subject of diet with reference to indigestion, Dr. Paris, Dr. A. Combe, Dr. Rob- ertson, Dr. Ticknor, Dr. T. J. Todd, and Mr. 50 he Diet and Regimen. 393 Mayo have furnished much information of tha best kind, and conveyed it in the most agree- able manner. It is impossible to adduce any- thing on this topic which has not been already stated and" illustrated by these able writers.— i. In considering diet with reference to indigestion generally, there are various circumstances re- quiring particular notice : 1st. The kinds and quality of the food ; 2d. The quantity and con- gruity of the food ; 3d. The times of eating, or the periods which should intervene between meals ; 4th. The kind and quantity of drinks ; and, 5th. The conditions deserving notice in connexion with eating and drinking. 56. A. The kinds and quality of food.—a. Dr. Combe justly remarks that a direct relation ought always to subsist between the qualities of the food and the nature of the constitution which it is intended to support. The highly concentrated and stimulating food necessary for the support of those who take very active exercise will prove too exciting to the irritable constitution of persons possessed of great ac- tivity of the brain and nervous system ; and the generous diet which suffices to rouse or sup- port a phlegmatic system will prove too nutri- tive for a person of a florid and sanguine tem- perament. For persons of a florid complexion, with great activity of the circulation, and a consequent liability to inflammatory diseases, the food ought to be calculated to soothe rather than to stimulate. Red meat, spices, wines, and fermented liquors ought to be used spa- ringly, and the principal support derived from soups, fish, mucilaginous vegetables, acidulous fruits, and diluting drinks. In lymphatic per- sons, on the other hand, where the circulation is weak and slow, and the functions feeble, benefit is derived from a larger proportion of animal food, while vegetables, soups, and fluids prove relaxing. To these persons, wine in moderation and spices are useful, if much ex- ercise be taken. Persons of a highly nervous temperament, of great excitability and sensi- bility to impressions, are injured by heating or stimulating diet. White meats, as fowl and fish, farinaceous and mucilaginous aliments, and ripe fruits, are most appropriate to them. Where the bilious temperament predominates, and much active exercise is taken in the open air, a full supply of animal food is necessary, and a moderate allowance of wine or other stimulus is borne with less detriment, if not with more advantage, than in the sanguine and nervous temperaments. Where the constitu- tion is of a mixed nature, a diet composed of animal and vegetable substances, in nearly equal proportions, is, under ordinary circum- stances, the best. The food, also, should be adapted to the age, state of health, and mode of life of the individual, and to the climate and season of the year. A diet which would be quite sufficient to a person of sedentary occu- pations would be inadequate to support an in- dividual subjected to frequent or constant ex- ertion ; and in warm climates and seasons, a smaller supply of food, particularly of a heating or stimulating kind, is necessary than in cold and temperate countries. In the former but little animal food is requisite ; in the latter, especially in very cold regions and in rigorous seasons, an abundant supply of this kind of diet becomes indispensable. 394 INDIGESTION—Or the Diet and Regimen. 57. b. Although there are few articles of diet which a healthy person, leading a sufficiently active life, may not eat with impunity, there are many which ought to be preferred, and others which should be avoided by the dyspep- tic. Vegetables are slower of digestion than animal and farinaceous aliments, and more lia- ble to undergo the acetous fermentation in weak stomachs, and to occasion acidity and flatulence. Fat and oily meats are also very indigestible, and give rise to acid or rancid eructations and heartburn. Soups and liquid food are acted upon by the stomach with great difficulty; and if the diet consist chiefly of them, they furnish insufficient nourishment, and never fail of producing the more severe forms of dyspepsia, and the diseases of debili- ty. Soups are hurtful when taken at the com- mencement of a full meal; but when little or no animal food is eaten along with them, and rice or bread is taken with them, so as to pro- mote their consistency, they are digested with greater ease. Pastry, puddings, rich cakes, and articles containing fatty or oily matter, are the most indigestible of all kinds of food. Plain, well-cooked animal food, particularly venison and game, kept a due time after it has been killed, and eaten in moderate quantity with bread, or with roasted, mashed, or dry mealy potatoes, or with rice, is one of the most digestible meals that can be taken by the dys- peptic. The kind, however, of animal food, and the modes of dressing it, should depend much upon the state of disorder, and the age and constitution of the patient. 58. c. Fish holds an intermediate rank be- tween the flesh of warm-blooded animals and vegetable food, as respects digestibility. It is less nutritious than mutton or beef; and a lar- ger quantity is requisite to satisfy the appetite. Whiting, haddock, and skate are the most di- gestible of salt-water, and perch of fresh-water fish. Gurnard, cod. soles, and turbot are suc- cessively richer and heavier, but easier of di- gestion than mackerel, herrings, eels, or sal- mon. Eels are, however, more digestible when they are stewed. Salmon is very indigestible, as usually obtained from the London fishmon- gers, for the reasons stated in the article Dis- ease (§ 46); but it is not indigestible when quite fresh and properly cooked. The same obser- vation applies to mackerel and herrings. Fish is most digestible when boiled; it is less so when broiled; and the least so when fried. The dyspeptic should eat it dressed only in the first of these ways. Shell-fish is slow of digestion ; some much more than others. Raw oysters are more digestible than crabs or lobsters ; but oysters, when stewed or otherwise cooked, are heavier than either. Fish is often rendered indigestible by the sauces, &c, taken with it. Vinegar, however, and lemon juice promote the digestion of it. Malt liquor ought not to be drank with fish. Fruit should not be eaten with it; and milk, likewise, should be avoided. 59. B. The quantity of food should always be proportioned to the digestive powers of the stomach and the wants of the system. Where waste is great, and growth active, an abundant supply of food is requisite, and the desire for it is commensurate with the demand. Those who lead sedentary lives, and whose circum- stances admit of free living, are peculiarly lia- ble to dyspeptic complaints, owing chiefly to the quantity of food indulged in. It is indis- pensable to a due and natural supply of aliment to the stomach, that attention be paid to the preliminary processes of mastication and deglu- tition. If these be performed too hastily, too much food will be received in a short time, in a state of insufficient preparation, and the stom- ach will be overloaded before the sensation of hunger can be completely allayed. As the dilatation of the stomach by the ingesta should be gradual, and ought not to exceed a certain limit, and as a definite quantity of gastric juice is secreted, according to the wants of the sys- tem and the habits of the individual, if more than the usual quantity of food be taken, the organ will be over-distended and a part of it will remain undissolved, producing the usual symptoms of indigestion. Such being the case even with the healthy, how much greater will be the disorder when excesses are committed by the dyspeptic. Sir F. Head very justly re- marks " that almost every malady to which the human frame is liable is either by high-ways or by-ways connected with the stomach ; and I must own I never see a fashionable physician mysteriously counting the pulse of a plethoric patient, or, with a silver spoon on his tongue, importantly looking down his red, inflamed gul- let, but I feel a desire to exclaim, ' Why not tell the poor gentleman at once, Sir, you've eaten too much, you've drunk too much, and you've not taken exercise enough !' " Dr. Ab- ercrombie observes, <; when we consider the manner in which diet is generally conducted in regard to the quantity and variety of food and drink, instead of being astonished at the preva- lence of indigestion, the wonder should be that any stomach, having such duties imposed on it, is capable of digesting at all." Much, cer- tainly, is to be done in dyspepsia by attention to the quality of the articles of food, but much more depends upon the quantity; indeed, the dys- peptic might almost be independent of attention to the former if he rigidly observed the latter. This opinion is supported by the experiments of Dr. Beaumont, showing that the power of digestion is limited by the amount of gastric juice provided by the stomach—an amount va- rying with the modes of life and the wants of the system. It is superfluous to remark that second courses, served up to gratify the pride of the host, overcome the stomach, paralyze digestion, and occasion acute attacks of indi- gestion. 60. It is impossible to assign any rules re- specting the quantity of food that should be taken, as it depends upon so many circumstan- ces. Mixtures of different kinds of food are in- jurious to digestion, chiefly by the inducement to excess in quantity which the variety affords, and by the incongruity of many of the articles. When only one dish is partaken of, Dr. Combe remarks, there is less temptation to exceed the quantity than when several are tried. The first intimations of a satisfied appetite are warnings to stop eating, which should never bo neglected by dyspeptics. If these be passed by, indigestion, or an aggravation of it where it is already present, will always result. The quautity of food should also have reference to the amount of exercise. When little or no waste is excited by exercise, the supply should INDIGESTION-Of i be remarkably moderate, as well as digestible. Persons who have removed from the country, where they have enjoyed active exercise in the open air, and have consequently digested well a full diet, generally become dyspeptic when they have removed to large towns, and are sub- jected to very different circumstances, espe- cially if they continue the same quantity of food, or if they increase it. 61. C. The times of eating.—In general, five or six hours should elapse between one meal and another. Even in healthy persons, diges- tion of a full meal is seldom over in less than four hours ; and in dyspeptics it is seldom dis- posed of until a much longer period has passed. The stomach, also, requires an interval of rest after the process is finished, in order to enable it to enter upon the vigorous digestion of the next meal. If food be taken before the organ has recovered itself from its previous exertion, the secretion of the gastric juices and the muscular contractions will be imperfect. The whole of the gastric juice which the stomach can secrete in a given time being engaged in the digestion of the first meal, the one taken too closely upon it will be insufficiently acted upon, and thereby undergo fermentation. The intervals between meals should be in relation to the quantity eaten, and the habits of the individual as to air and exercise. When the latter are enjoyed, the periods may be much shorter than when the habits are sedentary. 62. For dyspeptics, as well as for healthy persons, the meals should be regulated accord- ing to the necessary occupations and habits of the individual. For those, observes Dr. Combe, who work by day and sleep by night an early breakfast, an early dinner, and an early evening meal will be most conducive to health ; but for those who, against the laws of nature, keep late hours, late breakfasts and dinners are preferable. Persons who eat suppers ought not to breakfast till one or two hours after ri- sing ; but those who dine late, and eat nothing afterward, require breakfast sooner. As a gen- eral rule, breakfast about half an hour or an hour after rising will be found most beneficial. Those who are obliged to rise very early should take a cup of coffee or tea, with a biscuit, soon after getting up, and a more substantial break- fast about three hours afterward. If exposure to cold, to the morning dews, or to unwhole- some air, or to any other cause of infection, be incurred in the morning, the stomach should be fortified by coffee or by breakfast. The dys- peptic, especially, ought never to travel, or to enter upon any exertion with an empty stom- ach, and never with an overloaded one. 63. As a general rule, not more than five or six hours should elapse from breakfast till din- ner. For youth and convalescents, and for persons taking active exercise in the open air, the interval may be somewhat shortened ; but for sedentary persons it may be much prolong- ed. Much, however, should depend upon the appetite, which ought to have returned some time before dinner is taken. According to this, the most suitable time for this meal is about two o'clock. As many dyspeptics as well as others cannot dine until much later in the day, ought nothing to be taken till five, six, or seven o'clock 1 or ought a light repast to be taken at one or two o'clock, and the appetite be chiefly he Diet and Regimen. 395 reserved for a substantial meal at a much later hour? When dinner cannot be taken until eight or nine hours after breakfast, it will be necessary to have some refreshment in the mean time ; but it should be in relation to the time that will elapse until dinner, and to the ex- ercise taken. For persons of sedentary habits, a biscuit and a glass of water will be sufficient; but for the active and the young, especially if the interval be long, a more substantial lunch- eon is necessary. The habit of resorting to pastry-cooks for refreshment, and of taking wine with it, is generally prejudicial, and par- ticularly in dyspepsia. When dinner cannot be taken until a late hour, it should always be postponed for half an hour or an hour, until ex- citement or fatigue has subsided. 64. When the dinner is early—from one to three o'clock—a light meal of tea or coffee and bread is necessary ; but when the dinner is late, or little exercise is taken after it, tea or coffee should be used merely as a diluent, and no food ought to be eaten. After an early dinner, ad- mitting of time for its digestion and a return of the appetite before a late hour, a third meal, of light aliments, and in moderate quantity, should be taken, particularly by persons enga- ged in the open air. When ultra-temperance is practised by the dyspeptic, particularly when he lives actively, and retires to bed with an entirely empty stomach, he is quite as likely to have disturbed sleep and unpleasant dreams as if he had his stomach loaded.. He may even be wakeful and irritable, or experience a sense of unpleasant emptiness or gnawing at the stom- ach. All these may he removed by a basin of arrow-root or sago about an hour before bedtime. A light supper may, therefore, be ta- ken when the dinner is early; but it should be at least an hour or two before retiring to rest. 65. D. The dyspeptic, as well as other vale- tudinarians, inquire, What ought we to drink? but they rarely follow the question by the next important one, When should we drink? And they never inquire as to the temperature at which fluid should be taken.—a. Respecting theirs/ of these questions, it may be stated that water— either spring water or toast-water—is the safest if it be taken only according to the dictates of thirst. Whey, fresh small beer, soda water, and Seltzer water, are of service in many cases, as will be noticed hereafter; but fermented liquors and wines require greater restrictions. The young dyspeptic ought never to drink any- thing but water, toast-water, or whey. The more stimulating beverages will be prejudicial to him, unless during states of debility, for which it may be necessary to prescribe them medicinally. Of all these, spirituous liquors are the most injurious, and ought never to be taken in any form, nor in any variety of indi- gestion. Some of the asthenic states of the complaint, which are benefited by a moderate use of wine, are exasperated by spirits, or even by malt liquors. Dr. Beaumont found, on ex- amining St. Martin's stomach after a free in- dulgence in ardent spirits for several days, the villous surface covered with erythematic and aphthous patches, the secretions vitiated, and the gastric juice diminished in quantity, viscid, and unhealthy, although he complained of no- thing, not even of impaired appetite. Two days later, when matters were aggravated, the 396 INDIGESTION—Of the Diet and Regimen. erythematic appearance was more extensive, the spots more livid, and from the surface of some of them small drops of grumous blood exuded. The aphthous patches were larger and more numerous, the mucous covering thicker than usual, and the gastric secretions much more vitiated. The fluids extracted from the organ were mixed with much thicker ropy mucus and muco-purulent discharges> slightly tinged with blood. Yet St. Martin complain- ed only of an uneasy sensation, and a tender- ness at the pit of the stomach, with vertigo and dimness of vision on stooping. The tongue was covered with a yellowish brown coating, and the countenance was somewhat sallow. After a few days of low diet, with mild diluents, the inner surface of the stomach assumed its healthy state, the gastric juice became clear and abundant, the secretions natural, and the appetite- voracious. Dr. Beaumont adds that the free use of ardent spirits, wine, beer, or any intoxicating liquor, when continued for some days, invariably produced these morbid states. Eating voraciously or to excess, and swallow- ing food imperfectly masticated, or too fast, produced the same effects when repeated fre- quently in close succession. (Exper. and Ob- serv., &c, p. 237.) ^ He often observed that, when stomachic disorder, with febrile symp- toms, was present, or when influenced by. vio- lent mental emotions, the villous coat of the stomach became red, irritable, and dry; and that but little gastric juice was secreted on the food being taken, digestion being very much prolonged. No more wine, therefore, nor more of any other fermented liquor, should be taken, than may be found sufficient to support the strength and ameliorate the symptoms of the dyspeptic without quickening the circulation. 66. b. As a general rule, the desire for fluids is the chief indication of the time at which they ought to be taken; but large draughts should be avoided, as the stomach becomes suddenly distended, the juices diluted, and the muscular coat weakened by them. Besides, much more fluid may be thus taken than is necessary for the wants of the system. The dyspeptic ought never to drink largely, either during or soon after a meal. Frequent sipping, or drinking by mouthfuls, will be much more beneficial, and, ultimately, more quenching of thirst. Mild drinks are best taken about three or four hours after a solid meal. It is then that tea and cof- fee are used as beverages. These are always injurious when made too strong, or taken in large quantity, especially to the dyspeptic. Soda water drank at the time of dinner is hurt- ful, by distending and over-exciting the stom- ach. Seltzer water is less so ; but it is often of service some time after a meal, when there is much thirst. Soda water is then sometimes also of use. 67. c. The temperature at which fluids should be taken is of the utmost importance to the dys- peptic. Extremes of temperature are injurious even to the healthy, and not only to the stomach, but also to the collatitious viscera, and to the teeth. The bad effects of the ingestion of large quantities of cold water into the stomach have been often demonstrated; but the subject has been very superficially considered. Dr. Beau- mont remarked that a gill of water, at the tem- perature of 55°, received into St. Martin's stomach when empty, reduced the heat of the organ from 99° to 70°, at which it stood for a few minutes, and then rose very slowly. This experiment explains the injurious effects pro- duced upon weak stomachs by cold fluids taken during digestion, and the fatal effects of very copious draughts of cold water while the body is fatigued and perspiring; the shock which the constitution receives from having the tem- perature of the most vital and central organ suddenly and remarkably depressed paralyzing the other vital movements. It having been de- monstrated that a temperature of 98° is re- quisite to healthy digestion, it must follow that the use of ices, and particularly iced creams after dinner, or when digestion is proceeding, will be most injurious. A fit of indigestion is often caused by them ; and they seldom fail of lowering the vital tone of the stomach during the digestive process. The moderate use, how- ever, of cold or iced water, or of water ices, when this process is completed, and when there is no exhaustion, is beneficial, by indu- cing a salutary reaction in the organ. Ices can be only taken slowly, and in small quanti- ties at a time ; hence they produce a much less sudden fall of temperature of the stomach than draughts of cold fluids. Dr. Dunglison states that labourers in Virginia were frequently kill- ed by drinking copiously of spring water when overheated; but that such accidents have rare- ly occurred since they have been supplied with ice. The proper temperature at which soups, tea, coffee, chocolate, &c„ should be taken may be stated at about 100°; and at this grade of heat liquids will be found more quenching to thirst than at a higher or lower temperature. 68. E. The conditions necessary to promote a healthy digestion require a brief notice. The determination of the circulating fluids to the digestive mucous surface and collatitious vis- cera, and the copious secretion from these vis- cera during digestion, require that the function should not be disturbed by moral or physical perturbation or exertion. Rest of body and tranquillity of mind for a short time before and after, but particularly after eating, are hence conducive to digestion. Whatever derives the nervous energy and the circulating fluids from the digestive viscera, or causes oppression of these viscera, by overloading the large veins, is injurious during digestion. Hence blood- letting, hot or cold bathing, mental shocks, ex- ertions of any kind, and other circumstances which operate in this way, are more or less hurtful. As the quantity of gastric juice re- quisite to the digestion of a full meal is gener- ally secreted in an hour or an hour and a half after it is taken, or, at least, within two hours, even in the dyspeptic, bodily and mental re- pose is beneficial during this time. It is thus that a siesta after dinner is found so servicea- ble to the dyspeptic. But, by promoting diges- tion, it favours supply, diminishes waste, and consequently induces vascular plethora, and the usual consequences of this state, particu- larly in respect of the brain and liver. In dys- pepsia, the desire for rest after a repast is great in proportion to the quantity eaten, the ner- vous energy being concentrated in the digest- ive viscera in order to dispose of the ingesta. The state of the mind has a powerful influence on digestion: hilarity and ease of mind pro- INDIGESTION—Of the Diet and Regimen. 397 mote this function; wrhile care, anxiety, envy, and dissatisfaction impede it. Dr. Caldwell remarks that dyspepsia commences perhaps as often in the brain as in the stomach. It is al- most exclusively a complaint of the studious, the scheming, the daring adventurer, the stock- jobber, and the speculator, and of those who, over-exerting their brains, thereby injure them. 69. ii. Of the diet and regimen with reference to the different stales of dyspepsia. The observa- tions of Dr. Todd as to the diet suitable to the different states of dyspepsia are extremely just and precise. I shall therefore avail my- self of some of them.—A. During the asthenic forms of indigestion, the quantity of food should be reduced to the power of disposing of it; such articles as are difficult of digestion and weaken the stomach being altogether with- drawn.—a. The patient should be confined to a spare diet of animal food, and to a restricted use of fluids. A bulky meal ought always to be avoided; and when the appetite is impaired, abstinence will be frequently preferable to the use of stomachics. When the appetite does not fail, which is often the case when dyspep- sia is produced by mental exertion, the patient should cease eating before the appetite is alto- gether allayed. The tea or coffee at breakfast should be taken with very little milk and sugar, and very little butter ought to be used. An egg, lightly boiled, may be eaten by those who take sufficient exercise. The dinner should consist of lean animal food, particularly mut- ton, poultry, game, and venison, which ought to be roasted or broiled. Bulky vegetables should be avoided ; but mealy potatoes, yams, or rice, mixed with the gravy of the meat, young summer turnips, cauliflower, or French beans, may be taken sparingly. The least hurt- ful fruits are strawberries, morel cherries, and mulberries ; but they should be eaten as a part of the luncheon, rather than after dinner. Flu- ids, even when there is thirst, should be taken slowly, and in small quantity, and always after a meal. If the digestion or habit require the stimulus of wine, old sherry, or old port, with an equal part of water, should be preferred; but the quantity of either, or of both, should not exceed two or three glasses. Twice-dress- ed meat, rechauffees, and made dishes ought not to be eaten ; and the food should be masti- cated slowly and thoroughly. 70. b. The kinds of food most injurious in this variety of dyspepsia, and therefore to be avoid- ed, are sweet, mucilaginous, or acid fluids, and such as contain much milk ; puddings, com- pound dishes, and meat pies ; new bread, or heavy unfermented bread ; compact or fat dumplings, and pultaceous articles ; creams, curds, custards, cheese, and all preparations of milk; fat meat, particularly pork or bacon, young meat, all gelatinous parts of meat, and salted or smoked meat; the less digestible spe- cies of fish, and all shell-fish; strong broths, gelatinous soups, or concentrated dishes ; melted butter, oil, sauces, spices, condiments, and pickles ; bulky or flatulent vegetables, es- pecially cabbages, waxy potatoes, pot-herbs, beans, pease, cucumbers, &c ; most fruits, whether fresh or preserved ; currants, goose- berries, apples, plums, melons, all kinds of nuts or kernels, and preserves or jellies. Malt li- quors, particularly ale, perry, cider, home- made wines, punch, and shrub, should also be avoided. 71. c. Regular exercise ought to be taken in the open air; and the kinds of exercise that bring the greatest number of muscles into mod- erate action should be preferred. Celsus very justly advises persons subject to stomach com- plaints to exercise the upper extremities and parts of the body. There are several amuse- ments which have this effect, especially bill- iards, fencing, rowing, cricket, &c. For fe- males, singing, dancing, skipping, battledore, dumb-bells, and the exercises recommended by Mr. D. Walker, will be found very servicea- ble, especially when confined to the house by weather, or when exercise on horseback or on foot cannot be taken. 72. B. The diet and regimen most suited for the irritative states of indigestion differ considerably from those now recommended. In this varie- ty, bland, farinaceous, and semi-fluid food, in small or moderate quantity, is the most appro- priate, until vascular disorder of the villous coat of the stomach is removed by treatment. Saccharine, farinaceous, feculent, mucilagin- ous, and acidulous articles of food are most ea- sily digested in this condition of the organ. Gentle exercise, as gestation in a carriage or on horseback, sailing, swinging, and walking, is preferable to the more exciting kinds of ex- ercise. After digestion is completed, tepid or warm bathing, and frictions of the surface are generally beneficial. When vascular excite- ment is removed, the patient may gradually adopt the diet advised for the preceding varie- ty, beginning with light chicken, mutton, or veal broth, with toast or rice ,• and afterward the more digestible kinds of solid food may be used. 73. C. The wines and beverages best suited for indigestion are old sherry or port, diluted with equal parts of water, the finer kinds of claret, hock, white hermitage, and Sauterne; but these should not be taken in the irrita- tive forms of dyspepsia until vascular excite- ment of the villous coat of the stomach is re- moved. The diluents most beneficial are Selt- zer water with a small quantity of hock, or Selt- zer water with milk or whey, or limewater with milk or black tea, according to the pecu- liarity of the case. In the more irritable states of the stomach, whey, goat's whey, small quan- tities of Seltzer water, or the imperial drink, should be preferred. When the state of the urine indicates the impropriety of using vege- table or mineral acids, the alkaline carbonates may be substituted ; but, when indigestion has induced a torpid or disordered state of the bil- iary organs, not connected with inflammation, beverages slightly acidulated with the nitro-hy- drochloric acids will be found serviceable. 74. D. Several mineral waters, both natural and factitious, are most excellent aids in the treatment of the several forms of indigestion. —a. In the asthenic variety, the mineral springs of Clifton, Malvern, Bath, and Tunbridge Wells, and the carbonated chalybeate waters of Spa, Pyrmont, Carlsbad, Marienbad, Swelbach, and Eger, on the Continent; or their imitations prepared by Dr. Struve, are generally benefi- cial.—b. In the irritative states of dyspepsia, the springs of Harrowgate, of Ems, Plombieres, Vichy, and of Marienbad, or other alkaline 398 BIBLIOGRAPHY AND REFERENCES. mineral waters, will be used with advantage. When the functions of the liver are disordered, the waters of Cheltenham or Leamington, or of the Beulah Spa, and the springs of Seid- schutz and Pullna, may be preferred ; but when excitement of the villous coat of the stomach, and when the functiens of the excreting vis- cera are restored, the aerated chalybeate wa- ters already mentioned will be most service- able. [With respect to the use of the natural min- eral waters in this disease, Dr. Chapman gives the preference to the sulphur waters of Virginia, " as well from superiority of climate as the greater diversity of qualities. Imbosomed within a mountainous region," he adds, " where" the heats of summer never penetrate, and from which the diseases of the season are excluded, there is, within a very limited space, a group of some ten or fifteen of these waters, of deci- ded activity, including natural baths of every gradation of temperature and difference of med- ication. Not a little is to be ascribed to their medical properties, though, in a just apprecia- tion of them, we must also include the advan- tage of the change of scene, a purer air, a more cheerful society, and the interruption of perni- cious habits and associations. It is in these modes that a long journey over a delightful district of country, or a visit to a European metropolis, or a residence in some of the ge- nial climates of that section of the world proves so effectual."—(Loc. cit., p. 252.) We have little doubt that it is generally owing to these latter influences, and not to the qualities of the waters, that dyspeptic invalids are so often in- debted for an amelioration of their sufferings, although, under circumstances already indica- ted, the chalybeate waters are decidedly bene- ficial.] Biblioo. and Refer. — /. P. de Lignamine, De Uno- quoque Cibo et Potu Utili et Nocivo. Rom., 4to, 1474.—C. Apicius, De Arte Coquinaria. Mediol., 4to, 1498.—B. Fiera, Coeua, de eat Medics Artis quae in Victus Ratione Consistit. Argent., 8vo, 1530.—B. Platina, De Honesta Voluptate, de Ratione Victus, &c. Far., 12mo, 1530.—Albengnefith, De Virtutibus Ciborum et Medicam. Argent., fol., 1533.— C. Langthon, an Introd. into Physike wyth an Universal Diet. Lond., 8vo, 1550.—L. Comoro, De Vitae Sobriae Commodis. I'adoa, 4to, 1558.—J. B. Champier, De Re Cibana, lib. x.xii. Lugd. Bat., 8vo, 1560. — G. Gratarotus. De Regimine iter Agentium, lib. ii. Basil, 8vo, 1561.—A. Fracantianus, in Libro Hippocratis de Alim. Commentari us. Venet., 4to, 1566. —Af. Sybillinus, De Medicam. Stomachicis quae Ven- triculi mcdentur Iinbecillitatibus. Basil, 4to, 1580.—B. A. Ferrioli, Von den Ma£;enschwachkeiten, &c. Insprug, 4to, 15'J0.—B. Pisanelli, Trattato della Natura de Clbi et dej Bere. Venez, 8vo, 1506.—T. Cogan, The Haven of Health amplified on Five Words of Hippocrates—Labour, Mente, Drinke, Slepe, Venus. Lond., 4lo, 1598. — J. Bruyerinus De Re Cibana, lib. xxii. Francf., 12mo, 1600.— E. Hollyn- g/us, De Salubri Studiosorum Victu. Ingols., 8vo, 1602.— J. P. Surdus, Tractatus de Alimentis. Lugd., fol., 1602.— M. Zuccari, De Vera et Methodica Nutnendi Ratione. Neapoli, 4to, 1602. — /. L. Costaus, Tractatus de Potu in Morbis. Pap., 4to, 1604; et do Facili Medicina per Seri et Lactis Usum, libri tres. Pap., 4to, 1604. —P. Sismus, De Diaeto. Hagae, 12mo, 1604.—J. Quercitanus, Diaeteticnn Polyhistoricon. Par., 8vo, 1606. —/. Castalio, De Frigido et Calido Potu. Rom., 4to, 1607.—/. Sporisch, De Ratione curandi Morbos per Bonnm Diietam, lib. vi. Lips., 8vo, 1607.—R. Goclenius, De Portentosis Nostri Seculi Conviviis. Marpurz, 12mo, 1609.—A. Freitag, De Esculentorum et Po- tulentorum Facultatibus. Gen., 18mo, 1614. - J. Varan- da:us, De Morbis Ventriculi, lib. iii. Monspel.,8vo, 1619.— A. dc Balingham, Congressus Pomeridiani et Sennones Symposiaci, contra Cibi Potusque Intemperantiam. Col. Agr., 8vo, 1620 — F. Scacchus, De Salubri Potu. Romae, 4to, 1622. — P. Castellanus, KpcuMpuyia, sive de Esu Car- nitum, lib. iv. Antv., 8vo, 1626.—/. D. Sala, De Alimentis eteoruir. recta Administratione. Patav.,4to, 1628.—/. Hart, KXivtKn, or the Diet of the Diseased. Lond., fol., 1633.— S. R. Castrensis, Commentari us in llippocrate de Alimento. Flor., fol., 1635.—De la Chambrt, Nouvelles Conjecture* sur la Digestion. Par., 4to, 1636. — /. Fretnshemius. Da Callida Potu Dissertat. Arg., 12mo, 1636.—H. Mercunahs, Excerpta de Potion, ac Eduliis Antiquorum. Venet., fol., 1644.—L. Nonnius, Diaeteticon, sive de Re Cibana. Ant., 4to, 1646.—M. Sebiz, De Alimentorum Facultatibus, lib. v. Argent., 4to, 1650.— V. Buhus, De Calido, Fngido, et Tem- perato Antiquorum Potu. Rom., 1655. — Th. Muffet, Health's Improvement, or Rules of the Nature, , 17^2.— P. B. C. Graumann, Diatetisches Wochenblatt Flier Alio Stande. Rost., 8vo, 1783.—L. Spallanzani, Experiences sur la Digestion, par Senebier. Genev., 8vo, 1783.—/. T. Plcnk, Bromotologia, seu Doctrlna de Esculentis et Potu- lentis. Vien., 8vo, 1784. — 6'. Ferris, A Dissertation on Milk. Lond., 8vo, 1785. — B. Carminati, Richerche su la Natura e su gli Usi del Sugo Gastrico in Medicina e Chi- rurgia. Milano, 4to, 1785. — L. J. M. Daubenton, Me moire sur les Indigestions Plus Frequentes a l'Age de 40 a 45 Ans. Par., 8vo, 1785.—/. Rymer, A Tract upon Indigestion and the Hypochondriac Disease. Lond., 8vo, 1785. — Af. W. Neufville, Grundriss einer Abhandlung von der Sy.mpathia des Verdauungssytems. Goett., 8vo, 1786.—Af. Petit Radel, Essai sur le Lait Considere Medicinalement Par., 8vo, 1787. — T. Lardizabal, Memoria Sobre las Utilidndes de Chocolate. Pamplona, 8vo, 1788.—C. /. Boehme, Anleitung, die Vorzuglichsten Krankheiten der Ersten Wege Grund- [ lich zu Heilen. Leips., 8vo, 1788.—VV. Stark, Works of; BIBLIOGRAPHY AND REFERENCES. 399 Clinical and Anatomical Observations, with Experiments, Dietetical and Statical, Ed. by /. C. Smyth. Lond., 4to, 1788. — G. F. Hildebrandt, Geschichte der Unreinigkeiten im Magem und den Gedarmen. Braunsch, 8vo, 1789.—/. G. Reyher, Allgemeine Pathologische Dial Order Lebens- ordnung fiir Kranke. Schwer., 8vo, 1790. — G. Fordyce, A Treatise on the Digestion of Food. Lond., 8vo, 1791.— G. G. Richter, Praecepta Diaetetica, et de Materia Alimen- taria. Bern., J2mo, 1791. — C. Webster, Facts tending to Bhow the Connexion of the Stomach with Life, Disease, and Recovery. Lond., 8vo, 1793 (The original of Aber- nethy's system).—G. C. G. Wedekind, De Morborum Brima- rum Viarum Vera Notitia et Curatione. Nurub., 4to, 1792. — G. A. Gramberg, De Vera Notilione et Cura Morborum Primarum Viarum. Erlang., 8vo, 1793.—R. Squirrell, Es- say on Indigestion and its Consequences. Lond., 8vo, 1795. —F. Leonardi, Dizionario Ragionato Degli Alimenti. Rom., 8vo, 1795.— W. Buchan, Observ. on the Diet of the Common People, recommending a less expensive and more whole- some Mode. Lond., 1797.—R. Short, On Drinking Water, and on Warm Drink. Lond., 12mo, 1799. — A. F. M. Wil- lich, Lectures on Diet and Regimen. Lond., 8vo, 1799.— E. Taylor, Medical Remarks on Tea, Coffee, Tobacco, .* ~ '"a be £■£" . £ xs a jjila -_■ I'g-S o >-g o £ W cs. fc v. 3 3 5 2 o e- .9 ^-S ia.s x-s = a g to g " a 3 g f ,^.£'■3 S.I3.S o. 'i. Impalpable specific in- fections of susceptible persons. Diffusive or volatile infections, fre- quently epidemic. i. Palpable specific conta- gions. Consistent con- tagions. iii. Infections both diffu- sive and consistent. — Often epidemic. . Animal matter in a state of pu- tridity or decomposition. . Morbid secretions communicated from the lower animals by con- tact or inoculation. :. The poisonous bites of insects and reptiles. f Emanations from the secretions, ex- | cretions, and surfaces of persons ^ already affected. Propagating | their kind by a diffused and im- L palpable effluvium or vapour. A specific secretion or virus from the seat of disease perpetuating maladies always presenting the same characters. 'Diffusive and impalpable emana- tions, and consistent secretions from the bodies of the infected, either of which may produce the same disease.* The irritative fever, or malignant effects produced upon opening recent bodies, by the morbid se- cretions poured out in serous cav- ities. l Diffusiveordisorganizinginflamma- < tion of cellular parts. Inflamma- ' tion of lymphatics of veins, the Diseases, pro- duced by Infection vary with the sources and modes of infection, with the concentration or intensity of the infectious agents, and with the predisposition or susceptibility of the persons exposed to them. Certain of these agents pro- duce a determinate effect, or a specific form of disease, particularly those comprised under the third class.—A. It has been supposed that the terrestrial miasms or mephitic vapours, emitted by marshes and other sources of malaria, pro- duce only intermittent and remittent fevers. Some writers, however, have contended that true yellow fever, and even plague, also spring from these sources, aided by the influence of high ranges of temperature and an epidemic state of the air. That terrestrial miasms are capable of producing, under these circumstan- ces, pernicious or malignant forms of fever, which assume either a remittent or a contin- ued type, according to concurring causes and the state of the patient, I will readily admit; but that they occasion either true yellow fever or plague is an assumption founded on precon- ceived and fallacious views, which every cir- cumstance connected with the origin and path- ological relations of these maladies fully dis- prove. (See Art. Pestilences.) 23. That malaria, however, produces a wider range of. diseased action than has been long supposed, I will allow; for I agree with much that has been advanced by Dr. Macculloch on this subject, and believe that the less concen-, trated states of terrestrial exhalation, particu- larly in low grades of atmospheric temperature, will give rise to several diseases usually impu- ted to other causes, as to catarrhs or catarrhal fevers, rheumatism, neuralgic affections, sciat- ica, obstructions of glandular organs, and pre- mature decay. When terrestrial exhalations are concentrated or rendered more active by a warm and humid air, bilious inflammatory re- mittents, gastric or mucous fevers, cholera, dysentery, and visceral diseases will frequently result, according to the existing disposition or states of those exposed to them. 24. B. The contaminating effects of unwhole- some kinds of food and drink frequently declare themselves in specific forms and modes. Er- gotism, gangrenous ergotism, scurvy, scorbutic dysentery, "adynamic dysentery, &c, are illus- trations of this. On many occasions, however, the ingesta constitute only one of the sources of infection, or other causes concur with this in producing the effect. Mucous, gastric, and pu- tro-adynamic fevers and dysenteries, even when chiefly occasioned by septic or diseased articles of food, or by water containing putrid animal matter, are often aided in their appearance by additional causes ; when foul water is concern- ed in the production of septic or adynamic mal- adies, animal or vegetable exhalations, or both, and unwholesome food frequently co-operate with it. The fevers and dysenteries so gener- ally developed in armies, in besieged towns, &c, seldom proceed from a single source of contam- ination only. When they assume highly infec- tious and typhoid forms, it will generally be found that putrid and impure food and water, exhalations from animal exuviae, and from the surrounding soil containing numerous dead bod- ies imperfectly covered with the earth, famine, fatigue, and the depressing passions, first con- taminate the frame ; and that the exhalations from persons confined in close places, and from those first affected by those causes, heighten still farther the morbid effects, until a most ma- lignant malady is produced. It is extremely probable that the air of a place thus circum- stanced, and especially the moisture floating in it, may become so saturated with noxious efflu- . via derived from these sources as to assume a pestilential character, the infection extending to nearly all who breathe it, but becoming less remarkable as the distance from the focus of infection increases. Hence it is that in large, crowded, or populous cities, particularly in sea- sons when the temperature is high and the air humid, and is already contaminated by the cir- cumstances which necessarily attach to them, and especially by exhalations from animal ex- uviae and burying places, the infectious ema- nations from the persons first attacked by the resulting febrile maladies heighten the existing aerial contamination, produce a more marked effect, and more readily spread the malady in these places than in those differently circum- stanced. During the pestilence in Rome, du- ring 262 and 263, the air is stated by Eusebius and Cedrenus to have been so contaminated by the emanations from the sick and dead, that the dew which fell in the mornings and evenings presented a sanious or putrid appearance on the surface of objects. It is chiefly owing to this circumstance that when an infectious disease becomes very destructive, or assumes a pesti- lential form in crowded cities, it seldom spreads extensively in districts far removed from them, although it is generally communicated, to a greater or less extent, to the healthy by those who have left the source of infection, and by fomitcs; for the circumstances favourable to the infection are there wanting. 25. That continued fevers of a low, adynamic, typhoid, or putro-adynamic character, dysen- tery, erysipelas, hospital gangrene, phlebitis, puerperal fever, diffusive or disorganized in- flammation of cellular parts, and the diseases enumerated in the Classification, as the results of the various kinds of contaminating or infec- tious agents comprised under the second class of my arrangement, arise from these sources, may appear paradoxical to many. But an ex- tensive examination into the subject will show that animal affluvia produce those diversified effects, according to the nature of the effluvia, to concurrent circumstances, and to the pecu- liarities of the persons affected; and that the resulting maladies perpetuate their kinds when the conditions favouring this occurrence are INFECTION—Develo; present. That morbid actions, often of a most dangerous and malignant kind, follow the inoc- ulation of morbid secretions and septic animal matters, although these secretions may not have been taken from a person labouring under a dis- ease generally recognised as being infectious or contagious, has been evinced on various occa- sions, and shown even by experiments. Much, however, in these cases, depends upon the health of the persons who may be thus inocula- ted. The general persuasion that diseases usu- ally recognised as contagious alone can be communicated in this way is by no means cor- rect, for the range of infection by inoculation is much wider. Indeed, I consider it as a path- ological principle, that morbid secretions and septic animal matters, from whatever source, will, if applied to an abraded or divided living Burface, or allowed to remain in contact with a mucous, or even with the external surface, give rise to some one of the maladies assigned in the Classification to this order of agents; and that the morbid matters generated by these maladies will produce similar effects in others, if applied in the same way, provided that a pre- disposition to the infection exists. This pre- disposition manifestly consists of depressed constitutional power, and weakened vital re- sistance, often in connexion with disorder of the digestive organs, and sometimes with gen- eral cachexia. 26. The maladies which are produced by the third class of agents, or by specific infections and contagions, are, with few exceptions, so gener- ally recognised as the results of the operation of these agents, as to require no remark. The diseases that may be viewed as exceptions to this mode of origin by some writers, whose powers of argumentation and knowledge of the sources and course of morbid actions have se- cured for them but slight reputation with com- petent judges, cannot be more particularly al- luded to in connexion with their sources at this place. 27. C. The diseases produced by infectious or contagious agents may be modified or aggravated by superadded or consecutive causes. This is es- pecially the case with those febrile maladies which arise from endemic sources, and from animal effluvia. The emanations from the sick of these maladies, if allowed to accumulate around the patient, particularly where several are confined in ill-ventilated places, will aggra- vate the disease, impart to it new characters, and an infectious atmosphere may be thus gen- erated capable of producing a modified, or even a different, but generally a much more malig- nant malady than that which originally existed. The aggravation of diseases by the accumula- tion of the emanations from the sick, or from any other source productive of infection, ob- tains generally. On the other hand, free ven- tilation exerts a beneficial influence, and pre- vents the contamination of the circulating flu- ids, as well as the depression of vital power that would otherwise result. 28. Humidity and dryness of the atmosphere have much influence upon infectious maladies. The former not only gives activity to infectious agents, but also aggravates their effects, and predisposes the human frame to their operation. Infection is, in the first instance, thereby fa- voured and accelerated ; and it is subsequently PMENT OF ITS EFFECTS. 411 aggravated in the whole progress of its result- ing phenomena. Dryness of the air, on the other hand, either prevents infection or delays the development of its effects. The depress- ing passions, fear, and whatever lowers vital energy, are most influential and powerful con- curring and aggravating causes of infection, both before it is fully developed and during the course of its effects. 29. IV. Of the Period which elapses from the First Impression or Operation of Infec- tious Agents till the Development of their Effects.—The period which elapses from ex- posure to the agents of infection until the de- velopment of their effects varies remarkably in its duration, as respects not only different infectious maladies, but also different persons exposed to the impression of the same agent. This period has been denominated the latent period and the period of incubation by French pathologists. I have, in the articles Disease and Fever, called it the formative, premonitory, or precursory stage, or the period of premonition, because the changes taking place in the con- stitution during this stage are productive of the subsequent phenomena, and are generally mani- fested by certain symptoms, attention to which may often prove of essential service in the pre- vention or treatment of the consecutive disease. The duration of this period has been differently stated by different writers, as respects almost every infectious disease. In some of these dis- eases it is quite indeterminate ; but, as regards others, it is more uniform.—a. The precursory period of diseases which proceed from terres- trial or paludal emanations varies from six or seven days to as many months. From data obtained by Dr. Gregory, it would appear, that of a number of persons exposed to malaria pro- ceeding from the same source at a precise pe- riod, thirteen days was the shortest, and thirty- nine days the longest duration of this period; and that in the greatest number, agues and re- mittents were developed on the 20th and 22d days after infection. In some cases, where I had an opportunity of observing this period, re- mittent fever appeared in some six or seven days, and in others a few days later, after ex- posure to the cause. Dr. Marsh infers, from numerous instances furnished him in Ireland, that this period may be protracted to eight or nine months. 30. b. The duration of the formative period in typhoid fevers has not been observed with sufficient precision. Dr. Haygarth declared that the minimum was seven days, and the maximum seventy-two days. Dr. Bancroft inferred the minimum period to be thirteen days ; but the observations of Sir W. Burnett, Dr. Marsh, and others prove that the period is much shorter. Dr. Marsh, indeed, endeavours to show that the febrile rigour may succeed al- most immediately to the exposure to the infec- tious effluvium. But in many of the instances which he adduces there is every reason to sup- pose that a previous exposure to infection had occurred, that which seemed to have made the morbid impression having only been a consecu- tive or determining cause of the disease. Dr. Williams thinks that this period may extend from a few hours to a few weeks, or perhaps to a few months. I have stated that it may not continue beyond twenty-four hours in the worst 412 INFECTION—Development of its Effects. forms of these fevers, and that the most com- mon duration is from three to fourteen days. This agrees with some observations which I have lately had an opportunity of making. Dr. Gregory considers that the medium duration of this period in these fevers is ten days. 31. c. The precursory or formative period in measles generally continues from seven or eight to fifteen or twenty days. Dr. Bateman states it to vary from ten to fifteen days. Dr. Gregory from eight to twenty-one days. Dr. Williams remarks that the time which this poison might remain latent has been determined to vary from ten to sixteen days. This agrees with the observations of Dr. Heberden and Dr. Hue. Dr. Home, who first tried the inoculation of measles, observed that the eruption appear- ed on the sixth day afterward. The experi- ments of inoculation in measles by Vogel, Monro, Tissot, Cullen, Speranza, and others furnish no additional information on this sub- ject. M. Guersent is of opinion that hooping- cough appears five or six days after infection. I have stated that it is generally from five to nine days, or even longer, after exposure to in- fection before the cough commences. 32. d. In scarlet fever, the formative period varies in duration from one to twenty or twen- ty-five days. Dr. Williams considers that it continues from a few hours to about ten days. Dr. Binns assigns two days as the shortest pe- riod ; Dr. Withering three or four days ; and Dr. Heberden and Dr. Frank five days; Dr. Blackburn believes that the period varies from four to seven days; and Dr. Willan that it rarely continues longer than six days. The duration of this period depends much on the character of the epidemic. Dr. Maton observ- ed, in one epidemic, this stage prolonged to twenty-five or twenty-six days. In a most ma- lignant case of the disease which I recently at- tended, infection was produced by some of the secretion from the mouth of a patient having been conveyed by the hand to the glans penis of a different person. Most violent asthenic inflammation and excoriation extended thence over the genitals, to the groins, abdomen, and inside of the thighs. 33. e. In smallpox, the duration of the pre- cursory period varies from six to twenty or twenty-one days. When the disease appears in the natural way, or by the medium of the air, Dr. Gregory thinks twelve days to be then the usual period. When smallpox is inoculated, the eruptive fever commences seven days after- ward, but it may be delayed a day or two long- er. Indeed, cases occasionally appear in which this period is either shorter or longer than that now stated. 34. /. In plague, the precursory period may be very short. Sir Brooke Faulkner has men- tioned some cases in which the attack seemed to follow almost immediately, or within a few hours, upon the impression of the infectious ef- fluvium. Some writers have stated this period to vary from two to fifteen days, five days being its medium duration. The disease has occur- red on the fourth day after its inoculation. True yellow fever usually appears from two to twelve days after infection; but it may take place in a few hours after the impression of the morbid effluvium, when concentrated. In pes- tilential cholera, the precursory period varies from one to six days, according to my own ob- servations ; and this agrees with the statements of others. This period may, however, be some- what shorter or much longer than now stated. True or malignant puerperal fever usually occurs from one to five days after infection, but it may be delayed beyond this period. 35. g. The time that the infection of erysip- elas takes to develop itself has not been accu- rately determined. Dr. Williams thinks that it may vary from two to fourteen days. In the instance above alluded to, and in some others that I have seen, the period was not longer than thirty-six hours. In the various forms of infection proceeding from the inoculation of morbid matters, or from injuries during the dissection of recent or of putrid bodies, the constitutional effects are usually manifested within three days, sometimes in the course of a few hours, and very rarely after four days. 36. h. The morbid secretions productive of the various forms of venereal disease evince their effects at various periods, between one or two days and two months. The gonorrhceal affec- tion generally appears much earlier than the syphilitic; the former most frequently show- ing itself from two or three days to ten or twelve, the latter from six or seven days to two or three weeks. 37. i. The virus of rabies takes a longer time in developing itself than any other infectious agent. There can be no doubt of the precur- sory period of this malady being sometimes prolonged much beyond what is generally be- lieved, although the very long intervals stated to have elapsed in some instances are quite apocryphal. There are, however, well attested cases of two years having passed from the in- sertion of the virus until the appearance of the malady. Instances of from four to twelve months having thus elapsed are by no means rare. The shortest period of premonition in rabies may be stated to be twenty-one days. In the greatest number of cases, the disease appeared from thirty-one to sixty-three days af- ter the inoculation of the morbid secretion., 38. After the first impression of an infectious agent until the development of its effects, or during the whole of this precursory period, the change produced in the economy presents cer- tain general features, which are of the utmost importance to recognise and to estimate aright. These changes are not materially different in the different infectious maladies: they vary, however, in intensity as much as in duration ; but they often possess very nearly the same characters, which always manifest the produc- tion of a more or less noxious effect upon the economy—as depression of nervous and mental energy, and of all the manifestations of life. These manifestations are, however, severally depressed in different degrees in different mal- adies during this period; and certain organs experience this effect more than others, as well as betray a specific or peculiar mode of affec- tion, according to the nature of the infectious agent. In those distempers which proceed from the more intense or concentrated agents, and in which the precursory period is short and se- vere, the effect produced upon the nervous sys- tem is generally immediate and remarkable. Not only are the physical functions depressed and embarrassed, but the mental and moral INFECTION—Early Symptoms of. 413 powers are remarkably weakened or nearly an- nihilated. In true yellow fever, in plague, and in puerperal fever the patients become indif- ferent to their fate, and care not for the most intimate relations. The sensibilities are not merely blunted, they are almost destroyed; and a similar effect is observed in many oth- er infectious maladies, although not in so re- markable a degree. Much of the calmness displayed by persons in this, as well as in the more advanced stages of these diseases, results not so much from a philosophical or stoical suppression of the sentiments and emo- tions, as from a generally impaired power of the organic nervous system, and a consequent impairment or loss of the general sensibility, and of the cerebral energy. Hence the phys- ical change is often such that those parts of the frame which are the most intimately rela- ted to the manifestations of mind, or which either minister to them or are their instru- ments, are more or less incapable of dischar- ging their offices. 39. V. The Symptoms or Indications of In- fection vary remarkably in the rapidity of their production, in their intensity, and in their numbers, forms, and modes of grouping. But it is of importance that they should be recog- nised by the physician. When the infecting agent is intense, as when a concentrated ani- mal effluvium or an accumulated emanation from the, bodies of the sick is directed upon a susceptible person, then the effect may be as instantaneous as electricity, as well as most intense. In some rare cases of this kind, as in plague and in other pestilential maladies, life may be destroyed in a few hours by the morbid impression which it has been quite in- capable of opposing, and against which it has been unable to react. I have seen the emana- tions from typhoid fever, from yellow fever, and from pestilential cholera immediately pro- duce sickness, vomiting, pain, sinking and anx- iety at the epigastrium, faintness, oppression at the chest, remarkably weak pulse, head- ache, and general vital depression, with pale countenance and shrunk surface ; and from these the patient has never rallied, the symp- toms increasing in severity, and others super- vening, until death has occurred in a very few hours. 40. Where the agents are less active or less concentrated, or where the predisposition is not so great, a much longer time is taken in the development of the changes constituting the precursory period of infectious maladies ; and in the majority of those the vital powers resist the farther progress of these changes in that particular direction, and a salutary reac- tion is established. In many instances, little or no complaint is made after exposure to in- fectious agents, although a morbid impression has actually been made by them. In some only a slight malaise, or an indefinite feeling of indisposition, indicative of depression of vital power, only is complained of. In others the depression is much more manifest, and is at- tended with a weak or slow pulse, or with un- usual acceleration of the pulse upon slight ex- ertion ; with chills, alternating with flushings or heat of skin, depression of spirits, and pallor ot the countenance, great weakness of the joints, and impaired power of the digestive, se- creting, and excreting functions. When in- fection is produced through the medium of the respiratory organs, the earliest effect that is observed is a feeling of constriction or oppres- sion in the chest, or at the praecordia and epi- gastrium, attended by frequent sighing, gaping, forced and deep inspirations, and by uneasy sinking, depression, or nausea, and sometimes by pain at the stomach, and by vomiting. The natural and acquired appetites and desires are diminished or nearly abolished; nausea is read- ily excited by food, and the bowels are either costive or relaxed, or easily acted upon by pur- gatives. All the organic functions are im- paired, and the sexual desire suppressed. The patient feels debilitated and fatigued; com- plains of headache, vertigo, or confusion of ideas ; is morose, low-spirited, sluggish, indo- lent, or incapable of exertion, or of directing his attention long to any object; he readily perspires, and his breathing becomes short and quick on the least exertion. His sleep is un- sound and unrefreshing, and he wakens, com- plaining of lassitude or of pains in his back and limbs. All the cerebro-spinal functions are weakened or disordered. The countenance and skin are unusually pale, sallow, or un- healthy ; more rarely red ; the eyes are lan- guid and deficient in brilliancy; the breath is foetid or cool, and the tongue is often loaded, occasionally red or flabby. The urine is some- times pale and copious, and the cutaneous sur- face is dry, cool, and harsh or constricted. These symptoms are sometimes so slight as to escape particular attention, and are often in- sufficient to induce the patient to confine him- self. They are frequently much more intense, without being different as to kind; their inten- sity increasing more or less rapidly, until a sensation of cold running down the back, with formication, chills, or rigours supervene, indi- cating the approaching development of the mal- ady. 41. When infection is produced by inocula- tion, the more immediate effects are somewhat differently manifested, according to the nature of the morbific agent; and in those maladies which require a long, precursory period for their full formation, several of the above symp- toms are either altogether wanting, or are so slight as to escape detection. In some instan- ces, persons actually infected may complain but little, or may experience merely slight de- bility, inaptitude for exertion, various dyspep- tic symptoms, and depression of spirits. At last, some consecutive or determining influ- ence comes in operation, and the infectious agent, thus re-enforced, soon produces its full effects. 42. In some instances the premonitory pe- riod is characterized by remarkable mental de- pression, by a reserved manner, and by the an- ticipation of an approaching calamity, or even death. When a person who has been exposed to infectious agents, particularly those which are liable to become epidemic, is possessed with the idea of his impending dissolution, this unfortunate termination generally takes place. This symptom, more, perhaps, than any other, indicates a dangerous functional lesion of the nervous system. 43. There are various circumstances which fa- vour or retard the development of infection. Sev- 414 INFECTION—Manner of its Invasion. eral of them have been already noticed ($ 27). Many of those which favour the development of infection not only render the consequent disease much more severe than it would oth- erwise have been, but also complicate that dis- ease, and impart to it a fatal tendency. Expo- sure to wet and cold, unpleasant or distressing intelligence, a debauch, excessive fatigue, and exhaustion from any cause during the precur- sory period, will not only accelerate the effects of infectious agents, but also give rise to in- flammation, or congestion, or obstruction of some vital organ. This often occurs in mea- sles, scarlet and typhoid fevers, hooping-cough, smallpox, &c. Dr. Marsh justly remarks that a principal reason of the danger and fatality of fever among medical practitioners is, that du- ring the latent period they make an effort, day after day, to discharge their laborious duties, until at length they are reluctantly compelled to yield, the disease having gathered strength in the same proportion as they have made strong but ineffectual efforts to resist it. A slight illness may be prevented by a strong ef- fort, but a severe one is thereby greatly, often fatally aggravated ; and this is not the case merely in respect of fever, but of every malady produced by infection. The circumstances which retard or prevent the development of infection will be considered hereafter, when the pathological views here stated will be ap- plied to practical purposes. 44. VI. The Manner in which Infections and Contagions invade the Economy, and their immediate and direct Effects, have lately excited some discussion. And let it not be supposed that the subject is devoid of im- portance ; for correct views respecting it will lead to the adoption of means for the protec- tion of the system, both at the time of expo- sure and in the period which more immediately follows it, that will often prove successful in counteracting its earlier effects, or in render- ing the course of the disease more mild.—A. It is now about twenty years since I endeav- oured to show, by anatomical connexions, by functional relations, and by intimate observa- tion of the effects produced by the more ener- getic morbific agents, that their impression is first made chiefly upon the organic nervous sys- tem, although the change or effect thereby pro- duced necessarily soon extends to the vascular system, and even to the circulating fluids, and that this takes place when the infectious agent is inserted into a wound, as well as when it is inhaled into the lungs with the air. At the same time, I endeavoured to show that certain agents may more especially affect the circula- tion by their imbibition or absorption into the blood. This is more especially the case when the infectious agent is received into the ali- mentary canal with the solid or fluid ingesta, or when it consists of morbid secretions formed in an organ or part admitting of their passage into the circulation. There can be no doubt of the respiratory organs being generally im- mediately affected by all those agents which are conveyed through the medium of the atmo- Bphere. The cutaneous surface is sufficiently protected from the operation of the impalpable emanations constituting the most common and the most numerous infectious agents. The di- gestive mucous membrane, although less guard- ed than the cutaneous surface, is still less ex- posed than it to their action. It is chiefly, therefore, through the medium of the respira- tory surfaces that these agents make their di- rect impression. On these surfaces the air may be said to undergo a process of digestion, certain elements or portions of it entering in the circulation, combining for a time with the circulating fluids, and promoting their perfect sanguifaction and assimilation ; and from those surfaces certain gaseous fluids and elementary principles are given off which have served their purposes in the economy. There is every rea- son to infer that, during this process, noxious matters floating in the air, or dissolved in the moisture of the atmosphere, produce a morbid impression upon the nerves supplying these surfaces, and upon the respiratory organs gen- erally; and that this impression is more or less rapidly transmitted throughout the organic nervous system, the other organs and general systems of the body, more immediately de- pendant upon this system, soon manifesting the effects thus produced. At the same time, the noxious emanations, thus conveyed to the lungs in the course of the respiratory func- tions, most probably affect the condition of the circulating organs and of the blood itself, both these orders of effects taking place co-ordi- nately, or either of them in a more or less spe- cial manner. That certain infectious agents impress the organic nervous system directly and chiefly, is shown by the suddenness of the effects ; by the sensations experienced at the time of exposure to those agents, especially to the emanations conveyed in the air ; by the sense of constriction and oppression produced in the chest; by the frequent and forcible ef- forts made to dilate or fill the lungs, as if the impression of the infectious emanation had impaired the vital resiliency of these organs ; by the offensive odour frequently perceived at the time of infection ; by the sickness, fear, and alarm instantly afterward felt, and by the other phenomena already enumerated. 45. B. Next to the impression and change in the nervous system of organic life, the al- terations in the circulating organs and fluids, consequent upon infection, deserve attention. When infectious effluvia are inhaled into the lungs, the weak action of the heart soon indi- cates the depression of this system. The im- pulse of the heart is feeble, slow, or irregular and oppressed. The pulse is weak, soft, com- pressible, or small—sometimes irregular. It indicates a want of tone; and when the in- fectious agent has acted with much intensity, absolutely or relatively, the sensation imparted by the artery suggests the idea that the con- tractility of the coats of the vessel is much im- paired. From this defect of the contractility and tone of the blood-vessels arises, during the precursory period of diseases produced by the more energetic infections, the remarkable ten- dency to congestion of those parts of the cir- culating system, and of those vessels which are the most removed from the influence of the heart's action. Hence the congestions of the spleen, of the portal vessels and hepatic veins, and of the sinuses within the cranium ; and hence the retarded circulation through the lungs, and the fulness of the auricles and sinu- ses of the heart, giving rise to the sense of INFECTION—Manner of its Invasion. 415 oppression at the praecordia and in the chest, and to the frequent sighing and forced inspira- tions attending this stage of disorder. 46. The effects produced by infection on the blood are not so immediately, or, at least, not so sensibly evinced as those induced in the functions of organs actuated by the organic nervous system. The blood may, however, be affected without the alteration being percepti- ble to the senses ; and changes in the appear- ances of this fluid are usually visible before al- terations in its constitution can be detected by chemical tests or analysis. The pathological conditions of the blood during the earlier sta- ges of the disease consequent upon infection have not been sufficiently observed, and far less satisfactorily investigated. Those which have been described are the results of pro- longed or intense morbid action, probably aid- ed, in some cases, by treatment and regimen. I have given, in the article Blood, a full view of those alterations, and explained their sour- ces. But the subject, with all its interest and importance, has not since received any farther elucidation. The state of vital depression, im- mediately produced by infectious agents, gen- erally precludes the abstraction of blood, and the opportunity of observing its states. I have, however, seen some instances of blood having been taken from a vein during this state, ow- ing to a misinterpretation of the headache, pain at the epigastrium, and oppression at the chest then complained of, and to the epidemic disposition to vascular depletion so prevalent among practitioners, excited and promoted as this disposition was by inexperienced writers, who inflicted their crudities and inanities upon the public, as well as upon the profession, soon after the commencement of the present centu- ry. In most of these cases the blood flowed with difficulty, was of a very deep or dark col- our, and produced syncope or great depression upon the loss of a few ounces. It coagulated rapidly, and separated into a very dark, large, and soft coagulum, which sunk in the serum, this latter being small in proportion to the clot. In some instances the separation was very im- perfect, the coagulum being gelatinous; and occasionally no separation took place, particu- larly when the powers of life were remarkably depressed. The blood taken at the commence- ment of the cold stage of agues often presents the same appearances, but generally in a less degree. These appearances indicate rather the vital conditions of this fluid derived from the organic nervous system supplying the vas- cular system and vital organs than any change in its chemical constitution. It is not probable that the hamatosine is materially altered, or that the saline ingredients and albumen have undergone any diminution, as the circumstan- ces upon which these appearances depend have not been sufficiently long in operation to produce these effects. The fibrin is, however, changed or diminished, this substance evin- cing, by its attraction and cohesion, the state of vital or nervous power. When the fibrin contracts slowly, firmly, and so as to form a firm clot, and allow the free separation of the serum, or to give rise to a buffy or cupped sur- face of the coagulum, the nervous and vital powers are unimpaired, and vascular action is increased, and generally increased in propor- tion as this state of the coagulum becomes more remarkable. When, on the other hand, the fibrin adheres quickly but imperfectly ; when the attraction between its molecules is weak, and consequently, when either no coag- ulum is formed, the blood assuming a gelatin- ous consistence as it cools, or when the coag- ulum is loose and soft, with merely a slight separation of the serum, this latter either sur- rounding it in a small quantity, or partially, or altogether covering it, the constitutional pow- ers may be considered as greatly reduced; and, although the circulation may be accelerated, its tone and energy are much impaired, the vi- tal contractility of the coats of the vessels upon their contents presenting a weak antagonism to the action of the heart. 47. The occasions on which the blood seems to be more immediately contaminated by infec- tious agents are, first, when a specific virus or morbid secretion is inserted into a wound, or beneath the cuticle ; and, secondly, when pu- trid or septic matters are similarly applied. The period which elapses between the inocula- tion of a specific virus and the development of the constitutional affection, however, by no means shows that the immediate operation is upon the blood, and that this period is required for the production of morbid changes in it. If we examine the subject closely, we can arrive at this conclusion only, that the morbid matter affects first the vital conditions and actions, and ultimately the intimate organization of the part to which it is applied, converting the ap- pearances and sensible properties of the part to states somewhat similar to those character- izing itself; and that the contamination thus produced soon extends, either by its immediate effects upon the organic nerves supplying the vessels of the part, and consecutively on the blood, or by the imbibition or absorption of the morbid matter, or by both these channels, to the whole body, affecting more or less the blood, the secretions, and the soft solids. That the organic nervous system is the chief chan- nel by which the first change induced in the part is communicated to the whole body is shown by the circumstance of the constitution- al effect being frequently as great while the lo- cal change is slight as afterward, when it has become fully developed. Although the precise channel of primary infection cannot easily be demonstrated in cases of infection by inocula- tion, yet the ultimate effects, as respects both the solids and fluids, are sufficiently apparent. The facts and illustrations contained in the ar- ticles Blood (4 110, et seq.) and Fever (§ 18, 526) render farther remark on this topic almost unnecessary. That the blood undergoes, at an earlier or later period of most infectious dis- eases, a remarkable change as respects its ap- pearance and sensible properties, is sufficiently established. In what the chemical or intimate change may consist has not been shown by analysis.* There can be no doubt, however, * [Under the art. Blood we have given an account from Andral (PathologicalHematology, Phil., 1844) of the state of the blood in the pyrexia;, which the reader may consul^. If fever is not complicated with inflammation, Andral has shown that the fibrin does not augment, that it often remains in normal quautity, and sometimes diminishes to a lower point than we find it in any acute disease. Where the fibrin is much lessened the serum and clot are imperfectly separated from each other, so that there seems to be but little serum in proportion to the clot. In these cases thi BTANCES WHICH FAVOUR. 416 INFECTION—Circumj that, in the advanced progress of some of these maladies, the saline principles of the blood are either diminished in quantity or altered in their combinations, as shown by Dr. Stevens. In- deed, this may be considered as a necessary consequence of the abstraction, during the dis- ease, of the usual saline substances contained in the food. When the quantity of chloride of sodium used by an individual in the twenty-four hours is considered in connexion with the fact that the whole of it passes into the circulation, we must expect a remarkable diminution of this salt, or of its base, in the blood of persons who have been but a few days affected by feb- rile or infectious maladies. The earliest chan- ges, however, produced upon the blood are manifestly those of its vital conditions. 48. It is very reasonable to suppose that the influence exerted by the organic nervous sys- tem upon the circulating organs and vessels throughout their whole extent, and thence upon the contents of these vessels, will alter the ap- pearances and conditions of these contents, as itself becomes altered by the influence of infec- tious agents ; and that the effect thus produced upon the circulating fluids will reciprocate the morbid affection, and heighten disorder in the system more immediately and directly impress- ed; that, in short, nervous influence, which first experiences the morbid change, in commu- nicating this change to the vascular system and circulating fluids, soon undergoes a farther al- teration, owing to the changes it has itself pro- duced in these fluids. In some instances, how- ever, and especially when putrid matters are applied to a wound, a more rapid contamina- tion of the circulating fluids may be inferred. When these matters, or when morbid secre- tions, or blood in an advanced period of malig- nant or putrid diseases, are injected into the circulation, it is but reasonable to infer that the effects will be more immediate, and that they will be in most respects similar to the morbid conditions characterizing the advanced stages of the malignant or putro-adynamic maladies produced by self-perpetuating infections or con- tagions. The interesting experiments of Gas- pard, Magendie, Leuret, and Hammond have fully established the truth of these inferences, as shown in the article just referred to. 49. C. The morbid impression made upon the organic nervous system and the change indu- ced upon the circulating organs by infectious agents necessarily affect the secretions and excre- tions. As the secreting and excreting organs are actuated chiefly by the organic nervous sys- tem, and as the vital manifestations of this sys- tem are remarkably depressed by infectious agents, the functions of these organs must con- sequently be more or less impaired soon after iufection. It is chiefly owing to this circum- stance that the blood becomes altered in the progress of infectious diseases. In the article already noticed, I have fully shown that the imperfect performance of the functions of dep- clot is voluminous, often filling the whole breadth of the vessel in which it is received; of slight consistence, and easily reduced to a fluid pulp ; never elevated at its borders, and often divided into a number of grumous portions, which mix with the serum and colour it of a more or less deep red. The large size of the clot is not alone owing to a diminution of contractile power from lessening of the quantity of fibrin, but also to the comparatively large proportion of globules it contains.] uration is a chief cause of the morbid states of the blood ; and that, as these functions are im- paired in proportion as vital power is diminish- ed, so must the secretions and excretions be disordered both in the early and in the advan- ced stages of infectious maladies. In the for- mer of these stages, even the period of premo- nition, the disorder of these functions is oft- en manifest, but they are diminished rather than vitiated. In the advanced stages, they are prominently vitiated as well as diminished ; and sometimes, even when the vitiation is most remarkable, they are sufficiently abundant, or even remarkably copious. 50. D. The alterations produced in the soft sol- ids by infection are the latest in the procession of the consequent morbid phenomena, and vary remarkably with the nature of the infectious agent. Some of those agents produce certain determinate or specific effects upon the tissues. Thus the effluvium of smallpox affects the skin and mucous surfaces especially; that of scar- let fever, the throat, digestive mucous surface, skin, and the membranes of the brain ; that of measles, the respiratory and cutaneous surfa- ces, &c. ; that of plague, the lymphatic system and glandular organs; that of erysipelas, the integuments and cellular tissue ; that of syph- ilis, the absorbent glands, the periosteum, the skin, bones, and joints ; and so on, as respects most kinds of infectious diseases. These al- terations are, however, much modified, or ad- ditional lesions are developed, by consecutive changes or influences; by the temperament, predisposition, or previous disorder of the pa- tient, or even by the treatment, as when cer- tain complications appear from these or other circumstances, at the commencement or du- ring the course of infectious fevers. Among the changes induced in the soft solids by infec- tious agents, the most important, and evident- ly the most intimately dependant upon the state of vital manifestation, and the conditions of the circulating and secreted fluids, are the discol- oration and the softening of membranous and parenchymatous structures. This discolora- tion and softening, as observed soon after death, are perfectly independent of incipient dissolu- tion of the tissues, and are generally great in proportion as the infectious or contagious na- ture of the agent is remarkable. The general loss of the vital cohesion of the tissues is often so great that even the most firm and coherent structures are torn with ease, the substance of the heart and muscular parts also participa- ting in the change. (See art. Fevers, $ 527.) 51. VII. The Circumstances which favour Infection are numerous, and it is of impor- tance that they should be recognised and well understood by the physician. These circum- stances may be grouped, first, into those which are intrinsic, which concern the individual, or are proper to the recipient; secondly, into those which are extrinsic, or which concur or co-op- erate with the infectious agent.—a. The cir- cumstances proper to the recipient of infection are numerous, but the chief only of them can here receive particular notice. There is a sus- ceptibility to infection from birth, which, in re- spect to some infections, diminishes with age, or is entirely exhausted or destroyed by the disease which it produces. This destruction of the susceptibility to infection is remarkable INFECTION—Means of Protection from. 417 as regards the exanthematic contagions, yellow fever, and hooping-cough; and although it is not universal, yet the exceptions are very rare. In certain infectious maladies, as continued and typhoid fevers, the susceptibility increases with the progress to puberty, and diminishes gradu- ally from the twenty-fifth or twenty-seventh year to old age. The danger, however, in- creases with this diminution, if infection actu- ally takes place. Although typhoid fevers do not entirely exhaust the susceptibility to their infection, they manifestly weaken it. When a person has escaped infection, upon the first or the earlier exposures to several infectious mal- adies, he will generally continue to possess an immunity, unless circumstances should occur to increase his predisposition; for the infec- tious emanation produces a more sensible and marked effect on the economy, on the first oc- casion of exposure to it, than subsequently, un- less long intervals have elapsed between the periods of exposure. It is thus that several members of the same family so often escape, notwithstanding the rest are labouring under infectious maladies, the susceptibility to them diminishing with the frequency of exposure, un- less concurrent causes or influences re-enforce the infecting agent. 52. The kind of susceptibility which disposes to infection varies much with different infec- tious maladies. In some, as typhoid fevers, youth and the prime of life are predisposing cir- cumstances ; and yet, fear of the disease, fa- tigue, exhaustion, and other causes altogether of an opposite character, have a similar influ- ence, and concur with it. In others, as yellow fever, the seasoning, pernicious, and malignant fevers of warm climates, persons in the prime of life, and of the most robust and plethoric constitutions, are the most liable to infection ; while remittents and agues usually affect, in preference, the more debilitated, and persons of a weaker and more delicate frame. Most of the maladies which are capable of propaga- ting themselves exhaust the susceptibility to reinfection. The chief exceptions to this are, venereal affections, plague, and purulent oph- thalmia ; whereas, the infections which are in- capable of propagating themselves, unless oth- er causes be superadded, particularly those which consist principally of emanations from decayed vegetable products, leave after them an increased disposition to reinfection. A per- son who has once had an attack of periodic fe- ver is more susceptible of infection upon expo- sure to malaria, and a smaller dose of the poi- son will take effect. 53. Of the other sources of susceptibility to infection, the most important are, fear and the depressing passions, disorder of the digestive organs, general ill health, and whatever impairs the powers of life. All infectious agents pro- duce a morbid impression on the nervous sys- tem, and contaminate the circulating and se- creted fluids with a rapidity, and to an extent, cateris paribus, according to the weakness of vital power and resistance. When the ner- vous influence and vascular tone and action are insufficient to oppose these agents, the infec- tion then takes effect; the morbid influence extends ; the circulating fluids are either early contaminated or soon become deteriorated; and thus the whole frame is brought, not only II 53 under the influence of, but is actually polluted by the disease. 54. There are other circumstances which predispose to or increase the susceptibility of infection, but they are so well known, in re- spect both of their nature and modes of opera- tion, that they need not be noticed at this place. They are chiefly extrinsic to the body; and either precede, or are nearly coetaneous in their action with the infectious agent. Those which subsequently come in aid of this agent, and aggravate, modify, and complicate its mode of operation and effects, have already been al- luded to ($ 27). They will be found more fully discussed in the articles Disease (§ 61), and Endemic and Epidemic Influences. 55. VIII. The Means which protect from Infection, and counteract its Impression and Operation, are of the greatest importance, as respects both the science of the physician and the safety of the community. These measures may be divided into: 1st. Those which protect by excluding and destroying infectious agents, or by preventing communication with infectious persons or things ; and, 2dly, Those which are prophylactic, and which guard or fortify the in- dividual against the impression or contamina- tion of infections and contagions. The first of these classes of preservative means may be subdi- vided into, 1. Quarantine, and the separation of the infected from the healthy; 2. The exclu- sion of infected articles, or the destruction of all infection existing in them ; and, 3. The di- lution and destruction of the infections floating in the air, or in any other medium. 56. A. The separation of the infected from the healthy is the chief means by which a distem- per can be prevented from extending. This can be enforced only by governments and local authorities, when a pestilential or infectious epidemic threatens a country or district. To the neglect or imperfect accomplishment of the measures which belong to quarantine is chief- ly to be imputed the extension of pestilential maladies, particularly in countries bordering on the Mediterranean. The difficulty, however, of putting these measures in force, and the fa- cilities of evading them, especially by the trans- mission of infected clothes and other fomites, and as regards Continental countries having an extended boundary, or populous cities or towns having an extensive communication, are so great, that numerous instances of their infrac- tion must occur, and the chances of the intro- duction of these maladies be thereby increased. The extension of plague, yellow fever, and pes- tilential cholera, in different countries, has been entirely owing to the neglect of quarantine and of other means of prevention. If these means could be duly enforced in all their relations, not only those, but other infectious maladies, as typhoid fevers and smallpox, might be either entirely excluded from certain localities, or re- markably limited in their spread, particularly where the situation and boundaries of a place favour the application of these means.* 57. Next to the exclusion of infected persons or things from a place, the removal of those first infected to suitable places, where they may be properly treated, and where the exten- * [For some remarks on quarantine as connected with yellow fever in the United States, see arts. Yellow Fe- ver and Pestilential Cholera.]J 418 INFECTION—Means of Protection from. sion of the disease is duly guarded against, is of importance. The habitations of infected persons should undergo the processes of clean- sing, fumigation, &c, about to be noticed ; and all intercourse between the infected house and those adjoining ought to be prevented, or pla- ced under certain restrictions. In large com- mercial towns, and in populous districts, where a strict quarantine or sanatory measures, cal- culated entirely to prevent a malady from ex- tending, cannot be maintained, the mischief re- sulting from the attempt will be greater than the benefits which will arise to the community. But where they may be enforced, owing to the nature of the locality and other circumstances favourable to their due maintenance, they should be adopted, notwithstanding the tempo- rary losses, or even distresses of the place thus sequestered ; for the advantages of the few should give place to the safety of the many. 58. As intimately connected with all regula- tions of quarantine and seclusion, the duration of the period which elapses from the impression of the infectious agent to the development of the dis- ease should be taken into consideration. On this subject, the information which I have at- tempted to give (§ 29) will be found useful. It is obvious that a person may be exposed to a source of infection in one place, and may trav- el a long distance during the period of forma- tive or smouldering action, and not experience the developed malady until after his arrival in a healthy locality, where he may introduce the infection. In the present day of rapid convey- ance, a person may carry an infectious mala- dy, which he has caught in London, to any of the remotest parts of the kingdom, or from al- most any European country to this. 59. It is of no less importance to know the time which a person who has been ill of disease ca- pable of transmission from one to another, retains the power of infection; but this is a matter of still greater difficulty, even, than the knowl- edge of the duration of the precursory period. The body itself, probably, loses the power of transmitting a malady as soon as convalescence is so far established as to admit of free exer- cise in the open air. Probably a fortnight after the commencement of recovery from most in- fectious maladies, the power of spreading them has ceased. Where a disease has been com- municated at so late a period as this, there is every reason to suppose that the clothes have been concerned in its communication. It is, however, most difficult to assign a precise pe- riod with reference to any infectious malady, as its duration will entirely depend upon the personal habits of the individual, upon the ven- tilation and means of purification resorted to during illness as well as during convalescence, and upon the care taken with his clothes and person. Among the lower classes, infection probably continues longer to attach itself to the person than the period now named, owing to circumstances peculiar to them ; and there is every reason to believe that it may continue in their apartments or dwellings even weeks and months afterward, unless disinfecting means be carefully employed. 60. B. In many situations, and in several dis- tempers, the chances of infection by fomites are much greater than by communication with the sick. Articles of bedding, feathers, furs, body- clothes, &c, which have imbibed the effluvium of the affected, readily transmit most of the infectious diseases of this country, as well as the pestilential maladies of other countries, to very distant parts. It is astonishing how long woollen and silken bed and body clothes wiU retain the effluvium, so as to affect the healthy by it, when closely packed together, or exclu- ded from ventilation. The animal miasm which the clothes worn in dissecting rooms have im- bibed will be sensibly perceived many months afterward, if they have been put in a close place immediately after they were saturated with the foul air. The necessity of subjecting these articles to ablution, to free ventilation, and to other means of purification, is sufficient- ly obvious ; but by the lower classes, and even by other persons, all precautionary measures, even those which merely consist of common cleanliness, are most flagitiously neglected, al- though among them those measures are the most requisite. The crowded, low, close, and dirty state of their apartments, and the neglect of ventilation by them in all circumstances, and especially during disease, demand a stricter en- forcement of purification or disinfection among them than elsewhere. Before articles from them or other infected sources are introduced among healthy predisposed persons, they should be subjected to the disinfecting agents about to be noticed, and to the perflation of the air in suitable situations, or in places from which the public are excluded. 61. C. Disinfection.—During the continuance of an infectious malady in a family or place, it is the duty of the inmates of the one, and of the authorities of the other, to put in force cer- tain measures of disinfection ; particularly when, owing tc the general prevalence or nature of the malady, it may not be deemed requisite to remove, the sick to places suitable for their se- clusion and treatment. In alt circumstances, however, disinfecting means should be employ- ed, as tending not only to protect the healthy, but also to aid the infected; for it is obvious that it is much to the advantage of the latter to have the air and clothes in which they are con- fined frequently renewed, and the morbid efflu- vium removed or counteracted, than to be sub- ject to its concentrated influence during the course of the malady. To dilute, therefore, or to destroy the infections floating in the air, or attached to any other medium, is a duty we owe both to the sick and to the healthy. 62. a. Among disinfecting means, a perflation of pure, dry air, and the abstraction of all sour- ces of humidity, are the most universally bene- ficial and applicable. These alone pi-event several maladies, particularly those which pro- ceed from the sources of infection ranged un- der the first and second classes of these agents ($ 4), from propagating themselves; and when they can be fully enforced, they prevent the extension of most of those distempers which always proceed from specific infection and con- tagion. Whatever may be the sources of the morbid effluvium or emanation, dilution by a free ventilation will either weaken or destroy it—at least so far as to cause it to fail to pro- duce its usual effects. This result will be more certainly obtained when the air is dry. High ranges of temperature, by increasing the hu- midity of the atmosphere, favour infection, if a INFECTION—Means of Protection from—Disinfection. 419 very free ventilation is not preserved; and cold, although preventing infection when there is a free circulation of air, often also promotes it, owing to the means used to prevent currents of cold air. This is frequently evinced by the evolution or propagation of infectious diseases in the close wards of hospitals and other places during winter and spring. 63. b. Various means have been resorted to for the destruction or neutralization of infectious emanations, especially during the prevalence of destructive epidemics or pestilences. In the desire to establish the effica-cy of recently-in- troduced disinfectants, the older means have been undeservedly depreciated. Although the former are the most efficacious, yet it follows not that the latter were devoid of all disinfect- ing powers. The advantages derived in former times from fumigations by camphor, benzoin, myrrh, tar, and terebinthinate substances, and by numerous aromatic, fragrant, and stimula- ting drugs, were owing to more than one cir- cumstance. These means not only inspired those who used them with confidence, but also in some measure neutralized the operation of the infections emanation. The fumes from them, and from other exciting and fragrant substances, often counteracted the impression made by the morbid emanation upon the nervous system, by preventing the depression it other- wise would have produced. On this account, they may still be resorted to with advantage in some circumstances, particularly in cases of casual or short exposure to infectious ema- nations, or when it is desired to counteract those which are the less virulent and not gen- erally diffused. When judiciously employed, many of these substances aid the recovery of the sick, especially when the disease is attend- ed by much depression of vital power. Until the discovery of Labarraque's disinfecting fluid, and of the uses of the chloride of lime, they were the chief means that could be em- ployed in the chambers of the sick; those which are next to be noticed being, from their acrimony, suited chiefly to uninhabited houses. 64. c. Acids have long been in use as disin- fecting agents, under the impression that they possess the property of decomposing infectious emanations, or at least of diminishing their virulence. With this idea, the once popular nos- trum, well known under the name of" Thieves' vinegar," was brought into notice, and even at the present day, under the name of " Aromatic vinegar," it is much used by persons exposed to infection, and, I believe, often with advan- tage. Letters and papers brought from an in- fected locality are not infrequently dipped in vinegar; while clothes and other fomites, trans- mitted from a similar source of infection, are exposed to the fumes arising from the slow combustion of sulphur, or, in other words, to the action of sulphurous acid; but as this latter is found to be injurious to the respiratory or- gans, and as the powers of the former are too weak to be relied upon when acids are indica- ted for the purpose of disinfection, the nitrous and the hydrochloric are those principally used, although not without some risk to the inhabi- tants of the apartments subjected to their action. Nitrous acid was first employed by Dr. John- stone and Dr. Carmicheal Smyth. The latter, however, obtained the parliamentary grant for the disputed discovery, and in 1780 employed this acid to arrest the progress of a fever which was then raging at Winchester, among the Spanish prisoners confined in that city; and subsequently numerous ships and hospitals, which had become the seat of infection, were exposed to the same agent with success. It may easily be obtained by the combination, of nitre and sulphuric acid in proper proportions ; and it possesses the advantage of not requiring the aid of heat to effect the development of its fumes. 65. Hydrochloric acid was introduced in 1773, by Guyton Morveau, for the purpose of puri- fying the principal church at Dijon, the emana- tions from the crowded vaults below having so infected the air of the building as to render it unfit for public service. This acid was soon afterward employed with a similar intention in the prison of the same city; and its success in this case also served to establish its reputation. But the application of heat is necessary to pro- cure the evolution of the fumes with rapidity, from the substances from which it is usually prepared. As its use is not without some dan- ger to animal life, it is desirable that no heat should be applied when it is employed to disin- fect inhabited apartments, and that the process should be allowed to go on slowly. But, how- ever great may have been the reputation ofboth the nitrous and hydrochloric acids in times past, they are rarely used in the present day, both being compelled to yield to chlorine. 66. d. Chlorine was first brought into notice as a disinfecting agent by M. Fourcroy, in 1791; and was subsequently employed as such, on various occasions, by Mr. Cruikshank, of Woolwich, and by M. Guyton Morveau. It has since been used by Dr. Faraday for the purification of the Milbank Penitentiary, an ac- count of which was published by this celebra- ted chemist, in the 18th volume of the Journal of Sciences and the Arts. Chlorine, for the pur- pose of fumigating, is most readily and usually obtained, as is well known, by mixing chloride of sodium and the peroxide of manganese, and adding to them a due proportion of sulphuric acid; but as it is extremely irritating to the membrane lining the bronchi and the air-cells of the lungs, when evolved in any considerable quantity, and as it is hence totally inapplicable to inhabited apartments or wards of hospitals, the above process is entirely unavailable on these occasions. To obviate this inconveni- ence, M. Guyton Morveau introduced a very ingenious apparatus, by which the issue of gas could be regulated at pleasure; but this and all other processes have been altogether su- perseded by the introduction, by M. Labar- raqu-e, of the chloride of lime and chlorinated soda. There has been, indeed, much discus- sion as to the chemical nature of these com- pounds, but this is a subject not requiring no- tice here; practically it is of far greater im- portance to know that they are most powerful disinfectants, and that their success has been unequivocal in the most varied cases wherein the use of these agents are indicated. M. La- barraque recommends the chloride of lime as the substance best adapted for infected apart- ments, and considers the chlorinated soda, as more applicable to foul wounds, ulcers, &c. Both these substances, however, possess the 420 INFEc TION—Precautions against. property of preventing infection or putrefac- tion, and of arresting it when it has commen- ced [probably by decomposing ^maniacal and hydrosulphuric gases, which, there is reason to believe, are developed on th «se occasions] ; and they may both be used with perfect safety in sick chambers, in the wards of hospitals, and in prisons and other inhabited places. When it is desired to purif} any of these apart- ments, portions of linen steeped in the solution should be hung in var'ous places about the room, and the floor and walls frequently and freely sprinkled with i*. Some persons, how- ever, with more nicefv than discretion, object to the use of these sitbstances, in consequence of the unpleasant odour of chlorine, which they declare to be equally or more offensive than that of the infectious effluvium; but it should be borne in mind that the existence of the lat- ter is pregnant with danger to those exposed to it, while, in the diffusion of chlorine by means of these liquids, there is nothing perni- cious to life. [Paris states (Pharmacologia, Am. ed., p. 196) that, in the midst of the dreadful contagion that raged in Spain, the inhabitants always escaped in those houses in which fumigation of chlo- rine had been used, and that, during the epi- demic fever that raged over Ireland from 1816 to 1819, the persons employed in the chemical manufactory at Belfast, which contained in its atmosphere a considerable quantity of chlorine, were wholly exempt. Prof. Daniel has recently suggested (Lond. Phil. Mag., 3d ser., No. 121, July, 1841) that the sulphuretted hydrogen which abounds in the waters of the African Seas is the true cause of the endemic fevers of that country, or, in other words, the true malaria. He has shown, by numerous experiments, that decay- ing organic matter has the property of decom- posing sulphuric salts, and of developing sul- phuretted hydrogen; and he accounts for the presence of this gas on the African Coast by the mutual reaction of the immense quantities of vegetable matters which must be brought down by the intertropical rivers and the sul- phates of the sea-water. It was in consequence of this Report that the British Admiralty gave directions for affording to a ship, about to sail to Africa, the means of producing and applying the antidote, Chlorine. It is by no means, however, proved that sulphuretted hydrogen is the cause of malignant bilious remittents and intermittents; indeed, the theory has already been abandoned by many who at first adopted it, and is, in fact, unsustainable in the present state of our knowledge.] 67. Besides cleansing the air, chlorine, and all other purifying fumigations, will have a sim- ilar effect on the various solid substances and articles of furniture in the infected apartment. It is prudent, however, in addition to the em- ployment of the above measures, to wash these substances well with soap and water ; and as soon as the patient can be removed, the walls of the apartment should be whitewashed, and the room be well and freely ventilated prior to its being again inhabited. All bed and body jlothes, removed from a patient labouring un- der an infectious disorder, should be at once immersed in hot water, or in a solution of an alkaline lye ; and after being soaked in either for a considerable time, they should be subse- quently hung out in the open air, and occa- sionally sprinkled with the chlorinated solution. It must not be forgotten that the beneficial ef- fect of chlorine will be exerted only on a lim- ited quantity of air, and that it is by no means sufficient to correct any epidemic taint exist- ing in the atmosphere of a district or place. When employed, however, in a limited atmo- sphere, this and other disinfectants have proved of no small advantage in checking the spread of infectious maladies; but the power which they possess is far from being sufficient to preclude the necessity of avoiding unnecessary exposure to the sources of contagion, and of adopting preventive and precautionary meas- ures. 68. e. In addition to the forementioned means, an elevated temperature has been recommended hy Dr. Henry, as a powerful means of disin- fecting fomites, or substances imbued with in- fectious emanations. The effect of heat has been principally tried in eases of typhus and scarlatina; and although its power to destroy the infectious properties of the effluvia pro- duced by typhus may be questioned, yet the experiments of Dr. Henry prove that the em- anations of scarlatina are decomposed or dissi- pated by exposure, for ah hour at least, to a temperature of 200°. And it must be acknowl- edged that, where heat is of itself sufficient to exert a beneficial influence upon infected cloth- ing and other fomites, it is preferable, for this purpose, to chlorine or any other fumigation, being more easily and more extensively dif- fused throughout the whole of the substances conveying infection. Its use is, however, lim- ited to bed and body clothes, to trunks and packages, and other articles capable of imbi- bing and retaining the morbid emanation. [It is reported of Hippocrates that, like Acron of Agrigentum, he changed the morbif- ic state of the atmosphere at Athens by kin- dling fires (Galen, Therap. ad Pison; Aetius, v. 94). Acron's method of purifying the atmo- sphere is mentioned by Plutarch (de Iside et Osiride). For an account of Acron, see Fabri- cii (Biblioth. Graec, xiii., 32); Conringii (Intro- duct.), and Mangeti (Bibl. Med.). Pliny says of fire as a corrective of the state of the atmo- sphere, " Est et ipsis ignibus medica vis. Pesti- lential, quae solis obscuratione contrahifcur, ignis suffitu multiformiter auxiliari, certum est, Em- pedocles et Hippocrates id demonstravere di- versis locis" (H. N., xxxvi., 69). With the same intention, Simeon Seth proposes fumiga- tions with frankincense. The historian Hero- dian relates that fumigations with aromatics were recommended as a preventive of the plague. (See Adams's Com. in Paulus AZg\ neta.)] 69. IX. Precautions against Infection.— Every rational measure to avoid exposure t\eypovT) (from Cfkiyu, I burn), tyXiyua, (fkeypaaia, Gr. Inflammatio, Phlogo- sis, Phlegmone, Phlegmasia, Lat. Entzundung, Germ. Inflammation, Phlegmasie, Fr. In- flammazione, Ital. Classif.—1. Class, Febrile Diseases ; 2. Order, Inflammations (Cullen). 3. Class, Diseases of the Sanguineous Function ; 2. Order, Inflammations (Good). III. Class, I. Order (Author in Preface). 1. Defin.—Alteration of the vital actions of a part, manifested by morbid sensibility or pain, by redness, increased temperature, and swelling, gen- erally with more or less febrile commotion of the system. 2. Inflammations or phlegmasia constitute one of the most numerous classes of disease, and appear the most frequently in practice. They are the most common sources of structural le- sions, while they are, in their developed states, themselves lesions of organization, yet origina- ting in changes which are not at first, although they rapidly become more and more manifes* They are thus intermediate states between dis- ordered vital action and change of structure • retaining, however, the characteristics of the former condition, even when they have super-, induced the latter. They may be seated in any organ of the body, and in any tissue, ex- cepting the cuticle, hair, and nails ; but certain structures or parts are much more frequently affected by them than others. The phenomena characterizing inflammations ; the changes in the circulating and secreted fluids attending them; the effects produced by them locally and constitutionally, the remarkable variations these effects present, with the state of the sys- tem, and with the exciting causes ; and the al- most universal liability of the tissues and organs to their invasion, combine to impart the utmost interest and importance to the investigation of their nature and treatment. 3. In treating of this subject, I shall describe, first, the phenomena, local and general, constitu- ting inflammation of a sthenic form, or as observ- ed in a previously healthy person, with their course and terminations, or consequences; sec- ondly, the varieties or states inflammation assumes, owing to certain predisposing, exciting, and concurrent causes, to the previous condition of the patient, to morbid associations, and to the tissues affected ; thirdly, the causes and pathol- ogy, or rational theory of inflammation; and, fourthly, the treatment, with reference to the different forms, states, and complications of the disease. Under one or other of these heads I hope appropriately to introduce everything of importance connected with the causes, nature, and treatment of this most important, most com- mon, and but imperfectly understood deviation from the healthy state. 4.1. Of the Phenomena constituting Sthen- ic Inflammation, and of their Course and Terminations.—It is necessary, in order to form a satisfactory view of inflammation, to consider, first, its phenomena, as manifested in a previously healthy constitution. It then pre- sents characters which have been variously de- nominated, in order to distinguish them from those which attend inflammation occurring in previously disordered frames, as the adhesive, phlegmonous, healthy, reparative, sthenic, &c. I have preferred the last of these terms, as it is more appropriate to most of the states in which this species of the disease presents itself. As sthenic inflammation occurs both in acute or active, and in slighter or more chronic forms, I shall describe it accordingly, but with due reference to the succession of one to the other, to the usual procession of the morbid phenom- ena of each, to the effects upon the circulation and secretions, and to the ultimate results. 5. i. Of Acute Sthenic Inflammation.—A. Local Characters.—In this, which may be de- nominated the truest, or the most unequivocal form of inflammation, there is an increase of the vital actions; but this increase must be of a certain duration, and the vital actions must be altered in character as well as in degree, must be truly morbid, as I have contended in the ar- ticle Disease (t) 87, et seq.), to constitute in- flammation, and to distinguish it from the vital turgescence, which is temporarily produced by local stimuli, or even by mental excitement. The true seat of inflammation is always the ganglionic nervous system and the capillary vessels of the part affected ; the primary change, as will hereafter be more fully shown, originating with the former, but more fully ex- pressed in the latter constituent of the organi- zation.* 6. Acute sthenic inflammation commences with increased or altered sensibility or pain of the part, to which soon succeeds redness, from in- creased vascularity, from the enlargement of * I may here state, that this and other views connected with the pathology of inflammation were published by me, first, in 1815, and subsequently in 1820, 1822, and 1824, in the works referred to in the Bibliography. It is the more necessary to state this, as several of these views have been adopted by later writers, and brought forward with an air of originality to which they have no claim. INFLAMMATION—Phenoi vessels. The temperature of the part is raised, the functions disturbed, the secretions at first interrupted, and subsequently changed ; and swelling takes place. These phenomena are always present in a more or less remarkable manner, or in different proportions, and are much augmented when the system sympathizes and febrile action is developed. Neither of these constitutes inflammation when existing singly, and but four of them have generally been considered requisite to its existence, namely, pain, redness, heat, and swelling, Dis- turbance, however, of the functions, and disorder of the secretions of the part are constantly pres- ent, and are as much constituents of the dis- ease as are those more generally conceded to it. To these, the local symptoms, it will be ne- cessary more particularly to advert before the constitutional disorder, consequent upon the local affection, is considered. 7. a. Uneasy sensation, from its lowest grade, until it amounts to acute pain, is the primary symptom following the operation of the exci- ting cause, or characterizes that kind of excite- ment, or deranged influence of the ganglionic nerves forming the first series of the changes in the affected part, and it is heightened or kept up by the alteration thereby induced in the action of the capillaries. When the uneasy sensation amounts to pain, it is owing either to the de- gree of change in the organic nervous fibrillae, or to the communication of the morbid excite- ment, originating in these nerves, to the ter- minations of the cerebro-spinal nerves, with which they are associated in the tissues. The pain, therefore, of inflammation originates in, or arises from a change in the state .of the par- ticular influence exerted by the organic nervous fibrillae of the part; this change deranging the action of the capillaries supplied by these fibril- lae, and often exciting or otherwise disturbing the sensibility of the associated cerebro-spinal nerves. That the extension, however, of the morbid change to the latter nerves is merely contingent, is shown by the slightness of the pain, or by the absence of acute pain in many cases of severe inflammation of internal visce- ra, particularly those which are not supplied by these nerves; and that the morbid sensation originates in the organic or ganglial nerves, and not in the cerebro-spinal, is rendered prob- able by the circumstance of the most acute pains which are clearly referrible to the latter class of nerves, as those of neuralgia, trismus, and other spasmodic affections, not being .at- tended by inflammation. 8. The uneasy sensation is the sensible mani- festation of the primary change in the organic nerves of the part; of that change which indu- ces the vital expansion or turgescence of the capillary vessels, and the consequent increased influx of blood. The morbid sensation is after- ward increased to actual pain by the circum- stances just stated (§ 7), and by the excessive expansion and tension taking place in that part. It differs in severity and character according to the degree of inflammation, and to'the sensi- bility and structure of the affected part. It often consists of soreness or aching ; of prick- ing, itching, tickling, tension, heat, or burning; of painful throbbing, tearing, darting, gnawing, &c.; and in parts abundantly supplied with nerves, particularly with the nerves of sensa- :ena constituting Sthenic. 427 tion, it is most acute. In mucous, cellular, and parenchymatous structures the pain is rarely very severe. The substance of the brain, or of the lungs, or of the liver, or of the kid- neys is often acutely inflamed without sensibil- ity being materially excited. Severe pain in these diseases is owing either to the extension of inflammation to the serous or fibrous struc- tures, or to the tension of these tissues, caused by the swelling of the parts they enclose. Un- yielding and dense textures, as the fibrous, se- rous, and fibro-cartilaginous, are generally the most painful when acutely inflamed. Pain does not always represent the true seat of the disease. In cases of partial inflammation of the substance of the brain, pain may be felt only in some remote part of a limb, or in a part of the scalp. During the inflammation of the substance either of the lungs, or of the liver, or of the kidneys, or of the uterus, pain may be felt only in those ramifications of the cerebro- spinal nerves which are most intimately related to the organic nerves of the affected part, as in the vicinity of the clavicle or shoulders, in the limbs, &c. 9. It is necessary to study, not only the se- verity and character of pain, with reference to the existence of inflammation, but also its types or modes. The uneasy sensation attending inflammation is generally constant; and, al- though often exasperated at times, it is never altogether absent. Even when no pain is com- plained of, as often occurs in inflammations of internal viscera, tenderness to the touch, or to pressure, is generally present. When, with continued pain, or with a sense of soreness, aching, or of throbbing synchronous with the pulse, or of heat, more or less constant, there are tenderness on pressure, and increase of the morbid sensation on exercising the functions of the part, inflammation may be inferred, even when other indications of it are absent. But the most severe pains, without tenderness, or with perfect tolerance of pressure, and espe- cially if they are paroxysmal, and attended by complete intermissions, furnish no evidence of inflammation. 10. b. Redness, of itself, is not sufficient to indicate inflammation. It may arise from ac- tive congestion of the capillaries, or from a vi- tal turgescence of only temporary duration On the application of an irritant, redness of the part is not manifested immediately, although uneasy sensation is induced ; but it soon is de- veloped, owing to the morbid excitement of the nervous fibrillae, and, like this morbid state, it is more or less permanent. The redness which has thus arisen is caused by the vital expansion of the capillaries, and by the admis- sion of a larger current of blood into them, and of the colouring globules into a series of ves- sels which did not formerly admit them. The blood, also, during the sthenic state of inflam- mation, becomes somewhat more florid than usual in the capillary vessels. The redness is generally greatest in the centre of the inflamed part, or in that spot in which the irritation ori- ginated ; but it spreads more or less, and is gradually lost in the surrounding tissues. The colour varies in depth or hue with the progress and form of inflammation ; hut, in the species now being considered, it is more or less florid or deep. In very vascular, or highly organized 428 INFLAMMATION—Phenomena constituting Sthenic. parts, the tint is deepest, owing to the more intense state of action. 11. Increased redness of a part may exist, as just stated, without inflammation. In order to impart to it essentially inflammatory characters, the vascular action, from which the redness proceeds, must not only be excited, but also otherwise changed from the healthy state. It must be rendered truly morbid. Stimuli or mental emotions will produce redness, but this redness is not inflammatory; it soon disap- pears, and gives rise to no consequences or lesions. The excitant or irritant must, from either its continued or its peculiar action, change or vitiate, as well as excite the organic nerves of the part; must impart to them a truly morbid state or influence, which similarly affects the vital actions of the capillaries, not merely exciting, but also modifying that action, so as to give rise to effects very different from those observed in health. In this respect, chiefly, the redness of inflammation differs from simple vascular excitement, or injection, or congestion. In this latter state the vessels are distended, and contain more than their usual quantity of blood, the circulation through them varying in activity, either rising above or sinking below the common grade of celerity. This state, to which only the very loose and often inappropriately employed term, hyperemia, recently introduced into pathological discus- sions, is applicable, is, however, very different from true inflammation, although it may be readily converted into some one of the varie- ties of inflammation. It is unattended by that morbid state of the organic nerves of the part upon which the true inflammatory action of the capillaries depends. However denominated, whether congestion or hyperamia, or however qualified by the prefix active or passive, it forms no essential part, and constitutes no particular stage of sthenic inflammation, as supposed by some recent writers. 12. If we trace the course of the vascular dis- turbance, we shall find that a contraction of the capillaries of the part follows upon the applica- tion of an irritant, and upon the change pro- duced in the organic nerves of the part. The contraction is soon followed by a reaction or vital expansion of these vessels, an increased afflux of blood, and the other phenomena of the excited vital process. The veins receive the blood from the minutest ramifications of the capillaries, in such a manner as naturally to retard the capillary circulation in them. Con- sequently, when the action of the capillaries is morbidly increased, expansion of these vessels, and an excessive accumulation of blood in them, must necessarily follow; for the veins are in- capable of receiving and carrying onward with sufficient rapidity the quantity of blood sent to them. Owing to this circumstance, vessels previously admitting only the colourless blood, become expanded, so as to admit the red glob- ules ; and as the morbid process goes on, new vessels are probably developed, the blood also becoming, and continuing to be more florid as long as the sthenic action persists. 13. c. Increased heat, as well as augmented redness, is the result of the morbidly excited action. Experiments, however, with the ther- mometer show that the warmth of inflamed parts is not so great as the sensations usually indicate. Some writers, as Hunter, Aber- nethy, Mayo, and others, contend there is ac- tually no increase of the temperature above the healthy standard, but such is not the case. The temperature of an inflamed part upon or near the surface is usually several degrees higher than that of parts at some distance from it; and even the deep-seated viscera experi- ence a rise of two or three degrees, and often much more, above the healthy temperature of 98°. The existence of heat, even with in- creased redness, is not an unequivocal symp- tom of inflammation, for it may depend upon temporary or healthy excitement merely. It is necessary to be continued to indicate a mor- bid state of action. Moreover, it may be so slightly augmented as to escape notice. 14. As to the source of heat in inflamed parts, some difference of opinion has existed. Since Crawford proposed the theory of the depend- ance of animal heat upon the different capaci- ties of venous and arterial blood for caloric, the warmth of these parts has been imputed by many to the quantity of blood circulating through them, and passing from the arterial to the ve- nous state. Without occupying my limits with the opinions and discussions as to animal heat, I may remark that Sir B. Brodie considered, from his experiments, that the cerebro-spinal nervous system was instrumental in its produc- tion. This opinion, however, was not confirm- ed by the researches of Legallois, W. Philip, and Hastings. In 1820, 1822, and 1824 I pub- lished my views on the subject (see Lond. Med. Repos., vol. xvii., p. 370, and Appendix to Rich- erand's Elements of Physiology, p. 630), and contended that animal heat is not the result of the difference of capacity existing between ve- nous and arterial blood ; for, as Dr. Davy has shown, this difference is not sufficient to ex- plain the phenomenon, although it may be sub- ordinately concerned in producing it. I then stated that the various causes which modify the production of animal heat act, 1st, immedi- ately upon the organic system of nerves ; 2dly, upon the blood ; and, 3dly, through the medium of the cerebro-spinal system, modifying the in- fluence which this system imparts to the gan- glial. I then viewed animal heat more as a vi- tal secretion than as a chemical phenomenon, as proceeding from, and as being controlled by, the influence exerted by the ganglial system of nerves upon the vascular system and blood ; and the subsequent researches of Chossat and Ed- wards obviously confirm this opinion. Con- formably with this view, I have stated, in the works referred to, that the increased heat of inflammation is derived from the same source, from the influence of the organic nerves upon the vessels of the affected part, aided by the increased circulation through the capillaries; the nervous influence enlarging these vessels, or occasioning an erectile state of them, and thereby soliciting an afflux of blood to the part. The increased temperature of erectile tissues, consequent upon irritation of their nerves and expansion of their vessels, fully illustrates this theory of animal heat, and particularly with reference to inflammation. 15. d. Swelling has been assigned above aa one of the changes constituting inflammation. But, from what I have already stated, it should be viewed rather as a consequence of this act INFLAMMATION—Phenomena constituting Sthenic. 423 than as an essential part of it. Besides, swell- ing is not always present, owing to circum- stances about to be noticed. The morbid state of the organic nerves and the expansion of the capillaries are the earliest causes of swelling. But, as the diseased action proceeds, a more or less copious exudation of serum into the areolar tissue takes place ; a portion of the se- rum, and even of the red particles of the blood, passes through the pores or distended walls of the capillary canals, especially in cellular or mu- cous tissues, distending, tumefying, and thick- ening the inflamed part. Hence the areolae of cellular structures are found filled with a se- rous, sero-albuminous, and often with a san- guineous fluid, in which flocculi are sometimes seen floating, or adhering to the parietes of the areolae or cells, these parietes being often thickened. 16. The nature of the swelling entirely de- pends upon the state or kind of fluid thus exu- ded from the inflamed capillaries. The state of the fluid depends upon the kind of disorder of the organic nervous influence of the part, and of the constitution generally, and upon the de- gree of vital power exerted by the system. In the sthenic species of inflammation, this power, however much it may deviate from the healthy condition, is at least not depressed below this condition. The fluid exuded is therefore a product of increased or sthenic vascular action, excited and kept up by the influence exerted on the capillaries by the nerves in which the disorder originated. Hence it is generally sero-albuminous, or a mixture of serum and coagulating lymph, sometimes containing col- ouring particles when the morbid action is in- tense ; and the consequent swelling is firm, tense, and limited as to extent. The sero-al- buminous or coagulating character of the effu- sed fluid entirely depends upon the sthenic na- ture of the inflammation, and is of the utmost importance as respects the subsequent changes. When the organic nervous or vital power, lo- cally or generally, is depressed or otherwise vitiated, as well as depressed, the effused fluid is not albuminous, and does not coagulate. _ It is then either serous or sanguineous, or even sanious, and does not possess the characters of coagulable lymph. The consequent swell- ing is oedematous, soft, diffusive, or spreading, owing to the fluid state of the exudation, and its more ready infiltration into the surrounding parts. While organic nervous or vital power is unreduced, the exuded matter occasioning the swelling in the advanced stage of inflam- mation at least partially coagulates, and limits the extension of tumefaction. But when this power is much reduced, or greatly vitiated, as in the different forms of asthenic inflammation, this matter retains its fluidity, infiltrating and infecting the surrounding tissues. 17. The existence and amount of swelling chiefly depends upon the nature of the inflamed tissue. It is neither so early nor so obviously present in inflammation of dense structures as in that of soft and yielding parts. It is incon- siderable in fibrous, nbro-cartilaginous, and se- rous tissues, and is hardly apparent until the morbid action has continued for some time. In cellular, mucous, and parenchymatous tis- sues, the swelling is early and considerable. In certain parts, as in cellular tissue bound down by aponeurotic expansions, and in the in- ternal structure of organs surrounded by fibroua or unyielding membranes, the swelling is less, or more slowly developed; the pressure thus occasioned restraining the effusion and the ex- pansion of the capillaries. But, where the morbid action is intense, the pressure gives rise to a most distressing sense of tension, in- terrupts the functions of the organ, and some- times even the circulation in it, thereby de- stroying its vitality and occasioning dissolution. When the substance of the brain is inflamed, the nature of its circulation, the great division and tenuity of its capillaries, and the unyield- ing nature of its surrounding structures com- bine to prevent it from becoming much swol- len. Yet there is every reason to believe that more or less swelling actually occurs (see art. Apoplexy, and Brain—Inflammation of), and that the pressure on the inflamed organ, occa- sioned by the unyielding parts surrounding it, gives rise to the more dangerous symptoms ob- served in the advanced progress of the disease. 18. e. The functions of an inflamed organ, tissue, or part, are, as Mr. Morgan has very justly contended, more or less disordered ; and I may add that the disorder is one of the earli- est phenomena or constituents of the morbid action, being nearly coetaneous with the change in the organic nervous power, on which this action depends. The disturbance of the func- tions is generally in proportion to the violence of the disease. If the inflamed part performs a secreting function, the secretion is either di- minished, increased, or altered in character. Diminution of this function is observed, when the cutaneous surface is inflamed, at the com- mencement of acute inflammation of serous and mucous membranes, and when the morbid action in glandular secreting organs is sudden or intense. When parts near the surface are inflamed, perspiration is obstructed, and the temperature is thereby increased. It is onlj at the commencement of inflammatory actior in serous and mucous surfaces that their secre tions are diminished: as the disease proceeds-. their secretions become increased, but, at th.; same time, changed in their characters; the change varying with the intensity, form, and duration of morbid action, and with the state of the patient. Inflammation of glandular or- gans is generally attended by suspension or diminution of their secretions, as in hepatitis, nephritis, &c. But in many cases, one kidney only, or a portion of the liver, may be inflamed, the secretion being only diminished or some- what altered. It should, however, be recol- lected that the secretions of an organ may be suspended, increased, or morbidly affected oth- erwise than by inflammatory action. 19. The lesion of function attending the com- mencement of inflammation obviously depends upon the primary affection of the organic nerves. That accompanying the advanced progress of the morbid action proceeds not only from this source, but also from the alteration in the ca pillary circulation, from the consequent effusion of lymph in the inflamed tissue, and from tha swelling and mechanical obstruction therebj produced. 20. The throbbing is connected with the ob- struction to the return of blood, particularly from the expanded capillaries into the veins. 430 INFLAMMATION—Constit It is synchronous with the pulse, and is caused by the injection of blood into the part on each contraction of the left ventricle of the heart. It increases and renders the pain pulsatile ; when it occurs at an advanced stage of inflam- mation, it is usually soon followed by suppura- tion. It is increased by a depending position of the inflamed part, and by whatever either obstructs the return of blood from, or favours the flow of it to, the seat of disease. 21. B. Of the Local Appearances after Death.—Certain of the preceding local charac- ters of inflammation necessarily disappear with the termination of life; and the rest, as red- ness and swelling, either vanish, or remain for some time afterward. Redness does not al- ways continue after death; its absence, there- fore, is no proof that inflammation had not ex- isted during life. Its presence also, post mor- tem, is not sufficient evidence of its dependance upon this cause. At an early stage of inflam- mation, and before the capillaries have lost their vital tone or contractility, and before much serum or lymph has been effused, red- ness generally disappears after death. Even when much effusion of fluid, and other changes consequent upon the morbid vascular action, have taken place, the blood may have entirely forsaken the vessels before the parts have been examined. Where redness actually exists, much discrimination is necessary to determine whether or not it has proceeded from inflam- mation, or from a dependant position, or from transudation of the colouring matter of the blood from the vessels, or from incipient de- composition. It may arise from either of these. In many cases, two or more combine to pro- duce it: a depending position favours both the gravitation of the fluids in the vessels, and the exudation of the colouring particles in the lower parts. The injection caused by position more readily occurs in parts which have been inflamed than in those previously sound. Much, however, depends upon the seat and form of inflammation, and upon the circumstances con- nected with dissolution. Next to position, ob- structed circulation through the heart or lungs, or obstruction to the return of blood in the veins, most frequently occasions non-inflamma- tory injection and redness, particularly in mu- cous surfaces ; but, in such instances, the red- ness is more or less general or diffused in these parts, or exists in situations remote from each other, and is not attended by the usual products of inflammation. Attention to the circumstan- ces causing redness of parts after death will generally enable the practitioner to infer with accuracy its dependance upon inflammation. When it is associated with any of the usual products or consequences of this disease, as the effusion of lymph, or of a sero-albuminous fluid, with softening, swelling, &c, then no doubt as to its origin need be entertained. (See Diagnosis.) 22. C. Of the Constitutional Symptoms or Effects of Sthenic Inflammation.—The con- stitutional phenomena vary remarkably with the exciting causes, the intensity, and the seat of inflammation; and they are farther modified by age, habit of body, diathesis, and epidemic constitution. When inflammatory action takes place in a previously healthy person, and from causes which do not materially vitiate or de- jtional Symptoms of Sthenic. press the vital powers, or contaminate the cir- culating fluids, the constitutional effect pre- sents certain features which are rarely want- ing. It has been variously denominated as Symptomatic Inflammatory Fever, Sympathetic Synocha, General vascular Reaction, Inflammato- ry Fever, &c, and has been improperly descri- bed in connexion with, or, rather, as a species of true fever. Indeed, some writers, as I have shown in the article Fever (§ 91), particularly Clutterbuck, Marcus, and Broussais, have contended that the constitutional affection, pro- duced by the local changes constituting inflam- mation, is in no respects different from idio- pathic fever. In the article just referred to, I nave stated sufficient to prove the very remark- able differences between the two (§ 26-30), and I shall hereafter succinctly notice the subject. Indeed, the former is altogether distinct from the latter, and should not be considered in con- nexion with it, farther than to point out the di- agnosis. 23. In some constitutions, particularly the sanguineous, the irritable, and the nervous, the local lesions described above (§ 6), very soon af- ter their commencement, create more or less constitutional disturbance and febrile commo- tion ; while in others, as the phlegmatic or lymphatic, the melancholic or bilious, these lesions may have been of some continuance, or have proceeded far before general disorder is developed or becomes severe. The local change being the same, the constitutional ef- fect will vary remarkably in grade, form, and course, according to these and other circum- stances just mentioned. In some it will be rapidly developed; in others slowly, or after a precursory period of longer or shorter dura- tion, or after several efforts to produce it. The earlier constitutional symptoms are often neg- lected by the patient, and are seldom subjected to the physician. Occasionally the patient ex- periences chills or rigours, more or less severe, almost immediately after sensations of pain or uneasiness. In rarer cases, morbid sensation is not produced until either during or after the rigours. This is observed most frequently in inflammations of internal organs. More com- monly the patient complains, in connexion with pain, of uneasiness, or other morbid states of sensation referrible to a particular part, of weakness of the limbs, lassitude, general un- easiness, or lowness of spirits, of slight chills, formication, or of an alternation of slight chills and flushings. These may be the only precur- sors ; or they may be attended by disturbed sleep, a whitish or loaded tongue, a clammy state of the mouth, with vitiated taste, want of appetite, constipation, &c. With these, the local symptoms are aggravated, and severe rig- ours or shudderings are more or less rapidly pro- duced. The rigours are sometimes accompa- nied with nausea or vomiting. The counte- nance, general surface, and extremities, which were pale, harsh, or cold during the rigours and chills, soon afterward become warm ; and the pulse, which was previously small or constrict- ed, and but little accelerated, increases in quickness and volume. The consequent phe- nomena appear with a rapidity and severity varying with the intensity and extent of the local action. The secretions and excretions are diminished, and subsequently vitiated. The INFLAMMATION—Changes ob SERVED IN THE BLOOD IN STHENIC. 431 skin is hot and burning, the face flushed; the tongue is white, furred, or loaded, and, with the mouth, somewhat dry or clammy ; the appetite is gone ; thirst is urgent; the bowels are con- stipated ; the urine is scanty, high-coloured, clear, and emits a strong odour ; and pains are often felt in the back, or loins, limbs, or head, in addition to those referred to the inflamed organ. The symptoms indicate general vas- cular excitement and its usual consequences, unconnected with depression of vital power or contamination of the fluids. When they are severe or intense, and when the energies of life become exhausted, delirium sometimes takes place, particularly at night; but it rarely appears early, unless the brain is the seat of" inflammation, or readily sympathizes with the local affection, as in inflammation of the dia- phragm or of fibrinous parts. 24. The acuteness of the general symptoms is not always in relation to the severity of the local changes; but, according to the intensity of either, or of both, will the type of the for- mer be more manifestly continued. The less severe states of constitutional affection, and particularly when the local morbid action is neither extensive nor very acute, are charac- terized by exacerbations in the evening or night, during which the local symptoms are more or less exasperated, restlessness and want of sleep being generally present. In the morning the symptoms are ameliorated, and a tendency to perspiration appears. The course and duration of the constitutional affection vary with the severity and the seat of the local disease, and with the circumstances proper to the individual affected. The symptoms usual- ly increase either gradually or rapidly, accord- ing to the nature of the exciting causes, the acuteness of the attack, and the circumstances just alluded to, until they arrive at a certain pitch or acm'e, from which they decline more or less rapidly in some cases, and slowly in others. This change, whether taking place gradually and slowly, or suddenly and rapidly, depends entirely upon the state of the local af- fection. If the local symptoms gradually de- cline, the general disturbance subsides in a similar manner ; and if any of the more unfa- vourable terminations of the local disease about to be noticed occurs, the system evinces the change, as will be hereafter stated. 25. D. Of the Changes observed in the Blood in Sthenic Inflammation.—These vary remarkably with the circumstances determin- ing the severity, seat, and course of the dis- ease. I have described them so fully in the article Blood ($ 96, et seq.), that little more need be here adduced upon the subject. Much importance has been attached to the existence of a buffy coal, and of a cupped appearance of the coagulum. These states of the blood are most frequently observed in the species of in- flammation now being considered. But they are not always, nor even very generally pres- ent, nor at all stages of the disease in which they occur. They are even more commonly met with in some complaints which, although nearly allied to inflammation, are not purely inflammatory, as rheumatism. They have fre- quently a marked reference to the stage and seat of inflammation. In acute rheumatism they are very remarkable, and often become more so as depletions are repeated. I once witnessed a case of the internal metastasis of rheumatism, for which venaesection was re- pealed several times. ^ The buffed and cupped appearances became more and more remark- able ; and yet, upon examination after death, no signs of inflammation could be detected, and the internal viscera were, quite bloodless. When, however, serous and fibrous structures are inflamed, these states of the coagulum very generally exist. During acute inflammation of cellular and mucous tissues they are much less frequently observed. When compound or parenchymatous structures are inflamed, they are met with chiefly in certain stages and states of the disease. When an important or vital organ is inflamed, and especially when the patient is plethoric and the circulation op- pressed, these appearances often do not take place until the vascular load and oppression are removed, and the circulation is rendered free. There are various other circumstances which affect the state of the coagulum in acute sthenic inflammations, but they are noticed in the article just referred to. It is chiefly in the venous blood that cupped and buffed appear- ances have been seen ; for the occasions of noticing them in arterial blood are compara- tively rare, and unfavourable to their occur- rence. They have, however, been met with in arterial blood by Gordon, 'Gendrin, und others. [Mr. Addison claims to have established the following conclusions as connected with the blood : "1. That the colourless corpuscles exist in the blood of man under all circumstances, and are constantly circulating through the capillary vessels, to the walls of which they have a ten- dency to adhere. " 2. That they exist in great numbers in the blood of inflamed parts ; and that they may be seen accumulating in the irritated vessels of a frog's foot, and showing an increased tendency to adhere to their walls. " 3. That they exist in great numbers in the buffy coat of the blood. " 4. That the liquor sanguinis, especially that of inflammatory blood, fibrillates in coagulating, so that a thin film of it presents all the structu- ral characteristics and physical properties of fibrous or membranous tissue. " 5. That lymph and pus globules, exudation cells, and epithelium, are altered forms of the colourless corpuscles." (The Actual Process of Nutrition in the Living Structure demonstrated by the. Microscope, &c, by William Addison, F.L.S. Lond., 1844, p. 76, with 2 plates.) Dr. A. also maintains that neither the fibrin nor albumen of the circulating blood is diffused through its fluid portion, or liquor sanguinis; but that they are both contained in the colour- less corpuscles : of these he supposes that a large proportion burst or become ruptured as soon as the blood is drawn from a vein, owing to the sudden change of temperature to which they are exposed, or from other causes ; and that they set free the liquor sanguinis, which rises to the surface, drawing up with it the colourless corpuscles which have hitherto pre- served their integrity. These views, however, appear to us hypothetical, and, considering the variety of appearances described by different microscopical observers, require farther con- 432 INFLAMMATION—Changes observed in the Blood in Sthenic. firmation. It is now well established, by the researches of Andral, Gavarret, and others, that an excess of fibrin and of the colourless or lymph globules exists in inflammatory dis- eases, especially those of a sthenic character, and acute rheumatism. In some cases fibrin has been observed in the proportion of 10 parts in 1000, the natural ratio being from 22 to 32. It is found in excess in tuberculous diseases, pneumonia, rheumatism, cellular inflammation, or simple phlegmon, phlegmasiae of the mucous membrane of the respiratory and digestive ap- paratus, mercurial stomatitis, acute cystitis, acute inflammation of the skin, as in burns, erysipelas, &c.; also, of all serous membranes, lymphatic glands, and softening of the brain. As soon as inflammation begins, an increase in the fibrinous constituent of the blood is mani- fested. M. Andral supposes that the disease of the solid precedes the change in the blood; and that the occurrence of this latter explains, and is proof of inflammation being a general and constitutional disease. The sympathetic fever in the phlegmasiae is, he thinks, due to the alteration in the blood by excess of its fibrin. —(Williams's Principles of Medicine, ed. by J. Bell. Phil., 1844.) The increase of fibrin is so constant a phe- nomenon as to be regarded as a pathognomon- ic sign of inflammation, distinguishing it from other conditions tha't simulate it, and thus en- abling us to detect it at an earlier period than could be done by either general or local signs, the degree of increase bearing a constant pro- portion to the extent of the inflamed part and to the intensity of the morbid action. But it is to be observed that there is not only an ex- cess of fibrin, but an increase in its plasticity, or tendency to become organized ; thence ari- ses the rapid production of false membranes from fibrinous effusions, as well as from the more complete fibrous arrangement seen in the buffy coat, than that which the ordinary coagu- lum of blood displays. The increased propor- tion of the white or colourless corpuscles in inflammatory blood, and their special accumu- lation in the vessels of the inflamed part, has been abundantly shown by the independent ob- servations of Gendrin, Gulliver, Addison, and Williams. There is every reason to sup- pose that the white corpuscles are newly formed immediately upon the application of an irritant; and Mr. Addison has shown that they have the character of true cells. The above facts seem to prove very conclusively that the increase of fibrin, and its more contractile and separating quality, originate in the vessels of the inflamed part, and must be regarded as an augmentation of the vital process of nutrition developed by inflammation.] 26. The coagulation of the blood, and the ori- gin of the buffy coat of the coagulum, have been so fully considered elsewhere (see art. Blood, and my Appendix to Richerand's Elements of Physiology, p. 638), that I need adduce but lit- tle farther on the subject than to state the facts ascertained, and the inferences deduced from my investigations, and published in 1824, in the first edition of the Appendix just mentioned. The blood during life consists of serum, hold- ing in suspension small, regular, and insoluble globules, each of which is composed of a cen- tral, colourless spheroid corpuscle, and a col- oured envelope. The latter always continue."! to surround the former during life ; but, as life departs, and as the motion to which it gives rise ceases, the attraction between the central corpuscles and their coloured envelopes no long- er exists, the one completely separating from the other. The central corpuscles then obey the force which tends to unite them, and form a net-work, in whose meshes the liberated col- ouring matter, now detached from these cor- puscles, becomes enclosed, and thus the coagu- lum is formed. These central corpuscles, in uniting into filaments or other forms, consti- tute the fibrin, which, as respects its consti- tution, is probably only a modified or more high- ly animalized albumen, which abounds more or less in the serum. When the coagulum of the blood is exposed to a stream of water, the colouring matter, detached from the central corpuscles, is washed away, while the corpus- cles themselves remain aggregated in the form of fibrinous filaments. It is the various forms assumed by the aggregation or mutual attrac- tion of the central corpuscles, in relation to the separation, deposition, or entanglement of the colouring matter, and to the appearances of the serum in which these changes take place, which constitute the phenomena of coagulation, and give rise to the appearances of the blood char- acteristic of inflammatory action. In addition to these facts, the following inferences as to the causes of the phenomena of coagulation may be abridged from my notes above refer- red to : 27. 1. The globules of the blood possess a rotatory motion during life, this motion contin- uing until shortly before coagulation takes place. 2. This motion is the consequence chiefly of the organic nervous or vital influence which is exerted by the ganglionic system on the heart and blood-vessels, and which is par- tially imparted to the globules. 3. This influ- ence thus preserves the blood in a state of due fluidity. 4. The fluidity of the blood is hence a vital phenomena, or property derived from, and depending upon the vital conditions of the vessels in which, and the organs through which it circulates ; the vital conditions of the ves- sels and organs depending, as shown elsewhere, chiefly upon the organic nervous influence. 5. The cause of the coagulation of the blood is not to be found in external agencies, but in the loss of the vital influence and motion of the globules, proceeding from the sources just assigned, the power exerted by the ganglionic upon the vas- cular system. 6. The presence of air, particu- larly the oxygenous portion of it, and several physical and chemical agents, hasten coagula- tion, while others delay or altogether prevent it. 7. When coagulation commences at any point of a mass of blood, it is rapidly propaga- ted throughout the whole : rest favouring co- agulation, while motion delays or prevents it. 8. The heat of the body and the strength of the circulation are not causes of the blood's fluidity, but are both results of the same cause, namely, the vital energy of the vessels, and vi- tal endowment of the globules of the blood: both are co-ordinate, and both, as well as the phenomena connected with coagulation, are de- pendant on this source. 9. Coagulation occurs sooner in venous than in arterial blood ; and coagulation of arterial blood is still longer de- INFLAMMATION—Changes ob laved if it be prevented from leaving the arter- ies. 10. Coagulation takes place the sooner after the blood is removed from the vital sphere of the system, the weaker the vital energy to which it was subjected while circulating in the system. 11. The weaker the vital energy, and, consequently, the quicker the coagulation, the more lax is the coagulum which is formed. 12. Coagulation is more slow, and the coag- ulum more firm, the more energetic the vital action of the vessels. 13. As the central cor- puscles lose their coloured envelopes soon af- ter their removal beyond the sphere of the vital influence of the vessels, and as this is the first part of the act of coagulation following the loss of motion of the globules, so it may be inferred that.the colouring matter continues to surround the central corpuscles in consequence of the vitality emanating from the interior of the ves- sels and endowing the globules ; and that the separation of the colouring envelope from the central corpuscle is the result^of the loss of a portion or of the whole of that vitality, and of the rotatory (1) motion which it occasions; and, as the loss of vitality may be reasonably supposed to be quickest where it has existed in the lowest grade, the separation of the coloured. envelopes, and the attraction of the central corpuscles forming the fibrin, will be the quick- er, the weaker "the vital energy, and vice versa; but the coagulum will be the more lax or im- perfect, as shown by the facts already stated (10, 11). 14. Although the loss of the rotatory motion and of the colouring envelopes of the globules disposes the central corpuscles to at- tract each other, yet the attraction is weak in proportion to the depression of organic nervous or vital power endowing the vascular system at the time when the blood is abstracted ; and in some inflammations, as well as in some other diseases, the depression may be so ex- treme as to deprive the central corpuscles of all power of uniting in the form of fibrinous filaments. In such, cases these corpuscles merely mix with the serum like a gelatinous or albuminous matter, and either suspend the col- ouring substance, or allow its deposition to the bottom of the vessel; the central corpuscles separating imperfectly from the serum or com- bining with its albumen, or forming merely an almost colourless gelatinous mass in the upper parts of the coagulum. 15. The firmness of the coagulum is in proportion to the degree of organic nervous influence endowing the vascu- lar system, and to the emanation which the globules themselves derive from this influence.* * [Dr. S. L. Metcalfe has reduced the leading facts connected with the theory of coagulation to the following propositions (Caloric, its Mechanical, Chemical, and Vital Agencies in the Phenomena of Nature, 2 vols., 8vo, p. 1100. Lond., 1843): "1. That the contractile power of the blood when re- moved from the body, like that of the muscular fibres, is in proportion to the quantity of respiration, mean healthy tem- perature, and aggregate vital energy in the different orders of animals ; being greater in birds than in mammalia, and greater in the latter than in reptiles and fishes. " 2. That, as the temperature of arterial is higher than that of venous blood, so does the former coagulate more quickly and firmer than the latter. " 3. That, as the vital energy of animals is always dimin- ished by reducing their temperature below their natural standard, so is the coagulation of the blood retarded by the same means, and wholly prevented by long-continued cold. " 4. That the blood of individuals belonging to the san- guine or dynamic temperament coagulates sooner and more firmly than in such as are of a weak or phlegmatic consti- _ II 55 ISERVED IN THE BlOOD IN STHENIC 433 28. From what is now advanced, the appear- ances of the blood in inflammatory and other diseases will be readily explained. When the organic nervous power is depressed or exhaust- ed—as in asthenic inflammations, in typhoid and adynamic fevers, in the true infectious pu- erperal fever, and puerperal mania, in the worst forms of erysipelas and diffusive inflammation of the cellular structures, and in several other diseases, particularly when epidemic, or occur- ring in hospitals, the air of which is vitiated by crowding of the sick, and the decomposition of the discharges and secretions, as in lying-in hospitals—the blood taken from a Vein will often not separate into a distinct coagulum and serous fluid, but will assume the appearance either of a black, grumous, sanious, semi-gelat- inous mass, or of a straw-coloured jelly, at the bottom of which jelly the colouring matter forms a loose reddish brown, or blackish stratum. In such cases the blood, participating in the deficiency of the vital energy of the body, and being also, perhaps, deranged from the admix- ture of hurtful materials with it, which are not duly eliminated by the various emunctories, evinces the lowest grades of vital endowment, the attraction between the central corpuscles of the globules being too weak to form a coag- ulum and to exclude the serum, the colouring envelopes separating speedily from the central corpuscles, and forming a loose stratum at the bottom of the vessel. 29. It may be inferred, as corollaries from the foregoing, that the appearances which the blood exhibits have always an intimate relation to the vital conditions of the system, and to the excitement of the heart and blood-vessels; that the buffy coat is merely one of the manifesta- tions furnished by the blood, indicating reaction of the powers of life, or excitement of the vas- cular system; that the blood participates in the vitality of the body, through the medium of the vessels and organs in which it circulates and that, according to the degree or condition of this vital endowment, coagulation and the coagulum are modified in their phenomena and appearances, and the production of the buffy coat promoted or altogether prevented. (See art. Blood, § 81, et seq.)* tution, since its contractile power is diminished by whatev- er impedes the function of respiration, as in phthisis, asth- ma, disease of the heart, the cold stage of fever, and all' maladies of long standing, by which the powers of life are greatly reduced" (vol. ii., p. 648). The work above quoted is one of the most remarkable of the age, for the great learning and ability it displays; being characterized by a deep philosophical spirit, profound sagacity, and immense research, there can be no doubt that it is yet destined to exert a most important influence upon medical science, and' modify many existing opinions on physiology, pathology, and practical medicine.] * [The changes observed in the blood in sthenic inflam- mation are thus ably summed up, in the Brit, and For. Med. Rev., July, 1844, p. 103: "I. a. The quantity of fibrin in the blood undergoes a decided increase ; the plasticity of the whole mass, therefore, but especially that of the liquor sanguinis, is greatly augmented, b. There is a correspond- ing increase in the proportion of white corpuscles, which are present in large amount in the vessels of the inflamed tissues, and have a great disposition to adhere to their walls ; but which are also present, to aa unusual amount, in the entire mass of the circulating blood, c. The increase in the proportion of fibrin is chiefly a local action, exerted on the blood during its passage through an inflamed part, and probably effected by the instrumentality of the white corpuscles, d. There is usually an increase, not only in the quantity of fibrin, but in its plasticity or tendency to be- come organized, as shown by the greater perfection of the fibrous structure into which it passes in coagulating. This 434 INFLAMMATION—Chronic. 30. ii. Of Chronic Inflammation.—Inflam- mation may affect any tissue or organ in so mv consist in an increased attraction between its particles, which continues to operate for some time, causing contrac- tion of the fibrous net-work, subsequently to its first produc- tion, e. There is also an increased attraction between the red particles of blood, causing them to adhere together in rolls more firmly and for a longer period than they do in healthy blood. /. To these two causes, usually aided in their operation by the slowness of the coagulation, all con- curring to produce an increased tendency to separation be- tween the red corpuscles and the liquor sanguinis, we may ascribe the production of the buffy coat of inflammatory blood, g. The increased plasticity of the blood is so con- stant a phenomenon of inflammation, that it maybe regard- ed as essential to the presence of that state. •' II. a. On the other hand, the formative power of the in- flamed tissues appears to be diminished ; their usual functions, whether of nutrition or secretion, being com- pletely checked, or insufficiently performed, or perverted in their character, b. While, therefore, an over-production of fibrin is taking place in the blood, there is diminished con- sumption or appropriation of it in the tissues, c. If the in- flammation be severe in its character, the vitality of the tissues is so diminished as to cause, not only a cessation of their formative actions, but also an increased tendency to • disintegration, as shown in suppuration and ulceration ; ot positive death of a large part, as in gangrene, d. The de- pression of the vitality of the tissues sometimes appears to result from a previous over-excitement of it, as when in- flammation follows excessive use of a part, or the applica- tion of stimulants to it; but it is sometimes the consequence of some directly sedative action, as that of cold. e. Hence both determination of blood and congestion have a tendency to produce inflammation ; the one being a state of over-ex- citement, which is very prone to occasion subsequent de- pression, while there is at the same time a tendency to in- creased production of fibrin in the blood, the other being itself a state of depression of formative power in the solids, but not passing into inflammation, unless there be at the same time an increased plasticity of the blood. " III. a. The motion of the blood in the capillaries of the inflamed part is greatly retarded, as we might have anticipated from the impairment of the functional operations of the solids. There may even be a total stagnation of the blood in the capillaries of a considerable portion of the tis- sue, which will be followed by its death and disintegration. The degree of stagnation will depend upon the amount of the depression of the vitality of the surrounding parts, b. The motion of blood through the vessels in the neighbour- hood, however, is more rapid than usual,'and these vessels are themselves enlarged ; so that the total quantity which passes through an inflamed member in a given time is great- er than usual, c. The vessels are enlarged both in and around the inflamed part, in consequence of a diminution of the tonic contractility of their walls, which causes them to admit of abnormal distention by the impulse which the blood receives from the heart. This diminution is another evidence of the depression of the vital properties of the solid tissues in an inflamed part. "IV. a. The products of inflammation differ from those of the ordinary processes of nutrition and secretion, not so much in their materials as in the nature of the change which these have undergone, b. When the intensity of the inflammatory process is moderate, the liquor sanguinis, con- taining an unusual proportion of fibrin, and possessing a high degree of plasticity, is effused into the neighbouring tissues or upon the neighbouring surfaces, being generated, by the local actions of the part, faster than it can be with- drawn by its formative processes. By the organization of which it is susceptible, when in contact with the living solids, it spontaneously assumes the form of simple fibrous tissue, constituting false membranes on the surface, or con- solidating the substance into which it is effused, c. If the inflammatory process goes no farther there is no disintegra- tion of the original tissue ; but if its vitality be too far de- pressed it dies ; and the changes which it consequently un- dergoes impress themselves upon the fibrinous effusion. The fibrin loses its vital power of coagulation, and in this aplastic state becomes the chief ingredient in the liquor pu- ris; while the cells (pus-corpuscles), which are found float- ing in it, resemble the white corpuscles of the blood in a Regenerated form. d. When the inflammation is very se- vere, and the stagnation of blood in the capillaries of the part is complete, an entire loss of vitality in the whole tis- sue at once, or gangrene, is the result. Gangrene does not originate, however, in inflammation alone, since any olher cause, such as the long-continued action of cold or pressure, interrupting the capillary circulation, or obstruction to the supply of blood through the arterial trunks, will equally produce it, by the suspension of the formative processes thus occasioned. But unless some degree of inflammatory action, that is, an increase in the plasticity of the blood, be set up at the same time, there is an indisposition to the for- mild and obscure a form from the commence- ment as to proceed for a long and indetermi- nate period; and, in many cases, to escape detection for a long time, owing to the slight- ness and gradual progress of the phenomena constituting the inflammatory act. This may be termed Primary Chronic Inflammation. The chronic form of inflammatory action is, how- ever, frequently observed to follow the acute disease; the latter, owing to diathesis, treat- ment, premature exposure, and to the operation of injurious agents before recovery had taken place, only partially disappearing, or degenera- ting into a milder and more prolonged state of action. This state may be called Consecutive Chronic Inflammation. 31. A. The Local Symptoms vary remarkably with the mildness or severity of the morbid ac- tion ; for, as the term chronic, as well as acute, is merely conventional or relative, both mark- ing extremes of action, between which every intermediate grade is to be found, each of the phenomena already described, as characterizing sthenic inflammatory action, appears in differ- ent states of development in different cases and circumstances. Generally speaking, how- ever, all the local symptoms are much less se- vere than in the acute disease, and sometimes so slight as to escape detection. Pain is occa- sionally absent, or is so slight as not to excite attention. Redness is also sometimes slight, or not very remarkable. The temperature is not much elevated ; it is often not above the natural standard. Swelling is frequently slight, but it is sometimes very considerable; and throbbing is seldom complained of. The func- tions of the organ or part affected are generally more or less disordered ; but in some instances the disorder is slight, or even escapes detec- tion. This is especially the case when a por- tion only of an organ or part is chronically in- flamed. When an internal organ is thus affect- ed, it is chiefly by the presence of disordered function, and by the constitutional or sympa- thetic effects of the morbid action that the na- ture and seat of the disease can be detected. ' 32. B. The Constitutional Symptoms are often slight and obscure, sometimes prominent and characteristic. Febrile Symptoms are not al- ways present; and, even when most manifest, they are rarely of a continued type. They are generally remittent, or almost intermittent, the exacerbations being preceded by languor, un- easiness, or slight chills, followed by increased frequency of the pulse, by thirst, dryness of the mouth, and heat of skin. These symptoms come on in the evening, impair the rest, and subside in the morning, either with or without perspiration. The general health is more and more impaired, the strength fails, the flesh wastes, and the complexion waxes pale, sal- low, or unhealthy. If the generative or urina- ry organs are the seat of the disease, various nervous or sympathetic symptoms are present; and if matter forms, or ulceration takes place, the chills become more severe, the febrile exa- cerbations terminate in copious perspirations ; the urine is thick after standing, or deposites a sediment; emaciation proceeds more rapidly, and hectic fever is established. 33. iii. Progress and Duration.—Theprog- mation of the line of demarcation between the sound and the dying parts, and the gangrene has a tendency to spread."] INFLAMMATION—Sthenic—Complications—Terminations. 435 ress and duration of sthenic inflammation are influenced by the constitution or diathesis, hab- its of life, age, and sex of the patient; by the structure or organ affected, and by the treat- ment and influences to which the disease is subjected. The sanguine and irritable temper- aments, a full and robust habit of body, and youth or the vigour of age, not only impart a sthenic character to inflammation, but also cause it to assume an acute or active form, or to run its course rapidly. A similar effect is favoured by parts which are naturally vascular, and supplied abundantly with nerves, or en- dowed with high sensibility, and especially if they be placed near the centre of the circula- tion. On the other hand, the melancholic, leu- cophlegmatic, and nervous temperaments, the scrofulous diathesis, an advanced period of life, and the female sex, prolong the progress of in- flammatory action, and cause it to assume, either primarily or consecutively, a latent, lan- guid, or mild and chronic form. Structures endowed with little vascularity, and with a low grade of sensibility, as tendons, ligaments, fas- ciae, and bones; aiso parts far removed from the centre of vitality and of circulation, as the extremities, are most prone to inflammation of a slow and chronic character. , 34. The patient's habits of life have a re- markable influence in determining the charac- ter of inflammation from the commencement, in favouring the passage of the acute into chron- ic disease, and in disposing the latter to assume the former state. Full living, and the use of much animal food, or of exciting and intoxica- ting liquors, have these effects especially, and not only prolong or aggravate the morbid ac- tion, but also cause its unfavourable termina- tion. Similar results are also produced by in- judicious treatment; by exposure to a close, miasmatous, foul, or unhealthy atmosphere ; by certain epidemic constitutions of the air, depending upon electrical conditions, or other circumstances; by mental anxieties and per- turbations, and improper or premature exercise or excitement of the functions of the part af- fected. These not only prolong or aggravate acute inflammation, but also render its termi- nations more unfavourable than they otherwise would have been, and cause slight or chronic inflammatory action to pass into the acute and active state. 35. The circumstances just alluded to render the duration of sthenic inflammations quite in- determinate. The active and acute states may continue but a short period, but two or three days, or even not so long, until one or other of the terminations about to be described takes place ; and the slight or chronic state may en- dure months, or even years. Between these extremes, every intermediate term of duration, as well as grade of action, may be seen. The duration depends chiefly upon the organ affect- ed, acute inflammation in vital parts, especially the stomach and bowels, terminating most rap- idly. 36. iv. The Complications of sthenic inflam- mations deserve some notice, although hither- to the subject has received no attention from pathological and practical writers, owing mani- festly to the "verba magistri," the dictum of Hunter, that two diseases cannot co-exist in the same frame. This, however, does not ap- ply to inflammations, and hardly to other dis- eases, not excepting even specific contagions. The one morbid action may mask or absorb the other, but the one that predominates has its principal features somewhat modified by the association. In cases of chronic inflammation, particularly in females, and in young or ner- vous subjects, the sympathetic disturbance pro- duced by it will often attract the chief attention of the patient, and also of the physician ; and a disease, truly depending upon inflammatory action, in some one of its grades, may be view- ed as nervous, spasmodic, or functional. This most frequently applies to inflammations of the uterine and urinary organs, of the cerebro-spi- nal masses, and of the digestive mucous sur- face ; and is fully illustrated in the articles Hysteria, Hypochondriasis, &c. 37. When a vital organ is inflamed, either acutely or chronically, other parts sympathize more or less ; and when the inflammatory ac- tion is slight, the affected organ may not man- ifest the disorder by characteristic phenomena, the sympathizing parts actually presenting the chief disturbance. Parts, also, which were at first only sympathetically affected in their func- tions or sensibility, may either, from the sever- ity, or from the continuance of such affection, become more and more seriously diseased, un- til the structure is changed, and thus what was merely a symptom increases to a morbid asso- ciation, and, lastly, to a true complication, or even, ultimately, becomes the principal disease, the primary inflammation subsiding, or entirely disappearing, as the consecutive complication is developed. Instances of this are not infre- quent in respect of inflammations of the lungs, pleura, pericardium., and heart, the disease ori- ginating in either, and extending to the others, the primary affection being masked by the con- secutive disorder, and sometimes ultimately absorbed by it. Such occurrences still more frequently'take place when any one of the ab- dominal viscera is inflamed; two or more of them becoming consecutively affected, the dis- ease either continuing for a time to co-exist in them, or disappearing from the one as it is de- veloped in the others. 38. The complication of inflammations with each other, or with nervous, spasmodic, or con- vulsive disorders, or even with haemorrhage, is much more common than is usually supposed, the latter often depending upon the former, particularly when the inflammation is chronic, slight, or latent. In such cases, the passage of the disease into a more acute or active form becomes an advantage, by disclosing its nature. Such complications are frequent in childhood, and in females, particularly during the puer- peral states. Many of the convulsive affections of the former derive their origin, in a large pro- portion of cases, from inflammatory action; and most of the nervous, spasmodic, painful, and hysterical disorders of the latter arise from inflammatory action of a slight and chronic form in the uterus, ovaria, or urinary organs. 39. v. Terminations and Consequences.— Inflammation, correctly speaking, terminates only in two Ways : in resolution, or the recovery of the healthy state of action ; and in gangrene, or the death of the inflamed part. The other morbid conditions, improperly ranked as termi- nations, are merely consequences of inflamrha- 'erminations and Consequences. 436 INFLAMMATION—Sthenic—1 tion, the morbid vascular action giving rise to them still subsisting in most instances in some one or other of its forms.—A. When inflamma- tory action terminates in resolution, the phe- nomena subside very nearly in the order in which they appeared. Pain ceases, the red- ness and heat diminish, the swelling subsides gradually, and the functions slowly return. In many cases, however, the swelling continues with little diminution for a considerable time, and the functions of the part are restored with equal slowness ; the recovery of the impaired tone of the capillary vessels, and the absorption of the sero-albuminous fluid effused in the are- ola; of the tissues, being necessary to the sub- sidence of the swelling, and to the restoration of function. This termination may be looked for when the inflammation does not proceed too rapidly; when the pains are neither acute, lancinating, nor throbbing; when the sympto- matic fever gives rise to a general and copious perspiration, and when the urine deposites a sediment.—B. The termination of inflamma- tion in gangrene is so fully discussed in that article that nothing farther need be advanced respecting it at this place. (See art. Gangrene, § 3, et seq.) 40. C. Of the consequences or results of in- flammation, the most important are, exudation, softening, suppuration, ulceration, induration, thickening, and probably other organic changes. Several of these are treated of in separate ar- ticles, a simple reference to which, at this place, will be sufficient.—a. Exudation or effu- sion is the earliest and most common conse- quence of inflammatory action, the swelling, constituting one of the chief characters of in- flammation, being caused by it chiefly. Exu- dation is the deposition in the areolar tissue, in the parenchyma of an organ, in a cavity, or upon some surface, in consequence of excited vascular action, of a fluid consisting chiefly of the natural secretion of the part, gVeatly in- creased in quantity, and remarkably altered in its properties and appearances. This exuda- tion sometimes commences at a comparatively early stage, but most commonly it becomes abundant at an advanced period, or even to- wards the" close of the morbid action ; and it occasionally favours a resolution of this action, but not infrequently some degree of inflamma- tion still subsists with it. The fluid which is exuded or effused varies in its characters with the structure affected, and with the degree or activity of the morbid action producing it. Something, also, depends upon the function of absorption in the part; for when it is active, and the more fluid parts of the exudation are thus removed, the state of the remaining parts will be thereby much modified. Hence the fluid is serous, sero-albuminous, flocculent, tur- bid, liquid, thick, or partially consistent, ropy or glairy, coagulated, adherent, albuminous, or even membranous or fibrinous. The fluid ex- uded in inflamed cellular or parenchymatous structures is generally serous, turbid, sero-albu- minous, or flocculent, but becoming more con- sistent, albuminous, or otherwise changed as ab- sorption proceeds. That which is exuded from inflamed serous surfaces is either fluid and trans- parent, or turbid and flocculent, or thick, semi- coagulated, and albuminous ; films or layers of lymph, or of albuminous matter, covering the af- fected surface, or agglutinating opposite parts. The fluid exuded from mucous surfaces varies in different situations, and as the follicles or the mucous membrane itself is principally affected. Hence the morbid secretion is watery or thin ; or mucous, thick, and opaque ;. or glairy, ropy, gelatinous, and transparent ; or muco-puri- form, or sanguineous ; or muco-albuminous, or consisting chiefly of an albuminous lymph. 41. The intensity or activity of inflammatory action -influences not only the quantity, but also the nature of the effused fluid. When this action is weak or slight, the fluid is chiefly se- rous ; and in proportion as it is more active or severe, the effusion is more albuminous, and presents the characters of coagulable lymph. But the effused fluid is also much modified by the constitution, diathesis, and habit of body of the patient, and by the vital and physical in- fluences to which it is exposed for a time after its effusion. When the fluid is retained for some time in contact with surfaces which ex- uded it, the more watery portion is absorbed, and the albuminous part or the lymph becomes more plastic and solid, and, ultimately, even organized. This is shown especially in chron- ic and sub-acute inflammations of serous mem- branes. Even in mucous surfaces, as in the fauces, larynx, and trachea, the albuminous fluid exuded during inflammation is changed, not only by a partial absorption, but also by the evaporation during the constant passage of the air over the parts during respiration. The scrof- ulous, the gouty, and the rheumatic diatheses farther affect the quality of the fluids effused from inflamed surfaces ; but still more depends upon the intensity of the general vascular dis- turbance, in connexion with the state of vital power. When the former is energetic and the latter unimpaired, then the effused fluid is al- buminous, and abounds in coagulable lymph, a formative as well as a reparative process fre- quently resulting therefrom ; a formative pro- cess often appearing from inflammation of se- rous membranes, and a reparative process af- ter the division or wounds of parts. When the febrile and vascular disturbance is great, and organic nervous or vital power is much impaired, the fluid effused is watery, sanious, turbid, septic, offensive, &c, the morbid action being incapable of effusing a fluid sufficiently coagulable to be the medium of adhesion be- tween opposing surfaces, or to limit the spread of the morbid action to surrounding parts. Hence inflammation, in these circumstances, assumes the asthenic, spreading and disorgan- izing characters about to be considered. One of the chief and most important features of sthenic inflammation is its disposition to ex- ude a fluid more or less coagulable, by which parts adhere and unite, and which even be- comes organized, and arrests the extension of the inflammation, as well as limits the destruc- tion or disorganization of the parts in which it commenced. 42. Albuminous or coagulable matter exists in the fluids effused or exuded by sthenic in- flammation in various proportions. In the more liquid effusion, it is in small quantity, and is separated from the serum which suspends it, or holds it in solution by heat and by the min- eral acids; but of the more solid or consistent exudation, it constitutes the principal part. Be- INFLAMMATION—Terminations and Consequences. 437 tween these extremes it is found in every pro- portion. In puriform matter and pure pus al- bumen exists in the form of minute corpuscles, or globules, swimming in a turbid serous fluid. In this, as well as in the more fluid states in which albumen presents itself, it is incapable of organization ; but, in the more solid or plas- tic state, it often becomes organized, and is the bond of union between divided parts, when the powers of the constitution and the condi- tion of the circulating fluids admit of its pro- duction. Salutary or reparative effects, from the effusion of coagulable lymph, are evinced also by its effusion around abscesses, by its ag- glutinating serous membranes, when morbid formations, ulceration, and purulent matter are about to perforate them ; and by its obliterating arteries or veins, after ligatures- or in circum- stances where dangerous haemorrhage would otherwise occur. (See Abscess and Adhe- sions.) 43. b. Softening is a very general conse- quence of inflammation, and one of the earliest which attends it. Indeed, inflammatory ac- tion seldom continues long, particularly in an acute form, without impairing more or less the vital cohesion of the tissues affected. It often precedes suppuration, and it generally increas- es the disposition to effusion. It is most re- markable in mucous and cellular parts, and in parenchymatous organs, particularly the brain, lungs, liver, &c, these becoming more friable as well as softer than natural. But softening from this, as well as from other morbid condi- tions, is fully considered in the article devoted to the subject. 44. c. Suppuration is the natural result of in- flammation when it is allowed to attain a high degree of intensity, especially in cellular, pa- renchymatous, and mucous structures. Pus, the product of the suppurative act, is apparent- ly produced from the albuminous part of the blood by an altered state of the vital condition of the capillaries. It is very difficult to show satisfactorily in what this alteration consists ; but it probably is impaired tone, or deficient vital contractility of the capillary vessels, the arterial branches supplying them being still more or less excited. Suppuration may be viewed as a true act of secretion; although pus, as it usually appears, is somewhat changed in the course of its production by absorption, by the vitality of the parts with which it re- mains in contact, by temperature, and by evap- oration. The small, whitish flocculent masses often found in the purulent matter consist chiefly of a more concrete albumen secreted by the inflamed part. Although suppuration chiefly takes place in the structures mentioned above, yet it sometimes is seen in other parts, especially in the cavities of joints, and more rarely in serous surfaces. In these situations, particularly in serous membranes, it is general- ly a result of intense action in connexion with deficient power. 45. Mr. Hunter was the first who recog- nised with any degree of accuracy the changes which take place in the blood and in the capil- laries of an inflamed part during suppuration, inasmuch as he considered that pus was a re- move farther from the nature of the blood than the matter formed by adhesive inflammation— than coagulable lymph; and M. Gendrin is of the same opinion. The formation of pus in an inflamed surface or tissue takes place as fol- lows, according to the observations of Kal- tenbrunner, Gendrin, Carswell, and the au- thor. In the field of a microscope the inflamed capillaries seem uniformly red, and the circu- lation in them is retarded or has ceased. Se- rum and coagulable lymph are effused in the areolae of the tissue ; and, if the inflammation is very intense, the exuded fluid is more or less coloured by the exudation of red globules or of blood. The whole of the inflamed part is quite opaque. As soon as suppuration commences, the red colour begins to disappear in various points, giving place to a yellowish granular- like matter in the capillaries, and connecting cellular tissue. In the centre of the inflamed tissue, several of the capillary vessels, which were obscured by the accumulated blood, reap- pear, some containing red, others yellowish- gray globules, which gradually become more distinct, increase in number and size, begin to move slowly, and, traversing the capillaries, arrive at the surface of the tissue, or at the edges of the solution of continuity, if this has occurred, in the form of globules of pus (Cars- well). Gendrin states that he has distinctly seen the globules of blood, after stagnating in the capillaries of the inflamed part, losing their colouring envelopes, becoming opaque, and as- suming a grayish yellow colour, approaching to that of pus; and that he has traced them mo- ving slowly in the capillaries, and, as they ad- vanced to the suppurating surface, gradually acquiring all the characters of pus. The ob- servations of Kaltenb runner agree with those of Gendrin as to the transformation of the blood-globules into the globules of pus, and as to this taking place within the capillaries ; but they also seem to prove, what I have observed in several instances, that the red globules, or blood, exuded in an intense state of inflamma- tion into the areolae of the tissue, undergo a similar change to that which takes place with- in the capillaries when the circulation becomes stagnant in them ; and that pus may thus be formed without, as well as within, the capilla- ries of an inflamed part, the fluid portion of the secretion consisting of the serum of the blood. Kaltenbrunner even supposes that not only the blood of the inflamed tissue, but likewise a part of the tissue itself is converted into pus- globules. But I believe that this takes place only where suppuration is followed by ulcera- tion (§ 48), or where an ulcerated surface se- cretes a puriform fluid. 46. From these facts it is evident that, in an inflamed part, certain changes precede the formation of pus : 1st. A loss of the vital tone, or a change of vital action in the extreme ca- pillaries. 2d. A retardation or stagnation of the circulation, and partial coagulation of the blood in them. 3d. A change of the blood- globules into pus-globules, and the discharge of the latter with a portion of serum on the suppurating surface. 4th. A similar change of the globules of blood extravasated in the in- flamed part, these globules losing their colour- ing envelopes, and becoming the globules of pus. As connected with the subject of suppu- ration, some notice might be taken of the pres- ence of pus in the general circulation, or in situations remote from the seat of inflamma- 438 INFLAMMATION—Varieties or Modifications. tion; but as this belongs rather to the trans- lation and metastasis of inflammation-to con- secutive inflammation, it will be considered hereafter. 47. Pus, or purulent matter—the product of suppuration—is a slightly unctuous fluid, of the consistence of thin cream, which it otherwise resembles. It is generally of a whitish or pale yellowish colour, and of a mawkish or sweet- ish taste. It is nearly inodorous when cold, but when heated it emits a faint, sickly, and unpleasant odour. Under the microscope it presents corpuscles or particles swimming in a serous fluid. These corpuscles resemble the central corpuscles of the globules of the blood, deprived of their colouring envelopes, and con- sist of a highly animalized albumen. * The se- rous part of the secretion differs but little from the serum of the blood. In many situations, pus is mixed with the more natural secretions of the part, the latter being either altered in their characters or increased in quantity. This is especially the case in acute inflammations of mucous surfaces, the fluid excreted consisting of pus and mucus in variable proportions. The other relations of suppuration are fully consid- ered in the article Abscess. 48. d. Ulceration is distinguished from suppu- ration chiefly in its being attended by a loss of substance—by a destruction of parts, and by a more or less abundant secretion of a puriform, ichorous, foetid, sanious, and variously-coloured fluid. It may immediately result from inflam- mation, or be consequent upon suppuration, or the formation of an abscess. It depends chief- ly Upon causes connected with the treatment of the part in the earlier stages of inflamma- tion ; upon the diathesis, habit of body, or ex- isting constitutional vice, as scrofula, scurvy, syphilis, and upon the state of the digestive and excreting functions. Ulceration is always preceded by softening; by a loss of the vital cohesion of the tissue inflamed, at the surface or part most remote from the centre of circu- lation, or at the termination of the capillary vessels. Along with the softening there is also a more or less copious effusion or exudation of a serous fluid, in which the organic molecules, which have lost their vital cohesion, are lique- fied or suspended. Hence the discharge is ichorous, offensive, sanious, or coloured. In the more rapid or phagedenic states of ulcera- tion, and when the discharge is scanty, and in * [These globules are obviously a modification of the ex- udation corpuscles ; each consists of a fluid, with granules and molecules contained within a thin cell, which some- times has granules also on its surface. The granules ren- der the appearance of the investing cyst or cell obscure ; but its existence is clear from the action of distilled water, which causes the cell to dilate (by endosmosis) to double its for- mer size ; and what is curious, the contained granules swell also, which shows their vesicular nature (Williams). Pus globules are larger than the general size of exudation corpus- cles, apd exceed in size the blood discs (Gulliver). Ac- cording to Mr. Addison, they measure from g0'0fl to^1^ of an inch; besides, in size they differ from other exudation Corpuscles in being more distinctly vesicular, and containing a fluid as well as granules. Their more readily swelling, bursting, and shedding their contents under the influence of water or the solution of potass, may be referred to the same difference. This probably imitates the process by which the exudation corpuscle is converted into a pus globule. From a peculiar constitution, either of the corpuscles or of the adjoining fluids, the disposition to endosmosis is increased, and the corpuscles, and even their contained nuclei, swell into vesicles, instead of remaining in the gelatino-s condi- tion which characterizes the corpuscles within the blood- vessels and in coagulable lymph (Williams).] parts covpring abscesses, very probably the or- ganic molecules are absorbed nearly as fast as they lose that degree of vital attraction neces- sary to their cohesion in the diseased surface. From this, the relation of ulceration to sphace- lation and gangrene, particularly hospital gan- grene, is apparent. (See art. Gangrene.) 49. When an ulcerated part begins to return to a healthy state of action, the diseased se- cretion becomes more puriform or albuminous, and an attempt is made to restore the.loss of structure by a process called granulation. The vessels of the ulcerated surface acquire a more sthenic action; the disposition in the tissues to lose their vital attraction or cohesion is ar- rested ; and the secretion assumes at first a puriform, and afterward an albumino-puriform character; the albuminous or coagulable por- tion of the secretion coating the inflamed sur- face protecting it, and ultimately becoming or- ganized or partially identified with it. These changes in the ulcerated surface are evidently brought about by an improvement in the or- ganic nervous influence of the part; and hence the success of a treatment, general and local, calculated to restore or to promote the energy of this influence, especially through the me- dium of the digestive and respiratory organs. 50. e. Induration and thickening, or hypertro- phy of structures, consequent upon inflamma- tion, are discussed in the articles on these le- sions. It is unnecessary to offer any farther remark respecting them, than that they are gen- erally consequences of chronic inflammation, and of acute or sub-acute inflammations which have passed into the chronic state. They may also be referred to the exudation, into the areo- lar tissue, of a sero-albuminous fluid, the more serous parts having been absorbed, and the al- buminous parts organized or assimilated to the structure including them. From this source other organic lesions may arise, according as the exuded matters undergo a more or less complete organization, or according as they are retained in the state of merely minute amorphous masses disseminated in the areolae of the structures, and are preserved from dis- solution or change by the vitality of the sur- rounding parts. See arts. Induration and Hy- pertrophy ; also Disease.) 51. II. Varieties c.r Modifications.—Hav- ing described inflammation as occurring in a previously healthy constitution, or in its sthen- ic form, and having viewed this as the more usual and standard condition of the disease, whether appearing in the acute, chronic, or in- termediate states, it becomes necessary to con- sider the alterations or deflections from sthenic in- flammatory action, occasioned by the previous health or the existing constitution of the pa- tient, and by the nature of the predisposing, the exciting, and the concurrent causes. Many of the lesions of vascular action arising from these sources are so different from the true sthenic condition now discussed, as to admit of doubts as to the propriety of viewing them as inflammations; yet they have intimate re- lations to the sthenic disease, inasmuch as they possess nearly the same local characters as it, and often in a very remarkable degree— as they differ from it merely in kind, and often by slight shades only—as they may be con- verted into it by a general and local restora- INFLAMMATION—Asthenic—Characters. 439 tive treatment, and as the sthenic disease may be reduced to some one of these lesions by va- rious depressing influences or contaminating agents. 52. In the view just taken of sthenic inflam- mation, we have seen merely different grades of action, the disease being acute or chronic, or some intermediate state, usually called sub- acute, according to the degree of severity or of activity presented by the morbid action, rela- tively to the constitution and powers of the pa- tient. While the term active has been applied by many to the more acute states of sthenic inflammation, the word passive has been used as synonymous with the chronic conditions. To the former of these appellations, and to its application, little objection need be urged; but the latter is by no means applicable to any state of inflammation, neither to the chronic states of sthenic inflammation, nor to the asthenic va- rieties about to be considered. 53. With the increased local and general vaseular action, constituting the states of in- flammation above described, the constitutional powers are not much reduced or otherwise al- tered, nor are the depurating functions impair- ed, nor is the blood materially vitiated or dete- riorated, in the early stages at least, or until the disease approaches an unfavourable termi- nation. But in the varieties about to be no- ticed, the powers of life are much depressed or otherwise deranged from the commencement, the depurating or excreting functions are inter- rupted, the blood more or less altered, and the nervous sensibilities increased. Hence vital resistance to the changes consequent upon in- creased susceptibility and diseased vascular ac- tion is greatly impaired, and disorganization rapidly supervenes, and as speedily proceeds, unless arrested by the most efficient means. To these circumstances, however produced, are to be imputed those alterations or deflec- tions, from the sthenic or true form of inflam- mation, that frequently present themselves in practice, with characters varying with the cause and seat of the disease, and with the pe- culiarities of the patient. As the inflamma- tions already described present no obvious loss of power in their earlier stages, or until their terminations, and are therefore justly termed sthenic, so those about to be considered may be generally denominated asthenic, from the want of organic nervous energy and the loss of vital resistance to the progress of disorganization which they usually present, unless controlled by judicious treatment. They have also been denominated typhoid, venous, erythematic, and erysipelatous; but these are chiefly specific terms, the generic appellations, spreading, dif- fusive, disorganizing, or asthenic, being more ap- propriate. 54. i. Of Asthenic Inflammations.—A. Of the Local Alterations, or Characters.—a. Uneasy sensation, or pain, is the earliest, and some- times the most remarkable symptom, particu- larly when serous membranes or circulating vessels are affected, When the disease is caused by external injury, by the inoculation of morbid matters, as in punctures during dis- section, the pain is often early and acutely felt, even in cellular parts, although no other change has yet appeared. In nervous, susceptible, and weakened persons, the pain is so acute as to accelerate or increase the restlessness or de- lirium consequent upon the constitutional symp- toms, which are often remarkably severe com- pared with the apparent small extent of the lo- cal disease, especially when caused by an animal poison. Pain, however, is frequently not very severe in certain forms of asthenic inflamma- tion, particularly when parenchymatous organs are their seat, and when they are consequent upon some disease which has lowered or ex- hausted organic nervous power and sensibility. The inflammations which complicate or appear in the course of continued fevers are illustra- tions of this ; and the metastasis of erysipelas, or the transference of inflammation from an external part to an internal organ, seldom gives rise to much pain. The amount of uneasy sen- sation depends chiefly upon the tissue implica- ted, upon the exciting cause, upon the consti- tutional susceptibility of the patient, and upon the state of the blood. In cellular, mucous, and yielding structures, it is sometimes slight, particularly if the purity of the blood is impair- ed by imperfect excretion, unless the inflamed and turgid parts be partially strangulated by aponeurotic expansions, or other unyielding textures, as in diffusive inflammation of the cellular tissue, and in various states of erysipe- las. In this latter, and in inflammation of the lymphatics, the pain is generally tensive, burn- ing, or stinging, and occasionally remittent. There are always great tenderness and sensi- bility to the touch, unless the affected parts are deeply seated. 55. b. Redness and vascular injection are al- ways very remarkable. The former often ei- ther rapidly passes into a deep, dark, brownish- red, livid, or purplish hue, or presents more or less of either of these from the commence- ment. It is sometimes of a pale or yellowish red tint. The vessels are injected and dis- tended, and the current of circulation through them is slow or impeded. The already dark hue of the blood is farther deepened by this congestion, and the exudation of the serous portion of it is facilitated by the weakened state of the vital cohesion of the tissues, by the impaired tone of the capillaries, by the increas- ed frequency of the heart's contractions, and by the diminished crasis" of the blood itself. The discoloration and injection of the part in the various asthenic states of inflammation are generally indices of the extent to which the vital tone of the vessels and tissues is exhaust- ed, and the blood, especially that circulating in the part, is altered. 56. c. Increased temperature is present chiefly at the commencement of asthenic inflamma- tion, and when membranous tissues and circu- lating vessels are attacked. Even in these cases, at an early period, the actual rise of temperature in the affected part is often not greater than on the surface of the body gen- erally. Where the febrile disturbance is great, the pulse very quick and the skin dry, the heat of the general surface and of the diseased part is very considerable ; but it is also peculiar, as observed in typhoid and malignant fevers; it seems to be greater than it really is, and is at- tended by a stinging, harsh, and unpleasant sensation. As effusion into the areolar tissue of the part proceeds, and as the swelling ex- tends, little or no increase of heat is usually 440 INFLAMMATION—. •Asthenic—Symptoms. observed; and sometimes the temperature of the part may even be lower than that of the surface of the trunk, or even lower than natural. 57. d. Swelling is considerable, and some- times very great when cellular or parenchyma- tous tissues are affected. It is caused at first by the relaxation of the vital tone of the capil- laries and tissues, and by the injection of the former; but consecutively, and chiefly by the effusion of serum from the diseased vessels. The swelling is always diffused, is disposed to extend itself, and is never acuminated or Con- vex. It is generally soft, sometimes boggy or cedematous, and never elastic or hard, unless from the tension occasioned by aponeurotic or unyielding structures stretched over the swoll- en part. In mucous and serous membranes it is much less manifest, although existing more or less ; and, in them, it is owing chiefly to the distention of the capillary vessels, and to the relaxation of the tissues themselves. 58. e. The secretions and functions are always disordered by asthenic inflammation : the for- mer are altered and generally increased in quantity; the latter are remarkably impaired. When a secreting membrane or surface is at- tacked by it, the discharge is variously changed from the healthy state, the change obviously arising from the impaired state of vital power, the morbid condition of the blood, and the ac- celeration of the circulation. The effusion generally consists of a foul; dark, turbid, ich- orous, septic, sometimes whey-like fluid. In puerperal females it is often remarkably abun- dant, and contains much curd-like or semi-coag- ulated matter, partially separated from a turbid or whey-like serum. This watery, serous, or ichorous fluid is also abundantly effused in the areola of the asthenically inflamed cellular tis- sue (see Diffusive Inflammation of Cellular Tissue) ; and, owing to the deficiency or ab- sence of coagulable lymph or albumen, it readi- ly spreads to, and infects or contaminates the surrounding tissues. This is one of the chief characters of asthenic inflammation, its spread- ing or diffusive nature, especially, resulting from the states of general or local vital power, and of vascular action, which are insufficient for the formation of coagulable lymph, by which the local disease may be limited. 59. The secretions from glandular organs are also remarkably altered in quality as well as in quantity; but th-eir quantity is as often diminished as increased. Sometimes they are nearly or altogether suppressed, particularly in extreme cases of the disease, manifestly ow- ing to the loss of organic nervous influence or vital power in connexion with the distention of the capillaries. When the substance of the liver is the seat of asthenic or diffusive inflam- mation, bile is either not secreted, or is ab- sorbed as soon as it is secreted, giving rise to one or other of the forms of Jaundice ($ 28) described in that article as consequent thereon. The swelling, also, caused by the distention of the diseased vessels, and by the effusion into the parenchyma of the organ, is so great as to press upon the ramifications of the ducts, and to prevent the passage of the fluid along them as it is secreted. This is especially the case when the secreting organ is enclosed in an en- velope or membrane, which does not readily jield to the distention thus occasioned. 60. B. The Constitutional Symptoms.—Asthen- ic inflammations derive their peculiar charac- ters, local as well as general, from either pre- existing disorder or the poisonous nature of the exciting cause. The former consists chiefly of debility, as manifested in the assimilating, cir- culating, and excreting functions (see Debili- ty, § 13, et seq.). The vital powers are im- paired throughout the frame, and especially in the organs of digestion, circulation, and depura- tion. Hence, with increased sensibility and susceptibility of the nervous system, the blood soon becomes affected, and is less suited for the production of a healthy secretion, and for the formation of coagulable lymph or albumen in the seat of inflammation, than in persons otherwise circumstanced. When asthenic in- flammation depends upon the exciting causes, it will generally be found that they possess poi- sonous or contaminating properties which in- fect the frame, while they produce inflamma- tory action in certain structures by their spe- cific operation, as in the infection of erysipe- las ; or which contaminate the system by act- ing directly upon the part with which they come in contact^ as when a septic animal fluid or an animal poison is applied to a wounded or abraded surface. Very frequently asthenic in- flammations derive their constitutional as well as their local peculiarities from both these sour- ces ; from the previous state of health as well as from the nature of the exciting cause. In sur- gical practice, they not infrequently depend upon the severity of the shock sustained by the sys- tem in cases of very severe local injury, as in extensive bruises and crushing wounds, or after operations. In all cases of asthenic inflamma- tion, although the states of constitutional or vi- tal power and of the circulating fluid are chiefly concerned in modifying the character of the lo- cal disease, yet the local generally reacts upon the general affection, the one aggravating the other reciprocally and progressively, until ei- ther a fatal disorganization or arrest of func- tion takes place, or a favourable change is brought about by energetic means. This is evinced especially in the diffusive visceral in- flammations occurring in diseased or cachectic habits of body, or in the course of continued fevers, and in certain forms of erysipelas, and of inflammation of the cellular tissue 61. The severity of the constitutional symp- toms frequently has but little apparent relation to the extent of the local inflammation, the lat- ter being comparatively slight, and presenting but little of the spreading, diffusive, or disor- ganizing characters usually observed in con- nexion with remarkable febrile commotion and vital depression. A person may experience a slight abrasion or puncture of the integuments, followed by inflammation to no great extent, with a more or less foul discharge, or with a discharge not materially different from that fol- lowing sthenic inflammation ; and yet the con- stitutional affection maybe of the most violent description, and characterized by excessive vascular action, by great excitement and mor- bid sensibility of the nervous system, and by remarkable depression of nervous power and of vital resistance. It is this state of disease es- pecially which Mr. Travers has so well de- scribed under the terms Direct and Reflected Constitutional Irritation—terms which, in the INFLAMMATION—Asthenic—Symptoms. 441 present state of our knowledge,, convey as sat- isfactory an idea of the nature of these caus- es as any other that can be employed. The remarkable constitutional disturbance charac- terizing them has been ascribed to sympathy ; and probably it may be produced in some in- stances by the absorption of a morbid or poi- sonous secretion or fluid into the circulation : but the majority, and these the most severe and the most marked, as to all the peculiarities of these maladies, can be ascribed only to a morbid impression or lesion of the organic ner- vous system that is soon propagated through- out the frame, implicating, not only the vascu- lar system, but also the cerebro-spinal func- tions and all the vital manifestations. So in- tense a disease, produced by so slight a cause, and depending, apparently, upon so small a lo- cal lesion, is, it is true, very inadequately ex- plained by the terms irritative fever and consti- tutional irritation, and far less by that of consti- tutional sympathy; but the difficulty is, to de- nominate them by apy other name which shall be in every respect appropriate. 62. The constitutional symptoms attending upon asthenic, foul, or spreading inflammations appear variously grouped or characterized ,- but they may be referred chiefly to the following types or varieties: 1st. General and remark- able depression of organic nervous or vital power, without vascular reaction ; 2d. General depression of vital power, with vascular reac- tion or excitement; 3d. Vital depression, with acute nervous sensibility and cerebral disor- der ; and, 4th. Vital depression, with remark- able nervous excitement and vascular reaction. Although the constitutional commotion usually appears in one or other of these forms, yet it must be admitted that the arrangement is some- what conventional; that there are often inter- mediate or mixed states of disturbance ; and that the general affection may commence in either of these forms and pass into another, owing to the influences to which the patient is subjected in its course. Nay, fever attending sthenic or adhesive inflammation may be con- verted into either of these low types of fever by the more powerful depressing or contami- nating influences ; and the latter may be chan- ged into the former by agents of an opposite nature, similar alterations taking place, from the same causes, in the characters, consequen- ces, and terminations of the local affection. 63. a. General vital depression, without reac- tion, is not of frequent occurrence, and is pro- duced only by a very sedative or poisonous cause, relatively to the power of vital resist- ance, when depending upon a slight local le- sion. It is very frequently observed after se- vere shocks, crushing injuries, and operations. However induced, it usually commences with a sense of general coldness, sinking, anxiety at the epigastrium, nausea, occasional vomit- ing, and remarkable despondency or depression of spirits. The skin is of the natural or of a diminished temperature, and there is generally little or no thirst. The mental faculties become obscured or stupified, and the countenance collapsed ; and convulsive motions or twitches frequently occur. The pulse is weak, irregu- lar, small, or compressible; sometimes quick or intermittent, but always deficient in power. Vomiting is often attended by little retching, 56 matters being brought up with a species of sin- gultus ; and the alvine excretions are always morbid and offensive. As the powers of life sink, low delirium, coma, the supine posture, hiccough, complete physical prostration, sharp- ened features, and a cold, clammy state of the surface supervene ; the local disease either be- coming more deeply discoloured or extending towards the centre of the body, or passing into gangrenous disorganization. 64. b. Vital depression, with general vascular excitement and reaction, is much more common than the preceding variety of constitutional af- fection. It is generally ushered in by chills or rigours—sometimes with nausea, and even vomiting. The skin soon becomes hot, dry, burning, or harsh ; but occasionally the affect- ed part is hot and burning, while the tempera- ture of the surface is very little elevated. The pulse is generally above 110°, and sometimes it is 120°, or even upward ; it is compressible, open, broad, quick, and irritable, becoming more so, and smaller or weaker, as the disease proceeds. The tongue is foul or loaded, some- times glossy, and afterward dry and mahogany coloured. The evacuations are offensive and otherwise disordered. Medicines, or substan- ces taken into the stomach, are soon thrown off; and there is generally thirst, which is at first urgent, but becomes less so, and is at last not complained of, particularly when delirium takes place. Delirium first appears at night, and either remits in the morning or continues, and is often followed by coma. In some in- stances the vascular excitement is most rapid- ly developed, or reaction speedily follows the rigours, and all the symptoms soon become se- vere ; violent headache, with anxious, collap- sed countenance, succeeded by delirium, ap- pearing early. In other cases the general ex- citement is more slowly and more moderately produced, and not until several rigours and at- tempts at reaction have taken place. In either case exhaustion speedily occurs, and all the symptoms of the advanced stage of the prece- ding variety supervene. The disease is rapid in its progress, if it be not early arrested by treatment; and the local alteration extends more or less, assumes a more livid or dark hue, or more aggravated form, or becomes more dis- organized. When pus has been formed at an early stage of the local affection, and is con- fined in deep-seated parts, or beneath fasciae, it is often offensive, discoloured, and different from that discharged after sthenic inflamma- tion. In many instances the local alteration is apparently slight in relation to the severity of the constitutional affection; but in others it has extended to a very considerable distance along the absorbents, veins, or cellular tissues from its primary seat, and has thus either been overlooked or has infected the blood. (See ar- ticles. Cellular Tissue—Diffusive Inflammation of; Erysipelas ; Lymphatics, and Veins.) 65. c. Vital depression, with acute nervous sen- sibility and cerebral disorder, is very often ob- served to accompany asthenic inflammations caused by animal poisons and septic animal se- cretions, especially by the inoculation of either of them during the dissection of dead bodies. In all these the pain felt in the seat of injury is most excruciating, and is attended by gen- eral irritability and impatience; by irregular 442 INFLAMMATION—Progress and Duration. chills, loss of appetite, intense headache, white tongue, thirst, anxious countenance, nausea, and sometimes vomiting ; a frequent, small, quick, or irritable pulse; hot and dry skin ; sleeplessness, followed by delirium ; and, last- ly, a dry, brown state of the tongue ; vomiting, singultus, coma, subsultus tendinum, collapsed features, cold, clammy perspirations, and quick, laborious respiration. The febrile commotion often commences insidiously, and without rig- ours or chills, and proceeds with much rapidity. In this variety, particularly when produced by the causes just stated, morbid sensibility, gen- eral irritability, violent headache, and want of sleep, early delirium, and suppressed, imper- fect, or weak vascular reaction, are character- istic phenomena, the other symptoms being less constant. The local alterations generally con- sist of early and remarkably intense pain, ex- cessive and spreading tumefaction, and of pur- ulent formations, first on the seat of injury, but extending, successively, to parts nearer to the centre of the body, until the trunk and large cavities are reached. The cellular tissue, in the course of veins and absorbents, or around the glands of the latter, is most commonly at- tacked ; and, ultimately, the serous envelopes on internal organs, or even these organs them- selves, occasionally become implicated ; but other parts, particularly the lymphatics, fasciae, and veins, are often also affected. 66. d. Vital depression, excessive irritability, violent pain, and vascular excitement often attend cases of asthenic inflammation, arising from similar causes to those inducing either of the former varieties oU constitutional commotion ; the difference in the degree of vital depression in the one, of nervous disorder in the other, and of vascular excitement in a third, depend- ing chiefly upon the temperament, habit of body, vital power, age, and previous health of the individual, and upon the nature of the ex- citing cause. In proportion as the cause is of a poisonous, depressing, septic, or contamina- ting nature, relatively to nervous susceptibility and vascular activity, will the local affection be diffusive, spreading, or disorganizing, and the constitutional disturbance be characterized by a predominance of the symptoms marking ex- cessive vital depression, or acute nervous suf- fering, or tumultuous vascular excitement, de- void of the power of resistance. When the impression of the cause, or the subsequent in- fluence of the local disease, depresses the vital energies beyond recovery, or the power of re- action, the extension of disorganization and the sinking of the manifestations of life through- out the economy are remarkably prominent. Where either the cause or the local disease is less overwhelming, relatively to the state of constitutional power, reaction takes place, and efforts are thereby made to resist the progress of the local and general mischief. Violent pain and other severe nervous symptoms, whether occasioned by the nature of the exciting cause or depending upon the state of the system, may attend any of the varieties of constitutional af- fection, either that of continued depression or that of vascular reaction. Where the nervous sufferings are extreme, the vascular system usually evinces some degree of excitement; but it is often slight and without power. In certain cases the reaction is as excessive as that marking the second variety of constitu- tional affection ($ 63), is accompanied with the same symptoms, and runs a similar course, the only difference being in the greater affection of the nervous system than in it. In other cases vascular excitement is not sensibly raised, un- less in so far as the great rapidity of the pulse may indicate it, as in the third variety ( 56.) [When the inflammation is of a low charac- ter, or when the blood is poor in red particles, and especially when these two conditions are combined, the solid products of inflammation are less capable of organization, and therefore may be called cacoplastic. As the process of organization varies in degree, so these prod- ucts may attain to different degrees of struc- ture, forming membranes of a denser, less pli- ant texture, and less vascular than the serous membranes to which they are attached, and which they therefore shackle. Thus, patches of a kind of fibro-cellular or fibro-cartilaginous membrane are formed on the lungs, the heart, and the intestines, sometimes with the effect of materially impeding the functions of these several organs. Where the effusion of lymph is scanty and slow, its granular mode of de- posite is more obvious than in the more acute disease ; for, beingless ductile, it is less readi- ly spread or stretched by the motion of the parts. This is well seen in chronic inflamma- tions of the peritoneum and arachnoid, in which the deposite is almost entirely in granules or flattened patches, commonly called tubercles. These are generally of a buff or skin colour, of firm consistence, and sometimes exhibit slight traces of blood-vessels in them ; but sometimes their colour is more yellow and opaque, their texture uniform and tough, and they are total- ly destitute of vascularity. These constitute the formations described under the names cir- rhosis and crude yellow tubercle, and are the lowest of the organized products. Being, in organization and consistency, dissimilar to the membranes on which they are formed, they prove a source of irritation and constriction; and, being liable to ulterior changes (shrinking and contraction in the case of cirrhosis, farther degeneration and softening in the case of yel- low tubercle), they may bring farther mischief in contiguous parts. In some cases, again, more or less of the product of inflammation is aplastic, or totally incapable of organization, and is thrown off with the liquid in separate large globules filled with granules and molecules, constituting pus, or in detached flakes or curds, consisting of aggregations of irregular opaque corpuscles and molecules held together by a few fragments of fibrils: such effusions are exemplified in the sero-purulent liquid and curdy matter of low pleurisy, pericarditis, and peritonitis. It is ob- vious that such lifeless products must act prej- udicially on the containing structures, and the fact might be anticipated-that they are little susceptible of absorption. I have mentioned a low form of inflamma- tion, and an unhealthy condition of the blood, as causing the cacoplastic character of the products of inflammation. It may be added, that the long continuance of any inflammation, and its occurrence in subjects in whose blood fibrin abounds, while the red particles are scan- ty, will pretty surely render the products caco- plastic or aplastic. At the onset of inflamma- tion its products may be plastic, and the pro- cess of vascular organization may commence ; but if the inflammation continues, its product either is thrown beyond the reach of vascular communication or displaces that already ef- fused, and thus the outer layer will be in a, de- generating condition. Added to this, the press- ure of the liquid effusion may impede the con- struction and injection of the new membrane, which, therefore, is degraded into one of the cacoplastic or aplastic matters above descri- bed. Again, in scrofulous or cachectic sub- jects, the blood, although scanty in red par- ticles, abounds in fibrin, and this is readily ef- fused in inflammation ; but is of low vitality, and susceptible of little or no organization. There is yet another circumstance tending to lower the plasticity of lymph (although, from the observation of Mr. Dalrymple, it some- times-accelerates its organization), that is, the admixture of the colouring matter of the blood with it. Laennec supposed that contraction of the chest had its origin in hemorrhagic pleu- risy only. This is not correct; but I have many times remarked, after death, that lymph on the pleura and pericardium, in cachectic subjects, is much stained with blood ; and where patients with similar symptoms have recovered from inflammation, they have been affected with structural disease. So far as we yet know, the colouring matter does not form a material for organization; and, farther, it is very probable that in such cases the colouring matter is itself diseased.]—Select Medical Li- brary, p. 252. 78. III. Modification of Inflammation by Structure.—Inflammation has been consider- ed above chiefly with reference to vital power and vascular action, without, however, over- looking the modifications depending upon struc- ture. On this latter part of the subject a very few general remarks may yet be added. Dr. C. Smyth first ascribed the differences of in- flammation to differences of tissue ; and the writings of Bichat, Pinel, Beclard, Gendrin, and others have tended to give very general currency to these views, and to carry them much beyond their legitimate value. Struc- ture certainly modifies, not only the course and terminations, but also the results or products of inflammation ; but still the chief sources of difference are the states of vital power and of vascular action. ' Besides, inflammation of an organ or part is not limited to a single constit- uent tissue of that organ, although it may have 446 INFLAMMATI originated in one tissue only. It usually im- plicates two or more, although the cellular tis- sue, being, as it were, the matrix of the rest, is that chiefly affected. When inflammation thus extends to different textures, its charac- ters, terminations, and consequences are mod- ified more by the vital conditions above insist- ed upon than by differences of structure ; and, even when very differently organized parts are affected, the consequences of the morbid ac- tion in all of them are often very nearly the same, and are obviously owing chiefly to the states of vital power and vascular action. Even when mucous or serous surfaces are inflamed, the morbid action is seldom confined to them, the connecting cellular tissue being more or less implicated, and frequently also the adjoin- ing structures ; but the results and termina- tions of this action chiefly depend upon the constitutional affection; or, rather, the local and the general disease are both consequences merely of the morbid states to which they have been just ascribed, and are hence more inti- mately dependant upon them than upon other circumstances. In the present day, so much has been imputed to structure and to its modi- fications, natural and morbid; the alterations of function, of sensibility, and of action have been so generally connected with lesions of organization, both by teachers and writers, as to mislead those who are seldom at the trouble of thinking for themselves or of attending to the suggestions of common sense in medical observation and reasoning. Organization, func- tion, and disease are so frequently viewed in connexion, and function is so generally consid- ered as resulting from structure, and disease from alterations of structure, that the principle which not only endows, and regulates, and con- trols, and ultimately arrests the functions, but also alters the whole organization, is left out of the question ; and the results of observation in respect to its various conditions and agen- cies—the circumstances which modify these conditions, and which change its manifesta- tions in the various organs, either from healthy to morbid states, or from the latter to the for- mer—are either insufficiently apprepiated or entirely neglected. Too much is ascribed to the material and gross effects, while the con- ditions out of which they arise are kept out of view, in respect both of their primary opera- tion and of their continued influence. It is un- necessary to add anything to what is advanced on the modifications of inflammation by struc- ture in the various articles where the pathol- ogy of the different tissues and organs is fully discussed. 79. IV. Diagnosis.—Inflammation may exist in internal parts without being evinced by the usual local and general symptoms; and the parts affected by it during life may present very few, or even no indications of it after death, while some affections closely resemble inflammation, and cer- tain appearances very nearly approach those pro- duced by it in the tissues. To each of these points the diagnosis of inflammations in general has especial reference. 80. A. Inflammation may be so latent, or so obscure, owing to the absence.of the most im- portant symptoms, and to its seat, as to be rec- ognised with great difficulty. The more slight and chronic forms of inflammation are those )N—Diagnosis. most frequently latent or concealed; yet the most acute states, especially of an asthenic form, and occurring in states of the system characterized by impaired sensibility, or in vis- cera whose organic sensibility is naturally low, are often latent or obscure. These concealed inflammations have been noticed by Hoffmann, Baglivi, Stoll, Weinholt, Mayer, Meckel, Reyland, and Hartmamn, and been frequently observed in certain epidemics. They are more common in some organs than in others, espe- cially in the course of adynamic and typhoid fevers, and in other complications. Although they may be expected to exist chiefly, if not al- together, in parenchymatous structures, where the organic sensibility is the most obscure, yet they are not infrequent in serous and sero- fibrous tissues, which are usually acutely sen- sible in the inflamed state. A morbid condi- tion of the blood, as well as a generally impair- ed state of sensibility, seems to diminish sensi- bility in inflamed organs ; for the consecutive or secondary inflammations, which proceed from pre-existing inflammation or disease, are com- monly latent or concealed.—a. Epidemic fevers are very frequently complicated with acute asthenic inflammations, which seldom betray themselves during life, owing both to the de- pressed state of organic sensibility and to the condition of the blood. The brain, the lungs, the liver, the kidneys, the digestive and the respiratory mucous surfaces are the most liable to be thus a'ffected, without indicating, upon the strictest examination, the extent of mis- chief, even auscultation, percussion, and press- ure often failing in furnishing .the usual evi- dence of it. Inflammations, however, of the respiratory organs would much more frequent- ly be concealed if these means ol" investigation were not resorted to. Indeed, in fever, in in- fluenza, and in various epidemics, pneumonia would almost always be concealed without these aids. Inflammation of the abdominal viscera, during these and other maladies, often, also, does not become manifest, unless upon the strictest examination of the stools, the urine, and the patient's position in bed, and upon the closest observation of the effects of pressure, &c. 81. b. Inflammations of serous and sero- fibrous structures are not infrequently latent, especially when they commence gradually and proceed slowly, or when they appear under the same circumstances as have just been men- tioned. Pleuritis and pericarditis, in chronic forms, and as complications of febrile or epi- demic maladies, are often concealed ; and, al- though less frequently so when auscultation and percussion are employed, yet they often escape detection, especially when they give rise to little effusion, until disclosed by exam- ination after death. The same is observed, although much less frequently, with respect to peritonitis, which, however, often supervenes in more or less obscured states in the course of adynamic fevers.—c. Concealed or obscure inflammation of mucous surfaces, especially of the digestive, is remarkably common. Many of the disorders attributed to disturbed func- tion merely are actually slighter states of in- flammation. But much more severe, and even acute forms of the disease may exist in this tissue without the usual evidence of them INFLAMMATION—Diagnosis. 447 having been furnished, and may run on to dis- organization, and even to death. This, how- ever, chiefly occurs in the course of continued fevers, and in the other circumstances just mentioned. 82. B. Various febrile diseases, and painful and spasmodic affections, so closely resemble in- flammations as to be distinguished from them with difficulty.—a. Several internal inflamma- tions are liable to be mistaken for the more sthenic forms of continued fever; and that is the more likely to occur when the latter become complicated, particularly at an early period of their course. But internal inflammations, es- pecially those of a sthenic character, present, among the earliest phenomena, some, at least, of the principal symptoms of inflammation, even before the chills or rigours take place which usually attend their development. The disease is strictly local from the commence- ment, and is not attended by the vital depres- sion and loss of muscular power, which not only accompany, but also precede idiopathic fever. In the former the fever is sympathetic of and contingent upon the local affection ; in the latter the inflammatory complication is a contingency or accident, arising either soon af- ter the commencement or in the course of the constitutional malady. 83. b. Painful affections of internal or con- cealed parts are liable to be mistaken for in- flammation. But violent pain is not always an attendant upon inflammatory action ; and, un- less in very acute cases of pleuritis and peri- tonitis, the pain of inflammation is seldom so severe as that which is dependant solely upon nervous disorder. It is only when the pain is attended by increased vascular action and heat of skin ; by symptomatic fever, or, at least, by some degree of vascular excitement; by heat or tension in the vicinity of the pained part; and by a white, loaded, furred, or excited state of the tongue, and high-coloured urine, and when it is increased by pressure, that it be- comes an indication of inflammation. The pain of nervous disorder is intermittent or re- mittent ; it often suddenly ceases for an indef- inite time, and as suddenly reappears. It is not attended by a sense of burning, or of heat, or of throbbing, and it is generally eased by firm pressure ; whereas the pain of inflamma- tion, when severe, becomes gradually so, is continued, although often exacerbated at times, is frequently throbbing, and is always associa- ted with very marked disturbance of the func- tions of the pained part. 84. c. Spasmodic disorders are often referred to inflammatory action ; and about twenty-five years ago, when blood-letting was the alleged cure for everything, and for these disorders es- pecially, they were firmly believed to proceed from this source. However, like painful af- fections, they are more frequently purely ner- vous, or independent of inflammation. It is true that they may be complicated with one or other of its forms, and that either painful or spasmodic affections may proceed from conges- tion, or active determination of blood to the organs thus affected, or to parts in their vicin- ity ; but still these are not inflammation. Both classes of disorder most frequently proceed from some unnatural excitement or irritation at the origin, or in the course either of the | nerves supplying the painful or convulsed part, or of those connected with them. Thus, irri- tation of the intestinal or uterine nerves will produce pain or spasm, or both, in remote parts, by their direct and reflex sympathy; and the ir- ritation of calculi in the kidneys will occasion colic by the direct sympathy of the ganglial nerves, and pain or spasm of distant voluntary parts by the reflex sympathy of the cerebro-spi- nal nerves. (See Direct and Reflex Sympathy, in my edition of Richerand's Elements of Physi- ology, edit. 1824 and 1829, p. 546.) 85. d. Determination of blood to particular or- , gans may also be confounded with inflamma- tion ; and it may run on to the more sthenic forms 'of the disease, either in acute or in chronic states ; but care should be taken to distinguish between them. I have, in the arti- cle Blood (t) 25), entered fully upon the con- sideration of local determination of blood, and upon the differences between this affection and inflammation; and have shown that while the first of these consists only of augmented circu- lation and functions of a part, and is unattend- ed by symptomatic fever, or any other altera- tion, the second is an actively morbid state of the organic nervous influence, and of the ves- sels of a part, accompanied by symptomatic fever, and tending generally to change of struc- ture, and often to disorganization. In the for- mer the functions are usually increased, or in- ordinately excited, the organic sensibility being either unaffected, or not easily excited ; in the latter the functions are rarely increased, but always much deranged, or, entirely suppressed, organic sensibility being early excited or dis- ordered, and generally sensibly disturbed. (See art. Blood, $ 25-33.) 86. e. Congestion of blood in one or more or- gans has also been mistaken for inflammation, both during the life of the patient and in ex- aminations after death. In the article Con- gestion, I have defined it to be deficient vital tone or power, chiefly of the veins of an organ or part, occasioning accumulation of blood in them, and a languid or retarded circulation, the functions of the organ being thereby pro- portionately disordered. The pathological re- lations, terminations, appearances, and symp- toms of this form of disorder are there so fully described that it is unnecessary to notice, at this place, the distinctions between it and in- flammation, farther than that, in the former, the functions of a part are generally more or less impaired, without the organic sensibility being morbidly excited, and without symptomatic fe- ver being present ; in the latter there is not only disturbance Of functions, but also exalted or disordered sensibility and vascular action, and more or less febrile commotion. The one is a morbid state of the capillaries and arter- ies, originating in the organic nervous influence of a part, with which state the system gener- ally sympathizes; the other is an engorgement of the veins, sometimes extending to the capil- laries, owing either to a mechanical obstruction to the return of blood through the former, or to deficient vital energy of the affected organ. The blood in congested capillaries and veins is of a purple or black hue, while that in the ca- pillaries of inflamed parts is much more red or florid. (See art. Congestion of Blood.) 87. C. There are certain appearances observed rioNAL and Predisposing Causes. 448 INFLAMMATION—Constitui after death, which are often difficult to be dis- tinguished from those consequent upon inflam- mation.—a. The congestion of blood from me- chanical obstacles to the circulation in the veins will not be mistaken for inflammation, if the exact state of the congested tissues, and if the course of the venous trunks be carefully ob- served. It is in mucous membranes especially that the diagnosis is at all difficult, and in them only when the redness presents a ramiform appearance. In congestion from this cause the veins are full, often tortuous, and rarely varicose, states not existing in inflammation ; and the obstruction is commonly organic dis- ease of the liver, or of the heart, or of the lungs, or the pressure of some tumour on large veins. Mechanical congestion sometimes, how- ever, gives rise to inflammation, or is associa- ted with it, and then the difficulty of diagnosis is much increased; but the state of the tissues, the capillaries of which are thus congested, and the presence of one or other of the usual con- sequences of inflammation will generally lead to a correct conclusion. Dr. Macartney men- tions, in his work on Inflammation, which ap- peared as this article was passing through the press, that the arteries of a congested part are smaller than natural, and that he verified the fact by experiments ; the corresponding arter- ies to the veins, which were congested by tying them, being very much reduced in size. 88. b. Congestion from, position or gravitation is much more likely to be confounded with in- flammation than that produced by mechanical obstacles; but attention to the relative situa- tion of the congested part especially with ref- erence to a depending position and gravitation of the fluids, will generally aid the observer. When congestion of the capillaries is present, where gravitation could not aid in causing it, and when there is no manifest mechanical ob- struction of the veins, it must be ascribed to inflammatory action, although the usual con- sequences of such action are absent, for the inflammation may have been too recent to have given rise to them. 89. c. Redness from imbibition, or from the dyeing of the internal coats of vessels by the colouring matter of the blood, is sufficiently dis- cussed in the article on Diseases of Arteries (§ 38). It is of a scarlet red, is limited to the lining membrane of the vessels, and is uncon- nected with any change in them, or with any capillary injection, or congestion of the vasa vasorum ; whereas inflammatory redness in the internal surface of vessels is less uniform than it; is more dull or pink coloured; extends to all the coats, although in different degrees ; and is accompanied with capillary injection, with softening and opacity of the inner mem- brane, with thickening, serous infiltration, &c, of all the tunics. 90. d. Inflammation sometimes leaves no marks of its existence after death.—This occurs chiefly in the inflammatory affections of the skin, and in slight or incipient inflammation of serous membranes. But the redness attendant upon the disease is more frequently diminished after death than altogether banished. The inflam- matory redness of the skin, and mucous and serous membranes attending the exanthemata and continued fevers, often partially or wholly disappear after death ; yet these structures present appearances which may be inferred to have resulted from inflammation, and to have been associated with redness and vascular in- jection during life, even although the fact had not been demonstrated to the senses. When the skin has been affected, it usually assumes a purplish hue in the seat of affection, and the cohesion of the cuticle to the subsequent tissue is early diminished, so that it soon may be de- tached with ease. The vital cohesion also of mucous and serous membranes is impaired more than is usually observed, although all redness has disappeared, ,and, in these parts, as well as in the skin and cellular tissue, de- composition makes a more rapid progress than in the healthy structures. Vascular injection and redness may have vanished more or less, even in situations, and in forms of inflammation where some one of the usual consequences of the disease is present. In this case, however, there can be no doubt of its nature. 91. V. Causes of Inflammations.—i. Con- stitutional and Predisposing Causes.—a. Age has considerable influence upon the production and progress of inflammation. The disposition, particularly to the more sthenic and acute forms of the disease, is greatest in childhood and youth. It may be said to diminish gradu- ally from infancy to old age, while the more chronic and asthenic states become more fre- quent as age advances. The brain and mem- branes, the lungs and mucous surfaces, the skin, the serous surfaces within the thorax, and the glands are the most frequently affected in children and young persons ; and the digestive, respiratory, urinary, and generative organs at more advanced epochs of existence, and gen- erally in the order in which they are here enu- merated. 92. b. Sex has but little influence in predis- posing to inflammation. Males are more fre- quently affected, chiefly because they are ex- posed more than females to other predisposing and to many of the exciting causes. Females are most predisposed to inflammation at the commencement, during the continuance, and for some time after the disappearance of the catamenia, and during the puerperal states, es- pecially after parturition. 93. c. Of temperaments and diathesis, the most influential are the sanguineo-melancholic and irritable ; the scrofulous, gouty, and rheumatic. It is chiefly owing to the descent of tempera- ment and diathesis to the offspring that inflam- mations sometimes present an hereditary ten- dency. 94. d. Habits and modes of life dispose to in- flammations of various organs. Persons who are exposed to the open air and to atmospheric vicissitudes, or who take active exercise in the air, are liable to inflammation of the respiratory organs ; and inflammatory diseases generally assume a sthenic or acute character in them. Those who are indolent, sedentary, or confined to warm or close apartments and unhealthy lo- calities, are most subject to inflammations of the digestive, parenchymatous, and excreting viscera, particularly the excreting organs in the abdomen, the morbid action very frequently assuming either asthenic or chronic forms. The influence of modes of life in predisposing to and exciting inflammatory maladies is fully shown in the article on Arts and Employments. INFLAMMATION—Constitutic 95. e. Food and drink.—The liberal use of animal food favours the occurrence of every form of inflammatory action, or generates an in- flammatory diathesis. It is even very probable that certain kinds of animal food predispose to morbid vascular action in some structures in preference to others. The frequent or habitual use of pork seems to dispose chiefly to inflam- mations of the glands, joints, and bowels, and aids in generating a scrofulous diathesis. The laws of Moses, with reference to animal food, have evidently had a salutary influence in ren- dering scrofulous, gouty, and inflammatory dis- eases less frequent among the Jews than in any other class of the community. In warm cli- mates especially, the use of pork, and of the viscera and blood of animals, cannot fail of be- ing prejudicial; and there cannot be a doubt that the proneness to inflammations among Europeans, in hot climates, arises chiefly from the quantity of animal food and exciting liquors consumed by them. Persons who live much upon fish are liable to inflammatory affections of the skin and digestive mucous surface; and, while flesh meats favour, in temperate climates, a sthenic form of inflammatory action, living much on fish disposes chiefly to the more as- thenic and chronic states. 96. Exciting or intoxicating beverages predis- pose to, and often directly excite inflammation, particularly of the digestive and urinary organs. The habitual use of these liquors frequently in- duces and keeps up morbid vascular action, chiefly of these parts, of a sub-acute or chronic kind, generally passing into confirmed structu- ral change. These effects most commonly fol- low the use of spirituous liquors ; and, next to these, new wines and malt liquors are most prejudicial. Persons who use much of the for- mer soon become subject to enlargements and obstructions of the abdominal viscera, conse- quent upon repeated or protracted inflammatory action ; and those who drink the latter in large quantities, and who, at the same time, are very actively employed in the open air, as coal- heavers, draymen, &c., are liable to the most acute attacks, often attended by the most vio- lent constitutional commotion, and terminating rapidly in disorganization of the inflamed part. 97. /. A plethoric habit of body—the more im- mediate consequence of diet and regimen— remarkably favours the occurrence of inflam- mations. Persons who live fully and take in- sufficient exercise are extremely prone to these diseases, when exposed to atmospheric vicissitudes, and to cold, particularly if the body is quiescent, as when a person is carried rapid- ly through the air in an open carriage. Per- sons in large towns or cities, accustomed to warm, close rooms, or engaged in sedentary occupations, and living fully, when called to a distance, often travel on the outside of coaches, or in open carriages, and are surprised when they are attacked by inflammations, the slight- er forms and earlier stages of which they usu- ally neglect: the surprise would have been if they had escaped. In the article Blood, where the subject of vascular plethora and determi- nations of blood, are discussed (y 13, et seq.), I have shown how much fulness of the vascular system disposes to inflammatory action, and how frequently the latter follows as a conse- quence, or as a higher grade of the former. 57 onal and Predisposing Causes. 449 When this system is overloaded, some part is liable to experience over-distention and aug- mented flux, which often soon passes into mor- bid action, the balance of circulation being readily disturbed by external and internal, by physical and mental causes. In the article re- ferred to, I have stated the connexion often existing between congestions, general and local plethora, local determinations, and inflamma- tions. Congestions and local plethora are fre- quently dependant upon the state of the venous circulation, and this upon obstructions in the liver, lungs, or heart; the efforts made to pro- pel the blood in the capillaries, particularly un- der the influence of stimuli, readily inducing inflammation, especially of an asthenic kind. These states of vascular fulness, thus origina- ting and predominating in the veins, are most common in persons advanced in life. On the other hand, local determinations of blood pro- ceed chiefly from capillary expansion and arte- rial action, without venous obstruction ; are most commonly observed in the young and those in the prime of life, and most frequently pass into the sthenic forms of inflammation. 98. But there are other states of the vascu- lar system, upon which as much, probably, de- pends, not only in disposing to, but also in ex- citing morbid vascular action, as upon vascular fulness, and to which very inadequate atten- tion has been paid. These are the accumula- tion of effete and hurtful materials or elements in the blood, owing to imperfect depurating function. When the excreting functions of the kidneys, of the skin, of the liver, and even of the large bowels, are inadequately performed, the excess of hurtful, highly animalized, and irritating substances in the blood, as urea, &c, both predisposes to and excites inflammation in parts most susceptible of this cause of irri- tation, from previous disorder, or peculiarity of structure or function. Irritating matters, also, may be carried from the digestive organs, or other parts, into the blood, where they may act in a way similar to those just mentioned. Thus, inordinately exciting articles of food or drink, accumulated excrementitious matters in the biliary organs and intestinal canal, and morbid secretions pent up in any part of the body, are often absorbed into the circulation, and produce inflammations, varying in charac- ter with the kind of morbid matter producing it. (See art. Absorption.) 99. g. The influence of the digestive organs in the production of inflammations has been ac- knowledged, since it. was insisted upon by John- Hunter ; but it is Very probable that the dis- order of these organs, thus predisposing to in- flammations, and the predisposition itself, are associated effects of deranged organic nervous influence. There can be no doubt, however, that when the functions of the stomach and bowels are disordered or impaired, and when the liver is torpid, and accumulations of bile are formed in the biliary ducts or gall-bladder, a predisposition to inflammations is not only thus induced, but also a greater tendency to asthenic action is thereby generated. The state of the digestive organs often indicates <.he degree of organic nervous power attending upon the disease ; whatever deranges their functions, or aggravates existing disorder in them, increasing the general and local affection, 450 INFLAMMATION—Exciting Causes. and changing sthenic to asthenic action. The disorder induced in the organs of digestion gen- erally extends to the organs of excretion, not only by the direct sympathy arising from ner- vous endowment, and from the dependance of both classes of organs upon the same nervous influence, but also by the changes produced by the former in the circulating fluids, the predis- position to morbid vascular action being ac- cordingly heightened. 100. h. Mental, emotions also favour the oc- currence of inflammation, when excessive. Violent fits of passion may even excite the dis- ease, particularly in the brain, liver, or heart. The depressing passions, when extreme or of long continuance, induce the more chronic or asthenic states of morbid action, or cause the sthenic disease to assume either of these forms. The exhaustion consequent upon protracted or excessive nervous sensibility, and upon pain, has a similar effect. When pain is very vio- lent, it seems to act like to concussion of the nervous masses or of the body, and to severe crushing injuries or wounds : they all depress organic nervous power, and, when inflammation takes place, give rise to an asthenic or spread- ing form of the disease. 101. i. A predisposition to inflammations is often inherent in the frame from hereditary con- formation or temperament (§ 93), and from pre- viously disordered states of certain organs or tissues. Parts which have been formerly in- flamed are most prone to experience a recur- rence of the disease. Organs which are liable to simple excitation, or to actively increased function, are generally much disposed to the different grades of sthenic inflammatory action; while those which are torpid, debilitated, or exhausted are most prone to the asthenic states. Persons whose mental faculties have been in- ordinately exercised are most disposed to in- flammations of the brain and their consequen- ces ; and those who have over-excited or ex- hausted the digestive organs by too much or too rich food, and by intoxicating liquors, are most liable to inflammatory affections of the stomach, liver, and bowels. 102. k. The influence of temperature, season, and climate is shown, not only by their favour- ing the appearance, but also by their modifying the characters and forms of inflammations. High ranges of atmospheric heat produce in- flammations of the liver, stomach, and brain ; and, if heat be conjoined with humidity, these diseases assume a low or asthenic form, the bowels being frequently also affected. Pro- longed high temperature, especially when aided hy humidity, changes the state of blood, affects the biliary functions, and imparts a peculiar character to inflammatory diseases. Thus, in autumn, after hot summers, these maladies are frequently associated with marked gastric or bilious disorder ; and in winter and spring, when the air is cold and humid, they often pre- sent an erysipelatous or catarrhal form. A cold and dry state of the air is generally wholesome, if due exercise be taken ; and, without favour- ing the occurrence of inflammations, imparts to them an acute and sthenic character, the respiratory organs being the most liable to be affected. But there are other conditions of the air, or prevailing atmospheric constitutions, which dispose to inflammations, and bestow upon them, for a certain period, peculiar forms or features. The sources of these have not been ascertained, although they may probably be referred to electrical states and terrestrial emanations. However these prevailing con- stitutions may arise, there can be no doubt of their influence on inflammations, and of the necessity of ascertaining their nature and ef- fects, as being requisite to an appropriate and successful method of cure. 103. From what has just been advanced, the influence of climate on inflammatory diseases may be partly inferred ; for as the climate par- takes the most of either of the foregoing char- acters, so will these diseases be prevalent or be modified. In cold, variable, and humid cli- mates, inflammations of the respiratory organs, and the rheumatic and scrofulous diathesis, are most common. In warm, humid countries, in- flammatory action appears chiefly in the liver, digestive canal, and spleen; and especially when exhalations from the soil also come into operation, it either assumes, or rapidly passes into asthenic forms. 104. It should be kept in recollection that several of these causes of predisposition some- times act conjointly; that they may be suffi- cient of themselves to occasion inflammation, although they generally require the more effi- cient or determining action of the exciting causes next to be considered; and that, as most of them either continue in operation during the disease or are inherent in the constitution, they exert a very marked effect upon the form, progress, and consequences of the disease. Hence the ne- cessity of ascertaining them fully, and of ap- preciating them correctly, in order to treat with success the disease they are concerned in causing. 105. ii. The Exciting Causes are very nu- merous and diversified, but uncertain in their operation, or ascertained with great difficulty. Many of the predisposing causes, owing to their more intense or combined action, sometimes of themselves produce inflammations ; and, in such cases, the effect does not always appear in very obvious connexion with its real cause. In many instances of visceral inflammation, the exciting cause is very obscure, the disease pro- ceeding rather from a combination of circum- stances—some of them of fortuitous occurrence —than from any one very obvious agency. The more direct causes may be considered with reference to their mode of action in producing the morbid effect: 1st. Certain of them act by injuring the organization ; 2dly. Some excite the organic nervous sensibility of the part, and, consecutively, vascular action in it; 3dly. Oth- ers operate by affecting the function and circu- lation of the organ; inflammation resulting from those alterations in connexion with pre- disposition ; 4thly. Many produce a specific or truly morbid action in the part, changing the organic nervous sensibility, the vascular action, and all the vital conditions, both locally and generally; 5thly. Morbid matters secreted by an organ, or carried into the blood from a dis- eased part, may occasion inflammation by their direct effect upon the capillary vessels, as well as in one or other of the above modes ; inflam- mation of one part thus giving rise, by means of some one of its consequences, to inflamma- tion of another; and the morbid secretions from INFLAMMATION—Exciting Causes. 451 one organ inflaming others with which they come in contact. 106. A. The causes which act by injuring the organization are chiefly all external injuries, which divide, lacerate, or bruise a part. Struc- tures cleanly divided by a very sharp instrument are much less disposed to inflame than those which are lacerated, bruised, or punctured. La- cerated parts undergo much greater injury of or- ganization than simple division ; their nervous fibrils and vessels are torn, and both these con- stituents of structure are thereby severely affect- ed, the vitality of the part being often either directly or consecutively destroyed, and slough- ing frequently taking place. Violent contusions sometimes so disorganize a part as to prevent it from recovering any share of vital action. It then soon dies, and is cast off, or the system sinks under the shock primarily experienced, and the depression consecutively caused by the extent of local mischief, without inflammation having been fully developed. When contusions are slight, they recover without inflammation taking place ; but when the capillaries are in- jured, or when their contents have partially escaped into the tissues of the part, or even when their tone is so much exhausted as to admit of much effusion, and especially when the cohesion of the textures has been more or less altered or overcome, inflammatory action is very liable to occur, although it does not ne- cessarily take place. Punctured icounds readily induce inflammation, and generally in propor- tion to the bluntness of the instrument. A tri- angular or round instrument also produces it more readily than a flat and sharp one. The disposition to inflammation from punctured wounds chiefly depends upon their extent, upon the nature of the structures which are implica- ted by them, upon the quantity of blood effused in the parts which they have penetrated, and Upon the state of the constitution. Punctures of tendons, nerves, capsules, and aponeuroses are much more injurious than of other parts ; and the constitutional affection, in relation to the local injury and resulting inflammation, is very much greater. When much blood is ef- fused without a sufficient outlet, the punctured part being distended by it, and when blood is effused at the bottom of the wound, or in sur- rounding tissues, inflammation readily takes place, this fluid usually exciting inflammation in parts to which it is naturally foreign. The effects frequently also depend upon the nature of the body by which the puncture has been made. The teeth, claws, spurs, and spines of animals and fishes generally produce very se- vere and even dangerous injuries, the punctures inflaming readily and rapidly, although no poi- sonous fluid has been inserted in them. 107. Concussions or severe shocks are often followed by inflammation. The parts which suffer from this cause are chiefly the brain, the spinal chord, the liver, and spleen. It is not only organic nervous power that is dissipated or exhausted in such cases, but the organiza- tion is often more or less changed, minute la- cerations of structure^ or of capillary vessels, and consequent effusions or ecchymoses, being often found. The suspension of the functions caused by concussion is remarkably prone to pass into inflammatory reaction when this spe- cies of injury does not altogether extinguish them. Severe or prolonged pressure of parts often causes an asthenic inflammation of them, quickly passing into ulceration or gangrene. The removal of a gradually-increased or con- tinued pressure is often followed by a local and general inflammatory reaction, which in some cases, and as respects certain structures, be- comes very acute, as in the peritonitis conse- quent upon parturition, and upon tapping drop- sies of the abdomen. Ligatures, or other causes of constriction, act by impeding the venous cir- culation, and various positions have a similar ef- fect. They also aggravate inflammation when otherwise produced. 108. Various substances affect the organiza- tion of a part so as to induce inflammation, es- pecially mineral substances. When these are applied in concentrated states they destroy the organization, inflammation appearing around the injured part. The pure alkalies, the strong acids, and certain of their salts have this ef- fect ; but in weaker states they inflame the tis- sues in the mode next to be considered (§ 109). The bi-chloride of mercury, arsenious acid, &c, in an undiluted state, decompose or destroy the vital cohesion of the part; but in a weaker state they affect the organic sensibility and vascular action, thereby causing inflammation and cer- tain of its consequences. Extremes of temper- ature affect the organization almost directly, al- though in less grades ; they act chiefly in the manner just mentioned. 109. B. The causes which excite the organic nervous sensibility and the vascular action of the part, are'all those substances which are class- ed as stimulants or irritants. They act direct- ly, and chiefly on the parts to which they are ap- plied. Inflammations of the skin, intestinal ca- nal, urinary organs, and even of the respiratory passages, generally proceed from these sources. Prolonged friction, flagellation, the application of any of the above substances to the skin, or the ingestion of them into the stomach, and high ranges of temperature, produce inflamma- tion in this way. Volatile or diffusible stimu- lants, irritating gases, and fine particles of min- eral or vegetable substances floating in the air, often inflame the respiratory passages. The atmospheric air, especially the oxygen of it, frequently inflames parts whose organization is not suited to exposure to it. When the se- rous membranes of shut cavities are exposed to the air they first become dry, afterward more vascular than natural, and ultimately covered with a thin exudation of lymph, vary- ing in thickness, and in the proportions of se- rum and coagulable albumen, with the intensity of vascular action, the constitution of the pa- tient, and the powers of life. Mucous surfaces deprived of their epithelium, the skin without its cuticle, and other exposed or divided tex- tures are similarly affected, inflammation fre- quently supervening, unless when the lymph thrown out coagulates over them and com- pletely protects them from the air; and then the process of restoration usually takes place, underneath the protection thus formed. Stim- ulating substances may be taken into the stom-, ach, and pass from it into the circulation, with- out materially affecting the digestive organs, and yet they may inflame the organs by which they are excreted. Thus, cantharides and tur- pentine cause acute nephritis ; and spirituous 452 INFLAMMATION—Exciting Causes. liquors and the prolonged exhibition of iodine excite chronic inflammation and organic lesion of the kidneys, giving rise to dropsy. Low ranges of temperature also sometimes occasion inflammation, not, however, by directly exci- ting the nervous influence and vascular action, but by remarkably depressing both in the first instance, the consequent reaction proceeding to an excessive, severe, or prolonged state of inflammation. (See articles Cold and Gan- grene.) 110. C. The causes which affect the functions and circulation of an organ, aided by predisposi- tion, are numerous, and, like the preceding class, hardly admit of enumeration. Whatever inordinately excites the natural actions, and thereby the circulation of an organ, or what- ever primarily stimulates the vascular action of a part, will frequently occasion inflammation of it; for the increased function or circulation will run on to inflammatory action whenever a strong predisposition is present in the organ or constitution. The energetic actions of the brain are attended by augmented circulation, which may pass into inflammation. Increased function of the liver is often followed by inflam- mation of it. Excessive indulgence of the ap- petite and excitement of the stomach often pre- cede some of the forms of gastritis or enteritis. In these cases the natural actions are first in- ordinately excited, and morbid vascular action is thereby induced ; but in other instances the order of morbid procession is reversed: the causes increase the circulation in the organ be- fore the function is materially deranged. Thus cold, instead of benumbing sensibility, and of giving rise to a morbid vascular reaction upon its removal, in external or other parts on which it acts, often determines the momentum of the circulation upon internal viscera and surfaces ; and if these be not partially relieved from the load or congestion thereby occasioned, by a free exercise of their functions, inflammation is a frequent consequence. Interruption of the exhalation from the skin, constriction of the surface, and diminished circulation both there and in the extremities, combine to drive the blood upon tbe mucous surfaces and parenchy- matous viscera, increased function, augmented secretion, or morbid vascular action resulting therefrom, according to the states of constitu- tional power or of predisposition, and to the continuance or intensity of the cause. When cold is not protracted or intense, relatively to the constitutional energy and predisposition of the individual, the internal functions, especial- ly those of digestion and of excretion, the uri- nary particularly, are increased, and inflam- matory action does not take place; but when the internal determination is not relieved by augmented secretion, nor removed by a resto- ration of the circulation to the surface and ex- tremities, inflammation of the predisposed or- gan is often the consequence. Sudden, con- tinued, or frequent exposures to cold, vicissi- tudes of temperature, and partial exposure to currents of cold air, to humidity, &c, are the most common causes of internal inflammation, and especially of the respiratory organs. As respects these organs particularly, it is not the sedative influence of cold acting upon exhaling surfaces, the seat of active organic functions, but the reaction consequent upon the removal of this influence, that occasions the inflamma- tion, the primary influence of cold only dispo- sing the part to inflame when reaction takes place, or modifying the reaction so as to cause it to run on to -inflammation. Hence it is that persons, after going into a cold air from a warm apartment, generally escape inflammation of the air-passages, unless they be perspiring, or the predisposition to inflammation be strong, when they avoid a sudden return to a high temperature, by which reaction is liable to be morbidly increased; and hence the greater danger from exposure to much warmth after the prolonged or intense influence of cold than from the cold without the subsequent injurious action of heat. 111. D. The specific causes of inflammation, whereby the organic nervous sensibility, the vascular action, and all the vital conditions are truly morbidly altered, both locally and gen- erally, comprise all infectious, contagious, and contaminating matters, particularly when ap- plied to an abraded surface or wound. Most of the substances forming the second and third classes of infectious agents (see art. Infection, § 4), and arranged also under the head of Ani- mal Poisons (see that article), produce inflam- mation, presenting one or other of the local and general forms described under the asthen- ic species (§ 54, et seq.). The secretions and fluids of one person may excite inflammation when applied, as just stated, to another; but the effect is more certainly produced when these matters are taken from the dead body, and especially when they are the product of inflammatory or other disease. The serous, puriform, sanious, or sero-puriform fluids gen- erated by specific or constitutional maladies, and by diffused inflammations of the perito- neum, or even of other serous surfaces, pos- sess the property of exciting the asthenic or diffusive forms of inflammatory action in a very remarkable manner. The most danger- ous effects generally follow the inoculation of these fluids from the recently dead, or from the still warm body, or even the application of them to the skin. The next most noxious ef- fects result from the introduction of animal matter in a very far advanced stage of putre- faction. In both cases, but in the former es- pecially, the constitutional affection is most severe (§ 59). Even when the local injury is hardly to be perceived, as well as when it is more manifest (vesicles or pustules arising in its vicinity), inflammation extends through the cellular tissue in the course chiefly of the lym- phatics or veins, sometimes implicating these vessels, and abscesses form under the muscles, particularly under the pectoral and other mus- cles of the chest, a great part of the cellular tissue on the trunk, and even the serous sur- faces underneath, becoming implicated in the disease. Occasionally the inflammation pre- sents the characters of some one of the varie- ties of erysipelas: the particular form of the local, as well as of the general affection, de- pending upon the constitution and previous health of the patient, and upon the nature or properties of the animal poison. The most virulent of the morbid poisons seems to be the fluid effused in the large cavities, and particu- larly that found after puerperal peritonitis in recently dead bodies. The recent brain, the INFLAMMATION—Consecutive—Secondary—Causes. 453 substance of fungoid, carcinomatous, and me- dullary tumours, and the sanious fluids proceed- ing from diffusive, erysipelatous, and gangre- nous inflammations, are also frequently produc- tive of most noxious effects. 95. Although the most dangerous form of inflammation is caused by the fluids of the re- cent human subject, yet those of recently-killed animals produce no such effect. This probably arises from death being caused in the former by disease, in the latter by bleeding during a state of health. When, however, the fluids of animals which are either diseased or under the influence of inordinate excitement, or of its more immediate effects, are applied to a wound or denuded surface, the effects are often severe, although not so dangerous as in the former cases. (See arts. Infection, and Poisons— Animal.) 112. iii. Consecutive Inflammations.—Mor- bid matters secreted by an organ, or circulating in the blood, frequently produce inflammation of either neighbouring or distant organs.—This is an im- portant class of causes, and, like that immedi- ately preceding, generally occasions the asthen- ic or diffusive forms of inflammation. When the natural secretions of an organ are rendered unusually morbid or irritating, either from per- verted action, or from the accumulation of noxious elements in the blood, the canals through which they pass are often irritated and inflamed by them. The morbid bile formed during affections of the liver, or in the course of gastric, bilious, remittent, and continued fe- vers, often occasion the enteric or dysenteric complications occurring in these diseases. In- flammations of the colon and rectum also often arise from this cause, as well as those of the gall-bladder and bile-ducts. The secretions on the surface of the skin, especially when allowed to accumulate and remain on it, are the most frequent causes of cutaneous inflammation ; and alterations of the urine often occasion in- flammation of the urinary bladder. Indeed, most of the complications appearing in the course of febrile diseases arise either from the morbid state of the secreted fluids or from that of the blood itself, the organic influence being remarkably susceptible of their impressions, and the vascular system being readily excited by them to an increased action, devoid of pow- er or healthy tone. When vital power or or- ganic nervous influence is extremely depressed, as in adynamic, typhoid, or exanthematous fe- vers, the parts with which diseased secretions come in contact are unable to resist the im- pression made by them, or to throw them off by means of a healthy secretion from their own surfaces, and by sthenic muscular action. Hence this impression is soon followed by as- thenic inflammation. 113. Morbid matters may also be absorbed from mucous surfaces, from hollow organs, or from the more solid structures in which they have been formed, and be carried hy the lym- phatics to glands, and even into the veins and general current of the circulation ; and they may, moreover, be formed on the internal sur- faces of the vessels themselves, contaminating the blood in either case, or altering it in such a manner as to excite inflammation in various different and distant organs. Sanious or mor- bid fluids may be taken up from the cavity of the uterus, and, passing into the veins and blood, occasion phlebitis or other forms of ma- lignant puerperal disease. Morbid secretions in the intestinal canal may be absorbed and carried into the blood of the vena porta, and excite diffused or other forms of hepatitis; these results taking place the more readily the more unhealthy the secretions are that are ac- cumulated in these situations, and the more depressed the vital powers. 114. iv. Secondary Inflammations.—Mor- bid matters, also, from primary inflammations, may excite secondary inflammations, 1st. In the course of connecting cellular tissues or mem- branous surfaces ; 2dly. In lymphatics and ab- sorbent glands; 3dly. In veins ; 4thly. In par- enchymatous viscera; 5thly. In synovial cap- sules, &c.; and, 6thly. In serous or mucous surfaces. The secondary disease, in either of these situations, is most frequent when the morbid matters from the primary inflammation are effused in the substance of a part without being confined or limited by a barrier or cyst formed by coagulable lymph, and when organic or nervous power is much depressed.—a. The mode in which the consecutive or secondary disease is developed is different in most of these situations, and is perhaps doubtful as re- spects some of them. When the primary in- flammation of membranous surfaces or of cellular or adipose tissues is asthenic, it is not only dis- posed to extend in every direction without any break or interval, but it often advances to dis- tant or even remote parts without the intervals presenting any manifest change, and after va- rious intervals of time. Several states of ery- sipelas and diffused inflammation of the cellular tissue, and of mucous and of serous membranes, illustrate this. When the extension of the disease is continuous, the nature of the tissue, and the infiltration of the fluids from the pri- mary inflamed part, are the chief causes of it, in connexion with weak powers of resistance ; but when a part opposite to or adjoining an in- flamed surface also becomes inflamed, without the intervals between both being affected, the cause will generally be found to have been the fluids effused from the part first inflamed, which have acted as excitants or irritants of the healthy parts with which they have come in contact. Inflammations of serous, cutaneous, and mucous tissues frequently illustrate this fact. When distant parts are secondarily af- fected without admitting of this explanation, we can only infer that, as long as constitutional disease exists, so long will it continue to man- ifest itself locally or externally, or in some part or other of the same tissue which it is most disposed to affect, or in some other predisposed part. 115. b. In several asthenic, specific, and chronic states of inflammation, the morbid mat- ter absorbed from the primary seats of disease inflames chiefly either the absorbents or the glands, or both the lymphatics and glands; the former often in their whole course, from the primary lesion till the glands are reached, the latter principally in the groins, arm-pits, and neck. In either case, the connecting and sur- rounding cellular tissue is also inflamed, small abscesses are formed, or a diffused infiltration of a sero-puriform, sanious, or ichorous matter takes place in their vicinity, especially around 454 INFLAMMATION— the glands; and the disease is thus complica- ted and prolonged. The constitutional powers in these cases are affected more and more se- riously, owing to the effect, produced either upon the organic nervous influence, or upon the vascular system and blood itself, or to these causes combined ; but the local, and especially the general disease presents characters having more or less reference to the primary or exci- ting cause, from which, indeed, it derives its specific characters, as when inflammations are caused by a specific animal poison. 116. c. The veins are often the seat of the consecutive inflammation, especially after the primary asthenic forms of the disease, or when the powers of life are depressed ; when the fluid products of inflammation are effused upon wounded or divided surfaces, or are insuffi- ciently confined by the effusion of coagulable lymph, or by cysts ; and when morbid secretions remain long in contact with absorbing surfaces, or in situations where venous imbibition may take place, as in the cavity of the uterus after delivery, and on divided surfaces after ampu- tations and other surgical operations. In these cases, the consecutive phlebitis assumes vari- ous characters, according to the constitutional powers of the patient. If the vital powers be not materially reduced, coagulable lymph is thrown out upon the internal membrane of the veins, and the blood is thereby coagulated in them. The circulation through them is thus arrested, and the products of inflammation are prevented from mixing with the mass of blood. In such cases, the inflammation sometimes ex- tends to the more external coats of the vein, and small abscesses form externally to them, and press upon and obliterate their canals, the obstruction to the circulation in them thus oc- casioned farther preventing contamination of the fluids. In other cases purulent matter is secreted within the vein, and is partially con- fined either by coagula or by albuminous exu- dations on the internal surface of the vessel, or by both ; and, in some instances, even when these have been formed, the puriform matter has evidently mixed with the blood without coagulating it. When pus has been found in the centre of coagula, it is extremely proba- ble that it has caused the coagulation of the fibrinous portion of the blood in the partially obstructed vessel, and has thus become enclosed in the coagula. When the powers of life are extremely depressed, the secondary phlebitis is not limited by an effusion within the vessels of coagulable lymph, with or without pure pus, and by an extension of the inflammatory action to the external coats and connecting cellular tissue, as in the above states of the disease, but is rapidly extended along the internal sur- face of the veins ; the morbid secretion from the surface not consisting of coagulable or healthy lymph, or even of pus, but of a sero- puriform, or of a sanious or ichorous fluid, which is not capable of coagulating the blood in the inflamed veins, but which readily mixes with it and contaminates it, thereby producing all the phenomena of adynamic or malignant fever. (See art. Veins—Inflammation of.) 117. d. Inflammations of parenchymatous or other viscera are often secondary or consecutive upon primary inflammation of remote or exter- nal parts. The brain, the lungs, liver, and kid- -Secondary—Causes. neys are most frequently thus remotely affect- ed. In these cases there may be extensive inflammatory appearances without purulent col- lections ; but most frequently one or more purulent collections, or distinct abscesses, or merely puriform infiltrations of the inflamed parts, are observed. In some instances the puriform collections and infiltrations are at- tended either by very few marks of inflamma- tory action, or by almost none, so as to render it even doubtful whether they have resulted from inflammation, or from a simple deposition, or separation from the capillaries of the sec- ondarily diseased part of the morbid fluids ab- sorbed into and circulating with the blood. I believe, however, that in these cases the mor- bid matter in the blood excites a sufficient de- gree of inflammatory irritation of the capillaries of this part to form the diseased secretion infil- trating it; and that, as in other instances where inflammation has unequivocally existed during life, the principal indications of it, in the affect- ed tissues, have vanished soon after death. 118. When secondary inflammation seizes upon a parenchymatous organ, remote from that primarily affected, it will generally be found that it is owing to the passage of the mor- bid fluids from the primary seat of inflammation into the blood, these fluids consecutively infla- ming the parts most predisposed. In some cases the secondary disease has been preceded by, and is associated with phlebitis ; in others, this complication cannot be detected. Even in cases of primary, as well as of consecutive phlebitis, secondary inflammations of internal viscera, with purulent collections or infiltra- tions, are very frequent. But this subject is fully discussed in the articles Abscess and Veins. 119. e. Consecutive inflammations of synovial capsules, and in serous surfaces, are observed chiefly in similar cases and circumstances to those just described (§ 115, 118), when the blood contains morbid secretions, or when the veins are inflamed and the powers of life much reduced. The former of these structures are often affected by the contamination of the flu- ids consequent upon syphilis, and upon the sub- sidence of confluent smallpox ; the latter in the advanced stages of diffusive inflammation of the cellular tissue, or of phlebitis, or of inflam- mation of the lymphatics, particularly when either disease extends to the trunk. It also is sometimes consequent upon extensive burns or scalds, especially when the surfaces over the large cavities are primarily inflamed by these accidents. 120. /. Mucous surfaces are secondarily in- flamed, both by the passage of the fluid products of primary inflammation over them, as when laryngitis or bronchitis supervenes upon an ul- cerated cavity in the lungs, and by the absorp- tion of these products into the blood. These surfaces, especially those of the large bowels, perform an excreting as well as a secreting function, and the morbid matters, in the course of their elimination from the circulation, excite inflammatory action, generally of an asthenic form, not only in these surfaces, but also in other organs performing similar offices, as the kidneys, liver, &c. Thus, secondary inflam- mation and ulceration of the large bowels, kid- neys, &c, often occur in the course of tuher- INFLAMMATION—Prognosis. 455 cular excavation and ulceration of the lungs, and of abscesses in the liver. 121. VI. Prognosis.—The prognosis of in- flammation can be stated only in general terms. The more special circumstances connected with this subject must necessarily be consider- ed in the articles devoted to the inflammations of particular organs and textures ; for the re- sult will mainly depend upon the organ affect- ed, as well as upon the form, severity, and stage of the disease, and upon the consequences which may have already taken place. 122. A. As to the organ or structure affected, it is unnecessary to state more than that the danger of inflammation is great in proportion to the vital importance of the affected part. Acute inflammations of the stomach, of the in- testines, of the lungs, of the heart, of the brain, of the liver, and of the kidneys are all attend- ed by more or less risk, owing to the disturb- ance of function attending them, to the shock which the whole frame experiences from the attack, and to the consequences and changes of structure, or the disorganization which they often occasion. Yet the danger is still greater when the blood-vessels, whether arteries or veins, are inflamed; for the products of the morbid action are then liable to mix with and to contaminate the blood, and thereby to infect, in a very dangerous manner, the whole frame. Inflammations of serous membranes, particularly at advanced stages, and in unhealthy subjects, are always attended by great risk of life; for the fluids effused by the disease either accu- mulate to a fatal extent in the shut cavities they form, if effusion be not early prevented or restrained, or agglutinate their opposing surfa- ces, so as to impede the functions of parts and to occasion dangerous consecutive disease. Much, also, of the risk attending inflammation of parenchymatous organs proceeds from the extension of the disease to their serous surfa- ces, and from the effusion consequent thereon. Inflammations of mucous surfaces are much less dangerous than those already mentioned ; and chiefly because the secretions which they pro- duce favour a resolution of the morbid action, and are thrown off the diseased surface, a source of irritation being thus removed. They often, however, occasion great risk to life, by the extent of surface affected, and by the dis- turbance of the functions performed by it, as in cases of universal bronchitis, where the chan- ges produced by the air on the blood are impe- ded both by the disease and by the morbid se- cretion produced by it. Inflammation may also extend from these surfaces to adjoining struc- tures ; the substance of vital organs, and even their serous envelopes, becoming extensively implicated, and the danger proportionately in- creased. The consecutive, and particularly the secondary inflammations described above (§ 112, 114), are always most dangerous. 123. B. The form and severity of the inflam- mation necessarily influence the prognosis. In general, the asthenic forms are much more dan- gerous, other circumstances being the same, than the sthenic. Yet a very acute sthenic state of the disease, especially of internal vis- cera, may be as rapidly fatal as any other, the intensity of the morbid action soon exhausting vital power, and superinducing the more unfa- vourable consequences and terminations al- ready described, especially copious effusion, suppuration, gangrene, &c. The asthenic states of inflammation, even in external and non-vital parts, are seldom devoid of danger, unless they are early subjected to a most judi- cious treatment, for they generally originate in unfavourable circumstances : either the consti- tution of the patient is impaired, and the assim- ilating and excreting functions are weakened, or the causes which produced them are poison- ous, contaminating, or infectious. Their diffu- sive or spreading character, generally arising out of these circumstances, increases the risk, not merely from the extent of the diseased state that results, but also from the contami- nation of the circulating fluids that often takes place, and the consequent depression of the powers of life. 124. C. The age, strength, previous health, di- athesis, and habits of the patient are concerned, not only in favouring the production and the character of the inflammation, but also in mod- ifying its course, consequences, and termina- tions. Early age, strength of constitution, and previous good health are generally favourable circumstances, in respect both of the form and result of the disease; yet, in very robust and plethoric persons, accustomed to active exer- cise in the open air, and in the habit of drink- ing largely of malt or spirituous liquors, in- flammation is apt to assume a most intense form, rapidly terminating in gangrene, effusion, or abscess. Inflammations of previously weak- ened or diseased organs, or of parts which have formerly been the seat of inflammation or con- gestion, and in the scrofulous, gouty, or rheu- matic diathesis, are more or less unfavourable, particularly if affecting internal viscera, and, even in the mildest forms, are managed with great difficulty. The habits and modes of life of the patient remarkably influence the prog- nosis. Persons who live temperately and ab- stemiously, and particularly those who partake of little animal food, and who abstain from stimulating beverages, are seldom subject to severe or dangerous inflammation. On the other hand, persons who live grossly, who eat much animal food, and who drink much malt and spirituous liquors, experience the most se- vere and unfavourable forms of the disease, especially if they are engaged in sedentary oc- cupations or take insufficient exercise. 125. D. It is obvious that inflammations are more unfavourable in an advanced stage than when they come under treatment at an early period ; but the degree of danger will depend chiefly upon the consequences to which they have already given rise, and to the seat and form of, and other circumstances connected with the attack. The extent and exact condition of the local affection, and of the effusion which has taken place ; the extent to which the func- tions of the affected organ are impeded; the commencement or presence of suppuration, or the imminent risk of abscess; the state, sever- ity, and character of the constitutional affection; the degree of disorder manifested by the digest- ive, excreting, circulating, and nervous sys- tems ; and the state of the vital powers, must all be taken into account, and an opinion form- ed conformably with the conditions they sever- ally present; for, in proportion to the progress of the disease, and of any of its consequences, 456 INFLAMMATION—Theory ok Nature of. and to the amount of disorder manifested by the constitution generally, or by a vital organ in particular, will the risk of an unfavourable issue be great, especially if an internal viscus be the seat of inflammation. The degree in which the cause of the disease may operate during its continuance should also influence an opinion as to the result; for it is obvious that persistence of the causes will increase and pro- long the effect, and render the consequences more unfavourable than when the causes have been removed. (See arts. Abscess, Adhesions, Gangrene, and the articles on the diseases of the individual tissues.) 126. VII. Theory or Nature of Inflamma- tion.—The various states of inflammation can- not be satisfactorily considered without refer- ence to the structure and vital relations of the arterial and capillary vessels, and, indeed, of the vascular system generally.—A. The exter- nal or cellular coat of arteries is more dense than common cellular tissue, and hence it rarely partakes of the serous infiltration of this tissue. It sometimes, however, is the seat of inflam- matory exudations, particularly of coagulable lymph ; and it occasionally contains a small quantity of pus, and more rarely of extravasa- ted blood. It possesses the greatest degree of tenacity of any of the coats. The middle or fibrous coat is highly elastic, particularly in the circular direction of the fibres, and consists of a substance in all respects resembling the elas- tic ligament of the spine. The fibres compo- sing this tunic are connected by fine cellular tissue, but are easily separated by the pressure of a ligature. This coat is most developed in the large arterial trunks, and most subject to the impulse of the heart; it almost disappears in the smaller arteries, and entirely in the cap- illaries. The elastic power which it exerts keeps up a continued pressure on the column of blood in the arteries ; diminishing, however, with their size, until it nearly ceases in the capillaries. This elasticity accommodates the vessels to the quantity of blood passing through them, and facilitates the circulation by the pressure and reaction exerted on their con- tents. The internal or membranous coat is high- ly polished on its internal surface, is transpa- rent, and, although it resembles the finer serous membranes, it is more friable on pressure, and yet more elastic than they. 127. In the finer arterial branches and capil- lary vessels the fibrous or middle coat of the arteries disappears, so that these vessels seem to consist only of membranous canals, sur- rounded by cellular tissue. The muscularity and irritability of these vessels, although the subjects of so much discussion from the days of Vacca and Haller, are mere figments, which now deserve not the least notice. The mus- cularity does not exist, and the irritability is merely simulated by the changes consequent upon the application of agents which affect the organic nervous influence and vital contractility of the tissues and capillaries. 128. The nerves which supply the arteries and capillaries are chiefly ganglial, or derived from the organic or sympathetic system ; but filaments from adjacent parts of the cerebro- spinal nervous system communicate with them. Ganglial nerves have been traced around the arteries as far as the interior of the cranium, and the principal arteries of the extremities, by Weber and the author, in 1816 and 1817, and more recently by Ribes and others ; and there can be no doubt that they extend even to the capillaries, endowing these vessels with influ- ence, and with the properties evinced by them in health and disease. 129. The vital states which arteries and cap- illaries manifest, especially when influenced by stimulants or depressants, are these: 1st. Of turgescence, dilatation, or enlargement; 2d. Of contraction or constriction ; and, 3d. Of healthy or natural tone. The first and second are anormal states, the third normal, and con- sistent with all the natural functions. It is to the first of these that attention is principally to be directed in discussing the nature of inflam- mation ; but, before this state is considered, a very few remarks may be offered on the others particularized. 130. a. The constriction of arteries and capil- laries arises chiefly from agents which increase the vital contractility of tissues. Many of these agents are of very opposite natures, and yet they act, particularly in certain grades of ac- tivity and periods of operation, in definite modes. Cold, fear, and other depressing passions, se- vere injuries, shocks to the system, &c, con- tract parts susceptible of organic contractility, especially the skin ; arterial, capillary, and ve- nous canals ; cellular and serous tissues, &c., &c.; but, if the operation of these agents is intense or long continued, the natural tone of the contractile tissues and vessels is impaired, and vital exhaustion or relaxation ensues. A similar constriction of these parts follows the application of astringents and refrigerants ; the sudden diminution of the circulating fluids, as by haemorrhage or venaesection ; and the de- pression of vital power by whatever cause. The contraction of arteries and capillaries soon after death depends chiefly upon the weakened injection of blood into these vessels just before dissolution, and to the entire cessation of the action of the left ventricle. The organic or vital contractility of arteries and capillaries is then no longer antagonized by the action of the ventricles upon the column of blood they con- tain, and is consequently allowed to advance to the utmost permitted by the fibrous and cellu- lar coats ; the arteries, and even the capilla- ries, being consequently found nearly empty and constricted after death. But as contractile parts lose their rigidity or tone with the incipi- ent decomposition of the structures, the ves- sels afterward relax, so as to allow a larger column of fluid to be injected through them than in the living state. 131. b. In the healthy or natural tone of con- tractile tissues, the arteries, capillaries, and even the veins, fully participate. Still, this natural state of the vessels is liable to various deviations or deflexions, either to the side of turgescence or to that of constriction, without amounting to what constitutes a truly morbid condition. Numerous causes produce either constriction or turgescence, without reaching the pitch truly injurious. It is chiefly when the action of the causes is intense or continued, or when they alter, by their primary and spe- cific influence, the vital properties of the sen- tient system and contractile tissues, that the i effect becomes truly morbid, and diseased ac- INFLAMMATION—Opinions as to its Nature. 457 tion is set up. Much, however, depends, in such cases, upon constitutional disposition, or the degree and kind of susceptibility existing at the time of exposure to the causes. Agents which produce no derangement in some per- sons violently affect others, and the same cause, which was without effect at one time, may be most injurious at another, owing to varying states of organic nervous energy and suscepti- bility. 132. c. The state of turgescence, dilatation, or enlargement of the smaller arteries and capilla- ries, although a part of the inflammatory act, does not alone constitute it. Something more is necessary to its unequivocal production. This state may take place without being at all morbid, as in the excitement of erectile parts, in the development of the uterus and mammae during pregnancy, in the enlargement of col- lateral vessels after the obstruction of a large artery, in the act of blushing, and jn the rapid growth or restoration of parts. It may even be morbid, or, at least, the source of disorder, without constituting inflammation. The active congestions and determinations of blood to par- ticular organs, although often passing into in- flammation, yet are very different from it. In these vascular disorders, more or less turges- cence or dilatation of the smaller arteries and capillaries, as well as of the smaller veins, ob- viously exists ; but still this state is not attend- ed by the same phenomena, and does not give rise to the same consequences as are observed in the various forms of inflammation. This state of turgescence of the capillaries of in- flamed tissues has especially fixed the attention of modern pathologists ; and the question with them has been almost limited to the inquiry, as to whether the increased diameter of the capil- laries is to be imputed to relaxation, or debility, or to augmented action. The least material point of the many which should have fixed their attention has thus alone engaged the whole of it; and, while they have attributed everything to one or other of these conditions, they have entirely overlooked the fact that they are both contingent or consecutive changes, that either may exist according to the stage and form of the morbid action, and that the one as well as the other may be present quite independently of, and without inflammatory action. 133. The state of the capillary circulation in inflammation has been agitated since the com- mencement of the present century, and even at the present day, with a parade of useless, deceptive, and ill-conducted inquiry, dignified with the name of experiment. Numerous cold- blooded and other reptiles, and often animals, very differently organized from the higher spe- cies, have been tortured for evidence, where- upon an argument might be hung in behalf of preconceived hypotheses; and crude and pu- erile observations have been made the basis of doctrines, which have failed of attracting no- tice, either from having been imperfectly un- derstood, even by their propounders, or from having been overlaid by the multitude of words in which attempts have been made to convey them. Thus the author of a recent work, en- titled " A Critical and Experimental Essay on the Circulation of the Blood," &c, not only derives his inferences from imperfect observa- tions, made at similar sources to the above, 58 but also, because he observed an oscillating motion of the blood in the aorta of a frog after tying the vessel, jumps to the conclusion that " it would appear almost certain that the arter- ies possess a muscular contractile power ;" although the previous inquiry, as to the exist- ence of a muscular structure in the coats of these vessels, that some honest observers might, perhaps, have thought necessary, had never been entered upon by the author. " Such reasoning falls like an inverted cone, Wanting its proper base to stand upon." 134. Before entering upon a fuller explana- tion of my own views as to the theory of in- flammation, and which are essentially the same as were published at first, more than twenty years ago, and at several times subsequently, the opinions of some writers most deserving notice may be adduced ; although, as respects inflammation especially, a rational explanation of phenomena, as they are subject to our sen- ses, is to be preferred to a mere collection of opinions—of hypotheses, in many of which, parts only of the truth appear, the rest being either kept entirely out of view, or hid under an accumulation of loose analogies and incon- sequent argument, or buried in heaps of un- meaning verbiage. 135. i. Opinions as to the Nature of In- flammation.—A. Inflammation was very gen- erally attributed to vitiated states of the fluids, until Van Helmont ascribed it to an irritation which attracted the blood in a greater quantity than natural into the capillary vessels, the irri- tation arising from an affection of the archaus or vital principle. Willis, notwithstanding his espousal of the chemical doctrine of the blood, attributed more to the local irritation of Van Helmont, in the production of inflammation, than to the morbid condition of this fluid. To- wards the close of the seventeenth century, several theories of inflammation, and of disease in general, were promulgated. The followers of Des Cartes imputed inflammatory action to a fermentation excited by the aethereal fluid which they supposed the blood to contain, and which Des Cartes substituted for the gas* of Van Helmont. The opinions of Sylvius were merely modifications of those of the two pa- thologists just named, and an accommodation of them to the chemical doctrines of the day, acidity of the fluids performing an important part in this theory. Le Mort, Schneller (Theoria Mechanics Delinealio, 8vo. Leyd., 1705), and others adopted the mechanical parts of the doctrines of Des Cartes, and associated them with certain chemical hypotheses not much more deserving of notice. They imputed inflammation to irritation caused by the aethe- real particles of the fluids without any reference to other changes. The partial rays of light furnished by the rising of chemical science in Europe were soon employed to explain morbid actions ; but they led, especially at first, to lit- tle more than to modifications of the doctrines previously adopted, and particularly of the hu- moral pathology, and never disclosed results deserving of lasting attention.t * Carbonic acid and hydrogenous gases were partially known to Van Helmont, and this imperfect knowledge of gaseous fluids became the basis of several of his pathologi- cal views. t The Dutch physicians, at the end of the seventeenth 458 INFLAMMATION—0 pi NIONS AS TO ITS NATURE. 136. Pitcairn, the master of Boerhaave, first opposed the chemical pathology then very generally received, and applied the mathemati- cal doctrines promulgated in Italy by Borelli, Sanctorius, and Bellini, and still more widely disseminated by the classical work of Donzel- lini (De Usu Mathemat. in Arte Medica: in Guilielmini Opera, 4to. Genev., 1719, t. ii., p. 516), to the" pathology of inflammation. To those acquainted with the physiological and pathological views of Des Cartes, the mathe- matical doctrines of the Italian physicians will appear as a very obvious and easy application of mathematics to the mechanical parts of the pathology, of which this philosopher may be said to have been the founder. Although nu- merous modifications of the theory of inflam- mation were proposed by writers of the mathe- matical school, yet they may be generally refer- red to an error loci, or to the obstruction which they supposed to be occasioned by the passage of the larger-sized globules of the blood into a smaller series of capillaries, intervening be- tween the arteries and veins,* than are des- tined to receive them. 137. Boerhaave proposed a theory, which, if it was not altogether original, was, at least, an important modification of that of Pitcairn, and of the mathematical school. He supposed that the blood itself became more viscid, caus- ing a lentor in its circulation through the sever- al orders of capillary vessels, and an excessive engorgement of them ; an increased action of the larger vessels, and flow of blood in them, taking place to overcome the resistance and congestion. The close resemblance of this hy- pothesis to others much more recently proposed is very obvious. That the action of the larger arteries should be increased^ where an obstruc- tion to the circulation through the capillaries exists, may readily be conceded ; but that the afflux of blood can be increased, and obstruc- tion at the same time exist, is a contradiction in terms. In one essential point connected century, were among the chief writers on Pathology, and, consequently, on Inflammation ; and the schools of medi- cine in Holland were acquiring a reputation, which rose with the commercial prosperity of that country. But it is not altogether uninteresting to remark how many of the medical writers in it, about this time, adapted their patho- logical views, as well as their practical precepts, to the promotion of the traffic of the people. The foreign trade of Holland, rising upon the decay of that of Portugal, Spain, Venice, and Genoa, furnished numerous articles of luxury, not only to the Low Countries, but also to all Germany and the East of Europe. Many of the medical writers of the country brought them into general use ; and, whether they imputed inflammation and other diseases to inspissation, or to acidity, or to alcalinity, or even to effervescence of the circulating fluids, still tea, tobacco, coffee, and opium, in extraordinary quantities, were not only the chief remedies, but also the principal prophylactics recommended by them. * The mathematical school boasts of a numerous list of names eminent not only in medical, but also in mathemati- cal science and in art — of Guilielmini, Michelotti, Bernouilli, Baglivi, Perrault, Chirac, Quesnay, Hales, Mead, Sauvages, and others ; and furnishes many splendid examples of the dignity, as well as of the aid, which general science has imparted to the study and practice of medicine. The mathematical doctrine of inflammation was founded ou the belief that the globules of the blood consist- ed of various sizes, and that the red globule was formed of six serous globules, and each serous of six lymphatic glob- ules ; three orders of capillary vessels, suited to the con- veyance of these globules, existing between the arteries and veins. The obstruction caused by the passage of red globules into the wrong order of vessels constituted what they termed an error loci, and the cause of inflammation. While the Cartesians insisted much on the various forms of the globules and pores, the mathematicians contended chiefly for the different sizes of the globules and capillaries. with the theory of inflammation, Boerhaave differed altogether from Pitcair n. The former supposed that a constriction of the capillaries caused a congestion of blood and slower rate of circulation, while the latter considered that an increased diameter of the vessels had this effect. The great defects in the opinions of these physicians, independently of their incor- rect views as to the conformation of the capil- laries, and as to the constitution of the blood and blood globules, were their entirely leaving out of consideration the power exerted by the organic nervous or vital influence upon the ves- sels, and upon the circulation through them; and their being unaware of the fact, that both constricted and enlarged capillaries, or other vessels, may have the circulation through them either accelerated or retarded, according to the state of that influence by which the capil- laries, and tissues in which they ramify, are actuated. 138. While the mathematical theory of in- flammation and disease was evidently support- ed by, if it did not originate in, the philosophy of Newton, and was the first manifestation of the comparatively modern doctrines of solidism, the views of Hoffmann were more referrible to the system of Leibnitz, and a more com- plete adoption of the influence of the soft solids in the production of morbid actions. According to this celebrated pathologist, inflammation pro- ceeds from spasm of the smaller vessels, which suspends or impedes the circulation in one part, and determines it inordinately to others, red blood being thereby propelled into capilla- ries, which in other circumstances admit only the serous portion of it, pain, swelling, and heat resulting therefrom. This theory soon found supporters; and, notwithstanding the already promulgated doctrines of his contemporary and colleague Stahl, these soon became numerous. While the doctrines of Stahl and Hoffmann were dividing the schools of Germany, and es- pecially that of Halle, where they were taught by these celebrated professors, the opinions of the mathematical pathologists and of Boer- haave were predominant in this country and in Scotland, until the lectures and writings of the elder Monro, of Whytt, and of Cullen at- tracted notice. 139. The medical doctrines advanced in Ger- many at the close of the seventeenth, and at the commencement of the eighteenth centuries, had more or less reference to the most generally received metaphysical views. The relations al- ready noticed between the doctrines of inflam- mation hitherto adopted and the pathology of Des Cartes existed chiefly in respect of their more mechanical parts ; but the psychological opinions of Des Cartes, and of his successoi Malebbanche, were not made the basis of a system of pathology until Stahl adopted them as such at a very early period of life. Per- rault* had previously demonstrated the influ- * Perrault commenced his magnificent career as a physician, and soon acquired by his writings the first emi- nence as a physiologist, naturalist, painter, sculptor, mech- anist, and archiiect ; in which last character he is best known, especially as the architect of the beautiful facade of the Louvre. He translated and illustrated Vitruvius with splendid drawings and engravings ; wrote an extensive work, in two folio volumes, on the Natural History of Ani- mals ; published numerous Essays on Physiology and Phys- ics ; and at his death left for publication a collection of re- cently invented and useful machines. All his writings INFLAMMATION—Opi ence of mind upon all the bodily functions; but Stahl had reference to this influence in the production, not merely of inflammation, but also of all diseases, notwithstanding the objec- tions of Gassendi, urged against the physiology of Des Cartes, that the direct influence of the mind was limited to the brain and the organs of sense and volition. 140. The doctrines of Stahl and Hoffmann continued for many years to divide medical opinion, notwithstanding the efforts of Kaauw Boerhaave in behalf of the views of his more celebrated uncle, and his endeavours to con- nect them with the system of Hoffmann. In this country the opinions of Hoffmann, ac- cording to the explanation and modifications of them attempted by Cullen, became most generally adopted, particularly with reference to inflammatory diseases, although the able writings of Whytt strictly belonged to the school of Stahl. Of all the successors of Bo- erhaave, Gorter most strenuousty insisted upon the fact, that inflammation does not con- sist of congestion of the diseased part, but of an irritation affecting the vital condition of the vessels, and the circulation in them. The in- fluence of irritants upon the state of vital ac- tion was, however, first contended for by Glis- son ; but to Gorter and Gaubius belongs the credit of having more fully illustrated it, and developed the laws of excitement, thereby fur- nishing a basis for the doctrines of Brown and Darwin at a much more recent period. 141. While the doctrines of Boerhaave, Stahl, and Hoffmann were dividing medical opinion, and at a time when the views of Hoff- mann were gaining the ascendency in their more general adoption, Haller first published his opinions on irritability. He afterward de- veloped them more fully, and referred this property to the organization of the muscular fibre, but was opposed by Whytt, Lorry, and Gaubius, as to its precise source ; and, contra- ry to the opinion of the former, who referred irritability to cerebro-spinal nervous influence, he carefully distinguished it from, and endeav- oured to prove its independence of this influ- ence. He disputed the doctrine of this pathol- ogist, that exaltation of irritability determines the circulating fluids to inflamed parts; yet there is no doubt, as Whytt observes, that the '• heat, redness, and inflammation, brought on the skin by blisters and sinapisms, are not ow- ing to any increase of the force of the heart, or of the momentum of the blood in the larger vessels—though this is often an effect of their application—but merely to the action of these irritating substances on the cutaneous vessels, whereby the motion of the fluids in them is greatly augmented." Haller believed that the accumulation of blood in the capillaries was owing chiefly to constriction of the small veins, and that the derivation of this fluid to any particular part should be attributed to the removal of the resistance furnished by the state of the capillaries and veins. He agreed with Whytt that obstruction cannot of itself produce inflammation, and insisted upon ex- travasation of the red particles as constituting apart of the redness observed in some inflamed tissues. Winter, nearly at the same time as abound in originality ; for, in his very diversified studies, he was guided chiefly by observation and his own genius. NIONS AS TO its Nature. 459 Haller, published views as to irritability sim- ilar to those of this celebrated pathologist; and Verschuir greatly extended, and, at the same time, modified the doctrines of the latter, espe- cially as to irritability of the arteries and cap- illaries in warm and cold blooded animals. The chief sources of error in the observations of those eminent writers are their having view- ed the fibrous coat of the arteries as muscular; their imputing the properties of muscular tis- sues, not only to these vessels, but also to the capillaries, which are unprovided with this coat; and their confounding not only organic or insensible contractility and vital expansion, but also the elasticity of fibrous tissues, with the irritability or sensible contractility of mus- cular fibres. The intimate structure of parts, and the kind and degree of vital manifestation proper to each, were imperfectly known to them, and indeed to many of their successors, and were insufficiently distinguished one from another, and hence were confounded in such a manner as to vitiate most of their pathological inferences. 142. The chief modification in the theory of Hoffmann, suggested by Cullen, was his be- lief in a phlogistic diathesis, predisposing to and occasioned by local inflammation, this diathesis consisting in an increased contractility of the fibres of the whole arterial system. He object- ed to the opinion of Boerhaave, as to conges- tion of the vessels being a part of the inflam- matory state, and contended that the obstruc- tion is owing to spasm, which indirectly causes an increased afflux of blood to the affected part. " A spasm," he remarks, " of the extreme ar- teries, supporting an increased action in the course of them, may therefore be considered as the proximate cause of inflammation, at least in all cases not arising from direct stim- uli applied ; and even in this case the stimuli may be supposed to produce a spasm of the ex- treme vessels." 143. Some pathologists, towards the close of the last century, and in still more recent times, being unable to reconcile the idea of in- creased action with the enlargement of the capillaries, and the swelling constituting in- flammation, believing as they did that increas- ed action must necessarily be productive of contraction, had recourse to the supposition that the disease depended upon relaxation and diminished action of the extreme vessels ; others, again, ascribed inflammation to increased action of these vessels; and thus pathologists were di- vided into two opposing parties. The chief fallacies common to both were their having ta- ken it for granted that capillary and arterial vessels possess a muscular structure perform- ing the function of muscular parts ; and that an increased action, according to the one party, and a diminished action, according to the oth- er, constitutes the principal, and, indeed, the only morbid condition throughout the disease. These opposite doctrines have been so warmly discussed in recent times, each party endeav- ouring to support their own views by experi- ments, that it becomes necessary to consider them somewhat in detail. 144. B. The doctrine of relaxation, or dimin- ished action of the capillaries in inflammation, the blood becoming nearly stagnant in the di- lated vessels, originated with Vacca Berling- 460 INFLAMMATION—Opinions as to its Nature. hieri (De Inflam. Morbosa Natura, Causis, Ef- fectibus, &c, Flor., 1765), and was promulga- ted in this country by Mr. Allen, who modi- fied the opinion of Vacca, and contended that the action of the arteries is increased, a larger quantity of blood being thereby propelled into the weakened capillaries than they can trans- mit. According to this theory, the exciting causes, even when they stimulate the part, produce not an increased action of the capil- laries, but only excite the larger arteries sup- plying the inflamed structures, and ultimately quicken the contractions of the heart. The effect of this is, that a larger quantity of blood than usual is propelled into the weakened cap- illaries, and especially the colourless branches ; and upon this unusual quantity the weakened vessels are unable to react, so as to carry on the circulation, stagnation and obstruction in them being the result. Dr. Wilson Philip modified the doctrine of Vacca in a different manner ; and, while he maintained that the extreme vessels are primarily weakened, he contended that the action of the larger arteries supplying these vessels is consecutively in- creased, the differences between active and passive inflammations depending, according to him, upon the degree in which the arteries supplying the blood to the inflamed part are excited. In farther illustration of his views, by experiments and microscopic observation, Dr. Philip remarks that "the motion of the blood is retarded in the capillaries, in conse- quence of the debility induced in them ; an un- usual obstacle is thus opposed to its motion in the arteries preceding them in the course of the circulation, which are thus excited to increas- ed action." In this statement of his views one difficulty presents itself: How comes the de- bility of the capillaries, causing retardation of the motion of the blood through them, to fol- low directly upon the application of stimuli 1 Dr. Philip infers the debility from the apparent retardation of the circulation of the red glob- ules in his microscopic experiments ; and, hav- ing inferred the debility, concludes that the ap- parent stagnation must really exist. Thus reasoning in a circle, he states the above doc- trine as its result. The difficulty here advert- ed to seems not to have escaped Dr. Hastings, who appeared in support of the opinions of Dr. W. Philip. The experiments of Dr. J. Thom- son, stated in his excellent work on Inflamma- tion, had demonstrated certain points subver- sive of the doctrine of Dr. Philip, and of these Dr. Hastings took some notice. Inferring, with his master, or, more correctly, with Vac- ca Berlinghieri, that " inflammation consists of a weakened action of the capillaries, by which the equilibrium between the larger and smaller vessels is destroyed, and the latter be- come distended," he, nevertheless, is compelled to admit that increased action, or temporary excitement of the capillaries, may precede the debility constituting inflammation. " Certain stimuli," he remarks, " applied to living parts, produce an increased velocity of the blood's motion, and a contraction of the vessels. Du- ring this state of excitement, the part affected is so far from having anything like the appear- ance of inflammation, that the size of the ves- sels is diminished and the part paler. But if the stimulus be long continued or increased in power, the small vessels, which, in the natural state, admit only of one series of globules, be- come so dilated as to allow an accumulation of a much less fluid and redder blood in them, which loses its globular appearance, and moves much more slowly than that which previously passed through the vessels. The part now appears inflamed. If the stimulus be removed the blood-vessels do not soon regain their ori- ginal state; time is necessary to allow them to recover their contractile power, so as to prevent the impetus with which the blood is propelled by the heart and larger arteries from keeping up the dilated state of the capillaries." Dr. Hastings farther contends that, when acrid substances produce inflammation, debility of the capillaries takes place without previous ex- citement, the blood becoming very red, circu- lating very slowly, and stagnating in some of the branches. As Mr. Morgan remarks, the hypothesis of weakened action of the capilla- ries, and slower motion of the blood in them, has been the most generally adopted of the re- cent theories of inflammation, because it ad- mits of a more easy demonstration with the microscope. 145. All the supporters of this doctrine err in attributing little or no share in the inflam- matory act to direct excitement of the capil- laries—in believing that excitement must ne- cessarily be attended by constriction of these vessels, and that dilatation of them is incom- patible with increased vital action—and in dis- missing from their consideration the other mor- bid acts contributing to the production of the disease in its various stages and forms. That the extreme capillaries are weakened, dilated, and congested, and even that the blood stag- nates in them at a more or less advanced pe- riod of sthenic inflammations, and at a very early period of the asthenic forms, have been stated above ; but this condition is only one of several constituting the disease, which, in no instance and in no stage depends upon a singleness of event, as contended for by the espousers of this and the opposite theory. 146. C. The doctrine of increased action of the vessels in an inflamed part may be attributed, as stated above (§ 140), to Gorter and Gau- bius, if not to Glisson. They considered that inflammation was the consequence of irrita- tion, which increases the vital action of the vessels and propels the coloured blood into the colourless capillaries. Mr. J. Hunter believed that inflammation is an increased action of the vessels of a part, attended by accelerated cir- culation ; but he erred in supposing the vessels to be muscular, and the error vitiates more or less all his reasoning on the nature of the dis- ease. Mr. Morgan states that Mr. Hunter's " opinion of the nature of inflammatory action is not clearly stated, nor does it appear from his writings that he had ever made any experi- ments in order to ascertain the state of the mi- nute vessels." Mr. Hunter, however, has sta- ted his opinion of the nature of inflammation in several places, even in the same chapter, and to the purport just given. At another place he observes, " the very first act of the vessels, where the stimulus which excites inflamma- tion is applied, is, I believe, exactly similar to a blush. It is simply an increase or distention beyond their natural size ;" and again, "what- INFLAMMATION—Oi ever purpose the increase of the size of the vessels may answer, we must suppose that it al- lows a greater quantity of blood to pass through the inflamed part than in the natural state, which supposition is supported by many other observations." Indeed, the whole of the sec- tion on the " Action of the Vessels in Inflamma- tion" contains a very detailed and distinct ac- count of his views as to the nature of the dis- ease. As to the assertion that Mr. Hunter never made experiments to determine the na- ture of inflammation, the reader has only to refer to the section just mentioned, where he will find the details of observations and experi- ments made upon warm-blooded animals—not frogs, and other animals unsuited to the satis- factory elucidation of the subject—proving the justness of his views as respects certain states and stages of the disease. 147. The increased action of the capillaries in inflammation has been advocated by Dr. Parry, partly by Dr. J. Thomson, and by Mr. James ; yet most of the same fallacies which vitiate the doctrine of the opposite party may be urged against the majority of those who contend for the truth of this, and especially their belief in the irritability of these vessels. Indeed, this phrase has been employed by many without attaching any precise meaning to it, and without being aware that, if by increased action they meant increased contraction, or even an increased power of alternate relaxation and contraction, as in muscular tissues, the circula- tion of the inflamed part would be altered by it very differently from what is actually observed. The circulation, in health, through the capillary vessels does not require the aid of any action on their part; for the contractions and dilata- tions of the heart, and the elasticity of the larger arteries, are quite sufficient for the transmission of the blood, not only in the cap- illaries, but also in the veins. Agents which change the tonicity of the tissues will neces- sarily affect that of the extreme vessels, and, consequently, the state of circulation through them ; but such agents will seldom give rise to inflammation, unless by a succession of chan- ges, of which alteration of the state of circula- tion, whether increased or diminished, is only a part, as I shall endeavour to show hereafter. 148. The experiments which have been plan- ned and performed with a view of establishing the truth of either of these doctrines of inflam- mation, have been altogether vitiated by the circumstance of the chemical action : 1st, upon the tissues; 2dly, upon the capillaries ; and, 3dly, upon the blood of the agents employed in these experiments having been entirely over- looked. But this is not all; the physiological or vital action of these agents has been neg- lected, equally with the chemical action, and even with the changes they produce upon dead animal matter. These experiments abound, moreover, in other sources of fallacy, attributa- ble to the means and aids used in ascertaining the effects, and to the subjects upon which they have been performed. Can it be believed that all these circumstances—any one of which is sufficient to overturn the conclusions drawn from these experiments—have been neglected 1 Instead of observing closely the changes taking place in tissues actually inflamed, and the suc- cession of these changes in the different stages rioNs as to its Nature. 461 and forms of inflammation, as affecting "differ- ent structures, substances producing both vital and chemical alterations in the tissues, blood- vessels, and blood itself, have been applied to parts, and the effects directly and remotely pro- duced by them have been described as identical with inflammation, and made the basis of the prevailing doctrines of the disease. Before any inference, or even the smallest fraction of information, can be derived from the experi- ments paraded by many of the writers on this branch of pathology, it is necessary to bear in miftd that acids, or alkalies, or alcohol, or tur- pentine, or neutral salts, when applied to a vas- cular tissue, produce effects which are not iden- tical with any of the usual forms of inflamma- tion. Acids affect the nervous influence of the part; constringe, corrugate, or cornufy the tis- sues and capillaries; change the colour and state of the blood in the extreme vessels, and arrest the circulation in them ; and, if inflam- matory appearances supervene, much of the primary changes will still continue to modify its characters. Alkalies produce opposite ef- fects ; they weaken the vital cohesion of the tissues, partially dissolve them and combine with them, redden and otherwise affect the blood, and, according to their strength, influ- ence the form and termination of the morbid changes they produce in the part. Turpentine, and, in a less degree, alcohol, in their primary action, change the state of nervous power, con- stringe the capillaries and tissues, and retard the circulation in them; and neutral salts va- riously affect the vitality, the structure, the cir- culation, and the blood of a part, according to their individual constitution. When any one of the numerous substances which may produce inflammation is applied to a living tissue, the effects are not limited to the spot with which it is in actual contact. The impression ex- tends, and a modified, or even opposite action, may be superinduced in surrounding parts. If the substance be injurious, or subversive of vi- tal power in the part, more or less resistance is offered to the extension of the mischief. The injury affects the state of organic nervous power ; and the irritation or consequent reac- tion of this power, and its influence upon the surrounding vessels and blood, give rise to in- flammatory action, either in the seat of injury or around it. If a living membranous tissue be pricked with a red-hot needle, the following effects will result; but these effects, although inflammatory in many respects, are not to be viewed as identical with idiopathic inflamma- tion, as they have been by some writers, and for the reasons which will be stated. The red- hot needle will produce much pain, attended by the immediate constriction or corrugation of the tissues and capillaries; the blood being driven from the part immediately surrounding the puncture, the red globules undergoing a change in colour, and becoming stagnant in and adhering to the vessels adjoining the punc- tured spot. This is the immediate effect; but in a short time — varying, however, with cir- cumstances—the punctured spot either becomes dark or black at a central point, around which the vessels dilate, the injury having either de- stroyed their continuity or obstructed them. The increased vascularity, which soon takes place around the injured spot, now becomes ON—Pathology. 463 INFLAMMATK inflammatory, and is partly owing to obstruc- tion in this spot, and to the consequent devel- opment of the surrounding capillaries, so as to carry on the circulation. But the affection, by the injury of the organic nervous influence of the part, so influences the state of the extreme vessels as to produce the chief of the phenom- ena. Now the early part of the changes here observed are not to be viewed as identical with idiopathic inflammation, although illustrative of the production of inflammatory action by cer- tain injuries; for the agent employed cornufies the capillaries, stagnates and changes the blood in them, obstructs their circulation, and severe- ly affects the nervous influence; this last change especially producing, in the extreme vessels of the injured part, consecutive effects, which only are truly inflammatory, particularly in pre- viously healthy constitutions or structures. 149. In order to arrive at anything like a just notion of the nature of inflammation, the phe- nomena constituting it should be closely exam- ined from the commencement, whether arising spontaneously, or produced by an irritant or excitant. But the phenomena observed in a single tissue, or in a particular form of the dis- ease, are not to be viewed as constituting alone its characters in all stages, forms, and circum- stances. The essential characters, as well as the subordinate phenomena, of inflammation, vary in all the states and stages of it; they are continually changing with their duration and the nature of the causes which produced them, and according to the temperament, habit of body, diathesis, and constitutional powers of the patient. So diversified do they thus be- come, that it would be endless, if not impossi- ble, to describe them in all their conditions, periods, and consequences. The most promi- nent pathological states can only be mentioned ; the descriptions already given, and the obser- vation or experience of the reader, will supply deficiencies which must still remain, even after the most minute details. 150. ii. Pathology of Inflammation.—A. Of the Nature of the Sthenic Forms.—a. The or- ganic nervous tissue is primarily affected in the seat of inflammations of all kinds. I have already contended that inflammation, in its more sthenic forms, is a result of a morbidly excited state of the organic nervous tissue surrounding the ex- treme vessels or capillaries of the affected part, or a derangement from an unnaturally exalted condition of these nerves, on which the func- tion of these vessels, and, indeed, of the whole vascular system, have been shown to depend. One of the chief inquiries concerning the na- ture* and pathological relations of inflamma- * The views which f now proceed to state were pub- lished by me first, as already noticed, in 1815 ; on several occasions during the years 1821 and 1822, in the Medical and Physical Journal, and in the London Medical Reposi- tory; and still more fully in my Appendix to M. Riche- rand's Elements of Physiology, published in 1824. They were the result of a close investigation of the subject; and if the reader will refer to the section on Inflammation, which I added to the last of the works just mentioned, and after- ward to that of Kaltenbrvnner, published in 1826, he will find my doctrine and observations fully confirmed by his researches, as well as by those of M. Gendrin, also published in 1826. A very large reprint of my Appendix, containing the same section on Inflammation, without any alteration or addition, appeared in 1829. In 1835, and at still later periods, treatises and essays on Inflammation have been published by several writers, in which the principal parts of my doctrine have been adopted, but without any reference to the. original propounder of them. Of this I tion is, whether this excited or exalted state of the organic nervous tissue is one of simple excitement or not, whether the functions of the nervous tissue be merely increased above the healthy pitch, or whether or not they are also otherwise changed. I have stated them to be morbidly or unnaturally excited, thereby indicating that they are increased differently from what we observe in a healthy part from the application of a stimulus, as respects both the duration and the kind of action they occa- sion. 151. The duration of the healthy exalted ac- tion consequent upon simple excitement, men- tal or physical, is generally brief—the effects soon subsiding with the removal of the cause —because the nervous influence exerted on the capillaries is simply increased, without the mode or habitude of this influence being changed in kind. When, however, an irritant, stimulus, or other cause operates upon a part so as to change the mode of organic nervous influence endowing it and its capillaries, the consequent vascular excitement or action is not only of longer duration, but is also altered in kind : it becomes truly morbid; and it either subsides gradually before the conservative powers of this influence as exerted throughout the frame, or undergoes a succession of changes, until it terminates in one or other of the ways de- scribed, as usually observed in sthenic inflam- mations. 152. That the first change occasioned by the exciting cause takes place in the organic ner- vous influence of the part, is proved by the early effect produced by it upon the organic sensibil- ity, and on the functions more immediately de- pendant upon this influence. The uneasy sen- sation of inflammation, in its various states and modes, is to be ascribed (§ 8) to the mor- bid impression made on the organic or ganglial nervous tissue, and is to be viewed as the sensible expression of the consequent change in the condition of the influence exerted by this tissue in the affected part—as indicating a mor- bid state of this portion of the nervous system, producing and attended by deranged action of the capillaries in the affected organ, and often exciting or otherwise disturbing the sensibili- ty and functions of the cerebro-spinal nerves, with the terminations of which the former be- comes associated in many of the textures. The pain or uneasy sensation attending the changes in the organic nervous tissue, which affect the state of the capillary circulation, so as to give rise to inflammation, is, as shown above (§ 82), very distinct from the morbid sensibility often manifested by the cerebro-spi- nal ramifications, as in the different forms of neuralgia and of spasmodic affection; and, al- though the latter is much more acute and vio- lent than the former, yet it never gives rise to much vascular disorder. Excitement of the cerebro-spinal nerves has but little immediate influence upon the capillary circulation, except- thought it not worth while to take any notice at the time, as I was about having it in my power to do myself full jus- tice, and to an extent, in respect of circulation, infinitely beyond what could be reached by the works in question. It is very probable that the opinions first brought forward by me have been subsequently suggested to these writers, with- out having ever perused any of my writings on the subject; yet one of the works only, and that one containing a fall exposition of my doctrine, has been circulated to the esten- of several thousands. INFLAMMATION—Pathology. 463 Ing that of the countenance, as in the act of blushing ; and then this is only temporary. Whatever influence these nerves may possess over the circulation is only produced through the medium of the organic or ganglial nervous tissue distributed to the capillaries and struc- tures generally. This provision is important as respects the preservation of the healthy functions of parts ; for if the vascular system were directly under the dominion of the cere- bro-spinal nervous system, all the functions of circulation, secretion, nutrition, &c, which are subjected to the organic nervous influence, would be liable to continual derangement from the various impulses of the will and the pas- sions. From this it will appear manifest that changes in the cerebro-spinal nerves of an or- gan, or part, can have but little effect in the production of inflammation, while alterations of the organic nervous influence or sensibility are almost, if not altogether, necessary to its existence. In cases of severe injury to the spinal chord causing paraplegia, the lower ex- tremities are not more liable to inflammation than in health. 153. b. The causes being of an exciting nature, the primary effect on the organic nervous influence and on the capillary circulation will partly or chiefly consist of excitement—the sthenic states of inflammation generally resulting.—-Whenever the causes of inflammation, either directly or indi- rectly, are of an exciting kind, whenever ex- citement is even one only of the effects pro- duced by them, we must admit that the vital influence of the organic nervous tissue of the part upon which these causes act will be in- creased for a time by them; the excitement being, however, modified by their nature. The organic nervous tissue supplying the capillary vessels of the affected organ will especially manifest this effect in the altered action of these vessels. Whenever the organic nervous influence is locally increased, the vital actions of the associated capillary vessels are also aug- mented—the diameter of these vessels becom- ing enlarged, and a larger column of blood cir- culating in them with increased velocity. This is evinced during excitation of secreting sur- faces and of erectile parts, and by the enlarge- ment of the nerves and blood-vessels of the uterus after impregnation. That the principal part of the more direct effects produced by the application of stimulants to living structures consists of exaltation or excitement of the or- ganic nervous tissue, causing increased action of the vessels, is proved also by the phenome- na observed to follow such applications to or- gans or parts supplied either chiefly or only by organic or ganglial nerves. Now, if we admit, what cannot be disproved, that excitement of the organic nervous influence of a part increas- es the vascular activity and circulation of that part, it must necessarily follow that, whenever an increase in degree forms a part of the change induced in this influence by the causes of in- flammation, a proportionate augmentation of the size of the capillaries will take place—an active expansion, or turgescence, of the ex- treme vessels will result, and give rise to states of inflammation of a more or less sthenic char- acter, according to concomitant circumstances, either extrinsic or intrinsic, in respect of the person affected. But that the causes of sthenic I inflammations do not merely excite the sus- ceptible nervous tissue, and, consequently, vas- cular action, but also otherwise change the former, and consecutively the latter, is proved by the duration of the resulting effects and by the succession of alterations, both local and general, as above described. 154. c. In sthenic inflammations, organic ner- vous influence and vascular action are not only primarily increased, but also otherwise changed.— In the early stage of all inflammations there is every reason to suppose that the organic ner- vous influence of the capillaries and inflamed part is not merely changed in degree, but that it is also modified in kind ; and that the differ- ences existing, not only in the forms and va- rieties, but also in the stages of inflammation, depend upon the extent and combination of these changes—an excited, and, at the same time, a modified kind of influence, especially characterizing the sthenic forms of this dis- ease, the combination of impaired and altered influence with excited action constituting the more active states of the asthenic varieties. The irritant or other cause of inflammation seems to impress the organic or vital influence, or the ganglial nervous tissue of the part, or of the system more generally, in such a man- ner as to prevent this influence and the vascu- lar disorder produced by it from returning to the natural state, at least for a considerable time. Morbidly excited action is thus induced in the capillaries of a part, particularly in the sthenic forms of the disease, and is succeeded by other changes. When the exciting cause alters the organic nervous influence in other modes, the capillaries are co-ordinately affect- ed. If this influence is depressed as well as oth- erwise altered, locally or generally, either by the operation of the cause or by pre-existing dis- order, a state of action characterized by defi- cient power is the result. The specific forms which inflammation assumes when arising from certain causes, particularly from infection or inoculation, depends upon the mode or nature of the morbid impression made upon the or- ganic nervous tissue of the part, especially that distributed upon or interwoven with the capil- laries. The causes may act by their continued presence ; thus, irritating bodies, or the lesions of structure produced by chemical agents or by- injury, may prove sources of irritation to the nerves and capillaries of a part; but more fre- quently the exciting causes change by the im- pression made at first by them, the degree, mode, or state of influence exerted by the or- ganic nervous tissue upon the capillaries and smaller vessels, and upon the fluid circulating in them; the resulting morbid action present- ing corresponding and peculiar characters in respect of kind, degree, and power or tone. This is more remarkable in the more specific forms of inflammation, either produced by cer- tain poisonous agents or attending some con- stitutional maladies. 155. In experiments upon living tissues, the effects produced by various stimulants and as- tringents have, in some respects, been misin- terpreted by the experimenters ; and the slight constriction of the capillaries that directly fol- lows the application of such substances, and before the dilatation which subsequently occurs, has been viewed as the first part of the inflam- 464 INFLAMMATION—Pathology. matory act. But this effect depends upon the action of these substances, particularly of tur- pentine, alcohol, the salts, and many others, upon the vital contractility of the tissues and extreme vessels. The instant effect of these is more or less constriction of the capillaries ; but this very soon ceases, the natural state, or expansion beyond it, soon following. When the substance employed is of an irritating na- ture, without any astringent property, an en- largement of the capillaries is the next phenom- enon to follow the impression made by it upon the organic nervous tissues, this impression being frequently rendered instantly and acutely sensible. In observations or experiments made upon the living tissues, care should be taken to distinguish between the effects produced, 1st, upon the organic sensibility; 2d, upon the or- ganic contractility ; and, 3d, upon the physical properties of the tissues, upon their cohesion, elasticity, &c, or upon the properties which animal substances continue to manifest some time after death. Theirs* of these ceases in- stantly with dissolution ; the second remains for a short time afterward, but is soon exhaust- ed by strong stimuli; and the third continue much longer, but gradually disappear with the supervention of decomposition, yet admit of being more or less preserved and somewhat modified by various substances of an astringent and antiseptic nature. In the investigation of the nature of the changes in living structures, usually called inflammatory, the intimate rela- tion existing between these changes and the causes which induced them should not be overlooked. The mode of operation of the causes, especially with reference to the vital and physical properties just enumerated, and to the local and general circulation, ought to be strictly regarded; and the manner in which the results may be modified by constitutional predisposition should be taken into account. 156. d. The state of circulation in the early stages of sthenic inflammations.—The primary affection of the organic nervous tissue having been shown to be one of morbid excitement in the sthenic forms of inflammation, and the effects of this excitement to be turgescence, enlargement, or active expansion of the capillaries, it next re- mains to inquire as to the state of the circulation in the enlarged vessels. This topic has been much discussed, for observations of the current of blood in the capillaries are liable to error; and, besides, the flow of blood may be retarded at a single point, and greatly accelerated at others, particularly when inflammation is pro- duced by mechanical or chemical agents. The state of circulation also undergoes a succes- sion of changes, as will be hereafter shown, with the progress of the disease. It will not be denied that the organic or ganglial nervous tissue exerts a manifest influence, not only upon the capillary circulation, but also upon the blood itself; and that the secreting and other organic functions are under the dominion of this part of the nervous system. It conse- quently follows that excitement, depression, or other affections of this influence will produce co-ordinate changes, not only in the capillaries and related vessels of a part, but also in the state of circulation and in the blood in them. During excitement of the organic nervous func- tions of an organ, the vessels experience not only an expansion, but also an increase of tone, a vital turgescence. The capillaries, although increased in diameter, still retain the power of reacting sensibly upon the blood propelled into them, so as to preserve, if not to accelerate, the rapidity of the currents passing through them. The necessary result of these states is an increased flow of blood, and a rise of tem- perature, and these effects continue until the excitement is exhausted, varying, however, in feature as well as in continuance, and more especially in the associated phenomena and consequences, with the mode or kind of excite- ment directly resulting from its cause. 157. When the propelling power of the heart and the tonicity of the larger arteries give rise to an increased vis a tergo, and particularly when the expansion of the extreme vessels is such as to allow a portion of their contents to escape through the delicate or imperfect canals in which they terminate, or when an obstacle is opposed to the return of the blood through the veins, a portion of the red particles escapes with the serum into the inflamed tissue, gener- ally at minute or distinct points. This is ob- served especially when the tone of the capilla- ries in an inflamed part is exhausted, either by the nature of the exciting cause or by the pre- vious excessive excitement, before the in- creased action of the heart has subsided. 158. e. Of the development of new vessels in inflamed parts.—It is not only the vital turges- cence or expansion of the capillaries, so that those which could not admit the coloured glob- ules of the blood in the healthy state readily admit them in an inflamed part, but also the development of new vessels that is often ob- served. But this latter event takes place chiefly in serous membranes, and especially in albuminous exudations from the inflamed sur- face. It possibly may also occur in other parts, to a more limited extent, although it does not admit of so obvious a demonstration as in these. It can only occur in the various grades of sthenic inflammation, and it fully evinces that, although truly morbid in its nature, this form of the disease is characterized by vital activity, and by a deranged increase of the formative process in the affected part. In asthenic in- flammations, however much capillary canals may be enlarged so as to admit a greater col- umn of blood, no new vessels are developed, unless the asthenic be converted into the sthen- ic state. In the former state of disease, the expansion is the result of impaired vital tone and resistance, both of the capillaries and of the tissues affected; and the organic nervous power of the part and the action of the capil- laries upon their contents are incapable of forming either coagulable lymph or new ves- sels. In the latter state, nervous power and vascular action are capable of producing the one, and often, also, the other. 159. When sthenic inflammation affects se- rous membranes, the morbid exudation thereby formed on their surfaces is sufficiently consist- ent to admit of the extension or growth of new vessels from those which had become enlarged in the early stages of the inflammatory act, and to give them support until they acquire considerable development. But when the as- thenic disease implicates these membranes, the secretion from their surfaces is too watery or INFLAMMATION—Pathology. 465 serous to furnish consistent canals or channels in which the contents of the capillaries may be conveyed beyond those which are morbidly en- larged, without commingling with the rest of the effused matter. In cases where new ves- sels form, the exuded lymph or albumen into which they run is not only, to a certain extent, consistent, but also somewhat scanty, or, at least, not very abundant; but in cases where they cannot be formed, the fluid effused is gen- erally both serous and copious. 160. The production of new vessels in parts sthenically inflamed, particularly in exudations of lymph, is observed chiefly in young persons, and especially in those who are in the course of development. Occasionally the new vessels are numerous and distinct, even before the lymph has become at all abundant or consist- ent. In some very beautiful injected prepara- tions by Mr. Kiernan, the eminentpathologist, that, he kindly showed me, this was most re- markably demonstrated ; as well as the fact, which has been controverted by some French pathologists, that the new vessels shoot out from the inflamed surface, if not from those enlarged in the early stage of the inflammatory act. When new vessels form in the fibrinous lymph exuded from serous membranes, they may often be injected, the continuity of these vessels with those of the affected part being thereby clearly shown. Vet the most vascular part of the newly organized false membrane may not be that nearest the seat of inflamma- tion, the new vessels forming several anasto- moses, and occasionally becoming enlarged in some places at a distance from the surface whence they were produced. 161. /. Consecutive changes in the sthenic forms.—The successive changes taking place in the course of sthenic inflammations are con- formable with the laws of the animal economy. The excitement produced in the organic ner- vous tissue and capillaries of the part is ex- hausted with a rapidity and to an extent in proportion to its intensity relatively to the powers of the constitution and of the part af- fected ; and as the exhaustion proceeds, the tonicity of the extreme vessels and of the dis- eased tissue, as well as the vital cohesion of both, is weakened, the circulation through them retarded, and the colour of the blood deepened. The extent to which these changes take place, in connexion with the degree of general vascular action and of constitutional power, fully accounts for the lesions conse- quent upon sthenic inflammations. When phlegmasia arises from specific causes, the kind of morbid excitement primarily induced by them will, according to their nature, more or less modify these changes, and give rise to certain results in preference to others. We perceive this in the exanthemata and in vari- ous inflammatory diseases. The tissue affect- ed will also modify the continuance and mode, as well as the consequences of the morbid ex- citement. But there can be no doubt that the successive alterations in the inflamed struc- tures are merely consequences of the morbid impressions made by the exciting causes upon the organic nervous tissue, particularly in its connexion with the capillaries ; the states of these and the connected vessels, of the circu- lation through them, of the blood, and of the 59 diseased part, being the effects which may either disappear before the vital resistance of the frame, or terminate in any of the ways de- scribed above (§ 39, et seq.). 162. B. Of the Nature of the Asthenic States. —The remarks which I have just offered more especially refer to the nature of the more sthenic inflammations, and it is, therefore, necessary to consider the circumstances in which the asthenic states differ from these. It has been shown that these states proceed chiefly from constitutional predisposition, or from previous or associated disorder, or from the nature of the exciting cause. In either case, the organic nervous in- fluence, and, consequently, the tone or vital contractility of the tissues and capillaries in the seat of the disease, are quickly exhausted or readily depressed, and soon become otherwise morbidly affected—effusion, softening, disor- ganization, or gangrene, taking place with a ra- pidity in proportion to the primary vital depres- sion, or to eonsequent exhaustion, and to the nature of the impression made by the exciting cause. In cases of asthenic inflammation, ei- ther there has been originally or acquired great debility or deficiency of the organic nervous power, or the assimilating and excreting func- tions have been long disordered and imperfect- ly performed, or the exciting cause has been of a powerfully depressing or poisonous nature. Indeed, two, or even all of these circumstances, may be concerned, each more or less, in the production of some one or other of the morbid states of action comprised under the more ge- neric appellation, asthenic inflammation. Ow- ing to one or more of these circumstances, the vital, contractility of the capillaries and tissues of the affected part is impaired ; vital cohesion is weakened, so as to occasion remarkable soft- ening and friability of the structures ; the tone of the extreme vessels is so far lessened as to admit the effusion and percolation through the more yielding tissues of the more serous por- tions of their contents, sometimes coloured by red particles ; the vital resistance of the capil- laries, owing to the loss of tone, is insufficient either to resist even the weakened impetus of the blood, or to react upon it so as to carry on the circulation through them and the venous capillaries ; and, ultimately, increased effusion, retardation or stagnation of the blood in the minute vessels, and all the consequences shown to result from the asthenic forms of inflamma- tion (§ 70, et seq.), take place. Throughout the course of asthenic inflammations, the states of organic nervous influence, of vital action in the extreme vessels, and of the circulation in the affected part are incompatible with the produc- tion of coagulable lymph ; and hence the effu- sed fluid infiltrates the more soft surrounding tissues, and, owing to its morbid condition, caused by the states of vital action and of the blood, contaminates them, or promotes their disorganization. 163. The distention of the capillaries in as- thenic inflammations is referable to impaired or lost tone, rather than to an active vital ex- pansion or turgescence similar to that which characterizes the early stages of sthenic inflam- mations ; or, if the latter state exist at first, as it probably does for a very short time, in the less asthenic cases, it soon exhausts itself, and passes into atonic distention, with retarded 466 INFLAMMATION—Pathology. circulation. But there is every reason to infer that the current of the blood is impeded or re- tarded in the capillaries at an early stage, or even from the commencement of many cases of asthenic inflammation, particularly those caused by septic agents or animal poisons, and that the blood soon becomes stagnant in them, the various consequences already noticed ap- pearing according to the intensity and rapidity of the previous changes upon which this has been shown to depend. In proportion, gener- ally, as the circulation is retarded in the ex- treme vessels, the temperature of the inflamed part sinks, and the colour becomes deep or, livid, until a purplish or brown hue is acquired. As soon as these changes take place, disor- ganization soon follows, and proceeds with a rapidity in proportion to the weakness of vital power and resistance. If the organic nervous energy be aroused or re-enforced by appropri- ate constitutional and local means, the mis- chief may be arrested, unless it have already proceeded beyond the powers of restoration, and it may be ultimately remedied, as in the ad- vanced stages of sthenic inflammations. When the asthenic forms are arrested at an advanced stage, they generally assume more or less of the characters of the sthenic condition, repa- ration taking place as in that form of the dis- ease. [" It seems," says Williams,* " to be well established that an essential part of inflamma- tion is the production of numerous white glob- ules in the inflamed vessels, and that the ob- struction of these vessels is mainly due to the adhesive quality of these globules. The pro- duction of these globules must probably be con- sidered as an ultimate fact in the history of in- flammation and nutrition ; but it may be ob- served that sometimes it. seems to be the direct effect of an irritant acting on the blood-vessels and their contents ; in other instances it seems rather to result from determination of blood into previously-congested capillaries. Any cir- cumstances causing continued determination of blood, where congestion is already present, will occasion the production of the white glob- ules, and, consequently, inflammatory obstruc- tion may ensue. The complete obstruction of some capillaries by coagulation takes place in all cases of severe inflammation of the frog's web ; but there are slighter kinds of increased vascularity, in which there is no total obstruc- tion, but a continued enlargement of the capil- laries and veins, as well as of the arteries. This might be called simple determination of blood; but it differs from that of a transient character in the motion in the capillaries and veins being slower, and in the vast number of white globules seen moving slowly in them. Very probably this kind of process takes place in the lowest forms of inflammation, and an in- creased nutrition independent of inflammation. Something of the kind is generally seen in the capillary circulation of young frogs. "Numerous experiments and considerations lead to the conclusion that the most essential character of inflammation consists in an in- creased motion or determination of blood to the affected part, with a more or less obstruct- ed flow through the part, the force of the in- creased motion being partly expended in the * Principles of Medicine. Philadelphia, 1844. arterial portion of the dilated capillaries, and partly diverted into the collateral channels so abundantly supplied by the anastomosis of ves- sels. The obstruction in the vessels of an in- flamed part we have found reason to ascribe, in part, to the increased mass in the smaller vessels and to the diminished elasticity of their coats, and in part to the unusual formation of white lymph globules, which adhere to the walls of the tubes and to each other. Of the exciting causes of inflammation, the direct ir- ritants seem to produce obstruction in both these modes; those which act indirectly, on the other hand, in the first instance produce congestion, to which determination of blood being subsequently added, the inflammatory process begins; hence the latter causes, al- though very common, are not so sure of ex- citing inflammation as direct irritants are. " The effect of these changes, essential to inflammation, is to expend much of the circu- lating force conveyed by the arteries on their capillary terminations; and the enlargement and tortuosity of these capillaries, the produc- tion of globules which adhere to their sides, and their total obstruction by the same means, seem to be so many progressive expedients used by nature to direct the force of the circu- lation to that part of the vessels by which the process of reparation and nutrition is chiefly carried on." Between the application of an exciting cause and the establishment of that morbid action which goes under the name of inflammation, a certain period, varying in duration, elapses, which has been called the stage of incubation. Gradually the blood begins to flow towards the part affected with increased velocity ; the cap- illaries and minute arteries at first contract, and exhibit a diminished caliber, from increas- ed tonicity of their coats ; but this slowly van- ishes, and the same vessels become distended with blood. This forms the stage of simple vascular excitement, or vital turgescence of some physiologists, which may speedily subside on the withdrawal of the exciting cause; but if the cause persists, or is of a severe character, a stage of active congestion follows, which re- acts upon the general circulation, in conse- quence of which still larger quantities of blood are sent into the affected part, and the minute vessels become over-distended, and give way beneath thejr burden. The blood now begins to grow more viscid, the lymph globules to in- crease, becoming unusually adhesive to each other and to the walls of the vessel, thus lead- ing to obstruction. The circulation is, prob- ably, also retarded in consequence of an in- crease of vital attraction between the blood and the surrounding parenchyma. Exudation of serum and liquor sanguinis becomes more copious ; the fibrin of the blood is increased, not only in quantity, but in plasticity, or its tendency to become organized. The natural function of the part is at first exalted, then •prevented ; from the effusion of fibrin and co- agulable lymph the structure of the part be- comes changed, and, perhaps, to that extent as to be incompatible with future integrity of function. This state of things may also sub- side on the withdrawal of the cause, or it may advance to true inflammation, where the over- distention of the capillary vessels is fully es- INFLAMMATION—Pathology. 467 tablished, and their contractile power annihila- ted or suspended. The blood either slowly circulates through the part or actually stag- nates ; coloured and colourless corpuscles dis- tend the minute vessels, for causes already assigned ; the altered liquor sanguinis is ex- uded in profusion ; the coats of the capillaries yield, and blood is extravasated. In conse- quence of extravascular degeneration of the fibrinous effusion, or from a secretive elabora- tion of it ere it has left the vessels, pus is formed and extravasated, and thus the tex- tures become broken down and disintegrated. Coextensive and concomitant with these chan- ges, normal function is deranged and vitality diminished. It is now conceded by physiolo- gists, that although there is a remora, or stag- nation of blood in an inflamed part, yet that the circulation is preternaturally active in the parts adjacent. The arteries beat with greater force ; more blood is sent to the spot, which, however, meets with obstruction, and thus causes an unusual beating and throbbing ; ab- sorption seems to be suspended during the in- flammatory process, but is speedily resumed as soon as abnormal action has ceased, by which the part is restored to its former condi- tion. MM. Becquerel and Rodier (Gazette Medi- tate de Paris, 1844) have recently, by an exten- sive series of experiments, confirmed the ob- servations of Andral, that the development of a phlegmasia increases the fibrinous con- stituent of the blood. They have, moreover, shown that the cholesterine as well as fibrin is increased, while the albumen is diminished. The increase of fibrin they found to correspond with that observed by Andral, it being in di- rect relation to the extent and intensity of the phlegmasia, to its influence on the general state of the organism, and particularly to the febrile disturbance to which it generally gives rise. They found its increase, also, coincident with the development of the phlegmasia, and ac- companying, but never preceding it, and much more observable in acute than chronic phleg- masia. Blood-letting they found to have lit- tle influence on the fibrin, which decreases with the disease rather than with the means employed to combat it. Its increase in the blood, they observe, is usually manifested by the formation of a buffy coat on the surface of the clot, which is, at the same time, more dense than in the normal state ; or, if the buffy coat is not formed, by the presence of more or less numerous whitish striae, especially exist- ing near the superior surface of the clot, and announcing, as well as the buffy coat, the ex- cess of fibrin in the circulating fluid. In ac- counting for the 'fact that, while the fibrin is increased in inflammation, the albumen is di- minished, they suppose that these substances are the same, or at least that fibrin is derived from albumen, and that the increase of fibrin is produced by the transformation of an equaL quantity of albumen ; a change which may ea^ sily ocour, considering that they both have the same chemical composition. They found the quantity of cholesterine in inflammation nearly double that of the normal state ; and they sug- gest that it may be owing to a diminution of the biliary secretion from the rigorous diet en- joined, thus leading to an accumulation of this fluid in the blood. We have formerly remarked that the fibrin is also increased in chlorosis and in pregnancy. The opinion generally prevails among phys- iologists that fibrin has a spontaneous tendency to coagulate; that this spontaneous coagula- bility is a characteristic property of fibrin, by which it is distinguished from albumen and ca- sein ; and that the coagulation of the blood, and of various other animal fluids, depends on the spontaneous coagulation of the fibrin which they contain. Dr. Buchanan, however, of Glasgow, has recently advanced the opinion, which is sustained by a variety of-facts and experiments, that fibrin has not the least ten- dency to deposite itself spontaneously in the form of a coagulum; that, like albumen and casein, fibrin only coagulates under the influ- ence of suitable reagents ; and that the blood and most other liquids of the body, which ap- pear to coagulate spontaneously, only do so in consequence of their containing at once fibrin and substances capable of reacting upon it, and so occasioning coagulation. Thus, Dr. B. shows that the clot in blood, cellular membrane, and other organic solids have the property, by a sort of catalytic action, of inducing the coagu- lation of fibrin in liquids containing it.' Thus, if we mix a very small portion of liquid blood, just drawn from the vein, with six or eight parts of pure serum obtained from blood drawn the day before, we shall be able to separate a portion of fibrin in a perfectly soluble form, in a translucent mass* although the coagulation will be much retarded. This experiment shows very conclusively that the fibrin is actually dis- solved in the blood, and is not a constituent of the red particles. Dr. B. has also shown that a serous fluid, as that of hydrocele, may hold fibrin dissolved, and that this principle will not separate by spontaneous coagulation, requiring a catalytic action, similar to that of the clot in blood and analogous to the action of rennet, or casein, to induce it. These results show that spontaneous coagulability is no long- er a sure test for fibrin in organic liquids; and that the old division of blood into coagulable and uncoagulable lymph is founded in truth.— (See Lond. Med. Gazette, Aug. 8, 1845, p. 20.)] ] 64. C. Of the Intermediate States of Vascular Action and Vital Power in Inflamed Parts.—As shown in the article Disease (§ 87, et seq.), the states of organic nervous influence and vascu- lar action do not always present specific grades or forms, which certain terms can precisely represent. The terms applied to morbid action are entirely relative ; and while we use the ap- pellations sthenic and asthenic, to convey an idea of the more extreme and opposite states of nervous power and of vascular action, we must not overlook that every intermediate form and grade may exist between them. To de- scribe states, so diversified as these are, is ob- viously impossible. All that can be attempted is to notice certain circumstances generally ap- pertaining to them. The organic nervous pow- er, evinced by certain inflammations, may not materially vary in kind from the natural stand- ard or condition, and yet vascular action may be excessive and very acute, or much more moderate, and, consequently, more protracted or slight, and more or less chronic. The forms of inflammation, particularly as respects the} 468 INFLAMMATION—Pathology. acute, chronic, and intermediate or sub-acute states, result chiefly from the grades of organic nervous excitement and vascular action ; while the more specific characters which they present depend principally upon the conditions of the organic nervous energy, as regards not only the amount of the excitement or depression, but especially the alterations or deflections in kind from the natural habitudes of this energy. While the activity of the inflammation depends chiefly upon the grade of vascular action in the inflamed part, in connexion with the degree of general vascular commotion, the specific char- acter of inflammation arises principally from the truly diseased impression made upon the or- ganic nervous tissue of the part, and from the change thereby effected in the influence of this tissue on the vascular system, such change be- ing in the kind, rather than in the degree of organic nervous influence. 165. The varieties of Erysipelas, the local inflammations attending the different exanthe- mata, and, indeed, the numerous specific forms of inflammatory action induced by these and other infections or animal poisons, are illustra- tions of alterations in the kind or mode, rather than in the degree of local and general organic nervous energy and vascular action. In these, and in all the asthenic states of inflammation, there is a much-more remarkable alteration in kind from the natural standard than in the sthenic forms. The intermediate states between the most fully expressed sthenic and asthenic conditions, depend chiefly upon specific or other deviations in kind—upon the truly morbid changes now contended for, especially such as immedi- ately proceed from the nature of the exciting causes, or from contagion. The principal of these, owing to their specific form, are fully dis- cussed under appropriate heads. 166. D. Of the Existence of different States of Capillary Tone and Circulation in the same In- flamed Part and the Vicinity.—Much of the dis- cussion which has taken place as to the capil- lary circulation in inflamed parts has been ow- ing to the variations in this state during the course of the disease, and to the different vital conditions of the capillaries and of the small arteries in different parts, or in the several tissues comprised in the seat of inflammation. When compound or parenchymatous structures are inflamed, such differences or variations are the most remarkable, particularly if the disease has commenced at a single point. At this point, especially, the tone of the capillaries be- comes the soonest exhausted, and the current of the blood retarded ; and these states increase the vital turgescence of the surrounding ves- sels, and accelerate the circulation through them. When the substance of an organ is in- flamed, the fibrinous lymph exuded at the point first affected often retards, by its pressure, the circulation in the vessels at this point; and ow- ing to this obstruction, the surrounding vessels are the more readily developed, and more prone to become morbidly turgescent. The lymph effused also affects the vitality of the part, either occasioning more or less irritation to the organic nervous tissue, or perpetuating or mod- ifying the disorder of this tissue already exist- ing, that caused its effusion. Muller thinks that the lymph coagulates in the extreme capil- laries when the inflammation is seated in the substance of an organ ; but I believe that it is exuded in the areola? of the structure, thereby rendering the part more solid or dense; the change thus produced having been termed con- densation, solidification, hepatization, or spleni- fication, according to the appearances assumed, and to the organ affected. It is only in the sthenic forms of inflammation that the effused fluid gives rise to these changes, as shown above, 167. If the intensity of the morbid action in the spot first affected be so great as to exhaust its organic nervous power, or its vitality, and to retard its circulation, or to stagnate the blood in the capillaries, not only do the sur- rounding vessels become more turgescent and developed, but the blood which has thus stag- nated, and the tissue itself, undergo very mate- rial changes, as described above ($ 156). Hence very opposite states of the circulation general- ly exist in different parts of the seat of inflam- mation, especially when the disease is advan- ced. In cases of injury, particularly of lacera- tion, pressure, or other changes, the capillary circulation is often directly obstructed; and either independently of lesion of the organic nervous tissue and sensibility, or aided by such lesion, diseased vascular turgescence is thereby developed around the seat of injury—the capil- laries thus obstructed, and the blood contained in them, soon undergoing changes productive of suppuration, or ulceration, or gangrene, while sthenic vascular action is either proceeding in the surrounding turgescent vessels, or passing into exhaustion or into the asthenic condition, progressively from the point of injury, or from the spot first affected, according as the consti- tutional powers may resist or may favour the extension of the mischief. 168. E. Of the State of the Venous Circulation in Inflamed Parts.—There is every reason to believe that the venous circulation is locally more than usually active in the sthenic and acute forms of inflammation ; but that it is more or less languid in the asthenic varieties. When the former, also, goes on to suppuration, and especially to ulceration, the circulation in the veins, more immediately proceeding from the part, is generally somewhat retarded, the re- tardation increasing these changes. Hence the importance of favouring the return of blood from the part by position when these conse- quences of inflammation have taken place. Whenever the venous circulation is obstructed, effusion and oedema increase rapidly in the part affected, and in its vicinity ; and the consequent retardation or stagnation of the blood in the capillaries induces or accelerates disorganiza- tion. This is observed very frequently in ery- sipelas, and constantly when the inflammatory action extends to the veins, which not infre- quently occurs when the constitutional powers are depressed, or in the more asthenic forms of the disease. In such cases the local lesions are remarkably increased, not only by the stasis of blood in the capillaries, but also by the more copious morbid effusion caused by the obstruct- ed return of blood. 169. Of the Function of Absorption in the Seat of Inflammation.—In the early stages of sthenic inflammation especially, absorption seems to be less than usually active ; but, when the disease proceeds to ulceration, or even to suppuration, INFLAMMATION—Reparai and when it assumes asthenic forms, then the absorbent action is often increased, although there are numerous exceptions to this, ab- sorption sometimes being manifestly impaired. When the absorbents become inflamed, owing to the morbid nature of the cause, or of the matter formed in the primary seat of disease, then more or less of obstruction results, and the function is arrested, great tumefaction of the parts beyond the obstruction taking place, and increasing the local mischief by pressure and by the contaminating influence of the mor- bid secretion. In obstructed venous circulation the swelling increases rapidly, chiefly from aug- mented effusion ; in impeded absorption it ad- vances with nearly equal rapidity from the fluid being undiminished by removal. In either case the effused fluid undergoes material changes during its retention, and becomes more and more hurtful to the tissues containing it, and more irritating to the vessels which may ab- sorb it. 170. It was supposed by John Hunter and others, that ulceration depends upon increased activity of the absorbents of the part, when in- flammation has reached a certain period of its progress. But I believe that it is chiefly owing to the superficial softening or loss of the vital cohesion at that part of the inflamed tissue where the extreme vessels have lost their func- tions, and to the solution of the molecules of the tissues in the fluid effused from the diseas- ed surface (§ 48). Absorption is probably also concerned in the process, and in various de- grees, according to the seat of the inflamma- tion, and the states of organic nervous or con- stitutional power, and of vascular action. 171. G. Of the States of the Blood in the Cap- illaries of Inflamed Parts.—The blood circula- ting in inflamed parts presents very different appearances with the form and stage of the dis- ease. In the sthenic forms, and particularly in the early stages, before any of the more unfa- vourable consequences have supervened, the blood is florid, and partakes much of the char- acters of arterial blood ; but in the asthenic forms, and less remarkably in the advanced stages of the sthenic, it is more venous, or of a darker hue. It is sometimes quite purplish, or blackish, particularly when a tendency to sphacelation or gangrene occurs. Also, as it circulates in the capillaries, the globules seem, under the microscope, gradually to move more slowly, and to be attracted by the sides of the vessel, or to stagnate in the capillary canals. This change seems to commence in the smaller or capillary veins, and to extend, especially in the asthenic states of inflammation, in the di- rection of the minute arteries, the temperature sinking with the deepening of the hue, and with the loss of motion of the blood globules. In other respects the blood presents the appear- ances already described with reference to the different forms of inflammation. (See v 25, 66). 172. iii. Of Reparation of the Consequen- ces of Inflammation.—Reparation of the ef- fects of inflammation is accomplished only un- der the influence of life, although much assisted by art. It may be very briefly considered with reference, 1st, to the removal of those changes more immediately resulting from inflammation that are independent of loss of substance ; and, 2d, to the restoration of disorganized or of lost noN of its Consequences. 469 parts, where either has taken place. Whether morbid depositions are to be removed or losses of substance are to be supplied, restoration of the manifestations of life in the various organs to their healthy states is the chief intention to be fulfilled. Frequently nothing more than the subsidence of the morbid action in the affected part is necessary to the reparation of the injury done ; but often something more is requisite, and tfie aids of science are needed to assist in the work of restoration. 173. a. The softening, or impaired vital cohe- sion of the inflamed part, the fluids effused in the areola? of the tissue, and the coagulated lymph thrown out upon a serous surface, or poured into the porous structure of an organ, so as to solidify it, will generally be removed, when the morbid action which caused these changes has altogether subsided. With the return of the functions of the part the vital co- hesion will be restored, and the activity of ab- sorption will gradually remove the fluids effused in the substance or upon the surface of an or- gan. If the lymph have become partially or- ganized, or have formed false membranes on serous tissues, or have agglutinated the oppo- sing surfaces of shut cavities, the difficulty of removal will be increased and the time of ef- fecting it prolonged. But if the inflammatory action be entirely subdued the object will be ultimately attained, and with a rapidity and certainty in proportion to the restoration of the powers of life throughout the frame. Even when the coagulated albumen is organized into false membranes, or into cellular adhesions, their extent and their vascularity will gradual- ly diminish, and they will either entirely and slowly disappear, or become merely lax bands, or thin films, offering little or no impediment to the functions of the parts which they con- nect. Yet, where such adhesions form, a dis- position to returning inflammation will gener- ally exist, or the morbid action which produced them will continue in a much slighter and chronic state. It is chiefly to these circum- stances that most of the unfavourable results consequent upon adhesions are owing. The lymph effused in the areola? of a parenchyma- tous viscus, as in hepatization or splenification of the lungs in pneumonia, is commonly soon removed with the subsidence of the disease, and much more rapidly and certainly than the lymph poured out upon a serous surface. The albuminous exudations sometimes formed on mucous membranes very rarely or never be- comes organized, but are detached and thrown off as the diseased action subsides by an in- creased secretion of mucus from the follicles underneath. In the course, however, of their excretion from the canals which those mem- branes cover they often occasion remarkable disturbance, severe spasms, or even death by asphyxia, especially when they form on the re- spiratory surfaces, as in croup, laryngitis, &c. 174. b. When the organic nervous and vital powers continue but little impaired, serous and albuminous fluids effused during inflammation are generally removed upon the subsidence of diseased action, although the rapidity and com- pleteness of removal will depend much upon the nature, consistence, and extent of the effu- sion, and the states of constitutional energy. If the fluid is truly purulent, and especially if Treatment of Sthenic. 470 INFLAMMATION—' it form an encysted or circumscribed abscess, restoration is then generally difficult, and only to be accomplished, particularly when the col- lection is deep-seated, either by absorption or by the extension of the abscess to an external or internal surface, as is fully shown in theart. Abscess (§ 30). When the fluid of an abscess is absorbed, nothing but a firm cicatrix, gener- ally linear, or irregular and circumscribed, is observed in its former seat. But when ft finds its way to a surface and is evacuated, either the patient sinks under the local lesion and dis- charge and the constitutional disturbance, or the work of reparation proceeds under the in- fluence of the vital energies. In this latter case the discharge from the surface of the ab- scess becomes albuminous, the parietes con- tract, and the cavity diminishes. Instead of pus an albumino-puriform fluid is secreted, which gradually becomes more and more al- buminous and scanty. The fluid exuded upon the internal surface of the abscess at last pass- es into the state of coagulable lymph, under the restoring influence of the organic nervous energy ; it becomes vascular, and healthy gran- ulations thus form, and fill up the cavity which the contraction of its parietes is incapable of obliterating, and thus the injury and loss of substance are repaired. 175. In the reparation of ulcerated parts a similar process takes place. The softening and solution of the molecules of the tissues in the fluid discharged from the ulcerated part are first arrested by restoring organic nervous energy, by local or constitutional means, or by both. Thereby a more healthy secretion takes place, and suppuration is established, and is followed by granulation in the manner just described, the mischief being thus repaired. Ulceration is most prone to occur, and to proceed rapidly in parts exposed directly or indirectly to the air, or to the contact of irritating matters; and in those which are most distant from the centre of the circulation, and in which the capillary circulation is naturally weak or slow. Hence it is of importance to the reparation of an ul- cerated part to protect it from those sources of irritation. When an ulcerated surface is extensive and the tone of its vessels much im- paired, the discharge is generally so copious as to detach from it all applications calculated to protect it from irritation, and is so injurious or contaminating as to increase the mischief if allowed to remain any time in contact with it. The first object in such cases is to restore the organic nervous energy and tonicity of the capillaries of the part, and thereby to diminish the quantity and to improve the quality of the discharge. The fluid subsequently exuded on the diseased surface will often of itself serve as a protection ; and applications which restore the tone of the extreme vessels and diminish or coagulate the discharge, while they farther protect the part, will then be of service, com- plete reparation taking place under the eschars, or scabs, sometimes thus formed. In this man- ner strong solutions of the nitrate of silver, or other stimulating and astringent substances, often act very beneficially on ulcerated surfa- ces, whether the discharge coagulate on them or riot. But this subject will be more appro- priately considered hereafter. 176. c. In cases of divided or injured parts, when the blood or the fibrinous lymph exuded from the capillaries coagulates so as to pro- tect them entirely from the air, and without allowing coagula or any other substance to re- main that may occasion irritation, the healing process often proceeds without any evidence of phlegmasia taking place. When divided parts are brought in contact, after the haemor- rhage from them has ceased, the lymph exuded from the opposing surfaces will first slightly- agglutinate, and afterward perfectly connect them, small capillary vessels penetrating and organizing the connecting medium, which will diminish more and more as. it becomes firmly organized. In this process, which has been called by surgeons "union by the first intention," inflammatory action can hardly be said to ex- ist. If it actually take place, very different phenomena present themselves. This process has, however, been described as a consequence of phlegmasia—probably owing to the circum- stance of inflammation actually taking place in some parts or other of the surfaces, the union of which is thus attempted, and which various causes prevent, from uniting, and chiefly by ex- citing inflammation in them. It is very rare that divided surfaces entirely unite without this disease being excited in some portion or other ; for incongruous parts or tissues are often brought together that are incapable of uniting directly. These must necessarily become in- flamed, and give rise to the usual consequences of phlegmasia. Moreover, the fluids and blood effused from the divided structures, and the ligatures placed upon the larger vessels, are sources of irritation, seldom failing of produ- cing inflammatory action, although the more congruous tissues may have perfectly united. In all such cases union has taken place in the uninflamed parts only.—(See the Local Treat- ment of Inflammation.) 177. VIII. Treatment. —The treatment of inflammation must necessarily be guided by a variety of circumstances and considerations. The chief of these refer, 1st, to the disease it- self; 2d, to the individual affected; and, 3d, to the nature of the exciting causes.—a. The character, form, progress, and consequences of the inflammation existing at the time of treat- ment should be carefully weighed, as these severally require very different, or even oppo- site indications and means. — b. The age, strength, temperament, diathesis, habit of body, modes of living, and occupations of the patient, ought also to be taken into consideration, and the treatment modified accordingly.—c. The exciting causes, the states of constitutional predisposition, and the predominating influen- ces to which the patient is subjected, should be ascertained as fully as possible, and the means of cure selected with strict reference to them. As the form and character of the inflammation depend chiefly upon the circumstances here al- luded to, I shall discuss the treatment which observation has shown me to be most appro- \ priate and successful in each of the principal forms under which I have described this im- portant class of diseases. 178. i. Treatment of Sthenic Inflamma- tions.—A. Acute Phlegmasia.—a. At an early stage of all sthenic inflammations, the indica- tions of cure are, 1st, to lower general and lo- cal vascular action; 2d, to equalize the circu- INFLAMMATION—Treatmeni lation, and to derive from the seat of disease. Several of the means which are employed to fulfil the first also often accomplish the second indication. 179. (a) In order to lower general and local ac- tion, numerous agents are usually prescribed, according to the peculiarities of the case. These operate either upon the system in gen- eral, and indirectly upon the part affected, or immediately upon the latter, and consecutively upon the former, according to their natures and the manner of employing them.—a. Of those which act in the first of these modes, blood-let- ting is one of the most important. It has been, however, very much abused ; and the cure of inflammations has too generally been attempted by it ehiefly, or even alone. There are numer- ous circumstances which either very remarka- bly limit or entirely contra-indicate the employ- ment of blood-letting, in those morbid condi- tions in general which have been all denomi- nated inflammation, although differing greatly from each other; and even in this the least equivocal form of the disease, there are many considerations which should weigh with the practitioner in limiting the amount of the de- pletion on the one hand, Or in inducing him to carry it far on the other. The extent to which it may be prescribed should be deter- mined by the age, strength, temperament, di- athesis, and habit of body of the patient; by the constitutional symptoms ; by the vital im- portance and structure of the part affected ; by the duration of the inflammation ; by the states of the pulse and of the blood first drawn ; by the effects produced by a former depletion ; and by the condition of the tongue, skin, and urine. 180. If the patient be young and robust, and well nourished—if the disease be very acute, or seated in a vital organ or serous surface— and if the constitutional affection be of a man- ifestly sthenic kind, the quantity of blood taken at first should be very considerable, and it ought to he taken in such a manner as to make a decided impression upon the circulating sys- tem as soon as possible—or in a large and full stream, so that the rapidity of the abstraction may assist the quantity in the effects produced upon the disease. As I have recommended in the article Blood {§ 64), the depletion should be effected while the patient is in a semi-erect or semi-recumbent posture, in order that the desired approach to syncope may be more cer- tainly produced, without, however, causing syn- cope, for the reasons fully explained in the ar- ticle just referred to. The first abstraction of blood ought to be instantly followed by the means about to be noticed ($ 196); but the cir- cumstances now stated as demanding a full or large depletion in the first instance, will require a repetition of it, generally to a less amount, but in strict reference to the local and consti- tutional symptoms, to the effects produced, to the time which has elapsed from the first blood- letting, and to the appearance of the blood then taken away. 181. The pulse, the blood, and the character of the pain in inflammations furnish many use- ful indications as to the institution, the repeti- tion, and the amount of depiction; but they may mislead most remarkably, if the numerous ex- ceptions they afford, and the circumstances in which these exceptions occur, be not taken into r of Sthenic—Blood-lettino. 471 account. In inflammations of vital organs, and particularly of the stomach, of the intestines, or of the substance of the brain or liver, the very intensity of the disease may produce so severe an effect upon the constitution—so vio- lent a shock to the vital powers—as to deprive the pulse of firmness or tone, and to cause, not only an oppressed, but also a weak, small, slow, or an irregular state of pulse. In such cases the practitioner must not be deterred from blood-letting by this circumstance ; for, after a few ounces of blood are abstracted, the pulse will become more full, strong, and regu- lar. In all inflammations, especially of vital parts, depletions should be performed with a most attentive regard to the phenomena while the blood is flowing; and in cases similar to those alluded to, the effects ought to be most assiduously watched. If the pulse rise in strength, and especially if it become hard, as well as developed or full, the blood-letting may even at first be carried so far as to make an impression upon the circulation, and to reduce the pulse again in strength and fulness. When the pulse is open and throbbing, or jerking, as generally observed after copious hemorrhages, blood-letting will rarely be of benefit, although it has not been already resorted to, and it may be most injurious. Where a moderate blood- letting produces sinking or syncope, without affording relief, it will be injurious to pursue the practice farther, if, indeed, it has not al- ready been prejudicial. 182. A hard, tense, or strong pulse not only requires a very copious depletion at first, but generally also a repetition of it. If a pulse which was too frequent and too full is reduced in these respects—or if a hard, constricted, or small pulse is softer and freer—or if a pulse hitherto slow and oppressed has become more natural—it may be concluded that the bleeding has been of service, and that it may be safely repeated to a less amount if the symptoms re- quire it. If, on the contrary, the pulse has be- come weak, hurried, compressible, open, jerk- ing, irregular, or intermittent, without produ- cing relief, the bleeding has already proved in- jurious, and a repetition of it would be produc- tive of danger. It may be taken as a general rule, that when the pulse is above 110 and compressible, whatever may be the organ in- flamed, the system will not bear general blood- letting, even in the first instance. The local abstraction of blood, however, with caution, may prove of service. 183. The appearances of the blood first ab- stracted have generally influenced the physi- cian more or less in prescribing a repetition of depletion ; but they ought to be considered in strict connexion with the other symptoms. The appearances most deserving of notice are, the firmness or looseness of the crassamen- tum ; the proportion it bears to the quantity of the serum ; and the presence or absence of buffiness, and cupping of its surface. In the article Blood ($ 96, 97), and in a previous sec- tion ($ 25), I have fully discussed the appear- ances of the blood indicative of sthenic inflam- mations. These should receive attention in practice ; but 1 may here remark, that although a cupped and buffed state of the crassamentum is evidence of an excited state of circulation, and very frequently attends inflammation, yet 472 INFLAMMATION—Treatment of Sthenic—Blood-letting. alone, or without the presence of other symp- toms indicating the propriety of blood-letting, it is no proof that this measure has been indi- cated, or that its repetition is requisite. When, however, the crassamentum is large, firm, or dense, and the buffy coat is considerable, thick, firm, and tenacious, the other signs of inflam- mation being present, depletion may be repeat- ed, and occasionally oftener than once. If the clot be loose, has a thin or an irregular edge, and especially if it be small relatively to the quantity of the serum, a repetition of depletion will be injurious. In all cases the appearance of the blood depends much upon the manner in which it is taken, especially upon the size of the orifice, the posture of the patient while the blood flows, and the shape and size of the ves- sel in which it is received. A buffy, cupped, and firm coagulum will form in a deep or nar- row vessel, particularly if the blood flow rapidly, while neither of these appearances will occur if it be received in a wide and shallow vessel. 184. The pain and other local symptoms ought also to guide the practitioner as to the extent to which depletion should be carried; but these should not be exclusively confided in, for the most violent pains, as shown above (§ 82), are generally independent of inflamma- tion, and are not abated by vascular depletions. Nor are all alterations of sensibility depending upon inflammations to be relieved by blood-let- ting ; for the most severe pains accompanying asthenic inflammations will very often not be even mitigated by it, although altered sensibly in the sthenic forms, now more especially un- der consideration, will generally be entirely re- moved by it, if it be actively and judiciously practised. As long as pain and tenderness on pressure continue, the pulse being firm, resist- ant, or constricted, and not very frequent, gen- eral blood-letting may be repeated, although some exceptions to this rule may present them- selves ; but in most of these local depletions may be employed. If the pain return after having disappeared, or if it become exaspera- ted, although blood-letting has been instituted, a repetition of the measure is necessary, unless the other symptoms obviously forbid it; for, in this latter case especially, the first depletion has only relieved the load which overwhelmed the sensibility of the organ, and a second, or even a third, is requisite to restore the circu- lation of the part to its healthy state. 185. The absence of pain ought to be no argu- ment against resorting to vascular depletion, if other symptoms indicate the propriety of it; for intense inflammation may exist in the pa- renchyma of an organ, particularly the brain. the liver, the lungs, or the kidneys, and even in mucous or serous membranes, without pain being complained of, or without sensibility be- ing farther disturbed than is indicated by a feel- ing of heat, or of oppression, or of weight. 186. The functions of the inflamed organ ought also to indicate the propriety of repeat- ing depletion. When they are restored, then the chief object is attained, and no farther loss of blood should be inflicted on the patient; but if they continue to be suspended or disordered, or if they are only partially restored or impro- ved, local depletions, at least, are required, es- pecially if due time have been allowed for the first bleeding to produce its effects. 187. The tongue furnishes important indica- tions as to the propriety of general or local blood-letting. When the papillae are distinct and erect, the tongue being white or loaded, and inclined to be dry, or its edges or point more or less red, vascular depletions are gen- erally necessary. When the fur on the tongue is erect and white, and the sides and point red, blood may be taken away, if no symptoms con- tra-indicate the practice. On the other hand, when the papilla? or the fur is flat, and the tongue very moist or watery on its superior surface ; when it is broad, flabby, fissured, or lobulated; when its edges are indented by or retain the impression of the teeth ; when it is pale, especially at its point or edges; when it is tremulous on being held out; and when it is covered by a thick, dark mucus or fur, bleed- ing is generally inadmissible. 188. When the cutaneous surface is hot and dry throughout, depletion will be of service; but if it be cold, clammy, and shrunk, or if it be covered by a hot, clammy perspiration, blood- letting will be inappropriate, as the chief ob- jects intended to be accomplished by bleeding are to lower general action and to produce re- laxation, and these are already attained. If the urine is bigh-coloured, scanty, and does not deposite a sediment, blood-letting may be prac- tised, if other symptoms do not contra-indicate it; but if the urine be pale, limpid, and copious, it will generally be injurious. 189. Besides these guides to the institution and repetition of vascular depletion, there are various others, appertaining to the organ affect- ed, &c, which should guide the physician ; but these do not come under consideration in this place. The age, constitution, and diathesis of the patient, and the other states of predisposi- tion, as well as the exciting causes, however, require some notice. The very young (infants) and the aged should be depleted with caution. Persons of a nervous or lymphatic temperament cannot bear so large losses of blood as those who are sanguine, irritable, or sanguineo-mel- ancholic. In the gouty and scrofulous, in the previously diseased, in the ill-nourished, in the very obese, and in persons of a relaxed fibre, or leucophlegmatic or cachectic habit of body, such losses are generally injurious. 190. The nature of the exciting causes, and the influences, mental and physical, operating on the patient during treatment, should greatly in- fluence the amount of vascular depletion. In- flammations consequent upon active excite- ment, or attending vital reaction, are most benefited by this measure, while those caused by septic, poisonous, infectious, or contamina- ting agents are generally aggravated by it. All the depressing affections of mind, an air load- ed with malaria or paludal exhalations, the foul air of hospitals, and the confined atmosphere of large towns, particularly in crowded dwell- ings, in low cellars, in close lanes or alleys, and in manufactories, frequently not only pre- vent, the good effects of bleeding from ensuing, but also render its institution or repetition in- jurious. 191. The prevailing epidemic constitution, or the general character presented by epidemic and other diseases, should always be kept in recollection, especially as respects the employ- ment of blood-letting. The inflammations which INFLAMMATION—Treatment occur in the puerperal states, erysipelas, and the inflammatory complications observed in the courses of exanthematous and continued fevers, vary remarkably in their particular characters, according to the prevailing constitution. At the period of change from one general consti- tution to another, it is very difficult at once to determine upon the admissibility of blood-let- ting, particularly as regards the diseases just named and others allied to them ; but close ob- servation of the morbid phenomena, and atten- tion to the circumstances and considerations now enumerated, will lead to a right determi- nation as to this practice. Generally speaking, also, it will be found that all inflammatory dis- eases attended by a free state of the secre- tions ; by copious fluid defluxions, particularly from the seat of disease ; by a moist or relaxed skin, or irregularity and weakness of pulse ; by physical and mental depression, and espe- cially by great despondency, unfavourable an- ticipations of the result, or indifference to ob- jects of former or natural endearment, will ei- ther not be relieved or will be aggravated by blood-letting. 192. R. Local depletions are often sufficient, in many forms, states, or stages of inflamma- tion, to accomplish the ends in view. The cir- cumstances requiring local in preference to gen- eral blood-letting are chiefly the following : 1st. The slighter states of inflammatory action ; 2d. Forms of the disease approaching to or partaking of the asthenic condition ; 3d. A stage of inflammation too far advanced to ad- mit of or to be benefited by general depletion ; 4th. When venesection has been carried so far as not to admit of its repetition, the disease being either unsubdued or only mitigated, and requiring to be aided by this means ; 5th. When it is desirable to derive from the seat of dis- ease, as well as to deplete moderately ; 6th. When it is wished to remove local congestion of the vessels, and to restore the sensibilities and functions of the affected part; and, 7th. When inflammations occur in debilitated, ner- vous, or delicate constitutions, and as compli- cations of febrile or other diseases. 193. The modes in which local depletion should be performed also require attention. When a considerable quantity of blood is to be abstracted, and it is desirable to effect a rapid derivation from the seat of disease, then cupping is to be preferred ; but when the quan- tity is to be small, and when the application of warm fomentations and poultices to the part subsequently is likely to be serviceable, then leeches are more appropriate. Where the mor- bid sensibility and situation of the parts pre- vent the having recourse to cupping, a large local depletion being requisite, then a great number of leeches should be applied. In such cases the fomentations and poultices used to promote the bleeding will act beneficially in soothing the altered sensibility, upon which much of the diseased action depends. When the part inflamed admits of the direct applica- tion of leeches, it is often doubtful whether they should be placed upon it or not; for in some constitutions the punctures of leeches are followed by much local and general irrita- tion, or even by erysipelatous inflammation ; and if a small number be employed, they only increase the local irritation and determination, 60 • of Sthenic—Blood-letting. 473 without unloading the vessels of the diseased part. In these cases, depletion by more or less numerous or deep scarifications is some- times more beneficial than by leeches, espe- cially if the vessels are much engorged. It should also be recollected that bleeding by leeches occasions much greater depression, relatively to the quantity of blood abstracted, than by any other mode, especially in nervous and susceptible persons ; and that in some con- stitutions and situations the bleeding from their bites is not readily arrested. When the vital tone and cohesion of the tissues are much weakened, as in febrile and malignant diseases, a fatal loss of blood may take place from them, if the bites be not watched for a considerable time after they are removed. In some cases, cupping over the bites of leeches is very advan- tageous in abstracting both a greater and more determinate quantity of blood, in preventing a prolonged and Weakening discharge from them, and in determining the circulation to the part to which they were applied. 194. In visceral or internal inflammation it has often been recommended to apply leeches over the seat of disease ; but, unless some ad- vantage be expected from the subsequent fo- mentation, no additional benefit will result from the selection of this situation; and, if an inti- mate vascular connexion exist between the part inflamed and that to which leeches are applied, the blood may be injuriously deter- mined thereby to the former place. When the phlegmasia is entirely visceral, the application of leeches to that part of the external surface which is over the seat of disease probably ef- fects as complete a derivation from it as when applied to any other situation ; while the sub- sequent fomentation tends to equalize the gen- eral circulation, and to determine to the sur- face of the body. 195. In conclusion, the propriety or impro- priety of repeating blood-letting in inflamma- tion, as well as of adopting it in the first in- stance, cannot be inferred from one symptom or consideration alone. The constitution, hab- it of body, and previous state of the patient, the condition of the various functions, the in- crease or decrease of the pain, and other mor- bid phenomena in the affected part, and the other circumstances stated above, should chief- ly influence our decision upon these important points of medical practice. 196. y. Calomel and opium, as so ably rec- ommended by Dr. Hamilton, should be pre- scribed in a full dose immediately after the first blood-letting, whenever the inflammation pre- sents an active or sthenic form. In acute phlegmasia of a vital or important organ, from ten to twenty grains of calomel, and from two to three of opium, and one grain of ipecacuan- ha, may be given at once. This combination will generally succeed in keeping down the general morbid action to that grade to which it had been brought by the depletion, and in preventing reaction from following thereupon. It will also relax the cutaneous surface, deter- mine to the skin, and thereby equalize the cir- culation. In some cases, smaller doses, espe- cially of the calomel, may be given, and re- peated every fourth, fifth, sixth, or eighth hour, according to the urgency of the case, until a decided effect is produced upon the disease. 474 INFLAMMATION—Treatment of Sthenic. In all sthenic inflammations the specific effect of mercury upon the tongue and gums is not readily produced ; but as soon as it begins to appear, the mercurial medicine should be re- linquished, or the dose of it reduced. It is chiefly in cachectic persons, and in the asthen- ic forms of inflammation, particularly when vascular action is languid or low, or when there is but little excitement, that mercurials, especially in large quantities, are injurious. When sthenic phlegmasia is seated in serous membranes, or extends to them, the decided use of mercury, in the combination just pre- scribed, or in others hereafter to be noticed, is most requisite, in order not only to aid in the resolution of the morbid action, but also to prevent effusion, or the exudation of coagula- ble lymph, and the several ill consequences shown to depend upon effusion in its various states. 197. When inflammation implicates serous, fibrous, or even parenchymatous parts, prep- arations of antimony, especially James's pow- der or tartar emetic, may be combined with the calomel and opium, particularly for phleg- masia of the serous membranes of the chest and of the brain, and for pneumonia, &c.; but when mucous surfaces are inflamed, especially the intestinal mucous surface, ipecacuanha is preferable, and it may be given in large doses, as two, three, or four, or six grains, in the form of pill, with a full dose of opium. In many ca- ses, also, camphor will be beneficially conjoined with calomel and opium ; but when it is to fol- low a large depletion, or when sthenic inflam- matory action is not fully subdued, it should be prescribed in small doses, so as to act as a re- frigerating diaphoretic. It is chiefly in asthen- ic inflammations that full or large doses of camphor are required. 198. The repetition of calomel and opium, with or without either of the other medicines just mentioned, as to frequency, or the inter- vals between the doses, as well as the quanti- ties of both, should entirely depend upon the intensity, the seat, and the other circumstan- ces of the disease. The largest doses already mentioned should not be frequently repeated, unless in the most urgent cases. In some in- stances it may even be sufficient to give them only after each depletion, or to prescribe also, in the intervals, smaller quantities, as may be required. In the less severe states of inflam- mation it will be preferable to prescribe much smaller doses, as from two to five or six grains of calomel, and a quarter or half a grain of opium every four, six, eight, or twelve hours, according to the peculiarities of the case, in combination with either of the other medi- cines already noticed. After depletion has been decidedly employed, these doses will gen- erally be sufficient, even in the more severe cases, and will often give complete relief, with- out affecting the mouth, their good effects being manifested chiefly on the general and local states of action, on the skin, and on other ex- creting organs. 199. 6. Purgatives.—Unless it be desired to produce a very speedy effect upon the system by calomel, or other mercurials given in the above combination, an occasional or even fre- quent recourse to purgative enemata will gen- erally be necessary, although purgatives taken by the mouth may not then be requisite. Pur- gatives, however, are among the most impor- tant remedies used in the treatment of inflam- mations, their good effects depending upon sev- eral circumstances: 1. They evacuate morbid secretions and fecal accumulations, which in- jure the organic functions, and depress or oth- erwise derange the powers of life, and which thereby favour the extension of the local affec- tion, and increase the constitutional disturb- ance. 2. They diminish vascular fulness, by increasing the intestinal exhalations and the secretions of collatitious organs, and thereby lower febrile action. 3. They determine the blood to the digestive mucous surface, and de- rive it from remote parts. Owing to this last circumstance, they should be given with due caution when the digestive tube, or even when the viscera associated with it are inflamed. They are more serviceable in some inflamma- tions than in others ; thus they are more effi- cacious in congestions and inflammations of the head than in similar affections of the ab- dominal and thoracic viscera. The selection of, and modes of administering purgatives, also, are matters of great importance, but are so intimately dependant upon the nature of in- dividual cases that no general rules can be stated as to these topics. The refrigerant pur- gatives are usually the most appropriate, as the sulphate of magnesia, and other neutral salts, either alone or with the infusion of sen- na ; the bitartrate of potash with jalap; the spirits of turpentine with castor oil ; calomel with the compound extract of colocynth, or with jalap, &c. One of the best modes of ad- ministering these medicines is to give them at first, or a few hours after a full dose of calomel or blue pill, in briskly cathartic doses, so as to clear out the bowels, and afterward to keep up a more gentle action by milder and cooling do- ses, or by suitable enemata, or by both. The operation, as well as the antiphlogistic effects of these, and of other purgatives that may be employed, will be promoted by adding to them the potassio-tartrate of antimony, or ipecacu- anha. 200. e. Mercurials.—Although calomel is one of the best purgatives that can be given in this class of diseases, yet it, as well as other prep- arations of mercury, is often required for its alterative effects chiefly, not only after blood- letting has been practised, and as above ad- vised (§ 196-8), but also where depletion should not be adopted. In some cases it is necessary to use every means, and even several simultane- ously, in order to arrest the usual course of the disease, particularly in inflammations of serous membranes, and of the larynx, trachea, iris, &c. ; and one of these means is the rapid pro- duction of the specific effects of mercury. These effects being produced, not only is the resolution of the local morbid action thereby favoured, but also effusion is diminished, and the disposition to form coagulable lymph is en- tirely prevented. Hence mercurials, employed with the view of affecting the system, are most useful for inflammations of parts which give rise to albuminous exudations, and are either of little service, or even prejudicial, when pre- scribed for inflammations of cellular or paren- chymatous structures, especially if these as- sume a diffusive, or spreading, or irritative INFLAMMATION—' form. In such cases, other means, hereafter to be noticed, will be found more beneficial; but in acute sthenic inflammations, neither mercury nor any other means should interfere with blood-letting. It may assist in subduing and in removing several of the effects of these diseases, but it should never wholly supersede vascular depletion in some form or other. In chronic inflammations, however, where altera- tions of structure have commenced, and where they are but little influenced by depletion, mer- cury is one of the most efficient means that can be prescribed for the prevention of farther effusion, or other change, and for promoting the absorption of whatever deposition may have already taken place. 201. f. Spirit of turpentine is hardly known as an antiphlogistic remedy ; and yet, from an experience during nearly thirty years of its ef- fects, both in sthenic and asthenic inflamma- tions, I believe that none is more deserving of confidence if appropriately and prudently pre- scribed. As I have long ago shown (Lond. Med. and Phys. Journ. for July and August, 1820), the operation of this medicine depends upon the dose, the frequency of the repetition, and the combinations of it with other reme- dies. Hence it may be made available in ev- ery form of inflammation. In the sthenic form it is remarkably serviceable after depletions have been duly practised, and it may be used both internally and externally—in draughts, or in enemata—in liniments, embrocations, or fo- mentations. In all inflammations tending to copious effusion, or to fibrinous exudation, after blood-letting has been resorted to, and more especially when it becomes doubtful whether general depletion should be prescribed, or re- peated, or not, this substance, in hands expe-, rienced in its operation, is a most valuable remedy. In these cases it should be given in quantity sufficient to act upon the bowels and kidneys—either one drachm twice or thrice daily, or from three to six drachms once a day, alone, or with castor oil. It may also be ad- ministered-once or twice a day in enemata in larger quantities. Where it is desired to pro- duce as rapid an impression as possible upon the malady, not only should the one mode of exhibition be made subsidiary to the other, but both should be aided by the external use of this substance, in the form of a warm embro- cation, fomentation, or epithem. In such ca- ses I have generally directed several folds of flannel, large in proportion to the extent and severity of the disease, to be wrung as dry as possible out of very hot water, to be instantly freely sprinkled with spirit of turpentine, and applied immediately over the affected organ; to be closely covered, when thus applied, by wash leather, or a dry cloth, to prevent evap- oration ; to be kept thus applied as long as possible, or as the patient may endure it, and to be renewed as circumstances may require. In less severe cases, or at the commencement of inflammation, I have found a single applica- tion of this fomentation instantly arrest the disease, without depletion or any other means beyond a purgative medicine having been em- ployed. In chronic inflammations, the lini- ments containing this substance, prescribed in the Appendix (F. 296-311), may be used either as such or as embrocations, or they may be ieatment of Sthenic. 475 applied over the affected organ, on the surface of warm flannel, in the way just described. 202. The spirit of turpentine, thus employed internally or externally, or both, need not pre- vent a recourse to calomel or other mercu- rials, but may be used, particularly in the more urgent cases, in conjunction with them, the former aiding the operation of the latter. Al- though one of the most efficacious means of arresting inflammation and its consequences, there is no remedy that requires more dis- crimination and experience of its action and effects than this. Much of the disappointment sometimes felt as to its operation has been en- tirely owing to the inappropriate use of it, and to injudicious modes of prescribing it. The practitioner who is well acquainted with its effects, in the various doses and modes of using it, will find it most effective in lowering general action when inordinately excited ; in controlling local disease ; in arresting the ef- fusion of morbid fluids consequent thereon, and in determining the momentum of the circula- tion to the intestinal canal, to the urinary or- gans, or to the cutaneous surface, according as either effect may be desired, and thereby in deriving from the seat of disease. 203. y. Refrigerants and Diaphoretics.—Of these, the former are generally used in aid of more active measures, with the view of redu- cing the increased temperature, which aggra- vates or perpetuates the local morbid action ; and the latter are prescribed with the intention of restoring or increasing the cutaneous func- tions, of thereby equalizing the circulation, and of removing a portion of the serous and excre- mentitious elements in the blood. In many cases, substances acting both as refrigerants and as diaphoretics are most appropriate, or those which exert the former action more read- ily produce the latter effect. Indeed, whenev- er vascular action is sthenically excited, the skin being hot and dry, it is necessary to lower the general action, and to give such substances as act in this manner, as the most certain means of procuring perspiration. In the major- ity of cases, after vascular depletion and other evacuations have been duly employed, the cool- ing diaphoretics are thus indicated; and, al- though more active means may be still requi- site, particularly those already described, yet these wfll generally be found useful when taken in the intervals, or as occasions may offer. The diaphoretics which will be found most ben- eficial are, the solution of the acetate of am- monia, camphor, spirit of nitric ether, and a solution, or the wine of the potassio-tartrate of antimony, which may be variously combined, according to the peculiarities of the case. 204. Warm, vapour, and medicated baths are among the most energetic diaphoretics; but much judgment is required in prescribing them ; for their effects will entirely depend upon the form, state, seat, and stage of the in- flammation against which they may be employ- ed. In acute sthenic inflammations, they should not be resorted to until vascular depletion has been duly employed and alvine evacuations freely procured. When, however, the stomach or bowels are inflamed, they may precede the use of means for the evacuation qf the latter. In chronic inflammations of the internal visce- ra, or of the joints, fibrous tissues, &c, vapour 476 INFLAMMATION—Treatment of Sthenic. baths, various fumigating baths, and particular-1 ly those with sulphur or camphor, warm baths, ] especially those containing the decoctions of emollient herbs, or weak alkaline solutions; aqueous vapour with the fumes of camphor, or this latter conveyed around the patient, may severally be brought most advantageously in aid of other appropriate means. 205. 1?. Diuretics are sometimes required in the treatment of inflammations, not merely on account of any derivation from the seat of dis- ease thereby procured, but with the view of re- ducing whatever serous plethora may exist; and of removing from the circulation, by in- creasing the action of the kidneys, those ulti- mate products of assimilation which are liable to accumulate in the blood to an injurious amount during the febrile state, and thereby to heighten the local affection. With this inten- tion, several of the more refrigerant diuretics may be advantageously employed, especially the spirits of nitric ether, the bitartrate of pot- ash, and the neutral salts in small doses. They may be taken either in the patient's usual drink, or conjoined with the other medicines required by the particular circumstances of the case. . 206. t. Narcotics are occasionally beneficial, especially when inflammation is attended by great pain and irritability, and in the sthenic forms after vascular depletions and alvine evac- uations have been duly practised. Opium and the salts of morphia are the narcotics most fre- quently prescribed, although hyoscyamus, bella- donna, &c., may likewise be employed in some circumstances. Opium was much recommend- ed for inflammation by medical writers during the seventeenth and eighteenth centuries, and frequently in combination with other medicines; but its use, or. rather, its abuse,was also great- ly condemned. There are few medicines which require greater discrimination than this, and particularly when given in this class of dis- eases ; for the propriety of having recourse to it will entirely depend upon the seat, stage, and form of the inflammation, upon the constitu- tional symptoms, upon the means previously employed, and upon the dose and combination in which it is prescribed. Dr. Armstrong ad- vised large doses of opium after blood-letting, in a paper published in 1824 in the " Transac- tions of the Associated Apothecaries," under the belief that the advantages derived from the combination of calomel and opium, recommend- ed by Dr. Hamilton, were entirely to be ascri- bed to the latter substance alone. In this, however, he was altogether mistaken ; for this single remedy is not nearly so beneficial as in combination with calomel and the other medi- cines mentioned above (§ 196-8). Nor, indeed, did the practice present any originality ; for it had been employed by numerous writers and practitioners long before he advocated it, even before the periods which I have, already assign- ed.* Besides other instances in which I had * [The treatment of inflammatory affections by large doses of opium, as recommended by Armstrong, was prac- tised somewhat extensively in this country long anterior to its introduction into England. The late Dr. Post, of New- York, was partial to the use of this remedy in many of the phlegmasia?, especially when attended with severe pain, and gave it in large doses, combined with mercurials, as far back as the year 1800. During the epidemic pneumonia, which prevailed in almost every section of the United States, in 1812-13-14, opium was given, by many practition- ers, in large quantities), combined with calomel or tart, ant., prescribed it with great benefit previously to this time, I attended a case of phrenitis in 1820, with Mr. Carroll, of Walworth, in which three grains of opium were given at one dose, after blood-letting had been carried sufficient- ly far. In slighter cases, after vascular deple- tion and the operation of a cathartic, a large dose of laudanum, or of solid opium, has mani- festly aided greatly in tranquillizing the nervous system, in reducing vascular action, and in pro- curing refreshing sleep, the patient awaking with a soft or moist skin, and with freedom from pain. Dr. Stokes has recently adduced evidence in favour of this practice, and shown that it is peculiarly beneficial in cases of recent inflammation of serous and mucous membranes, where blood-letting and other antiphlogistic remedies are inadmissible, and where the sys- tem is greatly depressed. In most instances, however, opium, or the salts of morphia will be more advantageously combined with calomel, as above advised (§ 196-198), or with ipecacu- anha, or with camphor, or with James's pow- der, or the other preparations of antimony. Where pain is so excessive as to constitute the most prominent symptom, it is a most im- portant remedy. When great exhaustion follows blood-letting, owing to its having been carried too far, or improperly resorted to, opium and camphor conjoined are most valuable medi- cines ; and in the asthenic forms of inflamma- tion, especially, should never be overlooked, particularly in conjunction with other means. The salts of morphia in similar combinations will be found equally beneficial. 207. The other narcotics, as hyoscyamus, co- nium, stramonium, belladonna, &c, are less use- ful in inflammations, and not so generally ap- propriate as opium ; and yet instances often occur, in which a large dose of some one of these, according to the features of the case, may be preferred ; and, after blood-letting and alvine evacuations have been duly practised, and in the combinations already mentioned (§ 196-8), will be found frequently of service. The chief recommendations in favour of these are, the circumstances of their not interrupting or suppressing the functions of secretion and excretion, and of their relaxing spasm of cir- cular fibres and canals, as well as allaying irri- tation. It should, however, be admitted that, when opium is prescribed in large doses, it does not interrupt secretion or constipate the bow- els so remarkably as when given in smaller quantities ; and that, these effects are then fre- quently even not observed. 208. k. Sedatives.—Of these, colchicum is the most active ; and, in certain kinds of inflamma- tion especially, as the rheumatic and gouty, the most serviceable, when prudently prescribed. In the sthenic forms, also, of phlegmasia, it may often be advantageously brought in aid of other means. When it is desired to promote the se- creting functions of the kidneys, and thereby to eliminate from the blood urea and its combi- nations, or other materials which would in- crease the local and general affection, if allow- and often with good effects. It has also been used in a similar way in the treatment of acute rheumatism, gastritis, and inflammatory affections of the intestinal canal, espe- cially dysentery, general anti- phlogistic agent remain to be confirmed by farther experi- ments.] been freely procured, or when the disease be- comes chronic or complicated. 217. The abstraction of all causes of irritation, as well as of the exciting causes of the disease, is obviously requisite in the treatment of in- flammation. The excitement of the senses, es- pecially of the organs of sight and hearing, and of the mental faculties, should be carefully guarded against. Muscular action, and stimu- lation of the stomach by heating food and bev- erages, ought also to be prevented, the anti- phlogistic regimen being strictly enforced in all its parts. 218. X. Derivatives and counter-irritants.— These should never be employed until the gen- eral vascular excitement is subdued by blood- letting and other evacuations, and until a pow- erful impression has been made upon the local affection. These ends being attained, the mode of derivation or counter-irritation should next be considered. This should depend upon the seat, form, and duration of the inflammation, and the consequences to which it may already have given rise. In acute cases, and at early stages of the disease, the hot turpentine epithem, or application, already described (§ 201), is the most efficacious, the safest, and the most im- mediate in its effects. It should always be ap- plied over the inflamed organ, or as near it as possible. It is applicable to all forms of in- flammation, in whatever organ they may be seated. It tends, more than any other deriva- tive, to determine the circulation to the cuta- neous surface, and to prevent the more dan- gerous consequences of the disease. 219. Sinapisms are extremely serviceable, and produce their effects rapidly, but they are less efficacious than the turpentine epithem. The application of the strong solution of ammo- nia, with tincture of camphor and spirit of rosemary, as advised by Dr. Granville, is also of use, and especially in weak, irritable, or ner- vous persons, and when inflammatory irritation is attended by much pain. It produces a very rap- id effect, and either a superficial and slight, or a more severe and caustic action, according to the duration of the application. The liniment employed as a counter-irritant by the notorious empiric, St. John Long, was recently analyzed by Dr. Macreioht, who found it to consist of oil of turpentine and acetic acid, held in sus- pension by yolk of egg. Having prepared a liniment consisting of one ounce and a half of oil of turpentine, of one ounce of strong acetic acid, three ounces of water, and the yolk of one egg, the last three being rubbed together, and the first being afterward added, Dr. Macreight found it, in its sensible properties and effects, to be identical with the empirical medicine. That a liniment consisting of these ingredients should prove of essential service in many cases, can- not be doubted. For upward of twenty years, and for several years before this fashionable empiric appeared, I had frequent recourse to a liniment, consisting of equal parts of the com- pound camphor liniment and the compound tur- pentine liniment, with a little cajeput oil as a counter-irritant, varying it, however, according to the peculiarities of the case, and as pre- scribed in various parts of this work, and in the Appendix (see F. 296-311). When this liniment, or any of the others just referred to, is applied on the surface of warm flannel, or of INFLAMMATION—1 a cloth wrung out of hot water, over the sit- uation of internal or deep-seated inflamma- tions, it produces an almost immediate effect. But friction during ten or fifteen minutes with the cold liniment will give rise to erubescence, sometimes to exudation, and more or less de- cided relief. In acute cases, the former mode of application may be adopted ; but in chronic or sub-acute inflammation, particularly when alteration of structure has taken place, repeat-. ed frictions with this liniment, short of infla- ming the skin, are often to be preferred. When the irritation produced by it gives rise to vesi- cation or abrasion of the cuticle, the parts soon heal; but it is frequently of service to continue this effect for some time by the re- peated or prolonged use of the application. 220. Blisters may be employed as counter-ir- ritants in three modes : 1st, as rubefacients ; 2d, as simple and slight irritants; and, 3d, to procure a puriform secretion from the part. In acute inflammations they ought not to be pre- scribed until blood-letting has been carried as far as circumstances will permit; and in early periods of the disease they should not be ap- plied longer than seven or eight hours, and a warm bread and water poultice should be placed over the part to promote the vesication, and to prevent the irritation sometimes consequent on them. It will occasionally be advisable to place tissue paper between the blister and the surface. On children, blisters ought not to be applied longer than from three to six hours, and warm poultices should generally replace them, and be renewed frequently. For sub- acute and chronic inflammations, or for the advanced stages of the acute, blisters may be prescribed for a longer period, and sometimes with the intention of procuring a sero-puriform discharge from the blistered surface. 221. Warm pediluvia, the hip bath, and the semicupium are often useful modes of deriva- tion when the head or the thoracic viscera are affected, or when it is desirable to excite the uterine discharge. Their effect will generally be promoted by the addition of mustard and of common salt to the water. But in acute in- flammations the temperature should not be too high, or such as may heighten the general vascular action; they also ought not to be re- sorted to until depletion and alvine evacua- tions have been duly practised. Besides these, there are other substances sometimes used to produce counter-irritation and derivation, as croton oil, the powder or tincture of capsicum, bruised garlic, and scraped horseradish. They quickly produce a rubefacient action, when ap- plied on the skin, but are not so efficient in the severer cases of acute inflammation as those previously noticed; they are all, how- ever, often of service, particularly in the slight- er forms of the dieases that are attended by acute pain. Besides these, cupping with scari- fication, and dry cupping, are serviceable modes of derivation in the sthenic forms of phleg- masia. 222. The foregoing modes of counter-irrita- tion are most serviceable in recent, acute, or sub-acute inflammations. Those which are about to be noticed act chiefly as suppurants, and are most suited to the chronic states, or to the more advanced stages, or rather to certain of the consequences of the acute and sub-acute reatment of Sthenic. 479 forms of inflammation. They consist chiefly of ointments or plasters containing the potassio- tartrate of antimony, or cantharides, or savine ; the decorticated bark of the mezereon root, moist- ened in water or vinegar, and applied to a small portion of the cutaneous surface ; croton oil, either alone or suspended in twice the quan- tity of camphor or soap liniment or olive oil; issues and setons of various forms and kinds ; moxas, and the actual and potential cauteries. The exact circumstances requiring either of these means in preference to others are so nu- merous—the choice of them depending so en- tirely upon the seat, peculiarities, and stages of the disease, upon the constitution and diath- esis of the patient, and upon the other reme- dies employed—that no general rules can be stated for the guidance of the inexperienced in this respect; the powers of observation, expe- rience, and views of the practitioner must be his chief guide in the adoption of these as well as of many other means of cure. 223. It has been very justly remarked by my early friend and former colleague, Dr. Dungli- son, in his very judicious observations upon the use of revellents in the phlegmasie (see his excellent work, entitled General Therapeu- tics, or Principles of Medical Practice, &.C., 8vo. Philad., 1836, p. 363), that when we are desi- rous of maintaining a succession of revulsions, or a constant revulsion, we employ either re- peated blisters, or keep the blistered surface discharging by applying some of the other means just mentioned. Tartarized antimonial ointment is well adapted for chronic inflamma- tions, as of the lungs, because, while the pus- tules, induced in any one part of the exterior of the thorax, or elsewhere, are going through the stages of increment and maturation, a fresh crop may be elicited on some other part of the chest, and thus a succession of irrita- tions can be developed which is more beneficial than one that is more permanent. 224. It is of importance to determine the extent of surface to be affected by a revulsive application. This is not always so easy a mat- ter as may be supposed; for, if the vital con- ditions be affected by it in a very limited ex- tent of surface, the morbid action, intended to be remedied, may be entirely uninfluenced by it; and, on the other hand, if a very large sur- face be irritated, constitutional disturbance will be thereby excited ; or that depending upon the primary disorder, as well as the dis- order itself, will be aggravated or perpetuated. As to the time during which the counter-irri- tation should be maintained, but little can be stated, for it must depend almost entirely upon the circumstances of the case. On this topic, Dr. Dunglison remarks, that it is chiefly when the diseased action has been prolonged for a considerable period, and in affections of a neu- ralgic kind, that sudden and violent revulsions are productive of the most marked advantage. In the different phlegmasie, revulsions which implicate a greater extent of surface, and are more prolonged in their action, are decidedly preferable. In the former cases, moxas and the cauteries may be employed ; in the latter, rubefacients and vesicants. 225. The permanence or remittence of the counter-irritation deserves consideration in every case for which this means is prescribed. 480 INFLAMMATION—Treatment of Sthenic. In most of the phlegmasie, remittent revul- sion is more serviceable than a prolonged or permanent revulsion. Dr. Dunglison justly observes, that when an artificial irritation, ac- companied or unaccompanied with increased secretion from the part, has been established for some time, it ceases, in a great measure, to be a morbid condition, and cannot be ar- rested without an inconvenience or risk to some organ predisposed to disease; but if a succession of irritations be produced, the sys- tem never becomes habituated to them, and the repetition of the irritation, after a short period, is as beneficial as at first. A succession of vesicants, therefore, is to be preferred to a more permanent application, setons and issues losing much of their beneficial influence in the latter periods of their employment. 266. Broussais and many of his followers have contended that revulsive irritations should be stronger than the morbid action they are in- tended to replace, otherwise they tend to in- crease the latter; but although it is manifestly necessary to reduce the inflammation as much as possible by depletions, before counter-irri- tants are prescribed, yet great good will result from the judicious use of them. There are, also, several that may be very safely employed early in some of the phlegmasie, and even be- fore depletions have been practised, as the tur- pentine epithem, liniments, &c. (§ 201,219). I therefore agree with Dr. Dunglison in believ- ing that good will be derived from revulsions in appropriate cases, even'Should they fall short of the precise degree necessary for completely putting an end to the disease for which they were prescribed. 227. The situation to which revulsants or counter-irritants should be applied, relatively to the seat of inflammation, is deserving of atten- tion, especially as a contrariety of opinion ex- ists on the subject. And yet the very terms here used ought to guide the practitioner to the application of them to parts which are not sup- plied with tranches of the same nerves and blood-vessels as proceed to the seat of disease. Much, however, should depend upon the nature of the adopted revulsant; for the turpentine epithem or embrocation will never be injurious, but generally beneficial, however close it may be applied to the inflamed organ. But it is dif- ferent with blisters and other counter-irritants. I cannot agree with Dr. Thomson's and Dr. Chapman's recommendation to place these "as near as possible to the affected part." I have often seen mischief result from the early appli- cation of a blister to the scalp in meningitis and encephalitis, and to the throat in laryngitis and tracheitis. When, however, the inflammation is of an asthenic or adynamic kind, or when the sthenic form has given rise to effusion, blisters, as well as several other counter-irritants, may generally be applied close to the diseased or- gan. Yet, even in these circumstances, excep- tions to the rule are not few. The choice of situation must, therefore, depend upon the seat and character of the phlegmasia and other pe- culiarities of the case ; precise directions re- specting it can be given only when discussing the treatment of particular inflammations. In all cases the choice should be guided, as M. Begin remarks, by sound physiological princi- ples ; for they only can render this mode of practice more certain than it has hitherto been, and prevent the inconveniences which often follow it. 228. It has been already stated that blood- letting, both general and local, may be so insti- tuted, in several of the phlegmasie, as to de- rive from the seat of disease. The older wri- ters paid much attention to this method of de- pleting. Bleeding from the saphena vein, the feet and legs being immersed in warm water, was often prescribed for phlegmasie of the vis- cera, and particularly when consequent upon suppressed evacuations ; and bleeding from the vicinity of the anus by leeches is generally adopted by foreign physicians for inflammations of the liver, stomach, &c. Indeed, to derive the impetus of the circulation from the seat of the phlegmasia by vascular depletion, by ca- thartics or other evacuations, and by counter- irritants or other revellents, both internal and external, must always be a principal indication of cure in this class of diseases. 229. p. Of applications to the inflamed part it- self, there are some that require a particular notice. They may be all comprised and con- sidered under the following modes of operation: 1st. Those which reduce the temperature, and thereby remove one cause of morbid irritation and of vascular expansion. 2d. Those which soothe the morbid sensibility or diminish pain, either by their influence upon the affected nerves, or by diminishing the tension, rigidity, or pressure of parts. 3d. Those which con- stringe the expanded capillaries, restore their lost tone, and prevent the stagnation of the blood or promote the circulation in them ; and, 4th. Those which protect the part from exter- nal irritants, &c. It is obvious that many lo- cal applications produce benefit by acting in more than one of these modes ; but still they may be referred to one or other of these espe- cially. Moreover, many internal means of cure act upon the part affected, particularly in vis- ceral phlegmasia, in one or other of these ways. As topical means are applicable chiefly to exter- nal inflammations, which are generally viewed as belonging to the province of the surgeon, my remarks respecting them will be as brief as the importance of the subject will permit; yet it must not be overlooked, that most external inflammations, particularly when spontaneous, are merely symptomatic of constitutional dis- order—are only the external manifestations of visceral or general disturbance, or of hereditary vice ; that they all react upon the frame through the medium of the organic nervous and vascu- lar systems ; and,, consequently, that, while lo- cal remedies form only a part of the treatment required, the rest being employed with refer- ence to the internal and constitutional affec- tions, the entire treatment, even in the exter- nal phlegmasie, is more strictly medical than surgical, if, indeed, the distinction should be at all entertained. 230. (a) Of those applications which directly re- duce the temperature some notice has already been taken ($ 214). They have generally the effect, not only of removing a principal cause of excitement and irritation, but also of con- stricting the morbidly expanded vessels. Cold applications are, however, often injurious, and consequently inappropriate or hazardous, when- ever the external inflammation is merely the INFLAMMATION—Treatment of Sthenic. 481 outward expression of internal or constitutional disorder, as in gout and erysipelas; they are less so, however, in sthenic than in asthenic or spe- cific inflammations; for in the sthenic phleg- masie the vital energies are capable of resist- ing their sedative influence, and the suppression of the local affection rarely endangers internal viscera. But in the other kinds of inflamma- tion the repulsion of the external affection oft- en caused by these applications is frequently followed by serious internal disease. In such cases, the source of mischief is in the frame, and in some important or vital organ ; and when the effects are prevented from appearing externally, they often break out in some inter- nal viscus. 231. Of the numerous cold applications, there are few which are preferable to the solution of the di-acelate of lead, inasmuch as it combines astringent with cooling and sedative proper- ties. But this, as well as the common cooling or evaporating lotions, and cold or tepid water- dressings, should be suited to the intensity of the inflammations, and be used unremittingly until the local affection is subdued ; for if em- ployed only at intervals, or if at all intermitted, reaction will take place in the inflamed part, and the disease will be thereby aggravated, or, at least, perpetuated. We observe this in the treatment of scalds by cold applications, when used in this latter mode. When the inflamma- tion is of a specific or asthenic kind, and when it is attended by great tumefaction and excess- ive pain, or when cold applications do not give relief to the pain in a short time, they ought either not to be employed at all, or not to be continued, but give place to very different means. Also, when they produce general chil- liness, they ought not to be persisted in. 232. (b) Applications which soothe the morbid sensibility are, perhaps, more generally appropri- ate, and are certainly less dangerous in the symptomatic or specific phlegmasie just allu- ded to, than those which are cold. They all more or less diminish the tension of rigid and unyielding tissues, lessen pressure on sensitive parts, and have an emollient and soothing ef- fect. Moist warmth, employed in various ways, but especially in the form of steam, simple and. medicated, and of fomentations, poultices, and warm baths, also either simple or medicated, &c, is the principal agent by which the physi- cian or surgeon produces these effects. Steam, or warm aqueous vapour, has lately come into notice in the treatment of inflammations ; and we are indebted to Dr. Macartney and Dr. Wilson for a knowledge of its virtues in re- spect of its topical external use; for as re- gards its internal employment by inhalation in affections of the respiratory organs, it has been long prescribed. (See Asthma, and Bronchi— Inflammations of.) In the form of the vapour bath it has also been generally used, particu- larly in circumstances already noticed (§ 204). By very simple, yet suitable appliances, steam, either of water alone, or of water containing various narcotic or emollient herbs or extracts, or camphor, or acetous or tcrebinthinate substances, may be brought in contact with, or entirely sur- round the seat of inflammation. It may like- wise be inhaled into the lungs for the affections referred to, either in its simple or medicated states. When employed externally, and par- 61 ticularly to a limited extent of surface, it should be continued for a very considerable time, and at a somewhat higher temperature than when inhaled. The substances, also, whose fumes are conveyed in the vapour or steam, may be used in much greater quantity when applied thus externally and locally than when prescri- bed internally. Fomentations and poultices con- taining emollient, narcotic, or other medicines, are also efficacious, not merely by the moist warmth they afford, but, in great measure, by the impression made upon the nervous tissue by the particular medicinal substances they contain. The same remarks apply to medica- ted warm baths. 233. It is principally for inflammations at- tended by excessive pain, by much constitu- tional irritability, by a very frequent and irrita- ble pulse, and depressed vital powers, that the warm and soothing applications now mentioned are required. Hence they are generally appro- priate in the specific and asthenic inflamma- tions, and in them especially afford very great relief, particularly when brought in aid of judi- cious internal treatment and suitable regimen, and employed early in the disease. 234. (c) Applications which constringe the expanded capillaries, restore their lost tone, and prevent the stagnation of the blood, or pro- mote the circulation in them, are suitable to certain states of the advanced stages, and to some of the consequences of sthenic inflam- mation. They are also appropriate to most of the specific and asthenic phlegmasie from their commencement. When the former proceeds to ulceration, and especially if this assume a spreading or phagedenic form, the more ener- getic astringents, as the various turpentines and balsams; certain metallic salts, particularly solu- tions of the sulphates of zinc, of copper, iron, &c, of the nitrate of silver, and of the acetates of lead, zinc, &c. ; the dilute mineral acids; solutions of the chlorinated soda, of the chloride of lime, and of the chlorate of potash; various vegetable astringents and tonics; creasote, cam- phor, the vegetable acids, &c., are severally ben- eficial in such circumstances, when suitably- prescribed, and combined with other appropri- ate means—in some instances, with narcotics, and in others with mucilaginous or albuminous substances—occasionally in aqueous vehicles, and sometimes in unguents, cerates, &c. It is chiefly, however, when the states or conse- quences of inflammation just noticed are exter- nal, or near the surface, or within reach, that applications containing any of these are found useful; yet even when seated in internal sur- faces, as in the intestinal and respiratory, they are occasionally beneficial, employed either in the form of draught, pill, and enema, or by means of the inhalation of aqueous vapour par- tially charged with the fumes of some of them, Although it is chiefly for the advanced stages or consequences of asthenic inflammation that astringent substances are required, yet the ear- ly and acute stages are also sometimes bene- fited by them, however stimulating or irritating they may seem to be. Thus, in scalds, and in certain states of burns, the application of a cloth wetted with spirits of turpentine will gen- erally not merely afford relief, but hasten reso- lution of the inflammatory action. In such ca- ses it may be truly said, with Shakspeare, that, fREATMENT OF ASTHENIC 482 INFLAMMATION—1 " One fire burns out another's burning." 235. (d) Substances which protect the infla- med surface from the irritating influence of the air, and of the exhalations floating in it, are extremely beneficial in all cases in which the part is abraded or its continuity injured. They are, however, less useful when they prevent the morbid secretion of the inflamed part from being discharged. In most cases, therefore, they should be so employed as to prevent any accumulation of this secretion from taking place, whereby the surrounding tissues might be contaminated. Most of these substances are advantageously made the vehicles of astrin- gent or detergent medicines, thereby diminish- ing the discharge by constringing the extreme vessels, as well as excluding a chief cause of irritation, and of the consequent morbid secre- tion. The principal advantage derived from plasters, cerates, ointments, &c, is owing to the exclusion of the air by them from the abrad- ed or divided surface. In many cases of inju- ry, the fibrinous lymph exuded from the ex- treme vessels, by coagulating over them, pro- tects them from irritation ; and were this nat- ural protection more frequently allowed to re- main, and confided in, inflammation would less frequently supervene on these cases than it otherwise does. The albuminous exudations formed on superficial ulcerations and inflam- mations of exposed surfaces protect them in a similar manner, and dispose them more readily to heal; and if the inflammatory action should at any time be exasperated, so as to give rise to an increase of the morbid secretion or to the production of pus underneath the protection thus formed, the mischief will often soon sub- side and the secretion become absorbed, the parts healing under the scabs, or dried lymph or albumen covering them. Superficial sores, when protected by the white of egg, often heal underneath; and dressings with this substance, by entirely excluding the air, are often more serviceable in preventing inflammation after incised wounds and in promoting union than any other. Strong solutions of the nitrate of silver,* or of sulphate of copper, or sulphate of zinc, or other astringents, applied to ulcerating surfaces, not only excite the organic nervous tissue, and constringe and give tone to the ex- hausted extreme vessels, but they likewise co- agulate the albuminous portion of the secretion, and thereby protect the part against the irrita- ting influence of the air. They also change the morbid secretion, causing it to assume a more healthy character. Substances which either simply protect a raw inflamed surface, or act in the more complex manner just mentioned, * [The nitrate of silver deserves particular mention as a local antiphlogistic application, especially in the erysipela- tous forms of inflammation, and the different species of cy- nanche. Applied in substance, or saturated solution, to the sound skin bordering the inflamed part in erysipelas, it speedily checks the extension of the disease, and in the in- flammatory affection of the throat which complicates scar- let fever, there is no local remedy which exerts an effect so speedy and decidedly beneficial as this. In chronic la- ryngitis and bronchitis, unconnected with tubercular dis- ease of the lungs, an application of a solution of the nitrate to the larynx (40 or 50 grains to the ounce), after the manner recommended by Trousseau and Belloo, will often effect an alleviation, if not an entire removal of the disease.—(See New-York Journal of Med. and the Collateral Sciences, vol. v., 1844.) There is scarcely any form of local inflammation in which this article will not prove a useful topical remedy.] are especially serviceable in cases exposed to the influence of impure air, whether the impu- rity proceeds from terrestrial exhalations or from animal emanations, as in the wards of a hospital, or in close, low, or crowded habita- tions. 236. ii. Treatment of Asthenic Inflamma- tion.—When phlegmasia presents the asthenic form, the treatment should be very different from that recommended above. The states of organic nervous power and of vascular action differ from those attending the sthenic condi- tions ; and as the differences are great, so should the indications of cure, and the means employed to accomplish them, be different. As all the modifications of asthenia depend chiefly upon two classes of circumstances—upon de- pressed conditions of the constitution, and weakened functions of the viscera concerned in assimilation and excretion, and upon the sed- ative, poisonous, or septic nature of the exci- ting causes—so all the indications of cure ought to be determined, and the remedies selected with strict reference to these circumstances. If the local phlegmasia is associated with, or consequent upon general asthenia or debility, vital power must be augmented by suitable means, otherwise the local disease will more readily terminate unfavourably, especially if it exist in much intensity. If, in addition to general or constitutional adynamia or asthe- nia, there be impaired excretion, and conse- quently accumulation of effete elements in the blood, or deterioration of it, not only must vital energy be supported or roused, but also the ex- creting or eliminating functions must be exci- ted, and means employed which may correct or change the morbid tendency or conditions of the blood ; for if these ends are not attained, the structural lesions which the inflammation rapidly induces, instead of being arrested, or terminating in spontaneous resolution, would be rapidly accelerated, and themselves become the source of farther local disorganization, and of constitutional contamination. 237. Asthenic inflammations, whether de- pending upon original, acquired, or accidental states of the frame, and of the vital organs, or proceeding from specific causes, require a treat- ment directed more strictly to the conditions of vital power and function—to the constitu- tional affection and the existing visceral disor- der—than to the local disease ; and they, more- over, require this kind of treatment much more than the forms of phlegmasia already consider- ed. In the latter, the eonstitution and the vital organs have generally been either unimpaired or not materially affected, before the local dis- ease originated and drew them within the circle of its sympathies ; in the former, either the constitution, or some important viscus, or both, have been seriously deranged before the in- flammation appeared; this latter being either the consequence of, or an accidental contin- gency upon such derangement, and depend- ing upon it in its subsidence as well as in its appearance. Even when the asthenic forms of inflammation more especially proceed from specific or septic causes, still very much of their local characters and of their constitutional ef- fects depend upon pre-existing states of vital energy and of the assimilating and excreting functions. To these, in their antecedent as INFLAMMATION—Treatment of Asthenic. 483 Well as in their existing conditions, the atten- tion of both physician and surgeon ought to be mainly directed ; and neither the one nor the other will discharge his duties if he does not connect the forms and changes of the local af- fection with the constitutional disorder and the visceral derangements, and treat each of them with strict reference to the rest. 238. Although indications of cure should not be followed in succession, nor acted upon indi- vidually, and without regard to their joint oper- ation—although attempts at accomplishing one intention, without endeavouring to attain oth- ers at the same time, should not be made in as- thenic any more than in sthenic inflammations —yet it will be necessary to have just ideas as to the principal objects to be attained, in or- der to arrive at a successful issue, and as to the importance and applicability of them sev- erally in the treatment of each particular case. These objects or intentions should be entirely based upon the characters assumed by the con- stitutional commotion, by the visceral disorder, and by the inflammation—the seat and cause of the phlegmasia, and the circumstances im- mediately connected with the patient, being also taken into account. Upon these, the ac- tivity with which each indication of cure should be pursued, and the importance assigned to one or more of them, should chiefly depend. Influ- enced by these considerations, and by the phe- nomena and progress of asthenic phlegmasie, the physician, in their treatment, will pro- pose to himself: 1st. To promote organic ner- vous power, and thereby to enable the constitu- tion to resist the progress of the local disease ; 2dly. To preserve or to restore the healthy state of the circulating fluids, and the crasis of the blood, by promoting the excreting or depura- ting functions, and by other appropriate means ; and, 3dly. To assuage the urgent symptoms re- ferrible either to the local malady, or to the constitutional affection. The means which most efficiently fulfil the first of these intentions will generally also promote the attainment of the second and third ; and whatever has the effect of accomplishing the second will also most materially advance the other indications. 239. A. The constitution will generally be en- abled to resist the local progress of the malady, by whatever increases the tone or energy of the organic nervous system, through the medium either of the digestive canal, or of the respira- tory organs—by means of appropriate tonics and stimulants, and by a dry, pure, and tem- perate air, duly renewed. AH asthenic inflam- mations have a tendency to spread or to extend themselves with a greater or less rapidity, and to terminate unfavourably; the changes that successively arise tending to gradual disorgan- ization, or to more immediate sphacelation. Unless under the influence of agents which rally the constitutional powers, they seldom or never show a disposition to spontaneous resolution, as often observed in sthenic phlegmasia. The only exceptions to this rule are met with in those asthenic inflammations which constitute a part of specific constitutional maladies ; and these are mere symptoms, or parts only, of these maladies, and are generally co-ordinate with, and dependent upon them in their rise, progress, and decline. This tendency to spread, and to give rise to a succession of unfavourable changes, constitutional as well as local, re- quires agents possessing powers of sufficient activity to meet the intensity of the disease. As this tendency depends upon depressed or- ganic nervous energy and deficient vascular tone, as shown above ($ 58); and as the per- manent fluidity of the effused fluids, and their infiltration and contamination of the surround- ing tissues, depend upon these pathological states, it is obviously requisite to employ such means as attentive observation and enlighten- ed experience have proved to be most efficient in removing them. All parts which are the seat of asthenic inflammation rapidly lose their vital cohesion or tone; and this loss is partici- pated in, not only by the extreme vessels giving rise to a copious morbid effusion, but also by the tissues affected. The chief pathological con- ditions, from which all the consecutive changes have been shown to proceed (§ 162, et seq.), manifestly require an energetic recourse to those means which will enable the constitution to resist the progress of the local mischief. Where cellular or adipose tissues are implica- ted, the extension of disease, and even of dis- organization will be rapid, if organic nervous energy be not promoted, and if vascular action in the seat of inflammation be not changed by suitable remedies. In such cases, the consti- tution must be enabled, as John Hunter ably contended, to form coagulable lymph, either in or around the inflamed part; or, in other words, to change the fluid and often septic matter ef- fused in the areole of the tissues, that extends the mischief by infiltrating and contaminating them, into coagulable lymph or albumen, where- by these areole maybe rendered impervious to the more fluid part of the effused matter, and the progress of the local malady may be more readily limited. 240. The principle of treatment in asthenic inflammations being established, the means by which it may be most successfully carried out in practice will be readily found ; although the application of these means, appropriately to the varying phases of individual cases, requires great discrimination and care. In the truly as- thenic forms of phlegmasia, the principle con- tended for must be acted upon with decision, and without wavering or temporizing. In the treatment of them, doubt or hesitation is fraught with danger ; and proceeding,, as either gener- ally does, from ignorance of the true source and relations of the local malady, there will be ev- ery reason to fear that much of both positive and negative wrong will be farther perpetrated. The ignorant are usually presuming, and the half-informed self-sufficient. In other profes- sions and avocations the evils produced by both are comparatively trivial; but in the practice of medicine their consequences are of fearful and immeasurable importance to humanity. I have seen numerous cases of asthenic inflam- mation die in succession, without the occur- rence of a single instance of success to lull the suspicion that true principles of practice had not been adopted ; and yet the same principles were blindly pursued in each successive case. In a country where the most trivial invasion of the rights of property is visited by the most condign punishment, human life may be sacri- ficed to an extent that more than rivals both the pestilence and the sword, by ignorant pre- 484 INFLAMMATION—Treatment of Asthenic. tenders to medical knowledge—by the totally un- educated as well as by the half instructed—and not merely with perfect immunity from punish- ment, but actually with the protection of the government, that protection being virtually the most complete for those whose ignorance is the greatest! This sacrifice of human life, be it farther recollected, is constant and unceasing —not occasional only, or at long intervals, as that caused by epidemics, pestilences, and wars. It was said, upward of two hundred years ago, by a celebrated archeologist (Sir H. Spelman), " that while everything else had risen in nominal value in England, the life of man had become continually cheaper." What would he have said had he lived in the present day? 241. The means by which the indication or practical principle above contended for is to be fulfilled must necessarily vary with the circum- stances of the case ; but the decoction of cincho- na, or the infusions of cascarilla and of gentian, &C, with the alkaline carbonates (F. 381, 385, 387, 388, 445, 869), are generally beneficial, es- pecially when aided by warm aromatic tinc- tures or spirits. When the pulse is very quick, soft, and weak, and when the patient is physi- cally and morally depressed, the chlorate of pot- ash, serpentaria, or other stimulants, may be added to the above (F. 415-417, 437-439). In these cases, camphor in full doses, the prepara- tions of ammonia, and capsicum, or other spices and aromatics (F. 845, 852), may likewise be prescribed. In all asthenic inflammations, the excretions, and the fluid effused in the diseased tissues, are more or less acid—a state which is most readily corrected by the alkaline car- bonates, conjoined with tonics and aperients. In many cases, however, the preparations of chlorine, particularly the hydrochloric acid, the hydrochloric azther, and chlorinated soda, prescri- bed with tonic vegetable infusions or decoctions, and with camphor, aromatics, &c, are equally beneficial with the foregoing (F. 847, 848). 242. B. But, in order to promote the powers of life, and thereby to enable the vessels of the diseased part to form coagulable lymph, where- by the progress of mischief may be arrested, it is necessary, not only to excite the organic ner- vous system, but also to depurate and to correct the circulating fluids by appropriate medicines. This intention will be fulfilled chiefly by pro- moting the excreting functions by mild purga- tives, conjoined with tonics and aromatics, as the compound infusions of gentian and senna with the alkaline salts (F. 266), the compound decoc- tion of aloes with warm aromatic tinctures or spirits, or the infusions of rhubarb and cinchona (F. 55, 387, 433), or other similar remedies (F. 53, 215, 216, 872). In the intervals between the exhibition of these, tonics and stimulants should be selected, and given in doses and com- binations suitably to the seat and urgency of the disease. If the purgatives just mentioned act insufficiently, a dose of oil of turpentine and castor oil (about half an ounce of each) may be taken on the surface of milk, or of any aromat- ic water (F. 216), and enemata containing the same oils (F. 135, 151), administered according to circumstances. If the biliary secretion be suppressed or interrupted, calomel or Plummer's pill may be given at bedtime with camphor, and a draught containing the oils, or either of the above purgatives, may be taken in the morning. The combination of the mild alkaline salts, or of the chlorate and carbonate of soda (F. 439), with the foregoing tonic or other medicines, will generally correct the circulating fluids, di- minish the contaminating influence of the mat- ter effused in the seat of disease, and farther promote the fulfilment of the present indication. 243. C. From the commencement of the treatment it is often requisite to mitigate the more urgent, local, and constitutional symptoms.— a. The remarkable pain and tumefaction of the inflamed part are best relieved by anodyne fo- mentations, by warm bread and water poulti- ces, or by the local application of simple or medicated steam. In the more complete forms of asthenic inflammation, no advantage will accrue from the application of leeches to the inflamed part; although a recourse to incisions of the integuments, as recommended by Mr. A. Copland Hutchison and others, will often be of service when cellular and adipose parts are the seat of disease, and the tension is very great. I have seen also the application of a cloth moistened with oil of turpentine have a very remarkable effect both in mitigating the pain and in lessening the tension and tumefac- tion. It should be applied warm, and covered with wash-leather or oil-skin to prevent evapo- ration and cold. In several cases, where the swelling has been most extensive—the whole limb to the trunk having been affected—I have seen it subside very quickly after a decided re- course to the internal and external treatment here recommended. In most of these cases, the tone of the vessels has been rapidly resto- red, congestion of them removed, and the effused fluid absorbed, without coagulable lymph hav- ing been formed, or suppuration having super- vened, excepting in some instances at the point of injury, or where the disease originated. When this treatment is early resorted to, not only is the progress of the disease arrested, but also much of its more immediate effects is re- moved without the lesser evil, the formation of fibrinous lymph, for which John Hunter con- tended, having taken place. 244. b. At advanced stages of asthenic phleg- masia, more frequently, and even at early pe- riods occasionally, excessive pain and general irritability call for a prudent yet decided re- course to narcotics. In these cases a lowering treatment will neither mitigate the pain nor di- minish the other symptoms, but, on the con- trary, increase them all, and render still more rapid the already quick and irritable pulse. Here opium, or the acetate or hydrochlorate of morphia, or hyoscyamus in large doses, must be resorted to. But these ought always to be con- joined with camphor and some of the aromatics or spices. When delirium appears in the course of asthenic inflammation, depressing remedies are generally injurious ; but the narcotics just named, and combined as now advised, will be of the greatest benefit, particularly in conjunc- tion with the restorative treatment above rec- ommended, and after the excretions have been duly evacuated by appropriate means. (See art. Delirium.) 245. c. When asthenic inflammations are at- tended by general vital depression without reac- tion (y 62), the most energetic stimulants, ton- ics, and restoratives are necessary ; and if de- INFLAMMATION—Treatmek lirium supervene, camphor, ammonia, and opi- um, with warm aromatics, should be freely ex- hibited. 246. d. When organic nervous or vital pow- er is depressed, although much general vascular excitement exists (y 63), the pulse being rapid and weak, similar means to the above are re- quisite, but in less energetic doses. Camphor, with the narcotics already advised, and aromat- ic spices, mild stomachic purgatives, occasion- ally aided by a draught and an enema contain- ing turpentine and castor oils, are also most efficient remedies. 247. e. In cases characterized by depressed vital power, acute nervous sensibilty, and cerebral disorder (v 64), the means just recommended are urgently called for ; but the narcotics and camphor should be prescribed at an early pe- riod of the disease, and in large doses. The effusion of tepid or warm water on the head, according to the temperature of the part, may be employed. Medicated vapour or warm baths may also be tried, and medicated steam (y 232) may likewise be applied to the local malady. 248. /. When there are excessive irritability, acute pain, and vascular excitement (y 65), the internal and external treatment just prescribed, but modified according to the stage and partic- ular features of the disease ; a combination of camphor, calomel, and opium; stomachic ape- rients, with the alkaline salts, and an occasion- al recourse to turpentine and castor oil, in the form of draught or enema, are chiefly to be re- lied upon. 249. g. Great irritability of stomach may oc- cur at an earlier or later period of asthenic in- flammations, when attended by any of the forms of constitutional commotion just referred to. When this is the case, every endeavour must be used to allay it. Warm aromatics, or spi- ees and stimulants, with small doses of opium, will generally have this effect in the less ur- gent eases, particularly- when aided by the as- siduous application of the warm turpentine ep- ithem over the region of the stomach, and by the administration of stimulant and antispas- modic enemata. In such circumstances, those articles which are most grateful to the stomach should be selected, and everything of a depress- ing nature avoided. Effervescing medicines are seldom useful, especially if this very unfa- vourable symptom occur at an advanced period of the disease. More advantage will accrue from small and frequent doses of ammonia, camphor, capsicum, and other warm aromatics or stimulants—from small quantities of burned brandy, from strong and highly-spiced negus, and from other restoratives of small bulk—than from cold, relaxing fluids. I have seen much benefit derived in these cases from moderate doses of creasote, or of cajeput oil, in suitable vehicles^ or in the form of pills made with any absorbent substance. 250. h. When disorganization of the inflamed part has commenced, or is advanced, local means of an energetic kind may be prescribed if they ean reach the part in any way ; if they cannot, the constitutional treatment, aided by suitable diet and regimen (y 260), and by a pure, dry air, must be energetically but carefully enfor- ced. As to the topical applications which may be prescribed in these circumstances, some in- cidental observations have been already ofler- *t of Intermediate Forms of. 485 ed; but it may be farther stated, that those substances which constringe or impart tone to the affected vessels and tissues should be em- ployed, and that those which possess this as well as an antiseptic property in the most mark- ed degree, should be preferred. Strong decoc- tions or infusions of cinchona, or oak barks, the terebinthinates, the solution of chlorinated soda, or of the chlorate of potash, or of the chloride of lime, of creasote, may be severally employed in the form of either lotion or injec- tion, or on the surface of warm poultices, or in any other mode more appropriate to the pecu- liarities of the case. 251. i. During the treatment, especially of the advanced stages of asthenic phlegmasia, the absorption of the morbid matter from the seat of disease into the circulating fluids ought to be prevented by every possible means. This ob- ject can be obtained only by giving a free exit to whatever of this matter may have accumu- lated, and by preventing any collection of it from taking place. The internal treatment, which I have advised, will also have a most decided influence in preventing the absorption of it, and will enable the powers of life to re- sist whatever morbid impressions it may make in the seat of disease. The marked influences of all depressing agents in promoting the ab- sorption of morbid fluids, and the powers of tonic and restorative means in preventing ab- sorption, and the consequent contamination of the circulating fluids, as well as in enabling the constitution to resist the natural tendencies of these fluids and to throw them out of the econ- omy, have been fully shown in the articles Ab- sorption (y 15, et seq.), Abscess (» Nature de la Ph1Z«c &c,4to, 1823,-KaM.^, Comn? M 1 We,et Hra"*«r» torn, xir., p. 43.-Su«Var, Coinm. Med. de Modo quo Natura versatur^, &c, 4to, 1823. -Ml, Bericht uber die Ergebnisse in dem Chirurg. Klini- kum zu Landshut, 1824.-G. M. Sparer, De Inflam. Morb Anim. et Veget., 1824.-/. H. F Wiesmann, De Coalitu l«9i ra r*h1uo C(""Pore prorsus disjunctarum, dec, 4to, M.-i.i»ilim, Delia lnflammazione Commentario Alodena, 8vo, 1824 ; et Ricerche sui Trattamento delle Ma- lattie Inflammatory. Mod., 8vo, 1829.—G. Konig, Exper. circa Sanguin. Inflam. et Sanit., 1824.—Deslandes, in Re- vue Med., torn, iii., 1824, p. 49.—Bouillaud, in Ibid., torn. "., 1825, p. 256; ct torn, iii., p. 73 et 367 ; et in Nouv. Bib- lioth. Med., torn. i.( p. 5 et 147.—T. Dowler, in Med. Chir. Transact., vol. xii., p. 86. —/. Bostock, in Ibid., p. 94.— Philip, in Ibid., p. 397.—Berzelius, Ueber die Theoretische Chemie, Journal de Schweiggcr, vol. xii., p. 330. — Lalle- tnand, in Journ. Univ., torn, xxvii., p. 5. — C. A Koch, De Observ. nounullis Microsc. Sang. Cursum et Inflam. spec- tantes, &c, 1825. — K. F. Burdock, Observ. nonnull* Mi- crosc. Inflam. spectantes, 1825; et Die Physiologie, 1826- 1835, b. iv., Vom Blute.—/. Black, A Short Inquiry into the Capillary Circulation, with a View of the Nature of Infl;im. Lond.,8vo, 1825.-^4. Goldoni, Sulle Inflam. Trattato diviso in Tre Parti, part i., Ib25. — Pras, De l'lrritation et de Phlegmone, 8vo, 1825.—Chomel, in Diction, de Medec, torn. xii., p. 213. Par., 1825. — F. Paul, Comm. Phys. Chir. de Vulner. sanand., dec, 4to, 1825.—G. Kaltenbrunner, Exper- imenta circa Stratum Sanguinis et Vasorum in Inflamma- tion. Monach., 4to, 1826.—Salfender, De Reunione Par- tium Corp. Hum. Element., 8vo, 1826.—B. Trovers, Inquiry into the disturbed State of the Vital Functions, called Con- stitutional Irritation, 8vo, 1826 ; Farther Inquiry, pyv, the mind), which he de- fines to be an exaltation of the feelings and assifications op. 511 sentiments to a state of sadness, and which he considers to exist at the commencement of al- most all cases, and, with lesion of the sensi- bility, to constitute the fundamental character of insanity, appearing as one of the more im- portant features of the malady. It frequently, however, assumes a monomaniacal, or, as he more correctly terms it, monopathic form (from uovoc, single, and nddoc, disorder). 54. ii. Mania, or Hyperphrenie (from vircp, above, and pyv), which he views as a state of cerebral reaction, in which the whole or some of the active manifestations of the intellect, or traits of the character, or propensities, &c., are remarkably exaggerated and disordered. This species of insanity presents two states: that of erethism, or tranquil mania ; and that of orgasm, or furious mania. It may be par- tial—monopathic, or monomaniacal; or more or less general, as respects the extent to which the instinctive, intellectual, and moral powers are implicated. It may thus appear in the shape of ambitious, religious, lascivious, cov- etous mania, &c., assuming either a tranquil or a more or less furious character. The dif- ferent forms of this species may be associated with melancholia, constituting melancholic mania. 55. iii. Madness, or Paraphrenic (from napa, along with, and typrjv), which he defines to be cerebral reaction characterized by fantastic aberration. This species presents numerous varieties and modifications as to the extent and association of mental disorder ; but it is fre- quently partial or monopathic, and it may be either of a harmless or destructive nature. It is often associated with melancholia, or with ma- nia, or with both. 56. iv. Extasis, or Hyperplexie (from vircp, above, and irhijtiie, astonishment), which he views as sub-convulsive reaction of the cerebral power, characterized by immobility and rigidi- ty. This state, although often monopathic, is also frequently complicated with melancholia, or with mania, or with madness, or with any two, or even all of these. 57. v. Convulsions, or Hyperspasmie (from imp, and onaoube, violent contraction). This species M. Guislain defines to be reaction, with mus- cular and mental agitation. He comprises un- der it tremour, convulsive syncope, chorea, hys- teria, and epilepsy, disorders previously not sim- ilarly classed, although either of them often complicates one or more of the mental disorders already enumerated, and even all of them in rare instances. 58. vi. Delirium, or Ideosynchysie (from Idea, idea, and ovyxvoic, confusion), which he states to be reaction and aberration of the ideas, wandering of the intellects, illusions, halluci- nations. This may be monopathic, as when the patient is possessed by a single idea or illu- sion ; or it may be associated with one or more, or even with all of the mental affections just noticed. 59. vii. Incoherence, or RSvasserie, or Anaco- luthie (from avaaolovdia, incoherence). This state M. Guislain considers as different from delirium, inasmuch as in the latter the ideas run upon some illusion or hallucination, where- as in this state they arise vaguely, and with- out any connexion with each other, or with any particular subject or object: nothing is ex- pressed clearly or consecutively. In delirium, .ASSIFICATI0N8 OF. 512 INSANITY—Cl the idea, although false, presents some con- nexion, or even the colours proper to it. Inco- herence may be monopathic or associated: most frequently the latter ; and the association may be with either of the preceding affections, or with several of them. 60. viii. Dementia, or Noasthenie (from vooc, intelligence, and aadevla, debility): This state is viewed by M. Guislain as one of mental prostration and incapacity, in which the men- tal powers are palsied. This species is made to comprise those forms of insanity which con- sist of various grades of imbecility, original or acquired—congenital idiotcy and senile fatuity. Like the preceding species, it is either mono- pathic or associated; more frequently the latter, in which state it is usually the consequence of chronic or greatly prolonged forms of the dis- orders already enumerated. 61. I have thus fully adduced M. Guislain's arrangement of mental disorders, because it presents not merely a classification, but also an instructive analysis of them, especially when attentively considered in his own copious ex- position. For practical purposes, and for the inexperienced prs^titioner, it will be found de- ficient in simplicity; but, coming as it does from one of the most experienced and ablest writers on mental alienation, it deserves our careful attention and our respect. 62. M. Foville, in attempting a physiologi- cal arrangement of mental disorders, observes, that three orders of phenomena, sensations, in- tellectual combinations, and movements, suc- ceed one another in the actions of the nervous system; and that three orders of symptoms, exactly corresponding, show themselves singly or combined in mental diseases. In founding upon the existence of the symptoms of a single one of these orders, and upon the successive appearance of those of the other two orders, he hopes to have laid, not only a physiological, but also an anatomical basis of classification for the principal divisions of mental alienation, in- asmuch as he thinks it may be admitted, at least with the consent of many modern writers, that sensibility, movement, and intelligence have each their distinct organic seat, although dependant upon the same system. 63. As disorder of the ^intellects is the most constant, the particular instances in which it is alone present constitutes M. Foville's _/irs< di- vision, which comprehends mania, monomania, demency, and idiotcy, without complication with false perceptions, or with any disorder of the muscular system. In the second division, he arranges all cases characterized by the coinci- dence of disorder of sensation and perception with derangement of the intellects ; and, in the third division, he comprises those which mani- fest that disorder of the muscular system, usu- ally denominated general paralysis, or the palsy of the insane. In this third class he also com- prehends the epileptic insane, as well as idiots, whose limbs are wasted and paralytic. 64. Dr. Prichard has distinguished insanity into, 1st. Moral; and, 2d. Intellectual: the latter he has divided into (a) Monomania, or partial insanity ; (b) Mania, or raving madness ;. and (c) Incoherence, or dementia. Idiotcy, or mental de- ficiency, he has considered as entirely apart from, or unconnected with, any form of mental alienation. 65. Dr. Mayo, in his Pathology of the Human Mind, divides primary mental disease into, 1st. Perversion, or insanity; and, 2d. Deficiency of the mental manifestations. He subdivides Per- version of mind into, 1st. Moral incoherency; and, 2d. Intellectual incoherency: and Deficien- cy into, 1st. Brutality, or absence of the moral faculty; and, 2d. Imbecility, or intellectual de- ficiency. 66. I shall not notice at greater length the divisions of the various forms in which mental disorder presents itself that have been at- tempted by modern writers. Enough has been advanced to show the difficulty of the attempt, and to prove even (what many would en- deavour to conceal) that one form of mental disorder gradually and insensibly passes into that more nearly allied to it, not only in dis- tinct cases, but often also in the same individ- ual ; that, for instance, partial may rapidly pass into general insanity; that melancholia may quickly pass into mania, or mania rapidly lapse into melancholia, or that both may very fre- quently alternate ; and that the more simple states of intellectual disorder may be soon as- sociated with disorder of the sensations and perceptions, or be still farther complicated with lesion of the movements, in the form either of general palsy, or of epilepsy, or even of both. Nevertheless, although even the most different forms of insanity more closely approximate than is generally imagined, still it becomes ne- cessary to preserve and to recognise such dis- tinctions between them as really exist, inas- much as they furnish most important indica- tions for moral as well as for medical treatment. In the division, therefore, which I shall attempt, I shall endeavour, at the same time, to point out close relations as well as obvious distinc- tions ; and to follow the progress of mental dis- order from its more simple, partial, and com- mon forms, up to its more general and com- plicated states. Conformably with this inten- tion, I shall take a brief view, 1st, of the Par- tial Forms of Insanity—(a) as evinced chiefly in the moral manifestations of mind, and (b) as affecting principally the understanding Qr judg- ment ; 2d, of the General Forms of Insanity— (a) in the state of mania, or raving madness ; (b) in the states of incoherence and imbecility, or dementia; (c) in the state of fatuity, or anni- hilation of the powers of mind ; 3d, of Compli- cated Insanity, the insanity being associated (a) with paralysis, (b) with epilepsy, (c) with apoplexy, &c. Connate and Puerile Insanity— congenital privation of mind, or Idiotcy, and Pue- rile Imbecility ; Puerperal Insanity—insanity during uterogestation, after parturition, and du- ring lactation; and Suicidal Insanity—or sui- cide in relation to insanity, will be considered in separate chapters of this article.* * The following classification of the manifestations and affections of mind, with reference to their influence in caus- ing mental and corporeal disorder, was published some years ago by the author. It may be found of use in consid- ering the different forms of mental disorder, especially in relation to their arrangement, to their causation, and to their moral management. This classification of the affec- tions of mind is based upon the relations of the human spe- cies to the rest of the animal creation, especially in respect of those manifestations which are exhibited by the higher animals. The Instinctive Desires and Feelings form the First Class, as being the most generally extended ; and the Intellectual States and the Moral Emotions constitute the Second and Third Classes, as belonging especially to man, and as furnishing him with a numerous class of INSANITY—Partial—Moral. V. 513 67. III. Of the special Forms of Insanity.— In the above general description, I have con- ideas, which raise him above all other animals, which en- noble him in his social and moral relations, and which en- able him to derive advantages from the past to rationally enjoy the present, and to form the liveliest hopes, and even the firmest anticipations, of the future. CLASS I. Instinctive Desires and Feelings.—Strong and immediate incentives to action in the lower ani- mals, but controlled by reason in man. Order 1. Instinctive Feelings, tending to preserve the Individual. a. The sensations derived through the medium of the external senses contribute to the preservation of the in- dividual, by showing him what is injurious, and by en- abling him to supply himself with what his internal sensations or appetites indicate to be necessary to his existence.—b. The appetite for food and drink.—c. The desire of preserving the animal warmth.—d. The de- sire of repose.—e. The desire of place.—/. The desire of pleasure and the dread of pain.—g. The desire of continued existence. Order 2. Instinctive Desires tending to perpetuate the Species. a. Parental and filial affection.—b. The desires of sex.—c. Desire of society and social feelings, giving rise to mutual support. The sensations and desires are most powerful incentives of volition. The appeasing of the desires is necessary, not only to health, but even to existence. The inordii.ate gratification of them is most injurious to physical and men- tal health—is among the most fruitful sources of disorder of both mind and body. CLASS II. Intellectual Powers, or States of Mind. Order I. Powers of Consciousness, or the simple Intel- lectual Slates of Mind. — Injurious to health, chiefly from their injudicious or excessive exercise. a. Perception.—b. Attention—effects of protracted, to a single object, or train of investigation.-<-c. Concep- tion—accurate or inaccurate views—their effects.—d. Memory. This last power is more or less concerned in a large proportion of the states of mind affecting the health. Order 2. Powers of IntElection, or the more active In- tellectual States of Mind.—The excessive exercise or misdirection of these is more or less injurious to mental and bodily health. a. Simple suggestion or association of ideas.—6. Habit. —c. Imagination—its activity as influenced by the mor- al emotions of mind, sometimes beneficial, but oftener injurious to health. — d. Judgment, or reasoning.— e. Abstraction. Order 3. Ideas of Reflection, springing from the Exer- cise of the two former Orders of Powers.—Rational in- centives to action. a. Mental identity.—6. Time.—c. Power.—d. Causa- tion and truth.—e. Right and wrong.—r. Existence of a Deity.—g. Immortality of the soul. ' All these are seldom injurious to health, but are often beneficial in controlling the emotions and desires, in governing and directing the instinctive feelings, and in enabling the mind and body to resist the influence of injurious im- pressions and agents. CLASS III. Moral Afffctions of Mind, in which some of our Instinctive Feelings, as well as of our Intellectual Powers, are frequently more or less engaged. Order 1. The Instinctive, or simple Moral Emotions of Mind, often sudden and violent incentives to action. When strongly excited or much indulged, they are among the most influential causes of both mental and corporeal disease. a. Anger, indignation, resentment, revenge—their ef- fects upon health.—b. Sympathy—its effects.—r. Beau- ty, or deformity.—d. Love and hate, jealousy, domestic misery.—e. Pride, vanity, and humility — the liability of the former to lead to insanity.—/. Gladness, regret, sadness, and grief. Grief from lost objects of affection —its effects — counteracted by progeny. Grief from moral degradation the least supportable — why ? Ef- fects of sudden shocks of grief on sensitive minds. Dis- appointments of the affections. Grief from loss of for- tune, > P* i 1. Cases of less than three months' duration . . . 2. Cases of more than three, and less than twelve, months' duration . . . 3. Cases of more than twelve months' duration 4. Cases of relapse . . . 63 65 101 105 51 28 31 58 8 10 15 17 1 6 17 13 2 3 4 1 i 18 34 16 Total..... 334 168 50 37 10 69 Mr. Tuke states that several cases entered as recent were properly old cases ; and if these were excluded, together with those connected with diseases speedily terminating life, as con- sumption and apoplexy, the probability of recov- ery from insanity, in recent cases, is greater than nine to one. An able reviewer very justly remarks on this statement, which is strongly confirmatory of that long since made by Dr. Burrows, that it is deserving of attention, as the opinion generally entertained, in respect of cases even of recent date, is more unfavourable than ascertained facts should warrant, the de- sponding view taken of such cases evidently tending to relax the efforts which should be made for the recovery of them. [The following proportion of cases has been calculated by Dr. Earle (Am. Jour. Med. Sci- ences, 1843), from the annual reports of differ- ent American institutions for the insane : Maine State Asylum, from 1840 to 1841, 135 patients admitted, 34 recovered ; 25-18 per cent, of admissions. Massachusetts State Asy- lum, 1833 to 1841, 9 years, 1359 admitted, 588 cured; 4333 per cent. Vermont State Asy- lum, 1837 to 1841, 5 years, 396 admitted, 163 cured; 4116 per cent. Maryland State Asy- lum, 1835 to 1840, 5 years, 393 admitted, 135 cured ; 34 35 per cent. Ohio State Asylum, 1839 to 1841, 3 years, 343 admitted, 124 cured; 36-15 per cent. Kentucky State Asylum, 1824 to 1840, 16£ years, 841 admitted. McLean Asylum. Mass., 1818 to 1834, 16 years, 1112 admitted, 403 cured ; 3591 per cent. : 1835 to 1841, 7 years, 891 admitted, 474 cured ; 5319 per cent. Boston City Asylum, 1839 to 1841, H year, 153 admitted, 19 cured ; 12-42 per cent. Hartford Retreat, 1824 to 1841,17 years, 1068 admitted, 600 cured ; 56-17 per cent. ation in Recoveet. 541 Pennsylvania Hospital, 1752 to 1840, 88 years, 4366 admitted, 1493 cured ; 34 19 per cent. New York City Hospital, 1808 to 1820, 15 years, 1144 admitted, 509 recovered; 4448 percent. Bloomingdale Asylum, 1821 to 1841, 20^ years, 2598 admitted, 1200 cured ; 46 20 per cent. Bellevue Asylum, 1791 to 1821, 30 years, 1553 admitted, 704 cured; 45-33 per cent. Frank- ford Asylum, from 1817 to 1841, 25 years, 784 admitted, 336 cured ; 4290 per cent. Dr. White's Asylum, Hudson, N. Y., 1830 to 1840, 10£ years, 503 admitted, 230 cured; 45-72 per cent. Of 120,796 cases of insanity admitted into the different insane hospitals of Europe and this country, it appears, from the calculations of Dr. Earle (loc. cit.), that 49,046 were cured, being a proportion of 40T8^ to the 100. The per centage of cures of the aggregate number of patients in the institutions of each country respectively is as follows: United States, 41 13; England,39-21; Scotland,48-82; Ireland,4572; France, 36-71 ; Italy, 5010; Germany, 30 79; Holland, 3827. There are in Italy many ca- ses of this disease arising from a peculiar en- demic influence : the general curability of these sufficiently accounts for the high per centage of that country.] 198. C. The particular prognosis, or the symp- toms especially indicating recovery from insanity, requires a brief consideration.—a. A paroxysm of mania may continue a few hours, or days, or weeks, or longer, and then remit or entirely vanish; or it may assume the form of melan- cholia, and continue or alternate with mania to its termination. It is impossible to say when either form of insanity will subside : the more furious, however, the attack, the shorter, gener- ally, will he its duration, especially in mania. But when a remission of violence is attended by amelioration of other symptoms, it is a fa- vourable sign. If the malady have continued several weeks, and the system is suffering, the disease will prove obstinate, if not dangerous. Insanity terminates favourably more frequently by a visible decline of the symptoms, and a re- mission or complete intermission, than by crit- ical discharges. To these last, M. Esquirol attaches too great importance, Dr. Burrows too little, in this disease ; for, although alvine, haemorrhagic, urinary, and suppurative dis- charges, or boils and cutaneous eruptions, do not certainly remove the mental disorder, even when taking place spontaneously, yet they fre- quently do remove it. Fevers, hydropic effu- sions, and gout—particularly the last—have also sometimes removed the mental affection. These, however, as well as other diseases, have more frequently been followed by a re- mission, or, at best, by an intermission only. 199. b. Remissions, when thus or otherwise observed, may continue for days, weeks, or longer ; but the reason still continues partially deranged, and the sleep disturbed by dreams, or by unpleasant sensations, referrible to the head or sense of sight or hearing; and after a time the disorder resumes its full force.—Inter- missions are a perfect restoration of the facul- ties for a time, varying in duration from two or three days, or a month, to several weeks, months, or even years. Sometimes the return of the attack is after regular intervals, or peri- odic; but as often it is irregular. Insanity may 542 INSANITY—Relapses and Recurrences of. cease after a time, having passed first into a remittent or an intermittent state ; or it may disappear, more or less rapidly, and completely, without any return. A gradual and perfect restoration of the faculties, however, takes place in the great majority of cases of recovery, without any recurrence or exacerbation of symptoms constituting the states of disorder just mentioned. 200. c. The absence of false perceptions and delusions is a favourable circumstance ; but when they continue after the abatement of physical violence, a protracted case may be anticipated. A return of the natural feelings, of the affections, particularly to near relatives, and to former habits, is among the surest indi- cations of recovery. But in all cases, in form- ing a prognosis, the mental phenomena should be viewed in connexion with the physical symp- toms and state of the patient, and with such changes in the economy as have usually been viewed as critical in acute maladies, and par- ticularly those affecting the brain or its mem- branes—especially the restoration of suppressed discharges, evacuations, and eruptions ; or the spontaneous occurrence of these—as the hse- morrhoidal and catamenial fluxes, epistaxis, diarrhoea, furunculi, a regular fit of gout, &c. The utmost caution, however, should be ob- served in giving an opinion as to the event; but it is preferable to hold out hopes of recov- ery as long as there is a chance of it, other- wise the efforts to effect it may relax, and the patient consequently suffer. The following in- ferences are not materially different from those arrived at by Dr. Burrows and M. Esquirol. 201. 1. A cure is probable in proportion to the youth of the patient. 2. It is also probable in a ratio with the recentness of the attack. 3. The chance of recovery is the greatest in first attacks, and diminishes with each subse- quent attack, and with the duration of the dis- ease and age of the patient. 4. Mania is cured most frequently ; next, melancholia and mono- mania ; and lastly, and the least, dementia and fatuity. 5. Melancholia is difficult of cure in proportion to the degree of depression ; a dread of poverty, of poison, and perverted ideas of religion, indicating an obstinate disease. 6. Chronic insanity, whether mania or melan- cholia, seldom recovers. 7. The prognosis of puerperal mania is favourable. 8. Insanity with a propensity to suicide is not unfavoura- ble, if the patient comes early under treatment, and the disease be recent. 9. Acute dementia is curable ; but chronic demency and senile in- sanity are never entirely cured. 10. Heredi- tary predisposition protracts, somewhat dimin- ishes the chances of, but does not prevent, a cure : relapses and recurrences are, however, more to be expected where it exists. 11. When the insane are incapable of judging rightly of their own state, a cure becomes difficult. 12. An amendment of personal appearance, at- tended by an improvement in the mind, is indic- ative of recovery. 13. When the insane pre- serve or acquire all their physical functions, and eat and rest well, and present their usual appearance, without recovering their faculties, recovery is hopeless. 14. Insanity caused by excessive study, by the slow operation of moral emotions, or attended by hallucinations, by pride, &c, is seldom cured. 15. Complications with palsy and apoplexy are incurable, and are fatal ultimately; but those with epilepsy, or convulsions, may recover in very rare in- stances. 16. Men are more liable to relapses than women, one half of all relapses occurring in the first three months after recovery. 202. ii. Of Relapses and Recurrences of Insanity.—Recoveries from insanity are either complete or incomplete. Of the latter, there are many, who, although perfectly rational, are never capable of returning to the sphere they formerly occupied, or of performing the duties which they previously fulfilled ; their faculties having sustained a shock which can never be altogether recovered from. Dr. Prichard con- siders such cases to be about one tenth of the recoveries. Others remain longer or shorter in such a state of susceptibility that the slight- est causes occasion relapses; and they pre- serve their sanity only by continuing to live where no mental agitation or inquietude is likely to befall them, and throw them back into their former state. 203. a. A relapse may be said to occur when the malady returns while the patient has scarce- ly, or very recently, recovered, or when he is only in a state of convalescence. It may take place a few weeks, or two or three months after an attack of insanity. The precise time, Dr. Burrows remarks, when a cure may be said to be complete, is assigned with difficulty. Many experience, for weeks, even months, after re- covery, uneasy sensations or confusion in the head ; and, as long as these are complained of, no confidence can be placed in the stability of the cUre. But when these sensations entirely cease, and all the functions are restored, any subsequent access of insanity is, as in other maladies, a recurrence of it, and no relapse. 204. Men are said to be less subject to re- lapses than women ; but this is not the case, for many circumstances influence the chance of this event taking place, and to most of those men are more exposed than women. As soon as convalescence commences, the care of the physician and attendants is especially required; for, if imprudent measures be adopted before this period has been succeeded by restored health, a relapse will probably be thereby occa- sioned. The middle and poorer classes are more apt to relapse than the rich ; for the for- mer go from an asylum direct to their misery, and to encounter the exciting causes—probably the same causes which produced their derange- ment ; while the latter may enjoy intermediate measures of precaution. Most of the relapses, as well as recurrences of the disease, proceed from a premature or incautious gratification of habits and indulgences concerned in the produc- tion of the primary attack, or from too great mental exertion for the weakened state of the faculties, or from mental excitements or con- trarieties. 205. b. The probability of a relapse is gener- ally in a ratio with the suddenness of recovery, and is most frequent in mania. Recurrences are most common in melancholia; and, as well as relapses, are very apt to occur when the mind is influenced by religious fears. Relapses or recurrences are announced by nearly the same symptoms as preceded the first seizure ; and when warning has been taken by thete, and medical aid procured, a return of the mal- INSANITY—Fatal Termination op. 543 ady is frequently prevented. Indeed, it should always be remembered that, when the mind has been once disordered, a predisposition is thereby created to a return of the malady when subjected to any of the exciting causes. In some constitutions this predisposition or apti- tude to a renewal of the complaint is much stronger than in others ; and to its greater strength in some persons is partly to be attrib- uted the remittent or intermittent character it frequently assumes ; and the periodicity which it often observes, and which is probably owing to an increase of the predisposition by various physical influences recurring at stated periods. Each successive attack increases the morbid tendency to a return of the malady, and short- ens the interval between it and that which is to follow ; until at length the intervals not only become much shorter, but also more im- perfect, and the disorder at last assumes a remittent or a permanent form. 206. c. The proportion of cases in which in- sanity is recurrent has been generally overra- ted, in the opinion of Dr. Prichard. Of 444 re- coveries, M. Pinel reckoned 71 cases of relapse and recurrence; but of these 71 cases, 20 pa- tients had experienced several attacks ; 16 had left the hospital too soon ; 10 came afterward under treatment, and recovered without re- lapse ; 14 had given themselves tip to grief and intemperance; and several others were unfa- vourably circumstanced. M. Esquirol reports 292 recurrences of insanity out of 2804 recov- eries, or a little more than one tenth. M. Des- portes states that 52 recurrent cases were rec- ognised at the Bicetre, in 1821, out of 311 ad- missions, or 17 in 100; and that 66 were re- ceived at the Salpetriere out of 454 admissions, or 15 in 100. M. Georget, however, remarks that there were, among these cases of relapse and recurrence, many who had been discharged in a state of incomplete recovery, as well as a number of drunkards, who came every year to spend some weeks in these hospitals, having been taken there in a state of intoxication. 207. Mr. Hitch has furnished Dr. Prichard with the particulars of 68 readmissions from among 546 admissions. These 68 readmis- sions occurred in 25 persons only; and of these there were 17 men, 10 of whom were paupers, readmitted forty-nine times ; and 8 women, of whom 4 were paupers, who were received nine- teen times. Many of those who were read- mitted had been either removed uncured by the wishes of friends, or discharged " relieved on trial," their friends having found it necessary to replace them: some returned after an appa- rently perfect cure. The general inference at which Dr. Prichard has arrived is manifestly correct, that the improbability of a recurrence of insanity increases with the length of time which has elapsed without any sign of renew- ed disease, and that it is also greater in propor- tion to the completeness of the recovery. When the energy of the mental faculties is fully re- stored, relapse and recurrence are much less to be feared than when they remain weak and ex- citable. [It has been truly observed, that the liability to recurrence, or relapse, is probably greater in this disease than in most others, inasmuch as a large proportion of patients have the diathe- sis of insanity, or a predisposition to the affec- tion, either constitutional or hereditary. In pu- erperal cases, we know that the irritation of future pregnancy is very likely to provoke a re- turn of the affection. In the statistics of the York Retreat, England, it is shown that the li- ability to recurrence, after the first attack of insanity, is equivalent to at least 50 per cent. of the whole number of cases that recover. Of the patients treated in that institution, the pro- portion was greater, being 65-6 per cent. At the Pennsylvania Hospital, Blockley, of 176 ad- missions, 142 were of the first attack, 21 of the second, 4 of the third, three of the fourth, 2 of the fifth, 1 of the sixth, 1 of the seventeenth, 1 of the twentieth, and 1 of the twenty-first. At the Frankford Asylum, of 784 patients, 96 were of the second admission, 28 of the third, 8 of the fourth, 2 of the 5th, 1 of the sixth, and 2 of the tenth. Of the 96 admitted the second time, 51 had been discharged, cured of the first attack. At the time of readmission, 19 had been discharged less than three months, 9 of them cured ; 12 from three to six months, 3 of them cured; 16 from six to 12 months, 13 of them cured; 11 from one to 2 years, 8 cured ; 10 from two to three years, 4 cured; 9 from three to five years, 5 cured ; 16 from five to ten years, 7 cured ; and three more than ten years, 2 cured. Of 240 readmissions at Wakefield, 39 were in less than three months after the former discharge ; 31 from three to six months; 21 from six to nine months; 23- from nine to twelve months ; 51 from one to two years ; 34 from two to three years; and 80 from three to ten years.—(Earle.)] 208. iii. Of the Fatal Termination of In- sanity.—Although the state of the brain con- nected with insanity may be incompatible with the due exercise of the mental manifestations, yet it may not so disturb the physical functions as very materially to shorten or endanger life. This is shown both by the duration of insanity in many cases, and by the longevity of lunatics. Instances are adduced by M. Desportes and others of the long continuance of this malady. Among the lunatics at Bicetre, in 1822, 1 had been there fifty-six years; 3 upward of forty years ; 21 more than thirty years ; 50 upward of twenty years; 157 more than ten years. Among those in the Salpetriere, there were 7 cases upward of fifty years ; 11 from fifty to sixty; and 17 from forty to fifty. Although many live thus long in a state of insanity, yet the mean duration of existence is shortened by it, and chiefly owing to the following causes, each of which requires a brief consideration : 1. By exhaustion of organic, nervous, or vital energy ; 2. By the progress of the morbid state of the brain, associated with the mental disor- der, so as seriously to disturb the physical func- tions ; 3. By favouring the development of dis- eases of several vital organs ; and, 4. By the occurrence of accidental disorders which may he masked by the mental disease, or concealed by it until it assumes a serious form. The mental disorder, however, is often symptomatic or sympathetic, a consequence of disease more or less latent, of some important abdominal or thoracic viscus, yet seriously affecting the con- stitution and nervous power; the physical mal- ady being sometimes aggravated, and occasion- ally suspended for a time, by the sympathetic mental affection, but, nevertheless, terminating al Termination of. 644 INSANITY—Fat life sooner or later. This topic will be more particularly noticed hereafter. 209. a. Exhaustion and depression of nervous or vital energy may proceed so far as to fatally terminate the insane state.—This occurs chiefly in mania, wherein the inordinate excitement of the feelings, the constant agitation of both mind and body, the febrile disturbance of the system, and the continued want of rest and sleep, com- bine to exhaust the powers of life, and to occa- sion nervous depression and emaciation. In the majority of cases, the exhaustion either takes place gradually, or does not proceed so far as to endanger life ; and the maniacal state passes either into recovery or into dementia : sometimes, however, it is so extreme, or so complete, that the patient never afterward ral- lies, but rapidly sinks to death. This occurs most frequently during the'first two years from the commencement of the malady; and hence the greater number of deaths from mania at this than at any subsequent period. That this result should often follow in cases where the excitement and general perturbation are great, relatively to the amount of vital power, may be assumed a priori; and it is in these cases es- pecially that we find the organic lesions insuffi- cient to account either for the mental disorder or for the fatal termination. In extreme cases of melancholia, death may take place from de- pression, or sinking of nervous and cerebral power; and this state may be aggravated even to a fatal issue by a too depressing or exhaust- ing method of cure, or from want of those means of restoration required by the peculiarities or exigencies of the case. 210. b. The morbid state of the brain associa- ted with the mental disorder may proceed so far as to seriously, and at last fatally, disturb the physi- cal functions.—In these cases, the lesions of the brain may vary remarkably in respect of seat, extent, and nature of parts implicated in them ; and may commence gradually, and proceed slowly to fatal disorganization, or may take place more or less suddenly, and terminate rapidly. In either case, we can observe only the ultimate and gross results in our exami- nations of the brain and its appendages after death; but there can be no doubt that these, during their development and increase, give rise to phenomena, several of which have been described when treating of the principal compli- cations of insanity (y 167, et seq.), especially to the different forms of paralysis, to epilepsy and convulsions, to apoplexy, and to coma, either of which may terminate life.* * [" The distinguishing features of the paralysis peculiar to the insane are, 1st. Defective action of the muscles of locomotion. This, at first, is generally very slight, amount- ing to nothing more than an instability of gait, or tottering-, or, at most, a sudden yielding of the knees beneath the weight of the body, the patient partly falling, but again re- covering himself and pursuing his progress. It afterward increases, and sometimes entirely destroys the ability to stand. "2d. Defective action of the organs of speech. Words are uttered indistinctly, and, at times, so confusedly as not to be understood. It not unfrequently occurs that, in at- tempting to speak a particular word, the patient finds it im- possible to pronounce any portion of it. "3d. Exalted ideas of station, riches, and power. Per- sons affected with the disease generally imagine themselves either as one of the sovereigns of the earth, or as having command of inexhaustible stores of wealth. "4th. It is generally, if not always, incurable. " 5th. The pathological lesions are, thickening and opa- city of the meninges, with serous effusions between and be- 211. c. The development of serious diseases of vital organs seated in either the thoracic or the ab- dominal cavity, and even of the system generally, seems to be favoured by insanity; and it is to these diseases that a fatal termination is often owing. Many consider the occurrence of these diseases accidental, but they are so frequently observed among the insane, relatively to other classes of persons, that something more than chance is concerned in their production. As I believe that insanity—and particularly certain forms of it—is more or less connected with general debility of the organic nervous system, expressed more especially in the brain, so I consider that the functions, and subsequently the structure, of other important organs will suffer during the continuance of it, particularly if any predisposition to disorder in these organs have already existed. And, accordingly, we find that those viscera most obnoxious to disease, especially in weakened states of vital energy, are the most frequently attacked.— a. Most writers and observing practitioners have re- marked the great number of instances in which the death of insane persons was owing to tu- bercular consumption and inflammations of the pleura. In these cases, the pulmonary disease has generally proceeded in an insidious or latent form, until shortly before the fatal event has taken place. In many, insanity may be view- ed as inducing a disposition to disease of the lungs, and as favouring the operation of its ex- citing causes, which may be more than usually influential and frequent in their operation du- ring mental disorder. Dr. Greding found that 40 out of 100 maniacs, and 20 out of 25 melan- cholies, laboured under phthisis; and that 74 of 100 maniacs, and 20 out of 24 melancholies, were found to have more or less effusion either in one or both cavities of the thorax. This may be an extreme frequency of these compli- cations, or be owing to local or peculiar causes; but there can be no doubt of their frequency. Insane persons affected by these diseases of the lungs lose their strength, suffer slow or hec- tic fever, become emaciated, and at last have cough and shortness of breathing, with diar- rhoea. In this state, the insane symptoms rather increase than abate, and generally continue un- til death. In some cases the pulmonary disor- der precedes the mental disorder, or accompa- nies it. This is especially the case with mel- ancholia, as remarked by M. Esquirol, and with hypochondriacal monomania. In these, the im- pairment of vital power affects both the lungs and the functions of the brain, and sometimes both nearly simultaneously. neath them; their adhesion, by cord-like attachments, to the brain; and a degeneration and discoloration of the cin- eritious substance of the latter. " Death comes either very suddenly from cerebral con- gestion or epileptiform convulsions, or lingers long, until, from a generally depraved condition of the secretions, gan- grenous eschars, and sloughing of the flesh from the bones, and sometimes absolute loss of muscular action in nearly all parts of the system, the poor unfortunate patient ap- pears but little more than a motionless mass of corruption. " It is a remarkable fact, that while this affection is so prevalent in France as to have induced Esquirol to assert that ' one half of the insane die paralytic,' it is almost un- known in this country. Dr. Bell, of the M'Lean Asylum, mentions ' twelve or fifteen well-marked cases' which have been under his care. " The writer has had seven cases under treatment, nei- ther of which (a fact which is also stated by Dr. Bell in regard to those just nieutioned) was cured."—(Earle, in New-York Jour. Med., Nov., 1845, p. 378.)] INSANITY—Fatj 212. 8. Diseases of the heart and great vessels are also often concerned in hastening a fatal issue of insanity. M. Foville states that five out of six bodies display, upon examination af- ter death, some organic disease of the heart and great vessels, particularly hypertrophy of the heart. This is most probably owing, in part, as he supposes, to the violent efforts and agi- tation of insane patients. 213. y. Although diseases of the digestive or- gans frequently exist previously to the appear- ance of insanity, and are often more or less concerned in causing it, yet they often do not become objects of attention until after it has fully declared itself, when, from their nature or severity, they obtrude themselves upon the no-. tice. Whether the disorder consist of gastro-; intestinal irritation or not at the commence- ment, it frequently passes into it, and at last terminates in ulceration, originating chiefly in the mucous follicles, or in abrasion of portions of the mucous membrane. At the beginning • of the mental disorder, and particularly of mel- ancholia and mania, constipation is both obsti- nate and of long continuance, the most drastic or active medicines being required to act upon the bowels. But it generally at last gives way, and is followed by, or alternates with, diarrhoea. which sometimes passes into dysentery, and which rapidly exhausts the strength of the pa- tient without abating the mental disorder. 214. d. The cachexia already noticed frequent- ly dssociates itself with other maladies; in caus- ing a fatal termination of insanity, particularly with disease of the alimentary canal, and en- largement, obstruction, torpor, and congestion of the liver, and even also of the spleen. In many cases, this state of cachexia is evinced by a sallow, lurid, dirty, and scaly state of the skin, and by papular eruptions or discoloured patches. It sometimes proceeds to more ob- vious disease of the fluids and soft solids ; fu- runculi and carbuncles break out in different parts of the body, and sometimes slough exten- sively ; the gums become spongy and sore, and bleed upon the slightest irritation; livid blotches occasionally appear on the lower extremities, and complete scurvy at last supervenes. In other cases, emaciation, occasionally amount- ing to marasmus, a cold and clammy state of the general surface, diarrhoea, and colicky pains in the abdomen, take place, either with or with- out the more obvious indications of scurvy, and the patient sinks from the gradual decay of vi- tal power, and the effects of this decay upon the digestive, the assimilative, and nutritive functions. These cases are most frequently met with in dementia and chronic mania, the mental faculties indicating a failure of the vital manifestations of the brain altogether similar to that of the other important organs of the body. 215. d. There are other maladies of more acci- dental occurrence, which often terminate the life of the lunatic.—These, as well as the most of those just noticed, may be masked by the mental dis- ease, or entirely concealed by it, until they reach a serious or even dangerous form, or they may not be detected until disclosed by a post-mortem examination. The complaints of the patient even are often overlooked and taken for delu- sions. This is especially the case in hypo- chondriacal monomania and melancholia. But II 69 Termination of. 545 •the truly observing physician will frequently recognise, in the delusions of the insane, bod- ily disease of a serious nature. Several of the delusions already noticed have been shown to depend upon contingent organic lesion of a vi- tal or important organ. Sufficient proofs of the truth of this have been adduced above (y 21); and I need not farther allude to this topic than to press the importance of this connexion, and the necessity for carefully ascertaining what connexion may exist between the illusion en- tertained and visceral lesion. Many of the dis- eases which may be viewed as accidental only as respects their occurrence in lunatics, may, in some degree, be owing to the physical state of these individuals, inasmuch as they are more frequently attacked by these diseases, and suf- fer more severely from them than any other class of persons. Fevers and chronic inflam- mations are often met with among them, the former generally assuming a typhoid character, with predominant cerebral affection, and fre- quently terminating fatally ; the latter often giving rise to effusion, and causing death in consequence. 216. e. The diagnosis of visceral diseases in lu- natics is remarkably difficult, owing either to the unfounded complaints made by them under the influence of fancied and erroneous sensa: tions, or to the extent to which the mental dis- order masks the physical disturbance. Many lunatics labour under severe diseases without evincing them by any expression, because ei- ther these diseases do not occasion much suf- fering, or the disturbed state of their minds pre- vents the morbid sensation from being perceiv- ed. In this latter respect, the diseases of lu- natics are more obscure than those of infants, because the latter express their ailments by their cries and attitudes. M. Georget justly remarks, that where we observe a lunatic, who had previously been agitated and furious, be- come morose and taciturn, and, at the same time, lose his appetite, seek repose, and display a suffering and dejected expression, we ought to examine him carefully, for he is attacked with acute disease. The development of symp- toms will soon point out the seat and nature of the malady. But chronic affections are so slow in their approach, and so latent in respect of their symptoms, that they often reach a very advanced stage before their existence is sus- pected, unless a careful examination had been made before, as well as after their commence- ment. This is especially the case in regard of diseases of the lungs, hear', pleura, and of the organs of digestion. From this, it is manifest that insane persons should be carefully watch- ed and examined, and that the states of the lungs and heart should be investigated from time to time by percussion and auscultation. 217. /. The rates of mortality among lunatics have received much attention from M. Esqui- rol and Mr. Farr ; the former of whom states, that the highest rate, for the two sexes, is be- tween the ages of 40 and 50: that of women is greatest between 50 and 60; that of men be- twen 40 and 50. A greater number of men than women die insane; and this is partly ow- ing to the greater frequency of the more dan- gerous complications in the former than in the latter. M. Esquirol concludes, from a com- parison of different hospitals, the deaths to be, 546 INSANITY—Fatal Termination of. in mania, 1 in 25 ; in monomania, 1 in 16 ; in melancholia, 1 in 12; and in dementia, 1 in 3. He farther states, that a greater number of deaths take place in December, January, and February than in any other three months. Mr. Farr states, that the mortality furnished by Bethlem, St. Luke's, and the asylums at Staf- ford, York, Lincoln, Gloucester," and Hanwell, amounted to 10 40 out of 100 treated ; that the annual mortality among lunatics was 9 per cent.; and that the mean ages of those admit- ted at Bethlem varied from 36 to 39. That no precise idea can be formed, however, from these data, of the mortality of the insane, is evident, from the fact that two of the principal of these institutions do not admit any but recent cases, and that they do not allow these cases to re- main longer than one year. Enough, notwith- standing, is adduced to prove that insanity re- markably shortens the mean duration of life. [At the Massachusetts State Hospital, from 1833 to 1841, inclusive, the mean average age of 99 patients who died was 46-4 years, that of men being 47-2, and that of women 45 6 years. At the Pennsylvania Hospital (Blockley), of 176 patients, in 1841, 48 were more than 50 years old. At the Boston City Asylum, in 1840, of 208, 32 were more than 50, and 2 more than 70 ; and at the Worcester, Massachusetts, Asy- lum, during the first 9 years, of 1359 patients, 268 were more than 50. At the Maine Hospital, 1840 to 1841, of 135 admissions, 6 died, or 4-44 per cent. At the Massachusetts Hospital (Wor- cester), 1833 to 1841, 9 years, of 1359,109 died, or 7 50 per cent, of admissions. At the Ver- mont Hospital, at Brattleborough, 1837 to 1841, 5 years, of* 396 admissions, 21 died, or 5 32 per cent. At the Virginia Hospital, at Staunton, 1836 to 1841, 5Jf years, of 131,21 died, or 16 00 per cent. (12, in 1840, by dysentery). At the Ohio Asylum, Columbus, 1839 to 1843, 3 years, of 343 admissions, 36 died, or 10 49 per cent. At the Kentucky Hospital, at Lexington, 1824 to 1840, 16£ years, of 841, 337 died, or 40 65 per cent. (43 of Asiatic cholera). At the M'Clean Asylum, Charlestown, Massachusetts, 1818 to 1834, 16 years, of 1122 admissions, 96 died, or 8-55 per cent. South Boston, 1839 to 1841, 1£ years, of 153 admitted, 9 died, or 5 88 per cent. Hartford Retreat, Connecticut, 1824 to 1841, 17 years, of 1068 admitted, 69 died, or 6 45 per cent. Pennsylvania Hospital, Philadelphia, 1752 to 1841, 89 years, of 4366 admitted, 610 died, or 13 97 per cent, of admissions (many of delirium tremens). Ditto (Blockley), 1841, 1 year, of 176 admitted, 9 died, or 511 per cent. Belle- vue, New-York, 1791 to 1821, 30 years, of 1553, 154 died, or 991 per cent. Bloomingdale Asy- lum, 1821 to 1841, 21 years, of 2598,240 died, or 9 25 per cent. Frankford, Pennsylvania, 1817 to 1841, 25 years, of 784 admitted, 108 died, or 13-77 per cent, of admissions.—(Earle.)] 218. Considerable difference exists in esti- mates formed by writers of the numbers of deaths from the prevailing diseases among lu- natics. Indeed, no precise data can be furnish- ed on this point; for those who parade numer- ical data or details in this, as well as in other maladies, by no means satisfy us in what man- ner those details have been obtained. Numer- ical results, unless furnished by the ablest and most discriminating observers, and with the utmost accuracy and good faith, may mislead more than instruct; and this is a subject on which it is next to impossible to furnish them with precision. Besides, the comparative prev- alence of fatal diseases in lunatics will neces- sarily vary in different places, with numerous related circumstances and contingencies.* The diseases, also, of the insane are often so com- plicated that different observers may impute the fatal result to different affections or lesions even in the same cases, although the matter may seem to have been placed beyond dispute by a post-mortem examination. Thus, tubercu- lar formations in the lungs and extensive ulcer- ations in the bowels will often be found in the same case; or disease of the liver, lesions in the brain, and inflammation of the peritoneum, or of the pleura, in another ; or changes in the heart, effusions into the cavities, and lesions of some other organ, in a third ; and hence dif- ferent physicians may ascribe death to very dis- tinct organic changes. Some, even, satisfied with the alterations presented by one vital or- gan, may leave other important viscera either entirely unexplored, or insufficiently investiga- ted, although they may be equally, or even more affected. 219. Notwithstanding these objections, it may be conceded that the most fatal maladies among the insane occur nearly in the following order as to frequency: more or less sudden deaths from apoplexy, coma, and convulsions ; pulmonary and pleuritic lesions; nervous, ty- phoid, adynamic, and putro-adynamic fevers, usually with predominant affection of the brain; general palsy ; general cachexia, frequently with colliquative diarrhoea ; organic lesions of the liver, bowels, and mesenteric glands, caus- ing marasmus, &c. ; exhaustion of vital power without sufficient alteration of structure to ac- count for death; structural change of the heart, &c. ; and dropsical effusions into shut cavities, particularly the pleural and pericardiac; morti- fication, chiefly of parts pressed upon, and of the extremities ; organic changes in the stom- ach and pylorus ; chronic peritonitis, generally latent; alterations of the uterus, spleen, and pancreas, &c. Organic lesions of the brain, lungs, heart, and digestive organs are found variously associated, in most cases, upon ex- amination after death ; those of one organ pre- dominating over the rest in different cases, and * [We are also to bear in mind the dissimilarity in the na- ture of the institutions for the treatment of the insane ; some, for example, are public establishments under the direction of municipal governments ; others are endowed, and under the care of a board of trustees; others, again, are private in- stitutions. Some receive a large number of cases of delirium tremens, or intemperate persons, while others receive few or none ; some receive paupers exclusively, others pauper and pay patients, while a third receives pay patients alone. At Bloomingdale, no application for admission is rejected, what- ever may be the state or condition of the patient, curable or incurable, in ordinary physical health, or in articulo mor- tis (Report for 1842). At the Hartford and M-t'Iean asy- lums, no patient is admitted for a less period than three mouths; whereas, in most institutions, there is no restric- tion in regard to time. All these circumstances must ne- cessarily affect the results both of recoveries and deaths, to say nothing of the influence of locality and of prevailing ep- idemics, or particular types of disease ; to these should be added the length of time the asylums have been in opera- tion, as the mortality during the first few years is found to be much less than in subsequent periods, except in those institutions from which the patients ure invariably dis- charged at the end of the year. Much will also depend on the nature of the patients first received. In most instances a very large number of chronic and incurable cases are re- ceived on the first opening of an insane hospital, and th*. I ratio of recent cases increases with the lapse of time.] INSANITY—Fatal Termination of. 547 seldom presenting a due relation to the symp- toms or disorders complained of, or manifested during life. Diseases in the abdominal organs, and particularly in the intestinal mucous sur- face, are among the most frequent morbid as- sociations of insanity, but generally contingent upon it, and not until an advanced period of its progress; although, as will appear in the se- quel, they are also important physical causes of it. M. Esquirol observes, that of upward of 600 examinations after death, three eighths die of diseases of the abdomen, two eighths of diseases of the chest, and three eighths of al- terations of the brain and membranes. The proportion here assigned to the first class of diseases is probably too high, and especially in respect of this country. A very able writer re- marks, that the reports of lunatic asylums partly show that the corporeal ailments under which the patients languish and die are very often overlooked, and are, consequently, not met by proper treatment; and that these establish- ments are made a kind of show-houses, instead of being hospitals for the complicated diseases which involve the functions of the mind. " We grant," he goes on to state, " that the mental malady may often be but the first sign of that total impairment of the frame which phthisis, or hydrothorax, or scorbutus, or paralysis, or marasmus afterward more plainly declare ; but we suspect there are cases in which, if the life of the patient were preserved through some of the maladies supervening on the mental disor- der, the mind would be found to be restored, and the malady to be critical. With the pres- ent management of lunatic hospitals these con- jectures can neither be verified nor refuted. In many of them medical aid is considered to be nearly superfluous; and in some, we are in- formed that the appointment of physicians in ordinary has been, if not rejected by the gov- ernors, at least subjected to grave debate, as if the county asylum were no more than a supple- mentary county jail." — (Brit, and For. Med. Rev., No. xiii., p. 30.) [Dr. James Macdonald, late principal of the Bloomingdale Asylum, states (New-York Journ. of Med., vol. i., p. 337), that of 160 insane pa- tients who died in the asylum, the diseases of 117 were as follows: Asthenia, 19; phthisis, 17 ; delirium tremens, 10 ; fever, 9 ; apoplexy, 9; epilepsy, 8; palsy, 8 ; inflammation and softening of brain, 8 ; inflammation of bowels, 5 ; dysentery, 4 ; suicide, 4 ; diarrhoea, 3 ; drop- sy, 3; concussion of brain, 2 ; cholera morbus, 2 ; cholera Asiatica, 2 ; strangulation occur- ring to paralytics while eating, 2 ; abscess of liver, 1 ; lumbar abscess, 1 ; erysipelas, 1; in- flammation of lungs, 1; starvation, 1; total, 117. The term asthenia, Dr. M. states, is used to designate that state of exhaustion or loss of vital force which follows long continued and excessive mental and nervous excitement, and into which the insane often fall. As shown by the above, more die in this state than by any single disease. If all the diseases of the brain, including apoplexy, palsy, inflammation, &c, be added together, it will be found that a larger number have been destroyed by them than by the diseases of any other system. They amount to 32 in 117 deaths. Of 102 fatal cases at Worcester, Massachu- setts, Dr. Woodward gives the following caus- es : Marasmus, 24 ; epilepsy, 14 ; consump- tion, 9 ; apoplexy, 8 ; suicide, 7 ; disease of the heart, 6 ; cholera morbus, 4; mortification of the limbs, 3 ; haemorrhage, 3 ; inflammation of the bowels, 2 ; disease of the brain, 2; dropsy, 3 ; diarrhoea, 2; brain fever from intemper- ance, 2 ; dysenteric fever, 2 ; chronic dysen- tery, 2; lung fever, 2 ; old age, 1 ; chronic bronchitis, 1 ; gastric fever, 1; land scurvy, 1; congestive fever, 1 ; erysipelas, 1 ; disease of bladder, 1 ; total, 102. The term marasmus, in the above, is probably nearly equivalent to the term asthenia, as employed by Dr. Macdon- ald. Dr. W. remarks, that there is an eryth- ematic inflammation of the brain, attended with a bloodshot eye, a hot skin, rapid pulse, dry tongue, and muttering delirium, which is often mistaken for insanity ; and that if these improper cases were deducted from the list of deaths, it would materially lessen the bills of mortality. Of the 102 deaths, 23 took place within 20 days after admission ; 10 of which were recent, and 13 old cases ; 13 males and 10 females. The above will convey a very cor- rect idea of the causes of death in insanity in other institutions, as well as those above men- tioned. The mean average of age at death, of both sexes, was 46 (males, 47 ; females, 46).— (Ninth Annual Report of State Lunatic Hospital, at Worcester, 1841.)] 220. M. Esquirol gives the following tables of the mortality in insanity, according to the ages: No. Bicetre. of Men admitted from 1784 to 1794, 2405. 20 to 30......25 30 to 40......176 40 to 50......215 50 to 60......134 60 to 70......90 70 and upward ... 45 685" Salpetriere. No. of Women admitted from 1804 to 1814,2804. 20 to 30......58 30 to 40......83 40 to 50......143 50 to 60......173 60 to 70......123 70 and upward . . .210 79lT Table of the Mortality at the Salpetriere during 10 Years. 271 301 292 297 252 299 260 233 301 298 2804 Deaths during this period among those admitted be- fore 1804.............._52 _________________________________________________790 Of 790 deaths at the Salpetriere, from 1804 to 1814,382 occurred in the first year after admis- sion, 227 in the second, and 181 in the seven following years. 221. The table of deaths from insanity, and from the diseases of the brain most nearly alli- ed to insanity (p. 548), is made up from the " Abstracts of the Causes of Deaths registered in England and Wales from 1st of July to 31st of December, 1837, both inclusive." These abstracts, and the remarks accompanying them, by Mr. Farr, are extremely valuable to medical men. Table of Deaths from Insanity, and from Diseases MOST NEARLY ALLIED TO IT, IN England and Wa les, from 1st of July to 31st of December , 1837, inclusive. Names of Places. Area in Acres. Population according to the Census of 1831. Insanity. Delirium Tremens. Cephalitis. Paralysis. Apoplexy. ' Epilepsy. LIISEASE ol the Brain. 3 EL *4 I EL H o EL I H 3 S1 B EL i-3 o E. 3 5", 1 c EL S? B EL H o el 3 EL 3 EL EL i EL o EL The Metropolis, and parts of Middlesex, Surrey, and 44,810 37,797 38,060 41,520 2,660 1,323,888 3,861,100 1,407,913 1.691,572 '866,474 987,087 928,589 2,118,867 1,295,379 3,936,980 2,355,462 140,798 2,216,515 1,131,270 1,250,530 730,945 2,104,736 88,708 1,590,448 1,594,890 236,935 218,233 135,581 110,914 515,893 1,351,236 373,797 503,118 304,785 451,252 304,315 682,788 311,714 1,045,133 977,108 223,457 721,555 905,501 773,254 199,515 319,042 318,941 338,273 1,016,219 39 1 8 1 5 9 16 3 3 1 5 0 7 0 5 13 2 8 9 4 0 1 1 1 6 39 1 1 0 5 4 14 3 2 1 2 6 15 0 7 8 1 12 6 4 2 2 2 0 1 77 2 9 1 10 13 30 6 5 2 7 6 22 0 12 21 3 20 15 8 2 3 3 1 7 30 0 0 1 1 4 9 2 4 0 3 2 2 2 5 4 0 3 1 4 2 4 0 0 3 4 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 3 0 0 0 0 0 0 1 34 0 0 1 1 5 9 2 4 0 3 2 2 2 5 4 0 6 1 4 2 4 0 0 4 159 9 7 11 5 21 53 10 21 8 17 12 21 7 18 41 9 26 36 26 8 12 20 13 7 135 14 6 9 3 18 37 6 11 5 14 9 15 8 27 33 7 ; 11 22 27 4 8 12 7 6 294 23 13 20 8 39 90 16 32 13 31 21 36 15 45 74 16 37 58 53 12 20 32 20 13 161 23 22 1 8 28 95 42 39 18 22 18 39 22 65 63 9 45 58 33 10 23 57 33 73 176 17 13 7 13 27 107 44 32 30 27 17 63 13 78 83 11 51 50 21 13 31 34 22 72 337 40 35 8 21 55 202 86 71 48 49. 35. 102 35 143 146 20 :96 108 54 23 54 91 55 145 259 25 34 13 14 60 188 33 61 25 42 32 58 .24 96 104 11 64 69 40 34 41 40 21 60 230 6 17 10 11 61 168 37 64 30 29 35 59 22 72 87 21 60 44 42 28 36 30 26 39 489 31 51 23 25 121 356 70 125 55 71 67 117 46 168 191 32 124 113 82 62 77 70 47 99 64 3 6 0 4 1*1 30 9 12 1 8 8 11 4 20 12 3 13 15 12 9 7 0 3 13 43 4 7 1 2 19 32 12 8 6 6 11 9 9 21 21 2 19 14 9 12 4 1 4 16 107 7 13 1 6 30 62 21 20 7 14 19 20 13 41 33 5 32 29 21 21 11 1 29 570 91 10 2 16 5 8 66 5 14 4 17 8 11 5 33 50 5 14 10 18 5 9 10 8 14 436 71 8 5 9 5 17 35 3 12 4 11 5 14 26 32 4 14 6 10 3 10 5 3 326 162 18 25 10 25 101 8 26 8 28 13 25 12 59 82 9 28 16 28 8 19 15 15 1 17 764 Part of'Middlesex, Hertfordshire, Buckinghamshire, and Kent, part of Surrey, Sussex, Hampshire, and Berk- ■p Cambridgeshire, Huntingdonshire, and South Lincoln- North Lincolnshire, Rutlandshire, Derbyshire, Notting-hamshire, Leicestershire, and Northamptonshire . . Oxfordshire, Gloucestershire, Worcestershire (except Dudley), and Warwickshire (except Birmingham) . . Mining parts of Shropshire, Worcestershire, and Stafford- Cheshire, Shropshire, and Staffordshire (except mining Lancashire (except Liverpool and Manchester), south of West Riding of Yorkshire (except the northern part Durham, and the North Riding of Yorkshire, with the remainder of the West Riding (except the mining The mining parts of Northumberland and Durham . . Cumberland and Westmoreland, with the remainder of Area in Sq. Miles. 57,805 13,897,187 147 138 285 86 9 95 567 454 1021 987 1052 2039 1 1447 1264 2711 278 292 INSANITY—Appearances in the Brain after Death. 549 It is to be hoped that the reports of the regis- ter-general will appear annually. Mr. Farr states, that the insane who die in lunatic asy- lums have often been registered, improperly, under secondary diseases, such as apoplexy and diarrhoea. Under the head of violent deaths are included suicides, accidents, &c. ; and it cannot be doubted that the great majority, at least, if not the whole of suicides, are instances of some form or grade or other of insanity. 222. V. Of the Alterations of Structure connected with Insanity.—It is evident, even from what I have already stated, that few dis- eases are connected with so great a diversity of structural changes as insanity, and there is none which has given rise to so much discus- sion and difference of opinion as to the nature of this connexion as it has occasioned. It has even attached to itself a very particular inter- est at present, owing partly to its importance, and partly to the very opposite views enter- tained respecting it by some of the most expe- rienced of recent writers on mental diseases. But little information was furnished on this subject previously to the almost contempora- neous publication of some cases,, with the post- mortem appearances, by Morgagni and Meckel. Ballonius, and, long afterward, Bonet, had fur- nished a few particulars ; but these were rath- er of lesions found in the thorax and abdomen than of changes within the head; and it was not until the investigations of Greding, Mar- shall, and Haslam appeared that the appear- ances of the brain in fatal cases of insanity re- ceived any degree of attention. More recently, the researches of Pinel, Esquirol, Georget, Bayle, Lallemand, Bouillaud, Neumann, Guis- lain, Calmeil, and Foville have been most as- siduously directed to this interesting subject; still, the results furnished by them are of such a kind as to prove the necessity for farther in- vestigation, carried on independently of precon- ceived opinions. Although British writers have hitherto contributed but little to this depart- ment of medical knowledge, it is to .be hoped that those who have the management of public institutions for insanity in their hands will see the advantages which will result contingently even to those connected with themselves—will catch a glance of their own interests prospect- ively—from the encouragement of researches into the pathology and treatment of the most distressing of all maladies, not merely for the benefit of the few subjects of the maladies to whom they are guardians for a time, but also for the instruction of those to whom the com- munity have to look for aid in these calamities, and, consequently, for the advantage of all class- es in society. 223. i. Morbid Appearances observed in the Head.—A. The cranium seldom presents any change from the healthy shape, excepting ' in epileptic or idiotic lunatics. Greding states that, of 220, only 16 had the forehead contract- ed, the temples compressed, and the occiput large and expanded. In a few, the head was elongated and compressed laterally. In some, the head was almost round, or of a square shape: these were chiefly epileptic lunatics and idiots. I have observed, in (his class, one side of the head higher than the other, and sometimes, also, more prominent, while the other side receded, giving rise to the diamond- formed obliquity or deformity of the skull de- scribed by me in the article Cranium (§ 9). Of 26 cases, including epileptic lunatics and idiots, Greding observed 2 belonging to these latter with very small and quite circular heads. Of the whole number of cases (220), the skull was unusually thick in 167; this was observed in 78 out of 100 cases of mania, and in 22 out of 30- idiots. In some cases the cranium was re- markably thin. Numerous foramina were ob- served in the inner table of 115 out of 216 ca- ses ; and, in some instances, bony projections arose from this table. Similar changes in the cranial bones were noticed by Neumann and Georget, the latter of whom has inferred hy- pertrophy of these bones to be still more fre- quent in lunatics than stated by Greding. The bones of the head have likewise been observed more vascular than natural by Calmeil and others. (See art. Cranium, § 9-12.) 224. B. The membranes of the brain are fre- quently altered.—a. Greding found the dura mater adherent to the cranium in 107 out of 216 cases ; in a few instances, of a bluish black colour, thickened, and containing ossific depos- ites. Similar lesions were observed by M. Georget, who also detected the arachnoid some- times thickened, but smooth, and occasionally presenting, in places, additional lamina of a red or gray colour. The pia mater was, according to this pathologist, injected, thickened, and in- filtrated with serum, giving it at first the ap- pearance of a gelatinous deposite. Greding found it thickened and opaque in 86 out of 100 cases of mania, and beset with small spongy bodies in 92 out of 100; these bodies being united to the surface of the brain, and in some instances containing ossific matter. M. Cal- meil has described these excrescences, granu- lations, Or spongy bodies, to arise or grow from the pia mater, so as sometimes to penetrate the dura mater and cause absorption of the inner bony surface of the cranium.- and he has re- marked, that infiltrations and thickenings of parts are almost constantly found under these excrescences. The above changes in the mem- branes, and particularly in the arachnoid, have been recorded also by Haslam, by Guislain, and by M. Bayle. To these alterations, and to ef- fusion of serum between the membranes and in the ventricles, this latter physician ascribes the chief phenomena characterizing and contin- gent upon insanity. 225. b. Effusions of serum between the dura and pia mater were observed by Greding in 120 out of 216 cases of insanity, and in 58 out of 100 maniacs; and between the pia mater and surface of the brain, in 28 out of 100 cases of mania. The lateral ventricles were full of serum in 29 instances, and remarkably distend- ed in 23. They were equally distended in 10 among 24 cases of melancholia. The third ventricle was quite full in 57 out of 100 mani- acs, and in 16 out of 24 melancholies. The fourth ventricle was distended to the utmost in 80 out of 100 maniacs, and quite empty only in 3. It was greatly distended in every one of 24 melancholies examined. Dr. Haslam found serum effused between the membranes in 16, and in the lateral ventricles in 18 out of 37 ca- ses. Effusions between the membranes and in the ventricles were met with also by MM. Georget, Guislain, and Bayle, the last of 550 INSANITY—Appearances in the Brain after Death. whom ascribes insanity to inflammatory irrita- tion of the membranes; effusion following upon the inflammation, in his opinion, and occasion- ing the cessation or diminution of maniacal vi- olence, the great loss of power in the intellect- ual faculties, and the commencement of gen- eral paralysis, owing to the pressure caused by the effusion. According to this view, the prog- ress of dementia, fatuity, and general paraly- sis indicates a corresponding increase of effu- sion and of pressure on the brain. Other wri- ters, who differ from M. Bayle as to the origin and seat of insanity and general paralysis in chronic inflammation of the membranes, and of serous effusion from them, readily admit the great frequency of these lesions. Lallemand, Calmeil, Bouillaud, Casauvieilh, and Foville have all described similar changes to the above, but have viewed them more in connexion with alterations in other parts, and estimated them differently. 226. c. The choroid plexus was found in a healthy state by Greding in 16 cases only out of 216, and thickened and full of hydatids in 96 out of 100 maniacs. M. Georget has remarked that the choroid plexus was exsanguineous, and contained hydatidiform vesicles. The lateral ventricles were, in some instances, very small, but much more frequently large and distended, as just stated, with serum, which was remark- ably clear and limpid. The convolutions of the brain were often observed by M. Georget separated by an effusion of serum, and the pia mater thickened. 227. d. M. Foville states that, in acute ca- ses, the morbid appearances discovered in the meninges were chiefly injection of the pia ma- ter ; and that this injection was generally pro- portioned to the degree of inflammation exist- ing in the cortical substance of the convolu- tions. The small arteries and veins passing from the membrane and penetrating the gray matter were distended with blood : the arach- noid, in these cases, generally retains its natu- ral aspect. The chronic changes in the mem- branes, according to this observer, consist, for the most part, in opacity, increased consistence, thickness of the arachnoid, the formation of granulations and false membranes on its sur- face, and the effusion of serum into the cellular tissue of the pia mater and into the ventricles. The arachnoid is often, in patches or more ex- tensively, of a pearly whiteness. The opacity of this membrane is always attended by thick- ening, and in the place where the arachnoid and pia mater are naturally contiguous, they are found to be adherent. The opaque patches result from the deposition of albumen upon the arachnoid. 228. C. The substance of the brain has been more closely examined in cases of insanity, in recent times, than heretofore. Indeed, the progress that has lately been made in the mi- nute anatomy of this organ will necessarily enable the pathologist to recognise many le- sions of its structure, which were entirely over- looked in former times. The researches of M. Foville into the state of the brain in persons who have died insane are of great importance, and were carried on by him in the Salpetriere, aided by MM. Delaye and Pinel Grandchamp, and subsequently in the extensive hospital of St. Yon, near Rouen, which is under his care. The morbid appearances which I proceed to describe as having been observed in the brain, are chiefly the results of his investigations. 229. a. The gray substance of the brain pre- sents, in the most acute cases, on the removal of the membranes, intense redness of its sur- face, approaching to that of erysipelas. This is still more marked in the substance of the cin- eritious tissue itself; and it is more striking in the frontal region than in the temporal and lat- eral lobes, and in the higher regions than in the posterir parts. In acute cases of insanity, M. Foville states that the changes in the gray matter consist of uniform and intense redness of colour, with numerous mottled spots, vary- ing from a bright to a violet red, and bloody points or minute extravasations of blood ; of diminished consistence of this structure, coin- cident mostly with a slightly increased consist- ence of its surface; and of dilatation or enlarge- ment of its vessels. He has never observed, in these acute cases, adhesions of the mem- branes to the cortical substance, which are very frequent in chronic cases. To this cir- cumstance he ascribes the curability of recent cases, and the incurability of dementia and chronic cases. 230. In these latter cases the gray or cortical substance becomes much firmer and dense in the superficial part; and this part, owing to its uniformity, constitutes a distinct lamina, smooth externally, but irregular internally ; of a light- er colour than usual, and admitting of being torn or peeled off, leaving the remainder of the gray substance red, soft, and mammillated. Sometimes this pale and dense surface, or part of the cortical substance, is rough and granu- lated, containing small grains of a yellowish white. In conjunction with these, the volume of the convolutions remains natural, or is less- ened or atrophied. When it is the latter, linear depressions or irregular pittings exist on the surface of the convolutions ; and in the gray substance itself, small yellowish lacunae, filled with a yellowish serum, are found. These lacunae are supposed to correspond with, or to be the remains of the minute extravasations observed in acute cases. In other instances, the diminution of volume is a real atrophy of the convolutions, which appear thin and angu- lar, as if pinched up towards their extremities. This change is very frequent in the frontal re- gions of the hemispheres, and often particular- ly comprises three or four convolutions in each side of the sagittal suture ; a chasm filled with serum, occupying the place left by the absorbed substance. Coexistent with this alteration, is often observed a limited atrophy of the crani- um, or a circumscribed disappearance of the diploe, owing to which the external table ap- proaches the inner, leaving a superficial de- pression. In this atrophy of the convolutions the diminution of substance is confined fre- quently to the cortical or gray matter; what remains of it being harder than natural, and sometimes presenting, on close examination, a fibrous structure. It is also of a darker colour, and occasionally seems separable into layers, the exterior being pale, and the interior of a rose eolour. 231. Softening of the gray substance is also often observed in chronic cases of insanity, ex- tending through its whole thickness, and not INSANITY—Appearances in the Brain after Death. 551 superficial merely. This softening is generally attended by a greater depth of colour, which often approaches to brown, and is frequently so great as to amount almost to liquefaction of this structure. This extreme and general soft- ening of the cortical substance is not necessa- rily attended by a similar change of the white structure, but is sometimes conjoined with a hardened state of that structure. In these ca- ses the gray may be separated from the white substance by the effusion of water. These more extreme alterations are found, especially in the worst cases of dementia, complicated with paralysis and marasmus. MM. Foville and Calmeil have met with instances of this description, in which limited portions of the gray substance had disappeared previously to death. The gray structure in other parts of the brain does not present the same changes as have now been described as taking place in the convolutions, but generally exhibits altera- tions similar to those of the medullary or white substance. The cortical structure, however, of the cornu ammonis is in some cases soften- ed, and in others hardened. 232. b. The white or fibrous structure of the brain is often found altered in colour, density, and texture. It is frequently injected, and its vessels more or less enlarged, exhibiting nu- merous bloody points on sections of it. In oth- er cases it has a mottled appearance, of a deep red or violet hue, owing, as M. Foville be- lieves, to a finer injection of its vessels, as shown by the magnifying glass. These in- jections of the white structure do not always coincide with similar injections of the gray sub- stance. Sometimes the fibrous or white struc- ture is splendidly white, and generally, at the same time, increased in density, or hardened. This induration occasionally amounts to an al- most fibro-cartilaginous state. In two or three cases I have observed the increase of density nearly to resemble the white kind of caout- chouc. The hardened fibrous structure, how- ever, may not be remarkably white ; it is some- times of a yellowish, or of a grayish or leaden tinge. M. Foville accounts for the induration of this structure by supposing that the cerebral fibres have contracted adhesions to each other, so as to render their separation impossible. According to him, the fibrous mass of the hemispheres consists of several distinct layers or planes of fibres applied one upon the other, and connected by very fine cellular tissue. These planes are easily separable in the healthy state, but become inseparable in the course of mania. The occurrence of tubercles and tu- mours in the brain is considered by him as ac- cidental when met with in cases of insanity. 233. c. The cerebellum undergoes alterations similar to those observed in the brain, but much more, rarely. 234. d. The nerves sometimes present chan- ges corresponding with disorders of sensation and perception. M. Foville has found the optic nerves hardened, and otherwise altered in persons troubled with hallucinations of sight. 235. e. The morbid appearances found in cases of insanity complicated with general paralysis have especially engaged the attention of M. Calmeil. In this association of mental and of physical disease, it is very difficult to deter- mine, as Dr. Prichard remarks, what altera- tions are connected with either morbid state ; and certainly many of the changes met with by M. Calmeil in these paralytic cases are simi- lar to those regarded by various writers as connected with insanity, without reference to its association with paralysis. This patholo- gist concludes that general paralysis is not de- pendant upon compression of the brain by se- rous effusion, as supposed by M. BAYLE,but upon the disease of the encephalon, which gives rise to the effusion, and chiefly on inflamma- tion, of which the thickenings, and lesions, and vascular turgescence of the pia mater, and the peculiar condition of the gray structure, afford sufficient evidence. M. Calmeil has succinct- ly enumerated the changes observed by him in the encephalon, in this class of complicated ca- ses, nearly as follows.- Injection and absorp- tion of the bony structure; injections of the dura mater, separation of its fibres ; effusion of serum into the cavity of the arachnoid ; false membranes, organized or without organiza- tion ; cysts filled with blood in its two laminae ; simple haemorrhages in the arachnoid ; oedema of themeninges ; injections and thickenings of the membranes ; vegetations of the pia mater, and development of its vessels ; adhesions be- tween the pia mater and the convolutions ; disappearance of the gray substance ; soften- ing, induration, and discoloration of this sub- stance ; hardening and injection of the white or fibrous structure ; redness and tumefaction of the ventricular villosities; serous effusion into the ventricles ; apoplectic cysts ; erosions of the convolutions ; softening of the brain, or of the spinal marrow. These changes are so various, and so far from uniform in occur- rence, that they cannot satisfactorily explain the results imputed to them. M. Calmeil con- siders them all to be proofs of a chronic in- flammation of the brain ; and in this, as well as in his descriptions of many of the altera- tions, he agrees with M. Foville. This latter writer states that, in lunatics affected with gen- eral paralysis, he found the induration of the fibrous structure ol the hemispheres, described above (§ 232), wanting only in two cases, and in these the cerebral nerves, the annular pro- tuberance, and the medulla oblongata presented extreme hardness. He states farther, that this induration of the fibrous structure of the brain has been found in old men whose volun- tary movements have become uncertain or vacillating ; but it has never been seen in luna- tics whose muscular powers had remained un- impaired. I have observed induration of the spinal cord, with effusion of serum between the membranes, and other changes, in two cases of general incomplete paralysis unattended by in- sanity, both patients, however, having become delirious shortly before death. 236. The brain has occasionally been so in- filtrated with serum that the fluid has flowed from the surface of the incisions. This infil- tration has been so remarkable in a few in- stances as to constitute a true oedema of the brain. Much more rarely, as observed both by Esquirol and by myself, a multitude of pores or small cavities, containing a limpid serum, have been found in the substance of the brain, a section of the part thus changed resembling that of a porous cheese. In these cases the brain may be also somewhat indurated and 552 INSANITY—Appearances changed in colour. It is by no means deter- mined, as some suppose, that these pores or cavities are the sequelae of vascular extravasa- tions ; it is more probable that they are the con- sequences of softening, the pores being left by the removal of the molecules of the cerebral substance, which have lost their vital cohesion to the rest of the structure, and filled by a se- rous effusion. 237. /. The inferences which may be drawn from these researches deserve a brief notice. It will be seen from these that M. Foville as- cribes the morbid appearances to inflamma- tion, and in this agrees with Calmeil and others. But it will be remarked by many, and not the less by those who may have read the" article Inflammation in this work, that this term has been applied, and possibly is applica- ble, to several lesions, attended by changes in the state of capillary and vascular action, each differing more or less from the other, and ac- companied with different, or even opposite con- ditions of organic nervous or vital power ; and that, although these lesions may be apparently quite similar, and be followed by nearly the same results, in different cases or persons, yet may the state of vital power or manifestation, in respect not only of the functions of the brain, but also of the whole economy, differ remark- ably in each particular instance. It is well known that the lesions constituting, as well as consequent upon several kinds of phlegmasia? —upon phlogosis, or simple sthenic inflamma- i tion, and upon erysipelas and other forms of spreading or asthenic phlegmasia—nearly re- semble each other; but they are attended by very different constitutional disorder ; and this is independently of grades of activity or inten- sity of action. Besides, something should be ] attributed, in many cases, to the influence of the moral causes, and to the consequent men- tal excitement upon the cerebral circulation, with reference not only to prolonged erethism or excitement of the capillaries distributed to j the organ of mind, but also to constitutional or i vital power, and to the various maladies of! which the cerebral affection may be only a | symptom, or sympathetic disorder. We know that, in other organs or parts, a prolonged irri- tation or excitement of their capillaries by , agents which excite chiefly the nerves supply-1 ing them, will so determine the blood to them, and so enlarge and develop their vessels, as to give rise to appearances which nearly resem- ble the consequences of inflammation. We ! find, moreover, that the most violent forms of ■ mania and of delirium, and the most fatal when ' not judiciously treated, are actually those in which inflammatory appearances are the least i evinced, or in which states opposite to inflam- matory really exist. We find, also, lesions in the brain — whether inflammatory or not — equally extensive with those observed in the most general and complicated cases of insani- ty, and without any disorder of mind having existed during life. Can we, therefore, legiti- mately impute insanity, in all cases, to these lesions 1 or may not these lesions be just as legitimately imputed to the insanity 1 There is very probably a connexion between them in most cases; but neither the exact nature of the connexion, nor the intimate relations and source of the morbid alterations observed, have in the Brain after Death. been yet fully ascertained. This is, however, no reason wherefore we should altogether re- ject the conclusions at which able and expe- rienced observers have arrived, until we ob- tain others upon which more implicit reliance can be placed. 238. The morbid changes in the encephalon, M. Foville infers to be the results of inflam- mation ; intense, diffused, and general redness; in many cases, tumefaction ; and, in passing to the chronic state, the formation of adhesions between the cortical substance of the convolu- tions and the contiguous membrane : besides this, adhesion of the different planes or layers of the cerebral substance to each other in a certain number of cases. As the different tra- ces of inflammation are more constant in the brain than in the membranes, M. Foville con- cludes that the essential change connected with insanity takes place in the brain, and that alterations of the membranes are only acci- dentally connected with it. Among the mor- bid appearances in the brain, lesions of the gray structure are considered by him as the most constant in connexion with the mental disorder. Although M. Calmeil was inclined to ascribe loss of muscular power to disease of this structure, M. Foville contends that the facts upon which he founds this inference do not warrant this conclusion. In all the cases of general paralysis he has examined, there was, besides the change in the gray structure, some alteration, either hardening, serous in- filtration, or softening of the white or fibrous substance; and in most cases, in addition to these, there were adhesions of the principal planes of the cerebral substance to each other. 239. From the circumstance of the gray sub- stance of the hemispheres being found in a state of disorganization or atrophy, in cases where intellect was abolished, and the fibrous structure being natural where muscular power was unaffected, as well as from the fact of le- sions or wasting of this latter structure being observed where voluntary motion was lost or affected, M. Foville infers that the function of the gray structure of the brain is essentially connected with the intellectual operations, and that the office of the white or fibrous part is subservient to muscular action ; and, conse- quently, that, 1st, morbid changes in the for- mer part are directly connected with intellectu- al derangement; and, 2dly, those in the latter portion are connected with disorders of the mo- tive powers. He, however, admits that in some affections of the maniacal class succeed- ing the action of debilitating causes—as in the puerperal state—nothing has been discovered in the brain more striking than its extreme and general paleness ; and that, although some mot- tled appearances of a light red or rose colour are met with, these changes are too slight to be considered as idiopathic. M. Foville is there- fore induced to consider this form of mental disorder to be symptomatic of some deep-seat- ed disease of the uterus or abdomen. But, unfortunately for his argument, of several cases of puerperal mania which I have treated, I have not met with one that did present any serious or deep-seated disease in these parts. There can be little doubt, however, that the contradic- tory evidence given by different observers of the appearances of the brain in cases of insan- INSANITY—Appearances in the Brain after Death. 553 ity is partly accounted for, as remarked by an able writer, by the existence of cases in which the affection of the brain is merely functional and sympathetic, the primary disease being in some other organ, especially in some of the ab- dominal viscera. 240. The evidence of those who believe that insanity, although often connected with organic lesions of the brain, especially in protracted and extreme cases, does not necessarily depend upon them, requires some notice. Here the experience of M. Esquirol attaches to itself great importance. He remarks, that the bodies of lunatics offer numerous varieties as to the situation, number, and kind of morbid appear- ances, and that the lesions of the encephalon are neither in relation to the disorders of the mind, nor to the maladies complicated-with it. Some lunatics, whose mental and bodily dis- ease indicated extensive organic lesions, have presented slight changes in the brain ; while others, whose symptoms had been less severe, have been subjects of great and numerous al- terations. But even in the most protracted cases of insanity no organic changes whatever have been traced, either in the brain or in its membranes. He goes on to state, " that path- ological anatomy is yet silent as to the seat of madness, and that it has not yet been demon- strated what is the precise alteration in the en- cephalon which gives rise to thisdisease." The various states of the brain, compatible with in- tegrity of the mental faculties, have never been satisfactorily investigated, and probably will never be accurately ascertained; and it is by no means easy to distinguish with sufficient precision the appearances resulting from or belonging to concomitant maladies from those which belong to the mental affection. M. Es- quirol observes, that organic lesions of the brain are declared by symptoms distinct from the mental disorder ; that chronic inflammation produces compression and paralysis, and pa- ralysis results from cerebral haemorrhage ; and that tubercles, tumours, and softening of the brain have their peculiar symptoms, which can- not be confounded with mental alienation. Moreover, the sudden and instantaneous relief experienced in some cases of madness is not to be forgotten; nor the fact that every part of the brain has been found altered, suppurated, destroyed, without chronic lesion of the under- standing. 241. The maniacal form of insanity is rarely fatal, owing to any lesion of the brain ; but from fever, phthisis, and other associated mal- adies, or from sudden exhaustion of the sensi- bility or nervous power necessary to life. In a case which terminated in this latter manner, no lesion was observed in the brain after death; and in a young woman, accidentally killed in recent and furious mania, the brain and its membranes were likewise devoid of change. When a case is watched during life, M. Esqui- rol thinks that the period at which the organic lesion of the brain commences may be known by the symptoms. When mania has existed long, he is of opinion that the weakness of the last days of life disposes to local inflammations. Upon the whole, he concludes that, notwith- standing the labours of MM. Foville, Calmeil, Bayle, and Guislain, the organic reason of mental derangement is still undeclared. " Thir- 70 ty years ago," he adds, "I should have writ- ten willingly on the pathological cause of in- sanity : I will not now attempt so difficult a labour—such are the uncertainty and contra- dictions in the results of the examination of the bodies of lunatics after death up to this day. But modern researches permit us to hope for more positive, clear, and satisfactory no- tions." In another place, he admits that a dif- ference in the results of researches may arise from the greater care with which the brain is now dissected, and the slightest changes ob- served, and that, at earlier periods of the in- vestigation into the pathological anatomy of insanity, an account was kept only of obvious alterations. 242. Respecting this matter, M. Guislain appears to steer a middle course in his more recent work on Insanity. After various details, he concludes that, in the greatest number of organic lesions of the brain, a moral origin and functional state of disorder, without alteration of structure, first exists ; and that, when such alterations are present, they consist chiefly of whatever causes pressure of the brain, as effu- sion of serum, or of blood, lymph, or the for- mation of a false membrane ; or of constriction of the organ by its membranes, which, in their state of engorgement, incarcerate or strangu- late, in some respects, the hemispheres ; or of softening or other disorganization, to an extent that is incompatible with the due exercise oi the mental manifestations. He adds, that in- duration of the brain has been often observed by him, especially in the parieties of the lateral ventricles, and in the rachidian bulb, or upper portion of the medulla oblongata ; that epilep- tic convulsions frequently attend it; that con- vulsions are often also caused by organic le- sions of the membranes, and of the cineritious structure, but not constantly either by these, or by induration ; and that they may occur even without any visible change of tissue. He con- cludes, that absence of organic alterations of the brain is indicated by the full possession of muscular action and motion, and that the ex- istence of them is evinced by lesion of muscu- lar motion and of sensibility—that simple disor- der or excitement of the mental faculties, with- out dementia or palsy, exists independently of softening orcompression of the brain ; and that dementia or extinction of the intellectual pow- ers may depend, 1st. Upon sanguineous en- gorgement of the brain ; 2dly. Upon effusion of serum between the membranes or in the ven- tricles ; 3dly. Upon extravasation of blood be- tween the membranes or in the substance of the brain ; 4thly. Upon softening of this organ ; 5thly. On atrophy of it; 6thly. On induration of it ; and, 7thly. Upon exhaustion of its vital influence. 243. ii. Alterations in the Thoracic Vis- cera.—A. The lungs are diseased in a very large proportion of the cases of insanity which terminate fatally. The proportion has been differently estimated by the writers already no- ticed. M. Georget declares that he has found organic changes in the lungs in at least three fourths of the cases which he had examined, and phthisis to have been the cause of death in more than half the lunatics in Salpetriere. He describes the pulmonary disease as always chronic, and often so obscure as not to be de- 554 INSANITY—Alterations in the Abdominal Viscera. tected until the body is inspected. In these cases, the patient neither coughs nor expecto- rates, and he makes no complaint: he wastes, gets weak ; looseness or constipation succeeds; he dies : these changes take place slowly. Yet, notwithstanding the absence of cough and ex- pectoration, excavations are found in the lungs after death. But instances of latent phthisis occur independently of insanity. When, how- ever, both maladies are associated, the latter is more frequently sympathetic, or dependant upon the constitutional disturbance caused by the pulmonary disease, than is generally sup- posed ; and it then sometimes does not appear until the softened and absorbed tubercular mat- ter has contaminated the circulation, and there- by disturbed the functions of the brain. I have observed in persons predisposed to insanity, as well as in others, that, when tubercles are de- veloped in the lungs, and when softening and ulceration follow without any communication having been made with a bronchus, the prog- ress of the disease is generally latent. The tubercular softened matter undergoes changes during its retention ; causes thickening or con- densation of the parietes of the cavity contain- ing it, even while the cavity continues to en- large, and, if it be not evacuated by the bron- chi, neither cough nor expectoration will be present. But the constitutional disturbance caused by the accumulated matter, as well as by the organic lesion of the part containing it, and still more by the absorption of a portion of it into the circulation, will so disturb the or- ganic nervous functions, as to occasion, first, functional disorder, and consecutively even or- ganic lesion of such organs as may be most prone to disease from either an original or an acquired predisposition. 244. B. The heart is often changed in struc- ture in fatal cases of lunacy. Indeed, all the lesions of which this organ is susceptible have Deen found in the bodies of the insane ; but hypertrophy, passive dilatation, and softening of the parietes of the cavities, seem to be the most frequent. The proportion of cases in which organic alterations of the heart have been found has been differently estimated by writers. Romberg (Nasse's Archiv. f. Med. Erfahr., 1817) believed that five out of seven bodies present lesions of this organ; and M. Foville considered that five out of six dis- play alterations either of it or of the great ves- sels. 245. iii. Alterations in the Abdominal Vis- cera.—A. The digestive mucous surface very frequently presents evidence of inflammatory action, especially as respects certain of the con- sequences of this state. M. S. Pinel met with inflammatory appearances in this situation in 51 out of 269 bodies of lunatics ; and of these there were only 13 of disease of the other ab- dominal viscera. These appearances have been also observed in a number of cases by Prost, Percival, and Guislain. The frequency of displacements of the colon, first insisted upon by Esquirol, and especially with reference to melancholia, has already been attended to ($ 119); and has been remarked also by Bergman, Muller, Annesley, and Guislain. In most of the cases described by Esquirol, the displa- ced colon presented none of the consequences of inflammation. In some of the instances ob- served by Percival and Bergman, the colon was contracted, or more or less reduced in cal- iber through a great part of its length ; in oth- ers, it was in parts dilated and contracted, as well as displaced. M. Guislain attributes both the. displacement and the contractions to in- flammatory action ; the latter most probably arises from this cause ; but the former cannot always thus be accounted for. From the few instances which I have had an opportunity of observing," and from the history of many oi those which I have seen recorded, it seems probable that most of the changes observed in the colon have been consequent upon asthenic inflammatory irritation, with diarrhoea, and oc- casionally with a dysenteric or an irregular ac- tion of the bowels, which had existed at some time or other during the course of the mental disorder, and especially at a late period of its progress. Dr. Percival (Dublin Hospital Rep., vol. i., p. 144) observes, " that, on the dissec- tion of cases of insanity which have terminated fatally from chronic diarrhoea, the intestines generally exhibit an extensive mass of disease. The mucous membrane is inflamed, thickened, and partially eroded, and the area of the canal diminished, often considerably, in the lower in- testines." The mesenteric glands are often found more or less enlarged and indurated. In addition to these changes, haemorrhoidal tu- mours and fistula in ano are not rarely met with in dissections. 246. B. Although much importance was for- merly attached to disorders of the liver in caus- ing insanity, yet the researches of recent writers do not tend to confirm the frequency of this connexion. Esquirol, S. Pinel, Guis- lain, and Foville found comparatively few cases which presented organic changes in the liver and biliary apparatus. It is probable that lesions of the liver, in connexion with insanity, are more frequent in this country than in France, when we consider the influence of the abuse of ardent spirits in causing both insanity and liver diseases. In a case attended by Dr. Suther- land and myself, at the time of writing this, the liver is greatly enlarged The frequency, indeed, of biliary disorder in the insane cannot be doubted ; and the occasional association of organic lesions of the biliary organs with men- tal disorder will be allowed. The chief doubt, in cases where these organs present altera- tions, will be as to the nature of the connexion ; for it will be admitted that disease of the liver will sometimes affect the functions of the brain sympathetically, and that disease of the brain will exert a similar sympathetic influence upon the functions of the liver; and hence the pri- ority of affection of either of these organs will not readily be ascertained. 247. C. Alterations of the gall-bladder, cal- culi in this viscus or in the hepatic ducts, le- sions of the peritoneum and omentum, of the mesentery and mesenteric glands, of the pancreas and spleen, of the kidneys, and of the uterus and ovaria, have been severally found in the bodies of the insane, by Bonet, Schulze, Marcard, Oberteuffer, Piderit, Jones, Percival, Pow- ell, Stark, and others ; but these have proba- bly been accidental lesions, although they may, in a few instances, have had some influence in causing mental disorder, particularly in persons' otherwise disposed to it, by affecting the or- INSANITY—Prei ganic nervous energy in general, and especially that portion actuating the brain. 248. VI. Causes of Insanity.—Few sub- jects are of greater importance than a just rec- ognition of the numerous causes of insanity— of their individual and combined modes of op- eration—of the influence they exert in various forms of succession—and of the progressive changes they induce before the effect upon the mind is fully developed. And the importance of the matter is not limited to its bearing upon the treatment of the malady, but is even still greater in respect of prophylactic measures, and of rational plans of mental hygiene. In discussing this subject, I shall consider, first, the predisposing causes, or the numerous cir- cumstances which render the mind more sus- ceptible of or prone to disorder than in its natural and healthy state ; and, secondly, those causes which more immediately produce or ex- cite the disorder. And it must not be over- looked, that while the individual influences comprised under the former class are often va- riously associated in creating a susceptibility or proneness to mental disorder, the occasions or causes belonging to the latter class frequent- ly act, also, in conjunction, or in immediate succession. 249. i. The Predisposing Causes are the most important objects of study, particularly in respect of their bearing upon hygienic and proph- ylactic measures. The prevention of so ter- rible an infliction as insanity is, must be even of more importance than its cure, since the person who has once been insane seldom whol- ly regains his former social position, but is re- garded with more or less suspicion, and a union with him is avoided by prudent families. The discussion of this class of causes assumes, moreover, increasing interest and importance, when we consider that many of the circumstan- ces comprised by it are of more frequent occur- rence now than formerly, and are more influ- ential in exhausting, weakening, and dissipa- ting the mental powers in the present state of society than in former epochs of civilization; and that several of them may be even viewed as altogether arising out of existing social re- lations. 250. A. Constitutional predisposition is among the most predisposing causes of insanity. It may arise, first, from a certain conformation, temperament, or physical and mental constitu- tion, derived from the parents; or, secondly, from an original predisposition or conforma- tion, independently of disease in any of the pa- rents ; or, thirdly, from a state of constitution gradually acquired, or arising out of the contin- ued operation of causes which deteriorate or otherwise change the organic nervous and vital powers, and consecutively the digestive, assim- ilative, and effective functions. In the first of these modes the predisposition is transmitted from the parents ; in the second and third, it is generated de novo, and subsequently admits of transmission to the offspring, although not so certainly as in the first case. 251. a. Hereditary predisposition.—M. Esqui- rol states—and the circumstance is confirmed by the observation of others—that persons born before their parents had become insane are less liable to mental disorder than those born after it has manifested itself; and he farther ob- jisposing Causes. 555 serves, that the morbid tendency, or the actual disease, where it is transmitted hereditarily, is apt to show itself in different individuals of a family at a particular period of life. Instances illustrative of this latter circumstance have been adduced by him, and by Dr. Burrows, MM. Falret, Georget, and others. The he- reditary predisposition to insanity, M. Esquirol observes, is not more surprising than the pre- dispositions to gout, phthisis, or other diseases. It may be traced from infancy ; and it even ex- plains a number of caprices and irregularities which, at a very early period, ought to put pa- rents on their guard against the approach of in- sanity, and to guide them in the education of their children. In such cases, the education should tend to render the body robust, and to give tone to the nervous system. The consti- tution of the offspring should be changed as much as possible, by placing them in circum- stances different from those which surround them, or which have influenced the constitu- tions of the parents. 252. In some instances one particular form of insanity is transmitted ; either dementia, mania, melancholia, or states of mental disor- der followed by suicide, being thus observed in the same family. The particular variety of insanity evidently depends upon the tempera- ment, which, with the predisposition to this dis- ease, is derived from the parents. Not only the same form of mental disorder, but also the same physical disease complicating it, or ter- minating it, are apt to appear in the same fam- ily, more generally, or even exclusively; yet there are frequent exceptions to this rule. Where an hereditary disposition exists, differ- ent grades of the disorder, rather than different forms of it, are commonly observed—in one, merely various eccentricities ; in another, par- tial disorder of the moral powers; in a third, disorder of the understanding ; and, in a fourth, mania, dementia, &c. In families, also, in which insanity is hereditary, there is occasion- ally observed a greater tendency to diseases of the nervous system than in other families, as, to epilepsy, chorea, convulsions, palsy, &c. Dr. Prichard justly believes that a constitutional tendency existing hereditarily, or arising in the other modes about to be pointed out, is more important, in respect of the frequent occurrence of insanity, than all the other causes taken to- gether. It cannot be said, with propriety, alone to give rise to mental disease, without any ex- citing occasion ; but, if it be very strong, men- tal disorder will follow the operation of ordina- ry or very slight causes. 253. Dr. Burrows remarks, that Esquirol assigns only 152, out of 264 cases, in his pri- vate practice, to this cause, but that an hered- itary predisposition existed in six sevenths of the whole of his own patients. The most ex- empt from this taint were those whose mental disorder had a sympathetic origin ; as in puer- peral mania. Out of 57 cases of this latter af- fection, he could trace an hereditary taint in only about one half; but where it existed, the disorder was more apt to return. Dr. Burrows considers that this cause is more common in the higher than in the lower classes, as the former most frequently marry in their own rank, or even in their own families; and that wherever the system of clanship, or family con- 556 INSANITY—Predisposing Causes-. nexion, has been most strictly preserved, there it most prevails. Examples of this are said to have been numerous in the old Highland fami- lies of Scotland ; and Boethius mentions some very stringent measures which they adopted to preserve from hereditary maladies, or, rather, to prevent the procreation of those who might be tainted by them. That hereditary influence is less common in the lower classes than in the higher, is shown by Sir W. Ellis's report of the Middlesex Lunatic Asylum. There only 214 cases, in which the disease was inherited, were ascertained, out of 1380 patients admit- ted ; and for 125 of these eases no other cause of the malady than this could be assigned. It has been supposed that numerous instances of insanity occur among the Jews, from the cir- cumstance of their having kept themselves more free than all other races, and for a longer time, from intermarriage with strangers. I be- lieve that mental disorders are frequent among them ; but other causes may contribute to the frequency. Dr. Burrows states that the young- est insane patients he ever had belonged to a family of this race, and that in it he has ob- served the father and mother and six of their children insane. He farther remarks, that in- sanity is very prevalent among Quakers, who usually intermarry in their own fraternity. 254. It may be presumed that when an he- reditary predisposition to insanity exists in both sides of a family, the risk to the offspring will be much greater than where it is in one side only ; and that when this latter is the case, the child who bears a very marked resemblance, in constitution and mental character, to the parent exempt from hereditary taint will be most likely to escape the mental disorder; and the hereditary disposition will fail of being per- petuated by him, unless re-enforced by a similar taint, by marriage. But the child that most resembles the tainted parent will be the most liable to experience, and to propagate, the men- tal malady. 255. There are two points respecting which opinions are often required from physicians, namely, whether or not a person born of parents who have never themselves been insane, but who, one or the other, is descended from a family thus afflicted, may propagate the malady to his offspring 1 and whether or not a child born before insanity had appeared in either pa- rent is as liable to become insane as one born after the malady was developed 1 The first question, Dr. Burrows believes, should be an- swered in the affirmative, because he has met with insane persons neither of whose immedi- ate parents had themselves been insane, but some of the progenitors, or an uncle or aunt, on one side or other, had been so afflicted. I have known cases where the nearest progeni- tors to the patients, who had been disordered in mind, were grand-aunts or grand-uncles. The second question has been partly answered above ($ 251) by M. Esquirol. But Dr. Burrows considers that a child born, either before or after the accession of insanity in the parent, provided that parent's progenitors or relations of blood had been insane, is liable to the mala- dy ; but that, if the insanity of the parent were adventitious, and not hereditary, the child born before mental disorder had appeared will not have it by inheritance: how far a child born after the occurrence of adventitious insanity is liable to mental disorder, is decided with dif- ficulty. This writer believes that, whether it be adventitious or hereditary, once occurring, the morbid diathesis is thereby stamped, or generated. 256. b. The offspring may possess a connate predisposition to insanity, although neither of the parents, nor of the grandparents, nor any member of their families, had been the subject of it. Burton long since remarked, upon the authority of the older medical writers, that the offspring procreated of parents when they were far advanced in age are more subject than others to melancholy madness. There can be no doubt, that whatever produces enervation or debility in the parents will occasion a cer- tain amount of predisposition in their children to nervous affections and to mental disorder; and I believe that habitual drunkenness, or the abuse of spirituous liquors, by either parent, and especially by the mother, during gestation and lactation, causes numerous diseases in the off- spring, and more particularly disorders of the functions of the brain and nervous system in general. It also is very probable that the chil- dren of persons who have been weakened by premature or unnatural sexual indulgences and vices, or who are gouty, hypochondriacal, hys- terical, or otherwise debilitated, will be more susceptible of the operation of the exciting causes than the offspring of those who are con- stitutionally robust and healthy. M. Esquirol affirms, that many facts have been observed by him proving that a strong predisposition to madness has arisen from fright or terror sus- tained by the mother during pregnancy, and that marked cases of this kind occurred during the French revolutions. 257. It has been long and generally supposed that marriages within a confined circle, as be- tween cousin-germans, have the effect of im- pairing both the mental and constitutional pow- ers of the offspring. The opinion seems well founded, and is undoubtedly just, if the breed- ing in-and-in be continued for two or more gen- erations. The children of such families often die in infancy or early youth; are frequently scrofulous, and are liable to hydrocephalic and convulsive diseases ; and, if they grow up, are frail in body and imbecile in mind, or predis- posed to mental disorder. It is doubtful how far the scrofulous diathesis may dispose to in- sanity, but I believe that it has a very consid- erable influence. 258. c That there may be not only, 1st, an hereditary, and, 2dly, a connate, but, also, 3dly, an acquired predisposition of constitution to in- sanity, I firmly believe. This last state is quite independent of the two former, and of temper- ament or diathesis, and is generally the result of the operation of debilitating causes during infancy, childhood, and the periods of puberty and early adult age. Indeed, many of the mor- al and physical exciting causes may have this effect when acting in a slight but continued or constant manner. But there can be no doubt that early indulgences ; a tender, sensual, and luxurious education ; vicious modes of early in- struction ; masturbation, and premature or vi- cious sexual indulgences ; exhausting pleasures, and inordinate mental and physical excitements, relatively to the states of nervous and constitu- INSANITY—Predisposing Causes. 557 tional energy ; and various other causes, which debilitate the frame, increase the general sen- sibility, and augment the susceptibility of the brain and nervous system, will often develop, to a greater or less extent, a predisposition to insanity, which may be appropriately termed acquired. 259. It has generally been supposed, and po- ets have sung, that a great genius is closely allied to insanity. This is most erroneous. Persons with a too active and ill-regulated im- agination are predisposed to mental disorder ; but those who possess powerful intellects, and a vast range of powers and of intelligence, are much less disposed to it than others; and if they have become insane, the causes have been of an energetic kind, and overwhelming from their activity or association. 260. B. Temperaments, &e.—Persons of the melancholic temperament are more liable to the melancholic states of insanity than others; those of the nervous temperament, to mania, dementia, and monomania; and those of the sanguine, or sanguineo-nervous, or irritable temperaments, are attacked more frequently with mania than with any other form of men- tal disorder. M. Esquirol observes that, when persons of the lymphatic or phlegmatic temper- aments, or of a pale, exsanguineous habit of body, are affected with mania or monomania, dementia or incoherency is more liable to su- pervene in them than in others. This form of insanity is also likely to follow in persons of a full habit of body, with a thick head and short neck. Mental disease pursues a somewhat dif- ferent course in persons of different tempera- ments. Choleric or warm constitutions, or those with black hair and eyes, and vigorous frames, become violently maniacal, but experi- ence a shorter disorder, and more frequently terminating in a marked crisis than others. In- dividuals of a fair, pale complexion, with light hair, fall more readily into chronic mental dis- ease ; the dark-haired are liable to become gloomy monomaniacs ; red-haired lunatics are disposed to violence, and are treacherous and dangerous. He gives the following table of the general appearances of a number of lunatics : „ „ , , ... tt Of the medium fulness of habit . 122 External habit of SThinolemaciated......60 body. . . . }Fat...........fi „ . ,, (Tall...........102 HeiglU . . . |short..........lfl S Chestnut or brown......102 Blue and light.......98 Black..........17 Chestnut.........118 Fair or flaxen.......39 Gray or white (aged).....36 Black..........31 261. C. The form of the head in lunatics has at- tracted the attention of Greding, Pinel, Geor- get, Gall, Spurzheim, and others. M. Pinel believed that there are certain peculiarities in the shape of the skull, frequently observed in the insane, and particularly in cases of demen- tia and idiotcy. The two most prevalent forms which he specifies, are, 1st, a laterally com- pressed shape of the head, giving a very long diameter from the occiput to the forehead; 2dly, a short and almost spheroidal form—the above diameter being shorter than usual. He could not, however, detect any mental condi- tions corresponding with these opposite shapes. M. Georget states the result of the examina- tion of upward of 500 heads in the collection of M. Esquirol. One half of these presented no- thing remarkable, being regular and well form- ed. The other half were more or less peculiar in the form and appearance of the skull, and in the thickness, density, and organization of the bones composing it. Some skulls were une- qually developed, one side being more arched and larger than the other, especially the right. Others were somewhat oblique, one side of the head being too forward, and the other much be- hind. I have seen instances where these two malformations were conjoined. M. Georget found some skulls in this large collection,fin which the antero-posterior diameter was not more extended than the lateral: in these, the cavity was much elevated, especially in the pos- terior part. The cavities of the base of the skull presented likewise inequalities .- those of one side were sometimes larger than those of the other. Persons who have contracted heads, particularly as now described, not only are more liable to insanity than those whose heads are well formed, but lapse more readily into a state of dementia or fatuity, and are consequently less curable than others. It is chiefly in these hopeless forms of general insanity that these irregularities of the form of the head are ob- served. In idiots, as I shall show hereafter, these malformations are still more remarkable. 262. D: Sex.—The ancients, and especially C^elius Aurelianus, supposed that insanity oc- curred more frequently in males than in fe- males. Recent investigations, however, have shown this not to be generally the case in mod- ern times. Dr. Prichard quotes M. Esquirol as stating the proportion of insane females in France, to insane males, to be 14 to 11. M. Voisin considers the proportion as 13 to 10. In all Italy, the proportion is different, it being about 565 males to 500 females. M. Guis- lain states, that in Holland and Belgium the number of lunatic females to males is as 34 to 29. Dr. Prichard assigns the proportion in Great Britain and Ireland, of male to female lunatics, as 13 to 12 ; and observes that, in Eng- land, the number of insane men, compared with that of women, is more considerable than in Scotland and Ireland; and this excess on the side of the males is greater, according to Dr. Burrows, in the higher than in the lower classes of society. M. Esquirol confirms this observation in respect of France; and farther states that, in the North of Europe—in Ger- many, Denmark, Norway, and Russia—the pro- portion of male to female lunatics is as 3 to 2. Dr. Jacobi furnishes nearly the same results in regard of Prussia. In the United States of North America, the number of insane males is stated to be much greater than that of female lunatics. In the States of New-York, Penn- sylvania, and Connecticut, the proportion of the former to the latter is nearly 2 to 1. In summing up the results of his inquiries obtain- ed from various parts of the civilized world, M. Esquirol finds that the general proportion of insane males to females is about 37 to 38.* 263. The occurrence of insanity among fe- males is partly owing to the nature and vices * [From 1821 to 1836 inclusive, there were admitted into the Bloomingdale Asylum, New-York, 1346 males, and 691 females ; at Worcester, from 1833 to 1841, there were 710 males admitted, and 649 females.] 558 INSANITY—Predisposing Causes. of their education ; to their greater sensibility and keener feelings ; to the restraints imposed upon their desires and emotions ; to the cross- es, chagrins, and disappointments to which they are liable ; to reading romances and novels, and thereby exciting the imagination, without improving the.reasoning powers ; to the addic- tion to music, and the want of salutary and in- vigorating occupations ; and to the life of cel- ibacy they are often doomed to lead. These, and various other moral causes about to be no- ticed, contribute remarkably to the production of insanity among females. 264. The physical causes also operate ener- getically in producing insanity among this sex ; but they are chiefly disorders of the sexual or- gans. Irritation of the uterus, or of the nerves supplying it, and its appendages ; suppression, retention, or inordinate flow of the menses; and various organic lesions of these parts, have a very marked influence, sympathetically, upon the functions of the brain. Many of the moral causes, and emotions of mind, have but little influence, until they have first disordered the functions of the womb ; and as soon as this or- gan is disordered, it reacts upon the brain, and heightens the effects of the moral emotions. In such cases, as well as in many others com- mon to both sexes, the moral causes are often insufficient to induce the mental disorder, until they have first occasioned physical disturbance in some organ ; which disturbance, from its sympathetic influence upon the brain, becomes an additional cause of the disorder. Females, however, are often so circumstanced as to ex- perience very serious disorder of the circulation of the brain, from energetic mental emotions occasioning an immediate effect upon the man- ifestations of this organ, before any disorder can appear elsewhere ; and in some cases the consequent disorder is produced almost sim- ultaneously in both the brain and the functions or state of the uterus. We observe this espe- cially in the puerperal states, and, still more particularly, soon after delivery. 265. M. Esquirol remarks, that females be- come insane at an earlier period of life, are more liable to lapse into dementia, and are more disposed to religious insanity and to erotic delirium than males; and that all varieties of in- sanity, in them, are generally complicated with hysteria. Males, on the other hand, are more liable to mania and violence ; they are more dangerous, and more difficult to restrain : wom- en are more noisy; cry, and talk more; are more dissembling, and less readily confide in those about them. 266. E. Age.—Insanity, in the forms which have been described, is rarely observed before the age of puberty. Imbecility and idiotism are always observed in childhood ; but the instan- ces in which any form of true insanity has oc- curred at any epoch before puberty are very few. They have, however, been recorded by J. Frank, Dr. Haslam, M. Fodere, M. Esqui- rol, Dr. Prichard, and one case occurred in my own practice, and that was caused by fright. Two cases mentioned by M. Esquirol proceed- ed from the same cause. He met with one case of melancholia complicated with maras- mus in a child eleven years of age, remarka- ble for his large head and mental precocity. In- stances, however, more frequently occur of children becoming melancholic, and even delir- ious, from jealousy and envy, than is generally supposed. They sometimes are thus affected, although often only temporarily, by seeing the attentions of those to whom they are much at- tached bestowed upon others, and by being out- stripped in obtaining distinctions at school. 267. After fifteen years of age, insanity ceas- es to be a rare occurrence. About the period of puberty, in females, or when the catamenia are about to be established, melancholia and mania occasionally appear, and especially if the growth be rapid, and the catamenia are retain- ed, suppressed, insufficient, difficult, painful, or irregular. In these cases, and still more so at a later period, hysteria is generally attendant upon the mental disorder. During the first few years after puberty, in the male, mania and melancholia not infrequently occur ; the former generally from the excitement of sexual desires, the latter from masturbation or venereal ex- cesses. M. Esquirol remarks, that mania, in all its forms of excitement, appears chiefly in early life ; melancholia, in middle age ; and de- mentia in the advanced epochs of existence. In youth, insanity assumes an acute and vio- lent course, and often terminates by a remark- able crisis ; in middle age, it is more prone to become chronic, and is oftener complicated with disorder of the- abdominal viscera, but is sometimes resolved by haemorrhage from the haemorrhoidal vessels, or by diarrhoea. At an advanced age, it is apt to pass into dementia, and to be complicated with paralysis, apoplexy, &c, and recovery is much less to be expected. However, dementia may occur in the young, and very aged persons may be attacked by ma- nia, and recover from it; but these are only ex- ceptions from the rule just stated. 268. The ages at which insanity most fre- quently appears, are, that between 30 and 40; next, that from 20 to 30, and from 40 to 60. M. Esquirol, however, states, that the maxi- mum number of admissions of cases of insanity take place from 30 to 35 years of age ; that each five years, from 20 to 35, give nearly the same number ; that the admissions of males are more numerous from 25 to 30, and those of females, from 35 to 40; that the periods from 30 to 35 follow thereafter, for the men, and from 40 to 45 for the women ; and that the admission of males from 20 to 25 years of age occupy the third rank of frequency, while those of females hold only the sixth rank. From this it follows that insanity is most frequent at an earlier age in men than in women. M. Esquirol farther states, that the wealthy classes are much ear- lier attacked—or, rather, are affected in great- er numbers at an early age—than the laborious. M. Georget adduces the following calculation of the ages of insane persons on admission into several institutions in England and France : From 10 to 20 years of age . . 365 20 to 30......1106 30 to 40......1416 40 to 50......861 50 to 60......461 60 to 70......174 70 and upward .... __35 4409 269. Yet, although a greater number become insane from 30 to 40 than at any other age, INSANITY—Predisposing Causes. 559 still the number may not be really greater, rel- atively to the proportion of persons in society of farther advanced ages; and hence, 174 in- stances of the malady occurring in persons aged between 60 and 70, may actually show a great- er prevalence of it at that age than 1406 cases appearing between 30 and 40 years of age. That this, however, is not the case—and that a greater number, relatively to the proportion of persons existing in the community at that age, actually become insane between 30 and 40 years—is proved by the number of persons sur- viving out of each 1000 at successive periods of life. In this country, 410, out of each 1000 born, will reach 30; and 345 will reach 39 ; but 220 will reach 60, and 140 will attain 70; and if the mean number of those between 30 and 40 thus be 376, and that of those between 60 and 70 be 146, it will be at once manifest that the number of instances of the invasion of insanity is, relatively to the proportion of persons between 30 and 40 years of age, actu- ally greater at that period. 270. M. Esquirol, however, believes that a proportionably increased frequency of mental disorder, with the advance of age, really does obtain, although the predisposition, thus arising from advancing age, increases in an irregular manner. The increased number of insane per- sons, he adds, compared with the population of that age, is very striking between 50 and 55 years. From 70 to 75, and from this age to 80, it becomes enormous, owing to the frequen- cy of senile dementia. This is very probably correct; but it must not be overlooked that a very large proportion of the cases of hereditary insanity occurs between 30 and 40, or even earlier; and it is admitted that these cases constitute the great majority. [Dr. Woodward gives the following as the ages of patients when admitted at Worcester : Under 20 years, 79 ; from 20 to 30 years, 356; 30 to 40, 383 ; 40 to 50, 275 ; 50 to 60, 144 ; 60 to 70, 88 ; 70 to 80, 35 ; over 80, 1. Of these, 715 were single, and 508 married; 88 widows, and 48 widowers.] 271. F. Education.—There are few causes which more powerfully predispose to insanity than erroneous education and moral discipline in early age.—a. Too great indulgence in child- hood, and previously to, as well as during pu- berty, and a want of moral discipline then and up to manhood, with neglect of that education which inculcates, and, indeed, enforces proper principles of feeling and action, are undoubted- ly among the most deeply laid foundations of insanity. Persons thus brought up have their temper, emotions, and moral affections so little under command—are so subject to ebullitions of passion, to caprices, or violent and fugitive emotions—are so liable to act from momentary feeling and impulse—as to acquire a disposition of mind, or moral character, not only most un- amiable in itself, but also most prone to marked disorder, when subjected to its more immedi- ately productive causes. 272. b. The premature and overstrained ex- ertion of the mental powers is another most important cause of predisposition. In the high- er and middle classes of society, the mind is excited much beyond its powers ; and the child, being required to perform too much, with its imperfectly developed faculties, experiences, as a consequence of such premature excitement, increased vascular action in the brain and its membranes, at a period of life most disposed to vascular disorder in this organ ; and the found- ation is thus laid for chronic disorder, and especially for chronic inflammatory action of that part of the nervous system with which the manifestations of mind are most intimately al- lied. The quantity, as well as the diversity and range of mental exertion, now required from both sexes at a too early epoch of childhood, and during the period which elapses from mere infancy to puberty, while both mind and body are only in an early stage of formation, must necessarily prove injurious, both mentally and physically—and especially to those who are either delicately constituted, or tainted by any hereditary disposition to insanity. Therefore, when this disposition exists, not only should premature and overstrained mental exertion be avoided, but also should the feelings, the pas- sions, and the actions be subjected to strict discipline—to a discipline not too harsh or rigid, but rational and consistent. The mind ought to be formed under a kind restraint, and imbued with correct principles, and with a due sense of moral and religious responsibility. In the present day, too much attention is paid to an early cultivation of intellect, and to the mere acquisition of knowledge of facts and phenom- ena, to the neglect of the education of the moral affections, and of just principles of feeling and of acting. The great ends of education, as now conducted, are, as respects the one sex, the at- tainment of that knowledge and of that range of information which may enable its possessor most successfully to compete in the general scramble for wealth, for advancement in socie- ty, or even for existence ; and, as regards the softer sex, the possession of such accomplish- ments, and the acquisition of so wide and so superficial a range of ideas, in a very limited period of time, as may strike or captivate, or may be more readily and generally made avail- able in society, and thus become the current coin of the mind in conversation. These ob- jects are pursued in education in a manner but too well calculated to overstrain the early intel- lect, to exhaust the feeble mind, and to derange the hereditarily predisposed. The mind is en- gorged with food, not of the most wholesome or digestible quality, beyond its powers of healthy digestion and due assimilation, and even before these powers are fully evolved ; and hence but too frequently follow disorders, varied in extent and intensity, of its most impor- tant and effective manifestations or functions. 273. G. Climate and Seasons.—a. It is very doubtful what degree of predisposition can be ascribed to climate and seasons, especially as most of the differences in the numbers of the insane in different climates may be attributed to various moral and physical circumstances not necessarily dependant upon climate. In warm climates, and even in Turkey, and other Mohammedan countries beyond the tropics, and in hot climates, where the minds of the popu- lation are under the sway of the Romish and Greek churches, insanity is much less frequent than in temperate and highly civilized coun- tries. M. Esquirol, in accounting for the greater prevalence of insanity in temperate climates, attributes too much importance to 560 INSANITY—Predisposing Causes. sudden alterations or vicissitudes of tempera- ture. The greater frequency of the malady in these climates is plainly attributable to other causes than this. I believe, however, that a predisposition to insanity, and particularly to connate and puerile imbecility, and to dementia, is to some extent generated by marshy or mias- matous places, particularly in low districts sub- ject to inundations, and in low valleys placed deep between precipitous mountains. There the mind and body are checked or weakened in the course of development, and the latter early becomes the subject of diseases which impair its vigour and farther weaken the powers of mind. 274. b. The seasons, according to M. Esqui- rol, have some influence in causing insanity; but probably more as exciting than as predis- posing causes. High ranges of temperature seem to have considerable influence in causing or in determining the character or form of the disorder, and particularly mania, or the higher states of the malady. M. Esquirol has given a table of the admissions into the Salpetriere, during each month, for nine years, according to which it would appear that the lowest num- ber was admitted in January ; and that the ad- missions increased progressively from March till July, when they reached the maximum. They then progressively decreased till October. From this month to March they varied some- what in number, but not so much as to excite speculation. 275. H. Professions, Employments,Sf-c.—a. The frequency or infrequency of insanity among persons pursuing certain professions or employ- ments is obviously to be referred to the several circumstances more immediately connected with these employments; but most of these circumstances will be more fully considered hereafter. The learned professions certainly furnish fewer cases of insanity, relatively to the numbers exercising them, than any other class of persons in the middle ranks of the communi- ty. This, probably, is owing to the education for the professions, in early life, being such as tends more than any other to develop, and to strengthen, the judging and reasoning powers, without exciting the imagination, or prema- turely involving the feelings and passions. Some exceptions, however, may be found among young divines, who, from enthusiasm or anxiety respecting the state of their minds, have become partially or altogether insane ; but such cases are comparatively rare among the soberly and regularly educated. 276. 4. I believe that insanity is most preva- lent among artists, musicians, and actors, rela- tively to the number of persons pursuing these occupations. This frequency obviously depends upon a great variety of circumstances, many of which will be found among the moral causes of this malady. In the present day—for it was not so formerly, and in the palmy days of Ital- ian art — few artists receive an education, in early life, calculated to develop, or to strength- en the intellectual and reasoning powers. The imagination is early and almost exclusively ex- ercised ; and many of the instinctive moral af- fections of mind (see note, $ 66), which exert so powerful an influence upon mental sanity, are so often brought into inordinate action, without the due control of sound judgment and strict principle, that first partial, and ultimately general insanity is the more liable to appear. Besides, artists, in the wide acceptation of the word, are liable, in the exercise of their art, to sustained excitement, not merely of the imagi- nation, but also of the feelings and passions— to a certain tension of the mind—tending to ex- haust, and at length to disorder the intellectual powers. There are few classes, moreover, who entertain more extravagant ideas of their own -merits than those to whom I now refer; and who, consequently, are more liable to jeal- ousy, envy, disappointments, and wounded self- love. Poets and literary men are liable to the same imputation's, entertain the same ideas of themselves, and of others, as those who may be classed under the general denomination of artists ; but, in general, their education is sounder, and better calculated to strengthen the reasoning or controlling powers of mind. In all, the sedentary occupations, the insufficient exercise in the open air, and the irregularities of living, or the alternations of abstinence and dissipation, aid the moral causes of the malady in this class of the community. 277. c. It must necessarily follow that insan- ity will vary in frequency in different profes- sions and employments, with the degree in which they respectively call into exercise those moral emotions or causes, on the one hand, and the physical circumstances on the other, on which this malady has been found more espe- cially to depend. Next to artists, in the liabil- ity to mental disorder, may be ranked, accord- ing to the tables of M. Esquirol, merchants and traders, and military men. This may be expected, especially if brokers or speculators in the funds or share markets are included un- der this head : and, indeed, merchants, traders, manufacturers, and speculators, or gamblers in all kinds of securities or psuedo-securities,have, in recent times, so entirely fallen within the same category ; and are, from the governor or director of the most powerful corporate bodies in the world, down to the very humblest adven- turer in a bubble company, so generally and completely subjected, from the nature of their engagements—from the epidemic scramble af- ter gain at all hazards—to alternate excitement and depression — to elated expectations and painful anxieties—to hopes and fears—to fortu- nate anticipations and humiliating disappoint- ments ; and have the prospects of being, or are, in fact, one day as rich as Croesus, and the next even poorer than the meanest slave — that the mind, which probably has never been strong, nor duly strengthened by wholesome education, and by the early inculcation of sound principles of feeling and acting, at last experiences, and manifests the shock, in some one of the various forms of insanity. Shall the medical philoso- pher—contemplating the present state of socie- ty, seeing these things, and knowing the cir- cumstantiality with which insane acts and crimes are published, commented upon, and rendered interesting to vulgar tastes and minds —be surprised at the existing prevalence of insanity, and one of its most common results, suicide 1 The weak, the injudiciously tutored, and the pampered mind, after a career of ill- deserved prosperity — a prosperity often as in- iquitously enjoyed as unjustly earned—not in- frequently experiences a reverse, which it is INSANITY—Ex incapable of enduring without more or less of mental disorder ; but the reverse is commonly attended by circumstances involving also many confiding and innocent persons ; and thus more than one sustains a shock before which reason is shaken or entirely overthrown. 278. /. Previous attacks of insanity, or other diseases of the brain, greatly increase the sus- ceptibility of mental disorder. Although recov- ery from insanity often takes place without any subsequent manifestation of mental disease, and although even repeated attacks have been sustained, and a complete and permanent res- toration has occurred nevertheless ; yet much more frequently madness leaves the person, who has once been its subject, much more prone to a return of it. In many cases, the pa- tient continues, for a long period after recov- ery has apparently been established, more irri- table and excitable than previously to the at- tack : he is irascible; very susceptible of im- pressions ; and less capable of application to business, or of mental exertion. After every successive attack, this change in temper and character becomes more manifest, until the disease assumes a remittent, and ultimately a continued form ; a state of permanent incohe- rency or imbecility ultimately supervening. 279. Inflammations of the brain or of its mem- branes, frequent attacks of epilepsy, apoplectic and paralytic seizures, and fevers with predom- inant affection of the brain, often predispose to mental disorder. Indeed, these maladies are not infrequently both attended and followed by delirium, or some form or other of insanity, which generally disappears in a few days, or, at most, weeks after the primary malady has evinced signs of amendment, or after recovery from it has taken place. When either of these cerebral diseases are thus complicated, the dan- ger of the recurrence of a temporary, or a se- vere, or even a permanent attack of insanity, or of a return of the primary disease, attended by a more complete overthrow of the mental powers, is much heightened. This is especial- ly the case in respect of epilepsy, particularly when slight partial paralysis with mental disor- der follows the fit. In such cases, incoheren- cy, imbecility, and, ultimately, fatuity, often successively appear. In some instances, where the epileptic paroxysm is attended by violent mania, which subsides in a few days afterward, the mental derangement gradually becomes per- manent, and either supersedes the epilepsy, or continues complicated with it. When insanity is thus caused by epilepsy, sullenness, sudden irascibility, with a disposition to commit the most atrocious acts, and various manifesta- tions of moral disorder, often characterize the malady. 280. ii. The Exciting or Productive Causes. —Certain of the causes which have been al- ready considered may, from their nature or in- tensity, give rise to insanity, without the aid of any exciting occasion, or, at least, of any so marked as to attract the notice of the patient's friends. On the other hand, many of the causes about to be noticed, either from their slight but often combined action, or from their continued influence, actually predispose to, rather than excite insanity; or they affect so slowly and imperceptibly the mental powers, as well as the bodily functions, without giving rise to any sud- II 71 cciting Causes. 561 den or manifest shock of the mind, as to change the character or constitution of both, and there- by fit or prepare them for the injurious impres- sion of causes which would otherwise have been entirely innocuous. The exciting causes have been very commonly divided into moral and physical; and under these heads have been also comprised, by some of the best writers, the causes already considered, as creating a predisposition to mental disorder. And when the circumstances just alluded to, respecting the operation of these causes, are considered, there can be but little fault found with this ar- rangement. Some authors have differed as to the comparative influence of moral and physical causes in occasioning this malady. But the difference has arisen chiefly from the more ex- tended signification assigned to the latter term by some, and from their having comprised un- der it various important causes kept entirely apart by others, and especially the greatest of all causes, hereditary predisposition. Leaving this, therefore, out of the arrangement, or, rath- er, considering it separately, there can be no doubt of the influence of the moral causes, in the production of insanity, being much greater than that of the physical. Still the matter is not so satisfactorily solved, especially by refer- ring to statistical tables, as may be imagined. For, although it may have appeared, from the information received, that the malady was pro- duced by some moral cause; yet there may have existed at the time, or closely upon it, some physical disorder, and especially some functional disturbance of the digestive, assimi- lative, and excreting organs, or a morbid sus- ceptibility of the nervous system, or both, with- out the existence of which the moral affection may have been quite inoperative. Agreeing, however, with Heinroth, Pinel, Georget, Guislain, Prichard, and others, as to the great and predominant influence of moral over phys- ical causes in the production of insanity ; still, even in the cases where they seem to have been most influential, various physical or func- tional states or disorders may have existed, so as to predispose the nervous system to be af- fected by them ; or the moral emotion may have first occasioned some severe physical dis- eases, of which the mental disorder was the more immediate effect. 281. In proof of the predominance of moral over physical causes, most writers refer to the great frequency of insanity among highly civil- ized people, and its almost entire absence from savage or barbarous nations. The data, how- ever, are not to be depended upon, as respects savage communities. It is not correct to say, as many have, that insanity is unknown among them. It certainly is comparatively rare, or very seldom occurs; but it does occur among the greatest of all savages; various circum- stances, however, preventing persons in this state from being long troublesome to their friends or to the community; or, in other words, once an individual " loses his head," as the be- ing insane is very generally termed, he is soon got rid of; and his insane acts, before his state is recognised, often directly or indirectly ter- minate his existence. On this subject Dr. Prichard remarks, that "in a barbarous state of society, the passions are under no restraint— the emotions are impetuous; hatred and ma- 562 INSANITY—Exciting Causes. lignity are in perpetual exercise ; the fierce and sensual desires which are common to mankind and the inferior tribes are indulged without limit. Nor are the intellectual faculties with- out their exercise in carrying on the stratagems of barbarous warfare. We should conjecture that such a state of society, in which the pas- sions are in perpetual and violent agitation, would not infrequently produce insanity." Still, I contend that these are not the chief moral causes of which this malady is so frequently a result ; and that many of the physical disor- ders, which either predispose to or produce mental disorder, and which remarkably aid the operation of moral causes, are not very com- mon in savage communities. If we contrast the emotions which powerfully affect the hu- man mind in civilized society with those which have been just noticed, the consequences re- sulting from the former to the mind itself may be, in some measure, anticipated. When we consider the premature and excessive exertion of the faculties in highly civilized countries ; the restraints imposed by social institutions and legislation, and the consequences which often arise out of them ; the diversity of inter- ests and of feelings brought into action by many pursuits, upon which wealth, honour, and even existence, depend ; the long-continued anxieties, griefs, disappointed hopes, the fami- ly dissensions, and injured or lost affections; the chords of feeling too intensely strung ; the prolonged or intense mental exertion ; the con- tinued tension of the imagination, or of the in- tellectual powers ; the pride, ambition, and hu- miliations ; the distractions of the mind by re- ligion, by worldly speculations, and diversified engagements; the sudden reverses, the jeal- ousies, and the numerous causes continually impressing the moral sentiments and affections, and increasing the susceptibility of the nervous system, as well as disordering the general health ; when we contemplate the prevalence, the frequent recurrences, and often the almost constant operation, of all these circumstances in civilized life, we cannot be surprised at the effects produced by them upon the mind and nervous system, especially when we find that they seldom act singly, but generally in combi- nations, or associated with various predispo- sing and exciting or determining causes. 282. There are also other considerations, not to be overlooked in attempting to account for the greater prevalence of insanity in civil- ized than in savage communities. Children of weak physical powers are seldom reared among the latter ; and the higher intellectual faculties, and the finer and more elevated moral affec- tions, especially the powers of intellection, and the rational emotions of mind (see note, § 66), are imperfectly developed in them, and conse- quently less prone to experience or to originate mental disorder. In barbarous societies, the mind retains much of the constitution and char- acter presented by it in childhood and boyhood in more civilized communities : it is incapable of comprehensive views and combinations of thought, or of prolonged exertion; it retains the sanguine disposition of youth, and is little susceptible of care arid anxiety, and thinks of little but of present gratification and ease. On the other hand, while civilization develops all the finer emotions and affections, all the high- er and more reflective faculties, and augments the susceptibility of the moral feelings, as well as the general sensibility, it tends also to disorder them the more, owing to numerous resulting circumstances, which inordinately excite or seriously disturb them, and which thereby often ultimately overthrow them alto- gether. 283. M. Georget, however, most probably overrates the influence of moral causes in the production of insanity. He believes that 95 out of 100 lunatics have become so from the operation of the affections and moral emotions; and he states this to have been the opinion also of M. Pinel. It is in the age, he adds, in which the mind is most susceptible of strong feelings, and in which the passions are excited by the strongest interests, that madness is principally displayed. It is chiefly, however, in the higher and middle classes of society that the moral causes are most productive of insanity. This is shown by the researches of Esquirol, Geor- get, Guislain., and others. It is in them that the influence of civilization, in increasing the frequency of the malady, is especially manifest- ed ; thus proving the justness of the remarks which I have ventured above, and which are partly founded upon my observation of the state of society in savage communities. Among the lower orders, physical causes have more influ- ence than in the higher; and, of the moral causes, an unrestrained sway of the temper and passions is the most manifest. Physical causes are, according to the writers just men- tioned, more influential in females than males; and in the former, among the lowest classes, I would add, that violence of temper is the most productive moral cause of the malady. In farther considering the exciting causes, I shall offer a few observations, 1st, on the more re- markable emotions of the mind, of which in- sanity is often a consequence; 2dly, on the physical causes of the malady ; and, 3dly, on certain circumstances in the general habits and manners, and in the social and political states of our species, resulting from various combi- nations of moral and physical causes, which both indirectly and immediately occasion men- tal disease. 284. A. Of certain Moral Emotions.—a. The more violent passions and emotions some- times, by their sudden or vehement action, more or less disorder the functions of the brain, especially violent anger and terror. Unre- strained bursts of temper are very frequent causes in the lowest classes of the community, and particularly in females, in whom it acts ei- ther directly on the brain, or consecutively, by first disordering the uterine functions, or in both modes. M. Esquirol, however, assigns a greater influence to fright than to anger; but mania is the form of the disorder which most frequently results from both these causes. De- mentia much more rarely is occasioned by them. These emotions are the most intense and the most sudden of which the human mind is sus- ceptible ; and, fortunately, they are among the shortest in their duration. The nervous sys- tem, and particularly the functions of the brain, are more violently agitated by them than by any other ; and in many instances, where no pre- disposition to insanity exists, fits of convulsion, tremors, and various nervous affections are INSANITY—E: Ixciting Causes. 563 caused by them, especially in weak, nervous, and susceptible constitutions. 285 Care, anxiety, grief, distress, and all the depressing emotions, are the chief causes of men- tal disease. In the same category may be included domestic griefs and disagreements, family dissensions, ill-assorted marriages, re- verses of fortune, disappointments, prolonged fears, mental humiliations, jealousy, wounded self-love. The tables which I shall give here- after will show the relative influence of these and other causes in one civilized country. It will readily be admitted that it is chiefly in communities far advanced in civilization that these causes are most productive of this mala- dy. These causes act very generally in com- bination, either with one another, or with va- rious predisposing and physical circumstances: many of them operate upon the mind slowly and silently, and only by first disordering one or more of the bodily functions. Joy, and the more exciting emotions, less frequently occa- sion insanity than is commonly supposed. Es- quirol states, that the opinion of Mead, as to the frequency of mental disorder from this cause, is not well founded; but he admits the importance attached by Pinel to the struggle between religious and moral principles, and the passions and worldly interests — a struggle sometimes long sustained, and terminating in impairment of reason, and especially in melan- cholia. It is not only in their individual, but also in their combined operation, that the causes of insanity should be studied : and in order that sound principles subservient to rational hygi- enic and prophylactic measures may be de- duced from the study, the various combinations and successions of action should be recognised; and the intermediate changes, mental and phys- ical, ought to be traced as far as the means of investigation may be furnished us. It is chief- ly, also, by ascertaining the changes first in- duced in the functions of important organs, and the succession of morbid actions resulting therefrom, that we can be enabled to form ra- tional or successful indications of cure. 286. c. Religious impressions, and apprehen- sions of a future stale, are among the most im- portant mental causes of insanity. Religious madness, as it has been termed, has long been an interesting subject to the philosophic phy- sician ; and its frequency in Great Britain de- mands from him a particular notice of the vari- ous circumstances connected with it. I can- not agree with Dr. Prichard, in considering that the number of persons who become in- sane from religious hopes and fears is much less considerable than it is generally supposed to be. The frequency of disorder from this cause varies remarkably in different places and in different times; and the mischief often be- comes either endemic or epidemic, from every fanatic, or ambitious preacher, who is desirous of acquiring notoriety, or of being the originator, or the leader, of a particular sect—from any one, however slightly imbued with religious knowledge, or however ignorant, who wishes to be distinguished among those who are equally ignorant, but more honest, with him- self—and from any one who, already partially insane, believes himself inspired, and called by the Almighty to instruct and convert men, be- fore he is himself even partially instructed—be-1 ing permitted to "deal damnation round the land," and to excite the feelings and the fears, or to distinguish the hopes, of the ignorant, the nervous, the susceptible, and of the hysterical, without any control as to education, doctrines, or religious principles. As the numbers of these adventurers increase or diminish, so do the victims of this encouragement to disturb the minds of the community also vary in num- ber. In this vicious plenitude of liberty every- body enjoys not only entire freedom of thinking and speaking, but also of acting. The rogue who is too lazy to work is allowed, without inquiry into his knowledge or belief, and with- out hinderancC on account of character or of the mischievous nature of his doctrines, to har- ass the feelings, to excite the imagination, and to blight the happiness of many of those who listen to him. It is not seen, or, if seen, in no way guarded against, that the more dangerous the doctrine, the greater the fanaticism, or the more vehement and impassioned the declama- tion with which it is promulgated, the more in- tensely are the uneducated affected, and the mind disordered by it. The more absurd and inflated the harangue, the more frantic the manner ; and the greater the outrage on com- mon sense and decency, the moral infection sinks the more deeply, and spreads the more widely, until mental disorder assumes a truly epidemic form. That this is not over-stated, is sufficiently proved by what has taken place recently in this metropolis, by the camp-meet- ings in America, and by the " revivals" in Scotland and in that country. [Dr. Woodward attributes 100 cases out of 1141, of which the cause is stated to be " re- ligion," which is certainly not" a large propor- tion. Out of 843 cases of insanity received at the Bloomingdale Asylum, N. Y., and of which the causes are specified, but 59 are attributed to " religion" (40 cases to " religious excite- ment," 7 to " religious terror," and 12 to " re- ligious anxiety and doubts"). These terms were given by the friends, and therefore are entitled to consideration. We have no doubt that many cases of insanity are attributed to this source which are, in fact, owing to other causes. But that the American " revival sys- tem," so called, as often carried out by enthu- siastic religionists, is calculated to unhinge the mind from its moorings, and dethrone the in- tellect, we know from extensive personal ob- servation ; and we may be permitted to add, that we view the measures resorted to on these occasions no less destructive to sound morals and religion, than they are injurious to the physical and intellectual well-being of all who come within their influence. We would apply the same remark to " camp-meetings," and most of the other extraordinary means to awa- ken attention to the momentous subject of hu- man destiny in a future state of being.] 287. The frequency of mental disorder from this cause has been insisted upon by Darwin, Perfect, Falret, Jacobi, and others, but somewhat doubted by Dr. Prichard. Accord- ing to my own observation, I believe this to be a frequent cause of insanity in this country, particularly among Protestant dissenters—but of very irregular frequency, owing to the cir- cumstances just alluded to. The forms of dis- order caused by it are chiefly theomania, mel- 584 INSANITY—Exciting Causes. ancholia, suicidal insanity, mania, and mania complicated with hysteria. It must not, how- ever, be supposed that religious feelings are generally the only and sole cause of mental disorder among persons whose minds are much engaged with these sentiments, or that all the cases of insanity in which the mind is occupied with religious ideas have proceeded either solely or chiefly from this source. In the great majority, perhaps, of instances, other moral causes, or even bodily disorders, have either predisposed the mind to be influenced by these feelings, or have been associated with them in their operation on the mind. Dr. Ja- cobi observes, that the original cause of de- rangement is often some misfortune, or some physical influence, religious ideas rather de- termining the morbid effect upon the mind than actually originating it. There is much truth in this, and it is most important in respect of treatment. I have witnessed several cases il- lustrative of the justness of this view ; and, by acting upon it, they have had a favourable issue. 288. The more civilized the human mind, the more desirous it becomes to form anticipations of the future, or to entertain hopes and fears of good and evil, which are not limited to the present state of existence. In forming these anticipations, the knowledge of our imperfec- tions, and of our numerous acts of demerit, naturally impart to them a certain degree of gloom or despondency; and accordingly we find, in all civilized ages and countries, that these feelings, when inordinately indulged— especially during states of physical disorder, or when the mind "is already depressed by grief, anxiety, and bereavements, have caused men- tal disease. Dr. Heinroth has collected nu- merous instances from the early fables of Greece, showing that madness from this cause was not of rare occurrence in the ages of re- mote antiquity. The circumstances in the moral nature of mankind, on which religious in- sanity depends, cannot very materially change, and may therefore be expected always to pro- duce their usual effects ; still they may be more remarkably predominant, or very much less so, in certain periods and places, than in others; and that they have been, and still are, thus variable, is well known. Dr. Prichard ob- serves, that in France, since the revolution, the influence of religion on the community has been less than it ever was in any civilized country; and French physicians have informed him that cases of religious insanity have become pro- portionately rare. M. Esquirol states, that the changes during the last fifty years, " in the moral sentiments and habits of the people, have produced more instances of madness in France than all their political calamities. The change in ancient customs and fixed habits, in old and established sentiments and opinions for specu- lative theories and dangerous innovations, has contributed to this. Religion now comes for- ward only as a formal usage on solemn occa- sions, and no longer affords her consolation to the afflicted, or hope to the desponding. Mo- rality based on religion is no longer the guide of reason in the narrow and difficult path of life. A cold egotism has dried up all the sources of sentiment: there no longer exist domestic affections, respect, attachment, authority, or reciprocal dependences. Every one lives for himself; none is anxious to form those wise and salutary provisions which ought to con- nect the present age with those which are destined to follow it." 289. An enthusiastic, or a vehement and im- passioned mode of preaching, and declama- tions abounding with frightful pictures and con- demnation, are not confined to any sect; and, in some countries, are as common among Ro- manists as among Protestants and Protestant dissenters. The itinerant missionaries of all sects—of Romanists as well as of Protestants —are remarkable for fanaticism ; and for modes of preaching, more calculated to disorder the minds of persons, who are already suffering the ills of life, the depressing passions, be- reavements of affection or of fortune, exhaus- tion of nervous power, and bodily disease, than to afford the consolations which religion is in- tended to administer in these and other circum- stances of distress. 290. The question which has been often agi- tated, as to the greater prevalence of insanity among Romanists and Protestants, may seem to bear upon this topic, but not so closely as it may at first appear ; for, although mental dis- orders may be more frequent in the latter than in the former, it by no means follows that re- ligious feelings are the causes of this frequency, or that the numbers of the insane are greatly increased by cases of this kind. The number among Romanists may be as great as that in Protestants, other circumstances compensa- ting for the less influence of this cause in the former than in the latter persuasion. That religious insanity, however, is much less com- mon in Romanists than in Protestants, espe- cially Protestant dissenters, cannot be doubted by any one whose sphere of observation has enabled him to form any opinion on the mat- ter. Dr. Hallaran (Pract. Observ. on Insanity. Cork, 1818, p. 32) states, that in the Lunatic Asylum at Cork, in which the admissions of Romanists are about ten to one of Protestants, no instance has occurred, within his recollec- tion, of mental derangement in the former from religious enthusiasm ; but that several dissent- ers from the Established church have been so affected. The reason of this difference is ob- vious. The ministers of the Romish church will not allow the minds of their flocks to dis- trust points of doctrine and discipline, or to fall into these doubts, which distract the minds of those who are either wavering in their opin- ions or entertain entire liberty of conscience. 291. While Hallaran, Guislain, Leupoldt, Burrows, and others, contend for the greater prevalence of mental diseases in Protestants than in Romanists, Jacobi and Chiaruggi be- lieve that cases of religious insanity are also frequent in the latter. Dr. Jacobi remarks, that the character of religious madness in members of these two communities, and the manner of its accession, are, for the most part, different! In the lunatic asylumns of Roman Catholic Germany, many of the inmates of the lower classes have become religiously mad, from the delusions of a wild and unregulated imagination, excited by superstitious phantasms, through neglect of the culture of the understanding, and the overpowering influence of sensual passions. Dr. Prichard has given a table from Jacobi INSANITY—Exciting Causes. 565 of the comparative prevalence of insanity in the Romanists and Protestants of the Prussian States on the Rhine; and it appears from it that the proportion of lunatics in the former, compared with that in the latter, is as 11 to 10; and that the proportion is much higher among the Jews than in these persuasions. Still, this conveys no information as to the comparative prevalence of religious insanity among them. 292. Mr. Tuke's account of the Retreat, the asylum belonging to the Quakers or Friends, furnishes only 3 cases out of 149 which could at all be ascribed to anxieties connected with religion ; and in his list of causes of insanity among the inmates of this asylum, pride, am- bition, jealousy, rage, debauchery, penury, or care produced by hardships, &c.—causes so productive of insanity in other institutions—are not even mentioned. The exemption from these prevalent causes of mental disorder are attributable to the strictness of moral education and discipline, to the restraints imposed on the imagination and the indulgence of the passions, and to the absence of enthusiastic excitement on religious topics in this sect. Still, insanity is as prevalent among Quakers as among any other sect, relatively to their numbers, owing, as above remarked (§ 253), to the increased in- fluence, in them, of hereditary predisposition. £Dr. Macdonald remarks (N. Y. Journal of Medicine and Surgery, vol. i., p. 328) as follows on this subject: " One of the most intelligent members of the Society of Friends in Great Britain, and the author of a highly interesting work on the celebrated York Retreat, informed the writer, that the proportion of lunatics and idiots among his sect in England amounted to one in 200. Considering that there are only 20,000 Friends in England, and that marriages have been confined for many generations to this comparatively limited circle, the very great prevalence of insanity among them must be at- tributed, in a great degree, to this cause. The statistics of American insane institutions show that hereditary predisposition is by far the most influential cause of insanity in this coun- try, as it is found to be in every other.] 293. From what has been now stated, it will appear that the frequency of religious insanity in different persuasions and sects will depend upon the excess of fervour characterizing them. Exuberance of zeal on any subject soon passes on to madness in some constitutions ; and on religion, unless tempered by a sound judgment, it is apt to degenerate into fanati- cism, and thence into delirium, which often be- comes permanent. Excessive fervour, or en- thusiasm, generally shows itself in religion when any revolution of opinion or doctrine takes place, and when new lights and new sects arise among those who have received a cer- tain amount of education and religious instruc- tion. Dr. Robertson (Hist, of Charles V., vol ii.) has well remarked, that " when the human mind is roused by grand objects, and agitated by strong passions, its operations are apt to become irregular and extravagant. Upon any great revolution in religion, such irregularities abound most at that particular period when men, having thrown off the authority of their ancient principles, do not yet fully comprehend the nature, or feel the obligation of those new tenets which they have embraced. The mind in that situation, pushed forward with the bold- ness which prompted it to reject established opinions, and not guided by a clear knowledge of the system substituted in their place, dis- dains all restraint, and runs into wild notions, which often lead to scandalous and immoral conduct. Such was the effect in the first ages of Christianity, as well as at the era of the Reformation. The renunciation of the ancient faith, and ignorance of that which they had em- braced in lieu of it, excited converts to acts more resembling insanity than of that religion which inculcates the purest morality and gov- ernment of our passions." Dr. Burrows states that he does not recollect an instance of insani- ty from religion in any person steadfast to his ancient opinions. Wherever the disorder was suspected to proceed from this cause, it was clearly traced to the adoption of new tenets which had not been comprehended, and found to originate during the conflict in deciding be- tween opposite doctrines. 294. It must not be supposed, from what I have advanced, that the Christian religion is truly chargeable with causing insanity ; it ac- tually has an opposite tendency. Mistaken views, excessive fervour, unfounded fears, and various feelings arising from these sources, are the only causes of insanity in connexion with religion. Among those who entertain just and sober opinions on religious topics—who make Christian doctrines the basis of their morals, the governors of their passions, the soothers of their cares, and their hopes of futurity—insani- ty rarely occurs. The moral causes of de- rangement, which would not fail of producing injurious effects on others, prove innocuous in them, for these causes would be met by con- trolling and calming considerations and senti- ments, such as would deprive them of intensity or neutralize their effects. Truly religious sentiments and obligations soothe the more turbulent emotions, furnish consolations in af- flictions, heal the wounded feelings, administer hopes to the desponding, and arrest the hands of violence and of despair. 295. In considering how far insanity may have arisen from mistaken views, or ill-regu- lated zeal in religion, the influence of sounder Christian doctrines in preventing its occur- rence from other moral causes ought not to be overlooked ; but this beneficial influence is too often unheeded, from being seldom brought to the notice of the physician, or from being alto- gether concealed in the breasts of those who have experienced it, while the origin of mental disease in disordered religious feelings is ob- truded upon his attention. If the data could be procured, I believe that it would be certain- ly found that the very great majority of those who have committed suicide in states of mind which at least very nearly approach, if they do not altogether amount to insanity, actually ei- ther have been of no religion at all, or have entertained a very imperfect and inadequate sense of it; and that religious obligations have often suppressed suggestions of suicide, which would certainly have been committed if these had not been entertained. And farther, I be- lieve that a very large proportion of those who become insane, especially among the lowest and most ignorant classes, have fallen into this 566 INSANITY—E Ixciting Cause's. state from the scope given to their temper and passions, and from other mental causes, de- prived of that salutary control, and of those consolations furnished by the beneficent doc- trines of Christianity. The tendency of Cow- per to mental derangement was long opposed by the influence of true religious principles ; and, in later life, a sense of his duties and ob- ligations arrested his hand in the act of sui- cide. [Owing to the very incorrect manner in which our last census was taken, it is impossi- ble to state with accuracy the actual propor- tion of the insane to the population in our dif- ferent states. If we take those states which have made such returns as may be relied on, and if European statistics of insanity are to be admitted as correct, then the proportion of lu- natics to the whole population is greater in America than in Europe. But it is very doubt- ful, at least, whether much dependance can be placed on European statistics as connected with this subject. In Norway, which is be- lieved to be the only European country in which a regular systematic plan of instruction has been adopted, the proportion of lunatics Number of the Insane and Idiots in 296. B. Physical Causes of Insanity. — | The physical causes of insanity may be divided into, 1st. Those which affect the encephalon chiefly and immediately ; 2dly. Those which exhaust organic nervous power, and disorder the general organic sensibility ; 3dly. Those which act upon remote organs or parts, with which the brain is disposed to sympathize. Un- der the head of physical causes, M. Esquirol has arranged hereditary predisposition. In treat- ing of the causes of insanity, this should be viewed apart from the exciting physical causes ; for, although it often appears to Occasion insan- ity, without any other circumstance being recog- and idiots is 1 to every 551 inhabitants : a pro- portion certainly as large as exists in any part of the United States. The following estimates are considered to be considerably below the actual number of the insane and idiots in the United States, though they are undoubtedly as correct, if not more so, than the statistics of other countries on this subject. The difficulty arises partly from the fact that the insanity of some will be concealed by their friends, while many monomaniacs, and those but slightly deranged, will not be enumer- ated, because not considered actually insane. On the other hand, it is probable that some who are not deranged, but whose mental fac- ulties have become impaired by old age, or by defect of vision, or hearing, and some who are merely eccentric, hypochondriacal, and intem- perate, will be included. The chief errors, how- ever, in the census of 1840, it is supposed, re- late to the number of the coloured insane in the United States. Recapitulation.—Number of patients in the Lunatic Asylums of the United States in 1844, 2561. Number of admissions in 1844, 1926. Recoveries during the year, 845. Deaths, 294.] the different States and Territories. I nised to develop the predisposition, and al- though it is strictly physical, it still requires, from its nature and influence, an early and sep- erate consideration (§ 251). 297. a. Of the causes which more directly af- fect the encephalon—a. Insolation, sun-stroke, and exposure of the head to great heat, as to the fires of forges, &c., deserve a passing notice. M. Esquirol has observed considerable influ- ence from the last of these ; and I have known several instances of exposure to the heat of the sun in warm climates, and in hot days in temperate countries, having developed an at- tack of mania. Cases of this kind partake States and Territories. Whiten. Coloured. Total. Population. Ratio of insane and idiots to the Supp Public ortetl at Private Suppo Public ted at Private charge. charge. charge. charge. 207 330 56 38 631 501,793 1 : 795 New-Hampshire . . 180 306 8 11 505 284,574 1 : 563 Massachusetts . . . 471 600 27 173 1271 737,699 1 : 580 Rhode Island . . . 117 86 8 5 216 108,830 1 : 503 Connecticut .... 114 384 20 24 542 309,978 1 :572 144 254 9 4 411 291,948 1 : 710 New-York .... 683 1463 138 56 2340 2,428,921 1 : 1038 New-Jersey .... 144 225 46 27 442 373,306 1 : 845 Pennsylvania . . . 469 1477 132 55 2133 1,724,033 1 : 808 22 30 21 7 80 78,085 1 : 976 133 254 99 42 528 469,232 1 : 889 317 731 326 58 1432 1,239,797 1 : 866 North Carolina . . . 152 428 192 29 801 753,419 1 : 941 South Carolina . . . 91 285 121 16 513 594,398 1 :1158 51 243 108 26 428 691,392 1 : 1615 39 193 100 25 357 590,756 1 : 1655 Mississippi .... 14 102 66 16 198 375,651 1 : 1897 6 49 38 7 100 352,411 1 : 3524 Tennessee .... 103 596 124 28 851 829,210 1 : 974 305 490 132 48 975 779,828 1 : 800 363 832 103 62 1360 1,519.467 1 : 1117 110 377 47 28 562 685,866 1 : 1220 36 177 65 14 292 476,183 1 : 1631 42 160 50 18 270 383,702 1 : 1421 9 36 13 8 66 97,574 1 : 1478 Michigan . . • . . 2 37 21 5 65 212,267 1 : 3266 1 9 12 — 22 54,477 1 : 2476 Wisconsin .... 1 7 3 — 11 30,945 1 : 2995 2 5 4 — 11 43,112 1 : 3919 District of Columbia . 1 13 4 3 21 43,712 1 : 2082 Navy of United States 6,100 -- Total .... Population of the United 4329 10,179 2093 783 17,434 -- -- -- | -- 17,068,666 1:979 INSANITY—Exciting Causes. 567 much of the character of phrenitis, and are ac- tually such in most cases, especially at their commencement; while in others, more or less of congestion takes place, or follows a state of inflammatory action. It is chiefly where a marked predisposition has existed, or moral causes have co-operated with this, that mental disorder is developed, or persists for a consid- erable period. In some instances, exposure to the sun's rays first produces an epileptic seiz- ure, the derangement of mind either imme- diately following it, or appearing after several recurrences. These cases more obviously pro- ceed, at first, from the congestion, or vascular turgescence of the brain, or of its membranes, caused by the solar rays. Exposure to the heat of charcoal fires has also been observed to cause insanity, the fumes of these fires prob- ably contributing to these injurious effects. The liability of cooks to mental disorder, which has been remarked on the Continent especial- ly, is probably attributable to this cause. 298. 8. Frequent or habitual determinations of blood to the head, and congestions of the brain and its membranes, are among the most common physical causes of insanity, especially when an hereditary disposition to it exists; but, fre- quently, some fully-developed or specific organ- ic malady of the brain appears before the ef- fect upon the mind is manifested, especially apoplexy and paralysis. In these latter cases, softening of a portion of the brain, or haemor- rhage in some part of it, or both lesions, with various attendant changes, are the more im- mediate effects, and upon these the mental dis- order is only contingent in some instances. When mental disease follows apoplexy, some form or other of paralysis is often associated with it. The varieties of mental disorder con- sequent upon apoplexy, or upon paralysis, or upon both, are chiefly the several grades of de- mentia and forms of partial insanity ; but any other variety may also proceed from them. (See art. Apoplexy, § 52, et passim.) 299. y. Epileptic and convulsive affections are, perhaps, more frequently productive of insani- ty, and especially of the several grades of de- mentia (§ 155,156), than,any other disease, un- less, perhaps, apoplexy and paralysis. M. Es- quirol states that, of 300 epileptics in the Sal- petriere, more than one half are insane. It may be supposed that the influence of epilepsy in causing insanity depends chiefly upon con- gestion of blood on the brain, or vascular de- termination to it; but this inference may be only partially correct; for, even admitting that these lesions of the cerebral circulation are present in many epileptic cases, it does not follow that they exist in all of them. I believe that it will be found that when epilepsy is con- nected with, or depends upon a deficiency of blood, and great impairment of nervous power (see art. Epilepsy, § 27), that it is more apt to be followed by insanity than when attended by either congestion or determination of blood to the brain. M. Esquirol remarks that, although epilepsy and convulsions are often causes of insanity, especially of furious mania and de- mentia, that vertigo still more frequently pre- cedes, and is more destructive to the men- tal powers than they. I believe that vertigo more frequently proceeds from an impaired circulation in the brain, conjoined probably with weakened organic nervous energy of this organ, than from opposite states of the cir- culating and nervous system. Cataleptic and ecstatic affections and somnambulism may also . lapse into mental derangement; or, in other terms, the states of nervous influence and ol cerebral circulation causing these affections, may be only early stages or grades of the same physical disorder of which insanity is the con- sequence. 300. 6. The transference or metastasis of dis- ease to the encephalon is a not infrequent cause of insanity, especially where a predisposition to it exists. The sudden disappearance, or the suppression of cutaneous eruptions, of ac- customed discharges and evacuations, and of certain painful or constitutional maladies, has often been followed by mental disease. Cases illustrative of the production of inflammatory and other diseases of the brain and of the va- rious forms of insanity from these causes, abound in all practical medical works. The suppression of herpes, of scabies, and of other chronic cutaneous eruptions—of various dis- charges, as leucorrhcea, chronic diarrhoea, &c.; of haemorrhagic evacuations, as epistaxis, haem- orrhoids, menorrhagia, and of gout and rheu- matism—has frequently been followed by in- sanity, and especially by mania and melan- cholia, either in their simple forms, or compli- cated with paralysis or epilepsy. Where the mental disorder thus supervenes, distinct evi- dence of acute or sub-acute inflammation of the brain or of its membranes, or of both, is often evinced for some time before the mind becomes disordered. 301. e. Inflammatory, and other diseases of the brain, are frequently followed by mental de- rangement. The delirium symptomatic of these maladies, and of fever with predominant affection of the brain, may subside into one or other of the forms of partial or general insani- ty ; and the various organic lesions occurring in the encephalon and its membranes may be attended at an early stage with more or less mental disorder ; or, after having given rise to epilepsy, paralysis, or apoplexy, may be fol- lowed by such disorder. In such cases, how- ever, the mental affection is to be viewed rath- er as a contingency than as a necessary con- sequence of the organic disease. 302. f Injuries of the head are sometimes productive of insanity, owing chiefly to chron- ic or slow inflammatory action, and its conse- quences in the brain or membranes. In some cases, acute disease, attended by delirium, is the first effect; but, consequent upon this, any grade of chronic insanity may appear. Occa- sionally even the mental affection does not oc- cur until years have elapsed from the receipt of the injury, and it then may present every grade of severity, and may even be associated with epilepsy or paralysis. During the long in- terval that may thus elapse, various symptoms referrible to the encephalon are generally com- plained of, and are sometimes so manifest to the physician as to lead him to dread the im- pending calamity, and to employ means which as often fail as succeed in averting it. Dr. Prichard remarks that there are instances in which a slight peculiarity of character, not amounting to insanity, has remained long, and perhaps through the life of the individual, who 568 INSANITY—Exciting Causes. has sustained a severe injury of the head. Sometimes this amounts to a kind of moral insanity, the temper being more irritable, and the feelings less under restraint than formerly. In other instances, there have been greater energy and activity, more of excitement in the general character, which have been thought a change for the better, rather than a morbid alteration ; of this, two remarkable cases have come under my own observation. Van Swieten, Haller, and others have adduced instances of congenital and puerile imbecility having been removed by injuries on the head; and Doctor Prichard mentions a family, consisting of three boys, all idiots, one of whom, having received a severe injury on the head, had his faculties restored, and became a professional man of good talents. 303. b. Whatever greatly exhausts organic ner- vous power, both predisposes to, and directly occasions insanity.—a. Many, however, of those causes, which thus affect nervous energy, fa- vour congestion on the brain, and occasion disease of other vital organs, tending to disor- der the functions of the brain sympathetically. Of these, the most influential are masturbation and libertinism, or sexual excesses, sensuality in all its forms, and inordinate indulgence in the use of intoxicating substances and stimu- lants. The baneful influence of the first of these causes is very much greater, in both sex- es, than is usually supposed ; and is, I believe, a growing evil, with the diffusion of luxury, of precocious knowledge, and of the vices of civ- ilization. It is even more prevalent in the fe- male than in the male sex; and in the former it usually occasions various disorders connect- ed with the sexual organs—as leucorrhcea, dis- placement of the uterus ; difficult, or disorder- ed, or suppressed, or profuse menstruation ; both regular and irregular hysteria, catalepsy, ecstasis, vertigo, various states of disordered sensibility, &c, before it gives rise to mental disorder. In both sexes, epilepsy often pre- cedes insanity from this cause ; and either it or general paralysis often complicates the advan- ced progress of the mental disorder, when thus occasioned. Melancholia, the several grades of dementia, especially imbecility and monoma- nia, are the more frequent forms of derange- ment proceeding from a vice, which not only prostrates the physical powers, but also impairs the intellects, debases the moral affections, and altogether degrades the individual in the scale of social existence, even when manifest insan- ity does not arise from it. Sexual excesses, and libertinism in persons predisposed, hered- itarily or otherwise, have a similar effect to the former cause, although neither so frequently nor so certainly ; the mental disorder generally assuming the same forms and morbid associa- tions as have just been mentioned. 304. 8. Intoxicating substances and stimulants .are causes of mental disorders in most coun- tries ; but they are among the most influential of all the exciting causes in the lower classes, particularly in the United States of America, in Great Britain and Ireland, and in Germany. In France, Italy, and Spain, this vice is much less frequent. Spirituous liquors are the most generally indulged in, and are the most injuri- ous in their effects, not only on the nervous system, but also upon the digestive and excre- j ting organs. A large proportion of the admis- sions into pauper lunatic asylums arise from this cause, especially in large cities and manu- facturing towns and districts. Mania, mono- mania, and melancholia most frequently proceed from the abuse of intoxicating liquors ; and the cases which are thus caused are among those which are oftenest cured, at least for a time. The removal of the cause, and the use of sed- ative means, generally cure the attack; but relapses or recurrences are more frequent in these than in any other class of cases. [Dr. Dunglison (Cyclop, of Pract. Med., vol. iii., p. 49) remarks that, although alcoholic Ii. quors are a common cause of delirium—delirium tremens—they are not, so far as he has observ- ed, a frequent occasion of insanity ; and he re- fers, in support of this opinion, to the fact that insanity is frequent among the Society of Friends, who rarely indulge in the use of intox- icating drinks. But this has already been ac- counted for from hereditary predisposition (p. 565, § 292) occasioned by another cause. We agree, on this subject, with those who think that the use of alcoholic liquors is the most common and extensive cause of insanity in this country. Dr. Woodward, as already sta- ted, gives 204 cases out of 1141 of insanity known to arise from this cause, and thinks that many of the cases arranged under " ill health," " fear of poverty," " loss of property," " domes- tic affliction," " religion," &c, &c, would more properly fall under this.; In this opinion we cordially concur, and believe that it will be sus- tained by the statistics of all our insane hospi- tals, as it is by every day's observation and ex- perience. That there is something in the ha- bitual stimulation of alcohol which is calcula- ted to weaken the reasoning faculty, undermine the judgment, pervert the moral sense, and in- duce disease in important organs, as the brain and liver, which indirectly lead to mental un- soundness, is now too well established to need any argument at our hands.] 305. The excessive use of opium is as inju- rious to the nervous energies and to the men- tal powers as addiction to spirituous liquors; but the ill effects resulting from it on the mind are not often observed in this country. I have known several instances, all of them females, of the acetate of morphia having been used, in- stead of opium, as a restorative and intoxica- ting agent. It was ultimately more or less in- jurious in all; and in one, partial insanity, with suggestions of suicide, appeared ; but probably other causes contributed to the morbid effect. 306. y. The abuses of mercurials, and partic- ularly of calomel, as a common or frequent pur- gative, has, in several instances in which I have been consulted, been productive, first, of de- pression of the nervous power, and of a mor- bidly increased state of the general sensibility, and, subsequently, of melancholia and other forms of monomania. A surgeon, a pupil ot the late Dr. Currie, was in the habit of taking large doses of calomel at least twice, but more frequently oftener, in the week. He believed himself subject to disease of the liver, resorted to this medicine when he found his spirits great- ly depressed, and considered that he was better the day after taking it. He persisted in the frequent use of calomel, and became more and more nervous and hypochondriacal. He was INSANITY—E: Ixciting Causes. 669 afterward melancholic, entertained mistaken views of religion, and attempted suicide, which he accomplished in a subsequent attempt. The daughter of a clergyman in this city was attend- ed by this surgeon, and had very frequently taken large doses of calomel. Her health and spirits had become remarkably impaired, and her intellects disordered. There was no hered- itary predisposition to insanity on either side of the family. She had been fond of company and amusements; but was melancholic, phys- ically out of health, tormented by the most dis- tressing religious fears, and refused being seen by her relatives and former friends, when I was directed to visit her. Her despondency, mental misery, and religious delusions were remark- able ; and she had frequently contemplated sui- cide, in order to terminate her suffering. She completely recovered under a restorative treat- ment, aided by change of scene and of air, and by suitable moral management. 307. 6. The too frequent or excessive use of col- chicum, for the removal, suppression, or pre- vention of gout, has given rise to insanity in three instances in which I was consulted. In one of these melancholia was the more imme- diate disorder of the mind ; in the others, inco- herence and imbecility, with illusions, were the consequences. All powerful depressants, and even cold, either excessive in grade, or pro- longed in its operation, may occasion insanity by their operation on the nervous power. 308. e. Excessive or prolonged lactation, rela- tively to the patient's strength, profuse evacua- tions, particularly leucorrhcea, frequent menor- rhagia, profuse haemorrhoidal discharges, &c., have also induced melancholia, and other par- tial forms of insanity, and even imbecility, or more complete dementia, chiefly by exhausting the vital powers, especially of the nervous sys- tem. It will afterward be shown that puerpe- ral insanity is occasioned partly by this cause, or rather by the evacuations consequent upon parturition, in connexion with previous suffer- ing and increased susceptibility of the nervous system. Something also may be imputed to the altered state of the general circulation, and of the condition of the uterine organs. 309. c. Diseases of Organs with which the Brain more or less sympathizes, not infrequently cause insanity when a predisposition to it al- ready exists. So intimately associated in func- tion are all the organs of the body, through the numerous bonds of union furnished by the or- ganic nervous and vascular systems, that se- rious disease seldom exists in either, without the functions of one or more of the others being remarkably disturbed ; and when visceral dis- ease occurs in a person who has an hereditary or an acquired predisposition to mental disor- der, the former is often the cause of the devel- opment of the latter; various other circum- stances, however, moral and physical, often co- operating with this cause in the production of the morbid effect upon the mind. Of this class of physical causes, habitual constipation, inflam- matory irritation of the gastro-intestinal mucous surface, diseases of the heart and lungs, func- tional disorders and organic lesions of the ute- rus, and diseases of the biliary and urinary or- gans, are the most important. It is chiefly when these visceral' maladies appear in an ob- scure and insidious manner, and proceed slowly, 72 that the functions of the brain become disor- dered in a chronic form. 310. a. Without attributing nearly so much influence, as M. Broussais has done, to inflam- matory irritation of the gastro-intestinal mucous surface, it cannot be denied that its pre-exist- ence is of considerable importance in the pro- duction of the mental disorder. But it is very seldom the sole physical cause in these cases ; most commonly, exhaustion or depression of the organic nervous influence co-operating with it in producing the effect upon the mind. The disorder of the digestive organs is generally caused by the excessive use of stimulating and indigestible food among the opulent; and by constipation, intemperance, unwholesome food, and by cold and want among the lower classes. In these cases, hypochondriasis, or hypochon- driacal melancholia, first appear ; and various forms of general insanity supervene. 311. 8. Severe functional and organic disease of the heart or lungs may excite insanity in the predisposed, owing to disorder of the circula- tion in the brain, consequent upon interruptions of it in these organs. When mental derange- ment follows diseases of the biliary or of the urinary organs, it may proceed more immedi- ately from the influence on the brain of the ex- crementitial matters accumulated in the blood, in consequence of the impaired or disordered function of these organs. 312. y. Of the operation of the functional and organic affections of the uterine organs but lit- tle need be here added to what has already been observed. In these cases, the sympathetic ef- fect takes place, most probably, by the propa- gation to the spinal cord and brain of irritation originating in the sexual apparatus ; and the mental disorder is generally preceded and at- tended by one or more of the numerous forms of hysteria, or by epilepsy, and sometimes also by hypochondriasis, or great lowness of spirits. This is especially the case when the catamenia are difficult or suppressed. In many cases, not only uterine disorder, but also gastro-intestinal irritation, is accessory to the causation of the mental disease. 313. In considering the operation of all these physical causes, it should not be overlooked that it is often extremely difficult to determine whether the disorder originates in the brain— the other organs sympathizing with it — or whether the disturbance of the mental powers is altogether owing to disease of viscera re- , mote from the encephalon. But, however dif- ficult it may be, an attentive examination of the history and existing symptoms of the case should be instituted to the determining of this point, as much of the success of treatment will depend upon correct views regarding it. 314. 6. When organic nervous or vital power is much depressed, especially in. respect of the digestive and excretive functions, accumulations of morbid secretions, and collections of facal mat- ters, are liable to form in the intestinal canal, and particularly in the cacum and colon. These dilate, displace, irritate, and obstruct the bow- els, occasioning flatulent distention, spasm of the muscular coats, and various disorders of the whole tube, as well as of the collatitious viscera. These morbid accumulations are apt to occur even in persons who suppose their bowels perfectly open and regular; and they 570 INSANITY—Exciting Causes. more certainly take place in those who are ha- bitually costive or constipated. The effects, however, of collections of morbid secretions in the bowels—particularly in the large bowels— are not limited to these, or even to the adjoin- ing viscera; although, if even thus limited, they would often be sufficient to excite, by the inti- mate sympathy existing between the digestive organs and the brain, functional disorder of the latter, especially in persons already dispo- sed to such disorder. But there is every rea- son to believe, that when morbid or faecal mat- ters accumulate in the intestines, either with or without constipation, the chyle thereby be- comes more or less impure or contaminated, and that a portion of these matters is absorbed into the circulation, the blood being consequent- ly altered, and a state of general cachexia be- ing thus produced. Where the predisposition to insanity already exists, the morbid materi- als conveyed into the blood will be often suffi- cient to derange the functions of the brain ; and, not infrequently, this consecutive derange- ment will not be limited to these functions, but will extend to several others. 315. The sympathetic influence of the di- gestive organs on the brain, in connexion with the deterioration of the chyle, and the absorp- tion of excrementitious matters from the bow- els into the blood, will in this manner occasion hypochondriasis, melancholia, partial and gen- eral insanity, and, ultimately, even some of the complications which these occasionally present. The displacements and dilatations of the colon so often observed in melancholia, and some- times also in other disorders of mind, most probably result from frequent or habitual con- stipation, even previously to the appearance of mental derangement. And the inflammatory irritation of the gastro-intestinal surface, al- ready noticed (§ 310), as causing and attending many cases of insanity, is probably the more immediate effect of the impaired energy of the digestive canal, and of the accumulation in it of morbid matters; the consequences as re- spects the chyle and the blood, just contended for, increasing the effects upon the functions of the brain. The influence of constipation, or even of habitual costiveness, in causing insan- ity, and the good effects of powerful purgatives in the treatment of it, were well known to the ancients, and to most of the older writers ; and, though fully recognised in this country, have been imperfectly estimated on the Continent in recent times, and even erroneously viewed by many, and particularly by Broussais and his disciples. 316. e. Besides the above physical causes, pregnancy, the accumulation of morbid matters in the intestinal canal, and of bile in the biliary apparatus, the presence of worms in the bowels, hypochondriasis, and hysteria, frequently give rise to insanity. The abuse of medicines, and of all substances which act powerfully on the nervous system, and especially of green tea or of coffee, is occasionally, also, a cause of men- tal disorder. 317. f. M. Esquirol (Mai. Ment., t. i., p. 64, et t. ii., p. 682) has given the following tables of the causes of insanity, the first comprising only the physical causes among female cases; the second embracing both physical and moral caus- es in cases of both sexes at Charenton. Physical Causes. Hereditary predisposition . Convulsions of the mother du- ring gestation..... Epilepsy....... Disorders of the catamenia . Consequent on lying-in . . Critical age...... Progress of age . • Insolation....... Injuries of the head . . . Fevers........ Syphilis....... Mercury....... Intestinal worms . . . . Apoplexy...... Salpetriere 105 11 11 55 52 27 60 12 14 13 8 14 24 60 M. Esquirol's Establishment. 150 4 2 19 21 11 4 4 4 12 1 18 4 10 Causes, Physical and Moral. Hereditary predisposition . Masturbation,..... Libertinism and excesses of all kinds...... Abuse of mercury .... The abuse of spirituous li- quors ........ Insolation, &c...... Injuries on the head . . . Suppression of accustomed evacuations..... Suppression of habitual sup- puration ...... Consequent upon parturition Cerebral affections .... Epidemic cholera . . . . Domestic distresses, &c. . . Excessive study and watch- ings ........ Reverses of fortune . ." . Gambling....... Jealousy....... Disappointed affection . . Wounded self-love.... Fright........ Exalted devotion .... Excessive joy..... Reading romances, &c. . . Political events..... 10 1815 21 0 1 1 0 2J 1 H 337 52 146 44 136 16 49 6 18 37 16 35 24 2 13 32 1375 318. M. Esquirol remarks, that the causes were often ascertained with much difficulty, as the patients themselves were generally incapa- ble of assigning them, and the friends could not always do so, at least with any degree of pre- cision. It is probable, however, that two or more causes were concerned in producing the effect, and that various circumstances were omitted; he considers that hereditary predis- position is much more frequent than* stated in the above table. Under the head of domestic distresses are included all the moral affections which are called into action in the interior of a family. The political changes in Paris in 1830 gave rise to the cases from this cause, and to those produced by frights. 319. y. Sol-lunar influence was very general- ly supposed to excite or to favour the appear- ance of insanity, as well as to cause exacerba- tions of the malady. M. Esquirol could not verify this opinion by the results of his experi- ence. It is probable, however, that electrical states of the air, or sudden vicissitudes of the atmospheric electricity, in connexion with sim- ilar changes in the electrical currents through the body, have some influence on this malady. The effects of excessive cold and of great heat in causing madness, and the excitement produ- ced in lunatics by atmospheric commotions, are indications of this influence. However this may be, there can be no doubt of marsh mias- INSANITY—] mata being a not uncommon cause of insanity, and especially of melancholia and dementia. [The causes of insanity in this country have been very successfully investigated by Doctors Macdonald, Earle, Woodward, Brigham, and other physicians connected with our different in- sane hospitals, and the results spread before the public in the annual reports of these institutions. We shall present the results of investigation as deduced from observations made at the Bloom- ingdale Asylum, and the Massachusetts Hospi- tal at Worcester, as conveying a very accurate idea of the comparative efficiency of the vari- ous causes of mental diseases as operating in the United States. The professions and occupations that furnish- ed the largest number of insane were the fol- lowing : Farmers, 106; merchants, traders, 89; clerks, 45 ; labourers, 35 ; seamstresses, 29 ; grocers, 25 ; tailors, 19 ; students, 19 ; seamen, 17; tavern-keepers, 12; state-prison convicts, 11; cabinet-makers, 8; clergymen, 6 ; manu- facturers, 6 ; gentlemen, 5 ; hatters, 5 ; sea- captains, 16; curriers, leather-dressers, 16 ; shoemakers, saddlers, 15 ; carpenters, 25 ; house-servants, 22; lawyers, 20; iron found- ers, 18 ; farm-labourers, 12 ; physicians, 12 ; masons, 11; teachers, 10; painters, glaziers, 8 ; bakers, 5 ; butchers, 5; watchmakers, jew- ellers, &c, 5 : total, 663. Dr. Macdonald has remarked, that it is evi- dent, from an inspection of this table, that the classes most subject to insanity are those which are connected, either directly or indirectly, with commerce, and dependant on it for a livelihood. Of 804 persons whose occupations were ascer- tained, 242, making about 30 per cent., were de- pendant on commerce. The producing classes, including farmers, mechanics, labourers, &c, and making up the great bulk of inhabitants, furnish 395 out of 804 cases of insanity, or 49 per cent. Of these, the tillers of the soil, in- cluding 106 farmers, 12 farm-labourers, 2 plant- ers, and 2 gardeners, amount to 122, or rising 13 per cent., and mechanics to 206, or rather more than 23 per cent, of the whole number of vocations ascertained. Persons of studious habits, including the learned professions, and amounting to 67, form about 8§ per cent, of the whole number, leaving but 12£ per cent, from all the occupations not embraced in the above classes. Of persons exposed to the inhalation of deleterious gases, there were 14 in all, in- cluding 2 practical chemists, 8 painters, 1 man- ufacturer of soap containing prussic acid, and 3 white-lead workers. Causes.—The most important physical causes were the following : Hereditary, 155 ; cerebral disease, connected with apoplexy, palsy, and epilepsy, 55; suppression of established dis- charges, 5 ; lead in cider, and fumes of white- lead, 5 ; bodily disorder, 48 ; following parturi- tion, 43 ; constitutional, 34 ; succeeding fever, 31 ; functional and structural disease of uterus, 20 ; masturbation, 16 ; injury of the head, 15 ; congenital, 13; rapid growth at age of puberty, 13 ; metastasis, 9 ; cessation of menses, 8 ; in- solation, &c, 6.* The most important moral causes were as fol- lows : Pecuniary embarrassments and losses, * [Intemperance is stated to have caused about one fourth of all tho cases admitted, though not enumerated among the other causes.] xciting Causes. 57J 59 ; religious excitement, 40 ; domestic trouble, 31 ; over-exertion and abstraction of mind, 26; grief, or loss of relations, 23 ; unrequited love, 20; unhappy marriage, 17; anxiety of mind, 17; wounded pride and disappointment, 13; religious anxiety, &c., 12 ; remorse, 13 ; ter- ror, 9; avarice, 8; religious terror, &c, 7: total, physical causes, 511 ; moral causes, 843. Dr. M. remarks, that " when we look over our extensive country, and consider its im- mense progress in civilization, wealth, and lux- ury, the varied and increasing temptations to embark in the wildest schemes of speculation, the sudden accumulation and loss of fortune, the fluctuations of trade, the interest taken by almost every citizen in every political and financial movement that agitates the commu- nity, the activity of mind everywhere apparent, the fierce strifes of the predominating passions of ambition and avarice, involving so many mi- nor ones, and extending their influence through- out every class of society, we are compelled to believe that we have among us as many active causes of insanity as any country in Christen- dom." At the Massachusetts State Hospital at Wor- cester, 157 were farmers, 117 labourers, 52 shoe- makers, 50 seamen, 45 merchants, 37 carpen- ters, 29 manufacturers, 25 teachers, 18 stu- dents, 15 blacksmiths, 14 printers, 11 tailors, 9 machinists, 5 clergymen, 4 lawyers, 3 physi- cians, &c, and many not classed. The male patients had been previously employed in 54 trades or occupations ; the females from all the employments pursued by the sex in every de- partment of industry. Dr. W. very truly re- marks, that the production of insanity more gen- erally depends upon the temperament than upon the employment, and that few become insane who have good habits, calm and quiet tempers, and thorough discipline of their feelings. Among the causes, we have : From intemperance, 204; ill health, 208; masturbation, 113; domestic affliction, 145 ; religious, 100 ; property, 77 ; disappointed affection, 58 ; disappointed ambi- tion, 28 ; epilepsy, 40 ; puerperal, 36 ; wounds of the head, 17 ; abuse of snuff, &c, 8 ; hered- itary, 388 ; periodical, 251; homicidal, 20 ; ac- tual homicides, 15 ; suicidal, 154; actual sui- cides, 7 : dark eyes and complexion, 399 ; light hair, eyes, and complexion, 389 : from physical causes, 633 ; from moral causes, 408. Intem- perance, it will be seen, takes the first rank among the causes of insanity, and, as Dr. W. well observes, " is not only the cause of insan- ity, but is too frequently the source of other evils, which are prolific causes of the disease. If we could ascertain how many of the cases of ill health, of domestic affliction, of fear of poverty, loss of property, and even religious de- pression and melancholy, arise from it, the list would be appalling, and would be nearly or quite double what it now is." If we seek for the cause of insanity among men who pursue labo- rious occupations in the open air, we shall find it, for the most part, in intemperance ; for ex- ample, of 114 farmers, Dr. W. states that 43 became insane through this cause; of 70 la- bourers, 44 ; of 36 seamen, 22 were intemper- ate, and this was the occasion of their insan- ity. Dr. W. also enumerates "partial paral- ysis of the brain" as the cause of insanity in 15 cases; a pathological condition connected ^citing Causes. 872 INSANITY—E also with the intemperate use of -alcoholic drinks.—(Ninth Annual Report, &c, 1811.) Of 4089 patients, whose cases have been stated at five American institutions, the disease is sup- posed to have originated, from physical causes in 2026, from moral causes in 1445, and in 618 no cause was ascertained. Nearly all the phy- sicians of the American asylums believe in the paramount influence of physical agents in the production of this disease. It is, however, very evident that the remote as well as immediate causes are often involved in obscurity, and that observation and opinion are influenced to a very considerable extent by preconceived the- ory] 220. C. Various circumstances arising out op the manners and social and political states of a community may increase the fre- quency, or contribute to the production of in- sanity. Still, these states are more or less con- nected with the affections of the mind and the other moral causes, or are resolvable into them. —a. The social conditions resulting from pre- vailing modes of education have been consider- ed by M. Esquirol as most influential in in- creasing the numbers of the insane. Too much care is taken to cultivate the mind, not consid- ering that the affections of the heart require equal care. In all classes an education is be- stowed upon the young above what is suitable and proper to their station in society ; and hence, sentiments of ambition and of discon- tent with their condition are instilled into their minds from childhood. This early and ambi- tious education raises the mind of the young above, and too often in opposition to, the expe- rience of their parents ; and hence the opin- ions of the latter are despised or neglected. A person who has not been duly controlled in childhood is ill able to endure the vicissitudes and reverses to which an active life exposes him in the present state of society; his passions being thereby deprived of a salutary curb, and his reason of its surest props, insanity often fol- lows upon the least adversity. The manner of living in the easier classes of society—the pas- sion for dress, for exciting romances, for in- trigue, for frivolities and amusements, engen- der a constant thirst for excitement, and in- crease the frequency of nervous complaints and mental disorders. The vices, and the miser- ies and privations consequent on these vices, in the lower grades of society, have a no less marked influence in causing the latter of these effects more especially. 321. b. In country districts, the prevailing passions are less turbulent and exciting than in cities and large towns. Love, anger, and domestic contrarieties are the most frequent moral causes of mental disorder in the former ; while in the latter, ambitious views, specula- tions, disappointed hopes, reverses of fortune, excessive mental labour, watchings and late hours, greater depravation of manners, and more vicious indulgences, are added to these ; and, consequently, insanity is more prevalent in populous, commercial, and manufacturing towns than in rural places. In proportion as the latter causes are prevalent in any commu- nity, and are aided by a more or less general propensity to drunkenness, or to libertinism, or by the vices of education, and of conduct in the richer classes, and by the want of both in I the lower orders, so do the disorders of the mind become more frequent. 322. c. Even forms of government have con- siderable influence in contributing to this re- sult. There is not the least doubt of the ill ef- fects of a too great freedom of public opinion and acts, and of public writing and speaking, upon mental sanity. With the freedom of opin- ion, and the latitude allowed to the expression of it, without regard to the feelings and the in- terests of individuals, or to the morals and sympathies of the community, those emotions which most seriously disturb the mind, are brought into the most violent and distressing ac- tion, and the calm dictates of reason thereby overthrown. The political strifes, the popular elections, the borough and parish contentions, in this country and in the United States of North America, furnish sufficient proofs to the candid mind of the truth of this position. The exciting, the contaminating, and the disgusting occurrences and circumstances which daily, and even hourly, are placed before all classes in society, in most exuberant variety and partic- ularity of detail—the moral poison with which the whole is garnished, in the lowest, the cheap- est, and the most diffusible of these vehicles of abominations and of mental infection—the liberty which contaminates the innocent, de- moralizes the public, injures the feelings, and benefits only the worthless and the base—all tend to the consummation of the injurious ef- fect upon the mental health of the community —to the increase of crime, of madness, and of suicide. " Here, by the bonds of nature feebly held, Minds combat minds, repelling and repell'd: Ferments arise, imprison'd factions roar, Repress'd Ambition struggles round her shore j Till, overwrought, the general system feels Its motion stop, or phrensy fire the wheels." 323. d. Political commotions, by exciting re- venge, and the more violent passions of the public, by fomenting ambition, by rousing to in- tellectual exertions, and by overturning for- tunes and the established order of things, have a marked influence in augmenting the frequen- cy of insanity. The frights, terrors, outrages, distresses, and losses of fortunes, of friends, of honour, &c, consequent upon foreign inva- sions, sieges, and civil and domestic wars, are most frightful causes of derangement on these occasions. Numerous proofs of this have been adduced by the French and German writers since the last war. Revolutions, moreover, do not only greatly increase the numbers of the insane, but also impart certain characters to the prevailing mental disorders. M. Esquirol observes that, when the ancient monarchy was destroyed, many became mad from the loss of fortune and friends, and from the frights and terror caused by the consequent anarchy. When the pope came to France, religious in- sanity was most frequent; and when Napoleon made princes and kings, insanity from ambition and pride was frequent, and kings and queens were numerous among lunatics. Religious rev- olutions have a similar influence ; and even the prevailing ideas called into existence or ac- tivity by these revolutions, by great political events and by popular commotions, contribute both to the frequency and to the character of this disorder. The prevalence and features of I madness during the Crusades and for long af- INSANITY—Its Physiological Pathology. 573 terward ; during the Reformation in Germany, the Low Countries, and Great Britain; and during the civil wars and the temporary dom- ination of Puritanism, under the Long Parlia- ment and Cromwell, are illustrations of what I have just advanced. 324. e. M. Esquirol states, that a sedentary, indolent, or inactive mode of life favours the occurrence of insanity ; and that persons who have been accustomed to a very active life, as merchants, traders, professional men, and sol- diers who have led an irregular and an eventful life, are liable to this malady when they settle to the enjoyment of wealth and splendour. 325. /. Another circumstance of great im- portance presents itself in the relative frequen- cy of insanity in the married and single. The following table contains the results furnished on this subject by Esquirol, Desportes, Jaco- bi, and Prichard : Des-portes. Jacobi. Esqui-rol. i"te 3fe <5 Charenton. "5 £ 13 Widowers and widows 980 397 291 492 201 59 599 156 80 974 176 30 193 363 69 505 387 40 The differences in these results depend much upon the classes of persons admitted into the in- stitutions from which these results are obtained, and upon the limitations observed as to admis- sion. Still, enough is proved by them to sug- gest important considerations connected with the hygiene and prophylaxis of insanity. With respect to the results which are here adduced, Dr. Prichard observes that, as it appears prob- able that celibacy tends to augment the num- bers of lunatics, an inquiry is suggested as to the manner in which this result ensues. Is it through the restraints Which the condition of celibacy imposes, or through the vices to which unmarried persons are more frequently aban- doned 1 M. Esquirol is of opinion that, where one case of insanity arises from the former cause, a hundred result from the latter. A case occurred to me some years ago of a well- educated man, hereditarily disposed to insanity, who, after long periods of continence, experi- enced symptoms premonitory of mania. He married soon after having been under my care. Several years have since elapsed without any indication of mental disorder having appeared. Persons happily married generally lead more regular lives, in all respects, than the unmar- ried, and are more fixed in their pursuits and employments. In many other respects, also, the condition of married persons is much less favourable to the excitement of madness than that of celibacy.* 326. In taking a survey of the feelings, the emotions, and the passions, as well as of the numerous circumstances connected with the social states productive of insanity, the conclu- sion is irresistible, that the diminution of its frequency depends more upon the constitution * [At Bloomingdale, 600 married patients had been ad- mitted (1839), and 573 single ; widows and widowers, 84; being in the ratio of 47J per cent, married, 45J per cent. single ; 6$ per cent, widows and widowers ; corresponding very nearly with the ratio laid down by Esquirol.] of individual minds, proceeding from habitual control, and from a due exercise of moral and religious principles and obligations, than upon all other circumstances combined. " Vain, very vain, the weary search to find That bliss which only centres in the mind. In every government, though terrors reign, Though tyrant kings and tyrant laws restrain, How small, of all that human hearts endure, That part which laws or kings can rtiuse or cure! Still to ourselves in every place consign'd, Our own felicity we make or find : With secret course, which no loud storms annoy, Glides the smooth current of domestic joy. The lifted axe, the agonizing wheel, Luke's iron crown, and Damien's bed of steel, To men remote from power, but rarely known, Leave reason, faith, and conscience, all our own." 327. VII. Of the Physiological Pathology of Insanity.—i. Remarks on Mind and Or- ganization.—A. Of the Scope of these Inquiries. —The human frame respires, digests, thinks, will, and acts; in a few hours afterward, and often without any obvious cause, it performs none of these functions; and, in a few hours more, it falls into dissolution. These phenom- ena are familiarly known to us ; and, although they are considered by all to form a part of the established order of the universe, yet they must have engaged the reasoning powers of man from an early period of his social history, and have been among the earliest subjects of phil- osophic discussion. As the cause of these oc- currences is necessarily embraced by specula- tions as to the origin and nature of mental as well as of corporeal disease, so it may be sup- posed to have always been a matter of deep re- flection to physicians from the earliest ages. The constitution of the human mind leads it to search after first principles, in order to explain the operations continually taking place within and around it; and the hopes of obtaining in- formation respecting the source of the deran- ged states to which itself, as well as its associ- ated frame, is liable, and even of discovering the nature of its own origin and connexions, seriously interest a class of inquirers whose occupation naturally suggests these considera- tions. Yet, although these inquiries more im- mediately concern the practitioner of medicine, especially as respects the more obvious changes, which mind and its allied matter present to his view, still the intimate relations of both the one and the other, the nature of the connexion subsisting between both, and the more remon ved links of the chain which binds them to their first cause, and to the universal system of na- ture, are no farther disclosed to him than to any one else who patiently scrutinizes the objects, which come under his view. As man did not create himself, so neither can the faculties with which he is endowed inform him, of them- selves, even plausibly, either as to their own formation, or as to the original production of the frame which manifests them, or as to the connexions which the one has with the other, or even regarding the ultimate cause and cir- cumstances of the apparent dissolution of both. How can the machine explain the principles of its peculiar construction, or demonstrate the views which actuated its Maker 1 Low can we expect the powers of mind, which cannot be supposed to have been formed without a cause, to acquaint themselves of their own modes of being anterior to their present state 574 INSANITY—Its Physiological Pathology. of existence 1 and how much less can they fur- nish information respecting the nature of that cause from which they necessarily derived their origin 1 They may, however, enable their pos- sessor to recognise the phenomena which take place within and around him. They can mark the modifications and the sequence of opera- tions characterizing their own constitution, and the properties of substances by which they are surrounded ; and they may even expatiate be- yond the objects of sense : still, the powers of human intellect, exalted as they are, can nei- ther, through their own instrumentality, arrive at a knowledge of their own intimate nature, or of the manner in which they first came into existence; nor explain, satisfactorily, the kind of connexion which they hold with their first cause, on the one hand, or with the matter with which they are associated, on the other. Not- withstanding that the field is thus narrowed, it will be still found sufficiently extensive for ex- act research and profitable cultivation. 328. Although speculations respecting the nature and the material alliances of mind are sufficiently unprofitable, when directed to such topics as the above ; yet, as they disclose points of great utility, when they are pursued in a dif- ferent direction, they should not be altogether discouraged. It is to the medical philosopher that these points are especially manifested, and hence he becomes more particularly interested by discussions in which they are in any way involved. But, as his daily researches and oc- cupations are apt insensibly to bias the opin- ions he may form as to those subjects, so his inquiries will often betray, upon strict exami- nation, more of the idola tribus than of exact deduction. Besides this important source of error, there are others, in which he partakes in in common with all inquirers. How very few physiologists are truly sound reasoners and ex- act philosophers ! How often are the first re- quisites of valid argument overlooked, even at the outset of our researches after truth ! How few among those who peruse the discussions to which these researches lead discover the sources of error! and how many are carried along with the sophistries which flow from these sources! • 329. These objections, although strictly ap- plicable to those topics to which I have alluded as being placed above the reach of our facul- ties, have, however, no reference to the correct observation of the healthy manifestations, and of the derangements of mind. The former top- ics, at the best, can be considered, from their very abstract, or, rather, inscrutable nature, as matters of curious speculation ; the latter, be- ing objects of consciousness and experience, are the true subjects of philosophy, and, from their involving the welfare and existence of hu- man beings, are matters of practical importance in the scientific prosecution of our profession. 330. As our knowledge respecting life and mind can be derived only from a careful exam- ination of the phenomena which organized bod- ies present—for we have no experience of the former unassociated with the latter—so our ac- quaintance with the manifestations of mind can be obtained only by an intimate investigation of the nervous system, and of its functions, in the higher animals and in man, and by attend- ing to the objects of our consciousness. Of all the opinions which have been entertained as to the cause of vital phenomena, there is none in which these phenomena are not ultimately as- cribed to one or other of two causes ; namely, either to a certain organism of the materials of which the visible structure of the animal is composed, or to a principle totally distinct from, yet most intimately allied or associated with it; which principle seems to have suggested itself to all mankind, and to have received a distinct appellation. Opinions have necessarily been similarly divided as to the cause and mode of existence of the mental manifestations ; the one being, that they result from the organization of the brain and nervous system ; the other being, that, like vitality, they are distinct from the structures with which they are associated, and which are the instruments only of their opera- tion. Hence, physiologists are divided on this subject into two classes ; the one ascribing all vital and mental phenomena to organization; the other attributing it to a distinct principle—: to vitality—allied to organization, in which state of alliance only is it subjected to observation, and made an object of investigation and of ex- perience. Accordingly, the one class believes that the range and power of intellect entirely result from organization; the other considers that organization is only the medium or instru- ment of mental manifestation, while it contin- ues to be actuated by life ; that the powers of mind are the result of the vital endowment of the brain. Although opinions on this subject may be thus classed, according to their general and fundamental principles, yet they vary re- markably in their subordinate particulars, ow- ing chiefly to their discursions beyond the range of consciousness and observation, and into the regions of imagination and wild speculation. 331. The functions of the brain, in connex- ion with the doctrine of life, have attracted the attention of philosophers from a very early period ; and, during the last century, they have engaged the researches of some of the most acute inquirers who have "interrogated na- ture." The progress of our knowledge, how- ever, in this very interesting but most difficult field, has not been equal to the growing zeal with which it has been cultivated. This want of success is entirely owing to the circumstan- ces already alluded to—to the obstacles which beset us when entering upon investigations in which we encounter the mysterious union of mind with matter, and which relate to the more intimate states of both, and to their mutual in- fluences in different and often in contradictory cirQumstances and aspects. The operations of the nervous system, possessing, as it does, so extended a connexion with the mental powers on the one hand, and with the corporeal func- tions on the other, and reciprocally receiving and communicating influence during health and disease, could not be accurately traced, even in the more evident phenomena, without some reference to the sources and relations of vital and mental manifestations ; and hence have sprung up various and conflicting hypotheses, which have demonstrated little beyond the nar- row limits of our knowledge and of our powers. These humiliating considerations obtrude them- selves, when we view the numerous specula- tions which have been entertained respecting life and organization, and their relations to INSANITY—Its Physiological Pathology. 575 mental manifestation, from the earlier dawn of philosophy to the present time, when we con- sider the conclusions to which many of them lead, and when we reflect upon the small prog- ress that has actually been made in this depart- ment of knowledge. How little has been add- ed even to the physiological part of these re- searches, notwithstanding the self-felicitations of some recent inquirers, since the writings of Galen ! how much of what has been supposed to have been discovered still remains open to contradiction, cavil, and doubt! and what has the science of mind gained from the works of their modern followers in addition to What ap- pears in the discordant theories of Plato, Aris- totle, and Epicurus ! It cannot be a matter of surprise that human intellect has been toss- ed for many ages upon an ocean of uncertainty respecting its nature and relations, seeing that it was never guided by any sound principle of philosophizing by which it might have been navigated into a safe haven. Until the philos- ophy of Bacon extended, in this country, its in- fluence to the science of mind, but little care was taken to attend closely to the intimations of consciousness, and to investigate the nature, the extent, and the mutual relations of our fac- ulties. The more precise attention which has recently been paid by some writers in this coun- try to the objects of consciousness, and to the origin and history of our ideas, whether those which are derived from our senses, or those re- sulting from reflection, will serve to guide our speculations to conclusions more correct, and certainly more ennobling, than many of those are capable of accomplishing that have been entertained in modern times. 332. B. The opinions of the ancients respecting mind and the vital phenomena were sufficiently vague; and yet, when strictly examined, not much more so than most of the views promul- gated in modern times, ^vxn, anima, vital prin- ciple, or soul, according to some, were em- ployed by them to express the cause of the vi- tal actions, the term fan designating the effect of that cause. Democritus, Epicurus, and the Stoics considered the soul to be corporeal or material, but differed as to the matter consti- tuting it. Hippo maintained that it was wa- ter ; Democritus, that it was fire; Heracli- tus, that it was a vapour, or exhalation; and the Stoics, that it was warm or ignited air. Of those who believed the soul to be incorporeal, some considered it mortal, and others that it was immortal. Thales said that it was the origin of motion, and always in motion ; Py- thagoras, that it was a self-moving monad; Plato, that it was conceivable only by the un- derstanding, and Aristotle, that it was the first evTelexeta, or element bestowing on oth- ers the possibility of life. The Manicheans imagined that there is but one universal soul, which is distributed in portions to all bodies. Plato and others maintained the existence of a universal soul, by whose influence all things existed, but that living creatures possessed separate souls, which have a threefold consti- tution : reason, placed in the head as in a cit- adel, passion in the chest, and desire in the ab- domen. The Greek philosophers, who taught the immortality of the soul, generally believed in its transmigration. Galen, adopting the doctrine of Plato, considered the soul to pos- sess three faculties, located in the three cav- ities of the body: a ruling or rational one in the head, a vital one in the thorax, and a nat- ural one in the abdomen. These distinctions were long entertained in medicine, together with the subordinate faculties which Galen supposed to preside over particular organs, and which Harvey denominated sensus proprii, and Blumenbach, more recently, vita propria. 333. The Greeks, who believed in a vital principle, had long been accustomed to arrange its energies under different heads, as the typnv and the -trvpoc: the former implying the intel- lectual and voluntary functions, the latter the involuntary, which originate either in sensa- tion or instinct. Some of their authors ar- ranged the faculties of life under three heads, the vovc, (jipyv, and -dv^ioc: the first comprising the intellectual and rational powers; the sec- ond, those operations supposed to belong to the viscera of the thorax ; and the third, those spontaneous functions termed organic or vege- tative, belonging to the organs of nutrition placed in the abdomen. The Latin writers em- ployed the words mens, animus, and anima in senses nearly corresponding with those attach- ed to the terms used by the Greeks ; although Lucretius, in his development of the Epicu- rean philosophy, is by no means precise in the use of them, and more generally employs mens and animus as synonymous terms, or very near- ly as such. [The ancient Greeks, moreover, assigned the peculiarities of the actions of the different organs of the body to their being the residence of several immaterial agents. The Pastophori first alluded to these as genii, or demons, or decans of the air, and their pupils of Greece believed them to preside, under the control of a great master spirit, over the functions of the several organs of the body. By Hippocrates and Galen, these were termed Awdpeic, and were considered to reside, one or more, in each organ, in subserviency to the grand Evoppuv, or -Kvevua, and to be the immediate cause of the peculiar function which it performed. Thus, according to Galen, the heart was the resi- dence of three Avvdpetg, the dvvapte diaoreXko- fMevt], nipioTeXTiopevr/, and avarcKkoptvy, or those by which it attracted the blood from the lungs, retained it for an instant, and propelled it through the body. The same thing was un- derstood by Von Helmont, under the name of Archaii insiti, the number of which almost equalled the organs of the body, though all were held in subordination by one sovereign Archeus, corresponding to the trvcvpa already mentioned, and supposed to preside in the stom- ach. Harvey also admits in each organ a sen- sus proprius, subject to the general anima by which the whole body was actuated ; and Glis- son speaks of each organ as possessed of a " spiritus regius, qui aliud in jecora, aliud in liene, aliud in pancreati, aliud in ventriculo, et intestinis operatur."] 334. Epicurus, according to the explana- tions of Lucretius, was the first who con- structed a system of materialism. He ascri- bed organization, and the vital and mental phenomena displayed by it, to combinations of ultimate and invisible atoms, possessed of va- rious shapes. He does not attempt to show how these shapes co-operate to form either an 576 INSANITY—Its Physiological Pathology. animal or a plant. He merely asserts that the elements produce both from a combination of atoms, and that in his time many animals were formed, by showers and sunshine, out of the mud. This is one of the modes of spontane- ous evolution contended for by some of the modern German physiologists. It being im- possible to explain the manifestations of or- ganization and mind, and, indeed, of the uni- verse, by means of the doctrine of atoms alone, a being of superior power was introduced, and invested with great authority. This being, who belonged neither to atoms, nor to ele- ments, nor to any of their properties, was called Nature. "Her existence," observes Dr. Bar- clay, " being found indispensable to all the hy- potheses that exclude a deity, she is still pre- served in her high office by many of the mod- erns, and invested with great power, incessant activity, and uncommon prudence. She cre- ates and brings whatever lives to a state of per- fection, and does it all according to method, or agreeably to laws imposed upon her by a high- er power, which some call Fate, and others Necessity." We perceive the continual want which Epicurus and his followers experienced in their speculations of a first cause, one Su- preme Being, to whom they might ascribe the various laws by which the world is governed ; and we observe the manner in which his place is supplied by properties, powers, or principles, assumed by them to explain phenomena which, notwithstanding this assumption, must be ulti- mately referred to one great first cause. < 335. Lucretius, the enthusiastic expounder of the doctrines of Epicurus, after attributing all things to the formative and productive fac- ulties of his atoms, of earth, of the elements, and of Nature herself, thinks, nevertheless, that all must be regulated by diversities of seeds, or of organic particles, each endowed with a peculiar secreta facultas, which makes them both living and organic ; he is also obli- ged to conclude that the soul is deduced from a seed—that it is from its seminal qualities, and from this radical difference of its faculties, and not from a difference of organism in the body, that the lion is fierce, the fox crafty, and the stag timid. He rejected the opinion of those who believed that animating principles organized animal bodies ; and because he could not see how they did it, he therefore concluded that they did it not. Aware, however, that he might fairly be challenged, in his turn, to ex- plain how his seeds were originally organized, he is quite at a loss, and, forgetting the me- chanical properties of his atoms, has recourse to heat, air, and the invisible power of the wind, being, nevertheless, obliged to call in to his aid a certain mobile and active principle, that distributes motion and sensation to them all; but the origin of this principle he cannot explain. The opinions of Lucretius were evi- dently directed against the vulgar notions of the existence of divinities endowed with moral attributes; but they in no way influence the arguments in proof of a Deity, and a purer sys- tem of religion. He admits that it is impossi- ble to disregard the religious feelings and im- pressions which are interwoven with the very stamina of our constitution ; that no nation or individual is entirely without them ; that some notions of divine beings are quite irresistible, | and that they will spring up in the human mind as things indigenous, without the adventitious aid of education. " Quae est enim gens, aut quod genus hominum, quod non habeat, sine doctrina, anticipationem quandam DeorumT' 336. C. Of Modern Materialism.—It has been urged by all the favourers of Epicurian- ism, and by many of the followers of Gassen- di and Hobbes, but more especially by Buf- fon, Priestley, Darwin, Maupertuis, Blu- menbach, Cabanis, &c, that, as the manifesta- tions of mind are never met with, unless con- nected with a brain, and are suspended by compression of this organ, so the phenomena generally attributed to it are the result of its organization. That the combination and re- ciprocal action of the molecules of matter con- stituting the nervous fabric, of themselves, and unaided, produce, the various powers of mind, is the proposition which they support, however paradoxical it may seem, but which they can- not explain. The possibility of such combi- nations and reciprocal actions of the molecules of matter producing, unaided, such results, is not shown by any analogy, or by any proof. If mind proceed from certain associations of or- ganic particles, why has not some opinion as to the process been hazarded 1 Does our ex- perience respecting the mutual influence of ei- ther the elements or the aggregate of matter furnish us with resulting phenomena that can in any degree approach to the lowest mani- festations of either vitality or mind 1 If mind be supposed to be derived only from the com- bination of these particles, or from the opera- tion of certain of their products upon each oth- er, it may be asked whether it be possible to conceive that matter, in such a state, possess- es qualities of which the elements, or even the individual atoms, are divested ? and wheth- er experience has furnished us with any in- stance of mental, or even of vital phenomena proceeding from such combinations when mat- ter is removed beyond the influence of bodies or sources already endowed with life ? If, on the other hand, properties necessary to the gen- eration of the mental faculties be conceded to every particle entering into the formation of the encephalon, how can the idea of the subdi- vision of the powers of mind, to such an ex- tent as matter admits of, be allowed 1 Can the supposition be for a moment entertained that every molecule of this admirable organ has a fractional part of mind connected with it \ Many of the materialists, in order to account for the manifestations of mind, have had re- course to so many suppositions respecting the nature and endowments of matter, in respect either of its elements or of its aggregate, as were tantamount to a negative admission of the principle of vitality against which they had been arguing, with this notable difference, how- ever, that they required the operation of nu- merous agents, instead of more philosophically referring these manifestations to states of this first and noblest constituent of our nature. The genius of Leibnitz saw the difficulty that stood in the way of pure materialism ; and, in order to give the atoms of matter activity, and origin to the mental phenomena, he had recourse to the evrefaxeLai> or spirits of Aris- totle. 337. Cabanis and the later French physiolo- INSANITY—Its Physi gists adopted the doctrine of organism; and, in order to supply the want of a foundation to their structure, they seized with avidity upon the opinions of Gassendi respecting the origin of our ideas. Their hypothesis still required sup- port ; and, in order that it might receive such from a name looked upon with deferencethrough- out Europe, they unjustly imputed to Locke opinions which belonged to the two celebrated opponents of Des Cartes, already mentioned. Much of the credit which this doctrine acqui- red in France and in Germany arose also from the neglect with which that class of our ideas derived from reflection was uniformly treated— from the circumstance that the evidence of the senses and the information derived from expe- rience were considered as the sole foundations of our knowledge. It is very justly remarked by Dr. Barclay, that if it be supposed that all knowiedge is derived from the senses, and that matter is the only object of sense, it must be evident that, on this hypothesis, we cannot with propriety ascribe phenomena to anything but matter. But on what data is matter, in general, pronounced to be an object of sense 1 Its ultimate particles certainly are not so ; and its aggregates, though many of them certainly are, seem but little calculated to account for life and organization, and, at any rate, they by no means account for their own formation. But, whatever may be their formation or their consequences, they must be ultimately referred to those primary molecules which are utterly beyond the reach of our senses. Besides, if matter be supposed to include a variety of sub- stances, or, rather, everything that has an ex- istence, it is, on this supposition, no explana- tion of a phenomenon to say merely that it pro- ceeds from matter. He who hazards such an assertion should point out the particular spe- cies or the peculiar arrangement from which it proceeds, otherwise he gives us no informa- tion but that it proceeds from something un- known, and which he would wish to be called matter. We may, therefore, safely question the accuracy of the opinion that all our knowl- edge is derived from the senses; as well might we say that arts and manufactures are derived from the doors and windows of the houses by which the raw materials enter, to be afterward prepared by the industry and skill of the work- men. 338. As our senses are prior in existence to our experience, we have still more reason to question another opinion brought in support of materialism, namely, that all our knowledge is founded on experience, for a great number of our ideas are not directly derived from our own experience, but rather from the evidence of tes- timony. Besides, prior to experience, we pos- sess a species of knowledge which, as to self- preservation, is much more essential than any that we afterward acquire, which seems to pro- ceed directly from the Author of our being, and which, so far from being the result of our own experience and observation, is the very ground- work on which they are founded. Of this kind is the knowledge immediately derived from those natural instincts and feelings which reg- ulate the various functions of our system, which stimulate our intellectual powers, and which, according to their strength or their weakness, their healthy or their diseased state, II 73 iological Pathology. 577 impart a character to onr experience, our ob- servations, our reasonings, our conclusions. When we wish but to move a limb, by what experiment or process of reasoning do we come to know the necessary muscles, the particular nerves proper to excite them, or the amount of energy to be imparted to each, so as neither to exceed nor to fall short of the object in view 1 If we may take a view of the instincts which guide animals to the selection of food suited to their digestive organs—to know the appropriate means to overtake, subdue, or ensnare other animals—to provide against seasons of scar- city by laying up stores—to know the distant countries and the different climates where food is in plenty, and to which they can migrate—to learn that they can sleep during the winter without any food, and to select their retreats so as to avoid discovery—to calculate the time of sexual intercourse, with reference to the pe- riods of gestation, so that the birth of their off- spring may coincide with the seasons suited to their early and future exigencies; if we consider the age at which most of these phenomena are manifested in the classes of animals to which they severally refer, and the circumstances with which they are generally associated, and if we analyze the entire class of our instinctive de- sires and feelings (see note, $ 66), as manifest- ed both in man and in the lower animals, we must necessarily infer that the sources of our knowledge are much more extensive than the supporters of organism would lead us to be- lieve. Let us, therefore, as Dr. Barclay has well enforced, give due importance to these primary causes of action and feeling, for what- ever our reasonings or opinions may be, we will find them linked with some one or other of these original springs or energies of our constitution —with some instinct, appetite, or passion—with some one of those sources of action, which not only are prior to all our experience, observa- tions, and reasonings, but, what is more, are, during our lives, not unfrequently regulated by circumstances, external and internal, over which we have little or no control. 339. If such be the facts, what, then, it may be asked, is the use of experience, observation, and reasoning 1 The use of these in man is still great—great in proportion to the develop- ment of the intellectual powers. These, and the instincts, can, to a certain extent, mutually aid, oppose, and regulate one another, so as to preserve a juster balance in the moral and so- cial system. The instincts, too, as well as the intellectual faculties, may be diseased, may be perverted, or may be deceived, as they have been shown to be in most of the forms of in- sanity ; and in all cases where they point only to immediate objects, or act according to im- mediate circumstances, they give no warning of the snares, the troubles, and the dangers which are the consequences of indulgence. By following the impulses of instinct, to the neg- lect of experience and reason, passion and de- sire lead to acts of moral insanity. As we are able to ensnare, capture, or destroy the lower animals, by taking advantage of their unguard- ed, unsuspicious instincts, so we ourselves are often ensnared and captured, or ultimately even destroyed, by excessively indulging many of our instinctive desires and moral emotions, and by neglecting the dictates of experience, just rea- 578 INSANITY—Physiological Pathology—Phrenology. soning, and rational observation ; or, in other words, from a want of thit discipline of which the instinctive and moral feelings are suscepti- ble, and which we have the means of adminis- tering by possessing intellectual and reflective powers in a higher degree of perfection. The control of those feelings, however, is in propor- tion, not only to the perfection of these powers, but also to the use made of them. 340. I have been thus particular in noticing the opinions of Epicurus, because they have the same basis, and involve the same princi- ples, as modern materialism; and in showing that the doctrine of Gassendi and Hobbes, which ascribes all our knowledge to our senses, and which has been seized upon by every wri- ter of note who has more recently written in support of organism, is altogether unsound. The scope of this work allows me not to pur- sue farther this part of my subject, or to notice the several modifications of materialism which have been proposed in modern, and even in re- cent times. This is, however, the less neces- sary, as what has been already advanced will show the complete insufficiency of any theory based upon organism to account for the phe- nomena of life and mind* But I am compelled to examine briefly a modern doctrine which has met with a very favourable reception both in this country and abroad, and which has been applied, by those who favour it, to the 6tudy of insanity—I allude to the doctrine of Gall, or Phrenology, or Cranioscopy. 341. ii. Of Phrenology.—Of this doctrine, I may observe generally, that some of its prin- ciples are founded on opinions which have been, and still are, very generally admitted by physi- ologists ; while others, which especially belong to it, are assumptions, which even those who favour it cannot pretend to be proved, or at least expect to be admitted, by sound reason- ers, as data sufficiently established. Those who support phrenology, appeal to facts, assert that it is eminently a science of observation and rational induction, and, with apparent can- dour, call upon those who oppose it to make themselves acquainted with its principles and details, and then to observe and judge for them- selves. ; This seems rational; but, unfortunate- ly, when the advice is followed, and when the results militate against their theory, they en- deavour to rid themselves of the difficulty by asserting that the observer is mistaken, and unacquainted with the principles of their doc- trine ; thus virtually denying that any one can be acquainted with it, unless he be likewise a convert to a belief in it. When, however, press- ed by facts which seem irresistible, they have so many ways of eluding the difficulty, and espe- cially by means of their notions respecting the activity and volume of the individual organs into which they have divided the encephalon, and the development or activity of controlling, of opposing, and of co-operating organs, that there is at once an end of all argument with them. But the ability and eminence of many of those who have written in support of this doctrine, as well as the reception it has met with, and especially * For an account of the various hypotheses which have been advanced to account for life and organization, see the work of Dr. Barclay on this subject, and two articles by the author in the 17th and 18th vols, of the London Medical Repository, 1822. the very intimate relation in which it stands to the pathology and treatment of insanity, require that I should enter upon a more intimate ex- amination of it. 342. That the seat of mind is the brain, is proved by a general consciousness that this is the case, or by a similar testimony to that of the locality of the various senses ; and it may be farther proved by experiment—as by divi- ding any of the nerves, and by observing the resulting phenomena. The same inference is to be deduced from the injuries and diseases to which the brain is liable ; by the different grades and forms in which the mind is dis- turbed, impaired, or its phenomena cease alto- gether. Whether we can more precisely assign the locality of the mind, or the localities of its different manifestations, than by saying, in gen- eral terms, that the seat of mind is the brain, is a question which has been long agitated ; and it is upon the affirmation and negation of it that the believers and unbelievers in phrenology rest their doctrines. It was formerly supposed that the mind was located in the pineal gland ; but, as no evidence of this could be adduced, and as it could not possibly be proved by experiment, or supported by observation in disease, the opin- ion shared the fate of similar hypotheses. That the several faculties and propensities of mind reside in respective portions of the brain, is the fundamental proposition of phrenology. But, as Dr. Pring (Sketches of Intellectual and Moral Relations, 8vo, London, 1829, p. 71) has well observed, if we seek for the same evidence in support of this proposition, which showed that the brain, in general, is the seat of mind, no part of it will be found. In our perceptions of the objects of sense—in the pperations of mind— in the study of music, languages, mathematics, &c.—in the exercise of our passions or pro- pensities—we have no consciousness of the portion of the brain brought into action; and we cannot thereby assign any of these to one part of this viscus, rather than to another, or distinguish whether the seats of these manifes- tations or states of mind are different, or the same for all. 343. The proofs of locality afforded bydisease or injury are equally inconclusive, or, rather, are not to be found. Extravasations of blood in apoplexy will suspend the mental phenomena, or cause both them and life to cease, in what- ever part of the brain they may occur. Wheth- er such extravasation take place in the corti- cal, or in the fibrous structure, or in any situa- tion ; whether fluid is effused from the mem- branes, or into the cavities ; and whether the organic effects of congestion, concussion, frac- tures, depressions of the cranial bones, inflam- mations, or softening of portions of the brain, or the development of tumours, be contem- plated—we find only this common result, that all the phenomena of mind are more or less modified or suspended, or they cease altogeth- er. They may, however, be almost unaffected by some of these lesions; or some faculties and propensities survive, while others are lost; still the preservation or the loss does not ob- serve any regular connexion with the integrity or injury of any given portion of brain. But to state with more precision and detail the doc- trine of Gall : It is asserted, 1st. That the mind presents a certain number of faculties, INSANITY—Physiological Pathology—Phrenology. 579 passions, and propensities, all of which are in- dividually exercised by distinct portions of brain, which portions are the organs of these faculties or passions ; 2d. That these functions are performed, in their respective seats, in dif- ferent degrees in the same or in different per- sons ; 3d. That the strength or perfection of these functions or faculties is in proportion, in- dividually, to the size of the organ, and to the activity with which it performs its office ; 4th. That these organs are situated in the superficial parts of the brain ; 5th. That in proportion to their size is the protuberance of the skull over them ; 6th. That by an examination of these protuberances, the size of the organs, and con- sequently the degree of perfection of their re- spective functions, may be estimated; 7th. That the individual functions may be developed or restrained by education ; 8th. That the pre- ponderance of one or more of them may be re- pressed by the cultivation of others ; 9th. That the propounder of this doctrine was fortunate enough to discover the great majority of the situations in which the individual manifesta- tions of mind are located, and that the rest have been since ascertained ; and, 10th. That the system is applicable to the prevention and treatment of insanity, mental disorders con- firming the truth of it. I proceed to remark briefly on each of these assumptions. 344. a. The enumeration of the faculties may or may not be correct. Some of them are not simple, or even original states of mind, but, as certain of the propensities, arise out of sev- eral, which more or less subserve to their indi- vidual formation. Then, as respects others which are considered original arid connate, the sphere of action is either too extended or too limited, while no attempt is made to trace them to simpler and more original manifestations. The division of the faculties by the phrenolo- gists, moreover, is such, that explanations of character conformably with it would lead us often to infer that an individual both has and has not a particular genius, faculty, or endow- ment, or that he possesses opposite endow- ments in equal grades of perfection and activity, or that, both being equally developed and ac- tive, the balance vacillates between them till some circumstance affects a related faculty, and thus causes it or its opposite to kick the beam. The division of the faculties is opposed to just views of philosophizing, and is altogeth- er empirical. 345. b. That the faculties and propensities have their seats in particular portions of the brain, which portions are respectively the or- gans of the faculties and propensities, are two assumptions equally ill-founded with the fore- going. As the faculties of the mind are not dis- tinct entities, but merely states or affections, arising out of impressions on the special or gen- eral sensibility, or different modes of conscious- ness, according as these impressions are inter- nally and externally associated or related, so it is unnecessary to inquire whether these facul- ties have appropriate or respective seats in the brain. Our experience of what constitutes dis- tinctness of function, in connexion with organ- ization, does not permit us to extend the ap- propriation of function and organ to the mind and brain any farther than that our conscious- ness instructs us that the brain is the seat of mind, or the organ which is most intimately re- lated or associated with its various states and affections ; but it by no means informs us, nor even suggests, that these states or affections are the functions respectively of particular parts of the brain, or that these parts are the organs individually destined to perform appropriate of- fices. Having no proof arising out of our phys- ical and mental constitutions, how then are we to obtain any, or is any conclusive evidence to be obtained] We cannot obtain it either an- alytically or synthetically, compatibly with the continuance of life. Evidence, therefore, of the loosest kind—analogies, merely, have been ad- vanced in support of this assumption. As dis- ease or injury has been found to destroy the functions of sense, when implicating either the origins or courses of their nerves, so it has been supposed, from this circumstance, that there are particular localities for the powers of the mind. But this, instead of suggesting the existence of such localities, merely indicates that the impression from distant parts, or dis- tinct, organs, is conveyed by certain nerves, which, when diseased or injured in any part from their origins to their terminations, are either rendered incapable of transmitting sen- sation, so as to become an object of conscious- ness, or transmit it in a state of disorder, or imperfectly. Without farther pursuing facts which abundantly suggest themselves to every physiologist and pathologist, it may at once be averred that the proofs in support of the local- ization of the faculties of the mind are not merely defective, but altogether wanting, and that the loose analogies which have been ad- vanced are either inapplicable, or admit of va- rious explanations, none of which come in aid of the proposition. 346. Even admitting that the powers or fac- ulties of the mind exist as separate essences or functions, and that they occupy appropriate seats or spheres of the brain, it by no means follows that these seats are the organs which give rise to these powers. The viscera dis- charging specific offices are denominated or- gans, because they are the agents by the instru- mentality of which certain results or phenom- ena take place when actuated by life; and we perceive a very obvious organization appropri- ated to the office performed in the liver, kid- neys, lungs, heart, &c.; but we are unable to show by what arrangement of the substance of the brain a mathematical calculation, a process in algebra, a philosophical reflection, a cautious action, or a flight of imagination is produced. Indeed, the question whether certain states of mind, which the phrenologists have located in the brain, are really so seated, or should not rather be assigned to different parts of the ner- vous system, as they have been by most of the ancients, and by many modern physiologists, has not been duly considered by them, but at once have been assumed as functions of por- tions of the brain, which they have also assu- med without any sufficient proof as organs indi- vidually appropriated to the performance of a certain function, and to that only. 347. c. It is asserted that the functions are individually exercised in different degrees of activity in the same, or in different persons; but is this owing, when occurring in the same person, to an accidental change in the state of 580 INSANITY—Physiologicai the respective organ ! or is the organ under the control of volition 1 or both' How does voli- tion act upon each of the numerous organs] how is it located so as to bring each or all into play 1 and does it run from one to another 1 or, seated in the pineal gland or somewhere near, does it reach out certain appliances with which it is provided to each, and thus strike them in every variety of combination 1 If volition acts upon one, it must necessarily act upon all or any in- termediate number, in every possible mode of combination; and if this were the case, and the volition or desire comprehensive, how immense, both intellectually and morally, would be the result! If it be said that the will can act upon one organ only at a time, how then happens it that several must often be in operation to pro- duce the effects which the phrenologists admit as often occurring! That persons may have talents for particular pursuits, or certain pro- pensities in a greater degree than others, is one of the oldest and best established remarks re- specting the human mind. Our experience, however, warrants only the expression that there is a stronger or a more favourable dispo- sition in some minds to certain operations, propensities, and passions, than in others. But, as Dr. Pring has observed, that the existence of any one propensity or faculty is independent of all the rest, or requires to be spoken of as more than a disposition of that which is ex- pressed in the gross as the mind, cannot be in- ferred, 1st, because the disposition which makes the propensity related with its objects has the character of a common principle ; 2d, because the objects of a given faculty are presented to it through media—the senses—which are com- mon to all the other faculties ; and, 3d, because one ability is not perfect, or, in reality, does not exist without the concurrence, more or less extensive, of others. In truth, there seems little more reason for supposing that the differ- ent phenomena of mind are produced by nu- merous distinct faculties, than that it requires different hands to play different tunes upon a musical instrument. 348. d. That the strength of the faculty is in proportion to the size of the organ, is another fundamental proposition of the phrenologists ; but an assumption, equally with the preceding, supported only by loose analogy. The only an- alogical proofs, indeed, which can be adduced in favour of it are derived from the muscular and nervous systems—and these do not fully apply to the brain ; for it cannot be stated with truth, even as a general proposition, that mus- cular strength, either in man or in the lower animals, is in the ratio to the bulk of the mus- cles ; nor is it universally true that the largest nerves convey the greatest degree of nervous energy, although they generally may be infer- red to do this, since they are composed of a greater number of fibrils, each of which, or of the fasciculi into which they are arranged, trans- mits a certain amount of power, or, rather, of stimulus, to already inherent power in muscu- lar parts. Moreover, sensibility, which is a principal property of nerves, is not manifestly greater or more acute in a large nerve than in a small one, or in a branch much less than a trunk. The phrenologists are themselves aware of the weakness of this part of their foundation, inasmuch as they have recourse to activity, or Pathology—Phrenology. intensity of action, to explain phenomena which they cannot account for by means of volume. That the size and activity of function of the brain may be connected with the degree of men- tal manifestation, either singly or conjoined, may or may not be the case. The affirmative has been believed in for ages—chiefly from the loose analogies already alluded to, and from others presented by various organs or parts. Still, this is the only part of the system which retains any portion of plausibility upon a strict examination. The alternative, however, of size and activity is so readily resorted to against the opponents to the doctrine, and so easily suggests itself, as to preclude all argument re- specting alleged facts in proof or disproof of the system, and to betray the mind of the es- pouser of it into a state of blind belief. It ia obvious that, as long as size, relative and abso. lute, and activity and inactivity in every grade, are made bases of the doctrine, no fact, how- ever faithfully observed, can be adduced that will shake the faith of those who have embraced it, although every one who will give these articles of their belief due consideration must come to the conclusion that they actually negative the propositions they are intended to support; for if activity of function be admitted as respects certain of the organs into which they have di- vided the brain, inactivity must be conceded to others, or even to the same organ on different occasions; and if these states are so important* why have recourse to volume or development as the principal indication of endowment or function ] The shiftings between these states in argument respecting alleged phrenological facts ; the influence of allied or related propen- sities or faculties on those which are most prom- inent or most deficient; the countervailing op- eration of opposing organs ; and the different interpretation that may hence be put upon the ensemble of these organs as manifested by the cranium, must render the study, even if toler- ably based in truth, as one, at the best, furnish- ing opportunities of vague guessings into char- acter, in which no two speculators out of many may agree, or arrive at anything like a just con- clusion.* 349. e. The localization of the organs, and, consequently, of the faculties, in the external or more superficial parts of the brain, whether suggested merely by a desire of detecting their volumes, or by the circumstance of these parts presenting a greater diversity of arrangement, or structure, or form, is immaterial, inasmuch as they both equally fail in supporting the as- sumption. That the superficial and cineritious portions of the brain are more intimately rela- ted with, or instrumental to the manifestations of mind, may or may not be the case. We have no proof of a conclusive nature, either one way or another, although various circumstances and considerations, not amounting to evidence, have induced several writers to suppose that these parts are actually more especially sub- servient to the mental powers. Yet, that two or three convolutions, or two and a half, or one and a half, or half or three fourths of one only, should be devoted to one faculty or propensity, * The author, before he .was much known as a writer, had his head examined by several of the most eminent phre- nologists of the metropolis, but there was no near agreement between any two of them as to his disposition. INSANITY—Physiological Pathology—Phrenology. 581 while the next convolution, or those severally surrounding the portion thus devoted, and even the fractional parts of convolutions not belong- ing to that portion, should be very differently, or even oppositely employed, the ultimate ar- rangement of structure being the same in all, is certainly, if not the extreme flight of imagi- nation, at least the highest pitch of hypothetical conclusion. Numerous other arguments may be adduced against this assumption, but they seem quite superfluous. 350. /. That the protuberance of the cranium marks, and is proportionate to, the develop- ment or size of the particular organ of the brain underneath, often obtains, but not universally, or even generally. But this concession in no way supports the general doctrine, even al- though the protuberance of the cranium truly and constantly expressed the volume, or, rath- er, prominence of the part of the brain under- neath. However, this correspondence very oft- en does not exist, even in early life, for reasons that will suggest themselves to every anato- mist. We find, moreover, and not infrequent- ly, that there are prominences in the cranium where there are underneath no corresponding development of brain ; and that the skull is impressed internally by irregular enlargements of the convolutions of the brain, and yet no ex- ternal projection can be observed correspond- ing with the concavities in the internal surface. But the phrenologists contend, as we have seen, that the size of an organ is in proportion to the strength of the faculty; and, farther, that a faculty, not naturally very strong, may be great- ly strengthened by education or habitual exer- cise, even at advanced periods of life. Now, it may be asked, is it to be expected that, at adult or advanced age, as the faculty gained strength, and as the organ, as they suppose, becomes increased in volume, the portion of cranium placed over it will be protruded before it, so as to indicate the amount of increase 1 None but phrenologists could even dream of such a change as this in the skull at these pe- riods of life. Here, howevei, they may shelter themselves behind activity instead of bulk, or, if they still stick to the latter, and it evidently appearing that the bona does not yield to the growth of the subjacent organ, either the organ itself or those around it must be damaged by the consequent pressure—those in the vicinity must be atrophied in proportion to the hyper- trophy of the exercised part, and their functions injured accordingly, or even altogether annihi- lated. 351. g. It is evident that the proposition di- rectly based on the foregoing—namely, that the strength of the faculties may be estimated by an examination of the projections and depres- sions of the skull—requires no farther remark. That faculties and propensities may be devel- oped or restrained by education, is, and has long heen, admitted within certain limits. That the faculties acquire facility of action from exer- cise, provided that the exercise be neither ex- cess iv,- nor too long protracted, has been gen- era;;) iilowed. The passions and propensities, also, acquire strength from indulgence ; but this is not regularly or universally the case ; for, as remarked by Dr. Pring, a passion which, in the earlier periods of its gratification, was vehe- ment, might give place, after continued indul- gence, to an apathy with respect to the same objects ; and, in other instances, the excessive indulgence of almost any passion or propensity may terminate in disorder of it, or even in its imbecility or total extinction. That the pre- dominance of one passion or faculty may be restrained hy the cultivation of another is an old observation, which is not so universally correct as generally supposed, but which is re- ceived as an established axiom by the phrenol- ogists, as it agrees with the belief in the dis- tinctness of the individual mental functions and of their respective organs. As respects the passions, we generally observe, that when cer- tain feelings are frequently called into action, those which repress them, or are incompatible with them, are inactive, and less disposed to manifest themselves. This, however, does not extend to the purely intellectual powers ; for, as regards them, we do not find that the culti- vation of one power enfeebles the others; it merely tends to the formation of opinions un- favourable to the employment of another pow- er. All that our existing knowledge permits us to advance on this topic is, that certain modes or states of conscious sensibility or mind, being called into existence and action by their respectively rela- ted internal or external causes or occasions, these states continue to manifest themselves with an ac- tivity generally corresponding with the intensity, character, repetition, and duration of these causes ; and that a disposition thus to manifest themselves exists in proportion as they have been called into action or thus exercised, other states of mind be- coming inactive from the absence or insufficiency of those causes or occasions which are especially related to them, but assuming activity whenever these causes come into operation. 352. This proposition is equally applicable to the intellectual faculties, and to the propensi- ties or passions—to imagination, and compari- son, and reasoning—to the benevolent and to the malevolent emotions; and is aptly illustrated by Dr. Pring, who remarks, that a disposition to cruelty may be repressed for many years by a cultivation of the sentiments of benevolence, &c. ; these sentiments may prevail until the age of thirty, when, from injurious treatment, or unfavourable observations of human nature, it may be suggested, that mankind are altogether unworthy objects; that they merit hatred rather than love ; that, instead of the kinder offices, no species of cruelty is too bad for them. The original propensity would then be resumed, per- haps, even in greater force, from the contrast- ed sentiments which had been previously enter- tained, or from having been so long repressed. 353. h. It is obvious that, before the seats or organs of the faculties and propensities can be respectively assigned in the brain, it must be shown, first, that these faculties are severally .distinct; and, secondly, that each occupies an appropriate and equally distinct portion of the brain. These propositions, however, have been already examined, and rejected for want of proof. Notwiths' ; iding this, the phrenologists assert that those persons who have certain faculties and prop cities in a high degree have certain protuberances on the skull by which these faculties are denoted, these protuber- ances being the external signs of the cerebral organs, and of their respective offices ; and they support this assertion by the formation of the il Pathology—Phrenology. 582 INSANITY—Physiologica crania of those who had certain faculties and propensities in an unusual degree—these crania, as they aver, all having a protuberance for the same faculty in the same part or situation. But this practical application of their doctrine, upon the truth of which its utility entirely de- pends, altogether rests upon the facts which have been adduced in support of the proposi- tion that the same faculties are always indi- cated by the same external signs, in respect of situation and development. The number and correspondence of the facts, however, are de- nied by those who do not believe in phrenology. It is obvious to those who think that all physi- ognomical systems—that all attempts to estab- lish a doctrine by which the character shall be known from the external appearances of even a part, or of the body generally—may be sup- ported, however bizarre, by a certain number of coincidences, which may be viewed as facts proving its truth. When we take into account the number of the mental affections and facul- ties, the diversity of intellectual and moral character, and the endless varieties of form of the head, face, and body, and of their expres- sions, it must be obvious that any theory in which there is a reference of faculty to form will necessarily find support in a large number of coincidences—it cannot possibly be other- wise ; and if these coincidences be assiduously sought after, recorded, and marshalled as proofs of its truth, to the neglect of facts which dis- prove the connexion attempted to be establish- ed, the theory will appear to many, and espe- cially to those who are seldom at the trouble to think for themselves, a most brilliant dis- covery—and the more so, that it promises an almost intuitive knowledge of character, and the most useful practical application. It is not denied that some skulls present, in connexion— but, as far as the thing is yet proved, only in coincident connexion—certain propensities and faculties with certain external signs ; neverthe- less, it is confidently averred that others evince no such correspondence between the mental character and the external form, and even con- tradict it in all, or in the most remarkable of their respective parts. In the alternative, how- ever, of activity, the cranioscopists have a ref- uge from adverse facts—and, as I have already hinted, from sound argument; and behind this and various circumstances, as controlling, de- ficient, inactive, and concurring organs—they endeavour to intrench themselves. There are numerous other circumstances and considera- tions which strongly militate against the doc- trine of Gall ; but the scope of this work will not permit me to adduce them. The reader will find this topic more fully treated of in the able work of Dr. Pring, already referred to. 354. i. The applications of cranioscopy to the pathology and treatment of mental derangement that have been made by those who believe In it cannot be entertained; for as it appears, from the reasons assigned above, and from others that might be adduced, not to be based in truth, such applications of it can only mislead, or interfere with juster views, or even be pro- ductive of irreparable mischief. 355. Having thus disposed of a doctrine which has received very considerable support, and which has been viewed by those who entertain it as being of the greatest utilitv in understand- ing and managing mental disorders ; althoagh, even if most firmly based in truth, the utility of it in this respect is neither so great nor so obvious as they would wish it to appear; it farther remains briefly to consider the probable nature of the connexion of the mind with the brain and nervous system. [It was a remark of the profound and saga- cious Cuvier that, as "certain parts of the brain attain in all classes of animals a devel- opment proportional to the peculiar properties of these animals, one may hope, by following up these researches, at length to acquire some notion of the particular uses of each part of the brain." This philosophical mode of inves- tigating the physiology of the brain has been attempted by the school of modern phrenolo- gists, and, it is believed, not without some de- gree of success. Believing that the functions of the brain could only be established by an ap- peal to facts, these have been assiduously gath- ered on every side, so that, by means of busts, charts, mUseums, collections, lectures, and pub- lished essays, a belief in the doctrines of Gall pervades every part of the civilized world, and in our own country embraces a very large pro- portion of the population. We have no desire to enter here on a defence of phrenology, so called, for we are yet to be convinced of some of its doctrines; but we may remark, that to oppose it with success requires a specification of facts and details, not a general statement that the experience of the writer is against the alleged concomitance of mental faculty and cer- ebral organs; for a multitude.of positive ob- servations cannot thus be got rid of. Facts, we believe, will warrant the belief that the brain consists of a plurality of parts, or organs, each performing a distinct function ; although the parts concerned in each function may not all, as yet, have been correctly ascertained, we can scarcely avoid such a conclusion, when we see how the brain receives successive additions as animals rise in the scale of intelligence—how its successive parts are successively developed, as the human being advances from the foetal to the mature state ; not simultaneously, as a unit would be, but irregularly ; when we regard the phenomena of partial insanity and injuries of the brain, attended with a partial affection of the mental powers, and many other facts, known to all whose attention has been called to this subject. Considered as the organ of the mind, we suppose few will deny that it may be divi- ded into three great regions : the first, compri- sing the anterior lobes,- and serving for the op- eration of the intellectual faculties; the second, comprising the coronal region, and more imme- diately connected with the moral sentiments; and the third, comprising the posterior lobes and base, and serving for the manifestation of the propensities common to man with the low- er animals. Many of the principles of phrenol- ogy are common to it and physiology in gen- eral ; but the proposition that organic size is, cateris paribus, a measure of functional pow- er, is peculiar to phrenology, and lies at its very foundation. No phrenological writer claims that size alone is a measure of the functional power of an organ, but that it is only when oth- er circumstances are equal. This principle per- vades the whole science of comparative anato- my, as well as animal physiology, and it is not INSANITY—Physiological Pathology—Phrenology. 583 to be supposed that the brain forms the only exception to the rule. Camper's facial angle as- sumed this principle as its basis, against which, we believe, no objections were offered until the wider generalizations of Gall attracted the at- tention of the scientific world. Cuvier lays it down as an axiom, " that there are always cer- tain relations between the faculties of animals and the proportions of the different parts of the brain," and remarks, that " their intelligence appears to be always great in proportion to the development of the hemispheres and their sev- eral commissures." When the phrenologist maintains that size alone is not a measure of power and intensity, he merely adopts and car- ries out a law, which is admitted to apply to all other organs, namely, that the power of the brain may be defective from disease, original malfor- mation, or defective constitution; just as we see large muscles in persons of little strength, in lymphatic and relaxed constitutions, and where due nervous energy is wanting. Whether ob- servations can be so carefully made and so extensively repeated as to establish on an im- moveable basis the generalizations of Gall and Spurzheim, may, perhaps, admit of doubt; and yet we suppose it will be admitted that there is no other mode of settling this question but by carefully observing large numbers of cases, in which the same part of the brain predomi- nates in size over all the other parts, and as- certaining what particular quality of mind is exclusively in excess in the same individuals. If we cannot in this manner obtain any clew to a knowledge of the functions of the brain, it is difficult to perceive in what manner we are to arrive at it. Whether, then, we consider phre- nology as an exposition of the physiology of the brain, or as a theory of the philosophy of mind, it seems equally worthy our investigation, the first, to be determined by careful observa- tion of the concomitance and connexion of cer- tain functions with certain portions of the brain; and the latter, by the facility and consistence with which it explains mental phenomena, and admits of practical application to the purpo- ses of life. It is worthy of note, that some writers, who reject the doctrines of phrenolo- gy, yet inadvertently admit some of its funda- mental doctrines, as, for example, that the sev- eral faculties and propensities of the mind re- side in respective portions of the brain. Thus, Fletcher (" Elements of General Pathology," Edin., 1842, p. 431) remarks, that " the various forms of hypochondriasis and monomania can be explained only on the presumption, that, in each, a certain part of the brain, the seat of that form of thought, the excessive energy of which gives rise to the prevailing delusion, is preternatu- rally excited, and in a state, probably, of chron- ic inflammation. Thus, an over-excitement of the organ of form, size, colour, &c, may con- jure up to the imagination of the hypochondri- acal, not merely spectral illusions, of the falla- cy of which he is conscious, but forms and modes of personal existence, by which the im- pressions derived from the senses are more or less obscured, and they become stamped with the impress of reality ; and a similar over-ex- citement of the organs of destructiveness, pride, caution, veneration, &c, may, in like manner, cast over the monomaniac the prevailing crotch- et under which he labours. Such, then, appear to be the chief peculiarities of the faculty of thinking, dependant on a preternatural excite- ment of certain parts of the brain ; and it is easy to understand that too little excitement of these or other parts may equally give rise to a defect of certain natural faculties and propensi- ties. Thus, some persons have no sexual de- sire ; others, no love of offspring, nor of coun- try—no spirit, no pride, no anything," &c.— (Loc. cit.) Assuming then, as ascertained facts would seem to warrant, that the brain is not only the organ of the mind, but that the manifestations of every primitive faculty depend on a peculiar part of the brain, it follows, as a matter of course, that we must look for the cause of in- sanity in the brain, and the cause of the de- ranged manifestations of every special faculty in a peculiar part of the brain. We are to look, then, we suppose, for physical changes in the organ of the mind, and not for disease of the mind itself, as the proximate cause of mental derangement; for, as Spurzheim has well re- marked, the idea of derangement of mental functions must not be confounded with mental disease ; the manifestations of the mind may be deranged, but it is difficult to imagine any disease or derangement of an immaterial be- ing itself, such as the mind or soul is. Theo- logians and metaphysicians, who believe in the non-dependance of the mind on material or- gans for its manifestations, are not, perhaps, aware that they concede the mortality of the soul itself; for if it can fall sick, it may, doubt- less, also perish. It is a much safer doctrine, that in this life the mind and body are insepar- ably connected ; that the manifestations of mind are dependant on certain corporeal instru- ments ; that they cannot appear without them; and are modified, diminished, increased, or de- ranged, according to the condition of these in- struments, or organs. That the proximate cause of insanity is always corporeal, would appear to follow from considerations already adduced, namely, that it is often connate and hereditary; that it is influenced by age, sex, climate, season, and weather ; that it is brought on by injuries of the head, and various other causes which affect the body, as pregnancy, too rapid growth, stimulating drinks, mastur- bation, long fasting, &c.; that it is periodical, and has exacerbations ; that it is often accom- panied, or alternates with other corporeal dis- eases ; that it causes disturbance of sleep; is influenced by temperament, &c.: moreover, as has been observed, if the mind itself were dis- eased, it ought to be cured by reasoning. The character of individuals is also often entirely changed by blows, or other injuries, inflicted upon the head, as well as by diseases affecting that organ. Dr. Brigham, in his late work, en- titled ".471 Inquiry concerning the Diseases and Functions of the Brain, the Spinal Chord, and the Nerves" (New-York, 1840), thus sums up what he believes to be the ascertained functions of the brain : 1st. That the cerebral lobes, or the hemispheres of the cerebrum, are the seat of intelligence ; 2d. That the cineritious portion of these lobes, probably, is the seat of the men- tal faculties ; 3d. That the fibrous or medullary portions of the brain are connected with the motive powers, and transmit volition and sen- sation ; 4th. That the lobes of the cerebellum 584 INSANITY—Its Physiological Pathology. are not connected with the manifestations of the mental powers, but are with the motive, and appear also to be with the sexual propen- sity, and that the sympathy between them and the stomach is intimate ; 5th. That all the fac- ulties of the mind may be manifested by one hemisphere of the brain ; 6th. That different parts of the brain have different functions, and that the anterior portion of the cerebral lobes play the most important part in manifesting the mental powers, and appear to be the seat of the memory of words, events, and numbers ; 7th. That the striated bodies and the thalami are intimately associated with the motive powers of- the extremities ; 8th. That parts in the middle and at the base of the brain, such as the fornix, corpus callosum, septumlucidum, pituitary body, and pineal gland, are not connected with the mental faculties.—(Loc. cit.) To these might be added, that the corpora striata and their an- terior radiations preside over the movements of the lower, and the optic thalami and their radiations over the movements of the superior extremities. The above deductions have been derived from pathological investigations, and are worthy of candid consideration.* The objections brought forward by our au- thor to the main conclusions of the phrenolo- gists, although plausible, do not seem to us ir- refragable. We suppose it will now be gener- ally admitted that there are no insuperable dif- ficulties in the way to prevent the size and con- figuration of the brain from being pretty cor- rectly ascertained during life by observing the outward form of the head. The want of paral- lelism between the tables of the skull and the existence of the frontal sinus, except in the case of two or three of the smaller organs, are now known to influence the results too slightly to affect the important conclusions of phrenol- ogy, and are consequently abandoned as valid arguments against the science. All observa- tions made during old age or disease, were re- jected by Gall as inconclusive, and though af- fording valuable illustrations, have never been received as valid proofs by any of his follow- ers. Farther observation, and the accumula- tion of a greater number of facts, are still want- * [According to Solly, one of the ablest anatomists of the age, and who has recently adopted the doctrines of phrenology, as founded in nature (The Human Brain, its Configuration, Structure, Development, and Physiology, &c. Lond., 1836), the functions of the cerebro-spinai axis are as follows : The spinal cord has a two-fold office, first, it is a conductor of motion and sensation, the anterior columns being the organs of motion, the posterior of sensa- tion ; 2d, it is a centre from which power emanates, inde- pendently of the great cerebral ganglia, with which it is connected. The office of the corpora olivaria is to preside over the functions of the respiratory muscles. The poste- rior pyramidal bodies are devoted to the function of hearing ; the optic ganglia, or quadrigeminal tubercles, to that of vis- ion ; the olfactory ganglia to that of smell ; and there is every reason to believe, that the impressions received by the extremities of the auditory nerves in the one case, and by the optic and olfactory in the other, are converted into sen- sations in the respective ganglia in which they terminate. The cerebellum is one of the centres which influence and generate power, and most probably in connexion with the functions of the voluntary muscles. The pons varolii is the commissure, or instrument for establishing a communication between the different parts of the cerebellum. Moreover, from the fact that it has a quantity of cineritious matter distributed through it, it is believed to be, also, a generator of power of some kind, of the precise nature of which we have no knowledge ; and, lastly, individual portions of the great hemispherical ganglia, or cerebral lobes, perform sep- arate offices in correspondence with the different kinds of mental manifestations, as stated by phrenologists.—(Loc. tit.n ed to place phrenology on a secure and perma- nent foundation. We bespeak for it an impar- tial investigation on the part of medical men; for, as there is no branch of scientific inquiry that has been more misrepresented, ridiculed, and calumniated by enemies, so there is none that has suffered more from the weak and in- judicious support of its friends.] 356. iii. Of the Connexion of the Mind and Nervous System.—A. Those who have reasoned against the possibility of the exist- ence of the mind separately from the body have referred to the general agreement of the state of the former with that of the latter, and to the effects produced in the manifestations of mind by disease and injuries of the brain, as proofs of the truth of their doctrine. But the infer- ences drawn from these two classes of facts, as Dr. Pring justly observes, are by no means legitimate. As to the first class of facts, show- ing a correspondence of vigour at different pe- riods of life, between the mental powers and the corporeal functions, it may be remarked, that the changes in these severally, although to some extent simultaneous, are not so univer- sally, nor always in corresponding decrees: the faculties of the mind are sometimes unim- paired at far advanced periods of life, and the brain is fully developed long before the mental powers are in full vigour. Admitting, even, that the progress of the mind from infancy to old age is in general agreement with corporeal de- velopment and strength, yet it does not on this account follow that the changes of the mind in the course of age are dependant upon those of organization. There may be a simultaneous development without a necessary dependance. Besides, if the mental powers are entirely owing to the brain—are merely functions of this organ —wherefore are they not displayed at an equally early period of life with those of the liver, stom- ach, and other organs, all of which manifest a perfection of function, either soon after birth, or, at least, long before the mental powers are fully developed 1 According to the doctrine of organism, no answer to this question can be given; while those who believe that, in the present state of our knowledge, it appears im- possible for matter to give rise, of itself, to life or mind, and that a principle of vitality is ne- cessary to the attraction of material or inor- ganized molecules into specific organized forms, and to be allied and associated with them for the purpose of enabling them to discharge ap- propriate functions, will readily respond, that in the early part of their existence the brain and nervous system are the instruments chief- ly, under the dominion of life and mind, of sen- sation, and of the instinctive feelings and emo- tions ; and that, as fast as the mind is stored with the reports of the senses—as fast as con- scious sensibility is called into action, so as to form perceptions, and to perfect the results of sens*ation—so it becomes also capable of re- taining and comparing the objects of its con- piousness, of reasoning and reflecting upon ■'.■era, of suggesting new forms or combinations o/ them, and of drawing inferences from va- rious sentiments or feelings arising out of the internal and external causes or occasions which influence or excite it. 357. The class of facts, consisting of modifi- I cations or suspensions of the mental powers, INSANITY—Its Physiological Pathology. 585 from organic lesions and injuries of the brain, has been considered by the supporters of or- ganism as conclusive proofs that the mind is a function merely of this organ that can exist no longer when the fabric of it is destroyed. But it by no means follows that, because those powers are destroyed by disease of the brain, they are, therefore, the product of the organi- zation of this organ. All we know is, that a certain degree of soundness of the latter is usually necessary to mental sanity, and that the mind shall be, in one case, severely dis- turbed by a slight change of structure; in a second case, but slightly disordered by most extensive disorganization; in a third, unaf- fected by very remarkable lesions; and, in a fourth, most violently affected, without any ap- preciable alteration. Here, although the facts contended for are numerous, yet they neither correspond with one another, nor do the le- sions produce corresponding or co-ordinate ef- fects on the mind ; nor are the modifications of mind always to be referred to morbid con- ditions of the brain—the results are neither uniform, nor correspondent, nor universal — and hence the intimate dependance of mind upon the brain is not a legitimate inference from this class of assumed facts. The de- pendance of one thing upon another, it should be recollected, may be of different kinds : 1st. It may be that of absolute cause and effect, the latter existing only in consequence of the former, and ceasing with it. 2d. The depend- ance may be one of association or connexion, in which state the one cannot be manifested without the other, and any disturbance of ei- ther will have a reciprocative influence. The dependance may be either of the foregoing kinds, and be greatly affected by the contingent interference of a third, or foreign influence, not requisite to the existence of either, and espe- cially of that which suffers a change from such interference. While it is the first of these that is contended for by many, the second appears to be the kind of dependance that naturally subsists between the mind and the brain, the contingent interference of morbid action in the brain disturbing the states of the mind, and the structural conditions of the brain itself. 358. The exercise of the faculties of the mind is dependant upon a cause which is al- lied with, or which actuates the brain, and is modified or suspended in consequence of dis- ease or injury of the brain, not because the in- tegrity of this organ produced these faculties, but because the exercise of them is prevented by the foreign influence of a preternatural state of the organ with which they are allied. On this topic, Dr. Pring justly remarks that, in the case of disease or injury of the brain, fol- lowed by suspension of the functions of the mind, we do not know the agents or the mode hy which such suspension is produced. We perceive a change in the condition of the struc- ture, but whether the action of the mind ceases because a material arrangement is disturbed, upon the precise state of which the action of the mind depended as upon an essential cause, or whether this action ceases because it is im- peded by the foreign or preternatural influence of a fabric with which it is allied, we are pre- cluded the discrimination of experience. Yet the alternatives have this important difference, 71 that, in the former case, the mind cannot exist without a precise arrangement of a material structure ; in the latter, it may exist inde- pendently of such organization ; and, although liable to be disturbed or suspended by change of organization, in the same manner as any oth- er effect may cease under a foreign influence, yet its exercise may be resumed when this in- fluence is withdrawn. 359. The dependance of the mind upon the organization of the brain is said to be most un- equivocally shown by the effects of compression of the organ; but compression, like organic lesions, may impair or suspend the manifesta- tions of mind, whether they are a result of a certain state of organization, or whether they are only allied or associated with it. In the former case, the effect is one of necessary dependance upon its cause, the function ceas- ing upon a certain preternatural condition of the organ ; in the latter, the foreign interfe- rence disturbs or suspends the condition of the material fabric with which mind is associated, and as soon as this interference and its mate- rial consequences are removed, the manifesta- tions of mind are restored more or less com- pletely, according as the removal of the foreign cause of disturbance is complete. 360. It follows, from what has been advan- ced above, that disorder or suspension of the manifestations of mind, from disease or injury of the brain, is no proof that the mind is neces- sarily a function, or an effect or product of this organ ; but merely that the brain is the organ, instrument, or medium of communication be- tween the mind and the external world. 361. In favour of the belief that the mind is independent of the material fabric with which it is intimately allied or associated, or is a re- sult of vital properties superadded to and ac- tuating this fabric, numerous considerations and satisfactory evidence, if my limits could permit, might be adduced'; but it may be re- marked, 1st. That the circumstance of the op- posite doctrine, or that of organism, having been found fallacious and untenable, the only other doctrine by means of which the phenom- ena of mind and organization can be explained appears the more entitled to credit; 2d. That mind ceases to be manifested in consequence of an organic lesion in a particular or limited part of the brain—if the mind were the result of the organization, there is no reason why it should not still be produced wherever the or- ganization is perfect; 3d. That the principle or properties of life, endowing living animals from conception to death, and the structures which life endows and actuates, are undergoing a per- petual change, and, as existence advances, a perpetual consumption, without any loss of identity; that both the original vital endow- ment, and its associated structures, are perpet- uated from inorganic or from broken-down ve- getable or animal substances, as from their el- ementary sources, these substances containing the con. ' iuent properties or elements of life and of ..tr'icture; that this conversion and ap- propriation of the elements of life and struc- ture are performed by the changes produced in, and by the affinity or attraction exerted on these elements contained in dead or inorganic substances by life; and that this attraction is one of assimilation, by which a living principle 686 INSANITY—Its Physiological Pathology. separates, adopts, and unites its own properties or elements, and those of its allied structures, from the various materials furnishing them, thereby perpetuating their forms, as long as their own identity or existence is preserved, and as long as their elements are submitted to the influence or brought within the sphere of the vital endowment or principle, which alone is capable of thus acting; 4th. That it is ob- served of functions generally, that they are the results of life in conjunction with structure—■ of organization built up and actuated by the vi- tal principle endowing it; that the function of every organ is dependant upon the continuance of its life ; that it is not produced by the organ- ization—for the material elements composing the individual tissues and the general organi- zation are held together in a state of affinity or attraction and cohesion opposed to that which their chemical affinities dispose them to assume ; that this predominant affinity and co- hesion are owing to a vital endowment, and are therefore aptly denominated vital; and that, while it thus holds the material elements in a due state of attraction, appropriately to the con- stitution of the several tissues, it also enables them to discharge specific or peculiar offices or functions ; 5th. That, this dependance of func- tions upon vitality existing throughout the body, a similar dependance of function upon vital en- dowment may reasonably be extended to the brain ; and, 6th. That the evidence we possess as to life being the cause of the organization of material elements, and of its own perpetuation or renewal, as well as that of its allied struc- tures ; and as to its being a principle superadd- ed to, intimately allied with, and actuating a material fabric, and of which evidence such no- tice as the scope of this work will permit has been taken above ($ 336, et seq.), and in the ar- ticle Disease ($ 2, et seq.), is sufficient to show that the mind is the result of the vital endow- ment of the brain, without which endowment this organ would not only cease to be the in- strument of mental manifestation, but would also fall into dissolution ; its material elements, no longer being held together by the attraction of life, assuming those forms to which they are chemically disposed. According to this view, the evidence in favour of the immaterial- ity of the mind is the 6ame as that upon which the doctrine of vitality, or the primary agency and controlling influence of life upon structural arrangement or organization, and upon func- tion, is based ; and mind thus appears the high- est manifestation or property of life, in connex- ion with, and through the instrumentality of the brain—that particular congeries of tissues, in alliance with which only could its wonderful faculties become apparent. 302. Matter is known to us only by our sen- ses ; mind, by our consciousness. We know quite as little about the essence and occult qualities of mind as we know of matter; and, as far as our most profound conceptions of them can carry us, we have no ground for believing that they have anything in common beyond their derivation from parents, and the support or renovation they derive from surrounding media and materials furnishing the properties and elements of their development, perfection, and perpetuation. The principle which thinks, as Dr. Abercrombie remarks, is known to us only by thinking ; and the substances which are solid and extended are known to us only by their solidity and extension. When we say of the former that it is immaterial, we simply ex- press the fact that it is known to us by proper- ties altogether distinct from the properties to which we have given the name of matter, and, with the exceptions just adduced, has nothing in common with them. Beyond these proper- ties, we know as little about matter as we do about mind ; so that materialism is hardly less extravagant than would be the attempt to ex- plain any phenomenon by referring it to some other altogether distinct and dissimilar—to say, for example, that colour is a modification ol sound, or gravity a species of fermentation. 363. We have, in truth, the same kind of evidence for the existence of mind that we have for the existence of matter, namely, that furnished by its properties ; and of the two, the former appears to be the least liable to decep- tion. Of all the truths we know, says Mr. Stewart, the existence of mind is the most certain. Even the system of Berkeley, con- cerning the non-existence of matter, is far more conceivable than that nothing but matter exists in the universe. To what function of matter can that principle be likened by which we love and fear, are excited by enthusiasm, eleva- ted by hope, or sunk in despair'? These and other mental changes may be equally independ- ent of impressions from without, and of the con- dition of the bodily frame. In the most quiet state of every corporeal function, passion, re- morse, or anguish may rage within ; and while the body is racked by the most distressing mal- adies, the mind may repose in tranquillity. The mind thus being so frequently uninfluenced by the state of the bodily organs, and so dissimilar and distinct from the functions of these organs, what reason have we to believe that it is de- pendant upon organization, farther than in be- ing intimately allied with it, for the purposes of intercourse with the external world 1 When these purposes are fulfilled, this alliance is di- vorced ; and as mind, the highest grade of vital endowment, is insusceptible of decay, although liable to be variously disturbed by diseases of its allied fabric, the connexion ceases general- ly, in consequence of the state of this fabric having become incompatible with its manifes- tation. As soon as the organic life, or lower grade of vital endowment, or the properties of life actuating the organs of digestion, assimila- tion, circulation, respiration, and nutrition, and giving rise to functions subservient to the dis- play of mind, by means of the brain and nervous system, cease to be exerted on their respective organs/the vital cohesion of all the structures ceases, and changes take place in the arrange- ment of their constituent elements. These structures, however, are not annihilated ; their elements have only changed their forms; there- by furnishing an analogical proof, as remarked by Dr. Brown, of the continued existence of the mind or thinking principle—that it survives the disorganization and changes experienced by its allied fabric, by means of which its prop- erties or powers are displayed, and the various relations subsisting between it and the rest of the creation are established and preserved. 364. B. If we endeavour to inquire into the origin of mind, all the information which our INSANITY—Its Phys faculties enable us to obtain amounts merely to the following: that, in common with the other properties of life of which the structures are possessed, it is derived from parents ; is developed by the changes in the constituents of the ovum; is matured by the processes of growth ; is allied with an appropriate organiza- tion, or material fabric ; and, like the other vi- tal properties, subsequently manifests the phe- nomena which result from its own nature, and the agency of related causes. It is alone suf- ficient to establish, as Dr. Pring well remarks, the derivation of the mind from parents ; that the being who exhibits the possession of it is a production from parents ; that he is so endowed by an internal conformation; the materials of which are obviously from parental sources; and that he is not cotemporary with parents, Dut is a production peculiar to a more or less advanced and perfect period of their existence. The peculiar features, also, of the mind of the offspring are often found to resemble conspicu- ous ones which belonged to the parents; or, like the hereditary peculiarities remarked in the structures, the mental characteristics of parents are not manifested in the succeeding generation, but remain latent, and are display- ed by the one which follows. Thus, insanity is as conspicuously transmitted from the pa- rents to the offspring as any one of the hered- itary corporeal diseases. The association, however much or little, with the good or with the bad, with the well-informed or with the vulgar; the being familiarized with scenes or sentiments which captivate the imagination, or with topics which exercise the reason ; or con- finement to a sphere in which the mental im- pressions and exercises are little more varied than those of a horse in a mill—will individu- ally have an effect upon the character of the mind, and will concur with previous relations of growth to disguise its resemblance to the original from whence it proceeded. 365. From these and various other consid- erations, it may be inferred that the embryo derives its vital properties from both parents, those of either parent somewhat predominating in certain cases, and as respects certain prop- erties ; that these properties vary in grade in different classes of animals, the highest of which furnish incontestable proofs of the pos- session of several of those faculties which we attribute to mind; and that the same grade of vital properties is communicated to the embryo as characterize the parents—these properties developing in the embryo the material fabrics or structural arrangements about to become the instruments or media of their manifestation; mind, and especially the powers of association and reflection, being the highest grades of these properties, and requiring a more complete de- velopment of the brain for their display. 366. C. If, then, the conclusion that the mind is not a mere result of structural arrangement, is deducible from satisfactory evidence, it re- mains to inquire still farther for the relation sub- sisting between the mind and the material fabric with which it is associated. A perfect account of this relation is most probably beyond the reach of our faculties ; but, among various oth- er topics, it comprises much of what has already been alluded to, as well as a statement—1st. Of the circumstances upon which the existence siological Pathology. 587 of a mind or intellectual principle depends; 2dly. Of the mode of its connexion with the material fabric; and, 3dly. Of the mode by which changes or conditions of the mind, and of the organization, affect each other: but to these topics I can only briefly and imperfectly allude. 367. a. Most of the circumstances upon which the existence of mind depends have been noticed, as far as they are known to us. It has been shown above that the powers of mind are the highest properties of life evinced through the medium of a perfect nervous sys- tem ; that these powers, with the other prop- erties of life, are derived from parents; that they are developed during the early stages of existence ; that they become known to us only through the instrumentality or medium of a cerebro-spinal nervous system, actuated by the vital endowment of the frame ; that the phe- nomena of mind are produced chiefly by rela- tions subsisting between it and external ob- jects—by sensations transmitted to the brain and there disposed of, according to their rela- tions with the other properties or powers con- stituting the intellectual principle or mind, and partly, also, by its powers of suggestion, ab- straction, comparison, and reflection ; and that the connexion of mind with its material fabric is one of alliance, and not of necessary depend- ance, or of dependance only as far as the struc- ture may be required as a medium between the mind and external objects, or may concur to its support or phenomena. 368. b. The bond or connexion subsisting be- tween mind and organization can be viewed only as one of affinity or alliance; and the sole reason we can assign for this connexion is, that it is a law of nature. We have seen that this alliance is of such a kind as that the exist- ence of mind is not necessarily dependant upon the material fabric, but that we are rather en- titled to consider the organization to be depend- ant upon life, mind being those manifestations of life evinced by the cerebro-spinal nervous structures, and resulting from the vital endow- ment actuating these structures; for it is im- possible to conceive that an organized body could have come into existence without a vital or animating principle ; and it is equally impos- sible to conceive how an animating principle, and more especially its higher properties, or powers—the faculties of mind—could have been manifested or duly exerted, unless in most in- timate alliance with matter, the molecules of which it could so build up and actuate as to render them the media and instruments of com- munication with the other materials constitu- ting the visible world. When, however, the molecules of matter are thus built up, variously formed and actuated, they are incapable of perpetuation, in their numerous and wonderful states, or even of more than a momentary ex- istence, unless in alliance with and endowed by life—by that life which organized the mole- cules of matter, developing and perfecting them in their respective forms and grades of being. As soon as the alliance of life and organization is divorced, the former escapes the cognizance of our senses, our unaided reason being inca- pable of acquainting us with its subsequent states of alliance or existence, and the latter returns to its elementary states. Thus we per- 688 INSANITY—Its Physiological Pathology. ceive that organization, with all its phenomena, is dependant upon life from its commencement to its termination—its commencement resulting from the vital endowment bestowed at first by parents, and perpetuated afterward by assimila- tion ; its termination, ultimately, being conse- quent upon the loss or departure of this endow- ment, without which it can no longer exist. But while organization, with all its functions, is the result of, and is necessarily dependant upon a vital endowment, in all its grades and manifestations, this endowment is not neces- sarily dependant upon organization, although associated with it in such a manner as fully and duly to actuate it; and this latter conclusion is supported by the reasons assigned above (y 356), as well as by the consideration that life, in all its grades, may exist independently of the material fabric which it actuates, although pla- ced beyond the spheres of our senses. This is not above the range of conception or of prob- able existence, but admits of belief equally with other remote causes of visible phenomena; whereas the dependance of life and of its high- est manifestation, or mind, upon organization is incompatible with our experience of the nu- merous objects composing the external world, with our conceptions of possible phenomena, and with their causation, perpetuation, and ter- mination. 369. c. The mode in which changes of the mind and of the organization affect each other can be only obscurely or imperfectly recogni- sed ; but, still, enough is manifested to show, 1st. That changes in the manifestation of the mind affect the organization by primarily dis- turbing the functions of life in organs intimately related to the nervous system ; and, 2dly. That changes in the organization affect the mind, in consequence either of the molecular arrange- ment of the material fabric, necessary to the healthy state of mind, being disturbed, or of the affinity or alliance existing between this fabric and its vital endowment being weakened or de- ranged, or of disorder of this endowment occa- sioned by the changes of its associated material fabric, these changes deranging the manifesta- tions of life usually evinced by the brain. Each of these propositions requires farther remarks. 370. 1st. In illustration of the influence of the mind upon the organization, it may be sta- ted that the depressing passions impair the functions of digestion, and weaken the action of the heart; and, if these effects are intense or prolonged, the organization not only of the digestive and circulating viscera, but also of the brain, becomes affected through the medium of the nervous and circulating system. Here we perceive that changes in the functions of an organ affect both that organ itself, and also other organs related to it, by means of nervous and vascular connexions. 371. 2d. If the structure of the brain be changed, the consequences are not uniform either as to extent or character: there may re- sult disorder, 1st, of the mind ; or, 2dly, of con- nected or related functions; or, 3dly, of both mind and related functions. Yet these conse- quences are not necessary or absolute, they are merely contingent; they are not constant or uniform, but uncertain and frequent: for nu- merous facts prove that the fabric of the brain may be most palpably and variously changed without the mind being appreciably disordered, and that the most severe mental disturbance may suddenly occur, and as suddenly disappear where no lesion of the organization of the brain can be detected, or even inferred. These facts lead to the conclusions, 1st. That changes in the mind, or vital manifestations of the brain, do not result uniformly, or even generally, from a disturbance of the molecular arrangement of this organ ; and, 2dly. That changes in the mind depend either upon impairment or other derangement of the affinity or alliance subsist- ing between the fabric of this organ and its vi- tal endowment, or upon alterations in the state of this endowment, whether occasioned by le- sions of its associated structures, or occurring independently of such lesions. To either or both of these alterations disordered states of mind may be imputed ; and either of them will explain the fact that these states of disorder proceed in some cases from alterations of struc- ture, and in others without any appreciable al- teration. They both, especially the latter, ex- plain those sympathetic states of mental disor- der which are of so frequent occurrence. Thus, the organization, or even the function of a re- mote organ, is seriously disturbed, and the vital manifestations of the brain, or the mental pow- ers, suddenly become more or less disordered, and as suddenly are restored to their healthy state. There is, however, no reason to con- clude that the material fabric of the brain is altered in such cases. All that we are entitled to infer is, that the change in the primarily af- fected organ has so disturbed the vital endow- ment of the frame as to disorder in a special manner the manifestations of this endowment in the brain and nervous system ; or, in other words, so as to derange the states of mind, or the various conditions of conscious sensibility, in relation to its internal and external causes. From the preceding observations, and from nu- merous facts and considerations which my limits would not admit of being adduced, I may state the following inferences, as possessing more or less of practical importance, especially with reference to mental disorders, although their practical bearings may not be very obvious to the empirical or routine practitioner. 372. (1.) An organized being did not organize itself; the creature did not create itself, but was created ; and all we know with precision, especially in respect of the origin of the more perfect animals, is, that they have proceeded from parents or anterior living existences. 373. (2.) Our present knowledge warrants the conclusion that the derivation of organized bodies from parents depends upon certain ma- terial elements which proceed from both pa- rents, and which are endowed, or associated with a vital emanation from these parents, the combination or mutual influence of these ele- ments and of their vital endowment producing the new animal; and that the material elements furnished by the parents towards the production of their offspring, and vitally endowed by them, are of such a nature as to admit of conversion, under the influence of life, into those tissues more immediately required in the early stages of development, and of separate existence of the offspring. 374. (3 ) Every consideration of the subject confirms this inference—that not only does a INSANITY—Its Physiological Pathology. 589 vital emanation proceed from each of the pa- rents, in connexion with the material elements furnished by them towards the formation of the new animal; but also that this emanation, or vital endowment, is possessed of properties, al- though in a latent or non-manifested state, similar to those possessed by the parent which furnished it; and that the vital emanations or endowments proceeding from parental sources combine in producing the new animal, and form and develop the material elements with which they are allied or associated. 375. (4.) There is every reason to infer that the embryo derived from these sources requires to be furnished, for a time, with those elements of assimilation necessary to its development, and to its future state of independent existence; and that such assimilation and development are accomplished by means of the vital endowments derived by both parents, although re-enforced or promoted, or, at least, favoured by the cir- cumstances in which the embryo is placed in respect of one of its parents. 376. (5.) The animal, being thus organized by means of vital endowments derived from these sources, is afterward supported by these endow- ments ; the offices performed by each and every part of its frame, whether tending to the con- tinuance of its existence, to the perpetuation of its species, or to communication with ob- jects external to and remote from it, depend- ing upon these endowments being weakened as they become impaired, or disordered as they are disordered, and ultimately ceasing immedi- ately when they disappear or depart from the body which they thus preserved and actuated. 377. (6.) An organized body thus vitally en- dowed presents an assemblage of organs, each of which performs, while actuated by life, cer- tain offices or functions ; their tendency or pur- poses being, 1st, to continue the existence of the animal, by assimilation of the elements of matter external to itself; 2dly, to perpetuate the species; and, 3dly, to hold relations, more or less extensive, with the physical, and, in man, also with the moral or social world. These organs or viscera are respectively en- dowed with life, which is either intimately as- sociated with a general system or tissue, sup- plying all organs and parts of the frame, or is more generally diffused to all the structures, and even partially also to the circulating fluids; and they manifest this endowment in various modes, according to their organization ; their offices or functions being performed under the influence of life, and only by means of its influ- ence, but through the instrumentality of the organization. The functions of a living animal being thus altogether or entirely dependant upon life, these functions may be viewed as the manifestations or properties of life through the intervention or medium of the structures. Thus, irritability is a manifestation or property of life by means of the muscular system, and the va- rious modes of sensibility are manifestations or properties of it evinced by a cerebro-spinal ner- vous system. 378. (7.) Conscious sensibility, in all its forms, and the intellectual and moral states, in all their varieties, arising from the relations of consciousness with its numerous external and internal occasions, are the highest properties or manifestations of life through the instrument- ality of the brain ; perfected, however, or called into existence or activity, by sensation, educa- tion, and reflection. These manifestations of vital endowment by means of a perfect nervous system are the properties, powers, or faculties of mind, which are known to us only in alliance with this system. 379. (8.) The powers of mind being, then, the highest properties and manifestations of life, through the medium of a perfect nervous sys- tem, are dependant upon the vital endowment of the frame, or result from this endowment while actuating its allied material fabric; the states of conscious sensibility, or of the mental principle, depending as much upon it as upon changes in the organization of the brain itself. The faculties of mind are, therefore, manifest- ations of the vital endowment, through the in- strumentality and medium of the encephalon : this endowment, in actuating this particular part of the fabric of the body, evincing these faculties or mental phenomena. In this pro- cess, it is obvious that the particular conditions of the general vitality, whether as to power, or character, or quality, must influence the results or the manifestations of mind, independently of any change of an obvious or appreciable nature in the fabric of the brain ; and that disorders of mental manifestation will proceed as much from the conditions of the general vital endowment as from alterations of the structure of the organ. 380. (9.) It having been shown above that the vitality of the frame, as it endows and ac- tuates the brain, is not necessarily dependant upon, but is merely allied or associated with the brain, it follows that changes of the struc- ture of this organ may or may not affect the mental powers, so long as they are not of such a nature as to seriously disorder the vitality of the frame; and that, when the mental faculties are deranged in consequence of alterations in the fabric of the brain, the disorder is owing to the disturbance which such alterations produce in either the general or the local vital endow- ment, or both ; the local lesion affecting either the general vitality, or that part of it endowing the encephalon more particularly, or both, con- tingently and frequently, but not necessarily or uniformly. 381. (10.) The alliance of the vital endow- ment with the material fabric being intimate, it may be inferred that affections of the one will disorder and ultimately change the other, when intense or prolonged; although, in persons pos- sessed of robust frames and much vital energy, the disorder of either may be severe, without its associate being seriously changed. Intense affections of mind hence may or may not change the allied fabric, and vice versa, according to the susceptibility of the system, and various other concurrent circumstances. This being the case, much of the structural lesion observed in old cases of mental disease is as probably the result as the cause of such disease; the pro- longed disorder of the vital endowment of the brain ultimately modifying the organization of that structure or fabric which was the instru- ment or medium of the disordered manifestation. In such cases the mental affection will influence the general as well as the local vital endow- ment, although it is primarily merely a disorder- ed state of that endowment, either generally or locally, and react upon it to such an extent as 590 INSANITY- ultimately to change the allied fabric either of the brain or of remote organs. 382. (11.) As the powers of mind are mani- fested only through the medium of the enceph- alon, and are not the products of its organiza- tion—as they are the higher properties or man- ifestations of life only in alliance with, and through the instrumentality of this organ—and as affections of the vital endowment, or disor- ders of these manifestations, and changes of the intimate fabric of the encephalon, only con- tingently and frequently, but not necessarily or generally, disorder each other—so it follows, that the amount of the disorder evinced by the mental power is no index to the extent or na- ture of the change existing in the brain, nor even a proof of the existence of any such change ; and farther, that the extent of change in the encephalon produces no correlative dis- order of the mental powers ; and that most ex- tensive lesion may be present in the former without the latter being materially, or even at all, disordered. 383. (12.) Although lesions of the brain are often evinced by disorder of the mental powers, they are more generally and certainly indicated by the physical disorder, or by phenomena dis- played by distant but related parts. When lesions of the brain exist in connexion with dis- orders of the mind, these lesions, in respect both of their nature and extent, are indicated rather by the physical than by the mental phenomena ; the states of the general vital power, or endow- ment, being kept in view. 384. (13 ) Disorder of the vital manifestations of the brain being as dependant upon the states of the general and local vital endowment as upon alterations of the fabric of the encephalon, or even more so, it follows that the states of this endowment, generally and locally, and in connexion with changes of structure in various or remote, but related parts, should form the bases of our pathology of mental disorders, as much as lesions of the fabric of the encephalon ; and ought, moreover, to be the grounds and guides, as much as they, of our therapeutical indications, and the guides of our intentions and means of cure, whether hygeienic, moral, or strictly medical.* * [If the " mind is the result of the vital endowment of the brain," as contended for by our author, it is difficult to understand how " the mind is independent of the material fabric with which it is associated," a doctrine which, if we mistake not, is advocated in the preceding sections. The views and arguments of Mr. Copland, on the nature of mind and the mode of its connexion with matter, appear to us less clear and satisfactory than those advanced on most other subjects ; and we apprehend it would not be difficult to find a satisfactory answer to the questions he raises and the difficulties which he suggests. Mr. C. has al- ready admitted that the brain " is the seat of mind" (I) 342) ; how, then, can it be said that the " doctrine of or- ganism has been found fallacious and untenable?" (t> 361.) Phrenology not only claims that the brain, in our present state of being, is the instrument with which the mind acts ; that material organs are necessary for the mental manifest- ations, just as eyes and ears are necessary for sight and hearing, or a stomach for digestion, but it even goes far- ther than this, and contends that the opposite doctrine, viz., that the mind acts independently of organization in this life, militates against the immortality of the soul, making it a changeable essence, and subject to infinite alterations ; weak and fickle in infancy, strong in manhood, imbecile in old age, and liable at all times to be afflicted with idiocy and madness. The truth is, that the theory of Mr. Copland only removes the difficulty a step farther back: it substi- tutes another link in the chain—vital endowment—which is also presupposed by those whose views he strenuously op- poses. The phrenological school by no means support the doctrine that the existence of mind is necessarily dependant -Treatment. 385. VIII. Treatment of Insanity.—There are few maladies which are more successfully treated than insanity, when the means of cure are promptly employed, and appropriately to the varying forms and features of individual cases ; and there is none which requires, in or- der that all possible success should be obtained, a more comprehensive knowledge of morbid ac- tions, of the disorders, not only of the brain, but also of the other viscera, and of the intellectual and moral manifestations, as variously modi- fied, influenced, or disordered, by the predomi- nant feelings, the manners, the prejudices, the dissipations, and the vices of society. In at- tempting to give a full exposition of the treat- ment of mental disorders, as far as the existing state of our knowledge will enable me, it will be necessary, first, to offer some observations generally applicable to the treatment of insani- ty ; secondly, to state the means which seem most appropriate to the different forms of the malady; thirdly, to estimate the value of the principal remedies in the several states of de- rangement; and, fourthly, to consider the moral management of the insane. 386. i. Remarks more generally applicable in the Treatment of Insanity.—It was for- merly too much the practice to treat the in- sane according to a certain routine or system, without reference either to the causes, or to the form of the malady; and the routine or system followed was generally based upon some prevalent doctrine applied to it, or some generally adopted system of" pathology. Thus, the ancients had recourse to drastic purga- on the material fabric, but believe that it is a principle super- added to matter, on which, however, it depends entirely for its manifestations in our present state of being. If this is not proved by everything that we know of mind and body, in health and disease, then it would be difficult, we imagine, to find any physiological truth demonstrated connected with the human organism. So far as liability to the charge of materialism is concerned, we consider the theory of our au- thor quite as objectionable as that of the phrenologists, for he supposes the mind owes its manifestations to the infiuenct of the nervous system; whether the bond or connexion be one of affinity, or whether it be explained in some other manner, matters not. We call attention to this point, be- cause we conceive that it lies at the very foundation of the true pathology and treatment of the various forms of insan- ity. We believe it necessary to place derangements of the internal faculties in the same relation to the organic affec- tion producing them, in which physiology places the de- rangements of the external senses. As sight and hearing are not impaired without disease of the organs on which these functions depend, so there is every reason to believe that thought and feeling are never deranged unless the cer- ebral organs, by which they are manifested, have undergone some morbid change. These views lead us to regard de- rangement of the mind, not as a specific disease, but a symptom attending many different affections, having the brain for their seat; neither does this doctrine, sustained as it is by observation, experience, and pathological investi- gations, confound mind and matter, nor militate against a belief in the soul's immortality ; it leaves this great doctrine to be decided by Divine revelation, on which, after all, it must ultimately rest. We do not deem it necessary to go into an examination seriatim of the conclusions to which our author has arrived in relation to this subject; on one point, however, we may remark briefly. Mr. C. admits that the " brain is the organ, instrument, or medium of commu- nication between the mind and the external world" (I) 360), and he supposes that "changes in the organization affect the mind in consequence of the molecular arrangement of the material fabric necessary to the healthy state of mind being disturbed," &c. But, in $ 382, he states that " most extensive lesion may be present in the brain without the mind being materially, or even at all, disordered." This statement, so far as we know, can hardly be sustained in the present state of our knowledge in cerebral pathology ; it, moreover, clashes with previous admissions, and, if admit- ted, would go to sustain a belief of the entire independence of mind on matter in our present state, a doctrine which is rejected by our author.] INSANITY- tives, and especially to hellebore; the discov- ery of the circulation of the blood led to the employment of sanguineous depletions ; and the general adoption of the humoral pathology, at a still more recent period, was followed by a revival of the use of purgatives in this class of disorders. It must be obvious, however, to all who have observed the very different forms, the varying phases, and the numerous compli- cations of these disorders—who have viewed them in connexion with their causes, and with their effects upon the organization—that they, of all maladies, require not only the most di- versified, but also the most opposite means, according to the different causes and kinds of disorder, and to the changes observed in par- ticular cases. 387. Each case of mental disorder presents certain circumstances, all which require calm consideration, in order that it may be success- fully treated. 1st. The causes, whether moral or physical, predisposing or exciting, should be viewed, in respect of their individual and com- bined operation—of their action on the system generally, and on the brain, or any other organ, particularly—and whether acting primarily and immediately, or secondarily and sympatheti- cally. 2d. The state and stage of morbid action ought to be ascertained, as regards both the grade of action, generally and locally, and the influence which such action seems to exert upon the manifestations of mind ; and, 3d. The condition of the organic functions, not only as it may be the cause of general and local morbid action, but also as it may be the consequence of such action. On these circumstances are based those indications of cure which should be proposed when entering upon the treatment of every case of mental disorder. 1st. The causes should be removed in ways appropriate to their nature and combinations. 2d. General or lo- cal morbid action ought to be moderated, controlled, or removed, according to its nature, whether it be increased, or excited, or imperfect, or deficient. 3d. The several organic functions should be promoted, when impaired; and restrained, when inordinately excited, either individually or collectively. It is unnecessary to state here how these intentions are to be severally carried into effect. The method or plan of procedure must necessarily vary with the circumstances characterizing the different forms of the malady, and the individ- ual cases of these forms ; but the remarks which I have to make may be referred to each of these indications, and in their respective order. 388. A. The seclusion of the insane is a ques- tion of the first and greatest importance, not merely as respects the removal of the causes of disorder, although this is one of the chief points in which it should be viewed, but also as regards the physical and moral treatment. That every person who is more or less disor- dered in mind should be separated from those with whom he has been accustomed to live, and from his family and friends, and restrained from his accustomed habits and manners, and confided to the care of strangers, in a place al- together new to him, may not be affirmed uni- versally ; but the exceptions to this rule are not numerous, and should be made, in prac- tice, with care and discrimination. As to the propriety of this measure, the most expe- -Treatment. 591 rienced physicians in Great Britain and in for- eign countries are agreed. M. Esquirol re- marks, that recoveries are comparatively more numerous among the patients who come to Par- is to be treated than among those who inhab- it that capital, for the latter are less complete- ly isolated than the former. 389. a. The first effect of this measure is to produce new sensations, to change or to break the series of morbid ideas of which an insane person cannot divest himself: unexpected im- pressions are made upon him, arrest and ex- cite his attention, and render him more access- ible to counsels which may restore his reason. Generally, as soon as he is thus secluded, he is surprised and disconcerted, and experiences a remission of the disorder, that is of the ut- most consequence in the treatment of it, and in acquiring his confidence. The change is not the less useful, observes M. Esquirol, in com- bating the disorder of the moral affections of the insane. The disturbance of the nervous system renders the sensations morbid, and oft- en painful; their natural relations with the ex- ternal world are no longer the same as in health ; all things seem disordered or overturn- ed. The patient cannot believe that the cause of these phenomena is in himself. He is per- suaded that every one wishes to contradict and irritate him, because they disapprove of his ex- cesses : not understanding what is said, he be- comes impatient, and puts an unfavourable construction on what is addressed to him. The most tender expressions are taken as offences, or for enigmas that he cannot comprehend. The most assiduous care is vexatious to him. The insane patient, having become timid or sullen, suspects every one who approaches him, and especially those who are dearest to him. The conviction that every one is inclined to tor- ment, defame, and to ruin him, increases the moral disorder. With this symptomatic sus- picion of those about him—which generally in- creases, without any motive or cause, from in- evitable circumstances or opposition, and with the change in the intellects—to allow the pa- tient to remain in the bosom of his family might soon be followed by the most disastrous con- sequences, not only to himself, but also to others. 390. Where the husband suspects the cares and assiduities of the wife, or the wife those of the husband, and supposes that he or she is in league with those who conspire against him; where the lunatic believes that the members of his family are the slaves destined to obey his sovereign commands, or are the ministers or apostles of his mission ; where the cause of the mental disorder exists in the patient's own fam- ily, or arises from dissensions, chagrins, re- verses of fortune, or privations ; where the in- sane person entertains an aversion, hatred, or dislike to any member of his domestic circle, and particularly to any one who had been most dear to him ; or where the parent, or the son, the lover, or the friend, is impressed with the sentiment of his incapability of fulfilling the duties which he conceives to be imposed upon him, the necessity and advantages of removal, and complete separation from the object of his aversion, of his anxieties, or of his fears, are especially obvious and indisputable. The dis- like entertained by the insane to those who had 592 INSANITY—General View op its Treatment. once been most dear to them, without either cause or motive, imperatively demands the re- moval of the patient, who generally readily be- comes calm before, or attaches himself to, an agreeable stranger, owing either to the circum- stance of his presence being unattended by any unpleasant association or suggestion, or to a feeling of self-love which induces him to con- ceal his sentiments and his state, or to the nov- elty of the impressions produced by strange persons and objects. While these are the chief inconveniences and difficulties in the way of the treatment of the insane while they remain in the bosom of their families, there are great advantages to be derived from removal to a place suitable to the management of this class of patients. 391. b. But how should the seclusion or the separation of the insane be carried into effect 1 That it should be effected by means of an asy- lum or institution devoted to their treatment, in the great majority of cases, is generally ad- mitted ; although removal to such a place may be unnecessary in some instances, or unadvisa- ble in others, owing either to the character of the disorder, or to the peculiar position of the patient—to the circumstances connected with certain cases. Partial seclusion or separation may be resorted to in some cases, and espe- cially in those which are slight. A partial sep- aration is when the patient remains in his own house, and is separated either partially or alto- gether from the members of his family and his friends, and is placed in the care of one or more suitable persons. Seclusion is more complete when he is sent to travel, or to make a voyage, in the custody of proper persons, or Of one or more of his relations or connexions. And it is complete when he is removed to a residence al- together new to him, and surrounded by stran- gers, to whose care he is committed. Of this last kind of separation there are several modi- fications, the chief of which are .- 1st. A private residence, devoted to the patient and to those placed in charge of him ; 2d. A private asylum, containing several or many inmates ; and, 3d. A public or large institution, destined to the reception of a great number. In the great ma- jority of cases, the seclusion, in order that it may be fully successful, should be complete; and the last of these modes, when provided with all the appliances and advantages which many of these now possess, is the most useful, as it conjoins, with complete separation from the relations of the insane, several arrange- ments and circumstances obviously beneficial. M. Esquirol remarks, that the patient should be removed to an institution devoted to the treatment of mental disorders, rather than to a private asylum or residence. Partial isolation is much less successful than that more com- pletely afforded in a well-regulated institution. The chief objection which has been urged against the latter is the association with a num- ber of companions in misfortune; but this is not injurious, is no obstacle to recovery, but is even of service, inasmuch as it causes the pa- tient to reflect upon his condition; and, as the objects around cease to impress him, he is amused or distracted by those about him, is oc- cupied by the objects passing around him, and thereby abstracted from what is apt injuriously to engage his thoughts. Large institutions, moreover, present greater facilities for the pro- tection of the maniacal and furious, without having recourse to injurious or irritating means of coercion and restraint, and the attendants are more experienced in their management than in a private house of detention. The advan- tages, however, of treatment in institutions of this kind depend entirely upon the medical ac- quirements and the characters of those intrust- ed with their management; upon the nature and completeness of the arrangements, thera- peutical, hygeienic, and moral; and upon the organization and discipline of the whole estab- lishment. Still, there are cases to which re- moval to institutions or asylums for the insane is not applicable, however ably they may be managed, and their inmates treated; and, to these cases especially, removal thence might be productive of injury, particularly if the seclu- sion were not modified according to the sus- ceptibility of the patient, to the character of the disorder, and conformably with the pas- sions, the habits, the feelings, and the modes of living and manners of those subjected to it. It is not to be considered as a measure which should be universally employed. In this, as in all other departments of medical practice, experience—that is, close observation of phe- nomena, a knowledge of all matters related to individual cases, and a comprehensive view, and weighing of circumstances—will generally decide correctly as to its propriety. 392. Example, which has so great power over the opinions and actions of man, also influences the insane, who are often not deficient in saga- city and in the power of comprehending what is passing around them. The recovery or the departure of a patient creates confidence in others, and a hope of recovery and restoration to liberty. The convalescents, by their con- duct and advice, console and encourage those who suffer, and thus are of the greatest bene- fit ; one class of inmates of such institutions acting beneficially on the other, and favouring the success of the treatment. The calm, also, enjoyed by all; the moral repose arising out of removal from the habits, the business, the per- plexing cares, the domestic anxieties and cha- grins, and the irritating contrarieties to which they were previously exposed ; the regular mode of living, the judicious discipline, and the regi- men to which they are subjected, and the neces- sity of duly comporting themselves—of conduct- ing themselves with propriety before strangers and before one another—all tend to suggest ra- tional reflections, and become powerful auxiliary means of recovery. The cares and attentions which the insane receive in their own families are counted as nothing ; but the attentions paid them abroad, or by strangers, are appreciated, because they are novel, and are neither due nor exacted. Hence the control readily obtained by those to whose care they are committed, when they are kindly and judiciously treated. 393. c. For melancholic and various forms of partial or slight insanity, complete separation is sometimes unnecessary, or even injurious. Partial separation, travelling, and various modes of exerting moral control, according to the pe- culiarities of the case, are often best suited to these states of disorder. Mania, and several states of monomania, demand complete seclu- sion. Demency, imbecility, and idiotcy require INSANITY—General View op its Treatment. 693 more or less complete separation—at least from society. . Complete seclusion is generally ne- cessary to the poor lunatic, as he would other- wise be unprovided with the aid required to re- Btore him to his family. 394. d. Separation and isolation act directly on the brain, composing it to tranquillity, shut- ting out irritating impressions, repressing ex- citement, and moderating the exaltation of the passions and ideas. The sensations of the ma- niac are thereby reduced in number and inten- sity ; and his attention arrested, and even fixed, by thus being reduced, by the novelty of those which are excited, and by their frequent repe- tition. The melancholic and monomaniac are torn away by it from their morbidly concentra- ted thoughts and ideas, and are directed to dif- ferent objects or topics—especially when prop- er means of distraction are had recourse to— when judicious moral management is conjoin- ed with enlightened medical treatment. 395. e. In separating the insane from their families, the place of residence selected for them should be healthy, airy, and protected from cold winds, as well as from humidity and offensive exhalations. Their constitutions are generally more or less impaired and enfeebled, and they are consequently the more obnoxious to depressing influences and contaminating agents. They are generally predisposed to cu- taneous eruptions, enlargements of the glands, and general cachexia; and they therefore re- quire the more a dry and temperate, or even moderately warm air. It is a grievous mistake to suppose that they are insensible to cold and atmospheric vicissitudes. Although they may not give expression to their sensations, their constitutions, and even the states of their minds, are remarkably affected by cold, humid- ity, and sudden changes of weather and sea- son, against which they should be completely protected. 396. /. The period at which the seclusion of the insane should terminate is not easily de- termined. Experience of a diversity of cases and circumstances is the chief guide to a just conclusion. When this measure is found to be unavailing, after having been duly employed, the visits of near relations, friends, or former connexions, may be tried, great discretion be- ing used in the selection of those who are the first to be admitted to the patient. In such cases, the visit ought to be sudden and unex- pected by him, in order that it may make the stronger impression. The utmost care should be taken in the admission of the visits of friends to convalescents ; and, with them, suddenness and surprise should be guarded against. Upon the whole, it is preferable that seclusion should be prolonged, rather than that it should cease prematurely. This measure, moreover, ought not to be had recourse to in any state of delir- ium consequent upon, or symptomatic of febrile diseases, and seldom in puerperal insanity. 397. B. To establish the medical treatment upon a sure basis, it is necessary to obtain as com- plete a knowledge as possible of the predispo- sing and exciting causes of the malady; to as- certain the physical as well as the moral sour- ces and relations of it; to determine whether the physical occasions the moral, or the moral causes the physical derangement; and to rec- ognise the cases which will recover spontane- II 75 ously upon separation or isolation, and upon the removal of the causes; those which require chief- ly judicious moral management; those which demand medical treatment; and those for which a combination of these means will be requisite. Regardless of these and various other impor- tant considerations, the medical treatment of the insane has too generally been conducted either empirically, or in the spirit of a narrow and exclusive system. Influenced by theory, or a predominant doctrine, some have referred mental disorders to inflammation, and have abused the various modes of blood-letting ; oth- ers have believed that these disorders proceed from a morbid state of the biliary and digestive functions, and have disordered still more these functions and their respective organs by emet- ics and drastic purgatives; and many have con- sidered the nervous influence solely in fault, and have attempted to correct it by means of antispasmodics and stimulants ; hence the treatment has been nearly as often prejudicial as beneficial; and recovery has taken place in many instances, notwithstanding the means that have been used, rather than by the aid of them. 398. a. When called to a case of insanity, the obvious duty of the physician is to ascertain the predisposing and exciting causes ; the sev- eral Circumstances co-operating with these causes, or contributing to their influence and intensity ; the particular form or character of the: disorder, its duration, and physical rela- tions ; the states of the several functions, or- ganic and cerebro-spinal, and the connexion that may exist between the mental disorder and the states of these functions, or of their respect- ive organs. He will, moreover, observe what- ever may exist of a pressing nature, or what- ever indication there may be urgently requiring to be fulfilled; as, for example, whether or not the signs of vascular determination to, or ex- citement in the brain be obvious, and indicate impending risk to the organ ; whether there be general vascular plethora or vascular inanition ; whether some accustomed discharge, evacua- tion, or eruption has been suppressed; and whether or not the patient has been subject to some constitutional disorder, as gout or rheu- matism. It is manifest that these are matters most necessary to be known upon commen- cing the medical treatment of every case of mental disorder; and, without they are assid- uously investigated, in no one instance can such disorder be appropriately treated. Where these more urgent indications exist, they re- quire instant attention ; where the blood is strongly determined to the brain, the usual means of subduing the morbid action—local de- pletions, the cold affusion, or tepid douche, or shower bath, external and internal revulsants and derivations, suitable diet and regimen, &c, are requisite ; where the vascular system is plethoric or inordinately excited, sanguineous depletions, refrigerants, sedatives, evacuations from the bowels, the skin, and urinary organs, and low diet are necessary; where the cata- menial or the hemorrhoidal discharges, and eruptions or evacuations, either sanguineous or serous, or of other characters, have been sup- pressed, or have ceased to appear after the ac- customed interval, the most active means must be prescribed, in order to reproduce them, or as substitutes for them. 594 INSANITY—General View of its Treatment. 399. b. Having removed the cause and con- curring circumstances of the malady—having thus fulfilled the more urgent and pressing in- dications, and having remedied such morbid conditions of the organic functions as may have existed, the more acute symptoms or stage of the malady will subside in about 8, 14, 21, or 28 days, or generally within 40 days, and a re- mission, or even an intermission, will occur. At this period, judicious and appropriate mor- al means should be brought in aid of the phys- ical treatment, while the causes, moral, hy- geienic, and pathological, ought to be removed or combated. If the recovery does not proceed satisfactorily, or if these means, varied accord- ing to the particular circumstances of the case, do not produce beneficial results, other reme- dies, sanctioned by experience, must be tried. These, however, will be fully noticed in the se- quel. 400. C. As the malady thus lapses into a more or less chronic form, local or general man- ifestations of morbid action, which occasionally appear, return, or even remain, should be re- moved or suppressed by the usual and gener- ally obvious means ; and signs of disordered sensibility should be traced to their sources, and their pathological causes removed. When- ever disorder or disease of any organ in the ab- dominal or thoracic cavity is evinced, the fact of such disorder being frequently connected, either as cause or effect, with that state of the brain which occasions the disorder of its as- sociated mind, should be kept in recollection ; and an appropriate treatment ought to be di- rected to the quarter thus manifesting disor- dered sensibility or function, always bearing in mind that morbid action in the substance of the brain is more frequently indicated by mor- bid sensations and disordered movements and functions in remote than in adjoining parts. 401. During the whole course of the treat- ment, the several organic and reproductive functions require attention. The state of the digestive organs, and especially of the biliary and the intestinal secretions, and, indeed, the whole of the excretory functions—the faecal, the urinary, and the cutaneous—ought to be duly, or even daily observed, and promoted whenever scanty or suppressed, or restrained when they become so excessive as to debilitate. More frequently, especially at the earlier peri- ods of the malady, these functions require to be promoted ; and as the defect, as well as the dis- order of these functions, is often owing to im- pairment of the organic nervous or vital ener- gies, the restoration of their healthy states should be attempted chiefly by means which will also invigorate these energies. With this intention, stomachics, tonics, or restoratives should be conjoined or alternated with purga- tives, chologogues, or alteratives ; and the bow- els ought never be allowed to be confined, or the biliary secretion to be deficient. The ap- pearances and sediments of the urine should be ascertained, and alkalies or acids adminis- tered accordingly, with gentle stomachics and diuretics ; and the action of the skin ought to be duly regulated by the cold, the shower, the tepid, or the warm bath, and by frictions and clothing, according to the form or stage of the malady, and the particular conditions of the cu- taneous function. The states of the reproduc- tive organs also require observation, espe- cially of the uterus. And it should not be over- looked, that these organs are often abused by solitary indulgence, in such a manner as both to cause and to perpetuate the malady. Where this is detected, or even suspected, means should be contrived to prevent it. In advanced stages of insanity, although the treatment should be conducted, with reference to the removal of existing pathological states and of disordered mental manifestations, according to rational principles ; still, when means thus devised fail of success, other and more empirical remedies, sanctioned by experience, ought not to be neg- lected. To these, however, sufficient refer- ence will be made hereafter. 402. D. The clothing of insane persons, par- ticularly of the melancholic, should be warm. In general, flannel may be worn next the sur- face ; and dry friction every morning will be useful. The patient should sleep on a hair mattress and hair pillow. His head ought to be somewhat elevated, and generally uncover- ed. The insane epileptic ought to sleep in a very low bed, to prevent accidents during a paroxysm. The propriety of devoting strict attention to cleanliness, in respect both of his person and clothes, is obvious. 403. E. The food and diet of the insane must necessarily be varied with the nature, compli- cations, and stage of the disorder, and with the circumstances of particular cases. In the more acute attacks or stages of the malady, the diet and regimen ought generally to be antiphlogis- tic ; at a later period, and in more chronic ca- ses, and particularly in states evincing vital de- pression or exhaustion, the food should be more nutritious, in larger quantity, and easy of di- gestion ; but hot spices and stimulants ought not to be allowed. During convalescence, the diet may be more substantial, but not heating, and duly regulated according to the exercise that is taken. The meals should be at regular periods, and deliberately partaken of, and well masticated. A sufficient quantity of fluids should be allowed to assuage the thirst of the patient, which is generally urgent in mania, and in some cases of monomania; but they ought not to be given, unless when necessa- ry, or when, in certain cases, a profuse use of them forms a part of the treatment. 404. F. The management of convalescence is one of the most difficult parts of the treatment of the insane. If the patient be not placed in favourable circumstances for some time after the subsidence of the malady ; if he be not care- fully and kindly watched; if contrarieties of mind, family dissensions, and all the remote causes, moral and physical, be not sedulously avoided ; and if the diet, regimen, and mode of living be not suited to his constitution and the peculiarities of his late disorder, the risk of a relapse will be great. At this period, and for long afterward, much mental exertion or appli- cation, sudden bursts of passion, and excesses of every description must be shunned ; and the earliest manifestation of physical disorder—of headache, of disorder of the digestive organs, and of interruption of accustomed evacuations or discharges—should be met with local deple- tions, purgatives, revulsants, diaphoretics, and other means appropriate to the nature of the disorder. As convalescence proceeds, change INSANITY—Treatmen of air and of scene, and travelling with a suita- ble companion, or one capable of amusing, for- tifying, and even of controlling the mind, will be most beneficial; and such mineral waters as will promote the secretions and excretions, and, at the same time, strengthen the constitu- tion, without exciting or heating the circula- tion, or determining the blood to the head, will often prove of essential service. 405. G. The measures proper to prevent insan- ity, and more especially a relapse or return of it, are most obviously presented to the reader in the full exposition I have given of the predispo- sing and exciting causes. The avoiding of these constitutes the chief, and, indeed, the only proph- ylaxis. Young persons whose parents have been the subjects of this malady should have especial attention paid to both their physical and their mental development; and while the former is promoted by exercise in the open air and healthy occupation, the latter should be cul- tivated without being over-exerted, and sound religious and moral principles ought to be in- culcated, care being taken to avoid indulgence of the caprices, passions, and selfish feelings. The instruction of these persons should not be premature ; but the desires and passions ought to be early restrained. The judgment should also be early and judiciously informed, without fatiguing the mind ; and the control of parents or guardians ought to he prolonged for a con- siderable period after puberty, and until the mind, conduct, and constitution are fully formed. 406. ii. Of the Treatment of the Specific Forms of Insanity.—A. Partial Insanity.— The simpler forms or slighter grades of insanity severally require a moral management, as well as a medical treatment, appropriately directed to their different states and characters, which, however, are so diversified as to preclude the possibility of my considering the subject with reference to any but those which are the more common and prominent.—a. In the various stales of moral insanity (y 69, et seq.) in which the pa- tient is not labouring under any illusion, or er- roneous conviction, or disorder of the under- standing, the propriety of seclusion cannot be decided upon, excepting with reference to the features of, and the circumstances connected with individual cases. Many of these states of moral disorder, consisting chiefly of errors in action and conduct, are not of that grave and well-marked kind which is considered, in the eye of the law, to require the privation of lib- erty, although, in the majority of such instan- ces, the conduct of the patient may be such as will prove the most injurious to himself and to those depending upon him. In other less ques- tionable cases of derangement, and where the disorder is so restricted as to leave the patient, according to appearances, the exercise of a great portion of his reason, it is often difficult to come to a determination as to the propriety of seclusion. The opposition which the patient may experience may endanger the portion of intelligence that remains. It is as unnecessary as it is cruel to deprive a person oppressed by distressing feelings, or prone to terror or alarm, of his friends and relatives—of the attentions of his family—as long as he entertains no vin- dictive feelings or dislike to them, and espe- cially as long as his actions may be reasonably controlled by them. r of its Partial Forms. 595 407. a. In the state of gloom and mental de- pression to which some persons, the subjects of moral insanity, are prone (y 73), seclusion may be productive as readily of mischief as of benefit. For these, travelling, visiting water- ing places, medical treatment, the kind inter- course of those to whom the patient is partial, and the watchful attentions of the members of his family, or of those accustomed to attend upon persons in this state of mental affliction, should be tried before seclusion be resorted to. When suicide is contemplated, seclusion and control in an asylum will prove more success- ful than the most careful attentions in the bo- som of the patient's family. Still, in the ma- jority of such cases, this measure will be more successful chiefly in respect of the safe custody of the patient; for none besides will be equal- ly secure. The most vigilant keepers may be deceived by him when he is otherwise at large. 408. 8. When the disorder is characterized by unnatural excitement (y 74), seclusion and confinement are often requisite, and are gener- ■ ally successful by inducing reflection. When persons thus affected have a propensity to in- toxicating liquors, accessions of mania being thereby occasioned, seclusion is necessary ; but upon the restoration of liberty the morbid disposition returns. In all cases of moral in- sanity where the morbid propensity is danger- ous to the patient or to others, this measure becomes indispensable. When the disorder as- sumes a religious character (y 75), travelling, society, and a suitable moral and medical treat- ment are preferable to seclusion ; and confine- ment ought not to be resorted to unless suicide have been attempted or contemplated. 409. The treatment of all the forms of moral insanity ought to be essentially, although not exclusively, moral. Comparatively few instan- ces of these do not present more or less of phys- ical disorder, seated either in the head itself, or in some organ with which the brain sympathi- zes. Of this I have already adduced sufficient evidence (y 92-94). The moral treatment in all these must be based upon a knowledge of the remote causes of individual cases, and should vary with the circumstances of each. It is im- possible to state here in what this treatment should consist with reference to such circum- stances ; the subject will be as fully treated of hereafter as my limits will permit. Wherever physical derangement can be detected, or to whatever organ it can be referred, appropriate medical means should be directed against it, while the patient is enjoying the advantages of a suitable moral management. The general health should receive due attention ; and the functions of digestion, secretion, and excretion be duly promoted. Due restraint ought to be, as far as possible, imposed upon the passions and emotions, and change of air, wholesome exercise, and interesting occupations be pre- scribed. 410. y. The treatment of erotomania should have reference chiefly to disordered circulation in the brain occasioned by an excited imagina- tion and protracted desire, in connexion with great susceptibility of the nervous system gen- erally. If this affection be not alleviated, it will pass into more general disorder of the mental powers ; especially into melancholia, mania, or it of its Partial Forms. 596 INSANITY—Treatmen some form of dementia. When it occasions emaciation and hectic fever, thereby menacing the life of the patient, marriage may be sug- gested. In this, as in nostalgia, the accom- plishment of the desires of the patient is the chief or only remedy. When the object of de- sire is concealed, every art should be tried to ascertain its nature and source, as the ef- fects upon the mind that will consequently re- sult may be of much service, and a moral in- fluence may be exerted over the patient with greater advantage. Where marriage is impos- sible, change of scene, travelling, society, and the amusements of watering places, a tonic and restorative treatment, healthful and pleas- ant occupations, exercise in the open air in agreeable company, and suitable diet and regi- men, are chiefly to be depended upon. When there is any evidence of increased determina- tion of blood to the head in this, as in other forms of moral insanity, and especially when the scalp is hot or the eyes injected, the tepid or cold shower bath every" morning will be found of great service. 411. 6. The morbid propensity to intoxication (y 86) is, often attended by symptoms indicating not only a state Of irritation of the stomach, but also a general depression. of the nervous power. In this state, tonics, with small doses of ammonia, may be used with advantage ; and, in order to counteract the injurious effects of the intoxicating fluids upon the system, to pre- vent the disorder from leading to more general and severe derangement of mind, and to dis- gust the patient with these fluids, tartarized antimony, ipecacuanha wine, or other nausea- ting drugs, and even the extract of elaterium or croton oil may be added to them before they are partaken of by the patient. In two cases, one of which I attended with Mr. Hood, this method was found successful in causing a loath- ing of these fluids, in moderating the mania consequent upon the use of them, and in per- manently restoring the patients. In both these cases, seclusion, and a sufficiently permanent and close restraint, could not be conveniently put in practice : this plan was, therefore, tried in the first instance, and succeeded in causing a distaste of all kinds of intoxicating liquors. To succeed, however, by means of it, requires great care and management on the part of the friends of the patient. 412. e. Homicidal insanity (§ 89) and incendi- arism (y 88) are generally dependant upon an irregular activity of the circulation, or a morbid state of vascular action, especially in the brain. They are both frequently connected with disor- der of the uterine organs, or suppression of the catamenia; and, in males, with derangement of the digestive organs, and with sanguineous determination to the head. Medical treatment in these cases is mainly to be trusted to; for the morbid impulse to commit these crimes is often so violent as to be instantly carried into effect, either before moral restraint can be ex- erted to counteract it, or because this restraint is habitually so feeble as to be inefficient, or is not roused to the least degree of activity. The impulse to perpetrate such crimes may, indeed, be looked upon as one of the modes in which physical disorder of the brain, arising either primarily or sympathetically, deranges the man- ifestations of mind—those sentiments or pro- pensities which circumstances have called into activity being thereby disordered or morbidly exalted. In many instances, also, there is rea- son to believe that the morbid impulse to com- mit crime is only the climax of an habitual in- dulgence of passion and feeling, to the constant neglect of moral principle and restraint, and is a tolerably obvious consequence of cerebral ex- citement, the effects of which are determined or manifested in this particular manner or di- rection, owing to various predisposing and con- curring sentiments and circumstances. 413. In these cases, local or general deple- tions, according to the amount of local or gen- eral fulness, or of increased vascular action; the cold douche, cold affusion, or shower bath ; active purgatives, revulsants, and derivatives ; antimonial and other diaphoretics ; digitalis and other sedatives ; and the promotion of the se- cretions and excretions generally, constitute the chief principles of treatment, aided, how- ever, by a due moral influence, and by proper mental and physical occupation. 414. b. Partial disorder of the understanding (y 95) appears under so various and numerous forms as to require a treatment appropriate, not only to each of these, but also to individual ca- ses. Each patient should be a particular sub- ject of study, and the moral and physical treat- ment directed according to the character and stage or duration of the disorder, and the vari- ous circumstances connected with its develop- ment.—a. Hypochondriacal monomania is gener- ally an extreme state of hypochondriasis, and more or less intimately connected with physical disorder, commonly commencing in the digest- ive organs, and consecutively affecting the brain. The treatment should not be materially different from that which I have recommended for that disease ; and the hygienic means there advised (see Hypochondriasis, y 50), especially, should be adopted. In the majority of cases, complete seclusion will not be necessary, un- less the patient contemplate or attempt suicide. More generally, however, travelling, change of scene and of air, horse exercise, agreeable oc- cupations, hunting, the amusements of society and of places of resort—especially when at- tended and controlled by friends or suitable per- sons—will be found most conducive to recov- ery, particularly if an appropriate medical treat- ment, and the use of mineral waters of a resto- rative and deobstruent or laxative kind, be pur- sued at the same time. Every method should be tried, and especially those just mentioned, to abstract or seduce the patient's attention from those feelings and ailments with which his mind is exclusively and morbidly occupied. The strictly medical means should be varied according to the peculiarities of individual ca- ses ; and the more urgent symptoms should be palliated by suitable remedies. The bowels ought never be allowed to become costive, and their functions should be promoted by aperi- ents, conjoined with tonics, carminatives, and deobstruents. All the secretions and excre- tions should be duly promoted. Flatulence and gastrodynia must be allayed by magnesia, the hydrocyanic acid, gentle tonics, &c, variously combined ; and by spare diet, consisting chiefly of warm milk, with bread or boiled rice, or other farinaceous articles. | 415. 8. The treatment of melancholic monoma- INSANITY—Treatment of Melancholic. 597 ma (y 106) is most difficult, and, to be success- ful, requires a strict examination of the physi- cal and moral causes of each case, and an ap- propriate employment of moral, hygienic, and medical means.—(a) Moral treatment is of the greatest importance in this form of insanity, and in all its modifications, whether religious, or demonomaniac, or misanthropic, melan- cholia, or any other it may assume; but this part of my subject will be more appropriately considered hereafter. 416. (b) The hygienic measures that may be resorted to consist chiefly of attention to cli- mate, residence, exercise, clothing, and diet. The patient should reside as much as possible in a moderately warm, or temperate and dry air, or in a mild climate and a clear atmosphere ; and if he must abide for a time in a place where these advantages are not enjoyed, he should choose spring and summer, and migrate during autumn to the milder climate, where he should reside during the winter and early spring months. The patient's clothing should be warm, and consist of flannel nearest the skin; and this should be frequently changed. As melan- cholies are subject to cold feet, these parts should be carefully protected. 417. (c) Seclusion—at least complete seclu- sion—should be prescribed with great circum- spection. There can be no doubt of its propri- ety when suicide is contemplated, or has been attempted. But in other cases, partial seclu- sion, particularly in connexion with agreeable and interesting occupation and amusement, is more safe and beneficial. Seclusion, however, even when complete, often re-establishes the moral powers and the reasoning faculties when they are exhausted by indulgence of the pas- sions and desires. 418. (d) Exercise and suitable occupation are very important parts of the treatment of mel- ancholia, and of all the states of partial insan- ity. Travelling, voyaging—especially to a con- siderable distance, and with a fixed object, or with feelings of interest in what may result or occur—is one of the best means that can be devised. Exercise on foot or on horseback, regularly taken, so as to promote the cutane- ous excretion ; occupations in the open air, which are attended by moderate physical exer- tion and mental excitement; hunting, shoot- ing, and games of skill and activity, as cricket; and farming and gardening, are severally of great benefit. The chief objection to the last of these is the occasional stooping necessary to several of its duties. Billiards are also use- ful means, both of exercise, interest, and amuse- ment. Whatever moderately excites, interests, or occupies the mind, is serviceable in the treat- ment of melancholia; and especially if it, at the same time, abstracts the attention or imagi- nation from the object of its illusion. When music is properly selected, and prosecuted so as to accomplish these objects, the advantages that may be derived from it are great. As to the selection of modes of occupation and exer- cise for individual cases, much should depend upon the patient's previous and existing tastes and habits. A principal intention in this class of disorders, in all forms of partial insanity, is to detach the patient's attention, his mental de- votion, from the object on which he has mor- bidly fixed it, to seduce it to other objects, and to engage it with different subjects and matters of interest and importance. 419. (e) The diet of melancholic patients should be light, digestible, and moderately nu- tritious. Salted, highly-spiced, irritating, and oily or fat articles of food ought to be always avoided. The food should be simple, plainly dressed, consisting of very few articles at the same meal. Ripe and fresh fruits, in due sea- son, may be allowed. The quantity and kind of food should have reference to the amount of exercise. When this is so great as to freely promote the cutaneous, biliary, and alvine evac- uations, a more liberal diet may be permitted than in other circumstances. Great circum- spection is requisite in allowing this class of patients restorative or exciting liquors. If the head be cool, and the action of the carotids rather below than above the healthy standard, these may be. tried in small or very moderate quantity, and their effects observed. General- ly, however, the influence of gentle tonic and restorative medicines should be previously tried. [It is believed that a rather generous diet of a mixed kind is more generally adapted to the treatment of the insane than one of a lowering or antiphlogistic nature ; but it is, of course, to be conformable to the general curative plan of the individual patients. Much will depend on the previous habits and manner of living. The diet should, of course, in all cases be ordered by the physician, and, as in other diseases, adapted to the state of the patient and his di- gestive organs, which vary according to tem- perament, age, previous manner of living, and particular idiosyncrasies.] 420. (/) Medical Treatment.—The physical disorder requires, simultaneously with the adoption of the foregoing measures, and of suitable moral means, a judicious recourse to remedies calculated to promote or to correct the functions of the digestive organs, and, in- deed, of all the abdominal viscera. There are very few of these viscera which have not be- trayed more or less of disorder even long pre- viously to the development of the mental affec- tion. The functions of the skin are usuallyim- paired, and often require the tepid or the warm bath for their restoration. The alvine excre- tions, especially the intestinal, are generally re- tained, or voided imperfectly or with reluctance, owing manifestly to relaxation of the muscular tone of the bowels, and especially of the colon. The secretions are also deficient, and morbid from their retention. These physical condi- tions require for their removal the frequent use of aperients and laxatives, conjoined with ton- ics and other restoratives ; for their continu- ance would increase that state of excrementi- tial plethora of the vascular system in which melancholia and hypochondriasis often origi- nate, by depressing and disordering the vital manifestations of the brain. Even the urinary secretion is deficient, the discharge of the more excrementitious materials from the blood by the kidneys being partially interrupted, or defi- cient in respect of certain of the constituents of the urine. In most instances, the morbid materials carried into the circulation, or accu- mulated in it, owing to defective powers of di- gestion and assimilation, are not sufficiently discharged from it by the action of the kidneys, 598 INSANITY—Treatment of Melancholic. bowels, liver, and skin ; and thus the impure state of the blood influences the manifestations of the nervous centres. In such circumstances, the restoration of these functions, by suitable hygienic and medical treatment, is always a principal indication of cure. 421. The chances of recovery from melan- cholia may be almost said to be great in pro- portion to the manifestation of disorder in the organs of digestion. As the pathological causes of the mental affection show themselves the more evidently, the greater hopes may be en- tertained of the disappearance of" the latter with the removal of the former. Where these ex- ist, the therapeutical intentions should be di- rected accordingly. If the function of any or- gan be impaired or interrupted, the restoration of it is indicated ; if the hemorrhoidal or cata- menial evacuation is suppressed, means should be taken to re-establish it; if a cutaneous eruption have disappeared, or an accustomed ulceration or issue ceased to discharge, the skin should be acted upon, or some analogous mode of derivation and counter-irritation be adopted. It is, however, not always, nor even frequently, that melancholia can be referred to these, or equally manifest sources, and where such very obvious indications of cure as these present themselves. Still, there are generally to be observed certain conditions of the abdom- inal organs, of the cerebral and general circu- lation, and of the nervous system, which sev- erally require attention, and furnish the basis of a rational method of treatment. 422. Where the functions of the digestive organs are sluggish* the bile is morbid, dark, irritating, or scanty, and the various secretions and excretions insufficient for the due purifica- tion of the blood, or for the preservation of it in a healthy condition, it is clearly indicated to restore these functions by means which shall impart a new impetus to the vital endowment of their respective organs, and enable them regularly to perform their offices. In a very large proportion of cases, not only is the bile morbid, but the whole abdominal secretions are disordered, and certain of them are retained on the intestinal mucous surfaces, or even accu- mulated in the caecum and colon. The fre- quency of these changes, and the benefit re- sulting from the more certain means of remo- ving them, induced the ancients to have re- course to black hellebore, and the moderns to milder cathartics, to purgatives or to laxatives, in the treatment of this malady ; and the pro- priety of the practice, when the means are well selected and combined, and judiciously man- aged, cannot be disputed. In some cases, es- pecially where there is much torpor of the bil- iary apparatus and of the bowels, with accumu- lated sordes on the digestive mucous surface, a brisk emetic, or even an emeto-cathartic, is of great service early in the complaint and at the commencement of the treatment. When the strength of the patient will permit, a continued action on the bowels—an artifical diarrhoea— should be kept up, by means of chologogue or stomachic purgatives or aperients, for a con- siderable period; and purgative enemata may also be employed. A combination of the com- pound infusions of gentian and senna, with a neutral salt, and an aromatic spirit or tincture (F. 266), will be appropriate in these cases, and the spirit of turpentine, with castor or olive oil. may be prescribed in enemata. A similar means to these, of which a variety will be found in the Appendix, and in the articles Hypochondriasis and Indigestion, may be employed according to the peculiarities of individual cases. When the patient believes that his physical health is not in fault, or when there is a disposition to sanguineous determination to the head, James's powder, or tartarized antimony, may be given in small and frequently repeated doses, so as to keep up an action upon the skin or bowels, and to induce a feeling of bodily ailment, so as to dispose the patient to pursue a suitable treat- ment. 423. When indications of congestion of the brain, or of determination of blood to this part, or of general vascular plethora, or of inflamma- tory irritation of the gastro-intestinal mucous surface, or of fulness of the portal system, are observable, and especially if they have become more evident after the disappearance of an ac- customed evacuation, general or local blood- letting should not be delayed. Local depletions are generally most appropriate in these circum- stances, and ought to be decidedly employed, particularly in the more robust. Aret^cus per- mitted blood-letting only in the young and ro- bust in this complaint, and in small quantity, and chiefly in spring; Cullen considered that it was rarely useful; Pinel seldom employed it; and Esquirol advised it in nearly the same circumstances as I have recommended it. The application of leeches, and even the repetition of them, to the vicinity of the vulva, or around the anus, when the catamenial or hemorrhoid- al evacuations have been interrupted, or the portal system congested, and to the epigastri- um or hypochondria, or behind the ears, when uneasy sensations are referred to the enclosed organs, is generally attended with benefit; and this evacuation may be repeated even oftener than once, and commonly with advantage, al- though it may be requisite to administer ton- ics, antispasmodics, or restoratives at the same time. 424. Many cases of melancholia present a morbid susceptibility and sensibility of the ner- vous system. The patient is remarkably ner- vous, and his distress is evidently heightened by sanguineous depletions, however moderate, and by purgatives if too frequently exhibited, or even if they operate beyond the mere evac- uation of the bowels. Lorry has well descri- bed this form of melancholy, and very properly recommended for it calming measures—opiates, with gentle stimulants and restoratives. In these cases, the warm or vapour bath, the te- pid or warm douche, the affusion of warm or tepid water on the head, and the tepid bath, ac- cording to circumstances, will be of great ser- vice. Small doses of camphor, with opium, morphia, or hyoscyamus, or with the extract of poppy or lactucarium ; the infusion or the ammoniated tincture of valerian, or both con- joined ; the infusion or tincture of hop ; and other antispasmodics and diffusive stimulants, variously conjoined with sedatives, narcotics, &c, and a pure, dry air, change of scene, and light food, are generally beneficial in this state of disorder. If there be watchfulness and ir- ritability, the hop-pillow, or the sirup of pop- pies, or the compound tincture of camphor, in INSANITY—Treatment op Maniacal. 599 a small enema, will afford relief. When the disorder has been caused by masturbation, the cold affusion or shower bath, the cold plunge bath, and tonics, especially the muriated tinc- ture of iron, should be prescribed. As the en- ergy of the nervous system returns, more per- manent and energetic restoratives and tonics may be employed ; but during their use the se- cretions and excretions ought to be carefully promoted, and the bowels kept freely open, care being taken to prevent congestions of the brain or portal system. 425. In many instances, a combination of the several indications based upon the condi- tions of the abdominal organs and of the vas- cular and nervous systems, and the association of more or less of the means required to fulfil these indications, are often both necessary and successful. Thus, it is frequently of the great- est advantage to act energetically upon the bowels by means of stomachic or chologogue purgatives; to deplete the vascular system, either generally or locally; and, at the same time, to give stimulants, antispasmodics, and tonics, the choice of the several means depend- ing upon the characters and symptoms of indi- vidual cases. As to the propriety of exhibit- ing the more active tonics in melancholia, much doubt may be entertained; but if accumula- tions of morbid matters in the bowels have been removed; if the tongue be clean, moist, or watery ; if the secretions and excretions have been improved, and if a trial of them be not productive of headache, of increased heat of the scalp, or of feverishness, the use of them may be persisted in, care being taken to keep the bowels freely open, and to guard against local fulness or determination of blood. The diet, regimen, and the management of con- valescence, require no remarks beyond those which have already been made (y 402-405). 426. c. Demonomania, in its different forms, and especially theomania, or various states of religious insanity (y 121, et seq.), require a some- what similar plan of treatment, and the same indications of cure, as have been recommend- ed for melancholia, with which they are more or less closely allied. Moral treatment is par- ticularly necessary, but, equally with the phys- ical, should be varied according to the peculiar features of individual cases. In all the modi- fications of religious insanity, the consolations of religion, administered by sincere, moderate, and rational ministers of it, are of the greatest service. I have witnessed this in several ca- ses; and, when judicious moral and religious management is aided by a sound physical treat- ment, recovery will take place in the great ma- jority of instances. In no form of insanity is greater care requisite than in this, to protect the unfortunate patient, and his near relatives, or members of his family, from his insane im- pulses to commit suicide or murder. Pinel states that a person, after listening ta an alarm- ing sermon, considered himself as irretrievably lost, and murdered all his children, in order that they might not experience eternal damna- tion. Esquirol mentions the case of a wom- an who entertained a similar idea, and attempt- ed the lives of her children to preserve them from punishment in a future world; and nu- merous other instances of the same kind might be adduced. When persons thus disordered succeed in their horrible design, they rarely re- cover ; for no sooner is reason restored, than the distress experienced by them, when reflect- ing upon the act they have committed, occa- sions a return of the malady. 427. The physical disorder, both antecedent to, and coetaneous with the mental disorder, should be carefully investigated ; and particular attention devoted to the states of the brain, of the digestive organs, and of the uterine func- tions ; and determination of blood to the head prevented by local depletions, the shower bath, or douche ; by derivatives and aperients. In the more robust and young, the preparations of antimony, in small doses, and occasionally in larger quantity, so as to produce vomiting, are often of service. 428. In those cases where the patient enter- tains the belief that he is changed into some animal, or that he has changed his sex, or that he has lost a portion of his body, or that he car- ries about with him a living thing, or some strange substance in his abdomen, or that some singular matter is substituted for one of his or- gans or members, and acts from this impres- sion, the success of treatment is often not great. In many of these there is reason to suspect physical disorder, if not structural dis- ease, in the organ or part to which the insane delusion is referred ; and to that organ the in- vestigation and the treatment should be espe- cially directed. 429. B. Treatment of General Insanity. —a. Of Mania.—In treating mania, it is ne- cessary to have a most intimate regard to the stage of the disease—to the degree of general and cerebral vascular action and vascular ful- ness—and to the state of the secretions and excretions. The means which will prove most beneficial during the acute stage, and especial- ly in the early part of it, will be inappropriate, or even injurious, in the chronic period of the malady. The treatment of mania is both hy- gienic and pharmaceutical. The former com- prises various moral, intellectual, and physical means ; the latter, the internal remedies in- tended to subdue morbid action, and to restore the healthy functions.—a. At the commence- ment, and during the early or acute stage of the malady, the patient should be placed in a large, darkened, and well-ventilated apartment, the air of which should be fresh and cool. Unless his violence is extreme, he ought to be allowed the full range of that, or even of an adjoining apart- ment, in the watchful care of sufficient attend- ants ; and the restraint even of the strait waist- coat should be dispensed with, unless urgently required. Complete seclusion is most neces- sary, and it should be preferably conducted in a large institution, conformably with what has already been advanced on this subject (y 391). All means of irritation or excitement should be prevented, as far as may be compatible with safety to the patient and those around him. The visits of relatives, connexions, or even of acquaintances, should be prevented, and the patient ought to vbe exposed to the smallest possible number oY impressions and causes of excitement. The diet should be rigidly anti- phlogistic, and cooling diaphoretics, refriger- ants, and diluents prescribed. The nitrate of potash, the muriate of ammonia, the. solution of the acetate of ammonia, the spirits of nitrio tment of Maniacal. 600 INSANITY—Trea- aether, the solution of tartarized antimony, camphor julep, &c, may be severally used as refrigerant diaphoretics, or administered in the patient's usual drink ; or any of the articles prescribed in the Appendix (F. 588, et seq.) may be employed with this intention. 430. In this form of insanity, patients ought neither to be retained in their own houses nor confined to their beds. If they are turbulent, vociferous, and violent, their extravagance should be allowed to exhaust itself without being perpetuated by the excitement of contra- diction, irritating coercion, or violence, unless in as far as coercion is indispensable ; and, as soon as it shall have served its purpose, it should be relaxed. Soothing means, with firm- ness, and decision when circumstances require it, should always be tried, and never be depart- ed from, even when the utmost restraint is also imposed. The perceptions of the maniac are seldom so entirely obscured as to render him incapable of understanding kind and soothing treatment, or to make him altogether insensi- ble of considerate modes of having recourse to coercion : this has been proved by the able management of cases of this malady in the County Asylum, by Dr. Conolly. M. Esquirol also observed that coercive means should not be resorted to until the maniac risks his own life, or the lives of others ; and even then they should be temporary, and be laid aside as soon as a calm takes place. When the patient will not pass the night in bed, it is better to leave him unrestrained than to coerce him, if he evince no mischievous tendency. This writer has found that the more that liberty has been granted to maniacs, without compromising their safety, the fewer have been the instances of furious mania, and the more rare the instan- ces of the supervention of apoplexy and paral- ysis : complications not infrequently produced by the irritation and excitement caused or per- petuated by unnecessary or prolonged restraint, or by restraint imposed in a harsh, unfeeling manner. The moral treatment should be con- ducted conformably with the principles which will be stated hereafter. 431. The diet may be more liberal as the disease passes from the acute to the more chronic stage; but in all periods, hunger or thirst, if not appeased, augment the irritation and violence of the patient. The food should be of the most digestible and least exciting kind. In some cases, at the commencement of the attack, all food is refused ; but this re- pugnance wears off in a few days. Coercion, in such instances, is unnecessary, as the dis- like arises either from gastric disorder, or from excessive cerebral excitement; and, in both circumstances, abstinence is a necessary part of the treatment. At a more advanced period, the farinaceous and leguminous articles of diet, warm milk with bread, rice and milk, ripe and seasonable fruits, and the white meats, are the most appropriate. The drink should always be cooling and febrifuge, as already advised (M29). 432. 8. The strictly medical treatment requires the calmest consideration; the spirit of sys- tem, and an irrational method of routine, should be altogether banished; the means of cure should be appropriate to the peculiarities of each case at the time of prescribing for it. The exact pathological or physical conditions should be ascertained as correctly as possible, and remedies prescribed accordingly ; and with due reference to the age, habit of body, tem- perament, modes of living, and occupations of the patient; to the predisposing and exciting causes, to the season, and to the stage and previous character of the disease. At the com- mencement of the attack, and if gastric disor- der is manifest, one, or even two, emetics of tar- tarized antimony, dissolved in barley water, or in any other diluent, should be exhibited ; but if there exist general plethora, as well as inordi- nate vascular action in the head, a full blood- letting should precede the emetic. After the operation of this latter, increased action should be moderated by the continued exhibition of the solution of antimony with liquor ammonia; acetatis. It is sometimes requisite to repeat the blood-letting, especially if redness of the face or eyes, noises in the ears, a pulsating pain in the temples, or increased heat of the scalp, or augmented action of the carotids, still continue. When the first blood-letting has been copious, a local depletion may be suffi- cient, as cupping behind the ears or in the nape ; or the application of leeches to the tem- ples, or around the base of the head, or even to the anus. Great care is requisite not to bleed too much; for if maniacs be too much reduced by sanguineous depletions, they are apt to lapse into dementia or imbecility. 433. After the operation of the emetic, a full dose of calomel, either alone or with James's powder, may be given, and its operation promo- ted by some active purgative taken a few hours afterward, and preferably, according to my ex- perience, by half an ounce, or six drachms each of castor-oil and spirits of turpentine, in any suitable vehicle. If the action of these be tar- dy or insufficient, it may be promoted by the same or other active cathartics prescribed in enemata. If the cerebral excitement continue after these, or return, the warm or tepid bath, or a bath of an intermediate temperature, may be used, the patient remaining in it for a con- siderable time; cold lotions being applied to the head, or cold water being affused upon it. The bath may be resorted to, in this manner, every time that the delirium becomes violent. The bowels should be kept freely open during the attack, and the cooling diaphoretics already noticed, with diuretics, should be taken every four or five hours, particularly the solutions of the acetate of ammonia and of tartarized anti- mony with the spirits of nitric aether. The pa- tient's head ought to be kept cool by the usual means; and if the heat be at any time con- siderable, the ice-cap or the cold affusion may be used. 434. When the violence of the symptoms is abated, the patient may be allowed more liber- ty, and permitted to enjoy the open air, where he may give vent to his excitement, which will the sooner pass off by being unrestrained. The diet, which was heretofore extremely re- stricted, may be more liberal; and, if intervals of reason occur, the utmost kindness and in- terest should be manifested for the patient, the moral treatment coming in aid of the physical and medical during the whole course of the malady. If critical evacuations are manifested, they should be promoted by a more nutritious regi- INSANITY—Treatment of Maniacal. 601 men, by gentle tonics, or by means appropriate to the crisis that may appear. 435. The treatment is no longer rational, if all the periods and all the modifications of the disease are treated in the same manner. If mania have occurred after the suppression of an accustomed sanguineous discharge, early blood-letting, and, subsequently, local depletions, repeated at intervals, and in situations having reference to the accustomed evacuation, are indispensable. If it have appeared after deliv- ery, or upon the suppression of the lochia, or of the milk, purgatives, blisters, derivatives, and revulsants, setons, or issues, &c, are necessary. If it have followed some acute disease, upon too rapid growth, or on masturbation, the warm bath, with cold applications to the head ; a nu- tritious and milk diet; the use of asses' milk, tonics, cinchona, or quinine, with acids ; the cold shower bath, or salt-water bathing, will be most aseful. But in all cases—and especially when the mental disorder has supervened upon the disappearance of some cutaneous eruption, or of gout or rheumatism—aperients, purgatives, blisters applied to the nape and kept open, or setons there, or other permanent irritants of the skin, will he found of service. 436. When -mania appears in persons of a highly nervous temperament, it is generally in- dependent of vascular fulness, or sometimes is even owing to a deficiency of blood, a larger proportion being determined to the brain than to the rest of the body. In this case, the cold affusion on the head, while the lower part of the body is immersed in a warm bath, or the shower bath, the patient standing in a pan of warm water, is generally beneficial. If the disease be attended by irritation of the repro- ductive organs, tepid baths, cold enemata, and the internal use of the acetate of lead with hyoscya- mus, or of ipecacuanha with opiates, or camphor with vinegar, will be of service. In most cases characterized by nervous symptoms chiefly, the infusion and other preparations of valerian, small doses of camphor or of asafoetida, and prussic acid or laurel water, will be of use, when cau- tiously administered. In these especially, the cold douche, or affusion on the head, has both a physical and a moral effect in calming the patient. 437. If the disease resist these means, ra- tionally and appropriately employed, other rem- edies, of a more perturbating or empirical kind, may be tried, but these require the utmost cau- tion, and their effects must be carefully watch- ed. In strong, young, plethoric, and well-fed persons, blood-letting, generally or locally, may be repeated. When the propriety of venisec- tion is doubtful, small and repeated local deple- tions should be adopted, and those which may have a derivative effect ought to be preferred ; as four, five, or six leeches applied to the anus, and repeated every ten or fourteen days, ac- cording to the strength of the patient. The semicupium., cold application to the head, and purgatives with colocynth or aloes, will also be required ; and if these occasion a hemorrhoid- al affection, the circumstance may have a fa- vourable influence on the mental disorder. 438. Drastic purgatives are often of service, and particularly in the more obstinate states of mania. They frequently bring away brown, greenish, tenacious, and otherwise morbid se- 76 cretions, which had been long adhering to the intestinal mucous surface, or lodged in the cells of the colon and in the caecum, and which had either predisposed to or perpetuated the men- tal disorder. In some instances, a long course of purgatives is required fully to evacuate these accumulations ; but when this is neces- sary, the patient's strength should be prevented from sinking by a fuller diet and a more resto- rative regimen than would otherwise be requi- site. It is often difficult to administer these medicines so frequently, or in such quantity as may be necessary, as maniacs are often per- suaded that they are given to poison them ; but such substances as may be taken in their food—as calomel, croton oil, elaterium, &c.— may be employed. Croton oil may also be rub- bed over the abdomen, and cathartic enemata liberally administered. In cases of this kind, the croton oil may be prescribed in small doses, with the extract of colocynth, or the compound camboge pill; and, when the patient has no reluctance to medicine, the compound infusions of gentian and senna, with the sulphate of pot- ash, and some purgative and carminative tinc- ture ; or a draught containing equal parts of castor-oil and spirits of turpentine may be pre- ferred. If the purgatives occasion any increase of irritation, or are sluggish in their action, the warm or tepid bath will be found of great ser- vice. 439. When the integuments of the head ap- pear engorged with blood—and when, in the advanced course of the disease, or in its chron- ic state, the head or scalp seems congested— small and repeated cuppings behind the ears, or on the shaved scalp of the occiput, will often be serviceable ; or free incisions may be made in this latter situation, as advised by Dr. Prich- ard, and kept open by lint, or by pease, in the manner of a common issue. In chronic cases, moxas and the actual cautery, applied to the oc- ciput and to the nape, have been recommended by many Continental physicians ; but the other measures just named, or setons or issues in these situations, are equally efficacious. 440. The propriety of exhibiting opium in mania has been much doubted. But, when sanguineous depletions have been duly prescri- bed, and morbid accumulations in the bowels freely and entirely evacuated, if the scalp be neither remarkably hot, nor congested with blood, and if there be great restlessness, irrita- bility, and want of sleep—the maniacal excite- ment being the result rather of nervous disor- der than of vascular action—the judicious ex- hibition of opium, or of morphia, especially in conjunction with other appropriate medicines, will often be productive of the greatest benefit. The opium or the morphia, however, should be given in a full or very large dose ; and, accord- ing to the peculiarities of the case, it may be conjoined with camphor, or digitalis, or James's powder, or ipecacuanha, or calomel, or with an alkaline carbonate, or with aromatics. There can be no doubt of the benefit which camphor may produce in this state of mania, although this also has been disputed. Those who pos- sess weak powers of discrimination, whose knowledge of morbid actions and of the opera- tion of remedies is deficient or limited, will frequently fail in obtaining the usual advanta- ges from medicines, and will hence parade their tment of Imbecility. 602 INSANITY—Trea- skepticism as a mask for their ignorance; but camphor is a valuable remedy in the circum- stances of the disease now under consideration, yet it requires caution; and, when conjoined with nitre, and given in small doses in the more doubtful cases, or where heat of the scalp is still present—or when prescribed with hyos- cyamus, opium, or digitalis, or with vinegar, and in larger doses in the chronic states, and after evacuations have been energetically em- ployed and exhaustion is about to supervene— it generally is productive of the greatest bene- fit. If the premature or inappropriate use of it should increase the restlessness or heat of the scalp, cold applications to the head, and dilu- ents with vinegar internally, will soon remove all disorder, or even develop its good effects. Vinegar was much praised by Aret^eus, Lo- cher, and others in this malady; but Chia- ruggi advised it to be given with camphor. One drachm of the latter may be dissolved in about two ounces of distilled vinegar, and from an eighth to a fourth part of the solution may be taken in any suitable vehicle every four, five, six, or eight hours. Digitalis has been recom- mended by Dr. Locher, of Vienna, and by sev- eral British physicians, in this and similar states of mania ; and when exhibited in full, or even large doses, it sometimes is of great service; but its effects require most careful watching, especially when employed in the way most likely to prove beneficial. The surprise bath, or sudden immersion in the sea, or in a cold bath, as advised by Van Helmont and others, as well as the rotatory machine of Darwin, although recommended by some writers, are dangerous and highly empirical modes of treat- ment, which are now justly abandoned. 441. y. When mania assumes an intermittent form, the same principles of treatment as have now been advocated should be followed during each attack; and, when an intermission takes place, means should be used to prevent the ac- cession of a paroxysm. Cinchona and sulphate of quinia have been employed with this latter intention. Where vascular fulness and in- creased action, generally and locally, have been removed, and morbid secretions and fiscal ac- cumulations have been entirely evacuated from the biliary organs and intestinal canal, the sul- phate of quinine, conjoined with camphor, and with as much of the purified extract of aloes as will promote a free action of the bowels, and occasionally, also, with hyoscyamus, will prove useful during the intervals, if neither heat of scalp, headache, nor want of sleep, follow the use of it. My opportunities of re- sorting to this combination of means, in this particular state of disorder, have been few; but I have found the following of service: No. 270. R Quinae Disulphatis, Camphorae rasas et sub- actaj, aa 3ss. ; Extr. Aloiis purif., 3ss. ad 3ijss. ; Extr. Hy- oscyami, 3j.; Sirupi Simp., q. s. M. Fiant, secundum ar- tern, Pilulae L., quarurn capiat duas vel tres, bis terve in die. 442. When the patient has become calm, and begins to recognise his position and state, al- though some delusion or delirious excitement may remain or recur, or the moral affections may not be altogether restored, it will gener- ally be proper to remove him from the place to which he had been confined, and to surround him with novel objects, by which he may be amused, or his mind more agreeably engaged, and where he may enjoy the advantages of air and exercise. In this stage of the disorder a more nourishing and strengthening diet and regimen maybe permitted. But at all periods the strictest attention should be paid to the se- cretions and excretions, as well as to calm the mental irritation, and to diminish the number of impressions and causes of excitement by which this irritation is perpetuated. 443. d. The convalescence of maniacs is often prolonged and difficult; sometimes it is rapid. Some patients, when restored to their friends, to society, and to their natural habits, do not recover a complete state of health until many months have elapsed. These, especially, man- ifest great susceptibility and sensibility: they are readily vexed or irritated, are ashamed of their former condition, and often entertain fears at meeting with former friends. Some enter- tain a dislike, or a hostile feeling, to friends or persons who interested themselves in their behalf during their illness. Where this is evinced, the probability of a relapse, or of an attack of melancholia, or of an attempt at sui- cide, is great. Convalescents are generally very greatly benefited by travelling some time, or by a sojourn in the country, or in some suit- able place, before they are restored to their families, and are brought in intimate communi- cation with their relatives and friends, or with those who were witnesses of their malady. 444. b. Treatment of Dementia and Fatu- ity.—The various states of dementia and fatu- ity generally present little hopes of success from either hygienic, moral, or medical treat- ment.—a. That variety which M. Esquirol has denominated Acute Dementia (y 152) is, however, very generally remedied by a resto- rative method of cure : by walking and horse ex- ercise ; by the shower bath, followed by frictions of the surface ; by light and nutritious diet; by stomachic aperients, and attention to the secre- tions and excretions generally ; and by the ex- hibition of antispasmodics and tonics; especially valerian, musk, cinchona, ammonia, camphor, sulphate of quinine, &c, combined according to circumstances. The sulphate of quinine, con- joined with camphor, hyoscyamus, and as much aloes as may preserve the bowels gently open, is often of great service in these cases. The preparations of valerian with ammonia are also most useful. When evacuations have been suppressed or eruptions have disappeared, these should be recalled, or others substituted in their place. 445. 8. The chronic or confirmed forms of de- mentia and fatuity (y 152, et seq.) require a diet and regimen suited to the peculiarities and cir- cumstances of each case, and to the amount of exercise which is allowed, or the patient is ca- pable of taking. In addition to strict attention to the states of the secretions and excretions, the shower or cold bath, or sea-bathing, followed by frictions of the surface ; blisters applied be- hind the ears, or to the nape, and either fre- quently repeated, or kept open ; setons or issues in the same situation ; moxas applied to the oc- ciput ; incisions of the scalp, or the production of pustules on the shaved scalp by means of the tartarized antimonial ointment, are the chief remedial means. In many cases, these should be conjoined with the restorative treatment just advised (Y 444). In a very few instances, INSANITY—Treatment of its Complications—Remedies. 603 the occurrence of an attack of acute mania has had a critical effect. In all cases, country air, moderate exercise, and snch occupations as the incoherent, imbecile, or overthrown state of the mental powers will admit of being at- tempted, will prove of service, at least as re- spects the patient's bodily health. 446. C. The Treatment of Complicated In- sanity (y 162, et seq.) is the most hopeless, es- pecially when any of the forms of dementia are associated with general paralysis.—a. The means which have been just enumerated (y 445) are usually required in this complication ; and care should be taken to prevent the bowels from be- coming too constipated on the one hand, or too much relaxed on the other. In either case, in- flammation, rapidly passing into sphacelation, generally results. In some instances, the re- moval, by mechanical means, of hardened faeces from the rectum becomes necessary when the constipation, has been prolonged. Retention of urine is an equally frequent and dangerous oc- currence in the paralytic form of imbecility and incoherency, and requires a frequent recourse to the catheter. Incontinence of urine, or a fre- quent dribbling, owing to over-distentionof the bladder, is also a common symptom. In this latter case especially, care should be taken to keep the patient dry and clean, as unconscious or involuntary discharges of either the urine or fasces soon occasion gangrenous sores of the sacrum, or adjoining parts, in this class of pa- tients. Care is also requisite to preserve them from falls, and from injury from fire. 447. b. The complication of insanity with epi- lepsy or convulsions ( ' Li«- Ammonia, Acetatis 3jj. , Mist. Camphor* fj. ; Sirupi Aurantii 3ss. Fiat Haustus, ter in die sumendus.* 483. b. Prussic acid and laurel water have been recommended as sedatives in various forms of insanity. The latter was advised by Thilenius; the former by Dr. Seymour and Dr. Balmanno. Dr. Burrows states, that he made trial of prussic acid, but never derived permanent benefit from it in any one case. 484. c. Tartar emetic, in small and frequently repeated doses, in order to reduce vascular ex- citement in the brain, as well as in the system generally, was recommended by Willich, Mul- ler, Bodel, Frize, Burserius, and Baldinger. A combination of it with tartrate of potass, so as to act also upon the bowels, was advised by Pideret, Fordyce, and Hufeland. Several writers have prescribed it so as to produce more or less continued nausea. Drs. Cox and De Vos, of Berlin, consider it of great service when vascular action is excited, and when the haemor- rhoidal or menstrual discharges have been sup- pressed, or the portal circulation obstructed. These are, indeed, the circumstances especial- ly requiring it, whether existing in mania or monomania, and more especially in the sanguine or bilious temperament. Where there is more obvious vascular inanition or exhaustion, and in nervous and susceptible persons, a continued use of tartar emetic is injurious. The indica- tions for, as well as against this medicine, are nearly the same as those which relate to vas- cular depletions. 485. d. Cold water, drunk in large quantity, has been praised by Lorry, Theden, Hilscher, and Hufeland in melancholia and mania. I have seen it beneficial in melancholia compli- cated with hysteria. Avenbrugger advised it in those cases especially which are attended by a desire to commit suicide. Falret and Guis- lain, however, observed no benefit accrue from it in such circumstances. It is probable that, in the very few cases in whieh it has proved useful, it has acted chiefly as a sedative of ir- ritation in the digestive mucous surface and collatitious viscera, that has excited or perpet- uated disorder of the cerebral functions. The remarkably large quantities of water taken al- most hourly in most of these cases may like- wise have tended to remove obstructions from some one of the abdominal organs. Cold water acidulated with the vegetable acids, and more especially with vinegar, was recommended by Buchoz, Theden, Locher, Selig, and Bang, as a sedative and refrigerant of the vascular sys- tem ; and, in order farther to promote this in- tention, small doses of camphor, or of camphor- ated vinegar, were advised by Bona, Perfect, and others. Nitre was also similarly employ- ed, either alone, or with small doses of cam- phor, so as to secure the refrigerant and seda- tive effects of the latter. Cold water, medica- ted in either of these modes, and in the latter more particularly, or by the addition of the spir- its of nitric ather, is more likely to be of service than when used simply. Muriate of ammonia, however, is preferable to nitre in most cases, * [Dr Conolly states, that he has been entirely disap- pointed 'in the use of dig talis in mental disorders, and no longer employs it. Its depressing- effects are often distress- ing? without being followed by any manifest benefit.—(Loc. cii.n inasmuch as it combines a tonic influence with its refrigerant and sedative properties. Acetate of lead was likewise used by Schrceder as a sedative and refrigerant in mental disorders at- tended by vascular excitement; but no notice has been taken of it in such circumstances by recent writers. In conjunction with vinegar and narcotics, it is as likely to be of service in these disorders as in several others in which it has been lately employed. The biborate of soda and boracic acid were also formerly em- ployed, in order to allay vascular action in con- nexion with mental excitement. They have long fallen into disuse ; but I have had reason to consider them as still deserving of notice. [The best sedatives in these cases we hold to be exercise in the open air, the shower bath, and flesh-brush ; and especially the removal of all bodily restraints, and the constant manifes- tation of kindness, gentleness, and forbear- ance on the part of the attendants. Religious exercises, also, have often a wonderfully sooth- ing and quieting effect upon the minds of the insane, far more useful than " poppy, mandra- gora, or all the drowsy sirups of the world." A glass of beer and a light supper at bedtime are recommended by Dr. Conolly as a very use- ful anodyne in many cases, where opiates would have no effect.] 486. I. Stimulants and Antispasmodics are especially indicated in nervous temperaments and delicate constitutions, or whenever the mental disorder appears in connexion with de- ficient nervous or vital power ; when the head is cool, and the mental affection is independent of vascular fulness or action ; when sanguine- ous depletions and alvine evacuations have been carried sufficiently far ; or when exhaus- tion follows either these or the previous excite- ment. In other circumstances, particularly if the scalp continue warmer than natural, or the carotids pulsate somewhat more strongly, these may still prove of service, if refrigerants be applied to the head; or they may be conjoined, in such circumstances, with sedative and di- aphoretic medicines. Of stimulants and anti- spasmodics, the most frequently useful are, camphor, valerian, ammonia, asafoetida, ather, and the compound spirit of ather. Others have been employed, as the oxides of bismuth and zinc, cas- tor, serpentaria, arnica, electricity, and galvanism. 487. a. Camphor, in the circumstances just specified (§ 486), is a valuable remedy, and as such has been recognised by Wherlhof, Loe- denstein, Kinneir, Fischer, Remer, Aven- brugger, Perfect, Percival, and Hufeland. On the other hand, Haslam, Prichard, and Burrows esteem it of little value. Its influ- ence in this, as well as in other diseases, is very different, according to the doses and com- binations in which it is exhibited. Many years since, I entered upon a series of experiments, in order to ascertain its operation in different conditions of the system ; and, in a paper pub- lished some time afterward (Lond. Med. Repos- itory for September, 1825, p. 245), I stated the result of my researches, and of my experience of it in some cases of mania, which I had seen with Mr. Alcock, Mr. Carroll, and others. Since then I have prescribed it in several cases, both of mania and melancholia, and generally with more or less benefit. Dr. Millingen, in a work just published, forms a juster estima- 614 INSANITY—Of Remedies advised for. tion of it than many other recent writers. He states it to be a valuable medicine, but requi- ring much discrimination. It is not advisable, he adds, when there is cerebral excitement, with a hot, dry skin, full pulse, and wild coun- tenance ; but where there is much restless- ness and uneasiness, with a low, weak pulse, or cold and clammy skin, it will be found most beneficial. This is altogether in accordance with what I have stated respecting it in the pa- per just referred to. I have there shown that camphor in very small doses is refrigerant; but in full or large doses it is restorative, exci- ting the brain and nervous system, and consec- utively calming and anodyne. In mental dis- orders, it should not be employed until alvine evacuations and sanguineous depletions, where these are required, have been duly employed. The combinations in which I have most fre- quently prescribed it, are with opium, morphia, or hyoscyamus, or belladonna, or with nitre, or with the solution of the acetate of ammonia, or with digitalis, or with James's powder, or oth- er antimonials, or with the alkaline carbonates, or with acetic acid, or with any two of these that may be congruous with the circumstances of the case. Selig, Schoenheider, and Per- fect prescribed camphor with vinegar, and Friborg, with nitre and opium, in maniacal cases. The dose of camphor in mental disor- ders, as well as the combination and mode of exhibiting it, ought to be regulated by the pe- culiarities of the case, and the effects of the previous treatment. M. Esquirol usually di- rects from half a drachm to a drachm to be dis- solved in two ounces of vinegar, or dilute ace- tic acid, and given in an aromatic infusion in the course of the twenty-four hours. I have found this mode very serviceable in puerperal and hysterical mania, other appropriate means be- ing also employed ; but smaller doses are more appropriate in many cases. Cold applications to the head, the shower bath, or tepid bath, &c, may also be resorted to during its use, or when increased heat of the scalp or skin is caused by it. 488. b. The infusion and compound tincture of valerian have proved, in some cases of mania and of monomania, or melancholia, in which I have employed them, of great service, more es- pecially in the states of these disorders already described ($ 486). When these affections are associated with hysterical symptoms, or when the patient entertains the idea of committing suicide, or has a disposition to indulge or to adopt any dangerous caprice, these prepara- tions are often beneficial, particularly after ap- propriate evacuations, and in combination with the solution of acetate of ammonia, or with the alkaline carbonates, or with digitalis, hyoscya- mus, &c. Musk has been advised, in similar circumstances, by Thilenius, Locher, Selig, Pargeter, and Gmelin ; but it and castor, am- monia, asafatida, the oxides of bismuth and zinc, and the athers, are severally inferior to either camphor or valerian ; yet they are often useful, especially as adjuncts to other stimulants and restoratives, or to narcotics or sedatives, or even to tonics, in the more strictly nervous forms of insanity, and in cases of debility and exhaustion. 489. K. Tonics were recommended by Syd- enham, Selig, and Wintringham, and are ob- viously required in most of the circumstances in which stimulants and antispasmodics are in- dicated, and particularly in cases manifesting more or less of vascular inanition.—a. Cincho- na, or the sulphate of quinine—the latter espe- cially—is often preferable to other tonics, more particularly in the intermittent forms of insan- ity. The infusion of bark with the solution of the acetate of ammonia is most suitable when vascular or nervous excitement is passing into exhaustion, or in cases where the propriety of having recourse to tonics may seem doubtful. In circumstances of obvious exhaustion, or in- anition ; in the more purely nervous states of disorder ; in advanced stages, after evacua- tions have been carried sufficiently far, or when the head is cool, and the pulsations of the ca- rotid are not increased in strength or fulness, the sulphate of quinine, either alone, or with camphor and with the extract of aloes, if the bowels require to be kept freely open, will oft- en be of service. I have given the following pills, varied with circumstances, in several cases of partial and general mental disorder; the first, when the bowels are costive ; the sec- ond, when they are too relaxed. In this latter state, a combination of cinchona and opium was recommended by Ferriar. No. 275. ft Quinae Disulphatis 3ss.; Camphorae rasae 3ij.; Extr. Aloes purif. 3ss.—3ij. ; Extr. Hyoscyami 3jss.; Bal- sami Peruviani q. s. M. Fiant Pilulae L., quarum capiat tres, bis terve in die.—Vel. No. 276. ft Quinae Disulphatis 3j.; Camphorae 3ss.; Extr. Hamuli 3jss. (vel Pilulae Saponis cum Opio3j.); Sirupi Simp. q. s. M. Fiant Pilulae xxxvj., quarum capiat duas, vel tres, bis in die. 490. b. The arsenical solution has been pre- scribed by Neumann, Winckler, Ackermann, and Seymour ; and in states and circumstances of the disease for which I have advised the sul- phate of quinine, and especially in the inter- mittent forms of insanity, is well calculated to be of service. It requires not only great dis- crimination in entering upon the use of it, but also caution as to the quantity prescribed, and the continuance of a course of it; as excess in either may be followed by inflammatory irrita- tion of the digestive mucous surface, especial- ly in the large intestines, or by endocarditis. 491. c. The nitrate of silver has been recom- mended by Agricola and Kesler ; and, in cir- cumstances truly indicating the propriety of tonics, and when insanity has been occasioned by depressing or exhausting causes, and in purely nervous cases, it may prove of service. It has been considered as more particularly suited to the complications of mental disorders with epilepsy. When, however, this associa- tion is dependant upon vascular or structural disease of the encephalon, little or no benefit can result from it. I prescribed it lately in one case of this kind, but was obliged to discon- tinue it. I have, however, found it of service in two cases of melancholia, with chronic irri- tation of the digestive mucous surface. 492. d. The infusion and tincture of hop have been recommended by Dr. Mayo ; and, in the numerous circumstances and cases of the dis- ease requiring both tonic and anodyne reme- dies, they are appropriate, and likely to prove serviceable. They, moreover, admit of various useful combinations with other remedies in mental disorders. The preparations of iron, and chalybeate mineral waters, have been employ- INSANITY—Of Ri ed by Lange and others. They are beneficial in several states of mental disorder, and espe- cially in the more purely nervous cases, and in states of vascular inanition, or when derange- ment has proceeded chiefly from masturbation or exhausting discharges. The sulphate of cop- per has been prescribed by Boerhaave and Cur- rie. It is suitable chiefly in diarrhoea occur- ring in chronic mania, and dementia. Absinth- ium was used by Aret^eus and Paulus ^Egi- neta, and the muriate of baryta by Hufeland. 493. e. Various other stimulants and tonics have been recommended by writers on men- tal affections; but very few of these require particular notice. Phosphorus is mentioned by Loebel and Kamer. Its powerfully stimulant qualities require great caution in its use. Form- ulae for exhibiting it are to be found in the Appendix (F. 6, 7, 428). The extract of nux vomica is noticed by Murray and others : it also requires great discrimination in employing it (see F. 541, 542). Both these substances are suitable only in the more nervous forms of men- tal disorder, especially in melancholia and de- mentia, proceeding from exhausting and de- pressing causes, and in the circumstances indi- cating the adoption of the more energetic stim- ulants, and of chalybeates. In dementia and chronic mania, complicated with general palsy ($ 167), these medicines may be tried, upon the principle adopted by Celsus, " Melius est anceps remedium, quam nullum." The chelidonium was prescribed by Muller, on account of its stimu- lant, laxative, and diuretic properties. As it promotes the secreting and excreting functions, and thereby exerts a deobstruent and alterative influence, it may be tried in mental disorders complicated with obstructions or other diseases of the abdominal viscera, and especially in mel- ancholia. The decoction of hypericum was praised by Meyer and others. It is nervine and stimulant, and is most appropriate in the more purely nervous states of mental affection, and in melancholia, after sufficient alvine evac- uations. Dr. Mayo observes, that the use of re- storatives and tonics in the first stage of insan- ity is valuable in the nervous and serous states, but mischievous in the bilious and sanguine, and that, in the stage of exhaustion, they are re- quired in every temperament. 494. L. External Irritants and Derivatives have been long and generally recommended in the treatment of mental affections. They may be divided into, 1st. Irritants applied to the scalp; and, 2d, Irritants applied to parts more or less re- mote from the head, so as to produce somejdegree of revulsion or derivation from the seat of mor- bid action.—a. Scarifications of the scalp were ad- vised by Aret^eus, C^elius Aurelianus, Wal- ther, and Prichard ; but they are admissible only when the scalp and head are more or less congested, or when inflammatory irritation or structural change is inferred to exist in the en- cephalon. In nervous and susceptible persons, and in states of general or local inanition of the vascular system, they may prove injurious. The application of the actual cautery to the oc- ciput, or of moxas in the same situation, as ad- vised by Pascal, Larrey, and Valentine ; and artificial ulceration of, or setons or issues insert- in the scalp, as presciibed by Horn and oth- ers, are indicated and contra-indicated by the pathological conditions just mentioned. Inunc- MEDIES ADVISED FOR. 615 tion of the tartarized antimonial ointment on the shaved scalp, until a copious eruption of pustules is produced, was advised by Munro, Autenrieth, Jenner, Gumprecht, and others, and has been found of service in some cases of mania, especially when the acute stage is be- ginning to decline, or to pass into the chronic state. The application of blisters to the head was recommended by Thilenius, Durr, and Hufeland. The practice is not without haz- ard, particularly in the more acute states of mental disorder. It is more appropriate in the more chronic and low forms of derangement, and especially in imbecility and dementia. 495. b. The application of irritants so as to produce a derivative or revulsive effect is appro- priate in many of the more acute and'early, as well as in the more chronic states of mental disorder; and yet, in very irritable, nervous, and susceptible patients, in the early stage of mania, and in cases where the vascular system is rather deficient than too full of blood, these irritants often increase disorder by exciting the general sensibility. Where, however, the disorder has been consequent upon the suppres- sion of accustomed eruptions, ulcerations, and discharges, and in many cases of melancholia, or of other forms of monomania, derivatives and revulsants are often of much service. In the more acute and recent cases, and especial- ly of mania, they should not be resorted to un- til vascular depletions and other evacuations have been employed. 496. Various modes of producing derivation of disorder from the brain have been recom- mended. Several of these are already noticed, as also falling under other heads, especially purgatives, warm bathing, &c. Blisters on the nape of the neck, or on the legs, &c, are often resorted to ; but they are seldom of service rn mania, especially in the early states. They are useful chiefly in the stages of disorder just mentioned. Guislain recommends them to the nape, back, or insides of the thighs or legs, when insanity commences with depression of mind, or melancholia, and in some states of de- mentia ; but he has rarely found them service- able in this latter state. Avenbrugger applies them to the region of the spleen in melancholia ; and, when prescribed either to the epigastrium or to the hypochondria, they are sometimes of service in that affection. More advantage may be expected from issues and setons than from blisters, unless the latter be kept open for a considerable time. Zacutus Lusitanus ad- vised setons or issues to be inserted over the region of the liver or spleen in melancholia. In the majority of cases, however, their inser- tion in the nape of the neck is preferable, espe- cially in the other forms of insanity. Dry cup- ping in this situation is often of service. Dr. Burrows suggests the application of the cups as a derivative to the shaved scalp itself; and, doubtless, this place will often be preferable. I have, in some instances, caused the nurse or attendant to resort to dry cupping on the nape several times in the day, and to employ merely a large glass, tumbler, or any other convenient article for this purpose, and a piece of lighted paper. 497. The production of irritation or artificial eruptions on parts of the body still more distant from the brain, or on the surface generally, has 616 INSANITY—Of Remedies advised fob. been advised, in order to remove irritation from I this organ. They are commonly produced by the tartarized antimonial ointment, and by fric- tions with croton oil. Thilenius, Odier, Mu- zell, and Bartholomew recommend inoculation of the itch. Besides these, warm mustard pedi- luvia, mustard poultices applied to distant parts, and particularly to the lower extremities, the hot turpentine embrocation in situations remote from the brain, and irritating or cathartic enema- ta may severally be employed in circumstances which seem to require them, and especially when a tendency to coma or lethargy is ob- served. 498. c. Of the various modes of external irri- tation, Dr. Burrows and Dr. Muller consider pustulation, by means of the tartarized antimo- nial ointment or plaster, the best; and they prefer the application of it to the shaved scalp. Dr. Millingen prescribes it to the back of the neck. The choice of situation should depend upon the form and stage of disorder. In de- mentia, in cases attended by stupor or impair- ed sensibility, and when melancholia or men- tal depression is threatening to pass into ex- citement, the scalp may be preferred, after due evacuations have been procured. In some states of mania or monomania, this ointment, or plaster, may be applied to other parts. M. Guislain states that he has derived little ad- vantage from it in dementia; but that he has sometimes found it of service in melancholia and in mania. Dr. Jenner published several instances of its success, when applied to the epigastric region, nape of the neck, scalp, and other situations. During the eruption thus produced, a restorative treatment is often ne- cessary. 499. The insertion of setons in the neck is considered by Dr. Prichard to be most advisa- ble in mental disorders of a chronic form ; but he also recommends issues made by a long in- cision in the scalp, over the sagittal suture, where there is great intensity of disease, and a state of the brain threatening a fatal increase. In cases of stupor, and of dementia following apoplexy or palsy, or severe fevers, he believes this method more beneficial than any other. He also suggests a recourse to it in the com- plication of insanity with general palsy. M. Esquirol remarks, that dry cuppings, blisters, and irritating applications are most success- ful in cases consequent upon metastasis, in monomania attended by stupor, and in demen- tia uncomplicated with convulsions or paraly- sis. There can be no doubt of counter-irrita- tion being more appropriate in cases character- ized by torpor and insensibility, instead of mor- bid activity or excitement and intensity of feel- ing. Dr. Prichard observes, that in almost every case of paralysis, with a tendency to coma and lethargy, in which he has used this class of remedies, he has witnessed decided ad- vantage from them. The opinions of Dr. N. Hill, M. Guislain, and of Dr. Mayo, are also in favour of these means. [Observation abundantly proves that insani- ty presents as great variety, in relation to causes and circumstances, as any other disease what- ever, and that no general treatment can be laid down applicable to all cases; in other words, there is no specific remedy against it, as it is .no special disease, but arises from a variety of causes acting upon the mental functions, through their organ, the brain. The treatment naturally resolves itself into moral and medi- cal, the former of which will be hereafter con- sidered. The late Dr. Spurzheim was the first, next to our own Rush (who anticipated many of the recent discoveries in relation to the na- ture and treatment of mental diseases), who enforced the necessity of applying the general principles of pathology to the brain as well as to other parts of the body, and who pointed out the importance of treating its diseases in con- formity with their nature, and with cerebral structure and functions, instead of resorting to a senseless routine, or the incongruous variety of means at the same moment, which were for- merly in vogue. Dr. Rush had long ago re- marked (Med. Inquiries and Observations, vol. ii., p. 22), that " it is, perhaps, only because the diseases of the moral faculty have not been traced to a connexion with physical causes that medical writers have neglected to give them a place in their systems of nosology, and that so few attempts have been hitherto made to lessen or remove them by physical, as well as rational and moral remedies." Pinel, on the other hand, attached but little, if any, im- portance to medical treatment, but depended almost solely on the moral management; the truth, as generally happens, lies between the two extremes. In no country on the globe, it is believed, has the treatment of insanity been crowned with more flattering success than in the United States, as the statistics of our different institu- tions will show ; and this success is doubtless owing to the happy mode of combining moral, medical, and hygienic means, which characteri- zes the management of this class of patients, hot h in our public and private practice. In this coun- try, treatment is, to a great extent, regulated by those principles of pathology which modern researches have established, and which lead us to regard the proximate cause of insanity as corporeal, and seated in the brain. Dr. Rush led the way, by his truly philosophical work on the " Diseases of the Mind," in which he dwelt on the importance of the principle just laid down, and remarked, that " the successive and alternate changes of the different forms of mad- ness into each other show the necessity of re- nouncing all prescriptions for its names, and of constantly and closely watching the disease."— (Med. Inquir., &c., p. 237.) In no class of diseases, then, is it more im- portant to regard the causes of the disease, the previous health of the patient, the age and du- ration of the disorder, hereditary predisposi- tion, former treatment, &c, in order to arrive at a knowledge of the true indications. The treat- ment proper for recent cases would be injuri- ous to those of longer standing ; and those which arise from mechanical causes require far different management from those which are oc- casioned by bodily disease, or by moral influ- ences. That acute mania is sometimes caused by a hyperaemic or congested state of the brain, will not admit of a doubt; and here general and local bleeding, with cold applications early in the disease, will be attended with marked success ; but that this condition is rare, and very liable to be mistaken for one of an oppo- site kind, is equally true. " There is," as Dr. INSANITY—Of Remedies advised fob. 617 Conolly has recently remarked (Clinical Lec- tures on the Principal Forms of Insanity, &c, Lond. Lancet, vol. iii., p. 10, Am. ed.), " such an apparent superabundance of energy in the pa- tient as to betray an inexperienced practitioner into hazardous measures. When the face is flushed, the skin warm, the pulse quick ; when the voice is loud, the gesticulation vehement, it is difficult, at first, to believe that the vital power is not in excess ; and when this state of morbid excitement lasts for weeks or months, it seems scarcely credible that there is all the time a tendency to sudden depression of all the energies of life, and that no violent reme- dies are admissible. Yet, in the most recent state, the condition of the circulation is seldom such as to encourage even one bold depletion ; and, as the case proceeds, emaciation advan- ces, signs of exhaustion are perceptible, and sometimes there is sudden exhaustion and death. I feel myself, therefore, justified in cau- tioning you most strongly against general bleed- ing as a rule in those cases. I am convinced that it is not often admissible, and that it some- times does irreparable mischief, particularly if resorted to freely, or practised repeatedly." Dr. C. states that some of the worst cases he has seen were those in which the patients had been largely bled before admission, and where the violence had been increased by the loss of blood. Pinel remarks, that the early symptoms of mania were often aggravated by the low diet to which patients were subjected in his day, and that one of his first measures was to supply them with an abundance of sub- stantial and nutritious food ; and he relates ca- ses where, under the influence of such a diet, delirium rapidly subsided, and convalescence was speedily established. It is now, we believe, the general opinion among the physicians of our different lunatic hospitals, that although there may be cases in which bleeding may be useful, yet that they are very rare, and that the copious blood-lettings formerly recommended by Rush and Frank are altogether inadmissi- ble. Dr. Conolly stales that, in more than twenty years' practice, he has seen but two or three cases in which bleeding appeared to be useful; but has generally found it injurious, even in plethoric cases that seemed to war- rant its use ; and that, in six years' experience at Hanwell, he has found no encouragement to resort to it in a single instance. In two cases, he found its effects most unfortunate ; in both, a state of imbecility ensued, and an inability or indisposition to speak, which lasted in each case more than twelve months ; and in neither case was any amendment observed. Dr. C. is disposed to regard the excitement of the brain in mania as not dependant on increased action of the heart and arteries, a pathology which would seem to be supported by the fact that, in nearly all cases, the pulse is feeble, as well as rapid, and that symptoms of prostra- tion of strength early supervene. The same objections, however, do not apply to local as to general blood-letting, which is not only often admissible, but extremely serviceable. Leech- es will generally be found preferable to cupping. The late Dr Todd, of Hartford, Connecticut, was one of the first to prove the superiority of the tonic, anodyne, and soothing treatment over the depleting and antiphlogistic in mental dis- 78 eases ; the ratio of cures in recent cases un- der his management, being as high as 91 per cent. He made great use of conium macula- turn, stramonium, and hyoscyamus, and of the different preparations of iron, together with wine and cinchona, in the treatment of the insane, and found them more efficacious than any oth- er remedies. We subjoin the following remarks on the medical treatment of insanity from the pen of the late Samuel White, M.D, of Hudson, New- York (Address on Insanity, delivered before the N. Y. State Med. Soc, Feb. 5, 1844), as they are believed to represent the views of a major- ity of our physicians who are devoted to the treatment of the insane, and especially as they imbody the experience of a long life of labori- ous toil employed in the management of this class of diseases. " In the therapeutical treament of insanity," says Dr. White (Address on Insanity, p. 12), " every case must be considered and treated as an insulated one. Remedies must be applied to the constitution and peculiar features of each case. While the first indication is to remove or lessen, as far as possible, irritation as the immediate cause, pervading the cerebral and nervous system, and through sympathy the vascular, yet are we to bear in mind the con- dition of other remote organs morbidly excited, and participating in the general disturbance. For instance, the associative powers of the stomach as a central organ are immensely im- portant, as it regards the phenomena of dis- ease. So also, through arterial agency, de- fective secretion of the gastric juice, and loss of power in the secerning system, we account for local congestion, impaired appetite, and waste in fevers. ^ " Remedial means, when rightly applied, need be but few. And what is the popular aim, in the cure of diseases, at the present day 1 but to sustain the conservative principle, the strong- est in nature, by the revulsion of excitement to parts less essential to life, and equalizing cir- culation. Hence the importance that our first move, in the treatment of incipient insanity, should be based upon a correct diagnosis ; crit- ically regarding the necessary distinction ever to be maintained between phrenitis and active mania. The one concentrated inflammation, affecting the substance and meninges of the brain ; the other irritation, specifically embra- cing the nerves of sensation and volition, sym- pathetically disturbing every function and fibre of the human system. The first demanding bold depletion as the anchor of safety ; the lat- ter to be approached cautiously, by milder and more comprehensive means, as we shall pro- ceed to enumerate. "Here, then, permit me to remark that no one is competent to endure this searching or- deal who is not well versed, analytically and pathologically, in every branch of medical sci- ence. " Copious abstractions of blood should ever be avoided in insanity, as endangering demen- tia. Very few are the cases of insanity, even in its incipient stage, that admit of venaesec- tion. In such only as are plethoric and in the vigour of life is it admissible at all, and then only in a cautious degree. The pulse is de- ceptive ; for though there may be increased im- 618 INSANITY—Of Remedies advised for. petus of blood in the carotids, yet they will be found compressible, and the radial artery fee- ble in its action, showing an unequal distribu- tion rather than congestion. In such cases, where symptoms seem urgent, topical blood- letting, by leeching or cupping, may safely be resorted to without danger of collapse. In the treatment of six hundred cases, venaesection has not been resorted to in more than one in a hundred after they entered the institution, and then only moderate in quantity. Many, how- ever, have been brought to the asylum after two or three copious bleedings, undoubtedly with the best intentions ; yet the results have proved a prostration of the vital energies, more difficult to overcome than the original disease." "Active emetics are seldom admissible, as tending to a determination to the brain. Where there is great derangement of the digestive or- gans, ipecac and calomel combined, in such quantities as to produce an emetico-cathartic ef- fect, may prove salutary in their operation ; so also the blue mass, with one fourth part of ip- ecac, adds to its efficiency in restoring the functions of the liver. " Drastic purges are seldom advisable ; lax- atives, to keep up a steady action of the in- testinal tube, are far preferable, and may be aided by injections, due exercise, and a well- regulated diet. No particular formula can here be laid down. The judgment of the physician must decide on the quantity and appropriate- ness of the article, according to the constitu- tion and peculiarities of the patient. " Narcotics and sedatives are next in order. Opium, camphor, morphia, stramonium, coni- um, belladonna, and aconite are most to be re- lied upon, but require great prudence as to the time and manner of their administration. These are often improved by combination with other remedies ; for instance, opium, ipecac, and soap, equal parts, form a pill much easier given than Dover's powders. Camphor mixture, with half a grain of tart, antimony, and five drops of laudanum to the ounce, given in half ounce do- ses, is a powerful sedative and adjuvant in al- laying nervous excitement. Morphia with col- chicum, when there is a gouty or rheumatic diathesis, endangering metastasis, is a valua- ble auxiliary in treatment. Stramonium acts specifically on the sensorium, stimulating the absorbents. A saturated tincture of the seeds in camphor mixture is the best mode of admin- istering it. Conium is best combined with the different preparations of iron. Belladonna and aconite are often improved by combination. Extracts of these vegetables can only be relied upon when evaporated by solar heat. " Counter irritants, revulsive in their effects, are valuable auxiliaries, more especially in me- tastasis and suppressed eruptions, and are more cheerfully submitted to when allayed with some of the vegetable narcotics endermically applied. " Bathing.—One of the most powerful reme- dial agents in equalizing circulation is the warm bath. The patient should be immersed from twenty to thirty minutes, the heat at 96 Fahren- heit, refrigerating the head while in the bath, when the heat of the part should indicate its necessity. Warm bathing will be found par- ticularly beneficial and appropriate in melan- cholia and delirium tremens. Fixed alkaline salts added to the water are useful in remo- ving the sebaceous oil from the surface of the body. The nitro-muriatic bath is a valuable and effective agent in a congestive state of the liver, and should be repeated in connexion with the usual remedies, until we have evidence of a healthy secretion of bile. The value of the shower bath is known to all, yet it is too in- discriminately used. Great prudence and watch- fulness are necessary in its application. Should atony prevent a suitable reaction and warmth over the surface, it may do serious and lasting injury. A pitcher of cold water poured over the back part of the head is often grateful as well as useful to the patient. " In the second stage of insanity, a more ton- ic treatment becomes necessary, and it is to be regulated according to the age, constitution, and temperament of the patient. The various preparations of iron, nitrate of silver, followed with a solution of iodine to prevent a discolor- ation of the skin, conjoined with suitable mor- al treatment, will often decide the future pros- pects and destiny of the patient."—(Loc. cit.) " Insanity is a physical disease," says Dr. Woodward (9th Annual Report, p. 79), " and as susceptible of cure, by remedies which make impressions upon the system, as any other dis- ease of equal severity. Like other diseased organs, the brain often suffers by sympathy with other parts diseased, and the cure of the primary affection relieves the secondary in the usual way. " The influence of Dr. Rush's notion of the utility of liberal bleeding in insanity still clings to the physicians in the country generally, and we rarely have a patient committed to our care who has not been copiously bled. The physi- cians in the charge of" the institutions, both in this country and in Europe, have long since abandoned this practice as rarely beneficial, and often hazardous. It is a frequent remark, that it is often more difficult to cure the evil that arises from the loss of too much blood than to remove the insanity in violent cases of recent attack. " The condition in which the patient is found in violent mania, when the physician visits him, is not always duly considered. The great ex- citement of the pulse, the distention of the blood-vessels, the heat and redness of the skin, and the amazing muscular power which they sometimes exert, only show what he has done, rather than the condition in which he is ; they are the effects of his amazing excitement, and not the symptoms of his disease. A little cold water or ice applied to his head will afford him greater and more immediate relief than the loss of a pound of blood." "In a case of genuine mania, there is usu- ally no inflammation of the brain or its appen- dages ; the excitement is much more frequent- ly of a nervous character, and will yield more readily under a mild and safer treatment. Lo- cal bleeding, cupping, ice to the head, mild cathartics and narcotics succeed far better, and are less hazardous. Many cases yield like a charm to narcotics, if the system is prepared for their use, and they are prescribed in a prop- er manner and with discrimination. Bark and iron, combined with narcotics, dc well when excitement has abated and the strength re- quires to be restored. INSANITY—Moral Treatment op. 619 " In chronic cases of insanity, tonics, nar- cotics, baths, laxatives, and remedies that tend to remove local disease, if it exists, are often found beneficial. In certain torpid cases, the cold bath, with stimulants and acrids, is a val- uable auxiliary in the cure." " One thing is well established, that the in- sane cannot be as well treated at home as with strangers, nor as well in a private fami- ly as in an institution. Few physicians can give to them the attention which they require, or persevere a sufficient time with such rem- edies as they need, or with sufficient regu- larity. " The insane man is the only one who dis- cards the kind offices of his friends at the time when he most needs their aid and solace, and throws himself upon strangers. " In chronic cases, much benefit arises from a perseverance with remedies for a much long- er period than most physicians would prescribe them, or most patients pursue them."] 500. iii. Moral Treatment.—Recourse to moral management has either been too much neglected, or too exclusively adopted. It is but seldom that the truly philosophic physician is satisfied, even in the present day, that phys- ical treatment is duly associated with moral management; or that either, or both, are ap- propriately directed to the removal of existing pathological conditions, and of the associated mental disturbance. Yet both physical and mor- al means should be judiciously conjoined and directed to the peculiar circumstances of each case. It is impossible, especially in my con- fined limits, to describe the impressions which should be produced, and feelings excited, in or- der to combat the various states of mental dis- order that come before the physician. These means, to be appropriate and beneficial, must necessarily vary in each instance, and be so en- tirely based upon the ever-varying phases of disorder, as not to admit of description. Yet much useful information on this subject, and even the principles of moral management, will be found in the writings of Sir H. Halford, Dr. Mayo, Dr. Prichard, Dr. Burrows, MM. Guislain and Esquirol. 501. a. It is chiefly at the commencement of mental disorder, and when the stage of ex- citement is about to lapse into comparative calm, that moral treatment is most beneficial. Still, it should not be neglected at any period, as long as the patient retains any power of com- prehension. Dr. Mayo observes, that, supposing the morbid state to be commencing, every ef- fort must be made to strengthen the influence of the will. The patient, at this period, grad- ually surrenders himself—though not without a struggle — to some prevailing idea, fear, or delusion : he supposes his friends to be con- spiring against him, or insulting, or watching him; or he believes calamities of various kinds impending over him. Meanwhile, he is strug- gling against the morbid impression. His ef- forts, therefore, whether manifest or not, must be aided when right, and his mind tranquillized. His fears should be shown to be unfounded, and his hopes excited and encouraged. To ad- minister this aid is generally a matter of diffi- culty The danger of mischief to himself or others, as well as the occasional necessity of repression, dictates surveillance (which is al- ways irksome and distasteful), when it is most requisite to conciliate regard. 502. In this state of commencing or impend- ing insanity, the morbid sensations or percep- tions, and the unreal ideas or assertions of the patient, should not be rudely contradicted, and imputed to imagination. They are real to him; and to controvert them is the readiest way to irritate the mind, to destroy all his confidence in the judgment and friendship of his adviser, and to strengthen and confirm the disease. His mind requires to be soothed, diverted, and ab- stracted from the fears and anxieties by which it is absorbed, depressed, and exhausted. He should be told that his feelings and perceptions will soon change, as his health improves; he should be comforted by admitting the justness of his complaints, and cheered by attributing them to a temporary disorder of his general health, which will be removed by suitable rem- edies ; and these remedies ought always to be resorted to, in order, both that such disorder, which is never absent, may be cured, and that his confidence may be gained. At the same time that such admissions are made, and that the ut- most kindness and encouragement are evinced, the greatest firmness must be exercised : noth- ing should be yielded that ought not to be con- ceded. He will thus be brought to look for sup- port, and to trust to it, against his own insta- bility and weakness of purpose, as well as for aid in his struggles against morbid impulses and desires. In this incipient stage of mental disorder, much consequent mischief may be prevented by judicious moral management— by moral and religious consolations, mental ab- straction, and diversion ; by firmness, kindness, and moral control ; by change of occupation, of scene, and of air ; by travelling or voy- aging; and by the amusements and intellectu- al agremens of society. Foreign travel is gen- erally preferred in these cases, as affording greater novelty; and visiting watering places and mineral springs, in connexion with travel- ling, presents several advantages. These con- spire, with other circumstances, to excite, or to preserve hope, at the same time that they may be beneficially directed to the removal of physical disorder. At this period, nervous pow- er is depressed by the continued operation of debilitating fears and sensations, while the as- similating, secreting, and excreting functions are impaired; and hence, recourse to chalyb- eate, sulphureous, or saline waters, or to vari- ous combinations of these, in conjunction with moral influences, is frequently of the greatest benefit, especially in the hypochondriacal and melancholic states of disorder. In addition to these, regular exercise in the open air, particular- ly walking and riding, and, still more, exercise and occupations which interest the thoughts, and engage the feelings in an agreeable man- ner, as tennis, cricket, fishing, shooting, hunt- ing, gardening, farming, &c, should be en- joyed, with due precautions against injurious physical agents. The patient should almost al- together live in the open air ; but the air should be dry and temperate, and the situation eleva- ted. In unfavourable weather, in-door exer- cise and occupations should not be neglected. Amusements, also, may be often permitted, es- pecially billiards, chess, backgammon, &o\ 503. b. Even in the more violent mental ex- ral Treatment of. 620 INSANITY—Moi plosions observed in mania, or when intense re- action follows upon depression or melancholia, moral restraint and discipline are often of great service. The union of firmness with kindness, even in such circumstances, is not to be laid aside. As M. Pinel observes, the physician sustains, in these cases, the sentiment of his dignity, and the principles of a pure and en- lightened philanthropy. He allows the maniacs all the liberty compatible with the safety of themselves and of others; conceals from them the means of constraint which he is obliged to employ; and treating them with indulgence, leads them to suppose that they are only sub- mitting to the laws of necessity. M. Georget remarks, that active and incessant inspection must be exercised, particularly in an asylum, over both patients and attendants. Lunatics evincing a disposition to suicide should never be a moment out of sight. It is often necessa- ry to confine violent patients, and those who are addicted to indecent practices, with the strait-waistcoat. The only measures of pun- ishment, he adds, that should be practised, are the strait-waistcoat, seclusion in a cell, the shower bath, and some occasional privations. Dr. Prichard justly observes, that all means of punishment and intimidation should be used as sparingly as possible, and be of the most harmless kind. Solitary confinement and the strait-waistcoat are sufficient in ordinary cases. M. Foville has recourse to the cold shower bath, and to cold affusion on the head; the violent maniac being seized by a number of attendants, and subjected to the affusion until he becomes subdued. The circular swing has been used with a similar intention; and after it has been once used, a threat of its repetition is frequently sufficient; but the cold affusion is a safer remedy. When obstinate lunatics refuse to take food or medicine, persuasion should be first tried, and if it fail, threats and harmless punishments may be adopted. The stomach- pump may be had recourse to in these cases ; the use of it on one occasion will generally pre- vent the necessity of again employing it. 504. M. Guislain justly remarks, that the physician ought, as much as possible, to ab- stain from saying or doing anything before a lunatic calculated to inspire fear or dread, or by which he might become an object of aver- sion, or lose the confidence of the patient. Some other person should appear to be the agent in all restraints or punishments that may be required; and the physician should be re- garded as the protector of his patients, and the dispenser of kindnesses and indulgences. 505. c. When the acute stage, or the period of excitement, has passed, a calm usually fol- lows ; and in this state of comparative com- posure, the morbid delusions adhere to the mind less pertinaciously. The patient himself often begins to doubt their reality, and his es- tranged affections seem disposed to return. The observations of Sir Henry Halford on the moral treatment of this period are particu- larly deserving of attention. " If, at this au- spicious moment," observes this able physician and classical writer, " the intercourse of a dis- creet friend be permitted, it will cheer the pa- tient's heart; while, by kindness and attention, the physician will easily get possession of his returning confidence, and so induce him to un- bosom himself of the distempered notions which still continue to haunt him. These, although they be founded in palpable error, the physician will not combat, although he will take proper opportunities of hinting his doubts of their re- ality. He will never deceive his patient, but take pains to prevail upon him, whenever they recur, to refer them to his unbiased and more practised judgment; and to be guided by that rather than by his own, in estimating the cor- rectness of such opinions. He will act, as it were, upon a system of education, and will aim thereby at confirming the spirits and strength- ening the mind of the convalescent; and as the discipline employed in youth encourages and enforces the predominance of reason over the passions, so will discreet converse assist in restoring reason to her seat, and in giving her back again her proper sway over wild impulses. He will engage the mind agreeably, by present- ing to it new objects, and by recalling former pursuits to their wonted acceptance." "Had the patient, before he was ill," Sir H. Halford continues, " any favourite amusement of a harmless nature 1 Was he fond of music, for instance 1 Music, without exercising the atten- tion severely, has the power, however, to fix it; therefore, with this ' sola voluptas solamen- que mali,' the only gratification, perhaps, of which he is capable at this period of his men- tal darkness, he may be indulged immediate- ly." " Or, had the patient, before he became insane, a predilection for any particular stud- ies 1 Would he take the counsel of Lord Ba- con, and entertain such as fill the mind with splendid and illustrious objects, as histories, fables, and contemplations of nature 1 Or, did he prefer mathematics 1 and can he now be prevailed upon to enter upon a course of such reading 1 Plato has called mathematical dem- onstrations the purgatives of the soul, as being the most proper means to cleanse it from er- rors, and give it a relish for truth. Certainly, nothing more entirely bars the intrusion of thick-coming fancies, by occupying the whole mind, than mathematical studies." Sir H. Hal- ford states, that Dr. A----became deranged, while practising physic in the country, and, after a separation from his family for some months, was advised to resume the study of Euclid, having dropped hints of his partiality to it. He did resume it with the happiest ef- fect, and recovered at length so entirely as to commence business in London, and to practice until his death. 506. Experience has shown that monoma- niacs are injured by directing their attention, or by adverting in any way to their illusions. It is, on the contrary, requisite to engage their minds, as much as possible, with very different subjects, and with external objects. Still, au- thors have adduced instances of persons having been cured of their delusion by some deception. Thus, M. Esquirol states, that a lunatic would not pass his urine, because he supposed that, by doing so, the world would be subjected to a second deluge. He was at last prevailed upon by being told that the town was on fire, and that he could save it from the flames. But any advantage obtained in this manner is generally only temporary. During convalescence, pow- erful impressions on the mind, even in connex- ion with the patient's delusion, may rouse the INSANITY—Moral Treatment of. 621 patient, as if from a dream, and thus dispel the unreal impression. A female patient had taken the mast violent dislike to her family; the ti- dings of the death of a son in a foreign coun- try excited in her a desire to see her surviving children, and recalled all her parental affection, instantly sweeping from her mind her insane an- tipathies, and restoring her to right feeling and reason.—(Rep. of Glasg. Asyl., &c, for 1839.) 507. On this subject Dr. Burrows remarks, that to reason with a lunatic is folly ; to oppose or to deny his hallucinations is worse, because it is sure to exasperate : an impression on him can be made only by talking at, not to him. He will often notice what is said to others, and ap- ply much of it to his own situation or delusion. To endeavour to convince him, or to break the catenation of his morbid ideas by trick, fraud, surprise, or terror, is always attended by haz- ard. The chances are very many that it will not succeed ; and if it fail, the case is thereby rendered more intractable. "The confidence of his patients," Dr. Burroughs adds, " is the sure basis of the physician's success. A cheer- ful, encouraging, and friendly address; kind, but firm manners; to be patient to bear, but cau- tiously prudent in answering ; never making a promise that cannot safely be performed, and, when made, never to break it; to be vigilant and decided ; prompt to control when necessa- ry, and willing, but cautious, in removing it when once imposed ; these will always acquire the good will and respect of lunatics, and a com- mand over them that will accomplish what force can never attain." 508. Moral management must necessarily vary with the states of the disease. In the more violent state, restraint and medical disci- pline should be applied until violence subsides. In the more passive states, restraint is never necessary, unless there be a propensity to sui- cide, or to a solitary vice which is so frequent- ly a cause of, as well as often an attendant upon the mental disorder. To prevent this latter propensity is extremely difficult; but va- rious means may be had recourse to with ad- vantage, and these will readily suggest them- selves* Vigilance is necessary in all cases ; for the passive may change in a moment to the active or violent state, and mischief may thus be done before it can be prevented. [The results of experiments that have been made of late years, especially by Dr. Conolly, of Hanwell, justify us in the conclusion that restraint in violent cases is inexpedient, unne- cessary, and always hurtful. The following re- marks of Dr. Earle, of the Bloomingdale Asy- lum, on this subject, express, it is believed, the views that generally prevail among those who have charge of insane institutions in this coun- try : * Sir W.Ellis recommends apairofwide canvass sleeves connected by a broad shoulder-strap, so as to rest easily on the shoulders. They ought to come up well on the shoul rlers, and to extend about an inch beyond^ he■£»»" °f the fingers; the part covering the hand be ng ">*£ « *ift feterd\W^"ytwr.traps, on. going fn,m o„e rieeve fastened at^uie o* y loins tQ a slmlkr pos,llon fn the6 other sleeve; a second lower down; and by three ° i6 «.™L in the front, the latter being secured by similar straps in the tr , ^ ^ ^ prQ_ ^u^less^ssu^^ the chest, than the common strait- waistcoat. "The means of bodily restraint, 'tranquil- lizing chairs,' straps, muffs, wristbands, mittens, and other appliances for the confinement of the body and limbs, have been considered as neces- sary evils, or, perhaps, by some as necessary promoters of good, in establishments devoted to the accommodation of the insane. Hence they have been employed, even in very recent time, to a much greater extent than was neces- sary. " In our individual experience, we have found that, in proportion as we have become acquaint- ed with the insane—with their tempers, dispo sitions, habits, powers of self-control, and ca- pabilities of appreciating the ordinary motives which influence the conduct of mankind—has our opinion of the degree to which these means are necessary been diminished. Our practice has corresponded with this change of opinion, and the results have been eminently satisfac- tory. At the present time there is no patient in the asylum upon whose body or limbs there is any apparatus of restraint. In the men's department, no such means has in any instance been resorted to during the last six weeks, and in but a single instance during the last three months. In the case alluded to, a patient whose ordinary conduct is unexceptionable, but who is subject to sudden and uncontrolla- ble impulses to destructiveness, acting under the influence of one of his paroxysms, broke a chair and some windows, and his hands were confined by wristbands two days. " The so-called ' tranquillizing chairs,' which had for many years been among the means of restraint, were taken from the halls in April last, and neither of them has since been used. "It has heretofore been customary to keep a supply of the other kinds of restraining appara- tus in each hall throughout the establishment. About the 20th of November, everything of the kind was removed from the men's department, and deposited in the physician's office, where it has since remained undisturbed. And yet, during the period that we have been connected with the asylum, there has been no equal ex- tent of time in which there was so general a prevalence of quiet, order, good feeling, con- tentment, and reasonable conduct as during the last six weeks ; and, in support of this state- ment, an appeal may with confidence be made to the other officers and the attendants of the in- stitution, as well as to those gentlemen of the committee who have visited the several depart- ments of the establishment during that time. It is not asserted, for it is not our opinion, that restraints upon the limbs are never neces- sary. On the contrary, we believe there are cases in which the application of them is the most judicious course that can be pursued. We once heard a patient beg most earnestly to have her hands confined, lest she might injure herself. There is a female now in the asylum who is subject to frequent and very violent spasmodic paroxysms, or ' fits,' in which there is an uncontrollable propensity to bite herself. If her hands be unconfined, she immediately plunges her teeth into the flesh of the fore fin- ger, the upper portion of the thumb, or the arm. We have no hesitation in regard to the propri- ety of confining the hands in a case like this. One of the means of restraint, among the most simple, effectual, and least offensive to the pa- 622 INSANITY—Moral Treatment of. tient, is the Camisole, the only distinguishing peculiarity of which is, that the sleeves are of about twice the length of those of ordinary gar- ments. This being on, the patient's arms are folded, in the manner frequently adopted by per- sons in health, and the two sleeves are tied to- gether behind. Thus there is no pressure upon the body or limbs, no liability to abrasion of the skin, as with the wristbands and muffs, and the limbs are in a position as easy and agreeable as any in which they can be placed." (Earle, 2&th An. Rep. Bloomingdale Asyl., 1844, p. 34.) " Whenever they have been brought to the asylum in chains," says the late Dr. White, " I have made it a point to remove them with my own hands, as I am sure, by so doing, to gain permanently the confidence of the patient. " I once took by the hand a furious son of the Emerald Isle, and held an exciting dialogue respecting the heavy chain cast, round his an- kle and bolted to the floor. Though warned of my danger, as I approached him with a pleasant salutation, he as cordially responded, and re- ceived me as his friend. We at once made a binding contract: I was to knock off his chains, when he should be placed under my care, and he was to become my body-guard, and be obe- dient to all the rules of my house. A few days after, the bargain was consummated, and he remained faithful to his trust." " No other restraint is put upon our refracto- ry patients, under sudden impulses, than seclu- sion for the shortest possible period of time, and the use of a belt cast round the waist, with wristbands or a muff attached, to prevent them from tearing their clothes, and committing oth- er mischievous acts while at large." (White on Insanity, p. 15-16.) In the New-York Lunatic Hospital, we are informed that, besides seclusion, "leather and cloth mittens, and leather muffs and wrist- bands" are the only means of restraint; that strait-jackets and restraining chairs have nev- er been in the institution; and that the vio- lent and excited are more easily calmed by the warm bath, by cold showering to the head, and sometimes narcotics and opiates. " No better evidence," says Dr. Brigham (First Annual Re- port, p. 52), " need be given of the general dis- position of the insane to be quiet and orderly, when properly treated, than the fact that here have been, for several months, from thirty to forty men associated together, in each of our halls, not one of them under the least bodily restraint, and yet no accident of any importance has occurred, nor injury to any individual."] 509. d. During convalescence especially, moral treatment requires the greatest judgment and discrimination in all its relations. In this pe- riod, the dawnings of reason should be carefully observed and assisted, and every aid afforded to the struggling efforts of nature. The bodily disease is now loosening its hold over the men- tal powers ; and these powers may be now aid- ed in emancipating themselves from the morbid bondage. The suggestions, and, occasionally, the reasoning of the physician, advanced with kindness and sincerity, and in the soothing lan- guage of friendship, in this stage, often assist in removing weakened and decaying delusions. When convalescence approaches with a revi- val of the affections, the consolations of the physician are often requisite to calm the feel- ings which thus burst forth, and to guide them in right directions ; or his encouragements are necessary to elicit them, and to give them per- manency. Dr. Burrows justly remarks, that if, in reasoning with the patient on any remain- ing delusion, a painful recollection is revived, the subject should be changed, and resumed at another time. If any domestic event have oc- curred, during the loss of the patient's reason, likely to excite a strong feeling of joy or of grief, it should be withheld until the mind has acquired strength to bear it; and, even then, caution in communicating it is requisite. One of the most important and delicate tasks, in communicating with a convalescent as to the past and present, is, to preserve a due medium between gratifying and checking his eager im- portunities for information. Too great a flood of reminiscences, called up by much informa- tion, may endanger the mind enfeebled by dis- ease. The recollections of the past affect dif- ferent minds very differently. With some, the retrospect is a perfect blank; others remember the past as a dream ; others recollect all its re- alities. Some refer to the past with indiffer- ence ; others advert to it with gratitude to those who contributed to their recovery ; oth- ers recall it with pain and abhorrence, and avoid all reference to person, place, or circumstance connected with it. Whatever may be the im- pression on the mind of the patient, it should be carefully noted, and the conversation with him should conform to it. 510. e. Religious consolation is frequently of the greatest benefit in the partial and chronic forms of insanity, when judiciously resorted to. It has been, however, supposed by some to be injurious, or of doubtful advantage, because re- ligion is sometimes a cause of the malady; but, as I have shown (y 293), it is only mista- ken, unsettled, and fanatical views of Christian doctrines that occasion, in some instances, men- tal disorder; and, even in these cases, as well as in many others, the truths and consolations which true religion affords may be made most efficacious means of cure, when judiciously pla- ced before the mind of the patient, at a proper season, by the well-educated and sober-minded clergyman, and when the physician finds no circumstance contra-indicating the propriety of having recourse to them. Mr. Tuke very judiciously remarks, that the mild but powerful influence of the precepts of our holy religion, where these have been strongly imbued in early life, become little less than principles of our na- ture ; and their restraining power is frequently felt, even under the delirious excitement of in- sanity. Before, however, religious consolation or instruction should be attempted, some infor- mation should be acquired of every patient's former and present opinions and state of mind ; and then religion will often be most advanta- geously brought in aid of physical and moral treatment; and will tend not only to the resto- ration of the mental powers, but also to the preservation of them subsequently. The min- ister of religion, in order to be useful, should have free intercourse with the patient; and ad- minister consolation, or remove doubts, rather by private communication than by more public instruction or preaching. When the latter is attempted in an asylum, a judicious selection ought to be made of the patients, and the dis- INSANITY -Mom course should be suited to their states—to in- spire hope and confidence—carefully avoiding whatever may perplex the mind, or causo fear or alarm. 511. In a recent report of the Glasgow Asy- lum for Lunatics, it is stated that, in many in- stances, the personal and private, as well as public ministrations of the chaplain, have car- ried consolation and comfort to the minds of the patients, particularly those troubled with distressing apprehensions on religious subjects. The sermons delivered in the chapel are de- scribed as being adapted, as much as possible, to the peculiar circumstances of the audience, and as being the means of withdrawing their attention, for a time, from their prevailing illu- sions. Everything that is conceived to have a tendency to agitate the mind is carefully avoided, and pains taken to present the most soothing and practical views of divine truth. Two very important advantages are derived to the patients from the institution of public wor- ship—that of alleviating the malady under which they labour, and that of gratifying and strength- ening those pious feelings from which they de- rive the greatest consolation. 512. /. Employments and Amusements.— Ex- ercise, by equalizing the circulation, by deter- mining it to muscular structures and to the ex- tremities, and by promoting the exhalations and secretions, is of great service in the partial and chronic states of insanity. But it must be varied according to circumstances, and to the previous habits, conditions, and occupations of the patients. Walking and riding in the open air, or long walks in fields and woods, in com- pany with a suitable guardian, during as great a portion of the day as the strength of the pa- tient will permit, are often of great service. All establishments for the insane ought to be provided with the means of affording to their inmates regular exercise and employment in the open air. They should also be constructed with galleries and covered courts, freely admit- ting the air, where the patients may take exer- cise in wet weather. Gardening and various agricultural occupations should engage a con- siderable portion of time at stated periods of the day. In manufacturing districts many lu- natics may be made to follow, as a means of distracting their minds from their delusions, their several callings. In the Salpetriere, the women are permitted to sell a part of the prod- uce of their industry, and to apply it to the re- lief of their necessitous families. Females and men of sedentary habits should be engaged, as much as possible, in some regular occupation. In many asylums, especially abroad, the fe- males are occupied in embroidery, in spinning, knitting, sewing, and various fancy works. Most lunatics are disinclined to work ; but kind entreaties, or the prospect of procuring the means of extra comforts, will often tempt them to do something. Even in the early stages of dementia, it is not impossible to induce such patients to work at some merely mechanical occupation. Employments, suited to the pre- vious habits and stations of the patients, miti- gate the disease, and tend much to promote the recovery of curable cases. Where the taste and previous occupation of the patient leads to study or sedentary pursuits, these should not be indulged for too long a period al Treatment of. 623 without relaxation, or to the neglect of proper exercise in the open air. The greatest diffi- culty is to find employment or amusement for the higher classes of lunatics. They soon tire of the same pursuit. Reading, chess, cards, bagatelle, billiards, and other games, should be diversified with bowls, tennis, gardening, walk- ing, cricket, and various athletic exercises. [In many, if not all American institutions for the insane, reading-rooms are provided for the patients, which are furnished with books, news- papers, and periodicals, and which are read with much interest by many of the inmates. Writing-books, arithmetics, and slates are also placed in the hands of some, which contribute essentially to their entertainment and instruc- tion. At the Bloomingdale Asylum, Dr. Earle has made trial of the effect of delivering a se- ries of lectures on miscellaneous subjects, il- lustrated by diagrams and pictures, handsomely painted on canvass, which a large number of" the patients regularly attend, and with very happy results. At this institution, as well as at the State Hospital at Utica, &c, a regular school is carried on, which is attended by many of the inmates, and thus far the effects have been highly beneficial. As some of the faculties usually remain sound in mental derangement, we deem it very essential to recovery that these should be diligently cultivated. Where there is a taste for drawing, music, or mechan- ical contrivances, as turning, whittling, &c, that faculty should be employed; and the pa- tient should be tempted to make the best exer- tion he can with his intellect, which not only contributes to his happiness and comfort, but powerfully tends to substitute sound for un- sound ideas ; or sanity for insanity. The mor- al faculties must also be attended to, and the feelings brought into a healthy channel, which can never be done if restraint and harsh meas- ures are employed, the object of which will al- ways be mistaken by the patient. If the mind can be brought into a pleasurable state of ex- citement, and kept in that condition, while the mental faculties are agreeably occupied, if there is no organic disease present, a speedy recov- ery may be confidently anticipated. To ensure this, however, mental occupation and bodily exercise should go together.] 513. Music has been considered useful by several writers, as a means of abstracting the attention of lunatics from disordered trains of thought. M. Guislain observes, that music is useful with reference, first, to those who play upon some instrument; and, secondly, to those who listen to it. It should also be viewed both as a means of beneficially exercising the mind, and as a mere amusement. Persons who can use a musical instrument, and those who are fond of music, will sometimes derive advantage from it; but it is doubtful whether or not it will afford any benefit to others. Dr. Prichard states, that Dr. Cox considered that some ad- vantage was derived from it as an amusement; but that it is of little importance in the treat- ment of insanity, is proved by the circumstance of Dr. Bompas, the successor of Dr. Cox in the asylum conducted by him, having discontinued it. M. Esquirol remarks, that he has very rarely obtained any advantage from music. It sometimes calms the spirits, but it exerts no curative influence ; it may even render maniacs 624 INSANITY—Moral Treatment or. more furious. He, however, admits its bene- ficial influence during convalescence, particu- larly of those who have cultivated music or who are fond of it. In the more lethargic or dull states of madness, in melancholia, and in other forms of partial insanity, it is often of service, while it may prove injurious in some cases of mania, more especially those charac- terized by a tendency to violent excitement. When the patient has been a performer, play- ing on his instrument is allowable, as innocent- ly employing both mind and body. 514. g. Visits of Friends, and Restoration to So- ciety.—Convalescence is often checked, and the disorder reproduced, by the patient's impatience to be freed from all restraint; and the same effect is too often caused by the impatience and distrust of friends. During convalescence the physician has not only, as Dr. Burrows ob- serves, to encourage every dawning sign of re- turning reason, to employ the soothing lan- guage of friendship, and to calm the agony which reminiscence often generates, but also to repress impatience, and to contend with and remove the suspicion and want of confidence, which his cautious course usually produces in relations and friends, and which, if not steadily resisted, endanger the approaching recovery of his patient. The chief risks to which con- valescence is exposed, are the premature visits of friends, and removal from the proper sphere of treatment to an intercourse with relations and society, and with business and its various contingent annoyances and distractions, before the action of the brain and the manifestations of mind have been sufficiently restored or the restoration adequately confirmed. The diffi- culty of determining when friends should be admitted and when the patient should be re- stored to society is generally great, and the evils resulting from a too long seclusion are sometimes not much less than those which might accrue from premature intercourse. The experience and good sense of the physician will enable him to arrive at a just conclusion with reference to particular cases, for no gen- eral rule on this subject can be laid down. When convinced that either measure will be detrimental, resistance should be carried to the utmost, or until importunity on the part of those who have authority assumes the form of com- mand. " In yielding contrary to his judgment, the physician should distinctly throw all re- sponsibility on the applicant; otherwise, the consequence, if injurious, will certainly be cast on him." (Burrows.) I would add, that the commands of the friends, in such circumstan- ces, should be required to be made in writing; as they will be much more cautious than other- wise in thus making them, and as evasions of responsibility will often be attempted, in this as well as in many other matters, when there is no written document to prove its existence. 515. Before permitting the visit of any per- son, the state of the patient's feelings and views to that person should be ascertained. It will be also preferable to select for the first inter- view some one who the least interests the pa- tient's affections ; and, if this communication is borne without any ill effect, a nearer friend or relative may be selected, leaving the object of warmest attachment to the last. Proceeding in this cautious way, Dr. Borrows remarks, the too sensitive or feeble mind is gradually brought to bear a renewal of intercourse with- out being too much moved. But the physician might be deceived by the dissimulation of the patient, who will often assume an appearance of amendment merely to obtain an interview with a friend, his only object in seeking it be- ing to request his release, or to complain of his treatment. 516. Cunning being a characteristic of mad- ness, the physician should always be upon his guard against being imposed upon. Many are fully aware that, if they can conceal their de- lusions, they may be considered well; and, when only one delusion is entertained, it is often difficult to detect it. Dr. Burrows had a patient whose specific delusion gave rise to outrageous conduct requiring her confinement; and yet this delusion was successfully conceal- ed for nine months, at the end of which time it was manifested in an alarming manner. In this and similar cases, a recovery might have been prematurely or improperly pronounced. On the other hand, it is possible for an impres- sion, made previously to complete mental de- rangement, to be so firmly retained after recov- ery as to have the semblance of a delusion, and yet be none ; especially when no recollec- tion is retained of what has occurred between the accession of disorder and recovery, and when the patient reasons and acts upon this conviction, and reckons a circumstance long passed as having recently taken place. Much discrimination and experience are necessary to determine when seclusion may be terminated, and the patient restored to society. If the dis- order have been caused by intemperance, a longer confinement after convalescence is re- quired than in other circumstances; for the longer it is protracted, the greater is the chance of the patient being induced to relinquish a re- currence to the cause. 517. h. After the patient is restored to society, moral and hygienic management ought to be continued for a considerable period. Due care should be taken not to excite, or inordinately indulge the passions and desires. Irritations of rnind and body should be avoided, and all emo- tions which depress, equally with those which unduly stimulate the mind, ought to be evaded. Mental exertion is also injurious. The intel- lectual as well as the moral powers should not have too much imposed upon them. They ought, at first, to be only agreeably and gently exercised; and, as they re-acquire strength, more may be exacted from them. Travelling, agreeable society, change of scene and of air, regular and early hours of sleeping and dining, pleasant occupations, and exercise in the open air, are all of the most essential service after recovery. Of no less importance are regular and abstemious modes of living, and strict at- tention to the states of the digestive and ex- cretive functions. In a word, the predisposing and exciting causes ought to be carefully avoided. 518. iv. Classification of Patients, and Arrangement of Institutions, &c.—A. The classification of the insane, in both Dublic and private asylums, is too frequently dependant upon their nrtrjjL nnd^un^iiWdina*0 cir- cumstanc^i$^uftfa^oiiu£ig^stead of these being a^fe«TirJservient "TrKaJ^assification whichram/frmtribute to the safety and speedy NATIONAL library of medicine NLn QCHAAMIA 4 NLM009884184