m UNITED STATES OF AMERICA MB® WASHINGTON, D. C. OPO 16—67244-1 DUPLICATE From the ^fulpc library of the City of Boston. V/'/'/ Siterin rr.KDEVT. 90, &c.) Mr. Perc,v ' referred me to the second volume of his work: h° scarlatina in the horse is mentioned. ' wn*re SKIN—Classificat marks ; highly contagious, and affecting the sys- tem only once.—Spec. 1st. Variola Hominum.— Var.: a. V. discreta ; b. V. confiuens ; c. V. sine Variolis.—Spec. 2d. Variola Animalium.— Var.: a. V. vaccina; b. V. ovilis, vel Clavus.—Spec. 3d. V. varioloidea, vel Variola Hominis anomala. (See arts. Small-pox and Vaccination.) 73. Genus v.—Varicella—Chicken-pox.— An eruption of semi-transparent, glabrous ves- icles, with red margins, following and attended by a slight attack of fever; the vesicles seldom passing into suppuration, but breaking on the third or fourth day, concreting into small puck- ered scabs, and leaving no cicatrices ; affecting a person only once. — Spec.: 1st. V. lentiformis; 2d. V. coniformis; 3d. V. globular is. (See art. Chicken-pox.) 74. Genus vi. — Miliaria—Sudamina.—An eruption of whitish or pale reddish vesicles, the size of a millet-seed, in the course of severe in- fectious fever; the vesicles being distinct, con- taining a serous fluid, of a whitish, or reddish, or purplish hue, bursting in two or three days, and terminating in a scurfy desquamation.—Spec : 1st. M. simplex; 2d. M. abnormis. (See art. Miliary Eruptions.) 75. Genus vii. — Erysipelas.—Asthenic in- flammation of the integuments, consequent upon febrile disorder and a morbid state of the blood, affecting the skin or scalp more or less extens- ively, with a diffused swelling disposed to spread, propagated by infection when circumstances fa- vour the operation of the poisonous miasm.— Spec: 1st. E. simplex; 2d. E. complicatum. (See art. Erysipelas.)* 76. Order VII. — Dermatites contagiosa — D. specifics contagiosa — Aischrodes — Eruptiones contagiosa — Contaminating Erup- tions. — Erup'tions propagated by direct or me- diate contact, or indeterminate, but generally pro- longed duration, often contaminating the whole frame ; and certain of them tending to fatal ter- minations. 77. Genus i.—Scabies—Itch.—An eruption of distinct, slightly acuminated vesicles, attend- ed by constant itching ; the eruptions varying in character, but often concealing a parasite or aca- rus, either causing or produced by it, unattend- ed by constitutional disturbance.—Spec 1st. S. Hominis.—Var.: a. S. H. vesicularis ; b. S. pa- puliformis; c S. lymphatica; d. S. purulenta; e. S. cachectica.—Spec. 2d. Scabies Canis. (See art. Itch.) 78. Genus ii.—Sycosis—Mentagra.—A pus- tular eruption of a pale yellow colour, seated chiefly in the hairy parts of the face, as the chin, upper lip, cheeks, &c, affecting the hair follicles and connected tissues, bursting in the course of some days, and producing brownish crusts, which after one or two weeks leave indolent purplish tu- bercles ; the pustules being renewed in different parts, thus continuing for an indeterminate peri- od, and apparently propagated by a parasitic plant or cryptogamic formations.—Var.: 1st. S. sim- plex; 2d. S. contagiosum. (See art. Sycosis.) 79. Genus iii.—Favus—Tinea—T. maligna — Porrigo — Ring-worm. — A specific chronic inflammation, seated chiefly in the hair follicles, * The several forms and states of complication mani- fested by Erysipelas are fully described in the article re- ferred to, as they have been observed in many countries and climates by the author, and during different epidemic constitutions. ion of Diseases of. 871 exuding a peculiar yellowish substance, which accumulates and forms a cup around the base of each hair, the aggregation of a number of these resembling the cells of a honey-comb. The hair of the diseased follicles is altered, imperfectly nourished, and falls out; and if the disease be not arrested, the subjacent tissues became affect- ed. This contaminating eruption is usually seat- ed in the scalp, sometimes extending to the face, neck, and other parts of the body, and is commu- nicable to any part of the skin.—Var.: 1st. F. dispersus; 2d. F. confertus. (See art. Tinea.) 80. Genus iv. — Pustula Maligna — Conta- gious Anthrax.—A large vesicle filled with a sanious fluid, seated over a lenticular induration, which is speedily surrounded by an erysipelatous areolar swelling, which soon becomes gangren- ous, and contaminates the circulating fluids; caused by the contact of a septic animal poison, and communicable from person to person, and from the lower animals to man.—Spec.: 1st. P. M. Hominis; 2d. P. M. Animalium. (See art. Pustule, Malignant.) 81. Genus v.—Glanders*—Farcy — Farcy Glanders.—Fever of a low and malignant char- acter, attended by chancry sores of the membrane of the nose, and a profuse, offensive discharge, and by pustular eruptions, or tubercular, gan- grenous ulcers in various parts of the cutaneous surface, produced by the contact of the poison- ous matter.—Spec: 1st. Simple Acute Glanders; 2d. Acute Farcy Glanders; 3d. Simple Chronic Glanders; 4th. Chronic Farcy Glanders. (See art. Glanders.) 82. Genus vi. — Syphilis — Syphilitic Erup- tions—Venereal Eruptions.—A distemper con- tracted generally by impure contact, and charac- terized, externally, by copper-coloured spots, or by pustules, vegetations, excrescences, ulcera- tions, swellings, tumours, or imposthumes; in- ternally, by pains in the bones or periosteum, or by caries.—Spec 1st. £. eczematosa.— Var.: a. lenticularis; b. papularis; c. vesicularis; d. pus- tularis ; e. tubercularis.—Spec. 2d. S. squamosa. — Var.: a. Leprosa; Psoriasis. — Spec. 3d. S. vegetans. — Var.: a. verrucosa; b. Condyloma; c. Cauliflora; d. Frambasia; e. Crista-Galli.— Spec. 4th. S. exulcerans.— Var.: a. serpiginosa; b. fissata; c. excavata. (See art. Syphilitic Af- fections.) 83. Genus vii.—Mycosis.—A contagious dis- ease, consisting of fungous excrescences, occur- ring chiefly on the face, hairy scalp, or about the organs of generation, resembling a mulberry or strawberry, exuding a yellowish, fetid, and vis- cous humour, sometimes forming tumours of con- siderable size, and often attended by pains in the bones, by hoarseness, coryza or ozcena, ulcera- tion of the tonsils, &c. —Spec. : 1st. M. Fram- besioides, Frambasia; 2d. M. Molluscum, Am- boyna-pox; 3d. M. syphiloides, Sibbens, &c. 84. Order VIII.—Leprodes—Leprous Erup- tions. — Morbid degenerations of the skin, de- pending upon constitutional vice, attended by diminution of the sensibility of the diseased sur- * This malignant and contaminating distemper is gen- erated in horses from crowding, and from breathing a contaminated or foul air, and is communicated from them to man. There is great reason to believe that most, if not all the maladies comprised under this order, have originated in some of the lower animals, and have ex- tended, with various modifications, to man ; and not im- probably small-pox has had a similar origin, as well aa scarlet fever, as already mentioned. 872 SKIN—Classification of Diseases of. face, by general hypertrophy of the cutaneous tissues, by originating in endemic influences and bad food, insensibly and slowly, and by their very prolonged duration and hopeless cure. 85. Genus i.—Lepra Tuberculosa — Lep- rosy—Leprosy of the Middle Ages—Lepra He- braorum.f— Dusky-red or livid tubercles, of va- rious sizes, on the face, ears, and extremities ; a rugous and thickened state of the skin, impaired sensibility and falling out of the hair, excepting on the scalp; hoarse or altered voice, and ozoena; terminating in ulcerations of the affected surface, and extreme fetor; the distemper being often hereditary, and even contagious by means of the matter discharged from the sores.—Spec: 1st. Lepra Taurica—the Leprosy of the Crimea ; 2d. L. anasihesiaca; 3d. L. Hebraorum—Jewish or Egyptian Leprosy. (See art. Leprosy.) 86. Genus ii. — Radesyge. — Lassitude, tor- por, and heaviness of the limbs, stiffness and pains of the joints; a pale, bloated, leaden, or reddish appearance of the face, hoarseness of the voice, ozoena; a rugous, scaly, and callous state of the skin, especially in parts, followed by cracks, furrows, tuberculous callosities, and ulcers. — Spec. : 1st. R. vulgaris; 2d. R. scorbutica. 87. Genus iii.—Elephantia—Elephantiasis of the Arabians. — Hardness, lividity, and great tumefaction of one or both limbs, or of the scro- tum, owing to great thickening of the cutaneous and sub-cutaneous tissues, with an irregular, gla- brous, or scaly state of the surface ; endemic chiefly in warm countries.—Spec.: 1st. E. vul- garis; 2d. E. tuberosa; 3d. E. Scrotatis. (See art. Elephantiasis.) 88. Genus, iv.—Pellagra. —An endemic and hereditary malady, characterized by thickening, scaly excoriation, cracks, and deep fissures of those parts of the skin exposed to the sun or air; attended by general cachexia, by burning pains in the trunk and limbs, by disorder of the digestive organs and nervous system; at first appearing aft- er prolonged intervals, afterward being more con- tinued, and often fatal.—Spec.: 1st. P. Milanen- sis; 2d. P. Asturiensis. (See art. Pellagra.) 89. Genus v.—Ichthyosis.—Morbid enlarge- ment of the papillae of the skin, and thickening of lamella of the epidermis, either in parts, or more or less generally, presenting irregular com- partments often resembling the scales of fish.— Spec: 1st. I. hereditaris; 2d. T. papillaris; 3d. I. localis. (See art. Ichthyosis.) 90. Order IX.—Cancrodes—Cancerous Dis- tempers. — Cancerous diseases of the skin are characterized by their slow and insidious attack, by their prolonged duration, by their foul ul- ceration and lancinating pains, by their resist- ance to treatment, and by their general return to adjoining or remote parts after removal by ex- cision : they depend on a peculiar diathesis, which is often hereditary. 91. Genus i. —Lupus — Cancer Lupus, Sau- vages.—A disease of all the tissues of a portion of the skin, chiefly of the face, implicating also the subjacent cellular substance ; of remarkably slow progress and long duration ; always extend- ing either superficially or in depth, with a stinging sensation of heat; passing into ichorous and slow phagedenic ulceration, and destroying the tex- tures to which it extends.—Spec : 1st. L. su- perficialis ; 2d L. phagedanicus ; 3d. L. non-ex- edens scrpiginosus. (The different species of Lupus form the connecting links between the leprous and the cancerous diseases of the skin. See art. Lupus.) . - 92. Genus ii._-CARCiNus.-An alteration of all the tissues of the skin and subjacent cellular tissue, generally commencing as a small, nara, indolent tumour, with itching or stinging ; pass- ing into pungent or lancinating pains, ana oiten attended or followed by ichorous and slow ulcer- ation, and by general contamination of the frame. — Spec : 1st. C. scirrhosus — Carcinoma ; 2d. C verrucosus (Chimney-sweeps' Cancer); 3d. C medullaris; 4th. C. melanaus; 5th. L. ebur- naus. (See arts. Cancer and Scirrhous and other Tumours.) . 93. Genus iii. — Kelis. — A prominent, hard excrescence, sometimes cylindrical, sometimes round or square, flattened in the centre and ele- vated at the margin, projecting roots into the skin. __Spec: 1st. K.genuina; 2d. K. spuria.' 94. Order X. — Heteromorphaa. — Alter- ations of the skin, cuticle, or nails, not comprised under the foregoing, nor referable to changes or morbid actions similar to, or allied with, those which characterize the preceding groups. 95. Genus i. — N^evus—Vascular Navi — Moles.—A congenital alteration of a portion of the skin, consisting either of a convoluted conge- ries of capillary vessels, more or less elevated, in the form of a small vascular tumour, above the surface, or of a more diffused and dark or livid- coloured patch, or of a warty, hairy, or discolor- ed elevation or excrescence.—Spec.: 1st. N. vas- cularis circumscripta; 2d. N. vascularis diffu- sus; 3d. N. non-vascularis; 4th. N. pilosus. 96. Genus ii.—Verruca—Warts.—Avery circumscribed, hard excrescence, sessile or pe- dunculated, sometimes movable, sometimes more fixed, of nearly the same colour as the skin, its surface being rugged, horny, or hard, and not susceptible of inflammation, although the cuta- neous papillae to which it is attached are more than usually vascular.—Spec: 1st. V. vulgaris; 2d. V. Acrochordon. 97. Genus iii.—Tylosis— Corns. — Circum- scribed, dry, hard, lamellated callosities, owing to hypertrophy of the cuticle from pressure, which drives the altered structure inward upon the sub- jacent tissues, developed chiefly on the toes.— Spec.: 1st. T. indurata ; 2d. T. gomphosa; 3d. T. bulbosa. 98. Genus iv. — Onygosis. — Inflammation with swelling, redness, and pain of the matrix of the nail, causing malformation, induration, ever- sion, or inversion of the nail. — Spec : 1st. 0. acuta; 2d. O. chronica; 3d. O. cum Inversione; 4th. O. cum Eversione; 5th. 0. complicata vel assoctata. (Often associated with Psoriasis and Lepriasis, which see, § 23.)* nreferlbfe ^h.?^^™*^*"' in many resPects. preferable to that of Willan. The latter classes euml nXLL^-0niUvtr,eight ^f^ I ^ANt" KMAxi", u. bullae , HI. Vesiculje ; IV. Pustule • V Papu ls ; VI. Squam* ; VII.Tubeboula ; VIIL M^lfL MS yr^ °" the inte»ts each wine leaaing lorms which characterize the above order* The great objection to such a classification is thatX papular, vesicular, and pustular forms are not cons ant but are sometimes transformed into each other ,s ."I"™*' cle into abulia, and a mere redness into S'^ tule so that the distinctions founded on them aro nC arbitrary and illusory. We see this chan-e ™f X! ,Cn well illustrated in the varioloid or modified ^rT^r small-pox, which may assume almost every vLZ % pf taneous disease. So nothing is more common than ?« ££ papular forms of lichen pass into a squamous It, erythema to present papular or tubercular elevati™ OT the vesicles of scabies may assume a pustular form' °r SKIN—Classification of Diseases of. 873 99. Having exhibited what may be considered a strictly natural grouping or classification of the changes, appearing either primarily in the tissues of the skin, or contemporaneously with, or consec- utively upon, febrile and constitutional diseases, it will be seen that the local connexions, the symptomatic relations, and the more prominent features and alliances of these changes, are brought more completely and more accurately under view. And it will be more clearly perceived that these affections of the skin, so difficult to arrange, and so generally considered and treated as local alter- ations merely, are more or less important mani- festations, in the cutaneous tissues, of disordered or diseased conditions of one or more of the vital functions — of the organic nervous influence or energy, of the digestive and assimilating func- tions, of the depurating or eliminating functions, well as the papules of prurigo, &c. These and other cases of a similar kind only go to prove that there are no constant characters, nothing absolute in nature, especial- ly in morbid nature. Moreover, these instances of trans- | and, consequently, of the circulating fluids, and of the constitution or frame in general. Thus, a natural arrangement of cutaneous affections di- rects the attention more entirely to the relations, and constitutional and visceral dependencies, of these affections, and leads to rational and suc- cessful methods of cure, most of the affections grouped under the same order manifesting such morbid relations and connexions as require sim- ilar indications and means for each. 100. As artificial arrangements of cutaneous diseases have been so commonly received, and as they tend to facilitate diagnosis, I shall con- clude this subject by giving the improved modi- fication of the classification of Willan, by M. Rayer, the arrangement of Willan being itself only a modification of that originally published by Plenck. ' Albinismus seu Leucopa- thia, Nigrities, Ephe- lis, Lentigo, Chloasma, Melasma, Naevus pig- mentarius, Color caeru- Ieus, Color subflavus ; Artificial Discolora- . tions. ; Ichthyosis, Verruca, Pro- ducta cornea, Tylosis. ' Phlebectasia, Angiectasia capillaris, Naevus ara- neus flammeus, &c. Tumor vascularis. : Cheloidea, Tumores va- rii, Elephantiasis Ara- bica, Andrum, et Pe- darthorae, Barbadoes i. Leg, &c. formation of one genus or species of cutaneous disease into another are only exceptions to a general rule, or ac- cidental complications, which do not materially interfere I with an accurate diagnosis.] TABLE. Chapter I. Inflammatory Affec- tions, distributed according to the Number and Form of their elementa- ry Lesions. Section I. Having a single ele- mentary Form. Section II. Having several ele- mentary Forms. 1. Exanthemata.— beola, Roseola, Si cial Exanthemata. 2. Bulle.—Pemphi; lse—Blisters, Amp 3. Vesicule.— Her Scabies, Miliaris i Sudamina; Artific 4. Pustule.—Vario cinella, Acne, Ros< vus, Ecthyma; Ai 5. Furunculi.—Hoi thrax. 6. Gangrene.—Ant na, Anthrax Pestii 7. Papule.—Strophi tificial Papulae. 8. Squama.—Pityria lagra; Artificial S< 9. Tubercula.—Lu] phantiasis Graecori 1. Syphilis. 2. Ambustio. 3. Pernio. Chapter II. Peculiar States of the Skin not refer- able to Inflamma- tion. ANEMIE. .CONGESTUS SANGUINEI. HEMORRHAGIC. Chapter III. Morbid States of the secreting Func- tions of the Skin. Perspirationis Ephidrosls. Epidermidis Exfoliatio. Chapter IV. Neuroses of the Skin. Anaesthesia, Hyperesthesia. Chapter V. Faulty Structure, or unusual States of one or other of the Elements of the Skin. Pigmenti (Acuminata; Dyschromata). Hypertrophic GaNGRENA sim- plex. Cicatrices. Defectus congen- itus Cutis. EXTENSIO VEL Re- laxatio insoli- ta Cutis. Papillarum et Epi- dermidis. Vasorum Cutis. Corii, Membranes cellularis subcuta- neas, et Telse adi- posae. DIVISION I. Diseases of the Skin. Chapter I. Inflammatory Affec- tions, distributed according to the Number and Form of their elementa- ry Lesions. Section I. Having a single ele- mentary Form. Section II. Having several ele- mentary Forms. 1. Exanthemata.—Erythema, Erysipelas, Ru- beola, Roseola, Scarlatina, Urticaria; Artifi- cial Exanthemata. 2. Bulle —Pemphigus, Rupia ; Artificial Bul- lae—Blisters, Ampullae. 3. Vesicule.— Herpes, Eczema, Hydrargyria, Scabies, Miliaris sudatoria (suette miliaire), Sudamina; Artificial Vesicles. 4. Pustule.—Variola, Varicella, Vaccinia, Vac- cinella, Acne, Rosacea, Sycosis, Impetigo, Fa- vus, Ecthyma; Artificial Pustules. 5. Furunculi.—Hordeolum, Furunculus, An- thrax. 6. Gangrene.—Anthracion vel Pustula malig- na, Anthrax Pestis. 7. Papule.—Strophulus, Lichen, Prurigo; Ar- tificial Papulae. 8. Squame.—Pityriasis, Psoriasis, Lepra, Pel- lagra ; Artificial Squama?. 9. Tubercula.—Lupus, Scrofula, Cancer; Ele- phantiasis Graecorum; Artificial Tubercles. Exanthematica, Bullosa, Vesiculosa, Pustulosa, 1. Syphilis. \ Squamosa, Papulosa, Tuberculosa, Vegetati- 2. Ambustio. .3. Pernio. Chapter II. Peculiar States of the Skin not refer- able to Inflamma- tion. Anemie. congestus sanguinei. Hemorrhagic. Exanthematica, Bullosa, Gangrenosa. Exanthematica, Bullosa, Gangrenosa. r Purpura (Petechia?, Vibi- < ces, Ecchymoses, Der- ( matorrhagia). 874 SKIN—Classification of Diseases of. DIVISION I. Diseases of the Skin. DIVISION II. Alterations of the Dependencies of the Skin. DIVISION III. Foreign Bodies on the Surface, un- der, or in the Sub- stance of the Skin. TDeoenerationes fibrosa. ! Melanosis. LDegenerationes tuberculosa. . Secretio aucta, Vermes sebacei, Levatio foUieularis, Tumor foUieularis, Calculi Folliculorum. Chapter VI. Degenerations. Chapter I. Special Diseases of the Sebaceous Fol- licles. CHAPTEn II. "I A h Ductus congenitus Pilorum, Pili supernumerarii; Incre- Spccial Diseases of I me^ltuI'n insolitum Riorum, Coactio Pilorum, Alopecia, Canities, the Puiierous l< ol- I licles. ' j Plipa. Chapter HI. Special Diseases of the Unguial Mat- rices and Altera- tions of the Nails.. Onychia, Vita Conformationis et Structural Unguium; Ecchymosis subunguialis ; Incrementum insolitum Unguium ; Situs insolitus ; Ficus ; Defaedatio, Degeneratio ; Productio et Reproductio, A. Treatise on Gout, Scurvy, Lepro- sy, and other Cutaneous Eruptions, Svo. Lond 1777 — H. F. A. de Roussel De variis Herpetum Speciebus, &c, ftn°t",J sdornV"9-~£ «««*, De Crusta Lactea In- SS To™0' pFran?-'al779TJ/- PouPart< Traite des Dar- h£ r ! • P«ar" iVP"-J;J- Plenck> D°«"na de Mor- bis Cutaneis, 8vo. Vien., 1776, 2d edit., 1783.-C Ber- pT i™re2£e'£ss,ai s.ur >£ Traitement des Dartres, Svo. rar., i'»4.—h. Rigby, An Essay on Animal Heat and on Cutaneous Eruptions, Svo. Lond., 1785.-/ FCarfhm 7-rfiao te ia Bouce Amere dans les Dan res, Svo Par a ., ,-!o uvo-ges, Nosologia Methodica, 2 vols 4to' PPmane*,1768'V01; *•' P- 32-fcrf*. Ees Maladies de ?a Pa? 'l?90' ^ £re,cedent de8 Affections du Foie, 12mo. riaIi'r.KJU"~'s-//--/«cA-*ora,Dermato-Pathologia; or Prac- tical Observations on the Pathology and Cause of Diseases of the Skin, 8vo. Lond., 1792.-A. C. E. Maneor Un derretning von Radesygens, &c, Svo. Kopenh H92 - M. Bern, Memoire sur la Decoction du T»w'J^ i x au Traitement de la Gale, Svo. Par., 1794 1^ V?^ ferkorn, Ueber die Norwegische Radesyee unrt '<£1a(T hed, Svo. Altona, 1797.-A. DufresnoXsnd,SPedalsk- du Traitement, &c, des Dartres, 8vo. Par i-qcacte,res' cenzo Chiarugi, Delle Malattie Cutanee sordi'de in G~ SLEEP AND SLEEPLESSNESS—Physiological Pathology of. 875 ed in Especie, 2 vols. 8vo. Firenze, 1799. — /. Ruette, Essai sur ['Elephantiasis et sur les Maladies Lepreuses, Svo. Par., 1802.—G. Alley, Essay on an Eruptive Dis- ease arising from the Exhibition of Mercury, 8vo. Dub., 1804.—N. C. D'Audebert, Des Exanthemes epizootiques, &c, 8vo. Par., 1804.—/. Derien, Essai d'une Table Syn- optique des Mai. de la Peau, 4to. Paris, 1806.—A. Mori- arty, Description of the Mercurial Lepra, 12mo. Dub., 1804.—F. Dobscha, De Cute et de Morbis Cutaneis, 8vo. Jena, 1815.—/. Klapp, Chemico-physiological Essays on the Functions of the Skin, 8vo. Phil., 1805. R. Willan, Description and Treatment of Cutaneous Diseases, 2 vols. 4to. Lond., 1805-7.—/. L. Alibert, Precis Theorique et Pratique sur les Maladies de la Peau, 8vo. Lond., 1810. —W. Cooke, A Practical Treatise on Tinea Capitis, 8vo. Lond., 1810.—D. L. Suasso, Specimen Varicella? atque Scarlatineae, 4to. Amst., 1810.—D. L. Suasso, Specimen Rubeolarum et Morbillorum, 4to. Amst., 1810.—A. Ma- Ihias, The Mercurial Disease; an Inquiry into the Nature of the Disease produced by Mercury, 8vo. Lond., 1811. —/. C. Gales, Essai sur le Diagnostic de la Gale, &c, 4to. Par., 1812. — T. Luxmore, Observations on the Nature and Treatment of Tinea Capitis, 12mo. Lond., 1812.— T. Bateman, A Practical Synopsis of Cutaneous Diseases, Svo. Lond., 1813.—/. F. N. Jadelot, Notice sur le Traite- ment de la Gale au moyen des Bains, *fr j» Bost. Med. and ssurg. Journ., yol. :., p. .29, !"• *■ »■ Almon, In ibid., vol. 1., P-'.■-*• ^^"'qIq N s /' p. 113.-R. F. Joslin, In ibid., vol v p 249, N. S.-L. Callaehan In ibid., vol. iv.. p. 302, O. S. — H . \\. Ger- hardIn ihid" vol. xi., p. 368. (This paper contains the nW accurate and minute account of the post-mortem ap- oearances in Small-pox hitherto published.)—/. F. W. ?Tane, Some StatIStics of Small-pox and Vaccinatum Ibid., vol. xxiii. (xii., N. S.), p. 119. July, 1846. - Uilf. mm Kelly, Case of Variola, complicated with Purpura, in New York Journ. of Med. Jan.., 1851, N. S. ; and in New York Med. Times, vol. ii— S. G. Morton, In Am. Edit, ol Macintosh's Practice.—D. Hosack, Lectures on Practice of Med. Edited by Rev. H. W. Ducachet, New York.— Washington L. Atlee, Case of Small-pox Contagion, ap- parently conveyed by Letter, Amer. Journ. Med. Sci., vol. xxvi. p. 505.—Thos. Stewardson, Remarks upon Small- pox admitted into City Hospital, Philadelphia, during 1840-41-42, Ibid., N. S., vol. v., p. 81. —F. W. Sargent, Report of Cases of Small-pox admitted into City Hospital, Philadelphia, in 1845-46, Ibid., N. S., vol. xvii., p. 349.— Samuel Jackson, of Northumberland, On Ectrotic Treat- ment of, Phil. Med. Examiner, N. S., vol. ii., p. 464.—E. C. Banks, of Illinois, Small-pox appearing Spontaneous- ly, Ibid., N. S., vol. v., p. 518.—Anonymous, Observations upon Small-pox in Dover, N. H., Boston Med. and Surg. Journ., vol. xliii., p. 214.—Henry Gibbons, Sketch of Epi- demic Small-pox in Wilmington, Del.. Ibid., vol. ix., p. 355.—W. L. Sutton, of Kentucky, On Etiology and Diag- nosis of Small-pox, Western Journal of Medicine and Sur- gery, 3d series, vol. ii., p. 93.—T. S. Bell, On Small-pox and Vaccination, Ibid., 3d series, vol. vii., p. 22.—Report of Committee on Small-pox and Varioloid, Transactions New York State Med. Soc, vol. iii., p. 40.— William G. Mcacham, In Buffalo Med. Journ., vol. ix., p. 457.—Sam- uel Forry, A Dissertation on the protective Powers of Vaccinia, the Boylston Prize Essay for 1844, in New York Journ. Med., Sept., 1844.— William P. Dnvees, Practice of Physic. Phil., 1833. Also, G. B. Wood, R. Dungliscn, D. Hosack, S. H. Dickson, and /. Eberle (Systems of American Practice of Medicine). — James Stewart, On I Diseases of Children, and Transl. of Billard on Diseases [ of Children.—Lemuel Shattuck, Report of Sanitary Com- mission of Mass. Mr. S. says : " The first authentic ac- I count of the prevalence of small-pox in this country is in 1631, when it spread from N arraganset to Piscataqua, and westward to Connecticut River, sweeping off whole villa- ges of the Indians. In 1633 it also made great ravages among the natives; also in 1639, 1645, 1677, 1676, and 1702, when 4.4 per cent, of the inhabitants of Boston died of it. In that year inoculation for small-pox was intro- i duced into Boston. Rev. Dr. Cotton Mather, having read in the Transactions of the Royal Society of London fa- vourable accounts of the operation, recommended a trial of it to the physicians of Boston, but all of them unani- mously and decidedly opposed it, except Dr. Boylston. This enlightened physician first inoculated his own son, thirteen years of age, then two coloured persons in his family, and all with complete success. Subsequently oth- ers were inoculated. Great controversy ensued, and the | dispute ran high. Theologians maintained that such in- terference with the disease was sin, and should not be al- j lowed. Dr. Douglass headed the opposition, and so ex- asperated wore the minds of the people, that Dr. Boylston [ was frequently insulted in the streets, and forced to se- crete himself for some time, and afterward to visit his pa- tients only at night. Passion and prejudice on the one i side, however, were met with decision and success on the ! other ; and inoculation soon triumphed over opposition, and became general. During this epidemic, 15,759 persons —more than half the inhabitants—had the disease in the natural way, of whom 844 died ; 247 were inoculated by Dr. Boylston, and 39 by other physicians, of whom 6 only died. This was 1 death in 7 of those not inoculated, and 1 in 47 of those inoculated, showing very clearly the ad- vantages of inoculation."] SOFTENING OF STRUCTURE. — Synon.- Softness of organs ; Mollities ; MaXanonft (from uahanoc, mollis); Structura mollities; uaxaKoaapKog, Galen. Ramollissement, Fr. Erweichung, malacia, Germ. Classif.—General Pathology— Morbid Structure—Therapeutics. 1. An individual structure, or part, or organ, may present more or less softness, or diminution of its healthy or normal density, or of its natural state of vital cohesion ; it may be preternaturally soft, still retaining its usual amount of cohesion; it may be unusually friable, without being soften- SOFTENING OF STRU( ed, or without losing its density; but these states are comparatively rare, for when the one property is impaired the other is also diminished, and with softening cohesion is generally proportionately les- sened. Softness of structure is commonly not merely physical, but also vital. The structure evinces an impaired cohesion of its molecules, and a diminished vital resistance to external agents. When treating of the changes evinced by individual structures, I have always described, as one of these changes, diminution of their cohe- sion, or softening. Thus softening of the brain, Mollities cerebri, is considered in the article Brain ; softening of the heart, Cardiomalacia, in that on the Heart ; softening of the stomach, Gastro-malacia, in that on the Stomach, &c. 2. I. Pathology of Softening of Struc- ture. — Preternatural softness of structure is sometimes recognised during life, but most fre- quently comes under the observation of the phy- sician after the dissolution of his patient, and it then becomes sometimes a question how far it may be a post-mortem change. There can be no doubt that much of the softness often found in the brain or spinal cord after death is post-mortem, although the change may have commenced some time before death; and this remark equally applies to softening of the tissues of the digestive canal. (See this art., A 34, et seq.) 3. Softening of structure may occur after death. —1st. From the action of the gastric juice on parts with which this fluid is brought in contact soon after, or at the time of dissolution. 2d. From infiltration or maceration of effused fluids, and putrefaction. 4. Softening may take place during life.—1st. From congestion, and, still more manifestly, from effusion or infiltration of blood in the structure. 2d. From inflammatory action. 3d. From dis- ease of the arteries or veins connected with the softened part. 4th. From impaired organic nerv- ous power of the part, causing impaired nutri- tion, sometimes with serous infiltration, or with fatty degeneration, or with a certain amount of either of these. Softening of structure after death has been noticed when treating of changes ob- served in the digestive canal and in other organs; but I shall here offer a few remarks on the patho- logical conditions of which it is a consequence during life: 5. i. The several changes just enumerated as most frequently producing softening of structure are chiefly concerned in causing this effect in par- ticular organs or parts. But there are other states which occasion a more or less general softening or loss of vital cohesion in most of the structures of the body; and this softening may exist in a very remarkable degree throughout the whole frame, excepting the bones. It is presented to us during life chiefly in pestilential diseases and malignant fevers, and occasionally as a result of virulent poisons. The softening of the structures in these distempers is a consequence, as I have shown when treating of these distempers, 1st, of impaired and vitiated organic nervous influence ; 2d, of a contaminated state of the blood, with an impaired crasis of its fibrine, and change of the blood- globules ; these two prime factors of ulterior al- teration acting and reacting on each other. The softening of structure in the more severe cases of the several pestilences, and in the more malignant of exanthematous and continued fevers, had been in great measure overlooked until I described it in CTURE—Pathology of. 923 early parts of this work and in other places ; and to what I have advanced respecting these diseases, under their several heads, I must refer the reader for my description of this remarkable change— this general diminution of vital cohesion of the tissues—at an advanced stage of the malady, or towards the close of life, with the rapid acces- sion of putrefaction after death. This general and rapid form of softening may be called acute general softening of the tissues, to distinguish it from par- tial or limited softening, on the one hand, and from chronic general softening on the other. 6. ii. When softening of structure is partial as to its seat, or limited to a single structure or organ, it is a consequence of one or more of the patho- logical states enumerated above (§ 4).—A. It may be the result, or the concomitant, of congestion of blood in the capillaries of the part, or of an exuda- tion of blood from these vessels, and of the infil- tration of it in the substance of the part. When the vital or the organic nervous influence of the part and of its vessels is impaired, the blood is liable to congestion in the vessels, or to farther change ; and, as a consequence, or as a concomi- tant of this state, softening of the part is liable to supervene. If, as a result of this change in the capillaries and their contents, blood be effused into the structure of the part, softening still more certainly ensues, and with a rapidity proportion- ate to the failure of vital power and resistance in the surrounding parts. The softening which is observed is congested and enlarged spleen, wheth- er occurring primarily, or as a consequence of periodic fevers, and some of the cases of soften- ing of the lungs are illustrations of the conse- quences, or of the concomitant effects, of con- gestion of a simple or asthenic kind ; while the red softenings seen in portions of the brain, and the softening with ecchymoses and bloody infil- trations, observed in several viscera and structures in scurvy, purpura, asthenic haemorrhages, and in malignant or putro-adynamic fevers, &c, show the great extent to which softening proceeds when it is accompanied with exudations of blood. In all cases, when blood is exuded, infiltrated through the structure, or accumulated in masses, and re- tained even for a short time, softening of an in- flammatory kind, although asthenic as to tone, certainly supervenes, and extends more or less, according to the grade of vital resistance. 7. B. Inflammatory action is generally attend- ed by softening of the affected parts ; and when softening has not become apparent, or even when the part seems more dense, owing to the infiltra- tion of a concrescible lymph, there is a defect of vital cohesion, as evinced by increased friability. The sthenic and chronic states of inflammation evince less softening and friability than the more asthenic and acute states. Erysipelas and other spreading inflammations, and still more the dif- fusive inflammation of cellular and adipose tis- sues, are often attended by softening, amounting to diffluence and disorganization; and in proof of these changes, I have only to refer to these maladies, and to the art. Gangrene. 8. C. Disease of the arteries and veins, espe- cially of the former class of blood-vessels, is a very common cause of limited softening of organs. Obliteration of an artery, or even specific deposits in the coats, or other changes affecting the calibre, or impairing the healthy action of the vessel, as atheromatous or fatty deposits, may impair the nu- trition of the part supplied by the diseased vessel, 924 SOFTENING OF STRUCTURE—Pathology of. and thereby occasion softening and impaired vital cohesion of it. Instances of this connexion or sequence, or even sometimes concomitance of alteration, are often presented in the brain, heart, and other parts. Softening in these cases, more especially in the heart, is sometimes associated with a fatty degeneration of the structure of the organ. (See the chapter, in the article Heart, on fatty degeneration of its structure, § 224, et seq.) I have stated, when treating of apoplexy, that the change in the vessels of the brain, and in those of the heart, are sometimes the same at ad- vanced age ; and that whether the change be spe- cific deposits in, or atheromatous or fatty degen- eration of, the coats of the vessels, they frequently exist in the vessels of both these organs, and ac- count for the not infrequent complication of dis-' ease of the heart with either apoplexy or palsy. I 9. When the change in the arteries consists of atheromatous deposits in their coats—which de- posits were described by me in 1830, when writ-1 ing on the diseases of arteries, and were stated to ' " consist of a suety matter, greasy to the touch," &c. (see art. Arteries, $ 59)—then the struc- tures supplied by arteries thus affected are often not merely softened, but also otherwise changed ; the softened part being flabby, and as if infiltrated with serum, and with more or less oil-globules. In other cases, especially when this change in the arteries is connected with softening of the cerebral structure, serous effusion often accompanies it, especially into the adjoining ventricles, and occa- sionally as an infiltration of the softened struc- ture ; this effusion being probably the result of the physical condition of the organ, and either of the state of circulation in the part or in its vicin- ity, or of the atrophy sometimes attending soften- ing. Whether or no softening of the cerebral structure is attended by more or less of fatty de- generation, as observed in the heart, has not been ascertained; but it is not improbable that the fatty elements, contributing in their various degrees to produce what has been recently, and not always correctly, described as fat (and of which the earli- est notices are contained in various articles of this work, especially Arteries, § 59 ; Disease, § 135, et seq.; Heart, Structural Changes of, § 224, et seq.; Pleura, $ 100 ; Serous Membranes), are more or less augmented above the natural standard in the softened structure of the brain ; the healthy structure of the organ containing from three to eight per cent, of fat, which exists chiefly in the medullary structure. 10. Disease of, or obstructed circulation through the veins, produces softening of the tissues, the blood of which passes to the affected veins ; but the softening generally presents peculiar charac- ters. It is always attended by great congestion, or infiltration of serum, or ecchymoses, or by all three. The vital tone or cohesion of tissues thus circumstanced is already partially lost; and when they are subjected to any irritation, inflammatory action of an asthenic character is soon produced, which rapidly spreads, still farther softens the part, and ultimately destroys its cohesion and or- ganization. 11. D. The organic nervous influence of a part is more or less impaired, either previous to, or in connexion with, the changes already noticed as productive of softening. But this influence may be impaired primarily, and chiefly, and independ- ently of any of the changes now adduced. It is thus impaired either congenitally or hereditarily, or by the injurious agents in operation during early life ; and the consequences are a preternat- ural softness and flabbiness, and impaired vital cohesion of all the structures, not excepting even the bones, which, as shown in rickets and scrof- ula, are not only slowly and imperfectly devel- oped, but more or less softened, especially in their spongy parts. This chrome form of general soft- ening may exist in the foetus, without being he- reditary ; it may be hereditary, and yet not appear until some indefinite period after birth, as when it proceeds from scrofulous parents. It may be acquired from the nature or the supply of nour- ishment, or from the want of pure air, &c. ; the scrofulous, or rickety, or tubercular habit of body being thereby produced in young subjects, and the scorbutic at more advanced ages. Scurvy furnishes one of the most remarkable illustrations of chronic general softening, or general impair- ment of vital cohesion, advancing in a slow and progressive manner, commonly in adults, rickets equally illustrating it in children. The general cachexy resulting from the syphilitic poison, or from mercury acting in poisonous doses or modes, or from the use of the ergot of rye, or from other poisonous substances, is chiefly characterized by softening, implicating more or less the whole of the structures, although manifested especially in certain tissues, particularly the cutaneous and cellular, the osseous and periosteal, the mucous, &c, and, in certain of these, passing extensively into ulceration, of which softening is a general antecedent. 12. E. Softening often depends upon the asso- ciation in various degrees of the foregoing morbid states, especially those causing partial or limited softening, and, even when thus associated, in its slighter grades it may be transitory, as when it occurs from oedema, or saturation of the tissues of a part with serum. Such saturation may proceed from local weakness of the tissue, or of the capil- laries supplying it, or from more general debility, or from local changes, as obstruction in the return- ing circulation of the part, or obstruction of the absorbents, causing this lesion. The serous infil- tration may be soon removed, or it may persist, or it may increase, and the attendant or consequent softening may also increase, and even go on to disorganization; certain intermediate changes, however, sometimes appearing, especially asthen- ic inflammation. In these cases, the infiltration of serum, by its macerating property, weakens the vital cohesion of the tissue, or, by the possession of an irritating quality, induces a diffusive or asthenic inflammatory action, frequently passing into gangrene. The mere separation of the in- timate structure of cellular or adipose parts, by the infiltration into it of an inorganized and inor- ganizable fluid, if continued long, tends to loosen the vital cohesion of the part; and when this fluid contains, as often occurs, excrementitious or in- jurious materials, the result is both increased and hastened, especially as it often also associates with it other changes, seated in the vessels supplying the part, tending most rapidly to gangrenous soft- ening. 13. CEdema, or serous infiltration of the sub- stance of the brain, whether the antecedent orthe concomitant of softening of the cerebral struc- ture (for it may be either the one or the other), generally induces and accelerates the softening process in this structure more remarkably than in any other organ ; complete disorganization, SOFTENING OF STRUCTURE—Treatment of. 925 or decomposition, being thereby often rapidly in- duced. * Few parts, either by their physical con- dition or by the nature of their organization, are more frequently subject to serous saturation than the brain; and although the serous exudation is most frequently excessive between the mem- branes and in the ventricles—more or less fluid being always in these situations—still the ex- cessive accumulation of it in the ventricles will often affect the vital cohesion of the surrounding structure, so as to predispose to, or occasion soft- ening in this situation or in the vicinity, espe- cially in the scrofulous diathesis and in rickety habits, in which the vital cohesion of the tissues is generally weak. 14. Congestions of blood in parts, asthenic and erysipelatous inflammations, the accumulation of excrementitial and irritating materials in the cir- culation, and the operation of animal and contami- nating poisons, all in their several grades occasion more°or less softening, which is most remarkably manifested in those tissues, the organization of which is most loose or yielding, as cellular or mu- cous structures and parenchymatous organs. In these, especially, the softening is followed by the exudation of a fluid, which is neither pus nor con- crescible lymph, even when the softening is most inflammatory, but which, in the scrofulous diathe- sis, is either tubercular, or curdy, or sanious, or an association of these ; and in persons who are con- stitutionally exhausted, or whose blood is self- contaminated or otherwise poisoned, the morbid fluid, serous or sanious, infiltrates the adjoining tissues, softens them with various degrees of ra- pidity, and ultimately disorganizes or decomposes them. These consecutive states of softening, whether manifested in external or internal parts, in cellular and adipose tissues, or in mucous or parenchymatous organs, are presented to our ob- servation in the course of adynamic or malignant fevers, and after the absorption of puriform and sanious matters into the circulation, and in the several forms of erysipelas ; and whether puriform matter be formed in the softened part, or a sanious fluid, or a foul, contaminating serum, infiltrating adjoining parts, they always tend to farther disor- ganization, or decomposition or gangrene super- venes, unless vital power and resistance be re-en- forced, and the contaminating state of the circu- lation be counteracted or remedied by suitable treatment. 15. II. The Therapeutical Indications ap- plicable to softening of structures should be based upon the pathological states from which it appears to proceed, or with which it is associated. But the result of treatment will entirely depend on the acumen of the physician in detecting this con- dition of structure and the changes in which it originates, and in attributing to each its due in- fluence, and in adapting his means of cure to their several grades and relations. When treating, under their proper heads, of the several states of softening, as manifested in different structures, I then pointed out the measures most appropriate for each ; and, reviewing this lesion as one of the most advanced, and as one of the most dangerous, I then more especially considered the treatment most conducive to the removal of the changes from - It is not improbable that softening of the nervous centres is favoured, if not caused, by a deficiency of sul- phur or of phosphorus, or both, and of their combina- tions, in the cerebral structure, these substances being always present, but in varying quantity in this structure, in its normal states. which it proceeds. Whether arising from inflam- mations, especially the asthenic—or from conges- tions, hypostatic or others—or from obstruction of vessels, arterial, venous, or lymphatic—or from morbid matters conveyed into the circulation, and thereby affecting predisposed or previously dis- ordered parts—or from the diminution of certain elements necessary to vital density or cohesion, as phosphorus, or sulphur and their combinations —or from morbid poisons changing the states of organic nervous power, and of the circulating fluids, more or less generally—or, lastly from the nature of the food and from states of nutrition— the treatment of softening of structure has re- ceived due consideration, as respects, not only this particular lesion, but also the changes from which it proceeds. In the several articles on Abscess (y 62); Absorption (y 15, et seq.); Arteries (y 40, et seq.); Arts and Employ- ments (y 23, et seq.); Brain, softening of the (y 214, et seq.); Cachexy (y 4, et seq.); Cellular Tissue (y 9, et seq.); Choleric Fever of In- fants (y 11, et seq.); Congestion of Blood (y 12, 13,); Debility (y 25, et seq.); Digestive Canal, softening of (y 34, seq.); Dysentery, Asthenic (y 88, et seq.); Erysipelas (y 64, et seq.); Fever (y 559, et seq.); Gangrene (v 57, et seq.); Haemorrhage (y 40, et seq.); Heart, softening of (y 216, et seq.) ; Inflammation, Asthenic (y 236, et seq.); Intestines, soften- ing of, (v 131, et seq.); CEdema, Pestilences, especially the Haemogastric and Plague (in nu- merous places); and Scrofula. 16. In the treatment of softening of individual structures, as well as of the general softening of the tissues consequent upon malignant fevers, and morbid states of the circulating fluids, atten- tion should be chiefly directed to those patho- logical states of which softening is the conse- quence ; and these ought to be either removed or counteracted by means suited to these states, the most important of which have been indicated above (y 6, et seq.), or more fully mentioned in the articles just referred to. But it should always be remembered that the removal of the causes— a supply of deficient elements, in medicines, ali- ments, and mineral waters ; a suitable diet and reo-imen ; a pure, dry, and bracing atmosphere, with free ventilation ; a healthy discharge of the digestive fuctions, and the use of pure or appro- priate mineral springs—are the chief means of cure. Bibliog. and Refer.—R. Hooper, The morbid Anat- omy of the Hum. Brain, illustrated by coloured Engrav- ings of Organic Diseases of that Viscus, p. 17, 4to. Lond., 1828.—Mirat, In Diet, des Sciences Medicates, t. xliii., p. 161.— L. Rostan, Recherches sur une Maladie encore peu connue, qui a recu le nom de Ramollissement du Correau, Svo. Paris, 1823.—Lallemand, Recherches Anatomico- pathologiques sur l'Encephale et ses Dependances, 3 tomes. Paris, 1820.—1836, pluries.—R. Carswell, On Softening of Organs, in Cyclop, of Pract. Med., vol. m. p l.—A. Grisolle, Traite Elementaire et Pratique de Pa- thologie Interne, 8vo, 2 vols., 4th edit. Paris, 1850, plu- ries.—J. Vogel, Icones Histologias Pathologies, Tabulae Histologiam Pathologicam Illustrantes, &c, Latin et Germ., 4to. Leipsig, 1843, pluries.—J. Vogel, The Path- ological Anatomy of the Human Body. Transl with ad- ditions, by G. E. Day, p. 405, 8vo. Lond., 1847.—P. C. A. Louis, Memoires ou Recherches Anatomico-Patholo- giques sur le Ramollissement, &c, 8vo. Paris, 1826.— Cruveilhier, Anat.-Patholog. du Corps Humain, &c, 2 ts. folio. Paris, 1830-42, pluries.— C. Rokitansky, A Man- ual of Pathological Anatomy. In four volumes. Transl. for the Sydenham Society, 8vo. Lond., 1849-50, pluries. —E. A. L. Hubenrr, Specielle Pathologie und Therapie, b. 1. p. 58 8vo. Erlang— These, as well as other author- ities, may be consulted, but different views have been taken by them of softening of structure from those enter- 926 SPASM—Varieties of. tained by the author. (See also Bibliography and Ref- erences to the Articles just referred to, as well as to others in which softening of individual structures is treat- ed of.) IS. D. Gross, Elements of Pathological Anatomy.—W. E. Horner, Path. Anatomy.] SPASM —Synon.—Spasmus, anao/ioc (from anau); Hyperkinesia (from vtrlp, and xivqaic). I. Frank; Mobilitas nervosa nimia, Auct. var. Ataxia Spirituum: Spasmes, Fr. Krampfe, Germ. Cramp. Classif.—II. Class, II. Order (See Pref- ace). Definit.—Involuntary or abnormal actions of muscular parts; or, in other words, contractions of muscular structures, different in continuance, or in severity, or in recurrence from healthy action; con- stituting a generic pathological condition; and al- though most commonly a sympathetic, yet an im- portant morbid state. 1. I. Varieties of Spasm.—The ancients com- prised under the term spasm all convulsive af- fections or movements, but the sense in which the word is now and more strictly applied is the contraction or tension of a muscular structure, independently of volition, and often disposing to or followed by convulsion. Spasm, or cramp, fre- quently exists without convulsion ; it may affect either voluntary or involuntary muscles; and in either of these situations presents varying char- acters ; and it may be attended by consciousness, or by an abolition of sensation, or even by various derangements of sensibility and mental manifest- ation. The supporters and followers of the nerv- ous system of pathology, especially Stahl, Hoff- mann, Juncker, Sauvages, Cullen, and others, attached great importance to this morbid condi- tion, and sometimes inferred its existence, espe- cially in internal and involuntary structures, where there was no evidence of its presence. Although the partial revival of the humoral pathology, to which the early articles of this work have in no small measure contributed, especially those on the Blood, on Disease, on Absorption, Excre- tion, Infection, &c, has in some degree di- minished the importance which had been attach- ed to spasm as an influential pathological state, still it performs a part of considerable interest in the general doctrine of disease. 2. Sauvages arranged under spasm all involun- tary muscular contractions, and divided them into tonic and clonic. Under the former appellation he comprised those contractions which were more or less permanent or continued; under the lat- ter he ranged those which alternated with relaxa- tion ; and both forms of spasm he divided into partial and general. Partial tonic spasm, accord- ing to him, embraced strabismus, trismus, torti- colis, priapism, and cramp attacking any of the voluntary muscles. General tonic spasm consisted only of tetanus and catalepsy. Partial chronic spasms were carphologia, pandiculation, trcmour, palpitation, &c.; and General clonic spasms were eclampsia, epilepsia, hysteria, chorea, &c. Cul- len adopted the view of Sauvages, in consti- tuting spasmodic affections a distinct order of nervous diseases. Pinel, however, did not con- sider that the spasmodic state should be made the basis on which an order of disease might be founded. 3. It is very doubtful whether or no catalepsy should be viewed as a species of general tonic spasm, or even as a spasmodic affection at all. I have seen several cases of true catalepsy, and in these there was no increased action of muscles apparent. In cataleptic ecstasy, however, many of the voluntary muscles are more or less con- tracted ; and when catalepsy occurs in connexion with hysterical attacks, muscular contractions oft- en precede the cataleptic state. In most of the convulsive affections arranged under eclampsia, epilepsy, and hysteria, the seizure is generally tonic at its commencement, and clonic towards its termination ; so that it is very difficult to dis- tinguish between those convulsive or spasmodic affections which are tonic or which are clonic, these terms being altogether conventional, and the morbid states which they are intended to rep- resent passing gradually and insensibly from the one into the other. 4. MM. Pinel and Bricheteau divided spas- modic affections into those which are unattended, and which are attended by lesion of the faculties of intelligence. Dr. Mason Good arranged these latter under the genus " Comatose Spasm," as- sighing convulsions, hysterics, and epilepsy to it, as species. But hysterical spasm is often unat- tended by any comatose affection, or loss of sen- sibility ; and here, as well as in other morbid con- ditions, the difficulty of classification becomes ap- parent. Dr. Good divided his order of spasmodic affections, or nervous disorders affecting the mus- cles, into three genera, consisting of " Constric- tive Spasm," of " Clonic Spasm," and of " Syn- clonic Spasm." Theirs/ of these comprised pria- pism, wry neck, distortion of the spine, muscular stiff-joint, cramp, locked-jaw, tetanus, rabies, and suppressed pulse ; the second, hiccough, sneez- ing, palpitation, nictitation, subsultus, pandicu- lation ; the third, tremour, chorea, shaking palsy, raphania and barbiers. 5. Dr. Good defined his genus " Entasia," or constrictive spasm, to be " irregular muscular action producing contraction, rigidity, or both." The genus clonus, or clonic spasm, he described as " forcible agitation of one or more muscles in sudden and irregular snatches," or, in other words, agitative or tremulous motions of the muscles. The genus synclonus, or synclonic spasm, he stated to be " tremulous, simultane- ous, and chronic agitation of various muscles, especially when excited by the will," or a " mul- tiplied conjunctive or compound agitation, or tremulous motion." The reader, upon consid- eration of the above definitions, will be at a loss to perceive the generic differences between the genera, clonus and synclonus, and he may not be satisfied that tremour and shaking palsy should be ranked as species of spasm. 6. Spasmodic action may occur in either volun- tary or involuntary muscular structures. In the former it may be limited to one or more muscles, or extended to several, or even more or less gen- erally ; it may also, when so situated, be either simple, or associated with unconsciousness. In the latter class of structures, it is always partial or limited, and is generally complicated with ir- ritation, or congestion, or inflammatory action, in adjoining or related parts. Spasm, moreover, is most frequently and strictly a symptomatic af- fection, and is rarely a primary or idiopathic dis- order, unless when it occurs in the form of cramp, or from over-exertion of the muscles affected, or from bringing muscles that have been long dis- used into action. 7. Spasm may be arranged into, 1st, that af- fecting involuntary muscular structures, or those SPASM—Pathology of. 927 parts which are supplied only or chiefly by gan- glial nerves ; 2d, that attacking muscles which are influenced by voluntary nerves ; 3d, spasm implicating both involuntary and voluntary struc- tures ; and, 4th, spasm associated with want of consciousness. When spasm is seated in either involuntary or voluntary parts, it may be of va- rying duration ; it may be continued for a time, and then permanently relaxed; it may be thus continued, and afterward recurrent or convulsive ; or it may be recurrent or agitative from the com- mencement, thus presenting either of, or all the forms classed by Dr. Good as tonic, clonic, and synclonic, and being either partial, or limited, or more or less general. The limited states of spasm may be of considerable duration, and may even pass into a state of permanent contraction, although this may be a rare occurrence. Sever- al of the unnatural positions of organs or parts, as those of the eye, extremities, &c, have been attributed to spasm of particular muscles ; and probably the mal-position may have originated in this state, the contraction becoming permanent, while the spasm no longer existed; but it may have equally originated in a paralyzed condition of antagonist muscles. In these cases care should be taken to distinguish between tonic spasm, per- manent contraction of muscles or parts, and the deficiency of antagonist action. 8. i. Spasm of involuntary structures is an ele- ment of several diseases. It is most common in the digestive canal, in various parts of which it may exist in succession, generally in a recurrent, although sometimes in a more continued form. It may be limited to this canal, or be extended to adjoining parts, or even to voluntary organs. It may, when affecting the alimentary canal, be merely an exaltation of the peristaltic motion, as in diarrhoea or dysentery ; or it may be more se- vere, and attended by inverted action, as in vomit- ing, spasms of the pharynx or of the oesophagus. In these cases the spasmodic state is favoured either by extreme debility and sensibility of the seat of the disorder, or by inflammatory irritation, and is directly occasioned by any irritating sub- stance. In any circumstance, the spasmodic ac- tion will be produced by irritations sufficiently great to excite it; and when the vital power of the parts is low, and the susceptibility great, even the accumulation of the natural secretions within these parts, or a vitiated state of the secretions, is sufficient to cause spasm, as evinced by certain states of diarrhoea, by vomitings, by colic, bilious cholera, &c. When any irritating body is brought in contact with the mucous surface of the digest- ive canal, whether that be gaseous, fluid, or con- sistent, spasm will generally affect the parts there- by irritated, or their more immediate vicinity. The same effect follows inflammatory action and ul- ceration, which are often followed by spasmodic action, as demonstrated in various parts of this canal, in the pharynx, the oesophagus, the stom- ach, the duodenum, the small and large intes- tines. Similar causes produce similar effects in the urinary passages, and even in the respiratory passages. In these latter the spasmodic action is often the most remarkable, and is generally followed by very manifest effects. 9. Various involuntary canals or parts have been supposed to be seats of spasm in certain disorders without sufficient reason. Thus the gall-ducts have been accused of spasm in some states of jaundice, and the capillary vessels in the cold stage of fevers. That irritating or morbid bile, or irritants at the mouth of the ducts in the duodenum, may cause spasm of these ducts, is very probable, but there is no palpable demon- stration of this effect. That there is an apparent constriction of the capillaries, especially of those on the surface of the body, is very manifest in the cold stage of fevers and in states of vital depression ; but it does not follow that the con- striction is the consequence of spasm. It is merely the result of the contraction of these ves- sels upon a deficient amount, or the entire ab- sence of their contents, which are no longer pro- pelled with sufficient power to fill or distend them, during these states of the frame. 10. Spasm of the parietes of the cardiac cavi- ties has also been inferred to be present in cases of nervous palpitation, and when death has tak- en place suddenly, without any manifest organic lesion. That nervous palpitation is truly spas- modic, even when most exalted, is extremely doubtful. There is certainly remarkably increas- ed action and impulse, with all the symptoms de- scribed when treating this affection of the heart (see art. Heart, § 43, et seq.); but morbidly in- creased action is not quite identical with spasm, although often nearly approaching it. With in- crease of action, prolongation or irregularity of the contraction is generally present in the spas- modic state. If we admit the occurrence of spas- modic or spastic contraction of the parietes of the heart of a much longer duration than that which takes place normally, death must necessarily fol- low ; but I much doubt the existence of this le- sion, especially in such grade or continuance as to occasion death. It certainly has not been sat- isfactorily demonstrated, although admitted by some writers. 11. ii. Spasm of voluntary muscles or parts is of frequent occurrence, either in the form of cramps of particular muscles, or in that of con- vulsive action of several or many. Cramps in the extremities may follow over-action of the muscles attacked, or be symptomatic of disorder of the digestive canal, or of latent or inflamma- tory changes in the brain or spinal cord, or their membranes, or of the irritation produced by the circulation of effete or injurious materials in the blood, as in cholera, gout, &c. They may even follow a certain amount of pressure upon, or irritation of the nerves, supplying voluntary parts, either at the origins or in the course of these nerves, with or without any other manifest disorder. Cramps or spasm, of the lower ex- tremities especially, often precedes, recurring at intervals, for some time an attack of paralysis or apoplexy, particularly hemiplegia; and they often recur, in slighter grades, during the restoration of the lost power. Spasmodic actions of volun- tary parts may result from irritations in their vi- cinity, or in situations more or less remote, from irritations immediately affecting the nerves sup- plying these parts, or mediately and indirectly conveyed to them from a distance, as in trismus, tetanus, &c.; and the spasmodic action may be tonic or continued, or irregular or convulsive, or clonic or agitative, or recurring at intervals and occasioning snatches or starlings, and various ab- normal motions; or it may pass in succession through all those, as in irregular convulsions, in some forms of hysteria, and even in some cases of epilepsy. The spasmodic state, however, is subject to so many variations and anomalies, that 928 SPASM—Causes of. it is quite impossible to describe them correctly in all their details at this place. Those diseases in which spasm, in any of its forms, constitutes a principal element are fully described, and with especial reference to this morbid condition, under their special denominations ; it is requisite, how- ever, to notice certain associations of this condi- tion. 12. iii. Spasm may affect both involuntary and voluntary parts. It may extend from one order of parts to the other—most frequently from the former to the latter, if the succession of morbid phenomena be closely analyzed, although volun- tary parts manifest this disorder most evidently. Spasm, even when affecting most severely the voluntary muscles, may proceed from very re- mote sources of irritation, as I have shown in several places in this work before the subject was duly considered by any one else. Commenc- ing with those sources which are the nearest to the parts which are morbidly contracted, and con- cluding with those which are the most remote, we find that muscular structures may experience unnatural action or spasm in some one of its va- rying forms : 1st, from irritation in or near the seat of morbid action, as shown more especially in muscular canals—in the digestive, respiratory, and urinary passages ; 2d, from irritants affect- ing the nerves supplying the affected muscles, as evinced in both involuntary and voluntary parts ; 3d, from irritation or lesion of the spinal marrow at or near the origins of the nerves sup- plying these muscles ; 4th, from lesion (not nec- essarily structural) of parts of the brain, or of its membranes, having relations with the nerves going to the convulsed or spastic muscles ; 5th, from irritation of any portion of the digestive viscera and canal, or of the generative and uri- nary organs, transmitted by ganglial nerves to the roots of the spinal nerves, or to the spinal cord, and reflected the/ice by voluntary nerves to the external muscles and members ; 6th, from irrita- tion of any of the senses—of hearing, sight, smell, taste, or touch—transmitted to those parts of the nervous centres with which they are re- spectively in connexion, and thence reflected upon parts intimately related to them; thereby producing startings, tremours, sneezing, cough, retchings, or convulsive movements, as either of these senses are irritated or abnormally excited. These several sources of spasmodic action have been sufficiently illustrated in the articles Cho- rea, Convulsion, Epilepsy, Hysteria, Sympa- thy, Tetanus, &c. 13. II. Causes of Spasm.—i. The predispos- ing causes are the same as those fully described when treating of the individual species of spasm, these causes being generally common to all the species, the exciting causes, and the several in- trinsic circumstances or peculiarities of the pa- tient determining the form of the attack. He- reditary vice or disposition, congenital conforma- tion, a weak development of frame, the female sex, a warm and humid climate, the ages of in- fancy, childhood, and puberty, the critical epochs of females, premature sexual indulgence and mas- turbation, luxurious indulgences and voluptuous modes of living [the excessive use of tobacco and alcoholic stimulants], prolonged indulgence in bed or in sleep, inordinate devotion to music and poetical studies, excitement of the imagination, want of repose, mental anxiety, sleeplessness, ex- hausting discharges, the sudden suppression of accustomed evacuations, or of external pains; the gouty and calculous diathesis ; excited and ungratified, or insufficiently gratified, sexual pas- sions ; suppressed emotions ; the period of ute- ro-gestation, the puerperal states, abortions, ex- hausting lactation, inanition ; extreme states of vascular plethora, or of anaemia, &c, severally predispose, and often directly produce, some one or other of the usual forms of spasmodic disorder, or such states of spasm as may be considered as anomalous, or different from those commonly de- scribed by nosological writers. 14. ii. The exciting causes of spasm, whether specific or anomalous, are chiefly influences af- fecting the mind, the senses, the nervous centres, the alimentary canal and digestive viscera, the sexual and urinary organs, &c. ; more especially the violent emotions of mind, whether manifest- ed or suppressed ; severe disappointments and losses ; strong or strange impressions of the senses, startling noises, disgusting or horrible sights, objects of terror or surprise ; violent ex- citement and the influence of the imagination; titillation or irritation of the more sensitive parts of the surface, prolonged or violent pain ; disor- dered dentition and dental affections; derange- ments of the digestive canal, particularly the presence of worms, or of acidity, or of flatus, or of morbid secretions and excretions, or of faecal accumulations ; the passage of biliary calculi, or of disordered bile; irritation or excitement, or functional or structural lesions of the sexual or urinary organs or passages, calculi in the kidneys or bladder; inordinate or prolonged muscular ac- tion ; various organic lesions or external inju- ries, implicating either the parts affected, the nerves supplying them, or related portions of the nervous centres or their membranes ; sudden or extreme changes of temperature, or electrical con- ditions of the atmosphere; sudden suppression of discharges, eruptions, or external pain ; the dry- ing up of chronic ulcers; the nature of the in- gesta, especially acid or unripe fruit, poisonous articles mistaken for food ; the poison of lead, and numerous other injurious substances men- tioned under the head of Poisons. , 15. iii. The immediate or efficient cause of spasm —the pathological condition constituting this af- fection—has been a topic of contention among pathologists. It was generally ascribed to irrita- tion of the nerves supplying the affected muscles, either at their origins, in their course, or at their terminations; or to a sympathetic affection of these nerves propagated from distant but related parts to those thus attacked ; or to an irregular distribution through the nerves of the nervous influence or power, and determination of this in- fluence to the affected parts. Towards the close of the last century, Ritter, Sprengel, and oth- ers viewed spasm as a result of an alteration of the polarization of the terminations of the nerves in relation to the muscular fibres ; and this doc- trine, after having been neglected for half a cen- tury, has been revived at the present day, and supported by the connexion established between magnetism and electricity. This latter theory may admit of a certain degree of practical proof, by having recourse to electricity or galvanism, or of electro-magnetism, for the removal of spasm, an energetic recourse to either of these overcom- ing, as it does m slighter cases, as shown by my own observation, the morbid condition of the muscles. Nevertheless, the same agencies may SPASM—Diagnosis of—Prognosis of. 929 be viewed as equally successful in the removal of spasms, on the assumption of their dependence upon the irritation of the nerves in any way re- lated to the affected parts. The juvantia cannot always prove the nature of the affection. I have seen, as far back as 1820, the most severe cases of tonic and of clonic spasm produced by the in- ternal strangulation of a minute portion of the small intestines, and by the irritation of worms in the bowels, the violent affection of the volun- tary muscles having arisen from those causes and ceased with them, the irritation having been prop- agated by ganglial nerves to the roots of the spi- nal nerves, and thence reflected upon the muscles in which these latter nerves terminated ; the his- tory of these and numerous other cases favouring rather the old doctrine of irritation of nervous dis- tributions than the less old and recently-revived theory of altered polarization of the nervous fibres, with relation to the muscular tissue, in producing spasmodic actions. 16. III. Diagnosis of Spasm.—The existence or non-existence of spasm is in many cases re- markably evident; but in many others, even as respects some disorders which have been viewed as spasmodic, the evidence is by no means satis- factory. As to the insufficiency of this evidence in regard of some disorders, I have already hint- ed. We have no proof of spasm in any quarter in cases of catalepsy of a true pathological form ; at least, I could detect none upon a close exam- ination of several cases. The several forms of true tremour, as arising either from mental emo- tion, or from mineral or other poisons, or from functional or structural changes, evince no true indication of spasm. The disordered motion is merely the result of an imperfect determination or transmission of nervous power to the tremulous parts, owing to an insufficient or an interrupted Bupply of this power from the voluntary or invol- untary nervous sources, as either voluntary or in- voluntary parts are affected. 17. Various paralyzed parts may present states which may be mistaken for spasmodic affections; and the paralyzed state may rapidly pass into the spasmodic, and this latter into the former, which is much the most common. The existence, the morbid relations, and the translations of both these morbid conditions thus become extremely imperfect. Hysteria, the convulsions, and other spasmodic and anomalous affections of infants and children; diseases of the brain, or of its mem- branes, in the same class of subjects; diseases or injuries of the spinal marrow, &c.; epilepsy, ap- oplexy, paralysis, &c, either frequently or oc- casionally, present more or less of spasmodic ac- tion, often passing suddenly or rapidly into one of entire loss of power. The irritation, softening, effusion, compression, or other original morbid change affecting the nervous centres, while slight, or in a lesser degree, may occasion only cramps (spasmodic motions), but, when increased rela- tively to the state of nervous power, may cause the loss of all motion. We thus often observe that several maladies commence with more or less of spasm, or cramps in the extremities, es- pecially the lower, and soon pass into the para- lyzed state; apoplexy, epilepsy, paralysis, and various other specific and anomalous affections of the nervous system, manifest in many instan- ces this succession of lesion and of resulting phe- nomena. 18. Dr. M. Hall is of opinion that the spas- III. 59 modic affections ushering in many cases of these maladies commence, or are seated, in the super- ficial muscles of the neck; and that the spasm of these muscles, by compressing the larger veins, occasion congestion of the brain, and the several consequences of congestion when the spasm is not soon relaxed. He believes that " certain causes and principles, emotions and irritations, act directly or diastaltically upon the muscles of the neck," inducing what he designates " Tra- chelismus.-" "if this spasm can be dissolved, all its effects cease more or less perfectly." That the muscles of the neck are affected with spasm in many cases of hysteria, especially in the more severe or paroxysmal, cannot be doubted; and that those seizures which originate in violent mental emotions are often thus characterized, or even thus originate, may be conceded; but the spasm of these muscles is not so general, nor al- ways so early in the procession of morbid phe- nomena, as Dr. M. Hall supposes. When it does exist, and is either severe or protracted, the consequences which follow are generally serious; and it then constitutes an important portion of the courses of morbid actions and changes, each successive portion being the cause of that which follows it, as it is itself the consequence of that portion which precedes it. 19. Spasm of involuntary muscles must nec- essarily be imputed to irritation of the ganglial nerves supplying these muscles, or to some al- teration in the relations subsisting between the nervous and muscular fibres of the affected part. But when spasm attacks voluntary muscles, the irritation has been generally supposed to be seat- ed in, or to implicate, the voluntary nerves. It is, however, very doubtful whether the spasm of these muscles is so generally caused by irritation of voluntary nerves as is commonly believed. It is very probably so caused in many cases, as shown by injuries of the spinal cord, and by in- flammation of this part of the nervous system or of its membranes; but there are various diseases, in which spasm performs a chief or a subordinate part, where irritation of any part of the voluntary nervous system is by no means demonstrable, either the muscular fibres or the ganglial nerves supplying them being much more probably the primary seat of such disorder. In trismus and tetanus, in which the voluntary muscles are so severely contracted, there is no proof that the vol- untary nerves are primarily implicated ; for voli- tion produces no effect on the spasm, and what- ever lesion these nerves present, in some cases merely, may be consecutive much more probably than primary. In the most severe cases of spas- modic cholera, in violent cases of colic or ileus, and in others where a very limited injury is sustain- ed by a portion of intestine, as in partial stran- gulation, I have seen the spasm of the voluntary muscles as general as in tetanus, and continue in this state for long periods, and yet the cerebro- spinal nervous system must be inferred to have been free from all irritation but what was propa- gated to the spinal nerves from the ganglial nerves supplying the digestive canal. 20. IV. The Prognosis of Spasm may be most favourable, or the most fatal, according to the seat of spasm, and the circumstances in which it oc- curs. A spasmodic affection may terminate the life of an infant in a few seconds, especially when it is caused by disease about the base of the brain, or near the medulla oblongata, or their mem- 930 SPASM—Treatment of. branes; or it may cease in a very few minutes, where it is produced by acidity or by any other source of irritation in the alimentary canal. Clo- nic spasm of the diaphragm may arise, especially in young persons, from the deglutition of a hard or imperfectly masticated substance, or from acid- ity, flatulence, &c, or it may be the indication of a fatal issue in many acute and even chronic dis- eases. It may proceed from inflammatory action or irritation of one or more of the digestive or- gans, or from the sinking of vital power preceding dissolution. 21. Spasm affecting either involuntary or vol- untary parts is not attended by danger when it occurs in hysterical or nervous females, or when it cannot be traced to disease or injury of the brain, spinal marrow, or their membranes, or to antecedent or existing visceral disease, pectoral or abdominal. When, however, it has been pre- ceded or is attended by inflammatory action or by haemorrhage, or even by evidence of congestion of any important organ, or by effusion into any cavity, especially if haemorrhage has been excess- ive or effusion great, spasms of any part, and more particularly if they affect the diaphragm, or even the pharynx, oesophagus, or stomach, are a most unfavourable, and generally a fatal, symptom. 22. Spasms of either voluntary or involuntary muscles are always indications of great danger when they appear in the course of malignant or other fevers, and especially in an advanced stage of those fevers, or when they are present in pesti- lential distempers, or at the commencement of acute inflammation of abdominal organs, or at an advanced stage of chronic visceral or structural disease; the amount and imminence of danger depending upon the violence or malignity of the disease, upon the contamination of the blood, upon the stage of the malady at which spasms oc- cur, and upon their seats and extension. Spasms affecting the muscles of the superior extremities are always much more dangerous than those of the lower extremities, and, when they extend from the former to the latter, the danger is ex- treme. 23. Spasms of voluntary muscles attending gout or rheumatism are readily removed when they are caused by acidity and flatulence, or ac- cumulation of morbid secretions and excretions in the intestinal canal or in the biliary organs; but when in these diseases spasm appears inde- pendently of the disorders just mentioned, or when structural change is detected in the heart, or when the state of the urine indicates disease in the urinary organs or passages, more or less danger should be apprehended; and although present risk may be averted, a future attack, with its contingent danger, may supervene sooner or later. 24. Spasmodic attacks consequent upon pro- tracted lactation, upon menorrhagia, or profuse leucorrhcea, or upon other exhausting discharges, or upon manustupration or venereal excesses, or upon inanition or ancemia, are frequently tempo- rarily removed by treatment; but they return or assume a more serious aspect, if the morbid con- dition in which they originate be not removed by appropriate means, or they may pass from the hysterical character, in which they generally first present themselves, into the epileptic or into ma- nia or confirmed insanity. 25. Spasms occasioned by the extent or seat of injuries generally excite great anxiety, and an most frequently attended by danger. But the amount of danger, or even the absence of it, de- pends chiefly upon the nature and seat of injury, and the amount of vital shock (see art. Shock) attending it. When the cranium or spinal col- umn is the seat of injury, when there is a pene- trating wound or compound fracture, or when vital sinking indicates the violence of the shock sustained by the frame, the presence of spasm not merely complicates the injury, but also indi- cates its severity, and the imminent danger at- tending it. 26. V. Treatment.—It is obvious that the treatment of spasm should in a great measure de- pend upon the nature and seat of the disease, of which the spasmodic symptoms form either sub- ordinate or a most prominent part. When the spasm is more than a symptom, depending upon some special malady—when it constitutes an early, predominant, or principal morbid condition, either with or without loss of consciousness, it presents, according to its antecedent or associated and peculiar phenomena, certain special forms, which are described under the several heads of chorea, convulsions, epilepsy, hysteria, &c, and for each of which, in its several varieties, the treat- ment is fully described. It therefore remains only to state those general principles or indica- tions which experience indicates or contra-indi- cates, under certain circumstances and morbid conditions with which spasm is generally allied. 27. It would appear, from what has been stated above, that one or other of the different forms of spasm is contingent upon, or is produced by, one or other of the following pathological states: 1st, congestion ; 2dly, inflammation ; 3dly, irrita- tion caused by acid, acrid, or otherwise disorder- ed secretions and excretions ; 4thly, a contami- nated state of the circulating fluids ; 5thly, some structural lesion or injury affecting adjoining or remote nerves or the origins of nerves; 6thly, extreme exhaustion of organic, nervous, or vital power; 7thly, the excessive action of muscles, and the contraction of muscles independently of a co-ordinate or sufficient determination of voli- tion to them; 8thly, punctures or other injuries of tendons, nerves, or fibrous membranes ; 9thly, the irritation of the sexual or urinary organs; and, lOthly, two or more of the states conjoined. It will be seen, from a consideration of these an- tecedents, that spasm is most commonly a symp- tom of certain disordered or morbid conditions, to which attention should chiefly be directed in its treatment, and that it is only when produced as just indicated in the seventh and eighth of the above series of causes or circumstances, that spasm can be considered as a primary or idio- pathic disease. (See arts. Tetanus and Trismus.) 28. A. Congestion, in connexion with spasm, may be viewed both as an antecedent and associ- ate of this latter condition. It may, moreover, | be farther associated, as with irritation or some j structural lesion ; and as long as these are in ex- | istence, so long may the spasm continue or re- I cur, as various concurring causes may favour its return. The existence of congestion is often difficult to determine ; for when the spasm impli- i cates any part of the respiratory apparatus, or when it is so general as to give rise to convul- sions, with or without loss of consciousness, the congestion which is then made manifest is more the result of the spasm than the cause of it SPASM—Treatment of. 931 Congestion of tRe brain, or near its base, espe- cially if consciousness be lost, and congestion of the lungs and cavities of the heart, are common effects of general spasm or convulsions, especial- ly when any part of the respiratory passages is affected. Congestion may certainly exist in ei- ther organ antecedently to either spasm or con- vulsion, for it is frequently the cause of both; but the spasm may increase the congestion, and it may even be the cause of relaxing the spasm when the congestion becomes extreme. This lat- ter effect takes place chiefly in extreme conges- tion of the brain, when consciousness is lost; the congestion, in connexion with the circulation of imperfectly oxydized blood in the brain, both re- laxing the spasm and permitting the renewal of air in the lungs. The more moderate congestion in these cases first occasions spasm or convul- sions ; but when the congestion of unoxydized blood, increased by the convulsions, becomes ex- treme, then the spasms are relaxed and altogeth- er resolved, and either natural respiration is re- sumed, or death takes place from the cessation of respiration, owing to the effect produced by the congestion at the origins of the respiratory nerves. In cases of spasm, thus arising or thus associated, the treatment must be directed by the following intentions : namely, 1st, to diminish or remove congestion by means which experience has shown to be most efficacious in obtaining this object; 2dly, to prevent the recurrence of this condition and its contingent effects. 29. a. Spasm depending upon or connected with congestion of any vital or important organ has been too generally treated by large vascular depletions, both general and topical. In young, robust, and plethoric persons, and when the spasms have been consequent upon the stoppage of accustomed discharges, both the one and oth- er mode of depletion may be employed, but with extreme circumspection, more especially during the attack. In most even of these cases, local depletions are the safest and most efficacious; for when the circumstances just mentioned as warranting the depletion are not manifestly pres- ent, or when the patient is of a nervous tem- perament, either the local depletion should be small, or it should be altogether dispensed with, and other means be chiefly confided in. When local depletions are indicated, cupping is the most beneficial; and when the loss of any blood is justly dreaded, then dry-cupping may be resort- ed to. The circumstances indicating depletions, as well as those contraindicating them, require for their recognition great discrimination, guided by an enlightened experience, and are such, in their natures, complexities, and varied succes- sions and associations, as to be estimated correct- ly only at the moment by the closely observing physician. When, therefore, there is any doubt as to the propriety of blood-letting, it will be pref- erable to resort to dry-cupping, and to emetics and purgatives, conjoined with stimulants and antispasmodics—with these latter more especial- ly when nervous energy is much reduced or orig- inally weak. 30. b. Of emetics, especially when spasm is imminent, or when it attacks any part of the re- spiratory apparatus, the most energetic is the tinctura Lobelia, or Tinct. Label. Mtherea, given with vinum ipecacuanha to ensure its emetic op- eration, or with sulphas zinci. When vital or nervous power is much reduced, it may be given with spiritus ammonite aromaticus, or with cam- phor.* When blood-letting is manifestly indica- ted, or when congestion of, orvascular determina- tion to, the brain is urgent, then depletions and derivatives, as mustard pediluvia, should precede the exhibition of an emetic; and the affusion of cold water on the head, or cold sponging, may also be practised, the emetic operation and the relaxa- tion of spasm being often promoted by these means. When congestion of the liver is connected with spasm, local depletion, or dry-cupping, or both, are often required, and then the preparations of colchicum may be given, at first in a large dose, either with or without an emetic conjoined, and afterward relinquished for purgatives and anti- spasmodics. The operation of the first dose of colchicum should be carefully watched, particu- larly when large, and if vital depression follow it, stimulating antispasmodics, as ammonia, cam- phor, valerian, &c.,be exhibited. The spasms or convulsions which sometimes occur on the inva- sion of exanthematous fevers are often connect- ed with congestion, and for these an emetic and a warm bath are often of service. 31. c. Purgatives are generally beneficial, more especially when the liver or brain is congested, and when the spasm is connected with acidity aud flatulence of the digestive canal, or with ac- cumulations of morbid secretions, excretions, and faecal matters, as when spasms occur in colic, or in the course of gout, rheumatism, hysteria, hy- pochondriasis, &c In these, as well as in some cases of other diseases, not only are morbid ex- cretions thus liable to accumulate, but the blood becomes more or less contaminated by effete materials, which the impaired functions of the emunctories fail of removing. In these circum- stances, purgatives should be selected, with the view not merely of evacuating the contents or the bowels, but also of promoting the functions of excreting organs. When cerebral congestion is connected with spasms, then active derivative purgatives ought to be exhibited by the mouth and in enemata, and with this view, as well as with the intention of removing spasms by one of the most powerful antispasmodics that can be prescribed, a full dose of spirit of turpentine should be given with castor oil, or with other purg- atives, and administered in an enema. When the liver is congested or torpid, as may in many cases be ascertained by percussion, then calomel with camphor, and various other chologogue purgatives, will be most appropriate. 32. B. When the spasm is contingent upon inflammatory action, recourse to vascular deple- tions, general or local, is commonly required; and what has been stated above (y 29) respect- ing blood-letting is also here applicable to a great extent. It should always be recollected that in- flammations accompanied with spasm or convul- sion rarely admit of vascular depletions to the same amount as will be safely and advantageously borne in pure, uncomplicated inflammation. In- deed the depletions may even increase the spasm without materially diminishing inflammation, * [We doubt much the propriety of administering lo- belia emetics in any cases where " the vital or nervous power is much reduced." Such a condition powerfully predisposes to spasm, and it is very likely to be aggrava- ted by such a powerful acrid as lobelia. A simple emetic of ipecacuanha, or, if sedation is indicated, combined with a small quantity of antimony, will be preferable. We have known violent spasms produced by lobelia emetics in Thomsonian practice.] 932 SPASM—Treatment of. when injudicously employed, or when confided in chiefly, and when the inflammation is of an as- thenic character. In this latter state more espe- cially, and in other circumstances of this morbid alliance, deobstruent purgatives, conjoined with stimulants and antispasmodics, are required; and even in cases where vascular depletions are most indicated, not merely such purgatives, but also stimulating antispasmodics, may be most benefi- cial, with other restoratives which the peculiari- ties of the case will suggest. In some instances an emetic, judiciously selected and combined, will also be of much service, after depletion has been resorted to, when clearly indicated. In the worst form of spasm, as in that contingent upon as- thenic or cachectic inflammation, for which blood- letting is generally more injurious than beneficial, the early exhibition of an emetic, followed by purgatives, and by tonics conjoined with alka- lies, antispasmodics, counterirritants, &c, will be found more certainly useful than other means. 33. Spasms of the voluntary muscles, either limited or more or less extended, are often pro- duced by inflammation at or near the origins of the nerves supplying the affected muscles, or by inflammatory action, or irritation of the mem- branes in the vicinity, or by disease of the adja- cent bones, as shown when treating of lesions of the brain, spinal cord, and membranes, or of the cranium or spinal column; and for these, although general or topical bleeding may be requisite, ac- cording to the nature and features of the case, purgatives, alteratives, derivatives, counterirri- tants, sedatives, and the other means fully set forth in these articles, are especially required. 34. C. The dependence of spasm on acrid, mor- bid, or other irritants in the digestive canal is of frequent occurrence, both primarily and uncon- nected with any special malady, or so associated, as in gout, hysteria, &c. In all these circum- stances, emetics, purgatives, anthelmintics, &c, as above recommended (y 30, et seq.), are indis- pensable. In the gouty and rheumatic diathesis, equal parts of magnesia and sulphur, taken on several occasions, and followed by a more active cathartic, will be found efficacious ; and if there be reason to infer the presence of worms, the spirit of turpentine with castor oil, or anthelmin- tics, purgatives, &c, will be generally indicated ; but they should be afterward followed by chaly- beates, tonics, and antispasmodics, as recom- mended in the article on Worms. 35. Irritation of the higher portions of the ali- mentary canal by the irruption of acrid bile into the duodenum often occasions spasms of the ab- dominal muscles and calves of the legs, but these generally subside after the evacuation of the mor- bid matters; dilution of the acrid secretions by warm, emollient fluids, narcotics subsequently, and mild purgatives afterward, effecting a com- plete cure, generally in a short period. (See Cholera, &c.) 36. D. Spasm is not frequently occasioned by contamination of the circulating fluids, unless at a far advanced period of febrile and pestilential dis- eases, as in pestilential cholera, and when the functions of the kidneys are impaired, interrupt- ed, or otherwise disordered. In these circum- stances vital power requires support, while mor- bid matters are evacuated and the actions of the depurating organs are excited by their appropri- ate stimuli. We should, moreover, endeavour to change or counteract the influence of those ma- terials which thus accumulate in the blood—fo remove or neutralize them. They can be re- moved only by increasing the functions of the emunctories, and they may be neutralized by ap- propriate alkaline or mineral agents, and by anti- septic and antispasmodic medicines, as recom- mended when treating of the maladies in which spasms are most frequently observed. 37. E. Structural lesions, injuries, Jj-c, of the bones, or membranes near the origins, or in the course of, the nerves supplying the extremities or voluntary muscles not infrequently occasion spasm of these muscles, and require the means already recommended (y 29, et seq.), modified according to the nature of the lesion or injury, and to the peculiarities of the case in other re- spects. In these states of disease the perform- ance of the several excreting functions requires especial attention, and the evacuations a partic- ular examination. 38. F. Extreme exhaustion of vital or nervous power, causing spasm or irregular or convulsive actions of voluntary muscles, or of involuntary parts, is often irremediable, especially when it ap- pears at an advanced stage of pestilential or fe- brile maladies, or after large losses of blood, and in the course of exhausting or contaminating dis- eases. In these circumstances, powerful stimu- lants and antispasmodics—wine, opium, cam- phor, ammonia, oxyde of bismuth, ammoniated copper, cajuput oil, phosphoric acid, the prepara- tions of sumbul, arnica montana, the ethers, brandy, &c.—are necessary, and one or more of these may be conjoined with such preparations of iron, or of asafcetida, or of valerian, of zinc, of silver, of phosphorus, cannabis Indica, or of musk, castor, &c, as the peculiarities of the case will suggest. 39. G. When spasm or cramp is caused by ex- cessive action of the affected muscles, or by con- traction of muscles without a due determination of volition, it generally soon ceases, and requires merely frictions and quiet. If it recur, friction with stimulant liniments, the application of warm embrocations near the origins of the nerves or por- tion of the spine enclosing these origins ; frictions with chloroform or ether, or with turpentine and camphor, either over the affected muscles or along the spine ; and subsequently the cold douche or affusion, or sponging the spine night and morning with a tepid or cold solution of bay-salt, followed by gentle friction with the hair glove, &c, will generally prevent a recurrence of the spasm. 40. H. Punctures or injuries of tendons, c\c, are occasionally followed by trismus or tetanus, the most continued and dangerous form of spasm, and one which requires, more than almost any other disease, the most energetic stimulants, anti- spasmodics, and tonics; the powerful doses of sedative and narcotic substances rrerrrally resort- ed to for this affection tending rather to hasten than to avert dissolution. (See arts. Tetanus and Trismus.) 41. /. The influence of the sexual organs in pro- ducing spasm or convulsion is especially mani- fested by the female. But there are often other morbid conditions present besides either irritation, congestion, or inflammatory excitement, or vas- cular determination of these organs. Generally nervous power, especially organic nervous power, is disordered or depressed, the secretions disor- dered, and the excretions insufficient or retained; consequently, assimilation is impaired, and the SPINAL COLUMN—Pathological Relations of. 933 blood poor. The affection of the sexual organs is readily induced by mental emotion or desire ; and this affection reacts upon the brain and nervous system generally, is propagated by the ganglial system to both the abdominal and thoracic viscera, disordering the functions of the urinary organs, occasioning spasmodic actions of the alimentary canal, respiratory organs and passages, and often exciting spasms or convulsions, or both, by the extension of the irritation to the roots of the spinal nerves, and even to the spinal marrow, medulla oblongata, and brain. 42. The treatment hitherto recommended in these cases has consisted chiefly of stimulants and antispasmodics, and have been but insuffi- ciently directed to the sexual organs and to the mind. The morbid or irritated state of these or- gans should be removed, and sexual desires sup- pressed. Instead of stimulants and heating an- tispasmodics, cooling medicines, as nitre, small doses of camphor, magnesia, alkalies, &c, should be given in bitter infusions, and the mind ought to be occupied agreeably and profitably. When spasmodic affections occur in females or males, especially if the countenance become pallid or sallow, then the most noxious vice of all vices should be suspected, namely self-pollution (see arts. Debility and Pollution) ; and unless this be relinquished, and the mind be healthily and morally regulated, medical treatment will be of no avail. (See arts. Chorea, Colic, Convul- sions, Epilepsy, and Hysteria.) Bibliog. and Refer.—Hippocrates, Tlepi raw tv kcQi- \i\ Tpconaruv, Opera, p. 906.—Avicenna, Canon., 1. iii., fen. ii., tr. i., cap. 1, 18. — Bokel, Dissert, de Spasmis. Helmst., 1587.— Schenk, Observat., 1. i., no. 242.—/. R. Saltzmann, De Spasmo seu Convulsione,