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         THE






    CYCLOPEDIA



         OF





PRACTICAL MEDICINE.
VOL. I. 
C/ pth-
<? 
THE
             CYCLOPEDIA

                         OF


    PRACTICAL  MEDICINE:

                       COMPRISING

TREATISES ON THE NATURE AND TREATMENT OF DISEASES, MATERIA MEDICA

       AND THERAPEUTICS, MEDICAL JURISPRUDENCE, ETC., ETC.

                      EDITED BY

           JOHN FORBES,  M.D. F.R.S.
              PHYSICIAN TO THE QUEEN'S HOUSEHOLD, ETC.

       ALEXANDER  TWEEDIE, M.D. F.R.S.
   PHYSICIAN TO THE LONDON FEVER HOSPITAL, AND TO THE FOUNDLING HOSPITAL, ETC.

              JOHN CONOLLY, M.D.
       LATE PROFESSOR OF MEDICINE IN THE LONDON UNIVERSITY, PHYSICIAN TO
                THE HANWELL LUNATIC ASYLUM, ETC.

   THOROUGHLY REVISED, WITH NUMEROUS ADDITIONS, BY

           ROBLEY  DUNGLISON, M.D.
    PROFESSOR OF INSTITUTES OF MEDICINE IN JEFFERSON COLLEGE, PHILADELPHIA,
       LECTURER ON CLINICAL MEDICINE AT THE PHILADELPHIA HOSPITAL, ETC.
" Hec demum sunt quae non subgessit phantasiae imaginatricis temeritas sed phenomena practica
                  edocu e re."—Sydenham.
  IN FOUR VOLUMES.

         VOL. I.
ABDOMEN —EMM ENAGOGUES.
       PHILADELPHIA:
BLANCHARD  AND  LEA.
             1859. 


            Entered, according to Act of Congress, in the year 1645, by

                     LEA  AND  BLANCHARD,
in the clerk's office of the District Court of the United States for the Eastern District
                                 of Pennsylvania.
FAGAN, -STEREOTYPER.
COLLINS, PRINTER 
PREFACE OF  THE  AMERICAN EDITOR.
  It is  now upwards  of twenty years since  the  undersigned  agieed  to
engage with Dr. Copland and the late Dr. Gordon Smith, in the preparation
of an Encyclopaediac Dictionary of Practical Medicine, which should hold
the same relation to the department of Medicine, that Mr. S. Cooper's Sur-
gical Dictionary does to that of Surgery.  The project was conceived and
advertised in the year 1824, in the " London Medical Repository," of which
Dr. Copland and the undersigned were editors.   A prospectus of the under-
taking was drawn up, and arrangements were made for its publication with
the Messrs. Underwood, of London.   Towards the  latter end of that year,
the undersigned left England for the University of Virginia; and the panic,
which prevailed  in 1825 in the commercial world,  according to Mr. Petti-
grew, (Medical Portrait Gallery, Art. Dr. Copland,) caused  the publishers
to relinquish the undertaking.  It probably, however, gave the impulse  to
the appearance  of  the " Cyclopaedia of  Practical Medicine," of Drs.
Forbes, Tweedie, and  Conolly.  Of the signal  value of this  great work,
there is but one sentiment.  The general voice of the profession everywhere
nas, indeed,  sufficiently shown, that  the  hope expressed by the British
editors, in their Preface, has been amply realized.  It is  admitted, that they
have prepared a work  required  by the present wants of medical readers,
acceptable to the profession in general, and in all respects " a standard
work on the Practice of Medicine."   It was for  this  reason, and owing
to the  high opinion expressed of its merits by those on  this side of the
Atlantic, who had the good fortune to consult its pages, and to the anxiety
of the best informed that it should be rendered more available to the pro-
fession in this country, that the publishers determined, at a great outlay of
money and of labour, to reprint it.
  At their request, the undersigned  consented  to superintend the repub-
lication,  to  revise the  various  articles,  and to make  such additions and
modifications as  he might deem  desirable.  To  this determination he was
impelled, in part, by his knowledge  of the accomplished editors, and his
consequent anxiety, that the different articles should be preserved, as  far  as
practicable, in their pristine integrity.   Generally  speaking, they were  so
full and comprehensive, that but little modification seemed to be necessarj
In all cases, however, the undersigned has endeavoured to add the facts and
                                A*                            v) 
VI
PREFACE  OF  THE AMERICAN  EDITOR.
opinions, which form part of the medicine of the day, and to omit nothing
calculated, in his view, to throw additional light on the subjects canvassed.
These additions he has striven to make in such a manner as not to interfere
with the general tenor of the articles; and to cause them to read as if they
had proceeded from the pen of the original writers. The interstitial additions
are enclosed in brackets [ ].  Besides these, he has inserted different topics,
which had been wholly omitted in the English edition, some  of which are
essentially American in their character.   To these additions  his  signature
is appended.  For one article, on the History of American Medicine before
the Revolution, he is indebted  to Dr. J. B. Beck, of New York.
  In making these additions,  the  undersigned has endeavoured to be as
brief as perspicuity would permit; and, where his opinions have been fully
expressed elsewhere,—to avoid repetition, he has referred to them for further
details.   On  every occasion he  has  been  anxious  to cite the views  and
observations of cotemporary, and particularly of American, writers, where
such views and observations appeared to him to  merit especial notice.
  Appearing, as the work originally did, in parts, articles were necessarily
omitted in their proper places, and many were thrown into  a supplement.
This defective arrangement has been rectified as far as was practicable, so
that the American edition will, in this respect, be found to possess advan-
tages, as a book of reference, over  its English  prototype.
  The History of Medicine, which, in the English edition, was prefixed to
the alphabetic portion, takes its proper  place in the third volume of the
American edition.
  One subject only has been omitted—Medical Bibliography—which formed
an appendix to the last volume of the English edition, and was subsequently
published in a distinct form.  This the publishers determined to discard, in
consequence of the additional cost to the purchaser, which its insertion
would occasion;  and of their  conviction, that notwithstanding its intrinsic
value to a few, and the high character of its author—Dr. Forbes—it would
be considered wanting in interest and importance to the many on this side
of the Atlantic, who will seek  the work as  a guide to Practical Medicine.
ROBLEY  DUNGLISON. 
PREFACE  FROM  THE   ENGLISH  EDITION.
   The Editors have at length the gratification of laying the Cyclopedia of Prac-
 tical Medicine before the public ,in a completed state.
   It is impossible for them to look at the list of  the Contributors by whose assist-
 ance  this work has been accomplished without a deep-felt satisfaction ; distinguished
 as that list is by so many names of celebrity in modern medicine, and including so
 many of the professors  and teachers in  London, Edinburg, Dublin, and Glasgow,
 whose reputation  conveys a high  and just  authority to their doctrines.  To have
 directed some part of the scientific exertions of  such  writers to  the pages of  the
 Cyclopaedia, and, also, to have elicited from not a few of the most accomplished
 among the provincial physicians of the empire, numerous and  valuable contributions
 which but for the  comprehensive plan of  this work  might never have been commu-
 nicated to  the profession, is a result to which the Editors  must e rer feel proud and
 gratified to have conduced.
   With such efficient aid in all the  parts of their undertaking, they have  spared
 no personal pains, in the  hope by uniformity of plan, simplicity of arrangement,
 and the harmony and consistency of its several  portions, to  make  the Cyclopaedia
 fully  and  fairly to represent  the state  of Practical  Medicine at  the time of its
 appearance.  From innumerable foreign and domestic sources the scattered know-
 ledge which has  so fast accumulated since  the  commencement  of  the  present
 century  has thus  been  gathered  together, and  placed at the command of every
 reader of the English language.  Those acquainted with  the actual limitation  of
 such  knowledge before the appearance of this work, and who have opportunities of
 knowing how slowly even valuable  novelties are  diffused in a  form giving any
 assurance  of their worth, will  best be able to appreciate the importance of the
 extensive means  of reference which the  Cyclopaedia  has at  once introduced into
 the library of many English practitioners at home and abroad.
   The ambition of the Editors was not limited to the formation of a mere manual,
 fitted for those  who only demand the  smallest  supply of exact intelligence with
 which practice can be  carried on, or professional station maintained without a
 palpable exposure of ignorance.  Their object was no less than to  prepare a com-
 pendium of the best parts of ancient and modern medicine, theoretical and practical;
 not passing over with disregard the vast literature of the ancient writers, but rather
 rescuing it from the voluminous oblivion in which  much of  it was  lost; and also
 collecting with care the more accurate, condensed, and applicable  knowledge  of
 modern authors and of  modern times into a liberal  and consistent system, from
 works little known to the generality of English  readers,  and familiarly known to
 very few.
  Thus, whilst the great claims of the older cultivators  of  medicine  have never
 been  forgotten, the labours of the moderns, and  more particularly  of the French,
German, and Italian pathologists,  by which, conjointly with those of British prac-
 titioners, the whole face of practical medicine may  be said to have  been  changed,
have  attracted  the most diligent  and thoughtful attention.   The  learned reade'
                                                                  (vii) 
viii          PREFACE  FROM  THE ENGLISH  EDITION.
does not require to be assured that the task of reference for specific information to
many older works, once of  high and deserved authority, and still esteemed, is often
both  tedious and little profitable, whilst their ample volumes yet contain  much
valuable matter, not unworthy of preservation, and which it is no fruitless employ-
ment to endeavour to place along with the better arranged facts of later writers, in
one view, before the practitioner and the student.  Throughout the prosecution of
this large  design, it has never been forgotten that the Cyclopaedia would be referred
to by various readers for various objects; by  the young practitioner as the  guide
and counsellor of practice,  especially when beset with practical difficulties ; by the
older practitioner for complete and  concise information, and  for  medical  learning
not scanty and  illiberal, but without scholastic pedantry;  and by the student for
applicable knowledge,  suited to the actual time, collateral with and auxiliary to his
prescribed studies, and satisfactorily directing the efforts of his inquiring mind.
   At the  commencement of such an  undertaking, it was difficult not to call in
question the probability of its meeting with adequate  encouragement.  No such
work existed in this country;  and although works on a plan somewhat similar  had
been very favourably accepted on the Continent, still it might have been urged that
the English were eminently, almost exclusively, a practical  people, — that their
medicine, in the opinion of foreign critics, who appeared  to be dispassionate and
impartial, was essentially empirical,—and that until a very recent period undeniable
prejudices existed in the minds of many English practitioners of known practical
skill,  against all attempts to append theory to the  deductions of mere  experience.
Of the English  works known to have been most profitable to their publishers, many
were mere compilations, or of a description  adapted to the contracted prejudices
just alluded to;  whilst works which  have been thought  deserving of translation
into more than  one foreign  language, and had reflected honour on British pathology,
had in our own country met with comparative neglect.
   The progress of medicine during  the last forty  years had led to successive
editions of the  few systematic works already  existing, to which the recent acquisi-
tions  of medical science were somewhat inconveniently,  because incongruously,
attached.  The cultivation  of general anatomy, the changes effected in physiology,
and the immense advancement of the knowledge of morbid structure, required that
the whole of Practical Medicine should be presented in that reconsidered  and
augmented state which had been the result of this progression.   Several  parts of
medical study,  bearing closely upon  practice, had  moreover  undergone so  much
recent investigation as almost to constitute them new parts of medical science;—
such as the  effects of Climate on health and disease ;  the properties of Mineral
Waters; the mode of action  of Poisons, and indeed the whole subject of Medical
Jurisprudence; as well as the new methods of exploring diseases of the chest  and
abdomen; the laws of  epidemics, and  the means of promoting  disinfection; with
many other  questions of considerable  interest.  The greater intercourse which  had
tfiken place during a period of nearly twenty years of peace, between this country
and the Continent, had opened, vast stores of  pathological facts in connection with
almost every known disease, which yet remained imperfectly known to many to
whom a general work would be accessible, and which no editor had yet sought to
arrange and collate with the contemporaneous discoveries of our own authors or to
eombine  with  the  practical  improvements  acknowledged in our own  country.
Between  respect for the  old writers, and  the continual  contradictions  of them
occurring in those of later  date ; between the fame of the Continental authorities 
             PREFACE FROM THE ENGLISH  EDITION.           ix

and a  lingering attachment to opinions of which all  the  foundations had been
shaken;  .he  student of  medicine and the young practitioner found themselves
embarrassed in the attempt to arrive at stable  conclusions, or even to comprehend
the actual state at which medicine had arrived, and which no general work at that
time represented.
  All these circumstances encouraged the  presumption that if a work embodying
all these improved parts of medical knowledge,—simply and conveniently arranged,
and not unenriched by the treasures of an older period—full and accurate, but from
which all the superfluous matter that had been admitted into some foreign works of
a like form was  carefully excluded, — were  offered in the English language, its
reception would be such as to satisfy all who were concerned  in it, whilst  its pre-
paration would reflect no discredit on those who undertook it.
   It was in no small degree gratifying to the  Editors to find  that the publication
of the early numbers of the  Cyclopaedia was  attended with  circumstances which
conveyed an assurance of the general correctness of these views.  The circulation
of the work soon  extended to every portion of the British empire, to the Colonies,
and to America;  and the publishers have from time to time informed them that its
sale was steadily proceeding.   The Editors have undoubtedly received these inti-
mations  with pleasure; not only because they were connected with benefit derived
by those who  had adventured in a liberal  undertaking, but because they thought
they perceived in such circumstances a proof of an increasing zeal for exact  and
comprehensive knowledge on the part of British  practitioners of every rank, in
every part of the world.
   However natural  and proper it may be for the Editors to  take  a retrospective
survey of the work when it  is brought to a conclusion, and to examine with what
fidelity they have fulfilled  their  engagements, and how far  and how equally the
various departments of practical medicine  have in  their turn occupied their atten-
tion, it is hardly possible  to express the results of this retrospection in words which
will not expose them to the charge of being disposed to look back upon their exer-
tions  with too much complacency.  Yet they may perhaps be  allowed to say,  that
if the reader will take the trouble to inspect  the  mere titles of the articles con-
tained in these columns, comprehending nearly three  hundred original  essays of
known and distinguished authors, and will bear in mind either the leading physio-
logical divisions of diseases, or consider them with reference to the head, the chest,
the abdomen, the surface, or  the general condition of the body; as well as  the
subjects of obstetrical medicine, materia medica, or medical jurisprudence; he
will sufficiently appreciate the care bestowed to make  the Cyclopaedia satisfactory
to all who refer  to its pages, and  at  the same time strictly a book of practical
reference.  No subject, it is believed, immediately practical in its nature or appli-
cation, has been left out, although unnecessary disquisition has been as  much as
possible avoided.
   It  has consistently entered into their plan to  admit of a far wider  range ol
subjects than appears heretofore to have been  considered necessary in works pro-
fessedly written on  the practice of medicine, but a range  comprising many new
subjects of extreme importance to those engaged  in practice  or preparing for it.
Such  are the subjects of Abstinence, Acupuncture, Age, Ctiange of Air,  Antiphlo-
gistic  B,egimen, Asphyxia, Auscultation, Bathing,  Bloodletting, Morbid  States of
the Blood, Climate,  Cold, Contagion, Convalescence, Counter-irritation, Derivation,
Congestion and Determination of Blood, Dietetics, Disinfection, Physical Educa- 
X
PREFACE FROM THE ENGLISH  EDITION.
 ticn, Electricity, Endemic Diseases, Epidemics, Expectoration, Exploration of the
 Chest and Abdomen, Galvanism, Hereditary Transmission of Disease, Induration,
 Irritation, Infection, Latent Diseases, Malaria and Miasma, Perforation, Prognosis,
 Pseudo-morbid  Appearances, Pulse,  Softening,  Medical  Statistics, Stethoscope,
 Sudden Death, Symptomatology, Temperament, Toxicology, Transformations, Trans-
 fusion, Tubercle, Ventilation, Mineral Waters ; and those of various general arti-
 cles on the pathology of organs.
   The several articles relating to Diseases of the Brain and Spinal Chord, and  of
 their membranous coverings, including the important subject of the impairment of
 the  mental  manifestations,  will probably  be deemed by  every  candid reader to
 contain accurate views of morbid structure  and  faithful  descriptions of the  most
 important lesions  of the nervous functions.   How  great the talent  an_d how high
 the authorities on these subjects, will be at once seen by referring to the names of
 the authors of the articles Apoplexy, Inflammation of the Brain, Catalepsy, Chorea,
 Coma, Convulsions, Delirium, Epilepsy, Headach, Hydrocephalus, Hydrophobia,
 Hypochondriasis,  Insanity, Latent Diseases,  Paralysis, Plethora, Prognosis, Som-
 nambulism, Diseases of the Spinal Marrow, Temperament, Tetanus, Wakefulness,
 &c.  As regards the greater number of the authors of these articles, they are well
 known to have been previously in much esteem with the public for treatises more
 or less connected with  the  subjects on which they undertook  to  write  for the
 present work.
   The direction for many previous years of the attention  of one of the Editors to
 Diseases of  the Chest could not but make both him and his colleagues particularly
 desirous that on  the subjects of the numerous and serious diseases of the lungs and
 of the heart, the Cyclopaedia should contain the fullest and the most recent informa-
 tion ; and that the novel and still too much neglected methods of physical  investi-
 gation of Auenbrugger, Laennec, Andral, Piorry,  and others, should be  clearly and
 perfectly set forth.  In the articles  relating to these various maladies, contributed
 by Dr. Carswell, Dr. Cheyne, Sir James Clark, Dr. Darwall, Dr. Hope, Dr. Johnson,
 Dr. Law, Dr. Townsend, Dr. Williams, &c. it is hoped that no omissions will be found.
 These names are for the most part so familiar to the profession, in connection  with
 the several subjects on which they have written in  the Cyclopaedia, that the titles
 of the different  articles would alone  have suggested them, in order  to give the
 stamp of valuable authority to each.
  As regards Diseases of the Abdomen, it may without any impropriety be  men-
 tioned  that,  in  the  articles  Cholera,  Colic, Diarrhoea, Dysentery, Enteritis,
 Epidemic Gastric Fever, Gastritis,  Gastrodynia, Gastro-enteritis,  Haematemesis,
 Hemorrhoids, Indigestion, Jaundice, Inflammation  of the Liver, Peritonitis, Pyrosis,
 Tabes Mesenterica, Tympanites, Worms, Organic Diseases of  the Stomach, Liver,
 Pancreas, Kidneys, &c. &c, is included a more elaborate  and  practical exposition
of the pathology and symptomatology of the affections of the abdominal viscera
generally, and of  the  gastro-intestinal mucous membrane in  particular,  than  is
contained in any  single work previously published.   The importance of correct
 views of this large class  of common and much diversified  disorders, as  a basis of
 useful practice, is such as it would be quite needless to  dilate upon.   They involve
consequences most seriously affecting the health of the body and the  mind;  and
 the mismanagement even of the lighter forms  is largely productive  of human dis-
comfort and unhappiness.  They are also, in some  form or other, incidental to every
 constitution, and are literally of daily and hourly  occurrence.  From fever, the
 severest of  the acute diseases from which medical care effects frequent recovery, 
PREFACE FROM THE  ENGLISH EDITION.          XI
to the habitual distresses produced by the imperfect digestion of food, they demand
the continual attention of the  practitioner.  The relations  of gastro-intestinal
irritation with numerous disorders of the  chest, head, skin, and  extremities, and
with fever, as causes or effects, are among the most  interesting  questions which
have been agitated by the most eminent of modern physicians in this and in other
countries, and the practical application of the researches of pathologists concerning
the morbid states of the digestive mucous membrane remains an object  anxiously
sought by those acquainted with  the  exigences  of various practice, and who  are
not content to practise without reflection.
  So indiscriminate, also, generally speaking, is the treatment of the various modi-
fications of  indigestion,—the chronic irritations of the intestines are often so long
overlooked,—so empirically are undefined  disorders of the liver prescribed for,—
and the conduct of the dietetical part of practice, even in fevers,  and still more in
chronic disorders, is so capricious,—that it may be permitted to the Editors to hope
that some improvement may ensue from the circulation of the sounder and  better
founded notions of pathology and practice explained and advocated  in the  various
essays on abdominal diseases which contribute  to give value to these volumes.
   The department of Cutaneous  Diseases has,  it will  be seen, engaged the pens of
Dr. Corrigan, Dr.  Cumin, Dr. G.  Gregory, Dr.  Houghton, Dr. Joy, Dr. Kerr, Dr. A.
T. Thomson, and  Dr. T. J. Todd, by whom, as was to be expected, this important
branch of study, which enjoys  but a small share of popularity in this country, has
received full pathological and practical illustration.
   As  regards some affections  implicating the whole  system, and particularly the
fluids, it is  but just to allude to  the  admirable treatises on Gout and Plethora, as
being worthy of the  high reputation  before attained by the author of them  as a
philosophical physician and an experienced practitioner.  Nor can the Editors pass
silently over the elaborate article on Tubercular Phthisis, of which it is but  one
among many excellences that it invites the  attention from that contemplation of
local lesions which leads to practical results of little value, to a  more enlarged con-
sideration of the subject, pregnant with the most momentous practical consequences.
   The names of  Dr. Marshall Hall, Dr. Lee, Dr. Locock,  and Dr. Montgomery,
affixed to the several articles connected with the Diseases of Women and Children,
will be a sufficient assurance to every reader that this responsible part of medicine
has not been confided  to inefficient hands.   Nothing could be  more compatible
with the plan  of the Cyclopaedia than  the  brief,  clear, and instructive essays
furnished by these able and experienced practitioners.
   In the interesting field of Medical Jurisprudence  the work has  been benefited
by the  original and  masterly dissertations of Dr.  Arrowsmith, Dr. Beatty, Dr.
Christison, Dr. Montgomery, and Dr. Prichard.
   The well-earned fame of Dr. A. T. Thomson gives  to his numerous contributions
on subjects comprehended in the department of the Materia Medica, an  interest
of which every student must be  fully sensible; and it is but just to mention  that
for the limitation of these  articles within narrower bounds than those which the
author deemed essential to their full value,  the Editors are  solely accountable.
 With respect to the practical application  of some other medical  agents, as Galva-
 nism and Electricity, the reader is enabled to avail himself of the valuable informa-
 tion communicated by Dr. Apjohn, and marked by his characteristic accuracy.   To
 the same able writer the Editors  have been indebted for the comprehensive  treatise
 on Toxicology.    In the parts of  the work closely allied to chemical science, as ir
 the articles Calculi  and Mineral Waters, the  Editors have been honoured by the 
xii          PREFACE FROM THE  ENGLISH EDITION.

contributions of Dr. Thomas Thomson, of Glasgow, who has been  long known to
the  whole scientific world as one of the greatest authorities in modern chemistry.
  The value of the aid afforded in the general articles relating to various  parts of
Morbid Anatomy,  will be understood by all  who know the  great and deserved
reputation of Dr. Carswell, both in England and on  the Continent; a reputation
which cannot but derive increase by his great work on that subject, and its mcom-
parable pictorial illustrations, now in the course of publication.
  Many able contributions, not specially alluded to in these observations, demand
the  general and warm acknowledgements of  the Editors, as of  a character not
inferior to any which have been mentioned; and their especial  obligations to Dr.
Alison and Dr.  Bostock will  be evident to all who peruse with attention the Histo-
rical sketches prefixed to the practical portion  of  the  Cyclopaedia.
  As tending  in  a considerable degree  to  place the contents  of the work more
completely before the reader for immediate consultation, and  therefore important,
although laying no claim  to  merit  in  itself, the Editors  have  added a very minute
and extensive General Index.
  Hoping to be excused for  making these reflections on  a work now laid before the
profession in a finished  state, the Editors will only  add, that they have avoided
multiplied and artificial divisions, and have aimed at  that plainness of  arrangement
which most facilitates a ready and  immediate reference.   They have also  shunned
the  fault  of encumbering medical  literature with new and uncouth terms, always
preferring  those in  common  use, and of which the signification was the least
doubtful.   It has been their  constant  desire to guard the most inexperienced reader
from distraction in the  pursuit of practical  knowledge, and to  assist  the  more
advanced reader in the grouping and generalization of the  ideas with which his
personal  experience may  have imbued him.
  One of the most delicate  parts of the duty of the  Editors  in conducting  these
pages  from their  commencement to their  termination, has  been the occasional
adaptation of the articles composing it to the character or to the proposed  size of
the whole work.   Considerations which could  not properly be put  aside sometimes
caused modifications to be absolutely  necessary, in contributions which might have
been published unchanged as separate essays.   To say that this duty was  in  every
case performed without difficulty, or with the entire and ready acquiescence of the
writers, would be to assert what none who are versed  in literary composition, or who
know the natural feelings of authors, would give credit to.   That it was always
performed with a sincere regard to such feelings, and that no change of arrange-
ment, and even no verbal alteration, was made without just deliberation, they may
very truly affirm.   They  have the satisfaction of believing that such is the impres-
sion left on the minds of those  contributors who have  honoured  them with their
assistance.  With many, before unknown to them, except by reputation, the Editors
have the happiness to feel  assured that permanent  freindship  has arisen out of
what was at first but casual co-operation.
  In conclusion,  the Editors entertain a hope  that they have prepared a work
required by the present wants of medical readers, acceptable  to the profession  in
general,  and so capable by its arrangements of admitting the  progressive improve-
ments of time, as long  to  continue  what the general  testimony  of their medicai
brethren, as far as it has hitherto been expressed, has already pronounced it.  to be,
  standard British work on the Practice of Medicine.
   If such should prove to be the event, they will feel  themselves abundantly repaid
 for the labours which it has imposed upon them. 
                                LIST

                                   OF THE


                  CONTRIBUTORS

                                   TO THE


CYCLOPEDIA OF  PRACTICAL  MEDICINE,

                                   AND OF

           THE ARTICLES WRITTEN  BY EACH AUTHOR.
Alison, W. P., M.D. F.R.S.E. Professor of
   Medicine in the University of Edinburgh, &c.
       Medicine, history of, in the present century.

Apjohn, James, M. D. M.RJ.A. Professor of
   Chemistry to the Royal College of Surgeons
   in Ireland.
       Combustion, spontaneous human.
       Electricity.
       Galvanism.
       Toxicology.

Arrowsmith, R., M.D.  Physician to the Co-
   ventry Dispensary.
       Infanticide.

Ash, Edward, M.D. Physician to the Norwich
   Dispensary.
       Hiccup.
       Prognosis.
       Syncope.

Bardsley, James L., M. D. Physician to the
   Manchester Royal  Infirmary, Dispensary,
   &c.
       Diabetes.
       Hydrophobia.

Barlow, Edward, M.D.  Physician to  the
   Bath United Hospital and Infirmary.

       Antiphlogistic regimen.
       Congestion of blood.
       Determination of blood.
       Education, physical.
       Gastrodynia.
       Gout.
       Plethora.
       Rheumatism.

Beatty, Thomas Edward, M.D. Professor of
  Medical Jurisprudence to  the Royal College
  of Surgeons  in Ireland, and Consulting
  Accoucheur to the Baggot-Street Hospital,

  Dublin.
      Impotence.
      Dead, persons found.
      Rape.
      Sex, doubtful.
      riurvivorship.
      Wounds, death from.
                                 B
Beck, J. B., M.D. Professor of Materia Medica,
  in the College of Physicians and Surgeons,
  New York.
      Medicine, American, before the Revolution,
        History of.

Bigsby, John J., M.D. F.L.S. Senior Physi-
  cian to the Newark Dispensary.
      Spleen, diseases of.

Bostock, J.,  M.D. V.P.R.S.  F.L.S.  F.G.S.
  &c. &c.
      Medicine, history of.
      Pulse.
      Urine, morbid states of the.

Brown, Joseph, M.D. Physician to the Sun-
  derland and Bishopwearmouth Infirmary.
      Cholera.
      Contagion.
      Disinfection.
      Dysentery.
      Fever, intermittent.
         remittent.
         hectic.
      Hereditary transmission of disease.
      Infection.
      Malaria and miasma.
      Plague.
      Ventilation.

Btjrder, Thomas H., M.D.  Member of the
  Royal College of Physicians, London.
      Erethismus mercurialis.
      Headach.
      Jaundice.

Burne, John, M.D. Physician to the  Carey-
  Street Dispensary.
      Otalgia and Otitis.
      Hemorrhoids.

Carswell, Robert, M.D.  Late Professor of
  Morbid Anatomy in the University of  Lon-
  don.
      Induration.
      Melanosis.
      Mortification.
      Perforation of the hollow viscera
      Scirrhus.
      Softening of organs.
      Tubercle.
                               (ziii 
LIST  OF  CONTRIBUTORS.
xiv

Carter, H. W., M.D. F.R.S.E. Physician to
  the Kent and Canterbury Hospital.
       Delirium tremens.
       Ischuria renalis.
       Kidneys, diseases of.
       Nephralgia and Nephritis.
       Pancreas, diseases of the.

Cheyne, John, M.D. F.R.S.E. M.R.I.A. Phy-
  sician-General to the Forces in Ireland, &c.
       Croup.
       Epilepsy.
       Fever, epidemic gastric.
       Laryngitis.
       Wakefulness.

Christison, Robert, M.D. Sec. R.S.E. Pro-
  fessor of Materia Medica and Therapeutics
  in the University of Edinburgh, &c.
       Latent diseases.

Clark, Sir James, M.D.  F.R.S.  Physician to
  the Queen and Prince Albert, &c.
       Air, change of.
       Climate.
       Tubercular phthisis.

Clutterbuck, Henry, M.D. Physician to the
  General Dispensary.
       Apoplexy, cerebral.

Conolly, John, M.D.  late Professor of Medi-
  cine  in  the London University, and  Physi-
  cian to the Hanwell Lunatic Asylum.
       Alteratives.
       Disease.
       Hysteria.
       Medicine, practical, principles of.

Corrigan, Dominick  J.,  M.D.  Physician  to
  Jervis-Street Hospital, Dublin.
       Pemphigus.
       Plica Polonica.
       Rupia.

Crampton, John, M.D. M.R.I.A. King's  Pro-
  fessor of Materia Medica, Physician to Stee-
  ven's Hospital, &c. Dublin.
       Cyanosis.
       Diarrhoea, (with Dr. Forbes.)

Crawford, Adair, M.D. Assistant Physician
  to the London Fever Hospital.
       Brain, inflammation of the substance of (Cere-
          britis).
       Coma.
       Convulsions.
       Inflammation, (with Dr. Tweedie.)

Crawford,  Andrew, M.D. Physician to the
  Hampshire County Hospital, Winchester.
       Bronchocele.
       Chorea.

Cumin, William, M.D. Member of the Faculty
  of Physicians, Glasgow.
       Calculus, pathology and treatment.
       Cystitis.
       Dysuria.
       Incontinence of urine.
       Pityriasis.
       Psoriasis.
       Rickets.
       Scrofula.
       Sycosis.

 Oarwall, John, M.D. Physician to the Bir-
   mingham General Hospital.
       Anasarca.
       Artisans, diseases of.
       Ascites.
       Dropsy.
       Hydropericardium.
        Hydrothora-»
        (Edema
Duesbury, Frederick, M.D.   Physician  to
  the Dispensary, and to the Invalid Asylum,

  Stoke Newington.

       Transformations.

Dunglison, Robley, Professor of the Institutes
  of Medicine in Jefferson Medical College,
  Philadelphia, and attending Physician to the

  Philadelphia Hospital.

Besides the interstitial additions, the following articles:
       Acrodynia.
       Ansemia, (with Dr. Marshall Hall.)
       Anthracion.
       Aphthae, (with Dr. A. Robertson.)
       Asphyxia of the newborn.
       Blood, morbid states of, (with Dr. M. Hall.)
       Bronchial Glands, diseases of the.
       Bronchitis, summer.
       Cachexia.
       Cholera infantum.
       Cirrhosis of the lung.
       Colon, torpor of the.
       Croup of the adult.
       Delirium tremens.
       Dengue.
       Diarrhoea, adipous.
       Disinfectant.
       Enteritis, (with Dr. Stokes.)
       Eutrophic.
       Fever, malignant remittent.
       Galvanism, (with Dr. Apjohn.)
       Glanders.
       Heart, polypus of the.
       Intussusception.
       Jaundice of the infant.
       Laryngitis, chronic.
       Milk-sickness.
       Mind, soundness and unsoundness of, (with Dr
           Prichard.)
       Molluscum.
       Nauseants.
       Ophthalmia, (with Dr. Jacob.)
       Palpitation, (with Dr. Hope.)
       Parturients.
       Ptyalism.
       Rheumatism, (with Dr.  Barlow.)
       Sedatives,  (with Dr. A.  T. Thomson.)
       Spermatorrhoea.
       Spleen, diseases of the,  (with Dr. Bigsby.)
       Statistics, medical, (with Dr. Bisset Hawkins.)
       Stomatitis.
       Strophulus.
       Throat, diseases of the,  (with Dr. Tweedie.)
       Toothach.
       Toxicology, (with Dr. Apjohn.)

 Elliotson, John, M. D. F.R.S. Physician to
   St. Thomas's Hospital,  and  late  Professor
   of Medicine in the London University.

       Acupuncture.
       Neuralgia.

 Forbes, John, M.D.  F.R.S. Physician in ordi-
   nary  to her Majesty's Household, &c.

       Abdomen.
       Angina pectoris.
       Asthma.
       Auscultation.
       Bathing.
       Chest, exploration of.
       Diarrhoea (with Dr. Crampton.)
       Feigned diseases, (with Drs. Scott and Marshall.)

 Gillkrest, J.,  M.D. Deputy Inspector-Gene-
   ral of Hospitals, London.
       Fever, yellow.


 Goldie, George, M.D. Shrewsbury, late Phy-
   sician to the York County Hospital.
       Hcematemesis.
       Melama.
       Purpura.
       Urine, bloody. (Hsematuna.;
Grant, James, M.D. Jedburgh.
       Nyctalopia. 
LIST  OF  CON
Gregory, George,  M.D.  Physician to  the
  Small-pox Hospital

       Chicken-pox.
       Small-pox.
       Vaccination.
       Varicella.

Hall, Marshall, M.D. F.R.S. L. & E. &c.
       Abstinence.
       Anaemia.
       Blood, morbid states of.
       Bloodletting.
       Chlorosis.
       Diagnosis.
       Puerperal diseases.
       Symptomatology.

Hancock, Thomas, M.D. Liverpool.
       Endemic diseases.
       Epidemics.
       Influenza.

Hastings, Charles, M.D.  Physician to the
   Worcester Infirmary, &c.

       Constipation, (with Dr. Streeten.)

Hawkins, Bisset, M.D. F.R.S.  Professor of
   Materia Medica and Therapeutics  in King's
   College, London.

       Statistics, medical.

Hope, J., M.D. F.R.S.  Assistant Physician to
   St. George's Hospital, London.
       Aorta, aneurism of.
       Arteritis.
       Dilatation of the heart.
       Heart, diseases of the.
       Heart, fatty and greasy degenerations of.
       Heart, diseases of the valves of the.
       Heart, hypertrophy of the.
       Palpitation.
       Pericarditis and carditis.

Houghton, James, M.D.  Physician to  the
   South-Eastern Dispensary, Dublin.

       Lepra.
       Lichen.
       Noli me tangcre, or Lupus.
       Pneumothorax.
       Scabies.
       Urticaria.
       Stomach, organic diseases of.

Jacob, Arthur, M.D.  M.R.I.A. Professor of
   Anatomy to the Royal College of Surgeons
   in Ireland.
       Amaurosis
       Ophthalmia.

Johnson, Charles,  M.D.  Professor of Mid-
   wifery to the Royal College of Surgeons in
   Ireland.
       Hooping-cough.

Joy, William Bruce,  M.D.  Fellow of the
  King and Queen's College of Physicians in
  Ireland, and Physician to the Dublin Gene-
  ral Dispensary.
       Catalepsy.
       Dentition, disorders  of.
       Eczema.
       Elephantiasis Gracorum.
       Erythema.
       fever, infantile remittent.
       Glottis, spasm of the.
       Hydrocephalus.
       Tabes mesenterica.
       Worms.

Kay, J. P., M.D. Physician to the  Ardwick
  and Ancoats Dispensary, Manchester.
       Transfusion.
TRIBUTORS.                       XV

Kerr, William, M.D. Physician to the North-
  ampton General Infirmary.
      Epistaxis.
      Fungus hienaatodes.
      Glossitis.
      Hydatids.
      Parotitis.
      Pellagra.
      Pyrosis.
      Scorbutus.
      Tympanites.
      Yaws.

Law, Robert, M.D. Fellow of the King and
  Queen's College  in Ireland, Physician Ex-
  traordinary to Sir Patrick Dun's Hospital.

      Haemoptysis.
       Pleurisy, pleuritis.

Lee, Robert, M.D. F.R.S. Physician to the
  British Lying-in Hospital, London.

      Abortion.
      Fever, puerperal.
       Ovaria, diseases of the.
      Phlegmasia dolens.
      Uterus a nd its appendages, pathology of the.
      Veins, diseases of the.

Locock, Charles,M.D. Physician-accoucheur
  to the Queen, Physician to the Westminster
  General Lying-in Hospital, &c.
       Amenorrhoea.
      Convulsions, infantile.
      Convulsions, puerperal.
      Dysmenorrhea.
       Lactation.
      Leucorrhoea.
       Menorrhagia.
      Menstruation, pathology of.

MacAdam,  David H., M.D. Physician to the
  South-Eastern General Dispensary, Dublin.

       Peritonitis, (with Dr. Stokes.)

Montgomery, William F., M.D.  Fellow and
  Professor of  Midwifery, to the King  and
  Queen's College of Physicians in Ireland.
      Identity, personal.
      Pregnancy and delivery,  signs of.
      Rubeola.
      Succession of inheritance.—Legitimacy.

Paris,  J. A., M.D. F.R.S. President of the
  Royal College of Physicians, London.
      Dietetics.

Prichard, J. C, M.D. F.R.S. Physician to the
  Infirmary and to St. Peter's Hospital, Bristol.
      Delirium.
      Hypochondriasis.
      Insanity.
      Somnambulism and animal magnetism.
      Mind, soundness and unsoundness of.
      Temperament.

Quain,  Jones,  M.D.  Professor of  Anatomy
  and Physiology in the London University.

      Brain,inflammation of the membranes of, (Me-
          ningitis.)

Robertson, Archibald, M.D.  Physician tu
  the Northampton General Infirmary.
      Aphonia.
      Aphtbs.

Roget,  P.  M., M.D.  Sec. R.S.  Consulting
  Physician to  the  Queen  Charlotte's Lying-
  in Hospital, and to the Northern Dispensary,
  &c.

      Age.
      Asphyxia. 
TRIBUTORS.
xvi                      LIST  OF  COT*


Scott, John, M.D. Edinburgh.
       Barbiers.
       Beriberi.
       Elephantiasis Arabum.
       Feigned diseases, (with Drs. Forbes and Jlfar-
          shall.)

Stokes, William,  M.D. Physician  to  the
   Meath Hospital, Dublin.
       Derivation.
       Dysphagia.
       Enteritis.
       Gastritis.
       Gastro-enteritis.
       Liver, inflammation of.
       Peritonitis, (with Dr. MacAdam.)

Streeten, Robert J. N., M.D.  Physician to
   the Worcester Dispensary.
       Constipation, (with Dr. Hastings.)

Symonds,  J. A., M.D. Physician to the Gene-
   ral Hospital, Bristol.

       Tetanus.

Thomson, A.  T.,  M.D. F.L.S.  Professor  of
   Materia Medica  and Therapeutics  in  the
   London  University.

       Anthelmintics.
       Antispasmodics.
       Astringents.
       Cathartics.
       Diaphoretics.
       Diuretics.
       Emetics.
       Emmenagogues.
       Expectorants.
       Favus.
       Herpes.
       Ichthyosis.
       Impetigo.
       Narcotics.
       Refrigerants.
       Sedatives.
       Stimulants.
       Porrigo.
       Prurigo.
       Tonics.

Thomson,  Thomas, M.D. F.R.S.  L. &  E.
  Regius Professor of Chemistry in the Uni-
   versity of Glasgow, &c.

       Calculus, (chemical composition.)
       Waters, mineral.

Todd, T. J., M.D.  Physician to the  Dispen-
   sary, Brighton.
       Achor.
       Acne.
       Alopecia.
       Bullae.
       Ecthyma.
       Ephelis.
       Indigestion.
Todd, Robert B., M.D.  F.R.S. Professor  of
  Physiology  and General Anatomy, Kings

  College, London.
       Paralysis.
       Pseudo-morbid appearances.
       Suppuration.
       Spinal marrow, diseases of.

Townsend, Richard, M.D.  M.R.I.A. Fellow
  of the King and Queen's College of Phy-

  sicians, Dublin.
       Apoplexy, pulmonary.
       Atrophy.
       Emphysema.
       Emphysema of the lungs.
       Empyema.
       Heart, displacement of.
       Hypertrophy.
       Rupture of  the heart.

Tweedie, Alexander, M.D. F.R.S. Physician
  to the  London Fever Hospital, and to the
  Foundling Hospital.
       Abscess.
       Colic (with  Dr. Whiting.)
       Convalescence.
       Erysipelas.
       Exanthemata.
       Fever, continued.
       Inflammation, (with Dr. Adair Crawford.)
       Miliaria.
       Roseola.
       Scarlatina.
       Throat, diseases of the.

Venables, R., M.D. London.
       Liver, diseases of.

Watson, Thomas,  M.D. Physician to the
  Middlesex Hospital, &c.

       Hemorrhage.

Whiting, John,  M.D. Physician to the Surrey
  Dispensary,  &c.

       Anodynes.
       Cold.
       Colic, (with Dr.  Tweedie.)
       Colica Pictonum.

Williams,  Charles J. B., M.D. F.R.S. Pro
  fessor of Medicine  in University  College,
  London.

       Bronchitis.
       Catarrh.
       Coryza.
       Counter-irritation,
       Dyspnoea.
       Expectoration.
       Incubus.
       Irritation.
       Malformations of the heart.
       Obesity.
       Pneumonia.
       Stethoscope. 
CONTENTS   OF   THE   FIRST  VOLUME.
                      Contributors.         Page
Abdomen, Explorationof.Dr. Forbes........ 25
Lee..........  33
Tweedie.......  36
M. Hall........  42
Todd
Todd
Abortion
Abscess . .
Abstinence
Acbor....
Vcne  ....
Acrodynia...........   Dunglison
Acupuncture.........   Elliotson .
Age................   Roget....
Air, Change of.......   Clark......... 67
Alopecia.............   Todd......... 71
Alteratives...........   Conolly....... 74
Amaurosis
Amenorrhcea
Jacob.........  78
Locock........  89
M.  Hall..
Dunglison
Darwall.......  95
Forbes........103
92
Anaemia.........

Anasarca........
Angina Pectoris ..
Anodynes...........    Whiting......117
Anthelmintics........    A. T. Thomson.119
Anthracion..........    Dunglison.... 122
Antiphlogistic Regimen.    Barlow.......122
Antispasmodics.......    A. T. Thomson . 124
Aorta, Aneurism of....    Hope.........126
Aphonia.............    Robertson......139
.  ...               C    Robertson ..."), An
Aphthae...........■?     ~    ..       C140
  r                 (_    Dunglison...  $
Apoplexy, (Cerebral) ..    Clutterbuck ... 142
Apoplexy, (Pulmonary)    Townsend.....155
Arteritis.............    Hope.........163
Artisans, Diseases of...    Darwall.......170
Ascites..............    Darwall.......182
Asphyxia............    Roget.........188
Asphyxia of the newborn    Dunglison.....205
Asthma.............    Forbes........206
Astringents..........    A. T. Thomson .229
Atrophy  ............    Townsend.....234
Auscultation.........    Forbes........237
Barbiers.............    Scott..........264
Bathing.............    Forbes........266
Beriberi.............    Scott..........287
Blood, determination of    Barlow........290
Blood, Morbid States C    Marshall Hall
   of..............\    Dunglison ...
Bloodletting..........    Marshall Hall.. 296
Brain,  Inflammation C    Quain......Z 301
   of..............C.  Adair Crawford 5
Bronchial Glands,  Dis-
   ease of the......, ..    Dunglison.....331

B"-*"..........{    Z^-.'.-J331
    «     Summer.....    Dunglison.....342
Bronchocele..........    And. Crawford.3A3
Bulls...............    Todd..........352
Cachexia............    Dunglison.....353
Calculi..............    Thos. Thomson. 354
Calculous Diseases.....    Thos. Thomson.365
Catalepsy............    Joy..........378
Catarrh.............    Williams......382
Cathartics...........    A. T. Thomson . 385
Chest, Exploration of..    Forbes........391
291
Chicken-Pox.........Dr,
Chlorosis............
Cholera.............
Cholera Infantum......
Chorea..............
Cirrhosis of the Lung .
Climate..............
Cold................

Colic...........
Colica Pictonum......
Colon, torpor of the ...
Coma...............
Combustion,  Spontane
  ous Human........
Congestion of Blood...

Constipation......

Contagion...........
Convalescence........
Convulsions..........
Convulsions, Infantile..
Convulsions, Puerperal.
Coryza..............
Counter-Irritation.....
Croup..............
Croup of the adult ....
Cyanosis....... ....
Cystitis.............
Dead, persons found....
Delirium............

Delirium Tremens... <

Dengue .............
Dentition, Disorders of.
Derivation...........
Diabetes.............
Diagnosis............
Diaphoretics..........
Diarrhoea..........A
Diarrhoea, adipous.....
Dietetics............
Disease..............
Disinfectant..........
Disinfection..........
Diuretics.............
Dropsy..............
Dysentery...........
Dysmenorrhcea.......
Dysphagia...........
Dyspnoea............
Dysuria..............
Ecthyma............
Eczema..............
Education, Physical....
Electricity...........
Elephantiasis Arabum..
Elephantiasis Graecorum
Emetics.............
Emmenagogues.......
Contributors.     Page
Gregory.......395
M.Hall.......396
Brown........399
Dunglison.....426
And. Crawford. 427
Dunglison.....440
Clark........440
Whiting.......453
Whiting  ...•"? 45g
Tweedie.....5
Whiting......463
Dunglison.....466
Adair CrawfordAGG

Apjohn........470
Barlow........476
Hastings---? ^
Streeten.....5
Brown........500
Tweedie.......505
Adair Crawford.508
Locock........519
Locock........522
Williams......524
Williams......526
Cheyne.......534
Dunglison.....542
Crampton.....542
Cumin.......545
Beatty........548
Prichard......582
Carter......7 5g?
Dunglison...  5
Dunglison.....594
Joy..........595
Stokes........601
Bardsley......606
Hall..........625
A. T. Thomson.626
Crampton...->6S2
Forbes......3
Dunglison .... 642
Paris.........642
Conolly.......674
Dunglison.....689
Brown........690
A. T. Thomson.695
Darwall......701
Brown........720
Locock........728
Stokes........730
 Williams......732
 Cumin.......734
 Todd.........737
Joy..........743
Barlow.......750
Apjohn........765
Scott..........770
Joy..........773
A. T. Thomson.776
A. T Thomson.784
       (xvii) 
 
THE
                 CYCLOPAEDIA
                                      OF

PRACTICAL    MEDICINE.
   ABDOMEN (Exploration of the)__It is
 intended, in the present  article, to give a brief
 account  of the different methods employed by
 physicians for exploring, or physically examining,
 the external parts of the  abdomen, with the view
 of discovering or discriminating the diseases of the
 viscera contained in this cavity.   The  term here
 adopted  to designate  the  application. of these
 methods  (from the verb exploro, to  examine),
 although long received into our language, has been
 only very recently used in medicine in its present
 ?ense: it has been borrowed from the  pathologi-
 cal writings of the French.   In many parts of the
 present work  occasion will  be  found of pointing
 out the paramount importance  to the practitioner
 of a minute and accurate diagnosis of diseases, and
 of stating,  in detail, the various methods in use for
 acquiring this knowledge. Of these methods none
 are so certain  in their results,  and, consequently,
 so satisfactory to  the  mind, as those which are
 based on what are termed physical signs of dis-
 ease,  in contradistinction to  the more common
 class  of rational or sympathetic signs which are
 derived from the more variable  phenomena of dis-
 ease termed symptoms.  It is with the physical
 signs of diseases that exploration, in the sense  in
 which we  shall  employ it, has  to  do;  and in the
 present article it is intended to  restrict its use to a
 part only of the physical signs  by which abdomi-
 nal diseases are distinguished.       /
   Physicians  are  often  much too negligent  in
 examining the external parts of the body in inter-
 nal diseases.  From inadvertence, carelessness, or
 mistaken delicacy, they thus deprive  themselves
 of the simplest,  readiest, and surest means  of re-
 cognising many important affections. This remark
 applies chiefly to the diseases of the abdomen and
 chest, some of which are strikingly.expressed, if
 we may so speak, on the surface—either in a per-
 manent change of configuration, or in a temporary
 alteration of the natural movements, or both. Such
 important physiognomical diagnostics can only be
 obtained (except in rare cases)  by uncovering the
 body ,•  and  they can, in general, be immediately
 obtained by doing  so.  It happens constantly to
 those who  are accustomed to examine the surface
 of the  body in  internal affections, to  meet with
 examples of important diseases being mistaken or
 overlooked, merely because this simple proceeding
 had been neglected by the practitioner.  One of
 the most common cases of this  kind is chronic
pleurisy, the presence  of which is often detected
by a single glance at the  naked  chest;  one side
being  found to be  immovable, and either con-
    Vol.I___4                         p
tracted or enlarged beyond the limits of the healths
state.  Superficial inflammations of the parietes
of the chest  and abdomen have been treated as
phlegmasiae of the viscera in persons who had no
desire to conceal their complaints ;  while others,
from unwillingness to admit the existence of local
eruptions on  the skin, have equally  deceived their
medical attendants.  It is obvious that such mis-
takes could not happen to those who are accus-
tomed to examine the exterior parts of the body;
and it will not  be denied that, whenever they do
happen, they must tend to lower the character of
the practitioner in the eyes of his patient.  Such
mistakes are much more liable to be made respecting
females than  males, partly on account of the greater
delicacy  respecting  examination entertained  by
the physician in the case of the former, and partly
owing to the  greater obstacles to examination from
the peculiar nature of their dress.
  It  will not,  we trust,  be  imagined, from the
above remarks, that the writer  wishes  to recom-
mend the examination of the naked chest or ab-
domen in  every case of alleged disease in these
cavities.   In  most instances, even when a minute
investigation  is required,  it  is  unnecessary to
remove the under garment; and in the case of
females this is never to be done if it can be avoided.
In some  cases, no doubt, it may be expedient to
apply the hand to the skin, and even to inspect it
freed  from  all covering; but in the case of females
more particularly, neither should be had recourse
to, unless an  accurate diagnosis  cannot be  other
wise obtained.
  If physical examination is  of such general im-
portance as a means of diagnosis, it is especially
so in  the diseases  of the abdominal  cavity.   The
great number and importance of the organs con-
tained in  it, render  its  diseases proportionally
numerous  and  important; while the proximity
and intermixture of some of the organs, and the
variable  site  of  others, render their  symptoms
complex and multifarious,  and  their  diagnosis*
consequently difficult.   On the other hand, the
abdomen, from its  anatomical structure, seems at
first sight  to promise much  greater facilities for
the employment of physical diagnosis than  eithei
of the two other great  cavities of the body.  Il>
soft and yielding walls at once invite  and  adrm
of such examinations of the parts within as appeal
to be altogether forbidden  by the inflexible bonj
defences of the  others.  It will, however, be seen
hereafter, that, in regard to the  cb°st,  this supeii
ority of the abdomen is only apparent in as  far a>
relates to the  certainty of the results;  although rt
                                      (25) 
26
ABDOMEN,  (EXPLORATION  OF  THE)
is undoubtedly  real in respect  of the directness
and  obviousness of the methods of exploration
which are applicable to it.
  Previously to describing these methods, it is
necessary to notice  the  topographical relations of
the exterior surface of the abdomen to the parts
within.  This kind of knowledge is of the great-
est importance to the practical physician in regard
to many parts of the  body, but  more particularly
the chest and abdomen.  Without it he will con-
stantly be left in doubt respecting the parts affected
with disease, and will frequently be led  into  the
error of attributing the symptoms of  one suffering
organ  to another.  With the view of facilitating
the acquisition of knowledge of so  much value,
and  of enabling the  practitioner  accurately to
record his own observations, and to communicate
to others precise information respecting  the seat
and signs of internal diseases, it  has been  custom-
ary to map out the exterior surface  of the chest
and abdomen into different compartments, termed
regions, by means of imaginary lines  described
upon it, corresponding with  imaginary  planes
passing to  the  centre  of the body.  These lines
have not always been drawn in the same manner:
on the contrary, there  has  ever  existed great dis-
crepancy among the writers  and teachers of this
and  other  countries respecting  the  number,  the
extent, and the names of the regions.  This  is a
circumstance greatly  to  be  regretted ;  and it is
much to be desired  that some arrangement could
be pioposed which  might attain general assent
from teachers and practical  writers.  It is probable
that no plan can be proposed that is without even
obvious defects; but it would be greatly for  the
benefit of the student and the practitioner  if there
were a fixed plan of any kind, one plan universally
adopted, even if defective in some of its parts.  At
present hardly any two teachers  or writers adhere
to the same division or nomenclature.
  In the annexed regional  plans of  the trunk of
the body, (designed and executed by Mr. Paxton,
of Oxford,) the  nomenclature and divisions most
generally adopted have been  as  much as possible
adhered to ; but it was occasionally  found neces-
sary  to differ  in both  these points, in order to
attain  what appeared to be objects of practical
importance.   We have gone upon the fundamen-
tal principle of defining every region accurately, in
every individual case, by  drawing  all  the lines
perfectly straight, and  between points that are at
once  fixed in  their nature and obvious  to the
senses.   By these means there can  never be  any
doubt as to the intended  place or extent of par-
ticular regions,  whatever objections may be raised
against the propriety of the divisions.  As it was
found advisable  to extend  the same vertical lines
over the two  great  cavities of the trunk, we  are
under  the necessity of introducing the  diagrams
of the chest in conjunction  with  those of  the ab-
domen, in order to point out the fixed points from
which the lines are  drawn.   We shall only, how-
ever, in this place, take notice of the  abdominal
-egions, which, it will be seen, are  quite  distinct
from those of the chest.
  The  various  regions are,  as we have  said,
oounded by straight lines, or rather by direct lines
drawn  between fixed points, on a rounded  or
uneven surface.  The vertical lines which have
reference to the abdomen are five in number, and
run as follows:  1. from the external tubercle of
the pubes (or insertion of Poupart's ligament) to
the acromial  extremity of the clavicle (right  and
left side); 2. from the posterior boundary of the
axilla (or inferior edge of the latissimus dorsi) to
that point of the crest of the ilium, on which  it
falls vertically (right and left side); 3. along the
spinous processes of the vertebrae from the sacrum
to the nape of the neck.  The transverse  lines are
four in number, and are drawn exactly in  horizon-
tal  planes, as follows: — l.on  the point of the
xiphoid cartilage;  2. on  the last  short rib; 3. on
the anterior and superior spinous process of the
ilium  on each side; 4. on the upper margin of the
os pubis.  We have thus  three horizontal and
five vertical bands, and thirteen  regions in all; of
which five may be termed  anterior, four lateral
(two  on each  side), and  four  posterior. Their
names are as follows : — anterior regions, epigas-
tric, umbilical, hypogastric,  inguinal  (right and
left) ;  lateral regions, hypochondriac  (right and
left), iliac (right and  left); posterior regions, in-
ferior  dorsal  (right and  left), lumbar (right and
left).   We have not carried the  subdivision of the
inferior zone  to the posterior and lateral  parts of
the trunk ; because the parietes there are of such
a nature as to prevent us from deriving any aid
in the investigation  of the subjacent parts from
exploration.
   There are few  more  useful  exercises for  the
anatomical student than endeavouring to imprint
on his mind some plan of this  kind, and  to teach
himself by observation, and  by multiplied expeu-
ment  on the dead subject, the precise relations of
the regions to the viscera that lie beneath them
He ought  always to consider his knowledge as

                   Fig. 1.
 
ABDOMEN,  (EXPLORATION  OF THE)

             Fig. 2.                              Fig. 3.
EXPLANATION  OF  THE FIGURES.
Abdominal Regions.
4. Epigastric.
5. Umbilical.
6. Hypogastric.
9. Hypochondriac.
1. Humeral.
3. Subclavian
3. Mammary.
7. Axillary.
10. Iliac.
II. Inguinal.
15. Inferior Dorsal.
1G. Lumbar.
Thoracic Regions.
 imperfect, until he is able to state, with conside-
 rable accuracy, the organs, or parts of organs, that
 will be  wounded by  a stiletto  thrust in at any
 point.  It  is only after possessing such a degree
 of knowledge, that he can enter, with full advan-
 tage, upon  the study of the various methods of
 exploration which we are now about to detail, or
 that he can expect to derive from them the great
 practical benefits which they are  calculated to
 supply.
   The methods of exploring the  abdomen may be
 reduced  to three — inspection, manual examina-
 tion (or  palpation},  and percussion.  We shall
 notice them in  order.
   I. Inspection.   This term is here used in its
 simplest sense, as restricted to the operations of
 sight only.
  By inspection we judge  of the size, form, and
 movements  of the abdomen. The two last-named
conditions are,  perhaps, better ascertained by this
than by any of the other forms of exploration.  It
is needless to point out in how many instances
     8. Subaxillary or Lateral.
    12. Scapular.
    13. Interscapular.
    14. Superior Dorsal or Subscapular.

our judgments respecting the nature of diseases, a*
derived from other signs, are modified by the sizo
of the abdomen.   This is an important diagnostic
sign in many diseases, both acute  and chronic,
more particularly  perhaps in the diseases of in-
fants ; and it is often equally valuable as aiding
prognosis,  especially  in fevers  and  other  acute
diseases.
  The mere  form of the abdomen, independently
of its size, is no less valuable as  a sign, in many
cases.   By this  alone we are sometimes enabled
to form a probable conjecture, if not to decide  at
once, respecting the seat and nature  of a disease :
although a practitioner could not be justified  in
acting upon such knowledge without having  re-
course to other signs and other modes of exploia
tion.   In pregnancy, in ovarian dropsy, in ascites,
tympanites, and enlargements  of the liver, the
form of the aodomen is different.  In  certain cases,
the  direction of the  inferior border of the ribs
assists us in determining  whether enlargements
of the epigastric  and hypochondriac regions *>rigp- 
28
ABDOMEN,  (EXPLORATION  OF  THE)
nate in the abdomen or  within the chest.  In the
former case, we may expect the border of the ribs
to be turned outwards; in the latter, inwards, with,
probably,  a bulging out of the  ribs above  this
point.   In some examples of enteritis and colica
pictonum, the nature of the pain is very similar; ,
but the form and size of the abdomen are often very'
different, and sufficient to discriminate  the  two
diseases.  In the one the abdomen is distended, in
the  other  contracted.   In  some of  the  severer
febrile affections of children, the form and size of
the abdomen afford valuable signs to  assist us in
determining  a question frequently of great diffi-
culty, viz. whether the principal seat of the disease
is in the internal mucous membrane or in  the
brain.
   The movements  of the abdominal  parietes are
equally worthy  the practitioner's attention.   In
many cases,  these movements  are characteristic
of particular morbid states, and very considerably
assist  diagnosis, more  especially when  viewed
together with the motions of the thorax.  In peri-
tonitis, enteritis, and other  inflammatory diseases
of the abdomen, likewise in great distension of the
cavity from dropsy,  pregancy,  tumours, &c. &c.
the parietes  frequently  remain  motionless during
respiration, while the movements of the chest are
proportionally increased.  The reverse obtains in
analogous  affections of the thoracic viscera.  In
cases in which both sides of the chest are Tendered
immovable by pain or physical incapacity, the
abdominal movements  are  often  increased to a
remarkable extent.   This is particularly observed
in the case of double pleurisy, and also in asthma.
In the paroxysms  of this last affection, however,
the form and movements of the abdomen are very
different from those  observed in  the former.   In
asthma, the walls of the chest and the diaphragm
are forcibly retracted, and cling to the imperfectly
expanded lungs  ; the abdominal muscles are also
drawn in towards  the diaphragm, but are  at the
same time forced  into  violent yet very  limited
action.
   II. Manual  examination, or palpation.*
By the simple touch, or application of the hand
without pressure, we judge  of the size, form, de-
gree of sensibility, and temperature, of the exter-
nal walls of the abdomen ; and  by touch, combined
with pressure, (palpation,) we attempt to ascertain
yet more accurately the condition of the internal
organs.  For the performance of the former part
of the process, no other position  of the patient is
requisite but that which permits the free access of
the hand to the  surface  of the abdomen ; but for
the successful exploration of the  internal parts, it
becomes necessary that  the patient should assume
that posture which is most  favourable  for the
relaxation of the abdominal muscles.  This result
is best obtained  when the patient is  laid on the
back, with the  head moderately raised  and  bent
forwards on the  breast, the arms extended by the
sides, the thighs bent nearly at right angles on the
trunk, the knees apart and turned outwards, and
the feet resting on  the  bed  in  contact with each
other.   When so  placed,  the  patient should be
made to understand that he is  to exert as little
muscular  effort  as possible in retaining his posi-
Uon ; and we are to take  care that such exertion
  * " Palpation, the act of feeling."—Johnson.  From
pa.lpo, or palpor—-palpatio.
is not forced upon him by any proceeding of ours
which can be avoided.   Sometimes the mere cold-
ness of the hand, or even the simple touch, has
the effect of throwing the abdominal muscles into
action.  Apprehension  of pain from pressure has
the same  effect; and, likewise, misapprehension
of our wishes respecting the condition of the ab-
dominal parietes.   In  such cases we shall gene-
rally  find,  after a  short  time, that the  muscles
relax  gradually of  their own  accord, particularly
if the patient's attention is diverted from our pro-
ceedings ; or we succeed in our object by causing
the individual to take a deep inspiration, to cough,
or  speak; by which  means  the  state  of tonic
tension of the muscles is  destroyed.  Sometimes,
however, we find it impossible to obtain a com-
plete  relaxation ; and this circumstance is of itself
an important sign,  and taken in conjunction with
others is well deserving the attention of  the prac-
titioner.   The  patient, in these cases,  seems in-
stinctively to keep the muscles in a state of tension,
in order to ward  off the pressure from the parts
beneath, some of  which are inflamed, and there-
fore morbidly sensible.  This state of the muscles
is  often found  in inflammation of the intestinal
mucous membrane.
   It  is of the more consequence to ensure the
complete relaxation of the muscles, because their
tension not merely prevents the accurate examina-
tion of the parts beneath, but even occasions the
muscles themselves to be mistaken for  enlarge-
ment or induration of the viscera.  This remark
applies more particularly to the recti muscles, the
prominent bellies of which  sometimes  simulate
pretty accurately the inferior border of an enlarged
liver.  We have  often seen  this mistake com-
mitted at  the first  moment of exploration ; and,
although  generally, it has not always been cor-
rected by  further examination.
   The chief objects we have in view, in exploring
the abdomen, are  the  following : — To ascertain,
1, its form and  size; 2, its degree of tension or
solidity ;  3, its  temperature ;  4,  its sensibility ;
5, the  presence or absence  of tumours of the
viscera, or new growths within the cavity ;  G, the
presence of fluids  in  the  peritoneal sac ;  7, the
nature and extent of the  intestinal contents, &c.
Some of these require much more  attention than
others.   We shall only notice, with any degree
of minuteness, such of them as are of most im-
portance.
   The form, size, degree of temperature, tension
and  superficial  sensibility  of the abdomen, are
ascertained by the simple application of the hand
to  the different parts of it in  succession, or, at
most, by the gentlest pressure.  Some precautions,
however, and some further attention, are requisite,
in order to enable us to ascertain the true degree
of temperature and sensibility of the parts.
   Owing to the singular infidelity of our sensa-
tions as a measure of temperature, the greatest
care is necessary to prevent our being misled in
judging of the degree of heat from the testimony
of our hands alone.  Every body  knows that out
perceptions of warmth have relation as much to
the preceding as to the actual sensation.   We are
apt to consider a body as warm, solely because  it
is of  superior  temperature  to  one  previously
touched ; and  we may  almost  immediately  be
induced to reckon the  very same substance cold
after touching one that is of a temperature greatly 
ABDOMEN, (EXPL
higher.   The temperature  of the  hand  itself is I
also to be taken into account, and not  merely its
actual temperature, but its  habitual temperature.
Some persons  have hands  habitually  cold,  and
others habitually warm ; and it is not  likely that
such persons will judge similarly of temperature,
even when their hands chance to be equally warm
at the period of experiment.   It is still  less likely
that they will agree if their  hands are of different
temperature.  In examining the  temperature of
the abdomen, or of any other part of the body, it
will  be most safe to judgei rather of the relative
than of the absolute degree  of heat; and this  will
be best done by examining  alternately other parts
of the body presumed to be  in a state of health.*
   The temperature  of the  abdominal  surface is
frequently  an important sign of disease.  If very
elevated, it indicates inflammation of the subjacent
parts, or, at least, that  increased afflux of  blood,
which cannot  be practically discriminated from
the early stage of inflammation.  If that singular,
and, we believe, still unexplained pungency, which
attends certain febrile and inflammatory affections,
is present, the complication  renders the sign still
more significant of severe disease.
   In exploring  the degree of sensibility, the pres-
sure should, of course, in the first place, be made
in the gentlest manner, and  with  the  open hand.
If the surface is impatient of the  slightest  touch,
we may be assured that the cause of the tender-
ness is in the parietes.   If  no superficial tender-
ness exists, we proceed to examine the  parts more
freely by compressing the  parietes more or  less
forcibly, and in different directions.  Sometimes
we find that a change in the direction of the pres-
sure  produces  very  different results in the same
part.  In peritonitis, for instance, direct  downward
pressure towards the spine  is sometimes borne
tolerably well, when pressure in a lateral direction,
particularly such as forces the abdominal peritone-
um to slide over the intestines, occasions extreme
pain.  In chronic diseases, much greater freedom
may generally be used in our explorations ;  and
when considerable  doubt  exists  respecting the
nature of a disease, we should endeavour to bring
every organ of the abdominal cavity  within the
sphere of our explorations.
   Some  physicians, in exploring the abdomen,
seem to  consider it sufficient merely to pass the
hand across it once or twice, using  a  very gentle
pressure in the  suspected places.  Such a method
is often more calculated to mislead than  to instruct.
It may, indeed, satisfy the patient that his case has
met with due attention, while he has, at the same
time, been treated with gentleness and delicacy ;
but it cannot be satisfactory to the practitioner who
knows the value of this mode of investigating dis-
ease.   But while we recommend  the propriety of
a free exploration, it is necessary to caution the
young practitioner against adopting one of unne-
cessary violence.  Some  physicians make use of
so much  pressure, or  rather they apply  it in so
injudicious  a manner, that they hardly  ever fail to
elicit  from  the patient the expression  of pain in
the suspected  region.   This  is particularly the
case  when  the  pressure  is  made, with the very

  * Nothing can  show the imperfection  of mere  sen-
sation as a test of temperature, more strongly than the
fact constantly observed, of patients and their attendants
reporting particular parts as pretornaturally hot—" burn-
ing hot,"—which are found on  trial, to be of the natural
degree of warmth.
 RATION  OF  THE)                 29

points, or still more with the nails of the fingers
or when the soft parts are compressed against such
as are solid.  No very general rules  can be laid
down in such cases.   Experience of the natural
sensibility of the parts to pressure, in  health and
disease, can alone give the  true practical tact; but
even  experience, we find, may here, as in other
circumstances, be over-mastered  by the influence
of theory and prejudice acting on a weak judgment
or a  warm imagination.  In  every case,  while
exploring the  sensibility  of the abdomen, it is im-
portant to watch the  expression of the patient's
countenance; as this is  often found to be a truer
index of his sensations than his words are.
   If, in the course of our exploration, we discover
any unusual swelling  or indurated part, we must
endeavour to  ascertain  its  nature and various
relations,— its exact site,  size, form, consistence,
connexions, and degree of sensibility;  whether it
contains a fluid  or not, whether it is pulsatile or
not, and whether it is fixed or movable.  All these
circumstances are of consequence.  The situation,
size, and  form of the  swelling will enable us to
judge respecting the  organ or part affected ;  its
consistence, degree of sensibility, &c. will help us
to the  knowledge  of the nature of the tumour
itself.   In persons that are of a spare habit, and in
whom the abdominal  parietes are  relaxed,  and
more particularly in women  and children, whose
muscles are naturally small and feeble, we are
able to ascertain the condition  of almost all the
parts contained  in the abdomen with considerable
minuteness,  and to an  extent  beyond what  is
commonly  believed by  practitioners.   In  many
cases, for instance, it is easy to feel the mesenteric
glands when enlarged, and even the kidneys.  We
must,  however, be careful, in  making these free
examinations, not  to  mistake  natural  conditions
of the parts for  morbid deviations.   Masses of in-
durated  faeces in the  colon, and even the spinal
column, have been mistaken for  morbid  growths.
 (Bianchi, Hist. Haepat. 325.  Double, Semeiol. t.
i. 383.)   Errors of this kind may, in general, be
avoided.   The  movableness of the faecal masses
ought to  point out their  nature ; and the extreme
fixedness of the spine,  as well  as  its  form and
direction, will hardly permit such a mistake to be
committed by any one  possessed  of  a  common
. degree of anatomical knowledge.
   In examining the abdomen with the view of
detecting fluids  accumulated in its  cavity, we, in
some respect, reverse the preparatory steps recom-
 mended in  searching  for more solid matters.  In
exploring for  fluids, we wish the abdominal parie-
tes to be  in a state of tension rather than relaxa-
tion : and, with a view to obtain this result, if the
patient is in bed, and cannot conveniently get up,
we make him lie quite flat, with the head low and
the legs extended ;  or we even  increase the ab-
dominal tension still further by placing  a pillow
under the loins.   It is, however, still better if the
patient can be placed in  the erect position ; as the
abdominal walls are thereby  rendered  naturally
tense, and the fluids are accumulated at the inferior
and anterior parts of the cavity, in place of being
intermixed with, and in  some degree hidden by
the intestines,  as  is  partly the  case when the
patient is in  the horizontal  position.   The litt.e
manoeuvre for ascertaining the fluctuation of the
fluid is universally known.  It consists, simply, in
placing the palm of one  hand against  one side of 
30
ABDOMEN,  (EXPLORATION  OF  THE)

                          ^nder the last head, is a mode of percussion ; and
                             the very name so long borne by one morbid con-
the abdomen, with a firm but gentle pressure, and
tapping smartly with  the other hand  directly op-
posite to it on the other side.  If fluid is present,
the impulse will be transmitted through it to the
other hand, producing a peculiar vibratory shock
which cannot  be mistaken, after having been ex-
perienced a certain number of times.   The import
of this  fluctuation  as a sign of  disease is well
known :  it is almost pathognomonic of ascites, or
dropsy  of  the  peritoneum.   It is, however, also
found in other diseases of the abdomen ;  and is
generally acknowledged to be of importance, both
positively and negatively, in aiding their diagnosis.
For the various diseases in which it  is employed
as a sign, we refer to  the different articles of this
work, in which these diseases are treated. And we
would here observe once for  all, that in drawing
up the present paper we have always had in  view
the ampler diagnosis  which will  be found under
the head of individual diseases;  our object not
being to establish the diagnosis of particular dis-
eases, but to give the practitioner a  general out-
line of the  methods of exploration which are more
or less applicable to all the diseases of the abdomen.
   If this were the  place for such disquisitions, it
were easy to show, from the authority of  the best
practical authors of all ages, how very important
a place in the diagnosis of diseases has been always
assigned to the physical exploration  of the abdo-
men.   In the  early ages of physic, this  practice
was, from  various  circumstances, much more in
use than afterwards. Subsequently to the discovery
of the circulation  of the blood, when so  much
reliance was placed on the indications of the pulse,
and when men's minds were so much occupied by
theoretical  and metaphysical distinctions, the phy-
sical investigation  of diseases generally,  and of
those of the abdomen  among the rest, fell into
neglect.  It has, however, during the last fifty
years,  and more  especially  during  the  present
century, more than regained its pristine estimation
with all  well-informed physicians, and is at length
secured from all future decadence on the  immov-
able basis   of  organic pathology.   With  good
reason, therefore, we  may conclude this imperfect
exposition  of the method of palpation, as applied
to diseases of the abdomen, in the words  of  Hip-
pocrates and Baglivi.  " Certain  it is that he who
examines  the abdomen, as well as  the pulse, is
much less  likely to be deceived than  he who does
not."*   "  If physicians were always to examine
the abdomen, upon first visiting the patient, more
particularly in acute diseases, they would assuredly
commit  much fewer  mistakes  than  they do at
present, neglecting this  method  of exploration.
The knowledge of the condition of the upper parts
of the abdomen improves vastly  both our treat-
ment and our prognosis."!"
   III. Percussion.   (From percussio—percutio
—per  and quatio.)   This form of abdominal ex-
ploration had been used as an occasional aid to
diagnosis from very early times.   The manoeuvre
for detecting the fluctuation of liquids, mentioned

   * Deindcqui manibuscontrectavit ventrem [ac venas],
minus falli potest, quam qui non contrectavit. Hippoc.
Prcedict., lib ii., § v.
   1 Si  inedici tiostri temporis omnium fpgrotorum hypo-
chondria statim tractarent, in morbis potissimum acutis,
pauciores certe committorent errores quam faciunt spreta
iiypochondriorum observatione.  Qui  bene noverit hypo-
Ehondriorum statum in  morbis, quam bene curare nove-
rit, quam bene praesagire ! Baglivi de Prax. Med., lib.
u, cap. 9  Op. p. 39
dition of this  cavity (tympanites, from rv^avov,
a drum) is at once sufficient evidence of the prac-
tice, and of its antiquity.   It is only, however, of
very recent date that any attempt has been  made
to establish  a formal and elaborate system of dia-
gnosis, applicable to diseases  of the  abdomen, by
means of percussion.  M. Piorry, a young Parisian
physician,  has the honour of having, if not in-
vented, at least brought into a formal  and matured
shape, this new application  of the  discovery of
Auenbrugger, and with practical results of greater
precision and importance than could have been
anticipated .J
   In the article Auscultation a  full  account
will be given of the principles upon which per-
cussion, as a general means of diagnosis, is founded.
At present, nothing more will be attempted than
a  mere  practical  exposition  of  the method as
applied to the discrimination of abdominal dis-
eases.   We shall  only so far anticipate the details
of the article  referred to as to state that there are
two methods of eliciting sounds from the surface
of the body by percussion, with the view of  judg-
ing of the physical condition of the parts beneath,
— the one termed direct percussion, or, simply,
percussion ,-  the other mediate percussion.  The
former is the proceeding proposed  by the  great
discoverer  of  the method, Auenbrugger,  and con-
sists in  simply striking  the  part in  a particular
manner, with the points  of two or  more fingers
united ;  the latter differs very little either in prin-
ciple or practice, except that a thin plate  of solid
and elastic matter, as of wood  or  ivory, is  inter-
posed between the fingers and the surface of the
body.   In exploring the  chest by means of per-
cussion, the comparative solidity and elasticity of
its walls, as well  as the  nature of  its contents,
render the  interposition  of a sonorous body be-
tween the fingers and  its surface less necessary,
although it will be seen that this is useful even
there ; but in  the case of the abdomen such assist-
ance is absolutely necessary to  the production of
sufficient sound to enable us  to judge of the con-
dition of the  viscera  within.   In the following
observations it will, therefore, be understood that
mediate percussion is the method  always spoken
of.  The small ivory plate on which the percus-
sion is made has been  termed, by its inventor M.
Piorry, the pleximeter, or measurer of percussion.
In exploring the  abdomen by  this  method, we
make use of various degrees of force in  applying
the plate to the surface, so as to depress this more
or less, according to the  objects we have  in view.
In many cases percussion on  the plate pressed
slightly  on the  surface,  yields a very  different
sound from that elicited from it in the very same
spot, when it is pressed deeply  into the cavity of
the abdomen.   In the former case, the sound may
be perfectly tympanitic, owing  to the proximity
to the surface  of the  intestines containing air;
while  in the latter it is  often dull  or dead, from
the circumstance of the  plate having been depressed
below the  level  of  the  floating intestines into
mediate contact with  some solid or fluid body
incapable of yielding similar  sounds.
   \ The two following works,  by  M. Piorry  are well
worthy the reader's attention : —
   1. De la Percussion Mediate.  Paris, 1828.
   2. Du Precede Operatoire a stiivre dans 1'Exploration
des Organes par la Percussion Mediate.   Paris 1830. 
ABDOMEN,  (EXPLORATION  OF  THE)                  31
  In the following brief sketch of the results of |
abdominal percussion, we  shall, in a  great mea-
sure, follow M. Piorry, referring the reader to his
elaborate  work  for further information.   It will
scarcely  be credited, by those  who  have  never
practised, nor seen practised, this method, to what
a singular degree of minuteness of diagnosis M.
Piorry has carried it.  Such persons  may proba-
bly be disposed to consider many of his statements
as founded in delusion, if not in fiction.   But  it
may be well for them to recollect that the discove-
ries of Laennec  were so designated by many on
their first promulgation ; while, at present, within
the short period of a dozen years, only an insig-
nificant minority call in question the truth of even
the most remarkable of them.   We do not pretend
to have  verified  all the statements made by  M.
Piorry ;  and, indeed, nothing short of the indomi-
table zeal of a young Parisian  pathologist of the
present day could enable any one to  do so within
a moderate space of time ; but from our knowledge
of the results that are obtained from percussion as
applied  to the chest, and from numerous trials of
it in abdominal affections, since the publication of
M. Piorry's  first work, we  entertain no  doubt of
the general accuracy of his conclusions.   At the
same  time we  must admit, that to reach such  a
nicety of acoustic tact as is implied in several of
the  results recorded by  him,  will require more
leisure and continued application than most men
engaged in practice can afford to give.  But such
a practical acquaintance with the method  as will
be found highly  useful, may soon be  acquired by
any one ; and we consider it  the duty  of every
 practitioner to endeavour to acquire thus much at
least.
   The position of the stomach relatively with the
surface is well known.  In general, it occupies the
 epigastric and   left  hypochondriac  regions,  its
greater  extremity occupying  the  latter,  and  its
 smaller  extremity extending to the right side of
 the  epigastric region, or  even into the  superior
part  of  the right iliac.  But  its  position varies
 extremely, according to  its degree of fulness, and
 the  condition  of the  neighbouring  viscera.  It
 varies also greatly in respect of its  proximity to
 the abdominal parietes.   In the great majority of
 cases, some part of its  surface lies  in immediate
 contact  with the abdominal parietes, more espe-
 cially when it contains a considerable quantity of
 ingesta.   When empty, or nearly empty, it some-
 times is retracted towards the spine,  while the
 colon or  ilium  lies in the front of it.  As the
 stomach very generally  contains  a  considerable
 portion  of air, percussion over  its  usual site com-
 monly yields a very clear sound.  The  clearness
 of this sound is  found to be gradually diminished
 as food  or drink is taken.   When the stomach is
 filled  to repletion, it yields nearly as dull a sound
 as the solid  viscera.  When  it contains, at the
 same time, a considerable quantity both of air and
 liquid,  percussion  produces  a peculiar  sound,
 termed humoric  by M. Piorry, and  which  has a
 sort  of  silvery, vibratory  clearness,  somewhat
 resembling  the  metallic tinkling  of Laennec.
 This  sound  is  observed in  other  parts of the
 abdomen, where there  is an accumulation  of  air
 and liquid either in  actual contact or in  contigu-
 ous cavities.   It  is not, however, peculiar to this
 condition of  parts, being also found wherever the
 wr is  forced out of a large cavity through a small
opening.  The knowledge of the condition of the
stomach, as to emptiness or repletion, and likewise
as to the general quality of i ,s contents when full,
may be very  useful in  many cases, both in  prac-
tical medicine and  in  medical jurisprudence.
When we know, from  the history of the case, that
the viscus is  empty, or, at least, that it  does not
contain any food, a completely dull sound elicited
from its usual site will indicate that some conside-
rable morbid change has  taken place either in it
or the  neighbouring parts.  Its habitual tympany
will be manifested by signs of an opposite kind.
   In the state of health, the large intestines almost
always contain a very considerable quantity of
air ; the small intestines generally contain some
also.   In consequence of this circumstance, per-
cussion over their respective sites yields the tym-
panitic sound in  a greater or less degree, in pro-
portion to their proximity to the surface, the size
of the intestine, and quantity of air  contained in
it.  The coecum  being one of the most fixed parts
of the intestinal canal, and generally containing a
considerable quantity of gas, renders the right iliac
region usually sonorous  in the state  of health.
From  this point we can also,  in general, trace the
transverse arch of the  colon, by means of a tract
of clearer sound across the upper part of the um-
bilical region to  the left  iliac region.  It  is well
known how constantly this  intestine contains  a
large quantity of air.   The  left iliac region gene-
rally yields a duller sound than the right, but not
always ; the result being dependent  on the parti-
cular  portion  of intestine lodged  there, and the
state of its contents.   The sigmoid flexure, which
most commonly occupies this  region, contains, in
 general, more faecal matter than the coecum or the
 transverse arch of the colon, and  therefore yields
 a duller sound.
    The small intestines usually occupy the greater
 part  of the  centre of the abdomen, filling the
 umbilical  region, and encroaching, more or less,
 upon  all the adjacent  regions.  They may be said
 to be, in a considerable degree, surrounded by the
 colon.  They generally contain some air in the
 state of health ; but a great deal less in proportion
 to their size and other fsecal  contents, than the
 large  intestines :  they, therefore, yield much less
 sound on percussion.  When they contain very
 little  air and  much chymous fluid, they hardly
 give  any of  the tympanitic  resonance.   This
 natural dulness is sometimes increased by disease
 within the bowel, but it is, we believe, much more
 frequently diminished.  The increased dulness in
 the regions  occupied by the sonorous portions of
 the intestines is most commonly occasioned by
 disease external  to  their  canal. In affections of
 the mucous membrane, a morbid augmentation
 of the quantity  of gas usually contained  in the
 bowels is much more  common than  a diminution
 of it.   In many cases, the intestines are extremely
 distended with gas throughout the greater part of
 their  whole course; and  when this distension  is
 of  some  continuance, it  has been frequently
 described as a distinct disease, under the name of
 tympanites or  tympany,  from  the  drum-like
 tension of the abdomen produced  by it, and the
 loud sound  elicited on percussion.
    It is obvious that a practitioner, well acquainted
 with the various kinds and degrees of sound usu-
 ally elicited  in  health from  the regions chiefly
 occupied by the  hollow viscera, may derive much 
32
ABDOMEN,  (EXPLORATION  OF THE)
 important  information calculated to aid his diag-
 nosis and  prognosis, and to regulate his practice,
 by attending to the  modification of those sounds
 produced by disease.   In relation  to  this point,
 it suffices  to  notice the  different judgment that
 will  be formed in  two  cases  having the  same
 degree of swelling, but with the sound quite dull
 in the one, and tympanitic in the other.
   When the bladder of urine  is at  all distended
 by its  natural  contents, so as to project  beyond
 the edge of the pubes, its presence may always
 be easily ascertained  by percussion.  It yields a
 dull  sound, like that  of  ascites, which contrasts
 well  with the clear intestinal sound on all  sides
 of it, but is yet of a different character from that
 yielded by  a solid tumour.  M. Piorry assures us
 that  it is even possible  to ascertain  the presence
 and dimensions of the gall-bladder by the  same
 means.   We have never  attempted to verify this
 statement.
   The presence of  the solid  viscera and  of solid
 growths  of a  morbid  kind is ascertained chiefly
 by the  contrast of their  dull  sound with the
 resonance of the intestines  around.  It is, there-
 fore,  important  to be  well  acquainted with the
 natural  seat  and limits of these viscera in the
 state  of  health.
   In judging  of morbid  states of the liver, suf-
 ficient allowance is not always made for varieties
 that  occur  in  its position, independently  of any
 disease in the organ  itself.   Disease  of the right
 cavity of  the  chest  will  occasion  retraction or
 depression  of the liver, according  as it  is  of  a
 kind  to elevate  or depress  the  diaphragm.  Dis-
 eases  of the abdomen  will have the same effect
 by a  reverse operation.  Alteration  of the shape
 of the lower part of the chest from the effects of
 stays, sometimes  occasions a remarkable  change
 in the relative position  of  the liver as well as of
 the stomach.   From this cause the liver is some-
 times  completely hidden beneath the compressed
 border of the  thorax ;  at other times its left lobe
 is thrust before the stomach  into the left hypo-
 chondriac region, or depressed into the umbilical.
 Besides, the size of the liver varies  considerably
 in different  persons, and in  the different  periods
 of life.  In  the  majority  of healthy  and  well
 formed persons, its lower border scarcely descends
 below the margin of  the ribs, or encroaches upon
 the scrobiculus cordis.   The situation  and  size
 of the liver, both in health and  disease, are  well
 ascertained  by percussion.  It is bounded  by  the
 stomach on the left  side, and the colon  below,
 both generally containing air ; and it  is accurately
 bounded above  by the  lungs, always, in  health,
 full of  air :  it  lies,  therefore, yielding its  dull
 sound, in the midst of a sonorous region.   If the
 practitioner  is well acquainted with the ordinary
 size of the healthy organ, and takes into account
 all the circumstances that can influence its posi-
 tion in the individual case  before him, he will not
 often be mistaken respecting the actual size of the
 liver,  nor have  much  difficulty in  determining
 whether this  size is to be  considered  morbid.
 Manual examination will  here be of great value,
 as far as respects the inferior or abdominal border
 of the hyer ; but percussion and auscultation can
 alone  point out the upper limits of the viscus.*

  * It is impossible to notice every peculiarity of disease
 thai may interfere with the manifestation of the usual
•ounds of health;  or to lay down rules  of diagnosis
    The situation of the spleen being a good deal
  dependent  on that of the stomach, is less fixed
  than that of the liver;  still, generally speaking,
  it may be said to be placed  in  the left  superior
  dorsal region  immediately below the diaphragm,
  and a  little to the left of the spinal column.  It
  is entirely covered by the ribs.   Being surround-
  ed on  all sides, like the liver, by hollow viscera
  containing  air, (except when it  adjoins  the kid-
  ney,)  it would be very  easily distinguishable by
  percussion,  if it were  placed  as  close to  the
  exterior of  the body as the liver is.  But this is
  not  the case ; and we cannot,  therefore, expect
  either  the same distinctness in our signs,  or accu-
  racy in our diagnostics, here, as in percussion of
  the hepatic  region.  Still, there  can be no doubt
  that when the spleen is enlarged so as to displace
  the  floating viscera, and  approach  the  side, its
  presence  may  be  readily recognised.  M. Piorry,
  indeed, says that its exact site may be ascertained,
  in most cases,  even in health.
    The kidneys are usually seated about the mid-
  dle of  the inferior dorsal region, on a level with
  the last dorsal and two upper lumbar vertebrae.
  Being   separated  from the  surface  by the  thick
  mass of the lumbar  muscles, it  is  hardly to be
  expected that their place should  be indicated  by
 percussion ;  and we confess that we  never made
 the experiment.   If this accuracy of diagnosis
 were attainable, we are  somewhat doubtful if it
 would  be of any use.   Still M. Piorry assures us
 that, both  in  health  and disease, percussion is
 capable of  making  known  the  position of the
 kidneys, when exercised  with certain  necessary
 precautions  detailed by him.
   In no morbid condition of the abdominal cavity
 are the  results of percussion more satisfactory
 than in the  case of liquid effusions into the  peri-
 toneum.   In most cases,  either  inflammatory or
 simply  dropsical, the  effused  fluids seek the  low-
 est level, according to the position of the  patient,
 leaving the hollow viscera, containing air, to float
 partially above them.   Over  the  space occupied
 by the  latter, percussion wilL of course, elicit the
 tympanitic resonance ;  while over that occupied
 by the  denser liquid, the sound will be compara-
 tively dull or dead.  In general, the demarcation
 of the  sonorous and  dull regions is very abrupt
 and distinct ; and  is proved, by experiment,  to

 applicable to every such peculiarity.   While engaged in
 writing  the preceding remarks, we met with an  instance
 of this sort, in the case of a man affected with ascites
 and anasarca.  In this case, the liver was evidently very
 small, at least in its inferior portion, because percussion
 elicited the clear tympanitic sound over all the border of
 the ribs and for a couple of inches above this.   It was
 also evident that there was  no accumulation of water
 in the chest, at least to any extent;  and there existed
 no sign of pulmonary disease.  On the lower part of the
 right side of the chest, above the usual site of the liver,
 there was, however, a space of three  inches broad, in-
 cluding the nipple, and stretching laterally to a consider-
 able extent, which yielded a perfectly dull sonnd.  Was
 this the liver stretching so high into the thorax  ? or was
 it a tumour attached to the diaphragm ? Dissection ex-
 plained the difficulty at once.  It appeared that thisman
 on some former occasion had had inflammation of the
 peritoneal coat of the upper face of the liver, which had
 terminated in partially attaching the  viscus to  the dia-
 phragm  in such a way as  to form, by the adhesion, a
 shut but  empty sac between the peritoneal coats of the
 liver and diaphragm. On the supervention of ihe drop-
 sical disposition,  this portion of the serous membrane
 threw out its serum like the rest;  but having no outlet
 it accumulated ; and finding the diaphragm more yield-
ing than the liver, it thrust the former  upwards into the"
chest in the form of a tumour.  The sac contained neai
ly a pint of serum. 
ABORTION.
33
be always that of the temporary level of the fluid.
Change  of position immediately  alters the  rela-
tive positions of the dull  and tympanitic regions.
For example :  in the case of a moderate accumu-
lation of fluid, when the patient  is in the erect
position, the  whole  of  the lower  parts of the
abdomen, viz. : the  hypogastric, inguinal,  and
part, at least, of the epigastric, iliac, and inferior
dorsal regions, will yield  the dull sound ; but if
the patient assumes the horizontal posture, all the
anterior  regions  will resume the tympanitic re-
sonance, while the  dulness will be transferred to
the whole of the  lateral and dorsal regions.  The
degree of  dulness  of sound  is found to be in-
creased in proportion as  the percussion  is made
low down in the  regions containing the fluid.  It
was formerly stated that, if in cases of moderate
effusion  we  press  the  plate  forcibly upon  the
abdomen, we frequently reach  a point where per-
cussion  elicits a  dull sound, although  it  had
elicited a clear sound from the same  spot when
the plate was only pressed gently upon  the  sur-
face.   The fact  is  explained  by  the   pleximeter
having in the former case reached the level of the
fluid  in  the  abdominal cavity, after displacing or
compressing the hollow  bowels which had  been
floating  above it.   These various results indica-
tive of the presence of fluid are" frequently obtain-
ed when the quantity is  so small as to be undis-
coverable  by fluctuation.  As they  are equally
observed whether the effusion  is the consequence
of inflammation  or simple dropsy, they will be
found in most cases of peritonitis ; and, therefore,
percussion will prove, not merely  a  diagnostic of
this disease, but  a valuable aid in discriminating
it from enteritis, properly so called.   In inflam-
matory affections of the  abdomen, it is necessary
to be very gentle in our operations on account of
the painful state  of the parts ; and, in such cases,
it may be further  requisite to employ a broader
plate, with the  view of diffusing  the  pressure
more equably over  the tender parts.*
   In the encysted dropsy  of  the abdomen, the
results of percussion are, in several respects, dif-
ferent ;  and  the  differences   supply  means for
enabling us to distinguish the two affections.   In
the encysted  dropsy the  sound is much duller;
the fluid  not being able to change its place, the
sphere of dull sound is  almost fixed;  or if the
whole cyst changes its place, which it  sometimes
does  in different  postures  of the patient, the
hydrostatic line of  level is never formed as in the
case of the  loose effusion.   In these  cases, also,
we frequently find  the  tympanitic   resonance
beneath  the  cyst, which  could not be the case in
simple ascites ; and  the  line  of demarcation be-
tween  the dull and  sonorous  regions is  seldom
quite straight, as in the last-named disease.  It
is hardly necessary to caution  the reader that, in
all these cases, no one should be so imprudent as

  * M. Tarral  has  recently described a new mode of
detecting abdominal effusions, which he terms superficial
fluctuation. (fluctuation ptripherique).  His description
of it is as follows :  "  Plnce both hands on the abdomen,
two or three inches apart, and with the two fore-fingers
parallel to each other; then, while the hands are still in
this position, give slight blows or shocks on the abdomi-
nal pai ietes with the fore-finger of the right-hand : this
will produce an undulatnry motion in the effused fluid,
which will bo readily  perceived by  the  fore-finger of the
left-hand.  The same result is obtained,  if the right-
hand is quite raised,  provided the blows are given ob-
liquely, as if brushing the surface."—Piorry, du Procedi
Opiratoire, p. 137.                                 i
  Vol. I. — 5
to trust to percussion alone in forming a diag-
nosis.  In  all kinds of cysts, as well  as in other
tumours, developed  among  the floating viscera,
palpation  will be, at least, of equal  value with
percussion.   There are, indeed, few cases, if any,
in which the one should be employed  exclusively
of the other, in  the  investigation  of abdominal
diseases.   In  the case of solid  tumours, as of
cysts,  when  they approach  the   surface,  and
thereby displace  the  floating viscera, they yield
the  dull  sound  on  percussion.  When  seated
more profoundly, the dull sound is only obtained
by depressing the abdominal parietes  to the level
of the solid mass.
   Percussion is sometimes productive of the best
results in cases of indurations and tumours of the
abdominal parietes, such as chronic abscess in the
interstices of the  muscles.   In such  cases it is
sometimes  difficult  to decide, especially in  fat
persons, whether the tumour has  its  seat within
the cavity ;  and  here we have found percussion
afford great  aid in removing the difficulty.  When
the tumour is  seated in the  parietes,  percussion,
when  applied with sufficient force, will elicit the
clear sound, however solid the tumour may be, if
it is not of much  greater size than is  usually the
case in such instances.  In a  solid tumour, spring-
ing from within the abdomen  itself, and pressing
against the parietes, the  sound will be perfectly
dead.                         T      -^
                              John t orbes.
   ABORTION,  (abortus,)  signifies  the  expul-
sion of the  foetus from the  uterus before its  dif-
ferent organs have been  sufficiently developed to
enable it to  support  an independent life.  When
the product of conception is expelled between
this period  and the full  term of utero-gestation,
the process is usually termed premature labour.
   Abortion  is a frequent occurrence in the early
months of pregnancy, particularly among women
of the lower classes of society, who are exposed
to  much  bodily   fatigue  and  mental  anxiety.
[Dr. Collins, of  Dublin,  met with 293 prema-
ture cases  in  16,414 ; and  Dr. Beatty, with 21
premature cases in 1200.  Dr. Churchill records
65 cases of abortion in 1705 deliveries; Madame
Lachapelle,  116 cases in 21,960; and  M. Deubel,
35 in 420 ; making, in all, 530 premature cases in
41,699 deliveries,  or 1 in  78J.   It has been sug-
gested by  Dr. Guy as probable, that the  small
proportion observed  by Madame Lachapelle is
owing to the fact, that  the  females, who came
under her  observation  at La Maternite, were
in the latter months of pregnancy, when  abor-
tions are  comparatively rare;  and  the same  ex-
planation  may  apply to other cases.]  It is most
liable to occur in plethoric, irritable,  and nervous
subjects ;  in women  who are  affected with con
stitutional diseases, more especially syphilis ;  ii_
those who  have  deformity  of the bones  of  the
pelvis, or some  organic  disease in  the uterine
organs.  All the  chronic diseases,  therefore, to
which the  uterus  and its  appendages are liable,
may be considered causes of  abortion.   The pru
duction of polypi  in  the  cavity of the uterus, or
of fibro-cartilaginous  tumours in its  walls, and
morbid adhesions of the uterus to the surround
ing viscera, may  all, by impeding the regulai
enlargement of the  gravid  uterus,  give rise  to
premature expulsion of its contents.
  Other predisposing causes of abortion, though 
34
ABORTION.
less evident than those now enumerated, are  also
usually admitted by  authors : for  example,  leu-
corrhoea, irritability or too  great contractility and
rigidity  of the uterine  fibres and  blood-vessels.
Those who have insisted on rigidity of the uterine
fibres as  a cause of abortion have been led  into
error, by supposing that the uterus enlarges during
pregnancy by the  mere  force of the mechanical
distension  of the ovum,  and not  by the  gradual
developement of all  the textures of the organ, in
exact correspondence with  the  growth of  the
organs of the foetus.
  But by far the most frequent cause of abortion
is in the product  of conception itself; viz. in a
diseased condition of the foetus, or its involucra,
by which  it  is  deprived of life,  and afterwards
expelled  from the uterus like a foreign body.  The
blighted ovum is thrown off from the parent, as
fruit which has become withered is separated from
the branch of the tree on which it has been  pro-
duced.   We have  examined numerous ova which
have been prematurely expelled, and  in many of
these, where no disease was obvious at first, some
morbid  state of the  membranes, placenta, or em-
bryo itself, has been detected, sufficient to  account
for the accident, wholly independent of any con-
stitutional or local  affection of the mother.  Some-
times the chorion has been thickened, opaque, and
extremely  irregular,  or lobulated, on its  internal
surface.   The amnion, in some cases, has under-
gone similar changes, so  that the  healthy  appear-
ance of the involucra has  been entirely lost.  A
collection of serum, or blood, has not unfrequently,
also, taken place, between the chorion and amnion.
The placenta, in some cases of abortion after the
third month, has been hard, like  cartilage, small
and  imperfectly formed, with calcareous particles
deposited in its substance : in others, the placenta
has been unusually large, and its  vascular struc-
ture has  been changed  into a soft yellow fatty
substance ; or hydatids have been developed in its
tissue.   The umbilical cord, in these  instances,
has  been remarkably slender, and  the foetus  has
appeared to perish for want of a proper supply of
nourishment ; and not from  any defect in  the
organization of its internal parts.
  The brain of the foetus, or the thoracic or  ab-
dominal viscera, may all undergo various altera-
tions of  structure incompatible  with life;  and
where the life of the foetus  is extinct, it becomes
an extraneous body ; expulsive efforts on  the part
of the uterus are usually  soon set  up, and abortion
ensus as the  necessary consequence.  When the
ovum  is  healthy,  it adheres  to  the uterus  with
great force ; but when diseased, the slightest shock
to the mother, the most trifling mental affliction,
is sufficient to cause  it to  be expelled.  Women
have had the bones  of the extremities fractured
during pregnancy,  and have suffered other grievous
injuries, without miscarrying.  A woman men-
tioned by Mauriceau escaped by a  window from
the third floor of her house when on fire, and in
her  fall to the ground fractured her arm, yet
abortion  did not follow.  The case of a young
woman with a narrow pelvis is related by Madame
Lachapelle, who threw herself into a deep pit, and
suffered  injuries of which  she  subsequently died,
yet the foetus was  not expelled.
   All cases  of abortion  cannot, however, be
referred  to organic diseases of the uterine organs,
or of the embryo and its involucra ;  since it can-
not be doubted that the process often arises from
accidental detachment of the placenta, in conse-
quence of an  unusual determination of blood to
the vessels of the uterus, or contraction  ot  its
parietes.   The placenta adheres to the uterus by
means of the  deciduous membrane alone, which
is directly applied to the openings  of the uterine
sinuses.   If the impetus of the blood in these be
increased by an excited state of the general circu-
lation, or by irritation of the uterus itself, an unu-
sual afflux of blood  to  these vessels will take
place,  and the placenta will be forced from  its
connexion with  the uterus, more  or less exten-
sively, by the extravasation of blood  from the
openings of  the uterine sinuses, between the
placenta and uterus.   If this takes place to a con-
siderable extent,  the process  of gestation will  be
arrested, and  in a longer or  shorter period the
ovum  will be expelled.   In plethoric women, or
in those who  menstruate copiously, very  slight
causes may give rise to a hemorrhagic effort in the
uterine vessels, and to the extravasation of blood
between the uterus  and placenta, with the  other
consequences now described.  A  plethoric state
of the uterine organs is most frequently met with
in those who lead luxurious  lives, who sleep in
warm soft beds, and indulge to excess  in  animal
enjoyments.   This plethoric state  of the uterus
commonly gives rise to a  sense of weight  in the
hypogastric region, or irregular pains of the uterus;
but it  sometimes happens that the blood suddenly
bursts from the uterine vessels, and detaches the
placenta, where  there  has  existed  no previous
sign  of  unusual determination of  blood  to the
parts.
   Besides these causes,  there are  others which
excite undue determination of blood to the uterine
organs, as violent exercise, dancing, the use of the
warm bath,  the  employment  of acrid  cathartics
and emetics,  spontaneous diarrhoea, the irritation
of hemorrhoids, injurious pressure of the hypogas-
trium, and violent passions of the mind. Opening
the membranes of the ovum and evacuating the
liquor amnii  certainly gives  rise  to  premature
expulsion of the contents of the gravid uterus.
   [Occasionally a habit of aborting  is acquired  ;
so that it is  extremely difficult for  the female to
pass the  period at which the accident has occurred
in previous pregnancies.   Cases have occurred in
which it has happened .upwards of twenty  times
in succession, about the same period of gestation.]
   The symptoms which precede abortion will  be
greatly modified  by the  exciting cause.  For the
most  part, the expulsive process is preceded  by
unusual depression  of  strength and spirits;  by
attacks of faintness, sense of coldness in the pelvis,
palpitation, flaccidity of the breasts, a  disordered
state  of  the stomach and bowels, and other  symp-
toms,  which indicate  that  the embryo  has been
deprived of life.
   Where an unusual  afflux of blood to the  uterus
is the cause, the uterine pains or contractions are
usually preceded  for  some days by rigours, lassi-
tude, heat of skin, thirst, loss of appetite, excited
state  of the circulation, and sense of weight in the
pelvis and loins.  A  greater or smaller quantity
of blood then escapes from the uterus and vagina
with  pains occurring at intervals, like the pains of
natural labour.   Where the discharge of blood is
great, the placenta has  usually been extensively
detached from the uterus, and all efforts to prever. 
ABORTION.
35
the establishment of contractions are consequently
unavailing.   In some cases, where  a considerable
hemorrhage has taken place, with irregular pains,
in the early  months, the hemorrhage and contrac-
tions have both  been  suspended  by the remedies
employed, and the  foetus has been retained until
the full period.   In no case, however, has the pro-
gress towards the complete expulsion of the ovum
been averted, where the pains have recurred at
regular intervals, with discharge of blood from the
uterus, or a  certain quantity of  a dark-coloured
serous fluid, with softening of the os and  cervix
uteri, and the formation of the bag of  waters in
the mouth of the uterus  during the pains, have
taken place.   Under  such circumstances, all our
efforts to prevent abortion will prove wholly inef-
fectual.
   When the embryo  is dead, it is often expelled
in a short period, with little  pain and trifling  loss
of blood ; in other cases  the process is very pro-
tracted, continuing many  days;  and in  some rare
cases which have been reported, the ovum, after
having been retained  in the uterus  many months,
has passed through various stages of putrefaction
or  decomposition.  The  embryo may die before
the end of the third  month, and not be expelled
till the fourth or fifth month ; or a foetus of seven
or eight months may  lose its vitality, and not be
expelled till the full  period of gestation is com-
pleted.  In twin cases one foetus may die in the
latter months, and be  retained until the full period,
and then  expelled with the living child.
   It has been supposed that the embryo may be
expelled,  and  yet the  membranes  continue to
adhere to the uterus, and be completely developed.
The membrana decidua is said to acquire a  con-
siderable  thickness, and  the amnion entirely to
disappear, while the cavity of the chorion gradu-
ally contracting, the mass which remains is  only
a red fleshy  substance, in the  centre of which
there is sometimes visible a small serous cavity.
M. Velpeau and other French pathologists have
explained the  formation  of  fleshy moles on  this
principle, but their opinion  is not supported by
satisfactory proof; for though  these substances
are invariably the products of conception, it is not
certain that they are  formed by the growth of the
membranes subsequent to the death and expulsion
of the embryo.  In several  cases of this descrip-
tion no embryo was at any time  discharged.
   Treatment.—In premature  expulsion of the
ovum from  organic disease  of the uterine organs,
or from alterations of structure in the  embryo or
its involucra, any plan of treatment is not only
inefficacious, but even injurious, where the con-
tractions of the uterus have been excited to throw
off its morbid contents.  Where the symptoms of
abortion come on without any apparent cause, we
have reason to fear that they arise from this  state
of the uterus or its contents.  The treatment must
be directed  to the following  points :  first, to  pro-
cure a complete separation of the ovum ; secondly,
to moderate the hemorrhage and pain which may
accompany it.
   By removing plethora, where there  is general
fulness and excitement,  by venesection, and by
calming the violence of  the uterine  contractions
by sedatives, we shall  often prevent a protracted
discharge of blood ;  and by obtaining relaxation
of the os and cervix uteri, favour the complete
escape of the ovum.   Where there are no signs
of local or general plethora and excitement, blood-
letting is contra-indicated.
  In threatened abortion from congestion of blood,
or unusual determination pf this fluid to the  ute-
rus, with slight detachment of the placenta, and
irregular uterine  contractions, it  is  possible in
some cases, by the prompt application of remedies,
to arrest the mischief.  The greatest mental tran-
quillity, and absolute rest in the horizontal posture,
on a  mattress  or couch, with  the body lightly
covered, should be enjoined in all cases of threat-
ened abortion  of  this description.  If the patient
is plethoric, and  the pulse  accelerated, blood is
immediately to be detracted, in quantity  propor-
tioned to the urgency of the symptoms.   Twelve
or sixteen ounces should be taken from the arm,
and, if necessary, the same quantity should again
be taken  after a time.   Cold applications,  and
even ice, if it can be procured, should be  applied
over the  pubis.  A dose  of laudanum, or liquor
opii  sedativus, is to be  given, or a starch  and
laudanum clyster may be  administered, to  prevent
or quiet the uterine contractions.   The acetate of
lead is in these  cases a valuable  remedy.  Two
grains, combined with  a quarter  of a grain of
opium, may be taken every three  hours until the
discharge of blood begins  to abate.
   [Should the flooding be excessive, the  tampon
should be had recourse to.  This  may consist of
a piece of soft sponge, of sufficient  size, which
may be introduced in the dry state, or, lubricated
with oil or melted lard.   It favours the  formation
of a coagulum, and  the consequent arrest of the
hemorrhage.  When any portion  of the ovum is
retained in the uterus, it  is recommended by Dr.
        Dewees  to  employ  a wire crotchet, as
        represented in the marginal figure, which
        is one-third of the  proper size.  It  con-
        sists of a piece of steel, of the thickness of
        a small quill at its handle, and  gradually
        tapered off to its other extremity, which is
        bent to a hook of small size.   When the
        placenta  is  felt  to  be embraced  by the
        neck of the uterus, the crotchet may be used
        in the following manner.   The fore-fingel
        of the right hand is placed within, or at the
        edge of the os tincae ; and with the left the
        hooked extremity is conducted along this
        finger, until it is within the uterus.   It is
        gently carried up to the fundus, and  then
        slowly drawn downwards, which causes
        the curved  point to fix in the placenta.
        It may then be withdrawn, and the pla-
        centa  with  it.  In  every  case  in which
        Dr. Dewees used it,  the discharge in-
        stantly ceased.
           Dr. Bond, of Philadelphia, has contrived
        a forceps, with  the view of supplying the
        acknowledged defective means, in present
        use, for  the removal of the  placenta in
        cases  of abortion attended with  uterine
        hemorrhage.  The  forceps is about ten
        inches  long,  curved  laterally  upon  <t
radius of about twelve inches—the handles being
four inches, and the blades  about six  inches in
length.  The  blades terminate in  an elliptical
expansion, lbout an inch  long, and three  or four
eighths  of  an inch wide, without any fenestra.
The handles and blades, including the  expanded
part, are  bevelled or rounded off, so as to avoid
the risk of wounding or pinching  anv of  the soil
A
IM
 
36
parts.  Within this  rounded edge, the expanded
part is  made very rough, so as  to maintain  a
secure hold upon the body embraced. The forceps
may be made straight; but Dr. Bond thinks, that
in most cases the curved instrument will be found
more convenient for the operator  and easier for
the patient]
   As to the subsequent effect of abortion, it may
be stated as  a general fact, that, in a  very large
proportion of cases, it produces little or  no inju-
rious effect on the  constitution of the mother.   It
is an accident of very frequent occurrence in  all
countries, and has  often occurred without leaving
any  permanent injury.  Where  the process  of
expulsion  has been protracted, and much blood
has drained from the uterine vessels, a proportional
injurious effect has been the  consequence on the
general health of the mother.
   From what has  now been stated respecting the
causes and treatment of abortion, little requires  to
be said as to the management of women who are
habitually liable to  this  accident.  We are   in
possession of no means which can either prevent
or remove the numerous organic  diseases  of the
uterine organs, and of the  embryo  and  its involu-
cra.   Much,  however, may be done to  avert the
danger where it arises from plethora and  irritation
of the uterus alone, by obviating general fulness,
and  taking off the suceptibility to  premature con-
traction of the uterine fibres, by rest, mild diet, and
the occasional use  of anodynes.   Where there is
much constitutional debility  present,  we  must
adopt all the means we possess  for relieving the
weakness, and more particularly  the  cold bath,
and proper diet and exercise.  Warm  rooms and
late hours are to be avoided.
   [Dr. Churchill,  considers, that one of  the most
effective means for breaking in upon the habit is
to give the uterus  a long rest, by  separating hus-
band and wife for  several  months  ; and Dr. Hus-
ton  places great stress  on  the use  of opiate injec-
tions daily, with  continuance in  the horizontal
posture.   By these means, a tolerance on the part
of the uterus has been acquired, which has allow-
ed the gestation to go on  until the full period.]
   The practice of inducing abortion for criminal
purposes has prevailed in  all ages.  In the early
months it is extremely difficult,  from  the appear-
ances in  the mother, to  ascertain with absolute
certainty  that  abortion  has taken  place.    In
dysmenorrhcea there are, sometimes, membranous
substances thrown off from the inner surface  of
the uterus which  strikingly resemble the products
 of conception ;  and even if  the  uterine  organs
 are examined, we  shall not arrive  at  complete
 certainty on the subject.   Blood-letting, acrid
 cathartics, diuretics and  emmenagogues, cantha-
 rides, the juniperus  sabina, and various local
 means, have  been employed  to excite premature
 expulsion of the  embryo.  By the Ellenborough
 Act, passed  in 1803, it was ordained in this coun-
 try, " that if any  person shall wilfully administer,
 or cause to be administered,  any medicine, drug,
 or other substance or thing whatsoever,  or use, or
  cause to be  used or  employed, any  instrument,
  &c, with intent to procure the miscarriage of any
  woman not being, or not  being proved to be, quick
  with child, at the time of committing such thing,
  or  ising  such means, then, and in  every  such
  case, the  person  so offending, their  counselors,
  -wders, and  abettors, shall be  and  are declared
ABSCESS,  (INTERNAL)

                  CTiHy of felony, and  shall be liable to be  fined,
                  fmp Lned, set in and upon the pillory, publicly
                  or privately whipped,  or  transported beyond the
                  sr, for  any term not  exceeding fourteen years
                  The same act ordains that  administering  medi-
                  cines, drugs, &c, with the intent to procure abor-
                  tion, after quickening, shall be  punishable with

                   earThe absurd distinction between quick and not
                  quick with child, which is still adhered to  in the
                  laws of some  of  the  States, has been abandoned
                  in  England, in a  more  recent  statute—1 Vic-
                  toria, cap. 85.  The  following  is the law as  it
                  now stands :  " And be  it enacted, that whoso-
                  ever, with intent  to  procure the miscarriage of
                  any'woman, shall unlawfully administer to  her,
                  or cause to be taken  by her,  any poison or other
                  noxious thing, or shall  unlawfully  use  any in-
                  strument,  or  other  means whatsoever,  with the
                  like intent, shall  be guilty of felony, and  being
                  convicted thereof, shall be liable, at the discretion
                  of  the court, to be  transported  beyond the  seas
                  for the  term of his or her natural life, or for  any
                  term not  less than 15 years, or to be imprisoned
                  for any term not exceeding 3 years."]
                                                 Robert Lee.
                     ABSCESS, Internal--The  term abscess
                   (derived  from abscedo, to depart,  denoting  that
                  parts which were in contact have  become sepa-
                  rated) implies, in its pathological  sense, a  collec-
                  tion of pus in any of the tissues or organs of the
                  body.   The doctrines of suppuration will be fully
                  discussed  in  the  article  Inflammation :  in the
                  present we shall consider the  subject of internal
                  abscess, including what are termed purulent form-
                   ations.
                   I.  Of the takious  modes  in  which  fijiuj-
                     IENT FORMATIONS TAKE PLACE.
                     The theory of suppuration, or the process by
                   which the secretion of pus from an inflamed sur-
                   face takes place,  is, that the purulent fluid is sepa-
                   rated from the blood by a peculiar action of the
                   vessels of the inflamed part, of the precise  nature
                   of which we are ignorant.
                      When  purulent matter  is confined, and not
                   infiltrated through  the structure of an organ, it
                   constitutes, in strict medical language, an abscess,
                   the boundary of which  is formed either by the
                   tissue of the  organ  itself, or by  what is called an
                   accidental tissue.   In both cases the formation of
                   the boundary is accomplished by the same  means,
                   viz.: the effusion of coagulable lymph, which, in
                   the former, produces the union  and consolidation
                   of the  tissue of the organ  in immediate contact
                   with the pus, and thus prevents its diffusion ;  in
                   the latter, it  forms  a more or less perfect mem-
                   brane  over the whole of the surface from which
                   the purulent secretion had taken place, and hence,
                   the pus being enclosed, as if in a shut sac, is said
                   to be encysted.  It is to collections of purulent
                   matter of the  latter  kind  only, that  the  term
                   encysted  abscess is applied.
                      It would  appear that the  cysts of  abscesses
                   have  the property of secreting  as well as of ab-
                   sorbing  surfaces, from  the circumstance  of  an
                   encysted  abscess being  often speedily filled after
                   the pus has been evacuated, and that abscesses do
                   occasionally disappear without any external open-
                   ing ; the only inference  in  such cases being that
                   the pus has been absorbed.
                      In most instances, the structure of the tissue 
ABSCESS,  (INTERNAL)
37
surrounding a purulent collection exhibits evident
marks of alteration.  There is, in general,  vas-
cular turgescence ;  sometimes softening;  while,
in the part occupied by the abscess, the proper
substance of the organ has disappeared, its place
being supplied by  cellular tissue, in which  the
pus is deposited.
  Purulent collections  are not always, however,
bounded by adhesive  inflammation or by a cyst,
the pus as it is secreted being in many instances
diffused  through  the tissue of the organ.  Such
infiltrations of pus happen more frequently in the
lungs than in any  other organ,  and, till lately,
were confounded  with pulmonary abscess, which
very rarely occurs.   In most instances the forma-
tion of pus which constitutes these infiltrations is
preceded by inflammation of the  organ in which
they are found, but in others it would appear,  as
we  shall  presently explain,  that  the  matter  is
deposited by the blood in healthy structures.
   Another form  of purulent  collections is when
pus is formed in  natural cavities.  Serous mem-
branes  not unfrequently assume a  suppurative
action as a consequence of inflammation, and  in
this way large accumulations of puriform  fluid
take place in the cavity of the thorax, in the abdo-
men, and in the interior of the large  joints.
   The fluid effused varies in colour  and consis-
tence according as it is the  product of acute  or
chronic inflammation.  If it is the result of acute
inflammation, it  is of a  pale yellow or straw
colour,  transparent, or  more frequently turbid,
from admixture of small portions of coagulable
lymph, giving the fluid very much the appearance
of unstrained whey ; when it occurs after chronic
inflammation, the fluid is not only more abundant,
but also more turbid, from the greater quantity  of
purulent flakes with which it is mixed, and which
are often deposited  in such abundance as to  give
the effusion very much the appearance of common
pus.  These puriform  fragments fall to the most
depending part of  the  cavity, so  that the upper
portion of the fluid is of a thinner consistence
than the under or more depending.  The portions
of the inflamed membrane  are covered  with  an
exudation of coagulable  lymph,  which, when
recent,  is  easily detached ;  and  when this  new
formation has become vascular, it is changed into
a new structure, to which the term  false mem-
brane has been given.
   We have hitherto been considering the forma-
tion of pus as the consequence  of  previous in-
flammation of the  structure in which it is found.
It is necessary, however, to point out, that pus is
occasionally deposited in parts which exhibit  no
traces of the existence of antecedent inflamma-
tion.  This fact has been long known to patholo-
gists.  Mr. John Hunter was acquainted with the
occurrence of these  non-inflammatory purulent
deposits, as appears from the chapter in his work
on  Inflammation, entitled, " Collections of Mat-
ter  without Inflammation," and  since that  time
the fact has been noticed by various writers  both
in this and in other countries.
  Though Mr. Hunter  states  that  there is often
swelling, or thickening of parts, without the  visi-
ble  or common symptoms of inflammation,  and
that fbere are collections of matter somewhat
6imila| to suppuration which do not arise in con-
sequence  of common inflammation, he does not
appear to favour the doctrine of the possibility of
pus being absorbed into the blood, and afterwards
deposited  in another  part of the body ; but to
regard all such collections of matter as of a scro-
fulous nature, and different from true suppuration.
It is also evident that Mr. Hunter had only observ-
ed these purulent depositions in external struc-
tures.   Subsequent  observations however  have
proved that they also  take place  both in'internal
organs and in the different cavities, though  there
be no evidence of inflammation having previously
existed.
  It is the opinion of Andral and other  patholo-
gists  that these purulent deposits are the results
of absorption of pus, and that the pus,  after it is
absorbed from the suppurating cavity, is  separated
from the blood on  the surface or in the interior of
the various organs.  Andral  seems also inclined
to think that pus is much more readily formed in
some persons than in  others; in fact, that there
is in some individuals what may be termed  a
purulent diathesis.
   These  depositions of pus  succeed most fre-
quently to injuries and  surgical operations. They
are by no means however confined to these cases;
for instance, they are not uncommon after  phle-
bitis, or in fatal cases of puerperal peritonitis, and
in inflammation of the  uterus.  They also  occa-
sionally, though rarely, occur after continued fever
and erysipelas.
   There  are few tissues in which these non-in-
flammatory purulent deposits have not been found.
They form in the  brain, in the cavity of the
thorax  and abdomen, in the muscular  tissue of
the heart, in the parenchyma of  the  lungs, liver,
and spleen, in the substance  of the uterus, in the
ovaria, in the external cellular membrane, and in
the joints.
   II. Abscess in particular tissues.
   Although there is no structure in the human
body, if the epidermis,  nails, and hair be except-
ed, which does not occasionally become inflamed,
yet abscess does not form in  every tissue ; a par-
ticular kind of structure being apparently neces-
sary to its formation.  For  instance, it  cannot
take  place in  the dense structure of fibrous or
cartilaginous tissue, nor in that  of serous mem-
branes.  When pus is discharged from  these tis-
sues, it is  effused, either  upon their  surfaces, or
into the cavities which they invest;  but  abscess
never forms in their  proper substance.
   It would appear that abscess  occurs in  those
organs only into which cellular membrane enters
as one of their constituents : of all the structures
of the body, cellular membrane is that  in which
abscess  most frequently takes  place.  It forms
more frequently in superficial than in deep-seated
cellular tissue; this depends not on the principle
that there is  a greater inherent disposition in
superficial cellular membrane to assume inflam-
matory action, but that from its position it is  more
likely to be exposed to the exciting  causes of in-
flammation than that which is deep-seated.
   Pus occasionally forms in  muscular structure ;
in those cases it is deposited in the intermusculai
cellular  tissue, the  muscular fibre  itself being
apparently incapable  of assuming the  supparn
tive action.
  Purulent matter has been found in  all tho
parenchymatous tissues, either in  the  form of
abscess  or of  purulent infiltration;  as,  for n>
stance, in the lungs, in the  liver, in  the  spleen 
38
ABSCESS, (INTERNAL)
pancreas,  and  in the  kidneys.   The  encysted
abscess is more common in  the  liver; the puru-
lent infiltration in the other  organs.
   With  regard  to  abscess in  nervous tissue,
Andral remarks,  "It is a question which yet re-
mains  to be decided, whether, when the  nervous
tissue  is,  in  a state of suppuration, the pus is
furnished  by the  nervous tissue  itself, or by the
cellular membrane which enters into its composi-
tion.   It is, however, certain, that in some cases
of abscess of the brain  we  find in the  seat of
suppuration nothing but a  congeries of cellular
tissue,  which, in all probability, is the only source
from whence the  pus is derived, inasmuch as the
nervous tissue has completely disappeared.   Cer-
tain white softenings of the brain  have  been re-
garded by some authors as the effect of a purulent
infiltration of the  nervous tissue.  This is a mere
gratuitous hypothesis; there is no proof whatever
of the  presence of pus  in these cases of soften-
ing : all  that  the most  minute  examination can
detect  is  a  diminution in the  consistence of the
nervous tissue, which  in those cases appears to
manifest  a disposition  to return to  its  original
state."   (Vol. i. p. 498, Translation.)
   In alluding to purulent effusions  in the cavities
which  are lined with serous membranes, we stated
that pus is frequently secreted by serous tissue in
a state  of inflammation.
   Mucous membranes, however, take on  the sup-
purative   action  more  easily  than the   serous.
From the extent of this  structure in the animal
economy, suppurative inflammation  of  mucous
membranes  is  by  no  means   uncommon.   It
occurs, for instance,  in  the  bronchial membrane;
in  the mucous  lining of  the  kidney,  bladder,
and urethra ; in those shut cavities which  are lined
with mucous membrane, as  in the  maxillary and
frontal  sinuses; in  the cavity of the tympanum,
and in  the aethmoidal cells.   There is an import-
ant difference in the inflammation  of serous and
mucous membranes—the former are very liable to
adhesive inflammation, which it is hardly possible
to excite in mucous membranes.
   Lastly, pus has been found in the vascular sys-
tem, even in the blood itself.  It has been detect-
ed in the  veins which return the blood from parts
in which pus has been collected ; and also in in-
flamed  veins from puncture or after operations.
   The lymphatic vessels frequently contain  pus,
as, for  instance, when they  originate in  textures
which  are in a  state  of suppuration.
   III.  Of purulent Formation in Organs.
   1. Abscess in the Brain.—The brain is  not
unfrequently the  seat  of purulent deposits — the
pus being, in some  cases, infiltrated through its
substance ; in others, collected in distinct cavities
of different  sizes.  Sometimes  several small ab-
scesses unite so as to form a large cavity.
   Accoiding to Andral, in  the primary  stage of
 •erebral abscess, small drops of pus are seen scat-
tered, in  greater or  less numbers, through a  por-
tion of the  nervous  substance,  which is,  at the
same time, generally injected and softened.  These
drops gradually multiply, extend, and run into one
another ;  the solid parts between  them grow softer
and softer, and at last appear dissolved, as it were,
in  the pus, leaving only a few filamentous frag-
ments  behind.   We have, then, a cavity, which
however does not become distinctly circumscribed
til' some  time afterwards.  When the parietes of
marked,  they
this  cavity  first become distinctly
consist  merely of the nervous  substance itself;
but, subsequently, we observe on their surface, in
succession!/^  ■  ce.lulo-vascular  substanc  ,
either spread  uniformly over  their whole extent,
or existing only in small isolated points : secondly,
a real  membrane, which,  however, is still soft,
flocculent, and separable from this nervous sub-
stance : thirdly,  a membrane of more firm con-
sistence and distinct organization, which  is  suffi-
ciently tenacious to be detached,  either m shreds,
or in a single piece,  from the  subjacent tissue
(Vol. ii. p. 770.)
  The portion of the  brain  surrounding the ab-
scess is generally softened, when it is recent; but
when it has existed  for some time, the  structure
in the immediate  vicinity is very liable to become
inflamed,  and  to  undergo  various morbid altera-
tions consequent to inflammatory action.
  When  the abscess is situated  near the ventri-
cles, the purulent matter may force its  way into
them, from  the slow and  progressive  destruction
of the  cerebral substance.  When it is nearer the
surface, it generally extends  outwards, and then
bursts between the membranes.
  In those cases in which the cerebral abscess is
situated near the internal ear, the diseased action
sometimes extends to the bony  structure of this
organ, destroying, first, the dura mater, and after-
wards the petrous portion of the temporal bone.
In this way the contents of an abscess in the brain
have been discharged through the ear.  In other
instances  the  disease commences in the  ear, and
spreads to the membranes and  substance of the
brain.   On  dissection  of such cases pus  is found
in the  internal ear; the dura mater  is  softened
and detached  from the inner table of the skull;
the brain  softened, and either infiltrated with pus,
or containing  an abscess.  Several interesting cases
of this kind are recorded in  the works  of Lalle-
mand, Itard,  Abercrombie, and  others, to which
the reader is referred.
   Cerebral abscess has been  known in  some in-
stances to terminate,  also, in destruction of the
cribriform plate  of  the aethmoidal bone; and in
this way  the matter has been discharged  through
the nasal fossae.
   Purulent collections are occasionally found in
the cerebellum.  It has been remarked as diagnos-
tic of these latter cases, that the mental powers
are little, if at all, impaired;  hence the symptoms
of this lesion  are very obscure and unsatisfactory.
Andral states that in one solitary instance the tu-
bercula quadrigemina and  pineal gland were found
completely  destroyed, and their place  occupied by
an abscess.
   From the structure of the medulla  spinalis be-
ing precisely  similar to that of the brain, this por-
tion of the  cerebral organization is liable to the
same morbid  changes.  It has been found, in some
instances, infiltrated with pus ;  but  there  is  no
recorded  case of abscess  in its  substance.  Dr.
Carswell  met with a case of abscess of the spinal
marrow, in  a  woman of 45 years of age, a patient
of Mons.  Louis, and the particulars of which were
furnished him by Mons. Reynaud.  The pus  oc-
cupied  the cortical substance  of the right anterior
half of the spinal marrow,  formed a clindroH
abscess nearly five inches  in  length, and in son*
parts, more than a  line in diameter.   A similar
collection existed in the left anterior half, and was 
ABSCESS,  (INTERNAL)
39
likewise limited to the situation  of the  cortical
substance ; but it was not more than an  inch in
length, and terminated  in the former, about an
inch and a half above the primary seat of the in-
flammation.
   With regard to the progress of cases of cerebral
abscess, it would  appear, from the symptoms ex-
hibited previous to the deposition of pus, that in-
flammation of the membranes or substance of the
brain always precedes the  formation of  matter;
that after the deposition of pus the  inflammatory
action ceases,  the  symptoms diminish,  and the
functions of the brain  are in  part or entirely re-
stored, notwithstanding  the presence of such a
foreign body as an abscess.  The disease may then
lie dormant for a  considerable time, till the portion
of the brain immediately in contact  with  the ab-
scess takes on inflammatory action, and then the
features of the malady again indicate inflamma-
tion of the brain, of a more or less acute  charac-
ter,  which generally proves  fatal; death  being
caused, not by  the  abscess, but by the inflamma-
tion which supervenes.   It  must be admitted that,
in investigating  the history  of several recorded
cases of abscess of the brain, we find the  train of
symptoms very obscure and unsatisfactory.
   2. Abscess  in the interior of the  Month
and Pharynx.—The tongue is liable to inflam-
mation  and its consequences.   Abscess in its sub-
stance, however, is a very rare occurrence.  Though
 indral alludes to it after acute  inflammation, we
have not been able to find an instance on record.
   Abscess frequently succeeds to inflammation of
the  tonsils and  pharynx.   The cellular  tissue
which surrounds the amygdalae is very liable to
inflammation,  which occasionally terminates  in
suppuration, the matter being discharged  into the
mouth.   When the abscess is large, there is great
danger  of suffocation  from  the  pressure of the
swelling on  the  glottis.  Such  abscesses  some-
times form in the progress of  acute diseases, more
particularly fever, and the acute eruptive disorders
of children, and give rise to all the  symptoms of
croup.  If  the tumour can be discovered, it should
be opened by puncture ;  indeed, in some instances
of this kind, promptitude is necessary to  save the
patient's life.
   When an abscess occurs in the pharynx, it is
apt  to be  overlooked, because, from its situation,
it cannot be  easily seen.  When  it is suspected,
the finger  should be carried down  the pharynx,
and, if necessary,  the tumour  opened,  as death
has occasionally occurred from its pressure on the
glottis.   This has occasionally happened  in fever
and acute  eruptive diseases.
   Abscess in the cellular  tissue  connecting the
mucous membrane with the muscular tissue of the
oesophagus occasionally takes place, and gives rise
to dysphagia, more or less urgent  according to the
extent of  the  purulent  formation.   When such
abscesses attain a large size, they not only impede
deglutition, but,  by pressing on  the trachea or
lungs, produce considerable cough and  difficulty
of breathing.
   It is  often very difficult to distinguish abscess
from stricture  of the oesophagus.  In some in-
stances, on the introduction  of the probang, in
order to ascertain the cause of dysphagia, the true
nature of the disease has been ascertained by the
rupture of an  abscess, and  the discharge of pus
torn the oesophagus.
  Adhesive inflammation sometimes  takes place
between abscess of the oesophagus and the adjoin-
ing structures.  In  this way an  abscess of the
oesophagus, by adhering to the lung, has been dis-
charged through the bronchial tubes.
  3. Purulent Formations in the Chest.—
1. Purulent effusion into  the cavity of the chest
is not unfrequently  the  termination  of pleurisy,
particularly of the chronic form, and  constitutes
the disease termed empyema, which it is  evident
can only be considered as a secondary affection.
  The character of  the fluid effused into  the sac
of the pleura  differs according as  it  arises from
acute or chronic pleurisy.   When it  succeeds to
the former, it is of a pale yellow  or straw colour,
and generally  a little turbid from being mixed with
the coagulable lymph which is secreted by the in-
flamed pleura.   In  chronic pleurisy,  the  fluid  is
not only in larger quantity, but of a consistence
approaching to that of common pus, and generally
mixed with masses of coagulable lymph.
  As pleurisy seldom takes place in both sides of
the chest at the same time, effusion is generally
observed in one cavity only.   The  fluid is some-
times very rapidly secreted ; in other  instances it
takes place slowly and insidiously, the lung on the
diseased  side  being compressed  and pushed  to-
wards the upper part of the chest, in which situa-
tion it is often retained  by adhesions.  The lung
is sometimes so reduced in size as to  be scarcely
more than four to six lines thick, even in its mid-
dle,  and without careful examination  might be
considered to be totally destroyed.
  Sometimes  a tubercle in the stage of softening,
when situated near the pleural lining of the lung,
bursts into the cavity of the chest.  Pneumotho-
rax immediately follows ;  this is succeeded by in-
flammation of the  pleura,  and  rapid  effusion,
which proves  fatal in a very short time.  In some
cases,  however, adhesive inflammation takes place
between the pleura pulmonalis covering the tuber-
cle and the walls of the thorax ;  and thus the con-
tents of the tubercular cavity are prevented from
escaping into  the sac of the pleura.  In other in-
stances, the adhesive inflammation extends to the
parietes of the thorax, and in this way tubercular
matter escapes through a perforation in the chest.
(See Pneumo-Thorax and Tubercle.)
   Abscess of the liver or spleen occasionally bursts
into the cavity of the pleura, and induces inflam-
mation of the pleura and  purulent effusion.
   2. Abscess of the  lung is a  lesion very rarely
met with, though from the frequent mention made
of this pathological  phenomenon  by British  as
well as by some continental writers, we should be
led to imagine it was a common termination of
pulmonary inflammation.   The opinion of Laen-
nec on this point is very strongly  expressed.   It
appears from his statement, that there is no organic
lesion more rare than a collection  of pus in  the
substance of the lung; and  that, among several
hundred dissections  of persons who died  of peri-
pneumony, he had only met with a collection of
pus in five or six instances,  and in  these purulent
deposits were neither extensive nor numerous in
the same lung.  In  three  cases only was the col-
lection of pus of considerable extent,  but in thes*
there was  no  circumscribed cyst, the  wall being
formed by the pulmonary tissue, which was much
softened and  disorganized.   Laennec also states
that he had been  able  to find  only  two similar 
41
ABSCESS,  (INTERNAL)
cases on record, neither of which had the proper
cyst of phlegmonous abscess.
  Andral mentions the case of a new-born infant,
whose  lung  contained several  large  abscesses.
They had no resemblance whatever to  tubercular
excavation.   (Vol. ii. p. 539,  Translation.)
  3. The kind of suppuration to which the sub-
stance of the lung is occasionally liable is purulent
infiltration.   When it occurs, it is  accompanied
with hepatization, and appears to succeed  to the
most intense  degree of inflammation.   The con-
sistence of the  lung  is at  the same time much
diminished, being so soft as to break down when
handled.  The  pus  appears  in small detached
points,  so that   when  the lung is incised   or
squeezed, opaque yellow matter flows out.   It may
occupy an entire lobe, or only a small portion  of
it, and  sometimes succeeds to  pneumonia with
great rapidity.  Andral  asserts  that it has been
found fully formed four days after the first symp-
toms of pneumonia had made their appearance.
   The pulmonary parenchyma when  infiltrated
with pus presents a greyish ash colour, and, as the
second stage  of pneumonia has received the name
of red hepatization, the former condition has been
distinguished  by  the term  grey  hepatization.
When the lung, in this state, is pressed, the puru-
lent fluid exudes in greater or less  quantity, and
when it is squeezed  out, the lung frequently re-
assumes the red  colour and  hepatized appearance
of the  second  stage ; thus proving,  as  Andral
states, that the grey hepatization differs only from
the red in having its structure infiltrated with pus.
   4. The process of softening of tubercles presents
another variety of purulent formation in the  sub-
stance of the lung.  These  bodies, which  vary in
size, are in their  first stage semi-transparent, and
of a greyish colour; in some cases almost colour-
less and transparent.   In this state  they are pro-
ductive of little  inconvenience;  and hence indi-
viduals,  with pulmonary tubercles, often enjoy
uninterrupted health  for  years.    Sometimes  a
single tubercle has been found, but more generally
they are numerous, and situated in the upper part
of the lung.   In some cases  they are  superficial,
in  others deep-seated.  The tendency of these
bodies is to soften, and to form a  cavity in the
portion of the lung where they are situated.  Tbe
softening generally commences in the  centre, and
gradually increases  towards  the circumference,
until the whole  tubercle is converted into a fluid
mass.  One or more of the bronchial tubes become
perforated, through which the tubercular matter is
evacuated.   A tubercular  cavity is  thus  left, the
interior of which is traversed  by bands of  pulmo-
nary tissue, covered by tubercular matter, and the
smaller branches of blood-vessels, which are gene-
rally obliterated  and transformed into impermeable
cords.   In some instances, however, these vessels
continue  open,  and,  by  their erosion  or rupture,
occasion  haemoptysis.  The  larger  blood-vessels
 are  pressed  towards the side of the  excavation,
 lining, as it were, its  internal  surface.   The bron-
 chial ramifications undergo similar pressure ; but,
 according to Laennec, they  appear to be rather
 enveloped than pressed  aside  by the tubercular
 matter, the pressure  apparently  soon  obliterating
 their canal, as they are scarcely ever to be detected
 in the morbid structure of the lung. He moreover
 th;nks they  must have  originally traversed  the
 portion  of lung  occupied  by the tubercles, as, in
even the smallest excavation, one or more bron-
chial  tubes are found  opening into it.  These
tubes appear not  to  open sideways, but are cut
directly across on  a line with the internal surface
of the excavation,  while from their direction, it is
evident that they  originally crossed the excava-
tion.   The boundary of these tubercular cavities
is formed  by the  parenchymatous  tissue of the
lung, which has become more or less indurated or
infiltrated  with  tubercular matter.   The internal
surface is  lined by a  false  membrane, which  is
composed of concrete pus, and is so soft as  to be
easily detached by the sealpel.
   These cavities vary in number and size ; some-
times there is only one cavity, in others there are
several, which either remain isolated, or  commu-
nicate together  by fistulous  openings, varying in
extent from such as will scarcely contain  a filbert,
to those which occupy a considerable portion of
one lung.
   With regard to the possibility of the  cicatriza-
tion, or healing of tubercular excavations, it would
appear, from the  minute and distinct  researches
of Laennec, that  this  process  does take place,
though in  a very small proportion of cases.   For
a minute account  of the stages  of this reparative
process, we beg to refer to the work of Laennec,
and to the article  Tubercle.
   5. Besides the  sero-purulent  effusion  into the
pericardium  (from pericarditis,) abscess has been
found in the muscular structure of the heart itself.
The  abscess is not encysted, the pus  being dif-
fused in the cellular tissue, connecting its muscu-
lar fibres ;  and in all  the instances recorded,  it
appears that the previous inflammation had  been
confined to  the portion  of the structure of this
organ in which the abscess occurred.  The sub-
stance around the abscess is stated, in some cases,
to have been natural;  in  others, it appeared red
and softened.
   Abscess of the heart, however, is a lesion very
rarely met with, although frequent allusion to such
cases is made by the older writers, who, no doubt,
mistook the  sero-purulent effusion  into the  peri-
cardium  for  abscess.  There  are, however, on
record several well-authenticated instances of true
cardiac abscess.
   Laennec  mentions  the  case of a man,  sixty
years of age, in whom he found an albuminous
exudation of the  consistence  of boiled white of
egg, and of the colour of pus, deposited  among the
muscular fibres of the  left ventricle. The symp-
toms before death (orthopncea  and indescribable
anguish)  indicated acute inflammation of some of
the thoracic viscera.   He alludes to another case,
in a child  twelve  years of age, in whom he found
an abscess of the  size of a filbert in the left ven-
tricle.  This case was complicated with pericar-
ditis.   A similar instance is  mentioned by Andral;
 (vol. ii. p. 345.)
   In  a fatal case of  phlebitis  after venesection,
 which occurred at Bethlehem Hospital, Mr. Law-
 rence found, in addition to the disease  of the bra-
 chial veins, pericarditis, with deposition of pus in
 the muscular substance of the left ventricle, which
 was  also softened and partially broken  down
  (Med. Chir. Trans., vol. xv., p. 124.)
   4. Purulent Formations in the Alxlomen.
 —1. In treating  of the different modes  in which
 purulent  matter  is deposited in natural cavities,
 we  alluded to the suppurative inflammation  of 
ABSCESS, (INTERNAL)
41
serous membranes.  We have  already observed
that the secretion of puriform fluid is not an infre-
quent termination of chronic pleurisy.  The same
thing happens in peritonitis, in fatal cases of which
more or less sero-purulent effusion is found in the
abdominal cavity.  The consistence and quality
of this fluid vary according to the  duration of the
disease ;  and  hence,  from  the  character  of the
effusion alone, its duration may, in most instances,
be  inferred.   In  some  instances,  circumscribed
cavities,  containing puriform  fluid, are  found.
These originate in cases of partial or circumscribed
peritonitis, the boundary of the cavity being formed
by the effusion of coagulable lymph, by which the
convolutions of the intestines become agglutinated.
In other  cases,  purulent effusion  into the abdo-
men has been the consequence of  the bursting of
an abscess in  some of the  abdominal viscera —
the liver, for instance—or of intestinal perforation.
These intestinal  perforations may occur  in  any
portion  of the   alimentary canal,  but most fre-
quently take place in the small intestines, and are
generally the consequence of follicular ulceration
and progressive destruction of the muscular and
peritoneal tunics. When the peritoneal coat gives
way, the intestinal contents escape into the cavity
of the belly, and rapid  inflammation, followed by
death, is tb.e almost invariable result.
   In some cases, the adhesion of the bowel to
some adjacent part has prevented  the intestinal
perforation.  In a remarkable case of this kind,
the abscess communicated with  the caput coli, to
which, and  to  the parietes  of the  abdomen, the
omentum had contracted a very firm adhesion.  In
this manner a circumscribed cavity was  formed,
bounded by this portion  of omentum, the posterior
surface of the caput coli, and the portion  of  peri-
toneum lining the parietes at the part. This cavity
contained a small quantity of ill-conditioned pus,
 and three or four bodies which appeared to be the
 seeds of  fruit covered by earthy incrustation.  It
communicated with the  caput coli by  a  small
irregular opening, the mucous membrane around
 which was thickened and vascular.  (Abercrombie,
p. 338.)
    2. Abscess of the liver is not very common  in
temperate countries, but is  a very frequent termi-
nation  of hepatitis in warm climates.  The pus
 may be either infiltrated through the substance of
 the liver, or may be contained in  a cyst,  forming
the encysted hepatic  abscess.
    Abscesses of  this  organ vary in extent, being
 sometimes  very  small,  in other cases of a  large
 size, not less than three to four pounds of purulent
 matter having  been  found in  a  single  abscess.
(Abercrombie.)    They  differ, also,  in number :
there may be one abscess only, or there  may be
several,  which  are either perfectly distinct  from
each other, or communicate by fistulous openings.
Hepatic abscess, when of small extent,  may  be
absorbed ; more generally, however, adhesive in-
flammation takes place between the walls of the
abscess and  some of the surrounding structures.
In this way the pus may be evacuated externally
through  the parietes of the abdomen ; into the
right pleural cavity ;  through the diaphragm ; or,
should adhesion  have  taken place between the
fiver, diaphragm, and parenchyma  of the lungs,
the contents of  the abscess may  be coughed up
through an opening in the bronchi, and the patient
may eventually recover.  In other instances, the
   Vol I —6                         »*
abscess forms adhesion to some contiguous portion
of the alimentary canal, into  which the pus is
evacuated and discharged,  either by  vomiting,
should the abscess adhere to the stomach,  or by
stool, if the adhesion takes place to the alimentary
canal.  In a case  related by M:ilpighi, in which
the  abscess was situated near  the  gall-bladder,
adhesion took place, and the  contents were dis-
charged through the biliary duct into the bowels.
Andral alludes to  a case in which an abscess of
the liver communicated  with  the interior  of the
vena cava, and to another in which it opened into
the pericardium.   (Vol. ii. p. 598.)
   3. The  termination  of  inflammation of  the
spleen in abscess is uncommon ; indeed, idiopathic
inflammation of this organ is a very rare disease.
Purulent infiltration in the spleen, however, often
takes place at the same time that pus is deposited
in  other  parenchymatous  structures.   In  these
cases, it is probable that  the pus is  formed else-
where, and only deposited in the spleen through
the medium of the circulation.
   Andral mentions the case of a woman, in whom,
on dissection, he found a number of small abscesses
in the spleen, lungs, liver, and brain  ; the uterus,
however, was the  organ in which  the pus  was
originally formed ;  for the symptoms of inflamma-
tion of the uterus were those which appeared first;
and in the   instance of this  organ there were
several collections  of purulent matter, while  all
the uterine veins were filled with pus.
   The pus, in abscess of the  spleen, may  be dif-
fused through the parenchyma of the organ, or it
may be confined in a cyst of variable  extent. The
structure  surrounding the  abscess is  sometimes
unchanged ; more generally, however, it is softened
and considerably altered in its texture, so as to be
pulpy and easily broken down.   These abscesses
often  attain  an extraordinary size.  In  a case
recorded  in  the Memoirs  of  the  Academy of
Sciences, an abscess of the spleen contained thirty
pounds of purulent matter.  In  another mention-
ed in the same work, eight pounds of matter were
drawn off by tapping.  The patient died next day,
and the spleen was found  still to contain  seven
pounds of pus, the sac of the  abscess being eigh
teen inches in length and twelve  in diameter.
   Like abscesses of the liver, those of the spleen,
by forming adhesion to  some  adjoining viscus,
may burst into the cavity of the pleura, (Tweedie,
Clinical Illustrations  of Fever,) stomach, (Coze,
Journ. de Med. torn. 82,) colon,  (Jacquinelle,
Journ. de Med. torn. 88) ; or,  by the cyst  of the
abscess forming adhesion to the  kidney, the pus
may be discharged  with the urine.  The  matter
may be, also,  extravasated  into  the  cavity  of the
belly,  in  which case it proves rapidly fatal; or
the abscess may form an external tumour  in the
left  hypochondrium, and in this way the  matteT
may be discharged  externally, by an opening in
the abdominal parietes.
   Among the lesions observed  in the spleen in
fatal cases of fever, abscess may be  enumerated.
Though   rather uncommon, cases  of this kind
have been recorded.  Mr.  Wardrop states, in  a
note to Baillie's Morbid  Anatomy,  that  in some
of the British soldiers who suffered from the Wal-
cheren fever,  and  who  afterwards died in  this
country, the  whole substance of the spleen was
converted into a puriform fluid, contained  in :'ts
proper capsule. 
42
ABSTINENCE.
  4. The pancreas is very rarely diseased, altera-
tions of structure being less frequently observed
in this  than in any other organ of the body.  Sev-
eral cases of pancreatic abscess,  however,  have
been recorded.  Baillie mentions one case of it :
the  abscess contained a considerable quantity of
thin pus ; the pancreas being much enlarged  in
size.  Portal  mentions having met with  several
instances ;  and Andral once found two  abscesses
imbedded in the structure  of the pancreas, each
of which might have held  a hazel nut.   In a case
mentioned  by Dr. Percival, in  which  there was
jaundice with bilious vomiting, epigastric tumour
with discharges of blood and fetid  pus by stool,
the  pancreas was found greatly enlarged, and con-
tained  a large abscess, the ductus communis being
obliterated by pressure.
  5. The intestinal  absorbents occasionally sup-
purate, the pus being  either collected  in  a  cyst,
(the parenchyma  of  the gland being destroyed,)
or diffused through their structure.  In  scrofulous
children, in whom mesenteric disease is  more fre-
quently met with than in adults, these glands are
enlarged, and when cut into are found to contain
soft curdy matter intermixed with pus.
  6. Abscess is a common  termination  of  inflam-
mation of the kidney.  Renal abscesses are gene-
rally small; they are sometimes, however, of con-
siderable size, and lined with a soft membranous
layer.  Purulent  infiltration of the kidney has
also been observed, co-existing with purulent col-
lections in other organs. The abscess, again, may
be exterior to the kidney, in the cellular tissue in
which  this organ is imbedded.  The pus  formed
in renal abscess in general passes through the ure-
ters into  the bladder, and  is then expelled with
the urine.  Adhesive inflammation may, however,
take place  between  the wall of the abscess and
the parietes of the abdomen, and a communication
has thus been  formed  between nephritic  abscess
and the loins.  In some rare instances the  abscess
has burst into  the colon,  and the contents have
been discharged by stool.   A case of this  kind is
mentioned by Lassus.
  It should be  remembered, however, that when
puriform matter is passed with the urine, it is not
always from abscess  of the kidney.  The mucous
membrane lining  the  pelvis and  ureters, or the
bladder, occasionally becomes inflamed,  and  after-
wards  assumes, like  other  mucous  membranes, a
suppurative action.  It is impossible during life to
distinguish the one class of cases from  the other ;
nor is  this  of much practical importance, since the
treatment is precisely the same in both.
   7. Auscess occasionally  forms in the muscular
structure of the uterus, either in a circumscribed
cyst, or infiltrated through  its substance. In these
cases,  the uterine and hypogastric veins often con-
tain pus, and it is by no  means  uncommon, as
has been already stated, to find purulent deposits,
at the  same time, in  other organs.   When pus is
found  in the uterine veins, the prevailing  opinion
among pathologists is, that it is the result  of ute-
rine phlebitis, and that the pus which is found in
other  organs is deposited by the blood in its pass-
age from the uterus  through the various parts of
 the system.   Pus may also be collected in the
 t avity of the  uterus  and Fallopian  tubes.  Dr.
 Carswell met with one case in which the  pus col-
 lected in the cavity  of the  uterus was prevented
 Vom  escaping by the presence  of a false  mem-
brane, which passed across the orifice of the neck
of the uterus.
  8. Though abscess be  an occasional termina-
tion' of ovarial inflammation,  it is by  no  means
common.   There are several  examples, however,
on record, of ovarial abscess which  varied much
in size.   In  a case which lately occurred  to  the
writer of this article, (the  prominent  symptoms
of which were uncontrollable  vomiting  and sym-
pathetic fever,) the ovarial abscess  was of the size
of an orange.  They sometimes attain an enor-
mous size ; as in a case related in the North Ame-
rican Medical and Surgical Journal for  1826.   A
woman had an abdominal tumour which was ima-
gined to be ovarial  dropsy.  Its real nature was
only discovered after death, when the tumour was
found to be a sac, containing twenty  pints of well-
formed pus.
   In some cases, the  capsule of  ovarial abscess
has burst, and the pus has been  extravasated  into
the cavity of the belly.   An  interesting case of
this kind is related by Dr. Seymour, in his work
on  Diseases  of  the  Ovaria.   In  this  rise,  the
young woman,  after suffering  some  time from
hectic fever,  (the cause  of which was  not very
apparent,)  suddenly complained  of most acute
pain over the abdomen, and in  a few hours expired.
On opening the body, the cause of death was  ap-
parent.   A large quantity of pus was effused into
the peritoneal cavity, which had escaped from an
abscess  in the right ovary.
   The ovarial abscess  sometimes adheres to an
adjacent  organ, either to the uterus,  vagina, blad-
der,  or  to some portion  of intestine.   In  these
cases, the  pus is discharged  eventually into  the
viscus to which  the abscess adheres.
   Lassus mentions the case of a woman who had
long suffered from pain in the  right lumbar region,
supposed to proceed from suppuration of the kid-
ney, because pus was voided with  the urine.   Af-
ter death, the right kidney was found in its natu-
ral state, but there was an abscess in the right ova-
rium, which  was adherent to  the  bladder, into
which the pus had passed  through  an ulcerated
communication.  Andral met  with a similar com-
munication between one  of the ovaries and  the
bladder in a young woman, who died thirty-seven
days after her confinement.
A.  Tweedie.
  ABSTINENCE.  By this term is meant the
excessive or total privation of food.
  The animal frame is described by M. Cuvier as
a tourbillon, by which substances  are continually
taken from without, carried  into the circulation,
deposited, re-absorbed, and finally rejected.  The
mass both of the fluids  and of the solids is thus
supplied, repaired, or renewed.  If our object be
to diminish  this mass, abstinence  affords us, not
the most  prompt, hut the most permanent and
natural remedy.
  Not the mass only, but the sentient and moving
powers of the system are diminished by the pri-
vation of  food ;  and this both in regard to ani-
mal and organic life, to use the useful and expres-
sive terms of Bichat:  so that if our further object
be to reduce the powers of the system, abstinence
still furnishes us with the most simple and  direct
remedy.
  The ancient physicians were so impressed with
the importance of various modifications of diet in
the treatment of diseases, that they divided  the 
ABSTINENCE.
43
whole art of physic into dietetics, pharmaceutics,
and surgery.  (See Celsus, prsef.)   And, in re-
gard to  the employment of abstinence, the rules
of Hippocrates for the treatment of a patient af-
fected with varix or  aneurism  are precisely the
same as those of Valsalva ;  that is, diela qua quam
siccisimus et exsanguissimus fiat.   (De Morbis,
lib. i. sec. x.)
   Man  is thus sometimes subjected to the effects
of abstinence  by  the prescription of the physician.
Those effects  are sometimes  carried  to the  last
extremity by accident or calamity ; sometimes by
obstruction in the oesophagus ; and sometimes by
the  phrensy or  monomania of the  patient.  In
these several cases, we have, therefore, the oppor-
tunity presented to us of observing the effects of
the privation of food on the human subject.  The
investigation has been made still more complete,
by experiments  upon the lower animals.   (See
Recherches sur la Digestion, par  Tiedemann et
Gmelin, pp.  91, 160.)  In order  that  we  may
give as  practical  and useful a view  of this  subject
as possible, we shall treat of it under three heads :
—1.  Of the curative  effects.  2.  Of the  morbid
effects of abstinence employed as  a remedy.  3.
Of the  morbid effects of famine in  the other cases
to which we have alluded ; and, lastly, of the pro-
per mode of treatment.
   Curative   Effects  of Abstinence. — Ri-
gid abstinence is a most powerful remedy in all
acute dieases.  It should,  in  such cases, be car-
ried  far  beyond the  degree  prescribed  as  a
part  of the  antiphlogistic regimen; the object
being not so  much to  avoid  stimulus, as to in-
duce actual lowness,  to subdue the powers of the
system.
   Abstinence is  also  a valuable remedy in many
of the more chronic forms of disease : a state of
extreme inanition of the stomach  not only enfee-
bles the circulation, but acts most powerfully upon
the absorbent system.  With this view it has been
proposed to institute  a system of rigid abstinence
in cancer :  it  might probably be more successful
in some kinds of dropsy.
   An obvious application of abstinence, as a  rem-
edy, is  that made in  cases of disorder or  disease
of the stomach itself.  These affections are so con-
stantly  the effects of improper food, that, to change
the diet is obviously but to remove the most usual
cause.  To withdraw food nearly altogether  for  a
time would,  doubtless,  be to employ an actual
and powerful  remedy.   This is  so  evident,  and
yet the facts in illustration are so few in number,
that we cannot but recommend the subject for fu-
ture inquiry.   If a joint be morbidly affected, we
enjoin the most absolute repose.   The value of a
well-regulated but rigorous abstinence in cases of
disorder or disease of the  stomach itself, and of
some of  the  chylopoietic  viscera,  especially the
liver, would,  doubtless, be equally  great.   This
subject  has been well touched upon  by Dr. J. John-
son ; and  the writer of this  article  can add his
testimony to the beneficial effects of abstinence in
the cure of these diseases.
   It is impossible to refer to the subject of the use
of abstinence  as  a remedy  in disorders or diseases
of the stomach, without recalling to our minds the
services which M. Broussais has rendered  to this
department of medicine :  the  diite absolute, or
extreme abstinence, recommended  in  gastritis by
that author, is, assuredly, a far more natural  and
appropriate remedy, than  the  mistaken adminis-
tration of drastic purges, too much employed in
this country.
  The next object in enjoining abstinence, is to
reduce the mass of solids and of fluids.  Absti-
nence  is, therefore, the  most  direct  remedy  for
plethora.  This point has been ably treated  of by
Dr. Earlow, of Bath, in his Treatise on the Bath
Waters.   See the article Antiphlogistic  Regi-
men.
  The case which next presses itself upon our
notice, in regard to abstinence as a remedy, is
that of disease, or tendency to disease, within the
head.  The immediate threatening of  apoplexy
must  be treated  by active blood-letting; but the
remedy for the permanent disposition to this dis-
ease is the  most strict  abstinence.  The  most
rigorous system of  weighed or measured portions
of the least nutritious  and least  stimulant kinds
of food is to be enforced.
   We must now add a few words upon the cele-
brated use of abstinence in diseases of  the  heart
and arteries, in the hands of Valsalva,  as described
by Morgagni,  (lib. ii. ep. xvii. § 30,) from the
account  given  to him by Stancarius.   Sufficient
blood having  been  taken,  Valsalva  ordered  the
food and drink to be daily diminished, until it was
reduced  to half a pint of gruel in the  morning,
and less than half that quantity in the  evening ;
to this water alone was added, and that in a cer-
tain  measure  only, medicated by the  addition of
quince, &c.   When the patient was, in this man-
ner, emaciated, and so debilitated that he could
not  raise his hand from the bed, the  diet was
slowly and moderately increased, so as  just  to
maintain power enough for raising the body.  In
this manner these formidable diseases  were cured.
It is  confessed, (§ 31,) that  some thought  the
cure of Valsalva worse than their aneurism.   But
it was argued  that that which was not done early
in the disease,  with the hope of cure, might  be-
come necessary during its progress, without such
hope, from the incapacity for swallowing.
   Having thus noticed the principal  applications
of abstinence  in the cure  of disease,  we pass on
to describe its morbid effects when inappropriately
or improperly applied.
   2.  Morbid effects of abstinence. — The
morbid effects of abstinence usually steal on  the
patient,  and  even  the  physician, imperceptibly.
The excessive  privation of food is unnatural, and
therefore not to be borne long with impunity.  If
M. Broussais has, as we have  stated, done much
good, he has, also, been the author of much mis-
chief.   He has passed  from extreme to extreme,
and, in removing irritation, he has frequently in-
duced a state of exhaustion not less  painful and
perilous.  Interesting  accounts  of such events
have  been published by M. Barras and M. Cafort.
(See  the Med,  Chir. Rev.  for Jan. 1,  1831.)
Still more recently  the subject has been treated,
at considerable length, by M. Piorry.  (Procede
Opiratoire, &c, Paris. IS30, p. 368.)
   Having referred  such of our readers  as may
desire to enter more fully  into  the  subject  for
themselves, to these latest sources of information,
we purpose to  subjoin our own  remarks.  We
think, in the first place, that the effects of extreme
abstinence and its  concomitant exhaustion have,
generally speaking, not been understood; and, in
the second, that the morbid effects of abstinence 
44
ABSTINENCE.
have, more  frequently than is supposed, arisen |
from its misapplication.
  The first  part of the  series of  the  effects of
abstinence consists in simple debility and emacia-
tion.  The  countenance  becomes  pale, and  the
expression languid ;  the muscles  of  voluntary
motion  become  thinner  and  feebler;  the pulse
feebler and  smaller.  The  second  part  of  the
series is  different.  The  pulse is  augmented in
frequency; there is often  palpitation of the heart,
alternately with syncope ;  and there is pain of
the head, or  delirium ; symptoms which might be
mistaken, by the inexperienced or  unwary, for
those of increased action and power, whereas they
are but the feeble flashes or glimmerings of a light
ready to become extinct.
  Such a transition in  the effects of abstinence
is  frequently the consequence  of  an undue  ad-
ministration  of this remedy ; still more frequently,
however, it  arises from its inappropriate applica-
tion.  When cases of irritation are  mistaken for
those of inflammation, the morbid effects of ab-
stinence  are particularly  apt to occur.   The  for-
mer disease neither requires nor bears the remedy;
whilst, in inflammation, it is both essential to the
cure of the  disease  and  well  sustained  by  the
patient.  This is  a point  which  requires to be
well investigated.   The  ancients,  and  especially
Celsus, speak of a principle of encouragement in
the sick which they expressed in these words —
difficulter ferre  morbum,  (lib. iii. § 3.)  There
is  another principle not less  important, — diffi-
culter ferre  remedia.  It  would  be difficult to
induce the morbid effects of abstinence when there
is  a tendency to apoplexy ; but it would be very
easy to do so if palpitation, or some  other symp-
tom of gastric irritation, were  mistaken for  dis-
ease of the heart, or for inflammation.
  3. Effects  of famine.—In order  that  our
detail of  the morbid effects of  abstinence may be
the more complete,  we subjoin a  more detailed
account of the series of phenomena in those cases
which have  been continued to extremes.
  The first  case in point we extract  from  the
recent excellent  work  of M. Andral.  (Precis
d'Anatomie Pathologique, torn. ii. p.  769.)   A
man, addicted to drunkenness, was cast into  pri-
son for theft, and  reduced, at  once, to  a diet of
bread and water.  After  the first week, a disorder
of the intellectual faculties took place ; his coun-
tenance became pale and  expressive of languor,
his flesh wasted, and his strength declined ; his
nights were sleepless; shortly afterwards there
was delirium, which was mild at first, but subse-
quently furious.   The prisoner was now allowed
brandy.   The cerebral symptoms disappeared, and
the flesh  and  strength returned.   The effects of
abstinence and of  an amelioration  in the diet are
so obvious in this  brief  case that  it is full of in-
struction.  Abstinence and excess  induce similar
symptoms and effects; a  fact which cannot be too
deeply impressed  upon  the mind of the young
practitioner.
   Dr. P. M. Latham's interesting account of the
epidemic at the Millbank  Penitentiary is full of
facts which  bear upon the same point.   We refer
our readers  to it for much information.  The late
Dr. Gooch  observes,  in  regard to this  epidemic,
ihat " the prisoners were  suddenly put opon  a
diet fiom which animal food was almost entirely
Excluded.   An  ox's head, which weighs eight
pounds, was made into soup for one hundred peo-
ple which allows one  ounce and a quarter ot
meat to each person.  After they had been living
on this food for some time they lost their colour
flesh,  and strength,  and could not do  so much
work  as  formerly."   "At  length this simple
debility of constitution was succeeded by various
forms of  disease : —they had scurvy, dysentery,
diarrhoea, low fever, and, lastly,  affections of the
brain  and nervous  system."   The  affections,
"which  came  on   during this faded, wasted,
weakened state of body, were head-ach, vertigo,
delirium, convulsions, apoplexy, and even mania.
When bleeding was tried, the  patients fainted
after losing five, four, or even  fewer ounces of
blood."  On examination after death, " there was
found  increased  vascularity  of the  brain,  and
sometimes fluid between its membranes and in
its ventricles."  (Account of Diseases peculiar to
 Women, p. 150.)
   Interesting cases  of  abstinence  are  recorded,
with the full detail of its symptoms, by Dr. Currie,
(Medical Reports, Ed. 4, vol. i. p. 304,) and by
Dr. Willan, (Miscellaneous Works, by Dr. Ashby
Smith, p. 437.)   To these cases we  refer oui
readers ;  extracting  only what will be  sufficient
to portray the usual character of the late symp-
toms in the case of inanition, and lead to the due
distinction between the symptoms of disease of
the nervous system, which arise from it,  and those
which depend upon a primary disease of the brain
itself; for the case of extreme abstinence or famine
affords a remarkable instance  of the  singular
effects of exhaustion, and their similarity to those
of diseases of a totally opposite nature and origin.
   Dr. Currie describes the effects of inanition in
a case of obstructed oesophagus, as involving the
following circumstances : —
   The patient's age was 68.  The obstruction in
swallowing gradually increased from the begin-
ning of August, and on the 1st of November it
was complete.  The following plan was adopted  :
each morning,  at eight o'clock, he had  a clyster
consisting of eight  ounces of  broth, two yolks of
egg, and  forty  drops of laudanum ; this was re-
peated at three  p.  m.,  and at nine p. m., with
thrice  the quantity of laudanum.   Previously to
the evening draught, a hath was used, consisting
of one-fourth  part  of milk, and three-fourths of
water, at 96°.  In  a few  days the clysters were
augmented in quantity, and eight ounces of wine
were added, with an increased dose of laudanum.
This  plan was continued until  the  second of
December.  The rectum then  ceased  to retain
the clysters, and their employment was relinquish-
ed.  In spite of these plans the emaciation was
rapid : the patient had weighed 240 lbs. when in
health ;  on the 20th of November, he weighed
 154 lbs.; and on the 25th, 149 lbs. only.
   The pulse,  during the  month of November,
was that of health ; on the first of December, it
became small and frequent; on the second, it was
still more frequent though stronger, with delirium,
 and the case resembled the  last stage of fever.
" During this delirium, a perpetual and indistinct
 muttering occurred,  with  great restlessness and
 agitation ; the surface and extremities were some-
 times of a burning heat, sometimes clammy and
 cold.   The eyes lost their common direction the
 axis of each being turned towards the nose.  In
 this state, however, the sensibility of the retina 
ABSTINENCE —A CH OR.
45
was  not impaired, but rather increased, for he |
screamed out on the light of the window being
admitted, to which before he had been accustom-
ed.  At this time also the sense of touch seemed
more than usually acute, for he appeared disturb-
ed with every accidental breath of air.   The deli-
rium and the derangement of vision commenced
nearly  together, but we  observed the derangement
of vision first.  On the  first of December he com-
plained that he sometimes saw double ; but it was
not till the succeeding day that any considerable
incoherence  of mind was observed.  The pulse
became feeble  and irregular  on  the fourth; the
respiration, which had been singularly undisturb-
ed, became laborious ; the extremities grew cold ;
and in ninety-six hours, after all means of nutri-
tion as well as all medicine had been abandoned,
he ceased to breathe."  During the first periods
of this case there was little  complaint of hunger
or thirst; there was a stool, of a solid form, pale
colour, but natural foetor,  with each fifth glyster.
 The spirits  were even,  and the nights good.
   Dr. Willan's case was one of monomania.  He
 visited the patient on the 23d of March,  1786, on
,the  sixty-first day of his fast.   His  emaciation
was extreme, and he laboured under great imbe-
cility of mind; the eyes were not,  however, defi-
cient in lustre, and the voice remained  clear and
sound.  He was directed  to drink a pint of barley
water, and   two  cups of panada, which agreed.
 He  had a little fever in the first part of the night,
but slept better than usual.   On the  24th he had
 some mutton-tea; the pulse was small and  tem-
perate.  On the 25th he  took a  pint of milk for
breakfast;  a pint of  mutton-broth  boiled  with
barley for dinner, and as much rice-milk for sup-
per, at his  own request.   He  had  considerable
cravings for food all the day.  In the morning of
the  26th he drank tea,  and ate a  great quantity
of bread and butter, which he got from off the
 table in the nurse's absence.  Some time after he
 became sick, and vomited once or twice without
 much  straining.   About  noon he  had a figured
natural  stool, and  presently after  two or three
loose  motions.  His skin  was always dry.  In
the  evening he was apparently much better ; the
pulse  ninety and firmer.   On the 27th he took  a
little light bread pudding at dinner, and had two
eggs for supper ; he rested well and was cheerful.
 On  the 28th he seemed better ; he had  not  slept
well, however, nor had a  stool.   On the 29th the
 scene  was entirely changed ;  he began to lose his
recollection in the preceding evening ; and before
midnight became quite  frantic and unmanageable.
His pulse was increased in frequency, with con-
siderable heat on the skin, and tremors.   He con-
tinued raving, and  talking very incoherently,  as
he had done during the night.  A strong purga-
tive draught, and two clysters administered in the
course of the day, produced but little evacuation.
   He  remained nearly  in the same state of mind
as above-mentioned,  scarcely ever sleeping, and
taking very little nourishment, till the 2d of April,
when  a considerable quantity  of  loose  feculent
matter was  brought  away by a clyster.   Soon
after he became sullen, and took  no  notice of
what passed about him.  He was removed at this
time into the country, so  that he was  not seen
again  till the  6th of April.  He  appeared  then
emaciated to a greater degree, if  possible, than  at
 he first.  His pulse was  small and feeble, beating
120 strokes in a  minute.   April 7th and 8th ha
took whatever  nourishment  was  offered him,
knew those around  him, and  spoke sensibly, but
faintly.   On  the 9th, in  the  morning, he  died
quite exhausted.
  The case of abstinence affords a beautiful illus-
tration of the fact, that cerebral symptoms, resem-
bling those of increased action, do also arise from
the opposite state of the brain  and of the system.
The  effects  of  exhaustion frequently  stimulate
phrenitis in adult age, and hydrocephalus in in-
fancy,  and it requires the utmost  attention  and
sagacity to distinguish them.
  4. Mode of Treatment.—The  treatment of
the morbid effects of abstinence, like the treatment
of the effects  of exposure to severe cold, consists
principally in the cautious re-administration of the
natural stimulus.  All solid food must be avoided
at first, and especially milk, which becomes solid
in the stomach, and is more difficult of digestion
than other solids from being unmasticated.
  A  little thickened broth should  be  given at
intervals of four hours, and  the quantity very
gradually increased; and  the  bowels should be
carefully relieved by  enemata of barley-water.
  No one can read the case of Dr. Willan without
being  impressed with  the conviction  that the
treatment was most  injudicious.  To allow three
pints of food,— milk, broth, and rice-milk, on the
third day, after an abstinence of sixty days, was
quite preposterous.  One-third of this ration would
have been far too much !
   There is another aspect in which the effects of
abstinence and their treatment may be viewed. Mr.
Hunter observed, (Animal Economy, pp. 114,
115,) that if an animal be enfeebled  by abstinence,
its power of maintaining  its  temperature is  also
lessened.   It occurred to the writer  of this article
to witness the same  fact:  some white  mice  had
been neglected, and passed upwards of forty hours
without food ; they had become torpid and cold ;
by being held in a warm hand they were perfectly
restored to life and activity  before a morsel of food
had been administered.  From these facts we may
deduce  the inference, that to  administer warmth
is one of the most efficacious modes of remedying
the effects of abstinence.
   A  third  remedy  is  also  very important.   It
consists in assiduous frictions.  In cases of absti-
nence the powers of the  circulation are greatly
enfeebled.   The  most  direct  mode of restoring
these powers, after the administration of food and
warmth, is friction in the course of the venous
blood.  This remedy, therefore, must not be neg-
Iected-                   Marshall  Hall.

   ACHOR, like most of the terms used to denote
the morbid appearances presented by the skin, had
no definite meaning before the time of Willan.
By the word a%wpes, Galen and the ancient writers
who followed him understood  " ulcerations pecu-
liar  to  the hairy scalp, discharging,  from very
small pores, a viscid ichor, consequent to pustules."
They were considered by  them as a  smaller spe-
cies icvpiov, or favus, from  which the latter only
differed  in  exhibiting larger perforations, and in
discharging humour similar in colour and consis-
tence to Hymettian honey.  Alexander Tralliamis
and Actuarius  first distinguished  the  pustules
from  the ulcerations in  which  they terminate.
The Arabians, simply translating Galen, described 
46
the achores and favi under the titles of alsahapha,
or alsahaphati, and alsahara. By the early modern
writers, achores — manantia ulcera capitis—were
confounded  with tinea; and  in this sense the
term is used even by Plenck.  But, by the greater
number of writers  of the  eighteenth century, it
was separated from favus and tinea, and considered
as synonymous  with porrigo  larvalis ;  of  which
disease, however, Bateman, as well as Biett, is of
opinion that achores do not constitute the elemen-
tary form.  We are disposed to think that Alibert,
in distinguishing from  that affection a disease,
tinea muciflua, which had generally passed under
the same  name, has removed  a difficulty  which
might have been inconvenient to pathologists, and
has pointed out the disease to  which  the achores
most properly belong.
   According to the definition  of Willan, "Achor
is a small acuminated  pustule which contains a
straw-coloured matter, having  the appearance and
nearly  the  consistence  of strained  honey.   It
appears most frequently about the head,  and is
succeeded by a  thin  brown or  yellowish  scab."
The matter contained in the pustules does  not
concrete and form a crust, but the pustule breaks
and is succeeded  by small circular  ulcerations,
from which  a thin glutinous or oily mucous fluid
exudes, sometimes in considerable  quantity, and
sometimes forming white or yellow scabs, more or
less moist.
   The achor is  distinguished  from the other pus-
tules  as   follows:—from  the  psydracium, by
being more elevated, more distinctly circumscribed,
and less  generally grouped  and confluent; from
the favus, by being smaller but more pointed, and
by not being followed by the characteristic yellow
sulphur-coloured indented scab (deprimees en go-
det) which explains and describes the term ; from
the phlyzacium, by being  smaller and destitute
of its elevated  and  inflamed  circular base ; and
from the  varus, (which, for reasons  hereafter to
be assigned, we  shall include amongst the pus-
tules) by  being succeeded by  a scab  or ulcer in-
stead of a tubercle.
   Achor  is a  cutaneous affection peculiar to in-
fancy and childhood, and constitutes  the elemen-
tary form of some porriginous  diseases ;  but at
that period of life occasional eruptions of achores
appear from time to time without amounting to a
disease.   These seem  to be connected  with  a
plethoric state  of the  body in general, or of the
abdomen in particular, or with derangement of the
alimentary canal, and frequently co-exist  with  a
disordered state  of  the urine.  They  are most
effectually both relieved and  prevented by  mild
alterative doses of  the  pulvis  hydrarg. cum creta,
followed by small  doses  of rhubarb, with  either
soda or magnesia.               m  j  rponn

   aCNE.—By this term is understood a chronic
affection  of the skin, characterized by small pus-
tules, generally distinct, having their base more or
less hard  and of a deep red colour, which, after the
suppuration of  the pustule, generally  imperfect,
becomes a small hard, red, circumscribed tuberclej
almost indolent, suppurating  or resolving always
 very slowly.
   Among the best writers  on cutaneous diseases
 there exists a  difference of opinion as to the class
to which acne most properly  belongs, arising not
 ».i much from  the difficulty of determining the
ACNE.

   Mature of the vari, as from observing ^f10. ™I|lhfl
     different stages of their progress.  Pienck, Willan,
     and Bateman, considering them as tubercles, have
     placed the diseases  of acne in that class, whilst
     Alibert and Biett have arranged them with  the
     pustular diseases.   Any one who  has  observed
     the  progress of this eruption with sufficient at-
     tention, will be disposed to coincide with the last-
     named  authorities;  for the  circumscribed indu-
     rations,  or tubercles,  which  are so  constantly
     observed in this affection, are the consequences of
     pustules,  and do  not  constitute  the  elementary
     form of the eruption.
        Whilst pathologists have been divided upon the
     form of this eruption, another difference has arisen
     concerning the seat  of it, whether it is a disease
     of the cellular texture of the corion, or peculiar to
     the sebaceous follicles, originating in their obstruc-
     tion and inflammation.  This latter cause of  the
     pustules of acne had not escaped the  observation
     of Willan, for he has made it the  characteristic of
     his  second species,  acne punctata; and Alibert
     has also  noticed  the  disorder of the  sebaceous
     glands as  a source  of similar eruptions ;  but Mr.
     Plumbe,  in describing  this  as  constantly  and
     exclusively the  process of the formation of  the
     pustule of acne, has given an extent to  that opin-
     ion which is not borne out by fact.   In justice,
     however to this writer, we must not withhold  the
     following dissection of a case of  acne rosacea, by
      Gendrin  (Histoire  Anatomique  des  Inflamma-
     tions) :  "A  man of  fifty-five years of  age, who
     died of an organic disease of the stomach, was, at
     the same time, affected with  acne rosacea, which
      occupied the surface of the nose and  almost  the
     whole of the cheeks.   The day after his death the
      seat of the eruption  was of a bluish red colour, and
     incisions showed the  skin to be thicker and more
     dense than in the natural state.  On the surfaces
      of the incisions a  number of small  round  red-
     coloured  bodies were observed, which, examined
     by the lens, appeared to be  sebaceous crypts, evi-
      dently double their  natural size.  On  the surface
      of the skin were also to be  observed  the orifices
      of these crypts,  more dilated  than in  the healthy
      state, from which a  yellow caseous fluid  might be
      squeezed.   In the rete mucosum  of Malpighi was
      seen a closely reticulated  structure of  blood-ves-
      sels, of a  violet-red colour, and  the corion gene-
      rally was much increased in vascularity. Exter-
      nally the skin was unequal and elevated by small
      round  grains, which  were  felt  more  distinctly
      when a detached portion of the skin  was pressed
      between the fingers. These bodies were produced
      by the developement and induration of the seba-
      ceous follicles.  The  general tenacity of the  skin
      was considerably diminished."   Notwithstanding
      the proof apparently afforded by this dissection,
      we are convinced that the  emphragma sebaceum
      is not the most common cause of the pustule of
      acne ;  for, although one sometimes finds, particu-
      larly on the face  and  chin, small pustules which
      are caused in this way, and from which, after the
      pus has been evacuated, a small oval body, formed
      of indurated sebaceous matter, may be expressed ;
      and although a morbid accumulation  of this mat-
      ter is observed in several cases of acne, yet all this
      is far from proving  that this  state of the follicles
      is essential to this form of pustule.   And there-
      fore, we very often  see individuals whose follicles
      are in this state, without presenting any trace of 
ACNE.
47
acne;  whilst, on the contrary, we see acne unac-
companied by this state of the follicles ; and when
they do become complicated together, we never
see the infarcted follicles become true pustules of
acne ;  for, by compressing the latter at the period
of suppuration, pus  is easily made to  escape, and
not indurated sebaceous matter.  Nor is it correct
to say that the seat  of acne  is always coincident
with  that of the sebaceous follicles;  for, though
this may be true as regards the nose and forehead,
the contrary is the case in other parts where these
glands most abound, as at the orifice of the meatus
auditorius externus, in the axilla, or in the parts
surrounding the  nipple, the anus, and vulva.,
   Acne is- a cutaneous  disease which is pretty
r.teady and constant in its character, and not like
many  other cutaneous affections, apt to change its
elementary form for that of another, or to be fre-
quently complicated with other eruptions ; except
that in one species of this complaint (acne indu-
rata)  the vari approach to the nature of furunculi,
and in another (acne rosacea) there is a tendency
to erythema.  We have also sometimes observed
acne upon the face  to co-exist with eczema, par-
ticularly of the extremities, the hands or legs.
   The opinion which we hold of the nature of the
elementary eruption of acne will lead us to modify
the classification of Willan, by placing this disease
in  the order of pustular diseases, and by adding
varus  to the varieties of pustules.   In  the subdi-
vision  of the genus we have little alteration to
propose, except  that we should  prefer acne folli-
cularis  to acne punctata, as explanatory of that
species of the disease ; and  that as it is our inten-
tion to distribute the syphilitic eruptions according
to their external characters, considering the form
of the eruption  to be determined more by pecu-
liarity of individual constitution than  essential to
the nature of syphilis, we shall have  occasion to
subjoin another species.  Were this classification
perfectly natural, mentagra, or sycosis, ought to
find its place in this genus ; but not wishing to
introduce any innovation in the arrangement which
can be avoided,  we shall follow Willan and Bate-
man in considering it  apart.  This  genus will,
therefore, consist of the following species :—
   1. Acne simplex,       3. Acne induruta,
   2.-----follicularis,     4. -----rosacea,
              5. Acne syphilitica.
   1. Acne simplex,—Syn. 1ov6oi  (Grec.) ; Vari
(Lat.) ; Psydracia  acne (Sauv.) ;  Gutta Rosea
hereditaria (Darwin) ;  Dartre pustuleuse miliare
(Alibert) ;  Die Finnen  (Plenck.)
  This species consists  in  an  eruption  of  small
vari, appearing  chiefly  on the face,  temples, or
forehead, upon the  shoulders,  the  upper part of
the back, or breast.   These pustules, which are
not numerous, are  generally observed to succeed
each other.   They go through their course  sepa-
rately,  without   any symptom of  constitutional
disorder,  and generally  without any  local  pain,
heat, itching, or uneasiness, so that  it is  not un-
common to meet with people having a considera-
ble eruption of vari  upon the back,  without  their
being  aware of it.   These pustules first  appear
under  the form  of small inflamed  points, which
are felt in the skin like small hard seeds, about the
size of a pin's head ; they continue  to enlarge for
three or four days, and about the sixth or seventh
day they attain their greatest size, when they are
red, smooth, elevated, and somewhat acuminated.
They are hard, cut seldom  painful to the touch.
After two or three  days more, a small speck  of
yellow matter appears on the apices of some  of
the pustules ; when these break, a thinner mattei
is secreted which soon dries into a thin yellowish
scab.  After the suppuration  is finished, (which,
in proportion to the size of the pustule, is  always
inconsiderable,) and the scab separated, there still
remains a red point, a little elevated, which  only
disappears  very gradually.  At other times the
redness and swelling continue, and if that is the
case with a considerable number of the  pustules,
whilst new ones  are  appearing, the  disease  ap-
proaches more or less to the acne indurafa.   Or
when the disease has continued some time, a gen-
eral redness and  roughness  of the  intermediate
skin takes place from the  coalescence of the  in-
flamed areolas of the pustules.
   Sometimes, however, instead of the pustule:
appearing in succession, a considerable number of
them break out simultaneously, covering almost
the whole surface of the forehead ; a circumstance
which is most frequently  observed  in young  fe-
males.  And when the pustules exist in a consid-
erable number, the  sebaceous follicles appear to
suffer  a certain  degree of irritation, for the  skin
has an oily shining surface ; suppuration is retard-
ed, and the pus is smaller in quantity, and a very-
thin scab forms, which separates so  quickly that
it is sometimes not observed :  or, at  other times,
and more especially when  the eruption  is seated
upon the back  or shoulders, the suppuration is
more abundant, and the scab is thicker,  but soon
detached by the friction of the linen.
   This eruption, very correctly delineated in Bate-
man's LXII. plate, and in the 23d  of Thomson's
Atlas, is very inadequately represented in the 22d
Plate of Alibert's splendid work.
   The acne simplex, which is rare before puberty,
occurs chiefly in young people about that age, and
is very common in young females on the first ap-
pearance of the catamenia.   In some individuals
this eruption continues for  some time to recur, or
to become more troublesome at the  menstrual  pe-
riod, and  is not an  unusual attendant upon  dys-
menorrhoea : in others, who have  it partially, it
frequently returns at short intervals ;  but in others,
who are more strongly predisposed to it, it is more
extensive, and  never  wholly disappears, being
more or less troublesome at uncertain periods.  It
is a disease, even when present in a  very consid-
erable degree, perfectly  consistent with the enjoy-
ment  of good  health ; for  which reason  it was
formerly considered a salutary effort of nature  to
relieve the constitution.  Many people experience
a decided relief in  disorders of the  digestive or-
gans on the appearance of vari; so that, on many
occasions, they seem  to be critical.   And Bate-
man observes that severe indigestion, or continued
pains in the stomach, have  been immediately re-
lieved after  an eruption of vari; in which instances
there is occasionally also  an  eruption  of liehe-
nous papulae on the body and  limbs.   It appears,
however,  to be  most closely  connected  with an
imperfect performance  of  the  functions of the
womb, with  a constipated  state  of bowels, or a
sluggish state of the  secretion of the  liver;  and
hence the vari have  sometimes been  called atra-
biliary pustules.  It does  not,  like many othc
cutaneous diseases, depend  upon irritation or an
irritable state  of the  mucous  membranes  of tlw 
48
ACNE.
alimentary canal, but more often co-exists with an
atonic state  of the digestive  organs.  BuP what-
ever may be the pathological condition of the body
upon which it depends, the cause which has un-
questionably the leading influence upon this com-
plaint is hereditary predisposition.   Sedentary ha-
bits, an indolent  manner of living, extremes of
diet, spare as well as rich, and  anxiety  of mind,
tend to confirm this predisposition ;  and wherever
it exists, trifling causes are sufficient to excite the
disease.  Amongst these may be mentioned errors
of diet; excesses at table ;  violent exercise in hot
weather, or in heated rooms, especially when fol-
lowed by cold drinks ; eating cold raw vegetables,
as cucumbers, turnips, melons, when the body is
much heated ; exposure to the heat of  the sun or
of the  fire ; the application  of irritating cosmet-
ics ; vexation of  mind, bursts of passion, or any
strong mental emotion.
   It would be difficult to mistake the eruption of
acne simplex, in its pure state, for any other cuta-
neous affection.   Ecthyma is the disease which,
in appearance, it most resembles ; but the vari of
acne may easily be distinguished from the phlyza-
cious pustule of that disease by their smaller size,
by their slower progress, and by  their base contin-
uing indurated after suppuration : whilst the pus-
tules of ecthyma  are large and  superficial, never
accompanied with chronic indurations, and form
thick scabs more  or  less prominent.  When the
eruption of  acne simplex has frequently recurred
in the same part, as on the nose or forehead, the
skin takes on a general appearance, which, by an
inexperienced observer,  might be mistaken for  a
pustular or  the small tubercular syphilitic erup-
tion ; but  the particular red copper-coloured areola,
and the disposition  of the syphilitic tubercles  to
ulcerate upon their summits, will easily distinguish
them ; whilst the concomitant constitutional symp-
toms clear up all doubts which might arise.
   Bateman has  undoubtedly been guilty of an
oversight  in considering  the acne  simplex  as  a
local disease, and leaving it to be treated  chiefly
by external applications.  But in this opinion he
is, indeed, almost solitary ; for the  united experi-
ence of the best observers  is against him.   Like
almost every affection of the skin, when long seat-
ed in any part, it may persist as a  local disease ;
but in its  origin it is strictly symptomatic, and  is
invariably aggravated by any disorder of the func-
tions of those organs in which it has its source.
   When  the pustules of acne simplex are few  in
number,  they scarcely deserve any attention, ex-
cept as symptoms of some constitutional derange-
ment ; but  when they  are  considerable, they re-
quire the use  of different medical measures,  as
well general as local, on their own account.  When
the disease appears to be connected  with  an unsat-
isfactory  discharge of the uterine  functions, the
treatment must be directed to this object.   In young
persons of a strong and plethoric constitution, and
particularly if about the first appearance of the
catamenia, a small bloodletting will  afford the most
immediate relief; or, if there is  pain of  the  back
or  loins, a  few  leeches may be applied  to  each
groin,  the feet may be immersed in  a warm salt-
water pediluvium, and the bowels preserved in an
open state by some cooling saline aperient, as the
sulphate of magnesia dissolved in infusion of roses,
and acidulated with diluted sulphuric acid, or the
►ul  polychrest in combination  with very small
doses of rhubarb.   When the patient is more deli-
cate, the sulphur lotum in combination with mag.
nesia and rhubarb affords a very safe and satisfac
tory remedy.   It is conveniently administered as
follows : — R  Sulphur, loti, magnesia  aa 51.;
Pulv.  rhei.  9i.;   Pulv. rad.  glycyrrhtz. ^s.
Fiant pulveres sex, quorum unus bis terve die
sumendus.   To this may be added the use of five
grains of the pil. aloes cum myrrha at  bed-time;
or, if the patient is pale, and the circulation lan-
guid, small doses of the sulphas ferri may be com-
bined with the aloetic pill.   If the eruption is ex-
tensive or obstinate, five grains  of the pil. submu-
riat. hydrargyr. comp. may  be taken at bed-time,
instead of the  aloetic pill.  The  diet should be
light,  cooling, and easy  of digestion ; and wine
and all heating drinks should be abstained  from.
   The same  general treatment is applicable to
youns  male subjects ;  a small venesection, cool-
ing saline aperients, the powder of sulphur, mag-
nesia,  and rhubarb, and, if necessary, a few grains
of Pluminer's  pill, and a course of decoction of
taraxacum, with a little  sulphate of potass.  In
both cases, after the aperient and alterative  reme-
dies, the  diluted mineral acids  are  useful  reme-
dies.
   The best local  application to  the  eruption in
the early stage is decoction  of bran, decoction  of
the seeds of cucumbers or  melons, or the  emul-
sion of bitter almonds.  It is not until the  erup-
tion has declined and become chronic, that gently
stimulating applications are required, and they are
then of much  use.  The effect  of any irritating
lotion used in  the  early state of the eruption, is
to multiply the pustules; but  after suppuration,
when proportioned to the sensibility  of the local
affection, they are  often of  the greatest use.   Nor
in this period of the disease need there be any ap-
prehension of producing internal disorder  by the
 sudden  repulsion  of these  cutaneous eruptions;
it is only in the early and active state of the  dis-
 ease that headache and disorders of the  digestive
 organs have sometimes been thus produced.   The
 milder,  but sometimes  not the less efficacious,
 lotions for this purpose  are sulphurous  mineral
 waters, a weak solution of sulphuret of potass, (R
 Potassii sulphureti gi.;  Aquas f.Oi.) or the lotion
 which is made by  pouring  a quart  of boiling wa-
 ter upon an ounce of sulphur, and  allowing it to
 infuse twelve or fourteen hours.  When the erup-
 tion  is  extensive,  the  same preparations may be
 used in general baths at 96°, (R Potassii sulphu-
reti giv.;  Aq. c.  c. fiat balneum.)   Lotions,
 containing alcohol, afford very satisfactory appli-
 cations to this eruption. (R Aqux rosas Oss.; Alco-
 hol. f-3ii.; fiat loti0.)  The proportion of spirit
 must  be diminished or increased  according to the
 excitability of the  skin ;  but it  must not be for-
 gotten, that a slight increase of inflammation is
 often advantageously excited by the first applica-
 tion of a moderate stimulus; that this  transient
 irritation is  overcome by persevering in it;  and
 that, in this way, the skin acquires the  power of
 bearing an increased  degree of stimulus.  The
 efficiency of  alcoholic  lotions  is sometimes in-
 creased, by the addition  of  a little of the  liquor
 ammoniae acetatus, or acetous  acid, or  subcarbo-
 nate of ammonia.   The muriate of ammonia in
 lotion, is sometimes very useful in chronic cases
 of acne  simplex.   (R Aquae russe Oss.;  Alumi-
\nisgm.;  Ammonite muriatis 31.; Potaisiisul- 
ACNE.
4G
phureti ^i ;ft. lotw.)  When stronger irritating
remedies are necessary, which is, however, seldom
the case, muriate of mercury, in  small quantities
may be added to the alcohoiic lotions.  (R Aquae
destillat. Oss.; Alcohol, f.51.; Hydrargyri chlorid.
corrosiv. gr. vi. //. lotio.)   It sometimes happens,
that in old cases of acne simplex, much benefit is
derived from exciting an inflammatory state of the
eruption.   Bateman mentions a lady who  con-
sidered herself  much benefited, after  a  severe
inflammation,  and  even excoriation  of the  face,
which had been produced  by a poultice of bruised
parsley.   But it is  seldom necessary, in  this spe-
cies of the disease, to have recourse to the remedy
of Ambrose Pare, revived by Darwin, who affirms
that blistering the  whole  face, in small  portions
successively, is the  most effectual remedy for the
inveterate forms of this  acne.
   The ancients, in the treatment of vari,  chiefly
relied upon external stimulant applications.  These
consisted   of  lotions and  liniments,  containing
vinegar and honey, sometimes combined with an
emulsion  of bitter  almonds, and sometimes with
resin,  myrrh,  turpentine, and other gums,  with
alum,  soap, and Cimolian earth ; or the bruised
roots of the   lily, cyclamen, and narcissus.  But
the fruit of the wild vine (labrusca) is the appli-
cation which  Pliny (Hist. Nat. lib. xxiii.  cap. 14,)
mentions as most especially useful.
   2. Acne Follicularis, Maggot  Pimple.
   Syn. Acne punctata (Willan) -,  'tovdos (Greco-
rum); Varus (Latin); Crinones, Crimones (Va-
riorum Auct.); Grutum milium (Teutonice); Der
Gries  (Plenck);   Punctae  mucosae (Darwin);
Grubs (Anglice); Tannes (Gallici).
   Pustules, having the precise character of vari,
are observed to  have their  seat in  the sebaceous
follicles ;  sometimes originating locally  from the
accumulation  and induration of sebaceous  matter,
causing their obstruction (emphragmasebaceum);
and sometimes symptomatically, from inflamma-
tion of the follicles, arising  from some disorder of
the internal organs.  When the vari are  produced
by the first named cause, the sebaceous matter, by
being  exposed to the air at the mouths of  the fol-
licles, assumes  a black appearance, and the pus-
tules present  a black point on their summit, sur-
rounded by a very  slightly raised border of cuticle.
This circumstance, which gives sometimes a par-
ticular feature to the disease, afforded Willan the
specific character of acne punctata ;  but for which
as this appearance  is far from being constant, and
as pustules have their seat  in the follicles without
presenting it, we have substituted acne follicularis,
as better explaining the nature of the affection.
   A loaded and obstructed state of the sebaceous
follicles may exist to a considerable extent, with-
out inducing  inflammation ; and only very minute
hard white tubercles, of the colour and  size of
millet seeds, are to be observed, from which the
sebaceous matter being pressed out through the
circular orifice of the follicle, takes a filiform shape,
bearing a close resemblance to  a maggot.   That
it really owes its form to  the manner in which it
is  forced  through  the  aperture  of  the follicle  is
obvious ;   for, if the  black  spot  is  ruptu.'t-d by a
fine needle, it will  be seen to be a mere deposition
of sebaceous  matter of  a round  form.   In this
state they are commonly known by the name of
crinoncs,  worms or grubs.   [Recently, it has been
found, that these follicles  are occupied by a para-
   Vol. I---7                           e
sitic insect, (Acarus folliculorum,) which has been
found alone or in clusters of several in a single
follicle.   In the  perfectly healthy  state  of  the
follicles,  they are few in  number;  but  when
sebaceous matter, which seems to serve them for
aliment, is allowed to accumulate,  they abound.
The insect was first observed by M. Simon, of
Berlin, and has been since seen  and described by
Mr. E. Wilson,  in his  work on Diseases of  the
Skin.]   As the matter accumulates and hardens,
it  becomes a  source  of local irritation, and  the
sebaceous crypts,  in  consequence of  distension,
inflame and form  pustules, which suppurate im-
perfectly.  At other times these obstructed  follicles
remain stationary, without ever  passing into  the
inflammatory  state;  or the accumulation of  the
matter goes on  increasing until they form con-
siderable  follicular tubercles, resembling those of
molluscum,and sometimes tumours of considerable
size, or,  occasionally inflaming,  assume  the  ap
pearance of indolent boils.
   The disposition of the body  to the accumula-
tion of the sebaceous matter in the follicles of the
skin is much dependent upon peculiarity  of con-
stitution, but is always very intimately connected
with a constipated state of the bowels, so  that in
many individuals the necessity for aperient medi-
cine is indicated by the  sebaceous follicles  appear-
ing full or prominent.
   Besides this origin of  follicular vari, they may
also be produced  directly without any collection
of sebaceous  matter either by local irritation, in
which way some kinds of cosmetics seem to act,
or by inflammation of the  follicles arising sympto-
matically from the irritation of the internal organs,
as the bowels or the womb.
   The follicular may often be  seen  mixed with
the simple vari in this  and the  other species of
acne.  Of this complication there is a very accu
rate delineation in Bateman's LXII. plate.
   For the removal of follicular vari, besides  the
general treatment of acne simplex,  which is alsr
applicable here,  it is necessary to empty the folli
cles by mechanical means, either by pressing on
both sides of the pustules  until  the hardened
matter is sufficiently elevated to be taken  hold of,
or by employing a blunt curved forceps  for this
purpose.   But  when this  state of the  follicles
exists, to a considerable  extent, nothing so effec-
tually empties them and clears the skin as  the
vapour  bath,  followed  by the warm  sulphurous
bath.  Lotions  of sulphuret  of potass,  with or
without  alcohol, are of  great, service when  the
disease is of small extent. When the disease has
subsided, and the state of the skin  admits of it,
general  friction with  the flesh-brush, a  flannel
glove, or a coarse towel, is of great use.  The
internal  remedies most suitable in this complaint,
are  powders  of sulphur,  magnesia, and rhubarb,
with an  occasional  saline aperient.   Dr. Under-
wood recommended the use  of  a solution of car-
bonate  of potass internally,  and Dr. Willan was
in the habit  of  occasionally prescribing the oxy-
muriatic  acid ;  and  there can  be  no  doubt that
any other medicines which  improve the functions
of the  digestive organs  and benefit the general
health, have a considerable influence in correcting
this unhealthy state of the skin.   It is probably in
this way that the following alkaline tonic, recom-
mended   by  Dr.  A.  T.  Thomson,  produces its
effects;  (R Zinci sulphat.  gr.  xxiv. : Liquori* 
50
ACNE.
potassx f.^xii.;  solve.   Sumantur guttae xxx.
ex cyatho aquae bis quotidie.)
  3. Acne indurata, Stone-pock.
  Syn. AlddXiKts (Hipp.) ;  Vari (Latin) ; Dartre
pustulcuse disseminee (Alibert); Pustular solitariae
(Teutonici); Eiterfinnen  (Plenck); Pustulaj in-
flammatoriae (Lorry).
  In this species  the vari  are larger, less regular
in their figure, sometimes ovate as well as conoidal;
they are deeper seated ; the  inflammation of the
surrounding skin  is more extensive ; suppuration
takes place still more slowly, and is followed by
thicker scabs and  by partial indurations, more or
less  considerable, in  the  subcutaneous  cellular
tissue as well as in the skin.   It attacks the face
most commonly,  but  is also very frequently ob-
served upon the upper part of the back, shoulders,
and breast, and has sometimes been seen to cover
the whole posterior part of the trunk.   It affects
chiefly young adults of both sexes, but the severest
cases are met with in  young men.  It affects most
generally persons of  gross phlegmatic tempera-
ment, who have a thick  greasy skin : and though
the strong and robust  are more  frequently  the
subjects  of its attacks, it does not  spare the weak
or exhausted.  We have  certainly observed it
more frequently in patients of a scrofulous habit
than in others.   We  have known it co-existing
with a strong family predisposition to mania; and
it has been observed in connection with  the he-
morrhoidal constitution and pulmonary consump-
tion.   It  is sometimes  accompanied with symp-
toms  of abdominal derangement; but  it is also
sometimes the only discomfort of people enjoying,
in every other respect, perfect health.  In persons
predisposed, it is  generally  excited by irregularity
of diet, by cold food  or  drink when the body is
heated, and sometimes it is developed by external
irritating applications, as a  blister.
  This complaint presents  itself in very different
degrees of intensity.   Sometimes it is very slight;
a few red inflamed points show themselves in the
forehead, temples, the upper part of the cheeks, or
over the angles of the lower jaw ; these become
pustules of a  bright rose colour, which,  rising
slowly, only after two or three weeks, end in sup-
puration, or sometimes never arrive at  that state.
The pustules when red  are sore and tender to the
touch, but as  they decline they become livid  and
less painful.  These are succeeded by other pus-
tules.   After suppuration,  the skin on which they
are seated remains hard and of a bright rose  red,
and the  subcutaneous  cellular 'tissue  assists in
forming tubercles, or chronic indurations.  In this
manner, a certain number of pustules having suc-
ceeded  each other,  the affection  gradually sub-
sides.
   But,  in  general, the  disease  is much  more
severe ;  the whole face is  covered with irregular
bright red pustules and  livid red tubercles ; they
are particularly large  and  numerous on the rami
of  the  lower jaw and  under the jaw ; on the
temples and  cheeks ; and  smaller but  not less
thickly spread upon the nose and forehead.  These
tuberjlcs themselves  often   suppurate,  forming
superficial indolent abscesses  covered  with skin
of  a livid red colour.   They seldom point or  find
issue for their contents spontaneously, but occa-
sionally require to be discharged by the aid of the
 lancet, and then  the wound  heals slowly, leaving
 a livid  indented mark,  which never  disappears.
The intervals of the tubercles  arc  studded with
pustules in different stages of their progress, either
just beginning to appear, in a state of suppuration,
or covered with a scab, with red spots distributed
amongst them, so as sometimes  to give a general
red appearance to the whole  surface of the  skin.
Occasionally a number of black points, marking
infarcted mucous follicles, or true  follicular van,
are to be observed, here and there, in the intervals
between the tubercles and pustules,  but  chiefly
upon the sides of the nose, cheeks,  and forehead.
The skin  is greasy and  shining, and the whole
face much swollen and inflated, giving the  patient
a most disagreeable aspect, which  is very accu-
rately represented in Bateman's LXIII. plate.
   The pustules of acne indurata often leave traces
which  it is  impossible to efface, the  skin being
marked with many  very small scars, the effects of
former eruptions of this  complaint, more  or less
frequently repeated.
   Though this species of acne attacks frequently
both the face and back at the same time, it some-
times spares either  one  or the other, but in either
case the disease  is  of long duration  and tedious ;
and whether it terminates spontaneously or by the
power of art, the process is  only completed very
slowly, and patients remain very liable to a re-
lapse.
   Notwithstanding the severity of  the eruption,
the patient may enjoy  good genoral health,  and
attend to all his wonted avocations, unless he may
have to complain occasionally  of headach, or a
disagreeable sense of heat in the face ; and it has
been observed, that if a fever, or other severe dis-
ease,  should take place,  the eruption often sub-
sides or disappears  ; so that  its recurrence  under
such  circumstances is  to be deemed a  sign of
returning health. Bateman has seen the erethism
of a mercurial course, administered  for other pur-
poses,  occasion  the disappearance of this acne,
which returned with  the  restoration of flesh  and
strength, after the omission of the medicine.  And
we have observed that in  those cases in which the
disease is compatible with otherwise good health,
it is also invariably the most difficult to cure.
   When acne indurata is severe or of long dura-
tion, it is a disease most difficult to subdue, and
often resists the most skilful and the most perse
vering treatment.  If the eruption  is sudden 01
extensive, and appears in a subject of sufficient
strength, nothing makes so decided an impression
upon it as venesection ; and, even in delicate  sub-
jects, advantage may be derived  from the detrac-
tion of a few ounces of blood.  In  the inflamma-
tory state of the disease, cooling saline purgatives,
with a mild alterative mercurial pill  at bed-time,
and the antiphlogistic regimen form the essential
parts of  the constitutional treatment.    As the
disease declines, or becomes chronic, the  mineral
acids are  often  used with great advantage; and
the internal use of the sulphureous mineral waters,
as those of Harrogate, are amongst  the most suc-
cessful  remedies.   Dr. Bateman  thinks  that ad-
vantage  has  been  derived from the internal use
of small doses  of  soda,  sulphur, and antimony,
assisted  by proper external treatment.   Neither
purgatives nor the antiphlogistic regimen should be
continued longer than the first  active state of the
disease.   On the contrary, it  is frequently of ad-
vantage to have recourse to mild tonics and alkalis-
and,  on the  same  occasions, the greatest ber«fit 
ACNE.
51
has been derived from changing from a poor to a
more generous diet.   Lorry relates the case of a
water-drinking monk, whom he relieved of this
complaint  by the moderate use of wine.   The
constitutional disease with  which this complaint
appears to be most connected is atonic dyspepsia,
with a  constipated state  of bowels ; it  is,  there-
fore, obvious that a plain moderate diet of animal
food is more likely to agree than raw  vegetables,
cresses, and vegetable acids, used under the notion
of correcting the scorbutic state of the  humours.
   [In some obstinate cases  of  the different forms
of  acne, great benefit has  resulted, as  in other
chronic  cutaneous  cachexies,  from  a  thorough
change of diet,  and especially from putting the
patient on the use of saccharine  matter between
the meals, so as to modify the condition of the
chyle, and  through it that of the blood and of
the tissues.   An ounce and a half of simple syrup
may be  given with  this view  about three  hours
after each meal.  With the syrup may be associated
the iodide or ioduretted iodide  of potassium, in the
form of the liquor iodini  compositus (gtt. x—xx
ter die).  By a  perseverance  in  this  course for
eight or ten weeks, some very obstinate cases have
yielded,  See Dunglison's  Practice of Medicine,
2d. edit., p. 129.   Philad.  1844;  and  his Ele-
ments of Therapeutics and Materia Medica, Vol.
2, p. 315.  Philad. 1843.]
   But constitutional treatment would be of little
 avail without the  assistance of local  means for
accelerating the  progress of the pustules,  or for
promoting the resolution of the tubercles.   In the
early stage of the eruption, mild emollient  appli-
cations  are most  suitable, such  as  demulcent
decoctions  or poultices, which, if there is pain,
may be made with the decoction of poppy  heads.
 When the pustules have suppurated, and are slow
in  discharging themselves, it is advisable to apply
 to  them, as  Turner  recommends,  the common
 principles of  surgical  treatment.  After the pus-
 tules have discharged their contents, either spon-
 taneously, or by  means of the lancet,  stimulating
 alcoholic lotions, containing a small  quantity of
 corrosive sublimate,  are  chiefly to  be relied on,
 such as have been mentioned for the severer cases
 of acne simplex.   In the hospital of St.  Louis,
 at  Paris, the greatest  advantage has been derived
 from rubbing the pustules, as well  as  the  tuber-
 cles, with  the following ointment: R. Hydrar-
gyri ammoniat. 9i.  ad  gi.;  Ad'pis, £i.   But
 of all the preparations for  promoting the resolu-
 tion of the tubercles of acne indurata, none are,
 according to M.  Biett,  to  be compared   to the
 iodide of sulphur, mixed  with lard.   (R. Sul-
 phur,  iodid. gr. xii.  ad  gr. xxiv.; Adipis, §i.)
 M. Biett employs this remedy  in the wards of the
 Hospital of St. Louis with decided benefit.  In
 some severe cases of acne indurata submitted to
 the friction of ioduret of sulphur, the tubercles
 were resolved with astonishing rapidity.  But the
 good effects  of all these means  are  very  much
 promoted  by the  use of the  vapour bath, and
 more especially of the douche  of vapour, directed
 for twelve or fifteen minutes upon the eruption.
    It is principally in old chronic cases of the acne
 indurata, where the local affection has completely
 established itself, that it may sometimes be  neces-
 sary to have recourse  to  means  for  changing
entirely the action of the part; and for this pur-
pose, blisters, used by Ambrose Pare, under the
notion of drawing out the peccant humours, and
revived by Darwin, have been frequently used in
the Hospital of St. Louis,  and have been  found
eminently  useful.  [Solid  nitrate  of  silver  has
been  rubbed over the parts, and they have been
brushed over with one of the concentrated mineral
acids with a similar object.]
   During any recurrence of a considerable fresh
eruption, the means adapted to  the chronic state
of the disease must necessarily be suspended, and
recourse had to the constitutional and local  means
suited to its inflammatory state.
   M. Biett  has found that  when the disease has
disappeared, a lotion, or douche  of cold sulphur-
ous water is of great use in establishing the cure,
and in preventing a return of the  eruption.
   4.  Acne rosacea, carbuncled face.
   Syn. Zevtov  (Grec.) ;  Varus (Roman) ;  Gutta
rosea  et  rubedo  (Auctorum) ;  Gutta rosacea
oenopotarum et hydropotarum (Teutonice): Kup-
ferbandel  (Plenck);  Bacchia  (Linn.) ;  Gutta
rosea  hepatica  (Darwin) ;   Herpes  pustulosus
gutta  rosea, Dartre pustuleuse  couperose (Ali-
bert) ; Ionthus  corymbifer  (Good);  Saphirs,
Goutte rose, couperose (French); Roth-gesicht,
Roth-nase (German) ;  Red pimpled face.
   In  a correct pathological nomenclature, as the
last species might with  greater propriety be term-
ed acne furunculus, being a complication  of the
varus with  phlegmon,  or inflammation  of the
subcutaneous cellular tissue, so this species would
be more accurately distinguished under the name
of acne erythema, the pustules  of acne  being
combined with  an erythematic  inflammation of
the  skin.   In this respect, as regards the local or
external disease, acne  rosacea  differs from the
other  species, the vari  sometimes  preceding and
developing  the  erythema,  and  the erythema, on
the contrary, being sometimes the  occasion of the
vari.   From this circumstance has arisen the dis-
tinction  of  gutta  rosea,  observed by Nicolaus
Floientinus, Ambrose Pare, Astruc, and Plenck,
dividing it into species, under the  terms of sim-
plex, or pure erythema,—pustulosa and bacchia-
lis, the acne rosacea of Willan,  — and squamosa
ulcerans  and varicosa, the sequelae of obstinate
forms of that disease.
   The nose is,  commonly, the  first seat  of this
affection.   In persons predisposed, who are  gen-
erally of the middle age, after any  exciting cause,
as a full meal, heating drinks, or indigestible sub-
stances, the extremity of the nose becomes  of  a
deep red  colour, more  or  less  intense, which at
first  gradually  subsides with the removal  of the
exciting cause;  but,  at  length,  by  repetition,
grows to be habitual.   In this red shining ap-
pearance of the  nose, some elevated  points of  a
brighter red colour, sometimes distinct, sometimes
in groups, are afterwards observed.  These points
enlarge, becoming pustules, which suppurate at
their  summits;  but  the  suppurative  process  is
always imperfectly established,  forming  seldom
more than a small white acuminated point  on the
apex of the pustule, which makes  a striking  con
trast with the dark damask red colour  of the  pus-
tule,  an appearance which is well represented in
Alibert's XXI.  plate.   This white point  of the
pustule bursts and forms a thin white scab, which,
detaching  itself,  leaves  beneath  it  a hard phyma-
tous tubercle.  These pustules succeed each othe:
and  in this  manner the disease  perpetuates itself 
52
ACNE.
Sometimes the disease is confined exclusively to
the nose, which, from the repetition of this mor-
bid process, and the successive formation of tuber-
cles, increases very considerably in  size,  being
covered with  knobs  and  asperities, whilst the
blood-vessels of the surface of the skin are seen
enlarged, and the small veins appearing varicosed,
have the appearance of bluish lines, strongly con-
trasted with the general red colour of the surface ;
or the intermediate  skin is striated with reticula-
tions of enlarged cutaneous veins, resembling  an
injected membrane, an appearance which is cor-
rectly delineated in Bateman's LXIV. plate.   M.
Alibert thinks he has  observed, that the right side
of the nose is more liable to  be affected with this
species of acne than the left, a circumstance which
he connects with the influence of the state of the
liver upon this disease.   More generally the size
of the nose is  not increased, but its form only
altered ;  and the  disease  extends itself to the
cheeks, forehead, and chin,  so  as sometimes to
cover the whole face.   The red colour of the skin,
which is always more remarkable after dinner, or
in the evening, than in the morning, is not any-
where equal in degree, but is always more so in
the seat of the pustules.  The disease may cease
and return in different degrees of intensity ; but
after it has continued  for some  time, the surface
of the skin becomes uneven and  rough, and if the
disease  should even  disappear, the  skin  never
entirely recovers its natural state.
   In general this eruption produces little discom-
fort of feeling in proportion to its deformity, sel-
unm more than a slight momentary itching; but
some  persons  have the  face in  a very irritable
state, with the  sensation of heat  and  burning,
being frequently obliged to bathe the face in cold
or tepid water for relief.   After  eating, drinking,
or any moderate exercise, they feel a sudden glow
of heat in the face;  but it is chiefly when they
approach  the fire that  they  suffer most; it pro-
duces in them a sensation of pungent heat, or of
burning and itching.
   Hereditary disposition is, unfortunately, one of
the most common predisposing causes of this dis-
ease,  and one which  sometimes inveterately  ad-
heres to many  successive  generations.  Alibert
traced the disease, in one  family, through four
generations.  This predisposition frequently shows
an affinity with that of scrofula, but is always in-
timately connected with  the state of the functions
of the abdominal viscera, and hence causes tend-
ing to  establish  an  unhealthy  state  of these is
liable to induce this predisposition.  For this rea-
son, the indulgences of the table, in eating  as
well as in drinking, violent emotions, or long and
intense exertions of the mind, sedentary occupa-
tions, and  much  watching, are amongst the most
frequent causes of it.  Persons  of middle age are
consequently most liable to it; and it is  most fre-
quent in men of n hemorrhoidal constitution, and
in women at the critical period of life, or in such
as suffer  from disorder of the uterine  functions.
Notwithstanding the  difference of habits, it seems
equally common  to  both  sexes.  Sometimes  it
shows itself, or  is increased, during gestation;
but in other circumstances, it has been observed
to disappear during  pregnancy, and return after
parturition.  Besides these causes, anything which
favours or determines the  afflux of blood to  the
head, increases the tendency to  this complaint.
It will, therefore, be easy to understand, from the
causes just  assigned, why it should be met  with
amongst men of letters, lawyers, merchants, and
gamesters, and in public offices ; among women
employed in drawing, painting, and tambouring ;
and  in  those  whose avocations  oblige  them to
keep the head in a depending position.   It is not,
however, to be  forgotten,  that the acne rosacea
sometimes   appears  in people of the most sober
and temperate habits, and that it sometimes shows
itself in  conjunction with a state of exhaustion
and general debility.
  In people predisposed to this complaint, either
hereditarily  or by habits of life, it may  be imme-
diately excited by local irritation, as by long ex-
posure to a  hot sun, to the heat of the fire, or the
application  of strong  cosmetics.   Violent exer-
cise, bursts  of passion, or fits of  chagrin, are also
capable of  developing it.   Alibert mentions the
case of a lady, who, having been entirely cured
of the complaint during a methodical  treatment
of it at the establishment  at Tivoli, on receiving
some afflicting news, in the course of twelve hours
relapsed into  a  state worse than ever.   But it
most generally makes  its appearance after errors
of diet,  of which, when  the  predisposition is
strong, any  moderate degree is sufficient to  pro-
duce it.  These exciting causes explain why it is
so generally met with amongst cooks, glassblow-
ers, mowers, couriers,  and players.
   This complaint is, frequently,  a symptom  pre-
cursive of  diseases of the liver, but sometimes
they coexist contemporaneously.   It seems  gen-
erally to depend more  upon  a state of abdominal
plethora, or congestion  of the liver, than upon
any  irritation  or irritable state of the mucous sur
faces of the alimentary canal; and hence spongy
bleeding gums,  and habitually torpid  and  con-
fined bowels,  are its usual attendants.
   The treatment of acne rosacea  demands  great
perseverance,  and even  in spite of this,  it is fre-
quently unsuccessful.   To every form and variety
of this  complaint,  with  few exceptions, one  part
of the treatment is  generally applicable and essen-
tial, and it is  that which consists in a strict ad-
herence to proper diet  and  regimen, adapting  them
as much as  possible to the correction of that state
of body which constitutes the predisposition, and
avoiding all those  causes which have the power
of exciting it.  These views will  be attained by
leading a sober  temperate life,  by using a  mild
diet of easy  digestion,  by avoiding excesses at
table,  by abstaining  from  spirits, liquors,  and
sometimes even wine ; by  avoiding hot fires,  heat-
ed  apartments, and violent exercises, and by en-
deavouring to eschew violent emotions of mind or
close applications   of  the understanding.   The
power of this plan will  be increased,  and the
general object promoted by the use of appropriate
remedies, suitably adapted  to the  peculiarities of
the case.   If much local inflammation be present
with general plethora, a  moderate venesection
may render great service.   If the eruption is con-
nected  with the suppression of any accustomed
evacuation, the propriety  of endeavouring to re-
 store it naturally suggests itself;  if the menstrual
function is laborious, imperfect, or irregular the
proper  modification of the method of cure readily
 occurs ; if  a congestive state of the liver is pre-
 sent, or when the liver  is more  severely affected
 mild  alterative  remedies—as  Plummer's   pill! 
ACNE.
53
taraxacum,  and  sulphurous  mineral waters,  as
those of Harrogate, are  applicable.   These  last
are of known efficacy, and are much to be pre-
ferred to the saline mineral waters.   In  all cases
an open state of  the bowels is of importance, but
much purging is generally detrimental.   We have
great doubt  whether any constitutional remedy
has  a specific action upon the local  disease.   In
France  and  Germany  the dulcamara  and viola
tricolor  have been much used; but we think that,
united with  the general treatment, more  benefit is
derived from the  use of the liquor  potassae taken
a few hours after each meal.
   A judiciously  directed topical treatment is of
 ^reat importance  in the cure  of this  disease.   In
 sudden and acute attacks  a few leeches may be
 advantageously applied near the seat  of  the com-
 plaint,  especially when this eruption affects fe-
 males at the  critical  period of life,  although,  in
 Ihese cases, small general blood-lettings  are some-
 times of greater service.   In the same state, mild,
 tepid, demulcent  applications are  to be frequently
 used; amongst these the  decoction of beans has
 always enjoyed a great reputation : and  as the in-
 flammatory affection subsides,  sulphuretted lotions
 form the most useful applications.  If the disease
 is not benefited by these means, more stimulating
 lotions  may be had recourse to, but in general they
 are  less useful in this species of acne, and require
 more circumspection, for they not  unfrequently
 aggravate the complaint.  Gentle astringent lotions
 of alum, combined with  a very small quantity  of
 alcohol, are sometimes very useful, and  in an in-
 dolent state of the  local disease, the vapour-douche
 directed to the part affected, has been often found
 of great service ; the same state also sometimes
 admits of moderate friction, or resolving applica-
 tions.  It is to these cases that the remedy of Am-
 brose Pare, a blister applied to the diseased  part,
 deserves consideration,  a  practice  the utility of
 which has been occasionally verified  in the Hos-
 pital of St. Louis.  Nor are the general principles
 of surgical  treatment to  be neglected  here  ;  for
 when the vari are  seated in the follicles, the focus
 of irritation is removed by evacuating them.
   Besides these  general and local means of treat-
 ment, the nitro-muriatic  foot-bath, in the propor-
 tion of  two ounces of the acid to twelve pints of
 water,  has been  very much recommended ; and in
 many diseases of the  skin we have found  the
 greatest benefit from sponging the sound parts  of
 the skin, two or  three  times every morning, with
 a lotion consisting of two drachms of nitro-muri-
 atic acid, and two pints of water.  It is also  fre-
 quently of  advantage to apply a blister to the arm,
 or to open an issue as a derivative.
   5. Acne  syphilitica.
   Syn. Gutta rosacea syphilitica (Plenck) ;  Sy-
 philide  pustuleuse miliare (Alibert);  Pustules
 syphilitiques psydracees (Rayer.)
   The  multifarious  forms of cutaneous  diseases
 which have been described as originating in syphi-
 lis,  may fairly be said to  have deprived that  dis-
 ease of any specific character, for there is scarcely
 a morbid appearance presented by the skin which
 may not, in a modified  state, be found amongst
 syphilitic eruptions.  But if any one will take the
 pains to examine into  this matter,  he will  find,
 what might reasonably have been expected as be-
 ing more in accordance with the general laws  of
pathological  phenomena, that though there are
certain forms of cutaneous disease essential and
peculiar to syphilis, the  greater number of those
described as syphilitic, depend upon the  constitu-
tional  predisposition  of the individual, modified
by the syphilitic virus; and that whilst the influ-
ence of this disease impresses upon them a gen-}
ral character, their particular form  depends upon
the  pathological peculiarity  of  the  individual.
Thus, if lichen, lepra, or any other cutaneous dis-
ease, makes its appearance in persons tainted with
the venereal  poison, these  diseases, though origi-
nating in  ordinary causes, will suffer a relative
modification.   In proof of this, we find that the
syphilitic acknowledges the  same causes as the
other eruptions, being excited by errors of diet,
violent exercise, strong mental emotions, &c.   It
seems, therefore, more natural in a classification
founded  on external  characters, to distribute the
syphilitic eruptions in each genera as  their exter-
nal appearance would require them to be arranged,
rather than to confound them together under a class
of anomalous eruptions.  In this way the  general
treatment required for this disease  may be modi-
fied by  the  peculiar character of  each eruption,
and the  student will be led more  naturally to find
the  place of the eruption  in the classification.
This is evidently the view which  Plenck  took of
these diseases, and the plan which Willan intend-
ed to pursue;  but M. Alibert, as faulty in method
as correct in description, has  formed  the venereal
eruptions into a class under the name  of syphi-
lides, and  M.  Biett,  to  whom we are so much
indebted for a more  correct knowledge of many
of these diseases, has omitted to correct this error
of classification.  They who are conversant with
diseases of the skin, will  find some  difficulty  in
following Mr.  Carmichael  in arranging these erup-
tions under his papular, pustular, phagedenic, and
scaly diseases, and will be disposed to doubt whe-
ther, under these descriptions, he has been so suc-
cessful as to include such  as are  peculiar  to,  or
characteristic of, the venereal disease.
   Under the term gutta rosacea syphilitica, Plenck
had marked the acne  syphilitica.   It  corresponds
nearly to the disease  described by Alibert, under
the  term  syphilide pustuleuse miliare, and, by
 Biett and Rayer, pustules syphilitiques psydracees.
It is the least  common  of the syphilitic pustular
eruptions, and affects chiefly the  face, forehead,
 neck, and trunk.  The  pustules of this eruption
 correspond very neary in form and dimensions  to
 those of acne rosacea; they are round,  conical,
 and  acuminated, surrounded with  an inflamed
 areola, and possess the true character  of vari, sup-
 purating only at their apex, and invariably termi-
 nating in tubercles.  They are, however, distin-
 guished from them by their deep, red, amaranthine,
 or copper-coloured areola, by their brownish yel-
 low scab,  and by their  leaving  a small,  slightly
 depressed cicatrix.   A correct delineation  of acne
 syphilitica is still a desideratum in this branch of
 medicine;  but, in  general, the nose, cheeks, and
 forehead present a livid  copper colour, as if stain-
 ed with the lees  of  wine.  In these discoloured
 patches, pustules appear from time to time, which
 leave behind them small dark red tubercles, chiefly
 on the forehead, nose,  or  adjacent parts of the
 cheeks.   As the pustules succeed each other, they
are  to be seen mixed together in  every stage of
their process.  With the  acne  syphilitica may 
54
A C R 0 D V N I A — A C U P U N C T U R E.
sometimes co-exist eruptions of another character
(frequently scaly) upon the extremities.
   The acne syphilitica is always  a secondary sy-
philitic affection, consequent to chancre ; it is not
uncommon to see  it totally unaccompanied  with
any of the other secondary symptoms of that dis-
ease,  but its  most usual  attendants are  nodes,
inflammation  of the  periosteum, and nocturnal
pains.
   The specific treatment of acne syphilitica, which
must  still be that on which every prudent  practi-
tioner will  chiefly rely, demands  modifications
adapted  to the general nature of acne.   In the
early  state of the eruption  it is  better to  pursue
the means found useful in the ordinary forms  of
that disease, and to reserve the  mercurial treat-
ment  for the chronic  stage.  By this  method  a
much smaller quantity of mercury suffices for the
cure.   The  action of the mercury is rendered
much  more  efficacious when combined  with a
course of taraxacum or sarsaparilla.   In a case of
this disease, which came under our care lately, the
greatest improvement was effected in the eruption
by the use of sar'saparilla alone, given in powder ;
in general it is more efficient when combined with
mercury, and we are acquainted with no prepara-
tion which fulfils  this intention  better than the
celebrated decoction or tisan of Feltz.   (R. Aquas
Oxii:  Antimonii  sulphuret.  §iv :  Red. sarsa-
parillse ^ii :  Hydrargyr. chlorid. corrosiv. gr. iij .
Ichthyocollae  §iss.  The antimony to be enclosed
in a muslin bag, and  the ivhole to be boiled gen-
tly until the water is reduced one half, except the
corrosive sublimate, which is  to  be  added  after
the decoction has been  strained,—Oiss is the pro-
per daily dose.)
   As a local application the fumigation of cinna-
bar is the most efficacious, lotions being of little
avail.  From one to three drachms of the red sul-
phuret of mercury may be sublimed and directed
upon  the part by  a suitable apparatus.   Where
indurations remain after the specific treatment, an
ointment formed of the ioduret of mercury (R.
Hydrargyri iodid. rubr. gr. xi.  Adipis §i.) rub-
bed upon the  part, is  a remedy of great efficacy,
and is much  assisted  by the  occasional use of a
douche of vapour continued for twelve or fifteen
minutes-                        T. J. Todd.

   [ACRODYNIA.   Erythema acrodynia,  E.
acrodynum;  from axpos, extremity, and o&wv, pain.
A name given to an epidemic neurosis, which pre-
vailed at Paris, and the neighbourhood, during the
years 1828 and 1829,  and in which the most con-
stant  and remarkable  symptoms were  numbness,
formication, and, at  times, darting  pains  in the
hands and feet.  The  pain was compared  by the
patients  to that which would be occasioned  by
needles or pins run into the parts.   It was  aug-
mented by pressure ; was intense for a time; then
diminished, and after  a time disappeared, leaving
the skin  devoid  of its  natural feeling, and red—
the cuticle separating in  large flakes.  Occasion-
ally, the  mucous membranes of the intestinal canal
sympathized, as indicated by diarrhoea, vomiting,
gastrodynia,  &c.  The only constant symptom,
however, was the pain in the hands and feet.
   The disease was a precursor of the cholera, and
not less  inexplicable in its character and causation.
Some died of it.  It  spread chiefly amongst the
poorer classes, and where numbers  of persons
were crowded together.   In  the Caserne des Our-
sines, in Pans, it  attacked 560 of 700  inmates j
and in that of La Courtille, in four days, 200 out
of 500.  No one died of it.
  Various remedial agents  were employed ; but
they appeared to be of little efficacy.  The phe-
nomena were  met by  what appeared to be the
most  proper  agents;  and in  the  latter periods
of the epidemic,  the  therapeutist confined him-
self to the use of the warm  bath, fomentations,
frictions, and emollient  and  narcotic cataplasms.
(Dance, in Art. Acrodynie, in Diction, de M/.de-
cine,i. 515,  Paris, 1832.)
  About the same period, the  Dengue (q. v.) ap-
peared in the Southern  part of  this country and
the West  Indies.  It  seems to have been a con-
generous affection.  The same may be said of the
affections which have  occasionally been  described
under the name Kriebelkrankheiten by the Ger-
mans.
  The writer had recently under his  care a case
of sporadic Erythema acrodynum, which yielded
to pencilling the hands and feet with the tincture
of iodine, after a  variety of remedies had  been
used in vain.         RoBLEY  DUNGLISON.]

  ACUPUNCTURE.   The passing  a needle
into the body is termed acupuncture.   From for-
getting that the word puncture has two  significa-
tions,—that  it is used  to signify both the wound
and the act of making it, some  have termed the
operation acupuncturation.   But to  subjoin the
syllables ation to the word puncture  or  acupunc-
ture, is as improper as to  subjoin them to the
words preparation or fabrication, each  of which
already ends in ation  and has a similar twofold
meaning.  An exactly parallel error would be to
say manufacturation.
  The most obvious purpose of  this operation is
to allow the escape of the fluid of oedema or ana-
sarca through the skin, or of the  blood when su-
perficially accumulated ; but,  from  an  idea that
various disorders arose from  a  kind  of subtle and
acrid  vapour pent up, it was had recourse to, for
the purpose  of giving this vent,  by the  Chinese,
from time immemorial.  From China the practice
spread to Corea and Japan, where it  has for ages
been very common.
  Ten Rhyne, (Dissert, de Arthritide, de Acu-
punctura,  &c,  London, 1693,) a medical officer
in the East India  Company's service  in 1679,
gave the first information to Europe  of a practice
unknown to the Greeks, Romans,  or Arabians;
and states that a guard of the  Emperor of Japan,
appointed to conduct  the English to the palace.
was seized with violent pain of the abdomen and
vomiting,  after drinking a quantity of iced water
when heated.   He took wine and ginger in vain;
and then, persuaded  that he had wind, had re-
course to acupuncture  in  the  presence of Ten
Rhyne.  It appears that the Japanese are liable
to a violent kind of colic called senki, which they
regard as too severe to arise from morbid matter
in the cavity of the intestines, and ascribe to some-
thing morbid in the parietes  of the  abdomen, the
omentum, mesentery, and substance of the intes-
tines, converted by its stay in these  parts into a
vapour, the escape of  which from its  narrow pri-
son, by means  of acupuncture, is  immediately
followed by a cessation of the pain and distension.
The guard laid himself upon his back, placed the 
ACUPUNCTURE.
55
point of a needle upon  his  abdomen, struck its
head with a hammer once or twice to make it pass
through the skin, rotated it between his  fore-fin-
ger and thumb till it entered to the depth of an
inch, and then after thirty respirations, as it would
appear, withdrew it,  and pressed the punctures
with his fingers to force out the imaginary vapour.
He made four such punctures and  was instantly
relieved and got well.
   The needles are always made of the purest gold
or  silver, preferably of gold, and well tempered.
Their manufacture is  a distinct occupation, under-
stood by few,  and those  few are licensed by the
emperor.   Some  are  fine, about four inches in
length, with a spiral  handle for the  purpose  of
more easily rotating them : and are kept, by means
of a ring or a  piece of silk thread, in grooves, each
capable of holding one, at either side of a ham-
mer, usually  made of the polished horn of the
wild ox, ivory, ebony or some other  hard wood,
rather longer than the needle, and having a round-
ish head covered, on the side  which strikes, with
a piece of leather and rendered heavier by a little
lead within.  Others are of silver only, still finer
at their point, but with a short thick bandle bent
down upon itself; and are kept, several  together,
in a varnished wooden box lined with cloth : these
 are not struck with a hammer ; but a fine copper
canula, about an inch shorter than the needle, is
 sometimes employed  to  steady it, and prevent it
 from entering too far.  The selection of  the part
 fit for the operation, or for the application of the
 moxa,—the other great remedy of the Japanese,
 is usually  confided  to  particular  persons called
 Tensasi,—touchers or searchers of the parts, while
 those who apply the  needles are styjed Farittate,
 — needle-prickers, though occasionally the  com-
 mon people trust to their own experience, taking
 care only to prick no nerve, tendon, nor  conside-
 rable blood-vessel. The seat  of the cause of the
 symptoms is the proper part, and delineations of
 the body are  sold conveying this information.
   If the patient  does not bear the  needle well, it
 is at  once withdrawn: but if he does,  and  the
 disease  proves   obstinate, it  is introduced two,
 three, four, five,  or six times.  The  more severe
 the affection, and the  stouter  the  patient,  the
 deeper must be the puncture.
    Kaempfer,* a  physician  who accompanied a
 Dutch embassy  to Japan, in 1691, and  again in
 1692, informs us that the Japanese make nine
 punctures,  three rows of three each, at about half
 an inch  from each other, over the liver, in cases
 of colic, and that he  himself frequently witnessed
 the instantaneous cessation  of the pain, as if by
 enchantment.
   The orientals  do  not, however,  employ this
 operation in affections of the abdomen only.  In
 tetanus, convulsions  of all  kinds, apoplexy, gout,
 rheumatism, swelled  testicle  and gonorrhoea, and
 in fevers both  intermittent and continued, it is
 also celebrated among them ; enjoying credit, like
 all remedies of undoubted efficacy in certain dis-
 ease*, for power which it does not  possess over
 otners.
   Between the  frightfulness of running needles
 into the flesh and the  high improbability of any
 benefit derived from such a  practice, a hundred

   * Enrrelbertus Kampfer,  M. D  History of Japan,
 b.mslafed from the High Dutch by Dr. Scheuchzer. Lon-
 Ion, 1/27..
and seventeen years elapsed before any European
practitioner  made  trial of  it.   Dujardin in his
Histoire de la Chirurgie, and Vicq-d Azyr in the
Encyclopedic Methodique, mentioned it above a
century after Ten Rhyne had published, but only
to congratulate the world  that the statements of
Ten Rhyne  and Kaempfer  had  not induced  any
one  to practise it, and the first European  trials
werejnade by Dr. Berliozf of Paris in 1810.  Its
power proved so extraordinary that he  employed
it very extensively, and numerous  French prac-
titioners  imitated  his  example with  the  same
results.   A  body of  similar English  testimony
followed,  and acupuncture  affords  a  striking in-
stance of a good remedy discovered from ground-
less hypothesis, and  condemned without a single
trial for above a century.
   The diseases in which the power of acupuncture
is well established are pain and spasm not de-
pendent upon inflammation  or organic disease. In
rheumatism of the nerves, rheumatic neuralgia,—
as distinguished from that chronic form which is
generally  limited to a small  extent  of nerve,  lasts
a great length of time, and is independent of cold,
— the  invariable  causes  of   rheumatism ;  in
rheumatism  of  the fleshy  parts ; in  simple  pain
of any spot  ; and in  spasmodic and  convulsive
pain of various parts, whether local or migratory,
its utility is  very great, provided inflammation be
not  the cause.  Of 129  rheumatic cases treated
by Dr. Jules Cloquet, about 85 yielded to  acu-
puncture.   Of 34 published by others, 28  were
cured.  The writer of this  article employed  it in
St. Thomas's Hospital, and  published his  results
in the 14th vol. of the Med. Chir. Trans.  Of 42
cases, taken in succession  as they stood  in the
hospital-books, 30 were found to have been cured :
and the remaining 12 had clearly not been adapted
for the remedy, as either heat of the affected  parts
had  existed  or heat  had  aggravated  the  pain.
Experience  has fully confirmed the  fact, that, if
rheumatism  be at  all inflammatory,— be accom-
 panied  by heat, or  aggravated  by  a  high  degree
of heat, even though a moderate  degree do not
 aggravate the pain, no relief is in general to be
expected from acupuncture.  The omission of this
 distinction  and of a  little trouble to make it with
 nicety, will  be the  chief cause of the  operation
 proving unsuccessful in rheumatism.
   In  some  cases  of inflammation and organic
 disease, however, when pain has been felt appa-
 rently disproportionate to  those affections,  acu-
 puncture is  said to have afforded relief.
   The pain both of rheumatism and  of some ner-
 vous affections has occasionally  shifted  its seat on
 the  application of the needles, and yielded to  their
 repetition in  its  new situation.  Sometimes  it
 required longer chasing from part to part before it
 vanished.
   The cures of ophthalmia, blindness,  asthma,
 diplopia, and hooping cough, by this remedy, must
 be regarded  as lucky occurrences.
   The needles employed  in Europe are of steel;
 long and fine; and  furnished with either a knob
 of sealing-wax at  their head,  or, what is more
 convenient,  a  little  handle of ivory  or wood,
 screwing into a sheath for the needle.  [They are
 usually from two to four  inches luiig, the  length
 being adapted to the  depth it may be  desired to
   t Berlioz, Mrmoires sur les Maladies Chroniqucs, les
 Evacuations sanguines, et 1'Acupuncture.  Paris,  1816. 
5G
A C U P U N C T U R E.
make them penetrate.  If steel needles be selected,
-hey should he heated to redness and allowed to cool
slowly, in order that they may  be less brittle.  At
the blunt extremity of the needle  a head of lead
or sealing-wax is attached to prevent it from being
forced entirely into the body. This is the simplest
method of acupuncture, and it is as effectual  as
any other.   If a  needle-holder, or porte-aiguille,
be used, that recommended by Professor F. Bache
is as good as any that has been invented.   The
needle with its porte-aiguille consists of a handle,
with  a steel  socket,  to receive the end of the
needle, which may be fixed securely after having
been  inserted by the pressure of  a small lateral
screw.  By this contrivance the operator can  at
pleasure fix  in the handle a needle of the length
he may desire, and, after inserting it, he is enabled
to detach the handle by releasing the screw.  After
all, however, needles prepared in the simple man-
ner mentioned above are adequate to every useful
purpose.]  They are  best introduced by a  slight
pressure, and a semi-rotatory motion, between the
thumb and  fore-finger;  and withdrawn with the
same motion.   The  pain is next to nothing, and
often absolutely nothing.
  The operation may be performed  in  muscular,
aponeurotic,  and  tendinous  regions  ;  and  the
needle introduced to the depth of from i of an
inch to 2 inches, according to the thickness of the
muscles.   We should not advise it  to be passed
into viscera, articulations,  or  blood-vessels.   In
general no  fluid  escapes  when  the  needle  is
removed ; but now and then a small  drop of blood
follows;  and  once when  the needle  had  been
introduced into the pectoral muscle, I knew blood
to spirt forth, but it was immediately restrained by
gentle pressure,— an occurrence in  every respect
similar to what once happened in  the  practice of
M.  Bretonneau.*
  The period during which the needle remains in
the part is a  matter  of great importance.   The
pain may indeed cease instantaneously : but more
frequently does not till the needle has remained
some time : and my own experience accords with
that of others,— that  one needle, remaining  an
  * M. Bretonneau says, that he had passed needles into
the cerebrum, cerebellum, heart, lungs, and stomach, of
sucking puppies, through and through, and in all direc-
tions, with no sign of pain nor particular ill effect; un-
less when too large a needle was thrust into the heart,
and in one instance of this, a  little extravasation took
place into the pericardium.  So far from  fearing to acu-
puncture the heart, Dr. Carraco would have us do so in
the worst cases of asphyxia.  He declares  that,  in the
presence of several persons, he kept, several kittens under
cold water till they were apparently dead,—stiff, motion-
less, frothing at the mouth, without pulsation  of the
heart,— and regularly sunk to the  bottom every time
they were thrown into the water again ; that he  passed
a needle into the heart; that soon the needle began to be
gently agitated, then rapidly so, and  one voluntary mo-
tion after another gradually recommenced, till life was
fully re-established;  and that the animals did as well
afterwards as if nothing had happened.
  Death, however, by acupuncture of the brain or spinal
marrow, as a secret mode of infanticide, is  notorious in
works on State-Medicine.   "Guy Patin relates  that a
midwife was executed at Paris who had murdered seve-
ral infants, at the moment their head presented  at the
os uteri, by passing a long and very fine  needle into the
brain through the temples, the fontanelle, or the nape of
the neck, or into the heart and its large vessels. Alberti
and Brendel  quote similar examples.   In the  Causes
Celebres we read the  horrible story of a woman who,
towards the middle of the last  century, made it her busi-
ness to murder all the new-born infants that fell into her
hands by acupuncture,  practised at the beginning  of the
vertebral column, or in the brain, with the sole intention
the told the jucmes, of peopling heaven more and more."_
 vo4eri, Traite de Medccine Legale, t. iv. p. 492. sq.
hour or more, is far more efficacious than several
speedily  withdrawn.  I  usually  allow them  to
remain one or two  hours; and have known them
remain twenty-four hours, without any ill ettect.
I have  usually  found  the  operation  requisite a
second time, and in one case, lumbago  did not
yield till the  ninth  repetition.
  The  modus operandi  of acupuncture is un-
known.  It is neither fear nor confidence ; since
those who care nothing about being acupunctured,
and those who laugh at  their medical attendant
for  proposing such a  remedy, derive  the  same
benefit, if their case is  suitable, as those who are
alarmed  and those who submit  to  it  with faith.
Neither  is it counter-irritation ; since  the  same
benefit is experienced when not  the  least pain  is
occasioned,  as when pain  is  felt.   Galvanism,
likewise, fails to explain it; because, although the
needle  frequently  becomes  oxidated  and affords
galvanic phenomena  while in  the  body,  these
phenomena bear no proportion  to  the  benefit,
equally take  place when  acupuncture is practised
upon a  healthy person,  and do  not  take  place
when needles of  gold or  silver are  employed,
which,  however,  are equally efficacious with a
needle of steel.
   [We can  scarcely conceive the  effects to be
anything more  than a new nervous  impression
produced by the   needle  in the parts which  it
penetrates.]
  Acupuncture  has been successfully employed
to remove the fluid  of oedema and anasarca.  In
these cases,  the needle does  not require to be
passed deeply; its point has merely to go through
the cutis.  As soon as  this is done and the needle
withdrawn, a small  bead  of water appears at the
puncture, which  augments  till  the  fluid runs
down ;  and  the oozing will continue  for a longe:
or  a shorter time,— generally for some  hours,
occasionally  for  a few days, and  even after death,
should  that  event  take place.   Any number of
punctures may be made.   Although the puncture
is so minute, it is, in such cases, not devoid of
danger, any  more  than scarification, if practised
below the knee.  The  writer has frequently had
recourse to it with  great  advantage in oedema of
the scrotum and penis, frequently along the trunk,
and the whole length of the superior extremity,
and on the posterior part of the  thigh, and never
saw or heard of the least  inconvenience.   But
several cases have been related to him, in which
sloughing, and in some of which fatal sloughing,
resulted  from its  performance below the knee,
even though the needle had been passed merely
through  the cutis.  Before these cases came to his
knowledge, he had  acupunctured the leg, and even
the foot, in dropsy,  and never but once saw any
inconvenience, and that was merely a  suppuration
at each puncture.   It should evidently, however,
never be performed below the knee  except when
absolutely necessary, a circumstance  that hardly
can  happen, except in  oedema not  extending
higher than the knee : and when we  reflect that
acupuncture removes an effect only, leaving the
cause of the effusion untouched,  and that  a lar^e
number of effusions are the result of an inflamma-
tory state, or of sanguineous congestion, and that
while  lessening or removing these by bleedin"
general or local, or purging,  we are  employing
means which have also  a direct tendency to ex-
cite  absorption; and when  we reflect  upon th« 
AG
powers  of diuretics when those measures have
previously been  properly employed, we shall per-
ceive that the cases of dropsical effusion in which
acupuncture is required, are comparatively few.
   [Dr. Dunglison has used acupuncture  with ad-
vantage to drain off the fluid from the cellular mem-
brane in anasarca.  In such  cases,  larger needles
are advisable.  Some prefer them to be of the size
of an ordinary glover's needle, and of a triangular
shape,—a puncture of this kind being less likely
to close.  It has likewise been advised  in ascites,
in hydrocele, and in  every form ol encysted dropsy.
By M. Velpeau it has been proposed  to treat aneu-
rism by acupuncture. In performing some experi-
ments on animals,  he found  that arteries, punc-
tured by the needle,  became the seat of a coagulum,
and were ultimately obliterated.  In 1830, he read
a paper before the Academie Royale des  Sciences
of Paris, proposing the operation in the cases in
question, (Lond. Med. Gaz., and Amer.  Journal
of the Medical Sciences, Aug. 1831, p. 510).  He
found,  in  his experiments,  that whenever  the
needle remained three days in the flesh, the trans-
fixed  artery was completely obliterated.
   M. Bonnet treated eleven cases of varicose veins
by introducing pins through their  cavities, and
allowing them to remain there some time.   Nine
of these cases were cured.  The same treatment
was applied to hernial sacs.  He passed three or
four pins through  the hernial envelopes close to
the inguinal  ring, and, in order that they might
exert a  certain degree of compression, as well as
irritation, on  the sac, he  twisted the points and
heads upwards, so as to give them a circular direc-
tion.  The inflammation  usually commenced on
the third or fourth day, and the pins were removed
a few days afterwards.  M. Bonnet treated four
cases of inguinal hernia in this manner.   In two,
the hernia was small, and three weeks  sufficed for
the cure : the third was more troublesome. (Bul-
let. Geniral de Th'erap., and Amer. Med. Intelli-
gencer,  Dec. 1,1837, p. 317 ; and Archiv. Gene-
ral, de Medecine, Mai, 1839.)
   Acupuncture  has likewise been  employed to
remove a  ganglion of considerable size on  the
extensor tendons of  the  foot.  After  the needle
was inserted, pressure was applied, and  within a
week the tumour had entirely disappeared.  (Mr.
Vowell, Lond. Lancet, Aug. 25, 1838,  p. 770.)
When  acupuncturation  is conjoined with galva-
nism  or electricity, it constitutes galuano-punc-
ture  and electro-puncture (q. v.).   See, on  the
whole subject of acupuncture, Dunglison's New
Remedies, 4th edit., p. 53.  Philad. 1843.]
                          John Elliotson.
   AFFUSION.    See articles  Bathing  and
Fever.
   AGE.  In nothing  are organized beings more
remarkable than in  that perpetual mutation which
seems to constitute  the fundamental law of their
condition.  The whole period of their existence is
characterised  by a series of actions  and reactions,
ever varying, and yet constantly tending to defi-
nite ends.  The parts of which they consist undergo
continued and progressive  changes  in  their  size,
form, arrangement,  and composition.  The mate-
rials which have been united together, and fashioned
into the several  organs, are themselves  severally
and successively removed  and replaced by others,
which are again  in  their turn discarded,  and new
ones substituted ; till, in process of time, scarcely
   Vol.  I__8
E.                                        57

any  portion of the  sub.itance  originally  consti-
tuting these organs, remains as a component part
of their structure.
   This  continued renovation of the materials of
which the body consists, takes place in the most
solid  as well as in the softest textures ;  and so
great is the total  amount  of these changes, that
doubts may very reasonably be entertained as to
the identity of any part  of the body at different
epochs of its  existence.   A period of seven or
eight years was  assigned by the ancients as  the
time required  for  this entire change of  all  the
materials  of the system ; but modern researches,
which show us  the  speedy reparation  of  injured
parts, and the rapid renewal of the substance of
bones that have been tinged by madder given to
animals with their food, render it  extremely pro-
bable that a complete renovation  may  actually
take place in a much shorter period.
   General as this law may appear, it is subordi-
nate to  another and more  universally controlling
principle,  to which all beings endowed with life
are  subjected, namely, the Law  of  Mortality.
Every living being has a  period assigned for its
existence.   With  the germs of life  are intermixed
the seeds of death ;  and,  however  vigorous the
growth of the fabric, however  energetic the  en-
dowments of its maturity, we  know that its days
are numbered ; and that even if it should escape
destruction  from causes  that are  accidental  and
extraneous, it is sooner or  later doomed to perish
by the  slow, but  unerring operation  of  natural
and  internal causes, inseparable from  its.nature,
and coeval with its birth.
   In tracing the gradual succession of phenomena
that mark these  eventful changes,  and  constitute
the numerous and almost insensible steps of tran-
sition which connect them, a  multitude of inter-
esting topics of inquiry present themselves.  Much
instruction is afforded with regard  to the physical
laws of the animal economy, by the study of that
condition  in particular of the system, in which it
has passed its meridian state of activity, and may-
be regarded as on the decline ; and in  which the
causes that ultimately conduce  to  its destruction
begin to prevail over the conservative powers that
had  hitherto  predominated.  Such is  the state
which is emphatically denominated Age.
   As youth is the state of transition from infancy
to maturity, so age is the state of transition from
maturity to  decay.  In the early periods  of  life,
all the powers of the system are directed to  the
building  up of the  frame,  and of the different
organs;  to their  extension, consolidation, and
perfection ;  and to their adaptation to the perfor
mance of  their several functions.   The exertionb
made for the attainment of these objects are great,
and  commensurate with the magnitude and  im-
portance of the design; and they  give rise to  a
rapid and varied succession  of  changes.  An
abundant  store of materials is  wanted for these
operations;  and although  the  consumption and
renovation of these materials be considerable, yet
the supply much exceeds the loss;  and the body,
accordingly, continues to augment in  bulk.   In
course of time, these opposite processes  of repaia-
tion  and  decay approach nearer to  an equality,
and, at length, are exactly  balanced.  The parts
then cease to grow;  the  system has reached its
state of maturity ;  and the object  of the vital
powers and functions is now to maintain it in a 
53
AGE.
uniform condition of health and vigour, qualified
for  the exercise of all its  physical  and mental
faculties.  It cannot but excite  our admiration to
contemplate the accuracy of the adjustments by
which these objects are so perfectly accomplished,
and that equilibrium  preserved, with  such  won-
derful constancy, for so long a period of years.
  But at length there comes a season when the
balance, hitherto so evenly kept,  begins to incline ;
the powers  of  the  system are  less equal  to the
demands  made  upon  them;   a  diminution of
energy becomes sensible; and  the  waste  of the
body exceeds the supply.  Yet  nature is far from
abandoning  her work :  new  arrangements are
made, and new provisions resorted to for accom-
modating the system to these changes.  In pro-
portion  as the  supply of materials for  repairing
the waste of the organs  becomes less  abundant,
a more strict economy is adopted ;  the  resources
of the system are husbanded with greater care;
and the functions thus appear to go on for a con-
siderable  period without  any  material or  very
manifest alteration.  Yet all this time the changes
which are going on, though insidious, are no less
real.  Old age steals upon us by slow and imper-
ceptible  degrees, which, even  when  obvious to
others, are often unknown to ourselves.   Nature,
when the system is entrusted wholly to her  laws,
thus kindly  smooths  the path  along which we
descend the vale of life, and conducts us by easy
stages to  our destined place of repose.   But the
number of those who thus gently glide  along the
stream of years is  small indeed, compared  with
those whose declining age is withered by infirmi-
ties or embittered by disease.  The "Age that
melts in unperceived decay" is rarely  met with
amidst the  numerous and diversified causes of
premature decrepitude,  to  which  man,  in his
civilized  condition, is  obnoxious.
   Various and complicated as are the changes
which the system undergoes in passing from the
state  of  maturity to that of old age,  and thence
to decrepitude  and dissolution  ; and, different as
are the objects which  nature appears  to have in
view in the  several periods of life, it is probable
that a minute inquiry into  all  the circumstances
that mark these epochs, will reveal to us the con-
tinued and  uniform operation  of the same prin-
ciples throughout the whole succession of these
changes.   The experience we possess of the
plans and operations of Nature in other instances
is altogether in favour of such a hypothesis.  But
in order to form a proper estimate of the degree
of confidence to which  it  is  entitled, we  must
examine  the exact nature of the  progressive
changes which have been observed  to  take  place
by age in the several classes of  textures  and func-
tions composing the animal economy.
   In this inquiry our first attention will naturally
be directed to the mechanical properties of the
several  textures.  The most superficial view of
the  subject  will suffice  to  impress us with the
great difference that exists in the relative propor-
tion of fluids and  solids in the earlier and in the
later periods of life.  The primitive condition of
 the embryo is, in all animals, that of a gelatinous
pulp.   In this pulp we trace, by degrees, the form-
ation of filaments  and membranes : these extend
 and are fashioned into  organs of various  kinds,
 which  long retain their original softness of con-
 nstence and imperfect cohesion.  The accretion
of new materials imparts to them, in process of
Le, greater density and firmness.   The propor-
tion of solid matter that enters  into  their com
position  thus  continually  augments; the  body
expands  in all directions, and soon requires some
mechanical  basis of support.  This  support  is
provided  in the osseous structures that are now
superadded ; at  first only  partially, and m de-
tached masses;  but these  are afterwards united
into a  connected framework of bone, which  con-
tinues  to receive developement during the whole
period  of the  growth  of the body.  The  softer
textures  are at  the same time gradually consoli-
dated,  and acquire  a higher degree of elasticity :
while they,  in the same proportion, become less
flexible and less extensile.   All the parts that are
principally formed out of the cellular tissue ex-
hibit these changes most remarkably.  They are
very perceptible in  the membranes, ligaments,
tendons, and cartilages ; and they  may be traced
even in the muscles themselves.   The condensa-
tion of all these parts proceeds as  age advances,
and is then attended with  a general contraction
of their dimensions.  All the parts composed of
fibres  acquire toughness by age.   This  is matter
of common observation  with regard  to  animals
that are  used as food ; the flesh of old animals is
less easily torn  asunder by the teeth, and is less
digestible by the stomach,  than that of the same
species when young.   In very old  animals, parts
that had originally been muscular, appear, by a
change of substance, to be converted into tendons;
a denser material being substituted for the proper
muscular fibre.
   The deposition of a  bony material in various
structures to the purposes of which it  is quite
foreign, and where, consequently, it appears to be
misplaced,  is  an extreme  instance of the  same
tendency to increased density of texture.  Ossi-
fication  takes place, in advanced  age, in various
membranes, in the coats of the  blood-vessels,  in
the  coverings of the viscera, and more especially
in  tendons and cartilages.  A similar change
affects even the bones themselves ;  for  they be-
come  harder and more  brittle in the progress of
age.   The  tendency to  ossification, arising  from
the redundance of osseous matter, is occasionally
so  great  as to  lead to the  formation of osseous
tumours  in various parts  of the body.   In this
respect,  therefore, the bones differ from almost all
the other parts  of the body ; for while  the latter
shrink and contract in  their dimensions by age,
the hones, on the contrary, have a tendency rather
to  augment in  size, or at least to  increase in the
quantity of solid materials which  compose them.
Those bones, which, in the  adult, are  detached,
are frequently united  in advanced life : such  as
those  of the sternum and of the skull, the sutures
of which are commonly obliterated, first on the
inner, and  lastly on the outer surface ; so that, at
length,  almost  the whole  cranium consists of a
single bone.
   But even when not  converted  into  bone, the
fibrous structures lose their flexibility by age, and
acquire  a degree of rigidity which often disquali-
fies them for the performance of  their jsual func-
tions.   The joints  of old  persons  become less
pliable from changes of this kind taking place in
the synovial membranes and the surrounding liga-
ments.   The intervertebral cartilages  undergo by
 age, a similar process, which impairs considerably 
AGE.
59
the flexibility of the spinal column,  and contri-
butes to the bending forwards of the body and to
its diminished stature.  It has been  observed of
the fibrous tissues of old persons, that they assume
a deep yellow colour, indicating the condensation
of their  substance, and  resembling  what  takes
place when  they are artificially dried.
   From  a consideration  of these and  other cir-
cumstances, the general  fact may be considered
as  established,  that  the  proportion of  fluids  in
each organ, and  also  in the  body  generally,
diminishes as we advance in  life.  This remark
applies more especially to the  general mass of the
blood ; but  it holds good also with regard to all
the other fluids : and we  can  scarcely doubt that
a considerable  proportion of those  peculiarities
that  characterise the  period  of  senility  may be
traced to the  long  continued operation of this
principle.
   Together with the  mechanical changes of tex-
ture we  have now described, we  find that there
also  take place  considerable alterations in  the
chemical condition of the fluids and solids of the
body.  In the foetus and  the infant there exists a
large  proportion of water and of gelatin : phos-
phate of lime is but little  abundant, and fibrine is
but scantily developed.  These two latter elements
increase  in quantity as the  growth  of the body
proceeds.   On the other  hand, as age advances,
the gelatin  gradually disappears, or at least bears
a much  smaller  proportion to the other animal
constituents, namely, the  albumen and the fibrin ;
the aqueous portion is much diminished in quan-
tity, and  the phosphate of lime, as before remark-
ed, often accumulates in an excessive degree.
Not  only is the  quantity of  gelatin diminished,
but it appears  to undergo  an  alteration in  its
quality by the effects of age.   Glue obtained from
young animals is found to differ essentially from
that  which can be  procured from old animals.
Calves'-feet jelly is  not  the same with the jelly
afforded  by the feet of the full-grown ox.   The
latter has a deeper colour, is less digestible, and
passes more slowly into  a state  of  putrefaction.
A  similar remark  applies also to the fibrous tex-
tures  themselves,  which  become yellow by age,
are less  easily resolved by maceration, and resist
putrefaction for a much longer time than the same
parts taken from young animals.
   If we  next examine the changes which the  se-
cretions  undergo, we shall find that  they partake
of the general diminution of fluidity incident to
old age.   Those that consist chiefly of the watery
exhalations of the blood  are more scanty than in
early life.  The perspiration, for instance, is  far
less abundant.   A deficiency of  lymph is percep-
tible in   the cellular  tissue; and the lymphatic
vessels,  having less  fluid to convey, shrink in
their diameter : and  a large  proportion of them,
becoming useless, are obliterated and lost.  The
same  takes place with regard  to the lymphatic
glands, which,  from  being  hrge  and  turgid in
infancy,   are smaller  and more compact in the
adult, and either become ossified or entirely dis-
appear in  old age.   The blood  itself  becomes
darker coloured in advanced life.   From the dimi-
nution of perspiration, less animal matter is ex-
creted by the skin, and more is carried off by the
discharges from the mucous  surfaces.   We may
probably  ascribe to this cause the foetor which  is
so often attendant on  the breath of old persons.
From the same cause the urine is generally higher
coloured, more odorous, and more prone to calcu-
lous deposition.  From  the mucous membranes
of the nose, fauctu,  trachea, and lungs, there is
frequently, indeed, a disposition to  more  copious
secretion than exists in a less advanced age ;  but
this ought rather to be regarded as a state of chro-
nic disease than as the natural condition  of the
parts.  When  it  prevails,  however, the  mucus
poured forth is opaque, viscid, and tenacious ;  and
its abundance proves a source  of continual  dis-
tress to the aged valetudinarian by the obstruction
it occasions to free respiration,  and  by the perpet-
ual efforts required for its expulsion.
   The integuments, being  the  parts  of the body
most exposed to observation, exhibit more distinct-
ly, perhaps, than any other, the changes induced
by age.  It is doubtful whether the cuticle, which
of all the textures  seems to partake the least of
vitality, and which  has even been  considered as
wholly inorganic, suffers any other alteration in
process of years, than that of becoming somewhat
thicker and more dry, and  more disposed to peel
oft' in  scales.   Compared,  indeed, with its  struc-
ture in infancy,  when it is  very  thin and delicate,
and allows of the  ready transmission of impres-
sions  to  the subjacent nerves,  the  cuticle of the
aged presents a striking contrast; but between the
aged  and the adult the differences, in these re-
spects, are  scarcely  perceptible.  The principal
changes  that take place during the transition be-
tween these latter  periods  are  observable  in  the
subjacent textures.  The corpus mucosum acquires
by age a darker colour, as well as greater conden-
sation.   The cutis vera, also, exhibits greater den-
sity and  toughness ; while it  loses  in  the same
proportion its extensibility, and power of accom-
modation to the size and figure of the parts it co-
vers.   The difference  in the texture of the skin
at different ages is very perceptible  to the dissect-
or ; and  both the scalpel which divides the skin,
and the needle employed to sew it together after
division, meet with considerably greater resistance
in old than in young subjects.   As it no longer
adapts itself to  the  alterations  of position  or of
bulk  which occur in  the  subjacent parts, it be-
comes flaccid  and wrinkled whenever these parts
diminish by age.  All this is very perceptible in
the face, neck, and hands.   Hence we  may trace
the gradual shrinking and  corrugation of the  fea-
tures, which  recularly follow the progress of years,
and  which  afford  unerring  indications  of  age.
Witness the dark coloured furrows of the cheeks
and lower part of  the face, the result of reiterated
impressions from  various  passions,  of which the
predominating effect is to draw  down the  corners
of the mouth, and compress the nostrils : witness
the lesser lines on the temples, radiating from the
eyes, and denoting the increased efforts which ac-
company the  employment of those organs :  wit-
ness, also, the  deeper wrinkles in  the  brow  and
forehead, bearing the impress of intense and anx
ious thought.
   Grey  hairs, the proverbial attendant upon  age,
exemplify the operation  of the  same principle of
defective nourishment and suppressed secretion
Early and vigorous  in their growth, the hairs of
the head are generally the first to show symptoms
of decay.  Great differences  may,  however, be
observed in different individuals, as  to the period
when the hair exhibits a change of colour, or  falls 
GO
AGE.
off. In some, it grows grey at thirty years of age,
or even earlier;  with others,  this change does not
take place till other and less equivocal  indications
of age are manifested.  Many causes which affect
but little the general constitution, accelerate  the
death of the hair; and more especially the  de-
pressing passions, intense thought, and corroding
anxieties.   Fevers are  often destructive of  the
vitality of the hair, when they do not permanently
affect any other part of the body.  There is, how-
ever, an essential difference in the effects of dis-
ease and of old age  upon hair, inasmuch  as  the
former seldom destroy the bulbous capsule from
which the  hair  is formed;  and, accordingly,  a
new crop of hair is often found to spring up, after
a certain time, when the system recovers its vigour.
But the death of hair from  age  is hopeless and
irretrievable, for it implies the destruction of every
part of the root, as well  as  the  shaft; and  the
consequent separation of the  hair is attended with
the obliteration of the  canal  which it occupied,
and which penetrated the true skin.
   The loss of colour in hair  begins in the  shaft,
which first becomes grey, then white, and  lastly
transparent, giving to it  that silvery  appearance
which is esteemed so venerable  a mark of age.
Baldness  generally  commences  over  the   upper
parts of the temporal and occipital bones, particu-
larly in the male  sex;  and  thence spreads over
the whole upper  surface of the head.   The hair
on other parts of the body suffers corresponding
changes with those of the head, and also falls off
partially by age.
   The alterations which take place in the eyes
by the progress of age afford   another instance of
the tendency to a diminution in the aqueous con-
stituents of the body.  As the  quantity of the aque-
ous humour in the  anterior  chamber  of the  eye
diminishes,  the  cornea  necessarily becomes  less
prominent, and its curvature  being thus diminish-
ed, it ceases to have the same refractive  power.
The  vision of near  objects  becomes  indistinct;
because the rays proceeding  from  them, and arriv-
ing at the cornea with a sensible degree  of  diver-
gence, are not sufficiently refracted to enable them
to meet in a focus upon the  retina : and the  im-
ages  there  formed  are,  consequently, confused.
Such is the condition of the presbyopic eye, re-
quiring the assistance of a convex lens in order
to supply  this deficient  power of convergen e.
   There is, however, great reason to believe that
the mere change of convexity of the cornea is not
the sole, nor even the principal cause of the inca-
pacity of the presbyopic eye  to see near  objects
distinctly : for this defect is more connected with
the diminution in the powers of adjustment in the
eye, owing to impaired muscular power.
   Changes also take place  in the more internal
parts of the eye by old age ; the crystalline lens
generally acquires a yellow or amber colour ;  and
its transparency diminishes.  The sensibility of
the iris is  impaired; and the pupil is habitually
more  dilated than  formerly.  The  pigmentum
nigrum  has been known to lose its colouring
material, and to become almost transparent.  This,
 as well as the larger aperture of the  pupil, have
 been considered as  special  provisions of  nature
 for admitting more light to the retina, in compen-
sation for the diminished sensibility of the nerves
 of vision.
   It  is probable that the various parts of the in-
ternal  ear  arc  affected by  the progress of ago
The fluid which occupies the  internal cavities is
said to be gradually absorbed, so that at length .t
is  found to have  entirely disappeared.  When-
ever this happens, it  must of course be produc
live of irremediable deafness.   But  many other
causes, which relate to other branches of our sub-
ject, may contribute to the tendency to deafness
incident to advanced life.
   Among  the  causes  of the changes that take
place in  the internal organs, the most important
is  the  alteration  in the condition of the blood-
vessels.  Not only does the proportion which the
blood-vessels, taken altogether, bear to the whole
bulk of the body, undergo a gradual and progres-
sive diminution from infancy to youth, from youth
to manhood, and from  manhood to old  age ;  but
a material alteration takes place, during these suc-
cessive periods, in  the  relative disposition of the
several  classes of vessels  among  themselves.
While the  body is extending in growth, the arte-
ries are exceedingly numerous, and pervade every
part; but in proportion  as that  extension  ap-
proaches to its limit, they contract in  their dia-
meter, being less  capable of dilatation in  conse-
quence of the  increased  density  and rigidity of
their coats.  This  contraction  is chiefly percepti-
ble in the smaller  arteries; a number of the minu-
ter vessels become  impervious, and gradually dis-
appear, or  assume the form of ligamentous fila-
ments.   The  sanguineous  appearance  which is
common to  so  many parts in youth is  altogether
lost.  Few  red points  are seen on separating the
periosteum  from  the   bones, or the dura  mater
from the cranium, in old subjects ; and scarcely
any blood  issues  on making  a  section of these
bones.  In making anatomical injections, we al-
ways succeed  best with young subjects;  in  the
old, we can often do no more than fill the arterial
trunks, from the resistance  that is opposed to the
passage of the  injection into the lesser  branches.
The coats of the arteries themselves appear desti-
tute of the vessels which are proper to them, and
which are so conspicuous at a  less advanced age.
   But this obliteration of so large a proportion
of  minute arteries  and capillary vessels,  gener-
ally, is accompanied with a greater  comparative
dilatation of the veins.  The  coats  of the veins
are  originally thinner  than  those of the arteries;
and as they do not partake  of  the changes which
we have described  as taking place in the arteries,
they come to differ more and more from the latter
in  their  texture,  as age advances.   Instead of
thickening and contracting, it would  appear, in-
deed, that they became rather  thinner and more
dilatable than before.   This perhaps arises from
the coats of the veins having a smaller proportion
of  cellular  substance  interposed between  them
than the  coats of the arteries ; they,  therefore,
scarcely participate in  the increasing condensation
of  that substance, but are  more under the influ-
ence of the action of the absorbents.   Certain it
is that in extreme old  age the  veins are very full
and prominent, and their course  more  tortuous:
their total  capacity must therefore be increased.
Hence, while   the  total quantity of blood in the
body is diminished by age, a  greater  proportion
of the whole mass is contained in the venous than
in the arterial  system.  In youth this proportion
was nearly equal; in  age the  veins contain, DeT-
haps, two-thirds of the mass of blood. 
AGE.
61
  Much light has been thrown on the changes
that take place  in  the texture of the different
classes of blood-vessels by the researches of Sir
Clifton  Wintringham,  whose  experiments have
clearly proved the greater proportional density of
the coats of the arteries to that of the veins in old
than in young animals.   Hence  it follows, as  a
necessary consequence, that they  must yield more
easily to the distending forces of  the circulation ;
and hence, whenever a plethoric  state of the sys-
tem occurs, that fulness will, in youth, affect more
the arteries, and, in age, the veins.  It is on these
principles that Cullen founded  his celebrated and
beautiful theory of hemorrhagy,  which gives so
natural  and  satisfactory  an explanation of  the
prevalence of arterial hemorrhagies in the earlier
periods of life, and of venous hemorrhagies in  the
later periods.   Hence, also, the greater frequency
of hemorrhoids, and of sanguineous apoplexy in
the old.
   The veins of the  inferior  extremities  are very
liable to varices  in  advanced life ; and  they are
generally more dilated than those of the arms or
other parts ;  for  the pressure  of the column of
blood they have to support is a force which con-
stantly operates to distend them, and which, when
their  strength is diminished by age, they are un-
able to  withstand.  This proneness  to varix  is
particularly  observable  in  elderly women who
have borne many children, from the frequent dila-
tation the veins have experienced in consequence
of the pressure uf the gravid uterus.  It is re-
marked by Bichat, that, while young subjects are
preferable for  tracing the course of the arteries,
anatomists should choose old bodies for studying
that of the veins.
  It appears, also, that the growth  of the heart
does not keep pace with that of the  sanguiferous
system;  and  we  may presume, therefore, that its
force  does not increase in the  same  proportion
with the increasing density and resistance of the
solids.  This gradual alteration in the balance of
the forces of propulsion  and of extension, that
takes place during the growth of the body, is con-
tinued in  after  life, and is one of the primary
causes of the observed phenomena of  age.   The
diminished energy  of the heart, in these later
periods, is manifested  by the languor and  slow-
ness of the pulse, which becomes,  at the same
time, apparently more full ; occasionally we find
it intermittent, indicating the diminished irrita-
bility which pervades the system,  and in which
the heart at  length participates.   In old persons
the number of pulsations in  the  minute often
does not exceed fifty, and is sometimes even less
than this.
  The consequences resulting from the diminish-
ed energy of the circulation, and the deficiency
in the circulating  fluids, are sufficiently obvious,
and may be traced  in all the functions.  Not only
will less  blood be  sent to  the  several organs,  but
the blood that is sent, is, perhaps, less  completely
acted  upon by the air in  respiration, on account
of the diminished proportion  which is transmitted
through  the pulmonary system of vessels.   The
diminution of secretion, and the  deterioration of
the fluids prepared  by  the  secretory organs,  are
direct consequences of these changes.  The func-
tion of digestion  itself, the source of those ma-
terials from which the blood is prepared and its
losses replenished, and  from which all the parts
derive their nutriment, is less effective than for-
merly.   On the whole, however, the changes that
take place in the secretions, and in the powers of
digestion, are  less considerable  than those that
occur in other functions.  The liver and kidneys,
for example, are nearly as  active, and perform
their respective offices as completely in age as in
maturity, and  while  the  muscular  and nervous
powers have  sensibly  declined.   An exception
occurs, indeed, with regard to the secretions sub-
servient  to generation, which,  together with  the
generative  powers, entirely cease  after a certain
period of life,  which varies considerably in differ-
ent individuals.   In the male sex, after the func-
tions of the testes have ceased, an absorption fre-
quently commences in these glands, which shrink,
become soft  and pulpy, and sometimes  almost
wholly disappear.   The prostate gland, and espe-
cially the posterior lobe, is exceedingly liable to.a
morbid enlargement.   In the female, the  ovaria
shrink in size, and lose their vesicular structure.
The mammae, when not affected  by scirrhous in-
durations, are  also softer, less elastic, and fre-
quently pendulous ; but in advanced age they are
often   totally absorbed,  and  even  the nipple is
scarcely apparent.  The areola generally assumes
a darker colour, even prior  to the  period  when
menstruation ceases.
   This increased activity of the absorbent system
may, on the other hand, be considered as a com
pensation to the diminished power of the sangui-
ferous system.  The absorbents  seem to  retain
their powers for a longer time than the heart and
arteries ; and  their disproportionate action is the
occasion of  many changes, that take place in  the
form  and bulk of various parts.  It is one prin-
cipal cause of the general  consolidation  and  in-
duration of the organs.  It  is productive of a
state of comparative emaciation, from the removal
of the fat, which, in the  adult, is interspersed very
largely in the  subcutaneous cellular  texture, as
well as in many other more  internal parts.  The
effects of the  loss of adipose substance  are very
visible in the countenance ;  the eyes retreat into
the sockets, the cheeks  become hollow, the teeth
decay, loosen,  and drop out, the gums  and  the
alveoli themselves are reduced by absorption ; all
combine to  alter the features, and transform then
expression  to that which characterizes age.  The
lower jaw,  deprived of its teeth, advances, so that
the chin projects, and comes nearer to the  nose;
and the cavity of the  mouth being thus diminish-
ed  in  its capacity, the  tongue often appears too
large  to be contained  in it.   Amidst this general
change in  the configuration of the bones  of  the
face,  the nasal  cavities remain undiminished in
their size.
   At a  still more advanced  period, however, we
frequently have occasion  to  observe a failure of
action in the  absorbents, and a consequent ten
dency to dropsical accumulations.
   So intimately are all the functions of  the ani
mal economy linked  together in  one harmonious
system, that a change made  in any one of them
must  necessarily affect all the others,  by disturb-
ing the nice balance which is established by  nature
between them.   Hence  the  difficulty that must
always be felt in tracing to their  origin the long
and complicated series of changes that constitute
any considerable alteration  in the state of  the
system : and when, as in the  present case, the in 
G2
AGE.
quiry relates  to  alterations  that  are extremely
gradual, and extend over considerable  periods of
time, we are still less likely to arrive  at any cer-
tain  conclusion.  Thus, after prosecuting our in-
duction of  facts to the length of establishing cer-
tain  leading  principles, according  to which  the
slow progress of years affects the different organs
and functions of the body, we find great difficulty
in proceeding  farther in their  generalisation, and
in reducing them to a single principle.  We have
seen, for example, that a great number of changes
occurring in the body by the lapse of years imply
the  operation  of a general consolidating  cause,
affecting both  the solids and fluids, and exerted
especially on the cellular and  membranous  tex-
tures, which  appear to be primarily acted upon,
and  through which all the  parts into which  the
cellular texture enters  as  a principal  component
part, become also  more and more  condensed as
age  advances.  The  gradual diminution  of the
energy of circulation, and the obliteration of the
minuter vessels, constitute together another  gen-
eral fact, which includes a large proportion of the
phenomena characterizing the transitions from the
earlier to the later stages of life.  Now it may be
proposed as a  question whether these two causes,
while they  act conjointly, act  also  independently
of one another ; or  whether the  one is not  an
intimate and necessary consequence of the other.
Is the closing  of the capillary arteries, it  may be
asked, the effect of the tendency which  the  ani-
mal  fibre has to progressive condensation ; or is
not this condensation the effect, rather  than the
cause,  of the diminished impetus of the circulat-
ing fluids  incident to age ?  Again, if we admit
this  last hypothesis to be  the  true one, then we
have still farther to seek for the cause of this dimi-
nution of force in the circulating fluids : and this
brings us  to another step in  the  investigation,
namely, the inquiry into the changes which  take
place, in the progress of life, in the muscular and
nervous powers.
   The muscles are found to undergo, in the course
of years, changes as considerable, though perhaps
not so obvious, as the other textures.  They  par-
ticipate in the  condensation incident to the cellular
texture that enters  so  largely into  their composi-
tion, and which, as has already been pointed  out,
frequently  acquire, by the deposition of fibrous or
even osseous  matter, the density of tendon or of
bone.   This excess of density in the cellular mem-
brane, that invests the muscular fibres, is itself an
impediment to the free contraction  of those fibres,
which are, therefore, from this cause, performed
more slowly.   But independently of this, a change
also takes place in the muscular fibres themselves :
they become more rigid, and the total size of the
muscle is diminished.   Its contractility is also im-
paired ;  so that it is  less readily as well  as less
powerfully influenced by stimuli.   The muscles
of voluntary motion are less under the control of
the  will;  and the  involuntary  muscles execute
their functions with diminished energy.
   Not only is the  irritability of the  muscle im-
 p'uired, but also  that  property  which  has  been
 .lenominated its tone is diminished.  The texture
 of the muscles of elderly persons is loose, flabby,
 •md  relaxed : this  flaccidity is perceived  more
 especially  in  the  thick muscles of the lower ex-
 tremities, as the glutaei, the solaei, the gastrociiemii,
 an. biceps muscles ; while, at the same time, the
individual  fibres of those muscles are,  in^thern-
.elves, tough  and dense.   A  greater  degree of
vacillation Characterizes the act ions *  themuj.
cles of the limbs in  advanced age.  Hence the
tottering and uncertain gait of  the infirm old^man.
Bichat observes that this  irregular action of the
muscles is  generally accompanied by a  deter.ora-
tion of their substance, indicated by greater pale-
ness and the assumption of a light yellow colour,
as if an  approach was made  to their conversion
into  sebaceous  matter.  He  remarks  that  this
change is more commonly observed to take place
in the deep-seated muscles of the back,  which
occupy the longitudinal spaces between the pro-
cesses of the vertebra ; and that it does not affect
the muscular  system  generally, but only a small
number of isolated muscles.   (Bichat.  Anatomie
Generale, torn. iii. p.  336.)   The same  phenome-
non  has been noticed in  muscles that had long
been affected with paralysis.
   The prevailing diminution of muscular strength
is manifested, very unequivocally, in the affection
of the voice, which, in old age, becomes  shrill and
tremulous  ; and the
              " Big manly voire,
      Turnin? again towards childish treble, pipes
      And whistles in his sound."
   A diminution of tone is also exhibited  in the
muscular  coats  of  the  alimentary  canal;  the
stomach and intestines are habitually more di-
lated  ; that is,  they  do  not  so  readily contract
upon their contents, when  but little is  contained
in them.   The same is the case with  the bladder,
which remains large, even when  void of urine.
The diminution of power in  the muscular fibres
of the bladder is productive of a double evil; as
it is rendered less capable  of  retaining  the urine
when distended,  and  also less capable of com-
pletely   emptying  itself.   Together  with  this
want of power, the  bladder  often gets irritable
in advanced  life :  and to this increased irrita-
bility the enlargement of the  prostate  often con-
tributes, by impeding the action of the sphincter,
and lessening the diameter  of the canal of the
urethra.
   But  muscular  contractility is  itself  intimately
connected with the condition of the nervous sys-
tem ; and before we  can form a proper estimate
of the  causes that occasion  the  decline of the
muscular powers, we must  take into consideration
those that affect,  in corresponding periods, the
nervous powers.
   The  structure and  composition of the brain
undergo, by the progress  of age, changes no less
great and important than  those that affect other
parts.  The  substance of  this organ, at the time
of birth, is almost fluid ; so that, when taken out
of the cranium, it has hardly sufficient consistence
to retain its figure.   As the body grows,  it acquires
greater consistence and firmness ; in the same pro-
portion, we  may observe  that a  smaller quantity
of blood circulates in its vessels.   In  the progress
of life  this condensation  still proceeds,  and  the
subdivisions  of that  organ  are  more distinctly
marked ;  hence, in advanced age, the brain  be-
comes better  adapted for the anatomical study of
 its minuter  parts.  The distinction of colour be-
 tween its  medullary and cortical portions is more
 strongly marked,  and is particularly visible in the
 optic thalami, the corpora  striata, the cornua anv
 monis,  and  in that  portion  of the lower part of 
AGE.
65
 the  third  ventricle which  gives  origin  to the
 peduncle of the pituitary gland.
   An alteration also takes place in the chemical
 properties of the substance of the brain ;  Bichat
 remarks that chemical  re-agents act more slowly
 upon the brain of the adult than upon that of an
 infant.  This is more particularly the case with
 the dissolving power of alkalis, which is much less
 in the former than in the latter.  The  blood-vessels
 and membranes of the brain become more tough
 and rigid,  and  are  often incrusted with osseous
 deposits.   The dura mater is easily detached from
 the inner surface of the skull, in consequence of
 the obliteration of most of the vessels  that estab-
 lished a connexion between them.  It is only at
 the  sutures that it  remains attached : and even
 there the connexion becomes less firm as the su-
 tures become themselves obliterated by the progress
 of ossification.   The pia mater and tunica  arach-
 noides acquire greater thickness -,  and the former
 presents a  redder appearance  than formerly ; a
 circumstance which offers a marked contrast with
 the diminished quantity of blood in the sinuses and
 neighbouring parts.  In general  the whole mass
 of brain is diminished in size in advanced age, so
 that  it does not completely fill the  cavity  of the
 cranium.  Sometimes,  indeed, a contrary change
 to that above  described  is observed to take place,
 the  brain  of very aged persons being found in a
 softer and more  flaccid state than in the adult; but
 this should be considered rather as a diseased state
 than the natural effect of age.
   The nerves undergo changes from age very
 analogous  to those of the brain ; though, perhaps,
 less distinguishable, in  consequence of the  mem-
 branous covering  with  which  each of their  fila-
 ments is invested.  The  proportion of  nervous
 matter appears to  be diminished ;  as is certainly
 the case with the  number and size of their  blood-
 vessels.  The ganglions connected with the nerves
 become harder, and of a deeper grey colour, and
 shrink considerably in their size.
   The functions of the several parts of the nervous
 system are, doubtless, dependent on their organi-
 zation ;  but no  knowledge we have been  able to
 obtain of the nature of that organization from ana-
 tomical inquiry, or from any other mode of inves-
 tigation, has thrown any  light whatever on the
 mode  in which  these  functions  are conducted.
 We cannot, therefore, predict, except in the most
 general way, what modifications of function will
 result from  any  observed alteration of structure in
 this  system.  All  the knowledge we can attain on
 this  subject must be that derived from direct  obser-
 vation, and from induction of the facts so obtained.
 Now,  the whole series of phenomena that charac-
 terize the decline of life, indicate the gradual dimi-
 nution of  the energy of the nervous  system in
 general, and of the brain more especially.  All the
 sensitive functions  are  performed less perfectly.
 The organs of  the external senses  become  less
 capable of receiving impressions from  their respec-
 tive objects ; the nerves transmit more tardily and
 more feebly these impressions to the brain; and
 the perceptions  to which the transmitted  impres-
 sions give rise are  less vivid  and more transitory
 than formerly.
  The sensibility  of the system generally  is di-
 minished by age.   Bodily  sufferings, from  the
same  causes, are  less  acute ; and equal injuries
excite less  constitutional disturbance  ; inflamma-
 tion is more languid.  Painful affections, such as
 cancer, are felt less acutely in  age than in the
 meridian  of life, and  these, as well as all other
 diseases,,  have a disposition to  assume  a more
 chronic character.   The system is less susceptible
 of the action of contagions of all  kinds; and if, by
 a certain  age, it has not gone  through the usual
 course of exanthemata, and other diseases which
 affect the body only once in the course of life, it
 generally escapes tbem altogether.
   The temperature of the body is probably lower
 in  age than  in youth.   An explanation  of this
 fact has been  sought for in  the diminution of the
 quantity of fat, which, by its non-conducting pro-
 perties, prevents the escape of heat from the body:
 but it seems more reasonable to  account for it by
 the decline  of the powers  both of the circulation
 and of the nervous energy in general.   Whatever
 be  the cause, chilliness is a very common  attend-
 ant on old age.  It might, perhaps, be concluded,
 from reasoning a priori on the facts already stated,
 that the  more  easy exhaustion of the sensitive
 powers would call for a greater proportion of sleep,
 in order to restore and maintain  them. Yet we find,
 in reality, that old  persons sleep less than those
 that are young, and that their sleep  is much  less
 profound, and oftener  disturbed by dreams.  Pro-
 bably, the explanation may be  found in that law
 of  the economy which appears to regulate the
 quantity of sleep by the necessity that exists for
 nutrition.   Thus, when the body is growing, as in
 young children, sixteen hours out of the four-and-
 twenty are passed in sleep.  Adults sleep, on  an
 average, seven or eight hours ; but  for the aged,
 five or six hours are generally sufficient.  Many
 exceptions,  indeed,  occur  to  this,  as well as to
 every  other rule in which  the operations of the
 nervous system are  concerned  ; and especially in
 those  depending so much  upon habit, which is
 justly esteemed a second nature.  Persons of great
 age sometimes experience very distressing wake-
 fulness ; this is often the effect of cold feet, indi-
 gestion, or other internal sources  of irritation.
   The mind, as  well  as  the body,  is wasted by
 time.  The first indication of diminished vicour in
 the intellectual faculties is usually the decay of the
 memory.   The power of recollection, which is
 immediately dependent upon that of association,
 appears to have  a  closer relation to the physical
 condition  of the stnsorium, than any other of the
 mental faculties : for we often observe a failure of
 memory,  while the judgment  continues  unim
 paired. This loss  of  power is chiefly felt in  the
 case of new associations.  Thus  recent  events are
 recalled with much greater difficulty than old oi.es;
 and new  habits  can  hardly ever be contracted.
 The earliest notice that is given of this  partial
 decline of the faculties is generally in the  forget-
 fulness of the names of persons.  When  carried
 somewhat farther, the  names of things are with
 difficulty recollected.   The  mind loses that com-
 mand  of  language  which it formerly possessed ;
 hence  the tardiness of speech, and  heaviness of
 expression which characterize the conversation of
 so many persons of advanced age.  The garrulity
 of old persons is also frequently a consequence of
 the deficiency of memory, which effaces  the recol-
 lection of  what has just been  said,  and leads  to
continual reiteration of the same ideas.
  Not only are the bodily feelings impaired by
age; the mental sensibility  is also blunted, in ?»i 
64
AGE.
[east an equal degree, in all that relates to present
or recent  impressions.  Yet  it has often been
remarked that old persons feel acutely the loss of
former friends and companions.  How  often do
we not witness  the survivor of an aged couple
soon follow his partner to  the tomb !   The failure
of the sight, of the hearing, the senses which con-
nect us most largely with  the external world, con-
tribute much  to the  diminished exercise of  the
intellect, by abstracting the occasions for exertion ;
and we well know that, without exercise, the  intel-
lectual as well as the bodily powers  stagnate  and
become torpid.  To  this cause  are often added
impediments to bodily exertion arising from rigidity
of the membranes, stiffness  of the joints, debility
of muscles, and impaired nervous energy.   The
tottering steps and tardy movements of the infirm
old man can be accompanied with none of the
enjoyment which  attends the  exertions  of  limbs
animated by the  elastic spring of youth.   If, under
these circumstances,  he should  unfortunately be
deprived of the resources of mental cultivation, can
we wonder that he  is drivt n  for refuge to  the
enjoyment of those senses of  taste and smell that
yet remain ;  and that he  devotes himself to  the
cultivation of the  pleasures of the table, and  the
artificial excitation of spirituous liquors ?    Yet
even here  nature  imposes certain limits, beyond
which the votaries  of luxury are forbidden to pass.
   " Time hovers o'er, impatient to destroy,
    And closes all  the avenues of joy.
    In vain  their gifts the bounteous seasons pour,
    The fruit autumnal, and the vernal shower;
    With listless eyes the dotard views the store,
    He views, and wonders that they please no more.
    Now pall the tasteless meats and joyless wines,
    And luxury with sighs her slave resigns."
   Need we pursue this " strange eventful history"
to the last  melancholy chapter of man's existence,
and contemplate the wreck of those exalted facul-
ties which  ennoble his nature, and  of which the
deprivation lowers his condition far beneath that
of the beasts of  the field ?  Need we dwell upon
the sickening spectacle of  " second childishness
and  mere oblivion ;"  and disclose those mournful
contrarieties  of  our nature,  that drew forth  the
exclamation from the poet —
•  In life's last scene what prodigies surprise ?
  Tears of the brave and follies of the wise.
  From Marlborough's eyes the streams of dotage flow,
  And Swift expires a driveller and a show."
   Let us  rather draw  a  veil on this humiliating
picture of the frailties incident to humanity,  and
which forcibly remind us  of what
                       " We shun to  know,
       That life protracted, is protracted woe."
   To  revert, then, to the philosophical question
which has already occupied our attention,  let us
inquire whether  it  is possible, throughout the mul-
tifarious changes we have described  as character-
izing the  several  stages of  the transition from
infancy to  decrepitude, to discover the uniform and
progressive  operation of any  single  principle.
Admitting that the increasing density of the  cel-
lular substance is  the natural consequenee  of the
diminished force of circulation, aided, perhaps, by
the increased, or, at least, undiminished  power of
absorption, may we  not  advance a step farther,
and ascribe the diminution of the force of circula-
tion to the gradual loss of muscular  power arising
from a decline in the energies of the nervous sys-
tem >   If this be a legitimate inference,  then  this
declension of nervous power, which takes  place
with more or  less rapidity as we advance in life,
appears to be  the  general  principle  we were  in
quest of;  that is, the  ultimate  fact to which all
others are subordinate.  Appearances, then, war-
rant the hypothesis  that a  certain stock  of vital
force is imparted to  the embryo at its first forma-
tion, as a provision for  carrying  it  through its
destined career  of existence.  In every action of
the system a portion of this power is expended ;
and  the greater the  expenditure, the less must
there be remaining, till, at length, the  whole being
consumed, all movements  cease, like those of a
watch which  has run down, and of which the
main spring has ceased to act.
   That considerable differences exist in the  stock
of vitality originally  imparted  to  the frame in
different individuals,  cannot be doubted ;  some
being destined to a shorter, and others to a longer,
term of existence, independently of all  adventitious
causes that may occur  to disturb the regular course
of nature  in the demolition  of the fabric, and the
termination of life ;  while others, born with more
feeble stamina, yet highly excitable, anticipate the
natural epochs and stages of life, and, precocious
in their youth, are doomed  to premature  senility
and  decay.   Such  is  usually  the condition  of
dwarfs, who  generally die  at an  early  period,
bearing all the ordinary marks of extreme old age.
   From all  that has been said we  may draw the
conclusion,  that the  spontaneous  decay  of the
body, and decline of its powers invariably attend-
ing the lapse of years, arise altogether from causes
that are internal, and interwoven with  the very
conditions and laws of its existence, and  are but
little influenced by  external circumstances.   With
inorganic bodies precisely the reverse takes place ;
they owe  to external  causes their decomposition
and  destruction.  But living bodies  perish from
within, being  consumed by  the  very fire which  is
itself the  source of  their animation.
   If health be viewed as consisting in the proper
balance and harmony  of all  the  functions of life,
it is evident that this  condition may exist  in all
ages, and that it is  compatible  with  different de-
grees of energy in the exercise  of those functions.
Though  the powers  of the constitution  may be
enfeebled  by age, and  though the actions  may be
less vigorously performed, yet if they be duly pro-
portioned to one another, the system must be con-
sidered as in a healthy condition, and as fulfilling
the designs  of nature in the latter  stages  of its
existence.   In one  respect, however, there is a
material  difference between the health of  youth
and  the health of age  ; inasmuch as the former is
more secure and stable than the  latter.  In the
period of  youth, it is true, the greater activity of
the functions  often endangers the  equilibrium of
the system ; but then  the power of restoration is
at the same  time proportionality  more  efficient.
Rich in  its resources, the  constitution of  youth
rebounds  with  surprising  elasticity from  the de-
pression of a severe  illness, and even seems  to
gather fresh vigour from the shock.  In advanced
life,  on the contrary, this resilient  power  is defi-
cient : the fibres that  have been stretched beyond
the proper limits no longer return to their  former
state ; the spring no  longer re-acts with a force
equal  to that by which it is extended  ; and  a dis-
placement of  its particles is productive of  a per-
manent alteration in structure, and of augmented
incapacity to perform  the same  extent of action. 
AGE.
65
  The slighter deviations from the perfectly heal-
thy structure of the organs, which  are the con-
comitants of age, are of various kinds, and their
effects may be for a long time insensible.  Gradu-
ally, however, they increase in extent, until they
manifest themselves by some outward indications
of disordered  health ; obscure, perhaps, at first,
and apparently evanescent; yet, recurring at un-
certain  intervals,  and acquiring,  by  degrees, a
more decided  and  permanent character,  they at
length attract attention ;  and proper means being
resorted to for the correction of the  derangement
in the functions, the health  appears to be again
restored.
   Still, however, there is left a greater proneness
to disorder than before.   Various excitements and
exertions which formerly were harmless  are  not
so well borne.  Slighter causes of disturbance are
followed by some  particular symptom or sets  of
symptoms to which there may exist a predisposi-
tion in  the system ; such as  head-ach, lassitude,
dyspepsia, depression of spirits, palpitation, watch-
fulness, &c.   It seems as if something were  go-
ing  wrong,  and preparing  more serious illness.
Such is  generally  the progress of structural dis-
eases, which steal on by slow and insidious grada-
tions, producing for a certain  interval that unde-
finable state of impending disorder,  which only a
very  attentive  and scrutinizing observation  can
detect, but which exists long before  that eventful
period commonly characterized as  the  breaking
up of the constitution, or that in  which  positive
disease  has commenced its  hostile incursions.
Then, indeed, all that our most skilfully-directed
efforts can accomplish is to repulse the immediate
aggression, and obtain a  truce from that enemy
which is sure to renew the  attack, and  to whose
power the citadel we defend must  at last be un-
conditionally surrendered.
   It has been  observed that, independently of any
positive alteration in the structure of a particular
organ, there occasionally occurs, at a certain period
of life, a sudden and general alteration  of health,
which is of  uncertain duration, though generally
of no long  continuance, and  to which the term
climacteric disease has been applied.  This pecu-
liar condition has been well described by Sir Hen-
ry Halford in  an  essay  published in the  Medical
Transactions of the College of Physicians, (Vol.
iv. p. 316.)   This  disease, he observes, is better
characterized in men  than in women ; but even
in the former the period  of its invasion is by no
means constant, for it may occur at  any time  be-
tween the ages of  fifty and seventy-five. Its com-
mencement is often apparently determined by some
occasion  of feverish excitement, such  as an  act
of intemperance, a fall which seemed at the mo-
ment to be of no consequence, or even a common
cold.   Sometimes  it follows upon a marriage con-
tracted late in  life.  But the most  frequent pre-
disposing cause is mental anxiety and  suffering,
the corroding influence  of which will eventually
sap the foundations of the  most  robust constitu-
tion.
   The climacteric disease is  described, by Sir Hen-
ry Halford, as being marked by an  extraordinary
alteration in the  expression of the  countenance,
by an accelerated pulse, and by a wasting of the
flesh, without  any obvious source of exhaustion.
Wandciing  pains are felt in the head and chest;
tho trngue is white, the  bowels are  sluggish, the
  Vol. I. — 9                         r *
nights passed either without sleep, or without the
refreshment which sleep should bring with it, and
there is a general feeling of lassitude and of fever.
There is no deficiency of urine ; yet the legs offer'
swell.   These symptoms may be of some dura-
tion ; and may, indeed, proceed so far as to under-
mine the health to such a degree, that the patient
sinks under a disease which  seems to  have no
other characteristic than that of  a general failure
of the functions.  But when, as is most frequently
the case, the powers of the system are  adequate
to recovery, the symptoms are gradually mitigated
and disappear.  Then is there a return of com-
parative health  and strength, which may last for
many years.  But we may yet always remark that
the energies of the frame have been permanently
impaired ;  and  the  impression  made   upon the
countenance remains fixed  and indelible.
  Such is  the  climacteric disease in  its simple
form, as it  occurs in individuals who have enjoy-
ed previous health.  But when it supervenes upon
a frame  already  deranged . by habitual  illness, it
often assumes the feature and partakes of the cha-
racter of the predominant complaint. When thus
associated with the  effects  of structural  disorder,
it is  always difficult to assign the share that be-
longs to each specific source  of disease ; but the
existence of the  climacteric affection may some-
times be inferred  from the peculiar  expression of
the countenance already mentioned, from the unu-
sual  exasperation of the symptoms appertaining
to the organic  disease, and from  its proceeding
with greater rapidity to a fatal termination.  It is
owing to this frequent complication of previous
local  and constitutional  ailments with the evils
which are  the natural consequences of old  age,
that  the picture above drawn is not often realized
in actual observation.
  We shall now  proceed to  point  out  the  more
specific  diseases to which old age is most obnox-
ious, and by which life,  at that period, is  most
frequently terminated.
  Among the numerous indications of a wavering
in the equilibrium of the functions incident to the
decline of life, perhaps the  most important are the
symptoms of disorder  in the digestive  processes.
Dyspepsia, in all  its varieties, is  among  the  earli-
est as well  as most  common of the diseases of
advanced life ;  and its prevalence  at this period
may be traced to  many causes, of which the ope-
ration is sufficiently obvious.   The principal of
these is,  undoubtedly, the gradual decline of irri-
tability  and of muscular power  which  pervades
the whole system, and in which  the fibres of the
stomach and intestines must of course participate.
It often happens, that while the  powers of assimi-
lation have diminished, the appetite still continues
good ; and, consequently, more food is taken than
can  be  converted into healthy nutriment.   That
portion which is imperfectly digested being retain-
ed, tends, by its presence and accumulation, still
further  to  impede the due performance  of this
function.   The  distension  of the  stomach  and
bowels from flatus, and their continued  irritant
from  containing  acid or acrid materials, lay the
foundation of a vitiated habit, and  of permanent
injury to the tone of the organs.  Another cause
of imperfect digestion may be pointed out in the
loss  of  the  teeth, and the  consequent  defective
mastication of the food.   The mischief is  often
aggravated by the sudden  discontinuance of th« 
60
AGE.
salutary exercise which was formerly taken ; and
by an indulgence in  the  repose which,  after  a
life of exertion, is almost claimed as the privilege
of age.
   Increasing sluggishness takes place in the peri-
staltic action  of the bowels, more  especially if
exercise be neglected.   Hence arises a habit of
costiveness, and hence are  formed accumulations
in the large  intestines, and  more particularly in
the cells and flexures of the colon, which acquire
a preternatural size from habitual and  inordinate
distension.  In this  way the  foundation is often
laid for structural diseases,  which affect the coats,
and lead to fatal strictures of the great intestine.
   Another and more frequent attendant upon ha-
bitual constipation are hemorrhoidal tumours, often
productive of much  suffering, or profuse and dan-
gerous  losses  of blood ; and  leading, not unfre-
quently, to fistulous abscesses, which terminate in
a lingering and fatal hectic.
   Protracted dyspepsia may give rise  to hepatic
disease in all its various forms.  The cause  by
which these affections  are  most commonly deter-
mined, is  the abuse of spirituous liquors.  If the
habit of indulgence in this  Promethean  poison has
been  already  contracted, it is almost  certain to
increase during age, when the  cravings  of this
artificial appetite never fail to become more inex-
orable, and when the  power of self-control, toge-
ther  with the other energies of the mind, is gene-
rally  diminished.  Yet, provided a foundation has
not been laid  for diseases  of the liver at former
periods of life, either  from the  cause  just men-
tioned, or from the influence  of a hot  climate, it
does not appear  that  there exists  any particular
proneness to  this class of diseases in  advanced
life.
   The structural diseases  of  the liver, like those
of other organs,' are  mostly of a chronic character,
stealing on by slow  degrees ;  advancing to a cer-
tain point with comparative rapidity ;  then  appear-
ing  for a long  interval to  be stationary :  after
which they proceed another step, and again  stop.
As a considerable  portion  of life may be spent
while they are thus  passing through their  succes-
sive  steps  of aggravation, it is  natural to expect
that their last and more fatal stage  should occur
during the later periods of life, and thus appear
as the  natural  attendants  upon old  age.  One
cause, however,  may  be  assigned  for  the  more
aggravated symptoms, and more rapid  course of
structural diseases in advanced  life ; and  that is,
the greater proneness  to chronic inflammation  at
that period, which may itself be traced to a defi-
ciency  of that conservative power  which main-
tains the  healthy balance of the circulation.  This
more diffused and insidious kind of inflammatory
action is particularly apt to affect the serous mem-
branes.   Hence the aged are particularly liable to
those dropsical affections  which are the  natural
consequences of their inflammatory states.   The
same general principle will account for the ravages
of cancer being more  observable in the aged than
 in others.  We find accordingly that a large pro-
 portion of elderly females  are destroyed by cancer
 of the uterus or mamma ; while, in the male sex,
 the  structural disease  which more especially mani-
 fests itself in advanced life is the enlargement and
 scirrno-is  induration  of  the prostate  gland, and
 especially of its posterior lobe.  This latter dis-
 ease, besides  being productive of various local
inconveniences, such as  irritation of the bladder,
and painful obstructions of urine, frequently preys
upon  the general health, and tends to exhaust the
constitution.
  The  failure  of the urinary  functions  is also
amon"- the more frequent causes of distress in old
persons of the  male sex.   The  first indication of
a tendency to gravel is the deposition of uric acid
in the form of  crystals, like red sand, in the urine.
By degrees concretions are formed  in the pelvis
of the kidney,  giving rise to acute pain, and other
nephritic symptoms arising from inflammation and
abscesses  in the kidneys.  When these  concre-
tions  descend  into  the  bladder, the well-known
symptoms of vesical calculus  are excited, which
need  not be enumerated in this  place.   But inde-
pendently of calculus, the muscular power of the
bladder is liable to be much impaired in advanced
life, in a greater proportion  than other muscular
parts.  Two evils, apparently of an opposite kind,
yet both referable to impaired  action  of some of
the fibres  of the bladder, occur  as sources of great
inconvenience  and distress.  The one is retention
of urine,  from  debility  of those muscular  fibres
by  which it is expelled ; and the other is  the  in-
continence  of the  bladder, arising  from paralysis
of its sphincter.
   The first indication of a failure in  the muscular
powers of the bladder is  the  inability to  empty
itself wholly ;  some urine  always remaining  be-
hind, after  every attempt at expulsion.   If from
some accidental circumstance the urine has been
suffered to accumulate in too great a quantity, its
expulsion  becomes still  more  difficult, and may
even  be found  to be impossible, without the intro-
duction of  the  catheter.   After the bladder  has
thus been stretched to an excessive degree, its tone
is much impaired, and is with difficulty recovered;
and even  if the power  of retention,  to a certain
extent, is obtained, this power  may be accompa-
nied  by incontinence when that quantity is  ex-
ceeded, the urine continuing to come away invol-
untarily, while there is still a considerable quantity
retained in  the bladder.
   Gout, though it be not exclusively a disease of
age, should be ranked among those to which there
is a greater predisposition in the decline of  life.
Chronic rheumatism, and especially that form of
it which has been termed nodosity of the joints,
is more prevalent in aged persons than in others.
   The  organ which participates most largely in
the changes induced by age, and which also sym-
pathizes most extensively with  the stomach, is the
brain ; and  the diseases of this organ probably con-
stitute, on the whole, the principal source of fatality
at the advanced period of which we are treating.
The  failure of energy in  its functions frequently
shows itself in the alteration which takes  place in
the state  of mind;  in the predominance of more
gloomy views  of things, in habitual  despondency,
in  increasing listlessness  and  lethargy, in confu-
sion  of thought or loss of memory, in heaviness
and somnolency.  Old persons arc subject to noises
in  the ears, to occasional head-ach, and giddiness.
 Partial debility is manifest in some particular or-
 gan of sense or motion ;  the sight or hearing fails;
 a feeling  of numbness, or tingling, is perceived in
 the extremities ; wandering pains  are complained
 of in different parts of the trunk or limbs, which
 are ascribed to rheumatism, but which are found
 to follow more the course of the nerves  than of 
AIR, (CHANGE  OF)
67
the muscles, and  are  sometimes  referred to the
centre  of the  bones.   Sudden and  unexpected
relief is often experienced from these symptoms
by the  discharge of flatus from the  stomach  or
intestines.
   All these are but preludes to an  attack  of a
more serious character.   Palsy or  apoplexy sud-
denly supervenes, and  either at once  carries off
the patient, or, if for a time recovered from, leaves
him but the wreck of his former self.  It has been
computed that about one-fourth of all those per-
sons who attain the age  of seventy are destined
to perish by this disease.   It would appear,  from
a  computation  made by Dr. Heberden, that apo-
plexy and palsy have prevailed to a greater extent
in modern times than  formerly ;  for  the number
of fatal cases from these diseases, recorded in the
Bills of Mortality, is now double  of what it was
at the beginning  of the last century.
   This is not the place to enlarge upon the causes,
both remote  and proximate, of that class  of dis-
eases ;  it will be sufficient to  observe that  they
appear connected with a  local  plethoric state  of
the vessels  of the  head,  and more especially of
those belonging to the  venous system, in conjunc-
tion with the declension  of the  nervous  power.
In a large proportion of cases  they are  accompa-
nied with perceptible structural changes  either in
the cerebral substance, or in the vessels that sup-
ply  it.   Ossific depositions  in the coats of the
arteries of the brain are among the most frequent
of these changes.
   Various lesser  degrees  of impaired sensibility
and muscular energy, occasionally perceptible in
different organs, and constituting  what  is called
partial paralysis, are referable to the same causes.
Instances occur, in  the  relaxation of the upper
eye-lid, which, in  consequence,  hangs  over the
globe of the eye ; in the  dropping of the. under-
lip, which becomes  pendulous, and is no longer
able to retain the saliva;  in  the  faltering speech
and tremulous voice, and  in the relaxation of the
sphincter, already noticed.
   Cutaneous disorders frequently  make  their ap-
pearance during the decline of life.   They would
seem in  general to be more closely connected with
the  condition of the brain and nervous  system,
than with the state of the digestive organs.  Of
these the most distressing and intractable is the
prurigo  senilis, which, though unattended  with
any visible  eruption, is often  remarkably invete-
rate, and is the source of incessant and indescri-
bable torment to the individual whom it affects.
   The heart is frequently found to be diseased in
elderly persons ;  hence arises another train of dis-
eases, which will be described in their proper place.
It will be sufficient here to indicate ossification of
the coronary vessels, or of the valves of the heart;
increased size  of its  ventricles or auricles, and
dilatation of their cavities; aneurisms or ossifica-
tion of the  coats  of the  large vessels  connected
with the heart.   Collections of water in the peri-
cardium, the - frequent effect  of  these  organic
changes, contribute still further to  complicate the
symptoms and augment the danger  to  life.  All
these occasion more or less  impediment to the
action of the heart; and  the consequent  disturb-
ance of the circulation  shows itself in  various
v, ays.
   Inflammation  in the skin,  particularly in the
extremities,  is exceedingly apt  to terminate in
mortification during  old  age.   The  toes are fre-
quently the seat of this affection.  Carbuncle may
also be enumerated among the  diseases to which
there is a more particular disposition in the ad-
vanced than in early or middle  periods of life.
  The last class of diseases affecting aged  per-
sons, which we shall notice in  this  brief review,
are those of the respiratory organs.  The relaxed
condition of the mucous  membrane  of the bron-
chi, and the predisposition to a chronic  form of
inflammation, lay the foundation for  those  pro-
tracted forms of catarrh, of asthma, and of peri-
pneumony, which prevail so extensively in persons
of advanced  age.  In catarrhus  senilis, as  it  is
emphatically  called,  the  great  abundance  of the
secretion from the membrane  both  of the lungs
and nasal cavities, and its peculiar viscidity, which
demands great efforts for its removal, is the source
not only of great distress, but also  of gieat ex-
haustion of strength ; the constitution is frequent-
ly unable to withstand the repeated aggravations
of this complaint, which take place  in successive
winters.   Under these  circumstances, especially
the supervention  of peripneumonia notha is ra-
pidly destructive of life.   The  occurrence of that
species  of  epidemic  catarrh, at times so  widely
prevalent, and which is  known by  the name of
influenza, is always extensively fatal to very elder-
ly persons : indeed,  all inflammatory  complaints
affecting the  chest are incomparably  more danger-
ous at this period of life.  Asthma, which must
certainly be enumerated amongst the diseases of
age, is not, at first, or in  itself,  attended with the
same risk ; though, in its consequences, it eventu-
ally contributes to the abridgement of those years
during which the life of a person of  healthy lungs
would  otherwise have been prolonged.
                              P.  M.  Roget.

   AIR,  (CHANGE OF.)  Change  of air is  a
popular, and when  well directed, very powerful
remedy, in a numerous class of chronic ailments ;
in some acute diseases ;  and in a state of conva-
lescence from  disease  generally.   Its influence
also is, perhaps, still more remarkable in removing
that condition of the system which may be termed
rather a deterioration of  health than a formal dis-
ease, and which is occasioned by confinement and
sedentary habits,  or residence  in impure  air;  a
complaint which has been termed Cachexia Lon-
dinensis, although by no  means  peculiar to the
metropolis.
   The  striking  improvement produced  in the
health by a removal, or  a few weeks only,  from
the tainted atmosphere of a city to the pure and
invigorating  air of the country, is the subject of
daily observation.  Even a change from one part
of the country to another is often attended  with
remarkable benefit, and that when  there is  little
or no apparent difference between the two situa-
tions.
   We use the term pure and impure in this place,
because unquestionably the atmosphere in various
situations differs materially in  its purity, accord-
ing to the ordinary meaning of the term.   It may
be true that the air collected in the most confined
alleys of London, when  subjected to analysis by
the chemist, shall afford  the same proportion of
oxygen and azote as that to be  found on the sum-
mits of our highest mountains; but we have no
reason to believe that oxygen and a^ote constitute 
68
AIR,  (CHANGI. OF)
the whole  ingredients of the atmosphere.  The
present state of our chemical knowledge may not,
indeed, enable us to determine what  is the pre-
cise nature of the other  ingredients,  but  we are
not the less sure of their  existence, and  that they
often exert a pernicious influence on health.  The
attempts of chemical philosophers to ascertain the
nature of the agents now referred to,  which con-:
taminate the air in different situations, and speed-
ily produce specific diseases, or  more slowly un-
dermine  the  health,  have hitherto proved  most
unsuccessful.  Even  our means  of measuring
some of  the obvious physical qualities of the  at-
mosphere are still very imperfect; so that in treat-
ing of them we are often obliged to  employ the
terms in  common use, instead of the  more accu-
rate and  definite language of science.
   [Even the change from a better to. a worse  air
has been found serviceable.   In Edinburgh, the
inhabitants of the most airy parts of the New Town
have frequently sent their children,  when  labour-
ing under  hooping cough,  to the  Cowgate — a
filthy  street, which runs at right angles under one
of the  largest thoroughfares  in  the  Old Town,
and in which, at a certain hour in  the night, the
inhabitants eject all the  offensive accumulations
from their houses, to be washed away by the water
of the reservoirs let on for the purpose.]
  Although change of air implies  some  change
of climate, in the  extended  acceptation  of  this
term, yet by the former expression  is commonly
meant a removal from one place  to another in the
same country or climate.   And it is in this  more
limited sense that we  use the expression  change
of air on the  present  occasion.  In another arti-
cle, the  medical effects of different climates, and
of change of climate, will be fully discussed.  (See
Cltmate.)  In the present article we shall con-
fine ourselves  to  a  few practical  remarks on the
principal circumstances which should guide the
practitioner in prescribing change of air, in  order
that the  patient may derive  all  the benefit from
that remedy which his case admits of.  It is upon
the just adaptation  of the remedy to the individ-
ual case  that all the  advantages to be expected
from change of air depend.
  In designating the predominating qualities of
the air in different places, which give to them sev-
erally a peculiar character, in reference to  their
effect on the human body, we shall employ terms
in common use, as their import is well understood,
and they are sufficiently explicit for  our  present
purpose.  The epithets soft and  mild, as opposed
to sharp  and  harsh ;  moist or damp, as opposed
to dry ;  heavy or oppressive, as distinguished from
light and elastic, are expressions in general use ;
and the  effects  of  the conditions  of the atmo-
sphere which they indicate, in soothing or excit-
ing, in depressing and relaxing, or in exhilarating
and bracing, are well known by experience.  The
different states  of the atmosphere just noticed,
exert  a more powerful influence  in  proportion as
the constitution  is delicate, and, accordingly,
change  of air becomes a much  more  important
remedy in  the diseases  of  such persons.   It is,
indeed,   chiefly  from  observing  the manner in
which invalids  and delicate  persons are affected
by the atmosphere of different situations,  that we
are enabled to estimate its less powerful influence
on the more robust constitution.
   Habit, and the conservative powers inherent in
the human system, enable man to resist, to a cer-
tain extent, the action of the deleterious qualUies
of the atmosphere ; yet no person, however strong
may be his constitution, will  long remain allege-
ther uninfluenced by them.   Their effects are, in
general,  observable on  the  organization of  the
inhabitants of such places,  and in the manner in
which  the  various functions of life are performed
in a state  of health ; and  they are, perhaps, still
more remarkable in the nature and character of
the diseases to which such persons are most  ob-
noxious.   Although these circumstances are more
strikingly observed  in the  natives of different cli-
mates, they are sufficiently evident  in the inhabit-
ants of different districts in our island.   In proof
of this, we need only compare, in the state of
health,  the firmly-knit  frame,  the  florid counte-
nance, and the elastic motions of the mountaineer,
with the  sallow complexion  and languid gait of
the inhabitant of the humid  plain, or confined.
valley.  The contrast  is  equally strong when these
individuals are suffering  from  disease.  In  the
former, we have acute, febrile,  and inflammatory
affections ; in the latter, diseases of slower progress,
with comparatively little excitement of  the vascu-
lar system, but with great sensibility of the nervous
system.  Were any proof necessary that this  dif-
ference depended on the locality, we find it in the
fact that persons, in removing from one district to
another, gradually assume the characteristics, both
of health and disease, of the inhabitants of the new
locality.   For example, the character of the same
disease attacking the  Welsh  mountaineer on  his
own hills, will be very different from that which he
would  be subject to after a  residence of some time
on the southern shores  of Devonshire  or Corn-
wall.   The physician in the metropolis, who  has
constant opportunities of seeing patients from all
parts  of the country, cannot fail to remark how
much the character of their constitutions and the
nature of  their diseases vary according to their
place of residence.  It is unnecessary to point out
the important practical bearing of this observation,
which so  happily illustrates the well-known re-
mark of Baglivi, " differre pro  natura locorum
genera medicinas."   But  our  attention, for  the
present, must  be limited to the consideration of the
effects of change of air  in remedying disease  and
improving the general health.
   The leading circumstances which require con-
sideration  in  prescribing change of air, are  the
nature  of the disease,  the  constitution of  our
patient, and the quality of air best suited to these.
Before noticing these, however, it may be well to
make  a  few remarks on the  periods of disease a;
which change of air can  be employed with  any
prospect of benefit, or even without disadvantage.
   In acute, febrile,  or inflammatory diseases, it is,
of course,  during the stage of convalescence only
that change of air is proper :  but  when the con-
valescence is  sufficiently advanced  to admit of a
removal, and the season  of the  year is favourable
for such passive exercise in the open air as a con-
valescent  can bear, a  case  will rarely occur in
which the return of perfect health may not be
materially  promoted by such a measure.  When
the patient resides in  a crowded  city, or other
confined situation,  the  change is  more urgently
called  for; and, indeed, we  feel convinced  that
under  such circumstances, many cases  of severe
disease occur, after which complete restoration of 
AIR, (CHANGE  OF)
69
health is never  effected without  a change of air.
The person deprived of the benefit of such a mea-
sure attains only to a  degree of health inferior to
that which he enjoyed before the occurrence of his
disease ;  and  the  remainder of  his life  is often
little better than a state of improved convalescence.
  In those acute diseases which are accompanied
with little fever, change of air need not be delayed
till  the patient is convalescent.   When the more
active  period of the disease  has passed over,  and
the danger of creating inflammation  is greatly
diminished, and more especially when the disease
threatens to pass into the chronic form, a judicious
change of air will often assist powerfully in putting
an  end to  it.  As examples of such diseases, we
may mention the  subacute forms of bronchitis,
catarrhal affections generally, and hooping-cough
in particular.   But even in these cases the change
requires  to be  well-timed : if too  early, it  will
scarcely fail to aggravate  the disease ; if  deferred
too long, the  disease  may have  fixed itself in  a
chronic  form, and the  measure, consequently,
prove  much less  beneficial than if it had  been
adopted  at an  earlier period.   It is impossible,
however, to do more at present than to call atten-
tion to the circumstance ; the medical attendant
can alone decide upon the proper period of remcrVal
in  each individual case.
   In no class of diseases is change of air so ob-
viously and imperatively called for as those which
originate in the pernicious qualities of the  air of
certain localities, commonly, of late years, desig-
nated by the general  term  malaria.   The  most
conspicuous of  this class is  the  numerous family
of  aguish  disorders.   In these cases the  single
measure of change of air is often sufficient of itself
to remove  the disease ; and the more promptly the
change is  made, the more effectual it  is  likely to
prove.  This measure, however, should  never be
trusted to  exclusively in intermittent fever.   The
disease has been produced by a specific cause, and
generally requires a specific remedy for  its com-
plete cure.  If this be neglected, we shall frequently
find that the disease has only been suspended, not
cured.  The period when the paroxysms are sus-
pended by the removal of  the  patient from the
source of  his disease, is  the most favourable for
employing the  proper remedies for securing  him
against a relapse.   Even when the removal  does
not suspend the disease, it renders it more amen-
able to the action  of medicine ;  and, were it only
with this view, change of air should be adopted in
such cases whenever it is practicable.  The  per-
fect re-establishment of  health  is scarcely  ever
effected in the severer forms of those diseases, as
far as our observation goes, without  a complete
change of residence for a considerable time.
   The indiscriminate manner in which change of
air is recommended, with little regard to the  con-
stitution of the patient, the  nature of his disease,
or  of the place whither he is sent, are the  principal
reasons why this measure so often disappoints the
hopes of the  invalid  and  his friends.  It is quite
essential to success that the air of the place selected
should be  suited to the patient.   The  feeble and
irritable invalid will not bear a keen exciting air,
whatever may be his disease ; whereas the invalid
possessing a constitution of an opposite character
will feel increased vigour while breathing such an
atmosphere.  As an example of this difference of
result in the same disease, we may refer lo bron
chial  irritation.  In  sensitive irritable subjects
labouring under  bronchial disease, we generally
find a corresponding state of the pulmonary organs;
we have little expectoration, with a disproportion
ate degree of irritation and cough from  the slight
est exciting causes.  A dry and sharp atmosphere
in such cases cannot  be borne, while  a mild and
even humid air often gives  relief.  In persons of
a  more languid  habit, suffering  under the same
disease, we find  less  sensibility of the  mucous
membrane, and a much more copious expectora-
tion.   The  same dry and keen air which proves
so irritating in the former case is beneficial in this.
Were we to prescribe for the name without giving
due consideration to the nature of the disease and
the constitution of the patient, both these invalids
might be sent to the same place, the one to be
injured as much  as the other would be benefited.
What has just been said of bronchial affections is
equally applicable to dyspepsia, rheumatism, con-
sumption, and several other  diseases.  It would
be wasting the  reader's  time to  point  out  the
important  practical  inference to be drawn from
these observations.
   In recommending change of air, the next  cir-
cumstance which presents itself  for. our conside-
ration is, the relative preference to  be accorded to
a  situation in the interior of our inland, or on the
sea-coast.  The  season of the year will assist us
in deciding this  point.  Generally speaking, the
more sheltered parts of the interior form the most
eligible residences, to all classes of invalids, during
the spring and early part of summer :  after  mid-
summer, in the   autumn, and during the  winter,
the  sea-side affords  the best situations.  This,
however, is only to  be considered as a  general
rule,  to which there are many exceptions.  Whe-
ther  the situation  selected  be inland, or  on the
coast, the particular characters of its air must be
such as are suited to the patient, as very consider-
able differences exist in places situated  at no great
distance from each other, both in the interior and
on the  sea-shore.   There are also peculiarities of
constitution, which we can only learn from inform-
ation communicated  by the patient.   Some per-
sons, for example, never feel  well by the  sea-side
in any  situation, or at any season,  although to all
appearance their  ailments are such  as we know to
be generally benefited by a  marine atmosphere ;
while others improve during a  residence  on  the
coast under the  most unfavourable circumstances
of situation and  season.
   But  there are.few persons who require  change
of air, either with the view of preventing disease,
or of removing  its effects,  that will not derive
greater benefit from repeated  changes, than from
a  long  continued residence  in any one situation,
however judiciously selected.  The more sheltered
and  drier parts of  the  interior during the spring,
the more elevated and even  mountainous districts
in the  summer,  and  the south  and  south-west
coasts of our island during the autumn and winter,
afford a succession of changes capable of effecting
much benefit in numerous  cases in  which the
other measures of medicine are of little avail.  It
is to be regretted, however,  that  but a  small pro
portion of invalids, or of the more  delicate of oui
youth,  can  avail themselves  of  a change of  air
upon so extensive a scale as we have just been 
76
contemplating ; the rather because it affords one
of the most  powerful means of improving  the
general  health, and obviating the disposition to
tuberculous disease, which we possess.
   But here it is proper  to observe that the best
directed change, or succession of changes, of  air,
will produce little permanent benefit unless strict
attention be paid to regimen, more especially as
regards  diet.   Too  much is generally  expected
from the simple change  of air, while little atten-
tion is paid to the various circumstances compre-
hended  under the  term regimen, although these
are equally essential to the restoration to health as
the measure from which  so  much  is anticipated.
It should be strongly impressed  on the  minds  of
such persons as seek benefit  from change of  air,
and  more  especially  upon  dyspeptics, the most
numerous class of all, that,  without  adhering to
the regimen laid down for them, they will derive
but little advantage  from   the most favourable
change  of air.  Many  may, indeed,  find their
limbs stronger and their general health improved,
and even the more urgent symptoms  of their dis-
ease may cease to prove troublesome ; y£t all these
improvements will too often prove but fleeting, and
their return  to their usual avocations will soon be
followed by a return of their  old complaints.
   The  restricted limits  of  this article will  not
allow us to particularize all the diseases in which
change of air proves useful;  there are few, indeed,
to which it  is  not applicable at some period  of
their course.  The good effects of this  remedy,
when well directed, in the  morbid states of  the
mucous membrane of the respiratory organs, are
well known ; and  they are  scarcely less  remark-
able  in  disorders of the  digestive organs, and of
the uterine  system.   In  the functional derange-
ments of the nervous  system, also, whether origi-
nating in the diseases just alluded to, or the conse-
quence of sedentary and  confined life, change of
air will  be found a powerful means  of restoring
the tone of the  system.  In all these cases, indeed,
it is  a remedy for which we have no  adequate
substitute.
   [In all diseases in which  the affection appears
to be kept  up by habit, in other words, by accus-
tomed  associated actions, and especially  in those
that implicate  the nervous system, the beneficial
effects  of change of air  are  proverbial, and  are
acquiesced in by all observers.
   It is probable, that a great portion of the salu-
tary effects ascribed to  the waters of fashionable
summer retreats is dependent upon change of air,
and other extraneous circumstances.  Long before
the citizen of one of the Atlantic towns  reaches
the Alleghany springs  of Virginia, he  has  an
earnest  of the  advantages he is about  to derive
from change of air;  and many a valetudinarian
finds himself almost restored  during the journey,
fatiguing as it  is, through the mountain  regions
which bave to be crossed before he reaches  the
White  Sulphur, in  Greenbrier  county.  Many
persons, too, cannot drink the water with impu-
nity, and  are consequently indebted for their im-
piovement chiefly to change of air, but somewhat,
also, to  varied scenery and society, absence from
cares of business, and to greater regularity of living,
j-erhaps, than they have been accustomed  to.   In
making these observations,  it is not designed to
aflirm  that  mineral waters,  as in the ease of the
AIR, (CHANGE  OF)

               valuable spring in question, may not occasionally
               be important agents in the cure of disease ;  but,
               taking  invalids  in general, we are satisfied  that
               more is dependent upon change of air  than upon
               the administration of the waters.  The inhabitant
               of one of the Atlantic  cities,  and of most  of the
               districts to  the  cast  of the Blue Ridge, removes
               from a hot atmosphere to  one which is compara-
               tively cool,  and  where all the diseases that are
               common to hot  and malarious climates are ex-
               tremely unfrequent, and many of them unknown.
               The  advantage  is obvious.  He escapes the  dis-
               eases which  might  have attacked him had he
               remained through the summer in  his  accustomed
               locality ; and  hence the wealthy families of Lower
               Virginia are in the habit of spending those months
               in the mountain regions in which  they are espe-
               cially liable to disease in their own malarious  dis-
               tricts.  We can  thus  understand the reputation
               acquired by the inert Bath and Matlock waters of
               England, the  latter  of which has scarcely  any
               solid ingredient ; and  yet what crowds flock to
               these agreeable  watering-places; to the former, for
               the  perpetual  amusements, that  keep the  mind
               engaged, and cause it to react beneficially on the
               corporeal or mental malady ;  to the latter, for the
               erfjoyment  of the beauties of nature, for  which
               Derbyshire is  so celebrated.   It  is obvious,  that
               were such waters bottled,  and sent to a distance,
               so that the invalid might  drink them  at his own
               habitation, the charm  would  be dissolved.   The
               garnitures—more important, in this case, than the
               dish—would  be  wanting, and  the  banquet  would
               be vapid, and without enjoyment or benefit.  Less
               than twenty  years  ago, amidst the bubbles  that
               were engaging the minds and the  money  of the
               English public, it was proposed to carry sea-water,
               by means of pipes, to London ; in  order that the
               citizens might have the advantage  of sea-bathing
               without the inconvenience of going  many miles
               after it.   Had the scheme been carried into effect,
               the benefits from metropolitan sea-bathing  would
               not  have  exhibited  themselves in any respect
               comparable to those  of the same agent employed
               at Brighton  or Margate.   (Dunglison's Elements
               of Hygiene,^. 157."  Philad., 1835.)
                 It would  seem, therefore, that a mere change
               of the physical circumstances of the atmosphere
               in which we are habitually placed, is advantageous
               to the economy, and that  the vital forces act with
               increased energy, whenever we leave a locality to
               which we have been long accustomed, and  where
               the functions are executed under the influence of
               unvaried excitants, and pass to one differing  essen-
               tially from it.   Nor is it always necessary  that
               this  difference  should  be extensive.   Sir  James
               Clark remarks,  (The Sanative Influence of  Cli-
               mate, &c, 3d  edit.  p. 315:  Lond. 1841,)  that
               notwithstanding  the  uniformity of temperature
               which  prevails  among many  of the West India
               islands, the effect of a change from one to another
               is often very remarkable in improving the health,
               — a  fact frequently observed on  a large  scale,
               among the  British troops stationed in  the West
               Indies ; and he considers, that one of the most
               powerful means of diminishing the sickness among
               the  troops, in that climate, would be to remove
               them frequently from  one healthy island  to an-
               other.
                 The moral and j V.ysical effects of change of air, 
ALOPECIA.
71
during travelling, have been well depicted by Dr.
James Johnson.   ( Change of Air ,■ or the Philo-
sophy of  Travelling, &c. ;  Amer.  edit. :  New
York, 1831.)]
   But change of air is not  more valuable as a
remedy in the cure of disease and its consequen-
ces, than as a preventive of disease, more  espe-
cially in childhood  and  youth.  At this tender
and susceptible period of  life, the rapid  influence
of the atmosphere in which we live, in deteriorat-
ing or improving  the health,  is very remarkable ;
a change of a few weeks  from the country to a
large town being often  sufficient  to  change the
ruddy, healthy  child into a  pale, sickly-looking
creature, and vice versa.   The comparative in-
fluence of a town and country air on the health
of children is seen in a striking manner in the
families  of the higher ranks of society, who spend
a considerable part of every year in town.  Chil-
dren should never be reared in large towns, when
 this can be avoided ; and when unavoidable, they
 should be sent,  during  a part at least  of every
 summer, into the country, which, indeed,  is the
 proper place  for children, until their system has
 acquired sufficient strength to resist the injurious
 effects of city life.  When they cannot  have this
 advantage, we consider it the  duty of the medical
 attendants of families to  urge  a temporary annual
 residence in the country, as essential to the health
 of children, more particularly those who are deli-
 cate.  How many neglect this invaluable means
 of improving the health of their offspring, who
have it in their power, and would willingly adopt
it, were  they aware of its importance ! So strong-
ly, indeed, are we impressed with the value of this
measure from ample  observation, that we consider
parents resident in towns, who have the  means of
giving their family the advantage of country air,
and  neglect  it,  deficient  in  one of  their  chief
duties.   To young females, who, by the  habits of
society, are much more confined to the house than
boys, a  temporary annual residence in the  coun-
try becomes a measure of still greater importance,
and should be continued at least to the full period
of their  growth.   We have reason to believe that
the advantages of country air to  the young and
delicate are not yet sufficiently appreciated by the
profession, and we are therefore  anxious to call
their attention to it, that they may use  their in-
fluence with the public, upon whose minds if they
succeed  in impressing the full  value of  pure air,
they will be the means of contributing greatly to
the health of the rising generation.
                             James  Clark.
   ALOPECIA.—The falling off of the hairs, in
an unusual degree, from  any  part of  the  body
naturally covered with them, constitutes the essen-
tial character  of this  disease.   The name, which
is derived  from aXc^f, vulpes, because  the fox,
when grown  old  and during  summer,  has  been
observed to be subject to this complaint, has, since
the time of Sauvages, been used as the generic
term  of  the disease; but, by the  Greeks and
Celsus, it  was originally  confined  to one  of its
species.*
  * De Medicina,  lib.  vi.  cap. 4.  Aetius, Tetrab. 2,
Sermo 2,  55. Piso, de cogn.  et curand. morbis, lib. i.
cap. I.  Oribas. de loc. affect, cur. lib. iv. cap.  42.   Paul.
lib. iii. tap.  1.  Srrapion. lib. i. cap. 1.  Mcrcurialis, lib.
i. cap. 4 ;  lib. vi. cap. 4.
   Stx.  Fluxus  Capillorum,  Arete  {Celsus) ;
Tyria (Arab.) ;  Athrica, Depilatio,  Defluvium
Pilorum, Pelada, Pilarella (Auct. Var.) ; Pelade
(Paree) ; Alopecia (Sauvages) ; Calvities (Teu-
tonici);  der  Kahlkopf,  (Plenck) :   Trichosis
Area  (Good) ;  Gangrena Alopecia  (Young) ;
Baldness.
   The different manner in which the  hairs fall,
the state  of the skin  from which they fall, and
the healthy  or unhealthy state of the hairs them-
selves, lead  to considerable variety of form in the
disease.  Sometimes the hairs are shed irregular-
ly and indiscriminately, producing only a general
thinness of  the hair;  to  this Celsus applied  the
descriptive term, fluxus capillorum./j-  Sometimes
parts of the body are entirely  deprived of their
hairs, presenting smooth shining patches perfectly
bald ;  these are the areae of Celsus,  (Lib. vi. cap.
4.) the alopecia areata of Sauvages, the  porrigo
decalvans of Willan.  When the spots of bald-
ness observed no particular form, although usual-
ly they are nearly circular, they were denoted by
Celsus, after the  Greeks, a\u>irciaa;$  but when
they presented a lengthened serpentine form, gen-
erally commencing on each side of the occiput,
and sometimes continued until they united in
front,  the  term  ipiaa;  was  applied  to  them.§
Sometimes this disease is universal, leaving not a
single hair  upon any  part of the body ; (Welt's
Tr. Soc. Med. and  Chi. Kn. ii. 264.) in which
case  it was called, by  the  French, la pelade ,-
although some will have it that, with  the falling
of the hair,  a  desquamation of the cuticle  was
also meant by this term.  Sometimes the baldness
is confined to one particular part, most commonly
to the hairy scalp, when it formerly received  the
name  of <pa\dKpii><us  or uaSapuxris;  sometimes to
the eye-brows, eye-lashes, or other parts  of  the
body.  The fall of the hairs may take place more
or less rapidly ;  sometimes in  a few days,  and
even in a shorter period, the body has been known
to lose all its hairs ; sometimes the change is slow
and imperceptible.  Sometimes  the skin,  from
which the hairs fall, presents the ordinary appear-
ance—smooth, shining, without  redness or altera-
tion ; sometimes it is pale, of a dead white colour,
and furfuraceous ;  sometimes it  is covered with a
scaly scurf like pityriasis, which, when removed,
exposes an  erythematic  appearance ;  sometimes
the skin is  natural in sensibility, and  sometimes
it is affected with itching, or a  sense of pricking
or  pungent  acrid  heat.   Sometimes  the hairs,
before falling, as well as those which remain, pre-
sent an unhealthy appearance ;  at other times no
alteration  can be perceived in  them,  and those
which surround the bald spots are as  strong and
healthy as natural.  Nor  are  these distinctions
trivial  or of little help ; for they are all connected
with particular causes and  particular  conditions
of the body, and, therefore, lead to  precision of
treatment.
   The immediate cause of the falling of the hairs
is unquestionably a diseased state of the follicles
which nourish and support their bulbs, having the
same relation to them as the capsule or membrane

  t Loc. Citat. lib. vi. cap. 1.  Trallian. i. 2.  Actual
M. M. ii. 5; iv. 9.  Oribas. iv. 5. Fernet. Consul, i. 1
  J Id. loc. citat.  Galen,  de Cur. Morb.  sec. loc. lib. i
cap. 2.
  § Ccfcus,  loc. citat.  Oribas. de Loc. Affect. Cur. <»
42; viii. 22, 24.  Actuarius, M. M. v 'v 
72
ALOPECIA
which  sun  jnds the roots of the teeth, (for the
process of the formation of the teeth and the hair
is  perfectly the same) ; but the precise nature of
the diseased state has not been  determined.  It
would  seem to depend sometimes upon inflamma-
tion of the follicles, sometimes upon their ulcera-
tion, sometimes upon a temporary deficient action,
and sometimes upon atrophy or death of the folli-
cles.  In  the  body of  a  man  who had become
almost entirely bald in consequence  of a  putrid
fever, of which he  died, Bichat observed  all the
pilous  follicles  in their natural state, and small
hairs shooting forwards from their bottom ; but he
remarks that, before the fall of the hair in aged
people, the cavity of the bulbs of the hairs gradu-
ally diminishes,  and the follicles, which contain
the bulbs, at last disappear.  The destruction of
the pilous follicles may, however, be caused  by
pressure, by friction, and by other causes.  Thus
it has been observed to be produced by the pres-
sure of certain subcutaneous tumours.
  Alopecia may be a purely local and idiopathic
disease ;  the affection originating in the follicles
themselves.   This happens when it arises from
external causes, as from the application of quick
lime or other  depilatories ; from the fumes  of
quicksilver, as was observed by Forestus in gold-
smiths ; from exposure of  the head to the rays of
the sun ; from frequent pressure of weights upon
the head ; and  from friction of any hairy surface
by the  garments or otherwise.   Or it may be local
and consecutive, as when the follicles are injured
by becoming involved  in the inflammation, ulcera-
tion, or  other  morbid  process  of any adjacent
cutaneous  disease, as happens in  porrigo,  im-
petigo, variola, eczema, elephantiasis, and  several
others.
  Alopecia may also be secondary and symptom-
atic, a consequence of general  debility and con-
stitutional exhaustion ;  and hence it attends the
convalescence  of febrile diseases,  and the puer-
peral state ; hence, also, it is a common symptom
of the advanced stage of phthisis, of diabetes, and
of most cachectic diseases ; thus justifying the
prudence  of the  Romans, who  estimated  slaves
affected with alopecia at the lowest price.  Hence
it is  also observed in the  nervous debility  which
follows excessive  venereal  indulgences or seminal
emissions, and has been known to be produced by
painful and distressing headachs ; by long con-
tinued and intense study ; by the depressing pas-
sions,  as  fear;  by  cares, disappointments,  and
anxiety.   Of this kind was evidently that singular
case related by  Ravator, of a person, who, after a
violent commotion, was attacked with amaurosis
of the right eye, and all the hairs of the same side
of whose  body lost their colour, and fell from the
eye-brows and eye-lashes as well as from the head.
Of the same nature, also, was, in all probability,
the remarkable case of M.  le Chevalier d'Epernay,
(Gazette Francois, Feb. 23, 1763.) who, after an
assiduous application for the space of four months,
without any previous symptom of disease, lost his
beard,  his eye-lashes, his eye-brows, and, in short,
all the hair of his head and body.
   Alopecia may be a sympathetic affection, not
a symptom of a constitutional disease, but caused
by  a disease  or  disordered state  of some other
organ  or system  of organs.   The most common
t>nn  of  this description which  has come  under
our  observation,  is that  which  proceeds  from
chronic inflammation of the mucous membrane of
the stomach, giving rise to a  particular  form of
dyspepsia, which has. for this reason, been  called
inflammatory.  Of this nature,  probably, was
that mentioned  by Galen, (De Cur.  Morb. Sec.
Loc. lib. i. cap. 2.) arising from eating poisonous
mushrooms; and  that  other  noticed  by Hippo-
crates, (De Internis Affectibus, sect. 4.) in which
the reader  will readily recognize a well-marked
case of the above-named form  of dyspepsia (gas-
trite chronique), and to which case there  is, in an
excellent record of modern medicine, (Journal des
Progres, 1830. torn. ii. p. 43.)  a parallel  in  form
as well as in cause, and which, it is deserving of
attention, was afterwards succeeded by an attack
of diabetes  mellitus.  Of  the wme nature also
was in  all  probability  that  species of  alopecia
termed by the Arabians  (Avenzoar, Avicenna,)
bilious, in contradistinction to the  other species
which they  called phlegmatic ,• which last, in all
appearance, corresponded with that form described
by  Celsus  as most difficult of cure,  "pejus est
quod densam cutem et subpinguem ex toto gla-
brum  facit," coinciding with  the  observation of
some modern writers, that if the skin is pale  or
insensible, and it is difficult by friction to  produce
redness, the case is irremediable.   Of the same
nature  is the case  given  by Lemery, of a man,
who, some months  after  excessive catharsis, lost
successively all the hairs from  his body; and also
another strikingly singular case, which,  both in
its causes and its cure, justifies the opinion which
we have ventured  to  give  of  the nature of this
species of alopecia.  It is so  illustrative that no
apology is  required for relating it.   " Lodovico
Gnemmi, a  Piedmontese, fifty-seven years of age,
a person of great vivacity of temper, of a plethoric
habit, but spare form of body,  having the skin of
a dull white colour, began, in the winter of 1825
and 1826, to feel severe pains in the head, with a
sensation of burning heat over all the body, but
most particularly in the skin : it was to such a
degree, that, during the coldest night of winter,
he was obliged to throw off his bedclothes.  After
having passed fifteen days in this painful state, he
began by degrees to lose all the hairs of his head,
then  those,of the  beard, eye-brows, eye-lashes;
and in the course  of a month, there was not to be
found  a hair upon the surface of his body, neither
in the arm-pits, on the breast, on the genital organs
surrounding the anus, nor upon any of his extre-
mities.  All his skin was as smooth as polished
marble, and the slightest trace of hairs could not
be felt by the hand.  He remained for two years
in this state, so deformed by the loss  of his hair
that he hardly ventured to show himself in public,
but  always feeling  on the surface of his body a
sense  of pungent acrid  heat, more especially on
the surface of the scalp, which was always  mor-
bidly sensible and  painful to  the touch.  In the
beginning of March, 1828, he was  attacked with
a  severe peripneumony,  which was treated and
cured by the most  active antiphlogistic remedies,
viz.:  low diet,  general  and  local  blood-letting,
cupping, purgation, blisters, &c, and,  strange to
say, under the influence of this treatment, on the
decline of so severe an inflammatory disease and
in a state of the greatest weakness of the circula-
tion,  the hairs  which  had  disappeared  for the 
ALOPECIA.
73
space  of  two years, began again to shoot forth,
and continued  to do  so during all his conva-
lescence.   On their first  appearance they resem-
bled fine  soft wool, almost colourless wool;  but
they continued every day to  approach nearer to
their natural character, which they  had fully re-
covered at the end  of a  month, when, owing to
some imprudence in regimen, he was seized with
an acute  attack  of gastro-enteritis, which carried
him off."  (Journal des Progres, torn. xiv. p. 244.)
   Of the same  nature, also,  are  many cases of
partial  alopecia  (porrigo  decalvans)  which  we
have observed in adults as well as in children, and
which we have had the satisfaction of remedying
by treating the primary disease—chronic gastritis,
or inflammatory dyspepsia.
   This origin of alopecia  also accounts for the
connexion which we have observed between it,
 lichen, urticaria,  and pityriasis;  sometimes  co-
existing ; sometimes succeeding each other ; all
differently modified operations of the same cause.
   To this description of  alopecia ought probably
to be also referred" those  which have been attri-
buted  to  the use of certain  kinds  of food, and
which  have  been said  to prevail  at  particular
places.   Thus it is said  not  to be unfrequent in
countries where  the inhabitants  live chiefly on
fish ; as,  for  instance, formerly in  the  Shetland
Islands, where baldness from this cause was so
common  that it was a familiar saying that " there
was not a hair between them and heaven."  (Sir
R. Sibbald's Description of Shetland.)   Thus
Tournefort relates, that in the island of Mycone,
one of  the Cyclades, the children are either bald,
or seldom arrive at  the  age  of twenty  without
being so.   And, though it is difficult to assign the
cause,  it must   be  acknowledged that  alopecia
(porrigo decalvans) has appeared to be more com-
mon at Brighton than in other places, and that all
the cases the writer has  observed in this place
have  afforded symptoms  of chronic  irritation of
the mucous membrane of the stomach.
   Besides the causes of alopecia which have been
enumerated,  in distinguishing its different kinds,
there is one  which  has  been  observed by  Dr.
Willan and  others, not easily referred to  any of
them.   It is when the disease appears  to have
originated in the infection of porrigo scutulata;
for when this disease has spread through large
schools, in  some instances,  one  or two of  the
children have been affected ^ith alopecia (porrigo
decalvans').   We have purposely avoided placing
amongst the  causes  of alopecia  the  influence of
age, which belongs  more to the ordinary course
of nature  than to a process of disease, as well as
another cause which  is said to have  a wonderful
power in  modifying the growth of the hair.  We
allude to the circumstance of  eunuchs, when  the
mutilation takes  place in infancy, having  no
beard,  and yet never becoming bald ;  a change
which  is  more  properly  considered  a  deformity
than a disease, but showing a singular connexion
between the growth of the hair  and the develop-
ment of the genital organs, of which, however, the
perfect state of the body affords many proofs.
   There  is,  however,  one species   of  alopecia
which,  properly  speaking, ought to have been
arranged amongst the symptomatic  forms of that
disease, but  which, on  account  of its  specific
   Vol  L  —10                           g
nature, has generally been  separated from it —
alopecia syphilitica.  The falling of  the hairs  is
one of the most rare of the secondary symptoms
of syphilis, so much so that it is seldom met with
—not oftener, it has been calculated, than once in
fifteen hundred cases.  M. Cullerier, of the Hopi-
tal des Veneriens at Paris, who was  for twenty-
five years in the habit of seeing from two to three
thousand  venereal patients every year, states that,
upon the whole number, he had  not met with
more than three or four cases of universal alopecia,
and from fifty to sixty cases  of  partial alopecia..
Nor was  it observed amongst the symptoms of
that disease upon its first appearance in Europe;
for, either unknown or  at least unnoticed before,
it was  not until towards  the year 1538 that it
attracted the attention of observers—of  Rangon,
Fallopius, Massa,  Brassavola, and  Fracastorius.
From that period it seems  to have gone on  in-
creasing  to the  end of that century or to the
beginning of  the  next, since which time it has
been  progressively decreasing,  and  has almost
entirely disappeared in  temperate climates ; but.
if we may place confidence in some accounts, it
is less rare  in warmer regions, as in  Egypt, the
southern  provinces  of  Italy,  and  Spain.   It  is
however not entirely unknown amongst us. Cases
are to be found in the works of most medical
writers; one of the most recent is that of Professor
P. Metons.   (Clinique Chirurgicale.)
   When  this  form of  alopecia  first fixed the
attention  of observers, it  was matter of dispute
whether it was a consequence of the disease or of
its  specific remedy; but though it  appears, par-
ticularly from  the cases of Forestus, that alopecia
may be produced by mercury, there are not want-
ing cases to prove that  it has followed syphilis
when this remedy had never been resorted to; and
its  cure by mercury is a strong converse proof
that, if it ever arises from it, it is only under very
peculiar conditions.
   The syphilitic alopecia does not in itself present
any peculiarity to  distinguish it  from the other
forms of that disease. It is generally preceded or
accompanied by a furfuraceous state of the  skin,
from  which vast quantities of small scales are
daily  thrown off, in the  form of bran, and daily
reproduced, and the skin underneath  is observed
to be redder than natural.   But the cotemporane-
ous existence of other symptoms of the venereal
disease, and the history of the  case, will afford the
best data for diagnosis.
  It might be  inferred, from the great number and
the diversity of the remedies which  have  been
used and  recommended for the cure of alopecia,
that the method of cure was very uncertain, or the
forms of the disease very diversified.  As the con-
clusion is  usually drawn from  these premises, this
latter inference is generally overlooked. But if we
admitted it, as we  ought, it would lead  us not
always to  throw aside the multifarious farrago of
our predecessors as  so much useless rubbish, but
direqt us to seek in  the varieties of the forms  of
disease for the reasons of the application of such
various remedies ;  and, in our opinion, by recor.
ciling in this way the diversity of the disease with
the diversity of the methods of treatment, we should
entertain  a better  opinion and make a better use
of past experience. 
74
A L 0 P E C I A — A
L T E R A TI V E S .
| possible. For the direction and r.eans of effecting
 this, we refer to the treatment of Acxywhil.hr,,.
 The local applications in this form of the disease
 differ in no respect from those suited  to the ordi-
 nary species, except that a few grains  of corrosive
 sublimate mav sometimes be advantageously com-
 bined with  them;  and  frequently  shaving the
 diseased skin  is  a part  of the treatment  which
 cannot be dispensed  with.        rj,  j  Todd.
   Treatment. — From  the distinctions of the
different forms of alopecia which we have endea-
voured to point out, may easily be understood how
it may sometimes have been cured by phlebotomy;
by local depletion, as leeches, scarifications, and
acupuncture ; by  purgatives, low diet, and other
antiphlogistic remedies :  how, at  other times,
simple local means may have succeeded better, as
friction,  no matter whether with the  fat of the
mole, the snake, the hedgehog, or the bear;  or
with warm  exciting substances, as camphor, tur-
.pentine, naphtha,  laudanum, resin; with volatile
oils, as those of laurel, rosemary, mace, or cinna-
mon, or with the distilled water of bees-wax; with
acrid substances, as thapria, euphorbium, staves-
acre, nasturtium, mustard-seed,  garlic,  onions,
and tincture of tobacco ; with irritating applica-
tions, as friction with fig-leaves, nettles,  tincture
of cantharides, and even the  application of a blis-
ter : how at other  times advantage may have heen
derived from alkaline ingredients, which  explains
the use ;»f the laxivia of wood ashes, of burnt cane,
of the  burnt  hair of bears, and  of  applications
containing  the bile of different animals,  and the
ordure of birds, as the ancient remedy of stercus
columbinus:  how at other times such astringent
applications as alum, cimolian earth and  wine, or
green vitriol, the atramentum sutorium of Celsus,
may have answered  better; and how, whatever be
the form of the disease, or the nature of the treat-
ment, the frequent shaving of the diseased parts,
which has been recommended by all  writers, is a
remedy always applicable.
   When there exist signs of an inflammatory
state of the pilous  follicles, or erythema of the
surrounding skin, leeches may be  applied with
benefit, and a course of purgative remedies is  of
great service.   But when the disease of the folli-
cles appears to  arise from an inflammatory state
of the  mucous membrane of the stomach, leeches
must be applied to  the scrobiculus cordis, and a
regimen of mild bland diet must be insisted upon.
In the first case the best local  application is any
mild demulcent liquid, as  decoction  of  bran, or
mallows.  But when the skin, from  which the
hairs fall, indicates a deficient degree  of vitality,
the  parts  may be excited  by local  stimulants.
(R olei macis  ^ii. alcohol:  giv. M.)   Pencilling
the surface with a solution of nitrate of silver, or
rubbing it  with a liniment  of olive oil, and as
much  nitric acid as makes it  pungent,  but not
acrid, have been  found to  answer the same pur-
pose.   Of the use of tbe celebrated oil of Macas-
sar in  such cases we have  no experience, but the
solution of sulphate of copper in alcohol, lately
very much recommended by a German physician,
has failed in our hands.  When  the  skin  is fur-
furaceous, or the cuticle hard, shining, and imper-
meable, like parchment, it is of great use to wash
it frequently  with some alkaline  or sulphurous
solution (R Liq. ammonias acetatis f.^ii. ammo-
nix carbonatis 3H.  alcohol:  f.gss.  aq. fontan :
f%iv. fiat lotio.)  But when either of the foregoing
 states  of the skin is connected with  a deranged
 state of the general health, it is unnecessary to say
 that this demands the chief attention.
   When alopecia acknowledges  a syphilitic ori-
 gin, the specific remedy of  that disease  must be
 Dad lecourse  to exhibited in as mild  a  form as
  ALTERATIVES. — This term, although not
expressive  of a distinct class of medicines, is s<
frequently employed as to  require  particular ex-
planation.   By an  alterative course of treatment
is commonly meant the continued  exhibition of
certain  medicinal agents  supposed to  have the
power of altering certain disordered actions, chiefly
of a chronic character ;  and all medicines possess-
ing, or  supposed to possess, such  a property, no
matter to what class  in the Materia Medica they
may otherwise belong, are occasionally  denomi-
nated  alteratives.   Although the  term  is  often
used vaguely, the indication with which an altera-
tive medicine is prescribed is of the  utmost im-
portance.  It might  be said, indeed, in general
terms,  that  all  remedial  means  whatever  are
alterative, but the alteration sought  from the use
of specific alteratives, or of alteratives in the re-
stricted and ordinary acceptation of the term, is
such as is not readily, or at all,  to be obtained, by
general or  local bleeding,  by purgatives or diu-
retics, by tonics,  anodynes, or antispasmodics;
although the agency of particular medicines be-
longing to any of these classes is sometimes made
subservient  to an alterative course of treatment.
  Mercury, in all its various forms, is  one  of the
medicines most commonly employed as an altera-
tive ;  and the great  influence  it  exerts on the
whole economy, over all the secretions and excre-
tions, and over the nervous system itself, consti-
tute it  an  alterative, when prudently given, of a
most efficacious kind.   Even in certain  states of
fever, mercury has been employed with success
for  the restoration of  the  secretions, and, there-
fore, it may be said, as  an alterative.  In chronic
inflammation,  although here,  perhaps,  the term
alterative may be objected  to, small doses  of the
pilula hydrargyri or of  calomel  are often consid-
ered  highly serviceable : no cases  are more fre-
quent than  these, and in none  is  the  practitioner
more in need of some means of checking or alter-
ing actions, which, although neither  violent noi
immediately dangerous, are silently effecting struc-
tural  changes and irreparable mischief.   It would
certainly appear that, for this purpose, the  major-
ity  of practitioners rely  on the efficacy of mercury,
often in combination with opium.   In certain  in-
stances, of which chronic laryingitis may be cited
as an example, as vyell  as in the instances of new
formations,  even  of a  malignant character, the
addition of  a medicine  possessing narcotic proper-
ties may be useful on the principle of allaying the
disturbance of the nervous  system, a  disturbance
but little regarded or acknowledged in such cases,
but probably  intimately connected with the pri-
mary functional disorder  in  which  all  morbid
changes of structure, and even inflammation itself,
must commence.  Most persons of experience in
medicine have met  witli examples  of chronic dis- 
ALTERATIVES.
75
orders of a troublesome rather than of a danger-
ous nature, which have been ameliorated, or en-
tirely relieved, by the persevering use of some  of
the forms  of mercury ;  although  the  medicine
may have been given  at  first  without any other
reason than that  it afforded a chance of benefit.
Even irritable states of the  bronchial and intesti-
nal mucous membrane certainly sometimes give
way under this treatment;  but the  application of
it requires that caution of which nothing but ob-
servation  can teach the  value.  The  advantage
obtained in such  cases, and in others not unfre-
quently met with, from the  apparently indiscrimi-
nate employment of calomel,  may  eventually be
found to depend  upon some  general  law, which
has not yet been  explained ; or simply, as we be-
lieve John Hunter thought, one kind of irritation
superseding another,  and banishing it  from the
system.   No  medicine is so  commonly given in
disease of the mesenteric glands as calomel;  it is
by no means rarely administered in scrofula ; not-
withstanding the general  opinion of the unfavour-
able influence of mercury on the scrofulous con-
stitution ;  and notwithstanding the common  ac-
companiment with  mesenteric disease of a state
of intestinal irritation  or  of chronic inflammation.
In almost every varied disturbance of the  liver,
mercury is one  of the first  medicines  to which
many practitioners have recourse, and in the form
of the pilula hydrargyri it has been recommended
in many disorders of the  digestive functions.   A
practice so common must have been supported by
many cases in which it was found useful, although
the principle on which the  medicine acts, if it be
 not that of suspending morbid actions, is, in some
 of the  cases,  not very easily imagined.  In  the
case in which acute inflammation of membranous
parts is checked  by the employment of calomel;
or depositions, the consequences of such  inflam-
mation, are removed, of which iritis may be men-
tioned as  presenting  a striking illustration; this
medicine is given to produce a precise effect, which
experience has shown to  arise from its use.  In
the chronic forms of indigestion, its operation on
the secretions seems to explain the great advan-
tage often arising from  it.  In the other cases,
cases of mere irritation,  or cases in which  there
is a disposition to  new formations  not  ascribable
 to inflammation, the same medicine is given, often
 with the same good effects ; but the actions which
 are then  interrupted being  less understood, the
 medicine is only called an alterative.
    Antimony  is very often  employed in the class
 of cases just spokftn of, although not in them ex-
 clusively, as an alterative ;  generally in combina-
 tion with calomel.  The  benefit of this combina-
 tion is usually ascribed to an alterative effect pro-
 duced by them in the  secretions into the intestines,
 and in the cutaneous  exhalation ; in other words,
 in the functions  of the bowels and the skin.  The
 pulvis  antimonialis is, perhaps, most frequently
 used with this indication in extemporaneous pre-
 scription ; and a very useful preparation, the anti-
 monii sulphuretum pr^cipitatum, is conveniently
 united in the pilula hydrargyri sub-muriatis com-
 posita, with calomel.  In this, the celebrated  Dr.
 Plummer's pill, we meet with another alterative
in the guaiacum, which,  as well as the sassafras,
 the mczereon, and sarsaparilb  although not so
extensively useful, is  certainly of singular utility
in some  chronic  affections.  Daily  observation
shows the obvious  effects  of  the Plummer's  pill
on the bowels and on the skin :  the most observ-
able  of the immediate effects of  the sassafras and
the sarsaparilla are produced on the skin, although
some effect may occasionally be  observed equally
early on the intestinal and  renal secretions.   The
taraxacum is  a medicine not unfrequently given
in chronic affections of  the stomach or  the  liver;
and  its sensible, as distinct from its alterative ac-
tion, appears to be greatest  on the  urinary secre-
tion.  In the alkalis we have  another description
of medicines,  often prescribed as alteratives, par-
ticularly to scrofulous patients affected with  dis-
ease of the glands of the neck  or  of the mesen-
tery, or with diseases of the joints.  The  carbo-
nates of soda and potass, and sometimes the liquor
potassse  or the liquor calcis in combination with
sarsaparilla, or with some  of the bitters, are pre-
scribed in such cases, and  probably produce their
good effects by first acting  on the stomach itself
But there can be no doubt  that all these medicines
have an ultimate effect which  in  reality entitles
them  to the  name  of alteratives.   This  effect,
which may be simply expressed by the phrase of
altering morbid actions, may be secondary to their
action on the stomach,  or on the skin, or on both
these surfaces ; or it may  be  primary.   Accurate
observations on the states of the blood  in  disease
are  too infrequent to enable us to speak with con-
fidence  of the alterative effects of medicines on
that important fluid.  It is, however, highly  pro-
bable that the effects of some at least of the alter-
atives  are  secondarily, and  of others primarily
produced on   the  blood itself.   In many  of the
diseases in which they are most  employed, and
most useful, there is an  evident impairment of
secretion.  Secretion, although partly  dependent
on certain nervous  actions, demands, for its  per-
fect  performance, a healthy state of the blood, the
fluid in  which and  out of which all the  various
constituents of the various secretions are created.
Supposing that from some  disorder in  the blood,
we bave produced, certain  varieties of  disease on
the  surface, or in the stomach or intestines, or in
the  bones, ligaments, cartilages, or other solids of
the  body,—tbe effect of a medicine which removes
such diseases must  be  to  alter  that  first  morbid
condition of the blood ; and thus to cause healthy
secretion and  excretion, instead  of cutaneous dis-
ease, or chronic indigestion, or  venereal nodes in
the  tibia, or increased vascularity and depositions
affecting the  motions  of the joints,  or any other
morbid action  or formation for  the prevention or
cure of which we  prescribe alterative  medicines
Such, then, generally speaking, must  be  the  ac-
tion of alteratives.   They may amend the state
of the blood by previously  improving  the functions
of digestion and assimilation ; or they may directly
affect the process of sanguification, a process yet
imperfectly understood ;  but that alteratives do
actually change and improve the state of the blood
in many instances cannot  be doufeted.   We  find
in such facts, admitting them to be so, an  expla-
nation of the term  depuration, attenuation, &c,
used by the older  writers, and also  of the more
popular  expressions  of  " sweetening"  and of
" clearing" the blood ;  and in these terms we have 
76
ALTERATIVES.
a proof how long such an opinion has appeared
reasonable to pathologists, and how supported the
opinion is by common belief, founded upon com-
mon observation.
  But supposing  the nervous action which has
been spoken of, as essential to the proper perform-
ance  of secretion, to be  disordered in  cases  in
which alterative medicines are commonly consid-
ered to be indicated,—it  may still be  understood
how this functional office of the nervous system
may also be more efficiently performed when  an
alterative  medicine has corrected the disordered
state  of the intestinal canal; and there are not
wanting facts of a nature to incline us to ascribe
the influence of some medicines employed as alter-
atives, to their  direct operation on  the nerves.
Whether the use of hemlock in the case of some
tumours, and the effects of the prussic acid in cer-
tain examples of phthisis pulmonalis, may not be
of this kind, is at least worthy of some  consider-
ation.   That the addition of a small quantity of
the extractum hyoscyami, or of the  pulvis ipeca-
cuanhae compositus, to alterative doses of the pilu-
la hydrargyri,  in certain forms  of dyspepsia, is
serviceable in this way, seems hardly to  admit of
doubt.
  Physicians  of great authority, among whom
may be mentioned Dr. Heberden, have laid it down
as a rule to be  observed  in  the  management  of
obstinate chronic disease,  that we should with  all
care regulate the different functions of the body,
diligently observing any departure from their com-
mon  and healthy condition ;  and thus place the
constitution as nearly as we can  in  that state in
which its own efforts may be put forth for the cure
of such persevering and otherwise intractable mal-
adies.  It may at least be said, that this is often
all that the practitioner has it in his power to do;
and it might sometimes  be advantageous to the
practitioner, as well as to the patient, if the former
would limit his ambition by recollecting this.  If
the obscurity in which internal changes are effect-
ed, weakens the evidence in  many medical cases,
the  annals of surgery abound  with instructive
proofs of the extraordinary local benefit arising
from this kind of treatment.   This is that consti-
tutional treatment, in fact, which Mr. Abernethy
succeeded in  introducing into surgical  practice ;
and although the  disciples of that distinguished
pathologist, and even he  himself, may sometimes
have carried the principle too far, its foundation
is not weakened either by their erroneous  zeal or
by his eccentricity.
   Another rule, less scientific, and  less safe, and
emanating from authority less to be depended upon,
is, when a disease does not readily yield to  com-
mon treatment, to make some great impression on
the constitution, in the hope  that, in  the  general
commotion and agitation, disordered actions may
be rudely interrupted, or the actions of health feli-
citously restored.   Without entering  into  any
discussion concerning  the propriety  of the rule,
 Which might  perhaps admit  of justification even
 as leading  merely to the  introduction  of a new
irritation, its principle is unquestionably  alterative.
 Various means have been employed to produce
 the desired effect,—a large bleeding, a large dose
 of mercury, a powerful  opiate,  or repeated and
 large doses of metallic tonics.  All of these, and
other measures adopted with the same intention
have, we doubt not, been occasionally serviceable
Of the advantageous  operation  of  some of then
we have been witnesses ; particularly of the  us,
of a large dose  of mercury in very obstinate  sci
atica, and of opium in some old and unmanage
able  cases of epilepsy.
   There are certain auxiliaries  to  medical treat-
ment, which are frequently used with all the in-
dications which have been specified as pointing to
the employment of alteratives.  Thus, change of
air,  sea-bathing, alterations of  habitual clothing
and  sudden  or  considerable changes in diet, are
frequently recommended, and with the best effects
sometimes producing benefit  by  acting  on  the
stomach or  on the  skin ;  sometimes by acting
more directly on the  blood, or on the  nervous
system ; sometimes by improving the state of the
secretions or excretions ;  sometimes by removing
some obstacle to the proper performance of some
particular function ; and sometimes by producing
a new and  strong impression on the body or the
mind.  Many of these advantages are simultane-
ously  obtained by  taking the various  mineral
waters.   Change of place, and  temporary  change
of habits, freedom from business,  and the gentle
excitement of novel forms  of amusement, doubt-
less very powerfully conspire to produce the sin-
gular improvement of health so often observed in
patients resorting to Cheltenham,  Leamington,
Tunbridge, Malvern,  Harrogate, and other cele-
brated watering-places; although still a part, and
often a very considerable part of the improvement
is evidently to be ascribed to the daily and mode-
rate excitement of the stomach and bowels, and,
in some cases,  of the kidneys,  by  the ingredients
of the mineral water itself,  whicb  thus acts  as a
most  valuable  alterative of  the   whole  system.
That  the  external   application  of  the  waters
stimulates the skin to new action, and thus pro-
duces direct relief, and, in this way, or by sym-
pathy, improves the tone of the  stomach, or effects
more  extensive improvement, must also, we pre-
sume, be admitted.
   The class of chalybeates  contains agents which
have an evident effect on the circulation, as tonics.
Given, however, in the minute state of subdivision
in which they are held in  solution  in  natural
springs, they produce effects which entitle them
to the name of alteratives.   They  excite the  cir-
culation, which was  before  languid, and, in  all
probability, they alter and  improve the condition
 of the blood.   Either directly, or through  their
 first action  on  the  sanguiferous  system, or  by
 seme  direct or indirect influence  on the actions
 of the nervous system itself, or in more than one
 of these ways  at once, they stimulate the secre-
 tions, which were before scanty  and imperfect;
 and they more manifestly alter the state and  ap-
 pearance of the body than any other medicines
 whatever.   In  conditions of the  body suited  to
 their use, no alteratives are,  in fact,  so effectual.
 They substitute general energy for general debility,
 and revive the colouring  of health in  patients
 before pallid, or wan, or  discoloured, as in  the
 chlorotic, by long disease.  The illustration of an
 alterative by reference to remedies of this class,
 shows, however, the impossibility of effectually
| dividing alteratives from other classes of medicines, 
ALTERATIVES.
77
   When medicines are intended to act as altera-
 tives, they  are  usually given in  small  doses, re-
 peated every night for some weeks ; such, at least,
 is the general mode of prescribing alterative doses
 of calomel and the  antimonial  powder.   From
 two to five grains  of either are frequently  pre-
 scribed in this way, to adults, but most common-
 ly the smaller dose of both.  Five grains of the
 Plummer's pill contain rather more than one grain
 of calomel  and of the precipitated  sulphuret of
 antimony, and two parts of guaiacum.  In many
 cases of disordered  digestion, small doses of the
 pilula hydrargyri (gr. ii. or iii.)  are  given  every
 night or every other night, or still smaller doses
 twice or thrice a  day.  None of  these medicines
 can properly be  employed without interruption for
 more than a few weeks : if their good effects are
 not perceived in that time, a perseverance in their
 use will hardly ensure them ; their use may, how-
 ever, be suspended for a week or  a fortnight, and
 then advantageously resumed.  The  young prac-
 titioner should,  however, very carefully endeavour
 to distinguish those cases  in which an  alterative
 plan of treatment affords any prospect of amend-
 ment,  from those in which the loss of time in its
 ineffectual trial  will prove injurious.  _ The mind
 is prone  to any belief which favours indolence ;
 and there  are  practitioners who content them-
 selves with the delusion that no treatment, except
 the  alterative treatment, is  really efficacious in
 any chronic case.
   Another error, not very  uncommon, is the pro-
 tracted  employment of medicines of this  sort.
 Their effects, not being suddenly produced, are
 sometimes  overlooked ;  or being brought  about
 very gradually,  and long  expected  in vain, they
 are  at length  watched for with less diligence,  and
 disregarded when they might be discerned.   The
 complete discontinuance of an  alterative  is  of
 course best indicated by the desired improvement
 taking place in  any case.   When such medicines
 are properly applied, (and  no medicine  is useful
 but  by  timely  application,) indications of their
 general effects, and even of their mode of action,
 may clearly be  perceived.   The  tongue, for in-
 stance, loses its  morbid coating ;  the  appetite im-
 proves ;  the bowels become  more regular;  the
 skin grows smoother or  freer  from eruptions;
 the  mind becomes more  cheerful;  the patient
 sleeps  better; and  the countenance becomes ex-
 pressive of  that feeling of  general comfort which
 is incompatible  with chronic disease, and  arises
 from the due  and healthy performance of all the
 bodily functions.   Unless  some of these  effects
 result from  the use of alterative medicines, after a
 reasonable  continuance, the  practitioner should
 carefully  inquire into the  cause of such failure.
 He will  probably find  it in  some local  disorder,
 not  to be removed without  local treatment, and
 which  he ought to have recognised at an  earlier
 period.   On the other hand, when the  signs of
 amendment which  have been mentioned appear,
 it should be recollected that  to  persevere in  the
 use  of alteratives  is to apply to  the  body, in  a
 state of health, actual causes of disease.  It would
 seem superfluous to notice such plain  and obvious
particulars, if  observation did not show us that,
from the neglect of such plain and obvious things,
 rather than of things less on the surface, mistakes
 are daily committed.
   With respect to the guaiacum, which has been
 enumerated among the alteratives, and which  has
 a very ancient  reputation,  it is not easy  to ascer-
 tain its precise share in the good effect  produced
 by  the  compound calomel  pill.  Except in that
 formula, its application is nearly limited to certain
 cases of chronic rheumatism, in which, we fear
 it must yet be  allowed that Dr. Ferriar's observa-
 tion concerning  it  is correct; and  that, whilst
 there certainly are some forms of the disorder ir
 which its effects are excellent, it very frequently
 seems to  have no  effect  at all.   The  tinctura
 guaiaci  ammoniata,  in  doses of  one  or  two
 drachms, is the most common form in which this
 medicine has been employed in rheumatic cases,
 We have  ourselves little  to  say  of its efficacy
 when used alone ; and we  so often remark, when
 doubt  has  been once  cast  on  the  operation of a
 medicine, and  the  effect is carefully looked  for,
 that it fails to be observed,  as much to wish that
 not  only the guaiacum,  but many or most of  the
 articles in the Materia Medica were submitted to
 new and  careful clinical experiments.   No part
 of medicine is in more  need of complete reform
 than that which relates to  the actual  effect  of
 medicines daily and hourly employed.
  The  sassafras, like the guaiacum, is  not  often
 prescribed as an alterative by itself; it enters, with
 the  mezereon, into the composition of the  com-
 pound  decoction of sarsaparilla, a medicine  of
 great value  in  a very  large class of cases.  This
 decoction seems,  in English  practice,  to  have
 superseded the  once famous Lisbon diet-drink, of
 which sarsaparilla and the  sulphuret of  antimony
 were among the principal  ingredients.   This is
 not  one of the  alteratives of which the  good
 effects are  to be expected from small doses.   In-
 deed there is reason to think that disappointment
 has sometimes arisen from the decoction  of sarsa-
 parilla having been given in too small a quantity.
 In ordinary cases, the  patient is required to take
 a pint of the compound or of the simple decoc-
 tion daily; and three or five grains of the Plum-
 mer's pill, or three grains of the pilula hydrargyri,
 or five grains of the hydrargyrum cum creta, or a
 few grains of calomel and antimony, are common-
 ly prescribed to be taken at night during the use
 of it.  But if it is desired to ensure the full effect
 of the decoction of sarsaparilla, and  particularly
 if its operation is solely trusted  to,  the patient
 should be  persuaded to  drink two, three, or four
 pints a-day, and  sometimes even a greater quan-
 tity.
  An alterative plan of treatment generally com-
 prehends the use of some of the medicines spoken
 of in this  article.  Others  are occasionally em-
ployed with the same intention, but it is unneces-
sary to dwell upon them, for it will  be seen that
 the  line of division  is, after all,  rather  artificial
than real.   Whatever medicines may  be  employ-
ed with this indication, it should be remembered
that the proper regulation  of the  patient's  diet,
and strict attention to all  the articles of regimen,
are indispensable auxiliaries ; the effects to be ex-
pected from this kind of care being indeed ouvi
ously analogous to those  of  alteratives 
78
AMAUROSIS.
   [For alteratives, a term—as  often used—con-
veying  no distinct meaning, Dr. Dunglison  has
substituted  eutrophics,  promoters   of  healthy
nutrition.   See Eutuopuics.]   j  Qqnolly.

   AMAUROSIS, from auavpdu, to obscure.  This
is the name applied to one of the diseases of the
eye, in which defective  vision depends on impair-
ed sensibility  of  the  retina.  The  term gutta
tercna has also been applied to this disease, from
an erroneous notion that the dark enlarged pupil,
which  sometimes  accompanies it, is a drop of
black fluid which interrupts the passage of light.
In practice, when a patient without opaque cornea,
closed  pupil,  or  cataract, complains of lost or
defective vision, he is considered to suffer from
this disease.
   Viewing the exquisitely delicate organization
of the retina,  and the origin, course, and compli-
cated connexions of the optic nerve, it is not  sur-
prising that impaired vision  should  so frequently
be produced by disease in some part of the nervous
apparatus.  The ultimate fibres of the optic nerve,
expanded into a membrane of extreme tenuity,
supported  and  disposed  upon  a  membrane of
nearly equal delicacy, from whence  it derives its
vascularity, and covered and separated from the
neighbouring  choroid  by a tunic of still greater
delicacy, present altogether a piece of anatomical
organization most likely to have its functions im-
paired  by  slight deviations  from  the natural or
sound  condition.   Disorganization of the  hya-
loid membrane, upon which this delicate struc-
ture rests, or  of the choroid, with which it is ex-
ternally in contact, may also materially affect its
condition.   The  optic nerve, with  its vascular
and membranous  accompaniments, enclosed in a
sheath  of fibrous membrane  in its course through
the orbit, pierced by the central artery, and close-
ly connected  with other  arteries and  nerves,  is
exposed to many  injurious deviations from the
natural structure.  The same optic nerve within
the  head,  from the vicinity  of  large vessels,  and
its complicated nervous connexions at the place
of decussation, the  tuber  cinereum,  the  crura
cerebri, the thalami, and the tubcrcula quadrige-
mina, is liable to suffer from disorganization of its
own structure, as well as  of any of those  parts
with which it is  connected.   A  review of the
structure of the nerve of vision, from its origin at
 the tubercula quadrigemina to its anterior termi-
 nation at the ciliary processes, is  the best  pre-
 liminary exerc.^e for one about to study the dis-
 ease of amaurosis.
   Injury or  disease  of the brain,  as ruptured
 vessels, serous effusion, softening, tumor, or ab-
 scess, frequently impair the  functions of the optic
 nerve, although  such  injury or disease should
 exist  in  a  situation remote from  the origin  or
 course of the  nerve.  Amaurosis may, therefore,
 be  a  consequence of cerebral  disease, although
 the optic nerve should be sound from  its  origin
 lo its  termination.  [Lawrence on Diseases of
 the Eye, Amer. edit. p. 478 :  Philad., 1843.]
    Injury or disease  of a  nerve,  or  morbid  con-
 dition  or irritation of particular organs, affect in-
 juriously the brain and nervous system, and  thus
 impair the functions of the  retina : hence amau-
 losis from gastric, hepatic, or uterine disturbance.
  The  experiments  of Magendie,  inconclusive
as they  are,  and often  proving  too  much  for
the hypothesis  they are intended  to strengthen,
at least show that the  fifth pair of nerves exerts
some very important influence on the function of
vision ; pathological observations on this  subject,
although few in number as yet, lead to the same
conclusion, and the effects of injury of the frontal
nerve in producing amaurosis, long since observed.
establishes the fact.  Ptosis, depending on disease
of the third pair of nerves, is always accompanied
by defective vision.
  Arterial and venous  vascularity is an  essential
part of the organization of the retina, as it is of
the whole nervous system; the existence of large
vessels carrying red  blood in  a structure of such
delicacy  and transparency  is  even a remarkable
circumstance, when contrasted with the apparently
bloodless condition of  many other  white or trans-
parent  structures.  Increased  arterial action, or
obstructed venous circulation,  may, therefore, ma-
terially affect  the condition of  the retina, and im-
pair its sensibility.
   There is great variety in the perfection of vision
in different individuals ; which may be attributed
partly to  a difference  in  sensibility of the retina,
but in a still greater degree to a difference in pow-
er of adaptation of the eye  to distance.  It ap-
pears a great mistake to suppose that  this differ-
ence in perfection of vision depends altogether on
the power of  adaptation.  A difference in  perfec-
tion of vision  is often observed in  persons who
appear to enjoy an equally perfect power of adap-
tation.   A single lens remedies, in a great degree,
the defect arising from want of power of adapta-
tion ; but no  single lens will confer on a landsman
the distant vision of a sailor, nor on a long-sight-
ed person the power of distinguishing minute ob-
jects enjoyed by some near-sighted persons.   It
is scarcely reasonable  to suppose that  any altera-
tion in curvature  or relative positions  of the cor-
nea,  or lens, in birds,  can  take place sufficient  to
account for the great  superiority in  vision which
these animals enjoy.    The sight of nocturnal ani-
mals, and of persons  who can see perfectly in
obscurity, can only be  attributed to a superior sen-
sibility of the retina, as it is altogether independ-
ent  of any superior power of  adaptation.
   The sensibility of the retina is increased by two
totally different causes,—permanent exposure  to
a strong glare of  reflected light, or a long-contin-
ued  residence  in a  darkened  apartment.  The
inhabitants of snowy  countries  are  obliged  to
adopt the precaution  of  protecting the  eyes by
means of a goggle, with a slit opposite the pupil,
and the  inhabitants of towns  in which the build-
ings are white are said to suffer from inflammatory
affections of the eyes.   Persons immured in dun-
geons are said to acquire  a power of distinguish-
ing even small objects in  their obscure abodes, in
which, at first, they could not detect even  a glim-
mering  of light.   The morbid sensibility of the
eye to light, in what is called  scrofulous ophthal-
mia, is in a great degree  to be attributed  to the
 injudicious exclusion  of light  from the eye by the
 use of shades, or confinement in a darkened room.
 The effect of light and shade  upon the sensibility
 of the sound retina is beautifully exemplified  by
 the  simple experiment of directing the  eve  to 
AMAUROSIS.
79
some opaque object  intervening between the ob-
server and the  light.  If the  eye be  fixed for a
few minutes  upon the  sash  of a window, upon
turning it in a different direction, a luminous im-
age of the opaque sash remains.  In this case the
glare of light poured in through the glass on the
unshaded part of the retina renders it less  sensi-
ble, while the part shaded by the opaque  sash  re-
tains its original, sensibility ; all the retina is after-
wards exposed  to the same  quantity of light, yet
to that part which was shaded it is a glare, while
the part previously exposed to a stronger light has
its  sensibility  blunted.   If this  explanation  be
correct, it is at variance with  the fact previously
stated, that exposure to the glare of reflected light,
from snow or whitened buildings, raises the sensi-
bility of  the retina.  The sensibility,  however,
produced  by exposure in snowy countries appears
to be morbid and  permanent,  probably connected
with slight inflammatory action.   That inflamma-
tion of the eye is accompanied, in many cases, by
morbid sensibility of the retina, is confirmed  by
daily observation ; and we have  cases on record
of persons being enabled to read, even in the dark-
ness of night, in consequence  of accidental injury
producing inflammation.  Amaurotic patients, suf-
fering from  inflammation, often  observe an im-
provement in vision  while the inflammation con-
tinues, which ceases as it subsides.
   These  and  many other facts  and  reasonings,
which might be  brought forward, prove  that the
retina in  its most healthy and  natural  state is en-
dowed with different degrees of sensibility under
different  circumstances,  and, therefore, there can-
not  be any difficulty in admitting that  morbid
changes,  however slight, may materially alter  its
functions.  The  facts stated, also, show that  an
acquaintance with the structure and functions  of
the retina must be  the foundation of our know-
ledge respecting the disease under discussion.
   The discussion of the  causes  of amaurosis  in-
volves so many details, and presents so many ap-
parent contradictions, that some  arrangement of
the  materials  becomes  absolutely necessary.  A
primary division  into organic  and functional has
been suggested, and has been insisted  upon  by
Mr. Travers in particular.  This  has been object-
ed  to, and justly, on the ground that, although
we have abundant evidence of the occurrence of
the organic disease, yet, that it remains to be prov-
ed whether there is  any disease purely functional,
any disease which does not depend on structural
or  organic  alteration, however  temporary.   For
practical purposes we believe  the  distinction to be
good.   Daily observation proves that the  func-
tions of organs become instantaneously suspended,
and as suddenly restored ; and this has repeatedly
occurred in  the case of the  retina.
   By those writers  who  do not  attempt ahy  ar-
rangement of this intricate  subject, or who adopt
an imperfect one,  amaurosis is attributed to num-
berless causes apparently directly  opposite in na-
ture : to  inflammatory action and vascular tur-
gescence  from general plethora, or to debility from
hemorrhage : to menorrhagia or to amenorrhoea :
to suppressed perspiration, healing of  large ulcers
or issues, sudden suppression  of the secretion  of
milk, or  to discharge from  piles, nursing,  diar-
rhoea diabetes,  ptyalism, or venereal  indulgence :
to the removal  of cutaneous eruptions, or  to  the
occurrence of gastric or intestinal irritation, exan-
thematous diseases, dentition, or worms : to preg-
nancy, or to total  suspension or abolition  of the
uterine functions : to exposure to strong light, or
to confinement in darkness :  to drunkenness, nar-
cotic poisons, direct rays of a hot  sun, muscular
efforts, grief, joy, fear, rage : to wounds or irrita-
tion of nerves of the orbit, especially of the oph-
thalmic branch of the  fifth pair; to  neuralgia,
tooth-ach, or to total  paralysis of  those nerves :
to hydrocephalus, hydrothorax, hereditary  predis-
position, hysteria, typhus fever : to metastasis  of
various diseases, as gout,  rheumatism, and many
others.
  If the primary division into organic and func-
tional be good, it should afford us  some  clue to
this labyrinth.   The division, organic amaurosis,
must obviously include those varieties  of the dis-
ease which depend on alteration  in structure  of
the retina or  of the optic nerve to  its  origin, em-
bracing inflammation of the retina  and its  conse-
quences, increased vascularity, thickening, or other
alterations in texture, the organic disease by some-
described under the title glaucoma,  fungus, haema-
todes, and hydrophthalmia.  To this division must
also be referred those cases depending on wasting,
tumour,  or  other disorganization  of  the optic
nerve, pressure from exostosis, aneurism, or other
tumour.   The  functional form of the disease  ne-
cessarily includes those cases  which  depend  on
affections of the  brain without  actual diseased
condition of the optic nerves, derangements of the
vascular system, irritations of the gastric or intes-
tinal mucous surfaces, disturbed uterine functions,
mental  emotions, and  general  debility.   Hence
amaurosis from hemorrhage, plethora, venous tur-
gescence, menorrhagia,   amenorrhoea, diarrhoea,
worms, dentition, hysteria, venereal indulgence,
suppressed cutaneous eruptions, nursing, and sup-
pressed secretion of milk.  Diseases of the brain
present difficulties in the adaptation of this ar-
rangement.   Effusion of blood or  serum, tumour
or softening, may cause  amaurosis, either  by the
effect on the  sensorium generally, in which  case
the disease might be considered functional; or by
actual pressure or destruction of the optic nerve
in some place from its origin to its  exit, in which
case it is to be considered organic.
  If the example of some writers be followed,
who consider amaurosis, from whatever causes it
may arise, as presenting a  certain uniformity  of
character, every  symptom which  has ever been
found to occur in any form of the disease, must
be enumerated as the  symptom of that uniform
disease.  But it is obvious, that, although  a cer-
tain train of common symptoms present themselves
in every form of the disease, amaurosis from pe
culiar causes must afford peculiar symptoms.  Thi
symptoms common to the disease in all its varie
ties, must first be enumerated, and  those peculia;
to each particular form detailed as such particulai
form comes under consideration.
  Imperfection or loss of vision is, of  course, the
essential and prominent symptom of this disease;
that is, the principal complaint of the patient, anil
the cause of his visiting  the practitioner.   The
imperfection of vision varies  both  in degree and
form.   7 lie student complains  that  he can  no 
BO
longer read with comfort, the letters become con-
fused, indistinct,  and run  into  each  other; the
mechanic complains that he can  no longer follow
his employment; the watchmaker can no  longer
detect minute flaws in  his  work ; the  carpenter
cannot make a  correct joint; the smith no longer
distinguishes the thread of a fine screw  or the
head of a rivet; and  workers with the needle and
at the loom  become completely disabled from fol-
lowing their employments.   The next prominent
symptom is  the appearance of motes, films, gauze,
cloud, or coils,  intervening between  the observer
and the object, technically called muse® volitantes.
These appearances are thus described, by Mr. Tra-
vers, from personal experience :  " The musca voli-
tans is sometimes solitary,  following the eye at  a
fixed angle as it passes  along a line ; sometimes
two, three, or more, are presented ; more frequent-
ly an immense assemblage, descending in a cloud
as the eye is raised, and ascending as it is depress-
ed.  They are  obvious to so many analogies, and
apprehension of impending  blindness makes  pa-
tients so minute in  their observation  and descrip-
tion of them, that it is scarcely possible to do jus-
tice to our experience in attempting  to  describe
them.   Sometimes they are represented  as globu-
lar, sometimes  angular  and  flat, like  a piece  of
money.  Portions of flue,  of soot, insects' wings,
transparent  vesicles, or minute globules  of quick-
silver, connected like the links of a chain, or short
hairs with their bulbs attached to them, are ordi-
naiy  resemblances.   They occupy  the air with
some persons, and are seen upon looking  at the
sky, or upon a white sheet of paper, and especially
in shifting the  eye from one object to another;
to some they  appear in the fire or candle only,
and with others they seem to cover the ground, so
that they walk in them knee-deep."    [These  ap-
pearances may likewise  be present when there is
no serious affection of the  eye.  They are depend-
ent upon some modification in the  blood-vessels
of the retina, which may never interfere farther
with vision.   (Dunglison's  Human Physiology,
5th  ed., i.. 220:  Philad.: 1844.)]   The next
symptom of amaurosis is different  in its nature
from the last:  the  retina appears to be insensible
in some of its parts, while the rest retains the
natural  sensibility to  light. In such  case  the
patient complains of double vision, or interrupted
vision, as if portions of objects  were deficient, as
letters or syllables in words  when reading ; or of
half  vision, when one-half of  an object  is seen
distinctly and  the  other half is totally  invisible ;
or objects are seen  only when placed  in  a par-
ticular position, requiring some attention on the
 part  of  the patient  to  place the object in such
 a position  as  will  direct  its image to the sen-
 sible part  of  the  retina.   Ocular  spectra con-
 stitute  another symptom  of amaurosis ;  in this
 case the images of luminous objects remain on the
 retina after the  object  has  been  removed, or the
 eye turned  from it ;  as when the patient looks  at
 the sun, a candle, or a  patch of any  bright colour,
 on turning the eyes away or even  closing them,
 an image of those objects still presents itself, but
 jf.a different colour.  The symptoms complained
 of by an amaurotic  patient are thus  summed up
 by Mr. Lawrence, in  his published lectures : "The
 symptoms  of  amaurosis are such as are  derived
AMAUROSIS.

        ~f7om the altered state of the function °f ^part.
and under this head you may have every kind of
unpaired vision ;  every kind of defect m the per-
ception of objects  as  to  form,  colour, and then
relations to  each  other: the pat.ent who  has
amaurosis  generally  complains  of  weakness  or
dimness of sight; he cannot employ  the eye so
long as he used to do ; the letters of a book begin
to run into  each  other ; or other  evidences  of
imperfect sight  are noticed.  In this early and
incipient stage of  the  affection,  where  sight is
only partially imperfect, it has been called ambly-
opia  amaurotica,  amaurotic weakness of sight,
The various defects of sight  (vitia visus), enume-
rated as distinct diseases in nosological catalogues,
are only to be considered as  amaurotic symptoms,
forms of the impaired function.   Of these may be
mentioned, visus  nebulosus, visus  interruptus,
visus dimidiatus, visus muscarum, or myodesopia.
Floating  bodies  appearing  before the eye  have
been  called muscx volitantes, and when only a
single black speck is seen, it is called scotoma.  It
is not uncommon for a patient to see a black speck
in the centre of an object;  and as the  affection
proceeds, the opacity increases  in size, becoming
larger and larger, until it covers the field of vision.
When these objects increase in  number, they form
before the  eye  a sort of gauze or network, and
that state of vision has been called  visus reticu-
lafus.  Sometimes objects appear brighter than is
natural, and that is called visus lucidus, or pho-
topsia, and occasionally that brightness is so con-
siderable as to produce uneasiness to  the  patient,
which is then named  photophobia.   Isolated ob-
 jects are seen occasionally double, and hence the
name sometimes  given  to  amaurosis  of visus
duplicatus ; this, bowever, is generally the result
of strabismus.   There is also  a visut  coloratus
 and  a visus defiguratus, from objects being seen
of wrong  shape and colours.   In  particular  in-
stances, the eye  affected  with amaurosis becomes
near-sighted or  far-sighted,  or, as  it is  termed,
myopic or presbyopic ; a presbyopic  state of the
eye  is the most common  attendant on amaurosis;
it is less frequent for the  eye to become myopic in
this  affection.   It  is very common for patients to
be able to see objects laterally after they have lost
 the  power of seeing  them  in the direct line of
 vision."
   The symptoms above  enumerated  are denomi-
 nated, by Mr. Mackenzie, the subjective symptoms,
 while he applies the term objective to those now
 to be noticed ; in  other words, we learn  from  the
 patient the defects he experiences, and from obser-
 vation those which  are  visible  to others.  The
 state of the pupil, the action of the muscles of the
 eye,  the attitude or expression  of the patient, are
 of the latter description.   The changes in organi-
 zation obvious to the eye must be distinctly con-
 sidered when amaurosis from  this cause is dis-
 cussed.
   The size of the pupil, and the degree of activity
 in the motions  of the iris, often afford valuable
 information  as  to  the extent of disease, but, per-
 haps, not to be  so far relied upon as is generally
 supposed.  The motions of the iris, even if cor-
 rectly understood,  are still the subject of dispute;
 and  the complicated  distribution and connexion
 of its nerves is not  satisfactorily settled • it is 
AMAUROSIS.
81
therefore, not surprising that the state of the pupil
in amaurosis should  often be unintelligible.  It
cannot be  denied that, in the majority of cases,
defective vision from  impaired sensibility of the
retina  is accompanied by a sluggish  or  inactive
state of the pupil; and that, therefore, the  state
of the pupil must always be considered a valuable
guide toward a  correct knowledge of the cause and
extent  of the disease.  In  the  commencement of
the disease, the  pupil  dilates  and contracts  slug-
gishly  ; as  the disease increases, the pupil becomes
more dilated and fixed ; and in  complete blindness
it is fully  and  permanently dilated,  constituting
the true gutta  serena.  From this general  rule,
however, the practitioner finds many exceptions.
Complete blindness is not necessarily accompanied
by completely dilated pupil or gutta serena,-  on
the contrary, perhaps there are  more cases of com-
plete blindness with  contracted  or  half-dilated
pupils than with perfect dilatation.  It is also to
be remembered  that complete and permanent dila-
tation  of the pupil is not necessarily accompanied
by loss of vision : the application of belladonna
proves that it  is  not; and cases of fully dilated
pupils without blindness are occasionally met with.
Amaurosis, both complete and partial, is some-
times found to be accompanied by active and per-
fect contraction and dilatation of the pupil.   This
is not  the  place to attempt an explanation of these
apparent  anomalies ; the  subject  is  one of the
greatest difficulty, and involves so  many conside-
rations foreign to the present article, that the stu-
dent must be satisfied with the facts alone.
   The motions of the eye-ball and lids, and the
general aspect, gesture, and bearing of the patient,
often  afford valuable information  to the practi-
tioner.  Most  writers have described  the vacant
expression of countenance which is often observed
in persons  completely blind from amaurosis.  In
such case  the  patient approaches with a moping
stare and gesture of apprehension, as if completely
bewildered.  This is, however, often accompanied
by other symptoms of paralysis, and  is, perhaps,
to be observed  in those cases only which depend
on cerebral disease.   The gesture of the patient
blind from cataract is different, because vision is
not entirely gone ; he approaches in an attitude as
if endeavouring to see something through the thick
cloud  which is interposed between him and ob-
jects.   The motions of  the  eye-ball are  often
highly characteristic.  The eye is either  fixed,
with very  little mobility, or it  turns irregularly in
every  direction, with  a  trembling  oscillating mo-
tion.  This occurs most  frequently in bad  cases
of long standing.
   Squint  is another  symptom often observed  in
amaurosis.  This may arise from the effort  of the
patient to  bring a more  sensible  portion of the
retina into the position  in which it may receive
the impression  of the image  of the object;  or it
may arise  from  a diseased  condition of the third or
of the sixth pair of nerves. In the disease technically
called  ptosis, all  the  muscles supplied from the
third pair  of nerves  are  paralysed, and squint is
produced  by the  action  of the external  straight
muscle,  which  is  supplied  from the  sixth  pair.
Squint is also unquestionably produced by paraly-
sis of the external straight muscle from disease
affecting the sixth nerve.
   Vol. I.—11
   [The method of examining the eye, termed the
" catoptric," which consists  in holding a  candle
before  the  eye, the pupil  of which has been pre-
viously dilated by belladonna, and noting the images
of the  candle, affords valuable information, where
any difficulty exists, as is at times the case, whether
the disease be amaurosis or cataract.   When the
humours are unimpaired, and  the  affection is
wholly  in  the  nerve of vision, three images of
the candle  are seen ; two erect, and one inverted ;
the former reflected respectively from the cornea
and the anterior layer of the crystalline ; the latter
from the concave surface of the crystalline; whilst
in cataract the  erect,  or  the inverted  image, or
both, will be dull, indistinct, or absent, owing to
opacity of the anterior or of the posterior portion
the crystalline,  or of both.]
   The origin, causes, and symptoms of amaurosis
having been  discussed in  a general way, the dis-
ease is now to  be considered circumstantially in
detail as it depends on distinct and obvious causes.
The most frequent cause of amaurosis of the worst
form is internal inflammation of the  eye  and its
consequences.   This is, therefore, the first to be
considered.
   1. Amaurosis from inflammation  of the
     retina, and its consequences.
   That  amaurosis,  or,  to speak  more  plainly,
defective vision, must  attend inflammation of the
retina  is obvious ; it is, in fact, the symptom, not
the disease :  and, therefore, the subject of inflam-
mation of the retina must receive distinct conside-
ration. The first question to be settled is, whether
inflammation of the retina  ever  exists perfectly
insulated, and without involving the neighbouring
structures ; or  whether inflammation of the other
parts of the globe of the eye, as the iris or choroid,
ever occurs without  involving the retina.   This
is a question  of some difficulty.   The functions
of the  retina  are so frequently impaired from iritis,
both during the existence of inflammation  and
after it subsides, that the extension of the inflam-
mation from one to the other, or their co-existence
in both, must  be admitted ; and, therefore, the
general adoption of the term  iritis, and its frequent
application to inflammation of all  the contents of
the eye-ball, have proved most injurious, by direct-
ing the attention of the practitioner  to the state
of the  iris  exclusively, and placing out of view the
retina, which, from its  greater delicacy, and  from
its integrity being  so much  more  essential to
vision, should  be an object of greater anxiety.  It
is not  denied that iritis does occur without corre-
sponding  inflammation of the  retina; but it is
certain that they are both frequently engaged, and    <
that the disease, in  such cases, is general inflam-
mation of  the eye-ball, or internal ophthalmia.
   Mr. Travers says, in his Synopsis of Diseases
of the Eye,  page 137, that "the  retina is some-
times,  though  rarely, the seat of inflammation;
but it is a* error to suppose that intolerance of
light is a sign  of this affection, as is clearly proved
in the  strumous ophthalmia, in which, though the
intolerance is in excess, the retina is uninjuied :
and, secondly,  because the effect of inflammation
upon  a  nerve  of sense is  to produce  palsy, not
increased excitability."  That intolerance of light
is not necessarily a symptom of  inflamed retina
may be admitted;  but it is net  Droved that the 
82
AMAUROSIS
effect of inflammation  is to produce palsy of a
nerve of sense.
  The causes of inflammation of the retina are as
various  as  those of general inflammation  of  the
eye-ball.   The  disease may  arise  from  gout,
rheumatism,  syphilis, mercury, or typhus  fever;
or it may be  idiopathic, without assignable cause.
Mr. Lawrence appears to consider every form of
amaurosis to  arise  from inflammation.  He says,
'Amaurosis,  in its most frequent  and important
form, that  which is seated  in the  eye  itself, is
generally inflammation  of the nervous structure ;
including,  under that  phrase, all  d-egrees of in-
creased  vascular activity, whether designated as
fulness, turgescence, determination, congestion, or
as inflammation in its  most limited sense ; and
the usual result of inflammatory disturbance, that
is, organic change,  permanently destroying  the
function of the part."
  Mr. Travers describes the symptoms of inflam-
mation  of  the retina as follows :  " the first and
predominant  symptom  of inflamed  retina, viz. a
sudden  attack of vehement dashing pain  of the
most distracting kind, which is described to  extend
from the bottom of the  eye-ball to the occiput, or
in the  reverse  direction,  and the  supervention
within a few hours of  total  blindness, with occa-
sional sparks and flashes of vivid light."   " The
pupil, upon inspection, is gaping and motionless,
as in confirmed amaurosis, and the humours  are
thick and muddy."   Mr. Wardrop observes, that,
" When the retina is affected with inflammation,
the  disease is marked  by painful  vision;  intole-
rance of light; sparks  of fire, or  drops of a  red
colour falling before the eyes ; little  external red-
ness ; pain darting through the head ; with more
or less constitutional derangement."   To suppose
that inflammation of the retina is  always accom-
panied by those violent symptoms would be dan-
gerous in practice.  The disease is often mild and
insidious in its approaches, and marked  more by
defective vision than by symptoms of inflamma-
tion.  The  first care of a practitioner, on approach-
ing a person complaining of defective  vision of
recent occurrence, is, to ascertain whether there
be any evidence of the existence of inflammatory
action in the retina.   The symptoms may often
fail to  satisfy him; there  may be  no pain, no
morbid  sensibility  to  light,  no  headach.  The
state of the pupil is no guide, as it is affected, more
or less,  in  almost every form of amaurosis. The
form or nature of the spectra, or muscx volitan-
tes, does not  enable  him to pronounce with cer-
tainty.   The difficulty is,  however,  frequently
removed by careful inspection of the  state  of the
sclerotic coat.  The arterial  inflammatory vascu-
larity of the sclerotic has always afforded a charac-
teristic symptom of internal inflammation  of  the
eye-ball, and has been  dwelt upon with  emphasis
by Mr.  Saunders, and  subsequent writers.  The
red vessels converging toward the anterior part of
the eye-ball, in distinct lines, and forming by their
delicate subdivision into minute branches a bright
red zone round the circumference  of the  cornea,
is always pointed out to the student as an appear-
ance  indicative  of  internal inflammation,  and a
uniform accompaniment of iritis.   This appear-
ance  often, perhaps  always, in a greater or less
:legree,  accompanies inflammation of the retina ;
and when attended by defective  vision and com-
plaint of a  film or  gauze before the eye, should
probably be  considered conclusive evidence ol the
nature of the disease.
  The  treatment  of inflammation  ol the retina
must  embrace the  means  usually adopted to re-
move or restrain  inflammatory action,  modified
and proportioned  to  the nature, peculiarity, and
intensity of  the  disease in  each individual case.
Such are, general bleeding, leeching, and cupping,
nauseating and purgative medicines, mercury, and
blisters.   When the attack is accompanied by the
intense  and  alarming symptoms just now enume-
rated, on the authority of Mr. Travers, the adop-
tion of  a vigorous plan of depletion is obviously
demanded, and general and local bleeding indi-
cated ;  recollecting, however, that we  should not
be too  sanguine  as  to the result,  or place  too
much confidence in these resources,  unassisted by
other means.   Daily experience proves how un-
availing mere depletion is found in irritis, or gene-
ral internal  inflammation, and even how unsuited
to particular cases, however intense the symptoms.
The value of mercury in the treatment of inter-
nal inflammation of the eye in general, and of in-
flammation  of the iris in particular, is now so fully
appreciated, that no argument  need be employed
to induce the practitioner to give it a fair conside-
ration.   Mr.  Travers makes  the  following ob-
servations respecting its administration : " When
the amaurosis is  recent and sudden,  and either
the signs of an obscure inflammation are present,
or only  the  amplitude and inactivity of the pupil
correspond to tbe  patient's history, the indication
is less simple ; mercury should be introduced with
all convenient rapidity into the system, I mean so
as to ruffle in the least possible degree.   No ad-
tage is obtained  by salivation ; on the contrary, I
think it hurtful.    When mercury is beneficial, its
efficacy is perceived as soon as the mouth is sore.
I have seen it tried,  and  have myself tried it in
many cases  of amaurosis, without the smallest ad-
vantage ;  but in cases of recent occurrence, im-
perfect,  but  rapidly progressive from  bad to worse,
I have been witness to its  power in suddenly ar-
resting  the  disease in too many instances not to
entertain a  far higher opinion  of it than of any
other article of the Materia Medica."   Mr. Law-
rence, who,  we have  already said, appears to con-
sider  the majority of cases of amaurosis to arisa
from inflammatory action, sums up  the treatment
as follows :  " Our  object is to put a stop to vascu-
lar excitement, to prevent the permanent injury
of altered structure, and impaired  function in a
structure the peculiar delicacy of which particu-
larly exposes it to such danger.   We must, there-
fore, employ antiphlogistic treatment of a decided
character, and follow it up with a decision and
steadiness commensurate with the importance of
the affected  organ:  under the head of  antiphlo-
gistic treatment, must be included general and
local blood-letting, but more particularly the latter,
as, by cupping from the back of the neck or the
temples, or by the application of leeches, the eva-
cuation  of tbe bowels by purgatives, and a re-
stricted  diet.  Repose of the organ should be ob-
served,  more or less complete,  according to  the
nature of  the case ;  counter-irritation  by blisters,
from which  a discharge may be kept  up by irri- 
AMAUROSIS.
83
tating  dressing :  these are the means suitable to
the early stage of the affection, the stage of ex-
citement ; but if this treatment be not  found to
remove the change which  has been produced  in
the retina, we must have recourse to mercury,
which appears to be as decidedly beneficial in these
cases,  as in iritis, or general internal inflamma-
tion.   The remark which  I made respecting  the
use of mercury in those affections, applies also to
the present case, namely, that its  good  effect
mainly depends on the promptitude  with which
it is employed.  The alterative form is insuffi-
cient ; we  give it with the view of arresting in-
flammation in  the structure, which  is  the very
seat of vision : that structure is easily changed  by
the inflammatory process ;  our only remedy is to
push the mercury in a decided manner ; and, if
we do so, we  shall put a stop to the affection.
We have used mercury very freely for amaurosis ;
 we have used it until profuse salivation has been
produced, and many decided instances of the good
effect  of this  practice have  come  under our ob-
servation."
   The practitioner has other resources than those
above  mentioned.  Internal inflammation of the
eye yields often to remedies of very different cha-
racter ; and inflammation of  the retina forms part
of that disease.   Cases may occur where general
depletion is  inadmissible.    Old and debilitated
females, scrofulous subjects, persons already weak-
ened  by disease, poverty,  or confinement in  ill-
ventilated apartments, or who  have, perhaps, just
gone through a mercurial course, evidently would
not derive relief from such  treatment: on the con-
trary, they would require a  tonic plan of treatment,
with the free administration of bark and generous
diet.   If inflammation of  the  iris be arrested or
restrained by the administration of turpentine, as
stated  by Mr. Hugh Carmichael, and  it seems
agreed tbat in certain cases, probably of peculiar
character, it is a valuable  remedy, it  should con-
stitute one of the resources in inflamed retina.
Should the  inflammation occur in  a gouty  or
rheumatic habit, or alternate with affections of the
joints, or other symptoms of these  diseases, the
treatment must be modified  accordingly, and ad-
vantage  taken of the resources which  medicine
affords in  such cases.   Colchicum,  under such
circumstances, has  been  resorted  to with some
advantage.   The  eye should be protected from
the irritation of strong light; but total darkness is
unnecessary, and is probably pernicious, by  in-
creasing the sensibility of the retina.  Care should
be taken that, in excluding light, the free circula-
tion of fresh air round the patient should not be
interrupted.   No  circumstance has contributed
more  to the want of success in cases of this  de-
scription, than confinement of the patient to the
respiration of  an  atmosphere  contaminated  by
human effluvia.
   2. Amaurosis from disorganization of the
    retina, a coxseq.uence of inflammation.
   It is reasonable  to believe, that during  the  in-
flammation of the retina,  vision  is impaired  by
those  changes which uniformly  accompany  in-
flammation, as increased vascularity, and  excited
or altered sensibility ; while  the effects  or conse-
quences,  such  as  enlargement of  vessels,  and
thickening or disorganization of structure, remain
after inflammatory  action has  subsided.  These
two  states present  as  remarkable a difference in
character as the acutely inflamed conjunctiva, and
the vascular and  altered  condition heretofore de-
nominated the chronic stage of that disease.  In
practice this distinction must never be lost sight
of, because  the treatment of an inflamed retina
must be very different from that of a retina which
has  formerly suffered  from  inflammation.  The
practitioner, therefore, has first to ascertain whe-
ther  the case before him be actual existing inflam-
mation of the  retina, or disorganization produced
by inflammation.
   Cases of amaurosis from disorganization of the
retina  are of frequent occurrence, because this
state of the eye is produced by  every form of in-
ternal inflammation.   The patient complains of
defective vision, under all circumstances :  he can
read with difficulty, for  he  can only distinguish
the larger letters  ; he sees the  general  outline of
objects, or the more remarkable appearances in
form or colour, but he cannot distinguish  the fea-
tures of those near him, or recognise his acquaint-
ances.   A film or mote of precise unvarying form
appears to float before the eye, and frequently  a
uniform cloud or  mist interrupts vision.  A lighted
candle appears as  if seen  through  a  mist, or is
surrounded  by a  halo.   These  are  a  few of the
symptoms of which the patient complains :  many
others of the same description are occasionally ob-
served.
   On looking into the  eye in  such   cases, the
pupil may appear perfectly  transparent;  the iris
may be capable of acting, though sluggishly ; and
the cornea and sclerotic  may be in an apparently
healthy state.  On  a  closer inspection,  a  slight
irregularity  of the pupil  may be observed, which
becomes more remarkable  upon shading the eye
from the  light, and still more upon dilating the
pupil with belladonna, when  an adhesion of the
margin of the pupil to the capsule of the lens  at
one  or two points becomes visible.
   Where this little brown  string of adhesion  is
attached to the  capsule, a slight  opacity of that
part may be observed.   This is the slightest de-
gree of actual change of structure to be observed
in those  cases; in other examples the disorganiza-
tion is much more obvious.   If the eye has suf-
fered from severe internal inflammation, the  entire
margin of the contracted  pupil adheres ; causing  a
circle of  white opacity at  the place of adhesion,
and  leaving a central portion of the capsule and
lens transparent,  and capable of transmitting the
rays of light  to  the retina.  If the previous in-
flammation  has  been still more destructive in its
consequences, the  pupil is  much  contracted, or
even completely closed, and adhering to the cap-
sule of tbe lens, which  is  opaque ; constituting
capsular and, probably, lenticular cataract.   The
existence of the cataract  does not alter the case as
regards the  retina ;  it is still, partially  or wholly,
insensible to light,  as is often proved by the want
of success in operations for cataract in such cases ;
and this  very state of the eye  should  make the
operator cautious in his prognosis as to the result
of an operation, as  in such cases the cataract may
be removed, and  yet no vision  follow, on  account
of the disorganization of the retina.  The sclerotic
coat frequently  presents, in such  cases, a livid 
84
AMAUROSIS.
vascularity, with large veins ramifying through it
in every direction ;  and in the  worst  cases the
shape of the globe is altered, and the sclerotic  is
projected or stretched into a staphylomatous tu-
mour, or depressed into hollows by the action of
the muscles.   This state of eye-ball is highly cha-
racteristic of the completely unsound retina, and
proves the hopeless nature of the disease.
   In  considering the  treatment of amaurosis,  or
impaired vision, the  consequence of internal  in-
flammation, the first  question to be determined  is,
whether the treatment adopted  in the inflamma-
tory stage be applicable to this :  recollecting that
the state of the eye  now under consideration is a
consequence observed many months, or even years,
after the cause  has  subsided.    The doubts  re-
specting the state of  the retina, and the treatment
of its diseases, arise from the impossibility of see-
ing the alterations in its structure.  Opacities  of
the cornea, and  enlarged vessels of the conjunc-
tiva, are visible after  the inflammatory stage  of
purulent ophthalmia has  passed  away ;  and the
practitioner  is, therefore, satisfied that he cannot
remove them  by  a  repetition  of the depletion
which he first, adopted. If the thickness and vas-
cularity, which probably exist in the retina, were
equally visible, he would also despair of removing
them by his first plan of treatment.   Abstraction
of blood may be advantageous in full plethoric
habits, to relieve a turgid  state of vessels already
permanently enlarged ; but it should not be re-
sorted  to with the view of removing inflammatory
action, which  no longer exists.   Mercury is fre-
quently administered  in these  cases, and  appa-
rently  because it has been found advantageous in
the inflammatory  stage.  If mercury be of any
use in such cases, it is by promoting absorption
of lymph, or other deposit found during inflam-
mation ; it is  not, however, found to effect such
objects in  cases where deposits,  or  thickenings,
are obvious to the eye, as in opacities of  the cor-
nea, or in closed pupil,  and, therefore, probably
possesses no such power  here.   At all events,
mercury should not be indiscriminately  resorted
to, and a guarded prognosis  of the  result  of  its
administration  should be  made.  To  rouse  the
activity of the  impaired  function, or to raise  the
sensibility blunted by disorganization, impressions
on the extremities of the fifth pair of nerves may
be advantageously resorted to ; hence the  practice
of repeated blistering all round  the orbit, or  of
applying stimulating  liniments, or sinapisms,  in
the same situation.   With the same view, ster-
nutatories  may assist; and perhaps,  in certain
cases, electricity.
   3.  Amaurosis   from  vascular   turges-
     cence, NOT AMOUNTING TO INFLAMMATION.
   Amaurosis is sometimes caused by hemorrhage,
as well as by a general plethoric state of  the vas-
cular system ; but it is difficult  to determine why
this happens  in some cases only.   Hemorrhage
occurs every  day, and yet blindness from this
cause  is rare.   Amaurosis is not by any  means a
constant, perhaps not a frequent symptom of gen-
eral plethora, or that state  termed a determina-
tion of blood to the  head.   Whatever may be the
condition of the arterial capillaries  of the  retina
when the action of  the heart is suspended, inter-
 rupted,  or greatly weakened, blindness is  not a
necessary consequence ;  it does not occur m bleed-
ing unless faintness be produced ;  it does not at-
tend extreme weakness, with imperceptible pulse,
preceding death ;  nor is  it a consequence  of the
application of a ligature on the carotid, which re-
strains hemorrhage  or  cures  aneurism.  On  the
other hand, whatever may be  the state of the ve-
nous  capillaries of the retina, during a turgid or
obstructed  state of the venous circulation, blind-
ness is  not found to be a consequence of tempo-
rary pressure of the jugular veins, or of accumu-
lation of blood in the right side of the heart, from
disease of the  heart  or lungs.  These considera-
tions are important in a practical  point of view;
upon them  the practitioner founds  his estimation
of the degree  of value  of a system of depletion,
or the opposite plan of invigorating  or increasing
the activity of the vascular system.
   The first care of the practitioner in cases of de-
fective vision, without apparent inflammation or
disorganization of the retina, is to ascertain, as far
as symptoms admit, whether  there  be  reason to
suspect increased arterial or obstructed venous vas-
cularity.   The amaurotic symptoms afford no sa-
tisfactory evidence upon the subject. The informa-
tion must be derived from the appearance of the
patient, or the existence of undue vascular action
elsewhere, turgidity of the vessels on the surface,
especially those visible in the  conjunctiva or scle-
rotic, throbbing of the arteries of the head, or ful-
ness of the jugular veins.  Mr. Mackenzie, in his
Treatise on the Diseases of the Eye,  says,  " It
has been mentioned  that plethoric  persons are in
general  able  to  produce a degree of congestive
amaurosis  at  will, by stooping, tying their neck-
cloth tight, and the like.  We also frequently wit-
ness a temporary amaurosis from exhaustion.  For
instance, if the nervous  system is the seat of no
particular excitement at the time, we observe that
by the sudden abstraction of blood, the  organs of
vision,  and, indeed, all  the organs of  sense, are
strikingly enfeebled.   In some individuals the de-
bility continues for several days, and if any  one
of the organs of sense has been previously weaker
than the rest, the feebleness of that organ is gene-
rally increased by bloodletting.  When syncope
is produced by loss  of  blood, sight appears to be
the sense which fails first, and which recovers last.
Hearing is next, while smell, taste, and touch, are
less affected, and more easily re-animated by exci-
tation.   They return in a very short time to their
natural state ;  but it is not so with sight.  It is a
popular  opinion  that  bloodletting  weakens  the
sight, and, to  a  certain  length,  the opinion is
founded in fact."   This view may be contrasted
with that in the preceding paragraphs;  but what-
ever doubt may be entertained respecting the effect
of particular  states of  the  vascular system  on
vision, there can be none in practice as to the pro-
priety of removing,  if possible, a  turgid state of
the vessels, in persons suffering from amaurosis.
   If, therefore, a  person complains of defective
vision, with those symptoms which indicate vas-
cular turgescence, the cause  of this turgescence
must, if possible, be ascertained.   If the counte-
nance is bloated and purple, and  the conjunctiva
 full of large veins, and  there  are difficult respira-
 tion and other symptoms of disease  of  the heart
 or lungs, the cause is obvious.  Such cases are of 
A M A U
ROSIS.
83
daily occurrence, and in the indications of treat-
ment the removal of that cause must not be over-
looked ; or, if it cannot be removed, the prognosis
must be regulated  accordingly.  But if no such
existing disease be obvious, and yet defective vision
with symptoms of vascular turgescence be present,
that symptom must  be combated by the  usual
means ; as bloodletting local and  general; blisters
or sinapisms  behind the ears as counter-irritants,
or a seton in  the neck, as a permanent discharge;
sponging the forehead and head  with cold water,
using  the  shower-bath.  The bowels should  of
course be  emptied, and all future accumulation
there prevented, and the functions of  the stomach
and liver preserved in a state of perfection.  Ab-
stemious diet, exercise in the open air, alterations
in habits, and every other plan calculated to im-
prove the general health, sbould of course be en-
joined.  In the application of  this plan  of treat-
ment,  the  following observations of  Mr. Travers
deserve attention :   " A  loss  of  balance  in  the
sanguiferous  system, occasioning an undue deter-
mination of blood to the head,  often exists distinct
from general  plethora, and  is  aggravated  by loss
of blood.   Cases of undue determination of blood
to the organ are especially common after deep-
seated chronic inflammation, or distress from over
excitement, by which vessels have lost their tone ;
an effect decidedly  increased by depletion."
   4.  Amaurosis from  interruption  of the
     functions of the digestive organs.
   Whatever doubts may be entertained respecting
the efficacy of the treatment of amaurosis by eme-
tics and purgatives, it  appears  to be agreed on all
hands that defective vision is often a  consequence
of interruption  of  the  functions of the digestive
organs.  That amaurosis is, however, every day
attributed to  this morbid  condition where there is
no evidence  of the existence  of any such cause,
is known to every practitioner; but it is  equally
notorious that it is frequently  a symptom of dys-
pepsia, and its  occurrence from  worms or otber
irritating matters in the alimentary canal is a still
more decisive proof of the  effect of  such  causes.
It must not  be  forgotten, that  in the majority of
these  cases  the individual is exposed to those
remote causes which may lead to the interruption
of the functions of the retina  as well as those of
the alimentary canal.  The sufferers are generally
artisans or students, whose gastric organs may be
injured by  their sedentary habits, mental exertions,
or confinement in close and unhealthy apartments;
while vision may at the same time be impaired by
the application  of the eye to minute or brilliant
objects.  For practical purposes, it is only neces-
sary to determine whetber a patient  complaining
of impaired  vision, and  muscae  volitantes, with
sluggishly  acting or fixed  pupil, foul tongue, head-
ach, flatulence or acidity of the stomach, and tor-
pid bowels,  should be treated for his dyspeptic
symptoms, or only for the amaurosis ;  and, on the
other hand, whether a patient complaining of im-
paired vision, muscae volitantes  or  spectra, and
presenting  a  fixed or inactive  pupil, without any
apparent symptom of gastric  disease, should  be
treated with medicine calculated to remove dyspep-
sia.  Whatever doubt may be entertained respect-
ing the propriety of the administration of emetics
and purgatives  in amaurosis, where  the state of
                                         H
the digestive organs  does not indicate  it,  there
cannot reasonably be any in directing the atten-
tion to this object where defective vision is accom-
panied by gastric derangement.
  Schmucker and Richter in Germany, and  Scar-
pa in  Italy, have been the most decided advocates
for the emrtic practice; and in this country it has
been followed up with various degrees of success :
upon  the whole, however, the testimony of writers
is unfavourable to the practice, at  least unless in-
dicated by symptoms of gastric or biliary derange-
ment.   The  following  is  the plan  adopted  by
Scarpa :  " The first part of the treatment of im-
perfect amaurosis is restricted to emetics and  in-
ternal resolvents.  It is desirable  in  the majority
of cases, if the patient is  an adult,  to  prescribe
three  grains  of tartar emetic dissolved in four
ounces  of water, of which he should take two
spoonfulls every half hour until nausea and abun-
dant  vomiting  be produced.  The day after, he
should take the resolvent powders, composed of an
ounce of cream of tartar, and a  grain  of  tartar
emetic, divided into six equal parts.   The patient
should take one in the morning, another four  hours
after,  and a third in the evening,  for eight or ten
days in succession.  This remedy will cause some
nausea, and produce some more frequent discharge
of the bowels,  and  perhaps some vomiting.  If
during the employment of these  resolvent  pow-
ders the patient makes ineffectual efforts to vomit,
if there is a bitter taste in the mouth with loss of
appetite, without any improvement in vision, the
emetic should be repeated ; and  this for three or
four  times,  if  the  presence of  gastric irritation,
bitter taste in the mouth, tension of the hypochon-
dria, acid eructations, and  tendency to vomit  de-
mand it.  When the stomach is  cleared out, the
resolvent powders of Schmucker  should be pre-
scribed, consisting of tbe following ingredients :
Gum. sagapen., Galban. Sap. venet. aa. gi;  Rhei.
giss ;  Antim. et Potass. Tart. gr. xvi.  Ext. gly-
cyrr.  gi; Ft. pil. gran, unius.   Fifteen of those
pills to be taken night and morning for four  or six
weeks; or  the  formula of Richter, consisting of
the following ingredients, may be preferred :  Am-
moniac.  Assafcetid. Sap.  Venet. Valerianx rad.
Summit, arnicas aa. gii;  Antim. et Potass.  Tart.
gr. xviii. ft. pil. gr. 2.  Fifteen to be taken three
times a day for some weeks."  It is  scarcely  ne-
cessary to observe that the farrago composing these
resolvent pills can possess no peculiar virtue, and
that modern improvements place more valuable
remedies and resources in the hands  of  the prac-
titioner.  Nor need we repeat here the  plans of
treatment to  be adopted for the removal of the dis-
eased condition of the stomach or alimentary canal
The educated practitioner must suit his treatment
to the peculiarities of each particular case ;  keep-
ing in view the necessity of removing all offend-
ing matters from the stomach and bowels, avoiding
all food  or drink calculated to aggravate the dis-
ease,  and altering  as far as  possible the habits of
the patient.
   It is desirable to record the opinions of practical
writers respecting the treatment just  alluded to.
Mr. Travers, p. 304, says, «I do not recollect an
instance of decided benefit  from the emetic  prac-
tice, although, in respect to its  high authority.  I
have tried it fairly in many instances.   The  cases 
56
AMAUROSIS.
of gastric disorder to which it is especially appli-
cable, are most benefited by a long course of blue
pill, with gentle  saline purgatives and tonic bit-
ters.   In  most of those cases we must depend,
first, on the regulation of the visceral  functions;
and,  secondly, on the employment of such resto-
ratives as the system requires and can bear.  The
blue  pill, with colocynth, rhubarb, or aloes,  and
the combination of soda with rhubarb and Colombo
or gentian, are best adapted to the former purpose.
The  exhibition of general tonics is often strongly
indicated, and I have seen much benefit derived
from the mineral  acids, bark, steel, (when admissi-
ble,)  and arsenic, after a  due regulation of the
digestive functions.  I know of no article of the
class  of  stimulants that  has  any direct  claim  to
notice, or any approach  to a specific virtue, such
as has been ascribed to the arnica montana, aco-
nite,  &c."  Mr.  Lawrence,  who,  as has  been
already observed,  considers the majority of cases
of amaurosis to  depend  on inflammatory action,
or vascular turgescence,  observes,  " When  the
antiphlogistic treatment and a fair trial of mercury
have failed, I do  not know that it  is possible  to
effect any further essential  good by other means.
We  must  be  contented  with such management
and simple diet as are most  conducive to general
health, and  take the chance of such local amend-
ment as the affected organ may slowly  experience
under gradual general improvement.   Residence
in a  pure air, frequent exercise  out  of doors,  a
plain, mild, but nutritious diet, the regular use of
mild aperients, with the occasional employment of
a more active purgative, and repose of the affected
organ, form a combination of measures best calcu-
lated to invigorate the system generally, and thus,
as far as circumstances will admit, to  arrest local
disease.   The effects of counter-irritation may  be
advantageously tried in  conjunction  with such
measures.   Blisters  may  be  applied  behind the
ears, and at the  side or  back of  the  neck, and a
discharge may be kept up by the savin cerate.'
But  we prefer a succession of blisters, applying a
new one to a fresh surface every five, six, or seven
days."
   [The endermic use of strychnia has been advised
by Mr. Middlemore, (Treatise on Diseases of the
Eye, p. 290.) and by Messrs. Liston, Henderson,
Furnari, Petrequin and  others;  but  Mr. Tyrrel
and  Mr. Lawrence,  (On  Diseases of the Eye,
Amer. edit., p. 519,) have never seen it or veratria
exert any power over the disease.  It has been
used, also, internally, and in the form of collyrium,
containing from two to eight  grains to two ounces
af water; a little  acetic acid being added to render
the strychnia more soluble; and two drops being  let
fall into the eye a few times a day.  (Dunglison's
New Remedies, 4th edition,  p. 554, Philadelphia,
 1843.)
   Besides blisters, acupuncture, moxas, ammonia-
ted lotions, and every form of revellent, have been
used  to  the temples, behind the ears, or to  the
back of the neck. Some cases of imperfect amau-
rosis have likewise  been treated with success  by
galvano-puncture ; and similar results have been
obtained from the use of a galvanic current, made
to pass from  the mastoid  process to the superci-
 liary ridge, (Op.  clt., p. 40 and p. 327.)]
  5. Amaurosis from  exercise of  the  etk
     on minute objects.
  It cannot be  denied that defective  vision is
occasionally produced  by exposure to this cause;
but when  it is recollected that thousands, nay
millions, are thus exposed, in  a greater or less
degree,  some  doubt may be permitted  as to  its
operation, especially when  sufferers in  this  way
are exposed to other causes which affect the hearth
generally.   Students,  scriveners, printers, engra-
vers, microscopic observers, watchmakers, gilders,
furnace-workers, and cooks, are enumerated among
the sufferers from this cause.  But there are seden-
tary  or  unhealthy employments calculated to im-
pair  the functions  of many  organs,  and in this
way alone  to  produce that  state of the retina
which  accompanies the disease.   Simply using
the eyes constantly in  intently viewing minute
objects, although such objects should not reflect
any unusual quantity of light, appears to impair
vision  as  much as working  on brilliant objects,
at least we find as many cases of impaired vision
among  tailors, scriveners, shoe-makers, and cabi-
net-makers, as among engravers, gilders, glass-
blowers, or cooks.  The question which  it is  here
important  to solve,  is, what  is  the  state of the
retina in these cases ?  Is it a state of excitement
with  morbid  sensibility and  increased vascular
action, a state approaching to inflammation ?  or
is it the very reverse, a state of impaired sensi-
bility and defective vitality  ? Until these  questions
are solved, impaired vision,  from these causes,
cannot  be positively referred to  the division  of
functional  amaurosis more correctly than to the
organic.  It has already  been  stated  that  Mr.
Lawrence  considers amaurosis  of this  character
to depend upon inflammatory  action, or, " vas-
cular  activity,  whether  designated   as fulness,
turgescence, determination, congestion,  or as in-
flammation in its most limited sense."
  The symptoms, in cases of this description, are
merely impaired vision, disabling the patient from
following the usual pursuits  of reading or work-
ing ;  muscae  volitantes,  or  spectra,  of various
colours, forms, and qualities, floating before the
eyes ;  and a fixed or sluggishly acting pupil.  It
does not appear that the symptoms are materially
different,  whether  the disease  has  arisen  from
exercise of the eye  on brilliant  objects, or  on
objects  merely minute.
   Whether it may be advisable  to rely upon a
treatment directed to the improvement of the func-
tions of the digestive organs in  amaurosis, from
these  causes, must be  very  questionable.   The
principal reliance must be  placed in  the removal
of the  original remote cause.   The patient should
understand that  no remedies can avail while  he
continues  to exercise  the  eye as before.  There
can  seldom be much difficulty in accomplishing
these objects,  when the patient does  not depend
for a livelihood upon the exercise of his eye; but
the  poor  artisan has often  only  the alternative
between starvation  and blindness.   Under  such
circumstances, every argument  should be used to
induce the patient to give  up his trade for a sum-
mer, and to endeavour to earn his bread by rural
occupations.  The  most careful  inquiry and  ex-
amination must  be  made to  ascertain whethei 
AMAUI
there be any evidence of the existence of inflam-
matory  action or  vascular  turgescence  in the
retina.  The history and progress of the case, the
appearance of the sclerotic and pupil, the consti-
tution and habits of the patient, must be the best
guides.   The practitioner could not  reasonably
determine to  adopt  an  antiphlogistic treatment
with  a sallow, pallid, emaciated  patient, whose
eyes present  no unusual vascularity ; while  it
might be imperiously demanded in a bloated, gross
man of intemperate habits, and whose eyes are
disfigured by  vascularity.  If it be  necessary  to
adopt the antiphlogistic  plan, it is to be followed
up as detailed when speaking of inflammation of
the retina, and recourse had to  the administration
of mercury to the same extent.  If the digestive
organs are impaired in function, they must be im-
proved by the usual means.  If there is  no evi-
dence  of  inflammatory  action, but,  on the  con-
trary, a languid circulation  and general  debility,
every method calculated to improve the  general
health must be adopted,  as pure air, invigorating
diet, and  tonic medicines.  Blistering and  other
stimulating  applications  in  the vicinity of the
orbit, and pungent applications to the  nostrils,
and even  to the conjunctiva itself, may be found
of service.
   6. Amaurosis  from  injury or disease  of
     the  tiftn  nerve, or  its branches.
   It has  long  been known  that  injury of the
frontal nerve, or branch of the ophthalmic branch
of the fifth,  is  injurious to vision, and, conse-
quently,  that this  nerve exerts  some very im-
portant influence on this function.  Little more
than  this is  now known,  notwithstanding the
attempts of  Magendie to clear  up  the doubts on
the subject  by experiments on animals.  These
experiments, which are detailed in his journal of
physiology,  are of so violent  and destructive a
nature, and   so  much calculated  to disturb  or
destroy the functions of the nervous system gen-
erally, that the results stated to have followed can-
not be attributed to the mere division of the fifth
nerve.  It is, however, most probable, since vision
is impaired  by injury of a branch of the  fifth
nerve, that it should also be impaired or destroyed
by division  of its  trunk.  Pathological  observa-
tions,  hitherto not numerous  or  authentic, will
probably do  much more  toward elucidating this
subject than  destructive  experiments on living
animals.  No opportunity  should  be lost of as-
certaining the state  of vision  previous to death,
in persons whose fifth  nerve shall be found dis-
eased or destroyed.   The nature of the connexion
between the fifth nerve and the nerve of vision is
illustrated by the fact, that, in cases of conjunc-
tival  inflammation, modified by scrofula, violent
sneezing  is  produced by exposure  of the eye  to
light.  Disease  or  growth of a tooth has some-
times been found to impair vision.   Such a case
is recorded by Dr. Galenzouski, of Wilna, in the
Archives  Generates, where  blindness was  pro-
duced by a  splinter of wood becoming entangled
in a diseased tooth.  Mr. Travers, says, « I  have
seen an incipient amaurosis distinctly arrested by
the extraction of a diseased tooth, when the  delay
of a similar operation had occasioned gutta serena,
on the opposite  side, two years before.''  Defec-
tive vision frequently attends  neuralgia  in the
*OSIS.                                   87

vicinity of the eye.   Mr. Travers,  says, " There
is an intermittent  spasmodic pain accompanying
some cases of amaurosis,  shooting through the
orbit into  the head, of the most acute and dis-
tressing severity ;  it  makes a periodic attack at or
about the  same hour  every night,  and continues
for several hours ; it is  accompanied by convul-
sive quivering of the muscles of the eye and eye-
lids, and profuse lacrymation ; there is nothing in
the appearance of the  organ to explain its  nature
and origin.  What has been described as  an  in-
termitting  ophthalmia, is,  I think,  improperly so
termed—the pain, not the inflammation, is inter-
mitting.   The pain of tooth-ach,  according to  the
state of the vascular system,  is subject to  inter-
missions more or less complete ;  but the periodic
pain to which I refer, is independent of any visi-
ble  sign of inflammation.   I  believe it  is  a  tic
douloureux, affecting  one or more  of the  orbitar
branches of the fifth pair of nerves.   I have cured
it, in two cases, by arsenic, where opium failed to
prevent  the  paroxysm.  I  have  known one  in-
stance, of a  similar  affection, without any defect
of vision."  Mr. Wardrop  affords  the following
information  on this subject: " Wounds  of  the
eye-brow,  injuring  the frontal nerve, have fre-
quently been known to  produce amaurosis ;  the
amaurotic  symptoms  coming on in some cases
instantaneously,  and  sometimes long after  the
wound has  been  healed."   Morgagni mentions
having seen  a case of amaurosis produced by  a
wound above the eye-brow, which, he observes,
explains a passage of Hippocrates.   " The  sight,"
says the  father  of medicine, "is obscured in
wounds  which are inflicted on the eye-brow, or  a
little higher."  This curious fact  we have seen
illustrated in several instances; and it is an example
of the sympathy which exists between parts whose
nerves have  a direct communication, the ophthal-
mic branch of the fifth pair sending off the fron-
tal nerve, and also a twig to join  the third  pair to
form the lenticular ganglion.  It  is  only when the
frontal nerve is  wounded or  injured, and  not
divided,  that  amaurosis takes place ; for,  as will
hereafter be  observed,  amaurosis, following  a
wound of  this nerve, may sometimes be cured by
making  a  complete division of the  trunk nearest
its origin.   Portal saw  a child, who received  a
slight puncture on the forehead with the point of
a knife, which was followed by a considerable con-
vulsion  of the upper  lid.   This ceased when  a
small incision was made at  the place of the punc-
ture.  A gentleman  received an oblique cut in the
forehead, which,  from its  direction and  depth,
must have injured the frontal  nerve.  The wound
was  not accompanied by any severe symptoms,
and  soon  healed.  But  afterwards the vision of
this eye began to  fail,  and in a few months was
completely destroyed ;  the pupil was much dilated,
the  iris was not influenced  by variations of light,
and  had siight tremulous motions.    A sailor  got
a blow on  the edge of the orbit, from a ramrod
during an engagement,  at the place where  the
frontal nerve passes  on the  brow.   The vision of
that  eye was instantly destroyed, and when  we
saw him several years after tbe  accident, the eye
remained amaurotic, with a dilated and immovable
pupil : a cataract  had formed in the other eye.
An  officer, at the siege  of Badajos. received  a 
88
AMAUROSIS.
deep wound on the eye-brow by a piece of a shell,
which, from its direction, must have injured the
frontal nerve.   Great inflammation and pain suc-
ceeded the wound, the vision  of the eye  became
gradually imperfect, and, after a few months, was
entirely lost.  The pupil was very much dilated
and immovable, and  the  crystalline lens opaque.
Wounds of the infraorbitary  nerve  and portio
dura are sometimes followed by amaurotic symp-
toms.  Beer mentions an instance of the former;
and we witnessed the case of an officer, in whom
a ball wounded some branches of the latter nerve,
which was  followed  by amaurosis.  This  con-
nexion between the branches of the fifth pair of
nerves and retina affords a useful channel for ap-
plying remedies in diseases of retina.   It is not
injury of the fifth pair of nerves alone that proves
injurious to vision ; paralysis  of the upper lid,
with loss of power of moving the eye-ball, except
outward, evidently depending  on compression or
disease of the third pair, is also attended by defec-
tive vision.  The writer of this has very recently
seen a well-marked  case of amaurosis  with dis-
tinct  and  undoubted  paralysis of the abductor
muscle, disabling the patient from turning the eye
outward, and obviously depending upon compres-
sion or disease  of the sixth pair of nerves.
  To cure  amaurosis  from injury of the frontal
nerve,  or any  other branch of the  fifth pair, is
difficult, and often not to be accomplished.  Divi-
sion of the nerve appears an obvious resource, and
has been repeatedly tried, but  with little  success :
which, perhaps, might have been anticipated, when
it had been observed that amaurosis had sometimes
arisen from simple division, as in the removal of
a tumor.  Mr. Guthrie, says, « The only hope of
relief that we are at present acquainted witb, lies
in a free incision made down to the bone, in  the
direction of the original wound ;  and even of the
efficacy of this, I  am  sorry I  cannot  offer testi-
mony  from my own  practice, having failed  in
every case in which I  tried it."  Some of these
cases recover, or at least improve, by time ; a re-
sult to be expected, when it is recollected that the
numbness from division of a branch  of a  nerve
often disappears.  The  general  health,  in such
cases, should be attended to ;  all pressure on the
wounded part avoided, and gentle  frictions, with
a liniment containing belladonna, tried, especially
if there be pain.
   The occurrence  of blindness from injury of a
branch of the fifth pair is instructive, because, as
Mr. Wardrop  observes, it  throws light upon  a
question of importance in the treatment of amau-
rosis,  the  efficacy of superficial impressions  in
rousing  the sensibility  of  an amaurotic retina.
Some  appear to undervalue, or even discard the
use of stimulating applications to the vicinity of
the eye  in  cases of amaurosis, such  as blisters,
sternutatories,  liniments, rubefacients, sinapisms,
or pungent applications to the  conjunctiva itself:
but when we see violent sneezing produced by the
impression  of light, and recollect the other proofs
01 connexion of function between the nerves here,
we are more than justified in giving trial to  such
means.
   [In some cases, amaurosis  has yielded to the
extraction of one of the teeth of the  upper jaw,
 of the same side  as the affected eye ;  doubtless
through  the impression made  directly on rami
Nations of the fifth pair, and indirectly on the
retina."]                             „ -p*,,,,
  7  Amaurosis from injui.t of the bTE.
  Blindness is generally  the consequence of a
violent blow on the eye-ball, although none of the
visible parts of the organ appear materially injured.
What the real extent of the  injury m these cases
may be, is not certain ;  but it is very probable that
the delicate connexions of  the retina with the
neighbouring  structures are  injured  or  severed;
or there may be ecchymosis of its structure, or in
the cells  of the  hyaloid membrane.  Vision, in
such  cases, is greatly impaired, or  even totally
lost;  and the pupil is generally irregular in shape
and dilated.   If the accident be followed by in-
flammatory  action, the usual appearances of inter-
nal inflammation of the eye-ball are added.  The
prognosis, in these cases, must be very cautious;
because  the prospect of recovery depends upon
the extent of  the  injury, which  cannot be ascer-
tained.   If  vision begins to improve  some hours,
or even days,  after  the accident, which is often
the case, further improvement may be anticipated.
In such cases it may, perhaps, be  suspected, that
there has been more of concussion than  actual
destructive disorganization, and, therefore, gradual
recovery may be expected.   Even if  the improve-
ment in vision be  still slower, but  progressive,
perfect cure will probably follow.  But  if vision
be  greatly impaired or  destroyed, with  irregular
and dilated pupil, and  without any amendment
after  some weeks, the worst  may be apprehended.
When the injury, which is often the case, extends
to the iris or lens, and terminates in cataract, other
considerations, foreign to the present inquiry, sug-
gest themselves.
   The first care  of the practitioner, in  cases of
this description, is to avert or allay inflammation,
by cold applications to  the eye, local and general
bleeding, purgative medicine, and abstemious diet,
The  inflammation sometimes assumes a chronic
character, proceeding to disorganization of the eye,
as rheumatic inflammation  does,  and cannot be
arrested by the usual means.  Whether, in such
cases, recourse should  be  had  to mercury, is a
doubtful  question ;  but experience does not en-
courage the practice.   In this chronic state of the
disease, blistering is indicated, and may be resort-
ed to with  advantage.   Under any circumstances,
 after all inflammation, or danger of inflammation,
 has subsided, efforts should be made to rouse the
 sensibility of the  retina by  external  impressions.
 The means of effecting this object, which are ap-
 plicable to this case, as  well as to every other of
 loss  of sensibility of the  retina, without inflam-
 matory action, are, blisters, sternutatories, pungent
 applications to the conjunctiva, and  electricity;
 all which may be tried without injury,  and with
 some hope  of success.   The conjunctiva may be
 conveniently  stimulated by the fumes of ammonia,
 or by the vapour  of ether  evaporated  from  the
 palm of the band, as suggested by Mr. Ware.
   It has already  been  stated  that  amaurosis is
 caused by various diseases or habits, affecting the
 nervous  and vascular  systems  generally.  Such
 diseases or habits are eitber debilitating, as hemor-
 rhage and menorrhagia, diarrhoea, venereal indul-
 gence, suckling;  or they are calculated to accele- 
A M E N 0 R
rate vascular action, and produce a general ple-
thoric  condition, as  suppression  of accustomed
discharges, drunkenness, and gluttony.   Metasta-
sis of diseases, as of gout  or  rheumatism, or  the
removal  of cutaneous eruptions, may often  be
found  a  cause  of amaurosis.   Diseases  affecting
the optic  nerve  by pressure,  or  involving it in
some specific disorganization, as  aneurism, exos-
tosis, tumours of various kinds, fungus haematodes,
cancer, and caries of bones of the skull, necessa-
rily  produce imperfection  or  destruction  of  the
functions of the retina. Diseases  within the head,
as rupture  of vessels, ill-balanced  circulation, soft-
ening, hydrocephalus, enlargement of arteries, and
tumours, are some of the most frequent causes of
amaurosis.  General disturbance  of the functions
of the nervous system, not depending  on disease
of the brain,  as hysteria, and  those  affections
known under the common  term nervous  diseases,
are  often accompanied by amaurotic  symptoms.
In all  these cases the origin of the defective vision
is obvious  to the  practitioner, and the nature of
the origin suggests the treatment.   The amauroris,
in many of them, is merely the  symptom, which
disappears upon the removal  of  the remote dis-
ease.  The history and treatment  of amaurosis
depending on the causes just now enumerated, are
not, therefore, detailed here.   .        T
                             Arthur Jacob.
   AMENORRHCEA.   Amenorrhoea  has been
usually divided into retention  and suppression of
the menses.  Under this head we shall also con-
sider vicarious menstruation.
   I. Emansio, or retension of the Menses.
   The non-appearance of the  menstrual discharge
at the usual age does not, in itself, constitute  a
disease.  The condition of the bodily  develope-
ment must chiefly be taken into consideration, for
the age at which the  ovarian functions are first
manifested varies exceedingly.  Instances of very
precocious puberty are numerous  ; neither is it at
all uncommon to meet with cases where the men-
strual  discharge does  not  occur till a  very late
period of life : but if the  general health  is  not
affected, medical interference will  be rarely requir-
ed.  Climate has a  marked  influence  over  the
period of puberty.  Whilst in sultry regions sex-
ual maturity will usually take place at the  age of
eight or ten years, in colder countries it is deferred
till eighteen or twenty ;  and  in Lapland, accord-
ing to Linnaeus, women will often menstruate only
during the summer months.
   [Mr. Roberton (Edinb. Med. and Surg. Jour-
nal,  Oct. 1832, and Lond. Med. Gazette, July 21,
1843,) has endeavoured to show, that the age of
puberty is  as tardy in the colder as in the tropical
regions, and that were marriages  to take place in
England at as juvenile an  age as they do in Hin-
dostan, instances of very  early  fecundity would
be as  common in  England  as  they are in that
country.  He is  of opinion,  that early  marriage
and  early intercourse  between the  sexes,  where
found  prevailing generally, are to, be attributed not
lo any peculiar precocity, but to moral and  politi-
cal degradation, exhibited in bad laws and customs,
the enslavement more or less of the women, igno-
rance of letters, and impure  or debasing  systems
of religion.  He has  also  shown from statistical
evidence,  that menstruation does  not occur more
  Vol. I__la                         h«
LRHCEA.                                 89

early in the negress  than in the white female.
(Dunglison's Human Physiology, 5th edit.,  ii.
348.   Philada., 1844.)]
   In temperate climates, the usual period  of pu-
berty is about fourteen years of age ; and  when
the signs  are delayed  much beyond  that age, or
when the sexual developement takes  place, but is
not followed by the consequent monthly discharge,
amenorrhoea may be said to exist in the form we
are now describing.  The  two conditions of body
are, however, essentially different.  In the former,
puberty itself is delayed,  whether from idiosyn-
crasy, from want of constitutional energy, or from
defective organization.  In the latter, puberty ex-
ists ;  the  ovaria and  the  uterus  are  organically
matured ; but their peculiar function is suspended.
   In the former condition, we meet  with  young
women of eighteen or twenty  years resembling
children in  conformation, witb  a weak  and lan-
guid  frame, a feeble circulation, attenuated, colour-
less, and of stinted  growth. The case is obviously
one of constitutional debility, and, only as sucb,
requires medical treatment.  Should the general
powers be  renovated by  time, or  the judicious
employment of tonics, a nourishing diet, salubri-
ous air, and well regulated exercise, the menstrual
discharge will either take place with other signs
of puberty,  or the case will become of the descrip-
tion above alluded  to, and  presently to be noticed.
But  puberty may  also be delayed with another
condition  of body,  where the general  health and
strength continue unimpaired, the growth proceeds
as rapidly as in others, the  circulation is  active,
and the frame vigorous ; but there are  no  protu-
berant mammae, no sexual  propensities, a  slight
beard grows on the  upper  lip, and  the general
characteristics resemble those of a male. In such
a case the  probabilities  are  that  the  ovaries are
either absent,  or have become so diseased that
their functions are entirely lost.  A striking in-
stance is  related by Mr. Pott, where  a precisely
similar state was  artificially induced  by removal
of the ovaries in a  young woman in St. Bartholo-
mew's Hospital, although,  previously to the ope-
ration, menstruation and all the signs of puberty
had  regularly existed.   In such  organic  defects
medicine  is of  no avail; though, under the possi-
bility of  the  ovarian  functions being interfered
witb by the pressure  of some  neighbouring tu-
mour, the use of iodine, potass, mercury^ or other
medicines to promote absorption, might be  advis-
able.
   When, at the usual age of puberty, a decided
change in the system is  observed, and  a struggle
is evidently taking place to bring about the sexual
functions, although followed by no actual  devel-
opement,  we may conclude that the defect is only
in degree, and  that, by proper  assistance,  natuie
will  accomplish her  object.  In some cases, the
failure may be said to be merely local: the mam-
mae are enlarged, the pelvis has become capacious,
the pudenda covered with  hair, puberty is  estab-
lished, but the  menstrual discharge does not take
place.  There  are now peculiar symptoms set up;
head-ach, with a sensation  of fulness and   throb-
bing, a flushed  countenance,  heaviness, pains  in
the  back  and  limbs, and  a full  pulse, generally
remarkably slow, though,  in some cases, accele-
rated.  There  appears to be either a torpor  of the 
90
uterine vessels, which ought to secrete  the  men-
strual discharge, or (as some have  supposed) a
spasm  of their extremities.  The causes of this
condition are generally to be found in the previ-
ous habits of the patient;  for it is most frequently
met  with in those who have  led sedentary and
indolent  lives,  who have indulged  in  luxurious
and gross diet, and been accustomed to hot rooms,
soft beds, and too much sleep.  The ramedies are
usually successful, and  rapidly so.   In the first
place, the overloaded circulation is to be  relieved
by a brisk purgative, abstemious diet, and the ab-
straction  of blood ; if the symptoms of plethora
are strongly marked,  bleeding  from the  arm in
considerable quantity may be  required ; but, in
general, the application  of leeches  to  the  labia,
pubes, groins,  or os uteri, or cupping on the loins,
will be sufficient.  Bleeding from  the foot,  either
by leeches or from a vein, was formerly preferred ;
and  many practitioners of the present day  still
recommend it, as equally salutary and more pala-
table to the patient.  The purgatives most  effica-
cious in such cases are those which  not only un-
load  the vessels, but  stimulate the rectum :  aloes,
colocynth, or senna and the neutral  salts,  are pre-
ferable ;  and, in addition to these plans, pediluvia,
either  of simple  hot water, or made stimulating
by the addition of mustard-flour, may be used for
half-an-hour, night and morning.   This treatment
should be persevered in till the symptoms of  ple-
thora disappear, when it  may be  suspended,  and
merely a free action of the bowels kept up by the
daily use  of an aloetic purgative, either till the
menstrual discharge comes on,  or  till, at the  end
of about  a month, the congestive symptoms again
are perceived, to be again similarly treated.   Ex-
ercise,  especially  on  horseback,  will  materially
assist in   promoting  the  desired  effect, and,  of
course, all the old babits of self-indulgence  are to
t>e entirely broken through.  Should these  plans
fail,  we  must  have  recourse  to  those remedial
agents which have been supposed more particularly
lo have  the property of exciting uterine torpor,
and which we shall notice in considering the next
description of cases.
   In  these,  as puberty  approaches, there is a
marked derangement  of the general health, from
the powers being unequal to the impending  strug-
gle.  The patient has been,  perhaps, growing
rapidly, and has perceptibly become  much emaci-
ated ; the face  and lips  are pallid ; the hands  and
feet  cold, particularly  the latter ; there  is great
lassitude, and the least exertion produces fatigue ;
the tongue  is  foul,  the bowels  are costive, the
appetite is defective and irregular, the pulse slow
and feeble.  A more aggravated set  of  symptoms
gradually supervenes ;  the complexion becomes
peculiarly sallow, often of a greenish  tint;  and
hence  the name frequently given to this stage of
the  disease, green sickness,  or chlorosis : (see
Chlorosis.)   Every  part of the system partakes
of the general torpor;  the  circulation becomes
still more languid ; and the blood seems, as it
were, to stagnate in the veins.   The digestion is
nearly gone, the tongue covered with a dirty coat,
and indented, a.* the edges,  by the  teeth :  the
breath is fetid, and  there  are frequent acid or
offensive eructations, with air  rumbling in  the
bowels, which are generally obstinately confined ;
AMENORRHCEA.

          ~d when they are acted upon by medicine, the
             motions are dark and foul.  The appet.te is irre-
             Kular and capricious ; so that the most indigestible
             substances are  often  craved and  devoured with
             greediness ;  chalk,  slate-pencils, sealing-wax, tal-
             low, and dirt; for it is by no means  true that the
             lon°ing is always for articles which nature points
             out"as" salutary, as, for instance, anti-acids  and
             absorbents.   The spirits are weak and depressed ,
             hysterical tears are easily excited ; the girl pre-
             fers a moping solitude ; and decided  melancholy,
             with delusions, will  occasionally be manifested.
             The absorbents partake  of the general debility;
             and there will be puffiness of the face after sleep,
             and anasarcous extremities in the evening.  Pal-
             pitation  of the heart  will be frequently trouble-
             some, and there will be dyspnoea on  the  slightest
             exertion; and along with this  latter symptom, a
             short distressing cough.  Hence it is that there is
             no disease more frequently mistaken  for  phthisis,
             and  the error  is a most serious  one ; for much
             injury  would be occasioned by the remedies gene-
             rally administered for the latter complaint.
               The causes of this disease may be shortly stated,
             as all those which depress the vital powers, viz. a
             previously delicate  and unhealthy childhood, in-
             sufficient or  improper food, want  of  pure air and
             exercise, too close a confinement to study in schools,
             or to labour in crowded  manufactories,  the de-
             pressing passions, and, in particular,  according to
             many,  hope deferred, and disappointed sexual
             feelings.
               In treating the disease, the amenorrhoea must
             at first be considered as only one of the train of
             symptoms of disorder of the general health.  It is
             advisable to begin with an active purgative, which
             will  often bring away a large collection of highly
             offensive motions, with manifest relief to the pa-
             tient.   Small doses of blue pill may be afterwards
             occasionally  repeated, and purgatives of a warm
             and  stimulating character taken  every  morning,
             combined with a small  quantity of some bitter
             extract  or infusion,  until   the  tongue  appears
             cleaner,  and the  secretions  from the bowels are
             more healthy.  A more decided tonic of the vege-
             table class,  along with myrrh, rhubarb or aloes,
             and  ammonia, will gradually prepare the stomach
             for the  metallic tonics, and above all  others  for
             that medicine most useful in these cases, namely
             iron, which, in one  form or another, may be nearly
             always taken with benefit in a torpid condition of
             the venous system.  Upon the whole, perhaps, the
             Griffith's mixture (mistura ferri composita of the
             Pharmacopoeia) is  the most  serviceable of the
             artificial preparations of iron.   At the  same time
             the bowels  must  be kept fairly opened with the
             above-mentioned purgatives, those containing aloes
             being preferable.   The diet must  be, at first, light
             and  easily digestible ;  and, as the stomach is pre-
             pared for an  improved and more  nourishing food,
             wine, meat, and eggs may be taken.  Gentle exer-
             cise in a carriage or on horseback, particularly the
             latter,  with  sea-bathing or the shower-bath, may
             be ventured  upon  cautiously as the  strength im-
             proves.  A pure  air is very desirable, and on that
             account, when the patient  has a little advanced,
             nothing is  more  efficacious than a  residence at
             Tunbridge-Wells,  or some other places where
             chalybeate springs  abound, combining  the advan- 
AMENOE
tages of change of scene, a salubrious atmosphere,
amusement to the  mind, and the internal use of
the mineral water.
  With returning health  and strength, the  func-
tions  of health  may  be expected, and,  amongst
them, the menstruation ; but it often happens tbat
in this particular respect we are disappointed, and
we now come to the trial of those remedies which
have  been found by experience  to   act  either
directly or indirectly in promoting  menstruation.
For the more complete consideration of this class
of medicines,  we  refer  to the article Emmena-
Gor.uES.  It  will  be  sufficient here  to mention
those which  are considered  most serviceable  at
the present day.
   Some act by stimulating the neighbouring parts,
the rectum and  the  bladder; such  are the  more
drastic purgatives, aloes and melampodium ; ene-
mata of soap or turpentine; tincture of Spanish
fly ; savine, turpentine, and some of the balsams,
internally.  A combination of myrrh, aloes, sul-
phate of iron, and the essential oil of savine, has
been found frequently of great utility by the writer
of this article.  Warm hip-bathing, bot and stimu-
lating pediluvia, warm frictions to the hypogastric
ar'd lumbar regions,  electricity or galvanism ap-
plied to the  pelvis, have by many been proved
beneficial; and it is often of great service to com-
bine with one or other of these plans, the appli-
cation of leeches to the groins, labia,  or os  uteri,
or to the feet, once a month.  Compression of the
crural  arteries by the  tourniquet was  formerly
much in vogue, by  which a larger  quantity  of
blood was thrown  upon the uterus.   Irritation  of
the os uteri itself by  means of bougies has been
proposed, or the injection of a stimulating lotion
into the upper part of the vagina, which has suc-
ceeded in a considerable number of casos; for this
purpose a solution often drops of liqimr ammoniae
in  an ounce  of milk has been advised once  or
twice in  the  twenty-four ho>ir?, and on several
occasions the  effect  has been very  rapid.   Of
supposed direct emm-nagogues, the madder and
spignel,  formerly  ro  much  vaunted,  have now
fallen  into  disrepute.  The only  medicines  of
modern days, which can  at  all lay  claim to that
character, are iodine  and the ergot of rye.  Dr.
Coindet, of Geneva, considers the former the most
powerful and certain emmenagogue  we. possess,
and attributes its success in bronchocele to  the
sympathy which the uterus and the thyroid gland
manifest  for  each other. The  ergot  has been
extensively used in various conditions of the ute-
rus, and  certainly seems to exert peculiar and
powerful  action on that  organ, which  may, per-
haps, deserve the name of specific.  In the cases
before us, it may be tried in the form of decoction,
infusion,  or  powder.   The  writer has given it
frequently, and, in many instances, successfully,
in doses of ten grains and upwards, three times a
day.  In very irritable habits it must be cautiously
administered, as it has been found after a few days
to  produce  sometimes  violent and even highly
dangerous spasmodic effects.
   [Dr. Churchill (Diseases of Females,- includ-
ing those of  Pregnancy and Childbed;  Amer.
edit., p. 65 :  Philad.,  1843,) thinks that the  medi-
cines, of whose power of acting on the uterus there
is the least doubt, are iodine, ergot and strychnia ;
IRHCEA.                                 9]

yet it may be questioned whether these, or any
agents, have an effect which  adapts them for all
cases, and merits  for them the title of emmena-
gogues.   (See Emmenagogues.)   Dr. Ferguson,
indeed, (Library of Practical Medicine, 2d Amer.
edit., iii.  302,)  classes these  and other  agents
under the  title of "nostrums;"  and the truth
would seem to be that there  is, in the existing
state of knowledge, no remedy that acts  special!}
upon  the  uterus,  so  as to  restore  the menstrual
discharge  when obstructed.   They are all indi-
rect agents; and,  inasmuch as amenorrhoea may
be dependent upon opposite  pathological  condi-
tions, the  remedies  bave  to  vary accordingly.
(Dunglison's Practice  of Medicine, 2d edit.,  ii.
392 : Philad., 1844.)]
   There  is one circumstance to be kept in mind
in the management of these cases.  The menstrual
discharge  may  be secreted  regularly, but there
may  be no exit, the  passage  being closed by an
imperforate hymen, or  an obliteration of the va-
gina, either from  original malformation or from
disease. In these cases, in addition  to the periodi-
cal recurrence of the symptoms of menstruation,
there is a  gradual enlargement of the  abdomen
from the retained  fluid  collected in  the uterus, so
that unjust suspicions of  pregnancy are  apt to be
raised.  A manual examination at once  detects
the  impediment, and  it is easily  removed by  a
surgical operation.   [The obstacle may exist at
the external opening : at other times, a membrane
covers the os uteri, or the canal of the  cervix may
be imperforate.   In  the  last  case, Dr. Churchill
proposes  to make an artificial canal, by means of
a trocar, or an instrument resembling that used by
Stafford for dividing strictures of the urethra ;  but
it need scarcely be said,  that such an operation
should be decided  upon and executed with exceed-
ing caution.   Where  a  membrane over  the  os
uteri is the obstacle, it may be punctured or rup-
tured, and a probe or small bougie  may be passed
into  the  uterus, as described under Dysmenor-
rhea.  (Practice of Medicine, loc. cit.)]
   II. Suppression of the menses.
   Suppression of the menses  may take place at
any time  after menstruation has been  once fairly
established, and may be either acute  or chronic;
in the latter case  it is  most commonly the effect
of disorder of the  general  health, although by
females it  is apt  to be considered as the cause.
Acute suppression generally  arises   from some
cause acting immediately previous to or  during
the menstrual period ; such as an attack of fever,
exposure to cold or wet, anxiety of mind, frights,
or any agitation of a depressing character,  a meal
of improper  or indigestible  food, &c.    A few
years ago, a very  interesting case was communi-
cated by Dr. Burrows to  the  Medico-Chirurgical
Society, of acute suppression ending in mania and
catalepsy, which was occasioned by sexual inter-
course, under very exciting circumstances, during
menstruation.   Some have argued  that in these
cases the amenorrhoea is merely the effect of fever
excited in the system, and that the  secretion from
the uterus is checked, as  all other  secretions  are
in fever.   But this idea is not alwayn correct:
for often, during menstruation, the  sudden appli-
cation of cold or wet will stop the discharge, long
before the  existence of fever, and without any 
92
A M E N O R R H CE A — A N M MIA
subsequent fever at all.  In such instances, if the
patient puts her feet into warm water, gets into a
hot bed,  and  takes  some  diaphoretic drink  or
medicine, the discharge will return in a few hours.
But in many cases the acute suppression is pre-
ceded  or accompanied by general  fever,  quick
pulse, hot and dry skin, coated  tongue, a flushed
countenance,  violent head-ach,  throbbing of the
temples,  and  pain in the  back and limbs.   In
habits  at all  plethoric, abstraction  of blood  is
desirable ; an  emetic, followed by an  active saline
purgative, may be  also given ; a warm bath, hot
fomentations  to the abdomen, and diaphoretic
medicines, combined with  opium, will then  be
found  of the  greatest service ;  and  if, after we
have reduced the immediate symptoms, the men-
struation is  still suspended, we  may  consider it a
case of chronic suppression.
   Chronic suppression of the menses is either the
consequence of a previously acute attack, or is the
result  of impaired  health.  In  the latter case  it
often  comes on slowly, the menstrual discharge
either becoming gradually more and more scanty,
or the  intervals between  the periods being more
and more protracted, till  at last there is a total
suppression.   In either of these  cases  there is
much the same train of symptoms as described in
the history of  retention of the menses ; but there
is almost always much more head-ach and pain in
the loins.   The causes are also similar, and the
treatment varies only according to  the peculiar
derangement of health which produces or accom-
panies the suppression.   It would be useless to
repeat  the details,  and it will be only necessary to
state, that, here even, the discharge  may  be ob-
structed by a closure of the vagina from ulceration
after a difficult labour, or  as the effect of irritating
discharges.  The  possibility of  pregnancy should
also be kept carefully in view, as the  cause of the
suppression ;  and  this caution  is even applicable
to cases of retention of the menses, for a previous
menstruation  is not absolutely necessary for con-
ception,  but only   that condition of tbe  sexual
organs which  is directly preparatory to menstrua-
tion.   Sir Everard Home has stated a case where
menstruation  occurred for  the  first  time in  life,
after the birth of more than one child, the second
pregnancy taking place during lactation. Professor
Frank has related  a still more remarkable instance,
of a patient who  bore three successive children,
and never menstruated at all, either previously or
subsequently.
   Vicarious menstruation.
   The consideration of this curious freak of nature
is most appropriate to the history of  amenorrhoea,
because it does not occur except when menstrua-
tion is checked.  It appears to depend principally
upon  a  torpid  or  amenorrhoeal condition of the
uterus ;  and the periodical  evacuation being pre-
vented, either by  accidental causes immediately
before the expected period,  or by a previous indis-
position, a  larger  quantity of circulating fluid is
thrown back upon the system, and  forces a pas-
sage for itself at some distant part. It also usually
seems necessary that the vicarious  outlet should
be already in  a weak, irritable, or disordered con-
dition.  Accounts  are given   of  this periodical
discharge of blood taking place from the lungs, the
 aostrils, the  stomach, or the bowels; and these
are not  uncommon cases.   But instances have
also occurred where the  flow has  been from  the
bladder, the nipples, the umbilicus, the eyes,  the
ears, the sockets of the teeth, the skin generally,
and also from open ulcers in various parts  of  the
body.   It is the practice of some to bleed in these
cases,  to  diminish arterial  action ;  but it does
harm, except in very plethoric constitutions, when
leeches to the labia,  groins, or os  uteri,  a day
before the expected period, would be much more
beneficial.   The  object to be gained, is not only
to control and prevent the hemorrhage from  the
particular part by  the proper remedies, but  also to
rouse the torpid uterus into action.   In the inter-
vals of  the  attacks, metallic tonics, and especially
iron, should be freely given, combined with myrrh
and aloes ; and some of the  more direct emmena-
gogue plans may be tried  immediately before  the
expected period.   Opium has proved of great ser-
vice in  many of these cases, combined according
to  the  peculiar condition of the health, and  the
character of the part morbidly in action.  Thus it
may be  given in conjunction  with  the mineral
acids,  or the superacetate of  lead, a few days
before  the expected hemorrhage from  the lungs;
or in combination with the subnitrate of bismuth,
where  the stomach has been  the vicarious outlet.
   [In all cases it  is important to inquire into  the
cause of the aberration, both as regards the system
in  general, and  the uterus in  particular; and,
moreover, to attend  to the condition of the part
whence  the vicarous discharge  proceeds.   It has
been properly remarked, that the state of the organ
probably assists in determining the discharge to it;
hence, vicarious haemoptysis is,  perhaps,  of more
consequence than any other  form ;  and  partly,
also, because there is danger—even  if the dis-
charge  should be a mere transudation of  blood
through the parietes of tolerably healthy containing
vessels, that a predisposition may be left to some
other pulmonary affection.]       ~  T

   [AMYGDALITIS.  See Throat, (Diseases
OF THE).]
   ANAEMIA.  This term is derived from a, pri-
vative,  and atpa,  blood,  and means, therefore, a
deficient quantity  of the circulating fluid, or blood-
lessness.
   The haematosis, or formation of  the blood, is
begun in the stomach and completed in the lungs.
A morbid state of any one of the organs or func-
tions which concur to effect the haematosis may
lead to a state of  anaemia.   It is in  this manner
that we have a defective state  or quantity of  the
blood in some forms of dyspepsia, especially chlo-
rosis.   It is in this manner, too, that the workers
in  certain coal-mines have, from a  deficiency in
the pulmonary function, been struck with anaemia.
A similar state of anaemia has  also arisen from
disease in some particular organ forming a part of
the class of those which contribute to the haema-
tosis ; a case, the exact seat  of  which is often  ob-
scure.  It is scarcely necessary to add, that a state
of anaemia  is also the immediate  result of losses
of blood either artificially or  by natural  hemor-
rhage.   These are precisely the cases to which the
term anaemia has been variously and too indiscri-
minately applied.   M. Andral describes anaemia at
great length, and  has distinguished different forms 
ANJEMIA.
93
of local  anaemia,  or anaemia  of the individual
organs.
  The case of chlorosis, to which the term anae-
mia has been applied adjectively, will be treated
of distinctly  in  this work.   So will  the  case  of
ansemia from actual loss of blood.  In the present
article we  purpose to describe,  1. that  form of
ansemia which has occurred  in coal-mines ; and,
2. that other form of the disease which has an
obscure origin  in  the morbid condition  of some
organ contributing to the hasmatosis : 3. to these
will  be added the  view taken  of anaemia by M.
Andral, and especially the case of local or topical
anosmia.
   General anaemia is denoted by extreme paleness,
especially of those  parts whicb, being covered by
the thinnest and most transparent investing mem-
brane, expose the condition of the blood underneath
them, as the prolabia, the tongue, the gums, the
internal surface  of  the cheeks, &c.  The face, the
hands, and the general  surface  are pallid, and
slightly waxen  or icterode in  their  hue.  There
are vertigo, faintishness, palpitation,  and an im-
paired action of the organs  generally, especially
of the stomach and bowels, digestion being de-
ranged, with flatulency, constipation, &c.
   I.  The following description of the anaemia  of
the  coal-miners of Anzain is translated from  an
account  given  by M. Chomel,  in the article Ane-
 mic, of tbe. Dictionnaire de  Medecine :
   " All the workmen employed in one of the gal-
 leries of the coal-mines of Anzain fell sick in the
 summer of the year 11, although that gallery had
 been wrought for some  time.  The workmen  of
 the adjoining galleries escaped, although the only
 observable difference was that  they  were less ex-
 tensive,  and the  ventilation less difficult.   The
 disease began with violent colic, with tympanitic
distension, black and green alvine evacuations, to
which were added dyspnoea, palpitations and great
 debility.  These symptoms subsided in the course
 of twelve days, and  then  those of anaemia ap-
peared :  the face assumed  the  colour of wax ren-
dered yellowish by time ; the blood-vessels had so
entirely disappeared that not a trace of them could
be found where they are usually  most obvious, as
in the conjunctiva, eye-lid,  internal mouth; the
arterial pulsations were feeble ; these appearances
continued even during attacks  of fever, which
came on accidentally in some of  the patients: ex-
treme feebleness ;  great anxiety ;  slight oedema of
the face  ; palpitations ; shortness of the breath on
the slightest effort; perspirations  ;—such were the
symptoms :  although  the  appetite was  not lost,
yet  the digestion  was imperfect, and there was a
 progressive loss of flesh.
   " This state  continued  during six months or
a year, sometimes  terminating in death, preceded
by the  symptoms  which  first  appeared.  The
Societe  de l'Ecole de Medecine was consulted.
Four patients were conveyed to  Paris, and placed
under the care of M. Halle.  A nutritious diet,
infusion of hops and  gentian, the "vin antiscor-
butique," were conjoined with  mercurial frictions.
During this  treatment one  patient died ; on exa-
mination, the arteries and veins were found desti-
tute of coloured blood, and containing only a little
serous fluid ; incisions through the muscles  gave
rise  to no flow of blood, except a little from those
of the thigh.  The absence of blood, which was
in accordance with the external phenomena, led to
the disuse of mercury, and to the substitution of the
internal use of iron (limaille  porphyrisee,) in the
dose of a " gros " daily, under the form of opiate,
with tonics.  In eight or ten days there was an
evident amendment: several veins appeared under
the skin of the fore-arm ; the digestion improved ;
the shortness of  breath diminished.  On each suc-
cessive day the patients pointed out, as discoveries,
new veins, which had not been perceived the day
before.   The  amendment  was  progressive, and
quite complete when these men returned home.
  " Similar morbid appearances were  observed in
some of the patients who died at Anzain.  And
the same mode of treatment  proved successful
both there and at Dunkerque, whither some of the
sufferers had also been conveyed."
  The want of sun and the want of air seem to
have  been the causes  of  this singular malady.
These important agents appear to be essential to
the  haematosis.   [See Air,  change of.]   The
effects of the want of blood are  illustrated in an
interesting manner.  But the consideration of this
point is reserved for a distinct article.
   II. The origin  of the second  form of amemif
is more obscure.   We shall illustrate the subjec
by an abstract of a case published by Dr. Combe
in the Transactions  of the  Medico-Chirurgical
Society of Edinburgh.
   Dr. Combe  first visited his patient in July, 1821.
He looked like a man recovering from  syncope :
the  symptoms  were pallor,  languor,  breathing
easily hurried, pulse 80  and feeble, tongue  covered
with a dry fur; the bowels relaxed, the stools dark
and  fetid ; thirst, want of appetite, rejection of
food;  no pain;  no detectible  organic  disease.
The  patient was forty-seven, married, of regular
habits, and engaged, first in agriculture, and ther
as a  servant to  a corn-merchant; he was  never
blooded.  These symptoms had  stolen upon him
during two montbs; he said his head troubled
him ;  and the feet were oedematous.  Some tonic
medicine, a mild nutritious diet, and wine were
prescribed.  Afterwards iron, mercury,  opiates,
and  astringents were given.  Towards the end of
September, he tried a sea-voyage, and a chalybe-
ate spring.  He died  in January, with  all  the
symptoms of  hydrothorax.  On examination, not
a drop of blood  flowed on dividing the scalp ; the
dura mater was  moist, and displayed  few vessels,
and  those empty ;  near the vertex, to  the left,
there was an ossification ; the pia mater was pale,
its blood-vessels containing a pale serum, and air;
a slight effusion under the arachnoid.  The brain
was  soft and pultaceous, with  few vessels, and
little difference of colour between the cineritious
and medullary portions; the ventricles  contained
two drachms of serum ; and about  two ounces
were found at the basis.  The lateral sinuses were
moderately filled with pale fluid  blood ; the arte-
ries  at the basis were empty.  In the thorax there
were three pounds of  a lemon-coloured  serum ,
the lungs were of a pale grey, without  any mark
of gravitated  blood.  The pericardium  contained
an  ounce of  serum.   The  heart was pale;  the
right ventricle contained a pale coagulum ;  the
left was empty.  The inner coat  of the  aorta was
of a fine red  colour.   There was some moisture 
94
A N .E M IA.
in the abdomen ;  the  liver was of a light brown
colour ;  the spleen alone was of its natural colour,
and soft.  The arteries were universally empty, as
were the jugular and femoral veins; the lower
cava alone  contained any blood.
   The whole case, and, indeed the whole subject,
is exceedingly obscure.   It does not appear that
any examination of the  thoracic duct was made,
which is much to be regretted.
   III. We  now proceed  to notice  the different
forms of local ansemia;  and, in doing so, we shall
chiefly draw upon the recent work of M. Andral.
(Precis d?Anatomie Pathologique, p. 73.)
   M. Andral traces the  cases of local anaemia, 1.
to a diminution of the principal artery;  2. to cer-
tain affections of the nervous system; for instance,
may not the stomach become  anssmious like the
cheek ?  3.  to the hyperemia of other organs; 4.
to a  previous state of hyperemia in the organs
affected  with anaemia ;  5. lastly, without being
able to trace it to any of these causes, a state of
anaemia is sometimes seen in some particular organ.
M. Andral  adds that he  has observed this state of
anaemia particularly in  the brain, the heart, the
liver, the stomach, and some other parts of  the ali-
mentary canal, and some of the voluntary muscles.
   With a state of anaemia of  an organ, that  of
atrophy is sometimes conjoined.
   With anaemia of the  membranes, we  often ob-
serve an augmentation of  their secretions ; this is
seen in the serous and mucous  membranes, and in
cutaneous textures.
   When ansemia is induced in an organ by the
sudden  obliteration  of its principal artery, as  by
ligature, gangrene is the result.
   M. Andral concludes  this subject by the impor-
tant remark, that the symptoms of the anaemia of
an internal organ are  sometimes observed during
life : convulsions and  delirium  arise from ansemia,
as well as hyperaemia, of the  brain.   Similar
states of the stomach may lead to their  peculiar
symptoms respectively.
   It is,  indeed, quite plain that the state of anae-
mia, of  which the  actual  loss  of  blood is one of
the most   frequent forms, leads  to  phenomena
which  require  to be  carefully distinguished and
appropriately treated.    For the  fuller discussion
of this  important subject, we  refer our readers to
the article Blood.        ,,
                         Marshall Hall.
   [An.bmia is generally applied to that condition
of the system in which  there is paucity of blood  :
more properly it might be termed Hypxmia, or
Oligxmia.   It likewise  includes that condition in
which the watery portions of the  blood  predomi-
nate largely ; or what has been  called Hydroxmia,
or Hydrxmia.
   When blood  is drawn  from a patient  affected
with general anaemia, it  is found  to possess a
smaller  proportion  of crassamentum, and this is
loosely cohering : the quantity of serum, on the
other hand, is greatly augmented.  The essential
character of the blood of the anaemic is the oppo-
site to that of the  plethoric—paucity of globules.
fn 16 cases of  incipient  anaemia,  M.  Andral
(Hxmatologie Pathologique, Paris,  1843,) found
Ihe proportion  to  be  109  in  place  of 127, the
healthy proportion ; and in 24 cases of confirmed
inrcmia, 65.  In  spontaneous anaemia, slight or
considerable, he found the globules, alone, damn-
ished in quantity :  the  fibrin  and solid matters
of the serum  possessed the healthy  proportion,
In the anaemia  that follows hemorrhage, the glo-
bules, alone, may have their  proportion  dimm-
ished, but if the hemorrhage should augment, or
be renewed, the blood soon begins to lose some of
its other principles, and, along  with the globules,
the fibrin and the albumen of the serum diminish.
In anaemia induced by inappreciable modifications
of the organism, the composition of the blood was
affected as in spontaneous hemorrhage : thus, the
globules alone were found to  be  diminished, the
fibrin and  albumen of  the serum  remaining  the
same.   This was  the  case  in several  pregnant
females,  whose blood had lost globules without
any  diminution of its fibrin.   Andral  found  the
mean proportion of globules  in them the same as
in cases of slight ansemia.
   Owing to the proportion  of fibrin  to the red
globules being increased, the buffy coat is not an
uncommon phenomenon in anaemia, and especially
in chlorotic cachexia  (see  Chlorosis);  for it
appears that whenever there  is an increase in the
proportion  of fibrin  to  the red globules, and, at
the same time,  the coagulation  of the  blood is not
too rapid, the fibrin accumulates at the surface of
the blood, and  the buff  appears.
   Whenever a certain diminution takes place  in
the proportion  of the  globules,  a bellows' sound is
heard on auscultating over the arteries. According
to M. Andral, this is  connected with  the impove-
rishment of the globules, inasmuch as it is not
heard when the fibrin  alone is diminished in quan-
tity.  The same sounds are heard as  in chlorosis
(q. v.).   Chlorosis, indeed, belongs to  anaemia;
and  amenorrhoea is not  unfrequently accompanied
by the same anaemic condition.
   The different functional phenomena, which are
characteristic of ansemia, generally occur in a gra-
dual manner, and it is long before they induce so
much disease as to cause death.  In the very thin
state of the blood that accompanies it, hemorrhage
readily occurs  from parts in which the vessels are
but loosely protected by the tissues in which they
creep,—as from the mucous membranes,—the gas-
tro-intestinal especially,—and  these hemorrhages
greatly  hasten  the fatal termination,  both by the
increased exhaustion which  they  induce, and by
their laying the foundation for hydropic, or other
mischief.
   On the  dissection  of those  who have died  of
ansemia, the tissues have been found pale, and the
vessels and  heart almost exariguious.   The heart,
too,  is often atrophied, and its  tissue softened and
flabby, especially if the disease has been of long
duration.  The intestinal canal is frequently also
pale, and the serous cavities and cellular membrane
are infiltrated with serous fluid.
   In the treatment, it is all  important to inquire
into the pathological cause,  and  to  remove  it,
where practicable.  In almost all cases, it is essen-
tial  to  put  the patient on nourishing  diet, and
especially where the anaemia has been caused  by
imperfect nourishment; yet care must be taken in
the very impressible condition of the system which
exists in these cases, that undue excitement be not
induced.  The respiration of pure air is likewise
all important. 
                                        ANAS

   The best therapeutical agents are, the prepara-
 lions of iron,—the iodide, subcarbonate, citrate, lac-
 ffate or tartrate, for example.  The iodide, in the
 writer's experience, is the best form.   Dr. C. J. B.
 Williams, (Principles of Medicine,  Amer.  edit.,
 !>y Dr. Clymer, p. 143, Philad., 1844,)  considers
 \t to be most speedily efficacious.  It not unfre-
 quently, however, disagrees, and it becomes neces-
 sary to substitute one of the  other preparations.
 The different  mineral  and vegetable tonics may be
 given, but they have less efficacy.  To relieve the
 nervous erethism  that always exists to a greater
 or less degree, the hydrocyanic acid is well adapted;
 and a full dose of opium will  often allay the ex-
 cessive vascular and nervous tumult that sometimes
 prevails.   Under  careful management,  with the
 observance  of the  strictest  mental and  corporeal
 quietude, the  blood may  gradually  become im-
 proved in its  constitution, and the phenomena of
 anaemia gradually disappear.   (Practice of Medi-
 cine, 2d edit., p. 456,  Philad.  1844.)
                       Robley Dunglison.

   ANESTHESIA.  See  Paralysis.]
   ANASARCA:  from dva, through, and  aap^,
 flesh.  The word used  by Celsus, and other ancient
 writers, is ii-oadoKa ; or, as is explained by Caelius
 Aurelianus, aqua subter cutem.
   Anasarca occurs under many different states of
 the system : it essentially consists in the effusion
 of serum into  the meshes of the cellular tissue, and
 may take place wherever this structure exists.  It
 has usually been described as a peculiar species of
 dropsy, and is frequently  treated  of under  this
 head by authors.   Such a  plan is, however,  at-
 tended with very serious inconvenience ; as, in
 every species of effusion, the immediate condition
 of the exhalents varies but little, while that of the
 preceding series of vessels often differs most mate-
 rially.  What these different  conditions are, we
 shall endeavour to explain under the general article
 of dropsy.   In the present  article our purpose is
 to give a clear account  of the different circum-
 stances under  which  anasarca takes place; pre-
 mising, at the same time, that in some cases wbich
 we shall here treat of,  the  anasarca  is only the
 chief symptom, and that ascites, and even hydro-
 thorax, are occasionally joined  with it.
   Anasarca occurs  very frequently as an acute
 disease ; but in this case it is usually accompanied
 with the  inflammation of  some viscus; and in
 most cases  it  is  the  lungs which suffer.   The
 dropsy described  by  Dr. Abercrombie,  and  to
 which the attention of the profession was drawn
 a few years ago, is of this description : " The dis-
 ease comes on suddenly,  and generally affects
 persons in the vigour of life,   ft  is usually as-
 cribed  to sudden exposure to cold, especially after
 the  body has  been previously  overheated.   The
 first  symptom is an oppression and uneasiness in
 breathing; and, in a short  time, frequently in a
 few hours,  or in the course  of  the same day, this
 is  followed by the dropsical  swelling.   The affec-
 tion  of the breathing varies considerably in differ-
 ent cases.  In some cases there is only a feeling
of oppression  or  tightness  in breathing, without
pain or cough : in others there is pain, increased
by a full inspiration, with  sharp painful  cough;
and in others there is great  oppression of breath- ]
ARC A.                                    95

 ing, preventing the patient from lying down, ex-
 cept in one  particular posture, or even  prevent-
 ing him from lying down at all.  The pulse is, in
 some cases, a little frequent;  but in others it is
 not above the natural standard.  It is sometimes
 of good strength, but frequently rather weak, and
 in some cases irregular.  This anasarcous swell-
 ing is commonly observed first in the face ; from
■ thence it extends downwards  upon  the trunk of
 the body, and then to the extremities.  This pro-
 gress was,_ in one  case,  so  remarkable, that, even
 at night, after  the patient  had been  sitting  up
 through the  whole day, he was affected  with a
 great  degree  of  anasarca down to the middle of
 the legs, while the feet and ankles were free from
 it:  next  day the  feet and  ankles  were affected
 also.  This peculiarity, however, does not occur
 universally, for in  some cases  the swelling is first
 observed  in  the legs : but, in general,  the face
 is  affected  at a very early period.   The urine is
 scanty and high-coloured :  in  some cases it is co-
 agulable ;  in  others there is no trace of albumen.
 If the disease be now allowed to go  on, the swell-
 ing increases, and the  breathing becomes  more
 and  more  oppressed ; it may be fatal in  a few
 days, or it may be  drawn out to several weeks."
   Dr. Abercrombie remarks, with regard to the
 diagnosis of  this  disease,  that the affection  of
 breathing may exist without  pain and  without
 fever, and that, consequently, there  may be some
 danger of mistaking it for actual effusion into the
 chest.  With the  view  which we have of some
 of these affections, such an error would not al-
 ways be very important; because, if we had other
 evidence that inflammation were present, the oc-
 currence of effusion would not prohibit the  most
 active antiphlogistic remedies.  But in all the
 cases which we  have seen, there has been mani-
 fest pulmonary inflammation,  which, if it  could
 not be recognised by general symptoms, is always
 easily distinguishable by means of the stethoscope.
 In this, therefore, as in  so many other cases, the
 stethoscope  is a most important assistant in ar-
 riving at a correct diagnosis.
   The appearances found  on dissection  suffi
 ciently prove  that  this affection is of an inflam-
 matory nature, and, of course,  equally  prove the
 propriety of active antiphlogistic treatment.   The
 extent to which  this can be  carried varies neces-
 sarily with  the  condition of  the disease and the
constitution of the  patient.   In more recent and
 lighter  cases, a  single bleeding, or  even  a few
leeches, will be sufficient to  remove it; in  other
cases it requires the greatest firmness and deter-
mination to carry this remedy sufficiently far.
   A  very important illustration of  the value of
bleeding is  given in the Edinburg Medical and
Surgical Journal,  by Dr. Graham ;  for in very
few cases has  depletion been carried so far, even
with  impunity ;  in  still  fewer  has  it, when thus
employed, been attended with success.  It is cal-
culated to caution as well as to  instruct.   The in-
flammatory symptoms were detected  by the  rare
acumen of the physician, and his diagnosis being
correct, his treatment was consonant to his diagno
sis.  He had,  at the same time, a young man of
full and vigorous constitution to treat; and, with
this adjunct, his success was  striking.   But  it
becomes all  who  shall dare to carry  depletion a* 
96
ANASARCA.
far as Dr. Graham carried it, to unite his sagacity
with his boldness; for should the same treatment
be adopted in cases which have  not an inflamma-
tory  origin, or  should  the  patient have  a less
sturdy constitution to endure the remedy,  the re-
sult would most likely be fatal.
  Anasarca from the retrocession of erup-
     tions.
  The anasarca, which succeeds scarlatina, has
been mentioned,  by  Dr. Abercrombie, as  analo-
gous to that which has  been just described, and,
as it appears to us, with considerable reason. The
first, and hitherto the best account of this  disease
has been given by Dr. Wells, in  the third volume
of the Medical and-  Chirurgical Transactions.
Though  this disease  has frequently  occurred  in
our practice, we have never yet met with  a fatal
case ; for the morbid  anatomy of it, therefore, we
are indebted to  Dr.  Wells's paper  and  to Dr.
Abercrombie.   Burserius, from whom Dr. Wells
quotes, has  remarked that the  bodies of  several
persons who had died of the disease about 1717
having been opened,  the lungs, pleura, intercos-
tal muscles, diaphragm, kidneys, and intestines,
were found more or less inflamed ; that peripneu-
mony having hence  been  considered the original
disease, and the dropsical swelling only as a con-
sequence, blood  was  taken from the  arm  in the
succeeding cases, once or oftener, as the occasion
required ; and  that no one afterwards died of the
dropsy who  was thus treated.
  Dr. Abercrombie,  in  the  Edinburgh Medical
and Surgical Journal for April, 1818, has  related
the case of a child two years and a half old, who,
about eight or  ten days after  he had recovered
from a mild  attack of scarlatina, was  observed to
be anasarcous in the  face ; the swelling increased,
and extended  over other parts of the body ; at a
very early period of  the complaint his breathing
was  oppressed ;  the pulse frequent,  and  rather
small; the urine very scanty.  The swelling in-
creased;  the breathing  became  more and more
difficult; all the usual  remedies were employed
without benefit, and the child died about the tenth
day from the first appearance of the anasarca. On
dissection, considerable effusion was found  in both
cavities of the  thorax, and a little in the abdomen.
The lungs were dark-coloured and remarkably in-
durated,  so  as to resemble  the structure  of the
liver.  This was most  remarkable in the right
lobe; pieces cut from which  sank in water.
  The following case, extracted from Dr.  Black-
all's  work, proves still more clearly the inflamma-
tory  origin of  dropsy succeeding scarlatina.  Sa-
rah Elliot,  set. 30, was brought into the  Devon
and Exeter  Hospital, 1800,—in a state of great
distress, labouring under universal anasarca, and
an erysipelatous inflammation of the  lower extre-
mities, with much discharge and deep sloughs  on
the hips and sacrum.   The  urine coagulated,  al-
though not to  the extent sometimes observed, and
it flowed freely, as it is often known to do, when-
ever much  serum is discharged from the  legs.
Wne  had the  remains of a florid and sanguine
temperament, and had been  in  good health, till
about two months before, when  she was attacked
with fever,  with great redness of the face and ex-
tremities : soon afterwards she  became dropsical,
snd complained of sense of stricture in the chest,
cough  and pain under the  left  breast.  She  took
large  doses of cinchona  with  great  advantage.
She was quite inundated with the discharges from
the legs, and the  increased flow of urine.   I he
erysipelas disappeared,  and shortly after  all  ves-
tiges of dropsy : but the above-mentioned  sloughs
had penetrated  deeper than was anticipated ;  the
bones  became  carious, and, about  two  months
after, she died exhausted, the anasarca never hav-
ing returned.
   On examination  after death, the kidneys were
found  rather soft  and flaccid,  and  more  loaded
with fat than could  have been supposed after so
long an illness, but in other respects appeared na-
tural. .  There was no morbid appearance in  any
any other viscera of the abdomen.
   The pleura of the left lung bore  marks of in-
flammation, more  severe than the common adhe-
sive, for several small flakes and granula of coagu-
lated lymph covered it in several parts, principally
in a spot answering to the  seat of pain during
life ; and that membrane was separated from the
body of the lungs for about the size of a shilling,
by a very small deposition of pus.   Opposite the
same  spot the  pleura costalis was  inflamed.   In
other respects  the substance of the thoracic vis-
cera was sound, and there was  no unusual quan-
tity of water in the cavities.
   These two cases  sufficiently  attest  the  nature
of this anasarca, and we shall proceed to  its  his-
tory.
   We have already  stated that it succeeds the re-
trocession of the eruption in scarlet fever,  but sel-
dom earlier than three weeks from the commence-
ment of the fever.  It has never, within our know-
ledge,  been observed  to appear upon the  sudden
retrocession  of the  eruption, nor  is  it peculiai
either  to a mild or severe attack of fever. In all the
cases which  have  fallen under our own care, the
patient has never entirely recovered from the scar-
latina, but has remained languid and fretful.  The
sore throat has either partially, or,  perhaps,  en-
tirely  disappeared, and the appetite  has  slightly
returned.   In short, the patient has appeared con-
valescent.   In  this state, however, the patient has
remained  day after  day :  the  same languor  has
continued;  the  tongue,  after  having  become
cleaner, has  again been furred, and the appetite,
though not so  defective as during the fever, has
been exceedingly capricious.  The bowels are, at
the same  time, usually costive, and sometimes
both sickness and  vomitings accompany it.
   After this has endured for several days, or some-
times a month, the face is observed to be rather
puffed, particularly on first rising in the morning :
this rapidly increases, and the anasarca in a day
or two extends  over the whole body.  According
to Dr. Wells, however, it is rare for the whole
body to be affected :  and  he states  likewise  that
the hands  are more readily affected than the feet.
During this  time  there is also frequently much
torpor, and we  might be induced to suspect  that
effusion had taken  place into the brain.   In  a
case which presented itself at the Birmingham Dis-
pensary last year, the anasarca had come  on  very
suddenly, and the child completely lost all power
of articulation, which, though he lived for several
months afterwards,  he never  recovered.    The
dropsy had disappeared long before his death, and, 
ANASARCA.
97
from what we could learn, he died from phthisis.
He was not, however, in Birmingham at the time
of his  death, and, consequently, no examination
was made of the body.   The pulse is frequently
slower than in health.   In a boy  five years old,
examined by Dr. Wells, it was only fifty-eight in
a minute on the  first day of the disease ; on  the
third  day  it  became  quick, and  continued so
throughout the disease.   In the beginning of  the
disease the  urine  is  always  scanty,  and  very
quickly becomes turbid,  after  it has been  passed.
Dr. Wells says, " I have in several cases  allowed
the urine in this stage of the disease to  remain
undisturbed for several hours, when it has assumed
an appearance not hitherto observed by me in any
other  disorder.   For there was at the bottom  a
 very  white flocculent matter,  and above, a fluid
 of a pale white colour, and  somewhat turbid ;  the
 whole resembling  a mixture of soft curd  of milk
 and whey, when the latter has floating  through
 it  small  particles  of the  curd.   The patients,
 though they make but little water, have sometimes
 a freqnent desire to discharge it, and in this case
 a pain is felt by them in the region of the bladder
 when it is  pressed."   This  appearance of the
 urine is owing to the presence of the serum  of the
 blood, which may easily be ascertained by boiling
 it.  Sickness and vomiting are frequently present
 in this disease,  but they are commonly indicative
 of affection of tbe brain, and always ought to lead
 to a suspicion of it.  Costiveness is not more at-
 tendant upon this than many other  complaints,
 but in very young children the removal of con-
 stipation frequently effects the cure of the ana-
 sarca.
    According to Dr. Wells, symptoms of  extreme
 danger sometimes appear as early as the third  day
 after the face has begun to swell.   When the dis-
 ease has continued mild  for ten or eleven days,
 we never knew it give much alarm afterwards.
    The appearances of danger are various. Some-
 times they arise from an affection of the  head.
    "A girl, eight years old, on the morning of the
 third  day of the disease, complained of head-ach,
 which in the course of the same  day became ex-
 tremely violent.  In the evening  she was  seized
 with  convulsions, which,  from the report of her
 mother, continued nineteen hours, with  scarcely
 any intermission.  They then ceased, but return-
 ed in two  hours.   In this interval it was discover-
 ed that  she was blind, and that her pupils were
 much dilated.   The convulsions, after  they re-
 turned, continued thirty-six hours ; and the patient
 remained  blind eight  hours  after they  left  her.
 This child recovered.   Her swellings, which were
 confined to the face and hands, disappeared while
 the convulsions were present, but returned after
 they had ceased."  Dr. Wells remarks,  that  he
 had  " observed dropsical  swellings, from other
 causes than  scarlet fever, disappear during the
 presence of  convulsions."
    We have  already mentioned a case where the
 articulation was suddenly lost, and Dr. Wells has
 related one in which convulsions  following ana-
 sarca from scarlatina, proved fatal.
    In other cases the danger seems very clearly  to
 arise from disease of the abdomen.
    " A boy seven years old, who had shortly before
 laboured  under scarlet fever, was attacked with
    Vol. I.—13                         I
dropsy, which, on the eighth day after its appear-
ance, the first of my seeing him,  occupied in a
slight degree the whole surface of the body.  The
fever had commenced with vomiting and purging,
and these symptoms appeared again two days be-
fore he began to swell.  On the eleventh day he
complained  much of a pain in the bowels ; vomit-
ing  and purging attacked him  a third time, and
he died in  the course of the night.  His stools
were scanty and slimy."
  In the following  case, which is taken from Dr.
Crampton's Clinical Report of Dropsies, together
with bis observations upon it, the effusion did not
certainly occur after scarlatina, but it is most clear
that the author's opinion respecting its similarity
to that form of  dropsy  which  does  occur after
scarlatina,  is correct.
   A pale, thin, but  muscular man, who had lately
recovered from  the epidemic fever in the Hard-
wicke Hospital, was attacked, on exposure to cold,
with pains  in his  bowels, diarrhoea, and passing
of blood ; immediately after this, ascites to a con-
siderable degree  came on,  with anasarca of the
face, legs,  thighs,  and  scrotum; pulse eighty,
urine scanty and high-coloured, respiration unaf-
fected.
   He was  directed venesection to  ten ounces ;
after this his pulse  was reduced in frequency, and
the urine increased ; blue pill and cream of tartar
were given  ; his swellings very soon subsided, and
he was discharged  cured on the 10th of October.
   In this case, " the mucous membrane of the in-
testines first showed symptoms of disease ; on the
subsidence  of this, all the  serous membranes of
the body, including all the cellular substance of
the  skin, as well as the peritoneum, being in  an
excited state after fever and exposure to cold, they
readily took on them an inflammatory disposition,
which soon ended in effusion..  This is the kind
of  dropsy  which  frequently  follows  scarlatina,
measles, and small-pox : had  venesection been
resorted to in the  dysenteric stage of this com-
plaint, no dropsy  would in all probability have
ensued."
   Now, if we  compare these  two  cases, their
similarity will be as striking as  their terminations
were different;  nor is it difficult to account  for
this difference, since Dr. Wells,  to whom we owe
 so  much,  though  he suggested the propriety of
bleeding in this species  of the disease, acknow-
 ledges that he  had never employed it;  whereas,
 Dr. Crampton's patient was bled, and the regimen
 was antiphlogistic.
   Another source  of danger in  the anasarca after
 scarlatina  arises from  effusion into  the chest,
 always the consequence of preceding or  accom-
 panying inflammation of the lungs.  In this tose,
 the  symptoms are precisely those enumerated by
 Dr. Abercrombie.
   Anasarca appears  also  after the measles, but
 there is no difference between it and that  form
 which follows scarlatina.  The  same remark may
 be made when it follows the retrocession of chro-
 nic cutaneous  diseases,  which is by  no mean*
 rare.
   A girl, twentv years of age,  had been subject
 for  some months to an impetiginous affection of
 the whole body, but more particularly of the arms
 and hands, for which she at length applied to the 
98
ANASARCA.
Birmingham Dispensary.  After attending  about
a week,  the eruption suddenly disappeared, and
she was attacked at the same time with inflamma-
tion of the lungs and general anasarca.  She was
bled from the arm to the extent of twenty ounces,
with great relief to the lungs, and the blood was
buffed  and cupped.  The next day tbe  dyspnoea
had slightly returned, and she was again  bled with
a similar result.  Mercurial purgatives were given
at the  same time.  It was necessary, a few days
after,  to repeat  the  bleeding again, from  which
time the anasarca rapidly disappeared, but she did
not recover her  breathing completely till the im-
petiginous affection had re-appeared.
  If it  be  necessary to make any remark upon
anasarca after the retrocession of these pustular
eruptions, it would be  to  say, that it is, perhaps,
more  acutely inflammatory than  after scarlatina,
and usually demands  more decided and  active
antiphlogistic treatment.
  Anasarca sometimes  accompanies or succeeds
urticaria.   It is  seldom, however,  an important
disease, and generally yields to active purgatives.
  In considering the treatment of anasarca after
scarlatina, our first object must be to obtain  an
accurate diagnosis, both  as to the nature  of the
affection,  and the  particular  organs which  are
interested.  That  it is  always an inflammatory
disease  may not, perhaps, be maintained without
exception ; because we know that anasarca is as
frequently a consequence of debility as of inflam-
mation ; but, unquestionably,  in the very great
majority of cases  its character  is inflammatory.
This, then, being decided, the particular organs
which  are  affected is the next object;  and these
are, the brain, the lungs, the heart, the  liver, the
peritoneum, &c.   In whichsoever of these the in-
flammation is present, immediate attention must
be paid  to it.   Bloodletting  is  the  first remedy
demanded, and in almost every case this may and
should be general.  Should, however, the head be
affected, it will  be sometimes useful to apply a
blister to the nape of the neck immediately after
the bleeding.  If we suspect the  pericardium to
be inflamed, it will be  proper to  apply leeches to
the region of the heart, as well  as to bleed from
the arm ; and, indeed, this local bleeding is most
important.  Corvisart  has remarked that blood
taken from the region of the heart is much more
efficacious than when  taken from the system at
large, and our own experience has amply confirm-
ed the  remark.  It has  not the disadvantage of
producing  that  general and  distressing debility
which always must result from repeated venesec-
tion.   When  inflammation of the peritoneum is
present, which is easily known by the tenderness
on  pressure, the tension, and  the anguish of  the
countenance, always produced  by  inflammation
of this membrane, leeches in great number ought
to be  applied over  the  surface of the  abdomen,
and the bleeding encouraged for a  considerable
time.   Recourse should be also had to fomenta-
 tions, which should be as hot as the patient can
 bear them, and be very long continued,  indeed, as
 long as any tenderness remains,—supposing, how-
 ever, that this is not prevented by tbe application
 i.f a blister.
   In  inflammation of the mucous coat of  the in-
 U*tines, which is indicated by tenesmus, discharge
of blood, pain in the bowels, with much fla ulence,
and aggravated during every evacuation, &c, the
best situation for the application of leeches is the
verge of the anus, and the quantity must be regu-
lated by the severity of the attack and the strength
of the patient.  Sometimes  vomiting is present,
and  should  it not be  relieved by the bleeding, it
will be right to give some opium.   In enteritis, as
in peritonitis, fomentations are both useful and
important.
   We proceed  to  speak of the medicines which
should be given in  this disease.   In every case it
will be right to act upon the bowels, (excepting,
however, in those cases in which diarrboea is pre-
sent, of which we shall speak presently,) and care
should be taken that they be thoroughly evacuat
ed.  For this purpose we shall seldom find a bet-
ter combination than  calomel and jalap, but they
should not be continued after the bowels are well
opened.   Sometimes  individuals will be met with
upon whom this medicine will not act as a purga-
tive,  even though  frequently repeated ;  and  re-
course should then  be had to an infusion of senna,
with  sulphate of magnesia.  When the  bowels
have been evacuated, purgatives  should be sus-
pended, and mercury on no account should be
persevered in.   The danger of persisting in mer-
cury is so strongly insisted upon by Dr. Blackall,
and so completely agrees with our own experience,
that we gladly avail  ourselves of his  authority,
" There are," says this enlightened physician, "no
cases more  satisfactory or more creditable to the
practitioner, than those fevers of children with an
oppression of the  head, in  which  a  bold use of
calomel brings off black discharges, and the patient
from that moment recovers.   Without inquiring
here  whether  hydrocephalus is not thus cured
which never  existed,  I wish to confine myself to
that dropsy, when  distinguished by  the presence
of serum  in the urine ; and to state that after
scarlatina, the tendency to this  alarming conver-
sion is increased under the use of mercurial pur-
gatives ; that during  the exhibition of two grains
of mercury alone every night, which did not purge,
the  anasarca  has disappeared, and the mouth be-
come affected, and that there  cannot be a more
hopeless  or more  painful task  than that of sub-
mitting to the miserable routine of salivating such
patients."
   When  the  inflammation has been subdued, and
the  bowels opened, supposing  that  these means
have not been  sufficient  to remove  the dropsical
effusion, diuretics  should be employed ;  and cer-
tainly in  no disease may more perfect reliance be
placed upon digitalis  than  in  this.  In adminis-
tering, however, this  medicine, it is of great con-
sequence  to watch  its effects, and to be certain of
the  manner in which it  has been dried.   Some
years ago the writer of this article employed the
infusion to  a  great extent without producing any
effects.  Occasionally, perhaps, the  urine might
have been a little increased, but no change what-
ever was  caused in the pulse, although  as much
 as an ounce and a half had been given three times
 a day.   Surprised  at this result, he at length re-
 quested to look at  the dried leaf; and, instead of
 finding it quite green, it was as black as charcoal,
 and the whole  matter was  explained.  No effect
 could be  expected  from it in such a state 
                                      ANAS.

  Sometimes the digitalis may be beneficially com-
bined with other diuretics, particularly the squill
and the liquor ammoniae acetatis.  A very power-
ful diuretic, also,  occasionally in this disease, is
the spiritus colchici ammoniatus;  and we have
often succeeded with this medicine in exciting the
secretion of the kidneys, when we had failed with
many others.   It may, however, be remarked gen-
erally of diuretics, that they bear,  and even re-
quire, to be united together more than any other
medicines ; and we have often thought  that their
effect has  been in proportion  to the complexity of
the  prescription.  Tbus,  perhaps, when  neither
squill  nor foxglove has  succeeded  alone, they
have acted when united ; and it will often be well
to join them with others.   The sulphate of mag-
nesia, when combined with squills, paregoric, and
the  liquor ammoniae acetatis, has often  a very
decided effect upon the kidneys, and either does
not  act at the same time upon the bowels, or only
in a very slight degree.  The following formulae
have been very useful  in our own  practice : —
R Liquor, ammonix acetat. f-^ii.;  T. camphorx
comp. f.^i.;  T. scillx f.gi.;  Magnesix sulphatis
^i.; Infusi  Turaxaci  f.^iv.; a, f.^ss usque ad
f.^iss tertii quaque hora. R Sp. colchici ammoniat.
f.^ii.; Potassx  subcarbon. gi.;  Infusi genistx
f.^viii.; ab f.^ss  usque ad  f.^iss  tertia,  quaque
hora.
   [Diuretics of the stimulating kind are not, how-
ever, adapted for all  cases of anasarca, and espe-
cially for those that are dependent upon granular
disease  of the kidney.  In ordinary  cases, where
no visceral disease contra-indicates  their use, re-
course may be had with full advantage to the infu-
sion of juniper-berries,  alone, or associated  with
the bitartrate of potassa.  A solution of the bitar-
trate may also be given for common drink ; and
along with these a grain of squill and half a grain
of the mild  chloride of mercury  may be  given
twice or thrice a day until the mouth is  affected
slightly. This course, along with the  employment
of a brisk cathartic, as the  pulvis jalapae com-
positus  twice a week, offers as well-grounded pros-
pects of advantage in simple anasarca as any that
could be devised.  (Dunglison's Practice of Medi-
cine, 2d edit., p. 649.  Philad., 1844.)]
   When  the anasarca has completely assumed  a
chronic form, and  appears  almost stationary, Ba-
cher's pills are extremely valuable.  In the original
formula they contained powdered carduus  bene-
dictus, but this is perfectly inert.   The formula is
contained  in  Thomson's Conspectus, under  tbe
head " Extractum hellebori nigri."   Under  their
use the effusion often gradually disappears with-
out  any extraordinary increase in the secretions.
Occasionally  they  act upon the bowels, producing,
however,  tenesmus  much more  frequently  than
actual diarrhoea; their more  manifest effect is in
slightly stimulating the  secretion of the kidneys.
In some  instances their exhibition, after a few
days, is followed by the peculiar effects of poison-
ing from  hellebore,  head-ach, giddiness, fainting,
&c,  together with  irritation  of the  mucous coat
of the intestines.  Of course the medicine, under
these circumstances, must be  suspended;  they
may, however, be generally  resumed again  in  a
few days without any ill consequences.
  In what is connected with  the treatment of this
^RCA.                                    99

disease, nothing has been  said  of those cases in
which the effusion is preceded or accompanied by
diarrhoea.   Where this has an  inflammatory ori-
gin, as is generally the case  after scarlatina  and
other repressed eruptions, blood-letting  has been
already recommended ; and the only question that
remains to be considered is that of purging.  Now,
though diarrhoea may arise, in  the first instance,
from simple inflammation, or  irritation of the mu-
cous membrane of the bowels consequent  to the
preceding eruption, it will certainly be maintained
and aggravated by any accumulation within them;
and, consequently, to take care that such accumu-
lation has not place, is a most important duty of
the  practitioner.   Here, however,  he will often be
beset with difficulties ; for should the diarrhoea be
violent, there will be  such a general exhaustion
of the system, that  to purge  at once will be to
ensure a fatal result.  The mode of proceeding,
therefore, must first  be, to maintain the system by
opiates, and this even should  leeches be  employed
at the same time ; for it is a curious circumstance,
but  we believe perfectly true, that patients will often
better bear  the loss  of a small quantity of blood
than the debility resulting from  severe purging.
When rallying bas occurred,  it will  be  proper to
regard the state of the bowels ;  and if accumula-
tion be suspected, to administer a mild aperient,
such as  castor oil, or an infusion of senna com-
bined with some carminatives ; thus simply en-
suring the  evacuation of the intestines, without
exciting in any violent degree the secernents of
the  mucous membrane.   After  the  diarrhoea has
subsided, the treatment in  no  way varies from that
which has  already been laid down.
   In distinguishing  inflammatory from asthenic
dropsy, much stress has been  laid by Dr. Blackall
upon the presence  of serum in  tbe urine; but
upon this point we have made no remark, having
no  dependence upon it as  a  guide  of practice.
That it is never present without inflammation is,
perhaps, true; but to make  it really a test, the
converse ought also to be true, viz., tbose dropsies
in which it does not contain  serum  ought never
to be conjoined  with inflammation.   This, how-
ever, is by  no means  the  case ; and our  experi-
ence accurately  coincides with Dr. Crampton's.
" In many  of those," says this  author, " which
appeared to me to require  the prompt use  of the
lancet, the  urine did not coagulate.   Under this
impression, I ceased  to draw  any practical infer-
ence from  that appearance ;" and he  adds  in a
note,  " Dr. E. Percival, who  was my predecessor
as one of the physicians to the House of Industry,
mentions that the result of his experience on this
subject fully coincides with mine. After he had
tried dropsical urine by the test of coagulation in
a number of  cases, he at length lost all confidence
in the test,  either as an invariable evidence  of in-
flammation, or as a guide of practice.  His state-
ment is  likewise confirmed by the additional testi-
mony of Dr.  Reid, who  acted as  a  clinical clerk
at the House of Industry at the time those experi-
ments were  made."  We would much  rather,
therefore, recommend that reliance be placed upo.i
general symptoms than upon  the state of the urine
only, which, at the most, can  only be regarded as
an auxiliary to our diagnosis.
   The  observations which  have hitherto beeu 
100
A NA SARCA
made, regard acute anasarca as an inflammatory
disease.  This, however, is not always the case.
The following extract from Dr. Bateman's Reports
of the Diseases of London, shows that it may be
the result of a debilitating cause, and require a
tonic treatment. " The patient was a middle-aged
woman, in previous health. She was thrown into
a state of extreme fright and  alarm, on discover-
ing in the evening that she had lost her little store
of money, the  savings of several years,  and  the
next morning  she was anasarcous from  head to
foot.  By tonics, combined with diuretics, the dis-
ease was speedily removed."
   The last modification of anasarca to which we
shall advert  is that in which its pathology is very
obscure,  viz., when the effusion is connected with
disordered states of  menstruation. Dr. Abercrom-
bie affirms that such modifications of dropsy have
been too indiscriminately classed among the  ca-
chectic diseases, and referred to a debilitated state
of the system.
   Sauvages relates  the  case of a young woman
who became suddenly dropsical over the  whole
body a few  days before  the  menstrual period ;
when the menstrual discharge took place, the drop-
sical swelling disappeared.  The swelling returned
at the  same time and disappeared in the same
manner  for several  successive periods, till  at
length,  by a  course  of treatment which he  de-
scribes, it was prevented from taking place.—Sau-
vages Nos. Meth. vol. ii. p. 471.
   Hoffmann describes the case of a woman, thirty
years of age,  previously  strong and  healthy, in
whom the  menstrual discharge was in general
remarkably  copious.  Having suffered  from a
fright  immediately  before the menstrual period,
the discharge did not take place,  and  she  was
seized with  languor, loss  of appetite, and dropsi-
cal swelling to such a degree that the integuments
on the feet  burst and discharged serum in great
quantity.  The menstrual discharge having taken
place at  the next period, all these complaints were
removed.—Hoff. Med. Rat. (de Hydrope.)
   Similar symptoms have been  occasionally ob-
served in connexion with suppression of hemor-
rhoidal discharge after it has become habitual.
   Dr. Abercrombie adds, these cases  certainly
indicate  a state of the system very different from
that which we understand by the  term cachexia.
Such affections are usually treated upon the  plan
of merely evacuating the  effused fluid.   It forms
an interesting  subject of investigation whether
 they would not admit of much more  active treat-
ment.
   A  similar affection occasionally supervenes in
females  about the pariod  of the cessation  of the
 catamenia.   The anasarca comes on slowly and
 insidiously, and is in general best treated by small
 bleedings and purgatives, with restricted diet, and
 confinement to the horizontal  posture.
    Excessive menorrhagia is not unfrequently fol-
 lowed by  anasarca.  It  occasionally  occurs in
 young females when the menstrual secretion is
 profuse.  In these  cases  a considerable quantity
 of coagulated blood flows from the uterine vessels
 for the first two or  three  days of the  menstrual
 period.   Slight effusion in the lower extremities,
 and sometimes on the whole body, takes place,
 with considerable weakness.   Such cases are very
little under the  control  of treatment, unless  the
hemorrhagic  action, on  which  the  effusion  de-
pends, be checked.
  TFew topical applications are of much benefit.
The laced stocking, or any ordinary bandage,  has
been advised  to aid  absorption, and to afford sup-
port.   When the integument becomes inflamed,
as it often does in cases of great distension, wash-
es of subacetate of  lead, or  weak  creasote water,
may be prescribed along with the gentle  support
of the bandage ;  but in  most cases a warm,  soft
poultice will  prove more serviceable.  When there
is apprehension of spontaneous rupture of the in-
tegument, it  may be advisable to evacuate the fluid
hy° punctures with the point of a lancet.  Where
the vitality of the parts has been greatly depressed
by the protracted pressure of the fluid, gangrenous
inflammation sometimes attacks them.  To guard
against this,  the  punctures  ought not  to be  too
numerous or too  close together.   As the  fluid is
discharged, a gentle  and equable pressure should
be made, by  means  of a bandage, on the distended
integument.   The  operation of acupuncture  has
been used  advantageously to  drain  off the  fluid.
In such cases, larger needles than those in com-
mon use are needed.   Some  prefer them of the
size of an ordinary glover's needle, and of a trian-
gular  shape,—a puncture  of this kind being  less
likely  to close.  (Practice of Medicine, p. 651.)]
   Anasarca from organic disease.
   Anasarca is also a common consequence of seve-
ral organic  diseases, and its treatment  admits of
some  modification according to the  organ origin-
ally affected.
   In all chronic  diseases of the heart, if the  pa-
tient is not carried  off suddenly, anasarca ensues
towards the  termination of life.   It usually begins
in the face, and the first symptom perceived is the
swelled or puffed state of the eye-lids on rising in
the  morning.  To this in a short time succeeds
anasarca of  the  lower extremities,  gradually ex-
tending upwards, and at length  involving  every
part of the body.  Hydrops pericardii and hydro-
thorax are also usually present.
   [The most common cause of dropsical infiltration
unquestionably is, an  impediment to the circula-
tion of the blood, either in the great central organ,
or in some portion  of the venous system.  Very
frequently this impediment to the circulation in
 the heart appears to consist in a morbid condition
 of the valves, which, owing often to dilatation of
 the cavities  of the heart, become insufficient to
 close  the openings,  and,  consequently, seriously
 disturb the circulation  of the blood through  that
 organ.  This insufficiency, as a cause of dropsy,
 would appear to exist most frequently in the tri-
 cuspid valve.]
   The treatment of anasarca dependent upon dis-
 ease of  the  heart must be very much guided by
 the general symptoms which may be present at the
 same time ;  for it must be remembered  that the
 obstruction to the flow of blood through the heart
 is very apt  to produce  congestion  and  even in-
 flammation  of the lungs. If this be  present, there-
 fore, an antiphlogistic treatment must of  course
 be adopted.  But it may also be the result of mere
 debility, and the principal  inconvenience may re-
 suit from the  effusion  itself.   The latter  state
 chiefly  occurs in  very old cases ;  the former is 
ANAS
common when chronic disease of the heart oc-
curs in young persons, and of an irritable temper-
ament.
  The following case exhibits the  appearances
which are frequently found in young persons, and
affords a strong illustration of the proper mode of
treatment.
  A young man, only thirty-two years of age, had
suffered for two years from  disease  of the heart.
A fortnight before his death, his lower extremities
became  oedematous ; he was  attacked with vio-
lent palpitations, dyspnoea, and haemoptysis.   He
was bled, and the usual remedies were resorted to;
but the attacks of palpitation continued to increase
in. violence, the effusion increased, and he died on
the fourteenth day from  his first  confinement to
the house.   On dissection the lungs were found
externally healthy, but  generally oedematous and
gorged with blood; and the inferior lobe of the
right lung was completely hepatized.  The heart
was enormous, but  principally from distension of
the right cavities.  Their parietes were thinned,
and they were at least double their usual capacity.
The left cavities  also were larger than usual, and
the mitral and semilunar valves were in a semios-
seous  state.   Both  passages   were greatly  nar-
rowed.
   The above case is sufficient to show that some-
 times bleeding may be necessary  in anasarca aris-
 ing from disease of the heart; but this is not the
 place to pursue farther the appearances in hydro-
 thorax with which the external effusion is usually
 united.  They will more properly appear under
 that head.
   With regard, then, to the treatment of anasarca
 depending upon disease of the heart, we have first
 to consider its character.  If inflammatory, or even
 attended with much congestion,  bleeding will be
 very necessary; in  other cases,  and where the
 principal inconvenience arises from the effusion,
 we shall derive the  best assistance from purgatives
 and digitalis.  In all these cases,  however, we can
 only regard these medicines as capable of afford-
 ing relief:  the  anasarca  will  unquestionably re-
 turn repeatedly,  unless the original disease can
 be removed.
   Of the purgatives which are recommended for
 the removal of anasarca,  elaterium appears to de-
 serve the preference.   As a hydragogue, indeed,
 it is not excelled.  The  formula which we  have
 always employed, is that described by Dr. A. T.
 Thomson, viz. ss. gr. of extract of elaterium, with
 five grains of extract of gentian, given every hour
 till watery evacuations are procured ;  and so suc-
 cessful has it  proved, that we have  never  been
 tempted to change the combination.  In giving this
 very powerful medicine,  however,  considerable
 care ought to be taken that it be not continued too
 long.   In one instance, where, from the great re-
 lief which the patient  had derived the preceding
 time that he  had taken it, he continued it much
 longer than he was ordered,  most violent hyper-
 catharsis ensued, and  he became for a short time
 completely  maniacal.   The   delirium went off
 after a few hours, and so successfully  had the ela-
 terium emptied  him, that a  much longer period
 than usual  elapsed before the  effusion became
 again  inconvenient.
   In order to be of much service, the elaterium
RCA.                                   10J
should be repeated every two  or three days for a
fortnight, when it may generally be suspended for
a short time.  Occasionally given in this manner,
the dropsical effusion disappears for several months,
until it is again excited by cold or some accidental
aggravation of the disease of the heart.
   Another  remedy which of late  years has been
much recommended, is  the croton oil :  the chief
objection to it is its uncertainty.   Upon some in-
dividuals  a single drop acts very violently, while
upon others it appears to be perfectly inert.  We
have given  as many as five drops to one patient,
of the same preparation which caused upwards of
thirty large watery evacuations in another patient
who took  only a single drop.  When it does,
however, agree with the constitution, it is in some
respects  preferable to  elaterium, as the patients
sooner overcome its debilitating effects.
   It often happens that with disease of the heart
some disease of the liver  is combined ; and  here
mercurial purgatives, joined with diuretics, are fre-
quently very useful  During the last year we suc-
ceeded in removing  the dropsical  effusion by a
powder of calomel and jalap every morning for a
fortnight, giving diuretics at the same time, when
elaterium had only afforded very temporary relief.
   Sometimes the dropsical effusion is  attended
with great debility and hysterical symptoms ;  and
this will admit  neither of bleeding nor  purging.
Here the ferri  et potassae tartras combined  with
some mild tonic may often be employed with great
advantage.    The  tartarized  iron acts slightly,
sometimes indeed freely, upon the kidneys, while
its tonic powers support tbe general strength of
the system.  Occasionally this  medicine may be
beneficially used after slight  bleedings, especially
in those cases in which congestion and not inflam-
mation is present.
   Some  practitioners place very  great  reliance
upon digitalis, and certainly its effects  are some-
times quite marvellous.  We  shall only  remark
upon it,  that no medical man should  prescribe
digitalis without visiting his patient every day ; as
from its tendency to accumulate  in the system,
without this precaution it may often prove fatal.
   Organic disease of the uterus, attended by he-
morrhage, is occasionally followed by anasarca
The following  case  will illustrate  this form of
dropsy.
   A married female, thirty-six  years of age,  suf-
fered,  for  three years  before death, from cauli-
flower  excrescence of  the uterus, attended  with
profuse hemorrhage at intervals.  Some time after,
she became anasarcous.  The effusion continued
to increase so long as  the hemorrhage  recurred.
When  this ceased, she took  large quantities of
bark, and generous diet was allowed : the effusion
disappeared, and she regained  her strength.
   [Another cause of anasarca, and of dropsy of
the cavities, is the disease of the kidney, described,
of late years, as the disease of  Bright.  In all
works on  the practice of physic, suppression of
urine, or a sudden diminution  in the quantity of
the secretion, has been esteemed a cause of ana
sarca ;  but the researches  of modern  observera
have shown, that a pathological condition of tho
kidney, in which the  cortical  portion assumes a
granular character, and secretes aibumen from tho
blood, is by no means an uncommon cause.   The 
102
A N A s A R C A.
characters of  this renal  affection arc  described
elsewhere.
   Of partial dropsies, resulting from  temporary
obstructions of the circulation, a familiar example
occurs in intermittents, in almost all cases of which
there is  more or less enlargement of the  spleen,
and concomitant infiltration of the cellular mem-
brane ; but  both affections pass away after the
intermittent has  been arrested.
   On the examination of the subcutaneous cellu-
lar tissue of one who has died of anasarca, it  is
found distended by a limpid serous fluid, usually  of
a bright orange-yellow hue.  In the most common
cases of asthenic anasarca, it bathes the  cellular
tissue and the subjacent  muscles, which are ren-
de/ed unusually pale and  flaccid, and tear with
the greatest facility.  Sometimes the  infiltration
is confined  to the  subcutaneous cellular  tissue ;
but at others it extends  to that which envelopes
the fasciculi and the fibres of muscles, the ten-
dons, vessels and nerves, and occasionally  to that
which enters into the constitution of the  viscera.
Wherever the infiltration exists, the cellular mem-
brane is  much softened.   (Dunglison's Practice
of Medicine, 2d  edit., p. 647 : Philad., 1844.)]
   Local anasarca.
   Anasarca  may either  generally or  locally  at-
tend upon organic disease of any part of the body ;
but it scarcely seems  necessary to consider  these
more particularly.   We  shall now, therefore, pro-
ceed to consider those forms of effusion which are
confined to the lower extremities, and in many
instances do not even extend above the knee. The
first place is due  to phlegmacia dolens, which
must be  regarded as a local anasarca.
   The pathology of this disease formed for many
years a stumbling-block to medical men ;  and se-
veral very recondite theories were set  forth upon
the subject.  The investigations of Dr. D. Davis,
and other pathologists, at length appear, however,
to have set this question  at rest, and to  prove satis-
factorily  that " tbe proximate cause of phlegmasia
dolens consists in a violent and destructive inflam-
mation of the iliac  veins and their contributories,
including in some cases the inferior portion of the
vena cava."
   Dr. Robert Lee has entered more minutely into
the pathology of phlegmasia dolens, and  has en-
deavoured to prove that  it is connected not only
with inflammation of the femoral veins, but of the
uterine veins likewise.
   Phlegmasia dolens is occasionally  also in the
male, as  in the female subject, in idiopathic disease.
A short time ago the writer  of this article was called
to a man,  twenty years of age, a  carpenter  by
trade, who, after an attack of catarrh, was suddenly
seized with very extensive oedema of the right leg
and thigh.   The femoral vein could be distinctly-
traced,  as a firm, hard chord, very tender to  the
touch, from the groin to its passage through the
tendon of the triceps.  There were typhoid symp-
toms present at the same  time.  The oedema of
the limb was very  much reduced by the  applica-
 tion of leeches, and eventually the man recovered ;
 the treatment after the first few days being chiefly
 r onstitutional.
   In  the treatment  of  anasarca attendant upon
 scute inflammation of the veins, our first  atten-
 *ion must obviously be paid to the local affection ;
and the application of leeches in tbe course of the
vessel  is a most  important point.   At the same
time recourse should be  had to purgattvos and
more particularly to mercurial purgatives.   If by
these  means we  succeed  in removing or  greatly
diminishing  the  febrile state, we shall still have
to combat  the  disease in its  chronic  form, for it
scarcely  ever happens  that recovery  is at once
complete.
   If we look to tho appearances  which  the af-
fected   vessels  exhioit  upon  examination after
death,  we find them  generally more or less loaded
with coagulable lymph, sometimes  also accompa-
nied by pus.  From what we know of the great
irritability of the veins, and the  consequences of
injecting  pus  into their cavities,  we may  well
question if recovery be ever possible when  suppu-
ration  has  occurred within them ;  and it will be
therefore the deposition of coagulable lymph only,
in the chronic  form of the malady, that we shall
have to overcome.  Analogy teaches us that that
kind of inflammation which gives rise  to the effu-
sion of plastic lymph is most easily subdued by
mercury.  It is this which occurs  in iritis, which
affection is frequently first manifested to the prac-
titioner by the cloudiness induced by the presence
of coagulable lymph ; and in this disease mercury
almost deserves the name of a specific.  It is nearly
as serviceable in that chronic state  which remains
after  an acute  attack of phlegmasia dolens; and
we have frequently found  the compound calomel
pill, given  every night for two or three  weeks,
make  a very material improvement in the state of
the limb.  It may also be advisable, at this  period,
to combine it with mild tonics.   It too often hap-
pens, however,  that some  stiffness and swelling
will remain  during life, whatever may have been
the treatment employed.   In the  latter stages of
the complaint, frictions are very  useful.
   We have entered on the subject of phlegmasia
dolens with  the view of rendering the pathology
of the various  forms of anasarca as complete as
possible.   For a more  ample account of this im-
portant subject, we refer tbe  reader to the article
Phlegmasia Dolens.
   There is also an acute species of anasarca oc-
curring  in children, generally about three or four
years  old, and confined  to the legs, seldom extend-
ing above the  knee.  It  does not  appear  usually
united with any organic  disease, and  is generally
attendant upon that febrile  state to which children
of this age are  so liable  from  affections  of the
primae viae.   Sometimes it is accompanied  with
diarrhoea.    It  commonly disappears  under  the
treatment  employed  for  the  cure  of tbe original
disease.
   Local anasarca occasionally accompanies some
eases of amenorrhoea, and varies from mere oedema
of the ankle to extensive effusion reaching some-
times  as high  as the groin.  This affection, how-
ever,  is not always  attended with amenorrhoea,
 but may occur when the catamenial  discharge is
 not manifestly disturbed.   The first  symptom is
 swelling and pain about the ankle, more  particu-
 larly  troublesome towards night.   In  many  of
 these  cases, examination of the veins of the extre-
 mity  will detect tenderness or hardness, some-
where in  the  course of the  great veins  and we
have seen one  instance where the symptoms above 
ANASARCA —ANGINA  PECTORIS.
10.3
enumerated were the only symptoms present. The
spot most usually tender is just where the femoral
vein passes into  the ham, and  the affected part
often does not exceed more than an inch in length.
Frequently also the vein may be felt in this place
rolling like a chord under the finger.   A lady ap-
plied to us in January, who complained  of slight
pain and swelling at the ankles  at night.   There
did not appear to be  any other affection.  The
general health was good, and the catamenia were
regular.  There was tenderness and hardness of
the femoral vein in the spot alluded to above, but
more in the left than in the right thigh, the ankle
of which limb was more swelled than the other.
Some  leeches were applied, which removed both
the tenderness and hardness of the veins; and the
ankles never swelled after the bleeding. We heard
of her a few weeks afterwards, and she had had no
return.
   The following  case, however, affords an exam-
ple of the most frequent form of the disease, and
it is one of many in which the same tenderness
of the  veins  has been  exhibited, and which have
yielded to the same treatment.
   A young lady, aged  twenty-two, had long suf-
fered from hysteria and  its various complications,
 gastrodynia,  flatus,  &c, great  debility, and de-
pression of spirits.  The catamenia were always
 scanty.  Her legs began to swell about the ankles,
 and the swelling  gradually extended to the pelvis.
 There was considerable tenderness in the course
 of the femoral  veins.  Twenty leeches were ap-
 plied to the affected  part, with the effect of dimin-
 ishing the swelling ; but some  tenderness in the
 course of the  femoral  veins  remained,  so  that
 leeches were again applied.  After this the swell-
 ing of the limbs was still further diminished, and
 there was  scarcely any tenderness in  the course
 of the veins. A month afterwards the oedema had
 nearly disappeared.   She remained  some time
 under treatment   for dyspeptic symptoms, with,
 which the cedema was  combined, but no return
 of the effusion to any extent  was observed.   In
 this, however, as  in most of these cases, the ankles
 continued to swell  at  night in  a greater or less
 degree, but the cedema did not extend much higher.
   It is not always  that this  kind of effusion can
 be traced to  obstruction in the veins.  There are
 some leucophlegmatic  females in whom no local
 affection can  be discovered  to account for  the
 cedema, and in whom  it seems simply the effect
 of general debility.  In cases of this nature, the
 mistura ferri composita is frequently very bene-
 ficial.   The best mode of giving it is in combina-
 tion with  decoction of  aloes, or some mild ape-
 rient.    In  all  these  cases reference  must  of
 course be had to the accompanying symptoms.
 It would be idle  to lay down any positive rules
 for the treatment of the anasarca merely.
   There are, doubtless, other forms under which
 anasarca sometimes appears, besides  those which
 have been now enumerated.   Enough has, how-
 ever,  been done  to exhibit  the  principles upon
 which effusion should always  be  viewed, that is,
 not as a disease  in itself, but as an evidence  of
 some disturbance in the functions of the animal
 system, or upon some actual change in .the struc-
 ture of some important organ.
                               J. Darwall.
   ANGINA PECTORIS.  The affection thus
commonly designated has attracted great attention
since it was first formally noticed by Dr. Heberden,
about sixty years ago.*  The name above prefixed
was given to it by the author just mentioned, on
■account of its  " seat, and the sense of strangling
and anxiety  with which it is  attended ;" the word
angina (from ayxw>  siranguh) having been ap-
plied by the ancients to all diseases of the throat
accompanied by a feeling of suffocation or stran-
gulation.  (Celsus, lib. iv. cap. iv.)   The word
is still used  in this sense by the French, Germans,
and other continental nations, comprehending all
the inflammatory affections of the fauces, larynx,
trachea, and neighbouring parts, classed  by Dr.
Cullen under the head Cynanche.  It is evident
from the expressions above quoted from Dr. Heber-
den, that  he adopted the name in common use,
qualifying its new application by the addition of
the  word pectoris.   It  is, therefore,  incorrectly
said by Dr.  Frank, that this name has nothing in
common with the same word as  applied to affec-
tions  of the throat.j-   This author  derives the
term from the Latin verb  angere,  taking  this in
its more general or metaphorical sense, as signify-
ing to occasion distress, and  apparently forgetting
that this word is itself derived from ayx®* and, in
strictness of language, means the same thing.  As
the word  angina has ceased  to be applied, in the
medical language  of this country, to inflammatory
affections of the throat, we shall  adopt its  use in
the present  article without always  retaining its
qualifying adjunct pectoris.
   Angina can  boast of a very copious synonymy.
The following  are the principal  names by which
it has been  designated by different writers, and the
order of their imposition : —
   Cardiogmus cordis sinistri..........Sauvases, 1763
   Angina  Pectoris...................Heberden, 1768
   Die Brustbriiune....................Eisner,    1780
   Diaphragmatic gout................Butter,    1791
   Asthma Arlhriticum ...............Schmidt,   lTi'o
   Syncope Angens...................Parry,     1709
   Asthma  Dolorificum................Darwin,   1801
   Sternodynia Syncopalis.............Sluis,     380-2
   Asthma spaslico-arthriticum incon-) gtoeuer   ]g03
    stans  ..........................S
   Suspirium  cardiacum...............Stephen,   1804
   SternalKia.........................Baumes,   180(3
   Stenocardia........................Brera,     1810
   Pnigophobia.......................Swediaur, 1812
   Angor Pectoris.....................Frank,    1818
  [Neuralgia  of the heart.............Hope,     1832J
    Although the above catalogue  does not  go far-
 ther back than the time of Sauvages, there can be
 no doubt that  the complaint was well known to
 practical men from the earliest periods of physic ;
 but like several other affections now classed under
 particular names, and  regarded as  distinct dis-
 eases, it was merely considered as a symptom, or
 isolated group  of the ordinary symptoms, or as an
 accidental complication or  particular phasis of
 some  known disease; and, if noticed at all, passed
 under the  usual  name.  Before the time of Dr.
 Heberden,  indeed, Sauvages, after Poterius, cer-
 tainly noticed  and named  the affection as  a sepa-
 rate form of disease; but  of this fact Dr.  Heber-
 den was ignorant;  and his much fuller and moic
  * Some Account of a Disorder of the Breast. Read a*
the College, July 21, 1768.  Medical Trans, vol. ii. p. 53.
  t Hoc vocabulum nihil commune habet cum ec anginir,
sub quo faucium inflammatio vulgo intel'teitur.  Prii
Med. Univ. P. ii. vol. viii. p. 244. 
104
ANGINA  PECTORIS,
accurate history justly entitles him to the honours
of an  original observer.   .Many passages in the
writings of the ancients, and particularly in those
of Hippocrates, might, without much straining, be
made to apply to this disease, notwithstanding the
round  assertion  of  the  last named  author,  that
" the heart is a  dense and  solid body, and there-
fore  unsusceptible of pain."* Some have imagined
that  Aretaeus referred  to  angina under  the name
of TrvevpwScs ; but his account is much less charac-
teristic of the affection than many passages in the
writings  of  Hippocrates.  The  account which
Aretaeus gives of the second  species of angina
comes much nearer the disease which we  have to
describe under the same  name.   (Aretxi Opera,
p. 7. Oxon.  1723.)  In the works of Caelius
Aurelianus, a brief statement occurs in his chap-
ter on paralysis, which  has been  generally con-
sidered, and apparently with reason, as referring
to the disease  now  under  consideration.!   The
case  of Seneca, as  described by himself, has  also
been generally considered as a case of angina, and
we think most justly.   He terms his disease  sus-
pirium.  (Senecx Opera, t. ii. p. 136. Epist  liv.)
In perusing the medical writings of the  sixteenth
and  seventeenth  century, we  meet  with many
observations which can only apply to this disease.
These are most commonly found in their account
of asthma, with which, as a well-known disease,
and  as  having  some  of the  external symptoms
somewhat similar, it was most  likely to be con-
founded.  It was with this disease, or at least with
dyspnoea, that it was confounded by Poterius and
Barteletti, certainly the first medical writers who
notice the disease in such terms  as cannot be mis-
taken4   In the  works  of Hoffmann and Mor-
gagni, many well-marked cases of angina will be
found.§   One of the  earliest, probably, and  cer-
tainly one of the most unequivocal cases of angina
to be found in the English language, is that of the
lather of the great  Lord  Clarendon, recorded by
his son.   In this case the event  was fatal.||
   After the publication of Dr. Heberden's paper,
the disease was noticed by a vast number of medi-
cal writers  in  England,  France, Germany,  and
Italy, both in periodical publications, in the trans-
actions of societies, and in distinct treatises. Since
it first attracted attention, angina seems, indeed, to
have been a favourite with the profession, and the
mere catalogue of the published cases and mono-
graphs would  fill many pages.   The reader who
is curious in this matter is referred to the writings

  * Est cor res solida ac densa, et propterea dolore non
afHigitur.  De Morb. lib. iv. cap. x.
  t Erasistratus memorat paralyseos genus et paradoxon
appellat, quo ambulantes repente sistuntur ut ambulare
■ion possint, et turn rursum ambulare sinuntur.  Chron.
 ib. ii. c. i. p. 348.
  \ GluEedam est  respirandi difficultas (says Poterius)
qu«E per intervalla  deambulantibus  accidit.   In hac fit
prseceps virium lapsus, propinquis tenentur niti admini-
culis, alias humi corruerent; hi ut plurimum derepente
inoriuntur.  Pet. Porter. Op Orn.cum Annot. Hoffmann.
p. 302.  Franco/, ad Mmn. 1698.  Fabricius Barteletti, in
his Methodus in Dyspnmam,  (Bonon.  1632) speaks of a
variety of this affection, "quae in  ambulation^ motu
srumpens sola quiete mitescit."
  § A single case selected from the works of each of these
authors suffices to prove that they were well acquainted
witli the disease.  See Hoffmann.  Consult.  Med.  Cas.
S3. Op. t. iv. p. IK. Mergagni de Sed. et Caus. Morb!
lib. ii. epist. xxvi. art. 31.
  ll Life of Edward, Earl of Clarendon, (dated July 1668 1
Orford, 1761, vol. i. p lb.                    '
of Butter, Parrv, Black, Blackall, Eisner, Stoeller,
Jahn, Desportes, Jurine, Brera, and Zechinelh. In
the work of Zechinelli, in particular, a most ample
collection  of the  recorded facts  and  opinions
respecting  this  disease will be found ;  although
even his industry has failed to notice  a consider-,
able number of  important cases scattered through
the medical literature of this and  other countries.
(Sulla Angina di Petto. Padova,  1813.)
   History of  the Disease. — Angina pectoris
is a disease of an intermitting  character, in which
the patient has intervals  of comparative ease or
of perfect health, between paroxysms of greater or
less suffering.   The paroxysm usually  makes its
first attack  while the patient  is  taking exercise.
Whilst walking or running, and more particularly
if in the act of ascending an elevation at the same
time, he is all at once seized with a most distress-
ing sensation in the chest, usually in the region
of the heart, or about the  lower half of the ster-
num and towards the left side.  This sensation is
variously described, as a pressure, or stricture, or
weight; or as a positive pain of various character
and degree, sometimes obtuse, sometimes acute,—
tearing,  burning, or  lancinating.  There  seems
always to be something  peculiar in  the pain,
whatever be its  degree, unlike the pains of other
parts of the  body, and as if it  were  combined
with something of a mental quality.  There is a
feeling and a fear  of impending  death ; and the
primary symptoms of corporeal disorder are speed-
ily modified  by  the consequences of mental  im-
pressions conveyed through the nervous system.!
The patient makes a sudden pause, eagerly catches
hold of whatever is  next him for support, perhaps
raises the hand  to some object above him to which
he clings, or, it  may be, imperceptibly sinks down
on a chair or bank, as if unable to stand, yet afraid
of the movements  necessary to  seat him.  The
face is pale, the expression of the countenance
haggard, the whole  body is covered with a cold
sweat, and death appears to be impending no less
to the  inexperienced spectator than to the miser-
able patient.  Such, in fact, is sometimes the ter-
mination of the  paroxysm, but rarely, and scarcely
ever in the  early  stage of the  disease.  After
suffering in  the way described  for a  longer or
shorter period, varying in  different cases from a
few minutes  to one hour or more, the patient
revives, sometimes gradually, sometimes  suddenly,
and in many cases  immediately resumes the feel-
ing and the faculties of health.
  The pain is rarely confined  to  its primary and
principal site in  the cardiac region, but  increases,
in different instances, very variously both in direc-
tion and extent.  It shoots upwards or downwards,
or to the right side, and almost  always through the
left side  of the chest towards the shoulder and
axilla,  and  very  frequently into the left arm about
the middle of the humerus, or as low as the elbow.
Sometimes the pain in  the last named places is
extremely acute  ; and, frequently, sensations of a
similar kind, though less severe,  are experienced
all along the arm to the fingers, or in both arms,
or along the throat and side of the face, and occa-
sionally even in the lower extremities.  Generally,

  TT •' duidni ?" exclaims Seneca, reflecting on his owl
sufferings from this disease, " aliud enim quidquideil
.egrotare est; hoc  est  animam agere."  Epist. liv 
ANGINA
these  pains in the limbs accompany  or  succeed
that in the chest;  sometimes they precede it.  In
most cases the respiration is unimpeded, although
the patient seems at times as if he were unable or
afraid to  breathe.   At  other  times, and  perhaps
more  generally, deep inspirations are  made, and
are aided  by raising the arms and shoulders, with
the view of enlarging the chest as much as  possi-
ble.   Sometimes the breath is retained for a con-
siderable time.
   The  pulse  is found to vary  considerably  in
different cases.  Sometimes it is regular,  some-
times irregular; in one patient frequent, in another
slow ; sometimes  feeble,  sometimes strong, and
occasionally  altogether suppressed;  most  com-
monly,  perhaps,  it is regular, small,  and  weak.
Eructations of flatus are almost always  present,
and when present generally  afford relief.   Fre-
 quently, indeed, in the less severe cases, the parox-
ysms seem to give  way immediately  upon  the
 supervention  of  the  discharge; and  the  same
 result occasionally follows, but  much less com-
 monly, a similar  discharge downwards.   In the
 commencement of angina, the attacks are, in gene-
 ral,  comparatively mild ;  and commonly increase
 progressively in severity as well  as frequency, as
 the disorder is prolonged.   In a certain proportion
 of cases, the symptoms  are so mild as  to  give rise
 to doubts whether the affection is really  angina ;
 the whole paroxysm often consisting of an instan-
 taneous pang in the situation of the heart, passing
 off' nearly as soon as felt.   In others, the pain is
 of longer duration, and  is accompanied by more or
 fewer of the  irradiations to remote parts  which
 mark the severer paroxysms,— in particular, the
 pain of the left arm.  In a third  class of cases, the
 patient is suddenly invaded by an indistinct, very
 distressing, but not very painful  oppression in the
 region  of the heart.   He is agitated and alarmed ;
 his  sensations are distressing, his apprehensions
 are  more so.  He feels as  if the heart were vio-
 lently compressed ;  or as if it were distended and
 about to  burst, or as if its  movements were sud-
 denly arrested.   This last  sensation  is the most
 common. In every variety of paroxysm, whether
 slight or  severe, palpitation of the heart is not an
 unusual occurrence.  Sometimes  it precedes, some-
 times accompanies, sometimes follows the painful
 sensation ; but in many of the severest  and  best
 marked cases it is entirely wanting.
   Angina occurs  in both sexes, and at all ages
 above  that of mere childhood ;  but  it  is much
 more common  at particular  periods of life ;  and
 the severer cases, at least, are met  with  much
 more frequently in the male sex.   Of eighty-eight
 cases related by different authors, and to which we
 have referred  with a view to this particular ques-
 tion of sex, only eight occurred  in females, being
 exactly one-eleventh of the whole ;  and  of the
 total number  of patients, twelve only were under
 titty years of  age.  Were we, then, to be  guided
 solely by the  published cases, we should say that
 the common opinion, which represents the  disease
 as especially affecting  the  male sex and persons
 advanced in life, is  most just.  No doubt it is so;
 but still  it is  necessary to make softie allowance
 for circumstances connected  with these recorded
 cases, before they can  be received as grounds for
 fixing  the statistics of the disease, taken without
   Vol. I___14
ECTORIS.                             105
reference  to  its degree of  severity.   The  truth
seems to be, that of the more severe cases, particu-
larly such as depend  on  organic disease of the
heart and  large vessels, the great majority occur in
the male sex ;  while of milder cases, a very  con-
siderable proportion, perhaps an equal proportion,
are met with in females, and at an earlier  period
of life.  This, at least, is the result of our own
experience ;  and the  same  opinion is entertained
by writers of great authority.*  The same conclu-
sions as to the greater  frequency of mild ca_ses in
the female sex, and at an earlier age, are supported
by certain other results of the published histories
of angina.   Thus, while  only one-eighth  of the
males  recovered, no  less  than  one-half of the
females did  so, viz.,  four out of eight; and  of
these four, only one was above fifty years of age.
But it is to be further  recollected that the greater
mildness  and curability of the disease in women
will partly account for the  very small proportion
of this sex among the published cases.  The very
severe cases naturally attract mor;; attention,  more
particularly if, as often happens, they have  been
terminated by a sudden death, and followed by a
dissection ; and these are the cases that are usu-
ally recorded and published ;  while others of pre-
cisely  the same nature, but differing in degree, are
too  often  overlooked  or  even  forgotten.   From
these considerations, therefore, and from our own
observations, corroborated by those  of Jahn, Ho-
sack, Laennec, &c, we are disposed to believe,
that while among the severe examples of the dis-
ease, the  proportion of males to females may be
even greater than is commonly believed ;  among
the  milder cases,  theie may  be found as  many
women as men.
   There is no situation in  life peculiarly exempt
from this disease ;  but it attacks  some classes of
persons much more than others.  Like many other
diseases, angina is the attendant rather of ease and
luxury than  of temperance  and labour ; on which
account, although occurring among the poor, it is
more frequently met with  among the rich, or in
persons of easy circumstances.  This fact  alone
shows that its attacks are much more influenced
by adventitious circumstances than by natural
temperament.   The same  remark applies to  the
reported  prevalence of the disease  in  particular
seasons, and in what  has been termed particular
 medical constitutions.  (Laennec, De  l'Auscult.
 Med.)  It must,  however,  be admitted that  the
 greater number of cases depend  on causes of  loo
 fixed  and too formidable a quality to be modified
by circumstances of this  kind.
   Although by no means of rare occurrence,  an-
 gina cannot be said to be a common  disease, more
 particularly  in  its strongly  marked  form.   In the
 numerous instances of organic disease of the heart
 constantly met with in practice, symptoms which
 may be termed irregular angina, namely, morfc or
 less of pain or uneasiness in the  region of  flie
 heart,  suddenly coming on during  exercise, and
 obliging  the patient to stand still  for a short time,
 are complained of, in almost every case, in a greater
 or less degree ; but the severe affection described
 by Dr. Heberden and his followers, and of which
 an outline has been given in the beginning of this

   * Jahn, Ueber die Syncope Anginosa Parry.  Hufc
 land's N. Journ. 1806. 
106
ANGINA  PECTORIS.
article, is certainly not of frequent occurrence.  It
is proper to  observe, however, that the great im-
provements which have  taken place of late years
in  pathology, by enabling practitioners to connect
symptoms with their organic causes more accu-
rately, have necessarily diverted the attention from
the artificial  combinations of the old nosology;
and  as  the  knowledge of  cardiac affections has,
moreover, been particularly increased  by the dis-
covery of a very superior instrument of diagnosis,
it  is  probable  that many  cases which the older
authors would  have referred to angina, have  of
late years been looked upon and  recorded simply
as  diseases of the heart.  If only the well-marked
cases are taken, it will be found that the whole
number recorded  in  the works  of our  English
writers since the time of Heberden, as well as in
those of the  best authorities in France,  Italy and
Germany, does not much exceed  one hundred.
   If we were to form our opinion solely from the
results of the published cases of angina, we should
say that it was one of the most dangerous and
fatal of diseases.   For instance, in a list of sixty-
four cases now before  us, of which the result is
recorded, no less than  forty-nine  proved fatal,
almost all suddenly ;  while of the remaining fif-
teen the greater proportion are recorded as relieved
only. But we are by no means disposed to receive
such  results  as coming  at  all near the truth, as
regards the disease generally.  Most of the cases
in  the above list were examples of organic disease
of  the heart or large vessels ; and if  we were to
limit our views to this class  of cases,  the propor-
tion of deaths above  stated is probably less than
the truth.   But we shall  find  that a very large
chos of cases, legitimately ranged under tbe head
of  angina, have no necessary dependence on struc-
tm al lesion of the heart; and of these the general
res ult will be  found  very  different  from that re-
corded above.  It is from having  overlooked this
lant class of cases, that most of the earlier writers
on angina considered it as  almost inevitably fatal;
and  it is, perhaps, from  giving  too exclusive  an
attention to  the milder forms of the affection, that
some other authors have taken a view of it per-
haps as much too  favourable as the others did the
reverse.  Of the latter class of writers, Laennec,
Hosack, and Butter are the principal.  Laennec
considered the disease  as extremely common in its
milder forms, and  did not regard  it, in general, as
a »evere disease.  (Loc. Cit.)  Dr. Hosack believes
th«: severity of the affection to  have  been much
exaggerated, and looks upon it as very much under
the influence of medical treatment.*   Dr. Butter,
who considered angina to be a species of irregular
gout, says that he must  " impute the chief, if not
the  sole,  difficulty of curing the  disease to the
want of conformity of the patient himself with
regard to diet."-f-
   The following  synoptical view of some of the
statistical details  relating to angina will be found
convenient  for reference,  and is, therefore, sub-
joined, although in some  respects a repetition of
what has gone before.
      A. Results relative to the sex of the patients.
Totjl number of cases examined,....................gg
      Of these were, men......................po
                  women................... q
B.  Results relative to the age of the patients.
Total number whose ages are recorded,
     Of these were, above fifty.......
                  under fifty.......
  C. Results relative to the event of the cases generally.
Total number of patients, the event of whose cases is
  recorded...........................*...............^
     Of these there died (almost all suddenly). .49
     Were relieved or recovered..............15
D. Results relative to the event of the cases as regards sex.
                                 ................49
* Assays on various Si-bjects of Med. Sci., vol ii  288
f Treatise on Angina Pectoris, 2d edition p. 24.
1. Total number of fatal cases....................
     Of these were, men.....................47
                  women.................. 2
2. Total number of cases cured or relieved............15
     Of these were, men.....................11
                  women.................. 4
  Causes*__Under this head, we shall at present
notice  only the exciting causes of the paroxysms,
The remote and predisposing causes will be con-
sidered with more  practical  advantage,  athough
with less logical catenation, when we come to treat
of the  different varieties of the disease, and the
means of preventing and curing it.
  The exciting causes of the paroxysms of angi-
na, or  the circumstances under which they occur,
are, in general, so well marked,  and  so  constant
and uniform, that they might almost  have been
included in the description of  the disease.  They
may be stated  in  general terms, to be all such as
accelerate the flow of blood, or suddenly increase
the action of tbe  heart.  The principal  of these
circumstances are all  kinds of bodily exercise, as
in walking,  running, straining, &c, and the more
powerful emotions of the mind.  Of all the move-
ments  of progression, that of going up  stairs or
up hill is by far the most effective in inducing a
paroxysm ;  and it has been  frequently remarked
that, ceteribus paribus, walking  against the wind
is considerably more injurious than walking in a
contrary direction.  Sometimes  even walking in
the open air in perfectly calm weather has induced
a fit, when  the same degree  of exercise within
doors has had no such effect.   (Medical and Phy-
sical Journal, vi., p. 320.)  In some rare instances,
the first paroxysm  has  been induced suddenly
during powerful  bodily exertion,  as in  leaping,
raising a weight, &c.; j  and in such cases, it has
been found that a slight  rupture has taken place
in the  valves of the  heart or their appendages.  In
the earlier stages of a severe disease, and through
the whole  course of mild cases, the attacks are
commonly induced  by the more powerful  of the
causes  mentioned, or by others  of an analogous
kind ;  but as the  disease  increases in severity, the
slighter causes of the same kind suffice  to excite
a paroxysm.  Thus, in some unhappy individuals,
almost any .general  bodily movement, such as the
act of turning in  bed, or walking across the room,
or coughing, sneezing, or relieving  the bowels, or
even  thinking intensely, will occasion a seizure
In subjects of such  extreme susceptibility, parox-
ysms  will,  of course, frequently occur without
any very obvious cause.   Any of the causes being
applied immediately after a meal, acts with much
greater certainty and  force ;  and  sometimes the
mere presence of a full meal in the stomach seems
sufficient to excite a paroxysm.  In certain cases,
the attacks occur  most frequently at night, on th«
patient awaking from sleep, as is so frequently the

  t Black in Mem. of Med Society of London, iv., p. 61
Blackall on Dropsy, 2d edition, p.  381, 
ANGINA  P
ECTORIS.                             107
case with paroxysms of asthma ;  and this circum-
stance is  one  of several  which have  led  some
writers to consider angina as allied to that disease.
  Pathology of Angina.—In a perfect system
of philosophical medicine, founded on the basis of
the pathological condition of the organs primarily
affected, angina, such  as we have described it in
the preceding pages, would be banished from  the
list of individual diseases ;  since it cannot  be
denied that the various phenomena which consti-
tute the paroxysm  may be present in different
states of the system, or may even originate, as far
as we  know, in different states of the very organ
in which we believe them to have their site.  In
such  a system,  it could only be regarded as a
group  of symptoms — frequently found co-exist-
ing, it migbt be — but  still merely the incidental
attendants  of different diseases.   But as it is im-
possible, in the imperfect state of our actual know-
ledge, to say, in the case of angina, as in that of
so many other diseases, what morbid phenomena
are essential,  and what merely  contingent,  we
shall  attempt  no such refinement on the present
occasion, but following the steps of our numerous
predecessors, shall treat of angina as  a distinct
disease.
   In common language, the term angina pectoris
is  frequently  restricted to  the  more  prominent
phenomena of the paroxysm, as above described;
and there can be no harm  in  so applying it, pro-
vided its restricted meaning is not misunderstood.
But when  the disease angina is regarded in  the
comprehensive point of view which can alone lead
to  important practical results, it is very far from
being confined to the limits of the paroxysm.   On
the contrary,  it  must be considered as compre-
hending all the derangements of the system, gen-
eral and local, which  precede, accompany, or  fol-
low the paroxysm, or which  can in any way be
regarded as influencing it.  This is the notion of
the disease which exists in the mind  of every  ex-
perienced practitioner; and  this  is the sense in
which the word  angina is generally to be under-
stood in the  present  article, although  it will be
observed that we have already been using it in its
more restricted meaning.
   Seat and nature of the disease*— Numer-
ous considerations  prove that  the  pain in  the
paroxysm of angina lias its primary and principal
seat in the heart or annexed great vessels.   1. The
patients almost always refer their agony  to  the
region of the heart; the more distant pains of the
shoulder, arm,  &c, appearing to  spring from this
primary source, and being, in  almost every case,
subsequent to the invasion  of  the paroxysm.*
2. The peculiar character of the  patient's  suffer-
ings,  partly physical, partly  mental,  the anxiety,
dread, &c, are such as could only be produced by
the affection of an organ like the heart, on  whose
action life  so  immediately  depends, and  whose
disturbance is  so instantly perceived by the sen-
sorium.  3. The exciting causes  of the  paroxysm
are always such as are especially calculated to dis-
  * In a few cases the pain , as been found to commence
in the arm, and dart from ti ;s to the breast.  But we
believe this has always been in cases of long standing.
We are aware of no case of recent origin in which such
an occurrence lias been observed.   And this distinction
is importan .
turb the natural  action  of the heart;  namely,
bodily exertion, emotion of  mind, compression of
the heart by the  encroachment of other' organs,
&c.   4.  The  frequently fatal termination of this
disease, and the suddenness of the death,  are only
to be explained by disorder  of the  heart  or  great
vessels, as  the  affection of  no other organ in the
chest  or  abdomen could produce  such  a result.
5. But all these presumptive proofs, if we may so
term them, are corroborated, and, indeed,  confirm-
ed, by  the  physical  condition of the heart  itself,
ascertained by dissection in  fatal cases, and by the
stethoscope during the life of the patients.   In a
vast majority of the fatal cases of angina of which
dissections are  recorded, there  has  been  found
great  structural disease in  the  heart, or  aorta, or
both.   In  these  cases, there can  scarcely  be a
doubt entertained  that the pain  was seated in the
heart or great vessels ; and as the character of the
pain and other  symptoms  in cases in which no
organic lesion is recorded, have  been observed to
be precisely  similar  to those occurring  in the
former, it would seem unjustifiable scepticism to
disbelieve that both had the same site.  There
seems nothing improbable, much less  impossible,
in a heart  altogether of healthy structure becom-
ing the  site of such  a pain ; but  there is reason
to believe  that,  in the few cases of fatal angina
in which no organic lesion  was  found on dissec-
tion, the heart was not exactly of just proportions
or of perfectly sound structure.   We  found this
opinion  partly upon the published accounts of
those dissections, and  partly on our own  observa-
tions both on the dead  and  living  subject.   It is
easy to overlook  slight misproportions in the dif-
ferent cavities, and also various  morbid conditions
of the muscular  fibre  of the heart, which  may
have sufficed, nevertheless, to occasion the great-
est distress or disorder in the action of the organ..
And in many cases of the milder forms of angina,
we have  been enabled to ascertain during life, by
means of auscultation, that the  heart was not ex-
actly of  healthy proportions, either in relation to
its own  parts individually, or to the system gen-
erally.
   With  the view of more fully corroborating the
accuracy of these statements and opinions respect-
ing the seat of pain in the paroxysm, we subjoin
a brief outline of  the  results obtained  on dissec-
tion, in some of  the principal cases recorded by
authors since the time of Dr. Heberden.

A. Results relative to the existence of organic  disease in
                    general.
  Total number of cases of which dissections  are
given..............................................45
  Of this  number there was no organic disease (ex-
cept obesity) in....................................  4
  ------Organic disease of the liver only, in.....  -.!
  ------Organic disease of the heart or great ves-
sels, in............................................39
B. Results relative to the nature of the organic affections
           of the heart and great vessels.
  Total number of cases in which there was organic
disease in the heart or vessels.......................3*
  Of this  number there  was organic disease  of  the
heart alone, in.....................................10
  ------Organic disease of the aorta alone, in...  5
  -------Organic disease of  the coronary arteries
alone, in...........................................  1
  ------Ossification or cartilaginous degeneration
of the coronary arteries, in.........................1(1
  ------Ossification or other disease of the valves,
in................................................;n 
108
ANGINA  PECTORIS.
Disease of the aorta (ossification, or dila-
 tation, or both), in.................................24
   ------Preternatural  softness  of  the heart,*
 in.................................................12
   If we consider it as proved,  by the foregoing
 statements, that the heart and  its great vessels
 constitute  the seat of the  pain and all the  prin-
 cipal phenomena of the paroxysm of angina', it
 still remains to be inquired what is the nature of
 this pain, and what are its immediate causes, or
 the  circumstances on  which it  immediately  de-
 pends.   And there  seems no great difficulty  in
 coming  to a satisfactory conclusion in this matter,
 if we keep in view; 1. the facts  recorded relative
 to the frequency of  structural disease in the  heart
 and aorta in angina; 2. the characters of the pain
 itself, its instantaneous invasion  and cessation, its
 violence, its short duration, and  its  complete dis-
 appearance for long  periods of time ; 3. the nature
 of the actions  of the heart and  great vessels in
 health ;  and, lastly, the  nature and causes of  pain-
 ful affections in other parts of the body.
   We have no  doubt  that the  pain, and  other
 principal phenomena characterising the paroxysm
 of angina, may acknowledge different causes and
 depend on different conditions of the affected parts,
 in different individuals, and in the same individual
 at different times ; just as we find in other  parts
 of the body, more particularly in parts possessing
 a structure and functions somewhat analogous to
 those of the heart;   namely, the hollow viscera
 possessing  muscular tunics, and  destined to con-
 vey fluids.   The stomach, the intestines, the  blad-
 der, the gall-ducts, ureters, &c, are all subject to
 sudden   paroxysms  of  severe   pain,  frequently
 originating in very different causes, yet very  simi-
 lar in their external character.  In the stomach or
 bowels, for example, we may have  gastralgia or
 enteralgia,  of the  same general appearance,  from
 pure  muscular spasm ; from matter irritating the
 internal  membrane ;  from simple neuralgia, the
 source of irritation  being  at the  origin of the
 nerves; from over-distension, &c. &c. ;  and  each
 of these  may exist with various  organic diseases
 of the part, or without  any organic  disease ; and
 two or more of them may co-exist.  It is reason-
 able to suppose that  painful affections of this kind
 will much more easily be produced in  a diseased
 organ than in  a sound  one ; and, indeed, experi-
 ence proves, that although  almost all organs are
 liable to  severe pains, from  some unknown  tem-
 porary condition of the nerves themselves, usually
termed neuralgia ; yet that they  are much  more
 liable to  such painful affections when diseased in
their  structure,  and  consequently  disordered  in
 their  action or enfeebled in their  powers.  From
what has been already stated of the frequency of
structural disease  of the heart and  aorta neces-
sarily disordering their  action, it will  readily be
understood how easily  pain may be induced  in
these parts under various circumstances, and  from
many different causes ;  and it seems equally in-
telligible how similar pains may originate in the
same parts, under particular circumstances,  even
when no structural  lesion exists in  them.  In
this, as in so many other cases, authors have fre-
quently failed in  accounting for  the phenomena,
because they took too confined a  view  of the  sub-
  * In a great many cases the consistence of the heart
 • not noticed.
 ject, and were anxious to establish a greater sim-
 plicity in the production of the symptoms than
 nature acknowledges.
   Of the intimate nature of the  pain in the pa-
 roxysm of angina we know nothing ; but we know
 no more  of the nature of any pain.  All that we
 can propound concerning it is a  relation of the
 events which seem to lead to it, and the condition
 of the parts in which it occurs, at the time of its
 occurrence.   Wc  know that the pain is not of
 that kind which  arises from inflammation, or ulce-
 ration, or any other fixed physical alteration of a
 part.   All the circumstances attending it prove it
 to be of that kind which occurs in cramp or spasm,
 or from  pressure, or in the class of cases termed
 neuralgic, in which the painful  sensation is the
 result of  some unknown  temporary condition of
 the nerves of the  part, not manifested  by any
 physical  alteration  of them discoverable by our
 senses.   We have sufficient evidence that such a
 morbid condition of the nerves may be produced
 in a heart in all  other respects sound ; and when
 it takes place in  a heart manifestly diseased in its
 structure, we must consider the structural lesions
 merely as predisposing and  exciting causes of the
 pain.   That the structural lesions are not the im
 mediate and  necessary source of the pain is suf
 ficiently proved by its intermitting character, and
 the perfect ease  in the intervals, when the struc-
 tural lesion  is precisely the same as during the
 paroxysm.   The anatomical structure, the pecu-
 liar action and functions of the heart and annex-
 ed great  vessels, will  sufficiently explain all the
 modifications of the pain and  other phenomena
 observed in the anginous paroxysm.  The radia-
 tion of the  pain to a distance  from the primary
 and principal site of it is only in  conformity with
 what is observed in all other painful affections.
 Stone in the bladder produces pain in the glans
 penis ; calculus  in  the ureter, pain  in the  ab-
 dominal walls ; inflammation of the cartilages of
 the hip-joint, pain in the knee ; and what is per-
 haps a still more appropriate illustration, irritation
 at the origin of nerves in general frequently mani-
 fests itself only by pain at their extremities.  In
 a word, the pain, in the paroxysm of angina, may
 arise  from neuralgia, from spasm, from over-dis-
 tension ; and the other principal phenomena, may
 all, we think, be explained  by  the derangements
 of the functions of the heart,  considered as a
 muscular organ  charged with the office of circu-
 lating the mass of blood.
   Varieties of Angina.—Under this head we
do not mean to notice  the different forms of the
paroxysm as witnessed in different cases.  Such
distinctions are of little practical value.  We wish
here to advert to  the different circumstances, whe-
ther of a local or general kind, under which the
paroxysms take place, and which may materially
influence both  the prognosis and  the  treatment,
Some of the  most remarkable of these differences
have reference  to the  physical  condition  of th«
parts immediately affected in the paroxysm ; othen
to the state of the general system  with which the
local  affection is connected.  We  shall brieflj
notice  the chief of these  varieties in the ordei
now stated.
   In one class of cases there exists great structu-
ral disease of the heart  and aorta;  in another 
                                ANGINA  P

class there exists  either no  structural disease, or
none that can be  detected.   The former class of
cases  may therefore  be termed organic angina;
the latter, functional angina.  Each of these classes
may be subdivided according as  the  affection of
the heart and aorta  exists uncomplicated  with
other  diseases of  a  general  or  local  kind, or co-
exists with some such disease or diseases on which
it is more or  less dependent.   This classification
would give the following arrangement:—
              I.  Organic angina.
          1.  Pure, or idiopathic.
          2.  Complex, or sympathetic.
             II. Functional angina.
          1.  Pure, or idiopathic.
          2.  Complex, or sympathetic.
   1.  The cases that come under the first subdivi-
sion of organic angina are few in number.  They
are those in which the anginous paroxysms seem
to be  the direct consequence of organic disease of
the heart occurring in persons  otherwise healthy.
Cases of this kind are seldom very well marked,
the anginous symptoms being  either  feebly mani-
fested, or overpowered by the greater intensity of
the more  ordinary  symptoms  of heart  disease.
These may be considered, in one respect, as the
worst cases of angina, inasmuch as they hold out
little  prospect of  cure or even of alleviation.   Our
influence over diseases of the heart is very slight,
except they  are  partly the  effect  of some  other
disorder  of a more curable kind.
   2.  Under  the next subdivision of organic  angi-
na, we would include the greater number of the
best marked  and  more severe cases of this disease.
In these, along with the organic affection of the
heart or  vessels, or both, (probably not very great,
or, at least, marked rather by the paroxysm of an-
gina  than by the general  symptoms  of diseased
heart,) we have some obvious general disorder of
the system.   In  cases  of this  kind, the organic
disease of the heart and aorta seems often  to be a
consequence  of the co-existing disorder ; if  not a
consequence,  it is  always  greatly aggravated by
its presence ;  and hence the most successful medi-
cal treatment of the angina is that which has
direct reference to the concomitant disorder.
   Among the various structural affections  former-
ly detailed as constituting the essential or organic
character of these,  two classes of cases, different
authors,  at different  times, have  been anxious  to
select some one lesion as  the exclusive cause of
the disease.   The principal  of  these have been,—
ossification of the  coronary arteries, ossification
and dilatation of  the aorta,  accumulation of  fat  in
or around the heart, &c.  To these may be add-
ed, with equal  propriety,  several other  morbid
states of the  heart, particularly—softening of the
muscular substance of the heart, dilatation of one
or more  of the cavities, &c.   It will be  at once
admitted as a necessary consequence  of the result
of the dissections given  above,  that  no one of
these lesions is entitled to be considered as exclu-
sively the cause of the paroxysm of angina ; and
that some of those which have been  most gener-
ally believed  to be such, are equalled  or exceeded
in point of  frequency by others.  Thus we see
that the  ossification of the  coronary  arteries, for-
merly considered by so many as the chief  or sole
cause  of the  paroxysm, is  only of the same fre-
                                         K
                                           109

quency of occurrence as  disease  of the  valves,
while disease of the aorta is much  more frequent
than either.  But we think it probable that much
slighter deviations from the normal condition  of
the organs of circulation than any above noticed
constitute quite as frequent causes of this disease ;
more particularly of the  milder cases.  In  a cer-
tain proportion  of this  class  of cases  it  is  not
always possible to detect, during  life, the  exist-
ence of any organic lesion, much less the  precise
lesion ; and from the same cause, (its slightness,)
it is frequently overlooked in the examination after
death.  In a considerable number  of such cases,
however,  the  nature of  the  morbid  deviation  is
discoverable both during life and after death. The
most common  of these  slighter deviations from
healthy structure are, a  thin  and slightly dilated
state of the ventricles, and a want  of tojie  in the
muscular fibre.
   3.  We consider cases  of the kind just mention-
ed, in which the  organic deviation is so slight as
to be hardly discoverable, as constituting the great-
er number of those usually viewed by practitioners
as examples of pure functional or nervous angina.
It is  obvious that  in extreme  strictness  of lan-
guage they are not entitled to this  name ;  yet if
the deviation is only so slight as to constitute mere
feebleness, (and it  is  often nothing  more,) they
are probably as well entitled to the name as most
other  diseases  commonly  denominated nervous.
But it must be admitted  that in persons possessing
the best-proportioned hearts, and in which no de-
viation whatever from the normal  structure  can
be detected either during life  or after death, there
may and  do occur paroxysms of angina.  The
proportion of such  cases  is  however  very small
under any circumstances in a state of uncompli-
cation  with  other diseases;  and  we look upon
them rather as of possible occurrence than  as hav-
ing certainly met with them in practice.   Con-
joined, however, with some  other  disorder, as in
the next class of cases, we conceive they are  by
no means rare.
   4.  Under the head  of complex  or sympathetic
functional angina,  we must  comprehend  a large
class of cases ; and, for  the reasons stated  in the
last paragraph, although  not strictly philosophical,
we would, for  practical  purposes,  include  under
the present division all the cases of nervous angi-
na complicated with other diseases,  whether the
organs of the circulation are  perfectly sound and
well  proportioned,  or only  deviating  in  a very
slight degree from this state  of integrity.   Under
this head  are comprehended a very considerable
proportion of the cases met with in practice, and
not a few of those which present symptoms of the
greatest severity in the paroxysm.
   The limits of this article prevent us from enter-
ing  into  any lengthened  details  respecting the
morbid states, general or local, which complicate
angina, whether as simple coincidents or as piedis
posing causes.   It is highly  necessary, however,
that the attention  of the  practitioner  should  be
particularly called to them, since, as has been  al-
ready observed, almost all our remedial  measure*
must be directed rather against these complication!*
than  against the local affection which  gives the
disease its name and character.
   Of these  complications, there   is none mori'
ECTORIS. 
PECTORIS.
 110                            ANGINA  1

 desening of notice than that  multiform affection
 which is most commonly known by the name of
 dyspepsia.  In  its earliest and simplest stage,
 when consisting chiefly of mere functional disor-
 der of the stomach, this  affection  is  a frequent
 concomitant of angina, and sometimes is  the ex-
 citing cause of the paroxysms. In nervous habits
 it gives rise to much general disturbance, and ag-
 gravates local diseases, both by inducing general
 debility and exciting particular sympathies.  It is,
 however, in its latter  and  more complex stages,
 that dyspepsia displays its principal  power in
 modifying the condition of the system ; and it is
 in these that its connexion with angina  is most
 conspicuous.  In place of mere functional disor-
 der of one organ, there are now  fixed  structural
 changes in many ;  while numerous new functional
 disturbances are added to the primary one, and all
are become fixed  by long habit.  The mass of
blood itself, and most  of the secretions and excre-
tions have likewise become changed both in quan-
tity and quality.
  This general disorder of the system, which may
be termed secondary dyspepsia, sometimes  gives
rise to symptoms of angina, without any previous
organic affection  of the heart  or  aorta.  It fre-
quently also produces organic affections in  these
parts;  and if these already exist, it is one of the
most common and most powerful exciting causes
of the anginous attacks.  When, co-existing with
angina, this general disorder, in its progress, gives
occasion to other local diseases of a fixed  charac-
 ter, the consequence is sometimes an  alleviation
of the anginous symptoms, sometims an aggrava-
tion of them.   The organs which principally suf-
fer in this way are the brain, the liver,  the uterus,
and the skin.  When  the irritation has fixed itself
in the  brain, the case  becomes more  distressing
and unmanageable ; as then,  in  addition to the
various bodily disorders, we have  to combat the
fretfulness  and fickleness  of a depraved  temper,
and all the mental miseries of  hypochondriasis.
  There is no mistake more  prevalent  in  this
country, or  more practically injurious,  than  that
inflammation or other organic  lesions of the liver
are of frequent occurrence  as primary diseases ;
much more, that they are among the causes which
exert the most powerful influence  in  modifying
conditions of the  whole system, and  in exciting,
by their sympathetic  relations, numerous  other
maladies.   Functional disorder of the  liver is, no
doubt, a very common effect of secondary  dyspep-
sia ;  and  when  this  has  subsisted  a  long  time,
structural lesion, under the form of chronic inflam-
 nation, or induration, or hypertrophy of the gland,
 may be the consequence. But we are well assured
 that disease of  the liver is rare in this  country as
 a primary affection ; and we believe that  when it
 i;xists, it exerts less influence over the rest of the
 economy than is commonly believed.
   When, from any  cause, hypertrophy of the
 liver has  arisen,  the  viscus may encroach, more
 or less, upon the natural boundaries  of the chest,
 and impede or derange the healthy movements of
 .'ts contents.   And it  is from having  seen  some
 cases of this kind, and from  having  overlooked
 the more powerful agency  of the accompanying
 disorders, that Brera,  Portal, Latham, and others,
 have  considered  angina as a  mere sympathetic
affection of the heart produced by the encroach-
ments of the liver, or other abdominal viscera, on
the boundaries  of the  chest.  Nothing  can be
more  incorrect than this view of the case, as ap-
plied  to angina generally.  It is open to the charge
of overlooking numerous and obvious causes of a
much more influential kind, and selecting one that
is at once insignificant and of rare occurrence.
  The affections of the uterus seldom extend be-
yond  the  mucous membrane ; but as irritations
of this organ are important, both as creating local
drains, and as producing, by extensive sympathy,
irritation and disorder in the nervous system ; and
as they, moreover, very generally induce some de-
rangement of the important function of menstru-
ation  ; they deserve great attention from the prac-
titioner  when they complicate angina.
  One of the most constant and important com-
plications of angina is that state to which we com-
monly give the  name  of plethora, and which is
supposed to consist essentially in  an overloaded
condition of the vascular system, in other words,
a superabundance of blood.  It is probable, how-
ever,  that in the great majority of cases, the blood
is altered in its quality no less  than in its quan-
tity, the most common alteration being an increase
of its nutritive properties.   This,  at least, is  the
most  usual condition  of it  observed  in  angina.
Independently of actual proofs of the existence
of such a state furnished by the symptoms, almost
everything in the history of angina countenances
such an opinion.  1. The subjects of angina  are
mostly of the male sex, above  fifty years of age,
and a great majority of them belong to that class
of persons who  are enabled to indulge in full liv-
ing,  without the  necessity of  undergoing  severe
bodily labour, or  even  of using active exertion.
2.  Gout is a very  frequent disease in persons  sub-
ject  to   angina;  and  gout scarcely ever  occurs
(except  in  extreme cases of hereditary predisposi-
tion)  in persons that are not of a plethoric habit.
3.  Obesity is extremely common in angina.  The
deposition  of fat in the internal parts is. indeed,
so common, that many writers  are  disposed to
consider the  fatty accumulation as the cause of
the paroxysms.   4. The very existence of angina,
from whatever cause arising, tends to produce ple-
thora if it did not previously exist, or to increase
it if already present.  A sedentary life, and  the
abandonment of all active bodily  exertions,  are
almost  inevitable  consequences of  this disease;
and if the appetite continues good, as it often does,
and if no  dietetic regimen, having reference to
the diminished wants of the system, is enforced,
the occurrence of  plethora can hardly be avoided.
5.  We consider the formation of osseous deposits
in the aorta, coronary arteries, &c, so prevalent
in angina,  as an indication at once of plethora and
of  that  concomitant depravation  of the blooJ
which we know generally to precede the deposi-
tion of analogous morbid substances in gout, cal-
culus, &c.   6.  The beneficial effect of various
kinds of medical depletion  and low living, and the
ill effects of opposite practices, strongly corrobo-
rate the same view of the case.
  The connexion of angina with the gouty habit
deserves some further notice, as being a matter of
great  importance in respect both of the pathology
and  treatment.   This  connexion was early  ob- 
ANGINA  PECTORIS.
Ill
 served,  and  has had  considerable influence in
 modifying  the opinions  and practice  of many
 writers on the subject of the present article. But-
 ter seems to have been  the first who  particularly
 noticed it.   He, indeed, considered angina as no-
 thing more than a form  of gout.  Similar opinions
 are entertained by many subsequent writers, as by
 Macqueen, Eisner, Stoeller, &c.; and when stated
 with due regard to philosophical accuracy  of lan-
 guage, there can  be  little doubt  that this  opinion
 is correct  in a very considerable number of the
 cases of angina.   The fact is, that in such cases
 there exists the same general disorder of the sys-
 tem as in gout, of which one  of the most  obvious
 features is the state of plethora above mentioned.
 In a certain proportion of these cases we have all
 the local characteristic phenomena of  gout, either
 co-existing or alternating with angina ;  in others
 we  have the same  constitutional  symptoms, but
 the local disorder of the heart and great  vessels in
 place of that of the joints.  No doubt, there exists
 some real difference between the  two  classes of
 cases, which  gives to one the characteristic form
 of angina,  and to the other that of gouty  inflam-
 mation of the extremities ;  but the nature of this
 difference  altogether  eludes  our  observation in
 most instances.   It  is sufficient for our  present
 purpose to  be aware of the fact that, in a certain
 proportion of the cases of angina, the  same appa-
 rent constitutional disorder exists as in gout. This
 fact is abundantly proved by the evidence afforded
 by the published cases of angina, and is corrobo-
 rated by all that  we have  ourselves observed of
 this disease.
   Treatment of Angina*—Like that of all dis-
 eases of an intermitting or paroxysmal  character,
 the treatment of angina requires to  be considered
 in  two very distinct points of view,—in the  pa-
 roxysm, and in the  interval.  We shall therefore
 notice these separately.
   I.  Treatment in the paroxysm.—As  there can
 be no doubt that the paroxysms of angina arise
 under very different  conditions of the system, and
 as  they differ  very materially in their immediate
 causes, or in the condition of  the organs immedi-
 ately affected, all rational treatment must have re-
 gard to  these circumstances in individual cases, as
 far as  they  are  known or  can be ascertained.
 Painful  muscular spasm, or simple neuralgia of
 the heart and aorta, whether ultimately depend-
 ing  on  organic disease  of the parts or  not, may
 recognise very opposite exciting causes,  and may,
 therefore, be best relieved by  different  means.
 In  one  case, for  instance, the patient may be
 strong and robust, and his whole vascular  system
 overloaded ; in another, he may be the victim of
 long  previous  disease, with a deficiency both of
 blood and constitutional power ; while, in a third,
 the system may be comparatively healthy, with or
 without local disease of the organs of circulation,
 and with or without  great nervousness of  tempe-
 rament.   In all these varieties, the treatment will
 require  modification  to  suit it to the individual
 case.   When  previously known,  such circum-
stances must, therefore,  be kept  in  mind  by the
 practitioner ; when not known, an  attempt must
 be made  to ascertain  them before he prescribes for
the  patient.   Inattention to circumstances  of this
kind has often rendered the treatment much less
 effective than it might have been, or has rendered
 it decidedly injurious. It must be confessed, how-
 ever, that in many cases it is  extremely difficult,
 if not impossible, to come to any certain judgment
 as to the actual pathological condition  of  the
 affected  parts, or  even of the system  generally,
 during the paroxysm.  A previous knowledge of
 the patient, and, yet more, the having had oppor-
 tunities  of  studying the case in former attacks,
 will here be of the greatest importance.
   The violence of the patient's sufferings, and the
 belief in the nervous or spasmodic nature of the
 pain, suggested by its sudden invasion, would na-
 turally  lead the medical attendant,  in  the first
 place, to attempt  to  afford relief by anodynes.
 And  such, we find, has been  the common prac-
 tice of physicians when first called to a patient in
 a paroxysm, or when requested to prescribe means
 with  the view of checking  or mitigating its vio-
 lence in  case of recurrence.   Such attempts, how-
 ever, have generally been attended with  less suc-
 cess than might have been expected.   Rarely, in-
 deed, if ever,  has  a paroxysm  been  speedily and
 completely  removed, by such means;  and only
 in a very small proportion of cases has its violence
 been  mitigated.  In  angina,  as  in  tooth-ach  or
 tic douloureux, gastralgia, colic, or other violent
 pains, nature  seems as if she  scorned to be con-
 trolled by art, although so much under the influ-
 ence  of similar  applications when less needed, as
 in the case of milder pains.   And,  no doubt, in
 the disease  now under consideration, the state of
 mental distress and fear with which the bodily suf-
 ferings are complicated, has a powerful influence
 in counteracting the ordinary effect  of  anodyne
 remedies.  Our own experience would lead us to
 recommend the use of anodynes in the  milder
 cases only ;  and  more  particularly   in  those  in
 which there existed a feeble and exhausted  sys-
 tem, or  great  constitutional nervousness without
 plethora.
   Antispasmodics,   cordials,  carminatives, &c,
 have  been also much recommended and employed;
 and,  upon the  whole,  with  better success than
 anodynes.    They  have appeared,   in  different
 cases, to  afford  relief by imparting a temporary
 vigour to the nervous system generally, overpow-
 ered  as it seemed  by the bodily and  mental suf-
 ferings ;  or  by stimulating the heart  to increased
 action, and thereby enabling it to propel the load
 with  which  it was  oppressed ; or, simply, by in-
 vigorating the stomach, and enabling it to expel
 the flatus accumulated in it.   And it seems pro-
 bable  that such  means may operate  in all  these
 ways, and, perhaps, conjointly  in the same case.
 In cases in which  there exists  sufficient evidence
 of a plethoric  state of the vascular system, some
 attempt must be made to remove this before mean-;
 of the kind now under consideration  can be ap-
 plied  with any prospect of benefit, or  even safety.
 In most  cases where  venesection has been em
 ployed, and particularly if it has been carried to j
considerable extent, slight  doses of laudanum,
combined with  brandy or other  stimulants, may
be used,  always with  safety, and often with be-
nefit ; and the  probability of benefit will be greater,
in proportion  to the degree  of  exhaustion  and
nervousness present.  The aromatic and stimulant
medicines, usually termed carminatives, are mi'i 
112
ANGINA  PECTORIS,
particularly indicated in dyspeptic  complications,
and where there exist signs of distension of the
stomach by flatus.
   This circumstance of the stomach being so ge-
nerally oppressed with flatus during  paroxysms
of angina, and of the expulsion of this being al-
most  always  the harbinger of relief, if not its
cause, is  a remarkable feature in  the history of
the disease.  In  reading the numerous  cases re-
corded, one is struck with the frequent mention
of this circumstance;  and our own  experience
entirely  corroborates the observations made by
others,  that it is by no means rare  in subjects
who  are  altogether  free from  any signs of  indi-
gestion in the intervals of the paroxysms.  From
this and  other considerations,  there seems  little
reason to doubt that the gas is formed in the in-
testinal canal during, or immediately before, the
paroxysms.  Be this as it may, there can be no
doubt that its expulsion during these, forms, in
most  cases at least,  a rational indication of treat-
ment  ; since, whether a cause  or consequence of
the paroxysm,  its  expulsion  almost invariably
gives  relief:* and it is sometimes found that the
simple aromatic waters  are more effectual in pro-
ducing  this result, than  medicines  usually consi-
dered of greater power.j-
   A very different mode of relief, already noticed,
namely,  venesection, has been  occasionally em-
ployed with much advantage ;  and there is great
reason for believing, that, if more judiciously ap-
plied, it would have been  still more beneficial.
Several different circumstances met with  in pa-
roxysms of angina,  sometimes separately, some-
times  conjointly,  seem fully to justify the trial of
this remedy, even if its use  had not been vindi-
cated  by experience.  These are, the state of ge-
neral  plethora, so  frequently found in such pa-
tients ; the state of actual local plethora or morbid
accumulation of blood in the heart  and large ves-
sels ;  the state of relative local plethora  of the
same  parts from  feebleness of the  organ in  pro-
pelling its contents.   In all these cases the dimi-
nution of the mass of blood, if it can be effected
without immediate risk  of life, would unquestion-
ably be beneficial;  and the practice of several
eminent men has proved it to be often safe.   Dr.
Percival, Dr. Parry, Dr. Hosack, Mr. Allan Burns,
and several others, are of this number.   We  have
ourselves employed it with benefit in some strongly
marked cases  of angina; and  the  instantaneous
mid signal relief which every physician must  have
often  observed from  venesection in organic dis-
eases  of the heart, leaves no doubt of its useful-
ness in  this disease, when employed with  discri-
mination, and  with  the necessary precautions.
These precautions are well stated by Dr. Parry in
his Inquiry, in the following terms : " The patient
should be  placed in  the  horizontal posture, and

  * The apparent influence of gas in the stomach over
the motions of the heart is very remarkable. In certain
nervous diseases, we  have  seen intermissions of the
heart's action carried to such an extent that the patient's
life was considered in  imminent danger; and yet  have
known the  whole symptoms instantly removed by the
sudden expulsion from the stomach of a quantity of
flatus!
•  r In a case related by Dr. Fothergill, simple  pepper-
mint water is said to have given  great relief in this
■•'ay: "It was always by him in the night, and gave him
case when a reasonable dose of paregoric had been given
without benefit." FothcrgilVs Works, ii. 253.
blood should  be taken  away from  a  very  small
orifice, while, at  the same time, the  finger of the
physician is  applied to the pulse, in order to de-
cide on  the  propriety of continuing  or  discon-
tinuing the flow of blood.  If no person  of ade-
quate judgment is at hand, it may be right  to re-
strict the  quantity of blood taken away to  about
three ounces at any one operation."   (On  Syn-
cope  Anginosa,  p.   164.)     We have  already
stated, that where this  measure is deemed  ad-
visable, it ought to  take precedence of  the ad-
ministration  of cordials, which are  much  more
likely to act beneficially after the heart has been
partially freed  from the  load  which was oppress-
ing it: and such remedies will, in most cases, be
very  properly administered  after detraction of
blood.t
   As the affusion of  cold water in the paroxysm
of angina  has been  mentioned as  a remedy by
some authors, we notice  it here chiefly witb  the
view of entering a caution against its employment.
It can rarely be  employed with  benefit or even
safety.   The  partial  application of cold  water,
however, may be sometimes admissible as a stimu-
lant of the nervous system, just as we  apply it in
hysteria.   A curious  case of severe  angina  is re-
lated  by Joseph  Frank,  in which the  patient, a
medical man, found singular relief from the appli-
cation of cold water to the head ; and the relief
was more speedy, if, during the application of the
water, the  left hand  was placed, in a particular
manner, on the head.  The same author relates a
case in which the impending  paroxysms seem to
have  been averted  by the cold affusion ;  but, as
already stated, we cannot consider such a practice
as-generally safe.§
   [Laennec affirmed, that tbe remedy which most
frequently  succeeded with him in procuring alle-
viation, in cases of angina pectoris, and of neuralgia
of the heart of a slighter kind, and without radiating
pain,  was the  magnet; which he employed in the
following manner :  two steel plates, strongly mag-
netized, of an  oval form,  and slightly arched, so as
to admit of close  application to the parietes of the
thorax, were placed,— the one on the left pericar-
dial region,—the other on tho opposite part of the
back,  in  such  a  manner that the poles may be
exactly  opposite, and  the magnetic current may
traverse tbe part  affected.  When it procured but
little  relief, a  small blister was applied under the
anterior plate  with advantage.   Dr. Hope  (Trea-
tise on Diseases of the Heart, Amer. edit., by Dr.
Pennock, p. 466 : Philad., 1842,) states, however,
that they who witnessed the  application  of the
magnet by Laennec, did not, in  general, form so
favourable  an opinion of its utility as he did.  It
appeared to be more  successful when combined
with acupuncture.  Its effects  are doubtless alto-
gether revellent.]
   But although these or other  means  may  occa-
sionally afford relief, or may even ward off death,
it is evident that every kind of treatment confined
to the paroxysm is of very slight importance, when

  X A  strongly marked instance of the good effects of
venesection in the  paroxysm of angina is given bv Dr
Read,  .„ the Dublin Trans.  Vol. i. ]05 ; and a good illus!
tration of the injurious effects of  prematurely stimulat-
ing a feeble heart  already oppressed with its contents
is recorded in Parry's work, p. 1G3.           -""".nib,
  § Prax. Med. Univ. Part ii., vol sii. n. 273, 274, nota. 
ANGINA  PECTORIS.
113
 compared with that  which is to be employed  in
 the interval: the former can, at most, afford tem-
 porary relief;  the latter may cure the disease.  It
 is to  this part of the treatment, therefore, that the
 care  of the practitioner is to be  chiefly directed ;
 and it is to this part  of our subject  that we would
 claim his especial attention.
    II. Treatment in  the interval.—If it is of con-
 sequence for the practitioner to be acquainted with
 the precise nature of the case before him, to ena-
 ble him to prescribe successfully or even safely in
 the paroxysm of angina, it is  much more impor-
 tant  that he  should  have this knowledge to  direct
 his treatment in the  interval.  In many  cases, no
 doubt, it is quite impossible to ascertain the inti-
 mate character of the affection during the patox-
 ysm  ;  and in a certain  proportion  of these, the
 knowledge, if attainable, would  be  of little use.
 We  should still be reduced to the necessity  of ap-
 plying the same limited stock of means without
 any very inspiring confidence of a beneficial result.
 Circumstances, however, are very different  in the
 interval.  Here, an accurate acquaintance with the
 nature of the individual case is indispensably ne-
 cessary to enable us to institute treatment that
 holds out any  prospect of success ; while a prac-
 tice  adopted at  hazard,  or on merely empiricial
 principles, may not only be useless, but may lead
 to the most disastrous results.  The first and great
 object of the practitioner, therefore, on being called
 on to  treat  a case  of angina, will be  to  make
 himself acquainted  with its individual character.
 Beginning with the early history of the disease,
 he will trace it to its present stage, and will endea-
 vour, from the narrative of the  patient, and from
 the observation of the whole phenomena presented
 to him, to  form a clear judgment respecting the
 local condition of the organs in which the charac-
 teristic symptoms have their site ; and the state of
 all the other parts of the system, which can in any
 way  influence  these :  in other words, he  must en-
 deavour to ascertain the species or variety of angi-
 na, according to the  distinctions formerly pointed
 out.   Are  the paroxysms dependent on  some
 structural lesion of the heart and great vessels, or
 are these organs in their original  soundness  ?  If
 there is any deviation from the sound condition of
 these organs, what is the nature of this deviation ?
 Does structural lesion exist or not ?  or, if existing,
 can it be detected or not ?  What is the  actual
 physical condition of the heart ?   Are its  walls
 thick or thin ?   Are its  cavities  large or small ?
 What is the state of the general health ?   Is it
 such  as injuriously to influence the  recurrence of
 the paroxysms  in any way, or to aggravate their
 severity ?  If thus injuriously influencing the local
 disease of the  heart and  great  vessels, is it of a
 kind  to be remedied or mitigated by  medical treat-
 ment ?   These  queries comprehend most of the
 subjects  of inquiry  which  the  practitioner  who
 proceeds to treat a case of angina,  must keep in
 view ; and although it will sometimes be impossi-
 ble to obtain  precise  information  on every point,
 yet this will be practicable, in the greater number
 of cases, by care and attention, and by the employ-
 ment  of the  improved methods of investigating
 thoracic diseases furnished by  auscultation.   This
latter  method of exploration will, in a more par-
ticular manner, aid our recognition of the  physical
  Vol. I.—15                         k*
 condition of the heart;  and enable us, in a great
 number of cases, to determine the presence or ab-
 sence of organic disease in that organ.  This pre-
 cise knowledge is, no doubt, important in assisting
 us to regulate our practice with the best advantage
 to the patient;  but it is infinitely more so  in ena-
 bling us to form an accurate prognosis respecting
 the event of the case.  If the attacks recognise
 great  structural lesion of the heart or aorta for
 their cause,  we can  only expect  to mitigate the
 severity of the paroxysms, or to effect their tempo-
 rary removal.   If there exists  no structural lesion
 of a fatal kind, although the organs may not be of
 the soundest proportions, it is often practicable,
 not merely to mitigate or remove the paroxysms,
 but by great and constant vigilance on the part of
 the patient in avoiding the exciting causes, to pre-
 vent their recurrence altogether.  When the dis-
 ease is purely one  of functional disorder, a much
 more perfect and permanent cure may be expected.
 In all  these  cases, however, the general character
 of the  treatment will not greatly vary.   An or-
 ganic  lesion of the heart,  even of an incurable
 kind, can only be viewed, in relation to the treat-
 ment,  as a predisposing cause of the attacks, just
 as a heart that is naturally feeble or morbidly irri-
 table is so ;  and it is only in rare  cases that the
 organic lesion  induces  the paroxysm without the
 aid of obvious exciting causes.  No doubt, exciting
 causes  of a much  feebler kind will suffice ; but
 the very necessity of such causes at all to produce
 the effect, brings the case, as far as concerns the
 prevention of the paroxysms, under the same cate-
 gory as to treatment as the purely sympathetic or
 nervous angina.  In the  case  of organic disease,
 however, our expectations of  benefit from treat-
 ment, and the actual results, become wonderfully
 less.   Now,  indeed, we fight  not for victory, but
 merely to keep the enemy at bay.   We, however,
 use the same weapons ;  and if we  do  not strive
 with the  same  enthusiasm, we must, at least, be
 vigilant  and active; and-we  shall often be re-
 warded with a degree of success  that we scarcely
 dared  to hope for  at the commencement of our
 treatment.  For these reasons, in the following
 outline of what we conceive to be  the  proper
 treatment of angina, we  shall, for the most part,
 treat of the  disease generally, and refer only to its
 individual forms when this becomes essential from
 the necessity of recommending some peculiarity
 of treatment.
   In the small number of cases in which the an-
 ginous paroxysm depends upon organic disease of
 the heart, uncomplicated  with other disorders of
 the system of a general or  local kind, our mode
 of treatment becomes very simple.  It consists, in
 a great measure, in guarding  against the  causes
 which  obviously excite the attacks, and in observ-
ing a most cautious and  rigid regimen.   These
measures  will  be more particularly noticed pre-
sently, and they will be still more fully discussed
in the articles which treat  of certain other diseases
of the  heart.   The remedies of a more direct and
specific kind, which may influence the recurrence
of the paroxysms, will also come under our notice,
after we have considered the treatment best calcu-
lated to  reduce the more common  and complex
cases of angina  to  the state  of simplicity now
under consideration. The same remark will appi" 
114
ANGINA  PECTORIS.
to the cases of angina of the more purely nervous
kind, and also to those which  are connected with
mere organic feebleness of the  heart.  The great
rarity of such cases, compared with the frequency
of those of a more  complex  kind, renders the
treatment of them  of comparatively little  conse-
quence.  And there is an additional reason for not
entering upon the  consideration of  the treatment
of such cases at present, namely, an apprehension
lest  the attention  of the inexperienced  reader
might, in the  outset,  be loo strongly arrested by
the specific  remedies applicable to them, and be
thus diverted from the very different kind of ma-
nagement requisite  in the  more complex class of
cases, which, unquestionably,  constitute the vast
majority of those met with in  practice.
  We must refer to other parts of this work for a
detailed  account of the treatment  of the various
disorders formerly noticed  as complicating angina,
or as constituting what may be termed its consti-
tutional form.   The presence of the anginous pa-
roxysm renders  scarcely any modification  in the
treatment necessary.  On the present occasion we
can only make a few  general remarks on some of
the most important of these complications.
  Of the treatment of simple  or primary dyspep-
sia, as co-existing with angina, we shall only here
remark, that much  more is to be effected by a ra-
tional  system  of diet and regimen, both of body
and  mind, than  by  medicines; and  that, as a
general rule, the cautious, cooling, and macerating
treatment of our continental neighbours, will be
found more  successful than the endless ingestion
of bitters and drastic  purges, so much practised in
this  country.  In many cases,  no  doubt, the sto-
mach  is simply debilitated, and requires  tonics ;
but it is much more frequently irritated or inflamed,
and requires soothing  and depiction.  The prevail-
ing and most injurious error among many practition-
ers, is, apparently, to overlook the fact, that the
stomach or intestinal canal can be inflamed without
pain or the more common external marks of febrile
action ; or, being so, that they can be injured by the
stimulus of purging.   But  it is in the  complex
constitutional  disorder, whiCK  may  be  termed
secondary dyspepsia, that  these observations are
most applicable.  It is  to be feared that the true
nature of this disorder is not  well  understood by
the generality of practitioners.   It is one of those
diseases which may often  be said to be the oppro-
bria medicorum in the worst possible sense; since
it is not  seldom caused,  and  is very frequently
fixed  and perpetuated  by injudicious treatment.
In  no other disease is  the  over-active, or, as our
neighbours term it, heroic mode of practice so pre-
valent in England, productive  of such evil effects;
and in none is that mild, simple, yet comprehen-
sive system  of treatment, which  embraces  the
whole of the disordered organs and functions, and
rather prompts  nature to act rightly than super-
sedes  her agency, so  strikingly beneficial.  (See
Dispepsia.)
  In the very numerous class  of cases in which a
alethoric state of the system co-exists with angina,
and in many of which there is either actual gout
ot the  gouty diathesis, the chief indications will
be, first, to relieve the overloaded vessels; and,
secondly, to prevent their repletion.   Here  the
most obvious and  immediate remedy is venesec-
tion.  This may, in most  cases, be  beneficially
employed as a means of temporary relief, and will
advantageously be combined with the  use of pur-
gatives, colchicum, &c.; but the cure of the dis-
ease, if it is  curable, or its effectual  relief,  must
depend  on measures  of more permanent operation.
These are much  more dietetical than medicinal.
In the kind of cases now under consideration, and,
indeed,  in the great  majority of all the  cases of
angina, a most strict regimen, and as low a diet as
is  consistent  with the  maintenance  of healthy
function, is absolutely necessary.  It  is not  to be
inferred from this, that the complete  abandonment
of animal food  by the patient is recommended.
This probably may be necessary partially, or for a
time, but not generally.  All  that  is essential to
be kept in view  is that the diet be of  such a kind
as not to be too nutritive, or to occasion fulness.
In many persons, more particularly of  the  class
whose  cases we are now considering, an exclu-
sively vegetable  diet will  prove injurious, by pro-
ducing disorder of the stomach.   And  it is always
to be  kept in mind,  in treating such cases, that it
is  almost of as much consequence to  avoid  local
morbid  irritation of  this  organ as to  obviate ple-
thora.   We think, however, that a case can hardly
occur in which it will not be proper  to  limit the
patient  to the milder kinds of animal food, and to
a very moderate  proportion of this; the great bulk
of the  nutriment being  farinaceous.  In certain
cases, a small portion of wine may be  allowed;
but it will scarcely ever be  proper to  permit it to
be taken in considerable quantity; and malt liquor
must  be at once  and for ever abandoned, in  all
forms and proportions.   In certain of  the  moie
violent  forms of organic angina, it may sometimes
be advisable to attempt the relief of the disease by
a  systematic  reduction of  nutriment below the
actual wants of  the  system, as practised by Val-
salva ;  and we do not doubt that, if the selection
of cases for the experiment were good, and  phy-
sicians  and patients could be found endowed with
sufficient faith and courage to enforce and undergo
the trial, the very best results might occasionally
be obtained.   But it must be confessed  that such
a  mode of practice  is  but  ill  suited  both to the
weakness of humanity  and the uncertainty of the
healing art.
   It is  in the class of cases now under considera-
tion that counter-irritants are most indicated; more
particularly if the plethora is complicated with the
predisposition to gout, or  with actual gout.   And,
certainly, of all  the various remedies that  have
been  used in angina, none  seem to  have been, on
the whole, attended  with  more success  than this
class  of agents.  As a  general rule, it may be
observed that counter-irritation  is  much  more
beneficial in  those diseases in which there existed,
previously to the local  affection, a well-marked
disorder of the  system at large, than in cases of
pure inflammation produced by  accidental causes
in a system otherwise healthy.  In the  former case,
the artificial  irritation  and  discharge frequently
produce relief to the .system  analogous in  kind,
however inferior in degree, to that which always
attends the supervention of a spontaneous local
inflammation in such cases; while the institution
of an artificial inflammation in the other class of
cases, has frequently no other  effect than that of 
ANGINA  PECTORIS.          »                   115
adding to the  existing disorder and distress.   Dr.
Smyth, of Dublin, so far back as 1770, employed
issues  in  several cases of  angina with  marked
benefit, and, in two at least, with perfect success ;
in a third case, the disease seems to have  been
removed  by an issue of nature's own making, viz.
by a hemorrhoidal discharge, first of blood,  and
then of  pus.   Dr. Macbride,  who relates these
cases, expressly states that  one of these  patients
had a  strong  gouty taint.  (Edin. Med. Comm.
vol. v.  p. 12.)
  In Dr. Smyth's cases, the issues were applied
to the  thighs ;  and the same practice was adopted
by Darwin with  equal success.  " Four  patients
(says this author) I have now in my recollection,
all  of whom  I believed to labour under angina
pectoris in a great degree, which all have recovered,
and  have continued  well  three or four years, by
the use, as I believe, of issues on the inside of each
thigh ; which  were at first large enough to contain
two  peas each,  and  afterwards but  one.  They
took besides some  slight  antimonial  medicine for
a while, and were reduced to half the quantity or
strength  of their  usual  potation of  fermented
liquor."   (Zoonomia, vol. iv. p. 43.)   The reader
will understand the importance of the restriction
of the diet mentioned in this case.
   Irritants applied directly on  the cardiac  region
have been occasionally followed by no less fortu-
nate results.  In cases related  by Goodwin, (Med.
and Phys. Journ.  vi. 320.) Kriegelstcin, (Hufe-
land's Journ. B. xix. St. 4, p.  131.)  Lind, (Med.
 Chir.  Rev. N. S. iv. 497.)  and  others, a  cure
 appears  to have been effected by the application
 of antimonial irritants to the  chest;  and, in  Dr.
 Parr's case, great temporary  relief  followed the
 application of a blister to the same part. (Blackall
 on Dropsy, 365.)  In a case  noticed by Joseph
 Frank,  great benefit, " conspicuum  levamen,"
 resulted from the insertion of an issue between the
 ribs in the cardiac region.  (Med. Univ. Prsecept.
 P. ii.  vol. i. p. 269.)   Two of Dr. Blackall's cases
 are very much in favour  of this practice,  although
 only  offering  analogical  evidence of its efficacy.
 The subject of one of them, a  gentleman who had
 never for a single week been free from attacks of
 angina  for ten  years together, lost  every vestige
 of it  for the last nine years  of his life,  during
 which he suffered from ulcers of the lower extre-
 mities.   In another, a gouty subject, instantaneous
 relief during  the paroxysm was more than  once
 afforded by the application to the feet of " mustard
 cataplasms,  quickened  with  oil of  turpentine."
 (Loc. Cit. 409.)   But it is not as isolated means,
 used  empirically, that counter-irritants, or  any
 other topical  treatment, can  be expected to pro-
 duce  their full measure  of  benefit; it • is only
 when had recourse to as parts of a comprehensive
 system  of treatment, embracing the whole disease,
 that they can be used with much prospect of suc-
 cess,  or, indeed, that they  should  be used at all.
 When their application is  so  regulated,  both rea-
 son and experience counsel the measure in every
 case of obstinacy  or great  severity.
   A  most important part of the  treatment of an-
 gina is the avoidance of the exciting causes of the
 paroxysms.   By rigid  adherence to  the  proper
 regimen, and by constant vigilance on the part of
 the patient to eschew everything calculated imme-
diately to induce a paroxysm, very much may be
effected, even in the most hopeless cases, to alle-
viate suffering, and in mere  functional angina  a
cure may very generally be expected. In all cases
the patient should  be  so far instructed in the
nature of his complaint, as to be made aware that
whatever tends  to hurry the circulation beyond
the medium standard, is likely to induce a parox-
ysm, and he must have pointed out to him all the
circumstances that are capable of producing this
effect.   He himself will, indeed, have  learned, by
sad experience, the chief of  these circumstances,
and will require no admonition to induce him  to
avoid  them ;  but there may be others,  of  the
power of which he is not sufficiently aware, which
may, nevertheless, be exerting a baneful influence
over his malady.
   Some patients have been  so bold as to endea-
vour to master their paroxysms by persevering in
the very acts which had induced them ;* and  in
some few cases  the attempt has certainly been
unattended with any bad effects, if it was not pro-
ductive of good.  These cases, however, were  of
the slighter kind ; and there cannot be  a  doubt
that,  in every case, all  such attempts are  to  be
forbidden.  All strong exercises, and  more par-
ticularly walking  up hill or  up  stairs, and, in a
word,  every species of bodily movement  that  is
found  to induce the paroxyms, must be abandoned
as far  as possible.  Of this kind  may be particu-
larly noticed the act of stooping,  as in tying the
shoe-strings;  drawing  on  boots ;   straining   at
stool;  climbing a  high bed, &c. &c.   Those posi-
tions of the body  which tend to  lessen the  cavity
of the chest or abdomen, give double power to all
contemporaneous movements that accelerate the
circulation, and  are therefore to be  particularly
avoided.   It is chiefly on this account that a full
meal greatly increases the bad effects of exercise ;
although, in this case, no doubt, the fresh stimulus
imparted to the circulation by the recent aliment
co-operates.
   In regulating and limiting bodily exercise, how-
ever, great care  must be  taken  not to carry our
precautions too far;  as  insufficiency of muscular
 motion, by inducing morbid irritability of the ner-
 vous system, may operate almost  as unfavourably
 as over-exertion.   In all chronic nervous diseases,
— and angina, even when depending on organic
 causes, must, in one respect, be  considered as a
 nervous disease,—there is no species of treatment
 so beneficial as regular bodily exercise ; insomuch
 that, in the practice of medicine, we  are almost
 justified in considering the nervous and muscular
 systems as antagonist powers : the more the one
 is exercised,  the less irritable and excitable the
 other  becomes.   Accordingly, in  sympathetic an-
 gina and the  numerous analogous  nervous affec-
 tions of the heart, we  have invariably found the
 greatest benefit from a regular system of  exercise,
 conjointly with other means  calculated to restore

   * A remarkable example of this occurred to the writes
 of the  present article, while transcribing it for the press,
 in the person of a gigantic farmer, who seemed to fancy
 ho ought to rule diseases  as he ruled his team.  When
 the paroxysms attacked  him on horseback, he would
 throw the reins on  his horse's neck, put him to a canter,
 and bear his agony till he could sit no  longer!  When
 fairly beaten he came to the doctor, but it was too late
 he died suddenly during the night, not more than right
 davs after his first visit. 
116
ANGINA  PECTORIS,
the different functions  disordered.   And even in
the organic angina, such exercise as can be borne
must be strictly enjoined.  If, from experience of
tbe ill effects of his ordinary exercise, the patient
has renounced all exercise, he must endeavour to
renew  the practice, beginning  with the gentlest,
both in kind and degree.   By patiently persever-
ing in  this plan, he will often succeed in bringing
the system to bear  considerable exertions without
augmenting either the  frequency or severity of the
paroxysms.   That kind of exercise which is borne
best, will, of course, be most  used; but merely
passive exercise will not produce all the effects we
could desire.   The muscles of locomotion must be
kept in action.   Riding on horseback, or walking,
must therefore be enforced, as far as may be prac-
ticable or justifiable ;  and great care on the part
of the patient, in  avoiding  all unnecessary trials
of his powers, will often enable him to enjoy both
these modes of exercise to a considerable extent.
In walking, which  is,  on the whole, by much the
best mode of exercise, the patient must strictly
confine himself to level ground, and  must not
face the wind.   For these reasons, the  nature of
the place  of residence becomes frequently a matter
of much consequence.   If we are justified in send-
ing other  patients with chronic diseases from their
homes, for the sake of a difference in the climate,
we are warranted in doing the same, in the case of
anginous  patients, in order that  they may obtain
the advantage of a flat country, or  sheltered walks.
Change of air, indeed, in the usual sense of that
phrase, is very beneficial in many cases  of angina;
but whenever this  is recommended, the configu-
ration of the surface of the new  locality, and its
degree of shelter from winds, must be  considered
as much as the nature of the climate.   Occasion-
ally we meet with instances in which hardly any
degree or form  of exercise  can be borne ; the
wretched sufferer being reduced, through the  ever-
present terror of a paroxysm, to a state of almost
vegetable immobility.   In such cases it will gene-
rally be found that the only succedaneum for the
exercise that can no longer be taken, is a system
of diet so rigid as to approach the limits of starva-
tion ;  and if the patient has sufficient courage to
pursue this course, a greater relaxation from suf-
fering may still be obtained than  could have been
anticipated.
   A most important chapter in the history of all
diseases immediately connected with the functions
of the heart, is  that which treats  of their relation
to mental impressions; and in no case is the con-
sideration of this relation so important as in the
 prophylaxis of angina.   Two varieties of mental
 affections act powerfully on the  functions of the
 heart,—the depressing and the exciting passions.
 It  may be  difficult to prove  that anxiety, care,
 grief,  or  any other form of mental distress, does
 ever of itself and  directly produce disease of the
 heart; because such states of mind, if continued,
 are followed by  various other  bodily disorders
 which powerfully  co-operate in deranging the
 functions,  and eventually the  structure of this
 organ.  But no one  who has lived in the  bustle
 of life, and seen much practice, will doubt  for a
 moment  that the mental states now referred  to are
 among the most prevalent and most influential of
 the remote causes of such diseases.  When angina
already exists, it must be admitted that these, as
well as the exciting passions, are among the most
frequent exciting causes of the paroxysm.  The
result of the operation of both classes of  emotion
is the same, although somewhat differently brought
about; namely, an accumulation of blood in the
heart disproportioned to its powers of propulsion.
It is doubtful which of these causes is the most
powerful.  The exciting passions are usually con-
sidered as such ;  but it is probable that this  opin-
ion may  have taken its rise from their more osten-
tatious nature.  Anger is a social and public pas-
sion ; it  is clamorous, and will be  both seen and
heard.  Grief is  retired,  silent, and  secret; it  is
more conspicuous in its effects than  in its work-
ing.  Anger is, no doubt, also quicker in its ope-
ration  than sorrow ;  and the open and instanta-
neous  manifestation  of its  power  in  diseases of
the heart has procured for it a greater reputation
than has fallen to the lot of its less obtrusive but
still more formidable sister. Very many examples
of sudden  death  from anger, in diseases  of the
heart,  are recorded;  and not  a few of  these have
occurred in cases of angina.   These statements
prove  the great importance of mental discipline in
this disease ; and although " herein the patient
must minister  to  himself," it  is  the  duty of the
physician to point out to him  the  necessity no
less of the moral than  of the  physical means of
prophylaxis.
   It will be remarked that, in the preceding ob-
servations, we have  taken no notice of specific
remedies for the  relief or cure  of angina.  The
consideration of these has been purposely deferred
until now, with the view of impressing upon the
mind of the reader the much  greater  importance
of those plans of treatment, which have reference
to some  obvious or intelligible disorder of the sys-
tem.  When no  such  disorder exists, or  when,
having existed, it has been removed,  or,  at least,
has been attempted to be removed  by every ra-
tional means which medical science  affords, then,
and not till then,  are we justified in  making trial
of  that class of remedies of whose mode  of ope-
ration we are ignorant, and which have been de-
nominated specifics.   In certain cases, means of
 this kind   have  certainly  had  excellent effects.
 After  the ample discussion given to the more gen-
eral method  of treatment, we cannot here enter
 upon  any  detailed  statement of these  effects;
 much less can we attempt any explanation of their
 mode of action.   A consideration of the various
 nature and numerous complications of angina, as
 detailed in  the  preceding  pages, will show that
 remedies of this  class may possibly possess very
 different powers and modes of action, and yet lead
 to the s»me results.   Bark, iron,  arsenic,  nitrate
 of silver, the salts of copper, zinc, and other medi-
 cines  both of the  vegetable and mineral kind, have
 been  frequently employed.   In a few instances,
 narcotics,  such as  hydrocyanic acid,  belladonna,
 &c, have been found  useful.  In those cases in
 which the  paroxysms approach nearest  to  the
 purely neuralgic  character, remedies of this kind
 hold out the greatest prospect of success.  If there
 is  any reason to suspect a  malarious origin  or
 complication, bark, or rather quinine, will be found
 most  efficient.   In other cases  steel  and arsenic
 will deserve the preference.  Of all the prepara- 
ANODYNES.
117
tions of iron, the common carbonate and the sul-
phate seem the most powerful in nervous diseases.
The former must be given in large doses, as from
a scruple to a drachm, several times a day.  When
the stomach and general system were in a proper
state  for their reception,  we  have found these
medicines frequently of much benefit in diseases
of the heart,  whether  organic or sympathetic;
and they have often been found to mitigate, if not
remove, the attacks of angina.   The salts  of cop-
per have also been often tried; we are  not, how-
ever, aware of any very successful result  having
been obtained  from their use.   Arsenic and zinc
have  been productive of more benefit.   Several
cases,  evidently relieved or cured by these salts,
are recorded by authors.  A well-marked case of
angina, cured  by Fowler's solution, has been pub-
lished by Mr. Alexander, (Edin. Med. Comment.
xv. 373 ;)  and another cured  by  white  vitriol is
given by Dr. Perkins, (Mem. Med. Soc, Lond. iii.
580.)  The great length to which this article has
already extended prevents us from  entering into
fuller details.   The reader who has studied the
pathology  of  angina can  have no difficulty in
knowing  when  to  apply specific remedies,  and
which ought to have the preference.
                              John Forbes.
   [ANIMAL MAGNETISM.  (See Somnambu-
lism.)
   ANIMATION,  SUSPENDED.  (See
Asphyxia.)]
   ANODYNES.  The word  anodyne  takes its
origin from the Greek, a, privative,  and d&vvrj, pain;
and the literal meaning  is, a remedy which re-
moves pain.   The term  anodyne is often  used
synonymously with the terms narcotic and seda-
tive ;  but as these three words are all different in
their  strict signification,  it is  obviously right to
confine the employment of each of them to its
proper acceptation.  In a work like this,  an  im-
portant end is answered by taking up, as distinctly
as possible, the subject  which is suggested by the
word which stands at the head  of each  article  ;
and on this account narcotics  and sedatives will
not be particularly  mentioned  in this  place, al-
though they are generally classed  with anodynes,
as remedies which produce  a similar effect on the
animal body.
   When the practitioner wishes to relieve pain,
he  ought to ascertain, if possible, in the first place,
what  is the cause of  the pain.   The sensation of
pain seems to be essentially connected with the
operation of the nervous  system : it may arise,
1st, from an undue degree of pressure being made
upon  tbe nerves, or from an injury sustained by
external  violence :  2dly,  from increased sensibil-
ity  in the nerves  themselves ;  so that the pressure
of external objects, which, under ordinary circum-
stances, only  produces the proper  sensation of
t^uch, or as in some  parts, even no sensation at
all, gives origin to a painful sensation.  This in-
creased sensibility may be the  result of many  dif-
ferent causes, e. g.,  of morbid structure or of mor-
bid function of the brain, or of the spinal marrow,
or of  the nerves themselves.   When this increase
of sensibility occurs, pain may only be felt when
external pressure is  applied, and then it is denomi-
nated tenderness ,• or the pain may be felt inde- ,
pendently of such  pressure.  It  is very probable
that in some painful diseases there is nothing irior
bid except the function of the nerves themselves ,
no organic alteration, no inflammation, being dis-
coverable either before or after the death of the
patient.   Pain  in such cases is commonly  called
neuralgia.  It  occurs sometimes in   paroxysms,
leaving intervals of ease more or less  complete ;
sometimes it is  constant. Tic douloureux and the
periodic face-ach are instances  of this species  of
disease of the nerves.
   We know very little of the real nature of sen-
sation.   The opinion of Dr. Cullen, that a subtile
fluid pervades the nervous  system, that this fluid
is thrown into  motion by the application of cer-
tain agents, and that thus  sensation is produced,
is too conjectural and vague to be adopted by any
modern pbysiologist:  the same may be said of all
other known hypotheses on this subject.  It must
therefore clearly appear impossible to afford  a sat-
isfactory explanation of the  real nature of the sen-
sation of pain.   Probably  that peculiar property
of the nervous  system which we  denominate sen-
sibility,  or  the capability of feeling,  becomes  so
increased, in some instances, as to produce,  by
itself, the sensation of pain (these would be  called
instances of neuralgia) ; yet in  other cases  the
sensibility in the nerves seems to be increased and
pain produced  by certain appreciable  changes  in
the condition of the part wbich is the  seat of the
pain;  and this  may be illustrated by what occurs
in inflammation ; pain being almost the constant
accompaniment of  the other symptoms.  On  ex-
amination of the different  parts of the  body in
their  natural condition after death, those which
are the most sensible to the touch are found to be
more  plentifully supplied  with  blood-vessels  as
well as nerves ; as,  for example, the  ends of the
fingers and  the lips ;  both of which parts may  be
considered as instruments  of touch :  and it  ap-
pears that the large supply of blood sent to  them
is more than sufficient for the process of nutrition.
This fact, taken in connection with another, which
has been  a  matter  of frequent observation—viz.,
that when the flow of blood to these  parts is  in-
terrupted, without  any injury having  been  done
to the nerves themselves, numbness to a certain
extent is the consequence,—leads us to conclude
that the sensibility of a nerve bears some propor-
tion to the quantity of blood circulating in  the
capillary blood-vessels in connection with it.  We
should therefore expect, that when,  as  in the case
of inflammation, a larger quantity of blood is thrown
into these vessels, an increase of sensibility of the
nerves would be the consequence.   Many physio-
logical and pathological facts might  be  adduced in
corroboration of the  opinion  just stated; but
enough probably has been said to answer the pre-
sent purpose, which is to show that the increased
sensibility of a  part in inflammation depends very
much  on the increased determination of blood to
the part inflamed.
  Besides external violence  and increased irrita-
bility  of  the nerves, either connected with or inde-
pendent  of inflammation ;  inordinate  contraction
of the muscles, or spasm, must be  mentioned
among the causes of pain, and of pain, too, some-
times  of the severest kind.   The  probable expla-
nation of the production of pain  by  spasm  -n 
118
ANODYNES.
afforded by the circumstance of the pressure which
must be made upon the nerves by the contracting
muscular fibre, and must  give origin  to  excessive
sensation.  Of course when the nerves' are ren-
dered morbidly  sensible  by inflammation, or  by
any other cause, the pain from spasm will be more
severe.  Many facts warrant the conclusion that,
in some morbid conditions  of the. body,  excessive
sensibility of  the nerves and muscular spasm often
co-exist, as essential parts of the same disease.
It would not  be in place to inquire here  whether
the sentient  nerves, or  the  nerves  of  muscular
motion, or whether both,  are those affected when
pain is produced by spasm : indeed it seems to be
a point which we cannot determine, and probably
we should derive no practical advantage from the
knowledge were we able  to gain it.
   Pain may be alleviated or subdued, 1st, by the
removal of the  remote cause, such  as inflamma-
tion, spasm,  external pressure, &c; 2dly, by the
employment of remedies  which reduce the degree
of the sensibility of the nerves ;  and, 3dly, by the
employment of remedies  which render the brain
so torpid as not to allow the patient to feel the
effect of the usual  causes of pain when they exist.
   On the first of these heads  very little need be
said  in this place: indeed, the general means
which ought  to be employed for  the  removal of
the diseases which are  attended with pain cannot
be properly classed among the remedies which are
strictly called anodynes, although pain, along with
the other symptoms of such diseases, is  removed
by them ;  it may however  be, with propriety, re-
marked, that  in such diseases as inflammation and
spasm, the pain may often be  suspended during
their  continuance by  the medicines which are
strictly called anodynes, i. e., medicines -which  re-
duce  the  sensibility  of the  nerves, or produce a
torpor of  the brain, and  that it  may occasionally
be very desirable to administer them  for that pur-
pose. In spasm, indeed, the same remedies wbich
-ire calculated to  allay pain, will  frequently also
ailay the inordinate action of the muscular fibre,
(vide Antispasmodics ;) and  in many cases of
painful disease, anodynes may, by deadening the
patient's feelings, prove auxiliaries to those reme-
dies which are given with  a more direct  view  to
the removal of the disease itself; for  as  the  sen-
sation of  pain frequently acts upon the  system  as
a kind of irritant,  so the  suspension  of  that sen-
sation by  means  of an  anodyne, may, in many
diseases  of excitement,  allow such  diseases  to
come more completely  under the operation of the
remedies  which may be  administered to  subdue
inordinate action.  In many  instances  too, the
comfort of patients may with propriety be consult-
ed, and their sufferings  soothed  by the employ-
ment of anodynes, when they are not contra-indi-
cated, in diseases of  a painful nature.  Besides, it
is necessary,  in many diseases attended with pain,
to endeavour to procure sleep, and this  can be
r>nly done by the suspension  of pain ; for pain is
a common cause of watchfulness, and for this pur-
pose anodynes are frequently our only resource.
   The  exhibition of anodynes in inflammation,
however,  requires  the exercise of much judgment.
This remark appears to  be the more necessary,
because the  employment of some of them, espe-
rially of opium and the prussic acid,  has been of
 late strongly  recommended  as  antiphlogistic  re-
 medies : whether they are antiphlogistic or not is
 not now a question for our consideration, the pre-
 sent object being to guard the practitioner against
 their indiscriminate employment in inflammation.
 Pain, or tenderness, is one of the most unequivo-
 cal signs of the existence of inflammation, when
 taken in connection with its other symptoms ; and
 during the treatment of inflammation, when  no
 a?wdynes  have been employed, the  continuance
 of the pain will often afford  an indication, to the
 practitioner, that further active measures  are ne-
 cessary : but it is quite certain that inflammation,
 in a  considerable  degree, may be going on while
 all feeling of pain is suspended  by  the effect of
 an anodyne ;  so that in such a case the indication
 of pain will be lost, the  disease may be rendered
 obscure, and the treatment inert.  Besides the
 reason just assigned for caution in the employment
 of anodynes,  the stimulating quality which some
 of these remedies possess, ought to put the prac-
 titioner on his guard  against the indiscriminate
 use of them when treating inflammation.   It ap-
 pears better,  then, for the  purpose  of relieving
 pain, to depend generally on the means calculated
 to lessen  or  remove the inflammation itself,  at
 least in all recent and active cases :  this must be
 considered the most judicious mode of easing the
 feelings of the patient; but instances are daily
 met with in practice, especially of chronic  inflam-
 mation, where the  suspension of pain by  ano-
 dynes  is indicated by  the considerations which
 have already been assigned.
   The medicines which are strictly called ano-
 dynes, act either by reducing the sensibility of the
 nerves, or by rendering  the brain so torpid that
 painful feelings are not noticed.  It may be fairly
 questioned whether these medicines, when they
 are administered by the  stomach, do not  all pro-
 duce their effects in the same manner, by reducing
 the sensibility of the whole  nervous  system, and
 by thus rendering it less susceptible of feeling ;—
 all of them, when carried to a sufficient  extent,
 cause the brain to become torpid, and conduce to
 sleep ; and therefore they are  not only placed on
 the list of anodynes, but  also on that of narcotics.
 It is  not, however, to the  production of sleep that
 their anodyne quality is to be solely referred, be-
 cause, not unfrequently,  perfect ease from pain is
 enjoyed by a patient through their instrumentality,
 although the  mind is as wakeful as ever.   When,
 however,  these remedies are  applied  locally to
 painful parts, the action may  be entirely local;
 although when long applied in that manner, or
 applied in large  quantity,  they will  sometimes
 show an effect on the  brain, and it would be too
 much to assert positively that  their action is in
 any case entirely local.
   As a morbid degree of sensibility  seems some-
 times by itself to constitute  a painful disease, the
 employment of anodynes  may be occasionally re-
 quired as the principal means for the cure  of such
 disease : for this purpose it  will be generally ne-
 cessary to continue them for some length  of time.
   The following is a list of anodynes which are
 most commonly used.
   Opium.
   Hyoscyamus niger, (Henbane.)
I   Atropa  belladonna, (Deadly nightshade.) 
ANTHELMINTICS.
119
  Conium maculatum, (Hemlock.)
  Datura stramonium, (Thornapple.)
  Acidum hydrocyanicum, (Prussic acid.)
  The  doses  and modes of administering  these
remedies will be mentioned under the article Nar-
cotics.   Some others also will be there noticed,
which are occasionally employed  as anodynes as
well as narcotics; for whatever produces torpor of
the brain and  sleep, must, in accordance with the
views already given, be capable  of alleviating
pain.  Certain other  articles of the Materia Me-
dica, besides narcotics, occasionally suspend pain,
and may therefore be considered anodyne in their
operation.  These are the ferri subcarbonas, cin-
chona? cortex, and the arsenicum album.  It is
undoubtedly true that these are efficacious reme-
dies in many painful diseases ; but it is very ques-
tionable whetber they ever act directly on the sen-
sibility of the  nervous system ; they appear rather
in such instances to be capable of suspending the
morbid action  on which the  increased  sensibility
and pain depend, and therefore, strictly speaking,
 the application of the term anodyne to them does
not appear proper.           ,    ,IT
      v*    v  l             John Whiting.
   ANTHELMINTICS.—This term  is applied
 to  substances  intended to destroy, and to expel
from the body, intestinal worms.  [The defini-
 tion ought also to be extended so as to embrace
 agents that prevent their  generation.  The great
 object, indeed, is to remove  the predisposition to
 their generation.  The anthelmintics that destroy
 or expel, merely remove the parasites already pre-
 sent in the alimentary tube ; but unless the patho-
 logical  condition that gives  occasion to their  re-
 production is removed,  the  evil  will constantly
 recur.]    In order to acquire a full knowledge of
 the manner in which  these  substances  operate,
 and of their practical utility, we  ought to  make
 ourselves familiar with  the natural history of  in-
 testinal worms ; but  as this  information is  given
 under a distinct head in this work, we shall  con-
 fine our remarks, in the present article, to the
 means of relieving the  body from  these parasitic
 inimals.
   The remedies  belonging  to this  class of the
 Materia Medica are various, and on  this  account
 we regard that arrangement the most usefui, .n a
 practical point of view, which refers to thek r.ode
 cf operation.   The whole class may *oe c mveni-
 ently arranged under three heads -.--iv&juant an-
 thelmintics ;  tpeUfic anthelmintic; corroborant
 anthelmintics.
    I.  Evacuant  anthelmintic   are  substances
 which dislodge and expel v/crrus from the  intes-
 tinal canal, whether by * mechanical, a chemical,
 or a cathartic action.
    1. Among those e\«uant anthelmintics which
 operate  mechanicaiiy, we consider two prepara-
 tions only worthy of notice,—granulated metallic
 tin, and the setee jf the pods of the dolichos pru-
 riens.  Tin, stannum, appears to have been used
 as  an anthelmintic, in combination with common
 salt  and some other purgatives,  by Paracelsus ;
 (Opera Medico-Chemica.  Liber de Preparatio-
 nibus) ;  and  it  is mentioned also by  Quincy,
 (Quincy's Pharmacop. p. 246,) as a vermifuge ;
 but it was particularly introduced to the notice of
' the profession, in 1736, by Dr. Alston, (Alston's
Lectures on  the  Mat. Med. vol. i. p. 150,) who
prescribed it, for  the  first dose, to the extent of
an ounce, mixed in treacle ; for the second, which
was  not administered until three  days after the
first, half that quantity ; and then finished  by giv-
ing a purgative, whicb generally brought away the
worms.  It  is now prescribed in much  smaller
doses ; not more  than  a scruple, or at  most a
drachm being given for a dose ; but this is repeated
three or four times a  day for four  or five  succes-
sive  days,  and is followed  by a brisk  cathartic.
We  have found it useful chiefly in those cases in
which the ascaris lumbricoides was  present. Lewis
and  many others erroneously attribute the benefit
derived from this employment of tin to the arsenic
which  it frequently contains ; others ascribe it to
the tin being solvent in the gastric juice, and thus
forming hydrogen gas, which is poisonous to  the
worms ; an opinion which is supposed to  be sup-
ported by the efficacy of the aurum musivum, sul-
phuretted oxide of tin, which was formerly  much
employed as an anthelmintic.  In France a nearly
similar opinion of the poisonous nature of  tin is
maintained ;  for  wine exposed in tin vessels is
prescribed  as a  vermifuge.  One forcible  argu-
ment against these opinions is derived from  the
fact  that the worms  are generally voided alive ;
and  there can be very little doubt that the benefit
is derived solely from the mechanical irritation of
the worms by the grains of the tin—an  opinion
which is rendered more probable  by reflecting on
the manner in which lumbrici dispose themselves
in the  canal.  " The  dissection of one subject has
shown  me," says Mr. Rumsey, " that  they dis-
pose themselves in the most curious and tortuous
form, such  as I  thought exactly adapted to  the.
exertion of"their  muscular power against opposite
sides of their cylindrical abode, resisting,  by this
means, the effect of the propelling motion of  the
canal,  and  thus  keeping their station.   An  illus-
tration of this mode may be found in the  art em-
ployed  by  a chimney-sweeper to  counteract  the
effects of gravitation  by pressing against opposite
sides ol thv- cylinder in which he exerts his skill."
(ivL,dk,o-Chirurg. Trans, vol.  ix. p. 401.)  The
Lm ation excited  by  the tin prevents  them from
.etaining this position, and causes them  to  be
easily expelled.   The other mechanical agent well
adapted for  expelling the round  worm,  ascaiis
lumbricoides, is cowhage, dolichos pruriens—[mu-
cuna, of the  Pharmacopoeia of the United States,
 1842,1—a very common anthelmintic in the  West
Indies.  The setse on the outside  of the pods  are
scraped off, after sheathing them  by dipping  the
pods in syrup, and  then formed  into a  kind of
electuary, which is given in doses  of one  or more
teaspoonfuls, early every morning, for three suc-
cessive mornings ; this is followed by a brisk  ca-
thartic.  The seta?,  in the same  manner as  the
tin,  wound  and irritate the worms, obliging them
to leave their hold on the coat of the intestine,—
at least this is the usual opinion of their mode of
acting.  A  dessert-spoonful of the electuary is
given  to an adult,  fasting, for  two  successive
mornings :  many worms  are  usually evacuated
after taking  the second dose,  particularly  if  the
long thread worms be present.  The cathartic is
generally requisite to aid their expulsion, and if
it consist of calomel and scammony, any ascan.Ies 
M I N TI C S.
120                             ANTHEL

present in tbe  rectum are expelled  at  the same
Lime.  Neither the powder of tin nor the cowhage
are now so generally employed as they formerly
were.
   [The short, stiff bristles on the tube which ter-
minates the coriacious  and scaly involucre or cu-
pula that surrounds the nut of corylus rostrafa,
' beaked hazel,'  have been  found to possess similar
virtues  to  those  of  mucuna.   They  may be
given in the same  vehicle and  doses.   (Amer.
Journal of Pharmacy, Jan. 1843; and  Dungli-
son's New Remedies,  4th edit.  p. 200 : Philad.
1843.)]
   2. The  chemical anthelmintics  of this  (the
evacuant)  division  operate in two ways;  either
purely chemically, by dissolving the viscid mucus
or  slimy  secretion  in  which the worms are in-
volved ; or, besides  doing  so, also by stimulating
the  mucous  membrane,  and  by improving the
nature of the secretion, preventing the accumula-
tion of the slime.   Lime-water and  pure alkalis
may be regarded as almost simple chemical  ver-
mifuges ; the former is  perhaps more  useful, espe-
cially for removing the ascarides, when it is ad-
ministered as an enema.   When taken  into the
stomach, the  dose should  not be less than four
ounces; and it  is useful to combine it either with
infusion of gentian  or of chamomile  flowers.   If
the solution of the  alkalis, or their carbonates, be
employed, the dose should  be carried to its utmost
extent, beginning with small doses ;  for example,
from twenty to  thirty minims, and  gradually in-
creasing  the  number of minims daily until  two
drachms  or more be  taken twice a day.   The
alkalis also may be given  in bitter infusions,  that
of tansy for  instance,  and combined with some
essential oil in the form of an oleo-saccharum.
   3. The purgative anthelmintics have no other
effect than clearing  away  the superabundant mu-
cus, and such  worms  as  are detached  from the
coats of the intestinal canal, and  can be expelled
in conjunction with the  mucus.  Amongst the
saline purgatives, common salt and  sulphureous
waters,  such as those of Harrogate, have been
found most useful.   The  common salt combines
a tonic with its purgative property [and is positively
detrimental to entozoa when they are out of the
body].  It may be  given in doses of a scruple to
an ounce dissolved  in  a large quantity of water,
or double the quantity may be exhibited in  the
form of enema,  when the rectum is much infested
with the ascarides vermiculares.   The Harrogate
water,  besides  purging, operates  as  a poison to
the worms by  the  evolution of the  sulphuretted
hydrogen gas which it contains.  Rhubarb, scam-
mony,  and colocynth,  [castor oil, and croton oil]
operate as simple evacuants ;  and, for the same
reason, gamboge is sometimes employed : they are
generally  ordered with a view  of operating as
cathartics after the  employment of other anthel-
mintics. One of the  most common of the means of
expelling worms in children is to give a large dose
of calomel at bed-time, and on the following morn-
ing an ample dose of scammony with sulphate of
potassa : a large portion of bile is thus  brought
down into the bowels, which aids  greatly in  dis-
charging  the mucus of the  intestines.  In  the
;ases of children, indeed, active purging is borne
with much less inconvenience than in those of
adults ;  and the first object is always to effect  as
much as can  be done by cathartics, and then to
have recourse  to other means.
  II  Specific anthelmintics are substances which
destroy the worms by some  poisonous principle,
The Materia Medica is rich in  such articles, but
many of them have  been overrated, and are little
worthy of notice ; we shall, therefore, bring before
our readers those  only which experience has as-
certained to be valuable.   The rectified oil of ttir-
pentine, the best of these specifics, was introduced
into practice by Dr. Fenwick, for the  destruction
of the tape-worm.   It is usually given in  doses
of a fluid ounce, or  an ounce  and a half, which
sometimes  produce  sickness and purging, and
occasionally intoxication, but rarely tenesmus or
strangury ;  for in large doses its cathartic influ-
ence evidently stands in  the way of its  absorption,
and prevents, in particular, its effects on the urinary
passages.   In  some habits large doses cause a sen-
sation of chilliness and a tendency to sleep ; this
has been, in some  instances, partially obviated by
administering  the  oil soon  after a meal.  In al-
most  every case treated with oil of  turpentine
which has come under our notice, the worm has
been expelled lifeless, and of a  livid hue; the
poisonous quality of the oil  on these  parasites is
therefore obvious.   In  a few instances we have
had occasion to  aid its purgative effects by castor
oil, which appears to answer extremely well; in-
deed this oil has been lauded by  Drs. Odier and
Dunant, of Geneva,  as a specific in taenia.
  The beneficial  effect  of oil  of turpentine in
taenia led to its employ ment as  a  remedy for the
destruction of other worms.   In the hands of Mr.
Rumsey and others,  it has  been found very suc-
cessful in cases of lumbrici, when given in smaller
doses.  To a child of about three years of age, it
was given in doses of half a drachm, mixed with
four drachms  of thin mucilage of gum arabic,
twice or three times a day ; and  " continued  3
week, with some interruptions, within which space
one hundred and twenty, mostly full grown, lum-
brici were brought  away."*   It has also been pre-
scribed in the form of enema, to the extent of half
a fluid ounce  sheathed with mucilage of starch,
for removing the common ascarides from the rec-
tum ; some caution is requisite in this  mode of
using it; but  when  it can be  administered, the
worms are discharged in  great abundance.
  [Animal  oil,  DippeVs oil, which is identical
with the oleum cornu cervi, or oil of hartshorn
of the older Pharmacopoeias, is highly extolled, by
the Germans  more especially, and it  is unques-
tionably very efficacious, even in  cases of taenia;
but it is exceedingly nauseous, and few stomachs
can retain  it.   Its dose is  from  five  to twenty
minims, in molasses, for three mornings in  suc-
cession,— following  up the last dose  by a brisk
cathartic.
  The empyreumatic oil of Chabert,  made by
adding one part of animal oil to three  parts of oil
of turpentine,  leaving them  to  combine for four
days, and then distilling three parts, has also been
greatly praised as an  anthelmintic.  It, likewise, is
very nauseous; but it is very effective,  in the dose

  * Trans, of the Medico-Chirurg. Society of London,
vol. ix. p. 403. 
ANTHELMINTICS.
121
of a teaspoonful, in molasses, two or three times a
day.]
  The powerful poisonous influence of tobacco on
animal life has induced some practitioners to em-
ploy it as a vermifuge in cases  of ascarides : it is
thrown into  the rectum,  both  in the state of in-
fusion of the dried leaf, or  as  smoke.  In either
form, the danger attending its employment is suf-
ficient to cause its rejection from the list of  an-
thelmintics.
   The root of the male fern was employed as an
anthelmintic  as early as the time of Dioscorides :
it was afterwards  neglected, and occasionally re-
vived, until  the success  of Madame Nouffler's
practice, in the eighteenth century,  established its
reputation as a remedy for tape-worm.   According
to .Madame Nouffler's directions, three drachms of
the powdered root were  given in  the morning,
after  the patient had been prepared  by the exhibi-
tion  of an enema  on the preceding night; and
two hours after  the dose of the  fern-root had been
taken, a  bolus, consisting of twelve grains of
calomel, twelve of scammony, and five  of gam-
boge, was also administered.  This practice proved
frequently successful;  but,  with  Cullen,  many
practitioners  have attributed the  benefit chiefly to
 the purgative ;  an opinion,  however, which  has
been shaken by the  analysis of  the  fern-root by
 M. Peschier, of Geneva,  who  discovered in it  a
 volatile oil to which he attributes all its  activity.
 Thirty drops of this oil are equal to  three drachms,
 or a  full dose,  of the  powder :  it may be  given
 either in the form of an oleosaccharum made into
 an emulsion  with almond  mixture,  or  of pills
 made with crumb of  bread.  One  half of  this
 dose  is given at bed-time, and the other half on
 the  following morning, on the empty stomach ;
 and if it do not purge, a dose of castor oil should
 be given in the afternoon of the  same day.   The
 success of M. Peschier with this  oil appears to
 have been considerable, and has been confirmed
 by the experience of others.  In  every  instance
 the  worm was  voided  lifeless  ; whence  we may
 infer the accuracy of the opinion,  that it is  this
 oil which  acts  as a  poison when  the powder of
 the  fern-root is administered.   [See Dunglison's
 New Remedies, 4th ed., p. 312 :  Philad., 1843.]
   The bark  of  the geoftroya inermis, or bastard
 cabbage-tree  of Jamaica,  and the powdered roots
 of the Indian pink,  spigelia Marylandica, have
 been stated to be  as  certain  anthelmintics for the
 removal of lumbrici  as the oil of turpentine  and
 the male fern for that of  tenia.  The former  was
 introduced to the notice of the profession by  Mr.
 Duguid, of Jamaica,* and was much extolled by
 Dr. Wright,  who published the botanical charac-
 ters  of the plant.  (Phil. Trans,  vol. lxxviii.  p.
 507.)  The best form of exhibiting it is that of
 decoction, made by boiling an  ounce of the bruis-
 ed bark in two pints of water,  down to a pint.
The  dose for  an adult is two fluid ounces,  which
generally purge, producing also a slight degree of
nausea ; but  if cold water be drunk during its
operation, violent vomiting and much fever  super-
vene, which, however,  are  quickly relieved  by
purging with castor oil, and the free administra-
tion  of warm water  acidulated with  a vegetable
   * Essays, Phvsical and Literary, by a Society in Edin-
burgh, 8vo. 1770, vol. ii. p. 200.
   Vol. I.—16                          i
acid.  Although the active principle of this bark
is still unknown, it is very evident that it operates
as a specific poison to the worms ;  and this opin-
ion is confirmed by the fact, that, when it is tardy
in its operation, and  requires the aid of a  purga-
tive, its anthelmintic effect is more  decided.  It is
seldom employed in England.
   The Indian  pink  appears  to operate in its re-
cent state as a narcotic, unless it be given in doses
sufficiently  large  to  secure quickly  its cathartic
influence ; but in the  dried state  in which it is
usually  found  in this  country, its narcotic pro-
perty, if  it possess any in this state, is exhausted
in the destruction of the worms, as we have never
perceived its effects on the system of the patient.
It is administered in powder,  in doses of from  ten
grains to a drachm ;  but as far as  our experience
has gone, it requires the  aid of some other purga-
tive to secure its anthelmintic influence in mode-
rate doses;  and the violent effects  of a large dose •
are too hazardous to  be recommended.
   [It is  much used in  the United  States as an
anthelmintic.   Dr. Wood, indeed, thinks that it
stands there .at the  head of the anthelmintics.
(Dispensatory of the  United  States, 5th edit., p.
682 : Philad., 1843.)    It is certainly  highly
esteemed by many practitioners ; but others have
equal confidence in chenopodium, and much more
in oil of turpentine and its combinations.
   The bark of the root of pomegranate (Granati
Radicis Cortex, Ph. U. S.) has been much used
in taenia ; but the testimony in regard to it is dis-
cordant.   It is almost always given  in decoction,
which may be prepared  with  two ounces  of the
bark, boiled in a quart  of water down to  a  pint
and a half.  Of this, the dose  is two  fluid ounces
every half hour, until the whole is taken.   (Dun-
glison's Nevj Remedies, edit,  cit., p.  332 ;  and his
General Therapeutics and Mat.  Med.,  i.  211 :
Philad., 1843.)
   The seed of Chenopodium  Anthelminticum—
' wormseed' — chenopodium of the Pharmacopoeia
of the United  States — is one  of the  most popular
anthelmintics.  The common  mode of prescribing
it, to a  child three or four years of age, is to mix
one or two scruples of the powder  with molasses ;.
administering this for three nights in succession,
and directing  a cathartic  on  the following morn-
ing. The distilled oil, oleum chenopodii, or worm-
seed oil, is  officinal  in the Pharmacopoeia  of the
United  States.  It is  administered  in  the same
manner as the powder, in the  dose of from four to
eight drops, mixed with sugar or molasses.
   The wormseed of Europe is the fruit of Arte-
misia Santonica, or of a variety of A. maritima.]
   The  only other  anthelmintic of  this division
which requires notice, is one which has been very
seldom, if ever, employed in this country ; and
we bring it before our  readers only because we
have seen  its active principle,  veratria, operate in
expelling lumbrici, when it has been administei
ed, with another intention, in the form of wirn<
of colchicum.  The seeds of the veratrum saba
dilla, the substance to which  we refer, have been
long celebrated on the continent as  a specific in
taenia lata, and are much extolled by Seeliger and
M. Brewer.  The latter prescribed the powdered
seeds in  doses of three grains, which were taken
on an empty stomach in the  morning, for eight 
122
A N T H R A C 10 N —A N TI P II L O G I ST I C  REGIMEN.
successive  days; and  these, on  the  ninth  day,
were succeeded by a strong dose of gamboge and
valerian.  It is not easy to explain the beneficial
effects of this plan of treatment without referring
it to the veratria, which, besides acting as a direct
poison to the worm, stimulates the gall-ducts, and,
bringing a large portion of acrid bile into the
duodenum, sweeps out the dead worms.  In this
manner we have  seen  the  wine, and the other
preparations of colchicum, operate, in expelling
lumbrici;  but  we have  had no experience of their
influence in taenia.
  III. It only  remains to notice the last  division
of this  class  of  medicines, corroborant anthel-
mintics.   All  the substances, in the first divisions,
act merely upon  the worms already  existing in
the intestines,  either destroying  them or expelling
them  in a living state; thence the  necessity of
adopting means for preventing their recurrence ;
and as debility favours their production, it is obvi-
ous that tonics are indicated.  All the bitters may
be employed for this purpose, but the chalybeates
have with  much reason been preferred.   At one
time it was supposed that the preparations of iron
are poisonous  to worms, an opinion founded upon
the observation that the earth-worm dies when
submersed in  chalybeate solutions :  but the fact
that the earth-worm respires by the  skin, which
is not the case with intestinal  worms, was over-
looked ; and it is now generally admitted that the
chalybeates operate as anthelmintics by their tonic
influence, strengthening not only the alimentary
canal, but  the whole system.  Among the prepa-
rations  of iron,  the  sulphate  was  extolled  by
Boerhaave, who gave it  to the extent of a drachm,
dissolved  in  a pint of water, in divided doses,
within  twenty-four hours.  We  have found the
milder  preparations, particularly  the  tartarized
iron operate more favourably with children and
females, who,  as  we have  already  said, are the
chief subjects of  worms.   After  clearing the
bowels  with a large dose of calomel and scam-
mony, we  prescribe the tartarized iron, in doses
of  a  fluid drachm of the solution,  to  be taken
three times a  day ; but the  wine  of iron, in simi-
lar doses, or the tincture of the  acetate of iron,
of the  Dublin Pharmacopoeia,  in doses of fifteen
or twenty drops, given in  milk, will answer the
same purpose.  In cases of ascarides, chalybeate
water, such as that of Tunbridge, has been found
to be extremely useful  when administered as an

enema>                   A.  T. Thomson.
   [ANTHRACION (from avBpal, < a coal').  This
affection has an extensive synonymy; — Pustula
maligna,  Vesicula gangrxnescens,  Malignant
vesicle, Malignant pustule, and Persian fire.   In
France it  is  known under the  names, Pustule
maligne, Feu Persique, Mal-vat, Bouton malin,
&c.; and in Germany under that of MiIzbrandkar-
bunkel.  It is characterized by the appearance  of
a bleb filled with  reddish sero-sanguinolent fluid,
 under  which  a  small  lenticular  induration  is
 formed, which is speedily surrounded by diffuse
 inflammation  of an erysipelato-phlegmonous cha-
 racter.  The inflammation terminates in gangrene,
 wb'ch spieads rapidly from the centre to the cir-
 cumference of the tumour.  This  is the general
 character  of  the  affection ;  but  at times a white
line of demarcation checks its progress : at others,
the cellular tissue becomes rapidly  disorganized,
and deep caverns form beneath the skin.   AY hen
gangrene strikes the central part, the inflammation
extends to a considerable distance around,— the
skin being red, tense, and shining, and the  sub-
cutaneous  tissue  swollen, infiltrated, and often
emphysematous.  The affection is generally accom-
panied by great constitutional disturbance  ; and in
its progress, the symptoms become markedly ady-
namic, and the patient often sinks  and dies within
the first twenty-four hours from the onset.  When
it terminates  favourably, the phenomena  are the
same as in cases of local gangrene in general; a
line of separation  occurs, and the  constitutional
symptoms improve.
   It is the common belief that anthracion occurs
only from the contact of the matter of carbuncle
of animals.   Accordingly, it appears on parts of
the body  that are ordinarily  or accidentally  ex-
posed.  Thus, it is often seen on the face; never
on the scalp ;  and most commonly on the hand,
forearm, arm and neck.   (Rochoux, Dictionnaire
de Medecine, torn. 26. p. 510 :  Paris, 1842.)  It
would seem, however, that it may originate spon-
taneously in man.
   The treatment, where the  disease is produced
by the contact of virus, may be divided into that
which is  proper,  whilst  the affection is  entirely
local; and into  that which is necessary, where the
constitution becomes implicated.
   The plan thought to be most successful, in the
first case, is to make incisions through the  gan-
grenous parts, so as to permit escharotics to come
in contact with the sound textures, and induce in
them a new action.  A strong solution of nitrate of
silver, from 20 to 40 grains to the ounce of water,
or liquid muriate' of antimony, or diluted  or  even
strong muriatic acid, may be applied by means of
dossils of lint.  By some, potassa  has been ad-
vised ;  and  by  others,  chloride  of  zinc.  The
escharotics  may remain on a  few hours ;  after
which, turpentine dressings,  or  warm poultices,
may  be substituted.  On the next day,  if there
be no appearance of an extension of the disease,
the  soothing  treatment  may   be  pursued,  or
 poultices, to which aqua chlorini has been added;
 or an ointment of the  same ; or a cataplasm or
 ointment of chlorinated lime may be used.  The
 internal management must be the same-as in gan-
 grenous affections  in  general.  Tonics  are de-
 manded ;  and opiates  may be needed  to  allay
 suffering.   (Practice of Medicine, 2d edit. p. 113:
 Philad., 1844.)
              J        Kobley Dunglison.]
   ANTIPHLOGISTIC REGIMEN, (from ivrl,
 contra, and ^Adywo-if,  inflammatio).  The  term
 antiphlogistic regimen  implies the accessory treat-
 ment required in  aid of medical discipline for the
 removal of fever or inflammation.   So  essential
 is this aid, that neglect of it may render fruitless
 the most judicious course of medical treatment,
 on which account it merits the serious attention
 of every  practitioner.
    As the medical treatment of  fever and inflam
 mation will be  treated  of under the proper heads
 it  is unnecessary in this article to do more than
 notice the  assistant means by which its end may
 be promoted.  These may be considered  as the? 
ANTIPHLOGISTIC  REGIMEN.
123
regard bodily rest, diet, air, temperature, and men-
tal repose, under which all that  is essential may
be included.
  Bodily rest---Fever  and inflammation  being
characterised by morbid excitement, which, when
excessive or unrestrained, is  the  source  of much
injury, and to allay which is  the object of medical
interference, it becomes important to avoid every
influence by which it might be prolonged or ex-
asperated.   Bodily exertion increases excitement,
and  should  therefore  be suspended  by consigning
the patient, if not in every instance to bed, at
least to perfect quietude.   Under fever the whole
muscular system  becomes debilitated,  and even
slight exertions are not made without an effort far
greater than would be required in  a state of health.
During such  effort the motions  of the  heart, al-
ready  too frequent, become  still further  accele-
rated ;  more blood is transmitted  to the  lungs
than  can find a free passage through them,  and
the breathing is  hurried in proportion.  Such dis-
turbance of the  important functions of  the heart
and lungs is eminently unfavourable to the objects
which the physician has in view.   Independently
of locomotion, even the erect posture is not sus-
tained by a  frame debilitated by febrile  derange-
ment without a  painful effort, and is badly borne.
Under febrile or inflammatory diseases requiring
active treatment, therefore, it is always advisable
to enjoin perfect rest  and a recumbent posture, to
ensure which the  patient should be  kept in  bed
in all  cases where there  is  much  excitement to
allay.
  Diet.—This requires to be regulated both as to
quantity and quality.   Happily, under fever appe-
tite pretty generally declines, and  the patient is
thus debarred from taking what  would aggravate
his disorder. The suggestions of nature are always
worthy of attention, and in  no instance are they
more clearly announced than in  the inappetency
which attends the febrile state.  In the exposition
of fever and of  inflammation given in this work,
it will be seen how completely this disinclination
for food accords  with what our best knowledge of
fever  enjoins.   During  acute fever or inflamma-
tion, abstinence  is essential;  and so long as they
continue active,  the standard of diet can hardly be
too low.  Simple diluents are all  that the stomach
can bear, or  tbe patient require, and even  with
these the stomach should  not be oppressed.  So
powerful is  mere abstinence in abating fever,  that
it might almost be laid down as  an axiom, the
more  perfect the abstinence, the  less will be the
necessity for medical  agency.  The remarks here
made on  the quantity  of food  apply with even
greater force to its quality.  It is familiarly known
that animal food is more nutritive than vegetable;
consequently animal diet  must be  unsuited to  a
state of disease in which nutritive  matter is already
relatively in excess.  However opinions may differ
on the connexion of fever with an antecedent state
of plethora, all  will  agree  that  under fever the
ordinary expenditure of nutritive  matter in  the
several  secretions  of  health  becomes diminished,
from the secretory functions  by which the several
tissues are nourished failing in their wonted ener-
gies ;  whence the nutriment with which the blood
is, on the accession of fever,  already charged,  can
no longer be beneficially disposed of, and becomes
oppressive to the system.   To add to the load by
more diet, and especially by diet  so  nutritive  as
that which  animal  matter furnishes, cannot  be
judicious.   Nature  revolts  from it,  experience
condemns its use,  and enlightened  practice will
ever withhold it, however importunate friends and
relatives  may be, through mistaken  kindness, to
induce a relaxation of that discipline which  the
judgment of the  medical  attendant  leads  him to
enforce.  According as disease declines,  greater
indulgence  may, of course, be  granted ; but this
consideration belongs  to  the medical treatment,
and  is discussed  elsewhere.  The present article
professes only to specify what  is  meant by anti-
phlogistic regimen when  it  is  enjoined  by  the
medical attendant.
  Air—The time is happily gone by when febrile
patients were immured  in  heated chambers, over-
whelmed with blankets, a good fire maintained to
prevent the risk of cold, and every aperture through
which pure air could  enter, even to  the  key-hole
of the door, carefully closed.   Absurd and almost
incredible as this practice now appears, half a cen-
tury has scarcely elapsed  since it was generally
followed.  The  febrile sufferer is now allowed  to
breathe a pure  atmosphere, to ensure which is a
most essential part  of the antiphlogistic  regimen.
The intelligent practitioner, to whom the elements
of physics should be familiar, can  be at no loss to
ascertain whether the  circumstances of the inva-
lid's chamber be such as  to  afford the  necessary
assurance of adequate ventilation.  The confine-
ment of  air by closed bed-curtains is particularly
pernicious, and  should  be utterly disallowed,  the
use of these  being limited to averting direct cur-
rents, and moderating the glare of  light.   Even
light should not be wholly excluded from the sick
chamber, save where there is high excitement  of
the brain, or morbid sensibility of vision.
   Temperature.—On this head it may  suffice to
state that the best medium temperature for a cham-
ber  is about  60°  of  Fahrenheit's thermometer.
Circumstances may occasionally require it to  be
higher or lower.  As sensation is a very imperfect
measure  of  temperature,  the best security is  to
adjust the heat  by a thermometer suspended in the
room.
  Mental repose.—The observations made on bo
dily rest  are all applicable  to the state of the mind.
Mental excitement is capable of disturbing all the
bodily functions, and of exasperating every symp-
tom of fever.   Of ordinary exertion  of mind the
febrile patient is  soon  rendered incapable  by the
effects of disease,  which  speedily hebetate the
mental energies.  The morbid excitement of brain
which results  from its special  derangement  is.
itself a symptom of disease,  and,  as such, is the
proper province  of the  medical attendant, who
should direct the appropriate  treatment; all ordi-
nary  excitement of mind  of which  the patient
may be susceptible should  be carefully restrained,
or permitted only with extreme caution;  perfect
quiescence both of body and mind being that state
which will  best second  the medical treatment.
Indeed, it is the same  principle  which applies  to
both ;  for though in referring to mind the remarks
are  applied to the manifestations, the reasoning is
really directed not  to these,  but to  the  physical
state of  the  brain  on which they  depend, and 
124
ANTISPASMODICS.
which, under fever, is sensibly disturbed by what-
ever gives rise to much mental emotion.
  The moral  treatment of the invalid is, conse-
quently,  no unimportant part of  antiphlogistic
regimen.                      --,  „
                              E.  Barlow.
  ANTISEPTICS. -See Disinfection.
  ANTISPASMODICS (dvrl, against, and tnao-
/oi,  spasm) are usually defined stimulant sub-
stances which  allay irregular muscular contrac-
tion.   In whatever manner muscular action takes
place, it may be affirmed that it  is altogether at-
tributable to the nervous system ;  the nerves of
motion being  those engaged in  it, whether  the
stimulus or exciting power be mental or material.
The motion which is induced is transitory, and
always followed by a state of rest; it is this alter-
nation of motion and quietude, under due regula-
tion, which constitutes  the  distinction between
ordinate and inordinate muscular action.  If, after
muscles have contracted, they retain this condition
when  the exciting cause ceases to operate, they
are said to be  in a state of spasm, and such medi-
cines as have the power of resolving this state are
termed antispasmodics.  If  narcotics  allay irrita-
bility, soothe pain, and produce diminished suscep-
tibility to the  impressions of exciting agents, it
may reasonably be inquired in what respect anti-
spasmodics differ from narcotics.
  The chief circumstance in which antispasmo-
dics differ from narcotics is, that the  administra-
tion of the former is not followed by the insensi-
bility to  impressions, and collapse, which almost
invariably follow  the exhibition  of  narcotic sub-
stances.  ISo  such effects can be  induced  by anti-
spasmodics, even  in large doses; yet  they are as
powerful  as narcotics  in repressing  inordinate
muscular action.   In explaining,  therefore,  the
difference between antispasmodics  and narcotics,
we may hazard the opinion  that it is probable the
impression exerted on  the  extreme  nerves by a
narcotic is  confined  to those of sensation,  and
must  be communicated to  the brain  before the
effect  is produced ; whereas that  caused  by an
antispasmodic is confined to  the nerves of motion,
and produces  an immediate  and  more  permanent
result  by some changes effected in the state of the
motor nerves, independent of any communication
with the  sensorium.  If this opinion  be correct,
antispasmodics, in the strict meaning of the term,
stand  in the same relative position  to narcotics as
astringents to tonics. But, whatever may be their
mode  of action, the distinct nature of an antispas-
modic, acting  simply as such, is very obvious;  and
antispasmodics may be regarded as  holding an in-
termediate place  between narcotics and tonics,—
less diffusible  but  more durable than the former,—
more immediate but  less permanent than the lat-
ter.  Another point requires consideration,  viz.,
whether antispasmodics are  to be regarded as sti-
mulants or sedatives ?  If our hypothesis be cor-
rect, they  have a sedative  operation ; for if the
irregular or inordinate  action, which  they over-
come, be the consequence of irritation, either men-
 tal or corporeal, it follows that, in resolving spasm,
 the susceptibility  of impression in  the extremities
 of the motor nerves must be diminished, and this
 can only be the  result of a sedative  power.  It
 mav, however, be affirmed that this may be either
immediate, or the consequence of a previous stimu-
lant operation : thence, we can explain the reason
why some of these medicines winch are direct
antispasmodics stimulate the general system, and
consequently quicken  the  pulse ; s.nce,  ike  nar-
cotics  their primary action may be stimulant, and
quickly followed  by collapse.   According to  this
mode of reasoning, the same  results  may follow
from  tbe influence of the  exclusive operation of
antispasmodics on the nerves of motion, as  from
that of narcotics on those of sensation.
   Antispasmodics, as far as regards their mode of
action, may be divided into direct, or »those which
exert their influence on the nervous energy, but
neither as narcotics or tonics ;" and  indirect, or
»those narcotics and tonics which produce an an-
tispasmodic effect."
   The effects of antispasmodics are generally per-
ceptible  very soon after their administration, more
especially  if  the powers  of the  individual are
weak.   It should, however, be kept in mind  that
this class of remedies is of no avail, indeed is posi-
tively injurious when  the spasmodic muscular ac-
tion  is  the consequence of inflammation of the
brain  or  spinal marrow :  under  such circum-
stances, blood-letting and other measures calcula-
ted to subdue the primary  disease, are  the proper
measures  to be  adopted.   It  is necessary also to
mention  that the operation of antispasmodics is
very transient, and that by frequent repetition their
influence on the nervous system is much impaired;
the dose therefore  requires to be  modified very
much, according as the individual has or has not
been  accustomed to their employment.
   The Materia Medica  furnishes few direct anti-
spasmodics.   One of the most powerful, musk, is
too expensive to be generally  prescribed, particu-
larly  as the dose is required  to  be very large in
order  to obtain a satisfactory result from its em-
ployment.  We can bear  testimony to its power-
ful influence in diminishing  the violence of the
paroxysms of  idiopathic   epilepsy, and  greatly
lengtbening the intervals, when the dose is carried
to the extent of a drachm given at  intervals of
eight  hours.  It is most advantageously prescribed
in the form of bolus : the  mixture and the tinc-
ture of the Pharmacopoeias being very uncertain
preparations.   Much less can be said in favour of
castor, which is greatly inferior  to musk  as an
antispasmodic.
   Among the animal oils, that of Dippel, although
much lauded on the continent, and notwithstand
ing its success in epilepsy in the hands of Alibert,
 may  be regarded as an antispasmodic of little effi-
 cacy, and ought to be expunged  from the list of
 Materia Medica.  The oil of amber, also, formerly
prized as a powerful antispasmodic, is now scarcely
 ever  prescribed.  Valerian, assafectida, galbanum,
 and sagapenum, owe their antispasmodic properties
 chiefly  to volatile  oil, in  combination with resin
 and  extractive  matter : their efficacy in hysteria,
 spasmodic asthma, and similar affections, has been
 well   ascertained.   Naphtha was  formerly  much
 employed as an  antispasmodic  in diseases unat-
 tended  with inflammatory symptoms; and the
 West Indian practitioners still extol it in hooping-
 cough, and some other spasmodic diseases.
    With respect to indirect antispasmodics, little is
 required to be said.  In selecting them, we  must 
ANTISPASMODICS.
125
be guided by the state of the patient, and  the
nature of the exciting causes of the spasms which
we  are called upon to relieve.  If" they  are  the
result of local irritation, and kept  up by habit after
the removal  of the irritating cause, narcotics  are
to be employed as the  most powerful means of
allaying irritation, and  breaking  the habit which
has been acquired.   But if the spasm is maintain-
ed  by  a peculiar  susceptibility to  impressions,
which is always, more or less,  connected with
debility, then tonics  are to be administered ; and
the more rapidly  the body can  be brought  under
their influence, the better.
   Something may be expected to be said with re-
gard  to mental  impressions  as  antispasmodics.
There can be no doubt that some mental  states
produce and maintain spasmodic  action  in  the
body, while others as readily operate as powerful
antispasmodics.   As a minute consideration of
this question, however interesting in itself, would
exceed our limits, we  shall merely allude to  the
power of abstraction.   In every  instance of spas-
modic action, from whatever cause, the attention
 is directed to the part  affected ;  so  long as this
exists, no corporeal  agents  which do not make  a
 greater impression on  the mind than that pro-
 duced by the spasm, can resolve it: but when the
 attention is withdrawn  from the spasm, it  is in-
 stantaneously relaxed.   Thus, a  man has  his
 shoulder-joint luxated ;  and, after various attempts,
 the luxation cannot be reduced  on  account of
 spasm which has supervened, and which is main-
 tained by the attention of the patient being direct-
 ed solely  to the part; but  abstract the attention,
 and the spasm  instantly yields, and the head of
 the humerus slips into the socket.  In the same
 manner, and with the same success, the antispas-
 modic influence  of  abstraction has been experi-
 enced in hernia and other diseases  ; in its  appli-
 cation, however,  great judgment and nice discri-
 mination are requisite.
   In  reference  to  the practical employment of
 antispasmodics,  their  utility  is  confined  to one
 order  of diseases only, the spasmi.   In tetanus,
 the narcotic antispasmodics,  particularly  opium
 and camphor, have been  much  employed;  but
neither these nor the direct antispasmodics, musk,
 oil of  amber,  or assafcetida,  have  fulfilled  the
 anticipations of practitioners.  The most power-
 ful is, undoubtedly,  opium ;  and it is almost in-
 credible what doses of this remedy may  be ad-
 ministered in this  disease; fifteen  and  twenty
grains  have  been  given every  three hours, for
eight  and ten days successively,  with little effect
upon either the disease or  the  constitution  of the
patient.  When opium has proved beneficial, its
effects  have  been rarely obvious until after  the
tenth or twelfth day of its  exhibition ; but indeed
we may safely affirm that little reliance is to be
placed upon the influence of the  most powerful
antispasmodics, direct or indirect, in this disease.
   [The Cannabis Indica  or  Indian Hemp has
been  recommended,  by Dr.  O'Shaughnessy,  of
Calcutta, as  an  " anti-convulsive remedy"  of the
greatest value ; and when given  boldly,  and in
large doses,  as a successful remedy in traumatic
tetanus.  (Pereira,  Elements  of Mat. Med.,  2d
edit. p. 1096: Lond. 1842 ; and Dunglison's New
Remedies, 4th edit.  p.  133 : Philad., 1843.)]
  In  chorea, when purgatives have failed to pro-
cure relief, antispasmodics, such  as musk, opium,
and belladonna, have  been freely administered ;
but in this disease more decided  benefit has been
obtained from tonics operating as  antispasmodics
than  from either narcotics or musk.   Much ad-
vantage has  resulted from the use of the nitrate
of silver, the carbonate  of iron,  and  arsenious
acid ;  all  of  which operate as indirect antispas-
modics.   It is true, that, in some  cases in which
these  tonics have failed, the disease has yielded  to
the use of musk  and camphor; but, in general,
less advantage has been derived  from the employ-
ment  of  direct  antispasmodics, than,  from the
nature of the disease, might have been reasonably
anticipated.
  Antispasmodics effect  little  good in epilepsy.
Some of the  narcotics have sometimes appeared
to prove useful; but we have  seen them  all fre-
quently fail in relieving this disease.   Among the
indirect antispasmodics, the preparations of zinc,
copper, mercury, and  arsenic, have etch had  a
transitory reputation ;  but if any  of the metallic
tonics merit confidence, it is the nitrate of silver,
which operates by diminishing  the susceptibility
to those impressions that produce irregular action.
  In  asthma, at least in one form  of it, antispas-
modics have  been found highly beneficial.  Assa-
foetida among  the direct, and  opium  and stra-
monium among the indirect antispasmodics, have
been  found capable of  accomplishing every thing
to be  expected from this order of remedies in that
affection. It is singular that in this country opium
should  not have been  smoked,  in the manner  in
which the Chinese employ it,  for the relief of
spasmodic asthma; as  the  same circumstances
which  render  stramonium  serviceable  when
smoked are likely to render opium still more so ;
and the experiment is worthy of being  tried.  In
hooping-cough,  the direct antispasmodics have
been  little employed;  but some  of the indirect,
for  example,  belladonna and conium, are much  to
be relied upon.  Our experience in the use of the
extract of belladonna enables us to offer the fol-
lowing  directions for its administration.  Sup-
posing a child of five years of age to  be  the ob-
ject of hooping-cough,— after  administering an
emetic and purgative, a pill containing one-tenth
of a grain of extract of  belladonna may be given
every fifth hour; and the dose  gradually increas-
ed, until the  sight be affected, and a scarlet efflo-
rescence  closely resembling the  eruption of scar-
latina appears on  the  skin.   Whilst  this state
continues, the cough is often suspended ;  and by
maintaining  it for some time,  both the violence
of the paroxysms is abated, and the continuance
of  the  disease greatly  shortened.   The  adjunct
which we have found most beneficial is the hydro-
cyanic  acid,  in doses of one minim, administered
in  any convenient vehicle ; but it should be gen-
erally known that the efficacy  of 'he  extract  is
destroyed by alkaline solutions.*
   In  colic, the benefit  to  be expected from anti-
spasmodics depends much upon the exciting causes
of the attack.  In simple constriction of the in-
testines,  narcotics will  answer every  indication
intended  to  be  fulfilled ; but when flatulence  i.v
  * A fact ascertained by Frofessor  Runge.  Ann  di
 Chimie, tom. xxvii. p. 32. 
126
AORTA,  (ANEU
the exciting cause of the spasmodic constriction,
assafcetida  and the direct antispasmodics will be
found serviceable ;  and, when  there is constipa-
tion, calomel and  aperients must be joined to the
antispasmodics.    Opium,  in  such  cases,  tends
rather to augment than to impede the operation
of purgatives, although the extract of hyoscyamus
is  frequently preferred.
   In no disease  have antispasmodics  more  satis-
fied the anticipations of the practitioner than  in
hysteria.   [It is the only disease, in which, at the
present day, direct antispasmodics are much used.]
In this affection the convulsions  are of the most
severe  description.  During the  paroxysm, the
direct antispasmodics, especially assafcetida and
valerian, have been found very useful, when pre-
scribed  in  sufficient doses, which is  rarely the
case; for,  as we have already said, little benefit
can be expected unless the doses  be much larger
than those  usually prescribed.  During the inter-
vals, the metallic  tonics should  be chiefly  relied
upon as antispasmodics ; and, indeed, it is  only
by endeavouring to correct the morbid susceptibi-
lity existing in  these cases that any  permanent
benefit can be expected.
   Upon the whole, the  range of the order of anti-
spasmodics is extremely circumscribed ;  at  best,
the different substances can be regarded  as  auxi-
liaries only.  Spasm is to be  regarded rather  as
the result of causes which are to be removed, than
as a circumstance for which  remedies are  to  be
directly administered.
   [It would seem, that all the  direct — and  such
only can be esteemed true  antispasmodics—must
produce their effect by virtue of the new impres-
sion which they make on  the  olfactory and gus-
tatory, or on the gastric nerves, or on  both ;  thus
deriving from the inordinate action in  some other
part of the nervous system.   All  the  direct  anti-
spasmodics aie, indeed, well  calculated to effect
this derivation.   Most of  them, as  assafcetida,
castor, Dippel's  oil, valerian, and  skunk-cabbage,
being exceedingly offensive, and at the same time
possessed  of  excitant properties.  In  ordinary
cases of spasm, not dependent upon  an excited
state of vessels,  anything, therefore, that will pro-
duce a new nervous impression may  prove anti-
spasmodic.  Narcotics do so by  blunting the
impressibility  of the nervous  system ;  nauseous
agents produce their effects upon the  olfactory or
gustatory nerves ;  and, if they be excitants at the
same time, upon the nerves of the stomach.  Cer-
tain highly nervous and imaginative  persons can
feel pains wherever they  please ; and  many  an
individual, by the perusal of cases of  disease, has
fancied himself affected with the  same sufferings
which he has seen  depicted.   If, therefore, atten-
tion can direct the nervous afflux to  a part, it  is
obviously  of great moment so  to impress fhe ner-
 vous system of the individual, that no concentra-
tion of the kind may take place towards the suf-
 fering organ ; and this may be effected by engaging
 the mind,  in light cases, on some subject of enter-
 tainment or reflection ; in  stronger cases, by im-
 pressing the totality of the  nervous system, as by
 narcotics; or by  affecting nerves at a  distance
 from those implicated, as by the direct antispas-
 modics  more  especially.  (Dunglison's General
RISM  OF  THE)

Therapeutics and Materia Medica, i. 396: Philad
1843.)]                   A  t. Thomson.

   AORTA, aneurism  of the.   The aorta, in
common with the other arteries of the body, is liable
to aneurismal disease, the  anatomical characters
of which are comprehended  under the four fol
lowing varieties : —
   1st.—Dilatation, which  is  an  enlargement of
the whole circumference of the artery.
   2d.__True aneurism,  which  is  a sacculated
dilatation of a portion only of the circumference,
or of one side of the artery.
   3d. — False  aneurism,  which is formed  by
ulceration or rupture of the internal  and middle
coats, and  expansion of the  external or  cellular
into a sac.   It is called primitive, when all the
coats are directly divided,  as  by a wound ; and
consecutive, when  it is  consequent on ulceration
or rupture of the internal and middle coats.
   4th. — Mixed aneurism, which is  a superven-
tion of false upon  true aneurism, or  upon dilata-
tion ; that is, after dilatation, either partial or gen-
eral, of all the three coats, the internal and middle
burst, and the external alone expands into a fur-
ther  sac, surmounting the original  dilatation or
true aneurism.
   Formation  and  anatomical  characters
      of  the several species of aneurism.
   1st.  Dilatation, or  enlargement of the
whole circumference of the Aorta.—When
the coats of the aorta, whether from inflammation
or from any other morbid  action, have  become
diseased, they lose their elasticity, a quality which
resides principally in the middle tunic.  As  fluids
press equally  in every  direction,  the blood  pro-
pelled by each contraction of the heart into the
aorta, exerts not only a longitudinal,  but a lateral
force, which  expands the vessel,  and constantly
tends to enlarge its caliber.   The elasticity of the
arterial walls enables the vessel to resist this ex-
pansive force, and to regain  its  previous caliber
after the diastole.  Consequently, when the elas-
ticity is impaired  or lost, the vessel, not  being
able  to regain its original  dimensions after each
 diastole, becomes  permanently dilated ;  and this
 takes place to a  greater or less extent, and with
 greater or  less promptitude, in direct proportion
 to the predominance of the distending  over the
 resisting force.
   It very rarely happens that a dilated aorta docs
 not present, in its interior,  some of the morbid
 changes  already  described,  (see  Arteritis) ;
 namely, cartilaginous, steatomatous, atheromat-
 ous,  or calcareous depositions, with  a thickened,
 wrinkled,  and  fragile  state of the internal  coat.
 When  such depositions  are  not apparent, the
 walls, according to our observations, are always
 more or less indurated, opaque, and inelastic ; and
 are sometimes extenuated, particularly the middle
 coat,  and  sometimes thickened,  with a  softened
 and easily  separable state of the internal coat:  a
 condition of parts which is a much more natural
 cause of dilatation than paralysis of the middle
 coat, supposed by some authors  to  be  its cause
 when no depositions were manifest.
   The  ascending portion, and  arch of the aorta,
 particularly the latter, are by far the most frequent 
                         AORTA,  (ANEU

seats  of dilatation ;  but the descending portion,
both  in  the chest  and  abdomen, is  sometimes
affected, and the dilatation is then  either uniform
throughout  the  whole  length  of the vessel, or it
consists of one or even a series  of ovoid or fusi-
form  expansions.   The side  of  the artery adhe-
rent to  the  spine, and the lesser curvature of the
arch, yield less readily than  the other parts. Dila-
tation of  the aorta does  not,  in general,  exceed
twice the natural  caliber of the vessel, but we
have occasionally seen it attain three, or even four
times that size.   When such  is the  case, it fre-
quently presents many minor bulgings or pouches,
which give it a  considerable  resemblance to the
transverse arch of the colon.   The walls of these
pouches are often extenuated and semi-transparent
from  horn-like  and calcareous depositions, and it
is here more especially that mixed aneurism  is
apt to take place ;  for the brittleness of deposi-
tions  causes rupture of the interna]  and middle
coats, and the engraftment of false  aneurism upon
the true.
   Dilatation of the pulmonary artery is extremely
rare.   We have met with one remarkable case  in
which it was enlarged to four  inches  and a half
in circumference.  Dilatations, even though pouch-
ed, scarcely ever contain laminated coagula;  for
the surface is, in general, too smooth to arrest the
blood.  When they do take place, it is in conse-
quence  of an ulcerated or fissured  state of the
internal  membrane, which forms  nuclei  for the
adhesion  of fibrine.*  The coagula thus formed
occasionally fill  up the  whole  of the dilated por-
tion,  and  leave  the canal of the artery of its
natural caliber.
   The great arterial trunks rising  at right angles
from the aorta, as the innominata and cceliac, gen-
erally participate in the dilatation :  the  left subcla-
vian  almost always remains  exempt;  without
doubt, says  Laennec, on account of the acute an-
gle at which it  branches  off.  Dilatation takes
place not only  in  the aorta  and  its  immediate
trunks, but sometimes in smaller and more remote
arteries, as,  for example, the carotid by the side of
the sella turcica, the temporal -f and   emulgentj
with their ramifications, the arteries of the extre-
mities, and those feeding tumours of any descrip-
tion, particularly fungus haematodes and the hae-
morrhagic na?vus or aneurism  by anastomosis  of
John  Bell.
   2d.  True Aneurism, or lateral  partial
dilatation of the Aorta.—True aneurism dif-
fers from dilatation in the circumstances, that it is
an enlargement of a  limited portion  only of the
circumference of  the aorta ; that it generally rises
with an abrupt margin ;  and that its  neck is,  in
most  cases,  narrower than  the body  of the  sac.
Its formation is to be attributed to a loss of elasti-
city, and,  consequently, of resistance, in the par-
ticular part only that dilates ; and the proofs of its
existence  consist in  the possibility of  tracing the
internal and middle coats of the artery throughout
the whole extent  of the expansion, and  in the
presence within the  sac  of  those morbid appear-
  * Burns, on Diseases of the Heart, p. 206.  Bertin and
Bouittaud.  Casexxxvi.
  f Cruvrilhier Essai  sur l'Anat. Patholog. Pans, 1815,
t. ii. p. till.
  I Journal de Medecine par MM. Corvisart, Leroux, et
Boyer, torn. vii. p. '255.
RISM  OF  THE)                     127

ances which are peculiar to the  internal coats  of
arteries,  such  as calcareous,  cartilaginous, and
atheromatous depositions, with slight fissures, and
small red spots.  These proofs have, of late years,
been so frequently verified by dissection, that the
reality of aneurism by dilatation of all the coats
of an artery is no longer problematical.   Almost
all the  aneurisms of the  ascending portion and
arch are originally  of the  true  species,  but the
false  is sometimes  engrafted upon  them.  The
tumour generally springs from the  anterior or the
lateral part of the vessel,  while the posterior part
is little, if at all implicated : it sometimes attains
the magnitude of a mature foetal heart,§ and gen-
erally  inclines  to the  right side  of  the chest.
When it springs from the root of the aorta, and
the middle and  internal  coats  happen to burst,
there results, not a false aneurism surrounding the
true, as in other parts, but  a fatal extravasation
into the pericardium.  The reason  of this is, that
the part of the aorta referred to is destitute of the
cellular tunic, and the pericardium  which supplies
its place, not being  equally  extensible, bursts,  ra-
ther than dilates into a  false  aneurism.  In the
same way the deficiency of the cellular coat in the
arteries of the brain causes their rupture to be fol-
lowed by an apoplectic extravasation,  instead  of
by the formation  of an  aneurismal  sac.   It has
been stated by a recent writer  that a preparation
in Mr. Hunter's collection subverts  the  doctrine
that false aneurism does  not form  at the  root  of
the aorta.  The preparation of which  he  speaks,
however, is  not one  of false aneurism, as the mid-
dle coat  is perfect, the internal  one alone being
diseased, or removed,  (it  is doubtful  which,)  at
the base of the  sac.  It  has not  been  denied  by
authors that true aneurism may  form at  the root
of the aorta.  We have ourselves seen it in more
than one instance.   Coagula are occasionally, but
not often, found in true aneurisms ; they are usually
in masses, adherent by a peduncle, and seldom  in
layers investing the walls unless the aneurism  is
very large ;  the reason of which is, that the mouth
of the sac being  in  general spacious, the blood
has a sufficiently free ingress and egress to circu-
late with force, while the surface of the sac is  so
smooth as not to arrest the fibrine, and cause  its
deposition in layers.   But when the  circulation is
by any cause enfeebled,  the blood stagnates and
forms coagula in masses,  which become adherent
by limited portions or peduncles.   True aneurism
is much more rare  than  either false aneurism  or
dilatation.
  3d.  False Aneurism, or Aneurism hy ul-
ceration of the internal or middle  Coats.
__Nichols proved, by experiments made before the
Royal Society of London, that, when the internal
and  middle coats of an artery  are  divided, and
water or air is forced into the vessel, the  external
coat distends so as  to form  a small  sac, (Philos.
Trans, vol. xxxv. p. 443.)  In the  same  manner,
when the internal and middle coats are perforated
by ulceration or a fissure, the blood, by its  lateral
pressure, gradually raises  the  external coat, and
expands it  into  a sac, which communicates with
the interior of the artery, whose  caliber is  not en-

 § Corvisart. Journal de Medecine, par MM. Corvisart
Leroux, et Boyer, t. vii. p.  355. Laennec. <Je I'AvsruK
t. ii. p. 091. 
RISM  OF  THE)
128                    AORTA,  (ANEU1

larged, by a narrow aperture or neck.  As the dis-
tension proceeds, the external coat itself gives way,
and the sheath of the vessel next opposes the effu-
sion of blood ; finally, when this also  yields, the
contiguous parts, whatever be  their texture, con-
tribute to the formation  of the sac, they having
previously  undergone thickening and  agglutina-
tion by chronic  adhesive inflammation, to  which
distension had given  rise.  Such is the manner
in which the sac is formed in aneurism from ulce-
ration of the arterial coats.  It  presents no vestige
of the middle or fibrous coat, nor the depositions
connected  with  the internal membrane ;  but its
inner  surface is  extremely rugged  and unequal
from lymph irregularly deposited by  inflammation.
To this rugged surface adhere  the layers of fibrine
subsequently deposited by the  blood.
   Perforation of  the internal  and middle coats is
not always followed by aneurism of the kind de-
scribed.  Laennec met with a case  in which the
internal and middle coat  had  been  divided by a
narrow  transverse  fissure  extending  over two-
thirds of the circumference of  the artery ; and the
blood, instead of  distending the external coat into
a sac,  had  insinuated itself between it and the
fibrous, and dissected  them from each  other  over
upwards  of half the circumference  of the  artery,
from the  arch of the aorta to  the common iliacs,
(De 1'Auscult. torn. ii. p.  700.)   Fissures  of the
kind described result from cracks  or  lacerations
occasioned by calcareous depositions ; but the case
of Laennec, and two similar cases mentioned by
Mr. Guthrie, (Guthrie on  the Diseases of Arte-
ries, p. 40 and p. 43,) are the only instances  within
our knowledge in which a fissure has been follow-
ed by more than a circumscribed effusion of blood
around it, occasioning a slight swelling  of the
external coat.  Nichols found  this in the body of
George II.,  (Philos. Trans, vol.  lii. p. 269 ;)  and
Hodgson once met with it, (On Diseases of Arte-
ries, p. 63.)
   The late Mr.  Shekelton has  described,  in the
Dublin Hospital Reports,  vol.  iii.,  another  and
previously unnoticed kind of  aneurism ; namely,
the blood  had forced its way through the internal
and middle coats, dissected  the  middle from the
external or cellular  for the space of four inches,
and then  burst again  through  the  internal  and
middle coats into the canal of  the  artery  ; thus
forming  a new channel, which  eventually  super-
seded the old one ;  the latter having become oblit-
erated by  the pressure of the tumour.
   [The term Dissecting Aneurism was given
by Laennec to this form.  Many such cases are
now on  record.   Dr.  Pennock  (Amer. edit, of
Hope on Diseases of the Heart, p. 40S, Philad.
1842,) refers to  four  that have occurred in the
observation of American pathologists. In all these,
the lesion was identical; — the  separation  of the
laminae of the middle coat, by  blood driven  by the
propulsive force of the heart through a rent caused
by a laceration of the  serous  coat,  and a  partial
.upture of the layers  of the middle  coat.  From
the examination  of  these pathological specimens,
and from the fact that the attachment of the ex-
ternal fibres of the middle coat to the  cellular  is
much firmer than that of the layers  of the middle
coat between themselves, Dr. Pennock is induced
N\ believe that dissecting aneurism, when it occurs
to any extent, will be found to be  between the
laminic of the middle coat, and not between the
middle  and the outer coats  of the  artery.  An
excellent paper  by Mr. Peacock on this form of
aneurism is contained in the Edinburgh Medical
and Surgical Journal for  Oct.  1843.)]
  The causes of perforation  of the internal  and
middle coats, and the formation of false aneurism,
arej—i. ulceration, generally  occasioned  by the
detachment of calcareous incrustations, by athero-
matous depositions under the internal membrane,
and, more rarely, by tubercles, or small  abscesses
in the substance of the fibrous tunic :  2. rupture,
or cracking, which takes place when the tunics
have  been deprived of their  elasticity by cartila-
ginous, steatomatous, fungous, and calcareous de-
generation.*   The immediate or exciting cause of
the rupture is generally some violent  exertion oi
accident; and  in  most  instances patients  with
aneurism  date  it  from some occurrence  of this
kind.  Rupture does not appear ever to take place
in a perfectly sound artery  ; and if it did, the ex-
periments of Dr. Jones prove that it would not be
followed by an aneurism, as an  effusion of lymph
takes place, which strengthens the vessel in the
lacerated part, (Jones on Hemorrhage, p. 125.)
  While  aneurism of the ascending  aorta and
arch  are, in the first  instance, almost invariably
true,  though  they  occasionally become  mixed,
those of the descending aorta are  generally false;
and the caliber of  the artery is, with  few excep-
tions, not in the slightest degree dilated  opposite
to the tumour.  Aneurism by perforation of the
internal and middle tunics  is  the only species of
which Scarpa admits the reality ; but the inaccu-
racy of his  opinions  has been  fully proved, and,
as before stated, there is no longer any question
respecting  the  actual existence of aneurism by
dilatation of all the coats. The cases of false aneu-
rism that are on record are very numerous.   Re-
ference may be made to  the works  of Lancisi,
Morgagni, Guattoni,  Scarpa, Desault,  Warner,
Hodgson,  Home,  Laennec,  Bertin, and Bouil-
laud.
  4.  Mixed Aneurism, or false Aneurism
surmounting true.—This species is formed in
the following manner.  All the three tunics of
the artery first undergo an expansion, which, ac-
cording to its form, constitutes either a dilatation
or a  true aneurism : as  the expansion  proceeds,
the internal and middle tunics burst, and  the ex-
ternal, being more extensible, dilates into a sac,
surmounting the original enlargement.  Aneurisms
of this description are very numerous.   Whether
the cyst succeeding a perforation  of the  arterial
walls has been preceded or not by their dilatation ;
in other words, whether  the aneurism is true or
mixed, it communicates with the cavity of the aorta
by an aperture more contracted than its body, and
circumscribed by a prominent border, correspond-
ing with a kind of strangulation.   This disposi-
tion of parts has been perfectly described by Scar-
pa,  and admirably represented in his plates.
  General observations  on aneurisms of
     the aorta.
  Haller and MM. Dubois  and Dupuytren  have
remarked  a  variety of aneurism,  in which the
  * Scarpa on Aneurism, § 20, 21, 22. Laennec de I'Aus-
cult. loin. ii. p. 704.   Hodgson, p. 62. 
AORTA,  (ANEU
RISM  OF  THE)                     129
internal membrane makes  a hernia  through the
ruptured fibrous coat, and lines  the  sac, which is
formed by the external  or  cellular coat.  Hernia
of the internal  membrane  may occur, according
to Laennec, in very small aneurisms : he had seen
it in two, which were not  larger than  cherries;
but when the tumour increases, the internal mem-
brane  speedily bursts.   This he  found  to  have
been the case in two  other aneurisms which did
not exceed the size of walnuts, (De l'Auscult. torn.
ii. p. 693.)  The  experiments  of Mr.  Hunter,
Scarpa, and Sir E. Home  prove, that  when the
external and middle coats of an artery are remov-
ed, the internal one does not dilate into an  aneu-
rism, but either bursts, or is strengthened by gra-
nulations arising from its surface, and by adhesions
formed with the surrounding parts.
   Corvisart having  found  several firm, solid tu-
mours, of the size of nuts,  intimately adherent to
the aorta, while the external and middle coats ap-
peared  to be deficient at the point of attachment,
was led to imagine that extraneous tumours, for
such he conceived them to be, becoming  adherent
to arteries, led to the formation of aneurism,  (Essai
sur les Maladies du Cceur, p. 313.)   Hodgson, on
the contrary, regards the tumours in  question as
instances of aneurism cured, the sac having been
filled up by lamellatcd  coagula, (On Diseases of
Arteries, p. 127,) and the volume of the tumour
diminished by absorption ;  and Laennec, Bertin,
and the best authorities subscribe  to his opinion.
   As an aneurismal sac enlarges, the surrounding
 parts become involved in its composition.  Thus
 the  bones, muscles, and various other  structures,
often  contribute to  its  formation.  The viscera,
 also, become implicated when the tumour is situ-
 ated in their vicinity ;  and the membranes with
 which they are invested being distended to their
 utmost, finally yield, and the sac bursts into their
 cavities.  Accordingly, aneurisms  frequently prove
 fatal by discharging their contents into the lungs,
 oesophagus, stomach, intestines, bladder, &c. The
 size which the tumour  attains  depends  upon the
 nature of the surrounding parts, and is very much
 determined by  their extensibility — a  property
 which is almost in direct, proportion to the  quan-
 tity of cellular tissue of whicb they are composed.
 Hence it is that, when the disease  is situated at
 the root of the aorta, where the pericardium sup-
 plies the place of the more extensible cellular coat
 of the vessel, the sac bursts into  the pericardium
 before it has attained any great magnitude. Hence,
also, it is that, in the cranium, where the arteries
are destitute of the cellular coat, and are ill support-
ed by the pia mater  and the soft  pulpy substance
of the brain, aneurism is extremely rare ; for such
a lesion of the coats of the arteries as would else-
where give rise  to aneurism, is here attended with
rupture and apoplectic effusion.   It has  been al-
ready stated, however,  that the  arteries  of the
brain are not insusceptible of dilatation.
   One of the first circumstances that almost inva-
variably follows the formation of true aneurism is,
the deposition of the fibrine of the blood upon the
internal surface of the sac.  This deposition takes
place in successive concentric layers, which have
a different aspect according to  the date of their
formation.  The most  central  consist simply of
blood more or less firmly coagulated, and  they are
   Vol. I___17
probably formed subsequent to death ; a little far-
ther the coagulum is  drier,  paler, and  evidently
composed of a large  proportion  of  fibrine :  still
farther are layers of pure, whitish, yellowish,  or
greyish fibrine; and, finally, in contact with the
walls of the cyst, are layers of the same matter,
but completely opaque, of a somewhat friable con-
sistence, like  dryish paste, and  very closely  re-
sembling flesh which has  been deprived of  its
colour by boiling.  The most recent layers adhere
to each other so slightly as almost to float within
the sac; those beneath are united by a flossy  or
nappy cellular tissue, the adhesion being stronger
in proportion as the layers are older.  Patches  of
vivid red, formed by reticulated blood-vessels, are
occasionally found in the fibrine, and blood often
penetrates between  its layers, and stains those
which are friable, or decomposed.   Coagula  are
softer  in  some cases than in others, though  the
physical circumstances be the same in both. The
difference is probably owing to a difference in the
chemical qualities of the blood.   From these ana-
tomical  characters it is evident that lamellated
coagula form by the successive depositions of the
fibrine of the blood ;  and the depositions are ac-
counted for by the stagnation of  the blood within
the sac ; for it is proved, by experiment  and ob-
servation, that coagulation of this liquid takes place
whenever its  course is interrupted;  hence the
polypi that are found in the heart, the great veins,
and the  arteries,  when the circulation through
those  parts is obstructed.  The coagulation  of
blood within a false aneurism is favoured by two
circumstances, the narrowness of the aperture  of
communication with  the  artery,  and the  rugged-
ness of the interior of the sac.  In true aneurism,
as has already been  stated, the width of the aper-
ture of communication, and the smoothness of
the interior of the  sac  are unfavourable to  the
coagulation, and accordingly fibrinous layers are
very seldom found in those aneurisms, unless they
are of great size, although they often contain co-
agula in masses attached  at one part  only by a
peduncle of greater or less thickness.   The thick-
ness of fibrinous depositions within aneurisms is
sometimes very great.   Most commonly it is from
half an inch to an inch and a half, but we have
seen it exceed three inches : it is  generally greater
on one  side of the  sac  than another.   Laennec
has  seen fibrinous  coagula as  compact  and  dia-
phanous  as horn softened  to the utmost by heat,
and of a thickness exceeding five inches' breadth.
   Aneurisms, and  the diseases  of  the  coats  of
arteries which  precede their  formation, are much
more frequent in men than in women.   Of sixty-
three cases seen by Hodgson, fifty-six occurred  in
the former, and only  seven in the  latter.  (On
Diseases of Arteries, p. 87.)  We have found the
proportion rather larger in females  with respect
to aneurism of the  aorta, but with  respect to ex-
ternal aneurism it is much smaller, perhaps not
exceeding one in fifteen to twenty.
   [In the winter of 1843-4, Dr. Dunglison had an
opportunity of exhibiting to  the  clinical class of
the Philadelphia Hospital the morbid appearances
presented in three cases of internal aneurism .-
two of the aorta, and one of the  internal fliacs—
which occurred  in the  wards under his  charge
The subjects were all females.] 
130
AORTA,  (ANEl
  Effects of aneurisms of thj; aorta on the
     contiguous parts,
  The effect of aneurisms of the aorta on the con-
tiguous parts vary according to the volume, the
form, and the position of the tumour.  Dilatation,
when not very  considerable, produces  little de-
rangement  of the surrounding  parts;  for as the
swelling is  equable and diffuse, it does  not exert
a pressure on any one organ in particular, and its
magnitude is  not such as to create much inconve-
nience from general infarction.  The worst of its
effects are those which it produces  on the trachea
and  great bronchi;  for  though the pressure be
slight, it often suffices, in consequence of the great
irritability of these parts, to occasion considerable
dyspnoea.  It must not, however, be imagined that
dilatation is  an  unimportant affection :  it  will
hereafter be shown  that, when complicated with
enlargement of the heart, which it generally brings
on, it is one of the  most formidable diseases inci-
dent to  the circulatory apparatus.
   An  aneurism which  forms a defined tumour,
whether it  be of the true or the false species, and
whether it be  large or small,  may produce the
most pernicious effects.   These are,—
   1st. Such  as result  from  compression of the
neighbouring parts.
   2d. Such as  result from their destruction.
   1st.  By compression,  the functions of the lungs,
bronchi, heart, and  oesophagus, are  deranged, and
that sometimes  to a fatal extent.   In the abdo-
men the functional  derangements  are  compara-
tively inconsiderable, and  very rarely  endanger
life.   The  reason of this is twofold,—first,  that
the abdominal organs are not of so vital a nature
as the thoracic;  and secondly, that the tumour,
instead  of being pent up in a rigid bony case like
the chest, is permitted, by the yielding of the in-
testines, and the distensibility of  the abdominal
parietes, to expand freely in almost every direc-
tion.  Pressure on any particular organ, therefore,
is in a great measure  obviated by the  want of
counter-pressure—of a fulcrum. Ventral aneurism,
however,  sometimes deranges the  respiration by
preventing the due descent of the  diaphragm ; an
effect which may proceed either from  the magni-
tude alone of the tumour, or, what  is much more
common, from its being seated near or in the  sub-
stance of the muscle, and impeding its  motions.
Ventral aneurism is  also occasionally  character-
terized by involuntary evacuation of tbe urine and
faeces, by remarkable  alternations of constipation
and diarrhoea,  and  by  deep-seated excruciating
pains, resembling those  of lumbar abscess.  These
symptoms  arise  from compression  of the nerves,
particularly the  hypogastric plexus  around the
aorta.
   2d.  The consequences of destruction of conti-
guous  parts  are far more formidable  than  those
resulting from compression.  When the tumour
exerts an unusual pressure on  any organ or tex-
ture, adhesive inflammation takes place and unites
the  paits in contact.  As the pressure increases,
absorption and ultimately perforation of the sac
ensue,  and death from internal hemorrhage is the
immediate consequence.  The perforation  takes
 place  either by sloughing,  or  by  laceration, ac-
 cording to the  nature of the  membrane or texture
 perforated.   Thus, when the tumour advances to
RISM  OF  THE)

 the  skin, or when  it extends into a cavity  lined
 by a mucous membrane, it bursts  by the separa-
 tion of a slough which has formed upon its most
 distended parts, and not by laceration.  On the
 contrary, when  the sac projects into a cavity lined
 by a serous  membrane, sloughing of the mem-
 brane does  not take place, but the parietes of the
 tumour, having become extremely thin in conse-
 quence of  distension, at length  burst by a  crack
 or fissure, through which the blood is discharged.
 An  aneurism may  burst into a great variety of
 parts, which we shall notice in succession.
   When the  lungs are in contact  with the tu-
 mour, adhesion, absorption of the sac, and rupture
 of the  pleura take place, and  the effused  blood
 deluges the bronchi and  causes suffocation.  It
 often happens that an aneurism of the ascending
 aorta, or arch, compressing the  trachea, or one of
 the  great bronchial trunks,  opens  its way into it
 by ulceration of the cartilaginous rings and slough-
 ing of the mucous membrane, and causes suddenly
 fatal haemoptysis.   More rarely, perforation  takes
 place into  the oesophagus, and death then ensues
 from hacmatemesis. Aneurisms occasionally  burst
 at the origin  of the  aorta,  and  cause death by
 effusion of blood into the pericardium. The fatal
 event, however, is not always so sudden  as in the
 preceding cases ;  a circumstance which  Laennec
 attributes to the pericardium being supported, and
 the  effusion, consequently,  restrained, by the ge-
 neral  infarction of the chest, occasioned by the
 presence of the tumour.  This reason appears to
 us unsatisfactory,  because,  as  before explained,
 aneurisms  at the  root of the aorta generally  burst
 before  they attain  any  considerable  magnitude:
 nor, if large, would the resistance offered by the
 atmospheric pressure in the lungs, equal  the force
 with which the blood  tends to  escape  into the
 pericardium — a  force  equal to  the propulsive
 power  of the  left ventricle.   It  is, perhaps, more
 probable that the inextensibility of the pericardium
 beyond a certain point, and the resistance of the
 heart  to compression, form the  principal powers
 which limit the effusion of blood.  It would ap-
 pear that life is sometimes  protracted for a consi-
 derable period after the  rupture of the sac ;  for in
 specimens  presented to  the  Societe de la Faculte
 de  Medecine  by M. Marjolin, the  margins of the
 aperture, according to Laennec, were polished, as
 if of old  standing,  and,   as it  were,  fistulous.
 (Laennec,  Opt. Cit. ii. p. 715.)  Rupture into
 the pericardium is very  rare.  Laennec never met
 with an instance.   Tbe first that has fallen  under
 our own  observation  occurred  recently at  St.
 George's Hospital.  Morgagni (Epist. xxvi. Nos.
 7, 17,  21)  and Scarpa, (On aneurism, § xix. p.
 103, et sequent,)  however, have collected together
 a considerable  number  of these cases, and Hodg-
 son saw two, in  which the aneurism, beginning
 half an inch above the semilunar valves, occupied
 the whole  ascending aorta and arch.
    Aneurisms have been known, but very rarely,
 to burst into the  pulmonary artery.   M.M. Payen
 and Zeink  saw an instance, (Bulletin de la Fa-
 culte de Medecine, 1819, No. 3,) and Dr.  Wells
 another.*   Professor Monro, tertius, showed us a
 preparation  of an  aneurismal  pouch  springing
   * Trans,  of a Society for the Improvement of Med
 Chirurg. Knowledge, vol. iii. u fc5. 
AORTA, (ANEU
R ISM  OF  THE)                      131
from  the  aorta, directly  against the  pulmonary
artery ; and it is probable that, if the patient's life
had been  prolonged, ruptrwe would  have taken
place  into the artery.   The  left  cavity of  the
pleura and the posterior mediastinum are the parts
into  which  thoracic  aneurisms most  frequently
burst  It is extremely seldom, on  the contrary,
that they open into the right pleura. Laennec has
seen an aneurism of the descending aorta, which
had compressed  and  destroyed the thoracic duct,
and produced  engorgement of all the lacteal ves-
sels.   Aneurisms  sometimes  compress the  de-
scending  vena cava, and cause cerebral conges-
tion,  oedematous  intumescence of  the  face, and
even  apoplexy.   We have met with several in-
stances of this kind.  Corvisart,* and Bertin and
Bouillaud, (Traite des Maladies du Occur, p.  137,)
each cite a case of apoplexy thus occasioned.
   Another effect of aneurisms is to obliterate ar-
teries springing from or contiguous  to them.  We
have  met  with two cases  in which both the left
carotid and  subclavian were plugged up  at their
origin from  the tumour.  The obliteration is some-
times effected, not by a plug of lymph, but by
contortion or compression  of  the  vessel.   Mere
contraction  of the origin  of arteries from  these
causes is  very common.   Ventral aneurisms may
open  their  way into the various abdominal  vis-
cera,  as the  intestines, the  bladder,  &c.
   Aneurisms not only cause destruction of the soft
parts, but, what is still  more remarkable, erosion
of the bones. This phenomenon has been variously
explained.   The   old   pathologists  erroneously
ascribed  it  to a  chemical  solvent  power of the
blood.  Hunter, Scarpa, and  Hodgson, thought
that it resulted from absorption of the earthy mat-
ter, in consequence  of  the  pressure of the  sac.
Corvisart  and Laennec attribute it to a sort of de-
trition or wearing down, produced by a purely
mechanical  action.  Bertin and Bouillaud believe
that it is more or.less dependent on inflammation.
To us it  appears that absorption and  mechanical
detrition  are the  principal agents  concerned in
producing the effect.  That pressure is capable of
exciting absorption of bone is  certain, as the  ver-
tebrae have been found excavated by an aneurismal
tumour, without being divested of  their perioste-
um (Hodgson, p.  79.) ;  and there can scarcely be
a doubt, that, when a denuded bone is exposed to
the constant dashing of  a column of blood,  it un-
dergoes disintegration by the mechanical detach-
ment of its particles.  Whether inflammation ever
contributes  to the  effect, is difficult positively to
determine.  Appearances, however, are adverse to
this opinion, as pus has never been  found on bone
eroded by an aneurism  ;  as  exfoliation scarcely
ever takes place ;  and as nothing is discovered on
it analogous to the cicatrization or irregular repro-
duction which is observable in other bones  when
affected with caries.  Cartilage, whether exposed
to the action of the  blood  in  aneurismal  sacs, or
to the pressure alone of the tumour,  either remains
entirely uninjured, or suffers  incomparably  less
than bone.  This  is  most manifest in the inter-
vertebral substance, and the cartilages of the false
ribs.  The  circumstance is attributable  to  the
elasticity of cartilage, which protects it from me-
  * Journal de Medecine, par MM. Corvisart, Leroux,
et Boyer, torn. xii. p. 159.
chanical disintegration, and to its almost inorganic
structure,  which renders it little susceptible of ab-
sorption or ulceration.   The bones  liable  from
their position  to  be eroded by aneurism, are the
vertebra, the sternum, the ribs, and sometimes the
ossa ilii.
  It is principally by aneurisms of the descending
aorta  that  the vertebrae  are  injured.  In  these
cases the  portion of the sac in  contact with the
vertebrae is entirely destroyed,  and  its borders
adhere very firmly around the eroded  part of the
bone,  on which the blood plays freely  in conse-
quence  of the fibrinous layers having  been ab-
sorbed at that  part.  The destruction is sometimes
so deep that the shell of  the vertebrae  forms the
only partition  between  the  sac  and  the  spinal
canal.   Very rarely, however, does rupture take
place  into the canal.   We  are  not  aware  that
there are more than two instances  on  record, one
by Laennec in the Revue Medicale for 1835, and
another of which the preparation, by Mr.  Chandler,
is in the Hunterian Museum.
  Ventral aneurisms seldom produce erosion of
the bones;  because the abdominal  viscera  and
walls yield to  the tumour.
  It is by aneurisms of the ascending  aorta that
the sternum and ribs are eroded, and  the tumour
generally presents on the right side.  Aneurisms
of the  arch and the innominata project at the
upper part of the sternum, and about the clavicles,
which they have  been known to dislocate at their
sternal  extremities.  When  the  tumour is con-
nected with the posterior part of the arch, it shows
itself underneath the left clavicle.   According  to
Hodgson, when the periosteum contributes to the
formation of the sac, its vessels continue to secrete
an  earthy  matter, which,  in some instances, has
been deposited to such an extent as to  form a
considerable portion of the tumour.
  Small aneurisms have  the effect of destroying
the bones in a greater degree than large ;  a cir-
cumstance attributable to the greater concentration
of the pressure exercised by them.
  Signs and  diagnosis of aneurisms of the
     AORTA.
  The  signs of aneurism  of the aorta are of two
classes.
   1. General  signs.
  2. Signs afforded by auscultation, percussion,
&c.
  These two classes of signs will first  be described
separately, and a  brief summary  then  given of the
signs  of the two classes  conjointly, which refer  to
the several forms of aneurism.
  I. General signs  of  aneurism of  the
aorta.
  When an aneurism is buried deep in  the chest.
and not capable of being detected by the sight and
touch, it does not  present a single general sign
which is peculiar to itself, and, therefore, pathog-
nomonic of its existence.   There are even cases  in
which it occasions no functional derangement—no
inconvenience whatever; and  the first circum
stance that unveils the truth is, the sudden death
of the patient  while apparently in the enjoyment
of perfect health.   We have met with  six or seven
instances  in which large aneurisms  had  existed
without awakening  even a suspicion in  the  mind
of the  medical  attendant.   One, in  particular, 
132
AORTA,  (ANEURISM  OF  THE)
eluded the penetration of a distinguished foreign
auscultator,  though he explored  the lungs with
eminent success.   We  are acquainted with only
one general  sign of aneurism of the thoracic aorta
which is unequivocal and certain, namely, a tumour
presenting externally, and offering an expansive
as well as heaving pulsation,  synchronous with
the action of the heart.   Of the remaining general
signs,  a  large class are identical with those  of
organic disease of the heart, viz.  palpitation, dys-
pnoea, cough, tendency to syncope, terrific dreams,
starting from sleep, haemoptysis, livid or otherwise
discoloured  complexion, cerebral  or hepatic con-
gestions, serous  infiltration, &c.  This  identity
arises from an identity of cause ; namely, an  ob-
stacle  to  the circulation, which depends either
upon the aneurism alone, or  conjointly  upon  it
and a disease  of the heart, to which, sooner or
later, the  aneurism almost invariably gives birth.
It is obvious, therefore,  that the signs of this class
are equivocal.  There are, however, certain other
general signs which are more characteristic :  yet
even these are  of themselves ambiguous and  un-
satisfactory  ; as they only bespeak  lesions of the
viscera, or derangement of their functions, but do
not proclaim the latent cause of tbe mischief.  But
when  they  coincide with the signs derived from
auscultation, they lose their ambiguity, and  rise
into real importance ; for the two classes of signs,
general and stethoscopic, are  a  commentary on
each other,  and reciprocally borrow a precision
and certainty of which they are individually desti-
tute.  We  shall succinctly  describe the general
signs to which we  refer, and subjoin to each the
principal sources of fallacy.   The means of detect-
ing the  latter we  shall point  out in  the final
summary.
   1. When the tumour has attained a conside-
rable magnitude, the cavity of  the  chest is preter-
naturally crowded, and the patient complains  of a
sense  of constriction, infarction, and oppression.
But these sensations are common to  almost all
diseases of the chest.
   2. The radial pulses are  sometimes dissimilar,
or one is extinct; an effect dependent on obstruc-
tion or obliteration  of the arteria  innominata, or
left subclavian.   But  the difference of  the  two
pulses at the wrist may proceed from a  variety
of causes independent of aneurism of the aorta, as,
contraction  of the origin of either subclavian from
osseous, cartilaginous, steatomatous, or other depo-
sition ; obstructions  in  the  course of the artery,
occasioned by tumours, wounds,  subclavian aneu-
rism, &c.;  an irregular subdivision of the hume-
ral, brachial, or radial  artery.  We have  known
the most ludicrous  surmises  occasioned  by  the
radial crossing to the outside at the middle of the
fore-arm, and the superficialis  volae supplying its
place at  the wrist.
   3. When the origin of either subclavian is  con-
tracted, the pulse at  the corresponding wrist  is a
little later than the ventricular  systole.   We have
not found this symptom uniformly present.   The
heart is more frequently its source than the aorta,
and we have observed it to  be most considerable
in cases of  regurgitation into the left auricle ; but
obstruction  of the aortic valves may occasion  it in
 t minor degree, particularly if this lesion is accom-
 panied with extenuation or atony of the ventricu-
lar parietes.  When the sign exists in both pulses,
the presumption is strong that its source is in the
heart.
  4. According to Corvisart, a purring  tremor —
the fremissement cataire of Laennec — is  some
times perceptible to  the hand at the middle oi
upper part of the sternum, and indicates aneurism
of the ascending aorta.   Purring tremor, above the
clavicles, is an almost constant concomitant, and
therefore a valuable sign, of dilatation of the arch ;
but, according to our experience, it is  unfrequently
and imperfectly  occasioned by sacculated aneu-
risms, especially if lined by strata of lymph.  We
have  never known  the tremor to be  occasioned
below  the clavicles  by dilatation,  unless the en-
largement was so great  as  to extend  beyond the
lateral margins of the sternum, and allow the
tremor to be  felt through the  intercostal spaces:
but we have  met with one case in which a dilata-
tion of the pulmonary  artery, though not volumi-
nous, afforded a marked tremor between the carti-
lages of the second and third ribs on the left side :
this, however, is  not  remarkable, as  the  artery
naturally lies nearly opposite to the part described.
We have never known a sacculated aneurism
create a  tremor below the clavicles,  unless the
tumour  had  eroded  the bones of the chest, and
presented externally underneath the integuments,
   But the purring tremor  may be occasioned in
any part  of  the  chest  by mucous rattles, particu-
larly those of the snoring kind, in the large bron-
chial  tubes; and we have observed that, when
derived  from this  source,  it is a very common
cause of deception, in reference both to aneurisms
of the aorta and ossifications of the heart. Purring
tremor of the pulse  is regarded as a  sign, though
it is a fallacious one, of ossification  of the aortic
valves.   From many dissections, it has appeared
to us to  be generally connected with two circum-
stances,  viz.  a powerful action of the heart, and
ruggedness,  without appreciable  obstruction, of
the aortic orifice, or interior  of the  vessel.  It,
therefore, seldom exists, unless either the action
of the heart  be accelerated, or  the left ventricle be
hypertrophous.
   5.  When  the  trachea,  or  primary bronchial
divisions, are compressed by an aneurismal tumour,
a harsh  wheezing, or  sibilous  sound, proceeding
deep from the throat, characterizes the respiration;
the voice  is  either croaking or reduced to a whis-
per, or it is a compound of both ; the breathing is
often extremely laborious, and when  the heart is
simultaneously diseased, dyspnoea sometimes oc-
curs in paroxysms of the most suffocating severity.
 When the oesophagus is compressed, deglutition
of solids is  rendered difficult, and sometimes im-
 practicable ;  for the descent of the morsel excites
an excruciating pain  from the summit  of the
sternum  to  the  spine,  or  lancinating deeply  in
every  direction  through the chest.
   But compression  of the  trachea, or oesophagus,
with the  above symptoms, may be occasioned  by
tumours  of  any description.   Wheezing respira-
tion may proceed from  an  accumulation of gluti-
nous mucus in the great  branches.   We  have
likewise known it produced in an extreme degree
by laryngitis with  thickening  of the soft  parts
covering the arytenoid cartilages,  and  also  by
ossification  and ulceration of the  larynx  from 
AORlA,  (ANEURISM  OF  THE)                      133
strumous, syphilitic, and mercurial disease.  So
difficult is it to distinguish the seat of wheezing
respiration, that it has in many  instances been
imputed to an affection of the larynx, when it was
in reality  occasioned   by an  aneurism of  the
aorta;  and bronchotomy has several times been
actually performed with the view  of obviating
suffocation.
   6. \\ lion the vertebrae are eroded, the patient
suffers an intense terebrating pain in the spine ;
and when the brachial plexus of nerves is com-
pressed by the  tumour, an  aching sensation per-
vades  the left  shoulder, neck, scapula, and arm,
with numbness, formication,  and impaired motive
power of the limb.  But I have met with cases in
which  nearly  similar  pains were  experienced,
although  there was no  destruction of the  verte-
brae : and  it is common to hear individuals affected
with rheumatism or spinal diseases make the same
complaints.   The  affection  of the  arm  may be
occasioned by various  forms  of organic disease of
the heart, and it  thus constitutes  a  part of that
concatenation of symptoms which are denominated
angina pectoris.  We have likewise often met with
it in hysterical females subject to palpitation, and
occasionally in cases of pericarditis.  In all these
cases the  pain probably originates in  irritation of
the cardiac plexus of the sympathetic, propagated
to the brachial plexus.
   7.  When, in consequence of an adhesion be-
tween the aneurismal sac and the pleura, the blood
plays upon the lungs,  a sense of ebullition is  said
to be  experienced.  But  the  same  symptom is
familiar to individuals labouring under phthisis, or
chronic mucous catarrh ; and it proceeds from the
successive bursting of large bubbles,  formed by
the transmission of air through the fluid in  tuber-
culous caverns, or in the greater bronchial ramifi-
cations.
   8.  It occasionally happens that the patient suf-
fers excruciating pain  from a spasm, pursuing the
course of the  diaphragm,  and binding the chest
around,  as  with a cord.  This  symptom  is too
vague to  be important, and it also occurs in hys-
teria, gastrodynia, colic, spinal diseases, and rheu-
matism of the diaphragm.
   9.  A pulsation is  felt underneath tbe sternum,
or ribs, at the superior  part of the chest.  This,
although  one of the least equivocal signs of aneu-
rism, is not without ambiguity.   It may be occa-
sioned by a  tumour of any  description, as an en-
larged gland, or a  cancer, interposed between the
sternum and the aorta, and receiving the pulsation
of the  latter.  Even  Dr. Baillie  says, " But we
arc not to conclude from this symptom (viz., pul-
sation at  the superior part of the chest) that there
is certainly an  aneurism.  I have felt the same
kind of pulsation in other cases;  as, for instance,
where the pericardium was found  strongly to ad-
here  to  the  heart; where  there was a slight in-
flammation upon the surface of the  heart,  with a
iittle  more water than usual in the pericardium ;
and  where a morbid enlargement  had taken place
in the heart, without any aneurismal  swelling."
Every  one  much  conversant with disease must
have made the same observations.
   10.  A  pulsation is  felt  above  the sternum or
clavicles.  But this  may  be occasioned, 1st. by
enlarged  glands or other tumours seated on the
                                         31
subclavian artery, and receiving its pulsation ; 2d.
by varix of the jugular vein  at its junction with
the subclavian ;  both  of  which conditions have
deceived  expert  practitioners ;  3d. by subclavian
aneurism.  This affection sometimes resembles
aneurism of the  aorta  so  exactly, that it  is ex-
tremely difficult to distinguish them.  Allan Burns
records a case in which all the eminent surgeons
of the district were unanimous in pronouncing the
affection  subclavian aneurism, yet  it  proved to be
aortic.   (Surg. Anat. of Head and Neck, p. 30.)
Sir Astley Cooper has published a number of simi-
lar cases, and one is mentioned by Professor  Monro
tertius.  (Elements of Anat. vol. ii. p. 249.)  4th.
A pulsation above the sternum or clavicles may be
occasioned  by carotid aneurism.   This, also, may
readily be confounded with aneurism of the aorta,
or of the subclavian artery.   In  April, 1826, we
saw a  case at Guy's  Hospital, which led  to much
deliberation respecting the propriety of taking up
the carotid above a pulsating tumour, supposed to
be an  aneurism of that artery.  It was finally de-
cided that the tumour was too low, and the design
was judiciously abandoned.  The  affection  proved
to be a dilatation of  the aorta and arteria innomi-
nata.  The carotid  was  sound.   This  state of
parts was indicated to  us by the stethoscope.  Mr.
Hodgson met with a similar case.  (On the Dis-
eases of  Arteries, p.  90.)
   11.  The superior  and middle parts of the chest
are dull on percussion.  But this  sign is common
to an infinity of other diseases, and the resonance
is seldom  impaired  unless the aneurism  be very
large.
   It cannot be a subject  of surprise  that a series
of symptoms liable  to so many  fallacies,  should
have proved insufficient, without the aid of auscul-
tation, to dissipate the deep obscurity  involving the
diagnosis of aneurisms of the aorta.   We  have
next to consider the  second class of signs, namely,
II.  Signs of aortic  aneurism afforded by
   auscultation,  percussion, &c.
   The investigations of M. Laennec on aneurism
of the thoracic aorta, were limited and inconclu-
sive.  Accordingly,  he remarks that,  " Of  all the
severe lesions of the thoracic organs, three alone
remain without  pathognomonic signs to a practi-
tioner even  in  auscultation and percussion,—
namely,  aneurism of  the  aorta,  pericarditis, and
concretions of blood  in the heart previous to death.
   " Taking  the  part  of  auscultation  against its
immortal discoverer," we hope to  show that there
is now little difficulty in the diagnosis of the three
affections in question.   We shall  first present the
opinions of Laennec, and then offer the results ol
our own observation.
   Laennec's opinions respecting  the stethoscopic
signs  of aneurism of the aorta are as follows :—
On applying the cylinder,  in two  instances,  to
tumours presenting externally, he  found that their
pulsations  were  exactly  isochronous with  the
pulse  ; that the shock and sound  greatly exceeded
those  of the ventricles ; that the beating was dis
tinctly audible on the  back ;  and  that the auncu
lar sound could not be distinguished at all.  Foi
the  last  reason he  denominated  the  aneurismal
pulsation simple,  in contradistinction to  that of
the  heart,  which has  a double sound, in  conse-
sequence of the alternate  systole  and diastole of 
134
AORTA,  (ANEURISM  OF THE)
the ventricles.*   From these two  cases  he felt
certain that, in some instances, pectoral aneurisms
might be recognised by the simple pulsation, usu-
ally much stronger tban  that of the heart; but
he thought  that, in a larger  proportion of cases,
the sign would  be insufficient, for, as the slightest
dilatation of the heart renders its sounds audible
over the whole sternum, and even below and along
the clavicles, he imagined that, under such cir-
cumstances, the first or systole sound of that organ
would be confounded with the sound of the aneu-
rism, with which  it is synchronous; while  the
second, or diastolic sound, being audible  as far as
the tumour, would lead the auscultator to suppose
that  he there heard the beating of  the heart, and
not  that of the aneurism.   We shall presently
show that this reasoning is incorrect.   As the au-
ricular sound  is not audible over  the abdomen,
Laennec found no difficulty in recognising ventral
aneurisms by the simple pulsation.
   According to  our  experience, the  cylinder is
scarcely less capable of affording decisive  indica-
tions of pectoral than  of  ventral aneurism.   It is
unimportant whether the  pulsations be " simple "
or "double," for, though double,  they  may  be
distinguished from the beating of the heart by un-
equivocal criteria :  viz.—
   1st.  The first aneurismal sound, coinciding with
the pulse, is invariably louder than  the  healthy
ventricular sound, and generally than the most
considerable bellows-murmurs of the ventricles.
   2d. On exploring the aneurismal  sound from its
source towards the region of the heart, it is found
to decrease  progressively, until it either becomes
totally  inaudible, or is lost in the predominance of
the ventricular sound.   Now, if the  sound ema-
nated from  the  heart alone, instead of decreasing
it would increase on approximating  towards the
precordial region.
   3d. The second sound actually does sustain this
progressive  augmentation on advancing  towards
the heart; and, as its nature and rhythm are found
to be precisely similar  to  those of the ventricular
diastole heard in  the  praecordial region, it is dis-
tinctly  identified  as  the  diastolic  sound.  The
second  sound, therefore, corroborates rather than
invalidates the  evidence of aneurism afforded by
the first; for if both  sounds proceeded  from the
heart, both would, on approximating towards it or
receding from  it,  sustain the  same  progressive
changes of intensity.
   4th. Another  distinctive  characteristic of the
aneurismal  pulsation is the peculiar nature of its
sound.   It is a deep hoarse tone, of  short duration,
with an  abrupt  commencement and  termination,
and generally louder than the most  considerable
bellows-murmurs  of the  heart.  It accurately re-
sembles  the rasping of a sounding-board  heard
from a distance;  whereas the  sound occasioned
by valvular disease of  the heart has more analogy
to the  bellows-murmur, being somewhat  soft and
prolonged, with a gradual swell and fall.   It ap-
pears probable  that the  greater hoarseness  and
  * It is necessary to remind the reader that the systole
of the auricles was regarded by Laennec a< the cause of
tne second sound;  but, Recording to the experiments and
researches of the writer, the diastole of the ventricles is
the cause of that  phenomenon.  Vide Lond. Med. Oaz.
Aug. 1830, and a Treatise on the Diseases of the Heart,
nv the writer ltr31.
loudness of the aneurismal sound above than below
the clavicles, is attributable to its being reverbera-
ted throuch the chest before it arrives at the ear.
This probably is countenanced by the  following
considerations :—(a.) That, in several cases with
which we have  met,f although the sound above
the right clavicle was loud  and  hoarse, it  was
merely  a  whizzing (sifflement)  without  hoarse-
ness on the superior  part of  the  sternum, where
the dilated ascending aorta was in apposition with
the bone, and where,  consequently, the sound was
transmitted immediately to the ear.  (b.) That, in
the heart, the proximity of which organ  to the
thoracic parietes  is unfavourable  to the expansion
and reverberation of  its sounds, morbid  murmurs
are less hoarse and loud than those occasioned by
pectoral aneurisms,   (c.) That  in aneurisms of
the abdomen and extremities, where there is little
or no reverberation of sounds, there is a still less
degree of hoarseness  and loudness.
   The  abruptness of the aneurismal sound, com-
pared with the prolonged swelling character of the
ventricular murmur,  is owing to the latter being
generated by a gradual muscular contraction, while
the former is  due to  the  sudden  propulsion of a
fluid through a tube  naturally very resistant, and
rendered  still more unyielding by disease.  The
loudest aneurismal sound is that occasioned  by
dilatation, and it has more of the grating or rasp-
ing character in proportion  as the interior of the
vessel is more overspread with hard and  especially
osseous asperities.   WThen  the dilatation is con-
fined to the ascending  aorta, the  sound, impulse,
and purring tremor are stronger on the right than
on the left side of the neck ;  and the sound along
the mesial part  of the sternum—the  tract of the
ascending aorta—is superficial, and of a whizzing
or hissing character.   Old aneurisms,  the parietes
of which are thickened by fibrinous  depositions,
yield only a dull and remote  sound.   In all cases
of dilatation,  and in the majority of sacculated
aneurisms, the sound is  loudest  above the clavi-
cles, even though the impulse be stronger below.
In some cases of  the sacculated species it is louder
on the side of the neck opposite  to that where the
tumor exists.  We  have  found  this to proceed
from one or other of  two causes—first, disease of
the inner coat of the aorta  before  or  beyond the
tumor;  secondly,  the interposition  of the  sac,
thickened with fibrinous layers, between the aorta
and the super-clavicular region, in consequence of
which the source of sound,—the mouth and cavity
of the  sac,—was unusually  remote on the  side
occupied by the  tumor.
   The sound of aneurisms is, in most  instances,
audible on the back ; and when the tumor occu-
pies the descending aorta, and is extended along
the spine, it is often louder  behind than  on the
breast.   If it possesses on the  hack the  abrupt
rasping character, the evidence which it affords is
almost  positive ; for the loudest  sounds  of the
heart, when heard on the back, are so softened and
subdued by distance, as totally to lose their harsh-
ness.
   5th.  Purring tremor  is another characteristic
of the aneurismal pulsation.   It is more conside-
rable in simple dilatation than in sacculated aneu-

 l" fg29 f°r insUnce' Case 9' Lond- Med °az- Septembci 
AORTA,  (ANEURISM  OF  THE)
13f>
rism,  particularly  if the former be  accompanied
with  much  asperity of  the  internal membrane.
From numerous dissections, the fact  appears to
us to admit of the following  explanation :—in
cases  of dilatation, the  interior of the vessel is al-
most invariably rendered rugged by osseous, carti-
laginous, or other adventitious depositions ; and
the blood, in permeating such a tube, necessarily
occasions a  strong tremor,  as its  particles  are
thrown  into  preternatural  commotion and colli-
sion,  not  only by the enlargement of the  caliber
of the vessel at the dilated part, by which they are
diverted  from their direct course,  but also by the
roughness of the surface over which  they have to
pass.   In sacculated aneurism,  on the contrary,
though  a portion of blood  descends  into the sac,
the greater quantity pursues a direct and tranquil
course through  the smooth canal of the  artery,
and the tremor is therefore less considerable.
   We have uniformly found the  purring  tremor
confined to the  superclavicular regions, except in
the case of aneurisms which had protruded through
the ribs, and  presented  immediately underneath
the integuments.  It is rarely occasioned at all by
old aneurisms;  because, in consequence of their
magnitude and  the thickening of their sacs with
fibrinous coagula, they possess  little  susceptibility
of vibration.
   Purring tremor, proceeding from organic  dis-
ease of the aorta, may easily be distinguished from
that occasioned  by nervous agitation.  The  for-
mer  is  constant, or may be  excited at  pleasure,
simply by accelerating the circulation ;  it is  re-
stricted to a limited space above the  sternal extre-
mities of the clavicles, and is accompanied with
the hoarse aneurismal sound.   Nervous purring
tremor, on the other hand, is only occasional, oc-
curring when there is an exacerbation of nervous
excitement  and restlessness ;  it extensively per-
vades the adjoining arteries, and  the concomitant
sound is comparatively soft and feeble.
   Pulsation  attends every  species of enlargement
of the aorta.  In dilatation, it  exists  only above
the sternal ends of the clavicles, and always on
both  sides of the neck  simultaneously ; though,
when the enlargement is confined to the ascend-
ing aorta, it  is stronger  on the right than on  the
left side.   When dilatation is of a pouched form,
and of great magriitude, it  may occasion  pulsation
under the sternum.   Of this we have  met with
instances.  Carotid and subclavian aneurisms pro-
duce  impulse, sound, and tremor, on the affected
side  only, and by  this circumstance they may
easily be discriminated  from aortic enlargements.
   In  sacculated aneurism seated in the upper parts
of the chest, pulsation exists both above and  be-
low the  clavicles;  but  I have  generally found it
stronger below.   When the tremor is large, and
occupies  the  left  extremity of  the  arch, the im-
pulse is often perceptible from  the sternum to  the
left shoulder, and  as  low down as the third or
fourth rib.   When it lies in contact with the ribs
posteriorly, the shock  is sometimes felt  on  the
back.   This, however, is  a rare  occurrence.  A
pulsation under the sternum or ribs is one of  the
least  ambiguous signs of sacculated  aneurism.
  Summary of the  stethoscopic, in con-
junction witn the  general, signs of aortic
aneurism.
   Simple dilatation of the arch, and ascending
aorta.  Stethoscopic signs___1st. A constant pul-
sation above both clavicles at their sternal ends ;
stronger on the right  side if the  enlargement is
confined to the ascending portion, and never com-
municated to the sternum or ribs  unless the dila-
tation is enormous.  2. A hoarse  rasping sound
above both clavicles, of brief duration, commencing
and terminating abruptly. If the enlargement is
confined  to the ascending portion, the  sound is
louder above the right than the left clavicle, and
along the middle of the sternum it is superficial,
and of a hissing or whizzing character ; by which,
and  by the sound being situated  higher  up the
chest, it is distinguishable from that  of valvular
disease.   It is usually  distinct on the back, where
the  ventricular sounds, if audible  at  all, are very
obscure.   3. A purring tremor above the clavicles,
but never below.   It is  stronger, and the conco-
mitant sound is more grating, in proportion as the
interior of the aorta is more overspread with hard
and especially osseous inequalities.
   General signs of dilatation.  Frequently none.
When any exist, they are a slight degree of those
common to all organic  diseases of the heart, viz.
the signs of an embarrassed circulation.  They
assume a most aggravated aspect when dilatation
becomes complicated with organic disease of the
heart.
        Fallacies, and methods of detecting them.
   (a.)  Nervous arterial  excitement and reaction
after loss of blood, sometimes occasion an impulse
and  bellows-sound above the clavicles ; but they
may be discriminated by  the  impulse  being feeble,
and the sound more hissing  or whizzing than in
aneurism of the aorta, and by the absence of pur-
ring tremor.  It is, in fact, in the subclavian arte-
ries that the phenomena take place ;  for  though
the aorta be under the same excitement, its action
is not so violent as to extend in  any appreciable
degree  to the supra-clavicular regions.
    (b.)  Adhesion of the pericardium, particularly
when accompanied with hypertrophy of the heart,
we have, in many instances, found to occasion the
impulse and whizzing sound above  the  clavicles
in a still  more remaikable degree than nervous
excitement.   The phenomena  depend upon the
| suddenness, and, as it were, spasmodic energy of
the ventricular contraction.  They may be distin-
 guished by the sound being more whizzing and
 less hoarse, and the impulse more jerking, than in
 dilatation  of the  aorta ;  and they should always
 be suspected to proceed from adhesion, when the
 heart presents the  signs, and  the  history affords
 the presumption of that affection.
    (c.)  Dilatation  of  the pulmonary artery is >
 third, though extremely unfrequcnt, source offal-
 lacy : for the mode of detecting  it we refer the
reader to the next head, viz.
    Dilatation  of the  pulmonary  artery.-  We
 have met with one case  in whicb  this artery was
 dilated to the extent of five inches in its internal
 circumference.  It presented  the following signs.
    1. A pulsation  with purring tremor  between
 the cartilages of the second  and third ribs on the
 left side, and thence in a decreasing degree down-
 wards, but not appreciable  above the  clavicles.
 Also a slight prominence between the same ribs.
   2. An extremely loud, superficial,  harsh, saw
ing  «n".nd, audible above the clavicles  and over 
136
AORTA,  (ANEURISM  OF  THE)
the whole praecordial region, but loudest on the
prominence between the second and third ribs.
   General signs were those of hypertrophy and
dilatation of the heart, with which the dilatation
of the pulmonary artery was complicated.
      Fallacies, and the methods of detecting them.
   Dilatation  and aneurism of the aorta  are per-
haps the only affections for which dilatation of the
pulmonary artery could be mistaken.   The signs,
however, of the latter are so characteristic, that,
with due attention,  it is scarcely  possible to com-
mit an error.  Thus, a pulsation  between the car-
tilages of the second and third ribs could not be oc-
casioned by a dilatation of the ascending aorta ;  as
this artery,  even when  dilated,  is too far to the
right to extend beyond the margin of the sternum.
Again,  a sacculated  aneurism of the  ascending
aorta could not reach the  cartilages of the second
and third left ribs  without being very large, and
in this case it would form a much greater tumour
externally than existed in the  present instance.
The sound  also  of such  an aneurism would  be
dull, and as if remote, instead of loud and super-
ficial.   Finally, either a dilatation or an aneurism
of the aorta  would occasion a  greater pulsation
and sound above one or  both clavicles, than ex-
isted in the case of which we speak.
   Sacculated aneurism of the  thoracic aorta.—
Stethoscopic  signs.  1. A pulsation both above
and below the  clavicles, but usually stronger be-
low.   If the tumour occupies the ascending aorta,
its impulse  is  most perceptible  on the sternum,
and towards its right.  If it is seated  in the arch
or commencement of the descent, the pulsation in-
clines to the left side, and sometimes  reaches to
the  shoulder.   It  is occasionally perceptible on
the  back.    In  front,  the  pulsation  is always
stronger on the tumour than at some point inter-
mediate between it and the heart, and  generally
stronger than the impulse of the  heart itself.
   2. The aneurismal sounds described under dila-
tation,  but weaker.  In  large, old aneurisms,  it
has a dull and remote character, and is sometimes
louder  on the side of the  neck opposite to that
where the tumour is situated.   It  is  generally
audible on the back ; and when the tumour occu-
pies the descending  aorta, it is  often  louder be-
hind than in front.  If, on the back, it has more
of the abrupt, rasping sound than the ventricular
systole in the praecordial  region, the  evidence of
aneurism is almost positive.
   3. A purring tremor above the clavicles.  We
have never found it below, unless the tumour had
penetrated through the  ribs or sternum.   It  is
weaker than in dilatation, and  in old and  large
aneurisms often becomes  extinct.
   General signs of sacculated  aneurism.—Any
or all of the following signs may be  present.   A
pulsating tumour, presenting externally, and soon-
er or  later  causing livid  redness of  the integu-
ments ; deficient resonance on percussion ; a sense
of retraction  of the trachea, with  a wheezing respi-
ration and croaking or whispering voice ; dyspha-
gia ; an intense  gnawing or boring  pain in the
spine ; aching of the left shoulder, scapula, neck,
axilla, and arm, with numbness, formication, and
 impaired motive power of the  limb ;  a  sense of
 weight and infarction in  the chest; difference of
 the two pulses: purring tremor of the radials :
some or other of the ordinary symptoms of organic
disease of the heart.
     Fallacies, and the methods of detecting them.
  Pulsation beneath the sternum and  ribs, occa-
sioned  by amplified  glands, or  other tumours in
the anterior  mediastinum,  by hydropericardium,
by enlarged heart, or,  finally, by adhesion of the
pericardium, may, according to  our experience, be
easily discriminated from aneurismal pulsation by
the following criteria.
  (a.)  Pulsating glands, or other tumours in the
anterior  mediastinum, are  not attended with the
aneurismal sound ; and symptoms of a disturbed
circulation either do not exist at all, or  do not cor-
respond  in severity with the magnitude of the ap-
parent disease,  (b.)  Hydropericardium, instead
of producing  the gradual, steady,  and powerful
heaving  of an  aneurism, occasions an  undulating
motion, of which  some of the shocks are stronger
than others, and none are exactly synchronous
with the sound of the ventricular  systole.   The
motion is equally diffused over every part of the
space occupied by the fluid; whereas in aneurism
the impulse is notably stronger on the tumour and
on  the heart, than on the intermediate space.  Hy-
dropericardium is not productive of the aneurismal
sound.   Its history is  different from that of aneu-
rism, the latter being very often referred  to some
injury  or excessive exertion, suddenly followed by
pain or dyspnoea,   (c.) An enlarged heart causes
a pulsation over  a preternatural extent in every
direction ;  an aneurism occasions it in  its own
direction alone. The beating of an enlarged heart
is strongest at the point nearest  to the centre of
motion,  and it decreases progressively on receding
from that centre : the beating of an aneurism is
stronger on the tumour than at some point inter-
mediate  between it  and the heart; and  in most
instances it is stronger even than the  beating of
the  heart  itself.   Hence,  an aneurism distinctly
conveys the impression of their being two centres
of motion—the tumour and the heart; while the
pulsation of an enlarged heart is felt to be refera-
ble  to one alone.  Finally, the ventricular  con-
traction  of a dilated  heart produces a loud flap-
ping sound, and is not attended with  aneurismal
murmur or pulsation  above the clavicles.  We
have never known adhesion of  the pericardium to
occasion a pulsation which could be mistaken for
an aneurism,  until it had  occasioned enlargement
of  the  heart, its  ordinary  consequence.   In this
case the diagnostic symptoms  are the  same as
those of enlargement  of the heart, with one differ-
ence, that the motion is of a more unsteady, un-
dulating, and struggling  character,  (d.) Varix
of the jugular vein,  occasioning pulsation above
the clavicle, is distinguished  by the absence of
sound, the compressibility of the humour, and the
 languor of the  impulse,  (e.)  Enlarged glands,
 or  other tumours above  the  clavicles,  receiving
 pulsation from  a subjacent  artery, rarely occasion
 sound ;  and if any exist, it is  a feeble whizzing.
 Both it and the pulsation  are confined to the side
 affected.  If the tumour can be grasped, it will be
 felt not  to dilate laterally during the  ventricular
 contraction ;  and if it can be raised from the sub-
 jacent artery, its  beating will cease entirely. (/•)
 Subclavian and carotid aneurism occasion pulsa-
 tion, sound, and  purring  tremor on the affected 
                         AORTA,  (ANEU

side only, and these signs are more superficial and
distinct than in aneurism of the aorta.  The sound
resembles that of the  small hand-bellows, instead
of having the hoarseness  of  the forge-bellows.
(g.) Purring  tremor  of the chest,  proceeding
from mucous rattle, may be recognised  by its ceas-
ing when respiration is suspended.
   Sacculated aneurism of the abdominal aorta
is comparatively so easy  of  detection, that we
have not thought it necessary  to  enter into detail
respecting its signs.
   Stethoscopic signs.—1.  A constant pulsation
of extraordinary power.  It appears much stronger
to the ear resting on the stetboscope than  to the
hand.  The instrument may be  forced  down  in
various directions into close  proximity with the
tumour, and an idea of its position and dimen-
sions may be  thus  obtained.  2. A  loud, brief,
and abrupt bellows-sound, not so hoarse as  that
of aneurisms in the chest.  It is sometimes audi-
ble on the back.  The diastolic sound of the heart
is inaudible, and, consequently, the pulsation is
simple.
   General  signs. — They are those of impeded
respiration dependent on  an imperfect descent of
the diaphragm ; of lumbar abscess, with or with-
out caries of the vertebra ;  of renal disease; and
of pressure on the nerves or viscera  of the abdo-
men and pelvis ; but none are pathognomonic of
aneurism, except a pulsating and usually compres-
sible tumour, felt through the abdominal parietes.
       Fallacies, and methods of detecting them.
   (a.) A scirrhous tumour of the stomach,  (b.)
Enlargement  of the  pancreas  by  hydatids,  or
scirrhus—an extremely rare affection,   (c.) Fun-
goid, or  other  tumours of the mesentery, omen-
tum, transverse arch of the colon, or  diaphragm.
(d.) Indurated fxces,  air, or  masses  of tape-
worm, impacted in the  transverse colon.   When
any of these tumours rest  upon the  aorta,  they
receive its  pulsation,  and  frequently  occasion a
bellows-sound by compressing  the vessel.  They
may be discriminated from aneurism by their im-
pulse  being  comparatively  feeble,  particularly
when the stethoscope is applied laterally ;  by the
sound being only a  slight  whizzing;  by  the
tumour feeling incompressible ;  by  its being su-
perficial when connected with the stomach, colon,
or omentum ; and by its moving with the move-
ments of  these  viscera.   Finally,  the  general
symptoms are those of dyspepsia, or of malignant
disease, with slow and progressive marcor, with-
out derangement of the circulation,   (e.) An ac-
cumulation of serum  in  the  peritoneal cavity is
another source of fallacy, as the liquid transmits
both the  impulse and  the sound of the aorta more
distinctly tban  natural.  Dr. Young  made  this
discovery in 1815.*   As  it is easy to  detect the
fluid, we have  never found  this source of fallacy
to occasion the least embarrassment.
   Nervous pulsation of the abdominal aorta.—
This is a very frequent and deceptive affection in
irritable  and hysterical constitutions.   When  it
exists in conjunction with air pent up in the colon
or duodenum  and presenting the feel of a com-
pressible  tumour, the resemblance to aneurism is
  *Med. Trans, of Coll. of Phys.  of London, vol. v.
1815. No. 15.
  Vol. I.—18                        M*
RISM  OF  THE)                      137

still more complete.   After an  examination of
many cases, we are satisfied that attention to the
following circumstances will render the diagnosis
easy.  The cylinder may be pressed down on the
aorta so as to  yield a distinct feel of the vessel of
its natural caliber.  The sphere of its pulsation is
limited transversely, but extensive longitudinally ;
being usually  more or  less perceptible from  the
epigastrium to the bifurcation.  The impulse, in-
stead of being the gradual, steady, and irresistible
heaving of an aneurism, is a smart, though vigor-
ous jerk; and  the  sound, when  any exists, is
merely a  whizzing, almost  devoid  of hoarseness.
The general  symptoms are nervous or hysterical,
and the  pulsation  is of an inconstant character,
increasing and diminishing with the exacerbations
and remissions of the constitutional excitement.
   Spontaneous  cure, and  medical  treat-
     ment  of aneurism  of the  aorta.
   Previous  to entering upon  the treatment of
aneurism of  the aorta, we   shall  explain  the
mechanism  by  which  its  spontaneous  cure is
effected,  as the reader will thus be better enabled
to understand the principles on which the  treat-
ment is founded.
   The  movement of  the blood  within  the  sac
being retarded, partly by the roughness of its in-
ternal surface, and partly by the fluid being with-
drawn from the direct channel  of the circulation,
coagulation takes place, and lymph  is deposited
and organized in successive strata, until the cavity
is at length  completely filled.  The sac, being
then no longer exposed to the distensive  pressure
of the circulation, tends to contract by  its  own
resilience, and the compression of the incumbent
parts, absorption of its  contents takes place, and
the aneurism is finally reduced to a small, dense,
flesh-like  tumour.  In arteries of the second and
inferior orders, the coagulum generally extends to
and obliterates the caliber of  the vessel  itself ;|
but this is rarely the case in the aorta, as the force
of the circulation in so great a vessel prevents the
lodgement of  coagula.  Instances,  however, of
obliteration of the aorta by lymph are not without
example.   An important case has been published
by  our friend  Professor Alexander Monro,t and
Dr. Goodison describes another.
   It is principally in false aneurism that the cure
by  deposition  of coagula  takes  place.   In  true
aneurism, and  in  dilatation, such  a cure is very
rare ; for the walls being unbroken and  smootb,
and the aperture of communication with  the  sac
being in  general large, the blood is  seldom arrest-
ed  to  such  a degree  as  to  deposit lamellated
coagula.   When, however, the whole circumfer-
ence of an artery is converted into  a bony cylin-
der, there is a  great tendency to its obliteration by
a plug  of lymph.  Dr. Goodison's  case  was of
this description : and we have more than  once
witnessed the same in arteries of the second order,
  Hence, as the formation of coagula within the
sac is the principal means employed by nature in
effecting  the  cure of aneurisms, the primary oh
ject of medical treatment is to promote the depo-
sition of  coagula; and this  is best  accomplisbed

  t Vide Hodgson, Jones, Farre, Baillie, Petit, Desaulr,
and Scarpa.
  I Observations on Aneurism of the Abdominal Aorta,
by Professor Monro, ed. p. 5 and 8, 1S27. 
138
AORTA,  (ANEURISM  OF  THE)
by such  means  as have the greatest effect in en-
feebling  and retarding  the circulation.  Accord-
ingly, the antiphlogistic treatment, rigorously pur-
sued, is the most efficient remedy for aneurism of
the aorta.  This has  acquired great celebrity un-
der the designation of the treatment of Albertini
and  Valsalva.   By detraction of blood and spare
diet, they reduced their patients to so extreme  a
state of debility, that they were  scarcely  able to
raise their  arms from the bed.   Morgagni reports
(Epist. xvii.  art. 30.)  that when  Valsalva  had
taken  away  as  much blood  as was requisite, he
made it a custom to diminish the quantity of meat
and  drink more  and more every day, till he pro-
reeded so  far as to allow only half a pound of
pudding in the morning, and in the evening half
that quantity, and nothing else except water, and
this  also within  a certain weight.  After  he  had
sufficiently reduced the patient by this method, so
that, from weakness,  he could scarcely raise his
hand from the bed, in which he lay by Valsalva's
order from the  very beginning of the disease, he
increased, by degrees, every day, the quantity of
aliment until the necessary strength returned.
   To  render this  treatment safe and  efficient,
several circumstances  must be  taken into con-
sideration.  In persons of very feeble constitution,
its employment  is inadmissible, as it might be fatal
by inducing other diseases, or  irremediable de-
bility.   In individuals  sufficiently strong  to un-
dergo the treatment, but in whom  there is reason
to apprehend that extreme debility, if long con-
tinued, might  occasion  pernicious  effects,  this
state, when once induced, should be speedily re-
moved.  The depleting system should be actively
pursued  in the  first  instance, so as  to make  a
decidedly enfeebling impression on the circulation,
and thus allow of the contraction of the sac and
Hie deposition of a coagulum ,- but when the pulse
and general feelings of exhaustion indicate that
the impression has been made, its protracted con-
tinuance should  be  prevented  by a spare, but
nutritious diet, as a little  strong beef-tea or mut-
ton-broth.  The quantity of blood to be drawn
must depend upon the  constitution of the  patient
and the effect  produced.  In one  case under our
care, §x. were  abstracted for sixteen days conse-
cutively, with  an  excellent  result.   Others we
have seen bled  to £x. or xii., twice a  day, for six
or seven days ;  and this practice was  pursued by
Pelletan*  and  others; but we have found the
best effect to be produced with the least expendi-
ture of blood by drawing a considerable quantity,
as  from gxv. to xxv., in the first instance, and
repeating the bleeding to %x. or xv., within twelve
hours, and then taking ^vi. or viii., every six or
right hours, or  at such intervals  as to prevent the
establishment of re-action—a phenomenon, which,
by producing an inordinate energy of the circula-
tion, counteracts the  effect of the depletion.  Of
 this we  can entertain no doubt, both from exten-
 sive observation on  the  human subject, and ex-
 periments on dogs ; in  the latter of which we
 have seen bleeding, repeated daily or every second
 day for ten days, occasion the most violent arterial
 dirobbing.f   In individuals who  have not suf-

   * Clinique Chirurg. torn i.  Prem. Mem. gur les  Aneu-
 iHmes, p. 54.
   JTliis  subject has been developed with great ability,
ficient constitutional vigour  to  give rise to much
re-action, less frequent  and more  sparing  detrac-
tions  of blood will suffice, as, for instance,  from
5vi. to  xii., two,  three, or  four times  a week.
The blood  after  repeated  abstractions becomes
very  serous, of  a  pale crimson  instead  of the
natural dark venous colour, and has sometimes a
whitish cream on its surface after  standing twelve
hours.
   In aneurism of the aorta,  especially when con-
joined with organic disease of the heart, the bleed-
ing should  never, if possible, be  carried  to syn-
cope, as, in  such cases,  this phenomenon is apt to
be alarmingly protracted, and sometimes to termi-
nate  fatally.   The  blood,  therefore, should  be
drawn slowly, and in the recumbent posture, ^or
should  the venesection be  performed during  a
paroxysm of palpitation, as the  exhaustion conse-
quent on it, superadded to that  occasioned by the
loss of blood, not unfrequently sinks  the  patient
beyond  the possibility of  restoration.   When
there is much  pain  in the tumour, leeches afford
great relief to it, while they, at  the  same time,
conspire to reduce the circulation ; but they should
not he applied when  the integuments  are very
thin and discoloured, as they  are apt to induce
sloughing and rupture  of the sac.  Ice, as an ap-
plication to the tumour, has been  strongly recom-
mended ; but the pain  which it  produces, is, in
general, intolerable beyond  a  sbort time.  Its
occasional use, however, and, in  the intervals, a
cold cataplasm of linseed-meal and  vinegar, ate
very serviceable, by contracting  all the tissues and
promoting the coagulation of the blood within the
sac, when its current has  been  rendered  languid
by depletory measures.  When cold applications
are not employed, and  the tumour is painful  and
requires support, we have found  the emplastrum
belladonnse afford the greatest relief.
   The diet should consist principally of fluids, and
it should be  gradually reduced.  Pelletan some-
times allowed only two basins of broth in twenty-
four  hours,  and lemonade  as  a  common drink.
Valsalva, as before  stated, gradually reduced the
food to half a pound of pudding  in the morning,
and a quarter of a  pound in the  evening, with a
limited  quantity  of water.   By  thus gradually
reducing it both in quantity and quality, the solids
may easily  be brought  as low as four ounces, and
the  fluids  as eight, daily.   In  some even less  is
sufficient, and this  for  weeks together.  Both the
body and the  mind should  be  kept in a state of
the  most perfect quietude.  The recumbent posi-
tion should be constantly maintained.   Purgatives
which have a great  effect in weakening the action
of the  heart, should be frequently administered.
Digitalis is useful by producing the  same effect;
but it should not be pushed so  far as to bring the
patient strongly under its influence, as the syncope
induced by this drug is liable, in  affections of the
heart  and  aorta, to be fatal.  We  have several
times seen it extremely alarming.
   The well-known effect of the  superacetate o(
lead in controlling active hemorrhages, has  intro-
duced this as a remedy for aneurism. In Germany
it has been extensively used  for many years, and
 Dupuytren, Laennec, and Bertin have employed

by Dr. Marshall Hall, in concert  with whom ,vc -,cr.
f'.rmed the experiments alluded to.      w,M"n we ,iu 
A P HO IS I A .
139
it with advantage in France.  Our own experience
is  in  its f.ivour.  Its tendency to produce colic,
and inflammation of the mucous membrane of the
stomach  and intestines, may be counteracted by
conjoining  it with opium, and  commencing with
a small dose.   Half a  grain of each, gradually
increased to a  grain of the acetate in a pill, three
or four times a-day, is the form in which  we
employ it.   Any gastric irritation from it we have
always found to be removed by a dose or two of
castor-oil  promptly administered,  and  mucilagi-
nous  diluents.   When  the patient  has been  re-
duced as low as the constitution will bear,  the
state of the aneurism should be examined with the
utmost attention.  If it has undergone no amelio-
ration, the  treatment should  be  abandoned rather
than  the risk  incurred of reducing the patient
further, and beyond the power of the constitution
to sustain.   But if it is clear that the pulsation
and sound  of the aneurism are greatly diminished
or entirely  suppressed, and  the volume  of  the
tumour reduced, the practitioner  is justified in
persevering,—so far as he can do it without bring-
ing the life of the patient into palpable danger.
When the  amelioration has become confirmed, the
treatment should be gradually  relaxed, but absti-
nence and  the recumbent  position should  be  en-
forced, even for  a considerable period after  all the
symptoms have disappeared.
   The treatment of Albertini and Valsalva  should
not be adopted in a rigorous  manner, and with  a
curative view, unless the practitioner has  reason
to believe that the aneurism is of the false species,
viz. by rupture of the arterial tunics  ; or, if of the
true species, that the sac is not  a mere pouch,  but
so deep, and with so narrow  a neck  as to be con-
siderably removed  from the direct current of  the
circulation.  The  latter  state may  be  presumed
with  some confidence when the tumour, supposing
it to spring from the ascending  aorta, extends far
to either side ; or, whatever be its situation, when
its base is  remote from  the  caliber of the  artery.
Aneurisms of the descending aorta may be treated
as false : post-mortem inspection  having proved
that they are  almost  always of that description.
In cases of dilatation, and of shallow true aneurism,
the antiphlogistic plan  should be pursued to  a
moderate extent only, and merely with a palliative
object: for as, under such circumstances, coagula
scarcely ever  form, a  radical cure  is not to be
expected.
  It may be said, finally, that the efficacy  of  the
treatment of Albertini and Valsalva has,  in all
probability,  been somewhat  over-rated.  For, as
the diagnosis  of aneurisms of  the aorta was  in-
volved in much  obscurity until  the last few years,
it  is certain that many cases, reported as  cured,
were not aneurisms, but  tumours or nervous pul-
sation simulating  that disease.  Another  reason
has prevented  the treatment  from maintaining its
ground, namely, its severity.  Though patients
will submit  to rest and extreme abstinence, they
have rarely  fortitude to see bloodletting superadded.
The  practitioner, on the other hand, has seldom
the courage to insist upon it, knowing that  it is
not wholly  exempt  from danger, and that  it will
not infallibly be productive of a cure, especially if
not pursued with uncompromising rigour.
   Treatment of  nervous pulsation of the
aorta.—Though the treatment of nervous pulsa-
tion does not strictly come under the head of aneu-
rism, yet, as  the pulsation is a frequent concomi-
tant of aortic aneurtsms and organic diseases of
the heart, it  may not  be foreign  to our  present
purpose to advert briefly to its treatment.
   The indication  is, to  allay the  nervous irrita-
bility and excitement on which the pulsation de-
pends.   This may be effected by causing the pa-
tient to  maintain, as far as possible,  a tranquil
state of body and  mind ; by a mild cooling diet
and regular state of the bowels ;  by sedative reme-
dies, as conium, hyoscyamus, camphor mixture ;
and by these conjoined with  antispasmodics, as
assafcetida, valerian,  sulphuric aether,  if there be
hysterical symptoms.  It is scarcely necessary to
add, that attention to the catamenial  secretion is
of primary importance.  When the patient is suf-
ficiently tranquillized to bear tonics and stimulants,
the best remedies are the various preparations of
steel, with infusions and decoctions of cinchona,
cascarilla, columba, orange-peel, &c, the shower-
bath, much out-door exercise short of fatigue, and
a nutritious but not heating diet.
                                  J. Hope.
   [AORTA, inflammation of the.  See Ar-
teritis.]
   APHONIA (from a privativum, and ipwvij, vox)
is  the term used by  nosologists  to designate that
privation  or  suppression of voice, more  or less
complete, which occasionally takes place indepen-
dently  of coma or syncope.  Dr. Cullen has ar-
ranged it in the class Locales, and in the order
Dyscinecix, (or impeded and depraved motions,
from a fault of the organs ;) and has enumerated
three species ; viz :
   1. Aphonia gutturalis, from tumefaction of the
fauces  and glottis :
   2. Aphonia trachealis, from tumours of  neigh-
bouring parts compressing the trachea :
   3. Aphonia atonica, from  mechanical division,
or paralysis, of the nerves distributed to the tongue
and larynx.
   In all  these species  the  loss of voice is only
symptomatic; and purely owing to the preterna-
tural condition of the vocal  organs.  Indeed it is
very doubtful whether aphonia  is ever an idiopa-
thic affection.  In  many cases of severe  catarrh
it is an attendant symptom, and depends upon the
lining  membrane of the  larynx  being slightly in
flamed and thickened;  in the same manner as the
Schneiderian membrane of the  nose is thickened
when we are incommoded  by the sensation fami-
liarly called " stuffing in the head."
   Again, in many  instances aphonia precedes or
succeeds apoplexy ;  but in such cases it is indica-
tive of plethora, or pressure, within the cranium,
and is always to be regarded as a formidable  symp-
tom, not  from the mere inconvenience of the loss
of voice,  which is  only a subordinate  matter, but
from the  proof it affords that the  internal  cause,
whatever it be, that  interrupts  the nervous influ
ence, is situated about  the  base of the  brain, and
probably  in the medulla oblongata, the  part from
which  the  nerves of the tongue originate.  The
medulla oblongata, where the crura of the cere-
brum  and  cerebellum  effect a junction with tho 
140
APHONIA — APHTH.E
Bpinal chord, seems to be the great centre of ner-
vous union  and  sensorial power.  Hence  it has
been accounted  by pathologists the part of the
nervous system  most indispensable  to life.   Ac-
cordingly, in those cases  of apoplexy where the
speech is much or permanently affected, our prog-
nosis, for the reasons aforesaid, ought to be always
unfavourable.  Discussions of  this kind, however,
more properly belong to the head of  apoplexy.
   We have sometimes met with aphonia depend-
ing upon atony, or relaxation of the vocal chords,
in consequence  of long-continued over-exertion
of the voice in speaking, shouting, singing, or the
like.
   It is also  now and then caused by  ulceration  of
the lining membrane of the larnyx and its  carti-
lages ; a disease that gives rise  to rapid emaciation,
hectic  fever, profuse expectoration of frothy mu-
cus, and the other frightful symptoms known  to
modern practitioners under the name of phthisis
laryngea.   A fatal case of this sort, most distress-
ing  in  all  its details, lately came under our ob-
servation, where the ulceration of the cartilages  of
the larynx occurred as the sequela of syphilis.
   For the  most  part, however, aphonia, where it
occurs without any palpable disorder, or structural
lesion, of the organs of speech, is a modification
of hysteria; that Protean malady which assumes
such various shapes and hues,  and  gives  rise to
such irregular, anomalous, and perplexing  symp-
toms ; resisting  for months,  or  even years, the
most assiduous  and skilful efforts of the  practi-
tioner !  In cases of this class, the  loss of voice
is owing to irregular distribution  of the nervous
influence.   This  again is caused by general irrita-
bility, or susceptibility, of the whole nervous sys-
tem ; or, in other words, by " the hysterical tem-
perament."   We shall seek in vain  to restore the
voice until we have removed  that hysterical dia-
thesis on which the loss of it  depends.
   Cure.—When the disease  has not arisen from
a cause which contra-indicated  emetics, we have
generally begun  with one ; and  the  following is
what we have  commonly employed, repeating it
at intervals of three or four  days, and adding to
it, where the patient was robust, from  gr. ss. to
gr. i. of tartarised antimony:
     R Vini Ipecacuanhas f.^ix.
        Oxymellis Scillse  f.^iii.   M.
The success that has attended  its exhibition has
been most conspicuous.
   Where  the disease has appeared  symptomatic
of catarrh,  we have  followed up the emetic  by
saline,  demulcent,  and  expectorant  medicines.
Leeches, but  more especially blisters, to the fore
part of the throat, have had an excellent effect.
   Where aphonia seems premonitory of apoplexy,
 the most prompt and effectual depletion by blood-
 letting, cupping, and purgatives, must be resorted
to.  Where, on the other hand, it  is the conse-
quence  of apoplexy, we have  chiefly  relied  on
 supping  inter scapulas, leeches to the temples, a
 blister to the head, and,  above all, a seton in  the
 nape of the neck.
   When aphonia is symptomatic of hysteria  (as
 it so often is), the constitutional  treatment adapted
 to the latter must be had recourse to.  We would
 ■dvise the following formulae,  which  we  have
proved by experience to be well adapted  to this
and many other varieties of hysterical disorder:
     R Ferri Subcarbonatis ^i. ad £ss.
       Valeriana; Pulvcris gr. x. M. fiat pulvis  tei
die sumendus.  Or the following pills and mixture
may be prescribed :
     R Pilula? Galbani  Comp.
       Pyrethri pulveris, da ,^i.
       Olei Anisi guttas vi. M. tere  simul optime,
et divide in pilulas xxiv. quarum sumat ii. vel  iii.
omni nocte.
     Necnon, R Sulphatis Ferri g. ii.
       Acidi Sulphuric. Dil. M. x.
          Solve, et adde
       Infusi Gentiana; Comp. f.^ix.
       Aquae Cinnamomi f.giii.
       Sulphatis Magnesias, q'i. M. fiat haustus
bis quotidie sumendus.
   With  the  above plan, tbe  shower-bath every
morning, at  first  tepid and then cold, (with  or
without the addition of salt to the water,) may  be
conjoined, and should be persevered in for several
weeks.
   It is not unworthy of remark  that, in one case
of this  disease, which had  existed  long, and  re-
sisted a great  variety of remedies, we were fortu-
nate enough to effect a cure by half-drachm doses
of balsamum copaibx, given  three  times a day,
rubbed up with mucilage of gum arabic and pep-
permint  or cinnamon water.
                            A. Robertson.
   APHTHAE, (from tbe Greek an-™, accendo, to
inflame,)  is the term  employed to denote those
numerous white  specks, or curd-like vesicles, that
not unfrequently appear on the tongue and palate,
and gradually diffuse themselves all over the inside
of the moutb and fauces.  They ought to be con-
sidered  inflammatory exudations rather  than  ul-
cers; for they are not surrounded by any redness;
and, when they alternately fall off and re-appear
in successive crops,  (as  they are apt to do,)  we
find the cuticle abraded underneath, and the parts
excessively tender and smarting, but the cutis vera
unbroken.
   Three varieties are enumerated  by Dr. Mason
 Good and other modern  writers ;  viz. 1. aphtha
infantum,- 2. aphtha maligna,-  and, 3. aphtha
chronica.
   Dr. Cullen has  placed  this disease in the class
 Pyrexiae, and order Exanthemata,-  but his collo-
 cation  and definition apply  more  particularly to
 the  aphthae infantum,  or milk-thrush ,• which is
 the  only variety that can  be really  or generally
 considered idiopathic.  The  others are purely
 symptomatic, and  are chiefly  of importance from
 their indicating a reduced state of the vis viue, and
 an impoverished condition of  the blood.
   We  have  witnessed  the  appearance of  the
 symptomatic  varieties in a great many acute  dis-
 eases.   In cases of enteritis ; in bilious, remittent.
 typhoid, and  petechial  fevers;  in  hectic  fever,
 from confirmed pulmonary disease,  or from  the
 suppuration of psoas abscess in that irritable con-
 dition of the alimentary canal denoted by  fever,
 vomiting  and purging of bilious  or other acrid
 matters;  in the febris lenta attending diabetes,
 atrophy, &c.; in the fever accompanying slou§h- 
APHTHA.
141
ing wounds or scorbutic ulcers ; in short, in vari-
ous states  of great  constitutional  irritation and
prostration we have found  aphthae to supervene.
They are always to be looked upon as a most un-
favourable  symptom ;  not from any mischief in-
herent in themselves, or caused by thein, but from
their indicating general exhaustion and prostration
of the system.
   We have known, however, very  many acute
cases terminate favourably, notwithstanding  the
occurrence of aphthae during their progress;  and,
indeed, so long as the aphthous specks retain their
purely-white colour, little danger need be appre-
hended.   But when  the early crops  fall off and
are succeeded  by others,  at first yellow  in their
hue,  and gradually degenerating  into  brown or
black, they  may be looked upon as almost infalli-
ble tokens of a fatal issue to the concomitant dis-
ease, whatever that disease may be.
   In such  disastrous circumstances the  aphthae
pervade the whole alimentary canal.  Indeed some
authors of reputation contend, from the cardialgia,
singultus, acid eructations, and gripings that usu-
ally precede or accompany them, tbat they always
originate in the stomach, even before they mani-
fest themselves in the mouth and fauces.   Be this
 as it may,  it is unquestionable that in all cases
 where aphthae show themselves, they are preceded
 by evident  acrimony in  the stomach and duode-
 num.
   The treatment, under such a state of things,
 ought obviously to be directed  rather to the con-
 comitant disease than to the aphthous condition
 of the  mouth  and throat.  But  as  the latter is
 often productive of great distress  in swallowing
 either nourishment or medicine, gargles and other
 topical detergents  must  not be neglected.   We
 have experienced beneficial effects, in some severe
 cases, from pencilling the  inside of the mouth
 with a solution of argentum nitratum, in the pro-
 portion of ^ss, or even Qii, to an ounce of water.
 Gargles also of sage-tea,  or of simple  infusum
 rosae, are often useful.  One drachm of alum to
 a pint of infusion  of red  rose-leaves frequently
 has a good effect in cleansing the mouth.  But,
 upon the whole, the most soothing application we
 have yet found is the following :—
   R Sodas  boratis ji. ad gii.
      Aquae f.^vii.
      Mellis rosae f.^vii.
      Tinct. Opii f.^i.  M. fiat gargarisma.
 Frequent sips of this  are to be taken, and held in
 the mouth  for four or five minutes at a time, and
 afterwards discharged.
   The  aphtha infantum usually  attacks those
 children that are brought up by hand, rather than
 such as live entirely on the breast.  In such cases
 the exciting cause  is the  food not being properly
 digested, but becoming acid  and acrimonious ii.
 the first passives.
   The first step in the treatment is well to evacu-
 ate  the primae visa by castor-oil,  magnesia  and
 rhubarb, or manna dissolved in warm milk.   Our
 next measures  must  be to obtund acrimony, and
 excite perspiration.   These purposes will be best
 accomplished  by  the warm bath,  particularly
 where  there is much febrile heat, or where  the
child is tetchy and  restless ;  and also by f.gss of
 mistura cretae with M. v.  of vinuin  ipecacuanhse,
given every four hours.   We would recommend
the following formulae :
  R Cretan preparatss ^ii.
     Mucilaginis acacias  f.gss.   Tere  simul,  et
  adde aquae f.^iss.
     Liquor, ammon. acetat. f.gvi.
     Spir. aether, nitric, f.giss.
     Vini antimonii  f.^ss. M.
The dose a table-spoonful every four hours.
   With infants who cannot  employ a gargle,  a
linctus, consisting of gi of borax  (sub-borate of
soda), rubbed up in one  ounce of mel roses, and
applied frequently  to  the mouth and  fauces by
means of a feather, or a camel-hair pencil, is often
a useful succedaneum.
   Where the aphthae put on  a dark or sloughing
appearance, the sulphate of quinine dissolved  in
the  infusion of roses, or the  decoction  of  bark
acidulated with muriatic  or dilute sulphuric acid,
must be resorted to in doses adapted  to the age
and other  circumstances of  the  patient.  Port-
wine or brandy must also be  exhibited.  Gargles
and the inhalation of the vapour of warm water
and vinegar, must likewise be employed. Of all to-
pical applications, however, the most  powerfully
antiseptic we are acquainted with is the following :
   R Liquoris sodae chlorinatce, tincturae  myrrhas
da f.^ss.  Aquae f.^vi.   Aquae rosae f.^i. M. fiat
gargarisma saepissime adhibendum.

                            A. Robertson.

   [There  appears to be  a  marked difference be-
tween the pultaceous inflammation of the mouth,
that constitutes Aphthx Infantum, and the folli-
cular inflammation that constitutes Aphthx Adul-
torum.  The  latter — aphthous stomatitis — is
seated  chiefly in the  follicles of the  mucous
membrane of the mouth ; hence the name folli-
cular stomatitis, given to  it by some.   When
 the membrane is inspected at an early period of
 the disease, it  presents the  appearance of simple
stomatitis;  and afterwards, small transparent, grey-
ish  or whitish vesicles are perceptible, and at the
 base of each  vesicle there is a raised ring, which
 is resisting, and of a white colour.  Subsequently
 the vesicle gives way at the  top, and  allows the
 fluid to escape from  it; after  which  it  becomes
 transformed into an ulcer, which spreads, and is
 bounded by a red circle,— the raised  border that
 occupied or surrounded  the  base of the vesicle
 gradually disappearing.  Cicatrization succeeds,—
 at times rapidly, but at others gradually,— whilst
 at  others, again, it is  exceedingly tardy, and the
 ulceration  is very apt  to recur after it has  once
 healed.   Cases very difficult of management are
 occasionally seen in nursing-women; and, what is
 singular, they would seem to occur more frequently
 in  certain localities than in others, owing to causes
 that have not yet been appreciated.  The  stomati-
' tis of nurses is not, however, peculiar to this coun-
 try, as has beeif imagined by some.
   The treatment of the aphthae of the  adult must
 be regulated greatly by the concomitant condition.
 In the first instance, mucilaginous, and, afterwards,
 gently astringent collutories  may be  prescribed ;
 and, where the ulcerations are not numerous, they
 may be treated with solid nitrate of silver, sulphate
 of copper, or tincture of iodine.   If inflammatory
 symptoms  accompany  them, the  constitutional 
142
APOPLEXY,  (CEREBRAL)
phenomena must be met by appropriate remedies.
Often the affection is manifestly adynamic, and
requires the use of tonics, as the cold infusion of
cinchona;  and very  obstinate cases require the
thorough revulsion which travelling air and exer-
cise are capable of effecting. With the  same view,
the various eutrophics may be needed which are
prescribed in other cases of faulty nutritive action
of the dermoid tissues.   (Practice of Medicine,
2d edit. p. 32 :  Philad.  1844.)
                     Robley Dunglison.]

   APOPLEXY  Cehebral__Apoplexy  (from
the Greek  word diroTrAijo-o-w, to  strike) has been
defined, loss of sensation, voluntary motion, and
intellect  or  thought; respiration, and  the action
of the heart and general  vascular  system, being
continued.   The disease has been so termed from
the suddenness and violence of the attack in many
instances;  and, for  the same reason, the patient is
said to be attonitus (thunder-struck), or sideratus
(planet-struck) ; as if  the disease were of un-
earthly origin.
   It is  liable to  be confounded with  syncope or
fainting, and with  natural sleep ;  from  both of
which, for the purposes of practice, it requires to
be distinguished.   In syncope, respiration is sus-
pended, the pulse is not to be  felt at the wrist, the
features shrink, and the surface of the body turns
pale and cold.  In apoplexy, the  reverse of all
these takes  place.   It is less  easy to discriminate
between apoplexy and natural sleep : the distinc-
tion can only be made, indeed, by our  being able
to rouse the person from sleep, however profound,
by a certain  degree of irritation :  this cannot be
done, or but very imperfectly, in apoplexy.  The
suddenness  and  violence  with which apoplexy
often  makes its .attack ;  the total loss of conscious-
ness, of feeling, and of voluntary movement that
attends  it;  and the not unfrequently fatal termi-
nation of the disease, are circumstances well cal-
culated to  attract,  as they have actually attracted,
the attention of physicians from a very early pe-
riod.   We  find it  accordingly  described  by the
(Jreek and  Roman writers, and their successors of
the Arabian  school, with  a minuteness and accu-
racy that have hardly been exceeded  in  modern
times.   Little, however, is to  be found regarding
its intrinsic nature till within a comparatively late
period ; and even at present the pathology of the
disease  is far from being  satisfactorily settled, if
we may judge from the various and contradictory
opinions that have been entertained on  the subject.
   General description.—There  is  great diversity
in the mode of attack of apoplexy, as well as in
the  greater  or  less  severity of   its  symptoms.
Sometimes the attack is nearly instantaneous and
complete;   the patient,  previously in  apparent
health, falling down insensible, with an immediate
abolition of all the  sensorial functions.  On other
occasions the approach of the stroke is felt by the
patient; he  puts his hand to his head, or makes
an alarming exclamation  of  something  unusual
felt in the  head ;  and then falls down insensible.
In most cases, (and probably it would be found so
in all, if sufficient attention were paid,) the attack
is preceded, for a longer or shorter period, by pain
>n the head,  or by  more or less  of  disorder in the
■cti.torial functions; such as tinnitus aurium, im-
perfect vision, numbness or a sense of pricking in
the extremities, giddiness, imperfect articulation,
loss of memory, drowsiness, or nightmare.  The
degree in which  the sensorial  functions  are im-
paired in apoplexy is also various.   In the  more
severe cases, sensation, voluntary motion, and  in-
tellect,  are  all  entirely  abolished.   In  slighter
affections, the patient retains some degree  of con-
sciousness, is sensible to impressions, and capable,
to a certain extent, of voluntary movement.  The
pupils of the  eyes  are variously affected at differ-
ent times.  Although,  in many  cases, they  are
observed to be largely and equally dilated,  and in-
sensible to the impression of light, there  are still
more in which they are in  a contracted  state,
though often  unequally in respect of each other.
Sometimes  they contract and dilate  alternately
with great quickness, without being influenced by
the stimulus of light.   Sometimes one side of the
body lies motionless, without manifesting the least
degree  of feeling, even when  strongly irritated;
while convulsive movements, with perhaps  some
degree  of feeling, are perceived on  the opposite
side.  We are then enabled to predict that, in case
of recovery from the apoplectic state, hemiplegia
will  be left behind.   The disease consisting essen-
tially, as will  be shown hereafter, in a suspension,
more or less  perfect, of the  sensorial  or proper
functions of tbe encephalon, other functions are
not necessarily deranged ; nor when they are  so,
is it in any uniform way.  Respiration, in violent
cases of apoplexy,  is commonly slow and labori-
ous, the patient snoring  loudly as  in deep sleep.
At other times the  breathing is natural.  The
general circulation of the blood, as  indicated  by
the pulse at the wrist, is  equally various in apo-
plexy.   Sometimes  the  pulse  is slow, full, and
bounding ; with flushing and fullness of the face,
and  heat of the extremities :  at  other  times the
pulse is small and  weak, or  perhaps  irregular;
while the face is pale, the features are shrunk, and
the extremities  cold.   In extreme cases,  such as
are likely to prove almost immediately fatal, the
pulse  from the  beginning  is imperceptible, or
nearly so; the heart appearing  to be paralyzed, as
well  as  the voluntary muscles.   In such  cases
death quickly ensues.   The  alimentary canal is
also variously affected  in apoplexy.   In  some
cases, the power of swallowing is lost or impaired;
and in such it is hazardous to administer any thing
by the mouth, as being likely to  induce suffocation,
or at least  to excite violent  cough, which is not
without danger to the patient.  In  numerous  in-
stances apoplexy is ushered in  by vomiting; the
disease then is often  referred  to a disordered state
of the stomach, as  the primary cause ;  but gener-
ally without reason, the disorder of stomach  being
mostly secondary, and dependent upon  the brain.
The mistake  is important, as leading to  the em-
ployment of emetics, the. use of which is  not un-
attended with danger.  The bowels are commonly
torpid in apoplectic cases.  Sometimes, however,
the urine  and faeces escape involuntarily.  This
marks a state  of disease  which generally proves
fatal.  Profuse sweating is also among the most
unfavourable  signs.
   Apoplexy may last but for a short time, as a few
minutes, and  then entirely disappear ;  or it may
prove fatal immediately, or after the lapse of a few 
APOPLEXY,  (
hours ; it may even continue for several days, and
then prove fatal.   In a considerable number  of
instances it ends  In hemiplegia, consciousness re-
turning, while voluntary motion,  and sometimes
sensation, are lost.  Palsy  has thus been called a
minor degree of apoplexy.   Hemiplegia may take
place in very different degrees :  the entire half of
the body sometimes suffers, the medial line  being
marked with  great accuracy ;  so that one half the
tongue only, with its muscles, is  paralyzed.  Or
the affection  may be  confined to the face, or to  a
single limb.   The approach of apoplexy is some-
times denoted by merely a loss  of feeling in one
or more of the fingers.
   In some cases of hemiplegia, the sensibility of
the  part remains, or is even morbidly increased ;
while the voluntary muscles are alone paralyzed.
In higher degrees of the disease, both the blood-ves-
sels and the  absorbents appear  to partake of the
paralysis, if we may judge from the weaker state
of the pulse, as compared with that on the sound
side, and also  from  the oedematous  state of the
limb ; which seems to show deficient absorption.
   In all cases of apoplexy there  is a disposition
to a recurrence of tbe disease ; the number of fits
and the period of recurrence being uncertain.   In
most cases the patient is sooner or later destroyed.
Many  persons survive a considerable  number of
slight  attacks, but the more  severe  commonly
prove fatal on the second or third  occasion ; thus
verifying, in some  degree, the popular remark,
that the third fit of  apoplexy always kills the pa-
tient.
   Apoplexy  may take  place at  any age, but is
comparatively rare at  the early periods of life ; and
when it does occur  in the young, it usually comes
on slowly, and not by a  sudden  stroke, as at a
more advanced age.  A great proportion of old
people are cut off by  apoplexy.   The form  of
body appears to give  a predisposition to  the dis-
ease, as a large head, short neck,  and corpulency
of habit.  Luxurious diet, excess in drinking, pro-
longed study, and intense thinking, are all circum-
stances giving predisposition to the disease. Apo-
plexy is of more frequent occurrence in men than
in women ;  probably  from  the former being more
addicted to  excesses, both  as regards body and
mind.
   Morbid appearances.—It is reasonable to ex-
pect that the intrinsic nature of apoplexy might
be  determined by  a careful examination,  after
death, of the organ  principally affected.  This,
however,  as  will be  presently seen, is true to a
certain extent only ;  for there are numerous in-
stances on   record  of  apoplexy  proving fatal,
where no change in the structure  or condition of
the  brain could be  detected, that was at all ade-
quate to explain the  symptoms of the disease, or
to  account  for the deatb  of the patient.   And
even where manifest changes have been observed,
they have been so  various, and of so  common  a
description, as to afford no complete or satisfactory
elucidation of the subject.
   Many of the morbid appearances mentioned by
writers as having been observed  in the brain of
persons who have  died of apoplexy,  are by no
means to be considered as the immediate cause of
the apoplectic state, since  similar appearances are
found  in  other kinds of  cerebral disease,  while
CEREBRAL)                         143

they  are  not invariably  met  with  in apoplexy
itself.   The morbid  appearances to which we al-
lude are,  malformations of the cranium, ossifica-
tion of  the membranes or blood-vessels, adhesion
of the membranes, false membranes, alteration in
the texture of the brain, i. e. unusual hardness or
softness, tumours, hydatids, concretions of various
kinds, &c.   On  the other  hand,  cases  of apo-
plexy have been recorded in  which the apoplectic
seizure  has proved fatal without leaving  any dis-
coverable  lesion in  the brain,  though the symp-
toms were well marked before death.   To  these
cases, which are certainly uncommon, Dr. Aber-
crombie has proposed to apply the term simple
apoplexy.
   [It is  also termed  nervous apoplexy.   The
attack is almost  always sudden, and immediately
succeeding some powerful mental emotion. Should
tbe symptoms  of apoplexy have occurred many
times;  have continued for a  short  period  only,
and left behind them no evidence of modified con-
dition  of  the encephalic neurine, it has been in-
ferred that the apoplexy is of this variety.  This
inference  might,  however,  be very  erroneous,
inasmuch as  all  the  functional phenomena of
apoplexy  may be developed under a  hyperaemic
condition  of the  vessels of the  encephalon, which
may soon pass away.]
   The  morbid changes in the brain generally ob-
served  after  death,  which really appear  to  give
rise to the apoplectic state, are  the following :—
   1.  Extravasation of blood.—This is generally
a fatal  termination of apoplexy, and may be sus-
pected,  if  not positively predicted, when the attack
occurs suddenly and  unexpectedly, the patient be-
coming at  once  motionless  and insensible,  to
which condition  convulsions sometimes  succeed.
In other instances the individual does not become
instantly insensible,  but complains only of unea-
siness or fixed pain in the head, often confined to
one side.   He may remain sensible for some time
after the attack of head-ach ;  more or less oppres-
sion, however, succeeds, till perfect  coma is esta-
blished, from which recovery  never takes place.
The blood in those  cases is found  extravasated
most commonly  in the substance of the brain in
cavities of different  sizes ; sometimes there  is a
communication  between the cavity  thus formed
and the ventricles, or  the blood  finding its  way
through a lacerated opening to the surface, becomes
extravasated under   the   arachnoid   membrane.
When the blood has been effused in  one hemi-
sphere of  the brain, palsy  of  the opposite side has
been observed before death.  The appearance of
the  extravasated blood varies according to  the
duration of the disease.   When the apoplexy has
proved  suddenly fatal, the blood is dark-coloured,
almost fluid, or in soft semi-liquid masses.  If the
patient  survives for a longer period, the coagulum
acquires a greater degree of consistency, and is of
a  pale  red  and  sometimes  dark yellow colour.
The substance of the brain surrounding these apo
plectic cysts becomes altered : it generally appears
injected, and acquires a greater degree of softness ;
this softened state does  not extend  deep, but bt;
comes gradually less and less perceptible, till it is
impossible to discover any difference between the
sound  and  diseased  portion  of the  brain.  The
quantity of blood which  is  thus extravasated i« 
.44
very various :  in some cases it does not exceed a
few drops—often, however, two, four, or six ounces
have been found in these cysts.
  Extravasation of blood, nevertheless, is not  al-
ways fatal, as  appears from the changes observed
in the brain of persons who have survived  the
apoplectic  attack, but  remained paralytic, with
more or less disturbance in the sensorial powers.
In such cases the blood which has become effused
is partially or in some instances entirely absorbed,
and  the parietes of  the cyst undergo  a reparative
process—a partial cicatrization ; they approximate
and  become slightly connected by soft intersecting
bands, so  as to form little cavities, which some-
times contain a fluid of various quality and  ap-
pearance.  The number  of  these old apoplectic
cysts corresponds with  the sanguineous effusions
which have  at  different times taken place,  and
therefore  several have been found in the same
brain.   In some rare instances  these apoplectic
cysts  have  been found  completely  cicatrized,
which shows how  much is  often effected by the
reparative powers of  the system itself.  With re-
gard to the source of the hemorrhagic effusion, in
apoplexy,  it appears from the  researches of M.
Serres that the blood may in some cases proceed
from the minute vessels of the brain without rup-
ture, constituting that form  of the disease to
which the French writers have  applied the term
meningeal apoplexy : in these cases the blood es-
capes  from the vessels of the  arachnoid  into the
subjacent  delicate cellular tissue, or  into the ca-
vity of the ventricles ; and  the  substance of the
brain is sound.   When blood is found in the ven-
tricles, it may proceed from this source, or from
 the vessels of the choroid plexus, or from  a com-
 munication with an apoplectic  cyst  in the  sub-
 stance of the brain.
   The hemorrhage,  however, most usually takes
 place  from rupture of the  blood-vessels :* in el-
 derly persons the arteries of the brain often become
 diseased from ossification ; hence, when the blood
 is  impelled with more than ordinary force,  they
 are liable to give way, especially at those  periods
 of life, when the solids in general  lose their firm-
 ness.—" Omnes rami carotidis," says Haller, " qui
 cranio continentur,  tenui,  solida,, fragili  magis,
 quam reliquas arteriae,  substantia sunt."—Halleri
 prim. I'm. §  337.   Sometimes the  blood issues
 from a congeries of these small arteries, occasion-
 ally from an artery of considerable   size.  Thus
 M. Serres traced in one instance the  source of the
 hemorrhage  to  rupture of  the communicating
 artery of Willis.  In  another  individual it  took
 place from  aneurismal  disease  and rupture of
 the basilar artery.   In one case, reported by M.
  Moulin, of apoplexy which proved suddenly fatal,
  six ounces of dark-coloured blood were found  in
  the centre of the  cerebellum, which had arisen
  from  rupture of the trunk of the inferior cerebellar
  arteries.   It  would appear that, in all these cases,
  the morbid condition of the  arteries constitutes the
  principal and  primary lesion.  In the sixth vo-
APOPLEXY,  (CEREBRAL)

                 ^Iume of the Edinburgh Medical Essays, a case is
                    given by  Dr. Douglas, in which  the left lateral
                    sinus was ruptured ;  and a very uncommon case
                    (-quoted by Abercrombie) is recorded in the Me-
                    dical and  Surgical Register of the  Hospital  of
                    New York, of a  man who was  suddenly seized
                    with hemiplegia of the right side, and  died  five
                    days afterwards.  On  examination of the brain,
                    blood  was  found between the dura mater  and
                    bone, which was traced to erosion of a vessel from
                    caries of the inner surface of the  parietal bone of
                    the left side, not larger than a sixpence.
                       The most  frequent seat of extravasations of
                    blood in  apoplexy, according to  Morgagni, is the
                    corpus striatum.  This opinion has been found
                    substantially  correct  by  modern writers.    Of
                    twenty-eight  cases  examined  by  Rochoux,  in
                    twenty-four the extravasation was found  in the
                    corpus striatum.
                       [Of  386 cases, recorded  by  M. Andral,  the
                     extravasation was seated in the part of the cerebral
                     hemispheres, situate  on a level with the corpora
                     striata and the optic thalami, and at the same time
                     in both those bodies, in.............202 cases
                       In the corpora  striata, in..........   61  "
                       In the optic thalami, in...........   35  «
                       In  the portion of  the  hemispheres
                          above the centrum ovale of Vieus-
sens, in
27
In the lateral lobes of the cerebellum, in 16
Anterior to the corpora striata, in.. .  10
In the mesocephalon, in..........   9
In the spinal marrow, in..........   8
Behind the  optic thalami, posterior
  lobes, in  ....................   '
In  the median  lobe of  the  cerebel-
  lum, in.....................   5
In the peduncles of the brain, in ...   3
In one peduncle of the cerebellum, in  1
In the corpora olivaria, in........   1
In the pituitary gland, in.........   1
In the central white parts, in......   0
  * l_fhis  is not in  accordance with the investiga-
nons of pathologists.   On the  contrary, the appear.
anc.es on dissection favour the view that the hemorrhage
generally occurs from transudation through the parietes
of the vessels, which in many case3 are softened simul-
'aneously with or subsequent  to the  ramollissement of
il>e encephalic neurine.J
                                     386]

  Morgagni thought that the blood was more fre-
quently effused on the right than on  the left side
of the brain.   This, however, does  not accord
with the experience of Rochoux, who found, that
of forty-one cases, examined after death, in eighteen
the extravasation was in the left hemisphere ;  in
seventeen on  the right  side,  and  in six it had
taken place in both hemispheres.
   2.  Serous  effusion.—When serous fluid is ac-
cumulated largely in the  brain, so as to occasion
apoplexy by pressure, the chief seat of the fluid is
the different ventricles ;  though more or less is
generally found every where between the mem-
branes, often  passing down the spinal  column.
Apoplexy may be suspected to depend upon this
this cause, when the symptoms of oppressed brain
come  on slowly, and  in  an   imperfect  degree,
without any thing like a sudden stroke or fit.  In
many of these cases, however, of whit is termed
serous apoplexy, a sudden and  more violent attack
succeeds, so as  to prove quickly  fatal ;  and in
such  cases blood as well  as serum is  often found
effused in the brain after death.  Hence it is  ob-
vious that no ahsolute line of distinction can be
drawn between serous and sanguineous apoplexy 5 
APOPLEXY,  (CEREBRAL)
145
nor are they to be distinguished with certainty by
symptoms during life.
  Serous  apoplexy has been too generally sup-
posed to be the only form of the disease to which
persons of a spare infirm  habit, with pale counte-
nance and feeble pulse, are liable.   This,  how-
ever, is  a very erroneous idea.  In many  cases
which have presented, during life, all  the symp-
toms and characters which have been usually re-
garded as  pathognomonic of  serous apoplexy, ex-
travasation of blood has been  discovered on dis-
section.    Again,  in fatal  cases  of  apoplexy,  in
which serous effusion has constituted the  only
morbid appearance discovered, all the  symptoms
of  sanguineous  apoplexy  have  been  observed
during life, so that  the only legitimate conclusion
is, that the effusion is the effect of the previous
vascular disturbance in the brain, and  analogous
to the dropsical effusion which often occurs after
inflammation of serous membranes.   It is equally
apparent that the effusion is not the cause of the
apoplectic symptoms,—these are produced by the
morbid condition of the  brain  on which the effu-
 sion depends.
   The cerebellum being  seldom affected in apo-
 plexy, (the disease being  for the most part confin-
 ed to the  cerebrum,) accounts  sufficiently for the
 continuance  of the action of the heart, and of
 respiration during  the fit; these functions being
 more immediately dependent upon this part of the
 nervous system.   [This view is not sustained by
 the observations  of modern  physiologists.  The
 action of  the  heart is certainly not more immedi-
 ately dependent upon the cerebellum ;  whilst the
 medulla oblongata would seem to be the nervous
 centre of  respiration.]  For the same reason, other
 functions dependent upon the  general  circulation
 often go on unimpaired ;  as secretions of various
 kinds, and the evolution of animal heat.
   In many cases  an  unusual  degree of turges-
 cence of the veins upon the surface of the  brain
 has been  observed.  This appearance has furnish-
 ed the grounds of the doctrine of venous conges-
 tion, of which so much use has been made of late,
 in  attempts  to explain  the nature  of apoplexy.
 But there is a fallacy here, which renders such an
 explanation very unsatisfactory, as  will hereafter
 be shown.
   Causes of Apoplexy.—These have been  di-
 vided into external or obvious, and  internal, or
 such as can only be discovered by dissection after
death.  It is,  however, necessary to observe that
many cases are recorded of apoplexy taking place
 without  any  apparent  external  cause, while  no
internal cause, sufficient to account for the pro-
duction of  the disease,  could be  detected after
death.
   The obvious external causes of apoplexy are
the following :
   1.  Causes acting  mechanically,  by  making
pressure  on  the  brain :  such  are, fracture  of the
skull with depression of a  portion of bone; or
blood extravasated  immediately beneath the frac-
tured bone, without depression.  The reality of
this cause is shown by the effect of direct pressure
made upon the surface of the  brain  by the  point
of the finger, in cases where a portion of the skull
has been removed by the  trepan ;  or on the fonta-
nels or opening between the cranial bones  in the
   Vol. I.—19                          *
head of infants. Some nations are said to destroy
their supernumerary offspring in this manner.
  2. Causes tending to increase the arterial action
of the  brain ; either by direct application to the
head itself, or, indirectly, through the  medium of
other organs.   Of the former kind are, insolation,
or exposure  of the  naked head  to  the mid-day
sun ; and erysipelas affecting the scalp.   The in-
direct causes of vascular excitement of the brain
are various :—external heat applied extensively to
the skin, either through the medium  of the  sur-
rounding air, or by means of the hot bath ; breath-
ing a  heated  atmosphere,  especially  in crowded
rooms,  the effect  being probably increased  by
breathing contaminated air;  the inhalation of car-
bonic  acid  gas, and probably of other mephitic
airs ;  violent exercise ;  certain emotions of mind,
as anger,  terror, or joy ; indulgence in the  plea-
sures of the table, intoxicating drinks, opium, and
other drugs  of the  narcotic tribe.   Violent con-
cussion of the brain, occasioned by blows or falls,
induces a suspension  of the sensorial functions,
or an apoplectic state.  This suspension of func-
tions may be momentary, or it may be more dura-
ble ; even life itself may be instantly extinguished
in this way, according to the violence of the shock
sustained.
   3.  Causes which operate by impeding  the re-
turn of blood  from the brain ; as stooping ; the
application of  a tight ligature round the  neck, so
as  to  compress  the internal jugular veins ; tu-
mours of any kind so situated in the neck or chest,
as to interrupt the return of blood ^rom the  brain
to the heart;  diseases of the heart or lungs imped-
ing the transmission of the blood through the pul-
monary vessels; or  a voluntary suspension of
breathing  after a full  inspiration; as  in  blowing
wind-instruments,  or  in making  great  muscular
efforts of any kind.
   The internal causes of  apoplexy, or those that
are only discoverable after death, are—extravasa-
tion of blood in the substance of the  brain  or in
the ventricles, or serous accumulations in any of
the cavities, or between its membranes ;  tumours
of any kind, within the skull, of magnitude suffi-
cient to press considerably upon the brain.  Among
the occasional causes of apoplexy  also  may be
mentioned some  forms of fever, and all the  other
forms  of  cerebral inflammation.  Epilepsy and
hysteria, likewise, often terminate their paroxysms
by stupor, or an apoplectic state ;  which in gene-
ral disappears  after a few hours, though it  some-
times  ends fatally.  Extreme cold, long continued,
induces a state resembling apoplexy,  as far as re-
gards  the suspension of the  primary functions of
the brain.
   How these different causes, at once so numer-
ous and  apparently dissimilar in nature, operate
so  as to produce  the apoplectic state, is an inquiry
of some difficulty.  It is, however, one of much
practical importance, as the rational, and probably
the most  successful treatment of the  disease will
depend greatly upon a knowledge of the particular
cause, and its mode  of acting.   These  will be
more fully considered  hereafter.
   Theory of Apoplexy.—There are two points
here to be determined, or at least to   be inquired
into, namely, the primary and essential seat of the
disease, and the intrinsic nature  of the  affectio« 
146
APOPLEXY,  (CEREBRAL)
With respect to the for ner, there is little difficulty.
When we consider attentively the essential char-
acters of apoplexy,—that they all refer themselves
to the brain, and consist in a suspension or inter-
ruption of the sensorial or proper functions of this
organ, it would seem impossible to  refer them  to
any other source.   Some,  however, have  looked
to the  stomach as the primary seat of apoplexy,
at least in those cases where the attack supervenes
upon  a full  meal,  or is ushered  in by vomiting.
The notion that.a distended state of stomach acts
by compressing the descending aorta, and thereby
determining a larger flow of blood to the brain, is
too mechanical to be probable.   Were this a sat-
isfactory explanation, it would be an easy matter
to produce apoplexy at any time, by even mode-
rate pressure at the pit of the stomach.  An easier
explanation  may be given.  The  stimulus  of  a
hearty meal,  aided,  as it  commonly is, by strong
drink and mental excitement, has been sometimes
followed by, or it may be  said, has  given rise to,
a fit of apoplexy ;  but it is by exciting the vascu-
lar anion of  the brain that such a cause operates.
The brain is  still the part from  the  affection  of
which the apoplectic state arises ; the stomach is
merely the medium through which the brain is
impressed.   As to to the fact of many  cases being
ushered  in  by vomiting, thus affording,  it was
imagined, a proof that the stomach  is primarily
concerned, it is rather taking  the  effect for the
cause.  The same observation applies to the lungs.
When the lungs are so diseased  as to be  unable
to transmit the blood through them  with sufficient
freedom, the vital fluid will be deficient in those
properties which it derives from the atmosphere in
respiration, and by  which it is fitted  to  maintain
the living actions.   In this state, it may, no doubt,
contribute to the production of that general torpor
of system which is so evident in such  cases.  But
much more is attributable to the mechanical im-
pediment afforded to the return of blood from the
brain, by which the cerebral circulation is inter-
rupted, and the functions of the  organ  thereby
suspended or  annihilated : apoplexy, therefore, is
always and essentially a brain affection.
  The determination of the  second point of the
theory, viz., the  actual condition of the  organ
affected—the  brain—in  other  words, the  proxi-
mate or immediate  cause  of the symptoms, is  a
matter  of greater  difficulty,  and about which  a
variety  of opinions have been entertained ; few
of which, however,  are deserving  of serious no-
tice.  Among these may be mentioned the notion
that the symptoms  are caused  by a morbid  state
of the animal spirits,—by fermentation or ebulli-
tion of the blood,—by a relaxation  of the  nerves,
—by  spasm of the meninges or membranes cover-
ing the brain,—or by spasm  of the nerves and
vessels of the  brain, — (hence the term nervous
apoplexy, still employed  by  some to designate
those instances of the disease in which no  morbid
change is discoverable after death.)   It is hardly
necessarv to  observe that these notions are purely
hypotnetical, and rest upon no sort of foundation ;
and much more cannot be said, it  may be feared,
in favour of  the opinion of Dr. Cullen,  that cer-
tain of the causes  of apoplexy operate by induc-
ing an immobility  of the nervous fluid.   Other
immediate causes  of the apoplectic state  have
been assigned; as compression of the cerebral sub-
stance,  and  venous congestion; both of which,
however,  are liable to insuperable objections, as
will appear  upon  a fuller  investigation hereafter,
With much greater probability may the symptoms
of apoplexy be referred to  impeded or interrupted
circulation in the brain, a state which most, if not
all, of the known  and obvious causes of the dis-
ease  have a manifest tendency to produce, and
which seems fully adequate to the production of
the effect, namely, a suspension  of  the sensorial
functions.  When it is added that the treatment
of the disease will very materially turn upon the
admission or disproval of this opinion, it will be
readily  allowed to be deserving of  minute investi-
gation.
   The  nature of  apoplexy in general, however,
cannot  be understood, nor  its  most essential symp-
toms  explained,  nor  the  operation  of its causes
made intelligible,  without adverting  to  certain
physical peculiarities, by which  the  brain is dis-
tinguished from other organs.  These peculiarities
are not now brought  forward for the  first  time.
They were  long ago demonstrated by the eminent
professor  at Edinburgh, the  late Dr. Monro,  and
have  been recently confirmed by  a variety of well-
conducted experiments  instituted  on the  subject
by Kellie, Abercrombie, and others,  who  have
drawn  a  number of important conclusions  from
the facts so established.  These  facts, as well as
the inferences deducible  from them,  have  been
strangely  neglected, and  indeed have been scarcely
at all referred to either theoretically or practically,
by recent writers  on diseases of the  brain; al-
though  it is quite impossible, without having re-
course to  them, to  explain or  even to comprehend
a  great  number  of the phenomena that attend
such affections.
   The  physical  conditions,  then, by which the
brain is distinguished from other organs, are those
which follow :
   1st. The brain is enclosed in an unyielding case
of bone,  the cranium or  skull,  the contents of
which are by this construction excluded from the
influence  of atmospheric pressure.
   2dly. The cavity of the skull  is always accu-
rately filled by its contents, namely, the encepha-
Ion or general mass of brain, including the mem-
branes,  and vessels, and  the blood contained with-
in them.  So long as the skull  is perfect, there
can be  no rising and falling of the brain, so as in
the latter  ease to leave a vacuity between the skull
and the surface of  the brain, these parts being al-
ways in actual and close contact.
   3dly. The contents of  the skull solid as well.
as fluid, if not absolutely  incompressible, at least
are so by  any force that can  by possibility be ap-
plied  to them during life ;  and there  is no air, or
other elastic fluid, to be  found within the cavity.
   This incompressibility of the cerebral substance
is easily  demonstrated  by experiment.   It is a
property by no means belonging  exclusively to the
brain, more than to the whole of the animal solids.
This  is the less  to be wondered at, when it is
recollected  how large the proportion of water is
which  enters into the composition of these, and
that water,  as well as  other fluids, is so  nearly
incapable of compression as to require a vast force
to render it at  all  perceptible.  But  although the 
APOPLEXY,   (CEREBRAL)
147
substance of the brain, in common  with other
animal solids, be incompressible, its blood-vessels
will readily yield to pressure, so as to be emptied
of their contents; a necessary consequence of which
is, a stoppage of the circulation  in  the part so
affected.   The pressure may be made to take place
on any part of the brain, even the most remote
from the principal vessels ; yet nevertheless the
pressure, by operating through an incompressible
substance, may influence vessels the most distant,
so as  thereby to impede, if not wholly interrupt,
the cerebral circulation.
   The circumstances above  stated with respect to
the brain, lead to very important deductions, both
theoretical and practical. It follows, ex necessitate
rei, that  no material variation can  take place,
within a short period,  in regard  to  the  absolute
quantity of blood in the  brain.   No additional
quantity can be admitted  into the blood-vessels
situated there, the cavity of the skull being already
completely  filled by its contents.   A plethoric
state of over-fulness of the cerebral vessels altoge-
ther,  though often  talked of, can have  no real
existence ; nor on  the  other  hand can the quan-
tity of blood within  the vessels of the  brain be
diminished, any more than can wine or other fluid
be drawn from  a  cask without furnishing an
equivalent for the portion abstracted from it, by
the supply of an equal bulk of air, which in the
case of the brain can of course find no entrance.
No abstraction  of  blood therefore, whether it be
from the arm or other part of the general system,
or from the jugular  veins, (and still less  from the
temporal arteries,)  can have  any effect on the
blood-vessels  of the brain,  so as to  lessen the
absolute quantity of blood contained  within them.
   From the experiments  of  Dr. Kellie, it  was
found  that in animals bled to death the brain still
contained  the  usual quantity of blood; and in
some cases the superficial veins were found gorged
with blood, and the sinuses full;  the rest of the
body being  at the same time blanched, and drained
of its blood. In a few instances, the brain appeared
to contain less blood than usual; but then  there
was found  some  serous exudation.   When the
cranium of the animals subjected to  these experi-
ments was perforated before they were  bled, the
brain was as much emptied of its blood as the rest
of the  body.   In two instances of persons that had
been hanged, the cellular membrane  of the whole
head   externally  was  turgid  with   blood ; but
nothing peculiar was observed in  the  state of the
vessels of the  brain itself.   When  blood is sud-
denly or rapidly extravasated anywhere within the
skull,  the space thus occupied can  only be fur-
nished by the compression and consequent empty-
ing of the blood-vessels in other parts of the brain ;
and in  the same degree that this happens, it is
evident that the circulation  of such parts must be
interrupted.  But in  the  formation  of tumours
within the skull, and during the  slow accumula-
tion of serum from inflammation or any  other
cause, the cerebral substance itself may be absorbed,
to an extent corresponding with the bulk of the
tumour, or the quantity of serum  deposited.   The
circulation of the brain may then go on uninter-
ruptedly, and thus  the apoplectic  symptoms be
prevented.
   But although, under ordinary circumstances, the
absolute  quantity  of blood contained  within  tho
vessels of the brain must remain the same, there
may be great differences in regard to its distribu-
tion, and the force  and velocity with which it is
moved.   Thus, the arteries of the brain altogether
may be unusually distended  with blood ;  but in
this  case  the veins will be  in  the  same  degree
compressed and emptied, and the circulation of the
organ  proportionally  interrupted, with  a corre-
sponding interruption of functions.
  Again, there may be a partial fulness or disten-
sion of vessels in one  part of the brain only, but
this must be at  the  expense of the  rest of  the
brain, which will be proportionally deprived of the
usual supply of blood.   This will be the case in
circumscribed cerebral inflammation, as well as in
other cases of partial  excitement  of the organ.
The different parts of  the brain will  then be in
different, and perhaps opposite states, in regard to
the performance of their functions.  The functions
of one of the cerebral organs may  be  excited,
while those of another may be imperfectly carried
on or depressed.   Such an inequality in the state
of the cerebral  functions  is observable  in most
diseases  of  the brain ;  for there are probably  few
in which the whole organ is simultaneously  and
equally affected.
   In like  manner there may be great diversity
with respect to the force and velocity of circula-
tion in the brain ;  the  absolute quantity of blood
in the vessels remaining still the same.   In  this
way the functions may be more or less excited, or
more  or  less disturbed. These changes in the
state of the cerebral circulation are all independent
of  the  heart, the action of  which has but  little
influence over the brain or  its functions.  It fol-
lows, from what has been now stated, that blood-
letting, when employed as a remedy in apoplexy
or other brain-affections, however useful it may be
and undoubtedly is, in  many cases, does not effect
its purpose  by diminishing in any degree  the
absolute quantity of blood  in the brain,  but by
reducing the velocity and impetus of the circula-
tion there, and which it does by influencing the
general system.
   We have seen that the changes observed in the
brain  of  apoplectic persons are very  dissimilar;
and that, in some instances, as has  been stated
above, no material deviation from the natural state
of  parts has  been found ;  it is plain, therefore,
that such changes, when they do occur, cannot be
the proximate cause,  the causa continens, of the
symptoms, but are to  be considered, at  most, as
remote causes ; and, with regard to some  of them,
are to be looked upon rather as mere coincidences
than causes.
   The opinion that appears  to prevail most gene-
rally at present, as to the immediate cause of the
suspension  of functions that constitutes the apo-
plectic state, is that the remote  causes of the dis-
ease, such as extravasated blood, and accumulation
of serum, produce a  compression of the cerebral
substance, thereby interrupting its functions.  But,
besides that some of the remote causes of apoplexy
have no  apparent tendency to make  any direct
pressure on the brain, it must  not be overlooked
that the cerebral substance  being  in its nature
incompressible, cannot, so long as the  blood is
contained within its vessels,  be exposed to great*" 
148
APOPLEXY,  (CEREBRAL)
pressure at one time than another.  It must be in
some  other way, therefore,  than by compression
af the substance of the brain, that  the remote
;auses act in producing their effect.  It cannot be
questioned that pressure on  the brain of any kind,
if carried to a certain extent, is capable of inter-
rupting the functions of the  organ so as to induce
apoplexy ;  but there is good reason to believe that
the pressure operates upon the  blood-vessels, so as
to impede  mechanically the passage of the blood
through them ;—in a word,  that interrupted circu-
lation in  the brain is the proximate or immediate
cause of that  temporary suspension of the senso-
rial functions which  constitutes the  apoplectic
state.   To establish this opinion, it will be neces-
sary to show ground for believing, first, that these
functions are  dependent, for  their performance,
upon  the continuance of the cerebral  circulation ;
and, next, that all the remote causes, the operation
of which  is at all  understood,  have a manifest
tendency to produce such an interrupted  state of
circulation in the brain.  If  these points are estab-
lished, it is plain that a different indication of cure
ought  to  be  followed,  from  that usually  pur-
sued.
   It can scarcely be doubted, we imagine, that the
brain,  in common with  other organs,  depends
mainly for the performance  of  its functions upon
the continued  circulation  of  blood  through  its
vessels, and without which those functions must
soon cease to be performed.   This dependence of
the sensorial functions  upon the circulation of the
brain, is shown, first, in  the case of syncope ;  in
which the action  of the heart ceases altogether,
or nearly so, for a time ; and, consequently, little
or no blood is sent to the brain.  In this case, the
sensorial  functions  are suspended,  the  patient
becoming unconscious, insensible to  impressions,
and  without  voluntary movement.   If,  on  the
other  hand, the return  of blood  from  the brain to
the heart be obstructed  by causes influencing the
veins, the same interruption is  given to the circu-
lation of the brain, and the same suspension of its
functions follows.  This is seen, where the head is
made the most depending part, as in  stooping, in
persons who are  predisposed  to  apoplexy :  the
vessels for a time are incapable of carrying the
blood upwards against gravity, and it necessarily
therefore stagnates in   the  vessels of the brain ;
with the same consequence  as  before, suspension
of the sensorial functions.   Were it practicable to
tie the  internal jugular veins, it can hardly  be
doubted that the same  effects would follow ;  for a
less complete obstruction to the return of blood
from  the  brain, by these veins, produces similar
effects ; such, for example, as is  occasioned  by
tumours in the neck, or in the course of the supe-
rior cava, or by disease of the heart or lungs ;  all
of which give a tendency- to apoplexy.  There is
so far an analogy between the  two states of syn-
cope  and  apoplexy, that in both the circulation
01 the brain is interrupted, and in both the senso-
rial functions are suspended.   The  difference is
not as regards the brain itself, but the rest  of the
nody.  In  the  one case,   (syncope,)  the  blood
ceases to be sent  to the head  altogether; but in
the other case, (apoplexy,)  the  blood  is stagnant
in the brain only ;  while the heart continues  its
action, and the  general  circulation is still carried
on, the pulse beats, and the vivid hue of the coun-
tenance is preserved.
   These two cases, of syncope  and  apoplexy,
would seem to prove  sufficiently that unless the
circulation of blood through the brain be continued,
the organ is incapable of carrying on its functions.
But while this is admitted, it is of importance also
to know that the brain is much  less dependent
upon  the action of the heart and general vascular
system  than is  commonly supposed.   It is  upon
the action of its own vessels that the brain chiefly
depends for the  performance of its functions, and
the modifications which those functions occasion-
ally undergo,  both in health and in disease.   We
frequently  observe the action of  the  heart  and
general vascular  system  greatly  increased  and
disordered, as in acute rheumatism and other active
inflammations, where the pulse is full and strong,
and the general circulation carried on with the
greatest vehemence, and yet the proper functions
of the brain are undisturbed.   This it is not diffi-
cult to  understand, when we  advert  to the con-
trivances of nature to guard the brain  against any
violent  impulse  of the blood,  as  derived from the
heart;  by the bony and tortuous canals through
which the arteries enter the skull, the anastomo-
ses which  take place within,  and  the  minute
divisions and  ramifications which the arteries sub-
sequently undergo, before  they arrive at, and are
distributed throughout the cerebral substance.
   In  other cases, where the blood is sent sparingly
to  the  brain, and with  the  feeblest  impulse,—
where, in fact, the pulse at the wrist is scarcely
perceptible,  and the general circulation is nearly
at a stand,—the brain nevertheless, preserving the
action of its own vessels, and  thereby maintaining
its circulation, is found capable of performing some
of its most important functions ;  and that  often
within a few  moments of the termination of life.
In fact, in all the diseases of the encephalon, it is
the state  of action  in  the cerebral vessels them-
selves, and hardly at all that of the general vascu-
lar system,  which regulates  and  determines the
phenomena and effects of the disease.  The ex-
pression therefore, determination of blood to the
head, in such general use, appears to be unfounded,
as implying that the quantity  of blood impelled to
the brain, and the force of circulation there, depend
in  any material  degree  upon  the  heart's action,
instead  of the action of the cerebral vessels them-
selves.
   Of the mode of action of the remote causes of
apoplexy.—Let us  now proceed to inquire how
far the  different remote causes  of apoplexy have
actually a tendency to produce the  effect supposed
—that of interrupting the circulation  in the brain,
and thereby impeding, or more or less perfectly
interrupting, its functions.
   The  simplest remote or occasional cause of the
apoplectic  state is strong  pressure made on the
surface  of the brain from without.  When, for
example, the skull is perforated, or otherwise ren-
dered imperfect, and  the point of the finger  is
pressed with a certain degree of force on the brain,
the animal becomes motionless and insensible—in
other words,  apoplectic ;  and this continues till
the pressure of the finger  is removed.   According
to  the  theory proposed, it is obvious  that  such
pressure must of necessity have the effect of oh- 
APOPLEXY,  (CEREBRAL)
149
structing, more or less, the circulation  of blood
through the organ.  From the incompressible na-
ture of the cerebral substance, such pressure  may
affect the vessels situated in the remotest parts of
the brain, as readily as those to which the pressure
is more immediately applied.   Here, therefore, as
far as the  circulation of the blood  in  a part  is
necessary to the performance of its functions, we
hive  an  adequate cause  of the  suspension of
functions which characterises apoplexy.   In like
manner,  fracture of the  skull, with depression of
a portion of bone, or blood extravasated beneath
it, equally  induces an apoplectic  state, by com-
pressing  the blood-vessels, and which is seldom
relieved  till  the  depressed portion  of bone  is
elevated, and the extravasated blood removed.
   Extravasation of blood, or serous accumulation
in the interior of the brain, must necessarily have
the  same  effect, by  taking up space which can
only be furnished  by the blood-vessels yielding to
the pressure thus  made upon them.   In  all  these
cases it  is evident  that the circulation of blood
through  the brain  must be impeded or interrupted,
 in different degrees,  according to the extent of the
 pressure so applied.   If this should be great, and
 suddenly induced, such a degree  of stagnation
 may  take  place, as to  be incompatible  with life
 itself.
   Again, if a tumour is formed within  the  skull,
 whether it be a morbid production  of  any kind, or
 a case of common inflammation ending in abscess,
 in either case space is required, which can only be
 supplied, either by the removal of a corresponding
 portion of cerebral substance by the slow process
 of absorption,  or  by the emptying of the blood-
 vessels of  the  brain, as the natural consequence
 of the pressure which  such tumour is making on
 the surrounding parts.
   In all the cases above described, simple observa-
 tion, or dissection, will illustrate the nature of the
 disease,  by pointing out the  immediate cause of
 the impeded or interrupted circulation in the brain.
 But  there are other cases of apoplexy, in which
 dissection  detects  nothing adequate to explain the
 symptoms; which, therefore,  must  be otherwise
 accounted for.
   It has  been a  very generally received opinion
 that  such  an increased  determination of blood to
 the  brain  may take place as  to  give  rise  to an
 overloaded state of its vessels, so  as  to disable it
 for  the  performance of its functions, or, in  other
 words, to induce  an apoplectic state.
   This  supposed determination  of blood to the
 brain, and the  impeded state of functions arising
 out of it, have  been ascribed to increased action
 of the. heart.   But  it has been  already shown,
 that the brain is incapable of receiving  any addi-
 tional quantity of blood  in  its  vessels ; conse-
 quently, there can be no such over-fulness as has
 been supposed, to account for the oppressed state
 of the organ.   And were it otherwise, the  heart
 has  no  power of sending blood  to  the  brain in
 greater quantity than to other parts.  If the force
 of circulation  in  the brain be increased, as it un-
 doubtedly may be, such an effect  is  owing to the
 increased  action of its own vessels, and  not to that
 of the heart.  The phrase, determination of blood
 to the brain, is, therefore, without meaning.
   Much has been  said of late of venous conges-
                                        »*
tion, as one of the  immediate causes of the apo"
plectic state.  This notion  is founded, as before
observed, solely upon the fact, that in some cases
of apoplexy, the  superficial veins on the surface
of the brain are found gorged with blood.  Hence
it has been imagined  that the same state of veins
existed during life.  It is, however, a great  error
to suppose that  the appearances observed in the
body after death are a true representation of  what
existed during life,  especially as regards the blood-
vessels.  It is a general principle in physiology
that the arteries, in  consequence of the greater
degree of contractile power naturally possessed by
them,  empty themselves into  the veins,  as  their
last act of life ; and accordingly the blood is prin-
cipally found in the veins upon dissection.   This
law applies to the brain no less than to other parts:
and consequently the veins, which are principally
situated on the surface of the  brain, running be-
tween the convolutions, are always found more or
less distended with dark or venous  blood ;  while
the principal arteries, situated  towards  the basis,
are found comparatively empty.  Now no one can
believe that this state of the arteries and veins of
the brain, relatively to each other, could exist—
that the arteries could be empty and the veins full,
during life ; for such a state of things would be
clearly incompatible with  the  regular  movement
of the blood, which requires that there should be
a continuous stream throughout the vascular sys-
tem.   The  blood which the veins contain, what-
ever be its quantity, must be derived from the arte-
ries ;  and if there be  found,  after death, a more
than usual quantity of blood  in the  veins,—if
they  are  in  a  congested state, (to  use a modern
though unphilosophical expression,) or unusually
gorged with blood,—it is  only a proof that the
arteries, at the time of  death, had sent into them
an extraordinary quantity of blood;  and that they
had  probably been unusually distended during
life.  This  is confirmed by the fact that such  a
gorged state of  the veins  on  the surface  of the
brain  is  met with in  those cases  of disease in
which the arterial action of the  organ during life
has been the most violent.
   The term congestion,-therefore, as implying an
unusually distended state of vessels  in the brain,
applies to the arteries,  and  not to the veins ; the
gorged state of the latter taking place only at the
time of death.  The importance of this distinction
will be seen, in laying down the treatment of apo-
plexy, as well as other acute cerebral diseases.
   It remains to  be shown, how  such a distended
state of the arterial system of the brain is calcu-
lated to produce the apoplectic state, by impeding
the circulation through the organ.   This will be
best  illustrated by showing how the state called
intoxication, or drunkenness, is produced by alco-
hol, or other inebriating liquors.  Alcohol,  in all
its combinations, and however applied to the body,
proves a stimulus to the arteries of the brain; and
in whatever way it produces its peculiar or specific
effects, its  action  may  be  justly termed  specific
 with respect to this organ, as it produces nothing
 similar, at least  in an equal degree, on any  other
 This specific and stimulant power of alcobol with
regard to the brain,  is  evinced by unequivocal
 proofs of increased arterial action  in  the whole
 head ; as well as  by the disturbance in the statp 
 150                         A P 0 P L E X Y.

of the  sensorial functions which  it  occasions.
The increase of action in the  external  carotid
arteries is manifested bv  the  stronger pulsation
and increased size of  both the cervical and  tempo-
ral arteries, and by the flushing  of the face, and
redness of the eyes ;  all of which  clearly show
increased  action in the branches of the external
carotid :  and  that  a  similar state of  excitement
takes place in the internal arteries of the head and
their ramifications  throughout the brain, may be
inferred with great  probability from the increased
heat of the whole head, and  from the feelings of
the individual,  especially when  recovering  from
the effects of intoxication ; at which  time there
is frequently violent throbbing head-ach.
  Admitting, then, that the  peculiar and specific
effect of alcohol is  to stimulate and  excite the
blood-vessels of the brain to greater action, it will
not be difficult to  account for the  different  and
even opposite effects of the same  stimulus, accord-
ing to the degree in  which it  is applied, and the
time that has elapsed  from its administration : and
certainly nothing can well be more different than
the effects produced by a moderate use of wine, or
other strong  drinks,  and the highest state of
drunkenness.  In the one case, the greatest energy
and activity are displayed throughout  the  system
—in the other, some  of the most important func-
tions of the  brain  are nearly  annihilated.   This
apparent  incongruity of symptoms, however, will
vanish, if we  advert  to the effects of stimulation
on arteries in general, as applied in different de-
grees ;  and, at the  same time, recal to our recol-
lection  the  peculiar  physical circumstances in
which the brain is placed, as  already noticed.
  A moderate degree only of  excitement  of arte-
ries merely increases their action, and  augments,
in consequence, the  impetus  and velocity of the
blood through them, but without manifestly,  or at
least  considerably,  increasing  their  diameters.
Under a  more  powerful degree of excitement,
their diameters become enlarged ; the quantity of
blood in them is increased, and at the  same time
put into more rapid  motion.   These effects may
be readily seen upon  immersing an extremity, the
arm for example, in hot water :  both arteries and
veins become  enlarged ; the blood circulates with
greater force  and velocity; and  the  bulk of the
whole limb is increased.
  The same law doubtless holds good with respect
to the  blood-vessels of the brain.   There is the
same tendency as in other parts to enlarge their
dimensions  from the  application of stimuli; but
with this difference, that from the peculiar circum-
stances in which this organ  is placed, as before
pointed out, there is not room for the simultaneous
expansion of both arteries and veins.   The arte-
ries  becoming enlarged in their diameters,  as a
consequence  of their increase of action,  occupy
greater space within the skull  than before, and in
so doing necessarily compress the veins, these lat-
ter being  the only parts that yield to pressure. It
is obvious, then, that the movement of the blood
through the brain must be impeded,  in proportion
as the  veins are suffering compression ; and  this
again will depend upon the degree of excitement
nnd distension  that exists in the arteries:  and
thus the different degrees and  successive stages of
intoxication  are easily understood :  in the  first
(CEREBRAL)

 degree of excitement, by a moderate use of vinous
 liquors, the  movement  of the blood through  the
 vessels of the brain is augmented ; the action of
 the arteries being simply increased, without any
 material increase  of their dimensions,  the veins
 are still in a condition to receive  and to transmit
 the arterial blood.   In this state of the circulation
 of the brain, the  sensorial functions  are  simply
 excited, but without disorder;  the powers both of
 body and  mind are displayed with greater energy;
 but'in a higher state of excitement from the same
 cause, the arteries of the  brain become distended,
 the veins  are pressed upon, and the circulation is
 proportionally  impeded.   Disorder of  functions
 then succeeds to the  previous  state of simple ex-
 citement ;  and if the stimulus be  carried to the
 highest excess, the circulation of the brain becomes
 almost wholly interrupted ; and  the consequence
 soon  is an entire abolition  of all the sensorial
 functions, or in other words, the highest degree of
 intoxication.  This state continues till the excited
 and distended arteries gradually subside into their
 former  and natural state of action and  fulness;
 when the pressure is taken off from the veins, and
 the circulation through  the  organ is renewed:
 with this, a  restitution of its functions takes place,
 the stupor gradually disappearing.
    Another  cause  of excitement of  the  arterial
 action of the  brain is  the hot-bath ;  and, still
 more, the direct application of heat to the naked
 head, as in the coup-de-soleil, to which we have
 before adverted, botb of which occasionally give
 rise to apoplexy  ;  which  however is  generally
 temporary in duration, and for  the most part with-
 out danger ; unless, from the violence of action,
 a rupture of vessels should take  place, or inflam-
 mation should follow, when the character  of the
 disease becomes changed.   The apoplectic  stupor
 that attends both of these cases, wbether produced
 by the hot-bath or by insolation, admits of a ready
 explanation upon  the principle of arterial fulness,
 as before illustrated.
    Again, the arterial action of the brain is strong-
 ly excited by certain emotions of mind, particu-
 larly anger and joy ;  both of which, when  exces-
 sive, have been found  to induce  apoplexy, and
 sometimes witb a fatal result.  They may easily
 be  conceived  to operate  in  the way  mentioned;
 namely, by arterial fulness producing venous com-
 pression, and consequently interrupted circulation
 in the brain.
    Lastly, inflammation of the brain,  when gen-
 eral or extensive, whether it be a primary affection
 or arising in the course of other diseases, not un-
 frequently terminates in apoplectic stupor.  At
 the commencement, just  as in the early stage of
 intoxication,  there  is excitement, witb  more or
 less of disorder, in the sensorial functions : as the
 inflammation  increases, the  disorder of functions
 increases  likewise  ; there is  then  frequently furi-
 ous delirium.   At length, stupor takes place, and
 the patient often  dies  apoplectic.  Of all these
 changes we have frequent examples, in the cases
 of hydrocephalus, phrenitis, and idiopathic fever;
 these differ from  ordinary cases  of apoplexy, in
 possessing the characters of inflammation along
 with those of oppressed brain.  In all, the same
 cause of cerebral oppression  exists ; namely, ob-
 structed circulation induced immediately by arterial 
                             APOPLEXY,

fulness ;  which, in a circumscribed space, as that
of the skull, must of necessity compress the only
yielding  parts, the veins, and thereby impede, and
in extreme cases put an entire stop to, the circu-
lation of the brain, and thus destroy  life.
   Thus it appears that apoplexy may be produced
by a variety  of  remote  causes, all operating  in
different  ways, but  all leading to the same gen-
eral result — obstructed  circulation of the  brain.
Whether this be produced by direct external pres-
sure, or by extravasated fluids, or tumours, within
the  skull;  whether by  arterial  excitement and
consequent  distension,  as produced  by  either
alcohol, external heat, or mental emotions ; — or
whether  by any impediment to the return of blood
from the brain,  by causes influencing the veins ;
— the effect is  still the same,  and suggests the
same general indication of cure; namely, to re-
store the circulation of  the  brain.   The  means,
however, of doing  this will vary according to the
nature of the obstructing cause, the  removal  of
which is the principal object of  practice.
   It may be asked here, is there any cause (not
mechanical) capable of  influencing  the sangui-
ferous syst  m of the brain exclusively, so as  to
paralyse, as it were, its blood-vessels, and thereby
put  a stop to the movement of  the blood in that
organ ? Is apoplexy ever induced in this manner ?
Has carbonic acid, or any of the narcotic tribe,
such a power ?   Is natural  sleep, in which  the
sensorial functions are all suspended, the result
of diminished action in  the blood-vessels of the
brain, and consequent retarded  movement of the
blood through the organ  ?  And  may not dream-
ing  and  somnambulism  be explained on the sup-
position  that some  parts of the vascular system
of the brain continue in an active state, while the
rest become  quiescent ?   These are  important
questions, to which, however, a satisfactory answer
can  hardly  be given in  the  present  state of our
knowledge.   The insensibility induced by extreme
cold may perhaps be so  explained..  The  subject
altogether merits consideration.
   The prognosis in apoplexy is governed, in some
measure, by the  actual condition of the brain, and
also by the nature of the remote cause, and  the
possibility of its  removal.  This will be best un-
derstood  when we  come  to  the particular treat-
ment of the disease  under its  different  circum-
stances.  It may be observed in general, that  a
very large proportion of  cases of apoplexy termi-
nate  fatally ; some of them immediately, some
after  a longer interval.   Those  that do not prove
immediately destructive to life,  are often fatal on
recurrence,  though  repeated  attacks  may  inter-
vene.  Cases that  depend upon vascular excite-
ment merely, without lesion  of structure, and
without extravasation of blood, or accumulation
of serum in the  brain, may be judged of favour-
ably.   But  as these points can seldom be  deter-
mined with  certainty during life, the prognosis in
apoplexy is  always more or less doubtful, and for
the most part unfavourable.
   Treatment. — There is  perhaps  no disease
the treatment of which  requires so much  to be
directed by  theory or general principles as apo-
plexy.  The practice in  general use is, for the
most  part,  unnecessarily  violent; and, in some
respects,  contradictory.  Bloodletting to  an un-
(CEREBRAL)                         131

 reasonable  extent, vomiting, purging, blistering,
 sinapisms, and a variety of other stimulants, have
 all been administered with an  almost indiscrimi-
 nate and  unsparing  hand ;  as if, to  insure re-
 covery, it were only necessary to have recourse to
 sufficiently active  means,  without much regard
 being paid  to their nature or effects.  The treat-
 ment thus  becomes  needlessly complicated  and
 severe ; and there is reason to believe that the end
 sought after is often thereby frustrated rather than
 promoted.  It is  necessary, in order to practise
 with success, to  look not only to the symptoms,
 but to the intrinsic nature  of the  affection ;  and
 more especially to the various  remote  causes by
 which the disease may be  induced, the obviating
 of which is the principal  object of attention in
 the cure.   Without these distinctions being made,
 the treatment becomes little more than empirical.
 It is above  all things necessary to guard against
 the profuse and almost unqualified use that is
 made of the lancet on those occasions, apparently
 without consideration of what it  may  be  really
 capable of effecting,  and what  it is incompetent
 to  perform.  By  injudicious application, it  will
 not only fail to do good, but may impede recovery,
 and even tend to destroy life.
   Admitting  that the proximate  or immediate
 cause of  apoplexy in general,  as  far at least as
 this is understood, is impeded or  interrupted  cir-
 culation of blood in  the  brain, the simple  and
 obvious indication of cure to  be  followed, is to
 restore the circulation so obstructed ; which is in
 general only to be accomplished by the removal
 of the obstructing cause.   This  being various,
 and  different  at  different times, may require  dif-
 ferent and  even opposite  means  for its removal
 It  becomes necessary, therefore, to show the  in
 dividual treatment of  apoplexy, in relation  to its
 exciting or occasional cause ; and for this purpose
 it will be useful to follow the order laid down in
 speaking of the various remote causes of the  dis-
 ease.  These may  be usefully arranged  under
 three heads, viz. : 1st, such as  act by mechanical
 pressure on the  brain; 2d, such as act by pro-
 ducing arterial excitement and distension ; and,
 3d, such as occasion impediments to the return of
 blood from  the brain  by the veins.
   1. Treatment of apoplexy in reference to  the
 first division of causes.—When  apoplexy  is in-
 duced by  fracture of  the skull with depressjon, or
 where blood is effused immediately beneath  the
 bone, the  treatment  is simple  ; consisting prin-
 cipally in the  elevation or removal  of the depress-
 ed  portion  of bone.   The  means of accomplish-
 ing this are within the province of surgery.  The
 after-treatment consists in  endeavouring to pre-
 vent and  to remove inflammation by bloodletting
 and other analogous remedies.
   An interruption or suspension of the  sensorial
 functions may take place as the result of external
 violence, in which there is no injury  done to  the
 bone, nor other source of pressure on the brain.
 This has been referred to  concussion simply, 01
 the shock which the organ has sustained from  tho
 fall  or blow received.  The injury done to  the
 brain in some of these cases is  so  great,  as to
 prove immediately or  quickly fatal; and yet, upon
 dissection,  nothing has been found  adequate  to
 explain the effect.   At other times  vessels hnvo 
152                         A P O P L E X Y,
been ruptured, and blood found effused, sufficient
to explain the apoplectic state.  It is not possible,
at all  times, to  distinguish,  during  life, between
the effects of simple concussion, and those arising
from  the pressure of extravasated blood in  the
brain ; and  the difficulty is the  greater from  the
circumstance, that the case is often  complicated ;
the same degree  of  violence that  occasioned  a
rupture of blood-vessels, almost of necessity pro-
ducing a considerable shock to the brain.   The
distinction, in regard  to symptoms, that has been
supposed to exist in  the two cases of concussion
and  extravasation, is  by no means  to be  relied
upon.   Still less does there appear to be  a  foun-
dation for the widely-different methods  of cure,
that  have been proposed  with respect to  them.
The older  writers on surgery relied  principally
upon bloodletting in cases of supposed concussion,
as well as  in other injuries of the brain.   The
moderns, some of them  at least, influenced pro-
bably more by love of novelty than  real observa-
tion, condemn in toto the practice of bloodletting,
and recommend, instead of it, a  totally opposite
mode of cure ; namely,  the  use  of opiates  and
general stimulants.  In neither case  does the view
that  has been taken of the subject  appear  to be
altogether correct; nor is the practice recommend-
ed at all times  consistent with reason.   Experi-
ence,  which  has been adduced in favour of both
modes of practice, cannot  be  implicitly  relied
upon.   Upon the supposition that the brain  has
suffered only from  the shock, without depression
of bone, or extravasation of blood, it is not con-
ceivable  that bloodletting  should be  capable of
affording any immediate, relief.  The medullary
substance may have been deranged, or have  un-
dergone  an  imperceptible  solution of continuity
in the minuter parts of its structure ; or its vital
properties may bave been simply affected, without
physical or mechanical injury ; but in neither case
is bloodletting an  indispensable remedy.   There
is one point of view, bowever, in which blood-
letting may  be  considered of importance ;  and
that is, in regard  to its power of preventing  in-
flammation,  which is  an almost necessary conse-
quence of such violence committed  on the brain.
The propriety of bloodletting, however, will  still
be to be governed by  circumstances,  and especial-
ly by  the state  of the general  vascular  action ;
which differs considerably in different instances.
In some  cases of simple concussion  of the brain,
the general  circulation is carried on very feebly ;
the pulse is weak and soft,  with  varying  fre-
quency ; and the body is cold.   Such a state  can
hardly be supposed to require, or even to bear,
loss of blood.  At other times, the action of  the
general vascular system is  little  altered from  the
natural state.  In such cases, the moderate  ab-
straction of  blood  would be safe and proper, as  a
means of preventing subsequent inflammation.
It is scarcely necessary to add, that if the pulse at
the wrist is  fuller or  stronger  than  natural,  (as
may  be the  case from the first,  or it may take
place  at some period after  the infliction of  the
injury,) there need be no hesitation as to  the free
abstraction   of blood ;  limited,  of course, by  the
general strength  and  other circumstances of  the
patient.  But, admitting that bloodletting is  not
 squired  in  any particular case of concussion of
CEREBRAL)

the brain, docs it follow that opiates or stimulants
should be proper ?   What  possible tendency can
either of these have to  relieve the injury which
the brain has  sustained, either with regard to its
physical or vital properties ?   Even should the
general circulation be greatly depressed, still it  is
not easy to  see how exciting it by active  stimu-
lants should be productive of much good, as they
are not likely  to produce lasting good effects, nor
have  they any  tendency to remove the cause;
namely, the injury  the  brain has suffered.  On
the other hand, if largely used, they may increase
the tendency  to  inflammation, and thus become
objectionable.   Upon  the whole, except  the em-
ployment of bloodletting in the circumstances and
with the view now mentioned, the variety of apo-
plexy that results from what is termed concussion
of the brain,  admits only  of very simple treat-
ment.   With  the exception of inflammation, the
prevention and cure of which are objects of great
importance, relief can only  be hoped  for from
time,  and a quiet state of the organ.
   Apoplexy  arising  from  the  extravasation of
blood in the brain, (that form of the disease which
has attracted the greatest notice,)  cannot be cer-
tainly known  during life, though it may  often be
suspected.  When the  disease  occurs suddenly
and with violence ;  or, beginning  mildly, gradu-
ally gets worse;  and when  the stupor continues
for many hours, and is then  followed by only an
alleviation of  symptoms; there is  strong ground
for believing that a rupture of blood-vessels has
taken place in the brain.   This is a case in which
bloodletting has been used  with little discrimina-
tion, and often, there  is reason to believe, carried
to a hurtful excess.  It is evident that the remedy
can have no direct effect  in removing the extrava-
sated  blood ;  nor can it lessen the quantity of
blood altogether within the skull, so as to give ad-
ditional space, and  thereby diminish the  pressure
the effused  blood is making on the brain ; and
yet it is employed in these  cases as if it were ca-
pable of accomplishing,  with  certainty,  one or
other of these  purposes ;  it is used too with such
freedom, as if it needed  only to be carried to  a
certain  extent in order  to  insure  success.  But
blood, once extravasated, can be removed only by
absorption, which is a natural  and slow process,
requiring for its completion  at  least  a moderate
share of general strength. Large and unnecessary
abstraction of  blood in such cases, by weakening
the body altogether, rather  creates  an obstacle to
recovery than the contrary.  The  proper use of
bleeding in  such cases is, to  reduce that  violence
of arterial action  in  the  brain (often of a real in-
flammatory nature) upon which the rupture and
effusion  immediately depend, and  thereby to pre-
vent a further escape of blood. But for such a pur-
pose, only a moderate though perhaps repeated ab-
straction of blood can be required; and then always
in proportion to the  age  and other circumstances
of the patient,  and according  to  the  stage and
duration of the disease.   As mere matter  of expe-
rience, there is reason  to  believe that bloodletting
in these  cases  does much less good, and the omis-
sion of it less  injury, than is generally supposed.
As to the other remedies in  general use  on these
occasions, little can be said  in their favour, while
some of  them  are decidedly hurtful in their ten- 
APOPLEXY,  (CEREBRAL)                        153
dencies :  such is the case with extensive blister-
ing, or sinapisms, and internal stimulants of any
considerable activity.  From  the  very nature  of
the case,  they  can accomplish nothing beneficial;
while the immoderate use of them  may do harm,
ny exciting the general vascular action of the sys-
tem.  Vomiting is for the most part objectionable,
and  may be even dangerous,  by  the temporary
check it gives to the return of blood from  the
head.  Even where it is known or suspected that
the stomach is in a loaded state, the danger  at-
tending full vomiting is more  than a counterpoise
to any benefit  likely to be derived from the prac-
tice.  Sneezing, which has  been sometimes re-
commended for the relief of the  stupor, is little
less hazardous than the use of emetics.
   The treatment of apoplexy  dependent upon ac-
cumulation of serous fluid in the brain, or, as it is
termed, serous apoplexy, requires  a  further con-
sideration.   It has been already stated that no ab-
solute line of  distinction can be drawn between
 the sanguineous and serous forms of  the disease ;
 they are, in fact, frequently found  in combination,
 or rather to be considered as mere varieties of one
 and the  same affection.   Serous  accumulations
 in any of the  cavities of the body are in most in-
 stances the result of membranous inflammation ;
 not in general of an acute, but rather of a chronic
 or protracted description.  This primary depend-
 ence of serous accumulations, or dropsies as they
 are called, on inflammation, is not always distinct-
 ly seen,  on account of the mildness of the inflam-
 matory symptoms at first, and their having often
 passed away without notice, leaving  the accumu-
 lation of fluid behind.  Still, there  are but  few
 cases in  which the connexion of dropsy with in-
 flammation, as  its  primary  source,  may not be
 traced by accurate  inquiry.   This applies  to the
 brain, as much  as to  either of  the other cavities.
 In most apoplexies  that come on  slowly,  and
 which, on  this  account, are supposed to be of a
 serous nature, signs of preceding as well  as of
 existing  inflammation in  the cavity  may be  dis-
 covered ; such as head-achs, sometimes accompa-
 nied with flushing and  throbbing of the arteries
 about the  head ; together with more or less of
 general  febrile  action throughout  the  system,
 (which last is to be taken as an infallible criterion
 of the existence of topical inflammation  in some
 organ,) to say nothing of the  disturbance of func-
 tions which marks  the seat of the disease.  Mere
 serous accumulations, without other disease  of the
 organ, may account for a lethargic state of the pa-
 tient, but is hardly  sufficient to explain the  oc-
 currence of an apoplectic fit; which, being sudden
 in its attack, and disposed to recur by paroxysms,
 must depend upon some occasional and temporary
cause, and  not upon the mere presence of the
 fluid ; for this must be slowly collected, and  when
 once formed must be permanent, or, at all events,
is not likely to be rapidly absorbed.  No tempo-
rary cause of  such  disturbance, or rather suspen-
sion, of  functions as takes place in apoplexy can
be  suggested  with  so mucb  probability as  occa-
sional arterial  excitement, to which the brain ap-
pears to  be particularly prone.   Such a  disposi-
tion to occasional arterial excitement is a natural
consequence  of inflammation,  and may remain
long after the inflammation which gave rise to it
   Vol. I. — 20
has disappeared.   And  thus it  is that persons
liable to  apoplexy of this mild description, suffer
a great number of slight attacks with  impunity :
but in general are at length carried off' by one of
greater violence ;  and then  it is  usually found,
upon  examination after death, that extravasation
of blood  has  produced the fatal event; proving
that there is no  real or essential distinction  to be
made between serous and sanguineous apoplex'v.
  In  the treatment of apoplexy of this nature,
slow in its approaches, and occurring, as it occa-
sionally does, in feeble habits, a mild plan of cure
only is admissible.  Inquiry is to be made  as  to
the probable existence of inflammation, its degree
and duration ; and remedies  applied accordingly.
In  no case, even during the  fit, could  a large ab-
straction of blood  be  proper.   Such  a remedy,
supposing  the fit to be the  immediate result of
arterial excitement merely, without a  rupture of
vessels, is unnecessary, as  the increased vascular
action will probably subside  by milder  means,  or
even  spontaneously ; while, should effusion have
actually  taken   place, the  largest  bloodletting
could effect nothing direct towards its  removal,
and might even  prove immediately fatal.  At all
events, the patient would  be left in a less favour-
able state  for future recovery.  It is  here  as  in
epilepsy, in which, during the paroxysm,  unless
the disease altogether be of recent occurrence, little
can be done with advantage.  It  is in the inter-
vals,  for  the most part, that we can hope the mea-
sures adopted will be  permanently advantageous.
So  in apoplexy, of the description here alluded to,
the paroxysm, however alarming in  appearance,
is either  of no real importance, or, if it should be
dangerous from  rupture of vessels, or other injury
sustained by the part,  art can do little or nothing
for its relief.  In the intervals, and when a sus-
picion of inflammation no longer exists, it may
be proper to aim at removing the serous deposit,
by  diuretics or other such methods as are not par-
ticularly  detrimental to the  general health.   In
this point  of  view, the employment of  mercury,
however highly vaunted on  these occasions is of
very equivocal use.
   Serous  accumulation  in the  brain  appears  to
take  place at  times, as a consequence of impedi-
ments to the return  of blood  by the veins : hence
the stupor that is observed to occur in some pul-
monary affections, in which the blood is not trans-
mitted with freedom through the lungs.   This,
however, is rather lethargy  than  apoplexy, as  it
does  not occur  by  fits, unless  there  should be
actually  at the  same  time disease in  the  brain
itself.
   With  respect  to  tumours, or other alterations
of structure, observed in the brain of persons dying
of apoplexy, such are to be  considered  rather as
predisposing, and not  as  efficient,  causes of the
apoplectic state. Being permanent in their nature
when once formed, they can afford of  themselves
no  adequate explanation of a paroxysm or fit that
is only of occasional  occurrence.  This, as was
observed on a former occasion, must be referred
to temporary vascular  excitement, the  disposition
to which is produced and kept up by the  presence
of the morbid  structure.   Apoplexy may be sus-
pected to be of this nature, when preceded or ac-
companied by symptoms denoting the existent 
154
APOPLEXY  (CEREBRAL)
of chronic inflammation in the brain.  These mor-
oid  changes of structure  are generally found  in
combination with more or less of serous effusion.
Should  apoplexy take place  under such circum-
stances, bloodletting might be required for the im-
mediate relief  of the fit, but not to any great ex-
tent ;  the object being merely to diminish the  arte-
rial action of the brain, and thereby to put a stop
to that  temporary state of excitement which is
the immediate cause  of the paroxysm.  In  this,
as in other cases, sanguineous effusion may have
taken pbice; but of  this no  certain  knowledge
can be obtained till after  death.  If it were  even
possible to ascertain it during life, it would afford
no  additional  ground  for  profuse bloodletting.
Should  the patient survive the fit, it is then  an
important object to endeavour to remedy the dis-
organization which we may suspect to exist in the
brain, or rather to take off the inflammatory action
in the part, which has produced the alteration  of
structure;  for  over the morbid structure itself  art
has little influence.   It is, however, only in slight
and recent affections of the sort, that we can  hope
to be  successful;  though much may  still be  done
to mitigate and to check  the further progress  of
the mischief.   The  means  we  have  it in our
power to employ for the purpose are few and  sim-
ple.   Small and repeated bloodlettings afford the
best, if  not the sole  chance of success in  such
cases.   To enable the patient to bear these for as
long a period  as  may be  necessary to accomplish
the purpose, it is indispensable that he be allowed
to take food in reasonable quantity,  and of the
most simple digestible kind.  There is no better
guide, perhaps, on these occasions, than the natu-
ral  appetite, when not excited by  variety or  by
food of  a stimulant nature.  It is a great mistake
to suppose, either in this  or in other chronic dis-
eases requiring bloodletting, that  the attainment
of our object is likely to be frustrated by a mode-
rate use  of food, whether animal or vegetable  in
its nature.   Judging  from experience in chronic
forms of inflammation, the contrary rather appears
to be the case.  An unfounded preference appears
to be given to what is called local or topical bleed-
ing over venesection.   The term  topical or  local
is quite misapplied here, as no vessel  immediately
connected with the brain, or that can directly in-
fluence  its circulation, admits  of being opened
for the  purpose of letting blood.  It is to quan-
tity, and the rapidity of taking away blood, that
we are  to look, and not the part from which the
blood is taken ; unless indeed  it could be drawn
immediately from  the part affected ;  which  is  of
course impracticable.   The circulation of the dis-
eased part, as far as regards the abstraction  of
blood, can only be influenced through the medium
of the general circulation ; and this we can  more
icadily and effectually act upon by venesection or
general bloodletting, than by what is  termed  local
bleeding;  simply because we have a  command,
both  as to time and  quantity, in the one  case,
which we seldom can have in the  other.   The
safety of bloodletting,  in both modes, depends  upon
quantity •  but not so the efficacy  of  the practice.
[t might not  indeed  be prudent, or even safe, in
all cases, to abstract blood so rapidly  as to induce
fainting.   In  general, this had better be avoided ;
both as being seldom necessary, and as generally
alarming in appearance.
  The other means in use  for the  treatment of
chronic inflammatory disease in the brain, such as
purgation and counter-irritation by blisters, issues,
or the like, are of very inferior importance in com-
parison with bloodletting, in  cases  admitting of
the latter.   A  long-continued and rather  severe
employment of mercury has to all appearance been
attended with success in  many instances ;  but in
many also it has failed.   In the use of it, we are
not to forget its power of doing  harm as well as
good.
  The treatment of the second  order of apoplexies,
those that  arise simply from high arterial  action
and distension  of the vessels of the brain, without
extravasation or serous effusion, and without dis-
organization, is of a simpler kind, and more likely
to be attended  with  success.  Ordinary cases of
intoxication, from  the  excessive  use of  strong
drinks, in  general  require only quiet  and  repose
for a few hours; in the course of which the vascu-
lar action  of the brain  subsides into its natural
state, and  often  indeed  falls below  it, so  that a
stimulus of the same kind afterwards is found to
relieve  the feelings of depression that generally
succeed.   In aggravated  cases, however,  of thiu
description, and especially in persons unaccustomed
to the use  of strong drinks, more active measures
may be called for ; such as bloodletting to a mode-
rate extent, and purging, in order to subdue, more
quickly  and effectually,  the vascular  excitement
of the brain.  These should be accompanied with
the moderate application  of cold to the head, with
a view both  to  its sedative  and its constringing
properties, in  the hope that these effects may be
communicated  by sympathy from the  external to
the internal vessels of the head.  There is another
good reason for the employment of such means in
aggravated cases of intoxication, namely, that of
guarding against inflammation of the brain, which
now and then results from this cause.
   When the narcotic effects of opium and drugs
of the same class occur in an alarming degree, a
very similar  mode of treatment is required.  In
regard to the use  of bloodletting in both cases,
attention must be paid to the state of the general
circulation.  A soft and feeble  pulse, with cold
extremities, would not admit of bloodletting, but
might require,  on the contrary, the use of  simple
stimulants, such as ammonia, together with fric-
tions and  external  warmth.   Heat of the head,
and throbbing  of arteries, which are often  found,
even where the surface and extremities are much
chilled, call for the application of cold to the head,
as well as  in the case of intoxication.  The prac-
tice generally inculcated, in  cases of poisoning by
opium, is to endeavour  to keep the patient from
falling asleep, by every possible mode of irritation;
if such treatment be  proper  in the case of  opium.
one does not see why it should not be also adopted
in cases of intoxication by alcohol; for the symp-
toms are nearly alike in  the  two  cases.   If the
stupor or  suspension of the  sensorial functions
produced by narcotic substances  be owing to an
excited  and distended state of the arteries  of the
brain, irritation of any kind will only prove an
additional  cause of  vascular  excitement  in  the 
APOPLEXY,  (CEREBRA
brain.  It would  be well if  a  satisfactory appeal
could be made to experience,  in  order to decide
the point of practice :  but this can  hardly be done,
on account of the difference which exists between
different cases.
   Should the apoplectic state have been occasioned
by isolation, the hot  bath,  or mental excitement,
the treatment is simple.  Moderate loss of blood,
purgation, and the application of cold to the head,
would seem  to comprise all that can be  really
useful.  If, after  the  lapse  of  a few hours, con-
sciousness should  not return, the  probability will
be that the violence of arterial action in the brain
has been followed  by  the extravasation of blood ;
the proper management of which has been already
pointed out.
   Apoplexy  is  not an unfrequent consequence  of
inflammation of the  brain, whether this  exist in
the form  of membranous  inflammation  (hydro-
cephalus acutus of infants); of phrenitis ;  or  of
idiopathic fever, so called.  In each of these cases,
when so violent as to  threaten a fatal termination,
a  comatose  state bordering on  apoplexy  takes
place ; the apoplectic symptoms being  mixed  up
with and modified by those of inflammation.  This
termination of  inflammation  of the brain  it is not
difficult to understand.   In the early stage of those
affections, the vascular excitement of the  brain is
moderate  in  degree,  and not attended with any
considerable distension of vessels.  The circulation
then is not materially impeded, and the functions
of the organ are still  carried  on, though  in  an
excited and disordered way.  In the  further pro-
gress of the disease, the distension of arteries  in-
creases ; the circulation is by degrees obstructed  ;
and this is soon followed by  an interruption, first,
of the primary functions of the brain, sensation,
voluntary motion, and  intellect;  next,  the vital
functions, respiration, and the  general circulation
suffer, and life  becomes extinct.  The treatment
requisite in  all these cases is the  same ;  namely,
that which is adapted to subdue inflammation in
general ; regulated, however, by the circumstances
of the patient, and most particularly by the stage
of the disease.  When  the apoplectic state shows
itself early, there is no question  as  to the propriety
of bloodletting, and  that  with freedom.   In  an
advanced stage, and  especially when the general
circulation is failing, this remedy becomes equivo-
cal, and must be  used, if at all, with reserve and
caution.
   The  third variety  of apoplexy,  namely, that
which arises  from an  interruption  to the return of
blood from the  brain,  requires a different  mode of
treatment from  the others, on account of the diffe-
rent nature of  the causes  producing it.   This is
the state to which the term venous congestion has
been  applied,  but which  is nothing more than
stagnation of blood in the cerebral vessels, a state
which must necessarily take  place  if the returning
current of blood by the  veins be impeded  or inter-
rupted.   Am  this  interruption may be produced by
different causes, there will  be some difference in
the treatment.   In the  simplest case  of  impeded
return of blood from the brain,  that occasioned by
a dependent  posture  of the head,  all that is com-
monly required is to  raise  the head.  Should the
stupor be occasioned  by tumours  in  the  neck, or
in the course of the  veins  towards the heart, our
lL  AND PULMONARY)          155

being able to give effectual relief will depend upon
our  ability  to  remove or  lessen the  obstructing
cause.  In the case  of violent and extensive in-
flammation of the lungs, where, from the swelling
of parts, the blood  finds  its  way  sparingly and
witb great difficulty through the lungs, the impedi-
ment to the return of blood from the head, as well
as other parts, is seen in the livid hue of the cheeks
and  lips, in the bloated state of the  face and neck,
and  in the stupor, or imperfect performance of the
sensorial  functions.   Along with these, the pulse
at the wrist becomes soft, feeble, and  often irregu-
lar ; and  tbe extremities cold.  Such a state  of
things  is  nearly hopeless ; for it scarcely admits
of relief from art.  The feeble state of the general
circulation  will hardly admit of loss of  blood ;
while there are no  other means that promise a
better result.   The  practice  of giving stimulants
on those  occasions, merely because  the pulse  is
weak, and because bloodletting is not admissible,
is supported neither  by reason nor by  experience :
such practice is, in fact, in opposition  to both.
   In the more chronic cases of obstructed circula-
tion, arising from disease about the heart and
lungs,  a   disposition  to   apoplexy  is gradually
formed, which  may destroy the patient,  if he  is
not  previously  cut  off  by the  primary disease.
Apoplexy thus induced is commonly of the serous
kind ; it  takes place slowly,  from effusion conse-
quent upon long-continued impeded circulation in
the  brain,  and  rarely admits of remedy.  If, how-
ever, the primary  disease in the  heart or lungs is
in a favourable state for the employment of reme-
dies ; that is, if the inflammation be not of very
long standing,  the  organization not materially
deranged, nor the general strength much impaired,
there is still a chance that a cautiously-conducted
plan of treatment, adapted to  the relief of chronic
inflammation, such as has  been pointed out above,
may rescue the patient from destruction. A result
so favourable, however, is  seldom to be expected.
                          H. Clutterbuck.
   APOPLEXY, Pulmonary.  The term pul-
monary apoplexy has been  adopted by modern
pathologists to  signify an effusion of blood into
the  parenchymatous substance  of  the lung,  in
consequence of the resemblance which this lesion
bears to the extravasation of blood into the sub-
stance of the brain in cerebral apoplexy.   But as
the  name of apoplexy was originally  applied to a
determinate group of  symptoms, not  to any par-
ticular  form of organic lesion, we evidently divert
this term  from its  original signification  in thus
making it svnonymous with  the  effusion of blood
into tbe  tissue of  an  organ.  However, as the
term has  been sanctioned by the high authority
of Laennec, and is now generally  adopted  by
pathologists, it  may be as  well to retain it, though
certainly  objectionable, as  to  encumber our noso-
logical  nomenclature  with   the  term pneumo
hemorrhagia,  recently proposed  by  Andral,  as,
more aptly expressing the nature and seat of the
disease, while  it establishes  a contrast with the
term broncho-hemorrhagia, by which he proposes
to designate  the  exhalation  of  blood from  th<i
lining membrane of the bronchial tubes.
   For a long  period,  the  rupture of a vessel wa>
the  only fiouice of pulmonary hemorrhage recoe- 
156
APOPLEXY,  (PULMONARY)
nised by pathologists; and even  at  the  present
day, the expression of bursting a  blood-vessel on
the lungs is  used by many as synonymous with
na;moptysis.   The cultivation of morbid anatomy
has, however, tended to correct this as  well as
many other popular errors, and has  fully estab-
lished that,  in a large proportion of cases, the
source of the hemorrhage is to be found in a sim-
ple exhalation from  the  lining membrane of the
bronchia.   " I  have  repeatedly  opened," says
Bichat,  " the  bodies of persons who  died during
an attack of haemoptysis, and though  I examined
the surface of their bronchial membrane with the
greatest care,  and even  took the precaution of
allowing it  to  macerate  for some days before
examining it with a lens, I have never been able
to detect the slightest appearance of erosion, or of
the rupture of a vessel."
   Another source of pulmonary hemorrhage has
still  more recently been  described  by the author
of the well-known treatise on Mediate Ausculta-
tion, who states,  " that while the greater  number
of slight or moderate haemoptyses consist in  a
simple exhalation of blood from the lining mem-
brane of the  bronchial  tubes, the severer cases
onginate from a different source, and come chiefly
from the vesicular structure of the lungs :" and
this latter is the  variety of hemorrhage to which
he applies the name of pulmonary apoplexy.   It
is true  that  this affection  had been noticed by
earlier writers, and even described under  its pre-
sent name.  Haller, in his Opuscula Pathologica,
gives a brief and  melancholy account  of the death
of a friend, who fell  a victim to this disease ;  his
description of the  morbid  appearances,  though
general, is sufficiently characteristic of the  disease:
" In pulmone utroque, non inflammatio, non ulcus,
sed sanguinis universalis effusio  fuit, ut sudore
sanguineo in cellulosam fabricam effuso, et sensim
collecto,  nigerrima  demum  magna pars visuris
esset."  M. Lereille read a memoir on the subject
before the Academy  of Sciences in the year 1816;
and Doctor Hohntaum published an essay on pul-
monary apoplexy at Erlangen in 1817.  M. Laen-
nec's treatise was  not  published until  1819 :
however, as the  affection  was entirely unknown
as a common cause of haemoptysis before the pub-
lication  of his work, and as no  preceding writer
had given its precise  anatomical characters,  the
merit of having first accurately  described  the dis-
ease must be  accorded  to  Laennec, even though
the more equivocal merit of its denomination  may
be contested by others.
   Apoplexy of the  lung, like  that of the brain,
presents considerable variety in the symptoms  it
produces during life, and  the anatomical charac-
ters it presents after death ; for whilst in some in-
stances  it produces  no other inconvenience than
the expectoration of a few ounces of blood, it in
other cases proves as instantaneously fatal as the
most violent attack of cerebral apoplexy.   Neither
are its  anatomical characters  less variable ;  for,
while in its milder form  its effects  are limited  to
the sanguineous  infiltration of  the air-cells of one
or two lobules, it occasionally pours such a deluge
of blood into the substance of the lung,  that the
delicate  structure of the  organ is broken  down
oefore it, and even  its investing membrane, the
pleura, is ruptured by the violence of the  hemor-
rhage.
  The anatomical characters of pulmonary apo-
plexy as  described by Laennec, arc, a remarkable
induration  of the pulmonary substance, equal to
that of the  completcst hepatization :  the  indura-
tion, however, is very different from the inflamma-
tory'affection  of the  lungs  distinguished  by  this
term.  It  is  always  partial, and rarely ever occu-
pies a considerable portion of the lungs : its more
ordinary  extent being from one  to four cubic
inches.   It is almost always very exactly circum-
scribed, the induration being as considerable at the
very point of termination as in the centre.  The
pulmonary tissue around is quite sound and crepi-
tous, and has no appearance whatever of that pro-
gressive  induration  found  in pneumonia.  The
substance of the lung is indeed  often very  pale
around the haemoptysical  induration ; sometimes,
however,  it  is rose-coloured, or even  red, as if
tinged with fresh blood ; but even in this case the
circumscription  of the indurated  part  is equally
distinct.   The indurated portion is of a very dark
red, exactly like that  of a  clot of venous blood.
Wrhen cut  into, the  surface of the  incisions is
granulated as in a hepatized lung;  but in their
other characters these two kinds of pulmonic in-
duration   are  entirely different.   In  the  second
degree of hepatization, we can perceive distinctly
the black pulmonary spots, the blood-vessels, and
the fine cellular intersectures, all of which together
give  to this morbid  state  the aspect of  certain
kinds of  granite.  In  the induration of htemoptv-
sis, on the contrary, the diseased part appears quite
homogeneous, being altogether black or of a very
deep brown, and disclosing nothing of the  natural
texture of the part, except the bronchial tubes and
the  larger blood-vessels.  The latter have even
lost their  natural colour, and are stained with
blood.  In scraping  the incised surfaces of their
parts, we can detach a small portion  of very dark
half congealed blood, but in a much less propor-
tion than we can press out the bloody serum from
a hepatized  lung.   We  sometimes  find  two or
three similar indurations in  the  same lung, and
frequently both lungs are affected at the same time.
(Laennec on Diseases of the Chest, translated by
Dr. Forbes.)
   Nothing can exceed the accuracy of this de-
scription, but it only applies to the milder form of
the disease, when the extravasated blood is effused
into the air-cells  of  one or more lobules, and  the
individual survives for a sufficient length of time,
to have the fluid portion of the extravasation com-
pletely absorbed.  This condition of the lung may
be termed  its hxmoptoic engorgement, to distin-
guish it from another form of the disease, in which
the blood, instead of simply accumulating within
the air-cells, ruptures their delicate parietes, breaks
down the structure of the lung, and is extravasated
into the lacerated tissue.  It is to this form of the
disease  that the  name of pulmonary apoplexy i=
more strictly applicable, as  being  most analogous
to the condition of parts which exists  in cerebral
apoplexy.
   This form of the disease  seems to differ from
the hsemoptoic engorgement only in decree, the
laceration of the parenchyma of the lung,  and the 
APOPLEXY,  (PULMONARY)
157
consequent extravasation of blood,  being caused j
by the over-distension and rupture of the air-cells,
from the  excessive  quantity  of  blood which is
poured into them.  Accordingly, when the haemop-
toic engorgement is extensive, or takes place sud-
denly,  and with violence, we generally  find  its
interior broken down, and  occupied by extrava-
sated blood.   In a young man who died of organic
disease  of the  heart  in  the Whitworth Chronic
Hospital,  after experiencing a violent attack  of
haemoptysis  about a  week  before his death, we
found  the lower lobe of the right lung occupied
by a mass of haemoptoic engorgement as large as
an orange, and containing in its  centre a clot of
dark-coloured  blood of the  size  of a hazle-nut;
the cavity in which this clot was contained, had
evidently  been formed at the  expense of the pul-
monary parenchyma.   Laennec  alludes  to this
form  of the  disease  in  the passage, where, de-
scribing the  haemoptoic  engorgement,  he  says,
" sometimes the centre of these indurated masses
is soft, and filled with a clot of pure blood."  An-
dral has likewise noticed this variety of the disease
in his  treatise on pathological anatomy.
   In some cases the quantity of blood effused is
much  larger, and a greater  extent of the  pulmo-
 nary parenchyma is broken down,  so that a con-
 siderable portion of the lung is reduced  to a soft
 fluctuating mass, in which  there can only be dis-
 tinguished some remains of the  parenchymatous
 structure  of  the lung,  and  a quantity of effused
 blood, partly fluid, and partly coagulated, as in the
 case recorded  by Corvisart (Commentaires sur la
 Trait'c de la Percussion)  of a young man who
 retired  to rest apparently in perfect health, and
 was found dead in  his bed the next  morning with
 blood  streaming from his  mouth and nose.  On
 dissection, the interior of the right lung was found
 torn and  ruptured  in every direction, and gorged
 with  an  enormous quantity  of  dark-coloured
 blood ; the  bronchial tubes were likewise  filled
 with the  same fluid, as were also the trachea, and
 larynx, the throat, and  the posterior nares.   As
 examples of such extensive rupture  and disorgan-
 ization of the pulmonary parenchyma from extra-
 vasation of  blood are of rare occurrence, we shall
 briefly transcribe a case of this description, which
 fell under our notice in the Hardwick Fever Hos-
 pital.   A young delicate-looking man in an  ad-
 vanced stage of fever stooped out of  bed  to take
 up his spitting-pot, which had fallen ;  while in the
 act  of stooping, he  became  giddy, lost all con-
 sciousness,  and  fell  on the  floor;  he  remained
 insensible for some minutes, but after throwing up
 a large quantify of blood, he recovered so  far as
 to ask for a drink of  water;  he  drank with
 avidity, and again relapsed into a state of apparent
 insensibility, and died within an hour, discharging
 a quantity of  blood from his mouth and nose.  On
 dissection, which was made in eighteen hours after
 death, all the  air-passages  from  the mouth to the
 lungs were  found  filled with  dark  fluid blood.
 The right lung did not collapse when  the chest
 was opened, except its upper lobe, which appeared
 healthy and of its natural colour : the middle and
 lower lobes were externally of a uniform deep red
 colour, and when  pressed  under the finger con-
 veyed a distinct sense of fluctuation.  When cut
 into, a quantity of fluid blood rushed out, bearing
along with  it a  number of grumous clots, and
several masses of broken-down pulmonary tissue.
The interior  of  the lung  presented a shreddy
appearance,  and  resembled  a sponge which had
been steeped to saturation in blood.
  The anatomical characters of this form of pul-
monary apoplexy differ  materially from those de-
scribed  by  Laennec.  The  seat  of  the  disease,
instead of being circumscribed, solid, and present-
ing a granular surface, when cut, is perfectly un-
circumscribed, feels  soft and fluctuating  to  the
touch, and when cut into, exhibits a mixture of
fluid and clotted blood infiltrated through  the
parenchyma of the  lung, which  is ruptured and
broken  down.  These differences  may, however,
be satisfactorily accounted  for :  in  the haemoptoic
engorgement,  as  described  by Laennec,  the  cir-
cumscribed, solid, dark-coloured masses, varying
in  size  from  one to four  inches, are evidently
caused by the  infiltration of the blood into the air-
cells of the part, and its coagulation there ; as any
one may satisfy himself  by examining  in the
strong light of the sun the granular surface, which
a section of the part exhibits, and  by scraping it
gently with a  scalpel, so as to turn out the  little
rounded coagula  from the cells in which they are
moulded, after which the part will exhibit a dis-
tinct cellular  structure,  exactly resembling a sec-
tion of the corpus cavernosum penis.  The reason
of the lesion  being in  general  so  accurately cir-
cumscribed, is,  that the  cellular tissue which
invests  and  isolates  each  lobule  prevents  the
escape  of  the effused  blood into the adjoining
lobules.  The solidity of the part  proceeds  from
the  serous  portion of the  blood being absorbed,
and the fibrinous coagulum  becoming intimately
combined with the tissue of the part; for in those
cases where death  occurs  soon after the hemor-
rhage, the blood  is  uniformly found in the fluid
state : and  lastly, the dark colour which the hae-
moptoic induration presents, may be accounted for
by the stagnation of the extravasated blood, which
uniformly produces  this effect, as in  the  familiar
example of  an external contusion, and in Hunter's
well-known experiment of intercepting a  portion
of artery between two ligatures, and finding, after
a certain time, that  the  blood  thus confined  had
lost its arterial colour, and  assumed a dark venous
hue.  In this form of the disease there is no solu-
tion of continuity,  no breaking down of  the pul-
monary  tissue, but simply  an infiltration of blood
into the spongy texture of the part.
   But if the texture of  the organ is less resisting,
or the force of the  infiltrating fluid more irresisti-
ble, the  pulmonary structure gives way, and the
interlobular partitions which served to  bound the
progress of the  effusion being broken  down,  it
ceases to be  circumscribed.  In this form of the
disease the  blood is  seldom wholly coagulated, and
we believe never so perfectly as in the haemoptoic
engorgement.  For this fact, several satisfactory
reasons may be assigned.  In the first place, when
the hemorrhage  is  so violent, death generally fol-
lows before the  blood  has had sufficient  time to
coagulate perfectly, and to have its aqueous parts
absorbed.   It generally  happens  also that  those
extensive hemorrhages are connected with a pecu
liar liquid  state of the circulating  fluid, which
diminishes  its tendency tc  coagulate, and dispose* 
158
APOPLEXY,  (PULMONARY)
it to pass off more freely by the exhalents, as in
cases of scurvy, purpura, &c.  Besides which, we
may suppose that blood when effused in a large
mass is not as favourably circumscribed for having
its thinner  part absorbed, as when minutely sub-
divided, and each division placed in contact with
so active an absorbing  surface as the walls of the
air-cells.
   Another variety of pulmonary apoplexy is  that
in which the hemorrhage not only breaks down
the parenchymatous structure of the lung, but
likewise  ruptures its  investing membrane,  and
bursts  into  the  pleural sac.   This is by far the
rarest  form  of the disease ; we have  never seen
an example  of it, nor have we been able  to dis-
cover more than four cases of  it on record.
   1. The first is related by Corvisart (op. cit.).
Dr. Fortassin was found  dead in  his  bed one
morning after having retired to rest the preceding
evening  in  the apparent enjoyment  of excellent
health.   On dissection, the right pleural sac was
found filled with coagulated blood, the interior of
the right lung was  also gorged  with it, and its
surface exhibited  several rents, which extended  to
a considerable depth within its substance.  In this
case death occurred suddenly, and was  not  pre-
ceded by or accompanied with haemoptysis.
   2. In an analogous case, published by M. Bagb,
in the Revue Mcdicale, the patient was suddenly
seized with violent dyspnoea : his face became pale,
the pulse almost  imperceptible, and  death  super-
vened in a few minutes after  the commencement
of the attack.
   A quantity of bloody serum was found effused
into the left side of the chest,  and  with it about a
pint of dark  clotted  blood, which  evidently came
from a rupture in the base of the  lung, the inte-
rior of which was lr.-eerated and broken down,  as
the substance of the brain is in cerebral apoplexy.
   3. The third example of this form of the dis-
ease is recorded  by Andral, (Clinique Medicale,)
in the case of a middle-aged man,  who presented
the ordinary symptoms of pulmonary consump-
tion, attended with  a  slight  degree  of dyspnoea.
One morning he was found breathing with much
greater difficulty than  usual, and his sputa were
observed to  be slightly tinned  with blood  : during
the two succeeding days his difficulty of breathing
increased considerably, the sputa became more
deeply tinged with blood, and  he died in an ex-
treme state of dyspnoea.  On dissection a  quantity
of blood and serum was found in the left pleura,
the surface of the left lung was ruptured, the size
of the rupture being about an inch in diameter.
When the lung was laid  open, a  space  as large
as an orange was found, corresponding with the
rent on the surface, and occupied by fragments of
torn pulmonary tissue, mixed  up with adark gru-
mous blood.
   4. The fourth  and last case of this  description
on record is  that recently published by Dr. J. C.
Ferguson, in the  first volume  of the Dublin Medi-
cal Transactions.  A  robust  man,  aet.  36,  who
had occasionally  suffered from attacks of consti-
pation and bronchitis, complained, on the 19th of
June,  1829, that his  cough  was  increased, his
chest somewhat  oppressed, and his expectoration,
since the day preceding, slightly tinged with blood;
lus countenance was pale, his pulse about 90, and
feeble, and his  skin covered with a  cold  c.ammy
perspiration.   On the next day he felt relieved by
the operation of a purgative.  During the suc-
ceeding night he was rather restless ; however he
ate his°breakfast as usual, and while in the act of
stooping to put on his  shoes, he  complained to
his wife of loss  of vision,  seemed  to  faint,  and
died without  a struggle.  Examination made forty-
eight hours after death :—the left pleural sac con-
tained about  three quarts of blood,  the  scrum su-
pernatant, as in blood allowed to stand  after vene-
section, and the clot in considerable quantity, but
very soft, occupying the most dependent  portion
of the cavity.  The lung had contracted no adhe-
sion ;  the superior lobe was one mass of the most
perfect pulmonary apoplexy, the structure  of the
lung seeming to  be actually broken  up  by  the ex-
cessive effusion of blood into it;  the  apoplectic
mass was soft and flabby ; it  would scarcely bear
to be  incised,  but broke down  easily  under the
finger or scalpel.  On the superior and posterior
part of the affected lobe  a laceration of  the invest-
ing  pleura was found, about  one inch in  length
and half an  inch in  breadth, with  very irregular
edges, and immediately  over the point  where the
sanguineous  effusion into  the  substance of the
lung seemed most intense, and where  we might
naturally expect  the greatest violence to be oppos-
ed to its serous covering.   A remarkable fact in
the history of this case was, that he had expecto-
rated no blood  for fourteen hours before death, nor
in the agony was there any escape of blood from
the mouth or nares which might lead to  a suspi-
cion of the real  seat of the  disease.   The same
remark is also applicable to the preceding cases,
Nos. 1 and 2, in which  no htemoptysis whatever
took place before death,  and the cause of the fatal
catastrophe was only discovered on  dissection.
   The etiology of this disease is still involved in
considerable  obscurity.   In  fact, we know as little
of the peculiar modification which the  texture of
the lung undergoes when it allows the blood deter-
mined towards it to escape from  its vessels, as we
do  of the changes  which  these vessels  undergo
when  at one time they secrete pus, and  at another
exhale a thin serous fluid.  Andral supposes that
pulmonary apoplexy differs from bronchial hemor-
rhage only in its  situation, the former being caused
by exhalation  from  the  lining  membrane  of the
air-cells, as the  latter is by exhalation from the
lining membrane of the bronchia ;  in fact, he sup-
poses  that pulmonary apoplexy is to bronchial he-
morrhage what pneumonia is to bronchitis, — a
similar disease affecting  the ultimate ramifications
of the bronchia instead of their primary divisions.
He is  likewise  of opinion that in  a large  propor-
tion of cases the morbid alteration  to  which the
name  of pulmonary apoplexy is  applied,  should
not be regarded as the only source of all the blood
which had been  expectorated during life ;  on the
contrary, he  believes that the hemorrhage gene-
rally proceeds from a much larger  surface of the
mucous membrane, and  that  the dark indurated
patches of pulmonary apoplexy are caused by the
blood accumulating in those points whilst it was
removed from the other parts  of the bleeding sur-
face, and expectorated as fast as  it was effused
there.   By adopting this view of the subject, we
are enabled to  understand those cases of violent 
APOPLEXY,  (PULMONARY)
159
and profuse haemoptysis, in which, after death, the
extent  of the  haemoptoic engorgement is found
very small, and not at  all commensurate with the
quantity  of blood which had  been expectorated
during life.  The quantity of blood discharged in
this way  is sometimes so very great, that Laennec
conceived it impossible  to account for  it without
admitting that the blood in such cases experiences
a sudden  dilatation.  This  speculation, however,
as well as other theories respecting the state of the
blood and its capillary  vessels in hemorrhage, will
be with more propriety discussed  in  the general
article on that subject__See Hemorrhage.
   The occasional causes of pulmonary apoplexy
are, in general, the same as those  of  hemorrhage
from tbe bronchia.   (See Hemoptysis.)   It is
to be remarked, however, that the spitting of blood
which accompanies the formation  of tubercles, is
most frequently of the  latter species; while that
which occurs in subjects affected with organic dis-
ease of the heart is most commonly of the former
kind : the suppression of habitual discharges, such
as the menses,  hemorrhoids, or epistaxis, may give
occasion to both kinds  indifferently.   Plethora—
the sudden or long-continued impression of exces-
sive heat or cold, ought also  to  be  mentioned
among the occasional causes of this, as of many
other  diseases  of a very different kind ;  but in
 most instances such causes  would not of them-
 selves have been sufficient to produce the disorder,
 without  some  peculiarity  of constitution  in the
 individuals.  (Laennec, op. cit.)
   Of  all these, organic disease of the heart is de-
 cidedly the most common.  Of twenty-two  cases
 of pulmonary apoplexy  that we  have examined
 after death, fifteen, or rather more than two-thirds
 of the whole,  occurred in  individuals labouring
 under heart  disease ; in two instances only was
 the pulmonary apoplexy connected with tubercles
 in the lungs; in one  individual the  disease was
 caused by external injury ;  in  four cases we were
 unable to trace  the hemorrhage to any local im-
 pediment to the circulation, or  to any organic dis-
 ease either of the heart or  lungs.  Andral like-
 wise states, as the result  of his experience, that
 organic disease of the heart is  decidedly the most
 common cause of pulmonary apoplexy : (op. cit.)
 Cruveilhier relates two cases  of pulmonary apo
 plexy, (Diet, de  Medecine, &c.,) both of which
 were connected with organic disease  of the heart.
 Of two  cases  recorded by  Bouillaud  in  the Ar-
 chives Generates, one was connected with disease
 of the heart, the  other with hepatization  of the
 lung.  Mr. Burns, in his work on Diseases of the
 Heart, has  also  noticed the frequent  connexion
 between these diseases.  " The pulmonic vessels,"
 says he, (page 53,) " by the congestion and  con-
 tinued vis-a-tergo, are ruptured,  blood is forced
 into the  air-cells, or, if urged still further, all  the
 cellular  structure of the  lungs is crammed with
 blood  : these organs cut like liver, and sink when
 put into water."  Bertin, likewise, in his " Traite
des Maladies du  Cceur," particularly notices  the
influence of certain diseases of the beart  in  pro-
ducing pulmonary apoplexy.   According to this
author, hypertrophy of the right ventricle  has the
same tendency to produce  apoplexy  of the  lung,
that hypertrophy of the left has to cause apoplexy
of the brain, and by the same  mechanism  ; for as
the brain directly receives the shock of the column
of blood which is propelled by the aorta through
the left ventricle, so the lungs receive directly the
shock of blood which is propelled through the pul-
monary artery by the right ventricle.  According-
ly, when the parietes  of the right ventricle acquire
an  increased volume and proportionate increase
of energy in their contractions,  the blood is pro-
pelled  through the pulmonary vessels with such
an increased degree of force as is sometimes suffi-
cient to over-distend and rupture their parietes,
The hemorrhage produced in this way he consid-
ers to  be  of an active  character, and essentially
different from the  passive hemorrhage which re-
sults from the over-distension and rupture of the
pulmonary capillaries, arising from the mechanical
congestion of the lung  caused  by narrowing  of
the  left auriculo-ventricular orifice.  Of all dis-
eases of the  heart, these  have  the strongest ten-
dency to produce attacks of pulmonary apoplexy,
in consequence of the direct influence they exert
over the  pulmonary circulation ; but  the same
effect may likewise be produced by any disease of
this organ which  obstructs  the free transmission
of the blood.   We have  seen two  cases of pul-
monary apoplexy connected with hypertrophy of
the left and passive dilatation of the right ventricle.
   In a great majority of cases  the occurrence  of
pulmonary apoplexy  may no doubt be  traced to
the  agency of some of  the causes just enumerat-
ed, and may therefore be considered as  a second-
ary  or symptomatic affection.   But there are like-
wise cases of this disease, in which  the  cause ot
the  determination of blood  to tbe  lungs, and  its
escape from the capillary vessels, is  not preceded
by any marked  derangement  in the pulmonary
circulation  or other premonitory symptom,  and
must therefore, in the present state of our know-
ledge, be regarded as a primary or idiopathic  dis-
ease, though in all probability it is only the mani-
festation of some more  general  or  constitutional
derangement,  particularly in  those  cases  where
apoplectic extravasations are  formed in  several
organs at the same moment, as  in the head, liver,
and lungs, (Andral,) and in the case alluded to
by Laennec, where he found  large extravasations
of blood in the cellular  membrane of every limb,
of the trunk, and of the greater number of the
abdominal viscera. How far it may, in such cases,
depend on a morbid alteration of the fluids, or on
some disease of the  nervous  or vascular system,
it is not  our province  at present  to inquire, as
these  considerations  will find  their place in the
general article on hemorrhage.  Certain, however,
it is, that many cases of pulmonary apoplexy oc-
cur, which cannot be referred to any of  the  occa-
sional causes enumerated by authors : indeed, the
greater number of these overwhelming apoplexies,
apoplexies foudroyantes of the French, are of
this class.  Of the six  cases of apoplexy proving
 suddenly fatal, recorded in this  article, three were
 in the enjoyment of  perfect health up to the  mo-
 ment  of the apoplectic seizure ;  a fourth, described
 as occurring in a robust man in the prime of life,
 had occasionally suffered from attacks  of  bron-
 chitis and constipation  ;  a fifth was in an advanced
 stage  of typhus fever ;  and in one case only could
 the hemorrhage be referred  to any organic disease
| of the thoracic viscera. 
160
APOPLEXY,  (PULMONARY)
  The diagnosis  of pulmonary apoplexy  is, in
many cases,  a matter of considerable difficulty.
When the patient dies suddenly without haemopty-
sis,  as in cases No.  1  and 2  already recorded, it
will often be impossible  to determine, except by
inspection, whether death was caused by cerebral
or pulmonary  apoplexy, or  by rupture  of the
heart: and even  in  those cases where the fatal
attack is  accompanied with haemoptysis, the phy-
sician will sometimes find considerable difficulty
in ascertaining the source of the hemorrhage, as
the  bursting of an aneurismal sac into the bron-
chia may produce effects  precisely similar.  In the
more common and less violent forms of the  dis-
ease, in which an accurate diagnosis  is of much
more  practical importance,  the symptoms  most
pathognomonic, as enumerated  by  Laennec, are,
violent sense  of oppression in  the  chest;  great
difficulty of  breathing ; cough, accompanied with
irritation of the larynx,  and  sometimes by very
acute  pain of the  chest; expectoration of bright
and frothy, or black and  clotted blood, quite pure,
or mixed with salivaor mucus ; frequent full pulse,
with a particular kind of vibration even when soft
or weak, as it frequently- is  after  a  day or  two.
There is rarely any positive fever, and the heat of
the  skin continues natural, or nearly so ; frequent-
ly the heart and arteries yield the bellows-sound
to a very marked degree.  Of all these symptoms
the  spitting of blood is  the  most  constant and
most severe, and returns  by fits, accompanied with
cough, oppression, anxiety, intense redness or ex-
treme paleness of the  face,  and coldness  of the
extremities.   When the  hemorrhage is very great,
it comes  on  sometimes with  a very moderate de-
gree of cough, accompanied by a convulsive ele-
vation of the diaphragm, like that  which  takes
place  in vomiting.  (Op. cit.)
  But of all this assemblage of symptoms, there
is not one, not even the haemoptysis, which is con-
stantly present; and they may all occur conjoint-
ly without necessarily inferring  the  existence of
pulmonary apoplexy.  Haemoptysis  is decidedly
the most constant,  and  when very  copious, the
least equivocal symptom  ; but there are abundant
instances of pulmonary  apoplexy  occurring and
even  proving fatal with  only slight haemoptysis,
or even  without any expectoration  of blood, and
likewise  of profuse haemoptysis without any apo-
plectic extravasation.  Laennec observes that the
slighter cases of haemoptysis  depend upon a sim-
ple  exhalation  from  the  broncbia, but that those
cases  of  violent and extreme hemorrhage which
often  resist all medical treatment, almost invari-
ably proceed from the vesicular structure  of the
lung.   This  distinction  will  be found  generally
correct, but  still the quantity of the  haemoptysis
cannot be taken as a certain  index of the seat of
the disease ;  for the same author observes that,
when the haemoptoic  engorgement  is limited to
the extent of one or two square inches, the affec-
tion may be latent and unaccompanied with  any
spitting of blood.  We  have  seen  four cases of
this kind in  which no blood had been expectorated
during life, and it was  only on dissection that the
existence of  haemoptoic  engorgement was  dis-
covered.   Andral has likewise seen  several cases
of pulmonary apoplexy, in which the quantity of
-slood expectorated did  not exceed a table-spoon
full at a time ;  and in the more aggravated forms
of the disease,  death  is occasionally produced
before a  single drop of blood has  been expecto-
rated, as  has been  already proved  by several ex-
amples cited in a  preceding  part of this  article
On the other hand, the most profuse haemoptysis
may take  place from the bursting of an aneuris-
mal sac, from  the  rupture of a large vessel  in a
tuberculous abscess, or by simple exhalation  from
the mucous membrane of the bronchia.  The
quantity of blood expectorated can therefore only
afford  presumptive evidence  of pulmonary  apo-
plexy ; in order to ascertain  positively its exist-
ence,  we must have recourse to  the signs furnish-
ed by auscultation  and percussion.  These signs
are dulness of sound  in that part of the chest
which corresponds with the seat of the disease,
and the total absence of all respiratory murmur in
the same circumscribed space, together  with a
crepitating rale around this space ; this rale, which
here indicates a slight infiltration of blood, is al-
ways found at the  commencement  of the disease,
but is frequently  wanting  in  the  latter  stages.
When these  signs co-exist with pulmonary he-
morrhage, we may  be assured that  the seat of the
hemorrhage is in  the  substance of the lung, and
not simply in the bronchia.  Besides these, which
may be considered as the pathognomonic signs of
pulmonary apoplexy, there is likewise, especially
at the root of tbe lungs where the larger bronchia
are situated, a mucous rale with bubbles, which
seem to be large and thin, and formed by a  matter
more liquid than  mucus ; they also burst more
frequently, and with a peculiarity of sound which
cannot be  mistaken.   As the most common seat
of this disease is in the central parts of the lower
lobe,  or towards the middle  and posterior part of
the lungs, it is consequently on tbe posterior and
inferior part of the chest, that we ought to search
for them  with  the stethoscope.   (Laennec, op
cit.)
   The  rationale of  these  signs  is  sufficientlj
obvious ; the dulness of sound  and extinction ol
the respiratory murmur are caused  by the  san
guineous infiltration of the spongy texture of th«
part preventing the ingress of air, and converting
its porous  texture  into a dense  solid suDotance
The  crepitating rale in the immediate vicinity of
the haemoptoic engorgement in all probability arisen
from  the bursting of the air-bubbles a=> they pass
through the uncoagulated blood coiuained in the
adjoining air-cells, as the bubbling or. mucous rale
results from the bursting of the larger bullae in
the bronchia.
   If these  physical signs could uniformly  be de-
tected in every case of the disease, the diagnosis
of pulmonary apoplexy would be sufficiently sim-
ple ;  for  the haemoptysis  and general history of
the case would serve to distinguish  it from  any of
those diseases which exhibit the same stethoscopic
phenomena, such as lobular pneumonia or clus-
tered  tubercles.  It is evident, however, that nei-
ther   the dulness  of sound  nor the absence of
respiratory  murmur can  be  detected  when the
hasmoptoic engorgement is of small extent, espe-
cially if situated, as it often is, in  a central part
of the lung, or in that portion of the organ which
rests  upon the diaphragm; for the healthy pul-
monary tissue interposed between the  seat of the 
APOPLEXY,   (PULMONARY)                        161
disease and  the  parietes of the chest, must effec-
tually mark the morbid  sounds.   For this reason
the stethoscope rarely affords any positive infor-
mation in those  cases  of  pulmonary  apoplexy,
where the haemoptoic engorgement is confined to
a few isolated  spots, and even in more extensive
cases of haemoptysis it too often  fails to point out
the precise source of the hemorrhage.   In several
cases of  violent  and  copious haemoptysis, when,
from the  extreme state of dyspnoea and great con-
stitutional disturbance,  we had  every reason to
suspect the  existence of an  haemoptoic engorge-
ment, we have found the sound on percussion not
perceptibly altered, and have been unable  to detect
any other stethoscopic  evidence of the disease
than  a loud  mucous rale, which  only served to
indicate  the presence of blood in  the bronchia,
but afforded no information as to the source from
whence it came.  The same difficulty  of deter-
mining in certain cases  whether haemoptysis pro-
ceeds from bronchial hemorrhage or from pulmo-
nary apoplexy, has likewise  been experienced by
many other  persons well versed  in the use of the
stethoscope.   M. Cruveilhier even  goes  so far as
 to say that no information is to  be obtained from
 auscultation in such a case — " Quant a  l'auscul-
 tation et a, la percussion elles ne m'ont  rien ap-
 pris."  (Dictionnaire de Medecine, <$-c.)   In this
 opinion,  however, we can by no means coincide ;
 for by the aid of the physical signs laid  down by
 M. Laennec, we have  been  enabled,  in several
 instances, to ascertain with precision  the  nature
 and extent of the haemoptoic engorgement.
   The danger to be apprehended from  pulmonary
 apoplexy, must, as in other forms of haemoptysis,
 depend in a  great measure  on  the cause of the
 hemorrhage, the quantity of blood lost, and the
 previous  state of  the  patient's  health.   (See
 HiEMOPTXSIS.)
    When the hemorrhage supervenes  during the
 course of an organic  affection  of the  thoracic
 viscera, such  as disease of tho  heart, or the de-
 velopement  of tubercles in the  lungs, the nature
 of that  affection  must of course be  taken  into
 consideration  in forming our estimate of the pro-
 bable result:  in like manner, when it  occurs as  a
 vicarious discharge, or  as the  effect  of violent
 exertion,  general  plethora,  or any other  appre-
 ciable cause, the prognosis must depend materially
 on the nature of such cause, and the power we
 possess of removing or controlling it, so  that it
 shall not again produce a  repetition  of the he-
 morrhage.
    But, in all cases of pulmonary apoplexy, the
 prognosis should, cxteris paribus, be more guard-
 ed than in those forms of haemoptysis, where the
 hemorrhage proceeds from the bronchia, and the
 blood is removed from  the lungs as  fast as it is
 effused ;   whereas in pulmonary  apoplexy, the
 blood  accumulates in  the parenchymatous  sub-
 stance of the  lung, and often renders a  consider-
 able extent of that essential organ unfitted for the
 purpose of respiration :  besides  which, the blood
effused into  the  air-cells may in  some degree be
regarded  as a foreign body capable of producing
various morbid alterations.
   Laennec  states that  resolution of the haemop-
•oic engorgement takes place with considerable
   Vol. I. —21                        o*
facility, whatever may be the severity of the  dis-
ease.   In those instances where he had an oppor-
tunity of tracing the progress of this resolution
by dissection, he found  that  the  indurated parts
passed successively  from  dark red  to  brown or
pale red, and that,  in  proportion as the colour
faded, the  parts lost their granular texture  and
density.  When the resolution  is  complete,  it
leaves no trace of the disease in the pulmonary
substance : (op. cit.)  This favourable termination
of the disease may be known during life, by the
progressive improvement which takes place in the
patient's respiration  and general health, by the
sound or percussion becoming gradually clearer
as the resolution advances, and by the crepitating
rale becoming  audible over the surface of the
haemoptoic engorgement :  it is not, however, so
constantly  audible in this  disease as during the
resolution of pneumonia.   In a few  cases of  pul-
monary apoplexy  where we  had an opportunity
of watching  the progress  of the resolution,  we
were unable to  detect  either the crepitating or
sub-crepitating rale,  but  the sound on percus-
sion became gradually clearer, and the respiration,
which was at first extremely faint, slowly returned
to its natural state.  M. Boillaud  records a case—,
a solitary instance we believe—in which a clot of
pulmonary apoplexy  was  found surrounded by a
well  organized  cyst, precisely  similar  to those
which are occasionally developed round  apoplectic
extravasations in the brain, and which, like them,
was  probably destined to become an agent of ab-
sorption.   (Observations pour servir a  I'histoire
d'apoplexie pulmonaire par  M. J. Bouillaud.)
   Besides  these, which may be  regarded as the
favourable  terminations of  haemoptoic  engorge-
ment, others of  a less favourable  nature have also
been described  by pathologists.   Thus, according
to Andral,  " It  sometimes happens that the blood
extravasated  into  the lung, instead  of  being ab-
sorbed, has a tendency to acquire a right of settle-
ment there by becoming organized,  and thus ren-
dered capable of performing the  different acts of
nutrition and  secretion ;" in  this state it may be-
come  a nidus for the developement of different
morbid productions,  such  as tubercle, melanosis,
pus,  &c.   We  are  disposed  to  think,  however,
that the developement of tubercles can  seldom be
traced to  this  source,  as in eighty-six  cases of
phthisis, of the dissections of which  we have kept
pretty accurate notes, we only find mention made
of  an haemoptoic engorgement having been found
in two individuals ;  and even in these instances it
is just as  probable  that the  tubercles  may have
caused the apoplectic extravasations, or that both
may have been effects produced by a common
cause.  Laennec likewise observes,  (op. cit.) that
the haemoptysis which precedes or accompanies
the symptoms of confirmed  consumption, arises
much more frequently from bronchial hemorrhage
than from  pulmonary apoplexy ; and the accuracy
of  this observation has been  confirmed  by Louis
and Andral.
   The suppuration of the apoplectic mass, and lti,
evacuation by the bronchia, have been enumerated
by M. Cruveilhier (op. cit.)  among  the termina-
tions of this disease.  As, however, this opinion
is  not supported by observation, and is directly
contradicted  by Broussais (Phlegmasia  Chro- 
162
APOPLEXY,  (PULMONARY)
niqucs), we may conclude that its occ urrence is
exceedingly rare, if indeed it ever take* place.
  Lastly, pulmonary apoplexy has  been observed
to occur  as a precursory symptom of gangrene,
and may, we conceive, in some cases contribute to
produce it.   In one instance particularly we were
enabled to  follow the different stages of the dis-
ease from the formation of an extensive haemoptoic
engorgement to its conversion into a  large gan-
grenous abscess.
  The rationale of this  transition  may, we con-
ceive, be explained thus : in the  haemoptoic  en-
gorgement  the  circulation through the  indurated
mass is- completely obstructed by the solidification
of the part, and by the vessels leading to it being
plugged up with coagula of  fibrine.  This plug-
ging up of  the vessels has been noticed  by Laen-
nec, and more particularly by Bouillaud, (op. cit.)
and we have  repeatedly ascertained the  fact on
dissection.   Now if we compare the condition of
the part  thus circumstanced with  the pathology
of gangrene as laid down by the most recent and
approved authorities  on the  subject, we shall find
it placed under precisely the most favourable  cir-
cumstances for passing into  gangrene, or, as  the
disease has been more appropriately designated by
Dr. Low,  putrefactive  disorganization   of  the
lung.
  " I have already   shown,"  says M.  Andral,
(Treatise on Pathological Anatomy, translated by
Dr. Townsend, page 513,) "that gangrene is  not
necessarily   preceded  by  any  violent  degree of
irritation,  but  may be produced  by  any  cause
which retains  the blood  in the capillaries of  the
part, especially if by  such stagnation the  arrival
of fresh  blood  by the arteries  is  prevented.  In
some persons the slightest stagnation of the blood
has a remarkable tendency to be followed by gan-
grene of the part: this  disposition to gangrene,
which in these persons  is constitutional, may be
produced in others by a variety of causes ;  and in
Cruveilhier's folio work on  morbid anatomy we
read the following account of the pathology of
gangrene : — " Gangrene is  a  morbid  condition
which may occur primitively in any tissue of  the
body, or consecutively in  any organic disease, such
as inflammation, cancer, tubercle, &c.  In  fact it
always supervenes  whenever the  course  of  the
blood is intercepted either by a mechanical obsta-
cle, or  by the  obstruction of the  principal and
collateral arteries or veins."   (Anatomie Patho-
logique du corps humain, 3me livraison.)
  The consideration of this  subject will be more
fully resumed  in the  article  gangrene : we have
only alluded to it at present, because, if we admit
the possibility of  gangrene  supervening  on a
haemoptoic  engorgement, our prognosis must al-
ways contemplate the possibility of such an event,
especially when the engorgement is extensive, and
occurs in those conditions of the constitution which
have been  observed to be most favourable  to  the
formation of gangrene.
   The treatment of this disease must of course be
regulated, in a great degree, by the age, constitu-
tion of tbe patient,  and the  quantity of blood
already lost; the cause  of the hemorrhage must
likewise be taken into consideration, in order that
the treatment may be  adapted to the nature of the
disease, and not to the name it bears.  The mea-
sures pursued for the cure of pulmonary apoplexy
when connected  with purpura,  or  scurvy, must
differ very materially from  those which are em-
ployed when it proceeds from plethora, or hyper-
trophy of the heart.
  As a general rule, however, it may be laid down,
that the principal indications to be fulfilled in the
treatment of this  disease, are to arrest the  further
progress of the hemorrhage by the prompt employ-
ment of such  measures as are best calculated to
reduce plethora, moderate the action of the heart
and arteries,  and change  the determination  of
blood, and in the next place, to  prevent a recur-
rence of the hemorrhage by removing, or where
that is impracticable,  controlling  those  causes
which may in any way tend to  reproduce it, as,
by  re-establishing any habitual discharges, whose
suppression may have led to the  vicarious hemor-
rhaj*;, or  by removing, or at least palliating any
organic disease, or constitutional  disturbance with
which the hemorrhage might have been originally
connected.   The diseases both local and constitu-
tional with  which pulmonary apoplexy is usually
connected have been  already enumerated among
the causes of this affection ; it is therefore unne-
cessary to repeat them here:  the treatment adapted
to each will be detailed in their respective articles,
   As we shall have  occasion, when treating of
haemoptysis, to enter fully into  the consideration
of  the  different remedial agents  that  have been
found most efficacious in suppressing pulmonary
hemorrhage, we shall, in order to avoid repetition,
refer the reader to the  article on that subject, only
remarking that, as the hemorrhage is  in general
much more profuse in this  variety of the disease
than in bronchial hemorrhage, and as the accumu-
lation  of  blood in the parenchymatous structure
of the lung is always attended with considerable
danger and  distress,  and the resolution of the in-
durated part at best a slow and uncertain process,
our treatment should be proportionally prompt and
decisive.  With  this view it is  advisable to open
a vein largely, and draw blood freely, at the very
onset of the disease.   The  application of leeches
has generally  been found a very inefficient substi-
tute for the free  use of the lancet.   Dr. James
Clark states that, in  plethoric individuals threat-
ened with apoplexy or  haemoptysis, the applica-
tion of leeches frequently decides the  very occur-
rence of the disease it was  intended  to prevent ■
(note to  Dr. Forbes's translation  of Laennec.)
A very small  bleeding from a vein  may also, as
Laennec  observes, produce  the  same effect:  ac-
cording to this author, one  bleeding of twenty 01
twenty-four ounces on the first or second day will
have more effect in checking the  hemorrhage than
several  pounds taken away  in the course of a fort-
night.   It is even beneficial in general to induce
partial syncope by means of the first bleeding; and
he  adds that in cases of  this kind the fear of ex-
hausting the patient's strength is without grounds,
since we know that the most copious venesection
falls short of the loss of blood sustained from pul-
monary hemorrhage in young and robust subjects
even in the course of a few minutes ; while  the
debilitating effect of the hemorrhage is infinitely
greater than  the loss  of blood  produced by  the
lancet.  Should  the  hemorrhage  continue  after
the  pulse has  become small and weak, and the 
APOPLEXY,  (PULMONARY) —ARTERITIS.             163
strength much reduced, it will  not be prudent to
employ further venesection, but to have recourse
lo derivatives, among which  purgatives  are  un-
questionably the most efficacious.  A drastic ene-
ma or cathartic frequently checks the hemorrhage,
and even the hemorrhagic  molimen, especially if
they are  productive of faintness.   Nauseating
doses of tartar emetic have likewise been  found
beneficial in  controlling  the  circulation.   The
acetate of lead, too, has been  highly extolled in
this disease for its  sedative and  styptic qualities.
Dr. Mackintosh states that he has seen it, when
administered in full doses, act in the most  wonder-
ful manner in suppressing even those hemorrhages
 which were  afterwards  proved by  dissection to
 have proceeded from a ruptured blood-vessel in the
 lung, (Mackintosh's Practice of Physic;) and he
 strongly recommends it in those  cases  of pulmo-
 nary apoplexy where the patient has lost too much
 blood before we are called, or where the hemor-
 rhage continues after sufficient bleeding.  Prussic
 acid will also be found  useful in controlling the
 inordinate action of the heart  and arteries, which
 not unfrequently  subsists after  much blood has
 been lost, and  likewise in  allaying the teazing
 cough and irritation in the throat, which are some-
 times very troublesome in this disease.  We have
 likewise found digitalis useful  in  this way, parti-
 cularly in those cases where the pulmonary affec-
 tion was connected with diseases  of the heart.  It
 is scarcely necessary to add that the antiphlogistic
 regimen must be strictly enforced, and that  rest,
 silence, and cool air are indispensable.
                              R. Townsend.
    [APPENDIX  VERMIFORMIS  C^CI, in-
 flammation of the.  See Enteritis.]
    ARTERITIS.   Much difference of opinion has
 subsisted amongst authors respecting  inflamma-
 tion as occurring in the interior of the heart and
 arteries.  Some, amongst whom Laennec holds
 the most distinguished  place,  have  thought it
  extremely rare.; others have attributed to  it nearly
  all the morbid appearances and changes that are
  found in those parts.   It  will be  convenient to
  consider the subject under the separate  heads of
  acute and of chronic arteritis, ranging  under  each
  its proper anatomical characters, and the morbid
  alterations that appear to belong to it.
    Acute arteritis.
    The anatomical characters of acute arteritis are,
  redness of the internal membrane  of the heart
  and  arteries, an effusion of plastic, pseudo-mem-
  branous lymph on its surface,  and thickening and
  ulceration of its substance. Each of these charac-
  ters will be considered in  succession.
    Redness of the internal membrane of  the heart
  and arteries. — This is sometimes inflammatory,
  and sometimes not.   The redness  not inflamma-
  tory often  appears in the aorta, the  pulmonary
  artery, and  the  heart, and  is a  uniform intense
  colour, as if stained by the blood. Corvisart avows
  that he cannot give a satisfactory account of its
  nature and cause.  (Corvisart, p. 36.)    P. Frank
  regarded it as an inflammation of the arteries,
  which, according to him, occasions a peculiar and
  almost always fatal  fever.  (De  Curand. Homin.
  Morbis, torn. ii. p. 173.)   Bertin and Bouillaud
 havp considered it, whatever was its shade, as the
result of  inflammation.   (Traite, &c  p. 55.)
Laennec entertains an opposite opinion, and de-
monstrates satisfactorily that the redness in ques-
tion, when not accompanied by other anatomical
characters  of inflammation, is  the result  of san-
guineous imbibition.  This opinion has been con-
firmed by the discoveries of Dutrochet.*
   As it is necessary that the reader be  able  to
judge for himself, we shall give some account  of
this redness, adhering to the  description of Laen-
nec, which we have verified by repeated  experi-
ments and dissections.
   The redness is sometimes scarlet, and sometimes
brown or violet.  The scarlet redness of the inte-
rior of the arteries is often confined to the  internal
membrane  exclusively ;  and,  when  that mem-
brane is removed by scraping with the scalpel, the
fibrous  coat is found underneath as pale  as in  its
natural state.   But in  other  cases the  redness
penetrates more or less  deeply into the  fibrous
coat, and  sometimes reaches,  in  parts, even  the
cellular or external tunic.  The redness of the
internal coat is a perfectly uniform tint, similar to
that  which would be  presented  by a  piece  of
parchment painted red.   No  trace of  injected
capillaries can be distinguished in it, but  the tint
is sometimes deeper in  one part than  another.
Sometimes it diminishes insensibly from  the ori-
gin  of  the aorta to the place where the redness
ceases ; but very often it terminates suddenly, and
by forming abrupt  borders of an irregular shape.
Sometimes, in tbe  midst of an intensely  red por-
tion, is found  an accurately circumscribed patch
of white, which produces precisely the effect that
is occasioned  by an impression of the finger on a
part  of the skin affected with phlegmon  or ery-
sipelas.   When  the  aorta  contains very little
blood, the redness  only exists in the tract in  con-
tact with it, and forms a sort of ribbon.   The ori-
gin  and  arch  of the aorta are the  parts of that
artery which are tbe most frequently found  thus
 reddened.  Sometimes nearly  all the arteries pre-
sent  the stain.  The aortic and mitral valves then
participate in it, and appear as if they had been
 plunged in a red dye.   Though the red is scarlet
 in the  arteries, it is deeper on the valves,  approxi-
 mating slightly  to purple or  violet.   When the
 pulmonary artery is reddened, its valves  and the
 tricuspid  are  also  very commonly stained in the
 same way.  The  stain  of the right cavities and
 vessels of the  heart is a.ways of a deeper  and
 browner  hue than  that of the left; a circumstance
 dependent, in all probability, on the darker colour
 of the  venous blood.  The internal membrane of
 the  ventricles  and auricles  sometimes does not
 present any sensible change of colour, even when
 the valves are the  most deeply reddened.   Still, it
 is not  rare for the internal membrane of  the
 auricles to participate in the redness, and in  this
 case its tint resembles  that of the valves.  Mori-.
 rarely, the surface of the ventricles also presents a
 similar redness, but ordinarily  it is  browner  or
 more violet.  Sometimes the  internal surfaces of
 the ventricles and  auricles are the only parts red-
 dened  ; but this never occurs except when  the
 heart is gorged of  blood, and the arteries contain
 scarcely any.   The redness above described is not
   * Dutrochet, Nouvelles Recherclies sur l'Endosroos» el
 PExosmose. Paris. 182t*. 
164
ARTERITIS.
 accompanied  win  any  sensible  thickening  or
 vascular injection of the  stained membranes.  A
 few hours' maceration in water suffices to make it
 totally disappear.
   Such are the characters of the scarlet redness.
 We next come to the brownish  or violet stain.  It
 is  found equally on  the  aorta, the pulmonary
 artery, the valves, the auricles, and the ventricles.
 Most commonly, indeed, it is observed in all these
 parts at  once.  It is  often very  unequal in inten-
 sity, and is always more  marked  on the parts  of
 the vessels that, according to the laws of gravity,
 have been most in contact with the blood.   It is
 not so commonly restricted to the lining membrane
 as the scarlet redness ; for the muscular substance
 of the auricles and ventricles, and even the fibrous
 tunic of the aorta and pulmonary artery participate
 in the dye ; at least, in some points, and to a cer-
 tain depth.
   Such is Laennec's account of redness of the in-
 ternal membrane.  But redness, he contends  with
 great justice, is not sufficient to characterise in-
 flammation, particularly when it is not accompa-
 nied  by thickening or vascular injection of the
 reddened parts.   Moreover, the exact circumscrip-
 tion of  the redness in some cases, and its abrupt
 termination by geometrical though irregular  lines
 —an appearance  never seen  in inflammation  of
 serous membranes, though it is occasionally and
 to a slight degree in that of mucous*—banish the
 idea of  inflammation, and rather convey that of a
 stain by a coloured liquid which had run irregu-
 larly on  the reddened membrane, or which, on ac-
 count of its deficient quantity, had not been able
 to  touch every  part.  Again, the  circumstances
 under which the redness  is  usually found, coun-
 tenance  the idea of its being a  stain rather  than
 from inflammation.
  Laennec has found the scarlet red to occur  after
 a somewhat protracted agony in subjects still vigo-
 rous, but yet cachectic, in consequence of disease
 of the heart or otherwise.   The blood  in  these
 cases was never very firmly coagulated, and the
 body  most frequently presented some signs of de-
 composition. The brownish or violet red he found
 in those subjects  especially who  had died of  con-
 tinued typhoid fevers, of emphysema of the lungs,
 or of disease of the heart.  Almost all had expe-
 rienced  a long and suffocative agony ; in all, the
 blood was  very liquid and evidently altered, and
 signs of  premature decomposition existed in the
 bodies.   We have found it also very constantly  in
 cachectic subjects affected with passive hemorrhage
 from the gums, from ulcers, &c.  as in scurvy.  It
 is moreover, in summer particularly, and  in  sub-
 jects  that are  opened  more than twenty-four
 hours after death, that the dark discoloration  is
 most frequently met with.  Both varieties of red-
 ness, and particularly the brownish or violet, are
 accompanied with a greater or less degree of  soft-
ening of the heart, and with an increased humidity
of the arterial  walls.   In most instances these
states are evidently the  fleets of  a commencement
of putrefaction.  Laennec has strong doubts  whe-
ther the  scarlet redness ever produces  symptoms
sufficiently severe and constant to render it capa-
 ble  of being recognised.  He has found it in  sub-

  »  We have seen it in the trachea in variola. See also
 Hrn'onneau on Diphtherite.
 jects who had died of widely different complaints,
 and he was never  able  to  predict it by any con-
 stant sign.
   The cases which Bertin and  Bouillaud have
 adduced in substantiation  of their opinion, that
 the redness in question is of an inflammatory na-
 ture, are strikingly corroborative of the views of
 Laennec.  For,  of twenty-four cases, eleven are
 typhoid  fever, or other affections in which  there
 was a manifest alteration of the liquids, and pre-
 mature putrefaction.   The thirteen  other  cases
 consist almost entirely of consumptive patients;
 and the writers observe, in general terms, that the
 redness appeared to coincide with a remarkable
 fluid state  of the blood.  It must further be re-
 marked, that most of  their examinations  were
 made in summer, and more than thirty hours after
 death.
   In order to  ascertain experimentally whether
 blood could occasion a stain, Laennec enclosed  a
 quantity in a sound  and recent aorta, and placed
 the preparation  in  the stomach of the subject, in
 order  to preserve it from  drying, and to put it
 under  the same circumstances of decomposition as
 the rest of the body.  In twenty-four hours it pre-
 sented a perfect specimen of the scarlet dye, which
 was not weakened  by  reiterated washing.  Ac-
 cording to his experiments, blood too firmly co-
 agulated  causes imbibition feebly and  slowly.
 Blood  half coagulated, and particularly the blood
 still slightly florid, which may be pressed out of
 the  lungs, produces  the scarlet redness.   Very
 liquid  blood, and particularly that with a serous
 intermixture, produces  a violet  colour of greater
 or less depth.  If the artery be  only partly  filled,
 the dye occupies those  parts alone which  are in
 contact with  the blood, and forms a ribbon. If
 the  walls of the artery are firm  and  elastic, the
 dye requires a long time (seventy or eighty hours)
 for its  formation, and is never very deep ;  but if,
 on  the contrary, the walls are  soft, supple, and
 charged with humidity, the dye promptly  pene-
 trates through the whole thickness.  Warm  wea-
 ther and  the rapid progress of putrefaction are
 favourable to the imbibition.
  Boerhaave and Morgagni attributed the red
 colour to the stagnation  of blood which  takes
 place during the agony in  diseases accompanied
 with great oppression ;  and Hodgson maintains
 that arterial redness, such as that above described,
 does not arise from acute inflammation, as  it  is
 not accompanied  by any other anatomical charac-
 ters of inflammation.   When  occurring in the
 vicinity of coagula, it is, in his opinion, an  effect
 of imbibition  after death.
  It is impossible  not to  conclude from all the
 evidence now adduced, that redness of the inter-
 nal membranes of the  heart and  arteries cannot
 alone prove inflammation, and that it  is a pheno-
 menon  taking place during the agony, or  after
 death,  whenever  it  is found in  conjunction  with
 the following circumstances : namely, a prolonged
 and suffocative agony ; manifest alteration of the
 blood ; and  a somewhat advanced  decomposition
of the body.
  Such is  the redness of the internal  membrane
of the  heart and  arteries which is  not inflamma-
tory : we now proceed to that which is.  The co-
lour of the latter may be the same ;  for tho mem 
ARTERITIS.                                   165
brane, though inflamed, is still liable to imbibition.
In the absence of imbibition, the redness is fainter,
less shining, more  equably diffused, and less cha-
racterised  by streaks, patches, isolated  unstained
spots, and abrupt edges.
   Effisiox of lymph on the  internal mem-
     brane,  WITH  THICKENING OF ITS  SUB-
     STANCE.
   Whether the redness  be due to  vascularity
alone, or to this conjoined with imbibition, its  in-
flammatory nature  is known by  the  presence of
certain other anatomical  characters of inflamma-
tion.  These are, thickening, swelling, and puffi-
ness of the inner membrane;  and  effusion  of
lymph on  either its free or adherent surface ; and
a  preternatural  vascularity, with softening and
thickening, of the  middle arterial coat.  Each of
the coats  may  be  separated from the other with
much greater  facility  than natural  by scraping
with the nail or scalpel.  The internal and middle
coats, in short,  present all the phenomena of  the
adhesive inflammation, as it occurs in  other mem-
branes.   It is by  this inflammation  that, if  an
artery be wounded or divided ; if it be compressed
by a ligature or tumour ;  or if it be simply irritated
by ulceration of the  surrounding  parts  or a pul-
monary vomica, and  effusion of lymph takes place
into the cavity of the vessel, and into the cellular
tissue, both investing it externally, and connecting
its several coats, by which its caliber is obliterated
and hemorrhage prevented.
   Although obliteration  never  takes  place in  the
aorta from inflammation  alone, this vessel some-
times exhibits  the  vestiges of acute inflammation
more palpably than  smaller arteries.   Thus, in a
case seen by Dr. Farre,  the internal  coat of  the
aorta was  of a deep red colour, and a considerable
effusion of lymph  had taken place into  its cavity.
The lymph was very intimately connected with
the internal coat.  (Hodgson on  the Arteries, p.
5, plate 1,  fig. 5.)    Similar instances have been
seen by Hodgson,  (Ibid.  p. 6,)  Bertin, (Case ii.
p. 7,) and  apparently by Portal, (Cours d'anato-
raie medicale, torn  iii. p.  12?,) and Morgagni and
Boerhaave, (Morgagni, Epist. xxvi. Art. 36 ;) and
lymph has been found effused within  the auricles
and on the valves by Baillie, (Morbid  Anat. Edit.
5, p. 85,) Laennec, (De l'Auscult.  torn. iii. p.
127,) Burns, (On  Diseases  of the Heart, ch. ix.)
We have  met with it both in the heart and aorta.
Effusions of lymph  within the  heart  and  great
arteries, however, are very seldom witnessed ; and
hence it is, that Laennec thinks  inflammation of
the internal membrane of those  parts  extremely
rare.  (De l'Auscult. torn. ii. p.  598.)   But  the
presence or absence  of lymph is not  sufficient to
determine whether inflammation exist or not;  for,
in many instances, the lymph, when first effused,
is washed  away by the force of  a circulation  so
powerful as that in the heart and aorta.  Laennec
considers a layer found on the internal membrane
of the heart or great  vessels, to be the only incon-
testable sign of inflammation of  that membrane,
and, with ulceration, the only certain one, (Ibid.
p. 607 :)  for he doubts  whether iedness of  the
membrane, even when conjoined with thickening,
swelling, puffiness, and an  unusual development
of small vessels in  the middle tunic, would satis-
factorily prove inflammation in  a subject conside-
rably infiltrated, and whose  tissues are  very  hu-
mid.  (Ibid.)   This is a point which can only be
determined by the judgment of the physician in
individual cases.   We recently met with a case
precisely such as Laennec describes, and, at the
first glance, it struck us and two eminent medical
friends as being inflammatory ; but a brief inspec-
tion proved the reverse.   It is necessary, however,
to be alive to  this source of fallacy.  Kreysig,
Hodgson, and Bertin  and Bouillaud are of opin-
ion that lymph effused  by inflammation is the
source  of fungous or warty vegetations of the
valves.   Laennec rejects this opinion, and attri-
butes  the vegetation  to sanguineous  concretions
which adhere to the internal membrane, and be-
come  organized.   He does not  deny,  however,
that an inflammatory false membrane  may  be-
come the nucleus of these concretions.  This sub-
ject will be more fully considered under the head
of vegetations.
   Effusions of  lymph are, in some instances, the
result of chronic inflammations ; for they are found
in the  vicinity  of ossifications of  arteries  and
other morbid  alterations of a chronic nature.  We
have seen an ossified  common iliac obliterated by
a plug of lymph.  Hodgson has witnessed nearly
the same ; and Dr. Goodison found the aorta itself
obliterated by lymph, at a part where  its  whole
circumference was converted into a bony cylinder.
This lymph must have been, secreted gradually ;
as the force of the aortic circulation would  have
washed away any soft and copious recent effusion.
It is probable that the obliteration of arteries in
the neighbourhood of vomicae  and other ulcera-
tions, and of  tumours, is also occasioned by chro-
nic inflammation.
   Ulceration of the internal membrane___Ulcera-
tion  of the internal membrane  sometimes takes
place from acute inflammation, without any lesion
of the subjacent tissues.   This, however, is rare ;
for, in general, the ulceration is a consequence of
some  previous  chronic degeneration of the coats
of the vessel, and is, in the first instance, rather a
solution of continuity than an ulceration.  Such
is the case when it is occasioned by the detach-
ment of calcareous incrustations, or by the depo-
sition of atheromatous or other matter underneath
the internal membrane.   Ulcers from these causes
are not uncommon,  and  though  they do  not,
strictly, come under  the  head of acute arteritis,
they may be conveniently considered in this situa-
tion.  They vary in size from a mustard-seed to a
pea or bean, have  more or less thick and ragged
edges, and are sometimes so deep as to reach, and
even to perforate, the external or cellular  tunic.
Laennec describes  the  formation of these  ulcers
from  calcareous  incrustations  in the  following
manner :  " When a calcareous incrustation," says
he, " is detached  from the aorta, the species of
sinus left by it is filled up by fibrine, which be-
comes,  by decomposition, of the consistence of
friable  paste,  and  is often intermixed with phos-
phate of lime."  This paste, when soft and pulpy.
has  been denominated  melicere,  or atheroma.
Not  unfrequently, the borders of the  lesion are
reddened for a little distance; and this he  attributes
to imbibition of blood, (rendered more easy in an
altered structure,) rather than to chronic inflam
mation, which he thimks is not proved either ti 
166
ARTERITIS.
the presence of pus, or of any symptoms local or
general, that can  be referred to  it.  These lesions,
therefore, he regards as beimr, in the first instance,
merely solutions  of continuity  from  an  entirely
mechanical cause; and not  ulcers, occasioned by
inflammation.   He does not deny, however, that
the oldest and most extensive of them sometimes
become ulcers ; for the internal membrane at the
bordeis of the lesions  is slightly tumid  and red,
and  the surface of the fibrous  tunic at their base
is manifestly altered.   But he  contends that  the
inflammatory action which gives them the charac-
ter of ulcers, is the effect, not  the cause, of the
solution  of  continuity.   Solutions  of continuity
occasioned by the detachment  of calcareous in-
crustations,  are among the  most frequent causes
of consecutive false aneurisms.
  Small pustules filled with pus  sometimes, though
rarely, present themselves under the internal mem-
brane of  the aorta, and burst into its cavity.  It is
probable  that  they form  the genuine  or primitive
ulcers of that  vessel.—those which are the most
frequent cause of its perforation. They sometimes
throw  out  curdy, and even  calcareous matter.
Laennec thinks that these pustules are occasioned
by inflammation,  not of the internal, but of the
middle arterial tunic, or of the  fine cellular tissue
which unites the middle to the internal tunic; and
he is of this opinion, because, in inflammation of
all membranes, as the peritoneum, the pleura, the
mucous membrane  lining the  bronchia, &c.  pus
forms on their free, and not on  their adherent sur-
face.  Therefore,  as this secretion is found on the
adherent surface of the inner arterial membrane,
he infers that the inflammation occasioning  the
pustule is seated, not  in  that  membrane, but in
the  subjacent tissues.   Pus is scarcely ever found
on ulcers of the  heart and  arteries, because it is
washed away as soon as  secreted.  For the same
reason, it is  never found on the  internal surface of
arteries that are inflamed without being ulcerated,
though analogy  leads  us  to believe  that, under
these circumstances, it is secreted.
  Ulcerations  are extremely rare in the cavities of
the  heart.   We  recently  met  with  an instance,
originating in  a curdy deposition under the lining
membrane.  We  have never  seen or heard of a
case in which  inflammation, when confined to tbe
interior of  an artery, terminated  in  gangrene.
Arteries,  however, are  frequently involved in the
sloughing of surrounding parts; in  which  case
the  blood generally coagulates  in the vessels to a
considerable extent above the line of sphacelation,
and thus prevents  hemorrhages.   (Hodgson, p. 17.)
  It remains to be noticed that arteritis  is some-
times of an erysipelatous nature.  We allude to that
which follows an injury of an artery, as by a ligature,
\ gun-shot wound, &c. especially if there be deep-
seated disease  in the muscles of the part affected.
 The inflammation, in these cases, sometimes runs
along the internal coat of the artery till it reaches
the heart.  It is a most formidable disease, rapidly
producing great irritative fever, an extremely quick
pulse, complete collapse, low delirium, and gene-
rally deaf1.
   Chronic arteritis and the morbid alter-
     ations CONNECTED WITH IT.
  Arteries are more  subject to chronic  than to
 »cute  inflammation.   The  internal   membrane,
I when so affected, is  thickened, softened, and d j
I deep dirty red colour.  These appearances are not
j uniformly diffused, but are more marked in the
I vicinity  of  calcareous  and  other  degenerations.
 Hence some have supposed  that these degenera-
 tions were the cause of the inflammation. There
 can be  little doubt  that  they tend in many in-
 stances  to keep it up ;  but it  is highly  probable
 that  the degenerations themselves were originally
 caused  by increased  vascular action  of a chronic
 nature.   Whether the  increased vascular action
 be in every  case, particularly those of calcareous
 depositions,  strictly inflammatory, we shall inquire
 after  bringing  the  various  degenerations under
 review.   Meanwhile it may be remarked  that the
 appearances in arteries presented  by chronic in-
 flammation  accompanied with morbid depositions,
 have been well  known to authors from a very early
 period.   The ancient physicians ascribed  them to
 acrimonious, syphilitic,  and  scorbutic  humours
 pervading the system. Some modern writers also,
 particularly  Corvisart,  Scarpa, Richerand,  and
 Hodgson, impute them to similar causes, espe-
 cially to  the syphilitic virus, or to the  mercury
 used for its  eradication.
    Monnm alterations  in the coats of arte-
      ries, AND ESPECIALLI OF THE AORTA.
    The  morbid  alterations in the interior of the
 aorta which appear  to  be of chronic formation,
 are, steatomatous,  fibrous, cartilaginous, and calca-
 reous depositions, with a thickened, fragile, and
 inelastic condition of the arterial coats.  The most
 simple of these alterations is, a loss of elasticity,
 generally accompanied with increased density and
 opacity  of the coats of the artery.  This state is
 sufficient of itself to give rise to dilatation, by a
 process which will be described under the  head of
 dilatation of the aorta.
    Before describing  the  depositions,  it  may be
 premised  that  they originate, not in the  internal
 coat, but either in the middle coat, or in  the fine
 cellular tissue interposed between it and the inter-
 nal coat; that  this coat can sometimes be peeled
 off from them  in a perfect  state, even when they
 are far advanced ;  and that the productions them-
 selves are  more  analogous to those of a fibrous
 than of a serous membrane.
    The extent, the form, and the thickness of the
 productions  are infinitely various : sometimes the
 several  species exist separately, but  more  com-
 monly they  are  found more or less intermingled
 in the same artery.  The first and  most common
 appearance is that of small, opaque, straw-coloured
 spots, immediately underneath  the  lining mem-
 brane, with  slight inequality and corrugation of
 the membrane around them.  At a more advanced
 period  the depositions form considerable, slightly
! elevated  patches,  which,  becoming confluent,
 sometimes overspread the whole surface. Some
 of these patches have much the appearance and
 consistence  of  bees'-wax, or cheese, though in
 general  their cohesions and flexibility  are greater.
 These  are  usually  denominated   steatomatous.
 Others,  presenting nearly  the same colour, have a
 fibrous or ligamentous appearance ; while others,
 again,  are more  translucent,  white, and elastic-
 like cartilage or  fibro-cartilage.  All  the deposi-
 tions described  are accompanied with thickening
' and  loss of  elasticity of the  internal coat, which 
                                       ARTE

recomes knotty, wrinkled, and sometimes cracked,
scaly, and fimbriated.   This, however, is less deci-
dedly the case until earthy depositions have taken
place.  These generally commence in  the  midst
of a cartilaginous or  fibro-cartilaginous  patch,
though  they are  sometimes  found in detached
scales, and sometimes  in a soft or pasty form, in
the midst of cheesy, curdy, or melicerous matter.
When they form incrustations, the shape of these
is irregularly  flattened; the  prominences  being
towards the exterior rather than the interior of the
artery.   Their external surface sometimes presents
the imprint of the circular  fibres of the  middle
tunic.    Their  internal  surface  is  sometimes
smooth, and evidently  covered by the membrane ;
in other cases it is rough, and the membrane is
more or less  destroyed.  Calcareous depositions
occur most  frequently in the ascending portion
and arch of the aorta, but occasionally they per-
vade the whole of the  vessel, and even almost the
whole of the arterial system.   We saw a  case in
the Hotel Dieu, in which the  great arteries from
the heart to the ankle were converted into rigid
tubes by ossification, which in parts occupied all
the coats and the whole circumference  of the ves-
sels.  In  another  case, at  St. George's Hospital,
the common iliacs were  rigid  ; and  one of them,
which  was  converted into a long cylinder, was
obliterated by a plug of dense lymph.   The arte-
rial  system was elsewhere  more or less ossified.
Both the patients died with gangrenous sores  of
the legs.
   In the arteries at the base of the brain, calcare-
ous  and other degenerations  are remarkably  fre-
quent, and are a principal cause of apoplectic effu-
sions.  It is rare, indeed, to meet with an instance
of such effusion, exclusive of those dependent on
external violence, in which some disease of these
arteries may  not be  detected ;  and  it may  be
remarked in passing,  that, in  most instances, the
disease of the artery is connected with hypertro-
phy of the left ventricle ; whence it appears to be
referable to over-distension, to which the cerebral
arteries are more obnoxious than others, in conse-
 quence of their being  without the  cellular coat,
 and being ill-supported by the pulpy yielding sub-
 stance of the  brain.   We have  met with  several
cases of  epilepsy which had no  other obvious
cause than disease of the cerebral  arteries.  The
 arteries below the  pelvic divarication of the aorta
 are  more frequently  ossified  than  those  of  the
upper extremities  and  trunk.
   Calcareous concretions differ essentially from
natural bone.  For though some are  formed  by
the secretion of the earthy phosphate in cartilage,
even these have not the peculiar fibrous arrange-
ment of bone.   But in by far the greater number
of cases, the earthy matter is not secreted  in  any
cartilaginous matrix whatever, but is simply depo-
sited  in  the form of  an irregular homogeneous
crust or crystallization, without  any determinate
arrangement, and  without vitality.   The propor-
tion of animal matter  in these is very small.  Mr.
Brande found 100 parts  to  consist  of 65.5 of
phosphate of lime, and 34.5 of animal matter.  In
some specimens we have found  the quantity of
animal matter considerably less.
   When  ossification  is very  considerable, it is
sometimes attended with  induration, inelasticity,
RITIS.                                  167

and fragility, not  only of the internal, but of all
the  arterial coats ; and  this state. I have seen  at-
tended  in some cases with  thickening,  and in
others,  though less  frequently,  with extenuation
and a horny  translucency of the walls of the ves-
sel.   The aorta, so  affected, generally undergoes
dilatation, but very rarely contraction.  When the
depositions are partial and  limited, the internal
membrane in the intervals is often perfectly sound.
This is especially  the case in the ossifications of
old people.  It is  remarkable that, though morbid
depositions are so frequent in the aorta, they  are
extremely rare in  the  pulmonary artery.   Out of
upwards  of  a thousand cases, in which we have
examined this vessel, we have never met with cal-
careous depositions  in its coats, and only three or
four  times with  cartilaginous  and  steatomatous
disease and dilatation.
   Causes of morbid depositions in. tlie coats
of Arteries. — Some authors  have  considered
morbid depositions in the coats of  arteries to be, in
every case, the various metamorphoses of lymph,
effused by inflammation of  the acute kind and of
such intensity  as always to proclaim itself by  ob-
vious symptoms, and require  antiphlogistic treat-
 ment.  Others, again, have supposed that many,
if not all, of the depositions in question, take place
quite independently of inflammation of any kind.
 As  principles  of  treatment  of  a  decided  nature
have been founded  on each  of these  conflicting
doctrines, it  is  a matter, not of  mere speculation,
but of  practical importance, to look into the sub-
ject, and endeavour to ascertain the truth.
   Although it would be difficult to deny that acute
inflammation may, in  some  instances,  lay  the
foundation of morbid depositions in  the coats of
 arteries ; yet it is certain that  they may and do
occur independent of it; as they have been found
in  individuals  who had  never  manifested  any
symptoms whatever  of  inflammation,  and who
had  even constantly enjoyed  the  most perfect
health.   Analogical evidence derived from other
membranes leads to the belief that chronic inflam-
mation is, in most instances at  least, the main
agent concerned in the production of these depo-
 sitions.   Thus, for example, the dura  mater  an,i
 the pleura are  sometimes not only thickened  and
 indurated, but converted into fibrous, cartilaginous,
 or  bony tissue.   We  have  seen  the  dura mater
 converted into a calcareous plate nearly as large
 as  the hand, and overspreading one hemisphere of
 the brain.  The preparation was shown to us by
 Professor Monro, and is in  his museum.  Mr.
 Hammick showed us two preparations, in his mu-
 seum, of calcareous plates, of about two inches in
 diameter, on the  pleura.   Changes of this kind
 are, by general consent, attributed to chronic  in-
 flammation ; as they are not only found  in con-
 junction with  organized adventitious membranes
 and other anatomical  proofs of that form of in-
 flammation,  but are often attended with its syinp
 toms.  It is to be  presumed, therefore, that  cor
 responding changes taking place within an artery
 are referable to the same cause.   That the morbid
 depositions in the artery should  not  be  exactly
 identical with those found in other membranes is
 to  be anticipated  on principles  of general anato.
 my ; for the effused matter, which is the basis of
 every accidental production, differs in aspect  an'1 
168
ARTEi   l *S
nature according to the tissue in which  it occurs.
Thus,  as  well  remarked  by Bertin,  the  cellular
tissue  and parenchymatous  organs secrete  pus,
properly so called ;  thus serous membranes secrete
a coagulable matter prone to transform  itself into
cellular or serous layers ;  thus the periosteum fur-
nishes another matter, which  concretes, hardens,
and  ossifies; thus  the arterial  tissue,  composed
essentially of a fibrous membrane, exhales a liquid
which hardens, condenses, and becomes convert-
ed into cartilaginous patches, or  calcareous scales.
  But admitting the agency of chronic inflam-
mation as a cause of morbid alterations in   arte-
ries, there is  reason to believe, as before stated,
that some of them,  particularly  the calcareous,
may take place independently of it; for they are
found in most old people  ; they sometimes occur
in various detached points very remote from  each
other; they often consist of a simple calcareous
scale, or an opaque yellow spot,  without any  mor-
bid state of the surrounding membrane ; and  such
alterations almost always take place without afford-
ing the slightest  sign, either general or local, of
their formation.   Now, it is scarcely possible to
conceive  an  inflammation  which manifests  no
symptoms, which is restricted to isolated points
often remote from each other, which  leaves  none
of the ordinary vestiges  of inflammation in the
surrounding membranes,  and  which  is the  most
frequent at that period of  life when phlogistic ac-
tion is the least prevalent.  We are brought, then,
to inquire, what is the cause of morbid depositions
when they do not appear to be referable to inflam-
mation.
   Here it is necessary to  proceed with caution, as
the  ground is  purely speculative.  Laennec, in-
deed, thinks it the most simple and  philosophical
to acknowledge  that  we  know  not  the derange-
ment of the economy which produces an ossifica-
tion or a cancer, but  that very certainly it is not
the same as that which produces pus—as inflam-
mation, (De l'Auscult. vol. ii. p. 684.)  If we are
not satisfied to remain in  this  circumspect uncer-
tainty, we can scarcely venture farther,  in the ac-
tual state of our knowledge, than to suppose that
morbid productions are sometimes results  of  a de-
praved action of the vessels not identical with or
not  amounting to inflammation—a doctrine, in-
deed, which rests on the  basis of sound observa-
tion, and which has been extensively received,
since the accurate researches of the present  cen-
tury have  bred  a  "philosophic  doubt" on the
tenet of the ancients, that all accidental  produc-
tions are the effects of inflammation.  Admitting
a depraved action of the  vessels, it is rational to
suppose  that, like inflammation, it would derive
its particular character from the  tissue  which it
affects : hence that the  fibrous  and fibro-serous
tissues of the  arteries would degenerate into car-
tilage, bone, &c—the changes to which they are
most prone under the influence  of inflammation.
But what is it that calls this depraved action into
activity ?   It appears to  us  th n over-distension
of the arteries  by the force of the circulation is
what,  principally at least, produces the effect. To
(his opinion we are led by the following  conside-
rations : that  arterial ossifications are the  most
common when tbe left ventricle is hypertrophous ;
that (according to an observation of Boerhaave,
related by Morgagni) they are found in stags long
and often exercised in running, f.nd not in  those
which lead a tranquil life in the \ irks of the great;
that diseases of arteries  and  aneurism  are  more
common, in the proportion of at least seven or
eight to one, in men  than  in women, the life of
the former being much more laborious and the cir-
culation  more liable to excitement from  potation
of vinous or spirituous  liquors, &c; that ossifi-
cations, &c, occur in those arteries more especial-
ly which are  most  exposed  to  over-distension,
namely,  the arch of the aorta, which immediately
sustains  the whole  brunt  of the left ventricular
contraction, and the arteries of the brain, which,
not having the support of  a  cellular sheath, and
being bedded in a soft puffy substance, are weaker
than  any others ; that they  are  more especially
incident  to the aged,  in whom the arterial and all
other tissues sustain a diminution of elasticity and
cohesiveness  in  consequence of the diminished
vascularity which characterises old age.  Perhaps
the same reason, viz., over-distension, may be as-
signed for the remarkable frequency  of the arterial
depositions in those who have suffered much from
syphilis or mercury ; for as these maladies induce
a cachectic state which lessens the elasticity of all
the tissues, the arterial tissue would, under these
circumstances,  suffer proportionably  more  from
the distensive pressure of the circulatio 1.  To the
above catalogue we  may perhaps add gout—an
affection which is remarkably often attended with
arterial ossifications and their frequent  concomi-
tant, angina pectoris.  For the gouty habit is  in
general accompanied with a morbid degree of ple-
thora, and consequently  with over-tension of the
arterial system, leading to ossification.
.   It may be remarked, finally, that even they who
attribute all  the  morbid  alterations  in  arteries to
inflammation, admit  the  necessity of specific in-
flammations to account for those alterations which
are not normal products  of ordinary inflammation.
Thus Kreysig thinks that calcareous incrustations
are only produced  by gouty inflammation; and
Bouillaud, who employs the word inflammation
in perhaps too extended a sense, believes that (here
must be  a peculiar predisposition for each effect
.of the one same cause,—that every  variety of de-
position  must be the result of a different  specific
inflammatory action.
   Symptoms and diagnosis of acute Arte-
ritis.—The  diagnosis of arteritis is one of the
most difficult in  the range of medicine; as the
malady presents no signs that are peculiar to itself,
and distinguish it from other diseases.
   We shall first describe the signs by which some
authors have imagined that they could detect acute
aortitis, and  then  subjoin the sources of fallacy to
which, according to our  experience, those  signs
are liable.   The practitioner, being thus  warned
against  the  various  causes of deception, will be
better able to give their  full value to the  signs
themselves; and he  may in this way, we think,
make out the diagnosis with some success.
   The principal sign of acute aortitis, according
to authors, is a pulsation of the  aorta much more
violent than  in  the  healthy  state.  A  pain and
sensation of heat in the  region of the aorta, anxi- 
ARTERITIS.
169
ety, and faintishness, are symptoms of a less con-
stant nature, but which, nevertheless, it is import-
ant to mark.  To these are to be  added accelera-
tion of pulse, heat, and dryness of the  skin, thirst,
anorexia, and all the other concomitants of phlo-
gistic action.  The position of the thoracic aorta
is such that the strength of its pulse can only be
explored in  the hollow at the summit of the ster-
num and above the clavicles.  The  beating of the
ventral aorta may be more  easily examined, name-
ly, by applying the  hand, or, what  is better, the
stethoscope, on the abdomen.
   Violent pulsation of the aorta from inflamma-
tion is often accompanied with a similar pulsation
in any or all of the great arteries ;  the reason of
which  is, that the inflammation  not unfrequently
extends to  the  other arteries,  and even   to the
whole  of the arterial system.
   With respect to inflammation  of the  internal
membrane of the heart, it is  excessively rare in
an  isolated form, being almost invariably attended
either with carditis or pericarditis.   Analogy indi-
cates that it ought to be characterized  by augmen-
tation of the force and frequency of the action of
the heart and arteries, and leads us to expect that
when the inflammation reaches and disorganizes
the muscular substance, it  would  render  it inca-
pable of contracting with its natural strength and
regularity.   Observation confirms what  analogy
leads us to foresee.   In fevers, properly so  called,
which appear to be constantly accompanied with
an  irritation of the  heart, the frequency and force
of the pulse are the two principal phenomena that
strike our senses; but should the  fever assume a
typhoid type, and give rise to an irritation  of the
heart, so profound that the muscular substance is
itself attacked, the pulse loses its force and  regu-
larity while it augments in frequency, an  unex-
pected  death often  terminates this always  formi-
dable complication.  Should the patient recover,
the slowness of his convalescence  and the fre-
quency of pulse which characterize it, are probably
dependent either on an irritable state of the inter-
nal membrane left by the inflammation, or on soften-
ing of the muscular substance,—a subject to which
we shall revert when treating of softening.
   Such are the symptoms of acute  arteritis as-
signed by authors.   The fallacies to  which they
are liable are so numerous  that many  able  practi-
tioners formally avow their inability to make the
diagnosis.    The fallacies arise, 1st, from  the in-
flammatory complications with which arteritis, and
more particularly aortitis, is accompanied :  2dly,
from affections which, though  unattended with
arteritis, occasion arterial pulsation.
   1. The  inflammatory complications of aorti-
tis___Acute aortitis  is very rarely known to exist
fso far as we can judge from its  anatomical ves-
tiges—the only positive criteria) independent either
of continued fever,  or  of  inflammation of some
of the principal  viscera, particularly  the  lungs,
pleura,  and pericardium.  In  these complicated
cases the symptoms of aortitis are lost in those of
the concomitant malady, which is of itself capable
of producing, to a greater or less extent, the same
violent arterial pulsation  and the  same anxiety
and  faintishness  as  are considered  characteristic
of aortitis.
  Vol. I. — 22                           p
2. Affections  which,  though  unattended  with
      arteritis, occasion arterial pulsation.
   (a.)  When  the  interior of the ascending por-
tion, or arch of the aorta  is ossified or cartilagi-
nous, there  is generally a preternatural  pulsation
above  the clavicles, and this always takes  place
when the artery is dilated ; for, as the blood per-
meates the diseased or dilated portions with greater
difficulty than others, in consequence of its being
reverberated in counter-currents and eddies from
prominences in the vessel,  those portions sustain,
at each contraction of the heart, an increase of the
expansive force of the  blood, the  lateral  pressure
of which is always augmented in proportion as the
direct current is impeded.
   (b.) Persons of an irritable temperament, espe-
cially delicate  hysterical females and hypochon-
driacal males, are subject to morbid arterial pulsa-
tion, sometimes confined to  the aorta alone, and
sometimes universal throughout the system. When
it  is seated  in the descending  aorta, the patient
complains of "a fluttering"  in  the epigastrium.
   (c.) Morbid arterial pulsation is a phenomenon
of reaction after loss of  blood—a fact to which the
attention of the profession has  been drawn with
great ability by Dr. Marshall Hall, and which we
have  verified,  not  only by  observations on tbe
human subject, but  by extensive  experiments  on
animals, performed in concert with  that gentleman.
The pulsation  not unfrequently supervenes, and
subsists for  a considerable  time, after the free de-
pletions necessary for the  cure of acute inflam-
matory affections, as pleuritis,  pericarditis, peri-
pneumony,  phrenitis, peritonitis,  &c.   In  these
cases it would be a dangerous  error. to  suppose
that the pulsation depended upon aortitis.
   (d.) We have  found arterial pulsations to ac-
company adhesion of the pericardium,  especially
for the first year or so  after the attack of pericar-
ditis which  occasioned it.  The phenomenon is
attributable  to  the jerking and, as it were, spas-
modic manner in wbich the heart contracts under
such  circumstances.  It may  be  remarked that
there  was adhesion of the  pericardium  in two of
the three cases from which more especially Bertin
and Bouillaud derive their opinion that aortic pul-
sation is always a sign  of aortitis.   (Bertin, Obs.
xxvii. xxviii. and xxix.)
   (e.) Tumours, serous effusions, &c. in contact
with the aorta, give it the character of preternatu-
ral pulsation, as they transmit  its  impulse  more
strongly than the parts  which properly environ it.
The mode  of distinguishing these  pulsations is
treated of under the diagnosis of aneurisms of the
aorta.
   From this long catalogue of fallacies it will  be
apparent that  the  diagnosis of arteritis  is  beset
with much difficulty.  Still, it is not wholly hope-
less ;  for, by a negative process,—by ascertaining
that the pulsation is not attributable to any of the
causes mentioned,—I believe it is possible to form
an  opinion  which will  not be  very wide of the
truth.
   Of chronic arteritis, it is sufficient to say, that,
though it in all probability deteriorates the general
health, it presents no distinctly appreciable signs
but those of the structural  alterations,—the depo-
sitions, dilatations, and  valvular obstructions,—to
which it gives rise. 
170
A  JTISANS,  (DISEASES  OF)
  Prognosis.—Arteritis is not a dangerous dis-
ease by its immediate effects;  but it may lay the
foundation  of disease  of the  arterial  coats  and
valves  of the  heart, which may ultimately prove
formidable  by inducing  aneurism of the vessels
and disease of the heart.   When arteritis is com-
plicated with fevers, or visceral inflammations, the
prognosis must  be founded on the symptoms of
the latter maladies.
  Treatment of arteritis.—Arteritis  is to be
treated on the'same general principles as any other
inflammation ;  namely,  by bleeding, purgatives,
diaphoretics, low diet, cooling diluent  drinks, and
perfect tranquillity.  The  latter is absolutely ne-
cessary, as any efforts which accelerate the circu-
lation increase the tension, and therefore the irri-
tation, of the arterial system.  On the same prin-
ciple, remedies which calm the circulation, as digi-
talis, tartrate of antimony, superacetate  of lead,
are useful auxiliaries when discreetly employed ;
but they should not supersede the more important
remedies above  mentioned, nor  should  they be
given  at a late  period of the  disease, when the
symptoms, which of themselves become  compli-
cated, should be kept as  unembarrassed and clear
as possible.  When mercury is not  contra-indi-
cated  by a  strumous or shattered constitution, its
exhibition to the extent of slight but prompt sali-
vation,  after the first violence of inflammatory
action  has  been repressed, is attended with excel-
lent effects.
  When arteritis is complicated with visceral in-
flammation or fever, the treatment must be directed
to the primary malady.
                                  J. Hope.
   [ARTHRITIS.  See Gout.]
  ARTISANS, Diseases of.—The diseases of
artisans  must,  in every  civilized  country, be an
object of great importance, but in none can it be
so important as in Great Britain, so large a pro-
portion of whose inhabitants are engaged in manu-
factures.  In the present article  we propose  to
give a brief account of these diseases, and to ac-
company it, as far as  we can,  by  that of the
attempts which  have been made  to  deprive the
various trades of their injurious tendencies.
   The arrangement which we shall  follow will,
witb some modifications, be that  which was first
indicated by Ramazzini, modified by Fourcroy,
and again modified by M. Patissier. The ground-
work of the arrangement is  founded upon the
causes  of these disorders ; and we,  first of all,
have two classes.  The first includes the diseases
caused by moleculae, which, mixed with the air in
the form of vapour or fine powders, are  respired
by  the workmen, penetrate their organs, and dis-
turb their functions.   The second class compre-
hends  the diseases caused by  excess  or defect  in
the exercise of certain parts of the body.  Under
the first class are comprehended,  1. diseases pro-
duced by mineral moleculae;  2. those arising from
animal  moleculae;  3. those  which  result from
vegetable moleculae; and 4.  diseases which  are
 oroduced by the mechanical  action of moleculae
 or fine powders, arising from mineral or vegetable
 substances.  The second class embraces, 1. dis-
 eases arising from the effects of moisture and  of
 temperature,-  2. diseases from undue or excessive
muscular exertion of particular parts or organs •
3. diseases arising from sedentary habits.
  Before entering thus upon the effects of peculiar
substances  and the effect of particular positions, 3
preliminary inquiry  ought  to  be made into the
consequences of labour abstractedly taken.  There
is unquestionably considerable  difficulty attending
it;  but yet it seems  impossible to reject over-con-
finement alone, or over-exertion alone, as produc-
tive of severe maladies.   We are accustomed fre-
quently  to witness the  consequences  of over-
working  that most useful  animal, the horse ;  and,
in this respect at least, there is  nothing physically
different  between man and the  otier mammalia.
In  the horse, the kind  of labour has evidently
nothing  to do with  it, since  the same  exercise,
moderately taken, contributes to the  preservation
of his health and the improvement of his strength;
it is the quantity alone  to which the  injury  is to
be referred. Tbe same remark holds equally good
of man,  but very many  circumstances attending
his occupations  will  require  to be  taken  into
account.   In the first place, the quantity of labour
which different  individuals can  undergo without
detriment,  will vary  much with the original  con-
stitution of their bodies and their habits.  A  man
of great  natural physical strength, other  things
being equal, will perform  more  labour than a  man
of  less powerful  make ;  of two  men  of equal
natural powers, the one, accustomed to continual
hard work, will bear more than  the other, unaccus-
tomed to  such employment;  and, in the  second
place,  very much will depend  upon the quantity
of nutriment  which can  be  obtained.  A more
striking instance of this could scarcely be adduced,
than what occurred  to the persons engaged  with
Captain Franklin in the travels to the North Pole,
We find them preserving  their  strength, and easily
enduring the  journey to the  sea, though called
upon perpetually to  great bodily exertion;  but on
their return, having  been for some time deprived
of sufficient food, the strongest amongst them was
scarcely  able to carry his  gun,  and not at  all able
to steady it, so  as  to  obtain  any of that  supjily
which appeared within their reach.
   Taking, nevertheless, all these considerations in
review, there  are,  even  in Great Britain, many
instances of evil effects arising from the long con-
tinuance of labour—of that labour, which not only
would not be injurious in a moderate degree, but
would most  probably conduce to  the healthy
action of the  corporeal functions.   The majority
of  these  cases  take place among children,  and
chiefly among  those occupied  in cotton manufac-
tories.
   Upon this  part of our subject we  have fortu-
nately some very  strong evidence,  and  from a
source which  is perfectly unsuspicious.  A few
years ago, the injury which, it  was natural to sup-
pose, must ensue to young children, from too  early
overstraining  their physical powers, engaged tbe
attention of parliament, and, under the  influence
of  Sir Robert  Peel,  a  variety  of manufacturers
were  examined, together with many of the  first
medical  men  of the kingdom.  It was scarcely
reasonable to expect that the former should  have
observed, or, if they had observed, that they would
readily acknowledge, even to  themselves, the HI
effects which accrued to their young work-people; 
ARTISANS,  (DISEASES  OF)
171
and, accordingly, we find  that, for the  most part,
they utterly denied that any evil had ensued from
the confinement or the exertion.  We are far from
insinuating that, in  any  instance,  the manufac-
turers who were called stated any thing of which
they did not feel themselves convinced; but accus-
tomed  as  they  must be to  employ children, and
little as  they naturally would  feel disposed to
indulge in an inquiry which  must necessarily take
up much time, the probability is that  they would
be  in perfect ignorance of the subject.  Among
them, however, we find Mr. Owen not only  ac-
knowledging  but remedying, as far as in him lay,
the evils which arise from the too early and  too
long employment of children.  We are well aware
that the  Utopian visions  of this gentleman will
make many  persons receive his testimony with
deductions from its value ; but when he relates a
mere matter of fact, and when this fact is in per-
fect accordance with the opinions of the most
enlightened medical men,  we do not feel inclined
to detract one iota from its force.  In speaking of
the children who were engaged in his manufactory
at New Lanark, he says, "I very soon  discovered,
that, although these children were extremely well
fed, and clothed, and lodged, looked fresh, and, to
a superficial  observer, healthy  in  their counte-
nances, yet their  limbs were very generally  de-
formed, their growth was stunted,  and, although
one of the best schoolmasters on the old plan was
engaged  to instruct those children, they  made a
very slow progress even  in  learning  a common
alphabet."  We are the more  inclined to  confide
in this statement, from having made  similar  ob-
servations ourselves in an  asylum for children, in
a large manufacturing town.  In  this instance,
the individuals were certainly properly nourished,
but they  were confined eight or nine hours a day
in heading pins and straw-plaiting ; but this they
did  not commence till past seven years  of age.
Yet, upon an extensive comparison of them with
others not so confined, we have  no hesitation in
saying that their growth was stunted ; the buoy-
ancy of  infancy, usually  so remarkable and  en-
gaging, was lost; neither  was there that freedom
of action in the limbs, which, in children, is gene-
rally so conspicuous.
   Sir Astley  Cooper, who likewise gave  his evi-
dence before  the committee, states  the ill  effects
of confinement in  still  stronger terms, if possible,
than Mr. Owen ; and as he  asserts his opinion to
be the result of extensive  observation, it is parti-
cularly deserving of attention.  He says,  " The
result of confinement  commonly is not only to
stunt the  growth, but  to  produce deformity, and
to that point I can answer, from a good  deal of
experience, that deformity is  a common  conse-
quence of considerable confinement."   It does  not
appear that any of the other  medical men,  at least
if those who are knOwn to the  profession, had had
many opportunities of personal  observation ;  but
their opinions, so far as they  had been able to form
any, coincide with those which have already been
given.  It  must, indeed,  be admitted that even
medical testimony has been adduced to prove that
none of these evils are present in cotton factories ;
but it is not with  medical as with  common evi-
dence,  where, provided there  is  equal integrity,
the most numerous  witnesses must be credited.
In medicine much more is required ; ability, vigi-
lant observation, and great candour ; and a single
witness,  known to possess  these  qualifications,
is to  be listened to with much more confidence,
even with regard to mere matters of fact, than a
whole host of common  observers.  On this  ac-
count, therefore, even had  Sir Astley Cooper's
evidence stood alone, we should have been disposed
to believe it  rather than that of men who, how-
ever respectable they  may be in  their own little
world, are utterly unknown  beyond it.
  The bad effects of over-exertion, however, are
not confined to children, though the intemperance
and irregular habits of adults make it much more
difficult to  ascertain them.   Among the poor, the
idea of having over-worked themselves is not un-
common ; and, necessarily as suspicion attaches to
their own evidence, many cases have occurred to
us,  as we  feel assured they must  have done  to
others, in which general exhaustion and debility
were readily traced to this source.
  Such, therefore, being the consequence  of la-
bour, not with regard to the kind, but the degree,
it forms  a  most important  subject of inquiry, to
what extent an individual may exert his physical
strength without  deteriorating  or retarding  the
full development of his powers.  To enter  deeply
into this, however, would lead  us into digression
from our present  subject; and we must content
ourselves with stating the opinion of the late most
eminent physician, Dr. Baillie, and  in  which he
was supported  by Drs. Pemberton  and Tuthill,
Sir Gilbert Blane, Sir Astley Cooper, and Mr.
Carlisle.  *' Seven years  old," says Dr. Baillie,
" is perhaps the earliest  age at which children
should be employed in factories;  and for the first
year they should not be employed  more than four
or five hours a day; for the two succeeding years
six or seven hours a day ; afterwards they might
be employed ten hours a day ; and beyond that
in  my opinion, there  ought to be no increase of
labour."  That there are extraordinary  instances,
in  which  more than the time  here specified is
passed in labour, is unquestionable;  but these are
too few in  number to disturb the general accuracy
of Dr. Baillie's opinion.
   [By the modern factory  laws  of England, no
child under nine years of age is permitted to work
at all ; and before thirteen, it can  only be  em-
ployed for nine hours a day.  The necessities  or
the cupidity of parents, it would appear, are con-
tinually inducing them to misrepresent the ages
of their children ; and it has, therefore, been found
desirable to discover some test, by which the capa-
bility of the  child may be determined, without a
knowledge of its age.  A standard of height has
been  adopted  by the  legislature for  the purpose,
but upon grounds, which,  physiologically consi
dered, are very erroneous ;  as the  tallest children
are  often the most weakly. (Carpenter, Principles
of Human Physiology, Amer. edit. p. 482: Philad.
1843.)   According to Mr. Sanders, (The  Teeth
a Test of Age, &c.: Lond.  1842,) the degree of
advance of the second dentition  may be regarded
as a much  more correct standard of the degree of
general development; and it may be taken as a
guide to the age, in the large mass  of cases.]
  We now proceed to  the  consideration of the
first class which we have indicated  above, viz. US* 
172
ARTISANS,  (DISEASES  OF)
eases caused by moleculae, which, mixed with the
air in  the form  of vapour or fine  powders, are
respired by the workmen, penetrate their organs,
and  disturb  their functions.   The first  order
comprehends the diseases  produced by mineral
moleculae.
  1. Mercury.—The gilders of toys and buttons,
glass-platers, and  the workmen in  quicksilver
mines, are nearly the only individuals sufficiently
exposed to the fumes of this metal to be affected
by it;  though there is no doubt that  wherever any
one is  long occupied with mercury,  the same dis-
eases  would  occur.   One  of  the most common
consequences of exposure  to  mercurial vapours,
is  a great  increase of sensibility  to  cold.   Dr.
Gosse perhaps exaggerates when he says that such
workmen are so sensible to the variations of the
atmosphere that they may  be  compared to  living
barometers; but we have seen several individuals
who were immediately alive to very slight dimi-
nutions in  the  temperature of the air.  One in-
stance is still  before us,  which occurred  in  a
young lady, who was salivated by accident seve-
ral years since, and who  is still affected very sen-
sibly by every change in the atmosphere, though
she is entirely free from other  complaints.
  The workmen who employ quicksilver are sub-
ject likewise to all those diseases to which latterly
the name of pseudo-syphilis has been applied, as
ulcerations  of the mouth  and fauces, eruptions,
rheumatic pains in the limbs, and, in short, all the
affections which, in former times, were compre-
hended under the  title of cachexia.   Terrible as
these  disorders are, there is nothing* peculiar in
them consequent upon the  manner in which they
arise;  they exhibit the  same  phenomena, are
equally distressing, and equally obstinate, as when
proceeding from  the internal administration of
mercury for the cure of lues.
  The disease which seems more peculiar to the
workmen who employ this metal, is  that to  which
the name of mercurial palsy has been assigned ;
and it arises very seldom, if ever, from  the  exhi-
bition  of mercury as a medicine.  The attack of
this disease is sometimes sudden ; more frequently,
however, its approaches are very gradual : at first
the workman has less control  than usual over his
arms; then they are subject to  slight convulsive
snatches ; they become agitated, and at length are
in a continual state of tremor.  The  tremor con-
tinues to increase in intensity,  if the individual
still persist in his employment, and spreads from
the arms, which it commonly first attacks, to the
legs, and finally to the whole body.    The patient
is unable to execute perfectly any of the functions
which require a certain muscular power, such as
locomotion, mastication,  any  labour of  hands,
&c.   To these  succeed  sometimes pains in the
bowels, restlessness, delirium,  &c, with great de-
rangement of the  general  health.   After a time,
the latter appears to become more settled, and the
patient will often live for twenty years, utterly un-
able to make any useful exertion from the tremor,
though in other respects  tolerably well.  The fol-
lowing account of an  instance of this disease,
which occurred in a man of  sixty-two years of
age, and with whom it  had endured  for twenty-
live years, will illustrate  it much better than arty
more general description.
  At the time we saw him, all the voluntary mus-
cles were violently agitated, so that every attempt
to speak was  interrupted by the spasmodic con-
tractions of the jaws and tongue.   His head was
in a continual see-saw ; he  could  not hold any-
thing in his hands, and seemed to have no power
whatever  over them.    Any  attempt  to  obtain
control  over his muscles invariably rendered the
convulsions more violent.  Mental agitation in-
creased  them.  His teeth  had been  lost many
years, but had fallen out without being decayed;
his appetite was good,  and his sleep sound.  His
evacuations were voluntary.
  The disease in this individual had commenced
after  gilding  one year,  with a shaking in  one
knee, whence it had  spread to the rest of the body.
He continued to work, however, for seven years,
but  during that  time  was frequently obliged to
take a glass of rum to keep his hands steady, and
he always found his  tremors less after taking more
ale or spirits than usual; but when their immedi-
ate effect was  gone off, the complaint-was always
much more aggravated.
   It  is  generally supposed that  these tremors
never ensue  after the  medical administration of
mercury, and we  believe that mercurial palsy very
seldom  does  occur  under such  circumstances.
This is, however, perhaps  to be attributed to an
insufficient quantity being taken, or the medicine
being suspended  after  some time.   It is certainly
no unusual occurrence to find patients, who have
been  subjected to mercurial courses, exceedingly
sensitive, and  we once saw the tremor established
in a  child, to whom a considerable quantity of
calomel had  been given for incipient symptoms
of hydrocephalus.
   Long as the origin  of the mercurial palsy has
been  known,  we are yet unacquainted with any
treatment which is capable of removing it.  The
French prescribe, as usual, their tisans, but with-
out much effect.   In recent cases, the tremor van-
ishes spontaneously, provided the  patient ceases
to be exposed to the mercurial vapour.  Dr. Lett-
som  thought  sulphur  was a  specific against it;
De Haen, according to Dr. Bateman, placed much
confidence in electricity ; and Mr. Pearson says,
" that a free exposure  to the open air during  a
dry state of the atmosphere, whether hot or cold,
is, on the whole, the most effectual mode of de-
purating the habit from a mercurial impregnation."
The  Cavalier  Sementini, in  the eieventh volume
of the Giornale de Fisica, has given five instances
of the successful treatment of this  disease by the
nitrate of silver.   He  began with the eighth of *
grain ;  and by the time three grains  a day were
given, the good  effects were manifest, and in
twenty  days  more the man was perfectly cured.
We have never yet  tried the nitrate of silver, but
every other plan  has appeared to us entirely use-
less ; and  we  are inclined to believe, that after
obviating the  effects of  constipation, or opposing
any  other  symptom that is prominent, complete
abstraction from the mercurial vapour is alone ser-
viceable.   In  time the  effects in recent cases wear
off; but when an individual has once been seized,
he is very liable to a relapse upon exposure to the
original cause, and hence  his former employment
ought not to be resumed.
   Various plans have been suggested to obviate 
ARTISANS,  (DISEASES  OF)
173
 the ill consequences  attendant upon the employ-
 ment of mercury, and so far as regards button-
 gilding, the success has been tolerably complete ;
 at least, if it is not so, it is to be attributed to the
 inaccuracy  of  the apparatus and the negligence
 of the workmen, rather than  to any thing wrong
 in the principle of the operation.  In order to ex-
 plain this, it is necessary to take some  notice of
 the process  of gilding.  This may vary  a little in
 the different workshops as to the minutiae of the
 art, but not in any material respect.  Our account
 is taken  from the inspection  of two  extensive
 manufactories, one of buttons, and  the  other  of
 gilt toys.
   There are two parts of the process which are
 attended with  danger from  mercury, but in very
 different degrees.  The first and least injurious,
 and perhaps not at all injurious if  the  workmen
 are clean in their habits, is  the application of the
 amalgam to the  metal.  This, which  consists of
 gold and quicksilver,  is thrown into a small quan-
 tity of solution of mercury in nitric acid in button-
 gilding, and the buttons are stirred in it; in toy-
 gilding, the amalgam is generally diffused with a
 brush.   As little, if any,  of the  quicksilver is
 vaporized during this process, the principal  dan-
 ger arises from the workmen unnecessarily touch-
 ing the materials with the  naked hand, and  not
 exerting sufficient care to make thorough  ablutions
 before taking their meals.
   The next process, which consists in driving off
 the mercury by heat, is highly dangerous, in  the
 old and common method of gilding. This, which is
 technically named cap-and-pan gilding, is effected
 over an open  stove fire.   The articles are placed
 in a common frying-pan, and every now  and then
 are taken off and shaken in an  old hat.   During
 the whole of this time the mercury is very imper-
 fectly carried up the chimney, and, consequently,
 its fumes reach the  workmen,  more especially
 when the materials are in the hat.   This plan is
 now followed in the gilding of toys ; but in button-
 gilding an apparatus  has for some time  been em-
 ployed,  to  which,  if well   executed,  it seems
 scarcely possible to add any  thimr.  For  this pur-
 pose, the  buttons are enclosed  in an open wire
 cylinder, which is then  introduced  into another
 cylinder formed  of iron,  communicating with a
 flue, and  placed  over a stove.  At  the  entrance
 are folding  doors, with a small opening for  the
 iron rod, which passes through the wire  cylinder,
 for it to rest upon, and the wire cylinder has like-
 wise a support at the  opposite end, so that it may
 be revolved  within the iron cylinder  by the work-
 men.    The latter commonly stand several feet
 distant from the stove.  When  this apparatus is
 properly made, the draught of air is very great,
 and it seems scarcely  possible for those employed
 to be at all subjected to the fumes of the mercury ;
 and we believe that  it very rarely happens  that
 the workmen become disordered where it is used.
 It is somewhat unfortunate  that the  same plan
 cannot be employed  in toy-gilding, or that it is
 not; for we confess we are not ourselves aware
 or any really well founded objection to it.  Even,
 however, when the old method is employed, there
 is great reason to believe that  the  serious evils
 attending  it, arise for the  most part from the
carelessness  of  the gilders themselves.   As some
 corroboration of this  opinion, we  may state  that
 we have just seen a gilder who has now been  in
 the business for thirty-eight years, and the great-
 est part of  this period  he worked  at  a common
 stove, but without experiencing a  single inconve-
 nience  during  the wbole time. His  appearance
 was remarkably cleanly ;  and being an intelligent
 man, we  asked him  the  principal source  of the
 mercurial tremors, and  he answered, the careless
 and uncleanly  habits of those employed.   He
 himself had always been  accustomed  to  frequent
 ablutions, and  had  never eaten without this  pre-
 caution.  This instance does not, of course, prove
 that the evil effects of the mercurial vapours can
 always  be avoided by these means, but the obser-
 vation of most manufacturers  might be  citen  in
 proof of the workmen usually neglecting them.
   It would  not, perhaps, be quite fair to omit here
 the notice of M. d'Arcet's "  Fourneau d'Appel,"
 especially as the Academie Royale  des Sciences
 de l'lnstitut de  France awarded the prize of 3000
 francs,  left  by  M. Ravrio, for  the  invention  ; al-
 though, with due deference  to  such enlightened
 judges, we  are  far  from  thinking that it will,  in
 any great degree, be  efficacious in lessening the
 evil.  The  principle consists  in  increasing the
 draught of the stove chimney, by rarefying the aii
 at a certain distance above the fire.   That we may
 not ourselves misrepresent the apparatus, we copy
 the  following  account  from M. Patissier.   " II
 imagina de construire  un fourneau dit d'Appel,
 dont le  tuyau s'ouvre a  une distance calculee dans
 la cheminee, et  dont  la chaleur, dilatant l'air de
 celle-ci, augmente son tirage.   En  meme  temps
 on place  a. une  fer.etre  un  vasistas ;  il s'etablit
 alors dans l'attelier  un  courant ascenscionel, qui
 entraine avec rapidite dans la  cheminee les vapeurs
 et les gas nuisibles."  There are two most power-
 ful obstacles to  the  efficacy of this plan ;  the first
 is, that, in the common  method of driving off the
 mercury,  which  alone  seems  to  be  known in
 France, the articles are frequently removed from
 the draught for the  purpose of shaking them, and
 this when the metal is  still in  a state  of vapour;
 and the other is, the  additional expense which  it
 entails; which, in a  country not subjected to the
 perpetual interference of a police  in  its  private
 affairs, would be  a  great  obstacle to its adoption,
 and  go  far  to  annihilate  the trade of those who
 were compelled to adopt it, while others were not
 under a similar compulsion.  How far in France
 the recondensation  of the mercury may compen-
 sate for the  additional expense,  we do  not know ;
 but in England, where this has been long effected,
 it could, of course, be no recommendation.  Upon
 the  whole,  we  believe  the cylinder to be  fully
 adequate to its  intention, and  we  are  convinced
 that nothing but prejudice prevents  its application,
 under such modifications as might be found neces-
 sary, to  every species of gilding  in which mercury
 is employed.
   The next metal, of which we shall consider the
 injurious effects, is lead,  which, both from  the
 serious diseases it induces, and  its  extensive  em-
 ployment, may  be viewed  as  the next  in impor-
tance to mercury.
  2. Lead. — The  workmen employed in  lead
mines, those who purify it, cast it, in short all who
use its  various  preparations  in the  arts, are ex- 
174
ARTISANS  (DISEASES  OF)
posed to the deleterious effects of this metal.   Sir
John Sinclair  asserts that  one labourer  in three
dies annually in the manufactories of the carbo-
nate or common white lead.  Lead is particularly
dangerous in a state of fusion ; its particles pene-
trate into our organs through the pulmonary and
alimentary passages, and by the skin.   The work-
men are consequently subject to colic, and to a
particular species of palsy.
   The class of people most subject to these com-
plaints are  plumbers  and glaziers, painters in oil
and  water  colours, type-founders,  and  colour-
grinders.  But  though  these  are the  principal
persons liable to be injured by lead, we frequently
find the peculiar  diseases among other classes.
Excepting, however, in particular idiosyncrasies,
the same remark  may be  applied here as in  the
case of mercury, viz. that very much depends upon
the cleanliness of the workmen.  Dr. Fothergill
has given a curious illustration of this in a young
artist, who was in  the habit of sucking her pen-
cils ;  and, on the authority of Dr. Heberden, he
attributes many of the diseases of children to their
being permitted to  play with painted toys, which
they  are constantly  putting  to  their lips.  Sir
George Baker has recognised lead as the cause of
tbe Devonshire colic ; and it has been remarked
that the  use of leaden pipes for the conveyance of
water  employed in cooking,  is not  unoften  the
source of the same complaints.   Particular indi-
viduals are much  sooner affected  than others by
this metal,  as happens likewise with  mercury.
Thus, to reside in a newly-painted  house will
immediately  excite, in some persons,  the colica
pictonutn, as it has been termed, or dry belly-ach.
   [The workers in white  lead appear to be most
subject to the disease ; and the more volatile  the
lead  is  rendered, the more readily  does it  ap-
pear to  affect  the  system.  Painting the " dead
white,"  or  " statuary white," according  to  Dr.
Stokes, (Lectures on the Theory and Practice of
Physic, 1st Amer. edit. p.  180,) is the most dele-
terious form of using lead, to the house-painter.
In this case, white lead  is used,  combined with a
large proportion of  oil of turpentine ; and  the
outer air is  excluded as much as possible, so that
the air of the apartment becomes strongly impreg-
nated  with the lead.  It  would  seem, that  the
deleterious effects of lead are chiefly produced by
the carbonate.]
   The following account we copy from Dr. Pem-
berton, as being  more  concise  than that of M.
Patissier, not  to  say also more  correct.   " The
complaint (colica pictonum) is known  by a  vio-
lent and constanti^pain  about the  navel, with  a
retraction of  the integuments towards the spine,
by an obstinate costiveness, and by a frequent but
ineffectual desire to evacuate the  contents of the
bowels.   There is sometimes, though not  always,
 considerable retching ; and  when vomiting takes
place in this disease, what is thrown up is usually
 of a green colour.   This is a state of the complaint
 which  will last for several  days, during which
 time, however, the pain will vary somewhat in
 degree, though never entirely cease.  A mild kind
 Df delirium, nay, a perfect mania, will sometimes
 • ake place,  and  continue the  whole  time  the
 tiowels are  constipated.   These, however, are not
 «?ery common circumstances ; and when  they do
occur, they seem to have no influence in retarding
the patient's recovery. In this disorder, the greatest
relief from pain  is experienced  by  keeping the
trunk bent upon the knees.   The pulse is usually
not more  than a hundred in a  minute.  The
tongue  has a natural appearance,  and is moist;
and there is scarcely any fever.   The situation of
the pain  round the navel, the retraction of the
belly, the  costiveness,  the  absence of fever, the
pulse, and the preference given to a bent position
of the body, will distinguish this from every other
disease  of the abdomen." The treatment of colica
pictonum consists in evacuating the bowels, for
which  purpose  castor-oil  is  commonly chosen,
assuaging the pain, if necessary, with opium; and
in most cases  this  practice will succeed.   (See
Colic)
   When the colic has endured for some time, and
occasionally  when it has not been present, there
results  a peculiar species of paralysis, which affects
the  superior extremities «only — very  rarely the
inferior.  For the best description of the limb  in
this  state, we are indebted to Dr. Pemberton, as
likewise for a method of remedying it,
   The  wrist, says Dr. Pemberton,  in many cases
of this  paralysis, becomes remarkably flaccid and
loose, as if the weight of the hand had stretched
the capsular ligament.   The adductor muscles of
the thumb gradually  waste away.   This is  sup-
posed to arise from a more rapid absorption of the
part taking place, in consequence of pressure from
the  handle used in  painting ;  but  the wasting
being observed equally in each hand  would rather
militate against  such an opinion.    Dr. P. states
that he had long  thought some assistance of a
mechanical nature might be  applied likewise for
the purpose  of relieving the topical  paralysis, by
placing the muscles in  such  a state as that they
might again be enabled to resume their lost action.
Having formed this idea, he proceeded to put it to
the test of experiment upon a man who was per-
fectly paralytic in both wrists.   For this purpose
a splint was framed ; and for the manner in which
it ought to be  applied, we must refer to Dr. Pem-
berton's book.   The result, however,  was  most
satisfactory.  In nine weeks tbe extensor muscles
of the  right hand, to which the support had been
given,  appeared  to  have entirely  regained  their
natural strength; while the left, which  had not
been splinted, remained perfectly paralytic.  The
splint  was now applied to the left hand, and in
seven weeks the power of the extensor muscles
of that  hand also was perfectly restored.
   It is not to be expected that even this plan will
be uniformly successful ; but we have no hesita-
tion in saying that it has made  a disease for the
most part manageable, which was  formerly pecu-
liarly obstinate and hopeless.
   With respect to preventives, we have very little
to say; perhaps nearly every thing may be included
in one word, cleanliness, frequent ablution, and,
 as far as possible, frequent change of linen.
   [Since proper precautions have been  taken in
 some of the large smelting establishments of Great
 Britain, it has been found, that much fewer cases
 of lead  paralysis and lead colic have occurred than
 formerly.   These precautions consist  in  compel-
 ling the workmen, before going to  their  meals, to
 change their clothes, and  to carefully  wash their 
ARTISANS,  (DISEASES  OF)
175
hands with the aid of a nail-brush, so as to remove
every particle  of the  metal, and thus  prevent  it
from entering the digestive organs along with the
food.  It is affirmed,  too,  by  M. Brechot, (An-
nates d'Hygiene, t. xii.) that in the white lead
manufactories, the superintendents,  who do not
handle the lead, escape the disease.   (Guerard,
Did. de Med., 2de edit.xxvi. 105 :  Paris,  1842.)
Still, lead cachexia occurs at times, notwithstanding
every precaution ; and there  is great reason to
believe, that tbe channel, by which  the poison  is
often received into the system, is the air passages.
   Recently, subphuric  acid lemonade has  been
largely employ<jd as a preventive of  lead cachexia,
in the laboratories of Paris.  It has  likewise been
extensively used by Mr. Benson,  the managing
director of the British white lead works at Bir-
mingham, in the form of sulphuric beer, and with
great success.  It acts, he conceives, by converting
the poisonous carbonate into the innocuous sul-
phate of lead.   (Lond. Lancet, Dec. 17, 1842,  p.
435 ; and Dunglison's Practice of Medicine, 2d
edit. p. 170: Philad. 1844.]
   3.  Copper---Extensively as this metal is em-
ployed in  the manufactories  of this country, and
though we have  long  been acquainted with one
of the greatest manufacturing towns  in Britain, we
have not  had many opportunities  of seeing any
complaints among the workmen which could be
unequivocally referred to  it.   M.  Patissier says
that they become prematurely old, and are meagre
and unhealthy  in their  aspect.   To a  certain
degree this is true, but  we  believe it is  to be
referred partly to their confinement,  though chiefly
to their intemperance.   It does occasionally happen
that they  are attacked with colic, but the number
is comparatively  small.   The disorders of the chest,
to which the filers of copper are subjected, are not,
we believe, owing to the quality of  the metal, but
merely to  mechanical  irritation, and are common
to a considerable class  of workmen  who make no
use of copper.   The  brass-founders  frequently
become asthmatic ; but does not this  arise from
the vaporization of the zinc or speltre, which they
consequently inhale ?   We suspect it does.
   4. Arsenic and antimony are not  so extensively
used as to give rise to any disorder, though they
are employed but in comparatively minute quanti-
ties in  a great variety of the arts.   Tin, though
highly noxious when oxidated, as proved by Or-
fila, has no effect in its metallic state, and we have
never seen any tinmen whose complaints could  be
traced to their work.
   5.  The manufacturers of mineral acids, which
all emit very acrid vapours,  are liable, without
care, to be asphyxiated, and to severe  pneumonic
affections, from respiring these vapours.  By ope-
rating, however, nearly in the open  air, and taking
merely common  precautions, every  ill  effect from
these sources may for the most part be obviated.
   The  dippers   in brass-foundries and  gilding
manufactories, that is,  those  who prepare  the
articles for the gilding, by  cleaning  them in aqua-
fortis, are liable  to the same diseases, without due
caution.  Formerly, indeed, they  frequently  fell
victims to  their  occupations;  but tbis  process
having latterly boen conducted, for the most part
at  least, in the  open  air, the danger has  much
diminished. The impunity witb which the labour-
ers  may work is, however, manifestly dependent
upon their own conduct.
  We scarcely know  whether the  accidents to
which those who use the mineral acids  are sub-
jected ought to be mentioned here, as, with a very
slight degree of prudence, they may be entirely
avoided.
  The second order in  the first class comprehends
tbe effects  of animal moleculae, during  their de-
composition, and upon few  subjects have  more
erroneous views been entertained.
  The nightmen of Paris, who  are  employed to
empty the immense fosses cTaisance of that metro-
polis, have long been acquainted with the dangers
arising from the evolution  of the  gases.  These
have been divided  into two kinds, la mitte and le
plomb.  The  mitte  is  caused by  ammoniacal
vapours.   The plomb is commonly formed by the
sulphuretted hydrogen  and  hydro-sulphuretted
ammoniacal gases ; at  other times by azote.
   La mitte is announced by a sharp odour, which
occasions a  smarting in the eyes ; very  soon, the
globe of the eye and the pupils become red ; at the
same time there is  an uncomfortable feeling about
the nose, discharge, and pain, which, beginning
in  the orbit, extends  to  the forehead.   To this
state a blindness is often added, which endures for
one or two days.   The patients then experience
severe pains, and are unable to support the light;
they  become restless,  and  receive no  relief till
tears flow.  If the ophthalmia is slight, it is speedily
removed by shading the eyes and exposing them
to the  open air; if it is intense, the nightmen are
accustomed to wash their eyes with cold water, to
apply compresses upon the pupils wrung in the
same  liquid, and  to remain in bed in a dark
chamber.
   Dupuytren and  Barruel have observed that &
plomb produces two distinct affections — the one,
the most common and  the most terrible, caused by
the sulphuretted hydrogen and hydro-sulphuretted
ammoniacal gases, is accompanied by convulsions;
the other, true  asphyxia, from the want of respir-
able air,  is caused  by azotic gas, and is character-
ised by stupor.
   The evils arising from the latter  gas  can only
be removed by a free circulation of air, or perhaps,
if it were possible, by adding a quantity of oxygen
gas. But with regard to the former,  the discovery
of M. Labarraque in the disinfecting powers of
the chloruret of lime and soda, has removed every
danger, excepting that which may arise from com-
plete negligence.  The mode of employing  these
substances is by pouring them in solution  upon
the reservoirs or privies in which the matter evolv-
ing the gases is contained.  An easier mode, and
considering the cheapness of the chloruret of lime,
one which will more commonly be followed, is to
throw the chloruret in powder into the apartment;
and, from experience, we know this to be efficient.
 We refer the reader, however, for a more extend-
ed account of the  manner in which the.se chit ru-
rets should be employed, to Mr. Alcock's essay on
this subject, which contains  both the fullest and
the best  statement that has yet been  made.
   It will readily be perceived that the animal effiu
via to which the class  of workmen just alluded to
are exposed, differ much from every other  in  the
more complete decomposition which the matter has 
176
ARTISANS,  (DISEASES  OF)
undergone, and the greacer  accumulation of tbe
resulting gases.  Butchers, chandlers, &c, respire
these gases much more  diluted with air, and ap-
pear not to be afflicted by any diseases in conse-
quence of them.   We are much  disposed to be-
lieve that the disagreeable odour of the workshops
has been the principal reason  of  their reputation
for unhealthiness :  this  opinion is  confirmed  by
the testimony  of Dr. Bancroft, who has  collected
many facts in  corroboration of it.  Besides others,
he mentions the establishment of a manufactory
of adipocire at Conham, near Bristol, which was
not in the slightest degree injurious to the neigh-
bourhood, though  the smell was most  offensive.
To these he added his own experience at Rosetta,
where he was daily exposed to the effluvium of
putrid bodies,  and  felt no inconvenience ;  and a
communication from Mr. Lawrence, in which that
gentleman  says that his experience, as demonstra-
tor at St. Bartholomew's Hospital, was strongly
corroborative  of the opinion  that  putrid animal
effluvia are not usually detrimental  to health.
   That  animal  effluvia  are not, in this diluted
state, productive of fever, we may mention an-
other proof which is within our own knowledge,
and which we know would be confirmed by all
the medical men acquainted with  the  spot.  In
one part of the populous town  of Birmingham,
many slaughtering-houses were congregated ; and
yet, if any situation in  the  town could  be  men-
tioned in which the fewest cases  of fever have
occurred, it is in their neighbourhood.   M. Patis-
sier bears his testimony to catgut-makers not being
liable to putrid and malignant fevers, and  gives
what he believes the explanation  of it.   " S'ils ne
sont pas sujets aux  fifivres  putrides et  malignes,
e'est qu'ils travaillent dans des lieux ouverts, ou 1'air
circule  librement."  We believe, that  the  pallid
countenance, languid appearance, and swelled legs,
are neither peculiar to catgut-makers, nor the con-
sequence of their employment;  although this au-
thor intimates a connexion between these circum-
stances and the occupation.
   [It has been supposed that putrid animal  exha-
lations are a common source of fever — intermit-
tent, remittent, and continued — yet it would  not
seem that  disease  of any kind is often  produced
from this cause.  It may, indeed,  be affirmed, as
the  writer  has done elsewhere, from  numerous
observations, (Dunglison's Elements of Hygiene,
p. 108 : Philad. 1835,) that in the vicinity of the
workshops of the " knackers,"—whose occupation
it is, in the large cities of Europe,  to convert  the
dead horse to useful purposes, cats' and dogs' meat,
bones for  the  distillation  of hartshorn, &c___
although the atmosphere is intolerably fetid to the
casual visiter, neither the workmen nor the fami-
lies around are liable to malarious,  or to any dis-
order, which  can be fairly referred  to that cause;
that in  the year 1828, a committee  was  appointed
in Paris, to inquire  into the  circumstances con-
nected with the operations of the knackers ; and
every one examined by  the committee agreed that
they were  most offensive and  disgusting, but no
one that they were  unwholesome; nay, it was
even inferred, that they were conducive to health,
as all the men, women, and  children, concerned in
the works, had  unvarying health, were  remarka-
bly well in appearance, and strong in  body,  the
workmen commonly attaining old  age, and  being
generally free from the infirmities that accompany
it;  and when an epidemic fever was in full force,
not one of the workmen in  the establishment of
Montfaucon was affected by it; that, as already
remarked, the gut spinner, whose occupations prior
to the discovery by  M. Labarraque of the  disin-
fecting power of the chlorinated preparations, were
most offensive, owing to the putridity of the ma-
cerated intestines, enjoyed remarkable health ; and
lastly,  that although the tainted air of the dissect-
ing room is breathed month after  month, and for
many months, by hundreds of students in differ-
ent parts of the  globe, no epidemic fever or spe-
cial disease is generated.
   All these affirmations have been since confirmed
by a hygienist of distinction, (Parent Duchatelet,
Hygienepublique, Paris, 1836.) In the first place,
as regards the shops of the  knackers, or chantiers
dcquarrissage,  the filth and stench of whose ope-
rations are stated to be horribly offensive, M. Pa-
rent describes the establishment of Montfaucon, to
which  allusion  has  been made, as  immense, the
number of horses taken to it, either dead  or to be
killed, being twelve  or thirteen thousand annually.
The men are described  as enjoying the most flour-
ishing health, the women as most  fruitful, and the
children as pictures of  healthful energy.  Of the
health of the manufacturers, he speaks  in equally
strong terms; and he  adds, that the workmen in
the chantiers  were  remarkably exempt from  dis-
ease during the prevalence of cholera in  Paris.
There were fewer fever patients admitted into the
Hopital Saint Louis, which is situate  in the dis-
trict of the chantiers, than into any other hospital
of the metropolis.
   As respects the dissecting rooms, a  wide field
is afforded in Paris for testing whether they be
unwholesome to the students and attendants, and
to the inhabitants in the vicinity.   M. Parent un-
hesitatingly expresses his conviction that  there is
no ground for the belief that the dissecting rooms
are foyers of morbid emanations.   In support of
this opinion, he adduces numerous facts, and the
decided opinions of Lallemand, Desault, Dubois,
Dupuytren, Boyer, and many others ; and as re-
gards  the effect of the dissecting  room on the
health  of students and persons attached to  and
employed in them, his  testimony is no less  une-
quivocal.  He states, and brings forward  the  tes-
timony of Messrs. Andral, Lawrence, and others
in confirmation, that there is  no disease whatever
to which they are liable from the  cadaveric ema-
nations ;  that gastro-enteritis, meningitis, and ty-
phoid  fevers are very  frequent, according  to M.
Andral, among the students during  their  first
year's residence  in Paris; but these diseases depend
so little upon the mere  circumstance of dissecting
and remaining in the dissecting rooms, that they
are more common amongst those  who have not
begun to dissect. Desault was in the habit of say-
ing that he firmly believed the air  of the dissect-
ing rooms had saved him from attacks of epidemic
and other diseases, of which those  hospital physi-
cians and surgeons,  who seldom or never dissect-
ed, appeared to  be much more susceptible than he.
(American Medical Intelligencer, for 1838, p.
162.)]
   But though observation  appears to warrant the 
ARTISANS,  (DISEASES  OF)
177
conclusion that butchers are not subject to fevers,
nor to any other disorder which can  be  properly
referred  to putrid effluvia, there seems some doubt
whether  they do  not too freely absorb  nutritive
particles, as they are particularly liable to the dis-
eases arising from plethora, more especially deter-
minations of blood  to  the  head.   The  principal
circumstance adduced as  giving some probability
to this notion,  is, that cooks, whose appetites  are
proverbially bad, evince the  same  symptoms, and
frequently fall  victims to the same  maladies.  We
are inclined to believe, however, that  some errors
exist in both cases.   From the facility with which
butchers can  obtain animal  food, they usually
much indulge  in it, and many have acknowledged
to us that they are in the habit of eating it three
times a day.   The business of a cook, likewise,
compels him to be perpetually tasting the various
dishes which he is composing, and it is impossi-
ble to say how much is in  this manner  consum-
ed ; at any rate, the food is subjected to the  sto-
mach in the mode  most favourable to digestion,
and its nearly  total conversion to the nutrition of
the body.
   Butchers evidently  enjoy immunity from  con-
 sumption.   M. Patissier  says, " On  a reinarque
 qu'ils meurent rarement de  le phthisie  pulmo-
 nale."   Dr. Withering has stated, in a letter to
 Dr. Beddoes, which was  published by the latter in
 1793, that butchers and the makers of catgut  are
 exempt from consumption.   To these classes Dr.
 Beddoes has  added, from  information otherwise.
 obtained, soap-boilers, the fishermen and the fish-
 wives who  live in  the  neighbourhood  of Edin-
 burgh.  From our own experience in  a dispensary
 of considerable extent, we believe that  these  re-
 marks are correct;  chiefly, however,  with  respect
 to tubercular consumption.  From those  affections
 of the bronchial tubes which were formerly con-
 founded with phthisis, we  do not think  they are
 equally free.
   We shall dismiss, with a very few remarks, the
 remaining orders of this  class. They refer chiefly
 to the diseases incident  to medical  men, and to
 those persons  who  are employed in attendance on
 the sick.  It is generally admitted  that in few in-
 stances have the disorders to which such individ-
 uals are subjected been accurately traced to  their
 employment, excepting those which have evidently
 their origin in contagion or infection.   With re-
 spect to anatomists, their diseases are chiefly the
 results of accident, and diarrhoea  occurs in those
 who  are  unaccustomed  to dissection :  as to  the
 adage of physicians, " aliis inservendo consumun-
 tur, aliis medendo moriuntur,"  we  suspect  that
 there are many young physicians  waiting for  the
 exit of their aged brethren, who would be able to
 contradict it.
   With regard to the operation of the third order
 of the first class, viz. vegetable moleculx, we shall
 find that some of them affect  the system mechani-
 cally only, that is,  by producing local  irritation,
 which, however, is not influenced by the  specific
 properties  of the  impinging particles.   Others,
 on the contrary, act by virtue of  certain peculiar
 qualities, and  from which peculiar disorders arise,
which  no other  substances  have the power of
exciting.  These  circumstances  are  equally  true
 of mineral substances employed in the  arts;  but
    Vol. I. —23
we thought  it better to delay considering tbe
action of mineral particles as mechanical irritants,
till we could notice, at the  same time,  the  effect
of vegetable particles, especially as, in this respect,
they differ little, if at all, from each other.
   We shall  first  notice  the maladies of  those
workmen which  arise  from  the  quality of the
vegetable substance upon which they operate. Few
vegetable substances employed in the arts appear
to act chemically, if  we may so express ourselves
upon the animal system ; perhaps the only un-
doubted  instance is  snuff.  This,  however, acts
mechanically also, by affecting  the air-passages
Its peculiar  property induces headach, vertigo
nausea, and  perpetual  sneezing.   [Parent Du
chatelet (Annates d'Hygiene, &c. p. 1,) believes
that the manufacturers of snuff suffer slight incon
venience from  the reduction  of the  tobacco  to
powder (la demolition des masses), but not in any
other manner.]
   The bakers'  and grocers'  itch appear instances
of local diseases arising from  the peculiar quality
of dough, sugar,  &c.; but we are not sufficiently
acquainted with their origin to speak decisively on
this point.
   Wine-pressers, brewers,  and persons who ex-
pose themselves incautiously to fermenting liquors,
become sometimes completely asphyxiated by im-
prudent  exposure  to the evolving gases.  These,
however, are rare occurrences.   There may  be
other trades in which vegetable substances induce
disorder by virtue of their peculiar properties, but
we are convinced that they are neither numerous
nor important.
   The diseases which are produced by the me-
chanical irritation of moleculae or fine powders, are,
unfortunately, numerous.  The artisans  who suffer
from this cause, are  sawyers, millers, starch-
makers,  flax-dressers, weavers, wool-carders, fea-
ther-dressers, horn   and  pearl-makers ;  needle,
edge-tool, and gun-barrel  grinders ; iron and brass
filers, with many others.  These are the principal
labourers included  in  this order, but they  are
affected  by their  occupation  in very various  de-
grees.  That some owe their complaints, and too
frequently their  deaths,  to  their employments,
there is  not the slightest  question ;  and of these,
sawyers and millers, iron and brass filers, suffer
the least.   Then come  horn and pearl  button-
makers ; and,  among the  grinders,  it would  be
difficult to say which are  the most afflicted.  They
are universally short-lived.
   The diseases to which these workmen are sub-
jected are entirely such as affect the air-passages ;
indeed,  we  might  say  the disease, there being
scarcely any other than  that, to which the accu-
racy of  modern  pathologists  has given the name
of chronic bronchitis.   It  is known among the
different grinders under  various applications,  as
" pointers' cough,"  " grinders' rot," &c. There is
nothing peculiar in  the symptoms or  progress of
the complaint, when it has once commenced ;  but
knowing the cause, we feel  somewhat surprised
that it  does not attack  them  sooner, or that it
should attack them  at all.   It is true that  few of
these  mechanics live beyond thirty or five-anu-
thirty years of age ; but  till the last of their lives,
they are seldom  inconvenienced in any material
degree.  This, at least, is correct of the grinders ; 
178
ARTISANS,  (DISEASES  OF)
but in the horn  and pearl button-makers it  fre-
quently affects  them  early,  endures  for  many
years, and,  finally, assumes rather the  character
of asthma than of consumption.   All these work-
men have frequent recurrence to emetics, and  it is
very questionable if a better practice could  be ad-
vised.  We have ourselves had repeated opportu-
nities of observing their efficacy, and we make a
constant  practice of prescribing  one whenever an
individual,  affected by  his trade, presents himself
to us.  The  tartar emetic ointment, also, has ap-
peared of great service, when used to  the  extent
recommended by  Dr. Jenner;  but when only
applied for a few days, we have never perceived
the slightest benefit to be derived from it.   Upon
the whole,  however, the treatment varies nothing
from that which  the disease requires when excited
by other causes.
   Some of these workmen are likewise subject to
inflamed eyes, from the  particles impinging the
conjunctiva ; but these cases are not so numerous
as might have been expected.
   It is gratifying to be able to  state  that  human
ingenuity  seems  at length to have  invented an
arrangement which,  under some modifications,
may remedy the evils  of these most injurious oc-
cupations.   The liability of the needle-pointers to
consumption was remarked  by Dr.  Johnstone
many  years  ago, and  he  proposed a  muzzle of
damp crape to arrest  the  particles ; Dr. Gosse, a
sponge ; and M. d'Arcet, his " fourneau d'appel."
Whether any or all of these would be effectual,
we have no means, of ascertaining, for the work-
men would never apply the former constantly, and
the latter has never been  tried  in this  country at
all.  To Mr. Abrahams, of Sheffield, however, we
owe an invention, which it appears to us can only
fail of success from inaccuracy in its arrangement,
or negligence in employing it.   For  the particu-
lars of this  invention,  we refer our readers to the
forty-second volume of the Repertory,  and shall
here  only  extract some  of the testimony in its
favour from a vice-president of the Society  for the
Encouragement of Arts, and some of the grinders
themselves.  " I have no hesitation," this gentle-
man says,  " in stating my opinion, that, whether
considered  as a novel  and ingenious apparatus of
the mysterious power of the magnet, or with refer-
ence  to the more important object of  alleviating
one of the  evils incident to some of our manufac-
turing processes, and  thus rendering  them  con-
sistent with  the  paramount claims of humanity,
this  invention ranks as high as any that has  ever
been submitted to the Society."  Messrs. Cocker
& Son, of  Hathersage, observe  that " the pointer
who  has   most  frequently tried your magnets,
states  that, with the use of them and  the damp-
bag which  he has  suspended over the stone, be
had not  more dust, &c. floating about him in a
whole day, than he used to have in a quarter of
an hour."
   This invention appears to us the more valuable,
as one part of it may be applied to pearl  button-
turning,  and several  other processes,  with  very
little difficulty, and with great probability of  alle-
viating, if  not removing, the evil attendant upon
iuch manufactures.
   Before leaving this subiect altogether, we cannot
  .nit to notice an invention by Mr. Jones, for gun-
barrel grinding, in which no dust arose, and which,
being effectuated by a  machine, we should have
conceived  would  have superseded entirely  the
present mode of grinding.  Why it did not suc-
ceed with the inventor  in this country we cannot
tell unless it where " from that callous indifference
of the grinders to the fate which awaits them, that
their apprehensions are said to have been excited,
lest Mr. Abraham's inventions should  be success-
ful enough to  affect their wages."  The conse-
quence, however, has been, that the Emperor of
Russia, who saw the apparatus when in England,
induced Mr. Jones to settle in  his dominions;
and, unless we are  much misinformed, the plan
alluded to is there in full  operation.
   A local disease, which  is confined to a particu-
lar class of workmen, may be noticed in this place,
viz. chimney-sweepers' cancer.  Formerly it was
supposed to arise from the qualities of the soot;
but Dr. Gosse says, " the climbing-boys in Vienna,
I have been told, placed in different circumstances,
and not  exposed to the soot of coal, present a
similar disease."   Of the real origin of this com-
plaint, therefore, we  must be considered ignorant;
but that it is almost  peculiar to chimney-sweepers,
seems well ascertained.  " It always makes its first
appearance in the inferior part of the scrotum,
wbere it produces a superficial,  painful, ragged,
ill-looking sore, with hard and rising  edges :  the
trade call it the soot-wart:  in no great length of
time it pervades the skin, dartos, and membranes
of the scrotum, and seizes the  testicle, which it
enlarges, hardens, and renders truly and thoroughly
distempered ;  from  whence  it makes  its way up
the spermatic process into the abdomen, most fre-
quently  indurating  and   spoiling  the  inguinal
glands;  when  arrived within the abdomen, it
affects  some of the viscera,  and  then  very soon
becomes painfully destructive."  Such is the de-
scription  given of this frightful  disease by that
excellent surgeon, Mr. Pott.   Fortunately it is
but  rare; when, however, it has commenced,
there is but one remedy, and that  is " the imme-
diate  removal of the part;  I mean," says the same
author, " that  part of the scrotum where the sore
is ; for if it be suffered to remain until the virus
has seized the testicle, it is generally too late even
for castration."   Cleanliness might, perhaps, even
in this case, prevent the  attack ;  but in an occu-
pation in which cleanliness is  almost  impossible,
the occurrence of a disorder  of  such  virulence
ought to form a strong motive  for its discontinu-
ance.   The  frequency  of accidents, and tue bar-
barity of  master  chimney-sweepers,  have,  we
believe, very much contributed to the disuse of
boys,  and the employment of machinery; and
heartily should we congratulate ourselves if any
thing we could say should further so desirable an
end as its  entire adoption, and the  consequent
release of a number of poor objects from wretch-
edness and disease.
   We  shall now proceed to the consideration of
the second class ;  and, first, of the diseases arising
from  the effects of moisture and temperature.
   We very much question  whether any disease
whatever can be traced to moisture only, we mean
to moisture unconnected with its effects upon the
temperature of the body.  Some proof of this seems
to be afforded in the custom of Highlanders of din- 
ARTISANS,  (DISEASES  OF)
179
ping their plaids in water before sleeping in them.
A more striking circumstance, however, is that of
the shipwreck related by Dr. Currie, where the ma-
riners who died had been only occasionally washed
by the surge, while the survivors were always im-
mersed in it.  M. Patissier appears to have some idea
of the kind, for he says, " II vaut mieux travailler
dans l'eau, les pieds et les jambes nus, qu'avec des
gueUres et des souliers, qui  ont l'inconvenient de
retenir  l'humidite ;"  and thus will  continue  to
dissipate the heat, when no longer evolved in addi-
tional quantity by exercise.  Under this section,
therefore, we shall consider the consequences of
temperature and moisture combined.
   The human body, we well know, is susceptible
of bearing with impunity considerable  extremes
of temperature, if  the changes  from the one to the
other be not too sudden.  Injurious consequences
arise more from imprudence than from necessity,
and are particularly incident to bakers, brewers,
glass-blowers, brass and iron-founders, and various
 other workmen.   When heated with their work,
 they  very frequently leave the  shop,  even in  the
middle of winter, without any additional clothing;
 thus suddenly obstructing the perspiration, and too
 often  producing   rheumatism,   catarrhs,  asthma,
 inflammations of  the chest, and general dropsy.
 With the labourers of this class it is  very evident
 that nothing is wanting  but common prudence to
 prevent, for  the most part, those inconveniences
 which must otherwise ensue  from their occupa-
 tions.
   But there is another class of workmen who are
 perpetually exposed to a low temperature, or  are
 obliged to remain  for a considerable time together
 in shops overloaded with vapour, thus moistening
 their clothes, and rendering  them rapid conductors
 of  heat; viz.-  those  whose occupations compel
 them to work in the open air,  and exposed to the
 frequent alternations of the weather.   To these
 classes belong washer-women, dyers, fullers, water-
 carriers, gardeners, milkmen, farmers, fishermen,
 and  many others.  The diseases  of  all these are
 precisely such as we are accustomed to refer to the
 suppression  of  cutaneous  perspiration : and,  in
 marshy  situations, in addition  to the  disorders
 mentioned above,  we have  not rarely intermittent
 fevers.   The steepers of hemp are reported to be
 liable to intermittents, but manifestly  from  the
 exhalation  of miasmata  similar to  those which
 excite them  in fens and marshes.
   It would be difficult  to  mark out any plan for
 removal of the latter evil, excepting that of steep-
 ing  as little as may be in one  place, and  thus
 diluting the miasmata.  With regard to the former,
 we can only recommend the constant use of flan-
 nel, and perhaps a rather freer diet than is neces-
 sary under  other circumstances.   M. Patissier
 recommends the  fishermen to cover themselves
 with a cloak of cerecloth,  " d'une  capote en toile
 ciree," and perhaps it may  be  useful  to them.   It
 is  only possible  here, however, to  give general
 directions, and the indications are too plain to be
 mistaken by any one.
   [An occupation of this kind has taught us the
 effects produced  by large quantities  of fermented
 liquors.  There is a  body of  men employed  on
 the river Thames, whose  business it is to  raise
 ballast from the bottom of the  river.   As this can
be done only when the tide is ebbing, their hours
of labour are regulated by that circumstance ; and,
consequently, vary through  every  period of the
night and day.  They work under great exposure
to inclemencies of weather ;  their occupation re-
quires great  bodily exertion, occasioning  profuse
sweating, and much exhaustion.  In consideration
of this, their allowance of  liquor is very large ;
each  man,  according  to   Dr. William   Budd,
( Tweedie's Library of  Medicine, 2d Amer. edit.,
iii. 587,  Philad., 1842,) drinks from two to  three
gallons of porter daily, and  generally a consider-
able quantity of spirit besides.  This immoderate
consumption of liquors  forms the only exception,
as far as relates to food, which these men  offer  to
the lower classes in London.  Gout is remarkably
frequent among them, and although not a numer-
ous body, many of them are every year admitted
into the  Seamen's Hospital Ship affected with that
disease.   This,  as Dr.  Budd remarks, is a very
interesting fact, and seems to show that no amount
of bodily exertion is  adequate to counteract the
influence of  such large  doses of porter ; the expo-
sure to wet and changes of  temperature probably
favouring its operation.]
   2.  The second order  of this class comprehends
those diseases which arise from undue or excessive
exertion of particular parts  or organs.  Without
following  M. Patissier's division, we shall shortly
treat of the effects of immoderate muscular efforts;
immoderate exercise of the  voice  or sight;  occu-
pations  requiring long-continued standing; and
occupations which require pressure upon, or exer-
cise of, some particular  part.
   The diseases to which  persons are subjected
whose employments compel them to powerful ex-
ertion of the muscles, are hernia, aneurisms of the
heart and great vessels, hemorrhages from the nose
and lungs, laceration of muscles, and not unfre-
quently such injuries of the spine as  to produce
deformity and incontinence  of urine.   Of all this
array of  evils, hernia is the  most frequent;  M.
Patissier mentions that the London Institution for
the  Relief of Ruptures received, between  April
1807 and October 1808, five thousand three hun-
dred and eighty-seven individuals, of whom  seven
hundred and  sixty only were women.   From the
very general adoption of the steam-engine in this
country  for the  execution of all laborious work,
the  sources  of  these accidents and diseases  are
daily diminishing.
   The French are very fond of tracing aneurisms
to this cause, and it is possible that they may oc-
casionally proceed from it;  but'we are convinced
that  their frequency is  much over-rated.  Where
there is a predisposition in the blood-vessels to this
disease,  it may doubtless  be induced by violent
effort to a particular part; but from the compara-
tive rarity of aneurisms in this country, and from
their frequently happening  in women, where this
cause cannot be suspected,  we are disposed  to
believe that they ensue  only where there is such a
predisposition.  Of the  other consequences, lace-
ration of the muscles is the most frequent, and  is
often effected by a very  trifling effort;  but it is  an
accident of more inconvenience than importance,
if treated by a well-educated surgeon.
   Ramazzini has affirmed that a standing posture
is a no uncommon source of varices in  the legs. 
180
ARTISANS,  (DISEASES  OF)
Dr. Gosse has published a similar opinion.  M.
Merat has remarked also, " that the footmen who
stand long behind carriages on the points of their
toes — the only attitude by which they can avoid
the shocks — are subject to aneurisms of the pop-
liteal artery."  In an inquiry like the present,  it
is of some importance to distinguish between what
is merely coincidence, and what stands in the rela-
tion of  cause  and effect.   This,  we suspect, has
been very frequently overlooked by M. Patissier,
and, indeed, by French authors generally.   We
do not doubt that both Ramazzini and Gosse have
witnessed varices  in  individuals  whose general
posture  was standing, nor that M. Merat has seen
popliteal aneurisms in footmen ; but does it there-
fore follow that their occupations were the cause
of the disease ?  We are not aware that varices
are more frequent in men than  in women ; our
own experience, indeed,  is favourable  to  a con-
trary opinion, and  their origin we have in very
many individuals traced to pregnancy.  But when
we consider that standing is the position which
the  most  numerous class  of workmen  employ,
that there is, in truth, scarcely any art in which
the labourers do not stand for a very great length
of time, and yet that varices are very far from
bearing  any proportion in the diseases  of such
workmen, it does  appear to  us that this position
must be rejected as their cause.   With regard  to
aneurisms, it  is very  true that Mr. Hodgson, who
is  tho best authority on the subject, states  that
men are more liable  to  them than women ; but
he  likewise states  a similar fact as to " those  dis-
eases of the coats  of arteries, which precede the
formation of  aneurisms."   This  again, therefore,'
seems merely a coincidence.  The same observa-
tion applies  to  the  occurrence  of  aneurism in
tailors and shoemakers, in whom  the citation of a
single case is deemed sufficient by M. Patissier  to
mark it  as proceeding from their employments.
   Housemaids, from  kneeling  at  their work, are
unquestionably liable  to a swelling of the bursa
of the patella.   It seldom, however, proves of any
serious  inconvenience, though  occasionally, from
inflammation taking place, it becomes the subject
of surgical treatment.   It is sometimes early re-
duced by the application of leeches, but will return
soon after the patient has resumed her former em-
ployment.
   Under the same head we may place those dis-
eases which originate  from too violent or long-
continued exertion of the voice.
   The  evils  frequently  enumerated as  arising
from over-exertion of the vocal organs, depend, in
some measure, upon other causes  than mere exer-
tion.  From this alone, without question, aphonia
may occasionally proceed, cedema of the  glottis,
haemoptysis, and laryngeal phthisis; perhaps even
herniae  may ensue.  But if cerebral congestions
or aneurisms  of the heart are prevalent  among
orators,  in support  of the latter of which, however,
the only case  that we  have seen cited, is that of
the celebrated Mirabeau,  they are  rather to be
referred  to the effect of the passions. In the same
way, M. Halle has observed that public  singers
are liable to  a series of nervous  affections ;  and
here M. Patissier has very properly remarked  that
the love of music may degenerate into a predo-
minating passion.  " Musicians and painters," he
savs, » are, in general, the most enthusiastic of all
artists.   We  have seen  musicians become  de-
ranged, and musicomania has been observed by
many physicians."
  The treatment of the diseases  which  may be
traced  to  the  exercise of tbe vocal organs must
plainly be commenced by  a perfect  abstinence
from  the  exciting  cause ; but  whatever  farther
may be required must be dependent upon the  cir-
cumstances and constitution  of the  patient; and
if the  chest is threatened with any serious dis-
order,  which may  usually be recognised  by  the
presence of cough  and emaciation, the profession
which compels the  exercise of the voice  must be
altogether abandoned.
  Continued and intense application of the eyes,
or their subjection to vivid light, is  productive very
frequently of the loss of sight, very generally of a
diminution of its powers.   Watchmakers, micro-
scopic observers, and embroiderers, are often short-
sigbted.   " They are obliged to compress the eye
by the muscles attached to the globe, and to make
it, consequently, take a more convex form than
usual,  that they may be enabled to observe more
distinctly ; and their continual  compression pro-
duces myopia."
  The workers at  furnaces  and iron-forges fre-
quently become amaurotic, from the great glare
of the fires.   In all these cases there is evidently
no good  to be expected from medical treatment,
unless the patients  abandon their occupations.
  3. The  third and last order of  this class, and
with  the  consideration of which  we  shall con-
clude the present article, are the diseases attendant
upon sedentary habits. To enter fully into these,
to show the manner in which they are adverse to
health, and the proper remedies, would  take  up
nearly as much space as we have already occu-
pied.   It  can  he only an outline which we  are
now enabled to offer.
  The diseases of  literary men  are those which
originate from want of exercise, very frequently
from  breathing the same atmosphere too long,
from  the  curved position of the body, and from
too ardent exercise  of the brain.  Of these sources
of ill health, the last is alone  peculiar to them,
lawyers,  bankers' clerks,  &c. :  the former  are
common to them with a considerable number of
artisans,  as tailors, shoemakers, weavers, watch-
makers, jewellers, and a  variety of others. But
several of these last have  likewise peculiarities in
their  manner  of working, such as keeping  the
body  more or  less  curved, and pressing strenu-
ously against  the sternum or pit of the stomach,
which materially modify  their  maladies.  After
mentioning, therefore, the diseases common to
all,  we shall briefly notice  those  which  are  pe-
culiar.
  Perhaps no  position, if long continued, is more
injurious  to health than  sitting.   The artisans
who  have  practised it from  infincy very rarely
enjoy a vigorous constitution ; their countenances
are pallid and  leucophlegmatic, and they  wear the
appearance of old  age at that period which is
usually considered  as middle life.  « Sedentary
habits," observes Patissier,  " usually  cause  the
lymphatic  to  predominate over  the  musvulai,
nervous,  and sanguiferous system ;" hence scro-
fula,  rickets, cachexia,  &c.  « Those who  labour 
ARTISANS,  (DISEASES OF)
1S1
 sitting complain of hemorrhoids and pains in the
 kidneys : the females  are  subject to fluor albus
 and irregular menstruation."  In  all these indi-
 viduals, the most common, the most obstinate, and
 too frequently the forerunner of a more fatal  dis-
 ease, is dyspepsia. In those who are badly nourish-
 ed, which, however, happens rarely  in  the great
 manufacturing towns  of England, it  takes  that
 form which Dr. Bateman has described under the
 title of asthenia.   Obstipation of the bowels  is
 exceedingly  common  among  all,  and to this  is
 unquestionably  to be  traced  the  prevalence of
 hemorrhoids, and, not improbably, affections of
 the prostate gland.  "Their position is peculiarly
 unfavourable to  the functions of the  viscera of
 the abdomen and  chest; it  determines  dyspepsia,
 gastritis, obstipation, hemorrhoids, catarrhus vesi-
 cae, and enlargements of the viscera."   To these
 we may add, and so  conclude the subject, so far
 as this class  of mechanics are concerned, that, be-
 sides the evils arising from their position, many
 make  strong pressure  upon the chest and the pit
 of the  stomach.   Of this class  are  shoemakers,
 weavers of all kinds, button-burnishers, &c.  By
 this pressure, gastrodynia, to a very severe degree,
 is  often produced, chronic inflammation of the
 peritoneum,  and  phthisis.   The same evils are
 common, but much less intense, in bankers' and
 attorneys' clerks, who incautiously lean too strong-
 ly over the desk.
   Tissot has published a  small work upon the
 Diseases of Literary Men ; and though it contains
 much  that is fanciful, it is certainly deserving of
 attentive  perusal.  In  addition to the  disorders
 which  a continued sedentary position induces,
 they are liable to many from a too constant exer-
 cise of the brain.   " Severe,  dry, tetrick," says
 the singular and  facetious Burton, " are common
 epithets to scholars; and Patritius, therefore, in
 the Institution of Princes, would not have them to
 be great students ; for (as Machiavel holds) study
 weakens  their bodies,  dulls  their spirits, abates
 their strength and courage ;" " they are most part
 lean, dry,  ill-coloured,  spend their fortunes,  lose
 their wits, and many times their  lives."   From
 Aristotle downwards, the brain has been remarked
 to  suffer peculiarly from this over-excitement;
 and there seems no exaggeration in the assertion,
 that " headachs, arachnitis, apoplexy, mania, me-
 lancholy, and  particularly  bypochondriasis,  are
 its consequences."  In the present day there is
 more general temperance in  the pursuit of inform-
 ation ;  there is more diversity, and usually more
 bodily  activity.  Hence, probably, the ill effects
 are rare.  They are still, however, common ;  for,
 unfortunately, the energy which prompts to in-
 dustry  in  accumulating knowledge is almost al-
 ways conjoined with great moral  sensibility.  The
 plan which has served to diminish their frequency
 may, perhaps,  under   proper  management and
 adaptation, be successful in entirely  preventing
 them ;  and the advice  of Ramazzini  ought to be
 written up in the room of every intense student.
 "Nihil  majus salutare censeo, ac magis commen-
 do, quam  corporis exercitium quod nihil prestan-
 tius  ad  obstructiones expediendas, nativum colo-
 rem  roborandum, coctiones perficiendas,  trans-
piratum promovendum,  et scabiem fugiendam."
  [The diseases with which the  literary are spe-
 cially afflicted are those to which the sedentary are
 liable, even when the intellect is suffered to lie dor-
 mant ;  and, accordingly, dyspepsia and its gloomy
 concomitant, hypochondriasis, with general torpor
 of the digestive apparatus, are the common results :
 but these diseases are by no means liable  to de-
 stroy ;  and it may be affirmed, that literary men,
 as a body, attain as  high  a degree of longevity as
 men  of any other avocation.   In  antiquity, this
 fact was most remarkably established, and all our
 associations of ancient wisdom  are attached to the
 hair whitened by time, and to those venerable and
 venerated busts which exhibit  the characteristics
 of the  accumulated  wisdom of ages.  Germany
 affords  an  example of a class of men who  devote
 themselves, from an  early age, to literary  pursuits
 exclusively, and their longevity has been  every
 where a subject of comment. It has, indeed, been
 maintained, and with much evidence in its favour,
 that the pursuit of letters in Germany, as  every
 where else, is eminently favourable to  longevity.
 Blumenbach affirms that for  the half century and
 more of his connexion with  one of the most cele-
 brated universities in Europe, he had not known
 a  solitary  example of any youth falling  a  victim
 to his ardour in the  pursuit of intellectual distinc-
 tion ; and Eichhorn, one of  the most voluminous
 writers of his day—the eminent philologist  and
 historian—is said  to  have asserted boldly,  «that
 no one ever died  of hard study."   " The  idea,"
 said he, " is preposterous.   A man may fret him-
 self to  death over his books, or any where else,
 but literary application would tend to diffuse  cheer-
 fulness, and rather prolong than shorten  the life
 of an infirm man."   The writer's experience is
 completely in accordance with  that of those ob-
 servers.  He cannot, indeed, recollect  a  solitary
 case of serious mischief induced by too great in-
 tellectual exercise, although the cause has not un-
 frequently  been assigned.  Where the health is
 apparently injured by literary pursuits,  it  will be
 found that the evil is dependent rather on collate-
 ral circumstances, on irregularity of habits,  as re-
 gards eating, drinking, or sleeping, often acting
 upon a frame unusually susceptible of impressions,
 for such is a frequent accompaniment of  genius ;
 and, that these views are just,  is strongly corro-
 borated by examining the history  of female au-
 thors, most of whom have  been extremely long
 lived;  doubtless, in  a great degree, because they
 were exempt from that irregularity of life which
 history  shows to have been so destructive to  many
 of the poets, whose productions have appeared in
 youth, and the celebrity arising from which had
 led them into  society, and into  habits that have
 too frequently been most destructive.
  It is probable that literary occupations  cannot
 be closely pursued with the same impunity in the
 young as in the adult.  When  study is indulged
 to excess in early life, it may have  a tendency to
 induce a predominance in the nutrition of certain
 organs at the expense of others.  If any organ be
energetically exercised, its vital  activity is  exalted,
 and a larger afflux of blood takes place towards it,
so that it attains a greater degree of development
than where it is less used.  Hence, it can  be con
ceived, that a constant over-tension of the  intel
Iectual  powers,  especially  when conjoined with
irregularity in exercise, diet, sleep, &c, may  oeca- 
152
ASCITES.
sum augmented flow of blood to the brain, and
consequent disease  of  that  viscus,  even  in  the
adult.  Still more likely is  this to  ensue, if the
same application be made before  the orgms have
undergone  their  full evolution ; and hence  we
may conceive that early and intense  study may-
lay the foundation to faulty  development in other
parts of the frame, and to great energy of nutri-
tion in the  brain.   But whilst it is admitted that
such may  be the case, it probably happens  but
rarely, far less frequently than is believed.  (Dun-
glison's Elements of Hygiene, p. 474.   Philad.
1835.)
   Dr. Guy, in the Journal of the Statistical  So-
ciety  of London, (cited in  the  Provincial Med.
and Surg.  Journal for Dec.  16, 1843 ; and in the
Philadelphia Medical Examiner for March 9,
1844,) has entered at some length into an inqui-
ry on the influence  of employments upon health.
It confirms  the results arrived at by other observers,
in showing the  great advantage which the better
classes enjoy  over  other members  of   society.
They appear to have longer, and probably enjoy
better, health.   This is doubtless owing to  bet-
ter ventilation  and food,  and the greater atten-
tion bestowed on the places which they  inhabit.
It is partly also due, as Dr. Guy has suggested,
to the  facilities which  they  enjoy for  exercise in
the open air.  The great  difference between the
gentry and other  members of society is not more
worthy of  notice than the slight advantage which
the tradesman in Great Britain enjoys over the
class  of  workingmen :  according to  Dr.  Guy, if
we limit the comparison to the average  age, we
find that the tradesman lives about three quarters
of a year longer than the entire  class of working-
men—little more than a year and a half longer than
the class employed solely within doors—two years
longer than the men following the more sedentary
occupations, and about three years longer than the
class which consists chiefly of domestic servants. On
the other hand, the  life of the tradesman is shorter
by about  a quarter of  a year  than  that of the
entire class of out-door labourers.  The little ad-
vantage possessed by the tradesman over the mass
of workingmen,  Dr. Guy thinks, probably results
from the sedentary  life he leads, his want  of pro-
per exercise, and the small space which the neces-
sities of business allow him to appropriate to the
 accommodation of himself  and family.   Taking
 one tradesman  with another, it is, perhaps, not
unreasonable to suppose that he habitually  breathes
an air as impure, and follows an occupation nearly
 as unwholesome, as the class beneath him.   The
 labour which the  workingman has  to undergo,
 provided it is not carried to  excess, is more favour-
 able to health than the confinement to which the
 tradesman is subject; and this confinement raises
 him in the scale  of mortality but little above  men
 following thW more sedentary occupations.  Both
 classes of  men, the  tradesman and the working-
 man, are doubtless exposed  to unwholesome influ-
ences, which might be wholly removed  or greatly
 mitigated by the interference of others, or by  their
 own precautions.]
   In closing this article, we cannot omit to notice
 mat the different employments of life  are rendered
 Tor more pernicious than they would otherwise be,
by the intemperance of the individuals exercismg
them. Even the grinders, by their constant dnnk-
ir.T greatly increase the injuriousness of the small
particles which they respire.  The bronchial tube
is already predisposed  to inflammatory action, and
perhaps scarcely requires the additional irritation
of a foreign  body.  Among those who exercise
their  intellectual faculties  the  same observation
holds equally  good.  There  is  indeed no ques-
tion  that mental exercise  renders  the brain  in-
capable of bearing that stimulus which otherwise
might perhaps be borne with impunity.  A few
years ago a gentleman, fifty years of age, who had
the care  of very extensive concerns, applied  for
assistance on account of giddiness in his head.
He did not consider himself intemperate, yet  he
was  in the habit  of drinking three or four pints
of strong ale daily, and this his father, an old man
of ninety years of age, had done  for years without
any  inconvenience.  The difference, however, in
their habits was great.  The father, concerned in
agricultural pursuits, had little care, while the son
was called upon to exercise his  mind continually
and  intensely.  Fortunately it was  not too late to
point out the  error ; and a change of habits has
preserved him from any repetition of the attack.
   Such, then, is an outline of the  evils to which
mankind are  subjected  from  their occupations;
and  numerous as they are, it does not  appear that
any  are really and entirely unavoidable. Ingenuity
has already diminished tbe number, and may, per-
haps, do  so still farther ; but  it cannot be too
much impressed upon all, that more depends upon
the  individual than upon the  occupation.   In
many trades  cleanliness  will alone  be sufficient;
and with this and common prudence, few, per-
haps, of tbe employments of men would be injuri-

                              J.  Darwall.
ous to health.
  ASCARIDES.   See Worms.
  ASCITES.  This term is employed to desig-
nate abdominal dropsy, [dropsy of the peritoneum,]
and is the same with the Greek word aoKirnc, which
has been derived from acicbs, a bottle.
  Few subjects  are  involved  in greater disorder
than that of abdominal dropsy :  authors the most
esteemed have used  the  word  ascites  for every
kind of collection of fluid in the abdomen.  We
shall in the present article confine the word ascites
to effusion within  the cavity  of the peritoneum,
referring to their proper place ovarian dropsy and
dropsy of the uterus, which, though distinct affec-
tions, have hitherto been considered under this head.
  The  fluid  effused in ascites consists of serum,
exhibiting various degrees of colour, from a light
citrine to a deep brown.   Occasionally the scrum
is mixed with pus, and not unfrequently there are
flocculi of coagulable lymph.  This last state de-
notes that there  has  been inflammation of the
peritoneum.
  Diagnosis.—The abdomen  in ascites usually
begins to swell very gradually  ; the swelling  is
uniform, beginning  from the pubes, and gradu-
ally extending as high  as the ensiform cartilage.
In  the  first instance the abdomen is  prevented
from protruding very much by the strength of the
muscles, but  as the  accumulating fluid increases,
it overcomes their resistance, and a large pouch is 
ASCI
formed, depending in some instances considerably
below  and in front of the os pubis.   If at this
stage the left hand is placed on one side of the ab-
domen, and the  other side is  sharply struck with
the right hand, a sense of fluctuation is manifest,
such as cannot very often  be  mistaken.   To use,
however,  the  expressive   words  of  Heberden,
" neque tamen  nullus est errori locus  in hac re,"
and mistakes have been made, by which pregnancy
has been mistaken  for  ascites,  and  ascites for
pregnancy.   The former mistake is unquestion-
ably the most important, since, should paracentesis
be  carelessly practised under such circumstances,
the death both of the mother and the child might
be  the consequence.   The latter is not, however,
without its inconveniences, for  every  disease is
most easily overcome in its commencement, and
hence an  error  in the diagnosis may cause a very
serious loss of time.
   To distinguish pregnancy from dropsy, nothing
more is usually required than  an accurate know-
ledgeof the signs of the former ; but sometimes a
difficulty  of another kind exists, namely,  the pre-
sence of ascites with pregnancy.   In tbis case, in
the language of Scarpa, " the regular form and
body of the  uterus  is not evident to  the touch ;
principally from the enormous distension and pro-
minence  of  the  hypochondria, arising from  the
great quantity of fluid interposed between the fun-
dus and the posterior part of the uterus and abdo-
minal  viscera.   The urine is scanty  and  lateri-
tious, the thirst  is constant.   The abdomen upon
percussion presents  a fluctuation, obscure in  the
hypogastric region and  in the flank,  but suffi-
ciently  sensible and distinct in the hypochondria,
and strong and vibrating in the left hypochondrium,
between the edge of the rectus  muscle and  the
margin of the false ribs."  The previous history
of  the case,  with a  proper examination  of  the
neck of the uterus, will enable the practitioner to
decide  upon the combination  of  pregnancy and
ascites ; [yet a case occurred to Dr. Haighton and
to  Sir Astley Cooper, in which these gentlemen
were so far deceived as  to  appoint  a day for the
operation  of paracentesis, when fortunately, in the
mean while, the lady was taken in labour and deli-
vered.   The discharge of liquor amnii was enor-
mous.]
  Another important distinction is between ascites
and encysted dropsy, whether ovarian or from any
other cause.   The history of these  cases will
generally  afford sufficient information for an accu-
rate diagnosis.   In ovarian dropsy, the swelling
does not begin  from the lower part of the abdo-
men, nor is it  uniform, one  side or  the other
being most protuberant.    Should several cysts
exist, the parietes of the abdomen often feel tuber-
culated, and we are sensible  that its  cavity has
several  partitions.  Moreover,  when  the patient
turns from one side  to the other  in bed, a sensa-
tion of a heavy weight within  the abdomen, fall-
ing to the lower side, is perceived ; if the cysts be
attached higher up, a feeling  of dragging is  in-
duced, almost amounting to pain.   Hence patients
generally lie on the  side on which the attachment
exists.   In some instances, a  hard tumour is re-
membered to have preceded the distension of the
abdomen.    When  the  cysts  are few  and very
large, tbe  distinction is  exceedingly difficult, and
T E S.                                     lai

 sometimes  altogether impossible;   Even  then,
 however, an accurate investigation of  the history
 will generally explain the exact  nature of the
 tumour.
   Encysted dropsy has also its origin in the liver,
 to the lower edge of which large masses of hyda-
 tids  are occasionally attached.   In investigating
 this  affection, attention must be paid to the course
 of the disease and the direction of the swelling.
 In the very early stage  it is not likely  to be mis-
 taken for ascites ;  but as the parietes of the abdo-
 men become thinned, the presence  of a soft swell-
 ing  proceeding from the liver, and   sometimes
 exhibiting a  slight degree of fluctation, may be
 traced.   The history, however, of the tumour will
 afford some information.   In ascites the swelling
 proceeds  from below upwards, while  in  the  en-
 cysted  dropsy of the liver its progress  is from
 above downwards.  A more particular prominence
 of the  abdomen may be perceived on the right
 side.  To this also is to be added, that the gene-
 ral  health, as in  ovarian dropsy, is but little
 affected, that  the disease is usually of very long
 duration, that the  urine is passed  in  the natural
 quantity, and that real effusion either into  the
 cavity of the peritoneum or into the cellular tex-
 ture does not take place till a very late period of
 the disease.
   The  gall-bladder has been  much enlarged, and
 Mr.  Gibson has related a  case, in the  Edinburgh
 Medical Essays, in which it contained eight pounds
 of inspissated bile.
   Hydatids  form  upon   the  spleen,  and may
 equally give rise to encysted dropsy, as when at-
 tached to the  liver.  Dr. Donald Monro has related
 a  case  in which " a scirrhous  spleen  was beset
 with two little bags full of water, which weighed
 a hundred and twenty-six ounces  ;" and in  the
 case related by Mr. Gibson, a cyst was attached
 to the spleen containing six pounds of clear serum,
 without smell, but exceedingly coagulable.
   The  omentum and the  sides of  the intestines
 are likewise the site of encysted tumours, which,
 when they become large, may be mistaken  for
 ascites.    It is not very easy to  lay  down  any
 symptoms by which  these can be distinguished
 from true ascites in their advanced  stage ; but an
 investigation of the history of the disease, and a
 careful  examination of the tumour, will, in this
 case also, generally enable us to ascertain its na-
 ture.    The tuberculated  feel  which  we  have
 mentioned as  marking the  ovarian dropsy may be
 frequently perceived in these   affections, and little
 inconvenience is experienced  excepting from the
 bulk and  weight of the swelling.
   The distinction of the encysted form of dropsy,
 if this ought to be called  a dropsy, is  highly im-
 portant  in the treatment of the disease ; for while
 real  ascites or effusion within the cavity of the
 peritoneum is very amenable to medicine, scarcely
 any benefit can be afforded to encysted  dropsy,
 and our chief attention must be paid to the gene-
 ral  health of the patient.   Medicine  indeed  ia
 much more frequently injurious than  useful in
 encysted dropsies, when they exist alone.   In the
 later stages, however, real  ascites is usually con-
 joined with encysted dropsy,  either by the burst-
 ing of the cysts into the cavity of the peritoneum
 or by an increased secretion from that membranp 
184                                     ASCI

itself.  We have seen this occur in a case of ova-
rian  tumour, in which,  from the extent of the
effusion, the tumour for some time could not be
perceived, although it had previously been easily
felt.   Cases of this kind are of course to be treated
on the same principles as dropsy of the peritoneum
from any other cause.
  It is scarcely necessary to mention the distinc-
tion  between ascites  and tympanites, the latter
being easily  known by  the clear resonance  af-
forded when the abdomen is struck by the hand,
and the tense, light, and equable intumescence of
the abdomen.  The collection  of air within the
cavity of the peritoneum is  an exceedingly  rare
occurrence, though we can  hardly  doubt that it
has occasionally been met with; but the contrary
is the case  with large accumulations of air in the
stomach  and intestines, and more or less of this
form of tympanites occurs in ascites itself.   It is
not,  however,  a symptom  peculiarly demanding
consideration, nor admitting, when  thus united,
of any  particular  treatment.  It generally  indi-
cates some disease of the  liver, of which it  is a
very early  symptom, and frequently precedes the
ascites.
  Ascites,  whether idiopathic or sympathetic, ap-
pears united with  two different states of the sys-
tem—the  one  tonic, the other an asthenic state.
In the former there is more or  less of an  inflam-
matory condition of the peritoneum ; in the latter
no inflammation is present; and if we  attribute,
as Dr. Parry would  do, the effusion in this  case
also  to increased momentum, it can only be com-
parative, with  relation to the weakened  state of
the exhalents,  since, to  employ his own words,
" the effusion is not always proportioned  either to
the mere disposition  in the capillaries of  the part,
or to the  degree of increased momentum, but is
relative to the sum  of  the two  tbgether ;  and
hence, in  certain states  of  the capillary  system,
even the  healthy  impetus may  be  sufficient  to
cause effusion."  The symptoms of ascites neces-
sarily vary with its cause, and we shall therefore
proceed to  consider them  under the different beads
of idiopathic and sympathetic, tonic and  asthenic
ascites.
  Idiopathic, tonic, or acute ascites.—This  spe-
cies  of ascites exhibits different symptoms, accord-
ing to the exciting cause and  the constitutional
irritability  of the patient.   In some instances there
is little disturbance of  the  general  health, the
swelling of the  abdomen being the principal symp-
tom  that attracts attention.    Dr. Ayre has related
an example of this  kind in a young woman, in
whom it had only existed for three weeks.   Her
general health was not much affected, but the
pulse was somewhat increased in its force  and
frequency.  He succeeded  in  curing her in the
course of a fortnight, by  leeches and blisters, and
by  acting  at the  same  time  briskly upon the
bowels  and kidneys.  At other times it is more
evidently  inflammatory,  and connected  with,  if
not  dependent upon, inflammation  of the peri-
toneum—it is  accompanied by fever, pain in the
abdomen,  increased  by pressure, and by a hard,
sharp, and sometimes a  wiry pulse.  This form
of the disease  is generally attributed to cold, and
dometimes runs its course in a  very short time.
Several years  ago a young man, (twenty years
TES.

of age,)  labouring under  this species  of ascites,
came under our  care.  Three weeks  only  had
elapsed when the  patient applied for relief.  From
his report he had at first experienced only the
symptoms of catarrh, to which in a few days suc-
ceeded pain and  swelling of the abdomen.  He
was bled  immediately, and aperients were given,
after which the effusion  disappeared.   The origi-
nal cause of the effusion, however, had proceeded
too far to admit of recovery.  He gradually sunk;
and, upon examination after death, the peritoneum
was found  to be  inflamed, and much  coagulable
lymph  thrown  out, so that the bowels  were in
many places agglutinated.
   Idiopathic inflammatory ascites occurs also after
scarlatina, and is sometimes the principal form of
effusion, although it is always accompanied with
some degree of anasarca.   The progress in this
case is again different from the two forms already
noticed.   It usually appears very gradually, com-
mencing about nine or ten days after  the disap-
pearance  of the eruption,  and for some days it
is scarcely  apparent.  There is at this period a
suspension of convalescence, which had  previously
been progressive ; the appetite fails ; the tongue is
covered with a white fur;  the pulse is quickened,
and there is much thirst.  This may continue for
several days before the effusion in the peritoneum
is considerable enough to attract attention; and
the first symptom is an  inability of bearing pres-
sure upon the  abdomen.   When the bowels ate
now examined, they will  be  found very slightly
protuberant, but without fluctuation being percep'
tible;  there will be  tenderness upon pressure,
although  no complaint should have been made of
pain in the bowels : sometimes, however, patients
do complain of this pain, but it is usually mistaken
for slight colic, and  no notice is taken of it.  The
bowels are costive, the evacuations very offensive,
and the urine is scanty, and generally pale ; upon
boiling it, it always  deposits a greater or less
quantity of albumen.  The face is generally oede-
matous,  particularly in the morning,  while  the
contrary state  has place  in the legs and ankles,
they being oedematous  at night, and  nearly  01
quite free from oedema in the morning.
   These, perhaps, are the simplest forms of ascites
that can occur, nor can there be any difficulty in
ascertaining their origin, or their appropriate mode
of treatment.
   There  is, however, another species of idiopathic
ascites, the origin of which is not very manifest,
nor can we do more in this place than indicate its
existence.  It  is unaccompanied by  the  slightest
degree of anasarca ;  it commences very suddenly,
without any marked disorder of the general health,
without any precursory symptom, and without any
ascertainable exciting cause. During the last year
a workman in one of the  Birmingham manufac-
tories was the subject of  this species  of ascites,
and his abdomen  was as much distended in twen-
ty-four hours as that of a woman in the  last month
of pregnancy.   The pulse remained natural, the
tongue clean, and the appetite good.  The alvine
evacuations were clay-coloured, and  entirely des-
titute  of  bile.   Venesection  was practised, ra-
ther as a  matter of precaution than from any direct
indication, but without any apparent good or bad
effect.   The evacuations having indicated  some 
ASCI
TES.                                     1S5
hepatic derangement, mercury was given him, but
scarcely to affect his mouth.  Under this treatment
the effusion gradually disappeared, and for some
weeks he seemed to have regained his usual state
of health.  Between two and three months after-
wards he was reported to have suffered from  hae-
moptysis, but the result has not been ascertained.
   There is another form of ascites, most common
in children and young girls about fifteen or  six-
teen years  of age.   In  very many cases there is
no symptom attending  the effusion; in  others
there is considerable dyspepsia attended with much
weakness.  There is not often any anasarca.  The
urine and  the evacuations  from the  bowels  are
either quite healthy or  quickly become so under
the use  of  aperients and tonics.
   It is not very easy to obtain an accurate history
of the cases, for they are seldom brought for as-
sistance till after the effusion has endured for some
time.  Their early  progress attracts  no attention,
and we  may consequently infer that  the effusion
takes place very gradually.
   Idiopathic asthenic ascites.—This is unques-
tionably a much rarer disease than the acute form,
and generally succeeds exhausting causes, as pro-
fuse menstruation,  long-continued  diarrhoea,  &c.
The  effusion  usually  begins  with  oedematous
swellings of the lower extremities, and the ascites
succeeds in a longer or shorter time ;  sometimes,
however, the ascites precedes the anasarca.   The
constitutional symptoms of  these cases are loss of
appetite, great debility, low, weak, and often flut-
tering pulse, and  in women, with whom it much
more frequently occurs than in  the  opposite sex,
it is united with distressing hysteria.  At the same
time  the digestion  is very  greatly impaired,  and
solid food  is either rejected, or  complained of as
inducing severe pain.  Flatulence is also  a very
distressing symptom in this form of ascites.  The
bowels  are very  irregular,  either very costive or
relaxed, and the exhibition  of purgatives invaria-
bly increases the  general disturbance of the  sys-
tem.  If the disease be  suffered to  proceed with-
out medical assistance, the  effusion  continues to
increase, and the patient at  length dies from  ex-
haustion.
   The forms now mentioned are the chief species
of idiopathic ascites; and we next proceed to the
consideration of sympathetic ascites.  In this we
cannot equally divide the disease into tonic  and
asthenic ;  since, generally speaking, the asthenic
character predominates,  but in a state of the  sys-
tem  so  irritable that inflammation  often  super-
venes.
   Sympathetic, or more properly, perhaps, con-
sequential  ascites, is always  the result  of some
previous disease of an important organ, and is  the
result of the debility of the system  induced by
such disease.  The effusion is preceded by greater
languor  than had  been experienced  before—thick
dry skin, diminution in the quantity of urine, and
as the effusion increases, by a distressing dyspnoea,
the consequence of  the impeded action of the dia-
phragm  from  the  pressure  of the  fluid.  The
swelling of the abdomen is  often  preceded  for
weeks and months by an oedematous  state  of  the
ankles, particularly  at night; and this sometimes
will be wanting for  a short time, so  that the  pa-
tient flatters himself that it will  not. re-appear.
  V:l. I. — 24                         H,v
At length, however, the cedema  of the  ftet and
ankles becomes permanent, and  extends a little
way up the legs ;  and at the same time the abdo-
men becomes a little fuller, the patient cannot but-
ton his clothes, or, in the female, the stays will
not come together. From this period the progress
is more  rapid,  the abdomen daily becomes more
distended, and  fluctuation is soon manifested
Emaciation increases with the  effusion;  hectic
fever, if it  should not have  appeared  before, is1
established; and  the  patient gradually  wastes
away.
   The duration of dropsy, in this last case, is very
various.   In general it appears  long before  the
fatal termination ; but not unfrequently  the effu-
sion appears only  a few days before death, and the
quantity of fluid poured out in a short time is sur-
prisingly  great.   From our experience we  should
think that this  rapid  effusion  chiefly occurs as  a
consequence of diseased liver, in persons  naturally
of strong constitutions.  We  have never seen it
equally rapid when it has depended  upon the af-
fection of any other organ.
   Causes of Ascites.—The arrangement which
we have followed does not allow us much  to di-
late upon this point.  The acute species are clearly
dependent upon inflammation of  the peritoneum;
and we are induced to  believe that, in many in-
stances at least, this is the primary affection.  Dr.
Bright, however, is inclined to refer  the origin of
these inflammatory dropsies to disease of the kid-
neys, and to consider the inflamed state  of  the
serous membranes as only an accidental circum-
stance.   The more detailed consideration  of this
doctrine we shall defer to the article Drops r, only
here indicating the hypothesis.   We would, how-
ever,  remark that albuminous urine, which  Dr.
Bright  considers  as  diagnostic of renal dropsy,
much more frequently accompanies anasarca than
ascites; although  the latter, especially when  the
consequence, exhibits the  same peculiarity.
   The  exciting causes of  acute ascites  are cold,
intermittent fevers, the retrocession  of eruptions,
especially  when  they  have  disappeared  rather
earlier tban they ougbt to  have done, the suppres-
sion of habitual discharges, &c.
   The  asthenic dropsy we have already referred
to diarrhoea, hemorrhages, &c. by whatever cause
excited; and the sympathetic ascites, as the epithet
indicates, is rather a symptom  than an original
disease.
   Morbid appearances.—The morbid appear-
ances exhibited in ascites are almost  innumerable;
every derangement of an  important organ may
sooner or later give rise to this form of dropsy—
the liver, however, the spleen, and  the  kidneys,
are more particularly concerned in the production
of effusion.  In the peritoneum, which is the ini
mediate source of ascites, the  presence of inflam
mation is often proved by  a false membrane being
attached to it in different parts, and by the agglu-
tination of the bowels.  It is also subject to  thick-
ening, and instances are  on record where it has
become almost cartilaginous.  Dr. Ayre has related
a case, in which the dropsical  symptoms had dis-
appeared  twelve months before the death of  the
patient, which took place in consequence  of an old
liver disease.  On inspecting the body after death
the peritoneum covering the liver, and the organs 
186
ASCITES.
adjoining it were found of a nearly perfectly white
colour, and of the thickness  of chamois leather,
and  this appearance  pervaded,  more or  less, the
whole  abdomen.   In the  museum  at Guy's Hos-
pital, there is  a  preparation  of a portion of the
convex surface of the liver, and  of the diaphragm
corresponding  to it,  showing  the  peritoneum
covered with minute scabrous elevations.   In this
case " the  patient had  copious clear effusion into
the peritoneal  cavity."  Another  preparation  of
the peritoneum in the same museum, taken from a
dropsical patient, exhibits a portion  of the mem-
brane covered with  small  scrofulous  tubercles.
Steatomatous  and scirrhous excrescences on the
peritoneum are also found in ascites ;  and proba-
bly, in all  these  cases, the diseases of the mem-
brane are the causes of the effusion.
  Prognosis.—The  prognosis of ascites must
necessarily depend upon the cause, and in general
the idiopathic  disease is  curable, whether of the
tonic or the atonic forms ; while, on the contrary,
the sympathetic form of ascites very seldom admits
of a cure.  It may, indeed, be removed for a time;
and, in some rare cases, when the original disease
has been likewise removed, it has not returned:  it
must be confessed, however, that this is a very rare
occurrence.  In general, the effusion  returns very
quickly, and of the  sympathetic ascites,  we may
say with Itard, that  it is almost always  mortal.
This difference in the  prognosis renders it very
important  to  distinguisb  between  the idiopathic
and sympathetic disease ;  a distinction which it is
not in every case easy to make,  and which conse-
quently demands the closest  investigation on the
part of the physician.
  Treatment of Ascites.—The  treatment  of
ascites must vary according to  the origin of the
disease.  In the idiopathic and acute  form, bleed-
ing, either  general or local, or both, must be re-
curred to.  When ascites is produced by cold, and
in plethoric habits, general bleeding should never
be omitted  ; and  should the distension  of the ab-
domen continue unabated afterwards, with a toler-
ably firm pulse,  the  depletion may be  repeated.
If there is  tenderness  in  the  abdomen, it will  be
often highly serviceable to  apply a large blister
over this part, and sometimes to keep it open, or
to repeat it.   In  the dropsy succeeding scarlatina
in children, the  application  of leeches  will  be
generally sufficient, provided  they are applied in
considerable numbers.  In a child under five years
of age, from six to  eight may be ordered;  but
after this period  from  ei^ht to twelve  should  be
employed.   In stating  these  numbers,  it is  not
intended  that they should be permitted  to bleed
afterwards ; for so much inconvenience is often
experienced from  the indiscretion and carelessness
of nurses, that it is much better to  apply a larger
number, and to stop the bleeding immediately.  In
two  instances, where only four  leeches were  ap-
plied and the leech-bites were left  to bleed after-
wards, the patients evidently sunk exhausted from
the loss of blood.
  Mercurial purgatives should be administered in
the first instance, until the bowels have been com-
pletely emptied, after which  it will generally  be
advisable to suspend the use of  active purgatives
and to order diuretics.   Of these the digitalis pur-
purea is unquestionably the  most useful; and  in
the dropsy after scarlatina, it is  almost a specific.
The coagulability of the urine, which may have
resisted  bloodletting and purgatives, rapidly dis-
appears during the administration of digitalis, and
the effusion disappears at the same  time ; some-
times,  however,  the  coagulability  of the  urine
remains  long after  the  dropsy.   There are cases
in which so  much debility remains  after the em-
ployment of these means,   that tonics become
necessary, and in this case   bark or  steel  is the
most efficient.  Great care  should  be taken that
the use of tonics is not permitted while the febrile
state remains, since they might then  perhaps re-
produce the effusion.
   In the idiopathic asthenic  ascites, the first atten-
tion must be paid to the exciting cause, whether
this be hemorrhage, diarrhoea, menorrhagia, &c.;
and, as far as it  may be possible, this sbould  be
removed.  As the term  asthenic  indicates, tonics
are absolutely necessary for  this form of the dis-
ease, but much care is  required in our choice of
the particular remedy.  When the debility is very
great, and the irritability is at the same time con-
siderable, the stomach will seldom bear the more
powerful tonics, such as quinine, the  sulphate of
iron,  or the  stronger  vegetable  bitters.  Under
these circumstances it will be advisable to use the
mildest bitters, and these very weak, such as infu-
sion of calumba, infusion of orange-peel, &c. and
to recur to  the more powerful  remedies, as the
strength  increases.   In  those  cases of weakened
digestion which  occur among the  poor, and  to
which  Dr. Bateman gave the title of  asthenia, the
decoction of Iceland-moss will often be found very
beneficial, this  medicine possessing  the  double
qualities of  a nutriment and  a tonic.   A very ser-
viceable remedy also is the  ferrum  tartarizatum;
it acts  at the same  time as a tonic and a diuretic,
and is  decidedly the mildest of the preparations of
steel.  It affords very considerable relief in those
cases of  anasarca which are   connected  with dis-
turbed  action of the heart, and where it would be
dangerous to give any stimulating tonic.
   In that form of ascites which has been men-
tioned  as occurring  in children and  young girls,
the most satisfactory  results  have  been noticed
from the administration of  Bacher's pills.  This
remedy, which once obtained considerable  cele-
brity, is composed of equal parts of the extract of
black hellebore and gum myrrh, with a small por-
tion of the  carduus benedictus in powder.   The
latter, however, is void of all power, and, perhaps,
owed its introduction as much to its title of bene-
dictus  as to  any thing else.   It is now rarely kept
in the  shops.  The dose is a one-grain  pill three
times a day ; afterwards to   be  increased,  if the
patient can  bear it, to four or five pills  at a dose,
and given as frequently.
   The action of this  medicine upon the various
secretions is not evident.  Sometimes the bowels
are slightly relaxed, and sometimes  the urine is
increased ;  but quite as commonly there is no dif-
ference in these  respects ; and  yet  the effusion
gradually disappears.  There are, however, indi-
viduals upon whom the black hellebore quickly
aots as a poison, inducing giddiness, sickness, and
sometimes, but not very  frequently, purging; and
with such persons we  are obliged to  adopt a dif-
ferent mode  of treatment. 
ASCITES.
187
  It may be laid down as a rule in this as in all
other chronic diseases, that nothing is  to  be ob-
tained, but  much  may  be lost, by  violent and
hasty  remedies.  Even when relief is afforded by
them, as sometimes happens, it is at the risk of
inducing worse evils.   When, therefore,   either
Bacher's pills fail, or when from the idiosyncrasy
of the patient, they  cannot  be  taken,  our first
object must be to  investigate  very accurately all
the circumstances  of the  patient; the  state of
digestion ; the condition of the urinary and alvine
secretions ; and likewise of the cutaneous perspi-
ration.  If any one of these  is more particularly
affected, our attention should be directed to restore
the healthy function ; to  excite  perspiration,  to
improve the digestion, to  increase or correct the
secretion of urine.   For the first object, the com-
mon vapour bath, at a heat of  from 104° to 110°
Fahrenheit, may  be  advantageously employed.
Whether what are termed vegetable  medicated
vapour  baths  have any peculiar  virtue may  be
questioned, but there is no doubt that passing the
 steam through some aromatic herbs renders the
 bath  a  much  more agreeable application.  The
 bath in this form may be taken every day, or two
 or three times a  week only,  according  to  the
 strength of  the patient.
   In exciting the urinary secretion,  great  assist-
 ance  is sometimes derived from small  quantities of
 the blue pill, carried far  enough just  to  affect the
 mouth, but not to induce  complete  salivation.
 With these may be  combined the various diuretics,
 as squill, digitalis, nitrous  ether, liquor ammonise,
 acetatis, &c.   It has  often  been remarked that
 diuretics bear, or we might almost  say, require
 combination more  than  any  other  remedies, to
 produce beneficial  effects;  and  our experience
 amply confirms this opinion.  Any one of these
 alone will perhaps  have no effect, but when em-
 ployed  in union with other medicines of the same
 class, a remarkable increase in the flow of urine is
 the consequence.  This peculiarity must therefore
 be kept in mind in  prescribing ; and we must also
 remember that, to obtain any good result, we must
 often persevere for several weeks, changing our
 medicines every four or five days when  they cease
 to excite the  kidneys,  or continuing  the same
 remedies when their effect continues.
    It  may often be advisable to act upon the kid-
 neys even when no diminution is perceptible in
 the quantity of urine voided ;  as must be evident,
 if we consider that this  is generally the  easiest
 mode of carrying off" effused fluid.   If the diges-
 tive organs  appear  to suffer, the common plan of
 treatment of dyspepsia must  be  recurred  to,  for
 which we  refer more particularly to the  article
 upon that  subject.   We would, bowever,  remark
 that  the biliary secretions are generally more or
 less disturbed  in every species of dropsical effusion,
 and that much benefit is frequently derived from
 the employment of the nitro-muriatic acid  in de-
 coction of sarsaparilla, combined  with  alterative
 doses of the blue pill.
   To lay down any plan  for curing sympathetic
 ascites without curing the original disease would
 be idle; whatever is done for the dropsical effusion
can merely relieve the immediate distress,  and
 perhaps afford time for removing the  essential dis-
ease.   For  this purpose the  drastic purgatives,
such  as  elaterium, the croton oil, and gamboge
united with calomel, will be found useful;—some-
times frictions, either with oil alone or some stimu-
lating remedy^may be employed : diuretics, though
less  certain  and  less speedy in their effects, will
also  sometimes afford relief.
  Mercury is usually administered by empirics in
every kind of dropsy, and sometimes in obstinate
cases of ascites, with great success.  Great caution
ought, however, to be observed in the employment
of this drug, for by increasing the debility, it may
in some cases  increase the effusion.  To enumer-
ate all the remedies that have been recommended
for ascites would render this article unnecessarily
prolix ;  but as some have been mentioned which
act with  great energy, it may be necessary to give
a statement  of those  the  action of which  is less
decisive, and which require a long perseverance to
produce any good effect.
  To this  class  belongs  more particularly  the
supertartrate of potash, which was tried with great
success by the late Dr. Home.   It should be given
in drachm doses  in  the form of electuary, and as
much as from one to two ounces may be taken in
the  course  of the day.  Diluents should  also he
plentifully employed, or the cream  of tartar will
act on the bowels only, without affecting the kid-
neys.  The decoction of broom, or spartium sco-
parium, is a very popular remedy, and will in many
instances remove the effusion, when other reme-
dies fail. The decoction should be made of the
green tops, and  drunk for a considerable  time in
large quantities.   It usually affords relief in a few
days, by increasing the flow of urine.   Occasion-
ally  it is beneficially joined in decoction with par-
sley, apium petroselinum,  and the  root  of the
common dandelion, leontadon taraxacum.   This,
indeed, is a common drink in many country places,
and  deservedly enjoys a high  reputation for the
removal  of dropsical effusions.
   Opium, both alone and in the shape of the com-
pound ipecacuanha powder, has at times appeared
to produce singularly  good  effects  in  the cure of
ascites.   Its action, when any good is produced,
is powerfully sudorific.  Dr. Monro has given the
case of a man who, after quartan ague, was taken
with ascites, and  then swelled all over.  A num-
ber  of purgatives  and  other medicines were given,
but  did not  at all  relieve  him ;  and there seemed
to be little hopes of his recovery.   Dr. Knight
ordered  him a dose  of  Dover's  powder, which
relieved  him greatly, producing at the same time
very copious perspiration ; and by the alternation
of this powder with purgatives, the man eventually
recovered.  Frictions  with oil  have likewise been
recommended, and a case is given in the Philoso
phical Transactions, where  this alone  sufficed  for
the  removal of  an  old  case  of  ascites.   (Phil.
Trans, vol.  xlix.)
   In the article  Dropsy we  purpose  to consider
the  remedies employed in this disease more fully,
and to that article, therefore, we  beg  to refer the
reader for any  additional  information that may bo
required.
   The  last  point to which we shall call attention
in the present essay is paracentesis.  This opera
tion, although one of  the oldest in surgery, had
in the time  of  Dr. Mead, fallen into great disre-
pute, when  that learned physician pointed  out the 
ISS                                   ASPHYXIA.
circumstances which  rendered  it pernicious, and
the proper means of remedying it.   Our present
question,  however,  is, under what circumstances
it ought to be performed, whether as a curative or
merely an  alleviativc  measure.  It is  somewhat
curious that the first  patient on whom Dr. Mead
tried this operation and maintained pressure after-
wards, recovered, and  that, in  another instance,
which appeared  almost  hopeless, he  met  with
similar success.  Still this has not been the gene-
ral experience of the practice; and Dr.  Fothergill,
about the middle of the last century7, acknowledg-
ing the little success that had  generally attended
the operation, thought that  it incurred some part
of its disgrace from its being delayed till it could
have  no  other effect than procuring a very short-
lived  hope to the patient.   In  pursuance of this
opinion, he recommended the operation in several
cases  of ascites, which  terminated  successfully.
Since, however, Dr. Fothergill wrote, the operation
appears by no means to have increased in reputa-
tion.   Our own experience is  decidedly opposed
to it.   We  have frequently had  patients tapped
when the  effusion  was  very inconsiderable, and
had  existed  but a  short time.  Every care was
also taken, after the  operation, to  prevent the
occurrence of inflammation.  In all these instances,
however, the effusion rapidly recurred, and upon
examination  of several  after death, the  bowels
were found adhering by old depositions of coagu-
lable  lymph.  That  recovery  does  occasionally
take place after tapping is true ; but from exten-
sive inquiries among medical men, and from our
own practice, we are convinced that such cases are
rare, and we could almost go farther,  and say that
tapping even increases,  in many cases, the  ten-
dency to effusion.   In looking  also at the  cases
mentioned by  Dr. Fothergill, it  will be  found that
they  are  such as are generally curable without
an operation ; and to tap  sucb  patients would,
therefore, be to add to the danger of the disease.
  To these remarks some exception perhaps may
be made when ascites is conjoined witb pregnancy.
The distension  in this case is productive of so
much inconvenience, and even  danger,  that if the
dropsy does not readily  yield to the appropriate
remedies,  no delay should be  permitted in  per-
forming the operation.
  Whenever paracentesis is performed, the great-
est care should be taken  to prevent inflammation,
nor should the appropriate medicines be omitted.
Generally, indeed, the  kidneys act with  great free-
dom  after this   operation, gradually,  however,
diminishing their activity as effusion again ensues.
Hence it  becomes necessary again and again to
repeat the operation, and in some very rare cases
a perfect  cure has taken  place after repeated  tap-
pings.  The  quantity of fluid evacuated by  this
operation  has been enormous.   Dr. Mason Good
has collected some very remarkable instances.  In
an instance quoted from  Dr. Stoerck, twelve gal-
lons and  a half were evacuated  at once ; and Dr.
Scott, of  Harwich, performed the operation twen-
ty-four times in only fifteen months, and drew off
a hundred and sixteen gallons in the  whole.
  [The operation has  been performed in the same
case one  hundred and  forty-three times, and per-
haps oftener.   Not  long  ago, a case was reported
 0 tr.e Academie  Royale de Medecine, of Paris, by
M. Lecanu, in which paracentesis was  performed
eight hundred and sixty-six times, and the woman
was ultimately cured under compression of the abdo-
men.  In one case, recorded by Dr. Beall, of Mis-
souri, it was  performed ninety-six times within a
few years, and  the whole amount of fluid evacu-
ated was two  hundred and  seventy-five gallons
and  a half; the first fifteen operations yielding an
average of twenty quarts.  (Dunglison's Practice
of Medicine,  2d edit. p. 205 ;  Philad. 1844.)
  For evacuating the fluid, Dr. Prichard, of Bris-
tol,  England, (Land.  Med. Gaz.  Mar.  25, 1842,
p. 29,) uses  a needle, with a larger  groove  than
the common  exploring needle employed in empy-
ema, (q. v.,) with which  he  has  evacuated  the
fluid of ascites  with perfect ease and  safety ; and
with the advantage, that the pain  attending  the
operation is  so trifling, that the  patient will call,
occasionally,  for  a repetition  of it, after having
once experienced the relief that  follows its use.
He recommends, that both in ascites and  hydrotho-
rax, it should be used much earlier than the trocar
is generally  advised ; the practice  of deferring
paracentesis until all other means have  been long
tried, being, in  his opinion, a principal cause of
the frequent  return of the effusion.   Dr. B. Bab-
ington  employs a very small  trocar  and  canula,
which, together, are not  thicker than an ordinary
grooved  needle.  The instrument is provided with
a probe to pass through the canula.  (Lond. Lancet,
April 9, 1842, p. 60.)  After the operation, oppor-
tunity is afforded for examining into the condition
of the  abdominal  viscera, and  every endeavour
should be made,  by appropriate revulsion, to pre-
vent a re-accumulation of the fluid.  Great advan-
tage, in such cases, has resulted  from change of
air, as  from one of the crowded cities to a water-
ing-place, where  the individual can experience a
thoiough mutation of all the influences  surround-
ing him.]
  There are also examples of the  spontaneous dis-
appearance of ascites after some accidental hemor-
rhage, diarrhoea, or other discharge.   But the most
curious,  perhaps, on record is that related by Dr.
Mead.    At one  operation twenty  pints of clear
fluid had been drawn off.  In a few weeks the
patient  filled again, and  it was resolved to repeat
the tapping.  When, however, the surgeon went
the next day, the abdomen had  completely sub-
sided, although no evacuation of any  kind had
taken place in the night.   Cases  like these serve
to bring  into  doubt tbe power of  medicine.
                              J. Darwall.
  ASPHYXIA.—The term asphyxia is a palpa-
ble instance of  the change which the signification
of a word may  undergo in process of time from
that which is  indicated  by  its  etymology, and
which  it must  undoubtedly have borne when it
was  first introduced into  the language.   Being
derived from a<pi^n, the pulse, with the privative o,
its literal meaning is a loss or  suppression  of the
pulse, and, consequently,  a failure in the action
of the heart.  But this disordered state in its sim-
ple  form is  now  universally  designated  by the
terms syncope, leipothymiu,  ox  fainting.  As-
phyxia, on the other hand, is restricted to express
those cases of cessation of the heart's action which
arise from  a  particular cause, namely,  the inter- 
ASPHYXIA.
189
ruption of respiration, or, to speak more correctly,
the interruption of the  effect  produced by that
function on the blood.
  It is sufficiently established  by the researches
of modern physiologists, that the purpose of respi-
ration is to expose the portion of the blood which
has returned to the heart after  it has circulated
through the body, and which has acquired, in the
course of that  circulation, the  properties of dark
or venous blood, to the  influence of  atmospheric
air in the lungs.  The oxygenous portion  of the
air so received in the lungs, converts this venous
blood into florid or arterial blood ; that is, into the
state in which it is fitted for being again circulated
through  all the parts of the body.   In man and
all warm-blooded  animals, this  process is con-
stantly going on, and is  of such  extreme import-
ance in the animal economy, that its interruption
for a few minutes may destroy life.  This, then,
constitutes death from asphyxia ; asphyxia being
the condition of the  body consequent upon the
interruption to the arteriahzation of the  blood, and
implying the suspension of all the powers of sen-
sation and of voluntary  motion.  It is only during
 a'certain short period that this  state of  suspended
 animation, as it may be called, admits of recovery
 on the employment of  proper means ; but if its
 duration  exceed this period,  it is  irretrievably
 fatal.
   Various are  the ways in which respiration,  or,
 rather, the salutary effect  of  respiration  on the
 blood, may be interrupted.  It  is obvious,  in the
 first place, that, since  the beneficial effect in ques-
 tion is owing to the presence of  free  oxygen, the
deficiency  or absence of this element  in  an un-
 combined state in the  air  respired must produce
 asphyxia.   Azotic, hydrogen,  or  carbonic acid
 gases, or  air too highly rarefied  to maintain life,
 may therefore  be ranked among  this  first class of
 the causes of asphyxia.
   The respiratory organs of warm-blooded animals
 being adapted to the  breathing only  of air in its
 gaseous state, are incompetent to derive the requi-
 site influence from the oxygen contained in water,
 as takes place in the  respiration  of fishes.   Sub-
 mersion is, therefore, to the former a second cause
 of asphyxia.
   A third set of causes which may induce asphyxia
 comprise those that operate by preventing  the ac-
 cess of air to  the interior of the lungs.  It com-
 prehends what is properly termed  suffocation,
 whether the impediment be wholly  external, as
 when the  mouth  and nostrils are closed to all in-
 gress of air, or whether it be within the throat, by
 the introduction of any solid or  liquid substance
 which blocks  up  the glottis  or trachea,  or has
 penetrated into the bronchia, or whether the same
 effect  be  the consequence of  a disease attended
 with  such tumefaction of the membrane, or accu-
 mulation  of secretion,  so as to  close the tube.
 Analogous to these, and ranking under the same
head, is external pressure on the trachea, so great
as to prevent the passage of air ; an effect  usually
termed strangulation.
   A fourth class  of  causes include  those which
operate by impeding the mechanical  actions that
are necessary for  the alternate admission and ex-
pulsion of air which  constitutes breathing.  The
mechanism of respiration consists in  the elevation
and depression of the  ribs, which is chiefly per-
formed by the intercostal muscles, and also in the
descent and  ascent of the diaphragm, its  own
muscular  fibres  performing the first, and the ab-
dominal muscles being the chief agents in  the
latter  of these actions.  If the motions both of the
diaphragm and of the ribs be  at the same  time
prevented  from taking place, a stop is necessarily
put to  respiration, ■ and  asphyxia  must ensue.
Such  will be  the case when a considerable and
general pressure  is applied externally both to the
chest  and to  the abdomen, preventing their ex-
pansion ;  or, on the other hand, the pressure may
be applied internally to the lungs, as when fluid is
collected in the cavities of the pleurae, constituting
hydrothorax ; or when the same cavities are filled
with air, producing what is termed pneumo-thorax.
Such  will also  be  the consequence  of paralysis
affecting the  muscles  concerned in their actions.
The division of the pneumo-gastric, or eighth pair
of nerves, on both sides, proves fatal from its im-
pairing the powers of the respiratory muscles.
The fatal  effects of cold applied  extensively to the
body  have also been explained on the principle of
its paralysing influence on the muscles of respira-
tion.   But this may admit of doubt.
   We should naturally expect that each of these
several causes of asphyxia, while it produces that
affection with all its general phenomena, will be
respectively characterised  by certain modifications
of effect peculiar to itself, and which may  often
enable us to  distinguish  its particular operation.
The most perspicuous plan of treating the subject
before us  will, therefore, be to premise an account
of the more general phenomena that universally
accompany every form of asphyxia, and proceed,
in the second place, to point out such peculiarities
attending the different modes by which it may be
induced, as appear  worthy of remark.
   General phenomena of  Asphyxia. — The
phenomena consequent upon a deficiency of oxy-
gen in the gas which is in contact with the blood
in the  lungs succeed one another with different
degrees of rapidity, according  to the  greater 01
less extent of this  deficiency, or according as the
obstruction to respiration  is more or less complete.
The effects of a total interruption to breathing are
so quickly fatal as  scarcely to allow  time for ac-
curately observing  the order of their succession.
This  can  best be done when asphyxia is gradually
induced.
   The first perceptible effect of impeded respira-
tion is, a sensation of distress referred  to the region
of the lungs, accompanied by a strong desire of
fresh  air, and by an involuntary effort to dilate the
chest by throwing into action, not only the inter-
costal muscles and  the diaphragm, but also those
muscles which act as auxiliaries in the same office.
This  sensation  rapidly becomes more and  more
urgent  and  painful;  it rises to one of  extreme
agony, which agony, however, is but of short dura-
tion,  being quickly  lost in an overpowering torpor.
which steals  upon the senses,  and bereaves the
sufferer of every faculty  of consciousness.   The
struggle  is,  notwithstanding,  maintained  for  a
short time longer;  being  taken up, in  the absence
of consciousness  and  volition, by  the  natural
powers inherent in  the system, which still survive.
It is in this stage of the progress of asphyxia that 
\
190
ASPHYXIA.
various  irregular  and convulsive movements are
excited, both in  the  trunk and  limbs, as if the
system were instinctively prompted to these efforts
in order to burst the spell about to be cast around
it.  During  these commotions,  the  veins  of the
head are  observed  to swell;  the face, and parti-
cularly the lips, become  blue and livid ;  the eyes
are suffused, and seem  ready  to  start  from their
sockets.   At length these  involuntary and fruit-
less agitations subside into quiescence ; the powers
appear to  be exhausted ;  nature yields to necessi-
ty ; and a fatal immobility pervades the  system.
So complete is this general relaxation of the fibres,
that even the  sphincter muscles, which always
retain  their  irritability  to the  last moment,  at
length give way.   Yet the heart continues for  a
time to propel, though  feebly,   and with quick
vibrations, the venous blood it receives from the
pulmonary vessels : but, in  a few moments longer,
a stop is put to its motion, and  all circulation  is
arrested.  The asphyxia is now complete ;  and
the critical  moment is  arrived  when  life is fast
ebbing at its source,  and not an instant is to be
lost in  resorting  to the most  energetic means for
its recall.
   It is difficult  to assign the  precise period  at
which  resuscitation becomes  impossible ;  much
will depend  upon the mode in which the asphyxia
has been produced, upon the age and constitution
of the individual, and other circumstances here-
after to be noticed.
   Such, then, is  the  usual course of the pheno-
mena of asphyxia when  the abstraction of air has
been sudden and complete.  When more gradually
induced, the  sufferings  are more protracted ; the
painful sense of anxiety is accompanied by various
feelings referred  to the head,  such as  vertigo,
singing in the ears, and scintillations in  the field
of vision.  The  extinction of irritability is more
gradual, and is not attended  with epileptic con-
vulsions.  There is also  less suffusion of the skin
in the face,  but  a more extensive  discoloration
over that  of other parts of the body,  in which red
or livid patches often  arise.
   On inspecting  the body after death from simple
asphyxia, we find  that  it  presents externally the
marks denoting imperfect oxidation  of the blood
.n the  capillary vessels of the skin, which accord-
ingly is dark, and, in some places, purple.  These
livid spots are not unlike those so commonly met
with in bodies that have remained for some time
in  one position  after death  from other causes.
They  may  in  general,  however, be  easily  dis-
tinguished from the different situations which they
occupy in the body :  for the latter description  of
patches occur in the most depending parts of the
skin, and  seem to be the effect of the gravitation
of the blood in the vessels.  This is not the case
with the livid spots arising from  asphyxia, which
appear  to have their seat  chiefly in the  mucous
membrane of the  skin ;  for the corion itself is not
much  affected.  A section of the skin  in these
parts exhibits  numerous points where the blood
has been congested in the vessels at least, if not
extravasated.   The joints are generally rigid in a
greater degree than in other cases of sudden death.
The features of the countenance have an expres-
sion of Dain ;  the eyes are  distended and pro-
minent, and the pupils dilated.
  In the interior of the body the most striking ap-
pearance is the great  accumulation  of blood  that
has taken place  in  the  pulmonary system of
vessels, in the  right  auricle and ventricle of the
heart, and in the great veins which  terminate in
these cavities ;  while on the other hand the left
auricle  and ventricle are  comparatively empty.
The coronary veins  of the heart are rendered re-
markably conspicuous by their turgescence ;  and
this is  also the  state of the principal branches of
the vena cava.   The liver, spleen,  and kidneys
are gorged with blood, which  may be forced out
in large drops by slight compression  of the paren-
chymatous substance of these organs. The blood
itself is thick and dark coloured, and is but rarely
found coagulated.
   The  lungs are in a distended state ; and, if not
restrained by the  adhesions they may previously
have contracted with the sides of  the chest, they
often expand so as to meet, and even overlap one
another over the pericardium, when the anterior
mediastinum is cut  through.   Their colour  is a
dark brown ;  and, like the organs already men-
tioned,  they readily allow,  when  compressed, of
the exudation   of the  blood they contain.   On
opening the trachea, we find its mucous membrane
deeply injected  with  blood ; and this appearance
is still  more strongly marked  as we trace its pro-
gress into the lesser ramifications of the  bronchia.
The surface of the membrane is frequently over-
spread  with a  frothy liquid, slightly tinged  with
blood.   The fibrous  tissue which unites  the car-
tilaginous rings of the trachea and  bronchia is
also injected with blood, and  thereby presents  a
striking contrast to the white  colour of the carti-
lages themselves.
   When the previous  struggle has been violent,
indications are  afforded of fulness in the vessels
of the head :  the sinuses and  veins of the brain
are distended  with blood ; and a  section of the
cerebral substance exhibits an unusual number of
red points ;  an appearance which  is  often accom-
panied  by the effusion of serum in the ventricles.
But in  cases where death has  been attended with
but little disturbance, none of these appearances
are met with, and  all the vessels of  the brain are
in their natural state.
   The  root of the tongue, however, almost always
appears as if it had been injected ;  and its papillae
at this  part are remarkably distended.   The mu-
cous membrane of  the  epiglottis and larynx par-
takes of the affection of that which  lines the tra-
chea, and which has  been already described.
   Theory of  Asphyxia. — Very different  opi-
nions have been entertained as to the true theory
of the phenomena at  present under our considera-
tion.   Before  the chemical effects  of respiration
on the  blood had  been discovered, and  when the
action  of the pulmonary organs in promoting the
circulation was believed to be altogether mechani-
cal, the cessation  of  the motion of the  heart in
hanging or drowning  was ascribed to some mecha-
nical  impediment to  the  transmission  of blood
through the lungs, arresting it in its course, and
preventing its access to the left auricle.   But the
experiments of  Goodwyn  and  others have  suffi-
ciently  proved  that no  such mechanical obstruc-
tion exists ; and that  even after the fullest expira-
tion, the air remaining in  the  air-vesicles of the 
ASPHYXIA.
i91
lungs distends them sufficiently to permit  the
blood to circulate freely through  them.   The fact
may now be  considered  as fully established,  that
the real obstacle arises out of the interruptions to
those chemical  changes which  atmospberic air
produces on the blood  while circulating in the
pulmonary vessels,  and  which  convert  it  from
venous  to  arterial blood.   The  blood  which in
asphyxia thus retains its venous character does,
in  fact, for  a time pass through the pulmonary
circulation, and is conveyed into  the left ventricle,
which propels it through the arterial system.  But
this blood, which is  thus substituted for arterial
blood, has  deleterious properties : it  acts, in  fact,
as a poison on the organs to which it is sent.  The
presence of  this  deleterious agent deprives the
organs of the power of performing their respective
functions;  sensibility,  irritability, together with
all the physical and vital actions depending upon
these powers, are suspended ; and their suspen-
sion, even  for a minute, is fraught with the most
imminent danger to life.  Dr. Goodwyn,  to whom
we are indebted for the first consistent hypothesis
on this subject, had  conceived that venous blood
exerts  no  actually noxious power on the heart
itself, but that in all cases of obstructed respira-
tion the heart  ceases  to contract,  because  the
blood that  passes into it  is an insufficient  stimulus
to its left auricle and ventricle ; although, in  con-
sequence of  a difference in the structure and irri-
table properties of the two  sides  of the heart, the
same blood was a sufficient stimulus to  the right
auricle and ventricle.*   Bichat, however, appears
to have satisfactorily  established  the fact, that the
primary effect of the circulation  of venous blood
is  on  the brain, and  that  this effect  extends,
through the intervention of the brain, to the whole
nervous system.  The  succession of the pheno-
mena of asphyxia plainly demonstrates that loss of
 sensibility  takes place as soon as  this venous blood
has reached the brain, and exists for  some  time
before the  action of the heart is suspended.  This
effect on the brain is manifestly  the source of the
 convulsions  that ensue, and that  indicate the
strong impression made  upon the nervous system.
The patient, as it has been strongly but quaintly
 expressed, dies poisoned by his  own blood.
   The paralysing influence we are describing ex-
tends from the brain  and nerves  to other  parts; it
affects in  particular  the capillary vessels of the
lungs ;  the pulmonary circulation is consequently
checked ; and less and less blood being transmitted
through the  lungs from  the right to  the  left cavi-
ties of the heart, the quantity received by the lat-
ter is at length insufficient to maintain their action.
The contractions of the heart now cease ; its right
cavities remaining full,  while its left cavities are
nearly empty.
   The  cessation of  the action  of the heart was
accounted  for, by Bichat, on the supposition that
it was itself paralysed by the deleterious qualities
of the venous blood,  which, by entering the coro-
nary arteries, penetrated its  muscular  substance,
and destroyed its irritability.  If  we were to admit
this doctrine, however, there  would present itself
this obvious  difficulty in  accounting for the re-
newal  of the contractions of that  organ  on the
  * See his work entitled, " The Connexion of Life with
Respiration."  London, 1788, p. 80, 83.
re-establishment of respiration ; nameiy, that the
very power to which  it must owe the restoration
of its irritability, by tbe propulsion of fresh arterial
blood through the vessels, has, on this hypothesis,
been itself destroyed,  and therefore the means of
recovering it  do not exist.   Resuscitation  from
asphyxia  would, if this were true, be impossible.
But since daily  experience  shows  us that the
heart may be  made to renew its contractions even
some time after they have ceased, we are forced to
conclude  that that organ still retains, under  these
circumstances, a considerable share  of irritability,
ready to  be called into action, when a proper sti-
mulus is  applied.  On the renewal  of the action
of  the  pulmonary capillaries, by which means a
fresh supply of arterial blood is poured into the
left auricle and ventricle, these  cavities are urged
by  their  appropriate  stimulus,  which is that  of
mechanical  distension, again to contract and  re-
new the  circulation.   Arterial  blood being thus
again diffused over the  system, imparts its vivify-
ing influence  to  all the  organs ;  their suspended
functions are resumed, and animation is restored.
   In confirmation of the views  here  given, we
may cite  the  experiments  of Dr. Kay,* and also
those of Dr. Edwards,]-  which tend to prove that
when venous blood is made to circulate  through
the substance of muscles, it contributes  to support
their irritability in a  certain  degree, although less
effectually than arterial  blood.   Admitting,  then,
that the  heart  retains a certain portion of irrita-
bility, sufficient to account for  the renewal  of its
contractions under certain circumstances, it would
appear that the causes of the  cessation of its action
may be resolved partly into a deficiency of supply
of blood to the left ventricle, consequent upon the
paralysis  of the capillaries  of the lungs, which de-
prives them of the power of propelling it forwards ;
partly into its own diminished  irritability, arising
from the direct effect of the entrance of venous
blood into the coronary  arteries ; and partly also
into the participation of the heart with the general
deleterious impression made  on the whole nervous
system, by the  circulation of venous blood in the
brain  and other  parts  of the  system.   So inti-
mately are  all  the vital functions  connected  to-
gether, that it is extremely  difficult to assign to
each of these  causes the real share which v it  re-
spectively has in the production of the whole of
the observed   effect.   There can be little doubt
that any  one  of them would  of itself be sufficient
to  arrest  the  movements of  the whole machine ;
and that  the derangement  of any  one of the  func-
tions which are here implicated, would necessarily
throw all the  rest into  disorder, and destroy the
equilibrium of the system.   The first, in point of
time, in the series of phenomena consequent  upon
the suspension of the arterializing process, is the
affection  of the brain.   Were this  the sole  effect
directly  produced by  the want of oxygen, ot
superabundance of carbon in the blood, then might
asphyxia be ranged under the head of  apoplexy ,
and  tbe  subsequent failure  of  the circulation
would be a consequence of  the impaired energy
of the nervous powers which maintain the energy
  * See Edinburgh Medical and Surgical Journal, vo.
xxix. pp.  -42 and 4G, [and  The  Physiology, Pathology,
and Treatment of Asphyxia. Lond. 1834.]
  t De l'lnrluence des Agens Physiques sur la Vie. Pa'
i. ch. i. and part iv. ch. iv. 
192
ASPH
YXIA.
of the heart.   But this  can scarcely be admitted
to be the sole cause of death; because the motion
of the heart in  asphyxia is arrested much sooner
than it ever is in simple apoplexy.  We find, in-
deed, that in the latter disease the heart continues
to beat for many hours, or even  days, after  the
destruction of the faculties of sensation and of
consciousness; and  it appears at length to  stop
principally in consequence of the cessation of
breathing,  which always  takes place  when  the
abolition of the powers of voluntary motion  has
proceeded  a  certain length.  So that, in fact, it
may more  properly be said that apoplexy proves
fatal by inducing a state  of asphyxia, than  that
asphyxia is merely  a species of apoplexy, as it
has been erroneously classed in some systems of
nosology.
   The chief seat of the stagnation of the blood
in asphyxia is the minute pulmonary vessels; and
this may be inferred from the fact  that the whole
of that part of the vascular system, and  apparatus
connected with it, which precedes it in the order
of circulation,  is distended with  blood.   Such,
we have seen, is the  condition in which the pul-
monary arteries, the right ventricle and auricle of
the heart, the venae cavae, and all  their branches,
are found after death.   On the other hand, those
portions  of the vascular apparatus which  follow
this  point  in the order  of  circulation, are  nearly
empty of blood ; namely, the left auricle and  ven-
tricle, the aorta, and all its  branches  and rami-
fications.   The inquiry into the condition  of the
pulmonary capillary vessels, which this stagnation
of the blood in them  implies, would open a wide
field  of discussion ; for it would involve the dis-
puted question of the nature of the action  of the
capillaries,  the power they possess to propel their
contents, and the extent in which they contribute
to carry on the circulation.  Without  entering
into  this discussion, for  which this is not the pro-
per place, it will be sufficient to state that, by the
expression  of paralysis of the capillaries of the
lungs, we have merely  meant to denote that  con
dition which renders them incapable of transmit-
ting  onwards the blood which is sent to them.  It
might certainly be expected that, on the interrup-
tion  to  the chemical changes which  the blood
usually  undergoes  in  the lungs, these vessels
would be the first to suffer  from any noxious pro-*
perty which  the blood might thereby acquire ;
since they are more intimately in contact with it,
and more extensively exposed to its action. While
we admit, however, that this affection of the  pul-
monary  capillaries  is one of the principal causes
of the cessation of  the heart's action, it is  at the
same time  very probable that the diminution of
its energy, occasioned by the circulation of venous
blood through its substance, contributes in a great
degree to the same effect.   It is of great import-
ance, in a practical point of view, to obtain  a  true
theory of asphyxia ; since the success of the mea-
sures we mvay adopt for the purpose of restoring
suspended  animation will  depend  on its correct-
ness.
   [Experiments have been  since instituted, which
lo not accord in all respects with those of Dr.
Kay   Dr.  Keid concludes, that  the  suspension
of the functions of the encephalon is chiefly, if not
entirely dependent upon the circulation of venous
blood in  the  arteries.   He does  not,  howeve.,
maintain, that venous  blood  exerts  any noxious
influence upon the functions of the nervous texture.
but believes, that the effects are solely attributable
to the want of the proper excitation of the organ ■
for, when the circulation of arterial  blood is re-
newed, its functions rapidly manifest themselves,
provided this  be done  within  a given time.  He
believes, that the order  of succession  in which the
vital processes are arrested in asphyxia is as fol-
lows :—The venous blood is  at first transmitted
freely through the lungs, and reaches the left side
of the heart, by  which it is driven through all the
textures of the body.  As the blood becomes  more
venous, its  circulation  through the vessels of the
brain deranges the sensorial functions, and rapidly
suspends  them,  so  that  the  individual becomes
unconscious of  all  external  impressions.   The
functions of the medulla oblongata are enfeebled
about the same  time that the  sensorial  functions
are arrested, but are not fairly suspended for some
time  longer.    Immediately  after the  sensorial
functions are suspended, and the blood has become
still more venous, it is  transmitted with difficulty
through  the capillaries of the  lungs, and, conse-
quently, begins  to collect in the right side of the
heart.   A  smaller quantity of blood must  now
necessarily reach the left  side of the heart; and
the diminution of the quantity  of blood sent along
the arteries, conjoined with its venous character,
and the  ultimate arrest of the circulation, being
sometimes incompatible with the manifestation of
vitality in the other tissues of the body, general
death is sooner or later induced.  This view con-
sequently ascribes the phenomena  of  asphyxia
chiefly to the circulation  of blood that has not
been oxygenated in the lungs, or, in  other words,
of blood devoid  of the proper excitant agency, and
subsequently to arrest of the blood in the capilla-
ries of the lungs, which occasions the flow of arte-
rial blood towards the left heart to be arrested.
As a consequence of the want of the stimulus of
distension, the left cavities lose their contractility ;
—the right  auricle, which continues  for a time to
receive blood by the venae cavae, being  the ultimum
moriens.  The  nervous,  muscular, parenchyma-
tous and other tissues, no  longer receiving a sup-
ply of arterial  blood, cease, also, to  act;  but those
organic functions, which are effected •in  the capil-
laries of the general system, as  nutrition, secre-
tion and calorification, yield last; circulation con-
tinuing in  the  capillaries for  some  time after it
has ceased in  the larger vessels.]
   Pahticular  kinds  of Asphyxia.—The first
class of causes producing asphyxia we have stated
to be the deficiency of oxygen in the air respired.
These may  again be divided into three heads.
   First, Excessive rarefaction of the air.   Ani-
mals have often, for the sake of experiment, been
destroyed by being placed under the receiver of
an air-pump ;  and if the process has  not been too
long continued,  the mere re-admission of air is
generally  sufficient  to  restore  life.   The pheno-
mena they exhibit under these circumstances do
not appear to  differ, in  any notable manner, from
those which animals of the  same kind present
when suddenly  plunged  into  an atmosphere of
gas of the ordinary density containing no oxygen.
With regard to the human body, the  only way in 
ASPHYXIA.
193
which it is ever probable that death can arise from
the excessive rarefaction of the atmosphere, is in
the case of ascent to very elevated regions, as on
the summits of mountains  or in balloons.  But,
although the muscular  strength is  found to  be
much enfeebled under these circumstances, it ap-
pears never to amount to a degree that is danger-
ous to life.
   Secondly,  The  respiration  of gases,  which,
although  they  contain  no  oxygen,  appear  of
themselves to have no positively injurious opera-
tion on  the system.  To this class belong  hydro-
gen and azotic gases.  It  is found, accordingly,
that the voluntary endeavour to respire these gases
for a short time is unattended with danger.  This
has been proved  very satisfactorily by  the experi-
ments of Sir Humphry Davy,  and many  others.
The deviations from  this general result, which
have been observed by some experimentalists, may
readily  be accounted for by impurities  in the gas,
and more particularly by  the admixture of carbonic
acid gas.  In this way we may explain the obser-
vation of Sir Humphry Davy, who reports that he
experienced a  greater  sense of suffocation from
respiring azotic than hydrogen gas.  The  pheno-
mena exhibited by animals confined  in either of
these gases are those of simple asphyxia.
   Thirdly, The respiration of  gases having posi-
tively deleterious  effects upon  the  system.   To
this head may be referred carbonic acid and car-
buretted hydrogen gases, which produce no visible
changes on the animal textures ;  and also various
other gases, which exert an  immediate destructive
chemical action on the parts with which they come
in contact:  of this latter kind  are chlorine, sul-
phureous, and nitric acid gases, ammoniacal  gas,
&c.
   Asphyxia from the respiration of car-
bonic  acid gas.—The  instances  of  persons
losing their lives  from respiring air charged with
carbonic acid gas, are very frequent. The diffusion
of this  gas through a large  mass of air is exhibited
on a great  scale in mines, where it is  known by
the name of the choke damp.   From  its greater
specific  gravity, compared  with that of  common
air, it is always found  in the lowest parts of the
mine, and is on that account dislodged with great
difficulty.  In volcanic districts, streams of car-
bonic acid are often known to issue in considera-
ble quantities from fissures in  rocks ; a remark-
able instance of  which  occurs  in the celebrated
Grotto del Cane, in the neighbourhood  of Naples;
being so named because dogs  are kept  near the
spot, for the purpose of exhibiting to travellers the
effects of this  air upon these animals.  Their
heads are held  in the gas,  which onlyT rises  to a
certain level in the grotto, till asphyxia is induced;
from which state they generally soon recover, after
being removed  into pure  air and  plunged  into
water.   The  same gas  is  sometimes found  to
occupy  the bottoms of wells or vaults; especially
if they  have been  allowed  to  remain for a long
time unopened.   Large vessels, where  the vinous
fermentation has been carried on, such as brewers'
vats, become often filled  with carbonic acid, ren-
dering it highly dangerous for persons  to descend
into  them without having  previously ascertained
the  respirability of the air they contain.  This
may always be done  by letting down slowly a
  Vol.  I. — 25                          k
lighted candle.   If the  candle continues to burn,
the air that surrounds it is capable of maintaining
life ; and the place at which the candle goes out
will show the height to which the foul air reaches.
   The  vapour  of  burning charcoal,  which is
formed by the combination of its carbon with the
oxygen of the atmosphere, consists chiefly of car-
bonic acid gas, together with a certain small  pro-
portion of carburetted  hydrogen, depending upon
the presence of moisture  in the charcoal.  This
vapour has often been the cause of suffocation to
those who have been exposed to its influence.  It
has  often happened that  persons have gone to
bed  in a close  room in which a charcoal fire was
kept up through the whole of the night, and have
been found dead in the morning.  The  same fatal
effects have  resulted  from  breathing the air of a
lime-kiln, by persons  who  have approached too
near;  or who, having  fallen asleep on the side of
the kiln, have had the fumes which issued from it
blown upon them in consequence  of a change of
wind.
   The effects of the respiration of carbonic  acid
gas are somewhat different  according as it is in a
concentrated or diluted state.   If an attempt be
made to breathe it in its pure or undiluted state, it
is found  to make so powerful an impression on the
throat as immediately to  excite a spasmodic  con-
traction of the glottis, which remains completely
closed, so that  no portion of the gas can be made
to enter  into the bronchi, in spite of every effort
of volition.   Sir Humphry Davy introduced into
a silk bag four quarts of well-washed carbonic acid
in a state of great purity,  and  after a complete
voluntary exhaustion  of his lungs attempted to
inspire it.  It communicated a strong acid taste to
the mouth and fauces, and a sense of burning at
the top of the uvula.  It was in vain that he made
the most powerful voluntary efforts to draw it into
the trachea :  at the moment that the epiglottis was
raised a little, a painful stimulation was induced,
so as to close it spasmodically over the glottis; and
the same thing happened in repeated trials.  (Re-
searches concerning Nitrous Oxide, &c. p. 472.)
A similar trial of the effects of breathing this gas
had  been long  ago made by Pilatre de Kozier,
(Journal de Physique, xxxviii.  p. 418,) who, for
the purpose, went into a brewer's tub while it was
full of carbonic acid evolved by fermentation.  His
first sensation was increased heat and perspiration,
attended  with  itching, especially  in  the  eyes.
Whenever he attempted to  breathe, he was  pre-
vented  by a violent feeling of suffocation.   He
sought for the steps to get out, but as he was doing
so, the necessity for breathing increased, he became
giddy, and  felt a tingling  sensation in  his ears.
As soon as his  mouth reached the air he breathed
freely,  but for  some time could not distinguish
objects; his face was purple, his  limbs were weak,
and  he understood with difficulty what was  said
to him.   He soon  recovered, however,  from this
state.  This experiment was often repeated :  and
he always found, that  as  long  as he  remained
without attempting to draw his breath, he could
move without inconvenience; but  every attempt
to breathe instantly brought on the feeling of  suf-
focation.
  Persons exposed by accident to the influence of
an atmosphere  of tbis kind seldom  escape thw 
194

danger in which it places them.  It is not uncom-
mon, for example, to hear of a person descending
into a brewer's vat or into a vault, containing a
stratum of carbonic acid up to a  certain height,
and falling down in an instant, as if shot, without
the slightest struggle.  Another person  going  to
his assistance, and, of course, warned by his exam-
ple, prepares  himself to resist the  fatal influence
of the gas; yet with every precaution he  can take,
and with every provision for being pulled up by
assistants by means of ropes, we will suppose, tied
round  him for that purpose, he also is seen sud-
denly to drop, without his even being able to make
the preconcerted signal.   A third person descends
and undergoes the  same fate.  It has thus often
happened that several persons in succession have
fallen victims  to  their humanity in endeavouring
to rescue others from so  perilous a situation.
   These facts seem to  prove, in  the most une-
quivocal manner, the positively deleterious pro-
perties  of this gas,  which produces  a sudden
abolition of all the animal functions, without even
being  applied  to  any considerable extent of the
internal 'pulmonary  surface.   The  immediate
symptoms which it excites are, sensations referred
to the  head, pain, giddiness, a feeling  of debility,
which  mark the strong impression that is made on
the sensorium ;  and the  whole nervous  system is
doubtless in  like manner powerfully affected.  It
has been alleged also that the muscles of animals
destroyed by immersion  in irrespirable gases, lose
more of their irritability  than happens with those
which have been hanged or drowned.
   The symptoms  produced   by  the  continued
respiration of carbonic acid gas mixed with atmo-
spheric air, partake much of the character of apo-
plexy.  We  may still observe  that the primary
effects  appear to be produced upon the brain.
Headach, vertigo, slight nausea,  heaviness, and
irresistible  inclination to  sleep,  mark  the first
stages  of this  affection.   The patient passes from
sleep to coma, from which it is impossible to
arouse  him ;  the pupils become dilated,  the respi-
ration  stertorous.  The  countenance  is flushed,
the lips are   livid ; the  pulse  is  often full and
strong.  There is no gasping for breath, no painful
struggle, no unutterable  anxiety,  no  convulsion.
The transition from life to death is calm  and tran-
quil, and the functions and powers of the system
are one by one extinguished, as if  in obedience to
the  resistless   spell  of  some  potent enchanter.
Such  was the mode of death  chosen by  the
younger Berthollet when bent  upon suicide.   He
shut himself  up in a small closet by the side of a
chafing-dish of burning charcoal, carefully closing
every aperture through which the poisonous fumes
could  escape ; and quietly sate himself  down  to
register  the  successive  feelings  as  they  arose.
They were such as attend the operation  of a nar-
cotic.   The description  of them  which he had
written bad evidently been interrupted by a pause;
then followed an almost illegible word ; tbe pen
must then have dropped from  his hand  ; he pro-
bably never stirred afterwards.
   The particulars of two interesting cases of ex-
posure to the vapour of burning charcoal, with the
details of the treatment adopted, are given by Dr.
F3abington in the first volume of the Medico-Chi-
rurgical Transactions (p. 83) ; and  they are ren-
fXIA.

dered highly instructive by the judicious reflections
which  accompany  the narrative.  He  observes
that the fatality of this gas to the different classes
of animals  is, in  general, in  proportion  to  the
more complicated system  of their  organization.
On the human constitution, according to the  pe-
riod of exposure, and the degree of concentration,
its  effects vary through all  the shades  of giddi-
ness, pain of the head, anxiety, depression of  the
powers of life, impeded respiration, loss of volun-
tary motion and  sensation, to  the  complete  sus-
pension of  respiration and circulation.
   The power of resistance to this narcotic agency
appears to be less in youth than in a more mature
age.   The  two persons above mentioned, the one
a man  thirty-eight  years of  age, and the other a
boy of thirteen,  had gone to  bed  in a room in
 which a chafing-dish of burning charcoal  had been
placed  at the foot of the bedstead.   In the morning
 the boy was found  completely dead, having appa-
 rently gone off without a struggle ;  but  the man
 was in an apoplectic state, and by the employment
 of proper means eventually recovered. A parallel
 case is related by Bourdon, (Principes de Physio-
 logie  Medicale,  partie ii.  p. 650,)  of a woman,
 thirty-five  years of age, who, being reduced  to a
 state of desperation by jealousy and  misfortunes,
 had  taken  the  resolution  to destroy her own  life
 together with that  of her daughter, a girl of five
 years of age.  Having shut herself up with her
 child  in a  closet with a large  brasier of burning
 charcoal, the bodies were, some time after, found
 extended on the floor.  The mother was recovered
 without  much difficulty;  but none of the means
 that  were  tried  could elicit from  the child  the
 smallest sign of life.                 i
   Asphyxia from  carburetted hydrogen
 gas.—The respiration of  carburetted hydrogen
 gas is peculiarly fatal to life, appearing to act as a
 direct  sedative,  immediately destroying  the vital
 powers.  A bold attempt was  at one time made
 by Sir Humphry Davy to breathe this gas in its
 undiluted state : he took three  inspirations, which
 very nearly killed him ;  (see his Researches con-
 cerning  Nitrous Oxide,  p. 468.)   Even, when
 mixed  with  common  air, it has a singularly  de-
 pressing influence  upon the  powers of life. The
 extensive introduction of  this gas, within these
 few years, for the  purpose of lighting the streets
 and  public  buildings, is  likely to lead to the fre-
 quent occurrence of accidents of this nature.
   Gases of a more  compound nature,  and  still
 more deleterious properties, are often emitted in
 great abundance from putrefying animal and  ve-
 getable substances,  and  especially  from privies,
 sewers, and burying-grounds.  A striking account
 of the  remarkable effects produced by the exhala-
 tions from opening  graves has been given by Four-
 croy.  It appears, from the report of the grave-diggers
 who were examined on the  occasion referred to,
 that those men who happened to be standing imme-
 diately over a corpse, of which tbe abdomen was
 suddenly struck  into by a pickaxe, often fell down,
 on a sudden, in  a state of apparent death ; while
those who were at a greater distance, and received
the noxious effluvia in a more  diluted state, were
attacked with   nausea, giddiness,  tremors,  and
faintness, which symptoms  continued for some
hours.
ASPH 
ASPH
YXIA.
195
  Asphyxia from Drowning.—In our classi-
fication of the causes of asphyxia, submersion  or
drowning forms the second head.
  The general account we  have already given of
the  symptoms  and progress of asphyxia  in its
simpler forms, supersedes the necessity of entering
into a detail of  all the  phenomena attending as-
phyxia from submersion, and it  will only be requi-
site to notice those that are peculiar to this mode
of inducing the affection.
  The symptoms and appearances  met with  in
drowning vary considerably, according to the state
of the individual at the time of submersion, to his
ability to make efforts to save himself, to accidents
that may happen  to him after falling into the wa-
ter, to the depth and the temperature of the water,
and other circumstances.
  Let us first take the simplest and most ordinary
case of a healthy  individual, in perfect possession
of his faculties, falling into the water from a cer-
tain height,  and descending,  from the impetus
given by the fall,  to some depth below the surface.
He quickly rises again to the surface of the fluid,
buoyed  up  by difference  in specific gravity be-
tween his body and the water, and also frequently
receiving additional support from  air entangled  in
his clothes.   If able to swim, he supports himself
at the surface as long as his strength lasts him ;
when that fails, he is in the situation  of a person
who is unable to swim ; in either case he then
performs movements at random with his arms and
legs, and, while sinking to the  bottom of the wa-
ter, involuntarily grasps  any   object  that  comes
within the reach of his hands.  From the irregu-
larity with  which these actions  are performed, he
appears  at the surface, and  again disappears, seve-
ral times successively. Whenever the mouth hap-
pens to be out of the water a hasty gasp is made,
by which water as well as air goes down the throat,
and, exciting cough, is  partly  expelled from the
trachea ; but, by the same effort, the  air that had
been taken in at the same  time is also rejected.
This creates a fresh demand for air ;  and, as soon
as an opportunity occurs, another and more  hur-
ried attempt is made to satisfy it. This very eager-
ness tends but to  defeat its  own object; for if the
head be only half raised above the  surface, the
chance is that water is again taken in by the effort
to inspire.   It is  again rejected by the  spasm of
the glottis,  and the consequent  convulsive  action
of the muscles of the throat; and in the  painful
conflict of the two contending elements some wa-
ter is swallowed, and passes into the stomach. All
these violent efforts tend to determine blood to the
head; and  that blood, partaking  of the  venous
qualities, puts an  immediate stop to the functions
of the  brain.   Sensation  and  voluntary  motion
cease; the body sinks  motionless to the bottom
of the water, the  pressure of which on  the sides
of the  chest finally expels a  portion of the air
that still remained in the lungs when the last effort
was made.
  The account of these phenomena, given by Dr.
Goodwyn, is so clear and  concise that we shall
give it in his own words :—" When an animal,"
says that author, (Connexion of Life with Respi-
ration, p. 3,) "is immersed  in water, his pulse be-
comes weak  and frequent; he feels  an anxiety
about his breast, and stinggles to relieve  it; in
these struggles he rises towards the surface of the
water, and throws out a quantity of air from his
lungs.  After this, his anxiety increases ; his pulse
becomes weaker; the struggles are renewed with
more violence ; he rises towards the surface again,
throws out more  air from  his  lungs, and  makes
several efforts to  inspire ; and  in some  of these
efforts a quantity of water  commonly passes into
his mouth.  His  skin then becomes blue, particu-
larly about the face and lips ; his  pulse gradually
ceases ;  the sphincters are relaxed ; he falls down
without sensation and without motion."
   The following  is  the account given by the same
author of the appearances that present themselves
if the body be immediately opened.
   1. The  external  surface of the  brain  is of a
darker colour than usual; but the vessels are not
turgid with blood, nor are there any marks of ex-
travasation about them.
   2. The cavity  of the lungs contains a consider-
able  quantity of frothy fluid ;  and the pulmonary
arteries  and veins  are filled with black  blood
throughout their  whole extent.
   3. The right auricle and ventricle  of the heart
are still contracting and dilating;  the left sinus
venosus and auricle move feebly ;  but the left ven-
tricle is at  rest.
   4. The right auricle and ventricle are filled with
black blood, and  the left sinus venosus  and left
auricle also ; but the left ventricle  is  only about
half  filled with the  same coloured blood.
   5. The trunks and smaller branches of the arte-
ries proceeding from the left ventricle  also contain
a quantity  of this black blood.
   To this description we  may add  the following
particulars.   The face  is in general pale, though
slightly  livid ; the mouth contains a good deal of
frothy fluid ; the tongue  is  often  protruded be-
tween the teeth.  The same frothy liquid is found
in the trachea, bronchia, and air-cells of its lungs,
as also  some water, the  quantity of which varies
much in different instances.   The lungs  are of a
violet hue, and the blood they contain is fluid, but
less in  quantity than in  cases of asphyxia from
carbonic acid gas. ,  The left ventricle of the heau
is never completely  empty ;  the quantity of blood
found in it being generally about half that con-
tained in  the  right ventricle, (Coleman  on Sus-
pended  Respiration, p. 248.)   Some blood is also
found in the aorta.   In the stomach  there is al-
most always found  some portion  of the fluid in
which the person was drowned, and the  quantity
is sometimes considerable.  The vessels  of the
brain do not exhibit any particular appearance of
distension.*  The air contained in the lungs has
nearly lost the whole of its  oxygen.  This was
the uniform result of a  great  number of experi-
ments made by Dr.  Berger, of Geneva, on the air
that  was expelled from the lungs a short time after
immersion.]-
   Great discordance exists  in the representations
of different authors  as to  the  quantity of water
found in the lungs and stomach of drowned men
and animals, and its influence on  the destruction
of life.  De Haen was of opinion  that death is
  * Observations on Apparent Death  from Drownin"
&c.  By James Curry, M. D.
  f Essai Physiologique sur la  Cause de l'Asphyxie \ut
Submersion.  Par J. F. Berger, de Geneve, 1805. 
196
ASPHYXIA.
occasioned by water  flowing  into the lungs, and
stopping the passage of the blood in the vessels.
Dr. Cullen stated, from the result  of many dis-
sections, that there is often no water found in those
situations; and  never  any quantity likely  to  in-
jure the  organization  of these  parts, (Letter to
Lord Cathcart.)   Dr. Goodwyn's investigation of
this subject is  exceedingly satisfactory, and seems
to have  laid  this  question entirely at rest.   By
drowning animals  in a coloured liquid,  such as
ink, he ascertained that the quantity of fluid that
really entered  the  body was  infinitely less than
was adequate to produce death.  He drowned other
animals in quicksilver, which, from  its not mixing
with the animal fluids, could  be more  easily col-
lected, and its  quantity determined.   He  thus  as-
certained that only five drachms of the fluid in
which a cat was immersed entered its lungs while
drowning ; and  in order to determine whether or
not this could  occasion the death  of the  animal,
he made the following  experiment: having con-
fined a cat in an erect posture, he  made a small
opening in its  trachea, and  introduced through it
two  ounces of water into  its  lungs.  The only
effects it produced  were a temporary difficulty of
breathing and weak pulse ; but these symptoms
soon subsided, and the animal lived several hours
afterwards without experiencing any further in-
convenience.  At the end of this time it was stran-
gled, and two ounces  and a half of water were
found  in the  lungs.  Similar  experiments were
made with other fluids, and with nearly the same
result.   Hence  Dr.  Goodwyn  concluded that, in
drowning, a small  quantity of water does usually
pass into the lungs;  that it enters during  the
efforts to inspire, and, mixing with the pulmonary
mucus, forms  a  frothy fluid ;  but that the whole
of this fluid is insufficient to produce the changes
that take place in drowning,  (Connexion,  &c, p.
 19.)   The experiments of Dr. Goodwyn on these
points have been since confirmed by Mr. Kite and
Mr. Coleman.   Professor Meyer has also investi-
gated the same  question by  employing water in
which hydrocyanate of potash had been dissolved,
and testing the fluid found  in the lungs  with the
muriate of iron, (Medical Repository, vol. iii. New
Series, p. 436.)
   We have hitherto supposed the person to retain
his self-possession during the first moments of his
finding  himself in  danger  of drowning : but it
may^ happen that he was intoxicated  at  the time
he fell into the water;  or else the sudden impres-
sion of cold, or  the surprise and shock may have
overpowered his faculties, and may have occasion-
ed immediate  syncope.   It may also happen that
in the fall his  head has struck against some hard
body, and he may be stunned by the blow.  In all
these  cases, there is no struggle whatever;  the
body at once sinks passively  to the bottom, never
more to rise.   Here it is evident that all the effects
already described as the result  of a struggle will
not take place ;  and the only appearances  observ-
ed  after death will be those  of simple  asphyxia.
Paleness will be seen in the face as well  as in the
rest of the body ;  the trachea will merely contain
a little water, but no froth ;  the lungs will be but
little  distended, and will preserve their natural
colour ;  and there will be no great inequality in
the comparative quantities  of blood contained in
the arteries  and the veins ;  and no fluid will be
found in the stomach, but what was contained in
it at the time of submersion.
   We may  also suppose other instances in which
this sudden  syncope, or  abolition  of the cerebral
faculties, may occur after a momentary struggle;
in which cases  the phenomena  already described
will have been  in part produced, and the. further
changes prevented from  taking place.   All these
considerations  are  of great importance in their
relation to many  questions  of medical jurispru-
dence.
   The great diversity that may take place in these
and other circumstances will enable us, perhaps,
to explain the differences that are  met with in the
time  during which the  body may remain under
water, compatibly  with the possibility of restoring
life.  If the submersion have not exceeded five
minutes, and no blow against  a  stone, or other
violence has occurred to  complicate the effects, our
efforts at resuscitation, if properly  conducted, will
generally be successful.  After a quarter of an
hour, recovery  is not very common ; after twenty
minutes, or half an hour, it may be considered as
hopeless.   The longest period recorded in the Re-
ports of the Humane Society is three quarters of
an hour.   On  the other hand, some,  who have
only been a few minutes under water,  cannot be
restored to life  even by the prompt application of
the proper means.
   It appears from the first report of the establish-
ment for the recovery of drowned  persons at Pa-
ris, that out of twenty-three cases restored to life,
one had been  three quarters of  an hour under
water, four  had been half  an hour, and  three a
quarter of an  hour; the rest being for a much
shorter time.*
   The habit of being under water, as  in the case
of professed divers, may  enable a person to remain
in that situation  longer  than he otherwise would
be able to do;  but its power will  not go far.  The
Indian divers  employed in the pearl-fishery are
said to be capable of remaining three, four, and in
some cases  even five minutes without injury.  (See
Percival's History  of Ceylon.)   The  numerous
cases on record in which it  is alleged that life has
been  restored   after being   several hours under
water are totally unworthy  of credit.
    Asphyxia from strangulation.—The third
division of the  causes of asphyxia  comprehends all
those that prevent  the access of air to the lungs,
whether by suffocation or strangulation.  The
most  common of  these is  a ligature  round the
neck, as in the case of hanging.
    Considerable variety is observed in  the length
 of time during which  vitality continues  while
criminals are  suspended from  the gallows; the
 differences  depending, in a  great  measure, on the
 mode in which the rope  is adjusted  round the
 neck, the height and  suddenness  of the  fall, and
 other circumstances of violence attending the exe-
 cution.  Much also will depend  on the peculiar
 constitution and previous bodily  condition of the
 individual.   Convulsions of an epileptic character
 very generally  supervene on the loss of sensibility,
 which, if the closing of the  trachea be complete, as

   * Detail des succe.s de l'etablissement que la Villede
 Paris a faite en faveur des personnes nov6es   Paris,
 1773, quoted  by Dr. Good.               '  ' 
ASPHYXIA.
197
it generally is in consequence  of the  strong pres-
sure of the rope, very speedily follows the exclu-
sion of air   The face is always turgid, and suf-
fused  with livid blood.   This swelling and tur-
gescence extend also to the shoulders, arms, hands,
and chest, which are of a livid hue.  The eyes are
generally open, and  projecting, and the vessels of
the conjunctiva distended with blood.  The tongue
is frequently thrust out of the mouth, and wounded
by the convulsive action of the jaws; and a bloody
mucus issues, in consequence, from the mouth.
   The distortion of  the features, and  other marks
of strong muscular  action,  are  evidently  conse-
quences  of the violent struggles of the sufferer,
and are proportional  to the irritation excited in tbe
brain.  The  muscles which raise the  shoulders,
and assist the muscles of inspiration, are strongly
contracted.   The other muscles of  voluntary mo-
tion,  instead  of being rigid, are more relaxed than
 usual;  so  that the  limbs exhibit more flaccidity
 than  in cases of tranquil death.   The mark of the
 cord  will always be  evident round the neck, form-
 ing, when the person has been hanged up alive, a
 livid  depressed circle.  Frequently we find patches
 of ecchymosis on the surface of the upper part of
 the trunk and superior extremities.   The  fingers
 are bent, the nails  blue, and  the hands firmly
 clenched.  From the relaxation of the sphincters,
 the urine and faeces are often involuntarily expelled.
 Erection of the penis and emission of semen also
 frequently take place from hanging.
   It  is evident, from all  these circumstances, that
 the struggle  is usually more intense in this mode
 of death than in drowning.   This  happens more
 especially when, from the inaccurate adjustment
 of the rope, from rigidity of the  cartilages of the
 larynx, or from any other  cause,  the trachea is
 imperfectly closed :  for, in that case, a small cur-
 rent of air may still  pass, and, though insufficient
 to  support life, may contribute to  prolong the
 sufferings  and  struggles  of the  victim.  This is
 often observed  in   those who  voluntarily hang
 themselves, and who frequently suffer much be-
 fore  they die, in consequence  of  their inexpert
 mode of executing  their purpose ; and in whom
 we consequently find the cheeks,  lips, eyes, and
 tongue  particularly  swollen and prominent.   In
 the same proportion  as we meet with these  indi-
 cations of a more  protracted death, we find the
 lungs less gorged with blood, and the blood about
 the heart more equally distributed among its cavi-
 ties and great vessels.  For, in consequence of the
 admission of even a small portion of air into the
 lungs, the heart is enabled to keep up the circula-
 tion for a longer time, and is only more gradually
 overpowered  ; while, at the same time, the pres-
 sure of the rope on  the jugular veins in the neck
 obstructs  the return of  the blood from  the head,
accumulates  it in the vessels of the face, and gives
rise to the  appearances of apoplexy.
   But wherever the  obstruction  of the trachea has
been  complete, there is no evidence that death by
hanging is the consequence of apoplexy :  and, in
fact, when  the executioner is sufficiently expert in
his task, death is too suddenly induced to admit
of an  accumulation of blood sufficient for producing
apoplexy.  De Haen ascertained, from numerous
experiments on dogs, which he hanged and  opened
as soon as they were dead, that no marks of apo-
plexy were to be found in the brain.
   The  following  experiment,  performed  many
years ago  by  Dr. Monro, Senior, of Edinburgh,
proves incontestably that the immediate cause of
death in hanging is the exclusion of air  from the
lungs.  A  dog was suspended by the neck with a
cord, an opening having previously been made in
the trachea below the place where the cord was
applied, so  that air could pass into  the lungs as
freely as in ordinary respiration.  After  hanging
in this state for three quarters of an  hour, during
which time the circulation and the breathing went
on as usual, he was taken down, and appeared not
to have suffered  materially from the operation.
The cord was  then shifted  from above to below
the opening made into the trachea, so as totally to
prevent the ingress of air into the lungs ; and the
animal  being  again  suspended, was  in a  few
minutes completely dead.  (Curry, Observations,
&c.  p. 71.)
   It is very probable, however, that the degree of
obstruction to the  circulation  occasioned  by a
tight ligature on the neck, which presses upon the
jugular veins, has a considerable share in hasten-
ing the period at which death would  take  place
were it dependent on the  mere  interruption to
breathing : so that, from this  double cause, the
punishment by hanging, if  dexterously executed,
is probably unattended with much pain.  By the
violent means often employed in the execution of
criminals in this country, it may, indeed, happen
that another  and more suddenly fatal injury  is
produced, namely a dislocation or fracture of the
cervical vertebrae.  We have reason  to believe,
however, upon good authority, that such accidents
are rare, even when on a public scaffold a hardened
criminal leaps from the gallows to obtain a quick
termination to life ; and it can hardly  ever occur
in cases of suicide.  It is evident that, were any
fracture or luxation of the vertebrae of the neck to
take  place, immediate death  would ensue, and
would preclude all possibility of recovery, however
promptly assistance might be afterwards  afforded;
whereas instances have been recorded of victims
to the law  having been recovered by inflating the
lungs after the body had been cut down.
   Dr. Plott, in his Natural History of  Stafford-
shire,  (page 292,) relates that in the  reign of
Henry  VI. a  woman  of the name of Snetta de
Balsham, after having been  hanged  according to
the sentence of the law, and cut down after being
suspended  a whole night, was  found  to be still
alive;  in  consequence  of which  extraordinary
escape  she was pardoned by the king.  But  it
appears, from  Dr. Plott's  account, that she owed
her preservation to an  ossification of the larynx,
which kept open a passage for the air.   Attempts
have often  been made to defeat the  object of the
punishment by introducing a silver canula into
the  trachea, previous  to  the execution; but tho
intolerable  irritation excited in so sensible a pari
as the  glottis  by the presence of an extraneous
body, must ever preclude all hope of success from
such a project.   If the  method practised in Di.
Monro's experiment on a dog, were adopted in
the case of a person intended for execution, it might
certainly be attended with a successful result,   h 
198
ASPHYXIA.
is recorded, indeed, that an expedient of this kind
was actually tried in a remarkable case, the par-
ticulars of which are given by Dr. Mahon.  (Me-
decine Legale  et Police Medicale, torn.  iii. p- 62.)
murderous design.  It is  possible, for  example,
that the murdered victim may  have  been first
strangled, and  afterwards  suspended.   If,  there-
fore, we should perceive, on a person found hang-
viectne i^egaie ei ronce jvieuicaie, torn. m. y «—;  '"'~>------    '        ,.  ,-__, „:r„i„„ f„rn,„,i u„
 . .   .     /■ i        - ~              i    „i  :„~ iV.ot there are two distinct circles iormeu hy
A butcher, of the name of Gordon, was condemned  ing, that mere arc i»u           «„„.„,.„„„  ,1/
                                                a cord ;  or deep  impressions  of fingers  on  the
                                                throat;' and if, at  the  same time, the clothes  are
                                                torn, the hair  dishevelled, or other indications of
                                                resistance are observed, we may fairly presume
                                                that violence has been committed by another, and
                                                that it is not  a  case  of suicide.   All indications
                                                of this kind become the subject of serious investi-
                                                gation in any legal inquiry implicating  the guilt
                                                of parties accused  of such crime ; but as they con-
                                                stitute an important topic of medical jurisprudence,
                                                we shall pass them over as being foreign to  the
                                                purpose of this article.
                                                   Among the causes which induce asphyxia may
                                                be enumerated the introduction of foreign bodies
                                                into the larynx or trachea ; such accidents are not
                                                unfrequent, and produce  various degrees of im-
                                                pediment to respiration,  according to  the bulk,
                                                shape, and situation of the  extraneous body. Even
                                                if they do not immediately prevent the ingress of
                                                air, they excite by their presence such violent irri-
                                                tation and  spasmodic action, as are soon followed
                                                by a high  degree of active inflammation, which,
                                                producing  a swelling of the membranes, contri-
                                                butes still further  to contract the passage, and in-
                                                duce asphyxia.  The  nature  and succession of
                                                the  symptoms will,  of course, be very similar to
                                                those  of strangulation;  but  the sufferings  are
                                                more  protracted, the anguish is extreme, and the
                                                extinction  of the powers of life more gradual.  A
                                                person may even live for some days, if the trachea
                                                be only partially obstructed :  if the obstruction is
                                                complete, he  loses all sensation in a few minutes,
                                                and soon after expires. The Greek poet Anacreon
                                                is said to have lost his life in the eighty-fifth year
                                                 of his age, from a grape-stone which stuck in his
                                                throat while luxuriously quaffing some new wine.
                                                   Suffocation sometimes  follows the bursting of
                                                 an abscess which has  been formed in the tonsils,
                                                 and suddenly poured its contents into the larynx.
                                                 Croup occasionally proves fatal by the mechanical
                                                 obstruction which is created by  the adventitious
                                                 membrane that is formed in that disease.
                                                   Asphyxia  is sometimes the result of pressure
                                                 applied to the body in so general a manner as to
                                                 impede not only tbe motion of the ribs, but also
                                                 that  of the diaphragm.   This will happen, for
                                                 example, to a  miner,  buried  completely under  a
                                                 mass of earth that  has fallen upon him.  Death
                                                 will in that case be induced with greater  rapidity
                                                 than from most other causes of asphyxia ;  because
                                                 the pressure will force out nearly the whole of the
                                                 air contained in the chest, and preclude any further
                                                 movement of dilatation or contraction of its sides.
                                                 The circulation is quickly arrested, and no oppor-
                                                 tunity is afforded for the accumulation of blood in
                                                 the venous  system.   The body, accordingly, will
                                                 present no discoloration of the skin, no turgescence
                                                 of the veins, no  engorgement of the  pulmonary
                                                 vessels.  We have here, it is true, represented
                                                 what will happen in an extreme case.   Modifica-
                                                 tions will obviously arise, corresponding to the
                                                 peculiarity of circumstances existing in each, par
                                                 ticular instance, and into the detail of which the
                                                 exposition of these  genetal principles  renders it
to execution,  at  the Old  Bailey, for  highway
robbery,  in  the  beginning of  the  last  century.
Having amassed  great riches by  his  successful
career of crime, he persuaded a young surgeon, by
the hope of  a  great reward, to attempt to save his
life.  The surgeon proposed the plan of making an
opening low down in the trachea, and introducing
through  it  a  small canula.   This  was secretly
accomplished previous to the execution ; the blood
that was effused  in consequence  excited some
suspicion, but being attributed  to a  desperate
attempt  at  suicide, the  circumstance only occa-
sioned the hastening of the hour of his execution.
After the body had hung the  usual time, it was
taken down, consigned to the relations, and quickly
removed to  a neighbouring house, where the sur-
geon  was anxiously waiting to  receive it.  He
immediately drew some blood from the jugular
vein,  and enforced  every  means  calculated  to
restore  animation.  Gordon  opened   his  eyes,
heaved  a deep sigh, but expired  a few minutes
after.  The failure of success was  attributed  to
the great weight of the body, which increased the
violence done to the parts compressed by the rope.
   The  appearances presented  on  opening the
bodies of persons who  have been hanged, besides
the local marks from the pressure of the cord, are
exceedingly similar  to those produced by drown-
ing, and of  which we have already  given a suffi-
ciently  detailed account.  The right cavities  of
the heart, and the  pulmonary vessels, are full  of
blood ; the left cavities and the arteries very nearly
empty.  The principal  difference, however,  is  in
the state of the lungs, which are found remarkably
distended with  air, so  that  they  do not readily
collapse when the thorax  is opened.   There  is,
of course, no  water found in the bronchia or air-
cells,  as often  happens after submersion.   Dr.
Goodwyn ascertained that the  lungs of two per-
sons of ordinary stature, who had died from hang-
ing, contained in the one case two hundred and
fifty, and in the other two hundred and sixty-two
cubic  inches  of air ; whereas the lungs of those
who  die a natural death  contained  only  from
ninety  to  one  hundred and twenty-five  cubic
inches,  (Goodwyn, Connexion,  &c.  sect. iii. p.
 25, 26,) or, taking the mean of four experiments,
one hundred and nine cubic inches.  The reason
of this difference is obvious : persons about  to be
 hanged are under  the  influence  of fear, and will
 therefore naturally make a deep inspiration before
 the cord is tightened on the neck;  and the  pres-
 sure of the  cord on the trachea, when the body is
 suspended,  becomes immediately so great, that the
 air cannot again be expelled.   The absence of this
 obstruction in the case  of persons who are suffo-
 cated in other ways, such as by the  application of
 a pillow to  the face, will account for the difference
 in this respect  in  the  appearances after death.
 These appearances, when death has been produced
 under the circumstances just alluded to, approach
 more nearly to those of simple asphyxia, with  the
 addition, however, of traces of the violence that  has
 oeen done  to the victim in  the completion of  the 
A SPHYXIA.
199
unnecessary to enter.  We shall mention only one
remarkable instance,  in  which a person was  in
great danger of losing his life from inattention  to
the physiological conditions requisite for respira-
tion.   An  athletic black, of  pugilistic celebrity,
had been selected, from the fine, form of his chest,
and well-marked expression of his muscles, as  an
academic model.   It was wished  to obtain a cast
of his body ;  but this  being attempted  at one
operation, and in one entire piece, as soon as the
plaster began to set, he felt  on a  sudden deprived
of the power  of respiration,  and,  to add to his
misfortune, was cut off from the means of express-
ing his distress.   His situation, however, was for-
tunately perceived just in time to save his life,  by
breaking his bonds and releasing him from the
 extreme peril in which they bad  placed him.
   The consideration of the effects of the admis-
 sion of air, or of collections of fluid  in the thoracic
 cavities compressing  the lungs, as also the conse-
 quences of injuries to the spine above the origin
 of the phrenic nerves, or a paralysis of those nerves
 from any other cause, in producing asphyxia, will
 fall more properly under other heads.
    General treatment of Asphyxia___Although
 the suspension of all the vital actions of the system
 which takes place in  asphyxia has originated from
 the temporary interruption  in a single function,
 yet the derangement which has followed  is of so
 complicated a nature, and extends  to so  great a
 number  of important organs, that the mere  re-
 establishment of the  function primarily disturbed
 is not immediately followed by the  restoration of
 the rest, and by  the removal  of  all the mischief
 that has been  created.  The mere introduction of
 fresh air into the lungs cannot at once restore  the
 action of  the heart,  and still less that of the dia-
 phragm, and  the other muscles which are con-
 cerned in respiration, because these muscles  have
 lost either the whole or  the greater part of their
 irritability, in  consequence  of their baving  been
 supplied with venous instead of  arterial blood.
 While our first  and principal object is to bring  the
 blood contained  in the  pulmonary vessels under
 the influence of atmospheric air,  attention must at
 the same time be paid to the state  of the  circula-
 tion, and  to the restoration  of  those powers  by
 which that function, as well  as  respiration, is to
 be carried  on.   This double  object should con-
 stantly be  kept  in view in  all our attempts at
 resuscitation.
    The first of these  objects can be accomplished
 only by the artificial  inflation of the  lungs, and
 this should be done with as little delay as possible.
 The second object is to be attempted by the  judi-
 cious application of stimulants applied to various
 parts  of the body, so as indirectly to excite  the
 powers of the   nerves  and  muscles.   Warmth,
 friction, and electricity are among the most effica-
 cious of these means.  The particular mode of
 their application will depend upon the peculiar
 circumstances  of each individual  case, and  will
 come more properly to be considered when  we
 treat specifically of each kind of asphyxia.   But
 as the most important points in the management
 are common to  all cases, we shall proceed to con-
 sider them in this place, as properly belonging to
 the general view we are now taking of the subject.
 Valuable directions as to the most effectual methods
for recovering persons under asphyxia  have been
collected and published by the Royal Humane So-
ciety ;  of these we shall give an abstract, together
witb such additions as have  been suggested and
recommended by various authorities.
  It should be borne in mind that in all cases of
asphyxia, the first and principal measure  to be
adopted  is the  employment  of artificial  respira-
tion ; but if we have not the means of putting this
into execution, the next measure, in point of im-
portance, if the body be cold, as it generally is, is
the  application  of warmth, which  should be  re-
sorted  to without loss of time : and, as it can be
done without interfering with the  process of in-
flating the lungs, both methods may be employed
simultaneously.
  Several preparatory steps should be taken before
beginning the process for resuscitation. The body
should be stripped of its clothing, and  wrapped in
warm  blankets.  It  should be placed  on its back
on  a table, with the head, shoulders, and chest
somewhat raised ; and supported in that position.
The windows  and door of the  room  should  be
kept open in order to obtain as free a circulation
of pure  air  as possible ; and for the same reason
no  more persons should be admitted into the room
than are absolutely necessary.   Bottles of  hot
water  should be laid below the feet, in the  joints
of the knees, and under the arm-pits, if any cold-
ness is perceived in these parts.  Warmth is par-
ticularly efficacious in restoring the  circulation
when it is applied to the  region of the stomach
Immersing the body in a warm bath has been alsc
recommended,  and may in many cases be advan-
tageous.  Great caution, however, is  to  be exer
cised in the employment  of this,  as  well  as  of
other modes of suddenly  imparting considerable
heat.  The  degree in which it should be applied
so as to  contribute most to the patient's  recovery
will, indeed, depend upon a variety  of circum-
stances which should be duly weighed.  It is well
known that during the healtby state of the system,
while the circulation is vigorous, the temperature
of the body may be raised many degrees above the
natural  standard without injury to the powers of
life; but it appears, on the other hand, from  the
results of experiments on  hybernating  animals,
that when the  circulation of the blood bas ceased,
and the temperature  of the  body has been very
considerably reduced, if heat be then applied either
very suddenly  or in a high  degree,  life is soon
destroyed : whereas, if it be  applied  to the same
animals gradually, and  in a very low degree, tha
vital powers are excited into action, and the func-
tions are soon  restored.   Since the condition of
tbe body in asphyxia, as  Dr. Goodwyn  remarks,
 (Connexion of Life with Respiration, p. 110,) is
very analogous to the state of torpor which pre-
vails in  these animals, and since the  progression
of recovery is also the same, it is not unreasonable
to conclude that heat will produce the  same effects
on the  body in this disease as in  torpid animal?.
To favour the  recovery, then, most effectually, the
application of heat sbould be conducted on the
same  plan  that nature has  pointed  out in  the
awakening  of  hybernating  animals  from  their
state of torpor  ; that is, it should be applied very
 gradually  and  uniformly.   Accordingly it may
be  raised to  98°, hut not beyond 100°. 
200
ASPHYXIA.
  Nothing, however, should divert our  attention
from the means on which we  are principally to
found our hope of  success, namely, the extensive
application of fresh air to the pulmonary vessels.
There  are several ways in  which this may  be
attempted.   The  first  and  simplest mode is to
endeavour  to imitate  as much as possible  the
movements in natural  respiration, by first apply-
ing pressure  to  the chest and  abdomen so as to
compress the lungs, and expel a great part of the
carbonised  air which  they must necessarily con-
tain ;  then removing that pressure, so as to allow
the lungs and the sides of the chest to recover
their former dimensions by their natural elasticity.
In so doing  they  will necessarily draw in fresh
air through the trachea.  By repeating this double
operation  at  short intervals, so as to  imitate the
natural periods of  inspiration and expiration, we
may give the patient a  chance of recovery by de-
termining the commencement  of circulation, at
that critical time when  the vital powers are quick-
ly fleeting away, and  every moment is of the ut-
most consequence.  But tbese attempts to supply
the moving powers of the chest are always imper-
fect, and can  at best be considered as only auxi-
liary to more efficacious methods.  Still, however,
they may be  practised  when no better assistance
can be procured, or in the intervals of other pro-
cesses.
  The object being to  introduce pure air into the
inmost recesses of  the  air cells, so as to exert a
chemical action upon the blood in the pulmonary
vessels, some degree of force  must be used in order
to overcome  the mechanical obstacles to  its ad-
mission.  For this purpose a considerable quantity
of air should be introduced at each inflation ; for,
as Dr. Goodwyn observes, if only twelve cubic
inches be injected at a time, this small quantity
will occupy the larger branches of the trachea,
and consequently only a small number of the pul-
monary vessels will be exposed to its action : but
if a much greater  quantity  of air be forced in at
each time, some of it will pass into all the more
remote cells ;  and  when  they are thus uniformly
distended, the pulmonary veins, the sinus veno-
sus, and  left auricle, will he exposed as much as
possible to its action, and some of the arterialized
blood may be forced into them from the capillary
vessels.   Hence Dr. Goodwyn  recommends that
upwards of a hundred  cubic inches of air.should
be introduced into the lungs of an adult at each
inflation,  and carefully  drawn out again  before
more is introduced.
  In situations where  no proper apparatus is at
hand, air should  be  blown with force into the
lungs by applying the  mouth of the  operator to
that  of  the  patient, closing  his nostrils with one
hand, and gently expelling the air again by press-
ing the chest with the other, so as to  imitate the
strong breathing of a healthy person.   If any dif-
ficulty be found in inflating the lungs  in  this
way,  it may  be attempted  by blowing through
one of the nostrils, keeping at the same time the
other closed.  This operation is much facilitated
by  interposing a  short  wooden  pipe, of a  size
adapted to the nostril, into which it is to be in-
serted at  one end, while the other is applied to
the mouth of the  person who is to blow through
tf.  The  same tube will also be useful for receiv-
ing the pipe of a pair of bellows, when this instru-
ment can be procured.
  The blowing of air into the lungs of the patient
from the mouth of a person, who must necessarily
have breathed that  air, and therefore vitiated it,
has been objected to  as being inconsistent with
the very  purpose  we are  aiming at,  namely, the
supply of pure and uncontaminated air to the pul-
monary  cells.  On  the other  hand  it  has been
thought preferable, from its introducing  the air at
a higher temperature than that of the atmosphere;
but it is  certainly of much greater importance that
the air which is sent into  the lungs should con-
tain its full proportion of oxygen than that it be
of the temperature of the body.  Wherever, there-
fore, a bellows, or  other apparatus for the artificial
inflation of the lungs can be procured, we should
not  hesitate  to  employ it immediately, in prefer-
ence to any other method.
   The only instrument absolutely requisite for
the  performance of this operation is a common
bellows : but  the  services of an  assistant will be
required in every  case.  The pipe  of the bellows
being inserted into the nostrils of the patient, the
assistant must close the mouth  and the opposite
nostril, and at the same  time gently press back
the trachea, directing  it also  a little  downwards,
by pressing his finger upon the  most prominent
part of the larynx, commonly called  the pomum
Adami,  or Adam's  apple.  The bellows is then
to be opened, and immediately afterwards closed,
so as  to force air into the lungs.   Its  action is
now to  be stopped ;  the  nostril that had been
closed  should be allowed  to open,  and the lungs
made to  collapse by  pressing  down the  chest, so
as to  expel  the  air as completely  as  possible,
These actions should  be  repeated about fifteen
times  in a minute, so as  to  imitate the natural
movements which take place in respiration.
   The process of  inflating the lungs may be per-
formed somewhat more readily  and more com-
pletely with  instruments  constructed for this ex-
press purpose.   The bellows  employed with this
view by  the Royal Humane Society  differs in no
respect from an  ordinary bellows,  only  that it is
more accurately  made,  and  is  provided with a
short flexible tube, one end of which fits on to the
nozzle of the bellows, and the other is  inserted
into a silver tube, which is to be introduced into
the nostril.
   In  the  Report of  tbe  Humane Society it is
stated  that, as the trachea is always open through
the glottis, air conveyed through the mouth, the
nostrils being closed, would necessarily pass into
the  lungs.  If the cartilage  of the larynx be
pressed  against  the  vertebrae,  which  it  ought
always to  be, so  as  to close the oesophagus, and
prevent the passage of the air into the  stomach,
and at the same  time the  mouth and left nostril
be closed, and the pipe of the bellows inserted into
the right nostril,  the air  must  necessarily  pass
into the  lungs through the trachea, this being the
only opening through which it can find  its way.
   Dr.  Curry, in his " Observations on Apparent
Death,"  (p. 48,) gives the following  excellent
directions for conducting this process :__
   " While an assistant  sustains  the box-wood
tube (into which a common pair of bellows can be
made,  by the assistance of a strip of linen, riband, 
ASPH
3r tape,  to fit  accurately)  in  one nostril, and
stops the other nostril with his left hand, and with
his right hand accurately closes the mouth, an-
other  assistant (who  ought to be placed on the
opposite  or left  hand  of the body) is, with his
right hand, to  press  backwards, and draw gently
downwards towards  the chest the upper end of
the wind-pipe, that part which lies a little below
the chin, and which, from its prominence in men,
is vulgarly called Adam's apple,- by doing this,
the gullet, or  passage into  the  stomach,  will be
completely stopped up, whilst the wind-pipe will
be rendered more  open to  let the air pass freely
into the lungs.  The left hand of this second as-
sistant is to be spread lightly over the pit of the
stomach, ready to compress the chest and expel the
air again, as soon  as the lungs have been mode-
rately  filled ;  the  first assistant unstopping the
mouth or nostril  at the same time, to  let the air
escape.  The  same operation is  to be repeated, in
a regular and  steady manner, either until  natural
respiration  begins,  or until this and the  other
measures recommended have been persisted in for
at least six  hours, without any appearance of re-
turning life."
   It has been proposed to  inflate the lungs with
oxygen gas instead of atmospheric air ; and it is
exceedingly probable that if a supply of that gas
were  immediately at hand,  together with every
facility in the way of apparatus  for administering
it, its efficacy, in restoring  animation, would be
superior to that  of common air.  But the  cases
must be exceedingly rare in which we can command
these  means, and, whenever they are not in com-
plete  readiness,  it would be very wrong  to lose
any time in waiting till we can obtain them. We
are not aware, indeed, of any set of experiments
having been instituted  for the express purpose of
ascertaining the superiority of oxygen gas over
common air as  a means of resuscitation in as-
phyxia, except those of Dr. Goodwyn, who merely
says that he has employed oxygen gas in several
instances  in the smaller animals, and that the
recovery was  commonly more expeditious  than
where atmospheric air  was used  : but at the same
time he  acknowledges that he  had never  been
able to recover an animal by means  of  oxygen
gas where  good atmospheric  air had  been inef-
fectual.
   As a last resource, when the ordinary methods
of inflating the lungs have  entirely failed  of suc-
cess, and  more  especially  if there be reason to
presume  that the chief source of difficulty arises
from obstructions in  the larynx  and trachea, the
operation of bronchotomy  may be resorted to ;
which  will  allow of the forcible  and more perfect
inflation of the lungs  by means  of a pipe intro-
duced into  the opening made in the trachea. But
it is only under particular circumstances that we
need resort to this expedient.
   Various kinds of apparatus, some of a very com-
plicated description, have been, at different times,
proposed to be employed for  the purpose of effect-
ing the complete inflation of the lungs.   But, in
general, more  is lost than gained  by resorting to
complex mechanical contrivances, which are  often
out of order at the very moment when they are
wanted, and which always require time for their
adjustment,  and  practical skill in their manage-
  'Vol. I. — 26
TXIA.                                   201

 ment.   The simple instrument we have described,
 namely, the common bellows, with a pipe adjusted
 to its  nozzle, will be found  sufficient to answer
 every practical purpose ; and even the latter may-
 be easily dispensed with, if the pipe of the bellows
 be accurately applied to the nostril of the patient.
 By the introduction  of a catheter into the trachea,
 if such an instrument be at hand, the lungs may
 be very conveniently and  effectually inflated by
 blowing air through the tube.
   [In  recent times, it has been  shown,  that the
 apparently simple operation of inflating the lungs
 is not  as devoid of danger  as was for a long time
 imagined ;  and it has been attempted to prove,
 that many  cases may have resulted  fatally from
 the violence of the  insufflation, and consequent
 lesion  of  the pulmonary structure.   To prevent
 these results, M.  Leroy d'Etiolles  recommends,
 that a  graduated arc of a circle should be adapted
 to the  handles of the bellows.   One end of this
 arc is   attached to one  handle, whilst the other
 passes through a mortise hole in the other handle.
 The extent to which  the handles  are separated is
 measured by the graduated  arc,  and thus  the
 quantity of air sent into the lungs may  be  deter-
 mined.  With this  bellows  M. Leroy measured
 the quantity of air expired, without effort, into a
 bladder, by  persons of different ages, and marked
 upon the arc of the  circle  the  point to which the
 handle of the  bellows was raised in  each.  He
 also had curved silver tubes, to be introduced into
 the glottis, made of different calibres according to
 the age, so  as to render  it impracticable  to  intro-
 duce the  proper quantity of air, as indicated on
 the arc of the bellows, more  rapidly than would
 be inspired  at that age.  This apparatus is simple,
 and its adoption  has been properly and  strongly
 advised, on the ground,  that  verbal directions
 often fail  to impress  the mind with  a due  sense
 of the  dangers  attending  insufflation, especially
 when  it has to  be performed in such excitement
 and confusion as cannot fail occasionally to dimi-
 nish the caution even of experienced persons. In
 most of the  cases  of asphyxia, however, that
 occur,   no  such apparatus is at  hand ;  and  the
 operator is,  consequently, constrained  to  make
 use of  those agents that present themselves. These
 should  of course be employed with the  greatest
 precaution  to  prevent the evils that have been
 depicted by Leroy.]
  Gentle  friction of the  body with a warm hand
 may, at the same time  that  we  are proceeding
 with the  inflation of the  lungs, be employed  at
 first as a means of increasing warmth, and subse-
 quently, with a view of promoting the circulation
 of the  blood.  But the importance of friction, even
 as an  auxiliary means of restoring life, has, we
 think,  been  much overrated.
  The application of stimulants of various kinds
 has been  recommended with the  same intention
 of exciting  the action of  the  heart  and  of the
 muscles of  respiration.   "We should be  exceed-
 ingly cautious, however, in  the  employment of
 these means, and should in general confine our-
 selves  to those that are external.   In the instruc-
 tions for the recovery of drowned persons given
 by the Humane Society,  it is stated that irritation
 applied to the nostrils  has considerable influence
 in calling  into action the muscles: of respiration j 
202
ASPHYXIA.
and for this purpose it is recommended  that the
nostrils be occasionally  touched  with a  feather
dipped in spirits of hartshorn, aromatic spirit of
vinegar, &c.   With regard to applications of sti-
mulants  to  the  skin, they observe,  that  during
life the skin loses sensibility in proportion as it is
deprived of heat, and  does not  recover it again
until  the natural degree of  warmth  is restored.
Hence it may be inferred  that,  before this heat
has been recovered, all  stimulating applications
are useless, and, as far as they interfere with the
other   measures, must be  positively  prejudicial.
When, however, the  skin  has  in some degree
recovered its sensibility, spirit of hartshorn, or eau
de luce, closely applied,  or a liniment composed
of equal parts of spirit of hartshorn and salad oil,
may be rubbed on the wrists, ankles, temples, and
parts opposite to the stomach and heart.
   It has  also been  recommended to introduce
warm  and stimulating fluids  into the  stomach by
means of a syringe and flexible tube, such as that
generally attached  to the  stomach-pump;   for
until the power  of swallowing  is  pretty well re-
stored, it would  be dangerous to  attempt getting
fluids  down the throat in any other way.   Half a
pint of warm negus, or water with spirits of harts-
horn,  mustard,  or essence  of peppermint, may
thus be given.   The best time  for administering
a stimulating cordial of this kind  is a few minutes
after the process of inflation is begun.  A clyster
of a pint or more of water  moderately warmed,
with the  addition of the materials  before men-
tioned, or of rum, brandy, or gin, may be admi-
nistered.  Such, at least, is the  advice given  by
the Humane Society, in cases of drowning, which
may be considered as on  the whole judicious, pro-
vided  proper caution be used  in not going beyond
them.   Mr. Hunter certainly went much  too  far
when he recommended the application of stimu-
lating vapours to the interior of the lungs. (Obser-
vations on the Animal Economy, p. 136.)   For-
tunately for the  patient,  as Dr. Bostock remarks,
the natural  actions of the  organs  are  commonly
sufficient to exclude the vapours ; for, were they
admitted in any  considerable  quantity, suffocation
would be the consequence.   The only  use of
stimulating vapours, is to excite the nerves of the
nose,  which, by  their connexion  with the respira-
tory nerves generally, may eventually stimulate the
diaphragm to  contraction.  Not  contented with
the forcible injection into the stomach of stimu-
lating liquids, some have advised the introduction
of a piece of sponge impregnated with them, and
fixed to the end of a small rod of whalebone, in
order  that the  sides of the stomach may be, as it
were,  mopped round by  the sponge thus charged,
and  stimulated  in  every  direction.   (Good's
Study  of  Medicine, vol. iii. p. 562.)   In the Ber-
lin Transactions we find  a recommendation of the
use of a ventriculi executia,  or stomach-brush, to
produce internal friction  in the same manner. Dr.
Good, however, prefers the stomach-mop.   It is
hardly necessary to caution the reader against the
adoption of these extravagant proposals.  Neither
can we approve  of the recommendation of the in-
ternal  use of phosphorus,  also recommended by
 Dr. Good, on the authority of some German phy-
sicians, as one  of the most powerful stimulants
  et Known.
  Various other expedients have been suggested,
as means of  assisting  recovery,  which  are  not
merely  of dubious utility, but  should  be repro-
bated as exceedingly dangerous, and likely to frus-
trate the  very object we have in  view.   To this
head may be referred emetics, which should never
be given; and also tobacco clysters, either in the
form of smoke or infusion, the tendency of which
is to destroy instead of increasing the irritability
of the system.
  Slight  shocks of electricity,  or of galvanism,
transmitted  through the  diaphragm or heart, may
possibly be  used with considerable  advantage in
many cases  ; for this agent has the  power of ex-
citing  the contraction of a muscle which can be
no  longer acted upon by any other means.  The
galvanic apparatus being  very portable, and not
affected by the state  of the atmosphere, it seems
to be preferable, in cases of asphyxia, to the ordi-
nary forms of electricity. It is easily applied, and
its force can be  exactly regulated  by the  number
of plates we may employ.
  [A new method of application  has been sug-
gested by M. Leroy d'Etiolles. (Magendie's Jour-
nal  de Physiologie, torn, vii., viii., and  ix., and
Recherches experiment ales sur V Asphyxie, Paris,
1829.)   He introduced an acupuncture needle on
each side, between the 8th and 9th ribs, until the
needles reached  the fibres of the diaphragm.  He
then established a galvanic current between  these
by means of a pile of 25 or 30 pairs of plates an
inch in diameter.   The diaphragm  immediately
contracted,  and  an inspiration was made.  Ho
now interrupted the circle, when  the diaphragm,
urged by the weight of the abdominal viscera, and
aided by  gentle pressure made  on the  abdomen
with the hand, returned to its former position, and
an  expiration was  accomplished.  In  this way,
the two respiratory acts were made to succeed each
other, and regular respiration  was  re-induced.  A
continuous  current was likewise applied in seme
cases, but the respiratory movements were irregu-
lar, and nothing like natural  respiration resulted,
Leroy tried  his method on animals asphyxied by
submersion, and when they had not been under
water more  than five minutes, they were often re-
suscitated.  On different  occasions, he  asphyxied
animals of  the  same species, and apparently of
like strength, and whilst those  that  were left to
themselves  perished, those that were treated by
galvanism recovered.  A case has been published
in which the galvanic influence  from a battery of
fifty plates  was applied immediately to the dia-
phragm through an incision made below the sev-
enth rib.  The  muscles of the chest and abdomen
were instantly thrown into spasmodic action, which
subsided in  a  few minutes into the regular move-
ments of  respiration.  The man had been six or
seven minutes underwater.  (Art. Asphyxia, in
Cyclopedia of  Practical Medicine and Surgery,
vol. 2,  Philad.  1836 ; and Dunglison's Practice
of Medicine, 2d edit., p. 421, Philad. 1844.)]
  Bleedina; has  been recommended by physicians
of high authority ; but it is only under particular
circumstances that we can expect  it to  be benefi-
cial.   In  general its effects would be  injurious:
its use  is  strongly reprobated  by Mr. Hunter, and
it is  now scarcely ever had  recourse  to, unless 
ASPHYXIA.
203
there  are  very unequivocal  indications of great
pressure on the brain.
  The processes above  recommended  should  be
diligently  persisted in for several  hours ; unless
evident indications of death appear, such as  stiff-
ness of the limbs, dimness of the eyes,  &c.
   [When the heart has once ceased to beat, how-
ever, it is extremely difficult  to restore  it.   It is
important to bear in mind the cases on  record, in
which resuscitation  has been effected, as in as-
phyxia from drowning, after an immersion of sev-
eral minutes; but, at the same time,  we must
reject, unhesitatingly, many  of the marvellous
stories that have been handed down on  this sub-
ject.   Notwithstanding  these traditionary histo-
ries, and the philanthropic recommendation that
our attempts at resuscitation should be  continued
for several hours in cases of asphyxia, it is but too
true, that  our efforts will generally be fruitless
 after a perfect asphyxia  of a few  minutes' dura-
 tion.  On  the occasion of a  melancholy catastro-
 phe at Albany, in the  State of New York, in Au-
 gust, 1840, when many  persons were submerged,
 although some of the  persons were removed from
 the water in less than five minutes, and in two or
 three cases respiration was imperfectly  performed,
 in no  single instance did the  medical  gentlemen
 succeed in their well-directed efforts  at  entire re-
 suscitation.  (Dunglison's Practice  of Medicine,
 edit, cit., p. 415.)]
    The first signs of returning life  are slight con-
 vulsive twitchings  in  the  muscles of respiration,
 giving rise to gaspings and sighings.  By degrees
 these  spontaneous efforts become more regular,
 and natural respiration is  restored ;  and together
 with this the circulation returns.   Slight palpita-
 tion is sometimes felt at this  period  : on the  ap-
 pearance of these signs  our efforts  must be redou-
 bled ; for the crisis is arrived when the life of the
 patient is still exposed to much  hazard,  and can
 be saved only by the  utmost care and attention.
 Some time must yet  elapse  before  the vivifying
 influence  of the freshly generated arterial  blood
 can be extended over the system generally, and
 especially  before  the  functions  of the brain are
 restored.   The first return to sensation  is usually
 attended  with great suffering ; and the first  ex-
 pressions  of the feelings  of the patient  are  not
 those of gratitude  to  his  benefactors, but are ra-
 ther those of bitter complaint and deep resent-
 ment.
    There still  exists,  indeed,  a  period  of danger
 after the breathing has been  restored and the cir-
 culation re-established,  at which death may take
 place when we are least prepared  to  expect it.
 When animation  returns, therefore, the patient
 should not be left alone,  but watched lest he should
 require  further assistance ;  for  many  have been
 lost from want of attention,  who might otherwise
 have been easily saved.   We may quote in illus-
 tration the following case  mentioned by Dr. Paris,
 (In his  Life of Sir Humphry Davy, 4to. edit., p.
 '•9,) which  happened in the neighbourhood of
 Win Isor.  A corporal of the  Guards, of the name
 of Schofield, w;is seized with cramp  as  he was
 bathing in the Thames, and  remained  for several
 minutes under  water.  By  judicious  assistance,
 however, he was recovered, and  appeared to those
 about him to be free from any  danger, when he
was attacked with convulsions, and expired. Had
the respiration  been artificially supported at this
period, so as to have maintained the action of  the
heart  until the black blood had returned from  the
brain, it  is probable that the  life  of the  soldier
might have been preserved.
   It has sometimes happened that  the return of
sensation has been attended with delirium, or been
followed by an  attack of temporary mania.  Care,
indeed, is always requisite, even after the functions
have been  restored, to guard against the effects of
morbid  reaction, which gives rise  to various  in-
flammatory and febrile states.
   Treatment of particular  kinds of As-
phyxia.—The treatment of asphyxia from  the
respiration  of carbonic acid or any other of the
irrespirable gases, is to be conducted upon thegen-
eral principles above explained.  The first step to
be taken will naturally be to remove the body from
the influence of the noxious gas, and expose it to
a free and pure air.  As the temperature of the
body  is generally raised  above the  natural stand-
ard, the  affusion of cold water on the body may
be employed with great advantage ; for it  acts as
a  powerful stimulant, in consequence of the strong
impression made upon the skin, which is  a very
extensive sentient organ.  Sprinkling  cold water
upon the face and breast is a milder mode of ef-
fecting  the same object, and is well known to have
considerable effect in rousing persons in a state of
syncope.  The dogs which are made the  subjects
of experment at the Grotto del Cane, are  usually
plunged into a neighbouring lake  after  exposure
to the mephitic gas, as a  means of hastening their
recovery.  It need hardly be observed that if the
temperature of the body is below the natural stand-
ard, heat instead of cold should be applied.
   A  moderate  bloodletting  has been strongly re-
commended in this particular species of asphyxia,
on the ground of its being indicated by the symp-
toms of pressure on the brain.   It was conceived
also that the contractions of the great vessels and
cavities  of the heart, which are in an over-distend-
ed state  from  accumulation  of blood, would be
facilitated when they were relieved by the evacua-
tion  of some portion of  that excess.
   But  the theory upon  which this recommenda-
tion  rests is exceedingly doubtful.  In the  case
 recorded by Dr. Babington, bloodletting appeared
 to have an  injurious  effect, and we  are, on the
 whole, disposed to agree in the opinion expressed
 by that  judicious  and  experienced  physician,
 namely, that the restoration of breathing is the
 natural  and most effectual remedy to the altered
 balance in  the circulating system.  If, however,
 detraction  of  blood should  be  thought  necessa-
 ry,  the end will be  most quickly answered by
 opening the jugular vein, as recommended by M,
 Portal.
   In the case  above referred  to, galvanic shocks
 were passed through the chest at intervals of half
 an hour, for some hours, with apparent benefit, as
 they seemed especially to excite to  contraction of
 the  muscles of respiration.   Advantage  seemed
 also  to be derived from the forcible inhalation of
 oxygen gas.  During the convalescence  of  thii-
 patient his mental power seemed to be much im
 paired, and he cried bitterly when any person en-
 tered the  room ; a  state of imbecility Tvhich tV • 
204
ASPHYXIA.
quently occurs  in  ordinary  paralytic  affections.
Violent pain in the  stomach  is said  to  be occa- ]
sionally a sequel to  this species of asphyxia, for
which  a brisk purge  is the most efficacious rem-
edy.
  In cases of asphyxia from carburetted hydrogen
gas, the treatment must be conducted  upon the
same general principles  as in  those from carbonic
acid gas.
  Treatment of asphyxia from drowning.—On
the  subject of the methods to be pursued  for the
recovery of drowned persons, we cannot  do  bet-
ter  than transcribe the following directions given
by the Humane Society in  their latest  Report,
(The Fifty-seventh Annual Report, 1831, p.  62.)
as being those  sanctioned  by the most  extensive
experience.
  After the body is found, particular care should
be  taken  to employ the following means  in  the
order described, and as  quickly as  possible ; but
in the  precipitancy and  confusion usual upon such
occasions, cautiously to  avoid every kind  of vio-
lence and rough usage.   It is of the  utmost im-
portance,  first, to cleanse the mouth and nostrils,
strip off the wet clothes, wipe and clean the body,
and wrap it in dry clothes or  blankets, before it
is removed, in  order to obviate evaporation, and
the  effects of exposure  to a cold medium.   By
either of these  causes the temperature of the body
would  be  greatly reduced, and the prospect of
resuscitation  diminished.  The colder  the wea-
ther, the more desirable it will be to strip off the
wet clothes, and promptly put on dry ones ;  this
should be done upon the spot, unless a convenient
place is near at hand to carry into execution  the
more material preparations.  An error in the  first
steps  of the resuscitative  process may be fatal.
It cannot, therefore, be  too  strongly urged upon
those who humanely assist in these early moments,
and who  are seldom professional men, rigidly to
adhere  to these  few articles of instruction, that
they may thus  effectually prepare the way for the
restoration of life.  If they attempt to  take more
upon  themselves, their intentions,  though good,
may be subversive of the end in view, and defeat
the designs of the medical attendant.   More indi-
viduals are lost from the irregularity  and want
of order in the employment of the first means,
than  from any other cause.  The  time that is
spent by the humane assistant in the faithful and
exact adoption of these instructions, in the  first
steps of the resuscitative process, is  as  profitably
employed as the time and judgment of the medi-
cal  man can be ; for he cannot exert his skill till
the preparations have all been made.  Neither the
coldness of the body, nor the length  of time it
may have been under water,  should dishearten the
assistant from a vigorous and unremitting perse-
verance in his efforts.   His services  are, in short,
incalculable.
  In conveying the  body, it will be necessary for
the assistant to forbid persons lifting the body up
by  the shoulders, or taking hold of the  legs,  with
a view to carry it forward ; for in  this  posture it
will be impossible to prevent the head from hang-
ing back or bending forwards upon the breast,
either  of which positions of the head is injuri-
ous.   The best way to carry the body is  to place
; in a recumbent posture  on the back, with the
head and breast raised, on a door  or  board, or in
a cart.
   When arrived in the room prepared  to  receive
it, the body should be  stripped and  covered  with
warm blankets, and placed on a  table  of a  con-
venient height to admit of the  process  being em-
ployed  with facility ;  taking  care  to  keep  the
head  and chest raised, and to have the  nostrils
and mouth thoroughly cleansed.   If these arc in
any degree obstructed, the resuscitative process is
not likely  to  succeed.   Both  the  nostrils and
mouth should be free  and  open.   The inflation
of the lungs is then to be performed in the man-
ner we have already described, in  our general ac-
count of the treatment of asphyxia.
   While some of the  assistants  are engaged  in
performing artificial respiration, others  should be
employed in communicating continued  heat to the
body.   Dry, warm blankets, bags  of warm grains,
or sand-bladders, or bottles of hot  water, or  hot
bricks,  or blankets wrung out  of hot  water, are
amongst the means most readily  obtained.  The
body  may be placed before the fire, or in the sun-
shine, if strong at the time.   Whatever may be
the particular means employed, the restoration of
warmth should always be assiduously pursued.
Should the accident happen in the neighbourhood
of a steam-engine, brewhouse, bakehouse,  or any
place where warm water may easily be procured,
it would be of great importance to place the body
in a warm bath, moderated to a  degree  not ex-
ceeding 100°.   The warmth  most  promising of
success is that of a heated bed or  blankets. Bot-
tles of  hot water should be laid at the  bottom of
the feet, to the joints of the knees, and under the
arm-pits ;  and a warming-pan moderately  heated,
or hot bricks wrapped  in cloths, should be passed
over the body, and particularly in  the direction of
the spine.   A large bladder  should be  applied,
filled  with hot water,  and enclosed  in  flannel, to
the region of the stomach. The natural  and kindly
warmth of a healthy person,  lying by the  side
of the  body, has  been found  in  some cases of
adults, and  more  particularly of children, very
efficacious ;  but the warm  bath, when it  can be
procured, is  preferable to all other means  of com-
municating heat.
   With regard to the  use of friction and the ap-
plication  of stimulants, the  observations  already
given in the early part  of this  article apply in
their  fullest extent.  Bleeding ought never to be
employed  in this  stage  of the process;  though
circumstances may occur to render  it necessary
when the circulation has  returned, and a  morbid
reaction has taken place.
   Treatment of cases of strangulation.—In the
treatment of persons apparently dead from hang-
ing, or any other mode of strangulation, the same
means are  to  be  enforced  and persevered in  as
have  been recommended for the recovery of those
that have been drowned.   The posture in which
the body should be laid  is  the  same, excepting
that the head and shoulders should be raised some-
what higher.  The fulness of the vessels of the
head may  be such as  to require bleeding, which,
of course, will be most effectual if done in the
jugular -ein.  The quantity  of  blood to be ab-
stracted must be  merely enough to remove the
excess  that exists in the vessels of  the head but 
ASPH
YXIA.
205
should not be so great as to weaken the powers
of life.  At subsequent periods  of convalescence,
there may, from excess of reaction, arise a neces-
sity for taking away a much larger quantity.
   In  all  cases  where the cause of obstruction is
in the trachea, such as those  arising from the
introduction of an extraneous body, or the closing
of the passage from disease, the  operation  of
bronchotomy affords  the only chance of saving

Ufe"                           P. M. Roget.
   [Asphyxia  of  the  Newborn — Asphyxia
neonatorum. Should any thing interfere with the
due passage of the blood along the umbilical cord,
asphyxia will result; not owing only to the requi-
site  changes of the blood in the placenta being
prevented, but through the consequent interference
with  the circulation,  which has to be effected by
 the cord  and placenta, until the independent circu-
 lation is established by pulmonary  respiration.
 We can  thus understand, that if the cord should
 come down in such  a  manner  as to be strongly
 compressed for some time before delivery, asphyxia
 may  be  produced.   In  like  manner,  when the
 breech, feet, or knees present, there  is danger to
 the child, unless the delivery be rapid.  Occasion-
 ally,  too, the child  is stillborn in consequence of
 some morbid condition  of  the organs of innerva-
 tion.  Thus, owing to  pressure of the head in its
 passage through the  pelvis, or to  some modifica-
 tion  in  the encephalo-spinal centres, or  in the
 nerves distributed  to the respiratory  organs, the
 function of respiration is not established, notwith-
 standing that the circulation appears  to go on well
 along the  cord.   The child seems  to be  in  an
 apoplectic  condition.
   Asphyxia may pre-exist longer in  the newborn
 child than in  the  adult, in consequence  of there
 being less need of  a  highly oxygenized blood  for
 its support.
   If all circulation have ceased in the cord, there
 can be no advantage in keeping the connection
 between the child  and  the placenta  entire, espe-
 cially as the union cannot  fail to interfere with
 the due application of such resuscitative means as
 may be deemed necessary7.   At times, when the
 child is  extruded, and  the  placental circulation
 continues, the  stimulus of a smart stroke on the
 breech arouses the dormant energies, and it imme-
 diately begins to cry ;  but should this be insuffi-
 cient, the  infant  bad  better be  exposed to a
 moderately warm temperature,— for example, to
 the moderate warmth of a fire, so that the air may
 come in  contact with a large surface of the body.
 Generally, immersion  in  a  warm bath  is  had
 recourse to ; but the rationale  of its action is by
 no means unequivocal, whilst,  as Dr. Kay has
 observed,  (The  Physiology,  Pathology, and
 Treatment of Asphyxia,  Lond. 1834,) it  is not
 necessary to the application of a proper degree of
 warmth to the body of the child ;  it prevents the
 beneficial effects of the atmosphere on the skin ;
 and  moreover, is  found  to exert a  depressing
 influence on the nervous and muscular systems.
   In addition  to  these means, friction with the
dry  hand,  or  with  stimulating  liniments,  espe-
cially over the regions  of the chest and stomach,
as well as the application of spirit to the nostrils,
to rouse the  respiratory nerves to  action, have
                                          s
been recommended.   Should any mucus obstruct
the mouth and pharynx, it ought to be removed
by means of the  finger  enveloped in  a piece of
fine linen, dry, or dipped in a solution  of common
salt.  But, after all, these means are often found
unsuccessful,  and it  becomes necessary to have
recourse  to  artificial  respiration.   This  is the
great reliance of the practitioner in  severe cases.
Whilst artificial  respiration  is  persisted in, the
cord will' often be observed to pulsate, and to cease
when the operation is suspended.  In  the still-
born foetus,  it is not found practicable to execute
insufflation  by mere pressure on the chest, in the
mode advised for the adult.  In one case, Dr,
Blundell  diligently operated in  that manner for
fifteen or twenty minutes together,  without pro-
ducing  resuscitation, and, on examining the child,
on  the following  day, he found  that  scarcely a
particle of air had  entered the  lungs.   Nor can
insufflation  be readily effected  by blowing in  at
the mouth.   The only mode of doing it effectually,
is by means of a curved canula, or other analo-
gous instrument.  The  introduction of a  curved
tracheal pip_e into the  larynx  is by  no  means
difficult.  All that is  necessary is to pass the fore-
finger of the left hand upon the root of the tongue,
as far as the opening of  the  larynx,  and to insert
the tube,  held in the right hand, along the finger
as a director.  It will  readily  enter; and, by press-
ing  on the  neck, it can  be easily discovered whe-
ther the instrument be in the trachea or the oeso-
phagus.  The lungs  may then  be inflated by
blowing  air from the lungs of the practitioner
through the tube,  and  forcing  it  out again by
pressing on the thorax and abdomen,  and repeat-
ing this five-and-twenty  or thirty times in a mi-
nute.   In inflating, care must be taken that the
air is not driven in too forcibly.  The experiments
of M. Leroy d'Etiolles, (op.  cit.,) show, however,
that insufflation may  be  performed with much less
risk in the  infant than in the  adult, because the
structure  of the lungs is  firmer in the former, and
there is, consequently, less risk of rupture or dila-
tation of the air-cells.  It is no  great objection
that the air sent into the lungs  of the foetus from
those of the adult cannot be  as efficacious as pure
atmospheric air ; the young being,  as  before ob-
served, not  requiring such highly oxygenized air
as the adult.
   It  has been  proposed  that  a  small galvanic
apparatus, like that recommended by Leroy, and
before described, (p. 202,)  might be  used  with
advantage, to rouse the diaphragm to contraction.
(Dunglison's Practice  of Medicine,  2d  edit.  i.
444 : Philad. 1844.)
   The length of time during which  the efforts  of
the practitioner ought to be continued, must be de-
cided by his best discretion.  Where, from the ap-
pearance  of the foetus, or other evidences, he has
reason  to believe that it has been for some  time
dead in utero, all his endeavours must necessarily
fail.  It is  only in cases  in which  the child has
perished in the birth, that any means can be effec-
tive ; and in such case,  the energetic measures
already recommended, should be put in force, and
not be abandoned until  all hope is lost.  So long
as there is any hesitation in  the mind of the prac-
titioner, as  to whether  the child  he dead, b<>»
efforts should be perseveringly continued. 
206
ASTHMA.
  When the attempts  at  resuscitation have been
successful, the same attention is necessary, for  a
day or two afterwards, as in the varieties of as-
phyxia previously mentioned ; and when there is
reason to believe that the  state of  suspended ani-
mation  is dependent on, or connected  with, an
apoplectic condition,—as where the respiration is
very slow and laborious, and there is  evidence of
venous engorgement of the head and neck, with
pulsation in the cord, advantage is often derived
from permitting a teaspoonful or two of blood to

                     Robley Dunglison.]
  ASTHMA___The term asthma, like most terms
in medicine which have  been transmitted  to us
from  antiquity, in the  language of the people as
well as of science, has been applied to a great
many different affections.   Its etymology* indeed
justifies its use in all cases of difficult breathing;
and it was long customary for physicians to apply
it to every sucb case which was not produced by
some known disease  or  other  manifest cause.
Very often the coexisting  disease, although in fact
the cause, was entirely overlooked, or, if noticed,
was considered  as a consequence  of  the disorder
of the  respiration.  In popular  language, every
chronic shortness of breath, or dyspnoea, is  still
termed  asthma, and this  application  of the term
has certainly the sanction of many good practical
and systematic writers up to a comparatively recent
period.   In   another part of the  present  work,
under the termD jspncea, will be found an account
of the different kinds of short-breathing, of a con-
tinued  form,  referred,  for  the most  part, to the
organic lesions  on  which  they depend.  In the
present article, it is intended to confine our views
chiefly  to  that  variety of  disordered respiration
which, since  the time of  W'illis more particularly,
has commonly been denominated spasmodic asth-
ma, and which may be briefly defined, a difficulty
of breathing recurring in  paroxysms, after inter-
vals of comparative good health, and usually un-
accompanied  by fever.
   History  of Asthma.—Persons  subject   to
tsthma have generally more or less of warning of
the approaching paroxysm.  The precursory symp-
toms, however, vary greatly in different cases both
as to their nature and  the period of  their appear-
ance.   Some patients  have  indications  of  the
coming  evil  even  some  days previously to the
attack ; most have distinct notice of  its approach,
at least for some hours, but it occasionally attacks
with scarcely any previous warning.
   The more common precursory symptoms are
the following :  a feeling of general  languor and
oppression,  yawning,  heaviness of  the  head  or
drowsiness, distension of the stomach from flatu-
lence, and a feeling of tightness across  the lower
part of the chest.  Sometimes there is  more dis-
tinct headach, with general restlessness and fret-
fulness towards evening, also dryness of the nos-
trils  or fauces,  and other signs  of slight fever.-)-
This  feverish state of  the system  is  strikingly
 indicated by a circumstance mentioned by Floyer,
 namely, that in such patients as  have issues the

   * "Am, data, spiro—dn'£u), anhelo— anpa, spiritus— &ad-
 u<i£ta>.spiritun)difficuhertraho—a.a6pa,anbe\atio,asthma.
   f Vigilant,  noctuque parum et obscure incalescunt.
  Qretavs morb. diiuur. lib. i. cap. xi.
wounds  are  apt to become  sore  and  inflamed.
Sometimes in  place of dryness  of the  mouth or
fauces, there is an increased  flow of saliva, and
still  more frequently an increased flow of urine.
In most cases, the discharge of limpid urine, which
almost always is connected with the disease, does
not begin until after the invasion of the paroxysm;
but occasionally it comes on long before  this, even
a day or two  previously, and is the first indication
of the approaching attack.f   Many other  symp-
toms, perhaps of a  very slight kind in ihemselves,
but  too  significant to the  experienced patient,
present themselves in particular cases.   All the
primary  disturbances  most  commonly become
more manifest towards night, and  it is often amid
their increasing violence that  the dispirited patient
retires to bed anticipating evil.  Nevertheless, sleep
not unfrequently occurs, and  it is only after some
hours' rest, that the patient is suddenly roused by
uneasy sensations, and then finds that the asthma-
tic fit is already present.   In some instances the
patient does  not immediately awake on  the  inva-
sion of the paroxysm, but continues in a state of
half-consciousness  approaching to incubus, aware
of the approach of the disease, yet with scarcely
the  power  to  make even  the  usual instinctive
efforts to  resist it.   On becoming  thoroughly
awake, he finds the  overwhelming symptoms to
be—a great weight, tightness and constriction of
the chest, almost depriving him  of the  power of
dilating it.   He  raises  himself up, or gets out of
bed,  panting and  gasping for breath, and  often
wheezing so loud as to be heard at a considerable
distance.   He  calls or makes signs to  have the
doors and windows opened, and  frequently sits at
the latter for hours together, regardless of the cold,
and caring only for fresh  air, " as if (in the words
of Aretaeus) the house were too small and too
confined for his breathing."   We have known a
poor patient in  such circumstances,  not  merely
remain by the  open window,  but lean over it rest-
ing  on the  sill, with the  arm  hanging  on the
outside, for  several  nights together, and even in
winter.  It is a fact well worthy of notice, that in
such cases  the patients, although at  other times
very susceptible, rarely suffer, either immediately
or subsequently, from the  effects of the cold to
which they are  exposed.  This circumstance is,
in itself, sufficient  to prove, as will be  more par-
ticularly  noticed hereafter,  how profoundly and
extensively involved  is the whole  nervous system
in the  asthmatic  paroxysm.  But although the
feelings  of the  patient  instinctively require cool
air,  or, at least, unconfined  air,  and the trunk of
the  body is  generally covered  with perspiration,
the  extremities  are  almost  always  cold.  The
countenance is  generally anxious and haggard,
and the  face very pale ;  sometimes, however, it is
flushed or even livid.  There is usually a tickling
dry cough;  but this, as well  as the other functions
of the respiratory and vocal organs, is very imper-
fectly performed.  " The asthmatic (says Floyer)
can neither cough, sneeze, spit, nor speak freely."
Almost  always  there  is a  copious flow of pale
urine, as in hysterical diseases ; and at the com-
mencement of the  fit, the bowels are frequently
relaxed, with somewhat  of the impatient hurry
and imperfection of spasmodic action.  The pulse
   X Floyer on the asthma, p. 7.  Whytt's works, p. 602 
ASTHMA.
207
is generally very frequent, small  and  feeble, and
occasionally irregular; and in many cases there
is palpitation from the beginning of the paroxysm.
Sometimes,  however, the pulse  does not  vary
greatly from the state of health, and palpitation is
often  absent.  The  great  distress of the  patient
appears to consist in the  painful constriction of
the chest, and the consequent  inability to inspire
a sufficient quantity of air to remove the sense of
suffocation.   Unlike  angina pectoris, which  has
some  other points of similarity with it, the asth-
matic paroxysm cannot  be said  to be productive
of pain, in the usual  sense of  that word ; nor is
the mind of the patient overwhelmed with the
apprehension of  impending dissolution.   On the
contrary, the asthmatic is supported with the hope
and assured conviction that bis sufferings  will not
be of long duration.  And such is  generally the
case.   After two, three, or more  hours, the seve-
rity of the attack begins to decrease, the constric-
tion of the chest gradually relaxes, the inspirations
are easier and deeper; tbe cough becomes freer,
and is now attended by a loose and sometimes a
copious expectoration, which is always hailed by
the patient as at once the  sign and  means of his
relief. Exhausted  by his  sufferings, and soothed
by  the contrast of ease, the patient very generally
falls asleep, and the disease is for the present at an
end.  In  many cases, with this single paroxysm
the disease takes leave of the patient for  the pre-
sent,  there being an almost perfect  restoration of
his health on the following day.  Very frequently,
however,  after an  incomplete resolution of tbe
paroxysm, a second  makes its appearance on the
following night,  and this  alternation of suffering
and comparative health may go on for several days
before the patient  is completely freed from his
enemy, and a perfect intermission is  established.
After the paroxysms  there  frequently  remains
much soreness in the chest, arising partly  from the
strong but  abortive  efforts  of the muscles to ex-
pand the chest, and partly from the cough.  Some-
times these pains are very severe, resembling the
pleuritic stitch, and  migbt by the inexperienced
be  mistaken for  such.   However, the knowledge
that any internal inflammation is a very rare con-
sequence  of asthma, together  with tbe  external
soreness, and great  increase of the pains on mo-
tion,  will readily point out  to  the experienced
practitioner  the exact nature of the  case.
   On inspecting the chest of a patient in  an asth-
matic paroxysm, it is found to be much less mobile
than  during ordinary respiration.  The whole of
the upper parts of the thorax seem, indeed, to be
almost entirely without  motion,  and the  inferior
parts  are acting within  a very confined  range.
The abdominal muscles  are, as it were, unbraced,
and seem to be acting with greater freedom but
much less force than  usual.  They appear to have
lost their usual support  beneath, as if the viscera
were  retracted from them, and  they were playing
backwards and   forwards  over a hollow  space.
The stethoscope conveys scarcely any respiratory
sound during  inspiration,  except  an indistinct
hollow sort of murmur, altogether unlike the usual
respiratory sound,  and  so  slight as  to  leave  it
doubtful if the impression conveyed to the ear  is
really a sound or only  a vibration.  Expiration,
however, is distinctly marked over the greater part
of the chest, not, indeed, by the sound of healthy
respiration, but by a loud sibilant or dry  sonorous
rhonchus, corresponding  with the  loud sighing
wheeze audible by the naked ear.  This rhonchus
is often exactly like the sighing of wind through
crevices ;  and sometimes the tone  and key of the
sound approach  nearer  those of  a moan than a
sigh.  The  sounds are perceptible, during expira-
tion, over the whole  chest, even in  the extreme
points of the  lungs ; and equally so in patients
whose respiration is nearly inaudible  in the inter-
vals of the paroxysms.
  In  the  intervals, the condition  of different pa-
tients varies still more than in the paroxysm.   In
some  there  remains  scarcely any  sign of disease
either in the organ of respiration or in the general
system ;  but in the  great majority of cases there
are obvious symptoms  of the suffering of both,
although the patients themselves are often disposed
to deny  or  make light  of them.   The contrast
between  their  present condition and their suffer-
ings in  the paroxysm, is so  great, that they are
naturally  led to underrate or disregard any slight
deviations from the  state of perfect health which
may still  remain ; and as they are frequently not
incapacitated for the  common offices and amuse-
ments of  society, they may seem also, to the com-
mon observer, to  be  free from disease.  But their
state  will rarely,  if  ever, stand  the  test of the
inquiry  of the physician.  In almost every case
there will be found, on examination, some perma-
nent  local disease of the organs of respiration, or
of some other organ ; or there will be found some
considerable depravation of one, or of more than
one important  function ; or there will be a com-
bination of  all  these, constituting a complex chro-
nic disease, which may  involve,  in a greater or
less degree,  the whole system.  As the asthmatic
paroxysms  are frequently produced, or, at least,
kept up and aggravated, by the  attendant  morbid
conditions of the system, and  as the successful
treatment of these, as of all  diseases, will greatly
depend on the  precise knowledge of their nature
possessed by the practitioner, it becomes a matter
of the greatest importance U mvestigate  the habi
tual state of health of asthmai : patients.
   When the  disease has been of long  standing,
besides  the organic or functional  lesions of in-
ternal organs indicated  by the ordinary signs and
symptoms, the asthmatic patient bears in his gait,
in the form  of his chest,  and in his physiognomy,
the. indelible and unequivocal impress of his dis-
ease.*  The explanation of the physical alteration
of  the configuration of the  chest, countenance,
&c. is obvious, and  has  reference to the efforts
made by the muscles of  inspiration, in the parox-
ysms, to dilate the chest when compressed.   In a
great proportion of cases there exists a marked
alteration in the  natural sounds of respiration, as
detected by  the stethoscope.   The sound is either
altogether absent, or very much diminished in the
greater  part of the  chest.  In  some places it in
more  distinct, but still  much feebler than in the
state  of health.  Occasionally the feeble sounds
are interrupted by a  recurrent sibilous monchus,
or click, like that of  a valve.  At  the same time

  * In morbi cessationibus licet ipsi non decumbent^
obambulent, secum tamea illius signum circumferunt.-
Arctaus, loc. cit. 
208
ASTHMA.
the chest yields over as whole extent a very clear I lead us to believe that while many-tber affec
sound on percussion.
  After a longer or shorter interval the paroxysm
is usually renewed with all its  former characters,
being again succeeded  by a period of ease ;  and
in this alternation of comparative health  and suf-
fering, many years, and even the greater part of a
long life, are often consumed.   The times of re-
currence of the paroxysm vary extremely in dif-
ferent cases ; and although generally more uniform
in the same patients, they sometimes are very irre-
gular even in  them.  This irregularity must, in-
deed, be expected, when it is considered how  very
much the paroxysms are subjected to the influence
of extraneous  circumstances  (exciting causes)
which are generally altogether unfixed and uncer-
tain  in  their  recurrence.   Accordingly, we  find
paroxysms returning after intervals of  every va-
riety of extent—one in a week, or in a month ;
four  times, or twice, or only once in a year ; once
in  every alternate  year,  or only every seventh
vear.*   The paroxysms of astbma hardly  ever
exhibit  that exactitude of periodical recurrence
which distinguishes  some other  diseases,  and
which is no less characteristic  and striking  than
it is inexplicable, in the present state of our know-
ledge.   Yet some cases are recorded in which the
asthmatic fits  returned with singular uniformity.
In one mentioned by Wainwright the paroxysms
always returned at the menstrual period, during a
space of seven years, (Mechanical account of the
Non-naturals,  p. 14 ;) and in  another, by Fran-
sieri, recorded  in the first volume of the Memoirs
of the Royal Academy of Madrid, they are stated
to have recurred at every  new  and full  moon for
no less a period than one-and-twenty years.   But
these are most rare exceptions  to a general rule,
and are here noticed more for their curiosity than
as  deserving a place in a  general  delineation  of
asthma.
  The asthma affects both sexes, but  is more fre-
quent in the male than in  the female.-)-  It occurs
in every stage  of life, but most  commonly in mid-
dle life, being  rare in infancy and childhood, and
seldom  making its first attacks  in old  age.  It
makes its  appearance  in  individuals  of every
variety of constitution and  temperament, a neces-
sary  consequence of its frequent dependence on
other diseases  of accidental  occurrence.   It  is,
however, cxteris paribus, more common in  per-
sons of a nervous  excitable temperament than in
others.  It  is  not confined to  any condition  of
life.   Some authors, particularly Ryan, (Observa-
tions on Asthma,) consider it as being more com-
mon among the labouring classes, taken generally,
than among persons of better circumstances ; but
we are very doubtful  as to the  correctness of this
opinion, if we include in  the  proposition all the
varieties of asthma.  Our experience would rather

  * Memini unum aegrotum,  qui ex intervallis septem
innorum, sexius laboraverat hoc morbo. — Heberden
Comm. p. 57.
  f Joseph Frank (Prax. Med. Univ. vol. vii. P. II. 2, p.
:)83) states the proportion, as observed in his own  prac-
lice, to be six males to one female.  Taking into ar.count
all the varieties of the disease, we consider the propor-
lioe of males here given as by much too great. Aretaeus
Joe.  cit.) gives  an  opposite  statement:—"Huic  vitio
mulieres opportune sunt magis quam viri."  But from
Ihe explanation given by this author of the alleged facts,
 t is to be apprehended that his statement is as  likely
to have been the result of theory as of observation.
tions of the lungs, particularly those cf an inflam
matory kind, are  more frequent among the work-
ing population, this disease and some others are
less so than among the middle  and upper orders.
In certain departments  of humble  Lfe, indeed,
there can be no doubt that  asthma is much more
prevalent than  among the community generally.
Under this head we may include all those persons
whose occupations have  an immediate  influence
in disturbing  the respiratory functions, namely,
such as are exposed to great and sudden changes
of temperature, labourers whose positions mecha-
nically impede  the free movements of the chest,
and artisans who are  exposed to the inhalation of
acrid fumes and  substances in  a state of minute
mechanical division, &c,  &c.   Certain classes of
persons in the upper  order of society are likewise
said to be more subject to asthma,  those, namely,
who have occasion to  make frequent and great
efforts with  the lungs and vocal organs ; but we
suspect that this  latter opinion  has been founded
quite as much on theoretical grounds as on actual
observation.  It is also stated by authors (Diemer-
broek, Op. lib. p. 144 ; Bree, p.  175) that persons
accustomed to smoke tobacco  are more liable to
the disease.   If this  is true, we ought to have a
great  increase of asthmatics in the present  day,
when the very  atmosphere of England (in towns
at least)  is almost constantly impregnated with
the fumes of this nauseous herb.   Asthma seems
to prevail in every climate ;  but there  is  reason to
believe that, like  some other diseases of the lungs,
it is more common in temperate climates than in
either the very  cold or the very warm regions of
the earth.  Joseph   Frank,  who  resided many
years in  Italy, and afterwards in Poland, informs
us that he found  the  disease  more frequent in the
north than in the south.   (Med. Univ. Prax.  torn.
vii. p. 384.)
   Pathology of Asthma. — Systematic  and
theoretical writers, in attempting to  explain the
phenomena of  asthma, seem to  have been misled
from the truth by partial views of the subject, and
by that aim at extreme simplicity, which has so
often proved  a stumbling-block  to  medical inqui-
rers.   In contemplating  the  animal system in
disease, physicians have  too often been disposed
to overlook the fact, so obvious in health, that it
is  by a variety  of operations, all conspiring to the
same end, that results are produced ;  and, conse-
quently, that if we attempt to explain the opera-
tions of the living body,  whether in the healthy
or disordered  state, on any exclusive or isolated
principles, we must  inevitably fail.  The young
practitioner cannot too much guard himself against
the belief that all  affections  bearing the  same
name are of the same  nature, or depend on the
same  causes ;  as false reasoning, in cases of this
kind,  will inevitably lead  to  grievous practical
errors.
   In examining the pathology of asthma, we have
to consider not merely the phenomena of the pa-
roxysm, but of the interval also ;  and to investi-
gate the condition not merely of the respiratory
organs, but  of  all the other organs.   In this in-
quiry we shall  find that, although there may exist
in every case one or  more conditions  which  more
especially characterize the  disease, and without 
ASTHMA.
209
whose presence asthma could not be said to exist,
yet that there are many other conditions of the
system, or of particular parts, which  only occa-
sionally accompany the more specific phenomena,
and  yet constitute, in  the  cases wherein they do
occur, the most important  features of the disease.
It is upon these accidental or contingent pheno-
mena that the means calculated to prevent, relieve,
or cure  asthma more particularly depend ;  the
knowledge of them, therefore, is most essential to
the  practitioner;  and  every attempt  at exposing
the pathology of the  disease  must be  extremely
imperfect which does not take them into account.
With these  reservations, which are only such as
practical physicians find necessary, in  almost  all
cases, when applying the results of theory to the
actual phenomena of disease, we are disposed to
coincide in the opinion of Willis, Hoffmann, Cul-
len,  and others, respecting the proximate  cause
of the asthmatic paroxysm.  The theory of these
great men, as is well known, was, that the asth-
matic fit  consists  essentially  in  a spasm of the
muscular fibres of  the bronchi.  In admitting the
existence  of this spasm, however, as  essential to
constitute the disease, we are very far from look-
ing upon it, in a practical point of view, as in every
case the most important part of the affection.  On
the contrary, as we have just stated, many of the
other morbid  conditions, general or local, which
commonly precede or co-exist with this phenome-
non, are  of infinitely  greater importance, both
pathologically and  in  practice ;  but, so  long as
these conditions are unaccompanied by  this pecu-
liar affection of the muscular fibres of the bronchi,
the disease is not termed asthma.
   Although strong doubts have been entertained
by many  eminent  pathologists, not merely as to
whether such a spasmodic affection of the bronchi
actually  took place in asthma,  but  even  as to
whether it was possible for it to take place in any
case, we have no hesitation whatever in maintain-
ing the  affirmative  of the proposition as  true, both
in the general and particular instance. Not merely
the  preponderance  of authority, but anatomical
investigation,  pathological  phenomena,  analogy,
and probability, are all in its favour.
   The  older authors, particularly Willis  and
Malpighi, demonstrated to their own satisfaction
the muscular  fibres in the larger bronchi.   But
the facts mentioned by them have been not merely
confirmed but greatly  extended  by the minuter
researches of modern anatomists.
   In the  splendid  work of Reisseisen,  published
at Berlin in  1822, (Franz Daniel Reisseisen Uber
den Bau der Lungen,) the  muscular structure of
the bronchi is considered as a fact readily demon-
strable, and is minutely delineated from nature in
the plates.  " There is another apparatus," says
he, "appointed for  contracting the bronchi, which
consists of transverse  muscular fibres.   As far as
the cartilaginous rows extend, these fibres are  in-
serted into their perichondrium, on the inner edges
of their extremities, diverging a little, in order to
fill up the space  left between the rows.  They
thus  form a  muscular tunic, extended over the
fibrous or ligamentous substance which supplies
the place of the cartilaginous rings behind.   But
when the bronchial  cartilages, as they descend,
cease to be disposed in regular r'wvs, the muscu- |
  Vol. I.—27                         s*
lar fibres are distributed around the whole circum-
ference of the canal, being attached to and extend-
ing over the irregular cartilaginous plates, which
here  take the place of the imperfect rings.  Nor
do  the muscular fibres disappear with these carti-
laginous  plates.    Although become  extremely
fine, they can still be perceived by means of the
lens,  as far as it is possible to  lay the tubes open
with  the knife, more  particularly  in the lungs of
strong men who have died at an advanced period
of life."   Varnier, (Mem. de la Soc. Roy. de Med.
1779, p. 394 et seq.,) Cruveilhier, (Diet, de Med.
Prat. torn. iii. p. 610,) Ollivier,  and many other
physiologists  entertain  similar  opinions.   The
latter says that the bronchi contract on the injec-
tion of an  irritating  gas.   (Diet, de  Med.  Art.
Poumon,  torn,  xvii.)   Laennec, referring to  the
account given by  Reisseisen, considers the exist-
ence  of the bronchial muscles  as certain,   and
states that he had himself verified their presence
in the tubes of less than a line in diameter.   He
adds, " that, although it appears difficult to follow
the muscular fibres further, analogy leads us to
admit their existence  in the smaller branches,  and
perhaps even in the air-cells."   (De l'Auscult.
Med.)   A  strong analogical proof of the mus-
cularity of the smaller bronchi, is afforded by the
muscularity of  the trachea, a  circumstance  ad-
mitted  by all physiologists.   It would certainly
appear, a, priori, that  this part of the canal had as
little need of muscular fibres  as the bronchi.   In-
deed, it seems not merely certain that the bronchi
possesses  a power of muscular contraction, and,
consequently, of lessening their caliber, but that
the smaller ramifications, at least, in other words,
the whole lungs  are endowed  with  an active
power of dilatation, altogether independent of the
movements of the chest.   This  power seems
demonstrated by numerous experiments on living
animals, by the phenomena which have occasion-
ally been  observed in the  case of wounds of  the
chest,  and by  various circumstances,  both of a
pathological and physiological nature, which have
been ascertained in the practice  of auscultation.*
  The main phenomena of the asthmatic parox-
ysm are precisely such as would result from a
morbid contraction of the bronchial muscles ;  and
several  of them seem quite  inexplicable on any
other principle.
  The extreme suddenness of the attack in many
cases ; its equally  speedy removal  in others, some-
times naturally, sometimes through the effect  of
remedies; the character of the dyspnoea and of many
of the general symptoms ; the state of  the pulse,
the urine, the  countenance, the  skin, the intellec-
tual functions, &c. &c. all clearly demonstrate it
to be  of the kind usually termed nervous or spas-
modic.  The only questions  that  can be mooted
relate to the exact part or parts of these organs, in
which the spasm is fixed.   Is it in the muscles of
the larynx and glottis  ?   Is it in the smaller bron-
chial ramifications ?   Is it in the external muscles
  * See, on this subject, the following authorities; Dir.l
des So. Med. art. Poumon ;  Roux, Journ. de la Soc. <le
Med. torn, xxxiv.;  also,  his Melanges de Chirurgie, p.
87; Cloquet,  de l'lnfluence des Efforts sur  les Organes
Thoraciques, Paris, 1820; Chaussier, Tables Sj-ncptiques;
Laennec, De l'Auscultation Mediate ; Michaelis, "n it■«•.!,
ter's Chir. Bibl. vol. vi.  Also cases of Boerhaave, S"ill
Eruns, Voigtel, L irrey, &c. 
210
ASTHMA
of respiration ?  Or is it in more or fewer of Ihese
parts at the same time ?
   These questions  demand a moment's conside-
ration.
   There are  several forms of spasmodic stricture
of the upper portion of the air-tube, more particu-
larly of the glottis, well known to practical phy-
sicians.  The more  common of these  occur in
infants  and young  children ; but they  are con-
fined to no particular period of life.  An old lady,
a friend  of the writer of this article, has  all her
life been liable to attacks of this kind, which seize
her  instantaneously,  after long  intervals,  and,
during their continuance, entirely prevent inspira-
tion, and thus threaten immediate death.    After a
few seconds the paroxysm subsides, without leav-
ing  a  trace behind it.  The disease described by
Dr. John Clarke as a "peculiar  species of convul-
sion in infant children,"  and of which  a  more
complete account has recently been published by
Dr. Marsh, (Dublin Hosp. Reports, vol. v. p. 600,)
'i* evidently  a spasmodic affection of the  same
kind, but less strictly confined to the  glottis than
in the  case just mentioned.   In the infantile dis-
order, the spasmodic disposition frequently extends
over the wbole muscular system, inducing  general
convulsions.   The disease frequently termed spas-
modic  croup, and which occurs  also  most  com-
monly in children, but at a somewhat later period,
consists, in like manner, in numerous instances, in
a spasmodic affection of the glottis ; but,  in this
case likewise, the spasms frequently extend further,
in many instances affecting the greater part of the
air-tubes.   When this is the  case, the disease is,
in truth, a form of asthma, and ought rather  to be
named infantile asthma than spasmodic croup.  A
few practical writers represent the common form
of asthma, in adults, as  consisting almost exclu-
sively of spasm  of  the same  parts ; and,  among
others, Dr. Wilson Philip.  " The spasmodic asth-
ma (says this author, in his recent work,) appears,
properly speaking, not to be a disease of the lungs
themselves, but of the parts of the upper extremity
of the wind-pipe, in which the contraction of the
passage of the air, by spasm of its muscles, pro-
duces  the  violent  struggling for  breath  which
attends its paroxysms."   We shall examine the
validity of this opinion after  having noticed the
other theories.   The chief of these is  that which
represents the asthmatic paroxysm as consisting
in a spasm of the external muscles of respiration.
   One would imagine that it could  be no very
difficult matter to determine, after an inspection
of the naked chest of a patient in a fit of asthma,
whether the external respiratory muscles were in
a state of spasm or not:  and we cannot  help sus-
pecting that  some  of those  who have  been the
strongest advocates  for the affirmative of this pro-
position, have taken but little trouble to  ascertain
its truth in the most natural and  simple way. Our
own observations have invariably led  to  the  con-
clusion  that all the  muscles of which the action is
perceptible,  are, during  the paroxysm,  exerting
themselves strongly to dilate the chest; and there
are the strongest reasons for believing that the
muscles, the action  of which is  concealed, are in
the same condition.   It  is universally  admitted
that expiration is, in ordinary cases, effected, in a
great measure, by the mere mechanical sinking of
the walls  of the  chest, upon the cessation of the
active  muscular efforts of inspiration.   The  ribs
descend and the diaphragm ascends, and necessa-
rily, upon the relaxation of the muscular fibres,
the contraction of which had enlarged the cavity
of the chest.  And  if we take into consideration
the immense superiority of power of the muscles
of inspiration, and  remember  that these  are all,
during the paroxysms, exerting themselves to the
utmost to dilate the chest, it seems  extremely
improbable that the  power of their feeble antago-
nists, however exerted, could resist them.
   But independently of these negative, proofs, we
have many direct ones that the  principal site of
the  spasm is in the  air-passages,  and that the
instinctive and voluntary efforts of the muscles of
inspiration are almost exclusively directed to over-
come this.  Some of these direct  proofs are the
following.   Asthma, as we shall soon  see more
particularly,  is  very commonly  dependent on a
diseased state of the bronchial membrane, and the
attacks are  frequently  induced by  an  increase of
this state.  The resolution of a paroxysm is almost
invariably  accompanied by  a great increase of
secretion from the bronchi, which could hardly be
expected to be the case if the affection were seated
either in the muscles of the glottis or in the exter-
nal muscles of respiration.  Diseases of the bron-
chi, which  produce a  similar contraction of the
air-passages by  mere swelling of the membrane,
namely bronchitis,  and  an affection  producing
nearly the same  physical  condition of  the parts
from a sudden  congestion of the  blood-vessels,
give rise to a state  of respiration very like  that
which obtains in the asthmatic paroxysm.  Aus-
cultation of the respiration, during the paroxysm,
discovers particular sounds over  the whole extent
of the chest, which sounds can  only have their
site in the bronchial tubes ; and  as these  sounds
come on and go off with the paroxysm, it seems a
necessary conclusion  that they depend on  the
physical changes produced by this, and that those
changes take place in the bronchi.   Common
wheezing, as heard by the unassisted ear in asthma
and in most cases of dyspnoea, may exist in a very
marked degree without the auscultatory rhonchus,
which may be considered the pathognomonic sign
of bronchial infarction from whatever cause de-
rived.
   But while, for these  reasons, we  think it must
be allowed that the main site of the spasms which
constitute the asthmatic paroxysm  is the bronchi,
we are by no  means  of  opinion  that they are
exclusively confined to  these.   On the contrary,
we think it very certain that not only all the parts
already mentioned, but  others still more remote,
are frequently involved in the  same  disordered
action.  This is what must have been anticipated
from  a consideration of the  very nature of the
affection.   In all spasmodic  diseases  there is a
disposition towards  extension of the spasm  from
the original  or principal site, and, indeed, this fact
is perhaps more easily explained  on physiological
principles than the restriction  of the spasm to one
part or one set of muscles could be.  In all these
cases,  if the  nervous centres  are  not  primarily
affected, they invariably become so subsequently;
and the circumscription of the local manifestation
of the spasm to the muscles first disordered thence 
ASTHMA.
211
becomes very improbable.  Besides, we know that
muscles whose actions are  at all associated, are
very liable to suffer generally when one or  more
of the class are morbidly affected.  And, in the
present case, we admit that the  muscles both of
the larynx and  the  chest are frequently involved
in the progress of the paroxysm.  They are, how-
ever,  we believe, in almost every case, affected
secondarily, and it is therefore impossible  to sub-
scribe to the opinions of those who wish to  make
them the chief site of the asthmatic spasm.  Other
muscular affections, of a  spasmodic kind, are not
uncommon  in the  paroxysm  of asthma.   The
sudden  calls to empty the bowels are no doubt
partly owing to a morbid  action of the muscles
concerned in this process ;  although chiefly, per-
haps, the consequence of the same general  disor-
der of the nervous  and vascular systems, which
gives rise  to  the  pallid  and shrunk state of the
surface, the flow of limpid urine, &c.   In a young
man, now under our care, subject for  some years
 to periodic  asthma, which  generally attacks him
 during  sleep,  the first indication he has  of the
 invasion of the paroxysm is an involuntary spas-
 modic twitching of the right foot or leg, of which
 he is conscious for some time  before  he  is  fully
 awake, and  of which  the increasing violence
 awakens him.   The twitching always  leaves him
 on his becoming fully awake, but he  then  finds
 himself under  the full dominion of his  asthma.
   It must  not  be imagined from any thing that
 has been stated,  that we consider the asthmatic
 paroxysm as consisting exclusively of  a muscular
 spasm of parts otherwise healthy.  This, indeed,
 may be the case in a few instances; but it is not
 to be doubted  that, in the great majority of cases,
 the spasm not merely affects parts previously dis-
 eased, but that the  phenomena of the paroxysm
 are partly dependent on, and greatly modified by,
 these very  lesions co-existing  with the spasm,
 aggravating it, and, in turn, being  aggravated
 by it.
    Varieties   of Asthma. — Several methods
 present themselves  for classifying  the different
 forms of asthma met with in practice.  Our limits
 do not permit us to enter into any discussion as to
 their respective merits, nor to give our reasons for
 preferring that which is here adopted, further than
 to state that we think all classifications of diseases
 ought to be  founded, when  practicable, on the
 pathological condition of the affected parts.
    On this principle we shall divide cases of asth-
 ma into two classes or groups, according as there
 exists a sound or a diseased state of the bronchial
 membrane in  the  intervals of  the  paroxysms ;
 terming those  of the first  class nervous  asthma,
 and those of the  second  catarrhal asthma.  We
 shall now notice these in order.
    I. Nervous  asthma.—The characteristic quality,
 or, at least, the most manifest physiological pecu-
 liarity of the individuals subject to nervous asthma,
 is the extreme susceptibility of their nervous sys-
 tem.  They are said, in common language, to be
 nervous, or to possess the  nervous  temperament.
 This is the asthma of hysterical females,  and  is
 indeed, in manv cases, only one of the multiform
 aspects of hysteria.  It, however, occurs equally
 in males, and  in  female, who have no other symp-
 tom  of hysteria.   Every one must  admit that  m
persons subject to asthma  mere moral causes fre-
quently suffice  to  induce a  paroxysm; and  it
seems, at least, extremely probable  that  similar
causes, when more intense, or when the individual
susceptibility is greater, may give rise to the  dis-
ease in persons not previously subject to it.  The
records  of  practical medicine contain innume-
rable examples of the  influence  of  the nervous
system  over the asthmatic paroxysm.   In  Dr.
Parry's posthumous works some curious cases of
this kind are given.  In one, severe dyspnoea with
irregular action of the  heart was instantaneously
produced, in the presence  of Dr. Parry, by mental
agitation.   The paroxysm  lasted eight  or nine
days, and  terminated  with  considerable  mucous
expectoration, showing, by the way,  the power  of
a mere  nervous affection  to  produce, by its con-
tinuance, local disease.   In  another case of old
and well-marked asthma,  the same physician wit-
nessed the instantaneous removal of the paroxysm
by  fright.   Many cases of an  analogous character
might be quoted from authors, and most of our
readers of long experience in  practice  must have
met with similar instances.   The following case,
extracted from Dr.  Whytt's work  on the  nervous
system, is  a striking example of the disease now
under consideration.   "A  girl,  healthful, well-
made, and of a seemingly good constitution, began,
at the age of seven years, to  complain  of a  pain
at the lower part of the sternum ; this pain, which
returned after no certain intervals, became gradu-
ally more severe during the space of nearly two
years, after which, in place of it, the  patient began
to be affected, at times, with  a difficulty of breath-
ing, which returned frequently, without observing
any certain periods ; as a week, a fortnight, or a
month would sometimes  intervene  between the
fits.  She was generally seized with the fits all at
once ; and  after breathing with the utmost diffi-
culty for  half an hour, sometimes more  than  an
hour, she  would,  of a sudden, become perfectly
well, and fall a-dancing immediately after with her
companions.  It was observable that this girl had
no complaint of her stomach, no  cough, nor other
apparent fault in her lungs ;  nor did she usually
expectorate  phlegm when the fit went off;  and,
except in time of the asthmatic paroxysm, breathed
with the  same ease  as  any person  in  perfect
health." ( Whytfs Works, p. 603.)  Some curious
 examples of nervous asthma are given by Laennec
 in  his Treatise on Diseases  of the Chest.  One
 patient was instantly  seized with great difficulty
 of breathing on attempting to  travel in  one par-
 ticular direction,  and  was  instantly  relieved  on
 turning back. This happened repeatedly. Another,
 an  old  asthmatic, subject  to slight catarrh, was
 invariably seized with  a paroxysm if his lamp hap-
 pened to go out during the night, although he was
 asleep at the time.  (De 1'Auscultation Med.)   A
 singular instance of the influence of the nerves in
 producing asthma, without any local disease of  the
 lungs themselves, is furnished by a curious affec-
 tion prevalent in the east among persons  addicted
 to the abuse of opium.   It is a kind  of  spurious
 or  factitious asthma,  which attacks  opium-eaters
 on being suddenly deprived of their habitual dose;
 in the same manner, and, no doubt, for the  same
 reason, that delirium  tremens attacks  the spirit-
 drinkers of colder climates.   The patient is seized 
>12
ASTHMA,
.vith extreme  breathlessness, exactly resembling
that of asthma ; the countenance being haggard,
the pulse rapid, and the eye such  as we should
expect to find in a patient affected with  phrenitis.
If the disease is not relieved, it proves fatal in the
course of a few hours.  Some opium given in time
will immediately relieve all the symptoms.  (Hen-
derson in Edin. Journ. vol. xxiv. p. 51.)
   For the sake of those who are curious in noso-
logical arrangements, rather than  as being of any
practical value, the following classification of the
various cases which come under the head of nerv-
ous asthma is submitted to the reader.
   1. In a very small proportion of these cases we
cannot detect any disorder of the system, general
or local, which can be  considered as  at  all in-
fluencing the occurrence of the paroxysms. These
may be termed cases of pure nervous asthma.
   2. In an infinitely  larger proportion of cases
we find more  or less  of disease in the system
generally, or in some of the principal organs; and
which disease  appears  to be the remote cause of
the paroxysms, influencing the bronchial  muscles
indirectly through the  intermedium of  the brain.
Such cases  may be termed sympathetic  nervous
asthma.   This  order  may  be  subdivided  into
species, according to the nature or site  of the af-
fection which constitutes the remote cause of the
paroxysm.  For  an account of these we refer to
a subsequent part of this  paper, where they will
be noticed under the head of predisposing causes.
It could lead to no useful end to notice  tbem here
in detail.
   3.  In a third group may be included, under the
name  of symptomatic nervous asthma, (1) those
cases  which depend on diseases immediately af-
fecting the pulmonary nerves themselves, and (2)
those in which the paroxysms are directly induced
by organic disease of the lungs,  head, pleura, &c.
Of the former kind there are various examples to
be met  with  in  authors.  In a case  of asthma
related by Ferrus, a large  ossification  was found
in the centre of the pulmonic plexus, and which
compressed some  of the nerves.  (Diet, de Med.
torn. iii. p. 109.)   In a case of fatal  dyspnoea,
Beclard could discover no cause of the disease but
a tumour on one of the diaphragmatic nerves.  A
nearly similar  case is recorded  by Andral (Diet.
de Med. Prat. torn. iii. p. 109.) ;  and Parry men-
tions a case of " dyspnoea occurring by fits of ag-
grivation, and at last proving fatal, without any
 symptoms of local pneumonic disease," in a per-
son who had " thickening about the  upper part
 of the vertebrae of the neck, with some degree of
 distortion, from venereal affection."   (Posthumous
  Works, vol. ii. p. 16.)   The influence  of spinal
 irritation in producing palpitation  and other irre-
 gular action of the heart, is well  known ; and we
 apprehend that many of the chronic dyspnoeas and
 irregular asthmatic affections which we meet with
 in persons who are deformed, arise as  frequently
 from  disturbance of the spinal marrow produced
  l>V the distortion, as  from  disease of the lungs
  diemselves.
   The second subdivision of this group of cases
  includes those fits of spasmodic dyspnoea which so
  frequently accompany  diseases  of  the  heart, hy-
  drothorax,  &c.   Although  such affections  may
  time within the logical definition of asthma in as
far as the spasmodic condition of the bronchi is
concerned, (and they are, therefore, alluded to in
this  place,) it would be  to confound all  rational
principles of pathology to consider  them as such
in practice.  They may very properly be  named
spurious  asthma,- but the consideration  of their
nature and treatment belongs to another place.
(See Dxspxcsa, and the articles which treat  of
the diseases of which they are incidentally symp-
toms.)
  II. Catarrhal Asthma—In studying the van-
ous  cases  of asthma met with in practice, while
we  find,  in  the vast majority of instances, some
fixed affection of the bronchial membrane, we find
great variety in the nature, and still more in  the
degree of this affection.  In one  class of cases
there seems to be  merely some peculiar modifica-
tion of the sensibility of the bronchial membrane,
which renders it  susceptible  of  being excited  to
morbid action by various external influences.   In
others, however, and in  an infinitely larger num-
ber, there exists either  an  habitual catarrh of a
formal character,  or  such a predisposition lo  be
affected  by catarrh, as practically to amount to a
like condition of the parts. In many persons thus
circumstanced, there is such a susceptibility to  be
affected by cold, and  to  catch cold, that they can
scarcely  ever be said to be free from it.  The least
change of dress, the slightest draught of air,  the
most trifling dampness of shoes  and stockings, or
even standing for a minute on a stone floor, will
give an instantaneous chill, and produce  an  im-
mediate  and sensible change in the condition of
the  bronchial  membrane.   In many persons this
morbid susceptibility to  cold, fostered and perpe-
tuated as it is by improper management, arises to
so great a height as to be extremely inconvenient
In the case of persons in easy circumstances, we
sometimes see the susceptibility to cold so great,
or so exaggerated by the hypochondriacal appre-
hensions of the patient,  that life  is almost devoted
to the one object of escaping cold; and it must be
owned, with very indifferent success.
   Althousrh very  great  susceptibility to cold,  and
to  be affected by catarrhal  affections,  may  un-
doubtedly exist without any discernible fixed affec-
tion of  the  bronchial membrane, yet this is only
in  the  earlier stages  of such states.   Sooner or
later, and generally very soon, the  mucous mem-
 brane becomes disordered permanently ;  and  it is
 this local disease of the lining  membrane of the
 air-passages, together with  the general liability to
 be  affected by slight degrees  of  cold, which con
 stitutes the most common state of persons subject
 to  asthma.  Between the extreme limits of this
 bronchial affection, from mere increase of sensi-
 bility  up to the most  acute inflammation,   the
 degrees  of shades are infinite.  We can only in
 this place allude,  and briefly, to  the most  marked
 of  these.  For fuller histories of these affections,
 we  must refer to other articles in  this work,  par-
 ticularly to BnoM-ii itis, Catarrh,  [Pr lmoxari]
 Emphvsi::sia,  &c.
   The  catarrhal  affections with which the  asth-
 matic spasm  may  be  combined  may  be either
 acute or chronic.  As being by  far the most com-
 mon, we shall notice the  chronic  varieties  first.
 Indeed,  we  shall  only notice the acute  forms in
 compliance  with  general custom, as we wish our 
AST
 observations in the present article to be considered
 as applying  almost  exclusively to a disease  of a
 chronic nature.
   1. The first  variety  of the chronic catarrhal
 asthma which we shall notice is ranged under the
 present head more  from analogy than from any
 certain proof of its being essentially of a catarrhal
 nature.  Its essential characteristic seems to be a
 peculiar  morbid  sensibility,  or irritability  of the
 membrane lining the bronchi,  rather  than  any
 sensible  physical  alteration  of it.   If  a name is
 desired for it, it  might, in  the  language of Laen-
 nec,  be  termed  latent  catarrhal asthma.   No
 doubt, if our means of investigation were suffi-
 ciently minute, we should find  a physical cause in
 the membrane itself for the morbid irritability ex-
 hibited by it on  the application of certain stimuli;
 but  as our senses do not enable us to detect any
 such cause,  we must content  ourselves,  for  the
 present, with noticing the resulting phenomena.
 We are disposed to  infer that the affection of the
 membrane is of  the  catarrhal kind ; — firstly, be-
 cause, in incipient  catarrhs, we have  often  the
 same susceptibility of the membrane, without any
 other symptom of catarrh ;  secondly, because  the
 asthmatic or dyspnceal paroxysm, in the cases now
 under consideration, frequently terminates in acute
 catarrh;  and thirdly, because this state of  morbid
 sensitiveness almost  always degenerates, eventu-
 ally, into some of the forms of chronic catarrh. In
 its progress,  the first stage is the dry catarrh, and
 this  soon passes  into emphysema.
   This peculiar irritability of membrane in many
 cases  continues  perfectly latent  until  rendered
 manifest by the application of certain  stimulants.
 Some  individuals  are affected  by only one kind
 of substance, others by two or more.  Ipecacuanha
 seems the substance which,  of all others, exerts
 the greatest influence in cases of this kind.  Every
 practitioner  of experience must have  met with
 individuals  in whom this  idiosyncrasy was so
 strong that  they could  not remain in the same
 room in which a vessel containing powdered ipe-
 cacuan was opened, even at a distance from them,
 without becoming  immediately  affected with  a
 paroxysm of dyspnoea  more  or less resembling
 asthma.  We have  ourselves known some cases
 of the kind, and have had several others pointed
 out to us by medical friends, in our own  neigh-
 bourhood.   Other  persons, not  affected by ipeca-
 cuan,  suffer  similar inconvenience  from  other
 substances in a state of  minute  diffusion  in  the
 atmosphere;  such  as the smoke of sealing-wax,
 the effluvia from  hay, the  fumes of chlorine, car-
 bonic acid gas, &c. &c.   In some of these cases,
the dyspnoea passes off speedily ;  in others it lasts
a considerable time;  and in some it terminates in
formal catarrh.*
  * See a case of this kind in Parry's Posthumous Works,
vol. ij.  One of the most interesting examples of this
Peculiar effect of ipecacuan is  the case recorded by Dr.
frott in the Philosophical Transactions for 1776.  The
patient was the  wife of an apothecary, and became sub-
ject to regular attacks of asthma after her marriage.
For some years no particular cause was suspected; but
it was at length discovered that the paroxysm invariably
came on when  ipecacuan was powdered in the  shop.
This practice was accordingly discontinued, and she con-
tinued well eight or ten years; until one day, when her
husband again brought home some powdered ipecacuan,
and opened the packet in order to put the drug into  a
bottle, "his wife not being  far off at the time, and in
HMA.
    2.  The next variety of catarrhal asthma is that
 which is complicated by the disease  termed dry
 catarrh  by  Laennec.  It may, therefore be deno-
 minated dry catarrhal asthma.  It is, perhaps, the
 most  common form  of asthma.   For an account
 of the pathology  of the catarrhal  affection, we
 must  refer  the reader to the article which is spe-
 cially devoted to it.   It will be there seen that the
 progress of  this affection inevitably leads to the
 morbid dilatation of the terminal bronchi or air-
 cells ;  a pathological state denominated pulmonary
 emphysema by Laennec.  As the asthmatic pa-
 roxysms seldom occur in an early stage of the dry
 catarrh, it very generally happens that  the emphy-
 sematous condition of the lung coincides with this
 variety of asthma, a combination which explains
 the results of the exploration of the respiration in
 this disease, noticed in the beginning of the present
 article.  The  co-existence  of emphysema  with
 asthma must be looked upon as of most unfavour-
 ble augury in  relation to the cure, as  the  former
 disease, when  once fully formed, is hardly suscep-
 tible of cure.  In the variety of asthma dependent
 either on the dry catarrh  simply, or on this com-
 bined  with emphysema, the  precursor and  imme-
 diately exciting cause of the paroxysm, is almost
 invariably a  fresh attack of cold, or, at  least, some
 aggravation  of the habitual catarrhal state.
   3. The next variety of  catarrhal asthma is that
 which  is combined with the common chronic mu-
 cous catarrh.  It is the humoral asthma of the old
 authors.  In conformity with the names given t\
 the preceding varieties, it may be denominated tht
 mucous catarrhal asthma.  This form of catarrh
 is occasionally the  consequence of those last  de-
 scribed ;  but it is  still more frequently produced
 by repeated  attacks  of the acute catarrh.  It is the
 common  chronic catarrh, frequent in old age, and
 by no means uncommon in youth.  It is often the
 sequel  of acute  bronchitis, and  is, indeed, itself
 only a form of the same disease in a chronic state.
 Although the asthmatic paroxysm frequently su-
 pervenes  to this state, our own experience inclines
 us to  believe that it complicates  still  more fre-
 quently the latent and dry form's of catarrh.  Indi-
 viduals subject to the chronic mucous catarrh are
 frequently said to have fits of asthma when their
 habitual dyspnoea is merely increased by the super-
 vention of a fresh cold, or by the  aggravation of
 the habitual  chronic inflammation from any other
 cause.   No  doubt  such attacks  are often accom-
 panied  with  a slight spasmodic constriction  of the
 bronchi;  and therefore they are, strictly speaking,
 entitled to the name of asthma :  but paroxysms
 of sudden dyspnoea, in which the spasmodic affec-
 tion is  the  most  conspicuous phenomenon, are
 certainly not  very common ;  indeed, they must be
 considered as very uncommon, when viewed rela-
 tively to the extreme frequency of chronic mucous
 catarrh.
   The  preceding are the chief  affections of the

 perfect health."  This occasioned a most violent fit of
 asthma, which lasted eight days, becoming better during
 the day, and much worse at night.  This patient's fits
 from ipecacuan usually lasted a  few days, and went off
commonly  by an expectorai.on of viscid mucus.  Quere
 As most of the cases of asthma from ipecacuan have oc-
curred in people connected with drugs, are  we to con-
clude that the peculiar idiosyncrasy is much more general
than is supposed, and is not evinced only because nth:
persons do not come in contact with this drig? 
214                                    A S T H M A.
bronchial membrane, of a chronic kind, with which
the asthmatic paroxysm is complicated.  There
are some  others of an acute character yet to be
noticed, and which, when  co-existing  with the
paroxysms of asthma, entitle this to the name of
the acute asthma.  Two forms of this species are
met with in  practice, sometimes sufficiently well
marked  to be  readily distinguished;  but  fre-
quently, like the other species of asthma, so inter-
mingled as to render the discrimination impracti-
cable.
   1. The  first  of these  two varieties may  be
termed the acute congestive asthma.  Were it not
that we frequently see the most extensive  inflam-
mation and consequent  tumefaction  of the bron-
chial  membrane, without  very great difficulty of
breathing,  certainly without any of that extreme
and peculiar  dyspnoea which  characterizes the
asthmatic  paroxysm, we might agree with Parry
in  opinion  that mere  vascular congestion,  from
sudden determination of blood to this membrane,
might account for all the phenomena of asthma.
And there  can be no doubt that, in a certain class
of cases, this determination of blood is not merely
the precursor of the spasm, but that it constitutes
the greater part of the  pathological condition of
the affected parts.  Of course, there is some modi-
fication of  the nervous condition of the membrane
previously  to the  afflux of blood to  it; but it  is
extremely improbable that this modification is of a
spasmodic  nature : on  the contrary, it can hardly
be doubted that it is the morbid congestion of the
blood-vessels which  irritates the  muscular fibres
into spasmodic stricture.  In this mode of viewing
the case, (and the same observation is applicable
to all the  forms of asthma dependent on disease
of the bronchial membrane,) we must regard the
asthmatic  paroxysm  rather  in the light of a con-
tingency than  as  constituting  an  essential  and
necessary  part of the  pathological state.  The
nervous modification, the determination of blood,
the vascular  congestion,  or catarrhal turgescence
may exist  without any spasm ; and this  may or
may not supervene according as it is promoted or
opposed by individual peculiarities of a general or
local kind,  the nature of which it is  impossible for
us  to ascertain.  The external  phenomena  will
necessarily vary with the pathological condition
of the  parts ; but  it is probable  that phenomena
which appear to us similar  may be  the effect of
different conditions.  Thus  it is  probable that a
paroxysm of like violence  may equally follow an
extensive  congestion with a slight spasm,  or a
slight congestion with a great spasm ; and all the
various and relative modifications of which these
states are susceptible will  produce a great variety
in the phenomena of the disease.
   A strongly marked case of congestive  asthma
is recorded by Dr. Parry, in a person "who, without
any previous disorder of the chest, died in fifteen
or twenty minutes, with every symptom of spas-
modic astnma ;" and in whom, on dissection, the
only morbid appearance observed was " a complete
suffusion, of  a damask-rose colour, amounting in
e>ome  places  almost  to  blackness,  of the entire
mucous membrane of the trachea, and of  all the
lamifications of the bronchia."  (Parry's Elements
of Pathology, § 474.)  Cases so strongly marked
us this are extremely rare.  We are disposed to
look upon  them as analogous  to  that disease of
the lungs  termed,  by Laennec, pulmonary apo-
plexy.
  There is another  form of  congestion  of the
bronchial  membrane, immediately dependent on
disease  of  the  heart, which  is  a  common cause
of dyspnoea in such cases, and  is also sometimes
the  source  of  the  asthmatical  paroxysm.  The
state to which we allude is almost of a mechanical
nature,  being the direct result of impeded circula-
tion.   In certain habits the congested state of the
bronchial membrane may produce simple dyspnoea,
in others asthma ; and in many it is at once indi-
cated and cured by  haemoptysis.  In most cases of
this kind, the other mucous membranes, as well
as the venous  system generally,  are overloaded
with blood.
  2.  The  last  variety of  catarrhal asthma which
we  shall notice may be  termed acute catarrhal
asthma.  It only differs  from the last in coming
on  more slowly, and  in being complicated with a
common catarrhal affection of the bronchial mem-
brane, instead of a  rapid congestion of the  same.
Reasoning  a priori, one might expect cases of this
kind  to be very common.  Such, however, is not
the fact.  The  disease which has been termed the
hay asthma, when  amounting to that degree of
paroxysmal violence deserving the name of asthma,
belongs to  the form  now under  consideration;
although this  affection is much  more  properly
designated  by the name  of summer catarrh.  In
some cases of this  kind,  the dyspnoea is  certainly
considerable ; in a small  proportion of cases it is,
according to Dr. Bostock, the only symptom : but
we  have not met with a  single well recorded case
in which the dyspnoea assumed the true asthmatic
character.*  In that  class of persons,  formerly
noticed, in whom  ipecacuan  and  certain  other
exhalations have the effect of producing great
bronchial  irritation, the  difficulty of breathing is
sometimes  preceded by an acute catarrhal state of
the membrane.
  The two species of asthma last described com-
prehend those  cases, of not very unfrequent oc-
currence, which were first particularly noticed by
Millar under the name of the acute asthma, and
which, on  the  continent  more  particularly, have
very generally been since  termed Millar's asthma,
from this author. They also include many of the
cases which have been described by authors undei
the name of suffocative catarrh, false croup, spas-
modic croup, suffocative  asthma, &c.;  although
many cases so  denominated  have  been cases of
pure bronchitis.  It is hardly necessary to repeal
what was formerly stated, that both these forms of
acute asthma, more  particularly the acute catarrha.
asthma, are merely different shades of that exten-
sive pathological state which comprehends all the
forms of acute irritation of the mucous membrane
of the lungs, from the slightest  febrile turgescence
up to the most violent inflammation.  It is only
the  accidental complication of spasm that lends to
it its peculiar features ; and in our  treatment we
must  never forget, that   however  prominent, or
however (for the time) important this complication
may be, it  is only  a  consequence  of a state yet
more  important.  When  the spasm  is  removed,
  * See Dr. Bostock's Papers, Med.  Chir. Trans  vols. x.
and xiv.: also Dr. Parry's Posthumous Works, vol. ii. 
ASTK
we may have still a formidable disease to treat.  It
is truly remarked by  Millar, that the acute asthma
frequently lays  the  foundation for the  chronic
asthma.   In the present paper we wish principally
to confine our views  to the chronic disease, which
alone is properly termed asthma.  The acute asth-
ma  more  properly belongs to  the articles which
treat of  the diseases of which it is merely a symp-
tom.
  It is  hardly necessary to observe that two  or
more of the above forms  of  asthma, or rather of
the above pathological  states, may co-exist in the
same individual.   We  may  have  the spasmodic
paroxysm immediately excited  by purely nervous
causes, induced  in persons already affected with
disease of the bronchial membrane, while all the
varieties of the symptomatic asthma may equally
affect individuals who have or who have not such
an  affection  of  the  membrane.  We may even
have organic disease of the heart, lungs, or pleura,
together with disease of the bronchial membrane,
and yet the immediate exciting cause of the asth-
matic fit  may  be some  irritation  situated in  a
remote organ. In like manner, the acute forms of
the  disease  may supervene to the chronic.   AH
this complexity forms no  substantial objection to
the classification we  have  just  given of the varie-
ties of  asthma.   Our object  is not to  exhibit a
specimen of logical nosology,  according  to  the
ancient approved method,  but merely to lay before
the reader such a catalogue of the varieties as  he
is likely to  meet with in   practice, founded upon
differences in their pathology.  If the student has
once accurate views  of the true nature of diseases,
he  will  have little difficulty  in discriminating all
the varieties of them which it is of importance to
know.
   In referring to the preceding investigation, it
may  be  useful to give a brief recapitulation  of
some of the principal points which  seem estab-
lished.
   1. In the disease properly  termed asthma, there
is always present a  spasmodic contraction of the
muscles of the bronchi, and  sometimes  a similar
state of the  muscles of the  trachea, larynx, and
external muscles of  respiration.
   2. In a small  proportion of cases, the spasmodic
stricture may take place (idiopathically or sympto-
matically) without any  previous disease of the  af-
fected parts.
   3. In the great majority of cases, the spasmo-
dic  constriction  is  dependent on  a  pre-existing
irritation of the  mucous membrane of the air-pas-
sages.
  4.  Phenomena of a very similar character are
sometimes the  consequence  of a  congested  state
of the mucous membrane of the air-passages, with-
out any attendant spasm.
   5. The congested or tumefied state of the mu-
cous membrane almost invariably accompanies the
paroxysms, whether  this state be a cause or a con-
sequence of the  spasm.
  6.  The violence of the paroxysms is modified
no less by the degree of  the congestion than  by
the degree of the spasm ;  a great congestion  with
slight spasm producing, probably,  the   same re-
sult  as  a slight congestion with a great degree of
spasm.
  7.  In some cases, the  tumefied or  congested
IMA.                                     215

 state of the  bronchial membrane passes off en-
 tirely with  the spasm,  without  any exhalation
 from the vessels or augmented secretion from the
 mucous follicles.   More  commonly there is  a si-
 multaneous relaxation of the  spasm  of  the  mus-
 cular fibres, and an exhalation from  the mucous
 coat.  This  exhalation  most commonly puts an
 end to the disease for a time ; not unfrequently,
 however, the congestive  passes to  a more perma-
 nent state of inflammatory  irritation, under the
 form of pulmonary catarrh or bronchitis.
   Morbid Anatomy of Asthma.—In a  com-
 plete history of asthma  it would  be  necessary to
 give a full account of the state of the affected parts
 observed  on dissection.   In  the present paper,
 however, we must content ourselves  with a brief
 notice of some of the most common  appearances.
 Various circumstances render this part of the his-
 tory much less perfect than some may be prepared
 to expect.  In the first  place, asthma, strictly so
 called,  scarcely ever leads to  a fatal  result  in its
 early stages, and,  therefore, few opportunities are
 found  of investigating the pathological anatomy
 of it in its simple state.  Secondly,  in  a certain
 proportion of cases, even  if an opportunity were
 afforded of examining the affected  parts in the
 early stage, if the opinions formerly advanced are
 correct, we ought not to discover  any morbid ap-
 pearances after death ; any more, at least, than in
 hysteria, chorea, or other diseases of a purely ner-
 vous character.   Thirdly, the parts principally
 affected in the asthmatic paroxysms are so minute,
 and have been hitherto  so little examined in ordi-
 nary dissections, that it  is not wonderful if they
 have often  escaped  notice, even when  diseased.
 Fourthly, whatever may have been the pathologi-
 cal condition of the parts concerned in asthma,
 in the early  stages, it is  certain that the long con-
 tinuance of the disease induces  various organic
 changes in  other parts ;  and it is  often difficult to
 pronounce, with  certainty,  respecting  the  share
 which  certain morbid alterations had  in producing
 the phenomena  of the  disease.  In  the greater
 number of the recorded dissections  of  asthmatic
 patients, the morbid appearances are almost always
 to be looked upon either  as  the  consequence of
 the disease, or  as concomitant lesions, not  more
 closely connected  with  the  asthmatic  paroxysm
 than as remote or  exciting causes, and  constitut-
 ing no essential parts of the pathological state.
    Willis gives a dissection of a  person  who had
 long been affected with  asthma, and  who died in
 a paroxysm.   In  this case, he informs  us, all the
 viscera were sound, and among the rest  the lungs,
 there being  neither an  accumulation of fluid in
 the bronchi, nor any  stagnation  of blood in the
 veins, ( Willis, De Morb. Convuls. cap. xii. p. 94.)
 This must have been a case of pure nervous asth-
 ma, or of asthma  dependent on  the dry catarrh,
 the anatomical characters of which  last named
 disease, when existing  in its simple state, were
 unknown at the time this author wrote, and would
 hardly  have been recognised if known. The proba-
 ble fidelity of this  dissection is, however, supported
 by the  experience of the best modern anatomists.
 Laennec, when writing  on the subject of nervous
 asthma, makes  the following  statement: "  Even
 at the period in which we live, when the eyes of
 medical men are particularly directed to me mi- 
Ulfi                                     AST
nute investigation of the anatomical character of
diseases, I have met with many cases in which it
was impossible, after the most minute research, to
find any organic lesion whatever  to which  the
asthma could be attributed," (De 1'Auscult. Med.)
Ferrus says that in fifteen years, almost entirely
spent in hospitals, he  has not met  with  a single
dissection which could be fairly considered as ex-
hibiting the results  of simple  or idiopathic asth-
ma ; and he adds that the still greater experience
of Corvisart, Leroux, and Lerminier, leads to the
same result, (Diet, de Med. t. iii.) This statement
is confirmed by Jolly, who informs us,  that  the
results have been obtained by Andral, Bouillaud,
Cruveilhier, Guersent, &c,  (Diet, de Med. Prat.
t iii. p. 608.)   The last-named author relates two
cases, in infants who died of " an acute remittent
dyspnoea, with quick  pulse, praecordial  anxiety,
and dry cough," in whose bodies no organic lesion
whatever could  be  found,  (Diet, de Med. Prat, t,
iii. p. 126.)   Akenside gives an account of some
cases of asthma, which proved suddenly  fatal; in
one of which, on  dissection, nothing preternatu-
ral  was found except  a morbid redness  of the
lungs,  (Med. Transact, vol. i.)  In this  case, al-
though the phenomena of asthma appear to have
existed  during life,  the patient's  death, " suddenly
at night, in a quiet sleep," is more  like that from
disease  of the heart than asthma.   Dr. Heberden
gives the outline of the dissection of three cases,
of what he terms asthma.  One of  these was evi-
dently  a disease of  the heart.  In the second case
the thoracic viscera were sound, and no morbid
affection could be detected, except an exostosis of
the vertebrae.  The third case  was  a well-marked
example of pulmonary emphysema, (Commentar.
p. 63.)   This condition of tbe lungs, which must
be considered as frequently a consequence, as well
as a cause, of asthma, is noticed by many of  the
older authors, particularly Bonetus,  (Obs. 57, 58,)
Ruysch, (Obs. 19, 21,) Morgagni, (Epist. iv. 24;
xviii. 14,) Stoll, &c. &c.   It was,  likewise,  par-
ticularly described  by  our  countryman  Floyer,
many years ago, as  existing both in animals and
man; being, in hawks, the cause of the crocke, a
kind of dyspnoea produced by  over-straining in
flying;  and, in horses, the cause of broken-wind,
(Physician's Pulse  Watch.)
  The same condition of the lungs  is, also, men-
tioned  by Ridley, (Observ.  Med. Pract. p. 219,
234. Lond. 1703,)  Sir W. Watson, (Phil. Tran.
Abrid.  vol. xii. p. 145,) and  others of our older
writers.  The dissections recorded in the work of
Dr. Bree throw no light upon the morbid  anato-
my  of  proper asthma, as almost all  his cases were
mere symptomatic dyspnoeas, produced by organic
diseases of  other parts.   Dr. Baillie has  given us
accurate descriptions  of all the  varieties of em-
physema of the lungs, but, unfortunately, we have
no histories of disease to connect the lesions with
asthma.  We shall  conclude this brief exposition
"*ith a  notice of two cases  by  Andral, which ap-
pear deserving particular attention.   One of these
'«as a violent dyspnoea succeeding  the  retroces-
sion of measles, and presented, on  dissection, all
the  marks of bronchitis.  In the other, which sud-
denly supervened to the drying-up of an old ulcer,
and which might properly be termed  acute asth-
ma, the bronchial membrane was found reddened,
IMA.

 in  patches only,  in small spots.   Andral justly
 considers the inflammation, existing in  this case,
 as inadequate of itself to account  for either  the
 symptoms or the  fatal event, (Clinique  Med. t. ii.
 P- 72.)
   Diagnosis of Asthma. — The diagnosis  ol
 asthma is seldom difficult.  Itisoneof the diseases
 most readily recognised, and most familiarly named
 by the subjects of it, and  by their friends.  Still,
 as there are a few affections which have consider-
 able  external similarity  wiih asthma, it  will be
 proper briefly to notice them in  this place.  Sys-
 tematic writers, indeed, supply us with a formida-
 ble list of diseases, which tbey say may be con-
 founded with  asthma;  but to give any account
 of the distinctions between the greater number of
 them and  it, would  be only trifling with the read-
 er.  Even the few remarks we  are about to make
 are intended much more for the  student than  for
 those who have had frequent opportunities of wit-
 nessing the diseases in question.
   In the spasmodic affections  of the glottis de-
 pendent on hysteria, the whole fades of the dis-
 ease is very different from that  of asthma.  The
 somnolent languor,  and frequently recumbent pos-
 ture of the hysteric  patient, contrast very striking-
 ly with  the awakened eagerness,  the acute dis-
 tress,  and  laborious  voluntary  exertions of the
 asthmatic.  In spasmodic affections of the glottis
 from other causes,  such  as we  meet with  most
 frequently  in children,  but not often  in  them,
 there is a nearer approach to the external pheno-
 mena of asthma.  In cedema, or in inflammation
 or ulceration of the  glottis, in  all of which there
 is more  or less spasm combined with the fixed
 physical changes, an inexperienced observer might,
 at  first sight,  have  some doubts  respecting the
 nature of  the disease.   A  closer examination,
 however, will soon  remove all  difficulty.  In all
 the affections of the  glottis and larynx, the patient
 recognises and points out these parts  as the seat
 of his distress.  In  some there is  acute pain,  in
 all there is a marked and  obvious  sense  of stric-
 ture  there.  The patient frequently endeavours,
 by handling  the  external parts, to relieve this
 stricture.   He has  the  distinct feeling that the
 inlet is too small  for the supply of air necessary
 to his well-being; and generally, he has the addi-
 tional horror of impending  suffocation  from the
 progressive increase  of the obstruction.  Some of
 the most prominent  symptoms are also very differ-
 ent in the  two classes of cases.   In  the affections
 of the larynx, the sound produced by the passage
 of the air through the obstructed aperture  is very
 peculiar, and  very different from that which ac-
 companies asthma, which latter is merely an exag-
 geration of the  well known  sound of simple
 wheezing.   Almost  all these observations apply,
 mutatis mutandis, to every partial obstruction of
 the trachea as well as larynx, whether  such ob-
 struction arise from  foreign growths pressing on
 it, externally, from foreign bodies accidentally in-
 troduced into it, or from morbid formations within
 its cavity, as in croup.
   Cert.un  cases of severe bronchitis have likewise
 a considerable external  resemblance to  asthma,
 when first  seen.  In almost every instance, how-
 ever, a minute examination of the  various symp-
 toms, or even the history of the attack, will speed- 
ASTHMA.
217
lly remove  all doubt  of the  nature of the case.
We do not here allude to that class of cases which
were formerly noticed under the  name of acute
asthma, but to simple bronchitis, unaccompanied,
or almost  unaccompanied with  spasm.  In  the
cases termed  acute asthma, there  is, as  we have
seen, very frequently present an inflammation  of
the bronchial membrane ; but  this  is  in  itself
slight in degree, and bears, in relation to the sum
of disease,  only a small proportion to the vehe-
ment spasm with  which it is  accompanied.   In
affections of this sort, the immediate consequences
of the spasm usually mask, and, as it were, over-
whelm, the symptoms of inflammation, the coun-
tenance becoming  haggard and shrunk, the skin
cold and clammy, and the pulse incalculably quick
and extremely feeble. It is, no doubt, unfortunate
that such cases have been classed under the head
of asthma  at all; as there is  reason to believe that
the very name has had frequently the effect of  di-
verting the attention  of the practitioner from the
only part of the disease which is really of much
importance in a practical point of view.   Against
this danger, the judicious and experienced practi-
 tioner will  be on his guard, and will be careful not
 to adopt such measures of treatment for the relief
 of the  spasm, as  may tend to aggravate the  in-
 flammation ;  and  will sedulously watch the  de-
 clension of the former, so as to  be prepared to
 treat, when practicable, the more fixed  and more
 important affection of the mucous membrane.
   Very severe dyspnoea sometimes accompanies
 the more acute and pure forms of bronchitis;  but
 there are strong and obvious lines of distinction
 between it and asthma.   In the first  place, the
 stricture on the chest and  dyspnoea in bronchitis
 are very much less, and are also different in kind.
 In the inflammatory affection,  the chest is still
 capable of considerable dilatation, even  in  the
 severest examples, which  is never the case in the
 asthmatic paroxysm.   Secondly, the usual symp-
 toms of inflammation are present in bronchitis, a
 circumstance which never occurs in pure asthma.*
 Thirdly, the  history of the attack will  be found,
 on inquiry, to  be  very different in the  two cases.
 Like all inflammatory diseases, bronchitis requires
 a certain space of time for its development, and it
 never comes  to its acme suddenly as asthma does.
 Both may  be forming for some time ; but the  in-
 vasion of the  severe dyspnoea is  in the one case
 gradual, in the. other per saltum.  In  the fourth
 place, we may be allowed to state, for the benefit
 of the  inexperienced practitioner,  that a pretty
 accurate judgment may be formed of the nature
of the case (unless in the very first  attack) from
circumstances quite extraneous to the disease itself.
If the case  is asthma, the comparatively composed
*nd  unappalled countenances of the patient and
his friends, at once bespeak  the consciousness of
in  attack which  is neither novel nor dangerous.
Their  looks supplicate  relief from suffering,  not
escape from danger.   The state of things is very
 lifferent in a severe attack of genuine bronchitis.
  * Almost  all practical writers consider the presence
J fever as sufficient evidence that the disease is  not
Wthma. Thus Sydenham: " Notha hiec peripneumonia,
licet ad asthma siccum aliquantulum accedat, turn quoad
spirandi difficultatem, turn etiam alia qua;dam sympto-
inata, ab illo tamen satis dignoscitur, cum in ista mam-
festa febris atque inflammationis signa se prodant, quae
in hoc nusquam comparent." -Opera Universa, p. 271.
  Vol I— 28                           T
  The only other cases which we shall here no-
tice, are those  sudden  and violent attacks of
dyspnoea, noticed in a former part of this article,
which  frequently accompany' different organic
diseases of the thoracic viscera.   These cases, as
we  there showed, may be logically, but not patho-
logically,  ranged  under  the  head  of nervous
asthma.  They are more properly termed spuri-
ous asthma.  The previous history  of the  case
will, generally, suffice to point out the  difference
between  attacks  of  this kind and true asthma ;
and where  this is insufficient, proper attention to
the actual symptoms  and to the  physical signs of
thoracic diseases, will soon remove all difficulty.
The diseases which  commonly give rise to  these
paroxysms of spurious asthma,  are, dilatation of
the  heart,  contraction of the  valvular orifices,
hydrothorax, and certain  other chronic affections
which  directly circumscribe the  sphere of action
of the lungs.  It is fortunate that all these diseases
have become of very easy diagnosis since the dis-
covery of auscultation and  percussion.  In  most
cases the application of the stethoscope for  a few
minutes  to the  chest, or the employment of per-
cussion for  the same period,  will remove all
obscurity as  to the nature of the  affection.   For
details,  however, we  must refer  to the articles
which treat of those diseases individually, and to
the general article on Auscultation.
   The prognosis in asthma needs  no formal dis-
cussion.   It  may be  gleaned from what has  been
already delivered on the pathology of the disease,
and from the pathology of the diseases with which
the paroxysm is complicated, or  to which it  leads.
  Asthma  hardly ever proves fatal as asthma, that
is, in the paroxysm; but its frequent recurrence
not merely aggravates the pathological states  in
which it bas originated, but  leads  directly to the
production of other  diseases.  The popular say-
ing, which may be considered as almost prover-
bial, of asthma being a charter of long life, has
probably originated in the natural disposition of
the mind to exaggerate, beyond its  true degree,  *
any circumstance which has repeatedly turned out
differently  from  what we expected.  The  most
common of the diseases which originate in asthma,
are emphysema  of the lungs,  dilatation  of the
heart, hydrothorax,  and  other  forms of dropsy
For the prognosis in these cases, we must refer to
the respective articles in the present work, which
treat of the diseases individually.
  If asthma  is rarely fatal, it may be  said  to be
almost as  rarely cured, if this epithet  is applied
only to the entire and permanent removal of the
disease.  It is, however, frequently susceptible of
great mitigation, and retardation  of the paroxysms.
On the whole, bowever, it must be  admitted that
there are few diseases less amenable to the  inter
ference of  art.  It  has, consequently, ever   been
one of the  marked  opprobria of legitimate medi-
cine, and an  unfailing source of employment and
profit to charlatans.j-
  Causes  of Asthma.—In a former part of this
paper we had occasion to give  some account of

  t  As far as relates to the cure of asthma, the progno-
sis cannot, perhaps, be summed up  better than in the
words of old John of Gaddesden :—" Et primo sciendum
est, asthma in senibus  non recipere  curationem, nee in
alia tetate nisi difficulter, maxime si sit antiquum."—
Rosa Anglica, p. 290.  August. Vindel. 1595. 
219                                     ASTI

the causes of asthma.  The importance of the
subject,  however, renders  some  further  details
necessary.   We  shall notice, in order, first, the
remote or predisposing, and  secondly, the exciting
causes.
   I. Predisposing causes___One of the most com-
mon predisposing causes of asthma is hereditary
transmission ;  this disease, or the predisposition to
it, being, according to our  own limited observa-
tion, one of the most frequently inherited.   Like
other hereditary diseases, however, it often  seems
to affect rather an irregular course.   In most of
the cases the history of which we  have investi-
gated, while we  have rarely failed  to find some
one  of the near relations or progenitors of the
patient  subject  to  asthma, we  have very often
found the  immediate parents  to have been free
from  it.  In  some instances  we have known a
considerable proportion of the members of the same
stock subject either to this or some  other disease
of the organs  of respiration ; one being subject to
a chronic cough, another to permanent dyspnoea ;
one  being  liable to inflammatory attacks of the
chest, and  some  having already fallen victims to
consumption.   A strongly marked  case of here-
ditary asthma is one  recorded  by  Sennertus, in
the family of his wife.  Her father, two brothers,
a sister, and a sister's daughter, all laboured under
asthma.   (Sennert. Opera, torn. ii.  p. 169.) We
do not think that the phthisical constitution greatly
predisposes to  asthma.  Malformation of the chest
may,  perhaps, be justly enumerated  among the
hereditary causes of asthma, as this configuration,
or at  least the predisposition which  directly leads
to it, is very frequently inherited.   At all events,
it  must be admitted  as  one of the  predisposing
causes of asthma.  [This probably applies rather
to emphysema of the lungs than to  asthma ; and
many of the recorded cases of asthma in young
children  belong unquestionably to  emphysema.]
Other peculiarities of  structure of the respiratory
organs, both connate and acquired, predispose to
asthma, of which kind we may reckon narrowness
of the glottis, (Diet, de Med. Prat. t. iii. p. 599,)
&c.   And  here also,  perhaps, ought to be classed
that peculiar  morbid sensibility of the bronchial
membrane, already noticed, which renders it into-
lerant of certain  impregnations of tl.e inspired
air, more particularly ipecacuanha.
   Several diseases predispose strongly to asthma,
particularly chronic disorder of  the  stomach and
bowels, gout,  diseases  of  the  skin, and uterine
affections.  Still more strongly and directly predis-
ponent are all diseases which directly affect the
bronchial membrane, namely, all the varieties of
catarrh  and bronchitis, measles, &c.  Gout and
diseases of the skin must likewise be enumerated
as exciting causes, since their suppression, as  it
is  called, is frequently followed  by a paroxysm.*
The same is  true of  habitual morbid discharges,

  * " Proh Deum immortalem !  (exclaims Schneider)
quam  multi arthriticorum asthmate seu  suspirio extin-
guuntur !" It is  to be observed, however, that Schneider,
like most writers before the time of Willis, confounded
nil the diseases of the heart, &.c. producing paroxysms
of dyspnoea, with asthma properly so  called. This author,
leferring to gout as a great predisposing cause of such
attacks, quotes  a good saying of Dunetus to a certain
prince:—
   " Uuanj vousaves le goutte vous estes a plaindre
    Muand vous ne l'aves pas, estes a craindre."
rl M A.

 whether of blood, as from the hemorrhoidal ves-
 sels, or of pus from old ulcers  whether natural or
 factitious.   But, of all the predisposing causes of
 asthma, dyspepsia, in  some of its forms or conse-
 quences, is by far the most frequent.   Indeed, as
 several of the affections already  enumerated as
 predisposing to asthma, such as chronic diseases
 of the skin, uterine  and  hemorrhoidal affections,
 &c,  may, in  a  great  majority  of instances, be
 traced ultimately to  dyspepsia as  their cause, we
 may, without impropriety, set down to  the score
 of this affection  most  of  the cases of  asthma
 which are usually said to originate from the above-
 named diseases.  It is only,  however, in what
 may  be termed  secondary  dyspepsia,  or  that
 general disorder of the system which is so often
 the consequence of  long and continued irritation
 of the chylopoietic organs, that results of the kind
 now contemplated arise.  In these cases the dis-
 tribution of both the nervous power and the circu-
 lating fluids becomes irregular,  while the fluids
 themselves become  depraved.   It  is in this state
 of the  system that those  local congestions of
 blood take place, which  constitute the first per-
 ceptible ground-work of the very large class of
 secondary  diseases.    If general plethora  is pre-
 sent in cases of this kind, as it frequently is, then
 some form of gout, or local  hemorrhage, or mor-
 bid  increase  of some natural secretion,  is the
 mode in which nature seeks to relieve, and often
 does relieve herself  when she is most oppressed.
 But it  is more particularly in  producing changes
 of structure or of secretion in the mucous mem-
 branes of other parts, that chronic  disease  of that
 of the intestinal canal exerts its vicarious power.
 It is in this  way that  the  bronchial membrane
 sometimes  suffers singly,  sometimes conjointly
 with  that  of  other  parts, more particularly with
 that of the uterus and vagina in females.
    Many other predisposing causes are mentioned
 by authors, such as simple plethora, corpulency,
 erysipelas,  suppressed  perspiration  of  the feet,
 &c.   JVo doubt all these are justly accused, par-
 ticularly the first ; but we can  do no more here
 than refer  to them.
    But of all diseases which predispose to asthma,
 inflammatory  and catarrhal affections of the bron-
 chial membrane are by far the most frequent and
 effective.   Other diseases may be  said to  predis-
 pose indirectly, but catarrh directly.  In this class
 of causes we include  measles and all the acute
 eruptive diseases, as likewise fevers, which are so
 frequently  attended  by catarrhal  affections of the
 bronchial membrane.   Many  asthmatic  patients
 date  the  commencement of  the  cough,  which
 eventually, after  many years  perhaps, terminated
 in asthma, from the  measles or small-pox, or some
 severe fever.  These diseases had left behind them
 that  permanent catarrhal affection of the bronchial
 membrane, which we  have formerly shown to be
 the ordinary groundwork of asthma.  The same
 results  follow from  repeated  attacks of common
 catarrh.  In some of these last it would, perhaps,
 be n.ore correct to go a step further back, and state
 the predisposing cause of asthma to be an extra-
 ordinary susceptibility to the impression of cold,
 rather than the catarrh  itself, which is the conse-
 quence of this susceptibility.  The most common
 cause  of this  morbid sensibility to cold is t» be 
ASTHMA.
219
found in the luxurious habits of later times, which
have carried  to a dangerous  excess  the  comforts
of our dress and habitations.   In nothing is there
a greater contrast between us  and our ancestors
than in the luxurious closeness and warmth of
our apartments ; and  it will scarcely be  denied
that tbe result of such a mode of living has been
to render us more easily  affected by the rigour
and  changeableness of the climate  out of doors,
which, unhappily, appears rather to have retro-
graded than improved, while the endless invention
of new modes of defence in our domestic arrange-
ments, has made the  contrast still  greater.   No
author has dwelt  so much  on the consequences
of these luxurious  habits in  predisposing to asth-
ma, as  Withers,  whose  observations are most
pertinent,  and well merit the attention  of  the
reader.   (See  his  Treatise  on  Asthma.)  It is
frequently by inducing this  sensibility to the  im-
 pression  of  cold,  and by thus  predisposing to
 catarrh,  that  dyspepsia lays the foundation  of
 asthma.   Many other  of the remote causes  of
 asthma operate  in  the  same  manner, and among
 these, certain mental  states, particularly the de-
 pressing  passions.   Sedentariness and seclusion,
 the natural consequences of grief and melancholy,
 give rise  to dyspepsia, and dyspepsia induces the
 languid  circulation in  the skin,  extremities, and
 mucous membranes, which  seems to be the im-
 mediate cause of the increased sensibility to cold.
   II. Exciting causes.—Under this head must
 be comprehended  all  such circumstances as have
 been known immediately to  induce a paroxysm,
 whether  in  the predisposed  or  not.  These are
 extremely numerous and various.  Joseph Frank
 alone enumerates  upwards  of forty, and it is but
 justice to this learned and  indefatigable writer to
 state that he gives his authority in every  case.
 (Prax. Med. Univ. Pars ii. vol. vii. p. 386.)  Our
 countryman Willis, in general and more pithy
 terms, conveys  nearly the  same information when
 he informs us that " asthmatics can bear nothing
 violent or unusual.  From excess of heat or cold,
 from any great bodily exertion or mental emotion,
 from change of season or  of weather, from errors,
 even of  a slight  kind,  in the non-naturals, and
 from a thousand things besides, they fall into fits
 of dyspnoea."*  By far the most  common  and
  most important of these cases, we  consider to be
 the application of cold, or, at least, one or more
  of those circumstances, whatever  they may  be,
 which,  in ordinary cases, produce  catarrh.   Al-
 though it will  appear from what is gone before
 that we  do not deny the existence of cases of
  asthma of a purely nervous kind, and  altogether
 independent of any permanent local affection of
 the  bronchial  membrane, we are  decidedly of
 opinion  that they constitute  an extremely small
 proportion of the cases met with in practice. And
 we are further of opinion that out of the immense
 majority of cases  of asthma  from  other causes,
 nine-tenths  are complicated with some form of
 catarrh, or, at  least, with  a morbid  susceptibility

   * Asthmatici nihil violentum aunt inassuetum ferre
 possunt: a frigoris vel caloris excessu, a vehement! quo-
 vis corporis aunt aniini inotu, ab aeris aunt anni muta-
 lionibus quibusque  tnagnis, ab erratis vel levioribus
 circa res non naturales, imo propter mille alias oocasio-
 "cs in dvspnoeae paroxysmos incidunt.  — De Medicam.
 Oper. p. 209.
of the bronchial membrane to be affected by cold.
In this  very numerous class of cases, then, all
those circumstances which  induce  catarrh,  and
which  may generally be considered as some form
or modification of cold, applied to the whole body
or to a part of it, must be understood  to  be  the
usual exciting causes of the  asthmatic paroxysm.
   [Yet  in regard to the exciting causes, there are
some which induce asthma, and can scarcely be
considered  amqngst  the  causes of catarrh.   In
general, a cold and dry air suits the asthmatic, but
there are  singular  differences  in  this  respect.
Closing a door  has  been known  to bring on a
paroxysm;  and, with some, darkness increases
the  violence of  the  attacks.   One cannot  bear
smoke; another exists better in a smoky apart-
ment.   (Dunglison's  Practice of Medicine,  2d
edit. i.  327: Philad. 1844.)]
   All  practical writers on asthma lay great stress
on this exciting cause, but  none with such pre-
cision   and  effect as  Withers,  Ryan,  and Watt.
The latter  author in particular, in a short but
most valuable essay published in his Treatise  on
Diabetes, has very strikingly and beautifully illus-
trated the subject.  In several cases there recorded,
he has pointed out, with the greatest minuteness
and perspicuity, the gradual influence of the cause,
from the first impression of  the cold up to the in-
vasion  of the paroxysm.  (Cases of Diabetes, &c,
p. 254. Glasgow, 1808.)   Ryan had  previously
made the same observation, and applied it to prac-
tical purposes of the  greatest importance.   (Ob-
servations on Asthma, p.  40. London, 1793.)  In
these opinions our own experience leads us  fully
to concur;  almost every case of  asthma which
we  have met  with being traceable to the usual
causes  of catarrh, and  most  of them  being ad-
vantageously treated only on the principles which
regulate the practice in that  disease.
   Treatment of Asthma.—In this, as in other
diseases, the attainment of a just pathology would
 wonderfully abbreviate the labour of therapeutical
prescription.  In the writings of the older authors,
 who were,  in general, guided  either  by empirical
 views or by fanciful  theories  of disease,  we  find
 no  end to  the  array of medical  formulae,  until
 every thing that had been put on record  by their
 predecessors, or had been imagined by themselves
 or their contemporaries, as useful or likely to be
 useful  in  the  individual disease under considera-
 tion, has been displayed at  full length.   In our
 own days, and in the diseases of the nature of
 which  we  have acquired some accurate views, «
 few general  precepts will  convey to those  ac-
 quainted with the general   principles of thera-
 peutics all  that we have  to deliver respecting  the
 treatment of a disease. We  have not yet attained,
 in the  case of asthma, to  a pathology perfect in all
 its parts ; yet we trust that  enough has been re-
 corded in  the preceding pages to permit us to be
 more brief in the delivery of our practical precepts
 than some of our predecessors.
    In entering upon this  part of our subject, it is
 desirable that the reader  keep constantly in  mind
 that almost every thing  in  the  succeeding pages
 respecting  the treatment  of  asthma applies exclu
 sively  to the  chronic forms of that disease.   It
 will be recollected that  the  disease termed acute
 asthma is either a variety of  bronchitis, oi a violet 
220
ASTHMA.
congestion of the pulmonary mucous membrane,
and that it is to be treated on principles applicable
to such pathological  states, with little regard  to
the spasm which complicates it.  For the proper
treatment of this affection  we must,  therefore,
refer to the articles Bronchitis and Catarrh.
   The treatment of asthma, like that of all periodic
diseases, consists  of two parts, that proper in the
paroxysm, and that in the  interval.  We shall
notice these in the order now mentioned.
   I. Treatment in the Paroxysm___The simplest
mode of proceeding,  and that which will lead to
least  repetition  and  circumlocution, will be  to
notice tbe treatment under the head of the differ-
ent remedies or  classes of remedies which have
been  employed, or which may seem worthy  of
being employed.
   Bloodletting.   The  extreme  suffering  of the
patient in the asthmatic paroxysm will very na-
turally  suggest the employment of so powerful a
remedy as bloodletting.  This is, accordingly, one
of the  measures which the young  practitioner is
almost  sure to have recourse to upon being first
called to  a severe  case.   Experience,  however,
will inevitably lead to  opinions less favourable to
its use than might  be anticipated before a suffi-
cient trial of its efficacy.  It is, no doubt, a very
proper  remedy in some cases ;  but it cannot be
recommended as  one  that is  generally either use-
ful or safe.   It may be occasionally necessary as
an auxiliary to  other means, or as a measure of
precaution against the ill consequences likely to
be produced by the paroxysm on other parts ; but
it should never  be looked upon as a measure to
be had recourse to, like  many  others, on almost
empirical principles.   It  is a  remedy  too  im-
portant to be trifled  with.   It never, we  believe,
puts  an end to the paroxysm,  much less does it
cure  the disease; and its habitual employment in
an affection of frequent recurrence cannot fail to
be highly injurious.  It is  indicated in the early
attacks of young and robust subjects ; in cases of
great  general plethora; in fits  of  great violence,
in which the pulmonary circulation is much im-
peded, and the brain or other  important organs
are likely to suffer in consequence.  Cases of this
kind are denoted by the extreme violence of the
dyspnoea, lividity of the face, stupor, &c.  Bleed-
ing with leeches is never proper in the  asthmatic
paroxysm ; cupping may be occasionally useful,
especially when  there  exists much cerebral con-
 gestion.
   Narcotics, antispasmodics, Sec—Medicines of
 this  class seem  particularly indicated by the ob-
 viously spasmodic character of the  paroxysm, and
 Dy its violence ;* and  accordingly they have been
 very generally  prescribed in it, in one  form or
 other,  from the  earliest times.  It must be ad-
 mitted, however, that the success of such remedies
 has been very limited,  and the  practice but little
 trusted to by experienced persons, whether prac-
 titioners  or the subjects of asthma.  In the great
 majority of cases in which  opium  and the medi-
 cine* termed anti-spasmodics have been employed,
 they have  failed to afford  any relief; while in
 many  they  have proved injurious, either at  the

   *In qu'busdam  (says Poterius, speaking  of asthma)
 lanta est morbi ferocia ut a laudano incipere  cogamur
  roter Op. p. 301.   Francfurti, 1698,
time or in their subsequent effects. A little reflec-
tion on the pathology of the disease will readily
explain this  result.   In most cases the only por-
tion  of the disease which such  remedies are cal-
culated to relieve, (the  spasm,) is conjoined with
and dependent on a pathological condition  of the
bronchial membrane  over which they have little
or no  control.  This condition, if not  positively
inflammatory, is  certainly of an analogous kind,
and  the experienced  reader  need hardly  be re
minded of the inutility (to use no stronger term)
of anti-spasmodics in  other cases  of spasmodic
stricture dependent on inflammatory irritation of
the part, until this primary irritation has been re-
duced  by remedies of another class.  It is only in
cases of pure nervous asthma, or in those symp-
tomatic dyspnoeas, simulating asthma, which de-
pend on  organic disease  of the heart, &c. that
opium and other narcotics and  anti-spasmodics
are at  all likely to prove useful; and it is only in
these  cases  tbat  they  should be prescribed. In
the hysteric  asthma the good effect of opium was
long  ago  recognised by  Willis,-)- and we have
ourselves seen it very  successful in  the spurious
forms just mentioned.  In the true catarrhal asth-
ma we have never seen it useful, and  have often
seen it injurious.
   Stramonium. — This  medicine  had  formerly
been strongly recommended by Stoerk  and others
in  mania,  epilepsy,  &c.  but experience  of its
inefficacy  had long occasioned its discontinuance
in such cases, when  its use was again revived in
English practice in the beginning of the present
century, as  a remedy  for asthma.  It  had been
previously employed in India in the  same disease
with much  reputation, and it  speedily attained
great fame upon its introduction by Dr. Sims into
this country.  Since that time  it has been very
much  used; and although its virtues are found to
be greatly less  than was at first believed, they
have been satisfactorily proved  to be  such as to
entitle it to the first rank among  the  temporary
remedies of asthma.    The mode of its adminis-
tration is smoking it during the paroxysm, in the
manner of tobacco.   Considerable  difference ob-
tains among patients in this respect.  Some merely
take the fumes into the mouth ;  others  endeavour
to draw them into the lungs;  while others not
only do this, but likewise swallow the  smoke and
the saliva impregnated with it.  It is obvious that
the dose is very different in these  cases respectively,
 and may be expected  to  have a different result.
 The most common  immediate effects of stramo-
 nium  thus employed, are, a sense of heat in the
 chest, followed by expectoration, slight vertigo, or
 drowsiness,  and sometimes nausea.  In some cases
 the relief is almost  instantaneous,  the  patient
 feeling the constriction of the chest removed after
 a few  minutes, and his sufferings lost in refreshing
 sleep.  In other cases it entirely fails  to  afford
 relief, and in some  it decidedly aggravates the
 dyspnoea.   Sufficient attention has not been paid
 to discriminate the particular cases in which these
 opposite results  have been obtained, but it is pro-
 bable  that the  explanation given with regard to
 the more  common   narcotics  may  apply here.

   tPro subita dyspnoece mere  spasmodic* sedatione,
 nullum praesentius remedium  cxperlus  sum  laudani
 opiati tinctura nostra.   Willis Opera loc cit. 
ASTHMA.
221
When the cases are better selected, its good effects
will probably be more certain.  Fatal effects have
unquestionably resulted from the employment  of
stramonium in asthma ; but when we consider, on
the one  hand, that it is  truly a medicine of great
influence over  the  nervous system, and, on  the
other, that it has passed almost entirely from  under
medical supervision into the hands  of the unpro-
fessional public, it seems unreasonable to condemn
it on this  account.  Now that the enthusiasm
inspired by novelty  and hope  has subsided, and
full time has been  given to trace  its failures as
well  as  its triumphs, stramonium  has  perhaps
fallen in public estimation as much below its real
value as it was formerly raised above it.   It was
at first " the matchless specific," " the divine stra-
monium,"  and seemed  to  its  delighted  votaries
almost like  another elixir vitae.   For instance,  we
have the following account  of  it from Mr. Sills, a
respectable  merchant in London, who was one of
the first to use it.  In describing his own case, he
says, " The fits  generally  continued, with short
interruptions, from thirty-six hours to three days
and  nights successively, during which time I have
often, in the seeming agonies of death, given my-
self over, and even wisbed for that termination of
my miseries."  He made trial  of the stramonium,
and  then he writes thus :  " In truth, the asthma
is destroyed !  I drink  beer, eat of every thing;
and  if my mind was as free from perplexity  as  my
body is from asthma, I  would  again  enjoy   my
existence.   I never  experienced  any  ill  effects
whatever [from  its  use], and  I would rather be
without life than without  stramonium!"*  Alas
for physic ! that so  many of our fondest  hopes
respecting  its attainments must ever and anon be
blighted by time and experience !—that so many
remedies, deemed matchless on their first introduc-
tion, must now be ranged with the great mass to
which no higher  praise can  be justly awarded than
that they are occasionally useful when judiciously
applied!   With this limited  fame, stramonium
may take its place among the best remedies for the
 asthmatic paroxysm.
   [A friend of the writer, who suffers excessively
under the  disease, frequently  makes  manifest to
his medical attendant the relief he derives from  the
smoke  of  stramonium.     For  this purpose he
employs the dried stalk.   Others  use the  root;
 and others again the leaves only.  (See the writer's
 General Therapeutics and Mat. Med.,  i. 220 :
 Philad. 1843.)]
   Tobacco has also been much employed by asth-
matics,  either in  conjunction with stramonium, or
by itself.   It is considered in general as beneficial
in the paroxysm, and, in the estimation  of some
old asthmatics, its effects are not inferior to those
of the former  medicine.   Neither  seems produc-
tive  of relief unless expectoration is excited.j-

  * Communications relative to the Datura Stramoni-
um.   Lond. 1HI.
  t In a communication, with  which we were recently
favoured by an old and  intelligent asthmatic, he  thus
expresses himself:  "Smokinc tobacco or stramonium is
sure  to give relief if it produces expectoration, and it
will generally do so if the moment 1 awake [i. e. in  the
incipient paroxysm] I begin to smoke, and continue to
do so for three or four hours. Smokin?, I am able to say,
after  fifteen years' practice and suffering as much as
mortal can  suffer  and  not die, is the  best remedy for
asthma if it can be  relieved by expectoration.   I have
   Lobelia Inflata. — This new \ ledicine has for
the last few years more than rivalled stramonium
in public estimation ;  but we consider its preten-
sions to rest on much  slighter  grounds.  It  has
certainly been occasionally productive of great and
immediate  relief, but  has much more frequently
failed altogether ;  and  in cases where it had at
first succeeded, it has lost its efficacy on repeated
trials.   We have found it occasionally beneficial
in checking the  paroxysm  even in  cases of ca-
tarrhal  asthma, if given  at the very commence-
ment ; but have found it more certainly successful,
at least temporarily, in spurious cases produced by
hydrothorax and disease of the heart.   Further
trials are necessary to enable us to  speak  confi-
dently of its real merits.  It is given in the form
of a saturated tincture  of the leaves, in doses of
from half  a drachm  to a drachm and  a-half, or
two drachms.^
   In reference both to this medicine and stramo-
nium,  we must remark that, as their great powers
are  unquestionable  in  relieving the  asthmatic
paroxysm in  certain  cases, we suspect that our
frequent failures  arise from our own misapplica-
tion of the  remedy.    There is every reason to
believe that there is one particular class of  cases.
to which such medicines are applicable ; and the
attention of practical physicians cannot be bettei
employed than in endeavouring to  discriminate
them.   This  is a task which does not seem very
difficult, and which we do  not, therefore, despaii
of seeing accomplished.
   Coffee___This dietetic medicine has obtained
considerable reputation in asthma.   We are in
formed by  Sir John Pringle, that " Floyer, during
the latter year of his life, kept free from, or at least
lived easy under his asthma, from the use of very
strong coffee."  (Percival's Med. Essays, vol. iii.
p. 270.)  If this be true, the Knight of Lichfield
must have found some difficulty in reconciling the
utility of this  " hot drink" with his theories, or
even with his past experience.   But, be this as it
may, Sir John Pringle assures us,  on his own
authority, that coffee is " the  best  abater of the
paroxysms of asthma" that he has seen.  He  says
the coffee is to be made very strong, (" an  ounce
for one dish,") and the dose to be repeated every
quarter or  half hour.   This practice is sanctioned
by Dr. Bree, and has  been much used since the
publication of his Treatise.  Our own observation
and inquiries  lead us  to rank  it with  other  nar-
cotics  and  stimulants,  and, therefore, to place no
reliance on it as a general remedy.
   Ipecacuan, Squills, Sec. — Emetics are  recom-
mended by Floyer, Bree, and most  of the  older
authors, as being useful in the paroxysm. Should
this supervene to a  full meal, there can  be no
doubt  of such means  being proper ;  or if it occur
in  a person having  an  babitually  sluggish  and
loaded  state of the  stomach, there may be some
benefit in giving a gentle dose of ipecacuan.  But
they are not generally useful;  and in many cases
they are decidedly contra-indicated by the state of
the stomach.   Akenside was  a  great advocate foi
the employment of ipecacuan.  His practice was

been in the hands of all the doctors of-----for fifteen
years, and still I say, Smoke."
  I Eberle's Treatise on the Mat Med. Philadelph.  18S-'
Cases by Dr. Andrew, Glasgow Journ. vol. i. p. 177 
222
ASTHMA.
to give ^i. in the paroxysm to induce vomiting, j
(" which," he says, " failed not to produce great
and immediate relief,") and in the intervals to give
gr. v  every morning, or gr. x. every other morn-
ing, which was  also, he  says,  generally attended
with vomiting, but sometimes  only with nausea.
This practice he recommended  to be continued for
a  month  or  six weeks.   He  says the  medicine
proved  equally  beneficial, whetber  it produced
vomiting or merely nausea.  (Med. Transact, vol.
i.-p. 93.)   It is probable that it would have proved
still more  successful, if it had produced neither.
Ipecacuan is certainly a  remedy  of considerable
power in the asthmatic paroxysm ; but this seems
altogether  independent of its  emetic properties.
Practitioners of experience, without subscribing to
the doctrine  of homoeopathy, will certainly think
more  favourably of it on  account of its peculiar
tendency  to induce fits of asthma in  the predis-
posed.  Long before the time of Hahnemann, the
main  principle of his doctrine was recognised by
practical men in the adage—nil prodest nisi kedi-
tur idem.
   Many practitioners  are partial to  the  use  of
squill, which has the advantage of the personal
suffrages of both Floyer  and  Bree in its  favour.
It is  said to be most useful  when   it  produces
nausea  or gentle vomiting.   We have no expe-
rience of its effect that deserves notice.
   Refrigerants. — Vegetable  acids and  neutral
salts  of a cooling nature have been considered
beneficial by many, particularly nitre and vinegar.*
Remedies of this class have one great advantage
over many others that have been used in asthma,
that they  are not likely  to prove injurious, and
may  prevent the administration of such  as are.
Combined with mild diaphoretics and  small doses
of ipecacuan, we look  upon them  as the safest,
and perhaps, on the whole,  the best, in  the  most
cjmmon cases, namely, the catarrhal.   Indeed, it
remains yet to be proved  if,  in the  majority of
cases of asthma,  medicine possesses any resources
superior to those found most useful in simple catarrh.
   Derivants, in  the form of stimulant pediluvia,
sinapisms to the feet, &c, are recommended, most
particularly  by  foreign   physicians.    We  have
repeatedly tried  the warm foot-bath.  In  some
cases it afforded relief;  in  others it  immediately
aggravated the dyspnoea.
   [M. Ducros,  of Marseilles, found ammonia, of
the specific gravity .905,  applied over  that part of
the  cervical vertebrae which   corresponds  to the
pharyngeal  plexus, almost  instantly  arrest the
paroxysm, in some  cases ;  and  Dr. Graves  (.4
System of Clinical Medicine, Dublin, 1843,) has
found the application of a liniment, which is an
imitation of one used by a celebrated empiric —
St. John Long—of mucb service.  It is prepared
as follows : —
         R. Acid. acet. fort, f.^ss.
            01. terebinth, f.giij.
            Aquae rosae,  f.giss.
            01. limon. m_x.
            Vitell. ovi, q. s. ut fiat  mistura.  To
 be applied by means of a sponge to the nape and
 side of the neck, and the forepart of the chest.

   * Ex traditi=  mini ifgris nonnullos vidi  quasi mox
 biraguiandos, nisi potui datum esset acetum aquae frigids
 mistum   Si-- W Fordyce'n Fragmenta.
  It generally induces an eruption of small pimples,
after a few applications.  Benefit has also resulted
from  dry  cups, and  from  sinapisms  to the chest
and back ; and  as  the modification in the circu-
lation, produced by  a ligature round the lower
limbs, and the new condition thereby engendered,
have  prevented  an attack of epilepsy, the same
course has been advised  in  asthma.  Cold affu-
sions and aspersions have been  used with  benefit,
under a similar  view.]
  In concluding this brief and  somewhat contra-
dictory exposition of the  principal remedies em-
ployed in the asthmatic paroxysm, we need hardly
point out the inference to which it leads, viz. that
we  have  yet to learn a  rational and • consistent
practice in this  affection.  Hitherto, remedies have
been employed  too  much from empirical  views;
with little or no regard to the real pathology of
the disease  in  general, or to the peculiarities of
individual cases.  What  is  most wanting in our
treatment is due attention to these circumstances.
The list of  remedies given above  contains a suffi-
cient store of arms if we only knew how to wield
them.  For further information on this point, we
can at present do little more than refer the student
to the exposition of the pathology of the  disease
given above, and to the general  principles of
therapeutics.
   There are, however, one or two points in the
pathology of asthma which  appear to us to de-
serve much more attention, in reference to prac-
tice, than they have hitherto obtained either from
practitioners or patients  ; and respecting which
we shall therefore say a few words.  These points
are, the very general production of the paroxysm
by  cold, or  rather, by " catching  cold ;"  and the
identity of the very  earliest stage  of the disease—
that is, the  stage preceding the attack  of actual
dyspnoea—with that of common  catarrh.  If the
invasion of this stage  were carefully watched, and
means were taken calculated to check its progress,
it is not to  be doubted that the asthmatic parox-
ysm might be frequently prevented. In Dr. Ryan's
work  this precursory stage of asthma is noticed,
and its frequently inflammatory character recog-
nised.   " The   appropriate  remedies  for such
threatenings of asthma (he says) are bleeding and
blistering,  which have often to my knowledge
warded off the impending attack."   (Observations
on Asthma, p.  40.)   But it is in  the  Essay of
Dr. Watt,  formerly  noticed, that this important
part of the  pathology of asthma has had justice
done  to  it, and the  principles  of  treatment to
which it  leads have been satisfactorily explained.
In  several  cases there recorded,  the patients are
shown to have been able to recognise tbe approach
of tbe paroxysm some considerable time before its
actual invasion ; and by adopting  very simple
measures " to  check the cold,"  they frequently
 succeeded  in averting the asthma for  the  time.
 Those  measures  were  warm  pediluvia, warm
 diluents, and diaphoretics on going to bed, and
 sometimes  purgatives.  If ihese  means were fol-
 lowed by evacuations by the skin and bowels, tht.
 fit was  almost certainly prevented.  A  circum-
 stance mentioned by  one of Dr. Watt's patients is
 well worthy of notice, as strikingly illustrative at
 once  of  the pathology and proper  treatment of
 such  cases.  If the precursory symptoms of tbe 
ASTP
attack had conh nued for a number of hours before
the patient had  recourse to the usual  measures,
these were  found to be now worse  than  useless.
»The  bathing and warm drink,  which, in  the
earlier part  of the attack would have prevented the
fit, serve now to bring it on sooner and with more
violence."  (Cases,  &c. p. 248.) We recommend
this practice to the particular attention of the pro-
fession, convinced from our  own experience,  as
well as from that of the author just named, and
from the soundness of the  pathology on which it
is based, that it will be found of the most essential
benefit  in asthma.   The  great uncertainty and
lamentable  feebleness of our  therapeutic means,
after the disease is fully formed, enhance extremely
the value of  any kind of treatment  calculated to
prevent the invasion of the paroxysm.  We would
in  an  especial manner recommend  the employ-
ment of the  vapour bath  in this  initiatory stage
of  asthma,  as  calculated to  produce the  best
effects.   (See the article Bathing.)
   II. Treatment in the interval.—It will be ob-
vious to any  one who considers  the  pathology of
asthma, its different forms and  complications, its
various causes, and the important  modifications
derived from  difference of constitution in the sub-
jects of  it,  that  the  treatment  of  this disease, in
the interval, must vary greatly in individual cases.
Practical precepts,  which can  apply  generally,
must,  on this account, be very brief.   They  can
only have reference to the  disease  in its simplest
state, whether this has been its original character,
or has  been  brought about by the removal of its
complications by previous treatment.  When called
on  to  treat any case, our  first object will  be to
ascertain its peculiarities;  and, having ascertained
them, we must regulate our practice accordingly.
If the  paroxysms of difficult breathing appear to
be unconnected with any  very marked disorders
of the  system, except  such as are considered to
constitute an  essential part of the disease, we may
then proceed  at once to apply the remedies which
we consider best suited to the cure  of  asthma in
general.  If,  on the  contrary, we  find,  as will
generally be the case, that  the asthmatic affection
is complicated with and apparently influenced  by
some disorder of other  parts, it will be wrong to
apply any remedies specially directed to the cure
of the asthma, until these extraneous disorders are
removed, or at least attempted to be removed.   In
a former part of the present article we  noticed
some of the most important of these complications
under the name of predisposing causes.  We need
not repeat  what was  there  delivered respecting
their nature ; and for  their proper treatment, we
must refer to  the different articles in  the Cyclopae-
dia specially devoted to their consideration.  We
will only here remark  that, however much their
presence may modify the character of the asthma,
and the treatment requisite in it, their co-existence
with asthma  will rarely interfere  with  the  treat-
ment which is found generally most  successful in
them.
  It is requested that the reader will  bear in mind
the import of these remarks while  perusing  the
remainder of  this article.
  On proceeding to the special treatment of asth-
ma, the condition of the bronchial membrane will
engage the first attention of the practitioner, as it
IMA.                                     223

is on the morbid state of this, in the great majon'y
of cases, that the disease especially depends.   If
it is found that this membrane is the seat of any
formal disease, our most strenuous and persevering
efforts must be directed towards its cure or mitiga-
tion.  The catarrhal affections which complicate
asthma seem to possess no  essential  difference
from the same diseases  existing  without asthma.
Their treatment must, therefore, be the same; and
as this will be given in other parts of this work, it
would be to cause unprofitable repetition to notice
it here.  (See the articles Catarrh, Dry, Latent,
and Chronic; also Bronchitis,  and Emphysema
of the  Lungs.)  On  the present occasion we
shall only advert,  in a particular manner, to that
point of the  treatment which  relates to  the means
best calculated to prevent the incessant aggravation
of  the  catarrhal state  by fresh   attacks of cold.
Our readers  will be at no loss to understand the
importance of this branch of treatment, since we
have attempted to show that the renewal of the
asthmatic paroxysm, in very many cases, depends
on these attacks.
   Cold bathing.—Of all the means calculated to
lessen  the morbid sensibility of the  bronchial
membrane to the  impression of cold—in other
words, to diminish the  tendency  in  individuals to
catch cold—there is none at all comparable to the
application of water  to  the surface of the body,
under some form or other of the  cold bath.
   In the article Bathing, the principles on which
the cold bath operates will  be detailed, as also its
various forms, and the best methods of applying
them in particular cases.  On the present occasion
we can only afford  room for a  few general observa-
tions.
   In a climate  so cold and  variable  as that  of
England, it  is utterly vain  for those who are un-
fortunately very liable to catarrhal complaints, to
hope, by warm clothing, comfortable rooms, or any
plan of seclusion from the atmospheric vicissitudes,
to  escape  them.   The very efforts  such persons
make to  avoid  the unfavourable  influence of the
climate  only render  them  more subject to  it.
Here, as in the case of  most  other evils, moral as
well as physical, the best chance of success con-
sists in  strenuous  resistance.   If we do not posi-
tively attack  the enemy, we  must at least, if we
hope for safety, present a bold front and maintain
a strong defensive.
   It is only  by the return to hardier habits gene-
rally, and by the practice of cold  bathing, that the
persons whose cases we are now considering, can
hope to re-establish  the natural  harmony which
ought always to exist between the animal and the
climate it inhabits, and which in them  has been
unfortunately destroyed. Cold  bathing may  be
used in various ways; in the form of the common
plunge-bath, the shower-bath,  or by simple ablution
of the exposed surface.   In the case of asthmatics,
the latter is  the mode  generally  preferable in the
first instance, or else the tepid shower-bath.  Ab-
lution, when  proper, has a very  great  advantage
over all  the  other  forms of bathing, in being at-
tended  with  little  trouble,  and  being   accessible
to all.   The  process consists  in  simply washing
with a sponge, towel, or piece of  flannel dipped in
water, the trunk of the body, and then drying it,
using  strong friction at the same time.  On first 
224                                     ASTHMA.
commencing  the practice,  if in winter, the chill
must be taken off the water.  A portion of com-
mon salt must  be always  dissolved in it, in the
proportion of one or two ounces to the pint, or an
equivalent amount of vinegar added.  The time
for using the water is immediately on getting out
of bed ; and  this  is also the best time for using
the shower-bath, if the system is sufficiently vigo-
rous to bear the  shock without any further prepa-
ration.   (See  Bathing.)  Both these processes
may be used  equally in winter;  and to  these, in
summer, may be added bathing  in  the open sea.
This last  may be prolonged into the autumn, or
even through the winter, with great  advantage, if
the power of  re-action is sufficient;  but the num-
ber of asthmatic subjects who can bear this is very
few.  Indeed, in  prescribing the milder forms,
some preparation will often be necessary, and  in
all cases the greatest care must  be taken that  the
first application of the remedy does not induce an
attack of cold ; not, however, so much from any
particular risk  thereby occasioned,  as  from  the
effect such an event  may  have on  the  patient's
mind.   A severe  cold, so  caught,   may  entirely
destroy  all chance of  benefit from  the  practice.
Almost  all  our  patients will  be averse  to  the
remedy; and  when they can bring what they con-
sider as  experience in aid of their own strong pre-
possessions, what hope is there that they will listen
to our recommendations?
  In cases of extreme susceptibility to  cold, we
shall often find, on examination, that  there co-exist
with the asthma some form of dyspepsia, and a
feeble and irregular distribution of the blood, par-
ticularly on the surface and extremities.  In cases
of this kind,  before instituting the process of har-
dening by means of cold  bathing, exercise in the
open air, &c, it  will often be necessary to employ
measures which may at first seem of an opposite
tendency.  For  instance, if the dyspepsia is  de-
pendent on an inflammatory or irritated condition
of the mucous membrane of the stomach or bow-
els, low diet  and a cooler regimen, and  even re-
peated leeching  may be  necessary ;  and a course
of warm bathing  may be required, not only to
assist in the cure of the dyspepsia, but to improve
the condition  of the skin, and invigorate the circu-
lation generally, and particularly in the extremi-
ties.
   When instituted after proper  preparation, and
gone about with due caution, it is often quite sur-
prising how speedily the cold bath lessens the sus-
ceptibility to  catch cold ;  and  when strenuously
and judiciously  persevered  in,  conjointly with
proper exercise and regimen, and the avoidance, as
far  as  practicable, of  the  various causes which
produced and fostered the morbid sensibility of the
system  generally, and  of the lungs  in particular,
the benefit thence derived is often very remarkable.
The appetite and  digestion are improved ;  the
circulation becomes more  vigorous,  with a corre-
sponding increase of warmth in the extremities ;
and that  internal sense of vigour  and  activity,
which is always the source  of agreeable  feelings,
is once more experienced.  No longer shut up
like an exotic in a stove, the slave of every season,
the invalid  is now enabled to  go forth  into the
open air like  his  neighbours, and to take a share
ir  the  common business  and  pleasures  of  the
world.  Even in the cases where  tbe results of
this practice fall far short of those now described,
the benefit is  still  most substantial, and  such as,
we are assured, can be derived  from  no other
source.
   The practice of cold  bathing in asthma has not
merely the sanction, but the express recommenda-
tion of almost all  the  authors who have treated
professedly of the disease, and of most  practical
writers wbo have noticed it incidentally.  Among
the ancients, Caelius Aurelianus; and, among the
moderns,  Floyer, Withers, Millar, Ryan, Bree, are
all strenuous advocates  for the employment of cold
bathing in some form  or other.  None of these,
however,  advocate  the  practice with such zeal as
Ryan, whose treatise may be considered as almost
entirely devoted to its recommendation.
   Tonics.—The special medicines which have
been  most  recommended and used  in  asthma,
belong almost exclusively to the class of tonics.
But before proceeding to notice these particularly,
we must  be  permitted  once more  to  caution  the
practitioner against their indiscriminate use, with-
out due regard to the state of the system.  Great
discredit  has  been thrown upon many  valuable
medicines, and  much  injury  done to asthmatic
patients, by premature attempts to cure the disease
by means of tonics, and other specific remedies,
directed exclusively to act on the nervous system.
This  is, indeed, the besetting sin of British prac-
tice in chronic diseases; and we have good reason
to know that asthma forms no  exception to  a rule
too general.   Medicines of a  kind calculated  to
act with great power on the organ to  which they
are primarily applied,  are  frequently prescribed
without any reference to the existing condition of
that organ.   If general debility prevails,  and still
more  surely,  if the stomach refuses  to perform its
functions  with vigour, bitters,  bark, steel, are im-
mediately prescribed, with little or no regard to
the state  of the  stomach, although this  may  be
such  as altogether to contra-indicate  the use  of
such  remedies.  While active irritation or chronic
inflammation exists in the intestinal mucous mem-
brane, the true tonics are leeches, refrigerants, and
low diet;  and it  is only after the  recipient  has
been  prepared by such means, that tonics can be
administered without injury even, certainly with
any prospect of benefit.  We shall now notice, in
detail, some of the principal remedies  of this class
that have  been most employed in asthma.
   Bark. — The  well-earned  fame  of this  noble
medicine, in the  cure of the periodical affections
which originate in malaria, would naturally sug-
gest its employment in  a disease like that of asth-
ma ;  and  we find, accordingly, that it has been
prescribed and recommended by almost every  one
who has written on this  disease since the  intro-
duction  of cinchona   into  European  practice.
Floyer says, that nothing is more likely to prevent
the return of the paroxysm than bark ; and that,
even  in the cases of symptomatic asthma,  " though
it cannot prevent  the  fits, yet it greatly relieves
the sweats and faintness attending the  fits, and
headachs, and makes the intervals of the  fits long-
er."   Bree recommends it, but less  forcibly.   He
says it acts as other tonics, and is inferior to steel.
Ryan says that  " there  are few cases that will  not
admit of  its  use, particularly if the fits  are kept 
ASTHMA.
225
up by habit;" but he adds, that his success with
this remedy « has not generally answered his ex-
pectations."  Laennec  says, «when the  parox-
ysms  bear  a strongly-marked periodic  character,
cinchona often  diminishes their  frequency, and
sometimes  stops them altogether;" but  it does
not appear  clear that he here speaks from personal
experience.   The fact  appears  to be,  that bark
possesses  no  specific  powers  in  checking  the
return of the common asthmatic  paroxysm ; but
that it occasionally acts beneficially in two classes
of cases ; first, when  the  asthma is complicated
with ague,  as it sometimes  is, and, secondly, when
the stomach  or  general system is in a state  in
which a tonic of this kind  is beneficial.   If it im-
proves the  general health, it frequently aids in the
cure or  relief of asthma ;  and  it  need  hardly be
said that it will do so in the malarious  complica-
tion.  Cases of  this  last kind  are mentioned  by
Withers, (Treatise, p. 412, et seq.,) Frank, (Med.
Univ. ix. 407,)  Heberden, (Commentar.  p. 59,)
and others.  In  many cases of asthma, however,
we are convinced that  bark is not merely  useless,
but decidedly injurious ; and we  are on the whole
disposed to consider  it  as a medicine of very sub-
ordinate value in this disease.
   Steel.—This tonic has been  even more exten-
sively used than bark, and, we  apprehend, with
more general success.  In the cases which are
attended by that cachectic  state of the system  in-
dicated by  more or less of the  pale chlorotic as-
pect,  this remedy is often  extremely beneficial, by
imparting vigour to the stomach and system gene-
rally.  Bree is a great advocate for steel, which he
 considers as preferable to all other kinds of tonics.
Floyer's experience, however,  both  personal and
 professional, is rather against the use of steel. He
says, " Most asthmatics complain that steel  heats
them, stops their stomachs and breaths, and thick-
 ens the phlegm, and- at last produces a severe effer-
 vescence which  gives the fit."  He says, that both
himself and most of his patients were injured by
 the use of  the chalybeate mineral waters, although
 some were better for them, " the quantity  of cool
 water (as he simply observes) doing more  service
 than  the  steel  could  do  injury."  The fact, no
 doubt, in this case, as in that of bark, is, that suc-
 cess or failure will depend  upon the proper appli-
 cation of the remedy.   If  the general state of the
 system seem to  indicate the use  of steel, and if
the state of the  stomach and bowels do not forbid
it, we have no doubt that it will often prove a val-
uable remedy in  asthma ;  and  the class of cases
which are most  likely  to be benefited by its use,
are either those which  occur in what may be called
the chlorotic temperament, or  those which  seem
allied to neuralgic  affections,  not dependent  on
malaria, in which there can be  no doubt that steel
is often highly useful.   But in any case it will be
the particular condition of the  digestive  organs
and the general  system that will point out the pro-
priety of the remedy, and  not any supposed spe-
cific powers possessed  by it against the asthmatic
paroxysm.   If it is  contra-indicated by the  pres-
ence of such circumstances as render it useless or
injurious in other cases, the addition of asthma to
the group will not in any way remove this contra-
indication.
   Oxyd of Zinc.—This  medicine  has obtained
     Vol. I___29
celebrity as  a remedy for  asthma, chiefly through
the publication  of Dr. Withers's treatise, in which
it is strongly recommended, as possessing extraor-
dinary powers in the cure of this disease.   The
author records many cases illustrative of its effects.
In several it certainly appears to have been  bene-
ficial ;  but,  like most  promulgators of new  or
favourite remedies, he has greatly exaggerated  its
importance  as  a general remedy.   Dr. Withers
gave the medicine in doses, varying from five to
twenty grains twice or thrice a day.  This tonic
may be given in states of the stomach when bark
and steel are  inadmissible ; and certainly when
tonics  are indicated, it is entitled to a  trial, from
the ample evidence  adduced in its favour.  We
are not entitled to recommend it from experience,
having but seldom prescribed the remedy.
   Numerous other medicines of the class of tonics
have been employed in the  cure of this disease,
and have obtained much credit at different timer
from their employers.  There is, however, hardly
any which seems entitled to a distinct notice ; as
the principles above laid down must regulate then
employment in individual cases, not (as was then
stated) so much from the character of the asthma,
as from the  state of the  general  system and the
digestive  organs.   Acids  combined with  bitters
are greatly commended by Floyer, and he gives a
formula  for  an oxymel,  (p. 167,) by  which  he
says he was frequently relieved, and his fits were
kept off many  months.
   Depletory measures.—These measures, the very
reverse of the  last, have been recommended  by
various authors in the intervals, particularly local
or  general bloodletting, emetics, blisters, &c.   In
respect to this class of remedies, as to the  preceding,
it must be observed that they may be very proper
in certain cases, but that the indications for their
employment must be furnished by such states  of
the system  as  would  render them  proper inde-
pendently of the asthma.   This disease, consider-
ed simply,  and exclusively of the morbid  states
with  which  it may be  complicated, can  hardly
ever require the loss of blood, or render  emetics
proper ;  but if the  subject of asthma is suffering
from general or local plethora, or from any local
inflammation, general or local bloodletting will no
doubt  be very proper : in certain forms  of gastric
derangement an emetic will be equally so ;  and it
is very probable that the treatment  will, in both
cases,  be found to alleviate  the  asthmatic  parox-
ysms.   Still we must not say that these measures
are to be recommended among the general remedies
of asthma.   It  is somewhat singular that purg-
ing is  stated to be injurious in asthma  by almost
all our practical writers, even  by such as  rather
recommend  depletion in other  forms.  Judging
from the frequency of the dyspeptic complication,
and particularly of that form which consists in an
irritable  state  of  the  mucous membrane   of the
bowels, (asthmatics are rarely of a costive habit,)
we are disposed to believe that purgatives frequent-
ly prove injurious  in asthma  by increasing  this
irritation.
   Mild aperients, however, are useful when indi-
cated by a torpid state of the bowels and diseased
secretions ;  and sometimes even pretty strong pur-
gation is temporarily beneficial at least.  One of
our patients informs us ft at he took every day foi 
226
ASTHMA.
ten weeks  some  secret medicine  which  had the
effect of producing  four or  five'copious watery
evacuations daily, and that he remained free from
his asthma during eight weeks of the time, a pe-
riod much  beyond the average length of his inter-
vals.  He thought, however, he was  worse after-
wards.  Floyer says that purging  frequently occa-
sioned a paroxysm in his case.
   Various  forms  of local depletion and of coun-
ter-irritation have been strongly recommended in
asthma; and  certainly on  better grounds  than
several  of  the remedies already noticed.  Issues,
in particular, have been  a favourite remedy with
the majority of  writers  on  asthma.  They  are,
however, like most  of the other  remedies men-
tioned, indicated  in most cases more by some mor-
bid condition of the system co-existing with asth-
ma, than by the  asthma itself.   They are found
particularly useful in  gouty habits, in cases suc-
ceeding to  the drying-up of established discharges,
natural  or morbid, or the suppression of cutaneous
diseases.   In this latter case, various other coun-
ter-irritants have been recommended, and  espe-
cially the re-establishment  of the  original disease,
if practicable.*
   Warm bathing has been found  generally inju-
rious  in cases of asthma. Dr. Bree says it is hurt-
ful in every species.   He himself tried its effects
both during the fit and in  the interval, and found
that in the former case the paroxysm was much
aggravated, and in the latter it was induced in a
few hours and at an unusual period.   When this
extreme sensibility to the warm bath exists, it is a
very unfavourable circumstance, as the  most fre-
quent complication of asthma (the dyspectic)  is
so generally relieved  by this very  measure.  Is it
generally true that irritations of the mucous mem-
brane of the intestines bear  warm bathing well,
while those of the bronchi bear it badly ?
   Expectorants.—The various medicines, many
of them of very  different qualities and modes of
action, usually classed under  this  head, were for-
merly much employed in asthma ; as  often, how-
ever,  we apprehend,  from  false theoretical views
as from any evidence of their utility.  From what
has been above delivered respecting the pathology
of asthma, it is obvious that the disease does not
depend  upon any  accumulation  of  mucus or
phlegm in  the bronchi, nor yet upon the retention
of this in the glands that  secrete  it, according to
the theory of Bree.   Any increase, therefore, of
the excretory function of the bronchial membrane,
if it could  be  induced, must be  useless, in. this
point of view at  least.  There is,  however, a most
important class of cases in which the augmenta-
tion, or, at least, the alteration, of the  bronchial
secretion would  be very beneficial; and if we pos-
sess any medicines capable of effecting this, with-
out injuring, in other-respects, the secreting organs,
  * Zacutus Lusitanus seems entitled to the credit of
first attempting the  cure of diseases by restoring, by
means of re-infection, cutaneous diseases that had been
suppressed.  See Etmuller, op. om. p. 1!)3, who terms this
a noble discovery, egregium inventum. This practice is
particularly recommended in asthma by Baglivi: "Ex
scabie retropulso si asthma fiat, cum scabiosa dormien-
dum est, ut scabies revocetur, vel urticis caedendum  cu-
tis."  Op. p. 64.  Even the last alternative is not very
agreeable.  The first we find practised at  a comparative-
ly recent period, and it is said, with success.  See Haut-
fi'-rk's Recueil, &c.
such medicines certainly must be  deemed useful
expectorants in this case.  We allude to asthma
complicated with the dry catarrh, in which  we
have at once a low degree of chronic irritation of
the mucous membrane, and the secretion of a mi-
nute quantity of  a thick gelatinous and extremely
adhesive mucus,  very capable, by  its presence in
the minuter bronchi, of adding  mccbanically to
the difficulty  of  breathing.  Do we  possess  any
medicines capable of changing the secretory pro-
cess whereby  this morbid mucus is formed, so as
to prevent its formation ?  If we cannot do this,
have we any means of changing the character of
the secretion, so  as to render it more fluid or  less
tenacious ?   When secreted, whether mote or less
fluid, have we any means of accelerating  its  re-
moval  from  the bronchi ?  If we possess the power
of effecting any of these objects, are they attain-
able without  any  augmentation of  the chronic
irritation  of the  mucous membrane ?  The  full
discussion of  these questions will  naturally come
under  consideration in the articles  which treat of
the catarrhal affection of which the asthma is  an
attendant;  we would only here observe that rem-
edies of this kind are not to be  applied until after
the employment  of the ordinary means calculated
to lessen the irritation of the membrane, of which
this secretion is the product.
   The older authors did not doubt that they pos-
sessed  in their alterants, attenuants, incidents,
deobstruents,  remedies  calculated to diminish the
consistence  and  tenacity of  the blood, and  of the
natural or morbid products formed from it within
the body. Numerous remedies were ranged under
these various  heads ; being classed, generally, ac-
cording as they were supposed to  act chemically
or  mechanically.  The cbief of those which at-
tained  great celebrity were the pure alkalis, or the
neutral salts formed  from them, or the  combina-
tion of the alkalies with oil, constituting the vari-
ous kinds of soap.  These remedies fell into disuse
upon  the overtbrow of  the  humoral pathology,
and some of them, probably, were unjustly con-
demned on  account of the false  theories by  which
their operation was explained in  that system of
medicine.   Of late years the practice of adminis-
tering  the same remedies has been in a very con-
siderable  degree  restored, together with  a portion
of the doctrines  with which they  were  anciently
associated ;  while some have adopted the practice
without the doctrines.  In the end of the last cen-
tury Mascagni introduced the use of alkalis into
the treatment of pulmonary inflammations, upon
the principle of tbeir attenuating or solvent pow-
ers, and, it  is said, with great success ;-|- and his
practice has been zealously  followed up and  ex-
tended to other  diseases by  other physicians in
that country,  and with the greatest success, as is
alleged.};   A  practice somewhat similar had been
previously adopted, in Italy, by Sarcone, (Istoria
Ragionata,  &c.   Napoli, 1765,)  and,  more  re-
cently, Laennec  has strongly recommended it in
the cure of  dry catarrh, on the  ground of experi-
ence solely.  The medicines prescribed by Laennec
were the milder alkalis, either in the form of soap
  t See his Dissertation, Sull 'uso di  Carbonate di Po-
tassa per le renelli e peripneumonie.   Mem. Dell. Sot
Hal. torn. xii. 1^04.
  t Elogio del. eel. Anat. P. Mascagni  di T. Farnesa
Milan, 1816. 
ASTHMA.
227
or the common  carbonates.  He assures us that
he had  repeatedly witnessed the most beneficial
effects  of those both  in  dyspnoea  and asthma.
They augmented the  secretion from the bronchi,
and  lessened its tenacity.  (De l'Auscult. Med.)
Our experience leads  us to  think favourably of
this  class of medicines.   It will not be denied, at
the  present day, that  their  administration  is
grounded on sound pathological principles.
   Narcotics and Antispasmodics.—Remedies of
this class have, as we have seen, been very gene-
rally employed in the paroxysm of asthma ;  they
have likewise been often  used in the intervals;—
we cannot, however, say with much success. The
majority of them, indeed, are much more calcu-
lated to do harm than  good,  by disturbing several
important functions,  and we refer to them here
rather to warn the practitioner against their em-
ployment than to recommend this.
   Electricity,  galvanism,  magnetism,  animal
magnetism, &c. have all been tried  in asthma,
 and have all, it may fairly be said, failed.   Suc-
 cessful results from  each are, no doubt, recorded,
 but the general result is certainly complete failure.
 This, indeed, is to be expected on considering the
 pathology of the disease.
   [Yet  strikingly good  effects are at times wit-
 nessed from the employment of galvanism.  Seve-
 ral such are recorded by Dr. Wilson Philip (Ex-
 perimental Inquiries into the Laws of the  Vital
 Functions,  Lond.  1807),  and they  have been
 witnessed by the writer in several cases; whilst in
 most instances the remedy has failed.   Dr.  Philip
 transmitted  the galvanic influence from the nape
 of the  neck to the pit  of the stomach, and the
 power employed by him varied from ten to twenty-
 five pairs of plates.   Since  that time, galvanism
 has been repeatedly used  in such cases, but of late,
 the plates employed by Mansford in epilepsy (Re-
 searches into the Nature and Causes of Epilepsy,
 Bath, 1829) have been more commonly, perhaps,
 employed in this country. The disease is unques-
 tionably dependent upon erethism of the pneumo-
 gastric nerves ;  and all the phenomena exhibit that
 there is  a spastic constriction  of the small bronchia,
 from causes seated at  the extremities  or  in the
 course   of  those  nerves.  The  new impression,
 made by the galvanic agency, breaks in upon the
 concentration of nervous action, by exciting other
 portions of the nervous system, in the same man-
 ner as  we  observe spasms  or  ordinary  cramps
 relieved, or paroxysmal diseases  warded  off by
 agents  that are capable of  suddenly  impressing
 some part  of the nervous system.  (The writer's
 Practice of Medicine, 2d edit., i. 331 :  Philad.
  1844.)   The  magnet has been  used in similar
 cases, by establishing a magnetic current through
 the parts by means of several magnetised plates ;
 and Laennec  affirms  that he frequently found it
 diminish the oppression.   (New Remedies, 4th
 edit., p. 415 : Philad. 1843.)]
    Inhalation of vapours and gases—These, like
 narcotics, have most frequently been attempted in
 the paroxysm ; still they have often been used
 during  the intervals.   They cannot  be  said  to
 have been very beneficial.  Some of them, how-
 ever, seem to hold out a promise of being so even
 in the  most common form  of asthma; and, not-
 withstanding the slight benefit hitherto  derived
from them, we  are disposed to look to this class
of remedies with considerable  hopes of success.
Legitimate reasoning and strong analogy, at least,
are in their favour;  and it cannot now be denied
that a good deal of  direct experiment can also be
brought to testify in behalf of some of them. The
most common,  if not the general cause of asthma,
is, as we have  seen, permanent alteration  of the
mucous membrane of the bronchi, frequently cha-
racterised by obvious signs and symptoms, some-
times only inferred from the morbid sensibility of
the  part to external influences.   Although  we
know  that similar   affections  of other parts  are
curable by general means, still we find that, when
we are enabled to conjoin with these, applications
that act directly upon the seat of the disease, the
result is frequently  much  more  speedy and cer-
tain.  This is the case in diseases of the external
skin, of the stomach and bowels, and  in various
local affections of the mucous outlets of the body.
We are well aware  that applications of this kind
are  frequently  very injurious, in place of being
beneficial; but this  is an  argument against their
improper use only.   Every one must have wit-
nessed the extraordinary and instantaneous benefit
afforded  by local applications  to  the urethra, tbe
throat, the eye, in cases which  had been for weeks
or months unrelieved  by general treatment.   In
the dry catarrh we  have a morbid state of mem-
brane  very analogous  to  some  of the affections
now alluded to; and although, as in  these,  the
injudicious or  improper  use  of  local applica-
tions is  likely to increase irritation in place  of
allaying it, it  does  not certainly seem unreason-
able, a priori,  to expect that due care in adapting
the particular remedy to the individual case, might
be followed by results equally happy.  The his-
tory of asthma affords ample proof tbat the return
of the paroxysms is very much influenced by the
direct applications  made accidentally to the bron-
chial membrane.
    For a detailed account of the treatment of bron-
 chial diseases by means of the inhalation of medi-
 cinal substances, we must again  refer to the arti-
 cles Catarrh and Bronchitis, and to the various
 publications which treat  of  this subject.    We
 should only here remark that, of all the remedies
 which have been  employed in  this way, no one
 offers such a  promise of advantage as the dilute
 chlorine gas.   The observations and experiments
 detailed in the pamphlets of Gannal and Murray,
 and some trials which we  ourselves have made of
 it, lead us to  entertain  very  favourable expecta-
 tions of benefit from it in bronchial diseases. The
 inhalation of  vapours  of  various  kinds, particu-
 larly of resins, has long  been practised in pul-
 monary diseases.   We can only refer to the sub-
 ject in this place.*
    [It  has been proposed  to immerse paper in a
 saturated  solution   of nitrate  of  potassa,  and to
 dry it. A  portion of this is set  fire to, and allowed
   * Pee, Two Memoirs on the Inhalation of Chlorine,
 by M. Gannal.  Translated by Potter. London, 1830
 —Treatise on Pulmonary Consumption : by John Mur
 ray. London, 1830.   On the  Inhalation of Tar Vapoui
 see the publications of Sir A. Crichton, and a paper by
 Dr. James Forbes, Med. and Phys. Journ. for Oct. 162-2.
 [See also, on the inhalation of these substances, and on
 that of iodine, iodide  of sulphur, &c, E. J. Coxe, Prac-
 tical Treatise on Medical Inhalation, Philad. Ib41 ; aiit'
 Dunglison's New Remedies, edit, cit.] 
HMA.
228                                     AST!

to burn in the vicinity of the patient, (New  York
Med.  Gaz.   and  Amer.  Journ.  of the  Med.
Sciences, Jan.  1843,  p.  262.)  The writer has
frequently observed good  effects  from it both in
asthma and chronic bronchitis.]
   Climate.—Asthma is one of  the  diseases in
which the effect of change  of climate or change
of air is most conspicuous.   It is  the remark of
every writer  on the disease  that certain patients
have  an increase or alleviation of their symptoms
upon  changing their residence from one place to
another.   Sometimes a very slight change, as to
distance, has this effect; and even when little or
no difference in the nature of the climate or loca-
lity can be discovered.   According to our present
experience these remarkable  results  can  be ex-
plained on no general  principle.   One  patient is
best in the country, another in the city ; one  in an
elevated situation, another in  a low one.  Floyer
continued free  from his asthma while at Oxford,
but never failed to have an attack upon  returning
to his  native air in Staffordshire.   An asthmatic
lady, mentioned by the same author,  was always
immediately  attacked with dyspnoea upon  going
to Epsom from London, which went off on her
return.  Dr.  Bree was invariably attacked  upon
visiting Warwickshire from his  residence, forty
miles distant, and only two  hundred miles nearer
the sea level.  A gentleman, mentioned  by Dr.
Bree, could never  sleep in the town of Kilkenny,
in Ireland, without being  attacked with asthma ;
and Lord Ormond could never sleep out of the
same  place without suffering in the  same way.
The sister of an asthmatic  patient of ours, who
had long  suffered from  this  disease  in Sussex,
was completely cured by going to reside in Lon-
don, and remained well for  a period of  ten  years
which intervened between her removal and  death.
   [As  a  general  rule, perhaps,  the  air  of the
crowded city  is more congenial than that of rural
and elevated  situations.  A college acquaintance
of Dr. Watson can sleep in one inn in  Cambridge,
and not in another ; and he assured Dr. Watson,
that when in Paris, he never escapes an  attack
of asthma, if he attempts to sleep in the  back part
of Meurice's hotel,  and yet  never suffers  if he
sleeps in a front room.   (Watson's Lectures  on
the Principles and Practice of Physic, Amer. edit.,
p. 643, Philad.  1844.)  An asthmatic friend of the
writer, one of the most respectable inhabitants of
Baltimore, is  unable to sleep at his country-house,
which is  not more than  a mile and a half from
the centre of the town.   He has tried the experi-
ment  frequently, and the  result has always been
the same.   (Practice  of Medicine,  2d edit. p.
328.)]
  No doubt  these remarkable effects depend  on
causes of an  analogous kind ; and there  seems no
reason to doubt  that the general  principle will
yet be discovered, which will reconcile  and explain
ali  the seeming contradictions  and anomalies.
At present our knowledge falls very far short of
this precision ; still, attention to  the  ascertained
influence of particular climates on particular dis-
eases, and on the system in  general, and a close
study of the  pathology of the individual cases of
asthma, will  enable us frequently to be of  much
service to  such  of our patients as have it in their
nower to make choice of their residence.
   In selecting  a climate for an asthmatic patient,
we must be guided  precisely by  the  principles
which direct the application of any other remedy
or course of treatment.   A minute examination
of the individual case is always essential;  and in
making  this with  a  view to  the application of
climate, we must endeavour to ascertain, 1st. the
state of the bronchi;  2d. the  state of the general
health,  or the diseases  with  which the asthma
may be complicated ;  3d.  the relation, as to cause
and effect, which these diseases bear to the asthma;
4th. the character of the patient's general consti-
tution or temperament; and lastly, the ascertained
effect of  particular climates,  localities,  and sea-
sons, upon his  individual case.
   Although asthma is a disease of every climate,
and although  many  patients  have their severest
attacks in summer, there can be no doubt, that, in
the great-majority  of cases, a mild and equable
climate is much more favourable to the  asthmatic
than one  that  is cold  and variable.  Such  a cli-
mate proves beneficial in various ways, more espe-
cially in  the cases dependent on any form of chro-
nic catarrh.  It tends directly to remove the very
basis of the disease—1st. by the direct application
to the part of air of a milder and  more agreeable
temperature ;  2d.  by rendering  the  attacks of
acute catarrh less frequent, and thereby affording
longer intervals for  the restoration of the irritated
membrane ; 3d. by  promoting tbe cure of the
accompanying  disorders, which frequently exert a
most unfavourable  influence,  both on  the struc-
tural alteration of the  membrane, and on the
spasmodic affection of the bronchial  muscles;
and more particularly the disorders of  the diges-
tive  organs and the  skin; 4th. by enabling the
patient to improve the general  health and strength,
and to  fortify the system against  the impression
of cold by constant exercise in the  open air, and
by the uninterrupted use of the cold bath through-
out the year.  For more particular information on
this part of our subject, we must refer to the arti-
cles Chance of Air  and Climate in the pre-
sent work, and to  the very valuable work of Dr.
[Sir  James]  Clark on the general influence of
climate on chronic diseases.*
   Mineral vjaters.—These remedies have been
much employed- in asthma,  particularly  on the
continent.  We shall borrow from the author
just quoted the few lemarks which we intend to
offer on this part of our subject.   " When asthma
is complicated  with   chronic irritation of the
bronchial membrane, or of the digestive organs,
or with  a congested state of the  hepatic system,
or an unhealthy skin, a course of warm mineral
water will prove of  much  benefit, by relieving
those  morbid  affections which often induce and
always  aggravate  asthma.    There are several
mineral waters on  the continent which have a
high reputation,  and  we believe deservedly, in
this class of diseases.  Of this kind the springs
of Ems on the Rhine, of Bonnes and  Cauterets
among  the Pyrenees,  and   of  Mont   D'or in
Auvergne, are held  in  the  greatest estimation.
But there is more difficulty in selecting a mineral
water for the asthmatic patient than for any other;

rJt,TI,eJnfluence °f Climate. Second Edit.  Lond. 1830.
[Third edit, under the title of the Sanative Influence of
Climate, Lond. 1841.| 
ASTHMA —ASTRINGENTS.
229
as the source, most suitable to the diseases which
complicate it, may be in a situation which decid-
edly disagrees with the asthma.   However well
suited the waters of the Pyrenees or of Mont D'or
might  be to  the bronchial disease, it  would  be
useless to propose  a residence at either of those
places  to  an asthmatic person  who  could  not
breathe at a great  elevation ; or to send him to
Ems or Carlsbad who  could not live in a valley  ;
although tbe waters of these places might be ad-
mirably  adapted to the bronchial or  abdominal
diseases with which the asthma is complicated."
   The mineral waters of England, of an analogous
character, may be used in  the same cases ;  and
where abdominal  plethora exists,  the aperient
waters of Cheltenham  or Leamington will be be-
neficial in  relieving this.   The waters of  Bath
have  also been found beneficial in some cases ;
but in general they are not well suited to the pul-
monary  affection,  however they may be  so to
some of the complicating diseases.
   Diet. — The diet in all chronic diseases is  a
matter  of great practical  importance.  It is of
more especial importance in asthma, because dis-
order of the stomach is so  frequent a concomitant
and even a cause  of  the disease.   All the good
writers on  asthma are strong advocates for mo-
deration in diet; and  there is no disease in which
patients  are more unanimous  on  the same point.
Floyer is particularly zealous  against excess both
 in eating and drinking.  " Hunger  and thirst (he
 says) are the best cure for the asthma, especially
 little and very small drink."  " The less tbe asth-
 matics are nourished,  (he says, in another place,)
 the longer  are the intervals  of  the fits, and  the
 clearer is their  breath."   The principles  which
 ought to regulate the diet are few and simple ;
 but the  practice must be modified by the circum-
 stances  of individual cases.   Temperance  and
 moderation  are  universally applicable  and neces-
 sary, as  is also habitual vigilance  against being
 seduced from the regularity of invalid habits.  The
 particular system of diet is indicated much more
 by the concomitant affections than by the asthma
 itself.  If the disease is unattended by any very
 decided  disorder of structure in  the bronchi,  or
 elsewhere,  the diet may be  more  generous and
 less strict than  under a different state of things.
 If there is marked affection  of the bronchi, with
 little disorder of other parts, the only circumstance
 of much importance  to be attended to respecting
 diet, is that it  does not  tend, by being overfull,
 directly  to  increase this  bronchial affection, and
 to induce other disorders which might aggravate
 the primary disease.   But in almost all cases of
 asthma, we have  already  other  disorders which
 tend powerfully to aggravate and keep  up  the
 broncbial affection, and in the alleviation or cure
 of which diet is of paramount importance.  In
 this  list  we  may include  dyspepsia with its
 numerous progeny of general and  local diseases,
 plethora, gout,  gravel, diseases  of the mucous
 membranes  generally, of  the  liver, brain, uterus,
 skin, &c. &c.  For the dietetic management of
 these  diseases we must refer to the articles which
 treat of  them  respectively, and to the  general
article Diet.  The co-existence  of the asthmatic
paroxysm scarcely, in any degree, alters the diet
proper in these affections.      John Forbes.
  ASTRINGENTS,  (from astringere, to con-
tract,) are substances which produce contraction
and condensation of the muscular fibre.  It is still
undetermined whether these effects are the result
of the  action of the  astringent on the muscular
fibre itself, or on the  nerves of motion in contact
with it.  Muscular fibre is a compound substance
possessing  compound functions, some  of which,
as for  instance its cohesiveness, flexibility, and
extensibility, are physical ; others,  as  its sensi-
bility and contractility, vital properties.   We may
assume it as a fact, that the tenuity or density of
a muscle, not under  the  immediate influence  of
volition, is solely dependent on vitality.  It is this
vital tenuity wbich enables a muscle, during life,
to sustain a weight  that would  instantly over-
come its cohesive power and tear it asunder, after
death.
   Most writers  on the Materia Medica  have  en-
deavoured to explain  the  influence  of astringents
on the living body  by reasoning analogically from
their action on dead animal matter.  It is true that
substances which  give  toughness,  solidity, and
impermeability to the soft skin of a dead animal,
so as to convert it into leather, operate as astrin-
gents on the living muscular fibre.  Looking at
this fact, were the  inquiry to  proceed no farther,
it would not  be  surprising  that  erroneous  in-
ferences should be induced from it: indeed, the
presence of life  seems, in some instances, rather
to favour than to resist the operation of astringents.
   If we refer the action of astringents to the laws
of the  living system, it is evident that they can
only act as  stimulants ;  but, in admitting this, it
is requisite to draw the distinction between astrin-
gents,  stimulants,  and  tonics.   Stimulants  act
powerfully on the excitability of the part to which
they are applied, producing sensation and sudden
contraction or motion, and  extending their action
over the whole  frame ;   but  this is followed by
corresponding  relaxation.   Astringents operate,
also, by causing sudden contraction ;  which is
different, not only in  degree but in kind, from that
produced by general stimulants.   Tonics, while
they promote contraction and density, differ from
astringents,  in  so  far that their action is slowly
produced,  and  confined  within that limit which
may be regarded as the natural state of the healthy
solid.   Thus the  distinction  between  the three
powers, stimulus,  tone, and  astringency, is  suf-
ficiently obvious.
   If an astringent be applied  to any part of  the
body  on which the  action  induced  admits of
ocular demonstration, the first effect produced is
contraction  of  the muscular fibres and blood-
vessels of the part.  It is in consequence of  the
contraction which astringents produce in the fibres
of living tissues, that when applied to a wound or
bleeding surface, the  hemorrhage is arrested.  If
an astringent  be applied to the lips, they become
pale, from the diminished  diameter of the blood-
vessels, and the increased opacity of their coats ;
while a dryness and roughness is felt on the palate,
the  result of corrugation of the parts.  In this case,
as far  as regards  the corrugation, tbe nerves of
motion  only are impressed, and a  movement in
the  muscular fibres which they supply follows tho
impression.  If this  view of the subject be  cor-
rect, we may venture to  explain the operation of 
230
ASTRINGENTS.
astringents, by saving that they stimulate directly
the ultimate fibrils  of the motor nerves,  and
through them produce  an  immediate effect upon
the insensible contractility of the muscular fibres
which these nerves supply.  It is not difficult to
conceive that such an  action may be propagated
by sympathy to other parts, or even to the whole
system.   Hence,  if any acerb  fruit, as a sloe, for
instance, be chewed, a peculiar feeling, along with
the corrugation, extending over the whole body,
is induced.
  As it is not within the scope of this work to
examine the characters of particular astringents,
we shall merely class them according to their in-
fluence and mode of action.  All astringents  may
be classed under three distinct heads : — 1. those
exerting a tonic  influence ;  2. those  exerting a
sedative influence ; 3. those operating chemically.
   1.  The  substances embraced  under the  first
head  are both organic and inorganic : the  astrin-
gency of the former chiefly depends  on  tannin
[tannic  acid, the principium scytodephicum or
Gerbestoff of the Germans,] in combination  with
gallic acid, and with haematin, a peculiar principle
lately discovered : that of the  latter on oxygen in
various states of combination.   Tannin  may be
separated from the other components with which
it  is  combined in vegetable bodies ;  and in  this
state  it has been  employed on the continent in
cases of uterine hemorrhages ; and, according to
M. Cavalier, has succeeded in staying these when
ordinary astringents  have failed.  [It  has,  also,
been  given  in  diabetes, leucorrhcea,,gonorrhoea
and the most obstinate chronic catarrhs ; in  hae-
moptysis, in  the sweats  of  phthisis, &c.  &c.
(The writer's New Remedies, 4th edit.  p.  37 :
Philad. 1843.)]   It may be procured sufficiently
pure  for medicinal  use, by evaporating a solution
of  catechu  in cold distilled water,  filtering  and
evaporating  to dryness in a  water bath.  The
dose  of tannin is four grains, repeated every two
hours.
   Gallic acid is also administered  in nearly a
pure  state in Ruspini's styptic, which  the writer
,»f this article has discovered to be little more than
a solution  of gallic acid in  alcohol diluted  with
rose-water.   A simple solution of gallic  acid  is
equally effective ; and  in  this manner it may be
administered in doses of from five to twelve grains,
repeated every hour,  in hemorrhages of the  in-
testinal canal, or in those of the  bladder of urine,
i>r of the prostate gland.  But the usual mode in
which tannin and gallic acid are exhibited  is in
their natural combination, with  other vegetable
components, as  found in the roots of  rhatany
(krameria  triandria) ;  bistort (polygonum  bis-
torta) ;  the common dock (rumex obtusifolius) ;
avens (geum urbanum) ; and tormentil (tormen-
tilia, erecta) ; in the bark of the oak (quercus pe-
dunculata); that of the larch  (pinus larix) ;  and
of the white willow (salix alba.) ;  in the leaves of
bears' wortleberry (arbutus ursi) ; in gall-nuts,
the excrescences formed on the leaf-stalks of the
quercus infectoria  by the  puncture of the cynips
quercifolii, and the deposition  of its eggs in the
wound ; in the petals of the rose (rosa gallicai) ;
balaustines, the flowers of the pomegranate, (pu-
nica granatum) ; and in the  shell of the fruit of
the same plant.   Tannin and gallic acid are also
found in natural combination in kino, the inspis-
sated juice of the nauclea gambir, and of several
species  of eucalyptus; and  in  catechu, the  pre-
pared juice of the acacia catechu.  In prescribing
any of  these  varieties of  combination  of tannin
and gallic a^id,  it is of importance  to  be  aware
that the union of many substances with  them may
either destroy their  astringency, or render inert
the substance combined with them, so as to defeat
altogether the intention of the -practitioner.  Thus
all infusions or decoctions of astringent vegetables
are rendered nearly  inert by combination with in-
fusions or  tinctures of cinchona bark, cusparia
bark, and calumba  root:  they destroy the  active
principle  of ipecacuanha;  as well as the astrin-
gent influence of the salts  of  lead, copper, zinc,
iron, and  antimony,  and some of those of mercury.
The oxymuriate or chloride of mercury, however,
is  not  precipitated  by them ;  and,  it  is also  a
curious fact,  that altbough  tartar emetic is copi-
ously precipitated and rendered inert by infusion
 of galls  and  most  other  solutions of  astringent
vegetable matter, decoction of oak bark  causes no
change on that salt.  The  reason of this is not
 understood.   The  mineral acids weaken the ac-
tivity of astringent vegetable solutions; the astrin-
gency of kino is completely destroyed by combi-
nation with an alkali; and the astringent tinctures
are rendered inert,  consequently useless,  when
combined with the cretaceous mixture.   The na-
tural combination of tannin  with haematin, occurs
in logwood, the wood  of  the haematoxylon cam-
pechianum.  It is uncertain whether the haematin,
which appears to be one of the colouring principles
of the logwood, increases the astringency of tan-
nin in  the same manner as the gallic acid. Nearly
the same substances which are incompatible with
vegetable infusions and decoctions containing tan-
nin and gallic acid, however, are also  incompati-
ble with  the decoction of logwood, or the solution
of its extract.
   The inorganic astringents exerting a tonic in-
 fluence are substances containing oxygen united
 to various bases. Of those in which it is combined
 with a simple radical, the most useful are the sul-
 phuric and acetic acids.  The action of these as
 astringents is not easily  comprehended without
 referring to their operation  as  local stimulants,
 exerting  their influence  on  the circular fibres of
 the blood-vessels : at all events there is no founda-
 tion for the opinion entertained by Boerhaave and
 others  that these acids, in a diluted state, coagulate
 the fluids when taken into  the  system.  In ad-
 ministering sulphuric acid, it should be recollected
 that its action  is much modified by dilution, and
 thence that it may be prescribed in both active
 and passive hemorrhages ;  that it should be cau-
 tiously prescribed to women  who are suckling, as
 it  often  proves  hurtful  to  the  infant; that, in
 combining it with opium, the activity of the  nar-
 cotic is much increased by the  formation  of the
 sulphate  of morphia ; and that it ought not to be
 combined either with kino or catechu.  The same
 directions are applicable to the administration of
 diluted acetic acid.  Under this head of  astrin-
 gents we also find the metallic salts.  The  styptic
 nature of many of them  has been  long known
 Among the salts of iron, the sulphate can  only
\ be employed internally in  passive  hemorrhages, 
ASTRINGENTS
201
such,  for example, as take place in  scurvy and
purpura :  the hydrochlorate,  in  the  form of the
muriated tincture, diluted, is chiefly employed as
a local  astringent.  The sulphate of copper, in
doses  of from one-sixth of a grain to half a grain,
combined with opium, has proved useful in chro-
nic diarrhoea ; but notwithstanding the beneficial
effects derived from it in such cases, it must be
acknowledged that the internal administration of
sulphate of copper is always hazardous.  If head-
ach, vomiting, gripings, and cramps in the limbs
supervene on its use, it should be instantly dis-
continued, and a solution of white of eggs, with
sugar, should be freely administered ; or from ten
to fifteen  grains of ferro-cyanate  of potassa in
water.  Except  as external astringents, the salts
of zinc  are rarely  employed.  Nitrate of silver,
also, except as a local application, in  gargles  and
lotions, and in the form of lunar caustic, is in
limited use as an astringent.   In  ulceration of the
cornea, and in obstinate inflammation of the con-
 junctiva, two grains of the nitrate in a fluid ounce
of  distilled water  is of sufficient strength  as a
local  application ; but when  the  ulcers are of a
nature to threaten  collapse of the eye,  and pro-
 trusion of the iris, the proportion of the nitrate
 should be at  least  ten  grains  to a fluid ounce of
 distilled water ;  and the same degree of strength
 is requisite when  granulations show  themselves.
 The  solution, taken  up  on the point of a  hair
 pencil, should be first dropped into the eye at one
 angle, and then  followed by a drop of almond oil,
 applied  in the same manner.
   2.  The substances producing the effect of astrin-
 gents by exerting a sedative influence on the sys-
 tem, are chiefly the  salts  of  lead.  The  acetate,
 whieh is  that  most  commonly  employed as an
 internal medicine, is  a valuable  sedative astrin-
 gent ; and when combined with opium, and taken
 in conjunction with distilled vinegar, to prevent it
 from  being converted into the carbonate, it may
 be administered with perfect safety.  Indeed we
 have  satisfied ourselves  that the  carbonate is the
 only  poisonous  salt of lead ;  and that the others
 become so in the direct ratio of their aptitude to
 be converted  into the carbonate; thus we find that
 the subacetate is more poisonous than the acetate.
 From this fact, it might be concluded that the car-
 bonate of lead is the best sedative astringent; but
 as it accumulates  in the system, and  its action is
 not so easily regulated as the  acetate, the  latter is
 generally  preferred  for  internal use.  We  have
 given the  acetate  in conjunction with distilled
 vinegar, in doses of from six to  ten  grains every
 fourth hour, for six and  eight  successive  days,
with  the  most decided benefit, in pulmonary he-
 morrhages,  and  those  of  the  intestinal canal.
The vinegar  evidently prevents the decomposition
of the acetate by the carbonic acid extricated  in
the intestinal canal; and on account of its apti-
tude  to change into the carbonate, the alkaline
carbonates ought not to be given  at the same time,
although these are recommended, on the authority
of Dr. Christison, as antidotes in cases of poison-
ing by acetate of lead.   It may be  administered
in the form  of pills, and  washed  down with  a
draught containing half a fluid ounce of distilled
rinegar, and  twelve minims of tincture of opium.
When its effects are required to  be suddenly pro-
duced, solution is a preferable form  of the  medi-
cine.   Nothing  is more absurd than the custom
of prescribing infusion of roses acidulated  with
diluted sulphuric acid, at the same time with pills
containing the acetate of lead : the acetate is de-
composed, and an insoluble,  consequently inert
compound is produced ; so that the remedial in-
fluence of botb the salt of lead and  the sulphuric
acid is destroyed.  The subacetate and  the car-
bonate of lead  are  seldom employed except  as
external  applications.   It has been  asserted that
the effects of poisoning have  followed even their
external application ;  but in the only well authen-
ticated case, that related by Dr. Wall, in the first
volume of the Transactions  of the  College  of
Physicians, tbe colic which was induced followed
the immersion of the legs twice a day, for ten
days, in a bath of the solution of  acetate of lead.
We have never seen any bad effects  result from
the external use  of either  the acetate or subace-
tate, but,  assuredly, the carbonate  should be used
with  caution  to  external sores ; and neither the
subacetate nor carbonate should he internally ad-
ministered.   If  symptoms  of poisoning display
themselevs during the use of the salts of lead, the
best antidotes are sulphate of magnesia, or sul-
phate of soda, combined with opium;  and if para-
lysis has  already supervened, the acetate of strych-
nia will  be  found more useful than any other
remedial agent.
   The only other sedative astringent necessary to
be  noticed is cold.  The first effect  of a sudden
abstraction of heat from the body, or any part of
it, is  a peculiar  sensation, which is  accompanied
with  paleness and a corrugation  of  the  skin ;
resembling the effect produced by it on dead matter.
In  the living body,  however, its  effects are not
confined to where it is applied, but propagated to
internal and distant parts;  consequently the entire
system experiences the influence  of cold when it
is applied to a part.   So far the effect of cold  is
truly astringent;  but if the application  of it be
short or transitory, a reaction  in the system  takes
place, and defeats its  foimer beneficial influence;
therefore,  to  render  cold  a useful  astringent in
hemorrhagic attacks, it must  be applied for some
length of time, in which  case it checks the flow
of  blood  rather by its sedative than its astringent
influence.  In employing cold, something may be
gained by using  some media instead of others :
thus cold humid air abstracts heat from the body
more . quickly than  cold  dry  air, in  tbe  ratio of
330 to 80 ;  and, if water  be  employed, the more
free the fluid is from foreign ingredients, the more
rapidly the temperature of the body is  lowered.
The method of employing cold is also sufficiently
important to require attention : in haemoptysis, the
body should be exposed to cold air, and ice inter-
nally  administered, whilst  the  lower extremities
are kept warm :  in haematemesis, the  same expo-
sure  is proper, but  instead of ice taken by the
mouth, iced  water should be  injected per anum ;
and in uterine hemorrhages nothing is so effectual
as  the injection of cold water into the uterus  by
means of the stomach-pump,  so as to keep a con-
stant stream of the  fluid  applied  to  open vessels.
A temperature of 32° is  sufficient for every pur-
pose indicating the use of cold as an astringent.
   With respect to substances which  produce the 
232
ASTRINGENTS.
effects of astringents  by acting chemically on the
contents of the stomach and  intestines, very few
remarks will suffice.   Both lime and its carbonate,
or chalk, operate in checking diarrhoea by neutral-
izing  the  ascescent  matters which  augment the
irritability of  the  intestines,  and keep up  their
morbidly increased peristaltic movement.   Owing
to the little solubility of pure  lime, chalk, rubbed
up with mucilage  of gum  so as to suspend it in
any fluid, is preferred in cases of diarrhoea.  It is
incompatible, with vegetable infusion containing
much tannin, and with preparations of  ipecacu-
anha.   When it is necessary to  continue the use
of the chalk mixture for  some time, the bowels
should be cleared  with a purgative, as accumula-
tions  in the  form of hard balls are apt  to take
place  in them, and, lodging  in  the  folds of the
intestines, to cause much inconvenience and, occa-
sionally, hazard.
   [The agents, considered thus far, may be re-
garded as direct astringents ;  but profuse evacua-
tions  may be connected with different states of the
living system, so that  agents,  possessed  of no
astringent properties, may check  them  or produce
an astringent operation  indirectly.  Hence, there
may be direct  and indirect astringents, as  there
are direct and indirect tonics.   Opium, for exam-
ple, by allaying the augmented  peristole  in diar-
rhoea, may exert  an action of  astringency, and
diminish the number of discharges   accordingly,
it is often had recourse to in  such cases.   Again,
the increased discharges of dysentery are induced
by an inflammatory condition of the mucous coat
of the intestines : bleeding, therefore, by allaying
this inflammation, and castor-oil,—given occasion-
ally, so as to remove gently the morbid secretions,
—by taking away  the cause, may check the effects.
A predominance of acidity in early infancy lays
the foundation for many of the bowel complaints,
which are so common at that  age, and keeps them
up when  once established.  A proper antacid, as
before observed,  by  neutralizing the  acid, takes
away the  cause,  and  thus becomes  an  indirect
astringent.  (The writer's General Therapeutics
and Mat. Med. ii. 96, Philad. 1843.)]
   In a therapeutical and practical point of view,
astringents, when administered on  proper princi-
ples,  are a valuable  class  of remedies.  In  inter-
mittent fevers, the vegetable astringents have been
successfully  employed  in the same  manner as
simple tonics.   We can form no other idea of the
manner in which they prove beneficial  than by
supposing, that they obviate the relaxation which
favours the  influence  of  the  exciting causes of
agues.   On this account it has been asserted that
tonics and astringents operate in every respect in
a similar  manner ; but many tonics, such, for in-
stance, as sulphate of quinia, possess no astrin-
gency, and nevertheless are useful in intermittents;
and  it must be admitted that, as pure astringents
are seldom or never given alone in intermittents,
it is difficult to ascertain how much of the benefit
 is due to their influence.  They are employed  in
 continued fevers  only to moderate incidental diar-
 rncea and internal hemorrhages.
   In the phlegmasia, astringents are contra-indi-
 i.ated as general  remedies ;  but in that state of
 inflammatory  action  which  assumes a chronic
 character, and is kept up by debility and  increased
nervous excitability, such as occurs in the eye and
in the tonsils, they are local remedies of conside-
rable value.  Solutions of the metallic  salts, and
infusions of astringent vegetables, with  the  addi-
tion of diluted sulphuric acid, are well adapted for
these  cases.   Indeed, after inflammatory  action
has been subdued by the use of the lancet and
other  antiphlogistic measures, the application of
cold and  astringent solutions  tends  greatly to
restore the healthy action of the part.
   [In diphtheritic affections of tbe throat, a solu-
tion of nitrate of silver  has been found of great
benefit; and in cases of diphtheritic laryngitis, the
inhalation of finely powdered alum has been mark-
edly advantageous.  Not only—according to Laen-
nec—has it afforded great and speedy relief in tra-
cheitis, but in laryngitis,isthmitis, and pharyngitis.]
   No remedies are so important in the hemorrha-
giae as astringents ; but  they  are not to be indis-
criminately prescribed, or at all  times employed:
it is, therefore, necessary, to inquire what are the
circumstances indicating their use in these cases ?
Hemorrhages are properly divided into active and
passive.  In the first or active kind, the flow of
blood generally  arises from a plethoric condition
of the  vascular  system;  and it may, in  some
respects, be  regarded as an  effort  of nature to
relieve the morbid  fulness of  the vessels.  In this
form of hemorrhage, tonic astringents are improper;
and even those exerting a sedative influence should
not be resorted to until the vessels be either emp-
tied spontaneously or  by  the use  of the lancet
In passive hemorrbages tbe animal fibre is relaxed,
the red particles  of the blood  are diminished, and
diffused in a superabundance of serum, so that the
blood  assumes a pale watery aspect; while the
system suffers from general debility.  In this state,
astringents are  decidedly indicated, and may be
liberally  employed.  Although these  opposite
states appear very  obvious  in description, yet
much judgment and attentive observation are requi-
site to distinguish them  on many occasions.  If
we take, for example,  epistaxis, let us enquire,
what are  the peculiar  symptoms  which clearly
indicate the employment of astringents ?  When
bleeding takes place from the  nostrils of young
persons of a plethoric habit,  it may be critical, or
connected  with congestions, or a determination of
blood  to the head.  In this state the hemorrhage
should not be checked by astringents, unless it is
so profuse and long continued as greatly to  lower
the pulse, to produce pallor of the  countenance,
and exhaust the general strength.   On the con-
trary, when epistaxis happens  in weak boys or
youths, or in old persons; or when it is sympto-
matic of  diseased  liver, or  some  other internal
organ ; then astringents may be at once adminis-
tered to check the direct loss of blood, whilst other
means  are resorted  to for removing the exciting
causes of the  hemorrhage.  The best astringents
in these cases are  solutions  of metallic salts and
of alum :  they  may be either  injected into  the
nostrils, or dossils of lint soaked in an astringent
solution may be inserted ;  while at the same time
cold water is applied to the face and nape  of the
neck.
    In haemoptysis, if the excitement be considerable,
 the lancet must  be  employed,  after which the
 application  of cool  air, cold water, or  ice  to the 
ASTRINGENTS.
233
chest, with the  internal administration  of acetate
of lead and diluted acetic acid, comprehends the
necessary  measures.   When the loss of  blood is
considerable, these active measures should be im-
mediately  resorted to;  but if it do  not assume an
alarming aspect, and no predisposition to  phthisis
exists, and especially if it is  connected with sup-
pressed menstruation, measures calculated to  mo-
derate the hemorrhage  should be resorted to.  The
acetate of lead is admirably adapted for such cases,
and may be given to the extent of half a drachm
in  twenty-four hours,  if vinegar be administered
in conjunction  with it.
   In haematemesis, the  gallic acid or Ruspini's
 tincture may be  administered,  with iced water;
 but in  treating cases  of vomiting of blood,  we
 should always bear in  remembrance the fact, that
 this form  of hemorrhage is seldom idiopathic, and
 consequently that the  propriety of administering
 astringents  must  depend  on  the nature of  tbe
 primary disease.   The exhaustion which occurs
 in haematemesis  also  demands  some caution in
 prescribing sedative astringents; and it  is  occa-
 sionally even necessary to combine cordials with
 them.  In haemorrhois, the propriety of employing
 astringents is determined altogether by the nature
 of the remote  causes  of the disease.  The most
 common  is costiveness,  laxatives  are  therefore
 indicated  ; but after this  state  is removed, when
 the tumours are large, and the bleeding consider-
 able, astringents should be employed.  A pint of
 iced water thrown into the rectum every morning,
 and an ointment  composed  of powdered  galls, or
 of kino or catechu, or  oxide  of zinc may  be used.
 Accompanying haemorrhois,  we not unfrequently
 meet with prolapsus ani: the return of the gut is
 easily effected, but it  is only  by bracing the re-
 laxed sphincter that we can retain the gut in its
 place, which is best accomplished by injections of
 the infusion of balaustines or of the pomegranate
 bark.
    Haematuria is  generally owing to some disease
 of the bladder or  prostate  gland  ; but,  without
 neglecting the primary disease, much advantage is
 derived from the internal administration of a solu-
 tion of gallic acid in  infusion  of uva ursi.   The
 acid passes the kidneys unaltered, and  is  directly
 applied to the bleeding vessels.
   In menorrhagia, where there is general debility,
 astringents  are most  beneficial; in which  case
 cold water  injected into  the uterus should  hold
 either gallic acid or  alum  in solution.  If  the
 former be employed, half a  drachm may be used
 for every pint  of water; if the latter, a drachm
 will be sufficient.
    [Dr. Stevenson (Edinb. Med. and Surg. Jour-
 nal, July  1843,  p.  103 —110,)  has published
 several cases to show  the  value of gallic acid in
 Uterine  hemorrhage and  haematuria.   When its
 administration  by the  mouth is impracticable or
 objectionable, it may be used in the way of ene-
 ma.]
   In all external hemorrhages, where it  is unne-
 cessary to take up vessels, cold water is  the best
 astringent: it should be continued until  a clot is
 formed, after which the use of every application
 should be suspended, rest  enjoined,  and  nature
left undisturbed to perform her curative process.
   In the profluviffi, the employment of astringents
   Vor. I___30                         u*
is  often injurious : in dysentery, in particular, it
requires much caution.   If astringents be  indis-
criminately prescribed, they may increase an in-
flammatory state of the mucous  membrane, with
all its consequences;  and they  seldom fail to
cause most distressing  meteorismus.   When the
diarrhoea, however, is  considerable towards the
termination of the disease, and threatens danger-
ous debility ; and if the powers of the stomach are
at the same time much weakened, mild astringents
may be advantageously administered.
   In simple diarrhoea, depending on loss of tone,
whether arising from debility of the whole system,
or causes acting on  the  intestines  alone, astrin-
gents may be administered with great  freedom.
The best for this purpose are those containing
tannin and gallic acid, especially the krameria and
tormentil, combined with aromatics ; for example,
the essential oils of cinnamon or of cassia in the
state of oleo-saccharum.
   In diabetes, astringents have  been much em-
ployed : they have occasionally proved  useful;
but they are not to be relied upon in this intract-
able disease.   They have been found beneficial in
ephidrosis ; but this  must greatly depend on the
nature of the primary disease, to which the inor-
dinate action  of the cutaneous exhalents  is to be
traced.
   In gonorrhoea virulenta, much diversity of opin-
ion  prevails  with regard  to the employment of
astringents.   In the incipient  stage of the disease,
when there is a slight turgescence only of the lips
of the urethra, with heat, but  as yet no discharge,
the employment of an astringent injection, suffi-
ciently  stimulating to  excite  slight  pain in the
urethra, will often wholly check the disease ; and
the  same benefit occurs when, with scarcely any
pain or scalding, the  disease displays itself merely
by the  discharge.  The best astringents for this
purpose are the  metallic salts, such as sulphate of
zinc, in the proportion of two grains  to a fluid
ounce of water;  or sulphate of copper, in the pro-
portion of one grain to the same quantity of water.
When the pain and scalding,  in a more advanced
stage of the disease,  are very severe, the best  in-
jection  is subcarbonate of lead, rubbed  up with
mucilage and  opium.   When, however, the ardor
urinae  is  attended with  frequent chordee,  and
pains in the loins and thighs,  with much general
excitement, astringents prove hurtful.   The use
of astringent injections, in any stage of gonorrhoea,
is nevertheless objected to by some practitioners,
who conceive that they tend to induce stricture,
and other diseased states  of the  urinary  canal,—
an opinion unsupported by correct observation; on
the contrary, it is the long uncontrolled inflamma-
tory action which is  productive of such  states of
the urethra.
   In leucorrhcea, astringent injections have been
freely and advantageously employed ;  when due
care has been taken to discriminate between mere
laxity,  favouring an  increase of the natural dis-
charge  from  the vagina, from deficient actkn in
the  absorbents, and  that  state of excitemeut in
which the discharge is augmented in quantity, am
greatly altered in quality.  In the first state, much
benefit  is derived from the local use of nitrate oi
silver, in the  proportion of two grains  of the salt
to one fluid ounce of water;  and five minims of 
234
ASTRINGENTS —ATROPHY.
diluted nitric acid :  the latter ,'s necessary to pro-
tect the nitrate from immediate decomposition by
the albumen contained in the diseased secretion
of the vagina :  the  other metallic salts, particu-
larly sulphate of zinc and  of copper, solution of
alum, and decoction of galls and other vegetable
astringents, have been, also, foitnd serviceable. In
the second state, it is useful to apply leeches over
the pubes or on the groins ; or a cupping-glass on
the sacrum ; with the use of the  hip-bath, before
employing injections : and even  when  the proper
period to resort to them arrives, it is of importance
to select those that operate by exerting  a sedative
as well as astringent influence.
   In  affections connected with calculi in the uri-
nary organs, astringents have been employed with
evident benefit.  This is, perhaps, owing to their
improving the tone of  the digestive organs,  and
consequently effecting a more complete  conversion
of the food into healthy chyle.
   In  gastric irritation, the acid which is formed in
the stomach favours greatly the deposition of uric
acid in the kidneys ;  whatever, therefore, tends to
improve the tone of the stomach must  necessarily
lessen the predisposition to the formation of cal-
culi : in this manner astringents operate in reliev-
ing calculous diseases.
   In  many local affections,  the application of
astringents  is useful.  In many superficial inflam-
mations, as, for instance, erysipelas, erythema, and
herpes, which are more or less attendant on febrile
states of the constitution ;  as  well as in ophthal-
mia,  aphthae,  and  similar affections,   the  local
employment of astringents forms an   important
addition to  the general  treatment.
                           A. T. Thomson.
   ATROPHY, from a privative, and  rpo<ph, nu-
tritio, is a term used in medical  language to sig-
nify a deficiency in the nutritive powers of a part,
in consequence of which its natural dimensions are
reduced, and the number of its constituent mole-
cules diminished.  The process of nutrition essen-
tially consists in the several  solids receiving from
the blood, as it  circulates through them, a succes-
sion  of particles similar to those of which  their
structure  is  already composed ;  and throwing off
into the same circulating fluid such other particles
as are destined  to  be removed from their texture.
The  process by which  certain particles are sepa-
rated  from  the blood, and  appropriated to  the
structure  of the solids, is termed assimilation ; and
the process of detaching such particles as are no
longer fitted to form  an integral  part of  their
structure, may be termed the process of dis-assimi-
lation, or of interstitial absorption.
   On the equilibrium  of these two  processes the
 due nutrition of the solids essentially depends ; if
 either process  preponderates, the balance  of nu-
 trition is  destroyed : if, for example,  the powers
 of assimilation exceed those of dis-assimilation, the
 nutrition of the part becomes excessive; but  if, on
 the contrary, the powers  of dis-assimilation pre-
 ponderate, the nutrition of the parts is diminished
 in proportion. When one or more tissues or organs
 are affected in the  last mentioned way, they are
 said to be  in  a state of atrophy ; but when the
 affection is general, and the whole system partici-
 pates  in  the  atrophy, the  term  marasmus, or
emaciation, is more usually employed to express
it.  For this reason we shall confine the following
observations  to cases  of partial or local atrophy.
  The  effects  of atrophy vary considerably,  ac-
cording to the extent of the affection, and the tex-
ture of the part affected. The atrophy, for instance,
may be confined to one of the component tissues
of an organ,  the others still retaining their natural
dimensions,  or  even  acquiring  an increased  de.
velopment;  as  in the peculiar alteration  of  the
liver, described by Laennec as a new  morbid pro-
duction, under tbe name  of cirrhosis ,• but which
Andral has shown (Clinique Medicale, t. iv. p. 7.)
to depend upon atrophy of the red, and hypertro-
phy of the white, substance of that viscus.  In this
form  of atrophy the organ affected may retain its
natural dimensions, or may even increase in size,
the atrophy  of one of its tissues being more than
compensated for  by  the  hypertrophy  of another.
When the atrophy affects all the elementary tissues
of  the  part, a proportionate  loss  of substance is
necessarily produced.  The  membranous organs
are rendered thinner, and  this thinning of their
tissue may even go on until  it ends in their per-
foration.   The parenchymatous organs are dimin-
ished in bulk, except in  those cases  where their
internal structure becomes  rarefied, as occurs in
atrophy of the bones and lungs.   We have seen
the femur of an adult so atrophied internally as to
float  on the surface  of water like so  much cork,
while externally  it presented no appearance  of
any such  alteration.   The colour  of an atrophied
organ is usually paler than natural; it receives
less blood, and  is often so altered in its appear-
ance  as to retain few traces of its orginal organi-
zation ;  being in some instances almost wholly
reduced to  cellular tissue.  In cases  of extreme
atrophy, the organ affected may be reduced to a
mere rudiment, or may even disappear altogether.
It is  a curious fact that several organs, as they  fall
into  a  state of atrophy, frequently have a preter-
natural quantity of fat deposited on their surface;
 and this deposition of fat is in general proportion-
 able  to the extent  of atrophy, and  consequent
 diminution  in  the size of the organ.  We have
 repeatedly seen the muscular parietes of the heart,
 especially those of the right ventricle, considerably
 reduced in thickness, and coated with a deep layer
 of fat -. near the apex of the ventricle, this atrophy
 of the  muscular, and  hypertrophy of the adipose
 tissue is particularly  remarkable ; the muscle being
 sometimes as thin as paper, and covered with  a
 layer of fat  nearly half an inch in depth;  "Ana-
 logous phenomena are observed in certain circum-
 stances in the animal kingdom ; where, in propor-
 tion  as an  organ  decreases  in  volume, a fatty
 secretion  is  found to be deposited around it: thus
 in the spermaceti whale,  and  many of the  fish
 tribe, an  oily substance  fills the very  considerable
 space which exists between their diminutive brain
 and  the  parietes of the cranium."*  There are
 some cases  in which the atrophy  of an organ may
 be regarded as a healthy or physiological process;
 as when parts, whose functions  are no  longer
 required  in the  economy, waste away or even
 disappear altogether.  In the  foetus  in  utero the
 functions of the vesicula umbilicalis cease after the

   * Pathological Anatomy, translated from  the French
 of Professor  Andral by Dr. Townsend and Dr. West 
ATR
third month, and the organ itself disappears soon
after ; the meinbrana pupillaris likewise  ceases to
exist before the full period  of foetal life is accom-
plished.  Other organs that seem to be  essential
in foetal life fall into a state of atrophy soon after
birth;  amongst such  may  be enumerated  the
ductus arteriosus, and  venosus, and other blood-
vessels used only in  the  foetal circulation ; the
suprarenal capsules, the left lobe of the liver, and
the thymus gland.  Again, certain organs that are
constantly employed in youth and  manhood cease
to be as actively employed in  advanced life, and
accordingly  fall into  a  state  of  atrophy.   The
thyroid gland decreases in old age; the organs of
generation, too, lose their natural size.   M. Ribes
has  particularly described the alterations which
the corpus cavernosum  penis  undergoes  in old
age :  " the cells become  larger, and  the  membra-
nous  septa  that  intersect its  interior  become
thinner, and are even  partially absorbed, so that
quicksilver injections pass readily into it."   (Bull
de la  Faculte, t. vi. p. 299.)
   The ovaries and mammary glands are also, in
advanced life, reduced to mere rudiments ; and in
extreme old age every organ in the body falls into
a state of atrophy ;  the  digestive apparatus being
the last to share in the general decay.   Andral
states that atrophy, and consequent rarefaction of
the parenchyma  of the  lung, is one of  the most
constant causes of the  emphysematous condition
of that organ  so frequently observed  in old age.
" In the parts where this  alteration exists, there
are no longer to be found either bronchial ramifi-
cations or vesicles  properly so  called, but merely
cells of greater or less diameter, divided into com-
partments by imperfect septa or irregular laminae.
 The portion of lung in this condition bears  a per-
fect resemblance to the lung of the tortoise tribe."
(Op. cit.)   We  have had  repeated  opportunities
of verifying the accuracy of tbis description of the
changes which the  texture of the  lung undergoes
in advanced life.  Tenon calculates  that the osse-
ous parietes of the skull  lose  one-fifth of  their
weight in  old  age.   (Mem.  de l'lnstitute,  t. i. p.
221, an. vi.)   M. Desmoulins found the brain in
persons above  seventy  specifically  lighter than at
forty  years  of age; and  its  actual weight,  he
states, is diminished from one-fifteenth  to one-
twentieth of the whole : he likewise states, that
in old persons of both  sexes  the trunks of the
nerves, and their filaments, are considerably di-
minished  in  size  below  their standard  in the
adult.*
   These phenomena of atrophy  are still  more
remarkable in  those animals which,  during the
progress of their lives, undergo certain metamor-
phoses. Thus in  the   tadpole,  when  about to
change into a frog, the  tail gradually disappears,
and the  gills  are  obliterated,  their  place  being
supplied by lungs, which were in  a rudimentary
state so long as the animal retained the form of a
tadpole  and respired  only in  water.   (Andral,
Op. cit.)
   In  all these instances the atrophy may be re-
garded as  a natural phenomenon, regulated by a
general law in physiology—that all organs  attain
their  maximum of development  at  that period
  * De PEtat du SystOme Nerveux, &c. Journal de Phy-
sique, t. ix. p. 44-2.
PHY.                                    235

when  their functions  are  most  exercised, and
subsequently decline as their functions cease to be
required in the economy.
  But we  likewise find atrophy occurring under
other circumstances, and constituting a true mor-
bid  alteration.   Amongst the pathological causes
of atrophy  may be enumerated : —
  (a.) An  original deficiency  of  development.
From the science of embryology, which has been
so successfully cultivated of late  years, we learn
that the formative process may be arrested at any
period during  the evolution  of the foetus, so as to
cause  a total  suspension in the development  of
any  organ  or  set  of organs ; in consequence  of
which the organ thus  arrested in  its development
continues,  up  to the period  of birth, either imper-
fectly  formed  or  altogether  deficient;  in fact.
remains precisely as it was  at the period when its
evolution  was suspended.  In this way are pro-
duced the different varieties  of congenital atrophy.
In cases of congenital atrophy of the limbs, Rostan
and other  pathologists have seen the hemisphere
of the brain on the side opposite the deformity
converted into a serous sac,  as if from having been
early arrested  in its development;  and M. Serres
states that  when the cervical swelling of the spinal
cord is deficient, the upper extremities are like-
wise deficient; and that when the lumbar swelling
does not exist, the lower extremities are invariably
wanting.   These  observations would lead us tc
conclude that there subsists an intimate relation
between the perfect development of certain organs
and the perfect evolution of the nervous centres ;
but, on the other hand, there are also  facts which
would lead us to infer that  this relation is much
less absolute than  was for a long time supposed ;
and that,  under  certain circumstances,  all  the
different organs,  as  well   as their nerves, may
attain their full development, notwithstanding the
deficiency of the nervous centres.  Indeed, it has
been fully proved in several cases  of anencephalia
and amyelia,  that the nerves may be  perfectly
developed  independently of the existence of the
brain or spinal cord.  From these cases it appears
that the nerves  are  primarily  formed  in those
organs which  it is their office to connect with the
centres of the nervous  system ; and that they do
not  unite  with those  centres for  a considerable
time  after  their  first  rudiments are  perceptible.
(Andral, Op.  cit.)
  (b.) A diminution in the usual  supply of blood,
arising either  from a reduction in the whole mass
of the circulating fluid, as in phthisis, tabes mesen-
terica, and other diseases affecting the process  of
digestion and  sanguification ;  or  from any  local
obstruction to  the arrival of  arterial blood, as when
the main artery leading to an organ is obliterated.
or its caliber diminished: we have seen one of the
kidneys in  an adult as small as that organ usually
is in the foetus, and its blood-vessels proportionably
diminutive.  M. Lobstein records a case in which
the spleen  was no larger than a  filbert, and  the
splenic artery  so small as scarcely to admit a hail.
In  such cases, however, it  is not always easy lo
determine whether the atrophy of the organ is in
reality the  cause or the effect of the atrophy of its
artery; for we know that the arteries accommo-
date themselves to the size  of the organ they are
destined to support;  increase with their growth. 
236
ATROPHY.
as in the pregnant uterus, and diminish with their
diminution, as in the same  uterus after delivery.
   (c.)  A diminution  in the  nervous  influence
which regulates the movements, and presides over
the powers, of assimilation and nutrition in  the
part.  Thus in affections of the brain producing
hemiplegia, we generally find the paralysed limb
more or less wasted ;  and in all cases of injury to
the nerves, the atrophy of  the part to which  the
injured   nerve  is  distributed  invariably follows.
The degree of atrophy  is  not, however, always
proportional to the degree of paralysis, nor even to
the length  of  its duration.  In some cases, para-
lysed limbs become atrophied much more rapidly,
and to  a much  greater degree,  than  in others.
The cause of these differences  it  is not always
easy to determine.  It is probable that the various
diseases  of the nervous system which produce
paralysis do  not  determine  the  atrophy of  the
paralysed limb solely by destroying the power of
the will over the movements of the part, but that
there likewise  subsists a direct connection between
the nutritive functions of the part, and the nervous
influence which regulates its movements and inter-
nal operations ; so that the  capillary vessels, which
are the parts  more immediately engaged  in  the
process  of assimilation and nutrition, being held
immediately under the  control  of the nervous
influence, are, consequently, directly affected  by
any derangement or modification  of  the  nerves
which exert this influence  over them.  But even
admitting this hypothesis,  it still  remains  to be
determined whether this influence of the nerves
over the process of assimilation is  exerted  by all
parts of the nervous system indifferently, or by one
class of nerves in particular.  We have examined
the paralysed limbs of a great number of individu-
als, and have generally observed that in those
cases where the paralysis arose from disease  of the
brain, the wasting of the paralysed  limb occurred
slowly,  and was directly proportionate to the loss
of motion  in  the part: whereas  in those cases
where the paralysis arises from an affection  of the
nerves of the  part, the atrophy takes place  much
more  rapidly,  and is considerably greater than
could be accounted for by the mere  loss of motion.
In several of the old and infirm paupers who have
found an asylum in the Dublin House of Industry,
and who have been hemiplegic for a  number of
years in consequence of cerebral disease, the wast-
ing of the paralysed  limbs is very inconsiderable,
and indeed scarcely greater than would  have oc-
curred if the limbs had been voluntarily kept in a
state of inaction during the same length of time.
But in every case which we  have had an  oppor-
tunity  of examining, where the paralysis arose
from  an affection of the nerves of the part, the
atrophy  which ensued was exceedingly remark-
able, even  though the loss of motion in the part
Were only partial.  In cases of unreduced disloca-
tion of the humerus, the pressure of the head of
the bone on the brachial nerves produces a remark-
able atrophy  of the  arm,  even  though the limb
retains   a  considerable  degree of  motion.    Mr.
Bell relates two interesting cases of atrophy arising
from local disease of the  nerves.  In  one, " the
muscles and  ball of the thumb were wasted, so
that the bones and the strings of the tendons over
 .hem might be fell quite plainly."   In the  other,
he says » whilst the fore-arm is firm to the feeling
as you grasp it, the muscles of the arm are wasted
and loose, so that you can feel all the processes of
the humerus from its upper to its lower end ;  the
deltoid muscle is also quite  gone."  In comment-
ing on these cases, Mr. Bell observes, (Appendix,
p. 160,) "These affections  of particular muscles,
or classes of muscles, imply a very partial disorder
of the nerves :  a disease in  the brain, or a disease
in the course of a nerve, must influence the whole
limb, or that portion of it  to which  the nerve or
nerves are distributed.  But in these cases, par-
ticular subdivisions included in the same sheaths,
or running the same course, are affected."
   Another example of the excessive wasting which
occurs from affections of the nerves, is to be found
in the  paralysis which sometimes  accompanies
painter's colic.
   We  are  acquainted  with a gentleman whose
arm  was strained by an accident when he was a
child ; the injury was not attended to at the time,
and  the limb  is  now perfectly useless, and  so
wasted that it  does  not measure above one-third
of the circumference of its fellow.   M. Lobstein
mentions a case somewhat similar.   A man died
at the  age  of fifty-four, with  remarkable  atrophy
of his right leg, caused by a fall  received when a
child, by which the crural and sciatic nerves were
severely injured.  On dissection, all the soft parts
and  even the bones of the paralysed limb were
found  reduced to an extreme state of atrophy;  the
right femur weighed only three ounces two drachms
and  a  half, whilst its fellow  of the left side weighed
nearly  double.   The   gastrocnemius and soleus
muscles of  the sound  limb weighed eight ounces,
while  those of the  atrophied limb weighed only
two  ounces and six drachms.  (Traite d'Anatomie
Pathologique.)
   This excessive state of atrophy not unfrequently
follows when the nerves of tbe  part are  affected,
but, we believe, seldom occurs to the same extent
in cases of paralysis arising from disease of  the
brain :  in  the  latter case  the power of volition,
and  consequently of voluntary motion, is destroy-
ed, and the part becomes atrophied from  inaction
in the latter.   Not  only the  power  of voluntary
motion is  lost,  but the nervous influence, which
regulates the action of  the capillaries, and directly
controls the functions of nutrition, is likewise  in-
jured, and the atrophy of the part follows in pro-
portion.  It must, bowever, be admitted that fur-
ther investigations are required  to  enable us to
account for the great varieties we observe in  the
different degrees of  wasting in paralysed limbs :
it is probable that some  additional  light  may be
thrown  on the subject by investigating  whethei
the  nerves of sensation  or those of motion  are
more immediately connected with the function of
nutrition.
   (d.)  Another cause of atrophy is to be found in
the diminished  activity or total suspension of the
natural functions of an organ.   The effect of in-
action on the muscular system has  been already
alluded  to : a  similar  suspension of function is
found to produce the same  effect on  the internal
organs, in accordance with  the general law, " that
the development of an organ is directly propor-
tioned to  tbe  activity of its  functions."  When
one of the double  organs, as,  for  instance, the 
ATROPHY —AUSCULTATION.
237
lungj or kidneys, is incapacitated from acting, the
other invariably acquires an increase of volume
proportioned to its increased activity of function :
the converse  of this proposition is  equally true,
for when the functions of an organ are  by any
cause rendered less energetic than usual, it under-
goes a proportionate diminution  of volume.   A
remarkable illustration of this fact was observed
by M. Renaud in the dissection of a monkey, and
is described by  Andral, (Op. cit. vol.  ii. p. 456.)
«An enormous ganglion, filled with  tubercular
matter, had so  compressed  the main bronchial
tube of one of the 1 ungs, that its cavity  was al-
most completely obliterated ;  the lung  to which it
was distributed had undergone a  remarkable  de-
gree of atrophy ; and the thoracic parietes of that
side had contracted and fallen in, as in the  case
of absorption of a pleuritic effusion."   The atro-
phy of the testes in individuals  who  have lived
in strict observance  of their monastic vows, is  a
fact perfectly  authenticated.   Other instances
might likewise be adduced, but these are suffi-
 cient.
   (e.)  The last cause of atrophy to which  we shall
 allude is  inflammation.  We frequently observe
 an attack of inflammation succeeded by a marked
 degree of atrophy, or even  by the total oblitera-
 tion of the inflamed  organ.  In a soldier who had
 suffered from repeated  attacks  of hepatitis in  In-
 dia, we found, on dissection, the liver  reduced to
 one-fourth  its usual size, and composed principally
 of condensed cellular tissue.   Andral  mentions  a
 case of suppuration  of the  gall-bladder,  opening
 externally, and discharging several gall-stones, in
 which after death  no  trace of the gall-bladder
 could be found on dissection.*   Inflammation oc-
 curring in an  artery  or vein  not  unfrequently
 causes the obliteration of its  cavity, after which
 it speedily degenerates into a ligamentous cord.
 Another mode in which inflammation  sometimes
 produces the atrophy of an organ, is by the pres-
 sure exercised by the product of  the inflammation.
 Thus we find tbe lung atrophied by the pressure
 of the purulent fluid in empyema ; and in chronic
 pericarditis the  heart has been  found  corrugated
 on its surface, and greatly reduced in size.
   As to the treatment best adapted for the  removal
 of this morbid  alteration, the first  object of the
 practitioner should be to ascertain on which of the
 causes above  enumerated the atrophy depends,
 and, if possible, to remove it;  for unless we re-
 move the cause, it will be in vain to attempt re-
 moving the  effect; but  when  once   the  cause
 ceases to operate, the natural nutrition of  the part
 will soon  resume its  wonted  activity.   It may,
 however, in general be promoted by such measures
 as are calculated to invigorate  tbe  system, exer-
 cise the functions, and sustain the temperature of

 the  Part                    R.  Townsend.
   AUSCULTATION. — In  practical medicine,
 the term auscultation  (from ausculto,  to listen)  is
 properly applied to all the methods  used for  dis-
covering or discriminating diseases  by means of
signs having relation to the sense of hearing.   It

   * One of the Editors was witness of a similar result
in the case of a  ii?ht  reverend  prelate, who died at a
very advanced a«<, having suffered from  the disease no-
ticed in the text a great many years before  his  .'eath.
therefore comprehends the study of all sounds in-
dicative of disease, in any part of the body, whe-
ther produced naturally or  artificially,  and whe-
ther perceived by the unassisted  ear, or through
the help of instruments.
   The  following  synopsis  includes  all the  im-
portant signs of disease recognised by auscultation.
   I. Signs derived from sounds produced natu-
rally within the body.
   1. The sounds having their origin or seat with-
in the  chest.
   a. Dependent on the motions of the heart.
   b. Dependent on  the motions of the  lungs in
respiration.
   c. Dependent on  the action  of the vocal or-
gans.
   2. The sounds having their origin or seat with-
in the  abdomen.
   a. From the peristaltic movements of the intes-
tines when containing air.
   b. From the pulsations of the foetal heart.
   c. From the movement of blood in the utero-
placental arteries.
   3. The sounds having their origin or seat in
the arteries.
   II.  Signs derived  from sounds  produced arti-
ficially, within the body or on its surface.
   1. The sounds produced by percussion of the
surface.
   a. Of the chest.
   b. Of the abdomen.
   c. Of other parts of the body.
   2. The  sounds  produced by succussion of the
body.
   a. In the chest.
   b. In the abdomen.
   3. The sounds produced by the friction of the
parts of a fractured bone.
   4. The sounds produced by the contact of solid
instruments with calculi in tbe urinary bladder.
   It would seem,  at first  sight,  most  proper to
treat first of the sounds naturally produced within
the body.   It will, however,  be  found more for
the reader's  advantage  to notice previously  the
artificial sounds ; because these are more simple
and more easily  understood, and  because  the
knowledge of them will greatly facilitate the com-
prehension of the more complex  results of the
method applicable to the recognition of the natu-
ral sounds.  For this reason we  shall commence
with those signs derived from percussion of the
external surface of the body.
Auscultation of  sounds artificially pro-
   duced  WITHIN THE BOB! Oil OS ITS SUR-
   FACE.
   Percussion.—The application  of percussion
to the  surface of the body, with the view of pro-
ducing sounds whereby the physician might judge
of the state of the subjacent parts, was first made
about the middle of last century by Leopold Auen-
brug,  or Auenbrugger, a German physician, then
residing at Vienna.   This  method, unquestiona-
bly one of the greatest improvements ever made
in physic, was announced to the world in a small
volume, in Latin, first published in the year 1761
In his little work the author  scarcely notices the
principles  upon which the method is founded,  and
gives  us  no insight  respecting tho circumstances
attending its discovery.  The  >aew means of diag- 
238

nosis,  Inventum Novum, as he justly terms  it,
seems to have been received with slight consider-
ation, both by his own countrymen  and by for-
eigners ; and its value was never fully recognised,
much  less established in the  estimation  of the
medical profession, until  the publication of Cor-
visart's translation  of the original work,  in the
year 1808.  From this period, however, the prac-
tice of percussion became general in France ; and
it has since spread over every part of the civilized
world.  Its true value and importance were yet
further established  by the great analogous  disco-
very of Laennec in 1816; although this discovery
was considered  by many as calculated to  super-
sede the original method of Auenbrugger.*
   All  bodies, on receiving a certain degree  of im-
pulse,  are  susceptible of having their  particles
thrown into a peculiar kind of tremor or agitation,
termed vibration, which, when  communicated to
the auditory sense, constitutes sound.  The inten-
sity and permanency of this vibration differ great-
ly in different bodies, according to the nature  of
the sounding body, its form, the manner in which
the impulse is communicated to it, and the nature
of the medium in which it is placed.   The usual
medium of sound  to us  is  the  atmospheric air,
which receives  the  specific vibration from the
sounding bodies, and  conveys them to the  ear.
Air is, however, very far from being the best con-
ductor of sound ; much less is it essential  to the
conducting of sound,  as  was formerly imagined.
But as it is the  usual medium between  us and
sonorous bodies, its relations to these become  of
the chief importance in every inquiry having refe-
rence to tbe practical  habitudes of sound.  The
following approximative statement shows the rela-
tive conducting powers  of different  substances.
It is its peculiar aptitude  as  an intermedium, not
its actual powers of  conducting sound, that gives
to  air  a degree of practical superiority over  all
other bodies.   Taking the  conducting power of
air  as 1, the conducting power of iron and glass
is as 16, of copper  11, of wood 10, of silver 83,
of water 4 J.   Percussion is one of the most com-
mon excitants of sonorous vibration.  The sounds
produced by it will, of course, vary according to
the circumstances above mentioned ; but the same
body will always produce the same  sound  under
similar circumstances.  Upon this fact is founded
the practice  of percussion  as  applicable  to the
diagnosis of diseases.  If we are acquainted with
the qualities and circumstances which render bo-
dies when struck susceptible of particular sounds,
the sounds become  signs of these qualities, and
may be used as means of acquiring a knowledge
of  them.   This principle is practically acted on,

  * Auenbrugger was born in Graets in Styria, in 1722.
He  graduated at Vienna, and afterwards became physi-
cian in ordinary of the Spanish nation, in the imperial
hospital of that city.  In Ersh and Puchelt's Literatur
der Medicin he  is recorded  as the author of two other
medical works, relating to madness, one in Latin, pub-
lished in 1776, and the other in German in 1783.  In the
same record Auenbrugger is  stated to have died  so late
as the year 1809, in the 87th year  of his age.  The  In-
ventum Novum was first translated into French so early
ns the year 1770, by Roziere,  but appears to have drawn
little attention at the time.  Corvisart's translation, as
Hated in the text, was published in 18(18. The only Eng-
'i.-^h translation of this work was published in 1824, with
* si'lection of Corvisart's Commentaries, and additional
Votes by the translator. See "Original Cases, &c, by
J mn Forbes. M.D.  London, 1824."
'ATION.

in many cases, by artisans ; and might be applied
by physicians to the recognition of the qualities
of the  internal parts of the  human  body, with
much more effect, if the substances in the latter
were as simple and  distinct  as those  with which
artisans have to do.  There is, indeed,  a funda-
mental obstacle  in  the way of acquiring know-
ledge in this manner, namely, the  great  difficulty
of so cultivating the sense of hearing as to enable
it to appreciate minute modifications of sound.
But much more may be effected by practice, even
here, than is  commonly imagined.   Carpenters
and bricklayers are  in the daily habit of applying
percussion to the surfaces of bodies, with the view
of enabling  them to judge of the nature of the
parts beneath,  concealed by floors, walls, &c.  In
passing the hammer along the  floor or wall of a
room, they find no difficulty  in  ascertaining the
place of every joist, puncheon, chimney-flue, &c
The soundness of a beam  is  ascertained  in the
same manner,  and in the dark, as  readily, and on
the same principle,  as the money-changer judges
of the goodness of  a coin.
   In these and all other cases, the qualities of the
resulting sound, as has been already stated, depend
no less on certain accidental circumstances of con-
formation, medium, &c. than on the intrinsic con-
stitution of the bodies struck.   The same mass of
clay will yield an  entirely different sound when
percussed, respectively, in a dry pulverised state,
in a moist adhesive  state, when converted into a
solid mass by heat,  when formed  into a vase and
baked.   Of  all the modifications of form of which
matter is susceptible, that which we have supposed
the mass of  clay to assume  in the vase, namely, a
hollow body with thin elastic walls, and containing
air,  augments  the  sonorousness in  the  greatest
degree.  In  this particular configuration of elastic
bodies, the facilities of vibration of their particles,
and the degree of  their relations to the air, are
both  greatly increased;  and it is therefore suffi-
ciently obvious why their degree  of sonorousness
is increased likewise.   It  is  hardly  necessary to
adduce any exemplification  of a fact  which must
be familiar to every one.  We need only compare
the sounds from a solid log of wood, and from the
same log when hollowed into a pump, or box, or
manufactured  into a cask ;  or these latter sounds
with those  from the same bodies when filled with
any  matter of greater  density  than air.   Any
diminution of  the degree of elasticity of the con-
taining solid, or in the quantity of the contained
air, will diminish the degree  of sonorousness on
percussion.  Every  one is acquainted  with  the
difference of effect  in beating  a drum or tambou-
rine  when braced  and unbraced ; or  a bladder
when completely or only partially  filled with air.
   Among the  circumstances  extraneous  to the
nature of the  sounding body, which modify the
sound  elicited by percussion, the qualities of the
body which percusses, and the manner  in which
the  impulse is communicated, deserve attention.
A stroke on a  bell with an iron hammer and with
a wooden mallet, will elicit very different sounds;
so  will  a  blow with the pulpy extremity of the
finger and a slap with the open hand, on the sur-
face of the body.   In applying percussion  to the
investigation of disease, we endeavour to prevent
as much as possible all difference  of result from
AUSCUL 
AUSCULTATION.
239
these  circumstances,  by using a percussing  body
little susceptible  of sonorous  vibration,  and  by
applying it in such manner as to excite this vibra-
tion  rather in the  substance of the body struck
than in the point  of contact.  Our object is, of
course,  to  judge  of the qualities  of the  body
struck, not of the body  striking.
  The animal  frame, like all  other  material ob-
jects, is  more or  less sonorous when  percussed,
according to the nature  of its component parts,
their  mass, degree  of solidity, configuration, and
their relations to the usual medium of  sound, the
circumambient  air.   Percussion of a fleshy part
of the body, as the limbs, yields only a slight and
dull sound ; percussion  of a bone, as the tibia or
skull,  yields a much louder and  clearer sound ;
while percussion of a part that is hollow and con-
tains air, as the chest, affords a yet  louder sound,
 and one that is peculiar  to bodies so circumstanced.
 As many  diseases, by  altering the density and
 other qualities  of the body which  influence  the
 production of sound, necessarily alter the natural
 resonance, the  modifications of sound  discovered
 by percussion thus become means of detecting the
 presence, and appreciating  the extent,  of these
 diseases.
   The only parts of the body to which this mode
 of investigating disease has hitherto been applied
 with advantage, are the cavities of the chest and
 belly.  Both of these afford particular  facilities,
 from containing various  organs of different den-
 sity, and having well-defined  limits ; from  being
 hollow or containing naturally a certain proportion
 of air; and from the liability of this air to be dis-
 placed in disease,  by  matters of  much greater
 density.  Thechest, from having solid, tense, and
 elastic walls, and from  containing  at  all times a
 large quantity of air essential  to its healthy state,
 possesses  many  and great  advantages  over  the
 abdomen  in  admitting  the  application  of this
 method of investigation.  But even in the latter,
 the practice of percussion is  far from  being un-
 productive  of  important  results;  although  a
 somewhat more elaborate method is necessary to
 obtain them.—(See  Abdomen,   Exploration
 of THE.)
    Percussion  of the chest.—On considering  the
 anatomical structure and physiological actions of
 the human thorax and  the organs contained in it,
 we at once perceive that  this part of  the body
 possesses, in the state of health, qualities, as to
 matter,  form,  and  relations to the  atmosphere,
 which ought to  render it considerably sonorous
 when struck.   It  may, indeed, be not inaptly
 described  as a sort of elastic box or basket of
 bones and cartilages, the interstices of  the wicker-
 work being  filled up by a thin layer of flesh, and
 the whole covered, both externally  and internally,
 by a membrane of considerable density; the greater
 portion of the interior  cavity being occupied  by
 air diffused  through the spongy  texture of  the
 mngs.  In the state of health the lungs are always
 in close contact with the walls of the chest;  and
 as their solid materials bear only a very small pro-
 portion to the space occupied by the air contained
 within them, the same results, nearly, are obtained
 from percussion of the external  surface of  the
 chest, as if its cavity were filled with air. We say
nearly, because it will be seen afterwards that, in
certain cases in which air exists loose in the cavity
of the chest, the sound resulting from percussion
is then louder than in the state of health—proving
that the substance of the lungs, however rare and
porous, does impede the sonorous vibrations of the
air contained within it.  As many of the diseases
of this cavity mechanically exclude a portion of
the air contained  in it in the state of health, per-
cussion on its surface  will  in such  circumstances
necessarily indicate the  change that  has taken
place in the density of the  parts within; just as a
cask  that yields  one particular sound when filled
with  air, will yield another  when filled with water
or sand.
   Percussion may be  performed either on the sur-
face of the chest, or on  any  solid or tense body
firmly applied to it.  The former is termed direct
percussion, the  latter mediate percussion.  We
shall notice these in order.
   I.  Direct percussion  is  the mode originally
proposed  by Auenbrugger,  and has been univer-
sally adopted until within these  few years.  It
consists simply in striking the chest with the points
of  one, two, or more fingers  pressed closely toge-
ther, and observing the  degree and quality of the
sound thereby produced.   The hand  as  well as
the chest may or may not be  covered ;  the best
plan,  however, seems to  be, to keep  the chest
covered  and the  hand bare.   The blows  should
have considerable force, yet short of giving pain,
and should follow in quick succession, the fingers
being instantly raised  from  the chest, so that there
may  be free play  for the  elasticity or resiliency of
the parts struck.  A very few blows generally suf-
fice in the same  spot; sometimes a single blow is
sufficient; but it is commonly necessary to repeat
the operation  over a considerable  portion of the
chest, if not the whole of it.
   In practising  percussion, the operator does nof
form his judgments exclusively from the nature of
the sounds elicited.  He judges equally from the
tactual sensation communicated by the part struck,
to  the finger ;  and it  sometimes bappens that this
latter sensation is the more important of the two.
For this reason a bystander can never be so good
a judge of the state of parts  percussed as he who
 operates.
   Percussion may be performed on any accessible
part  of the chest, while the patient is in any posi-
 tion  ; but  certain  positions  are preferable, and,
 indeed,  necessary to  obtain  the full quantity of
 sound which any one part is capable of yielding.
 As the  intensity of sound depends partly on the
 quantity  of air, it follows  that the results of per-
 cussion will be modified by the particular time, in
 the  act of respiration, at which it is performed ,
 and  as we are always desirous of eliciting as loud
 a sound as possible, it is  generally preferable to
 percuss during  or immediately after  inspiration,
 when the lungs are full;  and  not during or after
 expiration, wben  they are comparatively  empty.
 In obscure cases, it is frequently necessary, or at
 least proper, to  make the  patient  take a deep in-
 spiration, and  then  retain his breath for a few
 seconds, while we operate.
    Besides the presence of  a  certain quantity S,
 air within the chest, it is essential to the produc 
210                               AUSCULTATION.
Lion of tbe full sound, that the walls of the cavity
be kept in as clastic a state, that is, as  tense as
possible ; just as it  is  necessary to brace  tightly
the parchment  on a drum or tambourine before
beating it.   With this view, we make the  patient
assume such  positions as stretch  the skin  and
muscles covering the walls of that  portion of the
chest  we  are going to percuss.*   Accordingly,
when practicable, it  is desirable  that the  patient
should be seated, and not lying down during the
operation.   If confined to bed, and able to sit up
in it, he should do so ;  if quite able to get out of
bed, he should rise and be seated on a stool.
When we  operate on the fore part of the chest,
we cause the patient to raise the head, and throw
the shoulders forcibly  back.   When we  operate
on  the back,  we  cause him to stoop  the  head
downwards, and to cross the arms, so as  to render
the whole  back rounded or arched.  When  we
percuss the side, we  desire the arm of that side to
be raised above  the  head, and  the  body to be in-
clined  to  the opposite side ;  and, on the  same
principle, we are careful  that  the garment over
which we  percuss is drawn very tight across  the
part, and is kept in very close apposition with  the
surface ; and, by means of the fingers of the  left
hand, we  can frequently not  merely do this, but
even aid the efforts  of the patient to stretch the
skin and muscular fibres beneath.
   In operating, we  prefer to strike a bone, as the
sound is  greater than when we strike  on softer
and less elastic  parts ;  but  this is a rule  which
neither can nor should  be always adhered to.  A
rule, however, which must never be forgotten or
infringed, in percussing comparatively both sides,
is to  strike on  similar substances, and, as nearly
as possible, on  exactly corresponding points, and
also with  the same  degree of force, and under  a
similar angle.  Inattention to any of these circum-
stances is very apt to mislead beginners.
   It is also right for the  student to be aware that
not merely the posture of the patient, but his situa-
tion relatively to other  bodies, will  modify  the
sound.  Thus,  bedding  and bed-furniture,  also
carpets, and other bodies that  deaden  sound in
general, will render that elicited from  the chest
less clear ; also the  size of the room, &c.; just as
is observable in the  case of musical instruments.
But, although it is well that the practitioner should
not be ignorant of this circumstance, it can seldom
materially  affect our practical conclusions.
   II.  Mediate percussion was only introduced
into  practice  a few  years since, by Mr. Piorry,  a
young physician of  Paris, and differs chiefly from
the foregoing in the employment of a small plate
of ivory  (named by  him pleximeter j)  laid  flat
upon  the  surface, upon  which plate the  percus-
sion is made.
   If  the bodies to which we apply percussion are
hard,  and more or  less elastic,  nearly similar
results as to sound  will  be obtained, wbether we
apply the  blows directly to  their  surface or to  a
 thin  plate of any solid and elastic substance laid
 upon  them.   In both cases, the character of the
  * This is less necessary in mediate percussion; indeed
n is often proper, in this method, to keep the muscles
relaxed.—Piorry, Du Procede Operatoire.  1830.
  I Measurer of percussion, from  jrXfjis, percussio, and
itf'poi, modus.
sounds  elicited will depend upon the nature of
the body under the part percussed.  The  degree
of sound, however, will  be considerably modified
according  as the  body to be  percussed  differs
much or little from the plate upon which the per-
cussion is made.   If the body differs  little from
the plate in solidity and elasticity, the sound will
be  nearly the same whether  percussion is made
on  this  or  on the  plate;  but if the body is soft
and inelastic, the difference  of sound in the two
modes  of percussion  will be very great.   When
we apply percussion to a  solid and elastic body,
the sound elicited is the result, not merely of the
direct primary impulse on the surface, but  of the
combined vibrations of the whole  mass of  matter
beneath it.  The primary sound immediately pro-
duced by the blow will, therefore, be  greatly mo-
dified by the latter,  and the  modification,  as ap-
preciated by the ear, will be  received as the one
sound produced.
   But if percussion be practised on a soft and in-
elastic surface, the impulse will not be propagated
to  the  interior, and therefore will elicit no reso-
nance from it.  In such a case, however, we have
nothing more to do than to  make a firm surface,
by  covering the  part with  a  thin lamina  of any
solid, such  as the plate of ivory before mentioned.
This closely applied to a body becomes as a part
of  it, and the sounds easily elicited by percussion
upon it, derive their character  from the state zi
the subjacent parts.
   The firmness  and tension of most  parts of the
thoraric parietes supersede the  necessity of using
a pleximeter on  them ; but some spots are covered
with a considerable  thickness of soft parts,  and on
these it is necessary for  the  proper  exercise of
percussion ; and the  same may be said when the
parts become  thickened or painful from disease.
In  the percussion of the abdomen, possessed as it
is of soft and yielding walls  only, the pleximetei
is  absolutely necessary  to  the production  of the
requisite degree  of sound; and  it is  yet  further
necessary,  in many cases, in order to bring the
superficial walls, by pressure, in contact with the
subjacent  parts.   (See  Exploration  of  the
Abdomkx.)  Mediate percussion alone may there-
fore be said  to  be applicable to the investigation
of abdominal  diseases.   It is at least  equally ap-
plicable with direct percussion to the  chest; and
as  it has decided advantages in some cases, and
no other disadvantage  in  any case  than the ne-
cessity  of  having  an  additional instrument,  it
 ought  to take precedence of the original method
 of Auenbrugger  in the investigation  of pectoral
diseases also.
   The  following are the relative advantages and
disadvantages of the two methods, as stated by
M. Piorry.  1. Direct percussion is often painful,
particularly in  unskilful  hands;  as  when  the
blows are  too forcible, when they are applied upon
the soft parts between the riSs, or when the nails
are prominent:  even, in  some  cases, the  degree
of  impulse necessary to produce sufficient sound
excites  either a  sense  of pain on the skin, or a
 painful  jarring within the chest, occasionally last-
 ing some time. The use of the pleximeter  enables
 us to avoid all these inconveniences ;  in the first
 place, because it defends the skin from the direct
 impulse of the  fingers; secondly, because a less 
A U S C U L
TAT ION.
241
degree of impulse is necessary to produce the re-
quisite sound ; and, thirdly, because the  shock is
much less felt from being equally diffused over a
considerable space.   Even in the case of recent
vesications, the interposition of the plate will fre-
quently enable us to employ percussion with little
or no inconvenience  to  the  patient.  2. As  the
walls of the thorax consist of  very different ma-
terials in different places,  and vary likewise greatly
as to their thickness,  &c. direct percussion can
only be  effective when made on the  more solid
points of the thinner parts of the parietes; namely,
the sternum, clavicles, ribs, and their  cartilages :
when made on  the  intercostal  spaces, pectoral
muscles, or mammas, it is both painful and inef-
fective ; and when  there is a great accumulation
of fat below the skin,  or the parts are  anasarcous
or emphysematous,  the sound is still more imper-
fect.  Mediate percussion  will enable us to  get
over most of these difficulties.  By means of the
interposed  plate we can percuss equally on  the
bone and soft parts  ; and the precaution so requi-
site  in  direct percussion  to percuss  on similar
parts on  both  sides,  becomes  unnecessary,  the
plate constituting a sort of artificial solid wall to
 the soft parts.  In the  case of anasarca or emphy-
 sema, by compressing the distended  parts with
 the  plate, we obtain a solid point whereon to em-
 ploy percussion, and thereby obtain results other-
 wise unattainable.  3.  Mediate percussion is much
 easier, and requires much fewer precautions than
 the  ancient method. In direct percussion we must
 never lose sight of the  rule that  the percussion
 must be made precisely  in the same manner  on
 Ihe  two  opposite sides of the  chest, to enable us
 to  deduce safe  conclusions from the  resulting
 sounds :  for instance, the blows must be made on
 similar  structures, with  the same degree of force,
 under the same  angle, &c.  With  the pleximeter
 these precautions are much less necessary, because
 we have here always the same flat smooth surface
 whereon  to strike,  and  an artificial wall every-
 where of equal  density  and elasticity.  Besides,
 less art is necessary in  arranging the fingers in
 the  latter case,  a single finger being  in general
 sufficient to elicit the  necessary degree of sound.
   In admitting  the validity of these  advantages
 of mediate over direct percussion, we  must allow
 that the  superiority  of  either  in  practice will
 depend greatly  on experience.   By one  well
 versed in direct percussion, an instrument  will
 not often  be needed  in the exploration of the
 chest, as  his experience will enable him to evade
 most of the inconveniences attending the former.
 The necessity of carrying an instrument, however
 portable,  will be felt by  some  to  be an incon-
 venience ;  but  this  can never be  admitted  as a
 reason for rejecting the  employment of a method
 which possesses decided  advantages.
   There  is a variety of  mediate percussion in
 common  use still more simple than that of Pior-
 ry's, and which  is well deserving the attention of
 the student.  This consists of  the substitution of
 one  or two fingers of the left hand for the plexi-
meter,—the back of the fingers being  uppermost.
This proceeding possesses  several of  the advan-
tages of M. Piorry's  method;  and it has even
some few over it, exclusive of its greater simplicity.
In cases where  there  is considerable emaciation,
   Vol. I. —31                        V
M. Piorry's method is liable to mislead, unless the
intercostal  spaces  are  carefully filled with some
soft  material;  as, without tbis precaution,  the
sound  may be modified by the bollow existing
between tbe  plate  and the skin.  Direct percus-
sion on the ribs, or the employment of the fingers
as a pleximeter, is often, in such cases, preferable.
If we  are careful  in applying the fingers so as to
make them fit accurately into  the natural depres-
sions, and thus form  one body,  as it were, with
the  thoracic  parietes, — we are often enabled to
use very forcible percussion without exciting pain,
and  also to  elicit as definite sounds as  by either
of the  other methods.  This  proceeding is  free
from another inconvenience which  occasionally
attaches to M. Piorry's method, especially in the
hands of beginners.   In  the  latter it sometimes
happens that the loudness  and sharpness of the
primary sound  arising  from the contact of the  two
surfaces, are so considerable  (particularly if the
nail be used, which it ought never to be) as to
drown, as it  were, the  secondary sound  resulting
from the modifying  influence of the  subjacent
parts, from which modification it is that we form
our  judgment  respecting  the  condition  of those
parts.   When  the fingers  constitute the plexi-
meter, we  have little  or none of this immediate
clatter when the blow is given.
  [Various instruments have been  devised for
pleximetric percussion by Drs. Burne, Winterich,
Bigelow, C. J. B. Williams,  and others ;  (Dr.
C.  J.  B. Williams, Lond.  Med.  Gaz.,  Dec.  16,
1842 ;  and, Gerhard,  Lectures on Diseases of the
Chest, p. 21 :  Philad. 1842) ; but, after  all, for
general purposes, the forefinger of the left hand,
with the palmar surface  to  the chest,  as men-
tioned  above,  makes  the  best pleximeter.  The
sounds rendered will be more distinct, if the patient
holds his mouth open, whilst the chesf is struck.]
  Whichever  method we  employ, ii  is  of  the
utmost importance that the opera!o;  he fully ac-
quainted with the relative sonorousness of the
different parts of the chest in the state of health.
This knowledge must be founded on an accurate
acquaintance with the topographical relations of
the  external and  internal parts, and can only be
acquired by experience.  In the article Explora-
tion  of the  Chest, these  relations  are fully
detailed.  At present we  can  do little more than
refer to it for information.   We shall  only here
remark that  the degree of natural sonorousness is,
in all cases, dependent on th» anatomical structure
of  the  external parts, and the nature and relative
position of the organs placed beneath  them le-
spectively.   The  thinner and tenser the parietes,
the  greater the mass of the air-filled pulmonary
substance beneath, and the closer it approaches
the  surface—the  greater will be the natural reso-
nance  on  percussion, and vice versa.   A little
practice on  the healthy chest will make the  stu
dent master of this subject; and he will find his
progress much facilitated  by the artificial plan in
common use of mapping out  the surface into dif-
ferent regions.  A knowledge of this plan  will
not  merely fix  more firmly and clearly the subject
in his own mind, but will enable him much moir.
readily to communicate his information  to others.
(See figures in the articles Abdomen and Chest.
Exploration  of  the.) 
242                               AUSCULTATION.
  Independently of the relative sonorousness of
different parts in the same chest, general differ-
ences occur in different individuals, which  it is
not always easy to account for ; some chests be-
ing very sonorous, and others comparatively  dull.
This might be expected, a priori, when the com-
plexity of the structure of the contained and  con-
taining  parts is  considered.   The greater or less
degree of robustness, fatness, &c. has certainly an
obvious effect; lean persons having always, ceteris
paribus, more sonorous chests than those  who
are fat.   This is one reason why percussion  fre-
quently fails to detect the presence of tubercles in
the lungs, the increase of sonorousness from the
extenuation of parietes compensating for the aug-
mented  dulness of the viscus within.  In children
generally, the chest is very sonorous.  This  may
partly arise from the small degree of development
of their muscles, and the absence of fat; but it is
probably, also, in part owing to the  peculiar rela-
tions of the lungs to the air,  in this age.
   The  sounds elicited by percussion from the
chest in  the state  of health  may be  changed by
disease in various ways,—in degree, in kind, and
in their respective site.
   It is, however, necessary to be aware that many
and important morbid conditions of the thoracic
viscera occasion little or no alteration in the sound.
This will be the case so long as the physical al-
terations which attend the disease have not ma-
terially  affected the  proportion of  air naturally
within the chest  in a state of health.  Thus, in
bronchitis; in the  first stage  of pneumonia ; in
pleurisy  attended by very slight effusion ;  in that
form of pneumonia termed interlobular, in which
the moibid change may only occupy a small point
in the centre of the  lungs ;  in the eaily stages of
phthisis  when the  tubercles  are  disseminated
through the pulmonary substance;  in diseases of
the heart and pericardium, without augmentation
of size ;  in nervous and neuralgic affections,  &c.;
there will  either  be no change in the sound, or
the change will be  so slight as to be appreciable
by few  observers,  and consequently not  to  be
generally admitted  as a  sign in practice.  That
there must, in reality, be a change  in the sound
in  all  the  foregoing cases in which any change
has taken place in the relative proportions of the
solid and aerial matter naturally contained within
the chest, cannot be doubted ;  but as the natural
imperfection  or defective cultivation  of our audi-
tory sense prevents the detection of this, the result
is practically the same as if no change existed.*
   The natural degree of resonance will be percep-
tibly diminished whenever the proportion  of air,
usually existing in the lungs, is lessened by the
addition of matters of greater density. The degree
of diminution of the natural sound may vary from
the slightest perceptible dulness to the completest
deadness, or total  abolition of the tympanitic re-
sonance characteristic of the presence of air in  a
cavity.   In the slightest  degree, the  dulness can-
not be  ascertained  to be  morbid from its actual
but from its comparative amount;  and an opinion
will not, therefore, be formed  respecting its cha-
racter  and indications, until after we have per-

  « M. Piorry scarcely  admits the necessity of the quali-
'nations above mentioned : his experience and fact are
However, much beyond the ordinary standard.
cussed the rest of the chest, particularly the cor-
responding  parts of  the opposite side.  In the
greater  degrees  of  dulness,  particularly  when
amounting to the complete  fleshy or dead sound,
the simple percussion of the part suffices instantly
to reveal disease.
   The morbid matters which take the place  of
air within  the  chest, and  thereby  produce the
diminution of sound, may exist either in the sub-
stance of the lungs,  or exterior  to these.   The
following are the principal alterations within the
substance of the lungs : hepatization in its differ-
ent forms and stages ; pulmonary apoplexy and
oedema when of considerable  extent;  tuberculous
degeneration or induration ; foreign growths dis-
placing and compressing the pulmonary substance,
such  as  cysts,  melanosis,  encephaloid tumours,
&c.  Exteriorly to the substance of the lungs are
all the varieties of effusion  or  accumulation  of
liquid in  the  pleura;  (pleurisy, hydrothorax,
haemalhorax;) tumours of different kinds deve-
loped in the cavity of the pleura or mediastinum ;
diseases  of  other organs, such as hypertrophy  of
the  heart,  hydropericardium,  aneurism of  the
aorta, and even enlargement of the liver, &c.   In
the case of accumulation of  liquid in the pleura,
the dulness of sound  may originate either from the
exclusion of part of the air  naturally  contained
there, or from the interposed  layer of liquid pre-
venting  the transmission of  the  sonorous  vibra-
tions to and from the air in the lungs, on account
of the different density of the media.
   The only cases in  which the natural resonance
of the chest is increased in disease, are dilatation of
the air-cells (pulmonary emphysema of Laennec,)
pneumothorax, and certain rare  cases of tubercu-
lar excavation.   In all those instances the  sound
is increased  because  the natural proportion of air
is increased, just as in the  preceding instances it
was diminished by the  diminished proportion  of
the aerial contents.  In emphysema, the morbid
sonorousness commonly exists on both  sides  of
the chest;  in pneumothorax it is, we believe, al-
ways confined  to  one side.   The only form  of
tubercular  excavation  which considerably  aug-
ments the natural  sonorousness, is that in which
a cavity  occupies  the greater part of  one lobe or
two lobes, and contains  but little liquid secretion.
In cases of this kind the sound is  sometimes a
good deal altered  in kind  as well as in degree,
having something  of a metallic resonance, as  if
elicited from a flask or cup  of metal.
   In the different articles in  the  present work
which treat of the individual diseases of the chest,
the practical application of percussion as a diag-
nostic measure will  be  set forth at  length : any
detail on such points would, therefore, be  super-
fluous on the present occasion.
   Percussion of the abdomen.  (See  Abdomex,
Exploration of.)
   Percussion of other parts of the body.—It doe*
not appear that percussion of any other parts of
the body beside the chest and abdomen is likely
to lead  to  any results  of  value.  In almost  all
affections of the limbs  and external parts of the
body, other  modes of physical  exploration, parti-
cularly manual examination, will supersede the
necessity of this method.    The only  cases in
which it seems to offer  any chance of being use- 
A U S C U L
TATION.
ful, are—tumours in the  maxillary  tnd  frontal
sinuses, and  hernia.   In the former cases,  it is
probable that a well-instructed ear would  be en-
abled, by mediate percussion, to ascertain whether
the sinuses were empty  or filled  with solid  mat-
ter ;  and in a case of hernia, no doubt a piece of
intestine filled with air  would  yield  a different
sound from one filled with omentum.   In  doubt-
ful cases, also, of swellings in the groin, this mea-
sure might assist in  discriminating an  enlarged
gland or other external tumour from hernia, cer-
tainly  from  an  intestinal  hernia.    But  it  can
rarely happen to the surgeon to require assistance
of this  kind ;  although tbe fact that the true diag-
nosis has only sometimes been made on the ope-
ration-table, shows  that  the proposal to seek aid
from auscultation in such cases  is not  altogether
absurd.  Piorry  asks whether in croup the  larynx
and  trachea, which naturally  yield a clear sound
with the pleximeter, will not  give  a  dull  one
when occupied  by the false membrane  of croup  !
This seems probable, but what is the information
worth  1
   Succussion.—This term is applied almost ex-
clusively to a method of exploring  pectoral affec-
tions mentioned  by Hippocrates.  It consists in
forcibly shaking the patient's body, and observing
the  sounds thereby produced.  It has  been also
sometimes used in the investigation of abdominal
diseases.   There is  only  one class  of cases in
which  this method can be productive of any re-
sults,  namely,  where  there is contained  both  a
liquid  and a gaseous  fluid in  an internal cavity  :
and the only  instances in which such a combina-
tion occurs are the following :—1. pneumothorax,
in which there  is an effusion into the cavity of
the pleura both  of liquid  and air ; 2. a large tuber-
culous cavity in  the  lungs containing  also  pus
or other liquid,  and air ;  3. an accumulation of  a
liquid  of any kind, and of gas, in the stomach or
large intestines.   The principle  upon which the
sounds are excited by succussion  in those cases is
sufficiently obvious :  it is  precisely  the same as
operates when we shake  a bottle or bladder  filled
partly  with water and partly with air.   The rapid
and forcible intermixture of the two fluids  of dif-
ferent  density, and  the impulsion of the heavier
of the two  against  the  walls  of the containing
vessel  or part, give rise to the sound of fluctuation.
In  pneumothorax, this sound is frequently per-
ceived  in the most distinct manner ; and as it is a
pathognomonic sign  of  this disease, it becomes
of great  practical value.   This sign  was  well
known to Hippocrates,  and is distinctly noticed
in several parts  of the writings  that usually pass
under his  name.   He appears, however, to  have
regarded it as a  sign of simple empyema ; being
unaware  of the fact  that  the presence of air is
absolutely necessary  to the  production  of the
sound  of fluctuation.  In empyema and  hydro-
thorax, no degree of succussion gives rise  to  any
sound ; as, indeed, must be evident to any one
who regards the principle  on which  fluctuation
depends.*
  * M.iny passages in the writings of Hippocrates prove
that the practice of succussion must  have been both  a
common and a successful means of diagnosis in the time
of that  phvsician.  We can only, in  this place, refer to
some of these.  We quote the edition of Vanderlmden :
-De Morbis lib. I v.  torn.  ii. p. 6.   De Morbis lib. II.
  Morgagni  likewise notices the practice, but in
a manner  that proves  his want of practical ac-
quaintance with it.  It  is to Laennec that we are
indebted for the true account of the principles on
which it is founded, and for the just appreciation
of its merits.  As already stated, succussion is  a
most valuable sign in pneumothorax ; and  as this
disease is now known  not to be extremely rare,
there are  no grounds (as  Laennec observes) for
leaving this method in  the oblivion into which  it
has fallen.   The mode of performing  succussion
is  the same as practised  and recommended by
Hippocrates.  The  patient, seated  in  a chair  or
in bed, is to be quickly, yet not violently, shaken
by  the shoulder, the operator stopping the suc-
cussion suddenly, and listening for the sound  of
fluctuation.  In  the proper  cases   this is  heard
most distinctly, and when so heard can never be
mistaken for any thing else.   We  have heard  it
quite as distinctly while the  patient was  in the
act of rising or lying down.   The  cases of tuber-
cular phthisis  without  pneumothorax, in  which
succussion produces the sound of fluctuation, are
very rare.   Laennec says he never met with but
one case of the kind.  The result can only be ex-
pected when the  excavation is extremely  large,
and contains a great quantity of pus as well  as
air.   The  sound  of fluctuation  in  the stomach  is
very readily produced in many persons who have
recently drunk much fluid, by tbe ordinary move-
ments of the body.  This becomes  still more per-
ceptible on succussion of the trunk.  It has been
attempted to apply this sign as  a means of  diag-
nosis in disease of the  pylorus ;  but it is worthy
of no consideration, inasmuch  as there are many
others greatly superior  in certainty, and therefore
in value.
  Auscultation of sounds artificially produced has
been applied successfully to certain surgical dis-
eases,  particularly  to  the discovery of doubtful
fractures and the  detection of stone  in the bladder.
The nature  of this work prevents any detailed
account of cases  of this kind :  they are  merely
referred to  on the present occasion with the view
of directing the attention of the surgical student
to the works which give an account of them.-j-
  Auscultation  of  sounds naturallx  pro-'
     duced within the body.
  This division  of our subject is almost  exclu-
sively  confined to the investigation of the sounds
which originate within the chest;  those having
their site in the abdomen or elsewhere being of
comparatively trifling importance.  The remainder
of this article will, therefore, be in   a great  mea-
sure devoted to the consideration of the physical
signs  supplied by  auscultation  of the thoracic
sounds.
  It is a singular fact that Hippocrates, upwards
of two thousand  years ago, endeavoured to ascer-
tain the existence  and  nature of diseases of the
chest  by means  of auscultation, that is, by the
sounds produced  by their presence within the
chest.   " You will know by this,"  he says, " that
the chest contains water and not pus, if, on apply
xliv. torn. ii. p. C9.  Ibid. xlv. p. 70.  Coac. Prenot. torn.
i. p.  5C5. De Locis in Horn. xxvi. torn.  i. p. 379.  Ibid.
xxviii. p. 3^0.
  f  See in particular Laennec, Aus. Med. torn. l. p. ]'7
Liifrane, Memoire sur les nouvelles applications du sib
thoscope; and Alcock's translation of the lattw. 
244
AUSCUL
TATION.
 ing the ear for  a certain time to the side, you
 hear a sound like that of boiling vinegar." Many
 other passages  in the writings that commonly
 go under his name, refer to the same means of
 detecting diseases.
   It hardly detracts from the merit of this great
 man, that, in the particular  instance  mentioned,
 his diagnosis is not true.  Owing to a prohibition
 of dissecting dead bodies,  which  existed in his
 time, it was scarcely possible  to be  accurate in
 such a case.  The merit of  the discovery of aus-
 cultation, or, at least, the merit of having first at-
 tempted to  discover diseases  of  the chest by
 means of auscultation, is unquestionably his ; and
 the chief object of the  present article is to show
 to  what a  wonderful  degree  of usefulness this
 discovery was subsequently carried by a  kindred
 genius, two-and-twenty centuries after it was first
 made.
   It would appear that the practice of auscultation
 in any of its forms, as employed by the Asclepia-
 des, bad almost  entirely fallen into  disuse, and
 even oblivion, with modern physicians,  until  a
 very  recent  period.  Laennec  informs us that,
 previously to the discovery of the stethoscope, he
 himself, Bayle, and others, were in the habit  of
 applying the ear to the side in studying diseases
 of the heart; and we  learn from a work of M.
 Donble, published two  years previously, that this
 physician was accustomed  to  employ the  same
 means in exploring diseases of the lungs.  Speak-
 ing of the  signs  furnished by respiration, and of
 the sounds produced by it within the chest in dis-
 ease, he says that, with  the view of hearing them
 more distinctly, " we must apply the ear closely to
 every point  of all its  aspects ;  by which means
 we can distinguish not merely the kind and degree
 of the sound, but even its precise site."  He adds,
 " I have frequently derived great benefit from this
 mode of investigation, which  is  peculiar to myself,
 and  to which I was naturally led by the employ-
 ment of the like method in exploring the pulsation
 of the heart." *   Long  before this period, indeed,
 one of our own countrymen, not of the medical
 profession, and who, in  all probability, was unac-
 quainted with the writings  of  Hippocrates, was
fully aware  both  of the existence  and  great im-
portance of internal sounds as a means of diagno-
 sis, and, as  Dr.  Elliotson well observes,  seems
 almost to  have prophesied the  stethoscope.   We
 quote the passage as extremely curious in the lite-
 rary history  of auscultation.  " There  may be a
possibility,"  says Hook, " of discovering the inter-
nal motions  and  actions of bodies  by the  sound
they make.   Who knows but that, as in a watch
we may hear the  beating of the balance, and  the
running of the wheels, and  the striking of the
hammers, and the grating of  the teeth, and multi-
tudes of other noises ;—who knows, I say, but
that it may be possible to  discover the motions of
internal parts of bodies, whether animal, vegetable,
or mineral,  by the sound they make ; that one
may discover the works performed  in the several
 offices and shops of a  man's body, and thereby
 discover what engine is out of  order, what works
 are going on at several times, and lie still at others,
 and the like."  " I have this encouragement not
  * Semeiologie Generale, par F. J. Donble, torn. ii. p 31
 Pans  1817.
to think all these things utterly impossible, though
never so much derided by the generality of men,
and never so seemingly mad, foolish, and fantas-
tic ; that, as the thinking them impossible cannot
much  improve  my knowledge, so the believing
them possible may, perhaps, be an occasion  for
taking  notice of such things as  another  would
pass by without regard as useless.  And somewhat
more of encouragement I have  also  from experi-
ence, that I have been able to  hear very plainly
the beating of a man's heart;  and it  is common
to hear the motion of the  wind  to and  fro in the
guts and other small vessels : the stopping  in the
lungs is easily discovered by the wheezing."  "As
to the motion of the parts one among another—to
their becoming  sensible, they require either that
their motions be increased, or  that  the organ be
made more nice and powerful  to sensate and dis-
tinguish them as  they are ; for the doing of both
which, I think  it  is not impossible but that in
many cases there may be helps found."   (Hook's
Posthumous Works, p. 39, et seq.)
   There is no reason  to believe that Laennec was
acquainted  with  these opinions of  the  English
philosopher;  nor,  if he had, would this know-
ledge, any more  than that which he derived  from
the writings of Hippocrates, have greatly detracted
from his merits as the discoverer of mediate aus-
cultation, and the inventor of the stethoscope.
   This  great man was born  in  Bretagne,  in
France,  in  the  year  1781,  and  early  devoted
himself to medicine.   He commenced his studies
in  Nantes, and  proceeded   to Paris  in the  year
1800, in order to complete them.  He there fol-
lowed  up his professional  pursuits  with all the
enthusiasm  of  genius; devoting  himself  more
especially to the investigation of the nature and
signs of disease, in imitation of his master, Corvi-
sart.  Under the guidance of this great physician,
he became a zealous and successful  investigator of
chest-diseases, by means of percussion; and, while
he  proved its full value, he soon became sensible
of  its imperfections,  more  especially in diseases
of the heart.  In cases of this kind, young Laen-
nec and several  of his fellow-pupils were accus-
tomed, in imitation of Hippocrates, to apply the
ear to the  chest, in  the  hope  of  thereby aiding
their diagnosis.   He informs  us that from  these
trials he derived little practical benefit;  but it was
from them that  he was led to a discovery of the
very greatest importance.  This was the discovery
of mediate auscultation ,•  his  account of which
we shall give  in his own words :
   " In the year 1816," he says, " I was consulted
by  a young  woman  affected  with  the general
symptoms of  diseased heart, and in whose case
percussion and the application of the hand were
of little avail,  owing to her being extremely lusty.
The immediate application of the ear being inad-
missible for obvious reasons, I happened to  recol-
lect a simple and well-known fact in acoustics,
and fancied it might be turned to some use on the
present occasion.  The fact I allude to is the great
distinctness with which we hear the scratch of a
pin at one end  of a piece  of wood on applying
our ear to the other.   Immediately, on this  sug-
gestion, I rolled  a quire of paper into a kind  of
cylinder, and applied one end of it to my patient's
chest, and the other to  my ear, and was not a little 
AUSCULTATION.
245
surprised and pleased to find that I could thereby
perceive the action of the heart in a manner much
more clear and distinct than I had ever been able
to do by tbe  immediate  application of the ear.
From this moment I imagined  that means might
be found to ascertain the character, not merely of
the action  of the  heart, but of every species of
sound  produced by the motion of all  tbe  organs
within the chest."   (De l'Auscult. Med. torn, i.)
   With that intuitive glance into the latent capa-
cities of things, which only belongs to inventive
genius, Laennec at once foresaw the great outlines
of the discoveries which were afterwards evolved
by his persevering industry ;  and he set to work
with a zeal and  enthusiasm worthy the great ob-
ject he had in view, and with a degree of success
and fertility of results much more remarkable than
the discovery itself.  At this time  he was physi-
cian of the Necker Hospital  in Paris;  and he
forthwith instituted in its wards a series of observa-
tions and  experiments on the new  method of
diagnosis, which were hardly  interrupted  for one
single day, until the discovery may be said to have
been almost perfected in his own hands.   He first
gave an account of his method to the Academy
of  Sciences, in 1818, and, in the following  year,
he published his immortal treatise  " De 1'Auscul-
 tation Mediate et  des Maladies des Poumons et
 du Coeur."
   In announcing this work, he boasted that " he
 had been enabled to discover  a set of new  signs
 of diseases of  the chest, for the most part simple,
 prominent, and certain, and calculated, perhaps, to
 render the diagnosis of these diseases as positive
 and circumstantial  as  that of many affections
 which come within immediate reach of the  hand
 or instruments of the surgeon."  And it must be
 allowed that this boast is in a great measure justi-
 fied by the wonderful precision introduced  by him
 into this department of medicine.
   The first object of Laennec  after his discovery,
 was to improve  and  perfect the rude  instrument
 he had used  in his  primary  explorations ; and,
 after many trials, he finally invented and adopted
 that which is  now in general  use.  This instru-
 ment  he denominated the stethoscope, (from o-Trj-
 0oj, pectus, and acoiriio, exploro.)   It is  now so
 well  known that  it  is unnecessary  to  give any
 description of it.  On a future occasion, we shall
 have to  notice the principles  on which it is con-
 structed, (see  Stethoscope;)  but  before we can
 comprehend these, or the manner of using it, it is
 expedient that we should be made acquainted with
 the nature of  the sounds which it is  intended to
 convey to the  ear.
   As  every form  of matter is susceptible of the
 vibrations which, when falling  on the ear, give the
 sensation of sound;  and  as the motion of most
 bodies, when accelerated to a certain degree, excite
 these vibrations  either in themselves or contiguous
 substances, it might be expected, a priori, that the
 thoracic organs, being in constant motion, should,
 in the performance of their functions, give rise to
 sound;  and that  they have been  observed  to do
 so, at  least when diseased, is  sufficiently evinced
 by the existence in all  languages of such expres-
 sions as " wheezing on the chest,"—" rattle in the
 throat,"—"hearing the heart beat," &c.   But no
attempt was made to classify or analyze tbe sounds
before the time of Laennec.
  The  motions that naturally take place within
the chest are those of the lungs and heart, in per-
formance of the functions of respiration and the
circulation of the blood ;  and  both these give rise
to audible sounds of various kinds and in different
ways.
  From what we know of the effects of currents
of air in producing sound when  passing through
narrow  channels, or when partially impeded  and
interrupted, as  by the branches of a tree, for ex-
ample, we should expect that the incessant passage
of air through  the  tubes and cells of the lungs,
together with the constant dilatation and collapse
of  these,  would be  productive  of very audible
sounds, if th.e ear  could be brought sufficiently
near their source.   At  first, indeed, we might be
led to consider them as altogether cut off from our
auditory sense  by the solid barriers of the chest;
but when we come  to  reflect that the surface of
the lungs  is always, necessarily, in close contact
with the inside of the walls of the chest, and that
these walls are only from a quarter to half an inch
thick, and  consist of substances favourable for the
transmission of sound, we are at once prepared to
expect that the sounds in question may be audible
through the thoracic  parietes :  and such is the
fact.  If we place  our ear  in close contact  with
the chest  of any  person while breathing,  more
particularly a child, we can distinctly hear sounds,
synchronous with inspiration and expiration, on
every part of the surface that lies over the lungs.
Although  sufficiently audible,  these  sounds are
still only  feeble in degree ;  and  emanate,  with
nearly equal intensity, from almost every point of
the surface of the cbest.  It is these qualities of
comparative  feebleness  and equal diffusion over
the chest, that prescribe one of the uses and forms
of the stethoscope—that, namely, in which it ful-
fils the office of a common ear-trumpet.   In this
case, the instrument consists of a cylinder of wood,
perforated longitudinally by a bore of nearly the
same size as the auditory canal, and swelling out
at the farther extremity into a funnel-shaped exca-
vation,  like the extremity of  a clarionet or bugle.
When  this is placed upon any part of the surface
of  the  chest, the ear, applied to the other extre-
mity, will receive  the whole  of the respiratory
sounds emanating  from that  portion of the  chest
included within its circumference—the sonorous
vibrations, or rays of sound, (if we may be allowed
the expression,) being  concentrated by the  fun-
neled extremity, and conveyed  along the tube to
the ear.  An instrument of this kind, then, is the
best for exploring the sounds produced by respira-
tion simply, whether  in health  or disease.   But
Laennec  found sufficient reason, in his progress,
to rpodify this, the simplest, and for respiration the
best, form of the stethoscope.
   In following up  his  researches,  he discovered
that the sounds produced by  the voice within the
chest are  of  great importance as signs in several
forms of disease ;  and he ascertained by expert
ment, that the particular sounds which are of most
value, are  best conveyed to the ear by a cylindei
perforated by a bore of an equal caliber throughout
In order to avoid the multiplication of instruments. 
246
AUSCULTATION.
(a thing always to be avoided when practicable,)
he conceived that the same trumpet-shaped cylin-
der might be made to answer the requisite end, by
having  fitted  to  its wider extremity a moveable
plug, of the same materials, traversed  by a perfo-
ration of the same diameter as  that of the upper
portion  of the instrument.   And  he  found, on
trial, that this answered perfectly.
  The only other organ within  the chest, which,
in the performance of its natural functions, pro-
duces audible  sounds, is the heart. These sounds,
as every one knows,  are  very perceptible by the
naked ear when placed in  contact with the sur-
face of the chest  on the left side.  There still ex-
ist doubts among physiologists as to the precise
cause of these sounds, and many different theo-
ries have been promulgated with the view of ex-
plaining them.  Some account  of these explana-
tions and opinions will be given in the sequel.  It
is sufficient for our present  purpose to  observe,
that in the exploration of the  heart, a solid  cylin-
der is preferable to a tube, because we here require
to judge, not merely of the sound, but also of the
shock or impulse communicated to  the walls  of
the chest;  and for the conduction  of impulse,  a
solid body is obviously superior to a  mere tube.
But here, again, the wish of avoiding the multi-
plication of instruments led  the inventor of the
stethoscope to be contented with such  a  form as
was found practically sufficient, though not theo-
retically the most perfect, for the exploration  of
the heart—namely, the cylinder with the infixed
plug or  stopper, such  as is used in the exploration
of the voice.
  In the common form of the stethoscope, then,
we  possess an instrument suited for the explora-
tion of all the sounds produced within the chest;
and we  may remark, that so   long as  the funda-
mental principles on which it is constructed are
attended to, its external configuration is compara-
tively of little moment.
  The  manner of using the stethoscope is ex-
tremely  simple.   The only precautions necessary
are, to keep its pectoral extremity always in exact
contact  with the surface on which it rests, and to
preserve the auditory canal of the ear in accurate
communication witb the perforation in the instru-
ment.   With the view of ensuring its  more per-
fect apposition, the hand that holds the instrument
is kept close to its further extremity, in such man-
ner that the little and  ring fingers may be employ-
ed as tentacula, or feelers, in regulating its appli-
cation.  A reference to the principles of its  con-
sliuction will point out the absolute necessity of
keeping the  whole of its pectoral  extremity  in
contact with the surface ;  and on this account it
must never be  inclined .from  its perpendicularity
to the surface  of the chest in  order to accommo-
date the convenience of the operator :  the ear
mus*. be moved to suit the instrument, not the in-
strument to suit the ear.
  The stethoscope  may be applied either to  the
naked chest or over the' clothes; as  it is found
that a moderate thickness of a  body of the den-
sity of cloth has only a very inconsiderable  effect
in diminishing the intensity  of the sounds.  In
certain cases, indeed, as in very lean and  deform-
ed subjects, it is quite necessary that the part we
»re examining should be covered, in order to give
to the instrument that perfectly smooth  and level
resting-place so essential to its proper action.  In
some cases of this kind  it is even necessary to
apply small compresses of linen in order to fill up
inequalities.
   As during percussion, and, indeed, more so than
in that case, there must be no noise in the patient's
chamber or its  immediate vicinity during our ex-
ploration with the stethoscope.  At least, this pre-
caution is necessary for beginners; although the
ear that is accustomed to  the sounds, will learn to
catch them  amid others that are much louder, just
as various  artisans  accustomed to live  amid the
noise of machinery, are able  to converse without
any great elevation of voice.
   A very few words suffice to state  in what way
the stethoscope becomes,  in the hands of an ex-
pert auscultator, the means of an  accurate  diag-
nosis.   By  it we learn that  the  motions of the
lungs and heart, in a state of health, produce cer-
tain determinate sounds  in certain  parts of the
chest; and that these  sounds are  modified in cer-
tain determinate ways, and certain other determi-
nate sounds superadded, in states of disease : by
the study of the symptoms during life, by dissec-
tion after death, and by considering the principles
of the generation of sound, we are able to connect,
as  cause and  effect, particular forms  of disease
with particular sounds ; hence the indications of
the stethoscope, in  certain diseases, become  posi-
tive physical signs of these diseases.
   We shall occupy the remainder of the present
article in illustrating this  proposition,  which in-
volves the  whole  doctrine of  auscultation  as a
means of diagnosis.
   Auscultation of the Respiration.
   I. Of simple respiration, natural and morbid.
—The sound of healthy respiration, as discovered
by the stethoscope,  is somewhat different in differ-
ent parts ;  having one character in the pulmonary
cells, another in the  larger bronchial tubes, and
another in  the  trachea.   The common  character
of all these may be said to be that of a prolonged
hiss or puff—such a sound as  is produced by
blowing forcibly into or through a small opening,
and not very unlike the blast  from the nozzle of
a pair of bellows.
   That which  originates in the pulmonary  cells
(and which may be denominated pulmonary, cel-
lular, or vesicular,) is  perceptible, in health,  ovei
every part of the chest with which the  lungs are
in contact.  It is such as  we  might expect to be
produced by the rapid passage of air through a
congeries of minute tubes  and cells, composed of
a thin and  moist membrane ;  viz., a low monoto-
nous sound, almost exactly  like that of a person
breathing through the  nostrils in  a placid sleep,
only feebler.  It  is a  double  sound; or rathei
there are two sounds ;  the one corresponding  with
inspiration,  the  other with  expiration;  and the
former is usually much stronger than  the latter.
We may produce sounds  artificially, or may  ima-
agine sounds more  or  less  resembling  this;  but,
of course, it must be heard in order that a perfect
idea of it can be communicated to the mind.  And
this is best done, in the first instance, by the ap-
plication of the unarmed  ear to  the chest  of a
child, as the sound  is naturally louder in children.
We recommend the naked ear in the first instance, 
AUSCULTATION.                               247
because it requires some little practice to use the
stethoscope, and because the mere application of
this to the  ear  occasions  a  rustling noise, which
might possibly be mistaken by the student for the
sound he is in search of.  When once heard  dis-
tinctly, this can never be mistaken.
  The sound produced in the trachea and larger
bronchi is, as formerly mentioned, somewhat  dif-
ferent from that produced  in the pulmonary cells ;
although it is not easy to  describe the difference.
In the  pulmonary or cellular respiration already
noticed, there is a character of slight crepitation,
or roughness, as if from accompanying  moisture,
which is wanting in the bronchial and tracheal kind;
and  these  latter, likewise, convey the impression
as if they originated in a  larger space.  The prin-
cipal difference between the tracheal and  bronchial
respiration consists in the  idea of larger caliber
being suggested by  the  former.  In  a state of
health, the bronchial respiration can only be heard
in the very largest bronchi.
   It is only by experience that we  can acquire a
perfect knowledge of the  sounds of healthy respi-
ration ; but having once acquired this knowledge,
it becomes easy to discover when this natural cha-
racter is changed.  This change only arises  from
disease ; and it is the great  object of  the practical
auscultator to detect the morbid  sounds, and  to
trace them to their causes in physical changes of
structure within the  chest.
   It has been  already said that, in the state of
health, the sound of pulmonary or cellular  respi-
ration is perceived over  every part of the chest
with which the lungs come  in  contact.   We are
thus enabled, in tbe living body,  to   trace  the
boundaries of these organs with the greatest accu-
racy.  These boundaries, generally speaking, are
the same as are indicated by the  circumscription
of the sonorous sphere in the trial of percussion.
As in  the case of percussion, also, the intensity
of the sound varies in different parts of the chest;
and the relative intensity  of the sound in different
parts generally corresponds in both  forms of ex-
ploration, the respiratory sound  being loud where
that of percussion is clear,  and vice  versa.   Ac-
cordingly, we may state the following  to be the
parts where the respiratory sound is perceived the
most readily and most constantly : the axilla, the
top of the shoulder above the clavicle, the subcla-
vian region before, and the subscapular region be-
hind.  In  general, the  respiration  is  loudest  on
the anterior parts of the chest.
   When the respiratory sound is perceptible over
all its natural sphere, and with its natural charac-
ters, we may be assured that there exists no  dis-
ease within the chest which materially affects the
lungs; we may be certain, at  least, that the  air-
cells are neither obstructed  by  fluids poured  into
them, nor  by compression from without.  When
the natural sound  is  altered, or no longer exists,
we may be assured that disease is present.
  [It is important to bear in mind, that difference
of sentiment exists as to  the comparative inspira-
tory murmurs of the two  sides under the clavicles,
which are the common seat of  tuberculous forma-
tions.   It has been asserted by Dr. Gerhard (Lec-
tures on the Diagnosis,  Pathology, and Treat-
ment of Diseases of the  Chest, p. 29 : Philada.
1842,) that the bronchial  respiration  is  decidedly
more distinct in the tight lung than in the  left,
especially at the summit; and  he accounts for it
by the greater diameter and  straighter  course of
tbe tubes at the summit of the right lung, which
are not lengthened and curved  as on the left  side
by the presence of the arch of the aorta.   On the
other hand, M. Fournet is satisfied, that  in per-
sons presenting all the characteristics of  healthy
lungs,  the sounds of inspiration and  expiration
are precisely identical in all corresponding points.
In the  few persons in whom he detected a  slightly
greater development of the expiration  under the
right than the left clavicle, there  were motives for
a doubtful opinion respecting the state of the lungs.
M. Fournet thinks, from the physical condition of
the two lungs, that there  is no reason why they
should furnish different respiratory sounds. Last-
ly, Dr. Stokes (on Diseases  of the  Chest, DubL
1837,) dwells especially on the importance of the
discovery made by him, that in many  persons
there is a natural difference between the intensity
of the murmur in either lung,  and in such cases,
with scarcely an  exception, the murmur of the
left is distinctly louder than that of the right lung.
It would appear, consequently,  and such is the
result of  our observation, that  at times there is no
marked difference between the two sides ;  that at
others  the intensity of the respiratory murmur is
greater on the right side ; and  at others, again, on
the  left.   (Practice  of Medicine, edit. cit. i.  p.
220.)]
   The  natural  sound of  respiration may  be
weaker or stronger; it may be absent altogether ;
and it may  be  complicated  with  adventitious
sounds.
   1. If the sound be weaker than natural in  any
one part, we may suspect that there is some  or-
ganic alteration in that part disturbing the  healthy
process  of pulmonary expansion;  that  is,  that
there is either slight condensation of the vesicular
structure of the  lungs, or partial obstruction of
the bronchi leading to that part, or slight displace-
ment of  the lung  from  the walls of the chest.   If
the feebleness of the respiratory sound be geneial,
however, we are to consider it  rather as  depend-
ing on  some natural peculiarity of constitution
than on  any disease of the lungs.   And we may
state generally, that mere feebleness  of sound,
even when existing partially, is  not much to  be
depended on as a  sign of disease ; when combin
ed, however, with certain other qualities of sound,
(as  it  commonly  is,)  it becomes of much more
value.   As we found, in respect  of  the degree of
resonance on percussion, that there  are great na
tural differences in different individuals; so it is
with regard to the degree of the respiratory  sounds.
But there is no connexion between these peculiar-
ities ;  as we frequently find  the chest very sono-
rous when the respiratory sound  is feeble.
   It is likewise highly necessary that the  student
should be aware, that the degree of  respiration  is
liable to  be gTeatly altered by various  temporary
causes.  In many persons, the first application of
the stethoscope  produces such  a degree  of ner-
vousness as to render the respiration hardly audi-
ble for a few minutes ;  and  it  is only by  waiting
until this state has subsided that we can ascertain
the real  character of the respiration.   In  others,
who are  not nervous, the habitual sound of respi 
243
AUSCULTATION.
ration is so feeble that it can hardly be perceived
in the ordinary mode of exploration, even after  a
considerable time ; and if the patency of the  air-
cells were not  proved by some additional  trials,
serious mistakes in diagnosis might be the conse-
quence.  The natural suggestion, in such  cases,
is,  to cause  the patient  to breathe  quicker or
breathe  deeper ; and this sort of artificial respira-
tion, particularly the quick  breathing, has often
the  desired effect  of rendering  the  respiratory
sounds sufficiently audible.  Sometimes, however,
these attempts  fail;  and it is necessary to have
recourse to others.   The most effectual  are the
various  efforts which produce a great want  of air
in the lungs, either by expelling an unusual quan-
tity of this fluid, or  by retaining it  much longer
than usual.   For this purpose we desire the pa-
tient to cough, to repeat a long sentence aloud, or
to count  as  many numbers  as  he can  without
drawing breath;  or  we desire  him  to  retain his
breath as long as he possibly can : in any of these
cases we frequently  find that the inspirations im-
mediately succeeding the forced efforts become
most distinctly audible in all the points of the
chest where they had been not at all or very slightly
perceptible  before.   We must never, therefore,
conclude, from a single and hurried application
of the stethoscope, that the lungs are impermeable
because we do  not at once  detect the sound of
respiration.
   2. It has already been remarked that the sound
of respiration is naturally much louder in children
than in adults.   This state continues until about
the twelfth year.   What may be the precise cause
of it is  not ascertained ; but that it  is  connected,
at least with greater activity of the organ, seems
to be almost proved  by the fact, that whenever  in
adults any portion of the lungs is called upon  to
perform more than its wonted share in the respi-
ratory act, that portion immediately yields a sound
as loud as that of the child's lungs.  Hence respi-
ration of this kind, when observed in the adult, is
termed puerile.  In  some few cases we  find this
loud respiration existing over the  whole  lungs,
and then  it helps to characterise certain forms of
dyspnoea.  But, in  general, it is found only  in  a
part of one or both  lungs, or in one whole lung ;
and in  this case it may be considered as almost  a
sure sign that the remainder of the organ is  ren-
dered incapable of performing its functions, from
internal obstruction or external compression of its
cells.   Accordingly, we  find  this partial puerile
respiration a constant concomitant of pneumonia,
pleurisy,  hydrothorax, and   all  other  diseases
which curtail the healthy proportions of the organ
of respiration.   When we observe this puerile
respiration  in  adults without immediately disco-
^ering  any physical cause for it, (as sometimes
happens,) there  are several morbid states of the
lungs which we may suspect.   It is sometimes
 owing  to the  dissemination of tubercles through
 lungs  otherwise healthy ;  sometimes to  partial
 lobular peripneumonies deeply seated in the lungs.
 Occasionally this condition of the respiration exists
 without any organic disease of the lungs, and can
 then be attributed to a nervous cause only ; and
 at times it is caused by disease of the heart,  with
 r/o other affection of the lungs except that which
arises from functional disorder of the circulation
in them.
  3.  Various morbid conditions of  the  organs
within the chest may prevent the sound of respi-
ration from being, in any degree, perceptible on
the surface.  The air may be prevented from en-
tering the pulmonary cells of a part of the lungs,
although  these cells aie perfectly sound, by the
temporary occlusion of a large bronchial tube by
tenacious secretions, as in the case of a catarrh or
common cold affecting the lungs.  Here the sound
of respiration is wanting, because the air-cells are
inactive;  and here  percussion will afford a good
sound.   While the  bronchi are free for the  pas-
sage of air to the air-cells, the cells may he entirely
filled up  by fluid or solid  matters, and therefore
incapable of admitting any air : this happens in
inflammation of the  lungs, and in  some other
cases;  here  percussion  will elicit a  dull sound.
The lungs, although sound, may be removed from
their natural situation in contact with  the walls
of the  chest, by the  interposition of matters  of a
solid, fluid, or gaseous character, poured  into the
cavity of the chest   As these matters will act in
the  same way, viz. by at once compressing the
air-cells, and  separating them from the walls of
the chest, they will  all equally destroy the respi-
ratory sound ; but they will furnish very  different
results upon application of the test of percussion.
For instance, in the case of solid or liquid effusion,
the sound will be quite dull; while, in the case of
gaseous effusion,  it will  be louder than natural.
The  diseases that  separate the lungs  from the
thoracic parietes  are pleurisy,  acute and  chronic,
hydrothorax,  pneumothorax,  &c.   These,  and
many other cases, show the necessity of combining
the  use of the two  methods in practice.  They
mutually throw a light on the indications of each
other, and thus stamp a double value on our signs,
By these  we are enabled to discover instantly, and
with the utmost facility, several most important
diseases,  which must  otherwise often elude tho
skill of the best informed and  most clear-sighted
practitioner.
   4. It was stated  that  the peculiar sound  pro-
duced by the passage of the air in the  bronchi,
termed bronchial respiration, is not audible in the
state of health, except occasionally  over the track
of the very largest branches. No doubt this sound
always exists in the  bronchial tubes scattered
throughout the lungs ; but in the state of health
it is  rendered imperceptible, partly  on account of
the bad conducting powers of the spongy texture
of the lungs, and partly from its intermixture with
the more general sound caused  by the expansion
of  the air-cells.   When, however, the vesicular
respiration is obstructed by disease, either by the
obstruction  or compression of the air-cells, (as
in inflammation of the lungs or pleura,) we then
 hear distinctly  the  characteristic sound  of bron-
 chial  respiration, even  in  the  tubes  of  middling
 caliber. This variety of respiration becomes, there-
 fore, an important sign in certain diseases.
   There are several varieties of the morbid bron-
 chial respiration which deserve notice, and which
 the student will find described at length in the
 works of Laennec and Andral.  In the more com-
 mon variety, the  sound  resembles  an intense de< 
A U S C U L1
gree of puerile respiration, and it might  be  mis-
taken for this  if percussion over its site  did not
give the dull sound.  At other times it resembles
the noise  made by  blowing  into  a quill;  and,
occasionally, exactly resembles  the brief,  brisk
puff used in blowing out a candle.  There is yet
another variety  of morbid respiration,  which, if
not actually bronchial, belongs at least to the same
class.  This is the  variety  named cavernous by
Laennec.   It would  appear sometimes to exist (or
a sound very like it)  in the case of dilated bronchi;
but its general site  and  source is  a morbid exca-
vation in the pulmonary  substance, arising almost
always from dissolved tubercle.   In these  cases
there sometimes exists  the most perfect illusion
of blowing into the ear through the stethoscope
during expiration  ;  while the  air  seems drawn
from  it during  inspiration.   This  sign  with  its
accompanying rhonchus  (which will be noticed
hereafter) is a most  important sign in phthisis.
   [The sound of expiration  becomes, at times,
prolonged,  and,  like the inspiration, may be ma-
terially altered in  character.   The  altered expi-
ratory sound was first urged as an important ele-
ment in  the diagnosis  of the earliest stages  of
tuberculosis of the  lungs by  Dr. Jackson, Jr., of
Boston.    Prolonged expiration  is, likewise,  a
physical sign of emphysema of the lungs ; and the
writer has observed it in  auscultating between the
scapula?, when he has had reason to  believe in the
existence of dilatation of the bronchia only ; and
occasionally he  has heard  prolonged  expiration
 apparently  as  a  natural  condition.  Dr.  Walshe,
indeed, (The Physical Diagnosis of Diseases of
the Lungs, Amer. edit., p.  194,  Philad. 1843,)
 remarks, that too few observers seem to be aware,
 that  under whatever  circumstances  obstruction
 exists to the free  circulation of air  in  the lungs,
 the expiration will be prolonged ;—" an  obstruc-
 tion,  which (experience  shows) never acts on the
 duration of the  sound without affecting  some of
 its other properties."    M. Fournet states,  that
 alterations  of character  of bronchial respiration
 always  set in with  the  expiratory  murmur, and
 only  affect the inspiration secondarily.  With this
 statement,  Dr. Walshe  says his own experience
 accords,  in  regard  to  chronic  maladies.   He
 believes it  to be  correct, also, in the very  great
 majority of cases of acute alteration of the paren-
 chyma of  the lungs, as in pneumonia; and  he
 thinks it  probable,  that  in  the few  exceptional
 cases, in which a bronchial  character has  been
 detected  in  both  murmurs simultaneously, the
 expiration  may in  reality have suffered first,  " and
 the period  of its  isolated  affection been so short as
 to prevent  its being  observed."]
    II. Of adventitious  sounds connected  with
 respiration.   Besides varieties of intensity, the
 respiration may be  altered by the  admixture or
 addition of sounds which do not exist in  the state
 of health.   These  adventitious sounds may  origi-
 nate  either in the bronchial  tubes, or in morbid
 states of the parts exterior to  the substance of the
 lungs.
   A. The sounds of the first class  are by far the
most important.  They are produced  by the pre-
sence of some  morbid  secretion within  the air-
tubes or pulmonary cells,  or by some  physical
alteration of the coats of these.  From one variety
   Vot. I. — 32
r A TION.                               240

 of  these sounds, audible by the naked ear, and
 termed, in  popular  language,  'the  rattle  in  the
 throat,' or ' the dead rattles,' the whole have been
 classed by Laennec under the name of the rattle—
 in  French rale,  in  Latin rhonchus.*   There is
 considerable variety in these sounds ; but several
 of  them are sufficiently well characterised to  be
 entitled to  distinct  appellations ; and these  are
 most valuable diagnostic signs.
   The different kinds of rhonchi have their site
 either in  the air-cells,  or bronchial  tubes, or in
 some morbid excavations formed  in the substance
 of the lungs ; and they are caused either by some
 substance within these,  more or less fluid, and
 moving in contact with air, or by some other ob-
 struction  in the  air-passages from  external com-
 pression or alteration of their coats.   A considera-
 tion of these different causes,  and of the  sounds
 resulting  from them, seems to point out  a very
 convenient mode of arranging them as follows :__
 1.  Rhonchi  having their site in the vesicles or
 air-cells — vesicular rhonchi,-  2. rhonchi  having
 their site  in the bronchial tubes—bronchial rhon-
 chi ; 3. rhonchi having their site in morbid exca-
 vations—cavernous rhonchi.  All the causes  of
 these sounds may be divided into two kinds, ac-
 cording as they are dependent  on the presence of
 a liquid, or on some change in  the coats or caliber
 of  the air-passages, or on obstruction from  matter
 of  a solid kind.   The  different kinds of rhonchi
 may therefore  be termed either humid or dry.
 We shall thus have our classification as follows :—
             I___Vesicular rhonchi.
    1. Humid vesicular rhonchus—Moist crepitous
        rhonchus—Rale crepitant of Laennec.
   2. Dry vesicular rhonchus—Dry crepitous rhon-
        chus—Rale crepitant sec a grosses  bulles,
        ou craquement of Laennec.
             II.—Bronchial rhonchi.
    1. Humid bronchial  rhonchus—Mucous rhon-
        chus—Rale muqueux of Laennec.
   2. Dry bronchial rhonchus.   a.  Sibilous rhon-
        chus—Rale sibilant sec  of Laennec.  b.
        Sonorous rhonchus—Rale  sonore  sec  of
        Laennec.
            III.— Cavernous rhonchi.
    1. Humid cavernous rhonchus — Cavernous
        rhonchus — Gargouillement,  Rale  caver-
        neux of Laennec.
    2. Dry cavernous rhonchus.  This species is
        added more on account of uniformity, and
        because it  is possible, than  because such
        a variety has been described.
    1. Moist crepitous rhonchus, or humid vesicu-
 lar rhonchus.—The sound characteristic  of this
 variety is compared by  Laennec to the crepitation
 of common salt when  thrown on hot iron ;  by
 Dr. Williams to the sound produced in rubbing
 between the finger and thumb  a lock  of hair, close
 to  the ear.  Other comparisons have been adduced,
 such as the noise of boiling butter, that occasioned

   * It is very desirable that some name  might be found
 for this phenomenon which would prove generally accept
 able lo British physicians.  In the translation of Laen
 nee the nearest English synonyme, rattle, was used, but
 this word has been adopted by few. The original French
 term rule appears to be most generally employed in this
 country ; but there are several objections to its use.  In
 the present article we shall give  a  general preference
 to  the Latin synonyme, rhonchus, also  employed by
 Laennec. 
250
AUSCULTATION.
by the bursting of the minute bubbles on the sur-
face  of  beer  or soda-water,  &c.   Of  these  the
comparison of Dr. Williams comes  nearest  the
natural sound;  but that which  resembles it still
more closely is  the crepitation of a healthy lung
distended with air, when compressed in the  hand.
Perhaps as just a notion of it may be conveyed to
the mind by  imagining the quality of roughness
superadded to the pure or smooth sound of healthy
respiration.   But, of course, a perfect knowledge
of the sound  in question can only be obtained by
the actual perception of it, and  tbe student is re-
commended  to lose  no  opportunity of making
himself acquainted with it, as it constitutes a sign
of great  practical importance.   The cause of this
sound is, no  doubt, to  be  sought  for in the com-
mixture of the respired air with the secreted fluids;
and whoever  considers the intimate churning of
the two fluids in a  confined space like  the air-
cells, need have no difficulty in admitting this as
the true explanation  of the  phenomenon.  It is
very probable that  the mere increase of the natu-
ral humidity of the membrane, without any formal
accumulation of fluid, or even that some other
physical alteration of this, without increased secre-
tion, may  occasionally give  rise to the crepitous
rhonchus : although, as it occurs only in cases in
which we know  an augmented  secretion to be
present, there is every reason to admit the pre-
sence of fluid as one of the elements in its pro-
duction.
   The moist  crepitous rhonchus is one of the most
constant and  characteristic signs of the first stage
of peripneumony, appearing with its invasion,
disappearing  on the supervention of hepatization,
and re-appearing with the partial resolution  of the
inflammation.  At its commencement this  rhon-
chus alters and obscures the natural respiratory
sound, but does not  entirely mask it :  as the in-
flammation increases, so does the intensity  of the
morbid sound, until this at length  entirely super-
sedes the other.  This rhonchus, however,  is not
exclusively confined  to pneumonia ;  being  ob-
served in oedema  and  apoplexy  of  the  lungs,
and oicasionally in  pulmonary  catarrh  and bron-
chitis ; and, according to Dr. Stokes, in the early
stage of phthisis, during  the formation  and deve-
lopment of tubercles.   (Irish Transactions,  vol. v.
p. 326.)   Indeed, if  we admit  that the presence
of fluid, the effect of inflammation, in the air-cells,
suffices  for its production, we  must expect that
it should be occasionally present in the other dis-
eases mentioned.   But its occurrence in them is
certainly very rare, while  it is so constant a con-
comitant of  the first  stage of pneumonia as to
justify its being considered as almost  pathogno-
monic of  it.   In  different states of the diseases
above mentioned, we  meet  with intermediate
varieties between  the moist  crepitous and the
mucous  rhonchus hereafter to be described.—
These varieties can scarcely be characterised by
words.  In the case  of cedema, and also in pul-
monary apoplexy,  the crepitous  rhonchus, ac-
cording to Laennec, conveys the impression as
if it originated in the rupture of larger bubbles
than  in the  case of pneumonia, in which the
bubbles appear to be of extreme minuteness.  In
a late work on Auscultation, by Mr. Spittal, some
Bccount is given of the sounds produced by the
bursting of bubble* on  the  surface  of different
fluids when  agitated.   He found that fluids of
the density and tenacity of serum  gave rise to
sounds most nearly resembling those of the moist
crepitous  rhonchus; and  M. Piorry states that
the very  same sound is produced  in the dead
body  by  injecting fluids  into the lun£s-  (Du
Procede Operatoire, pp.  81, 94.
   2. Dry crepitous rhonchus, or dry vesicular
rhonchus.—This variety occurs  only in emphy-
sema of the  lungs.  Laennec says it exactly re-
sembles the  sound produced by blowing into a
dried bladder, and conveys the impression of the
inspired air entering and distending lungs which
had been dried, and of which the cells were un-
equally dilated; but it is  somewhat to be sus-
pected that his knowledge of the  physical change
in the affected parts may have helped to suggest
this similitude.  It  is certainly  a  very different
sound from that last described; and it is a pecu-
liar sound.   It is observed most  distinctly in the
interlobular emphysema.   In any case it is only
heard during inspiration.
   3.  The mucous rhonchus,  or  moist  bronchial
rhonchus. This, as its name implies, has its site
in  the bronchial tubes, and not in their terminal
extremities or air-cells.  It is evidently produced
by the passage of the  air through tubes contain-
ing a fluid, and is, in fact, a mere bubbling going
on within the bronchi.   Laennec says  that  it
presents many varieties which can  be best con-
ceived by comparing the perceptions derived from
the sense  of hearing, with such as we fancy might
be conveyed by the sense  of sight.   In listening
to it, our  mental impressions  are similar to those
conveyed by what we see and  hear when one
blows through a pipe into  soapy water.  The ear
seems to  appreciate most distinctly the consist-
ence of the fluid which forms the bubbles, and
also their varying  size.   The consistence of the
fluid always appears, and  probably is, greater in
the bronchial  than in  the  vesicular rhonchus,
The moist bronchial rhonchus belongs principally
to  the  pulmonary catarrh and bronchitis, when
accompanied with  much mucous secretion, and
to  haemoptysis.  It  is obvious, however, that it
may occur in every disease of the lungs attended
by considerable expectoration, as in pneumonia
and phthisis.  A mere variety of this rhonchus
is that  named tracheal by Laennec, the fluid oc-
casioning the sounds being in this case accumu-
lated chiefly in the trachea.   In this variety, as
the caliber of the tube is larger, and the elements
of sound (if the expression  may be allowed,) in
gTeater quantity, the sound  is proportionally in-
creased—resembling occasionally, according  to
the expression of Laennec, the rolling of a drum
at  a  distance, or the noise of a carriage  on a
paved street.  In such cases the sound is com-
monly perceptible without the aid of the stetho-
scope;  but  sometimes when  found to be very
loud with this instrument, it is not heard by the
bystanders.   The tracheal rhonchus frequently
masks  the sounds  of the heart and  the  othsr
rhonchi when present: it may exist singly,but
it is usually complicated with the common  bron-
chial rhonchus.   The bronchial rhonchus is va-
luable  both as a diagnostic and prognostic sign-
It is often the best test we possess of the severity 
AUSCULTATION.
251
of  bronchitis,  by indicating the extent  of  the
affection;  the  danger of this disease being  fre-
quently marked by the extent of membrane in-
flamed.
  4. The dry bronchial rhonchus.—This includes
two varieties, the sibilant and sonorous rhonchus.
The former is  described by Laennec as being
sometimes  like a prolonged  whistle, shrill  or
base, low or loud; sometimes like the momentary
and interrupted chirping of birds, or the sound
emitted by the sudden separation of two portions
of smooth oiled stone.   The sonorous rbonchus
is  a dull, flat, prolonged sound; sometimes  ex-
tremely  loud.   At  one  time it resembles  the
snoring of  a person  asleep, at another the bass
note of a violoncello or bassoon; and, occasion-
ally, it is so like the  cooing of a pigeon  that we
might almost  be  tempted,  as Laennec says, to
fancy the  bird below tbe patient's  bed.   Tbese
varieties of sound, and many others, frequently
 coexist in  the  same person.  They  are, in  all
 probability, occasioned by  the causes to which
 they were originally attributed by Laennec,  viz.
 a diminution in the caliber of some portion of a
 bronchial  tube, by external pressure, (as of an
 enlarged gland or hepatized spot,)  by the  pre-
 sence of a tenacious clot  of  mucus  within  the
 canal, or  by the local  thickening  of its mem-
 brane.  Adopting Laennec's views, Dr. Williams
 explains the different  resulting sounds  in  the
 following  manner.   He  says, the form and  size
 of the isthmus, or contracted point,  will deter-
 mine the nature of the sound. Of  the acute
 whistling sound, called the sibilant rhonchus, he
 observes that, as we know  that such a sound
 may be produced by air passing through a small
 circular aperture, it may be supposed  that a con-
 traction of this kind causes it in this case. « The
 sonorous rhonchus  is rather produced by a flat-
 tened bronchus of considerable  size.   This con-
 traction, which leaves  little or  no  gaping aper-
 ture, throws  the  air  passing  through  it  into
 sonorous vibrations, after the manner of the reed
 of the hautboy, or  the lips in blowing a horn;
 or, perhaps, the production of this sound is  still
 more completely  represented  in the  manner in
 which a celebrated  ventriloquist imitates, with
 his lips, the buzzing of  a  fly."   In another va-
 riety of the sonorous rhonchus, noticed by Laen-
 nec, and which Dr.  Williams well characterises
 as resembling " the sound of a click-wheel," tbe
 sound is probably  produced, as  Dr. Williams
 says, "by a portion of very viscid mucus  at-
 tached to the interior of a bronchial tube, which,
 yielding with  a  jerking resistance  to  the  air
 forcing  its  passage, thereby causes  a  ticking
 sound."—(Rational Exposition,  &c. p. 32.)
   5.  The  cavernous rhonchus. — The  rhonchi
 hitherto  mentioned, although  depending on a
 morbid condition of  tbe  part  in which they ori-
 ginate, still have their site in cavities naturally
 existing  in the  state of health; that now to be
 considered is in every respect morbid—in its site
 as well  as its cause.   It may exist  in all cases
 where there is a morbid excavation in the lungs
 containing a fluid, and communicating with the
 bronchi; as in circumscribed abscess, and in local
 gmgrene of the lungs, and in  the latter stages
 of tubercle.  The last named is by far the most
usual source of this sign, insomuch that we doubt
if it arises once  in a hundred times from any
other cause.   It  is characterised by a strongly
marked mucous rhonchus or guggling, confined
to  a small spot, instead of being diffused over a
considerable portion of the lung, as is  usually
the case with the common humid bronchial rhon-
chus.  It is  particularly heard upon the patient
taking a  deep  inspiration, or after coughing; and
if,  under such circumstances, it is very strongly
marked, continues fixed in the same point, and
is not heard  in any other, it is one of the surest
signs of tuberculous  excavation, even  without
pectoriloquy and the cavernous respiration, which
will generally be  perceptible in the  same  point.
Andral, a high authority', considers  this  circum-
scribed bubbling rhoncbus, when well  marked,
as the very surest sign of a tuberculous cavity.
  In reference to all tbese louder rhonchi, it is
well  to  recollect that they  are often  audible
through  a pleuritic effusion: we must not there-
fore conclude  from their mere presence  that the
lungs are in contact with the chest.
  B. The second class of morbid sounds  which
complicate healthy respiration comprehends fewer
varieties, and  these of less importance than the
last.
   1.  Metallic tinkling, or metallic resonance.—
This name, literally translated from  the  original
epithet bestowed  on the sound by Laennec, (tin-
tement metallique,)  applies to one  of the most
singular, though  not one of the most important
results obtained  in the  exploration  of  thoracic
diseases  by means of auscultation.   This  sound
is  observed only in  cases where  there  exists
within the chest a large preternatural cavity con-
taining air.    By far the most common occasion
of it is  the  presence  of air  in  the sac of the
pleura in the  disease termed pneumothorax.   It
however  is observed,  although  very rarely, in
other cases, particularly in very large tuberculous
excavations.   As  in tbe great majority  of cases
of pneumothorax there coexists with the  gas a
liquid effusion in the pleura, and likewise a com-
munication between the pleural cavity  and the
bronchi,  Laennec, the discoverer of the pheno-
menon,  was   led  to consider  its production  as
almost exclusively confined to this complex mor-
bid state.  It  has,  however, been  since proved
that neither  the  existence of liquid  effusion, nor
the communication with the bronchi, is necessary
to its production.  The sound is most commonly
excited by the act of respiration, or speaking, or
coughing; but it also arises independently of any
of these.  Coughing produces it more frequently
and more certainly tban any of the  other respi-
ratory acts.   There  are two varieties  of  tbis
phenomenon, the  one  known by  the  general
name of metallic tinkling,-  the other termed  by
Laennec amphoric resonance, or buzzing,  (bour-
donnement amphorique.)
   The first of these varieties  resembles the sound
emitted  by a  cup of metal or  glass  when  gently
struck with  a pin, or into which a very minutr
pebble or grain of sand is thrown;  or it is  like
the sound of a brass wire vibrating under a sharp
but gentle stroke of the finger.  The amphoric
resonance is of a character less definite, but not
less distinct.  It is like the  sound  produced  b\ 
252
AUSCULTATION.
 blowing quickly and  forcibly into a  bottle or
 other large empty vessel having a small aperture.
 It is also called metallic resonance.
   Both these sounds  are most frequently occa-
 sioned  by  the  impulse  communicated  to  the
 gaseous fluid in the sac of the pleura, by a blast
 of air from a fistulous  opening in the lungs;  the
 difference of sound depending, most probably,
 on  the  nature of the opening.  They also origi-
 nate when there exists no such opening, the  im-
 pulse being conveyed from the air within  the
 bronchi through a stratum of condensed pulmo-
 nary substance, or other  matter capable of com-
 municating it, to the air in the cavity, the vibra-
 tions  of which are  the immediate  cause of the
 peculiar sounds.   The first  of the two sounds,
 the  metallic tinkling, is  likewise found  to arise
 without any external impulse, by the mere falling
 of a drop of fluid  from the  superior part of the
 cavity into the fluid collected in the under part
 of it.   The value of these  sounds  as signs of
 disease will be noticed in the article Pneumo-
 thorax, to which the reader is referred.
   2. Sound of friction.  This sound, termed by
 Laennec bruit  de frottement ascendant et  de-
 scendant, is rather  connected with the thoracic
 movements which effect respiration  than with
 respiration itself.   It was first observed by  Dr.
 Honore, but has been since more completely in-
 vestigated by M. Reynaud,  one of Laennec's
 pupils.  It is an  obscure dull sound, quite dis-
 tinct from the respiratory murmur, but  exactly
 synchronous with the motions of inspiration and
 expiration.  This sound  is precisely such as  we
 might conceive would be produced by the friction
 of a body, somewhat rough,  against the inner
 side  of the walls of the  chest, rising and descend-
 ing regularly with  the respiratory  movements.
 It is in general proportioned to the extent  of
 tbese,  being loudest during deep inspirations, and
 in some cases only audible then.   This sound is
 found to  occur only when there exists consider-
 able  roughness or inequality on the surface of the
 lungs or costal pleura.  Laennec considered this
 sound as a sign of interlobular emphysema; and
 it  seems probable that  it' is  so in certain cases.
 It has, however, been  found  more  certainly in
 pleurisy, when the membrane was rendered rough
 by partial effusions of a solid  albuminous kind,
 with little  or no  accompanying serum.   In this
 case  it is well established  as a  sign;  and it may
 be regarded as of favourable omen, inasmuch as
it denotes a moderate effusion,  and that the lung
is  sufficiently dilated to  come in contact with the
walls of  the chest.*
   Auscultation of the Voice* — If  we  apply
the hand to the chest while a  healthy person is
speaking, we  are  almost always sensible  of a
slight vibration,  at least,  evidently produced  by
the sound  of the voice; and  a vibratory sensa-
tion, rather than a  formal sound, is communi-
cated, under similar circumstances, by the stetho-
scope,  to the ear.
   [Great discrepancy exists amongst  observers,
in regard to the true signification of this vocal
fremitus  and its modifications, as the following
table, by  Dr. Walshe,  clearly exhibits.   (The
Physical  Diagnoses  of Diseases  of the Lungs,
Amer. edit. p. 164, Philad. 1843.)

          NATURAL VOCAL FREMITUS.
	Increased.	Diminished.	Uuaff-cted.
Laennec. Stokes.		In consolida-tion and in effusion.	
Rkynaod. Williams. Hourmann.	In consolida-tion.	In effusion.	
Grisolle.			In consolida-tion, from pneumonia at least.
FOORNET.	Impossible in any case.	In all changes of density, whether of increase or decrease.	
  *De l'Auscull. Med. 3me. edit. t. i. p. ]20.  Ibid. p. 335
note.   Ibid. torn. ii. p. 319, note.—Reynaud, Journ.  Heb-
oom   No  S5, p. 576.—Andral, Clin. Med. 2me. edit t ii
p. 61?
   Dr. Walshe is, we think, correct in entertain-
 ing not the slightest doubt, that M. Fournet is in
 error in the principle which he affirms in regard
 to the  non-increase  of vibration.   Like Dr.
 Walshe, we have found it manifestly augmented
 in cases of tuberculous consolidation of the top
 of the lung, as well as in pure hepatization.  Dr.
 Walshe adds, that he cannot  help feeling, that
 there is something of importance  yet to be dis-
 covered respecting this sign, which may furnish
 a ready clue  to the  contradictions in the state-
 ments of writers on the subject.]
   In many cases, indeed,  particularly in persons
 who  have large chests and a base voice, we recog-
 nise  a  distinct vocal resonance over the whole
 chest.  And  in every case, when we apply the
 stethoscope over the origin of the larger bronchial
 tubes, as between the scapulae, we hear the voice
 much more distinctly; sometimes even as loud
 as the  voice  from  the speaker's  mouth.  The
 words are also sometimes distinguishable; but
 they  appear as if playing  round the extremity of
 the instrument, and not as  entering, much less
 traversing, its tube.   When, however, we place
 the stethoscope on the larynx or trachea, on the
 fore-part  of the throat, while  the individual  is
 speaking, we  then  hear the  whole of the words
 passing directly through the instrument into the
 ear,  exactly  as if the mouth,  in place of the
 larynx, were  applied to the end  of the instru-
 ment ; and the voice  so  heard is much louder
 than  the natural voice heard  by  the other ear.
 The  cause of  these  sounds  (denominated by
 Laennec, from their site, bronchophony and laryn-
gophony) depends, no doubt, on the fact, that, in
 the act of speaking, the vocal vibrations always
 extend  inwards along the air-tubes, as well as
 outwards through the mouth and beyond it.  The
 stethoscope merely supplies a conductor for their
 conveyance to  the ear.   The  vocal sounds are
 loud and distinct in the trachea, because there is
 sufficient space there for the aerial vibrations that
 constitute  the sound;  because the more solid
 walls of this  part  are well calculated to propa-
 gate it; and because it lies near  the surface.  The
gradual loss of all these conditions favourable for
the generation and propagation of sound, as the
trachea descends into the chest and there becomes 
AUSCUL
T A TIO N.
253
transformed into small tubes traversing the spongy
texture of the lungs, sufficiently explains the im-
perfection of the  vocal  resonance in the larger
bronchi,  and its  total absence  in the  smaller
branches.
  In certain states of disease, however, both the
bronchial  and laryngeal sounds become  deve-
loped in places where they do not naturally exist;
and as it has been ascertained that the causes of
this morbid development of the voice are certain
fixed physical  changes of structure, these voices
from the chest become important signs of disease.
  [In the space, corresponding posteriorly to the
origin of the right bronchium, the voice resounds
more strongly than in the  corresponding part of
the  left  side.  According  to Sir  James Clark,
the natural resonance is more intense under the
right than the  left clavicle, and with this our ob-
servation accords.  Dr. Stokes, indeed, considers
that it is more intense over the whole of the right
side.   (On  the  Diseases  of the Chest, p. 297,
Dubl. 1837.)]
   The sounds produced within the chest by the
 voice, that are available  as  signs of disease, are
 of three kinds, and may be arranged as follows :
 —1. Simple bronchophony, or bronchophony with
 the healthy character, only developed in places
 where it does not exist in health; this, for the
 sake  of brevity,  we shall  term  bronchophony.
 2. Complex bronchophony, or bronchophony with
 the healthy sound modified in a peculiar manner,
 and developed in places where it  does not exist
 in health: this is termed xgophony.  3. Perfect
 laryngophony  developed in  the chest: this  is
 termed pectoriloquy.
   I. Bronchophony.   The   same  causes which
 render bronchial respiration audible in disease, in
 places where it is not perceptible in the state of
 health, render bronchophony equally audible, and
 for the same reason, viz. by rendering  the pul-
 monary  tissue a better conductor  of sound.
 Whenever, therefore, we have  tbe  substance of
 the lungs considerably condensed in the vicinity
 of  bronchial tubes  of  moderate  size,  without
 obliteration or great compression of their caliber,
 we may expect to have bronchophony developed.
 The morbid states in which it is found are chiefly
 hepatization and induration  from the deposition
 of solid tubercular matter.   It may also originate
 in other kinds of  condensation of the pulmonary
 tissue, such as pulmonary apoplexy, melanosis,
 &c, and also in certain cases of dilatation of the
bronchi.
   [This last fact shows, that consolidation is not
necessary to induce increased resonance of the
 voice.  Dr. Skoda, indeed, maintains  that  bron-
chophony is not always a persistent phenomenon
in hepatization; that at one time it is very strong;
at another  equally weak;  and the  cause of the
occasional disappearance of resonance  he  con-
ceives to be—the  obstruction of the tubes of the
hepatized part by  fluid matters ; as the resonance
readily  reappears when the patient  makes  a
deep respiration  or  coughs.   Dr.  Skoda  refers
bronchophony  to consonance  or   reciprocation
— a  well-known acoustic  phenomenon; and
the fact, above-mentioned,  of the occasional dis-
appearance of the resonance when the lung is
unquestionably hepatized, seems to corroborate
                                       w
this view.  (For the auscultatory views of Skoda,
see Edinb. Med. and Surg. Journal, for July 1841;
or American Med. Intelligencer, for Aug. 1841.)]
  The general characters of this morbid, or acci-
dental bronchophony, as it is termed by Laennec,
are as above described; some  further particulars
of the sound will  be noticed in the subsequent
paragraphs, when  we  come  to  contrast  some
other sounds with  this.  Bronchophony is most
valuable as a sign in peripneumony and in phthi-
sis.  In the former it is most evident when the
inflammation exists near the roots  of the lungs,
and  in the upper  lobes where the bronchi are
largest:  it is much less  frequent  and more ob-
scure in the lower lobes.  When the hepatization
has its site very near the surface  of the lungs,
and where the bronchi are  particularly large, it
frequently approximates to laryngophony.   The
bronchial respiration is  always present with bron-
chophony ; and frequently also the common vesi-
cular respiration, except in cases where the hepa-
tization is very  extensive.  Bronchophony is a
less important sign in phthisis, but when existing,
as it frequently does, beneath  the clavicles, par-
ticularly if on one side  only, and other symptoms
of this disease are present, it tends strongly to
confirm the general diagnostic.
  II. Mgophony.— If  in any of  the  cases  in
which the preceding sign exists,  a  thin layer of
fluid  is superadded, between  the surface of  the
lungs and costal pleura, the natural simple sound
of broncophony  is  so much  and so peculiarly
altered as to merit and obtain  a distinct appella-
tion, and be considered  as a distinct sign.  This
modification  of bronchophony has been termed
aegophony  by Laennec, (from a\\, a'lyd;, capra),
because  it possesses somewhat  of the broken,
bleating cry of the goat, and approaches the usual
key of this  animal's  voice.   It is a kind of sil-
very voice, of a sharper  and  shriller tone than
that  of the patient, seeming to float and vibrate
on the surface of the lungs, and  sounding more
like the echo of the patient's voice than the voice
itself.  Different  varieties of  this  phenomenon
resemble more or less closely various sounds with
which all are more or less familiar, e. g.  the voico
through  a speaking-trumpet,  or  cleft reed; that
of a person speaking with something between his
lips  and  teeth;  the  squeaking  of Punch, &c.
The last-mentioned comparison is certainly some-
times  extremely  exact, particularly in persons
who have a base voice.   The  sort of bleating so
characteristic of aegophony, seems, in most cases,
connected  with  the articulation  of the words;
sometimes it seems unconnected with this, so that
we can hear at the same time, yet separately, the
simple sound of the natural voice, and the  bleat-
ing  sound of aegophony.  In order to hear the
sound well, the instrument must be applied with
considerable force to  the  patient's chest, but the
ear must not be pressed against the  other end
with more than the usual force. Mgophony only
exists in pleurisy or hydrothorax,  when the quan-
tity  of effused fluid is  just sufficient  to form a
thin  layer between  the  surface of the  lung and
costal pleura. The compression produced by the
external  fluid seems to produce the requisite de
gree of condensation of  the pulmonary substance,
to enable it to conduct  the  bronchial resonance.; 
254
AUSCULTATION.
 and the passage of this through the stratum of
 mobile fluid on the surface, seems to occasion the
 peculiar modification of the sound above described.
 Dr. Williams  says, that in addition to the pre-
 ceding requisites, there must likewise exist a cer-
 tain proportion between the mass of liquid and
 the pitch and strength of the vocal sounds, other-
 wise the fluid will not he thrown into vibration.
 This, he says, is  proved by the fact that certain
 tones of the same voice are aegophonic and others
 not.  (Rational Exposition, p.  107.)  iEgophony
 is always found to extend over a certain portion
 of one side  of  the chest, being most commonly
 perceptible, at the same time, in the intrascapular
 region, round the lower angle of the scapula, and
 in a zone, from one to three fingers broad, follow-
 ing the line of the  ribs, from  the middle  of this
 bone to the nipple.   Of its importance as  a sign
 in pleurisy, we need only  quote the statement of
 Laennec, who  says that he had  observed it in
 almost every case of pleurisy which had come
 under his care  for the last five years  before the
 publication of  his second edition.  The same au-
 thor adds, that he has detected aegophony  where
 there did not exist above three or four  ounces of
 fluid within the  chest.  iEgophony only  exists,
 as already said, when the effused fluid is in mo-
 derate quantity ; it therefore is found to disappear
 when the pleuritic effusion surpasses this amount,
 and it again returns when absorption has reduced
 it to the proper quantity.   The  original  opinion
 of Laennec as to the cause of this singular phe-
 nomenon, seems to be generally admitted as just.
 He says, " I consider aegophony to  be owing to
 the natural resonance of tbe voice  in  the bron-
 chial tubes, rendered more distinct by the com-
 pression of the pulmonary texture, and modified
 by its transmission through a thin layer  of fluid
 in a state of vibration."  Dr. Williams says, that
 " the tremulous or subsultory sound  of the aego-
 phonic voice is produced by the successive  undu-
 lations of the  liquid, the  result of an irregular
 transmission of the sonorous vibrations."   ^Ego-
 phony and  bronchophony frequently exist toge-
 ther, as might be naturally expected; and, although
 each is sufficiently well marked to be recognised
 by its  distinctive characters, like all  similar phe-
 nomena they run into each other, and it  is not
 seldom impossible to pronounce with certainty
 whether the sound is tbe one or the other.
   III.  Pectoriloquy.   The most singular, as it
 was one of  the first, of the results of Laennec's
 exploration of the  voice, was the discovery of per-
 fect laryngophony in different parts of the chest as
 the consequence  of disease.  The  condition of
 parts necessary to  produce this  curious phenome-
non (termed by the  discoverer pectoriloquy,  or
chest-speaking, from pectus and loquor,) is the
existence of a preternatural cavity communicating
with the bronchi, amid the  spongy texture  of the
lungs ; the existence, in short, of a sort of artificial
larynx, or space sufficient for the full development
of the vocal  vibrations, which  always exist, in a
modified degree, in the larger  air-tubes.  When
the stethoscope  is placed on the chest directly over
a cavity of  this kind, the  articulate  and perfect
voice  of the individual seems  to reach the ear
Ihrough  the  tube, as distinctly  as when this  is
placed on the larynx ;  and  the voice thus  heard
 is often louder and more distinct than the natural
 voice  that issues from  the  mouth.   Cavities of
 this kind are occasionally produced by more than
 one disease of the lungs ; but  in  a vast majority
 of cases they are the result of the  suppuration or
 softening of tubercles.   The other cases in which
 this phenomenon may be perceived are, according
 to Laennec,  the  following :  cavities produced  by
 the  dissolution  of a gangrenous eschar, by  an
 abscess the consequence of peripneumony, and by
 the  bursting of a cyst into the bronchi.  When
 pectoriloquy  is well marked, there  is  a perfect
 identity  between  it and the sound of  the voice
 heard through the stethoscope when resting on the
 larynx :  and as this means of comparison is always
 at hand, a reference to it will be more serviceable
 than any description of the sound however elabo-
 rate.  It is to this that  the student must always
 recur  as a test of the fidelity of his judgments  in
 exploring the chest for pectoriloquy.  It is, how-
 ever, well that he should be made early aware that
 pectoriloquy so perfect as this is by no means of
 universal occurrence in  phthisis, even in cases in
 which we have  other proof of trie existence of
 tuberculous  cavities.  Indeed, we  are disposed to
 believe with  Andral that perfect pectoriloquy is by
 no means  extremely common, and that broncho-
 phony is frequently mistaken  for it.  Laennec
 was well aware that pectoriloquy was often very
 different in different cases, according  to the size,
 shape, and nature of the walls of the cavity, its
 degree of emptiness  or fulness, its mode  of com-
 municating with the bronchi, its particular site in
 the  lungs, &c. &c.; and  he was  careful  in de-
 scribing several varieties of it.  The principal of
 these  he termed  perfect, imperfect, and doubtful
 pectoriloquy.  He considers it perfect only when
 the transmission of the voice through  the  instru-
 ment is complete, and when it can be still furthei
 discriminated from bronchophony, by being con-
 fined to  one spot, and  by the corresponding cir-
 cumscription of the cavernous respiration and
 cavernous rhonchus, which commonly accompany
 it. It is imperfect when any one of these character-
 istics is wanting, and especially if the transmission
 of the voice is not evident.  It is doubtful when
 the sound of the voice is very feeble, and when it
 can be distinguished  from bronchophony only by
 the aid of other signs derived from  the considera-
 tion  of its site, the  general symptoms, and the
 progress of the disease.
   The circumstances which concur to render pec-
 toriloquy perfect  are, the complete emptiness of
 the cavity, the increased  density of the pulmonary
 substance which  constitutes its walls, its free
 communication with one or more bronchial tubes
 of a certain  diameter, and  its  proximity  to the
 walls of the chest.  The  absence of more or fewer
 of these  conditions will tend  to render pectorilo-
 quy more or less imperfect; but it may be very
 imperfect and yet not at  all doubtful as a sign of
 the existence  of a cavity.   In all cases of imperfect
 pectoriloquy, the discovery of the same sound on
 both sides must always render it doubtful.  It is
 however  to  be recollected  that  the most perfect
pectoriloquy  may become in  an instant very im-
perfect, or  may entirely  disappear, owing  to the
changes that  may take place in the contents of the
excavation, or of the bronchi leading to it.  Ev 
AUSCULTATION.
255
 cavations of a moderate size, and  of a  regular
 rounded shape, give the most perfect pectoriloquy.
 If the caverns are very large or irregularly shaped,
 the sound  of the  voice  is indistinct, and  this is
 also the case if they are very small.   The more
 empty  the  cavities  are, the  pectoriloquy is the
 more evident.  It  is also more distinct according
 as thb voice of the individual is more sharp ; and
 as women  and children have this kind of voice
 most commonly, it is well remarked by Laennec
 that we must be particularly on our guard, in their
 case, not to confound natural bronchophony with
 pectoriloquy.  The deeper the voice is, the reso-
 nance within the chest is the stronger;  and it
 often happens, in such cases, that in place of pene-
 trating the  tube of the  instrument,  it seems to
 sound at its extremity much louder than the natu-
 ral voice ;  as if the patient were speaking through
 a speaking-trumpet quite  close  to  us, and  not
 through the stethoscope into the  ear, as in com-
 mon pectoriloquy.   For further details  respecting
 this sign, we must refer  to the article  Phthisis,
 in which disease it constitutes a  most  important
 sign.  We must, however, be permitted  to observe
 that too much stress has been laid upon the value
 of pectoriloquy as  a pathognomonic sign of phthi-
 sis.   Where it  clearly and unequivocally exists,
 it is unquestionably pathognomonic ; and in many
 doubtful cases it is of inestimable value in deter-
 mining the nature  of the disease.  It cannot, how-
 ever, be denied that it is only in rare cases that its
 discovery influences either our diagnosis, prognosis,
 or practice.   The  rational signs of phthisis serve,
 in the great majority of cases, sufficiently to cha-
 racterise it; and when these are corroborated and
 crowned by the addition  of pectoriloquy, the case
 is in almost every instance  already  beyond  the
 power of remedy.  And yet we are far from wish-
 ing to  represent this sign as of little value even in
 phthisis. It is by it  alone, or by it and the other phy-
 sical signs  produced in caverns by the respiration
 and cough, that we can be certain of the existence
 of tuberculous cavities at all, or of their situation,
 number, or extent; and  every pathologist  knows
 how much  the prognosis at least, if not the treat-
 ment, may  be improved by this knowledge.  Be-
 sides, there are  several  cases, of not  very  rare
 occurrence, in which such knowledge is of infinite
 value both  as to prognosis and treatment.  One
 of these is  when  all  the  rational symptoms of
 phthisis are produced by  chronic  bronchitis ;  and
 another where one  or two tuberculous excavations
 exist in an otherwise sound  lung,  and without
 producing any of  the rational or constitutional
 symptoms of phthisis.  It  is unnecessary to say
 of what value to the practitioner will be the assu-
 rance of the non-existence  of pectoriloquy  in  the
 one of these  cases  and its existence in the other.
 In the  latter  case,  the voice from the  chest may
 announce the speedy approach of suffering,  and
 sorrow, and death,  perhaps  amid  all  the outward
 semblances of healtb; and in the former, its silence
 to all our questioning may not merely bid hope
lake the place of despair in the breast  of friends,
but may awaken the physician from the torpor of
inactivity, and induce him to adopt such measures
as may convert this hope into certainty.
   [It has been pn. posed to associate auscultation
with percussion ;— in other words, to listen witb
 the common stethoscope, or with one modified foi
 the purpose, whilst a part is struck in the ordinary
 metbod of mediate percussion ;  and value has been
 assigned to auscultatory percussion, acouophonia,
 or cophonia, thus practised ; but  it has not been
 much used, and  is affirmed  by M. Fournet (Re-
 cherches Cliniques sur I'Auscultation, &c.  Paris,
 1839,) to be  deceptive,—the perceived  sound
 bearing no precise relation to the condensation or
 rarefaction of the adjacent parts.  Hence, it has
 been denounced, but in too strong language, per-
 haps,  by Dr. Walshe,  as " obviously worse than
 useless."   (The Physical Diagnosis of Diseases
 of the Lungs,- Amer. edit. p. 154 : Philad. 1843.)
  The term autophonia  has  been given,  by M.
 Hourmann, to  an auscultatory process, of which
 M.  Taupin considers  himself  the inventor.   It
 consists in noting the character of the observer's
 own voice, whilst he speaks with  his head placed
 close  to  the patient's chest.   The  voice, it is
 alleged, will  be  modified by the condition of the
 subjacent organs.  M. Hourmann considers it  a
 really  useful sign in the  examination of infantile
 diseases.  (Walshe, Op. cit.)]
  Auscultation of tlie  Heart.
  If we apply the ear, with or without the stetho-
 scope, to the cardiac region of  a person in health,
 we  perceive,  most distinctly, a  series of sounds of
 a very marked and peculiar kind,  subdivided into
 uniform parts by a brief interval of silence, after
 every  second sound.  Two sounds  follow each
 other instantly, or within so short  a space that the
 ear separates them rather by  difference  in their
 quality than  from the intervention of any notable
 cessation of sound :  then ensues  a brief but well-
 marked pause, which  is  again succeeded by the
 first of the  twin  sounds.  This series of sounds
 may be perfectly  well  represented, as to rhythm,
 by musical  notation.  The relative  duration of
 the  sounds and pause  is represented  by Laennec
 to be nearly as follows :  the whole being divided
 into four parts, two of  these are occupied by the
 first sound, and one by the second sound  and the
 pause  respectively.  The  two sounds differ in
 kind as well  as in duration.    The first is nearly
 double the length of the  second, of a graver and
 more subdued tone, rather louder at its commence-
 ment than at its termination, as if it was about to
 die  away when suddenly interrupted by the second.
 The second is brief, smart; and clear, like a gentle
 tap  with the pulp of the finger on a solid table, or,
 according to Laennec's comparisons, like the sharp
 sound produced by the falling back of a valve, the
 cracking of a whip, or  the lapping of a dog.  [To
 convey a notion  of these  sounds, Dr. C. J. B.
 Williams employs the  compound word  lubb-dup,
 the  first  word of the  compound  expressing the
 protracted first sound ;  the latter the short second
 sound.]   Exactly  synchronous   with  the  first
 sound, there  is perceptible, in most cases, a well-
 marked impulse or shock, communicated evidently
 by a  body in motion  within, to the walls of the
 chest.  Every one acquainted  with anatomy and
 physiology will at once conclude that the sounds
 and impulse  just described are produced by the
motions of the heart; and this  conclusion will be
justified and  confirmed by  an examination of the
pulse in the extremities.   It. will be found, in ail
healthy subjects, that there is an invariable con- 
256
AUSCULTATION.
nexion between  the  sounds and  the pulse, every
stroke of the latter corresponding very accurately
with every  repetition  of  the  twin sounds.   As,
under every variation of circumstances as to loud-
ness, frequency,  &c, the  same exact relation  is
perceived, it cannot be doubted that there exists an
essential physical connexion between the causes
of the sounds and the pulse.
  For a long time after the discovery of mediate
auscultation, no doubt was entertained  that the
exposition of the motions and sounds of the heart,
given by Laennec, was the true one.  He asserted
that the first of  the two sounds accompanied and
was caused by the  contraction of the ventricles ;
the  second  by the contraction of the auricles; and
that the pause  intervened  between the auricular
and the yentricular sounds.  As  a necessary con-
sequence of this doctrine, he  taught that in the
natural  rhythm of the heart, the ventricular  sys-
tole comes first; is  followed  immediately by the
auricular  systole ; and this, in  its  turn, by the
interval of repose.
  The  accuracy of these  statements of  Laennec
was first called  in  question by Mr. Turner, in  a
paper published in the third vol. of theEdin. Med.
and Chir. Transactions ; and the  subject  has been
since more  completely illustrated by the observa-
tions and experiments of  Drs. Corrigan, Stokes,
and Hope.*  The experiments of the last-named
physician made on large animals (asses) are par-
ticularly deserving our attention  and confidence.
They are of such a kind,  indeed, as, in our opin-
ion, to set the question  at rest; the results having
been repeatedly witnessed  by  many most compe-
tent judges, and being in complete accordance
with the pathological phenomena observed in the
human  subject, during life and in the dead body.
Dr. Hope has recently repeated  his  experiments,
with results precisely  similar to those  formerly
obtained, and has been kind enough to favour us
with a  sketch of the  natural movements of the
heart and  the  relation of the sounds  to them.
This we shall here give almost in Dr. Hope's own
words, being happy  to avail ourselves of an au-
thority  so deservedly high, founded as it  is on the
most extensive observation particularly devoted to
the subject.
  Rhythm of the heart.—The first motion of the
heart which interrupts the  interval of repose, is the
auricular systole.  It is  a  very  slight and  brief
contractile  movement, more considerable in the
auricular appendix  than  elsewhere, and propa-
gated with  a rapid vermicular  motion towards the
ventricle, in  the systole of which it  terminates
rather by continuity  of action  than by the succes-
sion of a new movement.   The ventricular systole
commences suddenly, and  is accompanied with a
considerable  diminution of the  volume of the
organ.   Synchronous with the systole are the first
sound, the  impulse  of  the  apex  against  the  ribs,
and the pulse in vessels  near the heart : in the
-adials  the pulse follows  at a barely appreciable
interval.  The systole of the ventricles is followed
by  their diastole, during which they  return, by an
instantaneous expansive movement sensible to the
touch and sight, to  the same  state (with respect
l>>  size, shape, position, &c.)  as  during  the  pre-
  *  See the  communications  of these gentlemen in the
lancet  Edinb. Journal and Med. Gazette.
I vious interval of repose.   This movement, or dia-
 stole, is accompanied by the second sound, by an
 influx of blood from  the auricle, by a retractile
 motion of this cavity most observable at its sinus,
 and by a retrocession of the apex of the heart from
 the walls of the chest.  Next succeeds the interval
 of repose, during which the ventricles remain at
 rest, in a state of fulness, though not of distension,
 through  the whole period intervening between the
 second  and  the first  sounds; but  the  auricle
 remains  at rest during the  first  portion only of
 that period, the remainder being  occupied by  its
 next  contraction,  with which  recommences the
 series of actions described.
    The duration of the several parts  of a beat is
 the same as described by  Laennec : namely,
    1.  The ventricular systole occupies half the
 time, or  thereabouts, of a  whole beat.
    2. The ventricular diastole occupies one-fourth,
 or at most one-third.
    3.  The interval of ventricular repose occupies
 one-fourth, or rather less, during the latter half of
 which the auricular systole takes place.
    Causes of the  motions.—The auricles, which
 are always in a state of fulness, arrive, during the
 first half of the period of ventricular repose, at the
' state of  distension, by which they are  stimulated
 to contract.   The object of the contraction at this
 moment is  to  propel a small additional quantity
 of blood into the ventricles, for  the purpose  of
 bringing them  from the state of fulness to that  of
 distension;  an object which  could not be accom-
 plished without a contraction, as the blood could
 not  otherwise  force its way into the ventricles
 against the  resistance offered by their elasticity.
 These cavities, then, being brought to the state
 of distension, are  by this  stimulated to contract:
 they expel a  greater or  less proportion  of their
 contents :  in small animals, frogs for instance,
 they  expel  the whole ;  which  is proved  by the
 ventricle becoming pale.   In large animals they
 do not appear to expel  the whole, but the fact
 does not admit of demonstration.  During the act
 of expulsion, the apex is tilted up, in consequence
 of the retraction of the ventricles towards the base
 and upon the auricles, which, in a state of ex
 treme distension, are placed like a fulcrum beneatn
 them.  The diastole appears to be occasioned  by
 several concurrent causes, viz. 1.  That power  of
 the muscle  by which it  reverts from the state  of
 contraction  to that of relaxation, and in virtue  of
 which it exercises a degree of motion.  It may  be
 called elasticity until its nature is more positively
 determined.   2. The  distension  of the auricles,
 which is greater at this moment than at any other,
 as they  have been filling during a longer period;
 namely,  that of the ventricular  contraction,  or
 half a whole beat.   3. The weight of the ven-
 tricles collapsing on the distended auricles under-
 neath them.   4. The width of the auriculo-ven-
 tricular orifice, which allows the blood to shoot in
 instantaneously and with great  facility.   It is
 obvious  that, as so many powerful causes conspire
 to promote the influx  of the blood, an auricular
 contraction  for this purpose, as imagined by Laen-
 nec, would be superfluous.   The  escape of blood
 from  the auricles during  the diastole, causes the
 slight retraction observable  in  them  at the same
 moment. The expelled blood being instantly  re 
AUSCULTATION.
257
placed  from  the  venae  cavse,  distension of the
auricles recommences,  and the  same  series  of
actions is renewed.
   Causes of the sounds.—The ventricular systole
is the  cause of the first sound, by the impulse
which  it communicates to  the blood within it,
thereby exciting sonorous vibrations of that fluid.
[f the sound of the muscular contraction contri-
butes at all to the first sound, it can be only in a
very slight  degree.  The ventricular diastole  is
the cause of the  second sound, by the re-action
of the  walls on the  blood, and  the  consequent
production of sonorous vibrations, when its course
is abruptly arrested by the completion of the dias-
tole.  Hence this  sound is loud, brief,  and  clear.
The auricles are not concerned in the production
of the  two sounds,  as they take place when these
cavities are mofonless ;  nor do they appear to be
productive  of any  sound,  as  no third sound is
audible.
   [The causes of the two sounds can scarcely be
regarded as  settled.   From  accurate experiments
made by Drs. Pennock and Moore, of Philadel-
phia, (Medical Examiner,  Nov. 2,  1839 ; and
American Medical  Intelligencer, Dec. 1G, 1839 ;
or Pennock's edition of  Hope On Diseases of the
Heart, Philad. 1842,) they suggest, that the first
sound  may be a combination of that caused by
the contraction of the auricles, the flapping of the
auriculo-ventricular valves, the  rush of blood from
the ventricles, and  the  sound  of muscular con-
traction.   The second sound they refer exclusively
to the closure  of  the  semilunar valves by the
refluent blood from  the aorta and  pulmonary
artery.   The main results of the  experiments of
these gentlemen  accord greatly with what the
writer has entertained and taught on the subject.
Still, the matter is open for  fresh investigation ;
especially as M. Cruveilhier, from a case of ectopia
cordis, carefully examined by him, inferred that the
greatest intensity of the  first sound is in the same
situation as the greatest  intensity  of the second—
that is, at the origin of the larger arteries ;  or, in
other words, that  both sounds  are  seated in the
semilunar  valves.   ( Gazette Medicate de Paris ,-
Aout, 1841, p. 535.)  The different views on the
sounds of the heart, entertained  by different ob-
servers, are given elsewhere. (The writer's Human
Physiology, 5th  edit. ii. 119, Philad.  1844; and
Practice  of Medicine,  2d  edit.  ii. 460, Philad.
1844.)]
   We  now proceed to  examine more  minutely
the phenomena produced by  the  actions of the
heart, in health and disease, with  the  view to de-
duce therefrom such diagnostic  signs  as  they are
capable of  affording.  It is hardly necessary to
premise that the  auscultatory diagnostics of car-
diac  diseases are founded precisely on  the  same
principles as those which apply to diseases of the
lungs.  We  have  certain  natural  sounds and
movements, depending on the physical  structure
and natural action of the parts, and therefore  of
constant occurrence in the state of health.  These
sounds  and  movements are  changed from  their
normal  character  by disease, in a certain  deter-
minate  manner, in  accordance with  the  known
laws of physics.   If we are acquainted with the
movements and sounds  of health, and with their
various  relations,  we can  have no difficulty in
  Vol. I. —33                       w *
detecting their morbid deviations.   And as these
deviations  depend on fixed physical changes of
structure, just as the  normal sounds depend on
the normal structure, the  study  of the  former
sounds will enable us to ascertain  the existence
of the morbid  causes, as in the  other case  the
sounds  of health  indicated the presence  of the
normal structure.
   In strictness of language, auscultation can only
take cognizance  of the sounds which accompany
the motions of the  heart.  As, however, these
sounds are intimately connected with the  shock
or impulse communicated to the side, and  as this
important  sign is  appreciated  by the same organ
(the ear), though  not by the  same  sense,  it  has
been customary  to consider it along with the phe-
nomena of sound  and rhythm, which are  strictly
referable to the sense of hearing. As this arrange-
ment is  extremely convenient, we  shall adopt it
in the present  article;  and shall,  indeed, com-
mence with the  consideration of the phenomenon
which, in a philosophical arrangement, could  not
be admitted at all.
   I. Impulse.—This, as we have already said, is,
in the state of health, always coincident with the
first sound.  It  is not, however, exclusively con-
fined to this period of time in the state of disease.
The impulse may vary from the ordinary standard
in different individuals in health, and in the same
individual  in disease : 1.  in the period of  its  oc-
currence, or its relation to the sounds ;  2.  in its
individual  character, particularly in  its  degree or
intensity ;  3. in its sphere, or the eytent of chest
over wbich it is  perceptible.
   1. Although  the  impulse is usually  synchro-
nous with  the first sound, and with this only, it
occasionally accompanies the second sound also.
This, however, is of rare occurrence, and is only
met with in a particular form of disease.   It  has
also  a very different  character from the normal
impulse which accompanies the first sound.   It
is perceived, according to Laennec, to have its
origin  much deeper  within  the chest than  the
other stroke, and,  in  giving it, the heart seems to
be receding from the ear.  Most commonly  it con-
sists merely of a sort of trembling felt deep  within
the mediastinum ; and it is always very slight in
degree when compared with the normal impulse.
Dr. Hope  terms this second  impulse  the back
stroke, and considers it as in a great  measure con-
fined to cases of hypertrophy with dilatation ; or,
rather, that it is  observed more  particularly  in this
disease when existing in a great degree.
   2. There is great difference among individuals
in perfect health respecting the degree of impulse.
In some no impulse can be detected  either  by  the
hand or stethoscope ;  in others it is imperceptible
by the hand, and very perceptible  by the stetho-
scope ; and in some rare instances it appears on
the application of the hand to be very great, at
the same time that the instrument conveys  only a
slight impulse.   These varieties depend  on fixed
physical causes,  although they may not be readily
explicable  in every  case.   In lean  subjects  all
movements as well as sounds are more perceptible
from the greater susceptibility of the  chests of
such persons to vibrate, and their greater conduct
ing power.  In  nervous  flurry, the heart  acts
tumultously and not powerfully, producing rather 
258
AUSCULTATION.
a general commotion than  impulse;  hence  the  Impulse a bo ■disappears ^ w£e%*™ ™J
effect is more  distinct  to the  hand than to  the [  considerable hypertrophy upon ^ ^pervent on
              In  general,  the  impulse  consists  of great dyspnoea, as ,n pleurisy, pneumonia, the
stethoscope.
simply of the sensation of a slight blow or shock,
communicated to the spot on which the  hand  or
instrument rests, sometimes sufficiently strong  to
produce  a  perceptible elevation  of the  part,  at
other times only having  sufficient power to occa-
sion a sort of vibration without upward movement.
Sometimes the body that gives the shock appears
to be of large extent, sometimes quite small.  The
blows  are  sometimes quite distinct and abruptly
defined ; at other times  they  seem  to  run into
each other.   The causes of these differences are
also well known.  The brief, sharp impulse cor-
responds with  a sudden  abrupt  blow, unaccom-
panied by any heaving of the heart, and  indicates
an organ with thin parietes.   The prolonged im-
asthmatic paroxysm, and likewise in the congested
state of the lungs and heart which so generally
precedes death.
  In  all  these  cases perhaps, certainly  in  the
greater  number, the  disapearance  or diminution
of the  impulse depends on the natural actions of
the heart being impeded by the morbid accumula-
tion of blood in its cavities. Cases certainly occur,
also, in  which,  from  some unknown causes,  an
hyp'ertrophous heart does not give any  preterna-
tural impulse, as well as others in which an habi-
tually great impulse accompanies a  thin organ.
But these are merely exceptions—rare exceptions
__to a  general rule, which is unquestionably as
stated above.  The rationale of increased impulse
pulse,  with an  extensive heaving movement, is  from hypertrophy of the heart is sufficiently clear,
the sign of thick walls, whether  natural or from  In the first  place, tbe organ is larger, and its ac-
disease.  In all cases the degree of impulse varies ' tions will necessarily bring it more closely in con
greatly  according  to  the state  of repose  of the
patient.  Every kind  of bodily exercise or mental
excitement;  in other words, every thing which
stimulates  the muscular action of the heart, or
hurries  the circulation, augments the  impulse.
When  causes of this kind act powerfully, they
produce what may be  considered as a factitious
or temporary palpitation ; and in  such cases the
impulse of a healthy heart is sometimes very great,
being sufficient to elevate the ear as by a sudden
blow.   It is for this reason an invariable rule to
depend only on such  stethoscopic explorations of
the heart as are made during a state of quietude
both of body and mind.  In this state, in healthy
individuals having hearts  well  proportioned, the
impulse is in general  not very perceptible, and in
a considerable proportion of cases it is quite im-
perceptible.   When  the respiration is frequent
and  laborious, we must b,e careful not to mistake
the rise of the thoracic parietes, during inspiration,
for the  impulse of the heart.
   It may be stated as a general  rule, that, cxteris
paribus, the degree of impulse is in proportion to
the thickness of the  walls of the ventricles, the
impulse being greater, the  thicker the walls.  If,
then, we find  a degree of impulse beyond the or-
dinary  standard, habitually  present even during
repose,  we may be almost certain that there  exists
hypertrophy of one or both ventricles, more parti-
cularly  if the  pulse  continues  of moderate fre-
quency.  Increased impulse, as already stated, is
a constant result of increased action of the  heart,
without any addition to  its muscular substance.
But  in  sucb cases the pulse (that is, the contrac-
tion  of the heart) is always preternaturally fre-
quent.   Preternatural intensity of impulse with
natural frequency of action—or  with very slightly
increased frequency—can hardly arise but from
hypertrophy of the heart.
   Many causes, particularly those of a depressing
kind, greatly diminish the degree of impulse, and
sometimes entirely destroy  it,  when previously
existing in a preternatural degree.  Of this kind
are bloodletting, diarrhoea, whether natural or arti-
ficial, great abstinence, &c.; in  such and similar
states  of the  system, we must, therefore, be cau-
tious in pronouncing  against the existence of hy-
pertrophy  merely from the absence of impulse.
tact with  the  chest;  secondly,  having a greater
number of contractile fibres, its contractions must
be more energetic; and, thirdly, the very condi-
tion  of a hypertrophied  muscle almost involves
the fact of augmented irritability and activity.
   It  is well  remarked by Andral, that, even if we
were  unable to account  for the anomalies now
referred  to,  both  of  increased  and  diminished
impulse, we have no reason to doubt the truth of
the general proposition.   It is not to be wondered
at, if, in a machine so complicated, and subject to
such diversity of influences, as  the human  body,
we should meet with anomalies beyond our powet
of apprehension.  So long as they  continue to be
exceptions only, and do not militate against prin-
ciples, medicine need have no fear to acknowledge
their existence.
   3. The impulse, in health, is  in general felt
only  in the immediate region of the heart, that is,
in the  space  occupied by  the  cartilages  of the
fourth,  fifth, sixth, and seventh ribs, or, at most,
over the lower half of the sternum.   When this
bone is very short, it  is sometimes perceptible by
the  hand  in  the  epigastric  region.  Generally
speaking, the sphere of impulse is proportioned to
the size of the heart, a small heart being felt over
a small space, a large  one over a large space. It
is in some degree  also proportioned to the degree
of action of the organ, a heart that pulsates quietly
having  a less  extensive  sphere of impulse thar.
one that is excited to quick and vehement action
When  the  heart is increased in  mere musculai
thickness without proportioned enlargement of itt
cavities, the sphere of impulse is scarcely extended
beyond the  space already mentioned ; but in hy-
pertrophy combined with dilatation, it is extended
much beyond  this, being sometimes  felt very dis-
tinctly under the clavicles, on the right side of the
sternum, and occasionally even on the back.  The
impulse may  be  extended   beyond  its natural
sphere  by displacement  of the heart; although,
perhaps, in this case  it would be more correct to
say that the impulse is altered in its situation than
that  it  is extended  beyond  its natural  sphere.
Such alteration of the position  of  the  heart may
be either congenital, or the result of disease.  (See
Heart, Displacemen-t of the.)  In  this last
case, the causes of the displacement are generally 
AUSCULTATION.
259
of such a kind  as  are calculated to extend  the
sphere of sound also on other principles, namely,
from  disease of other  organs.   In  the state  of
health, the heart is  surrounded by parts very ill
calculated to convey impulse, on account of their
soft and yielding nature.   But if  the qualities
which render the parts unsuited for the trans-
mission of impulse have others of a different kind
substituted in their place,  the  extension of  the
impulse will  be  altered with the change in their
conducting powers.  Every  disease which renders
the parts adjacent to the heart more solid or more
coherent, will therefore  augment the  sphere  of
impulse.  Of this  kind are hepatization  of  the
lungs  from  acute or chronic pneumonia; com-
pression of the same parts  by pleuritic and other
effusions, or  by tumours exterior to  them ;  the
growth of foreign bodies within the pulmonary
substance, particularly of  a  solid  kind.  If, in
addition, the  lungs  are closely united to the walls
of the  chest, the  conduction will be  still more
complete.  Adhesion of the pericardium  to  the
heart occasions an extension of impulse otherwise
than  by simple  conduction.  In this case every
movement of the heart sets  in motion all the parts
to which the pericardium  is naturally attached ;
and if these and the adjacent parts should chance
to be condensed by  any of  the  causes  just men-
tioned, the impulse  may be then very widely ex-
tended.  An opposite condition of the pericardium
gives rise to somewhat similar results.  When this
sac is greatly distended with fluid,  as  in chronic
pericarditis, the heart floating loose,  as it were, in
its tumultuous movements, sometimes  carries its
impulse to a greater distance  beyond the  cardiac
region.  Sometimes the impulse is even conveyed
beyond the limits of the chest, as in the case of
an enlarged  liver encroaching on the thorax,  and
coming  nearly in contact with the heart.  (Med.
& Phys. Journ. vol. xlix. p. 385.)
   The cause of the  impulse communicated to  the
walls of the chest by tbe action of the heart,  was
formerly and for a long time considered to be  the
reaction of the column of blood thrown into  the
curved aorta, tilting  the loose  apex of the heart
forwards.  This explanation  has, however, been
of late questioned ;  and it seems,  indeed, quite
inadequate to explain the fact.   There seems little
reason to doubt  that the impulse is occasioned by
the muscular action  of the heart itself, although
there may be various opinions as to  the particular
movements which produce it.   All that is import-
ant in a practical  point of view are  the  various
relations which  this  phenomenon  bears to   the
pathological  Condition of  the  heart  and other
organs within the chest.
   II. Sounds of the heart.—These may be con-
sidered under two heads—-first, the natural sounds;
second, the adventitious sounds.
   A. Natural sounds.—These  may be considered
according to—I. their individual character;  2.
their  relation to the  impulse and  to one another;
in other words, their rhythm ; and, 3. their sphere
or the extent of chest over which they are percep-
tible.
   1 and 2. The general characters of the sounds
of  the  heart  and also  their rhythm have been
already given.   We  shall  only here observe that
there  is great variety in individuals  in respect of
these characters.   In some the sounds  are very
loud and distinct; in others they are the reverse
They also vary in their tone  or key, being some-
times grave or dull, and  sometimes  clear.  The
cause of these differences will presently be  ex-
plained.  Unlike the impulse, the sounds produced
by the action  of the heart are almost always, if
not always, perceptible in the cardiac region in
the state of health.  They are generally very dis-
tinct  as  heard by  the  naked  ear;  but they are
commonly  perceived more accurately by means of
the stethoscope.  It is found that tbe intensity of
impulse and sound depends on opposite conditions
of the heart,  and therefore they are  never, in a
state of health, present together in a great degree.
The impulse,  as we have already shown, is great
in proportion as the walls of the ventricles  are
thick ; the sound  is greater in proportion as they
are thinner.   The sounds of the left cavities of
the heart are chiefly perceptible near the junction
of the cartilages of the fourth, fifth, sixth,  and
seventh  ribs ; those of the right, more under the
sternum.
   3.  In the state of health we find the impulse to
be strictly confined to the region of the heart, or
to its immediate vicinity.  The sound, however, is
much more erratic, being frequently perceived  at a
great distance.   In certain persons, indeed,  the
sound seems  as  strictly circumscribed as the  im-
pulse, appearing  confined  almost  to the point on
which the. stothescope rests.  Such cases  are,
however, rare; and it is usual, even in the healthi-
est individuals, to perceive the sounds over a  cer-
tain proportion of the exterior aspect of the chest
at least; as, for  instance, the lower third  of the
sternum, or a little to the right of this, and mid-
way between the nipple and left clavicle.  There
are many circumstances, still within the range of
perfect health, which considerably  augment  the
sphere of the heart's sounds.  The range of sound
is more  extensive in infancy and childhood than
in adult  life.   It seems, also, to bear a pretty accu-
rate relation to the size of the thoracic cavity, the
range being  much greater, cxteris paribus, when
this is small than when it is large.  Hence in  per-
sons  with very  narrow  or  contracted  chests,
whether natural,  or  from the effects of disease,
constrained posture, or improper modes of dress,
the range of sound may be heard over the  greater
part of the chest, both before  and behind, and cer-
tainly if the heart \s naturally thin, or when the
circulation is hurried by the least agitation.   In
women,  even  when  well formed, the range of
sound is  greater than  in the other sex ; it is,
therefore, in  general very considerably greater in
them, since the  natural dimensions  of the chest
are  diminished almost universally  by the com-
pression of stays.  The thickness of the parietes
of the chest has also a considerable effect in modi-
fying  the  range of sound ; this being very con-
siderably increased by emaciation  or  leanness,
whether natural or  from disease.  Perhaps  the
augmented range of sound in children and female.)
is partly owing to the cavities of the heart being
proportionally larger, and its walls proportionally
thinner,  than  in adult males : in both the forme
classes of persons, the muscular system, as is well
known, is  l.ss developed than in the latter.   In
all these cases the sound  is frequently heard nve> 
260
AUSCULTATION.
the whole chest.   It is highly necessary, therefore,
before drawing any conclusions from the range of
sound  in individual cases, to ascertain the exact
structure and conformation of the chest, as well as
to procure a state of perfect quietude.   We think
it  necessary to insist the more  upon this  point,
because we believe it  is one on which frequent
mistakes are committed in practice; and as one or
other of the various causes of augmented range is
of such constant occurrence, we would say  that
this  is one of the indications which should be
most distrusted  by the young auscultator.  The
negative indications derived from a preternaturally
confined range  of sound, are much  more trust-
worthy ; since the  number of accidental circum-
stances which can temporarily diminish the range
in the case of persons in whom it is habitually
great, is much smaller.
   It is an important practical precept  in studying
the indications supplied by the range of sound, to
take into consideration the frequency of the pulse.
As every cause which augments the action of the
heart augments also the range of sound, we shall
be naturally much more distrustful of an extensive
range in cases where the pulse is quick than where
it is  slow, inasmuch as quickness of pulse is a very
common effect  of  mere temporary  causes,  and
slowness a very rare one.  An extensive range of
sound  with a quick pulse may be frequently ne-
glected, as  far as  relates to  the diagnosis of the
cardiac affection ; an  extensive range of sound
with a slow pulse  always demands investigation,
and  will frequently be found  to indicate disease.
   Exclusively of their influence in hurrying the
circulation, and thereby producing a louder sound,
many diseases of the chest augment the range not
only of  impulse, as already stated,  but  also of
sound,  merely  by  conducting  more widely the
natural sound.  All diseases  will have this effect,
which render the organs more solid.   Every form,
therefore, of inflammation of the lungs will have
more or less this effect, which will be the  greater,
the  nearer the  affection approaches  to complete
hepatization.  Compression of the lung from pleu-
ritic effusion will act in the same manner; and in
this case, as in  the preceding,  the points on the
surface of  the chest on which the sounds will be
most audible, will  depend on the  position of the
indurated or compressed portions within.  All solid
depositions in the pulmonary substance will  have
a similar effect,  proportioned, generally speaking,
to the  sum  of  their mass.  The most common
form under this head is phthisis ; and if  one had
previously  ascertained in health the range of sound,
some idea might be formed of the amount of tuber-
cular deposition from  the range in the state of
disease.  Even  when  the tubercles  have suppu-
rated,  and have left large empty cavities in the
lungs, the  transmission of sound continues to be
greatly facilitated,—the solidity  of the walls of the
excavations, and the compressed state of  the sur-
rounding pulmonary substance, more than com-
pensating  the actual loss of substance from the
disease. It is thus, as Laennec observes, that in
the  case of tuberculous excavations  of the  right
lung, we hear the sound better under the  right
clavicle and in the axilla, than 01. the left side, and
sometimes even better than  in  the region of the
heart itself.
  The sounds  of the heart are always in some
degree masked  by the respiratory  sounds, and in
proportion to the loudness of these.   In the cases
of disease in which there is a very loud rhonchus,
the sounds are completely obscured on the anterior
part of the chest;  it  becomes therefore proper, in
such cases, in order to perceive the precise nature
and extent of the sounds, to observe  them  in the
intervals between inspiration and expiration ;  and
these  may be prolonged designedly by the patient,
if it is found necessary.
  In  extending itself  from  the  cardiac  region
over the rest of the chest,  the sound of the heart
almost always  follows a fixed tract, being  heard
successively, according  to Laennec, in  the fol-
lowing places—the left side of the chest before;
the right side  before;  the left  side  behind; the
right  side behind.   " In these cases," says Laen-
nec,  " the intensity  is progressively less in the
succession  mentioned.  For  instance, it  is  less
under the right clavicle than under  the left; it is
somewhat less on the  lateral  parts of the left
side than under the  clavicle; it is  still less per-
ceptible  on the right side laterally;  and  much
attention is  commonly requisite to  enable us to
hear  the pulsations  at all in the back; particu-
larly  the  right side.  This  succession has ap-
peared to  be almost  constant, and may be taken
as  an index of the extent of pulsation.  For in-
stance, if this  be  perceptible on the  right side,
we may be assured that it will be  equally so
over  the whole sternum, under  both clavicles,
and over the left side;  but we are not sure that
it will be so on the back.   But if it be percepti-
ble on the back on the right side, we may calcu-
late on its being still more audible on every other
part of the chest."   As this  is the  succession of
health,— and  almost invariably,— it  is  obvious
that any deviation from it, at least  any great de-
viation  from it, may be considered  as produced
by disease, and may  thus  become a sign of some
importance.  For instance, if the sound is much
more audible on the  right back than on the left
back, or even on the left side, we have great rea-
son for  believing disease to be the cause of this
anomaly ; and the circumstance may tend mate-
rially to elucidate the diagnosis in doubtful cases.
If  tbe  heart retains its natural position,  some
change  must  have occurred in the contents of
the right  side of the chest, to occasion this in-
creased  power of conducting sound.
   When the sounds of the heart  are heard much
beyond  the  usual  sphere  of health, in cases.in
which the chest seems pretty well formed, and in
which  none of the  causes producing an exten-
 sive range can be detected, the individual  rarely
 enjoys good health.  Although he may not have
 any other of tbe more ordinary  signs of disease
 of the heart, it will  be found  that  bis system is
 a feeble one, and obnoxious to many morbid im-
pressions.  " In examining him attentively," says
 Laennec,  " we shall discover indications of that
 cachexy peculiar  to  some diseases  of the  heart;
 and we shall find that, if he has not formal dys-
pnoea,  his respiration is, at least,  shorter than
 usual; that he is  more easily  put out of breath,
 and  more subject  to palpitation.   This state, he
 adds, which is that of many asthmatics, may re-
 main stationary many years, and  does not always 
AUSCULTATION.
261
prevent  the  attainment of  an advanced age."
Our own experience  would  lead us  to  consider
such a state of heart, which is generally conge-
nital, if  not  the cause  of many  other morbid
states of common occurrence,  as, at  least, a cir-
cumstance greatly predisposing to  them,  and
aggravating  others   originating from  different
causes.  It tends powerfully to the production
of venous plethora  and its  numerous  train of
evils;  it  leads directly to a defective  distribution
of blood in the extremities  and on  the surface,
and to a superfluous store in the head and larger
viscera;  it is a very common  cause of head-aches,
particularly such as are commonly termed nervous,
and eventually leads to  apoplexy  and  palsy.
Such persons have almost always cold extremi-
ties.  We are even of opinion that that complex
disease,  scrofula, if not occasioned, is  at least
frequently hastened in  its development, and  is
filways aggravated, by  the  concomitance  of a
feeble heart.
   B. Adventitious sounds.—Besides mere changes
in the degree, extent, and  relative  succession of
the  sounds, their very character may be altered;
new sounds  may be superadded to  the old, or
may entirely take the place of  these.   The most
common  and most important of these changes is
the conversion  of the usual  sound into one re-
sembling  the puff of a  pair of bellows, or the
rough, grating  sound produced by tbe action of
a file, rasp, or saw upon  wood.   The  bellows-
sound, termed by Laennec  bruit de soufflet, most
accurately resembles the puffing of a small  pair
of bellows, as employed  to blow the fire.   The
new sound usually takes the place of the natural
one; sometimes the two are conjoined; it may
be present during the first and  second sound, or
only during one  of these.   The saw-sound, or
rasp-sound, bruit de scie, bruit  de rape, of Laen-
nec, is as happily named as the former variety,
as nothing can be more precise, in many cases
at least, than the resemblance between the sounds
of the heart and those to  which they are com-
pared. The  notion  of  smoothness is  always
conveyed by the bellows-sound, and that of rough-
ness by the saw-sound.  Yet  they gradually pass
into each other, from the slightest deviation from
smoothness in the bellows-puff through all the
intermediate gradations  of roughness produced
by a very fine-toothed saw,  a  wood-rasp, up to
the harsbest notes of a  large-toothed saw.  In
many  instances these anormal  sounds of  the
heart imitate,  with  singular accuracy,  both in
their individual qualities  and in the regularity of
their recurrence, the sounds  produced by a  car-
penter sawing through a small piece  of  wood at
a short distance from  tbe hearer.  The loudness
of these sounds is frequently very great, as heard
with the  stethoscope, being sufficient almost to
startle one on first applying the ear  to the instru-
ment.  Like  the bellows-sound, that  just  de-
scribed may occupy the place either  of  the  first
or second sound ; but it  accompanies the former
much  more  frequently  than  the  latter.  The
sound of  the saw or rasp is  often  heard  at  a
great distance from its site, like the natural sounds
of the heart;  the bellows-sound is  for the most
part  confined  to  the place where  it originates.
Both of them, however, are  occasionally perceived
in the arteries, at some distance from the heart.
The bellows-sound, in particular, is frequently ob-
served at a considerable distance from the heart,
and  even when no  such  anormal sound can be
detected in that organ.   When the saw-sound
exists in the heart, it may always be traced along
the arch of the aorta to the carotids and subclavian
arteries.   Laennec has noticed a singular variety
of the  bellows-sound, in  which  the successive
tones are modulated into regular musical notes.
He therefore terms it the musical bellows-sound.
   The causes of these morbid sounds have been
investigated with  much care by Laennec and his
followers.  At first  Laennec  considered them as
exclusively the result of contraction of the valvular
orifices  from organic disease.  Subsequent expe-
rience,  however, led him  to  conclude  that they
may exist without any discoverable change in the
orifices  or valves, wbile such change may exist
without  their concomitance; and he  at length
adopted  the  opinion that  all the varieties  were
owing to a spasmodic contraction of the parts in
which they originated.   As a general  statement
of the fact, this opinion  is certainly erroneous
Indeed it now seems fully established that the im-
mediate  causes  of all these  sounds  are certain
anormal motions or currents produced in the co-
lumn of blood, whereby this, which usually glides
on smoothly and  silently,  is thrown into  sonorous
vibration.  Whatever produces the movements in
question may produce the sounds; and one of the
causes may  certainly be that which Laennec sup-
posed.  A much  more frequent cause, however,
is permanent alteration in the  caliber of the canals
through which the blood passes, by some organic
change effected in them; and by much  the most
common cause is contraction of some of the ori-
fices of  the heart.
  The  bellows-sound  appears  to originate  in
much slighter causes than  the sound of the rasp
or saw,  and is, therefore, of less value as a sign
of disease.   Laennec ascertained that pressure on
an artery will reproduce the bellows-sound  after
it had ceased; and it is now known that the same
pressure  will frequently produce it in an artery
where it had  not before existed.  It is very con-
stantly present in  cases of bronchocele  of consi-
derable size, and gradually disappears as the turnout
is absorbed  under the  use  of iodine.  It is also
present in the arteries of the impregnated uterus.
It is frequently  removed,  when strongly marked
in the heart, by  venesection.  It  cannot, there-
fore, be admitted  as  a sign of organic disease, al-
though it is by no means to be disregarded among
the symptoms of diseases of tbe heart, more espe-
cially if it is permanently present.
  The sound of the saw or rasp is of less  frequent
occurrence than  the simple bellows-sound; al-
though there is  no  reason  to believe that their
causes differ otherwise than in degree.   Slightei
causes suffice to  produce the bellows-sound.  The
sound of the saw or rasp is occasionally perceiveu
in the carotid and subclavian arteries;  it is also
observed in  the  arteries of  the  enlarged thyroid
gland, and in those of the impregnated uterus.
It is, however, most constantly observed in the
heart, in the  case of  a  contracted state'of tne
orifices.
  In reference to  these adventitious  sounds, co' 
262
AUSCULTATION.
lectively and individually, we think the following
conclusions  may be deduced  from the considera-
tion of them:—
   1. The source of the  sounds is  some impedi-
ment to the  usual current of the blood, from some
physical alteration in the channel through which
it  passes, whereby such vibrations are excited in
the column of  fluid  as to give rise  to  audible
sound.
   2. The alteration in the  channel  may be mere-
ly temporary, and  produced in parts possessing a
healthy structure, from nervous causes, from want
of the natural harmony of  proportion  between
the size of the channel and its contents, and pro-
bably from  other  unknown  causes.   The  more
common cause, however, is  some fixed  physical
alterations in  the channels conveying  the blood ;
either a contraction or enlargement of caliber, or
some other deviation  from  the natural structure,
whereby the current is  more  or  less  impeded or
disturbed.
   3. We  are not justified, by the mere  presence
of any of these sounds, in concluding that organic
disease of the valves or valvular orifices exists.
   4. If the  morbid sounds disappear after repose,
bloodletting, or other  form of depletion, or  with-
out any evident cause, we may suspect that  they
originate in  mere functional disorder;  and  the
probability of this opinion will  be increased in
proportion to the period of  their absence.
   5. If they are not removed by  tbese  or any
other causes, or if they are  removed  for a  very
short period only, or are merely lessened  in de-
gree, we may conclude that they originate in dis-
ease of  the valvular orifices;  and this  conclusion
will  be still further strengthened  if  there exist
other symptoms of diseased heart.
   6. The probability  of organic disease  is  in-
creased  in  proportion  as  the  character of  the
sounds  approaches that of the sound of the saw
or rasp.
   7. The sounds  produced  by valvular  disease
become much weaker when the contraction of the
orifice  is extreme  than  when it is moderate, a
certain  extent and force of current being requi-
site to produce them in the highest degree.  Dr.
Hope says that he has often found  that when the
orifice was reduced to a crevice of two or three
lines in width, no sound whatever was produced.
   8. The following  is  a brief sketch of the ra-
tionale of the morbid or anormal sounds resulting
from valvular  disease, for which we are indebted
to the able physician just named.
   (a.)  When the aortic orifice  is contracted, an
adventitious sound, or morbid murmur, accompa-
nies the ventricular systole and  first sound; and
tvhen the valves, not closing accurately, permit
regurgitation from the aorta, a morbid  murmur
accompanies the diastole and second sound  also ;
but this last, when it occurs, is extremely slight
and brief, as the influx of blood from the auricle,
during the diastole, almost  instantly puts an end
to any regurgitation capable of producing sound.
   (b )  When the pulmonic  orifice is  contracted,
the effects are the same ; but  disease of the valves
jn this side  of the heart, as will be  shown in an-
other place,  is comparatively very rare.
   (c.)  Wnen the mitral orifice  is contracted, a
morbid murmur  accompanies  and sometimes en-
I tirelv supersedes  the  second sound,  being occa-
! stoned by the passage of the blood from the auri-
 cle into  the ventricle  during the diastole of the
 latter.   When  the valve, not closing accurately,
 admits  of regurgitation, a murmur accompanies
 the first sound, and this is sometimes excited by
 a degree of disease insufficient to produce  it dur-
 ing the  second.
   (d.)  When the tricuspid orifice is contracted,
 the results are the same as in the last case.
   There is yet an adventitious sound, of  a differ-
 ent kind, and  originating  in  a totally different
 cause, which deserves to be noticed.   This is  the
 sound which Laennec compared to  the  creaking
 of the leather  of a new  saddle, and which he
 termed cri du cuir.'  At  first he conceived this
 sound to be connected with pericarditis ;  but he
 afterwards gave up this opinion, and considered it
 as owing to accidental circumstances not of a mor-
 bid kind.  Other observers,  however, have been
 led to adopt Laennec's  first opinion ; and  several
 cases have been  published which  render it ex-
 tremely probable  that this peculiar sound  is pro-
 duced by the friction of the heart against the peri-
 cardium, when one or both have lost their polish
 from the effusion of solid lymph with little or no
 serum.  If this opinion be correct, the sound ought
 to present itself in most  cases  of pericarditis at
 some period of their course ;  and it should always
 be present when there is considerable albuminous
 exhalation with little or no serum.*   This sound,
 both in  its character, causes, and its value as a
 sign, is  precisely  analogous to the bruit de frotte-
 ment, noticed in a former part of this article.
   The  sounds  of the rasp or saw  are very fre-
 quently  accompanied  by a  phenomenon  which,
 like  that of impulse,  can only be brought undei
 the head of auscultation on a principle of conve-
 nience,  since, like impulse, it is appreciable by the
 sense of touch, not of hearing.   This is the phe-
 nomenon termed by  Corvisart  bruissement, and
 by Laennec frimissement  cataire,  terms which
 it is not easy to render in English, nor yet to find
 good substitutes for.  It is a  peculiar vibration or
 thrill communicated to the finger laid upon the
 heart or artery where  it exists, and which  resem-
 bles pretty accurately  the gentle tremor communi-
 cated to the hand of a person while  stroking the
 head of a cat when purring.
   When existing in the region of the heart, "the
 thrill" is identical with the sound of tbe saw, rasp,
 or bellows :  the difference being in the sense which
 perceives, not in the thing perceived.  If we could
 always say, from  the character of the thrill, with
 which of the two sounds of the heart it is identi-
 cal, it would be more  valuable as a sign than it is.
 It is  proper to observe that we do not always hear
 any of the sounds when we feel the vibration;
 nor, conversely, do we  always feel the vibration
 when we hear the sound.   This, however, is not
 any proof that both do not spring from the same
 physical cause.  The cause may exist in a degree
 sufficient to excite one sensation and not the other;
 tyst as we may feel or see the vibration of a mu-
 sical  string after the ear has  ceased  to hear any
 sound from it.  It is, therefore, ws conceive, with-
   * Colin. Exploration de la FoiCrin»__Theses de la Fa-
 culte  de  ."Med. No. 175. - De l'Au=cult. M6d. 3eme edit.
 torn. ni. pp. 60, 262.  notes. 
AUSCULTATION.
263
out  good grounds, that  Laennec considered  the
separate existence of these phenomena as proofs
of their non-identity.  (See Dr. Corrigan's Expe-
riments in the  Lancet.)  Dr. Hope  says tbat,
although resulting from  the  same causes as  the
morbid sounds, the purring  tremor or  thrill re-
quires, easterns paribus, a stronger current for its
production ;  for which reason it less frequently
accompanies  the passage of the  blood  from  the
auricles into  the ventricles, than  from the latter
into their  respective  arteries, or into the auricles
by  a retrograde  movement.  Even in the latter
cases, Dr. Hope adds, it is seldom strong unless
the ventricle  be hypertrophous, or the circulation
hurried. Laennec says the thrill is almost always
confined to the left side of the heart;  although it
is occasionally extended  much beyond this.  The
 hand must be pressed very firmly upon the heart,
in  order to feel  it well.   When  existing in the
 arteries, a middling degree of pressure enables us
 to  perceive it best; a  very  slight one  does not
 attain it, a strong one abolishes  it.   It  is some-
 times continuous, sometimes renewed  by  the arte-
 rial pulse ;  sometimes it is  confined  within the
 caliber of the artery,  sometimes it  is  perceived
 considerably beyond.   In no case have we  had
 occasion to observe the thrill more constantly and
 distinctly than in the thyroid arteries  in  cases of
 large bronchocele.
    Auscultation of tile Heart in the Foetus.
     Diagnosis of Pregnancy*
    M. Mayer, of Geneva, appears to have been the
  first who applied the tests afforded by  auscultation
 to discover  the  existence of  the foetus  in utero.
 In the Bibliotheque  Universelle  for November,
  1818, it was stated that this gentleman had ascer-
 tained that the sounds of the foetal heart are read-
 ily perceptible by applying the ear to the  abdomen
  of the mother.  Tbe subject was afterwards  pro-
  secuted, with the aid  of the stethoscope, by M.
  Kergaradec, and with additional results  indicative
  of its importance; and the following facts, verified
  by numerous auscultators in  this country and on
  the continent, are now as well ascertained as any
  detailed in former parts  of this article.
    There  are two auscultatory signs  of the  pre-
  sence of  a living foetus in the womb—1. the dou-
  ble sound of the heart; and, 2. the  existence  of
  the bellows-sound in the placental arteries, or ra-
  ther, in the uterine arteries immediately connected
  with the  placenta.
    1.  The pulsations of the  foetal heart may  be
  perceived as early as the fifth month, or between
  that and  the sixth.  They are characterised by the
  double sound of the adult heart, and  by  the pecu-
  liar rhythm  of this, which can never be mistaken
  for any other sound.  The sounds, when compared
  with  those  of the adult heart,  examined  in the
  cardiac region, are extremely feeble ;  but they are,
  when at  all perceptible, perfectly distinct.  They
  are distinguished from all arterial pulsation of the
  mother by the duplex rhythm, and by the extreme
  frequency of their recurrence.   The  foetal pulsa-
  tions are generally more than double that of the
  mother.  The sounds are found to be much more
  distinct at one time than another, in  the  same
  place, and  in different  places  at different  times.
  These variations no doubt result from the varying
position of the foetus, and from its relation to the
uterine parietes.
  The sounds will be  much more  distinct  when
the trunk of the foetus is in direct  contact  with
the uterus, and,  most of all, when the  anterior
part of its chest is applied opposite to the spot on
which the stethoscope rests.  When  the  whole
body  of the child is  removed from that side of the
uterus over which the instrument iests, it is doubt-
ful if the action of the heart can be at all perceiv-
ed.   The more copious is the liquor  amnii, the
less perceptible, cxteris paribus, will be the foetal
sounds.   The space over which  the sounds  may
be  heard is generally pretty extensive, being, in-
deed, frequently the greater portion  of the  region
occupied by the uterus.   It  is, however, in  gene-
ral, easy to discover the  point which is nearest  to
the source of the sounds, by the decreasing and
increasing intensity  of these, as our examinations
recede from  or approach  towards one particular
spot.  In general, the pulsations of the foetal heart
vary  from 120 to 1G0 in a minute.  In one case
noticed by Dr. Ferguson,  (Dublin  Trans,  vol. i.
New Series,)  the relative frequency of the mo-
ther's and child's pulse was singularly reversed;
the former being 100, while the  latter was  only
20.  We have met with no similar instance on
record.
    2. The second auscultatory sign of the presence
of the foetus has been termed the placental sound
or placental bellows-sound, likewise the uteropla-
cental soufllej.   It was first noticed by M. Kerga-
radec, and although a less absolutely certain indi-
 cation of pregnancy than the  sound of the  foetal
heart, it is a sign of great importance.   Although
 termed placental, there can be little doubt that the
 site of  the sound is in the  uterus, in the enlarged
 arteries which supply the placenta.*  The  sound
 assumes, at different times, all the character of the
 bellows-sound of the  heart.   It becomes  percepti-
 ble about the fourth  month of gestation,  and is
 then more distinct  than at a  later period.  Dr.
 Ferguson says that he has not observed  any vari-
 ety  of the sounds  to -be peculiar to  particular
 stages of pregnancy.   In the early stages, Laen-
 nec describes the sound as resembling  that  which
 is  produced by  discharging a blast from  a  pair of
 bellows into an empty bottle.   At  a later  period,
 the sound is duller, more diffused, and no longer
 conveying the impression of being  limited to the
 caliber of a single artery.  It assumes all the vari-
 eties of the valvular sounds of the  heart, from the
 simple bellows-sound to the sound  of the  rasp or
 saw.  Dr. Ferguson says that  the  most constant
 variety  "is  a combination of the bellows or tho
 sawing with  the hissing sound, commencing with
 one  of the former, and  terminating with  the lat-
 ter." These sounds are confined to a much smallei
 space than those of the foetal heart.   The  point
 where  they are most  audible is always fixed in the
 same person, but varies  in each individual.  In
 some, the sound can only he detected in a  single
 spot a few inches square.  There is no particular
 part of the  uterine  tumour in which the  sound

    * A striking analogical instance is afforded by the thy
 roid  arteries in bronchocele, noticed in  a former part o'
 this  article.  Query, will the same result be obtained .•■
 active hypertrophies of other parts of the system ? 
264
AUSCULTATIO
\ — BARBIE R S.
may not he found ;  but Dr. Ferguson  says  that
he has found it most frequently in the iliac regions.
The placental  sound is  always isochronous with
the pulse of the mother, and is unaccompanied by
any degree of  impulse.
   Whatever be  the  precise mode  of production
of this sound, there can be no doubt that  it has
its seat in the enlarged vessels  of  the  uterus in
that portion of it immediately connected wtth the
placenta.  This is proved by the following facts :
1. The sound, as already stated, is'confined  to a
fixed space  in each  individual.   2. This spot is
ascertained, by examination  after delivery, to be
always that to which the placenta  had been at-
tached.  3.  That the sound is not seated, at  least
exclusively, in the placenta is proved by the fact
that the sound is still audible for a short period
after the placenta is detached.  4.  It ceases im-
mediately upon the contraction  of  the  utero-pla-
cental arteries, as is  proved in cases  of death of
the foetus without delivery, and by its instantane-
ous cessation on the contraction  of the uterus after
delivery.  5.  It is in all cases synchronous  with
the  mother's  pulse   There  seems little ground
for believing, with Dr. Kennedy, (Dublin Trans.)
that the placental arteries themselves have  a share
in the production of the sound,  any farther  than
by their action promoting that of the uterine  arte-
ries.   The character of the sound is  changed by
the cessation  of the  foetal circulation,  as  by the
removal of the placenta, the  death of the foetus,
or tying  of the  cord,  (Dr. Kennedy denies M.
Ollivry's  statement that it is immediately extin-
guished,) the  sound becoming " abrupt, of sbort
continuance, and wanting the lengthened termi-
nating whiz observed in the perfect  sound." This
may easily be explained  by the change necessa-
rily  produced  in the uterine circulation  by the
removal of the foetal circulation, without  suppos-
ing that the placental arteries had any direct sbare
in its production.
   Great care  and attention are  requisite  on the
part of the auscultator in  investigating these  phe-
nomena.  The sounds  being very feeble,  perfect
silence is necessary during our  explorations, and
we must be  very  careful not  to  confound the
sounds with others which may exist  at the same
time, such  as the sound of  the  mother's heart
(which is often distinctly audible in the region of
the uterus), of the intestinal  movements, and the
sound of  muscular contraction produced in com-
pressing the abdomen with  the  stethoscope.   As
the phenomena are sometimes intermittent, or, at
least, not always perceptible, we must  not deny
their existence because they are  not discovered on
the first examination.
   The sounds may be  heard almost as well bv
the naked ear as tbe stethoscope ;  but to all  who
are accustomed to use this instrument, there are
numerous and very obvious reasons why it  should
be preferred.  It is, however, well that practition-
ers should be  aware that  the phenomena  may be
detected  by any one, whether a  practised  auscul-
tator or not.
   Different practitioners make the  patients adopt
different positions during exploration.  In many
cases the sounds are heard very distinctly while
the patient  is seated in a chair in her ordinary
dress ; but it is always preferable, when it  can be
done, for the patient to assume the horizontal pos-
ture, and  remove her  stays and thick petticoats,
The presence  of the  solid stays is particularly
objectionable, as they are apt to convey the sounds
of the mother's heart from the chest downwards.
   No one who is aware of the frequent and great
difficulties experienced by practitioners in detecting
pregnancy, and of the vast importance of doing so
in some cases, will have any doubt of the great
value of the  signs  now described.   They are al-
most as  certain  as the perception  of the  foetal
movements, and more certain than the touch; and
they possess  a very great superiority, in  point of
convenience  and delicacy, over the  latter.   It is
true, they have  not been detected  in some cases
of pregnancy ; it is probable that, owing  to some
peculiar idiosyncracy, they may  never  manifest
themselves in certain cases; but ample experience
proves  that their absence is  a circumstance of
extreme rarity.   Their absence, therefore,  must
not be considered as  an absolute test of the non-
existence of pregnancy; although  their presence
may be looked upon as the reverse.  Here, as in
every other case in  which  auscultation is  applied,
we have all the other signs to guide our judgment
in the  instances where the foetal  and  placental
sounds are not detected ; while in the vast major-
ity of cases, we have an additional sign, of almost
infallible  accuracy.   It cannot, therefore, be de-
nied that this form  of physical diagnosis has con-
ferred even on  puerperal medicine  a boon of im-
mense value.
   [Subsequent  auscultators have  not confirmed
the value of the utero-placental murmur.  Ute-
rine and  other tumours than the gravid uterus
have unquestionably  produced it.   (See the Art,
Pregnancy ;  also, Bouillaud  Traite  Clinique
des Maladies du Cosur, Paris, 1835; Hope on the
Diseases of the Heart, Amer: edit, by Pennock. Phi-
lad. 1842, p. 153; Raciborski, Manual of Ausculta-
tion, by Fitzherbert, p. 145, Lond. 1835.)  In a
case of fibrous tumour of the  uterus, the writer
heard it distinctly, (Dunglison's Human Physio-
logy, 5th edit., ii. 423) ; and Prof. R. M.  Huston
(Amer  edit, of Churchill's Theory and Practice
of Midwifery, p. 136) states, that he is satisfied
he heard it in a similar case, and, also, in one in-
stance  from  the presence  of an enlarged ovary.
The murmur is produced  by the pressure of the
tumour on the large vessels of the mother.]
   This article has extended to so great  a length
as to prevent us from offering  some general re-
marks  on the  actual  and comparative value of
auscultation as a diagnostic measure. We may
probably have another opportunity of doing so.
                              John Forbes.
   BARBIERS.  This is  a variety  of paralysis,
chiefly prevalent in  India.   Sauvages thus defines
it: " Motus gradientium genu retrahens cum tre-
more, formicationis  sensu, vocis raucedine.   India
familiaris."   Linneeus defines  it: " Partium tre-
mor, genuum contractura, stupor, raucedo." Sagar
adds to the definition of Sauvages, " Stupore dolo-
rifico artuum."  Dr. Aiken arranges the disease
as synonymous  with  "contractura."   Bontius
describes  barbiers  well, but he gives it  also  the
name of beriberi ; and Dr.  Mason Good has com-
pletely confounded  the two diseases : it is of im- 
BARBIERS.
265
 portance therefore that they should be  discrimi-
 nated.
   The leading features of beriberi are uneasiness
 with partial loss of power of the lower extremities,
 obstructed respiration, and general oedematous in-
 tumescence.  Beriberi is commonly an acute dis-
 ease.   Barbiers is characterized  by  pain,  numb-
 ness, and partial paralysis of the  inferior  and
 superior extremities :  sometimes the vocal organs
 are similarly affected.  Barbiers is generally a
 chronic disease.
    Bontius describes the disease as « a species of
 palsy, or rather a tremor;  for at the  same time
 that it  impairs the sensation of the feet and hands,
 sometimes  even of the whole  body, it induces a
 trembling.  It is more especially the product of a
 rainy  season.   In  general the  disease invades
 slowly  ; under particular circumstances it attacks
 suddenly.  Among  the chief symptoms of  this
 disease is a lassitude of the whole body ; the mo-
 tion and sensation,  especially of the feet  and
 hands,  are  languid and  depraved ;  and  for the
 most part a titillation is felt in these parts, similar
 to what seizes them in cold countries in the win-
 ter, but with this difference, that  the sensation in
 barbiers is more painful: the speech is sometimes
 so much obstructed that the patient can  scarce
 pronounce a syllable articulately."
    The translator of Dr. Bontius's  work  states
 that barbiers " is most violent and  frequent on the
 Malabar Coast, where  (especially in the months
 of January, February, and March,) it attacks those
 who unwarily sleep  exposed to  the land  winds
 which  issue every morning about sunrise from
 the neighbouring mountains :  suddenly seizing
 them with a painful sensation  in  the  periosteum
 of the arms and legs.   In some persons the pain
 abates  as the  day advances and the  air becomes
 warm ; but in others it continues  for a  considera-
 ble time, attended with a weakness of  the  knees
 and an uneasy sensation in the calves of  the legs
 and soles of the feet, especially  on any attempt to
 walk.   It is scarcely ever cured by medicine till
 after the shifting of  the monsoon, unless the pa-
 tient be removed to the coast of Coromandel, or to
 any place to the eastward of the  Baligat moun-
 tains, where by the changes of the air they quickly
 recover."
   Dr. Lind, in his account of  the diseases inci-
 dental to strangers in different parts of the world,
 says, " Barbiers is a species of the  palsy, a disease
 most frequent in India.  It  distresses  chiefly the
 lower class of Europeans, who, when intoxicated
 with liquor, frequently sleep  in  the open air ex-
 posed to the land winds.  Its attack is generally
 sudden, and  entirely deprives the  limbs of their
 motion; sometimes only part of them."
   The following is Mr.  Marshall's  account of the
 disease,  (Notes on the Medical Topography  of
 (Vylon :) « For the most part it commences with
 pain in the muscles of the thighs  and legs, parti-
 cularly of the bellies of the gastrocnemii.  This
 uneasiness is usually attended by a general numb-
 ness of the extremity and  an imperfect command
 of the powers of  locomotion.  Sometimes the pa-
 tients describe their  sensations  to be as if hot
 water or sand was running over the affected parts;
 at other  times they complain of a sense of formi-
cation accompanied witb a pricking kind of pain.
  Vol. 1 —  34                           x
  In some cases  the  hands  and forearms become
  similarly affected.  I never saw a case where the
  disease was confined  to one extremity.  In gene-
  ral there was but little difference in the degree of
  the  affection of the  extremity  of  one side from
  that of another.   In one case the muscles situated
  on the back part of the neck became affected, and
  eventually the powers of articulation were  much
  impaired.  This last symptom admitted of partial
  alleviations.   The  appetite for food is seldom
  much  impaired  during the early stage of the dis-
  ease.
    " When the disease has made considerable pro-
  gress, the patient is unable to walk steadily. Stand-
  ing or walking in general greatly aggravates the
  uneasiness of the limbs.   The patients have an
  infirm tottering  gait,  and those whose hands are
  affected  lose the power of feeding themselves.
  They seldom enjoy sound sleep, although  they
  seem to labour under a sluggish inactivity and an
  unwillingness to exert themselves.
    " The progress of the disease is sometimes pro-
  tracted to  a  period of several  months.   As  the
  complaint  advances,  the patients  express  their
 sensations of the affected parts to  be  as if they
 were  Iry  or dead,  and  almost entirely without
 feeling.   Loss of appetite, indigestion, and  ema-
 ciation soon follow ; the extremities  lose the natu-
 ral temperature; the exterior  muscles become
 paralytic, while  the flexor muscles  seem to  have
 some force, by which means the joints (particu-
 larly the joints of the fingers) become contracted.
 The  pulse is frequent, thready, and fluttering;
 the vital functions  greatly  impaired ;  and even-
 tually death supervenes."
   " The  general remote  causes  of this disease
 appear to be cold and  moisture applied to the
 body, intoxication, and the  excesses and irregu-
 larities consequent on  inebriety ; violent exercise
 in  the sun, lying down in the open air during the
 heat of the day; exposure to the cold chilling  dews
 of the night, and particularly by going to sleep in
 this situation ; suddenly obstructed  perspiration,
 by  exposing the  body but partially  covered  to a
 current of  cold  air;  long fasting,  and  perhaps
 every circumstance  which exhausts the human
 frame."
   Horses and dogs are sometimes liable to a simi-
 lar paralytic affection of the extremities, in India,
 which is universally ascribed to the land wind :
 they rarely, if ever, completely recover.
   The case of spasmodic disease described by Dr.
 Bostock in the Transactions of the  Medico-Chi-
 rurgical  Society,  vol. ix.  seems  to have been  an
 affection nearly allied  to, if not the  same as, the
 disease now  under  consideration.   The  patient,
 who was  in the middle of life, was first attacked
 with  achings  in the lower  limb on  one side, ac-
 companied with  a difficulty and  irregularity  of
 motion  which soon  extended to the other  side,
 and then gradually to the throat, so  as to impede
 deglutition, except with  great  pain and  severe
 exertion.   The larynx next became affected so as
 to prevent speech, and afterwards the muscles on
 the back of the neck.   The limbs were rigid, so
 that they were both bent and straightened with
difficulty.   The intellectual powers were at lengtn
affected and weakened  ; the failure of understana-
ing gradually increasing, principally showing itseli 
266
BATHING.
in paroxysms, during  one of which the patient
died.   No  cause of the disease could be traced
before  death, nor did dissection discover any or-
ganic change calculated to  account for the symp-
toms.  For the  treatment of this affection, see
Paralysis.                       j  ScOTT.

  BATHING.  In its most comprehensive sense,
the term bathing  means the immersion, for spe-
cial purposes, of the body, or  a part  of it, in a
medium  different from  that in which  it is  com-
monly placed.  Any substance which  constitutes
this medium, when considered only in relation to
the special purpose, is,  in medical  language,
termed a bath.
  A great variety of materials has been employed
to form baths, tbe enumeration of which in this
place  would be of little practical utility, however
it  might show literary research.  In the present
article we  shall  confine our observations almost
entirely to baths composed of water, watery vapour,
and air.
  We shall commence with the fluid water  bath,
as being that in  most general use, and by far the
most  generally useful.   The most important cir-
cumstance  respecting this bath, and  indeed  other
baths also,  is its temperature.   To the considera-
tion  of this, therefore,  we shall first  direct our
attention.
  The range of temperature within  which water
in a liquid form has been employed  for baths,
includes  about 80° or  90° of Fahrenheit's scale,
viz. from 33° up  to 112° or 120°.   A  lower
degree, for  obvious  reasons, cannot be  used ; and
as no therapeutical indication can ever require a
higher, we  need not extend the  scale in this direc-
tion, although baths of even a higher temperature
than  120°  may occasionally have been had  re-
course to.
  Various  subdivisions of baths, according  to
their temperature, have been adopted  by writers
on this subject—all the subdivisions being founded
on the presumed difference of  effect of the bath
at particular temperatures.   It is obvious,  how-
ever, that every classification of this  kind  must
be, in  some  degree, arbitrary;  it being  utterly
impossible  precisely to limit  the effects of any
class of agents upon a subject like the living body,
whose properties  and  susceptibilities  are perpe-
tually varying in the same individual at different
times, and  differ extremely in different individuals
at the same time.   In this respect bathing is pre-
cisely like  every other therapeutical  agent.  We
have the means  of calculating with  certainty the
elements of one  side of the equation only; the
result, therefore, cannot be otherwise than uncer-
tain.   As,  however, in the case of medicines, ex-
perience has enabled us to establish  an approxi-
mation towards a medium standard of results, in
calculating their effects on men in general, so, in
like manner, we have  obtained  certain averages
in the case  of  bathing.   And although, as we
iwe said, the conclusions  can, at best, be viewed
as mere approximations, still the knowledge of
them is of  g-eat utility in practice.  They must,
at all events, be  employed  as convenient expres-
sions of  known  facts by those  who  would  com-
municate information to others.
  The simplest and most natural division of baths
is into cold and hot;  the former comprehending
all  those  which communicate  the sensation of
cold,  the  latter  all which  occasion the feeling of
heat.   Although,  for reasons above  stated,  it is
impossible to fix the degree which  shall form the
boundary  between  the  two classes of sensations,
we  shall nevertheless, on the ground of practical
convenience, assume such a precise limit.  Gene-
rally speaking this boundary will be found between
the 84th  and  88th degree  of  Fahrenheit; and
although well aware that this range is sufficiently
small, we shall still further abridge it by naming
the intermediate degree of  88 as the precise limit,
denominating all baths of a temperature below this
cold, and  all  above it warm.
  In subdividing  these two sections  of baths ac-
cording to temperature, we would propose the fol-
lowing arrangement  to the  practitioner, as one
founded  on  practical  indications,  and therefore
likely to be useful,—leaving it always to be under-
stood that, in fixing the precise boundaries by indi-
vidual degrees, we are influenced more by motives
of convenience than from any belief that these are
the exact  and true limits of the different  classes
of baths :—
  1.  The cold bath,.......from  33° to  60°
  2.  The cool bath,...........  60° to  75°
  3.  The temperate bath,......  75° to  85°
  4.  The tepid bath...........  85° to  92°
  5.  The warm bath,.........  92° to  98°
  6.  The hot bath,...........  98° to 112°

              OF  COLD BATHING.
  §1.  Of the Phenomena and general ope-
      ration of the Cold Batli.
  When  a person in health first enters a bath of
cold water, he experiences a sensation of cold pro-
portioned  to the lowness of the temperature, and
a sudden impression on the nervous system, usually
termed a shock,  proportioned,  cxteris paribus,
partly to the degree of cold, and partly to the sud-
denness of  the immersion.  Frequent concomi-
tants,  if not universally constituent parts of the
shock, are, a greater or less degree of shivering
and convulsive anhelation, and a confused mental
feeling of surprise and apprehension.   If the tem-
perature is very low, these sensations are propor-
tionally vivid, but they are experienced in some
degree at all temperatures  below that conveying
the feeling of warmth.   Almost immediately aftci
the shock, the feeling of cold vanishes and gives
place to one of a  different kind.  This gradually
increases  and becomes speedily diffused over the
whole frame, the unpleasant sensations being suc-
ceeded by others of a decidedly pleasurable kind.
The water almost ceases to be felt, or is  felt as
communicating a sensation of warmth rather than
of cold.   If the immersion, however, is prolonged,
this sense of warmth gradually  decreases ; but if
the system is at all vigorous, and the temperature
of the water not extremely low, the renewed
sense of cold is, for a  time, rather pleasant  than
otherwise, the individual feeling as  if the external
impression were more than counterbalanced by
an active force within, of an opposite kind.   Aftei
a time, however, longer or shorter according to
the state of the system and the temperature of the
water, the sense of agreeable coolness is succeeded,
by one of actual cold ; more permanent tremon 
BATHING.                                    267
or sbudderings come on;  tbe extremities feel be-
numbed, and the whole body gradually becomes
languid, exhausted, and  powerless.   No  second
glow ever succeeds this second chill; but the feel-
ing of cold, numbness, general  discomfort and
debility increase  with tbe  continuance of the im-
mersion.  The face and whole surface of the body
become pale and shrunk, and obviously reduced
in size, as is familiarly evinced  by the falling off
of rings from  fingers on  which  they had fitted
tightly ; the pulse  becomes  smaller and more
feeble, and frequently slower than natural; there
is a feeling of oppression  on the chest, a disposi-
tion  to pass  urine,  and the sense  of chilliness
gradually increases to a strong  and general shiv-
ering.
   If the individual leaves the bath before the su-
pervention  of  the second  access of shivering, or
before this has continued long, he generally expe-
riences, on dressing,  a renewal  of  the reaction
which had followed the shock of  immersion, and
this having now nothing to counteract it, becomes
more vivid and permanent.  The pulse becomes
fuller and stronger than  before immersion;  the
face, lips, and whole skin  not merely recover the
colour and  warmth and  plumpness which they
had lost, but are actually enlarged beyond their
habitual state ; the rings, which during the chill
had dropped from tbe fingers, now fit tighter than
before the bath; all sense of oppression  in  the
chest and head, and of general languor vanishes,
and to this succeed  an exciting feeling  of inter-
nal buoyancy, and an agreeable consciousness of
animal power.
   The above is a brief account of the principal
phenomena usually produced by the bath of cold
water as used for medical purposes.   On proceed-
ing to analyze them, they appear to admit of  a
ready division into two classes, according as they
flow more or less directly  from the action  of the
bath — the  first comprehending the phenomena !
usually included under the term  shock, the second
those included under  the  term  reaction,-  and it
seems necessary, with a view to the practical ap-
plication of the bath as a remedy, to enter some-
what more  into detail respecting them, and also
briefly to notice  their physiological causes, and
their therapeutic  operation.
   I.  The shock. — Although it is impossible to
separate entirely, either speculatively or in prac-
tice, all the  phenomena included under the name
of shock, we can  still  see  that the system is
affected by it in various ways.
   1. The application of the cold  water  to  the
surface produces  an immediate and very powerful
influence on the economy through the medium of
wnsation.   The  whole nervous  system  seems
suddenly impressed, and as if about to yield be-
neath some hurtful power; but,  in general, before
any of the important functions have become ma-
terially disturbed, the conservative energies are
roused to successful  resistance.
  In certain states of  the body, however, the im-
pression is found to  be too powerful for the nerv-
ous system;  and there is  either  no reaction, or
this is too feeble to produce any useful results.
A complete and prolonged depression of the pow- ]
ers of life  may be  the consequence, or even  life j
itself may be extinguished.  Numerous instances |
are known of individuals being killed by the cold
bath, in this way.  Such persons have commonly
entered it when they were exhausted  by bodily
exertion and long-continued perspiration.
   2.  Refrigeration, to a certain extent, must of
necessity result immediately from  immersion in
the cold bath.  This effect must always be con-
joined with the  former.   Cxteris paribus,  it  is
proportioned to  the lowness of the temperature,
and the duration of the immersion.
   3.  There is an immediate retrocession of the
fluids from the surface of the body to the internal
parts. The bath produces this effect partly through
the nervous impression  excited by it; partly by
the contraction of the whole superficial capillaries
from refrigeration, forcing their contents inwards;
and partly through the  mechanical compression
produced  by a denser medium.
   4.  The cold water produces, to a certain extent,
a condensation of the tissues with which it comes
immediately  in contact, partly by the physical
abstraction of heat, and partly through a vital im-
pression  on the  organization.   The contractions
of the fingers, scrotum,  &c. are obvious instances
of this effect.   Parts not in contact with the refri-
gerating medium also contract, in sympathy with
those which are.
   All the effects now mentioned are necessarily
present  in every case, but their  relative intensity
may vary infinitely, according to the condition of
the subject, the mode of applying the agent, &c.
The predominance of the one or the other class is
of great consequence in a practical point of view ;
and it is important to know that the administration
of the bath may be so regulated  as to produce this
particular effect.
   II. Re-action.—The almost instantaneous result
of the shock is the excitement of the nervous sys-
tem to increased activity, in virtue, no doubt, of
that general principle of self-conservation bestowed,
in a greater or less degree,  on all living organized
beings.  The retropulsion  of the fluids from the
surface upon the  internal organs and large vascu-
lar trunks, producing mechanical distension, and
probably also vitally stimulating the  parts, unites
its effects  with those resulting from the direct con-
servative efforts of the nervous power.   The cen-
tres of vital energy, the brain and heart, are roused ;
the latter  organ re-acts with fresh  vigour on its
contents,  and  the blood is once more propelled
through the whole capillary system, more particu-
larly of the surface,  carrying with it  life, heat,
and renovated action.
   As the  effects of the cold bath, considered  as a
medical agent, are greatly varied according to the
mode in which it is applied and  the condition ol
the individual at the time he employs it,  it is no
great wonder that considerable differences  of opi-
nion respecting  its  mode of action should have
existed among physiologists and physicians.  By
some it has been deemed sedative, by others otimu
lant, by some debilitating,  by others tonic.  The
truth is, that its operation varies with the circum-
stances  of the case.   Regarded  abstractedly as a
medium of communicating cold, there can be no
doubt that the cold bath must be  considered as de-
bilitating  in the  highest degree, inasmuch as its
continued application will  eventually produce
death, from exhaustion of the nervous energy and 
268                                    BATI

derangement of functions essential to life.  But
when we speak of the cold bath medically, we do
not regard its absolute effects, but its effects when
applied in a particular manner, and regulated ac-
cording to certain views.  Like many other reme-
dies, it may be debilitating  to the  destruction of
life in one dose, and yet salutary and tonic in an-
other.  Accordingly, when  used  in  the  proper
case, at the proper time, and in the proper manner,
the cold bath is unquestionably one of  the  most
powerful tonics in the whole range of the Materia
Medica, and it is chiefly as such that it is used in
medicine.
   § 2. Of the special effects of the cold hath
    as a medical agent, and of the mode of
    ensuring them.
   The cold bath is employed, in individual cases,
chiefly with the view of producing one  of the
three following effects:—1. the  shock on the
nervous system, independently of the accompany-
ing refrigeration or subsequent re-action ;  2. the
refrigeration, independently of the nervous shock,
or vascular re-action ; and,  3. the re-action  inde-
pendently of the shock or refrigeration.   The two
first of tbese objects are of  inferior practical im-
portance ; the last comprehends nearly the whole
doctrine of cold bathing.
   I. The nervous impression, or  shock.—When
the cold bath is employed  with tbe view of pro-
ducing the  shock, properly so  called, or primary
nervous impression, and if it is desired that this
should be  great, the water  is used at a  low tem-
perature,  and  the application  of it  is sudden,
forcible,  and brief.   To this end  the patient is
either  plunged suddenly into the water and in-
stantly withdrawn, or the water  is dashed  over
him in the form of affusion.  A familiar example
of this use of the cold bath is the sprinkling the
face and breast of a  person disposed to swoon.
On the same principle a more copious affusion is
used in certain convulsive  diseases, more  espe-
cially those of an hysteric or purely nervous kind.
In  such  cases  the application  is often extremely
serviceable.  It has  likewise been used in con-
vulsive affections of a more permanent kind, as in
chorea, tetanus, and epilepsy, but with less bene-
ficial effect in general, and not always with safety.
The same  practice  was  formerly employed  in
mania; the mode  of administering it being, in
this case, to cause the unhappy maniacs to tumble
unawares into a deep plunge-bath or pond.  With
a similar view the cold bath, chiefly in  the  form
of a copious and forcible  affusion, was much em-
ployed in fever, in the hope of  breaking the train
of morbid actions in whicb fever was imagined to
consist.
   In all these cases, although the object is to ob-
tain the  primary nervous shock through the sud-
den impression made on sensation; yet  as there
necessarily co-exist with this, refrigeration of the
surface and  repulsion of  fluids to the internal
parts, the secondary effect,  termed re-action, is
frequently an inevitable result of this application
nf the bath.  In the cases, therefore, in which re-
action  is likely to prove injurious, the remedy
should not  be used,  as it  is hardly possible to
avoid its occurrence ; or when used, the applica-
tion should be extremely  short,  and the  body
should be  dried  immediately.   Before  making
ING.

trial, in any case, of a  remedy so  powerful, care
will, of course, be taken to ascertain,  as  far as
this  is practicable, the  powers  of the system to
sustain the shock.
  II. Refrigeration.   When the object is to ob-
tain  the refrigeratory action of the cold bath, with
as little as possible of the nervous shock or vas-
cular re-action, it must be applied in the way least
likely to  produce  the  two  last.  We  shall see
presently  that  the degree of re-action is,  cscteris
paribus, proportioned to the degree of cold, if this
is only temporarily applied ; we have just seen
that  the nervous impression is proportioned to the
suddenness and vehemence of the  application of
the water, and also to  its coldness ;  if, then, we
wish to produce the refrigeratory effect alone, we
must neither apply the water of a low temperature,
nor suddenly, nor forcibly.
   The  only cases in which refrigeration  is re-
quired as  a remedy, are those in which the animal
temperature is elevated above the natural standard;
and  this  happens only in  febrile diseases.  In
symptomatic fevers, the consequence  of local in-
flammation  of the viscera,  this remedy is rarely-
applicable ;  being usually,  when so  employed,
productive of  an aggravation of the  disease.  In
the  class  of fevers termed idiopathic, as  in the
common  continued fever of this country, or ty-
phus, cold water has been extensively used, and
often with benefit.  In the  preceding paragraph
we have  already noticed one mode in which this
remedy has been applied, not however with the
view of refrigerating the surface, but of suddenly
cutting short the disease.  When this latter object
is not attained, the result has commonly been an
increase of the febrile  heat  and vascular  excite-
ment.   To ensure refrigeration  in this and o'her
cases, the water should be  applied at first only a
little below the temperature of the skin, its heat
being insensibly and gradually reduced, but never
below that of tepid, or  at  most, cool.  The gen-
tlest mode of applying it is the best, as with a soft
sponge ; and  the process should be persevered in
without interruption until  the  desired effect is
produced.  The non-interruption of the applica-
tion  is the more essential in proportion as its tem-
perature is low.  In local affections of an inflam-
matory  kind, in which very cold lotions are used
as a refrigerant, as in cerebral inflammations and
in phlegmon, the result  is frequently different from
what is intended, from  neglect of the precaution
just mentioned.  The renewed application of the
cold  fluid, after a temporary suspension, frequently
gives rise to  a series  of re-actions  in  the part,
which are calculated  much  more  to aggravate
than to relieve the disease.   In such  cases, if the
lotion is very cold, its application ought to  be un-
interrupted until the intended effect is produced.
If the water is of a temperature little below that
of the body, the interruption of  its use will have
no further injurious effect than the subtraction of
the amount of good which its continued applica-
tion  is calculated to produce.
  III. Re-action,  or glow___The  cold bath may
be used, in the third place, with  the view of pro-
ducing its secondary effects — re-action.  As this
is by far the most important end for which it is
employed, and as, indeed, almost the whole prac-
tical doctrines relating to cold bathing are involved 
                                        BAT]

in the consideration of this subject, we shall devote
a considerable portion of the remainder of this part
of our  article  to an examination of the circum-
stances which obstruct or favour its production.
   1. The degree of re-action is, in general, cxteris
paribus, proportioned to the coldness of the water.
A very  cold bath is  followed by a  speedy and
powerful re-action ; a cool  bath by a slighter re-
action, and after a longer interval;  while a bath
approaching the limits of tepid produces scarcely
any re-action.
   2. In general tbe re-action is proportioned, cx-
teris paribus, to the suddenness and  also to the
force with which the  body is  brought in contact
with the bath.   An instantaneous immersion pro-
duces a greater re-action than a  gradual immer-
sion ; and a plunge from some height produces a
greater  re-action than  a gentle dip,  however ra-
pidly performed.   In  like manner, water falling
on the body from some height has a much greater
effect than simple ablution with water of the same
temperature.
   3. Within certain limits, that is, short of the
period at  which healthy re-action ceases to be
 produced, the re-action is, in general, proportioned
 to the period of stay in the bath,—in other words,
 to the degree of refrigeration.
   4. The re-action is commonly proportioned  to
 the vigour of the circulation in general, and more
 particularly to that on the surface ;  it is likewise
 proportioned to the warmth of tbe skin  and ex-
 tremities previously  to immersion.  It is, there-
 fore, a  constant rule that  persons with a feeble
 circulation  and  cold extremities  must endeavour
 to invigorate the circulation,  and increase their
 temperature previously to  using the  cold  bath.
 To ensure the  proper degree of power, it is even
 necessary, in some cases, to  administer  a warm
 beverage, or to  take a glass of wine before enter-
ing the water;  and were it always convenient, it
 would often be  beneficial, in cases of this kind,  to
 go into the warm bath for a  few minutes before
 immersion in the cold.
   5. Re-action  is greater,  cxteris  paribus,  if
 muscular motion is  exerted  in the bath, than  if
 the patient remains in  a state  of  repose.  Swim-
ming is therefore more tonic than simple immer-
sion, and the large open bath admitting of motion
more tonic than the common  small  bath.  The
increase of re-action  from motion is partly owing
to this producing a greater feeling of cold, by oc-
casioning a  quicker  change  of the particles  in
contact  with the surface ; but principally by the
increased  excitement  resulting  from  muscular
exertion.  In the  case  of  swimming,  as in  all
others, it is always to be understood, when spoken
of in relation to its power of increasing re-action,
that  the period  of stay in the water  is  not  pro-
longed  beyond  that  suited for the production of
all degrees of re-action.
  6. Whatever  tends to prevent  the temperature
of the   surface   from falling  below  the proper
degree, or directly stimulates  the  skin,  or excites
the action of the  heart, will proportionally in-
crease the power of re-action.  On these grounds,
the  speedy  drying of  the  body  on leaving the
bath, strong friction of  the surface or the applica-
tion of heat to it, the drinking of warm  fluids, or
active bodily exercise, will  ensure or increase re-
                                           269

action ; while the omission of these measures, or
measures of an opposite kind, will produce op-
posite effects.
   § 3. Of the practical administration of
     the cold  hath, and more  particularly
     of the salt-water hath.
   Although  it is certain that the most important
of the effects produced by baths depend on their
temperature, and on other circumstances having
no relation to their chemical constitution, it will
not be doubted by any practitioner of experience,
who has had sufficient opportunities of comparing
the effects of the bath of simple water with  those
of mineral waters or of the sea, that the chemical
composition of the materials  used  in bathing is a
matter of considerable importance.  Without at
all entering here upon the  question of the powers
of absorption possessed by the skin, whether of
water simply applied  to it or of substances dis-
solved  in  water,  experience has satisfactorily
proved that  the  effects of immersion  in  pure
water, and in water containing salts in solution,
are different.  Sea-water and mineral waters, par-
ticularly such as contain sea-salt or iron in  solu-
tion,  are more  tonic, stimulant, and bracing than
simple water, and when used as a cold bath are
productive of a greater re-action than  the latter.
When, therefore, the object is to produce re-action,
and to brace  the system, (and this is the object in
a vast majority of the cases in which the cold bath
is used,) sea-water  is always to  be preferred to
fresh.  If this cannot be procured, the water ought,
when practicable, to be rendered artificially saline
by the solution in it of common salt.
   For these reasons, and  because in  the greater
number of cases in which  cold bathing  is proper
the summer temperature of the sea is exactly that
most  suitable,—and, moreover, because this is the
form  of the cold bath in most general  use  in this
country,—we shall, in  the  present section, direct
our attention particularly to sea-bathing.
   1.  The period of the year best adapted for sea-
bathing is, of course, the summer and autumn, at
which seasons the temperature of  the sea on our
shores varies from 55°  to 70°.  Bathing in the
open  sea may, however, be prolonged beyond the
autumnal months,  and  even  through the whole
winter in particular cases.  It will scarcely ever
be  proper to commence sea-bathing in the  latter
season ;  but many  persons who  have  regularly
used it in the summer and  autumn may continue
it  through the severer season with great advan-
tage.   Such  a  recommendation  presupposes the
possession of a vigorous constitution,  or, at  leas',
great powers of re-action in the patient.
   2.  The time of the day for  bathing in the  open
sea must depend, in many places, on the state of
the tide.  A  slight deviation may be allowed on
this account; but the particular time best adapted
to the invalid must not yield  to reasons of  mere
convenience.   By the  majority of  persons for
whom the cold  bath is prescribed,  either  as  a
measure of hygeiene or as a remedy, the best time
for using it will  be about noon;  that is,  two o*
three  hours after breakfast.   At this time we may
presume that the system is sufficiently  recruited
by the assimilation of the  morning's  meal; and
we may yet farther be enabled to ensure re-action
by such previous exercise as may be deemed pro-
IING. 
270
BATHING.
per.   In very hot and calm weather, the sun is,
however, often  too  powerful at noon for delicate
persons, more particularly on those parts  of our
southern shores which are sheltered by high cliffs.
In these cases an earlier hour must be chosen, or
bathing in the open sea must be given up.
   When  the  constitution  is vigorous,  and the
temperature of tbe surface is uniformly high, and
when the patient rises from his bed refreshed and
active, the bath may be taken early in the  morn-
ing,  before  breakfast.  This is,  in general, the
best  time for using  the cold  shower-bath; and
the reason why it is  found  to suit better  at this
hour  than  the sea-bath, probably is,  that the
shower-bath is taken immediately on rising, while
the surface still retains all the warmth of the bed.
If one  could  plunge  into the sea as easily, and
before the surface is at all chilled by dressing, &c,
there is no doubt that the practice would suit very
well with many with whom it is found to  disa-
gree.
   In using the open sea in summer, it may be of
some consequence to recollect  that  the  tempera-
ture of the water may be very different at different
times, according to the circumstances of the local-
ity, the hour  of  the  day, and  the period of high
water.   If the  shore consists  of level sand or
shingle, the tide which flows in  the  afternoon,
over a large expanse of surface heated by the noon-
day  sun, during  the  period  of ebb, will often be
a  good  many degrees higher than the morning
tide in the same  place.*
   3.  In using exercise previously to tbe  bath,
with  the  view of rendering  the circulation  more
vigorous, according  to  the principles  formerly
stated, the invalid  must be  careful not to  induce
fatigue or much perspiration.   A slight moisture
on the skin (which, however, should be wiped off
previously to entering the  bath,)  forms no objec-
tion to its use, provided the surface still continues
warm and  the circulation   vigorous ; but if the
body has been for  some time  losing its heat by
copious perspiration, and the  general powers of
the system have been lowered by fatigue, the cold-
bath  cannot  be used without danger, however
warm the surface still may be.
   4. The mode  of entering the bath, the length
of time the patient  remains in it, and other par-
ticulars, must be regulated  according to circum-
stances.  From  what was  formerly  stated, the
propriety of entering the  bath suddenly  will be
seen,  and  likewise  the  necessity  of leaving  it
while there still remains sufficient power of reac-
tion.  The advice commonly given to a  patient to
take  at first only one  or two dips  to  ascertain the
power  of re-action  possessed by him, and gradu-
ally to prolong the period of stay  in  the water, is
judicious.  From five to ten minutes may be said
to be a medium period for staying in.   Moving the
body and limbs while in the water is highly ad-
 visable, and, of course, the exercise of swimming,

   * The following memorandum shows the temperature
of the sea at Bognor, on the coast of Sussex, in the sum-
mer  and autumn of the year 1831.
   On the 4th July, at mid-day, the temperature  of the
 atmosphere being 72^, the sea was 69°.
   July 1-2, T a. m. Atmosph. 63°, Sea 66°
   Aug.  3, 8 p. m. Atmosph. 05°, Sea 71°.
   Aug. 11, I p. m. Atmosph. 70°, Pea 71°.
   Sept. 5, 8 a. m. Atmosph. 64°, Sea 65°.
   Oct. 29,1] a. m Atmosph. 60°, Sea 54°.
j if the patient possesses tbe requisite power  and
 skill.   The body  should be  speedily dried,  and
 hastily but well rubbed  with a somewhat coarse
 towel, and the  clothes put on without any unne-
 cessary  delay.  In ordinary cases no further  pre-
I caution will be necessary to ensure  the requisite
 degree of reaction ; but in very feeble subjects the
 measures formerly mentioned in reference to such
 cases, must be  put in practice.
   5. The cold bath  may  be repeated daily or
 every other day, or twice a  week, according to the
 nature of the case, the effects of the  remedy,  and
 the state of the  weather.  It may  be continued
 indefinitely and  uninterruptedly, or it may  be
 taken for a short time, omitted for  a space,  and
 then resumed.   Where it is found  to agree with
 the patient, it ought to be  continued at  least  one
 month, and may be very beneficially extended to
 three.
    6.  A common and often  a most injurious error
 in the practice of sea-bathing is, that the  patient
 remains so long in the  water that the animal heat
 is lowered below  the proper degree.   This is an
 error, however, more  commonly committed  by
 persons using the bath as a luxury, than by invalids.
 In boys of a feeble constitution or strumous habit,
 we are  convinced that great mischief is often pro-
 duced in  this way, when it  is least expected. The
 principle on which such results are  explained  has
 been  ably illustrated by Dr. Edwards, in his  ex-
 cellent  work On the Influence of Physical Agents
 on Life.   It was  ascertained by him, in the course
 of his  experiments on living animals,  that  the
 temporary elevation or  depression of the  animal
 temperature, above or below the natural standard,
 not merely added to or  subducted from the system
 the amount of caloric necessary  to produce  the
 effect indicated by the  thermometer  at  the time,
 but modified, for some time  afterwards, the activity
 of the  calorific  process itself.  Animals whose
 temperature  had  been  raised by  artificial heat,
 were invariably found,  on the withdrawal of this,
 to continue for some time to generate more heat,
 in the  same period, than before  the experiment;
 and those whose temperature had been lowered, to
 generate  less.   Although Dr. Edwards's  experi-
 ments were confined to the inferior animals, both
 analogical reasoning  and  observation  leave no
 doubt that the principle is equally applicable to
 the human  subject.  Every one must  have  had
 occasion  to observe, and most people to experience
 in their own persons, tbe effects of a severe chill
 being felt long after the usual  temperature  has
 been restored.   Subsequently to long exposure to
 cold, as in a carriage or church, when the clothing
 is insufficient, or when cold bathing  has been
 improperly prolonged,  a sense of chilliness often
 remains  for days,  although the body  has been
 repeatedly and thoroughly  warmed  in the mean-
 time.   We have  known such a state continue foi
 two or three weeks, the individual daily expecting
 the invasion of some formal disease, and yet none
 such occurring.
    The corollary from these premises is, that when
 the cold-bath is employed with the view of invigo-
 rating the system, it sbould never be so  prolonged
 as  materially  to  lower the  animal  temperature.
 In such cases the re-action will either be imperfect
 or  it will be  succeeded by a sense of  chilliness 
BATHING.
271
In order to obtain the full degree of salutary re-ac-
tion, and at the  same time  to  avoid the risk of
subsequent chilliness, immersion in the  cold-bath
should cease just before the animal temperature is
sensibly diminished ; and it  may  be deemed, for
all practical  purposes,  a sufficient test that this
point has not been passed, as long as the primary
glow or reaction is felt  to continue.
  § 4. Of the  Temperate  Bath (75° to 85°).
  The effects of this bath on the system are pre-
cisely the same  in  kind as those of the  cold-bath,
but they are much  less in  degree.  This  bath,
therefore, is applicable in a different class of cases,
and it is also applicable in the same cases in which
the cold or cool bath may be of use, but  cannot be
applied without some hazard.  The Buxton water,
which is of  the temperature of 82°, is the best
natural example of this class of baths.  The shock
produced by water at  this temperature is small,
and the re-action proportionally slight.   As this
bath may, therefore, be safely prescribed in  cases
where danger might be  apprehended either from
the too powerful shock on the nervous system, or
the too  great and sudden retropulsion of fluids on
the internal organs, it will, for the  same  reason, be
found much less efficacious in the cases in which
 the principal benefit results from  a  powerful re-
 action.  It will also be frequently preferable in the
 case of delicate persons, and in persons of peculiar
 sensitiveness either of the whole system or of the
 skin only, in whom the  shock of the  very cold
 bath, or even  the cool  bath, cannot be borne ;
 although if it could be borne, its effect in repelling
 the fluids could be productive of no evil.  In such
 cases, and in others also of  a somewhat different
 kind, a bath of this  temperature will often be
 proper as a  preparation for the use of the bath at
 a much lower temperature.
   It  is, indeed, a question  often  raised,  whether
 the  patient  should at once  commence with the
 bath of the full  degree  of  coldness intended, or
 should at first  use one  of  a higher temperature
 and gradually  lower it.  For instance, should a
 patient for whom the cool or cold bath is prescribed,
 begin at once with it, or previously use that which
 we are now considering ?   This point can only
 be  fixed in individual cases.   Generally speaking,
 if there is any  doubt of  the  system being able to
 bear  the shock of  the  cold  bath, the  temperate
 should be raised, and more particularly in the case
 of delicate persons and women and children, and
 in persons who have a dread of the effects of the
 bath.
   It  is always to be recollected, however, that if
 our object is to corroborate the system by produc-
 ing rc-action, the lower temperature is decidedly
 best, if it  can  be  borne.  And we are  of opinion
 that among the vast number of cases in which the
 cold or cool bath  is indicated, very few will be
 found in which it will not be borne at once.  All
 that is necessary is, by proper management before
 and after the bath, and by making the  immersion
 extremely brief, to ensure the  salutary  degree of
re-action.
   $ 5.  Of the different Forms  of  the Cold
      Bath, and their particular Effects.
   1.  Large and  small baths—-open  and close
baths.  The observations heretofore made may be
considered as applying generally to every form of
bath by immersion, whether  the  water is in the
open sea, rivers, ponds, &c., or confined under a
roof in  large or small baths.   It must not, how-
ever, be imagined that it is a matter of indifference
to the patient under what circumstances the bath
is administered.  It may  be  stated  in  general
terms that bathing in the open air is more advan-
tageous than bathing under cover, and that a large
bath is  preferable to a  small one.   It is scarcely
necessary to observe that when a tonic effect from
the cold bath is the object, the open air, more par-    .
ticularly of  the  sea, will  be  much more bracing
than that of a confined apartment.   The size of
the bath is  of still  greater consequence.  In the
common domestic bath, the  patient can scarcely
have  the advantage of a complete  and sudden
immersion ; and all effective  motion, while in the
water, is completely precluded.   The  importance
of this  deficiency will be understood  from what
was formerly stated  on the subject of re-action: in
the small bath, the  degree of refrigeration is often
not sufficiently balanced by a proportionate degree
of this  salutary process.   For these and  other
reasons, the large baths at Matlock, Buxton, &c,
are decidedly preferable to the small baths at the
same places.  Of all the  substitutes for the open
sea which we have seen, the swimming bath lately
erected  at Brighton  is by far the best.  From its
great extent and  airiness, and the constant re-
newal of the water, this bath  certainly possesses
many of the advantages of the open sea, and it has
one superiority, that, namely, of being accessible
in every kind of weather and at any time of the
day.*
   2. The shower-bath. — The form and general
character of the shower-bath are too well known
to  require  description.   Its  effects  are, on  the
whole,  similar to those  of the plunge-bath of the
same degree of temperature  :  but there are some
differences between them which deserve the  notice
of the practitioner.
   The  immediate shock from the shower-bath is,
in general, felt to be greater than that from simple
immersion ; more  particularly if the  quantity of
water is great,  its  temperature low, and the fall
considerable.   On  the  other hand, owing to the
absence of  permanent compression of the surface
by a dense medium, and perhaps, also, owing to
tbe access  of air to the  skin in the  case  of the
shower-bath, the anhelation and precordial distress
are generally less in degree and certainly less per-
manent than in the plunge-bath.   From these and
various other circumstances, individuals constantly
present themselves to  the  practitioner who will
bear the one form of bath and not the other, or
who will be more  benefited by the one than the
other.
   In certain affections of the head, and in persons
predisposed to  such affections,  the  shower-bath
possesses a very decided advantage ovei the plunge-
bath, inasmuch as the shock  and refrigeration are
applied directly and in the first place to the head
And in these  and many other cases  also, it is a
great advantage possessed by this bath, that the
feet may be  immersed  in hot water during the
process.  This not  only tends to  prevent too great

   * The swimming bath at Brighton is 53 feet in diame-
 ter ; its depth from 3  feet 6 inches on one side to 5 feet C
 inches on the other. 
272
BATHING.
a repulsion of the fluids upon the internal organs
in cases where this is to  be apprehended, but in
feeble and sensitive persons it  tends at  once to
lessen the shock and to increase the re-action.
   It is an important  advantage possessed by the
shower-bath, when properly constructed,  that  it
can be increased or diminished in force, suspended,
renewed, shortened, or prolonged, according to the
feelings of the patient.*  The  small quantity of
water necessary to prepare a bath of  this kind  is
another great  advantage,  as giving  facility for
having it at any degree of heat required.
   3. Affusion, aspersion, ablution.—These may
be  employed  either  as general or  local  baths.
W7ater thrown over the naked body from a vessel
is a rude form of the shower-bath, and has similar
effects.  By  ablution, we  commonly understand
the process of applying water to the surface  by
means of a sponge  or towel.   When  general, it
differs only from the shower-bath in being attended
by a lesser shock, and consequently a feebler re-
action.  It is much more frequently used as a par-
tial bath, more particularly to the bead  and trunk
of the body, in which form we  consider it as one
of the most valuable applications both hygeienic
and therapeutic.   The daily  ablution  of the chest
with cold  water, containing vinegar or salt  in so-
lution, is  one  of the most  effective  tonics in a
numerous class of diseases,  and the easiest and
surest remedy of that almost general and, we fear,
increasing disease, a proclivity to catch cold.  (See
the article Asthma.)  This form of bath is always
to be used, by the delicate, in the morning, imme-
diately on getting up, while  the body still retains
all the warmth of the bed, unless, indeed, there  is
perspiration present at this time.
   The employment of cold ablution  as a remedy
in fever was formerly noticed.   In this case, pure
water should  be used ; in most other cases, salt
water, or water rendered artificially saline, is pre-
ferable.
   4. The douse (dash, or douche).—This form
of bath is well known by its foreign name.  It  is
of sufficient value to deserve an English  appella-
tion, and we venture  to revive an old one,  which
has at least the negative advantage of  being  less
discordant to  our orthography and pronunciation
than the French term.-(-  The douse  consists of a
small stream  of water directed  with  considerable
force from a tube upon some particular part  of the
body.  It varies in its power according to the dia-
meter of the stream, the temperature of the water,
and  the force with which  it is projected  on the
body.  It is  an agent of great  power; but it  is
more employed in the domain of surgery than
medicine.   This is, perhaps, the most effectual of
all refrigerants, owing to  the incessant and rapid
change of the  particles of the fluid applied to the

  * A shower-bath should be so constructed as to contain
a much greater quantity of water than is usually thousht
necessary, and to permit the shower to be suspended and
renewed at the will of the bather.  One of the most con-
venient forms is that which is erected over the common
domestic warm bath, and  which permits  the patient to
escape from under the  stream,  and to return to it at
pleasure.  The materials for enclosing the shower-bath
ought to be of wood, as cloth or canvass, whether painted
oi not, retains  moisture, and proves thereby injurious
by occasioning dampness.
   I The douse, (pronounced like house,) from the old neu-
ler verb, to douse, to fall suddenly  into the water.
part, and also to the compression on the capillaries
produced by the mechanical impulse of the stream.
A homely  form of the douse is  the  placing  the
affected part under the stream from the nozzle of
a pump, or the  spout  of  a tea-kettle.   The chief
instances of a strictly  medical kind in which this
form of bath is used,  are  to the head in cerebral
diseases, and to the loins in uterine affections.  In
inflammatory affections of  the brain, whether idio-
pathic or originating in fever, it is a most  potent
remedy.  It is also in frequent use, in some parts
of the continent, in mania.   In  all these cases it
requires to be  used with  discrimination  and great
circumspection, as  it is capable of producing  the
most powerful effects.
   5.  The  hip-bath, foot-bath, Sec.—There  is  no
limit to the number of partial baths but the num-
ber of parts of the body to which water  can  be
locally applied.   The  most important are the two
just named.  They are both Very valuable reme-
dies, and  their administration  is well understood.
The former is principally used in diseases  of  the
pelvic viscera ;  the latter  chiefly as a measure of
hygeiene.   Children  ought to be accustomed to
tbe daily  use  of the  cold foot-bath,  as nothing
tends more to prevent chilblains—a disease, how-
ever apparently  slight, of really  serious  conse-
quence in delicate habits.
   § 6.  Of the diseases in which the cold
     bath is employed; and the coiitra»in«
     dications to its use.
   The  applications of the cold  bath, both as a
measure of hygeiene  and as a curative agent,  are
numerous  and  important.  It is, indeed, one  of
the most valuable remedies we possess.   Like all
valuable and powerful remedies, however, its em-
ployment requires  great  caution and discrimina-
tion, first, as to whether it should be  used at all;
and, secondly, as to the form  and mode of using
it.  It must be confessed that in  a vast number of
cases no such discrimination is practised ; and it
will not be doubted by any physician resident in
the vicinity of the sea, that in the case of no other
remedy are greater mistakes committed and greater
mischief produced  than  in  the use  of the cold
bath.   It  is impossible, within the limits  of  the
present article, to do more than  give an  outline
of the numerous cases in which the cold bath is
beneficial.   This, however, is of the  less  conse-
quence, as  the practitioner who is acquainted with
the mode of action of this remedy, and  the  gene-
ral principles which ought to  regulate its employ-
ment, (and we have endeavoured to explain these
in the preceding pages,) will  have little difficulty
in applying it to individual cases.
   Before entering  upon the  consideration  of  the
diseases in which this  remedy is proper, it will be
well to give a  brief statement of the  particulai
conditions  of the system, whether morbid or not,
which either entirely forbid its use, or render great
caution necessary in employing it.
   I. The cold bath is less applicable in infancy
and old age than in youth and middle life.
   2. It is  not admissible during the menstrual
period, and only with  great caution during  preg-
nancy.
   3. It is inadmissible in great plethora; in cases
where there exists a predisposition or tendency to 
BATHING.
273
active hemorrhage, to local congestions in  the I
more  important  viscera,  &c.;  consequently  in
apoplectic subjects, in a tendency to haemoptysis,
&c.
  4. It is improper in persons affected with dis-
ease of the heart, particularly with dilatation or
valvular obstruction ;  and  it must be used with
great caution  in those who, without any formal
disease, have  naturally a thin and feeble heart.
This is often the case in strumous and phthisical
habits.
  5. It  is generally inadmissible  in indurations,
obstructions, or chronic inflammations of the in-
ternal parts  of the body, more particularly of the
principal viscera; Ukewise in all acute inflamma-
tions of the same  parts;  and  also  in  chronic
inflammations of tbe  mucous membranes of the
bronchi and intestinal canal, except when these
last are very slight.
   6. It is improper in loaded states of  the bowels,
more particularly if these are combined with a
 gorged state of the venous system of the abdomen.
   7. It is either inadmissible, or  only to be used
 with great caution, in most cutaneous diseases ;
 particularly  such as are apt, when suddenly re-
 moved, to be followed by internal affections.
   8. It is inadmissible in great general debility,
 and where there does not  exist  sufficient power
 of  re-action, more  especially if there exists  an
 habitually cold state of the surface.  In cases of
 this kind, however, the  cold bath may be often
 advantageously  employed after  the previous use
 of  the warm water or vapour bath, provided the
 debility is not  the result  of some local organic
 disease.
   One of the  most important class of  cases, short
 of  formal disease, in which the cold bath is bene-
 ficial,  consists of  the various forms  of general
 debility which show themselves in childhood and
 youth, either  as congenital constitutional peculi-
 arities, or as the consequences of previous disease.
 Of the first kind, the strumous  habit constitutes
 the most important example.  In cases of  this
 kind, when properly  selected, the cold sea-bath
 and a residence by the  sea-side  are frequently of
 very singular  benefit.  Every  thing,  however,
 depends on the judicious selection of the  cases,
 and on the  proper administration of the remedy ;
 since quite  as much  injury as benefit may result
 in  this  class of cases without the greatest care.
 In children  of a strumous habit we have at  the
 same time, in general, a feeble  heart, and a very
 sensitive  surface.  Great caution  is, therefore,
 necessary, in  first administering the bath, lest the
 shock be too powerful for the energies of the sys-
 tem, and be not followed by the necessary degree
 of  re-action.  Every measure formerly mentioned
 as  proper to ensure this result must be employed,
 as  otherwise the bathing will be highly injurious.
 In  most cases it will be found sufficient to take
 care  that  the circulation on the surface is  as
 vigorous as possible  previous to immersion ;  to
 make the immersion sudden and complete, and, at
 first, merely momentary, and to  follow it up by
 strong general  friction with flannels.  In more
 delicate subjects it  may be necessary to begin with
 the tepid or temperate  bath, or to take some of
 the additional precautions formerly noticed.  It is
 a matter of great consequence in bathing children,
   Vol. I. — 35
that they should not be terrified by tbe immersion,
and every precaution should be taken to prevent
this.  A course of baths, gradually reduced from
a high to a low temperature, is beneficial in this
point of view, even if it were not often so likewise
by improving the condition of the skin, and ren-
dering it more susceptible  of re-action.  It is to
be here understood that it is to the strumous habit,
and not to the diseases of scrofulous persons, that
the foregoing observations  are intended  to apply;
as we are well convinced that there are  few such
diseases  in which the cold bath is not injurious.
Great care must  therefore be taken by the practi-
tioner, before prescribing this measure, to ascertain
that there exists  no  local disease of consequence.
We do not consider slight swelling of the external
glands as a  positive  contra-indication of the cold
bath, provided  the internal organs are sound; but
such appearances are always suspicious, and  im*
pose greater caution  in  the use of the  remedy than
if they did not exist.
   When, in strumous habits, the system is free
from visceral disease, and  sufficient energy exists
to produce strong re-action, the frequent repetition
of this exciting and tonic process may eventually
establish a permanent degree of increased activity
and power  throughout the whole capillary sys-
tem, with an habitual development of a higher
degree of temperature  on the surface.   Such re-
sults may be considered equivalent to a change
in the very temperament of the individual; and
it is certain that they are  occasionally attained
by the use  of tbe  cold bath,  aided by suitable
regimen.
   In children of a feeble  and delicate habit, the
result  of previous  disease,  perhaps  still greater
caution  is  requisite in prescribing  the bath, as
such states  of general  debility frequently depend
on organic affections of the viscera.   In this last
case, the remedy is  altogether improper, and can-
not be administered without danger.  The same
remark is equally applicable to  persons in more
advanced life.   We may add, as  a general obser-
vation, that there is scarcely a  more  common or
more injurious practical error, than this  of assum-
ing debility to be general, when it  is the result
of some local affection. In all cases of  this kind,
at whatever period of  life, cold bathing  is seldom
beneficial, and very generally injurious.   Here,
as in most cases, it is  to  be viewed in the same
light as other tonics, which may  be  stated as ge-
nerally contra-indicated in  what may be termed
symptomatic debility.  In place of being strength-
ened,  such persons  are certainly debilitated  by
the treatment, and great risk is incurred, not only
of increasing  the primary  disease,  but of pro-
ducing others.  It is in such cases that we observe
the  occurrence  of  bilious  and  febrile attacks,
headachs, and other disorders, so frequently no-
ticed  as results of indiscriminate  sea-bathing.
Permanent headachs have  been  produced under
such circumstances.
   In cases of  a  debilitated and relaxed habit, free
from visceral disease, from whatever cause arising,
the cold bath may be considered as useful, if suf-
ficient power  of re-action  exist  in the system.
When the skin  is  relaxed  and flabby,  and there
is a great tendency to warm perspiration on sligb*
exertion, or  to cold clammy perspiration in oed 
274                                    B A T r

the salt bath is especially indicated.   In no class
of persons is  this measure more beneficial than
in those who inhabit a low, relaxed, damp cli-
mate, in whom debility and nervousness in various
forms,  and  relaxation  of the  skin  and mucous
membranes, are  frequent and  conspicuous ail-
ments.   When  combined with  a more bracing
climate, and dry pure air, the benefit from this
measure is  often most speedy  and  remarkable.
For  persons of this class, no place on the south-
ern  coast affords such advantages  as Brighton,
and  some other places in  its  vicinity, where the
high, airy downs come close to the sea brink.
   There is one  case  of debility frequently met
with in practice, which requires great caution in
prescribing  the cold bath, and where  frequent
mistakes are committed, for want of  due discrimi-
nation :  we allude to that state of debility which
so often precedes the development of tubercles in
the lungs, and which has been so well described
by Dr.  Clark, under the  name  of tubercular ca-
chexy.   (The Influence of Climate, &c.   Lond.
1830.)   If  tubercles already exist in such cases,
(and we know that they often do so without any
external or local symptoms  of  their presence,)
cold bathing will almost always be found to disa-
gree, and will tend to accelerate the  fatal disorder
of the lungs.   If only the predisposition  exists,
and  the system still retains sufficient power of re-
action, a cautious use of the cold bath may prove
Extremely beneficial; but in no case is more care
•requisite to ensure reaction,  without which the
measure cannot fail to be highly injurious.
   As a preventive of the numerous  diseases pro-
duced by cold, or rather by the variations of tem-
perature, the  cold bath, in one or other of its
forms, excels  all other measures.  In the  nume-
rous family of catarrhal disorders, it is almost the
only preventive  of value; and  frequently it  is
here of extreme value.   It obviously acts in vari-
ous ways in warding off these  diseases.   In the
first place, it acts as a tonic to the whole system,
thereby rendering it  less easily affected by delete-
rious influences from  without.   Secondly,  it
strengthens, in a peculiar manner,  the skin and
the mucous membranes of the  air  passages, on
which parts the morbific  impressions producing
catarrh are  generally made.  In the third place,
by accustoming the  surface to a  frequent change
of temperature, it renders it  less liable to suffer
from those which are unavoidable, and which are
known  to be the common causes of colds.  The
same observations apply, in a great measure, to
rheumatism, chilblains, and other   diseases  pro-
duced by the same class of causes.
   When used with the view of preventing these
diseases, the bath, in some form, ought to be pro-
longed  through  the  different seasons.   In the
summer sea-bathing will be best, and, afterwards,
the shower-bath, or ablution.   In  most cases it
will  be  found  sufficient to employ the latter par-
tially to the chest and trunk, after  the weather
has  become cold;  and  it should be continued
through the whole winter.
   The  cold bath may be said  to  be  applicable to
Lhe whole class of nervous diseases, properly  so
called.—that is,  diseases which  manifest  them-
selves cniefly  by morbid mobility or excitability
of tbe nervous function, and  irregular action of
ING.

tbe muscular  system,—provided there exists no
considerable physical change or obstruction, as it
is commonly called, in any important viscus, and
provided the first impression of the remedy is not
found too powerful, either as  an exciting or de-
pressing agent.  It is,  however, more generally
useful in those slighter, anomalous, nervous affec-
tions, so constantly met with in practice and under
such varieties of form,  than in the more formal
and well-marked diseases which are alone treated
of in our systems of medicine; although it is a
valuable remedy in many of the latter class, when
none of the contra-indications above noticed exist
against its use, and when it is applied in the mode
and form best suited to the individual case.  Of
this kind are chorea, hysteria, some cases  of epi-
lepsy, loss or depravation of certain functions, as
loss of voice, smell, taste, &c; certain forms of
hypochondriasis ;  local paralytic affections uncon-
nected with cerebral disease, such as loss of power
in the  sphincters of the bladder or anus; certain
cases of palsy of long  standing, in which all
active  cerebral affection has  been removed, &c.
In some of these  cases  the remedy is frequently
only of doubtful  utility, and  must therefore be
administered with great  caution.   The chief cir-
cumstances which contra-indicate its employment
in such cases, are tbe existence of organic disease
in the brain or spinal marrow, or a disposition to
cerebral congestion.  In all such cases, and wher-
ever any doubt exists as to the propriety of the
remedy, the shower-bath is the preferable form;
and this is the only form which should be used in
any case of epilepsy.
   The  cold bath is  beneficial in  many  chronic
affections of the mucous membranes attended with
discharges, such  as leucorrhoea, gonorrhoea, &c;
also in  certain cases  of chronic catarrh, attended
with little or no  inflammation of the bronchial
membrane,  particularly  in tbe dry catarrh,  and
in those forms which seem to depend rather on a
relaxed than  an  irritated state of the  bronchial
membrane.
   It is occasionally beneficial in cases of passive
hemorrhage, particularly epistaxis and menorrha-
gia.
   It is sometimes usefully employed in  cases of
nervous or functional dyspepsia, unaccompanied
with inflammation of the gastro-intestinal mem-
brane,  more particularly  after a  course of warm
bathing.  Its  employment in mania was formerly
noticed.
   For  the use of the cold bath in febrile diseases,
we refer to  the article  Fever.  We would only
here repeat, what was said in a former section, that
the tepid or cool ablution is the form most adapted
to such cases.
   The cold bath is useful in certain cases  of ame-
norrhoea, particularly where there exists neither a
very plethoric state of the habit, nor yet chlorotic
debility.  In chlorosis,  properly  so  called,  cold
bathing is rarely admissible.
   In no disease  is  the  cold bath more beneficial
than in the intervals  of asthma, when the system
is  otherwise in a proper state for the remedy. In
this case its principal action is, no doubt, as a pre-
ventive  of catarrh  or cold, which  is  by  far the
most frequent exciting  cause of the disease. It
also operates by giving tone to the nervous system, 
BATHING.
275
and rendering it the less susceptible of morbid
impressions.  (See Asthma.)  On the same prin-
ciples it is beneficial in the latter stages of hooping-
cough.  It is  likewise useful in the intervals of
ague, when  tbe  disease exists in  a simple state,
uncomplicated with any visceral affection.
             OF  WAHM BATHING.
   § 1.  Of the phenomena and operation of
     Warm Baths  in general*
   The only forms of the warm bath  which it is
our intention to notice in the present  article, are,
the water, vapour, and air bath.  As these  are
respectively  productive of  effects sufficiently differ-
ent to entitle them to be regarded as distinct medi-
cal agents, we shall treat of them separately ; but
as they all agree in some  important particulars, it-
will save repetition to notice  these,  in the first
place, under one general head.   This we shall do
in the present section.
   The immediate action of the warm bath on the
 system is,  like  the sensations  excited  by it, in
 many respects the reverse  of that of the cold bath.
 In the latter, nature seems to encounter  a  hostile
 power, which she must overcome before she can
 make it minister to her comfort; the pleasurable
 feelings thence resulting being derived rather from
 the operations of the system itself, than from any
 impressions  communicated  to  it  from without.
 The  warm bath, on the contrary, is directly grati-
 fying to  the feelings, and seems at once acknow-
 ledged as a power friendly to  life.   In the new
 medium, the surface and extreme parts seem to
 partake of that animating sense of heat which is,
 in general, confined to the trunk and central parts
 of the body.
   The following are  some of the principal modes
 in which the warm bath affects the animal body.
    1. It acts directly, and in a way altogether in-
 comprehensible  to us, on  the  nervous system;
 partly, no doubt, by modifying sensation, but also
 by producing effects which seem unconnected with
 any such modification.  Its effects vary consider-
 ably with the medium, but more particularly with
 the degree  of heat  communicated.  When the
 temperature of the bath is confined within certain
 limits,—as  for instance, when the water bath is of
 the temperature of 95°, 96°,  or  97°, the whole
 nervous  system  is, in general, soothed, the  feelings
 are gratified, and a gentle languor steals over the
 mind.  Slight degrees  of local irritation, pain, or
 spasm, that may  be present,  are  frequently re-
 moved, and even, in  some cases, great general irri-
 tability of the system  is effectually subdued, at
 least during the continuance of the bath.  At a
 temperature somewhat higher than this, the bodily
 and mental feelings are still gratified, but a very
 brief continuance of the remedy produces excite-
 ment in  place of tranquillity.  If the heat is con-
 siderably greater, the feelings are painfully excited,
 and the  temporary stimulus is  followed  by a pro-
 portionate degree of  exhaustion.
   2. The  warm  bath influences the system by
 elevating the temperature either of the whole body
 or a part of it.   If the parts which come in im-
 mediate  contact with the heating medium are be-
 low the general temperature  of the  body, they
 will be gradually raised to this temperature, if the
bath is continued.  If the heating medium is of a
temperature greatly above that of the body, it will
raise  the  superficial parts, and even  the  whole
mass  of blood, above their ordinary degree of beat.
The extent  of this elevation, however, as is  well
known, is confined within very narrow limits by
that wonderful power of the living body which
regulates  its temperature, in a  very considerable
degree, independently of all external influence.
While life remains, we can neither greatly elevate
nor greatly depress the general temperature of the
body  by any degree of heat  or  cold applied to it
This  conservative power, however, does  not  con
fe» a complete immunity from the operation  of
the ordinary laws that regulate the distribution of
caloric  in inanimate matter.  A great and  long
continued degree of cold sensibly depresses the
animal temperature even  of warm-blooded  ani-
mals, at least in  the external parts ; and a great
and long  continued heat raises it in like  manner.
   The degree of heat which can be borne by the
living body, as communicated by different media,
varies extremely.   The variation  depends upon
several circumstances in the  nature of the heating
medium, more particularly on its density, its capa-
city for caloric, its conducting  power, the  degree
of fixedness or mobility of its particles, &c. Thus,
the heating power of dry air is much less  than
that of moist air at the same temperature ; this is
much less than air loaded with vesicular vapour,
as in the  instance of the vapour bath; and this, in
its turn, is greatly less than  the common fluid or
water bath.
   3.  The warm  bath modifies very considerably
the functions of  the skin, as an exhalent and ab-
sorbent organ.    We must refer to  the writers on
physiology,  and  more especially to the work  of
Dr. Edwards,  (De l'lnfluence des Agens  Phy-
siques sur la Vie. Paris, 1824,) for the full expo-
sition of  this important effect of the bath.   We
can only, in this  place, refer to the principal points
which seem to be established.
   a.  In the state of health, the skin appears both
to exhale and  to absorb  fluids in the water  bath.
The  relative amount of the two processes appears
 to vary considerably  with the temperature.   At
very  low  temperatures, and up to about 50° Fahr.,
 absorption by the skin exceeds transudation. From
 this point to about 70°, the two processes would
 seem to  be pretty equally balanced.  Above this
 degree the transudation  exceeds absorption, and
 the excess  progressively increases with  the tem-
 perature.
   b.  The temperature of the  bath, or rather the
 degree of heat communicated  to the body, being
 the same, and other things being equal, the degree
 of absorption is proportioned to the density of the
 fluid in which  the body is immersed.  Much  more
 fluid is, therefore, absorbed in the water bath than
 in the vapour bath.  It is not ascertained that the
 amount of  exhalation is in  the inverse ratio of
 the density of the fluid ; on the contrary,  there
 are strong  grounds for  believing that this  is not
the case  : it is,  however, ascertained that in the
vapour bath the  transudation exceeds the absorp-
tion.
   c.  In the warm  air-bath the difference between
the two  p1  cesses is  at the maximum, since the
transudation is often extremely copious, while ab 
276
BATHING.
sorption is almost of necessity null  from the ab-
sence of the material to be absorbed.
  There is reason to believe  that the  absorbent
and exhalent functions are modified in other ways
by the chemical  composition  of the bath.   But
the whole subject stands in need of further inves-
tigation.
  4. The warm bath  modifies the texture of the
skin ; at least the bath of water and watery vapour.
This  effect arises  partly  from  imbibition,  and
partly from a specific action on the  animal fibre.
It is greatly less on  living bodies than on  those
which have become dead ; but still it is conspicu-
ously marked in them.   The ultimate effect  is to
soften, to expand, and  to relax the parts  with
which the fluid is in  contact; and it would appear
that its relaxant influence extends to parts  with
which it  is  only  mediately in contact.    After
immersion in the  warm bath, for a  considerable
time,  not merely  the  muscles of the limbs, but
even the abdominal  viscera appear to have lost a
portion  of their solidity and tension.  Much  of
the relaxing property  of the  warm bath on the
surface of the body is  no doubt derived from the
temperature ; as we  know that the cold bath has,
in a considerable degree, the very reverse opera-
tion.  Yet a good deal must  be attributed to the
effect of the water independently of the tempera-
ture, since we  find,  firstly, that even cold water,
if long  applied, produces  a softened state of the
skin ; and, secondly, that dry heat,  or  heat  con-
veyed through the medium of air, does not produce
similar effects.
  5.  The warm bath modifies the frequency and
force  of  the action of the heart.   This  is suffi-
ciently shown  by its  well-known effects on the
pulse.  The precise effects of  the  bath in this
way depend on many circumstances, some having
reference to the patient, and some to the bath.  In
general  it  may he said that when the  degree of
heat communicated  is  moderate,  and the sensi-
bility and irritability of the subject are not exces-
sive,  the  change  produced in  the frequency  of
the pulse is not remarkable.   If the medium is
water, and the temperature does not exceed  97°,
although the pulse and respiration may be slightly
quickened  upon  the  patient  first  entering  the
bath, yet after a short time, when the surface and
extremities have become moderately but thoroughly
warmed, and the nervous  system  accustomed, as
it were, to the new stimulus, tbe heart  and lungs
resume  nearly  their natural  action.  The  pulse
may be  somewhat fuller, but,  in general, is not
increased  in frequency.   When  the  temperature
is raised to the full heat of the blood (98°), it will,
in most cases, slightly augment the power and fre-
quency of the heart's action.  At still higher tem-
peratures,  the  pulse  becomes  considerably  in-
creased in frequency, and in a degree proportioned
to the temperature ;  and  if this is carried to the
highest  point at which it can be sustained, the
frequency  becomes extreme.*    When so much
excited, the  pulse occasionally continues quick
for several hours after the bath, and in some cases

  * See the experiments of Dr. Parr in his Thesis de
Balneo, F.din. 1773,and in his Medical Diet. Art. JSoi-
neam;of Fordyce, Blagden.and Dobson in Philos.Trans.
vol. Ixv p. 11], 403, 4H4 ; of Delaroche and Berger, Journ.
6a Physique, tomes 63, 71, 77 ; of Rostan, Diet, de Med!
'. ii. Art. Bain.
it does not regain its natural standard, until after
the patient has had a night's rest.
  6. The warm bath  modifies the relative distri-
bution of .blood throughout the system; more espe-
cially the  relative proportion of this in the exter-
nal and internal parts.   When a disproportionate
quantity exists in the internal organs, the warm
bath recals it to the surface, and in various ways:
lstly, by exciting the superficial capillaries to in-
creased action; 26*ly, by  relaxing and dilating the
external tissues, so as to render them not merely
capable of containing more fluid, but to force them,
by  a physical necessity,  to  draw an  additional
supply from other parts; 3dly, by directly reliev-
ing the local irritation on which the internal con-
gestion may depend.
  It is to be  observed, however, that this equal-
izing power of the warm bath only exists when
the temperature is of that moderate degree which
does not excite the heart to preternatural action.
If the stimulus of the heat augments the force and
frequency of the heart's contractions considerably
beyond the standard  of health, although  much
more blood  than before  may be attracted to the
surface, the internal parts are not unloaded in
the same proportion.   On the contrary, the whole
vascular system  being  stimulated to  increased
action,  and the contained fluids being in some
degree dilated by the increase of the temperature
an increased quantity of blood is thrown  into the
capillaries (at least in the same space of time) in
every part of the body.
  7. The warm bath increases the volume of the
superficial  parts of the body and of the  general
mass of circulating  fluids, in proportion to  the
degree of temperature communicated to  the sys-
tem.   This effect is obvious on the surface gene-
rally, and is demonstrated in parts capable of ad-
measurement.  Rings on the fingers, which we
had  occasion  to notice as becoming loose in the
cold bath, in the warm bath fit more tightly, the
soft parts on both sides  frequently swelling con-
siderably beyond  the diameter of the ring.   The
same thing is  shown by the  greater difficulty of.
putting on tight shoes after the warm bath.  Some
physiologists  attribute the principal results  ob-
served in the  applications of the hot  bath to the
expansion of  tbe fluids.   No doubt it must have
a certain  effect, but by  no means to the extent
which has  been supposed.  The effect of heat as-
a stimulus exciting the heart to increased action,
and  thereby throwing the blood with greater force
and rapidity through the  whole vascular system, is
of much greater consequence than its physical dila-
tation.  It must be recollected that the universal
and intimate penetration by the blood of all the
solid  tissues  will  soon  raise them to  the same
temperature as this  fluid, and, expanding them
proportionally, will remove the evils that might
arise from an over-distension  caused  by a dispro-
portion between the vessels and their contents.!
  § 2. Of the Warm Bath, strictly so called,
        (water from 92°  to 98°.)
  The general effects of  the warm bath  have been
mostly noticed in  the last section; but we  shall
give a brief recapitulation of them here, for the
  t  Is it probable that the impossibility of distension of
the hrnin, within the solid criinium, is one reason why
the effects of baths of very hif»h temperature are particu-
larly felt in the  head? 
BATHING.
277
convenience  of practical reference.  The  warm
bath possesses at once the somewhat opposite
powers of exciting and soothing the nervous and
vascular systems.  Its power of soothing the ner-
vous system  is direct and  obvious; its power of
exciting is, in general, confined within- the limits
of natural  or bealthy action.    It  may be said
rather to prompt  to normal action than to excite.
It acts as a direct but gentle stimulus to the skin,
augmenting the quantity of its blood, and' at the
same time relaxing its  texture.  It produces a
more general and  equable distribution of blood
throughout  the whole  system;  and,  in a  more
especial manner, derives it from the  internal parts
to the surface and extremities, without,  at the
same time, giving rise to undue action or  irregu-
lar  determinations to particular parts.   By  these
various actions it universally promotes absorption
and re-action.  Its ultimate effects are to  soothe
and refresh the whole  system, and, at the  same
time, to render all its functions freer and of  more
ready performance.  When its operation  is pro-
longed, the  soothing  and relaxing effects become
progressively more and more predominant, while
the gentle   excitement  proportionally  decreases.
By these various modes of influencing the system,
it is capable of fulfilling various indications in the
treatment of diseases, according to  the  mode of
its application, and the particular state of the sys-
tem at the time.  By relieving  pain  and irritation,
it acts as a sedative ; by restoring deranged  func-
tions, and rendering them of more ready perform-
ance, it  acts, like  the  cold bath, as an indirect
tonic.  By its soothing effect on the nervous sys-
tem, and its general powers of relaxing, it is  an
antispasmodic.   By  modifying  the  circulation in
the extreme parts, it is strongly derivative ; by its
action on the skin, it is directly diaphoretic ; and
by  more or fewer of tbese modes of action  com-
bined, it becomes a powerful  alterative.  It acts
in several  other ways, to which it is not easy to
give a  formal designation, but  which will  be
understood from what has been stated in the pre-
ceding section, and  what  we  are now  about to
deliver.
  Medical uses of the  warm  bath.—In treating
of the employment of the warm bath, it has been
customary  to consider it  under  two  heads, as
hygeienic and therapeutic, or preventive and  cura-
tive.  As, however, the bath is  never necessary in
the state of perfect health, and as most of the con-
ditions of the body in which it  has been  recom-
mended, are, in fact, deviations  from  this standard,
and therefore,  in strictness of language, morbid,
although perhaps not formally designated as dis-
eases—it is obvious that this classification is not
quite accurate.   We  shall, nevertheless,  so  far
comply  with the  customary arrangement as to
notice, in the first place, the milder forms of disor-
der ; and secondly, the more formal diseases.
  I. The following  are a  few of  the  cases  of
milder disorder, in which the warm bath is highly
beneficial:—
  1. In  fatigue  after great muscular  exertion,
particularly  if long  continued, as from fencing,
boxing,  hard walking or riding, playing at any
laborious game, as cricket, racket, &c.   In these
cases, the body should  be  allowed  time to cool
before the bath is taken,  and the temperature  of
this  should  not be higher than is absolutely ne-
cessary to produce the desired effects. In general,
94°, 95°, or 96° will be sufficiently  high.
  2. After a long journey, more particularly  in
the case  of persons of a delicate or feverish habit.
Travelling for  several  successive days, even  in
the easiest carriage and on the best roads,  pro-
duces, in almost every person, dryness of skin,
irregular distribution of blood, defective secretion
and  excretion,  general  irritation  of the nervous
system, and a slight degree of feverish  heat.   In
irritable subjects, and still more in persons affected
with some chronic inflammation, or tendency to
such, tbe excitement from travelling often  leads
to serious consequences if not speedily allayed.
In  such cases  the warm bath  is an invaluable
remedy ;  and,  when combined with repose and
abstinence, and a gentle aperient, may be regarded
as almost specific for safe travelling.
  3. In  sedentariness from any cause.  Also after
long-continued  mental  excitement  and loss  of
sleep, whether  accompanied by sedentariness and
seclusion, and  inactivity  of the external senses,
as in the labours of the study;  or with  bodily
exertion  and activity  of the external senses, as in
many departments of public and professional life,
or in the no less laborious  avocations of fashion-
able dissipation.
  4. The warm bath is very beneficial in nume-
rous other slight disorders of  the  system,  from
whatever cause arising,  and whether of a chronic
kind, or  the harbingers  of acute diseases.  Of this
sort  are  irregular  determinations  of blood, parti-
cularly  congestions  in  the internal organs, and
recession of it  from the surface and extremities;
nervous irritations of all kinds, and  disposition to
spasmodic affections ; a dry and harsh state of the
skin, either with a disposition to feverishness,  or
with coldness of the surface;  the  reverse state  of
relaxation of the skin, with a  disposition to clam-
miness and cold perspiration, &c.  &c.
  II. The warm batb is beneficially employed  in
numerous diseases of a more formal and serious
kind, and of very different  characters.   We can
only refer to some of those  in  which it is  most
useful :—
   1. Chronic  nervous  diseases of  a spasmodic
kind, unaccompanied by a plethoric state of the
system, or by fever, and not dependent on an in-
flammatory condition of the nervous centres.  Of
this  kind  are  cramps,  spasms, convulsions  of
various  kinds,  and  particularly  the  convulsive
affections of infants,  whether  depending  upon
idiopathic or sympathetic irritation of the nervous
system.   The  last-named qualifications must  be
strictly attended to, otherwise the  bath may  be
productive of great mischief, as we have reason to
know that it often  is  from such neglect.   We
shall have occasion to notice the cautions neces
sary in such cases hereafter.
  2. Various painful affections, chiefly  of a  nerv-
ous or spasmodic nature, occurring in spare habits,
and witbout  inflammation, or with  a degree ex
tremely disproportioned  to the severity of the pain
Of this kind are the numerous forms of neuralgia,
including sciatica and  lumbago,  gastralgia, and
colic;  also  gall-stone,  nephralgia,  stone in the
ureter, bladder, urethra,  &c.
  3. Certain  acute  inflammations, more espe 
278                                    BATHING.
 cially of ihe mucous membranes of the abdominal
 and pelvic viscera, when accompanied by great
 pain.   Of this kind are certain forms of enteritis,
 gastritis,  inflammations  excited by and  accom-
 panying  gall-stone and urinary calculi ;  some
 forms of dysentery,  diarrhoea, cystitis, hysteritis,
 &c.   In all these cases, or with very rare excep-
 tions, previous loss of blood, both  generally and
 locally, will be necessary to constitute the bath a
 useful, or  even a safe remedy.   With such  pre-
 paration, however, and if not contra-indicated by
 the plethoric habit of the patient, or other circum-
 stances, the bath, at a temperature not exceeding
 97°,  is often extremely beneficial.
   In  the  class of cases now under  consideration,
 a great mistake is frequently committed by the
 practitioner overlooking the  inflammations which
 accompany the pain and spasm, and prescribing
 at  once opium and  the warm bath, without any
 attempt to lessen, previously, the violence of the
 local  affection, or the  general  fever,  by proper
 depletion.   In instances of this sort, the  bath,
 more  especially  if administered at  a  high tem-
 perature, as  it often is, has a direct tendency to
 aggravate  in place of relieving the disease.
   4.  Certain chronic inflammations, congestions,
 or  irritations of several  of  the  same  parts, not
 essentially of a painful kind.  Of this sort is that
 extensive class of diseases of the intestinal mucous
 membrane, commonly arranged by French writers
 under the general name of chronic gastro-enteritis,
 and indicated  in different cases by the common
 symptoms  of dyspepsia, constipation, diarrhoea,
 &c.;  also  chronic inflammations or irritations of
 the uterus, vagina, bladder, kidney ;—dysmenor-
 rhcea,  dysury, amenorrhoea, leucorrhcea, &c.  In
 most of these cases local bleeding will  be proper
 previously  to the administration of the bath ;  and
 in  several  of the  affections of the pelvic viscera,
 the hip-bath will frequently be  preferable to the
 general bath.
   In  no class of cases is the  warm bath more
 strikingly  beneficial than in  those  affections of
 the stomach and bowels which are commonly
 ranged under the head  of dyspepsia.   This re-
 mark is more  especially  applicable  to  the  forms
 of this affection  in  which there co-exist a fixed
 local irritation in some part of the bowel, an  un-
 healthy state of the skin, and an irregular distri-
 bution of the blood, more particularly on the sur-
 face and  extremities.  And we may add  that
 there  are  few if any cases of dyspepsia,  of long
 standing, in which one or more of these states do
 exist.  It is well known that the skin has a much
 more  intimate  sympathy with the mucous mem-
 branes than  with the parenchymatous viscera;
 and this truth is in no case more strongly mani-
 fested  than in the effect produced  by the warm
 bath in affections of the gastro-intestinal mem-
 brane.   Besides  its  direct effect in this  way,
 through the  medium of the nervous system, it
acts at the same time locally on the skin as a
powerful derivative, and  as a  means of equalizing
the circulation in  the central and extreme parts.
A sensible  remark, made by M. Rapou, in speak-
ing of the effect of the vapour-bath in  this disease
is equally applicable to tbe warm bath.  He says,
that chronic inflammations of the mucous mem-
binne of the stomach and bowels are frequently
 confounded with diseases of a very different kind,
 such  as nervous  dyspepsia, gastralgia, &c.   In
 cases  of the last-mentioned kind, antispasmodics,
 bitters, tonics, &c, will often be beneficial; while,
 they will be extremely injurious in the former,—
 the irritation of the  membrane being thereby fre-
 quently  excited to inflammation ; or, if this  al-
 ready exists,  it will  be greatly aggravated.   In
 both classes of cases the warm bath is at least a
 safe application ;  and,  with very few exceptions,
 it  is a most salutary one.  Its  administration is
! therefore not affected  by error in diagnosis.  We
i may add that it is in the very cases where internal
! remedies are most prejudicial, that the warm bath
I is most  beneficial; namely, in  irritated states  of
 the mucous membrane, accompanied  either with
 obstinate costiveness  or a tendency to diarrhoea,
 or the one alternating with  the  other.  From  its
 action in such cases, the warm bath  may be said
 to be at once laxative and astringent; and  when
 its use is combined with proper diet and exercise,
 or,  at most, with  a few leeches  to the prsecordia
 or  anus, cures will often be effected by it, in cases
 of long  standing,  with  little or  no aid from me-
 dicine.   Cxteris paribus, the warm bath is the
 more  indicated in dyspepsia the more the surface
 deviates from the healthy state, whether in regard
 to  the distribution of the blood  in  it, or  to  its
 functions as a  secreting and excreting organ.
   5. The  warm  bath  is beneficial in  various
 chronic  diseases of a general and  cachectic kind,
 attended by great functional derangements of im-
 portant organs, and generally by a depraved state
 of  the blood, as well as an irregular distribution
 of  it.   Of this kind are gout, general disorder of
 the system  from  long-protracted  dyspepsia and
 loaded bowels, diabetes, chlorosis,  &c. &c.
   Few  questions  were  formerly  more  agitated
 among medical men than the propriety of warm
 bathing in gout, and more particularly of the warm
 waters of Bath.   The zeal with which the ques-
 tion was regarded has, however, greatly lessened
 in  our time;  partly  because longer experience
 has tended  to  solve  it  more satisfactorily, and
 partly because some  progress has been made  in
 ascertaining the  pathology of gout.  Diseases  in
 general,  and this  among the rest, are not now
 treated on principles so  completely  empirical  as
 formerly.
   In viewing gout in relation to its treatment by
 warm bathing, we may, in a great degree, although
 not  entirely, dismiss from  our  minds its specific
 nature, and prescribe  the bath on the same  prin-
 ciples as in  other diseases.  In the great majority
 of cases,  we consider it  as totally inadmissible  in
 the inflammatory stage of gout.   In the intervals
 of the disease  it is extremely applicable to many
 of the functional  and  other derangements that
 complicate it, or  constitute an important part of
 it;  but the propriety  of  its administration in in-
dividual  cases must entirely depend on the parti-
cular state or degree of these derangements, or on
other states of the system with which they may
be combined.  The great objection to the use of
the  warm bath in gout is the  state of general
plethora  with which this disease is so constantly
connected.  It  is  chiefly the absence of plethora
which  permits  the bath to exert its beneficial
effects m  many other diseases of a still more in- 
BATHING.
279
flammatory nature  than gout;  and  if we have
removed  this condition effectually in gout, the
presence  of some inflammation in the joints is not
a necessary contra-indication to  its use.  In the
general state of disorder in  which gout originates,
viewed abstractedly from the accompanying ple-
thora, there is  no single remedy more valuable
than the warm  bath; in the intervals of gout,
therefore, after  proper depletion, we recommend
its use in the strongest manner.
  6. The warm bath is useful  in  many chronic
diseases  of the  external subcutaneous textures,
with or without general disorder  of  the  system.
Of  this kind are chronic rheumatism, the local
sequel* of gout,  nodosity  and other chronic af-
fections of the joints, partial paralytic affections,
muscular contractions,  &c.  In many  of these
cases the local bath, in the form of douse  or va-
pour, is preferable to the general warm bath, more
particularly when combined  with the operations
of friction, champooing, &c*
  7.  A great number as well  as a great variety
of chronic  diseases of  the  skin, both  idiopathic
and sympathetic,  are  greatly  benefited  by the
warm bath in one or other of its forms.  In such
cases the bath  acts  directly  as  a topical remedy
modifying the actual state of the skin, as well  as
a means  of improving the general health and the
internal disorders with which the cutaneous dis-
ease may be connected.  This is  the class of cases
in which impregnation  of the water with various
saline or vegetable matters dissolved or  diffused
in  it, is  more especially useful, and in which the
stay in the bath may be prolonged  much beyond
the usual period.  When  not otherwise contra-
indicated, it  may be extended  to two  or more
hours.
  9.  The warm bath has been used, more par-
ticularly  on the continent, in the  cold stage of
severe fevers, and in the retrocession  or  imper-
fect development  of sqme  acute  exanthemata.
In such cases, it is employed with the view of at
once stimulating the skin topically, and deriving
from the internal organs.  The employment of
the remedy, however, in such cases requires great
discrimination, and we think it necessary to cau-
tion the young practitioner against its general use.
In fevers of long standing, marked by much ner-
vous  irritation,  harsh dry skin, &c, the warm
bath of a low temperature—or the tepid bath—
is very beneficial.
  Many  other  diseases may be mentioned  in
which the warm bath is occasionally found to be
a very valuable remedy; but we cannot here take
notice of all such cases.  We trust that  enough
has been stated to guide the  inexperienced prac-
titioner to  a safe application  of the remedy  in
most instances  that may present themselves.
   Cautions and contra-indications in the use of
the  warm bath.—There are few remedies more
frequently misapplied than  the warm bath,  or
ivhose misapplication is of more serious ill-con-
sequence.  It cannot be expected that we should

  * In many cases of this kind the local bath invented
by Dr. Blegborough, and termed by  him  the air-pump
vapour-bath, is extremely useful. This  apparatus com-
bines the advantages of dry cupping with the stimulant
or relaxing effects of the vapour bath.  See Facts and
Observations respecting the Air-pump Vapour-bath. By
R. Blegborough, M. D. Lond. 1803.
here enumerate all tbe cases in which it  may be
misapplied, or all the cautions  that  are requisite
in prescribing it.  These must, in a great mea-
sure, be derived  from the  general  principles that
regulate  its  administration ; but  every practical
physician must be well aware how frequently the
principles must  be modified  in  their application
to individual cases.
   The warm bath is either altogether contra-in
dicated in the following cases, or is not to be em
ployed without great caution or previous prepa
ration:—
   1. In very gross, full habits ;  in plethora of all
kinds, in great obesity.
   2. In persons predisposed to apoplexy or de-
termination  of  blood to  the head, hemorrhage,
particularly haemoptysis.   It is  equally improper
in most organic diseases  of the heart and great
vessels ;  and, in general,  in all cases, in which
the excitement of the circulation or expansion of
the fluids is  likely to prove  injurious.  In these
cases the risk,  generally speaking, may be said
to be proportioned to the heat  of the bath ; and
we are far from  asserting that a bath of  a mode-
rate temperature may not be safely administered,
under proper restrictions, in many of the  diseases
now alluded to.  Previous depletion, as  we had
formerly occasion to observe, will often enable us
to use the bath  of a moderate temperature in in-
flammatory  diseases, more particularly   such as
are accompanied with pain, or have their seat in
the mucous membranes.
   3. In  great relaxation of the  system, with  a
tendency  to  dropsy.   In cases  of this kind the
tepid bath, however, will often be useful.
   4. In extreme sensitiveness of the surface, and
in persons in whom the  pressure  of the  water
occasions great precordial distress.  In these cases
the vapour bath is often well borne and  is  very
beneficial.  A little  management will often get
over the difficulties mentioned in this paragraph.
   5. In all febrile diseases, whether accompanied
with visceral inflammations or  not, where there
is an active circulation  and a hot dry skin.
   6. During the presence of the catamenia, ex-
cept in cases of great urgency.  The warm  bath
may be used in pregnancy, more particularly in
the  early months,  but not without considerable
caution.   The contra-indications to  its use must
be found in individual cases ; but it may  be  stat-
ed generally that pregnancy, in  relation to the
warm bath, is to be viewed as  a state of excite-
ment, if not as an inflammatory disease.
   Many other grounds for its cautious  employ-
ment, and also for its total prohibition, have been
noticed  in the preceding  pages; to these and to
the principles on which the general administra-
tion of the remedy is founded, we refer the read-
er.  We would  here only add one important rule
which should never be lost sight of in prescribing
the warm bath,  or,  indeed, any  other powerful
remedy__and this is, never to  recommend it in
any disease  without proper examination of the
individual case.   Much practical  mischief is the
consequence of neglecting this cardinal canon of
therapeutics.  Examples  of this truth might be
drawn from most diseases in which the warm bath
is used.   Thus we have stated  that  it is  a mosi
valuable remedy in chronic  dyspepsia, gout, &c 
ING.
280                                    BAT I

&c, but it is so only provided there exists no ac-
tive inflammation, general plethora, or other anal-
ogous complications.   In many of these cases the
bath will be found extremely beneficial after loss
of blood, purging, or  low diet;  although before
these were had recourse to, it might have been not
merely useless but very injurious.   Infantile  con-
vulsions occur to us  as  another  case in point.
Generally speaking,  the warm  bath is extremely
beneficial in this class of diseases ;  but it is found
to be sometimes no less prejudicial, when applied
without due  examination of the peculiarities  of
individual cases.  In plethoric and gross children,
a very considerable proportion, the local abstrac-
tion of blood  from  the bead,  and the  complete
unloading  of the alimentary canal, are often ne-
cessary to render such a measure beneficial, or even
free from danger.
   Practical administration of the warm bath—
Under this head we  shall embody various import-
ant points  which require particular  attention  in
using the warm bath as a therapeutic agent, and
with which, therefore, the practitioner ought  to be
well acquainted.
   1. Temperature of the water.—The exact de-
gree of heat, between the  limits 92° and 98°, that
is to be prescribed, must be regulated by the pecu-
liarities of  individual cases.   In certain states  of
disease, and in particular  constitutions, the same
degree of temperature will be productive of very
different effects on the feelings  of the patient and
on the  system at large.  It may be  stated  as a
general rule, not however without  many excep-
tions, that any degree  of temperature  may be se-
lected between 93° and 97°, which is most agree-
able to the feelings of the patient.   Many persons
will  prefer  a higher  temperature  than the last
named degree, but few lower than the first.   If
the patient's  feelings require it, and  there is no
particular contra-indication in the case, the  tem-
perature of 98° may be allowed ; but we must on
no account go above this, if our object is to refresh
and soothe, not  to stimulate and  exhaust.   The
temperature of 95°  or 96° is, on the whole, that
which  is most generally pleasant and beneficial at
the same time; and if either  of these is found
sufficiently high to maintain the feelings of com-
fortable warmth, through the whole period of the
bath, the temperature  must not be raised.  If a
lower temperature, however, is found more agree-
able, this may, in most cases, be allowed  at the
will of the patient.
   Generally speaking, in the warm water bath, the
same degree of temperature must be kept up dur-
ing the whole period of immersion ; and this will
easily be effected by  the addition of a small quan-
tity of hot water about a quarter of an hour after
the patient has been  in the  bath.*   The  temper-
ature must always be  ascertained by the thermo-
meter in the first instance ; and the subsequent ad-
ditions of water are to be regulated by its indica-
  * Considerable difference  is observed in  the rapidity
with which the warm bath cools; dependent on the ma-
terials and construction of the bath, its size, the circum-
stance of the same  bath having been previously used or
not, the temperature of the  bather's body generally the
degree of motion kept up in the water, &c. &c.  The
only safe mode of regulating the temperature is by keep-
ing a thermometer constantly in the water, to be observ-
ed from time to time by the patient or attendant.
tions,  and not  by  the  feelings  of the  patient
Great  mistakes are often committed through neg-
lect of this rule, the temperature  being gradually
and imperceptibly raised  much above  that of the
warm  bath, with the entire frustration of the ob-
jects with which the remedy is prescribed.
   2. Period of stay in  the bath.—The time 'of
the immersion, like the temperature, must  be de-
termined by the practitioner in each case, accord-
ing to  the nature  of the  disease, the  constitution
of the patient, and the object for which the bath
is prescribed.   Speaking generally, a  quarter of
an hour may be said to be the shortest period, an
hour the longest, and twenty-five minutes to half
an hour the medium.  Periods greatly longer than
these,  however, are very common, more particu-
larly on  the  continent,  and are, no  doubt, very
proper and useful  in certain cases.  In the mine-
ral water baths at  different  places in Germany
and Switzerland, persons are accustomed to con-
tinue several hours consecutively in the bath, and
even repeat the immersion after a short interval,
so as  to remain in the water eight, ten, and even
twelve hours in  the course of  one  day.  The
effects of the bath are, in all  cases, greatly modi-
fied by the length of the immersion.   It may be
stated  as a  proposition  generally true, that the
bath, at the temperatures now under consideration,
is more relaxant, and deobstruent the  longer it is
continued.  If at all approaching the temperature
of the  blood, it has always some  stimulant effect
at first, and it is  only after  this  has  completely
subsided, that the  relaxing effects  are fully expe-
rienced.   For this reason the same bath may be
exciting if continued only ten or  fifteen minutes,
and soothing and  relaxing if continued twice or
thrice  as long.   It is not  merely in cutaneous dis-
eases,  in which one of the principal objects is to
produce a decided change in the affected parts by
the local action  of the fluid, that  the  immersion
for  several consecutive  hours is recommended;
the same practice is capable  of producing very
beneficial results in various chronic diseases of the
internal organs.  The least  consideration of the
subject, independently  of experience,  must lead
to the conclusion, that   an  action of this kind,
kept up for so long a time on the whole cutaneous
surface, must have a powerful effect as a revulsive,
and occasion important changes  in the condition
of the  internal organs.   We are  of opinion that
this mode of employing the warm bath is too little
practised in this country.  It can only be  conve-
niently obtained at thermal springs, where alone
large bodies of water of the  proper temperature
are always to be  had, and  where alone, conse-
quently, the large  or plunge bath  of this temper-
ature is to be found.  So prolonged a stay in the
common solitary bath would be altogether intoler-
able.   Admirable  opportunities for this kind of
bathing are, however, afforded  by the  large mine-
ral baths at Bath  in  this country, and at  many
places  on the continent.   The  Queen's Bath, or
the Cross Bath, at  the  former place,- is exactly
suited  to the purposes now  contemplated, being
of the  temperature best  adapted  to effect  them,
namely, from 94°  to 96°.
  3. Time of using the bath—This, like the pre-
ceding circumstances, cannot be  absolutely fixed.
When prescribed in acute diseases, the bath must, 
BATHING.
28*
of course, be employed at any time when needed.
In chronic diseases, or when used  as  a measure
of hygeiene,  the  hour of bathing may be fixed.
It is the practice at Bath, and some other mineral
springs, to bathe  early in the morning ;  but we
apprehend this practice is  adopted as  much from
motives of convenience as  because this  time is
deemed preferable.  On the  contrary, we should
say, as a general rule, that the best time for bath-
ing is between breakfast and dinner, either two or
three hours after breakfast, or an hour and a half
before dinner.  The latter period has this advan-
tage, that the patient is  less  tempted to expose
himself to the open air after the bath.
   4. The conduct of the patient while in the bath,
 as also  previously to  its use and afterwards, de-
 serves  some  notice, although this is  of less mo-
 ment, perhaps, than in the case of the cold bath.
 It is proper to enter the bath in as tranquil a state,
 both of body and mind, as possible.  The patient,
 therefore, must  not  bathe  while greatly  heated
 with exercise or stimulated by a recent meal, more
 particularly after  drinking  much wine.  A state
 of chilliness or coldness forms no objection to the
 bath.
   While in the  bath, the whole  body should be
 covered  with the water, or  rather the parts that
 have been once  immersed should not be left ex-
 posed to the air.   Friction,  with a coarse cloth or
 with the flesh-brush is generally to be  recom-
 mended.  In the large baths which admit of loco-
 motion,  this will, as a matter of course, be used,
 and should be used.
   After the bath, the patient should not unneces-
 sarily  expose himself to the open  air for some
 time, especially if the  weather  be cold ;  and  it
  may be  stated as a good rule for him to  remain
 quietly in the bouse for an hour after the bath.  It
  is not, however, intended  to be asserted that there
 is, in general, much, or indeed any risk in the pa-
  tient going abroad  immediately on coming out of
  the bath : on the contrary we believe that there is
  much  less risk  of catching  cold  immediately on
  coming  out of  the bath than  afterwards ;  and,
  except in the  case of very delicate  or diseased
  persons, there is  no objection to the patient walk-
  ing from the bath to his own home, if at no great
  d«etance.  We, however, consider it better that
  no unnecessary exposure or considerable bodily
  exerci&c should be taken for an hour or two after
  bathing, for the same reasons that we deem them
  impropei after  blood-letting or  any other import-
  ant therapeutic  operation.   When  one  of the
  objects of th«! bath is to excite much sensible per-
  spiration, it will  be proper for the patient to go
  to a warm bed after  it, to place himself between
  blankets, and remain there as long as the perspi-
  ration continues.  When  the  object is  not  to
  excite perspiration, the patient should not  go to
  bed, but dress  himself in his  ordinary clothing.
  It is a  slight circumstance, but  one deserving
  notice in this place, because of some consequence,
  and often neglected, that the towels used for dry-
  ing the body should be always warmed, and, of
 course, thoroughly dry.
   5.  Repetition of the bath.—The frequency of
 repetition of the bath, like the other circumstances
 connected with its exhibition, must be regulated
 by the exigencies of individual cases.  One bath
    Vol. I___36                        t*
daily is the maximum of frequency, (except in
certain cases formerly noticed ;)  once a week, the
minimum.   The most usual, and upon the whole
the best rule  is—to take the bath every second
day, or, at least, every third day.  Tbe length of
time that a course of warm bathing is to be con-
tinued cannot be at all fixed, except in individual
cases ; and  then only by observing the effects of
the remedy.
   6 Form  of the bath. — The  special mode of
applying the warm bath is not a matter  of indif-
ference.  It is true  that, in a great  majority of
cases, the common small bath,  in which the pa-
tient is immersed in the semi-recumbent posture,
answers every purpose  for which the  bath is ad-
ministered.   In some  cases, however, more par-
ticularly where the  immersion is greatly pro-
longed, tbe  constrained  position in which  this
bath is taken cannot be borne.   In such instances
the large open bath, which admits of locomotion,
is greatly to be preferred.  Even  independently
of the relief from the uneasiness of a constrained
position, there are  many cases  in  which the free
movements permitted in the large bath are directly
beneficial.   Of this kind are local affections of
the limbs and joints, in which the contemporane-
ous use of free motion and friction while in the
water is of the greatest benefit.  The advantage
is no less evident in many cases of internal dis-
ease.  We hold  it therefore far from a matter of
indifference in every case, which of the two forms
of bath is used;  and on this ground alone it will
frequently be proper  to give  the preference  to
Bath as a place of resort for the invalid for whom
warm bathing is recommended,—this being  the
only place in England where the warm bath, with
the full benefit of locomotion, can  be obtained.
   7. Influence of saline impregnations in modi-
fying the effects of the warm  bath.—In the pre-
ceding observations, we have spoken of the water
bath,  without regard  to  its impregnation with
saline  or  other  extraneous  substances.  It  is,
however, necessary to  notice these in this place.
This  subject is, perhaps,  less  regarded  in this
country than  it ought to be.   Many persons seem
to consider only the  temperature, deeming it  a
matter of  indifference whether  the water is that
in common use for domestic purposes, or is that
of the sea or of mineral springs.  This is a very
great mistake, and can only arise  from  inexperi-
ence or want of observation.  Two or three trials
on  delicate and relaxed subjects  will suffice to
convince any one that the two  kinds of baths are
productive of very  different effects.  In general it
may be stated that water containing  mineral  and
 saline substances in solution, is less relaxing and
consequently more tonic than pure water.  Such
compound baths can be borne for a longer period,
 and  are followed by  less exhaustion than baths
 of pure water.   Patients are also less liable to
take cold after the former.   When, therefore, the
 object is to produce great relaxation and exhaus-
tion, as in certain cases of acute inflammation,
pain, or spasm, the pure water  bath is to be pre
ferred ; while, on the  other  hand, the  saline or
mineral water bath is to be administered if the
object is not to exhaust but to refresh.   In cuta-
neous diseases, sometimes one  kind of bath will
be preferable, sometimes another, according to tho 
282                                     BAT
nature of the case.  The compound  bath is cer-
tainly more stimulant  to  the  skin, consequently
more derivative from the internal parts ; and this
circumstance will, no doubt, account for much of
the difference observed between the two kinds of
bathing.  It would, however,  be both unphiloso-
phical  and unjust  to consider  the  chemical com-
position of the  water as a matter of indifference,
provided the same degree of stimulus were com-
municated by it to the skin.  Without pausing to
examine the question as to the absorbing powers
of the skin, and  the  actual  transference of the
materials of the bath into the blood through this
medium, it is a matter of simple observation and
fact, that  the  effects  of  bathing  vary with  the
nature of the chemical composition  of the  fluid.
The warm baths attached to  the mineral springs
of  Bath, Buxton, Cheltenham or  Leamington,
Harrogate, Matlock, and Tunbridge-Wells, have
each peculiar effects.  The warm  sea-water bath
differs from all these; and, although the differ-
ence  may  not  be often appreciable, there  is no
doubt a difference  even in the  action of river, rain,
spring, and hard and soft pump-water respectively.
In the cases in  which the  saline bath is considered
preferable, an  easy and in general an  effectual
substitute is afforded by the addition of common
salt to plain water ;  and it will be found,  in prac-
tice, that such  addition is to be recommended in
the majority of cases  in which the warm bath is
prescribed medicinally. When used as a measure
of hygeiene, the saline bath is in almost all cases
to be preferred.
   § 3.  Of the Tepid Bath,  (temperature of the
      water from 86° to 92°.)
   The effects  of  the  bath of a temperature con-
siderably below that of the body, yet still commu-
nicating the sensation of warmth to the  surface,
are similar in kind to those of the warm bath, but
inferior in degree.  Generally speaking, the tepid
bath is less pleasant, less animating, less soothing.
It  possesses neither  the  direct stimulus  of the
warm, nor the  indirect stimulus of the cold bath.
When prolonged, in  place of the tranquillizing
effects produced by the warm bath, it gives rise to
a gradually increasing sense of chilliness  and dis-
comfort.  Caloric is carried  off  from the body
faster than it is produced, while the unstimulating
and relaxing medium  has no  power, like  the cold
bath, to rouse the  vital energies of the system to
increased vascular action and  augmentation of the
processes that produce animal heat.   In its medi-
cal effects, as well as in its thermometrical charac-
ter, the tepid bath may be said to occupy a middle
position between  the  temperate and warm baths.
In all  cases where we  consider the  warm bath
indicated, but are  apprehensive that from particu-
lar circumstances  it may prove too exciting, we
must of course reduce  the  temperature to the
degree that can be borne.  We formerly had occa-
sion to observe that only the very lowest degrees
of the warm bath are found tolerable  by some
persons; and  we may add  that, in some  rare
cases, even a still  lower temperature is necessary.
 In such individuals  the  tepid  takes the  place of
the warm bath as a matter  of necessity.  On the
other  hand, among  the class  of persons whose
cases  are  commonly benefited by the temperate
 with,  some will be found whose peculiarity of
ING.

habit will  require  the  temperature  to be  raised
within the limits of the tepid bath.
  Besides  these cases  requiring the tepid bath
from the  idiosyncrasy  of the patient, there are
others which require it from the peculiar character
of the affection.  Of this kind  are various mild
febrile diseases  connected with  much irritability
and  a dry harsh skin ; morbid states  of the skin
itself, in which there exist, at the same  time, a
very irritable and  a dry and  heated state of it.
There are many other cases in which the tepid
bath is beneficial, and which will readily suggest
themselves to those who understand the principles
on which the cold and warm baths are prescribed,
and  are practically conversant with  their  effects.
Our limits  oblige  us to  be contented with this
general reference, and  the very imperfect  outline
bere given.
   §  4.  Of the Hot Bath, (temperature 99° and
      upwards.)
   This bath is a powerful but  temporary stimulus
to the skin and to the nervous and vascular sys-
tem, and  in  a degree proportioned  to its tempera-
ture.  In the state  of health, and in disease gene-
rally, it has no soothing  effects ; nor does it, like
the  warm bath, gently  solicit  and  encourage  the
natural actions of tbe system, but  impels them
suddenly, forcibly,  and irregularly.   It tends more
to disturb than to equalize  action.  The heart
being powerfully excited, the blood is forced with
rapidity through the whole vascular system, the
pulse being raised  ten, twenty, and even fifty pul-
sations in the minute, and increased proportionally
in strength.   This preternatural force of the cir-
culation is felt in a particular manner in the head.
The carotids are seen and felt to beat powerfully,
and headach, giddiness, and other  cerebral symp-
toms are of frequent occurrence. The combined
effect of the increased action of the heart and the
direct stimulation  of the skin by the local heat,
occasions  a  great afflux  of blood to the surface,
which becomes universally red and  swollen. This
determination of blood  to  the surface does not,
however, like that produced by the  warm bath,
relieve the internal organs ;  on the contrary, it is
very generally accompanied by great  and irregular
determination of blood to these parts.  The great
tension on the surface is, after a time, relieved
by  the breaking out of a general  sweat  on all
parts not covered by the bath ; and there is reason
to believe that the same  takes place on the parts
that are immersed.  The other secretions are, like
the  distribution of  the  blood, irregular and uncer-
tain, some being increased and others diminished.
If the bath  is  continued, although  the pulse re-
mains quick, the general excitement is  speedily
followed  by universal languor, lassitude, and de-
bility;  and  torpor and  somnolency surpervene
from exhaustion of the animal  powers, as in the
case of the warm bath they had been induced by
the  tranquillizing influence of the remedy  on the
sensations and the nervous system generally.
   In their action, both  the  warm and hot bath
 are  stimulant to the nervous and vascular systems,
but  in very different degrees  and with very diffe-
rent results.   The primary effect of the  former
 may be compared  to that of  a moderate meal of
plain and wbolesome nutriment; that of the latter
 to the potent and sudden stimulation of vinous  or 
BATH
other  strong drinks;  and  their ultimate effects
may also be said to be analogous.   The gentle
stimulus  of the  warm bath  remains some  time
after its application, beneficially  prompting  and
aiding the healthy actions of the system, and  gra-
dually vanishing in the  habitual conditions of
health; the hot bath, on  the contrary,  excites
beyond the limits of safety, disturbs  the normal
actions of the system, and then suddenly disap-
pears, leaving behind it exhaustion and debility,
and frequently disease.
   The warm bath is in  common use as a measure
of hygeiene and for  luxury, as well as  a  curative
agent. The hot bath is exclusively therapeutical,
and its employment in this way is very circum-
scribed.  We  had   occasion  formerly  to remark
that there are certain peculiarities of constitution
and states of disease where it is necessary to raise
the temperature of the water above that of blood
heat,  before the ordinary effects of  the warm bath
are experienced.  In ordinary cases, however, the
bath at this high temperature produces the effects
 just described, and  these are obviously of a kind
which render it improper  as a remedial  measure
in  the great majority of instances in  which  the
 application of heat to the surface can be supposed
 to be indicated.  The hot bath is, nevertheless, a
 valuable  remedy in  certain cases.   Owing to its
 highly stimulating  and  exciting  qualities,  it is
 applicable  to morbid states in which the warm
 bath, if not injurious,  is  at least of inadequate
 power; as, for instance, when we wish to produce
 a great and rapid excitement either of the general
 system, or only of the skin, or of both at the same
 time.  It is tberefore  applicable in the following
 and other analogous cases : —
    1.  In extreme exhaustion, with  a  cold  shrunk
 state  of the skin and superficial parts of the body,
 and a concentration of the circulating fluids and
 the nervous energy  in the internal organs.  Exam-
 ples of this morbid state are furnished  by spas-
 modic cholera, certain forms  of pernicious fever,
 ague, &c.
   2.  In  sudden retrocessions of cutaneous  dis-
 eases, both of an acute and chronic kind; scarla-
 tina, measles, &c. &c.  &c.  In certain inflamma-
 tory affections of the internal organs, in which the
 circulation is equally concentrated in the interior
 of the system, and the  pulse is  too  feeble and
 small to allow venesection to be performed :  some
 forms of  enteritis and gastritis, as from retrocedent
 gout, are of this kind ; but the utmost caution is
 requisite  in applying the remedy in all such cases.
   3.  In chronic diseases of the skin.   In this case
 the bath is used chiefly as a topical  remedy in
some of  the  most  obstinate and indolent forms,
 with  the  view of exciting the skin, and altering its
physical  and vital  condition.   Its application in
cases of this kind  requires great discrimination
and caution ; but with the proper care it is capa-
 ble of being made a very powerful  remedy.
   4.  In certain cases of paralysis of long standing,
when there are no grounds for apprehending that
the stimulating  effects of the bath may induce
fresh  disease within the head.  The very existence
of  the paralytic state frequently renders  the  sys-
tem less susceptible of the stimulus of heat; apd
when  this is the case, there is no doubt that an
application so powerful and extensive as the  hot
ING.                                    283

bath must in many cases be productive  of excel-
lent effects.   This remedy is in great use at Bath
in such cases; the patients being  accustomed to
remain in water, of the temperature of 104°, up-
wards of an hour without suffering any inconve-
nience, and frequently with much advantage.
   In  most  of the cases  above mentioned, the
object  is to  obtain the  stimulating and not the
debilitating effects of the bath ; it ought, therefore,
to be  used at the highest temperature  that  is
deemed proper, and  continued  only  for  a very
short period.
   All the cautions and contra-indications formerly
delivered respecting the use of the warm bath, are
still more necessary in the case of the hot bath.
   § 5. Of the Vapour Bath.
   Forms of the vapour bath and modes of using
it.—In treating of the warm bath it was  almost
unnecessary to notice the  particular forms in which
it is administered, as  these differ very little from
each other, either in their nature or effects on the
system.  The case is different with  the vapour
bath; there being several modes of applying this,
which are productive  of  results respectively diffe-
rent.
   There are two principal  forms of this bath : —
1. The free  or public  vapour bath, steam chamber
or humid stove, bagnio, Russian or Oriental bath.
2. The confined  or solitary vapour bath, such as
is commonly used in  this country.
   1. The free or Russian bath consists of a close
room filled with vapour, in which the patient may
move about at pleasure, and where many persons
may bathe in concert.  The chamber is commonly
of considerable dimensions, and is arranged some-
what in the manner of a theatre, with benches
rising  one above  another.   In  the Russian and
German baths the vapour is produced within the
apartment by throwing water from time  to time
upon red-hot stones,  heated by  a furnace  under-
neath.  By this process  the whole room  is soon
filled with vapour, heated to a temperature vary-
ing from 112° to 160°  or  180°, the heat, owing
to the diminished gravity  of the  air, being pro-
gressively  greater with   the  elevation  of the
benches.  In  the best  arranged  establishments
there are various other apartments connected with
the bathing-chamber.  The bathers first enter an
ante-room, not containing any vapour, but heated
to the temperature of  from 75°  to  80°, where
they take off their ordinary clothing, put on a
propel- dress, and  then enter the bath.   On first
commencing the use of the  bath, the patient com-
monly remains on the lower benches, where the
temperature varies from 112°  to  120°.   At the
successive  visits he  progressively  ascends the
benches  until the temperature  is 130°  to 140°.
During the  bath it is customary' to rub the body
with soap-suds, wheaten-bran, &c, or to  have it
gently beaten with small leafy twigs.  It is also
common to apply a cloth, dipped in  cold water,
to the head  or face, or to have cold water thrown
on the head or some  part of the body, from time
to  time, by means of a  douche-tube, the watei
being applied either in an undivided stream, or in
the form of a small partial shower bath.   Having
remained the requisite time, the bather descends ■
from the upper benches,  and after  a short stay in
this lower temperature he retires to another room 
HING.
284                                    BAT!

heated with warm air, where, after being dried, he
puts on a flannel dress, and lies down on a couch
for some  time.   Frequently, previously to lying
down, the  patient drinks some warm fluid, and
takes other steps to  encourage perspiration.   He
then returns to the ante-room, where it is custom-
ary to remain a short time after being dressed, in
order that he  may  be somewhat  cooled before
going into the open  air.*
   2.  The confined or solitary vapour bath is that
in general use  in this country.  The distinctive
character of this is that the patient is restrained
from locomotion, being confined in a  small close
cell or tent of cloth,  containing the vapour.
   This form of bath  admits of three modifications:
a. the head of the patient being included in  the
apparatus, so that respiration is restricted to  the
air in which  the vapour is  suspended ; b.  the
head, or at least the  mouth, not being  included in
the apparatus,  so that the patient breathes  the
common air of the  apartment; c.  the apparatus
being  so  arranged  as  to  admit  of  the  patient
breathing  either  the vapour of  the  bath or  the
external air at pleasure.
   The  vapour  bath, as  generally used  in this
country, scarcely requires  description.  It consists
essentially of a  small frame of wood  surrounded
by a woollen or other cloth  impervious to vapour,
enclosing  a space little more  than  sufficient to
contain the  body of  the patient seated on a stool
in the centre of it.   The vapour  is admitted at
the lower part of the apparatus  by means of a tube
connected  with a vessel  of boiling water.  The
more common  modification of the bath used in
this country is that which permits  the patient to
breathe the air or vapour at  pleasure, by excluding
or including the head through  an opening in  the
side of the covering.   Fixed baths of this kind are
now common  at all our  watering-places, and in
most  of the large towns in the  kingdom ; and
there are  several varieties of  the apparatus of a
portable kind equally effective.   The best of these
are the modifications introduced by Captain Jekyll,
Mr. Green, and Dr.  Gibney of Brighton.-j-
   General effects of the  vapour bath. — As  the
principal effects produced by both the  vapour and
warm water bath depend,  in a  great  measure, on
the same  cause, namely, the  application of heat
and moisture to the  surface  of  the  body, it is  ob-
viously unnecessary  to enter on a detail of all the

  * Osann, in Encyclopiidisches Worterbuch der Med.
Wissensch. Art. Bad. Band. iv.  Berlin, 1830.
  t Many substitutes for these  more  elaborate contriv-
ances have been suggested, and may be extemporaneous-
ly employed with sufficient effect when such are not at
hand.  A thick blanket or two  thrown round a drying-
screen, or other frame of wood, aud placed over a steam-
tube connected with a  common kettle, answers the pur-
pose very well.  The common slipper-bath  may also be
used for the  same purpose, the patient being guarded
from the sides of the bath by a covering of flannel, and
the mouth of the bath being closed by a blanket placed
round the  patient's neck; the steam  being  admitted
through an opening in  the lower part of the apparatus.
Perhaps one of the simplest, least  expensive, and most
convenient forms of the portable vapour bath, consists
of a large open  wicker basket, like that used by wool-
staplers, reversed over the patient and covered with
blankets, the patient being previously seated on a small
stool or chair placed upon a piece of floor-cloth, near the
chimney of the apartment  The tube from a small port-
able §team-boiler, placed on  the common  fire, is intro-
duced along  the floor.   The  basket is so  constructed,
with a sort of open door at one  side, as to  admit of the
exclusion of the patient's head  at pleasure.
consequences resulting from the use of the vapour
bath, as this would be to repeat, in a considerable
degree, what has been already described.   Our
object will  be sufficiently  gained by  stating, in
this place, the chief differences which exist be-
tween the  operation  of the  vapour bath and the
warm water bath.   These  have chiefly reference
to the bath  as a  medium of communicating heat,
and as influencing the functions of the skin and
lungs.
   The difference in the beating power of different
media was formerly referred to when treating of
the water bath as a means of increasing the tem-
perature of the body.   It was there stated that the
heating  power  was greatly influenced by the
density of the medium, its capacity for caloric, its
conducting powers, the  relative fixedness  of its
particles, &c.  Cxteris paribus, the more intense
the degree in which these qualities exist in the
medium, the greater is its heating power.  The
following are the highest temperatures at which
the respective liquids could be borne by the hand
of the same individual : spirits, 130° ;  oil, 129°;
water, 123° ; mercury,  117°.   (Phil. Trans, vol.
lxv. p. 111.)  As a general bath, water can hardly
be borne at the temperature of 120° ; Rostan bore
it with great inconvenience for half an hour, of
the temperature of 115°.  In the form of vapour,
however, this fluid can  be  employed as a bath at
much higher temperatures.   The ordinary heat
of the Russian or Oriental bagnio is from 120° to
140° ; and it is occasionally raised  as  high as
180° or 190°.   The same difference of results, as
to the relative heating power of water and watery
vapour,  was observed  by Dr. Edwards, in his
experiments on  animals.  He  could  never get
frogs to  remain  alive more than two minutes in
water of the temperature of 104°, although the
head was not immersed ; while they survived the
same degree of heat in  vapour  (and breathing it)
upwards of five hours.  (Loc. cit. p. 374.)  When
conveyed by the still rarer medium of air, it is
well known that heat  can be sustained, without
inconvenience, at degrees  greatly exceeding the
highest now mentioned.  In the experiments per-
formed in heated rooms by Drs. Fordyce, Blag-
den,  and Dobson,  air  of a  temperature  varying
from 200° to 260° was borne for a considerable
time with perfect impunity.  A still higher tem-
perature, viz. 270°, had been previously borne by
some young women in  France, as  recorded by
Tillet and  Duhamel;  and yet  greater heat  has
been sustained by others since that time.
  In respect of the heating  power of watery va-
pour,  an important  difference results from  the
circumstance of  its being breathed or not by the
patient.  The application of the vapour  to  the
lungs  tends to increase the animal temperature,
not  merely by reason of the additional surface
thus exposed  to  the influence of the heating me-
dium, but because such application puts a stop to
the  cooling  process of evaporation constantly
going on from the lungs in a dry air.   It  is ex-
tremely difficult to ascertain the exact ratio of the
heating powers of water and of vapour in its two
different forms of application.  Judging, however,
from the results of common practice in the differ-
ent kinds of bathing, and from  a pretty extensive
examination of the observations  and opinioni of 
BATHING.
26o
practical writers, we are disposed to place reliance
on the following comparative view as containing
as near an approximation to the truth as can be
obtained on such a subject.  For reasons of prac-
tical convenience we retain the ordinary divisions
and titles of the warm-water bath.
	WATER.	VAPOUR.
		Not Breathed. | Breathed.
Tepid Bath .. Warm Bath..	85°— 920 1)20— 98° 980 — 106O	960 _ ]06O JlOO — 100O 106° — 120O 100O — 110° 120° —lliuo | 1100 — 130°
  Independently of its greater power of commu-
nicating heat to the body, when extended to the
pulmonary surface, the vapour bath, when so ap-
plied, will necessarily exert a very different local
influence than when its  action is confined to the
skin.  This  difference of effect must always be
kept in view in prescribing the remedy in affec-
tions of the  chest, or in  persons  predisposed to
these.
  There is little doubt that at the corresponding
degrees of temperature, the vapour bath occasions
a greater degree of cutaneous transudation than
the water bath,  a circumstance easily explained
by the difference of the two media as physiologi-
cal agents.  We would, however, make  one re-
mark here in  reference to this point, as it is of
practical  importance, and this is, that  a  part of
the  additional  perspiration experienced  in the
vapour bath  often arises from the disproportionate
degree  of temperature  employed.  Much greater
latitude is commonly permitted in regulating the
heat of the vapour bath than of the water bath:
and we know  that  the  former is  often  used  at
temperatures corresponding with those  of the hot
bath, when it is intended to be used—as a warm
bath.  One  of the  causes of increased transuda-
tion in the  vapour bath  arises from the greater
accumulation of fluids in the cutaneous  and su-
perficial tissues, a necessary physical result of the
greater rarity  of the medium; and this  circum-
stance, moreover,  constitutes  the  vapour bath a
more powerful derivative, cxteris paribus, than
the water bath.*
   It is particularly necessary in using the vapour
bath to attend to the actual  temperature as indi-
cated by the thermometer; even more so than in
the case  of  the water-bath; the gradual increase
being less felt owing to  the greater rarity of the
medium.  And  the caution is still more requisite
because,  in  using the vapour bath, the tempera-
ture is gradually raised-to the proper degree, after
the patient is in the bath.
   Medical uses of the  vapour bath.—Generally
speaking, the  solitary vapour bath in which the
head is not included may be  said to be applicable
in  the same cases as the warm water bath, and
to be productive of similar results.  An attentive
consideration of the peculiarities of action of the
two kinds above noticed will point out the parti-

    it is,  probably, in  this circumstance of the relative
amount of superficial compression in the two cases, that
we are to find an explanation  of a  phenomenon fre-
quently experienced in the water bath, and very rarely
in the vapour bath.  We allude  to that  feeling of pre-
cordial oppression on first entering the bath, which is so
distressing to many persons, and which, indeed, occa-
sionally renders this form of bathing impracticable ; the
Biidden retropulsion of the blood from the whole surface
of the body upon the heart and  lungs giving rise to the
feelings of distress alluded to.
cular cases in which the one is to be preferred to
the other.  The vapour bath at the corresponding
(not the same)  degree of temperature must be
considered as upon the whole more derivative to
the surface,  more diaphoretic, and  probably less
stimulating generally.   It seems, however, to have
a less soothing  effect on the  nervous  system.
This result, in some cases at least, is partly owing
to the more constrained and to  the  upright  posi-
tion in which it is usually taken.   The reclining
posture used  in the solitary water bath, where no
muscular effort is required to keep the body in its
position, gives it a decided superiority over the
common  vapour bath or  large  water-baths, in
cases of great debility or severe disease.  In such
cases, however, by a  particular contrivance, the
vapour  may  be applied to the patient in bed.
   Most of the cases  formerly noticed  under the
head  of the.  warm  bath are equally benefited by
the vapour bath,  and some seem  more benefited
by the  latter.  We shall  only  here refer to one
of these, namely, the  well known condition of
the system which precedes many acute diseases,
and which is familiarly known  by the  name of a
chill, because it is usually produced by the appli-
cation of cold. This state often exists  for several
days  before the re-action of disease  and fever su-
pervene.  It is the usual precursor of acute catarrh
or  bronchitis, asthma, pneumonia, rheumatism,
diarrhoea,  or dysentery, &c.; in a word, of the
numerous class  of inflammatory diseases which
derive their  origin from cold.  In most of  these
cases the vapour bath  is a very effective remedy
if  administered  at the proper  time and in the
proper  manner.   The most  proper time is the
earliest possible  after the application of the mor-
bific cause ;  but  the  remedy  may still  be applied
with benefit, although with much  less effect,  at
any time previously to the actual  establishment
of the  local  inflammation.  After this has taken
place, or is about to take place, the application of
the bath will, in most cases, be more injurious
than  beneficial.  In cases of the kind now under
consideration, the vapour bath,  particularly if the
vapour is breathed,  appears to  possess decided
advantages over the common warm water  bath.
But  although fully convinced  of the admirable
effects  likely to  result from this mode  of  treat-
ment, we  cannot consider it as  a  practice  to be
had recourse to at the discretion of patients, with-
out medical  sanction,  as, like all  powerful reme-
dies, it is capable of doing harm  as well as  good.
Under  proper regulation, we have little doubt that
it will in many cases effectually check  the morbid
process, which,  if left to nature, must end  in
formal  disease.   The temperature in cases of this
kind should not be  high.  The object  being  to
derive to the surface without exciting the circula-
tion, the  application  of  the  vapour  should be
commenced  at the lowest degree which is felt tu
be agreeable, as  about 95°, and  the temperature
should be gradually and slowly raised,  and should
rarely exceed 106°.   The more  copious the per-
 spiration that can be excited at a moderate degree
 of heat,  the more likely is  the result  to  prove
beneficial.
    §  6. Of tlie Warm Air  Bath.
    The temporary exposure of the naked body to
 the air of a common  chamber has been termed 
286
BATH
ING.
the air-bath;  and although it has not often been
formally prescribed in disease, it  has frequently
been  had recourse to as  a means of relieving
slight degrees of feverish  restlessness.  It  was
practised and recommended for this purpose by
Franklin.  The immersion of the body in air of
which the temperature has been artificially raised,
is  a therapeutical mean of much greater power,
and has been extensively vsed as such.   This is
what  is termed the vjarm air bath.  Like  the
vapour  bath, it is of two kinds, according as  the
air is breathed or not breathed.  Warm air cham-
bers have  been employed  on a  great scale, as
luxuries, by persons in health, and especially by
the ancient Romans.   They are still occasionally
used for medical purposes, but more frequently as
appendages  to  vapour  baths than  as  distinct
baths.  The  heated air chamber  has, however,
formed  a frequent  medium for experimenters to
ascertain  the effects of high degrees of  heat on
the animal body.  The experiments of Drs. For-
dyce, Blagden, and Dobson, in England,  of Dela-
roche and Berger, in France, and of many others,
undertaken with this view, were formerly noticed
and are well  known.  We allude to them here,
only  for the  purpose of  again remarking, that
owing  to the great rarity of the  medium and to
the cooling  effects of the  evaporation produced
by the dry air, a very  high degree of temperature
can be  sustained in air with little inconvenience.
Much  lower  temperatures, however, than were
borne in these experiments, suffice to produce all
the stimulating effects of  the  ordinary hot bath,
whether of vapour or water.  In the experiments
of M. Berger and Delaroche in air  of a tempera-
ture varying  from 150°  to 190°, the following
effects  are noticed:—A considerable  degree of
smarting was perceived  in different parts of the
surface, particularly in the eyes,  nose, and nip-
ples; the  superficial  veins became  universally
dilated; the  surface,  at  first  burning hot,  was
soon covered with general  and very copious per-
spiration.  The  temperature  of  the body  was
raised  several degrees;  the pulse  rose  to 160;
the respiration  became  anxious;  and headach,
vertigo, and other symptoms of cerebral  disorder
took  place.   The  above temperatures represent
those which correspond  with the  higher degrees
of the  hot  water bath.   Much lower, therefore,
are employed when we wish to  produce effects
corresponding to those of the warm water bath.
   The  warm air bath  is  now  most commonly
used as a solitary bath, the patient not breathing
the heated  air.   By much the most convenient
form of the apparatus is  that  introduced a good
many years since by Dr. Gower, under the name
 )f the  sudatorium*  This consists merely of  a
semi-cylindrical frame-work of wicker, laid over
the patient in bed, and  covered  with blankets.
By  means of a metallic tube  communicating
with the end of the frame, a stream of air, heated
by a lamp placed at the  extremity of the tube, is
directed into the hollow space formed round  the
patient. The speedy and  almost certain  effect of
this bath  is to produce copious general perspira-
tion.   It may be used at  different  temperatures,

   * S.'e  his little work entitled " Auxiliaries  to Medi-
cine"  London, 1819.
and  be so regulated as to correspond  with the
divisions adopted in the case of the water  And
vapour baths.   Although, as we have  stated,  a
much  greater degree  of heat is  required  in air
than in vapour  to produce either the elevation of
the animal temperature, or the stimulating  effects
on  the system,  still it is  found,  by  experience,
that a  moderate degree of heat is  alone necessary
to excite copious  perspiration.   No doubt  the
sudatory effect is greatly promoted by the rarity
of  the  medium  applied  to  the surface.   Dr.
Gower informs us tbat he found the most profuse
sweating take place when the air  was only  of the
temperature  of  85°, and he  adds that  he  " had
reason  to believe that at a much higher degree
the  effect  would be  rather  frustrated  than in-
creased, owing   to  the ardent heat  which  the
patient feels and complains of, without obtaining
the  relief which sweating invariably produces."
Our own experience with this apparatus does not
quite  correspond with this  statement of  Dr.
Gower.  We have,  however,  found that very
copious  perspiration may be excited by a tem-
perature not greatly above  this, viz., from 90° to
100°; and we are of  opinion that even when we
use  this bath more with the view to stimulate
the  surface  than to excite  perspiration, it will
seldom be requisite  to elevate the  temperature
beyond 120°, or at most 130°.f
   The warm air bath is most  analogous in its ope-
ration  to the vapour bath ; yet it is considerably
different from it.  It seems to possess all its stitnu
lating  qualities without  its relaxing and soothing
effects.  It is, therefore, a much more exciting ap-
plication at the  corresponding temperatures. I|
appears  to be more powerfully derivative to the
skin than any other bath, and more certainly pro-
ductive of perspiration within a short period.
   There are three classes of cases in which the
warm  air bath seems to be particularly indicated
—1. in  chronic rheumatism  and  other pains and
stiffness, as of the joints ;  2.  in  morbid states of
the skin, more particularly in  dry scaly eruptions
3. in acute diseases marked  by great  exhaustion
and retrocession  of blood from the superficial part9
of the body, as  in  certain forms  of fever, and in
the malignant or spasmodic cholera.   In the last-
mentioned diseases, (which alone  we  shall notice
in this place,) and in others of the same class, the
warm  air  bath, employed on Dr. Gower's  plan,
has great advantages over all other kinds of baths,
inasmuch as its effects on the system are as pow-
erful, while its  application can be made without
trouble or inconvenience, and without  any risk of
yet farther exhausting the patient.
   This bath  was occasionally used by the late Dr.
Armstrong in that form of fever which he termed
congestive.   The following brief extract from his
lectures will point out the cases in which he recom-
mended it, and the fortunate results which he ob-

  t The warm air bath, and its great power in inducing
perspiration, were well known to the older practitioners.
"Aliudgenus halneorum est(savs HoffmannIquxaudiiint
vaporosa sive Laconica.  In his vapores, sive sicci calidi
ex accenso vini spirilu halantes,  sibe  calidi huniidi ex
decoctis herbarum  cum vino vel aqua surgentes, imme-
diate ad universum corpus vel ad  certas duntaxat ip*im
partes,  admittuntur.  Est autem cafidorum  ejusmodi ha-
lituum  maxima vis ad eliciendum sndorem, tubulossub-
cutaneos aperiendos," Slc.—F. Hoffmann, Op Om.  torn, i 
                              BATHING.-

tained from its employment.  « The whole surface
is chilly ;  the blood has retreated from the surface,
3nd has been accumulated in some internal organ,
where it undergoes almost a complete stagnation,
or at least produces a complete interruption of the
venous circulation.   A derangement of the func-
tions of that part is the result, and, if that part be
important, of  the  functions of the  whole body.
The use of the hot air bath is to rouse the ener-
gies of the  system ; and in some of these cases
the patient is raised, as by the touch of a magic
wand,  from weakness  to strength by its applica-
tion."   (Dr. Armstrong's Lectures.  Lancet, vol.
v. p. 74.)
   We have much pleasure  in laying before  our
readers the following notice on the same subject,
with which we have been favoured by Dr.  Twee-
die : —
   «It  sometimes happens  that the febrile  poison
is so intense, and the living  power so depressed
by it, that, the subsequent efforts of the system to
bring on re-action being  ineffectual, the patient is
suddenly placed in great danger, and often  dies in
a few hours after the first appearance of the symp-
toms.  Under these circumstances the surface feels
cold and  damp, more especially  on those parts
which  are at a distance from the centre of the  cir-
culation ; the pulse  is feeble  and  compressible;
the  functions of  the  brain  are  disturbed;  the
breathing is anxious and hurried, and the lips are
livid.  All these symptoms depend on the pecu-
liar operation of the  febrile poison on the nervous
system, and on the irregular distribution of blood
consequent to this.   This fluid, probably changed
also in its properties, recedes from the surface, and
accumulates in the internal organs.  In other  in-
stances, sudden  collapse  supervenes in the more
advanced  stages of fever, and similar  symptoms
make  their appearance.   In  such embarrassing
circumstances, much judgment is requisite to res-
cue the individual from the danger in which he is
plunged.  Some writers have recommended blood-
letting with the  view of  relieving the congestion
which  is supposed  to have  taken place  in  the
internal  organs.  This treatment may, in some
instances, have been beneficial, though  it appears
to me that it can only  be adopted when  the circu-
lation, though oppressed, is still carried on with
some degree of vigour ;  because, should blood be
abstracted when the heart's action is weak, fatal
syncope may be induced.  It  should be remem-
bered that, though the heart's action is, in such
cases,  oppressed by  the accumulation  of  blood
which  it is unable to propel, this want  of power
in the  heart is  primarily induced by the peculiar
action  of  the febrile  poison on the whole nervous
system.  In this debility the heart, of course, par-
ticipates.  In  this state  of things, more benefit
certainly results from the exhibition of diffusible
stimulants,  while  at  the same time efforts  are
made to determine the blood to the surface by  the
application  of the warm air  bath.  In cases of
collapse coming on  in the later stages  of fever,
bleeding is out  of the question:  the patient,
already exhausted, is thrown into a species of con-
tinued syncope; and from this he is to be roused
by the cautious administration of stimulants, and
the application of the hot air  bath.  The exhibi-
tion  of stimulants is only to  be continued  while
BERIBERI.                           287

the pulse  continues  feeble and  soft; they are to
be immediately withdrawn, or given at more  dis-
tant intervals, when re-action has taken place."
  The pathological state in the early stage of ma-
lignant or Indian cholera is very analogous to that
in congestive fever ;  and the indications of treat-
ment  seem precisely similar.  In such cases the
warm air bath, speedily raised to a high tempera-
ture,  offers  one of the  best  means of fulfilling
these  indications; and  we are  happy to  observe
that very general preparations are making to  give
it a trial in the disease that has  just (Oct. 1831)
broken out at Sunderland.
   [This remedy was extensively used in the cho-
lera hospitals in different countries, and  was as
serviceable, perhaps, as any other external  agent.]
  This would be  the proper  place to notice the
other  forms of baths in  which  the heated air is
combined with sulphureous and other dry vapours;
but the consideration of these, as also of tbe me-
dicated humid vapour baths, particularly the chlo-
rine bath, must be postponed  to another occasion.
At  present we must content ourselves with refer-
ring to the works of MM. Gales  and Rapou, and
to the publications of Dr. Wallace, of Dublin.
                             John Forbes.
   BERIBERI.   The  disease  usually denomi-
nated beriberi was, we believe, first scientifically
described by Dr. Rogers, who published a thesis
on the subject in 1808, at Edinburgh.  He deno-
minates it hydrops  asthmaticus, a term  which
conveys an imperfect notion  of  the pathology of
the disease, a paralytic affection  of the lower ex-
tremities being, perhaps, a more constant symptom
of beriberi than dyspnoea and dropsical effusion.
Dr. Mason Good calls it synclonus beriberia, and
gives  the  following  definition :—" Spasmodic ri-
gidity of the lower limbs, impeding locomotion  ;
often  shooting to  the  chest, and obstructing the
perspiration and the voice : trembling and  painful
stupors of the extremities;  general  oedematous
intumescence."  This definition is tolerably accu-
rate ;  but in his description he confounds  a chro-
nic paralytic affection (barbiers) with the acute
disease now under consideration.
  The word beri is stated by Staff-Surgeon Mar-
shall,  in his Notes on Ceylon, to imply,  in the
Singhalese language, weakness  or  inability,- in
fact, we may consider it as a generic name, agree-
ing with our word disease.  The repetition of the
term beri conveys an idea of the greater intensity
or degree of debility.   Beriberi  is characterized
by oppressed breathing,  general  oedema, paralytic
weakness, and numbness of the lower extremities.
The attack is sometimes very sudden, but more
commonly the patient  complains for some days
previously of languor, weakness and inability, oi
unwillingness for motion. The  first appearances
are numbness and stiffness of the extremities, with
oedematous swelling  of  the feet and legs.   These
symptoms often show themselves simultaneously.
The  patient  experiences  great weakness  and
breathlessness, especially on motion ; the anasarca
extends upwards over the body, accompanied with
a peculiar feeling of numbness, with fulness,  and
a sense of weight and oppression in the scrobicu-
lus cordis ; the face becomes swollen and bloated.
and the lips are pale ; in the advanced stage they 
2SS
BERIBERI.
are blue and livid : dyspnoea is always present in
a greater or less degree, and is much increased by
exertion;  the  pulse  is usually quick,  small, and
hard, sometimes  little affected, but  as the disease
advances, becoming  irregular and intermittent;
the stomach is often very irritable, especially in
the advanced  stages of the disease; the bowels
are constipated,  the urine is  high-coloured  and
scanty, and sometimes suppressed.   As the disease
advances, the dyspnoea and anxiety become most
distressing ; the sleep is unsound and interrupted;
the patient complains of  violent palpitation, and
experiences great uneasiness, especially in a recum-
bent position ; the  feeling of weight at the pra>
cordia increases, and spasms of the muscles of the
chest and abdomen take place : vomiting becomes
incessant, the pulse  sinks, the lips and counte-
nance assume a  livid hue, and  the  patient is car-
ried off in a state of suffocation.   In cases where
debility, oppression,  anxiety, and dyspnoea are ex-
 tremely  severe from the  beginning, the patient
 sometimes dies  in  a space of time varying from
 six to thirty hours.   When the symptoms are less
 violent, the disease may continue for three weeks
 or a month, or, as frequently happens, the patient
 experiences a number of relapses, and is  at last
 carried  off suddenly, sometimes after the dropsical
 symptoms have  subsided,  and he seems to be con-
 valescent.  Mr.  Holloway had  two  patients, who
 died without appearing to awaken from a state of
 sleep.  In general, however, death  is immediately
 preceded by great agony.
   The  writer of this article  had  an opportunity
 of witnessing the phenomena attending this dis-
 ease  at Trincomalee, in  the  Island  of Ceylon,
 where it prevailed in 1815.  In some of the cases
 that came under his notice, the external or ana-
 sarcous symptoms  were  apparently unimportant,
 although death was the result.  Some  of the pa-
 tients expired who appeared to be recovering, and
 who stated,  shortly before death, that they were
 better than they had been for several days.  The
 dropsical effusion did not by any means appear to
 be the  immediate cause of death, and Dr. Christie
 states that some of his patients died who had no
 decided anasarcous symptoms ;  the face was, how-
 ever, bloated and leucophlegmatic.
    Beriberi was very prevalent in various parts of
 Ceylon from  1795 to 1803.   In the former year
 two  hundred  Europeans died  in Trincomalee,
 chiefly from  this disease.  (Rogers de Hydrope
 Asthmatico.)   It also prevailed at Colombo, both
 among European and native troops.   During the
 Kandyan war in 1808, its ravages were severely
 felt.  Among Europeans, those engaged in certain
 occupations,  such  as tailors, smiths, &c, were
 especially liable to  beriberi;  while commissioned
 officers,  women, and children,  were  generally
 exempted from it.
    This disease  appeared in a comparatively mild
  form in Kandy, in  1820-1, and ever since it has
  been little known in Ceylon.  Beriberi prevailed
  imong the  troops  in the Carnatic  in 1782-3.*
  Mr. Hamilton  says, " it  is principally, if not en-
  tirely confined  to  Ceylon, to the  Malabar Coast,
  and to that tract of country reaching from Madras
  as far  north as  Ganjam,  in no part extending in-

   * Med. Commentaries, vol. x. and Trans, of the Medico-
  Clururgical Society of Edinburgh, vol. ii. 1826.
land more  than 40 miles.   It  is  most prevalent
during the  decline of one monsoon and setting-in
of another, when  the atmosphere is loaded with
damp, raw, cold vapours, and the vicissitudes of
temperature are greater than at any other season
of the year;  and the instances are comparatively
rare where  it has been found to occur at a distance
from  the sea  exceeding sixty  or  seventy miles."
It may be remarked, however,  that Kandy, where
the disease was particularly severe, is at a much
greater  distance from the sea.  At Trincomalee
it was  observed  that the  most severe cases  oc-
curred during the change from wet to dry weather,
where a strong  and  hot  land-wind prevailed;
whereas at Palitoopane it appeared in 1814, while
the weather was remarkably dry.f
   Dr. Christie has remarked,  that a residence of
some months at a station where  the disease pre-
vails  seem  essential to its production.  Dr. Rogers
never saw it  attack an  individual who  had been
less than  six months in Ceylon.   Beriberi occa-
sionally occurs at sea, especially among Lascars
(Indian seamen) on  the outward-bound voyage.
Dr. Hunter has given a particular account of  the
probable causes, and  of the treatment employed
in  several  of the East-India Company's stations
where it prevailed.
   The  remote as well as the proximate causes of
this disease are extremely  obscure.  Drs. Christie
and Rogers, and several other  medical gentlemen
who  observed it in Ceylon, considered it a disease
of debility, arising from a want of stimulating and
nourishing diet, impure air, and  exposure to a
moist and marshy atmosphere while the frame is
debilitated by residence in an unhealthy station.
How far these circumstances  contributed to pre-'
dispose the system to beriberi,  it is difficult to say.
   Mr. Marshall (Notes on the Med. Topography
 of the  Interior of Ceylon) remarks that " during
 the insurrection in Kandy (1815), the troops  and
 public  followers were greatly  exposed to variable
 weather, privation in regard  to  food, and other
 causes of  physical and  mental exhaustion.  For-
 tunately, however, beriberi did not  supervene."
    Mr.  Colquhoun and others who  adopted every
 available  precaution  with  respect to  food  and
 clothing, were mortified to find  that the disease
 did  not seem to be materially  checked by their
 prophylactic  measures.  No particular cause could
 be assigned  for its appearance  in the 19th regi-
 ment, at Trincomalee, in  1815.
    There  is  extremely little accurate information
 before  the public in regard to the organic changco
 which  occur  in this disease.   The skin  is usually
 pale and  colourless;  and  Dr. Christie observes
 that a Temarkable degree of  obesity  exists, even
 after a long  continuance of the  disease.   The
 cellular membrane in general is found infiltrated
 with serum ; and Dr. Rogers states  that  he dis-
 covered a small quantity of fluid effused between
 the  brain and  its  membranes,  as  also  in the
 cerebral cavities.   Mr. Hamilton  says that he ob-
 served general vascularity in  the  brain, effusion
 of fluid into the ventricles, with appearances of
 congestion in the medulla spinalis.
  t Ridley, Account of an Endemic Disease  of Ceylon.
Dublin Hos. Reports,  vol. ii. p. 227, and Essay on the
Diseases incident to Indian Seamen on long Voyages,
by W. Hunter, Calcutta, 1804. 
BERIBERI.
289
   A greater or less quantity of serous fluid is
 usually  found  in  the cavities of the  pleura  and
 pericardium.  Dr. Rogers states that it varied from
 a few ounces to two pounds in  the former,  and
 in the latter from two to twelve ounces.
   In a case related by Mr. Marshall, the fluid in
 the  pericardium amounted  to four  ounces.   Mr.
 Hamilton describes a case where " a large quantity
 of fluid was effused into the cavities of the pleura,
 but none  into tbe  pericardium,  though on  this
 membrane, both externally  and internally,  there
 existed  evident marks of inflammation."  The
 lungs are gorged with blood and watery  fluid.
   In the abdomen  a quantity  of fluid,  varying
 from two  to three pounds, is commonly found.
 The liver is invariably described as being unusually
 large and very dark-coloured.  Mr. Marshall states
 that in  his case, on removing it from  the body, a
 great quantity of dark-coloured blood flowed from
 the  large vessels, and that it then became reduced
 in size  and natural  in colour.   The  whole sub-
 stance of this  viscus is commonly gorged with
 blood.
   Several other traces of disease, such as inflam-
 mation of the diaphragm, intestines, &c, are men-
 tioned by authors, but so loosely, that little reliance
 can be placed on their description.
   Diagnosis. — It is scarcely necessary to enter
 much into  the  diagnosis of  this disease.  The
 paralytic symptoms,  together  with the  dyspnoea
 and dropsical effusion, would appear sufficient to
 distinguish it from other diseases.  The mal d'es-
 tomac and cachexia Africana, which  have often
 been confounded with beriberi,  are totally  dif-
 ferent diseases.
   The real nature or pathology of this disease is
 as obscure as its origin. We know nothing satis-
 factory  respecting  the origin  of  the paralytic
 symptoms, nor regarding the immediate cause  of
 death, where there is little or no  dropsical effu-
 sion.  Accurate  observation and more extensive
 experience  are wanting,  to enable us to  arrive at
 any  thing  like a satisfactory  conclusion on   the
 subject.  From what we have seen  of  beriberi,
 and  from our subsequent experience in other dis-
 eases,  we are  strongly inclined to  consider  the
 dropsical affection  as the result  of inflammation.
 In fact, it seems to be one of the numerous modi-
 fications  of acute dropsy that  affect the cellular
 membrane  generally, but more particularly  the
 cellular texture of the lungs, whereby a condition
 Bimilar to that described  by Laennec,  under  the
 name of  cedema of the lungs, is produced.  We
 have often  been struck with the resemblance  in
 the countenance and  general appearance in pa-
 tients affected with beriberi, and in  the suffocative
 disease, with oedematous  effusion,  which  attacks
 children after measles  or hooping-cough.
   In no disease with which we are acquainted, is
 internal congestion so strongly  marked  as in beri-
 beri.   How far this congestion  may be  the origin
 of the  paralytic symptoms is a difficult question.
 Mr. Hamilton attributes them to  congestion  of
 blood in the brain and spinal marrow.
  Treatment.—The method of treatment pur-
 sued  by Dr. Christie,  and recommended  by him
 to the medical officers in Ceylon during the pre-
 valence of beriberi  in that  island  was in corre-
spondence with the views then  entertained of the
  Vol. 1. — 37                          z
  nature of the disease.  The patients were at once
  put  on a course of calomel and  squills; saline
  and antimonial medicines were also given,  and
  the  strength supported by cordial liquors, gene-
  rally gin-punch :  the  sheet-anchor,  however, as
  Dr.  C. forcibly expresses  it, was mercury, given
  so as to  induce ptyalism.   He  adds that, "by
  these medicines the symptoms in the milder cases
  are very often  removed in the course of a  few
  days, except the  numbness of the extremities,
  which generally remains  longer  than tbe rest."
  The pediluvium and stimulant liniments to the
  extremities were then ordered, and  the patients
  were put upon  a tonic plan of  bark and wine, or
  porter, which was continued for some time after
  all the symptoms had disappeared.   In the more
  severe  cases,  where  the  dyspnoea,  vomiting,
  spasms, or other  symptoms were violent, it was
  necessary to apply blisters to the breast, to make
  use of fomentations and the hot bath, and to ex-
  hibit^ the  strongest cordials and anti-spasmodics,
  such as brandy, and  particularly laudanum and
  vitriolic ether.   "  By these means I have," says
  Dr. Christie, « in most instances been enabled to
  relieve the dyspnoea and other urgent symptoms,
  and  procure time for the exhibition of the medi-
  cines mentioned above,  which it is sometimes
  necessary to  use for  several weeks."   Digitalis
 was  tried, but without any decided effect.
   Mr. Colquhoun  also trusted to mercury in this
 disease; but he remarks that  salivation did  not
 avert the fatal termination, for  the patients who
 died  in  hospital were frequently  in a state of
 ptyalism.
   During the period  in which the writer of this
 article had an opportunity of witnessing beriberi
 at  Trincomalee, the  method  of  treatment laid
 down by Dr. Ghristie was strictly pursued, but
 with little cause of congratulation  as to  its suc-
 cess.  The patients frequently  sank while under
 the  influence of mercury; and  he has often
 regretted that the  dyspnoea, discoloration of  the
 countenance,  &c, did  not lead to a  different
 mode of treatment.
   Mr. Hamilton  treated the first two cases which
 came under his charge according to Dr. Christie's
 plan,  and both  proved  fatal.   Dr. Hunter says
 that in one of the outward-bound ships venesec-
 tion was had recourse to, but without any effect,
 either of accelerating or  retarding the  disease.
 Dr. Rogers, in his  Dissertation already  referred
 to,  has the following words : " Quin et ad phle-
 botomiam tandem cursum  ejus funestum  celerius
 absolvit."  Increased experience appears to have
 induced Dr. R. to alter his plan of  treatment, for
 we find  from Mr.  Hamilton's statement, that in
 1822 he approved  of bloodletting, and  success-
 fully  employed it in two cases.
   Mr. Marshall remarks that in  1820 many cases
 of anasarca occurred among the European troops
 in Kandy : the  first  cases  were comparatively
 mild, and  a considerable  period elapsed before
 the well-marked and pathognomonic symptoms
 of beriberi appeared.  Brisk cathartics  and con-
 finement to bed  generally reduced the swellings
 and relieved the  numbness in a few days.  In  a
 case where the chest was severely affected, great
 and speedy relief was obtained by copious ami
repeated  bleeding.   The  depleting method  of 
DETERMINATION  OF)
2J)0          BERIBERI —BLOOD,  (

treatment was followed by Dr. Paterson,  in tbe
hospital  of the 45th  regiment,  then under the
superintendence  of Mr. Marshall, with decided
advantage.  Mr. Hamilton, as has been already
stated, having treated  two cases unsuccessfully,
was led, from the  morbid  appearances, to adopt
other  remedial means.  In tbe next  patient who
came  under his care, thirty ounces of blood were
drawn, pleno rivo, from the arm.  The blood was
buffed, and the operation was attended with great
relief; but as the symptoms returned, venesection
was repeated to the amount of thirty-five ounces,
with good effect.  Mercury was then had recourse
to,  with  laudanum, the vapour-bath, inunctions
of mercurial  ointment, with purgative doses of
calomel and gamboge till the cure was completed.
A similar mode of treatment was pursued  in two
other  cases, in one of which blood was drawn, to
the extent of sixty-five ounces, at three different
times  in the course of thirty hours.
  According to the views supported in the former
part of this paper, it will  be seen that our mode
of treatment  would be in accordance  with  that
pursued by Mr. Marshall and Mr. Hamilton.  The
quantity  of blood to be drawn must of course de-
pend  on the state of the disease, and the constitu-
tion of the patient; but we should  scarcely feel
inclined  to recommend the large and successive
bleedings employed  by Mr.  Hamilton.   If the
patient be placed in an upright position, and the
blood  be  drawn in a full stream, a smaller quan-
tity will  produce  a more  decided effect on  the
system, with less  risk of  producing subsequent
debility.  Free purging by calomel and gamboge,
while  the secretions of the mucous membrane and
kidneys are stimulated by  cream-of-tartar, squills,
&c, with the use of the  vapour or  warm bath,
and stimulating liniments to the  limbs and spine,
and blisters to the  chest when  the symptoms re-
quire  it,  will prove useful assistants  in the treat-
ment  of  beriberi.  We may  conclude with Mr.
Marshall's remark, that a more extended  clinical
experience is still necessary, before a due estimate
can be made of the true efficacy  of the depletory
means of cure.                    T  ~
                                 J. Scott.
  BLISTERING.   (See  Counter-irritation
and Derivation.)
  BLOOD, (DETERMINATION  OF.)—This
term is used to denote an afflux of blood to a par-
ticular part, impelled by increased arterial action.
When such  afflux exists  without  any obvious
increase  of impelling  power, it is  denominated
congestion.  Both may co-exist;  that is, conges-
tion may first take place, and, on vascular  action
becoming excited, determination may ensue, in-
creasing  still further  the  congestion, and  super-
adding those lesions  which determination more
especially occasions ;  or congestion  may be  pro-
duced by determination, and  may continue after
this has subsided.
  Congestion is more or less a passive condition ;
determination is always active.   On determina-
tion subsiding, congestion  may yield  to the sana-
tive powers of the constitution, unaided by medi-
cine ;  or  it may continue, and  require  special
means to be resorted  to for its removal.
  When congestion  takes place in any part, its
origin must be ascribed to  some weakness  of the
vessels of tbe part, causing them to yield to the
ordinary force  of circulation ;  in determination,
vessels which would resist the  ordinary force of
vascular impulse may become  over-distended by
increase of momentum ;  yet  here there must be
some relative weakness to cause them to give way.
The relative facility of yielding to  distension,
thence arising,  whether natural or acquired, may
influence  the  locality of the  determination; or
this  may be directed by  various  sympathies and
nervous connexions,  and also  by some  peculiar
property of the stimulus  which produces the vas-
cular excitement. Some determinations are solely
attributable to nervous sympathy, as those which
occur in health under mental  emotion.  In blush-
ing, for instance, there is obvious  determination
of blood to the  cheeks; nay, when intense, to the
whole neck and breast.   Similar instances might
be adduced, but it is needless to  advert to them,
morbid  determination being the  condition under
consideration.   It is, perhaps, from the influence
of nerves in giving direction  to local  determina-
tion, that certain stimulants determine blood more
particularly to certain organs, some causing blood
to flow more particularly to the brain, while others
tend to  induce vascular fulness  in the liver or in
other parts.
   Determination admits   of being  inferred  from
the symptoms which denote it, these varying ac-
cording to its  seat, and  to the functions of the
part affected ;  the fact of its occurrence is amply
verified by necroscopic examination when oppor-
tunity for this is afforded.
   As determination may  ensue upon congestions,
so may  it be followed by, or pass into, inflamma-
tion, of which indeed it seems to be an essential
constituent.   But as congestion does not necessa-
rily produce determination, neither  does determi-
nation pass necessarily into inflammation.  Such
determination, though an advance towards inflam-
mation, and prone to pass into  it, may yet  exist
so as to constitute formidable  disease, and thus
continue for an indefinite time without inflamma-
tion ensuing.   Congestion of blood, kept up by
determination, may take  place in the brain, lungs,
liver, or  any other  organ, without  evincing the
peculiar ■phenomena of  inflammation, and  may,
in each, cause appropriate disturbance of function
to a formidable extent.   When such cases are
treated  as subordinate degrees  of inflammation
they yield readily, and to practice less active than
inflammation would  require ;  but when from the
absence  of purely inflammatory  symptoms, they
are referred to debility or some  unexplained ner-
vous derangement, and are in consequence treat-
ed with stimulants, they rather  become  aroused
into inflammatory  action, which perhaps is in
such cases the  happier  result, as they are then
treated aright;  or tbey lead insidiously to disor-
ganisation of structure, thus  laying tbe founda-
tion of  some of the most irremediable of human
diseases;  for though medicine can do much to
correct functional disturbance, and  can to  a cer-
tain extent promote even  restoration of structure
where the organic change has been slight, it can-
not supply new organs,  nor  give to a scirrhous
and disorganised mass the efficient  energies of a
healthy viscus.   On which account the study of
determinations, and of the causes both local and 
BLOOD,  (MORBID  STATES  OF)
291
constitutional  from which they arise, is of  the
highest importance, as a just conception of their
nature and tendencies may enable the practitioner
to avert, by very gentle means, lesions  of  the
frame which, if suffered to advance ■ to a certain
extent, the utmost efforts of his art may be una-
able to remedy.   In this instance the maxim,
" principiis  obsta" cannot be too forcibly incul-
cated.  The special  determinations, however, be-
long not to  this  place ;  they either constitute, or
are connected  with, special diseases; under each
of which they will of course be found respectively
noticed.                  _,         _,
                         Edward  Barlow.

   BLOOD, (MORBID STATES OF.) —The
term blood needs no definition.  Every one knows
that the blood is that fluid  which  is  circulated
chiefly by the powers of the heart and arteries,
over  the  whole  animal frame, of every part of
which it constitutes an essential ingredient.  The
blood must be first viewed as arterial and venous.
The former, of a  florid  red  hue, flows from  the
extreme parts of  the  lungs to the  extreme parts
of the system; the latter returns from the system
to the lungs.  The blood itself is only one degree
more essential to life than its  arterial character.
In all the  high orders  of animals of  adult age,
life ceases  in a few minutes after the blood is pre-
vented from assuming the arterial character in the
lungs, by  cutting off' the contact of  the  atmo-
spheric air.  In  proportion  as  the individual is
younger, however, it bears the exclusion of the
atmospheric air better, and the detraction of blood
worse.  The blood, as it flows  along or from the
large vessels, has the appearance of a homogene-
ous fluid,  of a red colour, of a rather  viscid con-
sistency, having  a peculiar  flesh-like odour,  and
an unctuous feel.  Seen flowing along the capil-
lary vessels, or placed upon a portion of glass, by
the aid of the microscope, the blood presents the
appearance of globules  floating  in  a serous fluid.
Stagnant, or removed from its  vessels, the blood
soon loses its homogeneous character, and divides
into two portions, of which one is more solid, and
termed the cruor or crassamentum, the other more
fluid, yellowish, and  transparent, and denominated
the serum.
   We purpose dividing  the  subsequent remarks,
to which we shall endeavour  to give  a practical
character, into two  sections  : the first will treat
of the natural, the second of the morbid state of
the blood.
   There  are  several  modes of analysis of the
blood : the first is chemical, and consists in deter-
mining the secondary and ultimate elements into
which the blood may be divided ; the second may
be designated the physiological, and would con-
sist in determining the  elements of the blood as
it exists in  the different parts of the arterial  and
venous systems, under various circumstances ; the
last, which will  alone  occupy  us  in this  place,
may be viewed as the clinical, and consists of ob-
servations  on the blood  and its several parts, as
it undergoes its  spontaneous changes  on  being
drawn from an artery or  vein.   We have  desig-
nated this kind of analysis clinical, because it is
principally this which daily becomes an object of
greater interest  snd importance.  We, however,
by no means wish to exclude the other modes of
analysis from clinical inquiry.
  The first  part  of this clinical analysis of the
blood is, as we have  stated, into cruor and serum.
On a minuter examination, it is found that the
cruor consists of  two different matters, very easily
separable from each other, by immersion or wash-
ing in water.  The more  solid part of the cruor
is, by this simple process, deprived  of its  colour-
ing principle, becomes whitish, and appears fibrous:
it is designated fibrine.  The colouring matter is
more or less dissolved in the water :  it has been de-
nominated hxmatosine, (from atpa, aiparos, blood,)
to denote its constituting a peculiar and essential
part of the circulating  fluid.  Hsematosine  is not
a simple substance.  It is composed, according to
Berzelius, of .500 of oxide  of iron, .750 of sub-
sulphate of iron, .200  of magnesia, .200 of chalk,
and .165 of carbonic acid.   The serum is, in  its
turn, susceptible  of a  simple analysis.  Heat, or
alcohol, induces  the coagulation and deposit  of
one of its  principal  constituent parts;  this is
termed albumen.
   One of the first occupations of the medical stu-
dent should be, to become familiar by actual ex-
periment  with these  different substances.   The
experiment  itself is one of the simplest and most
instructive.   We learn by it at once the partial
solubility of hrematosine, the insolubility of fibrine,
the  solubility of albumen in  cold  water, and  its
insolubility  in hot.
   The  texture of the cruor, the quantity, appa-
rent and  real, of the  serum, vary; the serum is
sometimes  slightly opaque; the  haematosine  is
occasionally partly precipitated to the bottom  of
the vessel in which the blood is received.   But
these are probably morbid conditions, and will  be
considered in the ensuing section.
   Besides the albumen, the  serum contains vari-
ous substances,  of which  the following  are  the
enumeration and proportions according to  Berze-
lius : water .905, albumen .080, chloruret  of po-
tassium and sodium .006, lactate of soda  united
to an animal matter .004, carbonate of soda, phos-
phate of soda, with animal  matter  .004.   Doubt-
less each of these substances  has an important
influence in the animal economy.  The  little we
know of their influence should only excite us  to
further inquiry in regard to these substances.
   Besides these  matters, according to the  analy-
sis of Berzelius,  other substances have been dis-
covered in the blood :  as carbonic acid, substances
severally resembling mucus, oil, brain, the colour-
ing matter of bile, and of the urine and urea.
   For more minute details we must  refer  to  the
various systems of chemistry.   The clinical analy-
sis of the blood  must almost  inevitably be  con-
fined to the more obvious results of observation,
although we dare not exclude experiment alto
gether.
   Arterial blood is  less  abundant than venous.
It separates more promptly into cruor and serum.
It contains less albumen, and is at  once less vis-
cous and  less serous.   Dr. J. Davy found that it
possesses less specific gravity.  It is said to have
less capacity for heat.   It has more of the pecu-
liar odour of blood.
   One of the most interesting  questions  in  this
inquiry is that which relates to the differences in 
202
BLOOD,  (MORBID  STATES  OF)
the blood in the first and later periods of life.  It
is a singular fact that the  globules of the blood
in the foetus are larger than those of its mother.
According  to Prevost and Dumas, they are of
double the magnitude of those of a man of adult
age.  According  to  Fourcroy and Dr. Davy, the
albumen is  more abundant, and  the  fibrine  less
firm in infants than  in adult age.
  It is said that differences are perceptible in the
blood of youth and old age, and of the two sexes.
M.  Barruel has recently occupied himself  with
the latter subject.
   § 1. It may be safely alleged  that  there is no
external agent which may not, under extraordi-
nary circumstances, become the cause of disease :
it may also be  alleged that there is  no internal
part, whether it  be  solid  or fluid, in which the
seeds of disease may not be sown.
   The blood, of all the fluid parts of the animal
economy, seems,  from its  complicated formation
(may we not say structure  ?) to be most liable to
morbid changes.   The older physicians  observed
the dissolved state of the blood, as it was termed,
in some cases of  fever and scorbutus, and the sin-
gular appearance called buff upon the crassamen-
tum jn certain cases  of inflammation.   Had they
not unfortunately deviated  from the course of pure
observation,  we  should  now have  possessed  a
series of facts  of extreme  value.  But from  the
moment that certain unfounded chemical  and
humoral notions  began to  prevail,  and physi-
cians to speak  of the acidity, the alkalinity,  the
acrid, the  putrescent state  of the blood, and of
chyle, of milk, of pus, of bile in the blood, from
mere hypothesis, observation  was  at  an  end.
The  error  being detected, the  whole  humoral
pathology fell into disgrace, and physicians, pass-
ing from one extreme of opinion  to  another, be-
came pure  solidists,  as  they were termed, whilst
obvious and well ascertained facts became neg-
lected.
   But  now that all exclusive  views in physic
have ceased, and that every organ, every texture,
every  fluid  is subjected  to careful  observation,
there is no doubt that many morbid  changes will
be discovered, not only in  the  blood,  but in  the
other animal fluids, whether such as are provided
for the nutrition, or such as are separated for the
purification of the system.  Indeed if any of these
be  morbidly affected, the blood  itself must suffer
by the  addition  of what is  imperfect, or by the
retention of what should be discharged.  It is in
this manner that impure air, and impure diet, and
defective excretions  of the fieces, urine, or  per-
spirable matter, act in impairing the condition of
the blood.
   The first of the  morbid changes  which  take
place in the blood  relates to its quantity.  This
may be excessive or deficient:  the former state is
denominated plethora, and  will be treated of under
that head;  the  latter  condition  constitutes  the
state of anaemia,  of which an account has already
been given.  (See Plethora, Anemia.)
   The next changes in the blood relate  to excess
or deficiency in one or more of its  constituent
parts.  The cruor, the serum, the colouring  mat-
ter or bsematosine, may each be  too  abundant or
deficient.   The  same observation may  be made
 in regard  to the constituent parts  of the blood
viewed  under a different aspect: the fibrine, the
albumen, the saline ingredients may severally be
augmented or diminished.
  Other changes consist in the different manner
in which the spontaneous separation of the cruor
and serum takes place : sometimes this separation
is very  distinct;  the cruor is firm and  cupped,
whilst the serum is fully pressed out and appears
copious : in  other cases  the  cruor is  large and
loose in  its  texture, involving  a considerable
quantity of serum, the portion pressed out being
small:  in a third case, in which  the albumen ap-
pears to be in excess, this substance is  separated,
mingled with fibrine, and  attached  to the upper
surface  of the firm and  cupped  cruor,  forming
what is designated  the  buffy  coat: in a fourth
case  the  cruor is  small, distinct  in  form, yet
neither  firm nor cupped, and floats in a serum of
greater  viscidity than usual.
  A further series of changes  consists  in the de-
fective  coagulation of the blood, which  remains
more or less sanious, and is of various colours.
  In other instances the blood appears to be de-
ficient  in haematosine as well as in fibrine and
albumen.  It is  more or less  deprived of colour
and viscidity.  Its  cruor is  of a salmon colour.
Dropped upon white linen,  it scarcely affords a
tinge.  This  occurs  especially in cases of pro-
tracted  hemorrhage, and in chlorosis.
  Besides the changes in the proportion  of its
different constituent  parts, the blood frequently
contains matter foreign to its healthy constitution,
as  pus, the  encephaloid  substance, entozoa, cal-
culi.  At other times the blood itself undergoes
other changes, becoming grumous,  sanious, &c.
  That other changes still  are induced in the
blood,  is proved by experiment.   The morbid
blood injected into the veins or cellular membrane
of a healthy animal, immediately induces morbid
or fatal effects.  M. Gendrin  introduced an ounce
of the  blood  of a man  affected with fever  with
gangrenous pustules, into the  cellular membrane
of the groin of a cat.  Various symptoms followed,
and the animal died in little more than  six hours.
The  same effect was produced on injecting blood
of the  same patient into the crural vein of a dog.
Similar results followed the  similar injection of
the blood of a patient affected with variola.
  From these and  similar facts  it becomes quite
obvious that  the blood itself is morbidly affected
in various diseases,  as  the worst forms of fever,
variola, &c.
  The  blood may become morbid, not only from
a deficient  freshness of the air, and a  deficient
quantity of food, but from deleterious matters in-
corporated with the air or food.   Contagious mi-
asmata, malaria, may float in the atmosphere and
corrupt the blood.  Poisonous  substances may be
conveyed into the circulating system, more or less
promptly, by means of the diet:  many interesting
facts of this kind are on record; but none is more
so than the well-known influence of salt provisions
in inducing  scorbutus, and of  the  ergot  in indu-
cing a tendency to gangrene of the extremities.
   The  nervous system has also a direct influence
upon the  blood.  In  experiments  in which the
eighth  pair of nerves has been divided, it  is said
that  the venous blood is prevented from being
changed into arterial (Dupuytrcn) ; that the blood 
BLOOD,  (MORB
ID  STATES OF)
293
even coagulates, and the fibrine and hsmatosine
separate in the larger pulmonary arteries and veins
(Mayer) ; and  that arterial blood drawn from the
carotid was deprived of a portion  of  its fibrine
(Dupuy).
  The same experiment, performed by M. Dupuy
upon a horse, is said  to  have led to a dissolved
state of the blood.  Being injected into the veins
of another horse, this blood is said to have induced
gangrene.
  Who, after reading  these facts, will doubt that
the humoral pathology has  a solid basis in nature ?
It can,  however, only be  erected by observation
and experiment, conducted  with  extensive views.
Every inroad, every egress, every source of modi-
fication, physical or physiological, must be care-
fully taken into consideration in such an investi-
gation.
  § 2. We shall  now proceed to enumerate the
various diseases in which changes in the blood are
obvious enough to  be placed beyond a doubt,
yielding facts which may be added to science.
  The  first disease we shall mention is  fever.
There can be no doubt that the blood is variously
affected in various kinds of fever.   There can be
little doubt that  this affection of the blood is some-
times the primary affection.  If this fact be esta-
blished, the dispute whether fever be ever idiopa-
thic, that is, independent of local disease, will  be
at an end.
  Much information  respecting the  condition of
blood in fever may be acquired from some of the
more ancient  authors, especially of  what may be
termed the observant sect, as Sydenham, Huxham,
&c.  The latter author describes the appearances
of  the blood of  malignant  fever thus : " The era-
sis  of the  blood  is not sufficiently firm, too attenu-
ated ; the serum blackish  or tinctured with red."
(On the Air and  Epidemics,  vol. ii. p. 68.)   In
speaking of what  he designates  peripneumonic
fevers, or in modern language,  of fever complicated
with pulmonary affection, he says, " The blood of
such  persons   is  always  found  too  dissolved,
although it is generally florid and  specious, and
for  a long time preserves its serum;  examine it at
another time, and you will find the crassamentum
livid and exceedingly dissolved, and  swimming in
a great deal of  tawny, turbid, greenish,  or reddish
serum;  again, at another time it is  almost  black
and sanious, and not having the least cohesion."
(Ibid. p. 202.)   This  appearance  is  contrasted
with that of blood in pleuro-pneumony, in which
it "was very  thick  and viscid, and on growing
cold was  covered over with a whitish, and as  it
were leather-Id^ pellicle :"' (p. 203.)
  Such are still the appearances of the blood  in
various  fevers, simple and  complicated.   But an
entirely new series of observations is required, in
order that the subject may be raised to the level of
science in the other branches of medicine.
  The morbid appearances of  the blood in typhus
fever have been particularly noticed by Dr. Twee-
die, in his « Clinical Illustrations of  Fever."  He
states, that in this class of fevers the crassamentum
of the blood, instead of forming a firm coagulum,
is loose, small  in proportion  to  the quantity of
serum, and so  soft that it  breaks readily on at-
tempting  to  raise it, resembling  in consistence
half-boiled  currant jelly;  and that  in  some in- I
stances,  when abstracted  late in  the  disease,  it
scarcely  coagulated at all.
   The state of the blood in yellow fever has been
lately particularly and ably brought before the pro-
fession by Dr. Stevens.  (See Observations on the
Blood :  read at the College of Physicians, May 3,
1830.)  Dr. Stevens  observes—"On  examining,
soon after death, the black and dissolved  blood
that had been taken from the heart of those who
had died of the yellow fever, it was very evident,
even at  first sight, that several great changes had
taken place.
   " 1st.  The blood was more fluid than natural,
partly from an excess of serum, probably produced
by a stoppage of the secretions and the retention
of those fluids in the system, which ought to have
been thrown out by the secreting organs ; but in-
dependently of this, in these violent continued
fevers, as little nourishment is used, the fibrine or
solid part does not appear to be formed in its usual
quantity, and perhaps, also, it is exhausted  faster
than in  health, in supporting the  high and con-
tinued excessive heat, that is so  great in the com-
mencement of the inflammatory form of that fever.
In the first stage of the disease, the structure of
the red  globules  is  frequently deranged, which is
evident  from the fact,  that in those  fevers the
colouring matter is  often detached  from the glo-
bules  and dissolved  in  the serum, giving to that
part of  the blood,  when  it  separates from  the
fibrine, a bright scarlet colour, and  this colouring
matter cannot be separated from the serum, either
by filtration or any other mechanical means; but
as the disease advances, this red colour is lost, and
the whole circulating current  becomes  black, and
so thin that it has  no longer any resemblance to
the blood of health.
   " 2d.  The colour of the whole  mass of blood,
both in the arteries and veins, was  changed from
its natural scarlet, or modena  red, to a dark black.
I have frequently filled one glass with the  black
fluid  taken from the  heart, and another with the
black vomit taken from the stomach.   They were
both so unlike the blood of health,  and resembled
each other so  completely, that it was  almost im-
possible  to distinguish tbe one from the  other; and
from its  appearance  it was very  evident that such
diseased  blood could no more stimulate the heart
or support life in the solids, than putrid water can
nourish vegetables, or carbonic  acid  gas  support
respiration.
   " 3d.  In  violent continued  fevers, the saline
matter, like the fibrine, appears to be  exhausted
faster than  it  enters  the  circulation ;  the  blood
soon loses a great proportion of  its  saline impreg-
nation ;  it loses entirely its saline  taste;  and we
shall afterwards see that the black colour is a cer-
tain proof of the entire loss, or at least of the great
diminution of the saline matter.
   " 4th.  The  blood, though dissolved, was yet not
putrid; for the blood  is so essential to life, that
putrefaction of this fluid cannot exist in  a living
body.  But dissolution is  the first step towards
putrefaction ;  and when this to a certain degree
takes place, death of all the solids must follow.  J
may here add, that this dissolved state of the vital
fluid was the  cause, and not  the effect of death;
for I have sometimes seen the  blood,  even  pre-
viously to death, both  black,  and so thin that it 
294
BLOOD,  (MORBID  STATES  OF)
could scarcely be retained within the vessels; and
occasionally it has been observed oozing from the
tongue, the eyes, the skin,  and other surfaces,
where there was not even the slightest lesion.
  " The dissolved state of the blood  is the effect
and not the cause of fever.  But as it was evident
in many of the fatal cases, that  this dissolution
was  the sole  cause of death, it then became an
object of importance to find out some agent capa-
ble of preventing this fatal change in the whole
circulating current."
  " In the Asiatic cholera, on the other hand, the
blood becomes of  an unnaturally dark colour and
thick consistence."
  Considerable changes are induced in the blood
in inflammation.  It is well known that the blood
drawn in inflammation of the serous membranes
is apt to be cupped and buffed; that is, the cruor
is firm and contracted, and its  edges are much
raised above the  central  part of its  surface; and
its upper  portion  consists in a substance nearly
deprived of colouring matter.  This  buff consists
of fibrine  and albumen ;  the serum contains more
albumen than natural; and the crassamentum is
exceedingly firm.
  Is this modification of the blood the effect, or a
cause, of  the  inflammatory process  ?  That the
blood may be cupped and buffed independently of
inflammation,  is proved by the facts  of the occur-
rence of these phenomena in cases of pregnancy.
  It is true, on the other  hand, that the buffed and
cupped state of the blood is not so obvious on the
first day as on subsequent days, in cases of inflam-
matory disease.   It  must therefore  be concluded
that  inflammation, and  the  state of pregnancy,
and other sources  of excitement, and even blood-
letting itself, when so conducted as to lead to re-
action, induce the cupped and buffy state of the
blood.
  It is an interesting fact  to note, that the layers
and adhesions formed upon or from the surfaces
of inflamed serous membranes, are  of the  same
chemical  and  physical constitution as that of the
buff of the blood itself.
  It  is important to remark that it is not every
kind of inflammation which  induces the  cupped
form  and buffy coat in the blood.  Inflammation
of the  serous  membranes  and parenchymatous
substance  has  chiefly this  effect.  Inflammation
of the  mucous  membranes,  as  bronchitis, and
dysenteria, frequently occurs without any disposi-
tion to a cupped or buffed condition  of the blood.
Indeed, there is a greater difference between these
two classes of disease than their names would lead
us to suspect.
   Dr. Tweedie  has observed, in two instances of
acute  disease,  the buffy coat  on arterial  blood.
The  only reason  why this appearance  is not  so
familiar to us  is, probably, the  less frequent per-
formance of arteriotomy than of venesection.
   But besides the marked morbid appearances of
the blood in fever and in inflammation, very pecu-
liar changes take  place  in chlorosis.  In this dis-
ease there is a general state of bloodlessness; the
crassamentum is small, the proportionate quantity
of serum  large; a drop of the blood observed upon
white linen is seen to be extremely  pale.   It still
remains  to ascertain the exact proportions of
j fibrine,  albumen,  hrematosine,  &c. in  chlorotic
 blood, and to observe its  appearance under  the
l microscope.  It  still  remains to compare it with
 the blood  of persons blanched  by hemorrhagy.
 The morbid character of the blood in  chlorosis
 must  be  ranked amongst  the most unequivocal
 proofs of  the truth of a humoral pathology.
    The  next disease to be noticed in connexion
 with the pathology of the blood  is scorbutus, the
 stronghold of the humoral pathologists,—the pons
 asinorum of the solidists.  The defective cohesion
 and separation of the cruor, the  " dissolved " state
 of the blood in scorbutus, could never be forgotten
 by either party;  it was continually reproduced by
 the former, and pertinaciously  neglected by  the
 latter.
    Dr. Mead gives a vivid description of  the state
 of the blood in scorbutus.   " In the beginning,"
 he observes, (Medical Works,  Dublin, 1767, p.
 332,) " as  it flowed out  of the  orifice of  the
 wound, it might be seen to run in different shades
 of light and dark streaks.  When the malady was
 increased, it ran thin, and  seemingly very black ;
 and  after standing some time  in  the  porringer,
 turned thick, of a dark muddy colour, the surface
 in many  places of a greenish hue, without any
 regular  separation of its parts. In the third degree
 of the disease it came out as black as  ink  ; and
 though  kept stirring in the vessel many hours, its
 fibrous  parts had only the appearance of wool or
 hair floating in a muddy substance.
    " In dissected bodies the blood in the  veins was
 so entirely broken, that by cutting any considera-
 ble branch you might empty the part to which it
 belonged  of its black and yellow liquor.  When
 found extravasated, it was of the  same kind. And
 lastly, as  all other kinds of hemorrhage are fre-
 quent at the latter end of the calamity, the fluid
 had  the same appearance  as to colour and con-
 sistence,  whether it was  discharged  from the
 mouth,  nose, stomach,  intestines, or any  other
 part."
    There is no point in pathology more instructive
 than this of scorbutus.   The morbid influence of
 salt meat, and the curative influence of acids ; the
 baneful effects of impure air and impure diet, and
 the beneficial effect  of a  change  of atmosphere
 and regimen ; are shown more clearly in this dis-
 ease than in any other.   And as subsequent links
 of the chain, the influence of a " dissolved" state
 of the blood in inducing a " dissolved" state of the
 solids, to  use the  ancient phraseology, is equally
 remarkable in this disease.
    Nearly allied to scorbutus is purpura.   Some
 singular appearances have  been observed in  the
 blood in  this disease.   The crassamentum has
 been found separated without being firm, or con-
 tracted ; and  buffed  without being  cupped; its
 upper surface covered to a  considerable deptb by
 a  straw-coloured  substance  resembling ordinary
 jelly.   This, as well as the other parts of this in-
 teresting subject, still needs further investigation.
    As an improper kind of  diet produces a baneful
 influence upon the composition  of the  blood, so
 does a disordered and loaded state  of the bowels.
 This is apparent from the condition of  the  secre-
 tions : the saliva, the perspiration, the urine, are
1 alike deranged in their obvious qualities, but espe- 
BLOOD,  (MORB
ID  STATES  OF)                     295
cially in odour;  and there is more or less of the
bloodless appearance seen in chlorosis.
  Icterus is another disease in which the blood is
known to suffer.   The colouring principle, at least,
of the bile is retained in the blood.   It appears to
act as a narcotic upon  the brain, inducing drow-
siness.  The serum of the  blood and the secre-
tions from the skin  and kidney  are in some cases
alike tinged with the  yellow colouring matter of
the bile.
   Every one knows the  baneful influence  of a
suppressed state of  another secretion—the urine.
It cannot be doubted that  some  of the principles
of this secretion are retained in the blood.   Pre-
vost and Dumas  found urea in the blood of an
animal in which the ureters had been tied. In the
human  subject,  suppression  of  the urine, or the
presence of some of its  principles in the blood,
produces coma and death.
   M. Dance has recently renewed the idea  of a
former day, that the suppression of the secretion
of milk may, like that of the bile or urine, affect
the blood and  the secretions.  In one such case it
is said  that caseum was found in  the fluid of
ascites, evacuated from the abdomen.
   But if the secretions become sometimes  sup-
pressed,  and produce  a  reflex  alteration in the
blood, there is a case in which  the blood becomes
morbidly affected, together with  an  excessive se-
cretion, as in diabetes.   The blood in this disease
is more serous, and contains less fibrine than usual.
It would be interesting to  examine the effect upon
the blood of excessive perspiration, undue lacta-
tion, and profuse or protracted menorrhagia or leu-
corrhoea.
   The  facts which result from this inquiry are
these:—1. In many diseases, as fever, inflamma-
tion,  chlorosis,  scorbutus, there are  undoubted
morbid changes induced in the blood itself; 2. that
other morbid changes are induced by impure atmo-
sphere and an unwholesome diet; 3. that various
miasmata in the atmosphere, and various poisonous
qualities in  food, produce  morbid changes in the
blood ;  4. that suppressed secretions induce  mor-
bid changes in the blood ; 5. that excessive secre-
tions induce other morbid changes  in this fluid ;
and, 6. that an affection of the innervation, or of
the nervous system, may,  as is observed on a divi-
sion of the eighth pair of nerves, produce its pe-
culiar changes in tbe circulating mass.
   The practical indications  resulting from these
and other morbid states of the  blood will be no-
ticed  under the head  of  diseases in  which  they
chiefly are found.   We consider their statement
in this  place  as highly important in a  practical
point of view.
Marshall  Hall.
  [Hxmatology, or the examination of the blood,
has engaged the attention  of many excellent ob-
servers of late years, and with much advantage to
science.  When the  blood is  circulating in the
vessels it consists of a homogeneous fluid, to which
Br. B.  Babington (Cyclopxdia  of Anat. and
Physiol, vol. i. p. 415, Art. Blood, mSrbid condi-
tions of the) has given the name Liquor Sangui-
nis, and of Red Corpuscles.  The difference between
living and coagulated blood  may be expressed in
a tabular form as follows:
                  f Water,        •)           i _;
                  I Various Salts,  |           : I
= , Liquor Sanguinis, \ {£"£ »!»"«.  > ^rum.      S
u<f   *      6     j Extractive do.,            S-T!
                   Albumen,     J           | 3
                  (.Fibrin,        j Crassamen- | %
  . Red Corpuscles.                 j   turn.     J 5
  The  analysis  of  the blood by  M. Lecanu
is generally regarded  the most complete that has
been  made (Journal de Pkarmacie, vol.  ix. &
x, Paris, 1831, and H. Milne Edwards, Art. Blood,
in Cyclop, of Anat. and Physiol., vol. i. p. 411.)
The careful examination of the blood of two strong
and healthy men afforded the following results :
1st Analysis. I 2d Analysis.
Water.........................
Fibrin .........................
Albumen.......................
Colouring Matter...............
Fatty crystallizable Matter......
OilyMatter....................
Extractive Matters soluble in al-
  cohol and in water............
Albumen combined with Soda...
Chloride  of Potassium..........
Chloride  of Sodium.............
Alkaline Subcarbonates.........
Alkaline Phosphates............
Alkaline Sulphates.............
Subcarbonate of Lime..........
Subcarbonate of Magnesia......
Phosphate of Lime.............
Phosphate of Magnesia.........
Phosphate of Iron..............
Peroxide of Iron................
Loss...........................
Total....................  1000,000  I 1000,000
730.145
  2.100
 65.000
133.000
  2.430
  1.310

  1.790
  1.265
8.370
Ui
2.400
788.590
  3.565
 69.415
119.6-26
  4.300
  2.270

  1.920
  2.010
2.586
  A long series of connected  haematological ob-
servations has been made by M. Andral, both alone
and in association with M. Gavarret and M. De La
Fond (Annates de Chimie  et  de Physique, torn.
lxxv. & 3me serie, torn. v. and Hematologic Pa-
thologique,  Paris, 1843), which have developed
interesting results.  Their inquiries were directed
to the variations in the proportion of certain prin-
ciples of the blood, as the fibrin, corpuscles, solid
matters of the serum  and  water,  both in  the
healthy and  morbid  state.  The method adopted
for this purpose was  as  follows :—The blood was
made to flow into two different vessels.  Into one,
the first and last  quarters of the  blood were re-
ceived ; and into tbe other the second and third
quarters ;  in order that  the  similarity of the two
quantities might be attained as far as practicable.
The blood in one vessel was permitted  to coagu-
late spontaneously ;—that in the other vessel was
beaten with a small  rod in order to separate the
fibrin.  When the first portion had completely co-
agulated, the serum was carefully separated from
the crassamentum; and they then dried and weigh-
ed, first, the fibrin obtained by the rod ; secondly,
the  whole  crassamentum;  thirdly,  the serum.
The weight of the separated fibrin gave the quan
tity of it  contained in  the  clot.'  The weight of
the serum after complete desiccation gave the pro-
portional quantity of  solid matter contained  in its*
water.  The quantity of water driven  off from
the clot in drying gave the amount  of serum it
contained ; from which the proportion of the solid
matter of the serum that the crassamentum con-
tained could  be estimated.  Hence, by deducting
from the weight of the whole dried clot, first, that
of the fibrin separated by  agitation, and then thai
of the solid  elements of the serum, ascertained bv 
296                              BLOODLETTING.
calculation, the weight, of the red corpuscles was
obtained.  In order to ascertain the wbole amount
of solid matter in tbe  scrum, that which was as-
certained by calculation to exist in the fibrin was
added to that which was obtained from the sepa-
rate serum.  The proportion  of inorganic and of
organic matter  in  this solid residuum was ascer-
tained  by incinerating  it in a crucible ;  by which
the whole of the former was driven off, whilst the
latter was left.
  These researches have shown,  that the average
amount of fibrin in human blood  is 3 parts in the
1000.   In persons in health, the amount of fibrin
may oscillate around this average  so as to descend
as low as 2.5 ;  or  ascend as  far  as 3.5; without
actual disease existing.   M. Andral,  indeed, (He-
matologic, &c. p.  28.)  affirms,  that some indi-
viduals, without being sick, have the  ratio as high
as 4 ; whilst others have it as low as  2 ; but these
are rare cases, and belong to peculiarities of con-
stitution or to idiosyncrasies.
  The  average quantity of  red corpuscles in
healthy man was found to be 127 ; the maximum
being 140 ; and the minimum 110.   The maxi-
mum 140 is, however, according to M. Andral,
associated with a  state of plethora,  which, when
developed, is  really morbid.   Strength  of consti-
tution contributes most to raise the corpuscles to-
wards  their maximum, whilst congenital, or  ac-
quired  weakness,  depresses  them towards their
minimum. The  average proportion of the solid
matter of the serum was found to  be 80.  It, also,
is liable to variation within  certain limits  in  the
state of health;  but   whenever  it passes  those
limits, disease exists.
  The results of the observations  of recent hsema-
tologists, in special diseases, will  be given under
those diseases.         ~        „           n
                      Robley  Dunglison.]
  BLOODLETTING.   The detraction of blood
is either general or topical:  the first consists of
phlebotomy or  venesection, and  of  arteriotomy;
the second, of leeching, cupping, and  scarifica-
tion.
  As general bloodletting is, of all our remedies,
the most  powerful, its employment  requires  the
utmost consideration and precaution.   If we neg-
lect this remedy in  cases in which its  use is re-
quired, we allow the disease to make a dangerous
progress; on the other hand, if we employ it in-
advertently and inappropriately, we induce a dan-
gerous state of debility or exhaustion.  It will,
therefore, require  much care to  lay down such
rules as may  guide, or, at least, assist the  young
practitioner in the  due and efficient, but  appro-
priate and cautious, use of bloodletting.
  Of the circumstances which require considera-
tion in the prescription or performance of blood-
letting, the principal are,  1. the nature and stage
of the disease;  2. the velocity and the force of the
action of the  heart; 3. the condition of the pulse
at the wrist;  4. the appearance of the blood ; and,
5. the  effect  upon the patient,  in arresting  the
symptoms, subduing the  disease, or in  inducing
syncope.  In regard to  the repetition  of the blood-
letting, the same circumstances must be considered,
in conjunction with the actual state of the symp-
toms, the  appearances of the blood  previously
drawn  &c
  The  diseases which  require  bloodletting arc
chiefly  inflammation,  diseases of the head, and
some forms of fever.   Of the first class  it is re-
marked, that inflammations of the  serous  mem-
branes  and  of the substance  of organs- require
bloodletting much  more than inflammations of the
mucous  membranes : arachnitis,  pleuritis, perito-
nitis, pneumonia, hepatitis,  require general blood-
letting  far  more  than  bronchitis or dysentery.
The second  class,  or affections of the head, con-
sist either of inflammatory,  congestive, or organic
disease,  as arachnitis, apoplexy, tumours;  or of
what may be termed affections of nervous  irrita-
bility, such as are observed from intestinal derange-
ment, exhaustion,  &c.  and  in delirium tremens,
the  delirium traumaticum  described by  M. Du-
puytren, &c.   Now the diseases of the former of
these subdivisions require bloodletting proportioned
to their severity;  wbereas in those of the  latter
the detraction of blood requires great caution.
  Laennec  assures us that  the force of the beat
of the heart under the stethoscope is an excellent
criterion and guide for the use of the lancet.  As
this point does not appear to have excited further
attention, it will be especially proper to introduce
the  remarks of that eminent pathologist in this
place:  " In all cases  in which the  pulsations of
the heart are, proportionately, more energetic than
those of the arteries, we may bleed fearlessly and
be certain of an improvement in the state of the
pulse.   But  if the heart and  the pulse be alike
feeble, bloodletting will almost always precipitate
the patient into a state  of complete prostration."
(De l'Auscultation, t. i. p. 486-7.)  Laennec adds,
(T. ii. p. 481.) "the certainty and  facility with
which the stethoscope affords or excludes the indi-
cations for bloodletting, appears one of the great-
est  advantages  conferred by this instrument."
  It must be confessed, however, that as the pulse
may be "fictitie debilis," or apparently, not really,
a mark of weakness, so the  beat of the heart may
be apparently, rather than really, strong ;  this oc-
curs in  cases  of  mere  nervousness, and in one
stage of exhaustion.  But  in the instances from
which  such sources of error are excluded, it is
plain that an attention to the force of the beat of
the heart may be of the utmost advantage.
  The condition of the pulse is also one of those
circumstances which greatly assist us in the ad-
ministration of bloodletting.  But that  we  may
derive  all the advantage possible  from the state of
the pulse, it must always be considered in con-
nexion with the disease.   Thus in  enteritis, al-
though an inflammatory disease, the pulse is small
and feeble, and would not  to  the  inexperienced
suggest  the propriety of the  essential remedy,
bloodletting; in a certain stage of exhaustion from
loss of blood,  on  the  other hand, the pulse is
bounding and strong, and the  ignorant or incau-
tious practitioner might be led by it to an impro-
per  and unsafe detraction  of blood.  Still the
pulse, taken in this connexion,  is an important
guide to us for  the use of the lancet; its strength
indicating, its feebleness contra-indicating, the de-
traction of blood.
  [Mere quickness of pulse—taken  singly—can
never be regarded  as a positive indication for the
use  of  the lancet, inasmuch  as  it occurs in dis-
eases which are highly neuropathic, and especially 
BLOODLI
where they are accompanied at the same time by
debility;  and the practitioner who expects, under
such circumstances, to diminish the velocity of
the circulation  by bloodletting, will find himself
wofully mistaken.   In scarlatina,  quickness of
pulse is one of the most marked functional phe-
nomena,  and in tbe most malignant cases this is
often most strikingly  evinced ; yet bloodletting
can rarely be employed  in such cases, and  if it
should be, it will generally be found,  that the
quickness of pulse is increased rather than dimi-
nished by it.  (See, on the whole subject of Blood-
letting,  Dunglison's  General  Therapeutics and
Materia Medica, ii. 150: Philad. 1843.)]
   During the flow of blood itself, great attention
must be paid to the state of the pulse ; if it grow
larger, fuller, stronger,  the propriety  of taking
more blood is distinctly determined; if, on the
contrary, it  becomes  feebler, the further  flow of
blood must be arrested.
   In some cases the blood flows well, and displays
only a proper degree of the venous hue ;  in other
cases it flows tardily or scarcely at all, and  is of
an unusually deep livid hue.   The former  state
of things affords an indication  of the propriety of
proceeding with the detraction of blood ; the lat-
ter warns us of the necessity for the greatest cau-
tion in regard to this measure.  This distinction
has been recently particularly insisted  on in re-
gard to fever by Dr. Tweedie, in his work on that
subject.
   It sometimes occurs,  however, that  the blood
flows ill at first*  and better  shortly  afterwards.
This is particularly observed in those cases which
are  attended by a small pulse, and a cold, livid
surface,  as enteritis.   This improvement in the
flow of the  blood from the vein must be viewed
 as an indication of the propriety of allowing the
blood to  flow on.
   A change in the appearance of the blood, as it
 flows, from  the more livid to the  less livid hue,
must also be considered as indicating the propriety
 of the still further detraction of blood.
   The effect of the flow of blood upon the patient
 is  also to be strictly attended  to.  If pain for in-
 stance, or any other symptom of an inflammatory
 disease, remain unsubdued, it  is frequently  right
 to continue the  abstraction of blood.   If, whilst
 the strength  is good, stupor in apoplexy, or pain
 in pleuritis, remains unmitigated, tbe  blood  must
be allowed  to flow.   When, on  the  contrary,
 the disease  or the symptom  is alleviated or  re-
 moved, we  are frequently to  arrest the  flow of
blood, and  to  wait  and watch the  subsequent
state of the patient  and of the symptoms ; to re-
peat the  bloodletting if the symptoms return and
the strength of the patient remain good,  and vice
versa.
   But of all the criteria for the regulation of gene-
ral bloodletting,  the effect of  the detraction of
blood Opon the patient, in inducing syncope, is,
in our < pinion, the most important.  The princi-
ple of  this criterion  is only applicable in cases in
which 't has been previously judged right to re-
commend the  full effect of bloodletting; but in
such cases it appears to afford the precise measure
to which that bloodletting  should be carried.
   The principle  alluded  to may be stated thus  :
—1.  cxteris paribus,  some diseases  enable the
   Vol. I.—38
2TTING.                               097

system to bear a greater  loss of blood  than  in
health : 2. other diseases, on the  contrary, induce
an  unnatural susceptibility to the effects of loss
of blood :  3. these two points are severally esta-
blished by placing the patient perfectly  upright.
and letting blood  from a  moderate-sized  orifice
until incipient syncope be induced, the quantities
of blood  which flow denoting the  power  or the
susceptibility of the patient in regard to  the loss
of blood : 4. this effect is also accurately indica-
tive of the quantity of blood which  should  be
abstracted in order to subdue  the disease.
   It is found,  for instance,  that in  arachnitis and
apoplexy much blood  flows  before there is any
symptom of approaching syncope :  it is also well
known that it is necessary to  abstract much blood
in these diseases before the chain of morbid actions
can be broken.  It is probably not so well known
that these two facts  are precisely  commensurate
with each other; so that to bleed to incipient syn-
cope is to bleed precisely according to tbe exigen-
cies of the case.
   Pleuritis and pneumonia not  only require, but
enable the patient to bear the abstraction of a large
quantity of blood : bronchitis, on the other hand,
neither bears nor requires much loss of blood.  In
any case, if we place the patient upright and bleed
to  incipient syncope,  we abstract  precisely the
quantity  of blood which the patient will bear to
lose, and which the  disease  requires to  be with-
drawn.
   Similar remarks apply to peritonitis, and what
has been termed muco-enteritis.
   In other cases there is a difficulty in the diag-
nosis, and there  may be symptoms resembling
arachnitis,  pleuritis, peritonitis, without inflam-
mation :  such symptoms are apt to arise merely
from a loaded  and deranged state of the  stomach
or  of  the bowels;  some  indigestible substance
taken  under circumstances  of susceptibility, as in
the puerperal  state; the presence of scybala, or
unhealthy secretions. The intestines,  under simi-
lar circumstances, induce pain and affections of
the head  or abdomen so similar to inflammation,
as not easily to be distinguished from it.  In such
cases  we may, however, safely place  the patient
erect,  and bleed to incipient  syncope.  Whereas
in arachnitis we frequently abstract thirty, forty,
or  fifty ounces of blood, or  even  a still greater
quantity,—in these cases the loss of ten, twelve,
or  fourteen ounces  will  frequently  induce the
most decided syncope.
   We are thus furnished  at once  with  the due
measure of the remedy and the diagnosis  of the
disease.
   The same rule applies  in the  early  stage ol
fever,  in which, if there be  great  constitutional
power and  excitement, or  inflammation, much
blood  must and will be drawn; whereas, in cases
of  an opposite kind, there  will be early  syncope
—our safeguard against withdrawing an  undue
quantity  of blood.
   Having stated and explained the general prin
ciple,  it only remains to add  that several precau
tions  are  required in  carrying  it  into  practice.
We must not be deceived by that kind of fainting
which occurs from timidity in regard to the mere
operation.  We must not be misled by  tbe state
of  things very early and very late in the diseane 
298
BLOODLETTING.
In the former case the disease has not induced its
influence upon the  system;  in the second  it has
led to sad devastation of its powers, as well as of
the structure of the organ  affected.
   Chlorosis and every  form  of  dyspepsia are
amongst the diseases which  neither bear nor re-
quire bloodletting.
   There are diseases which  may be benefited by
the detraction  of a small quantity of blood, but in
which full  bloodletting would not be proper.
Such are,  some  cases of haemoptysis, diabetes,
and  probably  the cholera.   In regard to  these,
experience of  the past  alone can  guide us  in the
future.   The  principle just adverted to is only
applicable in  cases in which the full effects of
bloodletting are required, not exceeding the limits
of efficiency on one hand, and  of safety on the
other.
   The next point to be determined is the repeti-
tion  of the bloodletting.   The strength of the
patient, the force of the symptoms, the beat of the
heart and of the  pulse, must again aid us in our
decision.  But it is important to remark, that .if
at the first bloodletting much blood should  flow
before syncope is induced, it must be received as
a  criterion  that the disease  may  require, as  the
patient will bear, the early and efficient repetition
of the remedy.
   Much importance has been attached to  the
appearance of buff upon the blood, as an indica-
tion  for  further bloodletting.   This appearance,
however, if trusted  to alone as a guide, is very
apt to mislead the practitioner.  It occurs in many
other cases  besides inflammation, and especially
in almost all puerperal diseases.  A patient has
been daily bled in  puerperal  mania, on accouut
of the constant appearance of buff on the  blood,
and  bled to death !   Dr. Willan makes an excel-
lent  remark on this subject.   " Some practition-
ers," he  observes, " continue to  let blood in most
cases of acute rheumatism, thinking themselves
justified in their mode  of practice by the sizy
appearance of the blood.   The same principle
would lead them to empty the whole sanguiferous
system;  for every  time  bloodletting is repeated,
the blood becomes more and more dense or sizy."
(Diseases of London, 1821, p. 261.)   Not  only
:'* buff induced by other causes besides inflamma-
tion, but in some cases of inflammation it  does
not exist.   Much, too, depends upon the mode in
which the blood flows from the vein, and other
circumstances.  So that  the  light cast upon the
treatment  of  diseases  by this circumstance is
feeble, if not actually deceptive.
   The  " dissolved" state of the blood, and the
small quantity  of crassamentum compared  with
the serum, form  a more certain contra-indication
of bloodletting, generally speaking ;  and yet even
this is probably not absolute.
   The different modes of general bloodletting are
 venesection, performed in the arm  or foot, or in
 lie neck; and arteriotomy.
   It is almost needless to mention  that the arm
 is generally preferred.  The jugular vein, how-
 ever, should be opened when the head is affected.
 But  it  is  principally  useful  to have recourse to
 the  incision  of the jugular vein in children, in
 whom it is readily opened, and in whom the veins
 of the arms are small.
  Arteriotomy is preferred principally in cases of
disease of the head or of the eye, or in cases in
which  blood cannnot be obtained from the veins.
  Local  bloodletting is  chiefly  applicable as an
auxiliary to general bloodletting, and in local dis-
eases in which general bloodletting is not required.
In cases of inflammation within the head, chest,
or abdomen, after the  due  abstraction  of blood
generally, the local abstraction of blood is very
often employed most opportunely.  The second
remedy secures the  benefit  which the first  had
conferred.   In regard to the application of a large
number of leeches in such cases, a few words of
caution are, however, necessary.  The loss of the
blood  so  withdrawn is not  always well borrre
when the lancet has been used efficiently just be-
fore ; and if applied late at night, the flow of blood
is apt to continue unheeded, until an undue quan-
tity of blood has been  poured out.   Both these
events have occurred, and led to unavailing regret.
   Cupping is, generally speaking, a more efficient
remedy than leeching.   It is most  appropriately
applied to the nape of the neck, behind the ears,
to the  temples, to the various parts of the chest,
over the region of the liver, the  kidney, &c.  To
the softer parts of the abdomen, leeches must be
applied.
  Both these remedies are peculiarly efficacious
in cases in which the powers of the whole system
have been  duly subdued by  general bloodletting,
without the removal of the symptoms of the local
disease.  Only  the quantity so withdrawn after
the general  bloodletting must not be too great.
   In some chronic local affections, in which gene-
ral  bloodletting would be  inadmissible, the local
abstraction  of blood  by leeches or cupping be-
comes our chief remedy.   Such cases are chronic
inflammation  within  the  head,  thorax, or abdo-
men ;  especially when this is fixed chiefly to one
part or organ.   Inflammatory pain  long confined
to one part  of tbe head or chest, chronic  inflam-
mation of the liver, kidney, uterus, &c. are cases
in which local bloodletting is the appropriate re-
medy.
   It should not be omitted,  perhaps, that the ap-
plication of leeches near the  anus has been much
recommended in France, in  order to effect what
is supposed to  be  effected by hemorrhoidal  dis-
charges, viz.  to  unload  the  vena portse, and to
relieve the head or the liver.   This mode of local
bloodletting is also very beneficial in diarrhoea and
dysentery.  Leeches have also been  applied by
means of an  appropriate metallic tube to the
vagina or to the os uteri, in cases of inflammation
of those parts.
   These  appear to be appropriate  cases for iii'
use of local bloodletting by  cupping and leeches
Scarification is  a mode of taking blood in a few
cases of local disease, as in inflammation of th"
eye, of the tonsils, and in inflamed hemorrhoids.
   Morbid Effects of  loss of Blood.__The
morbid effects of loss  of blood may be divided
into the immediate and the more remote: the for-
mer occur at  the moment of the excessive detrac-
tion of blood or of profuse hemorrhagy; the latter,
at a more remote period, or during the course of
a continued drain from the  sanguiferous system.
The immediate morbid effects of loss of blood
are, syncope,  convulsion, delirium, coma, suddc 
BLOODLETTING.
299
dissolution ; the m )re remote  are, excessive re-
action, mania, coma, amaurosis, sinking.
  In  ordinary  syncope from loss of blood, the
patient first experiences a degree of vertigo, to
which loss of consciousness  succeeds ; the respi-
ration is affected in proportion to the degree of
insensibility,  being suspended  until  the  painful
sensation  produced rouses the patient to  draw
deep  and  repeated sighs, and then suspended as
before;  the beat of the heart and of the pulse is
slow and weak ; the face and general  surface be-
come pale, cool, and bedewed with perspiration ;
the stomach is  apt to be affected with eructation
or  sickness.    On  recovery  there is  perhaps a
momentary  delirium, yawning, and a return of
consciousness ; irregular sighing breathing, and a
gradual return  of the pulse.
   In cases of profuse hemorrhage  the state of the
patient varies :  there is at one  moment a greater
or less degree of syncope, then a degree of reco-
very.  During the syncope the countenance is
extremely pallid ;  there is more or less insensi-
bility ; the respiratory movements of the thorax
are at one period  imperceptible, and then  there
are irregular sighs; the pulse  is  slow, feeble, or
not to be distinguished ; the extremities are apt to
be  cold ; the stomach  is frequently affected with
sickness.  There are several  phenomena observed
in this state particularly worthy of attention. We
have remarked that, when the  movements of the
chest have been imperceptible or nearly so, in the
interval between  the  sighs,  the respiration has
still been  carried  on by means  of  the diaphragm.
It may also be  observed that  the state of syncope
is often relieved, for a time, by an attack of sick-
ness  and  vomiting, immediately after which the
patient expresses  herself as feeling  better  ; and
the  countenance   is  somewhat  improved,  the
breathing more natural, and the  pulse stronger
and more frequent.  It may  be a question, in this
case, whether the  state of syncope increases until
it induces sickness ;  or whether the stomach be
 nauseated  by  the ingesta usually administered,
 and the syncope be, in part, an effect of this state
of the stomach.  In any case, the efforts to  vomit
 are succeeded for  a time by an ameliorated state
of the patient.
   In cases of fatal hemorrhagy there are none of
these ameliorations.   The  symptoms gradually
 and progressively assume  a more and more fright-
ful aspect: the countenance does not improve,
but becomes more and more  pale  and sunk ; the
consciousness  sometimes remains,  until at  last
there is some  delirium ; but  every thing  denotes
an impaired state of the energies of the  brain ;
the breathing  becomes stertorous, and at length
affected by terrible gasping;  there  may be no
efforts to vomit;  the  pulse is extremely feeble or
imperceptible ; the animal heat fails, and the ex-
tremities become colder and colder in spite of every
kind of external warmth ; the voice may be strong,
and there are constant restlessness and jactitation;
at length  the strength fails, and the patient  sinks,
gasps, and expires.
   Convulsion, as  an immediate effect of loss of
blood, occurs when bloodletting has been inappro-
priately or unduly employed,  or  from excessive
hemorrhage.   It is apt to occur in cases in  which
the patient has been bled  in  a more or less recum-
bent position,  in which the blood  has flowed
slowly, or in which time has been lost during the
operation.   In  such cases much blood flows be-
fore  syncope is induced — too much to be  safe.
When the blood  flows slowly, we should  be cau-
tious how we bleed to deliquium even in the erect
posture ; in the recumbent posture it will always
be attended  with danger.
  The more usual occurrence of convulsions  is
from hemorrhagy.  In this  manner  such convul-
sions occur after parturition, and constitute one
form of puerperal convulsions.   A more frightful
and  formidable disease it is impossible to witness.
The countenance and the limbs are variously con-
torted, the respiration is laborious  and stertorous,
and  foam issues from the mouth; the colour  of
the face is  deepened,  and may be designated  as
being of a palish  lividity.   Such  a  case calls for
the utmost  presence of mind.  The alarm of the
by-standers must be quieted.  No hasty measures
must be  adopted.  The recumbent posture, the
sprinkling of  cold water upon the face, a  cold
lotion  applied  to the  head,  and frictions to the
feet, are  the  immediate remedies;  stimuli and
opiates, with nourishment, are to be administered
during the intervals of convulsion.
   Sometimes, instead of convulsions, a fit of de-
lirium occurs;  in other, rarer, cases, we may have
both delirium and convulsions.  This delirium  is
generally of short duration ; it has, in other in-
stances, continued so long as to deserve to be con-
sidered as  mania.  A  state of coma is  another
form of the  morbid effects of loss of blood.  Con-
vulsion frequently terminates  in  coma,  but the
latter symptom may arise without the former.
   Of these effects of loss of blood, delirium chiefly
occurs in adult age; convulsions frequently occur
both in  adults and in infants;  the state of coma
is most  frequent in infancy.   The last case con-
stitutes one of those  affections which are apt  to
be mistaken for hydrencephalus.
   Amongst the immediate effects of loss of blood
must be mentioned that of sudden and unexpected
dissolution.  The patient does not recover from a
state of syncope ; or, without  syncope,  he  may
gradually sink  after blood-letting.   This event  i?
particularly apt to occur if the patient be bled  in
the  recumbent position.  It has taken the  most
able and experienced practitioners by surprise.
   At various  periods after  the profuse  loss  of
blood, whether by bloodletting  or  hemorrhagy,
that state which has been termed re-action occurs.
This state of excessive re-action is formed gradu-
ally, and consists, at  first, in forcible beating  of
the  pulse, of  the carotids, and of the  heart, ac-
companied  by  a sense of throbbing in the  head,
of palpitation  of the heart, and eventually perhaps
of beating or throbbing  in the scrobiculus cordis,
and in the course of the aorta.   This  state  of
re-action  is augmented occasionally by a turbulent
dream, mental  agitation, or  bodily exertion.   At
other  times it is modified  by a temporary faint-
ness or syncope.  There is also sometimes irregu-
larity of the beat of the heart and of the pulse.
   In the more exquisite cases of excessive re-ac-
tion, the symptoms are still more strongly marked,
and demand a fuller description.
   The beating of the temples is at length accom-
panied by a throbbing  pain  of the head, and thf 
I
300
BLOODLETTING.
energies and sensibilities of tbe brain arc morbidly
augmented;  sometimes  there  is  intolerance of
light, but  still  more  frequently  intolerance of
noise, and of disturbance of any kind, requiring
stillness to be  strictly enjoined, the knockers to be
tied, and straw to be strewed along the pave-
ment ; the  sleep  is agitated and disturbed by
fearful dreams, and the patient is liable to awake,
or to be awoke, in a state of great hurry of mind,
sometimes almost approaching to delirium ; some-
times there is slight  delirium, and  occasionally
even continued delirium; more frequently there
are  great noises in the head, as of singing, of
crackers,  of a storm,  or  of a cataract;  in some
instances there are flashes  of light; sometimes
there is  a sense of great pressure or tightness in
one part or round  tbe head, as if the skull  were
pressed by an  iron nail, or bound by  an   iron
hoop.
   The action  of tbe heart and arteries is morbidly
increased, and  there  are great  palpitation  and
visible throbbingc of  the carotids, and sometimes
even of the abdominal aorta, augmented to a still
greater degree by  every cause of hurry  of  mind
or exertion of the body, by sudden noises or hur-
ried dreams  or wakings;  the patient is  often
greatly alarmed and   impressed with the feeling
of  approaching dissolution; the state of palpita-
tion and  throbbing is  apt to be changed, at differ-
ent times, to a feeling of syncope.  The  effect
of  sleep is in some instances very extraordinary,
sometimes palpitation, at other times a degree of
syncope,  or an overwhelming feeling of dissolu-
tion.  The pulse varies from 100 to 120 or  130,
and is attended with  a forcible jerk or bounding
of  the artery.
   The respiration  is  apt to be frequent and hur-
ried, and  attended with  alternate  panting and
sighing;  the movement of expiration  is some-
times  obviously and  singularly blended with  a
movement communicated  by  the   beat of the
heart;  the patient requires the  smelling-bottle,
the fan, and  the fresh air.
   The skin is sometimes hot; and  there are fre-
quently general hurry and restlessness.
   In this state of exhaustion, sudden dissolution
has sometimes been the immediate  consequence
of  muscular  effort on the part of the patient, or
of  his being too suddenly raised from the recum-
bent into the  erect position.
   The state  of re-action  may gradually subside
and leave the patient feeble, but with returning
health; or it may yield to the state of sinking.
This term is  adopted not to  express a  state of
negative  weakness merely, which may continue
long and  issue in eventual recovery, but to de-
note a state of positive and progressive failure of
the vital  powers, attended  by its  peculiar effects,
and by  a set of phenomena very different  from
those of exhaustion with re-action.   In the latter
the energies of the system were  augmented ; in
the former the functions of the brain, the lungs,
and the heart are  singularly impaired.  The sen-
the cheeks in breathing, &c.  Instead of the hurry
and  alarm on  awaking  observed in the c.ise of
excessive re-action, the patient in the state of sink-
ing requires a moment  to recollect himself and
recover bis consciousness, is perhaps affected with
slight delirium, and is apt lo  forget tbe cirrum-
stances of his situation, and, inattentive to the
objects  around him, to  fall again into a state nf
dozing.
   Not less remarkable is the effect of the state of
exhaustion  with sinking on the function of the
lungs;  indeed, the  very  first indication of this
state is to be found in the supervention of a cre-
pitus in the respiration, only to  be heard at first
on the most attentive listening ;  this crepitus gra-
dually  becomes  more  audible,  and passes into
slight rattling, heard in  the situation of the bron-
chi  and trachea; there  is also a degree of labour
or oppression, sighing,  hurry,  blowing,  in the
breathing, inducing acuteness  in  the  nostrik
which are dilated below, and drawn in above the
lobes £t each inspiration ; in some cases there is,
besides, a  peculiar catching  laryngeal  cough,
which  is especially apt  to come on during sleep,
and awakes,  or imperfectly awakes, the patient.
The heart  has, at the  same time, lost its violent
beat and palpitation, and  the  pulse and arteries
have  lost their  bounding  or  throbbing.  The
stomach and bowels become disordered and flatu-
lent, and tympanitic, and  the command over the
sphincters is impaired.
   The last stage of sinking is denoted by a pale
and sunk countenance, inquietude, jactitation, de-
lirium, and coldness of  the extremities.
   It has already been observed  that delirium oc-
curs as an  immediate  effect  of loss  of blood:
mania, or  delirium in  a more or less continued
form, is not an unfrequent occurrence, as a more
remote effect of the same cause.  That form of
this disease termed puerperal mania, generally
arises  from the loss of blood in  the predisposed,
A form of mania,  not to be distinguished, except
by the history of  the case, from  puerperal mania,
occurs  from loss of blood, independently of the
circumstance of parturition.
   Coma, amaurosis, deafness, and paralysis are
other forms of the effects of loss  of blood.  Cases
of the first kind are detailed  by Dr. Abercrombie
as well as by the writer  of this article.   Mr. Tra-
vers describes a form of  amaurosis from depletion.
Deafness from exhaustion is by  no means unfre-
quent ; and it occasionally remains for a  conside-
rable  length  of time.   Paralysis,  more  or  less
permanent, occurs occasionally in  extreme cases
of exhaustion.
   Various circumstances  exert  an influence in
diminishing or augmenting the disposition to pre-
sent the phenomena of loss of blood.   Inflamma-
tion of the  serous membranes and of  the paren-
chymatous substance of organs protects the system
from the  effects of loss  of blood ; gastric and  in-
testinal derangements have  a precisely  contrary
effect.   It is  probable that  the  mode in which
sibihties of the brain subside, and the patient is  these circumstances operate is  that  of inducing
no longer affected  by noises as before; there is, : different states of the  blood itself: inflammation
on the contrary, a  tendency to dozing, and gradu- j is known to increase the quantity of albumen in
ally some of those effects on the muscular system j blood, and in general to induce the disposition to
supervene which denote a diminished  sensibility  buff; chylopoietic derangements, on the contrary,
sf the brain, as snoring, siertor,  blowing  up of j induce an opposite condition of the  blood  In 
BLOODLETTING.
301
the former case the arterial system  is probably
more  firmly contracted upon its  contents, even
when a part of these is subtracted;  and in this
manner the disposition to  syncope  and to the
other effects of loss of blood may be obviated.
   Besides the affections described, there are some
organic effects  from loss  of blood.   There is a
disposition to effusion within the head,  so that
actual apoplexy as well as serous effusion  has oc-
curred in the last stage of exhaustion.  Another
effect of exhaustion  is effusion  into the air-cells
and bronchi, giving origin  to  a  peculiar  rattle
beard with the stethoscope, and  generally  of fatal
omen.  Tympanitis is another  effect  of  loss  of
blood ;  and a general disposition to dropsy, inter-
nal and external, is amongst the most frequent  of
 the effects of this condition  of the system.
   The  treatment  of the effects of loss  of blood
 must be resolved into  that  which is general  or
 constitutional, and that which  is  local;  and it
 must vary according to the peculiar state  or stage
 of these effects.   Syncope, re-action, and sinking
 require their appropriate treatment.   The consti-
 tutional treatment must be stimulant  in  syncope,
 sedative and soothing in the  state of re-action,
 and  restorative  in that of  sinking.  The  local
 treatment must vary with the organ chiefly  affect-
 ed, and with the mode in which it is affected.
   When syncope assumes a dangerous form, the
 principal remedies are, an attention to the posture
 of the patient, stimulants, and chiefly brandy, and
 the transfusion of blood.
   The effect of posture is not, even now, fully
 known.  It would be easy to allow the patient to
 lie over the edge of the bed, the head low upon
 the floor,  and  the  feet gently raised.   In this
 manner such  pressure  would be  restored to the
 encephalon as  would in many  cases support life,
 until, other remedies being administered, the pa-
 tient might be  placed  out  of immediate danger.
 We need not in this place notice the importance
 of a regulated mode of giving brandy and nourish-
 ment.   We think it is frequently given  in such
 quantities as actually to induce sickness and  its
 own rejection from the stomach, and so as to frus-
 trate the object of the physician completely.  The
 effect should be carefully watched.   The  physi-
 cian ought not,  of course, in such a case, to leave
 the patient for a moment.
   The next remedy is transfusion. Unfortunately
 it has  too frequently happened that  the proper
 period of adopting this measure has been  allowed
 to pass  by.  Not only  the vascular system is
 exhausted, but, after a  time, the functions  of the
 nervous system  have begun to fail.   It might be
 a question, therefore, whether  galvanism  might
 not be  usefully conjoined with transfusion.
   It is an important point to determine how large
 a quantity of blood tbe  system will bear to receive
 under various circumstances of exhaustion.  Too
 much may overwhelm ; too little may be  inade-
 quate to the accomplishment of the object in view.
 It is also an important question whether the ope-
 ration should be done at once, or at twice, or thrice,
 and with what intervals.  As the system cannot
 bear a sudden reduction of  the  quantity of blood,
 so it may not  be enabled  to bear its too sudden
 restoration.  It is almost needless to add  that a
due attention must be constantly paid to assist the
                                       2 A
arterialization  of the blood  by the  admission  of
fresh air;  and to sustain the animal heat by proper
clothing, and especially warm  applications  to the
feet.
  If there should  be  convulsions, delirium, or
coma, it may be necessary to apply a sinapism to
the nape of the neck ;  and in the two former cases
some  mild sedative, as the tinctura hyoscyami,
may be of advantage.
  In the case  of excessive re-action, the remedies
appear to be,  first,  extreme quiet of body and of
the mind ; then, the mildest sedatives, especially
the hyoscyamus; thirdly, the mildest nutriments ;
and lastly, and above  all, time.
  The pain and throbbings in the head, the  in-
tolerance  of noises, the  general susceptibility to
disturbance, the  palpitations  of the heart, alike
demand the utmost quiet, to which every  thing
soothing in the manner and treatment  must be
added.  The tinctura hyoscyami is, we think, the
kindliest  anodyne  and sedative in  these cases.
The cause and other  circumstances of  the case
point out  the necessity  for mild  nutriment, to
which perhaps the minutest quantities of brandy
may be added.
   It may be necessary to subdue  the throbbing
action  of  the head even by local bloodletting;
and it is most remarkable how small a  quantity
of blood being taken will relieve.   Two or three
leeches are frequently  quite sufficient.
   But  the most  unequivocal remedy is  a cold
spirituous lotion, applied  all over the  head by
means of a cap consisting of one fold of stocking.
   In exhaustion with  delirium, the tinctura hyos-
cyami should  be conjoined, in full doses, with the
other remedies.  Tbe morbid susceptibility,  not
only  of the brain but  of the heart, is greatly
assuaged by this remedy.
   In cases of exhaustion with sinking, stimulants
must be administered  abundantly. Cataplasms of
mustard may  be applied  to the nape of the neck
and to  the feet.   It is difficult to imagine what
would be the effect of  a transfusion of blood ;  we
have no doubt that galvanism would pre long life ;
and we should think the two  remedies might be
conjoined with advantage.
   In all cases  of exhaustion the functions of  the
bowels suffer.  Constipation and  flatulency  are
the usual consequences.   These are best relieved
by  the warm water enema, which must, however,
of course, be administered with due precaution, so
as to prevent  further exhaustion.
   It is interesting to observe the blunted  sensibili-
ties in syncope  and in  sinking, and to  compare
them with the morbidly acute  sensibilities of  the
state of re-action.   Sinapisms to rouse, and  the
tinctura hyoscyami to  lull them,  are,  in their
respective places, remedies of the greatest value.
                         Marshall Hall.
   BLUE  DISEASE.  (See Cyanosis.)
   BRAIN, Inflammation op  the.—Under this
term we propose to include the pathology, symp-
toms, and treatment of the inflammatory affections
of  the  brain and  of its  membranes.  We  adopt
this plan, not  merely because of the intimate rela-
tion subsisting between  these  structures, but  be-
cause, when we trace  the history of a number of
acute  affections of the encephalon, and examine 
'J02     B R AI N ,  ( I N F L A M M A TI 0 N  OF  T H E )— [ M E N IN G ITIS.]
 the lesions of structure presented after death, we
 shall frequently  find  that  the substance of the
 organ as well as  the investing membranes has
 been involved m the disease.   Hence arises the
 difliculty of  establishing  the diagnosis between
 inflammation of the parenchyma of the brain and
 that  of its membranes.   Both  forms of disease
 have been classed by the  majority of nosologists,
 ancient as well as modern, under the same  head
 as phrenitis, in consequence of their inability to
 draw any distinct  line of demarcation between
 their symptoms.
   Several modern  pathologists, however, (Lalle-
 mand, Rostan, Bouillaud, Gcndrin, &c.) baving
 devoted much time and attention to the study of
 cerebral  diseases, and collected a  large body of
 well-observed clinical cases, conceive  that  they
 have succeeded in  establishing correct rules of
 diagnosis between several  of the inflammatory
 affections of  the brain and of its membranes; and
 they affirm, moreover, that it is quite possible, in
 many cases, to ascertain the different degrees,
 stages, and  even seats of cerebral inflammation.
 The  rapid advances  made  of late years' in the
 knowledge of the physiology and morbid anatomy
 of the brain,  have no doubt greatly assisted modern
 observers in  discriminating the characters  of its
 various diseases.   It is  not,  in the mean time,
 improbable that they may, in some instances, have
 been led, by their zeal in a new field of discovery,
 to overstep  the  exact boundaries of fact.   We
 think there is, however, an equal probability that
 many of our failures in  diagnosis, in a class of
 diseases hitherto  so little  studied in this country,
 are  to be imputed  to a  deficiency in our  own
 powers of observation ; the old adage that  it is
 possible  to look  at an object without seeing it,
 which is not the  less true for  being trite, being,
 we apprehend, often verified  in the study  of the
 symptoms of disease.
   The result of  our own experience leads us to
 the conclusion that there are  extreme cases in
 cerebral affections which  can never be mistaken
 one  for another;  that there are cases not so well
 marked, in which the attainment  of  an accurate
 diagnosis is attended with greater difficulty;  that
 there are also mixed cases, in which one form of
 disease, which may have  existed separately  for a
 time, gives rise to another, or in which a disease,
 at first local,  becomes general.  All these circum-
 stances must necessarily  tend  to  complicate the
 bagnosis.  We should reflect, however, that the
 i-tudy of the pathology of  the brain is only in its
commencement ;  that  the surest  method of  ac-
quiring greater power of discrimination is to avail
ourselves cautiously of the information and expe-
rience of those who have already been labouring
in the field, and to bring to the further investiga-
tion  of this  intricate subject a spirit of careful
observation and strict induction.  We may thus
reasonably hope to  be enabled in time to rectify
their  errors, extend the sphere of our knowledge,
and establish  this important branch of pathology
on a  more practical  foundation.  The utmost that
can be expected from precise rules of diagnosis
m any class of diseases, is that  they should guide
us accurately in the great majority of cases ;  and
tiltnough it may occasionally bappen that they do
u->t accomplish this, they are  not on that account
 to be laid aside as of no value.   There is indeed
 no class of diseases in which the symptoms may
 not at times prove deceitful;  we thus have latent
 affections of the lungs and alimentary canal with-
 out any or with  only very slight symptoms ; and
 very decided symptoms of inflammatory or  other
 diseases of these organs without any or at least
 with only very insignificant disease.
   When either the arachnoid or pia  mater, which
 closely invest the brain, are extensively inflamed,
 the  functions of this organ become inevitably dis-
 turbed by sympathetic irritation, without its paren-
 chyma necessarily partaking of the inflammation;
 or if the inflammation extends to the parenchyma,
 it is mostly confined  to the  superficial layer  of
 cortical substance.  This is exactly the manner in
 which the functions of the lungs or intestines are
 disturbed in  pleurisy  or peritonitis.  Hence  in
 arachnitis  or  meningitis, besides headach  and
 intense fever, we  have an increase of the general
 sensibility, preternatural acuteness of the external
 senses,  violent delirium and convulsions,  and,
 finally,  collapse,  coma,  and  death.  Extensive
 and acute inflammation of the hemisphere of the
 brain will  be characterized by a nearly  similar
 train of symptoms.  In the great majority of cases
 the  two diseases  give rise to  each other, and are
 thus combined ;  it is  then  extremely difficult, if
 not impossible,  to discriminate  between them.
 There are, however, other forms of cerebral inflam-
 mation  more  circumscribed  in  their  seat, and
 chronic in their progress, respecting the diagnosis
 of  which it  cannot,  we think,  be any  longer
 asserted that the  practitioner is altogether left  in
 doubt.
   We shall now proceed to consider inflammation
 of the encephalon under two divisions, viz. 1. in-
 flammation of the membranes of the brain (menin-
 gitis): 2. inflammation of the substance of the
 brain ( cerebritis).
   I. Inflammation  of  the membranes  of
     THE BB.AIN (MENINGITIS).
   When we look into systematic works on medi-
 cine, we are at once  struck  with  the  confusion
 which exists in the nomenclature  of  cerebral dis-
 eases.   Thus the  term phrenitis, which has been
 so long and so generally known that it has passed
 into popular use, was employed by some of the
 earlier physicians  to designate that delirium which
 so frequently arises in  the course or  towards the
 termination  of different diseases ; whilst amongst
 the moderns it is  applied to inflammation of the
 brain or  of its membranes.  Tbe group of symp-
 toms which  Frank names encephalitis, is called
 phrenis by Vogel, meningitis by Herpin, cepha-
 litis by  Linnaeus, arachnitis,  or more properly,
 arachnoiditis by Martinet: and in different essays
 and  detached  publications  by  various authors,
 cases strictly  analogous are  collected together
 under the denomination hydrocephalus, hydro-
 cephalic fever, or  hydrencephalus.   All this has
 arisen from a difference of opinion  as to the  seat
 of the disease, one person considering it as located
 in the cerebral substance; a second in the invest-
ing membranes, viz. the arachnoid membrane, the
 pia  mater, or in both ;  whilst a third is  altogether
taken up with the consideration of the effused
fluid and of the means of removing it; not know-
ing perhaps that it is a mere consequence or result 
BRAIN, (INFLAMMATION  OF  THE )—[ME NINGITIS ]    303
of inflammatory action, and not at all an element
or a constituent of the original disease.  Cullen
was decidedly of opinion that we  could  not, by
any reference to tbe symptoms during life, or the
appearances presented  after  death, assign  exactly
tbe seat of the different acute affections within the
head;  and therefore he included, under the term
phrenitis, the inflammations of the different struc-
tures contained in the cranium, no matter whether
seated  in the substance  of the  organ or in its
investments.   Mason Good  gives what may be
considered  a qualified  assent to  this view of the
subject.   He observes that  " the  disease  may
commence in the membranes or in  the substance
of the  brain ; and if  it  were to  confine itself
strictly to the part first affected, instead of spread-
ing from one to the other, there would perhaps be
no great difficulty in determining from the symp-
toms before us its  actual seat; for whilst mem-
branous inflammation  is  accompanied by acute
and rousing pain, great heat, and a pulse perma-
nently and considerably quickened, parenchyma-
tous inflammation  is  distinguished by a heavy
and often stupifying pain, slight increase of heat,
pulse irregularly quickened, or sometimes, on  the
contrary, below the natural standard."  As each
of these conditions is occasionally presented to us
in different cases  of cephalitis, we  may, says  the
same writer, infer  that in  the one instance  the
disease is seated in the membranes, (inflammatio
meningica—phrensy—brain fever,) whilst in the
other it is situated in the  cerebral substance itself,
(inflammatio  profunda — acute dropsy  of  the
head.)
   [Notwithstanding the  assertion of some, that
meningitis of the different parts of the encephalon
may be diagnosticated by certain functional phe-
nomena, it is but  too true, that  it is  almost im-
possible to pronounce positively, during life, on
this matter ;  and such is the view embraced by
the best pathologists.  Happily, it is not a matter
of moment, therapeutically ;  meningitis, no matter
where situate, demanding precisely the same treat-
ment.]
   Nothing has contributed  more to the diffusion
of error in  medicine than the disposition so con-
stantly manifested to consider symptoms as if they
were diseases,  and diseases — entities, endowed
with individuality or a  uniform mode of existence.
It also but too frequently  happens that effects are
taken  for causes,  and, under  the  influence of a
hasty  disposition  to generalize,  conclusions  are
drawn from partial observations, confined perhaps
to a few detached instances.   The opinions enter-
tained, and the  doctrines taught with regard  to
inflammation, generally,  as  a morbid  condition,
furnish a full illustration of these errors.   Are
there not many who think and act  as if the effu-
sion in hydrocephalus were the essence  of the
disease, and not a result or effect of inflammatory
action  ?  It  is with many a  fundamental axiom
that  inflammation  softens  all  textures;  hence
"ramollissement" or softening comes to constitute
the anatomical character of the substance of the
brain when inflamed.  In point of fact, softening
is only  a single step or stage in the progress of
change, the first departure from the healthy con-
dition being a turgid and  tense state of the part
affected, which subsequently becomes  softened ;
but instead of passing on to suppuration, in some
instances the process of disorganization is arrest-
ed, and then the part becomes indurated.   Pinel
was so fully impressed with these views that in-
stead  of following the usual routine of commenc-
ing with a definition  of inflammation, he con-
sidered under so many distinct heads the inflam-
mations of the different primary textures of which
the body is composed, indicating the anatomical
characters  and the peculiar symptoms of each.
The arachnoid membrane, for instance, belonging
as it does to the class of serous tissues, resembles
them  in its lesions when  diseased, as  it does in
its  character and properties in the healthy condi-
tion.   Like all the individuals  of its class it be-
comes, when the  subject of different degrees and
modes of irritation, the seat of serous and purulent
effusions, as well as of exudations of  coagulable
lymph :  and as acute inflammation of the peri-
cardium, the pleura, or the peritoneum, are con-
sidered as  distinguishable by a special train of
symptoms, it would be natural  to infer that the
like lesion  of the arachnoid  must be attended by
its appropriate characteristics.
   These general views,  which  are  confessedly
applicable  to inflammation in other parts of the
system, would have induced the learned author
of the " Nosographie Philosophique," when treat-
ing of the  cerebral  inflammations, to divide them
into separate groups, according as they are seated
in  the  membranes or in the substance  of the
organ. But he was  too discriminating an observer
to  be biassed by a, priori views, or  led away by
the spirit of the system: he admits, that in order
to  keep up  the  unity of his plan,  it would be
necessary  to describe separately  cerebritis  and
meningitis, and  to  cite cases in which the exist-
ence of each could be distinguished by a special
train  of symptoms.  This he found  to be  im-
practicable, and consequently felt himself obliged
to include under one head, encephalitis, the gene-
ral history and the complex and varying symp-
toms  of inflammation,  whether  seated  in  the
membranes  or in  the substance of the  brain.
The majority of  our  practical men  subscribe to
the correctness of these views ; for they learn by
experience that it  is much  easier to  indicate a
diagnosis in a nosological table than to support it
at the bed-side of a patient.
   An examination  of  the structure of the  brain,
and of the peculiarities of the circulation in it and
upon  it, would also lead to the inference, that if
the meninges be the  seat of inflammation, the
contiguous cerebral  substance must participate
in  some degree  in the  irritative  influence.   In
other  organs the vessels, after entering them by
trunks and branches of various sizes, branch out
and ramify in  their interior until they become
capillary in their spongy and areolar tissue.   But
in the brain a different arrangement takes place  :
the vessels, after entering at the base of the skull,
communicate freely with one another, and  then
branch  out upon the surface of the brain, rami-
fying in an extended web  of cellular tissue [pia
mater] ; in this way they become reduced to sn
great  a degree of tenuity before they enter ths
substance of the organ, that it may be  said to be
surrounded by a vascular atmosphere from which
its supplies are derived.  Hence it is. that as th« 
304      BRAIN, (INFLAMMATION  OF  THE)—[M E NIN GITIS.]
 meninges and the contiguous cerebral  substance
 are supplied from the same source, each will more
 or  less become affected by any inflammatory ac-
 tion set up in the other.  [Meningo-ccphalitis.'j
 M. Bayle, in his thesis, gives six cases of what he
 considers chronic arachnitis,  as  in all of them the
 arachnoid membrane was thickened, opaque, and
 resisting, and there was found  some serous effu-
 sion ;  but  in  five of these cases portions of the
 cerebral substance were adherent to the mem-
 branes, and so much  softened  as to be brought
 away with  the latter when an effort was made to
 detach  them :  in five of them also the pia mater
 was injected, thickened, and infiltrated with serous
 fluid.  MM. Martinet and Parent, in their elaborate
 monograph on arachnitis, give the results of their
 examination of one hundred and sixteen cases,
 published with the expressed design of establish-
 ing the diagnosis  and  pathology of arachnitis.
 But though these cases are  classed as inflamma-
 tions of a serous membrane, we find  that in a
 considerable number of  them the inflammation
 had extended to the cerebral substance, the vessels
 of  the  pia mater being at the same time injected,
 and its substance thickened and covered with a
 serous or sero-purulent effusion  ; so that, judging
 from the post-mortem appearances, they were in
 fact mixed cases ; and in strictness we must refer
 the  symptoms or physiological indications pre-
 sented  during  life, to the lesions of the cerebral
 substance rather than to that of the meninges.
   The  brain confessedly presides over all the
 phenomena which are  attended with  conscious-
 ness, and over every act which  is influenced by
 the will; it is the organ of intellect, and the centre
 of sensation and of voluntary motion.  Moreover,
 through the pneumogastric  nerve, it influences
 directly the  functions of digestion and respiration,
 and indirectly (through the respiratory apparatus)
 that of the circulation.   Experiment also demon-
 strates its intimate connexion with the regulation
 of  animal temperature.  Now  if we  note  the
 symptoms   attributed  to inflammation  of  the
 arachnoid membrane, or look over the catalogue
 of them as enumerated by different writers, we
 shall find that they  are but  so  many lesions or
 disturbances of one or more of the cerebral func-
 tions, and as such they must arise from an affec-
 tion of the organ itself which holds these functions
 in dependence,  and not  of  the investing mem-
 branes,  which  cannot exert  on these  functions
 any  direct control.   Thus, when in a  summary
 of the  symptoms of  arachnitis we find delirium,
 spasm, and  rigidity of the muscles,  convulsions,
 vomiting, stupor, coma, contraction or dilatation
 of the pupils, with strabismus, we must refer them
 to an alteration in  the function or structure  of
some part of the  cerebro-spinal  mass, and not of
its investments merely.   The arachnoid and pia
mater are so simple in their  structure  and func-
 tion that we can scarcely assign  to inflammatory
action when set up in them any other indication
except pain or headach.
  Dr. Abercrombie expressly  gives it as  his opi-
 ■uon, " that our  knowledge  is  not  sufficiently
matured to enable us to say with confidence what
symptoms indicate inflammation  of the substance
of the  brain,  as  distinguished  from  that  of its
membranes."  The difficulty  of  establishing this
| point of diagnosis has been felt by all those who
 have treated of the subject.   There  are circum-
 stances, however, in which we can indicate with
 sufficient precision the symptoms of cercbritis, as
 distinguisbed  from any that can in strictness be
 referred to meningitis ; for instance, when the in-
 flammation  is isolated, and does not reach the
 membranes, as where it is seated in the thalamus
 or corpus striatum.  If in such a case the attack
 does not proceed with unusual violence or rapidity,
 the pathognomonic symptoms can be traced readily
 enough, and no  attentive observer would mistake
 the disease for arachnitis.   But if the inflamma-
 tion  occurs at the circumference of the organ,
 where the membranes and the cerebral substance
 are in contact, and both are supplied by the  same
 vessels,  then, though the  inflammatory action
 may at the outset be seated  in the meninges, it
 will  speedily extend more or less to  the cerebral
 substance,  and,  by complicating the  lesion, will
 confuse the diagnosis.  We have examined many
 cases which, on  a superficial inspection or hasty
 examination, would be set down as cases of acute
 meningitis ; but by carefully elevating the mem
 branes, we could distinctly observe  vessels, en-
 larged and distended,  passing into the  cerebral
 substance ; and  on examining the latter texture
 attentively, we could also  recognise  an  increase
 of its vascularity,  and occasionally some degree
 of change in its  colour and consistence.   In the
 great  majority of superficial  inflammations there
 is a mixed lesion, and all that discrepancy which
 their progress and symptoms present is explicable
 not merely by the extent  and degree of the in-
 flammation,  or by peculiar  idiosyncrasy, but by
 the fact that in some of them  tbe  inflammatory
 action is for the most part expended on the mem-
 branes, the brain receiving but slightly the irrita-
 tive influence; that in others the reverse obtains;
 whilst in  a third  group it seems as if concentrated
 upon the  vessels of  the pia  mater, the arachnoid
 on the one hand  and the brain on the  other being
 but slightly affected.   By viewing  the subject in
 this way, (and we are induced to do so from an
 attentive  consideration  of it,  as  well  as  from
 numerous post-mortem examinations,) we shall
 clearly perceive that the diagnosis of the mem-
 branous and parenchymatous inflammation in the
 encephalon has been considered obscure because
 in  very many cases they  occur simultaneously.
 From this mode of considering the subject, it will
 be  obvious that in a practical point  of view  it is
 of much more importance to be able to determine
 what  may  be considered  a previous question,
 namely, what are the symptoms which  indicate
 inflammation within  the encephalon, than nicely
 to mark its exact location.
   Cerebral  irritations are divisible into two great
 classes, symptomatic and idiopathic;  the former
 being by far the more numerous.  Broussais goes
 so far as to say that " the  brain is of all organs
 the one which is the least  liable to inflammation,
 inasmuch as it is seldom if ever affected directly,
 being almost always acted  on through its sympa-
 thetic  connexions with other viscera."  Sympto-
 matic  irritation is  for  the most part connected
 with and dependent on a morbid condition of the
chylopoietic viscera.   We frequently observe that
for  weeks previously to the occurrence of pain or 
BRAIN,  (INFLAMMATION  OF  THE)— [MENING ITIS.]
305
any disturbance  in the head, the  digestive func-
tions have been impaired, the bowels confined or
irregular, and the stools unnatural.  In many of
these cases, when the headach, retching, irregular
fever, and even coma, have  set in,  speedy and
permanent relief has followed the use of purga-
tives, and  the other means usually resorted to for
correcting disordered functions.  An irritative in-
fluence  is in such  cases propagated from  the
digestive organs to  the brain by reason  of the
close sympathetic  connexion which" subsists be-
tween them  in health and in disease; and  that
irritation,  if  kept  up for  a while,  will pass  into
positive inflammation, marked by  its usual  con-
sequences. The irritation of worms and of teeth-
ing may also induce similar results, more parti-
cularly in those constitutionally predisposed.  We
frequently observe these  cerebral affections to
spring up during the course of other diseases, of
which they may be considered as  complications ;
namely,  continued  fever,   scarlatina,  measles,
hooping-cough ; and they not unfrequently  fol-
low  accidents  or   injuries.   Hence,  says   Dr.
Abercrombie, it becomes  necessary  to  keep in
view those symptoms which  set in in the course
of these diseases,  or follow  such  accidents,  and
indicate the existence of a dangerous affection of
the head.  Referring  these   to their respective
seats, they are as follows :—In  the head—head-
ach, with throbbing and giddiness, tinnitus, sense
of weight and fulness, stupor, and propensity to
sleep.   In many obscure and insidious  cases  a
constant feeling of giddiness is the only remark-
able symptom.   In the eye—impatience of light,
unusual contraction  or  dilatation of the pupil,
double  vision,  blindness, distortion  of the  eyes
outwards, paralysis  of the lids, causing the  shut
eye, or the  gaping  eye.   In the ear—unusual
acuteness of hearing, great  noise in  the  ears,
transient deafness.   In the speech — indistinct or
difficult articulation, unusual quickness  or un-
usual slowness of speech.   In the pulse — slow-
ness, remarkable variations in its frequency.   In
the mind—transient fits of incoherence, confusion
of thought, forgetfulness, high delirium.   In the
muscles—convulsion or partial paralysis.  Whilst
examining complex cases of this sort, attention
should  be directed, not merely to ascertain the
existence  of  a particular symptom, but  rather to
determine whether there is a correspondence and
harmony  between the  symptoms ; — thus " the
peculiar oppression  which accompanies  a  high
degree of fever  is not considered dangerous, or
perhaps unfavourable ;  but the same degree of
oppression without  fever, or with a very slight
fever, would indicate a head-affection of a  danger-
ous character."  This remark is  applicable  also
to headach and delirium.
   Acute  Meningitis. — Under  this  term we
shall include all those cases  in which the inflam-
matory  action has its  principal  seat in the mem-
branes, but in which it is a legitimate  matter of
inference that an irritative influence is propagated
to the contiguous cerebral substance.
  This  affection presents a  train of symptoms
which  varies in different ages and  in different
temperaments.   Its  most  marked and ordinary
character at its outset is an increased sensibility to
all sorts of impressions, the ordinary  external in-
  Vol. I. — 39                      2 a *
fluences  producing  inordinate effects.  Thus a
child is restless and sleepless, seldom even dozing,
or if he does doze, from time to time starting and
waking up ;  he attends to every sound, the eyes
are suffused, the retina is so sensitive to light that
he winks or turns away if his face is directed to a
window or  to  a candle ;  the pupil is generally
contracted, but  not  invariably so.  The  head is
often moved about, or from side to side, so are the
limbs ; the temper is peevish, and nothing seems
to soothe  this  irritable condition but motion up
and down the room  in the arms of the  nurse or
attendant.   The state  of the bowels varies much
in different instances ; they may be  confined or
relaxed, but the stools do not present any unnatu-
ral appearance.  There is a minor degree of this
state which is marked by increased animation and
liveliness, which with ordinary observers may pass
for an increase of health and  vigour, though an
attentive observer will readily perceive that  the
countenance wants  that disengaged  air which
exists  in health ; and  on  making a closer exami-
nation he will  find that the eyes frequently close
and wink, and  the countenance  assumes an ex-
pression as of frowning :  the  hand, too, is fre-
quently raised  towards the head, and the fingers
are fixedly closed.   We occasionally observe in
children a state the very opposite of this—a state
characterised by a want of animation, accompa-
nied by plaintive moaning at times, and an indif-
ference to surrounding objects.  Though the child
does not sleep,  yet his  state is not that of waking;
and if roused, he betrays fretfulness and peevish-
ness.   These may be considered as so many indi-
cations of an incipient irritation, which in  some
constitutions may arise independently of any as-
signable agency,  but  which in  many cases is
referable to an irritation propagated  to the brain
from  the  peripheral extremities of  the nerves
during dentition, or  by worms  in the alimentary
canal,  or by vitiated secretions, or a torpid  liver.
The symptoms here indicated are by some persons
denominated fever,  some  epithet  being usually
added  for the purpose  of indicating its source or
its nature ;  hence the terms gastric, irritative, and
hydrocephalic fever.   The most expressive  term
that can  be employed  is  that  devised  by  Dr.
Nicholl, " sensitive erethism."  It is distinct from
inflammation of the brain, of which it is frequently
the precursor;  and according to  individual  pecu-
liarities or other modifying circumstances, it may
end in cerebritis, meningitis, or that  modification
of the latter called hydrocephalus : and  this ter-
mination is but too often unexpected  by the prac-
titioner, whose  attention has perhaps been directed
to secondary indications and minor effects, whilst
the erethismal  state  of the brain  has crept on un-
heeded.   The condition here indicated cannot be
supposed to exist unaccompanied by an increased
flow of blood through the cerebral  vessels, or in
other words, an increase in their degree of tension;
and as the tension may vary from a slight degree
of fulness to the greatest of  which the vessels are
susceptible, such a state of local determination of
blood will soon end in inflammation if not sub-
dued by proper means.  The actual inflammatory
attack is generally ushered in  by  headach  more
or less violent, (the pain being  referred to the
temples, the vertex or forehead, sometimes to the 
30G
BRAIN,  (INFLAMMATION OF  TH E ) — [M E N IN GIT IS.]
occiput and base of the  skull,) by intolerance of
light :  heavy and  suffused eye, with quick pulse,
are also  attendants; so, in many  instances, is
vomiting.  In adults, particularly those who have
suffered  much from mental disquiet,  spasmodic
twitchings  are sometimes perceived,  not unlike
those which arise from slight electric shocks.   In
children  and  very young persons it  frequently
commences with  a sudden  and  long-continued
convulsion without any previous warning.  After
a while the convulsive movements cease,  a remis-
sion takes place, and the patient appears free from
complaint  for one  or more days, when a second
attack  occurs, which may terminate in coma  and
death.   Some instances have been cited in which
no remission  occurred, insensibility supervening
on the convulsion, and death in thirty-six  or forty-
eight hours.   Martinet indicates  three stages of
the disease, each accompanied by a distinct group
of symptoms.  The first comprises the period of
cerebral excitement and increased sensibility above
noticed ; the  second is tbe stage of re-action, or
more properly that in which the cerebral irritation
is propagated to the muscular system, and other
systems  in immediate dependence on the brain ;
hence  it  is characterised  by restlessness and con-
vulsions, delirium, oscillations  or  commencing
dilatations of the pupils : its duration varies from
two or  three days to a week,  or  perhaps  two
weeks.  It is  not undeserving of notice, that when
the  arachnitis is seated on the convex surface of
the  cerebral  hemispheres, delirium sets  in  very
early,  and  becomes the prominent and characteris-
tic symptom ; whilst if it occurs at  the under
surface  and  base of the brain, coma is the more
usual  attendant, and  sets  in  early.   The third
stage is that of collapse ;  being marked by loss of
sense  and motion, by paralysis,  local  or general,
and coma ; its  duration varies from a few hours
to three  or four  days.  A considerable  number of
cases  do in  fact exhibit these regular steps  and
gradations of change during their progress; but
we frequently observe the state of collapse and of
excitement to co-exist; each of course being  par-
tial in its extent.   Thus one arm  may  lie motion-
less by  the side, whilst  the other is convulsively
agitated; and the muscles of tbe  eye-lids may be
paralysed, whilst  those about the mouth  are con-
vulsed.  Again, the first stage of the disease is
not in all cases ushered  in  either by pain or  con-
vulsions, by vomiting or fever.   A state  the  very
 opposite to this sometimes presents itself.  Thus
 Cruveilhier details the case of an elderly medical
 man,  who, after some fatiguing employment,  sud-
 denly became oblivious, looked stupid, could  not
 answer questions, and seemed  apoplectic  : he was
 treated  accordingly, but without relief; he  still
 remained comatose, passed urine involuntarily, but
 retained the  power of moving his  limbs, though
 the left side  seemed  weakened.   After death,
 serous effusion  was found  beneath tbe arachnoid
 membrane, extensively diffused over the brain and
 cerebellum,  mixed with albuminous  flocculi  or
 9akes of false  membrane.   This would be  con-
 sidered  as a case of serous apoplexy were it not
 for the  effusion  of lymph and  false  membrane.
 Another case was considered a feigned disease, so
 few indications of ill health, much less of cerebral
 inflammation, did  it  present.  It was that  of a
youth  at school, who was frequently accused ol
feigning  illness.   His countenance was  natural,
pulse not at all excited, nor did he  complain of
pain.  The medical attendant ordered him to get
out of bed and dress himself.   This he submitted
to very reluctantly; he went towards the fire-place,
tottering as he walked, and sat down resting his
head against  the  chimney-piece.  So  convinced
were all present that he but feigned illness, that
he was chastised.   He died soon after, when the
reality of his illness was ascertained  by examina-
tion ; a considerable degree of effusion of serum
and coagulable  lymph  being found  beneath the
arachnoid membrane.   This form of  disease Cru-
veilhier  calls  " meningite  sous-arachnoidienne
comateuse,-"  and  as he  has   met with  several
instances of it, he is disposed  to come to a con-
clusion the  very  opposite to  that which other
pathologists have  adopted, inasmuch  as when the
meninges over the convexity of the  hemispheres
is inflamed, it is, according to his experience, cha-
racterised by stupor gradually increasing to coma,
whilst headach, witb increase  of sensibility, deli-
rium and convulsions, are strangers to it.
   [Of late  years,  the  formidable  disease of the
encephalon, that occurs so frequently  in young
children,  and is generally called  hydrocephalus
acutus, has been regarded as tubercular meningi-
tis ,• or, in other words, as a deposition of tubercu-
lar  granulations on the  under surface of the cere-
bral layer of the  arachnoid, which is essentially
strumous in its character : and many cases are,
doubtless, of this nature.  (See HYnnocEPHALus.)]
  Morbid Anatomy.—After having been  the sub-
ject of inflammation, the membranes  present vari-
ous changes dependent  either on the duration and
intensity of the attack,  or on the frequency of its
recurrence ;  but all of them are referable to the
following heads,  namely,  simple redness of the
arachnoid;  thickening and opacity, with increased
firmness ;  serous  effusion beneath or upon it, or
into tbe  ventricles ; puriform, or sero-purulent
exudations ; false  membranes; increased vascu-
larity  and  thickening  of  the  pia mater.  The
redness of the arachnoid  varies in extent and de-
gree, and is usually  confined  to a few points on
the convexity  of  one or  both  hemispheres, or at
the base  of the brain.   It requires much care to
distinguish this state of the membrane from one
that closely resembles  it, and in which the pia
mater is minutely injected, and at  the same time
adherent to the aracbnoid.  To determine whether
the redness exists  in the arachnoid or only in tho
vessels of the pia mater, a part of  it should  be
cautiously raised from the surface of  the convolu-
tions, and  gently scraped with a scalpel, or ex-
posed for a few  minutes to a slight current  of
water ; if the membrane  is really inflamed, the
colour will be found  persisting, as if it were dyed
into it;  if the membrane is not inflamed, its natu-
ral transparency will be restored.  The alteration
most commonly observed  in the arachnoid is that
it becomes opaque and  whitish.  In  proportion as
 its  transparency  is  diminished,  its density and
 tenacity increase ; so that it  is easy to detach it
from the surface of the brain.   These changes are
 seldom, if ever, general; they are usually confined
 to  some parts on  the upper surface  of the hemi-
 spheres, or at the  base.   In most cases there is no 
         BRAIN,  (INFLAMMATION

appreciable increase of thickness, the  membrane
being merely  a little opaque, and of a milky hue.
This condition of the  arachnoid is almost invaria-
bly accompanied  by an effusion  of serous fluid,
either upon its free surface, beneath it,  or into the
cavity of the  ventricles.   The effusion varies in
quantity", being  sometimes not more  than a few
drachms, and in other instances amounting to
several ounces.  It  is usually limpid, particularly
when contained in the ventricles;  but occasionally
opaque  or  milky, and  mixed  with albuminous
flocculi  or  shreds of  lymph  if an  exudation  of
false membrane  exist at the same time.  When
the effusion is beneath the membrane, this is ele-
vated along the sulci  which separate the convolu-
tions, and presents  a  gelatinous appearance, as if
it had suffered a  change of structure ;  but if an
incision is made  along the surface, the fluid can be
made to exude, and then  the membrane subsides
to  its original position,  and exhibits no  other
change except that  of being a little opaque and
thickened.
   Dr. Abercrombie notices a modification of this
disease, remarkable from  its rapidity  and from
simulating hysteria, or even mania ; although on
examination  it presents merely a highly vascular
and injected  state of the pia mater, complicated in
some instances with slight subserous effusion.   It
commences with depression of spirits, to which
cheerfulness  soon succeeds, but finally passes on
to  delirium.   The  patient's manner is hurried ;
he talks rapidly, wandering from one  subject  to
another.  Obstinate watchfulness exists through-
out ; the pulse  is small  and rapid ; the  counte-
nance pale and  expressive of exhaustion.  The
treatment  is founded  on  these circumstances.
Stimulants cautiously given  afford relief, while
depletion  aggravates  the  evil, or produces but a
temporary  alleviation.
   Chronic Meningitis*—Meningitis is in many
instances so  slow in its progress as to  assume the
chronic form.  The disease is then characterised
by a different train  of symptoms.  According  to
Bayle, delirium  and progressive paralysis are the
constant attendants of chronic meningitis.  The
delirium is at first  partial;  it is  a  monomania
with weakness  of  intellect; but, after a  time, it
passes on  to maniacal  excitement, and finally
subsides into confirmed idiotcy.   The paralysis in
those cases does not exhibit  a total privation of
sensation and motion in any particular part of the
body ; it is at first slight,  but gradually increases,
and extends  to  the whole muscular system, ren-
dering the gait  feeble and vacillating, and ulti-
mately  destroying  the  power  of motion.  It  is
remarkable that  the diminution of sensation is not
proportioned  to that of motion.  Spasmodic move-
ments, with contraction and rigidity of the limbs,
sooner or later set  in ;  and, finally, epileptic  at-
tacks, which  terminate in fatal apoplexy.
   Besides  the injection  and  thickening of the
membranes, and tbe serous and  albuminous effu-
sions presented by the more  rapid  cases,  the free
surface  of the arachnoid  is found  studded with
minute conical granulations, or flocculi, so  as  to
lose its  smooth and polished appearance.  Conti-
guous parts of the membrane are also occasionally
found  connected by  bands of false  membrane;
 his most frequently occurs at some point of the
OF THE) —[MENINGITIS.]    307

inner flat surface of the hemisphere, where it is in
contact with the falx major.   The investing and
reflected parts of the membrane are also  found
closely adherent along  the  angle  formed by the
inner and upper sides of the hemisphere,  where
the superficial veins enter the longitudinal  sinus.
In this situation the  surface of the  arachnoid  is
found rough, and studded with/.small rounded or
irregular masses of a greyish white  colour,  which
are sometimes called glandulse Pacchioni.   These
productions do not exist in early infancy, or in the
healthy condition of the organ ;  they appear to be
an  albuminous exudation, the result of chronic
inflammation.  In many cases the membranes are
adherent to the subjacent cerebral substance, which
is found altered both in colour and  consistence.
[Of 151 cases, observed at Charenton, 65, accord-
ing  to M. Andral, (Pathologie Interne,)  lasted
from a month to a year;  81 from one to  six years;
and 5 from six to twelve.]
   Causes___Meningitis is a frequent consequence
of injuries of the head, of fractures, concussion, or
even wounds, of the scalp.  It not  unfrequently
happens that a wound of the head heals rapidly,
and that the  patient returns to his usual occupa-
tions, thinking himself quite well; but after ten
or fourteen days he begins to feel pain in the situa-
tion of the wound, which gradually increases in
intensity ;  and in a very short time all the symp-
toms of cerebral inflammation become manifest.
A child may suffer serious injury from a fall, and
as all mention of the accident is suppressed by his
immediate attendant, it escapes the notice of others,
and no ill effects follow perhaps for a week or two:
the  child then, however, loses appetite, becomes
restless and irritable ; febrile excitement, delirium,
and convulsions succeed, and too  often are the
precursors of a fatal termination.  In such cases,
the real cause of the  disease not being suspected,
it is generally attributed to the irritation arising
from dentition or worms ; but examination after
death shows that it is not merely a  sympathetic
disturbance,  there  being abundant  evidence  of
active meningitis.
   In the  list of causes should also be included
depressing passions ;  sudden fright, or unexpected
disappointment;  violent  emotions ;  immoderate
indulgence of any sort, particularly  in the  use of
spirituous liquors ;  tbe suppression of cutaneous
eruptions, and habitual evacuations or discharges;
insolation (coup de soleil) in warm climates ; de-
position of bone  in the dura mater ; tubercle de-
veloped in the cerebral substance, and extending
to the  circumference  of the hemisphere, so  as  to
become a mechanical irritant to the membranes.
   Such are the exciting causes of meningitis; but
there are  predisposing circumstances which con-
fessedly render some persons more liable to it than
others.  One  class of persons consists of those
who possess what is termed the apoplectic consti-
tution, indicated by a large head, short  neck, and
sanguineous temperament;  the other class exhi-
bits evidences of  the lymphatic  temperament,
together with considerable cerebral  development,
indicated by precocious talent.  Such persons in
early life are very liable to attacks of meningitis,
which terminate  in  serous effusion.  Sex also
seems  to be  a predisposing  cause, or rather the
peculiar  pursuits  and  habits  of  the sexe«   foi 
BRAIN,  (INFLAMMATION OF  T II E )-[C E RE B RIT IS.j
308
males arc more liable than females, according to | cine, ranges inflammation of the  brain under one
Martinet, in the proportion of three to one.  All , species, which he terms empresma cephalitis ; and
                                               1 he makes out two varieties, one superficial inflam-
                                                mation, called meningea, phrensy or brain fever,
                                                and the other profunda, affecting the substance of
                                                the brain and lining membranes of the ventricles,
                                                to which he refers hydrocephalus acutus; but he
                                                merely follows other nosologists in his description
                                                of symptoms and causes.  The first distinct ac-
                                                count given of that peculiar alteration of the brain
                                                called softening, and of its characteristic symp-
                                                toms, was by M. Recamier, physician to the Hotel
                                                Dieu, in  Paris,  who  considered  it as  one of the
                                                terminations  of nervous fevers.   Several of his
                                                pupils, and more  especially Lallemand, Rostan,
                                                Parent, and Martinet, have since pursued the in-
                                                vestigation of this interesting branch of pathology
                                                 with  considerable  success,  and  have  published
                                                 valuable works on cerebral diseases.  Nearly about
                                                 the same period the attention of the profession in
                                                 Great Britain was directed  to this subject by Dr.
                                                 Abercrombie, whose  pathological  researches on
                                                 diseases of the  brain are held in high estimation
                                                 on the continent, as well as  in his own country.
                                                 Some separate  cases of inflammation  and suppu-
                                                 ration of the brain are to be found in Dr. Baillie's
                                                 excellent manual of Morbid Anatomy.   He refers
                                                 to Dr. John  Hunter's account of softening of the
                                                 brain in  the Gulstonian Lectures, read before the
                                                 College  of Physicians in  1796, describing two
                                                 forms of softening ; that which occurs in old age,
                                                 and that which is combined with apoplectic  effu-
                                                 sion.  A valuable addition  has  been lately made
                                                 to our medical literature in this branch of pathology
                                                 by the medical  reports of Dr. Bright, whose splen-
                                                 did plates of the diseased structure of the brain-are
                                                 admirably illustrated  by a history of well-selected
                                                 cases.  It will  be  seen by this brief sketch of the
                                                 information afforded  in medical writings on in-
                                                 flammatory affections of the brain, that it is only
                                                 within our own times that our knowledge of these
                                                 diseases  has begun to assume a practical and sys-
                                                 tematic character.
                                                    Inflammation of the substance of the brain may
                                                 be divided into general and partial, acute  and
                                                 chronic.   The   general  inflammation  is always
                                                 acute.  The partial inflammation may be acute w
                                                 chronic.   Inflammation  of the   brain sometimes
                                                 commences suddenly ;  this is  not, however, the
                                                 most ordinary  case.   It is generally preceded by
                                                 a  variety of premonitory symptoms ; and as the
                                                 disease, when once fully developed, is very formi
                                                 dable, it is of the highest importance that the prac^
                                                 titioner  should be well  acquainted  with  these
                                                 symptoms.
                                                    The  most usual premonitory symptoms are, a
                                                 general uneasiness and  restlessness, with a  ten
                                                 dency to congestion  in  the bead ;  a  sense of
                                                 weight and fulness ; occasional attacks  of pain in
                                                 the  head, or of temporary apoplexy or epilepsy;
                                                 flushing of the face and  increased  heat of  the
                                                 head; drowsiness and vertigo; preternatural acute-
                                                 ness of the external  senses ; intolerance of light
                                                 and optical illusions ; contraction of the pupils,
                                                 strabismus,  or  imperfection of sight;  tinnitus
                                                 aurium,  or various other noises  in the  ear ;  con-
                                                 fusion of thought; failure of the memory ; mental
                                                 excitement or depression, or  some striking altera-
                                                 tion in the habitual character and pursuits of the
ages are liable to this affection, but not equally so:
of one hundred and sixteen cases recorded by the
author just cited, twenty-nine were under fifteen
years, forty-four from fifteen to thirty, thirty-eight
from thirty to sixty, and five  from sixty to eighty.
These results, it should be remembered, are taken
from hospital practice, in which the great  majority
of  patients  are adults.  In  private practice the
proportion of cases under puberty is much greater
than that here stated.   The ordinary  duration of
acute  meningitis  is  from  seven to ten days, but
death  may  occur on the third or fourth  ; few
cases  are prolonged  beyond  the twenty-fifth  or
thirtieth.
    [Chronic meningitis has  been rarely seen  in
infancy.  It is also uncommon between the ages
of 20 and 25;  but  is more  common between  25
and 30 ;  and attains the maximum of frequency
at  from 30  to 50.  As in insanity, a predisposi-
tion to it would seem to be laid in organization,  for
it appears in some families more than in  others,
and more commonly in the children of parents
 who have suffered by it.  It has been induced by
powerful emotions, and it is  affirmed by the abuse
 of alcoholic  liquors.   (The writer's Practice of
 Medicine, 2d edit. p. 180 : Philad. 1844.)]
    The treatment of meningitis will be included in
   e subsequent article, on  inflammation  of the
 substance of the brain.             T n
                                   J. <ciUAIN.
    II.  Inflammation- of the stbstance of the
      brain (Cerebritis).
    We find very little information  on the subject
 of inflammation of the substance of the brain, as
 a distinct and separate disease, in the early records
 of medicine.   It has scarcely obtained a separate
 place in  any of the nosological  arrangements;
 every variety of inflammation, both  of  the brain
 and its membranes, being generally classed under
 the head of phrenitis.  Bonetus  and  Morgagni
 are among  the first  writers  who make  any men-
 tion of the  morbid alterations of the brain arising
 from inflammation ;  but they give no very distinct
 history of the symptoms, being satisfied, in gene-
 ral, with naming the diseases :  many of their
 observations, indeed, are evidently taken from
 casual examination  of bodies  in  the dissecting-
 room, and  therefore  afford  very little satisfactory
 information.   Sauvages sets down loss of sleep,
 headach, subsultus tendinum, and  convulsions, as
 symptoms of arachnitis, and low delirium as that
 of encephalitis.   Cullen includes all the inflam-
 matory affections of the brain and  its membranes
 under the head of phrenitis, stating his inability
 to distinguish them from each other;  and the same
 course is followed by Frank.  Pinel, in  his Noso-
 grapbic Philosophique, endeavours to draw a line
 of demarcation between inflammation of the mem-
 branes and that of the brain  itself, but this attempt
 is altogether hypothetical:  he, however,  states
  hat after  ataxic fevers he  has found  injection,
 inflammation, and suppuration in the brain and
  ts membranes, and  therefore considers them as
  ie seat of the disease.  Several other French
 writers have  alluded to inflammation of tbe sub-
 stance of  the brain  as a concomitant of ataxic
 'evers.   Dr. Mason Good, in his Study of Medi- 
BRAIN,  (INFLAMMATION
OF  THE) —[CEREBRITIS.]     309
individual.   In some cases there is little appear-
ance of indisposition throughout the day, but the
symptoms arc aggravated at night: the sleep is
uneasy or disturbed by alarming dreams, and in
children  there  is  often  grinding  of the  teeth.
Pains in  the limbs and  frequent cramps, general
lassitude  and  muscular debility,  are often felt,
alternating with fits of shivering and feverishness;
the digestive functions are disordered ; there is in
general loss of appetite; often obstinate vomiting:
the bowels are either irritable or torpid, the secre-
tions being always unhealthy.
   The above symptoms precede  either general or
partial inflammation  of  the brain.   Those which
follow indicate more especially  the invasion  of
partial and  chronic inflammation.   A long-conti-
nued, fixed, and deep-seated pain in one part  of
the head  ; pain, numbness, weakness, a sensation
of creeping  and  tingling in one extremity or in
one half  the body ; or confined to one portion  of
the extremity : there  may be numbness and loss
of power in one  finger only, or in one set of
muscles.   Sometimes the speech is affected so as
to produce a  degree  of hesitation, stuttering, or
indistinctness of pronunciation.  Drowsiness, lan-
guor, depression of spirits, are observed  also more
particularly in the  chronic  form  of  cerebritis.
Some of these premonitory symptoms may have
been present for weeks, for months, or even for a
year, or  for  a longer period.   The  practitioner
cannot be too deeply impressed with  the import-
ance of the discovery  and  due appreciation of the
foregoing train of symptoms : many of them may
be overlooked  by  tbe  patient, unless his attention
be called to them ; he  attributes his ailments to
nervousness, debility, rheumatism, gout, and any
but the  real  cause.   He is  allowed, perhaps, to
live well; his  stomach is strengthened and his
nerves are soothed; whilst the disease in  the brain,
which will  certainly end in death, is suffered to
pursue its course.
   I. General Cereoritis.—General cerebritis is
always acute.   Its symptoms have been divided
into two periods : 1. the period of irritation or
excitement; 2. the period of collapse.
   The symptoms which characterize the period
of excitement are, intense pain  extending over
the greater part  of the head; great excitement
of the cerebral functions ; violent delirium  ; pre-
ternatural acuteness of both the  external and in-
ternal senses; intolerance of light; brightness, red-
ness, wildness, or protrusion of the eyes ; contrac-
tion of the pupils; tinnitus aurium ; flushing of the
face ; throbbing of the temporal  arteries ;  parox-
ysms of general convulsion ;  rigidity of some  of
the muscles on one or both sides of the body in
the interval of the paroxysms.   There are also
severe shooting pains in the extremities, greatly
increased by extending them ; twitchings of the
muscles of  the  face ;  rolling of the eyes ; quick,
suspirious,  and irregular  breathing;  rapid, full,
and  hard pulse;  subsultus tendinum ;  red and
dry tongue, either  tremulous when protruded, or
in violent motion,  pushing  out the cheek,  or
forcibly thrust  out of the mouth;  great thirst ;
occasionally severe vomiting, especially in  chil-
dren ; scanty and high-coloured  urine.  The pa-
roxysms  of convulsion are always attended with
an exaccbation of the symptoms.   The respira-
tion is hurried, and the pulse rises suddenly forty
or fifty beats  in a minute.  When the convul-
sions  subside, the  pulse and respiration become
comparatively slow and feeble.
  The symptoms just enumerated may last from
twelve to forty-eight hours, or more, when they
are succeeded by others of an opposite character,
which constitute the second  period, or that  of
collapse.  The headach is now no  longer  com-
plained of; the delirium gradually passes into
stupor and coma ;  the preternatural  acuteness of
the senses is succeeded  by obtuseness and insen-
sibility ; the  convulsions  subside into general
muscular relaxation, and more or less complete
paralysis succeeds.  The pupils become dilated
and motionless ; the eyes  sunk, pale,  and dim ;
there  is  sometimes strabismus, or deafness ; the
pulse  is rapid, small, unequal, or intermittent;
there  are frequent  rigors,  the skin afterwards
feeling  cold and covered with  a  clammy sweat;
the face is pale, sunk, and cadaverous ;  the respi-
ration is slow, or irregular and stertorous. When
the patient lies senseless on his back,  and swal-
lows with difficulty, the  fatal issue is not far dis-
tant.   There may  be several alternate paroxysms
of excitement and collapse, until  the patient
finally  sinks  into  a state  of  coma, whicb soon
ends in death.
  A great  resemblance is apparent  between the
preceding delineation  of general  cerebritis  and
that of arachnitis.   A more strongly marked and
permanent degree  of rigidity in tire muscles  on
one side of the body is, however, believed  more
particularly to indicate  cerebritis.   The disease
may have been preceded by some of the premo-
nitory symptoms,  and  have set in with headach
and delirium, terminating in coma ;  or the  inva-
sion may have been sudden, and attended by a
violent paroxysm of convulsions.   In the former
case, it is probable  the inflammation had its  origin
and principal seat  in the brain ; in the latter, that
it was confined to  tbe membranes.   The diagno-
sis between the two cases is, however, extremely
difficult; the one  generally giving rise to or ter-
minating in the other.
  The symptoms are of course variously modified,
according to the extent  and  intensity  of the  in-
flammation, which  may  occupy one half of the
brain  and  extend  in depth, or may  be spread
over the surface, or affect several isolated portions
in both hemispheres.
  General  cerebritis  in most  instances  proves
speedily fatal;  the inflammation  of  a  large por-
tion of the brain being incompatible with the pro-
longation of life.   In  the  majority  of cases  on
record,  death  occurred within a week ; in some
within twenty-four or even twelve houis, the  in
flammation  scarcely ever going beyond the first
stage.
  This form of inflammation of the brain may
exist in combination with inflammatory  affections
of other organs,  and  occasion modifications in
their symptoms demanding close attention.   The
intense pain  arising from inflammation in the
abdominal and thoracic viscera, when such a com-
bination exists, may not be felt  by  the patient,
although the inflammation  is pursuing its course
unabated.  This has sometimes led to the danger-
ous  mistake of believing a disease removed which 
310
BRAIN,  (INFLAMMATION  OF  T H E) _ [C E RE B RITIS.]
was  only masked.  Hippocrates was acquainted
with this source of delusion,  for  he says that
whenever a patient suffers and docs not complain,
mens xgrotat, the mind is diseased.  "V\ e have
seen serious  consequences follow  this deception
in cases of continued fever with head symptoms.
In such  cases, therefore, the practitioner cannot
be too  much  on his guard ;  and the very circum-
stance  of the denial of pain, without  amendment
in other respects, should  induce him to ascertain,
by manual examination  and every other  means,
the true condition of the principal viscera.  Par-
ticular attention  should be  paid to the region of
the bladder;  as  from insensibility,  the  bladder
gets over-distended and partially paralysed ; the
resistance of the sphincter vesica?  is overcome ;
the urine dribbles out by drops, and the patient
is supposed  to suffer  from incontinence, whilst
he is, in reality, affected  with retention of urine.
The same insensibility is the cause of the great
difficulty sometimes experienced in exciting vo-
miting in cerebral affections.
   II. Partial Cerebritis. — Partial inflamma-
tion of the substance of the brain may be acute  or
chronic ; the disease assuming a variety of forms
according to the  severity, extent, and scat of the
inflammation.   Its  invasion is generally  slow,
and preceded by some of the premonitory symp-
toms, which  are, in fact, the mere signs of that
state of local congestion  and irritation which im-
mediately precede inflammation.  We  shall first
give a description of  the  principal forms of the
disease,  and  then  take  a  general view  of tbe
symptoms.
   1. In partial cerebritis,  the  individual is  at-
tacked with  fixed, deep-seated pain in the head,
vertigo,  dimness of sight,  hesitation of speech,
sensation of tingling, pain,  cramps or weakness
in one or other  of the  extremities; one of the
limbs suddenly giving way during exercise, so  as
to occasion stumbling ;  or the walk  is  unsteady,
like that of a drunkard.   The general  health  is,
at the same time, more or less impaired.  These
symptoms may have gone on for  a certain time
without fever or affection of the intellect; so that
no serious alarm has been excited till the patient
is suddenly  seized with an attack  of coma and
insensibility.  He may recover from this in a few
minutes or hours, when  one arm  or leg, or even
one half the  body is found paralysed.  The para-
lysed limbs are almost always  first in  a state  of
permanent rigidity, and more or  less  bent,  in
consequence of the flexor  muscles  having greater
power  than  the extensors.   Lancinating pains
are also felt  in the muscles, and much  increased
by extension.   From all these  symptoms  the
individual may  so far recover as  to be able  to
leave his bed, the limbs continuing paralysed;  in
other  cases,  some  degree  of stupor and  mental
weakness remains, with a peculiar  frowning  or
 vacant expression  of  countenance ; the  patient
still, however, showing some signs of intelligence
when  roused.   Several  of the external senses
may  be affected; the sight of one  eye,  for  in-
stance, may  be  impaired or destroyed : or there
may De dilatation and insensibility of one pupil,
and contraction of the other, or strabismus.   In
 like manner, the sense of hearing may  be imper-
 fect, or wholly lost.   There may be symptoms  of
low fever, with delirium ;  but there is seldom any
violent re-action.  The assemblage of symptoms
just described constitutes the first period of the
disease, or that of cerebral irritation.
  After various intervals,  a second or even a third
attack  of coma  is experienced, and  the patient
either dies suddenly or sinks under gradual ex-
haustion.  As  the  disease  advances,  a change
takes place in the state  of the  paralysed limbs;
the rigidity, gradually subsiding, is succeeded by
relaxation, flaccidity, and complete paralysis. This
marks the second period of the disease, or that of
softening and complete disorganization of the por-
tion of brain  affected.
  2. In  many cases the paralysis of the limbs is
at first  only  partial ; a certain  degree of motion
is preserved,  but there  are convulsive  spasms,
generally of short duration ; and after  alternate
attacks of this description, the paralysis gradually
becomes complete.   This order of the symptoms
generally corresponds with  the progress of the
inflammation from the first stage, or that of excite-
ment, to the  second, or that of softening and sup-
puration.
   When the inflammation spreads from  the brain
to  the membranes, constituting the combination
of partial cerebritis and arachnitis, the side of the
body not paralysed is  generally affected with pa-
roxysms  of convulsion, in which sometimes the
paralysed parts themselves  participate.    These
diversities in the affections of  voluntary motion
will be more particularly considered in the gene
ral review of the symptoms.
   3. Tbe order in the progress  towards  complete
paralysis just described  is  sometimes  reversed;
there being at first sudden and complete resolu-
tion of the muscles ; and the spasmodic rigidity
with convulsions only appearing some time after.
It not  unfrequently  bappens that, if  the conges-
tion be violent and sudden, and the blood-vessels
weak or diseased, extravasation  of  blood take*
place in the  brain, either by rupture of a blood-
vessel  or exudation, before  the  inflammation has
had time to set in.  Instead of  a gradual loss of
voluntary motion, with spasmodic irritation of the
muscles,  there  is then a sudden  and  complete
abolition of muscular power in some regions of
the body, and a state of perfect paralysis, in con-
sequence of the sudden destruction of a portion
of  cerebral substance, and  of the  pressure exer-
cised by the  clot of blood.  This difference in the
mode of attack forms a  good line of distinction
between  sanguineous  apoplexy  and cerebritis, in
the great majority of cases.   After a certain time,
however, the clot of blood irritates the surround-
ing cerebral  substance, and excites inflammation:
pains,  cramps, and convulsions are then experi-
enced  in the relaxed and  paralysed muscles, so
that they sometimes become perfectly rigid : this
constitutes the form of disease known as consecu-
tive cerebritis.  Apoplexy and  cerebritis are dis-
eases which frequently have a common origin, viz.
cerebral irritation and congestion, and are  only
modified in their progress  by accidental circum-
stances ; though in apoplexy it is too  often the
custom  to consider only the extravasated blood,
which is a mere effect, and to  overlook  the pre-
vious  morbid condition of the  brain which was
the cause of the hemorrhage.  The invasion of 
BRAIN,  (INFLAMMATION  OF TH E ) —[C E RE B RITI S.]     311
cerebritis is generally slow, and characterized by
premonitory symptoms;  the course of the disease
is marked by great irregularity, by frequent  exa-
cerbations of some of the symptoms, and  by de-
ceitful remissions.   Apoplexy,  on the contrary,
takes place more suddenly, and often without any
very decided premonitory symptoms; the paralysis
is  more complete from  tbe beginning,  and  the
progress of the disease less variable.   Apoplectic
extravasation of blood sometimes takes place  in
the advanced stages of cerebritis, by the bursting
of a vessel in the centre of the softened mass of
brain: a sudden  attack of coma is generally the
consequence.  The  pre-existence  of  the  symp-
toms of cerebritis will  afford a  sufficient distinc-
tion of such a case from common apoplexy.
   4. Partial cerebritis is sometimes acute, and the
inflammation passes rapidly through its different
stages, as may easily be conceived in an organ so
vascular and highly organized as the brain.  The
patient may in that case sink under the first attack
of coma, and  the disease will be  generally found
to occupy a considerable portion of the brain.
   Even  when the disease is limited to  a small
extent, it  may prove rapidly fatal, in consequence
of the portion of the brain  it affects; as, for in-
stance, when its  seat is in the medulla oblongata,
or contiguous to the arachnoid and pia mater.  It
is proper also to remark that the extent of the in-
jury arising from  disease  of  the brain  is  very
much in proportion to the rapidity of its develop-
 ment : a very slight degree of pressure,  if sud-
 denly applied, is  capable of creating  violent con-
 stitutional  disturbance; this will account for the
 disproportion  sometimes observed  between  the
 severity of the symptoms and  the extent of the
 disease.   When  it  commences by an attack of
 paralysis, without coma, delirium, or any  serious
 affection of the  head, the  inflammation  is com-
 monly at first slight, and seated  near the origin of
 the  spinal cord.
   5. There is another form of cerebritis, in which
 the  inflammation is of a more chronic character;
 the  disease more  slow, obscure, and variable in its
 progress, and the paralysis of the muscles neither
 preceded  nor attended by symptoms  of irritation.
 The disease may commence with a slow and gra-
 dual loss of power, at first limited  to a single
 region of one of the extremities,  or  to a single
 set of muscles, and without pain, cramps, or ri-
 gidity ; the tongue  may be affected, or the sight
 of one eye;  or there may  be slight distortion of
 one side of the face: the paralysis gradually creeps
 on, until it has invaded successively the upper and
 then the  lower extremity, on one and  sometimes
 on both sides of the body.  The disease is not
 attended in its progress with any general re-action,
 the  only  appearances of disturbed health, for a
 length of time, being symptoms  of  debility  and
 decay, both bodily and mental; until, at tbe end
 of several  months, or perhaps longer, the  patient
 is suddenly seized with coma and convulsions, or
else  sinks under gradual exhaustion.  There are
sometimes, however, deviations  from  this uniform
 course, and the progress of the disease, although
slow, is marked by occasional affections of the
head and symptoms of general irritation.   This
is the form  of disease  which  has appropriately
enough received the appellation of creeping palsy.
It usually proceeds from a low state of inflamma-
tion of the brain, commencing in a small portion,
and gradually extending to a larger one  ; the in-
flammation  generally continues for a consideiable
time in the  first stage;  it may prove fatal in that
stage,  with symptoms  of  coma and convulsion;
or  pass on to softening  and abscess, with  their
usual consequences.  This is the form of disease
which usually attends that variety of white soften-
ing called simple softening, in which  the arteries
are frequently found diseased.  The disease also
sometimes terminates in permanent induration of
the portion  of the brain affected.
   A  good many  cases of partial induration  of
the brain have been related by Morgagni, Baader,
Abercrombie, &c.  &c.; they were  all of a pro-
tracted nature,  and characterized by a degree of
irregularity and intermittence in their symptoms,
which closely resembled those of  organic disease.
The disease in some cases assumed  so completely
an intermittent  form as to mislead with regard to
its real character.   This tendency  to periodicity
is of frequent occurrence in all the chronic forms
of cerebral  inflammation.
   There is a variety of chronic cerebritis peculiar
to  lunatics, who, after  being affected for a  consi-
derable time  with acute mania,  have  gradually
sunk into imbecility and  idiotcy.   The  paralysis
is not confined  to one  region, but extends to the
whole muscular system';  it is at  first slight, and
only indicated by a general tremor and debility ;
a sluggishness and vascillation in all the motions;
fatuity, and sometimes  low delirium : these symp-
toms gradually increase; the sensibility becomes
obtuse,  and the disease  generally  terminates in
paralysis with spasmodic rigidity, or in apoplexy.
The appearances after  death are—redness, soften-
ing, sometimes  atrophy, and a granulated appear-
ance of the cortical substance on the whole sur-
face  of the hemispheres;  chronic  inflammation
of the  membranes, which  adhere  firmly to the
surface  of the brain; serous effusions;  an indu-
rated state of the medullary substance, sometimes
with partial softening.
I   6. Partial  cerebritis is  sometimes  connected
with disease of the cranial bones.  Desault, Aber-
crombie, and others, have recorded some interest-
ing cases of a disease of the inner  table of these
bones, the outer table  remaining  perfectly sound,
so that there was no  external indication of the
disease.  The symptoms  were characterized  by
fixed, intense, and deep-seated pain in the head ;
 a  disturbed state  of  health;  violent  delirium;
drowsiness, double vision, and coma.  The dis-
ease seems  to have been the result of a very slow
inflammatory action,  lasting in  some  cases  for
many  years,  and gradually destroying  the  bone
 by caries.   On dissection,  the inner table of the
 bone has been  found destroyed;  the rough can-
cellated structure covered with lymph, or adhering
 to the inflamed and thickened dura  mater ; the
 membranes adhering to the brain, which was in-
flamed and softened.  In some cases the bone has
been reduced by absorption to a transparent thin-
 ness ;  the dura mater being also  partly absorbed,
 and  the brain  livid and   indurated.   In others.
 after a blow on the head, a small portion of tht>
 cranium has been  completely absorbea withou
'• any ulcerating process, leaving the  brain covered 
312     BRAIN,  (INFLAMMATION  OF  T H E ) — [C E RE B RIT 1 S.]
only by the healthy skin.   Two instances of this
kind are related by Mr.  Howship and  Mr. \\ il-
mar : in one of them there was hemiplegia ; both
patients survived, but the deficiency of  bone was
not  supplied.    More  generally, however, both
plates of the bone and the intervening diploe are
affected with chronic inflammation, which  brings
on a variety of morbid changes;  such as the for-
mation of bony tumours, or ridges, caries, exfolia-
tions, or excessive thickening of the integuments:
these finally  lead  to  inflammation of  the  brain
and its membranes.  Saviard mentions the case
of a woman in the Hotel Dieu, in whom, in con-
sequence  of an injury of the  head from  a fall,
successive exfoliations of both  tables of the cra-
nium took place to such an extent that the  pieces,
when put together, resembled the skull-cap as it
is sawn off in dissection: this  process occupied
two years, at the end of  which she was  dismissed
in  good health, but with  the  upper part  of the
brain covered  only by integuments.
   There  is  a  variety of  the disease beginning in
the  pericranium, which is often  accompanied by
very urgent symptoms ;  it is a chronic  inflamma-
tion of the periosteum, with thickening,  indura-
tion, and  sometimes suffusion of pus.   The cor-
responding portion of dura mater is inflamed and
thickened, and the disease extends to the  brain ;
the  intervening  bone  in  some cases remains
healthy, in  others it is  also diseased.   It is at-
tended with intense, fixed pain, and there is some-
times such exquisite tenderness in the part, that
the slightest pressure brings on syncope and con-
vulsions : there may be also various affections of
the  sight, hearing, speech, and  intellect, and
various forms  of paralysis or convulsions.  Relief
has generally  been afforded by deep incisions
down  to  the  bone, and  by exciting and keeping
up suppuration.   It may  be  necessary in some
cases to repeat the incisions.  In some instances
related by Mr. Crampton, the disease appeared as
a circumscribed  tumour: in one,  the swelling
spread  considerably,  and was  accompanied by
erysipelas; more generally, however, there is no
visible tumefaction.
   One of the distinguishing features of these va-
rious forms of disease is, their very slow progress,
owing  to the low state  of inflammation  of the
parts affected ; they have been known  to  last for
years, and even during a great  part of a patient's
life; and an  apparently very slight degree of in-
flammation  has in some cases  given rise, for  a
considerable  length of time, to the most  urgent
symptoms.  The  inflammation  has been excited
in  some  instances by an injury so trivial as to
escape  the patient's attention ;  though it  should
be kept in view that it is  not always confined to
the part  which was  the seat  of tbe injury, but
has sometimes a tendency  to spread  over the
cranium.  It  may also  occur spontaneously, in
 which  case it is  occasionally  connected  with  a
syphilitic taint, or scrofulous diathesis.
   In chronic otitis there  is a great tendency in
the inflammation  to spread from the inner ear to
tl o brain: suppuration  of the  brain has also, in
 some cases, made its way out by the ear; and  it
 is  generally remarked, that when the suppuration
 from the  ear is checked  or suppressed,  this is al-
 most immediately followed by symptoms of acute
cerebritis ;  and again, that as soon as the suppu
ration  of  the car is restored,  the symptoms of
cerebral inflammation disappear.   This  affords a
striking proof of the effects of pressure, and points
out the great caution which is  required in the
treatment of otitis,  to prevent  the  extension of
the disease to the brain.
  7. We shall conclude this account of the differ-
ent forms of cerebritis with some general remarks
on  the progress of the disease.  It sometimes
pursues its course without intermission, either to
a favourable or fatal  termination,  with only occa-
sional  exacerbations of the symptoms.   At other
times there are well-marked remissions, with an
apparent   amendment.   When  cerebritis passes
from the  first stage of  inflammation, or tbat of
excitement, into tbe  second  or  that of softening,
there may be such a  remission of the febrile
symptoms, although the paralysis remains, as to
excite hopes of recovery.  This should not, how-
ever, deceive the practitioner, as the  improvement
is often  merely delusive,  and soon  followed by
repeated relapses.   There are occasional instances
of the symptoms assuming a remarkable periodi-
cal course, and returning at regular intervals.  In
one case, after a wound in the  head, the patient
was seized every evening with  a paroxysm of
delirium,  succeeded by  stupor;  he  died in the
course of the fifth paroxysm; and  on dissection
there was found  extensive  inflammation of the
membranes,  and  suppuration  of the brain.  In
another case, in which the paroxysm set in at the
same hour, lasted exactly  the same time, and re-
curred  every second day,  the  symptoms were
those of  well-marked cerebritis,  and there was
complete  apyrexia during  the intermissions; the
arachnoid  and pia mater were found inflamed, and
there was a large undefined abscess  in the middle
lobe of the right  hemisphere.   These cases had
been  mistaken for  pernicious intermittent  fever,
and treated  by bark.  It is  not easy to explain
satisfactorily the cause of these  regular exacerba-
tions and  intermissions;  they  are  probably the
effect of  some sudden  congestion in the brain,
aggravating  the  symptoms.  There  is  a  well-
known tendency to periodicity in all the affections
of the cerebral and nervous system ;  the formation
of pus in every vital part is  also known to be at-
tended with occasional rigours and paroxysms of
hectic fever.  This tendency to intermittence and
periodicity is most frequent in chronic cerebritis.
   A number of interesting observations on cere-
britis in horses have been  made by M. Dupuy,
professor  in  the  Veterinary College of Alfort,
near Paris.  The spinal marrow was found more
frequently affected than the brain ; which is easily
accounted for by its being much  larger in these
animals, in proportion to the brain, than in  man;
and by its being also much more exposed to suf-
fer from violent muscular exertion.   The morbid
alterations  after  inflammation  corresponded in
every respect with those observed in the human
subject: the symptoms attending the disease were
— tremor  of the  extremities,  weakness, convul-
sions, tetanic stiffness of the muscles of the neck,
jaws,  and more especially of the hind-quarters,
which were the first to be  affected with paralysis.
One  remarkable symptom was,  a disposition in
the horses thus affected to place the head against 
BRAIN,  (INFLAMMATION  OF  THE) — [C E RE B RITIS.]     313
the wall and to push forward with  all their force,
so as  even to break through or overthrow parti-
tions.  They were  observed to  continue in this
attitude, with a kind of tetanic stiffness, for above
an hour, until the  paroxysm  of spasm  subsided,
when they dropped down from exhaustion.   The
disease always ended in paralysis, coma, and con-
vulsions.  It is one of the forms  of disease known
in this country by the  name of  staggers.
   General review of the symptoms.—We shall
complete the history of the different forms of cere-
britis by  taking  a general review of the leading
symptoms, pointing out at the same time the dif-
ferent pathological conditions  of the  brain with
which they seem to be connected;  so far at least
 as is practicable in the present state of our know-
 ledge.
   When the inflammation  occupies at the onset
 a large portion of the  brain, we have  seen  that it
 is generally complicated with meningitis, and cha-
 racterised by disturbance in all the vital functions;
 that we may recognise in the symptoms a  period
 of high  excitement,  and  one  of corresponding
 depression ;  and that it runs its course  speedily,
 either to a favourable  or fatal termination.
   When, however, a smaller portion of the brain
 is engaged in inflammation, as in partial cerebri-
 tis, the course of the disease is  seldom  so  rapid;
 its  invasion is  more  gradual,  and  preceded by
 symptoms of irritation in some  of  the organs of
 voluntary motion, sensation, or  intelligence ;  and
 in the more advanced  periods of the disease  the
 functions of some of these  organs become consid-
 erably impaired, or completely abolished.
    We have stated that, when partial cerebritis is
  fully established, one of the most constant  symp-
  toms of  the first period  is  paralysis  of voluntary
  motion,  with spasmodic rigidity of the  muscles,
 producing permanent  flexion of the affected limb.
  The limb is sometimes considerably bent, and its
  extension is attended with severe muscular  pains;
  this spasmodic  action generally shows itself first
  in the arm, in  which it  is always  greatest, and
  then extends to the  inferior extremity   When
  the muscles of  the face partake of the spasm, the
  mouth is drawn towards  the  paralyzed side ;  the
  eyelids are closed by the  contraction of the orbic-
  ular muscle, so that some  stiffness is felt  in at-
  tempting  to open them.   But  in  the more  ad-
  vanced stages, when the paralysis becomes com-
  plete, and the muscles are relaxed, the mouth is
  drawn by the healthy muscles to the side opposite
  that paralyzed.   Tbe eye continues  closed, but
  it is from the dropping  of the eyelid, in  conse-
  quence  of the  paralysis of the levator  palpebral
  superioris.
    Convulsive rigidity and  retraction of the mus-
  cles are  sometimes observed in connection with
  meningitis; but it may be generally distinguished
  from spasmodic paralysis by several well-marked
  signs.   There is no actual paralysis ; and when
  the  convulsive  retraction  intermits, the  patient
  fully recovers the power of voluntary motion in
  the same manner as after the paroxysms of spas-
  modic rigidity in tetanus.  This convulsive rigid-
  ity is scarcely ever limited to one region or to one
  side of the body, as in partial cerebritis, but affects
  a variety of parts at the same time on both sides.
  Another ground of distinction  is,  that the sensi-
    Vol. I. — 40                        2 b
bility remains unimpaired.   In  spasmodic paraly-
sis  the  rigidity and loss of voluntary motion are
permanent, and the sensibility of the affected parts
is more or less obtuse.
  The accuracy of these rules  of distinction  has
been considered by some as still  rather doubtful,
and this is a point in  the  pathology of these  dis-
eases  requiring  perhaps   further investigation.
We are of opinion, however,  that they are  not
without  foundation.  It is true that spasmodic
paralysis is  a very common symptom of chronic
meningitis ; but it is equally certain that, if the
brain be carefully examined, chronic inflammation
of the membranes will almost  always be found
combined with inflammation and softening of the
surface of the brain.  These views are supported
by the  authority  of Bayle, Laennec, Lallemand,
Gendrin, and several  other eminent  pathologists.
Spasmodic  paralysis, with pain  and other signs
of irritation, is generally characteristic of the first
stage of cerebral inflammation, or that of excite-
ment :  the  disease sometimes terminates fatally
at this period.
   When the  inflammation,  however, advances
towards the second stage, or that of softening and
suppuration, the rigidity and muscular contraction
gradually lessen, until  at  last there  is  complete
paralysis.   This   condition  of  the muscles  has
generally been found in connexion with softening
and disorganization  of some  part of the  brain.
An important difference exists, therefore, between
the  spasmodic and  the complete  paralysis : the
first, being  the effect merely of the  compression
and irritation  of  the cerebral substance occasioned
by the  great influx of blood in the first  stage ot
inflammation, is capable of being removed, if we
can only succeed in subduing the inflammatory
action  at  an  early  period ;  the second,  arising
from the complete destruction of a portion of cere-
bral substance, is  beyond hope  of recovery, since
there is yet no instance  on record  of the repro-
duction of  brain.
   When the paralysis is  at first partial, and in-
creases only gradually, the paralyzed  muscles are
sometimes affected with convulsive motions, gene-
rally of short duration.   This  usually happens
 when  the progress of the  inflammation  is slow,
 and the diseased portion of brain is  partly in the
 first and partly in the second stage of inflamma-
 tion.  When arachnitis supervenes on partial cere-
 britis, both  sides of the body may be convulsed ;
but in this  <;ase, when  the paroxysms of convul-
 sion intermit, one side only remains paralyzed.
 Convulsions  affecting  both sides of the body  at
 the same time may generally be considered symp-
 tomatic of  inflammation of the membranes, rous-
 ing into inordinate  activity the  functions of the
 healthy brain, and thus exciting violent irregular
 action  of the  voluntary muscles.  But, when the
 substance  of the brain itself is extensively dis-
 eased, the power  of voluntary motion is partially
 impaired or altogether destroyed.  General con-
 vulsions may also be the effect of simple pressure
 or of  nervous irritation;  but  in these cases the
 fever  which  attends arachnitis  is altogether ab-
 sent.   In  some  instances  one-half of the  uody
 has been violently convulsed, whilst  the other has
 remained  perfectly  motionless,  as if dead : this
 has been observed to arise from the  combination 
314
BRAIN,  (INFLAMMATION  OF  T H E ) -[C E RE B RITI S.]
of arachnitis with very extensive softening and
destruction  of one  side  only of the  brain.  In
other cases both sides of the body have been af-
fected with paralysis in succession ;  this generally
indicates the extension of the inflammation from
one hemisphere to the other, but these cases of
double cerebritis are not common.  In chronic
cerebritis we have seen the  paralysis  assumes a
different character ;  its invasion  and progress be-
ing very slow and gradual, and not usually attend-
ed with any muscular pain or spasmodic irritation.
Inflammation and softening of some of the  cen-
tral parts  of the brain (the  corpus  callosum, for-
nix,  and  septum lucidum) do not  occasion any
paralysis.
   The paralysis in  the latter stages of cerebritis
frequently affects the organs of speech.  In some
cases there is great volubility of  speech; this
principally happens on the approach of delirium ;
but  more generally the  utterance  is slow and
drawling :  at first there may be  only a slight de-
fect or hesitation in pronouncing one letter or cer-
tain  words ; at other times the patient is affected
with an entire  loss  of speech, either suddenly or
by slow degrees.  The loss of  speech may pro-
ceed from loss of memory alone, the  tongue re-
maining free; or the  tongue  and memory may be
simultaneously affected.
   Paraplegia,  which had generally been consider-
ed as always the result  of  disease  of the  spine,
iias  been  observed  by several writers  to depend
sometimes on  inflammatory or organic affections
of the brain alone, especially in  adults.  A paper
will  be found  on this subject,  by  Dr. Baillie, in
the  Transactions of the  College  of Physicians,
vol.  vi., and one by Mr. Earle, in the Medico-Chi-
rurgical  Transactions for  1828.   This subject
will  be more fully considered in the article Pa-
ralysis.
   The explanation of paralysis and  convulsions
affecting the side of the body opposite  to the dis-
eased hemisphere of the brain, is to be found  in
the decussation of the nervous fibres in the ante-
rior  portion of the  medulla  oblongata.  It takes
place so invariably that it may be almost consid-
ered as a general rule ; there are, however, seve-
ral well-authenticated cases  on record, of paraly-
sis having occurred on the same side  of the body
as that occupied by the disease of the  brain.  M.
Bayle, in the Revue Medicale for January 1826,
states that he had seen two  unequivocal cases  of
this  description in his own  practice, and  relates
eight similar  cases  taken from former writers ;
three of them from Morgagni.   A case in support
of the same fact has been published by Dr. James
Johnson, in the first  volume of the Transactions
of the Associated  Apothecaries.   Dr. Gall and
other modern  anatomists have  distinctly  shown
that the decussation of the nervous filaments  in
the anterior portions of the  medulla (corpora py-
ramidalia) is not always  complete, and that seve-
ral of these filaments are  sometimes continued
from each crus cerebri along the medulla spinalis
on the same side : this may afford some explana-
tion of the  cases in question, although it  is not
pernaps altogether satisfactory.  It  has been sup-
posed by some that the decussation  takes place in
the corpus callosum ; but this appears without the
least foundation.  This subject bas been discussed
by Dr. Yelloly at considerable length, in a paper
published in the first volume of the Medico-Chi-
rurgical Transactions.
  Next to the affections of voluntary motion, loss
of sensibility is one of  the most prominent symp-
toms  of cerebral  inflammation : the two  classes
of symptoms are generally combined, but seldom
manifest  themselves  exactly  at  the same  time.
The paralysis  of the skin  usually appears  later
than that of the muscles, so  that  an  extremity
may have lost the power of motion, while it still
preserves some degree of feeling. The sensibility,
however, gradually decreases,  until  at last it be-
comes very  feeble or totally  abolished.  The arm
is generally deprived of motion before the leg;
and the loss of feeling follows in the same order.
The loss of voluntary motion alone indicates a
less complete degree of paralysis than when com-
bined with loss of  feeling.  There are some inter-
esting facts  connected with  the loss of  feeling as
well as  with  diminution of temperature, which
we shall have occasion to consider  more in detail
in the article Paralysis.
   This account of  the symptoms derived from the
affections of voluntary  motion and  sensation has
been  deduced  from  a  careful examination  of a
large  body  of well-observed  facts collected by
others, as well as from our own experience.  It is
necessary, however, to keep in mind that the ac-
curate study of the symptoms in cerebral diseases
is too often  surrounded with many difficulties
and sources of error.   The patient is sometimes
in the situation of  a  child, unable to explain his
sensations, either past or present; the obtuseness
or total loss of consciousness, preventing the fice
and full  development of the  symptoms, alters or
completely conceals the true character of the dis-
ease ;  the absence, therefore,  of any of the lead-
ing symptoms, in  one case, under  such circum-
stances, is not to be taken as a proof of their fal-
lacy in every  other.  Several of the symptoms,
spasms and convulsions  for  instance, may be so
evanescent  as to escape superficial observation.
An accurate knowledge of  the comparative state
of the different regions of the body with respect
to sensation and motion is  sometimes attended
with great difficulty, and requires the most care-
ful examination.    We cannot always see the pa-
tient in motion so as to judge of the exact degree
of power he possesses over  the different muscles;
we must then make  him  grasp  or lift a  body.
The state of feeling  and of heat in each region
should likewise  be  accurately noted.   We feel
strongly convinced   that  numerous  mistakes are
committed in  all  these respects by  a hurried and
superficial observation ; and  we need  no  better
proof  of the truth  of this assertion  than the very
imperfect manner in which many of the cases on
record are reported, some of  the most important
facts  being  frequently  altogether omitted.   It is
always of considerable importance  to  obtain, <f
possible, a correct  account of the  history of the
case from the  earliest  appearance   of the symp-
toms ; for it is chiefly from  the mode of invasion
that the different forms of  cerebral inflammation
derive their distinctive  character, as they assume
a greater resemblance to each other in their latter
stages.
   We  have  noticed, among  the   symptoms .f 
BRAIN,  (INFLAMMATION
OF  THE) —[CEREBRITIS.]     315
acute cerebritis, paroxysms of increased activity
of the external  senses  and intellectual faculties,
such as intolerance of light, tinnitus aurium, vio-
lent delirum.  The pupils are contracted during
the period of excitement, but resume their natural
size when it subsides; this distinguishes cerebritis
from  sanguineous apoplexy, in which the pupils
are almost  always dilated.  Sometimes  there is
dilatation of one  pupil and  contraction of the
other; the pupil,  whether contracted or dilated,
may be immovable, which is always an unfavoura-
ble symptom.  Acute delirium and intense headach
are  more common attendants on the combined
inflammation of the brain and its membranes than
on that of the brain alone.  Inflammation of the
membranes, extending only to the  surface of the
brain, excites a considerable degree of sympathetic
irritation and general disturbance in the cerebral
functions, which,  however, continue unimpaired
so long as the  organs remain healthy; but when
the substance of the  brain itself is  deeply or ex-
tensively  inflamed, its  functions are rather op-
pressed and  impeded, in proportion to the extent
of the disease, than highly excited.
   Partial and chronic  cerebritis is scarcely ever
attended, in its first stage, with general excitement
of the cerebral functions.   When the  sight or
hearing is affected, it is on one side only; the in-
telligence is rather  partially weakened than ex-
cited.  Cephalalgia is not so constant in cerebritis
as in affections of the arachnoid and dura mater.
There may, however, be  a local fixed headach,
sometimes intermitting; but the pain subsides as
the disease advances and the brain becomes  more
deeply affected ;  headach,  therefore,  is a less un-
favourable symptom than stupor.  In some cases
the  pain has been felt on the side opposite to the
disease, an anomaly not easily explained.  In the
latter  stages of partial  cerebritis  the  senses  and
intellect  become  more seriously impaired, the pa-
tient falling either suddenly or  gradually into a
state of  coma, or being cut off by an attack of
meningitis.
   It has been generally remarked that  inflamma-
tion of the  brain  alone does  not occasion much
disturbance  of the circulation, as  large portions of
brain have been destroyed by suppuration, in inju-
ries  of the head, without any disturbance of the
pulse  or  general  re-action.   This has been ac-
counted for by the  heart receiving its nerves chiefly
from the great sympathetic, and  being only  indi-
rectly influenced  by  the brain.   The higb  fever
accompanying  some  cases  of cerebritis  is to be
ascribed  generally lo  the complication of the dis-
ease with arachnitis, or with inflammation of some
other organ.   Great and  sudden  variations  have
been noted  in the frequency of the pulse in very
acute cases;  it sometimes suddenly rises from 100
to 160; at another time it may be irregular or in-
termitting, or so feeble and slow as scarcely  to be
felt; and again quickly recovering its strength and
frequency.  These changes in  the  pulse corre-
spond with the alternate paroxysms of excitement
and collapse, and  are connected, as will be  seen
presently, with similar changes in the respiration.
   The respiration is  not in the least disturbed in
the great majority of  cases of simple cerebral in-
flammation.  This is satisfactorily accounted for
by Sir Charles  Bell's interesting discoveries re-
specting the origin and functions of the respiratory
system of nerves : large portions of the brain may
be destroyed, and  extensive  regions of the body
deprived  of sense and motion ; but as long as that
portion of the medulla which gives origin to the
nerves of respiration continues free from irrita-
tion, inflammation, or pressure, the functions both
of the respiratory and circulating systems proceed
without interruption, and life is sustained. When,
however,  the  inflammation  or  general  irritation
extends to the medulla, as  happens  in the parox-
ysms of convulsions which  sometimes  occur in
cerebritis, the respiration then becomes extremely
hurried ;  the violence of the convulsions forces
also the blood towards the heart, which is excited
by these  two causes  to redoubled action, in order
to relieve itself of the congestion by which it is
oppressed ;  hence the rapidity and  sudden rising
of the pulse :  as soon, however, as  the paroxysm
subsides,  the respiration  and  the pulse become
comparatively tranquil.   When  the  medulla is
exposed   to  pressure, the  respiration   is slow,
laboured, and stertorous.
   Difficulty of breathing  is on many  occasions
the effect of mere cerebral irritation, and there is
in reality a  cerebral  dyspnxa, which we have  no
doubt has sometimes been  mistaken for disease of
the lungs.  This  difficulty of breathing is distin-
guished  by its frequency, its  irregularity, and a
kind of hysterical sighing; or it is slow, laboured,
and stertorous, as  in coma.  Auscultation will be
found an invaluable  resource in all cases of doubt;
an accurate diagnosis in this respect is of the first
importance, especially in the latter stages of con-
tinued fever.
   The functions  of the digestive system are so
much under the influence of the brain, that they
must obviously sympathize with its  diseases ; the
sensations of hunger and thirst, for instance, being
greatly modified by  the various  conditions of that
organ.  Thus, in cerebritis the appetite is in gene-
ral deficient, and the digestion slow and imperfect,
especially in the  more chronic forms ;  there is
also a great disposition to  sluggishness  and con-
stipation of the bowels;  and the stomach itself is
sometimes so torpid,  that the strongest emetics are
insufficient  to  excite  vomiting.   In other cases,
however, there is  considerable irritability both of
the stomach and  bowels, with  vomiting or  diar-
rhoea, and a very unhealthy state of the secretions;
this   chiefly happens  in  children.  We  have
already sufficiently pointed out the influence of
cerebral affections on the urinary organs, and the
necessity of great attention  to the state  of those
organs when the functions of the brain are much
disturbed.
   The convulsions, paralysis, and other pathogno-
monic symptoms of cerebral inflammation, may be
referred  to  the  more  immediate  action  of three
causes :—1st, inflammation affecting  either the
membranes  or a portion  of the substance of the
brain : 2d, nervous irritation extending from the
diseased  to the healthy  parts of the brain,  and
stimulating  its functions : 3d, pressure.   The dif
ficulty in ascertaining from wbich of these causes
the various  symptoms arise, constitutes the chief
obstacle to our always forming an accurate diagn.j
sis in cerebral diseases.   Convulsions, spasmodic
paralysis, increased   activity  of  the  intellectual 
[116       BRAIN, (INFLAMMATION

faculties  and  external senses,  delirium,  and all
symptoms of excitement, may generally be consi-
dered to indicate either commencing inflammation
or nervous irritation in the substance of the brain
or its membranes.   Convulsions may also arise
from pressure  alone, although paralysis is its most
frequent  effect;  but the absence of all fever and
other symptoms of general irritation, will distin-
guish these convulsions from those of arachnitis
and cerebritis  : the same distinction applies to the
convulsions of a  purely  nervous character,  ob-
served in  hysteria, and after the use of certain
poisons, &c.
   The effects of pressure have  often been  exa-
mined by experiments on animals. If the cranium
of a dog is trepanned and pressure performed on
the dura  mater to a certain extent, the  animal
shows signs of great uneasiness, and is  affected
with general convulsions ; if the pressure is in-
creased, the convulsions cease, the breathing be-
comes stertorous, the animal torpid and comatose;
if the pressure is diminished, the breathing becomes
more free and the convulsions return ;  and if it is
entirely removed, the animal soon completely re-
covers.   The  principal  causes  of  pressure  are
congestion ; effusion of blood, pus, or serosity into
the ventricles, between  the membranes, or in the
substance  of  the brain;  organic diseases of the
brain or cranium.   The  obscurity in which all
these interesting questions are still  involved, is
capable, we think, of being considerably lessened
by  further investigation;  and  nothing would be
more likely to contribute  to  so desirable  an end,
than pathological observations made with care and
impartiality.   A valuable collection of cases illus-
trating the consequence of pressure on the brain,
will be found in Dr. Bright's Reports of  Medical
Cases.
   Some important  information is afforded on the
modifications  produced  by  pressure in  cerebral
diseases, by the results observed to follow injuries
of the head.  Many interesting  cases of this de-
scription  are  recorded  in medical and  surgical
writings.
   It is a matter of general observation in injuries
of the head, that when there is an external open-
ing forming an outlet  for the pus, extensive in-
flammation and suppuration of tbe brain may take
place, with only  very slight paralytic and other
symptoms, compared with those which arise from
spontaneous inflammation  of a much more limited
extent.   In confirmation  of  this we shall adduce
the extraordinary case mentioned by Mr. O'Hallo-
ran.  A  man, after an  injury of the head, lost a
considerable part of the frontal bone on the right
side • a great  opening was formed, and extensive
suppuration having taken place, there were  dis-
charged through it at each dressing immense quan-
tities of purulent matter,  mixed with large pieces
of cerebral substance, emitting a horrid smell, and
making, after  some time,  " a frightful cavern " in
the very substance  of the  brain.  On the eighth
day of this affection, the left hand and arm became
paralytic, and the left thigh  and leg on the tenth
day : the  man lived to the seventeenth, retaining
his faculties to the very   moment of dissolution,
and having continued  through the whole course
of tne disease perfectly composed and intelligent,
and with a pulse quite  natural.  Mr. O'Halloran
 OF THE) —[CEREBRITIS.]

says that he could affirm  that no less than three
ounces of the brain followed every  dressing after
the eighth  day.   These  facts clearly prove the
great share  which pressure has in the production
of the fatal  consequences attending  inflammatory
affections of the brain.  They enable us to under-
stand how the swelling of one portion of brain,
in the progress of  inflammation, may be sufficient
to exercise  considerable  pressure on  the  whole
organ ;  hence  the occurrence of  complete  hemi-
plegia with  disease only  of a small portion  of
brain ; and  that likewise of convulsions, paralysis,
affections of the external  senses on both sides of
the body, and coma, with disease on one side only
of the brain.  That there is a considerable ten-
dency in the cerebral texture to expand and swell
under inflammation, is made evident by the great
protrusion  of the brain through the openings in
the skull which sometimes takes  place after inju-
ries of the head.   The effects of pressure are local
or general, according to its degree : when slight,
it may excite convulsions;  -when great, it suspends
consciousness and paralyses motion  ; if long con-
tinued, it destroys life by interrupting the circula-
tion in the brain.
   Morbid Anatomy___Before proceeding to the
description  of  the different  morbid  conditions of
the brain, it may be useful to state  that there are
several appearances depending on accidental cir-
cumstances, which it is important not to mistake
for the effects of disease.  In persons who have
died of acute disease, the  brain is more injected
than in those who have died of chronic ; tbe in-
jection is  much  greater  also in cases of death
from asphyxia or after  violent convulsions.   In
chronic diseases the brain is often  very soft and
flaccid, whilst  in  acute diseases, where death has
taken place rapidly, its density is rather increased.
   After removing the membranes  from the surface
of the brain and cutting it in slices, a long expo-
sure to the  air is followed by a  considerable in-
crease of redness.  If, as frequently happens, the
head of the subject has been placed in a dependent
position, a considerable degree of  injection and of
uniform redness may be the result, in consequence
of the gravitation of the blood, and of its oozing
through  the pores of the vessels;  the  brain has
then an appearance  as  if  stained  or washed with
blood : the same takes  place when  the post-mor-
tem examination is delayed until a considerable
time after death, and putrefaction has already com-
menced : it occurs also more readily in hot wea-
ther and after malignant diseases.   But this kind
of accidental injection  and  redness of the brain
differs so greatly from that which  is the result of
disease, that it is scarcely possible to  mistake the
one for  the other ; in the  former case the blood
will be much more  easily  removed by ablution in
water, than in  the latter.
   It is important  also to notice that a very great
difference is produced in the vascular  turgescence
and redness  of the  cerebral substance, according
to the order in which the  cavities of  the head 01
thorax  are  opened.   When the  thorax is first
opened, it is evident that the vessels  of the head
and brain must be drained of some of their blood,
in consequence of the large vessels of the lungs
and heart being emptied.  The brain will  there-
fore always appear more loaded with blood, when 
BRAIN, (INFLAMMATION
OF THE) —[CEREBRITIS.]       317

  Cerebral congestion almost always accompanies
inflammation of its membranes, and this affords
an explanation  of several of the symptoms.  In
some instances  there is an effusion of a turbid or
limpid serum into the ventricles, or between the
arachnoid and pia mater ;  in others the arachnoid
is, on the contrary, remarkably dry.
  The  character of congestion varies according
as the arterial or venous system is  most involved
in the morbid action.   A loaded condition of the
venous  system is common  in old  people, in per-
sons affected with disease  of the  heart, or any
other complaint preventing the free return of blood
from the head; in those also who die of asphyxia,
or whose last moments are  attended with violent
and  long-continued struggle.  Venous congestion
is not so frequent an attendant upon inflammation
as the arterial; they are  distinguished from each
other by the  darker colour  of the  venous blood,
and  the evident  greater distension of  the  veins
and  their sinuses.   The quantity of venous blood
poured out is sometimes very  considerable.
  A high state of congestion, either general or
local, precedes inflammation.  General congestion
may cause death, either by compression or the ex-
travasation of blood, before  there  has been suffi-
cient time for  the development of inflammation.
Local congestion is  seldom  so rapidly fatal, and
time is afforded for the inflammatory process to go
through its different stages.
  Inflammation.—The first and most  simple
stage of cerebral inflammation is characterized by
a high degree of vascularity and a red florid in-
jection  of the  cerebral  substance.  When cut
through it presents a considerable  number of red
dots, out  of which oozes  blood, the naturally co-
lourless  capillaries being filled with blood.  Be-
sides these red dots, there are other small spots, in
which, owing to the rupture of the capillaries, the
pulp is infiltrated with blood ;  these spots or stains
are striated, resembling ecchymosis:  when nume-
rous, they give the cerebral substance a marbled
appearance, with various  tints of red,—the cineri-
tious substance of a deep red, the white  substance
of a marbled violet.  Tbe intensity of the redness
generally decreases from the centre to the circum-
ference of the inflamed portion. Several of these
spots of ecchymosis sometimes unite, and  form a
small coagulum of blood ; the diseased portion of
brain is rather firmer than usual, owing to the
turgescence of its vessels, and has less  tenacity.
All the preceding appearances will be more or less
strongly marked according to the intensity of the
inflammation.  They may occupy  a considerable
portion  of one of the  hemispheres, or a number
of circumscribed  spots in  different parts of the
brain, extending  more or less in  depth.   If the
inflammation be  extensive,  and combined with
arachnitis, it  may prove fatal in this stage. When
more limited, its progress is not so rapid, and  it
generally passes into the second stage or that of
softening.
  Softening, [or Ramollissement.']—In the se
cond stage of inflammation,  the substance  of the
brain becomes  completely infiltrated  with either
blood or pus, or both ; its delicate texture is broken
down, softened, and more or less diffluent. When
blood predominates, this constitutes the red soften-
ing.  The colour of the broken-down pulo varies
the head is opened before tbe other great cavities.
Finally, when tbe hammer  is used  to open the
cranium, a certain degree of redness  and  ecchy-
mosis is always produced round the line of  frac-
ture by  the concussion, which might, through in-
attention,  be mistaken for disease.
   There can be no difference of opinion respecting
the appearances which indicate inflammation of
the brain in its advanced and  confirmed stages ;
but the  case is very different  as regards incipient
inflammation.   Pathologists  are not yet perfectly
agreed upon the exact appearances which  consti-
tute  the commencement of inflammation  in the
brain, or any  other organ :  this has  at all times
been a fertile source of error in the history  of dis-
eases, cases of mere congestion having often  been
erroneously described as inflammation.  The  cele-
brated Laennec was perhaps justified in his opi-
nion that, as a general rule, the deposition  of  a
new product in any texture, such as pus or  coagu-
lated lymph, was the only genuine and  incontest-
able proof of the previous existence of inflamma-
tion.   Inflammation is, however, always necessa-
rily preceded by an increased flow of  blood to the
part; and, by  a timely removal  of the exciting
cause, this congestion may subside without  pass-
ing into inflammation ; but it is obvious that there
must  always be considerable difficulty in drawing
the exact  line at which congestion ceases and in-
flammation begins, or the physiological  condition
of the brain becomes pathological; nor is this in-
deed at all necessary for practical purposes.  These
observations will sbow the importance  of  guard-
ing against the  too common  practice  of  setting
down as  decided  inflammation every appearance
of redness and increased vascularity.  We  have
no doubt that  mere cerebral congestion has often
thus been mistaken for inflammation.
   Congestion.—In cerebral congestion [cerebral
or encephalic hyperxmia.] all the vessels on the sur-
face of the brain are more injected  than usual, and
it is easy to trace their minute ramifications.  The
substance  of the  brain,  when cut through, pre-
sents a greater number of red  dots, especially in
the cineritious substance ; but  between these red
dots the  brain preserves its natural colour : its
texture  is  not in the least altered, and this increased
vascularity is general.
   Cerebral congestion assumes sometimes another
appearance, that of uniform redness, which, how-
ever, is never general.  The white substance pre-
sents  a light  rose-colour, sometimes a deep red
tint not unlike mahogany ; the grey substance, in
which it  is more frequent, assumes a reddish or
scarlet  tinge ; the shades of red  vary  however,
being described as purple,  violet, chocolate, &c.
M. Billard observed a slate-coloured tint  in the
cortical substance of the hemispheres in two  indi-
viduals  who had presented signs of chronic irrita-
tion of the brain.  This uniform discoloration is
only found in patches in  different  parts  of the
brain: it  might not inaptly be compared  to that
condition  of the  lung which leads to pulmonary
apoplexy,  and it may likewise lead to cerebral he-
morrhage,  either by the  exudation of blood or
rupture of vessels.  An uniform blush of a rose-
coloured tint  or of a deeper red  frequently sur-
rounds apoplectic clots of blood, or softened  por-
tions of brain.
                                     2n» 
318       BRAIN, (INFLAMMATION

from a bright red to a wine-lee tint, with interme-
diate shades of claret, brown or ash.   In the cme-
ritious substance it is of a reddish grey  or brown,
from the mixture of grey substance with the blood ;
all traces of fibrous texture disappear.   The pulp
in the  centre of the diseased portion is diffluent,
and  contains  sometimes  loose  turgid vessels;
whilst towards  the circumference  it  is firmer,
deeply injected, and  presents the character of  the
first stage of inflammation.   There  may be seve-
ral softened-down spots, and small clots of blood
may be found in the softened mass ; the surround-
ing brain  presenting sometimes a serous infiltra-
tion or a kind of oedema.
   When purulent softening takes place, globules
of pus are seen mixed up with the deeply-injected
pulp,  giving  it a greyish or yellow colour.   As
the disease advances, the purulent infiltration be-
comes general, and presents a softened mass, con-
sisting of pus mixed up with brain.  This consti-
tutes  the  yellow softening.  The  same diseased
portion may show the different stages  of inflam-
mation :  the red and hardened state, at the circum-
ference ; that of semi-purulent infiltration next;
and the diffluent purulent softening in the centre.
The infiltration of pus may take  place  very irre-
gularly throughout the same inflamed portion : it
may be of various degrees of consistence;  semi-
concrete, in a state of jelly, or that of a thick fluid.
The pus  has  sometimes fused from the diseased
into  the healthy brain, forming  for itself a new
cavity.  The red and the purulent softening are fre-
quently combined,  one  portion  of  the inflamed
part presenting a sanguineous infiltration, and an-
other  a purulent; or else there  is  a  general mix-
ture of blood, pus, and brain,  of a dirty grey or
reddish colour.   It  is evident  that  the colour of
the inflamed brain must  depend on the nature of
the fluids, whether blood or pus, with which it is
injected, and on  the proportion  in which  these
fluids are  mixed.
   The cineritious substance is  the most frequent
seat of the  red softening;  its  great vascularity
strongly predisposing it to inflammation.  Thus,
of forty-six cases of cerebritis collected  by Lalle-
mand, the grey substance was  the  principal seat
of the inflammation in thirty-three, and the me-
dullary in only eight.   The surface of the con-
volutions, which consists entirely of cortical sub-
stance, was affected in sixteen cases; the corpora
striata and optic thalami, in which the grey pre-
dominates over  the  white substance, in thirteen ;
and  the tuber annulare, which  contains less of
grey  substance, only  in four.   Some influence
must be allowed to  the greater extent  of surface
of the cortical substance,  and to its  connexion
with the arachnoid.
   The softening  in  some  cases  is  of  a uniform
yellow  or greenish  colour, with  only a blush of
red at  its circumference, and the appearances of a
less acute degree of inflammation.   This is  the
form in which it is most  generally found in the
medullary substance, which is much less vascular,
is already stated, than the cortical.
   There  is a  variety of cerebral softening very
 listinct from  the preceding, and  which is called
rhe white softening,- it affects more particularly
the medullary substance.  The  pulp seems broken
sown  by a kind of serous infiltration, and presents
OF  THE) —[CEREBRITIS.]

the appearance of whipped cream,  with a  few
drops  of pure  serosity  sometimes   intermixed.
The colour is generally of the purest white, at
times, however, inclining to grey or yellow, espe-
cially when seated in the cortical substance:  it is
not surrounded by increased vascularity or  red-
ness, but rather by a state of cedema of the adja-
cent'brain.  This is the simplest form of softening
of the brain, and that most common to old people;
it  is generally attended with serous  effusions in
other parts  of the brain, and also with disease of
the arteries, which  is  supposed  to be one of its
principal causes.  The coats  of the arteries  are
either ossified  or affected with earthy brittleness ;
their tubes sometimes very much narrowed or ob-
literated, or else having a succession of small bony
rings; the inner coat is in some cases thickened,
soft, and easily separated.   The basilary  arteries
are the most subject to these changes of structure.
The veins have also  been found  diseased.   Dr.
Cheyne has seen a case (Abercrombie, Pathologi-
cal Researches on the Brain) in which there was
a deposition of a firm yellowish white substance
between the two coats  of the veins, and this ex-
tended to all the veins of the brain ; there was a
turbid effusion  between  the  arachnoid  and  pia
mater; the whole brain was bloodshot: there was
a portion of softened brain on the side of the left
ventricle, an inch in length, with a cavity in its
centre: Ihe patient had long suffered  from head-
ach, and died apoplectic.   The white softening
must not  be  confounded  with  that softness and
flaccidity of the entire brain  which occurs after
cachectic diseases, or those attended with great
prostration of strength and symptoms of putridity.
   Softening of the brain sometimes occurs round
a clot of extravasated blood : this may take place
consecutive to the extravasation, as the effect of
inflammation  excited around it; or else the soft-
ening may have existed previously, and the extra-
vasation have been  occasioned by the ulceration
and rupture of blood-vessels in the centre of the
broken-down  brain :  we shall consider this more
fully  hereafter.  Softening of the brain is  fre-
quently  observed round organic tumours, as the
result also  of secondary inflammation.
   With regard to the seats of softening,  the sur-
face of the convolutions, the optic thalami, cor-
pora striata, and medullary centres of the hemi-
spheres,  are the most ordinary seats of cerebritis.
It is less  frequently  met  with in  the  corpora
quadragemina, crura  cerebri, cerebellum,  medulla
oblongata,  and spinal  cord ; it is in fact most
frequent in those parts of the brain which have
the largest share  of cortical or cineritious sub-
stance, because that substance, as observed before,
is considerably more vascular than  the medullary.
The  cortical  substance of the convolutions is
sometimes extensively softened, whilst the white
substance beneath remains untouched;  this may
happen  in  arachnitis.   The white softening of
the brain,  which is  less decidedly inflammatory,
is most  frequently found in  the medullary sub-
stance.
   [M. Durand-Fardel (Traite du Ramollisseinent
du Cerveau, Paris, 1843,) found acute softening
by far most frequently in the  convolutions.   Of
33 cases, 31  were examples  of this seat of the
disease,  and  in 9 the convolutions were alone 
          BRAIN,  (INFLAMMATION

affected.  53 cases, collected from various sources,
gave the following  results as regards the seat of
the lesion.
   Convolutions and medullary substance .. 22
   Convolutions alone  . :•...............  6
   Medullary substance alone............  5
   Corpus striatum and thalamus opticus . .  6
   Corpus striatum alone...............11
   Thalamus opticus alone..............  4
   Pons Varolii.......................  3
   Crus cerebri.......................  1
   Corpus callosum  ...................  1
   Walls of the ventricles, septum........  1
   Fornix  ...........................  1
   Cerebellum........................  1
 Chronic softening appears to affect the  convolu-
 tions,  corpora  striata, and  optic thalami, in the
 same proportion as the acute.]
   Some of the central parts of the brain, such as
 the corpus callosum, septum lucidum. and fornix,
 are often affected with softening in hydrocepha-
 lus.   In  one of Dr.  Abercrombie's cases there
 was a ragged  irregular opening in the septum
 lucidum,  and  the opening was surrounded  by a
 ring of inflammation; the  inner surface of the
 ventricles was in  a state of high vascularity ; they
 were distended with colourless fluid, and the sub-
 stance bounding them was in some places consi-
 derably  softened.    The softening  is  sometimes
 confined to the corpus callosum.   It is evidently
 the  result of a serous  infiltration  of the medul-
 lary matter, whether the serum be  poured out  as
 the  consequence  of  inflammation or the reverse.
 This form of softening  is repeatedly  alluded  to
 by Morgagni,  and  by most authors  who have
 written  on  hydrocephalus.   Dr.  Abercrombie
 divides  hydrocephalus  into  two  species;  one
 depending on simple  inflammation of the lining
 membrane of the ventricles ; the other  attended
 with inflammatory softening of the corpus  callo-
 sum, fornix, and septum lucidum, and also of the
 cerebral substance forming  the walls of the ven-
 tricles ; the latter species he believes much the
 most frequent, and he is decidedly of opinion that
 hydrocephalus is  an inflammatory affection of the
 central parts of tbe  brain.   He  maintains,  also,
 that the effusion, which was  hitherto  considered
 as the  cause of the disease, is merely one of its
 terminations, contributing,  however, by the in-
 creased pressure  it  occasions, to  aggravate the
 symptoms.
   The softening of  the central parts of the  brain
 appears to be sometimes connected with diseases
 of debility, as likewise the serous effusion which
 accompanies it : this is found to be the case prin-
 cipally in old  paralytic people, and in those la-
 bouring under  dropsy and  other lingering dis-
 eases.   It  is ascertained  by  numerous  observa-
 tions that these central parts of the brain may be
 affected with  softening, even to a considerable
extent, without occasioning  paralysis  in any re-
gion of the trunk :  these parts seem  chiefly in-
tended to  connect together the hemispheres, and
have very little communication with the medulla
oblongata.  There  are  few cases on record  in
which  this variety  of disease has proved fatal
without any serous effusion  or other morbid alte-
ration,  although the  actual symptoms of effusion
were present.   This is, however, of such  rare
 OF  THE)-[CEREBRITIS.]     319

occurrence, that no practical conclusion can rea-
sonably be deduced from it.
   [In 32 cases of acute softening, recorded by
M. Duran/1-Fardel, (op. cit.)  paralysis was pre-
sent in 23 cases.  In two  cases, it was  general;
in one, there was simply weakened power of mo-
tion ; in 6, the paralysis was limited to the arm.
and in 14, it affected one  entire side.   At other
times, instead of the  limbs being paralysed, they
are more or less rigid and contracted.   Cases are
on record, and the writer has met with  such,
where the intellect was unaffected, although the
softening was great.   One  of the most interesting
examples of the kind was communicated in  a let-
ter to him, by Dr. Boerstler, of Lancaster,  Ohio,
(American  Medical  Intelligencer,  April 1837.)
In this case, the portion of the skull, previously
occupied by the right anterior and  middle  lobes
of the brain, presented a  perfect  cavity, which
was filled with some sero-purulent matter; and
the left hemisphere was in a  state of softening
down to the corpus  callosum.  It was  so  much
softened,  that  the slightest touch would remove
portions; yet, in his daily  visits to the subject of
this case, Dr. Boerstter could not  discover any
derangement of the  intellectual faculties, dulness
of sensibility, obtusenes of perception, impairment
of judgment,  or want  of  memory.   Such  cases
can, however, only be regarded as anomalies.
   The writer has elsewhere (Practice of Medi-
cine,  2d edit. p. 187, Philad. 1844) referred to the
case of a gentleman, who possessed his sensation,
volition, and  mental and  moral  manifestations
entire, even  when a clot of blood existed in  the
corpus striatum with extensive softening around
it.]
   General softening of the brain  is stated by
Andral to be exceedingly  rare in  adults, but to
occur sometimes in  new-born infants.   In thirty
cases of pultaceous softening  of the  brain,  ob-
served by M. Billard, there  were ten in which the
affection extended also to the whole of the spinal
cord; and in each of these  ten cases the  odour of
sulphuretted  hydrogen was perceptible.  The in-
fants  in whom this alteration was observed lived
for some  days after  birth,  but their  respiration
was laborious  and  imperfect,  theii limbs  were
flaccid and motionless, and the pulsations of  the
heart scarcely perceptible.   It  appears also, from
the labours  of M. Billard, that softening of  the
brain is most frequent in old people, and next to
them  in adults.   It is rather uncommon between
the ages of fifteen and  twenty, but  becomes less
so between two and  fifteen ; it may occur imme-
diately after birth, and is then  more considerable
and extensive  than  at  any other  period of life
it  is probable indeed that in some cases  it begins
even before birth.
   Having thus far described  the morbid altera-
tions  of the brain arising  from inflammation, it
seems desirable to inquire briefly into the nature
of these changes, and into the various  opinions
entertained respecting them by  medical writers.
   It is not a little  remarkable that the peculiar
morbid  condition of the brain  termed softening,
which has, with few exceptions, been overlooked
by pathologists in both ancient and modern times,
should not have escaped the attention of the  great
founder of the  medical art.  Hippocrates,  (lib. 
320
BRAIN,  (INFLAMMATION  OF  TH E)_ [C E RE B RITI S.]
 iii. de morbis, torn  ii. p. 96, edit, of Vander. Lin-
 den), gives an exact, although  short, description
 of cerebritis,  under  the name  of  cedema of the
 brain : this wonderfully acute observer seems to
 have justly appreciated  its true character, for he
 states that this tumefaction of the brain is an in-
 flammatory disease,  for which he recommends
 bloodletting.  Morgagni, Bonetus,  Lieutaud, Je-
 mima, in their accounts of softening of the brain,
 describe it as  a broken-down putrilage—corroded
 —consumed—and consider it analogous to gan-
 grene in other tissues.   Dr. Baillie concurred in
 this opinion, which has also been adopted by Dr.
 Abercrombie.  The  latter considers softening of
 the brain as the death of the affected portion, and
 that, like gangrene, it may arise from two oppo-
 site causes—from excessive action, which includes
 the cases with appearances of vascular injection,
 suppuration, &c. and from deficiency of action,
 owing to a failure of the  circulation, which in-
 cludes the  cases of white  softening with disease
 of the blood-vessels.  Among the French writers,
 M. Recamier  considers softening of the brain as a
 change of structure sui generis, distinct from any
 other, analogous to softening of the  spleen, and
 the primary  cause of certain  forms  of nervous
 fever.   Lallemand  [and  Durand-Fardel]  con-
 ceives it to be always an  inflammatory affection,
 passing through the different stages of tumefaction
 and suppuration, like phlegmon.   Rostan adopts
1 quite  an opposite  opinion, that it  is  a real gan-
 grene of the  brain, (gangrxna senilis,)  depend
 ing on a diseased state of the blood-vessels  : this
 opinion may  partly be accounted  for by the cir-
 cumstance  of his  observations  being  chiefly col-
 lected in the wards of the Salpetriere, which is an
 asylum  exclusively for  old people.  Laennec, who
 had paid great  attention to this subject, was of
 opinion that  softening  of  the  brain was of two
 kinds—the one inflammatory, in which pus, either
 fluid or concrete,  was deposited in the  cerebral
 substance, constituting the yellow or reddish soft-
 ening ; the other (the white softening)  depending
 on an infiltration  of the cerebral  substance with
 destruction of its cohesion by serous  fluid,  form-
 ing an cedema of the brain. He observed another
 species  of  cedema, without  destruction  of sub-
 stance, surrounding  sometimes inflamed  portions
 of brain, resembling the  cedema so common in
 the neighbourhood of phlegmonous tumours.
   If we turn  from these opinions  to an attentive
 consideration of what  is exhibited by dissection,
 we  shall find that  in  all the forms  of disease
 which have been  described, the substance of the
 brain is infiltrated either with  blood, pus,  or  se-
 rum, or with  various combinations of these  fluids.
 The cerebral  pulp  being  provided with only a
 very small proportion of cellular  tissue, and that
 of extreme delicacy, it  is easy to conceive that it
 should soon  become lacerated  by the deposit of
 any  considerable  quantity  of  fluid between  its
 libres and laminae; the pulp is then broken  down
 and  mixed up with the  interposed fluid.  The
 most  rational explanation of cerebral softening
 would seem therefore to be, to consider it not as
 a specific disease, but as the result of changes of
 structure following certain morbid conditions of
 the brain,  nearly  similar to those which  occur,
 'inder similar circumstances, in  other organs ; and
with only such modifications as are satisfactorily
accounted for  by the natural difference in its tex-
ture.   In the phlegmonous inflammation of other
organs, the parts affected are to a certain  extent
lacerated,  broken dowrr", and destroyed, previous
to the formation of an  abscess,  although this may
not take place so rapidly as  in  the brain,  the
parts offering a greater degree of resistance.
   One of  the effects  of inflammatory action is
ultimately to destroy the cohesion of tissues, al •
though in  some  of them their firmness may  at
first, in consequence of  the  distension of vessels
or deposition of concrete lymph, appear increased.
Some pathologists having erroneously considered
hardness and cohesion  as  always  synonymous,
have asserted that it is the property of inflamma-
tion to soften  hard tissues and  harden soft ones.
This is a complete fallacy. A portion of inflamed
lung  in the  second  stage appears firmer  to  the
touch  than healthy lung,  and yet  by a  slight
pressure  of the  fingers its  texture  immediately
breaks down ; it is found brittle ; the cohesion of
its parts is greatly weakened ; and it has lost its
tenacity.  The cohesion of tissues is  equally less-
ened  by cachectic diseases  and watery effusion.
But it may be  asked, since  the organization of
the brain is broken  down and destroyed, is not
this gangrene ?   It has just been  stated  that  in
the process which leads to the  termination of
phlegmon  in healthy suppuration, the central
parts  of the tumour  are broken down  and  disor-
ganized ;  a large cavity is formed  with loss of
substance;  and  yet this is  not looked upon  as
gangrene, and differs  very  widely from the ter-
mination  of the same tumour in gangrene :  in
fact, the term gangrene  cannot, strictly speaking,
be applied to every case of disorganization and
loss of substance.   There  is  in parts affected
with gangrene a tendency to rapid decomposition;
a  putrescence, exhaling  a specific  foetor, known
by the appellation of gangrenous,  which does noj
belong to suppuration, and has only occasionally
been  observed in spontaneous softening  of the
brain.  Genuine gangrene  of the brain is  stated
by most medical writers to be a rare termination
of inflammation of this  organ.   Laennec* says
he has very seldom  met with it;  Bayle gives an
account of one case of white softening with apo-
plexy and gangrene; Dr. Abercrombie, in  two or
three of his cases, speaks of the softened brain
mixed with pus having an  intolerable foetor, and
these were probably cases of true  gangrene.   In
a  case mentioned by Saure,  after  acute cerebritis
occasioned by a blow on the  head, the membranes
of the brain were of a livid  colour for an extent
of several inches, and the brain  beneath was
very black and  gangrenous  to the depth of seve-
ral inches.    The most numerous  accounts  of
undoubted gangrene of the brain  are those found
in surgical works treating of wounds of the head
with protrusion of the brain, and also of polypous
excrescences of the brain protruding through the
skull, and terminating in gangrene : in these cases
the cerebral substance  has been found of a purple
red or blackish grey,  considerably softened,  and
exhaling an ammoniacal foetid odour.

  * The writer of this article has heard Laennec stale
that he and Bayle had made together five thousand post'
mortem examinations 
        BRAIN, (INFLAMMATION

  Suppuration and Abscess.—The next va-
riety of morbid change in the brain incidental to
inflammation,  and  which  generally  follows the
preceding, is the passage of the  inflamed  portion
of the brain to complete suppuration and abscess.
The globules  of pus contained  in  the  softened
br.iin gradually unite and form homogeneous pu-
rulent collections :  these are either recent and
undefined, or of long standing and encysted.  In
the  undefined  abscess the  pus is  only circum-
scribed by  the cerebral  substance,  which is par-
tially  softened down,  and forms  a  cavity with
irregular walls.  The pus is generally mixed with
shreds of softened cerebral substance ;  it  varies in
colour and fluidity : it is either yellow, greenish,
or brown ; sometimes, as Laennec states, partially
concrete, like coagulable lymph, and floating in a
thinner fluid ; at others nearly homogeneous.  Its
smell  is usually that  of genuine pus, at times,
however, emitting a peculiar foetor.
   The formation  of  a  cyst  takes place in  the
brain by nearly the same process as in phlegmon;
the ragged sides of the cavity are lined with suc-
cessive layers of coagulable organized lymph, whose
delicate vessels  form a  union with those of the
brain, and become thus  connected with its  circu-
lation.  The first layers  are thin and delicate, but
others are superadded as in the adventitious mem-
branes of serous tissues, until the walls of the cyst
become firm and perfectly organized ; the internal
surface is smooth and somewhat analogous to the
structure  of mucous  membranes.    Sometimes,
however, the sides of the cyst are fibrous, cartila-
ginous, or incrusted with a calcareous deposit.  It
 would  appear  from numerous  observations that
the  rudiments of the cyst have been found as
early as the end of the first week ;  it gradually
acquires its completion, and is perfectly organised
between the third and fourth week.   It sometimes
continue- increasing in  thickness for years ; and
some  estimate may be  formed  of  the length of
time the abscess has  existed, by the  number of
layers in its cyst.   These facts have led to some
important practical conclusions in cases of medical
 jurisprudence.   An instance of this kind is related
by Lallemand (Lett.  IV.  p. 87)  in  which  the
physicians, consulted by a court of justice, were
enabled to decide that the death of a man, which
was supposed  to have  been occasioned by  the
beating he received from another who was on his
trial for murder, was distinctly to be attributed to
chronic inflammation of the brain combined with
otitis.   Encysted  abscesses  are sometimes  the
consequence of acute, and at others of the more
slow and insidious forms of cerebritis :  the pus,
being  once circumscribed, is prevented from  ex-
tending its ravages ; and  the life of  the patient
may be prolonged for years, exactly as in the case
of an  organic  tumour.  When  the  cyst finally
becomes the cause of death, it is by exciting fresh
inflammation in  the surrounding  cerebral sub-
stance ; or it  may  give  rise to arachnitis and
serous effusions, or to sanguineous apoplexy. The
symptoms which attend chronic encysted abscesses
sometimes resemble those of organic disease.
  Our attention is directed here  to  a rather  inter-
esting question__Do abscesses of the brain ever
heal, like those of other parts ?  There are some-
times found in the brain appearances of large cica-
  Vol I.—41
OF  THE)—[CEREBRITIS.]     321

trices : they have  in  general  been attributed to
the closing up of cavities  which contained apo-
plectic clots  of blood.   Lallemand and  other
writers are of opinion that  a similar healing pro-
cess  may take  place in encysted abscesses, after
the absorption of  their pus; and  that these are
not always to  be considered as  incurab'e   This
appears  by no means improbable, and is  rather
confirmed by  the  circumstances of the walls of
encysted  abscesses being  sometimes  united  by
transverse organic bands, which give them  a cel-
lular appearance.
   Suppuration may take place very rapidly in the
brain ; Laennec says he has known pus to form
in less than  twenty-four hours ;  and Dr. Aber-
crombie  mentions  two remarkable cases, in one
of which three well-formed encysted  abscesses
were found in the  brain, after an illness of twelve
days ;  and in  the  other several small undefined
abscesses at the end of four days'  illness.  Cere-
bral abscess being one  of the terminations of
inflammation in that  organ, is attended with the
same symptoms as those belonging to the periods
of excitement  and softening  already  described ;
they vary only according to the character, more
or less acute or chronic, and the seat of the inflam-
mation.   There are  a  great  many  interesting
cases  of abscess  recorded  in the writings of
Lallemand, Abercrombie,  Rostan,  and  of  some
of the ancients.
   There are a few cases on record of extensi ye
suppuration having taken place in the brain with-
out the manifestation of any symptoms indicating
such a  disease, until  immediately before  death.
Objections have been raised from this  occurrence
against the value of any  rules of diagnosis : it
should be observed, however, that such cases  are
rare, and that some of them are so superficially
described, as greatly to invalidate  the weight of
their evidence.  The best authenticated is one by
Dr.  Broussais, of a man in whose brain an  exten-
sive abscess was  found in the centre  of each
hemisphere, and in whom no other  symptoms had
been observed during  life than a peculiar dulness
of manner and taciturnity, which  terminated  in
coma after thirty-seven days' illness.   A solution
might be given of these cases by conceiving a
portion of brain to have been for a considerable
time in the first stage of low inflammation,  which
may exist without giving rise to any well-marked
symptoms, until,  from the sudden influence of
some strongly-exciting cause, it is made to pass
rapidly into the stage of softening and suppura-
tion.  The great rapidity of the formation  of pus
in the brain  has  already been  alluded to.   But
after all, why should not latent  diseases  occur  in
the brain as well as in other organs ?
   Abscesses have also been found  in the cerebel-
lum, but not so frequently as in other parts of the
brain.   Abercrombie gives the remarkable case of
a young girl in whom the left lobe  of the cerebe.-
lum was entirely converted into  a bag of purulent
matter of a greenish colour and intolerable  foetor;
it was contained in a soft and organised sac. The
symptoms were intense head-ach for several days;
a sudden rising of the pulse to 160; dilated pupii
and strabismus ; great debility and loss  of the
power of swallowing ; she was  nearly suffocated
each time she attempted  to drink.   She died of 
•¥*2     BRAIN, (INFLAMMATION
OF  THE) —[CEREBRITIS.]

left hand and arm, that the slightest breath of cold
air upon them brought on convulsions.   He died
rather suddenly,  after an  illness  of five years.
There was a superficial  induration  of the brain
corresponding to the seat of the pain, and under
the  indurated part there was an  abscess of the
size of an egg.
   Organic  Diseases. — It  is the   opinion  of
several writers, among whom is Dr. Abercrombie,
that the  state of  simple  induration  of the brain
just described, may be considered as  the origin or
first stage of the organic tumours sometimes found
in the brain; that these tumours are the result of
chronic inflammation ; and that the various forms
of scrofula, carcinoma, melanosis, fibro-cartilage,
or hydatids,  which they assume, depend on pecu-
liarities of constitution or other accidental circum-
stances with which we are unacquainted.
   Dr. Abercrombie mentions that in some cases
the  portion  of indurated brain has been found
 surrounded  by a  cyst, so as to form a complete
 tumour.   He thinks  it probable that this is only
 a part of the cerebral substance in a state of low
 scrofulous inflammation; that in its early stage
 it is a disease which may be cured ;  and that the
 formation around it of a cyst by the deposition
 of coagulable lymph,  or  its termination by an in-
 duration of the part, are  the points in its progress
 which give  it the character of organic  or hope-
 less  disease.  Accordingly,  this  might  be con-
 sidered as the intermediate step between chronic
 inflammation  and  the  development of  organic
 disease. This is an ingenious view of the subject;
 but it does not rest upon sufficient evidence to be
 received  yet as  an established truth : the whole
 question involving the origin  and  nature of or-
 ganic tumours, and  also of tubercles, is one of
 considerable interest  and  importance,  and  re-
 specting which  there exists much  diversity of
 opinion.
   The principal organic diseases are, bony tumours
 of the internal surface of the cranium ; thickening
 or excrescences of the dura mater; a variety of
 tumours in  the brain,  some  consisting chiefly of
 a whitish mass, having the properties of albumen;
 others more organised,  reddish,   and resembling
 the substance of the kidney; others carcinomatous,
 fatty, or tubercular : the latter are by far the most
 frequent,  particularly in children.   Ossification
 and long spiculae in  the dura mater, falx, or ten-
 torium, and serous  cysts  and hydatids are also
 sometimes found.  Tbere  are others of more rare
 occurrence,  such as  stony and  bloody  tumours,
 fungus  hsematodes,  melanosis,  fungous excres-
 cences of the brain or of its membranes, protruding
 sometimes through the cranium. There are several
 instances of a  clot of blood becoming  organised
 and forming a tumour.  It  is next  to impossible
 to distinguish  these  organic diseases from each
 other during life.  When there is any well-marked
 specific  diathesis, such  as  the  scrofulous or the
 cancerous, some  plausible conjecture may perhaps
 be  formed respecting their  nature.  In a few 01
 the recorded cases of cancer in  the brain,  there
 were severe lancinating  pains through the head;
 but this is not  a point of much  consequence, as
 they  are hopeless diseases.
    The existence of organic disease in the brain is
 manifested  by various lesions of  the intelligence,
exhaustion on  the  fifteenth  day.   Inflammation
and  softening  are  not,  however,  so  frequently
observed in the cerebellum as in other parts of the
brain.   The diagnostic symptoms are  in  general
very obscure ; the intellectual faculties are gene-
rally less affected than when the disease is situated
in the cerebrum.
   Ulceration.—This state of the brain has been
described by several writers, although it is un-
common.  It has been found on the surface of the
convolutions, on  the  optic thalami, and the cor-
pora  striata.  The ulcers present an irregular
surface, covered partially with either  a bloody  or
albuminous exudation, and having jagged edges.
In some cases it is hard  and  dry ; in others there
are fistulous communications between the ulcer
and deep-seated collections of pus ; and in others
the ulcer forms  the bed  of a coagulum of blood :
tbe ulcers vary in depth and dimensions.   Some
writers consider these ulcerations as affecting more
particularly the arachnoid and pia mater, and not
belonging to the cerebral substance.   This may
be true in some cases, but not in all.   Morgagni
speaks, in one of  his cases, of an erosion of the
corpus  striatum, and in  another of  an ulcerous
cavity at the base of the  left ventricle.   Two
cases of the same nature are recorded by Scout-
etten.
   There are  also  ulcerations occasioned by the
penetration of  foreign  bodies,  of which  many
cases are given  by Morgagni and other surgical
writers, but these are foreign  to  our present pur-
pose.
   Induration.—This is  mentioned by  Aber-
crombie, Andral,  Bouillaud,  Lallemand, and
others,  as an occasional  termination of cerebritis.
The induration may be  general or partial, and of
different degrees of density, from  that of wax to
that of fibro-cartilage.
   General induration has been observed in persons
affected with ataxic fever, and in some who have
died in  a  state of general  convulsion from the
poisonous effects of lead : it is  not  uncommon
 also in lunatics.   The brain  contains little or  no
blood, is of a bright whiteness, and the medullary
 substance more condensed  than  the  grey : the
 exact nature of this form of induration is yet but
 imperfectly known.
   Partial induration is of more frequent  occur-
 rence.   The simple chronic inflammation may, in
 some  instances, terminate in induration of the
 portion of the brain affected. The fluids contained
 in the  vessels, or  exuded between the fibres and
 lamina?,  whether blood, lymph, or pus, become
 concrete, and  continue  so for a  longer or shorter
 time.   The part, when cut into,  is as  firm as flesh
 or kidney ; either  of a  bright or dark red, or yel-
 low;' or else a slow process is  carried on which
 leads to  a conversion of the diseased  portion into
 a species of fibro-cartilage.   The induration may,
 after lasting a considerable time, pass into suppu-
 ration.   It either affects a considerable portion of
 the brain in depth, or  extends  superficially over
 the surface ; or there  are  several small circum-
 scribed indurated  spots.
    A curious case is  related by Baader of a man
  aged 40, who became suddenly  epileptic, with
  fixed local pain on the  left side  of the head, and
  i=uch exquisite  sensibility of the surface  of the 
BRAIN,  (INFLAMMATION  OF  THE ) —[CE RE B RITIS.]
323
voluntary motion, and sensation . the effects either
of pressure on the brain  or of  inflammation.
These diseases  bear, therefore, a  strong  resem-
blance in their symptoms to some of the forms of
cerebritis.  Acute cerebritis  is not very likely to
be mistaken for organic disease, as  the symptoms
of the former run their course with  a degree  of
rapidity and violence which never  belongs to the
latter. The diagnosis, however, between the more
chronic forms of cerebritis and  organic  disease
may sometimes be attended with greater difficulty;
and it is necessary  to  pay great attention to the
mode of invasion, progress,  and duration of the
symptoms  in  each class of diseases, in order to
distinguish them from each other.  The progress
of the symptoms in organic diseases is very slow,
irregular, and intermittent;  very trivial circum-
stances  are  sometimes  sufficient to  bring  on
attacks of cephalalgia,  vertigo,  temporary  apo-
plexy, or convulsion;  such as quick  exercise, bot
rooms, sudden  emotions, prolonged  attention in
reading or writing, a low position of  the head; in
fact, every thing calculated to disturb and hurry
the circulation in the brain.   When  this organ is
already  suffering from pressure,  a very slight
change in its circulation may suffice  to give rise
to the most alarming symptoms ;  but these sub-
side  as  soon  as  the  momentary congestion  is
removed, and the patient then recovers every ap-
pearance of his usual health.  In  some cases the
symptoms entirely  disappear for  a  considerable
time,  and  then  return  with increased violence.
The  disease  does  not  in general assume a de-
cidedly  active  and  regular  character  until the
surrounding  brain  becomes inflamed;  and the
two forms of disease being  then  combined, the
ordinary  symptoms of cerebritis make  their ap-
 pearance.*    In  chronic cerebritis,  although  in
 some  instances the symptoms may  be slow and
 irregular,  they  do not  in general exhibit  such
 sudden exacerbations or complete  and  protracted
intermissions, nor  are  they aggravated  by the
 same  trivial  cause.   Cases, however,  attended
 with much doubt and difficulty, may  sometimes
 present themselves, especially when chronic cere-
 britis  terminates in induration ; but it may be
 laid down  as  a general rule, which will materially
 assist in  forming  the diagnosis,  that  the  very
 large majority of cases of primary cerebritis run
their course  in  less than six months  from the
time  of the  full  development of the  disease  ;
whilst the  great majority of  organic  diseases last
beyond  that  time,  and  some even  as  long as
several years.  The tubercular diseases are those
the  course of which  is  most rapid, particularly
  * The late Dr. Wollaston died of an organic disease
of the brain, which there is good reason  to suppose
originated in slow  chronic inflammation:  we rind it
stated, in the post-mortem examination, that the  optic
thalamus of  the right side was found  converted into a
tumour a? large as a middle-sized  hen's egg ; towards
the circninference,  it  was of a  greyish colour, harder
than the brain, and somewhat of a caseous consistence,
but in the centre, of a brown colour, soft, and in a half-
dissolved state. We learn from Dr James Somerville,
who attended him, that he had suffered more or less for
several years from a train of symptoms corresponding to
those above described, and that he ultimately died para-
lytic. Four years previous to his death (in 1828) he read
before the Royal Society an ingenious  paper  on a pecu-
liar defect of vision to which he was subject,  and which,
it is highly probable, was a symptom of the incipient dis-
ease of the U'ain.
when there  is active  tubercular inflammation  in
other parts of the body.
   Hypertrophy. — Several  pathologists,  and
amongst others Laennec and  Jadelot, have de-
scribed an alteration of the brain connected with
its acute diseases, which they term hypertrophy .-
this  alteration  appears to  have been known also
to Morgagni.  Laennec observed  it  in  persons
who had previously been supposed to be affected
with hydrocephalus internus;  also  in  epileptic
children, and in  others who had died of convul-
sions.   The following are  its  distinctive charac-
ters :—the convolutions of the  brain are crowded
together and flattened ;  the  intervals  between
them disappear; and it seems  as  if the mem-
branes of the brain were too tight for it.  After
the upper part of the  cranium  has been removed,
it is found difficult to make it fit  on again,  the
brain appearing  too  large  for the cavity of  the
skull; tbe substance of the  organ is firm, contains
but little blood, and appears remarkably dry when
cut  into; the ventricles are, as it were, effaced,
and the various surfaces of the brain deprived  of
their ordinary moisture :  in  other respects  the
texture remains unaltered.  The affection is most
frequently  general.  Andral has however seen a
case, in which the left thalamus was one-fourth
larger than  the right, which was of the natural
size ; there had not been any particular symptom
observed during life, that could lead to a suspicion
of such a state of the  parts. No instance of hy-
pertrophy  of the cerebellum  has  hitherto been
published.   In a few rare  cases  the enlargement
of the brain has been carried to such an extent
as to occasion  an enlargement of the skull.   A
remarkable case is recorded in  the Archives  de
Medicine, 7th volume, of a child of five years of
age, who bad a head  as large as that of a stout
man ;  the  parietes of  the cranium varied  from a
line and a half to two lines in thickness ; it was
chiefly the hemispheres that were enlarged ; there
had not been  any peculiarity  in  the  intellectual
faculties ;—the death was owing to another acci-
dental cause.  The brain  appears  sometimes as
if generally enlarged, when its vessels are over-
distended with blood, in inflammatory fever, &c.
This state  must not  be mistaken for the hyper-
trophy just  described.  [See  Condie,  Practical
Treatment  on the Discuses of Children, p, 336 ■
Philad. 1844.]
   We shall briefly notice another class of morbid
alterations of the brain, as being connected with
its  acute affections ;  we mean those observed in
lunatics.   After  acute mania, the  cortical  sub-
stance on the whole surface of both hemispheres
has  been found deeply injected, and of an intense
red, similar to that of erysipelas.  In other cases
of longer standing the membranes had contracted
close adhesions  to the  brain; the cortical sub-
stance was  red and so  much  softened,  that  the
membranes could not  be removed without tearing
it away with them ;  it had also a granulated ap-
pearance.  In very old cases the convulsions have
been found  remarkably diminished  in size; and
this has  seemed to arise from the atrophy of the
cortical  substance, which was  reduced to a verv
thin layer, and of a pale dirty colour; there has
been generally in such cases a serous effusion, as
if to fill up the vacuum.   The medullary sub- 
324     BRAIN, (INFLAMMATION

stance has also been found to have undergone
remarkable changes : it was in  some cases highly
Injected, and  of a marbled  red  colour;  in  others
it had experienced a surprising increase of density,
being as tough  and difficult to cut through as
caoutchouc, and of a smooth shining white colour;
and, lastly, it has been found softer than in health,
and  flaccid.  A great quantity of serous fluid  is
sometimes  found in the brain of  old lunatics.
We  only notice  these  morbid  appearances very
briefly,  in  order  to give a general view of every
variety  of  change of structure produced in the
brain by  inflammation : they  will  be  described
more in detail in the article Insanity.
   The  different  morbid appearances of which  a
description has been given may be summed up as
follows :—
   1.  Increased vascularity; redness either dotted
or uniform, no change of consistence or structure,
no exudation of fluid or rupture of vessels.— Con-
 gestion.
   2.  Great increase of vascularity, intense dotted
redness, spots of ecchymosis, with a striated  ap-
pearance and effusion of drops  of blood, increased
firmness.—First stage of inflammation.
   3.  Infiltration  of blood,  and  softening of the
cerebral pulp towards the centre of the inflamed
portion. — Red softening.  Infiltration  of pus
mixed  up  with the disorganized pulp. — Yellow
softening.   The red and  yellow softening com-
bined.
   4. Serous infiltration  of the  cerebral  pulp;
softening of a  milk-white  colour,  without vas-
cularity.— White softening.
   5. Increased formation of pus of various colours,
 the walls of the cavity lined with a  membrane—
 Undefined abscess ,- encysted ditto.
   6. Loss of substance on the  surface of the brain
 oi that of the ventricles.— Ulceration.
   7. Infiltration of the pulp  or its vessels  with
 permanently  concrete  fluids ;  conversion into a
 more or less dense mass.—Induration.
   Diagnosis. — The  diagnosis between arach-
 nitis, apoplexy, and  cerebritis, having been al-
 ready fully considered  in  the  general  history  of
 the  disease,  a brief recapitulation is all that will
 now be required.  We have  seen  that the lead-
 ing  features of  arachnitis were the  absence  of
 premonitory symptoms; spasmodic and convul-
 sive  symptoms on  both sides of the body ; febrile
 excitement,  without decided  paralysis, followed
 by collapse.
   Those of apoplexy, sudden and complete para-
 lysis, without  spasmodic symptoms at the begin-
 ning ;  sudden invasion and rapid progress.
   Those of  cerebritis, symptoms of irritation fol-
 lowed by spasmodic paralysis,  only partial at first;
 the paralysis becoming complete as  the  disease
 advances; irregular exacerbations and remissions;
 well-marked premonitory symptoms.
   In laying down these  general rules, it is fully
 admitted that, in the present state  of  our know-
 ledge,  cases may occur, in which  the diagnosis
 will be involved in doubt and  obscurity.
   The distinction between cerebritis  and acute
 hydrocephalus  may sometimes be  obscure,  espe-
 ciallv in adults.  We have seen  that hydroce-
 phalus is  often  attended  with inflammation and
 softening  of the central  parts  of  the 'brain.   It
OF  THE) —[CEREBRITIS.]

may, however, be stated, in general, that in acute
hydrocephalus there is seldom slow, partial, spas-
modic paralysis of the extremities ;  the sight and
the speech are much more frequently affected.  It
is also characterized by high  fever, general  con-
vulsions,  irritability of the stomach, ending in a
state of collapse and coma; symptoms much more
resembling  those of arachnitis than  of partial
cerebritis.   When hemiplegia or other forms  of
paralysis  have occurred during its progress, in-
flammation and softening  of the brain have gene-
rally been  found, in  addition  to  the ordinary
morbid appearances of hydrocephalus.
   It is of importance to  attend  to  the circum-
stance that,  in  children, diseases  of  the brain
often  come  on  very insidiously, and may have
existed for some time previous to the appearance
of any very  decided symptom.  The  case of a
child  affected with  fever, restlessness, headach,
slight convulsions,  irritability  of  stomach and
vomiting, a foul  tongue and disordered bowels, is
looked upon as one  of gastric remittent fever, or
as the effect of dentition,  whilst there is  inflam-
mation going on in the brain or in its membranes,
which, however, is  not  suspected until delirium,
strabismus, or convulsions, point out an advanced
 stage of cerebral  disease.   The condition of the
brain, in  the febrile and  inflammatory affections
 of children, should always therefore be attentively
 watched.
   Some  of the  premonitory  symptoms of cere-
britis, such as pains in  a limb,  numbness, weak-
 ness, or stiffness, have been mistaken for rheumat-
 ism, and treated by local applications,  while these
 symptoms were  produced by disease of the brain.
 The absence of  all local swelling, redness, or ten-
 derness on pressure, will assist in sufficiently dis-
 tinguishing the muscular pains  in cerebritis.  In
 the same manner vertigo, cephalalgia, irritability
 of temper,  disturbed sleep, loss of appetite, and
 impaired digestion,  indicating  the  approach  of
 cerebritis, have sometimes been treated as nervous
 or  bilious  headach,  connected with  dyspepsia;
 and the true  character of the complaint has been
 overlooked, until the brain  has sustained  some
 material  injury.   The  importance  of diligently
 watching all those  premonitory symptoms which
 indicate  a  threatened attack  of cerebral disease,
 cannot be too strongly enforced.
    Epilepsy, chorea, nervous and hysterical con-
 vulsions, and several other  nervous  affections,
 bear  some resemblance  in many of their symp-
 toms to those of cerebritis.  We must refer, how-
 ever, to the history of these diseases,  for a more
 particular account  of their diagnosis.  We shall
 only observe in general,  that the greatest  atten-
 tion is often required to discriminate cephalalgia,
 vertigo, confusion of sight, and other symptoms
 of  affection of the brain,  connected with vascular
 excitement, from purely nervous irritation.   It
 must be remembered, in forming  our diagnosis,
 that both causes sometimes re-act on each other.
    The absence  of all tendency to permanent para-
 lytic affections in the purely nervous cases,  will
 be  a good general rule of distinction.   Much  use-
 ful information  is moreover to be obtained  by at-
 tending carefully to the predominant character of
 the temperament, and of  the  prevailing diathesis,
 whether sanguineous or nervous. Tbe great irreg- 
BRAIN,  (INFLAMMATION  OF  TH E ) —[C E RE B RITI S.]     325
ularity and mutability of pure nervous symptoms
form a striking contrast with the  comparatively
uniform and durable nature  of  those which ori-
ginate in disorder of the vascular  system.  We
must not, however, be led to imagine that pallid,
thin, and apparently nervous people, are exempt
from inflammatory affections of the brain, or that
others of a full habit and florid complexion are
not subject to purely neuralgic complaints.
   There are some conditions of the system  in
 which a distinction between the  genuine and spu-
 rious symptoms of inflammation and compression
 of the brain  is  of great importance.   A  patient
 in a state of exhaustion after long  illness, intense
 pain, copious bleeding, and  other  evacuations, is
 suddenly seized with violent headach, restlessness,
 hurried pulse, convulsions, coma, and apparently
 all the symptoms of acute cerebral inflammation.
 This is a common affection  in  children, and has
 often been mistaken for acute hydrocephalus.  In
 other cases, after great  anxiety  and depression of
 spirits, a person  is affected with delirium, incohe-
 rence, maniacal  excitement, a hurried  manner,
 great volubility,  and hallucinations ;  the pulse is
 hurried, rising  suddenly  to  perhaps  160:  these
 symptoms pass rapidly into  fatal collapse and  co-
 ma.  No morbid alteration is found in  the  brain
 in these cases,  except, perhaps,  slight vascular
 injection.  This affection has been mistaken  for
 arachnitis, mania, hysteria, and its true nature
 overlooked,  until  the  patient  has rapidly  sunk.
 The use of evacuations in such cases  is sure to
 hasten death; whilst  under the timely adminis-
 tration  of cordials, stimulants,  and opiates,  the
 symptoms are often  speedily relieved.   Towards
 the close of low fevers, when  a decided amend-
 ment has taken place, a series of symptoms some-
 times occur, simulating a dangerous affection of
 the brain.   The patient  becomes restless, com-
 plains  of headach, and  does not sleep, and at
 length lapses into muttering  delirium.   These
 symptoms are,  however, purely nervous  and  re-
 lieved by mild opiates  and a moderate allowance
 of wine.
    Cerebritis  may exist  in  combination with a
 variety of other diseases, such as  hypertrophy of
 the heart, chronic inflammation  of the lungs,  the
 liver, stomach, and bowels ; with continued fever,
 measles, scarlatina, erysipelas,  mania,  &c.  The
 diagnosis in such cases is not in general attended
 with much difficulty, although  one disease some-
 times lessens the violence of the other.  We have
 already directed attention to the important fact of
 severe cerebral  inflammation completely conceal-
 ing for a time the existence  of other diseases with
 which it may be combined.
   There are partial paralytic  affections  of  the
 face, neck, and extremities, depending  on inflam-
 mation  and compression in the  course of  the
 nerves, or on diseases of the vessels, which may
 be referred  by mistake to disease of  the brain.
 We are indebted to Sir Charles Bell for a most
 interesting  and  satisfactory  description of some
 of these affections. The absence  of any cerebral
 symptoms capable of accounting for the paralysis
 will direct the attention of the  practitioner  to its
 real causes.   The same may be said of the diag-
 nosis  between  cerebritis  and  paraplegia arising
                                        2c
from spinal disease, and tbe paralysis  also occa-
sioned by mineral or other poisons.
  Before concluding the subject of diagnosis, w«
shall briefly allude to the interesting inquiries of
some French pathologists, who have endeavoured
to point out the parts of the brain affected in cere-
britis, by the various modifications of the paralytic
symptoms.  We have seen  that  paralysis  may
affect one extremity, or both;  one  entire side of
the body,  or  the eyes, face,  and  tongue, either
singly,or in a  variety of combinations; that there
are the same diversities in the state of the sensi-
bility and intellectual  faculties.  How are the^e
modifications  to  be accounted for ?   Several of
the older writers  had conjectured that,  if the ner-
vous filaments could be traced up to their remote
origin in the brain, it would be found that  each
part of the body  receives regularly  its nerves from
a determined  part of the brain, so that any lesion
of that part must necessarily affect the  functions
of the organ to which it sends nerves.  The fol-
lowing are  the results of numerous pathological
observations made  on  this subject, by MM. Fo-
ville, Serres, Pinel  Grandchamp,  and   Bouillaud.
They are, of  course, to be  received with a  good
deal of reserve ;  but we still think them deserving
of  notice, if it were only to direct others in the
path of  inquiry.
   1. The paralysis of the  organs of speech de-
 pends on diseases of one or both anterior lobes of
 the brain.  There  are seventeen cases reported in
 the works of Lallemand, Rostan, and  Bouillaud,
 with paralysis of the tongue, in  which the  ante-
 rior lobes  of  the brain were  found affected with
 various  degrees  of inflammation  and softening ;
 on the other hand, an examination of about fifty
 cases, in the same  authors,  without loss of speech
 Or  paralysis of the  tongue, does not afford a single
 instance of inflammation or softening  in the an-
 terior lobes.   It  should be  noted  that  there may
 be loss of speech without paralysis of  the tongue,
 from mere loss  of memory ;  and  M.  Bouillaud!s
 observations lead him to think that the anterior
 lobes of the  brain preside  over the  memory of
 words, as well as over the organs of speech.  The
 above statement, if the facts on which it is found-
 ed can be relied  on, is certainly very  remarkable,
 and deserving of further  investigation.
   We remember  an  interesting  case under the
 care of  Dr. Cuming,  of Armagh,  in which  there
 was disease in the  anterior part of the brain from
 a blow received  on the forehead just above the
 nose : it was found necessary to remove a portion
 of bone with the trephine; and after a variety of
 remarkable and  untoward  symptoms,  the gentle-
 man perfectly recovered :  one  of the prominent
 symptoms was a loss of the memory of language.
   2. The paralysis of the inferior extremities de-
 pends on disease of the middle lobes of the brain,
 and  of  the corpora striata.  This conclusion  is
 not supported by  the same  number  of facts as
 the former.
   3. The paralysis of the  upper extremities de-
 pends on disease of the posterior lobes of the
 brain, and of the optic thalami.  This is likewise
 stated as yet  resting only on a small  number of
 facts. The paralysis  of  one arm  only has  been
 observed in  a   good  many cases, in   connection 
326     BRAIN, (INFLAMMATION

with inflammation at the junction of the poste-
rior and  middle lobes.  When several parts  are
paralyzed at the same  time, the  morbid  altera-
tions of the brain are supposed  to bo more exten-
sive, or seated near the  medulla oblongata.  Pa-
ralysis of the arm  and leg on  the same  side, or
hemiplegia, is  supposed to follow the  combined
affection  of the corpus striatum and thalamus, or
else disease of the crus  cerebri, from which these
two bodies derive their origin.
  The last speculation on  this subject which we
shall refer to, is one relating  to  the  respective
uses of the cortical and medullary substances  of
the brain.   We have seen that the  cortical sub-
stance has been found, in a great  many lunatics,
highly injected, and  often  inflamed, whilst  the
medullary  substance remained  healthy.   M. Fo-
ville and Pinel Grandchamp  have  conjectured
from this and some other circumstances, that  the
cortical substance was the  seat  of intelligence,
whilst the  medullary was intended to preside over
motion.  The principal other grounds of this hy-
pothesis are, the apparent decrease of the cortical
substance,  which has been found reduced  to a
very thin layer, in cases of imbecility ;  the small
size of the convolutions  and small  quantity of
cortical substance observed in the brains of idiots,
compared with those of intelligent beings.
  In the article Encephale, of  the volume of the
Dictionnaire de Medecine et de Chirurgie Pra-
ti([ue,  just  published, M. Foville, whose  recent
discoveries on some  points of the  minute, anato-
my of the  brain have deservedly attracted  much
attention, enters at  considerable length into  the
examination of the preceding considerations.  He
has adduced a number of striking  facts and argu-
ments  in their support, and lays down the follow-
 ng general propositions :
   1. The  joint lesion  of  the  corpus  striatum
and thalamus of one side gives rise  to  the same
paralytic  symptoms as  the lesion of  the whole
fibrous substance of the corresponding hemisphere,
of which they are  in some manner the centres or
 luclci.
  2. The lesion of  the crus cerebri is followed
by the same paralytic symptoms  as that  of the
corpus striatum and thalamus, which  are them-
selves  in a great measure  formed  by the expan-
sion of the fibres of the crus.
  3. A  lesion  of the  medulla  oblongata  pro-
duces all the symptoms which arise from the joint
affection of the crura cerebri and cerebelli; and if
we ascend still higher in the brain, from that also
of the  corpora striata, thalami, and hemispheres.
  4. If we direct our attention  to the portion of
the nervous system below this great centre of the
nervous  action  of the  brain, we  shall find  the
cerebral influence continue unimpaired in all parts
superior  to  any lesion  of  the  spinal marrow,
whilst it is completely intercepted in  parts infe-
rior to that lesion.
  Prognosis.— Cerebritis is  a  disease always
attended with considerable danger.  When once
fully  developed, it  has  hitherto  been generally
considered as incurable;  but since we have been
enabled,  bv a better  knowledge of  its true nature,
to app'y with promptitude more appropriate reme-
dies, the treatment is often successful, even under
t!io most unpromising  circumstances.  The  ex-
 OF THE) —[CEREBRITIS.]

tremely delicate structure, however, of the  bruin
its situation  in  a bony unyielding  case,  without
room for expansion, or any opening for  the exit
of effused fluids, and the great importance of the
integrity of  its  functions to  the  preservation  of
life, are circumstances which must always connect
a considerable degree  of  danger with its inflam-
matory affections.
   It may be  said in general, that so long as the
inflammation is  only in  the first stage,  and  the
texture of the brain not broken down by the infil-
tration of blood, pus, or serum, resolution is still
possible.  The following  circumstances may lead
us to  hope for this favourable termination: the
paralysis  being only  partial;  the  muscles firm,
not flaccid, and  retaining  some degree of  motion;
the sensibility being little impaired ;  after an at-
tack of coma, a gradual return to consciousness,
without affection of the  intellect;  sound sleep;
the tongue cleaning, and  motion progressively re-
turning in the  paralyzed parts.   It must not be
forgotten, however, that there are frequently exacer-
bations and remissions  in the symptoms ; intervals
of apparent recovery and a great tendency to re-
lapse.   It has been already stated that a delusive
amendment often attends the  passage of the in-
flammation from the first  stage into that of soften-
ing or suppuration.  Such an  amendment, there-
fore, at a bite period, is more to be suspected than
in any earlier stage of  the disease.   The continu-
ance  of headach, uneasy sleep, shiverings, and
languor  are   unfavourable  symptoms, whatever
may have been  the amelioration in other respects.
Headach and delirium  are less  unfavourable than
stupor and coma.   When profound coma is suc-
ceeded  by headach and delirium,  this is  rather a
favourable occurrence,  as  it indicates  a return of
the  previously  paralysed action  of  the brain j
when, on the contrary, they are followed by coma,
it  is  a bad  omen.  The danger  is of course in
proportion  to the  extent of the  paralysis, and
greater in  complete hemiplegia than when the
paralysis  is  confined  to  one  limb.   When the
paralysis extends to the  side of the body which
was  at first  free, the  danger is imminent, since
both  hemispheres are  then affected ; and  when
both sides are simultaneously paralysed, a speedily
fatal termination may be predicted.  Embarrassed
breathing is always a bad symptom.
   When the inflammation has reached the second
stage, and  the diseased portion of brain  has be-
come softened and infiltrated with pus, the danger
is  great and the recovery very doubtful. Paralysis
of the bladder and retention of urine are generally
fatal symptoms.
   The chronic form of cerebritis, accompanied by
very slow and creeping palsy, is  always an un-
promising  disease.   The  circumstance of the
symptoms at first being slight, and confined to an
apparently trifling numbness or weakness in a few
muscles, must not throw  the  practitioner off his
guard.  This form  of disease  is almost always
attended with a  considerable degree of failure  of
the  powers  of  the  constitution;  and sooner  or
later, in the  majority  of  cases, comes to an unfa-
vourable termination.   The more  acute.cases af-
ford  a  better prospect of recovery, there  being
sufficient  strength to  admit of the  use of active
remedies. 
BRAIN,  (INFLAMMATION  OF THE ) —[C E RE B RITI S.]
321
  The coma and paralysis following  a sudden
attack of sanguineous apoplexy are attended with
less danger than the coma and complete paralysis
of the latter stage of cerebritis ;  for there are nu-
merous  instances of the resorption of  a clot  of
blood, whilst those  of the  resorption of pus and
healing  of an abscess are extremely rare.   The
inflammation of  the brain consecutive  to san-
guineous  apoplexy is  always  dangerous, and
greatly  lessens the  chances of recovery.   Cere-
britis following  concussion is  generally severe,
and attended with greater danger than that con-
sequent upon an injury of the head with opening
in the skull.
   The  duration of cerebritis  varies according to
its form.  Acute cerebritis generally runs a rapid
course ; it may prove  fatal the first, second, or
third day, and seldom lasts more than from  ten to
twelve  days.  Chronic cerebritis is very variable
in its duration, being often attended  with inter-
missions and relapses; the disease may thus be
prolonged  for  several  months,  and  some cases
 have been described as lasting even several years;
 but it is more than  probable that when symptoms
 resembling  those of cerebritis   continue beyond
 five or six months,  they do not arise from genuine
 cerebral inflammation, but are  to  be attributed
 either to an organic tumour, or to some neuralgic
 affection simulating  chronic cerebritis.  In a col-
 lection  of thirty-four cases, nine died in the  course
 of the  first week,  six  in the second,  six  in the
 third, two in the fourth, and eight in the  course
 of from two to six  months.
    With respect  to age,  it appears that old age
 and childhood are the two periods of life the most
 exposed to cerebral inflammation.  The examina-
 tion of a large number of cases shows that more
 than two-thirds were persons above forty-five, and
 a majority of these  between forty-five and seventy.
 It is a disease,  however,  which  may affect all
 ages.   The frequency of falls and  blows on  the
 head in children,  the  irritation of dentition,  the
 pressure of the head during parturition, predispose
 them to  cerebritis, although  there is  perhaps a
 greater tendency at that  period of life to mem-
 branous inflammation.   Traces of cerebritis have
 been found in still-born children.  Men  are more
 subject to cerebritis than women, in the proportion
 of about two-thirds, owing probably to  their being
 more exposed to the influence of exciting causes.
 The disease, also,  is more common in hot than
 cold climates, and in summer than winter.
    Causes. — The  causes are   predisposing and
 exciting.  The only difference, however, between
 these often  consists in their degree  of activity;
 since a predisposing cause may become exciting
 if its  activity be  sufficiently  increased.  Every
 circumstance capable of causing congestion, or of
 disturbing  the balance  between the arterial and
 venous circulation  in the brain, becomes a  predis-
 posing  cause.  These circumstances are a plethoric
 habit, particularly  in individuals who  have short
 necks and are subject to habitual constipation, the
 diathesis justly termed apoplectic. Persons, how-
 ever, of a thin habit and slender make, with long
 neck and  pallid  countenance,  and  especially if
 such individuals  are intelligent, are  also under
 certain circumstances  predisposed to cerebral  af-
 fections, particularly when labouring under disease
of the heart.  An hereditary tendency to fulness
in the head and  diseases of the  brain may  be
reckoned among the  predisposing causes.  Hyper-
trophy of the heart, particularly of the left ven-
tricle, is  a very common predisposing and  some
times exciting cause.   The  celebrated  Malpighi
died  of an inflammatory affection  of  the  brain,
attributed to hypertrophy of the  heart, from which
he had  long suffered.   Disease of the  heart acts
either by impeding the regular return of the blood
from the head, or causing the blood to be propelled
with  excessive impetus towards  the  brain ; the
latter takes place more  particularly when the hy-
pertrophy is produced by obstruction in the aorta
beyond the origin  of the carotid arteries.  Inflam-
mation of the lungs, phthisis, and asthma  act in
the same manner in producing  cerebritis, though
these diseases are less powerful  exciting causes
than  those of the heart.   There is a great  predis-
position in phthisis to sudden  attacks of inflam-
mation of the brain or its membranes ; the patient
is all at  once seized  with  intense headach and
violent delirium, ending sometimes in confirmed
mania, and it is very remarkable that the pulmonic
symptoms, howsoever  severe, have  often in such
cases suddenly disappeared, and  have not returned
until the attack in the head had subsided, the two
affections thus alternating the one with the other.
It cannot be said in  every case that the cough and
other pectoral symptoms are merely obscured, for
we have seen cases of perfect  recovery from an
advanced  stage of phthisis,  by the supervention
of an attack of mania.  These are striking  exam-
ples  of the  actual translation of disease.  Dr.
Abercrombie  very justly observes  that  there may
be in scrofulous constitutions a tendency to scro-
fulous inflammation of the  brain, and that  tht
disease of the lungs is not properly to be always
considered as the cause of  the  head  affection ;
that in the same manner disease in the brain may
appear in connexion  with  the  disease  of any
other organ, and that diseased liver has often been
thus  improperly stated to be the cause of hydro-
cephalus.
   The mutual influence of the functions  of the
brain and  digestive organs  on each  other is so
 obvious as not to require any explanation; and
 thus the headach, drowsiness, and other signs of
 cerebral congestion, which follow over-distension
 of the stomach, or the abuse of spirituous liquors,
 are easily accounted for.  Habitual drunkenness
 is  perhaps one of  the most powerful  causes of
 cerebritis  or  arachnitis.  The  striking similarity
 between  the symptoms of  the last stage of in-
 toxication and  those of  apoplectic  coma  has
 been  frequently noticed.  The subacute  inflam-
 mation of the mucous membrane of the stomach
 and  bowels,  the  gastro-enterite of Broussais, is
 often accompanied by great  cerebral irritation.
 This complaint, in young children from two tu
 four years old, frequently terminates in coma.  A
 vitiated state of the secretions  of the  alimentary
 canal is a very active and frequent cause af cere-
 bral  irritation; it  accompanies that fretfulness and
 irritability of temper  which so  commonly pre-
 cede attacks of inflammation  in  the  brain .  the
 convulsions produced by intestinal worms are also
 the effect of sympathetic irritation.
    There is a disease of the urinary organs, known 
32S      BRAIN,  (INFLAMMATION

as ischuria renalis, of rather uncommon  occur-
rence, which  predisposes sometimes to dangerous
affections of the brain.   Sir  Henry Halford has
published an interesting paper on this subject.
(Transactions of the  College of Physicians, vol.
vi. p. 398.)   In many of the cases, after the pa-
tient nas suffered  for two or three days from dull
pain and sense  of weight  in the ilac regions,
these symptoms are succeeded by  great anxiety,
nausea, vomiting,  hiccup, cramps, slow pulse, de-
lirium; and  he  gradually  falls into  a  state of
lethargy and  coma.   The ventricles of the brain
are found on  dissection distended with  serum.
   The  suppression  of urine is  sometimes not
complete ; if there be perspiration,  it may  have a
urinous smell.  Suppression of urine is sometimes
not  attended with any  marked  inconvenience.
Dr. Parr, in  his dictionary, mentions the case of
a  person who  had suppression of urine for six
weeks  and yet recovered.  Dr. Abercrombie gives
a  case in which  the  suppression was  occasioned
by obstruction  of both  ureters; the patient died
on the thirteenth day, of a cerebral  affection.
   Ischuria renalis has  in  some instances been
supposed to  originate in a  disease of the brain,
causing paralysis  of  the kidneys.  The persons
most subject to this  affection are  fat corpulent
men, between fifty and sixty years of age, of a
gouty habit,  and naturally predisposed to cerebral
congestion, though it is sometimes also met with
in children.
   We have already said that inflammation of the
brain may occur  in  the course of a  variety of
febrile diseases, such as continued fever, scarlatina,
measles, &c.   It has often been observed as one
of the sequelae of scarlatina; and  when accom-
panied with  anasarca, its inflammatory character
has  been entirely  overlooked, and attributed to
mere serous  effusion in the brain.  There is a
great tendency to  cerebral congestion in the con-
tinued fevers  of this country ; thus of  eight hun-
dred and sixty-four cases treated in a large fever
hospital, six  hundred  and  two  presented head
symptoms.    Suppuration of  the brain  may some-
times occur  in the course of fever, but  it is not
very common;  of fifty cases of fever  with well-
marked cerebral  symptoms, pus and blood oc-
curred in only three.  Subacute inflammation of
the membranes is  of much more frequent  occur-
rence.   The  injury, however,  sustained by this
organ during an attack of fever with violent head
symptoms, often gives a predisposition to future
cerebral inflammation.
   Among the predisposing causes are to be ranged
suppressed evacuations.  That of  the  catamenia,
especially in  young women,  is often followed by
dangerous affections of the brain.   A similar re-
sult  may attend the suppression of artificial dis-
charges and  of cutaneous eruptions, the healing
of chronic  ulcers, erysipelas, gouty or rheumatic
affections of the joints, &c.  Over-exertion  of
mind, depressing passions, such as grief, fear, &c.
great bodily fatigue, long-continued  nervous head-
achs, and all neuralgic affections  of the  brain,
epilepsy, and mania,  operate as predisposing and
sometimes exciting causes.  The brain cannot long
puffer from nervous irritation without  a re-action
faking place  in its vascular system.
   External injuries are among the most direct ex-
 OF  THE) —[CEREBRITIS.]

citing causes; and this is much more frequently
the case than is imagined, particularly in children.
A considerable interval, sometimes two or three
weeks, may intervene between the  injury  and the
appearance  of alarming symptoms;  and  a  very
trifling fall or blow, wbich  is  often the cause of
serious  disease,  may have been altogether over
looked or forgotten.
   Exposure to  the  intense heat of the sun is a
powerful exciting cause.  It may bring on either
arachnitis, cerebritis, apoplexy, or mania.  The
same results may follow a sudden transition from
heat to cold.  Long exposure to intense cold acts
also in a remarkable manner on the brain, bring-
ing on inflammation, and sometimes the most vio-
lent maniacal delirium : there were many remark-
able examples of this during  Napoleon's cam-
paign in Russia.
   Inflammation  and suppuration of the internal
ear has  a great  tendency to extend to the brain,
and it is in  this manner it often proves fatal.  Te-
dious and painful dentition is a great source of
cerebral  irritation;  intense  and long-continued
pain from any cause often brings on delirium and
coma.   The ligature of large branches of  nerves
in  the neighbourhood  of the  head has had this
effect; of which  the following case,  related by
Lallemand, is a  remarkable instance.  The sub-
clavian artery was tied above  the  clavicle for an
aneurism in the axilla on the right side;  several
branches of the brachial plexus, supplied  by the
third cervical, were included in the ligature;  in-
tense pain was immediately felt in  the neck; this
went on increasing, notwithstanding  the most
active treatment; coma, conyulsions, and a strong
retraction of the  head appeared the seventh day;
the patient died on  the eighth.   The posterior
portion of the left hemisphere of  the brain  pre-
sented a large undefined abscess, containing soft-
ened  diffluent brain, and in the centre greenish
pus ; the sides of the abscess were deeply injected;
the arachnoid was healthy.   Such a case is inter-
esting both  to the pathologist and physiologist.
   The internal  use of certain narcotic and irri-
tating poisons may become a cause  of cerebral in-
flammation.   This is the special property of nux
vomica;  and we  have seen its unguarded  admin-
istration in hemiplegia  bring on a fresh attack of
inflammation  of  the  brain.  The  inhalation  of
putrid effluvia and contagious  miasmata, particu-
larly in very hot climates, and  when the system is
in a state of depression, has been quickly followed
by cerebral  inflammation.  We had experience of
this ourselves some years ago, while attending a
fever hospital.   After inhaling a horrid foetor
which  emanated from  a  patient in an advanced
stage of typhus gravior, we were instantly seized
with sickness and headach, as if struck by  a blow,
and, in  less than forty-eight hours after,  a dan-
gerous attack  of typhus fever supervened, attended
by strong cerebral symptoms.   The action of these
numerous causes is very variable; sometimes sud-
den and rapid, at others slow and imperceptible.
   Treatment.—The inflammatory nature of the
more acute forms of cerebritis and arachnitis is so
obvious, that their treatment has always been con-
ducted on correct principles.   Until very lately,
however,  the inflammatory  character  of partial
and chronic cerebritis  was either  entirely over- 
BRAIN,  (INFLAMMATION  OF  THE) —[CEREBRITIS.]     329
looked, or so imperfectly understood, that though
active treatment  was  sometimes  adopted  at  the
beginning of the disease, it was  soon laid aside,
and remedies  of  an opposite description  substi-
tuted.  These affections were in fact generally set
down as nervous; mistaken for rheumatism, neu-
ralgia, nervous dyspepsia, and debility, or nervous
palsy, and treated by tonics, electricity, and  stimu-
lants ; the fatal termination of the disease being
thus accelerated.
   Cerebritis and arachnitis are so formidable, that
their  prevention  is of no  less, if not of greater
importance, than their treatment.   It is extremely
important to have recourse to active measures on
the very first appearance of any of the premoni-
tory symptoms, however trifling : as we may thus
succeed in effectually removing that state of con-
gestion  and irritation of the brain, which is the
precursor  of inflammation.  The means of accom-
plishing this are,  the careful and  timely removal
of all the  exciting causes ;  of every source  of irri-
tation, both bodily and mental; regulation of the
diet;  avoiding  all  excesses;  relaxation from
study, change of air, general and local bloodletting,
counter-irritation, with  occasional   purgatives.
Great vigilance is particularly required in the ce-
rebral affections of infants and children, who  fre-
quently suffer without complaining.   A predispo-
sition to affection of the brain may often be sus-
pected by  some slight cast or rolling of the eyes ;
by dilatation  of the  pupils; or occasional start-
ing*, and  attacks of spasmodic croupy breathing
during sleep:  there  may be every other appear-
ance of perfect health with these symptoms, which
are often  only evanescent; but they  will not es-
cape  the  attention  of the  experienced observer,
and will be sufficient to put him on his guard.
   When it is necessary to  relieve  the brain from
habitual congestion by occasional topical bleeding,
the method of taking blood from parts as remote
from the disease as possible, seems to  us prefera-
ble to that  of abstracting  blood  from the head
itself.  When the vessels of a part are  partially
emptied of their  blood,  if  they have  been much
weakened by long-continued  over-distension  or
previous disease, so as to have lost their elasticity,
there will  be an immediate flow of fresh blood to
the part;  this will take place on mere hydrostatic
principles.  We have  tbus seen in an  eye long
exposed to injection  and low inflammation,  the
redness and suffusion much  greater the day after
an application of  leeches than it was before ; and
we bave  likewise known  headach considerably
increased  in  plethoric  and bloated people, after
leeches had been  applied to the temples.   On  the
other hand, no fact is better established than that
the loss of an exceedingly small quantity of blood
from certain parts of the body is sufficient to re-
lieve  distressing  symptoms  of congestion  and
oppression in others most remote from them; as,
for instance, a very slight discharge of blood (one
or two ounces) from the hemorrhoidal veins being
sufficient  instantly  to remove vertigo, flushing,
headach, or oppressed breathing :  the same is the
rase in a still more striking manner with  the cata-
menia, although some account must be taken of
the influence of uterine irritation over the system.
We prefer, therefore, in cases of habitual conges-
tion in the brain, taking blood occasionally from
  Vol. I. —42                       2 c *
the feet  or  legs, by opening a vein, or applying
leeches and  letting them bleed in a foot-bath ; or
the application of leeches to the anus, whenever
practicable.   We have  found this the surest me-
thod of affording permanent relief; and by repeat-
ing it at certain intervals, the tendency to cerebral
congestion may  be completely overcome.   We
have pursued  this plan in lunatics with the very
best results.   It  was a practice of  the ancients,
which has,  in our  opinion, been too much laid
aside.  When, however, there is active inflamma-
tion in a part, as it is most material  to unload the
vessels freely and quickly, the blood  had better, in
such a case, be drawn from the immediate neifh-
bourhood of the organ affected.
   The insertion  of an issue is often advisable, as
a preventive, in people of a plethoric habit.  The
head should be kept cool by the frequent use of
cold ablutions;  the hair cut short;  the head and
shoulders raised  at night;  tight bandages round
the neck must be avoided ; the daily use of the
cold shower-bath is often very beneficial;  but a
re-action takes place in the head unless it be used
with the feet immersed in  hot water.  The feet,
legs, and lower  parts of the body  ought  to be
carefully kept warm and dry.
   In the treatment  of cerebritis, when fully deve-
loped, attention must be paid to its two periods of
excitement and collapse.  The remedies chiefly to
be relied  upon are, bloodletting general and topical,
purgatives,  cold applications to the head, and
counter-irritation.
   In  the more  acute cases the patient must be
freely bled from a large orifice to the amount of
from twenty to forty ounces: one copious bleed-
ing has more effect in bringing about the speedy
resolution of the inflammation than several small
bleedings.   If the symptoms  continue unabated,
the bleeding must, however, be repeated several
times, at intervals of a few hours ; and this prac-
tice must be carried, during the first  period of the
disease,  to  the  utmost limit  of  the  patient's
strength.  It often  happens that very little im-
pression  is made on the disease by the first bleed-
ing, and  no amendment takes place until after the
second.  The symptoms often abate after bleed-
ing ; but  a  fresh exacerbation may  take place in
the course of a  few hours.  Topical bleeding, by
cupping  or leeches, is, under such circumstances,
highly beneficial.
   The head must be  shaved, and  pounded ice
mixed with  cold water  and vinegar may be ap-
plied  to  the scalp.  A very effectual method of
applying  cold is by making the patient hold his
head over a basin, and pouring a  stream of cold
water  on it from  a certain  height: this  often
removes  the heat and flushing, and calms the ex-
citement : it should be repeated as often  as the
heat and  flushing return.  The application of cold
to the body is always followed by a re-action, and
the temporary relief refrigerants  afford  will be
succeeded by  an increase  of the  inflammatory
symptoms, and their use become  decidedly inju-
rious unless their depressing action be kept up by
a steady  and repeated  application.   Some practi
tioners have, on this account, given the preference
to the use of a  mixture of alcohol  or ether with
liquor  ammonia? acetatis and water, applied nc'
quite cold, in order  to produce r»p:l evaporation 
330
BRAIN,  (INFLAMMATION OF T H E )- [C E R E B RIT I S .|
An excellent practice  is  that  of  keeping  the
patient's feet and legs immersed in hot water dur-
ing the application of cold to the head.
  The  remedies  next  to bleeding and cold, and
often  not less efficacious, are  active purgatives,
which must be administered at short intervals until
copious evacuations be procured.   Free purging
sometimes makes a greater impression on the dis-
ease  than even  bleeding,   in  some  cases no
marked  amendment has taken  place  until  the
bowels  have  been freely moved : they are some-
times exceedingly torpid, for reasons which have
been already assigned, and large doses of cathartics
may be required.   Combinations of calomel, jalap,
scammony, and cathartic extract, followed by an
infusion of senna with salts, are the  purgatives on
which  the most  reliance can be placed.   Croton
oil is also in these cases a valuable  remedy, from
the facility  of its administration and certainty of
its effects.   Mercury  may be  given freely as a
purgative, but no particular advantage has  appear-
ed  to follow its use with a view to affect the con-
stitution ;  it  is,  indeed,  found very difficult in
acute diseases to  produce ptyalism.
   We  have  sometimes  found  tartar  emetic of
great  service when there was  no  irritability of
stomach to prevent its being tolerated ;  the power
of  tartar  emetic  in controlling the  action of the
heart, and subduing the inflammatory diathesis, is
now fully established :  a solution in  the proportion
of one grain to the ounce, and two table-spoonsful
given every two,  three, or four hours, suspending
it should vomiting occur, has often been attended
with  great benefit.  The remedy  is in  general
well tolerated, owing to the torpor of the stomach:
violent vomiting  should, however, be prevented, as
it would obviously be  extremely injurious.
   In the second  stage of acute cerebritis,  that of
collapse and coma, general  bloodletting is to be
used more sparingly; decided advantage, however.
has resulted  from a moderate bleeding  even  at a
late  period.  In  this   stage, topical bleeding  is
more generally indicated.   There are  periods of
exacerbation  in  the symptoms which  should be
watched  and overcome by  these means ;  which
may be persevered in as long as there is any hard-
ness and resistance in the pulse.  We have seen
  patient instantly recover from a state of profound
coma by the  abstraction  of  a very small quantity
of blood with the cupping-glass.  When bleeding
is no longer advisable, moderate purging may still
be of use.   In this stage, we may have recourse
to  counter-irritation with advantage  : blisters may
be applied between the shoulders, to the occiput,
or to the neck or legs.   There is an objection to
their being applied to  the whole head, that it pre-
vents the subsequent  application  of cold.  We
have, however, in desperate  cases, seen a  decided
 amendment follow the application of a large cap
 blister.  Particular attention should  be  paid to the
 abdominal region, and especially that of the blad-
 der, which ought  to be examined  morning and
 evening, in order to detect retention of urine; and
 we must take care not to be led into error by an
 incontinence of  urine from the over-distension of
 the bladder :  this must be obviated by drawing off
 the urine with the catheter twice a day.
    In the more  chronic forms of cerebritis, unat-
 tended wnn fever or much general excitement, the
same activity of treatment is of  course not admis-
sible.  We must  still, however, pursue the anti-
phlogistic  plan,  modifying it  according to the
urgency of the symptoms.   During the period of
irritation, with cephalalgia, vertigo, or rigid spasm
of the extremities, moderate bleeding, general and
topical, purgatives and  counter-irritation, are the
only remedies from which any advantage is to be
expected :  they must  be repeated at longer or
shorter intervals, according  as the strength of the
patient and the continuance of the symptoms may
seem to  indicate.   A great deal is to  be accom-
plished in all chronic inflammations by persevering
in a moderate course of antiphlogistic  treatment.
We must watch carefully any signs of amendment,
remembering that there is a great tendency to re-
lapse, and that the natural course of the complaint
is characterised by irregular remissions  and exa-
cerbations.
   When  the period of irritation  is over, and is
followed by a remission of all signs of excitement,
by a complete paralysis of the  muscles, and by
tbe other evident signs belonging to the period of
softening and suppuration, the strength of the
patient must no longer be reduced  by active treat-
ment.  In all inflammatory diseases,  when the
stage of excitement and disorganization is over, a
process of reparation  commences,  which requires
for its completion a certain degree of power in the
constitution.  If at this  period we  persevere in
lowering  the general  strength, we deprive the
constitution of its natural resources,  and interfere
with its healing operations.  It becomes, therefore,
an object of  considerable importance to watch the
moment when  the tide of excitement is on the
turn, and when the powers of the constitution are
verging  to a state of collapse,  in order that we
may abstain  from an  injurious   interference, hus-
band the  patient's strength, and even support it if
required.   This precaution is particularly neces-
sary in old people and young children.  We think
it necessary  to lay some stress on this rule of
practice,  as  there is perhaps a tendency in the
present day to overlook it; and  we  have seen
considerable harm from carrying the antiphlogistic
treatment  beyond its safe  limitation.  We have
already alluded to the  pseudo-symptoms of cere-
bral congestion and inflammation which are some-
times  the  consequence, especially in children, of
extreme exhaustion, and require the use of cordials.
   After convalescence has been established, the
patient will  still require to  be closely watched for
some time, before his recovery  can be  considered
fully confirmed : he must be kept perfectly quiet,
free from every species of excitement, and the
regimen  duly regulated.   When the brain has
once suffered from inflammation, it is slow in re-
covering its tone, and the most trifling cause, such
as a slight mental exertion  or emotion, a full meal,
&c, has  been,  in many cases, sufficient to occa
sion a relapse.
   When cerebritis has occurred after  suppressed
evacuations  or the metastasis of other diseases, w<i
should endeavour to  procure   their return.  It
menstruation be  suppressed,  leeches  should be
applied to the  \niHs or inguinal regions, and the
 frequent use of hot ]>cdiluvia with flour of mustard
recommended.  If cutaneous eruptions or rheu-
matic gouty pains in the joints  previously exi-'ec1, 
BRONCHIAL  GLAN
DS —BRONCHITIS.               331
blisters or rubefacients  are to be  applied to the
parts originally affected.
  M.  Blaud  has published in the Bibliotheque
Medicale, vol. lxii. several cases in which he says
that he speedily  overcame the symptoms of cere-
britis  by  the  mere  compression of both carotids
for several  seconds; stopping thus  the flow of
blood  to the head.  Laennec considered this an
unsafe proceeding, and  not  easy  to  perform
without the risk of suffocation.  This plan  has
often  been  proposed as a means of checking  in-
flammation, and  also of preventing the accession
of the paroxysm of ague.  We  have, however,
never seen it tried, and should think its general
application  scarcely practicable.
  The following summary gives a connected view
of the various  morbid  conditions of  the brain,
which are the effects of congestion and inflamma-
tion, together with their symptoms.
   I.  Cerebral congestion, over-distension of  ves-
sels :—vertigo, tinnitus aurium, confusion of sight,
cephalalgia ;  if the pressure on the vessels be car-
ried to a  sufficient extent to intercept the circula-
tion,—simple apoplexy,-  seldom fatal; recovery
rapid.
   2.  If the  cerebral congestion be permanent, or
returns  frequently ; drowsiness, oppressed intel-
lect ;  the vessels become weakened, and on a sud-
den increase of congestion are ruptured ; extrava-
sation of blood,—sanguineous apoplexy.- destruc-
tion of cerebral  substance and compression ;  loss
of consciousness, permanent or temporary; sudden
and complete paralysis, without  spasmodic affec-
tion of the muscles.
   3.  General congestion, followed by  inflamma-
tion of a considerable portion of the brain ;  deep
injection ; partial sanguineous infiltration ; dotted
and ecchymosed  striated appearance of the cerebral
substance;—general cerebritis, (combined usually
with  arachnitis).  Period of high excitement of
all the cerebral  functions, with general convul-
sions, followed by a period of collapse and coma.
   4.  Partial congestion and inflammation of  the
brain: 1st  period,  the  same deep injection  and
sanguineous  infiltration, more circumscribed ;—
partial cerebritis.  Partial symptoms of irritation
in  the organs of motion and  sense ;  weakness,
pain, numbness, spasmodic paralysis, confined to
one side  or a few regions of the body:  2d period,
infiltration of pus in the cerebral substance;  sof-
tening,  abscess ; complete paralysis ;  relaxation
and  flaccidity of the muscles;  loss  of feeling;
abolition of some  of the external  senses or intel-
lectual faculties; death, either gradual or sudden,
by the extension of the inflammation,  or by pres-
sure.
   5.  After  sanguineous apoplexy and sudden and
complete paralysis, inflammation of the cerebral
substance surrounding the coagulum ; consecutive
cerebritis,- the paralysed limbs affected  with pains,
convulsive motions, spasnrodic rigidity.
   6.  Slow  and   gradual  congestion,  with  very
slight irritation ; long-coitinued  state of low in-
flammation, ending sometimes in softening, some-
times in  induration, or else in an infiltration of
serous fluids and white softening,-—various forms
iif chronic cerebritis,-  sense and motion very gra-
dually weakened and  impaired, without pains or
spasmodic rigidity in the muscles.
                         Adair Crawford.
  [BRIGHT, DISEASE OF.  (See Dnorsr.)
  BRONCHIAL  GLANDS,  DISEASE   OF
THE. The bronchial glands, or ganglions, seated
around the bronchia, where they dip into the tissue
of the lung, are  not uncommonly found larger
than usual, without there being any evidence of
their morbid condition during  life ; and hence  it
has been concluded that, when hypertrophied, or
otherwise diseased,  they seldom  produce   any
striking symptoms.  (Stokes, on Diseases of the
Chest, Amer. edit. p. 266, Philad.  1844.)  Thus,
in a case recorded by M. Andral, (CUnique Medi-
cate, torn i.) where an enormous mass of melano-
sis compressed  the right  bronchium, so as to di-
minish its diameter  by  one half, there was no
stridulous breathing, tbe signs being a feeble re-
spiration in one  lung, with intense puerility in
the other.  He states, however, that tumours of
the bronchial  glands frequently cause bronchial
and  tracheal compression.  It need scarcely be
said, that if they  are so large as to compress the
bronchial tubes, they must interfere with  breath-
ing; still, tbe compression may arise so gradually
as to account  for the very slight  effect they in-
duced on the breathing  in certain  recorded cases.
In children, they are frequently enlarged  by the
deposition of tuberculous matter,  and may  give
occasion  to dyspnoea, and  to  evidences  of ob-
structed circulation.  Dr. Stokes (op. cit.) affirms
that he has never met with an instance of stridu-
lous breathing, or even  bronchial compression,
produced  by their diseased condition ;  but Dr.
Golding  Bird  has recorded  cases  in which  such
compression  was  witnessed.   (See 4he  writer's
Practice of Medicine, 2d edit. p. 383,  Philad.
1844.)
  Tumours of the bronchial glands would appear
generally to grow forwards, and Dr. C. J. B. Wil-
liams (Lectures on the Physiology and Diseases
of the Chest, &c. Amer. edit. p. 252, Philad. 1839)
states, that  he has seen  them  pushing  out the
sternum or the  ribs on one side, and causing dul-
ness of those parts, and symptoms of displacement
of the lungs farther down.
   When  the  glands are greatly  augmented in
children  of scrofulous habits, there are no  signs
that can  lead to more than a  suspicion that the
morbid state exists. The scrofulous diathesis may
be  accompanied with  tuberculosis of the lungs;
and, if evidences of compression of the bronchia
exist, there may be no signs that can enable us to
pronounce positively, .that  such  compression  is
owing to enlargement of the  bronchial  glands.
These scrofulous  enlargements sometimes soften,
and are evacuated, by ulceration, into the bronchia.
The bronchial glands are also, sometimes, affected
by encephalosis ;  and it has been suspected by
Dr. Williams  (op. cit.) that encephaloid  disease
of the lungs generally originates in this way, and
spreads afterwards along the vessels  into the pul-
monary tissues.
   Should scrofulosis of the bronchial glands be
suspected, the treatment must be such as is proper
for the scrofulous cachexy in general.
                     Robley  Dunglison.]
   BRONCHI, DILATATION OF. (See Bno>
CIIIT1S, CHltOXIC.)
   BRONCHITIS.  This term is applied to in
flammation  of the mucous lining  of the broncni 
332
BRONCHITIS — [ACUTE.]
or air-passa
           ges  of the lungs.   There are few dis-
orders  of more common occurrence ;  and  few,
perhaps  none,  so varied  in  importance.   In its
slighter forms it is scarcely deemed an interruption
to health ;  but  when severe, it becomes a danger-
ous  and fatal  disease.   The  pathology explains
this diversity, and refers the danger, which attends
bad cases, to interruption of the due performance
of the function of  respiration.  It does not seem
correct, therefore, to  describe these different de-
grees under the different names, catarrh, bronchi-
tis, peripneumonia notha, &c. as some authors
have done.  The  term catarrh implies only the
flux or secretion which  accompanies the inflam-
mation.   We  shall therefore include  under the
present head all  affections of the bronchial mem-
brane, which exhibit  the characters of inflamma-
tion, and   reserve  the   term  catarrh for those
changes in the secretion of the same membrane
that do not appear  to originate in inflammation.
   Bronchitis presents itself under two forms, the
acute and  the chronic; the one differing from the
other in the greater intensity of the inflammation,
and in  the more  rapid  progress of the disease.
We shall therefore consider each form  separately,
as this method will enable us to point  out the cir-
cumstances which  characterize each variety.
   I. Acute Bronchitis.—The commoner cases
of acute bronchitis  generally succeed to coryza, or
inflammatory affection of tbe mucous  membrane
lining the  nose  and its  contiguous cavities, the
frontal sinuses.  Sometimes the inflammation first
attacks  tiie tonsils and fauces,  from thence  is
tranferred to the lining of the larynx, and gradu-
ally extends downwards to the trachea and bron-
chi.  In other instances the inflammation begins
in the bronchi  themselves; and  this mostly occurs
in those whose lungs are susceptible.
   The first symptom which characterizes bron-
 chitis is a feeling of roughness  in the  trachea,
which  occasions frequent attempts to clear the
 throat, and is much increased by  exertions of the
 voice, or of the organs of respiration.  It soon
 amounts to such a degree of titillation as to excite
 cough, which  is at first hard and dry.  At this
 time there is  generally more or  less  hoarseness,
with a tight feeling across the chest, which often
 amounts  to pain,  especially on  coughing, and
 occasions  considerable  uneasiness in breathing.
 Some signs of fever are usually felt at this period,
 such as lassitude, cold  shiverings, pain in the
 limbs, and some acceleration of  the pulse.   A
feeling of chilliness is hardly ever entirely absent,
 even in  the slightest cases.  The cough, which at
 first seems to be caused by an increased sensibility
 of the inflamed membrane, is very soon accompa-
 nied with expectoration  of a thin fluid, having a
 saline taste.  This secretion rather increases than
 otherwise  the  frequency of the cough; and, like
 the  fluid of coryza, when thin it seems to possess
 a peculiar irritating quality ; for, although the fits
 of coughing are not  so prolonged as  they after-
 wards become, they are more frequent and more
 irresistible  than at  any stage of the disease. It is
 during the continuance of this  form of secretion,
 likewise, that in the common cases of bronchitis,
 • he dyspnoea and pain in the chest first appear ;
 and  as  the expectoration becomes  thicker and
 more abundant,  these are Droportionately relieved.
It is this change in the character of tbe cough and
expectoration, that in common cases proves the
signal for a general amelioration of the symptoms.
The constriction of the chest is diminished or re-
moved ; the  pulse loses its  frequency;  the  skin,
which  was hot, becomes  cooled  by free perspira-
tion ;  the  urine,  which  was  scanty and  high-
coloured, becomes more copious, and deposits an
abundant sediment;  and tbe degree and rate of
the decline of all the troublesome symptoms very
generally correspond with the  chnnge of the ex-
pectoration.  This seems now to have lost its acrid
irritating quality, and has less of the saline taste
which at first characterized it.   In its appearance
it changes  from  a  glairy colourless liquid to a
pearly  tenacious  phlegm, increasing in consis-
tence and opacity as it  diminishes  in  quantity,
until at length each fit of coughing easily brings
up a pellet  of  opaque white, or greenish  white
mucus, to which the soot and smoke of  the air in
large towns often give a grey tinge.  This change,
or ripening  of the expectoration, is first observed
in  the  mornings  only, and  gradually extends, as
the disease declines, tbroughout the day and  night,
Towards its termination, the cough and expecto-
ration  are chiefly observed  in the  morning and
evening.
   Such is the ordinary course of the slighter cases
of acute bronchitis, for which  the nature of their
usual cause has obtained the name of " a common
cold."   But the  same  disease,  differing  from
these  only  in the extent of membrane affected,
presents a much  more formidable character. In
such severe cases, rigors and symptoms of general
fever usually attend  at the  onset of the disease.
The  patient suffers from headach, particularly
over the eyes, sickness and loss  of appetite, lassi-
tude and great prostration of strength, with  occa-
sional pains  in the limbs.  The tongue is foul, and
the urine  scanty  and  high-coloured.   The dys-
pnoea is often urgent from the beginning, particu-
larly in the  night;  and this symptom, as well as
the tightness and pain in the chest, is much aggra-
vated  by the fits  of coughing.  Tbe pain  in the
chest is most frequently  referred to the sternum,
and is more  obtuse than the pain of pleurisy ; it is
often accompanied with a sense of weight to which
the dyspnoea is ascribed.  The pulse is hard and
quick, but presents considerable  variety  as  to the
degree of frequency and  fulness.  The matter
expectorated is usually scanty at first, and  after-
 wards becomes copious ;  it is glairy, frothy, some-
times  streaked with blood, and its evacuation
affords but little relief to the cough or breathing •
it has  been compared to the  white of egg in differ
ent degrees of dilution : it is generally most frothj
when  moderately  viscid and in great abundance
its quantity increases, and there is a general  aggra
vation  of all the symptoms in the evening.  It v.
at this time  that the fever increases, the dyspnoea
is  most oppressive,  and the cough most distress-
ing.
   Between  the fourth and  the eighth days the
disease declines in favourable cases ;  the dyspnoea
is diminished, and is confined  chiefly to the even-
ing, when there is  almost always a tendency to
exacerbation.   The expectoration  now becomes
pearly and less abundant, and affords relief to the
dyspnoea.   The symptoms  of fever subside, °n<' 
BRONCHITI
S —[ACUTE.]
333
the disease  either entirely disappears or  passes
into the chronic form.  In certain cases, however,
if the therapeutic means have not been seasonably
resorted to, or have been insufficient to subdue the
acute symptoms of the disease within a few days,
a state of collapse very rapidly takes place ; the
pulse becomes  very  weak, frequent, and often
irregular; the countenance pallid and expressive
of great  anxiety, and  often covered with a  cold
sweat;  the strength is wasted by efforts to relieve
the lungs of the accumulating mucus ;  but the
cough becomes less and less effectual to remove
it, whilst the wheezing and audible  rattle  in the
large air-tubes  increase.   Lividity, delirium, and
other symptoms of the circulation of black blood
in the system, frequently succeed, and the patient
dies suffocated.   A remarkable feature  in  the
character  of the  worst form of bronchitis is, the
rapidity with which the collapse and symptoms
of extreme prostration and debility succeed to high
fever and well-marked  local excitement;  and this
circumstance indicates the  serious nature of the
attack on the vital functions.  The whole course
of these fatal cases is sometimes wonderfully rapid;
death ensuing  within  two days from the com-
mencement  of  the attack.   Tbey  are commonly
confounded  with pneumonic  inflammation,  and
are scarcely to be distinguished from it during
life but by the physical signs.   The severest form
of  bronchitis is,  however, more formidable  and
rapid in its course than pneumonia itself.
   In the  extremes of age,  and in  persons of
weakly  and  phlegmatic habit, acute bronchitis
frequently presents a form so different from what
has  been  just  described, that  it is necessary to
advert a little to these varieties.  In young chil-
dren  a very  fatal kind of bronchitis not  unfre-
quently comes  on in  a  most insidious  manner.
It may present at first the  aspect of a common
catarrh with coryza, without pain, much  fever, or
derangement of  the  general  health.  Attentive
observation,  however,  discovers a  frequency  and
wheezing in  the breathing, which  is  uncommon,
particularly before and  after the fits  of coughing ;
and the pallidity of the  countenance and  heavy
state of the child's spirits indicate something more
than  a common cold.  The cough is not always
present, so that this symptom does not indicate the
extent of  the disease ; and  as children do  not
expectorate,  the disorder in the chest  may escape
remark, until the dyspnoea suddenly comes on,
and renders  the  danger imminent.  Then  the
pulse becomes extremely quick, and the  severity
of the attack  is evinced by the manner in which
the respiration  is oppressed, and the circulation
disturbed.   This aggravation of symptoms often
goes off for a time, leaving the child in a somno-
lent state without much  cough  or  quickness of
pulse ; but if the breathing still continues quick,
the dyspnoea returns after a while with increased
severity, the frequency  of the pulse is increased,
stupor comes on, the lips become Jivid, and in this,
or in some  succeeding similar exacerbation, the
child dies suffocated.
  The disease which resembles this more than the
case before described, is  that form  of bronchitis
which attacks old people and those of lax phleg-
matic habit, and which bears  the  name  of peri-
pneumonia  nolha, or  spurious  inflammation of
the lungs.   Oppression of the breathing is here
one of the earliest symptoms, and it is accompa-
nied with a peculiar wheezing ;  but all the symp-
toms of inflammation are less  acute than  in the
intense bronchitis before described ; and the fever
that attends is of a lower and less phlogistic type.
There is perhaps a greater loss of appetite, and
more  disturbance of the  gastric function; the
tongue is loaded, and there is  much thirst.  The
pulse is quick  and  wiry; the  skin  not much
raised in temperature except in the evening. The
dyspnoea is liable to temporary exacerbations, which
are often so severe as to prevent the patient from
lying down, and  are accompanied by extinction
of the voice.   The expectoration is scanty at first,
but afterwards  becomes very copious and frothy.
The terminations  of this form of bronchitis, which
Dr. Badham appropriately denominates asthenic,
are much of the  same kind as those of the more
violent  inflammation ; but its  duration is com-
monly longer, and it has a great disposition  to
pass into a chronic form.   Persons liable to pitui-
tous catarrh, or who have habitually a cough with
copious thin expectoration, when  attacked  by
bronchitis, generally suffer from this form.
   Exciting Causes.—The usual cause of bron-
chitis is cold,  particularly when  conjoined with
moisture, applied  locally or generally, as for in-
stance, by wearing damp clothing, or exposure  to
a cold, moist, variable atmosphere, especially after
the body has been heated by  exercise,  crowded
rooms, &c.  But it appears that all sudden altera-
tions  of temperature  from cold to heat, and  cer-
tain epidemic states  of the atmosphere also, are
capable of  giving rise to  bronchitic affections.
Irritating gases and vapours may excite inflamma-
tion of the bronchial membrane ; but it is  of tbe
slighter kind, and soon passes away,  unless the
cause be  again applied.  A much  more  severe
bronchitis accompanies  some of  the acute erup-
tive  diseases, and frequently  causes  the chief
danger  that  attends  them.  In  some  cases the
eruption fades or  is  diminished,  to the great in-
crease  of the bronchial affection, which is then
announced by oppressive and dangerous dyspnoea.
The inflammation of  gout is sometimes translated
in a similar manner in those predisposed to bron-
chial  inflammation,  and  the  suddenness of the
attack renders these cases the more dangerous.
   Physical Signs.—In  investigating the patho-
logy of acute bronchitis, we shall find that a much
more accurate knowledge of the nature and extent
of the disease may be obtained by a study  of the
physical signs than by any attention to the gene-
ral symptoms alone.
   Inflammation of the mucous membrane  of the
bronchi at first causes tumefaction, and conse-
quently a diminution  of the caliber of the tubes.
This, occurring in individual  points, so  modifies
the passage of the air through them, that, as in a
musical instrument, a sound is  produced.   This
sound varies according to the form of the constric-
tion and size of the tube ;  but the general effect is,
that on applying the  ear to the chest we find the
ordinary respiratory  murmur  accompanied by
various  whistling  and wheezing sounds.  These
occasionally  present a graver tone, like the pro-
longed note  of a  violoncello or the cooing of  a
dove,  and then indicate that some of  the Iartre 
331                          BRONCHITIS —[ACUTE.]
bronchi are tbe seat of disease.  To such modi-
fications  of  the respiratory  sound,  M.  Laen-
nec gave the  names of the sibilant rhonchus and
the sonorous rhonchus.   They are the symptoms
of the earliest  stage of bronchitis, and are often
perceptible before the patient is aware of any suf-
fering in  the chest.   They prove moreover the
fact, supposed  by Dr.  Badham and doubted by
Dr. Hastings, that the dyspnoea of the early stage
of bronchitis is caused rather  by the state of the
mucous membrane than by the redundancy of its
secretion.   Both  the coarctation of  tbe tubes by
which air  is scantily admitted, and the  general
thickening of the membrane by which  the oxyge-
nation of the blood  is  intercepted,  appear to be
the physical or pathological causes of the symp-
tom in question.  Percussion  on the  chest  does
not detect any  loss of resonance.
   In  the progress of the disease, the auscultator
soon discovers the presence of a liquid secretion,
by the bubbling sound occasioned by the passage
of the air in the bronchi.  This is the mucous
rhonchus, and its presence announces the second,
the catarrhal or secreting stage of the inflamma-
tion.   By practice the ear soon becomes enabled
to distinguish  tbe several sounds  that  are  pro-
duced in  tubes of different sizes;  from  these a
pretty accurate estimate may be made of the situa-
tion and extent of the  inflammation ; and these
circumstances bear a relation  to the  severity of
the case.   When the inflammation occupies only
the large  tubes, as is  the case in common colds,
the bubbles  of the  mucous rhonchus are large
and uneven, and the  sound  of respiration  may
still be heard.   But if the  rhonchus is fine, and
accompanies the whole of the respiratory act, it
may be concluded that the disease is in the smaller
bronchi; and if extensive, the function must seri-
ously suffer.   In this  case there is  sometimes a
slight diminution of  the resonance on percussion
of the affected part.   The passage of the secre-
tion from a thin  to a consistent state, commonly
called the  ripening of  the cold, has  likewise its
distinctive symptom.  The bubbles of tbe mucous
rhonchus  first become  more interrupted,  and gra-
dually give place to a clicking, or a sibilant sound,
occasioned by  portions of the  inspissated  mucus
partially obstructing the bronchi.   Sometimes tbe
respiration of  a  portion  of lung  is entirely ob-
structed by a pellet of this mucus  in its princi-
pal bronchus ; and thus the dyspnoea occurring at
this stage of the disease is  explained.   These
several symptoms are  liable  to frequent change
from  the removal or  altered position  of the mucus
consequent on coughing or expectoration; and it
i- useful to avail  ourselves of this in  our examina-
tion ;  for we may thus prevent the mistake of
ascribing  absence of respiration to peripneumo'ny
or anv other cause.
   Tne varieties that we have  before described  as
occurring in the progress and termination of acute
bronchitis, depend on the character  as well as on
the extent of the inflammation.  In the  plethoric
and sanguine  temperament the  inflammation is
intense,  and remains  for a while  dry; and the
congested  and thickened state of the membrane
preventing  the  effectual arterialization  of  the
blood, may in this stage cause dyspnoea.   The
r 'pious  secretion, however, tiiat soon succeeds,
and  which appears  to  take  place  earlier  in the
dyspnoea of children, soon becomes an additional
interruption to the function, and unless removed
by  expectoration  or  re-absorption,  may soon
amount to suffocation.  The suddenness, as well
as the abundance of its  effusion,  increases the
danger of its effects; and this is the reason why
cases of bronchitis  suddenly supervening on  a
suppressed exanthema are amongst the most for
midable.   In old people,  again, and those of a
relaxed habit, there seems to be a serous infiltration
accompanying  the inflammation, which causes a
greater straitening of the  tubes  in the first stage,
than is usual in the other forms; and which is
only relieved by a free secretion from their mucous
coats.
  Morbid Anatomy. — The  anatomy of fatal
cases of  bronchitis, as far as it goes, is in perfect
accordance  with what  we learn from the phy-
sical  signs.  The lungs  do not in  general col-
lapse on opening the thorax;  the escape of air
being prevented by the obstructions in the  bron-
chi.   These in most instances contain a quantity
of frothy liquid, of the  quality of the matter ex-
pectorated  before  death.  Not  unfrequently it is
mixed with bloody serum ;  but this,  as it  is not
perceived in the matter expectorated, has probably
exuded from the surcharged blood-vessels  at the
moment of and after death.   Purulent matter is
also  sometimes observed, and mostly in very acute
cases, which have proved  fatal within four  or five
days.  The mucouu coat  presents an appearance
of red injection, aiffused, or in patches, of various
shades from 9 bright crimson to a brown red.  It
is sometimes thickened, ]*ut rarely softened ; and
never to the degree in which the gastro-intestinal
mucous membrane is frequently found.
  Diagnosis. — The  diagnosis of  acute  bron-
chitis is to be deduced from the leading symptoms
which we have given of  the disease; and if we
avail ourselves of the physical as well  as the gene-
ral  signs, its character will be quite  distinctively
defined.    It  is  distinguished  from  pneumonia
by the  nature  of the expectoration,  which, al-
tbough in severe cases often viscid,  is less so than
in pneumonia, and  wants altogether that rusty
tinge so  characteristic of  the latter disease : it is
also  distinguished by the  clear  sound on percus-
sion of the chest, and the  absence of the crepitant
rhonchus or bronchophony.  (See Pxeumoxia.)
From pleuritis, the clear sound on percussion is
sufficient to separate it.  Both these diseases may,
in some cases, be  confounded with bronchitis
without  reference to these tests, but these  never
fail to decide its character.
  Prognosis.—The prognosis in acute bronchi-
tis  must depend  on the extent of  the disease.
When the inflammation is partial, affecting a few
bronchi  only,  as  in common cases,  and without
much dyspnoea or fever, it may terminate in from
six days to  three  or four  weeks; and its disposi-
tion to pass off is always indicated by the expec-
toration  becoming opaque and  more consistent,
and  gradually  diminishing in  quantity.   This
change is always first observable in the mornings;
the evening exacerbation restoring the thin glairy
character to  the sputa,  even  in cases tending to-
wards convalescence.   A relapse  is  marked by
the expectorated  matter becoming  again transpa 
BRONCHITIS
rent and glairy, and this is  always accompanied
by an aggravation of the cough  and other symp-
toms.
  In the more extensive attacks of inflammation,
where the dyspnoea is great  and  unremitting, and
particularly where the fever was high in the be-
ginning, the prognosis may be very unfavourable ;
and if the acute symptoms  have already yielded
to the state of  collapse, it is to be feared that the
powci of the system is  insufficient to  restore a
function on which the disease has made a serious
inroad.   The extreme anxiety of the pallid coun-
tenance, and  a  slight appearance of lividity, an-
nounce  the asphyxiating effects of this  stage of
the disease ; and the universal mucous rhonchus,
with little or no respiratory murmur heard on the
application of the ear or stethoscope to tbe chest,
gives direct evidence of impending dissolution.
   There is sometimes  accompanying continued
fever a severe  bronchial  affection, which this ex-
amination alone can detect.  There is little cough,
and  the general symptoms  so mask the dyspnoea
that it may proceed to a fatal termination without
being distinguished from the symptoms of general
weakness and oppression that severe cases of con-
tinued fever commonly present.   (See Fever.)
   In severe bronchitis  of children, likewise, the
real amount of the danger can seldom  be  appre-
ciated by the  general symptoms in time for the
effectual application of  remedies ; but where aus-
cultation discovers, from a universal mucous rhon-
chus, that the inflammation is  extensive, and
occupies both  lungs  at once, great danger may be
apprehended, whatever be the amount of dyspnoea
and other  symptoms at  the time; for these fre-
quently  come  on in  paroxysms only, or are
scarcely marked in the  somnolent state in  which
the child lies during the remissions.
   The danger in asthenic bronchitis, or  peripneu-
monia notha, arises from the weakness and age
of the patient;  if these are  great, there will be  a
great risk of the strength proving unequal to clear
the  lungs  of  the  secretion  that is  so  copiously
poured out.  The respiration of old people bears
ill any sudden abridgment;  for the more rigid tex-
ture of  their lungs does not, as  in younger sub-
 jects, admit of additional or supplementary  respi-
ration in the healthy parts. (See Dxspnoea.)  One
of the most fatal forms of bronchitis is that  super-
vening on a suppressed eruption.
   Treatment of Acute Bronchitis.—1. The
slighter  cases of acute  bronchitis  are  more fre-
quently objects of domestic  than of formal  medi-
cal treatment.   When neglected, however, a com-
mon cold may give rise  to the most serious com-
plaints ; and we are far  from subscribing to a pre-
valent opinion to which even Laennec seems to
lean, that it must always run its  course.   By anti-
phlogistic diet, and a few simple means calculated
to restore the secretions, and, if required, to  cause
revulsion from the inflamed part, a cold may often
be checked in a few days, which  if left to  itself
might run  on for weeks, entailing on some sub-
jects other and worse evils.  The means  which
we have found most effectual  are as follow :—At
the first feeling of the  cold,  let  a  purgative be
given, with two or three grains of ipecacuanha or
James's powder.  Let a hot pediluvium be used,
the patient getting into  a warm and well-covered
(—[ACUTE.]                          335

bed immediately after, and promoting any disposi-
tion to perspiration by a warm draught  of thin
gruel,  barley-water, or any  other mild diluent.
If perspiration comes  on and the purgative ope-
rates well, the  cold is  sometimes  already cured ;
and it is  only necessary to remain at  home, and
to abstain from animal food and wine next day, to
prevent a return.
   If, however, perspiration do not follow, or if
the cough has already  come on, the disease gene-
rally proceeds, and we must then endeavour to
mitigate its severity, and bring it quickly thiough
its course.  If the patient cannot,  or thinks it not
worth while to remain in bed for a day or two,
he should clothe more warmly than usual;  for the
susceptibility of the body is such  as to render  a
very slight exposure enough to keep up the dis-
ease, and abstinence from meat and all fermented
liquors or spirits is at this period  equally neces-
sary.  To loosen the cough and lead the bronchial
inflammation to the stage of free secretion, small
doses  of ipecacuanha  or tartarized antimony are
often most effectual; and, although called a stimu-
lant  expectorant, squills,  when combined with
these, have always appeared to us to exert a bene-
ficial effect: ten minims of the tincture with thirty
of the vinum  ipecacuanha, and  six or eight of
liquor potasss, given  three or four times  a day,
seldom fail to  facilitate expectoration  and relieve
the  cough. Whether the alkali act by  facilitating
 the  absorption of the medicine, or by any specific
action on the vessels of the bronchial  membrane,
we cannot determine ;  but its effect in increasing
the  action  of expectorants we have proved in  a
variety of examples. Should nausea be produced,
the  dose of the medicines may be diminished ; and
if the cough is still troublesome at night,  a little
extract or tincture  of hyoscyamus may with  ad-
vantage  be added.
   This treatment is generally sufficient to  relieve
the  tightness across the chest, which yields as the
cough becomes loose;  but if the case is obstinate,
it may be necessary to resort to a blister, or some
of the means which we shall presently recommend
for the more severe forms of the disease.
   The inhalation of the vapour  of warm watei
may he sometimes  useful ; but we have seen it in
some instances increase the oppression ; and from
its effect of determining blood to the  part, we do
not  deem it so universally safe a measure in recent
 bronchitis as it has been represented to be.
   With  still more force would we object to the
cure by spirits or wine, as recommended by Laen-
nec ; not that we  doubt its  occasional  efficacy,
 but  from  the experience that where it does  not
cure, it greatly aggravates the inflammation. To-
wards the termination, when  the  matter expecto-
rated  has become thick  and  loose, and all febrile
symptoms  are dissipated, animal  food and wine
may be indulged in with impunity, and even with
advantage.  At  this  period,  too,  if the disease
shows a  disposition to  linger, much  good  may
often be obtained by using some of the stimulant
expectorants, as  myrrh, copaiba, &c.; and if ne-
cessary,  the cough may  be  allayed  by  opium.
This treatment will be  noticed under the head of
chronic bronchitis.
   There are very  many remedies which  are in
common  use for coughs, which it is  imDossil.-iu 
336
BRONCHITI
S —[ACUTE.]
here to advert to.  The safest are those which are
simply demulcent;  many are  stimulant  and nar-
cotic, and often do mischief. Ipecacuanha lozenges
is a remedy worthy to be named, as the conveni-
ence of its  form recommends it when more formal
medicines  are objected to; and although it is apt
to cloy the stomach before sufficient quantity can
be taken, it often proves as serviceable as the less
agreeable compounds of the medicine.
  2. The danger attending severe acute bronchitis
renders far more energetic measures  necessary;
and  these,  although generally of the  same  class
as those  usually directed against acute inflamma-
tions, must be exercised with more  than usual
discretion and caution.
  As long  as the phlogistic state continues, with
high fever, hard pulse, and great feeling  of strait-
ness and oppression in the chest, there can be no
doubt of the  propriety of bleeding more  or less
freely, according to the intensity of the symptoms,
and  the strength of the patient; but it is not pru-
dent, as  in pleurisy or peripneumony, to bleed to
syncope, or to push the measure with  an expecta-
tion of very  marked relief.   From  sixteen  to
twenty-four ounces may be taken  at first in severe
cases ; and the repetition of  general  bloodletting
must depend on tbe state of the pulse  rather than
on  other symptoms.   If it is weak, or if  the pa-
tient is  advanced in  life, we  must endeavour to
subdue the symptoms by less  violent means, such
as local  bleeding and medicines, rather than run
the risk of destroying strength that is absolutely
required for the act of expectoration.
  Cupping is generally to be  preferred to leeches,
as its effect is more speedy and more within con-
trol ; and it is of considerable advantage to apply
it to the part in which auscultation has discovered
the greatest obstruction to the passage of  the air.
   There is an objection which obtains so against
blisters, as to exclude their use in  many cases of
the early stage of acute bronchitis ; namely, that
before they rise, they always  produce an irritating
effect on the whole system,  which is  very apt to
aggravate for the time the inflammation for which
they  are applied.   This effect,  however, varies
much in different individuals, and in those whose
skin easily vesicates under a  blister, it is obviated
by the serous discharge that immediately succeeds.
  In other instances, it is advisable to  resort to
other counter-irritants, and we give the preference
to the tartar emetic.  To make it  available in an
acute disease, we have found  it necessary to excite
the skin previously to its application, by means of
a brush  or coarse  flannel, by applying  a warm
hand wetted with  ether or camphorated spirit, or
by a short  application of a mustard poultice  The
tartar emetic should then be  immediately rubbed
in, either in the form of a warm saturated  solu-
tion, or an ointment composed of  one part tartar
emetic  to  two  of spermaceti ointment.   With
these precautions we  have rarely failed to excite a
full  pustular inflammation in as  short a time as
that required for the rising  of a blister, with far
less  irritation to the system, and with decided
relief to the pectoral symptoms. We have reason
to believe  that  a minute quantity of the tartar
emetic is  absorbed into the  system, as  we  have
sometimes  observed nausea succeed its use ; and
this, instead of being injurious, as in  the  case of
cantharides, is a part of the  treat~ient which has
been found most serviceable.  This brings us to
the subject of internal remedies.
   At the onset of the disease, the earlier the bet-
ter, a brisk purgative should be  given.   Where
the inflammation is high, calomel, with a grain or
two of ipecacuanha, combined with jalap, scam-
mony,  or any  of the active  cathartics, is to  be
preferred, and  followed  by repeated do.^es of a
saline aperient, containing a small quantity of tar-
tarized antimony.   This medicine  proves  useful
not only  as an evacuant, but as a sedative and
diaphoretic, and the  nausea, which it sometimes
produces, is generally beneficial by modifying the
secretion of the bronchial lining, and  facilitating
expectoration.  For  the same reason, a full emetic
has been generally recommended, and is often de-
cidedly useful; but it is better adapted to children,
and to cases in which the bronchial secretion is
profuse, than to the  more inflammatory forms of
the disease.
   For the relief of the dyspnoea and cough, those
medicines  are  to  be preferred which act  on  the
vascular system.  The  sensation of  dyspnoea is
not to  be looked on  as  one merely of discomfort,
to be relieved by means which deaden sensibility,
but as an indication of the inroad made on a vital
function, which, if not restrained, must terminate
in its destruction.  To aid, therefore, the antiphlo-
gistic  measures  that we  have  already  recom-
mended, it is proper to administer such medicines
as are  likely to moderate the action of the vessels
and relieve the congested lungs.  Tartar emetic,
digitalis, and colchicum best  answer  this indica-
tion,  and  we  generally  prefer  the two  former.
The tincture of digitalis, in the  dose  of eight or
ten minims, with thirty or forty of the liquor an-
timon. tartar.,  three or four times a  day, is the
form which we usually adopt.   Of course it will
be necessary to watch the effects of these medi-
cines, and  to diminish  or discontinue the digitalis
if the  pulse become intermittent.  It will be  of
considerable advantage to increase the  dose  of
tartar emetic ;  and  if the dyspnoea continue, and
the mucous rhonchus in tbe chest is undiminished,
to persist in its use even should it excite vomiting;
for its  beneficial effects in peripneumony, to which
bronchitis,  in  its severe form, really approaches
very nearly, are sufficient to prove  its power to
restrain  effusion  and  promote  absorption.  Dr.
Badham strongly recommends this medicine in
doses " frequently repeated, and  increased till the
maximum which  the stomach can bear without
vomiting is attained."
   Calomel and opium combined, and given hi fre-
quently repeated doses, as in other acute  inflam-
mations, are likewise sometimes highly beneficial;
and we consider  that their use is especially indi-
cated,  where, as is  not unfrequently the case, the
bronchitis  is complicated with gastro-hupatic dis-
ease.  The opium should be in smaller proportion
than usual, and is,  perhaps, most safely given in
the form of Dover's powder.
   Should  the collapsed stage  have tome on, and
the symptoms of debility show that the  function
of respiration  has been  already so  much injured
as  to  reduce  the  excitability of the  system, it ia
necessary to resort to expectorants  of the  stimu-
lating  kind.   Of these the  Lest is carbonate of 
                           BRONCHITIS

ammonia, which often  enables a patient to expec-
arate what in his weakness might be sufficient to
 uffocate him.  We are disposed to think that this
 emedy  is more than an ordinary stimulant, and
acts in an especial manner on the bronchial mem-
brane.
  The  attenuating or solvent power of alkalies
may with advantage be resorted to in the  latter
stage of bronchitis, when  the matter of expecto-
 ition is very consistent, and, lodging in the  bron-
chi, occasions local absence of the  sound of re-
spiration, and,  if copious, dyspnoea.  The liquor
potasses, in doses  of ten minims', given with  the
vinum  ipecacuanha?,  is  productive  of  obvious
benefit.
  From what we know of the effects of the lobe-
lia  inflata in suffocative  catarrh of the chronic
kind, we should judge  it to be worthy of a trial in
the collapsed stage of acute bronchitis.
  Besides attempts  to relieve  the  lungs of  the
 oad which prevents  the  penetration of air into
them, another  indication  presents itself in this
stage, which is to  obviate  the bad effects of black
blood in the system ; for this it is, unquestionably,
 rhat gives that peculiarly depressed and adynamic
type which precedes the fatal termination.   Here,
unfortunately,  our experience fails us;  and  we
feel the necessity of appealing to further researches
of experimental physiology.
  3. It remains for us to notice the modifications
jf treatment which the several varieties before
described require.
  In the  bronchitis of young children emetics are
peculiarly serviceable ; for besides the beneficial
effect they  produce on the  inflamed  membrane
itself, the muscular action of vomiting greatly
assists expectoration, which can scarcely be effect-
ed at this age.  Purgatives, too, are generally of
more marked utility  than in  adults, and,  if re-
peated,  may  frequently prevent the necessity for
 general bleeding.  Dr. Hastings, however, highly
recommends bleeding from the jugular vein; and
 in imminent cases this  is probably the means most
 to be relied on.  Dr. Badham suggests opening a
 vein  in the  foot, and immersing  it  for a few
 seconds in  warm water,  which causes blood  to
 flow  in  sufficient abundance.   In  these  cases,
 especially, we  never can  proceed confidently  in
 the treatment without  frequently appealing to the
physical signs.  The  disease is so deceitful, (as
 Dr. Hastings remarks,) that  except the universal
 mucous rhonchus, which nearly or entirely oblite-
rates the respiratory murmur, no indication of the
imminent danger can be discovered.
  In the  asthenic form of the disease  in adults,
bloodletting is  rarely admissible, and never to  a
great extent.   To restrain the secretion in  the
bronchi, and to rid them of it by means which do
not  greatly  impair the strenglb, are here the ob-
vious indications.  Nauseating doses  of tartar-
emetic, or even larger, continued as in pneumonia
until tolerance is established, purgatives, and deri-
vatives,  better  fulfil  these intentions.   Blisters
answer  better here than in the more inflammatory
disease, but to be effectual, they should  be ample;
and  it is useful to  give squill and digitalis (ten  or
fifteen  minims  of  the  tincture of each, three  or
four times a day,)  during their operation ; for the
tiecretion of urine  is thus kept free, and there is
  Vol.1. — 43                      2d
-[CHRONIC]                        337

less chance of irritation of the system by the can-
tharides.   Dr. Badham recommends assafcetida in
the occasional aggravations of the dyspnoea, which
he, supposes  to  arise from a temporary spasm in
the  bronchi.  The  asthenic  form of  bronchitis
leaves a greater weakness than the  more  inflam-
matory; or rather, we should say, the weakness is
the consequence of the habit of body which causes
the disease to  assume  the  asthenic  form.  It is
therefore generally necessary to use  tonics after it
to restore the strength ;  and if an irritable cough
remains, without any excitement, opium may be
resorted to to allay it.  Change of air may some-
times  effectually answer both these purposes, and
will generally be found a beneficial adjunct.
   It is generally necessary to be peculiarly ener-
getic in the treatment  of bronchitis  supervening
on suppressed discbarges and eruptions.   Exten-
sive  counter-irritation, as  recommended above,
with tartar-emetic, would seem here to be espe-
cially indicated.  In case of repulsed gout, means
should be taken to bring the gouty inflammation
back to the  limb by mustard poultices  and hot
water ; but  these measures  are not solely  to be
depended  on.
   II.  Chronic  Bronchitis.—Chronic bronchitis
presents as  great a variety of form as the acute
disease ; and from the complications into which it
very frequently enters, it is  less  tractable in its
nature.  It is  not an  easy matter to define  dis-
tinctly the character which entitles a case of bron-
chitis to the  specific term chronic.   The duration
of the acute disease is very varied;  and it is fre-
quently renewed for such a length of time as might
truly gain it the name of chronic.   The distinc-
tion which Andral gives, although  by no means
peifectly exact, is perhaps  the best, inasmuch as
it  is  founded  on the  pathology  of the mucous
membrane itself.  As  long  as the  expectorated
matter remains  glairy and viscid, uniting in mass,
and without opacity, the inflammation is acute.
Towards the termination of an attack of this kind,
the sputa  become opaque, and are expectorated in
distinct masses, which, although consistent, are
not very adhesive  or glutinous.  Sometimes, in-
stead of diminishing and becoming  more consis-
tent, as when the disease is  about  to  terminate,
they remain  in  this state, or increase and  become
diffluent and heterogeneous  in quality, without
sensible increase of fever; and they then indicate
inflammation of the chronic kind.
   Chronic bronchitis in its slightest form mani-
fests itself only by habitual cough and expectora-
tion, which are increased by certain changes of
weather, and generally prevail most in winter and
spring.  It is  most  common in  advanced  life  ;
and in fact very few old people are perfectly free
from it.  In  its  severer forms it is accompanied
with dyspnoea, occasional pain in the  chusi  and
about the  prascordia, and  some  febrile symptoms,
especially  towards evening, palpitation, and disor-
der of the digestive  functions.  The  cough is
sometimes very severe, especially at night, and the
expectoration copious;  and  if these persist long,
they seldom fail to waste the body and reduce the
strength.
   The character of  the expectoration is various
Generally  it consists  of a greenish-white  mucus.
or  it may assume a  muco-purulent  appearance 
338                        BRONCHITIS —[CHRONIC]
and is often mixed with little thin pituita.  Some-
times the pituita are  abundant, as in pituitous
catarrh, and  a few masses of brownish  or  ash-
coloured mucus float in it.  Sometimes it is puru-
lent, and streaked with blood;  and in some cases
it is real  pus, presenting all the varieties that are
seen in  pus from other sources. In such instances
there are  generally a  quick  pulse and signs of
hectic;  and the disease tends to a fatal termina-
tion, with night-sweats, emaciation, diarrhoea, and
ill  the  common symptoms  of pulmonary  con-
sumption.  The worst cases  are  usually those
which succeed to repeated or severe attacks of
acute bronchitis, whether of the intense or asthe-
nic form.
  Exciting Causes.—When occurring in early
life, chronic bronchitis generally follows  hooping-
cough,  measles, small-pox,  or some cutaneous
eruption, and does not often succeed to an acute
attack.  A very distinct form of chronic bronchitis
is excited by tbe habitual inhalation of air loaded
with  dust.  Needle-pointers,  stone-cutters, those
who powder and  sift  the materials for making
china, and leather-dressers, are particularly liable
to this affection.  In  these cases it usually begins
with dyspnoea, which may continue for a conside-
rable time before the disease declares  itself.  In
the course of  a few months,  however, the dys-
pnoea is  increased,  and accompanied  by severe
cough  and  a  copious expectoration, sometimes
mixed  with  pus and  blood.  Not unfrequently
the cough brings  on  a profuse haemoptysis.  At
this time the constitution generally suffers much ;
the pulse becomes quick; thirst and fever attend ;
the tongue  is  loaded  ; and  the aggravations  of
dyspnoea  occasion  lividity of  the  countenance.
Unless  these symptoms are relieved by remedies,
and  a total abandonment  of the unhealthy occu-
pation,  they  become  worse;  the  expectoration
increases  to a great  extent,  and  becomes  more
purulent;  hectic,  with night-sweats,  succeeds;
and  the patient dies with  most of the symptoms
of  tubercular  phthisis.  (See  Artisans,  Dis-
eases of.)
   Physical Signs and Pathology.—The phy-
sical  signs of chronic, bronchitis do not materially
differ from  those of  the acute disease.  The re-
sonance of the chest  on percussion is scarcely  if
at all impaired.  The respiration is varied in  its
distinctness,  being often louder than usual, but
occasionally obscure,  and  accompanied with mu-
cous  rhonchus.  This rhonchus is not universal
ovei the chest, and seldom accompanies the whole
of the respiratory act.  It  very rarely happens,  as
in the  latter  stage of acute  bronchitis, that the
respiration is completely interrupted in a  part of
the lungs ;  and this proves that the mucus is in a
more diffluent  state, and yields to the air  passing
through the bronchi.  Occasional  sonorous and
sibilant rhonchi prove the partial  obstruction of
the  air-passages;  and this may  be either  by  a
thickening of the mucous membrane, or  by por-
tions of thick mucus; but these symptoms are
not  so  common  in  chronic bronchitis as in the
dry  and pituitous catarrhs.
   A remarkable  feature in chronic bronchitis  is,
 that  dyspnoea is  not  unfrequently present to a
 considerable degree, when  from the sound heard
 in the chest it  is plain that the air enter* the luno-s
as well as or better  than usual; the respiration
being distinct or even  puerile.  For a complete
consideration  of these  apparently  contradictory
phenomena we must refer to the article Dyspnea,
and  shall merely  remark here, that the nature
rather than tbe quantity  of the bronchial mucus
is probably the cause  of the  symptom in ques-
tion.
   The continuance of inflammation  has the effect,
ultimately, of altering tbe texture in the mucous
membrane of  the bronchi as  in other  parts.  Its
greater tenuity and simplicity of structure exempt
it from a number of the  changes which are inci-
dent on the gastric and intestinal mucous  mem-
branes ;  but it is nevertheless subject to softening,
ulceration, induration,  and thickening;  and the
effects that these  produce  on the caliber of the
bronchi are worthy of our attention.
   Morbid Anatomy.—The mucous membrane
is frequently  found, on dissection, of a deep red
colour, the redness  being diffused or in  patches.
It is of a more livid or violet tint than in tbe acute
disease,  where  it is usually  brighter and more
verging  on brown.   Not unfrequently, however,
the membrane is quite  free from this ;  it is some-
times even whiter than  usual, and this in cases
where there has been copious purulent expectora-
tion.  Softening does  not  occur  to  the extent to
which it goes in inflammation of the gastric mu-
cous membrane, and the simpler  nature of the
membrane explains  this.  (See  Softening of
Organs.)  Ulceration is also rare,  particularly
in the smaller branches of the bronchi, except in
those cases  which  arise from  the  inhalation of
dust, in which the mucous membrane is generally
ulcerated, often  to a considerable extent; and the
thickening and  general alteration of structure are
greater than in the ordinary cases of chronic bron-
chitis.  The  ulcers  are usually small, clean, and
do not extend below the  mucous and sub-mucoua
coats.  Thickening  of the membrane is a more
common effect, and  it sometimes occurs to a very
notable  extent,  nearly  obliterating  the  cavity of
the  tube.  It is rarely uniform, but generally af-
fects several  points, particularly at the bifurcation
of the tubes.
   Another and very remarkable state, produced
by chronic bronchitis, is a dilatation of the bronchi
It is  not of very unusual occurrence, and presents
itself to  the anatomist  in different forms.  Some-
times a single tube is dilated at one or more points
into  a  sac of various sizes,  in  some  examples
capable  of containing  a walnut.  In  other in-
stances  the dilatation  is  uniform, and extends to
several tubes, which enlarge, instead of diminish-
ing, as they divide.   Thus a bronchus of the size
of a straw is seen to dilate to that of a goose-quill.
Sometimes several branches from the same tube
are affected in  this manner.   The  mucous mem-
brane can always be  distinctly traced from the
undilated portions of the tubes, and usually with
some difference in  its texture.   It  is sometimes
thickened; in other instances  so extremely thin
as to give the dilated  portions the  appearance of
shining  vesicles amongst the  pulmonary  tissue.
Occasionally  either  the mucous membrane or the
circumjacent  coat becomes considerably indurated,
so that the dilatations are rigid, and scarcely sus-
ceptible  of compression  or dilatation;  bu' Uis 
BRONCHITIS
— [CHRONIC]                        339
mucous membrane is more frequently softened, so
that it can be scraped off by the nail.
  These dilatations, as the diseased  bronchi in
general, are frequently  found  full of pus, mucus,
or whatever kind of matter has been expectorated
before death.
  Laennec considers these organic changes to be
produced simply by the  thick mucus accumulating
and gradually causing a mechanical distension of
the tubes.   But  in  this case  we should discover
more  frequently  an  absence  of the  respiratory
sound in the part : such a  sign, although common
in the  latter  stage  of  acute  bronchitis, scarcely
ever occurs in the chronic  disease.   We are more
disposed to  ascribe  them,  with Andral, to  the al-
tered  texture of the membrane;  but even  this is
only the predisposing cause.   The physical cause
of dilatation of the  bronchi, we  apprehend, is to
be found in  acts of respiration  and cough exerting
a degree of pressure on the softened  membrane,
greater  than its  elasticity  can resist.   Thus the
forcible inspiration  which succeeds each  fit of
coughing acts with greater effect on these weaker
parts ; and again, the violent expiration of cough-
ing brings an undue pressure on the same tubes,
which,  distended in one   part, and partially ob-
structed by  the  thickening of their  membrane in
another, are perpetually exposed to a straining
influence.  Induration,  the effect of another de-
gree of the  inflammatory process, sometimes suc-
ceeds, giving the  dilated portions  that rigidity  that
is occasionally noticed  in them.   The effect of
these dilatations must be  to obliterate the neigh-
bouring cells, and to abridge  the function of the
lung.    Accordingly  the adjacent tissue is  found,
on  dissection, to be dense, and deprived of its
cellular structure ; and  when extensive, the  dis-
ease thus causes habitual dyspnoea.
   Diagnosis.—The characters of chronic bron-
chitis are such as easily to distinguish it from all
diseases  except  pulmonary consumption.   The
severer  forms sometimes so closely resemble  this
disease, that it is impossible to distinguish them
by the general symptoms; and even with the aid
of auscultation and  percussion the  distinction is
often very difficult.  The presence of pus  in the
expectoration, which  was formerly  considered
characteristic  of phthisis,  is,  we  have  already
seen, very common in chronic bronchitis;  and in
fact, that which occurs  in  the course of phthisis,
proceeds more from the  inflamed  bronchial tubes,
than from  the tubercular excavations themselves.
So likewise, hectic,  night-sweats, emaciation,  and
diarrhoea, frequently accompany both diseases.
  When unattended with  dilatation of the bron-
chi, an  attentive examination  of  the  physical
signs  will,  however, enable us to form a pretty
sure diagnosis.   It is in the absence of the signs
of phthisis  that  we recognise the  character  of
chronic catarrh; and as this negative test is weaker
than positive proof, so it is  necessary that it should
be often repeated to produce  certainty.  If, after
having repeatedly examined the patient, at differ-
ent hours, during several  weeks, there are found
no gu gling  cavernous rhonchus,  no cavernous
respiration, no pectoriloquy, and  no constant ab-
sence of the respiratory  murmur, and of the sound
on percussion, we may, with tolerable certitude,
pronounce  the disease  to  be  simply pulmonary
catarrh; and a  still further multiplication of ex-
aminations will remove all doubt.
  But if there be considerable dilatation  of the
bronchi, the same signs which are  produced by
tuberculous excavations in phthisis  may likewise
occur in chronic bronchitis.  If the dilatation is
produced at  one part of  the  tube, and  is  of  a
rounded shape, it may be the seat of pectoriloquy
and cavernous  rhonchus, in the  same manner as
a tuberculous cavity of the same size: but  if, as
is the more common case, the tubes are more uni-
formly and generally dilated, the vocal  resonance
in the tubes scarcely amounts to pectoriloquy, but
is rather a loud bronchophony ; and  the breathing
is accompanied with  a whiffing sound, more dis-
tinct than  tbe  bronchial respiration of peripneu-
mony.   It  is only by attention to the progress of
such cases that they can  be discovered not to be
phthisical.   A  tuberculous excavation  rarely re-
mains  stationary as  these do, but  enlarges and
gives a  pectoriloquy of a  greater extent; whilst
other excavations are  usually formed in other
parts.   Dilated bronchi rarely affect the sonoreity
of the chest on percussion to the degree that the
engorgement and infiltration about tubercular ex-
cavations do;  nor can they  produce  the other
physical signs of large cavities.  The most com-
mon situations of dilated bronchi  are in the scapu-
lar, mammary, and lateral  regions : the subclavian
and acromian are the more usual seats of phthisi-
cal signs.
  The only instance in which the sputa can assist
in the diagnosis is, when they  declare themselves
phthisical by the presence of tubercle, or portions
of the pulmonary tissue ;  in other respects  they
may be  exactly the  same.  A remarkable foetor
has been repeatedly observed in  the sputa where
the bronchi were dilated.
  It must  be confessed that cases  do  occur, al-
though  rarely,  which leave the most experienced
auscultator in uncertainty ; but  these are  excep-
tions of comparatively little practical importance,
and hardly detracting from the utility of acscul-
tation.   For  it need scarcely  be remarked  that
dilatation of the bronchi is quite incurable; and
it is often connected  with such extensive lesion of
the bronchial membrane as would leave the prog
nosis the same as in  phthisis.
  Prognosis.—The prognosis in chronic bron-
chitis depends very much on its origin, and on its
simplicity or complication  with  other  disorders
When succeeding to an  acute attack, and when
unattended with much derangement of  the gene-
ral functions, it does not  tend  to a fatal termina-
tion.  Even should  there  be some  purulent ex
pectoration and hectic, favourable circumstances
will sometimes  bring about a cure ;  and slighter
forms, though obstinate and lasting for years, seem
scarcely  to  have any effect  in abridging life.  But
in its  worst character, with constant  dyspnoea,
copious  purulent expectoration, hectic, and ema-
ciation,  and especially if attended with symptoms
of confirmed disease in the abdominal mucoua
membrane, or in the liver,  it is nearly as  fatal cm
phthisis  itself.   In  these  cases of complication,
the bronchitis is frequently secondary ; and there
are abundant examples which  prove that it  may
disappear entirely, if the abdominal  disease is ol
a tractable  nature, and yields to treatment. 
340
BRONCHITIS-[CHRONIC]
  In many cases the prognosis must depend on
the nature of the physical signs :  the  disease is
itself an attendant on phthisis ; and if these do
not establish with certainty that tubercles are not
present, the  case must always  be  considered of
doubtful prospect.  In  the first stage of phthisis
an  extensive bronchial inflammation frequently
attends, when  the tubercles  are very  numerous
and generally dispersed, before the stage of soften-
ing has come on.  In all  cases, therefore, which
the history and  constitution would indicate to be
phthisical,  the  presence  of  a general  mucous
rhonchus, with partial dulness  on percussion,
must be considered  a  sign of the worst import,
for  a tubercular disease of this description gene-
rally runs a  speedy and fatal  course.
  The cases of simple  bronchitis that prove fatal
are those  in  which  the  mucous membrane has
become so altered in its  structure and function,
that it  permanently impedes  the oxygenation of
the blood, and wastes  the body by its  secretion,
and the wearing efforts to evacuate it.  These
generally occur in old persons,  and those already
reduced by fever or  a severe  attack of acute  dis-
ease.    [Bronchitis  asthenica,  Bronchorrhcea.~\
One effect of the constantly imperfect  oxygena-
tion of the blood which  attends bronchitis,  is a
stagnation and  congestion of blood in  the lungs
and heart; hence organic diseases of the heart,
and effusion of blood and serum, not unfrequently
supervene to its long continuance.
  Treatment  of Chronic Bronchitis. — In
the treatment of chronic bronchitis, as of all chro-
nic diseases, regard must be  paid to the  time
required for the cure, and the  strength economised
accordingly.  Unless in  case of a temporary in-
crease  of  pulmonary congestion, or aggravation
of inflammation, bloodletting is not admissible ;
for  besides its  bad effect  in  adding to the weak-
ness, which is one of the worst characters of the
disease, it has but little power to control the action
of vessels  under the influence  of chronic inflam-
mation. Those remedies are to  be preferred which
act on  the extreme  vessels,  whetber directly, in
the diseased part, or  by establishing a new action
in another part of the system.
  The objection which we urged against blisters
in the  acute disease does not apply  here; and
they are often in a high degree serviceable.   It is
generally necessary to repeat them several times ;
for  few cases  yield  to a  single application.  In
some constitutions they produce a great prostra-
tion of strength, and  in  others  their  beneficial
effects  do not continue : in such cases an effective
substitute will  be  found in tartarized  antimony,
as recommended in the acute disease.   The  sup-
purative inflammation  that this excites is  often
more efficacious in removing  inflammation from a
deep-seated  part than  the irritation of a blister,
the effects of which usually cease with the serous
discharge.   When it happens that a blister  sup-
purates, a more permanent  benefit is  obtained ;
but keeping up the irritation  by means of cantha-
rides or savine  ointment has not the same effect
and is  more painful than salutary.   Counter-irri-
tation by tartar-emetic may, by attention, be regu-
lated to any degree ; and by slight re-application
a constant succession of pustular  eruptions  may
bn. continued for months, if required.   From this
measure, conjoined with  internal medicines, we
have seen the happiest results in cases of the most
formidable  aspect; and we have  scarcely  ever
known it fail to give some relief.  It seems to mo-
derate the irritation and secretion of the bronchia]
membrane, which often changes from purulent to
mucous during its use; and it enables the system
to bear a tonic and nutritive regimen without ag-
gravation  of the  bronchial  disease.   It  is by the
success  of a measure of this  kind that a well-
known modern empiric has gained a name famous
enough to blind  many to the  gross ignorance
with which he has  applied it.
   [Dr. Graves (A System of Clinical Medicine,
Dublin, 1843,)  has  recommended the formula
published at page 222 of this volume, as an imi-
tation of the liniment of this empiric, (St. John
Long,) which, he affirms, is an easily manageable
and efficacious remedy.
   A large  portion  of the  chest  may be sponged
daily with  the liniment, so as to  keep up an ery-
thematous  state of the surface.]
   The utility of expectorants in the chronic form
of bronchitis has  been  called in  doubt by  the
question — on what  principle  can  they  be pre-
scribed, when the secretion  is already redundant ?
But let it be remembered that the power  of ex-
pectorants  is not  confined  to  increasing  the
bronchial secretion ;  they tend also to modify it.
Thus,  in  acute catarrh, under  the same  expec-
torant  that at  first tends  to moisten the  cough,
the mucous secretion  becomes  consistent,  di-
minishes,  and  gradually returns to its healthy
state.  Ipecacuanha  is  certainly capable of pro-
ducing  this effect, and is perhaps the most gene-
rally useful expectorant that we possess.  In some
cases it  may be  given with great  advantage in
emetic doses, repeated  every two or three days.
In some obstinate examples of the milder form of
the disease attacking persons of robust habit, this
practice has effected a cure.  As an expectorant,
it may be  given in the dose of a grain or two of
the powder, or twenty minims to £ss of the wine,
repeated several times in the day, according to its
effects, and combined with squill, colchicum, digi-
talis, and  opium, as  the case may require.  It is
a useful  adjunct  to  any  expectorant medicine,
and is  only contra-indicated in case of profuse
night-sweats.
   Squill is of decided utility in some  instances
of chronic coughs, but rather in cases which are
slighter and  unattended with purulent expectora-
tion.   It is generally useful to combine it  with
an alkali;  and a small quantity of opium may be
added  to  prevent  it  from  passing off too rapidly
by the kidneys.
   Wherever the circulation is much accelerated,
and the dyspnoea  is distressing, the tincture of
digitalis is very likely to afford relief; and those
cases which simulate phthisis are  frequently tit
subjects  for its  use ; but it is necessary to watch
its operations, both on account  of  its. effects on
the circulation,  and  its  tendency to disorder the
stomach and digestive organs.   The same thing
may be said of colchicum, which is highly spoken
of by Dr. Hastings, who recommends the tincture
in the  dose of twenty drops three times a day, in
creased or diminished according to the effects.
   The  lobelia infiata  is a medicine less  known 
BRONCHITIS —[CHRONIC]
341
 in this country than it deserves. Its action seems
 to be of the same  class as colchicum and squill,
 but  it is more decided in its effects, and therefore
 likewise requires greater care in its exhibition.  It
 may be tried  first in the dose of ten minims of
 the  tincture  three  times  a day ; in  many  cases
 this  may  be increased to forty or fifty; but in
 others not more than five minims are borne  with-
 out  nausea, vertigo, and a feeling of faintness.
 From the manner in which it relieves the dyspnoea,
 it is probable that it operates as a sorbefacient as
 well as an  expectorant.  It is especially service-
 able in those aggravations  of chronic catarrh,
 which Laennec designates by the title of suffoca-
 tive, and  which do, in fact, sometimes produce
 suffocation.
   In  such cases, likewise, ammonia becomes a
 valuable remedy ; and the one, in  extreme cases,
 when suffocation is threatened, on which we must
 principally depend.   From five to  ten grains of
 the  carbonate may be given in camphor mixture,
 and  repeated, if  necessary, every  hour or half
 hour, according to  its effects.  In  the weak and
 atonic cases, without profuse expectoration, it  is
 a useful adjunct to squill, ipecacuanha, and  other
 medicines, instead of the fixed alkalies ; and, con-
 joined with  assafcetida  or musk, it is well suited
 to diminish  the  convulsive  character of  some
 habitual coughs, which are very apt to wear down
 the  patient, and deprive him of his nightly rest.
   [Tar-water was  at one time  greatly extolled in
 pulmonary affections,  and, among the rest, in
 pulmonary catarrh,  and  in  chronic bronchitis;
 and since the discovery of creasote — the  main
 active ingredient in  tar-water — fresh trials have
 been made with it.   It is occasionally of service,
 where the ordinary excitant expectorants are indi-
 cated.   Creasote  itself has  been  given  in the
 same cases;  but it does not seem to possess  more
 virtue than tar-water.]
   It would be endless to go through all the re-
 medies that have been extolled as effectual expec-
 torants in chronic  bronchitis.  All  the balsams
 and  gum-resins have enjoyed this reputation, and
 fallen again  in disrepute : some, as copaiba and
 myrrh, have  been resumed by some practitioners,
 and  not without reason; but their utility is limited
 to cases of the atonic kind. Myrrh we have found
 really serviceable,  particularly  after a course of
 the other expectorants, when its grateful and  tonic
 effects on the stomach give it an additional recom-
 mendation.  Copaiba frequently disagrees  with
 the stomach;  but  when it is  well  supported, it
 often restrains and  modifies the bronchial secre-
 tion.  Neither  of these medicines is eligible when
 fever or vascular  irritability is present;  and it
 may be considered a matter of doubt whether they
 do not  act rather as general stimulants than pe-
 culiarly on the bronchial membrane.
   [The acetate of lead has been thought worthy
 of great reliance in bronchitis accompanied by
 profuse secretion ;  its administration being limited
 to the period  of the disease in which the secretion
 is excessive.  The dose should not exceed twelve
 grains in the day, to  the adult.]
  There is a class  of remedies from which, if
 they  were  better known,  much good might be
expected ; those, namely, directly applied to the
diseased  membrane  itself by  inhalation.    The
                                     2d*
 vapour  of water does not seem to possess any
 property to recommend it in chronic bronchitis,
 unless  it  be  in  those rare cases of deficient or
 very viscid secretion, where  it may be  of  some
 use in relaxing  the vessels  and facilitating ex-
 pectoration.  Whether combining it with chlorine
 or with the vapour of iodine,  as lately practised in
 Paris in consumptive cases,  may be of any avail
 in this  affection, we want data to determine.   It
 is probable that they can scarcely be exhibited for
 a sufficient length of time to be effectual in a very
 diluted  form ; and  when stronger, they decidedly
 irritate and prove injurious.
   The diffusion  of the vapour in the air of the
 apartment, as has  been done  with  tar, is a pre-
 ferable method, as it ensures  the constant appli-
 cation of the remedy  without extra fatigue to the
 patient.  The inhalation  of  tar-vapour  has had
 repeated and extensive trials since Sir A. Crich-
 ton directed the attention of British  practitioners
 to it; and although its utility in phthisis has not
 been confirmed, many have  testified to its bene-
 ficial effects in certain cases of chronic bronchitis.
 As  it is of a  stimulating nature, it proves useful
 only in cases free  from irritability or from ten-
 dency to active inflammation  ; and it is important
 to watch its effects when  first  employed, and to
 diminish or withdraw it altogether, if it decidedly
 aggravates the cough,  and  quickens  the circu-
 lation.
   [Iodine has been administered;—at times, alone;
 at others, associated with conium, as advised  by
 Sir  Charles Scudamore, in  tubercular phthisis (q.
 v.) ; but whilst some extol it highly, others have
 not observed the  least benefit from it.   Conium,
 and other narcotics, have been  used  in the same
 manner — twelve or fifteen grains of the extract
 being diffused  in an inhaling apparatus, and the
 vapour drawn into the lungs  for a quarter of  an
 hour, once or twice  a day.]
   Another class  of remedies may  in many in-
 stances of chronic catarrh be judiciously conjoined
 with those already  noticed ;  those,  namely, that
 deaden sensibility, and allay that mobility of the
 muscular  system  which  greatly  increases  the
 length  and frequency of the  fits of  coughing.
 The most powerful  of these narcotics,  of course,
 is opium ; but on account of its tendency to check
 secretions  and increase local  congestions, it  can-
 not  with propriety  be given  alone, unless occa-
 sionally, for the  sake of obtaining a  night's  rest.
 In this case the  acetate or sulphate of morphia,
 or any of the acid preparations  of opium, such as
 Battley's liquor opii sedativus, is to be preferred ;
 and these  will generally be found to be safer me-
 dicines for habitual  use, in combination  with
 squill and ipecacuanha or other expectorants, than
 the  tincture or solid form of opium.   The tine
 tura camphora? composita is  also  a  very usefu
 narcotic in chronic coughs of the less inflamma-
 tory kind.
   There are other narcotics of very high utility,
 and  which are free from the disadvantageous  pro-
 perties that opium sometimes  manifests.  At the
 head of these  may be placed conium, the extract
 of which, in the  dose of four or five grains threo
 or four times a day, very signally relieves cough
and  irritation of the chest.  Dr. Paris, who greatly
extols  this remedy,  recommends the dose to be 
31-2
BRONCHITIS —[SUMMER.]
inert ascd until it produce some giddiness, tremor,
and uuusea, or a heavy sensation and tightness in
the forehead ; unless some  of these sensations are
produced, he considers  that the remedy has  not
had  a fair trial.   It  is always advantageous to
combine it with ipecacuanha; and the extract of
hyoscyamus is  indicated where an additional nar-
cotic power is desired.  The extract or leaves of
belladonna, in  the dose of a  grain or two, we
have  found a useful adjunct where  dyspnoea is
present.  The  tincture of digitalis may be  used
with the same view ; and either of  these medicines
is to be preferred to the hydrocyanic acid, which,
notwithstanding the praises lavished on it, must
be considered at least a very uncertain remedy.
   Besides these means, directed against the  local
disease, it is of the greatest importance to  attend
to the state of  the functions in general.  When-
ever  any fever attends, the daily  exhibition of a
saline purgative is advisable.   In  the more atonic
cases, if aperient medicine be required, a  com-
pound colocynth or aloetic pill is  to be preferred ;
and where the cough shows a convulsive charac-
ter, we have seen the  greatest advantage  result
from the daily  use of the pil.  aloes et assafoetidae
combined with ipecacuanha.
   Should there  be, as there very often is, any
complication witb abdominal  disease, it is of the
first consequence that this be not neglected.  Thus,
when pain of the right side  and shoulder, with
fulness and tenderness  in  the right hypochondri-
um, stools of unnatural colour, a  foul tongue and
turbid urine, discover disordered  function of the
liver and  alimentary canal, it will  be proper to
put the patient under such  an alterative course
of blue pill and the like medicines as may be best
calculated to bring back  the healthy action of
these  important viscera.
   Again, where  a florid tongue, tender epigastri-
um, frequent  thirst, dry skin, and nightly  acces-
sion of fever, indicate that the disease extends to
the mucous membrane of the stomach and bowels,
it is quite apparent that many  of the remedies
directed against the bronchial disease will not be
borne  or will  prove injurious, until  the  gastritic
disease be relieved by leeches  and blisters to the
epigastrium, castor oil, the mildest alterative  ape-
rients, and warm baths, with  the  most rigid  regu-
lation of diet.  For more ample directions on this
head we must refer to the several  articles Gastri-
tis, Dyspepsia, &c.   Whether these diseases be
primary or secondary is  a consideration of less
consequence than that, as  long as they continue,
the action of all remedies on the bronchial disease
must be uncertain or prejudicial.  Thus it is that
even digitalis and colchicum may  prove stimulant
until the gastritic disease be subdued.
   If due attention be paid to  the removal of such
complications,  and if the disease do not present a
decidedly  inflammatory character, the weakness
uf the system  may be  combated  by tonics,  espe-
cially the sulphate of  quinine.   In  case of pro-
fuse  perspirations, these  are  scarcely  to be dis-
pensed with, and may properly be combined with
sulphuric acid.
   The diet in  all cases of  chronic  bronchitis
should be mild and simple in  its nature.  Farina-
ceous and mill"' food is that  best adapted to the
 plurality of casvs, particularly when accompanied
by gastritic disorder;  but in  those cases  that  re-
quire nutrition in a smaller bulk, simple animal
food is not to be  withheld.  Notwithstanding the
eulogy bestowed  by  Laennec on the spirituous
treatment of  chronic mucous catarrh, we  consider
spirits and all fermented liquors in themselves as
decidedly injurious; and they are only to be ad-
mitted in a very few cases, where their assistance
in the digestive process is absolutely required.
   It is scarcely necessary to insist on  the import-
ance of avoiding extremes and sudden transitions
of temperature, improper clothing, and all those
circumstances that are in themselves frequent ex-
citing causes  of the disease : when  re-applied,
they must necessarily prolong it; and not a few
instances are met with where, owing to the nature
of our climate, it is impossible sufficiently to avoid
them.  In these  cases, in spite  of the most  care-
ful administration of these remedies, the disease
persists ; but a perfect cure  is effected by simple
removal to a more genial climate.  This is, per-
haps, the most effective remedy that can be resort-
ed to ; and where the circumstances of the patient
do not permit him to adopt it to its full  extent, a
change of air to the distance of a few miles may
often be productive of good.  The careful regu-
lation of the air  in  his  apartments  must be his
resource  in  the  winter  months.   (See Climate
and Phthisis.)  It is of importance to attend not
merely to the temperature, but also to the hygro-
metric state  of the air;  and it may be  useful in
some cases to follow Dr. Paris's plan  of  diffusing
 the  vapour of water  through the room during the
prevalence of those dry easterly winds which irri-
tate  the  mucous membranes, and aggravate the
cough.
   Of the means which  may be  called prophylac-
tic against bronchitis, that of sponging  the chest
daily with salt water, or vinegar and water, de-
serves warmly to be recommended. If this, which
may be  practised by the most  delicate, and the
cold plunge  or  shower-bath for  those  stronger,
were more commonly resorted to, the number  of
pulmonary invalids would be greatly diminished.
   [But few invalids, who are  subject to bronchi-
 tis,  can bear with impunity the contact of very
cold air with the pulmonary mucous  membrane;
hence they are compelled to breathe through folds
 of gauze, or to hold  a handkerchief to the mouth,
whenever they are exposed to it.  An instrument
has been invented by Mr. Jeffreys, called  a Respi-
rator, which consists of several strata of fine wire,
through which the air can pass with facility ; and,
in its passage, have  its  temperature modified, so
that no irritation is produced in the  lungs.  The
invention is ingenious  and useful.]
                        C. J. B. Williams.
   [III. Acute Epidemic Bronchitis.  (See In-
fluenza.)
   IV. Summer  Bronchitis.—This  singular  af-
fection has received various names.  It has been
called Summer Catarrh, Hay Asthma,  Hay Fe-
ver, and Rose Catarrh, and  is met  with in the
summer and  autumnal seasons, both in this coun-
try  and  in Europe.   It has received those various
names as indicative of the period of the year  at
which it occurs, or of the causes that  give rise
to it. 
                        BRONCHITIS

  Diagnosis.—The most common symptoms are
itching of the eyelids, and, at times, of the inner
canthi of the eyes, with irregular attacks of violent
sneezing, sense of weight in  inspiration, and, at
times, considerable  dyspnoea, copious  discharge
from the  Schneiderian membrane,  redness of the
conjunctiva, and  sense of weight in the forehead,
with suspension—partial or entire—of smell  and
taste during the continuance of the disease.  The
exacerbations have  been commonly observed to
supervene in  the morning, a short  time after ris-
ing; but frequently  they appear several times in
the course  of the day.   Many letters  have  been
published from patients descriptive  of their suffer-
ings from this strange malady.  (Elliotson's Prin-
tiples and  Practice of  Medicine,  Rogers's  edit.,
p. 720:  Lond. 1839; and the writer's Practice
of Medicine, 2d edit., i. 273 :  Philad. 1844.) The
attacks appear at times with such regularity, that
individuals have made it a point to  transact im-
portant business  prior to a certain day of the year;
being aware,  from their experience, that on  that
day  they are  almost certain  of the  presence of
their annual visiter.
   The functional phenomena  of  the  disease do
not place it, as  one of  its  names  would import,
under nervous or spasmodic asthma.   It appears
lo consist  essentially in inflammatory irritation
of the mucous membrane of the eyes, nose, and
the whole respiratory apparatus, — the dyspnoea
originating in this cause.  It  is rather  a form of
chronic or subacute bronchitis, and scarcely  to be
regarded as a combination of catarrh and asthma,
as it has been by some.
   Causes.—The prevalent idea is, that summer
bronchitis arises  from vegetable matter diffused in
the atmosphere ;  that it  is derived from the flowers
of certain plants, and that, in  a great number of
instances, it comes  from  grass or  hay ; but  it  is
against the notion of the effluvia from hay being
a common  exciting  cause, that haymakers  them-
selves are  said to be entirely free from it; and
that it is often met with in  towns, where  such
effluvia,  if  they  exist at all, cannot be in any con-
siderable quantity.
   The rarity with which the  disease is seen suffi-
ciently proves that the predisposition lies in idio-
syncrasy, which  would seem at times to be derived
from progenitors.   When such predisposition ex-
ists, the smell of hay may act as an  exciting cause;
but  in other instances it may  be an emanation of
a very different kind.  The odour  of ipecacuanha
is one  of the  most frequent excitants :  with
others, the same effect is induced by the smell of
the  rose, the bean-flower,  the guinea-pig, &c.
(Sec.; and  the case of  an English  nobleman  is
recorded, who is affected with sneezing and  asth-
matic symptoms  if  he  touches a  hare, or  rather
the fur of a hare.   Cases of periodical bronchitis,
analogous in  their character to hay asthma,  occa-
sionally  occur in which bay can by no means
be ranked  as a cause.   An  interesting example
of this kind  has been  given by the writer  else-
where.   (Practice  of Medicine, i.  275.)
   Treatment.—It does not appear  that much
advantage is derived from medicine in this disease.
The cold shower-bath has been regarded as the
best prophylactic, especially when  associated with
the internal use  of  the sulphate of quinia and the
IRONCHOCELE.                    343

 sulphate of iron, which, although not wholly com-
 patible chemically, form a compound that has been
 productive of advantage ; two or three  grains of
 the former and one grain of the latter being given
 three times a day.  A journey to the seacoast has
 likewise been advised, and, from change perhaps,
 the  paroxysm has been  prevented.  When the
 disease  is fairly formed, it runs its course greatly
 unmodified by remedies.  It does not bear deple-
 tion well nor a sedative course ;  yet a drachm of
 the tincture of lobelia three times a day is assert-
 ed  by a recent writer to  generally afford  relief;
 whilst another has  found  a cup  of strong coffee
 without sugar or milk the most successful remedy.
   Too  rigorous a diet and too free exposure to aii
 have been prejudicial to almost all.
   Distressing as the affection is, it is consolatory
 to  know, that  during the  autumn it  gradually
 ceases and disappears,—too often to recur  at the
 same period in subsequent yeais.   The efforts of
 the practitioner can only palliate the urgent symp-
 toms, and even in this respect his powers will be
 found very limited, and his  attempts to  afford re-
 lief too often either wholly nugatory, or produc-
 tive  of unexpected  aggravation of the  symp-

                       Robley Dunglison.
   Bronchitis Asthenica.  (See Bronchitis,
 Chronic.)]
   BRONCHOCELE means, literally, a swelling
 of  the throat, from f}p6y%os, guttur, and Krt\n, tu-
 mor ; and, in fact, every indolent tumour on the
 fore-part of the  neck, until recent times, passed
 under  that  denomination.   Modern physicians,
 however, have confined the  term to a chronic en-
 largement of the thyroid gland, sometimes com-
 plicated with a morbid growth in the surrounding
 structure.  There is no precise name for the dis-
 ease  in  this country ; but, from being more com-
 mon in Derbyshire than other parts, it has some-
 times been  called  the " Derbyshire neck."  In
 Switzerland, where in many parts it is  endemial,
 it is called goitre, probably a corruption  of guttur,
 and is generally  an attendant on that humiliating
 state of body and mind known by the  name of
 cretinism.   There is, however,  by no  means an
 invariable fellowship between  the  two diseases,
 although Professor Fodere has ascribed  the men-
 tal imbecility to  the  state  of the  gland, (Traite
 sur le Goitre et le Cretinisme, 8vo., Paris, an 8,)
 and Dr. Rush, of Philadelphia, has even deduced
 a theory respecting its uses from  this  supposed
 causation among other things, (Medical and Phy-
 sical Journal, vol. xvi. p. 208.)
   The  tumour, as we have stated, is of a chronic
 or  indolent nature, increasing gradually, and often
 continuing for many years,  or even a whole life-
 time, without affecting the general health.  It
 usually appears in early life, and is much more
 common among women, especially  those of a lax
 fibre, than  among  men;  insomuch, that in this
 country it is very rarely met with in the male hex.
 [It would seem, however, that in Switzerland, and
 in  some parts of India, where the disease prevails
 extensively, the  proportion  of males is greater.]
 In all the cases admitted if  the Hamoshire Coun
 ty  Hospital auung the last  ten years, amounting
 to forty-nine, the patients have, with only one ex
 ception, been women.   We are informed by Di
— I 
344
BRONCHOCELE.
Forbes, that out of seventy patients treated at the
Chicester Dispensary and Infirmary during the
last nine years, only two have been males.  It  is
also worthy of notice, that both the  latter cases
occurred in boys  of a very feeble  and feminine
habit  of body, and very backward  for their years.
The disease has, in some instances, been observed
to make its first appearance  during parturition,
and, in other cases, to have made  rapid  progress
during  gestation or suppression of the  menses,
(M. Brun. These sur Bronchocele.  Paris, 1815.)
The swelling generally embraces the whole gland,
but is sometimes confined to  the lateral  lobes,  or
the middle lobe, separately.  It is usually soft and
rather  flabby to the touch, though  somewhat un-
equal in that respect, and is for the most part free
from pain and of a natural colour.   It varies  in
shape, at first presenting but little outline, and
while   of  moderate  dimensions,  possessing   a
more   rounded  and  compact appearance  than
it afterwards preserves.  When  of considerable
size it  has a pendulous form, not unlike the dew-
lap of  a turkey-cock, the bottom being the largest
part.   In point of magnitude it varies still more
remarkably; often  remaining through life of  no
very conspicuous size ;  in other cases increasing
to a degree  of hideous  deformity : sometimes it
rises as high as  the ears.  Alibert mentions one
instance in which it descended to  the middle  of
the sternum;  and another in which it was of a
tapering cylindrical shape, and reached to the mid-
dle of the thigh,  (Nosologic Naturelle,  t. i., pp.
466-468.  Paris,  1817.)   In cases  of great en-
largement it impedes respiration, deglutition, and
the return of  the blood  from the head, by its pres-
sure ;  thus  occasioning  hoarseness, wheezing,
flushings of the face, headach, giddiness, and,  in
some  instances, even  death.  In   these  extreme
cases there are occasional pains in  the  tumour,
and the skin becomes of a livid appearance, with
the veins on its  surface  much swollen.   The late
Dr. Parry, of Bath, often observed bronchocele to
follow diseases of the  heart,  epilepsy, and other
maladies in which the blood is propelled with ex-
cessive momentum to the head, (Elements of Pa-
thology, p. 187, 8vo.  Lond. 1815.)  Flajani has
seen it accompanied with palpitations and irregu-
lar and intermitting pulse ; and he believes that
fatal disease of the lungs has been induced  by
the consequent  disorder in the pulmonary circu-
lation, (Collezzione d'Osservazioni e Riflessioni di
Chirurgia, t. iii. p. 283, 8vo.  Roma.)
   On dissecting the tumour, Hunter and Baillie
found it to contain cells with a fluid more or less
viscid; and Mr. Benjamin Bell states this to  be
frequently the  nature  of the disease.   »These
cells," says Baillie, " vary in their size  in differ-
ent  parts  of the  same gland, and  in   different
swellings of the same kind in different individuals.
Some of them are so large as to  be  able to  con-
tain a small pea, but most of them are of a small-
er size.  The viscid fluid, when  the gland has
 been preserved  some time  in spirits, is  changed
into a transparent jelly.  From  this account  of
the morbid change of structure which takes place
 in bronchocele,  it seems not unreasonable to sup-
 pose that the swelling  depends  upon  a vitiated
 and increased secretion in the gland.  The secre-
 tion, being in large  quantity, gradually distends
the cells, increasing  thereby their capacity, and
this enlargement of the cells forms  the general
swelling of the  gland,  (Morbid  Anatomy, 8vo.,
pp. 87, 88.)  The tumour is sometimes steatoma-
tous.   It is rarely found to contain purulent mat-
ter.  Occasionally it  has been in part converted
into cartilage or bone.  Dr. Hedenus, of Dresden,
states that he has almost uniformly found  this  to
be the  case, (Graefe's Journ. der Cbir. b. ii. Ber-
lin.)   Sometimes the enlargement  of the  gland
is a true sarcoma. Dr. Mason Good names  it sar-
coma cellulosum, or  cystose  tumour, and  states
that it generally consists of " oval cells, currant-
sized  or grape-sized, containing  a serous fluid,
sometimes caseous,"  (Study of Medicine, vol. v.)
Celsus has briefly and accurately described the
appearances on dissection  in these words :  " Mo-
do caro hebes,  modo  humor aliquis, melli aquseve
similis, includitur; interdum etiam  minutis ossi-
bus pili immisti," (Lib. vii., cap.  13.)
   [Occasionally, tbe  whole organ is transformed
into an osseous capsule, filled with various  kinds
of matter, especially  the jelly-like, the suety, and
the  meliceric.   Dr. Gross (Elements of Patho-
logical Anatomy,  p. 16 :  Boston, 1839,) states,
that he has a specimen of the kind in his cabinet:
one of  the lobes  has  almost  disappeared; the
other  is converted into a firm,  solid capsule,  as
hard as bone, though scarcely a line in thickness.
On sawing through  this  osseous tumour, which
does not exceed the  volume  of a hen's egg, he
found  it  filled  with  a white,  lardy, friable sub-
stance, not unlike semi-concrete cheese.]
   There have  been instances in which the tumour
has exhibited  a complication  of  almost  every di-
versity of structure.  De Haen relates a striking
example of this, in a person who died of  dropsy
from visceral tumours.   " In cadavere horrendam
mole thyroidasam glandulam  nactus, publice dis-
secui.   Mecum auditores  mirabantur nullum fere
genus  tumorum dari,  quin in hac sola thyroidssaiii-
veniretur.   Hie enim steatoma, ibi atheroma, alio
in loco  purulentus tumor, in alio  hydatrius,  in
alio erat coagulatus  sanguis, fluidus  fere in alio,
imo hinc glutine loculus plenus erat, alibi calce
cum sebo mista," &c, (Rat. Medendi, pars vii. p.
285.)  These circumstances countenance the opin-
ion that the same causes may produce most of
the different kinds of tumour,  the  modifications
depending upon the difference of site,  habit of
body,  idiosyncrasy, &c
   There are some other  diseases with which bron-
chocele  might  be confounded, and  which have
indeed at times been included  under the same
name.   Thus, the thyroid gland is  occasionally
attacked  with  acute inflammation, though, per-
haps, less liable to it than most other glands of the
body.    In such cases,  however, the swelling is
more  rapid in  its progress than  in  bronchocele,
but does not attain so large a size :  it is firmer to
the touch, painful  on pressure, and the disease is
much  more liable to terminate in  suppuration.
Again, schirrus of the gland may be distinguished
from goitre by its great hardness, by  occasional
darting  pains  in the part, and  by its  generally
occurring in advanced age, and  seldom attaining
to any great size.  Alibert,  however, states that
he has seen an instance of true goitre terminating
in cancer.  (Nosologic  Naturelle )    Aneurisms, 
BRONCHOCELE.
343
though  they do  not  frequently  occur in  that
situation, might possibly be mistaken for broncho-
cele ; but they may be distinguished by their sud-
den appearance after violent exertion, particularly
in coughing or laughing, by their  being soft and
compressible,  by their situation directly in  the
course of the carotid arteries,  and  by their strong
pulsation.   The lymphatic glands  are sometimes
so enlarged, in scrofulous cases, as to form tumours
of considerable size in the course of the trachea;
they may, however, be distinguished  from this
disease by their greater tenderness on pressure,
sometimes by  an evident  sense of  fluctuation, by
their being  accompanied with swellings in other
parts, and  by  the state of the  general health. In
some instances, indeed, the thyroid gland has, on
dissection, been found in a natural state, the whole
of the  tumour consisting of a diseased state  of the
 lymphatic  glands and cellular  membrane sur-
 rounding it.   Instances have occurred of tumours
 arising in consequence of the lining membrane of
 the trachea being forced out between the cartilages
 in violent fits  of coughing, sneezing, laughing, or
 other exertions of the  lungs.  Cases of this kind
 are  styled  the  real bronchocele by M.  Larrey.
 They  might,  perhaps, with  more propriety, be
 called  hernia  gutluris  or  hernia  bronchialis,
 names which  have been  sometimes given  to the
 common bronchocele.   Certainly, however,  this
 is not the disease which has been usually known
 by the name of bronchocele, and to which the
 terra is now almost universally confined ; and as
 we are not at present  considering the nosological
 propriety of the designation, we  would include
 such cases among the spurious goitres.   Their
 most characteristic symptom  is the complete dis-
 appearance of the  tumour when compressed. The
 voice, too, is almost entirely lost, and the respira-
 tion performed with the mouth wide open.  Larrey
 observed it  most frequently among the blind peo-
 ple who are employed by the priests to chaunt at
 the tops of the minarets  in Egypt;  and  he  met
 with two cases of it in subaltern officers, who had
 for a considerable  time been employed as military
 instructors.  (Medical  Gazette, vol. vii.  p. 88.)
 Dr. Barton, in his memoir on goitre as it prevails
 in America, states,  on the authority of  Fodere,
 that air has sometimes been forced, in like manner,
 into the substance of the thyroid  gland  and the
 surrounding cellular membrane.   (Medico-Chi-
 rurg.  Trans, vol. xi.  p. 242.)   Whether this be
 so or not, it appears certain, from the statement
 of various autbors, that the tumour is often in-
 creased on exertion of the  lungs.  Goitre may
 also be confounded with  encysted tumours situ-
 ated  in the course  of the trachea.   The  latter,
 however, are  generally rounder, more moveable,
 more elastic, and more equal to the touch : they
 are sometimes diaphanoua, and fluctuation may
 often  be perceived on pressure.   The period of
 life, too, may  at times  assist in the diagnosis.  In
 addition to these, spurious or complicated  cases
 of bronchocele, there are other instances in  which
 the gland itself is healthy, and the  tumour consists
 of condensed cellular membrane, sometimes inter-
 spersed with cysts.  Sometimes a  cyst, filled with
 matter of  a pultaceous or purulent nature, has
 been  formed  around  the  gland; and there have
   Vol I.— 44
been cases  in which the  enlarged  gland was sur-
rounded by a yellow fatty mass.
  We are so completely unacquainted with the
uses of the thyroid gland, and consequently with
the  peculiar causes of disease  in it, that it is not
wonderful, perhaps, that  there should  have been
so much conjecture and discordance  of opinion
with respect to the origin of bronchocele.  What-
ever may be the  primary  source  of the disease,
there is  much reason for supposing  that, once
established, it is often continued in families by in-
heritance ;* or, at least,  that a strong  predisposi-
tion to it is in this manner acquired.   Thus we
have known a woman with goitre, whose  grand-
mother,  father, paternal  aunt, and cousins, also
had  it; although  they did not all live in the same
place,  and no other  person in their  neighbour-
hood was affected with  the disease.   Similar in-
stances  have presented   themselves  to  others;
(Thomas's  Practice of  Physic, p. 573,  2d ed.,)
and it is well known that where cretinism pre-
vails, infants are often born with goitre.  In such
places, therefore, the effect of intermarriage among
the inhabitants is not to  be overlooked, as tending
to spread  and perpetuate it.   The  disease has
sometimes been attributed to a scrofulous  taint in
the  constitution ;  but as it is only met with  in
particular  districts, as it is not always nccompa-
nied with swelled lymphatic glands or disordered
general health, and as the tumour in bronchocele
is scarcely known  to suppurate  spontaneously,
while, on dissection, it has mostly been found  of
a totally different nature  from  strumous swellings,
the conjecture must  be  abandoned.   It has been
held by some that bronchocele arises from a defi-
ciency of nutritive  food ; and Dr. Mason Good
countenances this opinion.  He  states, that on a
visit  to  Derbyshire  "he  found  a  much larger
number of the poor affected with this disease than
he had ever seen  before, while the rich escaped ;
and he found, also, that  by far the greater part of
those who were labouring under it were not only
exposed  to all the ordinary evils  of poverty, but
derived their chief diet from that indigestible and
innutritive substance the Derbyshire  oaten cake,
which,"  he adds, " is probably the chief cause  of
all  the glandular and parabysmic enlargements
which are so  common in that quarter."   (Study
of Medicine, vol.  v.  p.  416.)  That  insufficient
nutriment may concur with other causes  in pro-
ducing the disease, is probable enough ; but that
this is its principal  origin is an untenable idea ;
since, in countries where the malady prevails
endemically,  the  rich are by  no  means  exempt
from it.   There  are other circumstances  besides
diet, too, capable, it may be, of producing it, and
to which the poor are more exposed than the rich,
as  we  shall  presently  show.   And  lastly,  the
oaten  diet, to which  Dr. Good attributes tbe dis
ease in Derbyshire, is still more exclusively  used
in Scotland, where the  disease is of rare  occur-
rence.
   It was long supposed, from goitre prevailing s,«
generally in mountainous countries, that it arose
from the habitual  drinking of snow-water.  This
notion seems to have been derived from Pliny,
  * Dr. [Sir] James Clark. Notes on Climate, Diseases, &c.
in France, Italy, and Switzerland, p. .'09, London, 1P20. 
346
BRONCHOCELE,
(Lib.  ii. cap. 37,)  and  copied  by  succeeding
writers, because  it tallied with  their doctrines of
cold and crude matters.  When it is  considered, ]
however, that no such cause exists where the dis-
ease prevails in this country ; that it is  rare in
Scotland, though common  in many parts of the
south of England ;  that the Swiss, wbo live con-
tiguous to  the glaciers, and drink no  other water
but what flows from the melting of ice and snow,
are free from the disorder;  and  that it is never
met with in Greenland, where  snow-water is the
common drink ;  while in Sumatra, where snow is
never seen, it is  of frequent occurrence ; it is evi-
dent that we must look for some other cause. Dr.
Richardson,  indeed, in his journey  with Capt.
Franklin to  the  shores of the Polar Sea, ascer-
tained  that at Edmonstone, where,  it seems,  a
residence of a single year is sufficient to render a
family  bronchocelous, the  disease is  seldom met
with in those who  drink melted  snow, but is al-
most exclusively confined  to those who use  the
river water.  (Franklin's Narrative, &c. pp.  118,
119.)    This circumstance, on the other hand,
countenances the opinion that goitre arises from
certain calcareous  or other impregnations of the
water  in common   drink.   The same view  is
strongly favoured  by Dr.  Bally, a native  of a
goitrous district  in Switzerland.  He says, "Bron-
chocele appears  to  me to be produced by certain
waters  which issue from  the  hollows of rocks,
trickle  along the cliffs of  mountains,  or  spring
from the bowels of the earth. That this is the case
I may instance some fountains in my own coun-
try, (Departement  du  Leman  au Hameau  de
Thuet,) the use of whose  waters will, in eight or
ten days, produce or augment goitrous swellings.
Such  of the inhabitants of the above village  as
avoid  these waters are free from  goitre and cre-
tinism."   (Diet, des Sciences  Medicalcs, t. viii.)
   Dr. Coindet states that  the use of hard water,
or the pump-water  of the lower streets of Geneva,
brings on the goitre very speedily, (Observations
on the  remarkable effects of iodine, &c. p. 7;) and
Dr. Manson  attributes the prevalence of the dis-
ease in Nottingham to the same cause.  (Medical
Researches on the effects of iodine, pp. 4,  5, 8vo.
London, 1825.)  The frequency, also, of  its oc-
currence in  the valleys of the chalky districts  in
Hants and Sussex  is certainly in favour of these
views.   In the central parts of Hampshire, how-
ever, we have almost uniformly met with it in the
valleys only; and even there its frequency is  by
no means  so great  as, in  our  opinion, to  justify
the conclusion that it arises solely from the nature
of  the  waters.  That it should  prevail to a far
greater extent in these vales than in  many much
more confined valleys in the more northern parts
of the island, may possibly arise  from the greater
moisture of the soil  where the  substratum   is
chalk : and partly, perhaps, from the greater de-
gree of miasmatic evaporation  occurring under a
more southern sun.
    [A  modern writer  on  bronchocele, Dr. Inglis,
 ' Treatise on English Bronchocele, London, 1838,)
 affirms, that the presence of magnesian limestone
 always implies  the co-existence of the disease;
 and Mr. M'CIelland, who  had  numerous oppor-
 tunities for observation in  India,  (Some Inquiries
 m the  Province of Kemaon relative to Geology,
&c. Calcutta, 1835 ; cited in British and Foreign
Medical  Review, for July 1839, p. 103,) states,
that in the course of his professional inquiries,
which extended over 1000 square miles, and were
prosecuted without any regard  to  theory, no in-
stance occurred, in which  goitre prevailed to any
extent, where the villages were not situate on or
close to limestone rocks.   Still, there are many
places, as the Vallais, in which there are no lime-
stone formations ; and in other places, where the
disease prevails, the water contains no calcareous
salts.]
   Whether or not the disease be necessarily con-
nected  with the impregnations  of the water  in
those places where it prevails, every circumstance
in  its history tends to prove  almost beyond a
doubt, that it is induced by the agency of some
one or more physical causes upon the constitu-
tion.   Larrey observed that almost all the inha-
bitants in the valley of Maurienne were affected
with  goitres,.(Mem. d-e Chir. Mil. t.  i. p. 123;)
and Postiglione remarks that, in Savoy, Switzer-
land, the Tyrol, and  Carinthia, there  are villages
in  which all  the inhabitants, without exception,
have these swellings;  the form and position of
which  are considered  as indications  of beauty.
 (Memoria sulla  natura  del gozzo, p. 22.)  Pro-
fessor Fodere, in  his journey  to  the maritime
Alps, made numerous observations in proof of its
being a disease of low and moist regions.  In the
chief village of the valley La Roja, which is situ-
ated  on  high ground, there is not a goitre to be
seen, though it is very prevalent in the immediate
neighbourhood, whicb is comparatively low.  He
found, indeed, that all elevated regions, and all dry
situations, whether warm or cold, were exempt from
the disease ; and he conceives tha*. throughout all
climates, i.  takes  its rise from the  same cause
—the humidity of the  valleys.  Dr. [Sir James]
 Clark, in  his " Notes on  Climate,  Diseases, &c.
in  France, Italy, and Switzerland," states that he
 agrees in most  respects with  Fodere as to  the
 origin of goitre, and expresses his opinion, that it
 is  probable,  if the villages situate in the low,
close, marshy situations of the Vallais, were  de-
stroyed, and the inhabitants removed to elevated,
dry situations, cretinism and goitre, which he be-
lieves to arise from different degrees of the same
cause, would disappear.   Dr. Gibson, also, in the
first number of the Philadelphia Journal for the Me-
dical and Physical Sciences, has collected a great
number of facts leading to the same conclusion.
   It  appears  from his statement, that bronchocele
may  be found as an endemic disease in all moun-
 tainous and marshy districts of the United States;
that  it generally prevails in valleys at the bottom
of  the highest mountains, in  the  neighbourhood
of  rivers, falls, lakes, or of the sea, and where the
soil is rich and sheltered.  Dr. James Johnson, in
his Excursion  through France, Switzerland, and
 Italy, recently published, has  some excellent re-
 marks on the physical causes of bronchocele and
 cretinism in tbe valley of the Rhone, drawn from
 his own personal observation.   •• Were this valley
 beneath a tropical sun," says he, " it would be the
 seat  of  pestilence  and death.  As it is, the air
 must necessarily be bad ;  for the  high ridges of
 mountains, which rise like walls on the north and
 south sides,  prevent a free ventilation ,  while in 
B R O N C H
summer a powerful sun beats down into the valley,
rendering  it a complete focus of heat, and extri-
cating from vegetation and humidity a prodigious
quantity ol malarh.  In winter, the high southern
ridge  shuts  out the rays of a feeble  sun, except
for a few hours in the middle of the day;  so that
the atmosphere is not  sufficiently  agitated at any
season of  the  year.   To this  must be added  the
badness of the waters, which, along the  banks of
the Upper Rhone are superlatively disgusting."
In  farther allusion to the  same subject,  he states
that, " it is remarked  that cretinism is  bounded to
certain  altitudes above the level of the sea.  The
Vallais itself, and  tbe  ravines  or gorges of the
mountains by which  it is enclosed, are  the chief
seats of this  deformity.  All, or almost  all, those
who inhabit  the  higher ranges of the mountains
overlooking the valleys, are exempt  from the ma-
lady.   This  single fact proves that  cretinism is
owing to a physical rather than a  moral cause, or
series of causes.  There can be no material differ-
ence  in the moral habits  of peasants  residing at
the base and on tbe brow of the same mountain.
If the former be more subject  to goitre and cre-
tinism than the latter, it must be owing to some-
thing in the air they breathe, the water they drink,
or  the  emanations  from  the  soil  on  which they
reside.  Saussure, Ferrus, Georget, and  all those
who  have  personal  knowledge on  the subject,
 acknowledge  that at a certain height (five or six
 hundred toises) among  the Alps, goitre and cre-
 tinism  disappear."   «In short,  we  find in  the
 Vallais, and  in the lower gorges or ravines that
 open  on its sides, both cretinism and bronchocele
 in  the  most  intense degrees ; as we  ascend the
 neighbouring mountains, cretinism disappears, and
 goitre only is observed; and when we get to a
 certain altitude, both maladies vanish."   (pp. 56
 to 58.)  We  believe that careful  observation of
 the  circumstances  under which  bronchocele is
 found to  prevail in  certain districts  of our own
 country would lead to similar views respecting its
 origin; and in this manner may be explained the
 fact, that  with us it almost  exclusively affects the
 lower  orders,  who are of necessity tbe  most ex-
 posed to such causes, and to those concurrent cir-
 cumstances which  poverty  and ignorance entail
 upon them.   Dr. Reeve, who visited  the Vallais
in 1805, for the purpose  of making personal ob-
 servations  on the causes of goitre  and cretinism,
remarks that  " all the cretins he saw  were in ad-
 joining houses in the little village called  La Batia,
situated in a  narrow corner of the  valley :  the
houses  being built up under ledges of the rocks,
and all of them very filthy, very  close, very hot,
and miserable habitations.   In villages  situated
higher  up the mountains,  no cretins are to be
seen."  (Edin. Med. and Surg. Journ. vol. v. p.
33.)  It would be  wrong, however, to pass over
the observations  of the  celebrated  Humboldt,
which certainly tend to throw some  doubt upon
these views.  He observes that, in South  America,
bronchocele is met  with both in the upper and
the lower course of the Magdalen  river, and  on
the flat high country of Bogota, 6000 feet above
ihe bed  of the river.   The first of these regions is
a thick  forest, while the  second and third present
a soil destitute of vegetation.  The first  and third
are exceedingly damp, the second peculiarly dry.
OCELE.                                347

In the first the air is stagnant, in the second and
third  the winds are impetuous.   In the two first
the thermometer  keeps up all  the year between
22° and 23° of the centigrade  scale; in the third
it ranges between 4° and  17°.  The waters drunk
by the inhabitants of Mariguita, where goitres are
tbe most hideous, are  not those  of snow, but of
springs  which flow over granite.   He states, also,
that the disease is progressively  extending  itself
from the lower provinces to the flat elevated re-
gions of the  Cordilleras.  (Journ. de Physiologie,
par F. Magendie, t. iii. p. 116.)
  Ramond, likewise,  in his observations on the
Pyrenees,  informs us that cretinism  and goitre
exist  among  these mountains even in greater ex-
tent and  degree  than in the Vallais, and under
circumstances  of locality very different; namely,
in open, well-watered, and well-ventilated valleys.
Upon the whole,  therefore, we are  scarcely war-
ranted  by  facts in considering that bronchocele
has its origin in any one exclusive source; though,
as we have  already stated, we think  it probable
that most frequently it is the offspring of a close,
stagnant atmosphere, impregnated with moisture
and the effluvia of the subjacent soil.
   [There is  something, at present, inscrutable in
the character of the locality which gives occasion
to the disease; and in reality we seem to know
no more of the immediate cause of this endemic
than of that of endemic diseases in general.   (See
the writer's Practice of Medicine, 2d edit. i.  557:
Philad.  1844.)]
   As bronchocele arises without our being able to
trace  with certainty its cause, so  does it often un-
expectedly disappear without any assignable rea-
son, even after resisting all the  approved remedies.
This  has frequently occurred under a change  of
residence, a circumstance which favours the  view
that we have  considered  the  most probable re-
specting the  origin of, the disease.   Alibert states
that  he has  known  many ladies in whom the
tumour has  subsided after a  residence of some
time in  Paris.  (Nosologic Naturelle, t. i. p. 473.)
   Treatment.—A variety of means have  been
employed for its cure,  both of a local and general
nature.   The former used to consist of dry rub-
bing the part;  bathing it with cold water; friction
with  stimulating lotions, liniments, or ointments;
mercurial applications, leeches, and blisters, kept
open  or repeated.   Electricity also has been em-
ployed,  and latterly galvanism, it is said, with some
success.
   Of the internal remedies, till within these few
years, the most celebrated was burnt sponge. This
was generally exhibited in doses of ten grains to
half a drachm, three times a day, in the form  of
an  electuary, infused in wine,  or  made into  a
lozenge, which was kept under  the tongue till dis
solved,  from  an idea that, in this manner, its in-
fluence  was more direct and speedy.  It was usual,
however, to accompany this remedy with  altera
tive medicines and  purgatives, chiefly mercurial;
and  although  we believe  the  efficacy of burnt
sponge, when unadulterated,* to be undeniable, il
  * It  is  stated by Dr. W. Gairdner, that chemists are in
the habit of substituting  charcoal  for burnt sponge, of
wliich an i't:l 'Liable proof is the fact, that it is sold at a
less price tlnn unburnt  sponge can  be bought for.  In
this manner i'r. Gairdner explains  the inefficacy of this
medicine in the iiands of  British practitioners, whilst it) 
348
BRONCHOCELE.
might not perhaps be easy to assign its exact share
»s a remedy when  combined with others.  That
mercurial  preparations,  internally  administered,
have in some cases cured the disease, even when
burnt sponge has failed, thore  can be little doubt.
There is an instance related  by Mr. Davies, of
Arelsford,  in  the 13th vol.  of the Medical  and
Physical Journal, in which two pounds of sponge
had been  taken without any  effect, and yet the
tumour entirely disappeared  in the course of ten
days, while the patient was taking mercury inter-
nally for some other ailment.  Preparations of
soda, potass, and iron; the muriates of barytes
and lime ; egg-shells, burnt hartshorn, and  even
burnt toads, have likewise  been  recommended.
Courses of sea-water, or mineral springs, and the
use of distilled water, which has appeared to Pro-
fessor Odier, of  Geneva, (who ascribes the disease
to the qualities  of the water,)  to  prevent the in-
crease of the swelling, and even to lessen its bulk,
have also been advised.
   Of all the medicines, however, which have been
administered for bronchocele, the substance called
iodine  is  unquestionably  the  most efficacious,
though it may  not deserve the  name of a specific,
which some of its advocates have been inclined  to
claim for it.   Of one  hundred and twenty cases,
treated by Dr. Manson, of Nottingham, where the
disease  appears to be endemic, seventy-nine were
cured, eleven  greatly relieved,  and  only  two de-
rived no relief.  (Medical Researches on the Effects
of Iodine.)   It is now considered certain, that on
the presence of iodine in burnt sponge depend the
virtues  of  the  latter in the  cure of goitre.  The
discovery of this fact is disputed between  Dr.
C'oindet of Geneva,  and his  countryman,  Dr.
Straub of Hofwyl.   There is no reason, however,
to suspect that either was aware of the other's
researches while prosecuting his own.  Dr. Straub
appears to  have been led  principally by the simi-
larity of smell  between iodine, burnt sponge,  and
other marine productions, to suspect the existence
of the former in these substances.  Dr. Coindet,
whilst making researches for other purposes, found
that the fucus vesiculosus, or bladder-wrack,  had
been recommended  by Russell for the cure of goi-
tre ; and as it is from this plant, and other species
of the same family,  that the  soda, with which
iodine is generally found combined, is extracted,
he was led to suspect that the virtues of sponge,
likewise a marine production, might depend upon
the same active principle ; a conjecture which was
soon after confirmed by the discovery made by Dr.
Fyfe, of Edinburgh, that  iodine existed in  the
ashes of burnt sponge.   M. Roulin  has found,
likewise, that the aceyte de sal, a South American
remedy  for the  disease, contains iodine.  (Magen-
die's  Journ.  de  Physiologie, t. v. p. 273.)  In
whatever manner the question  of  originality  may
be decided, it must be admitted that to Dr. Coin-
det's exertions we are principally indebted for the
speedy and extensive adoption of this new medi-
cine.  In goitre its  effects may be obtained either
by local application to the tumour, or by adminis-
tering it internally.   Where the  former  is suffi-

• irtues are so palpable and evident at Geneva that not
only physicians, but also the inhabitants in general are
non vi need of their reality.—Essay on the Effects of lo
dine, p. 2, fevo London, 18'24.
cient, it  is preferable  to the latter.   The formula
recommended by Coindet, and by Professor Brera
of  Padua, is that of an  ointment, composed of
half a drachm of hydriodate of potass mixed with
an  ounce and a half of lard,  of which a drachm
should be rubbed in over the surface of the swell-
ing, morning and night.  Brera, also, uses  an
ointment consisting of a  drachm  of pure iodine
and an  ounce  of lard.   Of this,  the quantity to
be rubbed  in is a scruple at a  time.  Dr. Manson
uses  a liniment,  composed of a drachm  of the
tincture  of iodine  mixed  with an  ounce  of the
liniment, sapon. comp., which may  be kept in a
phial, and the evaporation of the iodine, that takes
place in the ointment, be thus, he says, prevented.
For internal administration,  the  preparation  in
most common use  in this  country is tbe tincture.
Coindet directs this to  be made,  by  dissolving
forty-eight Genevese grains of iodine (forty grains
troy weight) in one ounce of  alcohol.   As, how-
ever, the strength of the  spirit varies, and it is
liable to evaporate, a weaker tincture is preferable,
from which the iodine is  less likely to be depo-
sited, and thus the deleterious  action on the bow-
els, which has  appeared  to Dr. Gairdner to be
more marked in proportion to the free iodine in
the preparation, avoided.   Dr. Manson directs the
tincture  to be made in the proportion of twenty-
four grains of iodine to an  ounce of rectified spirit;
and the  dose of this may be from fifteen to thirty
drops, three times a-day, taken in some distilled
water.  The dose of Coindet's  tincture is from ten
to twenty drops ; but Dr.  Gairdner, who has had
considerable  experience  in the use of iodine, and
has given us an excellent description of its occa-
sional mischievous effects, conceives this to be the
most objectionable  form  in which it is used; and
in this Dr. Kolley of Breslau seems to agree with
him.   (Reflexions, &c.  sur l'emploie de  l'iode.
Journ. Comp.   Fevrier,  1824.)  Iodine may also
be  given in the form of  pills, containing each
half a grain, made, as Brera  directs, with  elder-
rob and liquorice-root.  Dr. Gairdner prefers the
solution  of the  hydriodate  of potass  to any other
preparations, for internal use.   He directs it to be
made by dissolving half a drachm  of the hydrio-
date in one ounce of distilled  water; the dose is
from ten to twenty drops.   Dr. Manson prepares
it with twenty-four grains only to  an ounce—
Coindet witb thirty-six.  By adding ten grains of
iodine to this last, the solution of ioduretted hy-
driodate  of potass is formed, which Coindet con-
siders the safest preparation for internal use. The
dose of this  should not  exceed  five drops, three
times a day, on  its first  exhibition.  There is an
alcoholic, or ethereal tincture also, used  by Coin-
det, which, next to the last, he  prefers. Dr. Gaird-
ner states that he  has seen reason to believe that
bleeding from the arm in plethoric patients accele-
rates the effects  of the medicine, when absorption
is slow.  Goitrous  tumours are subject te sudden
augmentation of size during catarrh, or in febrile
states of the body, and  the efficacy of the local
application of iodine seems to be increased in such
circumstances by a  preliminary application  of
leeches.  Dr. Coster relates a case in the Archives
Generates de Medecine,  for July 1823, in which
galvanism and friction with iodine completely re-
moved a bronchocele, although  neither of '.hem 
BRONCHOCELE.
349
was successful  by itself.  And there can  be no
doubt that,  when  required, it  is  necessary to
improve the general health,  in order to afford the
remedy  a fair chance of success.
  When iodine is  administered internally, it is
necessary to avoid  combining it with substances
which may decompose it; it should be taken when
tbe stomach  is empty, and its effects  carefully
watched, as it has  sometimes produced the most
serious  and  even  fatal consequences; though,
under proper caution, it may be given with  per-
fect safety.   Dr. Kolley, who was  himself cured
of goitre by  means  of iodine, after all other reme-
dies had failed, and who has both taken and pre-
 scribed  it largely, gives us some instructions with
 respect to the circumstances which have appeared
 to him  to contra-indicate its  use.   He states that
 it is improper when there is a disposition to con-
 gestion in the head or other internal parts ; when
 febrile  or inflammatory  symptoms are present; in
 cases where there is diarrhoea, dyspepsia, or other
 gastric  affection, or hepatic  disorder ; when there
 is a disposition to hydrocephalus ;  and in phthisis
 pulmonalis, for which it has been  extolled  as  a
 remedy by some others.  (Op. cit. — or Medico-
 ('hirurg. Review, Vol. vi. p. 229.)   Dr. Gairdner
 informs us,  that so  great  had been the  ravage
 committed by the imprudent use of this medicine
 in the Pays de Vaud, that the government of that
 canton issued an injunction against its sale, ex-
 cepting under the signature and responsibility of a
 physician.  The mischievous effects which follow
 its use are generally insidious in their  approach.
 The patient becomes affected with a sense of faint-
 ness, tremor, and sinking ;  dimness of vision, pal-
 pitation, and other  symptoms of a nervous kind.
 The degree of tremor, Dr. Gairdner informs us, is
 sometimes so great, as to present some resemblance
 to chorea, though the limbs can always be  kept
 steady, when not called  on for exertion.   More
 violent effects than these occur at  times; symp-
 toms apparently proceeding from  the direct and
 acrid effects of iodine on tbe alimentary canal, and
 strongly resembling the Indian cholera: — violent
 and incessant vomiting, strong spasms of the back
 and legs, extremely frequent, small, and oppressed
 pulse, urgent thirst, and excruciating pain of the
 stomach and bowels ;  the latter being sometimes
 violently purged, at other times  obstinately con-
 fined.  For the prevention  of all bad effects  from
 the use of iodine, it is  an excellent rule to begin
 with small doses, and increase them gradually, so
 as never to exceed the minimum quantity required.
 (Dr. E. Barlovj.  Edin. Med. and Surg. Journ.
 Vol. xxi. p. 337.)  The muscular  spasms and the
 disturbance of the  nervous  system  appear to be
 more benefited by attention to diet,  air, and exer-
 cise, than by medicines.  Of the latter, all that is
 required are mild aperient medicines, which, com-
 bined with gentle exercise in the open air, a mild,
 sparing, and nutritious  diet, abstinence from wine
 and  other stimulants, and  the use of  the warm
 bath, soon restore  the  patient to health.   In the
 choleric affection, the remedies of much the great-
 est use are opiates, henbane, or hemlock, together
 with the warm bath,  and  mucilaginous  drinks.
 Purgatives and bitters are decidedly injurious. In
 the second  stage, when there appears to be an
 actual ulceration of the mucous membrane of the
                                       2e
bowels, the pulse,  instead  of being  small  and
oscillating, becoming  firm   and bounding,  the
treatment  requires  much  more discrimination.
The diarrhoea, which assumes a dysenteric form,
is best treated by the union of opium and ape-
rients.  The emaciation which follows the  im-
proper use of iodine is  rapid and extreme.  On
some parts of  the continent, a  wasting of the
mamma has occasionally been observed, during its
use, even when cautiously administered ; and we
have ourselves witnessed this effect.  Dr. Manson
found  it,  in one  case, to excite  ptyalism.  The
external  use of the remedy  seldom produces  any
unpleasant effects on the general system ;  but  it
sometimes stimulates the arterial vessels  of the
tumour  so powerfully  as  to produce  pain  and
inflammation.  In such cases, it may occasionally
be  necessary to bleed  the patient from the arm,
lest the inflammation should extend to the trachea;
but, in general, the discontinuance of the medicine,
together  with fomentations, poultices, and leeches,
is all that is required.
   [The preparations of bromine, as well as bromine
itself, (see the  writer's  New Remedies, 4th edit.:
Philad. 1843,)  appear to be equally  efficacious  in
the treatment of goitre ; but they are not as much
employed.]
   When both external  and internal remedies fail
in discussing the tumour, surgical measures have
been adopted to destroy or remove it.  Of the
former, the application of caustics, as recommended
by  Celsus, is  the  oldest.   This, however,  is  a
dangerous as well as a  painful and tedious mode
of cure.   Hemorrhagy, all but fatal, has sometimes
occurred  from it;  and Dr. A. T.  Thomson relates
an interesting case, in the eleventh volume of the
Medico-Chirurgical  Transactions, in which, from
empirical application of quicklime to an enormous
goitre, the most  dreadful inflammation, delirium,
and sloughing ensued.  The tumour has some-
times been punctured with a trochar when it  con-
tained cysts, or cut  into with the  scalpel.   The
latter, it appears, is a  very common  practice  in
Denmark; but unless  a drain be in this  manner
instituted in the part, no very permanent benefit
can be expected  from it;  and when suppuration
does ensue, dangerous  and  even fatal symptoms
have occurred from the formation of sinuses and
sloughing.  (Flajani, Colezzione d'Osservationi,
&c. t. iii. p. 283.)   Issues,  also, have  been estab-
lished in the. part, sometimes with success. Their
operation  apparently consists in breaking down
the tumour by the suppurative  process, but  they
may also act by communicating a stimulus to the
absorbents.  Goitres have been  cured by sponta-
neous suppuration,  or  by the  inflammation and
suppuration  arising from   accidental blows  or
wounds.   It is reasonable  enough, therefore,  to
expect that similar  processes artificially excited
should be followed  by like good effects.   When
circumstances  have  rendered such means advis-
able, the introduction  of one or more setons  in
the tumour is the most effectual mode of accom
plishing  it, and  attended with the  least risk ol
forming  sinuses.   Several writers of the last  cen
tury recommended  this mode  of treatment foi
goitre, but the attention of practitioners in this
country  has been principally attracted  to it by
the Memoir of Dr.  Quadri,  of Naples, published 
350
BRONCHOCELE.
in the 10th  volume  of the  Medico-Chirurgical
Transactions ; and  the  operation has since been
frequently  performed in England.   Some cases
are published in the 11th volume  of the  Medico-
Chirurgical Transactions, and in tbe 90th number
of the London Medical Repository; from which
it will appear that  the  operation is not so uni-
formly successful and free  from danger as Dr.
Quadri found it to be.   Alibert mentions a case
in which a seton produced  a partial diminution
of the swelling ; but two years after it was with-
drawn, the  tumour became painful, suppurated,
fifteen pints  of matter were discharged,  and six
ounces daily for  three  months after; yet, not-
withstanding, the  disease was only partially re-
moved. (Nosologie Naturelle, t. i. p. 466.) That
the success or failure of this remedy is  in some
measure dependent upon the nature of the swell-
ing is extremely probable, but from what specific
difference in  that  respect the difference  of effect
may arise we are  as  yet  entirely ignorant.   Dr.
Quadri states that he has passed a seton sixteen
times in as many  different directions through tbe
tumour without  any untoward accident.   In one
instance, endeavouring to perforate  it pretty deep-
ly, an unusual quantity of blood flowed from tbe
wound, perhaps more than  an ounce;  and the
tumour seemed to swell, as if injected with blood;
but the bleeding  ceased  spontaneously,  and he
states his conviction, that  unless the needle were
pushed deep enough almost to touch the scuti-
form cartilage, the principal trunks  of the thyroid
arteries would not be injured.  He states, also,
that the  consecutive  inflammation is of trifling
consequence.  When we consider,  however, that
the blood-vessels  of the tumours  are frequently
very much enlarged, there  may, without doubt,
be occasional risk of hemorrhagy.  In two out of
the four cases in the 11th volume of the  Medico-
Chirurgical Transactions, hemorrhage did occur,
though not to an alarming extent; and Mr. Sa-
muel  Cooper states that fatal hemorrhages  have
sometimes followed the operation. (Good's Study
of Medicine, vol. v. p. 322.—Note.)  It must be
admitted, also, that  active inflammation  excited
so near to the trachea may often induce  danger-
ous consequences, especially when  the tumour is
attached to that part.  In one of the cases related
in the Medico-Chirurgical Transactions, a patient
of Mr. Gunning's, in St. George's  Hospital, the
operation was followed by  fatal  sloughing,  and
there  was some  appearance of inflammation on
the lining membrane of the  trachea.  In another
case,  related by  Mr. James,  of  Exeter, which,
however, was ultimately cured,  there occurred ex-
pectoration of purulent matter and lymph, a great
degree of orthopnoea, suppressed voice, as in laryn-
gitis,  and threatening death, until the seton was
removed.   Dr. Hedenus, of  Dresden, informs us
that he has seen a patient die of tetanus after the
operation.  From our own experience, indeed, as
well as that of others in this country, we should
say that it  ought  only to be attempted when
symptoms  urgently demand it.  We have, it is
true, seen it at times produce but  few unpleasant
symptoms,  though  we  have witnessed  at other
times serious consequences  from it; so,  also, we
aave seen both successful and unsuccessful cases
with, regard to tne ultimate cure.   Of the former,
a case has been  reported in tbe Medico-Chirur-
gical Review, vol. vii. 1827, treated by Mr. Henry
Lyford, of the  Hants  County Hospital.  The
tumour, which was of four or five years'  growth,
and easily moveable, but  unusually hard, almost
entirely disappeared  in less  than  two months.
Dr. Quadri states that it is expedient to retain the
seton  in the  tumour for a considerable length of
time, in order to keep up the suppuration, until a
cure is accomplished,  as well  as to prevent the
formation  of  sinuses.   When the  suppuration
ceases, and the wounds are perfectly healed,  he
has observed  the curative  process  to go on  in
some cases until the goitre  is entirely dissipated.
The skin  which covered  the  swelling remains
corrugated a short time after the cure, but  soon
resumes its natural appearance ; and the cicatrices
left by the seton in a few months present hardly
any deformity.
   With  the  view  of cutting  off the supply  of
blood by which the tumour is  fed, the thyroideal
arteries have  been  tied, and the disease, in some
instances, removed by thus destroying the  balance
between  absorption and deposition.   Dr. Quadri,
indeed, suggests  that the effect  may  have  been
obtained simply from the increase of  absorption,
occasioned by the irritation of the ligature, and
from the inflammation and suppuration consequent
upon the operation.—(Medico-Chirurg. Transact.
vol. x. p. 26.)   But we  cannot  conceive that such
causes are sufficient to account for so dispropor-
tioned  an  effect.  The experiment,  we  believe,
was first attempted  by Sir William Blizzard, and
he succeeded in reducing the size of the swelling
one-third  in the course of a week; but the liga-
tures having then sloughed off, repeated bleedings
took place from  the arteries,  hospital-gangrene
ensued, and the patient was lost.  From  the cir-
cumstances of the case, however, the same event
was by no means to be  necessarily expected  from
the operation.  Accordingly, in  1814, Professor
Waltber of Landschut  repeated the operation  in
a case of that particular species of  bronchocele
which  he calls the aneurismal.   The patient was
a young man, in  whom the respiration was much
impeded  by the swelling, and  the upper  thyroid
arteries were  large  and pulsated strongly.  The
left thyroid artery being tied, on the third day after
the part of the tumour on  that side became less
tense, and the throbbing soon ceased. It continued
to diminish gradually, becoming at the same time
harder, and, as it were,  cartilaginous.  No febrile
symptoms followed  the  operation, and the wound
was completely healed  on the  twenty-third day.
At the end of a fortnight, the  left side of the
swelling having diminished one-third, the Professor
tied the right superior  thyroid artery, with a like
freedom from any unpleasant consequences.  The
right portion of the tumour also began to dimin-
ish ; but, though originally  smaller than the left,
it did  not waste away so completely as the latter,
which  at  last was  only one-third of  its  original
size.  Two years after, the remains of the tumour
produced  no  inconvenience.—(Neue Heilart des
Kropfes, &c.  8vo.   Sulbach,   1817.)  Another
operation of  the same kind was  performed  by
Walther in 1820,  and  with still more complete
success.   In  this patient, also, the tumour was
tense, hard towards its centre, and pulsated strong- 
BRONCHOCELE.                               35t
ly.   The face was pale and tumefied, the respira-
tion obstructed, and deglutition extremely impeded.
On exposing the left superior  thyroideal artery, it
was  found dilated  so  much as to surpass the dia-
meter of a  common  quill.   After it was tied, it
became considerably contracted below the ligature,
and  ceased to pulsate.  At the end of seven weeks
the  wound  was entirely cicatrised ;  deglutition
and  respiration were performed without any diffi-
culty ; the tumefaction of the  face had disappear-
ed ;  tbe left  half of the  tumour, originally much
larger  than  the  right, was reduced  to its natural
size; and the patient left the hospital  cured___
(London  Medical Repository.  October, 1822.)
The first apparently successful case of the opera-
tion in this country that we are acquainted with,
was that of  Mr. H. Coates, of Salisbury, published
in  the 10th  volume  of the  Medico-Chirurgical
Transactions.   The patient was a young woman,
in whom  the tumour was so large as to  render
respiration and deglutition extremely difficult, and
causing a noise in breathing, which might be heard
 at a considerable distance.   The superior thyroi-
 deal arteries  were large and pulsated  strongly.
 The left of  these vessels was  taken up.   On the
 next day there  was headach, and  some swelling
 of the neck and side of the head;  but these  gave
 way to the abstraction of blood, and in three  days
 all  unpleasant symptoms vanished.  The wound
 was completely healed  on the  fourteenth  day.
 The patient's breathing was  much improved, the
 size of the tumour being reduced nearly one-half;
 and in less  than  seven weeks from the operation
 she was discharged  from the hospital quite  well.
 In  consequence, however,  of an application we
 made to Mr. Coates for information as  to the final
 result of the operation, we are authorized to  state
 that, though the case proceeded extremely well for
 some  time  after the  patient was  discharged  and
 lost sight of, yet the tumour subsequently, he un-
 derstands, enlarged, and  in  the end destroyed her
 by suffocation.  Mr. Coates states that he has not
 repeated the operation in  any other case, nor should
 he be  disposed to do so from the result in this in-
 stance.  Mr. W. J. Wickham, of Winchester, has
 furnished us with the following notes of a case, in
 which one of the  thyroid arteries  was tied, in the
 Hampshire County Hospital,  the  operation  being
 followed in  like manner by  apparent success at
 first, and failure in  the  end.   He says, " It was
 the  largest  bronchocele  I  ever  witnessed, but of
 the  exact measurement  I have no memorandum.
 After the ligature  of  the artery, the swelling gra-
 dually diminished for about six weeks, after which
 it as gradually regained its former size. It seemed
 that the decrease of the tumour continued so long
 as the part of the gland, which had been supplied
 by  the vessel,  remained without nourishment;
 but as soon  as the  supply was  restored  by the
 anastomosing branches from the opposite superior
 and the two inferior thyroideal arteries, the swell-
 ing returned to its  former dimensions.   Such, I
 should conceive, would be the case, unless all the
 thyroideal arteries were obliterated, which it would
 be a very difficult task to accomplish, if not alto-
 gether impracticable, from the depth of the lower
 vessels.  In this case, after the foregoing operation,
 I introduced a seton through the gland, which was
 succeeded,  at first,  by great  tumefaction of the
part and alarming difficulty of breathing, but pro-
duced afterwards a slight diminution of the swell-
ing.  After  a few weeks, however, it was neces-
sary to withdraw the seton in consequence of its
having occasioned great constitutional disturbance,
and ultimately no benefit at all was derived  from
it.  The result of  the case, indeed, does not give
me much encouragement  to attempt a  repetition
of either plan of treatment on another occasion."
Mr. Samuel Cooper mentions, in his Surgical Dic-
tionary, that Mr.  [Sir B.] Brodie performed the
operation in one case without producing any mate-
rial diminution of the tumour.  Mr. H. Earle, how-
ever, has been more successful. He has  published
the result of a case, in  which he tied both the
superior thyroideal arteries, with great advantage,
though not with the effect of completely dissipating
the tumour.  The patient was a girl of seventeen,
in whom the gland was very painful, and so large
as  greatly to impede respiration  and  deglutition.
Her general  health was  bad ; she suffered much
from  pain  in the  head and drowsiness, and com-
plained of pain in her chest, and  cough, with foul
tongue, and  rapid pulse.   As the disease did not
yield to the  usual remedies, she was sent back into
the country on account of her general health, but
returned some months afterwards with the goitre
increased, so as to produce extreme dyspnoea, and
totally prevent her  from swallowing solid  food.
The  pulmonary  affection continued;  there  was
constant headach  and drowsiness, and  the pulse
was 120.   As the disease still resisted  medicine,
and threatened fatal consequences, the  operation
was determined upon.  The right superior thyroid
artery was found to be enlarged to the size of the
carotid.  On tying it,  there succeeded  intense
headach and increased  drowsiness, which  were
subdued by a full bleeding from  the arm, leeches
to the temples, purgatives, and digitalis.   In a few
days  the tumour was  found  to be diminished, re-
spiration and deglutition were much less impeded,
and the cough had nearly left  her.    Within  a
month she was sent home; the circumference of
the swelling being diminished three inches and  a
half.   A fortnight afterwards, the tumour remain-
ing stationary, she returned, to have the artery on
the left side tied.  This  was found of the size of
the radial artery.  No urgent symptoms followed
from its being taken  up; but the diminution of
the tumour was not nearly so great or so rapid as
after the former operation.  In a month the patient
finally  left  the hospital, with  no impediment in
swallowing or respiration, and free from cough,
the tumour being much softer and smaller.  Three
months after the operation it was continuing slowly
to  decrease.—(Med. and Physic. Journ.  vol. lvi
p.  201, & seq.)   From  all  that  we yet know of
this operation, we may  conclude that  it may be
performed, perhaps in most cases, with safety ; but
that it is advisable in all instances of bronchoceb'
is  much more than doubtful.  It  appears not tu
have been  uniformly successful even  in reducing
the tumour; still  less in the complete removal of
it.   When  it  is considered, indeed, how largely
the thyroid gland is supplied with blood, having
four considerable arteries assigned to it; and how
soon the place of obliterated trunks is supplied by
the collateral branches;  the  occasional failure of
the operation is not surprising, and the permanency 
H52                         BRONCHOCELE — BULL-E.
of its benefit, even in apparently successful cases,
may'sometimes, as we bave seen, be questionable.
When the urgency  of symptoms, however, de-
mands it, and more particularly when the tumour
is of a pulsating nature, a dexterous surgeon may
probably adopt this with as much safety and pros-
pect of success as any other surgical means of
relief.
  In some instances the goitrous tumour has been
removed, at once, by  excision.   This, however,
will appear to be  a most hazardous undertaking,
when we consider the number and magnitude of
the bloodvessels, and the important nerves adjacent
to the tumour, with which it is generally involved ;
the impossibility of using much pressure in such
a situation for  restraining hemorrhage; and the
risk of wounding the trachea and oesophagus, to
which the deceased mass is often adherent.   Pos-
sibly the removal of  the  tumour at an early stage
of its  progress  might not be attended with very
serious danger.   Mr.  J. Baillie Fraser tells  us, he
was informed in  his  tour through the Himala
mountains, that goitre, which prevails in the val-
L'vs there, was sometimes cured when early  means
were taken, and that these consisted in extirpation
of the part  by  the knife.  He adds that he  saw
some persons with the scars  from the operation
on  their throats, and  that, in these instances, the
cure was complete.   (Journal of a Tour through
the Himala Mountains, p.  349.  4to. London,
1820.)  In 1791, Dessault extirpated a tumour
of the right  portion of the  thyroid gland, which
was five inches in circumference, and proved to
be similar in all  respects to scirrhous glands, ex-
cept that  in the centre there was a cartilaginous
nucleus. In this case there were no very untoward
circumstances, and the patient was dismissed cured
on  the thirty-fourth day after the operation.   (Des-
s.iult's Parisian Chir. Journ. vol.  ii.)  The diffi-
culties and danger, however, attending the opera-
tion, when the tumour is large, of long standing,
and has  formed  extensive   adhesions, are very
great.   Air. Gooch relates two cases in which he
attempted this mode of cure.  In the first he was
compelled  to desist, before the operation was half
completed, in consequence of profuse hemorrhage,
which no means were able to stop ; and the patient
died in less than  a week.  The second had nearly
ended fatally, also, from loss of blood; this  dex-
terous operator being completely foiled in  his at-
tempts to stop the hemorrhagy by  ligatures.  The
patient's life was only saved by having a succes-
sion of persons to keep up a constant pressure
upon  the bleeding vessels, by means of their fin-
gers,  or proper compresses, day  and night, for
nearly a week.  (Gooch's Medical and Chirurgi-
cal Observations, p.  136.)   The  operation has
been  fatal, also,  apparently from  injury to some
of  the important nerves in the vicinity of  the dis-
ease.   A woman on  whom Dupuytren operated,
without losing more than a few ounces of blood,
was seized with hurried respiration, sickness, cold-
ness of skin, &c, and died soon after the excision.
The operation, however, has  accomplished a cure,
in  some instances even of the most  aggravated
description.  Vogel and Theden performed  it with
success.   Professor  Graefe, of Berlin, succeeded
in a case where the  tumour was so large that he
thought it advisable  to  perform the operation by
instalments, cutting off one side of the gland first,
and, after waiting  till the wound was healed, re-
moving the other.   In the course of the operation
he took up fifty arterie-.   (Lawrence's Lectures;
Medical Gazette, vol. vi.  p. 719.)   But of all who
have attempted excision in bronchocele, Dr. Hede-
nus, of Dresden, has been the most fortunate.   It
appears that he has performed it six times with
success.  In one instance the circumference of the
tumour was fourteen inches.  The operation  lasted
an hour and a half.  Some hours  after, there com-
menced a considerable oozing of blood  from  all
the wounded surface, which it required assiduous
care to suppress.  After the separation of the liga-
tures, on the eighth  day, there was a  considerable
hemorrhagy, and on the eighteenth  day  a  more
serious one occurred in consequence of a convul-
sive cough.  The  patient  lost two  pounds  of
blood ; tbere was a deadly paleness over his whole
body, dimness of sight, loss of speech and hearing,
and  extreme faintness.  By judicious treatment,
however,  his life was preserved, and he  was, at
last, dismissed cured.  (Graefe's Journ. der  Chir.
B. ii. p. 237. Berlin, 1822; or Quarterly Journal
of Foreign  Medicine.  No. 19, p. 317.)   A case
was published some  years ago, in which Klein re-
moved a  very large  bronchocele, but the patient
died upon the operating  table.  (Journ. der  Chir.
B. i. p. 120.—Journ. of Foreign Medicine, vol. ii.
p. 380.)   In short, judging from the results of the
operation, even in  the hands of the  most judicious
and highly skilful surgeons, we  may venture to
state  that it ought scarcely  to be attempted when
the  tumour is of  great  magnitude,  and  adheres
firmly to the neighbouring structures, and  certain-
ly, in no case, until  all other means have failed.
   Dr. [Sir James] Clark states that .Mr. Major in-
formed him  of a  case in which  the tumour was
successfully removed by  ligature.   In another, in
which Mr. Major himself adopted  that plan, the
patient was lost in  consequence of hemorrhagy,
from neglect of the attendant; or rather, he sank
under the low fever  which ensued from it.  (Op.
cit. p. 111.)
   It should be kept in mind  by  the  practitioner,
that the removal or  sudden subsidence of a  bron-
chocele is sometimes followed  by irregular action
of the heart, or some other functional disturbance.
                      Andrew Crawford.

   BRONCHORRHCEA. (SeeBronchitis,
Chronic)
   BULLAE, blains, an order of cutaneous dis-
eases characterized  by an  eruption of large thin
vesicles, containing a serous or sero-purulent fluid,
and succeeded by yellowish  or  blackish scabs,
sometimes by ulcerations.
   Syn. •t'XvKTaivai, IXkiZSus <p\vKTaivlSes, <f>.vKTilti,
(Hippoc. et vet. Grec.) ; no^<5Auy£j (rec.  Grcc);
Phlyctamse, A mpullae (Auct. var.); Bulke (Plenck);
Dartre plyctenoide (Alibert) ;  Bulles, Ampoules,
Cloches (F.);  Blasen  (Germ.) Blebs.
   Plenck was  tbe first to found a class upon this
form of eruption, for before his time the  diseases
distinguished by bullae were comprehended, toge-
ther with all vesicular affections, under the more
general term of phlyctsena? ; but not being  rigor-
ous in the definition of his class, he included  in
it phyma, a superficial collection of pus, a species 
                                BULL.E — C

Df paronychia, approaching nearly to the  nature
of furunculus.   Willan  had returned to the  an-
cient classification which placed vesicles and bullae
in the same order, from which  he was only in-
duced to depart  in deference to the well-founded
criticism of Professor  Tilesius, of Leipsic; and
they who have  seen much of vesicular eruptions
will allow that the  learned  professor might have
found reasons for his distinctions not less in  the
different nature   of the  constitutional affections
than in their external  appearances.   But in cor-
recting this error, Dr.  Willan  did not  remove
all the objections which might have been made to
his arrangement; for, whilst on the one hand he
retained,  in  the order of bullae, erysipelas, of
which vesications are only incidental phenomena,
he excluded rupia, of which disease they form the
proper elementary eruption.   It  is  therefore  our
intention to follow M. Biett, in part of his reform
of this classification,  leaving  pemphigus, pom-
pholyx, and rupia to constitute the order of bullae.
   This elementary form of cutaneous  eruption
may be produced by external as well as internal
causes ;  and hence bullae are the  ordinary effects
of blisters, as of  cantharides, ammonia, and many
other acrid or rubefacient substances;  hence they
are caused by burns, scalds, and frost-bites, and
are common consequences of friction,  pressure,
and  of distension,  as * occurs  in  cedema.   The
poisons of some  serpents are  also said  to give  rise
to eruption.  But the bulla? arising from the fore-
going  causes, generally denominated vesications,
we leave to  our surgical brethren, reserving to
ourselves those of spontaneous origin, which ob-
serve also a very different progress.
   The formation of these last is generally pre-
ceded  by an elevated  erythematous spot,  more
or less of  a bright colour,  which, in a certain
time, seldom exceeding  forty-eight  hours, is  fol-
lowed  by a  small vesicle, which  gradually  en-
larges to a blain.  The humour contained  in  the
bulla is in general serous and transparent, but is
sometimes sero-purulent, rarely sanguineous.  At
first  the  bulla is tense, and the humour may re-
main a long time accumulated under the epider-
mis ; but it becomes afterwards flaccid, whilst the
humour thickens, and often dries into  solid scabs,
more or less considerable.   Or,  if situated in a
part where the epidermis  is thin, the bulla bursts
after a few days, and is followed by a thin scab,
unless the surface be defended  from the air by a
portion of the detached cuticle, or  any other cover- ,
ing, when it presents  a white flocculent secreting
covering.  In either case  the skin gradunlly pro-
vides itself with  a new epidermis, or becomes  the
seat of an ulceration more or  less  deep.
   Though the diseases of this order may exist as
acute, they generally present themselves as chronic
disorders, eruptions of  bullae following each other
in regular succession.   As chronic  diseases they
are never  contagious, but  generally connected
with some disorder of  the constitution or the in-
ternal organs ; hence bullae are symptomatic of a
state of cachexy, of inflammation or irritation of
the mucous  membrane of the bronchi or the ali-
mentary canal, or of derangements of the function
of the liver.   'They are also observed incidentally
in small-pox, the bulla variolosa of Plenck.
   The pathological condition giving rise to this
   Vol. I. — 45^                       2 e *
i A C H E XI A.                             353

 form of eruption consists, as far as has been ascer-
 tained, in an inflammation of the rete mucosurn,
 or upper surface of the cutis, by which a more
 copious secretion of serous fluid takes place  than
 can be transmitted by the cuticle, thus causing its
 separation and  elevation.   In  proof of this we
 may mention that  the rete mucosurn  remains
 adherent to the cutis, and  is  not  detached  with
 the cuticle, as happens when  this latter is for-
 cibly  torn off.  The inflammation which gives
 rise to  the  formation of bullae  may be also  con-
 sidered to exist  in  a higher degree than  in ery-
 thema, for a higher degree of irritation converts
 erythema into bullae.
    As bullae may be dependent upon such different
 states of the body, it is obvious that their treat-
 ment must be  various; and therefore  we  may
 understand  how, in some diseases of this order,
 the antiphlogistic regimen may be required, whilst,
 in others, alteratives  or tonics may be  most ad-
 visable, and how, in all the forms, great attention
 to regimen is always essential.
                                 T. J. Todd.

    [CACHEXIA, Cachexy, Cacochtmt, Dxs-
 crast, literally  means  " bad habit;" from kcIkos,
 " bad," and el-tc, " habit."   It  has,  however, re-
 ceived  different  acceptations in  the history  of
 medicine, and been made to comprise various dis-
 eases,  which  are now  more generally  separated
 from it.   The acceptation in which it is employed
 generally at the present day, and always by the
 author, (see his  Practice of  Medicine, 2d  edit. ii.
 611, Philad. 1844,) embraces  chronic  affections,
 which are induced  by some vice in the  system of
 nutrition, whether such vice be dependent upon
 a morbid condition of  the circulating  fluid  that
 furnishes the pabulum whence the tissues  are
 formed, of the vessels of nutrition themselves, or
 of both combined.   This definition is  analogous
 to, and less liable to objection than, that of Dr. Cop-
 land, (Diet, of Practical Medicine, art. Cachexy,)
 " Depravity of  the  constitution,  without fever,
 affecting more or less the solids, the circulating
 fluids,  and the secretions."
   The  chief  morbid conditions that fall under
 cachexies, are scrofulosis, tuberculosis, scorbutus,
 chlorosis, rhachitis, hydrops, cancer, and syphilis;
 but with equal propriety we  might class amongst
 them tbe morbid results of splenic disease, of lead
 poison, and many  chronic  cutaneous affections,
.in all  of which the character of the circulating
 fluids,  or  the  condition of the function of nutri-
 tion, or of both, is modified.   In strictness, indeed,
 of definition, many  other diseases might be placed
 in the same division, which, although seeming to
 affect primarily particular portions of the frame,
 implicate, sooner or later, the whole economy.
   In  order  that the tissues  shall be duly nour-
 ished, the blood must be possessed of appropriate
 qualities.   Should it  fail  in  these requisites, and
 impress the parts which it bathes abnormously,
 faulty nutrition must be the consequence.  In like
 manner, if the blood  be healthy, and the  organs
 that are concerned in the nutrition of the  tissues
 be morbidly impressed, disease must result; hence,
 hypertrophy or  atrophy may  be induced, — in
 which  there may be simply an increased nutritive
 action in one case, and a dimi nution of it in ano ■ 
3W
CACHEXIA —CALCULI.
tbcr ;  01 the  nutritive  action may, under special
circumstances,  become so  much perverted,  that
substances may he formed and separated from the
blood, which bave nothing analogous to them in
the economy.   These last are  cases which are
considered by all to belong to cachexia.  Under
some inappreciable vice in  the system, the nutri-
tion of the tissues is so much perverted  as to give
occasion to various heterologous formations.  In
some  cases,  the altered  condition  of the  blood
gives  rise to a  train of phenomena indicating a
paucity of fibrin and red globules.   The blood is,
consequently, imperfectly adapted for the nutri-
tion of  the tissues, whose tone  is  diminished, as
indicated by the general appearance of the patient,
and by  an asthenic condition of all the  functions.
In  other cases, the pravity of  nutrition may be
evinced  by  morbid  conditions  of  the cutaneous
envelope, or by chronic cutaneous diseases.
   In regard to the diseases of the system of  nutri-
tion,  which  are dependent upon  some morbific
influence or vice, as scrofula, cancer, and syphilis,
the great indications are much  alike.   The only
mode by which the system can become dispos-
sessed of the vice is by inducing a new  condition,
which is incompatible with its existence ; hence,
every effort is made to occasion a change in the
circulating fluid by appropriate  therapeutical and
dietetic agents.  These may thus produce a new
action in the tissues which they bathe,  and  break
in  upon the  morbid condition.  With  this view,
recourse is had to those valuable  eutrophics—as
iodine and its various preparations—which are the
gifts of modern chemistry.  (Practice of Medicine,
loc. cit.)              Robley Dunglison.]

   [CECUM, DISEASES OF  THE. (See CON-
STIPATION.)]
   CALCULI,  (Chemical Composition  [axb
Microscopic Appearance.)]—The term calculus
is applied to any solid or unorganized concretions
found in the human body.    Such concretions
have  been found in almost all  the  mucous cavi-
ties and canals ; in the lachrymal passages ;  in the
mouth, for the tartar in the teeth is certainly of
this nature; in the tonsils; in the salivary and
pancreatic ducts ;  in the  stomach ;  in  the  intes-
tines ; in the gall-bladder and biliary passages ; in
the ramifications of the bronchi; between the pre-
puce  and glans ; in the ducts of the mamma ; in
the vesicula? seminales; in the  ducts of the pros-
tate gland, and in the  urinary canals and bladder.
Earthy concretions have also been found imbedded
in  the substance of the brain and other soft  parts ;
within  scrofulous abscesses ; in cancerous cavities,
and in hydatid cysts.  The deposition of this
earthy  matter seems to take place around foreign
 bodies  introduced into the animal  frame, as the
effect of the irritation  which they cause, and pro-
 bably as the means of rendering  them  less ob-
noxious to  the  living textures.  Thus where an
extra-uterine foetus has been long  retained, it is
usually found more or less encrusted with earthy
matter; and when musket-bullets  or other pro-
 jectiles have remained in the human body, their
 surfaces become covered with  a coating of what
 appears to be phosphate of lime.  Even  the vas-
 cular system is not free from  calculous concre-
 tions ; and small indurated masses have been found
within the cavities of veins, which have  thence
obtained the name of phlebolithes.
  Chemical Composition of Calculi. — Cal-
culous concretions were  noticed  by the ancients,
and  named, obviously from a notion  that  they
were of a stony nature, AtSia  by the Greeks, and
calculi  by the  Romans.  Hippocrates  describes
the symptoms of calculus in the kidney and urinary
bladder with  his usual precision.  Pliny enume-
rates a great number of remedies for this dreadful
disease, and Celsus describes a method of extract-
ing calculi from the bladder, which Heister praises
as excellent.  But we look in vain into the writings
of the ancients  for any  description of  calculi, or
any examination of their nature.
  The  first person who attempted to  speculate
respecting them was Paracelsus, though it is some-
what difficult  to form an accurate idea of the no-
tions which he  entertained on the subject.   He
seems to have thought that the calculus separates
from  the liquids of the  living body in  the same
way that tartar  is deposited from wine upon  the
sides and bottom of the  wine-cask.   This seems
to have been the reason that induced him  to give
the name of tartar to calculi.   This tartar, which
is apt to be generated in the living body,  was in
Paracelsus's  opinion  the origin of most diseases.
It differed in  its qualities according to the nature
of the liquid  from which it was generated.   He
gave  it the name of tartar, because it  burns the
patient like hell-flre in severe diseases.   It is de-
posited when the archeus acts with too  much im-
petuosity and irregularity, and when it  separates
the  nutritive  principle  with  too much activity.
Then the saline spirit unites with the earthy prin-
ciple, which  always exists in the liquids, but in
the state of materia prima,-  and this union occa-
sions the formation of tartar or calculus.
   The  subject of  calculus was taken up by Van
Helmont, in  his treatise De Lithiasi, which con-
stitutes perhaps the most important and valuable
part of all his works. He subjected various urinary
calculi  to a chemical  investigation, and showed
that they differed entirely in their nature from the
stony bodies which occur in the mineral  kingdom;
from which he drew, as a consequence, that they
did not originate from matter contained in  food or
drink.  Tartar,  he observed, was deposited from
wine, not as  an earth, but as a crystallized salt;
and  in the same way the natural salt of urine is
precipitated to  give  origin to a calculus.  This
precipitation may be imitated by mixing spirit of
urine  (solution  of carbonate of ammonia) with
rectified spirit cf wine.   A white precipitate  im-
mediately falls,  to which he gave  the  name of
ossa alba.  This view of the subject, which was
to a certain extent just,  induced  Van Helmont to
lay aside the  name tartar, which had been em-
ployed  by Paracelsus;  and to avoid ambiguity,
he employed the term due lech, to denote the state
in which the spirit of urine is precipitated when
it gives origin  to calculous concretions.  These
views he endeavoured  to confirm by an analysis
of urine, which was as  perfect  as could be ex-
pected when the experiments were made, and cer-
tainly enabled him to approach  much  nearer the
truth than any of his predecessors had  done.
   No attempt (so far as we know) was made to
determine the nature of calculi,  or to discover 
CALCULI
355
remedies capable of dissolving them in the blad-
der without injuring that organ, till the publica-
tion  of  the  second volume of Hales' Vegetable
Statics,  in the year 1733.   He exposed different
calculi to a red heat in  a  gun-barrel,  and  found
that they yielded  a quantity of air amounting to
above five hundred  times  their bulk — a greater
quantity of air than most other animal or vegeta-
ble substances could be made to yield.  This was
a decisive proof (if any had been wanting after
the experiments of Van Helmont)  that  urinary
calculi are quite different in their nature from the
stony bodies belonging  to the mineral kingdom.
Dr. Hales made several attempts to discover a sol-
vent of urinary calculi, but it is unnecessary to
relate them as they were not attended with suc-
cess.
   In the year 1743, Dr.  Whytt published an essay
to show that lime-water was a remedy for  the
stone.   This essay first appeared in  tbe  Edin-
burgh Medical Essays,  and  was reprinted with
them in 1747,  and finally published separately in
1752.   Soon afterwards Dr. Alston published A
Dissertation on Quicklime, in which  he  deduces
from his experience that lime-water may have a
tendency to prevent the formation of calculi; but
that it is incapable of dissolving them when once
formed.  As  neither of  these  gentlemen made
any experiments  on the calculi themselves, their
observations  contributed  very little towards  im-
proving our knowledge of the nature  of these
concretions.   The analysis  of  calculi  by Slare
contributed but little to explain their nature, (Phil.
Trans,  vol. xvi. 140.)   Boyle had subjected them
to distillation, and had obtained  an oil and a great
quantity of carbonate of ammonia.
   Such was the state of the chemical knowledge
of calculi, when, in the year 1776, Scheele pub-
lished a set of experiments upon urinary calculi
in the Memoirs of the Stockholm Academy, (Un-
tersokning om  Blose Stenen, p. 327.)  He found
all the calculi that he examined  of the same  na-
ture.  He  could  discover in them  no sulphuric
acid and no lime;  but they consisted of a pecu-
liar substance possessing acid properties, and cha-
racterized by dissolving with effervescence in nitric
acid, and assuming a beautiful pink colour when
the solution is evaporated  to dryness without the
application of too much heat.  To  this acid the
name lit hie acid  was  afterwards  applied, which
by Fourcroy was changed into uric acid, in con-
sequence of a remark  of Dr. Pearson.  Scheele
showed that all urine contains this acid.   Hence
the origin  of  urinary calculi came  to be under-
stood.   Whatever has a tendency to throw down
uric acid from urine may give origin to a calculus.
   To this paper of Scheele an appendix was add-
ed by Bergman, in which  he stated  the result of
his own experiments.   He detected  the uric acid
which Scheele had discovered, but  found also
some lime in all the calculi  which he  examined.
This important paper of Scheele constituted  the
first step, and it was a material one, towards a full
investigation  of the nature of urinary calculi.
   Hardly any addition was made to the facts as-
certained by Scheele and  Bergman till the year
1797, when Dr. Wollaston published  a paper  on
gouty and urinary concretions, in the Philoso-
phical Transactions.  In this  paper he gave  an
account of three species of urinary calculi, quite
different in their composition from those described
by Scheele.   The concretions  which  appear in
tbe joints of gouty persons, and which had been
known  to medical men  by the name of chalk
stones, he ascertained to be a combination of urii
acid and soda.   To the three new  species of  cal
culi he gave the names of fusible  calculus, mul-
berry calculus, and bone-earth calculus.
   The fusible calculi had  been first noticed by
Mr. Smithson  Tennant,  who found, that when
urged by the  blow-pipe, instead of being nearly
consumed, as happens to the uric  acid calculi of
Scheele and Bergman, they left a large proportion
which fused into an  opaque glass.   This be con-
jectured to be phosphate of lime mixed with othei
phosphoric salts of urine.  Dr. Wollaston found
that this kind  of calculus was white, and that it
consisted partly of  sparkling crystals composed
of ammonia-phosphate of magnesia. These crys-
tals had the form of short triangular prisms, hav-
ing one angle a right one and the other two equal,
and terminated by a pyramid of three or six sides.
The other constituents of this calculus are phos-
phate  of lime, and a very small quantity of  uric
acid.
   The mulberry calculus had been noticed  and
named  before  by medical men ; but no  attempt
had been made to determine its nature.  The sur-
face is irregular and knotted, bearing  a distant
resemblance to  the  mulberry.    Dr.  Wollaston
showed  that it is composed of oxalate  of lime,
mixed with  a little blood and other animal matter.
Calculi  of the same nature  are  sometimes  met
with, smooth on  the surface, and much lighter
coloured.  These, from  their  appearance, were
called hemp-seed calculi, and were not suspected
to be of the same nature with the mulberry, till
Dr. Wollaston ascertained their composition.
   The bone-earth calculi are of a brown colour,
and so smooth as to appear polished; they con-
sist of regular laminae, easily separated from each
other.  Dr.  Wollaston showed that they are com-
posed of phosphate of lime : hence the name by
which he distinguished them.  Before the blow-
pipe this calculus is  slightly charred: it then  be-
comes white;  and when urged with the utmost
heat from a common blow-pipe, it  is at length
fused.  As  this cannot be done with the earth of
bones, Dr.  Wollaston infers that  the  bone-earth
calculi are composed of neutral phosphate of lime:
whereas the earth of bones is known to be a  sub
sesqui-phosphate of  lime, or a compound of—
      1 atom phosphoric acid.........4.5
      1 $  atom lime.................5.26

                                    ~9.75

   Dr. Wollaston, in this  important paper,  also
examined the calculi from  the  prostate gland,
and  found them composed  of neutral phosphate
of lime tinged with  the secretion  of the prostate
gland.
   Some years  after,  a set of experiments  on  un
nary calculi was published by Fourcroy and Vau-
quelin.   They examined no fewer than five bun
dred different  calculi, and were thus enabled tc
add  a little  to the important discoveries of Dr
Wollaston, to which, however, they make no a' 
356
CALCULI —[BILIARY.]
lusion in their paper.  They found calculi com-
posed of urate of ammonia;  and in two different
calculi  they  found  a small  quantity of  silica.
The animal matter which serves as a cement to
the constituents  of the calculus, they consider as
sometimes consisting of albumen, and sometimes
of urea; but it  is evident  from  the  way they
speak of it that they had not  subjected  it to  a
rigid examination.
   The next addition to the chemical knowledge
of the nature of calculi was made  by Dr. Wollas-
ton in 1810, (On a new species of Urinary Cal-
culus, Phil.  Trans.  1810, p. 223) ;  by the dis-
covery of a urinary calculus composed  entirely
of  a peculiar  substance capable  of combining
equally with acids and alkalies, and which he dis-
tinguished by the name of cystic oxide.  It is of
rare occurrence  ; only about  six  or  seven such
calculi having been hitherto met with.
   The labours  of Austen, Walther, Brugnatelli,
Pearson, Brande, &c, have not added many new
facts to those already known ; but  Dr. Marcet, in
his Essay on the Chemical History and Medical
Treatment of Calculous Disorders, published in
1817, gives an  account  of two new species  of
calculi which he had  observed.  The first, which
he received from Dr. Babington, weighed  eight
grains, and was  composed of a substance to which
Dr. Marcet gave the name of xanthic oxide, from
the lemon yellow colour which it forms when act-
ed upon by nitric acid.   The other calculus was
about  the  size  of a pea, and the substance of
which it was composed possessed  the characters
of fibrin.  On that  account Dr. Marcet gave  it
the name of fibrinous calculus.
   In the year 1821, Dr.  Prout published An In-
quiry into the Nature and Treatment of Gravel,
Calculus, and other  Diseases connected with  a
deranged Operation of the  Urinary  Organs ,•  a
new and improved edition of which  appeared in
the year 1825.   In this work he  treats  at large
on urinary  calculi, and  the  states of the urine
connected with their formation; and has thrown
more light  upon the subject  than  any preceding
writer.
  Such is a short history of the principal discove-
ries  respecting calculi, chiefly of the  urinary or-
gans   We shall now take a view of the  differ-
ent calculi which are apt to  form  in  living ani-
mals, and point out their nature, and the causes
of their formation, so far as the subject has been
investigated.
   The calculi formed  in living bodies  are distin-
guished according to  the  organs  in  which they
appear.   We shall  notice  them  in  alphabetical
onler, dwelling principally on their chemical com-
position.
   1. Biliary calculi, formed in the gall-bladder.
  2. Gouty concretions, formed in the joints of
gouty individuals.
  3. Intestinal  concretions, formed  in the sto-
mach and intestinal canal of man and  the inferior
animals.
  ■i. Ossifications or concretions which occasion-
ally form in the pineal gland, the salivary glands,
(be pancreas, the liver, the spleen, the  lungs, &c.
  5. Calculi formed in the prostate gland.
  6. Urinary calculi, formed in  the  kidney or
ninary  bladder.
   I. Biliary Calculi.—Hard bodies occasion-
ally form in the gall-bladder, which, making their
way into the duct through which  the  bile passes
into the intestinal canal, prevent  the bile from
passing, and thus occasion  the well-known dis-
ease  called jaundice.  These concretions have
received the name of biliary calculi, or gall-stones.
Though their existence was  known  to  the an-
cients, and though they had  been  imperfectly de-
scribed by medical men, scarcely any thing was
known respecting their nature till  they were ex-
amined by Poulletier de la  Salle, about the year
1784, who found  that they were partly dissolved
by boiling alcohol, and that the alcohol  on cool-
ing deposited a number of  brilliant white plates,
bearing some resemblance  to spermaceti.  The
subject was taken up by Fourcroy in 1785, who
compared the matter of gall-stones to the fatty mat-
ter into which  human bodies had been converted
when left in great numbers, piled  on each other,
to spontaneous decomposition. To this substance
he gave the name  of adipocire,-  and the same
name was applied by him to the chief constituent
of gall-stone.  In  1814,  Chevreul showed that
these notions of Fourcroy were inaccurate; that
the substance discovered by Poulletier de la Salle
in  gall-stones was quite different from Fourcroy's
adipocire.   Chevreul gave it the name of choles-
terine (solid bile), and  showed that it existed as
a constituent in bile.  The biliary  calculi  hitherto
described may be divided into three species, name-
ly, cholesterine calculi, mellitic calculi, and calculi
composed of inspissated bile.
   1.  Cholesterine  Calculi*—These calculi are
not by any means so abundant as those  belong-
ing to the second  species, if we are to judge from
the number which we have ourselves seen. They
have  a white colour, and a  crystallized, shining,
lamellated structure.  Pretty frequently they have
a slight shade of brown, sometimes  indeed a de-
cided brown colour, owing doubtless to the mat-
ter of bile interspersed  through them, but in too
small quantity to be visible to the  eye, except  by
affecting the colour of the calculus.   These cal-
culi are composed of cholesterine, nearly in a state
of purity.   The largest we  have seen was about
the size of a hazel-nut, and very nearly spherical.
It is exceedingly light, owing to the low  specific
gravity of cholesterine.
   Cholesterine,  when pure, has a white colour,
and a silky  or  pearly  lustre.   It is lighter than
water;  it is tasteless  and  insoluble in water, and
possesses little or no  smell.   Boiling alcohol dis-
solves about the fifth part of the weight of it, but
deposits it on  cooling  in  small  brilliant  plates.
When  heated  to  about 279° it melts, and in a
vacuum it  may be sublimed without decompo-
sition.  It does not combine with potash, nor can
it be  converted into  a soap.  According to the
analysis of Chevreul, it is composed of—
      1 atom oxygen............   1
     37-5  atoms carbon.......... 28-125
     31-5 atoms hydrogen........   3-9375

                                   330625

But as it possesses neither acid nor  alkaline cha-
racters, and  is not known to  combine in  definite
proportions with other bodies, we have no means 
CALCULI—[GOUTY AND  INTESTINAL.]              357
of determining whether  these numbers  or some
multiple of them constitute the true compositions
of it.
  2. Mcllitic Calculi. — We  have given  this
name to by far the most common species of biliary
calculi; and we have named  them from the colour,
which bears a considerable resemblance to honey,
only it is browner.  These calculi have always a
polygonal shape, occasioned by mutual pressure;
for a number of them  always exist  in  the gall-
bladder together.  We  have taken six  out of a
gall-bladder  after death,  and the gall-bladder in
that case  was almost filled.   Most commonly they
have three blunt edges, and  have some resem-
blance  to two  low tetrahedrons applied base to
base, with their edges and  angles  rounded off.
The mean specific gravity is about 1-061.  Their
outer surface is smooth, and has a soft feel. When
broken, they exhibit a  thin outer crust, composed
of concentric  layers crystallized in small rays in-
clining towards the centre.  These crystals consist
of  cholesterine.  The  nucleus  has  usually the
appearance of granulated honey, and consists of
inspissated bile.
   In  the calculi of this species, which  we have
subjected  to analysis, very nearly 19.20ths of the
whole was cholesterine.  The rest was a mixture
of picromel and some other animal matter, which
was too small in quantity to admit of a rigid ex-
amination.
   3. Inspissated  Bile Calculi.—This species
has a yellow colour, contains little or no  choleste-
rine, but is entirely composed of inspissated  bile.
So far as our observations  go, it is much more
uncommon than either of the other two.   That it
exists, however, there can be no doubt, as Thenard
 examined several biliary calculi  belonging to this
 species.  The gall-stones of oxen are usually of a
 yellow colour, and consist of the yellow matter of
 bile mixed with minute traces of bile, which may
 he separated by water.   When thus washed, they
 are tasteless and insoluble in water and in alcohol.
 They are used by painters, though their colour is
 not permanent, but soon changes to a brown.
   As all  the  constituents of biliary calculi exist
 in the bile, there is no difficulty in understanding
 how they may be deposited  when the proportion
 of the constituents of that liquid undergoes altera-
 tion.
   Cholesterine  has been rarely found in  biliary
 calculi of the inferior  animals ; but that it exists
 in them also is certain;  for Lassaigne found the
 constituents of a biliary calculus from a sow which
he examined, as follows :—
     Cholesterine................  6
     White resin................. 44-95
     Bile.......................  3-60
     Animal matter............... 45-45

                                    looioo*

   II.  Gouty  Calculi. — It is  well known that
 :oncretions occasionally make their appearance in
 joints long subject to gout.  These concretions,
from their colour and  softness, have received the
name of  chalk-stones.   They  are usually small,
though they have been observed of the size of an
egg.  Their nature was first discovered by Dr.

         ♦ Ann. de Chiin. et de Phys. 31,220.
Wollaston  in  1797, who  proved that they were
combinations of uric acid  and  soda, or composed
of urate of soda.
   Gouty concretions are  soft and  friable.  Cold
water has  little effect  upon  them ;  but boiling
water dissolves a  small portion.   If an  acid  be
added to this solution, crystals of uric acid are
deposited on the sides  of the vessel.  They are
completely  soluble in caustic potash  when  the
action of the alkali is  assisted by heat.   When
they are treated with dilute sulphuric or muriatic
acids, the soda is  separated, while the uric acid
remains, and may  be obtained  in a pure state  by
filtration and washing.  When the liquid is eva-
porated, it yields crystals  of sulphate of soda  or
of  common  salt,   according  to  the  acid  used.
When the  uric acid thus  obtained is distilled, it
yields ammonia, prussic acid, and the acid subli-
mate of Scheele (pyruric  acid).  When dissolved
in a little nitric acid, it tinges tbe  skin of a rose
colour,  and,  when evaporated, leaves  a rose-
coloured deliquescent residuum.
   III.  Ixtestinal  Calculi.— Concretions  of
very considerable size are  sometimes found lodged
in the stomach and intestines; not so frequently
in the human body, but very often in  some of the
inferior animals.
   The only intestinal concretions from the human
body which we have seen are in the collection of
the  late Dr. Monro, of Edinburgh, and may still
be seen among  the preparations belonging to the
anatomical class in the University  of Edinburgh.
They amount to forty-one, and are  all very nearly
of the  same nature,  though they  differ  in size.
There  are fifteen calculi   exactly  similar in the
collection of calculi made  by Dr. Hunter, and now
belonging  to  the  University of Glasgow.   The
largest of these weighs  1057 grains, and as some
parts of it  are wanting, there can  be little  doubt
that its weight, when entire, was  at  least 1100
grains.   These  calculi  have a brown colour, and
are composed of fibres  interwoven together after
the manner of felt.  They have  altogether a cer-
tain resemblance to sponge.  They feel soft, but
are too hard to be much compressed.  The specific
gravity is about 1-4.  One of those in Dr. Hun-
ter's collection has a fruit-stone for  a nucleus.  In
most of those in Dr. Monro's collection no nucleus
whatever  can be  observed.   Dr. Monro  used  to
mention, in  his lectures,  that these concretions
had been found in the colon, and that they had
all  proved  fatal.   The  principal  constituent  in
these concretions is the felted fibrous matter, which
was naturally supposed  to have been derived from
the food.   Mr. Clift, of the College of Surgeons,
London, conjectured  that it might proceed from
oats.  This induced  Dr. Wollaston  to examine
the structure of the oat-seed, and the result fully
verified Mr. C lift's conjecture.  If the oat-seed be
denuded of its  husk, minute  needles, or beards,
forming a small brush, are seen planted at one of
its ends.  Dr.  Wollaston, on  examining  these
needles, and comparing them with similar  ones
detached  from  the calculi,  satisfied  himself  of
their perfect identity.  Hence these  concretions
were owing to the use of oats as an  article of food
as oats are employed by the common people  ol
Scotland as a common article of food, we  sec a
reason  why these concretions have  been observed 
359
CALCULI-[OF  THE  PROSTATE.]
chiefly in Scotland.  Mr. Children gives an account
of some formed in the human intestines, in Lan-
cashire, where also oat-mcal is in constant  use by
the common people.  (Phil. Trans. 1822,  p. 24.)
The other constituents  of these calculi are albu-
men, common salt, phosphate of lime, and phos-
phate of  soda.
   These are not the only calculi which have been
found in the human intestines.  Mr. E. Brande
described some composed entirely of carbonate of
magnesia, resulting from an  excessive and con-
tinued use  of magnesia for a long time.   In one
case a collection of several pounds of this sub-
stance was found lodged at the head of the colon,
which in consequence was much distended.  (Royal
Institution Journal, i. 297.)
   Dr. Marcet describes intestinal calculi voided by
tbe rectum possessing the properties of indurated
curd or cheese.  (Marcet on Calculous Disorders,
p. 127.)
   He describes other  small granular concretions,
which were conjectured  by Dr. Wollaston to be
the small woody knots which are often  found in
certain  pears ; and upon close examination  this
conjecture  was found correct.  (Marcet on Calcu-
lous Disorders, p. 132.)
   Some years ago the writer of  this article  re-
ceived from an eminent physician in Birmingham
a number of small flattened oval particles, which
had been voided by a patient of his.  They had
all the appearance of seeds, but did not resemble
any seed with which  wc  were acquainted.   At
last, after carrying about the  bodies for a conside-
rable time and comparing them with the seeds of
every species of fruit which he had  an opportunity
to inspect, we found that they were the seeds of
figs. The patient had been eating green figs, the
seeds of which had been voided entire.
   Mr. Children gives  an  account of a very  re-
 markable intestinal calculus which destroyed the
 life  of John Chambers, a young carpenter at Cli-
 thero in Lancashire, who  had been  in the habit
 of eating large quantities of unripe plums, and of
 swallowing them together with the stones.  Three
 concretions were formed in the arch of the colon,
 having a plum-stone for a nucleus, which in a
 short time destroyed his life.  These concretions,
 together with some others collected by Mr. Barlow
 and Mr. Coultate, surgeons in Lancashire, which
 are  deposited in the Museum of  the Royal Col-
 lege of Surgeons, London, appear, from  Mr.
 Children's description, to be intermediate between
 the oaten  concretions  in the collection of Dr.
 Monro and Dr. Hunter, and the triple phosphates,
 which occur so frequently in the intestines of the
 inferior animals.  They were laminated, and com-
 posed of alternate layers of the felted fibres of the
 oat and the  triple phosphates.   The  following
 table exhibits the constituents of one of these
 i-oncretions as determined  by Mr.  Children :
   Animal matter, chiefly gelatin......  25-20
   Resin..........................   3-90
   Ammonia-phosphate of magnesia. . . .   5.16
   Phosphate  of lime................  45-34
   Fibres of the oat.................  20-30

                                       99-90*
   The calculi found in the intestines of the infe-
* Phil. Trans. 1822, p. 28.
rior animals were examined with much care by
Fourcroy and  Vauquelin many years ago.  They
describe the following varieties:
   1. Biphosphate of Lime  Calculi. — They
are composed  of concentric layers, and very  brit-
tle. They redden vegetable blues, and are partially
soluble in water.
   2. Phosphate of Magnesia Calculi.—These
concretions are described as semi-transparent and
of a yellowish colour.  Their specific gravity is
2-160".  They  are laminated.  They are doubtless
very uncommon.   We ourselves  have never had
an opportunity of seeing any of them.
   3.  Ammonia-phosphate of Magnesia Cal-
culi—said to  be very common.   Their colour is
grey or brown, and tbey are composed of crystals
diverging like rays from a centre.
   4.  Fungous Calculi.—These concretions are
composed  of pieces of the boletus igniarius, dis-
posed in layers, and cemented  by animal matters.
These pieces  had  of course been  swallowed by
the auimals in whose intestines they were found.
   5.  Hairy Calculi. — These are found  in the
stomach and intestines of cows and sheep.  They
consist of  balls of  hair felted  together, and gene-
rally  coated externally with a very thin crust of
animal matter.  The  hair had  obviously been
licked by the  animals from their companions, and
had been felted by the action of the stomach and
intestines.  There are several of these concretions
in the collection  of Dr. Hunter belonging to the
University of Glasgow.   The  same collection
contains enormous calculi composed almost en-
tirely of phosphate of lime;  but as there is no
history attached to them,  we have  not ventured
to describe them, because we  do not know from
what animal, or from  what part of the animal,
they  were obtained.
    6.  In the same collection are five or six of the
celebrated  oriental bezoars, once so much  sought
after  as medicines  of  approved efficacy.  They
 are all smooth and polished, and have a greenish
colour.  They are small and  round, and long, so
 as to have a considerable resemblance to a cylin-
 der rounded  off  at  the  ends.  Three of these
 bezoars, sent by the Schah of Persia to Bonaparte,
 were found by Berthollet to be composed of  frag-
 ments of wood.   Another kind  of these bezoars
 (probably  artificial), analysed by  Fourcroy and
 Vauquelin, was found composed chiefly of resin.
    IV. Ossifications. — Concretions  are apt to
 appear in various glands of the living body. These
 consist constantly of phosphate of lime and  animal
 matter; or of a mixture  of phosphate and car-
 bonate of  lime and animal matter.  In some rare
 instances  they consist  almost  exclusively  of car-
 bonate of  lime and animal matter.  The seats of
 these ossifications, as they may be called, are the
 pineal gland,  the  salivary glands, the pancreas,
 the lungs, the liver, and the spleen.  The  concre-
 tions coughed up from the lungs  usually contain
 some  carbonate of lime, and  in  some  rare cases
 seem to be nearly destitute of phosphate of lime.
    V.  Calculi  of the  prostate  gland__
 [Prostatal Calculi.—Prout.]   Calculi occasion-
 ally form in the prostate gland, sometimes in great
 numbers at a time and of small size, but occasion-
 ally in smaller numbers, and  of a  size nearly as
 large as that  of a hazel-nut.   Often thev  do not 
CALCULI —[URINARY.]
359
exceed the size of the head of an ordinary sized
pin, and they arc rarely larger, judging from those
which we have seen, than a pea.  These calculi
were first examined by Dr. Wollaston, who found
them composed of phosphate of lime, mixed with
more  or  less animal matter.  Dr. Prout informs
us  that he has met with calculi from the prostate
gland  containing  a considerable  proportion  of
carbonate of lime.  The writer of this article has
met with  five or  six which contained very little
earthy matter, but which were composed chiefly
of  a  substance having considerable  analogy to
cystic  oxide.
   These calculi,  when  small, are nearly spheri-
cal, and have a yellowish brown colour : those
of  a large size are smooth and polished, and have
the appearance  of porcelain;  precisely similar,
indeed, to the phosphate of  lime calculi  formerly
described.   Dr. Prout is  of opinion that these
porcelainous calculi always originate in abscesses
of  the prostate gland.  But there are  not a few
of  them in Dr. Hunter's collection of such a size
that they could not possibly have been deposited
in  any cyst of the prostate gland.  These calculi
sometimes give little uneasiness,  and are not  sus-
pected till after death.
   [The composition of all calculi of the prostate,
according  to  Dr. Prout,  (On the Nature  and
Treatment of Stomach and Renal Diseases, Amer.
edit.,  from the  4th revised Lond. edit. p.  448,
Philad. 1S43,) is nearly the same,—that is, they
consist chiefly of phosphate of lime, a little  car-
bonate of lime, and animal  matter.  In  different
instances,  the relative proportions of the phos-
phoric acid to the lime and  the carbonate of lime
appear to vary considerably.]
    Uuixaky  calculi. — The  constituents  of
urinary calculi, so far as we know at present, are
the following substances :—
    I.  Uric acid.
    2.  Urate of ammonia.
    3.  Urate of soda.
    4.  Phosphate  of lime.
    5.  Ammonia-phosphate of magnesia.
    6.  Carbonate  of lime.
    7.  Silica >
    R.  Cystic oxide.
    9.  Xanthic oxide.
   10.  Colouring matter of urine.
   11.  Purpurate of ammonia.
   12.  Fibrin.
   13.  Mucus.
   14.  Urea.
  These substances seldom appear insulated or
constituting each  a whole calculus.   In general
several of them appear  together,  either mixed or
constituting alternate layers.   To  enable us to
form correct notions respecting  the way  in which
they make their appearance in the urinary organs,
it will be requisite in the first place to make a  few
remarks upon  urine.
  Urine, as is well known, is a liquid  secreted
from the blood by two large  glands called  the
kidneys, possessing a remarkable structure which
has been minutely described by anatomists.  The
quantity of urine  voided  daily differs  very much
in different individuals, depending  in  some mea-
sure on the quantity of drink and upon the state
of the skin.  But perhaps two pounds avoirdupois
or  14,000  grains  approaches somewhat  to  the
general average.  It is  transparent,  has a light
amber colour, and, when voided, has an aromatii
odour, which has been compared to that of violets
As it cools, this aromatic odour leaves it, and  an
other succeeds, well known  under the  name of
urinous.   In two or three days this smell  is sue
ceeded by  another, which  has a  considerable re
semblance  to that of sour milk.  It has a disagree-
able  bitter  taste,  and  a specific gravity  which
varies very much ; but which may  be  stated as
vibrating between  1-010 and  1-020; though in
certain diseases it rises as high as 1-050, or sinks
as  low as  1-003.   [According  to  F. D'Arcct
(VExperience,  No. Iv.,  Aug. 1838), it varies be-
tween 1-001 and 1 060.  Dr. Thomson (British
Annals of Medicine, p.  5, Jan. 1837) found its
specific gravity  in  an individual from 50 to 60
years  of age, and  in  perfect health, to bear  the
average 1-013; — the lowest specific gravity  be-
ing 1-004, and the highest 1-026 : (see the writer's
Human Physiology,  5th  edit, i, 294:  Philad.
1844.)]
   It  reddens vegetable blues, owing probably to
the presence of  a little urate of ammonia, and to
some biphosphates which it always holds in solu-
tion.   If we add to healthy  urine a few drops of
any acid, and set it aside for  some time, small  red
coloured crystals  are  deposited.  These consist
of uric acid tinged  by some colouring matter.  If
we evaporate a  quantity of healthy urine  to one
half its natural bulk, and  then mix  it w ith nitric
acid,  and set it aside in an open vessel, a number
of  beautiful crystals  in plates  make their  ap-
pearance.  They have a light yellowish  brown
colour and a silky lustre, and  consist of urea
combined with nitric acid.
  The presence of sulphuric  acid can be detected
in  urine by means  of a solution of chloride of
barium ; muriatic acid may be detected  by nitrate
of silver; and phosphoric acid by nitrate of lead  ;
the white precipitate thrown  down by which, as
far  as it is  a phosphate, being' again dissolved  bv
the addition of nitric acid.  Lime  may be detected
by  means of oxalate of ammonia. The quantity
of magnesia in urine is so small that it is scarcely
possible to  detect its presence  by  re-agents.  But
if a quantity of  healthy  urine be left for two or
three  weeks in a cylindrical glass  vessel, the
mouth of which is covered with paper, and then
be poured out, we shall find attached to the sides
of the glass a number  of small transparent crys-
tals consisting of  four-sided  prisms with square
bases.  These crystals  constitute a  double salt
composed of
    One atom phosphate  of ammonia  6-C25
    One atom phosphate  of magnesia   7
  The formation of these crystals proves evidently
that magnesia  exists in urine, though only  in
minute quantity.   Urine  also contains potash,
soda,  and  ammonia; the last of which may  be
detected by the  smell, if we add caustic potash to
urine concentrated by evaporation over  sulphuric
acid in the  vacuum of  an air-pump.   If we con-
tinue  this evaporation nearly to dryness, crystals
of sulphate of potash and sulphatc'of soda make
their appearance in it,  proving that  both potash
and  soda  enter  into the constitution  of  unm
The following table exhibits  the  constituents  of 
360
CALCULI—[URINARY.]
healthy urine according to Berzelius's  analysis,
which is the latest that we have.
  Water........................93-300
  Urea.........................  3-010
  Uric acid......................  0-100
  Mucus........................  0-032
  Lactic acid, lactate of ammonia, &c*  1-714
  Sulphate of potash..............  0-371
  Sulphate of soda................  0.316
  Phosphate of soda...............  0-294
  Phosphate of ammonia...........  0-165
  Chloride of sodium..............  0-445
  Sal-ammoniac..................  0-150
  Earthy phosphates, with a  trace  of
     fluorid of calcium.............  0-100
  Silica.........................  0-003
100-000
  Besides these substances, which form constant
ingredients  of healthy urine,  this liquid in dif-
ferent  diseases has been found  to contain albu-
men, fibrin, and red globules of the blood ;  nitric
acid,  purpuric acid,  oxalic  acid,  carbonic acid,
benzoic acid ;  cystic  oxide,  sugar, bile, pus, and
doubtless  also xanthic oxide, though that has not
yet been ascertained by observation.
  Of these different  constituents of urine  there
are only two that it will be requisite to describe
particularly in this place.  These are  urea and
uric acid.
  Urea, when  pure,  is  a transparent colourless
substance, having a pearly lustre and  crystallizing
in four-sided prisms.   Its taste is feeble ;  but it
leaves a sensible coldness on the tongue like nitre.
Its  smell is slight, but  peculiar,  and quite dif-
ferent  from  that  of  urine.   When  exposed  to
damp air it  deliquesces, but does not seem to be
decomposed.   The specific gravity of its crystals,
as determined by Dr. Prout, is 1-350.  At 60°
water dissolves more  than its  own weight  of  it,
and the solution may be exposed to the air with-
out undergoing any change, provided it be pure ;
but if  it be  contaminated with the smallest quan-
tity of foreign matter, it is speedily converted into
carbonate of ammonia.   Boiling water dissolves
any quantity of it whatever.  Alcohol of 0-816
dissolves at 60° about the fifth part of its weight
of it,  and at a boiling  heat  more than its  own
weight; but when the liquid cools, the excess  of
urea  separates in  crystals.   When  mixed with
the caustic  alkalis or alkaline  earths,  and  heated
(provided water be present), it is decomposed and
converted chiefly into carbonate of ammonia.   A
number of  curious facts, respecting the relation
existing between  urea  and cyanogen have lately
been  discovered, which throw considerable light
upon the occasional existence of prussic acid  in
urine,—a fact which seems pretty well established;
but it  would lead  us  too far from  the  subject  of
calculi to state them  here.
   [By the aid of  the microscope, the presence  of
a very  minute proportion of  urea may be ascer-
tained.  If its aqueous or alcoholic  solution  be
evaporated, and then a little nitric or  oxalic acid
be  added,  delicate silky crystals of nitrate  or
jxalate of urea are perceptible.  The evaporation

  *Tlie writer of this article has in vain endeavoured
«■< ascertain  the presence of these  bodies in  urine.
should  be performed on  a glass slide, and  the
subsequent crystallization  be examined by  the
microscope. (Dr. Griffith, Practical Manual, &c,
p. 17, Lond. 1843.)]
   Uric acid, when pure, is a white, tastelesb sub-
stance, existing  either  in powder or in minute
crystals, which seem to be four-sided prisms.  It
has  no smell.   According to  Dr.  Henry,  it is
soluble at 60° in 1720 parts of water; but Dr.
Prout could not  dissolve  it in   10,000 times its
weight of water.f   It dissolves  readily in a solu-
tion of caustic potash or soda, from which it may
again be precipitated in  a white powder by the
addition of almost any acid.  It  dissolves in nitric
acid  with effervescence,  when  assisted by heat.
When the solution  is  gently concentrated, crys-
tals of erythric acid form in it.  When the liquid
is evaporated  to  dryness, a beautiful pink sedi-
ment remains, which  is  a characteristic of this
acid.   On one occasion we have seen  uric acid
converted into urea by digestion in nitric acid.
The  experiment  was  made  by a surgeon  who
wished  to determine  the  nature of a calculus
which he had extracted.   The result not being
satisfactory, he brought both the calculus and the
substance into which he  had converted it, to the
writer of this article. The calculus was the com-
mon uric acid calculus,  mixed apparently with
muriate of ammonia.  The substance into which
it had been  converted was urea.  The surgeon
could not give a satisfactory account of the pro-
cess  which he had followed, and we attempted in
vain to repeat it successfully.
   Uric acid  combines with  the different bases,
and  forms salts  nearly insoluble.   The urate of
ammonia is  the  most  soluble;  it  dissolves in
about 480 times its weight of water, and the solu-
tion  has  the  property of  reddening  vegetable
blues.   If we put  a quantity  of healthy urine
under the exhausted receiver  of an air-pump over
sulphuric, acid, and allow it to evaporate spontane-
ously,  a sediment of urate of ammonia  gradually
attaches itself to the sides of the vessel in which
the urine is.  This seems to prove that in urine
the uric acid is in the state of urate of ammonia.
   [Uric  or lithic acid is always crystalline.   As
occurring in  urine,  the crystals  are  always co-
loured.   Their varieties of form are endless;  and
they are either separate, or combined  in clusters.
 When separate, the outlines are  either rhoraboidal,
square or rectangular ;  and all  their varieties, ac-
cording to Dr. Griffith, {pp.  cit.,) are explicable
by assuming them  to be  derived from the  right
rhombic  prism.    When  examined by polarized
light, the crystals of lithic  acid develope splendid
colours.
   Urate  or lithate of ammonia is almost always
 amorphous.  The radiating needles, seen upon its
surface have been described as composed of super-
 lithate of ammonia ; but  Dr. Griffith states, that

   t The probability is that both of these statements (in-
compatible as they may at  first  sight appear) arc sub-
 stantial correct.  Dr. Henry probably digested uric acid
 in water of 60°, and evaporated a  given weight of this
 water to  dryness in a moderate  heat, and weighed the
 uric  acid remaining.  Dr. Trout,  on the  other hand,
 digested one grain of uric acid in 10,000 grains of water
 without heing able to dissolve it.  The first experiment
 shows the quantity of uric acid which water can dissolve
 when the attraction  of aggregation is destroyed; the
 second the power which water possesses to destroy this
 attraction of aggregation. 
CALCULI —[URINARY.]
361
he  has not obtained  enough  to  enable  him  to
speak positively on this point]
  Let us now take a view of the different urinary
calculi, that we may see what light our knowledge
of the urine will throw upon their formation.
   1. Uric acid Calculi, [Lithicacid Calculi."]—
The uric acid calculus is by far the most common
of all, and to judge from the  number of calculi
which the writer of this article has had  an op-
portunity of inspecting, at least two-thirds of the
concretions formed in the kidney or urinary  blad-
der owe their origin to the deposition of uric acid,
either in a pure state, or combined  with ammonia.
As healthy urine contains urate  of ammonia  to
the  amount  of about  l-813th part, and  as this
salt  requires  about 480 times its weight of water
to dissolve it, we see at once, that, if  by  any de-
rangement in the digestive organs the quantity
of urate of ammonia in urine should be  tripled,
a portion of  it would of  necessity be  thrown
down, as the urine would not be sufficient to hold
the whole of it in solution :  for the urate of am-
monia would  amount to l-271st part of the urine;
so that about three-eighths of it would  precipitate.
Calculi composed of urate  of ammonia  are  al-
ways small, and seem nearly peculiar to children.
They are undoubtedly to be  ascribed to  the ex-
istence of an excess of urate of ammonia in the
urine,  which is a very common consequence of
indigestion, proceeding either from the use  of an
excessive quantity of food, or of food which does
not agree with the constitution of the  child.
  Whenever  a free acid  makes its way into the
urine,  uric acid constantly precipitates, and may
give origin to a calculus unless it be voided along
with the urine.  Now, as there is always  a quan-
tity of free muriatic acid in the stomach, and fre-
quently also  acetic  acid, it  is easy to see how
these,  when  they become excessive, may make
their way  to the urine, and occasion a precipita-
tion of uric acid.
  It is probable that most  of these calculi have
their origin in the  kidney, from which they are
not displaced  till they have gained  some size; for
if either urate  of ammonia  or uric acid were to
be precipitated in  the  bladder, as  they would be
in the state of  a powder or  of minute  crystal,
they would  probably be voided along with the
urine.  But,  after a nucleus has lodged  in the
bladder, it is easy to see how it increases in  size ;
because the uric acid, &c, as precipitated, is de-
posited on its surface, and adheres to it.
  Calculi composed of uric acid are generally of
a brownish red  or fawn colour, but occasionally
approaching to the colour of  mahogany.  The
surface  is  often  smooth, but  not unfrequently
finely  tuberculated.   This kind  of calculus is
usually composed of concentric laminae.  Its frac-
ture  generally presents an  imperfect  crystalline
texture, but sometimes an earthy one ; in which
ease  its colour is lighter, and it usually contains
a mixture of urate of ammonia.
  Before the  blow-pipe this calculus blackens,
emits a smoke having  a peculiar  colour,  and is
gradually consumed, leaving a minute quantity
of white ash, which  is generally alkaline.  It is
completely soluble in caustic potash, and precipi-
tated again by any  acid in  the form of a white
granular powder.  When a fragment of  it is
  Vol. I.—46                        2f
 mixed witb  nitric  acid, and  heated  on a watch-
 glass, it dissolves with effervescence;  and if the
 solution be evaporated  to dryness, the residue as-
 sumes a beautiful pink colour.
   This is by far the most common species of cal-
 culus.  The number of calculi composed of uric
 acid  alone,  or only  slightly mixed with  other
 bodies,  in the collection of Dr. Hunter, deposited
 in the Hunterian Museum belonging to the Uni-
 versity of Glasgow, amounts to ninety-eight.   Of
 these, sixty-seven are tuberculated on the surface.
 The  largest of them   measures  three  inches in
 length, and weighs 2340 grains..  Another weighs
 1817 grains.   Most of them are composed of con-
 centric  laminae, chiefly  distinguishable by differ-
 ence  of colour, and in the density or looseness of
 texture.   Some of them contain a small compact
 nucleus of uric acid ;  others not.
   The  uric acid calculi, quite  smooth on the sur-
 face,  in  the same  collection, amount to twenty-
 three.  No other difference between  these  and
 the tuberculated calculi can be pointed out, ex-
 cept  the  appearance of the surface.   Several of
 them are crystallized,  and they consist of laminae
 like the others.  In some of the internal laminae,
 tubercles can be distinctly recognised.
   There  are eight uric  acid calculi in the collec-
 tion,  of a much whiter colour and  more  chalky
 texture than the others.  Probably  they contain
 urate of soda.   One of these  contains a piece of
 bright iron as a nucleus.*
   Calculi of urate  of ammonia [or lithate of am-
 monia]  are  so rare that their  existence has been
 denied altogether.  There is  not one of them in
 the collection of calculi in the Hunterian Museum
 belonging to the University of Glasgow ; but the
 writer of  this article has had  an opportunity of
 inspecting and  subjecting to a chemical analysis
 a considerable number of such calculi.  The late
 Dr. Monteath,  surgeon in Glasgow,  had a high
 reputation as an operator for the stone.  He  had
 preserved all the calculi which he had extracted,
 and among them there were no fewer than  seven
 consisting of urate  of ammonia.  Most of them
 had been  extracted from infants between the ages
 of two  years  eleven  months, and  nine  years,
 though  one  was from  a man of forty.  It was
 dark-coloured, and  in  layers,  and about the  size
 of a wren's egg.
   They were all small, but sufficiently large to
 be subjected to analysis without  any great dimi-
 nution of their size.  The diameter of the largest
 was one inch and five-eighths.
   Urate of  ammonia calculi have a  clay colour ;
 the surface  is  in most cases  smooth,  but  some-
 times tuberculated.  The  stone is composed  of
 concentric layers,  and the fracture  is very fine
 earthy.   Before the blow-pipe it usually decrepi-
 tates strongly.   It is much more soluble in  water
 than  uric acid calculus,^ and  when  heated with
 caustic  potash  gives out a strong smell of am-
 monia.    Liquid carbonate of  potash or  soda
 readily dissolves the urate  of  ammonia calculus,
 although  they  are  incapable  of dissolving uric

  * Most of these calculi have been varnished. This is
 the reason  why the iron has remained bright.
  t It is not unlikely that the calculus originally examu
 ed by Scheele was composed of urate of ammonia.  ThH
 would account for its solubility, whicn he found muct
greater than that of uric acid cmculi ever is. 
362
CALCULI —[URINARY.]
acid calculi.  The reason of this is, that a double
decomposition takes place,; the carbonic acid and
ammonia unite together, and make their  escape,
while the caustic  alkali combines with the  uric
acid.   Two of these calculi consisted of urate of
ammonia alone ;  two had a nucleus of uric acid,
while the external part was urate  of ammonia ;
and three were mixtures of uric acid and  urate
of ammonia.
   Urate of ammonia  calculi are certainly rare.
They seem to be mostly confined to infants, or at
least to persons under puberty.  They occasion a
degree of irritation in the patient scarcely credi-
ble.   The  opening or shutting of a door, or the
least noise  or motion, produces a paroxysm of the
most  distressing kind.
   Uric acid exists very frequently as the  nucleus
of a calculus, the greatest  part of which  consists
of other  ingredients;  showing clearly to what
cause the origin of the disease must be ascribed.
   2.  Mulberry or Oxalate of Lime Calculi.
— Next to the uric acid, we  conceive that the
oxalate of lime constitutes  most frequently the
nucleus of  urinary  calculi.   This calculus  is
usually of  a dark brown colour, approaching to
that of dried blood.  Its surface is very rough and
tuberculated.   It  is  usually hard  and compact,
and,  when  cut through, exhibits an  imperfectly
laminated  texture.  Mulberry calculi commonly
approach the spherical form, and are never very
large.  The diameter of the largest in the Hun-
terian collection  belonging to the University of
Glasgow, is  two inches.   It weighs 1323 grains.
Before the blow-pipe this calculus expands into a
kind  of white efflorescence, which, when moist-
ened and  brought in contact with turmeric paper,
stains it red, owing to the  lime  being deprived of
its acid, and rendered caustic by the heat.   When
pounded, it  dissolves slowly in muriatic  or nitric
acid; and  the oxalate of lime may be  again
thrown down by ammonia.
   There is a variety of this calculus called hemp-
seed  calculus, from  some resemblance  which it
bears in colour  and lustre to hemp-seed.   It  is
 remarkably smooth and pale-coloured, and always
 of a  small  size.   A  number of these hemp-seed
 calculi usually exist in the bladder at once.
   [Oxalate  of lime, when present  in the  urine,
 occurs in crystals, whose form is a very flat octo-
 hedron. As they lie upon the field of the micro-
 scope,  they appear to have a rectangular or some-
 times a square outline.   When dry, they  seem
 to have a smaller square placed wifbin the larger,
 whose sides are  opposite the angles of the  latter.
 Sometimes,  they appear  in the  form of dumb-
 bells.  By polarized light  the dumb-bells  give the
 most splendid colours, whilst the octohedrons pro-
 duce very  little,  sometimes no alteration.   (Dr.
 Bird and Dr. Griffith, in op. cit.)]
   As oxalic acid is not a constituent of healthy
 urine, it is not easy to  conceive to what alteration
 in the blood or in the functions of the kidney its
 formation  is owing.  Probably  the appearance of
 this  acid is the consequence of the mode of liv-
 ing.   From a paper by Mr. R. Smith, of Bristol,
 entitled A Statistical Inquiry into the Frequency
 of Stone in the  Bladder in Great Britain and
 Ireland, it appears, that in the collection of cal-
 culi  belonging to the  Bristol  Infirmary,  amount-
ing to two hundred and eighteen specimens, about
five-twelfths, or almost one-half are either com-
posed entirely  of  oxalate of lime, or contain at
least a  nucleus of that substance.  Of the  one
hundred  and  eighty-seven calculi belonging to
different practitioners in Manchester, described by
Dr. Henry, about  one-fourth are either composed
of oxalate of lime, or contain it as a nucleus.  In
Dr. Hunter's collection belonging to the Univer-
sity of Glasgow, the  number of calculi composed
altogether of oxalate of lime amounts to only two.
But those which contain  a nucleus of oxalate of
lime amount to fifteen.  Of these, ten  contain a
nucleus of oxalate of lime, while the outer lamina
is uric  acid.   Five have  a nucleus of oxalate of
lime, while the outer crust is triple phosphate.  In
three of  the five  there are three lamina?; 1. a
nucleus of oxalate of lime; 2. a thick lamina of
phosphate of lime; 3. a thin crust of triple phos-
phate.
   We can draw no  conclusion from their num-
bers, because Dr.  Hunter has  left no documents
by which the  localities from which  he  procured
his calculi can be  authenticated.   As he did  not
himself practise as a surgeon, it is  obvious that
his collection must have been made by presents
from other persons;  and  being a  great favourite
with his pupils, who were settled in  almost every
district of Britain, it is probable that he drew his
supplies indiscriminately  from  the whole island.
   3.  Phosphate  of  Lime  Calculus,  [Bone-
earth Calculus.]—This calculus is generally of a
pale brown  colour, and its surface is smooth  like
porcelain, so as to  appear highly polished.  It is
very regularly laminated.   The lamina? are usual-
ly thick and very easily separated from each other.
The  shape is mostly oval, and the size is some-
times very considerable.  We have seen one taken
out of the bladder, after death, of such a size that
it must have  nearly filled  it.   It  does  not fuse
before the blow-pipe.   It dissolves readily in mu-
riatic acid, without effervescence, and is precipi-
tated undecomposed  by caustic ammonia.
   Judging from  the statements  of  Mr. Brande,
Dr. Marcet, Dr. Henry, and Mr.  Smith, who have
described the  constitution of no fewer  than  823
calculi, this calculus  in a  pure  state is exceedingly
rare, and generally of a small  size.   The number
 of calculi composed entirely of phosphate of lime,
in Dr.  Hunter's collection, is  43.  The largest is
 2-8 inches in length ; but it is not certain that it
was  from  a  human  bladder.  It weighs 2142
 grains.   The  finest of these  calculi is  composed
 of five  laminae, easily separable, and quite smooth
 and polished on the  surface.
   There are  11  calculi in the same collection,
 composed chiefly of  phosphate  of lime,  but the
 outermost coat of which  is the  triple phosphate.
 Thus the whole phosphate of  lime calculi in  this
 collection amount to 54, which approaches to  one-
 fourth of the whole.  But we  are not certain that
 some of  these  may not have  been from some of
 the inferior animals.   The number containing a
 nucleus  of  phosphate of  lime  and  an external
 coating of the triple phosphates  is small, not
 amounting  to a   tenth  part of  the  collection.
 There  is not a single calculus in which a nucleus
 of phosphate of lime is  followed  by a  lamina of
 uric acid or oxalate of lime. 
CALCULI —[URINARY.]
363
  As phosphate of lime (or at least biphosphate
of lime)  exists in urine, though in exceedingly
minute quantity, there is no difficulty in conceiving
how  it might  be deposited.   Whatever has the
property of rendering the urine alkaline, will of
necessity precipitate  phosphate  of lime from it.
For example,  if the  nature of the urea were so
much changed that  it should be converted into
carbonate of ammonia, which happens out of the
body whenever it is heated in contact with potash
or soda and water, it  is obvious that phosphate of
lime would be thrown down.
   4. Ammonia»Phosphate of Magnesia Cal-
culi.—[Ammoniaco-magnesian phosphate calcu-
li ,- triple phosphate of magnesia and  ammonia
calculi.']  These are always nearly white.  The
surface  is commonly uneven,  and  covered  with
minute  shining crystals.  The texture  is not at
all, or very imperfectly laminated.   This calculus
is soft, and easily broken and  reduced to powder.
But it is said sometimes to be hard and compact,
and when broken, exhibits a crystallized texture,
and  is somewhat transparent.  There is a remark-
able calculus of this  kind in the Hunterian Mu-
seum, belonging to the University of Glasgow.  It
 was taken from  the  bladder after death, which it
completely filled.  It was sent to the museum by
 Dr. King, of Irvine.   It  is an oval stone, consti-
 tuting a pretty exact cast  of the bladder.   Near
 the centre it is a little smaller, indicating  a stricture
 of the bladder in that place.  The length of this
 stone is five inches and a half.   Its circumference
 where thickest  is fourteen inches and one-six-
 teenth ;  but at the stricture only ten inches.  Its
 weight  is one pound  fourteen ounces  and  eight
 grains avoirdupois.  It is white  and  crystallized
 on the surface, bearing some resemblance to agal-
 matolite.  It is composed of a nucleus of uric acid,
 having  a brown  colour,  and  composed of many
 concentric laminae.   The external crust is ammo-
 nia-phosphate of magnesia, mixed with some ani-
 mal matter.   This calculus is the largest which
 the writer of this article has  ever  seen.  Before
 the blow-pipe this calculus gives off the odour of
 ammonia, and at length melts with difficulty.   It
 gives out ammonia when treated with caustic pot-
 ash,  and is very easily  dissolved by very dilute
 acids.
   It is a rare thing  to meet with a calculus com-
 posed entirely of ammonia-phosphate of magnesia.
 In the Hunterian collection belonging to the Col-
 lege of  Glasgow, which  consists of 225 urinary
 calculi and about 75 intestinal calculi, biliary cal-
culi,  and calculi belonging to inferior animals,
 there is not a single specimen of this calculus in
 a state of purity.  But mixed with phosphate of
lime it is by no means uncommon,  and  then con-
stitutes what Dr. Wollaston called fusible calculus.
It is  usually white  and  friable, somewhat like  a
mass of chalk.   It  is sometimes very  large.  It
fuses very easily before the blowpipe, and dissolves
with  great ease in  dilute  muriatic acid.  There
are fourteen such calculi in the Hunterian collec-
tion.  The  largest is  three-fifths of  an inch in
length,  and weighs  1758  grains.  One of these
calculi contains a piece of lead about the size of a
crow-quill, and  more  than an inch long, which
had served as a nucleus.   A second has a nucleus
of tin.   Besides these fourteen composed entirely
of the mixture of the  two phosphates, there are
seventeen calculi in the same collection having a
nucleus of phosphate of lime, but whose external
coat is the fusible calculus.  It is curious that this
external coat, which is usually much more abun-
dant than the nucleus, is not concentric with it.
The internal nucleus with which  the calculus has
obviously originated is frequently  within a quarter
of an inch of the outside of the calculus on one
side, and  more than an inch from it at the other
side.  It is obvious from this, that  the accumula-
tion of the fusible part of the c.alculus must have
been very rapid.
   As biphosphate of magnesia exists in urine, and
as it becomes insoluble whenever  the second atom
of acid is saturated with ammonia, we can easily
see that there ought to be a deposit of ammonia-
phosphate of magnesia whenever  the urine  be-
comes charged with ammonia.  Ammoniacal urine
usually indicates a broken constitution ;  and it is
remarkable  that in such urine  the  quantity of
earthy phosphates always increases enormously.
Hence  it happens that  the fusible calculus fre-
quently forms the outermost coat of large calculi,
and that whatever may  have been the  original
state  of the urine when the calculous  deposit  be-
gan to be formed, it ultimately terminates, unless
the irritating cause  be removed,  in tbe  urine be-
coming alkaline, and the consequent deposition of
the fusible  calculous matter.   Perhaps this may
be owing in some cases to improper medical treat-
ment ; for Dr. Prout mentions calculi which he
had examined, the outer crust of which consisted
of urate of soda.  In such cases the patient seems
to have been subjected to a course of alkaline me-
dicines till  the  urine  was  impregnated with an
excess of soda.   This occasioned  the deposition
of urate of soda, and  would  ultimately have  led
to the deposition of the triple earthy phosphates,
and probably to the increase of their quantity.
   [The bi or sesqui-basic triple phosphate of mag-
nesia and ammonia, is composed of minute ele-
gant  stellae.  It  is seldom found as a natural de-
posit, but may often be  detected  in urine which
has become alkaline by  keeping.   The neutral
phosphate is found in the form of  beautiful prisms.
Sometimes the angles are replaced  by facets. These
crystals  are recognized by their transparency, ab-
sence of colour  and peculiar forms.   When  ex-
amined  by  polarized light, the neutral phosphate
produces the most brilliant colours.   The stellar
bi-basic triple phosphate produces little or no effect
with  polarized light.   (Griffith, op. cit.)~\
   5.  Carbonate of Lime  Calculi.—These cal-
culi are not very rare in the inferior animals, though
they  are very uncommon in man.  Mr. Smith  de-
scribes some which  he had met  with  that bore  a
close resemblance to the mulberry calculi, and  yet
consisted of carbonate of lime.  (Med.  Chirurg.
Trans, xi. 14.)   Dr. Prout  mentions some  small
calculi which he had  seen  composed almost  en-
tirely of carbonate of lime.   They were perfectly
white and very  friable.   (Prout's Inquiry, p. 93 ;
[and  On the Nature and Treatment of Stomach
and Renal Diseases, Amer. edit,  from the 4th re
vised Lond. edit. p. 448:  Philad. 1843.]) In Dr.
Monteath's collection, mentioned  before, there was
a small calculus, which had been extracted from
a man in the 26th year of his age.   It was white, 
364
CALCULI—
[URINARY.]
but not friable, nor did it stain the fingers ; it was
composed of nearly one part of carbonate of lime
and two  parts of phosphate of lime.   There was
a very small internal nucleus  composed of bright
crystals, having the aspect of ammonia-phosphate
of magnesia.  This is the only calculus  that we
have seen having a nucleus of ammonia-phosphate,
and the  outer crust of which consisted of other
constituents.  Yet as the whole calculus was cal-
careous, it can hardly be considered as an excep-
tion from the general rule.
   The carbonate  of lime calculus  is easily  de-
tected by the  property which  it has of dissolving
in muriatic acid with effervescence, and the neu-
tral solution is abundantly precipitated by oxalate
of ammonia.
   6.  Cystic Oxide Calculi.—This calculus has
a yellowish white colour, and its surface, which is
commonly smooth, exhibits a  kind of crystallized
appearance.   It is not composed of distinct lami-
nae, but appears as one  mass, confusedly crystal-
lized  throughout its substance.  The fracture ex-
hibits a  peculiar glistening lustre, like that of a
body  having a high refractive  density.   When in
small fragments, it is semi-transparent.  This cal-
culus is  very rare,  only four  or five specimens
having yet been recognized.  When  treated by
the blow-pipe, it gives out a peculiar and charac-
teristic odour.  It is very easily dissolved both in
acids  and alkalies, and crystallizes with both.
   [Cystic oxide generally crystallizes  in  delicate
six-sided  and sometimes in quadrilateral plates.
At times, the crystals  are crenate at the  margin,
with  a dark nucleus, and often irregular laminae
are perceptible on  the surface.   The effect with
polarized  light is various ; sometimes colour is de-
veloped, but often not.]
   7.  Xanthic Oxide Calculi. — Of this very
rare calculus only a single example has been hith-
erto  observed.   It was given to  Dr.  Marcet by
Dr. Babington, who had it from  one of his  pa-
tients; but nothing farther is known respecting
its history.  It had an oblong spherical shape, and
weighed  about eight grains.  Its texture is com-
pact, hard, and laminated ; surface smooth, colour
cinnamon brown, and much heightened by adding
caustic alkali to the calculus in powder.   Before
the blow-pipe it splits  in  pieces, burns black, and
is consumed,  leaving  a  minute particle of white
ash.  When distilled it yields a fetid ammoniacal
liquid, from which carbonate of ammonia crystal-
lizes.   It is mostly soluble in  boiling water when
in fine powder, and the solution reddens vegetable
blues. On cooling the  greatest part  again sub-
sides  in white flocks.  It dissolves both in acids
and  alkalies,  though much more readily in  the
latter than the  former.   When  its solution  in
nitric acid  is  evaporated to dryness, the residue
has a bright lemon  yellow colour.  This residue
is partly soluble in water, to which it communi-
cates its  colour.   Thence the  reason of the name
xanthic oxide, by which Dr. Marcet distinguished
it.  It is insoluble  in alcohol, ether,  and oxalic
acid,  and  very  sparingly soluble in acetic acid.
(Marcet's Essay on the Chemical History and
Medical Treatment of Calculous Disorders, p. 95.)
   8. Alternating Calculus. — This  as  the
name imports, may consist of different layers  of
■ ny of the preceding species.  Hence its appear-
ance may be very varied.  The nui lcus is usually
uric acid  or oxalate of lime ; and the outermost
crust is not unfrequently composed of triple phos-
phate.   We have in the preceding account stated
the different alternations,  and the order in which
they occur in  the calculi  belonging to the Hun-
terian  collection in the  College  of Glasgow.—
There  was an alternating calculus in the late Dr.
Monteath's collection, which deserves to  be no-
ticed.  It was  oblong, being 1-75 inches long, and
1-375  inches  broad where  widest.  It was  com-
posed of three distinct substances.  The  nucleus
was oxalate of lime, not however pure, but mixed
with a  little phosphate of lime,  and with distinct
traces of uric  acid.  The second layer was com-
posed of uric  acid mixed  with some phosphate of
lime. The outermost coat consisted of phosphate
of lime mixed with a little uric acid.  This outer-
most coat was  divided into three distinct layers,
each of them composed  of the  same materials.
This calculus was not only composed of alternating
coats, but each coat was a mixture of two or more
constituents.  Indeed, this mixture of different in-
gredients  in the same coat is a  very frequent oc-
currence in calculi.  The most  common  mixture
is that of urate of ammonia with the phosphates.
In such cases  the urine was undoubtedly alkaline;
and such  a state, when it continues, is very apt to
occasion a redundancy of earthy phosphates, which
of course would be neutralized  and precipitated
by the alkali present.  This alkali, it may be pre-
sumed, is most commonly ammonia.
   9. Fibrinous Calculus.—This calculus was
sent to Dr. Marcet by Sir Astley Cooper.  It was
about the  size  of a pea, and had a yellowish-brown
colour,  somewhat  resembling that of bees'-wax.
Its surface was uneven, but not rough to the touch:
its  texture rather fibrous than  stratified, and the
fibres seemed  to radiate from the centre.   When
heated it took fire, swelled out, and burnt like an
animal  matter.   It was  insoluble in water and
muriatic acid  ;  but it  formed  a soapy solution
when boiled with caustic alkali, from wbich it was
precipitated by muriatic  acid.   Nitric acid dis-
solved  it  with difficulty.   When  boiled  in  very
dilute acetic acid, it swelled to  a  great size, and
was at last dissolved ;  and prussiate  of potash,
when added to the solution, threw down a yellow
precipitate.  These characters lead to the conclu-
sion, that the calculus in question was composed
of fibrin.  (Marcet's Essay, &c, p. 101.)  This
kind of calculus is very rare, having been observed
only in the case of a gentleman  between fifty and
fifty-five years of age, who passed in succession
three sucb calculi.
   Such is the  nature of the different calculi to
which  the urinary organs of man are liable.  The
mulberry calculi are the most difficult of explana-
tion, as they consist of a salt which does not exist
in healthy urine at all; yet they are not uncom-
mon, the  mulberry calculi in Dr. Hunter's collec-
tion amounting  to one-thirteenth of the whole.
But by far the most common calculus is the uric
acid one.   They amount, in the collection of Dr.
Hunter, to five-elevenths of the whole ; and they
are still more  numerous in the  collections which
have been described by others.  In Dr. Monteath's
collection, which consisted of about thirty calculi,
all of which he had  extracted himself, no fewer 
CALCULOUS  DISEASES.                         aOf}
than ten-thirteenths, or rather more than three-
fourths of the  whole,  consisted of uric acid or
urate of ammonia.
  There is reason to believe that, when uric acid
is deposited,  the urine  is acid;  a  state which is
very apt to follow indigestion,  or excess in eating
and drinking.
  The phosphate  of lime calculi are  generally
considered as rare, and  it is supposed that they
are always small in size.  If any conclusion can
be drawn from the number in Dr. Hunter's collec-
tion of calculi,  they amount to very nearly one-
fourth  of  the  whole.  Some  of them  are very
large;  but as  there  is no catalogue nor  history
accompanying  this collection,  we cannot be sure
that some of them are  not from the inferior ani-
mals.  Yet, as the calculi of the inferior animals
are  in  this collection  arranged  in a  separate
drawer, it seems to follow that all the calculi in
this part of  the collection were considered by Dr.
Hunter as human  calculi.
   The  fusible  calculi  usually indicate a broken
constitution.  Hence this matter commonly con-
Btitutes the  last coat of those calculi that have
been long in  the  bladder, and which  have been
taken out after death.   The calculi  belonging to
this class in Dr. Hunter's collection amount to
nearly  one-seventh of the whole.   But if we take
the  phosphate  of lime  and  the  fusible calculi
together, they constitute two-fifths  of  the  collec-
tion.   Probably they may be nearly as numerous
as the  uric acid calculi;  but as patients afflicted
with them frequently die, many of them are not
extracted  at all, and  thus  the number appears
much less than it ought  to do ; whereas the uric
acid being a deposit which is apt to be formed in
a  state of comparative health, the  operation is
much  more frequently had recourse  to, and of
course their numbers appear much more formida-
ble than those of the  pbosphates.   [See, on the
chemical history of urinary concretions, Dr. Gold-
ing Bird, in Guy's Hospital Reports, vii. 175.]
                        Thomas Thomson.
   CALCULUS.   (Pathology  and  Treat-
ment.)—The calculi which are found within the
urinary organs  are, of all those enumerated in the
preceding article, the most important to the prac-
titioner, and they have long attracted a large share
of attention from medical men.
   Urinary calculi  are  formed  by the diseased ac-
tion of the vessels which secrete  the urine, or by
a deposition from urine in a morbid state.  They
are also formed by the mucous membrane of the
Dladder, which  sometimes secretes an altered fluid
abounding in phosphate of lime; just as many of
the concretions enumerated take place in other
mucous cavities.
   In considering the formation of urinary calculi,
 here are certain chemical facts which require to
De stated before we can explain how precipitations
from the urine  occur.   When any acid, even the
carbonic, is added to healthy urine, a precipitation
af lithic acid after a short time  takes place ; the
acid thus added seizing upon the small proportion
of ammonia in combination with the lithic acid, and
by means of which it was held in solution.  (Dr.
Prout on Diseases  of the Urinary Organs, 2d edit
p. 12, [and on the Nature and Treatment of Sto-
                                     2f*
mach and Renal Diseases, Amer. edit. p. 163: Phi-
lad. 1843.])   Thus we see how the presence of any
uncombined acid in the urine will produce a lithic
deposit, and give rise to calculous disease, or aug-
ment a calculus already  in existence.   The acid
which  seems most  commonly to be the primary
cause of lithic  deposits, is the  muriatic, and its
source  the stomach, where it abounds  in  most
cases of indigestion.
  On  the  other  hand, by adding  ammonia to    »
healthy urine, a precipitate is produced, consisting
partly of phosphate of lime, and partly  of triple
phosphate of ammonia and magnesia : part of the
alkali uniting with the excess  of phosphoric acid,
which  held the lime  in solution, while another
portion combines with the phosphate of magnesia,
and  forms  a  salt  of  very  sparing  solubility.
Hence we  perceive the  connection which exists
between ammoniacal urine and  the deposition of
the phosphates.  The ammonia, thus performing
so important a  part in  calculous disease,  seems to
be chiefly derived from the decomposition of urea,
which  is effected readily by the presence of the
fixed alkalies and alkaline earths, and  by various
other substances.   These remarks will  serve to
explain in what way precipitations from the urine
do take place independent  of a morbid excess of
lithic acid, or of lime and magnesia ;  but it is by
no means to be inferred  that the excess of these
constituents of  urine is not respectively the imme-
diate cause of a great majority of calculous cases.
  When a calculous nucleus has been formed, if
it do not escape by the  natural outlet, it will re-
ceive from the urine  by which  it is washed suc-
cessive  additions of solid  matter.  It does not
appear, however, that in all such cases there is a
continual increase of tbe stone ; for we often find
it to consist of many distinct  concentric laminae,
varying in thickness, and sometimes also in com-
position.  It is, besides, obvious that  the occur-
rence of a deposit will depend on the condition of
the  urine, which may  be, and frequently is, so
healthy  that it lets fall no  concreting  matter.
Calculi have been known to exist in the bladder
for many years, yet without acquiring an extra-
ordinary size, wbich they must  have  done had a
continual increase been taking  place.   The  me-
chanical process of the  formation of calculi is suf-
ficiently demonstrated by dividing them accurately
through the centre; thus exhibiting their nucleus
and  the  successive layers of which very  many of
them are composed.  The nucleus is either itself
a concrete  formed by the kidney,—in two  cases
out of three lithic acid,—or some extraneous body
which  has  found its way into the urinary cavities.
The most common  of such foreign bodies is a clot
of blood; at other times the nucleus  has been a
fragment of a  bougie, a small hair, a portion of
lint  introduced through the wound in lithotomy, a
bit  of  straw, a musket-ball, a pin, a bodkin, and
even a filbert.  By such dissections of calculi we
are enabled to trace out with accuracy  the history
of their formation, to mark the changes which the
constitution  of the urine underwent during the
progress of the disease, and  to satisfy ourselves
that considerable intervals must have occasionally
existed between the successive deposits.
   Urinary calculi vary  exceedingly in their size,
form, and tenacity.   Some calculi do not equal a 
366                         CALCULOUS
DISEASES.
millet-seed in size, while others have been found
so large as to fill up the entire cavity of the blad-
der.   Mr. Earle has described a very large stone
which had been extracted, but with  a fatal result,
by the celebrated Cheselden.   Its weight was 18$
ounces,  its circumferetice in the  large axis was
11£  inches,  in  its short axis 10  inches.  Dr.
Charles  Preston  relates  in  the  Philosophical
Transactions, that he saw, at La Charite, in Paris,
a stone which weighed 51 ounces.   The  patient
died  under the hands of the  operator.  Mr. Har-
mer, of Norwich, extracted  from the  bladder a
stone which weighed 15  ounces,  and had a dia-
meter of 4f inches by Z\.  The patient  recovered,
but a fistulous opening remained.  (Gooch, Surg.
Observat. p. 54.)  In the case of Sir David Ogil-
vie, Mr. Cline performed  the operation, but could
not extract the  stone.   (Philos.  Trans.  1810.)
After death it was found to measure 16 inches  in
its longest diameter, and 14 in its  shortest, and to
weigh 44 ounces.  The Breslau collection contains
an account of a stone found in the bladder after
death, which weighed 72 ounces.   (Bresl. Sam.
vol. ii. p. 434.   1724.)    Kesselning relates that
he saw,  in Moraud's Museum  at Paris, a stone
which weighed six pounds three ounces; and the
model of another which was still larger.   (Hatter,
Dissert. Chir. t. iv. p. 251.)
  By far  the largest calculus which we have
ourselves seen is one presented  to the Hunterian
Museum at Glasgow, by Dr. King, of Irvine.   It
was  taken after death from the  body of a carter,
who had  for many years laboured under the dis-
ease.  Its form is irregularly egg-shaped,  with a
slight constriction  near  the middle; its greatest
circumference  is  14X   inches, its   shortest   10
inches.   It has unfortunately been broken, but it
is now so  carefully cemented together  by means
of plaister of Paris, that its appearance is in no
way  injured.   The weight of the calculus as it
now  lies, together with some fragments kept for
examination, has been ascertained by Dr. Thom-
son to be one pound fourteen ounces eight grains
avoirdupois.   It consists of two substances : one
resembling light brown indurated earth, and form-
ing the great mass of the stone ; the other an in-
crustation  of white  closely  crystallized matter,
which envelopes all but one or two  spots. The
surface of this crystallized portion  presents nume-
rous  short elevated lines and  small  indentations,
corresponding  apparently to the minute wrinkles
of the mucous  membrane with which it  lay  in
contact.
  Urinary calculi are usually spheroidal, and their
surface  is sometimes remarkably smooth, often
covered  with  minute crystals, occasionally tuber-
culated, or beset with sharp projections.  Calculi
of the kidney, when of  large size, sometimes pre-
sent  a complete cast of the dilated cavities  of that
gland, and  have  the appearance of corallines.
When several stones are contained  within a cyst
or pouch, their surfaces  become adapted to each
other, and the  whole often  forms  one globular
cluster.   Instances  are  recorded  where  calculi
have occupied  the  neck of the  bladder and pros-
tatic portion of the urethra, moulding themselves
to the form of the cavity, and allowing the urine
to drain  away  by their sides, (Ballingall, Ed.
Med  Chir. Trans, vol.  ii.)  and several histories
are to be met with of grooved (Blancard, Anat
Prat.  Cent. i. Ob. 94.   Walter, Mus. Anat. vol. i.
p. 31)  and even  perforated  calculi.   (Schurig,
Litholog. p. 371.   Blancard,  Anat. Pract. Cent.
ii. Obs. 34.)   Many calculi are so hard that they
cannot  be penetrated  withqut great  difficulty,
while others  are so loosely agglutinated  that the
pressure of  the  forceps  in  extraction  readily
crushes  them into a substance like mortar.   In
other cases the  calculous  matter has  never coa-
lesced into a solid, but remains in a soft state, like
newly-mixed plaister of Paris.
   In  reference  to the medical  history of calculi,
they may he conveniently divided according to the
situation in  which they are found ;  into renal,
vesical, and  urethral.  A fourth  description  of
calculus found in the genito-urinary organs is the
prostatal; but there is reason for believing that it
is not derived from the urine.
   1.  Renal Calculi.—It is an  observation  as
old as Fernelius, and it  may be traced even higher,
that all urinary calculi  not formed  on  foreign
bodies introduced into the bladder, originate in the
kidney ; and if we  except phosphatic concretions,
some of which appear to be formed in the bladder,
the doctrine  appears to be  substantially correct.
We will not  attempt to describe  in what exact
mode a calculus is  first formed in the kidney, nor
is it likely that we  shall even attain to more than
a probable conjecture on this subject.  As crystals
of lithic acid have been found in the tubuli urini-
feri, and even in the cortical part of the kidney,
(Wilson, Lect.  on the Urinary Organs, p. 213,
8vo.  1821,)  there  is good reason to believe that
in many instances  the  material of calculus con-
cretes almost at the moment of its secretion.   If
such solid granules be  retained  within the chan-
nels of  the kidney, it  is  obvious that  they must
become the centres of attraction for other particles
of concreting matter to arrange themselves around;
and as  they  increase in size, they will serve, by
their  irritation,  to derange the actions  of the
organs in which they are detained, and thus occa-
sion the secretion of a morbid fluid, abounding  in
the materials of  calculous  concretions.  Many
dissections have shown the great size to which
renal  calculi  may  attain,  and  the extraordinary
tenuity to which the secreting  organ which sur-
rounds  them  may  be reduced; and that too  in
some  cases without destroying its secretory func-
tion.  A remarkable  instance of such a calculus
occurred in the person of a natural daughter of
Sir Richard Steele.  No nephritic  symptom took
place until shortly  before her death, when severe
pain was felt  in the  region of  the right kidney,
fever followed, and  speedily proved fatal.  A cal-
culus of oxalate of  lime, weighing 7£ ounces, was
found in the right kidney, which was so thinned
by absorption  as to be  reduced to a mere mem-
brane.  In this  instance the stone could  be felt
during life through the  loins, inducing  the belief
that the kidney had  become  ossified.   (Catal.
Museum R. Coll. of Surg.  Lond.  Note by John
Hunter.)
   Mr. Cline used to mention in bis lectures that
he had been able to detect the  presence of calcu-
lus in the kidney of a very thin person.  But such
are extreme cases ; and many  instances  are re-
corded,  where, although renal calculus had been 
                             CALCULOUS

long in existence, no disease of the kidney was
suspected during the lifetime of the patient.   The
symptoms are in  general  obscure, and rarely en-
able us to ascertain satisfactorily the  presence of
stone in the kidney.  Among these may be enu-
merated, a feeling  of weight  and dull aching in
the loins ; sharp pricking sensations in the region
of the kidney;  obstinate pain, in some instances,
at the scrobiculus cordis; frequent fits of vomiting;
bloody urine, especially after exercise which shakes
the body ;  numbness, cramp, pain, or cedema of
the corresponding thigh; and, finally, occasional
attacks of inflammation of the  kidney.  Attacks
of this nature sometimes  destroy the patient by
their violence, but much more  frequently end in
the  discharge of  pus   from  the  kidney, which
escapes by the natural passages ; while tbe patient
gradually wastes away, and  after much suffering
from inflammation, or  perhaps  ulceration of the
bladder, at length dies  exhausted.  It is from this
propagation of disease to the  bladder that frequent
painful micturition comes to be a symptom of cal-
culus of the kidney.   In  some rare  instances the
inflammation has produced thickening of the sur-
rounding parts, and led to the  formation of ab-
scesses, which have presented  in  the loins and
formed  fistulse, giving  issue to the  urine, and
occasionally to small calculi.  Cases are recorded
in several of the older authors, where stones of con-
siderable size were extracted by the incision of such
fistula?.  Hence  surgeons have  been emboldened
to propose and sometimes to perform the operation
named  nephrotomy, for the  removal of renal cal-
culi ; but no distinctly detailed and well-authen-
ticated case  has  come  to our knowledge, where,
without  the previous existence  of abscess of the
loins, a calculus has been  successfully removed by
this operation.   (See  Mr. Hobson's relation of
his own case, Philos. Transact.,  abridged, vol. iii.)
Nor is it likely that the pelvis of the kidney  could
be safely approached with the knife  without the
previous security of that matting  of the  parts
which must occur before an  abscess can make its
way to the  surface of the loins.  When  a  stone
has  been formed  in the kidney, its weight, and
the current of the urine which is constantly pass-
ing  off, naturally  tend  to carry  it down through
the  ureter;  but it may be detained  by the  deep
situation in  which it has concreted, or by some
prominent points of crystal, which serve to fasten
it to the soft surface on which it lies ; or, after it
is loose, its size may be such  as to prevent it from
entering the ureter.  In some  instances  the cal-
culus has lain in  the orifice of that tube,  and re-
mained  there as a plug, allowing the urine in part
to escape, yet keeping,  at the same time, the pel-
vis and infundibula generally distended,  and in
this manner dilating these cavities gradually to a
great extent; causing absorption of the substance
of the kidney, and reducing it at length to a mere
capsule, having many  cells  communicating one
with another.   When the  distended and   atte-
nuated kidney is  seized with inflammation, pus
is formed, the interior receives a lining of albumen,
and  the gUnd becomes like  the cyst of a  large
chronic  abscess.   When the  stone is very small,
It occasionally  passes  along the ureter without
producing any sensible  effect; but in general the
system feels  the influence of the unwonted im-
 DISEASES.                          307

pressions which it induces.   Tbe patient is usu-
ally seized with nausea  and vomiting; a feeling
of alarm takes place, with cold  chills and smart
shivering; pain, often agonizing, shoots from the
loins  down to the  fold of the thigh, and thence
along the  limb.   The pain is usually felt on  the
inside of the thigh ; but in the recent instance of
a lady who passed  an irregular pea-like calculus
of oxalate of lime, the pain  stretched from  the
loin, by the crest of the ilium, along the  outside
of the limb.   In  men, the passage of a calculus
along the  ureter  is generally marked by  the re-
traction of the corresponding testicle, and some-
times even by inflammation of that gland.   It is
remarkable that, amid all this commotion, the cir-
culation is usually unaffected.   The pulse is calm
and  regular, and the  skin nearly of natural tem-
perature;  thus proving  that  the symptoms  are
occasioned  by a powerful  impression  on  the
nerves, and are wholly independent of inflamma-
tory disease.   But here, as in other cases of strong
nervous impressions,  inflammation  will arise in
consequence of this prolonged operation.  Should
the calculus be arrested in its progress down the
ureter, all  the symptoms become aggravated, in-
flammation in general speedily sets in, and,  if not
subdued, cuts  off the patient.  The greatest danger
in such cases  arises from the stone  filling up the
canal of the ureter, and  obstructing entirely the
passage of the urine;  thus forcibly distending the
cavities of the kidney, and  inducing suppression
of the secretion, which has been known to  occur
in both kidneys  where  only one  of the ureters
was obstructed.   (Brodie, L. Med. Gazette.  April
16, 1831.)  It might be supposed that the ureter
would in  some cases  become  so distended above
the impacted  stone as  to burst;  but if this ever
occur, it  is  certainly  an  uncommon accident.
Several circumstances render its occurrence  un-
likely ;  one of the first  effects of the pressure of
the confined urine  is to  act  mechanically on the
secreting  organ, and  diminish or altogether sus-
pend its functions; absorption of the aqueous part
of the fluid also takes  place, which relieves  the
distension of  the cavities : while fortunately the
ureter is very dilatable, and its  contents  are  not
urged forward by the  spasmodic action of power-
ful muscles,  as  when  retention of urine arises
from  obstruction of the urethra.   The ureter is
well  known  to  be  capable  of  great dilatation,
when the  current of urine is obstructed; it  has
sometimes been found as large as the small intes-
tine, and  elongated so as to have a zigzag  form.
Cases have even been met with where the  capa-
city of the ureter is said to have equalled  that of
the bladder.   The consequences of suppression
of urine and  of its absorption are low delirium,
coma, and  death.   (See Ischuiua.)   A fatal
result may  also  follow  the  retention  of calculi
in the  ureter in  a  more  gradual manner, by
the  occurrence  of inflammation,  ulceration  of
the ureter, and escape  of the urine into the ad-
joining cellular tissue.    In  some  rare cases of
stone in the ureter, abscess has occurred, followed
by fistulse opening in  the groin or lumbar region,
and  giving issue to the  urine.   Frank relates u
case where a  calculus was thus discharged from
the left  ureter.  In  many instances, although n
calculus be detained  in the ureter, its toim is so 
368
CALCULOUS  DISEASES.
irregular, or the relaxation of the tube is  such,
that the urine escapes by its sides, depositing new
matter on its surface, and  augmenting it far be-
yond the size capable of being transmitted  along
the ureter.  The deposition of calculous matter
under such  circumstances  is greatest  above and
below, thus  giving  the stone an oblong  or cylin-
drical  form.   Sometimes  one  calculus only is
found in the ureter ;  sometimes  there are many
smaller ones; and  instances are  recorded where
its  channel  was found  entirely  filled  up   with
gravel.  A calculus has  not unfrequently passed
along the ureter until it  reached  the point where
that tube pierces the coats of the bladder obliquely,
and has there been arrested.   Its extremity pro-
jecting into  the bladder has been felt by the sound,
and lithotomy performed for its extraction, which,
to the  credit of surgery, has in  more than one in-
stance been  successfully accomplished.  (Le Dran.
—Dessault.)
   2.  Vesical  calculus.—If the calculus, hap-
pily, drop into the bladder, there is a cessation for
a time of all urgent  symptoms ; and should its
size permit,  it is expelled through the urethra. In
the female, where  the urethra  is short and  easily
dilated, the  calculus  is usually  discharged ; and
hence the greater  rarity of stone in the bladder
among women.  Even when the stone has  rested
in  tbe female bladder, and grown to so great  a
size as to fill up and form  a cast of the partially
contracted organ, its pyramidal form has enabled
it to pass  by gradually dilating the urethra ; and
it has  been  expelled with throes  resembling those
of parturition.   Calculi of extraordinary size are
recorded, in the Philosophical Transactions and
other  publications, to have been discharged by
females in this manner.
   In males, the length and narrowness  of the
urethra, and the spasmodic action of the muscles
which embrace  it,  render the expulsion of  a cal-
culus from the penis much more uncommon than
its passage through the ureter.   In very few cases
is  a  calculus forced  through  the male urethra
without considerable  suffering, and sometimes an
incision is required to relieve the patient. Reten-
tion of urine for a longer or shorter period usually
occurs.  In one instance, where the recent forma-
tion of a false passage prevented the introduction
of a catheter, puncture of the bladder  became ne-
cessary, and was successfully performed through
the rectum  ;  the  small calculus being expelled
when  the congestion and  irritation of the  parts
had subsided.  Retention of urine in  infants has
not unfrequently arisen  from calculus sticking in
the urethra, or  plugging up its  internal  orifice.
The  practitioner, therefore, ought to  be aware of
the possibility of such an occurrence, and have re-
'jurse to the necessary method of ascertaining
and removing  the  obstruction.   A curved  probe
will often suffice, or a slender gum catheter may
be introduced, and  the water drawn off.   If relief
be not speedily given, the bladder inflames, con-
stitutional symptoms  arise, and the little patient is
soon carried off.   Many instances are recorded in
 ivhich symptoms  of  calculus  existed  from  birth.
 A  male child, mentioned  by Mr. Wilson,  ( Wil-
son, Lectures on the Urinary Organs, p. 210,) was
 unable, from his birth, to retain  his urine; and,
dying before he had completed  seven months, a
stone as large as a garden-pea was found in the
bladder.   Brendelius relates that two infants, one
two  days old, the other eight, passed calculi be-
fore  death, and  calculi were  also found  in  their
bladders.    (Brendelius,  Program,  de  Calculis
Vesic. et caeteris Natal.; also, Observ. Anat. Dec.
iii. ob. 1.)   Loeseke  found a calculis in the kid-
ney of a new-born  child.  (Loeseke, Obs. Anat.
Chir. Med. p. 39.)   Fischer relates that a boy, in
his twelfth week, after suffering excruciating pains,
passed a. calculus by the urethra as large  as a
date-stone.   (Hatter,  Disp.  Chir.  t.  iv.  p.  79.)
Hence we are warranted in believing that urinary
calculi are sometimes formed during the fcetal state.
   Should the calculus be retained in the  bladder,
which in the male most commonly happens, it
receives a gradual addition of substance, and be-
comes a source  of greater and greater irritation.
Although the existence of stone in the bladder
cannot be fully ascertained without its being felt
by an instrument introduced into that organ, yet
there are many symptoms which, when they con-
cur, afford  strong presumptive  evidence of the
fact.   When a calculus is loose in the bladder, it
is liable  to  constant  changes of position, which
usually occasion  sharp pain; and  in evacuating
the urine, the stone  is apt to fall upon the  inter-
nal orifice of the urethra, causing sudden stoppage
and severe straining.  After smart exercise or jolt-
ing of the body, the urine is generally mixed with
blood, from  the abrasion of the mucous membrane,
which is  loaded  with red vessels, and resembles
during life the richest vermilion-coloured velvet,
as we have  seen in a case of eversion  through a
vesico-vaginal fistula.
   The appearance of blood  in  the urine would
be much more frequent in cases  of calculus, were
it not for the protection afforded by an increased
secretion of  mucus, which acquires in this disease
an unnatural degree of viscidity ; thus enveloping
the calculus, and shielding the tender surface of
the  bladder.  A copious  secretion  of glairy mu-
cus is a constant attendant on the advanced stages
of calculus,  and also  on diseased prostate and
other prolonged  irritations of the  bladder.   It is
to be observed that this mucus is  seldom passed
in a separate state, but generally diffused  and sus-
pended in the urine, from which it gradually sub-
sides, and coalesces into a gelatinous viscid mass,
which adheres to the  bottom of the vessel, even
when it is inverted.   When this  separation has
taken place within the bladder, it is voided with
difficulty, and often plugs up the  urethia,  and
causes a temporary  retention of urine.   The co-
lour of the  mucus varies according to the degree
of irritation and the length of time it has existed.
From being clear it changes to grey, then to green-
ish yellow ;  and at length, when  the mucous mem-
brane has become extensively diseased, it is large-
ly  mixed with  purulent  matter.  The character
of the mucus is alkaline, even when the urine is
decidedly acid ; and it is justly  considered  as the
source of many of those deposits and  spongy con-
cretions of  phosphate of  lime which are found in
the bladder.
   The agony of a fit  of stone is generally known;
consisting of excruciatingly  painful efforts to ex-
pel the urine, during which  the abdominal mus-
cles, tbe diaphragm, the muscular coat of the blad- 
CALCULOUS  DISEASES.
369
der, and the levator ani are all in a state of strong
spasmodic action, and alternate  but brief relaxa-
tion.  From time to time this straining forces out
a few drops of scalding urine, while part  of the
contents  of the  rectum are  perhaps expelled  at
the same time with  eversion of the  bowel; but
from neither is the  least  alleviation  of suffering
obtained.   A vivid  and  accurate picture  of the
miseries endured in a case of calculus is exhibited
in a paper  by Dr. Marcet, where the patient has
described his own feelings, (Med. Chirurg. Trans.
vol. x.;)  and if we are to give implicit credit  to
the histories of the blacksmith  of Amsterdam,
(Tulpius. Obs. Med. 1. iv. c. 31,) and  the  cooper
of Konigsberg,  (Walther. Thes. Med. Chirurg.
Obs.  Cur. p. 195, ob. 60.) who cut into their own
bladders  and extracted the stones, we shall have
the strongest of all  evidence that  the sufferings
from calculus  are sometimes beyond human en-
durance.
   The chief cause  of all this agony seems to  be
 the contact of the calculus with the sensitive in-
 ternal surface of the neck of the bladder ;  at once
 irritating the parts to spasmodic contraction, and
 blocking up the passage of the urine; for  the pa-
 tient often  finds that by reversing his posture, or
 perhaps resting on his head and shoulders, he ob-
 tains relief.  The pain in the bladder shoots to
 the anus, the loins,  down the limbs, and is felt in
 an especial manner at the  extremity of the ure-
 thra, which causes  boys affected witb  calculus to
 seize and pull at the penis.   Hence elongation of
 the prepuce comes to be a symptom of stone, and
 the swelled and softened state of the little patient's
 fingers shows  how often they are bedewed with
 urine.  The ramifications of pain in a fit of stone
 are various and extensive,  and in some cases
 reach even to the heel or sole of the foot; a fact
 which we  have noted also  in  ulceration of the
 bladder.   A reference to  the multiplied  connec-
 tions of  the lumbar plexus and the  distribution
 of the great sciatic,  the ultimate ramifications  of
 which are  sent to the sole of the foot, will serve
 to explain  the great extent to which  the  pain  of
 calculus shoots.
    When a calculus is of great size, it is less liable
 to alter its position  and  is therefore usually pro-
 ductive of less irritation ; the  excruciating pain
 is commonly exchanged  for a distressing sense of
 weight at  tbe neck of the bladder.  Calculi occa-
 sion  comparatively  little uneasiness when they are
 supported  by  the   moderate contraction  of the
 bladder within its upper fundus  behind the pubes y
 and when  they get into fixed situations, as behind
 an enlarged prostate gland, or in cysts formed by
 the protrusion  of the mucous membrane between
 the bundles  of the overgrown  muscular  coat.
 This state  of overgrowth  of the muscular tunic
 of the bladder occurs in  calculus, as in   all  dis-
 eases of that organ  where frequent and long-con-
 tinued but ineffectual efforts are made to expel the
 urine.   Instances are occasionally met with when
 several,  sometimes  many stones are found  sepa-
 rately lodged in such pouches  in the same blad-
 der ; and  preparations of this description are to
be seen in most pathological collections.  A stone,
which had been distinctly felt by the sound, has
sometimes been thrown  into one of these cavi-
ties ; thus an end has been put  to  the irritation,
   Vol. I___47
and it has eluded the examination of the sound,
inducing the belief  that there was  no longer a
calculus in the  bladder.  Both the formation of
pouches in the  bladder, and  the  enlargement of
the prostate gland, are to be considered  as  conse-
quences  of the  irritation of calculus;  and  they
illustrate, in a striking manner, the  operation of
that conservative principle by which even the un-
controlled progress of diseases produces changes
which tend to the relief of the patient.  A still
more remarkable proof of the same fact is afford-
ed by those cases where  calculi  have ulcerated
through the coats of the bladder, and have  been
discharged from the  body, sometimes through the
walls of  the hypogastrium, at others into tbe rec-
tum, and in other instances into the vagina.   Cau-
mond  and Deschamps relate  cases of the  first,
(Journal Generate de Med. t. 27, p.  353,  &c.;
an. 1806, No. 124,)  and Johnstone of the second,
(Johnstone, Mem. Med. Soc. Lond. iii. p. 536.)
In  Mr. Johnstone's  case, the patient,  after years
of suffering from the usual symptoms of stone, at
length discovered pieces of gravel in  his stools,
which Mr. Johnstone was confirmed were urinary
concretions.  From that time all the painful feel-
ings ceased, and the patient  recovered perfectly,
without  any fistula  remaining.  A  female,  who,
at the age of twelve, got rid of a pretty large cal-
culus by ulceration into the  vagina, is  now, after
ten years,  in good health, but still suffering under
vesico-vaginal  fistula,  (Edinb. Med.  and   Surg.
Journ. vol. xxi.)  It is probable that in such cases
the stone had become imbedded in a  pouch be-
fore ulceration  commenced,  otherwise it would
have extended  more widely over the internal sur-
face, and proved fatal.
   The occurrence  of ulceration  of the  mucous
membrane of the bladder is one of the last in the
series  of changes produced by calculus;  and if
the patient has withstood all the other exhausting
circumstances of the disease, this seldom fails to
put a period to his sufferings.  In such prolonged
cases the bladder after death exhibits various de-
grees  of organic injury ; the  mucous  membrane
is  extensively  eroded,  the  ulceration  sometimes
reaching to the other coats of the bladder ;  or ab-
scess has  formed under  its  peritoneal covering.
The internal surface is in many places lined with
a layer of coagulated albumen, which is often en-
crusted  with  calculous matter.   Such  deposits
appear never to fasten on the organized  textures
themselves, but  on  a layer of albumen which
forms the  medium of attachment between  them.
The urine is probably, in most cases,  the source
of this incrustation  ; but it  may  also be derived"
from the internal  surface of the bladder, in the
same way  as earthy concretions are formed within
the cavities of abscesses.
   The effects of calculus in  the  bladder are not
limited to  that  organ, but extend to  the  ureters
and kidneys.   The  pressure of the urine, unable
to escape by the urethra, dilates the ureters and
cavities  of the kidneys, and the latter often ex-
hibit marks of inflammation,  and are  sometimes
found suppurated, or small depots of pus are dis-
covered  under the peritoneal covering.
   The long-continued  irritation  of a  calculus in
the bladder, or indeed within any of the urinarv
 organs, produces a change in the constitution of 
370                          CALCULOUS

Ihe urine, which loses its acid character, begins to
abound in the phosphates, and at length becomes
ammoniacal.   In  undergoing  this  change, the
urine first deposits the lithate of ammonia, then
the  ammoniaco-magnesian  phosphate, and the
phosphate of lime.   This morbid condition of the
urine,  termed the phosphatic diathesis, takes its
rise under various other circumstances of impaired
nervous energy of the kidneys  and bladder, be-
sides those connected with the wasting effects of
protracted calculous disease.  1 hus  injuries of the
spinal cord; continued irritat.on of the urinary
cavities from diseased prostate gland and strictures
of the urethra ;  immoderate sexual indulgences ;
disordered health, and general irritability induced
by excessive  mental  anxiety and fatigue; all have
the effect of occasioning  the  phosphatic diathesis.
Dr. Prout has satisfactorily shown  that all  varie-
ties of calculus converge  to  this point, and ulti-
mately end in the deposition of the phosphates.
In proof of the  correctness of this  opinion it is
sufficient to trace the progress of a long-contin-
ued calculous case, and to inspect the successive
laminae of which urinary calculi of long standing
are generally composed.  The  formation  of the
phosphatic diathesis  affords a clear indication that
the constitution  is breaking down  under the suf-
ferings of the disease, and requires that the ques-
tion of a surgical operation should  be considered
without delay.
   3.  Urethral Calculi___Calculi which have
commenced their passage along the urethra may
rje detained in their way, and become  imbedded
tn the side of the canal, where they  will continue
to receive new additions  from the  urine  which
washes over them.   In this manner urethral cal-
culi have occurred, and on  many occasions they
have  attained a considerable magnitude.    Their
general situation is in the perineum, where they
are found forming a hard prominent tumour.  In
some instances a single  stone is contained in  a
cyst communicating with the urethra ;  in  others
there is a pouch filled with numerous small many-
sided calculi, which  have evidently lain  closely
packed together.   On one occasion we witnessed
the  extraction of a stone  from  the  perineum,
which was as large as a pullet's egg, and consist-
ed of two portions, one of them having its round-
ed extremity fitted into a  cavity in the other. Mr.
Sisley, in  the Philosophical  Transactions, gives
an  account of a calculus weighing five  ounces
two  drams, which was expelled through a  dilated
urinary fistula at the upper  part of the scrotum,
(Phil. Trans, vol. xii. p. 351.)  In  an instance
which came under our own observation, eighteen
stones, varying from the  size of a mustard-seed to
that of a horse-bean, many of them polyhedrons,
were removed from a cyst forming a hard  tumour
Dehind the scrotum,  and  communicating with the
membranous portion of the urethra.  The exami-
nation of one of these stones showed it   to be
composed chiefly of  phosphate of lime deposited
in concentric lamina?, from which and the yellow
polished  surface which they  almost  all possessed,
we were led to believe them of prostatal  origin.
The following is probably to be referred  to the
same source.  A case of very large perineal cal-
culus, supposed to be of twenty years' growth, is
ro.ated iii  the Philosophical  Transactions, (Phil.
 DISEASES.

Trans., abridged, vol. iii.:) a sharp  angle  of the
stone was found  to have  penetrated  the rectum.
Its form  was irregular, and it  consisted  of two
parts, one jointed into the other.
  The  symptoms  produced by  calculi  in the
urethra,  or  in  pouches  communicating with it,
are those of urinary irritation, and  occasionally
retention of urine; but they seldom attract much
attention until the external tumour has become
considerable.
  4.  Prostatic Calculi. — Small calculi are
frequently  found within the  ducts  and  in ab-
scesses  of the  prostate  gland  :  sometimes they
are contained in one cavity, at others disseminated
in separate cells through the thickened substance
of the gland. Their surface is occasionally rough,
more frequently smooth  and  of a porcelain-like
polish—tbeir colour yellow or light brown—their
size varying from  a  mustard-seed  to  that  of a
hazel-nut.   Their chemical composition,  unlike
that of urinary calculi,  is always the  same.  It
appears  that they  are produced  by  the mucous
membrane of the prostatal ducts, or  by the sup-
purating surfaces of abscesses of  that gland; and
are not secreted by the kidney, or deposited from
the urine, and  therefore cannot in strict propriety
be  termed urinary calculi.  They may, however,
readily become tbe  nuclei of such stones, either
from the urine having access  to them while im-
bedded in the gland, or by their getting loose and
escaping into the bladder  Prostatal calculi have
often been found after death, where  no symptom
had indicated  their  presence ;  more frequently
they cause some degree  of irritation at the neck
of  the  bladder,  particularly when  the  urine is
voided ;  and if any  portion of  such calculus pro-
ject beyond the orifice of the duct or abscess, it
will be felt by  a sound entering the bladder.  The
instrument  in  these  cases  frequently forces the
small stone deeper into the cavity, and thus pre-
vents it  from being touched  by the sound in
several subsequent examinations, however dexter-
ously conducted.  It appears probable, from some
of the cases referred to under the head of urethral
calculi, that those of the  prostate,  when  accu-
mulated in great numbers, or of large size, occa-
sionally  form  tumours in the perineum, or pene-
trate into the rectum.
   Causes  of urixary Calculus. — The im-
portance of acquiring a knowledge of the  causes
from which urinary  calculi arise,  must be ap-
parent to every one who  considers that it affords
the only means by which we are enabled to pre-
vent the formation of this disease, the most pain-
ful in the catalogue of human maladies,  and its
recurrence  after the  sufferings and hazards of
lithotomy.  Calculus is  more common in  tem-
perate than in warm  or very cold climates : it is
much more incident  to early years  than  to any
other period ;  and  to old age  more than to the
prime of life.   Among those beyond middle age,
it occurs more  frequently in persons of sedentary
habits than in  those who lead an active life; and
in  those who  indulge in luxurious  living  much
more than  in  the  temperate  and  abstemious.
Hence there has long been observed  a  marked
connection  between a calculous and  a gouty ten-
dency.   But although the rich, the luxurious,
and the indolent are at a certain  age more  prone 
CALCULOUS  DISEASES.
371
to calculus than other classes, the poor  and the
destitute  in  early  years  enjoy  no  immunity
from it; for the ill-fed  and half-clothed children
of the manufacturing  and labouring population
are frequently afflicted with  stone.  All authors
who have written  on this  subject concur in stat-
ing, that females are greatly less subject to  calcu-
lus than males, notwithstanding their more seden-
tary habits.  The  more  temperate  and regular
modes of female life are  less productive of the
calculous tendency  ;  and  the  absence of the
prostate gland,  and the short dilatable urethra of
females, enable them much more readily to expel
such calculi as  have formed.
   Much persevering research has been directed,
by a succession of writers, to ascertain  the com-
parative prevalence of calculus in different parts
of the British islands, and among different classes
of society.  Ireland is still  admitted to furnish
very few instances of calculous disease; and there
certainly are strong  grounds for this opinion, al-
though we have no doubt that the state of society
in that  island opposes  many obstacles to the ac-
quisition of a full knowledge of the  facts on this
subject.   Scotland, which  had been set down as
affording a very small number of calculous cases,
is  now  ascertained to have been  quite  under-
estimated.  (Mr. Hutchinson in Med. Chir. Trans.
vol. xvi.)   The large manufacturing  town of
Paisley  appears,  from the very accurate returns
furnisbed by Dr. M'Kinlay,  (Ibid.)  to be almost
as productive of calculous cases as Norwich itself,
having yielded, in the ten years from 1820 to 1830,
eighteen cases of lithotomy in a population of
probably 42,000.  Both Mr. Hutchinson and Dr.
Yelloly (Dr. Yelloly in Phil. Trans. 1830)  seem
to us to have estimated the population of Paisley
too low ; but  making  allowance for  this,  and
some abatement  also for admitting into the enu-
meration private as well as hospital operations,
it must  be granted  that calculus is of compara-
tively  frequent occurrence  in  that town.   In
furtber  support of this opinion, it appears, from
information kindly furnished  to us by Dr. M'Kin-
lay, that the number of cases of lithotomy between
1810 and 1820 was probably greater than  in the
subsequent decade ;  and that, although  no  opera-
tion has occurred since his  report,  several cases
of calculus in  every respect  favourable for litho-
tomy,  are  now (July  1831) known to  exist in
Paisley.
   The comparative prevalence of urinary calculus
in different parts of England has been elucidated
by the inquiries of many able writers,  from Dr.
Dobson  downwards.   The  number of hospital
operations has  been assumed by all of  them as
the basis of calculation; therefore the result must
be considered as only a  distant  approximation to
the truth ; for  the number of cases of lithotomy
will not always preserve the  same proportion to
the real number of calculous  cases, but  will vary
according to the dexterity, enterprise, and reputa-
tion of the surgeons of the  place.   Thus in Nor-
wich, where distinguished operators  have existed
as far back  as  the beginning of the eighteenth
century—witness the epitaph on the  tomb of the
ecclesiastic Havers—not a case of calculus can
occur in  the city or neighbourhood without  being
speedily  detected,  and  probably   operated  on;
while in many other districts, cases  of stone are
allowed to proceed for years unrelieved, and per-
haps  wholly unsuspected.  The celebrity of an
hospital surgeon, or his  own exertions to obtain
reputation,  will  often bring to him cases from
very distant quarters, some of which may be  as-
sumed  in calculation as belonging to the district
where he resides.  Frank (Frank, De  Curand.
homin.  morb. De Calculo) tells  us that, previous
to the arrival of the celebrated Venetian  lithoto-
mist  Pagola at  Vienna,  calculus  was  deemed
rather uncommon in that metropolis, and only
one or  two  operations were performed annually ;
but after the surgeons  had  acquired experience
and dexterity from his example, the  operation  be-
came frequent, and the cures numerous. He adds,
that  calculus was believed  to  be  very  rare  in
Lithuania, until the establishment of the surgical
clinic at Wilna ; but that now the surgeons who
are skilled in the art of sounding find the disease
but too common.
   Norwich appears to be more productive of cal-
culous  cases than any other part of Great Britain
yielding one hospital case of lithotomy for every
21,000 inhabitants.   On the other hand, the city
and county of Hereford appear to be wholly free
from calculous  disease :  from 1775 till  the date
of Mr. Smith's  statistical inquiry (1818), no  pa-
tient suffering under calculus had applied at  the
Infirmary ;  and Mr. Smith could  not learn that
lithotomy had ever been performed within  the
bounds of the  county, (Medico-Chir. Trans, vol.
ii. p.  20,) which, it is worthy of remark, is noted
for its  cider, a beverage  hitherto supposed to  be
favourable to the  production of calculus.   Thus
we have the  two  extremes of the great pre-
valence, and the  apparent  non-existence  of cal-
culous disease, in different districts of England.
It has been  supposed that the diet of the inhabi-
tants of Norfolk is a main cause of  their liability
to calculus—a favourite article of food being hard
boiled, ill fermented, greasy dumplings.    These,
no doubt, are likely to cause  indigestion, and thus
give  rise to lithic acid deposits.  To this it has
been  objected, that many  cases of calculus occur
in that  district at so  early an age that diet can
have  no  influence in their  production :  but  the
diet of the nurse is known uniformly to affect  the
infant at her breast.
   Mr. A. C. Hutchinson has shown in  several
able papers, that  calculus is of particularly rare
occurrence  among  seafaring people;  and the
hospital returns of the  British  army prove also
that calculus is very seldom met with among our
soldiers.  [Sir William  Burnet, having   caused
the returns of the British naval hospitals, at home
and abroad, from April 1830 to Nov. 26, 1836,
to be  carefully examined, with reference  to this
point  of medical  statistics, it was found that the
only instance of the kind was one  of renal cal-
culus  in the hospital at Malta. The average num-
ber of seamen  and  marines voted  annually  by
the British Parliament,  during the  period  men-
tioned, including  2000 boys,  was 30,000.]  Tho
information  which has been obtained by Dr. Yel-
loly respecting the armies of France and Russia,
shows likewise  that  calculus is a  rare  disease
among  the  military  of those countries.   In ex-
planation of these facts, it ought to be remembered 
372
CALCULOUS   DISEASES.
that  none are admitted into either navy or army
6ut the robust and active ;  and that their services
are chiefly limited  to  that  middle period  of life
when calculus is very rarely observed to originate
among the labouring classes from whom soldiers
and  sailors  are drawn.   But, after  taking  this
fairly into account, we  are not disposed altogether
to deny the  greater immunity from calculus en-
joyed by individuals of both land  and sea forces ;
and we think that this serves to confirm, what
other observations  clearly  show, that a full sup-
ply  of  wholesome food,  good  clothing,  active
habits, and regular exercise, all  tend to prevent
the formation of calculus.  The state of the diges-
tion  and of the cutaneous  perspiration  must  be
admitted to  exert  a  powerful  influence on  the
secretion of  urine; for when the stomach habi-
tually abounds with acid, the urine rarely fails to
exhibit  in excess a similar condition ;  and  the
perspiration  influences, in a remarkable  manner,
the quantity  of lithic acid contained in the urine,
as the  experiments of Dr. Wilson  Philip have
satisfactorily shown. (Wilson on Urinary Gravel:
1792.)   Probably free perspiration is a principal
cause of the infrequency  of calculus in warm
climates.  The connection between calculous dis-
ease  and a  dry and  harsh state  of  the skin,  or
even  scaly  eruptions, has  long been remarked.
In the  case  of Horace Walpole,  it was observed
that  a cutaneous eruption, to which  he had been
many years  subject, yielded to the alkaline reme-
dies  which relieved his calculous symptoms.
   The  tendency to calculus appears in many in-
stances to be hereditary, like the kindred disease
of gout.  Dr. Prout and Dr. Yelloly both relate
remarkable facts in proof of this opinion ; and we
are inclined to ascribe to the hereditary nature  of
calculus a part, at least,  of that extraordinary
tendency to the disease which has long existed in
certain  districts.   Hitherto we have  been  unable
to discover  those local  peculiarities  of  soil and
situation which favour the formation  of calculus ;
but if we admit its hereditary nature, we have ob-
tained a key to some of those continued anomalies,
which otherwise appear incapable of  explanation.
It is clear that, in a district where calculus  is well
understood, and lithotomy often successfully per-
formed, a greater number of calculous individuals
will be preserved to propagate their race, than  in
districts where the operation is most commonly
fatal.  And  it is not beyond the range of  proba-
bility that individuals wbo have come from distant
quarters to some hospital of great repute, for the
purpose of submitting  to lithotomy, may settle  in
the city or its neighbourhood after the completion
of their cure.
   It has long been a  popular opinion that hard
waters are favourable to  the  production of cal-
culus, and one of our  latest and  best writers on
the subject expresses the same belief.  The effects
of such waters are diuretic,  and sometimes  slight-
ly purgative, and they are apt to disorder delicate
stomachs;  but it  is very  doubtful  whether  the
earthy salts which thev contain contribute  in any
more direct  manner to the formation of calculus.
   [In the great valley of Chester county, in Penn-
sylvania, where limestone abounds, a case of stone
•s of  rare occurrence.  According to Dr. Thomas
Harris,  of Philadelphia,  a respectable physician,
who had been  in extensive  practice  there for
twenty years, had never seen a case of it.  (The
writer's Practice  of  Medicine, 2d  edit.,  ii. 42:
Philad.  1844.]
  Injuries of the back have  been remarked  to
produce  a morbid condition of the urine,  usually
a change to an alkaline state ; and cases of renal
calculus have been distinctly traced  to  accidents
of this nature; several very interestinc:  examples
of which have been related by Mr. Earle (London
Med. Chir.  Trans,  vol.  xi.)  and  Mr. Wilson.
(Lectures  on the Urinary  Organs.)  Such in-
juries influence  the function  of the kidney  in
different  ways.    A   general concussion  of  the
spinal cord, or a blow  on the  spine in the region
of the kidney, will enfeeble its powers by dimin-
ishing the nervous  energy distributed to it, and
thus induce a morbid condition of the urine:  such
injuries will  also tend to weaken the expulsive
powers of the bladder, and by preventing it  from
ever being completely emptied, lead to the  decom-
position of the urine, and hence to the deposition
of the phosphates.  A blow on the kidney itself
is likely to prove a cause of calculous disease, by
the immediate effects of the concussion deranging
the action of the organ; and by small extravasa-
tions of blood, which cause irritation as  foreign
bodies, and furnish nuclei for future concretions.
Although clots of blood have often been found in
the centre of calculi, it is obvious that blood has
very frequently  been effused within the kidney,
yet no  calculus  has  followed ; the  blood being
washed  away before  it had time to cause that
irritation of  the  urinary organs which  disorders
the urine and occasions  deposits.  For it is in
this manner that extraneous bodies introduced
into the bladder become incrusted with calculous
matter, — causing in  the  first instance by  their
irritation a derangement in  the  secretion of the
kidney, and then furnishing a solid inorganic sub-
stance to which  the deposit may attach itself.  In
such cases the deposit  is almost  uniformly com-
posed of the phosphates,  but instances are met
with where it is formed of lithic acid; as  an ex-
ample of which,  we may mention a calculus in
the museum  of William Hunter,  where  this  sub-
stance  has formed  a  concretion, as  large  as a
plum, around a fragment of iron.
   Strictures  of the urethra  and enlargements of
the prostate gland  prove  causes of calculus by
the irritation which they produce  on the urinary
cavities, and by  their  subsequent effects  on the
general health, as well as by the obstruction which
they present to  the  complete evacuation of the
bladder.
   Treatment of Calculus. — In  the treatment
of calculous  disease, several different and highly
important  objects demand the attention  of the
physician—to correct the calculous diathesis and
prevent the formation of stone — to facilitate the
expulsion of calculi  when formed—to relieve the
sufferings of the patient, and  delay the progress
of the disease—and to  point out the  period when
a  surgical operation  offers the  best means  of
relief.
   When calculus has  been observed in  several
members  of  the  same family, or in successive
generations, it is  to  be presumed that  a strong
tendency to the  disease exists in their  constitu- 
                             CALCULOUS

tion ;  and precautions are therefore to be adopted
against its development.   For this purpose, active
habits ought to be encouraged, and the digestion
preserved in as vigorous a state as possible ; the
diet being nutritious, but  not  heavy or acescent.
A healthy state of the  skin  should be promoted
by the use of the flesh-brush, by warm clothing,
and occasional warm baths.   Even a residence in
a warmer climate during the early years of life,
may,  under certain circumstances, be  advisable.
On the  first  appearance of any thing unnatural
in the urine, it ought to  be  carefully examined,
for the purpose of adopting that plan of treatment
which its chemical constitution requires.
  The morbid  states  of the urine arrange  them-
selves under  the two great  heads of the predo-
minance of acid,  and the  predominance of alkali
or alkaline earths.  The  acid diathesis is chiefly
prevalent in infancy,  and  at  the commencement
of the decline of  life ; and in the early stage of
most  calculous diseases.   It may be truly said to
be by far the  slightest deviation of the two from
the healthy condition of the urine ; for the func-
tion of  the kidney has  been satisfactorily shown
to be an acidifying process; and the acid state of
all healthy urine  is proved by the change which
it produces on litmus paper.   The morbidly acid
condition of the urine exists under various forms;
from  that in which lithic acid is  deposited as  a
flocculent precipitate, or red gravel, to that where
a calculus of lithic acid is receiving  from day to
day  new additions  of size.   The urine in this
diathesis, when first voided, is usually clear, not
very plentiful, and is  of a bright  coppery colour.
It occurs under circumstances apparently the most
opposite — in the ill-lodged, half-starved, half-
clothed child  of  the  artisan  or labourer, in con-
nection with  loose chalky stools, feeble  digestion,
and a pallid aspect, — as well as in the pampered
plethoric  adult, who enjoys  the  pleasures of  a
luxurious table and  all the comforts of a modern
house.   The digestion of the latter  individual is
strong,  but his stomach is overtaxed, and unable
to accomplish the duty which is daily imposed on
it: his countenance  is florid, his frame robust,
and his habit probably gouty.  In both of these
cases there is frequent acidity of the primae viae,
but much greater in those of the  luxurious liver
than  in the  child :  the  difference,  however, is
 more than compensated in the latter, by the harsh
 unhealthy state  of the  skin,  which executes its
function imperfectly, and leaves an additional task
to be performed by the kidneys.   Guided by these
 views, our first object in undertaking the cure of
the child should  be, to have him warmly clothed,
comfortably lodged, and supplied with  a nourish-
ing diet, containing a moderate proportion of ani-
mal food.  Excess in this article seems to dispose
to the secretion of lithic acid.   The medical treat-
ment is to be commenced by a mild laxative of
castor oil, or rhubarb  and  magnesia ; and in many
instances great benefit will be derived from small
repeated doses of hydrarg. cum  creta,  or minute
doses of calomel.  After  this, alkalies and tonics
ought to be  given for  the purpose of correcting
the acidity of the primae viae and of  the  urine,
and of improving the powers of digestion.   Rhu-
barb,  gentian,  calumba,  and  cinchona,  may  be
enumerated as the best tonics;  and of the fixed
                                       2o
DISEASES.                         373
alkalies, potass is to be preferred to soda ; for the
lithate of potass is u very solul le salt, while the
lithate of soda is so much  th(  reverse, that  it
forms the chalk-stones of gout, and has been found
by Dr. Prout to constitute occasionally a consider-
able portion of a urinary calculus.   Although the
fixed  alkalies  are usually employed, cases of the
acid diathesis  do occur, both  in children  and
adults, where the stomach is enfeebled, and where
ammonia will  prove  more beneficial.  The vola-
tile alkali has also the  advantage of determining
to the skin, which it  is of great consequence  to
bring into a healthy state.   This  is  the descrip-
tion of calculous  cases which are so often met
with in manufacturing districts, and which seem
to have led Dr. Yelloly to suppose that there was
a connection between the  scrofulous  and the cal-
culous diathesis'.
   [It is affirmed by Dr. A. Ure, (Provincial Me-
dical and Surgical Journal, July  17,  1841,  p.
317,)  that hippuric  acid is  found  in  the  urine
after benzoic  acid has  been taken,  and that the
quantity of  uric  or lithic acid is  thereby dimin-
ished.   He  hence inferred, that  the uric acid  is
converted into the hippuric; and as the hippurates
are more soluble than the  urates,  it  was  sug-
gested by him, that benzoic acid might be advan-
tageously exhibited in lithuria or in cases of pre-
dominance of uric  acid.    The  observations  of
chemists have not, however, established this. On
the contrary, they have shown, that although the
benzoic acid appears to be converted into the hip-
puric, there  is no diminution in the quantity  of
the uric acid.   (Liebig, Animal Chemistry, Gre-
gory & Webster's edit., p. 316, Cambridge, U.  S.,
1842 ; and Professor Booth and Mr. Boye, in  Pro-
ceedings of the American Philosophical Society
at the Centennial Celebration in Philad., May,
1843.)]
   In the instances in which a calculous tendency
is combined with fulness of habit, a mode  of
treatment in  many respects  the  reverse of that
now described becomes requisite.   A spare  regi-
men and more active  habits ought to be recom-
mended ;  blood  should be taken by  cupping from
the loins, or from the arm by  venesection.   Calo-
mel should be given freely over-night, and follow-
ed next morning by rhubarb with  magnesia,  or
Rochelle salts.  The cure is to be completed and
confirmed by the employment of alkalies and bit-
ters, and  by a rigid adherence to  a system  of
moderate living and regular exercise.
   Under  the  head of acid  diathesis may be  ar-
ranged, not only deposits of lithic acid, but those
also of oxalate of lime and cystic oxide.  It has
been ascertained from the examination of calculi,
that the lithic acid diathesis and that of the oxa-
late of lime alternate with each other, thus show
ing their near  alliance  and mutual convertibility.
The cystic oxide diathesis, on the other hand, ap-
pears to be exclusive in its nature, all concretions
of this kind  being  of remarkable purity: it  is,
however, sometimes followed by a  deposition  of
lithic  acid; and  this, like  the other species  ol
urinary calculi, terminates in producing the  alka
line or phosphatic diathesis.
   The general principles of treatment in this clasn
of calculous diseases, is, certainly,  to counteract
the acid tendency by the use of alkaline remedies^ 
374
CALCULOUS  DISEASES.
but to this  there  arc  many exceptions.   In the
lithic diathesis it has sometimes been  found very
serviceable to produce  a copious discharge of that
acid,  by the exhibition  of turpentine combined
with  laudanum.   Dr.  Prout has employed,  with
advantage, the  muriatic  acid  in cases of oxalate
of lime diathesis; by which means he succeeded
in conveAng it into that  of  the lithic acid, and
thereby procured  great relief to his patient.   This
eminent physician,  who has so ably illustrated
the various forms of urinary disease, and to whose
writings the author of this article is so much in-
debted, proposes  a similar practice in the cystic
oxide diathesis, recommending the muriatic acid
to be given wherever the  state of  irritation will
permit, for the purpose of keeping the cystic oxide
in solution, and establishing in its place the  lithic
acid diathesis.
   [Liebig (op. cit.) and  Wohler ascribe oxalic
acid to the oxidation of uric acid ; and the former
affirms, that it is  a common occurrence in France,
when patients,  suffering  from  calculous  com-
plaints, go to the country, where  they take more
exercise, the compounds of uric acid, which were
deposited in the bladder during their residence in
town, are succeeded by oxalates, in consequence
of the increased supply of oxygen.  If these views
be correct, it would seem, that country air might
be injurious; but the  matter cannot be  regarded
as established.   (The writer's Practice of Medi-
cine, 2d edit., ii. 49 : Philad.  1844.)]
   Should a  calculous  tendency appear to be con-
nected with injury of the kidney,  or a  diseased
state of that organ, the employment of counter-
irritation,  and  especially  of  setons in its neigh-
bourhood, is distinctly indicated ;  and their  bene-
ficial effects have been  placed beyond  doubt by
the  observations  of  Mr.  Earle.   (Lond.  Med.
Chir. Trans, vol. xi.)
   When a  gouty disposition coexists with  a cal-
culous tendency, the  colchicum,  in combination
with the means already described, ought to be had
recourse to; but if the bladder already contain  a
calculus, we cannot with  safety push this medi-
cine  to.its  full  effect on the bowels, which in
cases of simple  gout and rheumatism  is  often
found beneficial.
   In  the  alkaline  or phosphatic  diathesis, the
naturally acid condition of the urine is exchanged
for an alkaline state; and the deposits now con-
sist  of the  phosphates.   This is  a much  more
formidable deviation from health than that which
we last considered, for it arises  as  a consequence
of other disease,  and is usually connected with  a
shattered state of  the constitution.  Our first
object  ought to  be, to  ascertain the  cause from
which the phosphatic  diathesis has  arisen, and to
remove or palliate it as far as we are  able.  The
spinal  cord  should  be relieved by counter-irrita-
tion, varying, according to circumstances, from  a
galbanum plaister to a seton  or a caustic issue —
the effects of diseased prostate alleviated by such
means as we possess; and if the symptoms have
arisen from calculus  in the  bladder,  its early re-
moval  by  operation presents the  only  mode of
effecting  a cure.   A/ree air, gentle exercise, and
a mild nutritious diet,  ought to be prescribed ; and
the tone of the digestive organs restored  by means
>>f the mineral  acids, bitters, and astringents. The
acids have been supposed to exert a direct influ-
ence on the urine, and there is no doubt that they
do pass the kidneys unchanged ; but their chief
beneficial  effects in the phosphatic diathesis are
accomplished  by influencing the organs of diges-
tion.   The  sulphuric, nitric,  and muriatic acids,
have  all been employed;  and the last has  been
found most generally useful.  Among the bitters
and  astringents the  uva ursi and pareira brava
have  deservedly obtained  a preference.  Medi-
cines which cause  a copious secretion of lithic
acid,  such as the  turpentines,  the seeds  of the
daucus sylvestris, and alchemilla arvensis, might
be supposed to prove beneficial when  an opposite
diathesis  was known  to  prevail; and cases  do
occur in which  they are found serviceable: but in
the greatest proportion of such  diseases, the irri-
tation of the urinary organs is so  great as  to
render their employment improper.  Indeed, it is
obviously of little  consequence  to  induce for a
time  a free  secretion of lithic acid,  without also
improving  that shattered  state of  health  with
which the morbid condition of the urine  is  gen-
erally connected.  It is worthy of  remark  that
such remedies  arc  powerfully  diuretic; now  in
the  phosphatic  diathesis the urine is  almost al-
ways superabundant, at times  excessive, which
forms  another   objection  to their employment.
This tendency  to  an unnatural increase  of the
urine, and the irritation, anxiety, and pain attend-
ing  the alkaline diathesis, point out opium  as a
valuable  remedy ;  and here, as in other states  of
prolonged suffering, it has proved truly a blessing.
Among the various forms in which this drug may
be  administered, perhaps the best are  the black
drop, Battley's liquor, and Dover's powder. Other
anodynes,  as hyoscyamus,  conium,  and bella-
donna, may be employed under less urgent symp-
toms ;  and  they  often  produce  very excellent
effects.
   Although mercury  is certainly  entitled  to a
place among the causes of the phosphatic diathe-
sis, and is therefore, on general principles,  to be
avoided, yet under certain circumstances  mercu-
rials are  productive  of  great benefit.  Dr. Prout
has well  remarked that in children  whose urine
deposits the phosphates, repeated doses of calomel
and  rhubarb are  exceedingly  useful; without
doubt, by correcting  the disordered  functions  of
the  digestive organs:  and in cases  of excessive
irritation of the  urinary cavities we have found the
full operation of calomel and opium signally bene-
ficial.  The existence of the phosphatic diathesis
is so  generally  combined  with a morbid state of
the alimentary canal—the stools being too pale, oi
too dark, or yeasty—that it is quite obvious  laxa-
tives and alteratives must be given;  but drastic
purgatives,  and even  free  purging,  are to  b«
avoided on  account  of the  tenesmus which they
are  apt to  occasion.   The  great  importance  of
attending to the feelings of the patient under this
form of calculous diathesis, and of removing when
it is possible every source of care  and anxiety, is
sufficiently  obvious.   Relief from the irritations
of business and the  fatigues of study is  equally
required ; and a change of scene  and air,  when
the patient can  be moved, is productive of great
benefit.
   Such are  .ie modes of treatment which appear 
CALCULOUS  DISEASES.                          375
to  be best adapted  to correct the  two principal
forms of calculous diathesis, whether the morbid
condition have recently  arisen,  or be  combined
with the existence of stone.
  When symptoms indicate  that  a calculus is
passing from the kidney to the bladder, the physi-
cian is usually called under circumstances of great
anxiety and  alarm.   In such cases, although the
pain be urgent, it is  not  always necessary to ab-
stract blood : it is a remedy, however, which ought
to be kept in view, and employed on the slightest
appearance  of a tendency to inflammation.  In
the  robust  and  plethoric,  venesection  is a wise
measure of precaution, and will have a useful
effect as a relaxant: even  in  persons of a less
vigorous frame, when inflammation threatens, the
immediate relief obtained by bloodletting renders
it  preferable to  cupping and  the application of
leeches.  During the passing of a calculus, all the
various methods of allaying pain are sometimes
required;—warm fomentations, bags of hot salt,
hot poultices,  the warm  bath, and anodynes in
every various form and mode of exhibition.  Some
difference of opinion may exist as to the propriety
of  giving diluents freely in such cases, so as to
produce an increased secretion of mild urine; but
it does not  appear  likely that a copious  flow of
urine will in  any case prove  hurtful;  for  if the
calculus be  not too large  to  pass, the increased
current of fluid will certainly render the process
more easy;  nay, there is reason to believe, that by
exposing a calculus  to the  constant  washing of
any aqueous urine,  some  of those  spiculae which
detain it in  its passage may be dissolved or worn
away.  Should the calculus be so smooth and so
impacted in the ureter that no urine can pass, the
probably fatal  result is not likely to be much has-
tened  by the use of diluents.
   When the calculus appears to be  delayed in the
 uretur, a brisk purgative of rhubarb and sulphate
of potass, followed by an enema, will be found to
facilitate its progress.  After the  renal calculus
has dropped  into the bladder, free dilution with
bland liquids or pure water ought to be persevered
in  to a still  greater  extent; and brisk  purgatives
of castor oil,  or rhubarb  and sulphate of potass
repeated at intervals. Should the small stone still
 be retained, its removal  should  be attempted by
dilatation of  the urethra.  By such means we
shall often succeed  in ridding the patient of what
would entail torture on his future  days, or bring
his life into  hazard by the operation of lithotomy.
   When a calculus is lodged in the bladder, and
there is no longer  any prospect of its expulsion
by the urethra, the  exertions of the physician are
chiefly limited to the two objects of lessening the
sufferings of  his patient and  preventing an in-
crease of the  stone.  The general  treatment is to
be conducted  on the principles already laid down
for  the management of the prevailing diathesis,
whatever that may  be; since by such means we
shall be most  likely to accomplish the two objects
stated above.   The irritation of calculus in the
bladder is in  most  cases remarkably relieved by
the administration of alkalies in the acid diathesis,
and of acids  in the phosphatic ;  but the soothing
effects of the  alkalies in the former  of these cases,
is  by  far the  more  striking and uniform.   Nay,
the power of  the nlkalies to allay  the  irritability
of the urinary apparatus seems not always limited
to those cases where  the  acid diathesis prevails ;
and  it is  worthy of remark- that their efficacy is
not diminished by combining them with the vege-
table acids.
  Gentle  exercise on foot, frictions, shampooing,
warm clothing, great  attention  to the  diet and to
the  state  of the  bowels, are all necefltery in the
management of calculus of the bladder.  Straining
at stool, whether from  a confined state  of the
bowels or the smart  operation of medicine, is to
be carefully avoided ; therefore  only the mildiEt
laxatives  should  be used.   Castor oil  is perhaps
of all others  the  best; but  a combination  of the
colocynth pill with hyoscyamus and a small pro-
portion of opium often answers remarkably well.
Under the agony of a fit of stone, the warm hip-
bath, heat applied in  various other ways, hot opi-
ate fomentations, and anodynes in suppository and
injection,  are our chief means of relief. Conside-
rable benefit has also been obtained from a clyster,
composed of half an ounce of oil  of turpentine
mixed with yolk of egg, and diffused in a pint of
thin warm starch.
  Long before the chemical nature of  calculi was
accurately ascertained, physicians conjectured that
they might  be dissolved while in  tbe body,  by
means of internal medicines ;  and the  opinion
was supported by the great and speedy alleviation
of suffering which calculous patients often derived
from alkaline remedies :  hence the belief became
general, and various nostrums were offered to the
public as certain solvents of the stone.   The most
celebrated of these was  the alkaline  solvent  of
Mrs.  Steevens, who  obtained from the  British
Parliament  five thousand pounds for the publica-
tion of its ingredients.  As both alkalies and acids,
when thrown into the stomach, are found to make
their appearance in  the  urine, they are without
doubt fitted to  produce some  alteration in calculi
within the bladder; but their action in  most inr
stances seems to be exceedingly limited.   When
alkaline lixivia have been long persevered in, they
seem to have had  the effect of rendering calculi
very brittle, (Dr. Henry, Lond. Med. Chir. Trans.
vol. x.) and in some instances to have caused ex-
foliations of their  superficial lamina?.  On exa-
mining the bladder of Horace Walpole, who had
taken  lime-water and soap for nine  years, with
great relief,  some exfoliations from two of the cal-
culi were observed.  (Philos. Trans,  vol. 1. p. 206.)
   Dr. Marcet also gives  a similar  testimony, re-
garding a case where alkalies had been used with
benefit for ten years.   (Marcet on Calculous Dis-
eases, p. 151.)  In a case  which fell under our
own observation, where the fixed alkalies had long
been employed, the patient passed many fragments
of concentric layers of calculus, which were solu-
ble in liquor potassae ; and he was for some years
before his death, which occurred at an advanced
age, nearly free  from urinary irritation.   When
the alkalies have been exhibited for  a considerable
time in a case  of lithic calculus, a superficial ad-
mixture of the phosphates with the acid is found
to have taken place ; and when this treatment  is
continued still  longer, the whole surface has been
found coated over with the same  salts.   In one
instance  related  by Sir  Everard Home, (On the
Diseases  of the Prostate Gland, vol. ii.) where tho 
376                         CALCULOUS  DISEASES.
alkalies had beon followed after a time by an ag-
gravation of symptoms, the stone, when extracted,
was found beset with spicular crystals of the triple
phosphate.  The relief from the irritation of cal-
culus procured  by the employment of  alkaline
remedies has in some  instances been so great, as
to lead to the belief that solution  of the stone
had actuary taken place; but on dissection it has
been found that the prostate gland was enlarged,
and  the  calculus lying in  the cavity behind it,
and thus prevented from falling against the sensi-
tive orifice of the bladder.   In the administration
of the alkalies, it must ever be kept  in view, that
the tendency of all calculous cases is towards the
formation of the phosphatic diathesis, and  that the
employment of the alkalies will necessarily hasten
the period of its occurrence; when the phosphates
will be deposited in abundance,  and tbe  calculus
will receive a more rapid increase than before.  A
vigilant attention, therefore, is required to prevent
the establishment of  this  diathesis,  which  will
readily be accomplished by abandoning the use of
alkalies,  and having recourse for a  time  to acids.
A phosphatic diathesis thus artificially induced, is,
without  doubt, much more manageable, and the
probable result  far less  dangerous,  than  when it
arises  in the natural progress of disease, and in
connection with an impaired constitution.
   [In France, the Vichy waters, which are highly
alkaline, have been celebrated, and their properties
have been canvassed by scientific observers, whose
opinions are worthy of all attention.  It would
not appear, that the destruction of calculi by this
water is  effected merely, or perhaps principally, in
the way  of solution, but that it is  accomplished in
a very considerable degree,—especially as regards
those of the triple phosphates,—by a kind of dis-
integration  of  their component particles.   When
calculi consist of the oxalate or the phosphate of
lime, mingled with lithic acid, lithate of ammonia,
or the triple phosphate, the Vichy water is said to
attack and disintegrate them rapidly.  This water
contains a large amount  of pure carbonic acid,
and nearly a drachm and a half of the bicarbonate
of soda  in every thousand drachms of the  men-
struum.   (See the writer's Practice of Medicine,
edit. cit. ii. 86.)]
   Proposals have  been made to dissolve calculi
by injecting appropriate  fluids into the  bladder;
but tbe trials hitherto made with alkaline  solutions
have shown that the bladder will not bear them
of sufficient strength to act effectively on calculi
of lithic acid.   On the  other hand, loose concre-
tions and amorphous deposits of the phosphates,
and of carbonate of lime, appear, from some late
experiments of  Mr. [Sir B.] Brodie, to be capable
of being gradually removed from the  bladder by a
weak  solution  of nitric acid,  sent in  a stream
through that organ, by means of a double catheter
of pure gold.  (London  Medical  Gazette, June
 18, 1831.)  This  prospect is highly gratifying,
 and we  trust the practice will prove as successful
 as the most sanguine  can anticipate; but it must
 be remembered  that cases of this description are
 in general complicated with such derangement in
 the general health, and  so much disease of the
 bladder, that nothing beyond a palliation of symp-
 toms can be looked for.
   fMr. S. Elliot Hoskins (Proceedings of the Royal
Society of London,  No. 56,) has endeavoured t<
discover some chemical agent which is  more en-
ergetic in  its action on certain varieties of human
calculi, and less  irritating when injected into the
bladder.   With this  view he suggests the employ-
ment of weak solutions of some of the vegetable
supersalts  of lead, such  as  the supermalate, the
saccharate, the lactate, &c. ;  but he gives the pre-
ference to an acid saccharate—the nitro-saccharate
of lead.   This salt must be moistened with a few
drops of acetic or of its own proper acid, previous
to solution in water  ; and the decomposing liquid
should not exceed in strength one grain of the
salt  to each fluidounce  of water.   The chemical
effects of these decomponents  Mr. Hoskins has
tried out of the body, and the results are certainly
encouraging.  More  recently, Dr. A. Ure has sug-
gested an injection of carbonate of lithia; and, as
urate of lithia is  the most soluble  salt which the
uric acid forms, it has  been thought by him an
advisable  injection  in cases of  the lithic acid cal-
culus.  Dr. Ure has not, however,  tried it: more-
over, the  carbonate  of lithia  is  extremely scarce;
but  he suggests  the importance of its preparation
to the pharmaceutical chemist.]
   In all cases of calculus in the bladder, the pa-
tient experiences most ease when there is a plen-
tiful secretion of urine, which,  by distending the
bladder, prevents the stone from being grasped in
the  muscular contractions of this organ.  It also
probably  preserves in solution  what might other-
wise form a new deposit on the stone; and there-
fore a free use of thin demulcent liquids, as barley
water, arrow-root, gruel, decoctions of prunes and
raisins, and of the  fibrous roots of the  leek, are
often productive  of  great relief to the calculous
patient.   But this system of dilution is obviously
not  adapted to all cases;  for, as we remarked above,
the  phosphatic  diathesis is  not unfrequently at-
tended with a superabundant secretion of urine;
and in such cases  any  increase of the quantity
would still prove more distressing.
   Although we cannot  remove a  stone from the
bladder by the internal administration of drugs,
surgery has invented various  methods by which
this object  may  be accomplished.   The  most an-
cient is that of  cutting  into the bladder, and ex-
tracting the stone through  the incision; and to
this the name of lithotomy has been given.  The
mortality from this operation has always been con-
siderable, and  uniformly very great in the hands
of the inexperienced and unskilful.  The propor-
tion of deaths to recoveries has varied exceedingly
in different hospitals;   but it is  gratifying  to be
enabled to state  that, over the island  generally, it
has of late manifestly diminished;  a result which
we  are inclined to ascribe to the more general dif-
fusion of surgical  skill.  In  the Norwich and
 Norfolk Hospital, the total rate of mortality in all
 ages and  sexes, from the opening of the institu-
 tion in 1772, has been  only 1  in 7-29.  Dr. Yel-
 loly, who has made this statement, (Philos. Trans.
 1829,) adds, that of late it has been reduced to 1
 in 8.6.   The following tables,  constructed by Dr.
 Yelloly, (Philos. Trans. 1829,)  from the records of
 the hospital up to June  1828, exhibit the compara-
 tive results of lithotomy at different ages and  in the
 two sexes.  The data here are more extensive, and
 the success is greater,  than in any other British
 hospital. 
CALCULOUS  DISEASES.
377
TABLE I.
Age or Sex.	Open-lions.	Cured.	Died.	Mortality.
	649	560	89	1 in 729
				
	618	531	87	1 in 71
	31	29	2	1 in 15-5
				
Both sexes.	292	272	20	
				
				
	357	288	69	lin 5-17
	155	140	15	
				
	202	148	54	1 in 3-74
				
	196	171	25	1 in 7-84
				
	161	117	44	1 in 3-56
				
Under 1G...........	317	294	23	lin 13-78
				
	332	266	66	1 in 5 03
T	ABL	E II.		
Age.	Opera-tions.	Cured.	Died.	Mortality.
	255	237	18	1 in 1416
	37	35	2	1 in 18-5
				
	62	55	7	1 in 8-85
				
	47	42	5	1 in 9-4
				
	46	43	3	1 in 15 33
				
40 to 50.............	41	31	10	1 in 4.1
				
	92	69	23	lin 4
				
60 to 70.............	63	43	20	1 in 3-15
				
70 to 80.............	6	5	1	lin 6
				
  These tables present  several results deserving
of particular notice.   The  rate of mortality be-
tween the ages of 30 and 40 is only  1 in 15-33,
while the decade immediately above  gives  1  in
9-4, and  that below 1 in 4-1.  Hence it may be
inferred that this small proportion of deaths is an
accidental anomaly, which  will not be  found to
correspond  with the  results of a  more  extended
experience.   In respect to the rate of mortality in
the two  sexes, and before and after puberty, Dr.
Yelloly's tables coincide completely with the gene-
ral observation  of medical  men.  The  mortality
in males is more than double what it is  in females;
and the mortality before puberty is very much less
than at any period after that age.   Tbe  operation
of lithotomy in females  is now almost wholly su-
perseded by the process  of dilatation, which may
be said to be wholly without danger; therefore,
if in future calculations the results of the total
cases of lithotomy do not  appear proportionally
more fatal than at present, it will obviously amount
to a  real diminution of  deaths.  The  low rate of
mortality before puberty is  shiefly to  be  ascribed
to the  facility of  reaching the bladder,  owing to
the small depth of the perineum,  and  to the im-
perfect development of the parts ;  which are great-
ly less  vascular and  less sensitive than  after that
age.   Therefore it may be  safely assumed as a
rule,  that whenever  a calculus is ascertained to
exist in the bladder, at almost any age before pu-
berty, lithotomy ought to be performed as  soon as
  Vol. I. —48                      2o*
convenient.  A disordered state of the health, un-
less the bladder or kidneys be actually ulcerated,
forms no sufficient objection ; for we bave known
the lateral operation performed  on an infant of
two  years and a quarter, though  in  a sickly and
very feeble state, with  the  effect of speedily re-
storing  him to sound health.   The operation by
being delayed becomes, after puberty, one of in-
creased difficulty and danger;  and a long train of
suffering is inflicted on the patient, while organic
changes are taking place in the urinary organs
which will ultimately render any operation  alto-
gether nugatory.   It would  seem as if the opera-
tion  of  lithotomy often  produced a  change in the
constitution, for it is rare that the disease is known
to recur after the extraction of  a calculus.  This
has been remarked by different writers, and parti-
cularly  by the late Mr. Martineau of Norwich,  a
very distinguished lithotomist.   He observes that
scarcely a case occurs in which the complaint re-
turns ;  and when a second operation  has  been
required,  he  believes  that  it may  generally be
traced to the  stone  having been broken, and  a
fragment left in the bladder.   (Medico-Chirurg.
Trans,  vol. xi. p. 413.)  The  propriety of per-
forming lithotomy at a more advanced  period of
life admits of more question.  Its difficulties and
dangers are greatly increased. Many circumstances
may then render it unwise  to put  life in hazard
by an operation ; and  the patient has arrived at
tbose years when he may be supposed  likely to
pursue  with steadiness that plan of regimen and
medicine  which will render his sufferings  more
tolerable,  and, in all probability, prevent the in-
crease of the  stone.   So soon, however, as the
phosphoric diathesis is fairly established,  whatever
be tbe  period of life, medicine  and regimen be-
come of uncertain efficacy, even  in  the  hands of
the  most skilful;  and extraction of the calculus
affords  the only  prospect of permanent relief to
the patient.
   A second method of removing calculi  from the
bladder is  by  detrition, or what has been named
lithotrity;  in which the stone is seized by an in-
strument introduced through the urethra, excavated
and  crushed,  and the debris  washed  out of the
bladder by injections and  the natural flow of the
urine.  The first attempt of this nature was made
by Colonel Martin, of the Indian army, who in-
troduced an  exceedingly  delicate saw through  a
canula into the bladder, and wore down a calculus
which  it contained.  Some years  after  this, Mr,
Elderton invented an  instrument for  the   same
purpose; and more lately M. Civiale, M. Leroy,
and the Baron Heurteloup have carried  the  plan
into  effective  practice by a variety of ingenious
instruments, and succeeded completely by  this
method in removing stones from the bladder.  The
number of cases to which lithotrity  can be applied
is very limited ;  for the bladder and  prostate  gland
must be healthy, and the  patient of a very tolerant
temperament, to admit of its being carried into
operation.   The principal evils which are apt to
attend  this mode of procedure  are, inflammation
of the  bladder, and  retention of small fragments
of the stone, which may at no distant period renew
the  disease.
   A third method of removing  calculi  from the
bladder is the dilatation of the urethra;  but it  i* 
378
CATALEPSY.
limited excepting for small stones, to female cases;
to which  it is  now ascertained  to be so perfectly
suited, that it has in a manner wholly superseded
in that sex they operation of lithotomy.  It is wor-
thy of remark that dilatation of the  female urethra
for this purpose is an operation  as  old as Franco
and  Fabricius Hildanus, and that it was practised
with great success by Proby, of Dublin, in 1693.
(See Dr. Molineux  in Philos.  Trans,  abridged,
vol.  iii.)
   Prostatal Calculi.— Calculi in  the  prostate
gland very often remain for a  great length of time
without causing any  irritation, and in that case it
is much  better not  to disturb tbe  patients by at-
tempts to extract them; but should they give trou-
ble,  the usual methods of allaying irritation of the
bladder ought  to be had recourse to, and surgical
aid  called in.   The  forceps of  Sir Astley Cooper
has  often been  used  with success ;  at other times
such calculi have been extracted by incisions made
 through the rectum or through  the perineum.
                                 W.  Cumin.
   [CANCER.  (See Scirrhus.)]
   CARDIALGIA.  (See  Gastrodyhia.)
   CARDITIS.  (See Pericarditis.)
   CATALEPSY, (derived from the Greek Kara-
 \dp0avo, to seize,) is applied to a very rare form
 of disease, characterized by the  sudden suspension
 of  consciousness and of  voluntary  motion,  the
 muscles  continuing  steadily  in that state of con-
 traction in which they happened  to be at the in-
 stant of  the attack,—and yet readily admitting of,
 and retaining  any other position of the body  and
 limbs, however inconvenient, in which they may
 be  placed at the will of the by-standers.
   The extreme rarity of this affection has caused
 its  existence to be doubted by several distinguish-
 ed  physicians, and  amongst  these, by Cullen, as
 he  never happened to meet with any instances of
 it which were not feigned.  There are now, how-
 ever,  a  sufficient  number of well-authenticated
 cases on record to render its existence unquestion-
 able.
    The attack is sometimes announced  by certain
 precursory  symptoms, as lassitude,  palpitation,
 headach, confusion of intellect,  stiffness in the
 neck, or pain  and slight cramps m the limbs ; but
 more generally it is instantaneous, the sudden ri-
 gidity of the  trunk  and  limbs, the suspension of
 the senses, and temporary interruption of the ex-
 ercise of the   intellectual  faculties, having been
  preceded by no premonitory stage.   The patient
  retains the posture of body and the expression of
  countenance  which he  cbanced  to  have  at the
  moment of seizure; and  by this  combination of
•  fixed attitude and unvarying expression, presents
  the air of a statue rather than that of an animated
  being.   The  eyes continue either fixedly open or
  shut, as they  happened  to be  at  the commence-
  ment ;  whilst the  pupil,  though usually dilated,
  contracts on the approach of a strong light.  The
  balance between the flexor and extensor muscles
  is  so perfect,  that any new position  given  to the
  head, trunk,  or extremities,  by an external force,
  is  easily received and steadily maintained.  This
  passive  energy of the muscular system, permitting
  the body to be moulded  into  almost as  great a
  variety  of attitudes as if it were  a figure of wax
or lead, is the distinguishing characteristic of the
disease.
   Catalepsy is an intermittent disorder, unaccom-
panied by fever, and  recurring in  paroxysms of
various duration ; more generally of only a  few
minutes, but occasionally  of  several hours, or
even days.  The length of the intervals is equally
liable to variation, and seems to depend in a great
degree on the recurrence of  the peculiar  exciting
causes.
   The return to the natural state is usually rapid,
almost instantaneous, accompanied by heavy sigh-
ing, and  generally by a complete restitution of
all the faculties both  of body and mind.  Occa-
sionally, however, pain  and  confusion  of head,
with a sense of fatigue  in  the limbs, are felt foi
some time after.  There is no recollection of  any
thing which occurred during the fit,  and  the half-
finished phrase which was  cut short by the  sei-
zure, has been said to be taken up and completed
 on the instant of recovery.
   During the paroxysm the  countenance is for
 the most part little altered, though it has in some
 cases been slightly suffused, indicating, along with
 the more forcible pulsation in the carotid arteries,
 an increased determination of blood to the brain;
 whilst in other cases, on the contrary, the face has
 been observed even paler than natural.  But these
 irregularities in the circulation, as well as frequent
 inequalities in the distribution of the animal heat,
 are in a manner common to all nervous affections.
 The respiration and action of the  heart  are often
 little  affected, though in  some cases the formei
 has been observed to be  much embarrassed from
 the extension of the spasmodic state to the mus-
 cles concerned in inspiration ; and the pulse has
 occasionally manifested a  considerable  deviation
 from its natural force and frequency, more usually
 tending to an increased quickness and diminished
 strength.
    Such is true catalepsy.   But the disease  docs
 not always appear in so perfect a form :  more fre-
 quently, indeed, its attacks  are of  a partial nature,
 the senses  not being altogether  obliterated, and
 the  individual  continuing  conscious   of every,
 thing passing around him, though utterly unable
 either to move or to speak.  This is the catochus
 of most nosologists.  Of this spurious  or partial
 catalepsy a very remarkable  instance is recorded
 in  Duncan's Medical  Commentaries, vol. x.  A
 woman was on the point of being buried alive in
 a trance,  and  endured all the horrors  of seeing
 her own body prepared for interment; for though
 in  the perfect  possession  of all  her senses, she
 was unable to move a muscle or give the slightest
 indication of life.   Galen has recorded  a similar
  instance of total loss of the power of  voluntary
  motion, whilst the consciousness continued unim-
  paired :  and  the author  of the  Philosophy of
  Sleep endured in  his own person an  apparently
  similar affection, to which he has given the title
  of day^mare.   In another  class  of cases, the  pa-
  tients, having still a certain degree of conscious-
  ness, are able to move  one hand  or limb, and to
  swallow food when put into their mouths.
    Ecstacy is a  disease nearly allied to, and by
  some authors treated of under the bead of epilep-
  sy ; and  so often do these disorders run into  one
  another, that of those nosologists who have sepa- 
CATALEPSY.                                  379
rated them, no two agree on their diagnostic signs.
According  to Dr. Mason Good, ecstacy is  suffi-
ciently distinguished by the inflexible  rigidity of
the muscles, whilst consciousness, as in catalepsy,
is for the most part suspended.  An instance of
this kind occurs in the first volume of the Medi-
cal Observations, in the case of a woman of fifty,
who was daily seized, for some years, with a rigid
contraction of all  the muscles of the body, and
such a profound sleep that nothing could awaken
her : she remained thus from sun-rise  to sun-set,
and then recovered, took her food, and continued
awake all the night, but relapsed  again into  the
same state every morning.   The greater number
of systematic writers, however,  place  the distin-
guishing characteristics of ecstacy in  a  high  de-
gree of mental excitement, co-existing with a state
of unconsciousness to all surrounding  objects, the
limbs being often  quite  relaxed.  The  fit is for
the most part induced by deep and long-sustained
contemplation of  some subject capable  of awaken-
ing an exalted  enthusiasm; and during its  con-
tinuance the patient often speaks with earnestness,
prays with fervour, or sings with much pathos and
expression.  Vivid dreams or visions of  an extra-
ordinary nature  occasionally  occur, and are  so
firmly impressed on the memory that they can be
minutely detailed afterwards.  But there is  much
reason to suspect that a majority of these  latter
cases have been counterfeited.  Dr. Chisholm has
recorded  a  remarkable  and apparently genuine
instance in a 'young  female, where  ecstacy alter-
nated with mania; the  limbs becoming relaxed,
 and the patient beginning to sing in a most touch-
ing manner as often as the maniacal state recur-
red.  To us, catalepsy and ecstacy seem to  be
mere  modifications of  the  same  morbid  state :
thus Sauvages gives a case in which the first part
of the paroxysm consisted in violent declamation
 and gesticulation, and loud singing, the girl being
 quite insensible to external objects ;  whilst in  its
 termination, the fit had all the characters of true
 catalepsy.
   As to the danger of catalepsy, though we have
 the high authority  of Boerhaave for estimating
 :t fatally, yet subsequent and more numerous ob-
 servations prove that death during the  fit is  a rare
 occurrence; and  where  such a  termination  has
 ensued, it has usually been from the affection be-
 ing complicated with or passing into other dis-
 eases, as apoplexy, mania, &c.  Rostan met with
 one fatal case where inflammation of the lung co-
 existed,  and  Pinel another which terminated in
 apoplexy.  Forestus has been cited by Sprengel,
 in  his History of Medicine, as an  authority for
 instances of fatal catalepsy attacking  simultane-
 ously a great number of soldiers at  the siege  of
 Metz; but any one who reads his narrative must
 feel satisfied tbat both Forestus and Sprengel have
 fallen  into error in applying the term to such
rases,  and that the sudden deaths attended with
 rigidity were simply the result of intense cold in
their exposed night quarters.  Forestus in a sub-
 sequent passage particularizes the case of a horse-
man, who being frozen  to death  on  the saddle,
continued to maintain his seat,  and  rode, statue-
like, into the camp, still firmly grasping the reins
and his weapon.   He supposes  that in such cases
'Iv; cold merely predisposed to catalepsy, and that
the maintenance of the erect posture and the firm
contraction  of the  muscles, were  sufficient evi-
dences of remaining vitality ; but this is evidently
a gratuitous  assumption.   It was  probably from
such cases as these  that Hoffmann came  to the
strange conclusion, that as catalepsy  occurred
most frequently in winter, it must depend on con-
gelation of the nervous fluid.
   Amongst the predisposing causes are, a highly
nervous temperament,  and  whatever tends to in-
crease  the susceptibility of the nervous system.
Of this nature are  all  such causes as are calcu-
lated directly to weaken the body, or to act pow-
erfully on tbe mind ; the depressing passions, as
violent sorrow,  continued  anxiety,  unrequited
love; intense and  long-sustained  application  of
mind.   Both sexes, and children as well as adults,
have  afforded  instances of it;  but females, and
especially those who have  a tendency  to hysteria
and hypochondriacism, melancholia or mania, are
the most frequent subjects of these attacks.  The
late Dr. Gooch met with  an exquisitely marked
case of catalepsy supervening to puerperal melan-
cholia, in a female  debilitated by repeated miscar-
riages.  The trunk, as she lay in bed, being rais-
ed to an obtuse angle, retained  this painful pos
ture;  the limbs remained in any position in which
they were  placed : when   set   on her  feet, the
slightest push threw her off her balance, and  no
effort was made to regain it. The eyes were open,
and the pupil, though dilated, contracted  on the
approach of a strong light.   Of these attacks she
had three, each lasting several  hours, and recur-
ring at the intervals of one and two days.  The
case afterwards resumed the form  of melancholia
and terminated favourably.  This, which is one
of the latest, best  authenticated,  and accurately
detailed cases of the disease on record, is  deline-
ated with all the  graphic  power  for  which this
distinguished physician was remarkable.
   To  the head of exciting causes may be referred
strong mental emotions, as terror, suppressed rage,
protracted meditation on deeply exciting subjects,
&c.  Fernelius mentions the case of a  student
who was seized whilst at his desk, and continued
during the fit, with his pen in his hand, and in a
fixed  attitude  of intense  application.  Bonetus
gives the case  of a  soldier, who having deserted
his colours,  on being  apprehended shortly after-
wards, was so terrified tbat he lost the power  of
speech, became as  immoveable  as a  statue, and
apparently  unconscious of every thing  around
him :  after  continuing in this  senseless  state
twenty days, during which he  took no food, nor
had any natural evacuation, he expired.
   General plethora, suppressed evacuations,  re-
pelled  eruptions, worms, and other sources of irri-
tation  in the digestive  organs, are reckoned among
the occasional causes of this disease.
   The paroxysm is sometimes induced  by very
trifling circumstances,  as a  sudden noise, a slight
contradiction, an unexpected visit, 01  a passing
fit of anger or impatience.
   Catalepsy is closely allied to the comatose dis-
eases,  apoplexv carus, lethargy ; and accordingly
we find it classed by Cullen under the order Co-
mata,  genus apoplexia cataleptica.  To epilepsy
also, it is nearly related, as  we  find this disorde* 
330
CATALEPSY.
occasionally assuming the cataleptic form, or the
diseases alternating.
  But in far the greater number of authentic and
fully detailed cases, catalepsy has appeared to bear
the strongest affinity to  hysteria ;  and, indeed, in
some of these seems to have been merely one of
the innumerable forms  of this Protean  disorder.
In support of this  view  we find  that females and
hypochondriacs are by far the most frequent sub-
jects of both these affections ; that they occur in
similar constitutions, viz., those characterized  by
a high degree of nervous mobility ; that they are
convertible into each other ;  and finally, that they
are  susceptible of relief from similar  modes  of
treatment.
   In illustration of this opinion we shall briefly
mention a case of catalepsy, which we  witnessed
some years  since.   The patient, a young woman
of eighteen years, having been cruelly treated  by
a man who was under promise of marriage to her,
and received a slight wound in the head and some
bruises in the breast, was seized with severe  and
repeated fits  of catalepsy.  These were usually
preceded by headach, vertigo, and tinnitus aurium.
During the continuance of the paroxysm she  re-
mained perfectly  insensible  to surrounding ob-
jects ;  the  breathing was  considerably  affected,
and the pulse rather quick and small; the  pupils
were dilated, the face assumed the expression  of
a smile; and the  limbs steadily maintained  any
position in which  they  were placed.   The dura-
tion of the fits was from five  to ten minutes, and
they recurred very frequently in the course of the
day.   After  each  attack, pain in the  praecordia,
headach, and a general  sense  of uneasiness were
complained of.  In  the intervals  the intellectual
functions were  usually unimpaired, though  on
some occasions a slight degree of stupor was ob-
servable.   After  the disease had existed some
weeks, the  fits were  occasionally accompanied
with screaming and  struggling.  She now suffered
from severe lancinating  pain  at the epigastrium,
increased by pressure, and accompanied with diffi-
culty of respiration,  pain in the small of the back
and in the right lumbar region,  and subsequently
some difficulty in  voiding the urine, and frequent
constipation.  The  most usual appearance  of  the
paroxysms now became that  of sound  sleep, and
their recurrence was much  more  frequent.  The
menstrual  flux  was not  interrupted.   The  fits
daily assumed more and more of the hysterical
form ; and by the use of aperients, local and gen-
eral bleeding, and counter-irritants to  the  spine,
ceased altogether in about two  months from  the
commencement of  her illness.  The   transition
from well-marked catalepsy into hysteria was so
remarkable in this case, as to leave little doubt of
the close  affinity, if not the  identity, of the  two
diseases.   The case  of Helena Renault, recorded
by Sauvages, seems to  have partaken of the  na-
ture of catalepsy, hysteria,  and epilepsy conjoint-
ly—all ceased on the spontaneous return  of  the
menses.
   One of  the most  remarkable cases given by M.
Petetin in  his treatise on catalepsy, if  it be at all
worthy of credit,  would seem to fall rather under
the head of animal  magnetism, or lucid somnam-
bulism,  than true  catalepsy.   He  asserts, not
merely that  consciousness  and  the  power  of
voluntary motion were abolished,  but that the
functions  of the senses were transplanted into
the epigastrium and into  the extremities of the
fingers and toes ; so that when  objects of taste,
smell, &c. were applied to these parts, they were
as accurately appreciated as they would  have
been by  the tongue, the nose, &c. in  the natural
state.  Strange  to say, these and some still more
startling facts do not rest solely on  the authority
of M. Petetin ;  he  is supported  in  his assertions
by other and equally respectable testimony.
  Diagnosis.—The diagnosis of catalepsy from
asphyxia, syncope, apoplexy, and apparent death,
usually presents little difficulty.   The suspension
of the circulation and  respiration, the flexibility
of the limbs, and the colour of the face or lips,
sufficiently  distinguish  asphyxia; while syncope
is readily recognised by the  three former circum-
stances co-existing  with paleness  of the  coun-
tenance.  In apoplexy there is  usually paralysis
of one side of the body and flexibility of the limbs,
whilst stertorous breathing and congestion of the
face are  common  attendants.   To discriminate
between catalepsy and  apparent  death is often a
matter of less facility, and more than one case is
on  record in which individuals in the state of
trance have narrowly escaped  being buried alive.
In  such instances the  disease must have existed
in  a very intense  form, and  been accompanied
with paleness, suppression of the pulse, weak re-
spiration, and a cold skin ; and here the stiffness
of the limbs might  be very readily mistaken for
that rigidity of the  muscles whicb characterizes
the  dead body.   But as the  pulse and respiration
are  never quite extinct in catalepsy, the use of
the stethoscope  to the region of the  heart, or even
the application  of the finger over the  seat of any
of the larger arteries, will enable us to detect the
one ; whilst the exploration of  the lungs by the
same instrument, and  the holding of a polished
mirror over the  mouth of the patient, so as to in-
tercept and condense the pulmonary exhalation,
will leave us in little doubt as to the existence of
the other.  The expression of the eyes and of the
whole physiognomy might  perhaps occasionally
afford  us additional assistance,  as  would also a
knowledge of the previous state of the health, the
mode  of  attack, and other  circumstances of the
case.  If, after  all,  there shall still remain  even
the shadow of a doubt, we must wait for the in-
dubitable evidence of incipient putrefaction.
   Numerous instances  of a state in some degree
resembling catalepsy having been feigned, are on
record, some of which  have resisted the infliction
of  the severest  modes of investigation.   One of
these stood out against the shower bath, electri-
city, and a variety of other  energetic kinds of
treatment, but was  detected by  the pulse of the
individual being found to rise, when a proposal
for applying the actual cautery was made within
his  hearing.   Another  young   soldier  resisted
measures  of still greater severity, such as the
thrusting of pins  under his finger-nails, scalping
and trephining  the head, &c. and persisted in the
deception till he obtained his lischarge; imme-
diately after which  he was seer  in perfect health,
and engaged in  active occupations  about his
father's house.   John Hunter, as Mr. Abernethy
used to  relate  in his lectures, proposed to detect 
CATAL
cases of feigned catalepsy by appending a weight
to the arm, and after some time  suddenly cutting
the  string  by  which  it was attached:  if  any
resiliency of the limb took place, he considered it
a proof that additional force had been voluntarily
exerted  for  the  sustaining  of the  additional
weight,  and that, consequently, the powers of
the  mind were  not  really suspended.  But even
this would  scarcely be conclusive, as it seems to
leave  the natural elasticity  of the muscles alto-
gether out of the account.   Indeed, after making
all due  allowance for what practice  and a  firm
determination can effect, we much doubt whether
the peculiar state of the muscular system which
exists in perfect catalepsy could by any effort of
the will be successfully counterfeited, or whether
very painful postures of the trunks and limbs
could be long supported without the occurrence
of such a tremor  in the  muscles as would reveal
the deceit.  And accordingly we find that im-
postors  rarely  attempt an  imitation of perfect
catalepsy, but  content themselves with the easier
 task of assuming a state of profound insensibility
 coupled with relaxation of the muscles.
   Morbid anatomy  has hitherto thrown little or
 no  light on the  nature of this  curious affection.
 As it is rarely fatal, few opportunities of dis-
 secting  such cases have  occurred;  and in those
 few, though the  brain and  nervous system have
been carefully examined, no morbid changes have
 for the  most part been discovered.   Still, if we
 are to adopt the axiom of some modern French
pathologists, namely, that every  change of action
 implies a change of structure, we should conclude
 that such morbid alterations, though inappreciable
by  our senses, must needs exist.   In  science,
 however, such dogmatical assertions, with nothing
 but  vague analogy  for their support,  are  mis-
 placed.   The converse of the proposition, or that
 change of structure necessarily implies a previous
 change  of action, might  be  maintained with at
 least an equal show of reason.  The great truth
 that the nervous system  generally gives the ini-
 tiative both to disorder and disease, has of late
 years been too  much lost sight of.  The younger
 Pinel has  attributed  the symptoms to an inflam-
 mation of the spinal marrow ;  but this does not
 rest on a sufficient basis of observation  to entitle
 it to  much credit; nor, indeed, is it probable, d
 priori,  that an  affection, the attacks of which
 commence and terminate  so instantaneously, and
 which have been known  to  recur at various in-
 tervals during  a period of many years, should
have inflammation for their cause.  A temporary
state of irritation and congestion of  the cerebro-
spinal system,  would seem to be more consistent
with  some  of  the  phenomena, and  to  give an
equally  satisfactory explanation  of the remainder.
As the disease seems to be often induced by sym-
pathy with the stomach, intestines, or uterus, the
ganglionic system  is  probably  also not  unfre-
quently implicated.
  As to those theories which propose to explain
the singular symptoms of catalepsy by a supposed
excess, deficiency,  or  immobility of  the  nervous
fluid, though .supported by the  authority of  high
names, they are surely unworthy of notice in the
present state of physiological science.  We know
little of the mode of action of the nervous system,
EPSY.                                  381

and  still less of its  irregularities :  a candid  con-
fession of ignorance in such a  case is infinitely
more favourable  to  the  advancement of know-
ledge than  the reproduction of such gratuitous
hypotheses.
  In the treatment of this disease the chief indi-
cations  are, to subdue  general  plethora when it
exists, by venesection and other depletions,  and
to obviate irregular determination of blood to the
brain and spinal chord,  by the  use of leeches or
cupping in the neighbourhood of these important
organs;  or (as  some  continental  practitioners,
guided by the old theory of derivation, prefer,) to
a more  distant part, as the feet or thighs.   The
existence  of headach,  confusion  of ideas,  and
flushing of the face; or of pain, and tenderness
on pressure in the course of the spine, will leave
us little doubt as to the propriety of these mea-
sures.   Counter-irritation in the form of blisters,
issues, or moxa will  subsequently be called for.
  The  state of the stomach, bowels, and  liver
must be carefully investigated, and every effort
made to counteract any irregularity in their func-
tions.   From the well-known  influence  which
these organs  exert  over  the  nervous  system
through the medium of sympathy, the importance
of this part of the treatment cannot be too much
insisted on ; but generally speaking, our object
should rather be to keep up the natural action of
the  alimentary canal, than to stimulate it  to ex-
cessive secretion by drastic medicines, as the  local
irritation  and the constitutional exhaustion in-
duced by  such means would, in  many cases,  tend
to exasperate the nervous symptoms.  The exist-
ence of general plethora will, however, justify the
use of free and long-continued catharsis ; and Dr.
Cheyne, in  his valuable work on  Comatose  Dis-
eases, has signalized the utility  of aloetic purga-
tives in such cases.
  A careful examination must also be made into
the state of the uterine functions, and if not  duly
performed, every measure taken to  restore them
to their  natural state.  In  those cases partaking
largely  of the nature  of hysteria,  the operation
of cupping  over  the loins or the  occiput, along
with large  turpentine  enemata,  should  not  be
neglected.
  In the intervals of the  fits, exercise, diversified
amusement, country air, and a  mild diet should
be  insisted  on.   Sauvages  records  instances  of
the  disease being removed by  a  milk diet and
country air alone.
  In those cases which appear to be purely nerv-
ous, the cold  shower bath, if not peculiarly dis-
agreeable to the feelings of the patient, and tonics,
should be tried.   But  above all  things the undue
excitement  of the feelings and of the  intellect
must be cautiously avoided.
  During the paroxysm, the application of  cold,
in the form of ice or evaporating  lotions,  to the
head, provided there be any proof of determina-
tion to the brain, and the immersion  of the feet
into a  warm stimulating foot-bath, are perhaps
the  only measures  we should  put  in  practice.
Valerian, ammonia, musk,  assafcetida, and othei
antispasmodics,  both in  draughts  and enemata,
are  usually employed,  with the  view either  of
warding off or shortening the duration of the fit,
but  generally with  no very marked  advantage. 
382
CATARRH.
The older writers recommend ligatures  to  the
limbs, and assiduous  friction with stimulant lini-
ments ;  but if the seat of the  disease be, as we
have  every reason to believe, in the  brain  or
spinal chord,  little can be  expected  from such
means.  Electricity and galvanism have  also been
suggested, and are said in  some instances to have
cut short the attack.   In the Dictionnaire  des
Sciences Medicales, it  is recommended  to direct
all our efforts to rousing the dormant sensibility
of some one organ ;  and a case is given from the
Ephemerid. Naturx  Curios, where this  was done
with success : but the mode of effecting it there
alluded  to  is one  which,  we believe, few practi-
tioners in this country would venture to recom-
mend.   M. Petroz has occasionally known music
to exercise a singular influence over  the  pa-
roxysm, diminishing  it materially both as to dura-
tion and intensity.
  Should the attack end in apparent death, the
importance of the immediate employment of arti-
ficial  respiration  is obvious ; and indeed, in  any
of these  cases where the  action of the heart and
lungs is greatly depressed, we should not be justi-
fied in neglecting it.  In  similar circumstances
the application of moderate warmth and the free
access of pure air are of the highest moment.
                                W. B. Joy.
   CATAMENIA.  (See Menstruation.  See
also  Amenorrhea,  Dysmenorrhea,  Menor-
rhagia.)
  CATARRH, Pulmonary. — Every disorder
of the mucous membrane  of the bronchi has been
included under this name.  Thus Laennec makes
the term  generic,  applied to the several species,
the mucous (acute and chronic), the suffocative,
the pituitous, the dry, and the convulsive catarrhs.
But as the etymology of the word (Kara,  deorsum,
iia.fiuo,) has relation rather to the secretion than
to the pathological state of the diseased membrane
itself, it  is better  to reserve the term  for those
forms of the disease in which unnatural secretion
is the only constant  or appreciable  phenomenon.
We  have accordingly  included under  the head
bronchitis  all those  affections  of the  bronchial
membranes which are  in any appreciable  degree
inflammatory, except hooping-cough, which  will
be found in its place.   The cases, therefore, ex-
cluded from that  head that require  consideration
under the name of catarrh, are those which Laen-
nec denominates the pituitous and the dry catarrh,
and  this rather from want of another term, than
from the aptness of the term employed.
   Both the pituitous and the dry catarrhs attack
the nasal as well  as the pulmonary mucous mem-
brane, and, like the inflammatory influenza, fre-
quently pass from one to the other.  According
to the extent of the membrane  affected,  they may
amount to a very trivial or a very serious malady;
and when they affect extensively  the  bronchial
membrane, they constitute the  disease in a great
number of the cases which are commonly called
asthmatic.
   1. Pituitous Catarrh.—This form of catarrh
is distinguished by the secretion of a thin, colour-
less, glairy liquid  from the bronchial membrane.
'This flux comes  on  in paroxysms,  attended with
dyspnoea and cough, which are relieved by  the
expectoration of a liquid, « frothy on  the surface
and underneath like the white of egg diluted with
water."   Such a  secretion  frequently  attends
bronchitis when it attacks persons of lax habit of
body ;  and, in fact, those cases  which have been
called pneumonia  notha seem to owe their pecu-
liar character to the pituitous secretion that occurs
in them.    It is sometimes likewise  present in
cases of cedema of the  lungs, and the first stage
of phthisis.   It  does occur  also idiopathically,
and  as such we have to consider it  here.  It is
either  acute or chronic.    In its acute form it
sometimes commences  as a  common  cold,  but
with a sensation of oppression and dyspnoe greatly
disproportioned  to  the slight febrile symptoms.
The attacks are sometimes of short duration, pass-
ing off entirely in  the course of a few hours, after
the expectoration of a quantity of the  fluid  before
described,  which sometimes amounts to  several
pints.   Not unfrequently they assume a periodic
character, coming on twice  or three times  a day,
the symptoms in the intervals generally disappear-
ing entirely.   Sometimes this  affection is com-
bined or alternated with what Laennec terms dry
catarrh,  and the tough pearly  mucus character-
izing the latter is often seen in the expectorated
matter.  The stethoscope discovers a variety  of
sibilant and bubbling rbonchi in the  chest, often
resembling  the chirping of birds, whilst during
the paroxysm the sound of respiration is impaired.
The chest sounds well  on percussion.  During
the intervals the same rhonchi are present,  but in
a much slighter degree, and the respiratory sound
resumes its distinct character.   The examination
of those who have died  during a paroxysm  of
pituitous catarrh discovers little  or no trace of in-
flammation in the bronchial membrane.   It is
sometimes a little thickened and softer than natu-
ral, from the infiltration of serum ; often perfectly
pale ;  and any blushes or striae of red that may
occasionally appear are very slight, and of trifling
extent.  These circumstances, and the fact that it
attacks most  commonly  those  of weakly  habit,
languid circulation, and little disposed to inflam-
matory symptoms, seem to indicate that it is rather
of the nature of a profluvium, arising from want
of tone in the vessels, than an inflammation. The
effects of remedies and the  nature  of the  predis-
posing causes confirm this  supposition.  It most
commonly arises in  persons who have for  a long
time  suffered  from disordered digestion, whether
arising from  habits of excess, or from  natural
weakness of the digestive powers.  In certain in-
dividuals a form of pituitous catarrh sometimes
happens during  the  summer months,  and it is
commonly attributed to an inhalation  of the efflu-
via of hay-fields, whence it has gained the name
of hay-fever  or hay-asthma ; but  this is appa-
rently more of the  nature of influenza.  After
one  attack, pituitous  catarrh  is extremely apt to
recur ; alterations of  temperature or irregularities
of diet being sufficient to re-excite it.  When it
has once established itself, like most other serous
fluxes, it is very difficult to  remove ; for the habit
of occasional profuse secretion being acquired, it
frequently does  not yield on  the icmoval  of the
original exciting causes.  Laennec remarks, that
it is common in gouty subjects  advanced in  age,
and in whom the gout has  become milder and 
CATARRH.
383
less regular.  The importance of pituitous catarrh
varies much according to  the state of the indivi-
dual whom it attacks.  When it seizes a subject
enfeebled by present or previous disease, it may
prove fatal in a few hours.  Again, its long con-
tinuance, when it has by habit become established
in the system,  sometimes wastes  the  body,  and
brings on disease of the heart, pulmonary cedema,
or some other  loss of balance among the vital
functions, that leads to the extinction of life.
   In  other instances, where the body is strong, or
the disease slight, it may go on for years, injuring
the comfort rather than the general health of per-
sons  even  far advanced in life.   Andral records
 an instance in  which a  sudden and  temporary
attack of pituitous catarrh, with very profuse dis-
charge, was attended with the removal of a hydro-
 thorax.  We have before remarked  that it some-
 times is excited  by miliary tubercLes in the tissue
 of the lungs; and  in all cases where  the constitu-
 tion of the subject, irregular resonance of the chest
 on percussion, with bronchophony, and constancy
 of cough and pituitous expectoration (not in pa-
 roxysms), indicate this lesion, the prognosis must
 bi more unfavourable.
   The treatment of pituitous catarrh must be con-
 sidered in relation to the paroxysms, and likewise
 to the disposition to them.  Tbe indications dur-
 ing the paroxysm are to facilitate the removal of
 the redundant  secretion,  and to prevent its fur-
 ther  effusion.   The means  which  we employ
 under the name of expectorants, have probably, in
 some  instances, both these effects, but in  a  very
 uncertain degree, and rarely in a manner avail-
 able in these cases.  Ipecacuanha, whether as an
 emetic, or in  a nauseating dose,  is perhaps the
 one from which most advantage has  been derived.
 It is best to obtain at  first its  emetic  effect, and
 afterwards to repeat  it in  such quantities as will
 keep  up a slight sensation of nausea.    The
 power which this remedy has in  restraining he-
 morrhages is probably of the same character which
 renders it useful here: but it is extremely difficult
 to say whether this is from any direct action on
 the affected vessels, or from its general effects on
 the circulation.    Tartar  emetic, in  large  doses,
 which Laennec found effectual in two  cases of an
 alarming aspect, probably has a similar mode of
 action ; and from  what we know of  its effects in
 peripneumony, it seems difficult to avoid attribut-
 ing it to a  sorbefacient power. The lobelia inflata
 would  perhaps more properly than these  come
 under the class of expectorants.   Of its utility in
pituitous catarrh we  have the testimony of prac-
 titioners of great sagacity and experience.   The
tincture has been given  in doses  of fifteen or
twenty-five minims every two or three hours, with
marked effect in  relieving the dyspnoea.  As has
already  been  remarked,  (see  Chronic Bron-
chitis,) it  is a medicine  that must be watched,
and stopped or diminished if vertigo or nausea
show that  its effecf on the system has been  pro-
duced.
   Of evacuants, which it  may be necessary to re-
sort to. to divert  the determination from the pul-
monary vessels,  those which produce watery dis-
charge are  to be  preferred to bleeding, which  is
seldom admissible, and only where there is marked
plethora of the system.   Diaphoretics  and diure-
tics,  if they can  be brought to act, will have a
tendency  to shorten the paroxysm.  Antimony
and  ipecacuanha, as already recommended, will
best  fulfil  the first effect, and squill may be used
with advantage as a diuretic.  Drastic purgatives
are  not generally  useful,  often injurious;  but
those of a milder kind  may be given with advan-
tage ; and when  irregularities of diet have been
the exciting cause of the paroxysm, a free evacua-
tion of the bowels may contribute most materially
to its removal.
   In many cases tbese means are of but little
avail; and when they do abridge or remove a
paroxysm, they are scarcely effectual enough to
prevent its recurrence.   Strengthening the system
by a mild but  tonic regimen, removing disorder
of the digestive organs, and the adoption of every
means calculated to improve the  general  health
and strength, often succeed better in curing pitui-
tous catarrh than any remedy directed against the
disease  itself.   The diet should be mild and nu-
tritive, consisting chiefly of farinaceous food and
plain meat.   The hours of eating should be regu-
lar,  and the quantity  moderate.  All spirituous
and fermented liquors are best avoided, and liquids
of all kinds should be taken sparingly.   Coffee
made by infusion is tbe best beverage, and seems
positively useful  in some cases in preventing the
recurrence of the paroxysm.  To strengthen the
digestive powers, calumba, rhubarb, or some other
bitter may be  given; and in some cases the sul-
phate of  quinine, with a  mineral acid, will  be
found of  good effect.   But  the safest  and most
efficacious tonics, are  country  air of a bracing
quality, such as  that  of Brighton, and the cold
shower or  plunge  bath.    Regular  exercise  is
highly necessary ; and that on horseback is gene-
rally the  most suitable.  It  is of importance to
attend to  the clothing,  that it be sufficient  to pre-
vent the cuticular exhalation from being checked
by occasional winds.
   2. Dry Catarrh.—This disease  is more  re-
cognised  as an asthmatic than  a  catarrhal affec-
tion.  In fact, the  term  catarrh  is not by  any
means appropriate in a disorder that is unattended
with flux  ; and but for the absolute want of ano-
ther term, it should not be employed.  The patho-
logical state of the  membrane, however, does not
so much differ, as the nature of the secretion, from
that in the disease just described.  There appears
to be a passive or venous congestion in the mu-
cous membrane of the bronchi, which neither in
its nature nor effects resembles inflammation. An
improved  nomenclature, founded on pathology, is
much to be desired; but it may be doubted whe-
ther it be  expedient to frame one until our  know-
ledge of pathology itself be much more extended
and definite than at present.
   The  symptoms of dry catarrh  vary much ac-
cording to its extent.   In its slightest degrees it
occurs  in those individuals  who, without any
other derangement  of health than  a sligb*  short-
ness of breath  felt on  exertion, expectorate every
morning a small portion of tough mucus of a pean
grey colour.   Sometimes,   however, there  are
cough and  dyspnoea,  which, coming on in pa
roxysms,  assume the form of asthma,  each  fit tei
minating  with  an expectoration of pellets  of th«
same dense mucus.  Occasionally there is a tole 
381
CATARRH.
rably copious pituitous secretion at tbe same time;
but this is uncertain, and bears no lelation to the
severity of the  preceding fit, which  seems to be
connected with the formation of the thick mucus.
Sometimes there is little or no  cough ; and the
dyspnoea, or rather shortness of breath, may con-
tinue  for months, or even years, without other
symptoms.  If an attack of bronchitis supervene,
there is generally an aggravation of the dyspnoea,
sometimes amounting to a  fit of asthma.  Laen-
nec, who is the only writer who has given a dis-
tinct account of this disease, remarks, that it most
commonly attacks gouty persons, those affected
with cutaneous eruptions,  and  those  disordered
by long excesses ; and he considers the slight and
dry coughs frequently attendant on various  func-
tional  disorders of the abdominal  viscera, and
which are generally called  nervous,  to arise from
a degree of dry catarrh.
   The physical sign  of this  disease is a suspen-
sion of the sound of respiration in the part affected,
while the corresponding part of the  chest sounds
well on percussion.  This  arises  from a tumefac-
tion of the bronchial membrane, which either of
itself, or assisted by  the  pellets of thick mucus
before described, more or less completely obstructs
the caliber of one or more of the tubes.  When
the obstruction is not complete, a dull whistling or
clicking sound accompanies the breathing;  and a
cough or forcible inspiration may sometimes dis-
cover the same sounds where in ordinary breath-
ing the air does not enter.  According to the ex-
tent of  the bronchi  thus  affected, the severity of
the disease will vary; but in all cases the expec-
toration  of the thick mucus brings with it some
relief of the  dyspnoea.  Andral records two cases
in which a fatal asphyxia was caused by such ob-
structions  occurring in one of the great bronchi,
and which no efforts of coughing  were able to
remove ; but these are to be considered as acci-
dental rather than as common cases.
   On  anatomical examination, the membrane of
the bronchi affected is found tumefied, and of dull
red or violet  colour, but without softening or ulce-
ration.   These circumstances, together with  its
duration, seem to indicate this affection, although
occasionally  originating in inflammation, to be of
the nature of passive congestion, with interrupted
secietion.  Although  not  frequently in itself a
dangerous disease, dry catarrh often much aggra-
vates the symptoms  of any other affection attack-
ing the chest;  and is  in itself apt  to induce the
organic  change called emphysema of the  lungs.
   The congestion of the mucous membrane con-
stituting dry catarrh,  chiefly  occurs, like  other
congestions,  in those persons in whom some func-
tional derangement has injured the balance of the
circulation, and impaired the tone of the extreme
vessels.   Disordered digestion, imperfect secretion
of the bile, and irregular alvine excretion, are the
 most  common  of  these   derangements ;   and,
 although they do not always give  notable  and
 direct  evidence  of  their  existence, the success
 attending treatment calculated to remove them is
 ro efficacious in relieving the affection in question,
 that it  should  be adopted  in all  severe  cases of
 ilry catarrh.   It is unnecessary here to particular-
 •ze the  treatment alluded  to ; but it may  be ob-
 ittvei that a proper regulation of the diet, to the
exclusion of rich, irritating, or acescent articles
of food, and all fermented liquors ;  the promoting
regular alvine evacuations of proper colour by the
aid of small doses of blue pill and ipecacuanha,
followed by castor oil, saline, or other mild aperi-
ents ;  and afterwards giving tone to the stomach
and system by a judicious administration of tonics;
__all  these measures, as the circumstances  may
require, may be  resorted to with the  greatest ad-
vantage, and are often more successful in the per-
manent  relief of the dyspnoea or  asthma of dry
catarrh than  any measures directed  against tbe
disorder itself.
   Laennec remarks that the means found useful
in chronic bronchitis and other forms of catarrh,
make no impression on this,  and are only  indi-
cated  when  any of these  are  combined  with it.
The indications are, to remove the congested  state
of the bronchial membrane, and  to facilitate the
expectoration of the dense portions of mucus that
obstruct  the  tubes.  Bloodletting, blisters,  and
evacuants in general, have  not the effect on con-
gestion that they have on inflammation ;  and the
state  of the  system is  generally not such as to
make the trivial  benefit that may result from them
equivalent to their weakening effect; but the same
objection cannot  be urged  against dry cupping,
wbich Laennec recommends ;  and friction of the
chest with rubefacient  substances, the occasional
short application of a  blister, wearing  a pitch-
plaister, or any of those means that may excite
the superficial circulation without weakening the
system,  may be  resorted to in most instances with
more or less temporary relief.
    With these measures we may properly combine
such  expectorant  medicines  as  may fulfil the
second indication, namely, to  facilitate the expec-
toration of the thick mucus, which by obstructing
the bronchial tubes becomes a principal cause of
the dyspnoea. As Laennec remarks, we may effect
this  by  any  means which will diminish the gluti-
nous  tenacity of this matter; and he conceives
that  we possess medicines  capable of attenuating
 the secretions and  rendering them more liquid, in
 the mild or very dilute alkalies.  He recommends
 either almond soap, in form of pills, with the pa-
 tient's meals, to the amount of ^ss. to 3'- a day,
 or the carbonated alkalies in doses of from twelve
 to thirty-six grains.  He  likewise made use of
 baths, both  salt water  and alkaline, made with
 four  ounces  of a  carbonated alkali.  He  con
 sidered sulphur baths  serviceable in cases compli-
 cated with herpetic diseases.  To the efficacy of
 alkaline medicines in dry catarrh we can add oui
 testimony.  We  have  already  spoken  of  theit
 utility in other  bronchial affections besides  those
 accompanied by a viscid secretion.  But in these
 their effect is more  marked  and unequivocal, and
 far from being  so  inexplicable as Laennec seems
 to consider it.  The power of alkalies and  acids
 to change the quality of the urine is well ascer-
 tained ; and  wbether it be by an effect on the
 whole mass  of blood, or by the agent passing im-
 mediately to  the kidneys, it is quite  certain that
 an acid or an alkaline quality may at pleasure be
 communicated  to  the urine by repeated doses of
 the corresponding  medicine given  by the mouth
 Now it is not indulging a supposition too chemi-
 cal, to consider that the formation of thick tough 
CATHARTICS.
385
mucus is incompatible with an  alkaline state of |
the fluids, since alkalies exert a remarkable solvent
power on mucus.   Then it must be held in view,
that the beneficial effects of alkalies are not limited
to the removal of the viscid  secretion ;  but by
likewise establishing a liquid  secretion from the
diseased membrane, they tend very  much to re-
lieve  the congested  state of its vessels.  To in-
crease this effect, it  is advantageous to combine
with  the alkalies, squill, ammoniacum, or some
other stimulating expectorant.  The  liquor po-
tassffi is the form of alkali  to which we  give the
preference ;  and we  have  found ten  minims or
more, with the same quantity of tincture of squills
and  £ss of the tinct. camphorae comp. in §i of
water, of more efficacy  than any  other combina-
tion in dry catarrh.  Where languor of the circu-
lation and  tendency to  spasmodic  asthma  are
present, a preference  may  be  given to combina-
tions of ammonia and ammoniacum ;  and if the
liquor potassse should ever appear to irritate the
stomach, castile soap, as recommended by Laen-
nec, may be substituted.  Inhalation of the vapour
of water, alone, or with  camphor or some other
aromatic matter, would  probably avail more here
than in other cases of pulmonary catarrh ; but we
have no experience  on  this  point.  Finally, we
must again insist on the importance of attending
to the state of the  other functions, and do all in
our power to remove the  disposition to local con-
gestions, by keeping free the secretions, and giving
tone  to the body by cold baths, frictions,  and
regular exercise.        c j  g  WlLLIAMg.

   CATHARTICS.   By  cathartics  are  meant
substances which accelerate the peristaltic move-
ment  of the  intestinal  canal,  and promote the
evacuation of its contents.  They operate locally
on the intestines ; but their influence  is extended
to the neighbouring viscera,  and,  in many in-
stances, to the whole system.   When their action
is confined to the intestinal  canal,  they  prove
beneficial by restoring its natural function. Their
 stimulus is often extended to the stomach, causing
 its contents to be propelled into the duodenum ;
 and they promote and increase the flow of bile
 and of the pancreatic  fluid,  by stimulating the
 excretory ducts of the pancreas and the liver.
   The kidneys, the bladder, and  the uterus, are
 also  influenced  by the  action  of  cathartics ; the
 secretion of the  first is  generally diminished by
 their continued exhibition, as  the  fluids which
 they  cause to be discharged by the bowels would
 have been excreted  by the kidneys.   The uterus
 suffers by contiguity.
   Cathartics differ with respect  to the part of the
canal on which they act: some particularly stimu-
 late  the  duodenum,  promoting  the  discharge of
the bile through the biliary ducts; as, for instance,
calomel and jalap;  others, as aloe's,  exert  their
action on the  colon  and rectum ; while a third
class,  the saline and oleaginous  purgatives, in-
crease the peristaltic  movement of the whole in-
testinal tube, and therefore operate quickly.   No
satisfactory explanation of the cause of this dif-
ference of action has  yet been advanced; but the
knowledge of the fact is  of great importance in  a
practical point of view.
   Cathartics  are said  to act generallyr when,
   Vol. I.—49                        2h
besides  the evacutions of the bowels, they also
cause a copious discharge of serous fluid from the
general  circulating mass : the suddenness of this
abstraction, combined with  the quantity of the
fluid discharged  from the exhalents, produces a
powerfully sedative  effect on the whole frame :
the force and velocity of the  pulse are lessened ;
excitement is diminished, and febrile  and inflam-
matory  action is overcome,  or, at least, greatly
lessened.   In some  instances,  indeed,  as  when
elaterium is administered, the discharge of watery
fluid is so excessive, that alarming and even fatal
effects have  resulted.  If purging be long con-
tinued, the chyle is evacuated; and hence, in pro-
tracted  diarrhoea, the  blood  loses its  red  colour,
the  surface  of   the body  becomes   pallid, an8
symptoms of exhaustion supervene.
   Cathartics excite  the general action of the ab-
sorbents, and on this principle is explained the
removal of extravasated fluids: even solid matters,
the product of disease, are sometimes  removed by
active purging ;  an  effect attributable to a law of
the system, by which a great discharge of  serum
is followed by a corresponding increased action of
the absorbents.
   Some cathartics  cause purging when they are
only applied to  the  skin ; thus, if a cataplasm of
rhubarb be laid  upon the pit of the  stomach of a
child, the bowels will be emptied; and aloe's, ap-
plied to any abraded surface, produce  the same
effect on the rectum as  if the medicine had been
taken into the  stomach,  This  may  be taken ad-
vantage of  when patients obstinately  refuse to
swallow  medicines, as  occasionally  occurs  in
childhood, and  frequently  in insanity.  On the
same principle, placing two or more drops of cro-
ton  oil  on the  tongue purges  briskly, when the
powers of deglutition are suspended, and  injec-
tions do not fulfil the intention of the  practitioner.
   Although the primary influence of cathartics,
that  of exciting the  alimentary canal,  is shared
by all  of  them, yet  they differ  considerably in
their secondary effects.'  Some operate quickly;
others very slowly:  some produce  nausea, griping,
and tenesmus;  others operate with little sensible
impression : some cause one copious evacuation
only ; others repeated stools.   The doses, also, in
which cathartics are administered, greatly modify
their action  : some, when given  in  large  doses,
only slightly increase  the peristaltic motion of the
bowels ; others, when given in minute doses, pro-
duce numerous watery stools with great irritation;
and some act so violently as occasionally to excite
inflammation.   Cathartics have been accordingly
divided  into laxatives,  purgatives,   and drastic
cathartics.
   1. Laxatives are   partially  digestible  sub-
stances, which gently stimulate the  inner coat of
the  intestinal tube, and moderately quicken the
peristaltic action.  They merely remove irritating
matters from the bowels, and thereby diminisb
what is termed  the tension of the  system,  and
abate the  disposition to febrile action ;  they are
on this account  employed in cases in wnich active
purging would prove detrimental.  Some laxatives
owe  their effects to a mechanical property ;  as,
for example, bread made of flour which has not
been bolted  or  freed  from all  the  bran, prove*.
aperient, owing to the little spiculse of the horny 
386                                 CATHARTICS.
 testa of the grain which have  been left in tbe
 flour.   The distension of the stomach by a large
 quantity of fluid  is often followed by evacuation
 of the bowels.  But many  laxatives  owe nothing
 to their physical properties  : this is the case with
 manna, sugar, honey, the pulp of the cassia fistu-
 laris, the juice of ripe subacid fruits, malted grain,
 fermented liquors, bland  fixed oils, sulphur, mag-
 nesia  and  subcarbonate  of magnesia, and  some
 other substances.
   2. Purgatives  are  indigestible   substances,
 which, taken into the stomach, or introduced into
 the rectum, irritate the coats of  the intestines and
 augment their peristaltic movement.  The  action
 of purgatives  is,  therefore,  merely an increased
 degree of that of  laxatives; but besides augment-
 ing the peristaltic  action of the intestinal  canal,
 they stimulate their secreting surfaces, so that an
 increased quantity of fluid is secreted by the intes-
 tinal exhalents.
   The necessity of employing purgatives is found-
 ed on the same circumstances which  demand the
 use of laxatives;  and as  their operation  also re-
 duces the powers  of the system, they are indicat-
 ed in diseases  of  excitement, in  which the mere
 evacuation of the  alimentary contents is a second-
 ary consideration.  In continued  torpor of the
 bowels, giving rise to  an accumulation  of  faeces
 in the  larger  intestines,  more  active  stimulants
 than simple laxatives are requisite; and hence in
 such cases purgatives are employed.
   Purgatives are procured both  from  the organic
 and the inorganic kingdoms of  nature.  Among
 those belonging to the first  are classed substances
 the effects  of which depend, — 1. on an acrid
 principle blended with a fixed  oil, as  in  castor
 oil; 2. on a stimulant volatile oil combined with
 resin, as in  the balsam of copaiba, and the various
 turpentines; 3. on resin in union with extractive,
 as in jalap, rhubarb,  and aloe's; or with cathar-
 tine, as in senna leaves;  or  veratria  with fecula,
 as  in colchicum.   Among  the  inorganic purga-
 tives, the  most  active are,  1. compounds of the
 oxides of metals  combined with different  acids,
 constituting salts;  for instance, sulphate of mag-
 nesia ; the sulphate and the phosphate of  soda ;
 the tartrate  of soda  and potassa; the sulphate,
 bisulphate, tartrate, bitartrate, and acetate of po-
 tassa : 2.  oxides of metals  in combination  with
 vegetable matter, as in the mercurial  pill, or with
 magnesia, or with chalk, as in  the  preparations
 termed, hydrargyrum cum magnesia,  and hydrar-
 gyrum cum creta : 3.  chlorides,  as that of soda,
 and the submuriate of mercury.
   3. Drastic  Cathartics  are   also indigestible
 substances, which  operate in the same manner as
 purgatives, but with greater energy, and affect the
 nerves of sensation more than either  laxatives or
 purgatives;  frequently  causing  griping,  or  tor-
mina,  nausea, and vomiting.   This  influence,
however, on the sensitive  nerves is not essential
to tht fulfilment of the intention for which drastic
cathartics are administered.  Drastic cathartics are
chiefly derived from  the organic kingdom of
nature,  and  consist  generally  of  resinous  and
resino-extractive  matters:  for  example, scam-
mony, colocynth, gratiola, gamboge, white helle-
bore root,  croton  oil,  the  root  of the common
dock, rumex oblusifo'ium, tobacco, and elaterium.
 One drastic  purgative only, the precipitative sul-
 phuret of antimony, is derived from the inorganic
 kingdom.
   Although cathartics have been described as be-
 longing to three genera, yet it  is impossible to
 mark the limits where the one set terminates and
 the other commences ; for all, with a few excep-
 tions, may be  arranged  under  one head, the dif-
 ference depending rather on the  energy of their
 action than on any specific or  peculiar mode of
 operation.  The effects,  indeed, of cathartics, de-
 pend on  such a variety of circumstances,  that
 laxatives  may operate in  some cases with  vio-
 lence, and a  mild and  scarcely  sensible action
 may follow the administration of the most drastic
 cathartics.   What are the circumstances that thus
 so powerfully modify the operation of this order
 of medicines ?
   We  may first  mention quantity as modifying
 the operation of cathartics ; and this is so obvious
 as scarcely to require any comment.  The  rule,
 however, is not general; as  some drastic purga-
 tives, for example, elaterium  and croton oil, exert
 their full influence in  such minute doses that it is
 impossible to  reduce their  action to  that  of a
 laxative.  On the other  hand, some laxatives, as
 sugar, manna, and magnesia, cannot, in any dose,
 be brought to operate  as  drastic cathartics.  The
 second circumstance influencing the operation of
 cathartics is mechanical  division.  The resinous
 purgatives, when coarsely powdered,  cause grip-
 ing and even tenesmus;  wbile,  in a state of more
 subtile  division,  they  operate with little sensible
 effect;  a circumstance at variance with the law
 which regulates the degree of action of most other
 substances.  Thus, if camphor  be combined with
 colocynth, the purgative  property of the gum
 resin is increased ; but at the same time its influ-
 ence on the sentient nerves is greatly diminished:
 and  the same effect is produced by the union of
 camphor with senna.  By  such a combination,
 the colocynth  is  rendered  more  soluble; but in
 the case  of  the  senna,  the activity  of which is
 augmented even when the camphor is added to
 the decoction,  some other  explanation must be
 sought  for.  The  third   circumstance  modifying
 the powers of some cathartics is  light, operating
 on impalpable powders.   Thus, if powdered rhu-
 barb be kept in a glass bottle, the portion on the
 side of  the bottle exposed to the light loses both
 its colour and its activity, while that on the oppo-
 site side retains both unaltered.   The last circum-
 stance which we  shall notice as  influencing the
 operation of cathartics is  combination.  Thus in
 cases of spasm, the operation of a cathartic is pro
 moted by its combination with opium ; and undei
 all circumstances, mixture,— as  for example, the
 mixture of sulphate of magnesia and bitartrate of
 potassa, of infusion of senna and  camphor mix-
 ture, and  compounds  of the resinous cathartics
 and  camphor,  and the  union  of calomel with
 jalap,  scammony, gamboge, colocynth, or rhu-
 barb,— promote  the action  of purgatives,  and
cause cathartic substances  to operate with more
certainty than when taken alone.
   Cathartics differ in  the time  necessary for the
production of their effects ;  some operating in a
few hours, others requiring  from eight to twelve.
These differences depend, in some degree, on the 
CATHARTICS.                                 387
mlubility of tbe substances in the fluids of the
alimentary  canal.   Thus the  saline  purgatives
operate  most quickly ;  the  resinous  require the
longest time.   It is probable also that their action
in different  parts  of the  intestinal  canal, is, in
part, to  be  ascribed  to  their different degrees of
solubility.  Some,  as jalap, are very  soluble in
the fluids of the duodenum, and act immediately
on  that  portion  of the  canal;  others  dissolve
more slowly, and  act on the  lower intestines;
whilst others, as,  for instance, calomel, acquire
activity  from  meeting with  acid in  the  stomach
and undergoing a  chemical change.   This rule,
however, is not without exceptions:  thus aloes is
more soluble than jalap, yet it operates chiefly on
the colon and rectum ; and even when applied to
an  ulcer on the surface, its  influence is still ex-
erted on the  large intestines.  A knowledge of
the time required  for the operation  of  different
cathartics is  useful  in  a  practical point of  view,
as  it enables  us  to adapt  our  remedy to the
urgency of the  case: the saline purgatives, owing
to the rapidity of their operation, are well adapted
to acute diseases, especially  those of a febrile and
inflammatory character ;  the  resinous, from  the
tardiness of their action, are better calculated for
chronic affections.
   Cathartics  differ in their ultimate effects upon
the system.   In general they induce a subsequent
costiveness ;  and  this is  supposed to depend on
the evacuation of the fluids of the intestines  being
so considerable, that some time is requisite  to re-
place them ;  but it is more  probable that it  is the
result of that law of the constitution which de-
termines that every increased action  must be fol-
lowed by a state of inactivity  or collapse.   The
more general, also, the  action of a purgative, the
more likely is costiveness to follow: an exception,
however, must  be  made,  as relates to castor oil,
which, when  given daily, operates in such a man-
ner, that the dose may be gradually reduced  to  a
few drops,  and yet  the effect  of a  full dose be
maintained.   Saline purgatives,  owing  to  their
operation  on  the  whole  intestinal  canal,  often
leave a greater sluggishness of the bowels than
existed  beTore  their exhibition.  Rhubarb, also,
has this  effect: but on the  contrary, those resin-
ous cathartics which operate on the lower portion
of the canal,  induce a more open  state of bowels.
   In the  administration  of cathartics, some at-
tention  must be paid to the  following circum-
stances :
   1.  Cathartics are more necessary and service-
able in warm than  in cold  climates; owing, not
only to the greater vitiation  of the contents of the
bowels and  the augmented  secretion of bile in
high than in low temperatures ; but to the  great
determination of fluids  to the  skin  in warm cli-
mates favouring the formation of scybala.  As to
the influence  of season, it is an old  maxim that
purgatives  should  be  given in the  spring and
autumn : and it is true that more inflammatory
diseases prevail at those seasons than  at  other
periods of the year ;  but the custom ought not  to
be  followed  by persons  in health, as it is apt to
induce a habit which may prove hurtful.
  2.  The constitution  of the  patient  must be
attended lo.  Cathartics  are  more  required by
persons of a  melancholic than those of a san-
guine temperament, the bowels  being generally
more torpid in the former than the latter.   There
is  an exception, however, to this rule in women,
who, although they are more commonly of a san-
guine temperament, yet are generally more dis-
posed to costiveness than men ; they do not how-
ever bear the operation of purgatives so well.   In
pregnancy, and during menstruation, drastic pur-
gatives  should not be administered, nor  should
cathartics of any kind be freely employed in states
of debility.   In  attending to  this rule, however,
it must  be recollected that debility may arise from
very opposite  conditions of the system.  Where
any idiosyncrasy exists, connected with the opera-
tion of cathartics, it should not be disregarded, as
much injury may follow the employment  of cer-
tain kinds of purgatives in such instances: thus,
in some individuals a dose of rhubarb will cause
convulsions closely resembling those of epilepsy ;
in  others the smallest quantity of calomel will
produce alarming syncope.  The readiness with
which ptyalism is induced in some individuals by
the last-mentioned medicine is also a circumstance
which sometimes requires consideration.
   3. Although  a costive  state of body is to  be
strictly  guarded against in childhood, yet it is cer-
tain that children bear the  action  of cathartics
worse than  adults.   On account of the depressing
effects of saline purgatives, those of a warm cha-
racter are the best adapted for aged persons.
   4. Cathartics ought not to be too  frequently
taken, as, by the excitement they produce  in the
mouths of the hepatic and pancreatic ducts, they
cause a hasty, irregular,  and  imperfect secretion
of bile  and pancreatic juice,  which is highly in-
jurious to the digestive function.
   5. As a  general rule, cathartics are inadmissi-
ble in inflammatory states of the alimentary canal
which have gone on to ulceration.
   6. The  nature  of a cathartic determines the
period of the day in which it  should be adminis-
tered :  if it require a long time to  operate, it
should be given at bed-time ;  if it act quickly, in
the  morning: thus saline purgatives, senna, cas-
tor-oil, croton-oil, and  elaterium, are best admin-
istered in the morning ;  the gum resins, sulphur,
and calomel, in the evening.   But the action of a
cathartic may at  any time be  quickened by copi-
ous dilution with warm aqueous fluids.
   7. During the  operation of a purgative, it is
necessary to distinguish  carefully those appear-
ances of the alvine  discharges  which are  the
results  of  disease  from those  produced  by the
cathartic.  Calomel always causes the evacuations
to appear  unnatural;  and, if it be requisite to
ascertain their real aspect, the  use of the medicine
must be suspended for a few days.   During the
operation of colchicum the stools are of a  bilious.
appearance; during that  of full doses of saline
purgatives, daily repeated, they assume a peculiai
colour; and the  effect of elaterium is to produce
stools resembling water in which meat has  been
partially boiled.
   With respect to the peculiar action of cathar
tics, it is necessary  to make a  few remarks.
   Among the laxatives, honey is apt to gripe and
to prove flatulent,  and the older it is the more
likely are these effects to follow its administration.
Cassia-pulp, which is now seldom employed ai.-<ne 
386
CATHARTICS.
in this country, produces nausea, flatulence, and
griping.   Tamarind-pulp, although  an agreeable
laxative, yet operates too gently to render it useful
when given alone ;  it is, therefore, usually com-
bined with neutral salts.  The same observation
applies  to manna.   Olive-oil operates  as a mild
laxative in doses of f.gii.  Sulphur, whether in the
simple sublimed state, (the  sulphur lotum of the
pharmacopoeias,) or in that of a hydrate, (sulphur
prsscipitatum,) is a mild but  certain  laxative, well
adapted to cases of habitual dyspnoea, in which it
is of much importance to keep the bowels open :
and  in hemorrhoids it is preferable  to purgatives,
not only on account of the mildness of its opera-
tion, but  because it produces soft, easily moulded
stools, which pass from the  rectum without irri-
tating the highly sensitive piles.  It may be given
daily, in  doses  of from gss. to  giss., combined
with gr.  x. or gr. xv. of  magnesia, until its odour
is manifested on  the skin, when its employment
should be intermitted  for a few days.  Magnesia
and  its  carbonate operate with  some  degree of
energy when  they  meet with much acid in the
stomach.  The pure magnesia is usually preferred
to the carbonate, on account of the inconvenience
produced by the extrication of the  carbonic acid
of the latter in the stomach.   Both of them, when
they  do not act freely  as  laxatives, are apt  to
accumulate, and form concretions in the stomach,
if taken daily for some length of time ;  hence, in
such  cases, it is proper occasionally to clear out
the bowels by means of a brisk  cathartic.  Mag-
nesia, besides exercising  its  laxative influence,
allays the irritability of the stomach ; it is conse-
quently  useful  in  the  dentition of infants  and
children, at which  periods  of life  there is both
much irritability, and  a prevailing  acescency of
the stomach.   The dose of  the  magnesia is from
gr. xv. to ^ii. for an adult;  that of the  carbonate
from ^i. to gi.:  when it is taken alone, the best
vehicle is milk.
   Among the purgatives no animal  substances are
found;  and the vegetable products,  although they
may be  in some degree digestible substances, are
not dietetical.   They  may be noticed  according
to their  effects.  Castor-oil, which  seems to  be
intermediate between  fixed  and  volatile oil, owes
its pioperties to an acrid principle which is  ob-
tained, mingled with bland oil, by the  expression
of the seeds of the ricinus communis, and is more
or less active according to the degree of tempera-
ture employed in the process; that now generally
employed is  expressed in  India  without  heat.
From its quick and mild operation it is  peculiarly
adapted  for  children,  puerperal women,  and  all
cases in which it is necessary to procure the eva-
cuations with little constitutional disturbance.  As
its effects are not influenced by combining it with
 opium, it is generally preferred to other purgatives
 in colica pictonum and calculous affections. None
 of the purgatives can  be so much relied upon for
 overcoming   habitual  costiveness  as  castor-oil,
 given daily  for  some weeks, gradually reducing
 the dose until less than half  a teaspoonful  be
 taken;  after  which the bowels generally continue
 to act w'thout farther artificial assistance; even its
 occasional administration leaves the  bowels in a
 ■•claxed state.  The tendency of castor-oil to nau-
 seate is a disadvantage, but it is counteracted  by
the addition of an  aromatic.   The dose for an
adult, to produce a full operation, is from f.jiv. to
f.^ iss.
  The terebinthinate  purgatives, for example the
balsams, as they are  incorrectly termed, of copaiba
and of Gilead, common turpentine, Chian turpen-
tine, and Canada balsam, are stimulant in propor-
tion to the extent of the dose.  In doses of f.^i,,
rubbed  into an emulsion with mucilage  of  gum,
balsam of copaiba affords much  relief in hemor-
rhoids ; and owing to the determination  which it
induces to the kidneys, acts in some respects as a
counter-irritant.   It may be administered in the
form of pills, by mixing it with one-sixteenth of
its weight  of calcined magnesia,  and exposing
this mixture to the  air until it  acquires a consis-
tence fit for forming it into pills.   The other tur-
pentines are most commonly exhibited in the form
of enema, in torpid  conditions of the bowels, and
in the sinking stage of some febrile diseases, par-
ticularly in erysipelas of a malignant kind. Under
such circumstances  the dose is from f.gi.  to f.3iv.,
rubbed up with mucilage  and manna.   In  some
habits the turpentines are apt to cause an  eruption
on the skin, closely  resembling eczema ; in which
case their use should be discontinued.
   The resinous purgatives, jalap, aloes, and rhu-
barb, operate variously according to  circumstances
of extent of dose, combination, and the state of
the patient.   In  a  moderate dose,  for instance,
from  gr. xii. to ^ss. of the powder, jalap operates
effectually  without  griping; in larger  doses it
gripes, and  produces  copious watery stools; and
when given in an  over-dose it excites hazardous
inflammation of the mucous membranes.  It ope-
rates  chiefly through  the medium of the nervous
system; for when it is injected  into the veins it
does  not act on  the  bowels, although when it is
combined with lard  and  rubbed on the skin it
causes brisk purging.   The fineness or coarseness
of  the powder, also, modifies  the operation of
jalap ;  and  it is probable that  its augmented ac-
tivity, when united  with  bitartrate of potassa and
other  neutral salts, is in part  owing  to the  aid
which they afford to  its comminution.  In  con-
junction  with calomel, the activity  of jalap is in-
creased, owing to the calomel aiding its stimulant
influence on the hepatic duct in the  duodenum.
The watery extract  operates mildly, and is on that
account well  adapted to  children; the  resinous
extract gripes violently and displays all  the  cha-
racters of  a  drastic  cathartic  without purging
much.  With respect to the state of the patient—
in nervous  and irritable  habits jalap operates too
violently ;  whereas in languid and  torpid indi-
viduals its purgative influence requires to be aided
by other cathartics.   Jalap is chiefly useful as  a
general  purgative in  febrile affections connected
 with an increased action of the liver, and a more
than natural  discharge of  vitiated  bile  into the
 duodenum.
   Aloe's  is a warm stimulating purgative, exerting
 little action  on the duodenum  and  small  intes-
 tines, but affecting powerfully the colon and rec-
 tum, a  peculiarity  which has  been erroneously
 attributed to the little solubility of the  aloes in the
 fluids of  the intestinal canal permitting  it  to pass
 nearly through its whole length before it is suffi-
 ciently dissolved  to exert  its purgative influence. 
CATHARTICS.
389
In small doses, for instance from  g. v.  to  gr. x.,
aloes  does not induce  an attack  of hemorrhois,
which, however, is not an unfrequent  result of
large doses.   It has been found useful in the dys-
peptic affections of cold and languid  habits, par-
ticularly  of  the sedentary and  hypochondriacal.
In combination with calomel or blue pill, or with
alkalies,  it  has been  found more beneficial in
jaundice than when given alone, notwithstanding
the opinion  of Cullen, (Materia  Medica,)  that
nothing is obtained by combining aloe's witb other
substances.   From the influence of aloe's  on the
rectum it is generally thought to be an improper
medicine  in pregnancy;  but  Dr. Denman  has
remarked that the  lower class of people use aloe's
on account of the  cheapness of  the medicine,  and
because it can be conveniently administered in the
form  of pills without any bad effects in such cases.
(Introduction  to the Practice of Midwifery.)  The
addition  of camphor to aloes renders its operation
both  milder and more certain.
   Rhubarb  is one of the  most useful of the resi-
nous purgatives, acting chiefly through the  me-
dium of  the nervous system, a fact demonstrated
by the effects of  its application in the form of
cataplasm to the surface;  for were  it absorbed, the
colouring matter would be  detected in  the urine,
which is  not the case; yet the apphcation of such
a cataplasm purges briskly.
   Senna owes its  purgative property to a peculiar
principle, discovered  by MM. Lassaigne and  Fe-
neulle, called cathartina.   This principle is  dis-
solved by water at  a temperature of 96°, which
takes up little of the extractive and other matters
on which the griping quality of senna is supposed
to depend ;  an infusion, therefore, made with dis-
tilled water  at  this temperature,  purges without
griping.   When the infusion is kept ready-made
and exposed  to the air, the cathartina is decom-
posed and the  extractive  oxidized.  Senna is  a
useful and  very  general purgative,  there  being
scarcely  any disease in which  purgation is indi-
cated, where  it may not  be administered.  The
purgative power of the infusion  is greatly  aug-
mented by the addition of camphor mixture, or of
the decoction  of  guaiacum: it is seldom given
alone; but  some  of the adjuncts  frequently pre-
scribed with  it, such, for  example, as  magnesia,
rhubarb,  and the carbonates of alkalies, destroy its
active properties.
   Notwithstanding the virulent effects  of colchi-
cum when given  in  an over-dose, it is an effica-
cious and valuable  purgative;  operating  chiefly
on the duodenum, and, by stimulating the excre-
tory ducts of the liver and the pancreas,  producing
copious bilious stools ;  diminishing febrile action,
and  allaying pain.  To   these effects  we  may
ascribe the  beneficial influence of colchicum in
gout and  rheumatism.  It may be demanded, why
do not other purgatives equally relieve these dis-
eases }   We  reply, — present  us  with  one  that
will act as decidedly on the hepatic and pancreatic
ducts, and we will  equally rely  on its powers.
The wine is  the  best form of  the medicine, be-
cause the acetic acid in it  is sufficient, in conjunc-
tion with the alcohol, to take up the whole of the
veratria, and is not enough to determine its action
chiefly to the  kidneys, which is the effect  of the
vinegar of colchicum.
                                     2h*
  The inorganic  purgatives  are  principally neu-
tral  salts.   The  most  commonly employed of
these, sulphate of magnesia, purges freely without
griping; but as  it frequently causes flatulence, it
requires in most  instances to be conjoined with
aromatics, or some warm bitter infusion, such as
that of cascarilla.  It operates chiefly on the duo-
denum ; and it is to  its presence  that many of the
mineral purging  springs,  as those  of Kilburn,
Cheltenham, Moffat,  Seidlitz, and others, owe
their active properties.
  Soda is  the basis of at least  three purgative
salts, the phosphate, sulphate, and muriate.  The
phosphate, on account of its similarity to common
salt, and  the mildness  of its operation, is well
adapted to  children  and delicate  persons: it acts
moderately in doses  of from giv. to ^ii.   Before
the  introduction of the sulphate of magnesia,
sulphate of soda was  the most commonly em-
ployed purgative : it is now less used.  Its nau-
seous  taste is readily and effectually covered by
citric or tartaric  acids; and when a purgative is
required to lessen rapidly the mass of the circu-
lating fluids, none answers more effectually than a
combination of three parts  of sulphate  of soda,
and one part of bitartrate of potassa.   Sea-water
owes  its purgative  influence to a combination of
muriates, of which  that of soda  is predominant.
All the salts  of soda  operate  upon  the  whole
length of the intestinal canal, stimulating the ori-
fices of the  exhalent vessels, and, consequently,
causing serous  discharges  in the form of thin
watery stools : they are, therefore, well calculated
for cases of febrile excitement, and those in which
there is a tendency  to plethora.   Their influence
on  the exhalent vessels also promotes absorption,
for the action  of the exhalents   cannot  be aug-
mented without a corresponding  increased  action
of  the  absorbents.   In  prescribing the salts of
magnesia and  of soda, it is important to under-
stand  the variation  of their action  produced by
various combinations.  Thus, the addition of sul-
phate of magnesia quickens greatly the action of
infusion of  senna;  while,  for  those who can
scarcely bear the operation of purgatives, the sul-
phate should be combined with bitter or aromatic
infusion, or even with sulphate of iron, as circum-
stances may direct;  and this rule holds good, also,
respecting the others.
   The salts of potassa are  more diversified  in
their action than those of magnesia  and soda.
The sulphate and bisulphates of  potassa  are use-
ful adjuncts to rhubarb and aromatic bitters  in
dyspepsia, accompanied, as it usually is, with tor-
pid bowels.  The dose of the sulphate is from gr.
x. to 9ii., that of the bisulphate ^ss to  £ii.  It
must be recollected  that the sulphate is decom-
posed by tartaric acid  and  converted into  the
bitartrate; hence it  cannot properly be prescribed
with infusions of tamarinds, nor with the infusion
of  senna with tamarinds of the Edinburgh Phar-
macopoeia.   As a purgative, the  neutral sulphate
is supposed  to extend its  action  beyond the  in-
testinal canal;   and, therefore,   it is generally
selected in cases of obstructions of the mesenteric
glands.  In  combination with aloe's, it has been
found to answer well in cases ol jaunau.e, in dys-
peptic affections, and in habitual costiveness. Thn
tartrate and bitartrate of potassa  differ consid*' 
d90
CATHARTICS.
ably in their mode of operation.   The former is a
mild  and efficient  purgative, operating without
griping;  and it has, also, the property  of lessen-
ing the griping quality of senna  and scammony.
It acts on the whole of the  intestinal tube ;  and,
as it operates rapidly, it is well suited to cases re-
quiring the aid of a quick and effectual  purgative.
The  average dose  is from  3L to 31V.   It is per-
haps the best purgative that can be prescribed, to
assist the effect of a large dose  of calomel  given
at bed-time ; thus,  from 31. to 3b. of tartrate  of
potassa,  in f.^iss of infusion of senna, administer-
ed in the morning,  after a dose of calomel  taken
on the  preceding  night,  operates rapidly, and
sweeps   away  the  bile  which  the calomel  has
brought  from the  liver.  The bitartrate operates
more on the exhalents  of  the smaller  intestines
than the tartrate, producing watery stools, flatu-
lence, and, in  some persons, griping.   From  its
property of acting  on the  exhalents, it is advan-
tageously prescribed in cases of ascites  and other
dropsical accumulations; hence its continued use
is productive of emaciation, and  to this property,
also, may be ascribed its utility in cases  of ple-
thora and obesity.   As it  is not very soluble, it
may be  given  either in  the form  of powder or of
electuary, combined with  jalap,  scammony,  or
sulphur.  The acetate of potassa in small doses
operates as a diuretic ;  but  in doses of from 3'i-
to 3iv. it purges freely,  if the surface of the body
be kept  warm.   It is, nevertheless, much inferior
to any of the other saline purgatives.
   With respect to the mercurial oxides and salts,
the mercurial  or  blue  pill and  calomel may  be
regarded rather  as  preparatives  for active purga-
tives than as purgatives themselves ; they operate
chiefly by stimulating the gall-ducts, when given
in  full  doses; and  as  alteratives, improving the
biliary secretion and increasing it, when the liver
is in a torpid state.  The hydrargyrum cum creta
operates also mildly ; but  it is seldom  employed
except in cases requiring the aid of a mild altera-
tive, or  as a  purgative for children in whom there
is  much acescency of stomach,  and  in  whom
there are, at the same time,  glandular obstructions.
 When  calomel is intended to operate as a purga-
tive, it should be given in much larger  doses than
are usually prescribed :  in  such  doses, for exam-
ple,  as  from  gr. x. to gr. xv. it  lessens the irrita-
bility of the  stomach when  this is excessive, com-
bines with, renders more fluid, and  detaches  the
viscid mucous  secretions adhering to  the  small
intestines, and augments the vascular and capillary
circulation in the mucous  coat of the  colon and
rectum.
   During its  administration it has been said that
 the aspect of  the  alvine discharges is rarely na-
 tural ;  the medicine  should, therefore,  be fre-
 quently intermitted for a  few  days, in order to
 ascertain the real  state of the  abdominal secre-
 tions.
    The last division of cathartics, the drastic pur-
 gatives, consist, almost entirely, of organic pro-
 ducts, involving some very  active principle. Their
 operation is  commonly attended with griping ;
 and in  some  instances the effects are so violent,
 that, unless  they be closely watched, much mis-
 chief may result from  their employment.   They
 exert a  powerful influence  on tbe exhalents -md
absorbents, and merit more justly  tbe  name of
hydragogues  than  any other  set  of purgatives
Amongst  them, colocynth is supposed to owe its
cathartic power to a peculiar principle which hat
been  named  colocyntine; but  this is uncertain
Colocynth operates chiefly  on the  larger inte*
tines; and, as with aloes, this happens even when
it  is  applied  to an ulcer on the surface of the
body.  When given in substance, the violence of
its operation  should be moderated by triturating it
with  gum or  farinaceous  matters.   It is  most
usually administered  in  the form  of extract, in
doses of from  gr. vi. to gr.  xv.; hut the aqueous
decoction  is  milder in its effects than the extract.
The  resinous  drastic  purgatives  most commonly
employed  are  scammony and  camboge.  Scam-
mony is a powerful griping  cathartic.  It is gene-
rally  combined with calomel, and is one of those
substances the acrimony  of  which is greatly mo-
dified by combining with it sulphate of potassa.
From its activity, it is well  adapted for removing
the scybala  that frequently remain, for  a long
time, in the cells of the colon in maniacal cases;
and  in combination  with  calomel and sulphate
of potassa, it aids greatly in removing ascarides
from the  rectum.   The  dose is from gr. v. to gr.
xv.;  it is  advisable generally to conjoin with it a
drop or two of some  volatile oil; and when the
bowels are irritable, if it be  ever proper in such a
case  to prescribe a drastic purgative, the watery
emulsion of  scammony, allowed to settle and de-
posite  the resin, will answer  the  purpose, as it
operates with  sufficient activity without griping
Camboge is  more  drastic  than scammony, ant!
frequently excites vomiting when  given alone,
even in moderate doses.   It is usual to combine
it with calomel, soap, rhubarb,  or  sulphate of
potassa.   The  average dose is from gr. iv. to gr
viii.   The drastic character of the root of black
hellebore  as  a cathartic was well  known to the
ancients, and one of their chief resources in the
management of mania:  but it may be  doubled
whether it possesses any superior advantages over
other active cathartics in tbat  disease, or even as
 a hydragogue.  One  of the most  active of the
 drastic cathartics is,  undoubtedly, the expressed
 oil of the seeds of the croton tiglium. Like castor
 oil, it is  the  solution of an acrid  principle in a
bland oil, in the proportion  of  forty-five parts of
 the  former to fifty-five of the latter.  The acri-
 mony of this  principle is  so  great, tbat the oil
 operates briskly by merely applying a single drop
 of it  to the tongue; nevertheless it seldom excites
 nausea or vomiting, and rarely griping.  In ma-
 niacal cases, in visceral obstructions, in dropsical
 accumulations, in delirium  tremens, in apoplexy
 and in all cases requiring ample and prompt eva-
 cuations, the oil of tiglium may be prescribed with
 advantage. The best mode of using it is to rub it
 up with sugar, as an oleo-saccharum,  in the al-
 mond emulsion ; or  to dissolve it in alcohol, as
 recommended by Dr. Nimmo.
   The last of tbis class  of  cathartics which it is
 requisite to  notice is elaterium, a vegetable pro-
 duct, which owes its  activity to elatin, a peculiar
 principle discovered by Dr. Paris,* and the  most

   * Dr. Clutterbuck first discovered the fecula now called
 elatin.—See his paper in the Medical Repository, quoted
 by Dr. Paris.—Editors. 
CHEST,  (EXPLOR
ATION  OF  THE)                  391
powerful  purgative agent yet known, as it con-
stitutes one-twelfth  only of the weight  of elate-
rium,  of which  one-eighth  of a  grain  only is
required to produce  brisk purging.   Elaterium,
when  properly managed, is an excellent drastic
hydragogue.  Sydenham employed  it successfully
in dropsy ;  but it fell into disrepute from the in-
discreet use  made of  it,  until Dr.  Ferrier,  of
Manchester, restored it to practice for the cure of
hydrothorax.  In administering it, the  strength
should be supported with moderate  stimuli, parti-
cularly ammonia, capsicum, or  camphor : under
every  circumstance the utmost caution is required
in its  administration, and no practitioner ought to
prescribe it unless he is able personally to watch
its effects.  The average dose to an adult is one-
sixth  of  a  grain ; and  this  should  be  repeated
every  sixth hour, until copious stools  are  pro-
cured.
   Among the inorganic drastic purgatives,  the
only substance requiring to be noticed is the pre-
cipitated sulphuret of antimony, which, however,
is employed  merely as a component of the com-
pound calomel pill.  It is a violent but very un-
certain cathartic.           A. T.  Thomson.

   CEPHALJEA,  CEPHALALGIA.    (See
HEAnACH\)
   CHEST,  Contraction  of.   (See Pleu-
ritis.)
   CHEST,  Exploration  of. — The  methods
employed by  physicians for  exploring or physi-
                   Fig. 4,
cally examining the  external parts  of the chest,
witb the view of discovering or discriminating the
diseases of this cavity, are  the following: — in-
spection, manual examination, mensuration, aus-
cultation,  percussion, succussion.    The three
latter methods  have been fully discussed in the
article Auscultation ; it therefore only remains
to notice the three former in this place.
  The relationship of the external to the internal
parts is  much more easily ascertained in the case
of the thorax than the abdomen, owing to the less
complexity and greater fixedness  of the contents
of tbe  former cavity.  The thoracic  viscera arc
few in number, and their boundaries are, in gene-
ral, accurately  defined.  In the  state of health
they cannot vary  their position; and their  dis-
placement is produced by  only  a small number
of well-defined  causes, the chief of which are
preternatural growths, or  the  accumulation  of
fluids within the  cavity  of the  chest, encroach-
ment of the abdominal  viscera  from  below, or
alteration of the solid walls of the  chest, chiefly
from distortion  of the spine.
  In the  article Exploration  of the  Abdo-
men, the  importance of knowing the  topogra-
phical relations of the external and  internal parts
of the great cavities was pointed out, and also the
means of rendering  this knowledge more precise
by the aid of artificial subdivisions of the anterior
of the body.   The principles adopted in dividing
the whole trunk of the body are there explained;
and the  figures  in pages 26 and 27 exhibit a repre-
                    Fig. 5.
 
39'J
  CHEST,  (EXPLORATION  OF  THE)

Fig. 6.                                           Fig. 7.
                   Front View.
       a. The heart.
       6. The lungs.
       c. The liver.
       d. The stomach.
       e. The transverse arch of the colon.
       /. The small intestines.
       g. The bladder.
       h. The arch of the aorta.
       i. The left subclavian vein.
sentation of the thoracic regions along with those
of the abdomen.  We must, therefore, refer the
reader to  those figures,  while we now proceed
verbally  to define the regions  which belong ex-
clusively to the chest.
   All the regions, as is explained in the  article
referred  to,  are bounded  by direct  lines  drawn
from fixed and conspicuous points on the surface
of the body, and whjch lines are either vertical or
horizontal.   The vertical lines having relation  to
the chest are eight in number, and run as follows:
—1. along the middle of the  sternum  from its
upper to its  lower extremity ;  2. from  the acro-
mia  extremity of the clavicle to the  external tu-
bercle of the pubes (right  and left) ;  3. from the
posterior boundary of the  axilla, or inferior edge
of the latissimus dorsi, to that point of the crest
of the ilium  on which it falls vertically (right and
left) ; 4. along the spinous processes of the cer-
vical and dorsal vertebra?;  5. along the posterior
or spinal border of the scapulae, from the clavicu-
lar transverse line to the mammary transverse line.
The horizontal or transverse lines are four in num-
ber, and  are  as follows :—1. around  the  lower
part of the neck, sloping downwards  to the upper
end of the sternum anteriorly, and to the last cer-
vical vertebra  posteriorly ;  2. around the  upper
part of the chest in the line of the clavicles ;  3.
around the middle of the chest, crossing the nip-
ples anteriorly, and touching the inferior borders
of the scapula? behind ; 4. around the lower part
of the chest on the scyphoid cartilage.
                    Back View.
        a. The oesophagus.
        b. The lungs.
        c. The aorta.
        e. The ascending colon.
       /. The small intestines.
        g. The descending colon.
        h. The caput coli.
        «". The spleen.
        k. The kidney. — 1. The trachea.
   By these imaginary lines the  trunk  is divided
into three horizontal and eight vertical bands, and
their intersections form, in all, sixteen compart-
ments or regions, of which two are superior, four
anterior, four lateral (two on  each side), and six
posterior.   They are named  as follows:—supe-
rior regions—humeral (right  and left) ; anterior
regions—subclavian (right and  left),  mammary
(right and left); lateral regions—axillary  (right
and left), subaxillary or lateral  (right and  left);
posterior regions—scapular (right and left), intra-
scapular (right  and left), subscapular or superior
dorsal (right and left).
   In the figures introduced into the present article,
to which we particularly call the attention of the
student, an attempt has been made to impress still
more strongly on the mind topographical relations
of these external artificial  subdivisions with the
viscera within.  In consequence of their introduc-
tion we shall  greatly abridge the remarks on these
relations which would  otherwise have been neces-
sary.  In studying them it is necessary  to keep
constantly in  view the figures in p. 27,  and the
explanation of  the regions which  accompanies
them.*   In fig.  4 and 5 the outlines of the  visce-
ra are delineated on the surface of the body; and
in fig. 6 and 7,  the regional lines of the surface
are drawn on  the viscera exposed in situ.
   The natural boundaries of the two great organs

,.»h A? belonein? a» l° ^e same series, we have contin-
article? numerat,on of the fiS"res begun in  the former 
CHEST,  (EXPLORATION  OF  THE)                  393
contained in the chest scarcely require to be point-
ed out.  Separated from eacb other by the medi-
astinum, which at its lower part includes the heart,
the two lungs are in contact with the solid walls
of the chest in every other point, and rest on the
diaphragm below.   The heart rests on  the  dia-
phragm on the left  side of the sternum, and ex-
tends upwards beneath this bone midway to the
upper part of the  chest.   Both lungs  descend
much lower on the  sides and back  than on the
fore  part of  the chest, on account of the position
of the  diaphragm, which stretches upwards from
behind  forwards,  so as to form an acute angle
with the spine.  The lungs are consequently pro-
longed  downwards, in very thin lappets, behind,
and  reach much lower than persons not very well
versed in  anatomy are apt to believe.  It is not
unusual to  find painful  affections  of the dorsal
pleura referred to the kidneys.   An opposite mis-
take is  occasionally committed on the fore part of
the  body,  affections of the liver and stomach be-
ing  referred to the lungs or heart, because the site
of the pain  is  considerably above the  margin of
 the  ribs.  We do not allude to those sympathetic
 pains which in dyspectic cases radiate far within
 the  true boundaries of the chest, but to pains fixed
 in the organs themselves.
   The general shape of the lungs corresponds
 with that  of the cavity in which  they are placed.
 The right lung is  larger  than the  left, but  does
 not  descend so low anteriorly, owing to the posi-
 tion of the liver on that side.   The upper lobes
 of the lungs rise as high as the first rib  and cla-
 vicle, and in the space between the  last-mentioned
 bone and  the anterior edge of the trapezius mus-
 cle the pulmonary structure is undefended by any
 bony or thick muscular covering, and consequent-
 ly lies very  near the surface.
   I. Inspection.—By inspection of the  chest we
 mean in this place tbe ocular examination of the
 chest freed from covering; and it is by this  alone
 that the actual configuration  of this cavity, whe-
 ther natural or morbid, can  be  ascertained  with
 certainty.
   The relative size of the  cavity of the  chest va-
 ries considerably in different  individuals even of
 the  same age, sex and stature.   This is a circum-
 stance of  much practical  importance, more espe-
 cially  in  relation  to  prognosis.   A very  small
 chest not merely  predisposes to diseases of the
 lungs, but renders them, when  they occur, more
 dangerous.  It even tends  to enfeeble the consti-
 tution   generally, by diminishing  the energy of
 the  respiratory  and  circulatory functions, and
 may thereby become  a source of aggravation of
 many diseases which have not  their seat within
 the  chest.
   A well-proportioned chest should be large in all
directions, more particularly in its antero-poste-
 rior and lateral directions.  Sometimes we see
great disproportion in this respect overlooked  from
imperfect  examination.  Generally speaking, the
cavity   of the  chest is proportionally  smaller in
women than in men;  and this natural conforma-
tion is  commonly  increased by the  use of stays;
often it is aggravated in an extreme and most in-
jurious degree. The effect of stays tends to dimin-
ish the  capacity of the chest chiefly in two ways ;
first, in its transverse diameter, by  compressing  it
   Vol I. —50
in every point towards the axis of the trunk on
its lower  half; and, secondly, in its vertical dia-
meter, by forcing the diaphragm upwards before
the compressed abdominal viscera. In these cases,
althougb  the  longitudinal extent of the  proper
cavity of the chest is greatly diminished, the ex-
ternal bony compages of the thorax is often length-
ened, the  lower ribs being forced downwards to-
wards the pelvis.  When this happens, the usual
topographical  relations of the external  and inter-
nal parts are often  greatly altered; and mistakes
in diagnosis are only  to  be prevented in  such
cases by careful  examination  of  the  body freed
from its coverings, and by  the habit of inspecting
bodies,  so distorted, after  death.  Another very
frequent cause of alteration of the  natural con-
figuration of the chest in women  is distortion of
the spine. Every experienced practitioner is aware
of the great frequency  of this affection  among
young women educated  at  boarding-schools, or
subjected to sedentary employments. The effects
of this change in the  natural  direction of the
spine in altering the shape of the chest are well
described by many of our recent surgical writers;
but they are still too imperfectly known by prac-
titioners in general.   The  real  nature  of such
cases can only be ascertained by inspection, more
particularly of the back.
   It is, no doubt, by inspection that we can judge
most accurately of the condition of the respiratory
function generally ; but it is not necessary to have
recourse  to this expedient in order  to ascertain
the mere frequency or  quickness of the inspira-
tions and expirations.  This we can do by merely
watching the respiratory sounds ; and the signs
and  indications thence derived for  the purposes
of diagnosis, prognosis, and practice, belong more
to the  general subject of diagnosis  than to the
physical exploration of the chest.   But it is im-
possible to ascertain the degree of mobility of the
whole thorax  relatively with  that of the abdomi-
nal parietes, or of one  side of the thorax relative-
ly with the other, without inspection ; and such
knowledge is  often of  much importance.   In cer-
tain inflammatory diseases of the chest, as pleu-
risy, more particularly when both sides are affected,
the walls of the  thorax often  remain nearly un-
moved, respiration being carried on almost entirely
by the diaphragm and abdominal  muscles.  In
this  case the abdominal movements are quick and
extensive, while those of the chest are the reverse ;
such a condition of the respiration has been termed
abdominal.   When inflammation exists  in the
abdominal cavity, the thoracic parietes are preter-
naturally mobile, while those of the abdomen are
inactive : in this state the respiration is said to be
thoracic.   It  is only by  inspection also  that we
can ascertain  certain conditions of the mere sur-
face,  which are, however, often of importance to
diagnosis.  Of this kind  are cedema of a portion
of the chest, the relative width of the intercostal
spaces, their degree of prominence, &c.
   But  it is by enabling  us  to ascertain  partial
contractions  or dilatations of  the chest,  not de-
pendent on spinal distortion,  that inspection is
most useful.   In some  cases, these partial altera
tions of shape  extend to both sides, but they arc
much more   commonly confined  to  one.   In
phthisis which has been very slow in its progress. 
394                  CHEST,  (EXPLORATION  OF  THE)
and when tubercles exist in both lungs, as usually
happens,  we  find  both sides  of the chest con-
tracted, particularly in the subclavian regions.  In
asthma, on the contrary, both sides are usually
considerably dilated, more particularly about the
middle  of the chest,  and rendered  much more
convex both before and behind.   In old  asthma-
tics this configuration of the chest is sufficiently
conspicuous, even when the body is covered.   Its
presence is always a proof of the permanent dila-
tation of the pulmonary cells, and, generally, of
an incurable disease.
   But  the alteration  of configuration produced
by disease in the chest is much more generally
confined to one side ;  and  the diseases in  which
this change occurs are chiefly pleurisy and pneu-
mothorax.  In  acute  pleurisy, when the effusion
is at all considerable, the affected side is percep-
tibly dilated ; and Laennec assures us that he has
often observed this effect on  the second day  of
the disease.   The  eye readily detects the  dilata-
tion when  it  does not exceed half an inch in the
whole semi-circumference of the  chest.  In chro-
nic pleurisy,  when the accumulation of fluid  is
very  great, the affected  side is often  very  consi-
derably dilated :  the  disease, however, frequently
exists without any dilatation.  In pneumothorax
the affected side is often  much dilated ; and here,
as in simple empyema, we sometimes see the in-
tercostal spaces elevated to the  level of the ribs,
or even above this.  Some of the  same  diseases
which produce dilatation of the chest, occasion  at
other times a contraction of it, either generally  or
partially.   Contraction of one whole side  of the
chest is a frequent result of pleurisy, the side be-
ing diminished in all its dimensions, the ribs being
pressed together, and  the intercostal spaces con-
sequently  nearly abolished.    Partial  contraction
or dilatation of the chest, permanent or temporary,
is still more common than a similar condition of
the whole  side.   When not dependent on distor-
tion of the spine, it may  always be regarded as a
sign  of disease within the chest, either  now or
formerly existing.   By  far the most  common
cause of partial contraction of the chest is circum-
scribed pleurisy.   In the  history  of the individual
diseases—phthisis, hydrothorax, pneumonia, pleu-
risy, empyema,  pneumothorax, &c.—the signifi-
cance and value  of the  foregoing signs will  be
more particularly pointed out.
   II. Manual Examination.—There are only
a few circumstances relating to the  physical con-
dition of the  chest which cannot be  ascertained
without the direct  application  of the  hand.  Of
this kind is soreness or tenderness of the surface.
Much tenderness of the surface  of the chest  on
simple touch usually indicates  an affection of the
external parts, either of the skin or muscles, as in
the rheumatic affection termed pleurodyne.  It is,
however,  sometimes  produced by  internal dis-
eases, as when a collection of pus in the pleura is
making its way outwards by perforation of an in-
tercostal space.   When, however, considerable
jtcs«—c is made in the intercostal spaces, pain is
very frequently experienced in pleuritic affections,
more particularly of a  chronic  kind.   In  chronic
pDeumonia, also, and in phthisis,  when the lungs,
as frequently happens, are adherent to the  costal
pleura, the  same effect is frequently observed : and
in cases of this kind we have often  found much
uneasiness produced by even the  gentlest percus-
sion, more particularly if made without the plexi-
meter.
   A preternatural  degree  of temperature of any
part of the surface of the  body has  been always
considered indicative of disease of the  particular
part,  or of those which  lie beneath  it.*  The
same rule  is, no doubt, equally applicable to the
diseases of the chest; but although  the fact may
be so,  it is interesting more as a pathological phe-
nomenon than as a  means of diagnosis, as it
scarcely ever exists where  we are  not provided
with more certain indications.  In acute pleurisy
and pneumonia, and yet more in the complication
of these, pleuro-pneumonia,  the external  surface
is often much increased in temperature; and this
fact was  taken advantage of by  Avicenna  as a
means of detecting the part  affected.  For this
purpose he proposed to apply wetted cloths upon
botb sides of the  chest, and concluded that the
side on which the cloth dried soonest, on account
of the greatest heat, was that in which the inflam-
mation existed.
   Manual examination discovers the presence
and degree  of muscular  robustness, obesity, or
emaciation,  also oedema,  emphysema, &c. with
much  greater certainty and  accuracy than mere
inspection : it also enables us to judge of  the na-
tural degree  of thickness of the thoracic parietes,
a circumstance sometimes  of considerable  import-
ance in appreciating the value of  other signs de-
rived from different methods of physical explora-
tion.
   [If  the hand be  applied to the chest whilst a
healthy person is speaking,  a vibratile  tremor,
called  vocal vibration or vocal fremitus,  is felt;
which, at times, is scarcely or not  at all percepti-
ble, but at others  is very marked, especially in
those  whose  voice is  grave.  In persons with
weak or shrill voices, it is absent  altogether, and
hence  is not felt in children, and is very often
absent in women.  It  is more marked, according
to Dr. Stokes, (On Diseases of the Chest,  p. 497:
Lond. 1837,) on the right than on the left side;
in front than  behind ; behind than  laterally ; is
scarcely perceptible in the  infra-clavicular, and
still less so in the interscapular sub-regions. This
fremitus is  heard not  only  when  the  person
speaks, but often when he coughs;  rhoncbi and
friction sounds can also  be appreciated  in the
same manner.  (Walshe,  The Physical Diagno-
sis of  Diseases of the Chest, p.  16,  Amer. edit.:
Philad. 1343.)  The writer has often been struck
with the difference in the vocal fremitus of the two
sides of the chest, where one lung has been affected
with tubercular or other consolidation, and the other
not.   (See Auscultation of the Voice.)]
  III.  Mensuration.—This process is confined
chiefly  to ascertaining the  comparative size of
the two sides of the  chest,  wbich relation  it
ascertains with much greater preciseness than
either  of the two  former  methods.   It  consists
simply in  measuring the superficial extent of the
chest by means of a piece of tape stretched over
it from certain fixed points.   As the contraction
or dilatation  may be in both the  transverse and
  * Et ubi in corporecaliditas aut frigiditas, isthic mor-
bus est.  Hippoc Aph. 39, sect. 4. 
         CHEST,  (EXPLORATION  (

vertical directions, it is necessary, if we wish to
be extremely precise to make two admeasurements,
one from the spine to the sternum, the other from
the top of the shoulder to the lowest rib. In gene-
ral, however, the transverse admeasurement is all
that is requisite.   In measuring the two sides, we
must be careful to  apply our tapes in a precisely
similar manner to each side.  In ascertaining the
transverse extent, we first make our measurements
idler a complete  expiration, and then after a full
inspiration.  It will thus frequently be seen that,
although little or no difference is found between
the two sides in the former case, it is very consi-
derable in the latter,—the  chest on  the diseased
side not  at all expanding during inspiration, and
probably expanding even more  than in the state
of health on the sound  side.  This  effect is ren-
dered particularly striking by fixing the  middle
of the piece of tape on the spine, and allowing
the two ends to  rest somewbat  loosely  on the
sternum, so as to be moved by the motions of tbe
chest: on  the patient taking a deep  breath, the
end on the sound side is seen gradually to recede
from the sternum, while that on the  diseased side
either  remains stationary,  or  recedes  to  a very
small extent.  In cases of contracted  chest  suc-
ceeding acute  pleurisy, in which  a cure has been
effected, it is interesting to watch, month by month,
the gradual expansion of the contracted side.  In
 such  instances we have been accustomed to sup-
ply the patient with a marked  piece of tape, and
 have  been  gratified to prove  by this  means, at
 certain intervals,  the  progressive return  of the
chest to its natural size.
   [The average result of the most accurate mea-
 surements of the chests of 20 persons not labour-
 ing under disease of the lungs,  gave, according to
 Dr. Stokes, (op.  cit. p.  498,)  for the  right  side
 17.86 inches; and for the left  17.23, or more
 than  half an  inch in  favour of the right lung.
 Of these,  the most  capacious  chest measured
 22 inches  for  the  right, and 21.50   for the
Jeft.  In one  case  only, the left side  was larger
 than  the  right,  and  in  three  the sides were
 symmetrical.  In the case  in which the left  side
 was more  developed,  the  man  was left-handed,
 and the biceps measured half an inch  in  circum-
 ference more  than the right.   Of  20 measure-
 ments made by the writer—ten of males  and ten
 of females, none of them labouring under disease
of the lungs, the average in the case of the males
gave 17.47 inches for the right side,—16.92 inches
for the left;—in that  of the females, 15.2 inches
for the right side, and 15.1 for the left.   (Prac-
tice of Medicine, 2d edit., i. 390: Philad. 1844.)
   The two  sides of the chest are affirmed to he
of  unequal  dimensions  in about five-sixths  of
healthy subjects; a mean excess of about  half an
inch existing  on the right side  in  right-handed
individuals; whilst in  left-handed  persons the
left side sometimes measures  more, or more fre-
quently the same as the right. (Walshe, op. cit.)]
   It has been  endeavoured to ascertain the capa-
city of the chest, or rather of the lungs, on ano-
ther principle, namely, by ascertaining  the quan-
tity of air the  lungs were  capable of containing.
This method was proposed by the late Mr. Aber-
nethy.  It is obvious  that  it does  not  lead to the
same results as mensuration of the external  sur-
F THE) —CHICKEN-POX.     395

face of the chest; this latter giving the  capacity
of the containing, the former the capacity of the
contained parts.  Mr. Abernetby's method consists
in making the patient take as deep an inspiration
as possible, and then expire through  a bent tuoe
communicating with  an inverted jar containing
water.   The quantity of water displaced  by the
air is a measure of the capacity of the  lungs  to
contain  air.  A person in good health with sound
lungs is able to displace six or eight pints ;  and
if the amount be greatly less than this, as for ex-
ample, only one-third or one-quarter, it may  be
inferred that the lungs are either obstructed  by
disease of their own substance, or compressed from
without.   " Muscular debility  or  spasm," says
Mr. Abernethy, " may occasionally make the  re-
sult of this experiment doubtful, yet in general, I
believe it will afford useful information.''  (Essays,
Part. II.  p.  157.)   In  this judgment we agree
with Mr. Abernethy.
   A more simple test of the capacity of the lungs,
founded on the same principle, has been proposed:
(Edin. Med. Journ. vol. xxxviii. p. 453.) ft con-
sists in  measuring the comparative length of time
occupied in making  a complete expiration after a
complete inspiration.  With the view of proving
that the expiration  is continuous, the patient  is
desired  to  count from one  upwards, as far as he
can, slowly and audibly ;  and  the  number of se-
conds during which he is  able to count, without
drawing breath, is noted by a watch : the number
of seconds is considered a proportional sign of the
quantity of air expired, and consequently of the
lungs.  Dr.  Lyons, who  proposes this  method,
says that the most  healthy individual  will  not
continue counting beyond thirty-five seconds ; but
in this  he is certainly  mistaken, as any  of our
long-winded readers  may prove  by personal ex-
periment.  In confirmed phthisis, Dr. L.  says, the
period of expiration never  exceeds eight, and  is
frequently less than six seconds; while in pleurisy
and  pneumonia  it may range from four to nine.
This test is of much easier application than Mr.
Abernethy's, but it is much less accurate: it  is
liable to variation from many causes, but  still, like
Mr.  Abernethy's, it may be occasionally useful.
                              John Forbes.

   CHICKEN-POX. —The terms chicken-pox
and  swine-pox seem  to have been in  use in Eng-
land  from a very early period,  to  express those
lighter  cases  of eruptive disorder, which, bearing
a general resemblance to small-pox, yet differ from
that disease in the mildness of  the  accompanying
fever and the shorter  duration  of the eruption.
Morton, the contemporary of  Sydenham, intro-
duced the term chicken-pox into scientific nomen-
clature, and it is now so universally adopted that
it is proper to inquire what are the pathological
characters of the disease thereby designated.   Is
the  chicken-pox  allied to small-pox7  Does  it
arise from  the  same contagion 1  Docs it give
security against small-pox 1  Can  it  be  commu-
nicated by  inoculation 7  These questions have
been argued for the  last hundred yeais,  and the
opinions of pathologists are still  far from being
made up concerning them.  It is obvious tnal
before we can undertake to establish the  diagnos-
tic characters of chicken-pox, we must have pre- 
396
CHLOROSIS.
viously fixed the distinguishing features of small-
pox.  On this account it is proposed to defer the
regular consideration of the former until the latter
disease  has  been  described.   A  brief  sketch,
however, of the eruptions  commonly  known in
England as  the  chicken-pox, may find a place
here.
  This  term is familiarly applied to  all those
eruptive complaints, in which, after a brief attack
of fever, the skin is covered, generally or  partial-
ly, with vesicles or imperfect pustules, which run
through their stages of maturation and decline in
three, four, or, at furthest, five days, the attending
constitutional symptoms being very slight, with-
out any threatening  of  danger.  Such disorders
are very common.   They are met with in infancy
and  mature  age.  They often appear to prevail
epidemically.   Dr. John Thomson, of Edinburgh,
believes that the whole of  them are modifications
of  small-pox,  and the  result of  the variolous
virus.   Other pathologists, again,  consider  that
under the term chicken-pox are included different
kinds of disease, analogous to each other in their
progress and termination, but differing  in their
causes  and  in their earlier  phenomena.  This
latter is the opinion, which, after very careful con-
sideration  of the  subject,  will be  adopted here.
Accordingly, the reader  will find under the head
of Small-pox (Modified) a description of that
class of cases wbich  are characterised by imper-
fect pustulation, occurring chiefly  in  adults, and
preceded by two  or  three days  of fever ; while
under the  head of Varicella Ltmphatica he
will look for those which have for their chief fea-
tures a sudden eruption of vesicles, preceded by
little or no fever,  and occurring almost exclusive-
ly in the periods of infancy and  childhood.
                         George Gregory.
   [CHLOASMA.   (See  Ephelis.)]
   CHLOROSIS, from  p^Xwpij, green ; the disease
known by the designation green-sickness.   This
singular affection is  chiefly incidental to female
youth ; it  occurs  sometimes, however, in the age
of childhood, not  unfrequently in married women,
 and occasionally in the young and delicate of the
 male sex ; and in these several  cases it  assumes
 modified forms, which will be carefully described
 in the sequel.
   History and Symptoms.—Chlorosis steals upon
 the patient very insidiously.  It  has pretty dis-
 tinctly three stages;  the incipient, the confirmed,
 and the inveterate.  It may be  characterized, in
 general, as uniting a morbid paleness  of the com-
 plexion, tongue, and general surface, with recur-
 rent pain  of the head or of the side, generally the
 left; palpitation, fluttering, breathlessness, nerv-
 ousness, and frequently attacks  of hysteria, with
 some tendency to loss of flesh and cedema.
   The first stage or period of chlorosis is usually
 little observed by the patient or friends.  There
 is a slight paleness, or  a little fading of a wonted
 florid complexion, and  the patient is only a little
 more languid and listless than usual, the ordinary
 amusements  or occupations, whether mental or
 bodily, being accompanied by fatigue, the nights
 restless, the mornings heavy.  With these changes,
 aowever,  there is imariably  a confined state of
 • ne bowels, a deranged condition of the stomach,
a tainted breath, a white ana pasty tongue, and a
morbid  appetite ;  and there is recurrent headach,
pain of the left side, palpitation, &c.  The cata-
menia are supposed to flow as usual, but an atten-
tive  inquiry discovers, that with  the complexion,
the uterine discharges also lose their colour.
  In the second or confirmed stage, every morbid
appearance, every symptom is  aggravated; the
countenance, the prolabia, the tongue, the gums,
the internal parts of the cheeks, the conjunctiva,
the general surface, and especially the fingers and
the  finger-nails,  become absolutely exanguious,
sometimes with  a  pearly, sometimes  with  an
icterode hue ; the eye-lids are sometimes slightly
oedematous, especially in the morning; the tongue,
besides being pale and exanguious, is ct'dematous
and  impressed with the teeth; sometimes slightly
loaded, sometimes morbidly clear,  and  glossy in
various parts ; the teeth are apt  to decay; the
skin becomes  gradually rather  dry ; a singular
change takes place eventually in the finger-nails,
which become brittle and easily split or break off,
so that frequently a pin can scarcely be taken out
of the dress.  An equally remarkable  change is
also occasionally  observed in the hair, which be-
comes dry and harsh, frequently splitting, and not
remaining " in curl;" the ankles become  tumid,
and more and more oedematous.  With the ac-
cession  and  progress  of these  symptoms, the
catamenia are found  to become more  and more
scanty and pale, and then to disappear ; the bow-
els  continue  constipated, with or without alter-
nations  of diarrhoea; the stomach is  oppressed
after eating ; there  are various  forms of pica or
morbid appetite, as for pickles, magnesia, cinders,
&c.
   With this  state of things there is  frequently
one  predominant symptom, which absorbs the
attention of the patient and friends,  and some-
times even deludes the medical practitioner. This
symptom is  sometimes a violent recurrent head-
ach ; sometimes pain of the side,  especially the
left side, just under  the mamma ; sometimes pal-
pitation of the heart; sometimes cough ; in other
cases  these symptoms vary and interchange, and
there is frequently every variety of affection com-
prised  in hysteria.   This predominant symptom
 frequently leads to the idea of arachnitis, of pleu-
 ritis,  of disease  of  the  heart,  or of incipient
 phthisis.
   Chlorosis is  frequently complicated  with ha>
 matemesis and melaena, and with  epistaxis.  In
 the latter affection the blood occasionally scarcely
 tinges the linen on which it drops.
   There is  also frequently  in this disease  the
 peculiar affection designated by Dr. Willan,  the
 erythema nodosum, and of which an account will
 be given in its proper place.
   The  second stage  gradually passes  into  the
 third, in which  some degree  of  emaciation is
 added, the oedema assumes a more or less aggra-
 vated form of anasarca, and  a  proportionate de-
 gree of danger now  attends the complaint.
   It frequently happens, from  the  insidious cha-
 racter of this  affection, and from the  severity of
 the predominant symptoms, that the case is mis-
 taken for one of an inflammatory character. The
 affection of the  head,  the pain of the side, the
 palpitation of the heart, have  severally led,  in 
CHLOROSIS.                                  397
many instances, to an abstraction of blood, equal-
ly inappropriate and useless, if not absolutely in-
jurious and dangerous.
  The distinction  is  not  always easy.  One of
the best sources of the  diagnosis, in doubtful
cases, is the degree of susceptibility to faint from
the detraction of blood.   This circumstance, added
to the general symptoms and  to  the  inefficiency
of those  remedies which  are adapted to the case
of inflammation, is an important criterion of pains
which are  not  inflammatory.   (See  Bloodlet-
tixo.)   The quantity of blood which has  been
unwittingly detracted, and the number of leeches
and of blisters which  have been uselessly as well
as needlessly  applied in some of these cases, are
quite extraordinary.
   [Singular phenomena are afforded by chlorosis
on auscultating the blood-vessels.  One of  these
has been termed bruit de diable, in consequence
of its resemblance  to that of the diable or hum-
ming-top of children.  It is heard most frequently
along tbe carotid and subclavian,  and, at  times,
in the crural arteries ; but never to the same de-
gree.  Commonly, it is heard on one side only.
M. Raciborski  (Nevj  and Complete  Manual of
Auscultation and Percussion,  translated by  fl.
Fitzherbert, p.  139 :  Lond. 1835,) affirms, that
during a year and a half that he bad punctually
attended the  clinical  wards of M. Bouillaud, he
had observed  the bruit de diable more than thirty
times, and had not met  with a single chlorotic
patient that was without it.  It would  appear, that
this  sound  is connected with  a predominance of
the watery portion  of the blood, but the  precise
mechanism of its production is not very intelligible.
   From an  analysis  of 88 cases of anaemia, in
which there  was  a continuous  or  intermittent
sound heard over the carotids, M. Andral (Hema-
tologic  Pathologique,  Paris,  1843,)  has endea-
voured to establish a ratio between a diminution
in the amount of globules and such sound.  Of
the 88  cases, the souffle was  continuous in 56 ;
intermittent in 32.  Of the 56 cases, in which it
represented the bruit de diable, in 28, the propor-
tion of globules was not above 80, and descended
as low  as  21.   The results of his observations
showed,  that in different  persons  the arterial
souffle does not always appear with the same de-
gree of depression in the proportion of globules. He
thinks, that the following rules exist  on this sub-
ject.   First. When the ratio of globules has
gone below  80,  the  bruit de  souffle  exists in
the arteries continuously.  To this  law he has
not  seen an exception.  Secondly.  When the
globules  remain above 80, the bruit may still ex-
hibit  itself; but it is  no  longer  constant.   It  is
still heard when the proportion of globules varies
between  80 and 100 ; and occasionally when it is
above 100.]
  Causes. — The most usual exciting causes of
chlorosis are  delicate and sedentary  habits : the
predisposing causes are those peculiarities of the
constitution involved  in the lymphatic tempera-
ment.  From the  influence  of one  or both  of
these caus'.i, chlorosis frequently prevails amongst
young persons of the same family ;  and when the
female part of  a family suffers in this manner, a
slight degree  of the same  or of a similar affection
is frtquently  traceable  in  the males,  denoted  by
                                      2i
unwonted pallor of the  lips, and  an oeuematoug
condition of the tongue.
  The influence of such habits in such a tempe-
rament as  has been  described, is first  seen in a
confined state  of the bowels ; the  colon becomes
loaded, and  the functions  of the  other digestive
organs, with  the  processes of assimilation and
sanguification, become deranged.
  In  an early stage  of chlorosis  the catamenia
are observed to become pale and scanty, and even-
tually they cease.  This circumstance has  led to
the  opinion that  the  peculiar  condition  of  the
generative organs, about the age of puberty, had
much influence in inducing the state of chlorosis.
Dr. Cullen  contends that the  retention  of  the
catamenia in  these cases  " is to be referred to a
certain state or affection  of the ovaria;" but this
he does not « pretend to explain."  Dr. Hamilton,
in his admirable work  on Purgative Medicines,
has argued against this notion  so satisfactorily as
to leave little  for subsequent writers to do.  It is
quite obvious, on carefully tracing the succession
of symptoms,  that the  first link in  the chain is
constipation, and  that the subsequent  links  are
the  effects  of the continued  operation  of this
cause.
  In some manufacturing districts, chlorosis and
some affections strictly allied to it, may, from  the
habits of the people, be justly said to be endemic.
In manufacturing towns, in Nottingham, for  in-
stance, the youthful and  almost the infantine parts
of the population are engaged during many hours
of the  day  bending  over the  tambour or lace-
frame.  The baneful influence  of the want of air
and  exercise, and  of a  sedentary  occupation,  are
speedily visible in the  pallid  and icterode  states
of the complexion, and in the listless manner of
these youthful sufferers.  The bowels first become
confined and  loaded ; the  appetite repels  simple
food ;  the breath becomes tainted ; the  gums  be-
come  swollen  and pale, and  the teeth decayed.
This state is gradually followed by the other  ap-
pearances and affections observed in chlorosis.
  Servants, and especially cooks, are particularly
liable  to chlorosis.  But the delicate  and inert
habits of the rich  not less frequently lead to this
affection.
  In all there is  the same torpor of the bowels,
the same defective digestion, assimilation and for-
mation of blood.
  Pathology.—Amongst tbe  series of morbid
changes induced in chlorosis, is an impaired con-
dition of the blood itself.   This  fact is particularly
noticed by M. Andral in his Anatomie Patholo-
gique, t. i. p. 87.  The quantity of serum  is pro-
portionately augmented, that of the crassamentum
diminished.   This appears to  be the true source
of the pallor characteristic of this disease, and of
the  greater  or less deficiency  in  colour and  in
quantity of the catamenia.  This is  also most
probably the cause of many of the symptoms of
chlorosis which resemble, in so  many  respects,  the
case of ansemia from actual  loss of blood.  The
same circumstance is also the cause of two events
occasionally observed  to take  place  in cases of
chlorosis; namely, delirium or mania, and sud-
den death.
  [In addition to the diminution in the proportion
of the clot to the serum in the blood of chlorosis, 
398
CHLO
ROSIS.
it is deficient, as  before remarked, in  red corpus-
cles ; hence, probably, the diminished  temperature
of the surface; the pallor and waxy appearance,
as  well as the want of colour in tbe catamenia,
and the pale  stain which the blood, in cases of
chlorotic epistaxis, leaves upon  linen.  In two
well-marked specimens of chlorotic blood, observed
by  Dr. B. Babington,  (Art. Blood, Morbid Condi-
tions of the, in Cyclop, of Anat. and Physiol.)
it contained  871  and 852 parts of water  in the
1000, instead  of 780, the healthy  proportion ; and
the colouring matter  amounted  to 48.7 and 52
respectively, instead of 127.  The albumen and
salts were in the  usual proportion.  As a general
rule it may be inferred  from the experiments of
Messrs. Andral and Gavarret (Annales des Sci-
ences Naturelles, Dec. 1840, & Mars 1841,) the
proportion of  red corpuscles  is diminished, whilst
that of the fibrin  remains the same; so that the
clot, although small, may be  firm.  Owing to the
diminution  in the proportion  of red globules,
whilst the  fibrin  remains the same,  the blood of
chlorotic patients  is not unfrequently buffy.   (See,
on  all this subject, the writer's  Practice of Me-
dicine, 2d edit. ii. 632: Philad. 1844.)]
  In  two cases the writer has witnessed complete
mania in chlorosis.  One of  the patients speedily
recovered ;  and the other was conveyed to a dis-
tant hospital, and died from the effort.
  Four cases of  chlorosis in which death took
place suddenly have  fallen  within   the writer's
knowledge.   In one of these  a careful  post-mor-
tem examination  was  made.   The patient having
been confined to bed for a few days with cold, be-
came much better, and was in good spirits ; after
having sat up for  a quarter of an  hour, and talked
cheerfully,  she suddenly became faint, gasped,
and expired.   On examination, some effusion was
found in the ventricles of the brain,  in the peri-
cardium,  and  the left cavity of the  pleura, the
right  cavity being obliterated  by adhesion; the
lungs were  gorged with  serum ;  the heart was
large; the liver much enlarged ; the hands were
of an ivory whiteness; the ancles were slightly
oedematous ;  and  there was abundance of adipose
substance.  The blood was pale and aqueous, and
the  clots formed  in the  large vessels were  small
and light coloured.
  The occurrence of sudden  death in some affec-
tions  termed nervous, and deemed innocuous, is
a fact which  has not been  sufficiently noticed.
The writer  has  been informed  of several such
cases within the last two years.  He suspects that
the  patients have been chlorotic and bloodless, and
that the case is like that of sudden death occurring
after great loss of blood.
  Treatment.—The remedies for chlorosis are
principally  mild  but  efficient aperient  medicines
and chalybeates.   It is important, in the first place,
to remove any load from the bowels by an  ample
dose of medicine, such as an ounce of the  oleum
ricini.  Afterwards, pills consisting of two  grains
of the Barbadoes  aloes and the same quantity of
the  sulphate of iron,  taken daily during dinner,
are  most efficacious,  and indeed, in  the writer's
experience, almost specific.
  It is sometimes useful to  interpose a draught
jf the tinctura and infusum rhei  with manna; at
Diner times, senna and the Epsom salt are required
to move the bowels  sufficiently.   In other cases
the warm water enema is necessary to ensure the
due effect of the aperient medicines.
   Other forms of the chalybeates are also  occa-
sionally advantageous, and especially the ammo-
niuret in the form of tincture, and the carbonate,
   A mild, light, nutritious diet  must be enjoined
with  these  medicines; and a system of moderate
exercises, in the free open air, especially riding on
horseback, must be enjoined,  carefully avoiding
fatigue.   The  general surface,  but especially the
feet, must be kept warm.
   It is  often necessary  to employ some distinct
remedy for  the pain of  the head  or  of the  side;
and  a blister is  the  best.  The  palpitation also
occasionally demands a  remedy, and  the tinctura
hyoscyami relieves this symptom.  Leeches, and,
a fortiori, general bloodletting are highly injurious,
perpetuating the constitutional disease.
   Chlorosis is frequently produced, and  frequent-
ly aggravated or protracted by some mental cause.
It is  important that the physician should at least
be aware of this fact;  he may  then sometimes
be enabled to remove an obstacle  to the recovery
of the patient, which, whilst it existed, might frus-
trate all his efforts.
   The remedies  for chlorosis may be enumerated
thus : the aloetic chalybeate ; mild nutritious diet;
exercise and air; horse-exercise and the sea-breezes
are also highly useful.
   Many other remedies have  been proposed for
chlorosis; but, in the writer's  opinion,  they are
both inefficient and unnecessary.  Those which
have been  enumerated have seldom failed to re-
move the disease ; whilst the other forms of aperi
ents and chalybeates have appeared far less effica-
cious.   The well-known Griffith's mixture, the
mistura ferri composita,  and the precipitated car-
bonate of iron, are of this character.
   [At the present  day,  the subcarbonate of iron
is  employed perhaps more than any other.   The
protocarbonate is also used  in the form  of the
PilukB Ferri Carbonatis of the Pharmacopoea of
the United  States, of  1842.  They are  the  pills
of Vallet, so called after their proposer ;  but they
have  not  appeared to the writer  to possess any
advantage over the subcarbonate.  The citrate and
the iodide of iron have likewise been  used of late
with benefit in this affection, (New Remedies, 4th
edit. p. 274 and  p. 290.)  If the  blood be exam
ined after iron has  been given for some time, Ine
proportion of the red corpuscles will  be found to
have augmented.]
   A disease  similar to chlorosis, which yields to
similar remedies, occurs  in infants and  children,
and  might for the  sake of distinction be termed
leucosis, from \cvk&s, white.   The  lips  and cheeks
are of a waxen pallor; the tongue, the hands, and
the general surface  are perfectly exanguious; and
there is extreme feebleness.  A few grains of rhu-
barb with  one-fourth of a grain  of the  sulphate
of iron, given twice a day, with a light nutrient
diet, and the fresh  air, and attention  lo warmth,
speedily restore the little patient to  its wonted
strength and colour.  This affection has been little
noticed.   If neglected, it sometimes takes the pa-
tient off with symptoms resembling those of hy-
drencephalus.
   A disease similar to  chlorosis  also occurs »n 
CHOLERA.                                     399
married females.   This affection sometimes, but
not always, arises  from  actual loss of blood ; the
late Dr. Gooch has designated such a case  acute
chlorosis.  More frequently an exanguious condi-
tion of the system arises from a defective assimi-
lation and formation of blood. The aloetic chaly-
beate is the remedy of greatest efficacy in restoring
the hsematosis.
   The occurrence of chlorosis in the delicate of
the male sex has been  noticed by Dr. Hamilton,
Sir Gilbert  Blane, and others, and  will  become
familiar to all who study this affection  witb  atten-
tion.   It has been already stated that in families
in which chlorosis prevails amongst the females,
a similar affection seems to attack the  males.  In
some such instances the writer has seen chlorosis
in its most marked character in the male sex.  It
is removed by the aloetic chalybeate.
                         Marshall Hall.

   CHOLERA.—This word is generally supposed
to  be derived from %oX^, bilis, and  the authority
of Celsus is ordinarily quoted in support of this
etymology.   There  is,  however,  an  obscurity in
the passage usually referred to in the works of this
writer, which renders it  doubtful whether he  means
that bile or the forcible manner in which it is
ejected has given origin  to  the name of the dis-
ease ;  for the Greek  word x^Pa  signifies a  water-
spout  as well  as the disorder  of which we are
treating, and it has been suggested that the adjunct
morbus, so frequently  annexed  to  it, when  em-
ployed in the  latter  sense, was  thereby rendered
 necessary for the purpose of due discrimination.
 However this may be, it is manifest from passages
 of different writers, especially from one of Celsus
 himself, that the words  %o\r)  and  bilis had a much
 more extended sense than our word  bile, being by
 no means restricted  to the  secretion of the liver,
 but applied  to any liquid discharge from the in-
 testines.  By Trallian  the  word  is  derived from
 ^iSWes, intestina.
    The disease being one of frequent  occurrence
 at certain seasons in various climates, and its symp-
 toms being of a very manifest nature, it early at-
 tracted  the  attention  of medical writers.   It is
 mentioned  at some length by Hippocrates (Epi-
 dem. lib. v.), who divides it into the moist and dry
 species, an  arrangement which  has  been adopted
 by some much more recent  authors.   Celsus has
 a  chapter upon  it (cap. xi. lib. iv.)  in which its
 symptoms are detailed  with  his accustomed accu-
 racy, brevity, and elegance;  and notice is taken
 of the occasional occurrence of  a watery  and a
 white discharge, circumstances which recent events
 have invested with considerable  importance.  He
 regards it as a highly dangerous disease, and speaks
 of the deaths produced by  it as of sudden occur-
 rence. Aretaeus treats of the disease, and is rather
 minute in his description of the discharges. The
 matter vomited is at first, he informs us, like water,
 and the alvine dejections are liquid  and  stercora-
 ceous;  whilst, if long indigestion  has been the
 exciting cause of the  disease, the discharges  are
 at first pituitous,  then  bilious.   Of more modern
 writers, our own  Sydenham treats  of the disease
 with that accuracy  of observation  and  practical
 good  sense which are  his chief characteristics as
 a  writer.   He regards cholera as having  in this
country an epidemic prevalence only during the
months of August and the early part of Septern
ber, and declares that  any occasional case which
may occur at another season, however  similar to
the epidemic in character, is in its  nature essen-
tially distinct from it.  Morton (Pyretologia, p. 16,
&c.) and Torti (lib. iii.  cap. i.  p. 124,) have de-
scribed cholera  as appearing in an intermitting
form and curable by bark.
   The disease is placed in  the class fluxus and
order alvifluxus of Sauvages; in the class  neu-
roses and order spasmi of Cullen, and very ap-
propriately in the class cceliaca and order enterica
of Dr. Good.
   The following definition will probably comprise
every case really belonging to the genus cholera:—
vomiting, purging, spasms,  prostration and col-
lapse,  or any four of these symptoms occurring
simultaneously  or in  a succession more or less
rapid.*
   For practical  purposes it seems sufficient  to
consider cholera as divided  into two species, ordi-
nary cholera  and the epidemic or malignant dis-
ease ;  such deviations from  the common type of
 these  disorders as are occasionally met with being
 indicated in the course of the article; [after which,
 some  remarks will  be made on  cholera  infan-
 tum.]
   I.—Common, or Sporadic  Cholera.—Ordi-
 nary cholera may be thus defined:—vomiting and
 purging, the  discharges during great part of the
 course of the disease containing generally a large
 proportion of bile; pain in the stomach and  intes-
 tines ; spasms, especially of the  muscles of the
 abdomen and lower extremities, and prostration.
 If collapse  occur, it takes place after the disease
 has endured some time apparently, as an effect  of
 the great discharge, spasm, and irritation.
   Besides these distinctive  marks of the  disorder,
 there  is generally found great inflation of the sto-
 mach and bowels; the fluid vomited is frequently
 enormous in quantity,  consisting  at first of the
 food in the stomach, and subsequently of matters
 variously coloured from  light brown to dark green,
 and expelled with great force;  and the stools, the
 appearance of which indicates  during  the greater
 part of the course of the disease, the same redun-
 dancy of biliary secretion  as is  denoted by the
 matters vomited, are generally copiously and for-
 cibly  expelled, though  sometimes  sparingly and
 with difficulty.  The dark  appearance here attri-
 buted  to the discharges in ordinary cholera must
 be considered as generally applicable only to this
 disease as it occurs in our own and other temperate
 climates; for a white appearance of such matters
 had been remarked as an occasional circumstance,
 by  Celsus  and  various other  physicians,  in the
 warmer regions long before the occurrence of the
 epidemic which  has recently attracted  so  much
 attention.  At the commencement of the  attack
 the skin is generally warm  and dry ; but after a
 few hours its temperature falls  considerably below
 the standard of health,  and it  is bedewed with a
 cold  and clammy moisture.  The  tongue is dry
 and the thirst excessive;  the urine scanty and
 high-coloured;  the pulse  rapid,  and  generally
 small and irregular; and the spasms which affect
* This definition is modified from that of Dr. Mar a it* 
400
CHOLERA —[COMMON.]
the muscles of the  abdomen and  of the  inferior
extremities,  and occasionally those of the hands
and arms, recur at short intervals, and are attended
with great pain.  After the disease has continued
some time,  the  countenance  appears anxious,
ghastly, and shrunk; the voice is feeble and inter-
rupted ; the sense of exhaustion is  extreme, and
in severe  and  protracted cases  the  tendency  to
fainting is great and alarming.
   Ordinary  cholera in temperate climates is not
very often fatal;  yet it  is a  dangerous  disease,
and  one which requires  much  attention  on the
part of the practitioner.  The approach of death
is denoted by the  continuance  of  the vomiting
and  purging, especially of the latter; by hurried
breathing; a countenance either of a purple hue,
or pale, anxious, and contracted ;  a  feeble and
fluttering  pulse, and  coldness of  the extremities
and  surface  generally. Cessation  of the vomiting
and  purging ;  warmth of the skin ;  the pulse ap-
proaching the  surface with a diminution of its
frequency ; the restoration of a tranquil expression
to the countenance, and the recruiting of the pow-
ers of the patient from a state of  oppression and
exhaustion,  indicate recovery.
   It not unfrequently happens that for some days
after the subsidence of vomiting, purging, spasms,
arid  other violent symptoms  mentioned,  the pa-
tient feels some uneasiness in the epigastrium and
other parts of the abdomen, which is increased on
pressure.  The pulse is at the same time sharp
and  frequent; the tongue always  dry, and either
red and  glazed, or covered with  a  brown fur ;
there is  great  thirst with complete  inappetency,
and  occasionally nausea, and the bowels are gen-
erally costive, though they may be readily excited
to action by laxative medicine if the stomach can
be made to retain it, the  discharges  procured be-
ing usually of a dark  green appearance.   These
symptoms, which denote gastro-enteritis superven-
ing on the high degree of irritation of the lining
of the digestive canal, require diligent attention;
for some cases in  which they had been overlooked
have proved fatal, though the patients had previ-
ously emerged from a state apparently more urgent
and dangerous.
   Diagnosis.—The factitious disorder produced
by an irritating poison, and  the  epidemic species
of the disease, are the only affections of the sys-
tem  with  which there is any risk of our confound-
ing the form of cholera at present under discus-
sion.  The distinction from the latter affection we
shall endeavour to point out in a subsequent part
of the article.   Professor Christison  (Treatise on
Poisons, p. 93, et seq.) places some reliance  on
the respective  duration of cases  of  fatal  cholera
and of poisoning from the irritants,  as a  ground
of distinction between them.   He informs us that
death from irritant poisons is seldom delayed be-
yond two days and  a half, and frequently happens
within thirty-six hours, sometimes within  twelve
hours, or even less ; whilst death from cholera  at
any  time is rare, but within  three  days very rare
indeed,  though it  may  occur in twelve  hours.
This statement itself shows that the comparative
duration  of  these affections furnishes no  secure
mean* of distinguishing them; and our  experi-
ence tells us, besides, that death from cholera with-
u. ilv-pp days, or even in twelve hours, is much
less rare than this able writer supposes.  Another
discriminating test pointed out in the Treatise on
Poisons, the sanguinolent vomiting which attends
cases of poisoning, we fear is not  more tenable
than the preceding ; for though a rare, we  know
from observation  that it is not an unexampled ac-
companiment of cholera.
  Though these circumstances, the duration of
the disease when  fatal, and the  presence or  ab-
sence of sanguinolent vomiting, seem insufficient
to distinguish the two affections, yet the conclu-
sion to be arrived at is, that the diagnosis between
cholera and poisoning may in many cases be form-
ed from symptoms  alone;  and certainly, that no
observing practitioner would be long at the bed-
side of a patient who had swallowed an irritating
poison in  a dose likely to prove fatal, without dis-
covering that he had something different from na-
tural disease to contend with.   It is true that he
might not have evidence of the fact  sufficient to
establish it in a court of justice, but his convic-
tion would be such as to excite him to  an exami-
nation calculated to elicit  satisfactory legal  testi-
mony.  The sense of burning in the throat, ex-
tending thence down  the  oesophagus  to the sto-
mach, is dwelt upon by the sufferer in a way that
is never observed in  cases of cholera, in which
the patient complains  of intense pain, but  never
dwells upon this  burning feeling as  constituting
the chief source of his sufferings, though he may
acknowledge its existence if questioned.  Besides,
as Professor Christison justly observes, it is cer-
tain that the sense of acridity or burning some-
times remarked in cholera never begins before the
vomiting,  whereas in many cases of poisoning,
though certainly not  in all, it  is the first symp-
tom.  It may be remarked, too, that it is  often
stated by the sufferer  to have occurred either im-
mediately or shortly after the swallowing of some-
thing.
  Nature of the Disease.—The first effect  of
the application of the  cause  of cholera seems to
be a violent irritation of the mucous lining of the
stomach and small intestines, which is propagated
to the liver either by continuity along its ducts,
or by sympathy between organs whose actions are
so intimately associated.  Some writers, reversing
the order here stated, consider the liver as the part
first affected, and the  manifest disorder of the  di-
gestive canal to be the effect  of the derangement
of that organ.  The order first mentioned seems
more in accordance with the agency of the usu-
ally  assigned causes of the disease, with its phe-
nomena, the effects of remedies upon it, and the
appearances on dissection.   The irritation is ex-
tended, it  would  appear, not merely to the  liver,
but likewise to the spinal marrow;  at  least the
parts supplied with spinal nerves are the seat of
violent spasms.   The  state of the  heart's action
at the onset of the disease, before exhaustion can
be supposed to have resulted from the mere effect
of the  discharges, renders it  probable that it is
affected through  the  medium  of the ganglionic
nerves or  spinal  marrow.   Whatever view may
be taken  of the  structures primarily affected in
cholera, it seems  beyond all question that  those
we have enumerated are the parts principally con-
cerned in producing its symptoms.
  Appearances on Dissection. — When  the 
CHOLERA —[COMMON.]
40.
disease is rapidly fatal, there is no discernible le-
sion  of structure; but if death  occur after the
lapse of some days, and especially if it take place
from the gastro-enteritis which has been described
as supervening  on cholera, the mucous  lining of
the stomach and small intestines is found more or
less strongly injected.
   Causes.—This disease was supposed  by Sy-
denham to be peculiar to the month of August,
and it  certainly in this country occurs  more fre-
quently during  this  month  than  any other; but
it may be observed  at  any season of the year
when a warm atmosphere during the  day alter-
nates with a considerable degree of cold at night.
As might be supposed  from this statement, its
most frequent exciting cause is exposure  to  the
chill of damp or cold air after unusual heat.   On
the same  principle, drinking cold water when the
body is heated  has  occasionally produced  an at-
tack.  Cases occur, too,  in consequence of taking
food or liquid  calculated to irritate the stomach
and bowels.  Malaria has been supposed to  be  a
cause  of  the disease ; and this opinion derives  a
great degree of probability from  its appearing at
 the season when autumnal intermittents  and re-
 mittents prevail, and the fact that many cases of
 sub-continued  or slightly remitting fever, and even
 of ague,  have  been observed, which commenced
 with  symptoms identically  similar to those  of
 cholera, (Medical Essays, by J. Brown, M. D., p.
 38).  A  remarkable example of the malarious
 origin of the disease occurred at  a school at Clap-
 ham,  in  August,  1829.  A very foul drain, or
 cesspool,  was opened, and jts contents were thrown
 into a garden adjoining  the school.  A day or two
 afterwards one of the boys was  attacked, and in
 two days more twenty otbers out  of the total  of
 thirty.   The disease appears to have considerably
 resembled the  Indian epidemic, the evacuations
 being much less tinged with bile  than  is usual in
 the ordinary cholera of temperate climates.   Two
 cases terminated fatally.  It was held by the high-
 ly respectable  medical  authorities  assembled on
 the occasion, that the effluvia from the putrid mat-
 ter had produced the disease, (Searle on Cholera,
 and Orton, p. 415).
   Treatment.—The counsel ordinarily given is
 to defer  the employment of medicine for  some
 hours after the commencement of the disease, lim-
 iting our endeavours during this  period to the ad-
 ministering diluents, such as gruel, thin chicken-
 broth, beef-tea, barley-water, &c.; but even if the
 patient's  earnest  appeals  for relief would allow
 of this delay,  it seems  more  than  questionable
 whether  it would be justifiable; for  some time
 has generally elapsed before medical aid is obtain-
 ed, and the cases must  be  rare indeed in which
 more powerful agents than those  mentioned may
 not be employed at the  time of our  arrival, and
 are not, in fact, demanded.
   Opium is the remedy which, from its  well-
 known effects in other diseases,  would naturally
 present itself to the mind of the physician as like-
 ly to allay the  irritation  ; and it is in  reality the
 best which he  can employ.  In  mild  cases, it  is
 often  found to  be the only medicine required ; but
 in more severe attacks it may be advantageously
 conjoined with calomel,  the combination  of  these
 medicines having an excellent effect  in  allaying
    Vol. I. —51                       2i*
gastric and intestinal irritation.   In slight cases, a
grain of opium,  or  a proportionate  quantity of
laudanum, may be given every second hour till
relief be obtained.  In those which are more se-
vere,  two or three grains of calomel,  combined
with a grain of opium, may be given at the sa.me
interval till three or four doses shall  have been
taken; or, the calomel being administered in pill,
a draught containing a  proportion of  laudanum
or black-drop,  equivalent  to  a grain  of opium,
may be exhibited along with it.
  Subsidiary  measures  should  accompany  the
employment  of  these  medicines.  The diluent
drinks already mentioned should be given at inter-
vals to allay the urgent thirst of the patient, but
in small quantities, lest they excite vomiting. Hot
fomentations to the abdomen  are  well  calculated
to afford relief; and the patient, if not  much ex-
hausted, may remain for a quarter of an hour in
a bath of 100°, if it can be obtained.   It must he
observed, however, with regard to the warm bath,
that in the epidemic disease the most experienced
practitioners decline its employment where there
is much collapse, on account of the distress it oc-
casions, and,  indeed, from the positive mischief
arising from the  necessity of  removing the sick
from the horizontal  position: dry heat is now
generally preferred in those cases, and it will be
proper to keep this fact in  view in our treatment
of  the  ordinary species, when the exhaustion is
considerable.   A large blister to  the  epigastrium,
previously fomented with hot vinegar, is frequent-
ly  useful in relieving the vomiting  and internal
irritation ; or sinapisms are sometimes  advantage-
ously employed to produce the same effect more
rapidly.  Scalding the  epigastrium, or, as it is
called,  the warm-water blister, is the prompt mode
occasionally employed in the cholera of the east;
but there is reason  to  apprehend that it  would
prove abhorrent to the feelings of patients in this
 country, and would be deemed a needlessly severe
 treatment of ordinary cholera.
    Should there be considerable exhaustion, indi-
 cated by coldness of the skin and  feebleness of
 the pulse, diffusible stimulants, such  as brandy,
 ether, and  ammonia, should  be  given in small
 quantities.  Draughts composed of carbonate of
 magnesia, aromatic spirit of ammonia, compound
 tincture  of cardamoms, and laudanum, are fre-
 quently well  retained by the stomach, and have
 a  good effect  in  such  a  state.   Strong beef-tea
 may be given, if the stomach become tranquil, in
 small quantities at short intervals, alternately with
 brandy and water.
    General  bleeding  is  neither required nor per-
 haps admissible, in the  course of the symptoms
 of what may be strictly termed cholera in  a tem-
 perate  climate; but  even  during  such symptoms
 either  there is occasionally such permanent ten-
 derness of the epigastrium, perceived in the inter-
 vals of severe pain, vomiting, and  spasm, as in-
 duces us to  conclude that the irritation  of the
 digestive canal has passed  into inflammation ; or
 the glazed or furred state  of  the tongue, the in-
 tensity of the  thirst, the sharpness of the  pulse
 and general uneasiness of the patient, without trie
 existence of permanent  pain, may lead us  to the
 same conclusion.   In either case the  application
 of a dozen or eighteen leeches to the epigastrium 
402
CHOLERA —[EPIDEMIC]
will  be attended with much  benefit.   After the
leeching, a large  emollient poultice  may  be ap-
plied,  followed, on  the  total  subsiding  of the
oozing from the leech-bites, by the application of
a blister to the epigastrium.
   In  the  gastro-enteritis, described as  sometimes
occurring after the cessation of the actual  symp-
toms  of  cholera, general bleeding  may  be per-
formed to the extent  the patient's  strength will
admit, not only with safety, but with great benefit.
Leeches  and  blisters to  the abdomen, and mild
mercurials, particularly hydrargyrus cum  creta in
doses  of  three or four grains  every fourth hour,
till some affection of the mouth is perceived, will
be found the best subsidiary remedies.
   Cholera frequently leaves the patient in a state
of extreme  debility, which  should be  sedulously
watched, for persons have occasionally died sud-
denly, when supposed to be recovering from the
disease, apparently from exhaustion.   The hori-
zontal posture, and mild and nutritious diet, con-
sisting of sago with milk, beef-tea, or chicken-
broth, with bread or biscuit, animal-jelly, &c. are
the appropriate remedies.  If the  bowels are cos-
tive, they should be moved by enemata ; for all the
symptoms of  cholera have been reproduced, three
days  after their subsidence, by so  gentle  an irri-
tant to the digestive canal as a dose of rhubarb.
   We had proposed to ourselves to terminate here
all that it appeared to us necessary to say under
the present head ;  but we are bound towards the
profession to admit  that the details  which  had
been  laid before us, previously to the manifest ap-
pearance of the  epidemic disease in this  country,
through  the channels of medical journals, of spo-
radic  cases which occurred in various parts of
England during the autumn of last year (1831),
preclude  the  possibility of our hesitating  to ac-
knowledge  a perfect identity between  the group
of symptoms  in  some  of  those  cases,  and  the
symptoms of the  choleric  stage of the malignant
epidemic form in which  cholera has of late years
committed such ravages. The fullest  details are
given in several instances, and  by  persons of
 whose accuracy we  cannot have  the  remotest
doubt. Respecting a case in the seventh regiment
 at Hull, which proved fatal  on the 11th of August,
 after an  illness of sixteen  hours and  a half, and
 in which the  assemblage of symptoms held to be
 characteristic  of Indian cholera  were  so very
 strongly marked, we may state that the gentleman
 who forwarded the details to the journal in which
 they appeared has sent us  his name, and pledges
 himself  for *beir fidelity.  In this case there were
 the blue skin, the total absence of pulsation in the
 extremities for some time before death, the sodden
 appearance of the fingers,  the  coldness of the
 tongue, the change in the voice, and the suppres-
 sion of  urine, all which are so particularly dwelt
 upon by innumerable  authorities  as peculiarly
 marking the  cholera spasmodica.
   II.—Epidemic, or Malignant Cholera.—
 Long prior to the  appearance of the  present epi-
 demic in the Delta of the Ganges in 1817, and it6
 subsequent diffusion over so large a portion of the
 globe, extensive and  destructive  visitations of
 cholera had been noticed by various writers.  One
 of these, we learn, occurred in Europe at  the close
 of the seventeenth century;  but most  of them
originated  in  the  east, and limited their devasta-
tions to that quarter of the world.   The indefati-
gable Mr. Scott has quoted, from the Madras Cou-
rier of 1819, a letter, which suggests the opinion
that a description, though certainly a very obscure
one, of  a disease resembling that which now pre-
vails, is  to be found in a Hindoo work  of great
antiquity;  and cites instances of  the epidemic
prevalence and great fatality of cholera from the
time of Bontius, in 1629,  to the present century;
but the  description of these  epidemic visitations
has not always reached us in  so detailed a form
as to enable us to judge correctly of their identity
with what has been recently observed :  enough,
however, may be  gleaned  to prevent our denying
this  identity in some instances; indeed,  it is  im-
possible not  to be struck with the resemblance
which certain of the more accurately reported of
these examples—especially one which occurred at
Ganjam, in  1781 — bear  to  that  now  existing.
But this much seems certain, that, however cases
in previous  visitations  may  have  resembled  in
character  those of the prevailing disease, no re-
corded  epidemic  of cholera has equalled this in
the wideness of its diffusion  and the  amount of
its ravages,  or has  preserved  its character and
intensity so little influenced by climate and tem-
perature.
   The  question  of the  identity  of  the disease
which  now  prevails in Great Britain and on the
continent  of Europe,  and that  which  ravaged
Hindostan, having been settled in  the affirmative,
at least as regards certain  of their most important
practical points, by the various respectable physi-
cians who have witnessed both diseases, we may
assume that much  of the valuable  information
transmitted to us from India, respecting the nature
and treatment of the malady which raged  there,
is applicable to that which is now committing its
ravages in Europe.
   1.  Symptoms of Cholera in India. — The
 disease generally  makes its attack in the night, or
 towards morning, with vomiting so excessive, that
 the whole contents of the stomach appear to be
 discharged;  and  nearly  at  the  same time  the
 bowels  are copiously emptied, as  though all the
 solid matters  in the ihtestinal canal were evacu-
 ated.   In some cases  a watery purging  precedes
 the vomiting by some hours ; but  they more fre-
 quently occur simultaneously.  After  the  first
 copious discharge, the patient experiences a dis-
 tressing feeling of exhaustion and faintness, with
 ringing in the ears and  giddiness.  The  subse-
 quent discharges from the stomach and those from
 the bowels  do not differ from each other in ap-
 pearance,  excepting as the matters ejected from
 the stomach  may be tinged by medicines or other
 ingesta: they are generally watery, colourless, and
 inodorous, and are compared in their appearance
 to barley-broth, or more  frequently to rice-water.
 Sometimes they  are  like  milk, occasionally yel-
 lowish, greenish, like muddy water or yeast; but
 the «conjee-stools,"   as  they  are emphatically
 termed, which consist  of  albuminous  flakes float-
 ing in serum, or discharges of pure serum, are Qf
 the most frequent  occurrence.   The dejections
 sometimes take place without effort or uneasiness,
 but occasionally very forcibly, with simultaneous
 vomiting, spasm, and sinking of the pulse.   This 
CHOLERA—
[EPIDEMIC]
403
violent action of tbe alimentary canal is not of
long continuance, the powers of the system being
unable to support it:  hence the vomiting  and
purging generally cease some hours before death;
but in some cases a discharge of serum takes
place  from the  rectum  on any movement of the
body till the fatal close.
  In most cases, some time  after  the  commence-
ment  of this affection of the intestinal tube, but
in others previously to it, spasmodic contractions
of the muscles of the fingers and toes are felt, and
these  affections gradually extend  along the limbs
to the trunk. The spasms are imperfectly clonic
or  convulsive,  with infrequent relaxations, are
attended with great pain, and leave for some days
afterwards  a degree  of stiffness  in the affected
muscles.   The  pulse is  from the first small, weak,
and accelerated; and  after a certain interval, but
especially  on the  accession  of spasms, or  severe
vomiting, it sinks  suddenly, so as to be speedily
lost in the  external parts.   The  length of time
during which a patient  will live in this pulseless
state is remarkable.  In a case related by Dr. Kel-
lett, the pulse was gone within three hours from
the attack, yet the man lived twenty-two hours in
that state.  On  the cessation of spasm and vomit-
ing, and sometimes apparently from the exhibition
of remedies, the pulse will return in the extremi-
ties for a short  time, and again cease.   The  skin
is cold from the  commencement of  the disease,
and as it advances, becomes gradually colder, and
is covered either with a profuse sweat or a clammy
moisture.   The state of  its circulation and  its
insensibility are sometimes  strongly  denoted  by
the following  circumstances :  leeches  will not
draw blood from it; blisters and other vesicatories
will not act;  and even the mineral acids  and
boiling water produce no effect, and some patients
are not even sensible  of  their application.   In
Europeans the  colour of the surface is  often livid ;
the lips and nails present  a  blue tint; and the
skin of the  feet and hands becomes corrugated,
and exhibits a sodden appearance, as if from long
immersion in hot water.
  With these symptoms coexist violent pain  of
the intestines, with a  sensation of writhing  and
twisting  there; heartburn,  which  the sufferer
compares to a fire consuming his entrails;  exces-
sive thirst; anxiety, with inexpressible uneasiness
about the praecordia;  hiccup ; jactitation ; and,
notwithstanding the actual coldness of the surface,
and even of internal parts which are accessible to
the touch, the tongue for instance, a sense of heat
which impels the patient incessantly to throw off
the bed-clothes.   The breathing is much affected,
being performed either  more  slowly  than usual,
sometimes for instance, in the advanced stage, only
at the  rate of seven respirations in a minute,  or
the inspirations  are short and sudden, with violent
pain from  spasm  of  the  diaphragm;  the voice
being   feeble, hollow,  hoarse,  and   interrupted.
The eyes  are sunk in  their orbits ;  the  corneae
flaccid, the  conjunctiva  frequently suffused with
blood; the features of the face collapsed ; and the
whole  countenance wears  a cadaverous  aspect.
The secretions, those  of the skin  and  intestines
excepted, are generally suspended.  The functions
of the  mind are undisturbed almost  to  the very
last moment of  existence.
  The  approach of recovery is denoted by the
rising of the pulse, the return of heat  to the sur
face, inclination to natural sleep, diminution  or
cessation of vomiting, purging,  and  spasms, and,
after  an interval, the  re-appearance  of  bilious
stools, urine, and saliva.*
  Regarding the above as a picture of the general
type of  a  disease rather variable in character, we
shall proceed to relate the more striking deviations
from  the  ordinary form  which were  observed in
India.
  Instead of the  exceedingly sunk  state, there
was a marked excitement, with a  hot and  dry
skin, and a pulse of considerable force, in several
instances throughout great part of the course  of
the disease.   (Madras Reports, p. xxv.)   This in
some cases arose from  the early  exhibition  of
stimulants,  but in others  it  appeared to be  an
essential part of the disorder.  These cases yielded
most certainly and readily  to treatment;  and ■
hence, many of them having been subdued with-
out the occurrence of sinking  or debility, it was a
matter  of doubt whether this description  of dis-
order really belonged to the  epidemic; but that
it did so was placed beyond all question by some
of  the  more protracted  cases degenerating into
the ordinary low form.
    The most  fatal  variety of  tbe disease was
denoted by the slightness of the commotion in
the system  : there was no vomiting;  hardly any
purging,  perhaps there  were  only one  or two
stools ;  with no  perceptible spasm; no pain  of
any kind; a mortal  coldness with  arrest of the
circulation coming on  from the beginning, and
the patient dying without a struggle within three
or  four hours.  Several instances were heard of,
at  Hoobly  and  other places, of natives  being
struck with the  disease, whilst walking  in the
open  air, and who, having fallen down, retched a
little, complained of vertigo, deafness, and blind-
ness,  and expired in a  few minutes.   Mr. Scott
informs us that this most deadly form  of the dis-
ease frequently manifested  itself in local epidemic
visitations, which  were  often observed in India,
all  the  cases  occurring at the  same time  in a
given district partaking of the  same peculiarity of
character.
  The collapsed form of disease first described is
that which  has been most frequently observed.
In  fatal cases  its  duration varies from  four to
eight hours ;   whilst in those  which terminate
favourably, a result often apparently due to early
medical assistance, the patient may be restored to
perfect  convalescence in a period  ranging  from
twenty-four to forty-eight  hours.  But in many
cases considerable disturbance of the  system in-
tervenes between  the  period  of  collapse  and
restoration  to  health,  or  this  disturbance  may
itself cause death.  The Indian reporters mention
two forms of  this disorder.  In  the one,  with
some excitement in the system, the bowels con-
tinue to discharge, for  many days, first  brown
and watery, then  dark,  black, and pitchy stools,
sometimes with blood, and with peculiar pains in
the bowels, particularly in the rectum. The othc

  *  Scott's Reports  on the Epidemic Cholera : Avder^on
on Cholera, E. M. and S. Journal, vol. xv. p. 324; Uiris-
tie on Cholera and the Pathology of Mucous Membrane*
Annesley's Sketch of the Diseases  of India, &.C. 
404
CHOLERA —[EPIDEMIC]
 a distinct febrile form, we  shall describe in the
 language of the Bengal Report:—
   "The  fever which almost  invariably attended
 this second  stage of the disease (in Europeans),
 partook much of the nature of the common bilious
 attacks of these latitudes.   There was a hot dry
 skin, a foul deeply-furred tongue, parched mouth,
 thirst,  sick  stomach, restlessness, watchfulness,
 and quick variable pulse, sometimes with delirium
 and stupor,  and other marked affections of the
 brain.  Generally, when the disorder proved fatal
 in this stage, the tongue, from being  cream-co-
 loured, became  brown, and   sometimes black,
 hard, and more deeply furred  ; the teeth  and lips
 were covered with  sordes ;  the state of the  skin
 varied, chills alternating  with  heats ;  the pulse
 became extremely quick,  weak,  and tremulous ;
 hiccough, catching of the  breath,  great  restless-
 ness, and deep moaning succeeded ; and the pa-
 tient soon sunk, incoherent  and insensible, under
 the debilitating effects of low  nervous fever,  and
 frequent, dark, tarry, alvine discharges."
   A consecutive fever, similar  to  this, we learn
 from Drs. Russell and Barry,  is of more frequent
 occurrence in Russia  than in India.  The follow-
 ing description  of it  we  owe to these gentle-
 men : —
   " After the blue cold period  has lasted  from
 twelve to twenty-four, seldom  to forty-eight hours
 or upwards, the  pulse  and external heat begin
 gradually to return,  headach  is  complained  of,
 with noise in the ears, the  tongue becomes more
 loaded, redder   at  the  tip  and  edges, and  also
 drier.   High-coloured  urine is passed with  pain
 and in small quantities, the pupil is often dilated,
 soreness is felt on pressure over the liver, stomach
 and belly; bleeding by the lancet  or leeches  is
 required.   Ice to the head gives great relief.   In
 short, the patient  is now labouring under a  con-
 tinued fever, not to be distinguished from ordinary
 fever.  A profuse critical perspiration may come
 on from the second or  third day,  and leave the
^sufferer convalescent;  but  mucb more frequently
 the quickness of pulse and  heat of skin continue,
 the tongue becomes brown and  parched, the eyes
 are suffused and  drowsy ;  there is a dull flush
 with stupor  and heaviness about the countenance
 much resembling typhus, dark sordes collect about
 the lips  and teeth, sometimes the patient is  pale,
 squalid, and low, with  the  pulse and heat below
 natural,  but, with  the  typhous  stupor, delirium
 supervenes,  and  death takes place from the fourth
 to the eighth day, or even later, in the  very in-
 dividual,  too, whom the most assiduous attention
 had barely saved in the first  or cold stage.   To
 give a  notion of the importance  and danger of
 cholera fever, a  most  intelligent physician, Dr.
 Reimer,  of  the Merchant-Hospital,  informs us,
 that  of twenty cases treated  under his own eye,
 who fell  victims to the disease, seven died in the
 cold stage, and thirteen in the consecutive fever."*
   The same gentlemen  state, as the result of
 their observation, that the following are the points
 of difference between the European epidemic and
 that of India :—
   " First, the  evacuations, both  upwards   and

   ♦Report of Drs. Russell and Barry to C. C. Greville,
 Esq., published among other papers, by authority of His
 Majesty's  Most Honourable Privy Council.
downwards, seem to have been  much more pro-
fuse and  ungovernable  in the Indian than in the
present cholera,  though  the characters of  the
evacuations are precisely the same.
   " Secondly, restoration to  health from the cold
stage, without passing through consecutive fever
of any  kind, was by far more frequent in India
than  here (St. Petersburgh), nor  did  the  conse-
cutive fever there assume a typhoid type.-)-
   " Thirdly, the proportion of deaths in the cold
stage, compared  with those  in  the  hot, was far
greater  in India, according to Dr. Russell's ex-
perience, than here.
   « Fourthly, the number of medical men and
hospital attendants attacked  with  cholera during
the present epidemic, in proportion  to the whole
employed, and to other classes of society, has been
beyond  all comparison greater here than in India
under similar circumstances."
   Dr. Kier of Moscow, gives the following de-
scription of the consecutive or secondary morbid
state.   " A second ordeal now begins, sometimes
as severe, and frequently not less fatal, though
more slowly so,  than the first;  this  is probably
the effect  of the morbid changes  which have been
induced during  the  first  period of the disease.
The appearance of the complaint is now entirely
changed,  insomuch that one who had not  seen
the patient during the first period, or been told of
the symptoms,  could not possibly know that he
was suffering from the epidemic.  I have observed
the disease in  this, its second period, to assume
four forms : the  first, an inflammatory, or rather
sub-inflammatory state of the stomach and bowels,
most frequently the latter, sometimes conjoined :
the second, inflammatory irritation of the lungs,
with pain of the chest, cough, viscid expectora-
tion, and  fever, appearing as  a critical metastasis
of the disease : the third, bilious or bilio-nervous
fever, with suppuration of the parotid glands; in
one case, with axillary suppurating bubo, towards
the end of the fever, an inflammatory irritation of
the lungs took place, ending  in vomica : and the
fourth,  a congestive sub-inflammatory state of the
brain and spinal chord.  This last, as was natural
to expect  from the nature and  seat of the affec-
tion, proved  by far the most  dangerous and  most
frequently fatal form of the second period :  it ap-
peared generally to supervene after the purging,
vomiting, and cramps had been relieved, and the
external heat in  some degree restored ; the pa-
  t If we compare the symptoms attributed to this con-
secutive fever by Drs. Russell  and Barry, with those
quoted from the Bengal Reports, the difference, between
this stage of the respective epidemics does not appear
very striking: the epithet typhoid seems almost equally
applicable to both.  Varieties were observed in the dis-
ease as it prevailed in the different Indian  presidencies,
and likewise between that which existed in Hindostan
and Ceylon, perhaps as considerable  as those now ob-
served by these  intelligent physicians.  In regard to
what is stated in the extract referred  to, relative to the
greater frequency at Petersh.ir<.'li of the secondary "ty-
phoid," or, as more commonly designated in India, low
biliary symptoms, we confess that we observe a discre-
pancy when we read a subsequent part of the same Re-
port, in which Drs. Russell and Barry stale, "Convales-
cence from cholera has been rapid and perfect here, as is
proved by the following fact. The Ministers of the In-
terior had given orders that all convalescents, civil a«
well as military at the General Hospital, should be de-
tained fourteen days.  We inspected ahout two hundred
of these detenus some days back, with Sir J. VVylie, and
found them in excellent health, without a single morbid
sequela." 
CHOLERA —[EPIDEMIC]
405
dent complained of pain in the back, between
the  shoulder-blades, or in some other part of the
spine, sometimes along its  whole tract;  he ap-
peared sleepy to such a degree that at first I was
disposed to attribute this state, in part at least, to
the  effects of the opium given in the first  period.
But I was soon convinced that the cause  of this
symptom, and of another strongly characteristic
of tbis form of the disease, namely, the filling of
the  vessels of the sclerotica with red blood, was a
congestive sub-inflammatory state of the brain and
spinal chord.  This striking symptom  at first be-
gan to show itself in the inferior part of the globe
of the eyes; it gradually increased, and little  by
little reached the upper part, while the eyes turned
upwards, exposing  the lower part gorged  with
blood.   The state of the patient generally ended
in a complete coma, and proved fatal a few hours
afterwards."
  Besides the various and  appalling  symptoms
which indicate general derangement  of the action
of  the solids, there are appearances in the blood
drawn during the collapsed stage, showing that
the fluids feel the influence of this formidable dis-
ease.  These appearances are very uniformly ex-
pressed  by  the  terms dark, black,  or tarry, in
regard to colour, and by thick,  ropy, syrupy or
semi-coagulated, in respect to consistence.   This
change in the condition of the circulating fluid is
fully proved to be in the ratio of the duration  of
the disease; the  blood at the commencement
seeming to  be nearly or altogether  natural, and
more or less rapidly assuming a morbid state as
the malady  advances.  This condition was less
conspicuous in  cases  of cholera ushered in  by
symptoms of excitement, than where  the collapsed
state of the system had occurred early;  and in
certain rare  cases it was not observable at all, and
the blood flowed readily from the vein ; but the
reverse was  the fact, both with  respect to its con-
dition and  the manner  of  its  flowing from the
arm, in an  immense  majority  of instances.  In
general,  after  a  certain  quantity of dark,  thick
blood had been  drawn, its colour became  lighter,
its  consistence less thick, and  the circulation  re-
vived, such appearances always affording grounds
for  a proportionably favourable prognosis.  There
is some discrepancy in the  accounts transmitted
to us of the mode in which this diseased blood
coagulates.   In  some instances, we  learn, the
coagulation  is rapid, whilst in others  it is slow
and imperfect.   Reporters are  unanimous in de-
claring it deficient in serum, and destitute of the
buffy coat.  The latter is occasionally observed
in  cases attended with re-action, in which the
blood is  not black and thick.   (Madras Report,
p. xxx. &c.)
  The discharges from patients suffering under
this disease  were subjected  to experiment by Dr.
Christie.  The  secretion consists of two  sub-
stances, the one a transparent  serous fluid, the
other an opaque  coagulum ; the former perfectly
soluble in cold water,  the latter quite insoluble.
These matters being  submitted to the action of
re-agents, the fluid part was  found to be  pure
serum, and  the  coagulated  portion  fibrin.  The
secretion, therefore, as  the author remarks, has a
composition similar to that of the blood deprived
of  its colouring matter; but  the serum is  in
much larger proportion to the fibrin than in that
fluid.
  Chemistry has been occupied in researches into
the composition of the blood and of the secretions
in this disease since it has extended  into  Europe.
Mr. Herman, of St. Petersburgh, who regards free
acetic acid as an essential constituent of the blood
when in  a healthy state, finds a deficiency of it
in that of choleric patients.  This gentleman, like
our Indian practitioners, has observed  that  the
crassamentum  bears  a larger proportion to  the
serum  in  this  disease than in  health ; and this
increased  relative quantity of crassamentum was
found to  be in direct proportion to the intensity
of the  disease.   The  fluids voided  by stool and
vomiting contained, he informs  us, besides water,
some acetic acid, a small quantity of osmazome,
salivary matter, butyric acid  and mucus.  They
very much resemble gastric juice, but do  not con-
tain any  free  muriatic acid.  In the  alvine dis-
charges, the quantity of butyric acid  is greater
than in the fluid voided  by vomiting ; and they
contain, besides, some albumen, a fetid, oily mat-
ter, and a small admixture of bile.*
   2. Character of  the epidemic as it ap-
peared in Sunderland in 1831. — Thus  far
our  account of this formidable malady has been
derived from  the very valuable mass of informa-
tion with  which we  have been favoured by  our
medical brethren in India, and  the  many intelli-
gent men who have witnessed its ravages on the
continent  of  Europe.   Circumstances  having
brought it under our own observation,  we shall
endeavour to convey  succinctly  to the  reader the
results  of our  experience, prefaced  by a few  re-
flections on the character and designation of the
disease, which  this experience has suggested to  us.
   A question  has been repeatedly discussed, but
without having been  so  far  settled  as either to
lead the profession to feel satisfied with the name
first given to  the disease, or to adopt  a  desig
nation more consonant with its  nature,  viz.— can
it properly be  considered  as belonging to  the
genus cholera ? or is its character so much more
closely related  to that of fever as to render  it  ad-
visable, consistently  with accuracy  of arrange-
ment and precision  of nomenclature, to  place it
among febrile disorders, and give it a designation
more corresponding than its present  one  with  its
new nosological position.   The vomiting,  purg-
ing, spasms, and prostration which are generally
considered  as  tbe   pathognomic symptoms  of
cholera, belong equally to a certain  stage of this
disease as to the ordinary form; and, in  addition
to this argument, it  may be  urged that only a
strong affinity  could have led men so  intelligent
as our Indian practitioners unanimously to  desig-
nate it by the term cholera.   It  is true,  that if we
limit our  view to one stage only of the  disease,
the former reason is forcible ;  but if we embrace,
as we ought to do, all its parts as we witness them
in  Europe, — if we  consider that  the  choleric
symptoms, if not fatal, prove but the commence-

  * Letter  to Dr. Todd, (Medico-Chirurgica.  K«>.ew,
July, 1831,  p. 285.)
  A specimen of the intestinal discharge from a thud
three years old, labouring under the  disease,  with which
we furnished M.  Magendie when he visited Sunderland
was analysed by that gentleman  ; and he informed  uw
that it contained albumen and mucus, and was alkalint 
406
C H O L E 1A — [ E P I D E M I C.]
ment of a series of changes to which a y one
who witnessed them alone would give the appella-
tion of fever, and which men of great experience
in the disease have declared they could not dis-
tinguish  from  typhus — if  we  observe, too,  that
long before this epidemic excited attention, symp-
toms strikingly resembling  those of cholera had
been observed to form the initiatory stage of cer-
tain malignant fevers,* — we are disposed to ad-
mit that  it is in reality a fever,  and  that to desig-
nate  it  merely cholera  is to  take a  part for the
whole, and to give  to the inexperienced, as far  as
a name can give it, an  erroneous idea of the dis-
ease.  At the same time it  would be advisable to
mark its relation, a relation which it unquestion-
ably possesses, to the disease from which it is dis-
sociated,  and  to  apply to  it  the trivial epithet
choleric.   Consequently with  these  views,  we
should  advise that the name  suggested by Dr.
Johnson, epidemic choleric fever,  be  in  future
adopted  as its designation.
   The argument against this change derived from
the  universal  employment of the other name  by
our Indian practitioners, is  not of much force;
for it is manifest, from many circumstances, that
in Hindostan, the  disease, in the majority of in-
stances,  consisted  of the cold  stage only,  many
reporters not at all adverting  to the consecutive
fever;  and Mr. Jameson  alone, in the  Bengal
Reports,  treats of  it at any considerable length.
So rare indeed was it, that  we  have met with In-
dian physicians of no inconsiderable  experience
in the disease, whose observation it had  escaped
altogether.   It should be remarked, too, that Mr.
Jameson declares the febrile stage  to  have  been
rare  and slight among natives in general;  but
that it  frequently occurred in Europeans and
natives  of robust  and  athletic  make.  It would
appear, that, in proportion  as the disease has  re-
ceded from its original source,  it has been under-
going more  and  more  a  transmutation into  a
febrile character.   Drs. Russell and Barry, it will
have been remarked, state that restoration to health
from the cold stage, without passing through con-
secutive  fever of any kind, was by  far more fre-
quent in India than at St. Petersburgh,  a  state-
ment which, while it  asserts  the  increased  fre-
quency  of fever, certainly implies that restoration
to health sometimes takes place without its occur-
 rence.   Now we can positively assert that we have
 not met with  a single case in  England, in which
fever did not intervene between the  choleric or
 cold stage and restoration to health;  and the  re-
 sult of inquiries we have addressed to individuals
 the most observing  and most familiar with the
 disease in this country, has proved that their ex-
 perience has coincided with our own.   It is true
 that in  some cases this fever has been  slight, but
 the choleric stage  has been so likewise; for  we
 have always observed a correspondence in inten-
 sity between these stages.
    Were we  to attempt a  definition of epidemic
 choleric fever, the  following, according to our ex-
 perience, would  comprise  its distinctive symp-
 toms.
    After watery diarrhoea, or other generally slight
   * For  further information on this point consult  Dr.
 Negri's Letter to Dr. Barry;  Morton, Pyretolosin,  pp!
 16. 33, 81 ; Torti de  Febribus, lib.  iii. cap. i. p. r->i • and
 Med. Essays, by J. Brown, M. D. pp. 37-30.
indisposition, vomiting and purging of a white or
colourless fluid, violent  cramps, great prostration
and colIapse,f  the last  occurring  simultaneously
with  the vomiting  and cramps, or shortly after
them.   Should the patient survive the  last train
of symptoms,  a  state  of excitement  and  fever
supervenes.
   We  can convey  a  correct idea of ihe disease
only by dividing it into three stages, the incipient,
the cold or choleric,  and the febrile .-  the division
is a natural one,  according with the character of
the disease.
   1.  Symptoms of the  Incipient Stage.—In
an immense majority of instances, diarrhoea has
been  the prominent symptom of this stage.   Lan-
guor  and  lassitude, and occasionally nausea and
vertigo coexisted with the disorder of the bowels,
and sometimes certain  of these  symptoms may
have  appeared without  it; but its  occurrence has
been  so common,  that we  have  treated  few cases
in which it has not preceded the more formidable
symptoms.  On examining the discharges, if we
have  an opportunity of doing so shortly after the
occurrence of  the diarrhoea, they will be observed
to be fcecal and bilious, but we shall find that they
subsequently bear the  serous character of those
which occur after the choleric stage is fully form-
ed ; they are passed copiously and without much
griping;  the  feeling  of  debility  which  attends
them is great,  and this diarrhoea is so exhausting,
that we have  met with patients,  especially those
advanced  in life, in whom a  considerable degree
of collapse had  occurred,  with  a  feeble pulse
scarcely exceeding  fifty, before the accession of
vomiting and  cramps.  The natural tendency of
this  purging,  is, we  believe, to  pass  into the
choleric stage; but the transition has frequently
occurred shortly after  some dietetic error, either as
to  quantity or quality of food, or after exposure
to cold.  The commencement of the purging has
sometimes  preceded by  several days the accession
of the choleric stage, and occasionally only by
eight or ten hours; but forty-eight hours has been
its mean duration, calculated from  a great number
of instances.  We  have dwelt the more on this
incipient stage from  a conviction, the result of
considerable observation of the disease, that sub-
sequent symptoms  might often be prevented, and
life preserved, by  the early and  appropriate  treat-
ment of the diarrhoea.
   [The  premonitory  symptoms,  consisting  of
more or less  derangement of the digestive  func-
tions, with diarrhoea to a greater  or less extent,
were generally termed cholerine.   The appella-
tion  was  also given  by  some, both to the pre-
monitory and  to the incipient stage.]
   2.  Symptoms  of  the  Cold or  Cholcrie
 Stage*—Our description will be more intelligible
 if we divide into two periods this very important
 stage, which has in truth given  its  name to the

   t By collapse,  in this definition, is meant the feeble-
 ness or almost  the  arrest of the circulation ; the death-
 like appearance, the coldness, shrinking, and occasional
 blueness of the  surface, which may in other diseases be
 observed after they have existed some time, and as the
 powers of life  are passing away; but which occur in
 what we shall call  the cold or choleric stage of the epi-
 demic, in a short time after its commencement, as though
 they  formed an essential part of it.   The degree and
 early accession  of this collapse, and the white discharge
 are the only distinctive marks that we are aware of be-
 tween this stage of the epidemic and ordinary cholera. 
CHOLERA—[EPIDEMIC]
40?
disease, and, by its fearful symptoms, has engross-
ed such  general attention, tbat the facts of its
being but part of a series of changes has been too
often lost sight of.
  First period.—The time of invasion has been,
as in India, in a great majority of instances, from
two to four o'clock in the morning.  The patient
is attacked with uneasiness of the stomach, occa-
sionally amounting  to  pain, to which speedily
succeeds vomiting of the characteristic fluid so
frequently described; and,  if diarrhoea  have pre-
ceded, which  in  almost all the cases  that have
fallen under our observation has been the case, a
purging of the same fluid, the fcecal contents of
the canal having been  previously expelled.   The
vomiting  is rarely full and effectual,  consisting
rather of apparently  unsatisfactory retchings than
of a full discharge of the contents of the stomach;
but sometimes these contents are expelled forcibly,
as if squirted  from  a  large syringe.  The dis-
charges from the bowels are occasionally scanty,
but  much more  frequently they take  place copi-
 ously  and  forcibly.   Simultaneously with the
 vomiting, or not unfrequently before  this symptom
 has occurred, cramps take  place, and the agony
 which attends them constitutes great part of the
 sufferings of the patient, who incessantly entreats
 that  friction  may be  applied  to  the  parts they
 affect.  However soon our visit may be made, the
 pulse will generally be found to be feeble and fre-
 quent ; the  skin in point of heat below the heal-
 thy standard ; the countenance  shrunk, and, if not
 livid, pallid;  and the respiration hurried,  if not
 checked,  as  it frequently  is,  by spasm of the
 diaphragm and intercostal muscles.  The circula-
 tion  sinks  remarkably, and sometimes  appears
 momentarily to cease, on every  occasion of severe
 vomiting or spasm.
   Second period. — The   mean duration of the
 preceding period varies from about eight to twelve
 hours;  the  vomiting  and  spasms then  either
 totally subside or recur at much longer intervals,
 and the patient sinks into  a state of extreme col-
 lapse.  The pulse at the wrist  is scarcely or not
 at all perceptible ; the surface is universally moist
 and cold, excepting as heat is imparted from with-
 out, for the  instant that the hands  or other parts
 are exposed,  they become of  an  icy coldness;
 blueness, if it exist at all,—but it is by no means
 an uniform  symptom,—is now conspicuous on the
 face  and  hands, which last have the shrunk and
 soddened appearance so generally described ; the
 tongue is moist,  and, if not actually cold, at least
 cooler than natural;  and the voice  is of  that
 mingled huskiness and feebleness  which strikes
 the ear  so  peculiarly.  In this condition there is
 little suffering, excepting from the sense of weight
 and  oppression  at  the praicordia,  of which the
 patient complains much;  for even should spasms
 occur, they are  now too feeble to excite  much
 pain; the respiration is slow; the  conjunctivas,
 especially in  their inferior hemisphere, are fre-
 quently injected with  dark-coloured  blood; and
 the insensibility of the stomach is  so  great, that
 the most powerful stimulants may  be  given and
 retained without the organ being apparently more
 sensible of their presence than  if it were a lifeless
 pouch.  The urine is suspended  throughout the
whole course of a choleric stage so intense as we
have described.
  However hopeless such a  state might appear,
we have seen more than one patient emerge from
it by the powers  of the  constitution, to have  a
faint chance for life  in  a very bad form  of fever,
after all the efforts  of art had  proved ineffectual
for bringing on reaction.  We have seen this ap-
parently spontaneous  transition  into the febrile
stage take place after the patient had remained for
many hours without any perceptible pulse at the
extremities.
  Premising that the danger in the cold stage, and
the degree and malignancy of the subsequent fe-
ver, are in proportion to the  collape which is ob-
served in this  stage, we shall  depict  one of the
lighter cases which occurred during the epidemic,
remarking that the shades of intensity in the dis-
ease are so infinite  that its  intermediate degrees
must be supplied by clinical observation.
  In one  of  the  milder cases extreme  collapse
does not take  place.  Whether by the powers  of
the constitution, or the remedies employed, there
is a subsidence, after a  period varying from eight
to twelve hours, of the cramp  and diarrhoea ; the
patient becomes calm and composed, but appears
rather low and sunk ;  the stomach remains irrita-
ble, occasionally retaining,  occasionally  rejecting,
food or medicine administered ; the  skin becomes
of a moderate warmth, but yet is cooler than na-
tural, and a good  deal of adventitious heat is re-
quired ; the pulse emerges to a condition of mod-
erate force, without much  frequency, being pro-
bably about  eighty, and  soft; the urinary secre-
tion, if it has been suspended during the spasmo-
dic period, which it is  not  always in the milder
cases, is restored ;  after the  lapse of a few hours,
should  vomiting occur, bile  is perceptible in the
matters vomited, and, generally by the assistance
of calomel or other laxatives, bilious stools are
discharged.
   The transition from  such a case is  into a mild
inflammatory fever, generally with some  affection
of the head ;  from which the patient recovers  in
a few  days,  by measures to be  subsequently ad-
verted to.
   3.  Symptoms of the Febrile Stage.—The
preceding stage, in most instances, makes  a very
gradual transition into the present one.  After
the  patient has remained in  the collapsed state
probably for a considerably longer time than the
medical attendant expected, some degree of warmth
will be found returning to the surface, which  for
a variable period, perbaps  for a  couple of days,
has been  almost  of icy coldness; and  the pulse
is proportionably developed, being very percepti-
ble at the wrist, generally about eighty,  and soft;
the vessels of the  conjunctiva gradually become
distended with blood ;  or if those of the infeitor
hemisphere have been so during  the stage of col-
lapse, the distension now diffuses itself over the
whole membrane; the patient, who on his attcn
 tion being roused is perfectly sensible, comp,ain»
of  severe pain in the  head, of a sense of giddi-
 ness, and that the light distresses his eyes.  The
 tongue in this early stage is clean and moist; the
 bowels  are readily acted upon by medicine, and
the discharges are feculent, and tbough somewhat 
108                          CHOLERA— [EPIDEMIC]
clayey, contain a proportion of bile ; but the uri-
nary secretion is sometimes either not restored, or
is considerably deficient for a day or two after the
establishment  of  fever.   In  the progress of  the
fever the tongue becomes black, and sordes  accu-
mulate about the teeth; the eyes  become  more
and more injected;  the intellect more and  more
torpid, though still the patient  can be roused to
answer questions, and even may make one or two
sensible remarks on his condition ; but the instant
the conversation ceases, the eyes are turned  up in
the orbit, exposing through the half-closed eyelids
tbe red sclerotica, and the patient is in a state of
profound  stupor  : the urinary secretion  is  now
established, and the urine, which at first was dark-
coloured and cloudy, is now limpid and pale; the
alvine discharges are darker coloured than at first;
and throughout the disease  there  is  a deficiency
of vascular action and of temperature, which we
have not observed to the same extent in typhus or
any other fever.   However  flushed  the  counte-
nance may appear, and it is often very considera-
bly so, the temperature of the surface is below the
healthy standard, and we have not  often  found
the pulse above ninety.  Typhoid is not an inap-
propriate designation  of the  condition  we  have
endeavoured to describe ; but we  think that an
individual who had once watched the progress of
such a case would run no risk of confounding  it
on future occasions with typhus;—the deficiency
of vascular and calorific power ;  the peculiar vas-
cularity  of the eye ; the absence of subsultus and
muttering delirium, (for though delirium occasion-
ally occurs during night, the condition of the in-
tellect is throughout  much more one  of  torpor
than of irregularity,) would be the marks by which
he would discriminate the two affections.
   The duration of  such a febrile stage as we have
described is from a week to ten days.   Its  termi-
nation has been in  a considerable majority  of in-
stances,  which have fallen under our  observation,
fatal.  The brain has appeared to us  to be the
organ mainly affected, and by this  view our treat-
ment has been chiefly guided, though at the same
time the condition of the intestinal canal has not
been  neglected.
   In another form, and one which supervenes on
a minor degree of collapse than the preceding, tbe
symptoms do not differ from those described above,
excepting that there are indications of greater ex-
citement, more warmth of surface,  and more force
and frequency of pulse. Depletion could be more
freely practised, and it was altogether a more tract-
able form of disease.
   Tbe mildest and most tractable type of the fe-
brile  stage was denoted by symptoms of general
but moderate excitement with  epigastric pain on
pressure, headach, and giddiness ;  the tongue be-
ing at the same time either clean, with a disposi-
tion to become dry and glazed, or slightly white
and furred ;  the  skin warm ; the pulse free  and
forcible ; the urine high-coloured,  and the  thirst
considerable.   In such a case there is little  or no
confusion of thought  or  delirium, and  the eyes
are not injected.   We need  scarcely remark  that
examples of this mild  and  tractable type  of the
 febrile  stage  occurred  after a  choleric  stage, in
 which the symptoms of collapse had been incon-
 siderable., in wbich the urinary secretion had not
been suspended, or which  had  not always beeh
attended with vomiting,  a  symptom  occasionally
wanting in slight cases.
  The writer met with but one example of con-
siderable affection of the thoracic organs, and this
occurred in  a case  in  point of general  character
not unlike the form last described, though some-
what more  collapsed.  The  affection was  bron-
chial, and was relieved by  a copious expectoration
of very dark-coloured sputa,—the patient recover-
ing.
  In the preceding sketch  of the  febrile stage, it
will be understood  that, as in the case of the chol-
eric stage, we have not attempted  to depict all the
various shades of intensity in which the disease
manifested itself.   The  extremes  are given :  to
have essayed to describe all the intermediate de-
grees would  have swelled the article  beyond rea-
sonable limits, and would  have proved  a burthen
to the memory of the reader, rather embarrassing
than beneficial at the bed-side.
   The varieties in the different stages which we
have left to  be  discerned  clinically by the reader
were, it ought to be remarked, essentially the same
in character  with the forms we have depicted, dif-
fering only from them and each other  in  shades
of  intensity  more or less minute; but there were
cases  observed  in Sunderland, as in   India, of
which the character constituted so considerable a
deviation from the ordinary type, that our descrip-
tion would be incomplete did we pass them unno-
ticed.
   In one such deviation from the  usual type, the
discharges were bilious during the choleric stage,
which, in fact, could not be discriminated from an
attack of ordinary cholera ;  a mild and tractable
form of fever ensued, and  the  patient  recovered.
One case of this kind occurred under the follow-
ing circumstances.  The  wife  died of  what was
then designated  malignant cholera.  The order
for  prompt funerals  did not at that time exist;
and on tbe day of her interment,  three  days  after
her death, the husband  sickened  of the form of
disease we are now describing, and recovered after
a few  days of fever.
   We witnessed a solitary example  of a form of
disease which has  been  particularly  described by
Mr. Orton,  as  being occasionally  intermingled
with the customary type of the malady in India.
In  our case there were trismus, and spasms of the
muscles of the throat so violent, that, till  they
were allayed by bloodletting, swallowing was im-
practicable ;  and when it  could be performed, it
was done with  an effort  resembling  that  with
which a patient in hydrophobia swallows water,
after having, by a strong mental effort, brought
himself to make the attempt in spite of his abhor-
rence  of it.   It ought to  be  remarked,  however,
that there was no dread  of water,  nor any charac-
teristic symptom of hydrophobia—the resemblance
was merely in the manner of  swallowing.  The
patient was  in  an excited state  throughout the
disease, which was of twenty-fours' duration, till
within two hours of death, when collapse occur-
red.   The complaint  commenced with vomiting
and purging; tbe matter vomited we were inform-
ed  was colourless; that  discharged by purging
we  learned  was at first rather yellow; but the
intestinal discharge which we saw, after the com- 
CHOLERA—[
EPIDEMIC]
409
plaint had lasted some hours, was colourless  and
mucous.   This being a solitary case  of the kind,
and fatal in the stage which we considered as cor-
responding with the choleric stage of the ordinary
type, we had no opportunity of ascertaining whe-
ther any or what form of fever would ensue.
  3. Prognosis.—The danger of the disease  is
in all cases, we believe, to be estimated from the
degree of collapse attending the cold or choleric
stage.  In India, it was remarked that the cases in
which the spasms and vomiting  were  the most
violent were by no means fraught with the most
peril, and  what we have seen of the  disease ena-
bles us to  bear testimony to  the accuracy of the
remark; for when we have heard attendants ex-
ulting in the cessation of the spasms and the fa-
cility with which the stomach  retained medicine
or food, and have felt at the same time the pulse-
less wrist and the cold and clammy hand, we have
seen in  these  apparently favourable  omens only
the natural progress of the  disease  from  a  bad
condition to one still worse.  Whether we are  to
dread a fatal result in the cold or the excited stage,
the intensity and duration of the collapse in the
former of  these stages are the measure of the  dan-
ger ;  for if the patient die  in this stage, he  dies
of collapse, and if he survive it and  pass into the
state of fever,  the character of this fever is malig-
nant and dangerous in proportion to  the same col-
lapse.
   4.  Diagnosis. — From ordinary cholera the
cold stage is to be distinguished, as  it appears  to
 us, by the peculiar  character of the  discharges,
which has been sufficiently  dwelt upon, and by
the degree of collapse and its early occurrence.
 Cases have been adverted to,  which, at least  in
the choleric stage, could not be discriminated  from
 ordinary cholera, excepting  perhaps  from   their
 taking place at a season of the year when ordina-
ry cholera is  never observed; but it may be re-
 marked that no one would infer the  existence  of
 the epidemic from such cases, though he might  be
disposed to acknowledge that they belonged to  it,
 if cases less  equivocal were simultaneously pre-
 valent, and especially if they originated under the
 circumstances mentioned in the preceding page.
   Notice  has been taken of sporadic cases which
 have occurred in  several  parts of  the kingdom
 during  the last year, and which have been re-
 ported in various publications.  We  have already
stated our opinion  as  to  the perfect  identity of
the group of symptoms  in certain of these cases,
and those which characterise the choleric stage
of the epidemic. These  cases have generally  been
fatal  as cases of cholera,  and probably on  this
account have  attracted  attention  and been re-
ported ;  and hence  what we  should  consider the
experimentum crucis  by  which  their essential
alliance to the epidemic, as it has manifested itself
in this country, or difference  from it  can alone be
proved,—the  intervention, or otherwise, of fever
between the cold stage  and  recovery,—is neces-
sarily wanting.   We have been favoured by a
gentleman of high character and attainments  (Dr.
Fenwick,  of Durham) with a report of two cases
regarded, at the time they occurred, as aggravated
cases of the ordinary disease; both took place  in
the interior, under circumstances in  which there
was not the slightest ground  to expect contagion,
  Vol.  I. —52                        2 k
and previously to there being any suspicion of the
existence of the epidemic in this country.  In one,
the symptoms bore, unquestionably, a considerable
resemblance to the choleric stage of the epidemic,
but no fever supervened.   The symptoms of the
other shall be given in the words of the writer.—
" The total,  or  nearly total suspension of the
secretion  by the kidneys ;  the watery vomiting
and stools; the severity of the spasms ;  the shrunk
and  corrugated  state of the skin on  the hands
and feet, and the blueness  of his nails, persuade
me that his  disease was of  the  spasmodic type.
In him, moreover, a  slow fever succeeded the
original symptoms,  and long  retarded his reco-
very."  We need not remark  that we would not
attempt to discriminate between such a  case  as
this and examples of the epidemic, believing their
character to  be identical.   This  case occurred in
the beginning of July, 1831.
   There is a certain form of the febrile stage, that
which supervenes on  a choleric stage,  attended
with  extreme collapse, which  the deficiency  of
the temperature and the circulation, the congested
state  of the conjunctiva from the very commence-
ment of the fever, and the peculiar torpor of the
intellect,  would enable,  as it  appears to us, the
observer to discriminate from any fever which we
are in  the habit  of witnessing in this country,
provided  he saw  the patient early and watched
him throughout;  but in the  majority of instances
the  diagnosis can only be  correctly drawn  by
coupling  the preceding  history of the case with
the existence of fever, and  with its character.
   5.  Appearances on Dissection. — The ex-
ternal appearance of the body closely resembles
that which has been noticed during life: the solids
are  shrunk,  the surface is livid, the skin of the
hands and feet is corrugated, the nails are  blue,
and the fingers often rigidly contracted.  There
is no evidence of any unwonted tendency to putre-
faction, nor any characteristic  foetor from the ab-
dominal cavity.
   In the  head are found marks of congestion, and
even occasionally of extravasation.  Such appear-
ances were not of uniform occurrence in the dis-
sections performed in Hindostan, but they were
found very constantly in those  made by Dr. Davy,
in Ceylon ;  and Dr. Keir,  of Moscow, discovered
in the  Russian disease  the- blood-vessels of the
brain and its membranes more or less turgid with
blood, particularly towards the base, with a fluid
effused into its convolutions, and more or less of
serum in  the lateral ventricles.
   In the  thorax, the pleura  and pericardium are
found, as the serous membranes generally are in
this disease, perfectly healthy,  with the exception
occasionally  of an unusual dryness.   The lungs
are sometimes in a natural state, but more fre-
quently gorged with dark-coloured blood, so  as to
resemble  liver or spleen; or they have  been found
collapsed  on each side of the spine, leaving the
thorax nearly empty.  This latter appearance Dr
Pollock, of the fifty-third regiment, explained  by
supposing gas  to be  extricated within  the cavity
of the pleura ; but the thorax having been opened
in  such cases  under  water, and no  air having
been found, Mr. Scott is disposed to ascribe it to a
contractile power exerted by the viscus, sufficient
to overcome  the atmospheric pressure.  Both  side* 
410
CHOLERA—[EPIDEMIC]
of the heart  ate  in  general distended with dark
blood, and  the  bronchi  are frequently filled with
mucus.
  In  the abdomen,  the  vessels of the liver are
often  much congested, and pour forth blood copi-
ously when incisions are made into  the  organ ;
but this congestion is not uniformly found ; the
gall-bladder is turgid with black bile, and its ducts
are sometimes constricted and impermeable, though
occasionally in  an opposite state. The peritoneum
is often quite healthy, but the portion investing
the alimentary  canal  has frequently an inflamed
appearance from  the  exceedingly loaded state of
the blood-vessels.  This congestion is sometimes
so great as to give the appearance of gangrene ;
but by drawing the finger over the surface, innu-
merable small  veins may be found  running  in
every direction, as in a preparation nicely injected,
and the texture is found to be  resisting and firm.
This  portion of  the  peritoneum,  however, occa-
sionally bears marks of actual  inflammation, espe-
cially if the patient has lingered long before death.
It then presents a thickened appearance externally,
and its colour varies from a pale vermilion, through
all the deeper shades, to a dark purplish hue ; the
former being chiefly  remarkable on the surface  of
the duodenum and  jejunum,  the latter  on the
ileum where  it  terminates in the csecum. At other
times, the  whole  alimentary tube, instead  of this
congested  state,  presents a blanched appearance
both internally and externally.  The omentum is
sometimes healthy ; at others, it presents tbe same
appearance of  extreme vascularity as  the  perito-
neal surface  of the alimentary canal.
   The  following appearances are discovered on
laying open  the  stomach and  intestinal tube.   A
white, opaque,  and viscid substance is found ad-
hering to the surface of  some  portions of the mu-
cous  membrane; and  in many  cases  it  is  so
abundant  in the intestines as completely  to fill
parts of them  of a  greater or less extent.  The
stomach and portions of the  intestines are filled
with  a transparent or turbid serous fluid, and fre-
quently  the viscid  matter mentioned above  is
found intimately mixed with  the serous fluid, or
floating in it in the form of flakes.  The mucous
membrane, except when inflamed, which  it not
unfrequently is,  has an  unnatural whiteness, is
often soft  and  pulpy,.and in  general—especially
in the stomach and small intestines—can be easily
detached by  scraping, in the form of a thick pulp,
from the subjacent coat.  These appearances are
sometimes more  or less partial; but some of them
 are generally found  throughout the whole  extent
 of the tube.   They extend in some cases to the
 mucous membrane of the bladder and ureters, and
 have been found in two or three instances in that
 lining the bronchi.
   In one  case only in India was the state of the
 spinal marrow examined ; and in that, strong in-
 dications  of inflammation  were  detected  in  its
 sheath ; the case, however, was in some degree a
 mixed one.  But Dr. Keir found, at Moscow, the
 blood-vessels of the vertebral column  and spinal
 chord more  or less loaded with blood, which was
 sometimes effused between its arachnoid and dura
 mater -, partial softening of the substance of the
 ■pinal cbord was sometimes met with, and marks
of inflammatory congestion in the larger nerves
were detected.*
  The dissections performed in Sunderland have
generally furnished results  corresponding with
those obtained elsewhere.
  In the head, venous  congestion of the brain
and its membranes  has been the most  uniform
and  prominent  appearance.   Serum has  been
found  in the ventricles of the brain and at its
base- but in many cases this has  been  in small
quantity, not exceeding that frequently observed
after diseases in which no affection of the ence-
phalon  was supposed to exist.   In some cases,
especially those in which death took place  in a
protracted stage, but occasionally in a rapid dis-
ease, fibrinous depositions existed between the
membranes.
   In the thorax the lungs have  uniformly been
found more or less gorged with blood, though in
many cases the  engorgement was in the posterior
part, and probably resulted from position.  These
organs were generally  crepitating, and free from
structural change.  Softness or flabbiness of the
heart has been noticed in several instances,  and
both its cavities and the vena? cavae and coronary
vein  have  been  distended  with  dark-coloured
blood.
   In the  abdomen,  the liver  has been  found
gorged, but occasionally its condition was natural.
The gall-bladder was generally distended, and the
ducts were constricted, so that the viscus could
not be  emptied by pressure ; but in some cases
they were  pervious.  The abdominal veins  have
been  found  generally  distended; but in several
instances, the vena portse and  meseraic veins have
constituted an exception to this rule, having been
found empty.  Vascularity and pulpiness of the
mucous lining of the stomach have been frequently
noticed ; but the former has  often been slight in
degree, and observers have felt disposed occasion-
ally to  attribute it to the exhibition of mustard or
other  stimulants;  whilst  the latter has by  no
means been  invariably  found. The lining of the
intestines has been found in many parts vascular
and pulpy ;  but these appearances are not inva-
riable, both lesions having  been found wanting,
and the pulpiness more frequently than the vas-
cularity.   The  peculiar secretion  has generally
been found in the intestines.
   The kidneys have been observed to partake of
the  general  congestion of  the  venous  system.
The bladder has generally been found contracted,
 and either empty or  containing a small  quantity
of urine.  In the case  mentioned, which was at-
tended with trismus and other  peculiarities re-
marked in India, but not in other examples of the
disease  in Sunderland, it was considerably dis-
tended.
   No  softening or  other  disease  of the spinal
 marrow, a little venous congestion excepted, was
 discovered in the few examinations of this organ
 made here.
   In concluding this rather unsatisfactory portion
   * Madras Reports, pp. 32, 34.  Anderson on Cholera
 Morbus, Edinburgh Medical and Surgical Journal, vol.
 xv.  Christie  on Cholera, p. 47.  Annesley, Diseases of
 India, 2d edit. p.  106, et seq.  Account of the Appear-
 ances after Death observed at Moscow, drawn up by
 Dr. Keir. 
CHOLERA—[EPIDEMIC]                           411
of our subject, we cannot refrain from expressing
a conviction  that  symptoms  during life  throw
much more light on the nature of the disease and
its appropriate  treatment than appearances after
death.
  6. Nature of the Disease.—Many writers of
great talent have preceded us in this very intri-
cate  branch of  the subject, and  much  ingenuity
has been displayed in the endeavour to trace all
the phenomena of the choleric stage, which has
been the principal subject of  investigation, to a
change in one part of the system. But  it must be
remarked  that  there  is little  accordance  among
medical reasoners  as  to the part of the body in
which the phenomena of the disease are presumed
to originate; for the nervous system  generally, the
ganglionic portion of it  exclusively,  the blood
itself, and the lining of the digestive canal, have
each found advocates equal in ability to plead their
cause.*
   The diversity of these views is a proof of the
intricacy of the subject;  and probably  also, since
 they have all emanated  from observing and inge-
 nious men, an evidence of the variable nature of
 the  disease;  each  reasoner  being perhaps influ-
 enced by that portion of the general phenomena
 of the epidemic which predominated in the cases
 it was his lot most frequently to witness.   Their
 partial nature, too, may be in a considerable de-
 gree ascribed to the unfortunate influence of the
 expression, proximate cause, as a  substitute for
 the more comprehensive term, essence or nature
 of the disease, on medical reasoning. Even  those
 who  affect to  use it as an equivalent term for
 nature of the disease, are yet insensibly influenced
 by the words they employ.  Amidst tbe crowd of
 phenomena presented  to  their notice  in  certain
 maladies, they often  assume, on  very insufficient
 grounds, that some one  fact is the original of all
 others, and this they invest with the title of proxi-
 mate cause.
   If the facts related respecting epidemic choleric
 fever are compared with the explanations offered
 of them, it will be found that each medical rea-
 soner has  attributed  the  commencement of the
 phenomena of the disease to an affection of some
 part of the frame, which affection unquestionably
exists in a very great number of instances, but
neither with that uniformity nor with that  priority
of time which can warrant  us in concluding that
it was the cause of all  the other symptoms.  It
seems a rational supposition that the remote cause
of a disease may act, in some instances,  first on
one, in others on another part of the system, from
some local weakness  or peculiarity of individual
constitution, or from  some specialty in the  mode
of application of the  cause ; and yet that  the dis-
ease shall retain in each case such a resemblance
to a  common  type as  shall prove its identity.  It
is likewise supposable that the remote cause may
make a simultaneous  attack on  more  than one
organ or part of the system^  Complex diseases,
such as fever, appear to furnish examples  of both
these cases.  The real  philosophy  of  medicine
seems to consist in ascertaining  the actual state
  ♦ T/iese are Dr. Kennedy and Mr. Orton for the first,
Mr. Hell for the second, Mr. Annesley and others for the
third, and Mr. Christie, with Roche and other French
writers for the last.
of the system of which symptoms are the signs;
and  if we  can  proceed through  the medium of
these signs and  post-mortem appearances, to one
sole change in one organ, the treatment is simpli-
fied, and science and art are gainers.  But there
are diseases, and this seems to be one of them, in
which we meet with a variety and complexity of
pathological conditions, all of importance, and all
to be kept in view in  their treatment.   It is true
that of these conditions some may arise from others
according to  known physiological  laws, as dark-
coloured blood from impeded respiration, and it is
right thus to explain them when possible ;  but the
uniform  endeavour to  trace all  to one primary
change, or rather, as  is more frequently done, to
assume one change  to be primary, and all other
morbid states to be but emanations  from it, is not
only unphilosophical, but is too apt  to tinge our
practice with undue partiality.
   Whilst we deem that no one writer has attained,
either by inferences drawn from  symptoms,  ap-
pearances after death, or both, a knowledge of tbe
affection of any one organ in cholera which can
be properly termed a  proximate cause whence all
the  other phenomena arise; or acquired precise
ideas respecting  the  nature of the  affection of
many organs which manifestly participate  in  the
disorder ; it is gratifying to acknowledge that their
labours have thrown much  light on  the condition
of many parts, and that very great practical good
has resulted from the  information thus obtained.
   That the nervous  system generally, and espe-
cially the ganglionic  and spinal  nerves, and  the
spinal medulla itself, are affected, is manifest from
many symptoms ;  but whether this affection arises
from a direct impression of the remote cause of
the disease on these organs, or from irritation pro-
pagated from the alimentary canal along the gan-
glionic nerves to the spine, we are ignorant.   Dr.
Kier's able researches have shown that in some
fatal  cases inflammation of a portion of this sys-
tem  has existed ; but its precise pathological con-
dition in cases which terminate favourably remains
yet to be ascertained ;  and it must be  remarked,
too,  that in fatal cases this inflammation has not
been always detected.  The state of the sangui-
ferous system is very remarkable :  but here too
we must feel some doubt whether the  feebleness
or almost complete arrest of the heart's action is
a primary effect of the cause of the disease, or, as
suggested by Mr. Bell, arises from the affection of
the  ganglionic system ;  or, again, whether  it re-
sults,  through  tbe medium of this  system, from
the condition of the alimentary canal.   Is the dark
appearance of  the blood  to be explained by the
feebleness of the action  of the right ventricle, as
a consequence of which but little blood is trans
mitted through the lungs and exposed to the influ-
ence of the air ?   According to this view, which
is suggested  with diffidence, the imperfection of
the  respiratory process will arise from the same
cause as in congenital malformation,of the heart,
such as the persistence after birth of the foramen
ovale, or the aorta arising from both ventricles, in
which a very small proportion of the whole mass
of blood is oxydized.   This hypothesis explains
readily the dark appearance of the blood, its accu
mulation  in  the great  veins of  the viscera,  the
coldness and lividity of the skin, and the imper 
412                          CHOLERA —[EPIDEMIC]
fection of the respiratory process, which has been
so ably illustrated by Dr. Davy.   This gentleman
was  the  first to show that the air expired by pa-
tients in the choleric stage is  colder and contains
less  than the  usual proportion of carbonic acid ;
and  that this is the case even  when the breathing
is full, free, and rapid.  The explanation offered is
confirmed by an  observation of  Mr. Ellis,  in  his
experiments on  respiration, that  " as the circula-
tion  declined, so likewise did the emission of car-
bon, and, consequently, the production of carbonic
acid."  The thickened consistence  of the blood
receives  a ready explanation  from the loss of its
serous part by the abundant  discharge from  the
inner intestinal surface.
   There are two morbid conditions of the lining
of the digestive  canal.  In one  it is in a state of
manifest inflammation ;  in  the  other it is white
and  pulpy, and easily detached from  the subjacent
coat.  Is this latter condition the result of a dis-
organizing inflammation which  has itself passed
away, or must we be content to describe the action
which has produced it by the very unsatisfactory
and  vague expression, disturbance of the function
of nutrition 1  This is a question rather of general
pathology than one connected solely with this dis-
ease ; but it is one as yet undecided.  The affec-
tion  of the alimentary canal is essential and pri-
mary, if any part of the disease is so; and it were
vain  to attempt to trace it to a morbid condition
of any other organ or system  of  organs.
   [Tbe German and French physicians have paid
considerable attention to an  eruption of isolated
granular  pimples,  chiefly  met with in the two
lower thirds of the ileum, which is  said to exist
in the vast majority of cases.   Owing to this erup-
tion, MM. Serres and Nonat gave the disease the
name psorenteria.  (Art. Cholera, par A. Nonat,
in Diet,  des Etudes  Medicates,  torn. iii. p. 416:
Paris, 1839.)
   Examination of the blood of a choleric patient
by M. Andral, (Hematologic Pathologique, Paris,
1843,)  showed  that  there was  no augmentation
of the fibrinous element, as is observed in severe
phlegmasia of the digestive tube.   The proportion
of fibrin was 3-3;  of globules 118; and of solid
matter of the serum 88.]
   The general suspension of secretion, which is
complete only when the collapse  is extreme, ap-
pears to result from the disorder of those systems,
the nervous and vascular, on which this important
function depends.  The apparent anomaly  pre-
sented by the  continuance of the cutaneous and
intestinal discharges amidst the general suspension
of secretion, is well explained by Mr. Bell's dis-
tinction between this function and  exudation or
exhalation.  (Treatise on  Cholera  Asphyxia, p.
56, 57.)
   Were we to  endeavour to illustrate  in a few
words the nature of cholera  by  examples  drawn
from analogous diseases, we  should say that its
choleric stage  presented  in a  more intense degree
the  initiatory  collapsed symptoms of certain bad
fevers before re-action had taken place, combined
with excessive  gastro-intestinal  irritation ;  whilst
the  febrile stage  bore a very close resemblance to
such fevers after the establishment of -e-action, or
in many cases was, at least in external character,
perfectly identical with 'hem.
  That the whole series  of phenomena  resulti
from the action of a morbific poison on the body,
there can be no doubt; but as yet, as in the case
of other fevers, we are ignorant of the  precise
nature of the primary change effected by it in va-
rious  organs  or systems;  and it is to be feared
that till more accurate ideas are attained respecting
the pathology of fever  in  general, this ignorance
will remain.   In  the febrile  stage, we would re-
mark, there are indications  by no  means equivocal,
of inflammatory affection of the  brain, and occa-
sionally of other organs, the analogy to fevers in
general being in this respect preserved.  Were we
to judge solely from what we have  ourselves ob-
served of the commencement of the disease, we
should consider the alimentary canal to be the part
of the frame which first felt the influence of the
poison ; but we should consider the condition of
the nervous  and vascular  systems much  too in-
tense in degree to be  merely sympathetic of the
state  of the  stomach and  bowels.  Many cases,
moreover, which have been reported from abroad,
particularly from  India, lead  to  the opinion, that
in various  instances the nervous system is prima-
rily affected.
   5.  Proportionate  Mortality. — The mor-
tality during the early prevalence of the epidemic
in  India in  1817 and  1818 was very great, but
either  from the abatement of the intensity of the
disease, or from the improvement of the  method
of treatment adopted by our medical  men, or, as is
more probable, from the co-operation of both these
circumstances, it was subsequently very much re-
duced.  There  is no disease in which unassisted
nature seems more powerless than this.  We learn
from the report to the Medical Board at Bombay,
that there  is  reason to believe that of 1,294 cases
which received no medical assistance, every indi-
vidual perished;  and  it is added, that it is not
ascertained that any case has recovered in which
medicine had not been administered.  From this
appalling statement, it  is  gratifying to humanity
to  turn to the following  records.  According to
the documents  collected by the  Madras Medical
Board, the number of  deaths caused  by it in the
army of that presidency during 1818 and the  four
subsequent years, was 4,430, of which 695 oc-
curred  among  the European troops, and 3,735
among the sepoys.  The  number  attacked  was
19,494, namely, 3,664 Europeans and 15,830 na-
tives.  The average strength of the army  during
the period included in the  reports  being 10,112
Europeans and 73,254 natives, it follows that in
five years 23 J per cent,  of the troops were at-
tacked, and that of these 22| per cent, were car-
ried off, or 5 J per cent, of the whole force of the
army.  This  statement, though  sufficiently dis-
tressing, is still a  proud monument to the skill of
the medical men employed, and to medical science
in general.
   We  hear,  in different  situations, of rates of
mortality infinitely lower than this.   Dr.  Burrell,
surgeon of the  65th regiment, reports, for instance,
from  Seroor, that out of sixty cases he lost four,
being at the rate 6-6 per cent.; whilst Mr. Crow,
at  the  same station, makes  the mortality much
less, declaring that the disease is  not fatal in more
than  one in a  hundred of  those who are early
succoured.  Dr. Burrell found, too,  that of a cer- 
CHOLERA —[EPIDEMIC]
413
tain description of cases, those attended with vio-
lent spasms, he saved eighty-eight out of ninety.
(Bombay Reports, p. 68, &c.)   In taking these
estimates into consideration, we  must always re-
collect, however, that in epidemics there  is often
a very wide difference  in  the  gravity of the dis-
ease at different points or  in different years,—in-
deed, sometimes at nearly the same  point and  in
the same year; so that when we hear of an ex-
tremely small  loss in proportion to the  number
attacked, long experience  does not  permit us  to
doubt that  in such  a case the type of the disease
has been very mild.
   The  ravages of the  disease in civil life, amid
 a comparatively  unorganized  population, where
 prompt assistance could not always be rendered to
 the sufferers, furnish a considerable contrast to this
 statement from the  British army,  and  strongly
 confirm the opinion expressed, of the importance
 of early treatment  in  a malady so rapid  in  its
 course, and in which the  efforts of nature are so
 impotent.
   At Busheer, in the Persian Gulf,  we learn from
 Moreau de Jonnes, that in 1821  a  sixth part of
 the inhabitants perished;  and at Bassora, in the
 same  year, Mr.  Rich  informs  us  that  eighteen
 thousand died, of whom fourteen thousand perish-
 ed within a fortnight.   The number attacked in
 Moscow from  September  1830 to January of the
 following  year,  was  8,130, of which  perished
 4,385,  or 54 per cent*  In the small  town of
 Redislscheft, of eight hundred sick,  we learn from
 Dr. Reimann, that  seven hundred died in one
 week.  The greatest success which has attended
 the treatment of  the disease in  the  Russian em-
 pire, so far as the  records have reached us,  oc-
 curred  in  the district  of  Orenburg, the number
 attacked being 3,590,  of  whom  865 perished, or
 about 24yL per  cent., a result  creditable to the
 vigilance of the Russian government, and to the
 skill and care of the medical men employed.  The
 treatment adopted was that of our Indian practi-
 tioners ; bleeding, calomel,  opium, warmth, and
 friction.-j-
   The disease  having, there is every reason to
 think, run its course through the town in which
 these observations were written,  it may not be un-
 interesting to mark the amount of ravage which
 it has inflicted.
   The town  comprised under the  general name
 of Sunderland consists of three  parishes, viz.
                                      inhabitants.
   That of Sunderland, containing. ...  17,060
   Bishopwearmouth...............  14,825
   Monkwearmouth and its immediate
      dependencies, in all which the dis-
      ease existed..................   8,850

                    Total.......... 40,735

 This computation  is  exclusive of certain out-
 townships, to which the disease  did not extend.
   The total number attacked with epidemic cho-
 leric fever out of this population  from its manifest
 appearance on the 26th of October to its  cessation
 in the middle of January, was 534, of whom 202
   * Memoir of Dr. Loder, physician  to  the Emperor at
 St. IVtersbureh. dated January 1831, and  read at the Aca-
 demy of Medicine at Paris.
   t Substance of a report published  by the Supreme Me-
dical Board of Russia.
                                     2k»
perished.  These deaths are  computed, with all
the accuracy which the parish registers and other
sources of information permit, to have  occurred
in the following proportions :—
   In Sunderland.....................  156
   In Bishopwearmouth...............  21
   In Monkwearmouth................  25

                    Total.............  202

   From this  statement it is manifest that, if the
disease pursue the same  course elsewhere that it
has done  in  Sunderland, the danger to a popula-
tion is to  be estimated less from their  numbers
than from various  circumstances in  their condi-
tion, and  particularly from  the proportion which
the labouring class  bears to the rest of the com-
munity ; for  the  parish of  Sunderland, in which
the mortality was  in  so  much higher a ratio to
the population than in the other parts of the town,
is tbat in which the  proportion of the labouring
poor is greatest;  though their situation  is by no
means so comparatively wretched as  persons un-
acquainted witb the habits of the labouring  class
in general, (and especially of that portion  of it
dwelling  in  sea-port towns,)  and consequently
destitute  of the  means  of accurate  comparison,
have taken pains to describe.  Besides the smaller
number of the labouring class residing in Bishop-
wearmouth, there are various circumstances,  such
as its situation being  higher, its streets wider and
better ventilated, &c. which probably contributed
to its proportionate exemption from  the disease.
Of the small number of its population who suf-
fered, it must be remarked, moreover, that  a  large
proportion lived  in an inconsiderable  part of the
parish, at its outskirts near the river, called Ayre's
Quay, inhabited  almost exclusively by the labour-
ing class.  In this small locality nine out of the
twenty-one deaths occurred.  It should  be ob-
served, too, that  in Monkwearmouth, situated on
the north bank of the Wear, the  disease was  con-
fined almost exclusively to  the lowest, dirtiest, and
most populous  district,  situated  near  the river,
called the shore.
   It is a fact of some importance that of the vic-
tims of the disease, seven only, so far as we  have
been  able to discover, were, in point  of situation
in life, at all above the labouring class.
   A simple calculation  shows that the mortality
amounted to one in two hundred and one and a
fraction of the whole population in which the
disease prevailed ; that of Sunderland was as one
to about a hundred and fifteen of its  population ;
that of Bishopwearmouth as  one to  seven  hun-
dred  and six, and  exclusive  of  Ayre's  Quay, as
one to somewhat more than one thousand ;   and
that of Monkwearmouth as one to three hundred
and fifty-four.
   There is nothing very alarming in such a rate
of mortality as we have described ; it is high on
the number attacked, but low on  the amount of
population :  and the  former circumstance and the
rapidity of the disease will probably  be  found to
constitute its most appalling features,  if its course
elsewhere in this country resemble that observed
here.  Other epidemics which visit us exceed it,
whether we regard the number or the quality of
victims, in the  amount of evil inflicted ;  but none
is to  be compared witb it in fatality in proportior. 
414
CHOLERA —[EPIDEMIC]
to the number attacked, or in the rapidity with
which it accomplishes the work of destruction.
  Our friend Dr. Ogden has furnished us with the
following  calculation,  which  is  interesting  pro-
vided the  results  of  similar calculations  made
elsewhere in this island correspond with it; for it
will thus be  shown that  in  one point of some
importance, the proportion of  the sexes attacked,
the disease here observes a  course directly  the
reverse of that witnessed elsewhere in its progress.
  Cases of cholera, known to be such, buried at
Sunderland between the 28th of October and 22d
of December:—
AGE.	MALES.	FEMALES.	TOTAL
15 and under..	..12 .	.. 13 ..	. 25
From 15 to 50.	..14 .	.. 33	. 47
	...37 .	.. 36 .	. 73
63
82
245
  Besides showing  that at the period of middle
life the number of female  victims of the disease
is double that of males, and that at the  two  ex-
tremes the numbers  are  as nearly equal  as  pos-
sible, this table shows how large a proportion of
aged persons the whole amount of mortality com-
prises,  these  constituting more than  one-half of
the total of deaths.
  The preponderance  of attacks in females  over
those in males at the period of middle life is pro-
bably to be  explained partly in the manner sug-
gested by Dr. Ogden, that the dress of  the latter
sex furnishes a better security against  cold  than
that of the  former; and  in  part by the circum-
stance that males at the working period of life are
better nourished than females,  being  frequently
the  only  members  of families  of their  class of
society who partake of animal food.
   For obvious reasons, we abstain from any sta-
tistical details connected with neighbouring towns
in which the disease is, at the time this is writing,
only  in progress.
   [From some estimates made in England by Sir
David Barry, it would appear that 38-5 per cent.
of the cholera patients  died.  In  1832, probably
5000 perished  in  London, and  in Great Britain
somewhat more than 20,000.   In Paris, during
the  epidemic of 1832,  more than  18,000  fata)
cases are said to have occurred.   In the Russian
provinces, the mortality was 58-6 per cent.  In
Naples, it was estimated at six to ten.   In Paler-
mo, it was dreadful.   Of a population of 150,000,
about 30,000 of whom, it was supposed, left the
town at the breaking out of the complaint, 25,000
died, or about a fifth part  of those who remained.
In some of the towns of the United States, the mor-
tality was taken as accurately as was practicable
It is thus stated by Professor Jackson, of Phila
delphia:
Places.	Population.	Cases.	Deaths.	Ratio of cases to population.	Ratio of deaths to cases.	1 Ratio of deaths to population.
	32,000 28,000 240,000 160,000	5783 4385 5547 2314	3292 1853 2782 935	1 in 5+ 1 in 6-5 1 in 25-3 1 in 70	1 in 2-5 1 in 2-5 1 in 2 1 in 2-5	1 in 10-5 1 in 15+ 1 in 15-5 1 in 173-2
						
  From the epidemic at Paris, attempts have been
made to calculate the  probability of death and
recovery in Asiatic cholera.  From these it would
appear,  that  the  daily  rate of mortality,  in the
first 12  hours, was 16  per cent.; in the next 12
hours, (12-24,)  37 per cent. ; in the 2d day, 11
per cent.;  in the 3d day, 8 per cent.  The mor-
tality of cases of cholera, in Paris, was 49 per
cent. The force of mortality attained  its maxi-
mum in cholera by the 21st hour, (18-24 hours;)
the maximum intensity of smallpox being attained
in days  10-15; of phthisis, in 6-9 months.  The
danger of cholera decreases as the  time advances:
the longer  a cholera  patient lives, the more likely
is he to  continue to live.  Half the deaths happen
in 24 hours.
   Thf. following table by Mr. W.  Farr shows the
probability of recovery from  the  severer attacks
of cholera at the end of 12  hours, and of one,
two, and three days :
      Cases.      To rec'r.   To die,
                       4907
1-2
0 hours, 10,000
        11185
1 day,   7616
2  '     6793
3       6991
 6.
5093
5093
5093
5093
5093
   Probability of rec'y.
  ■509 nearly  1 to 1
  555 —  ]-3 to 1
  ■669 —    2 to 1
  •750 —    :«o 1
  ■S09 —    4 to 1*]
and Causes*—On
                       £523
                       1700
                       1198
     Extent of Diffusion
the first branch  of this  subject we cannot  be
wrong,  so  frequently have its details been pre-
sented to the public,  in  assuming  considerable
          * [Practice of Medicine, i. 143.]
knowledge on the part of our readers ;  or in re
ferring those who may wish for more minute in-
formation than is ordinarily possessed or than we
have space to give, to the admirable chronological
table of M. Moreau de Jonnes.  The present epi-
demic  originated in the  district of  Nuddea, and
perhaps  in some  other parts  of the Delta of the
Ganges,  about  the end of May or the beginning
of June, 1817.  It did not during that year ex-
tend beyond  the territory of Lower  Bengal; but
in 1818  and the  early  part of 1819 it diffused
itself throughout the extreme length and breadth
of the  Indian peninsula, moving in  lines more or
less diverging, and attacking in succession places
generally more remote from the seat of its origin,
(though  striking deviations  from this  rule were
occasionally  observed,)  and situated in various
directions from  it;  but  leaving untouched many
districts  placed  between its lines of movement.
Its progress along the lines  it selected was won-
derfully   uniform,   being for  some  successive
months  at the  rate of  about  one  degree in a
month.  As early as  1818 it extended itself beyond
the boundaries  of Hindostan  into  the Burmese
empire and other territories of Eastern Asia, and,
making gradual progress through these  extensive
realms, reached China in 1820, and in the following
year visited  the numerous and populous islands
situated  in the Indian Archipelago.   The Isle of
France suffered its  invasion in 1819, and soma 
CHOLERA — [EPIDEMIC]
415
  cases occurred in the same year at one point in
  Bourbon, in which  island it  has not since ap-
  peared.  In 1821 it extended along the shores of
  the Persian Gulf, and during this and the follow-
  ing  year spread through parts  of Arabia, Persia,
  Mesopotamia,  Syria,  and  Judea,  and  closely
  threatened  Europe.   It appeared in the Russian
  territories in 1823, at Saillon, Ghillan, Orenburg,
  and Astracan ; but its further  northern and wes-
  tern progress was for a time arrested. It, however,
  re-appeared in Orenburg  in 1828,  and again in
  1829, and in 1830 advanced through the southern
  provinces of the Russian empire, till  it reached
  Moscow on the 28th of September of that year.
  Its  subsequent progress  through Russia, Poland,
  the Austrian dominions, the  north of Germany,
  and in England, is too familiarly known to render
  it needful that we should present its details to the
  reader.
    The space traversed as yet by this extraordinary
  epidemic may be conceived from  the following
  simple calculation. •  The Philippine islands form
  (so far as  is known) the eastern, and Mauritius
( the southern,  boundary  of  the   disease.  The
  former lie in east longitude 125°, and the latter is
  in  south latitude 20°.   Archangel is the most
  northern, and the vicinity of Edinburgh the most
  western point to which  it has  extended.  The
  former is in north latitude 64°, the latter in west
  longitude 3°.  Hence it is manifest that the dis-
  ease has passed over 128° of longitude and 84°
  of latitude.
     [On the 26th of October, according to the above
  account, it first appeared in Sunderland; in Janu-
  ary 1832, it was in Edinburgh ;  and on the 10th
  of February, in London.  Its  progress  in every
  town  in the British islands visited  by it has been
  accurately traced by Professor Graves, of Dublin,
  (Dublin Journal of Medical Science,  January,
  1840; reprinted in the American Medical Li-
  brary, vol.  iii.:  Philadelphia, 1840.)   It is singu-
  lar that there, as  elsewbere, it left a  number of
  places untouched, and others were but slightly
  affected.
     Cholera first appeared in Paris in March, 1832,
  and, with great rapidity, various parts of  France
  were  attacked.   From England the disease soon
  passed to Ireland,  and  appeared  in  Dublin  in
  March, 1832.   On the 8th of  June, 1832, it was
  first seen on this side of the Atlantic  in Quebec;
  and on the 10th it appeared at  Montreal.   On the
  21st of June,  it suddenly and unexpectedly ap-
  peared in New York,—all the intermediate cities on
  the seaboard of the  provinces of New Brunswick
  and Nova  Scotia, and  of the States of  Maine,
  Massachusetts,   and Rhode   Island,   remaining
  wholly exempt.  On Thursday, July 5, the first
  decided case manifested  itself  in Philadelphia.
  This  city  suffered  much  less  than Montreal,
  Quebec, and New York.  The disease spread in
  various  directions, visiting Albany, Troy, New
  Brunswick, and Rochester, in July; Baltimore,
  Washington, and  Boston, in  August.   During
  the same months, it was prevalent in several parts
  of New Jersey and  Delaware.  About the 1st of
  October it suddenly broke out at Cincinnati, and
  nearly simultaneously at Madison,  Louisville, and
  St. Louis;  and by tbe latter end of the month, it
  reached New  Orleans.   Leaving  the  Ohio,  it
visited Tennessee, Illinois. Indiana and Kentucky,
— Lexington, Maysville, and  some other towns,
suffering severely.   During  the  same year,  the
disease  visited  Campeche, where  it  was  exceed-
ingly fatal,—4000, out of a population of  20,000,
falling victims  to it.  It also visited the Havana
early in 1833, but never reached any other West
India island ; nor did it extend to Guiana, Deme-
rara, or  any of  the  embouchures of  the  great
South American  rivers,  Amazon, Orinoco, or La
Plata.  In 1834,  it  revisited many of the cities of
this country, which had  previously suffered, and
spread to others that had been left untouched; yet
singular cases of  entire immunity were met with.
Two of these  may be mentioned as  examples
Fredericksburg on the Rappahannock, and on the
great road from  Washington to  the  South,  may
be said  to have escaped almost wholly; and whilst
the disease was prevailing at Richmond, and  the
inhabitants of  Charlottesville, and of the  Univer-
sity of Virginia, in  its vicinity, were daily  ex-
pecting a visitation, not a case occurred, although
travellers daily arrived from the  afflicted city in
the  public stage.   Philadelphia  and  Baltimore
both suffered  again, but not severely, in 1834.
Charleston also  was  visited, with most of  the
southern towns.  The disease recurred, indeed, at
intervals, for a year or two, but ultimately disap-
peared, not to return, unless the  same endemico-
epidemic influences should exist, which favoured
its  progression previously.  In like manner it oc-
curred  at Marseilles  and Toulon in  1835;  at
Naples in 1836  ;  and at Bona in 1837.  Mar-
seilles was attacked, for the third  time, in the
same year, and it re-appeared  in the  autumn at
Berlin, Prague,  and Danzig.   The  number of
persons attacked in the Lombardo-Venetian States,
in  1836, was  estimated at  100,000, of whom
55,000 died.   In the latter part of 1837, the in-
habitants of the  British metropolis were  alarmed
by  the appearance of cases at Limehouse, which
were pronounced by some to be genuine Asiatic
cholera;  but,  by others, to  be  emanations  from
" alarmist  cholera-hunters."  The disease,  if it
existed,  never  certainly became  epidemic.   (See
the writer's Practice of Medicine, 2d edit. i. 132:
Philad. 1844.)]
   The questions naturally occur, what agent first
generated the disease ? and what has subsequently
diffused it over so large a portion  of the globe ?
   The first question must be answered by a sim-
ple statement of  the facts, that it originated in the
district mentioned after an unusual disturbance of
 the seasons with respect  to alternations of heat
 and moisture ; that it made  its  appearance at the
 commencement  of a rainy  season,  so excessive
 that the Gangetic  Delta  was converted into  a
 sheet of water;  and that the very first  point in
 which it was observed was the district of Nuddea,
 noted for the endemic  prevalence  of  cholera,
 where the whole year had been  rainy, and during
 every week of April and May (it began to mani-
 fest  itself in the latter montb)  there  had been a
 succession of thunder-storms.  From  this district
 it appeared  to diffuse itself over the rest of  Hin-
 dostan, its progress throughout the country being
 accompanied, as  Mr. Orton informs us, by circum
 stances somewhat similar to those which attended
 its origin. 
410
CHOLERA —[EPIDEMIC]
   The second part of the question cannot be dis-
missed so lightly.   As  is well known, the doubt
and difficulty regarding the subject  exist chiefly
with respect to the share which contagion has
had in  its diffusion ; and this question we shall
endeavour to discuss  as succinctly, and certainly
as  dispassionately and  fairly  as possible.  That
our opinion, in the course of the investigation,
has fluctuated, we feel it no discredit  to avow.
This fluctuation was either prior to the appear-
ance of the  disease  in this country, or to our
having  it a  sufficient  length of  time under ob-
servation to enable us  to attain a settled conclu-
sion ; and when we show the conflicting nature
of  the evidence from  which, under  the  circum-
stances mentioned, a conclusion was to be drawn,
it will be manifest that fluctuation or total scepti-
cism must have been its result.  As this evidence
consists  of facts  already before  the public, we
shall, for the sake of* brevity, rather  refer to than
detail them, classing  them,  as  nearly as  their
nature admits, according to the very  precise rules
laid down by  Dr. Alison for discriminating the
operation of contagion.
   1. Strong evidence of a disease being contagi-
ous is furnished by its appearance in communities
previously healthy shortly after the arrival of per-
sons from infected districts, who are themselves
suffering under the disease, or who  sicken  of it
soon after their arrival.  A striking example of
this sort is related in  the Madras Report of the
appearance  of the disease at Jaulnah,  after the
arrival of a detachment there from Nagpore, then
infected,  and  its  subsequent  diffusion from  the
former  place  to  the  towns of  Malligaum and
Hydrabad, and various  villages.
   Other  cases,  though few  so striking  as  this,
might be selected from the Indian records, but we
prefer referring to examples  which  occurred  in
the Russian epidemic.  In the fortress of Raziipna,
in  that of Iletsk,  and,  towards the  close of the
epidemic, at Caramala-Gubeerra, all in the govern-
ment of  Orenburg, the  invasion  of the  epidemic
coincided, in point of time,  with the- arrival  in
them and sickening of  persons  coming  from in-
fected places.  It  should  be remarked, however,
that in  these cases communication  was not al-
ways traced between the individuals  subsequently
and those first attacked; and in  the  case  at
Raziipna, it is distinctly  mentioned, that of the
individuals who visited the man first seized on his
arrival from Orenburg, then infected, not one took
the disorder.*
  Into the  opposite  scale, that of the non-con-
tagionists, may  be thrown  facts  which  tend  to
prove that it has originated in districts previously
healthy without any  ascertained  communication
with infected persons, and that, on the other hand,
the most ample intercourse has existed on various
occasions between  healthy and infected communi-
ties without the former having participated in the
disease.    Its  introduction into the city of Oren-
burg in  1829 was  not only not traced to commu-
nication from an infected district, but a conjecture
mat it might have  been introduced either by the

  *  On the Asiatic cholera as it appeared in Russia in
the  years  lt-.'i) and  1830,  by Dr. J. R_ Lichtenstadt.
(translated in the  Edinburgh  Medical  and  Sureical
Journal,  No. cviii.)                          s
caravan which arrives from central Asia at mid-
summer, or by the Kirghis, a semi-barbarous Tar-
tar horde, from whom  the government of Oren-
burg is separated by the river Oural, was, if nol
disproved, rendered in the highest degree impro-
bable.f
   " When the disease attacked the sixth regiment
at  Colabath in July,  1828," says Mr. Assistant-
Surgeon Spence, of the 52d regiment, " its  com-
mencement was a remarkable proof against  its
contagious  nature.  It was  in the  midst of the
rainy season, and not  a case  had been  seen for
months either in or  near Bombay,  when Assis-
tant-Surgeon  Campbell, in  paying  his  evening
visit to the hospital, found an old soldier, who had
been under treatment some time for hepatic affec-
tion, suddenly seized with cholera.  He went to
the opposite extremity of the building for the pur-
pose of consulting with  the surgeon, and  found
him busily  employed with another man, who had
been almost simultaneously affected.  Now it is
physically impossible that these two individuals
could have received the disease by contagion, be-
cause  that which does  not exist cannot  have
issue."  The disease  proceeded  with  unabated
violence till it destroyed  sixty men and several
women.   (Taken from Mr. Spence's  MS.; since
published in the Medical Gazette.)
   The following example of personal intercourse
between the  healthy  and infected without com-
munication of  the disease, is taken from Mr.
Annesley's  Sketch of  the Diseases of  India.
Cholera   attacked  the  field  force  stationed  at
Shalligaum in Kandiesh, and  raged with great
violence  among the corps posted on the left of the
line, while  the 17th battalion of native infantry,
who were  posted on the right of the line, were
exempt from  it,  though they had  constant com-
munication with the other men.
   2. The  gradual  diffusion of a disease through
a  limited community, those near the sick being
first attacked, and others in succession in propor-
tion to their  proximity,  is strong evidence  of a
disease being contagious.  But this evidence has
rarely  been furnished  by cholera;  the  general
statement from India, indeed, is of a totally oppo-
site nature ; for we learn that, on its appearance
in any place, numbers are simultaneously attack-
ed, and that, after committing unheard-of ravages
for a short period, its cessation is as sudden as its
invasion.   One example, however, resembling in
some degree this gradual diffusion, is given in the
Russian reports, and this is furnished by the staff-
physician,  Dr. Schimanski, with regard to the ex-
tension of  the disease at Iletsk.   He says he was
able to trace  the progress of the disease  in the
first eight  cases, thus  : — The husband of the
woman,  (a soldier's  wife,) from  Orenburg, was
taken ill three days after her; and  about the same
time, also, two girls who lived  in the immediate
neighbourhood of the soldier, and who visited him
soon  after his arrival from Orenburg: the  aunt
of these girls, who nursed him, was next attack-
ed ; and from  her it passed to her  own two sons.
(Edinburgh Medical and  Surgical Journal, No.
cviii. p. 130.)
  3. There is no circumstance connected with the
disease on which the  information received from
                     t Ibid. 
CHOLERA —[EPIDEMIC]
417
different quarters is  more contradictory than the I
comparative liability to it of attendants on the
sick and other members of the community.  From
India the testimony on this head is  so conflicting
that no conclusion can possibly be drawn from it:
a state of  complete scepticism is  that in which it
leaves the mind of an honest inquirer after truth.
That from Russia is  not of a much more decisive
character; such as it is, we shall present it to the
reader.
  During two months, observes  Professor Lich-
tenstadt, while the disease prevailed at  Orenburg,
and two  hundred  and ninety-nine patients were
admitted with cholera  into the military hospital,
the personal attendants on the  sick  remained
entirely exempt from the disease.   They consist-
ed of one hospital assistant, six pupils, as many
Baschkir lads, and fourteen  hospital servants, in
all, twenty-seven ; and their duties were to per-
form bloodlettings,  apply leeches, poultices, and
frictions,  and administer baths and the like,  so
that they  were compelled to be constantly breath-
ing the exhalations from the  bodies and clothes
of the sick, as well as to touch and handle them.
The  washerwomen  of  the  hospital  likewise
escaped ;  a  class of individuals,  who,  it is well
known, are  extremely apt to suffer from contagi-
ous diseases.
   On the other band, Drs. Russell  and Barry in-
form us,   " that  the  number of medical men and
hospital attendants  attacked with cholera  during
the present epidemic, in proportion to the whole
employed, and to the other classes of society, has
been  beyond all  comparison  greater  here (St.
Petersburgh) than in India under similar circum-
stances ;  twenty-five medical men have  been al-
ready seized, and nine have died  out of two hun-
dred and  sixty-four.  Four others have died  at
Cronstadt, out of a very small number residing in
that fortress at  the time the  disease  broke out
there.  Six attendants have been  taken ill at a
small  temporary hospital behind  the Aboucoff."
With  regard to this last circumstance, it is not
stated, as in another report by the  same gentlemen
 (not published)  bearing date 4-16 July, that " in
the great  Aboucoff hospital, where  there were no
cholera patients, but to which a temporary cholera
hospital  was attached behind  the building,  ten
persons residing within the area of the establish-
ment had been severely attacked up to the 12th
instant (N.  S.) with cholera."   This  leaves a
very different impression, and not being  aware
 of what  is  meant by " the  area  of the establish-
 ment," we cannot form an opinion how it may or
 may not bear towards the side of contagion.   In
 the last-mentioned  report, those  gentlemen also
 state, that in the Military  General Hospital,  in
which four hundred cholera patients  had been
 admitted from distant quarters, up to the morning
 of the 13th, "one attendant had  been attacked."
 But one  attendant where so many cases had been
 treated !
   These specimens, taken from an  immense mass
 of foreign evidence,  will suffice to show its con-
flicting nature on points essential to the decision
of a much litigated  and very important question.
There are certain branches of the subject, such as
the immunity apparently afforded by  seclusion,
which we have  designedly  omitted;  partly  be-
   VnL. 1.--53
cause they were unavoidably exposed to sources
of fallacy, and the testimony regarding them was
of the same conflicting  nature  as  the  specimens
which we have already  presented  to the reader;
and  partly that we might preserve space for  an
examination of the question, how  far the general
progress of the disease  favours  the  opinion that
human intercourse has been the instrument of its
diffusion; and  for the  narration of certain facts
illustrative of the general question which  have
fallen under our observation.
   The progress of the disease on the great  scale
having been tolerably regular both geographically
and  chronologically, —  that is, its having passed
from country to  country without leaving inter-
jacent  countries  untouched, and  those infected
having been so  in  some proportion, in point of
time, to their distance from its original  source,—
has  been  appealed to by two parties as evidence
of the accuracy of their opinions ; the one seeing
in it a proof of a continuous  stream of epidemic
influence  flowing from the point where the disease
originated; the other a transport of the  malady
by human intercourse from the same source.   To
the  opinion of a  flow of epidemic influence, have
been objected, and  apparently  with justice,  the
slowness  of the  progress of the  disease;  that  it
has  extended  its  territory in  spite of the opposi-
tion of continued and violent monsoons ; and that,
notwithstanding a degree of general regularity of
progress, there have been anomalies observed in
its course, such  as  its  having  left districts  un-
touched whilst all around  them  were suffering,
utterly irreconcileable with the opinion  advanced.
On  the other hand,  circumstances  have  been
observed, which render  it almost equally question-
able whether contagion  has been the sole instru-
ment of its diffusion.
   It has been asserted by the advocates of the ex-
clusive operation  of this principle, that the disease
has  always been found  to move in  the line of
human intercourse, and it must be acknowledged
that, whilst so migratory an animal as man in-
habits the earth,  it cannot well do otherwise ;  but
if it is meant to be asserted that its diffusion  has
been in proportion to the intercourse between in-
fected and healthy districts, the assertion is by no
means supported by  facts.   Its appearance at
Madras, for  instance, whither  according to this
doctrine it ought  to have been conveyed  almost
three  months earlier by trading vessels from the
infected districts, was  simultaneous, as Mr. Bell
informs us, with  its origin in parallel latitudes in
the  interior.   It did not  reacb Ceylon, to which,
on the contagious principle, it ought to have been
conveyed at a much  earlier  period, by shipping
from infected points of  the coast, until it had pre-
viously gained the nearest point to it on the con-
tinent, about Adam's Bridge,  and had  b.'en 'ong
prevailing on both coasts of the peninsula.  (Or-
ton  on Cholera,  2d edit. p. 332.)   Unfrequented
villages have been observed to suffer the invasion
of the disease as early  as the ma-its of intercourse
and  commerce;  thus,  from a  statement of  Mr.
Orton, it  seems to. have reached some village* on
the  north bank  of the Cavery, — detached from
any frequented road, and considerably to the east-
ward  of  Trichinopoly, — quite as  soon as  tins
large  and frequented town, whither it appealed 
418                          CHOLERA—[EPIDEMIC]
to have been imported by a company of sepoys.
(Ibid. p. 331.)
  Its movement along navigable rivers has been
dwelt upon as evidence that  human intercourse
has been the means of its diffusion; and it is an
argument of some force in showing that such in-
tercourse may have occasionally been instrumental
in effecting it: but when  we are informed by Mr.
Orton that the disease manifested this predilection
for the course of rivers  in the peninsula of Hin-
dostan, " where navigation is scarcely carried on,
even to the most trifling extent, on any river, and
scarcely an instance can be mentioned of a great
road running on the bank of a river, for they al-
most all cross them,"  we must  acknowledge that
more weight has been  attached to the argument
than it is calculated to bear.
   The disease, in its  general  course, has  mani-
fested a preference for one line of  movement, and
has  rejected another, though  there has been no
striking difference in the amount of human inter-
course between the two directions to explain  the
preference and rejection.  Its progress in a north-
western direction  across  the European continent
has been briefly described, and is  fully known to
the reader.  For three years  it prevailed  ii»  die
Ottoman territories bordering on the Levant; and
it would  appear,  without any deficiency  in  the
productive (or at least destructive) force  of those
germs of which we have recently heard so  much;
for in November, 1822, it numbered 4000 victims
in eighteen days  in Aleppo; yet it has not pene-
trated into Turkey in Europe, and  other extensive
realms on  the shores of the Mediterranean.  As-
suredly this  could not arise from  want of  means
of transport, and few will be  disposed to ascribe
it to the perfection of the quarantine department
of the Sublime  Porte.   Since its  appearance  in
this  country a similar  predilection has  been dis-
played ;  for we find it at this instant a hundred
and  forty miles to the north-west  of Sunderland,
whilst six  miles south is the extreme distance to
which it has reached in that direction ;  and from
the  point  which it attained,  Seaham  Harbour,
after attacking eight persons and destroying three,
it has since vanished.
   A circumstance which may be urged  against
the  exclusive operation of contagion, (and it is
against attributing too  much to  one  principle
alone that we are arguing,) is the unusual pre-
valence of disease, bearing a considerable relation
to epidemic choleric fever, which generally occurs
prior to the  appearance  of this  in any  given
locality.   The facts which might  be mustered  in
proof of the antecedence  of such  disease are far
too  numerous and consistent to  be  accidental.
Ordinary  cholera, sporadic cases not distinguish-
able from the epidemic, excepting  by the isolated
manner in which they occur;  epidemic diarrhoea;
gastric  and  intestinal  fever, have  been observed
in so many situations and by so many individuals,
from 1817 to the present instant, to  have been
the precursors of the disease, that  there cannot be
a reasonable doubt of the accuracy of the observa-
tion.  During the last year  the prevalence  of
these affections in various parts  of this country
has been matter of familiar remark among medical
men, and  many of them have  very properly taken
 vue to record their observation. (See Dr. Bnrne's
Dispensary Reports,  in  the  Medical Gazette for
July 2d, and July 16, 1831.)  In this neighbour-
hood, what Mr. Orton felicitously terms the skirts
of the  approaching  shower were manifest long
before the  epidemic made its formal inroad.   Or
dinary  cholera was  most  unusually  prevalent;
whilst cases of disease, certainly not distinguish-
able bv svmptoms from the epidemic, ocurred on
the  5th, 8th,  14th,  and  27th  of August;  and
cholera continued to  be very prevalent  and severe
throughout September. The cases which occurred
in August were not  matters of secrecy, but were
the  subject of conversation among the  medical
men of the place; and the writer frequently made
the remark, that we  were partakers of  an inferior
degree of the epidemic influence which existed on
the  continent.  But certainly at the time he did
not  (nor does he yet) ascribe them to imported
contagion; nor did he then  conceive that we had,
properly speaking, the epidemic among  us.  What-
ever view others  may now  feel  disposed to take
of these cases, it would be difficult for them to
suppose that the case we have mentioned, as hav-
ing  occurred  in  the  interior in the beginning of
July, was attributable to foreign importation.
   Under  either view, as it appears, whether we
conceive that a current of contagion flows towards
 a district,  or suppose  the disease  to be engendered
 there  by indigenous  causes, (not customary ones
certainly,  any more than those which  existed in
! the  Delta  of the Ganges in 1817,) and  then to be
 invested with some  contagious property, which
 observation of the disease will induce most candid
 persons to admit it possesses, it requires the opera-
 tion of  two principles to explain all the facts of
 the case ;  for even on the first supposition we are
compelled  to  imagine this double operation to be
in progress,—a current of contagion to be flowing
 from one  point, and a nidus for its reception to
 be preparing in another.
   We have been led to the conclusion that  the
disease  possesses  a   contagious   properly, from
 having  observed  that a considerable  proportion
 of attacks have taken place in individuals shortly
 after communication with the sick, or exposure
 to emanations from  the dead bodies, and, in part,
 from a few examples having occurred of the  dis-
 ease appearing in parts of the town or  neighbour-
 hood  where  it did  not previously exist,  on the
 sickening there of persons who had communicated
 with the  infected districts; but at the same time
 we  beg to remark  that there are circumstances
 which  tend  to  show that  this  property is ab-
 stractedly feeble in degree,  and to render it more
 than  questionable whether it can  be the  sole
 agent in diffusing the disease.
   This opinion  is founded  on the singular ano-
 malies observed in the course of the disease,  and
 which still mark its progress, and on  the follow-
 ing considerations:—
   1. .Members of that class of society  which has
 manifested the strongest predisposition to the dis-
 ease have  been very long exposed to the emana-
 tions from the sick under circumstances the most
 favourable to the propagation of the disease, with-
 out being infected.
   2. No death, and  scarcely an attack of serigus
 indisposition,  has occurred among the medical
I men,  though  they have  spent hours  in the pa- 
CHOLERA—[EPIDEMIC]
419
dents' chambers, assisting in frictions and other I
offices usually performed by nurses, and from the
fatigue they were undergoing might be supposed
to be peculiarly obnoxious to contagion.
  3. Medical practitioners have not in any ascer-
tained case conveyed the infection in their clothes
to patients whom they were attending for other
diseases,  or to their families.  Certain of them
have mingled unreservedly with their own families
after long attendance on cholera patients, without
any indisposition, however sligbt, occurring in
consequence.  It  is proper, however,  to  remark
that two  cases have occurred, one of them a fatal
one, which  might be attributed to the intercourse
of medical men with their families.
   4. When the disease has appeared in a private
family in a situation in life above the labouring
class, it has been confined, so far  as  the writer's
knowledge extends, and  he  is of opinion that he
is acquainted with the circumstances of all the
cases of the kind  which have  occurred,  to the
individual first attacked, and  has  not in  any in-
stance spread to the other members of the family ;
nor have in these instances  nurses or other casual
attendants on the sick suffered, though belonging
 to a class more obnoxious to the disease.
   5.  The agricultural villages in the immediate
 neighbourhood of Sunderland, which had through-
 out the whole progress of the epidemic the most
 unreserved intercourse with us, remained and still
 remain exempt from the disease.   The populous
 village of Deptford, situated near the river, at the
 distance of half a mile  from Ayre's Quay, where
 the disease was very prevalent and fatal, and hav-
 ing the  most constant communication  with  it,
 partakes of this exemption.*  The town of South
 Shields,  containing nearly 14,000  inhabitants,
 and distant from  Sunderland but  seven miles,
 remained exempt from  the disease (with the ex-
 ception of two cases, stated to be very slight, and
 not traceable to  any  communication with this
 place,)  during the whole  of its epidemic  pre-
 valence  here, though  calculations  have  shown
 that eleven hundred persons pass weekly between
 the two places.  Explanations have been offered
 of this exemption ; but they appear inadequate if
 we suppose  this disease  transmissible  to every
 locality by human intercourse, since typhus, scar-
 latina, and  other  infectious  diseases frequently
 prevail there to a great extent.  Even to the pre-
 sent moment, (Feb. 2,  1832,)  though its inter-
 course with Newcastle and other  infected places
 has been incessant, but seven cases have occurred,
 and, as  our intelligent correspondent there re-
 marks, " We have not as yet got  the disease as
 an epidemic, the  cases  have been so few and far
 between."
    6. Though the disease has appeared, in certain
 cases, to be  transferred to previously uninfected
 districts  by  spreading  from  persons who  had
 sickened there after arriving from places where
 the disease  prevailed,  yet facts  have   occurred
 which tend  to show  that  the  sickening of such
 persons  and the diffusion of the disease  have, at
 least in  some instances, been mere coincidences.
 ♦There were two slight cases in this crowded village
inhabited by the class most susceptible of the disease,
but it did not spread from them to the rest of the popu-
lation.
A woman of the name  of Liddle, who lived in
Sunderland, sickened at  the  town of Houghton-
le-Spring, six  miles  from this place, and died on
the  5th of December. The next case occurred on
the  8th of the same month, in the person of a
female named Cockburn, who lived a considerable
distance from  the' house where Liddle died, and
in a different street, and  had had no communica-
tion with her, direct or indirect; the family of the
house  in which the  death occurred, and the per-
sons who surrounded Liddle  in her illnes, escap-
ing all infection.  In many  other  instances in
which the disease has appeared in a mining dis-
trict or village, (and it has  spread extensively in
such situations,) the  first cases could not be traced
to communication with infected places.  In certain
cases,  however, and we shall  mention that of
Hetton, the persons first seized had been in com-
munication with infected districts.
  7.  On the first appearance  of the epidemic in
certain places, several have been  simultaneously
attacked ; at Earsden Colliery, for example, thirty-
two.  On its first breaking out here, it manifested
itself in three  distinct points, between which no
communication could  be discovered ;  and  the at-
tacks in two of these  points were stimultaneous.
It  could not  be  traced from any source of infec-
tion to the individuals first  attacked.  In  many
instances,  likewise,  instead  of residents  in  the
same  house being successively attacked, its inva-
sion of several has been  simultaneous.
   8. There were  feelings experienced by various
persons,  either otherwise in perfect  health, or
labouring under complaints distinct from the epi-
demic during  its prevalence here, such as spasms,
thrilling sensations of the extremities, and various
affections of the  nervous system,  which appeared
to  betoken  the influence of some  cause more ge-
nerally diffused than contagion ; since many per-
sons thus affected had  not  been exposed to any
source of infection.   The writer was  at first dis-
posed to attribute these occurrences to the in-
fluence of imagination; but  they occurred in too
many instances, and in persons too  little sensitive
 and imaginative, to allow him to adhere  to  this
 explanation.
    After assigning these reasons  for  questioning
 the exclusive operation of contagion,  we think  it
 right to remark that epidemic  choleric fever has
 committed  fearful ravages in  some  families, espe-
 cially in those of which the circumstances were
 calculated at once to give intensity to the  causes
 of the disease, and  to render the individuals com-
 posing them more obnoxious to the action of such
 causes.   Of one family seven were attacked with
 the disease, of whom five perished.  The  case of
 the first individual  of the series  constituted one
 of the sporadic cases, and it is incredible that the
 next in succession should have received infection
 from  him, four months having elapsed  between
 the dates of the respective attacks ; but it is  pro-
 bable that contagion was transmitted from the
 second and subsequent cases, the  diseases having
 commenced on the  following successive dates, the
 11th, 12th, 13th, 16th,  17th, and 20th of Decern
 ber.  The case which occurred on  the 20th was
 that of an infant,  aged thirteen months, taken
 from  the breast of the fifth patient in the order of
 succession. 
120
CHOLERA —[EPIDEMIC]
  Many other examples  of transmission through
families have occurred, but few so striking as this.
We are disposed to attribute to contagion its full
share in the production  of such cases, aided by
the circumstances  of night-watching,  neglect of
order and cleanliness, &c, which are accompani-
ments of sickness in the dwellings of the poor;
but we must remark that cases have fallen under
our observation and come to our knowledge, which
show a  proneness to the  disease in certain  fami-
lies, independent of reception  from  a  contagious
source.  The following is an example of this kind.
A respectable female, living in the village of Jes-
mond Vale, where the disease  did not exist, and
who had had no intercourse with the sick, receiv-
ed a letter announcing that  a sister,  whom she
had not visited during her illness, and who resided
at Hartley a distance of nine  miles, had died of
the complaint.  She sickened in an hour from the
receipt  of the intelligence, and died in thirteen
hours from the commencement of the attack.*
   The following propositions  appear to be reason-
able corollaries from the facts presented by this
extensive  and intricate subject.
   1.  Epidemic choleric fever originated in a cer-
tain district under  peculiar atmospheric circum-
stances ; but these circumstances having previous-
ly occurred in the same district without the pro-
duction of a disease identically the same, we  must
regard its terrestrial or atmospheric cause unas-
certained.
   2.  On many subsequent occasions  there  have
been marks of its commencement and gradual rise
in other districts, which show that, in their soil or
atmosphere, there has been a tendency to the pro-
duction of the disease  from causes equally unas-
certained as those which first originated it, and in
such districts it has ultimately displayed itself.
   3.  It has thus appeared  to arise in various dis-
tricts not  by any means  always continuous  with
those previously contaminated, but often situated
in some general direction  with regard to them,
declining in one district as it  arises in another,
and thus appearing to move  in  a succession  of
local epidemic visitations.
   4.  Within the district which it occupies it pos-
sesses a contagious property, or, in other words,
those individuals who have intercourse  with the
sick,  especially in  a  locally  impure  atmosphere,
are attacked  in  a  greater  proportion  than   other
members  of the community;  and it is probable
that this  same contagious property may be the
means of  diffusing  it through  a  district disposed
to the production  of the disease, earlier than  it
might have arisen spontaneously there, or of ex-
citing it in a district in which, notwithstanding a
degree  of predisposition,  epidemic choleric  fever
might not have arisen spontaneously ; but  facts
which we have mentioned tend to render it  ques-
tionable whether it can be  thus transferred to dis-
tricts unpredisposed to receive or engender it.
   5.  Within the  district where  it prevails, ordi-
nary endemial causes mingle their agency with
that of  the general cause of the  disease, and the
malady is found to vary in prevalence and inten-
sity in different portions of the same district: thus
tbe disorder is  found to assail more individuals,
   * Related to the writer by Mr. Greenhow, surgeon, of
 Newcastle, who attended the case.
and to be  more  destructive in parts which are
dirty,  and in those placed low or near  the  banks
of a river, than in portions  of the  district  differ-
ently  situated.  The effect of these endemial in-
fluences is illustrated  by the progress of the dis-
ease in the town  of Sunderland, and by the rav-
ages it has committed in the village of  Newburn.
The latter place is built along the  margin  of the
river Tyne, and between it  and the river there
intervenes  only a bank,  formed of a mixture of
mud  and sand, partially covered  at high-water;
whilst a shallow  stream  of water  flows through
the village.   Here, although the disease has not
ceased,  three  hundred and  twenty persons have
been attacked, and fifty-five have perished, out of
a population of five hundred and fifty.
   6.  The character of the disease  varies consid-
erably in the different  districts which it invades.
Thus we had occasion to observe that in a min-
ing population dispersed  over an  extensive tract
of country, the township of Hetton, the disease
was attended with less collapse than in the lanes
and alleys  of a populous commercial town, and
the mortality was  consequently much  less; for
we cannot too strongly repeat what we have al-
ready remarked, that the  collapse  is the measure
of tbe danger. These observations are made with
no view of depreciating the medical practice adopt-
ed  in that district, which  was extremely skilful
and prompt, and even, with due allowance for the
difference of the character  of  the  disease, very
successful.   It should  be   remarked,  moreover,
that extremely collapsed were  intermingled with
the milder cases, but  in  proportions  the very re-
verse  of those we  had  observed  elsewhere.  In
certain districts in Northumberland, we have rea-
son to know the disease  resembled, in its general
character,  that which prevailed at Hetton; but
among some other mining  communities  the ex-
tremely collapsed has been the  common form of
disease.  We have remarked, too,  that whilst in
some  situations  the  cases  have,  almost  without
exception,  commenced with diarrhoea, in  others
the proportion of instances in which this has con-
stituted the initiatory symptom  has been smaller.
   This difference in the form of choleric fever in
different local epidemic  visitations, the cases oc-
curring in any given district possessing a general
correspondence in  character, and  being  distin-
guished from those which occurred elsewhere, was
observed in India by Mr. Scott; and it  appears to
us that this circumstance, coupled with the trans-
mutation  of the  disease  more  and more  into  a
febrile form as it has approached  more northern
climes, displays a deviation from that sameness of
character observed in diseases  engendered  exclu-
sively by human contagion.
   It will hardly be expected that we should leave
entirely untouched the question, whether the dis-
ease  originated spontaneously in  Sunderland, or
was introduced from  abroad;   but the extent to
which we have already pursued this intricate por-
tion of our subject forbids our discussing it at any
considerable length.  Those who reason from the
postulate that the disease is diffused only by hu-
man contagion will of course decide for importa-
tion ; but others will very reasonably expect that
before this be admitted, it should be proved by the
same positive evidence that would be required  to 
CHOLERA —[EPIDEMIC]
421
substantiate any other  fact of importance.   Any ]
thing approaching to this, or even any considera-
ble  probability of such an  occurrence, we  have
been unable to discover ; and we cannot but agree
with Dr. Ogden, that, whatever were the facilities
for  the importation of cholera here, they were
much greater in other places ;  and  that if it has
been imported,  so  far  from following tbe great
routes of human intercourse,  it has  chosen one
of the least frequented  paths,  (See Medical  Ga-
zette for January 21, 1832.)  [See on all this sub-
ject the writer's Practice of Medicine, 2d edit. p.
138.1
  The predisposing causes of  the disease, and the
means to be adopted for  preventing its diffusion,
have been published to the world in such multi-
tudinous documents, that we consider it unneces-
sary to occupy our  pages with remarks  on  sub-
jects now so familiar.
   [After the prevalence  of cholera in England,
Dr. Prout (Bridgewater Treatise, Amer. edit., p.
 197:  Philad. 1834,) observed an  absence of the
common lateritious sediments in the urine;  and
about the time the disease first made its appear-
ance, he noticed a positive increase in the weight
of  the air,  similar to what might  be supposed to
be  produced by the diffusion of a heavy gaseous
principle through the lower regions of the  atmo-
sphere.  Hence he concluded, that the cause of
cholera and of the urinary peculiarity was a  poi-
sonous body analogous to  malaria, whose  high
specific gravity, and feeble  diffusive powers,  kept
it near the  earth's surface, along which it insen-
sibly crept, especially in low and damp situations.
He very properly,  however, does not lay much
stress on this conclusion.  During the prevalence
of  the above-mentioned state of tbe urine, he like-
wise noticed, in almost every individual,  an  unu-
sually acid state of the saliva, and of the cutane-
ous exhalations; and about the time  the cholera
prevailed,  and  a little afterwards, he saw  more
cases of oxalate of lime renal  calculi, and of for-
midable hemorrhage from the  kidneys, &c, than
he  had ever previously seen during the long peri-
od  that urinary diseases had occupied his  atten-
tion.  As the cholera  disappeared, these pheno-
mena gradually subsided.
   The epidemic at Naples was complicated  by a
verminous  constitution of the  most singular  kind
that  has ever  been recorded.  This verminous
epidemic was not,  however, confined to those who
died of cholera, or who were affected with symp-
toms of it,  but occurred in all  the inhabitants  of
the country; and it is  asserted that the most con-
stant morbid appearances, observed in cholera, such
as  injection  of the digestive mucous  membrane,
development of  the mucous follicles, the presence
of  an  unusual kind of mucus, and of tricocepha-
lous worms, with change in the character of the
blood, were equally met with  in  those who died,
during the  epidemic,  of other diseases than  the
cholera. (M. Thibault, cited in Amer. Med. In-
telligencer, Feb. 15, 1838.)]
   Treatment.—Previously to entering on this
very important subject, we  think it advisable to
endeavour  to correct the misconception which ap-
pears  to prevail very  generally  among  members
of  the profession, who have not as yet witnessed
the disease, that some  one specific remedy, or, at
                                       Si
least, plan of treatment, must be sougnt  for, and
when discovered invariably adopted.  The import-
ance very properly attached by all writers to  col-
lapse as a feature of the malady, and their candid
avowal of the difficulty they have encountered in
combating it, is the explanation of the fact  that
medical men  who  are  practically  unacquainted
with epidemic choleric fever, have  taken a view
of its treatment which in the case  of almost any
other disease they would have repudiated as un-
scientific.  We know no condition  more hopeless
than that of extreme collapse in the disease :—so
hopeless, indeed, is it, that often have we  ques-
tioned, in watching  a patient in this state, whe-
ther our art at present possesses or is likely to pos-
sess any  resources  against it,  or, in  seeing him
emerge from it, and he has  sometimes  done so
most unexpectedly, whether the remedies employ-
ed, or some hidden power of the constitution, had
been instrumental in effecting  re-action.  But it
should be remarked that only in a  proportion of
cases—a proportion varying, as we have already
observed,  in different localities, and in the  same
locality at different periods of the epidemic—does
this extreme  collapse  occur; and  that  even in
cases of which the natural tendency is  to  pass
into this deplorable condition, much may be done
by early treatment for its prevention.  These con-
siderations should teach physicians and  patients
that safety is to be found only in the early admin-
istration   of  remedies;  and  the   former, when
brought into contact with the  disease, will  soon
discover that success in its treatment must result,
as in the treatment of other fevers,  from  adapting
his remedies to the varying circumstances of indi-
vidual  cases  and  of the  different  stages  of the
same case, rather than from the trial of specifics
for one portion  only of an  extensive series of
changes:—that his practice, in short, to  be  suc-
cessful, must be rational, not empirical.
   In the observations we  have  to  make on  the
treatment, we shall follow the natural subdivisions
adopted in describing the disease.
   1. Treatment of the  Incipient Stage* —
We have adverted to two forms which this  stage
assumes.   In the one, there is  some  general un-
easiness, nausea,  and vertigo:  in the other  these
affections may coexist with diarrhoea, but the lat-
ter is frequently present without the former being
discernible.  The first of these forms, in which it
may be remarked that medical aid is rarely re-
quested, requires  that the stomach  should be un-
loaded by an emetic, and a table-spoonful of good
mustard  constitutes a very efficient  one; a Tew
ounces of blood should be drawn from a vein;  a
laxative  of calomel and rhubarb  administered ;
and the patient restricted  to a  diluent  diet, and
kept witbin doors and warm.   The treatment of
the diarrhceal form, to which  circumstances wit-
nessed by us lead us to  attach considerable im-
portance, must be noticed more at length.
   It was  mentioned that, in this diarrhceal  form
of  the incipient stage, the evacuations are at first
found  to be foecal and bilious;  but at the  timt
medical aid is summoned, they  have generally as-
sumed the serous character  which they bear in
the choleric stage.   A state of  the  system resem-
bling, in some degree, collapse, it  was observed.
coincided with this  condition  of the  alvine dis 
4<{2                          CHOLERA —[EPIDEMIC]
charges.   In this state  it was found very advan-
tageous to give a dose of calomel, conjoined with
a proportion of opium  and some aromatic,*  and
in twelve or fourteen  hours afterwards a  dose of
castor oil. On first visiting such a patient, a large
blister was generally applied to the abdomen, in
the jases under our care;  warmth  was enjoined,
—indeed where compliance with our wishes could
be enforced, the patient was confined  to bed,—
and it was directed that the diet should be diluent.
The subsequent treatment consisted in  the  em-
ployment of smaller doses of calomel and opium
for one  or two  successive nights,  and a second
dose of oleum ricini was sometimes administered.
   In  certain localities  the writer  has found  the
constitutional state accompanying  this stage of
the disease to be one  of marked excitement rather
than of  feebleness  and collapse, and some points
of the abdomen have  been painful on pressure. In
such cases  one general bleeding, or the very  libe-
ral application of leeches to the abdomen, has pre-
ceded the employment of other remedies.  In other
respects the same treatment has  been found suc-
cessful as that  adopted in  the preceding form, ex-
cepting  that no stimulating ingredient was mixed
with the calomel and opium.-j-
   Under these plans of treatment we have the
satisfaction  to state that, in every case which has
fallen under our immediate observation, the  dis-
charges  have resumed their natural bilious appear-
ance, and the  diarrhoea has been  finally arrested
without the supervention of a cold stage, and, con-
sequently, of fever,  though the disease had oc-
curred  in various  instances in persons who  had
been in  incessant  attendance on those ill of the
feverish stage,  and  though in all cases it  bore
 the  characteristic  marks  of what  we may  term
choleric diarrhoea.  It  should be remarked, how-
ever, that the choleric stage has  supervened, as
we have been informed, on diarrhoea which  had
been  skilfully  treated; but our  inquiries have
uniformly convinced  us that in such cases medi-
cal aid  had not been summoned till the  diarrhoea
had existed some  time, and the  subsequent stage
was closely impending.
   2.  Treatment of  the  Cold   or  Choleric
Stage.—In order  that we may be distinctly un-
derstood in  our observations on the mode of  con-
ducting this very important stage,  it is necessary
 that we should adhere  to  its subdivision into two
 periods. $

  * The following is the  formula we have usually em-
 ployed.
    R Hydrargyri chlorid. mit. gr. viii. vel. x.
      Opis,  gr. ii.
      Pulveris capsici,  gr. i ss.
      Confectionis rosas, q.ss. ut fiat bolus, statim su-
         mendus.
  t We think it proper  to remark, as probably the reader
 will perceive the discrepancy, that this  excited state of
 (he system was not enumerated among the  symptoms
 of the incipient stage of the  disease in our description
 of epidemic choleric fever. In extenuation of this omis-
 sion, and, perhaps, of certain deviations from strict order
 that may be  discernible, it should be mentioned that the
 composition  of this article and our acquaintance with
 ihe disease,  in various  localities, have  been simultane-
 ously in  progress, and we have deemed it better to sac-
 rifice some degree of regularity than to withhold from
 the reader information which  may speedily  prove va-
 luable.
   | The credit of this subdivision belongs originally to
 Mr. Kennedy.  Experience in the disease having con-
 vinced us of its practical importance, we have adopted
 >'. in this article.
  The  first  period  is  certainly  tbat  in  which
alone our most powerful means of arresting mor
bid  actions can be  employed with a considerable
prospect of success.   It may  be considered an
axiom in medicine, that fevers, to be successfully,
must be  early treated, and  the rule has a power-
ful  application to a fever so rapid in its course as
that under consideration.   But there are  many
obstacles to its being  generally acted upon amid
a town population ; and one considerable obsta-
cle, we apprehend,  will every where be found  in
that self-deception which seems to be quite a fea-
ture of the disease.   We have  met with persons
to whom,  from their peculiar ^situation,  all  the
symptoms of this fever were as familiarly known
as to medical men, yet when they were attacked
with  it, they did not  or would not recognise it;
and one  such individual actually walked out with
the disease upon him, and failed to send for assist-
ance  till eight hours  after its invasion, though it
was so severe as to  destroy him in twelve.  So
strong is this tendency to self-deception regarding
the nature of the disease when the choleric stage
actually  occurs, that  wherever choleric  fever pre-
vails, strong  appeals  should be made to the pub-
lic  on the necessity  of early  treatment  of this
stage, as well as  of due care of that which  gene-
rally precedes it.
   The first remedy to be considered is bloodletting,
and we shall  endeavour to point  out the circum-
stances which, so far as our observations extend,
indicate, and  those which forbid its employment.
Its safe administration  should be early, not  ac-
cording to mere  time only, but with respect like-
wise to  the rapidity  of  the disease, for one case
will have made as considerable a progress towards
actual collapse in two hours as another will have
done in ten ; and we should regard a considerable
degree of collapse, indicated by feebleness or arrest
of the circulation, and perceptible in the intervals
of  pain  and  spasm,   (for when these occur, the
pulse often sinks instantly, though only a second
before it had been  beating with considerable
vigour,^) as  an  imperative reason  for abstaining
from drawing blood.  But if we find the tempe-
rature not below or  but little below the healthy
standard, a pulse  of tolerable  force, and  strong
spasms recurring at short intervals, provided col-
lapse have not preceded this favourable condition,
we should at once open a vein, and  not lose an
opportunity,  which will never be restored, of pro-
bably preventing extreme  collapse, and either its
immediate fatality, or its more remote but scarcely
less fearful evils.  But should this condition, with
respect to circulation  and temperature, have suc-
ceeded to collapse,  either spontaneously or by  the
administration of remedies, our experience would
dictate that  bloodletting should  be carefully  ab-
stained from, as  we  have seen great  injury pro-
duced under such circumstances by its employ-
ment; cases  having  fallen under  our notice  in
which the loss of three or four ounces of blood has
destroyed the fruits of two  or three hours' assidu-
ous labour.  The difference in the effect of blood-
letting on conditions apparently very analogous,
but differing in  the  periods from the commence-
ment of the  attack at which they manifest them-

  § Query— Does this sudden and momentary arrest of
the circulation arise from spasm of the heart ? 
CHOLERA —[EPIDEMIC]                         423
selves, cannot be too strongly impressed  on the
reader's  attention.  Perhaps the only difference
in external character which can .be discovered be-
tween the  two  states will  be  the existence  of
spasms of considerable strength in the early pe-
riod, whilst in  that  more  advanced  they  have
nearly, if  not altogether, ceased; but  in the one
case bloodletting breaks  the morbid catenations,
and prevents collapse and congestion; in the other
it lowers  the vital energies which are  freeing
themselves from a state of oppression.  But again,
in a more advanced stage, when the constitution
is no longer balancing between collapse and  fever,
and the latter may be considered  as established,
bleeding is a suitable remedy, if the state of the
circulation and the general  condition  of  the pa-
tient render it admissible.  Thus,  then, there are
three periods of the disease  at which, according
to our experience, bloodletting may be employed:
occasionally in the incipient stage, as has already
been stated;  in the early part of the first period
of  the cold stage ; and at the commencement of
the feverish stage, under  circumstances to be sub-
sequently mentioned.
   We have been explicit on this head  perhaps to
prolixity, because we  found  great  discrepancy  in
the testimony of various  Indian and  continental
authorities regarding it;  and in the early part of
our experience 'of the disease, the selection of the
appropriate time for  bleeding,  and the  circum-
stances which indicated  or forbade it,  constituted
the greatest difficulty  we had to encounter.
   The measure to be adopted next in succession
to  bloodletting will depend on  the condition of
the patient.  If in a  short time after bleeding we
find a circulation of tolerable force, without much
tendency to general or partial deficiency of heat,
and if at the  same time there be pain in  the epi-
gastrium increased  on pressure, a very common
accompaniment of cases in which the tendency  to
collapse is least conspicuous, a large blister  or
sinapism to the abdomen, and a dose of  calomel
and opium, in  the proportion  of  from  eight  to
twelve grains of the former to  one and a-half  or
two of  the latter, will be  suitable remedies.—
Should  the circulation, on the other hand, be fee-
ble, with general or partial deficiency of warmth,
we should endeavour  to rouse the  system by full
vomiting,  and powdered  mustard is a very proper
means of accomplishing the object.   Half an ounce
of this substance, suspended in half an ordinary
tumbler of warm water, may be considered  a me-
dium dose, and one which, in a great majority of
instances, will act promptly and powerfully ; but
in a more  advanced stage of the disease, when the
collapse has been extreme, a whole ounce has been
required to produce the  full effect.*  After full
vomiting, sinapisms may be applied to the abdo-
men and along  the spine;  whilst the warmth of
the patient is supported by bottles of hot  water
wrapped in flannel,  bags of hot oats, and other
familiar  methods of applying dry heat, directed to
the extremities or other points of which the tem-
perature seems deficient.   Frictions of the parts
  *  It may save the reader some trouble to  inform him,
that an ordinary table-spoon, unheaped, contains half
an ounce of mustard; and that the  mustard sold in the
shops under the name of Durham mustard, which is of a
uniform bright yellow colour, is the most pungent and
efficacious.
affected with spasm will at the same time be pro-
bably required, and should be performed under the
bed-clothes.  We have not found any beneficial
effect, in relieving the spasms, from oil of turpen-
tine or  other stimulating  embrocations; the cold-
ness produced by their evaporation probably more
than compensating for any benefit they are in other
respects calculated to effect.  A bolus of calomel,
capsicum, and opium, the  latter not in a proportion
exceeding  a grain and a-half or two grains, may
be  administered as soon as the vomiting from the
mustard has totally ceased.  The quality  of the
liquid given at this period ought to depend  on the
condition of the  patient:  if, for instance, the ten-
dency to collapse be considerable,  a little weak
brandy and water should be given at short inter-
vals ;  but, should  the  circulation  be  tolerably
vigorous, and the temperature good, simple dilu-
ents, such as toast and water, constitute the most
suitable beverage.
   Should the patient be in a state of considerable
collapse, whether consequent  on neglect  of the
earlier  stage, or occurring, which will occasionally
prove to be the case, in spite of the most diligent
attention to it, bloodletting should  not form part
of  the remedial agents selected.   If the  tempera-
ture be in  any  considerable degree below  the
healthy standard, with the hands cooling rapidly
on  exposure  to  the air; the  pulse  at  the wrist
either very feeble or totally suspended; the breath
and  tongue cool; the surface shrunk and  pallid,
or  in certain parts livid ;  the vomiting and spasms
diminishing in their intensity, or totally ceased ;—
at  whatever period from the commencement of the
diseace this state of things may exist, bleeding
should  be abstained  from.  It will be  advisable to
endeavour to rouse  the system  by full vomiting ;
and half an ounce of mustard, or, if the attendant
prefer another mode of accomplishing the  object,
two table-spoonfuls of common salt, a scruple of
sulphate of zinc, or half a drachm of ipecacuanha
with a  small proportion of brandy may be admin-
istered.  Should  the emetic selected fail to produce
its  effect  in a quarter of an hour, it ought to be
repeated ;  or should the circumstances of the case
lead the attendant to suppose that the sensibility
of  the  stomach is very low, a larger  dose  of the
emetic  drug may be administered:  we recollect
having produced full vomiting by an  ounce of
mustard in a case of extreme collapse, in which
two smaller doses had  been administered succes-
sively without effect.  Simultaneously with the ex-
hibition of the emetic, dry heat should be applied
by  some of the methods already mentioned, or by
that very  convenient and simple apparatus, the
hot air-bath.
   Various  internal medicines of  the  stimulating
class have been recommended for this state.  Those
of  which we have  been led  to  form  the most
favourable  opinion   are  mustard, carbonate  of
ammonia, and oil of turpentine.  The first named
substance we have not unfrequently administered
in  doses of a drachm, (a tea-spoonful unheaped.)
at  intervals of an hour or an hour and a half, ap-
parently  with the  effect  of  giving additional
vigour  to the pulse, which had perhaps  been re-
stored by the vomiting ; of producing bilious dis-
charges from the bowels;  of restoring the urinary
secretion, and aiding the  system in '.he transitirm 
424
CHOLERA —[EPIDEMIC]
into the febrile stage.   If the carbonate of ammo-
nia be the stimulant employed, a convenient mode
of giving it is in doses of five grains every hour,
with carbonate of magnesia, which makes it more
easily retained  should the stomach still retain its
irritability.  Should oleum terebinthinse be select-
ed, doses of two drachms  may  be given  every
second  hour.   Whatever stimulant medicine be
employed, we should  advise that calomel in doses
of five or six grains, repeated at intervals of three
or four hours, should  be given at the same time,
with the view of aiding the  restoration of secre-
tion ; and, with the intention of  at once rousing
the system and lessening the irritability of the sto-
mach, that a large sinapism should be applied to
the abdomen, and another along the course of the
spine.
   Various  stimulating nostrums, if applicable to
any, certainly  only to this  period of the  fever,
have been  bruited forth to the world as  specifics
for the disease.  In  many of these we are of
course inexperienced, and of all we are convinced
the powers have been overrated, in some instances
from partial  and mistaken views of the malady,
and in  others from less pardonable reasons.   It
will not be deemed necessary that we should pass
them all in review; but of certain remedies wbich
have been proposed  for collapse, the professional
reader will require some notice.
   The inhalation of  oxygen  gas has been  sug-
gested from many quarters; and in some cases in
which  it has  been tried  here an  instantaneous
amelioration has been manifest, the pulse having
become more vigorous, the lips florid, and the pa-
tient having experienced relief from  praecordial
oppression  and  other distressful feelings, to an
extent and with a promptitude not afforded by any
other measure.  But the  experience of medical
observers in general has led them to conclude that
this  effect is very transitory; and some are of
opinion that they have witnessed an increase of
the collapse  after the temporary excitement, as if
the vital  power, instead  of being  permanently
increased by the measure, had been expended in
a momentary flash.   Of  some gentlemen,  how-
ever, the opinion regarding it is more favourable.
Our own opinion  is,  that  inspired for  a few
seconds in single bladders,  no great benefit  is
likely to accrue from it; but we should speak less
positively of the  effect of an atmosphere of diluted
oxygen breathed for a considerable period.
  The tobacco enema has been suggested by Mr.
Baird of Newcastle, and, as he  assures  ns, em-
ployed with considerable success.  We  acknow-
ledge that a priori  reasoning would rather have
led us from this  remedy than  suggested it  to us ;
but  knowing the fallacy of such  reasoning in
medicine, we are not disposed to treat with neglect,
still  less with contempt, a measure of the  bene-
ficial effect of which  a gentleman  of talent and
character adduces several examples.  It was pro-
posed after the disappearance of the epidemic from
Sunderland, and we  have no experience  of it:
but we would recommend that it  should  be tried
in a case to the successful  treatment of  which
other measures seemed inadequate, the practitioner
being governed,  as to its subsequent employment
or rejection, by  its effect.
   Two remedies have also been mentioned to us
by an individual of talent, and of great experience
in the  epidemic, Mr. John Fyfe, of Newcastle:
we shall, with his permission, make the readei
acquainted with them.   One  is the employment,
in the  period of extreme collapse, of an enema,
consisting of two pints of warm water, from four
to eight ounces of brandy, and  from one drachm
to two drachms of laudanum  or Battley's sedative
liquor.   This, he assures us,  has  the  happiest
effect, in abridging that stage  of the disease on the
intensity and duration of which so much of the
danger  depends.   The other is an enema contain-
ing a drachm of powdered mustard, which he has
found to be very speedily instrumental in restoring
the urinary  secretion.   This accords  with out
experience, as already  stated, of the efficacy of
this substance given by the mouth, in accomplish
ing the same object and the  restoration of the
secretions generally.
   Weak  brandy and water  may be  given  occa-
sionally during  the collapse; and we have ob-
served no injurious effect in this  or any stage of
the disease  from  the ordinary  diluents taken in
moderate quantities.
   3. Treatment of the Excited  or Febrile
Stage.—The treatment  to be  now pursued will
not require such lengthened discussion as that of
the preceding stages, which may be considered as
more exclusively  belonging  to this  disease; for
recognised principles, applicable to the treatment
of pyrexia in general, must be our guides in con-
ducting this  fever.
   The  fever constituting  this stage, be it in es-
sence what it may, has  inflammation accompany-
ing it, of which the principal  sites are the brain
and the lining of the digestive canal, and to the
subduing of  these, by such measures as the state
of the  system admits,  our attention should be
carefully directed.
  A form  of fever has been  described  as super-
vening on an extreme and long-continued collapse
in the cold stage, and in which  fever it was men-
tioned that the vascular action was low and feeble,
the temperature of the  surface under the healthy
standard,  and the distribution  of warmth  very
partial.   In this low form of disease we have not
ventured on  general bloodletting ; local bleeding
from the temples has been freely performed,  and
occasionally  too from the integuments of the ab-
domen,  wben there were any indications of in-
flammatory affection of the digestive canal; but
the great degree of intellectual torpor and insensi-
bility which  attends these extreme cases renders
the discovery of such an affection extremely dif-
ficult.   Blistering the  nape  of the neck,  and
shaving the  head  so as to permit the application
of cold,  will be found very suitable measures.  A
degree of irritability of  stomach, with occasional
vomiting,  is  a very  frequent  accompaniment of
such a case for the firsf two  or three days;  and
under   such  circumstances leeches  and subse-
quently  a  blister to the  epigastrium have  been
resorted to with benefit.
  Of internal remedies, that  on which most re-
liance is to  be placed is calomel, from its effects
on the  secretions, particularly  of the intestinal
canal, and from its facilitating the action of the
laxatives which the state of the brain renders it
advisable to administer.   If two  grains of calomel 
CHOLERA —[EPIDEMIC]
425
are given at intervals of three or four hours,  an
occasional gentle laxative, such as castor  oil or
calcined magnesia, will generally produce two or
three bilious discharges from the bowels.   Simul-
taneously with the administration of these  reme-
dies, the imperfect developement of heat and  its
partial distribution require attention.  The patient
should be placed near a stove  or  in some warm
situation, and bottles of hot water, or hot flannels,
should be applied to the feet, or other parts  which
are chilled.   Even whilst endeavouring, by local
depletion,  to relieve partial  determinations  of
blood, the  general state of the system has been
such as to require a little stimulus, and wine and
water has  been given,  especially at an advanced
stage of the  disease, and occasionally medicinal
stimulants,  such as carbonate of ammonia, cam-
phor, and sometimes, as a tonic, sulphate of qui-
nine ; but we cannot say that  mucb  benefit has
resulted from the latter class of agents.
   Such is the treatment we have generally adopted
in that form of the febrile stage which is dis-
tinguishable from  any  fever we have been in the
habit of observing here or elsewhere.   The more
excited form admits of  one general bleeding with
advantage,  the amount  of blood drawn  being
regulated  by the  degree of  vascular  action,  of
headach, of injection of the eyes, and various cir-
cumstances which would influence our proceeding
in any ordinary fever.   Should the  head, as it
generally does, continue  affected  after the  blood-
letting, the application  of leeches and cold should
be resorted to, the former being repeated, if neces-
sary, to such extent and at such intervals,  as the
degree of headach, intellectual torpor, and vascular
excitement  may seem to require.  Laxative medi-
cine should be administered;  and  the  purpose is
exceedingly well answered by calomel in doses of
four or five grains nightly, and six drachms or an
ounce of castor oil every morning.   The diet un-
der  such  circumstances should  consist  of the
mildest and simplest diluents, such as would be
demanded  in  any  case  of  inflammatory  fever:
after  the case has subsisted  some days, a little
wine  and  water may be given if  exhaustion  be
manifest, but it should not be continued beyond
the necessities  of the  case.   Though we have
seen few or no cases without  a degree of cerebral
affection, examples are  met with in which the dis-
order of the intestinal  canal is more considerable
than that of the brain.   Diarrhoea, the discharges
being deeply bilious; a red, glazed, and very dry
tongue; some degree of fulness and tension  of
the abdomen, and of pain on pressure there; and
scanty high-coloured urine, generally attend such
Rases.  The general treatment of cases in  which
such an affection exists, must depend on the state
of the system; but the intestinal disorder demands
the free application of leeches to the  parietes  of
the abdomen, repeated according to circumstances,
iuid the internal exhibition  of mild  mercurials,
such as hydrargyrum  cum creta, or blue pill,
with a small quantity of opium.   That kind  of
permanent fomentation which is  afforded by hot
poultices to the abdomen, after the application of
leeches,  has  been found beneficial.   The diet
throughout a case in  which this inflammation of
the mucous lining of the intestines exists, should
be mild and demulcent.   In cases of this descrip-
  Vol. I. —54                       2l*
 tion—indeed in the most excited as well as in the
 lowest forms of the disease in which the collapse
 of the cold  seems prolonged  through the febrile
 stage—it is  advisable to counteract, by warmth to
 the extremities and other points, that tendency to
 irregular distribution of blood  which  forms  so
 striking a feature of the disease.  Cases are oc-
 casionally met with, so mild  in all  their  stages,
 that  the fever requires no medical treatment but
 a few leeches to  the  head, a little laxative medi-
 cine, and  abstemious diet for a few days.
    [The intense thirst of cholera must be satisfied
 by a liberal  allowance of ice  or of ice-cold water.
 They are  most grateful, and tend to allay the irri-
 tability of the stomach.
    To arrest the diarrhoea in all stages, the  acetate
 of lead was much employed in  this  country, and
 was  highly extolled by many practitioners,  as well
 as by Dr. Graves, of Dublin.  In the writer's own
 observation  it was not attended with any strik-
 ingly salutary effects.  Strychnia was used  en-
 dermically,  and, it was  affirmed, with advantage.
 It was, also,  given  internally to allay vomiting,
 and  Dr. Ryan, somewhat hyperbolically we fear,
 states, that a twelfth of a grain, given in pill, and
 repealed a few times, has been frequently known
 to check a profuse diarrhoea with rice-water evacu-
 ations, and even when the  extremities were blue,
 in cholera, (Ryan's Universal Pharmacopoeia,  3d
 edit., p. 336 : Lond.  1839.)
    The extensive loss of serum, and, consequent-
 ly, of the watery and saline  parts of the  blood,
 led to the administration of solutions of common
 salt and of  the carbonate of soda internally, both
 by the mouth and in enema;  but  owing  to the
 suspension of absorption, these  substances  rarely
 or never got into  the  blood-vessels.   It  was then
 proposed  to inject them  into the  blood-vessels;
 yet although they became mixed with the  blood,
 they could not remove the pathological cause that
 gave occasion to the profuse separation of its wa-
 tery  and saline portions.   Hence, they were not
 found to answer  preconceived expectations.]
    Convalescence is in  many  cases  tedious, the
 strength being slowly restored, and slight irre-
 gularities of diet  sufficing to disorder the system,
 and  even to produce relapse.  For weeks  after
 the fever we have found tbe patient still languid,
 and exceedingly prone to irregular distribution of
 blood, especially  to  undue determination  to  the
 head, inducing headach (requiring the application
 of leeches)  on any  considerable  exertion.   To
 prevent such occurrences,  we have found it advi-
 sable that  the diet should  consist,  in  the early
 period of convalescence, of a  moderate quantity
 of vegetable matter only, and  that  the  transition
 to more abundant and substantial food should  be
 very gradual ; in short,  that convalescence from
 this  disease should  be  conducted  in  the same
I manner as that from other  fevers.
|    We have stated  that relapse may be produced
 by dietetic irregularities; and it is  important to
 observe that even the best directed  treatment  of
 the incipient or diarrhceal stage may fail in its ob-
 ject,  that of cutting short the disease, if such irre-
 gularities are indulged in.  The relapses, properly
 so called, have occurred at an early period of con
 valescence;  but we have witnessed  one example,
 and  that a very  severe one, of the recurrer r« 
426
[CHOLERA I N F A N T U M.]
epidemic choleric  fever after  an interval of two
months from the preceding attack.  This we were
disposed to consider rather as an example of second
invasion  than one  of relapse, though  it is proper
to remark  that the patient had  remained feeble
from the period of the previous disease.   No as-
signable cause existed for  the second attack.
   [During the prevalence of cholera, municipal
regulations were made in many of the  cities in
regard  to the articles of diet that might be allowed
with safety,  during the epidemic constitution.—
Some of these were of the most whimsical  kind,
dependent  probably, at times, on individual likes
or dislikes, caprices or prejudices.   Ripe fruits,
and  succulent vegetables, were generally  pro-
scribed :  yet the fact, that in charitable institutions,
where  no  such articles were  permitted, cholera
was  most fatal; that the disease prevailed most
fatally  at Moscow, St. Petersburg and elsewhere,
at seasons when  ripe  fruits and vegetables could
not be procured ;  and that where ripe fruits were
freely allowed, as  in London, at a later period of
the epidemic, no inconvenience was found  to re-
sult from them, ought to have created well-founded
doubts, whether the proscription were founded on
accurate observation.   (See the writer's Elements
of Hygiene, p. 302 : Philad. 1835 ; and his Prac-
tice of Medicine, edit.  cit. i. 147.)]
                           Joseph Brown.
   [III. Cholera  Infantum.—This  form of cho-
lera, commonly known under the name of sum-
mer comjjlaint, has been generally  regarded as
peculiar to the United States.  As elsewhere re-
marked,  however,  (Practice of Medicine,  edit.
cit. i.  147,)  it strikingly resembles the  affection
vulgarly called " watery gripes," in England.  It
does not appear to be known in  Paris :  (Barthez
and Rilliet, Traite Clinique et Pratique des Ma-
ladies  des  Enfants, i. 552:  Paris, 1843.)   It is
one of the most fatal affections to which children
are liable.   In Philadelphia, during  a period of
fifteen years, from 1825  to 1839 inclusive, 3352
infants died  of it—being almost 10  per cent, of
the whole  number of infants  under five  years of
age  who died  during that period; and 4-5  per
cent, of the entire mortality of the city.  (Condie,
Practical Treatise on the  Diseases of Children, p.
217 :  Philad. 1844.)
   Diagnosis.—Cholera  infantum commonly be-
gins with diarrhoea, more or  less profuse; but at
other times both vomiting and purging  come on
at first, without any premonitions; or the  infant
may have  suffered for a time  under gastric or in-
testinal derangement.   The  pulse is usually fre-
quent  and somewhat tense;  and there are almost
always manifest  signs of febrile irritation.   The
discharges are, at  first, extremely fluid and often
frothy, sometimes  tinging the cloths green,  and
at others leaving mucus  upon them.   In very se-
vere cases  the system becomes rapidly prostrated,
and the child may die in the course of twenty-
four hours; but more commonly the disease con-
tinues for a  few days  before either the  tendency
to convalescence or to death is manifest.  As in the
cholera morbus of the adult,  there is  often severe
intestinal pain, which may be increased by pres-
sure ;  and, at times, the  muscles of the  abdomen
and extremities contract spasmodically. The thirst
is  excessive, and the appetite gone or singularly
capricious.  If the disease be about  to terminate
unfavourably, emaciation makes frightful progress;
the febrile irritation is constant and manifest; the
child becomes restless and comatose, and gradually
sinks—the fatal termination being, at times, pre-
ceded by convulsions.  Frequently, the evacuations
exhibit the existence  of great  irritability of the
digestive tube, the food passing rapidly through it
without undergoing any change, and  being squirt-
ed out with great force.  At other times, they have
a putrid or cadaverous odour.  In  the more pro-
tracted cases, these appearances are more frequently
met with, along with aphthae of the  mouth, mc-
teorism of the abdomen, and other signs of follicu-
lar inflammation.   At times, before death, a vesi-
cular eruption appears extensively on the  chest,
which Dr. Dewees (Treatise on the Physical and
Medical Treatment of Children,) considered to
be  invariably  a fatal  symptom ; but  Dr. Condie
(op. cit. p. 219,) states, that he has  in many in-
stances known the patient to recover even when this
eruption has been the most extensive and distinct,
   The great indication of recovery is the appear-
ance of feculent matter, and  of the  ordinary  secre-
tions in the evacuations.
   Causes. — Excessive  heat is  unquestionably
concerned  in the causation.   It is, indeed, in the
summer months  that  the  disease  prevails  so
fearfully and so fatally in our cities ; yet some-
thing  more  than heat is required  to induce it
extensively ; for, in country situations, it is com-
paratively rare.   Atmospheric vitiation  must be
combined with atmospheric heat, and  hence it pre-
vails  in  the most crowded alleys of cities.  In
cleanly and well-ventilated districts, and in  large,
airy apartments, deaths from it  are  uncommon;
so that at times when the bills of mortality indi-
cate the greatest amount  of deaths, physicians
who practise extensively  in the better portions of
cities may see but little of it.  (Practice of Medi-
cine, i. 148.)  Dr. Condie (op. cit. p. 221,) states,
that when it occurs  in the  country, it is almost
exclusively in low, damp, and otherwise unhealthy
situations;  but  such has  not been the result of
the author's experience.   Age affords a predispo-
sition.  The common idea  is,  that  children are
more liable to it in the second summer than in the
first; but this does not seem to be confirmed by
statistical observations.  From the official reports
of deaths in Philadelphia and New York, it would
appear that, in the former city, of 229 deaths as-
signed to summer complaint, 142 occurred in chil-
dren under one year of age ;  75 in  those from one
to  two years ; and 12 in those from two to five
years.  It  rarely  occurs in infants  under  three
months of age.
   Under the predisposition  induced  by great at-
mospheric heat  and vitiation, it is clear that im-
proper aliment may be an exciting cause ; hence,
children brought up on spoon-meat suffer in greater
numbers  than those  that  are nourished  at  the
breast.
   In like manner, dentition may contribute to its
production.
    Pathological  Characters. — The  mucous
membrane of the bowels generally  exhibits evi-
dences of inflimmation, especially  of the follicles
which by some have been regarded as the primary 
[CHOLERA  INFANTUM.] —CHOREA.                  421
seat of the disease.   When it has existed for any
time, increased redness, in points and patches, has
been observed in different parts  of the stomach
and intestines ;  but attention has  not generally
been paid to distinguish whether these consist in
simple hyperemia or in inflammation of the lining
membrane.  The follicles are very generally en-
larged, inflamed, and occasionally ulcerated ;  tbe
enlargement, according  to Dr. Horner, (Patholo-
gical Anatomy, Philad.  1829,) often  resembling
a sprinkling of white sand upon the surface of the
mucous  membrane.  Occasionally, considerable
portions of the digestive tube are so  much  con-
tracted as scarcely to admit a small-sized quill; at
other times, portions of the mucous membrane of
the stomach and intestines are  greatly softened.
The liver is almost always enlarged.  This has
likewise been regarded  as the primary affection ;
but it is more probably  secondary.  The encepha-
lon, in nearly all cases,  has been found in a state
of hyperemia, and  in long protracted cases serous
effusions  have been met with in the ventricles, and
at the surface of that viscus.
   Treatment.—The general principles of  man-
 agement  do not differ  materially from those laid
 down  under enteritis of the mucous coat, and
 diarrhoea.   The cases that occur in the airy parts
 of a town are usually managed with facility, and
 carried to a fortunate issue; whilst those in the
 narrow alleys of the worst  parts too  often  resist
 every effort  of the practitioner.  It is all-important
 to remove the little sufferer from  the air tbat has
 generated the disease, to another situation.   This
 of itself is  often enough to  arrest the affection;
 but it may be necessary  to combine with it a gen-
 tle laxative — as a small dose of  calomel  or of
 rhubarb and magnesia.   Should the febrile action
 be considerable, it may be advisable to apply a few
 leeches to the epigastrium, more on  account of
 the revulsion, than of benefit to  be derived  from
 loss of blood, — covering the abdomen after the
 leech-bites have ceased to bleed, with an emollient
 poultice.  In other cases, especially where  there
 is great irritability of stomach,  stimulating  cata-
 plasms or fomentations may be applied, and in pro-
 tracted cases a blister.   Should the  disease not
 yield  to  the above treatment, small doses of the
 mild chloride of mercury may be  given frequent-
 ly, to produce a new action, if the  child be under
 two years of age,  which,  as  has  been  seen,  is
 usually the case.   After this age, there is  greater
 danger of inducing severe mercurial  stomatitis.—
 Should signs of acidity exist,  magnesia  in the
 ?arly  period, and  prepared chalk  subsequently,
 may be useful adjuncts.  Hence, the hydrargyrum
 cum cretii of the pharmacopoeias is a convenient
 preparation.  Where irritability of the stomach is
 present, which is  not relieved by external revel-
 lents,  injections of salt and water may  be used
 in the way  of revulsion ; or gentle excitants may
 be given internally, as  a drop or two of oil of
 aniseed  in  sugared water, or five or six drops of
 sulphuric ether in the same vehicle.
   It  need scarcely be said, that  should irritation
 from teething exist, the  gums should  be freely di-
 * ided, and should even the tooth not be set at liberty,
 the  revulsion, thus induced, may prove salutary.
 The warm  bath is  beneficial in  all periods of the
 disease.  In the more protracted cases, astringents
become necessary.  The acetate of lead has been
highly extolled by many.  (Dr. H. Lindsly, Amer.
Journ. of the  Med. Sciences, xxiv. 311.)   The oil
of turpentine  has  been  advised  when  there  is
flatulent  distension of the stomach and bowels;
and with the same view, a few drops of any of the
essential oils may be administered.  Great caution
must, however, be had in the use of both excitants
and  astringents.  During the convalescence any
of the milder  tonic  infusions may be prescribed.
   Throughout the disease, care must be taken in
regard to the diet; and, where practicable, the child
should be mainly restricted to the mother's milk.
Where this  cannot  be  done,  boiled  milk and
water, with any of the  farinaceous preparations,
as  sago  or arrowroot, may be  used.  By many,
the infusion of benne-leaves or gum-water is given
freely; but it may be  questioned whether these
mucilaginous substances are of much benefit;—
they may tend to shield and soothe the part with
which they come in contact, but they are difficult
of digestion.   The appetite is apt to be  very ca-
pricious—a great desire  being occasionally shown
for salted meat, salt fish, butter, &c.;  and it has
been esteemed proper to gratify  it occasionally to
a certain extent.  Doubtless,  in  many cases,  no
evil has resulted from such indulgence, but it must
necessarily be hazardous.  To allay the  intense
thirst, iced  water may  be allowed ; or the infant
 may be permitted to  suck ice contained in a piece
of gauze.
   At all periods of  the  disease, one of the  most
important curative agencies is change of air.  If
the child be removed into the country, this is the
best  course ;  but  where this  cannot be accom-
plished, riding or carrying the child about in the
open air is  of essential  service.
   In the Way of prevention, removal  during the
summer heats to the  country ;  or,  if compelled to
remain in town, sleeping on a mattress, with the
door and windows  of the chamber open; the daily
use of the tepid or cold bath ; exercise in  the open
air, and, if the child be weaned, well-regulated
diet, with especial  abstinence  from unripe fruits
and the succulent vegetable. The  constant use of
 a flannel bandage, even through the heat of sum-
| mer, has appeared  to the writer an important pro-
phylactic.

                       Robley Dunglison.]
i
   CHOREA.—The word chorea, as used by the
 ancients, signified a dance of  many people to
 music, being derived from x°P°s'  a band of singers
 and  dancers.  The  origin  of  its application to
 nosology is involved in  some obscurity.   Syden
I ham and other writers  have treated of the disease
 under the  name of chorea Sancti Viti, a desig-
| nation which has been very properly curtailed by
 Cullen and most subsequent authors.  This latter
 appellation, we are told  by Horstius, was  acquired
 in consequence of  some women  of disordered
 minds and affected with a peculiar restlessness of
 their bodies,  repairing,  once a year, to the chapel
 of t-'t. Vitus, near Ulm, and  continuing there,
 night and  day, leaping  and dancing, until they
 were completely exhausted.   By this means they
 were said to  be cured for a time ;  but at  the ex-
 piration of a year  the  disease returned,  and was
! again removed in the same manner. The malady. 
123
CHOREA.
however, which is commonly known by the name
of chorea, is very different in its symptoms from
the original disease  so called, although they have
been classed together, and sometimes supposed to
arise from the same causes.
   In  this, as  in  many other instances, it is diffi-
cult to determine by what name  the disease was
known  to ancient  authors.  Probably it was for
the most part confounded with other  convulsive
diseases.  Even Cullen, in the first edition of his
Nosology, included  it in  the general  term  con-
vulsio, from which, however, he afterwards  saw
reason to separate it.  Galen appears  to describe
it  with  tolerable accuracy under the name  of
scelotyrbe,  which means  " an  agitation of  the
leg."   " It is a  species  of atony or  paralysis,"
says he, " in which  a man is incapable of walking
straight on, and is turned round to  the left when
the right leg is put  forward, and to the  right when
the left  is put forward alternately.  Sometimes he
is  incapable of raising the foot, and hence drags
it  awkwardly, as those who are climbing up steep
cliffs."   It is also placed as a species of scelotyrbe
in the nosological systems of Sauvages  and Sagar.
Dr. Mason Good, in his arrangement,  ranks  it as
a  species of synclonus, the term by which he ex-
presses  " a multiplied, conjunctive,  or compound
agitation of the muscles."
   Cullen defines chorea  in the following man-
ner :  " Convulsive motions, partly voluntary, and
for the most part of one side, attacking either sex
before puberty, generally  between the tenth  and
fourteenth  year; the  motions of the  hands  and
arms resembling the gesticulations of players; one
foot being rather dragged  than lifted in walking."
Sydenham has described it in a very graphic  and
accurate manner, as being " a  species of convul-
sion which for the most part attacks boys or girls,
from  the tenth year to puberty.   It  first announ-
ces itself by a kind of halting, or rather insta-
bility, of one  leg, which  the patient  drags  after
him,  as idiots do.   Afterwards it shows itself in
the hand of the same side, which, when applied
to the chest, or any other part of his body, cannot
be retained in the same  situation by  the patient
even  for a moment, but is twisted about from one
place to another, however much he strive to pre-
vent  it.  If a full vessel  be given him to drink
from, before he can  bring it to his mouth he ex-
hibits a thousand gesticulations, like  a mounte-
bank; for as he cannot carry the cup in a straight
line to his  lips,  the  hand being  diverted  by the
spasm,  he tips it from side to side for  some time,
until at length, by good  fortune, approaching it
nearer to his lips, he jerks the liquor  suddenly
into his mouth and drinks it with eagerness,  as if
the poor creature were merely  performing a feat
to excite the  laughter of  by-standers."  (Syden-
hami Opera, p. 468 : Lipsiae. 1827.)   Dr. Hamil-
ton, in  his Treatise  on  Purgative  Medicines,—
after  stating that the disease chiefly occurs  from
the eighth to the fourteenth year,  in those who
are of  a weak constitution, natural or acquired;
that it is generally preceded by a variable appetite,
lo« of  vivacity, a tumid belly, and constipated
towels; and that  the  convulsive  motions  are
ushered in by slight, irregular, involuntary twitch-
ings, particularly of the  muscles of the face,__
presents us with tiie  following  description of the
 disease in its  more  aggravated  shape: "These
 convulsive  motions vary.  The  muscles of the
 extremities and  of the face,  those moving thn
 lower jaw, the head, and  the  trunk of the body,
 are  at different  times  and in different instances
 affected by it.  In this state the patient does not
 walk steadily ; his gait resembles  a jumping or
 starting;  he sometimes cannot walk at all,  and
 seems  palsied  ;  he cannot perform the common
 and  necessary motions with  the  affected arms.
 This convulsive motion is  more or less  violent,
 and  is constant, except during  sleep, when, in
 most  instances,  it ceases altogether.   Although
 different muscles are sometimes  successively con-
 vulsed, yet in  general the muscles  affected in the
 early part of the  disease remain so during the
 course of  it.   Articulation is  now  impeded,  and
 is frequently completely suspended.  Deglutition
 is  also occasionally  performed  with  difficulty.
 The eye  loses  its lustre and intelligence;  the
 countenance is  pale  and expressive of vacancy
 and  languor.    These  circumstances   give  the
 patient a fatuous  appearance.  Indeed, there is
 every reason to believe, that, when  the complaint
 has  subsisted  for  some time, fatuity to a certain
 extent interrupts the exercise of the mental facul-
 ties.  Fever, such as arises in marasmus, is not a
 necessary attendant  on chorea;  nevertheless in
 the advanced period of the disease, flaccidity and
 wasting of the muscular flesh take place, the con-
 sequence of constant irritation, of  abating appe-
 tite,  and  impaired digestion, the common  attend-
 ants of protracted chorea."   (Observations on the
 Utility of Purgative Medicines, chap.  iii. p.  69,
 et  seq.)   The sensations are little, if  at  all,  dis-
 turbed ; but in extreme cases there are hardly any
 of the voluntary  muscles exempted  from the spas-
 modic affection.   The tongue is occasionflly pro
 truded, the mouth drivels,  and the eye itself is
 twisted in various directions.   Not unfrequently
 there is some  pain of the head, for the most part
 in  the occipital region; vertigo;  and  imperfect
 vision.  The patient is often fretful, and liable to
 the same varied, desultory, and causeless motions
 which occur in hysteria.  The  disease is apt to
 recur more  than  once in the  same  individual.
 Occasionally  it  has  passed  into  hemiplegia oi
 epilepsy, and instances are recorded of its proving
 fatal  in  that  manner, or  by  exhaustion.   Dr.
 Elliotson mentions, that when  a student,  he saw
 a young woman, labouring under the disease, die
 apoplectic.  (Med. -Chir. Trans, vol. xiii. p- 252.)
 In most  cases, however, it terminates favourably,
 after  a duration of variable length.   In  eighty-
 four cases occurring at the Norwich Hospital, Dr.
 Reeves states  that the shortest period  of  medical
 treatment, was  two weeks ;  the  longest, eight
 months;  and the common average, seven weeks.
 (Edinb. Med.  and Surg. Journ. vol. viii. p. 314.)
 Although the  disease  commonly occurs between
 the ages of eight  and  fifteen, it is met with a«
 early as the fifth or sixth, and, on the other hand,
 even  in mature  years.  Dr. Powell mentions an
 instance of it in a lady of seventy, (Med. Trans,
 vol. v.) ;  and Dr. Bouteille relates one which oc-
 curred in a lady eighty years old, after hemiplegia.
 (New  Med.  and Phys. Journ.  vol. iii. p.  175'
 London,   1812.)   It  oftener  attacks  girls  than
| boys.  Heberden found it to do so  in the  propor- 
CHOREA.                                     429
tion of three to one, and Dr. Elliotson states that
his experience  presents nearly the same result.
(Med. Gazette,  vol. vii. p. 652.)   Of the eighty-
t>ur cases reported by Dr. Reaves, fifty-seven were
L-males, and  twenty-seven  males.  Of seventy-
two occurring in Dr. Manson's practice,  at Not-
tingham, fifty-three were females, nineteen males.
(.Medical Researches on the Effects of Iodine, p.
"■][).)   Of  eighteen cases in  the Hampshire
County Hospital, during the last ten years, six
were boys and the rest girls.
  Occasionally, chorea is complicated with hyste-
ria or  other disorders,  and  thus a confusion of
symptoms occurs.  In  some cases the disease is
of so partial a description as to continue  through
life without any injurious effects to the general
health,  or even any serious inconvenience.   Dr.
Mason Good mentions the case of a barrister of
great reputation, in whom the  only symptom  was
an occasional awkward snatching of the arms and
neck; and another of a person  who, though a dis-
tinguished vocal and instrumental musician,  had
extraordinary gesticulations of the face  and  cur-
vetings of the neck and head.  Most practitioners
have doubtless witnessed similar instances.
   The characteristic signs of the ordinary disease
are the permanency, the irregularity, and the partly
voluntary nature of the motions.  There are other
diseases of clonic spasm, in  which the motions are
perhaps  as  unintermitting  as in  this, but  they
present a regular and unvarying appearance.  On
the other hand,  spasms of an irregular description,
but not continuing,  are daily met with.   In both
these cases,  however, the  affection  should  be
classed under the general term convulsion.   The
partial  influence  of  the will over the muscular
contractions is,  for the most part, a circumstance
which  of itself distinguishes the  ordinary chorea
from every  other spasmodic  affection.  It  has,
however,  been  customary  to  include under the
same name  some more rare diseases  not always
possessed of these characters; and the term seems
to be somewhat loosely assigned to many abnor-
mous affections of a spasmodic  nature.  We admit,
indeed, that the very malady to which the name
was  originally given  does not present the charac-
teristic signs we have  mentioned ;  and it might
seem arbitrary  to separate  it  entirely  from  that
which  has received  the appellation, solely from
somewhat resembling it in appearance.   When it
is considered, however, that there are no sufficient
reasons for concluding that they are  of similar
origin, and that the disease to which  the  above
characteristics  do apply is  of  infinitely more fre-
quent occurrence, and is at  the same time univer-
sally known by the  name  of chorea, we think it
right, for the sake of avoiding confusion and error,
to confine our attention at  present to the  latter.
Afterwards we will subjoin some account of the
original disease, and other affections which resem-
ble it or have received the same appellation.  Some
of the German writers have distinguished the  two
diseases by calling one the German, or great St.
Vitus's  dance,  tbe  other  the  minor  St. Vitus's
dance, or chorea of England.   If they are still to
be included under the same genus, tbe difference
of their character might be better expressed by
styling  the one intermittens,  or periodica,-  the
other continua,- the  former methodica, the latter
 abnormis; according as the circumstances above-
 mentioned shall, one or other of them, be consi-
 dered the most characteristic  of the chorea com-
 monly met with  in this country.
   Causes.—The ordinary chorea  has been attri-
 buted to  various causes.  Sydenham ascribed it to
 a humour thrown upon the nerves.  By very many
 authors  it has been considered as a disease of
 general weakness of the constitution.  And others
 there are who conceive it  to arise from a partial
 and slow inflammation of the brain. With regard
 to Sydenham's hypothesis, it has followed the rest
 of the humoral theories, and does not now require
 notice. That the disease is always simply one of
 general debility,  is a notion opposed by the benefit
 sometimes obtained from bleeding, the very uniform
 advantage arising from purgatives, and  the occa-
 sional failure  of tonic medicines,  when uncom-
 bined with other remedies,  in the treatment of the
 disease.   Many  circumstances, however,  concur
 in showing that, though debility may not be the
 original cause of the disease, yet  it  is often the
 principal  reason of its  continuance  when  once
 established.  On the other hand, the idea that it is
 in general an inflammatory affection of the brain,
 as Dr. Clutterbuck and others have supposed, is
 contravened by the experience of Sauvages, Cul-
 len, and many other practitioners, who have found
 bleeding  very prejudicial in a great many cases.
 And although this was one of Sydenham's reme-
 dies at the beginning of the disease,  he does not
 advise it  to be repeated  frequently;  recommend-
 ing, however, the purgatives and tonics with which
 he accompanied it  to  be continued  through the
 whole course  of the complaint.   (Op. cit. 470.)
 Whether, as Professor Gregory supposed, (Edin.
 Med.  and Surg. Journ. vol. i. p. 33),  the success
 of Sydenham's practice was entirely owing to the
 tonics, or whetber it was attributable to the pur-
 gatives, or to both together, may possibly  be a
 matter of dispute ; but we think there  is not much
 reason to attribute it, in general or chiefly, to the
 venesection.  Dr. Armstrong, who mentions a case
 in which  the  free use of  the lancet  was nearly
 fatal,  states that  he considers chorea to arise from
 irritation of the mucous membrane of the stomach
 and smaller intestines,  accompanied with a torpor
 of the skin, liver, and colon.  (Lancet, vol. viii. p.
 70).   Dr. Hamilton, sen. from extensive experience
 of the benefit derived  from purgative medicines,
 and the general appearance of the alvine evacua-
 tions, considers the disease to arise from disordered
 bowels.  It has, however,  been suggested by Dr.
 Coxe, (Med.  and Phys. Journ. vol. xviii. p. 223),
 Dr. Uwins, (Edin. Med. and Surg. Journ. vol. viii.
 p. 411), Dr. Manson, (Medical Researches, &c. p.
 192), and others, that such torpor and derange-
 ment may be merely an effect of the disorder, or at
 most a simultaneous expression of disease.  Cullen
 thought that the malady depended upon " a state
 of mobility" in the system, (Materia Medica, vol.
 ii. p. 112) ; and we are so far of opinion with him
 as to  believe that chorea  may be induced by any
 irritating cause operating upon  a  sufficiently ex-
| citable habit  of body.   The greater  number of
 diseases  arising  before puberty are perhaps con-
j nected or complicated  with intestinal irritation  ;
[ and  chorea, among  others, doubtless frequently
, proceeds  from disordered alvine  secretions,  from 
130
CHOREA.
worms,  from  accumulated faeces,  improper diet,
&c.  But it has also been occasioned by affections
of the  mind,  such  as fright.*  Dr. Reeves states
that in the  majority of cases  the  disease is attri-
buted by the parents  to  this cause, (Edin. Med.
and Surg. Journ. vol. viii. p. 315) ; and Mr. Bed-
ingfield tells us,  that of upwards  of  forty cases
which occurred at the Bristol  Infirmary, by far the
greater number were  induced by fright.   (Com-
pend. of Medical  Practice, p.  52.  London,  1816).
It has also  sometimes arisen from  irritation.-)"   It
has been occasioned by a wound of the brain
through the orbit,  (Philosoph. Transact, vol. liii.
17C3), and other injuries about the head.  (Edin.
Med.  and  Surg.  Journ.  vol.  viii.  p. 406 ;  vol. ix.
p. 123.   Med. and  Phys. Journ. vol. xv. p. 127).
A case, in which  it  was induced in a man twenty-
three  years of age by  injury  to  the  scapula, is
related in the Medico-Chirurgical Review.   (Vol.
ii. p. 569.  1827).   It has also  been occasioned
by teething, (Edin. Med. and Surg. Journ. vol. i.
p. 32) ; by the  deleterious  influence of  certain
metals  and  their  compounds;  preparations  of
lead, for example, or of mercury, (De  Haen, Rat.
Med. part iii. p. 202.  New York Med. and Surg.
Register.   1818.    Med. and Phys.  Journ.  vol.
xlii.  p.  160);  by suppressing eruptions  of  the
skin, (Darwin's Zoonomia, vol. iv. p. 290.  Wendt,
Nachricht  von dem Krankeninstitut zu Erlangen.
1783); and frequently  by  retarded  or difficult
menstruation.  (Bedingfield's Compendium,  &c.
p. 52).
   [Age occasions a marked predisposition.  The
disease is one of  childhood.  Of  32,976 children,
admitted into the Hopital des Enfans  of Paris,
during 10 years,  only 189, according to M. Rufz,
(Archives Generates de Medecine, iv. 239  : Paris,
1834),  were affected with chorea ; so that it is
not very common.   In  the  composition of their
chapter on this  subject, MM. Barthez  and  Ril-
liet, (Traite CUnique et Pratique des  Maladies
des Enfans, ii. 294 : Paris, 1843), state that they
had analyzed only nineteen cases, and some  of these
were  communicated to  them by  other observers.
In a  recent clinical  lecture  on chorea, (Medical
Examiner, Jan.  27, 1844), the writer stated  that
he had not seen, altogether, more perhaps  than
thirty well-marked  cases.  The ages, at which the
disease prevails most, are from 6 to 14.
   Sex, also, affords a predisposition, according to
all observers.   Of  240 cases, recorded by  M.  Du-
fosse, 79 were in boys, 161 in girls, (H. Bell,  Art.
 Choree, in Diet, des  Etudes Medicates, Paris,
 1839); and of the 189 cases referred  to above,
51 were males, and 138  females.    From the cases
that have been recorded  by different practitioners,
it has  been  calculated, that  the proportion of
females to  males is nearly 3 to 1.   (Practice of
 Medicine,  2d edit.,  ii. 240 : Philad. 1844.)
   In regard  to  constitution, great difference of
sentiment  has existed.  Some—as the Franks—
affirm,  that it occurs  chiefly in  the scrofulous

  * Stoll, Rat. Med.  part  iii. p. 405.  Edin. Med. and
Surg. Journ. vol. ix. p. 382.  Med.  and Phys. Journ. vol.
Iii. p. 262.  Med. Chir.  Transact,  vol. x. p. 225.   Med.
Gazette,  vol. i. p.  195.  Malison's Medical Researches!
 p. 196.
  4 Edin. Med. and Sure. Journ. vol. i. p. 3] ; vol. iii. p.
■Ml ;  vol. xii. p. 401.  S-e also Haygarthon Imagination
 -s a Cause, and as a  (Jure of Disorders of the Bodv. 8vo
 Bath, 1800.
and  the  rickety; while others, as Dr. Elliotson,
(Principles and Practice of Med., Amer. edit, by
Dr. Stewardson, p. 624 : Philad. 1844), M. Rufr,
and  MM. Barthez  and Rilliet, state, that no con-
stitutional difference is perceptible between those
who are affected with  chorea and those who are
not.   A  like discrepancy exists in regard to the
colour of the hair.   MM. H. Bell, Rufz and Du-
fosse say that the subjects are chiefly light-haired :
whilst Dr. Watson (Lectures on  the Principles
and Practice  of Physic,  Amer. edit. p. 360;
Philad.  1844)  remarks,  that  the  disease occurs
much  more  frequently in  children having  dark
hair and eyes.   It  would appear,  also, that a pre-
disposition  to  chorea  may be transmitted from
parent to child.   (Elliotson, op. cit.)
   The disease  may unquestionably be developed
by imitation, and hence the necessity in boarding-
schools of keeping the patients separated. (Andral,
Pathologie interne.)   It is  proper, however, to
remark,  that M. Blache states, that in the large
Hopital  des Enfans, of Paris, he never saw it pro-
duced in this manner.
   Dr. Bright has drawn  attention to the  connec-
tion of chorea, in certain  cases, with affections of
the heart and pericardium; and Dr. Addison  has
noticed mitral bruit or other signs of morbid ac-
tion of the mitral  valves to be pretty uniformly
present in chorea,—which he is rather inclined to
consider an effect of the disease than a cause. (The
author's Practice of Medicine, ii. 241.)]
   It  is  extremely  probable that  the convulsive
motions  may be continued, merely from  habit, a
considerable  time  after the original  cause is re-
moved.^  Mr. Hunter, of Glasgow, conceives that,
although the motions are not at first dependent on
any derangement of the brain or spinal cord, yet
the  irritation,  which acts at first locally  on  the
nerves of the  affected muscles, may spread till it
affect the root  of the nervous system itself; and
in this way he would explain the continuance of
the  convulsive  motions after the  removal of the
original  cause,  (Edin. Med. and Surg. Journ. vol.
xxiii. p.  270.)   May the morbid appearances, such
as  the following, which have been observed in
some cases of chorea after death, be accounted for
in this manner ?
   In two instances Dr. Willan found some ounces
of serum in the ventricles of the brain, (Reports on
the Diseases of London, p. 245.)  Dr. Coxe, of
Philadelphia, who conceives that chorea uniformly
arises either  from hydrocephalus or its forerunner,
inflammation and turgescence of the blood-vessels,
found, in  a fatal  case,  the vessels turgid,  and
twelve ounces of serum in the ventricles, (Med. and
Phys. Journ. vol. xiii. p. 405 ; vol. xviii. p. 221.)
Dr. Patterson,  of Londonderry, (who,  in opposi-
tion to Dr. Coxe's  Views, and in  accordance with
Dr. Percival, of Manchester,—see Medical Tracts,
vol. i. p. 125, 1791,—considers that in chorea, as
in other convulsive diseases, hydrocephalus is foi
the most part rather a result than  the caused) has
related a case in which he found the blood-vessels
  % " Sspe tamen malum consuetudine ingravescens le
vioribus causis excitatur, parum cognitis, neque facile
observandis."  Gregory, Conspectus Medicin.  Theorel.
vol. i. p. 212.
  § This question is ably argued between Drs. Coxe and
Patterson, in  the 13th, 15th, and 18th vols, of the Med.
and Phys. Journal. 
CHOREA.
43
turgid, and traces of inflammation in tbe brain, a
kind of serous diffusion over tbe convolutions, and
three  ounces of serum in  the ventricles.*   He
also  mentions a case in which the  patient,  after
being cured  of  chorea, very soon fell a victim to
hydrocephalus,  (Med. and Phys. Journ. vol. xv. p.
127.)  M. Serres states that in one case he found
a fatty tumour  resting on the tubercula quadrige-
oiina; in  another, marks of  considerable excite-
ment, with bloody effusion at the base  of these
bodies ; and in  two others the whole of their sub-
stance was  inflamed, and the inflammation ex-
tended to the roof of the fourth ventricle, (Lancet,
vol. xiii. p. 133.)  It appears also that he has, by
experiments on living animals, found that injury
of these  parts  is followed by motions  similar to
those of chorea.   We are not aware that these
experiments have been  published in detail, and are
therefore unable to estimate their accuracy or con-
clusiveness.   We would, however, express a doubt
whether M.  Serres's cases of chorea were of the
ordinary species; and  we think  that the simple
fact of their proving fatal, in  some measure justi-
fies  us  in  this hesitation, especially  when the
vagueness with which  the term has been  often
used is taken into consideration.  We shall pre-
sently remark  on the probable  origin  of those
more rare diseases which have been  denominated
chorea.  In  the mean time, we shall only mention
that M. Serres  admits that he has seen  cases of
chorea in which no injury in the brain  could be
discovered after death.   In a  fatal case of a some-
what anomolous character, published by Dr. Haw-
kins, there was no  morbid appearance discovered
within the cranium, but earthy concretions were
found in the pancreas,  omentum, and mesentery ;
tubercles in  the lungs ; and the uterus was large
and vascular, with its  lining membrane highly
injected, (Med  and Phys. Journ.  vol. lvii. p. 240.)
    [The fact,  that  the disease generally termi-
nates in perfect health, shows that  the  affection
of the neurine  is not serious, and classes the dis-
ease amongst the neuroses.   They  who believe
that the cerebellum is the regulator of the move-
ments would necessarily place chorea in  that part
of the encephalon.   Dr. Marshall Hall refers it,
with  convulsive  movements  in  general, to  his
reflex system ;—in other words, to the true spinal
marrow.  The disease belongs,  however, rather
to a badly regulated volition, like that which ex-
ists in stammering, which has, indeed, been called
—not inappropriately—a " Saint Vitus's dance of
the voice," and is, consequenty, encephalic rather
than  spinal.   The  disease is essentally  a func-
tional affection of the nervous  centres, in the
large majority  of cases, but  of what precise na-
ture we know not,—except that, generally,  signs
of great nervous mobility and debility are present,
and have to be energetically combated.]
  Treatment. — If proof were wanting of the
varied origin of chorea, it might perhaps  be found
in the numerous and sometimes conflicting reme-
dies, which have  from  time to time been extolled
as successful in its treatment. From this circum-
stance, indeed, it has been concluded  by some that
the  disease in general subsides spontaneously, and

  *  .Med. and Phys. Journ.  vol. xv. p. 110, et seq.;  vol.
xviii. p. .Mi; or "  Letters concerning the Internal Dropsy
of the Br-un."  1794.
is but little under the control of medicine ;  a be-
lief which receives some degree of countenance!
from  the  general tediousness of the  complaint,
under any mode of treatment.  It is, doubtless,
quite as difficult in  this disease as in many others
to distinguish between mere sequence  and conse-
quence.   As  we  have, however, a perfect convic-
tion of the efficacy of certain remedies, almost op-
posite in their nature to others which  have been
sanctioned by high authority, we must either ad-
mit a difference  in the exciting causes, or explain
the seeming inconsistency by supposing  that one
remedy  cures the disease by removing the appa-
rent cause, and  another by  correcting  some state
of the system which may either render it suscep-
tible of  its influence, or be itself an immediate and
essential link between  that cause and the symp-
toms of the disorder: for example, that of the two
most approved methods of treatment  in the pre-
sent day, purgative medicines  may be beneficial
by removing causes of irritation from  the intesti-
nal canal;  while metallic  tonics may cure the
malady  by correcting  a weak, mobile, or irritable
state  of the  body, without which  such irritating
causes would not have produced the disease, and
in consequence  of whicb, indeed, it may often  be
prolonged after such causes are removed.
   Since the  publication of  Dr. Hamilton's work,
" On  the  Utility of Purgative Medicines," the ad-
ministration  of  cathartics  has almost uniformly
entered into, if  it  has not constituted, the sole
treatment in  chorea.   Though it formed perhaps,
the principal part of Sydenham's practice in tbis
disease, it had become in a  great measure discon-
tinued ; and  Dr. Hamilton undoubtedly produced
by his treatise a most important and useful change
in this respect; and proved, in a vast many cases,
not only the  safety, but the  extraordinary efficacy
of very powerful cathartics.  When the disease
is yet in  an  early stage  and scarcely established,
gentle aperients may  be sufficient, or indeed  all
that it is  proper to administer.  But  he tells  us
that in  the confirmed stage, when the intestines
have in a great degree lost their sensibility, and
the accumulation of fseces is  great, whoever un-
dertakes the  cure of chorea by purgatives, must
be  decided and  firm  to his purpose.  Powerful
medicines must be given, in successive doses,  in
such  manner that the latter  doses may support
the effect of  the  former, till the expulsion of the
accumulated matter is completely effected.  When
worms  are  known  to have been passed by the
bowels, or are suspected to be  the cause of the
complaint, the most successful, if  not a specific
remedy, is the oil of turpentine, in a full dose  of
from  three to six drachms, or more, according to
the age of the patient  and other circumstances.
   [The oil  of turpentine  is a  valuable  remedy
in chorea, whether produced by  worms or not.
When the bowels  have been torpid, and the girl
is of an age at which the first occurrence of men-
struation  may be looked  forward to, its advent has
appeared  to  have been hastened, and great relief
to be produced by turpentine.]
   Although  purgatives, however,  are in  many
cases the most  efficacious remedies, and perhaps
necessary  in the greater number, both in com-
mencing  the treatment, and at intervals  after-
wards, we believe  most practitioners  will  admit 
432
CHOREA.
thai  they have often failed in removing the dis-
ease,  and that medicines of another kind  have
succeeded without their assistance; while Cullen
and  other high  authorities state that  they  have
found repeated evacuations, of any kind, in many
cases injurious.
   In most  instances,  more  especially after  the
exhibition of purgatives, we conceive  that of all
remedies tonics are the most successful.  Syden-
ham used only the vegetable tonics; and Cullen
preferred cinchona to the metallic preparations, as
being of safer administration.  We think there is
no doubt, however, that the  latter  possess  con-
siderably more  efficacy, and  many of them  are
now found to be perfectly safe, in infinitely larger
doses  than  were  formerly  considered prudent.
The  preparations of  iron, zinc, copper, silver,
and arsenic, are those which have principally been
exhibited.
   Dr. Elliotson has  contributed much  to establish
the efficacy of the subcarbonate of iron in chorea.
In the thirteenth volume of the Medico-Chirurgi-
cal Transactions, he published an account of eight
cases cured  by it, and proved that  it might, and
required to be given  in much  larger doses than
had before  been  usual.  Even  the presence of
headach, giddiness, and symptoms of paralysis, do
not always, he says, forbid its use, but frequently
disappear under its  exhibition.   In four  of these
cases no purgatives were  administered, and in
some of the others they could have aided but little
in the  cure. * In his  lectures,  published in the
Medical Gazette,  he tells us that he has since
cured many dozen cases by the same medicine,
and has scarcely  failed in a single instance ;  and
adds that he thinks it  will prove effectual in more
cases than any other remedy.  Occasionally it has
boen necessary  to continue  it for three  months.
(Medical Gazette, vol.  viii. p. 653.)  The dose of
the medicine may at first be  from half a drachm
to a drachm, increased by degrees to three or four
drachms, and taken  every  six  hours, in  gruel,
mucilage,  or treacle ;   which latter may obviate
any constipating effect from it.   The  sulphate of
iron has also been found  of some efficacy in cho-
rea, and may be administered in doses  of from one
to four grains.
   [The ferro-cyanuret of iron has been adminis-
 tered with success,—three grains being given in
 the  form of pill three  times a day.]
   The sulphate of zinc has great power over the
disease, and may be given in considerable doses,
 when they are increased in a  gradual  manner.
 The oxyd  of that metal, however,   is a  more
 manageable preparation, and we have  found it of
 the  most  uniform  efficacy.   It may   at first be
 given in doses  of five grains, and  gradually in-
 creased.  We have given it, in one case, in doses
 of  twenty-five  grains.  Mr.  Bedingfield  states
 that  this remedy was so  speedily and decidedly
 successful in the Bristol Infirmary, that he cannot
 help regarding it as a  specific.  Upwards of forty
 cases, occurring  there, were, with one exception,
 cured by it;  and  he attributes its failure in other
 hands  to its  not  having been  administered with
 sufficient regularity, or in sufficient doses  to excite
 nausea.  Some of the cases, however, were cured
 without tbe nauseating effect.   (Compendium of
Medical Practice, p. 51.)   [The cyanuret of zinc
has likewise been efficacious.]
  The preparations of copper having been some-
times efficacious in other convulsive diseases, such
as epilepsy and hysteria, have been given in cho-
rea.   The sulphate may be administered in doses
of a quarter  of a  grain, or half a grain, twice a
day, and the quantity increased if the  stomach
will bear  it.   The ammoniuret, or  the cuprum
ammoniatum, introduced  into practice by Cullen,
is of safer exhibition,  though it should  also  be
begun in very small doses.  Cullen states that  he
had in some cases increased the dose by degrees to
five grains and upwards, and that he  had often
found it to cure epilepsy.   In chorea its virtues  do
not appear to have been by any means so striking
as  those  of iron and zinc.  Dr. Uwins relates a
case which got well under its use, combined with
digitalis and  myrrh.  (Edin.  Med. and Surg.
Journ. vol. viii. p. 408.)
   The nitrate of silver, likewise  a successful
remedy in epilepsy, has been occasionally admin-
istered  in chorea.  In our own practice it has
almost uniformly disappointed  our expectations.
By others, however, it has  sometimes been found
successful; as in a case related  by Dr. Uwins, in
the Edinburgh  Medical  and Surgical  Journal,
 (vol. viii.  p. 407 ;) in two, by  M. Priou, in the
Medical and Physical Journal, (vol. Iii. p. 262 ;)
in another, by Mr. Franklin, in the  same work,
 (vol. xxxiii.  p.  273;) and  in  another, by Dr.
Crampton, in  the Transactions  of the King and
Queen's College of Physicians,  (vol. iv. p. 114.)
   The liquor arsenicalis has been used as a tonic,
in this as in some other diseases, with consider-
able  success.  Several cases of its  efficacy  are
published in  the fourth, tenth, and   eleventh
volumes of the MeJico-Chirurgical Transactions.
In two  of these arsenic was   the only  remedy
used, (vol. x. pp. 227, 229 ;)  in the others it had
been preceded  by purgatives.   The  dose of the
solution should at first be three drops thrice a day,
and  it may  be increased to ten drops or more,
according to its effects.
   Of the  vegetable tonics, Peruvian bark will  be
found the most powerful.   Cullen says  that  he
 found it remarkably useful in this disease. Gen-
 tian, likewise, and other bitters, have  occasionally
 been of service.   De Haen used the leaves of the
 Seville orange-tree as a stimulant and tonic  in
 spasmodic diseases, with  considerable success.
   Iodine is a medicine which has lately been used
 with some success in  chorea, probably  from pos
 sessing a tonic and stimulating power.  Dr. Man-
 son has published a number of  cases  which were
 successfully  treated  by it, in combination with
 mild cathartics.  (Medical Researches, &c. p. 187
 et  seq.)   Dr. Gibney, of Cheltenham,  has also
 published two cases in which  it was used with
 success along with other  medicines, (Medical Ga-
 zette, vol.  i. p. 54;) and Dr. Peltz relates a similar
 case in the Philadelphia Journal.  (See Med. and
 Phys. Journ. vol. lix.  p. 454.)   It may be given
 in the form of tincture or the solution of the hy
 driodate  of  potass.   The  former,  Dr.  Manson
 directs to be made by dissolving twenty-four grains
 of iodine  in an ounce of rectified spirit; and  the
 dose may be from five  to ten or fifteen drops three 
CHOREA.
433
times a day, in  some distilled water.  He makes
the solution by dissolving twenty-four grains  of
the hydriodate of potass  in an ounce of distilled
water; the dose is ten drops to twenty.  As the
preparations of iodine, however, have been made
of various  strength by its various  advocates, and
will probably continue so until admitted  into our
pharmacopoeias, they  ought to  be administered
with due consideration ; very mischievous effects,
and in some cases an  affection not unlike chorea
itself, having been occasioned  by its  incautious
exhibition.  (See Bronchocele.)
   Of the remedies used for the purpose of giving
tone or strength to the system,  cold  bathing and
cold affusion are  not to be overlooked.  [The
Russian  bath and sulphurous baths have, like-
wise, been found serviceable.  (Practice of Medi-
cine, 2d edit. ii. 244 :  Philad. 1844.)]  Electricity
and galvanism, also, have been recommended, and
the former employed in some instances [especially
of late, by Drs. Addison and Golding Bird] with
advantage.
   Narcotic medicines  have been frequently used
with  benefit, though they have occasionally been
useless if not injurious.   Stoll  used the extract
of belladonna, in doses of one  sixth or one fourth
of a grain every six hours, with great advantage;
and Cullen says that he found opium very gene-
rally useful in chorea.  (Materia  Medica, vol. ii.
p. 246.) Dr. Patterson  mentions that an unusually
severe case in the  Bristol Infirmary was cured by
opium and  camphor;  and Mr. Bedingfield tells
us that the only case  under his observation there
which resisted  the oxyd of zinc, was cured  by
laudanum and tartarized antimony.  Digitalis has
by some been occasionally found of service ; and
in the twenty-eighth  volume  of the Edinburgh
Medical and Surgical Journal  two cases are  re-
lated in  which the  convulsive  motions  ceased
under the use of hydrocyanic  acid,  preceded  by
purgatives.  Some cases are related in the Medical
and Physical Journal, in  which  a speedy cure
was effected by colchicum, without its producing
a cathartic, or any  other sensible operation. (Vol.
xxxi. pp.  181, 292.)
   [Testimony has  been afforded in favour of cimi-
cifuga, which, in large doses, is an acro-narcotic.
The dried root may be given  in powder in the
dose of a  teaspoonful  three times  a day ; or it
may be given in decoction.  (New Remedies, 4th
edit. p. 164 :  Philad. 1843.)]
   Musk,  valerian,  camphor, and  other antispas-
modics have occasionally been given, but in gene-
ral without any benefit. Two cases however, are
related in the fifth  volume of the Medical Trans-
actions, in which  Drs. Powell  and Maton found
the first of these successful.  The cardamine pra-
tensis, also, had at one time a reputation in this
disease.   Sir George Baker published some cases
of spasmodic affection, two of them chorea,  in
which it appeared to him  to be of decided benefit;
but there  is little confidence now placed in it.
  Although we conceive that in the great majority
of cases chorea will be most successfully treated
by means of purgatives and tonics, more especially
the  latter, it cannot be denied that  instances have
occurred in which  there has been  such affection
of the head as to indicate  the  propriety of local,
or even general  bleeding, and other antiphlogistic
  Vol. I. — 55                         2n
means of cure.   Bleeding, as we have seen, was
one of Sydenham's remedies ; and Cullen admits
that he had in some instances found  it useful,
though frequently very hurtful.  In one case, Dr.
Robert Watt found that it had an almost imme-
diate effect in allaying the convulsive movements.
(Cases and Observations,  &c.  Paisley, 1808.)
Dr. Clutterbuck  has  in a number  of  instances
prescribed  it, at  intervals of a few days, ten or a
dozen times, and even oftener, without any other
active  remedies,  and  without failing of success.
(See his Lectures.  Lancet, vol. xii.  p. 421.) Dr.
Armstrong, who  trusted principally  to cathartics,
aided by diet, exercise, air, and the tepid bath, to
restore  the functions of the skin, cautions us
against the free use of the lancet, and mentions a
case, as we stated above, in which it nearly proved
fatal.  (Lectures.  Lancet, vol. viii. p.  70.)
   The use of external counter-irritants has often
been of much service, especially when  there has
been any considerable affection of the head. Blis-
tering the scalp, or rubbing it with  tartar-emetic
ointment, has been adopted with this indication.
The  same  remedies  have been  applied  in the
course of the vertebral column, a mode of treat-
ment whicb> accords  with  the conclusion  drawn
by Magendie, from the experiments presently to
be recounted, that the direct cause of  motion is
in the spinal chord;  and  which would therefore
promise, as it  has afforded,  in  cases of a more
permanent  description, especial  advantage.  For
such purpose, also, a seton  in the neck, the moxa,
&c. have  been  recommended.   As  the disease
often arises about the period of puberty, from im-
peded  menstruation,  the application of a  blister
to the  sacrum promises to be useful.  Dr.  Chis-
holm states that he found it successful after pur-
gatives and antispasmodics had  failed.  (On the
Climate and Diseases of Tropical  Countries, p.
97, 8vo. 1822.)   Mr. Swan, of Lincoln, found it
to have an immediate effect in allaying the con-
vulsive motions.    (Edinburgh  Med. and  Surg.
Journal, vol. xxii. p. 94.)
   When  chorea  arises from  the coming  of the
second set  of  teeth,  lancing the gums, or the
removal of  some of the first  set, will be proper.
Instances in which the  disease  was speedily re-
moved in this  manner by Drs. Monro  and Gre-
gory, are  referred to in the first  volume  of the
Edinburgh Medical and Surgical Journal, p. 32.
   Darwin, as he conceived the disorder to arise
sometimes  from  the  itch being hastily repelled,
begins his directions for  the cure by telling us to
"give  the patient the itch again."  (Zoonomia,
vol. iv. p. 291.)   He  also  furnishes us with an
ingenious suggestion, that perpetual  and repeated
efforts  should be made to move each limb in the
designed direction, in  expectation of the  same
good effects that follow from such efforts in stam-
mering.  Independently of any other benefit from
such an  exercise, one evident advantage  would
be, the abstraction of  the patient's attention from
his complaint—a matter of no slight importance
in this and many other convulsive diseases.  M.
Louvet Lamarre found the  exercise  of the  skip-
ping-rope of much use in one instance.   (Med.
and Phys. Journ.  Vol. Ix.  p. 89.)   On  this sub-
ject  Dr. Mason  Good remarks that a long and
punctual discipline of  the affected limbs to regular 
434
CHOREA.
and measured movements, might, where the dis-
ease is not very severe, recal them to their wonted
order  and firmness ;  and adds that with this view
the exercise  of dancing,  by which the original
chorea Sancti Viti is said to have  been cured so
singularly, may  be well worthy  of  attention.
(Study of Medicine.  Vol. iv. p. 485.)   The  in-
fluence  also  of music  alone, independent  of the
measured efforts in dancing,  ought  not  to be
overlooked.   In some of the diseases resembling
the original  St. Vitus's dance, as  we shall pre-
sently see, an extraordinary passion for music has
been  among  the most prominent symptoms ; and
Dr. Armstrong relates a case in whicb music had
the effect of procuring sleep,  and of ultimately
curing the disease altogether, after  it had resisted
purgatives, sulphate of zinc, the arsenical solution,
and  various  other  means.   (Lectures.  Lancet.
Vol. viii. p. 70.)   When the will retains any
power over  muscular  action,  as it does  in  the
ordinary form of the malady, it might be expected
that such power, in a person susceptible to  music,
would be irresistibly or unconsciously exerted, to
reduce the erratic movements as much as possible
into harmony with its measured cadences.  Nor
will  this  appear  fanciful  to  any one, who, being
endowed  with a musical ear, may have  experi-
enced how difficult it is, while music is sounding,
even  to obey  the  will in movements whicb  do  not
accord with its measures.
   [Under the head  of chronic chorea, Dr. Wat-
son (Lectures on the Principles, <0ec.  of Physic,
Amer. edit.,  p. 364: Philad. 1844,) has  placed
partial choreas, tics, spasmodic  tics, or nervous
tics, which consist in the most irregular and fan-
tastic movements  of  certain  muscles,—at first
dependent upon  bad habits, badly  regulated  vo-
lition, but subsequently executed  independently
of all volition.   At times, they arise  in  conse-
quence  of some morbid  condition  of the  nerves,
and   in  spite of every effort  of the  individual.
There is no plan of treatment which can be ser-
viceable  in  such  cases.  Mental attention, with
appropriate  revulsion, may be sufficient;  but if
not, every other  agency must  fail.   There is no
danger, however, in these affections.]
   We shall now advert to  those singular affec-
tions  which seem to have been erroneously  classed
with  the  foregoing  disease,  as well  as to some
others which appear to have been equally entitled
to tbe appellation of chorea.
   There is the following curious account of the
original chorea Sancti  Viti, in Burton's Anatomy
of Melancholy.   " Chorus Sancti Viti, or  St. Vi-
tus's  dance ;  the lascivious dance Paracelsus calls
it, because they that are taken with it can  do  no-
thing but dance till they be  dead or cured.  It is
so called, for  that the parties  so  troubled were
wont to go to St. Vitus for  help; and  after they
had   danced  there  a while, they were  certainly
freed.  'Tis strange to  hear how  long  they will
dance, and in what manner, over stools,  forms,
tables;  even  great bellied women sometimes, (and
yet never hurt their children,) will dance so long
that they can stir neither hand nor foot, but seem
to be  quite dead.  One in red clothes they  cannot
abide.  Music above all  things  they love ; and
therefore magistrates in Germany will hire musi-
cians to play to them, and some lusty sturdy com-
panions to dance witb  them.  This disease  has
been very  common  in  Germany, as appears by
those relations of Schenkius, and Paracelsus in
his Book of Madness, who brags how many seve-
ral persons he hath  cured of it.   Felix Platerus
(de Mentis Alienat. cap. iii.) reports  of a woman
in Basil,  whom  he  saw, that danced  a whole
month together," (Vol. i. p. 15. 8vo. edition.  Lon-
don, 18'2G.)   This malady appears to have been
generally considered as  a disease  of the mind, and
we learn  from Horstius  and others, that it was
liable to recur every year at the same period. The
movements do not seem to have been actually
spasmodic, but rather to have arisen from an irre-
sistible propensity to muscular action, increased
to a sort of phrenzy  by the  sound of music and
the force of imitation.  The frequency of the dis-
ease, as reported, however, gives rise to suspicions
of imposture.
   Baglivi, who has given us an account of some-
what similar symptoms arising  from the bite of
the ta antula, or  venomous spider, in Apulia, and
cured  exactly in the same manner, states that  the
diseaso was  very often counterfeited by the wo-
men, who in  that country lived  solitary lives, for
the purpose  of enjoying  the agreeable diversion
of music  and dancing,  which was only allowed to
those afflicted with the  malady.   " In fine," says
he, " the  musical entertainment  of this country"
(in allusion to the mode  of curing  the disease)
" is  so very agreeable to  the women, that 'tis a
proverb with  us, «// carnevaletto delle donne.'"
He informs us, however, that there really was  an
unfeigned disease arising from the bite of the  ta-
rantula ;  Sauvages  has  named  it tarantismus;
and  says that " those who are stung die in a little
time without the present assistance of music, all
other remedies giving no relief."   His description
of the symptoms  and the mode  of cure are very
singular.   " A few hours after the bite," says  he,
" the patient is seized  with a great difficulty of
breathing, a heavy anguish of heart, and  a prodi-
gious  sadness,"  &c.  The malady, " after  the
sharp fit of the violent symptoms, which appear
for  the  first  days,   is   over,  ends  at last in a
peculiar kind of melancholy, which continually
hangs upon  the  sick person, till  by dancing, or
singing, or change of air, those violent impressions
are quite extirpated."—" Many  of these persons
are never well but among  graves and in solitary
places ;  and  they '11 lay themselves along on a
bier,  as  if they were really dead ; they '11 throw
themselves into a pit as if they were in despair.
Maids and women, otherwise chaste enough, with-
out any regard to modesty, fall  a sighing, howl-
ing, and into very indecent motions, discovering
their nakedness ;  they  love  to be tossed  to  and
again in the air; and the  like.   There are some
that will roll themselves in the dirt like swine,  and
are  mightily pleased with the exercise.  Others,
again, you cannot please, unless they be  soundly
drubbed on the breech,  heels, feet, back, &c. And
there are  some that take a great  pleasure in run-
ning.  There are also curious  observations made
about colours; some of which are very agreeable
to those persons, as others are offensive to them.
In describing the manner in which they are work-
ed upon by music, he says, " When any are stung,
shortly after it they  fall down upon the ground, 
CHOREA.
435
half dead, their strength  and senses going quite
from them.  Sometimes they breathe with a great
deal  of difficulty, and sometimes they sigh pite-
ously ; but frequently they lie without any man-
ner of motion, as if they were quite dead.  Upon
the first sounding of the music the forementioned
symptoms begin slowly to abate; the  patient be-
gins  to move his fingers, hands,  feet, and succes-
sively all the parts of the body ;  and as the mu-
sic increases, their motion is accelerated ; and, if
he was lying on the ground, up he gets, (as in  a
fury,) falls a dancing, sighing, and  into  a thou-
sand  mimic gestures.   These first  and  violent
motions continue for several hours, commonly for
two  or  three.   After a  little breathing in bed,
where he is laid to carry off the sweat, and that
he may pick up a little strength, to work he goes
again, with as much eagerness as he did before,
and every day spends almost twelve hours by the
clock in repeated dancing; and, which  is truly
wonderful, so far is he from being wearied or spent
by this vehement exercise, that (as they say)  it
makes him more sprightly  and strong.   There
are,  however,  some  stops made ; not from  any
weariness,  but  because  they  observe the musical
instruments to be out of tune ; upon the discovery
of which, one would not  believe what vehement
sighings and anguish at heart they are seized with;
and in this case they continue till the instrument
is got into tune again,  and the  dance renewed.
This way of dancing commonly holds four days,
it seldom reaches to the  sixth.  Every patient has
not only his particular tune, but also his particu-
lar instrument;  some a  pastoral pipe, others a lit-
tle drum, cittern, harp, timbrel, violins, and pipes
of several sorts.  Here 'tis remarkable that some-
times the musicians will  tune three or four differ-
ent sorts of sounds without having the least effect
upon the patient.  But when they fall into a tune
that's accommodated to the poison, they presently
receive the benefit of it.    However, this  must be
taken for a truth, that how much soever they vary
in their particular tunes, yet they all agree in this
—to have the  notes run  over  with  the greatest
quickness imaginable, (which quickness of sound
is commonly called tarantella.)  And therefore
the players that have not their lesson  to  learn in
these matters, easily discover the cheat of tbe wo-
men ; for if they  find  that  they presently take
any  motions, and jog on indifferently, without any
regard to the swiftness,  slowness, or other differ-
ence of sounds, they give to  understand  that the
honest woman is but in  jest, and afterwards expe-
rience puts  the  matter  out of doubt," (Baglivi's
Practice of Physic, p. 363 to 382, passim.  Lon-
don, 1704.)  He states  that the disease, like the
German  chorea  Sancti Viti, generally  returned
about the same time of the year that the patient
was stung; and seems much at a loss  to  under-
stand either how it was  produced,  or  in what
manner it was  cured.   He appears  inclined, in-
deed, to account for the  latter, by  the  profuse
sweatings induced by the violent exercise ;  but he
admits that the physicians could not cure it by
artificial sweatings.  A  cony which was stung by
a tarantula and died on  the  fifth day after, was
not at  all influenced by music.  On  opening  it
after death, he tells us that " the veins and arte-
ries of the brain were swelled up, and the brain
itself a little inflamed, and  set about with black-
ish spots here and there.   The  lungs and other
entrails  were  distended with  clotted and  black
blood.   In the ventricles of the  heart  were ob-
served greater clots of blood, and small branches
of a  polypous concretion.   There was abundance
of serum  lying about the  outward  parts of the
brain.   The other parts were sound and untaint-
ed."  (Page 386.)  There  is a case related in the
New York Repository,  (Hex. ii., vol. i., p. 1-11.
Med. and  Phys. Journ. vol. xv.),  of a convulsive
disease,  ascribed  to the bite of a spider, which,
like  that from the tarantula, was most effectually
counteracted by music.  In the  latter malady, as
as in the original St. Vitus's dance, the principal
peculiarities  were the  excessive  love for music,
and  desire of muscular motion, especially in regu-
lated measures.   In  both  there  was  a  liking or
dislike of certain colours ;  and in  both, the  ima-
gination at least,  if not  the intellect, was from the
commencement disordered.  Such, however, it  is
almost needless to observe,  are far from  being the
characteristics of the ordinary chorea.
   Mr. Kinder Wood has  related a singular case
in the Medico-Chirurgical Transactions, which he
names chorea  Sancti Viti; and it certainly  had
much in common with the original disease of that
name.    The  patient,  a  married woman,  aged
twenty-two, after complaining of severe pains in
the right side of  the face, succeeded  by  heaviness
and  wildness of the eyes, became affected with ex
traordinary involuntary motions, commencing in
the eyelids, which were opened and shut with ex-
cessive  rapidity.  They then affected the muscles
of the extremities.  The palms of the hands were
beat rapidly on the  thigbs, and the  feet on the
floor, the arms being at times extended,  the palms
turned  outwards and inwards, and the backs of
the wrists  struck violently  on each other, or the
middle  fingers on the  palms of the hands with
great quickness.  The motions soon  extended  to
the  trunk of the body and the pelvis  ; and the
patient  was half raised from  the  chair, and in
stantly reseated in rapid succession.  Sometimes
she  was forcibly thrown on her feet, when she
jumped and stamped violently, and she had  often
a propensity to spring or leap upwards,  and strike
the  top of the room with  the palm of  the hand.
Frequently she would  dance on one  leg, holding
the  other with the hand.   These attacks  were
accompanied with headach, sickness, and vomit-
ing, which generally succeeded  the  affection of
the  eyelids.  On  the third day she began to strike
the  furniture  and doors violently with  her hand,
and was  greatly pleased   with  the sound.   At
length  the bystanders  observed  that the strokes
assumed  a regular  tune  and measure, and the
motions were changed into a step about the room,
regulated by an  air, or series of strokes upon the
furniture  as she passed. Though, previous to hei
illness,  she could not even  dance a country dance,
she  would now move about in all the elegance of
a  minuet.   When she looked around, she had an
irresistible propensity to spring  up and touch lit-
tle  spots  or holes in the ceiling ;  and she would
dart the forefinger with amazing rapidity and pro
cision through a  hole in a  wooden screen. A pei
son, thinking he recognised the tune which she
beat on the furniture, began  to sing it, and sbe 
430
CHOREA.
danced directly up to him, and continued dancing
till she was out of breath.   A drum and fife were
now procured, and she immediately danced up to
the drum, and as close to it  as  possible, till  she
missed  the  step,  when  the  motions instantly
ceased, and this was always found to be the case.
The motions  were always found to  cease, also,
when the measure was  changed, or increased in
rapidity beyond her power to  keep pace  with it.
When a continued roll was kept up on the drum,
it had likewise the effect of stopping the motions.
Their approach was  therefore watched,  and  by
uniformly rolling the drum when it was observed,
the chain of  associations which constituted  the
disease was at  length broken.   Mr. Wood states
that the alvine excretions were unnatural during
the complaint, and  that the menstrual discharge
appeared on the  evening of the day on which it
ceased; together with an eruption on  the skin, in
diffused patches, of a bright red  colour. Whether
these were essential circumstances in the history
of the case is a question worthy of consideration.
Mr. Wood  thinks that  the  case establishes  the
connection of such instances of inordinate muscu-
lar action with some  peculiar state of the mind.
He tells  us,  however,  that  the patient's  spirits
were  good, her perception and judgment accurate
and just; that during the absence of the  parox-
ysms she went  about  many household  affairs ;
and that she had a  correct knowledge  of her situa-
tion, and of the advantages she  derived  from the
agency of the drum, with an anxious desire to
continue its use.   A subsequent less severe attack
of  the complaint disappeared  under  the use of
aperients and tonics; and the third and last, which
terminated in  spasmodic affections of the abdo-
men, chest, neck, and face,  seems to have been
chiefly benefited  by bleeding.  It is curious that,
after  the nature  of the motions was  changed in
this last  attack,  the  drum had no  effect  upon
them.  (Medico-Chirurg. Trans, vol.  vii.)
   [In another work,  (Practice of Medicine,  edit.
cit. ii. 295,) the author has given, on the autho-
rity of a young  medical friend, an account of a
singular affection said to be somewhat common in
the southeastern portion of the state of New York,
and known  among the  common  people  as  the
magrums.   It is said to consist essentially  in  a
spasmodic action of all, or nearly all, the volun-
tary muscles.   In the involuntary movements, the
upper part of the air-passages occasionally parti-
cipate, as witnessed by a clucking sound in the
neighbourhood of the glottis, and a manifest  im-
 pediment in the powers  of speech.  The move-
 ments of the  face, neck, extremities and body,
 wholly  cease  during sleep.    The disease  very
 rarely makes  its  appearance before adult life,  and
 attacks after forty-five years of age are very  rare.
 It rarely or never ceases whilst  life lasts, and ap-
 pears to be hereditary.]
    Of the disease which has been at  times preva-
 lent in some parts of Scotland, and known by the
 name of " the leaping ague," the following  is a
 concise  description :—" Those affected first com-
 plain of a pain in the head  or lower part of the
 back, to wbich succeed convulsive fits or fits of
 dancing at certain periods.  During the paroxysm
 Ihey have all  the appearance of madness, distorting
 ibeir bodies  in  various  ways,  and  leaping  and
springing in a surprising manner, whence the dis-
ease has derived its vulgar name.   Sometimes
they run with astonishing velocity, and often over
dangerous  passes, to  some  place  out of doors,
which they have fixed on in their own minds, or
perhaps  even mentioned to  those in company
with them, and then drop down quite exhausted.
At other times, especially when confined to the
house, they climb  in the most singular  manner.
In cottages, for example, they leap from  the floor
to what are called the baulks, or those beams by
which the rafters are joined together, springing
from one to another with the  agility of a cat, or
whirling round one of them with a motion resem-
bling the fly of a jack."  (Edin. Med. and Surg.
Journal, vol. iii. p- 835, or the Statistical  Account
of Scotland, by Sir J. Sinclair, passim.)
   The most recent published case of this disease,
so far as we are aware, will be found in the 31st
volume of the Edinburgh Medical  and  Surgical
Journal.  Mr. Crichton  states that the patient
was a girl fifteen years old, and that the affection
was announced by  frequent shakings, with foam-
ing at  the  mouth, followed by coma.   In addi-
tion to many  of the symptoms mentioned in the
foregoing passage, such as dancing, jumping upon
the furniture of the room, running round a table,
springing on the top of a door to swing backwards
and forwards, leaping over  a staircase  at one
bound, and desiring  to spring out of a window;
she had likewise the following singular affection:
" she would occasionally converse with  those in
the room, but in a language that no stranger, and
hardly even those  of the  family who were con-
stantly beside her, could understand.  This arose
from her commencing the sentence with  the last
word, and very  frequently pronouncing the words
themselves  with the last  letter foremost.   At
times, when  by no possibility  she could  make
herself be understood  by her parents or sisters,
she became irritated, and would write down what
she wished to convey ; but her manner of writing
was equally singular, beginning at the right edge
of the paper,  and writing backwards towards the
left, the last word of the sentence  first, and often
the last  letter of the word first; and this  she per-
formed with great rapidity, and seemingly without
 consideration."   (Vol. xxxi. p. 300.)  She had a
 propensity  to secrete things; and so irresistible
 were the impulses to motion, that the strength of
 several  people was  insufficient to constrain her.
 Purgatives afforded  her little benefit.  Opium be-
 fore the paroxysm sometimes prevented it; and
 the shower-bath cured the disease, though it pro-
 duced locked jaw for eight days.  The  "leaping
 ague" may be said to consist, generally, of a mor-
 bid propensity  to  running, leaping, dancing, or
 tumbling, which  the patient is unable to resist.
 The muscular motions, though in  a great degree
 involuntary, are performed  with  more agility and
 exactness than usual;  for the person affected can
 run with greater velocity, leap with greater vigour,
 and do feats which  even professed tumblers could
 not equal,  balancing the  body  with correctness,
 and dexterously avoiding dangers.   It is scarcely
 necessary to point  out how  widely the disease
 differs in  all these respects  from tbe  ordinary
 chorea.
    M. Piedagnel has related  the case of a man, 
CHOREA.
437
who, after some symptoms of cerebral affection,
was seized with an irresistible propensity to move
forwards, only stopping when exhausted.  Find-
ing his apartment too confined for the gratification
of his propensity, he would sally into the streets,
and continue  walking straight forward until he
dropped down, and  was  obliged  to  be brought
home in a litter.  On opening the head, several
tubercles were found, involving in  a particular
manner the   anterior  part  of the  hemisphere.
(Journal de Physiologie, torn.  iii.  or  Magendie's
Physiology, translated by Dr. Milligen, 3d edit. p.
189.)  In direct opposition to this case, Dr. Lau-
rent, of Versailles, exhibited a young girl  to  the
Academy of Medicine, who, in the  attacks of  a
nervous disease, was irresistibly propelled  back-
wards, and with some rapidity, being unable to
avoid obstacles or hollows, and, consequently, re-
ceiving many bruises and falls in  her course.
(Magendie's Physiology, p. 191.)
   An account of a very remarkable case, in which
a young girl,  in Renfrewshire, was affected with
violent  fits  of leaping, dancing, running, crying,
fainting, &c, was  published  at  Edinburgb, in
1698.   It was entitled " A True Narrative of the
sufferings of a Young Girl, who  was  strangely
molested by Evil Spirits, and their  Instruments,
&c."  The disease being ascribed  to witchcraft, a
commission was appointed by the king to inquire
into  the matter, and  seven unfortunate beings in
consequence were condemned to the  flames !
   One of the  most extraordinary cases of convul-
sive  disease on record has  been  related by  Dr.
Robert Watt,  of Glasgow, in the  5th volume of
the Medico-Chirurgical Transactions, under the
title  of Chorea, or " Periodical Jactitation."   The
patient was a lively, but rather  delicate girl, ten
years old, from Ayrshire.  She was first seized
with excruciating headach, and almost incessant
vomiting, increased by the slightest inclination of
the body either backwards  or  forwards.  These
symptoms continued  for a month, during which
time she lost the power of speech and of walking.
At the  end of that  time  she was seized with  a
propensity to turn round  on her feet, like a top,
with great velocity, always in  one direction, and
was  gratified when the attendants  assisted her in
increasing the rapidity of her movements.   After
continuing nearly a month these motions ceased,
the headach returned with increased severity, and
was  succeeded by a  total loss  of  power over the
muscles of the neck.  In  a  short  time  after, she
was  seized  with a  new kind of motion.   She
would  lay  herself across the bed, and, turning
round like  a roller,  moved rapidly from one end
of it to  the other.  The fits continued at first for
about two hours; but they gradually increased to
six or seven hours daily.   On  being carried  into
the garden, she rolled rapidly from one end of a
walk to the other ; and, even when laid in the
shallow part of a  river,  though at the point of
being drowned, she began to turn round as usual.
Nor  did the  sudden  dashing of cold water over
her interrupt her movements.   Her rotations were
about sixty in a minute.   In a month or six weeks,
the movements became of an entirely new kind.
The patient  now  lay upon her  back, and, by
drawing her head and heels together, bent herself
like a bow, and then allowing her  head and heels
                                    2m*
to separate, her buttocks fell with  considerable
force upon the bed.  She repeated  these move-
ments ten or twelve times in a minute; at first
for  six  hours  daily, and at length  for fourteen.
After this had continued for about five weeks, she
was seized with a propensity to stand upon  her
head with her feet perpendicularly  upwards.  As
soon as the feet were elevated in this manner, all
muscular exertion seemed to  be withdrawn,  and
the body  fell  down as if dead;  her knees  first
striking the bed, and  her  buttocks  striking  her
heels.   This was no sooner done  than she in-
stantly mounted as  before, and continued to do
so,  from twelve  to fifteen times in  a minute, for
fifteen hours a day.  The disease left her after a
spontaneous diarrhoea, having previously resisted
cathartics,  an  emetic, local bleeding, blistering, a
seton in the neck, &c.   Dr. Watt states that  an-
other instance, similar to this, had occurred some
years before in  Ayrshire, and that  he had been
informed of a third in  the same county: in both
of these,  also,  the  patients  were young women.
There  is  a case mentioned in the 3d  volume of
the  Edinburgh  Medical  and Surgical  Journal,
page 437, in which a young girl was affected with
a species of motion  similar to the first which Dr.
Watt's  patient presented.  " Her complaint began
with convulsions of the diaphragm and abdominal
muscles, producing  an action like  retching, or
something between hiccough and retching.  Con-
vulsions of the extremities supervened, and in the
paroxysms, which lasted  several  hours, she  per-
formed  the most singular motions; at one time
bounding upon her bed, then turning round  and
round, as upon an axis; then running round the
outside  of  the ropes by which her hammock  was
suspended."   She had several paroxysms a day,
coming on at stated intervals, and  she had con-
stant pain, which she referred to the  region of the
uterus.   Nothing  was  discovered on dissection
after death, which could at all explain the nature
of the disease : some time before she was affected,
she had rather a severe fall upon her head.
   Mr. Hunter, of Glasgow, relates a case in which
the principal symptom was  a convulsive rotation
of  the head and trunk; he entitles it, therefore,
" rotatio," or chorea.  The patient was a female,
twenty-three years  old, and unmarried.  While
lying on her back, the head was rolling from  side
to  side, with  a quick, regular, and  continued
movement.   When  a  fit came on,  " she sprang
with a strong convulsive movement from her back,
and sat up in the bed.  The rotatory motions of
the head now became furious and alarming.  They
were executed with such immense rapidity, that it
was difficult even for  eye to follow them.   She
appeared  absolutely  to be looking backwards  and
forwards, and in every direction, at  the same in-
stant.   The movements, while in the sitting  pos-
ture, were not confined to the head ; for the whole
trunk  likewise  partook of the rotatory  motions,
the breech being the pivot upon which the whole
turned.   These convulsive  motions  continued
about a minute, when they took a new but equal-
ly  strange direction.  The  flexor  and extensor
muscles of the head and trunk were alternately
called  into  action, and without the breech af the
patient  moving  from its first position, her head
was rapidly carried  forwards to  her knees,  and 
433
CHOREA.
backwards to her pillow, for about half a minute,
when the paroxysm ceased, and  left the  patient
greatly  exhausted."  (Edtnb.  Med. and  Surg.
Journal, vol. xxiii.  p. 261.)   Mie was perfectly
rational, but the external senses were blunted and
torpid.  She sometimes had fifty paroxysms in a
day.  The  disease  appeared to commence in the
uterine region, where there was pain on pressure ;
and it was cured by rubbing tartar emetic oint-
ment on  the scalp, and along  the course of the
vertebra?.   A case in some respects similar to this
has occurred in  our own  practice, in the  person
of a young woman, who was affected for  a  long
time with rotation of the  head, without pain, but
accompanied by  intolerance of light.  The mo-
tions, however, were far more  gentle and  slow
than in Mr. Hunter's case, and they were unin-
termitting.
   A  patient  attended  by  Dr. Conolly  became
subject, about  the period of the cessation  of the
catamenia,  and when  menstruation had  become
irregularly  performed,  to  violent paroxysms of
rotation :  they  occurred many times in a day, and
were always preceded by an inordinate disposition
to talk.   When  the fits came  on, the head was
forcibly rotated from side to side about eight times
in a second, and the paroxysm commonly lasted
three or four minutes.   In this case, the affection
yielded to cupping behind the  neck, application
of leeches to the head, and the persevering use
of aloetic purgatives.
   Another  singular form of disease, which has at
times been  ranked with chorea,  is that affection,
by some authors called  matteatio,  and consisting,
principally, of a striking of the knees with one or
both hands, as with a  hammer.  The hands are
generally open, but sometimes  they are clenched.
Morgagni mentions a case of this description,  in
which one hand was  convulsed ; on extending
any of its fingers the other hand  became affected
also ; and if attempts were made to arrest the mo-
tions by force,  they became both more violent and
more general.   We ourselves  recollect  the case
of a man, in the Hampshire County Hospital,  in
whom there was a constant and uniform  striking
of the palm of  one hand  upon  the side of the
thigh, to such a degree, as speedily to wear out
the part of his  dress on which it fell.
   In the preceding cases of anomalous  convul-
sions, it  will be observed that there was for the
most part a periodical return and  intermission  of
the spasms, as well as  some method or regularity
in the movements themselves.   In both  these re-
 spects they differ from the common chorea of this
country.   Other cases have been met with, oc-
curring in paroxysms,  but in which the  motions
were obedient  to no rule or method.  Dr.  White,
 of York,  describes  a case of this kind in the fourth
 volume of the  Edinburgh Medical Commentaries,
 p. 326,  in which  the  muscles of various  parts
 were, not simultaneously, but in succession, pain-
 fully convulsed, producing  appearances  so gro-
 tesque as to defy  description.   Three  cases, oc-
 curring  in one family  in  the county of Rutland,
 are related  by Dr. Armstrong, in the ninth volume
 of the same work, p. 317, in which the  patients
 were affected periodically, and  suddenly, with fits
 nf shrieking, jumping, writhing, &c. The disease
first occurred after hooping-cough, and Dr. Arm-
strong considered it as epileptic.
  There are some singular instances recorded of
affections like the last being propagated by sym-
pathy or imitation.  These have  generally been
attended,  and in  the  first instance, excited  by
religious or some other  species  of enthusiasm.
This was strikingly the case in that extraordinary
epidemic, as it  has  been called, which prevailed
in 1742 in the parish of Cambuslang, in Lanark-
shire, during the ministry of Mr. Macculloch, and
produced  by his preaching and  exhortations on
the subject of regeneration.  (Edinb.  Med. and
Surg. Journ., the Inquirer,  No.  11), vol. iii. p.
441). A similar epidemic occurred in the western
districts of America, in  consequence of the elec-
trical spread of religious enthusiasm throughout
the states of Tenessee and Kentucky, about the
year  1800.  Dr.  Robertson,  who published  an
account  of it, states that the converts indulged
in alternate  fits of coughing, laughing, singing,
shouting, and extravagant gesticulations, until, at
length " to their own astonishment, and the diver-
sion of many  of the spectators, they continued to
act from necessity the curious character  which
they had commenced from choice."*   He informs
us  that  the convulsions were  generally  in the
muscles of the neck, trunk, and superior extremi-
ties ;  and that they were sometimes so violent as
to throw the patient on the ground, " where, for
some time,  his  motions  resembled those of a live
fish when thrown on  land, more than anything
else."
   M. Magendie relates a case  of the most extraor-
dinary nature, in which the power of the will over
the muscular motions was, at intervals, entirely
lost;  but instead  of the muscles being paralysed
or remaining at rest, they were abandoned to the
most irregular and  indescribable  movements for
hours together.  After stating  that the disease was
preceded by great mental  anxiety, followed  by
melancholy, the understanding remaining how-
ever  entire in  all other respects, M.  Magendie
describes the peculiar symptoms of the case in the
following words :  " It is impossible to paint, by
language,  the variety  and oddity of his motions
and positions.  Had he lived in the times of igno-
rance, he would,  beyond all  doubt, have  passed
for one possessed ; for his contortions were so far
removed  from  the motions proper to mankind,
that they might easily have passed for diabolical.
It was wortby  of remark that, in the midst of
these contortions, in which his slender and pliant
body was  sometimes carried  forward, sometimes
thrown back, or to one side, like certain tumblers,
he never lost his equilibrium ; and  that  in the
multiplicity  of attitudes  and  singular motions
which he exhibited for several months, he never
once happened  to fall.   At certain times his mo-
tions would pass into the train of ordinary actions.
Thus, without the least participation of his will,
he was seen to  rise and  walk with rapidity, until
he met with a solid body that  opposed his passage
Sometimes he walked backwards with the same
readiness,  and  was  only stopped by a  similar

  * Edin. Med. and Surg. Journ. vol. iii. p. 446; or an
Inaugural Essay on Chorea Sancti Viti, by Felix Robert
son, of Tennessee.  8vo.  Philadelphia, 1805 
                                         CHO

 cafise.  He has often been observed to re-assume
 the power  over certain  motions without being in
 any way capable  of directing others.   Thus his
 arms  and  hands  frequently obeyed  his will, and
 more  frequently still, the  muscles of his counte-
 nance and speech.   It was sometimes possible for
 him to retrograde in an instant, where progression
 forwards was anyhow  prevented ;  and he then
 employed that retrograde motion to direct himself
 towards  objects to  which  he wished  to  attain.
 Finally, these movements, which might be called
 automatic, never lasted an entire day. He enjoyed
 pretty long quiet intervals between the accessions;
 his nights were always tranquil.   Although his
 muscular  contractions  were  extremely violent,
 even  to the extent of producing abundant sweats,
 when they had ceased,  he perceived no sensation
 of fatigue  in proportion to the efforts  which he
 had made; as if the intellectual action  which we
 exert  to excite our motions were  that which in
 the healthy suffers most exhaustion."  (Compen-
 dium of Physiology, pp. 201 and 202).
   The causes of such anomalous cases of convul-
 sion,  and the manner in  which they operate, are
 exceedingly obscure.  Modern physiologists, how-
 ever,  have  afforded us some light on tbe subject.
 Thus, Magendie has, by experiments on some of
 the lower animals, shown great reason  to believe
 that the will has more  particularly its seat in the
 cerebral  hemispheres, while the  direct cause of
 motion is in the spinal  marrow.   We can easily
 conceive,  therefore, says  he, " why,  in  certain
 cases,  these  motions are not  produced, though
 commanded by the will; and why, in certain cir-
 cumstances of a  contrary  nature, very  extensive
 and energetic motions are developed without any
 participation of the will."   (Op. cit. p. 202.) In
 some  of the  following experiments  confirmatory
 of this view, it will be observed that many  of the
 anomalous symptoms in the cases  we have just
 related, were produced by  artificial means.
   M.   Magendie found  that the cerebral  hemi-
 spheres might be deeply cut into, or even entirely
 removed, provided  the  corpora striata  were not
 injured, without any marked alteration of motion
 taking place.  In a number of cases he has seen
 birds,   reptiles, and  fishes,  run,  leap, and  swim,
 after  the  hemispheres were removed.  Neither
 does the longitudinal section of the corpus callo-
 sum, or its  entire removal, produce any additional
 effect  upon the motions.   But if the corpora stri-
 ata be removed,  the animal immediately  darts
 forward,  and runs  rapidly, as  if impelled  by  a
 power within which it cannot resist.   This effect
 arises from the  destruction of the white and stri-
 ated  portion  of these bodies, for the  removal of
 the brown matter does not produce any change in
 the movements of the animal.  In  unison with
 these facts, M. Magendie has opened several im-
 moveable horses, or horses that cannot  go  back-
 wards, though  they can  move forward   with
 rapidity; and he  has in all of them found  a col-
 lection of water in  the lateral ventricles, which
 must have compressed the corpora striata, and had
 even disorganized  their surface.  He considers it
 extremely probable, therefore, that there  exists in
man and  the mammalia  a  force or impulse which
tends to carry them forward, and which in  a state
of health is directed by the will.   Again, both he
RE A.                                     439

 and others have found that lesions of the cerebel-
 lum cause animals to move backwards contrary to
 their will.   He  found also that injuries of the
 medulla  oblongata   produce  the  same effect.
 Pigeons, into which he forced a  pin through that
 part, constantly receded, for  more than  a month,
 and even flew backwards.  The energies of the
 cerebellum and medulla oblongata appear, there-
 fore, to be directly opposed to those of the corpora
 striata;  those of the one counterbalancing the
 other in the sound state, and being rendered pre-
 ponderant, or otherwise, by disease or injuries of
 the respective parts.  A still different effect was
 produced  upon  the  movements of  the  animals
 when the  peduncles  of the  cerebellum were
 divided.  In that case the  creature rolled laterally
 upon  itself, as if impelled by a  great force ; the
 rotation being made  upon the side on which the
 peduncle was cut; the animal making sometimes
 more than sixty  revolutions  in a minute, and the
 motions  continuing  frequently   for  eight  days
 without a moment's interval.   The same effect
 was  produced by vertical  and entire sections of
 the cerebellum ;  the motions being more rapid
 according as the  section was nearer  to the origin
 of the peduncles.  When  the  cerebellum was cut
 vertically into two perfectly equal parts, the animal
 first rolled once or twice to one  side, and then as
 often to the other, as if for relief.  Similar effects
 to these  were obtained  by  sections  of  the  pons
 varolii, which, together with the  peduncles of the
 cerebellum,  forms a circle round  the  medulla
 oblongata.  Sections to the  left of the median
 line produced rotation to the left, and sections on
 the  right side of the line, rotations  to the right.
 A movement  in  a circle,  resembling  that of the
 manege, was  occasioned by a  section of the me-
 dulla oblongata,  where it approaches the exterior
 of the anterior pyramid,   if cut on the right  side,
 the animal turned to  the right; and when cut. on
 the  left, it turned to the  left.  Lastly, when the
 spinal marrow was separated from the brain  by a
 section made behind the occipital bone, the influ-
 ence of the will appeared  to be entirely cut  off
 from the movements; which, however,  did  not
 cease,but became very irregular in extent, rapidity,
 duration, direction, &c. (Compendium of Physi-
 ology, p. 187 to 193—200 and 201.)
   These experiments, as well as  those of Rolando
 and of Flourens, are strongly in  favour of the
 opinion, that individual parts of  the brain answer
 individual purposes, so far, at least, as regards the
 power of regulating  our movements.  Such sin-
 gular and anomalous  instances of muscular action,
 therefore, as those we have related, may arise from
 causes which produce an excitement or oppression
 of certain parts of the encephalon, without affect-
 ing  the other parts.   Certainly in many, or most
 of the cases, marks of cerebral affection  were ob-
 served.   In M. Piedagnel's case, as we have already
 mentioned, several tubercles were found  pressing
 upon the brain ;  in the immoveable horses, watei
 was uniformly discovered in the ventricles ; in the
 rabbit that died from the bite of the tarantula there
 were marks of inflammation,  congestion, and effu-
 sion of serum on  the brain.  In the leaping ague,
 one of the first symptoms is pain in the head.  Dr
 Watts's  case was preceded by excruciating head
 ach and  incessant vomiting;  Mr. Kinder Wood' 
440                                     CLIMATE.
was attended with the same symptoms ;  and the
patient whose  case  is  referred to in the  third
volume  of the  Edinburgh  Medical and  Surgical
Journal, had had a severe  fall  on the head  some
time previous  to the  convulsive  affection.  Al-
though the existence, therefore, of partial pressure
or other  affections  of the  brain may not in all
cases have been  discovered, or  even  discover-
able, — since,  unless it arise  from a permanent
cause, it may be impossible  to detect it after death,
— yet  it must  be admitted that there are  strong
grounds for attributing these cases to such an
origin, and for directing our remedial attentions ac-
cordingly.   Whether the strange mental or mono-
maniacal  symptoms  which have sometimes ac-
companied the convulsive  motions, may, as well
as tbe latter, be attributed  to an affection of cer-
tain individual parts  of the brain, is more problem-
atical.   The  disciples of Gall and Spurzheim,
however, would doubtless advert with complacency
in Mr. Wood's case  to the prominent symptoms
of excitement  in the vicinity of their organs of
time and tune, as confirmatory of their doctrines.
[See Watson, Op. cit., p. 367.]
                      Andrew Crawford.
   [CIRRHOSIS. (See Liver, Diseases of the.)
   CIRRHOSIS OF THE  LIVER.  (See Liver,
Diseases  of the.)
   CIRRHOSIS  OF  THE  LUNG.    Under
this name, Dr. Corrigan, of Dublin, has described
a pathological condition, the  general character of
which is  a tendency to consolidation  or contrac-
tion of the pulmonary cellular tissue with dilata-
tion of  the bronchial tubes.  The diminution of
the lung is regarded by him as the first step of the
disease, and the dilatation of the bronchia the con-
sequence  of this.  The primary seat of the disease
he considers to be—the web of cellular tissue, con-
stituting the matrix of the  lung, which has a ten-
dency to contract, so as to  produce, when the dis-
ease is  advanced, a very considerable obliteration
of the  air-cells.  (Dublin Med. Journal, May,
 1812, and the writer's Practice of Medicine, 2d
edit., i. 201 : Philad. 1844.)]
                       Robley Dunglison.
   CLIMACTERIC DISEASE.  (See Age.)
   CLIMATE.  The general import of the word
climate (from  ic\iua,  regio,) is  sufficiently under-
derstood,  although it is not easy to give an accurate
definition of it.   In medicine the term is used to
designate those habitual conditions of the atmo-
sphere, in connection with  the state of the surface,
 soil, exposure, &c. of particular countries or dis-
 tricts, which are capable of influencing the health
 of persons inhabiting them.
   The subject of climate may be  treated under
 two distinct divisions, physical and medical. The
 consideration of the former, or physical climate,
 we must  leave to the natural historian, as not com-
 ing properly within the scope of this  work,  al-
 though affording matter of the  greatest interest to
 the medical philosopher.  The latter or medical
 climate, may also be considered under two sepa-
 rate heads—as it affects the body either in causing
 or curing disease.   The latter part of the subject,
 or the consideration  of climate as an agent in the
 prevention and cure of disease, is that which we
 propose to treat in  the present article; availing
ourselves, however, of tbe physical character? of
climate and the geography of disease, as far as a
knowledge of these departments of the subject tends
to illustrate the medical application of climate.
   We shall first give a brief account of the cli-
mate of the principal places in  our own Island, in
the South of Europe, and in the Northern Atlan-
tic, which have been most frequented  by invalids;
and endeavour, at the same  time, to  determine
their respective characters and their relative merits.
We shall then point out the  diseases which are
most decidedly benefited by change of climate, and
the particular  situations most suitable  to each.
   The influence of climate on the animal economy
is now so well  known  and  appreciated by the
more observant  part  of  the   profession, that it
would be a waste of time, in a work of this nature,
to  enlarge upon the  advantages  which may be
derived from  a well-timed and judicious change
of  it  in  the treatment of disease.  The removal,
for example, from a cold, humid, and variable cli-
mate, to one which is warm, dry, and more equa-
ble, is well known to  be  productive  of the most
beneficial effects  on a large class of invalids, when
other  therapeutical agents are  of  little  avail;
while, on the  other hand, a contrary change is as
certainly  attended by a deterioration of the  health,
and often by the supervention of fatal diseases,
even in persons previously in the enjoyment of
good health.
   If our limits permitted, it would not be difficult
to  account for many  of the  effects of climate,
whether favourable to health or the reverse.  For
instance,  when  we reflect on the powerful in-
fluence of a warm  dry air on almost all the func-
tions of the animal economy, but more especially
its obvious agency  in promoting an equable dis-
tribution  of the  circulating fluids over the whole
system, and particularly  its effect in  augmenting
the activity of the circulation in the capillaries of
the surface,^nd in diminishing in the same pro-
portion the congestion of the  internal vessels, (a
state which   very  generally obtains  in  chronic
ailments,)—we bave a satisfactory explanation of
much of the benefit which invalids experience by
a removal from a cold to  a warm climate.  If we
take into account also the effect of the continual
action  of a bland  atmosphere on the extensive
surface of the respiratory organs, both as abating
irritation of the  lungs, and enabling them more
effectually to  produce those changes in the blood
that are essential to health, we have another very
obvious explanation of the results observed. And
if to these we add the influence produced  on the
nervous system generally, on the external senses,
and  through  them on the mind, and, reversely,
the re-action  of the mind on the bodily functions
— we need have little difficulty in  accounting for
 the beneficial influence of the  change  of  climate
 which we are now considering.
    The contrary  state of the functions  and of the
circulation, and the  diminished energy  of  the
 nervous  system induced by  a change from  a
 genial  to a  cold  and humid  climate, will with
 equal readiness account for most of the evil con-
 sequences so frequently  observed under such cir-
 cumstances.
    Independently, however, of  these  effects, more
 directly attributable to climate, properly so called, 
CLIMATE.
441
 there are many incidental circumstances attending
 a change of tbis kind, which have often no small
 share in improving the condition of the invalid.
 The hopes inspired by the measure itself, the in-
 fluence of the journey or voyage, the change of
 scene, of occupation, and often, also, the escape
 from business and other sources of discomfort and
 care, all claim a part in the benefit produced.
    While all these circumstances will, therefore,
 have their due  weight with the  physician, when
 deciding upon such  a  change  of climate  as we
 are now contemplating,  he must not omit,  at the
 same time, to take into account the inconveniences
 and even disadvantages, which in many  cases are
 inseparable from the removal of the delicate in-
 valid from his own home and country.  These
 latter considerations will  rise in importance  in his
 mind according to the advanced  state of his  pa-
 tient's disease, and consequently the  diminisbed
 prospect of permanent advantage from  the mea-
 sure.  So  many circumstances  of a conflicting
 nature often present themselves for our considera-
 tion in such  cases, that  it is only by a compre-
 hensive and dispassionate view of all the bearings
 of the case that we can come to a right  decision,
 and then often not without difficulty.  It is per-
 haps the rarer case, that we have merely to con-
 sider the nature of the patient's  disease, and the
 probability of its being benefited or cured by any
 particular climate.
   Among  the numerous  circumstances  which
 require  attention  in  recommending  a change of
 climate, one of much importance is often entirely
 lost sight of,  both by the physician  and his pa-
 tient :—we mean the necessity of perseverance in
 the regimen and mode of life which  the peculiar
 nature of the disease demands.   This  must be
 urged upon the invalid as the condition on which
 alone he can expect  to  derive  benefit from the
 prescribed measure.
   We would press upon the  minds  of  our pro-
 fessional brethren the importance of giving  a full
 consideration to all the circumstances which have
 been just noticed ; as we  are satisfied, from ample
 observation, that change of climate has not hither-
 to been productive of all the benefit  which it is
 calculated to effect, — nay, that it has often done
 positive mischief, chiefly on account of the incon-
 siderate and injudicious  manner in which it has
 too generally  been prescribed  and  carried  into
 effect.
   We  shall now proceed to give some account
 of the individual  places in this and  other coun-
 tries which  have  been chiefly resorted to by in-
 valids, on account of the mildness or other pecu-
 liarities of their climates.
   English  Climates.—The great desideratum
 in this country  is to find a  mild climate  and
 sheltered  residence for our pulmonary and other
 delicate invalids  during the winter and  spring :
 we shall therefore direct our attention principally
 to  this point.
  Our warmest winter residences in England are
 mostly found on the southern and south-western
 shores; indeed it  is their vicinity to the sea which
 in a great degree renders  them warmer than the
inland parts in their respective vicinities.
  The mild region  of England admits of a na-
tural division into four districts or  groups, each
  Vol. I. —56
 having some peculiar features in its climate which
 characterise it  and distinguish it from the others,
 both as regards its physical and  medical qualities.
 These are—^
    1. The south coast,  comprehending the tract
 of coast  between Hastings  and  Portland Island,
 including the Isle  of Wight; 2. the south-west
 coast, from the  latter point  to Cornwall;  3.  the
 district of the Land's End; and  4. the western
 group, comprehending the places along the bor-
 ders of  the Bristol  Channel and estuary  of the
 Severn.
    South Coast.—The superiority of the climate
 of this district  exists chiefly during the months
 of December, January, and February.  In March
 the temperature of  this coast, and  that of the  in-
 terior, (e. g. the vicinity  of London,  which  we
 select as  a convenient  point of comparison,) is
 nearly the same.   In April and May, the tem-
 perature  of the interior rises above that of  the
 coast and continues higher, though in a less ratio,
 through  the summer months.    In October  the
 mean temperatures are again equal,  and in No-
 vember, that of the coast begins  to exceed the in-
 terior.  The only places on the south coast which
 we consider deserving  of particular notice, are,
 Undercliff in the Isle of Wight, and Hastings and
 Brighton on the coast of Sussex.
    Undercliff is decidedly the most sheltered anu
 warmest  of these places, and it has moreover this
 convenience over most  of our other winter resi-
 dences, that it also affords a good summer climate,
 a circumstance of considerable importance to many
 invalids.   Unfortunately, at present, few can avail
 themselves of the  advantages  of this sheltered
 district, from the want of the necessary accommo-
 dations.    [Of late,  the accommodations for  in-
 valids have been greatly increased.  (Sir James
 Clark, The Sanative Influence of Climate, p. 134.
 Lond. 1841.) The Isle of Wight presents a great
 variety of healthy and beautiful  sites for different
 classes of valetudinarians,  both as winter  and
 summer residences.]
   Hastings follows Undercliff in point of shelter
 and warmth during  the winter and spring months.
 Its situation at the base of a range of steep  hills,
 which protect it in  a considerable degree from the
 north and north-east winds, render it a milder
 and more sheltered residence during this season
 than the other parts of the coast of Sussex.
   [St. Leonard's is  about a  mile to the westward
 of  Hastings.  The  climate  of the  two places is
 almost identical; — but  the  accommodations are
 much better at the former.  (Sir James Clark, op.
 cit.  p. 126.)]
   Brighton differs  materially in  the character of
 its climate from  both these places.  It is more ex
 posed to  northerly winds, but the  atmosphere is
 drier and  more  bracing.  While inferior to Un-
 dercliff and Hastings as  a residence in diseases
 of the respiratory organs accompanied with much
 irritation, it offers advantages over both to invalids
 of a relaxed and nervous habit who are not very
 excitable.   Autumn  is the season  during which
 the climate of this place possesses tbe greatest ad
 vantages; and even  to the end of December it is
one of the mildest climates in our island, and most
favourable for a large class of invalids ; more espe- 
442
CLIMATE.
«"ially for cases  in  whicb a  relaxed state  of the
system is a leading feature.
  Invalids who select the coast of Sussex as their
winter residence, might find it advantageous to
pass the autumn at Brighton and the winter at
Hastings.
   Soutii-wcst Coast. — The winter climate of
the south coast of Devon has long been  noted for
its  mildness.  The temperature of its more  shel-
tered spots during the months of November, De-
cember,  and  January, (when the  difference is
greatest,) is,  in the  average,  about  five degrees
higher than that of London during the  same pe-
riod : whereas, on  the  south coast, the difference
scarcely  exceeds two  degrees.  This superiority
of temperature over London at both places, occurs
chiefly  during the night;  though the  days are  I
proportionably warmer, and the temperature  more
steady on the south-west than on  the south coast. |
In  making  this comparison, however, between
these two districts, it is right to observe that Un- j
dercliff is  not taken into the account for want of ■
sufficient data.
   Various places on the coast of Devonshire are
held in repute on account of the beneficial effects
of their climate,  more especially in pulmonary
diseases.  The  principal of these are  Torquay,
Dawlish, Sidmouth,  and  Exmouth.  Salcombe,
the Montpelier of Huxham, is unquestionably one
of the warmest spots in our island during the win-
ter ;  but it possesses few accommodations, and its
sheltered climate is confined to too small a  space
to  admit of its ever acquiring importance  as  a re-
sidence for invalids.  Indeed, this limited character
of the climate is the  great defect of all  the places
 on  this coast,  with the exception  of  Torquay.
 Here the invalid has the advantage of a consider-
 able tract of sheltered country, some part or other
 of which will afford a protected  ride or walk, in
 whatever direction the wind blows.  Torquay is,
 superior in  this  respect  to every  place  in  our
 island.  Its  position, also, on  the southern  decli-
 vity of  a range of  pretty steep  hills,  composed
 chiefly of calcareous rocks,  renders  it compara-
 tively dry.   Hence, while Torquay  possesses all
 the advantages of the climate of this coast, its
 chief disadvantage (humidity) is  felt  in a  less de-
 gree than elsewhere.
    Land's End.—The only place in this district
 deserving particular notice is Penzance,  which has
 long been frequented  by  invalids on account of
 the mildness of its winters.   Penzance has a very
 peculiar climate,  which depends on its almost
 peninsular situation at the south-western extremity
 of the  island.  A remarkable equality in  the dis-
 tribution of the temperature throughout the  year,
 and throughout the day and night, is  a  striking
 character of this place.  In this respect, indeed,
 the climate of Penzance is superior to that of the
 south of Europe, and the  only climate which we
 have examined that excels  it is  that of Madeira.
 This peculiarity of the climate  of Penzance will
 be shown at once by comparing it with that of
 London, where the difference between the warm-
 est and coldest months is 26°, while  at Penzance
 it is only 18°.  In winter, Penzance is, on an ave-
 lage, nearly six degrees and a half warmer than
 London during the night, and but little  more than
 three degrees during the day.
  In other respects the climate of the Land's-End
does not stand so high in a medical point of view.
It is very humid ;  the quantity of rain which falls
annually  at  Penzance being nearly double that
which falls in  London, and  the  number of rainy
days much greater.  This district is also proverbial
for  the frequency and violence of its gales; and
Penzance, owing to its total want of shelter from
the northerly and easterly winds, is colder durino
the  spring than  either  Torquay or Undercliff.
Hence  it is  that  although Penzance possesses a
decided superiority over all the other situations in
our  island in  the  mildness  and equability of  its
winter  climate, its humidity, exposed  situation,
and liability  to winds, render it inferior  to several
other places  as a residence for invalids.
   In giving the  above as the character of the cli-
mate of the  Land's-End, we are fully borne out
by the experience of Dr. Forbes of Chichester, who
resided there for some years, and to whose excel-
lent  Medical Topography of this district  we are
chiefly indebted for our information respecting  its
climate, and the influence of this on disease.
   Flushing, a small village in the vicinity of Fal-
 mouth, is the only other place in this district de-
 serving notice.  The position of Flushing differs
 from that of Penzance only in  being somewhat
 protected from the north and east winds by a low
 range of hills which rises immediately behind  it.
 But the place  is extremely confined, and deficient
 in  accommodations for invalids.
   Before quitting the south-west coast and Land's-
1 End, it is proper to remark, that, though varying
 somewhat in degree at different places, the predo-
 minant character  of the climate is that of softness
 and  humidity ; on  the  system generally, it has a
 soothing but relaxing influence.
   From this character of the climate of  the whole
| south-western coast of our island, it will be at once
 understood that it is most suitable for the irritable
 and  inflammatory habit, and least  so for the re-
 laxed nervous constitution ; that in the dry, irri-
 tated conditions of  the  mucous  membranes, with
 a parched state of the  skin, it will prove benefi-
 cial ; whild  in the morbid states of the same mem-
 branes, accompanied with  copious  secretion,  or
 when  there exists  a disposition  to  profuse dis-
 charges of any kind, it will prove injurious. Even
 many  of  those  cases  which  are  benefited by a
 temporary sojourn, would be injured  by a perma-
 nent residence in this  district.   The climate,  in-
 deed, possesses qualities of so marked a kind, that
 when  it ceases to do good, it generally begins  tn
 do harm; hence it will seldom  be prudent, much
 less advantageous, for the invalid who has passed
 the winter and spring on this coast, to prolong  his
 residence through the summer ;  he will in gencml
 do  well to  betake  himself to a drier  and mom
 bracing air, especially if he intends to  return  tho
 succeeding  winter.
    Unless the circumstances which we have jusi
 pointed out respecting the character and effects of
 this climate, and  the nature of the constitution
  and diseases of the invalid, are kept in view, little
 benefit will  be derived from a residence in Devon-
  shire.
    West of England.—Clifton,  the  only place
  in the western district which we  deem it necessary
  to notice, has several local advantages, and p°» 
CLIMATE.
443
sesses the best climate in the part of the country !
where it is situated.  Compared with that of the
south-west coast, it is more exciting, more bracing,
and drier, but not  so  mild.   It is  therefore less
mite J for pulmonary and other diseases, accom-
panied with much irritation, and with a tendency
to inflammation.  On the other hand, it is better
adapted to invalids  of a  relaxed, languid  habit;
and is also very beneficial in many cases  of dys-
pepsia, in affections of the  mucous  membranes
with much secretion, and  in the scrofulous affec-
tions of young persons.
  In  making a selection  among these, which we
consider the best winter climates in our island, in
any  particular case, we must  consider well  the
character of the patient's  disease and the  nature
of his constitution, before we venture  to decide
upon the situation  best suited to him.   But by
attention  to these points, and  to the qualities of
the different climates, which we have endeavoured
to state as clearly as the nature of the subject and
the extent  of our  knowledge would  admit, the
medical practitioner will not err greatly.  In order,
however,  to illustrate the  subject further, we shall
add  a few  more particular observations  on the
practical application of English climates to disease.
   The climate of the  south coasts of Devon and
Cornwall will be found very efficacious in sooth-
ing an irritated and  irritable state of the  respira-
tory organs, and of the mucous surfaces generally ;
as in chronic  inflammation of the  fauces, and of
the laryngeal, tracheal, and bronchial membrane,
of a dry irritable character, or at  least accompa-
nied with little secretion, and  highly  susceptible
of increased irritation from sharp, dry winds.  In
dyspepsia depending chiefly on an inflammatory
condition of the mucous  membrane of the diges-
tive  organs; in  disorders of the uterine  system,
arising from a similar condition of the parts, giving
rise  to dysmenorrhcea; also in the numerous ner-
vous affections originating in the disorders of these
two  influential classes of organs, this climate may
be confidently recommended, and  will generally
be found beneficial.  To these may be added cuta-
neous diseases of a dry, irritable character.  On
the other hand, in  disorders of the same organs
and  parts attended with passive  congestion, or
very copious secretion; in dyspepsia from an ato-
nic state  of the stomach, and in  disorder of the
uterine  system,  accompanied with  an excessive
flow  of the catamenia, or  leucorrhaea;  and, in
short, in all diseases attended with  a relaxed state
of the system generally,  benefit  is not to be ex-
pected from the climate of the south-west coast;
more especially  if  the invalid prolongs his resi-
dence beyond a few  months. The  climate of
Clifton, as has been already remarked, will prove
more favourable in  the  cases last  referred  to.
Brighton  also presents   an excellent  autumnal
climate  for such invalids,  and  to persons  of little
constitutional  sensibility  offers a  good residence
throughout the winter, provided the more sheltered
situations be  selected.  Hastings  is a residence
better adapted to invalids suffering from  pulmo-
nary irritation.  During the spring months, that
is, after March, any  dry sheltered situation in the
milder districts of  the interior we believe to be
superior to the south coast, with the exception of
Undercliff".
  After this survey of the best winter climates in
England, it may be expected that we should take
some notice of our more salubrious summer resi-
dences.  On this subject, however, it is not neces-
sary to go into detail, as there is no lack of healthy
situations to which our invalids  may repair with
advantage during this season.  In the selection of
a summer,  as of a winter residence, the same cir-
cumstances require attention, both as  regards the
character of the climate  and the  nature  of the
invalid's disease.   The milder and more sheltered
situations must be  chosen, even during this season,
for delicate and very sensitive invalids; while for
the relaxed and enervated, and those possessing
less  sensibility, the bracing air of the bigher and
drier localities  will prove more  suitable.   To a
large class  of invalids our sea-side watering places
offer a  variety of excellent  situations;  and for
those cases in which sea-bathing promises benefit,
they deserve a preference  over the interior, espe-
cially during the  latter part  of the summer  and
autumn.   Several of  our  inland watering places,
independently of the advantages to be obtained in
many cases from the use  of  their mineral waters,
afford  good summer climates ; and, indeed, some
of them, more on this account than any other, have
become places of fashionable resort. Among these
we may mention  Malvern,  Cheltenham,  Leam-
ington, Tunbridge Wells, Matlock, Buxton, &c.
When the  intention  is to use the mineral water,
the climate must of course be made subservient to
this object; but when a choice  of waters  is ad-
missible, it is of importance to many invalids that
the climate selected also be suitable to them.  In
general it  will be advantageous to invalids who
have taken a course of mineral waters at  any of
those places, to pass the autumn by the sea-side,
as at some  of  the  driest places on the south, or
south-east  coast.   In the greater  number of cases
in whicb travelling is  borne without inconveni-
ence, several  changes, or a succession of  short
journeys, will be more beneficial than a residence
at any  one place during the  whole season.  It is
remarkable how such repeated changes, with fre-
quent  gentle  exercise, especially  on horseback,
renovate the  constitution enfeebled by disease,
enable  it  to overcome many  chronic  affections,
and contribute to the restoration of permanent
health.   But we  shall have occasion to recur to
this subject.
   [The Island of Bute, which lies in the Frith of
Clyde, about 18 miles below Greenock, resembles,
in the character of its climate, the south-west of
England and France,  and the Channel  Islands,
although  its  temperature is considerably  lower
than any of these.  As a winter residence for in-
valids, it is considered by Sir James  Clark, (op.
cit. p.  170,) to hold out  considerable  advantages
to tbat  cbiss for whom a soft,  equable, but rathei
humid  atmosphere is indicated.
   Cove, on the island of the same name in Cork
harbour, has one  of the mildest climates in Great
Britain, corresponding in general characters, and
its influence on diseases, with the south-west of
England, and othei similar climates. In equability
of  temperature, Cove is surpassed by few places.
Recent observations have shown, that  the mean
difference  of temperature of  the days and nights
rarely exceeds four or five degrees, and often, in 
444
CLIM
ATE.
the winter  months, does not exceed one  degree.
The town is completely sheltered from the north
wind, and, from  its southern exposure, receives
the full  influence of the sun  and the southern
breeze.   (Stokes  on  Diseases  of the  Chest,  2d
Amer. edit. p. 427 : Philad.  1844.)]
   Before commencing our  review of foreign cli-
mates, the islands of Guernsey and  Jersey  re-
quire some notice, as they are occasionally resort-
ed to by invalids from this country.   The climate
of these islands resembles in its general charac-
ters that  of the coast of Devonshire;  it is some-
what warmer  but not more steady, and is  more
exposed to high winds.  Those from the south-
west prevail during the autumn and winter, while
those from  the north-east often continue for weeks
together  during the spring, producing  the  same
unpleasant effects on  invalids  which  arise  from
them in this country.  The  climate is found by
experience to be beneficial in the same diseases,
and in constitutions of a similar character, as that
of our south-west coast; the observations there-
fore formerly made relative to the class of invalids
that may expect to derive advantage from the  lat-
ter, apply equally to persons who may be sent to
Jersey, which, of the two islands, is in all respects
the best suited for invalids.   The summer climate
of these  islands is delightful.
   Foreign  Climates. —  The  climate  of  the
South of France  has long  been held  in repute,
Dut all the  southern provinces of that country are
far from  possessing  the same  climate;  those
situated on the eastern  frontier being very differ-
ent in this  respect from those on the western.   It
is  highly important, as we  shall presently show,
to  attend to this distinction  in recommending the
south of  France  as a place of residence for  in-
valids.
   South-west of France.—We comprehend
under this division the tract  of country which
extends  from  Bordeaux and Bayonne to  Tou-
louse.
   The transition  from  the  climate of the south-
western shores of our  own  island to that of  the
south-west of  France is easy and natural,  inas-
much as  they exhibit a striking similarity in their
general  characters.   Taking the south-west of
France  generally, the mean annual temperature
is  only about 4° bigher  than that of  the south-
west  of  England.  Both climates are soft and
rather humid, and agree, and disagree, generally
speaking, with diseases of the same character.
   Pau is the only place in  this district of France
which we deem it necessary  to notice particularly.
This little town, which has  been a good deal fre-
quented of late years  by invalids from this coun-
try, is pleasantly  situated at the base of the Pyre-
nees ; and  when  its close vicinity to that range
of lofty  mountains is  considered, it certainly pos-
sesses a far milder winter and spring climate, and
is  much less subject to high winds and extensive
transitions  of temperature than might be expect-
ed.  One remarkable  circumstance in the charac-
ter of its climate is the mildness of the spring,
and  its comparative exemption from  sharp cold
wmas during that season.  In this respect it bears
a  very favourable comparison with the climates
of the south of Italy.   While  Pau is 6° colder
than  Rome during the winter,  it is  only  2£°
colder in the spring.   Compared with the warm-
est parts of England, the same superiority of its
spring climate holds good.  Penzance during the
winter  months  is 3°  higher  than  Pau, but 5°
lower in the spring.   This mild character of the
spring  constitutes  the  great  advantage  of the
climate.   Pau  is also very free from  fogs, and
possesses a dry soil.  Its chief fault is  the un-
steadiness of its temperature.   It mav however be
considered, upon the whole, the most favourable
residence for invalids in the south-west of France,
as far as we have had the means of judging.  The
difference between the climate  of Pau and that of
the best situations in England is not great.  It is
drier and warmer in the  spring, and  the northerly
winds  are much less  trying  to invalids  than in
this  country.  One  advantage  possessed  by it is
its vicinity to the delightful watering places among
the higher  Pyrenees,  which offer to the invalid
who has passed the winter at Pau a  healthy sum-
mer climate without the inconvenience of a long
journey.
   South-east of France.—Under this  division
we include that extensive tract of country which
stretches along the  shores  of  the Mediterranean,
from  Montpelier to the  banks  of  the Var, the
boundary stream between France and Piedmont,
The climate of this  district is  warmer and drier,
but more irritating  and exciting than that of the
south-west.  It is also subject to sudden vicissi-
tudes of temperature, and to frequent harsh, cold
winds.   This great liability to cold piercing winds,
more especially the  north-west, (mistral,) which
often continues to  blow with considerable force
for many days together,  renders the whole of this
country an improper residence for patients suffer-
ing under, or peculiarly  disposed to  inflammation
or irritation of the respiratory organs.  We con-
sider the custom, therefore, which has long pre-
vailed,  of  sending  consumptive patients  to the
south of France, a grievous error; an error which
the obvious  character of the  climate, and the re-
sult  of ample experience  of  its effects,  should
have  long since corrected.   There  may  be con-
stitutions having a  tendency  to tuberculous dis-
ease, which might even derive  some  benefit from
a temporary residence in this  climate ; but when
tubercles already exist in the lungs, it will  cer-
tainly prove  injurious.
   After this account of the climate and its effects
on phthisical patients,  (the cases which have been
chiefly sent thither,) it will  be unnecessary to say
much of the different places in this district which
have  been  most frequented  by  invalids.   We
shall, however, notice  the  principal  of these
briefly.
  Montpelier.—This place has now so completely
lost  the character which it once possessed as a
mild climate, that it may suffice to  remark here,
that a more improper  residence could scarcely be
selected for a person disposed  to pulmonary dis-
ease.   Its high, exposed  situation renders  it liable
to all the evils of this climate in a remarkable de-
gree ; and it is,  moreover,  well ascertained  that
pulmonary inflammation  and  phthisis are among
the most prevailing diseases of the place.
  Marseilles.—Although less exposed than Mont-
pelier,  this  is an equally improper  residence for
consumptive invalids. From the manner in which 
CLIMATE.
445
the environs of Marseilles are  divided into small
properties, surrounded with high walls, the invalid
has no means of taking proper exercise,  or  of
breathing  country  air;  and without  these, con-
sumptive invalids can derive little advantage from
any climate.  For cases likely  to benefit by a dry
sharp air, Marseilles forms a good winter resi-
dence.  It is said to prove particularly favourable
to persons who  have suffered from intermittent
fever.
   Hyires possesses  the mildest climate in the
whole of this district, and this advantage it owes
chiefly to its sheltered situation  at the base of a
range of hills which protect it, in  a considerable
degree, from northerly winds.  The country also
around this little town differs in its character from
that  of Provence generally (which comprehends
the larger portion of the district now under consi-
deration).  The hills here present the appearance
of verdure,  being  covered with shrubs, many of
 them evergreens, affording a pleasing contrast to
 the bare  and rugged  mountain masses which form
 so striking a feature, and compose so large a por-
 tion of Provence ;  a country which very generally
 disappoints  the expectations of the traveller, and
 especially of the invalid, whose hopes have been
 raised high  respecting the beauty of the  south of
 France.   The  extensive orange gardens which
 flourish  under the immediate shelter of Hyeres,
 and the verdure of its hills, afford  evident proofs
 of the amenity of its climate, while by experience
 it is known to be one of the most favourable resi-
 dences for invalids in this part of France, — cer-
 tainly the best with  which we are acquainted.
   Nice.—This place has long been celebrated for
 the mildness of its climate,  and continues to form
 the favourite resort of a numerous class of invalids,
 both from this and other northern countries.  Al-
 though situated in the same line of coast as Pro-
 vence, Nice is superior to it in several  respects.
 In the general qualities of its climate it certainly
 resembles that of the south-east of France ; but it
 has some important local advantages over the best
 parts of that country.  By its steep and lofty range
 of mountains it is  protected  from  the  northerly
 winds, and especially from the mistral, which we
 have stated to be  so prevalent, and which expe-
 rience proves to be so injurious to delicate invalids,
 in Provence. This circumstance gives a compara-
 tive  degree of softness  to  the climate :  but it is
 still  rather  exciting.  Nice is  not exempt from
 cold  winds, especially during the spring;  indeed,
 the prevalence  of these constitutes one of  the
 principal objections  to the climate of this place in
 pulmonary  diseases generally.  For consumption,
 even in its earlier  stages, we consider Nice an un-
 favourable situation, in a very large proportion of
 cases.  In bronchial diseases of the dry irritable
 character, it is also prejudicial; and in dyspepsia,
 depending on an irritated  or  inflammatory condi-
 tion of the  mucous  membrane of the stomach, it
 is equally so.   So decidedly, indeed, is this  the
 case, that when such a  state  of the digestive  or-
 gans exists, the invalid will  derive  little benefit
 from a residence  at Nice, whatever may be  his
 disease.   Though warm and  dry, the climate is
 ill suited to irritable habits. With  languid, torpid
 constitutions, on  the other hand, it  agrees well.
 In the scrofulous affections of young persons pos-
                                        2 s
sessing this character of constitution, it produces
the best effects; as it does in chronic hronchial
disease accompanied  with  copious expectoration,
and  in what has been termed humoral  asthma.
In chronic rheumatism it is found very beneficial;
and  in deranged health from  various  causes, in
which a dry, warm, and rather exciting climate is
indicated, advantage will be derived from a winter
spent at Nice ; provided always that the state of
the digestive  organs which we have adverted  to
does not exist.  In consequence  of the tendency
of the climate to aggravate and even excite gastric
irritation, a more abstemious  diet is requisite for
invalids than  in England.   The summer at Nice
is too hot for  any class of invalids.
   [Villa Franca, situate on the  southern base,  or
rather declivity of a steep and lofty range of moun-
tains, and having a beautiful bay extended  before
it, is immediately  to the eastward of Montalbano.
It corresponds in its general character  of climate
with Nice ; than  which, however, it is said to  be
drier and somewhat warmer. Menton is described
as a  very retired spot, about 14 miles  from  Nice,
on the Genoa road;  and San Remo, still farther,
is even more  protected  from easterly winds ; but
the accommodations at those places are not  good.
 (Sir James Clark, Op. cit. p. 214).]
   Italy.—The climate of tbe south of Italy differs
little in actual temperature from that of Provence
and Nice, but it  is  softer, more humid, and less
exciting.  On the other hand the sirocco, which
is scarcely felt at the latter places, forms an objec-
tion to the Italian climate,  tbough this objection is
not of much  weight during the winter.
   The only  places which we  consider deserving
of notice  as  winter  climates in  Italy, are  Pisa,
 Rome, and Naples.
   The climates of Pisa and Rome resemble each
 other in  their general qualities.  Rome is some-
 what warmer in the winter.  It  is also drier than
 Pisa, though more  humid than Nice  and  the
 parching climate of Provence.   About one-third
 more rain falls at Rome than in the latter country,
 and  the  number  of rainy  days is considerably
 greater.  Taking into account all the qualities of
 the climate of Rome,  we consider it  one of the
 best of  Italy :  to  the invalid capable of  taking
 exercise in the open  air, it affords advantages over
 both Naples and  Pisa.  Patients, on the other
 hand, who can bear  little  exposure to the air, and
 who must therefore confine themselves to the most
 sheltered situations,  will find in the Lung'Arno in
 Pisa, a residence possessing advantages, perhaps,
 over every other place in  Italy.
    Naples differs somewhat in the character of its
 climate from both the last-named  places.   Inde-
 pendently  of the effect which  its immediate vici-
 nity to the sea may have in modifying  the climate,
 it is more subject  to winds, and the air is more
 exciting than that of  Pisa or Rome.   As a resi-
 dence  for  invalids  labouring  under  pulmonary
 irritation, or  chronic rheumatism, it is inferior to
 both; nor arc we aware of any cases  in which it
 ought to be considered a more favourable climate.
 The beauty  of the scenery around Naples, how-
 ever, and the gaiety and excitement of the piace
 and climate  altogether, prove very attractive to
 strangers generally, and render it a very agreeable
 winter residence for persons who visit  Italy ratbei 
446
CLIMATE.
as a recreation than for tbe removal of actual dis-
ease.
  The  diseases in  which  the climate of Italy
proves most beneficial, are chronic bronchitis and
rheumatism.   We have, in particular,  observed
many decided examples of the beneficial effects of
a residence at Rome in both these  diseases.  But
it is still more in the numerous cases of deranged
health which scarcely  admit  of  being defined,
though well  known to  the medical practitioner,
that a tour and winter  spent in Italy will prove
beneficial.  Such persons need not be limited  to
any particular situation, but may, with  proper cau-
tion, visit the different places frequented by stran-
gers in the  south  of Italy, and that even with
greater advantage  to their health than if they had
remained stationary at any one of them.
   These  observations have reference  to the cli-
mate  of Italy during the winter and spring, that
is, from October till May or June.  To such as
are under the necessity of remaining in that coun-
try through the summer, the baths of Lucca, Sien-
na, and the vicinity of Naples afford  the  coolest
residences.
   There may be several situations on the  shores
of the Mediterranean whicb have  climates equal,
and perhaps superior to those whicb have been
mentioned.   Malaga has been particularly  men-
tioned to  us  as possessing a very mild winter cli-
mate  ; but our information respecting the south
of Spain  is  too imperfect  to  enable us to speak
positively on this  subject.   And  even  were the
climate of that country superior  to  that of the
south of Italy, the want of proper accommodations
and the various comforts which are as  necessary
to the invalid as climate, forms an insuperable ob-
jection to them as places of residence for  delicate
English invalids.
   The Mediteb iniax islands  do not merit
much notice.  Some parts of the  coast  of Sicily
afford a  pretty good winter climate;  but here
again the difficulty  of  obtaining the  necessary
comforts, and even conveniences  of life,  renders
them almost useless to English invalids.
   This objection,  however, cannot be made, to
Malta, the only island  in  the Mediterranean be-
longing to  this country.   All the  wants  of the
invalid may be supplied here, and the  packets
 which are established between this place and Eng-
land  afford the means of reaching it conveniently.
But,  unfortunately, the  climate of Malta has little
to recommend it to any class of invalids, and least
of all to such as suffer from pulmonary affections.
 The  arid nature of the soil, the  quantity of im-
 palpable  dust which is  suspended in the  atmos-
 phere whenever tbe weather is dry, the currents of
 cold  air to which the capital (the residence of in-
 valids) is subject during the winter, and  the fre-
 quent and heavy  rains  which  prevail during the
 same season, render it an unsuitable residence for
 patients of this class.  It may not be irrelevant to
 mention also that phthisis carries  off a  large pro-
 portion of the inhabitants  of  Malta, constituting
 nearly one-tenth of the whole mortality, according
 :o Dr. Hennen.   Indeed, the full  and satisfactory
 information  respecting the medical topography of
 Malta, supplied by this gentleman, affords more
 than  sufficient  grounds  for excluding it from the
 'ist of climates which promise any advantage to
phthisical patients.   We are not, indeed, aware of
any class of invalids likely to derive much advan-
tage from the winter climate of Malta, and we are
not acquainted with any to whom its summer cli-
mate would not prove injurious.*
  Atlantic  climate. — The  climate  of  the
Northern Atlantic  in  the  temperate  latitudes is
more  steady than that of the Mediterranean, and
imparts  a similar character to the climate of its
islands.   Various groups of islands scattered over
this ocean, between the 28th and 38th degrees of
latitude, having been praised for the excellence of
their  climate, and  occasionally frequented by in-
valids in consequence, deserve some notice in this
place.  The  Azores, the Madeiras, and the Canary
Islands in the Eastern, and the Bermudas and the
Bahamas in the Western Atlantic,  have all been
recommended  as suitable residences  for persons
requiring a  mild and equable climate,  and more
especially for consumptive invalids.
   As our information respecting the climate of
Madeira  is the most complete, we shall notice it
first,  with the view of making  it a standard of
comparison in  estimating that of  the other islands.
   Madeira.__The minute and careful observa-
tions of the late Dr. Heineken and of Dr. Renton,
for a series  of years, have afforded us  sufficient
data  to form an accurate estimate  of  the climate
of  this  island ;  and although our materials for
enabling us  to judge of the other Atlantic islands
are much less  complete, they leave little doubt in
our minds that Madeira is superior to any of them;
while it affords conveniences in  other respects as
a residence for invalids possessed by none of them.
The  height of the central ridge of mountains
which compose the greater part of this island, al-
though it may detract somewhat from its warmth
during the winter, contributes greatly to  temper
the  heat of its  summer.   It gives Madeira  the
advantage of a cool land-breeze during the night,
which, alternating  with a refreshing sea-breeze in
the  day, moderates the summer heat in  a very
material degree ;  while  the  trade winds which
prevail at this  season in the latitude  of Madeira,
contribute also to its coolness  and salubrity.  The
invalid, moreover, by  choosing for his summer
residence an  elevated  situation  in  the interior,
finds a climate considerably cooler than that of
Funchal which is  situated on the sea-shore and
affords the best winter residence.
   Comparing  Madeira  with  the south-east of
France and  Italy, we find that, although its mean
annual temperature is only about six degrees high-
er than that of these places, this  temperature is
very differently  distributed throughout the  year,
the range being  far less  at Madeira  than in the
most favoured spots in the south of Europe. Thus,
while the winter is twelve degrees warmer than
in  Italy and France, the summer is  five  degrees
cooler ; and while the mean annual range at Ma-
 deira is only fourteen degrees, it is nearly double
 this  at Pisa,  Rome, Naples,  and Nice.  In the
 equable distribution of heat throughout the year,
 it  possesses a similar superiority over the same
 places; for example, while the mean difference of
  * We refer those who desire to examine the facts upon
 which the above character of the climate of Malta rests,
 to Dr. Hennen's Sketches of the Medical Topography ofthi
 Mediterranean, &c.  [See, also, Sir James Clarke, op. cit
 p. 241.] 
CLIMATE.
447
temperature  of successive months  at Madeira is
only two degrees, at Rome and Nice it  is four,
and at Pisa and Naples five degrees.
  In  the  progression of temperature during  the
day, it maintains the same superiority ; the mean
range for twenty-four hours being ten degrees by
the register thermometer, while at Nice it is nine
degrees, at Rome ten degrees, and at Naples thir-
teen degrees by the common thermometer.  In
steadiness of temperature from day to day, (a very
important quality in a climate,) Madeira excels all
those places greatly.  There is also a considerable
difference in respect to  the dryness of the two cli-
mates.  Nearly the same quantity  of rain falls at
Madeira as at Rome ; but there are only seventy-
three days on which any rain falls, while at Rome
there are  one hundred  and seventeen days.  The
rain at Madeira also falls at more regular seasons,
chiefly in the autumn, the atmosphere being gen-
erally dry and clear for the remainder of the year.
   The annual range  of atmospheric pressure  is
very small, which  is the case also at Rome  and
Naples.
   From  this  comparison,  the  superiority  of the
climate of Madeira over that of the south of  Eu-
rope will  be at once seen.  We shall have occa-
sion  hereafter  to  notice their comparative influ-
ence on  disease.
   Canary Islands.—These  rank next  to  Ma-
deira in  point of climate.  They are somewhat
 warmer;  the  mean annual temperature  of Fun-
 chal, the  capital of Madeira, being 65°, while that
 of Santa  Cruz, the capital of Teneriffe, is  nearly
 71°.  This  excess  of temperature, however,  is
 not equally distributed over  the whole year, the
 difference between the winter temperatures at these
 two places being considerably less than  between
 their summer temperatures; while Santa Cruz  is
 7° warmer than Funchal in summer, it is only 5°
 warmer in winter.   The temperature is also more
 equable throughout the year at Madeira than  at
 Teneriffe ; the difference between the mean tem-
 perature of  summer and winter being 9°  at the
 former place, while it is  12° at the latter.   The
 want of sufficient  materials prevents us from com-
 paring  the  climate of Teneriffe  more  minutely
 with that of Madeira.  It seems  probable, how-
 ever, that when we are better  acquainted with the
 climate and topography of Teneriffe, we  may find
 it  a favourable winter residence.  But whatever
 may be the merits of its  climate, it is at present
 very deficient in the other requisites necessary to
 render it a suitable abode for delicate invalids.
    The Azores, or Western Islands,  as  they
 are sometimes called, lie about  5° north of Ma-
 deira, and considerably more to the westward.  In
 their external characters these islands  resemble
 Madeira  and  the  Canaries.   We have  not had
 the means  of making ourselves  sufficiently ac-
 quainted with the temperature of the Azores to
 speak very positively on the subject.   The climate
 appears to  be mild  but somewhat humid ; less
 warm than  Madeira during the winter, and more
 oppressive during  the summer.   They  certainly
 possess  no  advantages in point  of climate over
 Madeira, while they afford few of the conveniences
 which that  island  offers to invalids.
    [The mean in-door temperature of a room with-
 ot  fire,  carpet, or curtains,  in Villa Franca, on
the southern coast of St. Michael's, during  the
period from Dec. 1838 to April 1839, was 60°.9,
with a mean range of 3°.6.   The mean out-door
temperature, during  the same time, was 60°. 10,
and  the mean daily range 7°.6.   The highest
point to which the thermometer rose in the shade,
between eight o'clock in the morning  and ten at
night, was 76° ; and the lowest point to which it
sank was  51°.   The average  out  of  doors was
not, however, taken with the  register thermome-
ter;  but it approximates  the truth.  Sir James
Clark (op. cit., p. 288.) is of opinion that a change
from the Azores to Madeira, and  from  thence to
Teneriffe, would prove, in  many cases, more bene-
ficial than a residence during the whole winter in
any  one of those islands.]
   Bermudas.—This numerous cluster of small
islands  is in the  same latitude as Madeira, and
differs little from it in the mildness of its winter
climate. From the stormy character of the West-
tern Atlantic, however, these islands  are much
more liable to high winds in the winter than Ma-
deira, while  their low character  and arid rocky
soil  render them extremely hot during the  sum-
mer, and quite improper at this season for the resi-
dence of such invalids as are likely to be sent from
this country.
   Bahamas.—This is another and much  more
extensive group of low islands, further south than
any of  those which have been mentioned, being
only just beyond  the limit of the  tropics.  The
climate of the Bahamas has not much  to recom-
mend it.  The winter and spring are considerably
cooler than  the same seasons  in the West Indies,
while the temperature of the  summer and autumn
is nearly the same as in  those islands.  During
the  winter the temperature is subject to rapid and
considerable vicissitudes, and cold, harsh, north-
erly winds are not unfrequent. The close vicinity
 of the Bahamas to the North American continent
 no doubt has the  effect of rendering the climate
 less equable  than  it otherwise would be, judging
 from what we know of insular climates generally
 in the same latitudes.
   We  may safely  dismiss  these  two western
 groups  with this brief notice  ; as from the charac-
 ter  of  their climates, their  great  distance from
 England, and the few local advantages which they
 possess, they are never likely to  prove beneficial
 as a residence for invalids from this country.  They
 are  better suited, in point of climate, and more
 conveniently situated, particularly  the Bahamas,
 as a temporary  retreat for the inhabitants of the
 islands which we are now to notice.
   West  Indies. — Although these  islands are
 not often  resorted to by real invalids, yet there
 seems  to  exist,  even  among the  profession, a
 vague idea that they afford a  preferable climate to
 that of any  of the places which we have noticed.
 That this opinion  has been  formed from an im-
 perfect knowledge of the  nature and  effects of a
 tropical climate, we shall endeavour to show.
   The mean  annual temperature of the Wesl-
 India Islands, near  the level  of the sea, is about
 80°, and during the six  months  which include
 the  winter  season  the temperature  is only  2-
 lower.   Now it will be readily admitted that  few-
 invalids are likely to be benefited  by so high u
 temperature, more  jarticularly when  continued, 
448
CLIMATE.
almost without sensible variation, night and day.
The extreme  annual range in  the West Indies
does not exceed 20°, while the mean daily range
throughout the year is only 6°.   But it is not so
much the  actual degree of temperature of a tropi-
cal  climate,  as  its  unceasing  and  unvarying
character,  which oppresses and  exhausts the in-
valid, more especially in  cases where there exists
a disposition to symptomatic fever.
  [Moreover, it appears  from the British  Army
Reports, that nearly twice as many cases of con-
sumption  originated among the  British troops in
the West  Indies as at home : twelve per thousand
of the aggregate strength of the troops serving in
the West  Indies being attacked annually, whilst
of the Dragoon Guards,  serving in Great Britain,
the ratio is only 6£ per  thousand.   The disease,
according to tbe same reports, is even  of more
frequent occurrence among the black than the
white  troops.   (Sir James Clark,  op. cit., p.
303.)]
  From this brief account of the climate  of the
West Indies, it is evidently  an  improper one, ge-
nerally speaking, for consumptive invalids, who,
nevertheless, are frequently sent thither.  The
uniformly high temperature, and almost cloudless
skies which afford no shelter from the direct rays
of a tropical  sun,  preclude  invalids from  taking
exercise in the open air, the principal object  for
which they are generally sent abroad.  There  is
no  twilight to compensate for  the heat and glare
of the  day, and the nights are too hot to admit of
refreshing repose.  When  we  add  to the fore-
going  evils  of climate the  many privations, dis-
comforts,  and annoyances which  are  almost in-
separable  from  a  temporary residence  in  these
islands, and  the  still more  weighty objection
derived from the experience of medical men who
have resided there, we may consider the question
of the propriety of sending patients labouring un-
der consumption to the West Indies as finally set
at rest.  The concurrent testimony of all the me-
dical men whom we have consulted on the sub-
ject, and whose  opportunities of judging were
ample, establishes  the fact that consumptive cases
sent thither from this country proceed  much more
rapidly to a fatal  termination than  in temperate
climates.
   Notwithstanding what has just been stated re-
specting  the climate of the West Indies and its
influence on consumption, we are not prepared to
say  that  some, nay, many  cases  of deranged
health, of a different nature, might  not be bene-
fited by passing a few of the  less sultry months
(from November  to  February) in that  climate ;
more especially  if the invalid possesses the means
of enabling him to spend the greater  part of his
time on  the water,  merely visiting some  of the
more  healthy islands occasionally.   The remark-
able revolution effected in the distribution  of the
circulating  fluids, and the immense increase  in
the  secretion from the  cutaneous exhalents,  ex-
cited  and steadily maintained  by a high  atmos-
pheric temperature, and this continued without
intermission for many months, or  even years, is
 ■mquestionably capable of producing material and
 very important changes in the animal economy,
 und may therefore be made a powerful agent  in
the cure of chronic diseases.
  Calculous  disorders are extremely rare in  the
West Indies, a circumstance which probably de-
pends, in a great degree, on the abundance of the
cutaneous secretion, by which  the largest propor-
tion  of fluid  is  discharged  from the system, and
along  with it some of  those saline  principles
which constitute the chief ingredients of which
urinary calculi  are composed.  A well known
case has  been recorded  of an officer who was
about  to undergo the  operation of lithotomy in
this country : he was suddenly ordered to Jamaica,
and  after some time no calculus  could  be dis-
covered in the bladder,  nor  were there any symp-
toms of the  existence of one.  Aneurisms and
diseases of the  heart  and large vessels; are also
rare, and the osseous deposits, which are so gene-
rally found in the coats of  the  larger  arteries in
persons who  die  at  an  advanced  age  in cold
climates, are  said to  be rarely met with in those
who die at a  similar  age  in  the West Indies.
Gout is not common, and rheumatism neither fre-
quent  nor severe.
  Reasoning on the above facts, we should expect
that the climate of the  West Indies would prove
serviceable to persons  labouring under what has
been denominated the  calculous  diathesis, in
which  there  is a  constant  disposition  to  renal
irritation, and the formation of gravel, upon any
material change  of the weather, or any trifling
derangement of the digestive organs.  The func-
tions of the  skin  in  such persons are generally
imperfectly performed, and it is not unreasonable
to believe that the powerful action excited, and
unremittingly kept up for  some months,  in the
cutaneous exhalents might effect a  permanent
change in the constitution, and if followed up by
warm  clothing, daily  friction,  and a proper diet,
might entirely destroy the  disposition to the for-
mation of gravel.   Upon the same principle this
climate also promises benefit to persons in whom
we have  either positive, or strong presumptive
evidence that ossific  deposits  are forming in the
arterial system,  and  laying the foundation  of
aneurism or  diseased  heart.  Reflecting on the
powerful effect of a high temperature on the vari-
ous  secretions, we think it  not improbable that
the  further progress of  such  a morbid  process
might be  checked by a timely removal  to the
West  Indies, or any similar climate, and  a  re-
sidence for a longer or shorter period there,  ac-
cording to the circumstances of the case.  What
has  been  already stated respecting the  rare occur-
rence  of calculous disorders and  diseases of the
arteries in this climate, affords some grounds for
such a conjecture; and  it  may  be adduced in
further support of it, that gout, a disease intimate-
ly related  in  its nature and causes  to both  the
preceding  affections, is greatly relieved, and even
entirely cured in many cases, by a change from a
cold to a hot climate.   This effect of climate  has
long been known.   Van Swieten mentions  the
case of a gentleman who had  almost entirely lost
the use of his hands and feet from gout, and who,
after a residence of nearly three years  in the East
Indies, returned perfectly free  from disease,  and
continued so;  and  Haller relates the  case of
Lord de Poincy, who, when an old man, went to
the  warm American islands,  and  got rid  of his
gout and  other infirmities.  And such instance* 
CLIMATE.
449
must have come under the observation  of  almost
every physician.
  Scrofula is a very rare disease in the West-India
islands, and  there  are many cases of scrofula in
this country  which we have little doubt would be
greatly benefited, if  not  cured, by a temporary
residence in  that climate.   The cases in which we
should expect the greatest benefit are  those in
which the disease exists chiefly in the  lymphatic
glands in torpid constitutions.
   [United States.—For those of delicate lungs,
it would appear, that St. Augustine, Tampa Bay,
Pensacola, Mobile, and certain situations  on tbe
Peninsula of  Florida, are the  best situations,
 judging merely from meteorological registers ;  but,
 in  all such  cases, the extent  of  accommodation
for the valetudinarian  must be taken into account.
 The places  on the eastern  seaboard, especially,
 are exposed  to  frequent north-east storms, during
 which, however, the invalid must remain at home ;
 yet there are few days during the  winter when he
 cannot have the salutary revulsion which exercise
 in  the open  air is capable of effecting.   Hence,
 any of these situations has  a decided  advantage
 over those of the northern and middle states.  In
 the interior of Georgia,  Florida, Alabama, or
 Louisiana, the  same objections do not apply;  and
 accordingly, they are  often visited by the invalid
 during the winter, and with great advantage.
   During the  summer, the wide extent  of this
 country affords great choice of residence.   The
 sulphur springs  of Virginia, especially  the red
 sulphur; and the  warm, the hot, and  the sweet
 springs, are  often frequented.  These are situate
 high above the level of the sea, and afford as great
 a change as difference of climate can easily effect.
 During the  summer,  a tour may  be made to any
 interesting region  that is capable  of exciting  new
 impressions  upon the mind; and, of late,  favour-
 able attention has been directed to the northern
 lakes as a summer residence  for  invalids of the
 south ;  and  a tour to them may be of great advan-
 tage  to those  from  every part of the country.
 (Prof. Drake, The Northern  Lakes, a Summer
 Residence for Invalids.  See also the writer's Ele-
 ments of Hygiene, 2d edit. Philad. 1844.)
   Southern Hemisphere.—The climates of the
 southern hemisphere  are calculated  to  exert the
 same sanative agency  on the frame as those of the
 northern.  From their situation south of the equa-
tor, their seasons are the reverse of ours.  August,
 September,  and October, constitute the  spring
 months; November, December, and January, sum-
mer ; February, March, and April, autumn, and
 May, Jnne,  and July, vjinter.
   Of tne  climate  of  certain portions  of  South
 America, we know something from the observa-
tions of the navy surgeons more especially.  It
rarely happens, however, that invalids are  sent
Ihither for change of  climate.   Dr. Burrough re-
sided four years in Lima, and did not meet with
a single unequivocal  case of phthisis, which ori-
ginated there during that period ; although  scrofula
was not uncommon,—a fact which confirms the
view of the  distinctness of scrofulosis and tuber-
culosis.   Hr stated to Dr. Morton, (Illustrations
of  Pulmonary  Consumption, p. 159:  Philad.
1834,) that he knew many foreigners in consump-
tion to be much benefited by a residence in Lima;
  Vol. I.— 5"                     2x*
but that in  every instance where they had been
tempted to go  farther south into Chili, the effect
on their constitutions was fatal.
  The Cape of Good Hope is occasionally re-
sorted to by  invalids from India and England.—
From the Army Medical  Reports it appears, that
the climate is at least as  favourable to health  as
that of Great Britain.  The  troops are less  sub-
ject to diseases of the lungs at Cape Town,  than
in the other British colonies; and there is a smaller
proportion of deaths from consumption than has
been observed  in our foreign stations, except the
East Indies.  Rheumatism is, however, very com-
mon.   The  places chiefly resorted  to  by invalids
from  India  and England at the Cape of Good
Hope, are Rondebosch, about  five, and Wynberg,
about eight miles from Cape Town;  at both  of
which places there are good accommodations.
   The climate of Australia is said to be remark-
ably healthy.  Europeans, enervated by  a residence
in India, are very much invigorated by a short  re-
sidence there.  (Sir James Clark, op. cit. p. 336.)]
   We  have now noticed the principal climates,
both in our own and foreign countries, which  have
acquired the greatest reputation as places of resi-
dence for invalids, and regarding which our infor-
mation is sufficiently accurate  to enable us  to
speak with much certainty.  From a residence at
one or other of these places, or at several of them
in  succession,  all that climate can effect may, we
believe, be obtained  by the  invalid whose disease
admits  of benefit from  a change of  this kind;
provided  always that the climate which  is best
suited to his disease and constitution be selected.
In making  this selection we must, in  the present
state of our knowledge,  be guided chiefly by ex-
perience; for although an acquaintance witb the
physical characters of a climate is highly useful in
enabling  us to form a tolerably  correct  opinion
respecting the diseases in which it will prove bene
ficial; still,  until we have had some experience of
its effects, we can never be sure that our conclu-
sions are correct;  so complex  is the  subject  of
climate, and so many are the circumstances, some
having reference to the  agent and others to the
subject, which  require to be taken into  account.
   We shall now state briefly the effects of climate
on those diseases on which it has  been found to
exert the greatest influence.
   Pulmonary Consumption is the disease in
which, from its supposed dependence  on climate,
and its being  found to  resist all other modes of
treatment, this remedy has been more particularly
had recourse to, and almost as the only remaining
hope.   This is not the  place to enter into a full
detail of the circumstances under  which  climate
promises benefit in that disease.   (See the article
Pulmonary  Consumption.)   We  may, how-
ever,  remark here,  that climate, to be  productive
of real  benefit, must be tried at a much earlier pe-
riod in the progress of tubercular disease than it
generally is.   Such  is  the insidious  manner  in
which  consumption, in  many cases, steals upon
its victims, that it has too often stamped its indeli-
ble impression on the vital organs ere the alarm is
sounded, or climate or any other effectual  means
of treatment, have been seriously thought of.  Be
fore we can reasonably hope to cure phthisis, wo
must take a much  more t on prehensive view  ol 
450
CLIMATE.
ihe pathology of that disease than we have hitherto
done :  in place of fixing our attention  solely on
the diseased state of the lungs, we must direct it
to the  morbid condition of the system,—to the
tubercular cachexia  in which phthisis has its ori-
gin.  As regards the application of climate to the
disease, it is not, we believe, saying too much,
when we state that  consumptive patients are, for
the most part, sent abroad one year at least, often
several  years, too late to derive any essential bene-
fit from change of climate.
   During that peculiar state of deranged health
which may often be observed to precede tubercular
cachexia,* and during  the existence of  this  mor-
bid state of the constitution, before the disease has
manifested itself in  the actual  development  of
tubercles  in the lungs, change of climate forms a
powerful adjunct to the other means best calculated
for removing such a state of the system.  When
tubercles  already exist  in the lungs, the chances
of cure  are immeasurably lessened ; but even then
climate  affords  one of our most valuable resources,
and one which promotes the salutary action of all
our other remedies ; and although our  hopes of
benefit  under such a discouraging state of things
must  in general be faint, we believe the further
progress of the disease may, in  some  cases, be
thereby arrested.  But such instances of success
are no doubt very few, compared to the many which
proceed unchecked in their course to a fatal termi-
nation, in despite of climate and every other means
which   we can oppose to  their  progress.   We
would therefore beg  to impress upon the minds of
our professional brethren the urgent necessity of
directing their attention to the earliest indications
of this  disease,  seeing  how  utterly  inefficient all
our efforts are even  to stay its fatal career, when
so far advanced as to manifest  itself to the com-
mon observer.   Until  the tubercular affection of
the lungs, whicb constitutes the essential character
of what is commonly  termed phthisis, is consi-
dered in  its true character, as the last stage of a
disease,--as the result of a morbid  state of the
system,  which in its progress might often be cured,
but which in this its termination is scarcely to be
/■emedied,—we  must still continue  as heretofore,
little better than idle speptators of the ravages of
a disease which destroys one-fourth of our popu-
lation, and numbers among its victims a large pro-
portion  of the best and fairest of our youth.
   In proof of the correctness of our opinions  re-
specting the influence of climate on phthisis in its
early and late stages, we shall give the experience
of Dr. Renton, an intelligent and observing  phy-
sician, who has long  practised at Madeira, and has
had ample opportunities of watching the effects
of that  climate on phthisical invalids sent thither
from this  country.
   This  gentleman has  favoured us with notes of
the cases which came under his  own particular
observation.  From  these  we find that  between
the years  1827 and  1830, nineteen  patients
labouring under confirmed phthisis arrived in Ma-
deira, the whole of whom died;  the greater num-
ber on the island, the remainder after returning to

  * For  an account of this affection see a work by the
writer uf this article, entitled -'The Influence of Climate "
fee . o 315, &c.  at edit. Lond. 1830. 3d Tedit. Lond.
England.   Of  thirty-three  cases  of incipient
phthisis, whicb  arrived  during the same period,
twenty-three are now at home, (June, 1830,) ap-
parently  in good health;  two remain  in the
island, one apparently well, the other considerably
better  since his arrival, but  still in  a  doubtful
state;  two  died, one in the  island, and another
after leaving it: the fate of the remaining six is
not known.  We consider this statement as  a
satisfactory reply to those who doubt and cavil
respecting the influence of climate;  their  opin-
ions being  formed  in  general from a few  cases
sent abroad at a period of the disease when no
hope  of benefit could  be  reasonably  entertained,
It is only by such numerical records as the above,
that we  can expect to arrive  at accurate conclu-
sions respecting the influence of any means of
cure in a disease, which will prove fatal in a very
large proportion of cases, under any circumstances,
The result  in the first  series of cases  is  nothing
more than  every one would  expect  who is ac-
quainted  with the nature of phthisis, and knows
the state of the lungs  in what generally passes
under the name of confirmed consumption.  But
while Dr. Renton's experience of the effects of the
climate of Madeira shows  the  inutility of change
of climate in the advanced period of phthisis, it
holds out considerable hopes from the adoption of
this measure in its early stages :  of thirty-three
cases  of incipient  consumptions,  twenty-four
were  apparently cured.  Such a ratio of  success,
we have reason to believe, has never before  been
observed  among  consumptive invalids  sent to
Madeira, and for this plain reason—that they were
rarely sent till the disease was  too far advanced to
admit  of recovery.   Dr. Renton  remarks in his
communication  to us, " With respect to the inva-
lids sent out, they have been very different for the
last two or  three years  from those sent out for-
merly."   We  have  the satisfaction  of thinking
that we have contributed, in some degree, to this
favourable result, by  our appeal to British physi-
cians in  the work  already referred to;  and we
shall be happy to find that the striking proof of
the truth of our former remarks,  now recorded,
induces our professional brethren to pay still more
attention  to this subject.
   Of the Atlantic  Islands, Madeira; in Italy,
Rome and  Pisa ;  and in England, Torquay and
Undercliff, afford the best climates for consump
tive cases.  [Sir George Lefevre (Thermal Com-
fort, Amer. edit. p. 39 :  New York, 1844) recom
mends Valentia, in Spain.   In the United States,
St. Augustine, Savannah, Mobile  and Pensacola,
on the sea-board, are often visited; and occasion-
ally the interior of the peninsula of Florida, Ala-
bama or Louisiana.]
  In stating these places to be the most favourable
residences, we beg to be understood as referring to
the winter chiefly.   Italy, during  the  summer, is
decidedly injurious to the phthisical invalid ; and
those who have passed the winter in  the milder
climates  of England  should  in general seek a
more bracing air in summer, such as that of  Mal-
vern, or even some of the more elevated and drier
districts of  our  island;  or, what would  be still
better,  they might in the  course of this  season
change  from one place to another, taking  care
always  that no place was visited  possessing a 
CLIMATE.
451
climate decidedly hostile to their particular state
of health.   Such frequent changes of residence,
when judiciously conducted, and  combined with
exercise on horseback, and a regimen suited to the
particular state of the patient, are among the most
effectual means which we possess for preventing
consumption in persons predisposed to it, more
especially in early life.
   Chronic  Bronchitis. — The morbid  condi-
tions of the mucous lining of the  larynx, trachea,
and  bronchi are greatly influenced by climate, and
the  change from a cold and moist  to a mild and
dry  air seldom  fails  to relieve, and occasionally
removes them.  The situations which have been
mentioned as most favourable in phthisis are best
suited also  to  bronchial diseases generally.  Of
the  continental climates, those of Rome and Pisa
are the most beneficial in cases attended with an
irritable state of the  affected  parts without much
secretion; and that of Nice in cases attended
with less sensibility, a more copious expectoration,
and  a relaxed state of the system  generally.  Ma-
deira, as far as our  experience goes,  has  proved
more beneficial  in the former class of cases than
in the latter.   In  England, Torquay and  Under-
cliff afford the  best  climates  in the first class  of
cases, and Clifton in the latter, in which Brighton
also  is a very  favourable residence during  the
autumn.
   Asthma is often greatly relieved and occasion-
ally  ceases under the influence of a mild climate,
more especially when complicated with disease of
the  bronchial membrane, as it almost always is
when of some duration. In what has been  termed
humoral asthma, Nice is  the best residence ;  but
Rome is preferable  when this disease is accompa-
nied with an irritated  state of the digestive organs,
a complication  which is exceedingly common.
   Chronic Rheumatism.—Climate produces
the most decidedly beneficial effects in this disease,
and  that  often with surprising rapidity, even  in
cases of long standing, which have resisted  the
best-directed medical  treatment.   We  would par-
ticularize  Rome and  Nice as  the best residences
for invalids  suffering from this  complaint. The
preference to be accorded to the  one or the other
place will depend upon the character  of the pa-
tient's constitution  and the state of his digestive
organs.  When there exists  an irritable state  of
these, we  have  already remarked that the climate
of Nice will generally disagree, whatever may  be
the  more  prominent  disease.   [Signal benefit is
often derived, during the summer, from the  Warm
Spring and  Hot Spring baths of Virginia.]
   Gout is  remarkably alleviated  by a warm cli-
mate.  In  the  selection of a  residence for the
gouty invalid, we must be guided by the particular
state of his constitution,  and  the effects  of the
different climates which have been already pointed
out.   Genoa is rather remarkable for the rare  oc-
currence of the disease among its inhabitants. But
a wanner  climate than any part of Italy would, in
many cases, we have no  doubt,  prove still more
effectual  in removing  gout.   We have already
remarked  the effects  of the West-Indian climate
in this disease.
  Scrofula. — Strumous  affections,   especially
when seated  in  the skin  and lymphatic glands,
are frequently cureci,  and the  general health  is
greatly  improved, by  a mild climate.  In such
cases Nice and  Rome have appeared to  us  the
most favourable residences ; but  in  giving a pre-
ference to either, in this and all other complaints
in which a residence in these places is useful, the
practitioner must always keep in view the charac-
teristic  peculiarities of these  climates formerly
pointed  out.  There are cases  of this disease in
which the  climate of the West Indies,  as already
remarked,  would prove more effectual than any
European climate ; those, namely, of an indolent
character with little disposition to febrile excite-
ment.
   Dyspepsia. — Different forms  of  dyspepsia,
hypochondriasis, and other nervous affections, in-
timately connected with a disordered  state of the
digestive organs, all of which are aggravated by a
cold and humid atmosphere,  are  much mitigated
by a winter's residence in the south of Europe, if
aided by proper regimen.  Attention to the diet is
particularly necessary  in changing from a cold to
a warm climate, and in no class of cases is this
more requisite than in those of which we are now
treating.  (See Dyspepsia.)
   The dyspeptic invalid  from the north will re-
quire to be still more on his guard  in the south
of Europe than in his own country, particularly
as regards  the use of stimulants;  but in  nervous
and hypochondriacal cases the state of the mind
must always be taken into  consideration in  our
selection of a climate and residence for the invalid.
Unless we  can produce an impression on the mind
as well as the body, we shall make little progress
in the cure of these affections.   A change from
one place to another will, generally speaking,  be
better than a long residence at any one; as much
of the  benefit obtained in such cases arises from a
constant succession  of new and agreeable impres-
sions made  upon  the mind.  A judicious and
timely change of climate, combined with a consi-
derable extent of travelling through a country and
scenery which excite  a lively interest, produces
the best effects  on the health of persons whose
minds have  been overstrained  and exhausted by
long-continued application to the same subjects,
or whose general health  has  been destroyed by
chronic dyspepsia, and die abuse of medicines, to
which it too  generally  leads.
   A  single  season  properly spent in the south,
more especially in Italy, is  often productive of
the most salutary effects in restoring the energy
both of the mind and  body;  and if due attention
is paid to regimen, especially as  regards diet,  the
benefit derived will be  both greater and more per-
manent than can be obtained, perhaps, from any
other mode of treatment.
   The  morbid states  of the mucous membranes
generally are  greatly benefited by a mild climate.
We have already remarked its beneficial effects in
the diseased conditions of the bronchial membrane,
and that of the  stomach,  in  dyspeptic affections.
In similar states of the intestinal  membrane,  ac-
companied  with chronic diarrhoea, a mild climate
will contribute powerfully to restore the parts to a
healthy state.  Dysmenorrhea, which is frequently
dependent on irritation  of the mucous membrane
of the uterus,  is often quite removed, and the
healthy state of the whole uterine functions  re
stored. 
452
CLIMATE.
  Irritable cutaneous diseases are also much alle-
viated by  a residence in a warm ciimate.
  It would be impossible, without extending this
article to an undue length, to particularise all  the
disordered conditions of  the  system in which  the
change to a mild climate proves useful; but we
must not  omit to notice several distinct periods of
life at which the beneficial effects of such a mea-
sure have appeared to us most striking, when from
any cause the health has become deranged. The
first is during  childhood.  From what has been
said, in the early part of this article, of the opera-
tion of a  mild  climate  on the various  functions,
it will  be easily understood  how beneficially  this
influence  must be  exerted at this early period of
life, in favouring the growth and development of
the system ;  and accordingly we have had abun-
dant opportunities of observing the excellent effects
produced  on the health of delicate  children by a
residence of one or two winters in Italy.
   When  the health of children is  naturally deli-
cate, or when it has been rendered  so by some of
the diseases of childhood, such as measles, hoop-
ing-cough, scarlet  fever, &c, no  measure with
which we are acquainted will  prove so effectual
in restoring the health as a change to  a  dry  and
warm climate.
   Again, about the period of puberty,  or  a little
before this time, a change to  a  southern  climate
for one or two winters is a measure which, if judi-
ciously advised and carefully executed, will seldom
fail to  improve the general health of delicate  per-
sons, and favour the full development of the  sys-
tem which takes place at this period of life;  and
when  there  exists a disposition to  tubercular  dis-
ease, it will tend materially to  obviate it.  We beg
however,  to  observe, that we speak of the effects
of climate in those cases, not so much as a single
remedial  measure, as  a measure which, while  it
contributes  powerfully  of itself to  improve  the
health, favours the operation of a proper regimen,
and such other remedies as the circumstances of
the particular case may  require.
   The third period of human life at  which we
have remarked  the  powerful influence of a mild
climate in ameliorating  the health, occurs  at a
more advanced age.  The two  first occur while
the body  is  yet in progress to maturity, the third
when it has passed the zenith of  its power.   In
the first instance, a mild climate enables a delicate
frame to  attain more  certainly its  full maturity;
in the latter it prevents it  from sinking prema-
turely into decrepitude, and  enables  it to prolong
its existence until the  period marked for its natu-
lal decay.
   From  about  the age of fifty to  that of sixty,
though not unfrequently at a much earlier period,
either when  the system is naturally weak, or the
causes of disease  have  been powerfully applied,
the  impaired condition of health now  alluded to
usually supervenes.  This state  is marked rather
by anomalous disorder of various functions, indi-
i ative of  a premature decay  of the powers of  life,
liian by any formal disease acknowledged in our
systems  of nosology.   The  activity of the mind
and the bodily vigour  have sunk  many degrees,
without  any evident  cause, and the individual,
rwnh in   appearance and  feeling,  seems  rapidly
lapsing into premature old age  and its  accompa-
nying  infirmities.  This  disordered  state of the
health  has been termed the Climacteric Disease;
but, as we have already remarked, it occasionally
occurs long before the period of life at which this
change of the constitution is stated to occur natu-
rally.  (See Age.)
  The causes which  lead to this condition of the
health are various ;  as, for instance,  an anxious
and sedentary life, long-continued and close men-
tal application, or irregular and  intemperate habits
of living; and oftener still it is the  consequence
of the combined influence of several of these
causes.  From  whatever  cause it originates,  a
change for one or two  years  to a milder climate
will  prove of  the greatest  benefit in restoring the
invalid to his  wonted health.
   Before  closing this brief survey of climate, and
of  the various  diseases  benefited by  it, there
remains one circumstance to be noticed, and  it is
one of some importance to the invalid :  we allude
to the  proper period for his returning to this coun-
try from  the  milder regions where he  has  been
sojourning.   Invalids finding a very sensible  im-
provement in  the state of their  health, are too apt
to consider themselves well, and become impatient
to return home on  the least  feeling of inconve-
nience from the heat of the spring.  Influenced
by this or  other causes, they  frequently err by
leaving a southern climate too early.   A relapse
of the disease, for the cure or relief of which they
were sent abroad, is not unfrequently the conse-
quence; and  thus it  often happens that  by a little
impatience, or imprudence, and occasionally  from
ignorance of  the  consequences, the advantages
obtained  by  passing a whole  winter in  a  mild
climate are  speedily destroyed.   It should be the
care of the medical  adviser to warn  his patient,
before he leaves his  own country, of the  risk he
runs by returning home too early.  If his winter
residence  has-been Italy, the invalid  should avoid
recrossing the Alps till the summer is fairly  esta-
blished in Switzerland.  He may commence his
journey northwards  from his  winter quarters in
May, but should linger in the north of Italy, or
among the  Italian lakes, till  he finds  the  heat
inconvenient.   This will  seldom happen before
the  first or second week  of June; and  whatever
may be his  feelings  in Italy, the period we  have
just mentioned will be sufficiently early to arrive
in  Switzerland.  Independently of  the risk of
exposure  to  cold while  crossing the Alps, which
may, indeed,  be avoided by proper clothing  and
arranging the day's  journey so as  to complete  it
before sun-set, the invalid will find a remarkable
difference between tbe atmosphere of  Switzerland
and that of Italy.  He will be particularly sensi-
ble of the keenness of the evenings and nights in
Switzerland.   Indeed,  the  scenery of these  two
countries does  not differ more remarkably to the
eye  than  does their climate to the feelings.
   When the  winter has been passed  in Madeira,
or  any of the  other Atlantic  islands, and  more
particularly the West Indies,  the  invalid should
be still more  careful  not to leave his quarters too
early in the season.   By a little care to avoid ex-
posure to the  sun, he may escape injury from the
heat;  but it  will be difficult  for bim to guard 
CLIMATE —COLD.                              453
against the  pernicious effects  of our cold north-
east wind as he enters the Channel, or arrives on
our shores.
   A delicate invalid who has passed the winter
in  any southern climate,  should  endeavour to
arrange his  journey or voyage so as not to reach
England before  the middle or rather the  end of
June;  and  his  warm clothing, which he  may
have  laid aside,  should be  resumed the moment
his feelings  tell  him  that he is entering a colder
and more variable climate.
   [Invalids  who have passed the winter in the
West Indies, or in the southern part of the United
States, should be especially careful not to return
too early to  their homes.  The spring months are
markedly those  of great vicissitudes, and trying
to  the delicate.   Dr. Jackson, of  Boston,  who
sends his patients chiefly  to Cuba, directs them to
remain there until the last of April; then to go to
Georgia or South Carolina, and to return to Bos-
ton very slowly,  so as not to reach  New England
until  the end of June; and the course is precau-
tionary and  wise.   (Sir James Clark, op. cit. p.
306.)   Should the  invalid be unable to  pursue
this course,  he ought to remain  in his  winter
retreat until  the end of May, if practicable.]
   It is of the greatest consequence to invalids to
maintain an active state of the circulation in the
surface and  extremities, which  cannot be  done in
this country  without the  assistance  of warm
clothing.  The increased circulation  in  the ex-
treme  vessels  is one  of the  effects  of a warm
climate, from which the invalid  derives the greatest
advantage;  and  it should be his especial  care to
preserve it  while in  progress to  and after his
arrival in a  colder, as  to  the steady maintenance
of this  for a considerable length of time he must
mainly look  for the preservation of his new stock
of health.
   In  leaving his own country, therefore, in the
early autumn,  on his way to a  warm climate, and
in returning home in the  succeeding spring, he
should avoid exposure to great vicissitudes of tem-
perature, and thus endeavour to secure the advan-
tages, as it were, of  several successive summers.
                            James Clark.
   COLD.—It is designed under this head  to treat
of the morbid effects of excessive cold applied to
the human body, and  of  the means of removing
them;  and also  of  the  application of cold  as a
remedy in diseases.
  The term  cold is relative, and, perhaps,  strictly
speaking, ought to be  restricted  to  that sensation
which is produced in the  animal body by  the ab-
straction of caloric from it, in consequence of the
application of any solid, fluid, or gas, of a lower
temperature  than itself.  In common language,
however, cold  is  spoken  of as a  positive agent,
and by some men of science it has been supposed
to have as distinct an existence as  caloric, or the
matter of heat.   The  result of some experiments
instituted to  demonstrate  that cold may be radiat-
ed in  the same way as caloric, appears  to  have
confirmed this opinion in some  minds;  but the
effects produced by those experiments are expli-
cable on the  supposition  that caloric is radiated,
and not an agent of an opposite character.
  The sensation  of cold  is  not always produced
by the same degree of temperature, for it depends
very much on the state of the body previous to
its application ; indeed, what  may be  considered
a low temperature under some circumstances will
cause the  sensation  of warmth, and  a compara-
tively high temperature will produce that of cold.
If the  right hand be immersed in water at the
temperature of 80°  of Fah., and  the  left in an
equal quantity of water at 40°, the former will
receive the sensation of heat, and  the  latter that
of cold ;  but if  the  two  quantities of water be
then mixed, and both hands dipped into the mix-
ture at the same time, the  feeling of cold  will be
produced in the right, and the feeling  of warmth
in the left;  so that no fixed temperature  can be
called either hot or cold.   The generation of ani-
mal heat, or, in other words, the internal develop-
ment of  caloric, is accomplished by a process con-
tinually going on in  the body, more actively per-
haps at some times than at others.
  The abstraction of caloric from the body within
given bounds may be regarded as a salutary pro-
cess ; on this  circumstance  the  degree of vigour
observable in the human frame, in temperate cli-
mates, so much  greater than in either what are
called  the torrid  or frozen regions, may  in no
small measure depend ;  the degree of  abstraction
being neither so great as to leave the system tor-
pid, nor so slight as  to render it oppressed.  In-
stinct and reason  have led to attempts to regulate,
by various artificial means, this cooling effect of
the surrounding atmosphere in cold climates and
seasons, as well as by contrivances for cooling the
air in hot regions, to protect the system  againsl
the effects of excessive heat; and it is a remark
able fact, that a provision in nature seems in some
degree to be made to accomplish the same object
in the animal kingdom ; for in very cold climates
wool and hair grow abundantly long and thick on
the brutes, so as to protect  them  against  cold,
while in  the hotter climates their skin  is scarcely
covered;  and the same animal on being removed
from a cold to a warm country, or from  a warm
to a cold one, is found to change the length of his
coat.   Thus dogs taken from England to  India
will often lose all their hair; and in our own cli-
mate the horse is  well known to have  the length
of the hair covering his  skin  regulated by the
clothing in the stable.
  Perhaps  the temperature  of the atmosphere
which  is  most congenial to the human body is a
range between 55° and  70°  of Fall.;  but  habit
has much to do  with this, as  with almost every
thing connected  with the  actions of the animal
economy.  An extreme  degree of heat may be
often  endured without  much inconvenience by
those who have been long habituated  to it; and
the same may be said  of cold.  But  when the
system has been making an effort, if the expres-
sion  may be used, to resist the bad effects of either
a very low or high temperature, a great and  sud-
den change in the surrounding  atmosphere is ab
ways productive of inconvenience.  This remark
refers not to a change of climate only,  but to the
vicissitudes which may occur in the temperature
of the  atmosphere in the same climate.  Persons
who are  strong and robust, however, feel less ;n-
convenience from these sudden changes than those
who are weakly ;  hence the imoortance of re<*u 
454
COLD.
lating the quantity of clothing  according to  the
powers of the system, and especially according to
the vigour with which the circulation of the blood
is  carried  on.   A  very frequent exposure  to
changes of temperature will often enable the body
to resist the ill effects of these changes, and affords
another instance of the power of habit.  The fact
just mentioned is illustrated by the good health
often enjoyed by  those persons who attend large
furnaces, glass-blowers, smelters, &c.   The won-
derful  power  of the  body to accommodate itself
to the circumstances under which it is placed, is,
in this particular, exemplified in a very striking
way.  Hence, undoubtedly  have  originated the
various modes of attempting to  harden the sys-
tem, and thus to  prepare it to resist the  morbific
agency of cold.   It is undoubtedly true that such
means will often  give tone to weakly persons, and
prepare them  for  the  vicissitudes of climate ; but
with such persons much care is requisite that the
plan be not carried too hastily into effect. Indeed,
it will be found that many cannot by any care be
brought to bear it, and  in such instances warm
clothing must be mainly depended on as a defence
from the sedative action of cold.
   This leads  to the more special consideration of
the morbid effects produced on  the human body
by the  undue degree of the abstraction  of heat
from it.
   Caloric, or heat, as it is commonly termed, acts
as a stimulant when applied to the animal body,
its effects being local or general  according  to the
extent and degree of its application :  it increases,
like most other stimulants, the action of the heart
and blood-vessels; but (as is also the  case gene-
rally with  stimulants)  a  secondary effect occurs,
which consists in a collapse, (or in an action low-
er than that which  is natural,) after the excite-
ment has subsided.  Effects exactly the reverse
of these take place from the abstraction of caloric,
or, to use the common phrase,  from the applica-
tion of cold.  Heat is tberefore a  stimulant, and
cold a sedative, although the exact mode in which
heat or cold acts on the body will  probably never
 be determined.
   The well-known immediate  effects of a con-
 siderable abstraction of heat are — the sensation
 which is called cold, pallor of the skin—from the
absence of blood in the  capillary vessels; or  a
 reddish  blue colour  especially of the  hands, ears,
nose, lips, from a delay of blood within the capil-
 laries, so that it becomes venous; — a shrunken
 state of the  skin, and a  contraction of it around
 the small  glands which  are imbedded in  it, and
 around the hairs, causing it to become rough, and
 to resemble the surface of a plucked goose ; hence
 the technical term  cutis anserina.   The  same
 state of the  skin of the  scalp  often  causes the
 hair to rise in some degree from the head, with  a
 feeling of  tightness; this  is called horripilatio.
 The extremities  of the body  suffer first,  as  the
 fingers, toes, ears, nose, &c, i. e. the parts farthest
 from the heart.   The fingers  and  toes become
 sensibly smaller, so that rings which fitted before
 fall from the  fingers, and shoes drop from the feet
 for which  they  were  not  previously too  large.
 The action of the  heart  becomes diminished  in
 force, and sometimes also in frequency—the latter
 'iniiig most commonly the result of exposure to a
very intense degree of cold ; and not unfrequent-
ly the pulsations, although weak, become more
frequent than natural.  These symptoms, which
may be considered the moderate effects of cold,
will  vary greatly as  to  their degree in different
persons  exposed  to  the  same  low  temperature:
indeed, to some persons the abstraction of heat by
the cold  air of a  frosty day affords a  grateful feel-
ing, and to such it may be really salutary:  this
will be referred to when  speaking of the therapeu-
tical effects of cold.   In all persons, however, a
very intense  degree  of  cold  will  produce  un-
pleasant sedative effects ; and in those who have
been previously debilitated, the powers of the  sys-
tem are depressed to an alarming, and even some-
times to a fatal extent: indeed there are very  few
individuals who have such vigour as to be enabled
to resist the consequences of exposure, without
sufficient clothing, to the  severity of  the winter
months  in the frozen regions, or to the  intense
cold which is met with in passing over very high
mountains.  The vascular  system  is not alone
affected  by the  agency of cold on the body, as is
proved by the symptoms  which occur in the more
severe cases of exposure; the  brain and nervous
system generally being soon brought under its in-
fluence.  Perhaps it  may be witb propriety sup-
posed that the nervous system primarily receives
every  impression  from external  agents; and that
cold, therefore, first acts  on this system, the  vas-
cular system being only secondarily  affected:  this
question need not be here discussed.
   Numbness, or a want of the ordinary acuteness
in the sense of touch, is a consequence of expo-
sure to  cold : this numbness  is experienced by
most persons in  their fingers and toes on a very
cold day, or  after having been  long immersed in
cold water.  It is worthy of remark, here, that in
these  individuals there  appears to be something
very peculiar as it respects the  action of cold on
their extremities ; the blood appears to cease to
flow altogether into the vessels of the fingers  and
toes, which look exactly  (as the common  expres-
sion implies) like those of  a dead person ; and so
torpid do they become under these circumstances,
that a pin can   scarcely be felt when placed be-
tween the ends  of  two of the  fingers, and the
motions of  the  hand are regulated, not by the
touch, as is usual, but entirely by the sight.  This
singular idiosyncrasy has never received  a satis-
factory explanation:  it  does not  appear to arise
from debility of  the vascular system alone, for it
is found in some who have no  sign of such de-
bility : probably it may depend, as all idiosyncra-
 sies appear  to  do, on an  original peculiarity of
 structure: it is found to prevail in individuals of
the same family.  The  very  great  diminution
 (almost suspension)  of sensibility in  such  cases
 may arise in some  measure from a want of the
 necessary supply of blood to the extremities of the
 nerves; as it is  an undoubted fact that their  sen-
 sibility is greatly regulated in  its degree by the
 quantity of  blood circulating  through the capil-
 laries.  It may also  in  part depend on the direct
 effect of the cold on  the nerves themselves; but
 that this action on the nerves is  not the only cause
 of the torpor is  rendered probable, if not proved.
 by the fact, that if artificial warmth be applied so
 as to  bring the fingers  to  their natural tempera- 
COLD,
455
ture, the sensibility will not return until the circu-
lation is restored.
  The whole surface  of the body becomes  less
sensible to the  touch  under the influence of  a
great degree  of  cold;  and the sense of taste  is
sometimes  blunted.   But  further,  when  a  still
greater  effect is produced, the  brain  loses its
energy, and an  irresistible  desire to sleep ensues.
Here we may again  observe that it is hardly pos-
sible to determine whether  this is  the direct result
of the action  of the  Cold  as  a sedative on the
brain, or whether it depends on a want of the due
supply of blood  to that organ, on  account  of the
diminished action of the heart.  When this over-
powering tendency to sleep has commenced, much
danger is to be apprehended ; for  it has generally
been found, when indulged, to be  the  precursor
of death.   The  interesting account given by Cap-
tain Cook  of the  excursion of Dr. Solander  and
Sir  Joseph Banks, with  nine  other  individuals,
over the hills of Terra del Fuego, affords  a very
strong illustration of this effect of cold.  Dr.
Solander, who had witnessed the torpor and death
produced by severe cold while crossing over some
of  the mountainous  districts  of the  north of
Europe, thought it necessary to put his compan-
ions on their guard, and requested them to resist
determinately the strong tendency to  sleep which
he expected some  of them  would  feel; his words,
quoted by  Captain Cook,  were,  " Whoever  sits
down will sleep, and whoever sleeps will wake no
more."   The  doctor was  the first who began  to
experience the anticipated effect of the cold;  and
so irresistible was the inclination to sleep, even in
him, that in  spite  of his judgment and  fears he
entreated  his  companions  to  allow  him  to  lie
down; they  acted upon the knowledge he  had
afforded them for their own safety, and  partly by
entreaty and  partly by force kept  him  for some
time from  indulging his destructive inclination ;
but at last, becoming themselves almost exhaust-
ed, they were obliged to leave him  behind together
with two black servants  who had  also become
drowsy.   Dr. Solander  was,  however, roused,
although with the  greatest difficulty, after having
slept about five minutes only, and  carried to a fire
which some of the party had  succeeded in kin-
dling, and thus narrowly escaped  death, although
for a time he almost lost the power of his  limbs.
The two poor blacks perished.
  Many examples  of this  extreme effect of cold
will  be found on record in  the writings  of  travel-
lers  and historians.   [See Copland, art. Cold,
Diet, of Practical Medicine; Dunglison's Elements
of Hygiene, 2d edit.: Philad. 1844; Guerard, art.
Froid, Diet, de Med., xiii. 522: Paris, 1836 ;  and
Veiter & Michaelis,  art. Kalte, in  Encyc. Wor-
terb. der Medicinisch. Wissenschaft. xix. 271: Ber-
lin,  1839.]  The  same effect is  produced, to  a
certain extent, in this country in very  severe win-
ters.   The  celebrated traveller Dr. Edward Daniel
Clarke, the late eloquent Professor of Mineralogy
in the University of Cambridge, was on  one occa-
sion  nearly losing his life by cold.  Having per-
formed divine service at a cburch  near Cambridge
in the afternoon of a  very severely cold snowy
Sunday, in the year  1818  or  1819, he mounted
his horse for the purpose of returning home. Soon
finding himself  becoming  very cold  and sleepy,
 and knowing well the danger of giving way to
 sleep, he put the horse into a fast trot, hoping by
 that means to arouse himself  from the  alarming
 torpor which was coming over him :  this  means
 was unavailing ; and then fearing that he  should
 soon fall from  his seat, he dismounted and deter-
 mining to use every  effort to resist  sleep, put the
 bridle under his arm  and walked as rapidly as he
 could.  This, however, did not long succeed : the
 bridle  dropped from  his  arm,  his  legs  began to
 falter, and  he was just sinking down upon the
 snow, to rise, probably, no  more, when  a  gentle
 man who knew him came up to him in a gig, and
 rescued  him  from his perilous situation.   This
 account was given to the writer of this article by
 Dr. Clarke himself the  succeeding morning; he
 then felt languid and feverish,  after  having had a
 good deal of re-action during  the  night, but the
 effect soon passed off entirely.
    The action of cold is probably, as  has been
 already remarked, greater on  those persons who
 have naturally a  weak circulation, or who have
 become  weak from  any debilitating  cause ;  and
 this last  is the reason why those  are very soon
 affected by it who have  undergone  much fitigue
 A moist  state of the skin  from perspiration oi
 damp clothing will  also accelerate the  effect of
 cold, by superadding  to the direct effect of the cold
 air the further abstraction of caloric  by evapora-
 tion.  It is a curious but well-established fact, that
 when the mind is deeply engaged, the body is less
 affected by cold ;  and it is perhaps on this account
 that maniacs will often bear exposure  to extreme
 cold without complaining.
    When the  body is warm, and the  circulation
 vigorous, provided there be no perspiration  on the
 skin, the  bad effects  of exposure to cold are less
 likely to be experienced.  The common practice,
 therefore, of persons cooling themselves gradually
 before they pass from a warm room into the open
 air has originated in error : the greatest  protec-
 tion from the bad consequences of such  a change
 is  found  in a vigorous circulation, a warm dry
 skin, and thick clothing.
    Long-continued immersion of the body in cold
 water seems to be productive of nearly the  same
 symptoms as those which arise from exposure to a
 very cold  atmosphere.  It  has been  asserted, on
 the ground of recorded facts,  that less danger is
 likely to  ensue from  immersion in sea-water than
 in fresh water ; and  it has  been alleged that this
 minor degree  of effect is referrible to the  stimu-
 lating quality afforded to the sea-water by the salts
 which are dissolved  by it.   This solution  of the
 facts is probably in  part correct; but it must be
 remembered that the  water of the sea is rarely so
 cold  in  winter as that of  rivers,  the  immense
 mass of the ocean requiring a much longer  period
 than that of a winter to cool it down to the lower
 degrees of temperature of the winter atmosphere
 there must besides, by means of the  tides, be  a
 continual admixture  of the warm water from the
 southern  seas with the colder water of the  north-
 ern.  A doubt, however, cannot be entertained of
 the advantage which persons who are exposed to
 the misfortune of shipwreck during  severe cold
I will derive from keeping themselves immersed ir.
j the sea-water ; and not only because the water is
| warmer than  the atmosphere, but also because u 
456
COLD.
will  prevent the effects of evaporation.   Many
interesting accounts of shipwrecks have b'.en pub-
lished which show that this is not mere theory.
  The  complete and  speedy destruction of  life
from exposure to intense cold may result from  the
general sedative effect which  has been  already
described; but when  life  is not  totally lost,  the
extremities may lose their vitality, and mortifica-
tion to a greater or less extent ensue.   Limbs  are
frequently in this way mutilated  in cold  seasons
in northern latitudes, and in very high situations ;
when the surface of the nose and the ears suffers
in this way, they are said to be frost-nipped or
frost-bitten.
   But the injury sustained from exposure to cold
is not  always dependent on its  direct  sedative
action, for it may produce disease, and even cause
death, by that secondary effect which is  denomi-
nated  re-action.  This re-action after depression
consists in the return of the  action of the vascular
system ; if moderate, it may go  little beyond  the
natural degree : the  pulse becomes rather more
frequent and full,  and  the  heat of the surface
greater than natural, and a glow is experienced
over the  whole body : this  soon passes  off,  and
leaves no evil consequences.   But when the re-
action is  great,  the vascular excitement is so in-
creased beyond its due bounds  as  to constitute
fever,- and  perhaps  there may be in reality no
difference between this state of the body and fever
from other causes.  The symptoms are often the
same,  and sometimes last as long; but the fever-
ish state  in a day or two will give way, in  many
cases, on using  very mild remedies, or even with-
out  any remedies at  all: such  cases are  called
ephemeral fever.
   Fever is not the only consequence to be  feared
from re-action  after exposure to cold;  local in-
flammation may follow this general re-action,  and
any of the  internal  membranes or organs may
become the  seat of  the  inflammation;  but  the
particular organ affected  in each case may be de-
termined by some local predisposition : thus  one
person will have catarrh, another cynanche ton-
sillaris, a third pneumonia,  as a consequence of
exposure to  cold.
   It  appears from what  has  been said, that  it is
 to the excess of the  re-action  that such effects,
 both local and  general, are to be attributed ;  and
hence  the importance of guarding against every
 circumstance which may bave a tendency to  sti-
 mulate the system immoderately after exposure to
 cold,  and of employing  measures  calculated to
 subdue the  action of tbe heart and blood-vessels
 when there is a threatening  of sanguineous ex-
 citement.    The danger of  applying heat  too
 rapidly is now  generally known, as well as  that
 of administering internally any strong stimulants.
 A person  who  has  become  seriously affected by
 cold  should be placed in warm air about 65° or
 70°, and should be well covered over with flannel
 ho prevent the heat, as it becomes generated in the
 body, from passing off.   Friction of the surface
 bv means of the warm  hands  of  two or three
 attendants,  or  with  warm  flannels, may be  em-
 ployed :  in extreme cases the body may be wrap-
 ped in hot  blankets  until  re-action commences;
 large  hot poultices or fomentations may be applied
 with  advantage to  the abdomen; the warm air,
vapour, or water  bath, about the temperature of
98°, may be  employed  in  those  instances where
the vital spark appears almost extinguished. The
means already recommended  must be  combined
with the  employment of internal  stimulants, al-
cohol, spices, ammonia, &c.:  but it must be borne
in mind that it is desirable to avoid  the employ.
ment of internal  stimulants to any great extent:
indeed, to avoid  them altogether  if possible, as,
after  re-action has  commenced,  they,  by their
action on the  system,  may  cause the injurious
consequences of excessive excitement. If asphyxia
(or a suspension  of  the action of the heart and
lungs) succeed to the application of cold, artificial
respiration, and the other means recommended in
the  treatment  of asphyxia,  may be  required.
When the heat and  action of tbe system begin to
return, care is especially necessary lest the excite-
ment rise to an  immoderate  degree.  The same
principle must be  our  guide in attempting to
prevent  injurious consequences after  the local
effects of cold.   Chilblains, which are a common
consequence of the local application of cold, may
be  prevented by  warming the parts affected very
gradually, and by cooling them,  as  soon  as re-
action takes place, to the extent of producing the
sensation called the hot-ach.
   Large draughts of cold  fluids, taken when the
body is fatigued and perspiring, are often pro-
ductive of serious or even fatal consequences: the
effects are a faltering of the pulse, laborious breath-
ing, dimness of sight, giddiness, and then general
torpor and death.  The proper mode of treating
these cases has  never  been  well pointed out; it
appears, however, a rational practice to give, as
soon as possible, some warm fluid, to  apply hot
fomentations or poultices to  the epigastrium, and
to resort to the means indicated by the principlei
already laid down.
   The abstraction of caloric from the body may
and is frequently made to conduce to the recovery
of persons labouring under disease.
   As a therapeutical agent, cold is employed to
accomplish one of the three  following purposes:
—1st, to depress inordinate action of the vascular
system; 2d, to relax the muscles;  3d, to give
vigour to the body.
   The sedative  effect produced by cold has been
already sufficiently dwelt  upon to show how it
may be employed beneficially to subdue high vas-
cular action.  In inflammation, therefore, and in
fevers, cold may very often be considered  as one
of  our  most valuable remedies.  It may be sup-
posed  by some persons, that the beneficial effect
resulting from tbe employment of cold in inflam-
mation  and  fever, arises from the simple diminu-
tion of the heat: indeed it is most probable that
it was on occount of the augmented heat in those
diseases that it was  at  first resorted  to; but oui
present  improved pathological views  enable us to
form a more correct judgment of the action of
remedies; and  there cannot now exist a doubt
that the advantage arising from the use of  cold in
fever  and inflammation is to be ascribed to its
allaying vascular action.
    When inflammation is  situated in the external
parts of the trunk of the body, or in  the extremi-
ties, one of the means most commonly employed
to  subdue it is the -ir nidation of an evaporating 
COLD.                                       4."i7
lotion.  The lotion may be used cold, and then
the heat is  in some degree abstracted directly by
the cold fluid; but the principal advantage (unless
the lotion is constantly applied) is derived from
the evaporation of the fluid.  It is not, therefore,
absolutely necessary  that  the  lotion should be
colder than the body of the patient, as evaporation
will take place more  speedily when it is tepid;
and in some cases it is preferable to use it warm,
on account of its being more agreeable to the feel-
ings of the patient.
   Although there cannot be a doubt entertained
of the advantage  of employing cold  applications
in cases of common inflammation of the surface
and of the  extremities of  the body, yet by many
it is held to be  problematical  wbether they are
properly employed in  cases of internal inflamma-
tions, as of the membranes and organs included
within the skull, the  thorax, and the abdomen;
as by such  means tbe blood may be so thrown
upon the internal parts  as to  aggravate  the in-
flammation.   As  it respects the  brain  and  its
membranes,  this reasoning, although at first sight
plausible, is  evidently fallacious.  The object in
cases of inflammation being to lessen the flow of
blood to the  part affected, any  means which will
control the action of the carotid  arteries must be
useful in inflammation within the head, as it is
by those arteries that the greater part of the blood
is conveyed thither.   Cold applied to the scalp
will be  found to  act as a sedative, not only upon
the vessels of the integuments, but (by a sym-
pathy which is well known to  exist between the
larger and the smaller vessels) upon the carotids
also.  It  must  be clear,  therefore, even  from
theory, that  cold  applied  to the integuments of
the  head will be  of service in inflammatory dis-
eases of the  brain : but  experience has long de-
cided the point,  and  no  practitioner omits  this
powerful remedy  when he  has to combat with
such affections.
   The immediate effect produced  by a sudden
dash of  cold water, or by a stream of the same
poured upon the face and  head, is found useful in
many states of the brain.  This mode of using the
remedy is sometimes  adopted with advantage in
phrenitis, in  hysteria, in  syncope, and in cases
where narcotic poisons have been taken in large
quantities, especially opium. The advantage may
be owing in  some degree,  as in  inflammation, to
the sedative effect of the cold  upon the blood-
vessels ; but  this  cannot  account  for the benefit
produced in syncope,  and the sudden impression
made on the nerves by the cold must be also taken
into the account.
   ft seems to remain doubtful whether or not cold
may with advantage,  or even with safety,  be ap-
plied to the chest  or abdomen when there  exists
inflammation of the membranes or viscera within
those cavities.  This  practice has, however,  of
I ite been recommended by some physicians whose
opinions ought to have weight,  and especially so
as the recommendation seems to be grounded on
the result of experience :  the limits of this article
will not allow of a full examination of this inter-
esting subject;  the   author, however,  may  be
allowed  to say,  that  in  some  cases of phthisis
pulmonalis, where the  pleura   has  become in-
flamed, an evaporating lotion, applied  over the
  Vol. I___58                        2 o
part in pain, has often appeared to be of consider-
able service.
  Cold applied  to  the  body has become a very
common remedy in fever, when  the system is in
a state of very high excitement; and it is undoubt
edly a remedy  of almost unequalled  efficacy in
such  cases.   It may be employed by means of
cold fluids received into the stomach, or by means
of water or air applied to the surface.  From the
time of Hippocrates  the powerful effects of cold
have been appreciated in controlling febrile action ;
and it has from  that period  to the  present time
been  occasionally lauded as  an  important thera-
peutical agent: but it was not until of late years
that its applicability in cases of fever  became fully
understood.   We are more especially indebted to
the late Dr. Currie of Liverpool for our knowledge
of the value of this refrigerant, and  of the mode
of employing it, (on the Effects of Water, &c. in
Fever, London,  1805 ;) although very  valuable
information may be found scattered through other
medical works.   It is not in all cases of fever that
this remedy can be employed with advantage, c*
even with safety :  it is  only  calculated to subdue
excessive action when that action is accompanied
by a  temperature of the body  above 98° :  even
among  such  cases  there may be a few in which
some  other  peculiarity  may forbid its  use,—for
example, when the skin is moist.  At least, if it
be employed under such circumstances, it  will
require the  greatest caution, even although the
temperature of the body be high, which, howe-er,
is very unusual  when the  skin perspires.  In
measles, cold is in no  case to  be applied to the
skin,  nor are cold fluids to be drunk.  Neverthe-
less, in scarlet fever cold is of the greatest service
in moderating the action of the system.  It is pro-
bable,  although  not clearly  proved,  that where
fever is accompanied by some visceral disease, this
remedy may act injuriously, by  determining  a
large  quantity of blood to the internal parts of the
body.
  The circumstances which, when combined, may
justify the  employment of cold as a sedative in
common fever, are an increase of the animal heat
above 98° of Fahrenheit, a  uniform  increase of
temperature over the whole body, and a dry state
of tbe skin over the whole surface.   If there be a
tendency to perspiration, it will  show itself first
in a damp state of the palms of the hands, or of
the axillae.  Should  a sense of chilliness be felt by
the patient, that  also will render the employment
of cold of doubtful propriety.
  Several different  modes  of bringing the  body
under the influence of cold are resorted to by  me-
dical  men.
  First, immersion of the body in a cold or tepid
bath.
  Secondly, affusion  of cold or tepid water over
the body.
  Thirdly, sponging the body with a cold or tepid
fluid.
  In some few cases, and in the  very early stage
of re-action, fever has been arrested in its progress
by the cold  bath  or by  cold affusion ;  but where
fever is fairly established, it can rarely be suddenly
put a  stop to by these or by any other means : we
can then only mitigate the severity of tht symp-
toms,  and thus give a better chance of the occur 
458
COLD.
rence of a favourable crisis.  But tne practice of
immersing the patient in a bath, or of throwing
water over the body,  has of late been very rarely
adopted; and its disuse  has not  been without
reason, for considerable inconvenience both to the
patients and to the attendants is given,  especially
in private  practice,  by the employment of  both
these modes.  But the principal objection to them
arises from  the  impossibility of determining the
precise  extent to which we ought to  carry the
sedative effects of cold, while the body is immersed
in the water, or  while it is passing over it in the
way of  affusion.  The patient  may be kept too
long or too short a time in the bath, or too  little
or too much water  may be affused;  so that the
action of the system may be too much  depressed,
or not  sufficiently  overcome.   These  objections
cannot  be  made to  sponging the  surface of the
body with cold water : by  this means the cooling
process  can be  carried to the exact extent which
is required ; the criterion for judging of the effect
being the feelings of the patient — a slight chilli-
ness will mark the time to desist.   Two or three
attendants  should be employed at  the same time,
with  large wet  sponges,  passing them over the
different parts of the naked body in  succession,
until the chill comes over the patient, who is then
to be placed  in a  dry bed and  moderately co-
vered.
   The temperature of the  water when  used with
the sponges may not be a matter of much  mo-
ment, as it  is by means of  the evaporation  that
the heat is principally abstracted from  the body :
tepid water  (from 70° to 90°) will in general be
found most agreeable to the feelings  of the pa-
tient, and it will be equally, if not more speedily
efficacious in reducing the morbid heat. It seems
also probable, for reasons already assigned,  that
re-action will not so  quickly occur after tepid as
after cold sponging.   When the desired effect  is
produced by this mode of  refrigeration, the pulse
becomes softer and slower, the skin cool and per-
spirable ; headach, if before existing, is relieved,
and frequently  delirium  is  suspended, and the
general feelings  of  the patient  are so improved
that sieep  will  follow.  The remedy will,  how-
ever, require repetition  to  derive from it  its full
advantage, and this  should be as soon as re-action
takes place to  any  extent;  indeed the  sponges
may be used partially or generally  many times in
the day and night;  but should the pulse rise very
speedily, and the heat return  very soon after  it
has  been reduced  by this remedy, other means
must be combined with it, as  bleeding, purging,
&c: but in by far the majority  of  cases of fever,
dependence may be placed on refrigeration alone
to keep down inordinate action.  Vinegar, spirit,
ether, &c,  are  sometimes used to increase the
evaporation, but these are seldom required.
   Cold air admitted into  the  patient's room, or
a current of air passing over his body, will  often
tend  to allay vascular excitement:  hence poor pa-
tients, in fever, who have been lying in their own
confined apartments, are  often  speedily benefited
by removal to an hospital  through the open air.
It is  very questionable if  any medicine admitted
into the stomach is  worthy, strictly speaking,. to
be called a refrigerant, at least to be called so on
account of any  quality which it possesses,  except-
ing its low degree of temperature, although many
articles of the Materia Medica are reputed to have
this effect;  but on this point the reader is referred
to the article Refhigkhants.
   When hemorrhage occurs from increased action
of the circulation, or is accompanied  by  such  in-
creased action, it may very frequently be restrain-
ed by the sedative effect  of cold.  The local  ap-
plication of cold to the bleeding vessels, or cold
so applied as to act upon the large vessels  which
supply those which  are  bleeding, will be often
found of very great service ;  for example,  in he-
morrhage from  the  nose  (epistaxis), cold water
used  to  the face and head will often of itself stop
the flow of blood; but in cases of bleeding from
the internal organs, cold, made to  act upon the
system generally, will often be found  of great use
in helping to restrain the action of the heart.  A
patient  labouring  under hemorrhage from  the
lungs (haemoptysis), may with great advantage be
kept  uncomfortably cold : of course when the he-
morrhage is not active, but of the passive charac-
ter, injury rather  than benefit might result from
the employment of this  means.
   The depressing effect of cold upon the ener-
gies  of  the animal body is remarkably exemplified
in the debility which is felt in the muscles of a
person who has been long exposed to a very low
temperature ; indeed it is very probable  that the
sedative action  of cold on the circulating system
is to  be ascribed to  a diminution of the irritability
of the muscular fibres of the heart and blood-ves-
sels.   When, therefore, an inordinate contraction
of the muscles occurs, as in spasmodic  diseases,
the  sedative quality  of cold  may cause  them to
relax when that remedy is applied to  the body to
a great extent.   The cold bath and cold  affusion
have  for this  purpose been  frequently employed
in tetanus ; the relaxation, however, which often
occurs immediately after the  application,  is gene-
rally of very short  duration, and it ought to  be
remarked that the sudden shock experienced  on
the first impression of the cold water will often
excite  an  exacerbation  of the  spasm, and that
immediate death has  ensued in a few instances.
 This mode of  treating the disease is certainly, in
 general, far from  being effectual; and it cannot
 be deemed altogether a  safe one.  The sedative
effect of cold on  the muscles  has  been said to
 show itself in  alleviating the irregular actions in
 chorea, hysteria,  and  other  convulsive diseases;
 in these cases  the  cold bath  or  shower bath has
 been recommended. As an instance of the effect of
 cold  in  producing  muscular relaxation, it may be
 stated that surgeons are  sometimes able to  reduce
 with great ease a dislocated limb during the tem-
 porary debility, which is induced in  the muscles
 after long immersion  in  a cold bath.  There are,
 however, other remedies capable of producing re-
 laxation of the muscles, wbich must be consider-
 ed much more certain than cold. (See the article
 Antispasmodics.)
   The  last therapeutical  agency of cold  which
 remains to be considered, is its invigorating qual-
1 ity when employed  in  cases of debility,  or, in
 other words, its tonic property.              .
   It has already been  remarked that the direct
 effect of a moderately cold atmosphere is grateful
 and  refreshing to  the feelings of some  persons; 
                                    COLD —

those who have naturally a very vigorous and too
rapid a circulation, those who suffer from the pro-
duction of too much animal heat, and those who
are liable in warm weather to have an inordinate
secretion  from the skin, are generally benefited by
the cold season of winter:  by such persons, from
their feelings, a  cold  frosty day will  be  called
bracing and invigorating.   To those individuals,
however, who have a languid  circulation, either
naturally or as the effect of disease, cold  weather
is far from being either agreeable or beneficial.  It
has been found on inquiry that a severe winter is
in this country, and especially in the metropolis,
productive of more disease than a  milder season;
the old and the infirm being  the  chief sufferers,
(Bateman, on the Diseases of London.)
   An especial reference must here  be made to the
beneficial effects of that moderate  degree of the
re-action in weakly persons which follows the ap-
plication  of cold to the surface.  The glow which
pervades  the body, arising  from the increase of the
circulation, is  often at the moment accompanied
by a sensible increase of vigour and activity. The
benefit appears to depend very much on the blood
being thrown in  greater quantity into  the capil-
lary vessels, and on  a consequent increase of tbeir
action in preserving  the well-being of  every part
of the system.   Cold, therefore, in this respect,
seems  to act indirectly as one of the  diffusible
stimulants.  (See the article Bathing.)
   Some  kinds  of diseases of the  skin  are bene-
fited by  cold or tepid bathing.  When there  is
much inflammatory  action of  tbe cuticular ves-
sels, it is desirable to  avoid re-action, and this  is
best accomplished by the use of tepid water, (about
70°,) keeping the body a longtime immersed, and
afterwards preventing the  skin  from getting hot:
in other cases, where an eruption seems to depend
on a torpor of the cuticular vessels, it is desirable
to favour the  occurrence of re-action.
   On the whole, the action of cold on the human
body may be  regarded as very important in a the-
rapeutical point of view ;  it requires, however, as
all remedies do, much judicious management; but
with such management it is every day made the
means of alleviating sufferings and of prolonging

                           John Whiting.
   COLIC, (colica.)   This  term,  derived  from
kuXov, colon, the name given  to the large intes-
tine, is  in its  medical application  restricted to
cases  in which there is pain in the bowels, obsti-
nate constipation, and  generally  vomiting, but
without symptoms of pyrexia.   The pain which
accompanies enteritis and  diarrhoea is denominat-
ed tormina, or griping.
   Symptoms.—In cases of colic, although there
 ie no  tenderness  at first, the  attention  of the
patient is soon attracted by pain which is gene-
ia!ly felt  near the umbilicus and in the lower part
of the abdomen, though sometimes  over the whole
belly.   In most cases it is relieved  by pressure, so
that the patient endeavours to get relief by lean-
ing upon his folded arms, or upon  the edge of a
bed, table, or chair ; sometimes by  lying with his
weight upon  the  abdomen.  The  pain, however,
may be increased  on pressure.   Dr. Abercrombie
states that an  intestine which has become rapidly
Jistcndcd is painful on pressure, though bv a'^n-
COLIC.                                 459

tion the kind of pain can generally be distinguish-
ed from the acute tenderness of peritonitis.   The
pain, although constant, comes on  in paroxysms,
accompanied by a sense of twisting or wringing,
especially  about the  navel.   The abdomen is
sometimes retracted, or drawn  inwards; and oc-
casionally the partial spasmodic action of the ab-
dominal muscles gives  an idea of the formation of
balls or knots in the belly.  In other instances the
abdomen feels tense, elastic, and sonorous on per-
cussion, from accumulation of  flatus, which, after
passing through the intestines with a rumbling
noise, is expelled,  temporary relief generally fol-
lowing its  expulsion.   These  symptoms  are
usually from the  first  attended  with vomiting,
which is often so incessant, that whatever is taken
into the stomach is sooner or later rejected;  and
in severe cases,  from an inverted peristaltic a"tion
of the duodenum, the vomiting assumes a bilious
character.
   A variety of this disease, called flatulent colic,
is very common in dyspeptic persons, more par-
ticularly in those  who are ill  nourished, or who
are addicted to the use of spirits; and in children
who are improperly fed, or whose bowels  are dis-
ordered.  In this form there is  little sickness, and
seldom constipation, but painful retention of flatus
in the bowels, the colic depending principally upon
debility of the muscular  fibrfs  of  the  intestines.
Another very painful affection of a similar nature,
which is not unfrequently mistaken for the effects
of gall-stones, appears to depend on flatulent dis-
tention of the upper part of the intestinal canal—
the duodenum and jejunum.  In cases of this de-
scription,  the  pain is felt chiefly in the  right
hypochondrium, often extending to the back ;  and
in consequence of the pressure on the ductus com-
munis choledochus, wbere it perforates the  duo-
denum,  the  flow  of bile is interrupted:  hence
these attacks are often  accompanied or succeeded
by symptoms  of jaundice.  In  such cases, on the
subsidence of the pain, there is usually a percep-
tible movement  of  air in  some part of the  intes-
tines, accompanied  by  a gurgling noise and  dis-
charge  of  flatus.   The pain occasionally  ceases
entirely, but recurs at irregular intervals, varying
from an hour to a day or two.  This  distention
of the duodenum and jejunum  is occasionally ob-
served in dyspepsia,  and in these  cases bilious
vomiting generally  takes place.
   When inverted  action  takes  place throughout
the greater part  of the  alimentary canal, not only
the contents  of  the stomach and small intestines
are discharged by vomiting, but those also  of the
large intestines.  The vomiting is then termed
stercoraceous, and  such  cases  an; denominated
ileus, or the ileac passion.
   The bowels, both in colic and ileus, are  obsti-
nately constipated ; so that ordinary doses of ape
rients do not act.
  At the commencement of the attack, the tongue
is white, clammy, but  soon acquires a thick coat-
ing or fur.  The pulse is often natural, sometimes
rather slow ;  but when the pain is excessive, or
when the symptoms do not yield to the remedies
adopted, it becomes quick, and  the  skin hot, indi-
cating the threatening or supervention of inflamma-
tion of the. bowels:  hence the occurrence of febrile
sv-^r^ low in coijc sho<i''l  never be overlooked 
460
COLIC.
  Several divisions of colic, founded on the sup-
posed causes of the disease, have been proposed
by systematic writers.   Thus Cullen has enume-
rated  no  fewer  than seven varieties.   1. Colica
spasmodica,  characterized  by  retraction  of the
umbilicus and  spasm of the abdominal muscles.
2. Colica stircorea, arising from  accumulation of
the contents of the bowels.  This form occurs in
costive habits, and is speedily  removed by active
cathartics, which often  expel an  incredible quan-
tity of faeces.   3.  Colica meconialis is  applied to
the spasmodic  pain of  the  bowels which infants
suffer from retention of the meconium: it is evi-
dently a modification of the last variety (sterco-
rea).   4.  Colica accidentalis implies the origin of
the disease from acrid  ingesta, and is frequently
induced in individuals by particular articles of diet.
5.  Colica callosa, in which there is a feeling of
constriction ascribed to some fixed part of the in-
testines.  6. The colica calculosa arises from the
formation and retention of intestinal calculi.  And,
7.  Colica pictonum, produced by the poisonous
effect of lead on the system, which will be after-
wards particularly considered.
   All writers appear to agree in the opinion, that
during the continuance  of colic there is some
cause which impedes  or  obstructs the passage of
the alimentary  contents.   It is with  reference to
this obstructing caufe that disputes among practi-
cal writers have arisen.   The solution, however,
of these  discrepancies will be found  in  the fact
that the  symptoms of  colic originate in a variety
of causes. Cullen was of opinion that spasm was
the essential cause of colic, and founded his varie-
ties of the  disease on the supposition that the
spasm is the result of the operation  of different
agents on the  muscular  fibres of the alimentary
canal.  Dr.  Abercrombie, on  the  other  hand, at-
 tributes the symptoms  of colic to a certain loss of
 the muscular power in a  portion of the intestine,
 in consequence of which it does not act in con-
 cert with the other parts, but becomes distended
 by the impulse from the parts  above, which in the
 healthy state would have excited it to contraction.
 He therefore infers that in colic  the distended part
 is  the real seat of the disease, and that the con-
 tracted part  is not contracted by  spasm, but merely
 collapsed, because it is empty, its muscular action
 being unimpaired.
    It appears to us that the symptoms of colic may
 be referred to one of the following causes; spasm,
 obstruction, over-distension, inverted action.  Al-
 though Dr. Abercrombie  calls in question the pos-
 sibility of spasm  occurring in the  muscular fibre
 of the intestines, he cannot be said to have proved
 this point;  he has, however, made it clear that,
 in many instances where colic has been supposed
 to arise from spasmodic  contraction of some part
 of the bowels, it ought to have been referred to
 another cause.   It would require numerous facts
 to show  that all  muscular fibres are not occasion-
 ally liable to a state of spastic contraction; and it
 cannot be fairly doubted  that, when irritating mat-
 ters are passing through  the bowels, such matters
 may cause an  undue  degree of contraction, so as
 to obstruU the passage of the contents of a portion
 of the tube which is  above the point of contrac-
 tion.   We can in no  other way explain the occa-
  sional production of colic from acrid ingesta.  We
know, however,  that  obstruction  giving rise to
colic, often  arises from  organic diseases, such as
stricture in some portion of the intestine ; various
morbid growths in the intestinal canal diminishing
its  calibre;  from hernial protrusion or internal
hernia;; intussusception or invagination ; twisting
of the bowels, or a long band of organized lymph
encircling  them, forming a ligature.  Colic also
sometimes originates in adhesion between the ad-
joining portions of intestine,  between  the intes-
tines and other viscera, or between the intestines
and the parietes of the abdomen.   Moreover, ob-
struction and a consequent attack  of  colic may
arise from mechanical causes, such as collections
of  hardened faeces, calculous  concretions formed
in  the intestines, large  gall-stones, or  hard  sub-
stances which have been swallowed  and become
impacted in some part  of the alimentary canal,
Many of these  latter  causes may act in conjunc-
tion with spasm ; indeed it is probable that spasm
will, as Dr.  Cullen supposes, often be induced by
their presence, and that  thus hard  substances may
be arrested in their progress downward by exciting
a spasmodic action of the muscular fibres arounij
them.
    It is  also plain, when any of the causes of ob-
 struction just mentioned occur, that by the deten-
 sion of the  gaseous fluid, or solid contents of the
 bowels above the point of obstruction, over-disten-
 tion of the  intestines must ensue, the peristaltic
 action become  inverted, or their  muscular power
 altogether lost, as happens in an over-distended
 urinary bladder.   It is  an interesting subject of
 inquiry, whether, independently of any obstruction,
 the muscular power of any part of the intestines
 may sometimes become  so  paralyzed as to be in
 capable of propelling its  contents onwards; and
 whether from this cause over-distension can take
 place to such a degree as to cause colic.  Dr. Aber-
 crombie, we have seen, has pronounced it  to be
 his belief that the  muscular action is entirely de-
 stroyed, the part  which has been distended falling
 flat when it is emptied, and  presenting a broad
 surface like an empty bag, without any tendency
 to contraction.   He gives a case in which the pa-
 tient lived for eighteen hours, with a free external
 opening directly communicating with the distended
 intestine, but without any discharge taking place,
 though the part contained only air and fluid faeces,
 and in which, notwithstanding  the intestine for a
 considerable space above the  opening must have
 been entirely deprived of its muscular action: on
 examination after death the part presented only a
 uniform distension, without any remarkable change
 either in colour or texture.  Dr. Abercrombie there-
 fore concludes that such want of power is the
 common, if not the constant cause of this disease.
 He  gives  also an interesting case,  accompanied
 with painful local distension, in which, after resist-
 ing the most active purgatives,  galvanism succeeded
 in procuring copious evacuations.   Cases of colic
 are, no doubt, daily observed, which appear to
 arise from this cause; and it  is probable that this
 debility of the  muscular  fibre produces, in many
 cases, the painful gaseous distension which often
 succeeds to enteritis or violent diarrhoea.  Is it not
 probable that colic from the effects of lead is pro-
 duced in this  manner ?  Lead when applied ex-
 ternally does unquestionably  destroy the tone of 
COLIC.                                      461
the muscular fibres of the limbs;  and it would be
a very remarkable circumstance, if the same agent
caused  paralysis  in  one part of the body  and
spasm in another.  This species of colic, therefore,
(colicapictonum,) may be adduced as a presumptive
proof of the accuracy of Dr. Abcrcrombie's opinion,
viz. that the symptoms of colic  may require for
their production nothing more than  the  loss of
tone of the muscular fibres  of some portion of the
intestinal canal.  In these  cases the part of the
intestinal tube which is affected  will, from want
of power, be incapable of propelling  its contents
onward ; and thus by continuing to receive with-
out being able to transmit them, the portion of
intestine becomes more and  more distended, and
at length the whole  tract above  the point of the
accumulation  assumes an  inverted action.  Dr.
Abercrombie thinks  that this loss of tone in  the
muscular fibre may  be caused  by  rheumatism ;
 and as  it is well known that colic often succeeds
 to exposure  to cold, this theory is plausible.
   In colic  arising from spasm  of some  of the
 fibres of the muscular coat of the bowels, or by
 mechanical  obstruction, the same distension and
 inverted action may take place; only in such cases
 they are the result of the obstruction, and not of
 the debility.  It has been asserted by some writers,
 that an inverted action of the whole or of part of
 the alimentary canal, may be produced  independ-
 ently of either  debility, spasm, or obstruction :
 they adduce, in proof of this opinion, the speedy
 discharge by tbe mouth of fluids which have been
 thrown into the bowels by  clyster.  These last
 are called cases of simple ileus, and  perhaps the
 evidence adduced to prove the existence of such
 a state is still open to controversy.
   Morbid Anatomy.—In the preceding account
 of the history of colic, it has  been shown that the
 symptoms are  dependent on a variety of causes,
 many of which are removable ;  but those cases in
 which the colic or ileus is  merely symptomatic
 of incontrollable organic disease in the alimentary
 canal, are beyond the possibility  of removal.   Dr.
 Abercrombie, to whom the profession is  so largely
 indebted for the record of many valuable cases
 and pathological deductions, states that  ileus  may
 be fatal without inflammation, and gives two cases
 in which a large part of the small  intestine was
 found in a state of great and uniform distension,
 without any appearance of inflammation. In other
 instances, besides distension, lividity or incipient
 gangrene has been found, but without any appre-
 ciable change of texture: in some cases the usual in-
 flammatory  exudation was not observed ; in others
 there was vivid redness, and in more advanced
 cases gangrene, with and  without exudation of
 false membrane.  Hence the usual  progress of
 the disease in the fatal cases  is into inflammation
 and its consequences—the inflammation  varying
 from a recent tinge  of redness to extensive  gan-
 grene ;  and it should be kept in view that these
 changes may  be going on in a latent  form  with
 every variety of symptoms.   Indeed we meet with
 cases in which inflammatory exudation has gone
 on to  a considerable extent  before death, yet in
 which there was neither frequency of pulse  nor
 tenderness of abdomen.
   Various  kinds of mechanical  obstruction have
 been found  in fatal cases of  ileus.   The obstruc-
                                      2o*
tion is occasionally connected with disease of the
intestine, with hernial protrusions, with adhesions
between two contiguous portions of intestine ; so
that, as in a case recorded by Dr. Abercrombie. a
turn of intestine insinuates itself between the two
adherent portions.   Various  forms  of internal
hernia, twisting of a portion of the bowel  upon
itself, intus-susception  01 invagination and calcu-
lous concretions (intestinal calculi), have also been
discovered in fatal cases of ileus.
   The  symptoms  of colic  have been  traced  to
various organic changes of structure, which dimin-
ish the caliber of the  intestine.   Under these are
comprehended contraction or stricture of the bowel,
which are situated less frequently in  the  small
than  in the  large  intestines;  various  morbid
growths  or  tumours  having their  origin in the
internal surface of the bowel,  and which  in their
progress gradually  diminish its diameter, till  at
length even liquids do not  pass  through  the dis-
eased or contracted portion.
   The following observations  of Dr. Abercrombie
are valuable from the practical  inferences to which
they  give  rise. " From  a review of the whole
subject, it appears that there is a remarkable va-
riety  in the morbid  appearances in those cases
which are usually included  under the term ileus.
We have  seen simple  distension without any
change of structure, and we have seen even exten-
sive inflammation and gangrene.  We have seen
in several instances the distension apparently tak-
ing place at an early period,  and gradually  increas-
ing through a protracted case,  and then fatal, with
little or no change in  the texture of the part; and
in others, we have seen  at a very early period,
and with  much less distension, extensive inflam-
mation, and gangrene.  It would therefore appear
probable, that in the cases which assume the cha-
racter of ileus, there is great diversity in  the pri-
mary state of the affected parts;  that in  some it
consists of simple loss  of muscular power, though
it may pass  into inflammation  at an advanced
period ; while  in others it  is at an  early period
connected  with inflammation  as a part of the
primary disease. These cases seem to differ from
enteritis in their symptoms chiefly by the absence of
fever; and in the morbid appearances, by being fatal
with simple gangrene, uncombined with the floc-
culent or pseudo-membranous deposition, which
is so prominent a character  of enteritis.  Now
gangrene in the intestinal canal appears  to  be
chiefly a disease of the  muscular coat.   A state
resembling it is indeed observed occasionally  in
the mucous  membrane; but  the  cases in which
this occurs are accurately distinguished by their
own peculiar symptoms, and they do  not affect
this part of the inquiry.  When, in the cases now
under consideration, therefore, we find gangrene
uncombined  with any other  morbid  appearance,
we are perhaps warranted to  conjecture that the
muscular coat has  been the principal seat of the
inflammation.   It seems to  constitute a modifica
tion of disease of much practical importance, quilt:
distinct from enteritis, and assuming simply the
characters of ileus; but a modification of ileus  of
the  most formidable  kind, and very rapidly fatal.
We shall  afterwards  see reason to  believe that
inflammation may be seated in the peritoneal coat
alone, producing a disease which may  be fata! 
462
COLIC.
without  any interruption of the  action  of the
canal,  or that  it may affect  the  peritoneal  and
muscular coat at once, giving rise to the disease
which  we commonly call enteritis."   (Pathologi-
cal and Practical Researches on  Diseases of the
Stomach and Intestinal Canal, p.  140.)
   Diagnosis. — It is  necessary  to distinguish
colic—1. from enteritis ; 2. from hernia ;  3. from
obstinate vomiting,  sympathetic of disease in some
distant part.
   The absence  of  fever, the pain being generally
relieved  by pressure, the  aspect  of the  counte-
nance, and tbe quiet soft pulse, will generally dis-
tinguish colic from  enteritis.   It is however never
to be  lost sight of, that enteritis may not only
exist, but may be proceeding to a fatal termination
without frequency  of the pulse or abdominal ten-
derness.  On the other hand, there may be abdo-
minal  tenderness from simple distension of a por-
tion of the intestine, but without  inflammation.
The stage of the disease must also be taken into
consideration;  though in the primary there  may
be no  inflammation, in  the more  advanced  stage
it may supervene, and thus prove fatal.
   When the symptoms of colic arise from a her-
nia, the protrusion  will  generally lead to its detec-
tion; besides, there is no pain in the beginning at
least, and when it  does occur, it is more  circum-
scribed, and  the  tenderness does  not extend over
the abdomen until  the hernia has existed  some
time, and has become strangulated.
   There are many  diseases accompanied by sym-
pathetic vomiting,  which may, without sufficient
care, be confounded with colic.  The sympathetic
vomiting may  arise from renal  or biliary calculi,
but in these cases there  are some local signs of the
origin  of the affection; in the  former case, pain
of the back, and along the groins to the testicle
and thigh, and disorder of the urinary functions ;
and in the  latter, a greater disturbance of the
functions of the liver, together with pain chiefly
felt in the situation of the gaH-ducts; besides,  in
neither of these diseases  is there the same obsti-
nate constipation of the bowels as in colic.
   [In  the form of colic,  generally termed 'bilious,'
a vitiated condition of the bile has commonly been
considered the cause;  but in the mass of cases
this is certainly a secondary result.  The disease
consists, essentially, in  great impressibility of the
nerves of the digestive tube, under which a neu-
ropathic condition  is induced : this extends to the
liver, which, under the erethism, increases its se-
cretion ; and, in like manner, an increase, and a
morbid condition of the different  intestinal secre-
tions are occasioned.  In this form of colic, prior
to the  appearance of the characteristic symptoms,
the patient usually suffers under symptoms of dis-
ordered stomach and intestines, bitter taste, yellow
fur on the tongue,  nausea, vomiting, &c.  When
the colic occurs, the pain  is excessively severe,
cutting and  screwing.   The thirst is great, and
anxiety and  restlessness are attendants.   After a
while, bilious vomiting supervenes, and the bowels,
which  had  been  previously confined,  or with
scanty discharges, are evacuated freely—the faeces
being  largely mixed with  bile.   The symptoms
then gradually abate, and terminate in entire re-
storation to health.   Very frequently, the disease
i- attended with fever,  and the severest forms are
apt to end in  inflammation of the intestines and
death.   (Practice of  Medicine, 2d edit. i.  163:
Philad.  1844.)]
  Prognosis.—The prognosis in this  disease
must depend principally on the nature of the ex-
citing cause.   When  it arises from acrid ingesta,
such offensive matters will generally pass sponta-
neously  or  by  proper treatment, and thus the
symptoms will  cease.   When,  however,  hernia,
intus-susceptio, stricture, or organic disease, pro-
duce  an  obstruction,  of course  the danger  is in
proportion to the hazard arising from the  disease
on  which the colic depends ;  the  symptoms  of
colic, in such  instances, being entirely symptoma-
tic  of the primary affection.   But, as we  have
seen, it  is by  no means an  easy task, nay,  often
impossible, to distinguish the cases originating in
such obstructions from those which are less  dan-
gerous ;  and the prognosis should therefore not be
formed  hastily in any  case.
   It has been  observed by Dr. Abercrombie, that
ileus has been fatal  while  the contents  of the
bowels  were of a natural appearance; and when
obstruction has existed, its entire removal has not
been  followed  by   corresponding  relief of  the
symptoms.
   Treatment. — We have seen that colic  may
depend  on causes which are capable  of removal,
as well  as on  incurable organic disease : and the
symptoms in  both classes of cases being nearly
similar,  it is  impossible to  ascertain  whether  or
not  the  colic  depend  on causes  capable of being
removed: we  must proceed on  the  supposition
that the disease is still capable of being controlled.
It is  always,  however, a necessary precaution  to
ascertain  that the  symptoms do not  arise  frotr
hernial  protrusion, as it has not unfrequently
happened that hernia, which has been the cause
of the symptoms,  has been overlooked, and the
life of the patient thus exposed to danger.  When
the practitioner is satisfied that there is no hernial
protrusion,  or that  there  is no evident external
cause to  account for  the symptoms, it will  be a
safe practical  rule  in  all cases of obstinate colic,
more particularly if the pulse  rise and there be
tenderness of the  belly, and  the powers of the
patient  do not  forbid  it, to abstract  blood,  both
with  the view of anticipating  inflammation,  oi
subduing that which is to be apprehended, and as
a powerful means of procuring the  evacuation of
the bowels ; the syncope, which generally follows
bloodletting, especially if performed when the pa-
tient is  placed  in the upright posture, being often
accompanied  with  this effect.  The bloodletting
may therefore be carried to this extent in all cases
where the patient  is vigorous, and even repeated
if the state  of the pulse  and other symptom!
require  it.
   In persons who are  weak, and in elderly people,
however  <]ue  consideration must be given as  to
the expediency of bloodletting.  In  such cases
the topical abstraction of blo<»i  may be more ad-
visable.
   It is a matter of nice practical inquiry, how far
the intestines  should be stimulated by purgatives:
on this  point Dr. Abercrombie truly observes thai
the adaptation  of the  remedies to the individual
cases demands  the utmost  discretion: it is im-
possible  to  lay down  any general rules.  There 
COLIC —COLICA  PICTONUM.
463
 are some  cases which yield at first to a powerful
 purgative, and there are  others in which an active
 purgative  is decidedly injurious.   [Dunglison's
 Practice of Medicine, 2d  edit.  i. 163 : Philad.
 1844.]   With these sentiments our  individual
 experience leads us to concur, as well as with the
 plan of administering, at short intervals, moderate
 doses of mild  aperients.  Sometimes large doses
 of calomel, eight, ten, or even twenty grains, will
 remain on the stomach, and in the course of a
 short time move the bowels ; in other instances
 very small doses of purgatives  in combination,
 and  frequently  repeated,  answer this purpose.
 Purgatives will often operate best when combined
 with sedatives, and this is explained by the effect
 of the sedative taking off resistance by allaying
 undue contraction  in the  muscular fibres of the
 intestines, while  the purgative excites the general
 peristaltic action,  and  increases the  secretions
 from the mucous membrane.  Calomel combined
 with opium may be given  with advantage  every
 second hour for three or  four times, and then a
 full dose of castor oil.  If  the oil be rejected  by
 vomiting, it may be repeated with the addition  of
 twenty or  thirty  drops of laudanum, and an ene-
 ma, containing castor oil and laudanum, be ad-
 ministered to assist the operation of the aperient.
 In some  cases attended with most obstinate vo-
 miting, we have seen a drop of croton oil rubbed
 on the tongue, and  repeated  six, eight, or ten
 times, at intervals of  half an  hour, procure solu-
 tion of the bowels when  every  other  purgative
 had been rejected as soon  as  it had reached the
 ttomach.
   While we endeavour to act on the bowels by
 aperient medicines given by the  mouth, and also
 in cases in which they are at once  rejected, it  is
 expedient  to stimulate the  colon by injections :
 these may consist  of a  combination of  various
 purgatives  in common use—infusion of senna,  to
 which may be  added neutral salts, cathartic ex-
 tract, croton  oil, turpentine,  &c.  The forcible
 injection of a large  quantity (five or six pints) of
 warm water, in which soap  has been  dissolved,
 has proved successful.  The tobacco glyster has
 been  administered  when the ordinary   remedies
 have  failed.  It should be exhibited with much
 caution.   Dr. Abercrombie recommends that the
 enema should be  made by infusing fifteen grains
 of tobacco  in six  ounces  of boiling water for ten
 minutes.  If no effect has been produced by this
 injection after  the  lapse of an hour,  it may be
 repeated in the strength of one scruple to the
 same  quantity  of water ; and so  on, until such
 effects are  produced (slight  giddiness,  muscular
 relaxation,  &c.) as  show that  its peculiar action
 on the system  is taking  place.   It may then be
 repeated at intervals of one or two hours, if the
 case do not speedily yield.   With  these precau-
 tions he states  that be has seldom seen any un-
 pleasant effect  from the free use of this powerful
 remedy.  He adds, if while the tobacco  injection
 is  used in  this manner,  mild  purgatives, such  as
 aloes and hyoscyamus, are  repeated in  full doses
 every hour  or two,  the treatment is perhaps that
 which is most generally adapted  to the  ordinary
cases of ileus, with  the assistance of one or two
bleedings if the symptoms require it,  and  espe-
cially if the patient be of a M\  habit.   Opiates
 are very often useful in colic to allay pain.  After
 a full bleeding, when there  is tenderness, the ad-
 ministration of a full  dose  of opium, combined
 with an aperient, or thrown into the rectum  by
 glyster, is often followed by relief of the pain, and
 evacuation  of the bowels.   Still,  however, from
 the tendency of opium to diminish secretion  and
 to suspend the peristaltic motion of the intestines,
 it  should not be  indiscriminately prescribed, but
 only  when there are paroxysms of severe  tormina.
 In these cases it should either be combined with
 a purgative, or, if given alone, it  should be fol-
 lowed by some aperients.
   There are other measures which should be put
 in force :  the warm bath;  hot fomentations, to
 which  laudanum may  be  added : large blisters
 or oil of turpentine may also  be applied  to the
 abdomen.
   When the  means  recommended  have  failed,
 some physicians have  advised the administration
 of crude quicksilver in doses  of one or two pounds.
 Sometimes  the sudden  dashing of cold water  on
 the extremities, and  the application of cold  to the
 belly, have afforded relief by  procuring evacuation
 of the bowels.  These are severe  measures, and
 are only  to  be adopted when  the  disease  has
 resisted every other plan of treatment.
   In  cases  in which  the  colic depends on in-
 curable organic disease, all  measures  are alike
 unsuccessful.  The  patient  is generally,  under
 such  circumstances, speedily  relieved of his suffer-
 ings by death ; though in some instances  life is
 protracted for  an  uncertain period, during which
 the unhappy victim  endures  the greatest agony.
 The only resource left  is palliation by narcotics,
 and other means calculated to soothe the sufferings.
   [In bilious colic, the great indications ot  treat-
 ment  are, first, to remove the spasmodic condition
 of the canal; secondly,  to evacuate morbid  secre-
 tions  ; and  thirdly, to prevent the occurrence  of
 inflammation.   In  plethoric and  active habits,
 bleeding may  be  prescribed, with frictions and
 stimulating  cataplasms  to the abdomen;  glysters
 of soap and  water with  laudanum or spirit of tur-
 pentine may be thrown into the colon ; and should
 these  remedies not be  effective, full doses of opi-
 ates may be given  by the mouth or rectum, until
 relief is obtained.  Should  there be danger of the
 supervention of inflammation, blood may be  taken
 from  the  arm, or  leeches may be  applied to the
 abdomen, followed by  the application of a warm
 cataplasm; with mild cathartics, as castor oil and
 laudanum, aided, if necessary, by emollient or ano-
 dyne  enemata.]
            John Whiting.—A. Tweedie.
   COLICA  PICTONUM.—This form of colic
 is generally  traceable to  the  action of lead  upon
 the body, and is so called from  its  occurrence as
 an epidemic at Poictou.  It  has also received the
 names Devonshire colic, painters' colic, plumbers'
 colic.   It  seems  probable, from both  fact  and
 analogy, that  this  metal produces a specific dis-
 turbance of the animal  economy, of whicb dis-
 turbance the symptoms of colic  are only a mani
festation, so  far as  the alimentary canal partakes
 of the disorder. This agent, however,  may pro-
duce  a  local  disease, the  effect of its morbifk
agency showing itself more  strongly in the nan 
COLICA  PICTONUM,
464

lo which it is immediately applied.  Persons who
are employed in lead manufactories,  or  in  smelt-
ing ores which contain  lead, painters, who use
much white lead,  and plumbers  are  more parti-
cularly the subjects of this disease;  but it occa-
sionally happens to patients  who are employing
some of the preparations of this metal for the cure
of disease.  Moreover this form  of  colic has oc-
curred epidemically, and has been (as in the case
at Poictou) supposed to arise  from  the employ-
ment of the acetate  of  lead in  clarifying wine,
cider, and  other liquors.   (See the papers of Sir
George Baker in the Transactions of the College
of Physicians of London.)
   [The principal marks of lead cachexia are said
to be—a peculiar bluish or bluish-grey tinge of the
gums, which sometimes extends  over the mucous
membrane of the mouth generally, and  which has
been regarded by Dr. Burton (Watson's Lectures
on the Principles and Practice of Physic, Amer.
edit. p. 712 : Philad. 1844)  as an infallible proof
of the presence of lead oxide in  the  system ; the
teeth at the same time  become  discoloured, and
affected with caries : there is a  sweetish,  styptic,
astringent taste in  the  mouth,  with  a peculiar
foetor of the breath;  sallowness  of  the skin, and
dull yellow tinge of the conjunctiva, general ema-
ciation,  soft, small,  compressible pulse,  and in
rare cases, a considerable reduction in the number
of  its beats.   Of these symptoms,  the discolor-
ation of the gums and teeth  is most frequent, and
most  characteristic,  and  it  is considered to be
 owing to the deposition of a very minute film of
 sulphuret of lead on  the mucous surface, and on
 the  enamel of the teeth.   It  is important to attend
 to  these  premonitions, for of 1217 cases  of lead
 colic  observed  by M. Tanquerel des  Planches,
 (Traite des Maladies de Plomb:  Paris, 1839,)
 1195 were previously affected with one or more
 of them ; and  in many instances, by attending to
 these premonitions, with temporary cessation from
 work, the threatened attack of lead  colic was pre-
 vented.]
   This affection has more largely fallen under
 the observation of those physicians on the  con-
 tinent residing where it prevails  endemically.  M.
  Ranquc, Physician to the Hotel Dieu  at Orleans,
 has given a clear account of it,  as it occurred be-
  tween the years 1820 and 1826, among the per-
  sons who are  employed in  the  white-lead manu-
  factories at Orleans; and from this  physician's
  account the author  is induced  to  lay before his
  readers the symptoms  of the  disease.   At first
  the patient loses bis appetite; he feels sick, with
  increased discharge  of  saliva from the  mouth ;
  there is disturbance in the nervous system, and
  his nights are restless.  He then vomits  and dis-
  charges every  thing he has swallowed, mixed with
  bile and morbid secretions ; to this  succeeds pain
  in the abdomen, which is at first not constant, but
  returns at intervals, these intervals  being  longest
  at  the  commencement of the disease.  The pain
  is  severe  about the navel, the epigastrium, the
  bypochondrium, the loins, and  above  the crest of
  me ileum.  As the  disease  advances,  the  pain is
  almost constant, but is  usually most severe at
  nignt,  and is not  increased by pressure.  The
  abdomen is generally flat, but sometimes feels as
  if  knotted, n other cases more or less distended.
The disease  is now attended with headach, pain
of the limbs,  especially of the inside of the thighs,
knees, calves of the legs, ancles, and soles of the
feet.  There is no fever ;  the pulse,  indeed, is
often below 60 in a minute.  Constipation of the
bowels is an  invariable symptom, although it does
not always occur at the very commencement; the
bow.els  are excessively obstinate, and when fasces
are 'discharged, they are dry and lumpy.  The
appearance of the urine is generally natural. The
expression of the patient's  countenance indicates
distress, and there is great prostration.  Symp-
toms of inflammation  of the peritoneum occur
now and then at an advanced stage of the disease,
indicated by tenderness  of  the abdomen, frequent
hard pulse, and other  febrile symptoms; and in
some rare instances the cerebral functions are
disturbed.
   The  pain  of the  limbs is sometimes very
speedily  succeeded by  paralysis, but  it is  more
frequently after the severer symptoms have passed
away that the extremities become so affected.
   [The disease, in the large mass of cases, ter-
 minates favourably.  Of 500 cases, treated at La
 Charite, in Paris, only 5 had a fatal issue; and in
 3569 collected cases, there were only  95 deaths,
 or about 1 in 30.]
   The  appearances  presented by dissection after
 death throw but little light on the nature of colica
 pictonum.   Inflammation  of any of the textures
 appears to be  only accidental, and is probably the
 effect, when it occurs, of the strong purges which
 are often used, or of the distension of the bowels,
 which  is usually, if not invariably discovered.  It
 is particularly mentioned by those who have had
 opportunities of inspecting the bodies  of persons
 who have died from the .effects of lead, that the
 bowels  appear remarkably pale, as if the quan-
 tity of the  blood in  the  vessels was less than
 usual.   As  has just  been remarked, the intestines
 are often greatly distended in  some parts, but in
 others they are contracted.   Whether this con-
 traction  is the consequence of spasm, or (as Dr.
 Abercrombie  would say)  only the  natural state
 of  the tube when empty, it  is not easy to deter-
 mine ; and this uncertainty about the cause of the
 contraction  renders  it very doubtful whether  the
 distension is  the consequence of spasmodic  ob-
 struction, or the effect of debility or paralysis; but
 as  we  know that the action of lead on other mus-
 cular fibres  of the body is to destroy their tone, it
 is  the most probable conjecture that those of the
 intestinal canal,  when  affected by this  poison,
 cease to be able to propel their contents  forward,
 and that in this way distension takes place.
    The foregoing history rendera it clear that the
 action of lead upon the system is very  general;
 and it also seems calculated to lead to the opinion
 that the symptoms arise from changes in the in-
  testines, analogous  to  those which are produced
  in  other parts of the body.  The primary impres-
  sion made by  this metallic  poison is probably upon
  the nervous  system, which secondarily  causes a
  change  in  the  blood-vessels  and the  muscular
  fibres.   Upon the muscular and vascular system
  it seems to act as a powerful sedative.   It is pro-
  bable  that it is on account of its sedative action
  on the capillary system that lead is found useful
  in some cases of hemorrhage and inflammation— 
COLICA  PICTONUM.
465
may it not be  from this  same  action upon the
capillaries that the muscles become paralysed 1 It
is a well-known fact that without a due supply of
blood to their texture, the  muscles lose their tone.
The shrunk wasted state, and  the  blanched ap-
pearance of the  muscles of persons who  have
died after having  been paralytic from lead, seem
to  favour this  opinion.   In explanation  of the
primary action  of lead upon the nervous system,
it is difficult to form a reasonable conjecture.  The
acute pains which  are felt at the commencement
o'' the disease in different parts of the body, forbid
the supposition that it acts as a sedative upon the
nerves ;  and the fact that  the  sentient nerves of
the limbs, when  the  muscles  are  paralysed  by
lead,  remain as sensitive as in health,  favours the
same conclusion.
   It  may here with  propriety be  observed, that
after  the first severe symptoms of colica pictonum
have  been removed by free evacuations from the
bowels, there remains usually great torpor of the
alimentary canal,  and that it is probable that this
torpor is the result of a paralytic condition,  more
or less complete, of the muscular fibres which pro-
duce  the peristaltic action of the canal.
   Treatment. — The remarks on the nature of
the disease  tend to show that the treatment of
colic  arising from the  poisonous  effects  of lead
must be regulated by nearly the same indications
as those which  have  been recommended  for the
treatment of colic  from other causes.  The object
is,  first,  to procure a full discharge of the alvine
contents, and afterwards  to restore the bowels to
their  healthy  condition.   Purgatives, combined
with  sedatives,  seem well  calculated to fulfil the
first  intention;  and no  combination  is  better
adapted than that  of calomel and opium in the
proportions  already recommended.  After  a few
doses, a large dose of castor oil,  or  a drop or two
of croton oil may be given ; enemata  also will be
found valuable  auxiliaries;  they should be admi-
nistered  about  the time the purgatives  may  be
expected to  begin to act.   The warm bath, the
tobacco enema,  and the other measures suggested
as useful occasionally in  the cure  of colic, may
here also be employed ; and should  there occur
tenderness of the abdomen, or any of the signs of
inflammation, bleeding from the arm or by leeches
will be required.   Emetics are employed  largely
on the continent.  At the Hospital La Charite, at
Paris, a very complicated plan of cure is adopted,
but which, when analyzed, seems to be analogous
to that which has  been recommended  in this arti-
cle, although strangely pursued :  it  consists of
emetics,  cathartics, enemata, diluents, and ano-
dynes. (See M. Andral on Abdominal Diseases.)
M. Ranque,  in  the memoir already  alluded to, re-
commends, on  the ground of extensive evidence
of its efficacy, the  employment of strong counter-
irritation to the abdomen and back by means of a
plaster  which  contains  cantharides  and  tartar
emetic; and he also  prescribes a liniment,  made
with  some convenient vehicle, containing the ex-
tract  of belladonna, to  be rubbed  on every part
where pain  is  felt; he uses also belladonna in
clysters; and the  same sedative by the stomach,
in  the form of an ethereal tincture,  (31. of the
powdered leaves to f.^iii. of sulph. ether, of which
twenty drops is the dose.)   The only peculiarity
   Vol. I. — 59
in this method of cure is the counter-irritation,
which  may probably with advantage be added to
the list of curative means.
  If the  opinion  be correct that lead acts as  n
powerful  sedative upon the blood-vessels, no mea-
sure can  appear  better calculated  to  meet  this
morbific  effect than  powerful irritants.  It is  a
fact well  established that the paralysis which re-
sults from lead is most effectually treated by the
use of blisters or other stimulating applications to
the parts  affected ; and may  we not,  on the same
principle, (through the medium of the sympathy
which  is so  obviously  maintained between the
surface and the parts contained within the abdo-
men,) hope to rouse the activity of the circulation
of the intestinal canal  by strong irritants applied
to the skin ? When the first urgent symptoms are
overcome, and the bowels have been made  to act,
great attention will be  required  to restore com-
pletely the tone of the digestive powers.  Besides
those means which have been enumerated  as ap-
plicable during convalescence from common colic,
astringents and  stimulants seem  particularly ser-
viceable  when a  patient is recovering from colica
pictonum. Alum in doses of ^-i. with a few grains
of ginger or capsicum, may be taken with decided
advantage two or three times a-day, with an occa-
sional  aloetic  purge.  The  desideratum in this
stage of the  ailment is to restore the tone  of the
weakened bowel; and  this will be most  probably
obtained by the combined effects  of external and
internal  stimulants and astringents,  wholesome
and nutritious food, and a free state of the alimen-
tary canal.
   [Of late years, alum (gr.  xv. to ^ij. every four
or five hours) has been highly extolled, as well as
sulphuric acid lemonade.  M. Gendrin (Videcoq,
art. Colique, in Diet, des Etudes Medicates, Paris,
1830)  affirms, that he  has  cured more than 300
cases, by administering daily from a drachm to a
drachm and a half of sulpburic  acid, diluted in
three or four pints of water.  The cure was effected
in three  or four days. The experience of Gendrin
has  been corroborated  by other observers ; but
others, again, have not been so fortunate.   (See
the  writer's  Practice  of Medicine,  edit.  cit. i.
169.)
   It has been elsewhere shown (Art. Artisans,
Diseases of, p. 175,) that sulphuric acid is largely
used in  many lead works and  laboratories, and
with great success, as a prophylactic]
   The dry belly-ach of the  West Indies is a dis-
ease of  nearly the  same description as the colica
pictonum, and so is the colic of Madrid, mention-
ed  by  Dr. Pascal, (Mem. de  Med. et  Chirurg.
Milit. 1826.)   Dr. Musgrave, of Antigua, has, in
the Medical Repository, 1825,  given a very good
account  of the former of these two diseases which
is so very common among the negroes  of the
West India islands.  He attributes the complaint
to a morbid condition  of the liver;  but,  in the
estimation of the writer of this  article, without
sufficient evidence. The condition of the alimen-
tary canal, which has already been pointed out.
and especially that  portion of it, the duodenum,
which receives the gall-ducts,  seems sufficient to
explain  the disturbance  of the  biliary  function
which he describes.  In the West Indies the dis
ease is attributed to the new rum whicb is drunk 
466
COMA.
by the slaves.   Dr. Musgrave depends principally
on mercury for the cure of this complaint, and
carries it  to salivation, assisted by bleeding and
purgatives.  It is  evident  that this gentleman is
influenced in his plan of treatment by the patho-
logical views he entertains  of the disorder; and it
is a question which no one is better qualified, by
talent and opportunities, than himself to decide,
whether the cure  may not be  accomplished by
mercury more sparingly administered.
                            John Whiting.
   [COLITIS.  (See Dysentery.)
   COLON, DISEASES OF THE.   (See Con-
stipation and Enteritis.)
   COLON, TORPOR  OF  THE.   This dis-
ease is the  source of anomalous symptoms, and,
although generally the result of other morbid con-
ditions, is worthy  of a distinct mention.   Many
pathological phenomena,  commonly  referred  to
the heart and  stomach,  unquestionably acknow-
ledge for their cause this affection.
   Diagnosis.—Torpor of the colon is thus de-
fined by Dr. Copland, (Dictionary of Practical
Medicine, Art. Cojon, Torpor of tbe)—" General
debility, with indigestion ;  slow or irregular state
of the bowels ; distension, borborygmi, or stridu-
lous noises in the  course of the colon ; frequently
pain  or uneasiness,  sometimes with tumours in
some part of this viscus."
   Causes.—Torpor  of  the  intestine  may  be
owing,  at times, to defective action of the system
generally, and of the colon in particular; but not
unfrequently  it appears  to  be dependent upon
narrowness of the canal, which occasions a dila-
tation of the intestine above  the narrow portion,
in which  faeces or air  may accumulate, and give
rise to all the phenomena of ileus ; or by pressure
interfere with the functions  of neighbouring or-
gans.  Occasionally, hard tumours,  painful on
pressure,  exist  in the colon, especially  in  the
ascending portion. The writer has attended many
cases in which various  evidences  of  indigestion
were present, with irregularity in the alvine eva-
cuations ; generally, constipation alternating with
diarrhoea;  great irregularity of the heart's action ;
often intermission of the pulse; giddiness,  appa-
rently from modified  circulation in the encepba-
lon;  and undefinable uneasiness referable  to the
stomach and bowels, which is often relieved by a
moderate dinner,  so that the after part of the day
may  be passed in  comparative comfort.
   Treatment.—This must vary with the  cause,
where  it is appreciable.   When the condition
indicates general or local debility, the preparations
of iron, as the subcarbonate or the citrate,  or the
sulphate  of zinc, may  be prescribed, with the
Russian belt, and  a diet easy of digestion.   This
course  must be persevered in for weeks.  Change
of air should  be  recommended, and the bowels
be kept open by enemata rather than by cathartics.
 Violent purgatives  have always appeared to be
positively  injurious.   Where narrowness  of the
canal exists, it must be treated as noticed under
Constipation-; and when  attacks of enteralgia
supei /ene,  they must be met as inculcated else-
where.  (See Colic.)
   In almost all cases of torpor of  the colon, the
writer ha* found decided advantage from a  gener-
ous diet,  restricted, however,  in  quantity, and
from the use of a glass or two of dry wine, as
sherry, at dinner.   (Holland, Medical Notes and
Reflections, Amer. edit. p. 108: Philad. 1839;
and the writer's Practice of Medicine, 2d edit, i,
155:  Philad. 1844.)
                      Robley Dunglison.]

   COMA, (from ku>, or kcu>, to  lie down,) a pro-
pensity to sleep ;  in pathology, a  suppression,
more or less complete, of the powers of sensation,
thought, and voluntary motion.   This may occur
in various degrees, from a state of slight temporary
drowsiness  and torpor to  one  of profound and1
permanent stupor with general paralysis both of
feeling  and motion.   The  mental powers  alone
may be affected, whilst sensation  and voluntary
motion remain  unimpaired.  There  may be sus-
pension only of some of the intellectual faculties,
as occurs in somnambulism and several forms of
lethargy ;  or  thought, sensation,  and voluntary
motion may be  alike completely abolished, and
life only sustained by  a partial supply of nervous
influence to the involuntary organs. These modi-
fications of disease are easily accounted for by the
natural divisions of the nervous system into parts
having distinct functions.
   Coma is a symptom not  characteristic of any
one condition of the brain, but may exist in con-
nexion with  morbid  actions very  different and
even opposite in their nature.  Nosologists have
on this account been greatly embarrassed how to
dispose of comatose affections in their classifica-
tions of disease, so as  to bring  them under one
head.   By attempting this they have introduced
a degree of confusion  calculated to lead to dan-
gerous mistakes in practice; for comatose  affec-
tions, decidedly connected with  an  inflammatory
condition  of  the  brain, have  been  erroneously
ranged under the class neuroses  or udynamix, to
which classes some other of these affections, ori-
ginating in debility,  legitimately belong.  Coma
may either be  a primary affection, or supervene,
in the  course of other diseases, as a symptom. In
Cullen's system, comatose affections constitute the
first order of the class neuroses, under the title
Comata, which order is divided  into  two genera,
apoplexy and paralysis.   Those affections which
are more especially comatose, such as apopleiy,
carus,  cataphora, catalepsy, ecstacy, and all the
varieties of lethargy,  are included under the first
genus.  Dr. Mason Good, in his Nosology, classes
all the affections characterized  by torpor,  eithei
mental or corporeal, under the genus  carus, hav-
ing six species—asphyxia,  ecstasis, catalepsia, lc-
thargus, apoplexia, paralysis.   The strong sym-
pathy  which the different parts  of the brain and
nervous system have with each other, establishes
a  close connexion between several of these  forms
of coma, and they  not unfrequently pass into one
another.   In the present article we intend to con-
fine ourselves to a  brief description of the charac-
teristic features  of each  of these affections; a
more  detailed  history  of  some  of them will be
given  under separate heads.
   By  lethargy is meant a torpor both mental and
corporeal, with deep  quiet sleep ; it  has a close
affinity to natural sleep, differing chiefly in being
more prolonged, and depending on a morbid con- 
COMA.
467
dition of tbe brain.  This is the slightest form of
coma, and has been termed  also, by some writers,
cataphora.
  Catalepsy, or trance, is a total suspension of
sensibility  and  voluntary motion, mostly also of
mental power :  the pulse and breathing  continue
natural, the muscles are flexible, the body yield-
ing to and retaining  any given position.   (See
Catalepsy.)
  Ecstacy is a total suspension of sensibility and
voluntary motion, mostly also of mental power ;
the pulse and breathing remain natural, the  mus-
cles are rigid, the body erect and inflexible.  It  is
persons of a nervous  temperament and  ardent
imagination, much given to reverie and  deep ab-
straction, who are most  subject to this  affection.
The  power of  attention  appears wholly concen-
trated on one  train of thought  engaging only a
few of the intellectual faculties, whilst the others
remain in a state of  complete torpor.  The pa-
tient  seems to experience, for the time, a high de-
gree of intellectual enjoyment.  This is the de-
 scription of ecstacy given  by ancient writers, by
 some of whom it has  also  been  termed catochus
 and catoche
   There is a complete abeyance  of the  mental
 faculties, of the  external  senses, of feeling, and
 voluntary motion, in the most perfect and aggra-
 vated forms  of coma.   The pulse is  generally
 very  slow, either full and soft, or small and hard ;
 sometimes intermittent, at  others, however,  rapid,
 feeble,  and  irregular.   The  breathing  is  slow,
 laboured, and stertorous, the stertor arising from
 the relaxation and paralysis of the muscles of the
 internal fauces.   There is sometimes dropping of
 the lower jaw and  distension of the  cheeks  at
 each   expiration, with  difficulty of  deglutition.
 The  pupils are dilated and  insensible to the strong-
 est light: in  some cases, however, they are  either
 contracted or insensible, or one pupil is contract-
 ed and the  other dilated.  The surface  of the
 body and the  extremities are cold  and clammy ;
 the patient lies supine, and there are several other
 distressing symptoms indicating the rapid approach
 of death.  This is the form of coma  that  gene-
 rally attends diseases affecting the structure  of the
 brain,—apoplexy, paralysis, meningitis, cerebritis,
 hydrocephalus, &c.   It has been named by some
 nosologists carus.  Others have described  coma
 as a degree of torpor more profound than lethar-
 gy, but less than carus.  Coma is  sometimes at-
 tended with low  muttering delirium, and has then
 been  called  coma vigil;  and  when  resembling
 more a profound sleep, coma somnolentum.
    The attack of coma is sometimes sudden, with-
 out any premonitory symptoms, and it may as-
 sume at once its  most aggravated  character, ter-
 minating speedily in dissolution.  In other cases
 the  loss  of sense and  motion is  less complete,
 and  consciousness returns in a few minutes or
 hours.  There may be a recurrence of the  attack
 in either regular or irregular paroxysms, as  occurs
 in epilepsy.   The invasion  and progress  of the
 complaint are, however, sometimes very slow.  It
 commences by a tendency to drowsiness,  which
 gradually increases until it  reaches the state  of
 complete coma.   It frequently succeeds or  alter-
 nates with convulsions and high delirium, and in
such cases is to be considered a symptom of worse
omen than delirium.
  The most frequent and obvious cause of coma
is pressure on the brain.   A state of perfect coma
can be  produced artificially by applying pressure
to the brain of an animal, and the coma is reliev-
ed the moment  the  pressure is taken  off.   The
brain is exposed  to  pressure  from a  variety of
causes.   Tbe principal of these are, congestion,
inflammation, effusions of blood, pus,  or serous
fluid, organic tumours seated  in the brain, in its
membranes, or on the parietes of the  skull,  frac-
tures of the skull, with depression, &c.  Coma is
perhaps too  frequently attributed to serous  effu-
sion in  the brain, which may exist in a consider-
able  degree  without any coma, more  especially
when it takes place very slowly.   Sudden attacks
of  temporary coma  sometimes  occur  in  conse-
quence of  the distended state of  the stomach and
bowels, compressing the large vessels in the neigh-
bourhood of the heart, and causing an  accumula-
tion of blood in the head.
   Another very important and not uncommon
cause of coma  is a deficiency of nervous energy
of  the  brain.  There are various ways in which
this may happen.   It may take place suddenly, as
the consequence of a violent shock or commotion
given to the brain by a fall  or a blow, causing
some temporary derangement of the contents  of
the head,  and  suspending the operation  of the
nervous principle;  this  is termed concussion.
The same effect  may  be  produced without any
physical cause, by  violent impressions made  on
the nervous centres, and suddenly paralysing, as it
were, the action of the  nervous principle, as some-
 times happens after strong mental emotions, or the
intense pain of severe  operations.  In  such  cases
 the patient sinks  into a state  of profound coma,
 from which  there are instances of his never  re-
 covering ; nature  appearing,  as is remarked  by
 some writers, suddenly to relinquish the struggle.
 Intense cold acts on the brain and nervous sys-
 tem by producing a state of numbness  and torpor
 which  speedily  passes into coma, and  terminates
 in  death.
    This loss of power in the functions of the brain,
 or  in the nervous principle of the brain, may  how-
 ever have occurred very gradually ; and the fact of
 this  being a cause  of coma is a highly important
 one, which, until lately, had been too  much  over-
 looked.  The profession is much indebted to the
 late  Dr. Good  and to Dr. Marshall Hall for hav-
 ing  directed  their attention to  this  principle in
 pathology.  After protracted  attacks of inflamma-
 tory diseases, when the patient, although consider-
 ably weakened, is considered nearly convalescent,
 he sometimes falls into a state of coma, preceded
 occasionally by acute cerebral symptoms.   Chil-
 dren are  particularly  subject to tbis  variety of
 coma  from exhaustion ;  they lie  in  a state of
 insensibility, the  pupils dilated, the eyes open and
 insensible, the face pale, the skin cold, and  the
 pulse feeble ; they may continue for a day or two
 in this kind of stupor, and then recover. We ap-
 prehend, however, that these symptoms have often
 been mistaken for those of hydrocephalus, and
 that death has  been hastened  by the active  treat-
 ment employed.  There are in other cases symT 
463

toms  of considerable  nervous irritation, headach,
delirium, great frequency and irregularity of pulse,
general restlessness,  which  are  sooner or later
succeeded by fatal coma.   This affection has been
observed in persons who had long suffered from
great  mental distress.   Dr. Kellie and Dr. Aber-
crombie have attempted to give an explanation of
these  phenomena, which appears not unreason-
able ;  they suppose that when the general volume
of the blood is  much diminished, that balance of
the circulation in the brain which seems  neces-
sary for the healthy condition of its functions is
destroyed ; that the arteries of the brain  become
contracted  in their caliber, in consequence of re-
ceiving a less quantity of blood ;  but that, as  the
whole quantity of blood in the head  must always
continue nearly the same, a proportionate accu-
mulation  takes place  in the veins and their si-
nuses, producing venous congestion.  The con-
siderable venous congestion  observed in the heads
of animals which have been bled to  death, whilst
the other parts of the  body are blanched, and
drained of their blood, favours this explanation.
Some of the old writers mention a form  of  apo-
plexy analogous to this affection, to which they
have given the  name  of apoplexia ex inanitione.
A state of high mental excitement is in some
cases  followed by collapse and coma.  This hap-
pens  in individuals endowed with a highly sensi-
tive and irritable nervous system, possessing more
imagination than judgment, and  subject  to alter-
nations of great exhilaration and a proportionate
depression  of spirits;   It is persons of this tem-
perament who are generally exposed to attacks of
lethargy, catalepsy, somnambulism, &c. The coma
of hysteria  belongs to  the same class of cases.
   The  use  of  certain medicinal  and other sub-
stances may be followed  by coma, in consequence
of their specific action on the brain  and nervous
system.  This is the case with narcotics and spi-
rituous liquors.  The effects of spirituous liquors
and of some stimulating narcotics, may partly be
accounted for by their causing an increased flow
of blood to the head, and a temporary congestion ;
but, independent  of this, they bave  a  direct  and
specific action on the nervous energy, which they
first highly stimulate and disturb,  and next  appear
to prostrate and paralyse.  This  is what  occurs
in intoxication from alcoholic liquors and opium.
There are  other powerful narcotics, the effect of
which seems to be that of at once paralysing and
extinguishing the nervous energy without previous
excitement, causing  thus almost  instantaneous
death.  This is the mode of operation of the upas,
tobacco, belladonna, &c.  Some narcotics  stimu-
late in small doses, and cause direct stupor in
large  doses.
   Amongst the causes of comatose affections are
to be  mentioned, retrocedent gout, the suppression
of exanthems or old  sores, of the hemorrhoidal
and menstrual flux, &c.  In cases of coma, strict
inquiry into these points should never be omitted.
   The  great practical importance of being  able
to distinguish  accurately between  the different
varieties of coma must appear obvious, when we
consider how widely the causes which have  just
been  enumerated differ from each other in their
nature, and that the most opposite remedies will
be  required  for their removal.   The diagnosis,
IA.

however, in these affections is sometimes involved
in great obscurity ; and when the attack of coma
is sudden,  as the physician is required to act im-
mediately,  he may find himself placed in  a deli-
cate and perplexing  situation, for the life of the
patient may depend  on his selecting the right
course of treatment.
   The important question he will have to deter-
mine is, the exact condition of the brain to which
the  symptoms of  coma  owe  their  existence;
whether they  are to be ascribed  to any of the
causes  of  cerebral pressure, such  as congestion,
effusions of blood, pus, or serous fluid, fractures
of the skull, with depression, &c.; whether sim-
ply to the  weak and  torpid state of the  nervous
energy of  the brain, or whether finally  to both
these causes, and in what degree  they are com-
bined.  Much correct information respecting these
points, and the degree  of danger with which the
case  is  attended, will  be obtained by inquiring
carefully into  the state of the  circulation and
respiration, and into that likewise of the tempera-
ture and sensibility of the surface of the body and
of the  extremities : an accurate account of  the
patient's state of health  previous  to the attack
will sometimes throw  considerable  light  on its
nature.
   In the milder forms of coma, the structure of
the brain  is not  affected; there is  only a slight
degree either of vascular congestion  or of nervous
torpor, or  else a combination of both these con-
ditions.  The patient lies  in a quiet sleep, out of
which he  can  sometimes  be momentarily roused
by calling  aloud or shaking him.   The breathing
is tranquil and free ;  the pulse  soft and regular;
the temperature of the  body natural, and the feel-
ing but little impaired ;  the pupils may be a little
dilated, but retain some  degree  of motion.  This
is the usual condition of the patient in attacks of
lethargy, catalepsy, ecstacy, and in the coma which
follows moral emotions.  When coma supervenes
on gradual exhaustion, the antecedent circum-
stances of  the case, the pallidness of the  counte-  >
nance, feebleness of the pulse, and coldness of the
surface, will sufficiently point out its true nature.
   The characteristic features of the most aggra-
vated form of coma have already been described;
they are generally to be ascribed to  some disease
seriously affecting the  structure  of the brain, or
else  to a  formidable prostration of its nervous
power.   Stertorous breathing has been insisted on
as a  sure  sign of danger ; its  absence  is  not,
however, to be  taken  as a proof of the  reverse.
But we  may lay down  as  a general  rule, that the
danger is  always in  proportion  to  the degree in
which the respiration,  the  circulation, and  the
temperature of the body arc affected.
   The  distinction between the  coma which  fol-
lows  simple concussion of the  brain, and  that
arising from compression in consequence  of frac-
ture and depression of  the cranium, or else effu-
sion of blood on its inner surface without fracture,
has been a point of interesting inquiry with sur-
gical  writers; having principally for its object to
determine  under  what  circumstances  operations
are to be performed in  injuries of the bead.  A
great deal  of valuable information on this subject
is to  be collected  from  the works of Pott, Aber-
nethy, and Dessault.   Cases of slight concussion
CO 
                                          CO]

are  easily  distinguished from compression, the
patient still retaining some degree of conscious-
ness and feeling,  and  the  stupor  being  soon
relieved.  But in cases of very violent concussion,
where  the  prostration of the sensorial power  is
extreme,  the coma is so complete, and the symp-
toms so  closely resemble those of compression,
that the most experienced observers acknowledge
the  difficulty of drawing any exact  line of dis-
tinction between them.   The chief source of ap-
prehension in simple  concussion is the period of
stupor  being followed by one of inflammatory re-
action.
  Abernethy gives  tbe following very graphic
account of concussion, which he thinks  may be
divided into three stages.  The first  stage is that
of  insensibility and derangement of the bodily
powers, which immediately succeeds the accident.
Whilst it  lasts,  the patient scarcely  feels any
injury  that may be inflicted on him.  His breath-
ing is difficult, but in general without stertor; his
pulse intermitting, and his extremities are cold.
But such a state cannot  last long;  it goes off
gradually, and is succeeded by another, which he
considers the second stage of concussion.  In this,
the pulse  and  respiration  become  better, and
though not regularly pel-formed, are  sufficient  to
maintain  life and to diffuse warmth over the
extreme  parts  of the body; the feeling of the
patient is now  so far restored that he is sensible
if his skin be pinched ; but he is stupid and inat-
tentive to  slight  external impressions.  As the
effects  of concussion diminish, he becomes  capa-
ble of  replying to questions put to him in a loud
tone of voice, especially when  they  refer to his
chief suffering  at  the  time, as pain in the  head,
&c.;  otherwise he answers  incoherently, and as
if his  attention was occupied by sometbing else.
As long as the stupor remains, the inflammation
of  the brain  seems to be  moderate ; but as the
former abates, the latter seldom fails  to increase,
and this  constitutes the third stage, which  is the
most important of the series  of effects proceeding
from concussion.   These several stages vary con-
siderably in degree and duration.   Mr. Abernethy
proceeds  to observe that  the treatment must be
different  in each of them, and to caution against
the very  free  use of stimulants in the first  stage,
which is too often prescribed, and  particularly
against their continued exhibition in the  third
stage,  when  a  plan of  treatment  directly the
reverse is required.
  The coma produced by excessive  intoxication
has some similarity to  that of apoplexy, and we
have known this  lead  to ludicrous mistakes, not
very creditable  to  the  practitioners' discernment.
The smell of the breath will  in most cases supply
a sure  means of  avoiding  such errors; in  some
extreme,  though rare instances, actual coma has,
however, supervened.   It is  deserving of notice
that impostors, who feign epilepsy, with a view  to
extort charity, can always be detected by examin-
ing their eyes, when the pupils  will be found in
their natural state  as to size  and sensibility.  In
epilepsy  they are  almost always contracted and
insensible.  In  coma they are generally,  though
not always, dilated, and their sensibility is  more
or less diminished.
  Syncope and asphyxia bear a close resemblance
                                      2p
1A.                                       469

to  coma in many of their symptoms;  they  are
characterized in common  with coma, by the  ab-
sence of sensation  and motion, by dilatation and
insensibility  of tho  pupils,  &c.   They  differ
chiefly, however, in  the state of the respiration
and general circulation.  The primary cause of
syncope is  a diminution  or  temporary cessation
of  the action of the  heart;  the brain being thus
deprived of the usual supply of its natural stimu-
lus, the flow of nervous influence  from the sen-
sorium, which is indispensable for the maintenance
of  all the actions of  life, is suspended, and a
general torpor with other  symptoms of apparent
death is the necessary consequence.  In asphyxia
the circulation is also stopped, through the inter-
ruption of the functions of the lungs.   The  pri-
mary symptoms therefore  in  both these diseases
are a  great feebleness or complete suspension of
the action of the heart and lungs, and the occur-
rence of coma is but secondary ; while, when the
same symptoms  occur in  coma, it is only secon-
darily and in  its  advanced stages.  It is not un-
important to  attend  to these  distinctions, for we
have seen a protracted fit of syncope in a fat cor-
pulent person mistaken for apoplectic  coma,  and
 the adoption  of active remedies nearly, followed
by fatal consequences.
    As the treatment of the various kinds of coma-
 tose affections will be described under their  re-
 spective heads, we intend  in the present article tc
 confine ourselves to some  general observations on
bloodletting  in this  class  of diseases.   When a
 person is suddenly deprived of sense and motion,
 the practitioner sent for is  expected by the alarm-
ed friends to employ instantly some active  and
efficient means of  relief, and  it is a very general
rule with the profession to have recourse at once
to  the  lancet.   Should there even  be  any doubt
in  the mind of the practitioner respecting the pro-
priety of  such a course, he may still be driven tc
adopt it, in deference  to the opinions of the public,
who ignorantly conclude that, because bloodletting
affords relief in some sudden  fits, it is equally
essential in all.  If the patient recovers, The cure
is  attributed to the venesection ; and if he dies,
it  is  hastily  inferred  that  nothing would have
 saved him.   If we turn, however, to a calm con-
sideration of the various and  very opposite causes
of comatose affections, it will appear a most obvi-
 ous truth that nothing can be more contrary to
 the legitimate deductions of science,  and more
dangerous in  practice,  than  this indiscriminate
 and empirical use of the lancet.  It has been seen
that among the causes of coma, some are con-
nected with morbid conditions of the substance of
 the brain, for tbe  removal of which bloodletting
 is the only, if  not  a  sovereign, remedy ; but  that
 on  the  other hand  coma  is  frequently  to  be
 ascribed to a deficiency or prostration of the ner
 vous energy of the brain,  in which case it is evi
 dent that the subtraction of any large quantity ot
the vital  fluid can only have  the  effect  of  pre
venting the powers of the  constitution from rally
ing, and  of thus  turning the  scale against the
patient's  recovery.  We  have little  doubt that
some  of  the  recoveries from coma after  blood-
letting ought to be considered as  lucky escapes
from death, rather  than cures.
   There  are, as just stated, well-marked cases in 
470
COMA — COMBUSTION, (SPONTANEOUS)
which there cannot be a shadow of doubt as to
the propriety of venesection ;  as, for instance,
when the  coma is very profound, with a flushed
face,  hot skin, full and  strong pulse, stertorous
breathing,  &c.  But when  in the  young, the
aged, or  the infirm, there  are evident symptoms
of great debility ;  when the face is pale,  tht  skin
and  extremities  cold, the pulse feeble, the breath-
ing not  much embarrassed, &c,  the propriety
of general depletion to remove symptoms of coma
is more than questionable; all the  relief  that
bloodletting is capable of affording can be obtain-
ed from cupping or leeches, should even  local de-
pletion be thought necessary; and we have  seen
coma depending on cerebral pressure very quickly
relieved  by the  abstraction of  only three or  four
ounces  of blood  from the head; an  apparently
trifling cause being sometimes sufficient to destroy
the balance of the circulation in the brain.
   We are aware that there may be cases in which
the indications both for and against general blood-
letting are so nicely balanced, that it is difficult to
determine which course to pursue.   Under  such
circumstances we must proceed with great  cau-
tion,— and a small bleeding may be tried for the
purpose of  exploring the nature of the case; we
should watch the effects  produced, as the blood
flows;  and in all doubtful cases it is preferable to
 take a  small quantity only  at first, as the opera-
tion  can easily be repeated if judged advisable.
 In coma as well as in asphyxia, when the powers
 of life  are  sunk very low and  appear to  be fast
 ebbing, a favourable re-action is  sometimes pre-
 vented  from taking place by the circumstance  of
 either the  brain  or  the  heart being completely
 overpowered  by an excessive accumulation  of
 blood.   The  timely abstraction  of  a very few
 ounces of blood has sometimes appeared to be of
 essential service in  such  cases, by relieving the
 mechanical oppression of the organ, and enabling
 it to recover a slight degree of action,  sufficient
 perhaps to  lead gradually to  a favourable re-action
 in the other vital functions ;  whilst copious bleed-
 ing unfler similar circumstances would most.pro-
 bably have completely extinguished the remaining
 sparks  of life.
   The  temperature  of the  surface of the  body
 may be considered one of the safest guides with
 respect  to  the propriety of bloodletting, together
 with the state of the pulse and the  action of the
 heart.   We  have  never,  indeed, seen beneficial
 effects  follow venesection, when the  animal heat
 has been very low, even although the strength of
 the pulse might  appear  to  justify its being pre-
 scribed.  The temperature  of the body is, per-
 haps, a safer general criterion of  the exact condi-
 tion of the powers of life than even the pulse;
 for do we not see the arteries pulsating and throb-
 bing with great force and frequency in cases where
 there is an undoubted tendency to  debility and
 sinking]   Whilst,  however,  a  low state of the
 animal temperature is sufficient of itself to coun-
 ter-indicate copious depletion, the opposite condi-
 tion must not always be conceived  to justify the
 use of the  lancet; for a morbid pungent heat is a
 frequent attendant on a state of  great irritability
 of the  nervous  system, characterized  also  by a
 quick throbbing irregular pulse, but indicative of
 a general and dangerous defHency of the powers
of life.  This important point of pathology will
be more fully examined in the article Inflamma-
tion.   We shall conclude therefore by repeating,
that the practice  of bleeding  rashly  and indis-
criminately to a large amount in all cases of sud-
den loss of  sense and motion, cannot be too
strongly deprecated.  A good  papei on this in-
teresting subject, by Dr. Latham, will be found in
the 6th volume of the Transactions of the Lon-
don College of Physicians.
                        Adair Crawford.

   [COMBUSTIBILITY,  PRETERNA-
TURAL.  (See Combustion, Spontaneous.)]
   COMBUSTION,   SPONTANEOUS  HU-
MAN.  When we reflect upon the difficulty with
which the proximate principles of the animal
kingdom are made to undergo  combustion, even
when exposed under the most favourable circum-
stances to an elevated heat, it is not to be won-
dered at that relations of this process having spon-
taneously occurred should have been received with
suspicion and ascribed for a length  of time to cre-
dulity or imposture.  That cases, however, of this
kind have really taken place seems now establish-
ed by indisputable evidence; but while the fact is
very generally admitted, we are still, as in the in-
stance of meteoric stones, at a loss  for an ade-
quate  explanation of it.  Before  entering .upon
an  analysis  of the  different conjectures  which
have been hazarded upon so obscure a subject, we
shall first quote, for the  purpose of illustration, a
few well-authenticated  instances  of  individuals
who have fallen victims to this most  mysterious
of all human affections.
    Cornelia Bandi, Countess of Cesina, an Italian
lady, sixty-two years of age, having felt drowsy one
evening, retired earlier than usual to bed, and was
attended by her maid until she fell  asleep.  When
the girl on  the following morning entered her
mistress's apartment for the purpose of awaken-
ing her, a dreadful spectacle presented itself.  At
the distance of four feet from the bed there was a
heap of ashes, in  which the head, legs, and arms
of the countess alone could be traced.  The head
lay between the legs, but the half of its posterior
part, together with the  brain and  chin, were en-
tirely consumed.  The legs and arms were unin-
jured.  The ashes, which alone remained of the
rest of the body, when touched, left upon the fin-
gers a greasy fetid moisture ; and  a sooty matter
was deposited upon the furniture  and tapestry,
and had even penetrated into some drawers and
soiled  the linen  which  they  contained.  There
was no unusual derangement of the bed, the bed-
clothes being merely thrown aside, as  is the case
when  a person gets up.   The wax of two candles
placed  upon a table near the bed was  melted, hut
the wicks remained unconsumed.  It is deserving
of remark that it  was a constant practice of this
 lady to bathe her body with camphorated spirit
 of wine.   This case was first published by Bian-
 chini, but is chiefly known to the  British public
 in a paper communicated to the Royal Society by
 Dr. Cromwell Mortimer, and which may be found
 in  the Philosophical Transactions for the year
 1745.
    Don G. Maria Bertholi, a friar, who lived in
 Mount Volere,  went to  the  fair of Filetto. and 
COMBUSTION, (SPONTANEOUS)                    471
having walked about all day, retired in the even- I
ing to the house of a relation at Fenile, to spend
the night.  Upon his arrival, he  went direct to ,
his bed-room, and had a handkerchief placed be-
tween his shoulders beneath  his shirt.  In a few
minutes after, having been left alone, a singular
noise,  mingled  with  cries, was  heard  from his
room; and when the people  of the house  rushed
in, they found him on the  floor, surrounded by a
lambent flame, which retired  as  they  approached.
When visited next morning  by Joseph Battaglia,
a surgeon of Ponte Basio, the integuments of the
right  arm were found loosened from the muscles,
and hanging down, and those  of the  back, be-
tween the shoulders  and the  thighs, were in the
same  state. The part of the right arm which had
sustained most injury appeared in  a state of inci-
pient  putrefaction, and  next  day was quite gan-
grenous.  On the third day  there were  thirst, fe-
ver, violent convulsions,  fetid  stools, vomiting,
and delirium; and the gangrene  had  extended to
all the injured parts.   On  the fourth day he fell
into a comatose state, which  lasted two hours, and
then  died.  Battaglia  observed, during his last
visit,  that putrefaction  had commenced, and in-
deed  had  already made  considerable  progress.
The nails had loosened and were ready to fall off.
The stench was insupportable, and maggots crawl-
ed from  the  body at every point.  The account
which the patient gave of his singular attack was,
that he felt a blow upon the  right arm as  if in-
flicted by a club, and  then saw  a spark hanging
to his shirt-sleeve, which immediately reduced  it
to ashes.   The  handkerchief already spoken of,
as  also  his  drawers, were  uninjured; but his
nightcap was consumed, although his hair was
not touched.  There was no empyreumatic smell,
and not a trace of fire or smoke in the room.   It
should also be observed that  the night was  calm,
cool, and-clear.
   A detailed account of this case appeared in the
Allgemeine Literatur Zeitung, for 1786.   It has
been transcribed by most writers on juridical medi-
cine, partly in consequence of its singularity, but
chiefly because  it is  conceived  to illustrate and
support the electrical  theory  of the origin of what
is denominated  spontaneous combustion.  It  is
also remarkable as being the  only well-established
instance of an individual who suffered from such
a calamity having lived sufficiently long  to give
an account of the manner in which  he was at-
tacked.
   Anne Nelis, wife to a  wine and  porter mer-
chant, living in  South Frederick street, Dublin,
let in her husband, who had been out at a partyT,
between twelve and one o'clock  on  a Saturday
night.  After some  altercation  had  taken place
between them, both being in a state  of intoxica-
tion, Mr. Nelis went up stairs to bed,  but in a few
minutes came down to request his wife to accom-
pany him, an invitation which she positively de-
clined ; upon which he took with him her candle,
observing that if she was determined to sit up, she
should do so  in  the  dark.   Next morning the
maid-servant  having  opened the windows  of the
back parlour, observed something in the  arm-chair
in  which Mrs.  Nelis  usually sat, which  she  at
rirst sight imagined to  have been put there by
voung Nelis, who at the instant entered the room,
for the purpose of frightening her.   Upon exami-
nation, however, it turned out to be the remains
of her mistress, who was  found in  the  following
state.  She was  seated in the chair, at a distance
from the fire, which appeared to have burned out,
with her head leaning upon her right  hand, and
bearing behind against the wall.   The trunk  of
the body  was burned to a  cinder, as  also the
clothes which invested it; but  the  pelvic region,
the lower and upper extremities, and  such por-
tions of her dress as covered these parts, sustained
no injury.   Her face had a scorched appearance;
but her bair, and the papers she had put in it, had
entirely escaped.  The back and seat of the chair
had not suffered, but its arms were charred on the
inner side where in contact with the body.  With
the exception of the arms of the chair, the com-
bustion bad  not  extended to surrounding bodies.
The room was filled with a penetrating and offen-
sive odour, which was still perceptible after the
lapse of several days.  This  woman was about
forty-five years of age, of low stature,  had rather
a tendency to corpulence, and was a confirmed
drunkard.   The preceding facts may, we believe,
be depended on, tbough we have experienced very
considerable difficulty in collecting them.  Strange
to say, there was no inquest;  and  such was the
anxiety of the family  to bush up every thing con-
nected with the  occurrence, that  a request made
by  Dr. Tuomy, late  Professor of Physic in the
School of Medicine, to  be permitted to  examine
the body, was refused.
  The following case is  extracted from  the Me-
thodist Magazine for 1809,  as related by a Mr.
Wood, a Wesleyan  minister, then  residing in
Limerick.   " Mr. O'Neil,  keeper  of  the  Five
Pounds Aims-House  in the city of Limerick, was
awakened about two o'clock at night by  a person
knocking at his room door, upon which he arose,
and having inquired who knocked, he opened the
door, and going with the  person who had called
him into his apartment,  which lay under  Mrs.
Peacocke's room, he found a dead body lying on the
ground burning  with  fire, and red as copper, hav-
ing dropt down from the loft, which was on fire.
Examining the loft, he saw a large hole, the size
of the dead  body, burned through the boards and
ceiling.  He instantly ran up  stairs, and having
burst open Mrs. Peacocke's room-door,  saw in the
middle of the room the burnt hole through which
the  body had fallen.  Having with  assistance
quenched the fire about the hole, he examined by
what means  the  body had taken fire,  and could
find no cause.   There was  no candle  or candle-
stick near the place, no fire in the grate but what
was raked in tbe ashes, as is the manner of pre-
serving fire by night; the  room was  examined,
and nothing bad taken fire  but that part of the
floor through which she had fallen.   Even a small
basket made of  twigs, and a  small trunk of dry
wood which lay near the  hole, escaped, and were
not so much as touched by the fire.
  "This phenomenon was the next day examined
by the mayor, clergymen, and  several  gentlemen
of the city.   The  impossibility  of ascertaining
the cause of the fire, the extraordinary circum-
stance of no part of the room being burnt but tne
centre of it, through which  she had fallen, added
to the well-authenticated  circumstance of her in 
472
COMBUSTION.  (SPONTANEOUS)
cent diabolical imprecations and lies, obliged every
observer to resolve  so awful an event into ' the
visitation of God's  judgment in the punishment
of a daring and persevering sinner.' " — It is pro-
per to  add  here, that for the leading facts of this
case we do not rely  solely upon the  Methodist
Magazine.   They have been detailed to  us in a
letter received from  Mr. Wood  himself, and con-
firmed  by an intelligent lady residing  in Limerick,
who personally inspected the floor through which
the hole was burned ;  the  repairs  undergone  by
which  still  point out the  spot at which the per-
foration took place.   We should not omit to men-
tion that Mrs. Peacocke was aboat sixty years of
age, and that  she  indulged immoderately  in in-
toxicating liquors.
  Mrs. Stout, widow of a watchmaker, and mar-
ried a  second time to a man of the name of Hanna,
went to bed one evening in apparent health, and
was found  next morning burnt to a cinder on the
floor of her  bed-room.    When  discovered,  a
vapour was still issuing from her mouth and nos-
trils, and  those parts  of the  body  the  form  of
which  had  not been altered, immediately crumbled
down  upon  being handled.  Her  chemise and
nightcap escaped uninjured.  This  case  occurred
in 1808, at a place called Coote Hill, in the county
of  Cavan.  The subject of it  was about sixty
years of age, and an inveterate dram-drinker.  An
inquest was held, and from the impossibility of
accounting for the  occurrence  upon any known
principle, the verdict was — " death by the visita-
tion of God."
  A. B., a woman of about sixty years of age,
who lived  with her  brother, in the  county  of
Down, retired one evening  to bed with her daugh-
ter, both being, as was their constant habit, in a
state of intoxication.   A little  before day some
members of the family were awakened by an ex-
tremely offensive  smoke which pervaded  their
apartment, and on going into the chamber where
ihe old woman and her daughter slept, they found
the smoke to proceed  from the  body of the for-
mer, which appeared to be burning with an inter-
nal fire.  It was as black as a coal, and the smoke
issued  from every  part of it.   The combustion
having been  arrested, which was  effected with
difficulty,  although there was no flame, life was
found  completely extinct.   While the body was
being removed into the coffin, which was done as
soon as possible, it was dropping in pieces.  Her
daughter, who slept in the same bed, sustained no
injury  ; nor did tbe combustion extend to the bed
or bed-clothes, which  exhibited no other traces of
fire than the stains produced by the smoke.  Ac-
cording to  the testimony of one  of  the relations,
who is represented as a woman of the strictest
veracity, there was  no fire  whatever in the room.
The subject of this case had been grossly intem-
perate  for several days before her decease, having
drunk  at this period much more ardent spirit than
usual.
  For  the  preceding facts we are indebted to the
Rev. Mr.  Ferguson, of Camden-street,  Dublin.
They are given almost exactly in his own words.
He bad professional opportunities of acquaintance
with the family, and  he  states that shortly after
uie occurrence, he  examined the room in which
the old woman had  been  burned,  and  satisfied
himself that the fire had not extended to the bed,
bed-clothes, or furniture.
  From the cases just related, and several others
which  might be quoted from  the writings of Vic
D'Azvr. Lecat, Lair, Kopp, Dupuytren, and Marc,
it would appear fully proved that the human body
is capable of being  reduced to such a state as to
undergo  spontaneously, [?] or upon the contact
of  flame,  rapid  changes analogous   to those
which may be effected by  the  agency of fire.  A
careful examination, also, of the  histories of the
several instances upon record,  has enabled us to
collect, at least with some  probability, the circum-
stances  which  precede, accompany, and charac-
terize this malady ;  for  such it obviously must be
considered.  These we  shall now enumerate, as
they will  serve as  a  guide to our  inquiries re-
specting the immediate  or proximate cause of the
phenomenon.
  1. Spontaneous combustion would  appear to
be a calamity almost peculiar to the old and feeble;
for  it has seldom occurred to persons of a robust
constitution, or under sixty years of age.
  2. Women seem particularly prone to it. Thus,
of the  seventeen cases collected by Kopp, sixteen
occurred  to females, while the  subjects of the
eight cases mentioned  by Lair are all of the
same sex.
  3. Individuals  who have thus  suffered have,
generally speaking, been remarkable for the inac-
tivity of their  habits,  for corpulency, or the oppo-
site state, great emaciation, and for their inordinate
use of spirituous liquors.
  Of the circumstances which distinguish spon-
taneous from ordinary combustion, the following
seem most deserving of notice :—
  1. The combustion spreads with extraordinary
rapidity;  the decomposition  of  the entire body
being usually effected in an extremely short period
of time.
  2. The flame is of a lambent and flickering na-
ture, of a blue colour, very difficult to extinguish
by water, and  not  readily communicable to in-
flammable bodies placed in its vicinity.
  3. A strong empyreumatic odour is usually ex-
haled, and there is found upon adjacent  objects a
fetid and moist fuliginous deposit, of a greasy
nature.
  4. The trunk is generally  entirely consumed,
but portions of the head and extremities are occa-
sionally left uninjured.
  Before examining the theories which have been
advanced in explanation of spontaneous human
combustion, it will  be  convenient  to  define in
what ordinary combustion consists, and the con-
ditions indispensable to  its production.   We shall
thus be  the better  prepared to pronounce upon
received hypotheses a correct and impartial judg-
ment.
  When  any two forms of matter, whether they
be simple or compound, combine chemically with
the  evolution of heat and light, combustion is said
to have taken  place.  In order, therefore, to the
production of tbese phenomena, the contact of at
least two dissimilar principles, having for  each
other a strong affinity, is  essential.  Combustion
may thus obviously result from the chemical ac-
tion of a variety of principles;  but, in all ordinary
cases, one of the substances concerned is oxygen, 
COMBUSTION,  (SPONTANEOUS)
473
and the other carbon, or hydrogen, or some com-
pound of both these elements.  If to these we add
sulphur  and  phosphorus,  which  are associated
with the preceding as component parts of animal
bodies, we shall have enumerated all the elements
with which we  can have any thing to do in our
present discussion.
  But the mere contact of oxygen with a com-
bustible is seldom, of itself, sufficient to determine
union, much less union with the development of
heat and  light.  Carbon and sulphur may be en-
compassed by oxygen, and  hydrogen mixed with
it, without the occurrence of any chemical action;
and  though this is not true of phosphorus, the
union of which with oxygen takes place at the
usual temperature of the atmosphere, yet the pro-
cess is slow, and visible  flame is altogether want-
ing.  These  observations  are  equally applicable
to the compounds which  the  combustibles form
with each other, with a single exception.   All of
these but phosphuretted hydrogen, which inflames
upon mere contact with oxygen gas, require,  in
order to accension, the application of a somewhat
elevated heat.  Neglecting, therefore, for a mo-
ment, this particular compound,  it may be laid
down that tbe conditions of ordinary combustion
are two-fold:
   1. That the  combustible be in  contact with
oxygen.
   2. That its temperature be considerably raised.
   Now  the human body  is a  combustible com-
pound, and is constantly surrounded by an elastic
medium, one-fifth of whose volume is pure oxygen
gas.  One of the conditions, therefore, necessary
to combustion,  is here fulfilled; and experience
tells us that the co-existence of the other, that is,
of a sufficient heat, will actually determine accen-
sion. But the human body, at least in a state of
health, does not spontaneously take  fire ;  and we
 also know that  when heat is applied to any parti-
cular part  of it, the mischief done is local, and
does not  extend to remote  organs.  In reference,
therefore, to the subject  of  this article, two ques-
tions present themselves for solution.
   First, whence arises that extreme degree of in-
flammability  of the human body,  in virtue of
which its combustion is so readily produced, and
occurring  at  any one point, is propagated with
rapidity  to distant parts ?   And,  secondly, how
does the combustion  commence — what  is  the
origin of the first spark ?
  As to the  cause of the preternatural combusti-
bility of the human body,  the opinion generally
entertained is, that it is  to  be  found in the alco-
holic impregnation, which,  as is alleged, invaria-
bly accompanies such a state.  In support of this
doctrine, it is affirmed that individuals who die of
intoxication emit at every point a  strong smell of
spirits; that the colour  of  the  flame  afforded by
the latter is precisely the same as that which has
been observed in cases of spontaneous combustion;
and, lastly, that all who  have fallen victims  to
this calamity have been remarkable for the immo-
derate use of intoxicating liquors.
  That the bodies of drunkards may become,  as
it were,  soaked with  alcohol,  seems fully esta-
blished by  observation.   Thus, Breschet found
the  different  tissues of  the bodies  of criminals,
opened shortly  after their  execution, to evolve a
  Vol. I. —60                      2p*
strong smell of eau-de-vie; and a similar observa-
tion has been made by Dumeril and Cuvier upon
the body of a  labourer, at the Garden of Plants,
who had died  from the effects of  a large quantity
of wine, which he  had drunk for a wager.  Dr.
Marc  also mentions the  case  of a shepherd of
Laliowitz,  addicted to  excessive drinking, who
during  his  last illness was constantly affected
with eructations of an inflammable nature, and
which emitted a strong alcoholic odour.   Some,
indeed, adopting an ancient physiological dogma,
that, however the ingesta may vary, the chyle is
always  the  same, deny the possibility of alcohol
entering the circulation unaltered.    It  should,
however,  be recollected that  many  substances,
such as the colouring matters of madder and rhu-
barb, and the odoriferous parts of musk, camphor,
and garlic,  do certainly  resist the assimilating
powers  of the digestive apparatus, and re-appear
unchanged in  the secretions.  Nor are such facts
even  opposed  to  the opinion to which allusion
has just been made.   These substances may enter
the blood directly  by the veins, which are now
known  to exercise the function of absorption, in-
stead  of reaching  it through the  circuitous route
of the lacteals and thoracic duct.
   But  the  theory  of alcoholic impregnation is,
per se,  quite insufficient.   When a healthy indi-
vidual dies of intoxication, his body is found but
little,  if at all, more inflammable than if he had
perished from any other cause; and if the flame
of a candle be applied to an anatomical prepara-
tion just removed from the spirits in which it has
been preserved, after the combustion of the alcohol
has ceased, the surface of the preparation alone
will be found burned.
   From these considerations it appears pretty cer-
tain, that though  the human body  may to a cer-
tain  extent become impregnated with alcoholic
vapours, its combustibility will not,  by this alone,
be  materially augmented; and  that,  therefore,
when a great tendency to combustion  exists, it
must be the result of some peculiar pathological
state.   In what this state consists, it  is probably
impossible,  with any accuracy, to  assert  in the
present state of our knowledge;  but  every thing
which we know upon the  subject justifies us in
inferring that the causes which produce it are such
as have most influence in reducing the powers of
life and enervating the system.   Thus it occurs,
as we have seen, almost exclusively to people ad-
vanced  in  years,  and of  constitutions broken
down or enfeebled by intemperate habits.
   A theory of preternatural human combustibility
has been more recently advanced  by Dr. Marc,
which appears better sustained by facts than that
of alcoholic impregnation.  This learned  physi-
cian, who has apparently studied his subject with
great  attention, contends  that the combustion is
owing to inflammable gases which are, in such
cases, developed throughout the system.
   That inflammable gaseous products are usuallv
present in the stomach and intestines,  in health as
well as in disease, is a fact well known  to the
physiologist;  but it seems difficult to admit that
these  can be evolved in tne different  tissues uur-
ing life  ; for such an opinion would appear to in-
volve  the possibility  of the occurrence  of some
degree of spontaneous decomposition antecedent 
474                    COMBUSTION,  (SPONTANEOUS)
to death.   There is, however, sufficient evidence
that this has occasionally occurred.  Besides the
case of Father Bertholi already detailed,  several
others to this effect might be quoted.   We shall,
however, confine ourselves to the following, which
is of recent date, and quite to the purpose.
   A man ill  for fourteen days with beadach and
colic pains, followed by an attack  of diarrhoea,
which lasted three days, was taken by M. Bally
into the Hotel-Dieu.  Upon entering the hospital,
his left thigh and scrotum  were  swollen, and his
respiration was short and impeded ; but he com-
plained of nothing but weakness of  the lower
limbs.  During a fit of delirium, which lasted a
few minutes, he spoke of having been bitten by a
dog in the leg ; but upon examination no mark
of any such injury could  be found.   He died on
the night of the day on which he had been ad-
mitted into the hospital, and on examination eight
hours after, exhibited  the  following appearances :
—Blood had transuded from the thighs and trunk,
and was also  found, in a gelatinous state, in the
nasal cavities.   The whole of the surface of the
body was emphysematous, of a -"iolet colour, and
studded  with  a  vesicular eruption in detached
spots,  the vesicles being filled, some with a red-
dish serum and gas, others with gas alone, the
latter being of  a white colour.   The left leg and
thigh were most swollen and puffy, and evidently
contained fluid.  The abdomen and scrotum were
also much distended, the gas in the former occur-
ing not within the intestines, but in the cavity of
the peritoneum.  The  brain and spinal marrow
were healthy, but the vessels of the pia  mater con-
tained air.   Upon cutting  into  any emphysema-
tous part, a gas escaped, which was set on fire by
the  flame  of a candle;  and from a perforation
made in the abdomen  a  gas issued, which  was
ignited in  a similar manner, and burned with a
bluish flame.
   This case,  which was  communicated  to the
Academie Nation ale de Medecine, excited a good
deal of discussion.  M. Bally  considered it as
illustrating  Dr. Marc's  theory  of  spontaneous
combustion, while others looked upon it as proving
tbat the  putrefactive process, from which alone
they conceived the gases could be derived, may
set in before  death.  This  latter opinion  may
appear paradoxical, but it  does  not seem at  all
improbable, much less  impossible, that a sponta-
neous  though  limited decomposition may in cer-
tain states  of the system take place in the living
body.  The elements of organized matter are, we
know, combined, under  the influence of vitality,
into compounds very different from those which
they would form if submitted to the sole agency
of their mutual affinities.  When released  from
the controlling influence of the vital powers, they
enter into new  arrangements; and it is but rea-
sonable to expect that  effects similar, at least in
kind, may attend the diminution of those powers
which  is  the  consequence of disease, to those
which  are known to follow upon their extinction
by death.
  I* is not,  however,  necessary, in  order to
account for the development of the gases, to resort
to the hypothesis  of putrefaction.  They may be
the  products  of  depraved  secretion;  and  this
opinion seems even  established by the many cases
upon  record  of the  cellular  substance having
become emphysematous without  tbe occurrence
of any external injury.  In fact, spontaneous em-
physema  is at present recognized by all nosolo-
gists.  (See the article Emphysema ; also Frank
de  Retentionibus, and the articles Emphyseme
and Pneumatose, in the Dictionnaire des Sciences
Medicales.)
   But though we admit with Marc, that inflam-
mable  gases   may  be  developed  during life
throughout the different textures, yet  this will
not explain the completeness of the  incineration
which has been observed to occur, nor the rapidity
with which the combustion spreads over the whole
body.   If a taper be applied to carburetted hydro-
gen, it  will burn  merely at its point of contact
with the oxygen of the atmosphere; and to deter-
mine the instantaneous inflammation of a given
volume of such  gas, it must, previously to the
application of the taper, be mixed with  a certain
quantity of oxygen.   These facts, so familiar to
the chemist, suggest a necessary  modification of
the hypothesis of  Marc.   The  gases   evolved
cannot be all of an inflammable nature,  but must
include a proportion of oxygen, to act the part of
a supporter.   On this supposition they will con-
stitute  a  species of  explosive mixture, and we
shall  be  enabled  perfectly  to  comprehend the
rapidity and the extent of the destruction which
must ensue from their accension.
   It  must, however, be admitted that, though
oxygen may proceed from secretion, it is a gas
not likely to be liberated by any process  of spon-
taneous change, for it does not occur amongst the
products  of putrefaction.  The  views, therefore,,
which have been here advanced must, until con-
firmed or  refuted  by chemical analysis, be con-
sidered as chiefly recommended by tbeir adequacy
to explain phenomena.
   Having attempted  to account  for the preter-
natural inflammability of  the  human body, we
shall  now direct our  attention to  the manner in
which the combustion commences.   In  most of
the recorded cases some ignited body, as a candle,
fire, or lighted pipe, has been found in the imme-
diate  vicinity of those who have  suffered.  The
consequence  of this  has been  that  some have
attributed  the origin  of the  combustion  in every
instance to an external cause.  Such was  the doc-
trine first  taught by Vic D 'Azyr, and  since sanc-
tioned by Lair, Breschet, Dupuytren, and others.
Should it  prove well founded, the  epithet sponta-
neous  will obviously cease to be applicable to
human combustion.
  Others, however, amongst whom may be men-
tioned Maffei, Lecat, Kopp, and Marc, conceived
this theory inadequate to the explanation of all
the cases  with which  they were acquainted, and
to supply  its  deficiency,  called in the  calorific
powers of the  electric fluid.
  That electricity, in  the  form  of  a spark, is
attended with  the  disengagement of heat, and is
capable of setting inflammable substances on fire,
are facts  which cannot  be contested.   But  the
source of  the electric accumulation, in the cases
under consideration,  remains to be satisfactorily
pointed out.  And, indeed, it may  be  added, that
the statements that have hitherto been made upon
the subject rest upon  mere conjecture. Somo 
COMBUSTION,  (SPONTANEOUS)                    475
conceive that certain persons possess the power of
generating within  themselves  a  state of electric
tension, and quote relations of  individuals  who
emitted sparks at the suggestion of the will.   Dr.
Marc has adopted this improbable hypothesis, and
coupled with it  one of his own, which  appears
equally destitute  of foundation.  The gases  with
which the body abounds in its combustible  state
sometimes become, according to him, ideo-electric,
from an  elevation  of their temperature, whether
produced by exercise, exposure  to a fire, or any
other cause ;  and hence proceeds the spark which
determines the accension.  Lastly, others conceive
the spark when it occurs to be purely accidental,
and to result from the electric fluid selecting the
human body as a conductor in its passage to or
from the earth.  This latter supposition being the
only one which in modern science is admissible,
we arrive at the conclusion that  electricity can
scarcely ever have any  thing to do in producing
human combustion.
   It is believed  by some  that  cases  of  genuine
spontaneous combustion have taken place, or that
tbe human body has sometimes taken fire,  as  it
were, of  its own accord, without the  application
of  external  heat,  or the  agency of electricity.
Assuming such to be the fact,  can  any rational
explanation of it be assigned ?   This is almost
the only  question of a theoretical nature connect-
ed with the subject of this article which  remains
to be discussed.
   Of the elementary principles which enter into
the composition of the human body, phosphorus
must be reckoned as one of the most abundant.
It exists, in very considerable quantity, as a con-
stituent of bones, and, in many of the secretions,
in the form of phosphoric acid, united  to  some
base; and is  also to be found, in a peculiar  state
of combination, in the cerebral mass, and in the
fat which is deposited throughout the  cellular tis-
sue.  When putrefaction occurs  in the dead body,
experience proves  that phosphorus is  evolved
amongst  the gaseous products in union with hy-
drogen ;  and  there seems little  reason  to  doubt
that this  is one of the gases which are occasion-
ally generated throughout the different  textures
of the living system.  Now, if this be admitted,
as phosphuretted hydrogen inflames upon contact
with the  atmosphere, we shall  have a perfect and
simple solution of the difficulty of  spontaneous
combustion.   This theory was very early advanc-
ed, and  has  been particularly insisted  upon by
Morelli and Fanzago, and more recently by Grab-
ner Maraschin :  (Journal  Complementaire de
Dictionnaire de Medecine.)   It is, however, pass-
ed over in silence by the majority of writers.
   There  is another  mode of  accounting for the
spontaneous  combustion  of  the  human  body,
which  is entitled to  a  brief  notice  here.  The
chemical  actions  which give rise to the inflamma-
ble gases of which we have so often  spoken, are
attended by the development of heat; and when
this rises beyond a certain point, combustion, it is
alleged, must ensue.
  In support of these views, the spontaneous fir-
ing of pyritic  coal, heaps of charcoal,  oat-meal,
cotton, and black wad soaked with oil, are appeal-
ed to.   Whatever may be thought of this  hypo-
theses, the records of medicine prove that the pro-
duction of inordinate heat may be classed amongst
the well-established consequences of disease.  In
the Essay of Maraschin  already  quoted,  three
cases  are detailed which will illustrate  this posi-
tion.   We shall merely mention one  which  oc-
curred, in 1822, to Balbiani, an Italian physician,
and which was communicated by him to Morelli,
Chemical Professor at Pisa.
   A farmer, twenty-six  years of  age, was  seized,
in the beginning of January, with an intermittent
fever  connected with gastric irritation.  On  the
seventh day he felt in the throat  a  burning heat,
ascending from the region of the stomach, so  in-
tense  as to resemble the effects of the application
to the  body of red-hot coals.  His  breath, which
smoked, could not be borne  by the hand  at  the
distance of two feet.  He incessantly drank cold
water, but with only temporary relief.  The thirst
was succeded by a most voracious  and insatiable
appetite, the internal heat continuing  unabated.
He was treated by repeated immersion in the cold
bath,  conjoined with the exhibition  of draughts of
iced water; and was finally cured perfectly.
   From the preceding  facts and arguments  the
following conclusions maybe deduced:—1. The
human body admits of  being reduced to a  highly
inflammable state.   2.  This condition is  chiefly
owing to the development, by perverted  secretion
or incipient putrefaction, of gases  constituting  a
more or less  explosive  mixture, but is  probably
often promoted by the dispersion throughout  the
system of  alcoholic  vapours.    3.   In  most  in-
stances of  human combustion  the  process  has
commenced in consequence of the  contact with
the body of external fire, or of an  electric spark.
4. Cases truly spontaneous, if  any such have oc-
curred, must be referred to the  disengagement of
phosphuretted hydrogen, or to the caloric devel-
oped  by those internal actions which determine  a
highly combustible state of the body.
   Before concluding this  article, it will be pro-
per briefly  to advert to  its medico-legal  bearings.
The human body,  in  a state  of perfect  health,
may be consumed by accident or design, and it is
obviously a matter  of  the  first  moment,  with  a
view  to the protection of innocence and the pun-
ishment of  guilt, that  we  should  be  enabled to
distinguish  such cases from those in the consider-
ation of which we have now been engaged. The
importance of the study of spontaneous combus-
tion under this point of view is usually illustrated,
in works upon medical  jurisprudence, by the cele-
brated case which  occurred  at  Rheims in 1725.
The wife of a man of the name  of Millet, who
was much addicted to the use of spirituous  drinks,
left her husband's bed one night, and  was  found
next  morning, at a short distance from the kitchen
fire, reduced to a  heap of cinders.  Millet, who
was suspected of intriguing with a handsome  ser
vant-girl in the house,  was accused of  the mui-
der of his wife, and being sentenced to death, was
saved from execution by the report of a commis-
sion  of medical men, who, after having investi<
gated all the facts, declared it to be  a case of spon
taneous combustion.
   By attending to the circumstances already enu-
merated as characterizing  spontaneous combus-
tion,  we shall be in no  danger of confounding  n
with  that which may be produced by the ordinary 
476
COMBUSTION —CONGESTION  OF  BLOOD.
artificial means.   Thus, when the subject  of the
calamity  is a  female, advanced in years, and of
intemperate habits;  when  the  destruction has
been very rapidly effected, and nothing remains
unconsumed but portions of the head and  extre-
mities ;  when the room is filled with an offensive
empyreumatic odour, and  a moist and fetid  sooty
matter is deposited upon the ashes which remain
and upon the  walls and furniture ;—these circum-
stances, or the greater number of them concur-
ring, remove all doubt respecting  the spontaneous
origin of the fire.  On the other  hand,  when the
combustion is of  the ordinary kind, and has  been
the result of accident, it will generally be but par-
tial, and  not directed in preference to any  partic-
ular part of the body.  In such cases, also, it will
almost invariably be found to  have extended  to
adjacent  combustible substances.  Lastly,  when
designedly produced, there will be evidence of the
consumption of a large quantity of fuel.
   As to  the  appropriate treatment of individuals
who manifest a  tendency to  spontaneous com-
bustion, nothing  certain can be laid down : nor is
our ignorance on this head much to be lamented,
at least in a practical point of  view ; for such an
affection is seldom announced  by any precursory
symptoms.  Should, however, such a case as that
which occurred to Balbiani be encountered, no-
thing appears more  judicious than the  treatment
to which he resorted, namely, immersions  in the
cold bath, and copious draughts of cold water.
Dr. Swediaur, indeed, states  that spontaneous
combustion is very  prevalent in  the north of
Europe, from  the excessive use of eau-de-vie, and
that the tendency to it, when detected, is  with
certainty  removed by the administration   of re-
cently voided  human urine.   Upon  this state-
ment Fodere observes, " credat Judxus," and we
do not hesitate to avow that we  participate fully
in his scepticism.            James ApJ0HN>

  CONGESTION OF BLOOD.  [Hyperemia.]
—Though this term is familiar  in medical  writ-
ings,  and  in  daily  use  among  practitioners, it
appears to be employed as expressing  simply an
acknowledged fact, rather  than as referring to any
pathological  exposition  of the  phenomenon  to
which it relates.   [It is often employed  in  a
strangely imprecise manner,  and, too frequently,
it is to be feared, to shroud the ignorance of the
practitioner as regards the precise pathological
condition.]
   Congestion of blood  and  determination are
terms not unfrequently used to denote  the same
state;  yet they  do  not signify  the same thing.
By congestion is  implied  simple  engorgement of
blood-vessels,  without reference  to  any contin-
ued increase of vascular action ;  while determin-
ation  includes the idea of the  increased impetus
with which the blood is propelled into the affected
part.   Local  inflammation  is perhaps  the acme
of this state,  combining  the whole three  condi-
tions ; though each of the preceding may exist in-
dependently  of it, and without  passing into  it.
[Hypersemia is. however, a precursor of inflamma-
tion in almost all, if not in all,  cases.]
   The subject, though  undergoing much  discus-
sion in various works on pathological anatomy, is
not yet sufficiently matured  for the several  facts
and reasonings lo be embodied in a special essay.
The several  local congestions will  of course be
noticed under the heads of the diseases in which
they respectively occur.   The general  principles,
so far as any are deducible  from  such facts as are
ascertained,  will,  perhaps,  be   best  understood
when presented in connection with general patho-
logy of the circulation.  Simple congestion evinces
over-distension of vessels, and clearly implies de-
bility of  their coats.  In  several  tissues it seems
the result rather of irritation than of pure inflam-
matory  action.  When it passes into inflamma-
tion, this seems more  dependent on the general
state  of constitution,  on the plethoric condition
of the blood-vessels,  with  the tendency towards
febrile and inflammatory excitement  which this
induces, than  on the  primary  irritation,  or the
congestion occasioned  by it.  Hence congestion
might be considered as passive or active ; the for-
mer term applying to tbe simple state, the latter
to that   in which inflammatory  action is either
concomitant  or superinduced.
   Facts, however, are still wanted for establishing
a  clear  and  consistent theory of congestive ail-
ments.   These facts the researches of pathologi-
cal anatomy, so zealously and minutely pursued
at  the present day, cannot fail  to supply;  and
when sufficiently accumulated, it will not be diffi-
cult to arrange them so as, with  the aid of correct
physiology and sound pathology, to  deduce the
principles of their occurrence, and establish on a
rational  basis the  curative  treatment of the mor-
bid condition to which they relate.  The presence
of  internal congestions must, for practical  pur-
poses, be of course inferred from the symptoms
which indicate them ;  and to connect the symp-
toms with the  structural lesions which they de-
note, so  as to furnish practical   guidance in their
treatment, is  the proper object of  medical research.
This can be  accomplished only by multiplied ob-
servations of phenomena,  generalised by  a  cau-
tious induction.  An  essential  part  of this  in-
quiry, however, consists of a scrutiny of those
modifications or changes of structure which the
morbid actions occasion, and by  which the effects
of  these can be traced on necroscopic examina-
tion.   The correctness of all theory must depend
on the accuracy of the facts from which it is de-
duced ;  and as no complete theory of internal  con-
gestions can  be established without  the aid of
numerous facts derived from actual inspection of
the diseased  parts after death, it  is of importance
that inquirers  should be aware  of the fallacies
by  which they are  liable to be misled in the in-
spection of the structures and tissues supposed to
be diseased.   These fallacies are displayed by M.
Andral,  in his elaborate and valuable work on
pathological  anatomy, with a minuteness and ac-
curacy which  merit the highest  praise.  To ren-
der any  account of his laborious  researches would
exceed the bounds of the present article, without
sufficing for  that completeness  which a  perfect
essay on congestion would require.
   It may be noticed that the different degrees of
colouring  observed  in  internal  parts after death,
which are so  often attributed to  increased vascu-
larity, and supposed to denote  the pre-existencc
of  congestion  or inflammation,  may  result  from
various causes independently of disease. Of these 
CONGESTION OF  BLOOD —CONSTIPATION
477
M. Andral specifies several; the passive hyperae-
mia, which bas always a tendency to take place
in the last moments of life in parts abounding in
capillaries ;—mechanical  obstacles to the  venous
circulation, formed a  longer or  shorter  period
before death ; — the hypostatic accumulation  of
blood in depending parts;—the transudation of
blood through its vessels;—other peculiar trans-
udations ;—various gases, &c.  He also remarks
that  differences are presented  according  to the
part examined, the age, the period of the digestive
process  going on at the time of death ; with other
circumstances.
   Unless due allowance be  made  for all such
sources of deception in noting the effects of mor-
bid  actions,  as  displayed in structural  lesions,
the evidences afforded by pathological  anatomy,
though  generally  regarded  as the  most  certain
which medical science possesses, must  be as fal-
lacious  as medical facts derived from the observa-
tion of mere symptoms and of outward phenomena
are so  often  alleged to  be.  From  the industry
and  precision, however,  with  which this  branch
of science is now cultivated, there is every reason
to hope that pathological anatomy will in no long
time rest on a sure and stable foundation, furnish-
ing in the truth and extent of its facts a basis on
which a firm and abiding superstructure of patho-
logy may be ultimately reared.
   The  treatment of local congestions must depend
partly on the nature of their site, but principally
on the  cause  which  occasions them; whether
general plethora exciting increased arterial actions
and  determination of blood  to particular parts ;
simple irritation inducing an increased  afflux of
blood by the local  excitement occasioned ;  or me-
chanical obstruction causing a retardation of blood in
extreme vessels, with over-distension of their coats,
and preventing its free return by the refluent veins.
   Each of these states must require an appropriate
 adaptation of remedies;  for if a just discrimina-
 tion be  not practised in this respect, no consistency
can  be preserved, nor any uniformity of success
be realised.   If congestions result from a plethoric
habit, mere local treatment can never  give effec-
tual or permanent relief; the affection recurring
so  soon as  the  local means  are  discontinued.
 With these means depletion  and  abstemious diet
must be combined, else  disappointment and fur-
ther decline of health  must ensue.  On the  con-
trary, if there be  no plethora, and the congestion
be owing to irritation only, then general deple-
tion is  not  only unnecessary  but injurious, en-
feebling the system, and weakening those efforts
by which the congestion would  be naturally re-
lieved.   In  both respects are  errors committed.
Many congestions originating in  plethora  are
treated  as local diseases until  structure becomes
permanently and  irremediably altered ; while con-
gestions arising from  irritation are occasionally
confounded  with  inflammation,  from  a delusive
resemblance in some of their symptoms, and blood-
letting is injuriously resorted to.   In no class of
diseases is  the former  error of more frequent oc-
cuirence than in  affections  of the  stomach and
bowels.   Increasing plethora begets almost neces-
sarily a congestive state of the gastro-intestinal
mucous membrane, the constitution  endeavouring
to throw off its  redundancies  by this  and other
outlets;  secretions become  increased  and  then
vitiated ; digestion is impaired ; appetite declines ;
and a condition results to which the term dyspep-
sia is  usually applied.   Indigestion and loss  of
appetite  are  regarded  as the disease ;  they are
imputed  to weakness of stomach, and tonics are
employed ; some amendment may be  felt by I he
capillaries being  excited, and the  appetite may
improve, but the disease is not thus arrested, nor
a healthy condition restored.   The capillaries may
contract  upon their contents, and thus abate the
congestion so far as they are concerned ; but it is
only by repelling the blood into the vessels which
led to them,  and thus substituting  another  form
of disease more mischievous and less  remediable,
because  less within the reach  of those curative
processes by which the constitution so  continually
rectifies its own derangements.  In this condition
tonic treatment,  subsidiary to depletory, may be
and oftentimes is  of service ; when employed as
the chief means of cure, or to the neglect of evacu-
ants, it  is invariably pernicious.   The  natural
relief derivable from increase of secretions being
arrested, the blood repelled, not only overloads the
larger vessels which lead immediately to the capil-
laries, but becomes in time  congested more dis-
tantly in  several of the viscera, giving rise to dis-
eases of various kinds.
   With respect  to the diseases which,  arising
from irritation, present appearances simulative of
inflammatory action, and in which  congestions
often occur, much valuable  information  may  be
derived from the works of Dr. Gooch,  Dr.  Mar-
shall Hall, Mr. Travers, and  others,  who  have
done much to introduce greater discrimination and
accuracy  into the treatment of such complaints.
   [See, on the whole subject of Hyperaemia, Dun-
glison's  Practice  of Medicine,  2d  edit.  i.  520 :
Philad. 1844;  and Dr. C. J. B. Williams, Prin-
ciples of Medicine, § 287 :  Philad. 1844.]

                               E. Barlow.
   CONSTIPATION. —The word constipation
is derived from the Latin constipo, to crowd  toge-
ther, a compound of con and stipo, to fill up close.
The corresponding term obstipato, under which
costiveness is usually described by Latin authors,
is from ob and stipo,  to stop up, and  the  root of
the Latin stipo seems to be  the  Greek arvtpu, to
bind as an astringent, to thicken.   The true im-
port of the  word constipation, therefore, would
appear to be the collecting and  impacting of the
excrementitious  matters, the  residuum  of the
various  processes concerned in  alimentation, in
some part of the intestinal tube.
   Constipation is not so much marked by the in-
frequency of the evacuations from  the bowels as
by their  firmness of consistence, and by the occur-
rence of fulness  and tension in various parts  of
the abdomen, and  other symptoms indicative of
impaired or  impeded action in one or  more of the
various  organs contributing towards  the passage
of the  refuse of the  alimentary  process.  The
observations of Heberden afford  so apposite  an
illustration of these views that we shall not hesi-
tate to refer  to them in this place: — " Homines
frequentia alvum exonerandi plurimum inter se
differunt.  Alteri semel tantum singulis mensibus
venter solutus est; alteri  duodecies quotidie o»;- 
478
CONSTIPATION.
scendit per triginta annos, uti  ipse inihi narravit,
et dein septies quotidie per septein annos ; neque
vir  hie  intera macuerat,  quin potius aliquanto
habitior factus erat."  It is obvious that with one
of the  persons here alluded to a daily evacuation
would have been in fact an attack of diarrhoea,
while with  the  other it might have been justly
considered  as  indicative of constipation, and  in
cither case much general disturbance of the system
would  probably  have  arisen.   Similar instances,
though not to  so great an  extent,  frequently pre-
sent themselves to our notice,  especially amongst
females, with whom the functions  of the intestinal
canal seem generally to be less regular than  in
the male sex.
  Constipation has commonly been considered  by
writers on nosology as it occurs in  persons  of a
lax and weak  habit  of body ;  in those of greater
rigidity of  temperament; and  as arising from ob-
struction in some part of the  intestinal  tube.  It
will be sufficient for  our present  purpose, if we
treat of it under the heads of simple constipation
and constipation from  obstruction,  leaving  the
more refined divisions till we  come to consider
the variation produced in the symptoms by the
immediate  pathological  state  to which they may
owe their origin.
   Under simple constipation we mean to include
those morbid affections which, without more pro-
minent  disease,  are characterized by a confined
state of the bowels arising from various causes so
acting upon the  mucous and muscular coats of the
bowels as to impede the regular and efficient per-
formance of the  functions of these organs.
   In accordance with these  views  the leading
symptom  of simple constipation  is a  costive or
more consistent state than usual of the faecal ex-
cretions, with  a less frequent  call for evacuation
than is customary with the individual when in a
state of perfect health.  Other symptoms usually
attendant upon this state are, more or less pain in
tbe  frontal  or occipital regions, some degree  of
fulness and tension of the abdomen, a foul tongue,
with loss of appetite, and often  an  undefinable
sense of oppression, accompanied with  corporeal
languor and listlessness  of mind.  These symp-
toms are,  however,  materially modified by the
immediate cause giving rise  to the attack; and
since it is  of the first importance, in respect  of
treatment,  that  the relation which the symptoms
and causes bear to  each other  should be  fully
established, it will  be desirable  to consider the
variations  thus induced somewhat more at length
when passing the causes under review.
   Causes. — 1. The first cause of constipation
to which we shall allude, because the most simple
in its nature,  is laxity or  debility of the fibre of
the muscular coat of the intestines.  Constipation
from simple debility  is not an unfrequent occur-
rence,  and is apt to arise during the debility which
attends convalescence from acute diseases.  It is
also observable in those who lead a sedentary life,
and have a general pallid look and relaxed fibre.
An opportunity  of verifying, by post-mortem exa-
mination, the  state  of debility and wasting of  the
muscular  fibres  of the larger intestines,  which
uccurs in this condition of the system, does  not
 uften arise : but the  following example affords a
 good illustration of this lesion, and serves also to
show, that without care and circumspection,  the
diagnosis  is not always easy to  be attained.   A
bookseller, aged forty, who led a  sedentary life,
had from his youth experienced great difficulty in
regulating his bowels,  and had  constantly been
using bitters and cathartics under medical advice.
Latterly vomiting had succeeded to the symptoms,
and he  had become  pale and emaciated,  which
induced a suspicion in the minds  of his medicial
attendants that he was labouring under diseased
pylorus.   Under this view of the case the use of
active aperients was discontinued, and an attempt
was made to regulate the action of  the bowels by
enemata, but without avail, as the attendant could
never succeed  in injecting  any quantity of liquid
into the rectum, and consequently small portions
only of liquid faecal matter were  ever brought
away.  The patient, finding himself grow weaker,
and considering that he  had  no hope of relief,
would  not  consent  to  any  examination of the
rectum;  and  as the vomiting and constipation
continued, he gradually became  exhausted, and
died.   On examination after death, the stomach
was found to contain nearly three pints of a dark
coffee-coloured fluid.  The mucous membrane of
the organ was not  redder than natural, but it was
generally  thickened.   The small intestines were
nearly empty,  and  were not diseased.   The colon
throughout its whole extent was enlarged, and its
muscular  fibres were thin and pale  ; it also con-
tained faecal matter and a  great  quantity of gas.
In the descending colon and in the sigmoid flexure
this was more particularly remarked, and the faecal
matter was here very hard.   The  whole of the
rectum was enormously distended with very hard
faeces.  On pursuing the investigation downwards
to the termination  of tbe rectum at the anus, no-
thing like stricture was discovered ; but the intes-
tine was much dilated,  and the muscular  fibres,
even near to the anus, were remarkably thin and
pale.   The intestinal mucous membrane did not
seem to be at  all diseased.
   It is not often that we have  an opportunity of
witnessing  so decided  a  case of debility  of  the
muscular fibre producing constipation as this  ex-
ample affords ; but analogous instances, in debili-
tating  diseases,  occasionally  happen, where  the
faeces will lie for a length of time  in the extremity
of the rectum,  without the  patient having  the
power of voiding the accumulated hard  mass,
and  surgical  aid  is  sometimes necessary for its
removal.
   This accumulation of the faeces from debility
of muscular fibre  is by no means uncommon in
old people ; indeed we believe the existence of a
weak propulsive power in the large intestines to
be the most frequent cause of constipation in ad-
vanced age.
   When any part of the intestinal canal has been
inflamed, the  care which is subsequently required
in regulating the diet and in selecting the aperients
necessary to keep up a due action  of the  bowels
is familiar to every practitioner of medicine.   In
fact,  the  necessary consequence  of inflammation
having existed in  any part  is  debility, and when
this occurs in a hollow organ, such as the intesti-
nal canal, we are naturally led to expect, after tho
 acute  symptoms  have been  subdued, a loss of
power in tbe  inflamed muscular fibre, and conse- 
CONSTI
quently distension of the bowel and retention of
its contents.  « Inflammation," observes Dr. Aber-
crombie, (Pathological  and Practical Researches
on Diseases of the Stomach, &c. 2d edition, p. 7,)
" seems also  to destroy the action of muscular
fibre.  Thus,  intestine which has been inflamed
is generally found in a state of great distension,
showing the complete loss of its healthy muscular
action; and, if the disease has gone on until the
intestine has either become ruptured, or has given
way by ulceration, it is found to have fallen toge-
ther like an empty bag, without any appearance
of muscular contraction ; whereas bealthy intes-
tine, when it is empty, contracts uniformly into a
round cord." The constipation, then, which arises
during  convalescence from  inflammation of dif-
ferent parts of the intestinal canal, and which is
so readily induced by slight irregularities of diet,
is the direct  result  of debility of  the muscular
fibre, and  in  cases where the  inflammation  has
arisen from obstruction, may be altogether inde-
pendent of  the original cause of disease, though
perhaps often attributed  to its continued or re-
newed  operation.  Several  cases illustrative of
the preceding observations  will be  found in the
work which has  just been  referred to.  The fol-
lowing affords a similar example, and at the same
time shows the tendency of previous debilitating
causes to produce constipation. A female servant,
aged  twenty-four, had  miscarried about the fifth
month of pregnancy, and was much weakened by
profuse hemorrhage.   She  then had diarrhoea,
which  was checked by appropriate measures.
Subsequently  the bowels became obstinately con-
stipated, and  there was tympanitic distension of
the abdomen with some pain on pressure, espe-
cially in the  right iliac region.  The skin  was
jaundiced, and there was bilious vomiting, with
much depression  and sunk countenance.  The
vomiting was  checked by the application to the
epigastrium of a fold of linen soaked in laudanum;
but the measures employed to procure  an evacua-
tion from the  bowels were unsuccessful,  and the
enemata  administered  were  returned  without
effect, though it was ascertained by examination
that the rectum   contained  frecal  matter.   She
gradually sunk,  having had one copious  evacua-
tion a few hours before she died. On examination
of the body, the capillary system in general  was
found injected with dark-coloured blood, the heart
and  larger  blood-vessels  being empty.   In  the
abdomen, the  omentum  and peritoneal coat of the
intestines were vascular in  places,  the colour of
the vascular injection being more florid than in
other parts of  the body ; and upon  some portions
of the small intestines  circumscribed  patches of
lymph were found adhering to the surface of the
serous membrane. Portions of the mucous mem-
brane of the stomach, duodenum, and small intes-
tines were  also injected,  and there was  evident
thinning of the coats of the ileum near its termi-
nation in the valve of the colon.  A sac formed
by the doubling of the peritoneum  between the
rectum and  uterus was found filled with purulent
matter, whicb  was confined by recent adhesions
in its vicinity.  Pus was  also  found in  the sub-
stance of the  uterus near the cervix.  This case
was obviously one of inflamed uterus with subse-
quent peritonitis;  but the constipation appears to
1 AT I ON.                               479

 have resulted  from the general  debility, induced
 in the alimentary canal by the acute disease which
 had previously existed there, and  the remains of
 which were found on examination.
   2. The  secretions  concerned in the process of
 alimentation may be  vitiated in quality or  defi-
 cient in  quantity.  Under  these  circumstances
 there will be a want of stimulating power in the
 alimentary mass resulting from their combination
 with the  food;  the  propulsive powers  of the
 muscular coat of the bowels will  not  be  so  effi-
 ciently  called into action, and  constipation  will
 necessarily  result.   Slight changes of this  kind
 in the nature  or quantity of  the secretions are of
 very common  occurrence, and  are perhaps the
 most frequent cause of the more trivial and tem-
 porary irregularities in the excretive function,  to
 which every one is more  or less  liable.   When
 these causes are more permanent  in their action,
 they become  of greater importance.   Thus the
 biliary secretion is frequently disordered without
 giving rise to any other inconvenience than the
 omission or retardation  of a customary evacua-
 tion ; but when the morbid  change is more in-
 tense in degree, or prolonged in its duration, the
 constipation is more marked, and inspection of
 the evacuations  commonly  shows  the impaired
 state of the function of the liver, by deviation
 from the healthy  colour and consistence  of the
 faecal matter.  The evacuations will be found of
 firmer consistence, less homogeneous in their ap-
 pearance, frequently containing portions  of  con-
 siderable hardness, and the colour will be pale and
 clayey, dirty or muddy, greenish or dark, accor-
 dingly  as  the bile is less copiously poured out
 from the biliary ducts, or so  vitiated in its nature
 as not to preserve its usual characters.  In such
 conditions of this secretion, in addition  to the
 constipated and otherwise altered state  of the al-
 vine discharges, there  is  more or  less  uneasiness
 in  the  region of the liver, scarcely, however,
 amounting to pain; tension of the upper part of
 the abdomen; a moist brownish fur coating the
 tongue ; a muddy colour of  the conjunctiva, and
 pain of the head, usually referred to the occiput,
 with a sense of heaviness or  oppression.
   The existence of an altered state of the mucous
 secretions poured  out from the surface of  the in-
 ner membrane of the  intestinal canal, and from
 its  numerous glands and follicles, though probably
 of not infrequent occurrence, is much more ob-
 scure  in its  characters,  and consequently  less
 easily recognized.   In  the early stage of fever and
 of  most inflammatory diseases there  is  a  sup-
 pressed or diminished  state of these as well as of
 most of the other secretions, which  appears  to
 contribute much to the confinement of the bowels
 occurring  in  such cases.  And hence we have
 more or  less of oppression  at  the epigastrium,
 with tension  and fulness  of the  abdomen,  con-
 stantly attendant upon febrile diseases. The op-
 pression and tension  of  the  abdomen  have been
 referred to an inflamed condition of the stomach
 and  small  intestines; but  we aie inclined  to
 question the correctness of ascribing those svmp-
 toms which are indicative merely of oppression,
 and are of such  frequent occurrence in  various
 febrile states, to inflammation, when the vasculai
 fulness arising from suppressed secretions affords 
480
CONSTIPATION.
so adequate an explanation of the attendant phe-
nomena.  Many cases of diarrhoea, and especially
such  as  arise from exposure to cold and wet, if
closely investigated, will be found to be preceded
by  costiveness of some duration.  In  such in-
stances  one  of the  first  links in the  chain of
causation appears to be a suppression of the secre-
tions  from the intestinal mucous membrane, while
the general progress  of the symptoms  affords a
striking  analogy with the effects produced by  a
similar exposure upon  the  corresponding  mem-
brane of the  pulmonary  system.  The primary
effect of  the exposure is in either case the same,
the capillary vessels of the membrane become dis-
tended by the  blood  thrown into them  in an in-
creased proportion, and  a suspension of secretion,
producing local oppression and constitutional dis-
turbance, is the immediate  result.  Should  this
condition not be relieved, a degree of inflamma-
tory action is induced, which is subsequently fol-
lowed by the pouring  cut of the altered secretions,
the products of that inflammation,  constituting
coryza,   catarrh, or  diarrhoea,  according  as  the
Schneiderian, the bronchial, or the intestinal mu-
cous  membrane may  have been  originally acted
upon  by  the exciting cause.
  Cases  of disordered digestion not unfrequently
occur in which much tenacious  mucus is occa-
sionally brought up from the stomach, and it will
readily be allowed that, the surface of the mucous
membrane being thus  covered  with  its morbid
secretions, the customary  changes cannot take
place in  the food, and much distress must be the
necessary consequence.  Such a state  of the folli-
cular  and mucous  secretions existing  in  other
portions  of the intestinal  tube will  necessarily
tend  to  lessen the  susceptibility of its internal
surface to the  stimulating impression  of its con-
tents, and may thus prove a cause of constipation.
We have witnessed cases  in which such seemed
to be the sole cause of the  detention of  the
alimentary mass in various parts of the bowels ;
and in these examples we have found  the  evacu-
ations to consist sometimes of a mucous or muco-
gelatinous substance, at others of ftecal  matter
mixed, or, when formed, smeared with a mucous
fluid,  apparently of considerable tenacity. In  Dr.
Abercrombie's work  upon Diseases of the Abdo-
men there is a case,  (Op. citat. p. 314,) which,
as far as  the state of the bowels is concerned, af-
fords  a good  illustration of these remarks ; and
the  slowness of the  bowels in the following case,
related by the same  author, probably admits of
explanation upon the  views here advanced.   "A
lady, aged about thirty, had been in  bad  health
for  four or five months,  and when I saw her was
wasted like a person in an  advanced  stage of
phthisis.   She had a small frequent pulse and bad
appetite,  but complained of nothing except  some
undefined  uneasiness in  the  abdomen.    The
bowels were slow, requiring the constant use of
medicine ; the motions were consistent and  form-
ed, but always of the  deep brown colour of dark
mahogany or  rosewood  ;  and  no  treatment had
any effect in  correcting  that colour.   The  abdo-
men was collapsed, and nothing  could  be dis-
covered by examination.  Some time after I saw
tier, she  began  to have  uneasiness in her chest,
"ith slight cough ; she then became liable to fits
 of coma, in which she  lay with her  eyes  open,
 but unconscious of any thins ; at length she had
 repeated paroxysms of convulsion, and  she died
 in a state of the most  extreme emaciation, after an
 illness of eight or nine months' duration.  On in-
 spection no disease  could  be discovered in  the
 brain, and the lungs  were quite healthy, except
 some very old adhesions of the pleura.  The in-
 testinal canal was throughout so  thin  as  to be
 transparent like goldbeaters' leaf.  On the mucous
 membrane there was  in many places a tenacious
 mucus  of a dark  brown  colour, but  no disease
 could be  discovered in the membrane itself, and
 no  morbid  appearance could  be  detected in any
 organ."   (Op. cit. p.  336.)
  3. Perhaps the most common cause of simple
 constipation of the bowels is to be found in the
 nature of the diet  to which, in the  present artifi-
 cial state of existence, we are accustomed to resort.
 Food which is imperfectly soluble  in  the gastric
 secretions, unless  of  an irritating  quality,  must
 necessarily impede the process of  digestion and
 assimilation throughout its  several  stages.   It is
 unnecessary here to  point out those  articles of
 diet  which come  under this  description; but it
 may be stated as a general principle, that accord-
 ing to the readiness and completeness with which
 this solution is accomplished within the stomach,
 except in cases where the product of the digestion
 is of a too stimulating or irritating nature, will be
 the perfection of the subsequent parts of the pro-
 cess, and the gradual  and regular transmission of
 the mass through the whole course of the aliment-
 ary canal.   There are, however, many substances
 used for food, which,  after  they have passed the
 stomach, are so little  fitted for  the purposes of
 alimentation, that  they are not taken  up by the
 absorbent vessels which open upon  the intestinal
 mucous surface, and consequently form a part of
 the refuse to be propelled onwards, and ultimately
 rejected  as excrementitious.  When these  sub-
 stances are taken  in  considerable quantity, they
 give rise to constipation, and occasionally even to
 fatal obstruction from the  firmness and intracta-
 bility of the resulting mass.  The seeds of various
 plants  seem especially  to  have  this  tendency
 when  taken in any  quantity, and  instances in
 which  the kernels of tbe nut,  walnut, or almond
 have been productive of injurious and even alarm-
 ing effects, by inducing constipation and obstruc-
 tion  of the bowels, must have occurred to almost
 every practitioner  extensively engaged in  the
 duties of his profession.   Two cases of  fatal ob-
 struction, the  one  resulting from almonds eaten
in considerable number, the other from nuts, have
 arisen within the knowledge of the authors of this
essay.
  4. Increased tone of tbe muscular fibres of the
 middle coat of the  intestines may not infrequently
 give rise to a remora in the passage of their con-
 tents, and the effect of many of that class of me-
 dicines  called astringents appears to be owing to
 their tonic powers.  It has been remarked by Dr.
James  Johnson, that  the beneficial effects  pro-
duced  by travelling, on the general strength and
health, are commonly  accompanied  by a confined
state of the bowels.  This is no doubt to be  attri-
buted partly to the increased  activity  of the ab-
sorbents, by which the alimentary mass is left in 
CONSTIPATION.
481
a drier state  than when  the assimilating organs
generally are in a more debilitated condition, but
in part also to the increased tone of the muscular
fibre, by which its contractions are rendered more
equable, and consequently the  resistance offered
by one portion of the intestine to the propelling
powers of another so adjusted as, by retaining the
mass  longer  in its passage through the bowel, to
.co-operate with  the  increased  tone  and activity
of the absorbents in  extracting  a greater quantity
of nutriment than under other and less favourable
circumstances could  be obtained.  Such a state is
a  frequent  accompaniment of  a healthy  and
effective performance of the functions of diges-
tion, and  may be considered rather as indicative
of the excess of health  than as  requiring  to be
interfered  with  by having  recourse to  remedial
measures.
   5.  Constipation is a symptom of very common
occurrence in those morbid states of the encepha-
lon in which  more or less oppression is observed
to exist;  and in such a condition of the brain and
nervous system it is probably owing to the defi-
ciency of that influence exercised by  these im-
portant parts of our  frame over every organ, and
in the performance of every function of the body.
Usually the existence of this state of cerebral op-
pression  is sufficiently  evident  from   symptoms
more especially characterizing it, in itself  consti-
tuting the disease; but cases occasionally occur in
practice in which the constipation will be found
to be the prominent morbid  condition, and the
oppressed state  of the brain  not  more marked
than is usual; more or less headach, as we have
before observed, commonly attending a confined
state  of the  bowels.  For instance, a child may
have had no evacuation from the  bowels for two
 or three days ; there  may be considerable fulness
and uneasiness  of the abdomen, with a  white
 tongue and  loss of appetite.  There may also be
some dulness of expression and headach.  The
symptoms  are naturally  considered  to depend
upon the confined state of the bowels,  and appro-
priate  purgatives are given.  No action results,
however, from these measures.   There is oppres-
sion of the  brain, and  the impressions,  which,
 under other circumstances, would have been suf-
ficient to  have excited the dormant powers, are
here insufficient.   If a few leeches be now applied
to the head, the bowels will be almost immediately
relieved.   The constipation, then, in such a case
will clearly  have arisen from the interchange of
communication between the brain and the organs
of alimentation  being suspended, or at least ma-
terially impeded.  It is, in fact, symptomatic of  a
morbid  condition of that organ, as in other cases
it may be of a morbid condition  of the liver, of
the intestinal mucous membrane, or of the mus-
cular coat;  it is, however, the prominent symp-
tom, and indeed the  actual expression,  of  disease
to be removed only by remedying the  cause giv-
ing rise to it.
   The  obstinate  constipation  which  occurs in
connection with  irritation of the spinal cord in
some cases of irregular hysterical disorders, should
here be noticed, since we have seen instances of
voung females in whom all the symptoms of ob-
struction  of the bowels  have apparently  arisen
from  ro  other  cause.   The  possibility  of the
  Vol I. — 61                         2 n
symptoms arising from this cause should always
be borne in mind when the patient is of the age
and  temperament liable to hysteric paroxysms;
and  where  such is  the case,  particular  inquiry
should  be made  into the state of the menstrual
secretion, and the most careful examination of the
medullary column  instituted,  both  by  pressure
over the vertebrae, and by  drawing  a  sponge,
which  has  been  immersed  in  water as  warm as
can be borne, down the spine.  Not unfrequently
some irregularity of the periodical discharge will
be discovered to exist, and some portion of the
spinal column will be found tender.  When such
is the case, by having recourse  to the appropriate
remedies for this class of diseases,  an apparent
obstruction, which had withstood  the best-directed
measures, and in which the most  powerful cathar-
tics  had been of  no avail, will rapidly give way.
   6. Another  cause  of confined bowels is an
increase of the secretions from other organs of the
body.  There is an adaptation of  the several func-
tions to each other, and a relation existing among
them, which, if disturbed, gives rise to many very
interesting morbid affections.  If any one function
be  either   diminished,  increased,  or  otherwise
altered, some one, or perhaps all the others, will
also be disturbed.  Thus, if  the  functions of the
skin be interfered with, and the perspiration be
checked, we have diarrhoea not unfrequently esta-
blished as a compensation, or there is an increased
flow of urine  to  obviate  the injurious effects
which would otherwise be  induced by  the  sup-
pression of  the natural secretion.  Again, in dia-
betes, where the urinary secretion is increased, the
secretions both  from the skin  and the intestinal
mucous membrane are considerably diminished ;
and we have the constipated bowels,  the dry
glazed  tongue, and the harsh dry skin, which so
commonly  accompany  that disease.   Thus,  also,
in cases where the powers of life  are breaking up,
an alternation in the  state of the impaired  func-
tions may not unfrequently be observed strikingly
illustrative of these views.

   We come now to consider the second  class of
cases ;  namely, those in which  a  constipated  state
of the  bowels  is produced  by obstruction to the
passage of  the faecal mass through some part of
the  alimentary canal.
   1. One of the most important causes productive
of constipation by obstruction, both on account of
the very precarious state in which the  sufferer is
often placed, and the nature of  the remedies to be
adopted, is  the  constriction  of some part of the
intestines in  consequence of hernia.   The  con-
sideration of this cause belongs more especially to
surgery; but whenever obstruction of the bowels
exists, careful examination of  the usual seats of
ruptured intestine should be  made.   But without
producing  actual obstruction, the existence  of  a
hernia necessarily interferes with the regular per-
formance of the  functions of that portion of tho
intestines in which it is situated, both by inducing
a tendency to lodgment of the  faecal  matter in the
sac, and by disturbing the peristaltic action of the
muscular coat.  In the treatment of constipation
it will  be  necessary,  therefore,  to keep this in
view,  since  very different measures  may be re-
quired when a portion of the intestine is in such  a 
482
CONSTIPATION.
state, from those which would be  proper  under
Other circumstances.
  2. In  enteritis, colic,  and  ileus, constipation
forms a very prominent part of the disease, and
one  which, independently of  the  morbid  state
giving rise  to  it, frequently requires  much and
anxious attention. The subject is amply discussed
under the articles Colic  and Enteritis.   We
should, however, observe,  that it is  doubtful how
far those cases of colic which have been referred
to obstruction arising from spasmodic constriction
of a portion of the bowels are really  owing  to
this  cause.  We are convinced that  many of these
are to be attributed  to a paralysed state of portions
of the muscular coat of the bowels  rather than to
spasm ; that, in fact, the obstruction arises rather
ence in producing tbe disease ;  as, for instance,
where there is adhesion of a portion of intestine,
the regular peristaltic action of the  part is  im-
peded, and this  peculiar state of contraction ii
found to exist below the obstructed part, though
in such a case it can scarcely be supposed to arise
from  spasm.  (Pathological Researches, &c. p.
145.)
   3. But of all the causes which occasion consti-
pation of a very obstinate  nature, none are more
frequent and important  than certain changes of
structure which occur in the large intestines, the
whole course of  which,  commencing with  the
caecum  and terminating at the extremity of the
rectum, is  liable  to  various, and  some of them
 ntractable morbid affections.  It will be desirable,
spavin ^  luai, in mv/ij k«v ww wv»v..-------------
in that  part of the bowels  in  which  the  faecal  in enumerating some of  these, to enter rather
mass  is retained from defect of propulsive power,
than from spasmodic action of the muscular fibres
of the portion  immediately beyond it;  and the
modus operandi of opium in such cases  seems to
consist in moderating the action of  the propelling
fibres behind, and thus affording time for  the over-
distended bowel gradually to empty  itself of its
contents, rather than  in resolving the supposed
spasm of the portions beyond.   This explanation
is likewise more in accordance with many of the
more into detail than might seem at first  sight to
be necessary, as it will be impossible to lay down
any thing like  correct rules, with  respect to the
management of a  costive  state of the  bowels,
unless an  accurate view is taken of the more
obvious  deviations  from  health  in   the large
intestines which  are connected with  this affec-
tion.
   The diseases of the  caecum alone are  of great
importance, and until  lately have  attracted very
causes concerned in the production of these forms [ little attention.   Looking to the structure of this
                                                portion  of the  intestinal canal, and considering
                                                the complexity of its mechanism, it cannot be a
                                                matter of surprise that  it frequently becomes the
                                                seat of disease, and that occasionally we find the
                                                contents of the alimentary canal lodged in large
                                                quantities in this pouch.  Any one who reflects
                                                on  the  manner  in which the fold of mucous
                                                membrane projects from the  ileum, and is con-
                                                nected with the  corresponding membrane  of the
                                                caecum to form the valvular mechanism, by which
                                                a barrier arises between those  two  portions of the
                                                alimentary canal, must be prepared to find  in this
                                                part occasional  obstruction,  and  cannot  fail to
                                                wonder  that from year to year,  in many  indi-
                                                viduals, the functions of this admirable portion of
                                                the human machine are  performed  with the  utmost
                                                regularity and  integrity.  If it  be considered,
                                                further, that where the caecum connects itself with
                                                the colon, and for some distance afterwards, the
                                                contents of this  part of the  alimentary  canal are
                                                propelled forward  in opposition  to the laws of
                                                gravity, additional reasons  will  appear why  it
                                                should frequently happen that when the larger
                                                bowels  become  overloaded,  the  caecum  should
                                                more especially  suffer.
                                                   The natural construction, then, of this  part of
                                                the alimentary canal is  such as to  render it proba-
                                                ble that impediments might arise to the propulsion
                                                of its contents  onwards.  A state of costiveness
                                                is not unfrequently connected with intestinal con-
                                                cretions, and these are  most commonly  lodged in
                                                the caecum; and instances are recorded, where,
                                                after having been retained there for a considerable
                                                length of time,  they have been discharged  by the
                                                rectum.  A  nucleus  is  often found  imbedded  in
                                                 the centre of these concretions,  as  for instance,
                                                 some extraneous substance, which may have been
                                                 accidentally swallowed, and  after having  passed
                                                j into  the caecum, have  there  gradually collected
                                                 around it a considerable quantity  of faecal  matter;
                                                , thus it is well known that pins, needles, pieces of
of colic: thus, in the colic produced by lead, it is
more  consonant with the  known effects  of that
deleterious agent upon other parts of the body, to
infer that partial and irregular paralysis of portions
of the intestinal canal, rather than obstinate spas-
modic contractions, should result from exposure to
its  influence.  Dr.  Abercrombie's  observations
upon  this  subject, with the cases of which they
are illustrative, are well worthy of attentive study,
and the conclusions at which he has arrived are
in  strict accordance with the preceding observa-
ti ins.   The following considerations are adduced
by  him as confirmatory of the view which he is
disposed to take:—1. that the collapsed state in
which it assumes the form  of a cord appears to be
the natural state of healthy intestines, as  indeed
of  other muscular organs  when  they are  empty,
as, for instance, the bladder; — 2. that a state  of
uniform distension with lividity may occur as a
primary disease of  the intestinal  canal  without
any appearance of obstruction, and without  any
rart of it being in a contracted state;—3.  that in
ileus  the  collapsed  parts  are almost invariably
found in a healthy condition, the morbid appear-
ances being  for the most part confined to the dis-
tended part; — 4.  that the suspended action has
continued when the  obstruction below has  been
entirely removed, and the parts above were appa-
rently  healthy; — 5.  that  in a case where  the
application of galvanism was uniformly followed
by copious evacuations from the bowels, the agent
employed must have acted upon a part the func-
tions of which were impaired, not upon one which
was  spasmodically  contracted ; — 6.  that cases
occur in which the state of distension arises from
causes entirely of a different nature, without the
 peculiar contraction .'eferred to, at  the same time
 that there are  others  in which, though the disease
 .nay be traced to a mechanical cause, this peculiar
 contraction existed below  the seat  of obstruction,
 out could not be considered as having any influ- 
CONSTIPATION.
483
bone, and stones of fruit,  may  be detained, and
become the  centre  of alvine concretions.  Upon
this point much valuable information will be found
in Dr. Monro's work  on Morbid Anatomy, where
several interesting facts are described concerning
these productions, and their influence is shown in
interfering with the propulsive action of the bow-
els, and inducing constipation.
   It is of great importance to bear in mind that
these concretions, as well as scybala, collect in
large masses in the caecum and colon, as a want
of accuracy  in distinguishing this accumulation
has  often been the  occasion of embarrassment to
the practitioner, by  leading him to suspect  the
existence of some more important lesion in  the
adjoining viscera.   An accurate  examination of
the abdomen by compression will generally enable
him to distinguish the tumour which is produced
by distension  of the caecum, in  the  right iliac
region;  and  where this  is  unconnected  with
inflammatory action in the investing peritoneum,
but  little tenderness is  discovered  in  the part.
The  extent  to which the  caecum, on  some  occa-
sions, becomes enlarged, is very remarkable.   It
has been found sometimes  nearly equal in size to
the  stomach,  and the pressure  produced under
such circumstances by its accumulated contents,
has occasionally been so great that rupture of the
distended bowel has occurred.
   We have  now been considering the  least for-
midable  of those conditions of the caecum, which
are  productive of constipation ;  and all  that is
necessary in  such cases for  the restoration of a
more healthy state of this  part is, that  the  accu-
mulated  load should be removed.   This, however,
in the case of concretions,  is not always an easy
matter; for  they are  often very  firm in texture,
and cannot be dissolved by any medicinal agent;
and even when they are dislodged from the caecum,
and carried on into  the rectum, they are  some-
times  productive  of acute pain, and a  constant
and ineffectual effort to evacuate the  bowel by
stool, and may ultimately  require  surgical  assist-
ance  for  their  removal.  The following case,  de-
tailed by Dr. Walker, of Huddersfield, in a com-
munication  published in  the  Midland  Reporter,
(Vol. iii. p.  236,) is worthy of attention :
   " Lydia   Turner,  aged  forty-two,  had  for
twenty-three  years suffered from pain  in  the
right  iliac  region,  with  considerable  tumour,
which varied in size, and was larger  at  the time
of menstruation.  She was subject to great irregu-
larity in  her bowels, had  frequent diarrhoea, and
could part with little at once, which was as  fre-
quently  followed by  constipation.   On January
21st, 1827, whilst carrying a can  of water,  she
felt, as she  described, something break and  fall
down, which was followed  by immediate desire to
have a motion, but nothing passed.   After having
had  a restless night,  she  sent  for Mr. Jubb, of
Halifax,  and  stated she had  something  to  part
with, and that she had had pains, as  strong as
labour pains, all night.  On examination he found
a hard substance in the rectum pressing against
the sphincter ani,  which  appeared  too large to
pass.  It was, however, witb some difficulty, re-
moved with a pair of lithotomy forceps, and proved
to be a very large, hard, and tough scybalous mass.
Tbe woman  lost the pain, and had never  after-
wards  a  return of the tumour in the right iliac
region."
  The immediate cessation of all symptoms on
the removal of  the hard substance, necessarily
implies that there was  little  or no disease in the
texture of the caecum  in this case, and that the
accumulation arose from want of proper propul-
sive action in the part.  There are, unfortunately,
cases  where the  accumulation in the caecum is
combined with considerable  disease, either in the
peritoneum investing  this part of the alimentary
canal, or in its mucous lining ; either of which
occurrences makes the constipation more formi-
dable than if it arise solely from a want of proper
muscular action.   This is not the  place to enter
very fully  into  a description of this particular
form of disease, but its frequent connection with
constipation makes it necessary to place before the
reader  the more prominent characters which show
the existence of  this lesion.  In  addition to the
tumour, which  is  felt in the right iliac region
where  the caecum is simply distended by an accu-
mulation of faecal  matter, there is, when  its peri-
toneal covering is inflamed, tenderness on pressure,
usually confined  to the part, though not unfre-
quently extending more generally over the  abdo-
men.   Sometimes the functions  of the bladder
are affected by the contiguity of  the disease, and
a morbid  irritability of that organ results.   The
constitution, also, is generally more affected; the
tongue becomes white  and flabby, and occasional
nausea arises.   If the inflammatory action extend
itself to the general peritoneal covering of the in-
testines, there  are then present the more obvious
symptoms of peritonitis, under which the patient
usually sinks.   The following case strongly illus-
trates the destructive effect of this diseased action,
when it commences in the peritoneal investment
of the  caecum, and extends over the abdomen:
  A healthy boy,  aged ten years, received some
months before his death a blow on the lower part
of the  abdomen, after which he complained of a
good deal of pain in the  right iliac region, and
his bowels became costive.   As but  little import-
ance was  attached to the accident, no advice was
taken upon the  subject, and being at school, he
allowed his bowels to remain for a length of time
inactive, occasionally complaining of a good deal
of pain in the abdomen.   At length, after con-
tinuing for some weeks in this state, without any
medical assistance, he became so ill that prompt
measures  were demanded.  The case then pre-
sented all  the  appearances  of peritonitis; and,
more  especially, the tenderness on pressure was
remarked  in the  region of the caecum.  The most
active  treatment, by bleeding, general  and  local,
large doses of calomel, the warm bath, and blisters,
was adopted, but without avail;  and he died in a
week after medical advice was resorted  to.  On
examination of the body after death, the abdomen
was  found distended ; and when  a section was
made so as to expose its contents, a sero-purulent
effusion, amounting to about eight  ounces, was
discovered.  The  omentum   adhered slightly  to
the peritoneum.   The peritoneal covering of the
intestines generally seemed inflamed, and  towards
the right iliac region the intestines were evidently
united together by the deposition of lymph.   The
principal disease was in the peritoneum investing 
434
CONSTIPATION.
the caecum, the commencement of the colon, and
the termination of the ileum.  The colon and the
ileum were united to each other and to the caecum.
In all of  these parts  the peritoneum was much
thickened  and injected with blood.   Part of the
peritoneal  covering of the caecum was  ulcerated,
and corresponded to an ulcerated portion of peri-
toneum lining the lower part of the abdominal
muscles, just where  the  spermatic vessels enter
the abdominal ring.   There was a considerable
accumulation of faecal matter in the  caecum, but
the mucous  membrane lining this part was free
from disease.
  Affections of the mucous membrane  lining the
caecum are likewise not unfrequently the cause of
constipation.  Thickening of the membrane form-
ing what is called the valve of the caecum, occa-
sionally occurs, and produces obstruction to the
free passage  of the contents of the bowels.   The
following  case occurred in  a young lady of deli-
cate constitution, who had throughout life been
of a  costive habit of body.   For many weeks
previous to the acute  attack which seemed to be
the immediate  cause  of  death, the bowels  had
been unusually inactive, never indeed being moved
without the  use of active aperients.   She often
complained  also of uneasiness in the right iliac
region; but on examination, no particular tender-
ness was produced by pressure, nor was there any
remarkable tumour or fulness in that part.  After
having taken some active doses of cathartic medi-
cine,  without  any effect  being  produced on the
bowels by them, this young lady was  seized with
violent vomiting and  general pains over the  sur-
face of the abdomen, with considerable tenderness
on  pressure.  Very active  remedies, as  copious
bleeding,  large doses  of  calomel, blisters, warm
baths, were  used without any relief, and she  died
in thirty-six  hours after the severe symptoms came
on.  On examination after death the  peritoneal
covering of the bowels was very slightly  inflamed ;
but when the mucous  membrane lining the bowels
was exposed, it was  found  extensively diseased.
A great portion of the ileum showed marks of in-
flammatory action, and as that part of it was ap-
proached  which terminates  in the caecum, con-
siderable thickening was observed, and  when the
caecum itself was opened, the whole mucous mem-
brane lining  this bowel manifested great alteration
of structure.   The valve of the caecum  especially
was much  thickened, showing that  chronic in-
flammatory action had for a length of time been
going on in  that part.  The diseased  action ex-
tended to  the mucous  membrane  lining  the com-
mencement  of the  colon,  but  did  not  proceed
further.
   [Of late,  great attention  has been  paid to the
inflammatory affections of the caecum, as well as
of the  appendix vermiformis caeci;  and much
valuable information has  been obtained in regard
to pathological conditions, which had  been  pre-
viously overlooked.   (See Enteritis.)]
  It sometimes  happens that without any very
acute pain or other severe symptoms, a consider-
able tbickening  takes place  in  the  membranes
which compose  the caecum, and, excepting con-
stipation  and  emaciation, no other  remarkable
change arises in the  state of health.  For exam-
ple, a young woman, who had for the  most part
enjoyed very  good health,  became  costive,  and
was not in her usual spirits ; but not being other-
wise unwell, no attention was paid to this state of
things, although progressive emaciation was, after
two months,  added to the symptoms.  She at
length complained of pain in the right iliac region,
and on examination, a tumour, which was  tender
on pressure, was discovered there.  After this was
known, remedies were promptly employed ; leeches
and blisters were repeatedly applied to the neigh-
bourhood of the affected part; and  a course of
mercurial alteratives and saline aperients was com-
bined with these remedies; but they proved un-
availing, for  the young  woman  gradually ema-
ciated and died.  On examination of the abdomen,
the mesenteric  glands were  found  to be enlarged.
The stomach was healthy, and so were the small
intestines.  When the caecum was examined, its
coats appeared  much thickened ; indeed, in some
parts the coats  of this bowel were  nearly half an
inch in thickness.  This was produced by a de-
posit of layers of lymph upon the mucous mem-
brane.   The  commencement  of  the colon was
also similarly,  though not  to the same degree,
affected.
  But  thickening of a  chronic  nature in  the
mucous membrane of the caecum  is not the only
pathological change of this portion of the  intes-
tinal canal which  occurs in  conjunction with a
costive state  of the bowels.  The very reverse
now and then  happens, and  this membrane  be-
comes  exceedingly attenuated, and  in  patches
ulcerated, notwithstanding which the costive state
continues, as  the following observation testifies.
  The subject of this case was a lady of a deli-
cate constitution, who  was about  forty years  of
age.  She through life had  been  a victim to the
most obstinate  constipation, and had suffered  so
much from this cause, that she had for years been
in the habit of taking daily aperients ; at the same
time that the  most drastic  purgatives, which had
often been given,  had occasionally failed in pro-
ducing the desired effect.   Her last illness com-
menced  with  severe vomiting, accompanied by
acute pain in  the epigastric region, and  complete
inactivity of the intestinal canal.  In despite of
all remedies that could  be applied, the vomiting
and constipation continued.  She  lingered  many
weeks in this state, gradually emaciating, and re-
jecting  every kind of nourishment.   She con-
tinually referred to the  epigastrium  as  the only
seat of uneasiness; and as there was  no tender-
ness on  pressure of any part of the abdomen, the
sense of sinking at the pit of the stomach and the
continued  vomiting led the medical attendants to
suspect that there was disease either in the stomach
or the duodenum.  Not  a  suspicion  was  ever
entertained that the caecum or any  part of the
larger intestines was the seat of disease.   On
examination  after  death, the  stomach and duo-
denum were found perfectly  healthy.   The small
intestines  were empty :  the peritoneal  covering
of the ileum  seemed  redder than  natural.   The
mucous membrane of the small  intestines was
healthy.   In  the caecum the mucous membrane
displayed  a very curious alteration of structure:
it was  of a very dark colour, and had  become
very thin, so  that the muscular coat of the  bowel
was readily exposed.   In one  part the membrane 
CONSTIPATION.
485
was ulcerated for the size of a bean.  At the com-
mencement  of the colon  the mucous  membrane
was of a dark colour, and  as thin as gold-beaters'
skin.   The  least touch separated it from and ex-
posed the muscular  coat  of the intestine.   This
condition extended for about  a foot, when the
mucous membrane was  observed to be thickened,
and appeared inflamed, and in  patches ulcerated.
The inflamed and thickened state of the mucous
membrane with  occasional  ulceration continued
until  the colon  terminated in the rectum, which
latter  throughout its course from thence to the
anus  seemed to  be free from  any disease.  The
large   intestines  throughout were loaded  with
hardened faeces.   The liver was not quite healthy ;
it had a nutmeg appearance, and its texture was
less firm than natural.   The spleen and pancreas
were  healthy.
  There is much reason to believe that affections
of the caecum producing constipation, have been
frequently mistaken for  diseases of other organs,
and certainly for none more commonly than  for
diseases  of the liver; an organ which, for a long
period, was  regarded as  the fruitful source of all
abdominal disorders, whilst the affections which
arise  in the  course of the  alimentary canal  itself
were  much neglected.   The functions of the cae-
cum are likewise liable  to  be interrupted by any
deviations from  health  in the  contiguous parts,
whereby the propulsive  force may be so deranged
as not to transmit the  faeculent mass from the
small to  the  large intestines ; for if the neighbour-
ing viscera are only slightly altered in their struc-
ture,  the  passage  of the  contents  of the bowels
through  the  valve may  be materially impeded, if
not altogether  obstructed.  The part which  is
more  especially liable by its derangement of func-
tion to impede the propulsive action of the caecum
is the colon, particularly  the ascending portion,
and the transverse arch.
   Simple want of propulsive power in  the  colon
is sufficient  to cause accumulation in this bowel;
and when the ascending  portion  and the trans-
verse arch become thus distended with faeces, the
pressure upon the liver  occasionally so interferes
with its functions, that the diseased condition may,
without care, be  mistaken for hepatitis itself. The
pressure upon the ductus communis  choledockus
induces an icteric appearance, and  there is  even,
at times, uneasiness and fulness in the right hy-
pochondrium.   Constipation is of course the  re-
sult, and the caecum suffers distension  and conse-
quent disease.   We cannot, however,  at all times,
under these circumstances, discover any tumour
in this part,  as the enlargement must be consider-
able before it can be ascertained by external ex-
amination.  An  erroneous judgment,  therefore,
may readily be formed ; and the affection, which
is arising simply from the distension of the  colon
and caecum,  may be mistaken for enteritis or he-
patitis, or even  nephritis; for  it is by no means
uncommon for the urine  to be scanty and very
high coloured, and for pain to extend up the right
side of the loins and  to the region of the  right
kidney.  But under such  circumstances, the con-
stipation continuing, and the fteces being pent up
in the colon and  caecum, much irritation is  of
course excited, and long-continued disease of the
mucous membrane of these parts may be thereby
                                     2a*
induced; for the secretory glands of this  part of
the colon being necessarily  obstructed,  chronit
inflammation may be produced in them, and thick-
ening of the coats  of the  bowel to a prejudicia.
extent eventually ensue.
  Other and more serious organic affections  may
also result from  this disposition to constipation,
and from  the  disease of the mucous membrane
connected with it.   Ulceration may arise, or, what
is more common, a portion of this  large intestine
may become contracted, and thus  oppose a per-
manent obstruction to the  free passage of the con-
tents of the alimentary canal.   Examples are not
unfrequent,  and the following instance  may be
sufficient to adduce.  A labouring  man, aged for-
ty, had  been for  many months liable to constipa-
tion.  His bowels  occasionally would not be mov-
ed for a week, and he had been subject to  an ap-
pearance of icterus  when the  constipation was
most  urgent.  During the  paroxysms of pain,
which often came  on when the bowels had  been
some  time confined, he  writhed  about in great
agony, and tbe  pain was generally accompanied
with violent vomiting.  When, at length, by the
assistance of  enemata and active aperients the
bowels were acted  upon, a very large quantity of
faecal  matter usually  passed away, and it  was of-
ten of a pale colour.  In this case  there was not
any tenderness in  the right iliac region, nor was
there  any tumour to be discovered in that situa-
tion.  The patient, however, was a corpulent man,
and the examination was thus rendered more dif-
ficult  than it would otherwise have been.  After
various paroxysms of the nature above described,
and from which  he  had  been recovered  by ene-
mata  and aperients, he died in  very great suffer-
ing, apparently exhausted by the frequent recur-
rence  of vomiting and pain.  On  examining the
abdomen there was not discovered  any disease of
the peritoneum; the liver, spleen, and pancreas
were  likewise healthy.   The stomach also  and
the small intestines were not apparently diseased.
The caecum was enlarged, and  contained  a  large
quantity of faecal matter.  At about three inches
from its commencement  the colon became  very
much contracted, and for nearly an inch in length
it had a scirrhous  appearance, and when  a longi-
tudinal  incision was made in this  part, the coats
of the bowels had  a cartilaginous feel.  The cali-
ber of this part was so much narrowed  that the
little finger  could  scarcely pass through  it.   No
other  alteration of  structure was discovered in any
part of  the larger intestines  to the  termination at
the anus.
   It is worthy of remark, that  a stricture of any
portion of the colon may exist for a series  of
years, and the only result observable from it shall
be an habitual state of constipation, which, after
the occurrence  of paroxysms of severe pain re-
sembling colic, may end by abundant and relaxed
stools, into which  state of softness it appears to
be, under such circumstances, necessary  that the
alimentary mass should be reduced before it can
pass freely from  the  bowels.  After such a  state
has continued for  years,  and a costive condition
of the bowels  has been almost habitual, an lppo-
site state occurs, and a tendency to diarrhoea con-
stantly prevails.  There is reason to believe that
this change in the  condition of  the bowels, when* 
486
CONSTIPATION.
constipation has been long  kept  up by a stricture
in any portion of the colon, sometimes arises from
ulceration taking place in  the constricted portion
of the intestine, by which means a  more easy
transit is afforded to  the contents, and a greater
degree of irritation of the mucous membrane lin-
ing the bowels is produced.  The following  case  '
strikingly exemplifies this  circumstance.  A gen-
tleman,  aged sixty, had  for  more  than twenty
years been troubled with habitual constipation and
occasionally colicky pains.  After a severe  cold,
which  very much  affected  the bronchial  mem-
 brane, and from which he with difficulty recover-
 ed,  the  condition  of the  intestinal  evacuations
 became very much altered, and, instead of being
 costive  as they formerly were, always of a liquid
 nature,  two or three motions  occurring daily.
 Under this increased evacuation from  the bowels
 he became thinner and weaker.  His tongue also
 continually showed a  morbid  incrustation,  and
 the skin was  dry and rough.  The  most careful
 examination of the abdomen  could  not discover
 any unnatural tenderness ; and although he occa-
 sionally complained of griping  pains, it was  not
  very common for him to do so.  The  relaxation
  of  the bowels continued  for many months, and he
  sensibly  declined in flesh  and  strength.   At
  length, after  an unusually severe attack of diar-
  rhoea, which  was also  accompanied with hemor-
  rhage from the bowels, his life fell a  sacrifice to
  this prolonged disease.  On examination  of the
  abdomen, the peritoneum generally appeared  free
  from disease, excepting  at one  part, where  the
  arch of the colon was adherent to the edge of the
 liver.   The stomach  and  small intestines  were
 healthy ;  the  mucous membrane lining the caecum
 as well as at the commencement of the colon  was
 healthy;  but   near  the  transverse  arch it  bore
 marks of inflammatory action, and when the  in-
 vestigation  was pursued to that part of the  colon
 which was adherent to the liver,  a large ulcer was
 discovered, surrounded by very hard edges.   The
 ulcer extended nearly through  the circumference
 of this part of the intestine, and  the intestine  it-
 self was contracted for half an inch, as  is custo-
 mary in scirrhus.   The mucous membrane of the
 colon, extending onwards  to  its sigmoid flexure,
 was a good deal inflamed.  It may be inferred that
 the  habitual constipation  which  marked the life
of this gentleman for twenty years, was owing to
the contraction of the colon, and which was only
succeeded  by some months' diarrhoea, when ulce-
ration had so destroyed a portion  of the contract
irards  of
an obstacle to the free transmission onwa
the feces contained in the arch of the colon. But
in addition to this very common state  of contrac-
tion of the sigmoid  flexure of the colon, it ap-
pears to be correctly ascertained that organic stric-
ture of the intestines is more frequent in this part
than either in the ascending portion or in the arch
of the colon.  If, indeed, we attend to the annals
of medicine,  and  consider  the  many instances
there are on record of this form of disorganization
  .. this  portion  of the  alimentary canal, we are
 compelled to admit that it is  not an  unfrequent
 cause  of obstinate  constipation.  At  the  same
 time it should be observed, that in proportion as
 organic  constriction approaches the exit  of the
 bowels at the anus, so does it become more easily
  investigated by external means ;  and, consequent-
  ly, as  a cause of constipation, it is more frequent-
  ly ascertained when it occurs in  tbe sigmoid flex-
  ure of the colon than when it is produced in the
  ascending or transverse portion.   For in addition
  to the signs depending upon the disturbance of
  the intestinal action which direct us in this as
  well as in  other intestinal  affections, we have it
   also in our  power, in this instance,  by passing
   bougies  and flexible  tubes,  to  become tolerably
   certain  of the diseased state into which the intes-
   tinal  tunics have degenerated, at least when the
   scirrhous condition is so  far advanced as to pro-
   duce  any extraordinary obstruction to the transit
   of faecal matter.  It is true that this investigation
   may not be very easily made by those who hastily
  come to a conclusion with respect to the state of
  their patient; yet the anxious inquirer after tmth,
  although not always  able  to cure the  affection,
  may have the satisfaction of discovering the cause
  of the constipation, and  of laying down such a
  plan as may materially alleviate the suffering, and
  for a time at least  arrest the fatal termination.
  There is nothing novel in cases  of this kind, but
  still it is not amiss to impress the mind with strik-
  ing facts which bear directly upon  any subject
 under consideration, and the  following example
 seems very much to the  purpose.  A  gentleman,
 aged fifty-eight,  who had  for many years been in
 the East Indies, and was of a full habit, and what
 is commonly called a strong constitution, became,
 after his return from India, liable to  constipation,
 for which, during the space of two or three years,
 he was in the habit of  taking aperient medicines.
 At length the constipation assumed a  more seri-
ous aspect, for it became very difficult to move the
bowels excepting by  the exhibition of very  active
ed part as to  render  the  passage of the  contents  cathartics; indeed, so  obstinate did they become,
more easy, and when in  consequence a greater  that they resisted  altogether ordinary measures,
 degree of irritability had been given to the whole
 course of the large intestines.
   But it is not either in the  ascending portion or
 in the transverse arch of the colon that alterations
 of structure,  producing  constipation, are most fre-
 quently brought under our notice. It is at its sig-
 moid flexure  that this intestine seems more  espe-
 cially prone to fall into  a state  of disease.  Spas-
 modic stricture, in this part, appears  often to arise
 and  to be the cause of constipation.  On exam-
 ining bodies after death, the tendency to contrac-
 tion  of this portion of  the alimentary canal  has
been frequently observed, and where tbis tendency
•svists to any  great extent during life, it must prove
 and in consequence vomiting  and distension of
 the abdomen came on.  He was treated  as  for
 enteritis,  by bleeding,  warm bath, calomel,  and
 castor oil, and enemata were  administered.  He
 recovered under these measures, but it was only
 to suffer at the end of a short  time a recurrence
 of the symptoms.   The same , wnedies then failed
 to relieve  him, and the common form of enemata
 returned without any quantity of faecal discharge.
 I was at  this juncture that it was thought desira-
 ble  to ascertain whether, by introducing  a hollow
tube into the colon, and by  injecting warm fluids
 nto it, any beneficial effect might result, and whe-
ther any obstruction  might thereby be discovered 
CONSTIPATION.
4ff»
in the sigmoid flexure.  No  obstruction was ex-
perienced within ten inches of the anus ;  but at
about twelve inches there seemed to be a difficulty
in passing on  the  instrument.  A considerable
quantity of fluid, however, was injected into the
intestines, and  it was happily followed by a free
evacuation of their contents.   The patient  from
that time again recovered, and by the habitual use
of gentle saline aperients, and the daily injection
of warm fluids into the colon, he was  for several
months kept  in a very comfortable state, and en-
joyed  very  tolerable health;  fatal  obstruction,
however, in the end took place, and he died about
a year after the attack before-mentioned.  On ex-
amination after death, all the viscera of the abdo-
men were quite healthy, excepting the caecum and
colon.  The caecum showed  marks  of much dis-
 tension, and its coats  were  thickened, and the
 mucous membrane lining this  part was inflamed
 and thickened.  There  was  nothing  worthy  of
 notice in the ascending portion or transverse arch
 of the colon; but in tbe sigmoid  flexure, not  far
 from the rectum, there was a very  remarkable
 narrowing of the intestine.  For the space of half
 an inch the coats of the bowel had here become
 scirrhous and  cartilaginous,  and  ulceration was
 commencing in  the  inner portion.   The  colon
 and caecum were much loaded with faecal matter.
   But  without  any particular contraction occur-
 ring in any one portion of the large intestines, it
 sometimes happens  that  habitual constipation is
 accompanied with  a  general  thickening  of the
 mucous membrane lining the caecum and colon,
 and the sigmoid flexure of the colon is more espe-
 cially the seat of this alteration of structure.  The
 means  of investigating this state of the large  in-
 testines do not often occur, as, unless  some  other
 disease be connected with it, fatal  effects  seldom
 result.   A lady, aged forty-five, who died of can-
 cer of the breast, had always been of a very costive
 habit of body, and had latterly never been  moved
 without the aid of aperients or enemata.  She bad
 occasionally  suffered very much from pains of the
 abdomen and griping, and when the bowels were
 much constipated had been subject to attacks of
 vomiting.  Death took  place  apparently  not so
 much from this state of the bowels as from the
 exhaustion  induced  by  the  cancerous  affection.
 On examination of  the  body, the stomach and
 intestines as far as the sigmoid flexure of the  colon
 were healthy, but from that part to the middle of
 the rectum there was considerable disease.  The
 mucous membrane was thickened and highly vas-
 cular, and the  inflammatory action had  extended
 to the  other coats of the  bowels, and the perito-
 neum  covering that part  of the colon was found
 adhering to  the  contiguous parts.   The thicken-
 ing and adhesions seemed to be of long standing.
   4. Numerous, however, as are the instances in
which a costive state of the bowels is produced by
disease in the  caecum and colon, they are  not so
frequent as  those which arise from affections of
the rectum.  The structure and functions  of this
part of the  intestinal canal, and  its contiguity to
important viscera in the pelvis, in  some measure
account for  this. "The  rectum," observes Mr.
Chevalier, "  commences from the colon, close to
the last vertebrae of  the loins, and passing down
into the hollow of the sacrum, it takes the curva-
ture of that bone, in which it lies comparatively
loose, invested  anteriorly, but not posteriorly, by
the peritoneum.  When it reaches the os coccy-
gis, it quits  the peritoneum entirely, and  is con-
nected  loosely  by  cellular membrane with the
bladder, in the male, and the vagina in the female,
with the muscles  of the perineum, with the leva-
tores ani, the sphincter  ani, and the common  in-
tegument.   This  lower portion  of the rectum is
easily  distensible ;  but  while it is  in a  natural
state, the peculiar sensibility of its internal surface
speedily excites it, when  moderately  distended,
unless the faeces are unnaturally hard, to expel its
contents, and its muscular fibres are  competent to
enable it to  do  so, with a very moderate assistance
from the action of the abdominal  muscles.  It is
needless to say of how  much consequence it is to
the general health that the sensibilities of this im-
portant organ should  remain unimpaired, and that
strict attention  should be paid to the regular per-
formance of its functions ;  if this be long neglect-
ed, its  natural sensibility becomes gradually di-
minished, it will remain overcharged for an undue
time ;  the energy of  its muscular fibres will  be-
come impaired  ; so that a  more forcible  exertion
of the  abdominal muscles will be required to expel
the stools, and  not unfrequently this will often be
insufficient, without  some medicine be taken  to
quicken the action of  the bowels."   (Medico-
Chir. Transactions, vol. x. p. 402.)
   The morbid affections we shall notice as occur-
ring in the  rectum, so  as either to cause or in-
crease the constipated condition of the bowels, are,
relaxation of the rectum, stricture of the  rectum,
haemorrhoids, and  spasmodic contraction  of the
sphincter ani.
   Relaxation of the  rectum is not unfrequent in
delicate children,  in whom, when the bowels have
been for some  time in  a very irregular state, the
rectum is often found  to  become prolapsed,  ap-
parently from the want of a due  degree  of con-
tractile power in  the  muscular parts of its  lower
portion.   This form of relaxation of the rectum is
very common ; but there is another which is  not
so  open to  observation,  and which has  conse-
quently often been  passed without being noticed.
It exists ' sometimes without any external protru-
sion of tbe bowel, for the whole  of this portion of
the  intestinal  canal  becomes  much  distended,
whilst the colon, and the rectum itself above  the
distended part, retaining  their contractile power,
the upper part of the  rectum sometimes falls down
within the lower, constituting what may be  term-
ed an  internal prolapsus.   The harmony of action
between the upper and lower part of the rectum
being  thus destroyed, the stools  are expelled with
difficulty in small irregularly-shaped pieces.   The
difficulty thus  occasioned becomes a source of
considerable irritation to the lower part of the rec-
tum,   and  tenesmus, with  ineffectual  straining,
leads to distension of the haemorrhoidad veins and
increased secretion of mucus from the intestine
The parts adjacent  do not fail to  suffer from this
disturbance  : in men, the prostate gland and neck
of  the bladder become affected;  and  in  women
uterine irritation and frequent micturition are the
result.   In  other instances the rectum  becomes
dilated to an almost incredible  extent,  and  tht>
whole pelvis filled with  faeces ; whilst, at the same 
4^8
CONSTIPATION.
time, little or  no effort is made by the bowels to
discharge this extraordinary accumulation.   This
state of the rectum is most commonly observed in
females, and in those whose sedentary occupa-
tions lead  to  a neglect of  those measures  neces-
sary to ensure regularity of the functions  of the
intestinal  canal.
   Stricture of the rectum is, doubtless, a much
more  frequent disease than, until  within these
few years, it was supposed to be.  In all cases of
constipation  of long duration, the  state of this
part of the intestinal canal should be particularly
examined, with a view to  ascertain  how far it is
connected with stricture.   Mr.  Salmon,  in  his
late Essay on Stricture of the Rectum, considers
this bowel as composed of three portions ; the first,
or upper portion, extending from the termination
of the sigmoid flexure of the colon half way to the
anus,  and  having  its concavity forwards;  the
second, or middle portion, extending to the pros-
 tate gland, and  having its concavity upwards;
the third  comprehending the last two inches of
its course, and having its concavity turned slightly
backwards;  and he  is of opinion  that stricture
 always occurs at the junctions  of the  upper and
 middle, or of the middle and lower of these com-
 ponent curves of the rectum with each other, or
 at the point where the upper curve unites with the
 sigmoid flexure of the colon.  Its  most frequent
 seat appears  to be at the junction  of the upper
 and middle curves,  five or six  inches  from the
 anus, and consequently beyond  the reach  of the
 finger.  The next most frequent seat is where the
 sigmoid flexure of the colon terminates at the rec-
 tum ; and  it is  least frequently found in  the im-
 mediate vicinity of the spbincter ani.
    Many symptoms are written down in books  as
 attending upon a contracted state of the  rectum,
 but little dependence can  be placed upon these  as
 being always present; and with the exception of
 constipation, we cannot rely with confidence upon
 any.  It cannot, therefore, be too often repeated,
 that when costiveness exists habitually, the state
 of the rectum should be closely examined,  For it
 has been clearly proved by the  labours of Sher-
 win,  Mossman, Home, Copeland,  White, How-
 ship, and Salmon, not only that  scirrho-contracted
 rectum, — a disease, the carcinomatous malignity
 of which but too surely defeats the best-directed
 attempts of the practitioner to save the life of the
 sufferer,—is of not infrequent occurrence, but also
 that much more often stricture of the rectum may
  arise from  other causes of a far less  serious na-
  ture, which by skilful management admit of cure
  or alleviation.  It seems now  to be pretty gene-
  rally conceded, that stricture of a  spasmodic na-
  ture, not dissimilar to spasmodic stricture of the
  urethra, may arise in the rectum, and, if not judi-
  ciously managed, may lead  on  to thickening and
  induration  between the muscular and villous coats.
  Even in this stage, however, the suffering may be
  considerably alleviated;  and when  the  disease
  arises from  causes of an accidental nature, as  the
  irritation of drastic purgatives, it may be altogether
   removed.   Should it originate even in some defect
   of structure, as  from narrowness  of the sigmoid
   flexure of tne cmon, or from unusual prominence
   of the superior part of the sacrum, still the prac-
   titioner may hope to afford some alleviation of the
costive state, by bearing in mind the  cause upon
which it depends.
  Habitual costiveness, then, being the most con-
stant effect produced by a  strictured  state of the
rectum, we need not dwell here on the sense  of
fulness, which is said  generally to be felt in the
transverse arch of the  colon, and especially to-
wards  the sigmoid flexure  of that bowel;  on the
sense of pressure, and sometimes acute pain with
violent spasmodic  contractions near the same part;
on the uneasiness felt on going to stool, attended
with difficulty in voiding the  faeces;  on the sen-
sation of tenesmus and uneasiness still continuing
after the evacuations ; or on the changes in quan-
tity, size, and figure induced  in  the  evacuations.
   We must  not allow ourselves to be lulled into
a false security by the stools not having an irregu-
lar figure, and not being in  small quantity at a
time; for Mr. White very justly remarks,  " if the
stricture should happen to be so low in  the rec-
tum as not to allow room for the accumulation of
the  fseces, it  must appear evident that they will be
found uniformly  small  in diameter  (in  propor-
tion to the  degree of stricture,) while they con-
tinue to be  discharged  in a  figured  state.  And
also, when  the stricture is high up in the rectum,
so long as the gut below retains its natural expul-
sive power,  an accumulation will be prevented,
 and the diminished size of the faeces will continue.
   But as the disorder increases, the   inferior por-
 tion of the intestine  gradually loses  that powc#;
 and when the contraction becomes considerable, a
 small  quantity of faeces only  passes at a time
 through  the stricture,  and  being insufficient to
 stimulate the lower part of the rectum, which in a
 great measure is deprived of its natural action, an
 accumulation goes on from time to time, until at
 length it becomes difficult to  remove ; and on
 these occasions faeces  of a natural size are often-
 times discharged."
   In  the costiveness which depends upon me-
 chanical obstruction of the  fseces in their passage
 through the rectum, we have before  observed that
 pains of a spasmodic nature in the  course of the
 colon occur; and there is also often  a  sensation
 as if a cord were  tightly tied around  the abdomen.
 The great distension  to which the colon is occa-
 sionally  subjected from the accumulation of faeces,
 owing to the costiveness produced by the strictur-
 ed  state  of the rectum, may explain  these distress-
 ing feelings.  The enormous extent to which the
 colon becomes dilated, in some instances, in con-
 sequence of this  mechanical obstacle to its passing
 forward its contents, is truly astonishing.   Its
 circumference, under such circumstances, has been
  found, throughout its whole course, equal to  that
  of  a stomach  of the full size, and  the muscular
  fibres  and  longitudinal bands proportionably in-
  creased in size.
     It is usually in cases where the costiveness has
  been in existence for a very long period that the
  colon is found so enormously distended, and when
  stricture of the  rectum has proceeded  gradually,
  and has at length arrived at so aggravated a  state
  that scarcely any fseces can pass through the con-
  tracted  part,  that this dilated  condition  of the
  colon is most  remarkably developed. The follow-
  ing case occurred some years ago at the Worces-
  ter Infirmary.   The patient,  Elizabeth Stockall, 
CONSTIPATI ON.
489
was for three or four years the victim of stricture
in the lower part of the rectum, which was suffi-
ciently near the sphincter ani to admit of her be-
ing relieved  from time to time by dividing  the
stricture with a bistoury ;  and for two years the
accumulated  faeces arising from the  costiveness
were, as it became necessary, removed either by a
division of the stricture, or by the use of glysters.
She never complained of much pain down at  the
strictured  part of the rectum, but very often in the
direction  of  the  sigmoid  flexure  of the colon.
There was in this case so little  contractile power
in the rectum below the stricture, that the faeces
passed by little and little  through the contracted
part,  and accumulated in large quantities  in a
pouch below the contraction, and it was necessary
to wash this  accumulation away by the repeated
use  of clysters.   At  length, the strictured part
would  no longer admit  of  the passage of any
faeces, and stercoraceous vomiting took place, soon
after  which  her existence terminated.   On ex-
amination of the abdominal viscera, the first thing
that claimed attention was  the  arch of the colon
distended to the size of a large stomach, and com-
pletely concealing the small intestines. On further
tracing the colon, the dilation of it was found to
be equally great  from the csscum to its termina-
tion in the rectum.   The sigmoid flexure of the
colon was displaced  from its usual situation, and
 lay across from the  left to the right iliac region.
The rectum  also, from its commencement to the
 strictured part, near the anus, was equally dis-
 tended. The faecal matter contained in the caecum
 was hardened, but that in the colon and  rectum
 was soft and pultaceous.
   Numerous, then, as are the instances in which
 costiveness depends  upon stricture of  the rectum,
 we must again revert to the importance of atten-
 tive examination of  this part  in habitual costive-
 ness ; for although additional symptoms often un-
 equivocally point to this lesion  when it exists, as
 in the above examples, in  a very marked  degree,
 yet there are instances in which, with the excep-
 tion of costiveness, no symptoms point to this dis-
 eased state of the bowel, and the practitioner can-
 not  have this  important truth  too strongly im-
pressed upon his mind,—that actual examination
 by the finger or bougie, after the faeces have been
evacuated, during which the patient should make
 an effort as if to go to stool, is the only means of
detecting this disorder.
   Hxmorrhoids have an intimate relation to cos-
 tiveness.  This affection,  in  its commencement,
appears generally as  a determination of blood to-
wards the rectum, recurring periodically and irre-
gularly, and may be produced by any cause which
interrupts the  free return  of blood from the rec-
tum.  The pressure of faeces habitually retained
in this bowel  is, consequently,  one of the chief
causes  from  which  this  troublesome affection
arises.  It would be deviating from the subject of
this article to enter into any lengthened statement
regarding the pathology of piles ; neither is it ne-
cessary here to enter at  any length into the in-
quiry, whether they are to  be generally regarded
as merely a topical affection.  Dr. Cullen was of
opinion that the disease  is purely local, and his
reasons for so considering it were, that piles take
p.ace before the period of life at which a venous
   Vol. I___62
plethora  happens; that they frequently  arise in
females in whom a venous plethora determined to
the haemorrhoidal vessels cannot  be  supposed to
occur ; and that they happen to both sexes, and to
persons of all  ages,  from causes which do not
affect the system, and which are manifestly suited
to produce a topical affection only.  According to
Martinet," piles appear under the form of tumours,
varying in size  and more  or less  thickly  set, aris-
ing from the dense cellular tissue which  connects
the mucous to the muscular coat, contained in a
sort of cyst, thin, smooth,  or sometimes villous in
its interior, and adhering by its external surface to
the submucous cellular membrane.  In many in-
stances these tumours are  formed  of a reddish vas
cular spongy tissue, or of a sort of parenchyma or
fungous  flabby tissue,  analogous to  the  erectile.
Sometimes they depend upon  partial dilation of
the veins, which  may be easily proved by the in-
troduction of a probe into the vessels."
   Mr. Calvert, in his practical treatise on haemor-
rhoids, makes a  very proper distinction  between
the two kinds of haemorrhoidal tumours, viz. the
firm fleshy, tubercular masses which form the pro-
per and  genuine piles, and the  dilated vein or
haemorrhoidal varix, which essentially differs from
the former in morbid structure.   It is scarcely ne-
cessary to point out the importance of a cautious
examination of these tumours when they arise in
persons of a costive habit  of  body.   Their fre-
quent connection with stricture  of  the  rectum,
with  diseased uterus, with diseased prostate gland,
and with  prolapsus ani, all  force  upon us the ne-
cessity of carefully investigating  all  the  circum-
stances arising in or near the rectum which  may
exert any influence in keeping up the costive
state.   (See  Hjkzmorroids.)
   The fact is incontestable, that piles  are not  only
a common effect of constipation, but that  they
likewise frequently themselves become a  cause of
aggravating the previous inactive condition of the
bowels.   This manifestly  arises from their offering
a mechanical obstacle to the descent of the faeces ;
for by their  number and  magnitude they some-
times block up the lower part of  the rectum.   At
the same time  it is also by no means uncommon
for these  tumours,  by their long continuance or
frequent recurrence, to produce considerable thick-
ening in the  cellular membrane which surrounds
the lower part of the rectum, and in this way mate-
rially to interfere with the action of the sphincter
ani.  Persons who suffer  from haemorrhoids are
very  subject to prolapsus ani ; and the thickening
which occurs in the cellular membrane  near the
anus often increases the uneasiness that arises
from this cause.   In  the  common  accident of
falling down of the lower part of the  rectum, this
bowel is generally soon replaced ; but if there be
thickening of  these parts, an unyielding ring is
sometimes formed which  does not readily return,
a circumstance  which sometimes operates  very
unfavourably as  an obstacle to the evacuation of
the rectum.  It must also  not be forgotten  that
internal piles occasionally occur from the enlarge-
ment of the veins higher up  in  the  rectum, and
there offer a mechanical  obstruction  to  the  pas
sage  and discharge of the  faeces.
   But there  is another mode  in  which piles  may
prove a cause of constipation,—by spasm of the 
490
CONSTIPATION.
sphincter ani.  These tumours  are  liable to be-
come inflamed, and when  they are so, the  sensi-
bility of the mucous  tissue surrounding them is
greatly  increased.   This  is propagated  to the
sphincter ani, and sometimes violent contraction
of this muscle takes place, and thus spasm of the
sphincter ani, by impeding the  evacuation of the
rectum, becomes an occasional cause of constipa-
pation.   The  office of this important  muscle is,
so to close the extremity of the rectum as to pre-
vent the escape of its faecal contents, unless when
a voluntary  effort is made for that purpose.  But
under some  circumstances of increase of the sen-
sibility  of the  mucous  surface  lining the lower
part of the rectum and the verge of the anus, this
muscle  sometimes becomes spasmodically affected,
or contracts with too much power, and in this
manner offers a barrier  to the  evacuation of the
rectum.  When this  condition  arises, it requires
a more  than ordinarily powerful voluntary  effort
to pass  the faeces ; and if they happen to be hard-
ened and in large quantity, the evacuation is with
great difficulty, or not at all, effected.
   Spasm, however,  and increased action of the
sphincter ani may exist without our being enabled
to detect any inflammatory or other local affection
likely to call  it forth, and thus may  become in
itself a legitimate cause  of constipation.  In deli-
cate females of high sensibility, and who are of
the  idiosyncrasy usually called  nervous, it is not
unusual to  observe  obstinate   constipation, the
faeces being  retained in  the rectum,  On examin-
ation of the rectum we  may fail to find any local
cause capable of accounting for this effect, except-
ing  a highly spasmodic  state of the sphincter ani.
In such cases the vehemence with which this mus-
cle contracts on the slightest stimulus being ap-
plied to it is so great, that it is often with diffi-
culty that, for  a time, even the tip of the  finger
can  be passed within its circumference.  In short,
the  sphincter seems  to partake of the increased
mobility which characterizes the general system.
When, however, such a state takes place, it must
obviously oppose  an obstacle to the passage of
stools from  the rectum ; and we need not, there-
fore, further insist on the necessity, in all cases of
nervous excitement, of taking the spasmodic affec-
tion of the sphincter ani into consideration, when
endeavouring to obviate habitual constipation.
   We have now passed under review the princi-
pal  causes existing within the alimentary tube or
in immediate connection with its functions, which
concur in producing a constipated state  of the
fecal discharges ; and  we have only further to
offer a few observations  respecting those causes
which may  be termed external or adventitious, to
conclude this part of our subject.
   Among the most important of these are tumours
existing in  various parts of the abdomen, which,
by their pressure upon different portions  of  the
intestines, frequently obstruct  the passage  of the
faeces.    When these tumours are of considerable
size, they may in general be readily detected, and
their connections by a careful  examination to  a
certain extent ascertained.  Those existing in the
 neighbourhood of the rectum, sigmoid flexure of
 the  colon, and caecum,  are most likely to produce
 constipation.   It  is, however, in cases in which,
 in consequence  of inflammation, adhesions and
connections of portions of the intestine have been
formed, that obstruction  of the bowels generally
occurs.  These  adhesions may be  such as mate-
rially to impede  the ordinary and regular progres-
sion of the faeces by interfering with the vermicu-
lar action of the muscular coat of the bowel, or
they may be such as to produce complete obstruc-
tion by  the constriction  and pressure  induced.
The following case affords  an illustration of these
observations:—A woman of middle age, the mo-
ther of several children,  had a tumour occupying
nearly the whole of the abdomen, in which fluc-
tuation was distinctly perceived.  The urine was
scanty and turbid, and there was much constitu-
tional  disturbance.   Digitalis and  other diuretic
remedies were employed  with the effect of induc-
ing a free discharge of urine and the rapid subsi-
dence of the tumour.  Some months afterwards
the swelling had partially returned, and the bowels
had become constipated.   The abdomen was now
found  irregularly tumefied and  painful on  pres-
sure, but not much enlarged; and  at this period
fluctuation could not be  satisfactorily made out,
There was, however,  obstinate  constipation,  vo-
miting, quick small pulse, shrunk  countenance,
and prostration  of strength.  She  lingered  some
days in this state, but no  means which could be
employed produced any  effect  upon the bowels.
On inspection both ovaria were  found  to be  en-
larged ; the left  was not  much larger than a full-
sized orange, but the right ovarium occupied nearly
the whole of the lower part  of the right side of
the abdomen, and upon bern<r opened was found
filled  with  faecal  matter.    The intestines  and
other abdominal viscera were so  agglutinated to-
gether that it was impossible to trace any portion
of them, but it appeared  that the communication
which had formed between the right ovarium and
the large intestine was at the spot where from the
pressure complete obstruction must have been pro
duced.
   The  importance of instituting an examination
of the rectum in all cases of obstinate constipa
tion has already been fully insisted  upon.   In
the thirty-first volume of tbe Edinburgb Medical
and Surgical  Journal, a  case is reported by Mr.
Alexander, of Wooler, which, at the same time
that it sfl'ords  a singular  and interesting example
of obstinate constipation  caused by the pressure
of an enlarged and scirrhous uterus, forcibly shows
the  necessity of  careful  examination wherever
there is any difficulty in tracing the constipated
state to its  cause.  " The patient,  a woman who
had been  labouring under habitual and in  the
present instance obstinate costiveness, stated that
for a long time past she had had great difficulty in
voiding her stools, which were  always passed in
small quantity, and very  much  flattened.   Upon
examination per anum the obstruction was found
to be produced by an enlarged and  indurated ute-
rus mechanically compressing the rectum against
the upper part of the sacrum. At a little distance
from the anus a part of the  scirrhous mass  could
be felt of a pyriform  shape; and after the finger
was carried over this, a still larger projection could
be discovered  extending  backwards and upwards,
and partially occupying the hollow  of the sacrum;
beyond this neither the finger nor any instrument
could be passed.   The  coats of tbe rectum ap- 
CONSTIPATION.                               49]
peared perfectly sound, and could be made to slip
backwards and  forwards  over the  surface of the
tumour, indicating that, as far as the finger could
be passed, there existed no adhesion between them
and  the  morbid parts.  The os uteri examined
per vaginam was  considerably dilated.  Its lips
and the inner surface of the cervix, so far as could
be felt, were  thickened   and of a cartilaginous
hardness.   By introducing the fore-finger of one
hand into the rectum, and of the other into the
vagina, a considerable portion of the indurated
mass could be as it were embraced between them,
which could thus  distinctly be  felt  to  involve
almost the whole substance of the womb."  The
passage was  kept open for a few days  by render-
ing  the faeces liquid,  but  in the course of little
more than  a fortnight the  obstruction  became
complete, all measures made use of to remove it
being of no avail.   In this state  she  lived nine
weeks, during which time she suffered  much from
paroxysms of severe pain and from sense of dis-
tension.   At the expiration of this period, proba-
bly from some  change having taken place in the
tumour, violent  diarrhoea came  on, under which
she  ultimately sunk exhausted.   No  inspection
could be obtained.  (Edin. Med. and Surg. Journ.
vol.  xxxi. p. 220.)
   A similar effect upon the function of defecation
may be produced by displacement of the uterus—
a morbid condition  which, although  not strictly
speaking a tumour, yet by the unnatural pressure
which it occasions upon the bowel, may act pre-
cisely in the  same manner in obstructing the pas-
sage of its contents.   An example of this kind is
narrated in Hufeland's Journal, by Dr. Pitschaft,
of Baden, and quoted by Dr. James Johnson in a
late number of the Medico-Chirurgical  Review:—
'• A  woman who had passed through several diffi-
cult labours, suffered  for  three  months (during
which time  the catamenia  were  absent) from
various distressing feelings in the  abdomen, and
at length from  a retention of urine and from a
most obstinate  constipation.  The urine was dis-
charged only by drops, and the use of the cathe-
ter was  therefore  required.   For the space of
twelve days no evacuations from the bowels could
be procured, although  all sorts of purgative medi-
cines had been tried,  and the distress of the pa-
tient was extreme from an almost constant tenes-
mus, complete  loss  of appetite, nausea,  and a
tympanitic distension of the belly.  Dr. Pitschaft
was summoned to her  relief; he at once suspected
the existence of a retroversio uteri; and his sus-
picions were verified  by  a vaginal examination.
The uterus was easily replaced, and anodynes and
gentle aperients soon restored  her  to  perfect
health."
   Other   causes productive  of  constipation  by
pressure upon the bowels  from without might be
enumerated, but it will be sufficient in this place
briefly to  allude to diseases of the spinal column
and undue prominence of the upper part of the
os sacrum.  Either of  these causes may be instru-
mental, under  certain states of the  alvine dis-
charges,  in  producing constipation.   When the
distortion induced by disease of  the spine is con-
siderable,  the  narrowing of the  pelvic  orifice
which occasionally occurs is such  as  very mate-
rially to interfere with  the propulsion of the feces
through the lower bowel, and accumulation in the
sigmoid  flexure and  descending portion of the
colon is a necessary consequence. The projection
of the sacrum may  also  occasionally  act  in  «.
similar manner, namely, by narrowing  the pelvis
and thus impeding the passage  of the faeces froir
the lower portion of the colon into the rectum.  P
is necessary to keep these causes in mind,  since
in  every case the  degree of relief afforded  must
necessarily  in a  great  measure  depend  upon a
correct estimate being formed of the morbid con-
dition from which the symptoms take their rise.
  Treatment. — Perhaps  there is  no variation
from  the state  of health  to which the  humat.
frame is liable, in which the importance of correct,
rules  of practice  is less understood and appre
ciated than that under consideration, and certainl*
none  in which  the habitual comfort  of  a  largt
proportion  of the community is more  intimately
concerned.  The annoyance arising from the con-
stant  necessity of taking  aperient medicines  is
only to be conceived by those who have in their
own persons experienced it, or  have  been in the
daily  habit of witnessing it in others.  The ha-
bitual  use  of strong  cathartics, the  necessity for
which is often induced by  the  practice  of taking
them, affords in but too many instances most for-
cible illustrations of the evil effects of empiricism,
various instances of  organic disease of the sto-
mach and intestines being manifestly derived from
their  employment.  We can  scarcely therefore
estimate too highly the importance of establishing
those principles which may  lead to a more correct
mode of treating, not only the severe  forms of
constipation, but  those minor degrees  of  this af-
fection which, arising from various causes, are of
daily  occurrence, and  require for the  most part
much care and attention to rectify.  In the obser-
vations which follow  we purpose to pursue the
same divisions of the subject by which we have
been guided in  the preceding part of this essay;
and by pointing out the relations existing between
the various morbid conditions giving rise to this
functional disturbance and the general principles
of treatment applicable to  each, we  hope to lay
down such rules as may  prove  serviceable in the
management of a class  of diseases  which  every
practitioner will find to be  of nearly equal extent
with the practice in which he is engaged,  and the
correct treatment  of which involves the  comfort
of almost every patient intrusted to his care.
   We have referred simple constipation to  debil-
ity of fibre, to  deficient or altered secretions, to
indigestible or improper food, to increased  tone, to
an oppressed state of the cerebral functions, and
to an increase of one or other of the secretions
from the skin, kidneys, and  other organs not so
immediately connected with the intestinal canal.
   1.  The indications of  treatment in constipation
arising from the first of these causes, where there
is simple debility of fibre or loss of tone in the
muscular coat of the bowels, are, manifestly, great
care in the regulation of the diet, and such a com-
bination of mild  aperients with  tonics as  shall
effect the object to be  attained without inducing
local irritation or over-excitement of any  portion
of the affected organ*.  A  weak  muscular organ
may be completely paralyzed by over-exertion,  at
the same time that moderate exercise with appro 
492
CONSTIPATION.
priate support may restore its tone and  enable  it
to fulfil its functions with efficiency and regular-
ity.  Nothing can  be more injurious,  therefore,
in the convalescence from acute diseases, during
which, as has been before shown, a degree of this
weakened condition is always to be found, than
the practice of giving powerful doses of cathartic
medicine, because the debilitated intestines do not
evacuate their contents with the same  regularity
and precision as when their powers are in the
efficient  state of perfect health.   A  protracted
convalescence is the least evil likely to result from
such a procedure, and we feel  convinced that a
recurrence  of the original disease is not unfre-
quently  produced by these measures.   This  is
especially the case where the intestinal  canal has
been the seat of inflammation.   In such cases it
is of the first importance  to guard against any
thing capable of exciting local irritation of the
debilitated organs, whether  in the shape  of food
or medicine.   The  food  should  be altogether  of
liquid consistence until the bowels are disposed to
act without  the assistance  of medicine, and  to
procure  the  necessary  evacuations the  mildest
aperients only should be had recourse  to.   Cas-
tor oil, or a few grains of rhubarb and magnesia
with aromatic powder, or the hydrargyrum  cum
cretS with rhubarb, will be  found in such  cases
safe and in general effective  aperients;  or  a
drachm  of the  sulphate  of  magnesia in infusion
of  rhubarb or chamomile with some tincture  of
bitter orange-peel may occasionally be taken with
advantage.   Should these measures fail, it is bet-
ter to have recourse  to enemata than  to employ
more drastic purgatives.
   [Some catbartics are better adapted than others
for developing  the  dormant impressibility of the
whole intestinal canal.   Such are the  saline ca-
 thartics. The writer has found great  advantage
from the following  combination: — R. Magnes.
sulphat. §j.; Potass, bitart. gij.; Aquae bullientis
 Oij. M.  The dose of this  factitious mineral wa-
 ter is a  wine-glassful, which must be taken  every
 morning.  By persevering  in the use  of this  for
 some weeks, the tendency to constipation has been
 removed in some very obstinate cases.  (Practice
 of Medicine, 2d edit. p. 153 : Philad. 1844.)]
    When, however, this state of debility has been
 of long continuance and unconnected with any
 preceding acute disease, as frequently occurs in
 persons of advanced life, it will be necessary to
 have recourse to more powerful measures.   It is
 in such cases that  the sulphate of quinine in com-
 bination with  some of  the  resinous cathartics is
 often productive of the best effects.   Four or five
 grains of aloes or cathartic extract with one grain
 of sulphate  of quinine  and a  small quantity of
 some aromatic essential oil, given at intervals of
 eight hours, will be found to regulate the dis-
 charges from  the  bowels,  and  not unfrequently,
  after having been persevered  in  for a few days,
  the dose of  the aperient part of the combination
  will require to be  gradually reduced.   It  should
  be borne in mind, that from  the  accumulation
  which occasionally takes place in such instances,
  the feces are apt to lodge in various parts  of the
  intestinal tube.  When this has taken place in
  the rectum, they may require to be broken  down
accumulation occurs in the colon or crecum, which
may usually be ascertained by careful examina-
tion of the abdomen, copious enemata should  be
thrown up, and the contractions of the bowel pro-
moted by occasional frictions over the  surface  of
the abdomen with  stimulating liniments, and  by
the wearing of a flannel roller passed round  the
body  so  as  to  afford moderate  compression and
support.
   [In the torpor of the intestines  in which there
is a disposition to form scybala, and to retain them
in the cavity of the large intestine,  Dr. Marshall
Hall  (The Principles of the Theory and Prac-
tice of Medicine, p. 398 : Lond. 1837,)  considers
the principal remedy to be, a daily aloetic pill and
a warm-water enema ;  and the plan will certainly
succeed generally.]
   2.  When a deficient or vitiated state of the bil-
iary,  mucous,  and  other  secretions  poured into
the intestines proves a cause of constipation, it
will be necessary in the first instance to have  re-
course to measures fitted to correct the  deranged
function. We know of no medicine which exerts
so powerful an effect in promoting and  restoring
the biliary secretions as mercury, and accordingly
in some or other of its forms this  agent is em-
ployed whenever the bile is supposed  to be  defi-
cient in  quantity or impaired in quality.  There
can be no doubt that where there is a torpid  state
of the liver, and much general  oppression of  the
system with constipation, a full dose either of blue
pill or of calomel  combined with the compound
extract of colocynth, at bed-time, and followed up
in the morning by a solution of  salts  in infusion
of senna, will often materially relieve the symp-
toms, and indeed may  generally be  had recourse
 to in the first instance with marked  advantage;
but unless there is evidence of inflammation  ex-
isting in the liver,  or some change  in  the  struc-
 ture  in that or some other organ—in short, where
 the disease is simply functional, we  do not feel
 disposed te recommend the plan  of mercurializa-
 tion  to the extent to which it has been carried in
 such cases.   The particular attack is  certainly in
 many instances quickly removed under  this treat-
 ment, but we doubt much whether there is not a
 greater disposition to a recurrence of the symp-
 toms than where  the  case  has  been  treated by
 other measures,  less powerful indeed in the first
 instance, but perhaps on that  very account  more
 permanent in their effects.  Where the deviation
 from health of the biliary secretion is but slight,
  and its  effects are  chiefly discernible in the consti-
 pation induced, we have seen the bowels brought
  into a regular state, and the evacuations restored
  to their natural appearance, simply  by small doses
  of colocynth witb Castile soap  taken  at regular
  intervals of eight  hours, and that even in  cases
  where this condition has been  of long standing,
  and to  remedy which  the habit of taking large
  doses of strong cathartics had been acquired.  The
  effect of this plan  of treatment, wben steadily
  pursued for some  time, has been such as to require
  the  gradual  diminution  of the quantity of the
  aperient, and at length its entire discontinuance.
    Constipation, with  pale colour of the evacua-
  tions,  muddiness of the conjunctiva, and sallow-
  ness of countenance,  is often found to occur in
md removed by manual means,  and where the [ individuals of sedentary  occupations and  torpid 
CONSTIPATION,
493
habit, in conjunction with a feeble circulation and
highly  nervous temperament.   In  such  cases,
large, or even moderate  doses of mercurials are
productive of  very serious injury, either inducing
great constitutional depression  or  considerable
irritation in  some part  of  the intestinal  tube.
Small doses, however, occasionally prove benefi-
cial, as for  instance, a single grain of blue pill
with an equal quantity of extract of henbane and
camphor, followed  by a few grains  of carbonate
of  ammonia  in  infusion  of dandelion with  a
drachm of some  bitter  tincture,  taken twice or
three times  daily,  the  bowels having  been pre-
viously evacuated by a combination of some of the
resinous cathartics. Under this treatment we have
seen all the symptoms rapidly give way, the bowels
becoming regular,  the colour of the evacuations
healthy, the conjunctiva and skin clearing in the
very  same individual in whom larger  doses of
mercury had induced local irritation of the  intes-
tinal mucous membrane to a very serious extent.
   [Recently,  ox gall has  been  strongly advised
by  Dr.  Charles Clay, of Manchester, England, as
a direct solvent of accumulated hardened  faeces,
the  consequence of defective quality or quantity
of bile  in the alimentary canal.  The inspissated
bile is given in pills in the dose  of three or four
grains,  three  or four times a day.  Dr. Mettauer,
of Virginia, (American Journal of the Medical
Sciences, July 1843,) employs the inspissated bile
of  swine.  It  is  very  questionable,  however,
whether the bile of animals can  be productive of
benefit  in  such  cases.  It is,  indeed,  doubtful,
whether the bile  have any agency in stimulating
the intestines to the propulsion of their contents;
and hence any indication founded upon  an affirm-
ative view  must  be  regarded  as  questionable.
Sufficient observation has not been  had to decide
the matter.]
   Of those more obscure cases,  in whicb the se-
cretions from  the glands, follicles, and surface of
the mucous membrane appear to be  deranged, we
have so little definite information, that in the pre-
sent state of our knowledge it is scarcely possible
 to say what measures are most likely to be bene-
ficial :  but where  the evacuations  have  been
scanty and  covered with  slimy  mucus, or have
consisted almost entirely of a gelatinous matter,
much benefit will be derived from a combination
of blue pill with  ipecacuan  in  moderate  doses,
given at proper intervals,  until  the stools become
more healthy, and followed  by the tincture of
benzoin in doses of from ten to fifteen drops three
times daily.   Where there is  reason to suppose
that the secretions from  the  mucous membrane
are  very viscid and adherent  to its surface, the
croton oil will be found a  valuable remedy  in ob-
viating the attendant costiveness.
   3. In the treatment of  cases where a slight de-
gree of constipation has been induced by taking
improper food or that which  is indigestible in its
nature,  the first object is fully to  evacuate the
bowels  of their contents, which may be done by
almost any of the usual cathartics,—for instance,
five  grains of  calomel with eight or ten of com-
pound extract of colocynth, followed by the com-
mon black draught, after an interval of six  hours,
or on  the  following morning,  according  to cir-
cumstances.   The  subsequent measures will, of
                                       2u
course, be chiefly dietetic,  such as the prohibition
of that species  of  food  which  has been  found
injurious, and the recommendation of that which
is more soluble in the secretions of the stomach,
and  more  readily assimilated  in the subsequent
parts of the processes of digestion and nutrition.
Should  more  permanent  disturbance  have  been
produced, and  the  secretions have  become disor-
dered so that the constipated state continues, it
will  be necessary to have recourse  to the  mea-
sures recommended under the preceding division.
  It is, however, in constipation arising from this
cause that we find those severe cases of obstruc-
tion of the bowels which not unfrequently demand
all the resources and- all the perseverance of the
physician to conduct to a successful termination.
Some hours  after a hearty meal, in which there
has been either  excess in the  quantity of food
taken,  or inattention to  its quality, the bowels
will  become  constipated,  at the same time that
there is a sense of distension of the abdomen ge-
nerally, with fulness  and uneasiness on pressure
in some part of the larger intestines. Under these
circumstances a dose of aperient medicine is taken,
which may either give rise to  considerable pain
without affording any relief, or may be rejected
by vomiting.   More powerful cathartics are now
given, and the distended bowel,  through the inju-
dicious and hasty use of such measures, is irritated
into inflammation, and much and often irremedia-
ble mischief done  before medical  advice is had
recourse to.   The  first efforts  of the physician,
under  such circumstances, should  be directed  to
subdue the inflammatory action by general and
local bleeding, and having accomplished this ob-
ject, without which all that can be done for the
relief of the patient must be in vain, he may direct
his attention towards the  removal of the obstruc-
tion and procuring the evacuation of the contents
of the bowels.  We will not  say that in no  in-
stance where constipation arises from undigested
food, is the removal of it to be attempted by ape-
rient medicines,  for if the patient  be  seen before
any threatening of inflammation has taken  place,
it may be right to give a full dose of calomel com-
bined with cathartic extract and extract of hen-
bane ; but if this fail of its effect, and  local  unea-
siness be induced, or if the medical practitioner  be
called  to see his patient under  the  circumstances
before-mentioned, it will be  desirable to  avoid
giving purgatives by the mouth,  and to endeavour
to remove the obstruction by the use of copious
enemata, assisted by frictions of the abdomen, &c.
The following case,  though one of frequent  oc-
currence, will perhaps point out the mode of treat-
ment to be pursued in such cases better than more
general observations.
   A man of middle age had experienced a severe
attack of colic with constipation, for which he tooK
some strong cathartic medicines without relief to
his symptoms,  but with the  effect of inducing
considerable tenderness  in  the  left iliac region.
where there was also  some fulness.  Leeches were
applied to the seat of the  pain with immediate re-
lief, and after the pain had subsided  the bowels
were readily evacuated by enemata, followed by a
saline  aperient.  In the course of a few days,  in
consequence of some irregularity in diet, his bowelai
became again constipated.  Tbree grains of calo- 
494
CONSTI
PA TION.
mel, combined with eight of compound extract of
colocynth and  three of the extract  of henbane,
were ordered.   No  evacuation followed,  but  the
pain returned in the left iliac region, and was now
accompanied by general tenderness and tympanitic
distension of  the abdomen, and some nausea and
disposition to vomiting.  He was  bled from  the
arm, and leeches were  twice applied  to the abdo-
men within a few  hours,  and afterwards  warm
anodyne fomentations.  Under these measures the
inflammatory symptoms gave way, the tenderness
and tension of the abdomen subsided, but the de-
scending colon, just above the  sigmoid  flexure,
could be felt distended, and the  part was uneasy
when pressed.   Copious enemata of thin gruel
and of salt and water were repeatedly thrown up,
and  as  there was  some difficulty experienced in
passing them, the rectum was examined, and  a
bougie  introduced as  far  as it  could be passed
without giving pain, but  no unnatural  state of
the lower  bowel  was detected.  The  enemata
were returned at first without change, but subse-
quently they became  more and ' more coloured.
The obstruction now appeared  to descend ; gentle
friction  was made  over the part with  castor oil,
and the enemata were persevered in, till at length
a considerable quantity of faecal  matter, in a dis-
solved  and fluid  state, came  away.   The local
uneasiness then  completely  subsided,  and  the
bowels  were  subsequently regulated by a tea-
spoonful of sulphate   of  magnesia  with fifteen
drops of tincture of henbane, taken in peppermint
water every morning.   The duration of the con-
stipation in this case was eight days.   An enema
of cold water,  as recommended by  some of the
French practitioners,  was  thrown up  once,  but
without producing  any apparent effect;  and  as
the measures employed  were found to  be gradually
effecting their object, it was not thought necessary
to have recourse to  others,  the success of which
might have been doubtful.  Among those means
which have been recommended in such cases, the
dashing of cold water over the lower extremities
has succeeded in removing the obstruction where
other measures have failed; and the warm bath is
frequently a very effectual remedy.   The princi-
ples of treatment, however, to be kept in  view are
manifestly to subdue and keep down inflammatory
action, and steadily to persevere in soliciting rather
than in forcing the evacuation of the contents of
the bowels.
   4. Where  a constipated state of the  bowels is
produced by increased tone, it is scarcely such as
to require remedial measures for its removal, and
is best counteracted by taking a greater proportion
of ripe fruit  or well-boiled vegetables,  or other
food of a slightly laxative nature.
   5. The treatment to be  followed in cases where
the constipation is complicated with and the effect
of an oppressed state of the functions of  the ner-
vous centre, may be deduced from the observations
which we have  already had occasion to  make in
the first part of this paper, while considering this
cause of the functional disturbance. The attention
must, in all  such cases, be directed to relieving
the cerebral  or  spinal  oppression by the applica-
tion of leeches to the temples or by drawing blood
t»y tupping from the back of the neck, at the same
time that efficient doses of aperient medicines are
given to act upon the bowels. The use of calomel
is especially beneficial in such cases, probably on
account of the tendency of this medicine to equalize
the circulation.
  Children seem to be very  liable to this form of
constipation, and in consequence of the predispo-
sition which the age of  infancy gives to hydroce-
phalus, it becomes a subject requiring close  and
anxious attention.   Whenever, therefore, there is
a confined state of the bowels existing in a child,
accompanied with  heat of the scalp and  any  dul-
ness or heavil -,ss of expression, it  is of the  first
importance cai   My to  watch the progress of the
case.  From two to ten leeches, according to the
age of the child and severity  of the symptoms,
should be immediately applied,  and from on°  fn
three  grains of calomel, with four or five of jalap
given and  repeated  according  to  circumstances.
When the head has be?n  relieved by the local
depletion, the subsequent operation of the cathar-
tic will be materially assisted by the employment
of the warm bath.
  The obstinate  constipation  which  occurs in
females  of an hysterical constitution, and where
spinal irritation has  been  ascertained to  exist,
requires a mode of treatment materially  differing
in many respects from  that which is adapted  to
other forms  of this functional  derangement.   In
such  cases it will  be necessary to apply leeches
and blisters over the painful vertebrae, with other
measures recommended under the head  of spinal
irritation.   The  most efficient  aperients will be
found to  be combinations of  aloes with myrrh,
galbanum,  and  other  antispasmodics,   together
with terebinthinate enemata, and where the symp-
toms  of  hysteria  are  more decidedly  marked,
clysters containing assafcetida will occasionally be
found successful when other remedies have failed
of their effect.  In  a very interesting case reported
by Dr. O'Beirne, (New Views  of the Process of
Defecation, &c.,)  in which there was most obsti-
nate constipation, (no faeces, it is affirmed, having
been passed for six months,) attended with great
constitutional disturbance,  and subsequently as-
certained to  be  connected  with spinal  irritation,
immediate  relief to  the constipation was expe-
rienced  from the  employment of the  tube  and
syringe,  as  recommended by the author in cases
of constipation.   A  gum-elastic tube was intro-
duced into the sigmoid flexure  of the colon,  and
an injection thrown  up  through the tube with the
effect of removing, in less than two minutes  after
the withdrawing of the  tube, an  enormous masii
of solid faecal matter. The patient was not, how-
ever,  restored to health  till proper  measures  had
been adopted for the cure of the spinal disease.
  6.  In the case of excessive secretions from other
organs of the body inducing constipation of the
bowels, the obvious  indication  is to moderate the
activity of the disordered functions, and to restore
the general equilibrium; but as this is  a subject
which scarcely  falls within  the compass of our
present object, we  shall content ourselves with re-
ferring to such of the essays in the preceding pages
of the Cyclopaedia  as relate especially to these dis-
eased states, and in which the measures to be  pur-
sued in such cases will  be found detailed. 
CONSTI
  In the second class of cases, or those in which
the constipated state is connected with and  de-
pendent upon obstruction  taking  place  in some
part of the intestinal tube, the treatment will often
be found to require the greatest circumspection.
   1. The frequent connection of this condition
with hernia is one which should ever be borne in
mind, and in  no instance is it of more importance
to ascertain the cause giving rise to the attack than
in the cases where constriction of the bowel arises
from this source.   A careful examination  should
therefore always be made, to ascertain  this point,
and should  a portion of  intestine be  found dis-
placed and incapable of being reduced, no time
should be lost in  requesting  tbe assistance of the
surgeon.  The measures to be subsequently pur-
sued fall under the department of surgery, and
will be found detailed in the valuable works of Sir
Astley Cooper and others upon this subject, with
whicb that branch of the  science of medicine is
enriched.
   2.  For the treatment of constipation, when it
arises from inflamed states of the serous and other
textures forming the coats  of the bowels, we must
refer to the articles Enteritis and Peritonitis ;
and where it occurs in connection with what has
been  considered  spasmodic constriction  of  the
muscular coat, to the article Colic.   We have
already expressed our opinion  respecting the in-
frequency of the existence  of spasm as a cause of
constipation  and  colic, and shall  therefore only
further observe, that the measures which are com-
monly found  successful in such instances, viz. local
blood-letting, frictions, anodyne fomentations, and
the internal  exhibition of opiates, are  precisely
those which  are calculated to moderate the action
of the propelling fibres of  the muscular structure,
which by the twisting pain experienced in these
affections would appear to be in a state of partially
increased activity  above   the distended  portion,
rather than of fixed spasmodic constriction below it.
   3. The treatment of that form of constipation
which arises  from an affection of the caecum, must
be regulated  by the kind and degree of disease ex-
isting in that part.   If there be reason to suspect
that the caecum has become distended with fecal
matter,  but  without any chronic inflammatory
thickening of the intestinal  tunics having taken
place, then a plan of stimulating  purgatives may
answer  well  the  object we have  in view.  Two
pills, for example, may be given every other night,
containing five grains of blue pill and five grains
of  compound extract of colocynth, and a mixture
may be directed twice a day, of carbonate of soda,
compound decoction of aloes, and infusion of quas-
sia ; in  addition  to  which an enema of salt  and
water may be injected by means of the syringe
every morning, taking care that a  sufficient quan-
tity of fluid  shall  be thrown up to pass into the
caecum.
   If, however, there be reason to suppose that tbe
inactive state of the caecum arises  from, or is con-
nected with,  a chronic inflammatory action in the
mucous, muscular, or peritoneal coat of this intes-
tine, then it will become necessary to conjoin local
bloodletting and blistering with the purgative plan,
and the kind  of purgative  must be changed.   Ca-
lomel, in conjunction with cathartic extract, may
then be given every night, and a saline aperient,
ATION.                                495
consisting of sulphate of magnesia, carbonate of
magnesia, and peppermint water, may be admin-
istered every four hours.  If the symptoms do not
give way to these measures, it will be desirable to
employ the  mercurial inunction over the abdomi-
nal surface, or, what appears to answer still better,
to use  an ointment consisting of one ounce of the
mercurial ointment  with half a  drachm of hydrio-
date of potash.  An ointment thus formed is sin-
gularly efficacious in promoting the absorption of
thickening produced by chronic inflammation. In
some obstinate cases of inactivity of the  caecum,
we have seen the best possible effects follow the
use of the compound gamboge pill, ten grains of
which may be given every night at bed-time, and
may be continued  until tbe tumour which is felt
in the  region of the caecum is lessened  by  the free
evacuation of the bowels.  It is surprising to ob-
serve the immense  discharge  of  offensive faecal
matter, bearing  the appearance  of having  been
long retained in the bowels, that is passed away
in some examples of constipation  connected  with
accumulation in the caecum; and  those accus-
tomed to watch  the progress of such cases would
scarcely be disposed to believe that so much could
be retained  in the intestinal canal.  Where once
the disposition  has taken place in the caecum to
allow its contents to accumulate, and thus to  form
a  large pouch full of feces, it  requires much cau-
tion in diet and  regimen  to prevent a recurrence
of the same affection, and  indeed we believe in
many instances, despite of all the care  that can be
taken, this occurrence  cannot be averted.   A due
attention to exercise of the body, and  a proper
regulation of the diet, taking the precaution to eat
such things as are light of digestion and of rather
an aperient quality, will often for a length of time
secure a due degree of peristaltic action in this
part of the  intestinal carfal, and preserve it  from
undue distension.  In addition to this, the applica-
tion of a stimulant mercurial plaster over the part,
and the  frequent use of  an enema, especial care
being  taken that a  sufficient quantity of fluid is
injected into the colon, are very important.
   The treatment of constipation  which  depends
upon  a diseased condition of the colon,  requires
great discretion  in  the use of remedies;  for if in
this case irritating cathartics are injudiciously used,
much  mischief may be produced, and there can be
no doubt that the continued use of violent cathar
tics may go far to occasion permanent stricture ol
the colon.
   When it happens that from any cause the colon
has not for  some time passed  on  its contents, but
has allowed the feces to accumulate there, spasm
of the muscular bands of this  intestine is some-
times produced.   This is  not a state in which the
use  of drastic purgatives can  be of any  service;
on the contrary, they may increase the spasmodic
action and  add  to  the griping pains,  without re-
lieving the  bowels of their load.   The exhibition
of a dose of calomel and opium, with half an ounce
of castor  oil, repeated every four hours, will  in
such cases often act freely upon  the  bowels, ana
relieve the pain.
   Where the longitudinal bands of this pan  of
the intestines are in a painful state, it is more espo
cially necessary  to avoid inducing  any  appearance
of dysenteric motions  by  tbe use of irritating ia- 
496
CONSTI
PATION.
thartics, such as senna, &c, but those of a milder
and  more  soothing nature  may  be  employed.
Sometimes, in an inactive state of the colon, stools
are passed containing much mucus and very little
fecal matter, whilst at the same time a large quan-
tity of faeces may be retained in the  cells of the
colon.   The daily use of unirritating injections is
in this case often attended with much advantage,
and the decoction of linseed is particularly suita-
ble for the  purpose.  It is not,  however, well to
trust entirely to enemata.  The  use of alterative
and  gently aperient  medicines will greatly assist
in bringing  about a more  healthy action of the
colon : one  grain of blue pill and one grain of
extract of henbane taken three  times a day, to-
gether with  a mixture consisting of fifteen grains
of sulphate of magnesia, one drachm of mucilage,
and  an  ounce and  a-half of  water, will very fre-
quently greatly assist in discharging the accumu-
lation from  the colon, and in bringing about a
healthy secretion from its mucous membrane.
   If constipation be depending upon an inactive
state of the  colon, unconnected with  any disease
of its mucous  membrane, the compound extract
of colocynth in combination with calomel may be
given at bed-time  twice  a week, and a  senna
draught the  following morning.  This plan, how-
ever, should  not be long continued, but after a time
recourse should rather be had to daily enemata of
salt and water,  or of gruel.  It is in  this form of
constipation, when of an obstinate nature, that we
think much benefit arises from the use of croton
oil, one drop of which may be given in combina-
tion with soap every four hours ;  or half a drop
of the oil may be administered with cathartic ex-
tract and calomel, in the proportion of four grains
of the former  to  one of the latter, every four
hours.
   Should constipation \>e dependent  upon stric-
ture, either  in the ascending portion or in  the
sigmoid flexure of the colon, it is usually attended
with peculiarly severe pain and  much flatulence.
It is here of  particular importance  to  avoid  all
violent and irritating medicines ;  for the most part
the preparations of mercury are not of any  avail,
and  if calomel  is given, it should be combined
with an  anodyne.  As  an aperient, sulphate  of
magnesia in small doses, dissolved  in water, with
the addition of a few drops of laudanum, and
given every  three or four hours, when assisted by
injections, will  often succeed ;  or castor oil in
small doses  frequently  repeated, and combined
with a few drops of laudanum, will act upon the
bowels without exciting much pain.
   It is of great importance, when stricture of the
colon exists, to be enabled to use some remedy,
which, without proving in  any way irritating,
may keep up the peristaltic action of the bowel.
The tincture of benzoin is a medicine of this kind,
and we have often known twenty drops of it taken
three times a day succeed  in  keeping the bowels
active, in some instances of constipation apparent-
ly dependent upon some stricture of the colon. In
constipation also of this nature we  observe the
happiest effects from the occasional use of aperient
saline mineral waters.   The waters of Leaming-
ton or Cheltenham have often succeeded in giving
temporary relief to many persons who have looked
'or it in vain from other remedies.
   When  the cause of obstruction exists in tho
sigmoid flexure of the colon, we have the disease
more within  reach than in its ascending or trans-
verse portions.  If,  therefore, the ordinary mea-
sures which  are employed fail in getting rid of
the fecal accumulation, we may sometimes obtain
relief by passing a hollow flexible tube into the
colon, which if possible should be carried through
the strictured part.   We are then enabled to in-
ject the fluid immediately through the affected
part, and in this manner the colon is  sometimes
called  into action,  and a very large quantity of
feces is passed  away.  It is  diffcult to say how
much fluid may  in some of these cases be thrown
up, it depends so much on the degree of dilatation
that the colon will admit of in particular instances.
The quantity we have known to vary from less
than a pint to as much as a gallon.  This latter
quantity we  remember- to have  seen  frequently
thrown up in an old gentleman, who for years
had been  the subject of constipation  from enor-
mous accumulations in the colon,  which appeared
not to be the result of stricture in any part of it,
but merely from want of action  in its muscular
fibres.   In this  case,  after constipation of long
duration,  as  much  as a gallon of salt  and water
has been  thrown  up  every  morning for a week
successively, and scarcely any fecal matter would
for several days pass; but  at length the repeated
use of the injection would call the muscular fibres
into activity, and then an enormous mass of fecal
matter would be parted with, sometimes amount-
ing to so great a quantity as to render it a matter
of astonishment how the  colon could  have been
so far  distended as to contain so large an accu-
mulation.   This was  an instance  of paraplegia ;
and it is in cases of this kind that we believe the
colon, without any  stricture, is most liable to be-
come enormously distended  by its faecal contents.
   A modification of this practice has lately been
recommended by Dr. O'Beirne of Dublin, in his
work on the Process of Defecation, which he con-
siders to be  applicable in most cases of constipa-
tion.  His plan  consists " in the introduction of
a large-sized  gum  elastic  tube  through the  anus
into the sigmoid flexure  of the colon, and, after
giving exit to such flatus and fluid feces as may
happen to escape, adapting to it a  proper syringe,
and throwing up such purgative fluids  as circum-
stances may  make  it necessary to select."   For
more particular details we must refer to the work
itself, and  to  the cases with which it is  illustrated.
   [The common  mode  of  throwing enemata
into the rectum only by the ordinary  syringe or
by the bag  and pipe is  often exceedingly inef-
fective.  If we desire to  have the full benefit of
the injection, the  plan,  recommended by  Dr.
O'Beirne,   and  now  in  constant use, is  indis-
pensable.]
   4. When constipation depends  upon relaxation
of the  rectum, we cannot expect to produce  any
great effect  upon the  disease by remedies taken
into the stomach.   It may nevertheless be some-
times desirable to improve the general tone of the
alimentary canal, and  to stimulate the muscular
fibres of the relaxed intestine.   With this view
the use of a mixture twice or three times a day,
composed  of carbonate of soda, infusion of senna,
and decoction of bark, will often prove beneficial 
CONSTIPATION.
497
But  in  this affection, as Mr. Chevalier very pro-
perly observes, »the principal  and most certain
relief is to be obtained from the proper employ-
ment of glysters, the composition  of which is to
be regulated by  circumstances.   At first those of
a mild  aperient  nature  should  be preferred, and
thrown  up by a syringe;  and these  should be
repeated after  regular  intervals,  so  as to re-
accustom  the  rectum to  empty itself  in an ha-
bitual way.  Gruel, the  decoction of mallows,
broth, or milk  with  some  honey, will answer the
purpose very  well; but  more  permanent  good
will  be derived by  using afterwards the infusion
of chamomile, or  the  old  decoction  pro  fotu,
which,  by gently stimulating the torpid surface
of the  bowel,  may bring on a proper  contraction
of its coats.   Where the  very lowest part of the
rectum  continues so dilated as to allow the upper
still  to descend, from four to six ounces of a strong
decoction of oak-bark,  or  an  infusion  of  galls,
thrown up as  gently as possible every  night, will
be attended with the  most  beneficial  effects.  If
this  be not readily retained, a little starch, or a
few  drops of  tincture  of  opium, or both, may be
added  to  it;  and  care should  be taken,  at the
same time, so to regulate the diet and medical
treatment, that  the upper part of the intestinal
tube may be excited to due action, regularly, but
not  violently."
   5. It is particularly  important that judicious
management should be adopted to keep the bowels
properly open in  stricture of the rectum.  So
much  mischief  may  be  done by irritating the
bowels  by drastic  purgatives,  that no reflecting
practitioner will now venture to use this class of
aperients  where stricture of  the  rectum  exists.
But we may often, by mild and frequently repeated
doses of gentle aperients,  which have a tendency
to keep the faeces in a liquid state, succeed in pre-
venting severe  constipation from  taking   place.
 The remedies which  are  most beneficial in this
 state are  combinations of small  doses of simple
extract of colocynth, extract of henbane, and blue
' pill, to  be repeated every or every second night,
 castor oil  taken  in the dose of a teaspoonful every
 second  or third  morning, or one drachm of sul-
 phate  of magnesia  dissolved  in  six  ounces of
 water, and taken every morning. We have known
 instances where, by this means, life has been ap-
 parently much prolonged  in stricture at the lower
part of the  rectum, as the feces have been kept
continually liquid, and all accumulation above the
 strictured part has been prevented.  On the same
principle, great benefit occasionally arises in con-
stipation from stricture of the rectum, by having
recourse to the use of mineral waters.   During a
residence of three weeks  or a month  at Chelten-
ham or Leamington,  we have  known  persons
thus affected greatly relieved, and the bowels kept
in  an  open state, without  any irritation  of the
strictured part being thereby produced.
   We  must not, however,  trust to these or any
other remedies given by the mouth, as, fortunate-
ly, the cause  of constipation in this case is suffi-
ciently  near the anus to allow of remedies being
there applied, and sometimes with great effect, to
remove it. The stricture may sometimes be dilated
by means of bougies, and  the mechanical obstruc-
tion to the evacuation  of the  feces in this way
   V„l. I. — 63                      2 ii*
removed ; or we have it in our power to throw
up  glysters  through the strictured part, thus ren-
dering the faeces more pultaceous and more readily
transmissible through the narrowed part  of the
intestinal tube.
  There may be doubts as to  the applicability of
bougies in every case of stricture, the irritation
produced by them being so great as to counter-
balance any advantage that may be expected to
be derived  from their use.  Where the stricture
is of a scirrhous or carcinomatous nature,  there is
but little prospect of any benefit being  derived
from  their  employment, and we have  oftentimes
known, where the introduction of the bougie has
been attempted in such cases,  that the pain aris-
ing from it was so  great, that the patient would
rather suffer from the disease than the  remedy.
Indeed, it is obviously most judicious in this form
of the malady to abstain from  using any means
that cause irritation, and all that we can  attempt
in  this unpromising condition  is to relieve the
bowels of their load with as little disturbance of
the affected  part as possible.   On  this  account
glysters of milk and water, or decoction of lin-
seed, are preferable  to those of a more stimulating
nature ; and where  the  evacuation  produced  by
their injection is productive of much pain, it will
be  desirable  even to allay the irritation thus oc-
casioned by a small  glyster  of landanum  and
starch.
   It is, however, in  strictures which are originally
of a spasmodic nature, and in which  afterwards
thickening and induration  are  occasioned by an
effusion between the muscular and villous coats,
that bougies are used with greatest  advantage.
But surgeons seem very  properly to be far more
cautious than they were formerly in the  employ-
ment  of the bougie, even in  these cases.  Mr.
Salmon  is  entirely opposed lo  the  daily use  of
the bougie.   He maintains that  the  advantage
derived from dilatation of the  passage  is counter-
balanced by the frequency of the irritation,  and
informs us  that since he has ceased  to use the
bougie daily, and made  it his practice to intro-
duce  it only  once every three  or five days, he has
effected the required dilatation more rapidly. The
manner of introducing the bougie we will give in
the words of Mr. Salmon :  " A full-sized  bougie,
not less than eleven inches in length, thoroughly
softened and well oiled,  adapted to the shape of
the passage through which it is to be passed, is to
be  introduced with  the  convexity  of its curve
towards the sacrum, in  which way it is to  be
passed upwards and backwards about  two inches
through the third portion of the bowel, provided
it gives no pain; for the introduction will com-
monly produce  an  uneasy  sensation.   We con-
tinue to propel the  bougie in the same direction,
about three or three and a half inches higher, o»
through the second portion of the rectum.  The
point  of the  instrument  will  now bear  directly
upon the hollow of the sacrum, and the  but-end
towards the left side of the body. With the view,
therefore, of avoiding the sacrum, and of accom-
modating the instrument to the great curve of the
rectum, we change  its position by describing the
segment of a circle from left to right, with the
but-end, turning it upwards,  at  the  same time
continuing  to propel the  instrument.   Having 
498
CONSTIPATION.
described  this segment, we shall have carried the
bougie full four inches farther, or to what may be
considered the extent  of the rectum.   But it is
yet to be introduced into  the sigmoid flexure  :
we therefore slightly depress  the but-end of the
instrument, at the  same time propelling it  up-
wards till the whole is fairly within the sphinc-
ter.  Upon encountering obstruction, trifling pres-
sure is  to be maintained for a minute or two;
and  if under  this careful pressure  the pain in-
crease, and  the instrument remain  stationary,  it
is  to be withdrawn, the next size introduced, and
so on from above  downwards, till we ascertain the
size of the bougie, which passes with trifling pain
or difficulty fairly into the sigmoid flexure."
   We  have here  given, we believe,  the latest
and  best  authority with respect to the  use of
the bougie; and, without denying  the  utility of
bougies in some cases of constipation from stric-
ture of the rectum,  wie must again repeat that the
irritation of the bougie is sometimes more intoler-
able than the stricture  itself.   We, therefore,  pre-
fer in  all cases of  this nature, where any degree
of irritation is produced, trusting to the daily ad-
ministration of an  enema of gruel  or of linseed
tea, which will generally, unless the contraction
is  to a very great  extent, succeed in emptying the
rectum, and in checking the further progress of
the disease.
   With  regard to  dividing the stricture  by the
knife, as  a means  of relieving  constipation, we
believe  it is  now rarely practised ;  and,  indeed,
the numberless instances in which fatal peritoneal
inflammation  has succeeded  to  that practice are
quite sufficient to deter us from further trials of it.
   As regards  the  management of constipation
where it is connected with hxmorrhoids, it would
require  a full consideration of the  manifold  cir-
cumstances which should regulate our  treatment
of the latter affection to enable us to do full  jus-
tice  to this question.  Haemorrhoids and consti-
pation stand so immediately in the  relation of
cause and effect,  that it is often  difficult to deter-
mine their mutual dependence upon each  other.
It  is the  general  opinion that the frequent neces-
sity for  the use of cathartics, and more especially
those of a drastic  nature,  as aloes,  colocynth,
scammony, &c, is the chief cause of the appear-
ance of haemorrhoids in constipation ;  but there
is  after all a  great source of  fallacy in this con-
clusion ; for it must be evident that the same con-
stitutions which require the frequent administra-
tion  of  purgatives are also  those most liable to
attacks of haemorrhoids.  We must therefore not
too decidedly determine that the use of cathartics
is  the cause of haemorrhoidal tumours.
   There can, however, be no question  that when
haemorrhoidal  tumours have  made  their appear-
ance, and more especially when  they become in-
flamed,  and the  cellular membrane  surrounding
them thickened, it requires much caution in  giv-
ing medicines for the relief of  constipation.  It
is  always, under such  circumstances, of great
moment to determine how far the haemorrhoidal
tumours themselves,  and the thickening of the
cellular membrane at the lower part of the rectum,
are producing mechanical obstruction to the  ex-
pulsion  of tbe feces;  and if so, to direct such
luca' means as are likely to remove them.   For
example,  if  much  inflammation  exist  in  the
tumours and the parts adjacent, it will be desh-
able to abate it by the  application of leeches and
the use of anodyne fomentations; and  we should,
at the same time, relieve the bowels  by the  exhi-
bition of some aperient which will not prove irri-
tating to the inflamed piles.  A pill  consisting of
two grains of blue pill and two of extract of hen-
bane may be given, and with it a dose of castor-
oil, varying from two drachms to half  an  ounce;
which  treatment will generally succeed in reliev-
ing the immediate obstruction and suffering aris-
ing from the piles, and make it more easy subse-
quently to command the action of the  bowels by
enemata.   As  an habitual  aperient to keep  the
bowels in a laxative state, sulphur has long been
employed in haemorrhoidal affections, and is most
suitable  in  combination  with  supertartrate  of
potash  and  given twice a day, so  as  to  prevent
the bowels becoming costive.   When  obstruction
has taken place from piles, a more active aperient,
as before stated, will be necessary.
   But perhaps the most troublesome state of con-
stipation, as connected with piles, is that in which,
from their long existence, thickening of the cellu-
lar membrane  of the  lower part of the rectum,
forming a sort of ring around the sphincter,  takes
place.   Under this state it often becomes neces-
sary to  employ  local means to diminish  the  ob-
struction  thus  occasioned.  On examination, we
sometimes discover  that the thickening may be
diminished, and the  obstruction to the feces les-
sened,  by  the removal  of  one or more of  the
tumours,  and wherever this is found to be  the
case, we should not delay adopting this necessary
means  of relief.   Considerable difference of opin-
ion exists as  to the best way  of removing hae-
morrhoidal  tumours, some  preferring excising
them by the scalpel, whilst others make use of the
ligature.  There are advantages in each mode of
procedure.  By using the ligature we avoid all
risk of haemorrhage;  but the  irritation  that is
occasioned sometimes becomes serious,  and the
inflammatory  action occasionally extends far  up
the rectum : this more especially occurs, if any
portion of the mucous membrane lining the lower
part of the  bowel should  happen to be included
in the  ligature.   When, therefore,  the mucous
membrane of the  rectum extends over  the  hae-
morrhoidal tumour,  a  ligature, except  in  an ex-
treme case, should never be applied.  But  there
are other  means besides  the removal  of the
haemorrhoidal tumours whereby the  obstruction
arising from them in the lower part of the rectum
may be diminished.   When the extremity of the
rectum  becomes filled by several tumours  of a
chronic nature,  the  compression of  them by the
introduction of a bougie into the rectum every or
every other  day will often lessen their size, and
thus facilitate the evacuation of the feces.   As-
tringent applications may also  be resorted to  for
the purpose of removing haemorrhoidal tumours
Strong  solutions of sulphate of zinc in  the less
severe cases, and the application of the gall-oint-
ment, often  produce very beneficial results.
   But necessary as  it is to attend  to the  loca'
affection,  when  constipation  is aggravated  by
thickening of the mucous membrane of the lower
part of tne rectum and by haemorrhoidal tumours, 
CONSTIPATION.
499
still we must bear in mind that much  also is to
be effected by diet and proper regimen^ the object
of which should be to keep the bowels in a soluble
state.  The occasional use of mineral waters, and
especially those of Harrogate, deserves much  at-
tention, and will greatly assist  our endeavours to
relieve this kind of constipation.   We  have also
known  instances of this  nature,  in  which  the
daily  use of a  drachm  of  Epsom salts dissolved
in  six ounces  of water has greatly relieved  the
inconvenience  arising from tbe obstruction pro-
duced by haemorrhoidal tumours.  It is, however,
unnecessary  to dwell longer on  a part of  our
 subject  more  especially treated of in  the  article
 HEMORRHOIDS.
   Spasmodic  affection  of the  sphincter ani—is
 jery troublesome in  some persons who are subject
 » obstinate constipation.  Where it arises from
ihe presence of an  irritable or inflamed pile, or
from  chronic inflammation of the mucous mem-
orane lining the extremity of the rectum, these
affections must be attended to and  removed by ap-
propriate treatment.   Sometimes the  removal  of
the painful pile becomes  necessary;  and  some-
times the  application of leeches to the  extremity
of the rectum  affords relief, when the spasmodic
affection depends upon chronic inflammation  of
that  part.   We  do not, however, always find,
when we have  removed the pile  or  the chronic
inflammation of  the rectum, that the spasmodic
affection of the sphincter gives way, in which case
the constipation still  continues.   Great benefit
will then  be derived from the use of  an  opium
suppository, or  from passing a bougie into  the
rectum  every  other  day, allowing it to  remain
there  from twenty minutes to  half an hour each
time,  under  whicb  treatment  the  spasm will
usually  give way.
   In  some individuals of high  nervous excite-
ment, spasmodic affection of the  sphincter  ani
exists alone, without any piles or inflammation of
the mucous membrane of the rectum.   We have
found soothing glysters injected daily, and the  use
of the bougie every other day, generally remove
this very troublesome form of constipation.  These
measures  should  be combined with  a plan  of
treatment calculated  to invigorate the  system and
to allay  nervous irritation.
   The treatment of constipation, when it is ascer-
tained to arise from the pressure of tumours, must
necessarily in  the greater proportion  of cases  be
merely  palliative.   Where the  tumour admits
neither  of removal  nor cure, the keeping  the
bowels in a soluble state  by  castor oil or  other
mild aperients, and the use of enemata, are almost
all that can be done  towards alleviating this con-
dition.  Change  of  position, when adhesions  of
the tumour to  the neighbouring  parts have  not
been  formed, may in some instances be of ser-
vice ;  and  when the pressure  arises  from  dis-
placement,  as in the  case before detailed, in which
constipation of twelve  days' duration attended
with much suffering arose from a retroversion  of
the uterus,  the restoration of the displaced part to
its natural  situation  will afford immediate  relief.
In narrowing of the pelvis from undue prominence
of the sacrum,  or other cause producing accumu-
lation  of feces in the colon, the measures required
are  similar to  those which have already been  re-
commended for the removal of this accumulation,
where it depends upon stricture seated at the up-
per part of the rectum.  The circumstances im-
pending the transit of the feces in each case are
so far the same, that the  passage  through which
they are to be propelled is narrowed or constrict-
ed ; but in the one instance it is by a cause seated
in the coats  of  the bowel,  in the  other by one
acting from  without.  In  this latter case, how-
ever, there is not the same suffering from the use
of the necessary means, as  the  inner  surface of
the bowel is not in so irritable a condition ; and
the cause, though  perhaps incapable of removal,
is at the same time not likely to progress witb the
same rapidity.
  Previous to bringing these  observations to a
conclusion, we shall endeavour to impress the im-
portance of attention in all the slighter and merely
functional forms of constipated bowels,  to two or
three general directions, which should always be
given to those who are liable to suffer  from this
state.   It is of great consequence in all such cases
to establish regularity,  both with respect  to the
times of taking food and the general tenor  of the
daily habits.   The tendency to periodical returns
of the same condition of the system has been fre-
quently observed, both in the state of health and
in that of disease.  In disease the regular occur-
rence of the evening  exacerbation in  irritative
fevers—of the paroxysms in intermittent and neu-
ralgic affections at the same hour of the day—of
epileptic attacks at  weekly or monthly periods,
afford familiar instances ; while  in  health the re.
gularity with which  the returns  of appetite and
disposition to sleep occur are equally striking.  It
is, therefore,  a point of considerable importance in
these cases of constipation to make the attempt al
an evacuation at a certain regular hour  daily ; foi
when once the habit is formed, the  call  to  evacu-
ate the bowels at the same hour will rarely fail.
  Regular and sufficient exercise is a most neces-
sary adjunct  in these cases, as nothing tends more
to predispose to  constipation than  close attention
to sedentary pursuits.  Where this is a  necessary
part of  the  habitual occupation, too much stress
cannot  be  laid upon  setting apart a portion of
each day for  the exercise  of walking.   In many
of those who suffer from constipation, the powers
of the mind are  much exercised ; and where this
is the case, daily ablution of the head  with cold
water, with the occasional use of the shower-bath,
will be found especially beneficial.  Indeed, these
measures  may always  be used with advantage
where the powers  of the system are not in too de
bilitated a condition to admit of their employment
  To these precepts, which  it is in the  power of
every one to  follow, we shall only further add, the
importance of avoiding late hours at night, and of
rising early in the morning.  Indulgence  in the
habit of lying in bed, is peculiarly pernicious in
predisposing  to  constipation.  The perspiration,
both sensible and insensible, is increased ; and as
a necessary consequence, the urinary and other
secretions are diminished; in addition  to which,
the skin is  kept in  a  debilitated  condition,  and
from the intimate sympathy  existing between this
organ and the intestinal canal, the due perform
ance of the functions  of the latter is necessarily
interfered with.   ~         TT
                Charles Hastings,
                Robert J. N.  Streeten. 
G IO N.
500                                 CONTJ

   CONSUMPTION.  (See Phthisis.)
   CONTAGION,  (from contagium, contagio,
contingo, con and tango, Lat.) — By this term is
meant the propagation of disease from one indi-
vidual to another ;  though it is sometimes used,
both in speaking and  writing, to  denote the mat-
ter by which the propagation is effected.   In cer-
tain  cases,  those of inoculation, we  have perfect
knowledge  that this propagation is produced by
the communication of a noxious matter from the
individual  first affected to him who receives the
disease,  and from analogy, and from our inability
otherwise to explain the effect on the system, we
infer that in all cases  of contagion there is a com-
munication of such matter.  The body seconda-
rily affected has the property of again generating
and communicating to others a similar matter, the
disease produced in every case being the same in
kind as  that existing in the body where  the mat-
ter causing it is engendered.   Diseases thus  pro-
duced, and possessing the power of engendering
such a matter, are  said to be contagious, and the
matter generated is called contagious matter, or
contagion.
   All examples of disease produced in one human
being by the application  of  matter derived from
another do  not come within the scope of this  defi-
nition.  For instance, in  the case of certain dis-
section-wounds, or in the examples related by Mr.
John Hunter, of disease produced by the trans-
planting of teeth, there is no reason to think that
the individuals from whom the matter was derived,
laboured under any disorder similar to that which
was  engendered, nor  is  it ascertained in either
case that the disease possesses the power  of pro-
pagating itself.  But were  it distinctly  proved
that either  disease possesses such a property, then
would it be contagious,  though arising  from a
non-contagious source :  for we are not  justified
in denying that a contagious disease may be gen-
erated by other morbific causes than contagion.
   Contagious diseases may be divided into those
whereof the contagious matter acts only by posi-
tive contact between the individuals communicat-
ing and receiving  the disease, or by its  transfer-
ence in  a visible form from one person to another
by inoculation; and   into those which,  though
communicable by contact, and in  some cases by
inoculation, are besides  capable  of  transmission
from individual to individual through the medium
of the atmosphere.  Contagion is therefore imme- ■
diate or mediate—contactual or remote.
   To the former division are to be referred syphi-
lis, gonorrhoea, sivvens,  frambcesia, itch, porrigo,
Egyptian ophthalmia, cow-pox, and probably pel-
lagra and  the mentagra of the  ancients :  to the
latter, small-pox,  chicken-pox,  measles,  scarlati-
na, [?] hooping-cough,  [1] plague, typhus, hos-
pital gangrene, influenza, [?] puerperal fever, and,
according to the opinion of some persons, yellow
fever, and  cholera of  India.  It has been  shown,
too,  by Dr. Wells,  that erysipelas occasionally
manifests a contagious property.  There  are two
other diseases which were  formerly  considered
contagious, lepra Graecorum and lepra  Arabum
(elephantiasis).  The former is  unquestionably
not  contagious, and  from the observations made
by tlu>  late Dr.  Adams  in the lazar-house  at
Funchal, there is every reason to think the latter
 equally devoid of  this quality.  Of the two dis-
 eases communicable from inferior animals to man,
 hydrophobia  and glanders,  it is not ascertained
 that they may be transferred  from  one human
 being to another, which certainly would have been
 the case with respect to the former, had it pos-
 sessed  the property  of remote  contagion.  The
 opinion entertained by many veterinary surgeons,
 that the  latter is communicated by contact from
 horses  to the human species, has been amply con-
 firmed by the researches  of Dr. Elliotson of St.
 Thomas's Hospital :  whether it be  further com-
 municable from one human being to another is not
 ascertained.
    Of the nature of  the matter  of contagion  we
 know nothing; but attempts have been made to
 ascertain  the laws which  regulate  its  diffusion
 through tbe atmosphere.  The following are some
 of the  results of these attempts which have been
 given to  the public ;  although there is reason to
 think that they do not  merit implicit confidence.
 Dr. Haygarth informs us that in  1777 he began
 to ascertain by clinical observation  according to
 what  law the variolous infection, and, in  1780,
 according to what law the febrile  contagion is
 propagated.   He is of opinion that the pernicious
 effects  of the variolous miasms  are limited to a
 very narrow sphere.   In the open air and in mode
 rate cases he supposes that the infectious distance
 does not exceed balf a yard; and hence, he says,
 it  is probable that even when  the distemper is
 malignant, the infectious influence extends but a
 few yards from the source  of the poison.  He is
 of opinion that the contagion of fever is confined
 to a much narrower sphere than that of small-pox.
 (Letter to Dr. Percival, p. 8.)
    By Dr. Clarke we are informed tbat tbe most
 malignant fever  does not  render the atmosphere
 infectious further than a few feet from the patient,
 or from the  contagion preserved in clothes,  furni-
 ture, &c.; and daily observation, he remarks, con-
 firms  the opinion  that a person must remain a
 considerable time within the sphere of infection to
 receive it. (Report to the Committee of the New-
 castle Dispensary, 1802.)
    The poison of  plague has been  said to  be so
 fixed, that to be affected by it requires almost con-
 tact, unless  the patient's breath  be inhaled, by
 means of which the  disease is readily communi-
 cated.   We  have already  intimated a suspicion
■ that these restrictions on the sphere of contagion
 have been imposed with more precision than sound
 induction warrants;  but  we  believe  it may be
 considered a  rule that within this sphere the dan-
 ger is greater, other things  equal, in proportion to
 the proximity to the patient.
    Certain circumstances influence  the  extent of
 contagious diffusion.   Of these the most distinctly
 ascertained  are  atmospheric impurities ; for it is
 ever observed, and  we believe it may be predicated
 of every  disease  possessing the property of remote
 contagion, that its  contagious matter is propagated
 to greater distances  in a  dirty, crowded, and ill-
 ventilated apartment than  in one of which the air
 is pure ;  whilst diffused through  an atmosphere
 of the latter description, it is speedily deprived of
 its noxious  properties.  The same principle ap-
 plies  to  articles  of  dress  and furniture ; those
 which are contaminated with animal  secretions 
CONTAGION,
501
and effluvia being much more readily impregnated
with contagious matter than those which are clean.
At the same time it must be remarked, that the
neglect of cleanliness implies  the multiplication
of foci of contagion from the foul clothes and the
presence of the discharges from the bodies of pa-
tients, and the accumulation of contagious  mat-
ter from the  neglect of ventilation; and hence,
though filthy apartments  are hot-beds  of pesti-
lence, part only of  their effect is  to be ascribed to
foul air.
   Besides these auxiliaries of contagion  acting in
a limited district, there are others more exten-
sively diffused, of which the influence is important.
Some of these are  well known, whilst others are
cognizable only by  their effect on the propagation
of disease.  The effect  of those, the nature  of
which is ascertained, varies in the case of different
contagions.  The diffusion of plague, for  instance,
hf favoured by a temperature high within a certain
degree;  whilst it  is checked, if not altogether
extinguished, by the cold of winter, and  likewise
by very high  temperatures, such  as the  heat of
certain parts of Africa in  summer, as mentioned
by Alpinus,  and that of the Harmattan winds.
Typhus, we know,  prevails at low degrees of  heat,
as likewise do measles and scarlatina; and so of
different contagions, we find the effect of tempera-
ture on  them varies in the  case  of different dis-
eases.  A moist and still atmosphere, may, if we
mistake not, be  declared favourable to the propa-
gation of all  contagious  disorders ;  whilst  it Is
sometimes suddenly checked by  strong  commo-
tions  in the air, such as storms and hurricanes.
   But besides  these  appreciable atmospheric
states, which in one way or another influence the
diffusion and action of the matter of contagion,
there are conditions of the  air favourable to  its
diffusion, or  otherwise, of  the  real  nature  of
which we are  ignorant  beyond  their influence
over the propagation of disease.  It has  occurred
to every medical man to see diseases, justly  con-
sidered contagious,  unusually  prevalent in  one
season compared with another,  though there  may
have been no discoverable difference in the atmo-
spheric states to explain this variety in their pre-
valence ;  and to see them, on the other hand,
decline and finally  disappear long ere  individuals
susceptible of the contagion were wanting, without
there  having  been  any  appreciable change in the
state of the air to account  for that in the disease.
This  atmospheric peculiarity, to  which the name
epidemic constitution has been sometimes applied,
occasionally appears to possess  a  limited  locality;
for we find a contagious disease  prevailing  in a
town  or village, whilst  places in  the  neighbour-
hood escape, though there is a constant intercom-
munion between the infected and healthy  districts;
or such a disease may spread extensively in one
town, whilst in  anotber, similar as to the habits
and character  of the population,  and not remote
in situation, it may exist, but be by no means  so
prevalent.
  A distinction  has been proposed  between  dis-
eases  transmissible  from  one  human being  to
another, and  between the terms applied  to them,
founded on the influence exerted  by atmospheric
peculiarities over their propagation.  It has been
suggested that the  word contagious  should  be
limited  to  diseases which are capable of trans-
mission  under any circumstances  of  the  atmo-
sphere, pure or impure, such as measles or  small-
pox ; whilst  those which are communicable only
in impure or vitiated air, as some have conceived
typhus  and certain  other diseases to be,  it has
been proposed to designate by the term infectious
exclusively.  It will be  understood that a corres-
ponding distinction is intended between the words
contagion  and  infection.  In the  first place, it
may be remarked that the distinction between the
diseases  to which  the terms are proposed to be
respectively applied is  hypothetical ;  for  atmo-
spheric impurities  and peculiarities appear to have
an influence on the transmission of all diseases,
and  it seems  very questionable whether  any dis-
ease, not in its own nature communicable,  is ren-
dered  so  by  such impurities  and  peculiarities.
Again, the words have long been  used by medical
men, when speaking of the transmission of dis-
ease, as  strictly  synonymous,  and   they  have
applied   them   indifferently to  small-pox  and
typhus ;  and  the  attempt to  restrict them in an
unwonted  manner has  been  productive of con-
fusion,  such limitations  having  the same  per-
nicious  effect as needless neologism.  It may be
remarked, however, that infection, though in  the
ordinary language of the profession strictly syno
nymous with contagion when employed to denote
the  transmission of disease, is used in a sense
which the latter word does not admit, that of con-
tamination by any thing injurious to the human
frame ; for which see Infection.
   Of the  diseases  enumerated  as  contagious,
small-pox,  measles, scarlatina,  and hooping-cough
affect individuals but once in  the  course of their
lives; at least  this is a very general rule.  The
privilege of furnishing  immunity  from  future
attacks  has been claimed, too, for yellow  fever;
but it  seems very questionable whether the  ex-
emption afforded by it  be of the  general nature
of that enjoyed  by those who have undergone the
exanthematous  diseases  and hooping-cough.   It
is indeed doubtful whether the  comparative immu-
nity  furnished by attacks of that disease be  any
thing more than  part  of the general seasoning
process  by which  the  constitution  becomes har-
dened against  the  influence of certain climates
and  their diseases.  Were  it  unequivocally esta-
blished, yet would it furnish no material evidence
in favour of the supposition of this disease being
contagious, unless  the furnishing  of  exemption
from second attacks were a property of contagious
diseases generally, whicb is not the case.
  A period generally intervenes between the ap
plication of contagious matter and the occurrence
of the  disease which it generates, varying in dif
ferent diseases, and in different cases of the same
disease;  for instance, in  scarlatina this period is
said  to  range from  three to five days, but occa-
sionally extends to twenty-one, (Dr. Maton, Med.
Trans, vol. v. art.  xi.;)  in  measles from  ten to
fourteen; in natural small-pox  from six to twenty-
one ; and in the inoculated disease from  four to
eighteen; whilst Dr. Whytt's very unhappy ex-
periment showed the interval for inoculated plague
to be only three days.   The contagion of  typhus
is sometimes instantly felt in the system, as in an
example which the late Dr. Gregory used to relate 
502
CONTAGION.
in his lectures,  of an individual  who instantly
sickened and became affected with fever on kicking
some chaff thrown out of a bed on which a pa-
tient ill of fever had  lain ;  and in another men-
tioned by  Dr. Tweedie,  in  his  Illustrations of
Fever, of a nurse in the Fever  Hospital,  who
sickened whilst  examining  the  evacuations  of a
patient, and  passed through a most severe form
of fever.  Dr. Marsh's observations upon the ori-
gin and latent period of fever (Dublin Hospital
Reports, vol.  iv.) abound  with  striking instances
of the instantaneous occurrence of the disease on
the. application of  its cause; but the interval from
the application  of the  poison  of typhus  to the
production of its  effect, there is reason to think,
extends frequently to  three weeks or a month, and
even sometimes to sixty-eight days, (Bancroft on
Yellow Fever, p. 515.)   The latent period of the
poison of hydrophobia is  longer than that of any
other disease we are acquainted with.  This period
in the case of some diseases is not one of  perfect
health.  In that of typhus a great degree of ner-
vousness,  inappetency,   mental  dejection,  and
debility  often  precede for  days or  weeks  the
symptoms which  denote  the commencement of
the  febrile movement in  the system.  It has oc-
curred to the writer to observe cases in which the
low but exhausting degree of indisposition  attend-
ing this period has constituted the greater part of
the  disease which has destroyed the patient.  He
has  visited persons  who, though they had felt
themselves indisposed for weeks, had persevered
in  their accustomed  avocations  in spite  of this
feeling, which they thought lightly of, and  have
then suddenly sickened with the worst symptoms
of the  last stage of typhus, and expired  within
forty-eight hours.   An author already  quoted, Dr.
Marsh, deserves the  thanks  of the profession for
calling their  attention  to the importance  of this
period and its proper management.
   The most certain  evidence we can have of a
 disease being possessed of a contagious property
 is its being  communicable by inoculation.   By
 this  is meant the transference of a  visible and
 palpable  fluid, through which we must suppose
 the subtile matter of contagion to be diffused, from
 one individual to  another, or from one to another
 part of the  same individual.    It is  designedly
 practised, as is familiarly known, in small-pox and
 cow-pox, and  also,  from  improper  motives, in
 purulent ophthalmia.   The application  of the
 matter of gonorrhoea  to the eye of the  person
 affected with it is an example of the second kind
 of inoculation mentioned.  Inoculation of one in-
 dividual  from another is possible in all cases in
 which a morbific  matter, capable of being trans-
 ferred by art, is engendered, of which examples in
 addition  to those  mentioned may be found  in both
 divisions of contagious diseases.  Some disorders,
 too, which do not during the life of the  patient
 generate a matter which  may be artificially trans-
 ferred, have yet appeared to be communicated in
 this way by dissection-wounds; a description of
 cases very distinct from those adverted to  of such
 wounds, in  which the individual dissected did not
 die from a disease of the same nature as that pro-
  duced in the injured individual.
    Tne  other proofs are,  repeated examples of
persons contracting disease from contact with per-
sons labouring  under it, or from being  near to
them, or from  being in  the same  situation with
respect to fomites.   An  inference may be drawn,
too, from the exemption  of individuals from a dis-
ease who sedulously avoid  the sick and  fomites,
compared with the liability of those who neglect
such  a precaution.   By fomites are  meant mat-
ters, such as goods of any kind, clothing or fur
niture,  which, having been  near the sick, are im-
pregnated with the emanations from  their bodies.
This  may happen to the clothes  of individuals
who visit them ;  and in  this way an  attendant or
visiter of patients may communicate  a disease to
others though he escape  it himself, being secured
from it in certain cases  by having previously la-
boured under it;  in others by insusceptibility of
that peculiar contagion,  as is frequently exempli-
fied in puerperal fever.   It  is obvious  that the
poison  may by accumulation exist in  a very con-
centrated state in fomites which have been long
near the sick or in contact with them, and  conse-
quently we find  that some of the worst cases of
contagious disease are produced by their means.
   With respect to diseases  communicable only
by contact or inoculation, all doubt of their con-
tagious nature has long ceased ; and of those enu-
merated in the second division, some, which can-
not be propagated by inoculation, especially of
the exanthematous disorders, are admitted by ali
observers to possess this property.  But respect-
ing others  the agreement on  this point among
medical men  is by no means  uniform; and con-
troversies have hence arisen as enduring and acri-
monious as any recorded  in the annals of medi-
cine.   The  attempts to decide this perplexed
question in the case of any disputed disease, must
be made in another  part of the work ; but it be-
longs to this  place to point out the tests, (which
owe their value to  their being proofs of the cir-
cumstances already  mentioned, the reception of
 disease by  direct intercourse with the sick, and
 immunity from it by rigid seclusion from them,)
 by which any individual case should be tried, and
 by whicb alone it can be decided.
    1. Contagious  diseases  frequently spread in
 places previously healthy, shortly after the arrival
 in them of persons from infected districts.   The
 same remark applies to fomites.  It is the more
 apt to occur in the case of persons, if they be sick
 on their arrival or become so shortly after.
    2.  When a case arises in a limited district, the
 disease spreads gradually through it as from a
 centre towards a  circumference, but more rapidly,
 cxteris paribus,  in  proportion to the density of
 the population, and the  intercourse of the healthy
 with tbe sick.
    3.  Persons whose official duties  bring them
 into habitual and close communication  with the
 sick, such as the medical officers and  other attend-
 ants on public  institutions which contain many
 cases of a disease, are affected with it in  a greater
 proportion than other members of the community
 similarly circumstanced with themselves,  the in-
 tercourse with the sick excepted.   The number
 infected from among the different classes of such
 attendants bears  a proportion to the closeness and
 duration of their communication with the  sick; 
CONT
for instance, tbe nurses, and in military hospitals
the orderlies, are more frequently attacked than
the medical officers.
  4. The contagious quality of a disease may be
inferred from frequent instances of the success of
measures taken to prevent its propagation, such
as the early removal of the sick.  The importance
of the evidence to be derived from this source can-
not be more clearly shown than by the following
statement of Dr. Alison : " We should have little
difficulty in pointing out above a hundred houses
where  a single  case of fever has occurred, where
the patient  has speedily  been.removed  and the
place cleaned, and  where there has been no recur-
rence.   But we should hardly find five houses in
all the closes of  the  old  town of Edinburgh, in
which a patient in fever has lain during the whole
or even during the half of his disease, in which
other cases of the  disease have not shown them-
selves."*
   5. Those who seclude themselves from all com-
munication  with the  sick and with  those  who
visit them,  and receive  no  commodities  which
have been in their  possession or near them, escape
the  disease;  whilst  persons  similarly  circum-
stanced in all respects, the seclusion excepted, are
attacked by it.   The  same rule applies to coun-
tries or districts secluded by quarantine or other
regulations from neighbouring countries, similar
in soil and climate, where disease  is  prevailing;
though it must be acknowledged that the cases
are rare in  which a  precise  conclusion  can be
drawn from this latter case of exemption.
   6. An inference favourable to tbe  supposition
of a disease  being contagious,  may  be deduced
from the circumstance of there being nothing  in
the soil or climate where it prevails fitted to  en-
gender other  causes of disease, such as malaria.  A
 similar inference  may be drawn, when disease is
prevailing in a limited district, from  the  cleanli-
ness observed there, and  the  consequent  exemp-
tion from infection which might be occasioned by
the effluvia from decomposing animal and vege-
table recrements.  The previous state of health,
too, of the district or country, particularly as re-
gards the disease which is the subject of investi-
gation and diseases of the same kind, may furnish
the medical reasoner with powerful arguments.
   It must be remarked that, in all investigations
into disputed cases of  supposed  contagion,  as
many tests as possible should be brought to bear
upon the  points;  and that these tests should be
secured by a  specification of all particulars which
tend to sbow that malaria was not an agent in the
production of  the disease respecting which  the
controversy  exists.  A reference  to a few exam-
ples of the successful  application of the tests will
be  the best  means of putting the  reader in pos-
session of the nature of the detail required for the
security of his argument.
   Those  of  Dr.  Alison  have already been  re-
ferred to, and  the  reader may be assured that he
can consult none more valuable.
   In Dr. Tweedie's Clinical Illustrations of Fever
the following instance is  given of  the successful

  * On Epidemic Fever, Edin. Med. and  Surg. Journ.
vol. xxviii. p. 241, whore the reader will find most of the
tests enumerated successfully applied, to show the con-
tagious nature of the fever of this country.
GION.                                  50a

application of the third test, the prevalence of dis-
ease among persons officially employed about the
sick.
  " Every physician, with one  exception, (the
late Dr. Bateman,) who has been connected witb
the Fever Hospital, has been attacked with fever
during his  attendance, and  three  out of  eight
physicians have" died.    The resident  medical
officers, matrons, porters,  domestic servants, and
nurses, have one and  all invariably been the sub-
ject of fever; and the laundresses, whose duty it
is to wash the patients' clothes, are so invariably
and frequently attacked that few  women will un-
dertake this  duty.  The  resident medical officer
was attacked with fever, and it became necessary
to appoint some one to  perform his duties.   The
first person who thus officiated took  the  precau-
tion of sleeping at home, yet his duties were soon
interrupted  by an attack of fever which  confined
him a considerable time.   He was succeeded by
an individual in robust health, a disbeliever in the
doctrine  of contagion.  He  performed his duty
only ten days when symptoms of severe fever ap-
peared.
   " There is no security in this narrative, striking
as  it is,  against the favourite argument  of the
non-contagionists; but the following collateral cir-
cumstances present an obstacle  to the intrusion
of malaria, which only bigotry or  the spirit of par-
tizanship  can enable it to  surmount.   The Fever
Hospital  stands in the centre of a  large field,
where the production of malaria is  exceedingly
improbable, and on the same lawn, and within a
few yards of it, stands  the Small-Pox Hospital ;
but no case of genuine fever has  occurred among
the medical  officers or domestics of that institu
tion for the last eight years."   The relation these
facts bear to the argument is  sufficiently manifest.
   In the case of plague, of the contagious nature
of which  it would be easy to accumulate proofs,
the following example, selected  from hundreds,
of the influence of fomites, special seclusion from
the sick,  and close intercourse with  them, illus-
trates well the nature of  the  evidence to  be de-
rived from the third  and fifth tests.   When the
plague  was  prevailing  in Valetta, in Malta, in
1813, the strictest  precautions were used  by the
inhabitants  of the  Augustine Convent situated in
the town to exclude  the disease.    At  length,
however,  a  servant, contrary to regulations, went
into a part of the town  where  the disease pre-
vailed, and  purchased clothes supposed to be in-
fected.  Soon after he returned he confessed what
he  had done, and was  immediately shut up, to-
gether with  one of the brotherhood  who  volun-
teered to  attend him.   Both of them were  taken
ill and died,  but no other person in the convent
suffered.  A disbeliever in contagion  would attri
bute the disease of the  servant to exposure to the
malaria of the district  in which he  bought the
clothes;   but the monk's  malaria must have ex-
isted in the convent:—how strange that it should
have smitten only one of the brotherhood, and he
the individual wbo alone had intercourse with the
sick servant!
   There  can be no better  exemplification  of ine
first test  than  the  occurrences in the Island of
Ascension in 1823.  This island, remote from
any other land, of volcanic origin, ana the surface 
504
CONTAGION.
of which consists of volcanic ashes, excepting in
one  point called the Green Mountain,  elevated
2500 feet above  the level of the sea, where there
is a thin earthy soil favourable to vegetation, but
which is very dry, whilst  the volcanic surface  is
said  to be dry, arid, and barren, was uninhabited
until 1815, when a few British troops were  sta-
tioned there on Buonaparte's arrival at St. Helena.
During  the  seven years which elapsed from the
7th of "March, 1816, to the 7th of May, 1823, but
two fatal cases of fever had occurred in the island.
On the  20th of April of the latter year,  the  ship
Bann arrived there from Sierra Leone with yellow
fever on board,  which had attacked  ninety-nine
of the  cre-v, and ultimately destroyed thirty-four
of them. I jrty-five men, ill of fever, were landed
on the island from this vessel.   Eight days  after
the arrival of the Bann, one case of fever occurred
among  the inhabitants ; but eighteen  days after,
or on the 7th of May, fever of the same character
as that  which prevailed on board  the ship, showed
itself most decidedly ; and  from this  time until
the  16th  of June, or within  six  weeks, fifteen
persons died, of twenty-eight who  were attacked
with the disease,  out of  a  population consisting
of only  thirty-five marines, with some women and
children.*
   This case is valuable so far as a much-litigated
point of pathology is  concerned, but it owes much
of its value to  the specification  of collateral cir-
cumstances ; such as the nature of  the soil of the
island,  and its  previous  comparative  exemption
from fever, which render it  improbable that  mal-
aria of a degree of intensity sufficient to produce
such a  disease, had been generated  there.  At the
same time it must be remarked that  some cause
of fever was endemial at Ascension, for twenty-
three cases had taken place in its small popula-
tion during the  seven years preceding the arrival
of the  Bann,  viz., ten cases  of continued fever,
eleven  of bilious  remittent, and two  simply re-
turned  fever; and of these cases  two had  been
fatal, one of bilious remittent, the other of con-
tinued  fever.  It may be observed, too,  that isl-
anders, who rarely receive the visits of strangers,
are  liable to be attacked with sickness  of some
kind on their arrival, though the visitors may not
be  unhealthy ;  as we understand is  occasionally
exemplified among  the Shetlanders.   Hence we
cannot conclude positively that the disease was
imported into Ascension ; but it must  be acknow-
ledged  that this case wears more  the air of im-
portation  than  any which  has been  given to the
public—indeed  most other attempts to prove im-
portation  have  been signal failures — and that a
few more  cases equally  striking  would  set the
question of the contagion  of yellow fever at rest
for ever.
   The subject would be  left very imperfect  if we
 did not bestow some attention on the  question,
 how far contagious diseases may be produced by
 other causes than contagion ?  By admitting that
 the matter of contagion  is the  product of a dis-
 eased vital action, we are by no means forbidden
 the supposition that  the  diseased vital action  re-
 quired to engender such matter may occasionally
 owe its origin to other causes.
   ♦Official  Report  of  the Fever, which  appeared on
 board his Majesty's snin Bann, Sec, by  W. Burnet, M. D.
  To commence with  the  simplest case,—if any
member of a family becomes affected with  catarrh,
arising from catching cold, how constantly do we
find it passing successively from  individual to in-
dividual of the family, till  the whole are infected,
in the manner of contagious disease, though there
be no reason to think that  the individual  first af-
fected received it from any other source than cold,
or cold and moisture.
   The  itch  appears  to be engendered by mere
filth,  but when  thus  produced is manifestly con-
tagious.    Some  forms of  porrigo,  too, arise
spontaneously, but yet are disseminated  through
schools and families from the individuals in whom
they have thus arisen.
   Certain  soldiers of a regiment may have suf-
fered at some  previous time from Egyptian oph-
thalmia ; they may have been cured of the disease
and  remained  free from all symptoms of it for
months, or even  years; and the regiment shall
consist partly of such men, and partly of men who
have never bad ophthalmia.   If  one or more sol-
diers who  have previously suffered from  the dis-
ease, have  the eyes inflamed from exposure to the
sun's rays, cold, or intoxication,  and the  inflam-
mation is so considerable as to produce secretion
from the conjunctiva,  and the regiment is at the
same time  in  barracks, so that the soldiers are
brought into habitual contact,  the disease will
spread in the manner  of a contagious disease, af-
fecting equally those who  had previously  suffered
and  those who had not;  though the individuals
first affected had not been  perhaps for years with-
in the reach of any supposable contagious source.
The  writer is not stating a mere hypothesis, but
a matter which  has fallen more than once under
his own observation.   Is  it supposable that any
poison had lurked inactive about the eyes of these
men  for so long a period ? or, is it not much more
probable that, the eyes being disposed to a certain
form of disease, the contagious matter  was really
the product of the inflammation arising from the
common causes mentioned ?
   If from over-crowding, imperfect  ventilation, or
neglect of cleanliness, or all conjointly, any single
sore in the ward of an hospital  becomes affected
with the disease  called hospital-gangrene, it ex-
tends to all the sores of the locality.  The affec-
tion of these, it is true, may be justly ascribed to
the  common pernicious  influence; but  let the
causes  of this  influence, over-crowding, defective
ventilation, &c. cease, and cases of healthy sores
be admitted, and  the  existence of the contagious
principle diffused through the air, or adhering to
fomites, is speedily manifested in the character of
the  sores ; and tbis will continue till the place is
evacuated  and subjected to a thorough disinfecting
process.
   The experience of  the whole  profession proves
that  erysipelas generally arises  independently of
contagion  ;  but  the  facts adduced  by  Dr. Wells
 leave it beyond  all question that  this disease is
 occasionally communicated by  intercourse with
 the  sick.-(-   Whether it owes tbis property, which
 it certainly displays  but  occasionally,  to some
 peculiarity in the nature of the  disease,  or to ex-

   t Transactions of a Society for the Improvement of
 Medical and Chirurgical Knowledge, vol. ii. p. 213, tc 
CONTAGION —CONVALESCENCE.
50U
trinsic circumstances, does not appear to be ascer-
tained.
  It has already been remarked  that certain cir-
cumstances of crowding, filth, and imperfect ven-
tilation,  favour  the propagation  of contagious
diseases ; but there  is every reason to think that
the contagious fever of this country may not only
be  aided in  its  diffusion by  these circumstances,
but may actually be engendered  by them.  We
often see in epidemic seasons, fever, not traceable
to any other  source, springing up in the abodes
of the poor,  apparently produced by the concen-
tration  of  human  effluvia,  and  the decomposi-
tion of animal and vegetable recrements, though
possessing a contagious character when  thus
engendered.   This mode of  generation appears
often to take place  in  seasons of scarcity, when
physical privations and the  depressing  passions
render the poor  a more easy  prey to disease, and
by depriving them  of  the moral  energy required
to  preserve order and  cleanliness in their dwell-
ings, fit these for engendering infection ; whilst
the want of clothing and fuel leads them to block
up every chink  and aperture by which  fresh  air
might gain  admittance.  The same origination
of  a  contagious disease from a non-contagious
source is observed in the typhus of crowded hos-
pitals, jails, and ships, instances of which  are  so
numerous and  familiar to the profession that it
would be to  waste  the reader's  time to quote in-
dividual examples.  It  does not seem necessary
to examine into the question, whether the mias-
mata produced  by the effluvia of  congregated
human beings, conjointly with filth and its con-
sequent animal  and vegetable decomposition,  be
 identical with those  generated  by the  diseased
 vital  actions  existing in fever $ for  in the present
 state of our knowledge of the subject we  have not
 the means of deciding it. No inference can fairly
 be drawn from  the identity of the  effect, for cer-
 tain  diseased states are produced by a variety  of
 remote causes, this expression being employed in
 the sense usually annexed to it by medical men.
   How far other diseases, which according to the
 very general opinion of the profession depend ex-
 clusively on  a specific poison for their diffusion,
 may in  some instances owe their origin to com-
 mon causes, or  such as are  independent of con-
 tagion,  it might appear presumptuous to say.
 That their diffusion is influenced by atmospheric
 causes, is beyond all question, and  there are phe-
 nomena displayed by some of them which tend to
 excite at least a suspicion  that such causes may
 occasionally engender  them.  To  select an  ex-
 ample from the  exanthemata:—scarlatina appears
 suddenly in  the latter  end of autumn ;  many are
 simultaneously  attacked — so many at the com-
 mencement  of the epidemic, that it is wonderful
 where the foci of contagion  exist to contaminate
 them :   in  its  course  it manifests  unequivocal
 signs of contagious power; it  disappears some-
 times suddenly, at others gradually, but long be-
 fore  subjects susceptible of  the disease are want-
ing : no cases are seen for some  months ;  and in
the following autumn the same course is recom-
menced, and the same phenomena are again dis-
played.  Where lurks the poison whilst thus in
abeyance,  or does  it exist any where ?  Similar
doubts  and difficulties might be suggested  by  cir-
   V0l. I. — 64                        2 s
cumstances  connected with  the prevalence of
measles and hooping-cough.
  From  the preceding observations it is manifest
that the subject is one of great intricacy, and that
an ample field is open to the cultivation of the
diligent,  ingenious, and  candid.  It is to be re-
gretted that the researches into this very  difficult
and important subject should generally have been
conducted rather with a view  to  support some
preconceived notion, than in the spirit of honest
and zealous inquiry after truth.
  Means of preventing  the propagation of con-
tagious diseases.—These may be succinctly stated
to be,  the  separation, as far as  is consistent with
humanity, of the sick  from the healthy; clean-
liness of the person of the patient, and cleanliness
and  free ventilation of his apartment;  the im-
mediate  immersion in hot water and subsequent
washing of all  clothes, &c. removed from his
person, which might become fomites;  the avoid-
ing, on the part  of the attendants, of needless and
long-continued proximity to ths  sick, inhaling
their breath, and standing in the current of air
which  passes over them ;  and the supporting of
the general health of the attendants by nutritious
diet and the rest which nature requires.   (For
further instructions, see Disinfection and Ven-
tilation.                 T       t-,
                           Joseph Brown.
   CONVALESCENCE.  This term is  applied
to denote the period or intermediate state  between
the cessation of a disease and the full restoration
of health.  When we speak of convalescence from
disease, it is implied that there has been  indispo-
sition of a more or less serious character, and of
some duration, as it is obvious it would be impro-
per to  apply this term to ailments of a trifling de-
scription.  The transition  from disease to conva-
lescence, and from convalescence to health, which
is seldom sudden, more especially in chronic dis-
orders, is announced  by the disappearance of the
more prominent characteristic symptoms.
   Convalescence is observed to be not only more
slow but less  permanent in chronic than in acute
diseases.  It is also modified, in some respects, by-
individual  circumstances:  thus, in  infancy and
childhood  it is  shorter than in the middle or ad-
vanced periods of life ; it is likewise more  pro-
tracted in  persons of  a feeble constitution, and in
those who bave undergone long-continued rigorous
antiphlogistic treatment, or who have had profuse
hemorrhage.  It  has been  asserted that conva-
lescence is in some instances  influenced by cli-
mate, and that recovery takes place sooner in tem-
perate than in hot countries,
   The changes which indicate  the stage of con-
valescence vary according to the nature of the
previous illness.  They are much less remarkable
in chronic than in acute disease.   In  chronic af-
fections  the restoration  of the  functions  of the
part affected is very  slow and  imperceptible: if
there has  been  much emaciation, the flesh and
bodily vigour are slowly regained,  even  though
the  local disease have been  completely removed.
Convalescence from acute disease, on the other
hand,  is more rapid and perceptible,  and is an-
nounced by the cessation of the more severe symp-
toms, general as well as  local.  The frequency of
tbe pulse abates, the heat of the skin diminishes, 
506
CONVALESCENCE.
tbe thirst decreases, the various functions are gra-
dually restored to their natural  state :  the tongue
becomes clean, the appetite for food returns, and
the patient  enjoys  intervals  of refreshing sleep.
Besides general  signs of amendment, the change
from disease to health is evinced in the improved
aspect of the countenance : this has always been
regarded as a sure criterion  of returning health;
indeed it may be laid down as an axiom deduced
from experience, that unless  improvement in the
countenance accompany the amendment in the
symptoms, the condition of the patient is unsatis-
factory.  The state of the intellectual  powers also
becomes improved on  the  approach of conva-
lescence—there is greater mental energy—the me-
mory, judgment, and  imagination, assume their
former activity,  though continued mental  effort
sooner induces fatigue than  in health.   Conva-
lescents from acute disease, however, show great
sensibility to external impressions, particularly  to
extremes of heat or cold ;  they evince also a mor-
bid nervous susceptibility, and  are therefore more
prone than usual to irascibility.
   Another  circumstance which  often materially
interferes with convalescence, is the supervention
of some other disease during  this period.  It is by
no means unusual to find  that the original disease
from  which  the  invalid  was recovering  is from
some cause  suddenly  renewed, for it should be
remembered  that a predisposition having been
given by the previous disease, the symptoms may
be reinduced by the application of less powerful
exciting causes  than those  which produced the
disease  in  the first instance.  In other instances
we find that some accidental  inflammatory disease
appears, and places the convalescent again in dan-
ger.   This  often happens in cases of continued
fever; and  in the eruptive fevers some accidental
symptoms  ocasionally  arise  which materially in-
terfere with  convalescence.   Thus, in small-pox,
after the eruptive stage has passed over, secondary
fever often  supervenes, which may  be  in some
cases traced to  some local  disturbance;  and we
not unfrequently observe  in this disease, as well
as in measles, a  troublesome form of ophthalmia
which is  tedious and  often  dangerous to vision.
In measles, the  convalescence  is very frequently
interrupted by some other local inflammation, ge-
nerally  of the lungs, or  by  the  supervention of
glandular disease,  more particularly  in  the ad-
vanced  period of the  disorder.  In scarlet fever
the stage of convalescence  is also occasionally pro-
tracted  by various  symptoms, which  often  prove
tedious and difficult to subdue.  Anasarcous swell-
ing of the extremities of an acute character, with
or without  internal effusion; glandular enlarge-
ments, inflammation of the car, inflammation of
the large  joints, irritation of the mucous mem-
brane of the bowels, are among the more trouble-
some sequelae which materially  retard conva-
lescence in this disease.
   Besides  these  general circumstances which are
observed in convalescence from acute  and chronic
diseases, there are others which characterize reco-
very from particular affections.   It will be found
to be a general rule that recovery takes place more
slowly in  primary than in  symptomatic  fevers.
This  slow recovery from  fever, strictly so called
is owing to the more general affection of the solids,
as well as to the  more tedious nature of  the dis-
ease, which often, in spite of the most judicious
measures, runs on for an indefinite period.  In in-
flammatory disorders,  on the other hand, wheu
the local affection is subdued, the febrile symptoms
in general  gradually abate, so that the patient is
not only convalescent in  a comparatively short
time, but the stage of convalescence is  also vf
proportionably limited duration.
   In diseases of the brain the functions  of this
organ  are  seldom at  once completely restored;
hence, in the stage of convalescence, we often ob-
serve various imperfections either in  the intellec-
tual powers or in some of the senses, and these
may continue even after the causes which induced
them have been removed.  When  the  cerebral
affection has been  attended with paralytic symp-
toms, the  muscular movements  often remain in
some degree impaired for a considerable time after
the  individual  may be  said  to be convalescent.
This imperfect state of the muscular  power may
exist alone, or it may be associated with some de-
fect of the mental  functions, or of some of  the
senses.  From these various morbid conditions of
the  nervous system  the invalid may  ultimately
completely recover,  or more or less imperfection
may continue for life.
   In convalescence from pulmonary diseases, some
symptoms  often remain which indicate the  pre-
vious affection, such as  cough, or slight accelera-
tion of the breathing on any sudden or unusual
exertion.   When these  symptoms continue, it is
evident that the  lungs have not  regained their
healthy condition ;  that  although the progress of
the  malady has  been arrested, it is  not  wholly
subdued ; and consequently that it is very liable
to be again induced  on the supervention  of even
a slight exciting cause.   The same  continuance
of slight symptoms is  often remarked in  diseases
of the abdominal viscera.  In dyspepsia the diges-
tive organs very slowly recover their tone, the con-
valescence  being often  protracted by errors in
diet; and  after the  more  prominent  symptoms
have ceased, the stomach remains for a long time
exceedingly sensitive, and never fails  to give am-
ple evidence of displeasure, when oppressed with
food of an  improper  quality, or with greater quan-
tity than it can readily digest.   In inflammation
of  the  mucous  membrane of the intestines too,
there is often for  a long time  a troublesome state
of the bowels, besides great tendency to  renewal
of  the inflammatory action which may have jusl
ceased, on  the application of a very  trivial occa-
sional cause; hence the necessity of attention tc
minute dietetic precepts in this class of diseases.
   After these general observations, we shall offer
a few remarks on the management  of convales-
cence.  It is almost unnecessary to say that this
must vary  according to the nature of the previous
disease, its intensity, and the special  circumstan-
ces which  each individual case presents.
   In external diseases the principles of treatment
are not only more obvious, but the. application and
the effects  of remedies more nicely regulated, than
in internal disorders, and for this obvious  reason,
that the progress  of the disease can be ascertained
with almost unerring certainty.  The state of ar
internal organ can only  be  known by symptoms,
which it must be admitted  give  too  often uncer- 
CONVALESCENCE,
507
fain and imperfect indications of its actual condi-
tion.  There is,  however, one  among  many im-
portant  advantages of the knowledge of the nature
and treatment of surgical diseases to the  medical
practitioner, that  it enables  him to form a pretty
exact estimate of the value  of curative measures,
and of the circumstances which  advance or retard
recovery.
   In  cases of ophthalmia, it  is well known that
it is imperative to abstain from all use of the eye,
not only during the treatment,  but for  some time
after the inflammation' has  been subdued.   Any
deviation from this  obvious  principle  is  imme-
diately followed by such effects as  are generally
sufficient to  bring  conviction of its importance.
The same necessity for caution in cases of inflamed
joints comes almost daily under notice.   If, there-
fore, such precautionary measures are  necessary
in external diseases, in which the various changes
are evident to the senses, they are equally requi-
site in those  of internal parts, more especially of
the  inflammatory kind,  in which the changes
which the organs undergo are almost precisely the
same, while there is the same tendency  to relapse,
or renewal  of the diseased condition, after any
irregularity in the management  or conduct of the
convalescence.
   It is quite evident tbat the first indication in the
management of convalescence  is to avoid those
causes which primarily  induced the disease.  An-
other obvious principle is, that the measures to be
pursued should always have  reference  to the na-
ture of the previous disease, and  the organ or parts
which have been  affected.   This principle will at
once suggest the propriety of abstaining from those
circumstances which  require such exercise of any
organ whicb has lately been diseased, as might
endanger a renewal of the morbid action.   Thus,
for instance, in recovery from disease of the brain,
whatever entails on the  patient undue  mental ef-
fort, should  be deferred  to a more distant period.
In affections of the  organs of  respiration  or of
circulation, whatever tends to excite the one  or
the other must be avoided.  It will also be neces-
sary to  regulate not  only  the various  functions,
but the  diet, exercise, and likewise  the tempera-
ture  of  the  apartment.   In  convalescence from
diseases of the alimentary canal, the practitioner
will have to attend to the state of the bowels, but
more particularly to the  proper  regulation of the
patient's food.  These examples might be extend-
ed ; but  enough  has  been advanced to illustrate
the principles we  have endeavoured to  inculcate.
   Another important circumstance in the ma-
nagement of convalescence  is  the proper adminis-
tration  of remedies.  This  must be regulated by
particular indications.   In some instances, it may
be necessary to continue for a time the employ-
ment of the  remedies which were administered
during the disease; for  instance, after recovery
from dropsical diseases, it may  be useful to con-
tinue  the purgatives or  diuretics till the convales-
cence be nearly established.  In other cases the
lemedial part of  the treatment may be  entirely
suspended, giving  occasionally  such  medicines
only as  particular circumstances may require.
   The most important department of the manage-
ment  of  convalescence is the proper regulation of
diet.   It is almost inconceivable bow many errors
are constantly  committed in  this respect, chiefly
I from want of conviction, on the part of the patient,
 of its important influence on his  recovery, and oc-
 casionally from misconception, on the part of the
 medical attendant, of the principles on which the
 diet should be conducted.   It is  a  common error
 to suppose that the  debility, which  is the  almost
 invariable consequence of acute disease, and which
 is more perceptible when the invalid first attempts
 to make exertion, is to be  removed  by nourishing
 food and stimulating drinks :  it is no unusual cir-
 cumstance to meet with such erroneous impres-
 sions  even in cases of muscular relaxation from
 cerebral disease.  When indiscretion is committed
 under  such circumstances, the  previous disease,
 which  had just been subdued, is very  generally
 rekindled, and all the primary symptoms are thus
 reproduced.
   Such errors are more liable to be committed in
 cases  of tedious convalescence,  where there is a
 state  of undefined indisposition,  attended  with
 impaired vigour, so  that the invalid does not gain
 strength, or perhaps loses it progressively.   If the
 state of the organ that was primarily diseased be
 examined, the cause of the slow recovery will, in
 the majority of instances, be  detected.   The dis-
 ease has possibly not been  wholly subdued, or it
 may from some cause have been renewed.  Under
 such circumstances  the folly and hazard of adopt-
 ing a  stimulating plan of diet and  tonic  remedies
 is apparent; the only rational  indication  is to
 arrest the disease if it  be not entirely subdued, or
 have been reinduced.
   The necessity of  proper  regulation of the diet
 is greater  in convalescence from  acute  than from
 chronic diseases ; it becomes the more necessary
 when  the  previous  disease has  been severe and
 protracted, or, though not protracted, when rigor-
 ous antiphlogistic measures,  and especially large
 evacuations of blood, have been  employed.   The
 tendency, however, of  chronic visceral disease to
 assume, perhaps suddenly, a more active  form,
 should always be kept in view, as well as the fact
 that nothing is more likely to induce such  excite-
 ment than errors of diet.  It  would lead to  tedi-
 ous repetition were  we to point out those  forms
 of chronic disease to which this  remark  is appli-
 cable : in such an article as  the present, general
 principles only can be given, which the  practi-
 tioner may apply to individual cases.
   The  return from  the  bland  unirritating food
 which  has been allowed in tbe active stage of
 acute  disease, to food of a more  nourishing qual-
 ity, should be gradual : the first  step should he to
 substitute another article of the same class of fari-
 naceous food, increasing by degrees the quantity,
 which  should be divided into portions to be  taken
 at short intervals.   Milk, particularly asses' milk,
 is a very suitable article of diet  for delicate  con-
 valescents, and especially children.  Another pro-
 gression may be made by substituting a weak
 infusion of animal food with  a moderate quantity
 of farinaceous  admixture, either  of arrow-root,
 prepared barley, rice, or stale  bread.   If  the  con ■
 dition of the patient admit of it, the liquid  nour
 ishment may be  abridged,  and  a  very small al-
 lowance of  solid animal  food  allowed.  Great
 care should  be taken in the selection  of, anu
 mode  of dressing, the  animal food.  In general,
 mutton is most  easily digested, and, if it  agree,
 may be preferred exclusively for  ti~e first eight 01 
503
CONVALESCENCE —CONVULSIONS.
ten days, or exchanged occasionally for chicken.
The propriety of first allowing white fish as being
a more digestible kind of food  for  convalescents
is questionable.  It affords certainly a less  quan-
tity  of nourishment than animal food, (though
this  advantage may be gained by diminishing the
allowance of the latter,) but  it  is certainly more
difficult to digest, and therefore  less  suited  to the
convalescent, besides  that it affords  opportunity
for indulging in  condiments  and additions of an
improper kind.   In the advanced stage of conva-
lescence from acute disease, if there be nothing to
forbid it, one or two glasses of sherry, mixed with
water, may be allowed. When the  convalescence
is completed and the health restored, a more libe-
ral scale of  diet may be gradually adopted, though
for a very long time great care should be exercised,
so as to avoid any articles which are likely to dis-
agree.  It should also be impressed on the  mind,
that the quantity as well as quality  of the  food is
to be regulated—indeed convalescents often suffer
more from too much food, even of a proper kind,
than from food of an improper quality.
   The due  regulation of exercise forms  another
important part of the management in convales-
cence.  This should  not be  suddenly resumed—
nor  at any time  carried to  such  an extent as to
induce  fatigue;  and  should  be suitably adapted,
not  only to the powers of the  invalid, but to  his
previous habits and condition of life.   We have
already shortly adverted to the necessary precau-
tions in exercising the  functions  of the  organs
which have been previously diseased.  It must be
obvious that while all undue exertion of an organ
is prohibited, the bodily  exercise  should be so
regulated as not  to   produce  excitement, which
might not  only be  injurious,  but  endanger  the
safety of the organ previously diseased,
   The necessity of suitable clothing in convales-
cence is so  obvious to the invalid, that it  seldom
requires to be inculcated by the medical attendant.
In temperate places, and more  especially in those
situations where the  temperature is variable, it is
necessary to protect the surface for a time by warm
clothing, and particularly by  flannel under-gar-
ments.   Some  delicate  persons suffer so much
irritation from the use of flannel, that it becomes
necessary to interpose a linen under-dress, or to
substitute calico.  It should  be explained to inva-
lids that the use of woollen garments is  not so
much for the purpose of affording additional heat,
as to protect the surface from sudden atmospheric
changes, which, by chilling  the skin or  exciting
the  circulation, might reproduce the primary dis-
ease.
   The atmosphere of the chamber  to which the
invalid is for a time confined should be frequently
renewed ;  and while attention  is paid to  ventila-
 tion, the temperature should  be duly regulated.
 In the winter and spring months it should be kept
 as nearly  at from 55° to 60° Fah., as possible,
 while the invalid continues weak.   When he has
 regained his strength it may be gradually reduced,
 so as to enable him to bear the ordinary tempera-
 ture of the season, first in  an  airy chamber, and
 afterwards in the open air.   When circumstances
 permit, nothing in general tends so much to pro-
 mote and establish recovery  as what is commonly
 'crmed  change of air.   In most  instances, the
improvement in the looks and feelings of the inva-
lid, very soon after he has removed from  a  con-
fined to a more  salubrious district, is remarkably
striking.
   For further  illustration of this subject, how-
ever,  we refer  to the articles Change of Air,
and Climate.                 a.  Tweedie.

   CONVULSIONS (convulsio, from convello, to
pull together.)   By the term  convulsion is meant
a diseased action of the  muscular tissues charac-
terized  by violent involuntary contractions, with
alternate relaxations.  This  diseased  action is
common to  the  muscles both of voluntary and in-
voluntary motion, but occurs  much  more  fre-
quently in the  former. The term spasm has been
applied  by  some to the inordinate  action of the
involuntary muscles; the term convulsion being
more particularly reserved to designate the  irre-
gular contraction of the  voluntary muscles.   By
Cullen and some other writers  the term spasm
has also been applied to the  fixed contraction of
parts.   When the contractions have been of some
duration, and are not quickly succeeded by alter-
nate  relaxations, they  have been  called tonic
convulsion, as  is exemplified in tetanus; whilst
involuntary alternate motions of contraction  and
relaxation have been termed clonic convulsions,
of which hysteria affords an example.  The term
convulsion  has sometimes been exclusively appro-
priated to clonic convulsion;  but as the principal
difference between  clonic and  tonic convulsions
consists in degree, and they both originate in the
same causes, it is more  convenient for practical
purposes to include them under the same head.
Very slight  and quick alternate motions  of con-
traction and relaxation constitute what is called
tremor.
   Convulsions manifest  themselves  in  various
degrees and under various forms.  They occur as
 a symptom in  the course of many diseases, and
they sometimes assume  such  regular and  well-
 defined characters as to  constitute distinct and
 separate diseases ; as, for instance,  in the  case of
 tetanus and hysteria. Convulsive affections have
 been classed by most nosologists among the neu-
 roses, or nervous diseases.  Sauvages,  Vogel, and
 Cullen include them as a  genus in the  order
 spasm.  Cullen defines this  order  " an irregular
 clonic  contraction of the muscles, bordering on
 but short of lethargy."   The presence or  absence
 of lethargy depends, it will be seen, on the seat
 of the  exciting cause.   This  genus  contains  a
 great  many species; but he has made separate
 genera  of  several convulsive affections, such as
 hysteria,  tetanus,  and   epilepsy.   Dr.  Mason
 Good's arrangement of convulsive affections  is
 very complicated : they are included in the class
 neurotica.   He makes one genus of tonic convul-
 sions  termed entasia, including tetanus, hydro-
 phobia,  wry neck,  muscular  distortions of the
 spine,   cramps, &c.   Another  genus of clonic
 convulsions is termed clonus: this includes sin-
 gultus, sternutatio, palpitatio, nictitatio, subsultus,
 pandiculatio.   A  third  genus  called synclonus
 comprehends  tremor, chorea, shaking palsy, ra-
 phaneia, and  beriberia.   His last genus  is  called
 syspasia, or comatose spasm, in which he places
 convulsion, hysteria, and epilepsy. 
CONVULSIONS.
509
  Convulsions have  also been divided  into pri-
mary and secondary ; acute and chronic; continued
and intermittent,  &c.;  but  these divisions  are
unimportant, as they  lead to no practical end.
  There are attacks of simple convulsion,  partial
and general, that  cannot be referred to  hysteria,
epilepsy, or any of  the  well-defined convulsive
affections  which  have  received generic names.
These varieties of simple convulsion will form
more particularly the subject of the present paper ;
and as convulsive affections are generally entitled,
by the  formidable  character  of their symptoms
and the imminent danger  which frequently at-
tends them, to the attentive consideration of the
practitioner, we propose taking a general view of
their pathology, and  of  the principles whicb are
to regulate their treatment.
   Convulsions may  be local or general; each
part may  be  separately and successively affected,
or the whole frame may be convulsed at once: in
some cases the convulsive movements are confined
to one side of the body.  We shall first consider
the manner in whicb different parts  of  the body
may be separately affected with convulsions.
   Local  Convulsions___When the eyelids are
 affected, if the convulsion is confined to  the leva-
 tor palpebral superioris, the upper eye-lid is forci-
 bly drawn up, and cannot be  closed ; the eye-ball
 consequently remains uncovered, and is exposed
 to painful irritation : this occurs sometimes as a
 local  affection, especially in neuralgia of the supra-
 orbital nerve.  If the orbicularis muscle be affected,
 the eye-lids are forcibly closed, and can witb diffi-
 culty  be  separated.   Slight  convulsions  of the
 muscles of the eye cause a rotatory motion of the
 globe from side to side or else upwards.  This is a
 frequent symptom of visceral irritation, especially
 in children, in whom it often  occurs during sleep.
 When these muscles are more violently convulsed,
 there is strabismus,  or a violent contortion  and
 rolling of the  globe in the socket; or else  the eye
 is firmly fixed, staring and protruding.  The iris
 being possessed of contractility is susceptible of
 convulsive action; the  pupil is then either very
 much contracted  and  immoveable,  or  else it  is
 alternately closed  and dilated by quick and irre-
 gular oscillations.  Both pupils may be differently
 affected, one remaining fully dilated when exposed
 to light, whilst the other contracts; or  one may
 remain stationary, the other being alternately con-
 tracted and  dilated.   There  are in this  respect
 great variations.
   The convulsions  of  the muscles of tbe  face
 give  rise to a great variety of remarkable and op-
 posite  expressions.  The whole of the features
 may  be fixed  and immoveable,  or there  may be a
 constant change  of expression  by the momentary
 contraction of separate muscles in  quick succes-
 sion ; or  tbe  convulsions may affect only some of
 the features, causing, for instance, slight  evanes-
 cent  twitchings of the lips or  distortion  of the
 mouth ; or else an elongation and drawing up of
 the commissures of the mouth.  This last variety
 gives rise to  a  species  of convulsive  laughter,
 sometimes closely resembling the smile and laugh-
 ter of health, especially in infants, but often more
 violent: this  is the raw Surdonicus of  the an-
 cients.  When the muscles of the jaws  are affect-
 ed, there may be grinding of the teeth  or a vio-
                                       2s*
lent clattering of the jaws ;  or else there is a per-
manent rigid spasm, rendering the lower jaw fixed
and  immoveable,  as  in trismus.   Persons of a
highly nervous temperament are sometimes affect-
ed with an habitual twitching of certain muscles
of the face;  these  generally arise from constitu-
tional causes, and  are  difficult to be  remedied.
Convulsions of the muscles of the tongue cause
it to be violently twisted in the mouth so  as to
push out the cheeks, or else it is forcibly protrud-
ed ; it is very liable in  that case  to  be severely
wounded by the teeth, and has in some rare cases
been completely cut off.  A  tremulous state of the
tongue when  put  out is  a  sure sign of general
nervous debility.
   When the muscles of the neck  are  simultane-
ously convulsed, the neck feels hard, and the head
is  drawn back; if only those on  one side,  the
head is drawn to that side or partly turned round.
There may be, from  this cause, either a perma-
nent rigid contraction, or a convulsive agitation,
or a simple tremor ol the head and neck.   These
modifications  are  observed  in wry neck and pa-
ralysis agitans.
   Convulsion  of  the  muscles of the  pharynx
impedes deglutition, and gives rise to spasmodic
dysphagia.   The.  convulsions of the muscles  of
the larynx cause laryngeal dyspnoea and  suffoca-
tion, and either various alterations  or a total  ex-
tinction of the voice: these are frequently symp-
toms of inflammatory and spasmodic croup.  The
sensations of stricture  and strangulation  in  the
throat which so often attend hysteria, chorea, hy-
pochondria, &c, are  owing to a convulsive  state
of the anterior muscles of the neck.
   Convulsive affections of the muscles of the tho-
rax (the intercostals,  diaphragm, &c.,)  are some-
times the primary  cause of habitual  dyspnoea or
of violent  paroxysms of cough and suffocation,
constituting   a variety  of convulsive  asthma.
When the convulsions are  severe, the breathing
is very irregular :  there are a few short inspira-
tions and expirations;  then a  long  intermission
without any breathing, followed by several  deep
inspirations, with  heaving of the cbest and sigh-
ing : in some  extreme  cases  the  constriction of
the chest has been so violent as to stop the breath-
ing altogether and cause asphyxia.  This irregu-
lar and  occasionally  hurried breathing gives  rise
to a corresponding state in the action of the heart,
 which  becomes  violently  increased ;  there  is a
sudden and considerable rise in the frequency of
the pulse, which might be mistaken for fever ; the
circulation subsides, however, with the paroxysm
 to its natural standard.  A convulsive state of the
 diaphragm gives rise to hiccup, which  is  some-
 times a most distressing and obstinate complaint.
   The  convulsions  of the  abdominal  muscles
 cause in some cases a violent retraction and hard-
 ness of the abdomen;  in some a convulsed agita-
 tion  of the parietes of the  thorax, bearing the
 closest resemblance  to irresistible laughter;  and
 in others a peculiar undulatory motion ol the  ab-
 domen frequently observed  in hysteria.  It is not
 improbable that the globus  hystericus depends on
 a partial  convulsion of the  abdominal  muscles
 extending upwards  to the diaphragm,  and  the
 muscles of the thorax, neck, larynx, and pharynx.
 The late experiments on the causes of vomiting 
510
CONVULSIONS.
prove that the contractions of the abdominal mus-
cles have as great a share at least  in  its produc-
tion as those of the stomach.  The  sphincter mus-
cles are often convulsed, as is  seen in the tenes-
mus of dysentery, the dysuria of the irritable uri-
nary bladder, and the retention of urine from per-
manent spasm of the sphincter vesicae.
   When  the muscles  of the  trunk  are  affected
with convulsions, the  body is  forcibly bent back-
ward or else  to one side: this  is termed opistho-
tonos, and  is  a  frequent symptom of  tetanus.
There is a partial and permanent rigidity  of these
muscles  in   muscular  distortions  of the spine.
Painful cramps of the  dorsal and lumbar  muscles
are sometimes experienced in  acute rheumatism.
   In convulsions of the  upper extremities,  the
fingers are clenched on the  hand  and round  the
thumb,  and the hand is turned in  pronation ;  the
fore-arm is  bent  on  the  arm,  or moved back-
ward and forward as in the act of striking. There
may  be  very slight and  partial  convulsions of
these muscles, discovered only by the startings of
the tendons (subsultus tendinum) on placing the
hand on the wrist; these  sometimes  indicate  the
approach of a severe convulsive fit.
   Convulsions manifest themselves in  the lower
extremities  by  the strong  retraction  of the  toes
inwards and downwards, the legs  and thighs  be-
ing rigidly drawn up  or alternately bent  and  ex-
tended.  In these cases the  flexor and extensor
muscles are principally affected,  and the adductors
or abductors but seldom.
   The involuntary muscles are  also  liable to be
affected with convulsions, although much less fre-
quently  than those of voluntary  motion.  The
action of the heart is sometimes  very  much  in-
creased and irregular in nervous palpitations,  and
in several of its organic diseases;  or its  motions
may  be suddenly stopped  by a  violent  spasm of
some duration, as occasionally happens in angina
pectoris, and in cases of retrocedent gout or rheu-
matism.
   The muscular coat of the stomach is subject to
severe and  painful spasmodic contraction in gas-
trodynia, and  in  cases  of  obstinate  vomiting.
There are strong partial spasmodic contractions of
the muscular coat of the intestines, in the tormina
of dysentery, the gripings of colic, the borborygmi
and tympanitic affections of hysteria.   The mus-
cular apparatus of the urinary bladder  is often
thrown into a state of spasmodic  irritation in  dis-
eases of the urinary organs.  That of  the uterus
is susceptible of a sufficient degree of  inordinate
and  convulsive action in  the puerperal  state to
cause occasionally a  rupture of  the viscus,  and
the  regulation  of  its contractions  both before  and
during labour is always an important object in the
practice of  midwifery.
   The different varieties  of convulsions which
have been described may exist  separately, as dis-
tinct affections; they may be variously combined;
and  some of them may  pass imperceptibly  into
jach other.
   General Convulsions.—General convulsions
 consist of various  combinations of the  symptoms
 that  have been described as characteristic of local
 convulsions.  The mode of attack and  progress
 of the  paroxysm exhibit considerable  variations.
 Sometimes the attack  is sudden and without  any
warning ; but more generally there are  some pre-
monitory symptoms, especially in children, and in
patients who have had previous attacks:  of this
kind are coldness of the extremities, vertigo, float-
ing  spectra  before the  eyes,  starting at  slight
noises,  peevishness  and  irritability of  temper,
alternate paleness and flushing of the face, dis-
turbed sleep, irregular breathing, hiccup, cramps
in the hands, legs, and feet, flatulent uneasiness
of the bowels, and tension in the left hypochon-
drium.   In some cases  a sensation of creeping
cold along the back, like an aura, creating shiver-
ing, is the  premonitory symptom.
   The paroxysm is ushered in by dull pain or a
sense of weight in the head, drowsiness, flushing,
vertigo, either loss  of sight and a sense  of com-
plete darkness, or flashes of  light and bright
objects  moving before the eyes, ringing  of bells or
the noise of roaring cataracts in the cars, sickness,
pain and sense  of oppression in the  epigastrium,
&c.  These symptoms are quickly succeeded by
general convulsive  contractions of all the volun-
tary muscles and many of the involuntary, in the
manner just described in the account given of
local convulsions. The face is hideously distorted;
the  protuberant  eye-balls roll  rapidly in every
direction with a wild  stare and constant  motion
of the eye-lids ;  there is grinding or gnashing of
the teetb, occasional protruding  of the tongue and
foaming at the  mouth, with a deep hissing noise,
occasioned  by the  hurried  passage of  the air in
breathing through the teeth.  When the respira-
tion is  laborious .and very much obstructed, there
is a dark redness of the face and scalp, and a pur-
ple  colour of the whole body, together  with  a
full  strong pulse and violent beating of the caro-
tids ; in other cases the face is pale and the pulse
small and contracted.  Limpid urine is  frequently
voided in large quantities, and sometimes evacua-
tions by urine and stool are expelled  with great
violence.  The muscular force exerted  in  the
course of the convulsions is in some cases enor-
mous, shaking the entire room, and requiring five
or six attendants to control the patient.  Several
authors relate cases   in  which  the contractions
have been of such intense violence that the teeth
have been broken, blood has burst  from the nose
or been effused under the skin,  producing general
ecchymosis, and even limbs have been  luxated or
fractured.   (Eph. Nat. Cur. Dec. Ann. 7.)  The
violence of the muscular contractions gives some-
times very severe pain.  The occurrence of deli-
rium, coma, and insensibility during or after the
attack will depend altogether  on the degree  and
manner in which  the brain is affected.   If the
convulsions are symptomatic  of organic disease
of the  brain,  the paroxysms  are  likely to be
attended with  delirium,  followed  by  coma  and
insensibility ; when there is no organic affection,
but merely functional disorder,  as  in the  case of
simple convulsions, the consciousness  is not im-
paired, or only  in a very slight degree.
   The paroxysm may sometimes cease  in a few
minutes, when  the patient  immediately recovers;
or after he has remained for  some time under a
sense of suffocation,  the  impeded  circulation and
all the other symptoms may be relieved by a sud-
den fit of sobbing and deep sighing, as in hyste-
ria:  but the paroxysm occasionally lasts for seve 
CONVULSIONS.
511
ral  hours, as many even as twenty-four, at  the
end of which the patient falls into a profound and
long-continued sleep, from which he awakes sud-
denly, unconscious of what  has happened: lan-
guor, vertigo, and sickness generally succeed these
prolonged attacks.   The  paroxysms  may return
again at uncertain intervals, and be thus renewed
until they spontaneously  subside.   This is  the
most common  course  in  puerperal and infantile
convulsions.  The fits may finally prove fatal by
causing apoplexy or asphyxia, and this  has some-
times happened  in the  first attack : not unfre-
quently they leave behind them  paralysis, chronic
epilepsy, chorea, permanent squinting, &c.  In
some cases the  mental  faculties have been  de-
stroyed, and the  patient  has   been  reduced  to
idiotcy  or imbecility.  A remarkable  case  has
been recorded  in the Medical Repository,  by Mr.
Thompson, of  Whitehaven, of loss of speech and
hearing in a child six months old, who had been
suddenly  seized  with convulsions :  her  vivacity
remained  and  her health was  unimpaired.  She
continued  in this state until her sixteenth year,
 when, after the noise of a public rejoicing,  she
was observed to recover the sense of  hearing, and
she soon began to articulate.  Convulsions some-
 times terminate by critical evacuations;  the pa-
roxysm has not unfrequently  subsided  on  the
 appearance of  epistaxis; and there  are cases on
 record where the convulsions always terminated
 by copious hemorrhage from the mouth, nose, and
 ears.  Diarrhoea or vomiting are terminations of
 still more frequent occurrence.  A state  of pro-
 found syncope  has sometimes supervened on con-
 vulsions ; and  there are instances recorded of the
 patient never  rallying, and of its proving conse-
 quently fatal.  But in cases of this description,
 after the  excessive  nervous exhaustion which
 generally follows a long-continued state of violent
 agitation of the whole nervous system, the patient
 may remain for a considerable  time in a  state of
 lethargy or torpor, without showing  any  signs of
 life, and still ultimately revive.   It is under these
 circumstances that many horrible cases of prema-
 ture interment are stated  to  have  taken place,
 especially of women and children.  The truth of
 some of these cases may be called in  question, but
 there are  others which appear but too well authen-
 ticated ; and there are  also undoubted instances
 of persons  having  very narrowly escaped being
 interred, whilst in the torpid condition now men-
 tioned.
   The paroxysm just described is a delineation
 of the severest form of convulsion.   In the majo-
 rity of cases the disease is of a much milder cha-
 racter : there is no affection of  the intellect, local
 congestion, or  fever ; the convulsions affect only a
 few muscles at a time, extending in succession to
 the others ; they may be  confined to one side of
 the body,  or attack both alternately : this consti-
 tutes the convulsio erralica of Good.   The pa-
 roxysms  may return only after  long intervals
 more or  less  regular ; the ordinary  period in fe-
 males is menstrual or lunar : this is the convulsio
 recurrens of Good.  In  some  cases the muscles
 of respiration,  and those especially of the larynx,
appear to be chiefly affected, and the  patient emits
shrill or  yelling sounds, which circumstance has
induced the same writer to form a separate variety
with the name of convulsio ejulans.
  An  important variety  of convulsions  is  that
connected  with  the puerperal state;  they may
occur in the latter periods of pregnancy, rarely,
however, before the sixth month ; during parturi-
tion, or in  the first few days after delivery.  As a
separate article is devoted to this form of convul-
sions, we shall  merely state in  general that its
symptoms  are in some degree  modified by the
close  sympathy  which exists between the uterine
system  and the  sensorium  ; in consequence of
which there is a greater tendency to oppression in
the head than in any other variety of convulsions;
the breathing is  stertorous, and the muscular ac-
tion peculiarly violent.  (See Convulsions, Puer-
peral.)
   Convulsions are likewise of very frequent oc-
currence in infants, owing to their great mobility
of frame.   In these cases the convulsive motions,
especially of the mouth, eye-lids, and fingers, are
so  excessively rapid that it is  often difficult to
follow them : this  constitutes the  eclampsia of
Sauvages.   We shall  confine ourselves to this
brief notice of infantile convulsions, as, in conse-
quence of  their  great  importance, they will also
form  the subject of a separate article.  (See Con-
vulsions, Infantile.)
   Convulsions  may occur  in  the  progress  of a
great many diseases.  There is scarcely an acute
disease with which they are not occasionally com-
bined.  They sometimes manifest  themselves at
the beginning of inflammatory and bilious fevers,
and at the invasion also of nervous and malignant
fevers, especially in hot climates.  The rigours of
the cold fit in the severer forms of ague have as-
sumed  sometimes the  character  of convulsions,
and the patient  has sunk under them, there not
being sufficient  power  in the constitution to bring
about a re-action. When convulsions occur in the
latter stages of  continued fevers in combination
with  delirium or coma,  they  generally indicate
some dangerous affection of the brain.  It should
be remembered, however, that the salutary critical
terminations of fever  have been observed  to be
ushered in by  some violent perturbation of the
whole system, of which convulsions are occasion-
ally a symptom  ; this apparent aggravation of the
fever often deceives the attendants, who mistake
it for the approach of  death.  The writer  of this
article  experienced on the  twenty-first day of  a
nervous fever, a most  frightful fit of convulsions,
attended with laughter, hysterical sobbing, violent
protrusion of the tongue, vomiting, &c,  which,
however, were soon relieved  by  the bursting out
of a profuse perspiration and a complete remission
of fever.   Convulsive  paroxysms are not uncom-
mon in the remittent fevers of infants ; and unless
the progress of the disease be carefully attended
to, it may  be mistaken for  hydrocephalus.   The
distinction between the two diseases is obviously
of  considerable  moment, for the latter is always
attended with great danger, whilst  the  former is
rarely fatal.
    The eruption of the exanthemata, particularly
variola, rubeola, scarlatina, &c. is not unfrequently
preceded  by convulsions.   In such cases convul-
sions  have been considered bv  the  majority of 
512
CONVULSIONS.
writers as a favourable omen ; a  few, however,
have maintained an opposite opinion,  and cases
may sometimes  occur that  seem  to justify this
conclusion.  When after  a  violent constitutional
disturbance, attended with  convulsions, only  a
very slight eruption makes its appearance, which
quickly vanishes, the effort  of the constitution  is
apparently unavailing :  as the brain sympathizes
strongly with affections of the skin, the irritation
which  should  have been  fixed on the skin may,
in such a case, be transferred to  the brain, and
become the exciting  cause   of some  dangerous
cerebral  disease ; the  convulsions will  then  be
severe  and  frequently  repeated,  and  they  may
ultimately prove fatal.   Convulsions are also  of
frequent occurrence in hooping-cough and croup;
in all  inflammatory  and  organic diseases of the
brain and  spinal marrow ;  in some severe cases
of organic disease of the heart, owing probably  to
an embarrassed state of circulation in  the brain ;
and  they have been observed,  too,  in calculous
affections of the urinary bladder and  kidneys.
Acute  diseases have sometimes terminated, as  if
by sudden transition,  in  attacks  of chorea, epi-
lepsy,  &c.
   It is well known  that the closest sympathy
exists  between the brain and the genital organs.
The development of those  organs at the age of
puberty  is frequently  productive  of considerable
constitutional disturbance and nervous irritation ;
this is  more especially the  case  in females : the
first appearance and  regular development of the
menstrual  discharge  is attended  in some cases
with a great struggle in the  constitution,  and may
be characterized by convulsive paroxysms in com-
bination with many other  painful  symptoms. The
susceptibility of the  nervous system being consi-
derably increased, very slight moral or  physical
impressions are sufficient to excite convulsions.
If the struggle ends in the  full and regular deve-
lopment of the uterine functions, the convulsions
disappear, and the health will be firmly  re-estab-
lished.  It has been observed that chorea,  epilepsy,
and other diseases of youth, generally subside at
this critical period, if the constitutional changes
peculiar to it are not  interrupted; but that these
diseases become confirmed  and  aggravated,   or
others make their appearance, when there is not
sufficient power in tbe constitution to bring about
the accomplishment of this  important end.  The
spontaneous cessation  of the  catamenia at the
usual  period  of life  is sometimes  marked,  like
their first appearance, by considerable disturbance
of the  health,  and convulsions  either  local  or
general  are among the occasional symptoms  of
the  climacteric diseases of women.
   The convulsive affections connected with dis-
order of the uterine functions do not always follow
the usual regular course, but assume sometimes
an infinite variety of anomalous forms ; appearing
in combination with  other formidable  diseases,
resisting for years every mode  of treatment,  and
subsiding  at  last without  apparent cause when
least expected.   The  following is a general enu-
meration of  the  principal  symptoms  of these
anomalous cases : — convulsive affections  of the
.imbs or muscles of the trunk, sometimes resem-
bling  tetanus,  chorea,  or catalepsy;  permanent
spasmodic retraction  of some of  the extremities,
or weakness amounting sometimes  to complete
paralysis, which is often accompanied by remark-
able convulsive contractions of the paralytic limbs;
feeling of great weakness in the back,  attended
frequently with severe pain and excessive tender-
ness on pressure, confined to one part or extend-
ing along the whole of the spine ; a variety of
cerebral symptoms;  intense headach,  permanent
or periodical ; vertigo, tinnitus aurium, temporary
delirium, mental alienation,  or fits  of lethargy ;
various neuralgic and convulsive affections of the
face; sudden  attacks of blindness;  difficulty of
deglutition; extinction of the  voice  or  loss of
speech. Severe paroxysms of dyspnoea, combined
sometimes  with  violent palpitation;  spasmodic
affections  of the  alimentary  canal; remarkable
irritability of stomach  and sometimes  severe vo-
miting, which we have seen continue with very
little intermission for several  months;  attacks of
spasmodic colic, with immense tympanitic disten-
sion of the  abdomen ;  obstinate constipation, and
an extremely vitiated state of the biliary and in-
testinal secretions ; sometimes distressing dysuria,
at others retention of urine, the urine being gener-
ally clear  and very  copious, in some cases very
turbid and scanty.
   It would  be impossible to describe the various
extraordinary combinations  under which  the pre-
ceding train of symptoms may present themselves:
there may be  sudden and  rapid transitions from
one  extreme  to  another;  we  have  seen in the
same patient well-marked symptoms of apoplectic
coma and paralysis, epilepsy, catalepsy,  tetanus,
and  maniacal delirium, succeed each other with
incredible rapidity,  and finally subside  without
any  material injury to the health.  The force
exerted by  the lady who was the subject of this
case, during the paroxysms, was quite extraordi-
nary.  It frequently happened, during even the
intermissions, that, when she took hold of a chair
or any other object,  her  hand would suddenly
contract upon it independently of her will, and
with so firm a grasp that  the utmost strength of
two persons would  be insufficient to loosen the
fingers, and she would be obliged  to wait until
the spasm subsided of its own  accord.  In other
cases the patients have laboured for a considerable
time  under apparent  symptoms of  formidable
cerebral or spinal disease, such as apoplexy, hydro-
cephalus, paralysis, &c,  and have  iltimately re-
covered, although their condition was considered
perfectly hopeless.
   The pathology of these anomalous diseases is
still involved in  much obscurity ;  it is highly
probable,  however,  that they have their origin in
neuralgic affections of the brain and spinal mar-
row, and that the ganglionic nerves of the great
sympathetic have also considerable influence  in
their production.  Dr. Abercrombie  has  recorded
several highly interesting cases of this description.
One of the  most remarkable is that of a lady aged
twenty-four, who, during  a period  of above six
years' illness, was  affected in succession  with
hemiplegia, loss of speech, chorea, sudden attacks
of blindness, convulsions  of the muscles of the
back,  legs,  and  arms. These  convulsions  were
occasionally so violent, that her body would  be
suddenly  seized with a kind  of  convulsive spring,
by which it would be thrown  out of bed on the 
                                    C 0 N V U ]
                                               <
floor, and from the floor back again into bed ;  at
other times she would leap on the top of a ward-
robe fully five feet high; the mind remaining all
the while unimpaired.   Subsequent to  the  pre-
ceding symptoms she suffered  from difficulty of
deglutition,  and convulsive motions of the neck,
producing for weeks together a constant rotatory
motion of the head. The last-mentioned symptoms
continued four years, with  intervals of  tolerable
health  of only a few weeks'  duration.   Menstrua-
tion was all  along extremely irregular and scanty,
and the bowels were torpid.  The treatment during
the six years previous to Dr.  Abercrombie's at-
tendance, had  been  copious, general,  and  local
depletion ; active purging and  counter-irritation.
She was of  a  pale and bloodless  aspect, though
not reduced in flesh.  An  entirely opposite  plan
of  treatment was now adopted ;  three grains of
sulphate of iron, combined with  sufficient aloes
to regulate the bowels, being exhibited three times
a day.   At the  end  of three weeks,  a severe
paroxysm of the rotatory motion of the  head un-
der which she was labouring, stopped suddenly ;
at the  same instant  menstruation took place in a
more full and  healthy manner  than  it had done
for many years,  and  from that  time  she com-
pletely  recovered.   This  case  affords  a  striking
example of the anomalous nervous affections  in
question, and is highly interesting from the result
of the  treatment.
   The prognosis  of  convulsions is very uncer-
tain ; it depends on the nature  of the causes, the
age, the habits of life,  and preceding  diseases.
When  the  affection is purely  nervous,  without
fever, or any organic affection  of the head, there
is little to apprehend ; but if the attack begin with
symptoms of cerebral affection, or if it terminate
in stupor or coma, the case is  not free from dan-
 ger.   Acute organic disease is always  attended
 with fever;  simple nervous irritation is almost al-
 ways without it.  After  a long-continued parox-
ysm, arising  only from  nervous irritation,  the
patient may fall into a state of stupor bordering
 on coma from mere excessive nervous exhaustion;
 this must not be mistaken for the coma of organic
disease.   Convulsions towards the end of fevers,
 or of inflammatory diseases of the brain, are al-
ways alarming.
    We have already stated what were the conclu-
 sions  to  be drawn from the appearance of con-
 cisions at  the invasion of fevers and of eruptive
diseases.   Paroxysms of long duration are at-
tended  with danger.  In  those cases, in which
from great  nervous susceptibility convulsions are
very easily excited, they more readily subside, and
are the less dangerous ;  they  are thus  attended
with less danger in women than in men, in youth
than  in old age.   This fact  had not  escaped
Aretaeus, who said, Mulieres  nervorum disten-
sionibus magis opportunx sunt quam viri, sed et
frequentius etiam liberanlur.—Lib. i.
   Causes.__The causes  of convulsions are pre-
disposing and exciting.   The predisposing causes
are either constitutional or accidental.   Constitu-
tions  in which the nervous temperament predo-
minates are the most  obnoxious to  convulsive
affections.   We  know  nothing  of the essence
of  the nervous power, but one of the  remarkable
laws which  regulate its operations is, that within
   Vol. I___65
SIONS.                                513
certain limits its irritability increases as its energy
diminishes.   The nervous  temperament  derives
its essential characters from nervous debility, com-
bined with an increased susceptibility to external
impressions.  This condition of the nervous sys-
ten is commonly observed in persons of relaxed,
debilitated, and  delicate fibres ; they are extremely
sensitive to  the  action  of  all kinds of stimuli,
whether physical or moral, and are  endowed with
great  mobility  of disposition  and  fickleness  of
temper; they are also frequently disposed by their
laxity of fibre to plethora;  and we shall see pre-
sently that over-distension of the blood-vessels is
not unfrequently an exciting cause of convulsions.
The nervous temperament  is, however,  some-
times observed in persons of a thin and delicate
habit  of body, and associated at others with a firm
and rigid, though spare  fibre.   It is evident, from
what has just been stated, that women and chil-
dren will be more predisposed to convulsions than
men or persons advanced in life.
   The  accidental  predisposing causes are nume-
rous,  and  most  of them may  become  exciting
causes.  " We may state, in  general, that they  are
to be  found in  all  external  circumstances calcu-
lated to create debility either bodily or mental.
   Exciting Causes.—It is generally admitted
that the nervous power, whatever may be its  na-
ture, proceeds either from the brain singly, or  the
brain and nerves jointly.  Although  the muscles
may appear to possess a certain degree of special
irritability, it is incontrovertible  that they derive
their power of contraction from the  nervous influ-
ence  transmitted to them by the brain and differ-
ent parts of the  nervous system.  The muscles
of voluntary motion receive their  nerves chiefly
from  the  spinal  marrow, and  but  few compara-
tively from  the brain; the muscles of involuntary
motion (the muscular textures of the thoracic and
abdominal viscera) are mostly supplied with nerves
from  the ganglions of the  great sympathetic, re-
ceiving only a few from the brain.  The innume-
rable  ganglia and  plexuses of the great  sympa-
thetic appear to be formed principally by large
and numerous branches  coming from the spinal
marrow.  During  a state of health, the contrac-
tion of  the voluntary muscles is completely under
the control of the brain, this organ  being the seat
of volition.   But during convulsions the  volun-
tary muscles are excited  without the  concurrence
of the will, and are entirely withdrawn from its
influence.   Irritation in the brain  alone  is suffi-
cient to produce  general convulsions,  in  conse-
quence of the great influence of that organ over
every other part of the  nervous system ;  but  the
existence of convulsions does not, on that acciunt,
always necessarily imply  that there is an affection
of the brain ; it is easy to demonstrate by experi-
ments that any  kind of irritation applied either at
the origin of the nerves in  the spinal marrow, or
in the  course of  the nerves themselves,  will be
sufficient to produce convulsions in all those mus-
cular parts to which the nerves are  distributed. A
primary affection either  of the  brain  or spinal
marrow is not,  therefore, essential to the mani-
festation of convulsions.  Cullen, Dr. John Clarke,
Brachet, and other writers have  advanced  the
doctrine that convulsions are always the result of
cerebral irritation ; but  this opinion is evidently 
514
CONVULSIONS.
untenable.  The occurrence of loss of conscious-
ness in convulsive affections will depend  on the
brain being the seat of the disease, and  on the
manner in which it is affected; for a slight irrita-
tion of the brain, sufficient  to excite convulsions,
mav exist without diminution of consciousness.
   When the exciting cause acts  on the brain, the
convulsions are likely to be general, although par-
tial convulsions are occasionally traced to  some
disease in the brain of very limited extent.   If the
exciting  cause is  applied  to the spinal cord, all
those parts receiving nerves from the portion of
the cord below the  seat of the irritation may be
affected with convulsions :  and if applied  in the
course of a nerve, the muscles to which that nerve
is distributed  will be alone  affected ; all convul-
sions produced in this manner may be considered
as primary or idiopathic.  But convulsions fre-
quently occur in  a very different manner, with
respect to the seat «f the exciting cause.   Instead
of its  being  applied  either at the origin or in the
course of the  nerves, and the  irritation  being di-
rectly transmitted to their extremities, these pulpy
extremities themselves  receive the first  irritating
impressions from  the various  stimulating  agents
they come in contact with on the surfaces of the
organs; these morbid impressions are then trans-
mitted along  the  nervous fibres to the brain and
spinal  marrow, which  organs communicate the
irritation  by reflection  to the whole frame.  The
great sympathy of several organs with  both the
brain and spinal marrow becomes thus  a  prolific
source of general disturbance to the entire nervous
system, of which the uterine and digestive organs
afford examples in the production of hysteria, and
of various  other convulsive affections.  The con-
vulsions  occurring  in the  manner just  described
may be termed  secondary or sympathetic.   It is
very remarkable that pain in  any part, sufficiently
severe  to bring on convulsions, completely disap-
pears during the fit.
  The nervous  power which acts on tbe muscles
may be produced in excess or in deficiency, or it
may be irregularly transmitted.   The causes  of
nervous irritation are extremely numerous.   One
of the most simple is pressure :  when applied me-
chanically to the brain  of an animal, if slight, it
causes convulsion ; if great,  numbness, paralysis,
and coma.   Pressure on the brain or spinal  mar-
row may be the effect of congestion  or inflamma-
tion.   An  habitual determination of blood  to the
head in people of a plethoric habit renders them
very prone to suffer  from convulsions.  This is
frequently the case in puerperal women.  Inflam-
mation of the membranes of the brain  is  gene-
rally attended with very  violent  convulsions, much
more  so than inflammation  of the substance of
the organ.
  Among the other causes of pressure and irrita-
tion  are to be reckoned extravasations of blood,
the serous effusions of hydrocephalus, organic tu-
mours, bony tumours or spiculae growing from the
inside of the cranium,  and  injuries of the  head
with fracture and depression.  Causes of  a similar
nature may affect the spinal marrow.  There are
other more indirect causes  of  cerebral irritation.
It was observed by Morgagni, with respect  to me-
chanical injuries, that the nearer they were to the
nead the greater was their influence on the  brain;
[ that, for instance, a very slight cut over the oibit
 was more likely to excite cerebral irritation than
 a much  severer wound in a  more distant part.
' The severe cerebral  irritation which  sometimes
 attends dentition  may  be accounted  for  on the
 same principle.  Carious teeth are often an active
 source of cerebral and nervous irritation, and have
 not unfrequently been the occasion of slight con-
 vulsions  in individuals of very irritable tempera-
 ment.  The laceration of nerves is a very frequent
 cause of tetanus, or severe convulsions.  It is sin-
 gular that the muscles to which the injured nerve
 is distributed may be the last affected with convul-
 sive action ; convulsions, however, do wot always
 follow inflammation of  the nerves.  Convulsions,
 either local or general, are likewise frequently oc-
 casioned by tumours compressing nerves in their
 course ;* by contused  and lacerated wounds  of
 other parts, especially  of  ligaments  and  fibrous
 tissues; dislocations, compound fractures, &c, and
 finally, by intense pain,  whatever be its source.
   Gastric  and intestinal  irritation  have always
 been considered among the most active causes of
 convulsions, especially in children ; it may be suf-
 ficient to instance the convulsions occasioned by
 worms, and the distressing cramps so frequently
 experienced from  the presence of acidity in  the
 primae viae.  We have already alluded to the great
 influence of the uterine functions  on the brain and
 nervous system, and to their being a most frequent
 source of nervous irritation and convulsions. This
 arises in puerperal women from  two causes—the
 distension and pressure  of the uterus causing an
 accumulation  of blood in  the head, and the high
 degree of nervous susceptibility which attends the
 puerperal constitution.
   Among  the occasional  causes of convulsions
 may be mentioned, exposure of the bare head to
 the  heat of a burning  sun ; sudden  transitions
j from heat to cold ; suppressed perspiration ; the
[ suppression of eruptive  diseases,  such  as variola,
 rubeola,  and  of many  chronic cutaneous  erup-
 tions ;  and that likewise of old sores, and of the
 menstrual and hemorrhoidal discharges; the retro-
 cession of gout and rheumatism, and  of several
 other  diseases.  A  strong  excitement of the ex-
 ternal senses  sometimes produces  great cerebral
 irritation. Very sensitive women have been thrown
 into convulsions by the scent of flowers, or by
 deeply impressive music, or the unexpected sight
 of an object either of interest or aversion: the
 effect of  the smell  of paint on some constitutions
 is also well known.
   Moral  emotions may be  considered among the
 most powerful causes of convulsions, particularly
 when operating upon the sensitive minds of chil-
 dren.   This is a point of considerable importance
 as respects  the  conduct to be  pursued towards
 them,   and  the  regulation of their dispositions.
 The exciting  and  the  depressing  passions  act
 very differently ; the first, as anger and excessive
 joy, throw the individual into a state of high ex-
 citement, causing a determination  of blood to the
 head; the second, as fear, occasion  a  sudden col-
 lapse and prostration of the nervous power.  There

   * Sir H.  Halford mentioned, in a paper read before the
 College of Physicians, several  casts of severe neuralgia
 of the infra orbit irv  nerve, caused by the pressure of
 bony tumours wilhin the infra-orbitary canal 
CON VULSIONS.
515
are numerous instances of an attack of epilepsy,
chorea, or even of fatal convulsions, resulting from
a sudden fright.   Great mental  exertion, loss  of
sleep, excessive anxiety, the abuse of spirituous
liquors, by gradually exhausting the nervous en-
ergy, create an extreme degree of irritability, which
has not unfrequently induced convulsive fits.
   Convulsive affections are very much under the
influence of habit; so that even after the removal
of the exciting cause, there may be regular repe-
titions of the attack, in consequence solely of the
portion of the nervous system which is affected
having acquired a depraved habit.  Many curious
instances  of this description are to be  found in
medical writings.   These habits of recurrence are
sometimes not broken off without great difficulty.
Another  peculiarity of convulsive affections is,
that they can be acquired by the mere power of
 imitation.   In sensitive children,  and young fe-
 males endowed with great  nervous susceptibility
 and a lively imagination, the influence of example
 on the nervous  system is very remarkable ; the
 instances of individuals so constituted being seized
 with an attack of convulsions, chorea, or epilepsy,
 merely through the shock experienced by witness-
 ing others affected in the same manner,  are by no
 means  uncommon.  In  the history of the dark
 ages,  when  superstition  and  fanaticism had  a
 strong hold  of men's imaginations, there are re-
 corded several instances of nervous affections,
 combined  with   various  hallucinations,  having
 spread like epidemics, from the  mere contagion of
 example.  An extraordinary instance of the influ-
 ence which  the  strong  excitement  of  religious
 fanaticism is capable  of  exercising over the  ner-
 vous system was seen as late  as  1724 in Paris,
 during the persecution  of the Jansenists : after the
 death of  Deacon  Paris, one of  the highly revered
 chiefs of the sect, crowds of his followers went in
 pilgrimage to the place  of his  burial at St. Me-
 dard, where they fell on his tomb, and were  ap-
 parently seized with the most violent convulsions :
 they asserted that,  after passing through this or-
 deal,  they  arose  miraculously  cured of any  dis-
 ease with which they might be affected  ; and this
 practice was continued  for a  considerable time.
 Some of his disciples were no  doubt impostors;
 but it is well authenticated that many credulous
 zealots actually worked  themselves into convul-
 sions by the  mere power of  their  imaginations.
 Willis and several other writers state that convul-
 sive affections of children have occasionally ap-
 peared as epidemics.  A disease  of  this descrip-
 tion carried off a great many children in Paris  at
 the close of  the  last century ; and it is remark-
 able that it attacked likewise young dogs.
    Convulsions  are also  frequently produced by
 narcotic and irritating poisons.   To obtain  this
 effect, narcotics must be given  in small doses ; for
 if the dose be large, it  may at once destroy the
 irritability, when coma and death will ensue with-
 out any  struggle.  The  nux  vomica  seems  to
 possess the specific virtue of exciting muscular
 contractility, and has  on that  account been  suc-
 cessfully applied to the treatment of certain forms
 of paralysis.   Most of the mineral poisons  occa-
 sion convulsions by exciting violent inflammatory
 action.   Exposure to  the fumes  of  mercury and
 lead produces either a convulsive tremor or com-
plete paralysis, by weakening the nervous energy.
The inoculation of the rabid virus is followed by
the frightful convulsions of hydrophobia;  and
most of the other animal poisons have a similar
property, though in a much  milder degree.
  Several of the causes we have enumerated have
a direct tendency to  excite in the brain or spinal
marrow various degrees of congestion  or inflam-
mation ; and there can be no doubt that in some
cases this is the true  pathological state of these
organs.  We  must  not, however, by  any  means
consider this as the  most common  form  of dis-
ease, for in the majority of cases the accession of
the paroxysm is not attended by any vascular ex-
citement, and there  is merely a state  of nervous
irritation and functional disorder.
   Convulsions are sometimes produced by  a state
of the brain the very  reverse of plethora or vascu-
lar congestion; and  when it is, on the contrary,
deprived of the supply of blood necessary  for the
continuance of its  functions.  This often happens
after a large and sudden abstraction of blood from
the arm, or profuse hemorrhage, and  during the
last struggles of life.  It should be remembered,
therefore,  that convulsions  arise both from an
increase and a  diminution of vascular action ; and
that nervous debility is  the essential character of
that state  of the nervous system in which they
originate:  a repletione aut ab evacuatione fit
convulsio. is one of the aphorisms of Hippocrates.
It is also  deserving  of  notice that many of the
appearances of vascular turgescence which may
be observed in the brain and spinal cord  in fatal
cases of convulsion, are  the mere accidental effect
of the violent  struggles  of  the  patient in  his last
moments,  the same as occur in all cases of violent
death.
   In  the  description  formerly  given  of some
anomalous convulsive  affections,  we noticed  a
variety of disorders of the thoracic and abdominal
 viscera, combined  with great  disturbance of the
nervous system, and  a violent convulsive action
 of many of the voluntary muscles ; we stated that
 several of the complicated symptoms of those
 affections  might perhaps be accounted for by a
 reference  to the functions  of  the spinal  marrow
 and  of the great sympathetic  or visceral nerve.
 Several ancient writers have conceived that many
 spasmodic, convulsive, and nervous diseases have
 their origin in affections of the spinal cord and
 great sympathetic.    This was the  opinion of
 Hoffman, Ludwig,  Lieutaud, Burserius,  Portal,
 &c.   The  functions of these  divisions  of the
 nervous system have been  more accurately inves-
 tigated since  by  Bichat, Legallois, and Olliviei
 but the subject still remains involved in much un
 certainty.  They have  made it, however, appear
 highly probable that many  of the diseases of the
 thoracic and abdominal viscera are to be attributed
 to morbid conditions of the spinal marrow and of
 the ganglionic nerves of the great sympathetic.
 There can be no doubt that the sympathy exist-
 ing between these two classes of nerves is much
 greater than  is  generally  imagined;  proofs of
 this are afforded by the great muscular debility of
 the  lower extremities,  and  the severe  cramps,
 which so commonly attend  diairhoea or dysentery,
 and chronic dyspepsia;  and on the other hand by
 the  attacks of diarrhoea, gastrodynia, and cramp 
516
CONVULSIONS.
of the stomach, which are frequently the effect of
cold and wet feet.  In  some chronic affections,
moreover, of the thoracic and abdominal viscera, a
careful examination of the spinal column has led
to the discovery of one or several spots excessively
tender on pressure, and by  applying  leeches or
cupping-glasses  and  counter-irritants  to  those
spots, we have seen  in several instances severe
palpitations of the heart, oppressive dyspnoea, gas-
trodynia, or  great irritability of the  stomach, re-
lieved  in a very remarkable  manner: these are
pathological  considerations  highly deserving of
further inquiry.
  [The greater part, if  not the whole, of convul-
sive diseases  may be  referred mainly to the true
spinal system  of Dr. Marshall Hall, or, in other
words, to the grey matter or chain  of  ganglia in
the centre  of the spinal cord.  (See  Dr. Hall's
Lectures on the Nervous System and its Diseases .-
Lond. 1836 ; or, the Physiological Works of Miil-
ler, Carpenter ; or, the writer's Human  Physiol-
ogy, 5th edit. i. 71: Philad.  1844.)  In some of
the cases, the mischief is in  the spinal  marrow
itself, or is centric; but in the large majority of
convulsive diseases, it is eccentric, or the irritation
is conveyed to the spinal marrow by afferent nerves,
and the morbific  influence is reflected  from the
spinal marrow by efferent or motor nerves, so as to
involve various organs.   Strychnia, doubtless, acts
centrically, or, in other words, upon  the  spinal
centre, when it induces tetanic convulsions.]
  Treatment.—In the account given of the pa-
thology of convulsive  affections, it is  stated that
they may originate in a variety of causes differing
very widely in their nature, and that they are also
considerably  modified by age, sex, and tempera-
ment.   The  treatment  adopted during the parox-
ysm must therefore be regulated by a careful con-
sideration of all these  circumstances.   We  must
endeavour to ascertain whether the increased irri-
tability  of the nervous  system, which  is the pri-
mary source  of  all convulsions,  proceeds  from
increased vascular action in  the brain or  spinal
marrow, or  from  mere  nervous  irritation;  and
whether the  exciting cause has its  seat in the
brain, spinal marrow, or course of the nerves, or
the convulsions are to be attributed to the morbid
condition of some other organ.  If the convul-
sions occur in a full plethoric subject, with  well-
marked  symptoms of cerebral congestion  or in-
flammation,  fifteen or  twenty ounces  of blood
must be taken from the arm or jugular vein ;  and
this may be repeated  in ten or twelve  hours,
should  the symptoms continue unabated ; when
the strength  of the patient no  longer  admits of
general depletion, or when the symptoms of vas-
cular excitement  are  less urgent,  local  bleeding
by  cupping on the temples or nape of the neck
may be employed, and in some cases may be con-
joined with  general bleeding.
   In cases,  however, depending chiefly on  cere-
oral and nervous irritation, and characterized  by
a general delicacy of frame,  spare habit of body,
a pale face, small frequent pulse, irregular hyster-
 ical breathing, and other signs of a  purely ner-
 vous temperament, copious bleeding is highly in-
 jurious, and only aggravates the  symptoms by
 increasing the general irritability.   There may be
 intermediate states, requiring a moderate degree of
local depletion, tbe discrimination of which must
be left to the judgment of the  practitioner.  We
must also add, that local plethora in the brain and
other  organs may sometimes  exist with general
debility, and that paleness and  languor should not
in such cases deter the practitioner from  having
recourse to local bleeding ; the treatment of  such
cases  requires, however, no  ordinary degree  of
tact and caution.   It is very important to bear in
mind  that the violence  of the  convulsions is not
to be taken  as a test of the strength of the patient,
for no convulsions are more violent  than those
which occur after profuse hemorrhage and extreme
prostration ; and,  as convulsions  arise  probably
from  mere  cerebral and  nervous  irritation  in a
considerable proportion of cases, the  practice  of
indiscriminate copious blood-letting  in every case
of sudden fits, so much in favour with the public
and  a portion  of the  profession, cannot  be too
strongly deprecated;  the  principles we laid down
on this subject  when  treating of coma, apply
equally to convulsions.
   The application of cold is often of great ser-
vice in convulsive diseases.  Cold applications to
the head are particularly  beneficial, provided they
be used assiduously ; they may consist  of cloths
dipped in water and vinegar, or  pounded ice put
into a bladder; or a still better method is the affu-
sion of cold water over  the  head, frequently re-
peated.   The cold bath, which  has been advised
by some,  may  be suited  to  robust constitutions,
but would be injurious, during the paroxysm, to
the weak and irritable; the  cold affusion, as re-
commended by Dr. Currie, is less  objectionable,
and in cases depending on pure nervous irritation,
especially in hysterical females, the  shock given
by dashing  cold water over the body has some-
times cut short the paroxysm, and prevented  its
recurrence.   The same effect  has been obtained
by free  exposure to cold air, especially in children,
as recommended by the late Dr. Gregory, of Edin-
burgh.  A  free circulation of cool air round the
patient is always most desirable.
   The  application of heat, through  the  medium
of the warm bath, is highly beneficial and in very
general use; it soothes, relaxes, and acts as a dif-
fusible stimulus.   Tbe warm bath is  therefore of
great service in cases attended  with a  high degree
of general nervous irritation, or in which  cutane-
ous eruptions have been repelled, and  particularly
when there is a dry rough skin and great rigidity
of fibre.  The affusion  of  cold water  over the
head, whilst the patient is in the warm  bath, or
stands in  warm water, is an excellent practice.
   Purgatives  have always  been classed  among
the most powerful remedies in the treatment of
acute nervous diseases ;  the operation of a brisk
cathartic  during  the paroxysm has the effect in
many cases of immediately subduing  the violence
of the symptoms, and more especially where they
have been  induced by a disordered  state of the
bowels :  a combination of calomel and jalap is the
most active and efficacious form of cathartic; in
patients of  a delicate constitution and in children,
a preference should be given to the milder purga-
tives, such as calomel and rhubarb. When cathar-
tics  cannot be administered by the mouth, they
will act almost as efficaciously in the  form of  in-
jection   Whilst  moderate purging is decidedly 
C 0 N V U
beneficial, the repeated exhibition of drastic  pur-
gatives, which has been  a favourite practice of
late years in this country,  cannot be too strongly
condemned, as tending to induce a state of gene-
ral exhaustion  and nervous irritability similar  to
that which is the effect of excessive bleeding. No
one can have been kept for a few days under the
constant operation of brisk cathartics without feel-
ing a considerable  degree of languor  and irrita-
bility.  These objections are particularly applicable
to tbe continued  use of calomel  and other mer-
curial preparations.
   When the  primary cause  of all  diseases  was
referred to the nervous system,  and the various
morbid phenomena were  attributed to spasm and
nervous  debility,  opiates  and  stimulants were
largely administered  on  all occasions,  and the
death of the patient was often accelerated by over-
excitement. In modern times, however, since the
doctrines of inflammation  have been so generally
applied to the investigation of the  nature  of dis-
eases,  and  their  various  symptoms  have been
referred to morbid conditions of the vascular sys-
tem, practitioners have fallen into the opposite
extreme, and  laying  aside all due  consideration
of the  state of the nervous system, have employed
such remedies only as tend to reduce excessive
vascular action.   In the class of affections under
consideration, if the violent agitation of the  ner-
vous system continue, after adequate bleeding and
purging, the administration of an opiate is clearly
indicated, and  will often  be  very advantageous.
 When prescribed under the circumstances stated,
it should be given in large doses.
   The external application of laudanum, in the
 form of frictions, combined with stimulating lini-
ments,  is  an  excellent  mode  of administering
opiates, especially  to  children.  Sometimes the
direct application of opium to the skin,  after the
cuticle bas been raised  by vesication and  remov-
ed, has been found a very efficacious  method of
 exhibiting it.
   The habitual use of opium creates, as is well
known, an extreme degree of weakness and  irri-
tability of the nervous system.  It has sometimes
occurred that after the habit had been long ac-
quired, and the opium has been suddenly with-
drawn, the most formidable attacks of convulsions
have supervened in consequence of the exhaustion
and sinking of the nervous power;  the patient
must therefore  be only  very gradually  weaned
from his indulgence  in the use of opium, some
other less pernicious stimulant being,  if possible,
substituted. We have known the spiritus aetheris
nitrici  and camphor mixture given in  such cases
with considerable advantage.  The above remarks
are  equally applicable to the abuse of spirituous
liquors.
   A variety of antispasmodics, such as ammonia,
musk,  aether, camphor, valerian, and other medi-
cines of this  class,  have  been  recommended  to
mitigate the  violence  of the paroxysm ; their
powers, however, are  so doubtful that they are
not entitled to much confidence.  These remedies
appear  sometimes to afford  relief  by  facilitating
the  expulsion of flatus  from the  stomach and
bowels.  It may also  be  added, that when there
are symptoms of acidity in the  stomach, alkaline
medicines combined with antispasmodics and aio-
                                       2t
.SIONS.                                517

 matics  may be  given with  advantage;  a tea-
 spoonful of calcined magnesia in some aromatic
 water  has been known  immediately to relieve a
 fit of asthmatic dyspnoea or severe cramps  in  the
 lower extremities.
   Counter-irritation is  beneficial when  applied
 with due moderation ;  large blisters to the head
 are decidedly injurious, preventing the application
 of cold, and having rather a tendency to increase
 the cerebral irritation ; small blisters are therefore
 preferable, and their  revulsive effect  is best  ob-
 tained by applying them to the feet, calves of the
 legs, the  inside of the thighs, or along the spine.
 Sinapisms and other  stimulating poultices  may
 be used in the same manner, or tbe feet and hands
 may be immersed in a mustard bath: these sim-
 ple remedies of former times are too  much  neg-
 lected in  the present day.
   Convulsions arising from profuse hemorrhage
 or after excessive bloodletting,  are  generally at-
 tended with giddiness,  fainting, dull throbbing,
 pain in the head, and a tendency to  coma;  under
 such  circumstances we must have recourse to the
 administration of diffusible stimulants in small
 and frequently repeated  doses :  brandy in  warm
 gruel is the stimulant, perhaps,  to be preferred ;
 it may be given alternately with  carbonate of am-
 monia or aether.  Whilst the head is kept cool by
 evaporating lotions, great  care must be taken to
 preserve a due degree of heat in the extremities
 and on the surface  of  the body  by  the usual
 means.
   In cases of convulsions  from poisons, the first
 object will be to evacuate the stomach by the ex-
 hibition of  powerful emetics, or  the employment
 of the  stomach-pump; the subsequent treatment
 must vary according to the symptoms and nature
 of the poison, as will be  detailed  under the proper
 head.   We refer to other articles in this work for
 the treatment  of convulsions occasioned  by the
 action  of lead and mercury on  the animal eco-
 nomy ; the modifications  applicable to the treat-
 ment of  puerperal and  infantile convulsions are
 also detailed in their proper place.
   The local treatment required when convulsions
 are occasioned by wounds of the nerves, or the
 laceration of any part of the body, will be speci-
 fied in the article Tetanus.  In convulsions de-
 pending  on organic disease of the  brain of long
 standing, the treatment, it  is obvious, can only be
 palliative.
   The regulation of the prophylactic treatment is
 of the highest importance  in  all  convulsive affec-
 tions, but more particularly in  those  anomalous,
 severe, and protracted  cases which were described
 under  a separate section.   The  paroxysms in
 such cases frequently resist every attempt to sub-
 due them, and little can be done but to mitigate
 their severity.   We stated that  these anomalous
 affections are distinguished by considerable disor-
 der in the  functions  of the uterine or digestive
 organs,  and by  a highly  disturbed state of the
 nervous system, depending on some morbid con-
 dition of the brain, spinal marrow,  or nervous
 apparatus of the great sympathetic; and that there
 is often great  difficulty in ascertaining whethei
 the disease originates in  a primary affection  of
 some  portion of the nervous system, or  in  the
 morbid condition of any  of the other organs. Our 
518
CONVULSIONS.
attention  should, therefore, be directed, after the
removal of urgent symptoms, to the gradual ame-
lioration of the general health, as tne  most effec-
tual means of overcoming diseased action in par-
ticular organs.
   Our remarks on  the injurious  effects of exces-
sive bleeding and purging during  the  paroxysm
are  particularly  applicable to  the prophylactic
treatment.  It  has  frequently happened that  the
dull headach and vertigo, wrinkled brow, throb-
bing of the temporal  arteries  and carotids, con-
vulsive twitches of the features, watchfulness and
restless anxiety, with alternate states of chill and
morbid heat,  rapid,  small, irregular  pulse, and
subsultus tendinum,  which are  sure  indications
of that extreme irritability of  the brain and ner-
vous system so appropriately called cerebral ere-
thism by Dr. Wbitlock  Nicholl, have  been mis-
taken for symptoms  of inflammation ; and this
serious error has -led  to a perseverance in those
very measures which have induced and  are cal-
culated to  aggravate the  morbid  condition  in
question.   Instances of this description have not
unfrequently fallen under our own observation ;
and a remarkable one is afforded in the  case we
have quoted from  Dr. Abercrombie.   Although
copious and frequent  bleeding  may  appear  to
afford  temporary relief when there are symptoms
of plethora, it increases  the laxity  of fibre which
so  strongly predisposes to a plethoric habit.   A
tendency  to plethora in  the  head will  be best
counteracted by occasional revulsive bleeding from
the  lower extremities: as, for instance,  the  ab-
straction of a few ounces  of blood  from  the feet
by means of leeches, or the opening of a vein, the
bleeding being  encouraged  by  immersion in  a
warm foot-bath.   We have found  this plan par-
ticularly useful  in  cases  of suppressed  or irre-
gular menstruation, and  by having recourse to it
at the approach  of the  menstrual period, or on
the  first  appearance  of any   of the  symptoms
threatening an  attack of convulsions, we may
often succeed in warding it off*  Bleeding along
the  course of the spine by  leeches or cupping,
particularly when there is tenderness on pressure,
will sometimes  relieve very distressing symptoms
of dyspnoea, palpitation,  vomiting, and  gastro-
dynia, or partial convulsions of the muscles of
voluntary motion; this is  a practice hitherto too
much  neglected.   Leeches may  also  be  applied
with advantage  to  the rectum.  It ought,  how-
ever, to be made a general rule not to carry blood-
etting to  such  an  extent, with  respect either to
its frequency or amount, as to impair the  general
strength,  unless there be  decided  symptoms of
inflammation.   Counter-irritation along the spine
by means  of blisters,  tartar emetic  ointment, and
stimulating embrocations  combined with  opium,
has been found a very useful adjunct to local de-
pletion in  convulsions depending on affection of
the spinal marrow.
  Whilst violent purging  is  to be deprecated, a
moderate  course of alterative purgatives,  if judi-
ciously  managed, will  generally form an'  import-

  * Dr. Prichard, in his able work on Nervous Diseases
liaspven an excellent account of the convulsive affec'
Uon. which  not  unfrequently accompany  d.sordereu
menstruation and of the mode of treatment ■ to which
lue reader is rererred for more ample detail?.
 ant  part of tbe  prophylactic  treatment.   The
 function of secretion appears to be under the spe-
 cial  control of the nervous system, whatever influ-
 ence chemical affinity or galvanic agency may be
 supposed to have over the  ultimate  changes of
 the blood in the secreting organs : hence  it  is that
 in all cases of long-continued  disturbance  of the
 nervous system, we find  the  secretions  vitiated,
 and becoming in  their turn sources of irritation :
 this is well exemplified in chlorotic women, and
 in chronic  mental  alienation.   The secretions,
 therefore, in nervous  diseases should always be
 carefully examined, and means adopted to restore
 them to a healthy state. This is to be principally
 accomplished by the continued exhibition of mild
 purgatives for a  certain length of time,  so  as to
 obtain free  and natural evacuations, but  stopping
 short of the irritating  and debilitating effects of
 active purging.   We must be guided in the selec-
 tion, dose, and frequency of repetition of  the ape-
 rients by the habit of body of the  patient, the
 appearance of the tongue, and  state of  the sto-
 mach, and the nature of the alvine and urinary
 discharges.   We have found a combination  of
 equal parts of the massa pilulae hydrargyri,  pilula
 rhei comp. and  extractum catharticum,  produce
 the desired effects.
   Tonic and antispasmodic remedies, given either
 singly or in  combination with purgatives, are  in
 general remarkably well suited to that state  of the
 nervous system which  predisposes to convulsions.
 We would observe, however, with respect to this
 class of remedies, that  if given so  as to  create  a
 high state  of  habitual excitement,  their effects
 will be  decidedly injurious.  The practice,  there-
 fore, of administering indiscriminately strong doses
 of ammonia, ether, or valerian, and allowing  a
 free  use of wine, to nervous and hysterical women,
 is often highly improper.   We  can only expect
 to do good as far as we can succeed in gradually
 and  permanently increasing the tone of  the ner-
 vous system.  This effect may be fully  obtained
 by moderate doses of some of  the tonic and anti-
 spasmodic  medicines,  given  for a  considerable
 length of time, in conjunction with gentle  aperi-
 ents.  The preparations of iron and bark are the
 tonics generally  to be preferred, for their  great
 efficacy in  restoring the tone of the nervous sys-
 tem  whenever it  has  been gradually much im-
 paired.   Iron has also the advantage of acting as
 an emmenagogue, and  correcting that deficiency
 and  irregularity  in the functions  of the uterus
 which is so often the sole cause of the disordered
 state of the health : a striking instance  of its
 power in this respect  is afforded in the  case of
 anomalous convulsive diseases already alluded to,
 as quoted from Dr. Abercrombie.  We have used
 with considerable  advantage, in similar cases, the
 carbonate of iron combined in a mixture with car-
 bonate of ammonia and tincture of aloes ; it must
 be given to  the  extent of between one  and two
 drachms in the twenty-four hours:  when carried
 beyond this dose, it remains accumulated and per-
 fectly inert in the alimentary canal.   The prepa-
 rations of zinc, the solution "of arsenic, the nitrate
 of silver, and several of the fetid gums have like-
 wise been  strongly recommended,  and  may no
doubt on many occasions  be given with  benefit.
 All medicines acting on the nervous system 'ose 
CONVULSIONS,  (INFANTILE)
 their effect by habit; and it is a good general rule
 to substitute occasionally one for another.
   The cold and warm bath are still more valuable
 remedies in the  prophylactic treatment of convul-
 sions than during the paroxysm.   The daily use
 of the cold shower-bath, with the  feet immersed
 in hot water, and also cold  sea-bathing  in sum-
 mer, tend powerfully to  increase the tone of the
 nervous system.   The warm bath or tepid shower
 bath must  be  ordered for delicate patients, too
 sensitive to bear the sudden  impression of cold;
 nut  it is very desirable to lessen by  degrees this
 extreme  susceptibility, by  lowering gradually the
 temperature of  the water.  We must in general
 be guided  by the feelings  of the patient and the
 vigour of the constitution in the  choice of the
 cold or warm bath.  There is a remarkable  sym-
 pathy between the functions of the skin and those
 of the brain and nervous system; and it is always
 of great  importance to excite a healthy action  of
 the  skin, which  is generally dry and  torpid,  in
 persons  subject  to  convulsive affections.   The
 natural vapour-baths  found in the  caverns of the
 volcanic mountains in the neighbourhood of Na-
 ples were in great repute for the cure of convul-
 sive diseases among the  Romans, and  are still
 much resorted to by the present inhabitants of the
 country.  We have seen the use of vapour-baths
 attended with the very best results in  some in-
 tractable cases of convulsions.
   There are few things of greater importance in
 the  treatment of convulsions  than  the regulation
 of the diet,-  for a disordered and irritable state  of
 the  stomach and bowels  frequently operates as  an
 exciting  cause.   In cases attended with general
 plethora and a  tendency  to cerebral congestion,
 the  diet must be very spare; animal food and fer-
 mented liquors are to be  entirely prohibited, and a
 milk and vegetable  diet, with light  broths, pre-
 scribed.  By persevering  in  this  soothing plan,
 attacks of convulsions threatening to assume the
 character of regular epilepsy have been completely
 overcome.   In  cases,  however, of  an  opposite
 description, characterised  by  languor and irrita-
 bility, the diet, although simple, should  be  nou-
 rishing.
   The moral management of the patient  requires
 attention ;  pains should  be taken to  remove him
 from the influence of every predisposing and ex-
 citing cause, such as crowded hot  rooms, late
 hours, sedentary habits,  mental anxiety, &c.  It
 is of consequence to provide some occupation or
 diversion for the idle, in order to withdraw them
 from the  study   of their own feelings ; as few
 things tend more to increase  nervous irritability
 than a mind preying  on  itself.   The  power  of
 volition over the functions  of the nervous system
 is greater than is generally supposed.  When con-
 vulsions recur from mere habit, this morbid  habit
 has  in some cases been  completely  broken  by a
 strong and  sudden effort  of the will :  it is advisa-
 ble, therefore, not  to encourage such patients  to
 yield to their feelings by  showing them too much
 sympathy,  but rather to remonstrate with  them
 temperately, insisting that they  have  it greatly  in
 their power to resist the first approaches of the
paroxysm, if they will only  resolutely determine
to exert it.   It is quite certain that children have
been frightened  out of  convulsions  as  well  as
                                           519

 frightened into them ;  and it is  by acting on the
 nervous system through the medium of the  ima-
 gination,  that  quacks,  soothsayers, and  fanatics
 have acquired  such celebrity in  the cure of ner-
 vous diseases.             *       .-,
                         Adair Crawford.

   I.  Contulsions,  Infantile.   The  present
 article is intended to include only those convulsive
 diseases which are either peculiar to the earliest
 periods of life, or are accompanied with such cir-
 cumstances as modify the symptoms, and require
 some peculiarity in the treatment.  Convulsions
 are  so  frequent in young children, and so often
 fatal, that it becomes of great importance to con-
 sider whether their nature, causes, and  treatment
 are  properly understood.  Without hesitation it
 may be stated, that till very recently authors and
 practitioners were by far too apt  to generalize in
 these cases, and the practice consequently degene-
 rated  into  routine, and that often on  mistaken
 principles.  In  most  cases  the   convulsions  of
 young  children are symptomatic of some other
 disease,  [or are  eccentric;]  but although  the
 recollection of  this fact is extremely important,—
 as upon the  nature of  that particular disease the
 treatment chiefly depends,—yet there is  sufficient
 danger in the immediate attack to render it proper
 to give a full history, in the  first instance, of the
 affection itself, the symptoms which are present,
 and the best mode of alleviating  them.
   History of the Attack. — Mr. North, in his
 excellent work on the convulsions of infants, has
 described  various symptoms which  may be  con-
 sidered premonitory of an impending attack, in-
 dependently of the existence of any  particular
 disease, and all of which evince an increased irri-
 tability of system.  The most striking of these
 alterations in  the  child's  usual  habits are,  the
 starting  at very slight  noises,  a  disturbed sleep,
 with frequent fits of crying  from trifling causes,
 and great peevishness of temper.  There is,  also,
 often, a frequent fixing of the eyes, an oscillatory
 motion of the  pupils, a momentary contraction,
 and again a sudden dilatation of  the pupil, and a
 want of consent between the pupils of both eyes,
 so that one  will contract whilst the other dilates.
 The countenance is alternately flushed and pale ;
 sudden animation is followed  by  as sudden a fit
 of languor,  and irregularity in the breathing, par-
 ticularly with  short catchings of the breath fol ■
 lowed by long  and deep inspiration.  Hiccough,
 too, frequently occurs.   The fingers are kept con
 stantly  twitcbing, or the hand  is clenched, the
 thumb  stiffly contracted on the  palm,  the  toes
 drawn in, and the foot and wrist bent downwards
 To these symptoms may be often added a peculiai
 blueness about the mouth, and a  pinched counte
 nance.  Many of the  above  appearances, how
 ever, are overlooked by the attendants; and often
 without anv warning whatever a convulsion takes
 place.
  In the attack  itself there  is,  says  Dr. John
 Clarke, " a universal spasmodic contraction of all
 the voluntary and many of the involuntary mus-
 cles of the body, accompanied by foaming at the
mouth,  protrusion of the tongue, staring of the
eyes, distortion  of the eye-balls, laborious and ob
structed respiration, sometimes accompanied with
a violent redness of the face and  scalp at the be- 
520                     CONVULSIONS,  (INFANTILE)
ginning of the paroxysm,  followed  by a purple
colour of the whole body at the end of it." This,
however, is  the history of a severe case : there
may be  only slight twitchings  of the  face or of
the limbs, with a distorted eye, and bluish circle
round the mouth.  The limbs may be  alternately
relaxed  and contracted, and only one part or one
side of  the  body may be  convulsed at the  same
time: in some instances this happens  alternately
with a  similar affection of the other side several
times in regular succession.  As the paroxysm
subsides, the convulsive motions become gradually
less violent and less constant;  the natural colour
and appearance returns; the child  takes a deep
and full inspiration and is then able to cry ; and
frequently  a  refreshing  sleep  succeeds.   The
attacks may be renewed and again subside several
successive times, till perfect relief is obtained ; or,
on the other hand, even the  first  paroxysm  may
be  fatal.  The convulsions may be momentary,
or may  last  only  for a few minutes ; or they  may
continue,  with  but short  intervals, for  a  great
many days.   Except the  exciting  cause of the
paroxysm is of such  a nature  as to be  attended
with fever or disturbance of the intellectual func-
tions, these characters are not essential to an attack
of convulsions.
   Pathology* — It  has been laid down as an
axiom by the late Dr. John Clarke, that «in every
case of  convulsion the brain is  at the time organ-
ically affected, either  directly or indirectly."   As
the management of the case depends essentially
upon a  correct view of this important question, it
is highly necessary  to investigate  its accuracy.
Mr. North has very  ably exposed  the fallacy of
Dr. J. Clarke's assumption, and the errors  into
which a supposed existence of " head affection"
has led many practitioners.  That the nervous
system is  implicated in the immediate  convulsion
is not denied, but that the brain is " organically"
affected, or that even  a congested state of the ves-
sels of  the brain takes place in every case, is ex-
tremely improbable.   The brain is often in a very
opposite state to that of vascular excitement or
plethora;  being  on the contrary, from the  con-
tinuance of exhausting causes, placed in that con-
dition of " diminished energy of the vital force,"
which leads to what has been called nervous irri-
tability.   The distinction between these two oppo-
site states may be recognised by an observant eye
with tolerable  facility, and by  attending to  the
previous history and  condition  of the patient, and
to some peculiarities  in the  attack itself.  Where
there has  been a hot  skin, particularly of the head
and face, a flushed countenance, a rapid and  hard
pulse, a suffused red state  of  the conjunctiva, a
contracted pupil, with intolerance of light,— an
excited circulation through the brain very clearly
exists, probably leading on to inflammatory action.
And again, where the child is  heavy and stupid,
the pupils dilated, the eyes occasionally or  con-
stantly  contorted, and the  power  of fixing  both
on the same  object   much  impaired; the  pulse
irregular or slow ; the veins on  the forehead, neck,
and  scalp,  turgid and  dark;  the countenance
bluish ; the  head large, occasionally hotter  than
natural; and the fontanelle permanently elevated
and convex ;—a congested state of  the vessels of
 :he brain,  especially of the  sinuses, evidently
exists.  But on tiie other hand, it is  very com-
mon to meet with convulsions where the child is
pale and thin, the  body wasted by illness or by
violent and exhausting remedies, the skin cooler
than  natural, and the veins on the  surface appa-
rentiy bloodless.  In  such cases the head, at first
sight, looks .disproportionably large, but this will
be found to be an  erroneous impression, arising
from the diminished bulk of the body  and  neck.
In  this description of case, also, there is a very
important guide, (though not noticed in books on
the subject,) viz.:  the fontanelle being depressed
and concave.   Although there may be drowsiness
and stupor,  a dilated pupil and  squinting, and
although during  the immediate  convulsive  par-
oxysm, by  the violence of the muscular agitation,
the countenance  becomes flushed, the  vessels of
the scalp loaded, and the fontanelle elevated, yet
this condition is only temporary, and  any thing
but a state of vascular energy or plethora can be
supposed possible.   The eyes of  the  profession
have been  opened latterly to this condition of the
brain in infants, as  simulating hydrocephalus, by
the writings of Drs. Gooch  and Marshall Hall;
and the same valuable  observations are quite as
applicable to the  subject of convulsions.   It will
be  easily understood, therefore, how faulty must
be the routine practice of abstracting blood, as a
matter of  course,  in  all  cases  of convulsions.
[See  Dunglison's  Practice  of Medicine, 2d  edit.
ii. 222 : and his  General Therapeutics and Mat.
Med.  ii.: Philad. 1843.]
   Causes*—It has been already stated that in-
fantile convulsions, in nearly every  case, are to be
considered  rather as symptoms of other  affections,
and our  mode of treatment must  be in  a  great
measure  influenced by the  supposed cause.   It
may be doubted,  indeed, whether  real  idiopathic
convulsions ever occur.   These causes  are so nu-
merous that it would be nearly impossible to enu-
merate them  all, and many can only be just al-
luded to, as the diseases themselves are  treated of
in other parts of this work.
   From the first moment of birth a child is liable
to convulsions, from pressure on the head during
labour, or  from mechanical injury in an artificial
delivery; and there is  not  a malady which can
occur during the early period of infancy which
may not give rise to an attack.  Retention of the
meconium, stoppage of the urine, an ill-condi-
tioned state of the umbilical cord  after division,
an irritable, relaxed, or loaded state of the bow-
els, a full   stomach,  air  in the intestinal  canal
causing painful gripings and oppression, improper
food,  a strong glare of light, and loud  noises, are
amongst those causes which are most apt to occur
in the first  few weeks of infant life. As soon as
the process of teething commences, from the great
irritation and  often febrile  excitement produced,
convulsions are liable to be brought on  with every
tooth, as  it makes progress  through  the gums.
Worms in the intestines frequently excite convul-
sions, their presence in the body being distinguish-
able by the usual symptoms.  The sudden drying
up of cutaneous eruptions, or of discharging sores
behind the ears or upon the head, without keeping
up at the  same  time a free evacuation from the
bowels or elsewhere, is occasionally followed by
convulsive attacks ; and the onset  or sudden sup- 
CONVULSIONS,  (INFANTILE)                     521
pression  of measles,  small-pox, or any eruptive
febrile diseases, is often accompanied by them.  A
fit of hooping-cough will often terminate in a re-
gular convulsion from the violence with which the
blood is driven  to the  head, and the difficulty with
which it  circulates through  the  lungs.   The  fre-
quent improper drugging of children  with ardent
spirits, or patent  medicines  containing opium, for
the purpose of  keeping them quiet and  procuring
sleep, keeps the tender nervous  system of an  in-
fant in such a state of irritability, that convulsions
will very probably supervene ; besides the chance
of an over-dose at once inducing an attack.  Con-
vulsions  may  occur  from  mere  pain, however
caused, if severe and long continued,—the degree
of pain required of course depending on the con-
dition of the child at the time,  as to an irritable
or  a plethoric  state of the  brain.  In  the same
way, sudden frights, violent passions, fits of crying
or of coughing, and  any rapid rotatory motion,
may be causes of attacks.  Blows on  the head,
concussions of  the brain, organic  lesions of that
organ, tumours, bony deposits, or  coagula within
the cranium, inflammation of the membranes, and
either chronic or acute hydrocephalus, must also
be enumerated  among the causes of convulsions.
   Infantile  convulsions  have been stated  to  be
sometimes epidemic, but as Mr. North has very
properly  observed, it  would be more  correct to
presume  that from local causes some epidemic dis-
ease had prevailed,  of which convulsions were
symptomatic.
   Prognosis.—In prognosticating the result of
a convulsive attack, regard must be chiefly had to
the causes, if they can be ascertained,  the  possi-
bility  of  removing them being the  ground  on
which we should rest our  opinion;  but though
this will  be our safest  guide as to  the probability,
it must always be recollected that any  single  pa-
roxysm,  if severe and  long-continued, may be
fatal: we must also be partly guided  by the con-
stitution  of the  child;  a very irritable  constitution
will be thrown into convulsions by much slighter
causes than one more robust and of a less degree
of susceptibility ;  the prognosis, therefore, in  the
latter cases should be more guarded.
   Treatment.—The treatment of the immediate
attack is generally well  understood, even by mo-
thers and nurses.  The great point perhaps is not
to  attempt too much.  A  warm  bath  is usually
the first  thing tried, and will often alone be suffi-
cient to abate the paroxysm, but is not  to be used
indiscriminately.   [There  is  generally, however,
so much  hurry  and confusion, and the warm bath
is, withal, attended with  so  much  inconvenience,
that it has been abandoned  by many.  By some,
friction with a warm flannel is substituted for it.]
Other means are—dashing cold  water on the face
and head, wet  cloths  or pounded ice  constantly
applied to the  scalp,  [or to the  neck and spine;
(R. B. Todd,  Lond. Lancet, April  30,  1842,)]
clysters of aromatic distilled waters, or  of assafce-
tida, combined with castor oil or the neutral salts;
chafing the hands and feet with brandy or arther.
should the abdomen be distended  with  air, which
is very commonly the case,  a few drops of sal vo-
latile may be given in peppermint-water, and the
belly  rubbed freely with the  hand, or with any
gently stimulating liniment.  A purgative of an
   Vox.. I.— 66                      2t*
 active character, consisting of calomel with jalap
 or scammony, may be given if the child can swal-
 low ; or, should any improper article of food have
 been recently taken, an emetic should be admin
 istered.   It is not always possible to collect accu
 rate information  on  this point at the time, for it
 does not always follow that the offending aliment
 should have been very recently eaten. The writer
 attended a case  whero, vomiting  being excited,
 immediate relief was obtained by the expulsion of
 several undigested  raisins, which had been given
 to the child (four years of age) nearly a week be-
 fore.  It is the constant plan of some practitioners
 to abstract blood in  all cases  of convulsions in
 young  children ; but, as we have shown already,
 this is  not to be defended in all cases by reason,
 nor does experience justify the practice.   Where,
 however, a plethoric or too energetic condition of
 the vessels of the brain obtains, it is undoubtedly
 desirable to  relieve  the  head by  bloodletting.
 Very often, where  there is an  obstinately consti-
 pated state  of the bowels, purgative medicines
 will not succeed in removing some offending mat-
 ter from  the intestines until cerebral pressure has
 been removed by  taking away blood  from the
 neighbourhood.  For this  purpose,  opening the
 jugular vein is the readiest and perhaps the most
 effectual method; or, should it be preferred, cup-
l ping, or the application of leeches on the temples,
 or behind the ears, may be had recourse to.  The
 quantity of  blood  drawn  must  depend  on the
 strength of the child and the violence of the symp-
 toms ;  and although on the  whole, under  such
 circumstances, children of a tender  age  bear the
, loss of a larger quantity of blood than would be
 supposed, very safely, yet care must  be taken lest
 the child be brought into that state of exhaustion
 in which convulsions are very apt to occur  from
 an exactly opposite cerebral condition. The writer
 of this article saw  a plethoric child, of a year old,
 cupped  to fainting during a severe convulsive at-
 tack, and no sooner had  the  faintness  subsided,
 and the child was  left bleached, with a depressed
 fontanelle, than  a  second and still  more violerit
 convulsion  took place, from which  it was  with
 extreme  difficulty  recovered.   Should the child
 be of an age at which the process of dentition
 would  be at  all likely to be going on, we should
 be overlooking a very essential part  of the treat-
 ment if* the  gums were not to be freely and ex-
 tensively scarified:  long before a tooth is near the
 surface this is often of great service,  and  removes
 one  of  the  most  frequent causes   of irritation.
 Should  the  case  be  one  of great irritability  of
j brain without plethora, after attacking the exciting
 cause where it is possible to remove it, should the
 convulsions  still  continue,  antispasmodic medi-
 cines  may be liberally administered, such as the
 assafcetida mixture, ammonia, camphor, aether and
 musk, and even opium ; but from the uncertain
 effects of the latter medicine on very young chil
 dren, this must be done with great caution.  Where
 there has been a very irritable state of the bowels,
 opium is particularly useful when combined with
 chalk and aromatics ; the pulvis cretae compositua
 cum opio of  the Pharmacopoeia is  a convenient
 form, from the small quantity of the opiate which
 it contains;  from one to ten grains may be given,
 according to the age of the  child,  and repeated 
522                     CONVULSIONS,  (INFANTILE)
 every hour or two, till  the  desired effect is  pro-
 duced.  Most of the advertised convulsive powders,
 as they are termed, consist of chalk combined with
 musk and aromatics.  In some instances, and not
 always in very weak and exhausted children, there
 is constitutionally an exceedingly irritable  state
 of the nervous system, leading to convulsions re-
 sembling those of an epileptic nature.  In these
 cases, tonics of a very decided  character, iron for
 instance, have been found by the writer sometimes
 as useful as they have been long known to be in
 a more advanced age.  A child two months old,
 large and fat, was seized with violent convulsions
 suddenly, the bowels having been disordered from
 bad  breast-milk  for a few days previously.  The
 convulsions lasted for seventeen days, sometimes
 occurring three  or four times in an  hour,  and
 never ceasing for more than  four or five hours at
 a time.  The  fontanelle was depressed  and con-
 cave always  in  the  intervals of each  paroxysm,
 and  no  blood was  taken in consequence ;  the
 treatment consisting of antispasmodics, external
 applications, clysters, purgatives, and also of opi-
 ates, one drop of laudanum having been adminis-
 tered eveYy  hour  for a considerable  number of
 doses.   This treatment was  pursued for a fort-
 night with no permanent  improvement.  On the
 seventeenth  day the bad success of the previous
 remedies induced  the writer  to try the carbonate
 of iron, of which five grains in honey were given
 every two hours for two days.  After  the second
 dose the face became  florid, the  fontanelle  ele-
 vated, and the convulsions ceased.   In the inter-
 vals  of the fits the child took copiously of breast-
 milk, by  means  of  a spoon, during the whole
 period.   The infant remained well for a twelve-
 month, and then died from hooping-cough.
  [In the asphyxia, occasionally seen  in  the con-
 vulsive fits of children, it has been advised to prac-
 tise  artificial respiration  by breathing  into  the
 mouth of the infant from  the practitioner's own,
 closing its nostrils, compressing the thorax  after
 each inflation, and observing  the  natural periods
 of frequency as nearly as possible.]
  When the immediate paroxysm of convulsion
 has been subdued, its recurrence must be carefully
 guarded  against  by attentively investigating the
 state of the child's health  up to the time of the
 seizure, and  also  avoiding  and removing what
 may appear to have been the remote cause of the
 immediate attack.   It is too much the fashion in
 all cases where fits have occurred, at once to be-
 gin a system  of  starvation and depletion.  It  is
 obvious that this plan can only be  adapted to the
cases where there are evident signs of plethora or
 of determination of blood to the head.  Where
exhaustion and emaciation already exist, a care-
 fully graduated strengthening plan, both  of diet
 and  medicine, becomes  proper, and, united with
 quiet, and a  change to a purer atmosphere, will
 often answer our most sanguine expectations.  It
would  only be  useless repetition to detail  the
treatment proper to each of the many causes  of
 convulsions  enumerated  above; we refer to  the
 different disorders under their  respective  heads.
 It will  be sufficient to recollect that when once
 children have been seized with  convulsions, they
 are  very likely to  recur, even  from causes  very
dissimilar to tbose which produced the first attack;
 the brain remaining more susceptible than before.
 Every thing which  may add to this susceptibility
 should  be carefully avoided ;  the  bowels should
 be  regulated, the  diet narrowly watched, both as
 to quantity and quality, the exercise kept within
 bounds, heated rooms and late hours interdicted,
 and even the moral  and  intellectual education
 should  be conducted with  reference to this condi
 tion of brain,—too great and too frequent mental
 excitement being highly pernicious.
   Before concluding  this article it is proper to
 notice that very young infants are often affected
 with what  nurses call " inward fits."   In these
 cases there is a  rolling about of the eyes when
 asleep,  a drawing  down of the mouth with slight
 twitchings, frequent smiling during  sleep, and
 occasionally a little blueness about the  mouth.
 These  symptoms  are  owing generally to disten-
 sion of the stomach and  to  flatulence,  and  are
 easily dispelled by frictions on the stomach, back,
 and bowels, or a little  sal volatile, or some of  the
 aromatic distilled waters.
   There is a convulsive affection of a very pecu-
 liar character which attacks very young children,
 and was described  first by Dr. John Clarke, in
 his Commentaries on the Diseases of Infants.   It
 has been named "cerebral croup," "spasm of the
 glottis,"  " the crowing convulsion," <$r.c.  The
 particular  account,  however, of this  interesting
 disease, will  be found in a separate article.  See
 Glottis, Spasm  of.)
   [A peculiar form of convulsions  has been de-
 scribed, which consists in bobbings of the head
 forward.  These are slight at first,  but in process
 of time they may  become so frequent and power-
 ful as to cause a  complete heaving of the head
 forwards towards the knees, and then immediately
 relaxing into the  upright  position, — something
 similar  to the  attacks of  emprosthotonos.    (J.
 W.  West: Lond. Lancet, Feb. 13, 1841.)  The
 child does not lose its consciousness.  Sir Charles
 M. Clarke, who had seen four cases of it, from the
 peculiar motion of the head termed  it  Salaam
 Convukion.  In some  of the cases that have lived
 beyond  the  age of puberty, idiotcy has occurred.
 The pathology of  the affection is unknown.  As
 remarked by the  writer  elsewhere, (Practice  of
 Medicine, ii. 224,) it would be curious to observe,
 whether the lesion give  any countenance to the
 views entertained  by Magendie  in  regard to the
 cerebral seat of the forward impulsion, referred to
 under Chorea, (q.  v.)"|            ,„ r
              v    yj            C. Locock.
  II. Contilsiuvs, PuEnPERAL.  In a work not
professedly devoted to midwifery, a  notice of this
formidable occurrence must of necessity be brief.
  History of the Attack.—The  real puerperal
 convulsions can  scarcely  be  mistaken  for any
 other disease, and when once seen and recognised
 are  not likely to  be soon  forgotten.   They may
occur not only during the process of parturition,
 but also in the latter period of pregnancy, and
again in the first few days after delivery. 'They
are  generally ushered in  by certain  precursory
 symptoms;  but sometimes  there is no  warning
whatever, or one s,> slight as to have escaped the
notice of the  attendant.   Usually,  however, pre-
ceding the attack  there is  dull pain  and weight
in the head, constant  drowsiness, flushed coun- 
CONVULSIONS, (PUERPERAL)                     523
tenance,  with  a  full slow pulse, and  partial  or
occasional failure of sight.  At other times, or in
other cases, the preceding symptoms are  succeeded
by sudden  and most acute pain  in the  head, loss
of sight, or the sensation of dark,  or  of bright,
fiery objects moving before the eyes, ringing  in
the ears, and generally sickness, with  pain and
oppression at the pit of the stomach.   The patient
is then seized with twitchings  of the  face  or a
rigid contraction of the jaw, followed immediately
by  violent  universal convulsions, resembling  in
many respects an attack of epilepsy.  The face is
distorted, the  tongue protruded, with foaming at
the mouth, and a peculiar deep hissing noise from
breathing sharply through the closed teeth; the
 eyes  are fixed or  rolling irregularly, the pupils
 dilated, and  the limbs  are strongly and convul-
 sively agitated.   After a time the paroxysms ter-
 minate in stupor,- with  stertorous  breathing, from
 which, after  an  uncertain interval, the patient
 will often  awake suddenly, unconscious of any
 thing  whicb  has passed, and  apparently  well :
 shortly after, perhaps, the convulsions  again  re-
 turn,  and  several  successive  fits  of  a  similar
 character may recur.  Apoplexy occasionally fol-
 lows, and the patient may then die in the coma-
 tose stage; but this termination is  not  frequent
 where proper curative means have been employed.
 The occurrence  of apoplexy may be  considered
 rather  as  an accidental complication, not  by
 any means necessarily attendant upon  the  dis-
 ease.
    Causes.—The immediate causes of puerperal
 convulsions are often very obscure.   They appear
 sometimes to depend upon a loaded state of  the
 vessels of  the brain; at other times the brain  ap-
 pears to be influenced by distant irritation, either
 in the uterus or  in the digestive  organs ; and
 again, in some cases,  puerperal  convulsions  are
 induced apparently by a peculiar irritability of the
 nervous system.   It has been remarked that there
 has been a greater disposition to puerperal con-
  vulsions in those patients who have been in early
  life subject to convulsive attacks, particularly of
  an epileptic  character  ;  and also  in  those who
 have suffered similarly in former labours, and have
  omitted  those measures  usually employed as pre-
  cautions.  That the uterine organs are in some
  way particularly implicated,  is  evident from  the
  convulsions  being of a character which may be
  said to be  peculiar to the state of either pregnancy
  or parturition.
    The immediate  attack may be brought on by a
  loaded or disordered stomach,  or  by  food, how-
  ever small in quantity,  of an indigestible  kind.
  Some  substances,  shell-fish for instance,  have
  been found very frequently to induce convulsions
  in the puerperal condition, when  at other  times
  they may have been taken by the same individual
  with  perfect impunity.  A sudden  fright, afflict-
  ing intelligence, or any unexpected or depressing
  mental emotion may excite the paroxysm ; hence
  it has been long remarked that unmarried womer
  are more  particularly  likely  to  be  sufferers from
  convulsions,  from the circumstances of shame an 1
  distress under which  their children are usually
  born.  The  violent straining caused  by labour-
  pains, and even the disturbance of the  frame by
  the earlier uterine contractions, causing a tempo-
rary rush of blood to the head, will  sometimes
bring on convulsions.
  It must be recollected that although convulsions
occur most commonly  under the circumstances
described, they occasionally take place also in a
very exhausted state of the frame, when the sys-
tem has been nearly drained of blood by excessive
uterine hemorrhage, or other depletions.  In these
instances there  is generally considerable danger,
partly from the great irritability consequent upon
the  exhaustion, so that much slighter  causes will
produce  more violent effects, and partly from the
greater  difficulty of applying remedial measures.
In these cases the pulse  is rapid and  weak, and
the countenance pale and bloodless.  Half a cen-
tury ago, puerperal  convulsions were much more
fatal than at present;  for we  are told by writers
of  the period, that upon an average, full half of
the patients died ; whereas now, as is well known,
when properly treated,  they usually recover.
   [From the reports of different observers, collect-
ed  by Dr. Churchill, (The Theory and Practice
of  Midwifery, Amer. edit., by Professor Huston •
Philad. 1843,) it  would seem that about one case
in  four has terminated  fatally ;  although this is
doubtless more  than the average.   Examination
after death throws little or no light on the patho-
logical condition.  Often, nothing morbid has been
perceptible.  At other times, there has been hy-
peraemia  or effusion of serum.  The neurine is
doubtless affected, but in a manner at present not
appreciated.  The disease is, in other words, a
neurosis.]
   Treatment. — This is to  be regulated  espe-
cially by noting the cause of the particular attack.
As a general rule it may be stated, that copious
abstraction of blood in a large stream is the most
efficient means  of shortening  the attack and  se-
curing  the  safety  of the patient.   Where the
pulse is strong and  full, and the  frame robust, the
 quantity that  may be taken with impunity and
 advantage is often  very great;  and  where from
 circumstances it is difficult to procure a sufficient
 supply from the arm, the temporal artery may be
 opened, or cupping-glasses applied behind the ears
 or on the temples.   [Advantage, too, may accrue
 from compressing the carotid arteries  in the man-
 ner advised for several convulsive affections, (New
 Remedies 4th edit.  p. 188 : Philad. 1843.)]  An
 aMivc  purgative, as scammony, senna, or jalap,
 cjmbned with calomel  in a full dose, may be
 E.iven ;  or  if there  is a difficulty in  swallowing,
 one c r two drops  of the croton oil may be smeared
 ipon the back of the tongue.   An injection of a
 stimulating and purgative character may also be
 throtcn  into the rectum; and  for this purpose
 nothing perhaps is more effectual than turpentine.
 Cold washes, or bladders  containing  pounded ice
 may be applied to the head, and hot mustard poul-
 tice:, to tbe feet.  The propriety of repeating  the
 bleeling, and  the time of doing so, either locally
 or  generally, must  depend upon the power of the
 patient and the state of the pulse as well as Uj.on
 the continuance of the  symptoms.  In the coma-
 tose state, or in what may be called a more chronit
 staire of the disease, blisters to tne head or to the
 back of the neck may be of service,  but they arc
 scarcely admissible  previously.   In  this stage a
 free action should be kept up from the bowels, and 
524
CONVULSIONS,  (PUERPERAL)
the turpentine enemata are especially useful.  For
some considerable time after the immediate symp-
toms are subdued, the patient  must be kept per-
fectly quiet, all causes of irritation must be avoided,
and the diet should be spare and simple.
   [Whilst it is deemed  advisable to diminish the
quantity of the circulating fluid, the patient should
abstain  as much as possible from watery drinks,
inasmuch as  under the copious draughts from the
circulating system,  they  would not fail to  pass
readily by imbibition through the coats of the blood-
vessels, and  supply  the  loss that had  been sus-
tained.]
   Where the patient has been, before the attack,
much reduced  from  exhausting  illness, or  from
hemorrhage,  we are not always to  think it neces-
sary to bleed, and to bleed furiously.   Bloodlet-
ting must in such cases be had recourse to with
very great circumspection ; and if necessary at all,
local bleeding, witb the other remedies  mentioned
above, is all  that we should venture upon.  It is
well known  that dogs have  been bled into con-
vulsions, and it is  probable that a  similar condi-
tion of circulation in the brain exists in the cases
now referred to.   There  has  been  much  discus-
sion as to the propriety of giving  opium in puer-
peral convulsions, some having spoken very highly
of  its  advantages,  while others  have decidedly
thought it  pernicious;  but  this  difference  of
opinion has  arisen  solely  from the want of dis-
tinction between the character  of the cases to
which it is or is not applicable.   Experience of
this fact has  led  the writer of  this  article to be-
lieve, that whilst opium  is certainly injurious in
puerperal convulsions of the class first described,
it is often,  especially when combined  with full
doses of camphor, most salutary in the latter, as
well as in those cases of an hysterical  character
presently  to be  mentioned.   From  one to  two
grains of opium, with four or five of camphor may
be  given, and repeated every hour or two  till the
proper effect is produced ; and in  the  exhausted
cases described, the desired effect is  to subdue the
paroxysms, strengthen and steady  the  pulse, and
restore colour to the  countenance.   Another point
of  dispute has been, whether  emetics are  appro-
priate  remedies  in  these attacks, — the  doubt
arising  from the supposed bad effects likely to
occur from the violent efforts to vomit causing the
blood to be  impelled more forcibly to the head.
Where the  attack has been produced by a loaded
stomach or by indigestible food, spontaneous vomit-
ing has often  happened  with great and sudden
relief to the patient, and in such  cases, but per-
haps only  in such, benefit will often  arise  from
seconding the natural efforts by administering an
emetic.
   The  last inquiry of importance  is, ought we to
deliver  immediately  in all cases of  puerperal con-
vulsions where the child or the placenta still re-
mains in the uterus ?   This is rather  a question
of experience than of reason ;  for although it may
be said that the presence of the child or the pla-
centa  in  the uterus may keep up the exciting
cause, yet it is well  known that  convulsions will
often occur  at a considerable interval after de-
livery has oeen completed; neither are they always
relieved by emptying the uterus, where they have
oegun  before or during labour.  Many object to
any  artificial  hastening of the birth, unless the
child's head is within reach of the forceps, on ac-,
count  of  the  uterine  irritation produced  by the
process of dilating the  os uteri, to turn  the  child
and bring it down by the feet.  It may  be  stated
generally, that the  most experienced practitioners
have  agreed, that it is advisable to  deliver, either
by turning or the forceps, (whichever may be ap-
plicable,)  whenever the parts are in  a state to per-
mit this to be done without much difficulty.
  It may  be proper to add to this account, that
where convulsions have occurred in a former con-
finement,  it is very desirable that in any future
pregnancy the patient should be closely watched
towards the latter  part of the time :  great  quiet
should be enjoined, the bowels  should be kept
regularly  open, and  the diet be spare; and should
symptoms of general plethora appear, or of deter-
mination  of blood to the head, bleeding is to  be
had  recourse to.
  There  are  occasionally puerperal  convulsions
of a  less  formidable character than those  above
described,— unless  indeed they be mistaken for
them, — and which consists  rather of unusually
violent paroxysms of hysteria than  of proper con-
vulsions ;  as, however, they may occur during, or
shortly after parturition, they are  very frequently
confounded with them, and  treated accordingly.
The  distinction  may be  easily recognised by the
absence of stertor and perfect coma, by  the  great
quantity of flatus discharged from the stomach and
heard rolling about the intestines,  by the globus
hystericus, and by the rapid and remarkably con-
tracted pulse during the fit, which becomes slower
and  more  expanded in the intervals.  The limbs,
and  particularly the body, are as strongly agitated
as in the  real puerperal  convulsions, but the face
is much  less so.  As it is too common for  inex-
perienced practitioners to consider all convulsions
connected with the  parturient condition as alike,
and  to treat them on  that supposition, it is im-
portant that these distinguishing marks should be
accurately  recognised, particularly as,  although
not  uncommon,  these  cases  have  been scarcely
noticed in works on midwifery.   There is no ne-
cessity in these  instances to bleed  the patient, or
to proceed  to delivery, if that has  not already
taken place.  All that is required is the free ad-
ministration of the customary  antispasmodic medi-
cines, camphor, sether, ammonia, assafcetida, &c.:
and  in such  cases  opium  or any other narcotic
may  be safely and  beneficially exhibited.   Cold
water should be freely dashed upon the  face, and
much advantage will  be obtained by warm fric-
tions and  stimulating applications  freely  applied
to the stomach, bowels, and spine,  whicb produce
or assist the expulsion of flatus from the stomach,
with great and rapid relief to the  patient.  Per
feet quietude of mind and body is afterwards very
important.
                                C. Locock.
  CORYZA, nasal catarrh, gravedo, ox cold in
the head,  as it is variously termed,  is an inflam-
mation and altered secretion of the  pituitary 01
mucous membrane, lining the nasal  fossae, usually
arising from cold.   Although considered a trivial
disorder, there are very few, short of severe pain,
capable of producing more bodily discomfort.  As
this  is, however,  commonly but of short duration, 
CORYZA.
525
it is chiefly on  account of tbe coughs  and bron-
chial affections  to which it frequently leads, that
coryza claims our attention.
  It begins with a sense of fulness  and obstruc-
tion in one or both nostrils, accompanied with the
secretion of a  thin  colourless fluid.  This flux
comes on in an increased quantity from time to
time,  and  the increase  is always  attended by
aggravation of  the uncomfortable feelings  of ful-
ness ; whilst frequent sneezing, titillation  in the
nares and fauces, and a copious flow of tears from
the full  and injected eyes, show an acrimony in
the discharge as well as an increased sensibility
in the pituitary membrane.  This property of the
humour is further  proved, in the  progress of the
disease, by the redness and excoriation of the end
of the nose and the skin above the upper lip; and
it may be considered a remarkable feature in the
character of the inflammation.  The sense of smell
is always impaired, often  entirely destroyed, and
that of taste usually suffers  more or less.  Head-
ach is a very common attendant; it is principally
confined to the forehead, and accompanied with a
feeling of weight and  heat over the brows.   The
partial or complete obstruction of the nasal pas-
sages, although caused entirely by the tumefaction
of the membrane,  gives the feeling of their being
plugged  up by something, which induces frequent
and ineffectual  attempts to remove it by blowing
the nose.   From the same cause the voice is ren-
dered thick and nasal.  If  the attack  is  severe,
there is frequently considerable pyrexia, with loss
of appetite,  and pain of the limbs, and in  almost
every case there is  an unusual  feeling of chilliness
and susceptibility of cold.  The disorder is at its
height generally about the third day,  and then it
begins to decline ; the flow  from the  pituitary
membrane  becomes  more scanty  and viscid, the
swelling and obstruction  abate, while the  head-
ach and other  symptoms are proportionately re-
lieved.  Between  tbe  fifth and the seventh day
the disorder is entirely  removed.   Not  unfre-
quently,  however, fresh cold  is taken from the
slightest  cause,  and the coryza, with its attendant
symptoms, is kept up for a longer time ;  and as
long as the secretion is copious and thin, no ame-
lioration  of the other symptoms takes place.  A
very common consequence of the diminution of
the coryza is the transfer  of the inflammation to
the mucous  membrane of the trachea and bronchi,
and, in fact, there  are few cases  of  cold  in the
head  which are  not followed by more or less
cough.
   Causes.—The usual cause of coryza  is,  as we
have  before remarked, cold applied  generally or
locally,  and it is the more likely to produce it, if
the cold be applied to a part of the body in a state
of free perspiration. But a sudden transition from
cold to heat seems to be likewise  capable  of ex-
citing it.  A slight form of coryza may be  caused
by the contact  of smoke  or other irritating va-
pours with the nostrils ;  but  this does  not bear
the same character.  Coryza generally accompanies
measles,  and sometimes small-pox and scarlatina.
It is likewise a  principal part of the epidemic dis-
ease called influenza.   Whether excesses of diet
are really capable of exciting coryza,  or whether,
as is  more  probable, they only  act  as  strongly
predisposing causes, it is certain that a sore throat,
passing into a cold in the head, is a very common
sequel of a debauch.  It is commonly imagined
that a cold in the head is rather a  sign  of strong
health than  otherwise:  this  is  only so far true,
that, in those liable to it, the cold affects a part of
less importance ; whereas if the lungs, the tonsils,
or the bowels are naturally delicate, the applica-
tion of cold  is more likely to produce  disease in
these  parts.  Liability to  take cold in any way-
must certainly be considered  as a proof of weak-
ness of the constitution, and where it exists in a
great  degree, such a  succession of colds some-
times  attacks an individual, that for months he is
not free from  the  uncomfortable  symptoms  of
coryza.   Such  protracted cases  it is  proper  to
separate from  those chronic  cases  of  profuse
pituitous  secretion,  or  phlegmorrhagy,  [blen-
norrhea,] which are sometimes met with, affect-
ing the nasal membrane in  the same way that
pituitous catarrh attacks  that  of the bronchi.  In
these there is no inflammation, and the diseased
secretion does not possess those irritating proper-
ties that  are so  characteristic of  acute  coryza.
Nasal  phlegmorrhagy,  as some  French  writers
term it,  attacks those of  debilitated  and  leuco-
phlegmatic habit, and sometimes comes on peri-
odically.  The flux is occasionally very abundant,
and we have  known it sufficient to wet five or  six
handkerchiefs in two or three hours.  In  the in-
tervals there  is a cessation of secretion; but, as in
pituitary catarrh, (into which it is apt to pass,)
the membrane  is generally left somewhat tume-
fied.
   When coryza attacks  infants, it  sometimes so
completely obstructs the nostrils as to  interfere
with the process  of sucking  the breast, in which
nasal respiration is necessary.   The child leaves
off repeatedly, and becomes  purple in the face,
and fretful in a few seconds after each time that it
takes the nipple.  In such cases it becomes neces-
sary to feed the child with a spoon.
   Coryza does  not lead  to suppuration.  Pus  is
sometimes secreted  by the nasal fossae, but not in
consequence  of the coryzal form of inflammation,
which terminates by the secretion becoming viscid,
and then opaque, and then of a dirty greenish 01
yellowish colour,  after  which it returns to  its
natural  state.
   Treatment.—The coryzal inflammation does
not require bleeding or any extensive evacuation.
An aperient,  followed by a diaphoretic, in strength
proportioned  to  the severity of the symptoms ;
the pediluvium  at night, with  water as hot as it
can he borne, which the  addition of a little mus-
tard will  render still more effectual;  abstinence
from all kinds of stimulating food; and confine-
ment  to bed  to  keep up cuticular exhalation, are
the measures generally resorted to  ; and  if they
have  not the effect of shortening  the duration,
they certainly mitigate the symptoms  of coryza.
It is the  common practice to drink copiously of
tea, gruel, or some  other diluent, during a cold:
as long as this promotes  perspiration it is of some
utility, and although it augments  the  flow from
the pituitary  membrane,  it has the effect of dimi
nishing its acrimony by dilution.   It is the acri-
mony  of this  discharge which  re-acts  on  the
membrane and keeps up  the inflammation and its
accompanying disagreeable symptoms.   On this 
526
CORYZA —COUNTER-IRRITATION.
 circumstance depends the efficacy of a measure
 directly opposed to that just noticed, but  to  the
 success of which we  can  bear decided testimony,
 —we mean a total abstinence from liquids.   To
 those who have  the resolution to bear the feeling
 of thirst for thirty-six or forty-eight hours, we can
 promise a pretty certain and complete riddance of
 their colds, and, what is perhaps more important,
 a prevention  of those coughs  which commonly
 succeed to them.  Nor is the suffering from thirst
 nearly so great  as  might be  expected.   This
 method of cure operates by diminishing the mass
 of fluid in the  body to such a degree that it will
 no  longer supply the  diseased secretion.   Any
 thing that may  contribute to reduce  the quantity
 of fluid in the body will assist in the plan of cure,
 and shorten the time necessary for it to take effect.
 It is, therefore, expedient  to begin the treatment
 with an aperient, followed by a diaphoretic, as is
 usual, and this  is  the more necessary when any
 fever  attends; but beyond  this no  further care
 need be  taken,  and  the  individual  can   devote
 himself to  his  usual  employments  with  much
 greater impunity than  under the  ordinary treat-
 ment.  The  coryza begins  to be dried up about
 twelve hours after leaving off liquids; from that
 time the flowing to the eyes and  fulness  in  the
 head become less and less troublesome; the secre-
 tion becomes gelatinous, and between the thirtieth
 and the thirty-sixth  hour ceases altogether : the
 whole period of abstinence needs scarcely ever to
 exceed forty-eight  hours.   It is then as well to
 return to the moderate use  of liquids, as the first
 indulgence is apt to be excessive.  It is not neces-
 sary to limit  the solid  food any more than to that
 which is plain and simple, except  where there is
 acceleration of the pulse  or gastric irritation, in
 which  cases animal  food should  be  proscribed.
 For the sake  of comfort in  mastication, the food
 should not be of the driest  kind.   Thick puddings
 and  vegetables, with or without meat,  will  be the
 best dinner ;  and toasted bread, or biscuit, merely
 moistened  with  tea,  or other  liquid, for  other
 meals.  A single cup  of tea is  enough to  bring
 back the coryza  immediately, after twelve hours'
 abstinence has removed it.  We doubt not that it
 will  be said that  this  plan  of cure is  worse than
 the disease; and so it may be in some instances.
 Tt may be  called  always a  choice of evils ; but
 we do  not believe that any one who  is liable to
 severe colds,  after once experiencing the amount
 of good and  evil  resulting from  this method,
 would hesitate between them; and it  is for them
 that  we make it  known.   We have never wit-
nessed any evil from this abstinence from liquids
for the time prescribed; but it is not unlikely that
it may do harm in persons with irritable stomachs,
or in  those liable  to urinary disorders.  Modera-
tion  in liquid food, which may be assumed as a
corollary from what has been already said, is one
of the best preventives against the bad effects of
exposure to cold.  When there is a  large quantity
of liquid in the  system, there must be increased
perspiration, and, therefore, greater  risk from the
effects of cold.
  Chronic  coryza, or  nasal  phlegmorrhagy, is a
 disorder which arises from deranged digestion,  or
nome other functional ailment that has  a tendency
'" diminish the tone  of the fibre.  It generally
 attacks elderly people, and in all respects resem-
 bles pituitous catarrh of the bronchi, with which
 it is often vicarious.      c  j  R Williams.

    COUNTER-IRRITATION (from contra and
 irritare).  This  term,  which  is  of recent intro-
 duction, has been  adopted in  medicine to desig-
 nate  any irritation artificially established with a
 view to diminish, counteract, or remove  some
 other irritation  or inflammation  existing in the
 body.
    Counter-irritation  is generally applied  on the
 external surface of the body; and although some
 external medicines,  as purgatives, emetics,  &c.
 probably in part owe  their efficacy to the counter-
 irritation which  they  cause, we  shall  here restrict
 our attention to  external counter-irritation.
    To  understand  and determine the value of
 counter-irritation in the treatment of disease, it is
 necessary to inquire  into  the principles of its
 curative influence, and  the laws of those  actions
 on which that influence depends.  Unhappily this
 inquiry is restricted by the limits of our knowledge
 on the  subject of inflammation and  irritation in
 general; but enough information may be gathered
 to regulate  in a general way the  employment of
 this remedy in practice.
   Nature not rarely  cures diseases  by counter-
 irritation ; and it was probably from her example
 that art first adopted the  practice.  It is  a com-
 mon case to see an  inveterate functional disease
 subside on the appearance of a cutaneous erup-
 tion.   This more frequently occurs in sub-inflam-
 matory affections of the mucous membrane ; but
 examples are not wanting in which mania, para-
 lysis, chorea, and various other diseases have been
 similarly cured.   The exanthematous and other
 eruptive diseases are  probably  cases of a some-
 what analogous description ; for whether the erup-
 tion be the direct result of a curative molimen, or
 effort  of the  constitution,  or  proceed from  the
 peculiar affinity of the skin to a virus or morbific
 cause wandering in the body, its occurrence is
 within certain limits salutary.   This is proved by
 the relief manifestly afforded to the internal func-
 tions,  and  sometimes  by  the  moderation  of the
 fever,  on the external  eruption of  measles, small-
 pox, scarlatina, erysipelas, &c.   Sometimes, it is
 true, the fever is  increased  by  this  event, and  all
 the  symptoms may  in consequence  assume  a
 worse aspect.  So, likewise, a chronic disease of
 the skin occasionally  relieves  a pre-existent  dis-
 ease of the  mucous membrane ; whilst in other
 cases it re-acts on and aggravates it.
   Now such various and even opposite effects are
 equally produced from a new or coimter-iinidXxon
 artificially established  in the system ; and it is,
 therefore, obvious that, unless judiciously admin-
 istered, this  remedy may prove prejudicial instead
 of salutary.  Experience continually proves that,
 under  certain conditions of the  system, a  blister
 or other counter-irritant aggravates the inflamma-
 tion which it was  applied  to remove.  If we in-
 quire what  these  conditions  are,  we  shall find
 them chiefly to consist of  an excited  or  irritable
state of  the general circulation, and  a suscepti-
bility or excessive sensibility of the nervous sys-
tem.   We shall find, however, that the  remedies
employed as counter-irritants  have other effects 
COUNTER-IRRITATION.
527
which in a considerable degree modify this quali-
fication  of their utility.
  Having thus in principle limited ourselves in
the expectation of advantages from counter-irrita-
tion, we may proceed  to  consider its effects and
uses in  the various forms in which practice has
employed it.
  Counter-irritation may  with advantage be con-
sidered  in relation to its degree, and to the differ-
ent tissues or  parts which it affects.  We  shall,
therefore, notice successively the remedies called
rubefacients; vesicants; pustular or  empyematous
counter-irritants ; setons, issues, perpetual blisters;
and cauterizing counter-irritants.
   Rubefacients.—In the slightest degree, coun-
ter-irritation consists in an erythematic excitement
of the capillaries of the skin, terminating in com-
plete resolution, sometimes with desquamation  of
the cuticle.   An  application  exciting this degree
of counter-irritation is called rubefacient.  Moder-
ate degrees of heat, (between  100° and  150°,)
whether dry or with moisture, essential oils and
spirits,  aether, mustard, pepper, the strong alkalies
and acids diluted, or weak acids in a concentrated
form, and the  strong counter-irritants applied  for
a short  time or diluted, act as rubefacients on the
skin, and are severally used with a view  to this
degree  of counter-irritation.   Being unaccom-
panied  by any evacuation except an increase  of
the imperceptible perspiration, the action of rube-
facients illustrates, better than  epispastics of the
severer  kind,  the principle of counter-irritation;
and the instances of their  utility are neither slight
nor rare.   A flask of  hot water  or  a bag of hot
sand; a poultice  formed  of bread-crumbs  or lin-
seed-meal and hot vinegar, with various propor-
tions of mustard or pepper;  an ammoniacal lini-
 ment or an essential oil applied by friction ; pieces
 of cotton or flannel wetted  witb aether or  cam-
 phorated spirit, and laid on the skin, evaporation
 being prevented by covering them with the warm
 hand, are rubefacient remedies  which  are  often
 successful in removing slight  internal inflamma-
 tions, and in  moderating those which  are  more
 intense.  An incipient sore-throat  is often cured
 by an ammoniacal liniment applied to the anterior
 part of the neck; a slight bronchial or a rheu-
 matic inflammation by the same, or by the appli-
 cation of cajeput or other  essential oil on the chest
 or part affected;  a  gastritic affection, marked by
 nausea, pain, and irritability of the stomach, and
 particularly when resulting from a  powerful dose
 of medicine, is frequently relieved by a sinapism,
 or even a hot flask to the epigastrium;  and  a
 rubefacient property is joined to the derivative of
 a pediluvium, when, with the addition of mustard,
 pepper, or the strong acids, it is used  to relieve
 the brain in  fever with  sleeplessness or low  de-
 lirium.    Some   chronic  inflammations  of  the
slighter kind have likewise their more permanent
rubefacient remedies.  Thus  a galbanum  or  a
pitch plaster,  occasionally  rendered more irrita-
ting by the  addition  of  a little cantharides, is of
no small utility in chronic coughs  and rheuma-
tism.   The  old  composition of soap plaster and
muriate of ammonia,  so  useful  for  the knees of
house-maids, is another  example;  but we may
find one still more familiar in the effect of new
flannel worn next the skin, which unquestionably
owes  some of its  salutary influence to its rube-
facient  property.  To these  instances of rube-
facients we may add friction  and electric  sparks,
both  of which  are  essentially rubefacients: the
latter often produce  a  papular eruption; and the
magnetic plates which have been  recommended
by some French physicians are asserted by Laen-
nec to have a similar effect.  These means, how-
ever, will be noticed under their respective heads.
  Rubefacients, especially when  extensively em-
ployed, are general  as well  as local stimulants;
and although their local effect is such as to coun-
terbalance their general  effect in  cases  of low
febrile excitement, they cannot be admitted where
a generally phlogistic diathesis  prevails; whilst
in intense inflammations they must give place to
the stronger kinds of counter-irritants.
  Besides the  examples  of slight  inflammation
which we have adduced as fit cases for rubefacient
applications, there are  others of a  mixed  kind  in
which they are not less successful.
  Spasmodic affections, particularly those attack-
ing the  stomach and  bowels, various pains and
aches, such as tooth-ach, ear-ach, &c, which seem
to partake of a nervous as well as of an inflam-
matory character,  are often more immediately re-
lieved by hot flasks of fomentations,  a mustard
poultice or pepper plaster, than by any other rem-
edy.   These affections probably have more to  do
with  congestion,  or unequal distribution of the
blood, than  is  generally supposed; and to this
circumstance we are inclined  to ascribe much  of
the efficacy of  these applications: but it may also
depend on the physiological law, that  if the sen-
sibility of a part is increased, that  of the adjoin-
ing parts is diminished.   In  great depression  of
the vital powers, as in  typhus fever, asphyxia, &c,
the general stimulus of sinapisms, stimulant fric-
tions, and the like, is advantageous ; but  we shall
speak of this under the head  of blistering counter-
irritants.
   The most active kind of rubefacient counter-
irritants are sinapisms or mustard poultices ; arid
their action is so speedy and  energetic, that  they
are the most eligible  remedies where a sudden
local irritant is required.  They are usually  com-
posed of flour  of mustard  and bread-crumb in
equal or in various proportions, moistened to the
consistence of  a poultice  with hot vinegar.   MM.
Trousseau and Blanc, in  the  Archives de Mede-
cine (Scptembre,  1830,) have detailed some curi-
ous experiments on the composition of sinapisms.
They found  that vinegar very much impaired the
stimulant properties of the brown mustard  com-
monly  used in France, which contains the  husk
as well as the flour  of the seeds, and they there-
fore recommended that  sinapisms  be made with
water.   The English mustard powder, however,
which is the yellow farina separated entirely from
the cortical part of the seed, is equally efficacious
when mixed with vinegar and with water.  Sina-
pisms made from mustard recently ground act more
promptly than those from mustard which has been
for some time kept.   MM. Trousseau and Blanc
tried the admixture of alcohol with sinapisms, but
found it inferior to either vinegar  or water.   Dr.
 Paris recommends the mixture of oil  of turpen-
tine  to  quicken the operation of sinapisms ;  its
efficacy depending on its extracting the essentia! 
528
COUNTER-IRRITATION.
oil, in wnich the stimulant quality  of the  seeds
resides.   Sinapisms  produce, in the  course  of a
few  minutes after  application,  a  sense of heat,
which increases to a smarting aid burning  pain
of almost intolerable intensity.  After a while this
subsides, and is succeeded by a feeling of weight
and fulness, with active throbbing  of  the arteries.
In the course of twenty or thirty minutes the burn-
ing pain again returns, and unless  the patient  be
insensible from  some  cerebral affection,  he can
never bear the application  of a  sinapism beyond
three quarters of an hour.   The  effects  on  the
skin are remarkable.  Applied for  a few minutes,
a sinapism docs not produce a redness  in propor-
tion to the pain ;  but a short time after its removal
the part becomes of  a scarlet colour.   When left
on for ten minutes and upwards, the skin becomes
of a deep crimson or purple colour, which remains
long after all sensation has ceased.   Vesication is
sometimes irregularly produced after  forty or fifty
minutes' application, but it is imperfect, and greatly
disproportioned to  the  degree of inflammation.
The intensity of the inflammation  is  such that
there is  considerable risk of gangrene supervening,
if the sinapism remain applied for  more than  an
hour.  As long as sensation is  preserved, the ex-
cessive pain would be  a security against its being
too long applied ; but in cases of  stupor and in-
sensibility it should not, therefore, be permitted to
remain  beyond  an hour.  The pain excited  by
sinapisms may be allayed by cold applications, or,
according to MM. Trousseau and Blanc, by cata-
plasms  of hyoscyamus, belladonna,  and  stramo-
nium leaves, or by ointments containing extracts
of these plants.   Sinapisms are classed here be-
cause their rubefacient is their most  salutary pro-
perty ;   vesication and  gangrene being their occa-
sional or accidental rather than their desired effects.
In the  inflammation of organs which sometimes
comes on in the progress of fever,  in  nervous and
spasmodic disorders, and  in  inflammations  dan-
gerous rather from their seat than  from their ex-
tent, they are remedies of the greatest value.
   Vesicants.—The next degree  of  counter-irri-
tation which we shall notice is that in which the
excited  capillaries throw out a serous  fluid, which
detaches the cuticle from the cutis, and raises it
in blisters.  The  more powerful of those  agents
which  we have  noticed  as rubefacients, if kept
applied  for a  sufficient  length  of time, produce
this  effect; but  their vesicant is  not always  in
proportion  to  their  rubefacient  property;  and
others which are more certainly and exactly vesi-
cants, are more generally preferred.   Several ve-
getable  juices produce  an eruption  of small  blis-
ters ; as that of some kinds of ranunculus, cle-
matis, &c.  But  the Spanish  blistering-fly, the
cantharis. or  meloe vesicaforia, is   the remedy
which best answers as a vesicant, and is the one
almost  solely employed.   The  active property,
according to the researches of Robiquet, appears
to reside in a peculiar principle  soluble in aether
and in  oil, to which is  applied the name of can-
tharidiu. The  form,  therefore, in   which  it  is
most successfully applied is in a compound of the
powdered flies with hog's lard, or some such ole-
aginous substance, and a due  proportion of wax
or resin to give it the consistence  of  soft  plaster.
This spread on  leather, or any other convenient
substance, and applied to the skin, soon produces
a sense of heat and pricking in  the  part, attend-
ed, if the application  is  large,  with some excite-
ment of the  circulation  and quickness of the
pulse.  If it be removed in  two  or  three hours,
its effect is  merely rubefacient, and no blistering
is produced; but if it be allowed to remain  for a
space varying in different individuals from five  to
ten hours, the skin will  be found raised  in  large
blisters filled with a yellowish  serum, which con-
tinue to rise after  the blister has  been removed,
In some cases they do not appear until after it
has  been dressed; and it is,  therefore,  unneces-
sary to keep the plaster on until  they are formed,
or till,  as it  is  commonly expressed,  the blister
rises.   When the  blisters are fully risen, they are
snipped with a pair of scissors, which  allows the
serum to escape ;  and if it be intended  that the
part should  heal, it  is  dressed with  simple  oint-
ment spread on  a linen rag.  The  serosity con-
tinues to escape, and  sometimes to raise fresh blis-
ters, for some hours after; these  must be treated
as before,  and  the  dressing  renewed twice  in
twenty-four hours.
   The  discharge  of  serum produced  by blisters
renders them evacuants as  well as  counter-irri-
tants ;  and  this property must be taken into ac-
count in judging of their remedial powers.  Until
the  vesication is  complete,  they have all those
general stimulating effects which we  have noticed
as belonging to counter-irritants in general.  But
the serous effusion greatly modifies this, insomuch
that after a blister  is dressed, it is common to find
the pulse weaker than before its  application. The
first  excitement of a blister  often communicates
itself to the mental faculties ;  its discharge  com-
monly causes a general depression, with a dispo-
sition to sleep.  These different  effects are much
more marked in  some individuals than  in others,
and are necessarily modified by  the existing dis-
ease.   But cantharides have properties of a pecu-
liar kind, which not  unfrequently exert an influ-
ence on the general operation of blisters.  When
their active principle  is absorbed into the system,
it proves very irritating, and in a peculiar manner
affects the urinary organs, causing strangury and
even  bloody  urine.   To obviate this, it is com-
monly recommended  to persons during the opera-
tion  of a blister  to  drink copiously  of diluent
mucilaginous  liquids  ; but we cannot refrain from
expressing our conviction that  this  practice de-
feats much of the  good  effect  of  the  blister.  In
many inflammations,  particularly in  those of the
thoracic cavity, a chief object  of blisters is to re-
strain the effusion of serum  internally, or to pro-
mote its absorption ;  and this they do by extract-
ing serum from the mass of blood in the adjoining
vessels.  But  if liquids are thrown in such quan-
tities into the  stomach, they  are  rapidly absorbed
into  the circulating   fluids, counterbalance the
effect of blisters as local  evacuants,  and reduce
them to simple counter-irritants.   In  such inflam-
mations we are convinced by experience of the
advantages of abstinence from any bulk of liquid,
and  would, therefore,  look  for  other means   to
avoid the irritating effects of  absorption from a
blister.   This may pretty  effectually be  obtained
by interposing between the skin and the blistering
plaster a piece of thin gauze or muslin, moistened 
COUNTER-IRRITATION.
529
with oil, which being a menstruum of the blister-
ing principle, transfers its effects to the skin, whilst
the gauze or muslin prevents the particles  of fly
from adhering to the skin, after the separation of
the cuticle has rendered  it an actively absorbing
surface.   By taking  care, also, not to allow the
blister to remain  on longer than is necessary, we
may  generally  avoid  these  unpleasant  conse-
quences :  six hours  is generally sufficient; for
whether the  blister may have risen or not,  if the
skin at this time appear  very red and inflamed,
the vesication  will almost  uniformly take  place
after its removal.  It has been asserted  that  by
boiling  the cantharides their peculiar effect on the
kidneys is prevented, while their blistering power
is unimpaired : of this  we cannot speak from ex-
perience;
   Before  concluding our remarks on  the  reme-
dial powers  of blisters, we shall  add a few cau-
tions for their management.  The due contact of
the blister with  the  skin  is of importance;  and
this may  be  effected  either by a bandage or by a
few strips of adhesive plaster: but if too great a
pressure be exercised, it will restrain the inflam-
mation  of the capillary vessels,  and no vesication
will ensue.   It is not advisable to apply a blister
to an excoriated  surface, as tbe absorption of the
acrid matter and  its unpleasant  consequences are
very apt to ensue.  When, from peculiar idiosyn-
crasy, blisters  produce great  irritation,  local or
general, the  addition of a little powdered opium
or acetate of morphia to the plaster may give  re-
lief.  An excess of  inflammation,  which  occa-
sionally ensues after the rising of a blister,  some-
times with  erysipelatous  or  eczematous appear-
ances  around  it, is  best  relieved by poultices,
which are proper applications whenever it  is de-
sirable  to moderate  the  irritation.    When the
blistered  part shows a disposition to  gangrene,
which is not unfrequently the case with children,
it must be treated on general principles, as by sti-
mulating  or  other applications, solutions of  chlo-
ride of lime or  soda, and  bark exhibited  inter-
nally.  To avoid this consequence in children, it
is advisable  never to allow the blister to remain
on more than six hours; and a poultice should be
substituted if the inflammation be at all high.
   Simple blisters,  or, as  the French term  them,
vesicatoires volans,  (in contradistinction to those
which are kept  discharging  by an after applica-
tion,) are remedies  much  and deservedly esteemed
in the cure of inflammations.  As rubefacients, or
simple counter-irritants, they yield  to  sinapisms
and other remedies  which we shall presently no-
tice;  but their effect  as  local depletories  gives
them a superiority over  most other  counter-irri-
tants.   In common with  the  other remedies  of
this class, they are  unfit for the first stages of ex-
tensive  acute inflammation ; but when the general
excitement of the circulation, and the intensity
of the  orgasm,  have been so lowered by blood-
letting and other means,  that the temporary irri-
tation of the  blister may be  borne without risk, its
action becomes highly salutary ;  in  the  first in-
stance drawing off the irritability from the diseased
part,  and then removing or exhausting it  by an
effusion of serum. This effusion proves the means
of so deriving  to the blistered part, that the mor-
bid exhalations in other oarts are re-absorbed and
   Vol. I__6?                        2c
drained off;  and hence blisters,  more than rube-
facients, are.  adapted to inflammations of serous
membranes.   Besides the caution required not to
apply blisters at too  early a stage, it is generally
necessary to  beware of placing them too near the
seat of inflammation ;  for their contiguity  may
greatly aggravate it,  causing two inflammations,
as it were, to run into one.  This must be left to
the discretion of the practitioner ; but it may be
suggested that in inflammations of the pleura,—
in those superficially affecting the pulmonary sub-
stance, as indicated  by auscultation,—in those
attacking the  membranes of the  brain  or the
larynx, it is better to place the blister on some
part adjoining rather than immediately over the
affected  part; and  to make up  by extent of the
surface blistered, for any diminution of effect from
distance.  In fact, in  all acute inflammations large
blisters are to be preferred to small ones ; for the
•irritation from the  latter is nearly  as great, with-
out the same good  effects.  In chronic inflamma-
tions the case may  be somewhat different,  as it is
usually necessary to apply a succession of blisters ;
and the weakening effects of a  large discharging
surface might make small ones preferable.  Of
chronic inflammations, those affecting the serous
and mucous membranes receive the most  benefit
from blisters.  In pleuritic and peritoneal inflam-
mations accompanied by effusions, their evacuant
effects are likewise of  decided  utility ; and with
this view they should  be of large size.  But in
inflammation of the  parenchyma of the viscera,
and in that  of membranes without much  liquid
effusion, the more powerful counter-irritants are
of greater efficacy.
   We  have already noticed that rubefacients are
sometimes valuable in continued fever, on account
of the stimulus  which they convey to the vital
powers; and we may extend this  observation to
blisters, which, judiciously administered, are often
doubly useful,  both  by  the general  excitement
whicb  they  afford, and  by their  local counter-
irritation  and evacuation relieving the several in-
ternal organs, which almost constantly suffer in
these fevers.   But, equally as in  the case of acute
inflammations,  during  the stage of synocha 01
morbid excitement  they must be excluded as inju-
rious. It requires much nice discernment to decide
on  the time  at which blisters may with advantage
be  used.   Dr. Rush  considered  that there  is  a
period in all fevers  at which they would  prove
salutary ; but we shall not  attempt  here specifi-
cally to define  it.   (See  Feyeti.)   By counter-
irritants or  revulsives  of the  most  prompt and
powerful kind, as boiling water, some signal cures
have been effected in the worst forms of fever;
the patient having  been by them at once awaken-
ed  to  consciousness  from coma or extreme col-
lapse.   M. Marjolin  cites his own  case as  hi:
example of  this treatment; and Dr. Macintosh
records one which  occurred in his  practice eight
or ten years ago : and we  have heard of other
instances of  its  success.   As there is a great risk
in the subsequent effects of the local injury, which
generally tends to gangrene, this practice can onlv
be resorted to in extreme  cases.
   What has been said of rubefacients in spasmo-
dic and  convulsive disorders may  be equally ap-
plied to blisters, which are in fact the form eene»- 
530
COUNTER-IRRITATION.
ally resorted to, although full blistering is probably
inferior to sinapisms repeatedly applied for a short
time.   There is likewise a state of general irrita-
bility  of the system, accompanied  with various
and  occasionally  fugacious  pains,  but without
hardness or fulness of  the  pulse,  that is often
greatly  relieved by  the  application of  a blister,
which seems to localise the irritation,  and  thus
relieve the  system.
   An exception is commonly taken to the use of
blisters in the case of inflammation of the kidneys
and other parts of the urinary apparatus,  on ac-
count of the irritating effect of cantharides towards
those organs through absorption; and  although
this  may generally be prevented by attending to
the precautions which we have before enumerated,
it is acting safely to prefer  some other counter-
irritant. This leads us to say a few  words on
other vesicating remedies.
   All  those irritant  agents which act in the  most
prompt and energetic manner, without destroying
the cuticle, raise it at first into blisters filled  with
a serous fluid.  Thus, boiling water, or its vapour,
the concentrated alkalies, or metal  heated in water,
as recommended by Sir Anthony Carlisle, produce
this effect.  Intense heat, the strong acids  and
some metallic salts corrugating and destroying the
cuticle, act more immediately as escharotics.   But
this mode  of blistering  is  very unmanageable, as
the inflammation  accompanying it is of a  diffuse
and uncertain character, and often leads to severe
sloughing.  There is  a method of applying the
vapour of  boiling water in a jet, by means of an
eolipile, or vessel with a narrow orifice, which
might  be  so  regulated  as to  produce vesication
without proceeding deeper; and  the liquor am-
moniae triturated  with  an equal weight of  hogs'
lard may be applied, so as to produce full blister-
ing in fifteen or twenty minutes; but unless  great
speed is desirable, these agents,  even thus modi-
fied, are not eligible as  mere vesicants.
   Pustular or Empyematons Counter-ir-
ritants.—We have hitherto referred to those de-
grees of artificial external inflammation which ter-
minate in resolution or serous effusion.  There is,
however, an important  class  of counter-irritants,
affecting the cutaneous texture more deeply, and
determining the secretion of pus.  A blistered sur-
face sometimes spontaneously takes on this degree
of inflammation ;  and the same effect is frequently
brought on by particular  applications to  it; but
 is these methods of counter-irritation  are  of a
 mixed  kind, we shall  presently return to  them
 under the  head of issues and setons, and here no-
tice particularly those applications which bring on
suppurative inflammation of the  skin in the form
 ff pustules.  The sulphuric and nitric acids, their
escharotic  power  being blunted  by dilution with
oil or  lard, produce an inflammation, which soon
assumes the form of pustules, small and distinct,
or large and confluent, according to the proportion
and strength of the acid used.  But the  substance
most eminently calculated to  excite the pustular
inflammation is tartarized  antimony. We owe the
introduction of this medicine  as a counter-irritant
 to the late Dr. Jenner, who  employed  it in the
 form of ointment, in the proportion of one  part of
 the  salt to five of spermaceti ointment.  It has
 ►.ince  been extensively employed  in practice, and
is almost as generally used  as  a pustular irritant,
as cantharides are to produce vesication.   In our
own hands we  have found  it so manageable as
well as effectual a counter-irritant,  that we consi-
der it  a remedy  of equal  importance,  with the
blistering fly itself;  but, as  much  of its efficacv
depends on the method of its  application,  before
describing  its advantages  we shall  premise some
precautions on this point.
  Tartar  emetic  exerts no  corrosive or  solvent
power on the cuticle ;  it therefore sometimes hap-
pens that considerable difficulty is experienced in
making the cutis feel its effects, and  this obstacle
is of course greater  where the  cuticle is naturally
dense or thick.  To obviate this we recommend
the part to be previously excited, either by friction
with warm flannel  or a flesh-brush, or by some
stimulating application of a penetrating quality,
such as camphorated spirit  or strong vinegar, or
a  mustard  poultice applied for a  few minutes.
When the vascularity  and sensibility of the skin
have been  thus exalted, the tartar emetic ointment
is to be rubbed  in, and  it will then take a more
equal as well as more  certain effect: instead  of
having a few large and unmanageable sores pro-
duced in two or three days, as  is often the case in
the usual  method, a vivid erythema immediately
succeeds, which in the  course of a few hours
breaks out into a  thick crop of pustules,  the size
and course of which vary according to the strength
of the ointment and tbe duration of its applica-
tion.   On  these points it is not easy to lay down
any absolute rule;  for, as  in the  operation  of
blisters, much depends on the individual constitu-
tion.   We generally prefer an ointment of con-
siderable  strength,  for instance, made with one
part of tartar emetic and  two of simple ointment.
If the fullest effect be desired, the friction, both
preparatory and with the  ointment, should each
be  persisted  in for fifteen or twenty minutes.
This generally leads to the speedy formation  of
confluent  pustules,  which  go on  to maturation.
To diminish this  effect it is best to shorten the
period of friction with  the ointment; and where
we wish for the slightest degree of counter-irrita-
tion, it  is  generally sufficient  to smear the oint-
ment on  the part previously excited by  dry fric-
tion, or by some of the other  applications before
enumerated.
   Another mode of counter-irritation  by tartar
emetic is, the employment of a saturated aqueous
solution :  the  elegance  and convenience of this
form render it  peculiarly eligible where the oint-
ment might be considered  disgusting.   It is ex-
pedient to  make the solution as warm as the skin
can bear it, as the heat both enables the  water to
dissolve more of the salt, and  quickens the effect
on the skin.  The part being previously excited
as  for the  ointment, the solution  is to be gently
rubbed  on  it by means of a piece of flannel, and
continued  for a longer or shorter time, according
to the degree of effect desired.  The pustules thus
excited are usually small and  numerous, and un-
less the application  have been  continued  for some
time or repeated,  they dry up  and  heal speedily.
As this  application leaves no marks or seams, it
is particularly suited  to  females, who  generally
renounce  all medicaments  which  may  leave  a
trace behind. Plasters sprinkled with tartar eme- 
COUNTER-IRRITATION.
531
tic in powder have  been greatly recommended ;
but we have found their operation very uncertain ;
in some cases inefficient, and  in others causing a
frightfully ulcerated  surface, which the removal
of the plaster necessarily exposes.  After the ap-
plication of the tartar emetic, whether in ointment
or in solution, the part should be covered with a
piece  of rough flannel, which, if  it be  desired,
may be made still further to promote the effect by
a little ointment smeared on  it.  By this system
of management tartar  emetic may be made  to
produce  any degree  of counter-irritation, from a
papular or erythematous  blush to an extensively
suppurating sore.
   Pustular or suppurating inflammation thus ex-
cited  is generally more permanent and profound
in its  counter-irritant influence  than vesication.
The formation of pus requires a greater develop-
ment of vital action, a higher degree of local irri-
tation than serous effusion, without proving more
stimulant to the system.   For  this  reason  we
consider the tartar emetic counter-irritant better
adapted  than blisters  to remove deep-seated  pa-
renchymatous  inflammation,  even  of  the  acute
kind; and  although it  must  not  supersede  the
free previous use of depletory measures, yet it
may be employed with less hesitation than blisters,
inasmuch as the absorption of the medicine into
the system  proves antiphlogistic instead of irri-
tating.   That such an absorption does take place
is probable from the nausea which  sometimes  at-
tends  the use of the medicine;  and we have
known in a few instances violent vomiting ensue.
   In the method which  we have  recommended
 for its  application,  counter-irritation  with  tartar
 emetic  may be brought to  its greatest effect of
 copious suppuration in from ten  to twenty hours,
 and a full pustular eruption  may be brought out
 in five.  This rapidity of effect places it on a par
 with blisters ; and the greater intensity of its  in-
 flammation  renders it a better counter-irritant.  It
 is perhaps inferior to them in pleurisy, meningitis,
 and those inflammations in which the principal
 danger arises from  serous effusion.  In gastritis,
 likewise, its tendency to excite  vomiting  may
 render it objectionable.  In most other acute  in-
 flammations, if its proper application be attended
 to, we prefer  it  to blisters, and in none has it
 proved more beneficial than in those of the lungs
 and air-passages.
   In chronic inflammation  the  efficacy of tartar
 emetic counter-irritation is more generally acknow-
 ledged.  We have  found it far more beneficial
 than either  blisters or setons in chronic bronchitis
 and pertussis; and if we can venture no further,
we may unhesitatingly assert that we have seen it
retard  the  progress  of tubercular consumption.
An eruption excited and  renewed on the chest,
sometimes on  one side, sometimes on the other,
seems in these cases to act as a safety-valve to  the
system, letting off" any incipient  disposition to in-
flammation  ; and thus, without  much impairing
the strength, enables the body to bear tonics, and
a more generous  diet than it would otherwise sup-
port.   It has been  found of signal utility in dis-
eases of the joints and of the bones, and is  pre-
ferred by some surgeons to moxa.
   Numerous cases of epilepsy, chorea, and other
convulsive diseases, also cases of mania, paralysis,
and neuralgia, have been recorded, in which tartar
emetic counter-irritation on the nape of the neck,
along the spine, or the course of a nerve, has pro-
duced  relief, and even a cure.   But  as  in  these
disorders the scientific physician must see patho-
logical causes  of very various nature, it would be
irrational to assert that the remedy in question is
universally applicable to them.  As often as they
arise from, or are aggravated by, some local inflam-
mation, irritation, or congestion, we can at  once
perceive its utility ; but we can never be reason-
ably confident in our expectations of success when
we remember  how often there are  immediate or-
ganic causes for these diseases.  In these and other
complaints,  nature not unfrequently throws out a
hint in the  form of a  spontaneous eruption; and
the physician  may witb great  advantage  be in-
structed by  it, and second her efforts by means of
this remedy.   From  the facility with which this
counter-irritation may be excited and kept up for
any length of time by a slight  fresh application,
it is well adapted to remove or prevent inflamma-
tions  of the eyes, ears, and fauces, which some-
times engraft themselves on the habit, and are very
difficult to remove.
   A remarkable effect has been observed to  ensue
in a few cases from  the  use of tartar emetic oint-
ment ;  namely, an irritation,  sometimes very se-
vere,  of the genital organs.  We have never seen
this except  in cases where the ointment had  been
used for several days in succession, which is rarely
necessary according to the method which we have
recommended for its use.
   When the inflammation excited by tartar eme-
tic runs too high, it may, as in the case of blisters,
be moderated  by  a warm bread poultice, which
does  not interfere with  the progress of the pus-
tules.
   Perpetual  blisters, issues, and  setons. — We
have  delayed  to notice these counter-irritants, be-
cause they are of a mixed nature, and occasionally
partake of the qualities of all those which we have
already described.  The inflammation which they
excite is of very various degrees of intensity, and
the discharge  which they occasion  is sometimes
purulent and sometimes serous.
   Blisters  are kept open by removing the raised
cuticle by scissors, and by applying, instead  of the
ordinary dressing,  an ointment or  cerate  of an
irritating quality.  A small portion of cantharides
is sometimes  used for this  purpose, but the bad
effects of its absorption, which frequently ensues,
raise  a great objection to it.  A cerate containing
euphorbium and the unguentum resinosum has
likewise been employed  with the same view. But
the ceratum sabinae is that most commonly resort-
ed to; and, if duly managed, it is capable of main
taining a more equal degree of  irritation and dis>
charge than any other.  It is, however, necessary
to attend to the strength  of  the cerate applied,
and if discharge be the principal object, it  ought
to be applied in a diluted form.   Blisters kept open
in this way, without profoundly affecting the skin,
sometimes  yield a copious secretion of pus, and
then  prove most salutary.  With a  continuance
of the  same application, howe-er, this very com-
monly becomes thinner and again serous;  and ii.
time  the part is  habituated to  the irritation, dries
up, and heals. To prevent this, it is  necessary to 
532                         COUNTER-IRRITATION.
remove tbe films of coagulable lymph which form
upon it; to keep  down  vegetations by touching
them with nitrate of silver or burnt alum; and
occasionally to cleanse the surface by an emollient
poultice, or by warm fomentations with flannel.
By changing the stimulating ointment, the irrita-
tion and discharge may be preserved much  longer
than when one only  is employed.  On the  whole,
however, this method of counter-irritation is trou-
blesome and uncertain, and  may well be  super-
seded by  a succession of blisters,  or  by tartar
emetic.
   By issues and setons irritation is applied more
profoundly, being  brought immediately  into  the
subcutaneous tissue  itself.  The former are made
by  producing  an opening in the  skin, either by
incision, by a  blister, or  the  application of some
escharotic substance, such as potassa fusa,  nitrate
of  silver,  muriate  of antimony, &c,  and intro-
ducing  some foreign body,  as  a pea or a glass
bead, into  it, which  keeps up the  irritation, and
forms a constant  ulcer.   In  producing the ulcer
by  means of caustics, it is necessary to limit  the
operation, and defend the adjacent parts by  a piece
of adhesive plaster, with  an  aperture in it of  the
required size of the  ulcer.  A bit of  potassa fusa
placed in this  aperture in the  course of four or
five hours forms an eschar, surrounded by an areola
of inflammation.   This eschar being dressed with
citrine,  or  other stimulating  ointment, begins to
detach itself and to secrete  pus in the course of
four or  five days,  and  after tbat falls off, leaving
an  ulcer more or less profound.
   Setons are made  by  passing a  lancet-bladed
needle, with a fasciculus of thread or silk attached
to it, through a portion of the integuments (pinch-
ed  up between the finger and thumb), so that  the
threads are left in, with the ends hanging  out at
each orifice.  To increase the irritation, the thread
is anointed daily with the unguentum resinosum,
and shifted or renewed to keep  the wounds open
or discharging.  The necessity  for the renewal is
superseded by substituting a long strip of caout-
chouc or of lead for  the threads.  The inflamma-
tion at first excited by setons is  sometimes  so
intense as to require the application of poultices
to moderate it; and  their dressing and  manage-
ment require  many  precautions which  it is  the
province of surgery  to teach.
   Issues and  setons, when in full operation,  ex-
cite a phlegmonous inflammation, attended by a
discharge of an  abundant  thick  pus.  This is
most frequently the case with  setons, and with
issues formed  by  caustics; and these are, there-
fore, the most powerful  and  profoundly acting of
their kind.  But like perpetual blisters, they  are
apt, with the  same  material   of irritation,  to  be-
come indolent and  callous, and the secretion serous
and less abundant.  When energetic, these reme-
dies are of great utility in chronic  inflammations
of various kinds.  If any distinction can be made
as  to the  kinds in which  they  are most service-
able, it may be suggested that the circumscribed
textural inflammation of  viscera  are peculiarly
benefited by their use.  When in a more moderate
form, and secreting serum,  they  act  rather  as
evacuants, and have been, not unaptly, compared
to  a new secreting  gland  in the system.   They
ihus occasionally  prove  safeguards against apo-
plexy, palsy, and other  diseases of  repletion;
although implicit reliance ought not to be placed
on  such means.   For the same reason they are
proper  adjuncts  in the  cure of long-continued
cutaneous disorders, preventing any ill effects from
the suppression of the natural counter-irritation.
So, likewise, in  all cases where  setons or issues
themselves have been for some  time  used,  it is
proper to be cautious  in suppressing them, by
doing it as gradually  as possible, and carefully
ensuring the free action  of the bowels  and other
secretory organs.  As a  means of restraining the
growth or  diminishing the size  of tumours and
bronchoceles, setons have been found of some use;
and the drains  which they afford have likewise
checked the increase of dropsical effusions.
   [There are other agents, which,  according  to
their  mode of application, are  capable of inducing
more than  one of the effects already mentioned.
When croton oil, for example, is  rubbed in small
quantity, and for a short time, on the  surface, it
induces inflammation  of the  skin, which  gradu-
ally disappears  of  itself.  When the friction  is
longer  continued,  pustules  are   caused,  which,
when they are numerous, run  together or are con-
fluent; and, around the  spot where the confluent
eruption is seated, papulae appear over a wider
extent, which are transformed into pustules, and
are surrounded  by a red base or areola.  Com-
monly, the eruption is perceptible in twelve hours
after  the first friction; but at times not until a
later  period.   In the course of from three to six
days, the eruption again disappears.   The erup-
tion is never so painful  as that  induced  by the
ointment of tartrate of antimony  and potassa.
   Frictions  with croton oil  are  adapted  for all
cases in which local counter-irritation is required.
It is important, however, to bear in mind, that the
oil may be  absorbed, and  act on the bowels, and
may not, therefore, be  adapted for intestinal dis-
orders, in which counter-irritation is indicated. If
the skin be thick, and insensible, it  may be well
to rub it previously with flannel, or to  apply first
a  rubefacient, especially when it is desirable to
produce the  effect speedily.   On the other hand,
when the skin is excitable, the croton  oil  should
be mixed with  from one to four or five parts or
more of olive oil, oil of turpentine, or soap  lini-
ment.   (See the writer's General  Therap. and
Mat. Med. ii. 265: Philad. 1843.)
   The essential oil of  mustard is  occasionally
used  wherever a  counter-irritant is needed.   It is
used  either in  the form  of friction,  or where a
more powerful  effect is needed, by dipping strips
of linen, of the proper size, in the oil, and suffer-
ing them to dry  on the part.   Burning pain im-
mediately succeeds, and  is often so insupportable,
that the patient  objects  to wait until the linen is
dry.  (New Remedies, 4th edit.  p. 463 : Philad.
1843.)
   Ammonia has been employed to  excite rube-
faction and vesication.   The pommade ammonia
cale of Gondret  has  long been  used in chronic
affections of the brain, incipient cataract, amauro-
sis, &c, being  applied  to the top  of the head.
(Gondret, Considerations sur rEmploi du  Feu
en Medecine, &c.: Paris, 1819 ; and Traite Theo-
rique et Pratique de  la Derivation, &c: Paris,
1839.)  The formula? for summer and  for  winter, 
COUNTER-I
RRITATION.
533
recommended  by  M.  Trousseau,  (Journ.  des
Connais,  Med. Chir. cited  in  Medico-Chirurg.
Rev.: July,  1840) are as follows: for summer,
three parts of lard, one of suet, and four of liquor
ammonix,- for winter, equal parts of lard and
liquor ammonix. More recently, a stronger and a
weaker ammoniated lotion have been extolled ex-
travagantly as counter-irritants  by  Dr.  Granville.
(Counter-Irritation, &c,  Lond. 1838, or Amer.
Med. Library edit.: Philad.  1838.)   The milder
of these is made  as follows  : Liq. ammon. fort.
f.51.: Spirit  rosmarin. f.gvi.;  Tinct.  camphor.
f.^ii.M.;  the stronger as  follows: Liq. ammon.
fort, f.gx.; Sp. rosmarin. f.^ss.; Tinct. camph.
f.jii.    M. Raspail (VExperience, 24 Juillet,
 1840) has recommended the  following lotion, the
effects of  which, he says, are often  instantaneous
in  relieving  intolerable headach :  Liq. ammon.
p. 100 ;  Aqux destillat. p. 900 ;  Sodii chlorid.pu-
rif. p. 20 ; Camphor, p. 2; Essent. ros. q. s.  The
whole to be mixed cold.   A piece  of linen is to
be steeped in this solution, and applied over the
 part of  the head which  is the  seat of  pain, care
 being taken that none of the  fluid passes into tbe
 eyes.
   The stronger of Granville's lotions gives  rise,
 in  a few  minutes, to  vesication over the whole
 surface to which  it is applied, almost as rapidly,
 indeed, as if  boiling water were placed upon tbe
 part.  The strength  can be regulated  so as to
 produce either full vesication or simple rubefac-
 tion, by varying the quantity of the liquor ammo-
 niae.  As a  general rule, tbe application should
 be seldom continued longer than  from one to six or
 eight minutes.  But, in order to excite the higher
 degrees of counter-irritation, as vesication  and
 cauterization, as much as ten or twelve minutes
 may be necessary.
   The  mode of applying these liquid counter-
 irritants is first to impregnate with them a piece
 of  cotton  or linen, folded six  or  seven times; or a
 piece of  thick or  coarse flannel;  and then lay
 either of these on  the spot, pressing with the hand,
 at the same time, very steadily and firmly on the
 compress, over which there  should be placed a
 thick towel  doubled  several times, so that  not
 only the  evaporation  of the lotion may be  im-
 peded, but the hand  employed in pressing the
 compress  on  the part, may not  suffer from direct
 or  indirect contact with the liquid.  Care must
 be  taken  that  the  ammonia  does  not  reach the
 eyes or nose.  (Granville, op. cit. Amer edit. p. 39.)
   There  can be  no doubt that the ammoniated
 counter-irritants are valuable agents in all  dis-
 eases that are benefited by  a  sudden and powerful
 revulsion, and especially in different forms of neu-
 ralgia.   One great objection  to  them is, that they
 are apt to induce sloughing  and sores  difficult to
 heal.  Care  may prevent these ; but at times they
 occur in spite of every precaution.   (New Reme-
 dies,^.  197.)]
   Cauterizing Counter-irritants. — By this
 term we designate  all those  operations in which
 heat, in such degree  as  to cause disorganization
 of  the part, is applied as a counter-irritant.   The
 common  effect of all these is the formation of an
 eschar, or dead slough, surrounded by a more or
 less intense inflammation,  which causes the sepa-
 ration of  the dead part and the production of an
                                      2u*
ulcerous cavity in its place.  The local inflamma
tion, thus excited, may be very intense,  and the
suppurative discharge very perfect;  and this kind
of counter-irritation is proportionately energetic in
its effects on the disease, in the same manner as
others.  But there  seems  to  be another peculiar
result from the application  of  vehement  heat:
namely,  a strong  impression, or shock, on the
nervous system, whicb  in certain diseases is not
without its salutary influence.
   Heat, with  a  view to cauterization, is applied
by heated metallic instruments, burning  substan-
ces, boiling water or its vapour.   Instruments of
iron or copper, heated to  different degrees  of in-
candescence, are sometimes used  to produce local
irritation  and sores.  This operation,  which  is
called the  actual  cautery, produces, more than
any other method, that  shock to the nervous  sys-
tem to which we have just alluded.   It has been
found useful  in checking violent convulsive dis-
eases, such as  epilepsy, hysteria, and local spasms.
It  is difficult to judge whether its efficacy depends
on the pain, or on some other change wrought in
the nervous system ; the  effect is certainly some
times produced  before such a degree of local in
flammation has been excited as could  act by vas-
cular counter-irritation.
   A  red-hot  iron  is  sometimes  used  to form
issues ;  and for this purpose it  is applied with
considerable pressure to the part for eight  or ten
seconds, and repeated if it is wished to make the
ulcer deep.  A portion  of skin and  of the cellular
texture  underneath is thus killed,  and forms  an
eschar, which  in the course  of six or eight days
is  sloughed off,  and the  ulcer produced may be
treated as an issue.  The painful and formidable
nature of this operation excludes it from general
adoption; and, with  the  exception of  the cases
just alluded to, we  do not know that it can claim
any superiority over that  with caustic, which  is
attended with  little pain.  The good effects of the
actual cautery are, perhaps,  obtained  with least
attendant inconvenience when the metal is heated
to a  white heat.  Thus  applied, it immediately
destroys  the vitality and  sensibility of the part;
and if the surrounding skin is protected by cover-
ings  of  wetted paper or other  suitable  substance,
in the way which has been recommended by Dr.
A. T. Thomson, the suffering of  the patient  is
much diminished,  and the  advantages of  the
remedy  are with more  certainty procured.   The
actual cautery is more  frequently resorted to in
surgery  for tbe  destruction of malignant produc-
tions and morbific poisons.
   There is a metbod of  cauterization, called by
surgeons transcurrent, which partakes more than
the preceding of the nature of a counter-irritant.
It consists in lightly passing an iron, heated to a
cherry red, on the  surface of the skin in parallel
lines, at such  a  distance from each  other that an
intervening space may be left free from inflamma
tion.  In this  way long narrow eschars are form-
ed, which in  the course of eight or ten days are
enlarged ; whilst the whole surface becomes high-
ly inflamed, and is not relieved from the painful
and  phlogosed state  of a common burn until a
copious suppuration ensues, which  often lasts fo:
a  fortnight or more.   The fever  and irritatior
which this process occasions forbid its  employ 
534
COUNTER-IRRITATION.
ment in any but very chronic and indolent cases.
It has proved very successful in removing chronic
enlargements of the joints,  and the remains  of
rheumatic affections.
  Cauterization by  substances  in  the  state  of
combustion has of late years been  practised to a
considerable extent  in the form  of what  is termed
moxa.   This method is said to have been adopted
from Japan, where  moxas  are  made  of a down
obtained from the leaves  and tops of a species of
artemisia, made into a cone, which when lighted
burns spontaneously.  The pith of the  stalk of
the sun-flower and of other  helianthi  likewise
possess  this property, which is owing to a small
quantity of nitre in their composition.  The ma-
terial generally employed in Europe for moxas is
cotton, rendered downy by carding, and made into
a roll an inch long, and from half an inch to two
inches in diameter.   This is held by a forceps or
wire, with one  end  in close contact  with the skin,
whilst the other is set on fire;  the adjoining parts
being protected by wet pasteboard or linen.   The
combustion is supported  either  by blowing or fan-
ning, or by a slight impregnation of nitre  pre-
viously given to the cotton.  The  sensation  pro-
 duced  by the  burning of a moxa is  first that of
 warmth, rather agreeable  than otherwise;  this
 soon increases, as the fire approaches the surface,
becomes itching, then more and more painful, and
 attains  Its acme  of intensely  sharp scalding pain
when  the  combustion reaches the  skin, which
 smokes and becomes crisp under it.  The neigh-
 bouring skin  is  vividly inflamed,  puckered, and
 sometimes  slightly blistered.   The  eschar  thus
 formed  is  deep,  and  requires a fortnight  or
 upwards before it is separated.  The ulcer formed
 discharges  pus abundantly, and by the aid  of a
 pea may be converted into an  issue.
   The gradual manner in  which heat is commu-
 nicated to  the part in the burning of a moxa
 causes it to penetrate  more deeply  than any other
 form of actual cautery.  Hence  as a remedial
 agent it is well adapted to  make an impression on
 deep-seated  inflammation;  and in  diseases of the
 spine and  its contents, in scrofulous and rheuma-
 tic swellings of the joints, in  chronic diseases of
 the liver,  kidneys, and  other  internal  organs, in
 paralysis and neuralgia,  it  sometimes proves more
 effectual  than any other  remedy.  It  is often
 necessary, however, to employ several  moxas in
 succession ;  and if the disease be of  some extent,
 several simultaneously, before the  good effects
 become apparent.   Moxas may be applied  with j more apt to involve the surrounding parts.
bility of the diseased  tissues which  cannot be
included in their counter-irritation.
  [Various  forms of moxa have been proposed.
Mr.  Leney  (London Medical Gazette, July 15,
1842) soaks a piece of lint in a strong solution
of nitrate of potassa, dries it, and cuts off pieces
of the size  of the thumb-nail, which  he fastens,
with thin adhesive plaster, over the seat of pain ;
sets fire to the opposite extremity, and then applies
the blow-pipe.   The pain during the  process is
very severe; but the Irish, he  affirms, prefer it
greatly to the application of a blister.  Professor
Griife (La  Lancette Francaise, Jan.  26, 1839)
employs moxas made of wafers, dipped in a  mix-
ture of three parts  of  oil of  turpentine and one
part  of  sulphuric  ether.  Before  applying  this
inflammable matter to the skin, it is  necessary to
remove carefully the superfluous liquid.  These
moxas are  said  to ignite readily, burn promptly
and uniformly, and do not crepitate.
   Of late, a plan for exciting vesication on the
surface has  been  adopted, which must be regarded
as a kind of moxa.   It produces rapid vesication,
but  is  said to  be complicated, and attended  with
intense pain, (Granville, op. cit. Amer. edit. p. 21
and p. 42.)  A piece of  linen or paper, cut of the
requisite  size, is immersed in spirits of wine, or
brandy. It  is then laid on the part to be blistered;
care  being taken that the moisture from the paper
or  linen  does not  wet the surrounding surface.
The flame  of a lighted  taper is applied quickly
over the surface, so as to produce a general  igni-
tion, which is exceedingly rapid.  At the conclu-
sion of this operation, the cuticle is found detached
from the true skin beneath.  In cases of convul-
 sions, the region of the spine has been treated in
 this  manner, and with good effect.   (C. J. Ed-
 wards, Provincial Med.  and Surg. Journ. Jan.
 1842.  See, also, the writer's  New Remedies, edit.
 cit. p. 441.)]
   A cauterizing effect may be produced by boiling
 water, or better by its vapour.  The best method
 of effecting this is by an eolipile, or  vessel with a
 narrow tubular  mouth, and kept boiling by means
 of a lamp.  The jet of  vapour issuing in full force
 from  this is directed  against the part, which is
 covered with thick pasteboard or linen, with an
 aperture of the form and size of the part intended
 to be cauterized.   The pain caused  by this opera-
 tion is  very severe, and  the slough  formed very
 deep.  It most resembles moxa in its effects; but
 the wound produced by it is  less manageable, and
greatest advantage as near as possible to the dis-
eased part;  but if their effect is  intended  to  be
deep, it would  not be proper to  apply  them on
parts where cartilage, tendon, or  bone  are close
under the surface.
  Moxas are sometimes applied  with  a view to
                       C. J. B. Williams.
  CRISIS, Critical Days.  (See Disease.)
  CROUP.—(Synonyms—Cynanche trachealis,
C. laryngea, C. stridula, Angina polyposa, Suf-
focatio  stridula,  Morbus  strangulatorius,  &c.)
counter-irritate without producing an eschar. The i We prefer croup to the other appellations, mas
moxas in this case are  made of sun-flower pith,
or of light  cotton  impregnated  with nitre.   The
combustion is effected without blowing, and  is not
Buffered to reach the skin.   Under this form, fre-
quently applied, they have been found useful in
promoting the absorption of indolent effusions in
joints  and  cold  tumours.  It  is  probable that
much of their effect in these cases depends on the
•timulus which they impart to the  organic  sensi-
much as it does not  convey an erroneous notion
of the nature of the disease whicb it designates:
that disease is not a mere cynanche, or quinsy.  It
will be shown that  inflammation, which is the
characteristic of the  order of diseases  to which
croup belongs, is  not confined to the throat, but
generally extends through the ramifications of the
bronchi; therefore, C. trachealis and C. stridula
ought  no longer to  be retained as nosological 
CROUP.
535
terms.   The terms suffocatio stridula and morbus
strangulatorius are indefinite, and  would equally
apply to the  various  affections  in which those
symptoms of croup—the inspirutio strepens, vox
rauca, and  tussis clangosa—are  engrafted  on
other diseases, and which will be treated of under
their respective titles.
  This disease was honoured with the  attention
of the greatest man of the  present age—if he can
be called great who had no just sense  of moral
grandeur.  In consequence of the  general order
which Napoleon issued from the head-quarters of
Finkenstein,* many essays on croup were written
by foreign physicians of ability, in which nothing
is omitted in illustration of that disorder which
industry could collect or method could arrange.
   Occasional Causes.—In the early part of his
professional  life, the writer of this article lived on
the coast of the Firth of Forth, where croup may
be considered an endemic disease, and where every
 facility was  afforded  for cultivating an  acquaint-
 ance with it.  During the last twenty-two years,
 while practising medicine in Dublin, his opportu-
 nities of witnessing  croup have not been unfa-
 vourable, especially when attending a dispensary.
 While  discharging that duty,  he  had frequent
 occasion to observe the disease among the ragged
 and half-starved  children  of the poor  who  live
 near the canals which surround the city ; or in
 Ringsend, near the estuary of the river Liffey ; or
 in  Sandy mount,   lying between Dublin and its
 bay: indeed the disease is prevalent, in the latter
 end of winter and  in  spring,  along the whole of
 the eastern and northern coasts of Ireland.  With
 respect to its prevalence  along the rest of the  sea-
 coast,  no inquiries were  made;  his  inquiries,
 however, sufficiently confirm the received opinion
 relative to the principal occasional cause of croup,
 viz. that in Ireland,  as in  Scotland, it  is  chiefly
 produced in the neighbourhood of large bodies of
 water, running or stagnant, fresh or salt.
   History. — The  disease  may  occur at  any
 period from the second or third month after birth
 to  puberty.   The younger  children  are when
 weaned, tbe  more liable  are they to croup.  After
 puberty  it scarcely ever occurs.   Some families,
 those especially in which  the children are  of  a
 sanguineous temperament and full habit, are much
 more liable to tbe disease  than  others.  It often
 attacks  children   who have  not fully  recovered
 from a previous illness.  It is liable to recurrence,
 at distant intervals, upon exposure, not merely to
 an atmosphere  which has been  influenced  by
 passing  over a large body of water, but to any of
 the causes which  produce common catarrh.
   Hoarseness, in very young children, does not
 usually attend common catarrh ; and hence when
  *Ce fut au quartier general de Finkenstein Ie4 Juin,
1807, que S. M. I. et R. donna l'ordre  d'ouvrir un con-
cours sur  la maladie  coniiue sous le nom de croup; et
c'est en execution  de  cet ordre que son excellence Mon-
seigneur le ministre de  1'inte.rieur mit la question sui-
vante au concours.
  Determiner, d'apres les monumens pratiques de I'art,
et d'apres des observations, les caracteres de la maladie
connue sous le nom de croup, et la nature des alterations
nui la constituent; les circonstances intcrieurcs et exte-
rieures qui en determinent le developpement; ses aftini-
tes avecd'autres maladies; en etablir,d'apres une expe-
rience  constante et comparee, le traitement le plus efh-
cace; indiquer les  moyens d'en arreter le-progres et d'en
prAvenir l'/uvasion.
observed in a  child  living in  a district  which
generates croup,  this symptom is  always much
more deserving of attention,  especially if accom-
panied  with  a rough cough,  than it would be
after puberty.  This remark  may  be  supposed
scarcely  worthy  of  the  reader's attention ;  but
having  had innumerable opportunities of ascer-
taining that inflammatory affections of the mucous
membrane of the larynx and bronchi in children
owe their complexion to the mode of treatment
adopted during the first six or eight hours  of the
attack, when no  other  symptom but hoarseness
exists, we  consider the  observation important to
parents  whose  children  are liable  to croup, and
consequently to their family physician.
  In the approach of an attack  of croup, which
almost always  takes place in the evening,  proba-
bly of a day during which  the child  bas  been
exposed  to the weather, and often  after  catarrhal
symptoms  have existed for several  days, he  may
be observed to  be excited, in variable spirits, more
ready than usual to laugh or to cry, a little flush-
ed, occasionally coughing ; the sound of the cough
being rough, like that which attends the  catarrhal
stage of the measles.  More generally,  however,
the patient has been for some time in bed and
asleep before the  nature of the disease with which
he is threatened is apparent;  then, perhaps with-
out awaking, he gives a  very unusual cough, well
known  to any one who has witnessed  an attack
of the croup ;  it rings as if the child had coughed
through a brazen  trumpet;  it is  truly a tussis
clangosa;  it penetrates the walls and floor of the
apartment, and startles the experienced mother—
" Oh I am afraid  our child is taking the croup :"
she runs to the nursery,  finds  her  child sleeping
softly, and hopes she may be mistaken.   But re-
maining to tend him,  before  long the ringing
cough,  a  single  cough, is  repeated  again  and
again :  the patient  is roused,  and then  a new
symptom  is  remarked ; the sound of  his voice
is changed;  puling, and as if the throat  were
swelled, it corresponds with the cough : the cough
is succeeded by a sonorous inspiration, not unlike
the kink in pertussis — a crowing  noise,  not so
shrill, but similar to the sound emitted by a chicken
in the pip, (which in some  parts of Scotland is
called the  roup, hence probably the word croup ;)
the breathing,  hitherto inaudible and natural, now
becomes audible,  and a little slower than common,
as if the breath were forced through a narrow tube;
and this is more remarkable as the disease advances.
A blush of inflammation may sometimes  be de-
tected on the fauces, and in some rare instances a
slight degree of  swelling round the larynx,  and
the child complains of uneasiness in  his  throat,
and says he is  choking.   The ringing cough fol-
lowed by crowing inspiration; the breathing, as
if the air were drawn into the lungs by  a piston:
the flushed face ;  the tearful  and bloodshot eye;
quick,  hard, and incompressible pulse;  hot, dry
skin;  thirst, and high-coloured urine — form  a
combination of symptoms which indicate the com-
plete establishment of the disease.
   Sometimes the symptoms  enumerated subside
about midnight,  even in the absence  of medical
treatment; perhaps  to return in the cou.se of the
following  evening.  From seven or eight  o'clock
till midnight this  complaint is always at its height. 
536                                      CROUP.
but in general, unless  the patient be treated with
promptitude  and judgment, the disease may be
expected  to  terminate fatally ;  a  new order of
symptoms, the second stage of croup as it is called,
taking place in the course of the next day.
   When the first or inflammatory stage of croup
just described  has  not  subsided  or received  a
check, the cough, from being  loud and  sonorous,
becomes husky and suffocative ;  it resembles the
cough which attends tracheal phthisis, and cannot
be heard at any distance  from  the bed;  the voice
is whispering; the respiration  wheezing;  the
countenance pale ;  lips livid ; the skin motley ;
the eyes  languid ; the iris with less colour than
natural ;*  the pupils dilated ; the tongue  loaded,
and  with  purplish  edges; thirst considerable;
skin much less hot;  and  the stools dark and fetid.
In this, the second stage, or that of  suppuration,
the breathing may often be remarked most free in
positions which are generally  least favourable to
easy breathing, as, for example, when the head  is
low and thrown back.  When the breathing is a
struggle for life, the patient sometimes will sud-
denly obtain relief, which, however,  in general  is
only temporary.
   From the state described in  the last paragraph
comparatively  few  patients recover.  The eyes
now become hollow; the countenance sinks; the
circulation gradually fails; the  extremities are cold
and swollen ; jactitation and  drowsiness  occur ;
the respiration becomes frequent, interrupted, and
laborious; and, after gasping for a longer or shorter
time, the child  dies;—the duration of the  disease
being varied according  to the  stamina of  the pa-
tient.   When fatal, croup at an average occupies
a period of four days.   Sometimes, however, the
second stage is prolonged for two or  three weeks,
and  the  patient, expectorating  freely,  slowly
emerges from a condition  which repeatedly  had
appeared hopeless.  Along with puriform fluid, of
which  the sputa chiefly consist, there is sometimes
expectorated a white soft tubular matter like ma-
caroni stewed in milk, which  is called the mem-
brane of croup.
  Prognosis.—The danger to which  a patient
in croup is exposed  may be easily computed by
any  experienced practitioner  who  will  bestow
some  consideration  on  the first  or inflammatory
stage of the disease.  In this stage the hoarseness
and cough (unaccompanied with the pulse of in-
flammation), how distinctive soever of croup, do
not imply  tbe existence of danger; a hard ringing
cough, followed by  a  crowing  inspiration, will
often take place during several successive nights ;
and these symptoms may exist  without danger,
so long as the breathing is free and pyrexia ab-
sent.  Very active treatment may not be required,
but vigilance will be  necessary.  The medical at-
tendant must be within  call,  and see  the child
more than once in the course of the evening, and
take care that he is under the eye of a steady and
experienced nurse, by whom he may, without de-
ay, be certified of any  symptom  indicative of
stricture of the glottis or inflammation of the bron-
chi.  While  the  breathing is  inaudible and  the
  * This paleness of the iris,  which often attends the
advanced stage of diseases, especially of the lun<»s and
which is a very unfavourable symptom, has, we'think
">een overlooked.                                '
 pulse quiet, all may be considered, so to speak, ns
 safe; but  when  the child  crows in  inspiration,
 when the breathing is audible, the air  as if forced
 through a  narrow tube, dry rather than wheezing
 —a sound which  any one may voluntarily pro-
 duce by contracting the glottis while he inspires,—
 or when the respiration is cooing or croaking,
 danger  is  present;  inflammation has  seized the
 larynx, has  caused tumour and great  irritation
 there, and  has extended into the bronchi.   This
 is no longer  a case for expectation, but for action.
 On the other hand,  when the cough becomes
 loose, the  voice  more natural; when the symp-
 toms  of inflammation abate,  while no symptom
 of the second stage exists;  we may give all rea-
 sonable encouragement.   In the stage of suppu-
 ration the  prognostic is always unfavourable; but
 a prudent  physician in  prognosticating the issue
 of any  disease of childhood ought not to deliver
 himself without  reservation;  he ought ever to be
 ready for any contingency unfavourable or favour-
 able ; his prognostication ought to be declared, to
 use the words of a late eminent physician, to be
 "subject to  the  uncertainty of  all  medical  opi-
 nions."
   Diagnosis.—The diseases which are liable to
 be mistaken  for croup are the following:—
   1. Measles.—This disease often resembles croup
 so much, that the most experienced physician need
 not be ashamed of  mistaking the catarrhal symp-
 toms, which, with a ringing cough, usher in the
 former  disease, for the latter.  This he will the
 more readily  do, unless he knows that the measles
 are in  the neighbourhood, or that the  patient,
 some twelve  or fourteen days before, was exposed
 to their contagion.  Upon the efflorescence taking
 place in the measles, the symptoms  resembling
 croup disappear.
   2. Cynanche pharyngea.— When  inflamma-
 tion  runs very high in this  species of quinsy, we
 have known  it extend to  the larynx, and croup
 thereby has been simulated ;  but cynanche  pha-
 ryngia will not be mistaken for croup, even under
 such a complication, if the fauces be carefully in-
 spected,  and if it  be recollected that  cynanche
 pharyngea  is attended with complete  dysphagia,
 whereas in croup the patient can always swallow
 with ease.
  3. Cynanche membranacea or maligna.—This
 disease, when the morbid action descends from the
 fauces into the larynx, is more  liable to be mis-
 taken for the croup  than any other.  In croup,
 therefore, the fauces, which  are scarcely, if at all,
 inflamed, ought to be examined with care, thus to
 distinguish it from cynanche  membranacea, or
 any congeneric disease.  If  the fauces are disco-
 vered to be spotted, as it were aphthous, encrusted
 with a membrane, or apparently sloughy, the dis-
 ease is not  croup.  Moreover, cynanche maligna,
 being propagated by contagion, often occurs in
 several  persons of a family  or neighbourhood at
 the same time,  and can be  traced from house to
 house, while  croup  is  non-contagious.  When
 two of a family have been  attacked at the same
 time with croup,  which we  have often  known to
 be the  case,  it has always manifestly appeared
that both had  been exposed to a cold damp at-
mosphere,  or. to some other adequate  occasional
cause. 
CROUP,  (SPASMODIC)
537
  4. Hysteria.—Hysteria, which mimics so many
diseases, not unfrequently assumes the character
of croup.   By  the  first case of this kind which
he witnessed, the writer of this article was so com-
pletely deceived that he  ordered  the  patient, a
young lady who never had menstruated, to be let
blood, and he remained during the operation.  Be-
fore she had lost more than a cupful of blood, she
fell into hysteric catalepsy.  The vein, of course,
was immediately closed, and by means of draughts
of  camphor julep,  Hoffmann's  anodyne liquor,
with five or six drops of the acetum opii in each
draught, her croup was easily cured : but hysteria
exhibited itself in various forms before she finally
recovered.   Whenever  a  physician is called to a
young lady said to be  affected with croup or in-
flammation of the windpipe, let him bear in mind
 that hysteria sometimes acts the  part of croup to
 the very life, and even although  he cannot detect
 any overt act of hysteria, let him look narrowly
 into the history of the patient, and carefully study
 her diathesis before he delivers his opinion.  More-
 over, the patient's age will always be a guide to a
 true diagnosis, croup  not  occurring in adult age,
 or even in adolescence, and hysteria being rare
 before puberty.
    Spasmodic Croup.—The symptoms  of croup
 which depend upon stricture of the glottis  differ
 so in degree, (sometimes  suffocation appears im-
 pending, sometimes the breathing is nearly natu-
 ral,)  as to prove in many attacks the existence of
 spasm; this, however, is spasm caused by inflam-
 mation, for which  no antispasmodic will be  equal
 to venesection.  That inflammation in  this dis-
 ease  often spontaneously is  resolved, the spasm
 depending upon it subsiding at the same time, is
 unquestionable, and has given rise to a belief en-
 tertained  by those chiefly who  have  overlooked
 the evidences  of inflammation,  that  there  is a
 purely spasmodic species  of croup; we  therefore
 take  the opportunity  which presents itself of ob-
 serving that the hysteric affection just alluded to
 is the only species of spasmodic croup with which
 we are acquainted.  The term spasmodic  croup
 has been applied  to affections  of very different
 kinds, by which many discussions have  been ex-
 cited.  We are convinced that tbe difficulty  at-
 tending these discussions has arisen  chiefly from
 that fruitful source of error, the misapplication of
 terms.  The designation spasmodic croup we have
 reason to believe has often been applied  to the
 hysteric affection  which  we have just described.
 It has also been applied to a well-known disease
 of infancy, which  one of our latest  authors  de-
 scribes as follows : '• Spasmodic  croup  occurs in
 very young children, and  appears at  the  com-
 mencement of the  period of dentition : sometimes
 earlier, and but very rarely after the child has
 reached its third year.  The crowing  noise which
 some infants make in  respiration, and which nurses
 occasionally consider as a sign of thriving, is no-
 thing more than the  air rushing through the aper-
 ture  of the glottis in a  state of spasmodic con-
 striction ;  and wherever  this symptom appears,
 (however well the  infant may seem in  other  re-
 spects,) it is always advisable to pay attention to
 it, and remove the source of intestinal  irritation,
 which  will generally be discoverable.  In  some
    Vol. I.- 68
instances the constriction is both  slight and mo-
mentary, and the spasm never produces either un-
pleasant or dangerous consequences: in others it
is  longer  continued, and  the  infant works  and
struggles for breath, becomes  purple  in the face,
and is apparently dying when the spasm begins
to  relax, and a long-drawn,  crowing inspiration
sets all things to rights again.........  In
the fatal cases  of spasmodic  croup, death  is ex-
tremely sudden : the infant may be apparently in
good health, and in a moment he makes a violent
effort to inspire, which occasions something like a
faint scream or cry, becomes  black or  swollen in
the countenance, and dies before assistance can
be procured."  Now this is a graphic  description
of a disease of which  an accotmt will  be found
in Dr. Clarke's Commentaries on the Diseases of
Children, there entitled,  " a peculiar  species of
convulsions in infant children,"  which  has also
been  sometimes called  chronic croup, sometimes
inward fits; and  which is furthermore  distin-
guished by a clenching of the  hands  upon  the
thumbs, and a bending of the toes downward and
inward, by which the foot appears slightly clubbed.
This affection, which  ought never  to  be called
croup, is not attended with cough.  On dissection
there is no trace of inflammation in the windpipe;
the seat of the disease, it can scarcely be doubted,
being in the brain.
   Having  repeatedly  observed  the  symptoms
which in children  are  supposed to constitute a
non-inflammatory  variety of  croup, and to which
most frequently the term spasmodic  croup is  ap-
plied,  symptoms  which  may  be found in  Dr.
Good's valuable work, The  Study  of Medicine,
embodied under the title of Laryngismus Stridu-
lus,  viz.,  " sense of  suffocation  commencing  in
the  night; voice  shrill and croaking;  counte-
nance flushed  and swollen ; distressing struggle
for breath ;"—we  were  naturally anxious to de-
termine their true  nature; and as it appeared that
these symptoms took place  at the  time of night
when croup is generally at its height; that  they
were brought on by causes which produce croup;
that they occurred in individuals and families lia-
ble to croup;  that they were most  certainly re-
lieved by the internal  remedy most efficacious in
croup, namely, an antimonial emetic;  and, on the
other hand, when  it was considered  that  genuine
inflammatory croup often invades suddenly and
without any catarrhal  symptoms preceding, and
that its most formidable attacks will  often subside
as the symptoms of the supposed spasmodic croup
are represented to do, without remedial treatment;
there  appeared to  us  no sufficient grounds for
establishing a spasmodic variety of the  disease.
A sounder conclusion could not be drawn relative
to spasmodic croup than that with which the late
Dr.  Kellie ends an able letter on this  much-con-
tested point.  " After embarrassing myself a long
time about spasmodic  and  inflammatory croup,
and using my opportunities of observation to the
best advantage of  which  I was capable, with the
 view of establishing the diagnosis  of these two
diseases, I came at length to persuade myself that
there was  truly no essential difference between
 them, other than what arises from degrees of vio-
lence, and the obvious circumstance of internals- 
538
CROUP.
sion and continuance."  (See Dr. Kellie's Letter,
Pathology  of the  Larynx  and  Bronchia, by J.
Chcvne, M. D., p. 136.)
   Predisposing Cause. — There would be less
difficulty in explaining the nature of the predis-
posing cause of croup, did we know why the dis-
ease ceases at puberty.   The difference between
the glottis of a child of three years and of twelve
is scarcely  perceptible; whereas at puberty the
aperture of the glottis is quickly enlarged in the
male in the proportion of ten to five, in the female
of seven to five;  at the same time the bronchi en-
larging, and the voice undergoing a corresponding
change.  Upon the windpipe and bronchial sys-
tem, changed in  their constitution, enlarged  and
invigorated, the 'occasional  cause of croup is  no
longer able to produce an  adequate impression:
it may be conjectured, then, that in the immature
state of the organs affected we are to look for the
predisponent cause of croup.
   Pathology of Croup.—Upon dissection, ap-
pearances are displayed  which  satisfactorily ac-
count  for  the symptoms  of this disease.  The
symptoms,  as the  reader must have observed, are
those of inflammation affecting the air-tubes of
the lungs.   The  sound of the voice, the sense of
strangling,  (which the writer well recollects, hav-
ing had a dangerous attack of the croup when he
was not a very young child,) prove that the larynx
is much affected ; while the  state of the com-
plexion in  the second stage, even when the un-
easiness in  the throat is relieved, the quickness of
the breathing, the cooing respiration, the puriform
sputa, would show that the inflammation has ex-
tended through all the branches  of the bronchial
tubes.   Nay, the  examination of the body after
death, explains the sudden relief which the patient
sometimes  unexpectedly  obtains in the  second
stage of the disease, as also the ease  which  he
finds  in positions generally unfavourable  to free
Orea thing.
   The mucous  membrane is  found  inflamed,
and, in consequence of this  inflammation,  the
larynx, trachea, and bronchial tubes are generally
lined  with  a membranous substance,  varying in
consistence, of the same  sort with that which, as
has been  observed,  is sometimes expectorated  :
this substance, in  a  fluid form, fills the bronchi.
In the trachea it is  soon dried,  and there it ob-
tains form  and consistence ;  it is often partially
detached.   Evidences of inflammation may gene-
rally be discovered over the whole of the mucous
membrane  of the lungs ;  the cavity of the lungs
is always full of  fluid; the interstitial  cells are
sometimes filled with serum; nay, we have known
parts of the lungs hepatized, and inflammation ti,
extend not merely to the parenchyma, but to the
serous  membrane, in consequence  of which we
have seen  fluid  effused  into the  cavity  of  the
pleura.  In many dissections  the lungs  have  a
solid feel, do not recede when the thorax is open-
ed, and cannot be compressed.
   The membrane of croup has  been found par-
tially detached, which will  account for its being
sometimes  coughed  out; and  as children often
swallow what would  be  expectorated by  adults,
there  is reason to think that it  is much  oftener
transferred  to the stonach, upon which the strug-
gle within the larynx -eases for  a time; and this
explains the gleams of hope afforded in tbe second
sta^e,  which,  however, for the  most  part  are
gradually  obscured  by  the  steady  advance of
bronchial inflammation  and effusion.   The relief
obtained  in  unfavourable  positions may  be  ex-
plained as follows:  the  trachea has  its capacity
increased by being  stretched  to the  full  extent,
which happens when the head  is thrown back-
ward ; wbereas when the patient sits,  which is
generally the easiest posture in difficult breathing,
the head  falls  forward, and the membrane, espe-
cially  if  it be in part  detached, being  doubled
together, fills the trachea  at one point, and com
pletely obstructs the passage of the air.
   Prophylaxis.—When croup has  once occur
red in a  family, it will  probably renew  its visits,
and will attack the same  child or some of the othei
children  on  a  future occasion ;  the  physician
therefore  should  instruct parents with regard to
prevention.  If possible, children  liable  to croup
ought  to live at a distance  from bodies of water.
They ought  not to  occupy warm rooms, or have
a superfluity of bed-clothes.  Beginning in sum-
mer, they  ought to  be  sponged with cold water
every  morning, and rubbed dry with  a  coarse
towel.   In winter and spring they ought to wear
flannel next their skin, and  to have the neck cover-
ed.  They ought not to drink  fermented  liquor.
Their diet at all times, although nourishing, ought
to be light; and finally, when the weather is cold
and damp, and especially  during the prevalence
of the east wind, they ought not to be in  the open
air between October and May.
   Treatment.—When a child  becomes hoarse,
and begins to cough, let every kind of stimulating
food be  withdrawn; let him  be confined to an
apartment of  agreeable  warmth;  have  a tepid-
bath ;  and take a drachm of the following mixture
every hour, or every two hours, if it produce sick-
ness :—
       R Viniipecacuanhae ^iii.
           Syrupi tolut.  Jv.
           Mucil. acaciffi ^i. M.
and all danger will probably be averted.  Where-
as, if no  change be made in  the quality  of the
food, and  if he be sent into the open air, he will
probably undergo an attack of bronchitis  or croup.
   When  the breathing becomes affected in croup,
or  when  there  are  symptoms  of inflammatory
fever, an  emetic should be given without delay,
and blood should then be drawn from  the arm, or,
in very young children, from  the jugular vein,
unless very great relief should follow the operation
of the emetic*  Next we would give the patient
a powder  consisting  of calomel  and James's pow-
der, probably two, three, or four grains of the for-
mer, with two or three grains of the latter, and we
would  then have him put in  a tepid-bath,  and
supplied with diluting drinks.   Every third hour,
the calomel and James's powder ought to be  re-

  * We have adopted  the following expedient, with ex-
cellent antiphlogistic < fleets, in violent inflammation of
the lungs occurring in a robust constitution   Having
ordered an  emetic to be given, in eight or ten minutes
after, before sickness  has commenced,  we have had a
vein opened, and have found, before ten or twelve ounces
of blood had flowed, that the  patient has  become sick,
vomited freely, and fallen into a slate of colliquation,
which has  lasted for  a con>iderable time, — a power-
ful impression being thus made, at a small erpense of
blood. 
CRO
UP.
539
peated :  if it should not, after a third dose, affect
the bowels, a dose of castor oil may be given.
  The quantity of blood drawn from a child un-
der two years  of age ought not  to  exceed five
ounces; in  a child  of seven  or eight it  may
amount  to  eight  ounces.   But one  venesection
will  seldom suffice in a severe case of croup ;  it
will very often be  necessary, in two or three hours,
to repeat the operation.   When a second blood-
letting fails  to moderate the symptoms, we gene-
rally order  leeches to be applied to  the upper
extremity of the sternum ; three or four to an in-
fant, ten  or  twelve to a child of as many years
old.   Leeches  ought  not to be applied to the
region of the larynx,  as children, in croup, will
be found most impatient of the degree of pressure
necessary to stanch the bleeding when profuse.
   If manifest  improvement  be  not produced by
the application of the leeches, and if it be judged
unsafe to have more blood drawn, a blister ought
to be applied  to  the lower  part of the sternum,
and  a solution of  tartar emetic given.  The dose
of tartar emetic may be from a quarter to a half
grain, and this may be repeated, according to its
effect, and to the urgency of the attack.  Sickness
ought to be excited, and hence the dose, if it have
no such effect, ought  to be repeated in half an
hour, and,  if great prostration  be not produced,
the dose ought afterwards to be repeated hourly
while symptoms of inflammation continue.
   These may appear violent measures,  but  be  it
remembered that, in a vast  many cases, the fate
of the patient will be decided within twelve hours ;
nay, there are cases in which  the inflammatory
stage will  be over  in  six hours from  the  com-
mencement of the disease.
   [In mild cases  of croup, not  preceded by bron-
chitic or pulmonic  disease, in which  the child is
suddenly attacked with croupy cough and breath-
ing  at night, with little or no  fever, the disease
appears to be more spasmodic than inflammatory,
and is generally  removed by an emetic, with  or
without the  warm bath.  Such  cases  are  often
treated  at home,  without disturbing the medical
attendant, by the  Hive or Croup Syrup of  Dr. J.
R. Coxe,—the mel. scillae compositum of the Phar-
macopoeia of the  United States, — the dose of
which, as an emetic for children, is from ten drops
to a fluidrachm, repeated every  fifteen or twenty
minutes, until vomiting is induced.]
   With respect to the treatment of the second
stage of croup, or that of suppuration, little can
be added to what may be found  in a work on the
Pathology of the Larynx and Bronchia, published
by the writer of this article many years ago.  In
that publication it is recommended to give half a
grain of tartarized antimony, dissolved in a table-
spoonful of water, to a cbild two or three  years
of age, every half hour, till sickness and vomiting
are produced ; and  in two hours after the last act
of vomiting the  same process  is to  be recom-
menced, and  so repeated while  the strength will
admit.  The following case suggested this mode
of treatment:  a child, with  disordered bowels,  so
delicate  as not to admit of being let blood, was
threatened with croup, every night, for five or six
nights.  Whenever the breathing became difficult,
the child took as  much of the antimonial solution
as induced  vomiting, and invariably with relief to
the difficult breathing.   Perceiving that in croup,
then pretty generally supposed to be a disease of
the trachea, every part of the inner surface of the
lungs, from the  larynx  through the ramifications
of the  bronchial tubes,  was in general affected,
and considering that nothing could more  effec-
tually moderate the vascular action in that organ,
and at  the same  time  dislodge  the exudation
which fills the bronchial tubes, than  the solution
of tartar emetic, all  reliance was  placed on that
remedy  in the second stage of croup,  more espe-
cially  as it was found  that bloodletting in that
stage only accelerated the  death  of  the  patient.
The solution of tartar emetic was prescribed the
more freely, from a child having been observed to
take six or eight grains  of  tartar  emetic, without
vomiting being produced.   In  few cases has the
writer  known children  survive the second stage
of croup ; in  all of these, however, they recovered
while using  a solution  of tartarized antimony :
" Emetics he  had repeatedly given in the second
stage of croup, but  in these cases  of recovery the
patients were kept sick for two or  three days with
scarcely  any  interval.  With the  exception of
tartar emetic  no medicine with which he  is ac-
quainted is entitled to  confidence in the  second
stage of croup: calomel uncombined, as  recom-
mended  by Rush,  he  has  often given without
benefit.  Indeed, tartar  emetic in croup, so as to
produce continued  nausea, has been his  sheet-
anchor since  1799."  (Essay on  Cynanche Tra-
chealis, or Croup,  by J. Cheyne,  M. D.  Edin.
1801.)
   As  there is in inflammations  of the  mucous
membrane of the bowels a point of time, when
life being rapidly on the ebb, a patient may some-
times  be  rescued by the substitution of  opiates
and cordials  for the antiphlogistic regimen ; so
also is  there,  in bronchial inflammation,  a time
when we may with advantage lay aside all lower-
ing remedies  and give  burnt brandy and ammo-
nia, to which may  be added calomel, with a mi-
nute quantity of opium, and  the application of
spirit   fomentations to  the  surface.   Gasping,
failure of the pulse, and a clay-cold  surface, show
that our  only faint  hope is in cordials: it must
be admitted,  however,  that a clear  discovery of
the point at which this change of  treatment ought
to take place is the reward  of clinical experience
alone, and cannot be made in the closet.
   In  the treatment of  this disease we  have but
one point more to consider, namely, the propriety
of attempting to remove the membrane of croup
by means of a surgical operation.
   Considerable  difficulty will attend this opera-
tion.   The larynx of a  child from  two  to twelve
years of age  is a very narrow tube, not more than
three-eighths  of an inch  in diameter;  conse-
quently, to admit the  introduction  of a  pa.r of
forceps, the cartilages must be cut across to a con-
siderable extent, involving  bleeding from the thy-
roid veins, which sometimes has  been productive
of suffocation.  But even  were  the  larynx laid
open  without hemorrhage, disappointment  will
probably arise from  the  state of the  adventitious
membrane, which sometimes  possesses so little
cohesion as not to admit of being laid hold of by
an instrument  for  the  sake  of detaching  and
removing it • nay,  in some cases in which the 
540
CROUP.
inflammation is intense, there is no appearance of
a continuous membrane, the secretion  from the
inflamed surface  existing in the form  of shreds
and detached  portions.   " Dans  plusiers  cas, et
tout  recemment encore, des medecins tres-distin-
gues out pratique la tracheotomie sur des indivi-
dus affectcs de  suffocation  et de voix  croupale,
qu'ils regardaient comme dependantes du croup.
L'operation d'abord, et l'ouverture du cadavre en-
suite, ont  prouve qu'il  n'y  avait pas de  fausses
membranes.''—Guersent Dictionnaire de Mede-
cine, tome vi. p. 213.
  Before having recourse to the operation, sup-
posing  it easy, safe, and  likely to end  in the
extraction of the adventitious membrane, it will
be proper to ask, is the false membrane in the
larynx,  which it is  the  object of this formidable
operation to remove, in  general the cause of the
patient's death ?  We   apprehend not.   First,
because in  several dissections  which were long
ago made with a view of determining  the effect
of the  membrane of  croup in  obstructing the
larynx,  it so happened that within that membrane
a space  was left for a current of air sufficient to
support life:  in these bodies  the cellular  substance
of the lungs was distended with serum,  the rami-
fications of  the  bronchi were filled with puriform
matter, by which the air was excluded, and the
bronchial  membrane  was  universally  inflamed,
thereby  preventing the arterialization of the blood:
the children had  perished from  the lungs being
unable  to contain a quantity of  air sufficient to
support the circulation,  and from the  bronchial
membrane  being unable  to act upon that reduced
quantity.  Secondly, because when the membrane
of croup, fully formed, is expectorated, the disease
is generally fatal, even when all  the  benefits of
the operation are obtained.   If  the disease were
confined to the larynx, then,  and  then only, would
bronchotomy be advisable.  The following are the
very  pertinent remarks  of Mr.  Porter on  this
subject:—" But bronchotomy has in many cases
of croup been successful.  True; but where are
the thousand instances to the contrary that might
be brought against each  single one of these ?  I
have performed the operation myself on  the child,
and  have seen it frequently done by others, and
in no one case has the  life  of the patient been
saved.  I have known and  heard of it  often, but
never  understood that  it  produced a  recovery.
Most practitioners are fond of publishing cases of
successful operations, but are not so  willing to
make known those of  an  opposite description,
from an idea that these  supposed failures might
lower them in public estimation; but  these de-
tached and  solitary expositions of fortunate sur-
gery are calculated to produce very serious injury,
if they encourage others to  similar attempts, in
the hope of similar results.   If it was possible to
place a  list of those cases in whicb bronchotomy
had  proved  unserviceable, in array against those
wherein it had  seemed to  be useful, it  would be
scarcely necessary to  advance any further argu-
ment in proof of its  uncertainty ; and medical
men  would  rather tuin their  attention to the
improvement of that  internal  treatment, which
will generally be efficacious if resorted to in time,
than look for advantage in the performance of an
operation from which experience holds  out  such
 slender hopes."   (Observations  on tbe  Surgical
 Pathology of the Larynx, &c. by  U". H.  Pwter,
 A. M. &c.)
   [The testimony for and against the  operation
 has been- given  elsewhere :  (See  the  writer's
 Practice  of Medicine, 2d edit. i. 246:  Philad.
 1844.)  It would appear, that of 140 operations,
 112 terminated fatally.]
   Improvement of the internal treatment of croup
 will, in  all  probability,  chiefly flow  from the
 acquisition of more clear and determinate views
 with respect to the nature of that disease.  Some
 of the  latest authors  on nosology have formed a
 juster conception of croup than their predecessors
 did, having  classed it with diseases of the lungs
 and not of the throat.  Swediaur represents croup
 as a genus of the order Phlegmasiae, and entitles
 it Bronchitis; Young as a species of the genus
 Cauma, or inflammatory  fever, under  the title of
 Cauma Bronchitis; and  Good includes it under
 the genus Empresma or visceral  inflammations,
 calling it Empresma Bronchlemmitis,  or mem-
 brane-like inflammation   of  the  bronchi.  The
 latest of these authors observes  that croup essen-
 tially  consists in  an  inflammation that  spreads
 through the whole range of the windpipe, from
 the larynx to the minutest  ramifications of the
 bronchi.
   This is a juster view of the matter than that of
 some of our contemporaries in France, who have
 endeavoured  to  identify croup  with  affections
 primitively of the fauces, beyond which they often
 do not extend ; affections some of which  in their
 constitution  are the  opposites  to  croup.  MM.
 Bretonneau,  Guersent, and others, have endea-
 voured to prove  that croup and epidemic angina
 maligna  are  one and  the same disease; that
 although there may be some little variety  in their
 seat, there is none in their nature:  " M. Breton-
 neau a demontre que l'angine maligne epidemique
 est  une veritable inflammation pelliculaire, sem-
 blable a celle du croup.   II a prouve ensuite, que
 ces deux  maladies, identiques quant  aux  altera-
 tions pathologiques, ne different que par  rapport
 au siege qu'elles occupent."—Guersent, 1. c.  It
 is  strange, that  among a people remarkable for
 their minute  and patient study of disease, and
 their refined arrangements, croup and  cynanche
 maligna  should be considered identical, because
 of a certain  gross resemblance between them,
 because  in  both there  may often be  found  an
 adventitious membrane, and because in the latter,
 when the diseased action is extended to the wind-
 pipe, there may arise some of the symptoms which
 belong to  the advanced stage  of  the  former.
 What  real  identity can  there  be between two
 diseases,  the one  caused by cold, the  other  by
 contagion ;  the one always purely inflammatory,
 the other generically typhoid; the one requiring a
 decidedly  antiphlogistic  treatment, the other local
 stimulants of the most powerful  kind, tonic medi-
 cines  and cordials — bark and wine, according to
 the  procedure  of our  fathers >   If  we  yield
| ourselves  to this figment of our ingenious neigh-
 bours, we must, in the present instance, relinquish
 one  of the  great advantages  which  nosology
 affords, namely,  a ready  means  of distinction
 between diseases  similar  in appearance but differ-
, ent in their essence. 
CROUP.
541
  If this attempt at the identification of contra-
ries should succeed, it  is  obvious that the  treat-
ment  of croup, which at present is  simple, will
hereafter be complex, difficult, and uncertain.  To
bear out this  assertion, we  shall briefly examine
some parts of the  chapter which  Laennec  has
written on  croup, assuming it as a fair represen-
tation of the opinions of his countrymen.   I pre-
fer an appeal to  Laennec, as (although  in  point
of practice he is  often  marvellously deficient) the
genius of  that great observer, and the ability of
his translator, have obtained for his treatise on the
diseases of the  chest,  authority in Britain  as a
work of pathological reference.
   Laennec tells  us that " sometimes croup is con-
fined to the bronchia  and  their branches, there
being no trace of it  in the  larynx and  trachea."
This fact would  require to be established. " More
commonly, as has been shown by Bretonneau, the
inflammation  commences  on  the  tonsils  or the
pharynx, and from thence  spreads at the same
time downwards  to the  larynx, and  upwards to
the  cavity of the nostrils, which latter it some-
times entirely covers.  Occasionally the false mem-
brane extends to  the stomach."   Again, " If the
disease commences  in the fauces, spots  of a yel-
 lowish  or greenish  colour,  surrounded by a  deep
 red, are at first perceived on the tonsils, the pillars
 of the veil of the palate, or the back  part of the
pharynx;  these  specks  gradually extend,  unite,
 and increase in thickness, so as at last to form a
 complete crust like that of  inflamed  blood, lining
 the whole  entrance of the  fauces, and extending
in a greater or less degree into the larynx, trachea,
 and bronchia."   Such incrustations, proceeding
from an inflamed membrane, and extending into
 the  larynx,  every  experienced  physician is ac-
quainted with, in cynanche maligna.   In  scarla-
 tina anginosa also, inflammation and incrustations,
extending  from  the fauces to  the larynx,  may
often be observed ; and we doubt not that  such
appearances are  observable in a species of  angina
which can be classed neither with angina maligna
nor with  scarlatina anginosa;* but  in genuine
croup, as it occurs in Scotland and Ireland, never.
   If it be objected that the  diphtherite of M. Bre-
tonneau and the  cynanche maligna  of Cullen are
different diseases, and that the  French physician
endeavours to identify  with croup  a  form  of an-
gina, under the name  of  diphtherite,  with which
English physicians  are unacquainted, or have not
described in their writings ; we  would  meet the
  * We have seen instances of membranous angina, (oc-
curring during the prevalency of gastric  fever,) which
did not appear to belong either to cynanche maligna or
scarlatina  anginosa,  and which  a French  physician
would probably have considered as  specimens of diph-
therite, or, it may  be, of croup.  We recollect attending
in one family two  children who died of angina, accom-
panied with an exudation of concrete lymph,  which
from the symptoms must  have  lined the upper part of
the windpipe as well as the fauces : this exudation, as it
appeared on the fauces, we considered  to  be a  slough,
the discovery  of Bretonneau  not  having been made.
Many years after,  three  children, also  in one family,
were affected in a similar manner, during a similar epi-
demic constitution, two of whom died.
  These cases  were not attended with an  efflorescence
of the skin,  nor were they traced to contagion,  but  we
cannot affirm that  the disease was not epidemical.  At
the period of the occurrence of the last three cases, a
similar incrustation often covered  the fauces of those
K'ho were labouring under gastric fever, to which dis-
ease we  were  inclined to  think that this angina  was
allied.
                                         2v
objection by calling the attention  of the reader to
the following passage in Laennec, wherein a dis-
ease, which is either cynanche or maligna or an
ideal  affection,  is  upon the  authority of MM.
Guersent and  Bretonneau  termed  croup.   "In
some cases  of croup, such as occur  in  hospitals,
the state of the system is very different, there be-
ing evident marks of a septic change in the fluids
of the body: the pulse is  but little accelerated.
the skin harsh and dirty,  the debility extreme
and the  breath fetid,  even  when no gangrenous
specks appear: this variety is, by Guersent and
Bretonneau,  denominated   asthenic.   Asthenic
croup would  seem  occasionally to be propagated
by  infection."  Asthenic croup! croup with an
unaccelerated pulse, fetid breath, and propagated
by  infection!—Laennec, after describing croup,
talks of  that  affection resulting from a gangrenous
angina, in which eschars are distinguishable before
the  appearance of the  false membrane,  and  in
which the  gangrene  is  indicated by its  peculiar
odour.   If  the  disease of M. Bretonneau  be not
cynanche maligna,  let it henceforth be known as
diphtherite  plastic  angina, angine  couenneuse,
or angina membranacea, or let  the  next observer
invent a new name more to  his  taste ;  only let
him not term it croup, which is a  title  already
applied  to  an  affection of a very different kind,
which belongs to another order of diseases.
   [Almost  all pathologists  admit, that the essen-
tial  character of croup is  a violent laryngo-tra-
cheitis, with  tendency to the exudation  of plastic
lymph;  but the generality  of British and Ameri-
can practitioners regard it to be very different from
the diphtheritic inflammation that occurs  in diph-
theritic  stomatitis and pharyngitis,  described  by
Bretonneau  and Laennec.  In primary croup,
as it has been termed by Dr. Stokes, the  accom-
panying fever is  symptomatic.   It  is this which
is met with in childhood; whilst secondary croup
is a symptomatic affection, and is the croup of the
adult—the  diphtherite of Bretonneau.  Between
these two  forms of croup Dr. Stokes has  pointed
out the following differences :
     PRIMARY CRODP.
 1. The air passages primarily en-
gaged.
    Necessity for  antiphlogistic
treatment, and the frequent success
of such treatment.

 5. The disease sporadic, and, in
certain siluaiions, endemic, but ne-
ver contagious.
 6. A disease principally of child-
hood.
 7. The exudation of lymph spread-
ing to the glottis, from below up-
wards.
 a The pharynx healthy.
 9. Dysphagia either absent or very
slight.
 10. Catarrhal symptoms often pre-
cursory to the laryngeal.
11. Co
plication
th acute pul-
    teristic
    SECONDARY CROUP.
  I. The laryngeal affection second'
ary to disease of the pharynx and
mouth.
  2. The local disease arising in the
course of another affection, whicb is
generally accompanied by fever.
  3. The fever typhoid.
  4. Incapability of bearing  anti-
phlogistic treatment; necessity for
the tonic, revulsive  and  stimulating
modes.
  5. The disease constantly epidem-
ic, and contagious. [?]

  G. Adults commonly affected.

  7. The exudation  spreading to the
glottis, from above downwards.

  8. The pharynx diseased.
  9. Dysphagia common  and severe.

  10.  Laryngeal symptoms super-
vening without the pre-existence of
catarrh.
  11.  Complication with   such
changes rare.
  12 Breath often characteristically
feid.J
 12 Absence of any ch
odour of the breath.

   The  directions given  by Laennec relative  to
the treatment of croup evince a judgment in this
matter,  perplexed and distrustful of itself and  of
the resources of medicine;  a  disposition to tem-
porise, arising, as we may infer, from his concop
tion of  the nature of the subject being slouded. 
YANOSIS.
>
   French physicians have of late so honourably
 and successfully distinguished themselves by their
 zeal in the prosecution of pathology, that we would
 readily yield  them  our  confidence, did we not
 know that  such a disposition of mind  ought ever
 to be resisted.  The  same rule ought to guide our
 researches  into the nature of disease which gov-
 erns the student in a much higher department of
 knowledge, viz. " Prove all things;" to which very-
 well may be added on the present occasion, " hold
 fast only that which  is good."    j  £HEYNE
542                            CEOUP-C

"In doubtful  cases,"  he says,  "it  would seem
preferable rather to omit bleeding than to destroy
by injudicious depletion the powers  requisite for
the separation  and excretion  of the  false  mem-
brane."  As to the question of bleeding in croup
when the disease  is  once established, no  doubt
ought  to exist, unless perhaps  we  may hesitate
with respect to its  stage.   If the patient is  in the
first or inflammatory stage  of croup, no experi-
enced physician will omit bleeding;  if in the se-
cond, or that of suppuration, no physician will
propose it.  If it were doubtful  to  which stage
the symptoms belonged, it would be  preferable  to
bleed: the anceps  remedium ought to be prefer-
red.  Bloodletting would  probably bring  relief  if
the patient were still  in  the  first stage, and  by
that measure little would  be taken from our hopes
were he in the second, from which so few recover.
Nothing but the mingling together of incongrui-
ties  and consequent  misapprehensions of croup
could have induced an eminent physician like M.
Bretonneau to make so dangerous an observation
as the  following: " I  am  forced to declare, con-
trary to  the  received  opinion,  that bleeding  in
croup has done harm, and accelerated rather than
retarded  the spread of the coriaceous inflamma-
tion.   I did not abandon  this measure till after
reiterated proofs of its injurious  effects."   Physi-
cians need not be told  not to  bleed  in cynanche
maligna,—it never was their practice to do so, nor
would  they willingly bleed in  any form of mem-
branous  angina ; but  if  they  renounce bloodlet-
ting in the first stage  of croup,  which they are
taught to do by this  sweeping dogma of alleged
experience, they will part with the best  shaft  in
their quiver.   This is no  question of nosological
subtilty; if so, we would  bave kept aloof: it  is
a matter of life and death.
   We shall conclude these observations with one
more quotation from Laennec. " All practitioners
who have had occasion to see  a  good deal of this
disease, will readily admit that these  measures, al-
though very rational and conformable to the re-
sults of experience in the treatment of inflamma-
tory diseases in general,  are  nevertheless  rarely
sufficient, and that very few well-characterised in-
stances have yielded  to their influence."  Such a
conclusion naturally  flows  from  an attempt  to
identify a sthenic and  an asthenic disease.   The
reader may be assured that the  practice of medi-
cine would be  much  more satisfactory than it  is,
were the  nature of every disease  as well under-
stood, the principles of treatment as clear, and the
results as uniform as  in  the instance of genuine
croup.  If croup is considered as purely an in-
flammatory  disease,  and,  in consequence,  if the
treatment of it be rigidly  antiphlogistic, the  event,
when timely aid is afforded, will be  almost inva-
riably favourable.  If,  indeed, the golden oppor-
tunity is lost, and the first stage is allowed to pass
without proper assistance being given, while the
importance of his profession in his own eyes must
be enhanced, the physician can  accomplish com-
paratively  little, and  the gloomy reflection  of
Laennec, being modified, may be  assented to,
namely, that very few well-characterised instances
of croup, in the second stage, will yield to the in-
fluence of measures  even the most  rational  and
conformable to the results of experience.
   [Notwithstanding  the  strong  remarks of Dr.
Cheyne, the difference between idiopathic or pri-
mary,  and symptomatic  or  secondary croup,  is
now, as before remarked, admitted by pathologists;
and hence it becomes necessary to make some ob-
servations on the treatment of tbe latter, or what has
been called Croup of the Adult, which is con-
nected with the same diphtheritic babit that gives
occasion to diphtheritic stomatitis and diphtheritic
pharyngitis.  The remarks as to pathology  and
therapeutics,  made under the latter disease, are
equally applicable to the present.   Mercury ad-
ministered so  as to  affect the system, has been
given  with the  view of diminishing  the plastic
tendency of the blood, and cases are recorded in
which  severe diphtheritis of the air-passages ap-
peared to yield  to it.  Great reliance  has, how-
ever, been placed  on the topical applications re-
commended in diphtheritic pharyngitis, and espe-
cially on the  muriatic acid, nitrate of silver, and
alum, applied in the  manner recommended under
chronic laryngitis, (q. v.)  Tracheotomy has like-
wise been advised in diphtheritic laryngo-trache-
itis, when urgent symptoms  arise that threaten
suffocation.  Perhaps in  such cases  it might be
more serviceable than in primary croup, in which
there is so frequently a combination of bronchial
and pulmonary inflammation.  It has been  pro-
posed also with another view, to introduce through
the aperture the local applications that have been
found useful.  Fragments of the pellicular exuda-
tion  have been occasionally expelled through the
opening, and  through it agents, as calomel, have
been introduced  to  act on the  morbid surface.
Eight  grains of calomel, introduced in this way,
appeared to M. Bretonneau  to afford marked re-
lief in  one case.    Powdered sugar and  powdered
alum  have been  blown into the larynx through
the aperture in  the  same manner.  One of the
great  advisers  of  topical  agents  introduced  into
the larynx, M. Trousseau, seems, however, to have
less confidence in them than formerly.  They are
not much employed.  (Practice of Medicine, 2d
edit. ii. 247: Philad.  1844.)
                      Robley Dunglison.]
   CUPPING.   (See Bloodletting.)
   CYANOSIS, (niavoc vCooc,) morbus cxruleus,
blue  disorder, blue jaundice of the ancients,  a
morbid appearance which consists in the skin as-
suming a blue, purple, or violet colour, especially
in those parts where the cutaneous capillary  ves-
sels are superficial, as on the cheeks and lips.
   This colour may be a symptom of many differ-
ent diseases; but in  some  instances it is of so
marked a purple, and the accompanying symp-
toms are so variable  that most physiologists have 
CYAN
given this affection  its denomination  from  the
colour developed, in preference to one  from any
assemblage of symptoms ; thus constituting  the
appearance of an idiopathic disease under the ap-
pellation of cyanosis.  Whether they are justifia-
ble in so doing is questioned by others, who con-
sider the blue colour as indicative of a cachectic or
scorbutic habit, or attributable to other causes.
  Cyanosis is generally accompanied by difficult
respiration, palpitation of the heart with diminu-
tion  of  the natural temperature, an irregular or
intermitting pulse,  and  is  often  attended with
dropsical.symptoms, the face especially, in addi-
tion  to the purple colour, being bloated  and oede-
matous: all these symptoms are much aggravated
by any  exertion.
   Wben this  disorder first attracted  the notice of
physicians, it was considered to depend on an ul-
cerated  state of the foramen ovale.  A few cases
where this imperfection occurred were first  ob-
served in young subjects, who survived but a short
time, the  blue colour being intense, and the arte-
rial  system supplied  with dark venous blood, to
the circulation of which through the arteries  this
 tint  was attributed.   This view was  confirmed by
 the  observations  of several  distinguished  anato-
 mists ;  Senac, Morgagni,  and  others,   reporting
 that they  had in such  instances found free com-
 munications between the right and left cavities of
 the heart, which  should not have existed.  This
 view appeared to be confirmed by chemical facts,
 with relation to the blood  not having  undergone
 that change in the  lungs which vivifies it and fits
 it for the general circulation ; as well as from the
 symptoms which those subject  to such affections
 had suffered previous to death,—dyspnoea, dimin-
 ished temperature,  weakness, languor, and an en-
 gorged  state of almost  every  organ ;  symptoms
 generally  associated with a want of the due oxy-
 genation of the blood in the pulmonary circula-
 tion.
   Although cyanosis is often found in connection
 with an open  state  between each side of the heart,
 many cases have also occurred where this imper-
 fection  has been absent, and yet in  which all the
 symptoms of  cyanosis have presented themselves.
 Corvisart was one of the first who put this opinion
 upon record ;  stating that a permanent blue colour
 of the  integuments was often  connected with an
 unnatural communication between the  cavities of
 the  heart, but that  many facts induced  him to say
 we  could not always arrive at the  same conclu-
 sion.   Several examinations after death occurred
 to him  and others of his contemporaries, in which,
 though the blue colour had been strongly marked
 during life, there was no communication between
 the  opposite  sides  of the heart.  The writer of
 this article has met with some cases  of this de-
 scription, insomuch that for  some years he began
 to doubt  the necessary connection between the
 blue colour of the skin  and such a free communi-
 cation.  On  the other  hand, he has seen several
 cases where  there was a free opening between
 both auricles  and ventricles which must have sub-
 sisted for  many years, and yet in which there was
 no cyanosis.   In  one  of these cases, which  is
 published  in  vol. i. of the Medical Transactions
 of the  College of Physicians in  Dublin, (New
 Series J tbe communications were so large  and so
OSIS.                                   543

free that the heart might be  considered single, or
consisting of  one auricle and  one ventricle: in
this  instance  there was no  cyanosis.   Nearly
similar appearances occurred to Fouquier, Bres-
chet,  and Bertin; and  indeed  have occurred to
all those who have been conversant with the dis-
eased appearances of the heart.   One case in par-
ticular was met with by Breschet, in which the
left subclavian took its rise from the pulmonary
artery, and yet  there  was no blue  colour in
the parts  supplied by the ramifications  of that
vessel.
   [A case has been published by Professor Huss,
of Stockholm, (Gazette  Med. de Paris, 14 Fevr.
1843,) in which  there was  a communication be-
tween the  aorta  and pulmonary  artery without
cyanosis; and, more recently, (Edinb. Med. and
Surg. Journ.: Oct. 1843,) Dr. Craigie has inferred,
from  a case related by him,  as well as from seve-
ral others, first, that the open state of the foramen
ovale is  rarely  a primary  and  solitary  lesion;
secondly, that when it is a solitary lesion it. is not
injurious, and the venous blood of the right auri-
cle is not thereby necessarily mixed with  the arte-
rial blood of  the left auricle; and thirdly, that in
opposition to  what has been hitherto  usually
taught, the open state of the foramen is, in a large
proportion of cases, the means of prolonging life,—
an imperfectly oxygenized blood being adequate
to maintain vital action.  (See Asphtxia.)]
   It  would appear, then,  that  the  mixture of
venous with  arterial blood will not necessarily
produce cyanosis, and that the foramen ovale may
be open, allowing this  admixture to take place,
without the disease in question being  the result.
   Difficult questions, no doubt, will arise with
respect to  the consequences of the want of oxy-
genation in the  blood.   How is a limb  deprived
of arterial blood to maintain its heat ?  How can
it preserve its vitality, or retain its colour ?  It is
probably because  the circulation is  free and un-
embarrassed, and that there is no obstruction to the
depletion of the  extreme capillaries.  A free and
uninterrupted circulation of the blood through the
capillary system  appears to be  necessary to  the
maintenance  of  a proper colour in that fluid :
stagnation or obstruction impairs it in proportion
to its amount.  John Hunter  included a portion
of an artery between two ligatures, thus inducing
a stagnation  in the intercepted fluid : the result
was a change of colour from bright red to purple
in the blood thus separated and brought to a state
of rest.  In  all instances also  of ecchymosis and
petechial extravasion, the effused patches or points
assume a purple hue.
   A  partial stasis, then, in the capillaries, whether
venous or arterial, on the surface, should more or
less   exhibit  a purple  tinge;  and  such  actually,
takes place  in some  morbid  states  not usually
noticed.
   Towards the close of fevers terminating fatally,
and in other disorders where the functions of the
nervous system are much impeded, and the circu-
lation consequently begins  to  fail, we have often
observed  the  purplish colour in the  lips, cheeks,
and inside of the mouth ; appearances which may
be evidently  seen long  before  death.   And what
is this but a  cyanosed state, induced by a stagna-
tion  in  the  capillary system,  which  now wantN 
544
CYANOSIS.
its propulsive power, when deprived of the  ner-
vous energy ?
  All the anatomical observations on this subject,
however, confirm the fact, that in every instance
of cyanosis examined after death, the right cavities
of tiie heart have been found enlarged, dilated, or
thickened, whether there was  accidentally an
opening  or  not.   Corvisart, in  particular,  enu-
merates a blue or violet colour  of  the face and
>ips as appertaining to  organic lesions in the right
cavities of the heart,  and of the whole venous
system, which is in a great measure under  their
guidance.
  In  persons of an advanced age,  affected  with
disorders of the  heart, this bluish tint is not un-
common,  and generally occurs  in  concurrence
with an  injected or dark colour of the mucous
membranes.  In  these disorders, towards the close
of life, there generally occurs some obstacle to the
aortic circulation ;  this obstacle is generally con-
nected with  hypertrophy  of the left  ventricle;
stagnation of blood in the lungs then takes place ;
and to this succeeds passive dilatation of the right
cavities of the heart.
  It has  been further observed  that infants at
birth  are  often  cyanosed  : this  may arise either
from the  impermeable state of the lungs, or  from
want of action of the respiratory muscles, especially
after tedious and difficult labours.  Inflation  of
the  lungs, and other aids, frequently remove  this
blue tint  by exciting respiration.
  A want,  then,  of renovated  arterial or  oxy-
genated blood is not the only cause  of cyanosis;
it appears to  depend also on obstructed pulmonary
circulation, or other impediments to a free return
of the blood to the right cavities of the heart.
  A bluish  or cyanosed appearance on the sur-
face is known also to take  place when  nitrate of
silver  has been administered internally ;  and this
tint has  in  some instances become permanent.
The nitrate, in all probability, is decomposed, and
oxide  of silver becomes deposited in  some part of
the superficial cutaneous tissue.
  The tin^e  imparted to the skin in  liver diseases
differs  altogether from the violet hue  peculiar to
affections  of the  heart.  There  is  a  variety  of
jaundice described by Dr. Baillie, in  the Transac-
tions  of  the  College of Physicians of London,
which he calls the black jaundice,  where the colour
in some degree  approximates to  the blue tinge;
but  in the disease described by him  the colour is
more  of  a leaden  or sooty character.   In  some
few instances, where there was melanosis  of the
liver,  the  tint of the skin  has  appeared  to the
writer of this article unusually dark,  and differing
from the ordinary colour observed  in  hepatic affec-
tions.   But in all these instances the distinctive
characters are sufficiently  striking.   The state of
the  circulation and of the  respiration is  almost
sufficient to afford a diagnosis; and there are other
characteristic symptoms sufficiently impressive and
well known,  which need not be enumerated.
  Bluish  and bruised  patches occurring in  pur-
pura,  and in  ecchymosed  states, do not require
notice further than that they are  often  connected
with  obstructed  circulation in  the lungs  and
through the heart, or with  failure in the nervous
energy ;  but  for  information  respecting these the
'eader is  referred to tbe article Purpura.
  With respect to the treatment of cyanosc affec-
tions, it is obvious, when it is considered that they
depend  on organic lesions, that no general plan
suited to cure idiopathic cyanosis can be laid down.
The radical or complete removal of such disorders
is quite beyond the reach of our art.  The treat-
ment must  be palliative, depending of course on
the precise mode of lesion  in  the individual  in-
stance to be treated.
  In  all cases  it is important to maintain  a heal-
thy state  of the digestive functions by  suitable
diet and the use of such medicines as regulate the
bowels; as  the functions of the  liver  and other
organs  of assimilation are  principally  deranged,
for  want, in  some instances,  of  blood properly
renovated in quality,  and in others from  the  cir-
culation not being sufficiently free and unobstruct-
ed through these organs.
  Acute pulmonary affections  often supervene in
subjects of this description; and bloodletting and
the other usual aids  are  required  more promptly
than in ordinary instances where there is no such
complication.  But it may be  observed that per-
sons advanced in life, or even at earlier periods of
existence, when weakened by protracted suffering,
do  not bear sanguineous depletion well.   It has
been  already remarked  also, that sufferers from
this disease  are frequently affected with dilatation
of the right cavities of the heart, and  that in a
passive form; in these cases bloodletting, which,
except in  cases of excessive sanguineous plethora,
affords only momentary ease, is often followed by
great prostration of strength.
  When  this  disease is attended with  dropsical
symptoms, the remedies usually  resorted to  in
dropsical affections will afford  temporary relief.
  In  those  cyanose disorders where the strength
is much reduced, the circulation languid, and  the
temperature below the natural  standard, consider-
able benefit will be derived from  wine, cordials,
and stimulants; and opiates will control symptoms
arising from tumultuous and  irregular action  of
the heart.  It is important to maintain  a tranquil
state of both mind and body; active exertion is
nearly precluded in such disorders, but gestation
in the open air is most useful in mitigating the
symptoms and prolonging life.
  [In the Cyanosis of the New-Born, Cyanosis
neonatorum, Professor Meigs (Proceedings of the
Amer. Philos. Society at the Centennial Meeting
May, 1843) lays great stress on the effect  of posi
tion.  He recommends  that the child  should  be
placed on its right side, with its head and shoul-
ders inclined upwards, upon pillows, and  be kept
in  this  position for hours.   « Upon placing the
child  thus,  its septum  auriculorum  becomes a
horizontal plane, supporting the blood in  the left
auricle.  The  weight of that blood presses the
valve of the foramen ovale into coincidence with
the plane  of  the septum, and closes the patulous
orifice.  The succeeding injections of blood take
their proper route to the lungs  and the system, so
that a few acts of the  respiratory muscles give
sufficient doses of oxygen to the blood to dimiii
ish, and to rapidly remove, the excess of  carbon,
and the child is cured."
  Rest is, doubtless, an important agent in many
of these cases in establishing the circulation pro-
perly ; but,  on the other hand, a smart blow or 
CYST
the breech  not  unfrequently effects the  same ob-
ject more speedily.  Where the cyanosis is owing
to positive  malformation, no  agency will be  of
any permanent advantage. (Practice of Medicine.
2d edit. i. 489 : Philad. 1844.)]
                             J-  Crampton.
   [CYNANCHE LARYNGEA.  (See Laryn-
gitis.)]
   CYNANCHE MALIGNA.   (See  Scarla-
tivv and [Throat, Diseases of the.])
   CYNANCHE  PAROTIDCEA.   (See  Pa-
rotitis.)
   CYNANCHE  PHARYNGEA.   (See
[Thiioat, Diseases  of  the.])
   CYNANCHE  TONSILLARIS.  (See
[Throat, Diseases  of  the.])
   CYNANCHE  TRACHEALIS.   (See
Croup.)
   CYSTITIS.   Cystitis, or inflammation of the
bladder,  exists   in  various  degrees, from  that
slightest form which is indicated by an increased
secretion of mucus from  its lining membrane, to
the intensely inflamed state which  runs rapidly
on to gangrene.  Although the several inflamed
conditions of the bladder  are so intermingled, and
pass so gradually one into another, that they re-
quire to be  viewed in close connection in order to
be clearly understood ; yet it is useful, for practi-
cal purposes, to distinguish between the bighly
inflammatory or acute cystitis, and the mild or
raucous form to which Lieutaud gave the name,
now generally  applied to it,  of  catarrh of the
bladder.
   I. Acute  Cystitis.—Acute inflammation of
the bladder is known to exist by burning pain in
the region of that organ,  pain  at the extremity of
the urethra, tenderness of the  hypogastrium, and
frequent calls to void urine, which is expelled  in
small  quantities  and  with distressing  spasms.
The local symptoms of inflammation are accom-
panied with the usual constitutional disturbance,
ushered in  by  smart  shivering, and denoted  by
frequent  tense pulse, hot  skin,  thirst, loss of appe-
tite, constipated bowels,  and  much restlessness.
As the disease advances,  the pains shoot from the
bladder to  the  anus, the loins, down the thighs,
and even to the epigastrium;  complete  retention
of urine  takes place, and the distended bladder is
felt as an  oval tumour  rising tense  above the
pubes.   The tenderness,  which was at first con-
fined to the hypogastrium, diffuses itself  over the
whole  abdomen; obstinate  vomiting  of bilious
fluid and hiccup take  place ; delirium comes on,
coma  or convulsions  at  length  supervene, and
death follows.  The urine, during the progress of
the inflammation, undergoes several changes.   At
tbe commencement it is high coloured, as in other
inflammations ; then becomes mingled with flakes
of coagulated  albumen,   or with blood,  bloody
urine being more especially  observed when the
disease has been induced  by a  poisonous dose of
cantharides:  as the disease proceeds,  the  urine
acquires  a  highly offensive odour from its am-
moniacal and  putrescent condition, resembling
more the washings of putrid  flesh  than  human
urine.
   In this brief  sketch of  the  symptoms of acute
cystitis, we may trace the progress of the inflam-
   Vol. I. — 69                      2v»
ITIS.                                   545

mation  from the  mucous coat of the bladder,
which is the most irritable and the most readily
affected by disease, to the  muscular  tunic, and
lastly to the peritoneal.   Anatomists have  well
remarked that the first of these membranes is but
loosely  connected  by cellular membrane to the
second, and this still more loosely to the third;
but they have erred in believing that acute disease
is  not speedily communicated  from one to the
other.   A strong and  indissoluble sympathy links
them altogether, and renders them prone to follow
each other in the train of inflammation.
   When acute  cystitis, instead of commencing
within the  bladder, is communicated  from some
of the adjacent  parts, as  the uterus, the rectum,
or the immediately adjoining cellular tissue, the
order in whicb  the coats become successively in-
flamed will  be different;  and the muscular  or
peritoneal coat will then be the first affected.  It
is  rare  for the whole mucous membrane  to  be
seized at once with inflammation : most commonly
it affects the portion lining the neck of the blad-
der,—sometimes the upper fundus, at  other times
the anterior part, at others the posterior,—and in-
volving the orifices of the ureters, it obstructs the
entrance of the urine, causes the ureters to become
distended, and  producing pressure upon the kid-
neys, in this manner speedily proves fatal.
   A slight degree of inflammation, or perhaps we
ought to say irritation of a mucous  membrane,
causes an increased secretion from its surface; a
greater converts the natural mucus into a puriform
fluid ; and a still  higher  degree of inflammation
replaces the secretions by an effusion of plastic
lymph.  This progression we find in  the inflam-
matory  affection of many other  mucous surfaces
besides that of the bladder; of which the exuda-
tion  of croup, and the false membranes discharged
from  the alimentary  canal  and the uterus, are
examples.  The last change produced in the mu-
cous membrane of the bladder by inflammation is
gangrene, which  sometimes  affects  the  whole
surface; at other times it appears in patches; and
in either case it is  often found that at one spot all
the tunics  have become  sphacelated,  perforation
has taken place, the urine has escaped into the
peritoneal cavity, and thus destroyed the patient.
   When cystitis is prolonged, the mucous mem-
brane becomes ulcerated, and the  ulcers,  when
small, bear no remote similitude to primary syphi-
litic  sores, by their excavated surfaces and raised
margins; a fact which we have had opportunities
of verifying  by dissection.  Ulceration is  often
more extensive, for the whole interior of the blad-
der has been found eroded, and in some instances
the muscular fibres of the  organ have been ex-
posed as if by the knife of the anatomist.  When
ulceration of the mucous  coat deepens and pene-
trates through the other tunics of the bladder, it is
usually accompanied  by  the  effusion of  plastic
lymph exterior to the ulcer, which thus glues the
neighbouring  parts  together,  and  prevents the
escape of the urine : but instances have occurred
in which an ulcer  of the  bladder has  terminated
in perforation, just as from gangrene, though moie
slowly, and in like manner has proved fatal.  The
existence of ulceration of the bladder cannot  be
certainly known during the lifetime of the patient;
but there is always reason to suspect it when di*- 
546
CYSTITIS.
ease of that organ has been of long continuance,
when the pain is unceasing and excessive,  and
when pus is distinctly detected in the urine.  We
must not, however, expect to see pus in a separate
state, for it is rarely discharged without a copious
admixture of mucus ;  and this we have known to
be the case when dissection revealed  ulceration
both of the kidney and bladder.
  Inflammation  of the  muscular  tunic  of the
bladder may arise either in the membrane itself,
or be communicated  from the adjacent textures.
In some cases  the inflammation of this membrane
has induced circumscribed suppuration, (Chopart,
Maladies  des  Voies urinaires,  t. i. p. 453 ;) in
others  the pus  has been  infiltrated extensively
among the muscular fibres (Bonetus, Sepulchre-
tum, lib. iii. sect. 23)  of  the bladder.   Extensive
abscesses have also been  found between the mus-
cular and peritoneal coats; and  death has  in this
manner been produced in numerous cases of litho-
tomy.   Chopart relates a very interesting case of
large abscess around the  bladder, which occurred
in the  practice of Moreau.   In this  case, that dis-
tinguished surgeon,  after making an  opening
above  the  pubes,  struck his bistoury into  a sus-
pected spot near the anus,  and formed a counter-
opening,  by which he succeeded  in saving his
patient.
  Inflammation of the peritoneal coat is often the
close of a fatal disease of the bladder;  but that it
takes place under other circumstances, without
any dangerous consequences,  we have  sufficient
evidence from the old adhesions not unfrequently
found  connecting this part to the omentum,  to
portions of the intestine, to the uterus, or to the
rectum.   In  a recent case of diseased  prostate,
the omentum  was found attached to the peritoneal
covering of the upper fundus of the bladder.
   In all prolonged diseases of the urinary bladder,
when  frequent  ineffectual attempts are made to
evacuate its contents, the  muscular coat acquires
an extraordinary  increase of size  and firmness,
separating into distinct bundles, which project on
its internal surface,  and  leave spaces through
which  the mucous  membrane  is  forced,  thus
forming small pouches  : this  is not the  conse-
quence of inflammation, but of increased muscular
action.  There  is, however,  an indurated and
thickened state  of the bladder which is produced
by inflammation,  and of which Frank has given
an interesting example, where he was led  to con-
clude  that the whole  anterior part of the bladder
was in a state  of callous induration.  (J. P. Frank,
De Curand. Horn. Morb. torn. v. Retention. Mu-
coso-Lymphat. Vesica.)
   When  acute  cystitis   is  about to  terminate
favourably, and the  violence  of the disease  has
spent  its force, the natural mucus  of the bladder
is increased in quantity and altered in its appear-
ance : it separates from the  urine on standing,
and forms a ropy  gelatinous-like fluid,—the com-
plaint passing into that milder form which has
been named catarrh of the bladder.
   Causes.—Acute cystitis is induced by direct
injuries, as by wounds, contusions, severe exercise
on  horseback, prolonged  travelling in  a carriage
 over rough roads, the introduction into the  bladder
 of foreign bodies, as bougies  and sounds: the
 latter  are too  often incautiously used :  indeed to
the examinations made under such circumslanets
may, in some instances, be traced the  fatal result
of the subsequent operation of lithotomy.  Calculi
themselves also produce cystitis, commonly of the
mild or chronic  form, or catarrh  of the  bladder.
All mechanical  obstructions to the discharge  of
the urine, as strictures of the  urethra, enlargement
of the prostate  gland, and calculi 1 >dged  in the
neck of the bladder, may  prove causes of cystitis.
It is  induced likewise by exposure to cold and
moisture, by excess in drinking,  by the  internal
use of cantharides, and even by their application
to a highly sensitive  and partly abraded  surface,
as in Ambrose Pare's case of the lady who was
cured of an obstinate eruption in the face by blis-
tering,   (ffiuvres, fob p. 777.)
   Cystitis also takes place by continuous  inflam-
mation  spreading along  the mucous membrane
from the urethra in gonorrhoea, or from the kid-
neys when they are diseased.  It may likewise be
communicated by an extension  of inflammation
from adjacent parts; from the translation of mi-
gratory diseases,  as  gout and  rheumatism;  or
from the recession of cutaneous  eruptions: these
are, however, causes  of  chronic  rather than  of
acute cystitis.
   Treatment.—The treatment of acute  cystitis
is to  be commenced by free venesection  and the
warm bath, which  may be followed by leeches to
the perineum and groins.  Should the bladder be
much distended, its contents ought to be evacuated
without delay, but until some impression be made
on the local inflammation, the introduction of the
catheter will  be  exceedingly painful, and produc-
tive of  no permanent  relief.   A full dose of calo-
mel ought to be given, combined with a  grain or
two of opium ;  and after some  hours the bowels
may be relieved by castor oil or an emollient ene-
ma.  Free perspiration ought  to be kept up by
Dover's powder and  the  cautious use of antimo-
nials; while warm opiate fomentations or poul-
tices, bags of heated salt, or bladders filled with
hot water, are applied to the pubes and perineum.
Diluents  should be freely given, and tbe patient
restricted  to a spare  diet of the mildest  kind of
food. When cystitis has  terminated in the forma-
tion of abscess,  this ought, if within  reach, to be
evacuated as early as possible by a free and de-
pending opening ; while the tendency  to hectic
is checked by cool  air, tepid  sponging,  and the
mineral acids, and the strength of the patient is
supported by gentle  tonics and  light nutritious
diet.   When ulceration   has  fairly  established
itself within the bladder, the resources of our art
are rarely of much avail; but we are not war-
ranted in assuming that  such cases are altogether
incurable ; for instances  are recorded, and  some
 have come under our  own  observation, in which
 health  has been restored after calculi and other
 foreign  bodies  have escaped by ulceration from
 the bladder.  The sufferings arising from ulcera-
 tion of the bladder are remarkably mitigated by
 the full action of calomel and opium, and by the
 formation of issues over the pubes.   Benefit  has
 also been  obtained from the  administration of uva
 ursi, pareira brava,  and the  weak saline and
 aerated mineral  waters.
    Of the practice of  injecting mucilaginous dilu-
 ents and mild astringents into the ulcerated blad- 
CYST
der, we cannot  speak fum  experience; but  we
feel strong doubts of its efficacy, and are disposed
to think that the operation would prove irritating
and injurious.
  When acute cystitis has arisen from calculus in
the bladder, the obvious remedy is extraction, as
soon as the  subsidence of urgent  symptoms will
permit.  If cystitis can be traced to the translation
of gout or rheumatism, the application of irritants
to the situations where these diseases  previously
existed, and the  administration  of  colchicum,
must be had recourse to, while the means already
mentioned for subduing inflammation of the blad-
der are carefully put in practice.
   II.  Chronic Cystitis.—This form, which has
also been called mucous  cystitis,  and catarrh of
the bladder, was  at one  period  considered  an
uncommon  disease; the laborious and  accom-
plished  Hoffmann  designated  it  " rarus  vesicae
affectus."   It exists either in connection  with  a
febrile state  of  the body, or with simple irritation
of the bladder or its adjoining and associated parts.
Generally it is met with as a sporadic disease, but
like the affections  of some  other mucous  mem-
branes, it  may prevail epidemically.  Gunther
describes such an  epidemic  as  prevailing  in  the
autumn of  1782.   (Sommering, Ueber die tod-
lichen Krankheiten der Harnblase und Harnrohre
alter Manner.)
   Symptoms.—The symptoms of chronic cys-
titis are, frequent calls to void urine, with more or
less pain in  the  region  of the  bladder and at the
extremity of the  urethra, either before  or  during
the process.   There is also, in most cases, tension
of tbe hypogastrium, which may depend either on
increased  sensibility of the bladder, or on  disten-
sion from urine.   In all cases there is discharged
along  with  the  urine an increased quantity of
mucus, somewhat  altered from its natural appear-
ance.   Even in health a slight  mucous cloud is
deposited from the urine  in cooling; hut in the
disease we are now considering,  the quantity is
 greatly augmented,  sometimes  bearing  the enor-
 mous  proportion  of more than one-half  of  the
whole fluid  discharged  from  the bladder.   (Cho-
part, torn. i. p. 415.)  It is usually voided sus-
pended in the  urine, from which  after a  time  it
subsides, forming a  jelly-like substance, so viscid
and tenacious  as  to be with  difficulty detached
from  the bottom  of the vessel.  At  other times
 the mucus  is discharged from the bladder in a
separate state, and of so thick a consistence as to
obstruct the passage of the urine, and even  to plug
up the  catheter.   The  mucus, which was at first
pellucid or grey, becomes in the progress  of the
complaint  yellowish, then  greenish,  sometimes
streaked with blood  ; and at length, when  ulcera-
 tion is established, largely mixed with pus.  The
character of the mucus is always alkaline,  and
the urine often of the same  nature—ammoniacal,
sometimes highly  fetid.
   The pathological changes discovered in cases
of chronic  cystitis  are  chiefly, injection  of the
mucous membrane, occasionally enlargement of
the veins, and when the disease is of long stand-
ing, overgrowth and thickening  of  the  mucous
tissue.   Ulceration  is likewise  often  observed  to
have taken  place at the close of the disease, when
it has been  severe and long protracted • on other
ITIS.                                   547
occasions  acute  cystitis has supervened on the
catarrhal affection, presenting after death the usual
marks of the disease.
  Causes.—Chronic cystitis, or catarrh of the
bladder, originates in many and various causes.
It .has sometimes occurred at the crisis of fevers,
as the mode in which solution has taken place ;
in other instances it has alternated with mucous
discharge  from the bronchi.  Exposure to  damp
and cold, and to sudden  variations of tempeiature,
has given  rise  to the disease :  it has also, as well
as the acute form, originated from the translation
of gout and  rheumatism,  and the repulsion  of
cutaneous  eruptions.   But  its most  frequent
causes are calculus  in  the bladder  and enlarge-
ment of the prostate gland.  It occurs much more
rarely among the young than  the old, and amonj
females than  males,—circumstances which are tc
be explained  by reference  to  the peculiarities ol
the female, and  to the period  at which the  pros-
tate  usually becomes the  subject of disease.   On
more than one occasion we have traced a distinct
connection between  mucous cystitis and a stru-
mous habit; causes having produced it in indivi-
duals of this constitution, which would not hav«
been  sufficient to excite the disease in those of  a
more robust constitution.
  Treatment.—Catarrh of the bladder, though
classed with inflammatory diseases, rarely requires
the employment of  depletion, unless when  the
pain in  the region of the bladder is considerable,
and  then  the  application of leeches is usually
sufficient.  Should the  disease appear in connec-
tion  with  other mucous discharges, and be accom-
panied with febrile symptoms, the warm bath, the
saline mixture, and  opiates; and if it have arisen
from  the translation  of gout or rheumatism, or the
repercussion of cutaneous eruptions, free perspira-
tion,  and  stimulating the  part where the previous
disease was fixed, will be  proper.  In gouty and
rheumatic cases the administration  of colchicum
offers the best  mode of cure.   When the  affec-
tion depends on an enfeebled constitution or scro-
fulous habit, the mineral  acids, bitters and astrin-
gents will be found beneficial.  Of astringent re-
medies  the best are  pareira brava, uva ursi, kino,
and  catechu.    But  in  this form of the disease
more advantage is often derived from stimulants
of the  urinary  organs, such  as the turpentines,
and above all small doses of  copaiba and  cubeb
pepper.   [Turpentine, with the catheter kept con-
stantly  in the  bladder, comprised the treatment
usually adopted  by Dupuytren  at one time.]   In
such cases, also, change of air and sea-bathing on
a dry and open shore have  been productive of
much benefit.  The diet  ought to be mild  and
nutritious, consisting of  milk,  eggs,  farinaceous
substances, and a moderate proportion of animal
food.  In almost all instances of this disease,  spi-
rituous liquors, even in moderate quantity, are in-
 jurious ;  cases however  do occur when a small
 quantity of generous wine will be found beneficial.
   All irritation of the sexual organs  should  be
 avoided ;  and if the  patient have contracted  im-
 proper habits, they must be abandoned before  any
 bope of cure can be held  out.  The patient ought
 to spend  much  of his time in the open air, using
 gentle exercise : he should reside, if possible, in a
 dry  and  elevated situation, and ought  to  be  al 
548
CYSTITIS —DEAD,  (PERSONS  FOUND)
ways warmly clothed,  wearing flannel next the
skin.  More benefit will often be found to accrue
from a careful adherence to these directions re-
garding diet and general management of health,
than from the employment of any medicine.
   The injection of the bladder with mild diluents,
such as barley-water, afterwards  rendered  more
stimulant and astringent by the admixture of
some mineral water, has been practised and highly
recommended by Dessault, Chopart, and others ;
and we are inclined to think that advantage may
be derived from the mere distension of the mucous
membrane under catarrhal disease ; just as gleety
discharges from the urethra are cured  by the in-
troduction of a full-sized sound or bougie.
   [Where  the  disease  is manifestly  connected
with an atonic condition of the parietes of the blad-
der, the catheter or  sonde a  demeure becomes
indispensable, through  whicb  appropriate  injec-
tions may be sent into the bladder.
   In the more chronic  forms, Sir Benjamin Bro-
die has injected  nitric  acid  largely  diluted.  At
first, the proportion  ought not to be more than
one minim to two fluidounces of distilled water ;
but  afterwards the proportion may be doubled.
The bladder should be first washed out with a
little tepid water; the acid  solution should then
be  injected, and be allowed to remain not longer
than  thirty  seconds.   This may be repeated  at
first every two  days, and afterwards  every day.
Should the injection be followed by pain and other
evidences of inflammation, or the urine be tinged
with blood, the repetition must be postponed. In-
jections of tar-water, along with  the internal use
of turpentine, were highly extolled by M. Dupuy-
tren.   (La  Lancette  Franqaise, 8 Avril,  1837.)
The iodide of iron would make a valuable injection
in such cases.  Injections of soot have likewise
been used with  benefit.   (New  Remedies, 4th
edit.: Philad. 1843.)  In very obstinate cases, it
has  been advised by M. Lallemand to cauterize
the  interior  of the  bladder.   (See the writer's
Practice of Medicine, edit. cit. ii. 73.)]
   }Vhen catarrh of  the bladder, &c. depends on
the presence of a calculus or other foreign  body,
no cure can be effected without extracting what
causes  the  irritation ; but  after  its removal we
sometimes find it necessary to administer  tonics
and urinary stimulants, such as have  been already
named,  before the discharge will cease.  And in
all  cases of this  nature  the operation should be
immediately followed  by a careful attention to the
state of the cutaneous surface ; and warm clothing
should in an especial  manner be enjoined.
   When the disease  arises  from enlargement of
the prostate  gland, the only remedies which can
be of avail are those suited to the  treatment of
that disease.                     tIT ,~,
                                W. Cumin.

   DEAD, (PERSONS FOUND) —Under this
head we propose to treat of those causes by which
life is  suddenly or quickly  extinguished in per-
sons previously in  the apparent  enjoyment of
good health.  Cases  of this kind  are  peculiarly
the objects of legal investigation by the  coroner ;
and as all medical men are liable to be called on
lo assist him with their professional information
and opinion,  it is of  the  utmost importance that
;lear notions of the true nature of the phenomena
 that  present  themselves should  be entertained.
 The  object of  such inquiry being to ascertain
 whether death was natural  or owing to some  ac-
 cidental cause, the whole subject of sudden death
 may  be conveniently arranged under two heads,—
 namely, 1. sudden death from natural  causes : 2.
 sudden death from violent  causes ; comprehend-
 ing under  the latter every variety, whether the re-
 sult of accident or of criminal intention.
   Our first duty on the discovery of a supposed
 dead body, is to ascertain whether any spark of
 life  still remain, by rekindling  which  animation
 may  be restored ;  and this leads us, before enter-
 ing  on  the  causes and phenomena  of  sudden
 death, to consider the states of body that may re-
 semble death, and to point out the means of dis-
 crimination between those cases in which life is
 really extinct, and those in which the  exercise of
 the vital power is only suspended.  Nothing is
 more certain than death ; nothing is at times more
 uncertain that its reality: and numerous instances
 are recorded  of persons prematurely  buried, or
 actually at the  verge of the grave, before it was
 discovered that life  still remained  ; and even of
 some who were resuscitated by the knife of the
 anatomist.  Pliny, who devotes an entire chapter
 to this subject, entitled " De his qui elati revixe-
 runt," amongst  other instances  gives that of the
 Roman consul Avicula, who being supposed dead
 was conveyed to  his funeral pile, where he was
 reanimated by the flames, and  loudly  called for
 succour; but  before he could be  saved, he was
 enveloped  by  the  fire and suffocated.   Bruhier,*
 a French Pbysician, who wrote on the uncertainty
 of the signs of death in 1742, relates an instance
 of a young woman, upon whose supposed corpse
 an anatomical examination was about to be made,
 when the first stroke of the scalpel revealed the
 truth : she recovered, and lived many years after-
 wards.   The  case related  by  Philippe Pue is
 somewhat  similar.  He proceeded to perform the
 Caesarean  section  upon a woman who  had to all
 appearance died  undelivered, when the first in-
 cision betrayed the  awful fallacy under which he
 acted.   A remarkable  instance of resuscitation
 after  appearent death occurred in France, in  the
 neighbourhood of Douai, in the year 1745, and is
 related  by Rigaudeaux,  (Journal  des  Scavans,
 1749,) to whom the case was confided.  He was
 summoned in  the  morning to attend a  woman in
 labour, at a distance of about a league.  On  his
 arrival, he  was informed  that she had  died in a
 convulsive fit two  hours previously.  The body
 was  already prepared  for interment, and on  ex-
 amination  he could discover no indications of life.
 The os uteri was sufficiently dilated to enable him
 to turn the child, and  deliver by  the feet.  The
 child  appeared dead also; but by persevering in
 the means of resuscitation  for three hours, they
 excited some signs of vitality, which encouraged
 them  to proceed ; and their endeavours  were ulti-
 mately crowned with complete  success.  Rigau-
 deaux again  carefully examined the mother, and

  * " Dissertation sur 1'incertittitle des signes de la mnrt,
et  I'abus  des it.terremens  et einliaumens  precipites."
 Eruhier mentions leu cases in which persons still living
were treated as dead ; of these, 52 were buried alive, 4
were opened before death, 53 revived spontaneously after
being  placed in  their coffins, and 72 were supposed to
have died when  they really had not. 
DEAD,  (PERSONS  FOUND)
549
was confirmed in the belief of her death ;  but he
found that, although she had  been in that  state
for seven hours, her limbs retained their flexibility.
Stimulants were applied in vain ;  and he took his
leave, recommending that the interment should be
deferred until the flexibility was lost.   At five p.m.
a messenger came to inform him that she had re-
vived at half past three.  The mother and  child
were  both  alive  three  years  after.   There  is
scarcely a dissecting-room that has not some tra-
ditional story handed down of subjects restored to
life after being deposited within its walls.  Many
of these are mere inventions  to  catch the  ever-
greedy ear of curiosity;  but some of them are, we
fear, too well  founded  to  admit of much doubt.
To this class belongs the circumstance  related by
Louis, the  celebrated  French  writer on  medical
 jurisprudence.  A patient who was supposed to
have died in the Hopital Salpetriere, was removed
to his dissecting-room.   Next morning Louis was
 informed  that moans had been heard in the  thea-
 tre ; and  on proceeding thither he  found, to his
 horror, that the supposed corpse had revived dur-
 ing the night, and had  actually died in the strug-
 gles to disengage herself from the winding-sheet
 in  which she  was enveloped.   This was evident
 from the distorted attitude in which the body was
 found.   Allowing for much of fiction with which
 such a  subject must ever be mixed, there is still
 sufficient evidence to warrant a diligent examina-
 tion of the means of discriminating between real
 and apparent death: indeed, the horror with which
 we  contemplate a mistake of the  living  for the
 dead should excite us in the pursuit of knowledge
 by which  an  event  so repugnant to our feelings
 may be avoided.
   Life consists (at least as far as we can perceive,)
 in the presence of  a preserving principle, proper
 to  all organized beings, and peculiar to each spe-
 cies, which opposes  itself continually to the  influ-
 ence of the physical and chemical agents that sur-
 round us.  Tbe effects of these agents in altering
 the forms and nature of inorganic substances we
 daily witness, while  our frames resist them in
 every latitude.  This power, in  conjunction with
 sensation and motion, constitutes the state of life;
 a state which subsists  as  long as this power re-
 mains.   But we do not see  this power;  it only
 renders itself sensible by the motions given to the
 heart, lungs, and  other organs ;  and it is by the
 existence  of  these  motions,  that  we generally
 judge of the  existence of life.  This isolated ab-
 stract principle cannot  subsist, as far as we know,
 without the instruments by which it makes  itself
 visible;  it is for this reason that these are  to be
 particularly considered on the present occasion,
 without in the least, however, diverting  us  from
 the consideration of a  great first cause.  If life
 depends upon the  presence of a force or power
 continually opposed to the action of physical and
 chemical laws, real  death will  be the  loss of this
 force, and the abandonment  of organized bodies
 to  these  agents; while apparent  death  will be
 only the suspension of the exercise  of  life, caused
 by some  derangement of the  functions which
 serve as  the  instruments of vital  action.   This
 suspension must last for a considerable time, if we
 may judge by the cases collected by credible au-
 thors, to  some of which we have alluded, and by
the numerous instances of drowned  persons  re-
stored to life  after long submersion.   From this
definition of  life; and death, it would follow that
putrefaction is the only evidence of real death ;
but in many instances it would be  attended with
much inconvenience,  and often  with danger, to
wait for this confirmation of the extinction of life.
In malignant diseases, and during times of severe
general  sickness, the keeping of bodies disinterred
until putrefaction announced the  reality of death,
would be a measure fraught with  considerable risk
to the  lives  of  the  survivors.  It  then  becomes
desirable that we should be acquainted with those
signs by which we may judge that life is extin-
guished by the interruption of its functions.
   As respiration is  a function most essential to
life, and at the same time the most apparent, the
cessation of it may be considered  as an indication
of death.  But  as in certain diseases and  states
of  great  exhaustion it becomes very slow and
feeble, so as to the casual  observer to  appear quite
extinct,  various methods have been  adopted for
ascertaining  its existence.  Thus,  placing  down
or other light substance near the mouth  or nose ;
laying a vessel of water on the chest, as an index
of motion in  that cavity ; holding a mirror before
the mouth in order to condense the watery vapour
of the breath;  have all been proposed  and em-
ployed, but they are  all liable to  fallacy.  Down,
or whatever substance is employed, may be moved
by some agitation of the surrounding  air ; and
the surface of a mirror may be apparently covered
by the  condensed vapour  of the  breath, when it
is only  the fluid of some exhalation from the sur-
face of the body.  We, therefore, agree fully with
the judicious observations of Dr. Paris (Paris and
Fonblanque, Med. Jur. vol. ii. p.  10,) on  this sub-
ject.  " We feel no hesitation in asserting that it
is physiologically impossible for a human being to
remain  more than a few minutes in such a state
of  asphyxia  as not to betray some  sign by which
a medical observer can at once recognise  the  ex-
istence  of vitality ; for if the  respiration  be only
suspended for a short interval, we may  conclude
that life has fled for ever.   Of all the acts of ani-
mal life, this is  by far the most essential and in-
dispensable.   Breath  and life are very  properly
considered in the Scriptures as convertible terms;
and the  same synonym, as far as we know, pre-
vails in  every  language.   However slow and
feeble  respiration may become by disease, yet it
must always be perceptible, provided the naked
breast and belly be exposed; for when the inter
costal muscles act, the ribs are  elevated, and the
sternum is pushed forward: when  the diaphragm
acts, the abdomen swells.  Now this can never
escape  the  attentive eye: and by looking at the
chest and belly, we shall  form  a  safer conclusion
than by  the popular methods which have been
usually adopted."
   The absence of the circulation of the blood has
been looked  on as a certain indication of death ,
but this is a test not much to be  depended on, fo'
it is well known that persons may live  even for
hours, in whom no trace of the action of the hean
and arteries can be perceived.   In applying  this
test, it  is necessary  to  remember that  it often
occurs that the pulse at the wrist cannot be felt if
the limb  be extended or everted; but if it's beni, 
550
DEAD,  (PERSONS  FOUND)
and the hand turned inwards, it becomes percepti-
ble.  We  should, therefore, perform this move-
ment,  by which  the artery  is relaxed,  and the
passage of the blood is facilitated when only fee-
bly propelled.   Sometimes, also, the artery can be
felt between the thumb and  first metacarpal bone
when it is  not to be found at the wrist.  It is well
to seek for the  artery at the bend of the  arm, as
the pulse can often be felt  there  after it  has left
the wrist.  In these examinations it  is necessary
to press very lightly, lest we should obliterate the
pulsation altogether ;  and care should be taken to
guard against mistaking the beating of the arteries
in one's own fingers for that of the  artery under
examination.  The trial should be made at every
part where large arteries pass ; and sometimes the
proceeding of laying the body on the left side, and
placing the hand  under the region  of  the heart,
may be adopted.   The  stethoscope may be used
with great advantage in these  cases, as  any mo-
tion of the heart will be sure to become sensible
through the aid of this instrument.
   The temperature of the body has also been pro-
posed  as a guide, but this is very fallacious, as it
is well known  that  the cooling of  a body after
death is influenced Dy many  circumstances, such
as  age, habit of body, and  the disease of which
the person died.   With respect to age, it has been
observed that the bodies of young persons retain
their heat  longer than  those of old.   In fact, in
old age, the winter of life as it has been  termed,
death is  scarcely any thing  more than to  become
cold ; and  in those cases the temperature of the
body is rapidly reduced to that of the surrounding
medium.  Hei.ce we derive  a caution in judging
of priority  of death  among a number  of bodies
overwhelmed by the  same accident;  for the body
of a young person found warm, and that of an
old one found cold,  would not indicate that the
former had survived the latter.  This will be more
fully trea'.ud of in another article.  (See Survi-
vorship.)
   The habit of body has also been  observed to
exert  an influence over the rate of cooling after
death, and  it is  found, cxteris paribus, that fat
bodies lose their heat sooner than lean, but putrefy
sooner.  The disease which  has destroyed life is
a powerful controlling agent  in  the loss of tem-
perature  after death.  Thus it  has been  long
known that in apoplexy the body retains its heat
for a considerable time.   This has been particu-
larly noticed by Portal.  Again, in that disease or
accident frequently witnessed in tropical climates,
the « coup de soleil," we are informed  by Bade-
noch that the bodies of the sufferers remain warm
much longer than in other  forms of death.   In
most kinds of asphyxia except that by drowning,
but especially in asphyxia by noxious gases, the
dissipation  of the animal heat is greatly delayed.
lu cases of the latter description, Orfila found the
heat preserved for twelve hours after  death;  and
we are informed by Samoelowitz, that during the
great plague at Moscow, the  bodies of those who
were speedy victims to that disease preserved their
temperature much longer than the bodies of those
who die by ordinary diseases.  Besides these cases
in which the animal heat is preserved to  an  un-
usual length of time  after death, there are others
ir wLicn it U rapidly los* during life, and  even
 when  there  is  no danger of death, as in some
 forms of hysteria, and in syncope.  It is also  an
 effect of submersion in water, and is usually ob-
 served in the bodies of those restored to life  after
 drowning.   Flexibility of  the  limbs  succeeding
 their rigidity is one  of  the  most  characteristic
 signs of death : we say succeeding their rigidity,
 because  so  long as the limbs are flexible, if the
 flexibility has  not succeeded  stiffness, we  may
 presume that there are some remains of life.  We
 are indebted  to Nysten and Louis for some valu-
 able observations on the occurrence  and duration
 of the cadaverous  stiffness.  The rigidity of the
 muscles  commences  in the trunk  and neck; it
 then  spreads  to  the thoracic  extremities,  and
 finally reaches the legs and feet, and in subsiding
 it follows the same course.  Its duration is in pro-
 portion to  the  lateness of its  occurrence, it being
 found to continue longer in those  cases in which
 it commences latest.   Its energy and duration are
 always in  a direct ratio with the degree of de-
 velopment  and energy of the muscular  system  at
 the moment of death : thus it is extremely strong
 in the  bodies of athletic individuals, in those who
 die of tetanus, or who  are asphyxiated by noxious
 gases whose deleterious action does  not affect the
 contractility of the muscles.  In all animals, the
 moment  when  stiffness  commences  is  that  in
 which  the vital heat appears to be nearly extinct.
 Professor Louis, from observations made  upon
 more than five hundred subjects  after death, found
 that at the moment  of the absolute cessation of
 the vital movements,  the articulations began  to
 become stiff even before the loss  of animal heat.
 Fodere has verified the justness of this observa-
 tion several times in hospitals, and concludes that
 the flexibility of the limbs is one of the principal
 signs by which we may judge  that a person is not
 dead,  although there  is no  other sign of life.
 During the whole time  this  contraction of the
 muscles continues, they resist the action of chemi-
 cal forces,  and it is only when suppleness is re-
 stored  that putrefaction commences.  Nysten re-
 gards this stiffness as a measure of the resistance
 opposed by organic to chemical forces.  Life on
 the point of extinction seems to  take  refuge in
 the muscles, and there causes the spasms we speak
 of, and during their continuance is able to resist
 the operation of chemical forces.
  The occurrence  of  the  cadaverous stiffness  is
 subordinate to the same causes that  influence the
 loss of temperature.  We have  seen that old age
 favours the dissipation of animal heat, and in like
 manner it is observed that the muscular  rigidity
 comes  on soonest in the bodies of old persons.
 The habit  of body in which  the  temperature  is
 longest preserved is that in  which  stiffness of the
 limbs is  slowest in its invasion; thus  the  bodies
 of full and fat persons remain  longer flexible than
 those of meagre and lean.   And again,  those dis-
eases which are followed by a long continuance
 of warmth are also remarkable for leaving a corpse
in an equal degree flexible ; while those in which
the body is rapidly  cooled, as haemorrhage for ex-
ample,  favour the approach of the muscular spasm;
and after death from these, the  body becomes soon-
est and sometimes suddenly stiff.   From this con-
currence  between the spontaneous cooling of the
dead body, and  the supervention  of the cadaveT- 
DEAD, (PERSO
ous stiffness, it might be presumed that accidental
cooling  would  be followed by  a  similar effect;
and this is precisely  what takes place ; for bodies
left exposed in  cold situations, as on a field of
battle, are found to become rapidly stiff.
  The rigidity of the body is a criterion of  great
value, as  it points out the general contraction of
the muscular fibre that occurs shortly after disso-
lution ; but in regarding it as a test of death, it is
necessary  to guard against mistaking the stiffness
that arises from other causes for  the cadaverous
stiffness.   In persons frozen but not yet dead, or,
in other words,  susceptible  of reanimation, the
rigidity  of the  body is very  great, but on  close
examination it  is found not to be confined to the
muscular system, but to pervade all parts of the
body. The breasts, belly, and skin, are all equally
hard with the muscles, to which  alone the stiff-
ness is confined in that from death. This, coupled
with the crackling noise caused by  forcible flexure
of a joint,  will be sufficient mark of discrimination
between the two.  Moreover, it can scarcely  be a
source of error, because it  is an effect of the acci-
dent to which the person  has been exposed, and
if it does not yield to the appropriate remedy (the
gradual application of heat), it will be an indica-
tion that the subject  is really dead.
   The stiffness that occurs  in certain  forms of
syncope and convulsive  diseases  can  never be
confounded with cadaverous rigidity, if proper
attention be paid  to the facts connected with it;
for in the  former case it takes place immediately
after the invasion of  the disease, and always pre-
cedes apparent  death, while the  body still  pre-
serves a considerable degree of warmth ;  whereas
the cadaverous stiffness is not observed until some
time after  death, and when the heat of the body
is scarcely sensible.  In all stiffness  of this  kind
there is much difficulty in moving a limb ; so far
it resembles that  from death ;  but  after having
bent the limb,  on ceasing to apply the  force, it
immediately flies  back to  its   former  position ;
while the  dead limb, on the  contrary, remains in
the position in which it is placed. -  If death really
takes place in any of these convulsive  diseases,
the muscular contraction  ceases with the extinc-
tion of the nervous influence to which it was
owing, and the true  cadaverous stiffness succeeds
at the proper time,  and  runs its usual course.
But above all, the termination of the cadaverous
rigidity in flexibility serves to distinguish it from
every other, and is a certain indication  of disso-
lution.
   That peculiar cast of countenance termed from
its  first describer  the Hippocratic, has  been re-
garded by some as another sign upon which reli-
ance may  be  placed  in judging of the reality of
death.  It is thus described by Hippocrates: " The
forehead wrinkled and  dry ;  the eye sunken; the
nose pointed, and bordered with a violet or  black
circle; the temples sunken, hollow,  and  retired;
tbe ears sticking up ; the lips hanging down ; the
cheeks sunken ;  the  chin  wrinkled and hard  ; the
colour of the skin leaden or violet; the hairs of
the nose and eye-lashes sprinkled with a yellowish
white dust." Such is the  alteration in the human
physiognomy that usually takes place after death.
But it is also produced by the  near  approach of
death; often  by  the sight of imminent danger;
)NS FOUND.)                         551

 and is  also commonly observed in criminals  at
 execution, whatever may be the degree of tran-
 quillity assumed.  Moreover, those who perish by
 sudden death, or of short diseases in which disso-
 lution is not expected, preserve their usual phy-
 siognomy ; while, on the other hand, the counte-
 nance may be pale,  ghastly,  and  contracted  in
 nervous and hysterical affections without extinc-
 tion of life.  Finally,  there  are some individuals
 whose integuments during life have a leaden and
 cadaverous aspect, and whose countenance during
 natural sleep puts on an appearance little removed
 from the Hippocratic. From these causes we think
 that little reliance can be placed on the countenance
 as a test of death.
   The  changes that take place in the eye  after
 dissolution are remarkable, and have been regard-
 ed by some authors as satisfactory  indications  of
 death.  These  are, the cornea becoming opaque,
 and covered with a thin slimy membrane, wbich
 breaks in pieces when touched, and  is easily re-
 moved  by wiping; and  general flaccidity  of the
 eye-ball, which  may be  perceived by placing the  .
 finger on the upper eye-lid and  moving  it  gently
 over the surface of the eye ;  when the point of the
 finger will sink on coming over the  cornea, and a
 distinct ring will be felt, marking the attachment
 of this membrane to the sclerotic coat.  Certainly
 these signs are valid in many forms  of death, but
 they do not exist in all,  and are therefore not in-
 fallible.   The  reason why  they  are sometimes
 present and at  others wanting, is  evident when
 we consider the causes upon which these changes
 depend.  The  cornea  owes its brightness mainly
 to the tension of the eye-ball,  produced by a full
 secretion of the humours.  This  is proved  by
 evacuating a portion of the humours of a recent
 eye, when the  cornea will become flaccid and
 opaque; or by taking an eye some time dead, and
 with the cornea already opaque, and compressing
 the  humours towards the anterior part,  when the
 cornea  will reassume its brightness.  We find the
 appearance of  the living eye  influenced by the
 same cause, and hence we see the dim cornea in
 very aged  and meagre persons produced by a defi-
 ciency  in the ocular in common with every other
 secretion.   We do not speak of the arcus senilis,
 but of  the general opacity of the cornea observed
 in  such individuals.   Hence we can understand
 why in death after long illness, when the powers
 of  reparation  have been for a length of time im-
 paired, the eye should exhibit its want of fullness
 by a flaccid and dim cornea.  On the other hand,
 we  are led  to  expect,  when  death takes place
 suddenly in a  healthy person, that the eye will
 preserve its lustre for a much longer period ; and
 this experience  confirms ; for it has been observed
 that after death by apoplexy, asphyxia, prussit
 acid, &c.  the eyes preserve their  integrity  for a
 considerable time, owing to their  being  at the
 time of death in a state of tension by the due se-
 cretion of the  vitreous and aqueous  humours.
 Moreover, it has been  observed  that  in  severe
 diseases of long continuance,  and  even in some
 affections of the mind, the eyes have become dim
 and shrunken, although  death may not happen,
 and thus another source of fallacy arises.
   Different physical tests have been proposed for
 doubtful cases,  such as incisions, burns, Mister* 
552
DEAD,  (PERSONS  FOUND)
cupping, flagellation, &c.;  < ut of these it may be
said that there are so many instances of disease
affecting the nervous system, in which their ap-
plication causes no sensation in the sufferer,  that
they will be still less likely to  produce any effect
on the  sensorium in a body  nearly deprived of
/ife.  The influence possessed by galvanism in the
production of muscular contraction in the living
body has  led to its  adoption  as  a test of death;'
and with certain limitation it is one of considera-
ble value ; for although the muscles retain their
contractility for  some time after absolute  death,
yet if the  death be real, they soon lose it, and be-
come insensible to this stimulus.  On the other
hand, if the least  spark  of life remain, the  con-
tractility will be also present,  and on the applica-
tion  of the galvanic fluid it will  be evidenced by
contraction.  Galvanism thus becomes a test not
of life, but of the reality  of death, for if the mus-
cular fibre does not obey it, there  can be no doubt
that vitality is extinguished.  It  should  be recol-
lected, however,  that different parts of the mus-
cular system retain their contractility, and conse-
quently their obedience to the galvanic stimulus,
for different periods after death. (Diet, des Sciences
Med. art. Mart.)  Nysten found,  in the body of a
guillotined criminal which was given to him im-
mediately after execution, that the contractility of
the left ventricle was extinguished in forty-nine
minutes after decapitation  ; that  of the  stomach,
intestines, and urinary bladder continued for fifty-
six minutes ; while tbat of the right ventricle and
diaphragm  remained for  two hours.  He found
the locomotive muscles  lose their contractility in
proportion  to their free  exposure to the atmo-
sphere, and those  that were  not at all exposed
continued excitable during four  hours;  but the
auricles of the heart, although in contact with the
air during the whole time, did not cease to  con-
tract, when stimulated for four hours  and forty
minutes.   From many similar  opportunities of
observation possessed  by  Nysten, he  concludes
that the  muscles cease to be influenced by gal-
vanism after death in the  following order : 1. left
ventricle ; 2. intestines and stomach ; 3.  urinary
bladder ;  4. right ventricle — this retains its  con-
tractility under  galvanism for one hour ; 5.  oeso-
phagus, for half an hour longer ;  6. iris; 7. mus-
cles  of animal life ;  8. auricles.
   We have now alluded  to the  chief criteria of
real  death ; and  we may conclude this part of our
subject by stating that those most entitled to  con-
sideration are flexibility subsequent to rigidity of
the joints; loss  of contractility  of the muscles
under  galvanism;  and   incipient  putrefaction.
These  are not liable to any  important fallacies :
the rest are, for the reasons  already mentioned,
more or less equivocal.
   It now remains,  before we  proceed to consider
the causes of sudden death, to make a few obser-
vations on the  changes which the human body
undergoes after dissolution ; and we  prefer doing
so in this  place, because  the subject naturally
follows that which we  have  just discussed, and
also because a knowledge of the attendant  pheno-
mena and their causes is often of the highest im-
portance to the medical jurist in enabling him to
determine the length of time  a body  submitted to
me inspection may have been  dead; or the period
at which dissection  may  be  attempted with  a
prospect of useful results.  It is sometimes of the
utmost moment to  the surviving relatives  of an
individual found dead, that it shall be determined
at what time death  took  place ; of  this a case
mentioned by  Dr.  Male (Elements  of Juridical
Medicine, p. 101)  serves as  a good  illustration.
At the Lent assizes, held at Warwick in the year
1805,  a cause was  tried in  which a gentleman,
who was insolvent,  left  his  own house with the
intention (as it was presumed from his preceding
conduct and conversation)  of destroying himself
Five weeks and four days after that period, his
body was found floating down a river.   A com-
mission  of  bankruptcy  having  been taken out
against the deceased a few days after he had left
his home, it became a question of great import-
ance to the interests  of his  family  to  ascertain
whether he was living  at that  period ;  for if it
could be proved that he was rtot,  his property
would remain untouched by the legal  proceedings.
From the changes which the body had undergone,
it was presumed that he had  drowned himself the
day he left home;  and to corroborate  this pre-
sumption,  the evidence of Sir George Gibbes of
Bath was required, as he had lately been engaged
in experiments on the changes produced  in animal
substances by immersion in water.  He stated on
the trial that it required five  or six weeks to effect
changes similar to those observed in the body of
this  individual; and upon this evidence the jury
were of opinion that  the deceased was not alive
at the 'time the commission was taken  out, and
the bankruptcy was accordingly superseded.
   A few weeks back the writer of this article, in
passing along the canal  on the south side of Dub-
lin, on  a Saturday, observed a crowd collected on
the bank;  on approaching, be discovered the ob-
ject of their attention to  be the body of a man
recently withdrawn from the water.   None of the
bystanders knew anything of the individual, or
of the time at which he had been drowned ; but,
from the fresh appearance of the body, the general
belief was that he had fallen in the preceding
evening.   From certain appearances (to be more
fully treated of hereafter) tbe writer  was induced
to doubt the truth of this supposition,  and to assert
that the man had lain in the water for at least five
days.   An accidental circumstance served to cor-
roborate this opinion.  Seeing the individual well
dressed, and  not observing any hat, the writer
inquired whether one had been found with him,
to which he received a negative answer; when a
boy, who lived in  the neighbourhood,  came for-
ward and mentioned that a hat and handkerchief
were found in the water at that place on the pre-
vious Tuesday morning, just  five days from the
time of finding the  body.   These  articles  were
afterwards proved  to have  belonged to the de-
ceased.  This was a case  in which,  from the
appearances presented by  the body, very positive
testimony could have been given as to the length
of time that had elapsed since death ; and in case
any  question  similar to that in the preceding in-
stance  was pending,  such testimony must have
been of the bighest importance.
   The changes that take place in the body after
death may be divided into those that occur  before
and  those that follow the invasion of putrefaction. 
DEAD,  (PERSONS  FOUND)
553
   To the  first stage belong diminution of tem-
perature, contraction of the muscles constituting
cadaverous  stiffness,  and lividity of certain por-
tions of the  surface.  We  have  already  taken
notice of the causes by which the loss of heat and
muscular rigidity are influenced, and therefore it
is unnecessary to  allude to these phenomena at
present. The extensive lividities usually observed
on the back parts of the body shortly after death,
are entirely owing to gravitation ; the blood, still
fluid, and no longer kept in  its proper course  by
an impelling power, obeys the  physical law  by
 which it is inclined to  seek  the  most depending
 situations,  and this  takes place in the interior as
 well as on the exterior  of tbe body ;  of which we
 have examples in the gorged state of the posterior
 portion of  the lungs, and  in the vascular turges-
 cence exhibited by  the gastro-intestinal  mucous
 membrane  in the lowest part of depending convo-
 lutions. (Trousseau, Dissertation inaugurale. Pa-
 ris, 1825.)   That all these  appearances are the
 result of gravitation is proved by the fact that we
 can produce them in other  situations by altering
 the position of the body; thus, if it be  turned  on
 the face, instead of remaining as it usually does
 on the back, the skin  of the face,  breast,  belly,
 and anterior  parts of  the  limbs will  be  found
 livid, while the back will retain its natural colour,
 and the congestions  in the  interior of the  body
 will all be found in the anterior part of the organs.
 Nay, the lividity, having formed  on the back, can
 be made to disappear, if the body is turned before
 it becomes cold, and the blood  coagulates.  Of
 this the writer has convinced himself by experi-
 ment.  As  it has happened that these lividities
 have been  mistaken  for the effects  of  violence,
 and suspicions of murder  having  arisen  there-
 from, it is necessary,  in judging  of such appear-
 ances, to  take into consideration the attitude in
 which the  body may have  lain  during  the first
 few hours after deatb, the great extent of surface
 occupied by them, and the absence of any effusion
 or infiltration of blood into the  cellular tissue.
 We shall have to recur to this subject when we
come to treat of the effects  of blows on the  dead
body, and  their resemblance to the consequences
of injuries inflicted during life.
   Tbe second stage is marked by the occurrence
of putrefaction.   This  is  a process peculiar  to
organized  substances, and it seems to follow as a
consequence of the manner in which their ulti-
mate elements are combined during life.  These
elements are few in  number—oxygen, hydrogen,
carbon, and nitrogen  constitute tbe great  bulk of
organized  substances.   Other elements, as phos-
phorus, sulphur, iron, Jime, potassa, and silica,
are occasionally present, but in quantities so  small
as not to invalidate the  statement just made. But
we find these elements combined  in various pro-
portions, and thus constituting the different proxi-
mate principles of which our bodies are  made up,
such as fibrin, albumen, gelatine, urea, stearine,
elai'ne, cholesterine,  &c, which  in composition
differ from each other chiefly in the proportion of
their component elements.  Now  these  combina-
tions are not such as the ultimate elements have
the greatest disposition to form ;  in other words,
their natural affinities lead them to different  com-
binations and to the production of more permanent
  Vol. I.--70                       2w
 compounds, namely, water, carbonic acid, ammo-
 nia, &c. This disposition is controlled by vitality.
 and as  long  as it  continues,  the  operation  of
 chemical laws seems  suspended; but as soon as
 life  is extinguished, the elements abandon their
 former combinations,  and  enter into  new ones,
 and this constitutes putrefaction.  The presence
 of nitrogen expedites this process, and hence
 vegetable substances,  which with few exceptions
 are  deficient in this element, undergo the change
 more  tardily and imperfectly ;  and some animal
 substances, as, fats, oils,  cholesterine, in which
 nitrogen is  absent, are little disposed to the putre-
 factive fermentation.
   The human body,  in common with other ani-
 mal substances, suffers this dissipation of its prin-
 ciples after death; but as the phenomena attending
 this change are not constant  as to time, order,
 and results, it is necessary to  inquire into those
 causes that influence its course.
   The conditions necessary to the speedy putre-
 faction of a dead body are the  exposure  to  air,
 moisture, and  a moderate degree of heat.   The
 presence of air, however, does not  appear  to  be
 essential, although its exclusion retards the pro-
 cess.  Putrefaction  in vacuo was denied by Gay-
 Lussac, but some experiments by Guntz of Leip-
 sic have proved the possibility of its occurrence.
 He took some pieces of human flesh, and having
 freed  them from any air  that  might be lodged
 among the fibres by plunging them into mercury,
 he passed them into jars inverted over  and filled
 witb the same fluid.  The  flesh rose to the top of
 the jar, and the apparatus was kept in a moderate
 temperature.   Putrefaction went on,  but  at  a
 slower rate  than if the air had been admitted.   In
 a few  days  the flesh became soft  and pulpy, and
 of a grey colour.  Gas was generated, which was
 found to be carbonic acid gas, and some highly
 fetid  fluid  covered the surface  o'f the  mercury :
 the flesh had  lost one-third of its  weight.   He
 also ascertained  that blood alone will putrefy in
 vacuo.  For  this purpose he  placed  the fore-
 finger of his left hand  under an inverted jar filled
 with mercury, and then made an incision into the
 integuments.   The blood rose to the top,  and  in
 five  days it was found to be undergoing putre-
 faction ; an accident by which  the apparatus was
 upset prevented an analysis of the product. These
 experiments show that though the presence of air
 expedites the process, it is not essential.
   A moderate temperature is  a most important
 condition.  If the heat  be too high, it prevents the
 occurrence  of putrefaction by rapidly dissipating
 moisture; and  if too low,  the process is equally
 arrested, and,  it would  appear, from the same
 cause, — for the fluids being converted into solids
 by congelation, are as  efficiently deprived of the
 power of assisting putrefaction (so long as they
 continue in  that state) as if they were altogether
 removed.   The practice of packing salmon in ice
 for the purpose of preserving it fresh during long
 voyages  is  a  familiar  illustration of this  point.
 But the most extraordinary instance on  record  is
 the preservation of the  mammoth discovered some
years ago in Siberia enclosed in a block  of ice, on
 breaking into which the  animal was found entire
and fresh.   This being a specimen of an extinct
species of animal, it is of course impossible to ca! 
554
DEAD,  (PERSONS  FOUND)
culate the number of centuries it must have been
enveloped in its icy tomb.  Below 59° Fahren-
heit, the process is  slowly performed, and at 32°
it is altogether suspended. The temperature most
favourable to its perfection is from 60° to 80° or
90°. This is the range of the thermometer during
our summer, and hence at this time putrefaction
most readily goes forward.
  Moisture  is an indispensable condition.  This
is shown by the readiness with which substances
otherwise disposed  to  putrefy are  preserved  by
drying, as smoked meats, fish, &c.;  and still more
strikingly by the preservation of animals buried in
sand.  Caravans in crossing deserts have been
overwhelmed by tbe shifting  sands, and the bodies
of men and camels have lain for centuries until
exposed by the same cause, when they were found
dry, shrunken, but  without  any signs of having
undergone putrefaction.   Instances  of this  kind
have  occurred  in  Egypt,  Arabia, and  Persia.
Chardin  (Traite des Exhumations Juridiques, par
MM. Orfila  et Leseur, vol.  i. p. 382,) mentions
the preservation of  certain bodies in the sands of
Corassan (Persia), where they had been buried
two thousand years.
  It is supposed that the preserving power pos-
sessed  by some burying-places, as  the vaults of
the  Cordeliers  at  Toulouse, and  those of  St.
Michan's, Dublin, is  owing to the dry  and ab-
sorbent nature of the surrounding  soil.   In these
situations bodies rarely putrefy, but they  undergo
a process of natural  mummification.  The pro-
ducts of putrefaction,  wLen  conducted under
favourable circumstances, are — water, ammonia,
carbonic  acid, carburetted hydrogen, sulphuretted
hydrogen, phosphuretted hydrogen, nitrogen, and
hydrogen gases, and there remains a friable matter
of a deep brown colour containing the salts of the
body and some carbon.
  From  these cursory observations it must ap-
pear that the transformation of the dead body
will be influenced  by  the medium  in which it is
placed.   The media  existing naturally,  and  to
which all others may be referred, are the earth,
air, and water.  But as  these do not exist  in a
purely separate state, being found mixed together,
—as air  impregnated with water, water with air,
and earth with  both, — the  term group  may be
given  to these combinations.   Thus we  have
earthy group, watery group, and aerial group, by
which are meant the combinations  usually exist-
ing between these media. A group is called cold
when the temperature is  below 32°; cool  between
32° and  (<i)°; warm between 60° and 100°;  and
hot when it is above 100°.
  The metallic oxydes and salts which enter into
the composition of  the earth exercise but a small
influence in the transformation of a dead body.
The  action  of this medium depends upon the
greater or less exactness with which it excludes
the  access of air and water.  Thus sandy soils
which quickly absorb water, and argillaceous soils
which collect water round a  dead body, differ ma-
terially in their effects ; in the former decomposi-
tion goes on slowly, and  is sometimes, as we have
seen, altogether prevented ;  in the latter putrefac-
tion readily  takes place, and sometimes the trans-
formation into adipocire is effected.  Fresh ground
or gardens which are rich in mould, and  the soil
of church-yards, appear to act as a sort of ferment
which  assists  putrefaction ; for  it is found  that
flesh enters sooner into  the putrefactive process
when surrounded  by  substances  already under-
going that change.
  We have alluded to the formation of adipocire,
and it is necessary, before we leave this part of
our subject, to make a few observations on  this
curious phenomenon.   Adipocire, so termed from
its resemblance to  fat  and wax, is a peculiar sub-
stance of a  soft ductile nature and whitish colour,
produced by dead  animal substances undergoing
decomposition  under  particular  circumstances.
We are indebted to Fourcroy for the first scienti-
fic account of this peculiar transformation.   His
attention was  directed  to it on the occasion of the
celebrated exhumations  practised  at the  ancient
burying-place Des Innocens at Paris, in the years
1785, 86, 87, when from fifteen to twenty thou-
sand bodies were removed for the purpose of era-
dicating this cemetery.   This spot differed  from
common burying-grounds, where each individual
body is surrounded by a portion of the  soil.  It
was the burying-ground  of a large district, where-
in successive  generations of the  inhabitants  had
been  deposited  for upwards of  three centuries.
The remains  of the human bodies  immersed in
this mass of putrescence were found in three dif-
ferent states, according to the time they had been
buried, the place they occupied, and their relative
situations with regard to each other.  The  most
ancient were simply portions of bones irregularly
dispersed in the soil,  which had been frequently
disturbed.   A  second state, in  certain bodies
which had  always been insulated, exhibited the
skin, the muscles, the tendons, and aponeuroses,
dry, brittle, hard, more or  less  grey, and similai
to what  are called mummies in certain caverns.
The third  and most  singular state  of these  soft
parts  was observed in the bodies which filled the
common graves  or repositories.   These were cavi-
ties thirty feet in depth, and twenty on each side
appropriated to  contain  the bodies of the poor.
Each cavity contained between 1000 and 1500,
packed side by  side in rows, without any inter-
vening earth; so  that it  might  be considered,
when  filled, as  an entire mass of human bodies
separated only by  two planks of about half an
inch thick.  The first of these receptacles opened
in the presence of Fourcroy had been closed  for
fifteen years,  the coffins were in  good preserva-
tion, but a little settled, and the  wood had a yel-
low  tinge.  When  the  covers of  several  were
taken off, the  bodies were observed at the bottom,
leaving a considerable distance  between their sur-
face  and the  cover, and flattened as if they had
suffered a strong compression.  The linen which
had covered them  was  slightly  adherent to the
bodies, and with the form of the different regions,
exhibited,  on removing  the linen, nothing but
irregular masses of a soft ductile matter of a grey-
white colour.  These masses environed the bones
on all  sides, which had no solidity, but broke by
any  sudden pressure.   The appearance of this
matter, its  obvious composition and its softness,
resembled common white cheese ; and the resem-
blance was more  striking  from the prints which
the threads of the linen  had made  upon its sur
face.   The grave-diggers asserted  that they never 
DEAD,  (PERSONS  FOUND)
55*i
bund this matter in bodies interred alone; but
that the accumulated bodies of the common graves
only were subject to this change.   Fourcroy re-
marked  that  the conversion appeared in different
stages of  advancement, so that in various bodies
the fibrous texture and  colour, more or less red,
were discernible within the fatty matter; that the
masses  covering the bones were entirely of the
same nature, offering indistinctly in all the regions
a grey substance, for the most part soft and duc-
tile,  sometimes  dry, always easily  separated  in
porous  fragments, penetrated witb cavities, and
no longer exhibiting any traces of membranes,
muscles, tendons, vessels, or nerves.  By examin-
ing this substance in the different regions of the
body, it was  found that  the skin is  particularly
disposed to  this  remarkable alteration.   It was
afterwards perceived that the ligaments and ten-
dons no longer existed, or  at least had lost their
tenacity, so  that the bones  were entirely unsup-
ported,  and left to the action of their own weight.
In all the  bodies so changed, the abdominal cavity
belonging to the  human subject.   Each of them
was enveloped in  linen, and placed in  a small deal
box, which was buried at a depth of two feet and
a half.   They  were disinterred on the  30th of
July, 1829, seven months and twenty-seven days
after having  been deposited  in  the  ground.   In
place of the stomach they found  about half a
drachm of adipocire not in the least ammoniacal,
but  composed of margaric and  oleic acids  and
lime.  The skin presented here and there the ap-
pearance of  adipocire, and  furnished  on  analysis
a calcareous soap;  the  testicles were  similarly
transformed.  The omentum had preserved its as-
pect and structure  in several places, whilst in
others it was changed into a yellowish fatty mass,
having the odour of Roquefort cheese, and com-
posed  of lime  and the  acids  mentioned  above.
These distinguished experimenters, although pret-
ty certain that the presence of the calcareous soap
at the expense of the ammoniacal, in these sub-
stances, was  owing to the rain-water in filtering
through the ground having dissolved  some of  the
had disappeared.  The integuments and muscles  calcareous salts, which having thus got access to
of this region being converted into the white mat-
ter, like  the  other soft parts, had subsided upon
the  vertebral column,  and were so flattened as to
leave no place for the viscera;  and accordingly
there was scarcely ever any trace  of them  ob-
served in the  almost obliterated cavity.   The
thorax was also flattened, and its viscera were no
longer  discernible.    Sometimes  an  irregularly
rounded  mass was found, which appeared to have
arisen from  the fat  and fibrous substance of the
heart. The  features of the  face were converted
into adipocire, and no longer distinguishable,  and
some of  the  same matter occupied the cavities of
the mouth and orbits.   The cranium constantly
contained the brain, changed into a similar sub-
stance.  From various observations, it was found
that this fatty  matter  was capable of enduring in
these burying-places for thirty or forty years, and
is at length corroded, and carried off by the aque-
ous putrid humidity which there abounds.
  Adipocire, according  to M. Chevreul,  consists
of  margaric acid, oleic acid,  a  little bitter sub-
stance,  of an  orange-coloured  principle which
tinges the acid, of a trace of odorous principle, of
the interior of the wooden box, decomposed the
ammoniacal soap, and changed it into calcareous,
nevertheless thought it necessary to prove by di-
rect experiment that it really was so.  According-
ly they prepared an ammoniacal soap with pure
stearic acid and caustic ammonia, and  plunged it
into  a solution of sulphate of lime.   At the end
of three  weeks,  on examining the soap, it  was
found entirely changed into stearate of lime, and
sulphate  of ammonia was formed.  They made
also  another experiment:  two human stomachs
were  buried, one in  a leaden box enclosed in a
wooden  one,  the  other  in wood  alone:  si-ven
months   afterwards they  were  taken  up.  The
stomach  contained in the wooden box was trans-
formed into a soap partly ammoniacal but chiefly
calcareous, whilst tbat enclosed in the lead offered
no trace  of saponification, and was but  little al-
tered.
   " It is manifest,"  say  they, " that, in  this last
experiment, the  progress of the putrefactive  pro-
cess  bad  been greatly retarded in consequence of
the double  envelope, and particularly of the leaden
cases; and every  thing leads to the conclusion,
ammonia, very small quantities of lime and potass,  that if the apparatus had remained under ground
and some salts.   The alkalies we have mentioned
partly saturate the margaric and oleic acids.  The
latter exists in a very small proportion relatively
to the margaric, which abounds in this substance.
It is easy to perceive from this analysis  that adi-
pocire is a soap with double acid and ammoniacal
base.  Sometimes, however, the acids are  found
combined  with  lime.   This  has been  observed
when  bodies undergo the change in water contain-
as long as was requisite for converting the stomach
into soap, this soap would have been of the am-
moniacal and not of the calcareous kind." (Traite
des Exhumations Juridiques, torn. i. p. 366.)
  Adipocire  is only formed when fat  and some
azotized substance  are found together.  The fatty
matter furnishes the margaric and oleic acids, and
the other the ammonia.   This is  proved by the
following circumstances.  Entire dead bodies, or
ing carbonate or  sulphate of  lime ;  and also in  entire parts of a dead body, such as a head, one
earth  permitting the infiltration of water which  of the  limbs, or the thorax,  parts in which are
has dissolved these salts in its progress through it.  found  skin, fat, muscles, cvc.  are changed into
In both cases the ammoniacal soap is first formed,  adipocire in stagnant or gently moving water, but
and is then decomposed  by the calcareous  solu- ' isolated muscle furnishes but a small portion of
tion ;  manrarate and oleate of lime, and carbonate [ this substance, and that only when it is rich in fat..
                                                Fat washed, freed from blood, and separated from
                                                parts which contain azote, is not transformed into
                                                adipocire.  Neither does the fibrine of the blood,
                                                when perfectly washed and free from fat, undergo
                                                the chsirje.  Orfila found that portions of skin
                                                previously deprived of the  subjacent cellular tis
or sulphate  of ammonia  being the result.  To
prove that such is the case, the following experi-
ments were made by Orfila and Lcseur.
  On the 4th of December,  1828, they interred a
stomach, a portion of skin with the subjacent cel-
lular tissue  two  testicles, and an  omentum, all 
556
DEAD,  (PERSONS FOUND)
sue, were not saponified after eight months of in-
humation ;  while similar portions of the skin of
the same individual, to which the cellular substance
was  left adhering, and buried during the  same
time, were  converted  into adipocire.   It appears
that a sojourn of about  three years in the ground
is  necessary for the complete transformation of a
body, and  that the  change goes forward  more
quickly in water; and it is only when a number
of bodies are buried  in the same grave, that the
process is perfect, those at  the bottom being the
first to undergo it.  A thick stratum of earth over
the grave is necessary, in order to confine the gases
given out in the first stages  of putrefaction.
   [A medico-legal question has arisen respecting
the length of  time which  a  body must remain
in water, in order that  this transformation of the
tissues may take place.  (See the writer's Human
Physiology, 5th edit.  i. Philad. 1844.)  Dr. Gibbs
found,  that by macerating muscle in water for
about a month, he was only able to obtain a small
quantity of adipocire.  Dr.  Harlan observed, that
the integuments of a cranium were, by macera-
tion, converted into it in about six weeks ; but in
some experiments instituted by Mr. Taylor, (Ma-
nual of Med. Jurisprudence, p. 515: Lond. 1844,)
the conversion of muscle and fat to adipocire was
not complete in stagnant water under two months.]

   The  chief object of the medical jurist to whom
a dead  body is  submitted for inspection, is to as-
certain  the cause of dissolution.  In order to assist
in this investigation, we will follow the arrange-
ment already proposed.
   I. Death from Natural Causes.—Death is
the  inevitable  condition to which all  bodies that
possess life must, sooner  or later, be  reduced.
This termination of their existence forms a grand
distinction between   organized  and unorganized
matter.  The gradual termination of life, or natu-
ral death strictly so called, is  very different in  its
phenomena from the more  common or accidental
death.  In natural death man expires, as it were,
in detail; the external functions and those of the
animal life being almost annihilated, whilst those
of organic life still remain  in vigour.   The active
powers gradually desert  each organ; digestion
languishes;  secretion,  absorption, and  capillary
circulation are arrested; the general circulation is
then suspended in  the large vessels;  and  lastly,
the contractions of the heart cease.  In accidental
death, the  general circulation  and respiration are
first arrested, while  the other functions  are suc-
cessively and slowly extinguished.  So that it has
 >een said that  in the former life is first extinguish-
ed in the parts, and  then ceases in the heart, the
 influence of death being exerted, as it were, from
 the circumference \o  the centre ;  while in the lat-
ter it ceases first in the heart, and then in all the
 parts, death proceeding from the centre to the cir-
 cumference.   The termination of life  termed  na-
 tural death is a very rare occurrence in the human
 species in a civilized state :  animals  often reach
 it; but the cessation of existence from mere old
 age has become with  us a rare phenomenon.  Hal-
 le, estimates the average  probability of  human
 life, and deduces the  conclusion that only one in-
 dividual in fifteen thousand reaches the hundredth
 year.   Accidental death, in  contradistinction  to
natural death, becomes, therefore, an object parti-
cularly worthy of attention.  This may take place
in two ways—either as the slow and gradual ter-
mination of a lingering disease ;  or as the sudden
result of some  great  disturbance of the animal
economy, and then called sudden death, as in apo-
plexy, hemorrhage, concussion, asphyxia, &c.
   We  now come to consider the natural causes
of sudden death, and our observations upon them
must be necessarily brief, as it would not be pos-
sible  to enter into detail upon them in this place;
a circumstance not of much consequence, as they
are most of them treated of in separate articles
through  this work.   However, we  may notice
some of the most frequent and remarkable. These
are apoplexy, rupture of an aneurism or of a  large
vessel into  one of the cavities; bursting  of puru-
lent cysts or other collections of fluid, or of blood-
vessels into the air-passages; ossification of the
valves  of the heart;  rupture of this organ; as-
phyxia idiopathica.
   Apoplexy may attack at any  age, but in the
great majority  of cases  the  age is above fifty
years : certainly it may be  said  to  be a disease
rather of the decline of life.  It is a disease which
in  some  instances may be mistaken in  its  early
symptoms, and may terminate fatally in situations
which  preclude  any observation of  the event.
Those most predisposed  are  of a  full  plethoric
system, with large head and short neck.  Diseases
of the blood-vessels of the brain, such as ossifica-
tion of the arteries, aneurism, and obstruction of
the sinuses, lead to rupture of their coats ; and it
is well known that hypertrophy of the heart some-
times produces apoplexy.   In ordinary cases  an
examination  of the  brain sufficiently developes
the complaint.  Blood is  usually found  in some
part  of this organ, rarely on  the  surface,  more
commonly  in or about the corpora striata or optic
thalami,  or effused into  the  ventricles.   In old
apoplectics who have had many shocks, cysts en-
closing  clots of blood  are found; and the brain
surrounding them is often  observed in  different
stages of inflammation  or ramollissement.   (See
Apoplexy.)   It  should be  borne  in mind that
 persons seized  with apoplexy may  fall from a
 height,  and thus bear  marks of external injury
which might mislead a superficial  inquirer as to
the cause of death.   In cases of rupture  of inter-
 nal aneurisms, or purulent cysts,  or of ossification
 of the valves of tbe heart, an examination of the
 body will exhibit the true nature of the disease.
 The  last of the  natural causes of  sudden death
 which we have mentioned is that peculiar disease
 termed by Mr. Chevallier » asphyxia idiopathica."
 A  case of this rare and remarkable affection  came
 under  the  observation of the writer a few years
 ago.   The subject of it  was a  healthy woman,
 forty years of age, in  the ninth month of preg-
 nancy.   She complained suddenly  one evening
 of weakness and sickness of stomach, and  on
 making an effort to vomit, she fell  back and ex-
 pired without any struggle.  The writer examined
 the body the following day, and inquired diligent-
 ly  after every cause of death in each of  the cavi-
 ties ;  but he never saw more healthy organs, and,
 taken altogether, certainly never a  sounder body.
 But  the state in whicb the heart was found led to
[ a discovery of the nature of the case.   The  pa- 
DEAD,  (PERSONS  FOUND)
557
rietes of this organ were entire, but quite flaccid,
and  all  its cavities were empty ;  while  its proper
veins were much distended with blood.   This so
exactly resembled  the appearances described by
Mr. Chevallier, and the manner of death corres-
ponded so fully with that of the cases he  men-
tions, that it was thought justifiable to refer the
cause of death to the disease just  alluded to.  Mr.
Chevallier accounts for death in  these cases by
supposing a sudden loss of power in the vessels,
chiefly in  the minute ones, to return the blood to
the heart; in  consequence of which this organ,
after having contracted so as to empty itself, and
then relaxing, continues in that state for want of
its  accustomed stimulus, and so dies.  We  men-
tion this  in order to  show  that  such  cases are
sometimes to be met with, and that it is necessary
to be prepared to detect them.  For further infor-
mation we must refer to the paper alluded to.
   II. Death from Violent Causes.—The wide
extent of  this  division, and the great importance
of the topics included in it, render it of the deep-
est interest  to the medical jurist.  The violent
causes of  sudden death may  be reduced to seven
heads, viz. asphyxia,  poisoning,  wounds, burn-
ing, cold,  starvation,  and  lightning.  From the
very able  manner  in  which  the subject of as-
phyxia has been handled in a former part of this
work, little  remains to be said upon its  general
phenomena  and theory.  (See Asphyxia.)   As-
phyxia  may be defined  the  suspension of the
function of respiration, and consequently of the
circulatory and cerebral functions.   The inter-
ruption  may affect primarily either the  mechani-
cal or chemical phenomena of expiration.  The
mechanical are the motions of the parietes of the
chest, producing inspiration and  expiration  ; the
chemical  are the disappearance of oxygen  from
the  air  taken  into the lungs, the  disengagement
of carbonic acid gas, and the conversion of the
venous into arterial blood.  Asphyxia may  com-
mence by  the  cessation of either  of these classes
of phenomena; but in whichever  it first begins, it
speedily involves  the  other,  and  both  are  soon
equally  suspended.   A violent  compression of
the thorax, such as is produced by the falling of
heavy  beams  of timber,  portions of buildings,
roofs of mines, &c. a double wound giving en-
trance  to  the air into both cavities of the chest,
rupture of the  diaphragm by which the abdominal
viscera gain admission to the chest, the effusion
of large quantities of fluid into the pleura,—all
these put  an end to the mechanical phenomena
of respiration  by interrupting the motions of the
thorax.  In other  cases these motions cease, but
from a different cause ; we allude to paralysis of
the  muscles that move the parietes, which hap-
pens when the spinal marrow is cut across, or is
pressed on above the origins of the phrenic nerve,
or above the third cervical vertebra, or when the
whole nervous energy is  destroyed, as  by light-
ning.  Most commonly, however,  it is the second
class, or the chemical  phenomena of respiration,
that cease  first; and the motions  of the chest are
only interrupted because the  black  blood, which
is then driven into all the organs and especially
into the muscles and  brain, does  not carry along
with it the power of excitation necessary to carry
on the  functions of these  parts.   This interrup-
                                    2w*
tion of the chemical phenomena may be produced
in various ways : thus sometimes there is total in-
terception of the passage of air into the lungs, as
when an  animal  is placed  in vacuo, or is smo-
thered, drowned, or strangled ; at other times, an
aeriform fluid  does enter these organs, but is not
possessed  of the principle necessary to act on the
blood contained in them, such as azote and hydro-
gen gases.   It may be  that the gas inhaled is en-
dowed with  deleterious properties; either that  it
irritates the lungs,  as the sulphuric acid gas, mu-
riatic acid, and ammoniacal gases.; or that it acts
upon the whole animal economy as a poison, such
as carbonic acid  gas,  nitrous  acid,  carburetted
hydrogen  and hydro-sulphuretted gases.   Thus
we find that, by the total  interception of all air,
or by the inhalation of noxious gases, the chemi-
cal phenomena of respiration may be arrested.   It
is to this we shall  direct our attention at present,
as the cases in which the mechanical phenomena
are first affected are more rare, and will  be after-
wards considered in treating of death from wounds
or bruises, and from lightning.
   The causes that produce death by asphyxia are
drowning, hanging, and strangulation, smother-
ing,  and the inhalation of  noxious  gases or air
deprived of oxygen.
   The physiology  of  Drowning having  been
already fully discussed  in the article  Asphyxia,
we shall  proceed  to   consider  the medico-legal
questions  that  may arise  in the case of  a  body
found in water.   These may be  arranged under
the following  heads :—1. whether the  body was
immersed  before or after  death ; 2. whether the
individual has fallen in by accident, has drowned
himself, or has been thrown in by others.
   1.  The inference that the person was living at
the time of immersion  is drawn from an attentive
examination of the external state of the body, and
from  a careful anatomical  investigation.   The
body  of a drowned person usually presents the
following appearances.   It is commonly very cold,
apparently even colder than the actual tempera-
ture ; the  limbs are more or less stiff according to
the time that has elapsed since death ;  the visage
is swollen,  often  dark-coloured,  but  sometimes
pale; the  eyes are half  open  and the pupils
dilated ; the mouth is filled with froth ; the tongue
is advanced  beyond the teeth; and the chest and
belly  are  elevated,  the latter being  often much
distended.   This state  of the body is  common to
those who perish in cold clear water, as the sea,
rivers, &c.;  but the body is  sometimes drawn out
warm, although  death  is so complete that anima-
tion  cannot be restored, the countenance violet-
coloured, and the veins of the neck turgid.   This
happens in  drowning  in warm fluids or in alco-
holic liquids,  or  in marshes where  deleterious
gases are disengaged, or when the person has fall-
en into the water in a  state of intoxication.  The
ends  of the  fingers are often  found  rubbed or
scraped, and  dirt  or sand, of a nature similar to
that of the bottom of the water, is perceived under
the nails.  Coupled with these is the negative
sign furnished by  the  absence of any lesion that
could have caused death previous to submersion.
The  internal  appearances  disclosed  on  opening
a drowned body are generally tbe following.  The
epiglottis  is  found elevated, an-1  a  quantity of 
558
DEAD, (PERSONS  FOUND)
froth fills the trachea and bronchi;  the lungs are
dilated and  gorged with blood ; black  and fluid
blood is found in the right cavities of the heart in
a much greater  quantity than  in the  left.  The
diaphragm  is  depressed, and  water of a nature
similar to that in which  death took  place is dis-
covered in the  stomach.   In the head there is
turgescence of tbe blood-vessels, more or less  in-
tense as the death has  been more or less speedy,
and  in  proportion to  the  amount  of struggling
made by the individual.   Orfila, (Archives Gen.
de Med. Aout, 1827,) in a memoir read  at the
Academy of Medicine, has reviewed all the signs
given by authors for determining whether immer-
sion took place before or after death ; and the con-
clusion he draws  is, that there is no certain sign
of submersion during  life  but the presence of
water,  similar to that in which it is found, in the
stomach and  air-passages; provided  that, with
reference  to  the  stomach, the  water  has not
been swallowed before submersion, and has not
been injected after death  : and with respect to the
lungs,  that the water shall have penetrated to the
last  uronchial ramifications,  and  has  not been
injected  before  death ; and that the  body shall
not have remained long in  a  vertical position in
the water, so  that the water might  have entered
after death.   It would  appear  from  this that we
possess two  certain signs  of submersion  during
life;  but the restrictions  imposed  on them  are
such, that, taken  apart from  others, they are al-
most useless in  the  great  majority of cases.  In
speaking of water in the air-passages, Orfila must
have meant the froth formed by this fluid with the
air; for it is  very seldom  found in substance in
this situation.   Devergie (Annales  d'Hygiene et
de Med. Leg.  t.  ii. p. 432 ; [and Medecine Legale,
2d edit. ii. 392:  Paris, 1840] states that in  a
great number of cases he could  find but very slight
traces  of water  in the trachea ; and in two only
did he observe it in any quantity.   Indeed, from
the observations of Cullen, (Letter to Lord Cath-
cart,)  Goodwyn,  (Connection of Life with Re-
spiration,) and  Meyer, ^Medical Repository, vol.
iii. New Scries,) it is  plain  that  a very small
quantity of water enters the air-passages in drown-
ing ; and this is speedily converted into froth by
the motion  given  to it in  the attempt at respira-
tion.   On  the subject of this froth, Devergie
makes  some  interesting observations,  the sub-
stance of which is  as follows :—It is  commonly
white,  consisting of numerous  and  very small
bubbles, constituting a lather  rather than a froth
properly so called.  It never adheres to the  tra-
chea by mucus, but is in immediate contact with
 that tube.  All the bubbles that  form it have a
 watery  envelope, easily broken,  and  often  on
 opening the  trachea  the  greater  part disappear
 like soap-bubbles.  The froth of drowned persons,
 then, has but little analogy with the expectoration
 of pneumonia or catarrh;  and it  is sufficient  to
 have attentively observed it to avoid confounding
 them.  Its formation  necessarily brings with  it
 the idea of vitality, for it cannot take place with-
 out motion, an impulse communicated to a fluid
 and a gas in  mutual contact.
   In order to appreciate its mode of formation, and
 the value that it  may possess as  a sign  of sub-
 •netsior. during life, it  appears necessary to inquire
how it is produced in other cases than asphyxia
by submersion.  In  pneumonia, for example, the
individual is induced to expectorate  because the
extreme  bronchial  ramifications  are  filled  with
mucus, and the air can no longer reach them, and
come into contact with  the blood to effect the ne
cessary changes.  The  invalid expels  a frothy
matter, because the mucus secreted under the in
fluence of bronchial irritation is beaten and mixed
up with the air by the alternate and quick efforts
of inspiration and  expiration, which constitute
coughing.  The formation of the froth takes place
more easily as the irritation is nearer to  the  last
bronchial ramifications, when the  tubes, being of
a smaller diameter, are  more easily obstructed. It
is, on the contrary, produced witb great difficulty
in the trachea, on account of the great dimension
of this canal.  In drowned  persons  similar  phe-
nomena  take place, after they have expelled a part
of the air contained  in their  lungs.  They are
soon solicited by the desire to respire;  a  small
quantity of water enters  the  trachea, and causes
a most distressing stimulus, of which we have  a
proof in the great suffering experienced by per-
sons into whose larynx  a drop  of fluid has  acci-
dentally fallen  while swallowing;  a brisk and
sudden expulsion of the  water is  effected, but it
is rarely complete: the portion which  remains
dissolves a little mucus, and becomes viscid, whilst,
at the same time, new  inspiratory efforts  draw in
a new quantity of water : from that  time the air,
agitated  with this fluid, rendered more viscid, con-
stitutes the froth.  This is formed with more diffi-
culty in the trachea than in  the last  ramifications
of the bronchi; and consequently we esteem its
existence in the superior part of the  trachea as  a
more certain sign of the life of the individual at
the  moment of submersion than  when it is met
in the extreme branches.  This phenomenon does
not leave very durable  traces of its existence, for
it is sensibly diminished, and  even  often disap-
pears under the influence of putrefaction.  The
 portion of the air-passages where it  is preserved
during the longest period  is at the bifurcation of
 the trachea.   In winter it may be discovered in
 most  cases after eight or ten days, but  later  it
 completely disappears.   It is true, that if we ex-
 cept the water contained in the stomach, the other
 signs of submersion have not a  more extended
 duration.  It should be understood that the water
 thus taken into the lungs is not, as it was formerly
 supposed, the true cause of  death ; an opinion  to
 which Baron Larrey seems to incline in  his Me-
 moires.   The  experiments  of  Goodwyn  have
 shown that a much larger quantity of water than
 that which is found in the lungs  of  drowned ani-
 mals, may be  introduced into  the  air-passages
 without causing death.  Thus, he passed into the
 lungs of a cat, through an opening in tbe trachea,
 two ounces of water;  a large quantity when com-
 pared with the size of the animal. It had, imme-
 diately, difficulty of breathing and a feeble pulse;
 but these symptoms soon abated, and it lived sev-
 eral hours afterwards without much  apparent in-
 convenience : after this he strangled it, and found
 two ounces  and a  half of fluid  in  the  air-tubes
j and cells.
   The  presence of water, then,  in  the  lungs  of
! drowned persons in the form of froth is to be con 
DEAD,  (PERSONS  FOUND)
5!>9
sidered as an accidental and not essential circum-
stance, although it is one of very constant occur-
rence.   If this fluid is  found  in large  quantity,
and in substance, that  is,  not  beaten into froth,
the inference would be that it had passed in  after
death.   With respect to tbe presence  of water in
the stomach, it has been proved by many authors
to be a constant  occurrence; and when  it is dis-
covered in this organ, and  is identical with  that
in which the body is found, it  furnishes a strong
indication of submersion during life, being a ne-
cessary  consequence of the  act of  deglutition.
For it has been proved by Fine, Orfila, and Marc,
that it is never found in bodies plunged into wa-
ter after death, and  cannot be  made to  enter the
stomach without the assistance of a tube passed
into the oesophagus.
   [A circumstance, whicb influences materially
the quantity of water contained in the stomacb,
is the depth of water in which the individual was
drowned.   This is  shown by some experiments
instituted by Mr. Taylor.   (Elements of Medical
Jurisprudence, p. 121.)   A cat  was lowered to
the depth of 55  feet in the Thames ; another was
held two feet below the surface.   The  stomach
of the first cat contained a large quantity of wa-
ter ;  that of the  second scarcely any.  A third cat
was  permitted to rise  repeatedly to the surface.
The stomach of this cat was distended, but not
so much as  the one that had been lowered to the
depth of fifty-five feet.   The influence of pressure
of water is,  therefore,  considerable ;  and as has
been  remarked  by  Dr. Guy  (Principles of Fo-
rensic Medicine, Part 2, p. 317 : Lond. 1843,) it
is probable,  that where the water is very deep, the
 pressure of  the fluid may  overcome the resistance
 offered  by the  collapse of the  oesophagus, even
 although the animal died previously to submer-
 sion.
   It is proper to remark, that where water has
 entered the  stomach, it may not be found  there
 after death.   If  the head be  permitted  to  hang
 down lower than the stomacb, the water will run
 out.  Two cats  were drowned in nine fathoms of
 water.  After having remained  at this depth for
 half an hour, they were removed, and suspended
 with the head downwards.  Water drained freely
 from  them,  and on examination of  the  bodies
 three days afterwards,  none was discovered in the
 stomach or alimentary tube.   (Taylor, op. cit.)]
   From the above-mentioned  circumstances the
 following conclusions  are drawn by Devergie :  1.
 that almost  all  the signs, taken singly, do not
 prove that the individual  was  living at the mo-
 ment of immersion; 2. that the one whicb fur-
 nishes the strongest presumption is the existence
 of froth placed in immediate contact with the lin-
ing membrane  of a sound trachea;  3. that this
sign acquires a value greater  as its situation is
nearer to the mouth ; 4.  that water in the air-
passages is  a sign of little value, for if it can pen-
etrate the trachea after death,  and extend even to
 the  last bronchial ramifications, as  Orfila has
shown, it becomes  almost useless; 5. that  water
in the stomach is one  of the most constant  signs,
but its value is greatly diminished by the difficulty
of proving its identity with the fluid in which the
body has been  immersed; 6. that if  each sign
taken  singly gives  no certainty, the  assemblage
of all in the same individual  may enable a posi-
tive conclusion to be drawn.
  The proofs that death occurred before immer-
sion are drawn from the absence of all those signs
just enumerated; thus the thorax and  abdomen
will be found flat,—no excoriation of the ends of
the fingers,—no dirt or sand under the nails,—no
turgescence of the cerebral vessels,—and no froth
in the air-passages.   The lungs will be collapsed,
and the diaphragm will not have passed  the natu-
ral line.  The stomach will be found  not to con-
tain any of the fluid in which the body is found,
and in addition  to  these  negative proofs, marks
of violence may  be  discovered on the body quite
sufficient to account for death.  These marks are
divided by Fodere,  (Med. Leg. torn. iii. p. 112,)
into  three classes :  1st. those which  are totally
independent of any connexion  with  the circum-
stances of drowning.  Of this nature  are  the
usual signs of poisoning ; a regularly formed ec-
chymosis round the neck, indicative of strangula-
tion, or wounds  inflicted  by  fire-arms or cutting
instruments.   All  these lesions have an essen-
tially distinct character which cannot be mistaken,
and hence the evident importance of examining
carefully the external appearance  of all bodies
found in water.  It was by pursuing  such an in-
vestigation that Deveaux discovered, in  the body
of a woman found in water, a penetrating wound
under the left  breast, made by a very small instru-
ment which had reached her heart.  2dly. Marks
of violence which  may have resulted from  acci-
dents attending submersion, or may be caused by
previous  homicide, such as unequal  irregular
wounds which do not penetrate far into the body,
contusions, fractures, and luxations.   In all such
cases we should  ascertain, if possible, the height
from which  the  individual may have fallen,  and
the resistance  he may have  encountered in the
fall.   The rapidity  of the current, and the rough-
ness of the banks of a river  may also cause ex-
tensive wounds.   Dr. Fine remarks  that  the ra-
pidity of  the  Rhone, and  the numerous  mills
erected on its  side,  often  produce most shocking
wounds in the bodies which are driven  against
the stakes in the stream, or  are drawn  into the
machinery.   3dly.  There may be lesions received
after death.   These are to be distinguished from
those inflicted during life by the lividity and  flac-
cidity  of their edges, the absence of  tumefaction
and  redness, and want of hemorrhage, or, if the
latter be present, by the fluidity of the blood.
   2.  It being  ascertained that the subject was im-
mersed while living, it is often of importance to be
able to say whether the drowning was the result
of accident, of suicide, or of homicide.   The solu-
tion of these  questions  is to be obtained by an
examination of what may be termed the external
circumstances of the  case.  The locality of the
water may be such as to  account for the deceased
having accidentally fallen into it, or its situation
may at once preclude the possibility of such an
event.  Indications  of  struggling on the  brink,
such as tearing of the ground, and many footsteps,
together with ecchymoses on  the person  of the
deceased,  may lead  to the supposition  of homicide.
Thus, in  the case  of Mr. Taylor, who was mur
dered at  Hornsey in December 1818,  marks of
footsteps deep in the ground were discovered  neat 
560                        DEAD, (PERSONS  FOUND)
the New River;  and on taking out the body, the I observations of M. Devergie are entitled to much
 hands were found clenched, and  contained  grass
 which he  had torn from the bank.  (Paris and
 Fonblanque, Med. Jur. v. iii. p. 41.)
   However conclusive the existence  of ligatures
 on the hands and  feet of the deceased may ap-
 pear,— as  to the  question of the forcible interfer-
 ence  of others, it should be recollected that sui-
 cides have  sometimes adopted such precautions in
 order to insure their death.  There  are some in-
 stances on record, in which the individuals  seem
 to have pursued this  course. (Op. cit.)  In  June
 1816, the body  of  a gauging-instrument  maker,
 who  had been missing for some days from his
 home, was  discovered floating down the Thames.
 On being  taken  out, the  wrists  were found tied
 together and made  fast to his  knees,  which  were
 in like manner secured to each  other.  He had
 been  in a  state   of mental derangement for two
 years.  The cord witb which he had tied himself
 was recognised as  one that had  hung from the
 ceiling over his  bed, by which he  used to  raise
 himself up, as he had  been confined to bed for
 some weeks.  He was a  good swimmer, and it
 was presumed he had  taken this precaution to
 prevent himself from employing that power.  The
 verdict returned  was, " found  drowned."  The
 other instance was  that of a man,  aged twenty-
 eight, who  with a wife and child was  reduced to
great  distress.  On a certain day he took an affec-
tionate leave of his family, declaring he would not
leturn until he had procured some employment by
which he should be  able  to buy bread for them.
The following day his body was taken out of the
 New  River with his hands and legs tied.  A card
with his address was found in his pocket, and also
 ihree-pence; when  he  left home he had  five-
 pence, and  it was supposed he had purchased the
consideration,  from the  unrivalled  opportunity
afforded for their formation.   He was authorized
to carry on his investigations at the establishment
called " La Morgue" in Paris, a building on  the
banks of the Seine, to which are transported all
bodies found dead in the city  and its environs,
and where they are exposed during three days for
the purpose of recognition by their friends.  The
number thus exhibited exceeds three hundred  an-
nually, and includes all manner of violent deaths.
In  case of the sudden disappearance of an indi-
vidual, his friends repair to the Morgue, and leave
with the porter an accurate description of his per-
son, his  clothes, and the  period at which he was
last seen; and when a  body is brought in, it is
carefully examined, and if it corresponds with any
of the descriptions that have been left, notice to
that effect is sent to the  persons interested, who
come and claim it.  The number of persons  re-
cognised  is  very  considerable;  in  the  first  six
months of the year 1829, out of 148 bodies 116
were claimed.  Of this number 62 were drowned,
of whom 45 were recognised.  Being  thus fur-
nished with positive information as to the time of
immersion and that of finding the body, Devergie
was enabled to prosecute  his inquiries with great
accuracy.  He found that in  general no change
takes place  on the exterior before  the fourth  or
fifth day, and the cadaverous rigidity frequently
continues two, three, or even  four days after im-
mersion.  This is probably owing to the coldness
of the medium in which the body is placed.  About
the fourth or fifth day, the skin  on  the palms  of
the hands begins  to whiten, and this change  of
colour takes place particularly on the ball of the
thumb, and the fleshy eminence  on  the inner side
of the  palm over the metacarpal bone of the little
cord with the deficient sum; the verdict brought ( finger, together with the lateral surfaces  of the
in was  "insanity."  Another case of a similar , fingers.  The back of the hand docs not partake
nature has been lately published.   It was that of  of this colouring, and the rest of  the  body pre
a gentleman who was found in the Seine at Paris,
having his feet, wrists, and neck tied with a cord.
After detailing the appearances of the body, the
reporter concludes with the following note: « Mr.
X----  had bound his  neck, limbs, and hands by
means of a rope with  slip knots, in order to put
it out of  bis power to  aid himself when in the
water, and thereby to render certain the execution
of his  suicide." (Ann. d' Hygiene et de  Med.
Leg. t. ix.  p. 207. [See, also, his Medecine Legale:
Paris, 1840.])   We mention these cases to show
how i autious a medical man should be in forming
an opinion in similar instances, and how necessary-
it is to  weigh well every circumstance before  he
expresses  that opinion before a legal tribunal.
  It is often, as has been already mentioned, of
the highest importance to the survivors, that an
approximation to the time that has elapsed since
death should be arrived at.   For assistance in such
in  investigation, the medical jurist will turn in
vain to the systematic works on legal medicine, it
being only within the last  few years that any ac-
curate information on  the subject was possessed
by the  profession.   We are indebted  to  M. De-
vergie for  the first essay on this  interesting sub-
ject, one concerning which the most vague notions
were entertained previously to  the  publication of
the  memoir alluded  to. in the year J 829
      sents nothing particular.   On the sixth or eighth
      day, the skin at the  back of the hand begins to
      whiten ; at the  same time that the sole of the foot
      has acquired a similar tinge: the skin of the face
      is softened, and  of a more faded white than the
      rest of the body.  On the fifteenth day, the face
      is slightly swollen and red ; a greenish spot begins
      to form on the skin over the  middle of the  ster-
      num ; the hands and feet, with the exception of
      the  dorsum of the latter, are quite white, and the
      skin of the palm of the hand  is wrinkled.   The
      subcutaneous cellular tissue of the  thorax is red-
      dish, and the cortical substance of the brain takes
      on a green colour in the upper part  of that organ.
      At one month, the face is reddish brown, the eye-
      lids and lips are green and swollen, the neck is
      slightly green, and a  spot of about  six inches in
      diameter, brown in colour and with a green areola,
      occupies the superior and middle part of the  ster-
      num.   The  scrotum and penis are enormously
      distended by gas, the latter being sometimes in a
      state of erection from that cause.  The skin of the
      hands  and feet  is quite  white  and  very much
      wrinkled, presenting  the  appearance  of having
      been long enveloped in a poultice.   The hair and
      nails are still very adherent.  The lungs are em-
      physematous, and fill the cavity of the chest over-
1 he ,  lapping the heart,_a condition different from that 
DEAD, (PERSONS  FOUND)
561
which these organs  present at a more  advanced
period.  At a month and a half, besides the ap-
pearances first mentioned, the neck and thorax are
found very green, and the cuticle begins to detach
itself round the base of the hand where it joins the
wrist.  At two  months, the body is covered with
slime, which penetrates through the clothes.   The
fice is enormously swelled and of a brown colour,
the lips are tumefied and  separated so as to ex-
pose the teeth.   The skin  on the  middle of the
abdomen, as well  as that of the arms, forearms,
thighs, and legs, is still in a natural state.   This
is a most remarkable fact, and establishes a  strik-
ing difference between the progress of putrefaction
in water, and when  the  body  is exposed to the
atmosphere; in the latter case, the abdomen being
the first part to  manifest  any change.  At this
period  the  skin has become detached  from the
hands and feet, and having the nails attached to it,
forms as it were a glove.   The skin and nails of
the feet are longer in separating than those of the
hand.  The hair begins  to fall off, and  is easily
removed by pulling.  The  veins are almost com-
pletely empty of blood and commonly  distended
with gas.  The inner surface of the arteries is red,
and that of the trachea between the  cartilages pre-
sents the same colour.   If at the moment of death
the right cavities  of the heart were gorged  with
blood, the internal surface  of the ventricle is of a
 jet black colour; and in contrary cases an analo-
gous appearance is presented on the opposite  side.
Devergie considers this a most important diagnos-
tic mark of death by asphyxia.  At two months
and a half, the  green colour of the skin extends
to the arms, forearms, and  legs;  the  nails are
completely  detached from  the hands  and  feet;
some adipocire  is formed  on  the  cheeks,  chin,
breasts, arm-pits, and anterior part of the thighs :
the abdomen is greatly  swollen by putrefaction
within; the muscles at this period preserve  their
natural colour, and do not  appear altered in  tex-
ture.   At  three months  and a half, there is ob-
served destruction of the  scalp, eye-lids, and  nose,
to such an extent as  to make it difficult to tell the
age of the  individual.  The  skin of the breast is
generally of a greenish brown ; the centre of the
abdomen is of an opaline colour, and  scattered
with  small  ulcerations  caused  by the water.
Larger corrosions are found  in  different parts of
the body.   The  hands and  feet are completely
naked of skin.   The lungs no longer fill tbe tho-
rax, but leave between them and the pleura cos-
talis a space filled with reddish serum.  At four
months and a half, occurs complete  destruction of
the face and scalp,  leaving  the skull bare; the
remains of face, the neck, and anterior  part of the
thighs is entirely converted  into adipocire; and
small eminences, indicating the commencement of
calcareous incrustation, are observed on the pro-
minent parts.  The brain presents traces of adipo-
cire in its anterior part.  Devergie has not classified
the changes  that  take  place at more  advanced
periods.  The period from which  we  have ex-
tracted the foregoing account has  been severely
criticised  by Orfila, (Traite des Exhumations Ju-
ridiqucs, t. ii. p. 83,) who endeavours to overturn
the facts and doctrine  contained in it.  But we
think he has been satisfactorily and triumphantly
replied to by Devergie, (Annales d'Hygiene  pub.
  Vol. I.—71
et de Med. Leg. t. v. p 429, [and Med. Legale, i.
229,)]  who  adduces as  the  best proof of the
validity of his  conclusions,  four cases,  in which
the periods of immersion,  varying  from  fifteen
days to one, two, and eight months, were ascer-
tained  with the help of his table.
  As the  physiological phenomena observed in
persons dead from hanging and strangulation
are nearly the same, we  shall  consider  them
together in the  present section, pointing out the
differences between them as we proceed.
  Notwithstanding the authorities of Boerhaave,
Morgagni, and  Portal, who imagined that apo-
plexy was the immediate cause of death in hang-
ing, it is now generally admitted that the event is
owing to suffocation.  This opinion is confirmed
by the experiments  of Gregory and Brodie, from
which it  appears that if  an artificial opening be
made  into the  trachea of an animal, below the
ligature by which it is suspended, it will continue
to live.  But we must admit that other  injuries
are sometimes inflicted, of themselves sufficient to
account  for death, such  as compression  of the
nerves of the  neck, and fracture or dislocation of
the spine.  With respect  to the former, Dr. Paris
remarks :  " Although the pressure of a ligature
on the nerves  of the neck cannot be considered as
the immediate cause of death in hanging, yet Mr.
Brodie has very justly observed that if the animal
recovers of the direct consequence  of the strangu-
lation, he may probably suffer from the effects of
the  ligature   upon the  nerves  afterwards.  Mr.
Brodie passed a ligature  under  the  trachea of a
guinea-pig, and tied  it tight on the back  of the
neck  with a knot : the  animal was uneasy, but
nevertheless breathed and moved about.   At the
end of fifteen minutes the ligature was removed ;
on the following morning, however, it was found
dead.  On dissection no preternatural appearances
were discovered in the brain, but the lungs were
dark  and  turgid  with  blood, and presented an
appearance similar to that which is observed after
the division of the  nerves of the eighth pair.  < I
do not,' observes Mr. [Sir B.] Brodie (manuscript
notes), ' positively conclude from this  experiment
that the animal died from an injury to the eighth
pair, but I think  that such a conclusion is highly
probable;  and it becomes  an object of  inquiry
whether a patient, having recovered from hanging,
may not in some instances die afterwards from the
injury of the par vagum.' "  (Paris  and Fon-
Manque, Med. Jur. v. ii. p. 44.)   Fracture or dis-
location of the  spine, when  they  do take place,
must of course contribute to the speedy death of
the individual; but these  accidents are very rare,
even when tbe fall is great, as in public  execu-
tions.   In  numerous instances  that  have  come
under  the observation of the writer, this cause of
death  was never observed.   As  in  the  case  of
drowning, two questions  present  themselves  lor
solution by the  medical witness :  1. whether the
individual  was  suspended before  or after death .
2. whether it  was an act of suicide or of murdei.
An individual found suspended may have been
killed in different ways; first, he may  be hung up
after having  been murdered ; and again, he may
have committed suicide by  hanging after having
previously tried  to  destroy  himself by olhei
methods, in which he has failed, as bv fire-arm* 
562                       DEAD,  (PERS

cutting the throat, &c.  In the first case we might
be led to mistake murder for suicide, and in the
second suicide for assassination.  It is necessary,
then, to be aware of the signs by means of which
death by strangulation in general may  be distin-
guished,  in whatsoever manner it  may  happen.
These are lividity and distortion of tbe  counte-
nance, protrusion of the eyes, which are frequently
suffused  with blood,  projection  and  wounding of
the  tongue by  the  teeth.  The  latter  depends
upon the position of the rope : if it be  below the
cricoid cartilage, the  tongue  is pushed out; but if
it presses above the thyroid cartilage, it is carried
along with the os hyoides  backwards. In addition,
we have  the  mark of the cord around the neck
forming  a livid depressed  circle ;  the fingers usu-
ally bent, the nails  blue, and  the  hands nearly
closed, with swelling of the chest, shoulders, arms,
and hands, and sometimes  ecchymoses in these
situations; also semi-erection  of the  penis, and
emissio  seminis.  Cases  of  death by  hanging
occasionally  present  themselves  in which  the
countenance is pale ; this arises from the  sudden-
ness of death in some individuals, and particularly
if the spine  be  dislocated.  On  dissection,  the
body presents nearly the  same appearances  as
those described as caused by drowning, with the
exception of water in the air-passages.  A bloody
mucus issues  from the mouth and nose;  but this
is very different from the froth of drowned  persons.
The  principal vessels of the  head and neck are
filled witb blood, and sometimes ruptured.  With
respect to the  bruised mark  of the rope  round the
neck, it  is stated by M.  Klein (Journal de Med.
prat, de  Hufeland, 1815)  to be an uncertain sign,
—an opinion founded on fifteen cases  of suicide
by  hanging,  in  all  of which  it  was wanting.
Reiner,  (Annates de  Hygiene  pub. et de Med.
Leg. torn. iv. p. 166,) of  Breslau has more lately
investigated this subject on an extended scale, and
out of one hundred cases  collected by him, eighty-
nine presented the sugillation on the neck in an evi-
dent manner.   In one case,  instead of ecchymosis,
the skin was  found of a yellowish brown colour,
like parchment;  in two others the skin was exco-
riated ;  in  another  putrefaction  prevented any
certain examination ;  and in nine cases it is ex-
pressly  mentioned that ecchymosis  was wanting.
It  follows from  tbis, that  out of  one  hundred
hanged  persons,  nearly  one-tenth were  found
without  a bruised mark.  But if this  proportion
is  sufficiently great  to induce medical jurists to
withhold unlimited confidence in this sign, it is at
the same time too small to destroy  the validity of
the general rule,  that such impressions  are  found
in hanged persons.  In"all the  cases  that  have
come under  the  observation of  the  writer, the
mark of the rope was most  distinct.  These were
all executed criminals, in whom, from  the nature
of the ligature  and  the  height  of the fall, such
impressions might be expected ; but even in the
 most unfavourable circumstances the ecchymosis
 has  been strongly  marked.  Remer  (loc. cit.)
 mentions  that it  has taken place  notoriously in
 those found strangled in a position in which either
 the feet  or the knees had  not left the ground.   In
 all  the  instances  observed  by us, the ecchymosis
 did not  occupy the part of the  skin with which
 the rooe was  in contact, but formed two lines on
 )NS  FOUND)

 either side of  it,  one  above,  the  other below;
 while the  intervening  portion, the part actually
 compressed by  the cord, resembled dark-coloured
 parchment.
   It is  quite  necessary that  the medical  jurist
[ should not be content with the  discovery of a blue
 ring on  the neck, but tbat he should cut into it, in
j order to examine the extent of  the extravasations,
 and the injury  done to the parts in its neighbour-
 hood.  The height of the fall must cause a differ-
 ence in the injuries inflicted  on the  parts  com-
 posing the neck.   When the individual falls from
 a considerable height, as in  public executions, the
 lesions produced are very extensive.  Dr. Houston
j (Dublin Hosp.  Reports, vol. v.  p. 317) has pub-
! lished an account of some dissections of criminals
 in whom the similarity of injury is most  remarka-
 ble.  " Both the individuals were strong  plethoric
 men,  executed  for murder.   Their  death  was
j evidently caused by strangulation.  The cervical
 vertebrae were unbroken, and the  spinal marrow
 and brain presented no  trace of injury.  In both,
 the sterno-mastoid muscle, on the right  side (the
 opposite to that on which the knot of the  rope was
 applied) was  ecchymosed, contused and  broken;
[ that of the left side was  only slightly bruised.
 The os hyoides and  thyroid cartilage were com-
 pletely severed  from each other.  The omo-hyoid,
 sterno-hyoid  and  thyro-hyoid  muscles,  were so
 bruised  and lacerated,  that only some stretched
 shreds of them remained to hold the parts  together.
 The thyro-hyoid  membrane was also torn across,
 and the epiglottis,  pulled from its root to  the back
 of the  thyroid  cartilage, had passed up with the
 os hyoides and tongue into the back part of the
 mouth.   The skin alone remained unbroken, and
 interposed  between the rope and the cavity of the
 pharynx.   This was the only  region of  the neck
 which gave evidence  of much  injury ; the  great
 vessels  and nerves all  escaped unhurt.   In two
 other criminals, which more lately I have had an
 opportunity of examining, precisely the  same
 effects  had been produced by the rope on the soft
 parts of the neck, and  without any injury to the
 brain or spinal  marrow."  The preparations from
 which the  above statement  is taken are preserved
 in the museum of the Royal College of Surgeons,
 Dublin.   The  semi-erect condition of the penis,
■ and emission of semen, are  signs which,  although
 frequently  met  with, are not constantly found in
 hanged  persons.   Thus  Klein,  in  tbe memoir
 alluded  to, states he did not perceixe them in any
 of the  instances examined by him,  and Remer
 found  them  only in  the proportion  of three to
| four.  In  some of the  cases  examined by the
, writer  they were  wanting, but  in  the  majority
 there  were evident traces  of  excitement  of the
 organs  of  generation.   The practice  adopted by
 worn-out  libertines, of  causing themselves  to be
 half hanged  in  order  to   arouse their  dormant
 generative power, is  a  proof that some effect is
 produced on these organs by suspension.  But as
 erection is not constantly found  in hanged persons,
 we cannot accord to this phenomenon  much value
 as an indication of death by strangulation, unless
 when accompanied with other characteristic  signs.
j It adds, then, to  the  certainty  of this kind of
j death, but it is no proof when  it exists alone, for
| it has been found  in other forms of violent death; 
DEAD,  (PERSONS  FOUND)
563
and its absence  is no proof of the contrary.  A
remarkable proof of the occurrence of this phe-
nomenon in hanging is given by M. Guyon, (An-
derson's Quarterly Journal of  the  Med. Sciences,
vol. ii. p. 151,) surgeon-major  at Martinique, who
attended  the execution of fourteen persons, with
a view of  ascertaining  the truth respecting the
disputed subject of emission.   Being situated near
them at the place of execution, he observed the
penis of all become erect at the moment of stran-
gulation, and immediately after five of them made
water abundantly.  An hour  after execution he
found in nine of them the penis in a state of semi-
erection, and its canal filled with a kind of matter
with which the shirt was too profusely impregnated
 to allow it to be supposed tbat it  came from any
 other organ than the prostate.
   [In some experiments made at  Lancaster, Pa.,
 upon the  body of a criminal executed there in
 1839, it was observed, that there was an ejection
 of fluid from  the urethra, but no erection.  This
 fluid when examined afterwards by the microscope,
 was found to be mucus, and  to contain no sper-
 matic animalcules.  (Amer. Journ. of the Med.
 Sciences, May, 1840, p. 26.)]
   The second question is, whether it was an act
 of suicide  or of murder.  It is admitted by most
 medical-legal  writers that this is a difficult and
 unlikely method of committing murder, unless the
 assailants be numerous  and powerful.   Dr. Smith
 remarks, " It  is perhaps not going too far to say,
 that a man cannot be bung alive  by others, unless
 his hands  be previously tied, and probably his legs
 also."  Accordingly, when a body is discovered
 hanging, the  first impression  is  usually that the
 individual  has hung himself.  But this  opinion
 should not be confirmed until  an  accurate investi-
 gation has been made into all  the external circum-
 stances connected with the occurrence.  It should
 first be ascertained that death  has been caused by
 strangulation  ;  for it  has happened  that  crafty
 murderers have destroyed their victims in some
 other manner,  and  then  suspended  the body  in
 order to create the suspicion of suicide. But sup-
 posing  strangulation to be recognized, particular
 attention  should be paid to  the part of the neck
 which bears  the impression of the ligature, and
 the  kind of mark left by it. Thus, if we find the
 track of the cord to be  low  down,  and to pass
 horizontally round the neck, while  another and
 fainter impression exists at the upper part, taking
 an oblique course, it should excite suspicion that
 manual strangulation had been resorted to in the
 first  instance, and that the body had been hung
 up after death.  An examination of the dress and
 person of  the deceased  will sometimes aid the in-
 quiries of justice by pointing out the signs of re-
 sistance and struggling, or robbery.  It is neces-
 sary, however, to judge of any marks of external
 violence with great caution, for although they may
 generally  be  esteemed  proofs of homicide, they
 may have been purely accidental, or  have been
 inflicted by the individual previous  to voluntary
 suspension.   De Haen records the case of a per-
 son  who, while hanging, inflicted  several wounds
 on his face ; and Ballard (p. 409,) mentions a case
 of suicide, in which the  individual  first cut his
 throat partially. The  following  interesting case
 is related  by Dr- Male.  (Juridical Medicine, p.
243.)  " An apprentice-boy in my neighbourhood,
working alone in an attic, tied one end of a rope
loosely  round his   neck, whilst his master was
from  home, probably without  any intention  of
destroying  himself, and twisted tbe other  round
the projecting part of the top of a door, the planks
of which were irregular and somewhat divided;
a small stool, on  which he  stood, slipped from
under him, when  he  fell  forwards, striking his
temple against the corner of a box  which cut him
to the bone;  he lay along the floor, his head and
shoulders only elevated a few inches above it; the
cord  not being tied  had  run nearly its  whole
length,  and then caught between  the  planks  of
the door, in which state he died.  Tbe wound
was magnified by popular rumour into  many, and
vengeance  was denounced against the innocent
master, who was accused of having first killed and
afterwards  suspended  the boy.   On  examining
the boy, the mark of the cord was found  to ex-
tend  from  ear to ear;  the vessels of the brain
were turgid, the thyroid cartilage broken, the nails
blue, and the hands firmly closed.  From this and
other important circumstantial evidence, the coro-
ner's jury were convinced that the  charge was un-
founded."   It should be recollected that  a  person
may  be hanged  accidentally,  and therefore the
usual verdicts of insanity, or felo de se, are not to
be given in all cases where proofs  of homicide do
not exist, without due caution.   A remarkable  in-
stance  of  this kind  is related by Dr. Gordon
Smith, (Principles of Forensic  Medicine, p. 236,)
which  occurred in April 1821, in  Northampton-
shire.  A girl, aged thirteen, was  swinging in a
brewhouse, and near the rope used by her for that
purpose was another for the purpose of drawing
up slaughtered sheep.   In the course of the exer-
cise her head got  through a noose of this  second
cord, which pulled  her out of the swing, and kept
her suspended at a  considerable height until dead.
   [Mr. Taylor (Elements of  Medical Jurispru-
dence, p. 173,) relates another case.   A boy,  ten
years old, had been amusing himself by fastening
a piece of  plaid gown  to a loop in a cord which
was suspended from a beam in the room.   In  the
act of  swinging he raised himself up, and gave
himself a  turn, when  the loop of rope suddenly
caught him  under the  chin, and  suspended him
until life was wholly extinct.   A  playmate wit-
nessed  the occurrence.]
   We  have said above that it is difficult, without
an overwhelming  force, to  hang an individual
against his will;  but, on the other hand, it is sur-
prising with  what facility death may be  accom-
plished by this means, in situations which at first
view would seem to preclude its possibility. The
late Prince of Conde,  who committed suicide on
the 27th of August 1830, was found hanging  to
a window-shutter, with his  feet touching  the
ground  and  his  knees bent.   The attitude  in
which the  body was found raised  some suspicion
of foul play, and a most accurate investigation ef
all the circumstances connected  with the event
was  instituted,  from  which  it appeared to have
been a case of voluntary suicide.  An interesting
memoir (Annales de  Hyg. pub. et de  Med. Leg.
torn. v. p.  156,) on the subject, was published  in
January 1831, in  which- are  related  several  in-
stances of  self-destruction by hanging, where  tho 
564
DEAD,  (PERSONS  FOUND)
bodies were  found  in the  most  extraordinary
situations and attitudes, accompanied with plates
of the same.  In one a man was found in a gran-
ary hanging by a cotton handkerchief made fast
to a rope whicb stretched  across; the knees were
bent, so that the legs formed  a right angle back-
wards ; the feet were supported on a heap of grain,
over which the knees hung at a distance of a few
inches.   In another, a prisoner was found hang-
ing to tbe bars of a window  so low that he was
nearly sitting on the ground ; he had previously
tied bis hands together. In  a  third, the body was
found in  a vertical  position, with the heels resting
on  a  window-stool.  In the fourth, an English-
man, a prisoner in  Paris, hung himself in his cell,
which was an apartment with an arched roof, and
at the lower part of it was  a  grated window, the
highest part of which was not near the height of
a  man;  nevertheless  he hung himself  to  this
grating, and was found almost sitting down, with
his legs stretched out before  and  his hips within a
foot and a half of the ground.   In a fifth, the at-
titude of the body  was similar  to  the first: tbe
man had  suspended himself to  a  large  iron pin
driven into the wall to support the bed-curtains,
and his feet, bent  at a right angle, rested on the
oed, while his knees approached it within a few
inches.   In  a  sixth, the point of suspension was
so low that the  person (a  female) was obliged to
stretch out her legs, one before resting on the heel,
the other behind  resting  on the toes, in order to
accomplish her purpose.  In  a seventh, a female
was  found stretched at the foot of her bed, the
legs, thighs, and left hip,  lying on the floor ; the
upper part of the body was raised, and suspended
by a cord fixed on  tbe neck,  and fastened to the
hospital-bed.   There are  other cases  recorded in
the memoir alluded to,  of  persons found  hung in
equally extraordinary situations,  but we think  it
unnecessary to  particularize them.   A few years
ago a man, aged seventy-five, destroyed himself
at Castle  Carey  by fixing a  cord round his  neck
while sitting on bis bedside,  leaning forward till
his purpose was accomplished.   His wife,  who
had for years been bed-ridden, and therefore not
likely to  have been fast asleep,  was in the room
during the transaction,  and knew nothing of what
was going on.  (Beck's Med.  Jur. by Darwall, p.
283 ; [or 6th edit. ii. 139 :  Philad. 1838.)]   In
order to show the power of the will and  firmness
of resolution in certain  suicides, we  quote the fol-
lowing case from Remer, (loc. cit.)  "  Une femme
alia, avec l'intention de se pendre, de la chambre
ou ses enfans se  trouvaient,  dans celle ou ils cou-
chaient.   Sa fille ainee, agee d'environ huit  ans,
la suivit  bientot, et la trouva pendue ; la  fille ex-
erca tant de tractions sur sa mere pour a detacher,
qu'elle y parvient  en rompant le lien.  Alors la
mere, qui avait toujours la corde au cou, repoussa
son enfant dans la  premiere  chambre, la repri-
manda, et lui ordonna, ainsi du' a ses freres et ses
soeurs, de rester ou ils etaient, revint sur ses  pas,
et se pendit une seconde fois.  Les enfans allaient
chercher du  sd-cours, mais  ii n'etait plus temps."
From these cases we learn how quickly conscious-
ness must be destroyed in  this form  of death • for
were it not so, some exertion would  be made by
the individuals to save themselves after the expe-
r-ment had been tried to a certain extent.
I   Strangulation, properly so called, differs from
 hanging in  the individual not being suspended;
 but whether death  be caused by  suspension or a
 ligature drawn tight, or by the hand alone, or any
 other pressure on  the trachea, the  physiological
 phenomena are the same.  Strangling is a more
 common method of committing murder than hang-
 ing, arising from the greater facility with which it
 is accomplished.   A  remarkable instance of this
 is that  of Dr. Clench, who was strangled in a
 hackney-coach in  London, in 1692, by two men,
 who called him out in the  night under pretence
 of taking him to  visit a patient.  After driving
 about the city for more than an hour the  two  in-
 dividuals left  the coach,  and the  coachman found
 Dr. Clench  sitting in  the bottom with  his head
 against  the cushion.  He was quite dead, and had
 a handkerchief around his neck, in which was a
 piece of coal placed just  over the windpipe. The
 coachman had not tbe slightest knowledge of the
 transaction, having heard no noise while driving
 the carriage.
   The  appearances presented  by strangled per-
 sons, when a ligature has been employed, do not
 differ much from  those  already detailed, as cha-
 racteristic of death by  hanging.   The position of
 the rope-mark  constitutes the chief point of dis-
 tinction ; if it is not at the upper  part of the neck,
 there can be no doubt the person was not hanged :
 dislocation  of the  neck is not to  be expected, but
 the cartilages of the larynx and trachea frequently
 suffer.  The track of the ligature in strangling is
 horizontal,  and usually rather low down on the
 neck.   A question has arisen as to the possibility
 of strangling being resorted to for the purpose of
 suicide.   Upon this subject Fodere remarks: « Je
 dirai relativement  au  second chef de la question,
 qu'en general les  impressions circulaires laissees
 par la simple strangulation  forment seules une
 presomption  d'homicide, parcequ'il  n'est guere
 possible de se donner la mort par ce moyen, les
 mains cessant de  faire  force au moment ou la
 compression commence a s'exercer."   (Med. Leg.
 torn. iii. p. 174.)   Notwithstanding this  opinion
 he  relates a  case  communicated to him by Des-
 granges of Lyons, on which  the  Society of Medi-
 cine were consulted,  and replied that  voluntary
 strangulation  was  possible.  The case was that
 of an individual found strangled  in a hayloft by a
 handkerchief which had been tightened by a stick.
 Another case of a similar description is given by
 the same author.   One  of a more recent date is
 recorded by  Dr. Dunlop, (Beck's Med. Jur.  by
 Darwall, p. 290,) on the authority of a navy-sur-
 geon, a  friend of  his.  A Malay, who on board
 of a man-of-war in the East Indies had made re-
 peated attempts to commit suicide, at last succeed-
 ed by the means alluded to.  He tied a handker-
 chief round  his neck, and with a  small stick
 twisted  it several times,  and  then secured it be-
 hind his ear to prevent its untwisting.   Jealousy
 was the cause assigned  for the  act.  The well-
 known case  of General Pichegru, who was found
 strangled in  prison, in Paris, during the consulate
 of Buonaparte, gave  rise to various suspicions •
 and the rarity of  this form  of  suicide, together
 with  a  general disbelief in its possibility, served
 to strengthen  the common fame of  that day, that
 he had been thus privately murdered in order w 
DEAD,  (PERSONS FOUND)
565
avoid the risk of  a public trial.  Certainly the
condition in which the body was found seemed to
point to such a conclusion.  It was lying in bed
on the left side, in an easy attitude, with the knees
bent, and the arms lying down by the side, with a
black silk handkerchief twisted tightly round the
neck by means of a stick  passed  under it.  The
cheek was  torn  by the ends  of the  stick in its
rotations.   In allusion to this  case, Remer (Ann.
de Hyg. et de Med. Leg. t. iv. p. 186,) observes :
»Je n'ai d'ailleurs  ici aucune intention de me
constituer le defenseur d'un homme  qui a trop
verse de sang pour ne pouvoir pas prendre facile-
ment sur lui un meurtre de plus.  Bien mieux,
j'accorde que ce  genre de mort n'est que tres rare-
ment le  resultat d'un suicide, mais je doute que
sur cette seule consideration, et sans autres preuves
plus fortes, on puisse  absolument affirmer qu'il y
a eu meurtre."   Indeed, when we  consider the
number of cases, that occur, of suspension, some
of which we have mentioned,  where the position
in which the body is found  establishes with what
promptitude  the loss  of sense must  have taken
place, or how strong the desire of  self-destruction
must have  been when the resolution was  once
 taken, we think it  is going too  far  to deny the
 possibility  of death by voluntary strangulation,
 however cautious  we may be  in  receiving testi-
 mony on the subject.
   Persons destroyed by manual strangulation ex-
 hibit, instead of the circular  ecchymosis on the
 neck, irregular patches corresponding to the fingers
 of the assailant.   We must not expect, however,
 to find the internal  mark of suffocation so distinct
 as in cases of hanging, because the closing of the
 air-tube  not being  so  complete, the functions of
 respiration and circulation go on in some measure
 for a longer time.  Traces of violence on the chest
 and limbs  are also frequently observed in conse-
 quence of the struggling  and  force  employed in
 the act.
   [In rare  cases, strangulation may be accidental.
 An extremely dissipated, drunken, and disorderly
 woman went to  bed intoxicated,  and was found
 strangled in her  bonnet-strings. It appeared that
 she went to bed with her bonnet  on, and falling
 out of bed, her bonnet became fastened  between
 the bedstead and the wall, and  she, being so drunk
 as to be unable to loosen the strings, was, in con-
 sequence, strangled.  (Guy, op. cit. p. 336.)]
   Death by smothering  is nearly  allied to the
 former.   It consists in cutting off the supply of
 air to the lungs by forcibly closing the mouth and
nostrils.   This form of death  is more usually ac-
cidental  than intentional, because, unless in the
case of  very young or old feeble  persons, it is  a
difficult method of committing  murder.  Children
have been  smothered in bed accidentally, by the
nurse or  a pillow, overlaying them  in sucb a man-
ner as to close the mouth  and  nostrils.  Persons
in a state of intoxication may  be smothered acci-
dentally  by falling with the face in mud, shallow
water, or the like, and being unable  to  extricate
themselves  they perish  by   suffocation.    But
drunken persons are  also easily destroyed by in-
tentional smothering, of which the woman Camp-
bell murdered by the notorious Burke and  Hare
in Edinburgh in 1828, furnishes a  melancholy
'-xample.   This  was the last of three charges of
                                       2x
murder  laid in the  same indictment as having
been committed within  six months in the same
way, and for the same purpose, of supplying sub-
jects  for  the  anatomists'  dissecting-room; and
there is  now no reason to doubt that, in conjunc-
tion with their two accomplices who turned king's
evidence, they had carried  on the dreadful trade
of human butchery to a far greater extent.   The
direct evidence of the manner of death, as derived
from the testimony of the  accomplices, was that
Burke and Hare were fighting together, when the
deceased, in attempting to part them, was struck
down by Hare to  a sitting posture on the floor ;
that Burke, as soon as he had overpowered his
companion and thrust him on the bed, threw him-
self on the deceased, kept her down by the weight
of his  body, and covering her mouth and nose
with one hand while he applied the other  under
her chin, held her thus for ten or fifteen  minutes
till she  was dead.  The most remarkable appear-
ances presented by the body when examined two
days  after  death, were  the  following:—joints
flaccid ; features composed, red, and rather more
turgid than natural; lips affected with dark livor;
conjunctivae of the eyes, even in the horizontal
position of the body, much injected with blood ;
a little fluid blood on the  left cheek, proceeding
apparently from the nostrils; tongue  not protru-
ded or  torn by the  teeth ; the scarf skin  under
the chin much ruffled, and  the surface of the true
skin dry and  brown  when denuded, but without
blood or  surrounding ecchymosis;  integuments
every where very  free of lividity except on the
face ; no  effusion of blood or laceration of the
parts around the windpipe ; no injury of the car-
tilages ; the os hyoides  and the thyroid cartilage
farther apart than usual, in consequence of stretch-
ing of their interposed ligament:  on the inside of
the windpipe some tough mucus,  not frothy, with
a few points of blood between it and the  mem-
brane, which last was healthy ; organs within the
chest perfectly natural; the lungs remarkably  so,
and unusually free of infiltration ; blood in the
heart and  great vessels, and  indeed  throughout
the whole body, very fluid and black, and accumu
lated in the right cavities of the heart and great
veins.   There were some appearances of violence
on the limbs and in the spinal canal, unnecessary
to notice, as they were the  effects of injuries after
death, caused  by forcibly doubling up the body to
enclose it in a box.   Upon this case,  Dr. Christi-
son (Edinburgh Med. and Surg. Journal, vol. xxxi.
p. 243,) (from whose admirable and detailed  ac-
count we have extracted the foregoing) very just-
ly observes: "A conviction  has gained ground
among  the public, and has been encouraged by
the sentiments currently expressed in society by
some medical men,  that the  signs of suffocation
generally, and  as they existed in the body of the
woman Campbell in particular, are so obvious and
characteristic that they would of  themselves, and
independently  of a  knowledge of  collateral  cir-
cumstances, at once attract the attention of a pro-
fessional person  conversant  with anatomy,  and
excite a very strong and well-grounded  suspicion
of the cause of death.   This idea, if erroneous,
must have a pernicious  tendency in various ways.
A sufficient reason for my taking notice of it is,
that it  may throw  medical  inspectors off theu 
566
DEAD,  (PERSONS  FOUND)
 guard, by leading them to expect strongly-marked
 appearances in every case of death by suffocation.
 That such appearances  are very fir from being
 always present, should  be  distinctly understood
 by every medical man.
   " In the body of the woman Campbell, no per-
 son of skill, whose  attention was  pointedly ex-
 cited by being told that from general circumstan-
 ces murder was probable, but the manner of death
 unknown, could have failed to remark signs  that
 would raise a suspicion  of suffocation.  But if
 his attention had not been roused,— if, for exam-
 ple, he had examined it in the anatomical theatre
 of an hospital, without knowing that suspicions
 from general  circumstances were entertained re-
 garding  it, he  might  have  inspected it even
 minutely,  and yet neglected the appearances in
 question.  Nay, a person of skill and experience
 would have been more  likely to do  so than an-
 other, because every one who is conversant with
 pathological anatomy must be familiar with such
 or similar  appearances as  arising  from  various
 natural diseases."
   For persons found dead from noxious inhala-
 tions and poisoning, see the articles Asphyxia
 and Toxicology.
   Persons found Burned.__In cases where
 bodies are  found  dead with traces of  extensive
 burning upon them, the  medical jurist, to whom
 the investigation may be committed, has some
 delicate and interesting questions to solve.  This
 difficulty has been of late years  increased, by the
 admission of the possibility of spontaneous human
 combustion, and be is now expected to state—1st,
 whether burning was the cause of  death  or not,
 or, in other words, whether the body was  burned
 before or after death; 2d, whether the  burning
 was spontaneous or ordinary combustion.  It is
 much to be feared that a  want of information re-
 specting the peculiarities  of these different  cases,
 has led, even in times not very remote, to the con-
 demnation of  innocent persons.  « On a vu dans
 le  courant  du dixhuitieme  siecle,  condamne a
 perir sur l'echafaud, un malheureux habitant de
 Rheims, accuse d'avoir assassin^ sa femme, et de
 l'avoir ensuite brtllee, afin de se derober au sup-
 plice qui  l'attendait; et  M.  Vigne  a jette  des
 fleures sur la  memoire  de l'infortun6 Millet, dont
 la femme. sujette a 1'ivrognerie, fut  trouvee le 20
 Fevrier 1725, presque entierement consumee dans
 sa cuisine,  a un pied et demie du foyer."  (Fo-
 dere, M6d. Les;.  torn. iii. p. 204.)   Two cases
 related by Dr.  Christison, (Edin. Med. and  Surg.
 Journ. vol. xxxv. p. 316,) on the authority of the
 late Dr. Duncan, appear to us of a similar nature.
 In each the prisoner  was accused of having mur-
 dered his wife, and burnt  the body  afterwards to
conceal the murder.  " The first was the case of
 a man, Gilchrist, who was condemned and exe-
cuted at  Glasgow.   The  prisoner  and  his wife
lived  on  tolerably good terms, but  used  to take
fits of rambling an~  get drunk for days together.
At  last, on one of these occasions,  after their
return home in the evening, the people who lived
in the floor above them heard a noise like that of
two persons struggling, and soon  afterwards a
rattling or gurgling  and moaning, as of one cho-
king or bleeding to death.  They   so  strongly
 sitsnected  that all was  not right, that thev called
 down to Gilchrist through  the floor  that they
 were  afraid  he was killing  his  wife.   In  no
 long  time  they were  further  alarmed by  the
 smell of fire  and  the  filling  of the house with
 smoke;  upon  which they  went  down to Gil-
 christ's   apartment  and  demanded   admission.
 After some  delay he  admitted  them, and  in
 doing  so  appeared to  have  come out of  an
 inner room,  where  he  said  he  was  asleep  in
 bed.  On letting them  in, he stumbled  over the
 body of his wife, who lay in the outer apartment
 quite dead, kneeling before a chair and  very much
 burnt.   In these circumstances  the prisoner was
 accused of having murdered her and then  burnt
 the body to conceal the manner of death; while,
 on  the contrary, he  alleged he had gone to bed
 tired, and knew nothing of what had befallen her
 till  he was  awakened by his neighbours, and that
 he presumed her clothes had caught fire while she
 was intoxicated and  burnt her to death.   The
 medical gentlemen who had  been appointed  to
 examine  the body,  merely reported that they found
 the body so  much burnt that they could  learn
 nothing from it  as to the cause of death.  The
 general evidence was all against the prisoner. He
 was accordingly condemned, although the precise
 manner of  his wife's death was  not proved  even
 presumptively, and the sentence was put in exe-
 cution ;  but to  the very last he vehemently and
 solemnly denied that he was guilty."  The second
 case occurred to Dr. Duncan within the  same year
 at  Leith.   « The  general evidence was of the
 same nature as in the case of  Gilchrist, but even
 stronger against the  prisoner.   He lived on bad
 terms with his wife.  On the evening of her death
 she returned  home at a late hour with a lighted
 candle, after  getting some whiskey at a neigh-
 bour's.   At this time the prisoner was in bed; but
 some time afterwards there was heard a consider-
 able noise, like  that of struggling, and  of chairs
 pushed up and down the room ; and after this the
 man was  heard  in  an adjoining bed-room, endea-
 vouring to quiet his child, who  was crying.  Pre-
 sently the neighbours were alarmed by  a strong
 smell of fire proceeding from the prisoner's apart-
 ments.  At last a man forced his way in by break-
 ing the window.  On entering  he found the room
 full of smoke, and observed something burning red
 in  a corner,  over  which  he  instaAtly threw  a
 pitcher of water, and which proved  to he the body
 of the woman  burning on the hearth."   Dr. Dun-
 can was present at  the examination of  tbe body
 under the sheriff's warrant, and  reports *s fellows:
 " We found some parts of the body, especially the
 belly, burnt to a cinder.  We then  examined the
 parts on which the fire had acted more moderaMy,
 namely, the face  and  extremities, and here there
 was every mark of vital  re-action; some flpnts
 were merely red and inflamed;  others scorched to
 a hard transparent crust, but surrounded with d s-
 tinct redness, and a  great many  blisters filled  wl'h
 lymph perfectly different from those produced m
 the dead body, which are  not  filled with a flui',
 but with air or vapour.   In short, we found  a[ ■
 pearances exactly similar  to those  of fire on  \
living  body, and therefore we reported  as  oi
unanimous opinion, that the deceased was bun
to death."   As there was no proof  of the prisoi
er's having set fire to her, he was not four d guilt! 
DEAD,  (PERSONS FOUND)
567
Dut tne jury returned the  intermediate verdict of
not proven.
  It is worthy of remark, that although the possi-
bility of spontaneous combustion was not mooted
at the time  of these  occurrences, yet the acute
mind of Dr. Duncan  led  him to perceive some-
thing extraordinary in the phenomena which  pre-
sented themselves ;  and he particularly comments
upon the violent and destructive  action of the fire,
compared with the small quantity of combustible
matter consumed.   In neither case was there any
trace of burning in the house or furniture, and in
the last the woman was found on the hearth with
part  of her clothes unburnt,  and a  chair  from
which she had fallen quite entire.  She was dead
when the neighbours entered, and in the dark the
body was discovered by a red light issuing from it.
  Upon  reviewing tbese cases,  particularly  the
last, we cannot avoid  agreeing with Dr. Christi-
son, that the body was in that  singular state in
which it is  apt to  undergo spontaneous  combus-
tion ; it being  difficult to  explain otherwise  the
great extent of injury inflicted.   It is not our in-
tention at present to enter into a discussion of the
theory of spontaneous human combustion, that sub-
 ject having been already most fully and ably treated
of in a former article, (see Combustion, Spon-
taneous); but we wish to direct the attention of
 practitioners  to that interesting  phenomenon, in
 order that they may be prepared to detect it when
 it occurs ; and we have mentioned the instances
 just quoted  as examples  in which a  knowledge
 of this peculiarly morbid condition of body might
 possibly have saved the lives of innocent persons.
   Was the body burnt before or after death ?—
 This  question can  only be solved by  a reference
 to the phenomena which are known to  occur on
 the application of a burning heat to a living and
 a dead  body, and  by observing  those  indications
 of vital reaction which are peculiar to  the former,
 and remain visible after life is extinct.  We are
 indebted to Dr. Christison (Edin. Med. and Surg.
 Journ. vol.  xxxv. p. 321,) for  some  interesting
 experiments  and observations made  for the  pur-
 pose  of arriving at a more  certain knowledge of
 these phenomena; particularly with a view of as-
 certaining whether the effects of a burn on a living
 body can be imitated immediately after death by
 the application of heat.  It appears that the most
 immediate  effect  of the application  of heat  to  a
 living body is a blush of redness to a considerable
 extent round the burnt part, removable by gentle
 pressure, disappearing in  no long time, and  not
 permanent  after  death.   Next  to  this  in  order
 (according to the author quoted), and occurring
 most generally at the very same time, is  a narrow
line  of deep  redness, separated from the burnt
part by a stripe of dead  whiteness, bounded to-
wards the white  stripe by an abrupt  line of de-
marcation, passing at its outer edge by insensible
degrees into  the  diffuse  blush already described,
but not capable of being  removed  like it by mo-
derate pressure.   In every instance in which Dr.
Uhnstison watched the effects of the  actual cau-
tery, as well as in those cases observed for him by
others, this deep crimson line  appeared in a very
few seconds, sometimes  in five, generally within
fifteen, and once  only so late as thirty seconds.
Dr. Christison never failed to observe this appear-
1 ance on the bodies of persons burnt a few hours
| before death, forming a  line on  the  entire skin
 near the burn, from a quarter to half an inch in
 breadth, and about half  an inch from the burn.
 Blistering is the next appearance in point of or-
 der, but it is not a very constant  consequence of
 a  burn  if life be  extinguished  a few  minutes
 afterwards.  When the heat is applied by means
 of a scalding  fluid, blisters usually appear in a
 very few  minutes.  Yet sometimes, in very ex-
 tensive burns  of this kind, especially in young
 children,  there is  no vesication  at all  in  many
 hours.   " It follows, then, that the only effects of
 burns which appear immediately after the injury
 and remain  in the dead body, are, first, a narrow
 line  of redness near the burn not removable by
 pressure, and,  secondly, blisters filled with serum;
 that  the  former is an invariable  effect;  but  that
 the latter is not always observable when death fol-
 lows the burn  in a few minutes."
    In order to try whether these appearances could
 be imitated  by the application of burning sub-
 stances after death, Dr. Christison made the fol-
 lowing experiments :
    1. In a stout young man who  had poisoned
 himself with laudanum,  a  very  hot poker and a
 stream of boiling water were applied to the skin of
 the chest  and inside  of  the  arm  one hour after
 death.
    2. A stout young woman died in ten or twelve
 days of a low typhoid fever, and at her death was
 but little  attenuated.   Ten minutes after death
 boiling water was  poured in a continuous stream
 on the breast and outside of one of the legs.
    3. A very powerful, athletic young man poison-
 ed himself with  laudanum.   Four hours  before
 death a tin vessel filled with boiling water was
 closely applied on  several parts of the anus, and a
 hot smootbing-iron was held to the outside of the
 hip-joint.   Half an hour  after death a red-hot
 poker was applied to three  places on the inside of
 the arm.   The body was examined in thirty-eight
 hours.  " Some of the spots burnt during life pre-
 sented a uniform blister filled with serum ; on two
 there was no blister, but  the cuticle was gone, and
 the true  skin  dried  into  a reddish translucent
 membrane, at  the edge of which there were drops
 of serum,  and also particles of the same fluid dried
 by evaporation.  Round  all these spots there was
 more or  less scarlet redness, particularly  round
 the two spots last mentioned.   A bright red bor-
 der,  half an  inch wide, surrounded the  whole
 burns; and the redness was  not in the  slightest
 degree diminished  by firm pressure.   The  spots
 burnt after death were some of them charred on
 the surface, and not elevated :  two presented vesi-
 cations, but the blisters  were filled with air, the
 cuticle over them  dry and cracked, and  the  sur-
 face of the true  skin beneath was also quite dry.
 On the white parts of the skin there was no adja-
 cent  redness."  Similar appearances  were  pre-
 sented in the two former experiments  to those
 now mentioned as the effects produced after death.
 Three other experiments  were made on amputated
 limbs immediately after operation, with results of
 a  similar nature.  From  these  experiments  it
 appears that the application of heat to the hotly,
 even a few minutes only after death, cannot pro
 duce any  of the signs  of vital re-action  formerly 
DEAD, (PERSONS  FOUND)
563
described ;  and that a line  of redness  near the
burn, not removable by pressure, and likewise the
formation of blisters filled with serum, are certain
signs of a burn inflicted during life.
  Was the burning spontaneous or ordinary com-
bustion ?  We have already referred to the article
Spontaneous Human  Combustion for an ac-
count of this extraordinary phenomenon  and its
probable causes.  It is remarkable that by far the
greatest number of victims  to this  accident are
females.  Sixteen out  of seventeen  cases related
by Kopp, and all those, amounting to eight, given
by Lair, were of this  sex.   In  like manner the
four  cases  mentioned by Dr. Apjohn  as having
occurred in  Ireland, were all  old women, and in
all the use of spirituous liquors had been carried
to a  great extent.  This kind of combustion pene-
trates the body with extraordinary rapidity, and
the flame which accompanies it is with difficulty
extinguished by water :  but although it acts so
rapidly and extensively on the body, it is observed
that  objects in the neighbourhood, unless those in
actual  contact with it,  are  not attacked.   The
trunk  of the  body is the part that  suffers  most,
being generally almost  entirely consumed, while
the head and extremities are more spared.   The
rapidity and depth of these combustions, together
with the small quantity of other surrounding com-
bustibles  consumed,  contrast  strongly  with the
slowness observed when bodies are burned on  a
funeral pil ■>, or at the stake, and  lead us to under-
stand  that similar effects cannot be the work of
criminal intention, for when burning is resorted to
in order to conceal crime, its operations are in-
finitely mot >  slow, more imperfect, and extend
more  to  surrounding  objects, than in  cases of
spontaneous ;ombustion.
   Persons found Dead from Cold. — Death
from this  cause is by no means  rare in countries
where the  winter is very severe, as we learn from
accounts of travellers  in Siberia, Lapland, Swit-
zerland, &c.: and  even in these countries, when
the  winter is unusually severe, cases occur which
equally illustrate the  destructive effects  of  cold.
If such accidents happen at a  distance from in-
habited places, in snow and  frost, they are  gene-
rally too strongly marked by circumstances to be
mistaken.   But they  may  occur  in  populous
places, and even in large cities, and are then more
liable  to  misconstruction and suspicion.  " The
degree of cold necessary for  the production of its
fatal effects varies  in  a very remarkable degree
with the strength and circumstances of the  indi-
vidual to whom it is applied, as  well as with the
rapidity of the cooling process.  In some instan-
ces  we find man enduring an extreme  degree of
cold with but little inconvenience, whilst in others
we  see him perishing in a temperature  at which
water retains its fluidity." (Paris andFonblanquc,
 Med.  Jur.  vol. vii. p. 950.)  There  is a very
striking description of the effects of cold in the
 account of the first voyage of Captain  Cook.
 When the Endeavour was  off Terra del Fuego,
 Sir  Joseph, (then Mr.) Banks, Dr. Solander, and
 some  others of the company, wished  to make  a
 ootanical excursion to  a mountain that appeared
 out a short distance from the  shore.   They set
 out, twelve in number, including domestics.  An
 intense cold  seized them, which they  were en-
couraged to resist by Dr. Solander, who bad cross-
ed the mountains separating Sweden and Norway,
and knew the fatal effects of yielding to its influ-
ence.  He assured  them that whoever sat down
would  sleep, and that whoever slept would  never
waken.   Nevertheless, he was himself the first to
yield to the desire for sleep, against which he had
warned  the rest.  He begged to be allowed to lie
down ; he stretched himself, and slept some time
upon the ground covered with snow, and it was
with great difficulty that  his friend Banks  could
rouse him to go a quarter of a mile to a fire which
he had lighted.  A black servant of Mr. Banks
lay down also, replying to  the threats of  death
held out to him, that he only desired to be allowed
to sleep and die.   Dr. Solander, when aroused at
the end of five minutes, had almost lost the use of
his limbs, and his feet were  so shrunken that his
shoes fell off.   It was  not possible to waken  the
negro, and  he perished with another negro who
had been left for a moment with him to  assist
him.  All the persons  in  the expedition felt the
effects of the cold  more  or less, but the whites
were all saved, even Mr. Buchan, a painter, who
had a fit of epilepsy, to which he  was subject
   In this example,  as well as from  more recent
observation in the  polar  seas, it  appears that a
great degree  of cold,  particularly  when joined
with fatigue,  produces  in the body a stupor and
numbness almost  insupportable,  and  that the
ardent  desire to sleep  arising from this stupor is
such that it cannot  be  conquered  by the fear of
the  consequences.   We also perceive that men
least accustomed to cold  are those who most
readily  sink  under  its  influence,  as  we find the
negroes dying while the whites were saved ; and
also that strength of mind and body tended  much
to enable the sufferer to resist, since Sir Joseph
Banks,  a  man endowed  with great moial and
physical energy, was the  one who  suffered least
of the whole party.  The same cause will enable
animals to  sustain  cold with impunity.  For in-
 stance, among hybernating animals, as the dor-
 mouse  and   marmot,  it  has  been  observed,  in
 experiments made to ascertain the cause of their
 sleep, that the most vigorous are the most suscep-
 tible of invigoration by heat; and  that they are
 least readily  thrown into a state of slumber by
 artificial cold during summer.  Fodere, who was
 a Swiss, says  that while  inhabiting his native
 mountains, all the  cases  of death of this nature
 whose histories he could discover, were of sickly per-
 sons, children, old men, or females. From the experi-
 ments of Mr. [Sir B.] Brodie, to ascertain the source
 of animal heat, it is plain that the temperature of
 animals is in some way or other dependent upon
 the  integrity  of the  functions of the nervous sys-
 tem ; and hence the power of an  animal to resist
 cold will be determined  by his power of generating
 heat.   Now it is found that any cause  by  which
 the powers  of the  nervous system are impaired
 favours the action of cold upon the body ; and for
 this reason  an  individual  labouring  under  the
 effects of a narcotic may be killed by a degree of
 cold that otherwise would have been quite sup-
 portable.  It is for this reason, also, that intoxi-
 cated persons perish in severe cold more readily
 than those whose nervous system is not so  im-
 paired.  Dr. Paris (loc. cit.)  notices  two instances 
DEAD,  (PERSONS  FOUND)                        569
that occurred in London, a  few winters back, of
drunken persons being taken to the watch-house,
and there not being any charge against them they
were dismissed  by the constable of the night, and
perished in the  streets.  A  military friend  of his
communicated to him an instance where, out of a
great number of troops who were exposed  to in-
tense cold,  the  only one who perished was under
the influence of intoxication.  This was also ex-
emplified on a large scale in the disastrous retreat
of the  French  troops from  Russia; for we learn
from La Beaume's account that intoxication seem-
ed to insure death.
   Mr.  [Sir B.] Brodie is inclined to think that cold
probably destroys the principle of vitality equally in
every part, and does not exclusively disturb the
functions of any particular organ.  This opinion
is supported by the experiments of Dr. Chassat.
   In cases of persons found  dead from cold, if the
 accident be recent, attempts may be made to re-
 store life.   The application of heat should be very
 gradual; and artificial  respiration  may be  tried
 with a prospect  of utility.  Internal stimulants
 should be cautiously administered after signs of
 returning animation are apparent.
    Persons  found  dead  from Hunger* —
 Food being necessary to the maintenance of life,
 it is plain that  its deprivation cannot be endured
 for any length of time without causing death, and
 those cases of long fasting,  or of refraining alto-
 gether from food for years, have all turned out to
 be impositions.  It has, however, been ascertained
 that the want of nourishment is borne differently
 by different  persons, a  difference  depending on
 age, health, constitution, sex. &c.   Tbus, a great
 number of persons doomed  by some calamity at
 sea or elsewhere to perish by this dreadful death,
 do not all die at the same time, but some, accord-
 ing to their constitution, have the sad privilege of
 surviving their companions  in misfortune. Young
 persons bear hunger worse  than old,  and sooner
 sink under its influence,—a fact no less  correctly
 than beautifully  illustrated  by Dante in his de-
 scription of  the sufferings of Count  Ugolino and
 his children,  four in number, all  enclosed in  a
 dungeon  together,  and  condemned  to death by
 starvation. The father is represented as surviving
 until the eighth day,  having witnessed the  death
 of his sons in the  order of their  age, beginning
 with the youngest.  We see that in general, of
 the two sexes,  women bear  the  privation of food
 more easily than men ;  thus, in all  accounts of
 long voluntary abstinence, three-fourths or  more
 of the individuals are of the female sex.  Women
 usually do not consume much, and all being equal
 as to  age and health,  they require much less
 nourishment than men.  The power of resisting
 hunger varies also  with the  total  privation  or
 otherwise  of water.  Redi  (Osservazioni intorno
 agli Anim. viventi, No. 3, 4,) made many experi-
 ments to discover  how long animals could live
 without food.  Of  many fowls that he kept with-
 out eating or drinking, none passed the ninth day.
 He gave to  One as  much  water  as  it chose, of
 which it  drank freely  and  often during sixteen
 days, and it did not die until the twentieth.  Dogs
 in like manner lived much  longer when allowed
 water.  But it would appear from a number  of
 instances,  that the moisture of the atmosphere of
    Vol. I. — 72                       2 x •
the place in which an individual may be confined
may compensate in some degree for the want of
drink.   Fodere relates an  instance where three
women  in Piedmont were overwhelmed by snow,
and shut up in a narrow stable without any pro-
vision for thirty-eight days, and at the end of that
time were rescued alive;  and he thinks it probable
that they owed their preservation to the moisture
of the place of their confinement;  the absorbents
of the skin being  thus able to derive a  certain
portion  of the fluid for the use of the  system.
Chaussier reports the  case of some workme.i who
remained  fourteen days  without eating or drink-
ing, shut up in a deep damp quarry, by the sudden
falling in  of the roof.   They  were withdrawn at
the end of that time,  with  a  small feeble pulse,
scarcely any heat, and just a spark of life remain-
ing, wbich was with difficulty kindled.  The ab-
sorption of moisture had  sustained  them, as it did
the women  at  Bergamoletto.   A  very  striking
instance of the power  of water to prolong life
occurred in the case of Luc Antoine Viterbi, who
starved himself to death  in  prison  at  Corsica.
(Paris and Fonblanque,  Med. Jur. v. ii. p. 69.)
From the fifth to the sixth day,  to  hunger insen-
sibly succeeded the much more grievous suffering
of thirst, which became so acute, that on the sixth,
without ever deviating  from his   resolution,  he
began to moisten his mouth occasionally,  and to
gargle with a few drops of water  to relieve the
burning pain in his  throat; but  he  let nothing
pass the organs of deglutition, being desirous not
to assuage the most insupportable cravings, but
to mitigate  a pain  which might have shaken  his
resolution.   Until  the  tenth  the   thirst  became
more and more intolerable, when, overcome by
excess of pain, he seized  the  jug of water and
drank immoderately.   On the thirteenth,  the un-
happy man thinking himself at the point of death,
again seized the jug and  drank twice.  On awaken-
ing on  the morning of the fourteenth, and finding
his powers restored,  he fell into a rage with his
keepers, protesting that they had  deceived him,
and then began beating  his head against the wall
of  his  prison, and would inevitably  have killed
himself had he not been prevented.  During the
nineteenth, the pangs of hunger and thirst appear-
ed more grievous than ever ; so insufferable indeed
were they, that for the first time Vitft-lri let a few
tears escape him, but his invincible mind instantly
spurned this human tribute.   On the twentietb,
he declared to the gaoler and physician  that he
would not again moisten his  mouth,  and feeling
the approach of death he  stretched himself, ask-
ing, as on a former occasion, whether he was well
out,  and  added,  'I  am prepared to leave this
world.'  Death did not this time betray his hopes.
On the twenty-first Viterbi was no more.  In this
interesting case, which we have here abridged, we
perceive the effect of a  small portion of  fluid in
producing vigour  in  a body worn out by  absti-
nence.   There  can be  no doubt  Viterbi would
have died much earlier if he had not  made use of
 the water.   In the examination  of  bodies dead
from hunger, the following characters are usually-
observed.   There is general emaciation of  the
body, together with  an acrid fetid odour.   The
 eyes are open and red, the tongue and throat dry,
 and  the  intestinal canal  is  empty.  Tbe gall- 
570
DEAD,  (PERSONS  FOUND)
 bladder  is usually filled with bile, which  exudes
 and tinges the neighbouring viscera.   The lungs
 are  shrivelled, and  all the other organs healthy.
 It is thought by Fodere that some conjecture may
 be drawn as to whether  the person has been  to-
 tally deprived of water or not;  for, according to
 the  experiments of Dumas,  the dogs which  he
 killed by thirst had  the viscera inflamed, and the
 blood thick and coagulated — phenomena which
 did not present themselves in the bodies of those
 dead from hunger alone.
   Persons found dead from Lightning. —
 Death from  this cause is sufficiently  common to
 warrant a consideration  of it in this place.   Its
 phenomena may be  studied by observing those of
 common electricity, as  it  has been  sufficiently
 proved  that they are identical.  The human body
 is alike affected by both, and death, whether it be
 occasioned by the discharge of an electrical bat-
 tery or  by  that of a thunder-cloud, exhibits effects
 precisely analogous.  Two theories respecting the
 manner of death by lightning are extant, the first
 that of Mr. Hunter, the second of Mr. [Sir B.] Bro-
 die.  Mr. Hunter supposed that when death is thus
 occasioned, there is an  instantaneous and  total
 destruction of the vital principle in every part of
 the  body,  and that the  muscles are therefore re-
 laxed and incapable of contraction ; that the limbs
 do not stiffen as after other forms of death, nor
 does the blood coagulate, and that putrefaction is
 rapidly  set up.  On the other hand, Mr. [Sir B.]
 Brodie concludes from his experiments, given from
 his manuscript notes by Dr. Paris, (Med. Jur. vol. ii.
 p. 64,)  that an instantaneous extinction of vitality
 does not take place, but on the contrary the func-
 tions of the  brain are those on which  the electric
 shock exercises its primary influence.   In  one  of
 his  experiments an electric  battery of six jars
 having  been charged  with electricity, the shock
 was made to pass  through a guinea-pig  in  the
 longitudinal  direction from the  head  to the tail.
 The animal  immediately fell on  one side insensi-
 ble,  as  if  stunned; a convulsive action  of the
 muscles of the extremities was observed, but did
 not long continue, and the function of respiration
 was not interrupted.  In a few minutes sensibility
 was restored and the animal recovered.  In another
 experiment a shock  from  nine jars was passed  in
 the  same manner  through another  guinea-pig.
 The animal immediately  fell on one side, exhibit-
 ed a convulsive action of the voluntary muscles
 of the limbs, but uttered no cries, and although
 attentively  watched, no signs of respiration could
 be discovered after the shock had passed  through.
 Three  minutes  afterwards  Mr.  [Sir B.] Brodie
 opened the chest, and found the heart acting with
 regularity and vigour  ahout eighty times  in the
minute,  and circulating dark-coloured blood. The
peristaltic motions of the  intestines were also visi-
ble, and the muscles obeyed the galvanic stimulus.
  In this experiment it is  plain that  neither the
irritability of the muscular system at large nor
that  of the heart was destroyed by the shock, but
death took place as from a severe injury  of the
head and destruction of the functions of the brain.
 In this case Mr. [Sir B.] Brodie  remarks, that  if
the lungs nad been  artificially inflated, the action
of the heart might have been maintained, and the
 Miima' probably restored  to life.
   When a discharge of lightning strikes a human
 body, it may affect  the  surface and produce vesi-
 cations, wbich  most  commonly,  according  to
 Mayer, pass in the  direction of the spine ; or il
 may penetrate a particular part  of  the  body and
 act  locally.   The clothes are not unfrequently
 torn,  and  buttons,  coin,  or  other  metallic sub-
 stance melted, but  occasionally cases  are  met
 with where the clothes are uninjured.  Death has
 sometimes occurred when the thunder-cloud has
 appeared to be at a considerable distance.  This
 is accounted for by supposing it to be a discharge
 of electricity from the earth to  the cloud, which
 had become  negatively electric, constituting what
 is termed the returning stroke.  All discharges of
 electricity occur in  consequence of the approach
 of two bodies in opposite states of electrical excite-
 ment.  When  a  substance excited  positively  is
 brought near another in its natural  state and in-
 sulated, the electric equilibrium of the  latter  is
 instantly disturbed, the parts nearest to the former
 become  negative, and the distant ones  positive.
 If the body  is not insulated, its  electricity passes
 into the earth, and the whole becomes negatively
 electric.  If, on the  contrary, the exciting  body
 be negative,  it causes the  contiguous parts of a
 body in its vicinity to become positive.  Hence it
 is established  as  a law, that an electrified  body
 tends to produce in a  contiguous  substance  an
 electric state opposite to its own.  The electricity
 developed  in this way is  said to be  induced, or
 excited by induction.   The  construction of the
 Leyden  phial is  upon this principle; when the
 inside of the jar  is rendered positive by contact
 with the prime conductor, the outside, if in com-
 munication with  the earth, parts with electricity
 and  becomes negative ; both surfaces are therefore
 electrified,  but in opposite states; and if a com-
 munication be established  between  them by  a
 good conductor, the excess of electricity instantly
 passes along it, and both sides of the jar return to
 their natural condition.  Now when a negatively
 electric cloud approaches the earth, all objects  in
 its vicinity  are positively  excited,  and when it
 comes within striking distance, — that is, so  neat
 that the tendency of the  electricity to pass from
 the positive  to the  negative body overcomes the
 resistance of the intervening portion of air, — the
 equilibrium is restored with a report  and a flash
 of light, exactly as in the discharge of the Leyden
 phial.  If a  person  is found in an open place 01
 under a tree  shortly after  a thunder-storm, with
 the  ordinary  appearances  mentioned  above, we
 may attribute his death to lightning, and  parti-
 cularly so if the  metallic  substances  about him
 are found melted and his  clothes  torn or burnt,
 while dissection exhibits no other cause of death.
  Persons found dead  from Wounds.—On
 the trial of Count Koningsinark for the murder of
 Mr.Thynne, Mr.Hobbs, the surgeon, being pressed
 by counsel to discriminate between the relative mor-
 tality of certain wounds found on the  body of the
 deceased, replied,  »I believe there  never was  ;>
 wound but it might  prove mortal."   This is an
 opinion in which  every one who has  had oppor-
 tunities of witnessing a variety of injuries must
coincide, from  the extraordinary and  unexpected
results which  sometimes  follow.   Thus, indivi-
duals have been known to recover  from wounds 
DEAD,  (PERSONS  FOUND)
571
which, from their extent  and the importance of
the organs  implicated, left no  room for  hope ;
while others have perished after the  infliction of
violence so slight, and producing such trivial local
effects, as  to  have  almost escaped  observation.
Such consequences, however, must be considered
as exceptions  to the  usual  course  observed in
similar instances ; and taking wounds in general,
we must admit that they allow of classification in
reference to their mortality.   Any such  classifi-
cation can never be made complete or definite,
from the exceptions just  alluded to, as  well as
from the impossibility of proving  the absolute
similarity of two wounds, however they resemble
each other, when  one individual dies and  the
 other recovers, and also from the endless varieties
 of constitution  in  different individuals.    It is,
 therefore,  upon  their  usual or  more  common
 effects that such a division can be adopted for our
 present purpose.
   The term wound, in medico-legal  phraseology,
 is much more comprehensive than the same word
 in surgery.  In the latter it means a solution of
 continuity : but  in  the former it also comprises
 injuries  of every kind caused by  mechanical vio-
 lence, such as bruises, contusions, fractures, luxa-
 tions, &c.  in which sense it is to be understood in
 the observations  that follow.
    [It would appear, that  the present rule in Eng-
 land is, that no injury constitutes a wound in law
 unless the continuity of  the  skin  be broken ; so
 that in  a case where blows were  inflicted with a
 hammer or iron instrument sufficient to break the
 collar-bone,  and violently bruise but not break
 the skin, it was held not to be a wounding within
 the statute (Archbold.)   A man was tried at the
 Central Criminal Court, in  August, 1838, on a
 charge  of cutting and wounding the prosecutor.
 The prisoner struck  the prosecutor a severe blow
 on the  temple with a heavy stone  bottle, which
  was thereby broken to pieces.   The prosecutor fell
 senseless,  and it was a long time before  he reco-
 vered.  The medical witnesses underwent a rigid
  cross-examination by the prisoner's counsel,  re-
  specting the meaning of the word " wound." They
  said that there had been a separation of the cuticle
  or outer skin of the temples, although there was no
  absolute wound in the  usual  acceptation of the
  word.  They farther deposed that the prosecutor
  had lost the sight of his  left eye, and the hearing
  of his left ear, and he was for a considerable time
  in a state of great danger,  from which he had
  scarcely recovered.   The prisoner's counsel main-
  tained that the injuries were not such as to con-
  stitute cutting and  wounding in law.  The court
  said, in order that a wound, in  contemplation
  of law, should have been inflicted,  it was neces-
  sary that the whole skin, and not the mere cuticle,
  should  have  been separated and divided; and  as
  the evidence did not show distinctly, that there
  was such  a wound, those counts of the indictment
  could not be sustained.   The  prisoner was found
  guilty of an assault.  (Taylor, A Manual of Me-
  dical Jurisprudence, p.  282: Lond. 1844.)]
    The  chief points to be decided by the medical
  examiner in  the case of a body  found dead with
  wounds,  are,—1st, Were  they inflicted during
  life?  2dly,  were they the cause of death ? and
  if so, were they the result of suicide or homicide ?
In order to settle these points, it will be necessary
to consider the classification of wound? just  al-
luded to.   They have  been divided, for the pur-
pose of medico-legal inquiry, into  four classes,—
1st, those absolutely mortal; 2d, dangerous ; 3d,
not mortal; 4th, accidentally mortal.   This divi-
sion of wounds is founded, as  has been already
stated, upon the usual  terminations of such inju-
ries, because  it is  well  known  that death  some-
times follows  those  of  the slightest  description ;
and that others of the  gravest kind terminate  m
recovery.   Metzger (Page  327,  and  Beck, by
Darwall,  p. 324) mentions an  instance  of death
from  hemorrhage brought on  by the  slightest
scratch of the thumb-nail.   Dr. Paris (Paris and
Fonblanque, Med. Jour. v. ii.  p.  116) states  he
has seen a case in which the extraction of a tooth
was followed  by death  in forty-eight  hours ; and
a similar  case is  reported by Mr. Blagden, (Med.
Chir. Trans, vi. viii. p. 224.)   An instance oc-
curred lately to the writer of this article, in which
a fatal hemorrhage followed  a superficial incision
made into the upper gum of an infant to liberate
one of the incisor  teeth.  On inquiry, it appeared
that another child of the same family had died of
hemorrhage  from  some  equally  slight  cause.
Leech-bites have  been known  to produce deaih
in children ; and in  the case of Brain (Cro.  Eliz.
778.  Paris and  Fonblanque,  v. ii. p.  122)  tried
for the murder of Watts, it was proved that the
deceased died instantly from a blow on the calf
of his leg.  On the  other  hand, we  are not with-
out instances of equally surprising recoveries from
injuries of the severest  kind.  We have seen per-
sons survive  extensive fractures  of  the skull, in
whom portions of the  brain have protruded.   Dr.
Male mentions the  case of a mendicant in Paris,
from whose  skull a portion of the bone was de-
tached, large enough to be used by him to receive
 alms.  The  celebrated case of Mr.  Tipple,  (re-
 lated  by Mr.  W. Maiden.   London,  1812,)
 whose thorax was  transfixed  by the  shaft of a
 gig, is a striking  illustration of the  present sub-
 ject.  Dr. Dunlop  (Beck's  Med.  Jur. p. 332) re-
 cords a case of duel in the West Indies, in which
 one gentleman hit another in the  eye, the ball of
 which was completely  obliterated ; and the leaden
 bullet, passing in through the  orbit, came out in
 front of the external ear ; nothwithstanding which
 destruction of the  eye as well as injury of  the
 brain, the officer  recovered with the same facility
  as if he had only  undergone  the infliction of a
  flesh-wound.
    On account of these variations from tbe usual
  course, the consideration of injuries from  wounds
  in a medico-legal point of view, is, on the conti-
  nent, and was formerly in these countries, a mat-
  ter of much  more  intricacy than it is  at  present.
  A person inflicting a wound on another was held
  amenable for the consequences during a year and
  a day ; a most inconvenient principle of  respon-
  sibility, and  one  particularly calculated to create
  confusion, by either   involving the innocent  or
  suffering the guilty to escape.  Chaussier relates
  a case illustrative of this  point.  Two men whu
  had had some previous misunderstanding,  encoun
  tered each other on  a public  walk, when, aftei
  some altercation,  one of them struck the other with
  a  light  cane  and  retreated ; the other, enraged, 
572
DEAD,  (PERSONS  FOUND)
pursued him, but had  not  advanced many steps
when he fell dead.  On examination of the body,
it  was found  that  he had an aneurism of the
aorta, which had burst from the excitement under
which he laboured at the moment.   Fortunately
for the administration of justice in this kingdom,
that act of the legislature called the " Ellenborough
Act," relieves  the medical  witness of the present
day  from  those  serious embarrassments  under
which our predecessors must have laboured; as
by it, wounding with an attempt to kill is deemed
equally  criminal whether death be the result or
not.   This, considering man as  an accountable
being, is the true and just view to take  of the
crime.  Still,  however, the testimony of the me-
dical  witness will always be important, as by the
nature of the injury, its seat, and  direction, the
evil intent is often to be inferred.
   Of mortal wounds those which  cause instant
death are wounds of the brain, of the heart, and
large vessels connected with it,  of the spinal mar-
row  on the neck,  and blows  on the  stomach;
these are all for the most part followed  by imme-
diate death.  Wounds of the brain must be con-
sidered  as  less fatal than  those  of  the  heart, in
consequence of the recoveries which are some-
times observed to take place after them, and even
wounds of the heart are not necessarily immedi-
ately fatal.  The late Due  de Berri lived for eight
hours after being stabbed through the left  ventri-
cle,  and similar  cases are on  record.   Next in
order as mortal wounds may be mentioned those
which interfere with the function of respiration,
such as extensive wounds of the diaphragm, and
injuries which lay open both sides  of the  thorax
in a  considerable degree, and thus impede the dila-
tation of the lungs.  Among dangerous wounds
must be ranked tbose of the pharynx and oesopha-
gus, stomach and chylopoietic viscera, the danger
of which will be  of course in  proportion  to the
extent of the injury.  Also, wounds of the uri-
nary bladder and  of large blood-vessels  in the
head, thorax,  and   abdomen;  severe  contusions
over any of these cavities ; wounds  of the extre-
mities implicating the  great blood-vessels, or caus-
ing compound fractures, or in tendinous situations
from the danger of tetanus supervening.   In the
class of slight wounds are  included those injuries
by which  the skin  and muscles  are  bruised or
divided, and where no tendon, aponeurosis, large
nerve,  or  blood-vessel is  touched,  and the sys-
tem has not  received any severe shock ;  to this
class belong simple fractures and luxations.  The
last   class, or  wounds accidentally mortal,  are
influenced by different causes,  which render this
division an arbitrary one, and will  be considered
when we  come  to  treat of those  circumstances
which alter the medico-legal  character of wounds.
   In the article Pseudo-morbid Appearances,
 [and in a previous  part of this  article,] allusion
has  been made to the spontaneous lividities which
 occur on the surface of dead bodies;  the nature
 and  causes of which, and the  means of distin-
 guishing them from the effects  of contusions in-
 flicted before  death, are there pointed out.  But
 there is another source of error connected with
 the  examination  of  the surface, which it is neces-
 sary to dwell a little upon before we proceed  to
 consider wounds of particular  parts; that is, the
possibility of appearances  being caused  '>y vio-
lence offered to the body after death, whi<h will
resemble those that result  from injuries received
during life.
  That such a resemblance does occur is certain,
if the blow be inflicted within a certain time after
dissolution, and  the power of discriminating be-
tween the two is  of the utmost moment to the
medical jurist.  We  are indebted to Dr. Christi-
son for the most accurate information we possess
upon this subject,  (Edin.  Med.  Surg.  Journ.
v. xxxi. p. 236.)  His  attention  was  forcibly
drawn to it on the occasion of  the trial of Burke
and Hare at Edinburgh for  the murder of the
woman Campbell for  the  purpose  of selling her
body.  Before the confession  of the accomplice,
the whole weight of the case rested on  the  medi-
cal evidence ; and one of the questions to be an-
swered was, whether  certain  bruised  marks and
subcutaneous extravasations of  blood, found on
different parts of the  body, were indications of
injuries received  before death.   Being unable to
find in authors on medical jurisprudence any in-
formation precisely applicable to the  case, except
what rested  on  physiological  speculation,  Dr.
Christison proceeded  to subject the  question to
the  extent of experiment. For this purpose, a
large dog being strangled,  and the hair on various
parts of the head, trunk, and legs, being shaved,
heavy blows were inflicted on  these spots with a
hammer, at intervals of from five minutes to two
hours after death  ; but at the end of twenty-four
hours no trace of injury appeared in the seat of
any  of  the  blows.   The  next  experiment was
made on the body of a female an hour and three-
quarters after death.   Several  heavy blows were
inflicted with a  stick  across both  shins, on the
fore-part of the thighs, on the breast, and on the
side of the neck.   In  less  than ten minutes, deep
bluish-black discolorations followed the blows on
the  breast and   neck.  Twenty-five hours  after
death the blows  were  shown  on the  thighs, by
faint stripes consisting of bluish-black points.  On
the breast and neck the stripes  were  as deep in
tint  as any contusions  inflicted during  life, but
without swelling, the colour  corresponding with
the prominent part of the  stick.  A  severe  blow
had been struck over the crest of the ileum twenty-
 three hours after death, which caused ruffling of
 the cuticle at the  time, but no  further appearance
 of injury.   The third experiment  was on the
 body of a man.   It was struck with a stick on
 the  left side of the back three hours and a quar-
 ter after death.   More blows were  struck on the
 right side seventeen  hours after death.  An ex-
 amination was made forty-seven hours after death,
 when the blows first struck were marked  by two
 long narrow stripes of dark lividity, with an in-
 tervening colourless stripe corresponding with the
 prominent part of the  stick.   The  redness was
 confined in this, as in the  former case, lo the mere
 surface of the true skin, the rest  being natural.
 The marks of the latter blows consisted  of dry-
 ness and brownncss of the surface, without effu-
 sion.  The fourth was on the body of a young
 man, four hours  after  dissolution.  It was  struck
 with a stick, and on  subsequent examination  it
 was  found  that  wherever the cuticle had been
 comminuted, the mark was dry and brown, but 
DEAD,  (PERSONS  FOUND)
573
there was no other discoloration of the skin.  The
subject of the fifth experiment was a stout young
man, on whose back several  heavy blows  were
struck with a mallet two hours after death.   The
body was inspected five hours afterwards, and pre-
sented deep lividities in the seat of the blows, but
the substance of the skin was nowhere infiltrated
or discoloured.  The  general  conclusions to  be
drawn from the preceding facts are thus  stated by
Dr. Christison.
   " In respect to external contusions, the experi-
ments show that for some hours after death blows
will cause appearances, which, in point of colour,
do not differ from the effects of blows inflicted
recently before death ;  that the discoloration gene-
 rally arises, like lividity, from an  effusion of the
 thinnest  possible  layer of the fluid  part  of the
 Wood on the outer surface  of the  true skin ; but
 sometimes  also from  an effusion of thin blood
into a perceptible  stratum of the true skin itself;
 and  that  dark fluid blood may be even effused in
 the subcutaneous  cellular tissue in the seat of the
 discolorations,  so  as to blacken  or redden  the
 membranous partitions of the adipose  cells, but
 that this  last effusion is never extensive. It can
 hardly be doubted  that the appearances now de-
 scribed will exactly imitate slight contusions in-
 flicted during life; but I conceive that the blows
 in the latter case must be trivial."
   "  When a blow  inflicted during life is  more se-
 vere, it may have the  following  effects, few  or
 none of which, so far as we  know, can  originate
 in violence after death.   1.  There may be swell-
 ing from the amount  of the extravasation ;  this
 is certainly never  caused in the dead body.  2.
 When the violence has been applied a  few  days
before death, there will be a yellow margin round
 the black mark, which is another appearance that
cannot be formed  except during life.  3.  There
 may be clots of blood in  the subjacent cellular tis-
 sue, either  with or without  swelling : these ap-
pearances I have never seen accompanying  con-
tusions caused in  the  dead body ; but it may be
doubted whether clots might not be formed if the
injury was  inflicted very soon after death, and had
the effect of lacerating a considerable vessel in the
neighbourhood  of loose cellular tissue.  4. In the
instances in which the blood does not coagulate
at all after death,  contusions caused during life
may be recognised by the extent of the effusion
into  the cellular tissue.   In a part not liable to be
infiltrated by its depending position, and not in
the vicinity of a  large vein, a deep effusion of
fluid blood, which fills  and distends  the  cells of
the cellular tissue can hardly be produced on the
dead body.   5.  Perhaps one of the most charac-
teristic signs of a  contusion  inflicted during life
is, incorporation of blood  with the whole thick-
ness of the true skin, rendering it black instead
of white,  and increasing  its firmness and resist-
ance. This sign may not be always present, for,
as every one knows, a blow may cause extensive
extravasation below the skin, without affecting the
skin  itself.   But when present, I am  disposed to
consider it  characteristic, because I  have never
been able to produce it in the dead  body, and it
is not easy to conceive how such a change can be
wrought in so dense a texture as the skin, with-
out the force and agency of living vessels."
   " It is impossible to fix absolutely the limit  of
 the interval beyond  which  contusions cannot  be
 imitated by violence applied to the dead body.  It
 appears to vary with  the state of the blood, and
 the time which elapses before the body cools, and
 the joints stiffen.   Sometimes the appearance  of
 contusions  can hardly be  produced  two  hours
 after  death (Experiment 5th) ;  sometimes they
 may be slightly caused three hours and a quarter
 after it (Exp. 3rd) ;  but I should be  inclined  to
 think  this  period very near  the extreme  limit.
 Wherever tbe warmth of the  body and laxity  of
 the muscles were not considerable at the time the
 injury was inflicted, we may be sure the appear-
 ance of contusions cannot be considerable (Exp.
 2c?).   It is probably, therefore, only on the trunk
 that even in the most favourable state of the body,
 namely, when  the blood remains altogether fluid,
 any material mark of contusion can  be produced
 so late as two hours after death."
   With respect to wounds of the head, it is well
 known that all kinds  of violence are  more dan-
 gerous in some constitutions than in others.   In
 good  constitutions, wounds may not be  danger-
 ous, which  in  old, bilious, or scrofulous  habits,
 are often attended by death, chiefly in consequence
 of the erysipelatous  inflammation that succeeds
 them.   Fracture  of the  bones  of the  cranium
 may take place without any correspondent injury
 of the integuments, and the  symptoms  in such
 cases  are extremely equivocal and deceitful.   A
 mere  simple fracture when no more  is  implied
 than solution of continuity  confined  to .the bony
 substance without displacement or injury to the
 neighbouring parts,  is  not necessarily an  event
 of great importance.   In so simple an  occurrence
 we can hardly suppose bad consequences to arise.
 Simple cases like  these, however, are very rare,
 and these injuries are almost always complicated
 with some affection more or less severe of the in-
 ternal parts.  Although fractures may  be  consid-
 ered more  dangerous  when  accompanied with
 depression, yet we  cannot  ascertain  the  precise
 degree of injury sustained by  the contents  of the
 cranium from the external wound, nor does it fol-
 low that the more extensive it is, the more certain
 is  the danger.  In  fact,  our  knowledge' of the
 economy of the brain is very limited, and though
 injuries of it are generally of a most serious char-
 acter, yet we find surprising recoveries  take place.
 The effusion of a small quantity of blood or pus
 upon  its surface may, and  often does, cause the
 most alarming symptoms, and terminate in death ;
 while,  on the  other hand,  large portions  of the
brain  itself have  been  removed, and foreign bo-
 dies, as a musket-ball, and  portions  of the skull
have been  lodged in  it, and recovery  has taken
 place.  It is hence" exceedingly difficult to  define
 the exact amount of injury to the head necessary
to  cause death ; nevertheless, in case of a body
found dead with fracture of tbe  skull, and wheie
no other sufficient cause of death can be  ascer-
tained, we are justified in attributing the event  to
the injury.  We  come to  this  conclusion  from
our knowledge  of another effect of violence offer-
ed  to the head,  and which must always accompa
ny the former in a greater or less degree,—name
ly, concussion or commotion  of the brain.  By
concussion of the  brain is  meant a violent and 
574
DEAD,  (PERS
ONS FOUND)
sudden shake of the organ without  any apparent
wound or mark of injury being left.  It may be
caused by violence  offered directly to the head,
or transmitted to it by falls on  the feet  or  nates.
A remarkable instance of the former is  given in
the Transactions of the  Royal Academy of Paris.
A stout  young criminal was  condemned  to be
broken on the wheel, and wishing to escape the
execution, ran head foremost against the wall of
his dungeon, and instantly fell dead.   On open-
ing the head, not the slightest  appearance  of in-
jury was  discoverable in  either skull,  brain, or
spinal  marrow, except a very minute separation
in the squamous suture  of one  side.
   Certain injuries done to the face belong to this
division of wounds.  When these are confined to
the face alone, the most serious consequence may
be  no  more than deformity ; but mortal wounds
have been inflicted through the face on the con-
tents of the cranium.  The most common of these
is where a sharp-pointed instrument is struck into
the eye, and pierces the  orbital plate of the frontal
bone.  The celebrated comedian Charles Macklin
was tried in the year 1753 for the murder of a
brother-player,  whom he struck accidentally in
the eye with a cane, in some altercation that took
place in the green-room.  (Stale Trials.)  Tho-
mas Hallum, the  sufferer, died  the next day, and
it was found that the point of the cane had passed
through the orbital  plate, and wounded the brain.
A case  occurred  some years ago in Dublin of a
similar  nature.  A  gentleman  received a  thrust
of a watchman's pike in the  eye, in some drunken
broil in the street :  the  immediate effects were so
trifling, and the external wound so slight, that he
took no notice of it until he was attacked with in-
flammation  of the  brain, which killed  him in a
few days.  Mr. CoIIes, under whose care he was,
opened the head, and found  a small round hole in
the orbital plate of tbe frontal bone, in the neigh-
bourhood of which there was a large  collection
of pus.   The part is preserved  in the  museum of
the College of Surgeons of Dublin.  In  like man-
ner, blows upon  the nose have not only crushed
that organ, but also driven  the ethmoid bone up
into the brain ;  and  sharp-pointed  instruments
have sometimes penetrated the  brain through this
organ, and proved fatal.  Such instances as these
show how necessary it is to investigate with the
greatest accuracy all cases of sudden death ; for
without the greatest care and attention, cases of
this description must elude discovery.  We make
this observation in order to induce medical ex-
aminers to bestow more pains on the highly im-
portant trust they undertake,  for it must be con-
fessed  that in investigations of this sort, we fall
far short of the  diligence of our Continental
brethren.
   As connected with wounds of the head, we may
observe that children, either before  or after birth,
may be, and  have been, destroyed by fine sharp-
pointed instruments passed through  one of the
tontanelles.   A Parisian midwife  was  executed
some years ago on its being discovered that she
was in the habit of procuring still-born children
for those who desired it, by  piercing the brain of
the infant before its birth  with a fine  wire.  A
woimd of this description leaves very little mark
and would of course escape superficial observation.
  The neck comprises many important parts, a
wound of which is necessarily followed by death.
Wounds of the  integuments and muscles of the
neck may be considered simple wounds, although
they are  sometimes difficult  to heal  in  conse-
quence of the mobility of the parts ;  but wounds
of the  carotid arteries, jugular veins, and  spinal
marrow, are for  the most part immediately fatal.
Lacerated wounds of the carotid  artery, however,
may not be quickly followed by death, an instance
of which came within our knowledge some years
ago.  The artery was torn by the horn of a cow,
and the bleeding from the wound, although con-
siderable, was not sufficient to destroy the patient,
who survived long enough to have the artery tied,
and subsequently recovered. It has been said that
a complete division of the trachea is  mortal; but
the danger  attending a wound of this sort arises
from the  injury usually inflicted upon  the  great
vessels and nerves  in its neighbourhood at the
same time, more than from the wound of the air-
tube itself, for we know that mere division of this
part is not  necessarily fatal, although  it may be
very difficult to  heal from the great mobility of
the part,  and the constant  passage of the air
through it.   Wourtds of the  pharynx  and oeso-
phagus are much to be dreaded, as  well on ac-
count of the other important parts which must be
wounded  along  with them, as from  the circum-
stance  that through this channel the nourishment
of the body is conveyed, and that the act of deglu-
tition is directly  opposed to a speedy  adhesion  of
the parts.   The following case gives a good pic-
ture of the  dangers  and difficulties  attending
wounds of these parts.  (Edin. Med. Surg. Jour.
v. xvi.  p. 353.)  A few years ago a  prisoner  in
Edinburgh jail  cut his tbroat transversely, divid-
ing the larynx  quite across  at the upper end  of
the cricoid cartilage, and the separated extremities
receded from each other to the distance of three
inches ; the great vessels  and nerves escaped in-
jury from the cut being so high.  The  professional
gentlemen who  saw him were satisfied that the
oesophagus was  also cut entirely across.  Several
attempts must have been made, as another open-
ing was afterwards  discovered in  the windpipe.
In this state a junction of the parts was found to
be impracticable, and the ligatures that had been
applied with the view of making the best possible
approach were separated by  his  incessant  exer-
tions in passing water through the  mouth, and
out at the wound,  in which way he used  several
buckets full in  the course of  one day.  He was
supported in the first instance by nutritious ene-
mata, and  afterwards by means of a tube conveyed
through the wound into the oesophagus and sto-
mach.  After  much trouble to  the practitioners,
and considerable risk to the patient, the functions
of breathing and  ingestion were carried on through
a tube in each passage introduced by the wound,
the tracheal tube being removed when it was ne-
cessary to apply  the other.   The man was  after-
wards tried, acquitted, and liberated from jail, and
continued to live  under  the  disadvantages  men-
tioned.  Besides the parts just  alluded  to, the
neck gives  passage to the  par vagum and the
great sympathetic nerve, injuries of which, even
partial  or at but  one side, must be considered  of
the most dangerous kinds, as from them princi- 
DEAD, (PERSONS FOUND)
575
pally  the  cardiac  and  pulmonary plexuses are
formed.   Injuries to the spinal marrow, either by
fracture  or dislocation of the vertebrae,  or  by a
wound penetrating between two of the vertebrae,
are absolutely fatal.   Fracture or dislocation  is
generally the result of accident, as a fall, or  what
coachmen are liable to—striking the head against
a low arch-way in driving under  it.   They also
sometimes, though rarely, occur in hanging.   But
they may happen  in  consequence of  disease; a
striking example of which  came  under  the ob-
servation of the writer some years ago.   A boy,
who was under  treatment in the Richmond  Hos-
pital (Dublin) for  some  disease of the leg, was
one morning, during the visit, sitting  up in his
bed talking to  those  around him, when  his head
suddenly fell forward on the breast, and  he  drop-
ped dead.   On  examination, it was found that
the  root of the  odontoid process  of the second
vertebra, and the transverse  ligament  that  binds
it in its situation, was ulcerated, and in the mo-
tion of the head it had broken off, and  compress-
ing the  spinal cord, had produced instantaneous
death.
   A consideration of the important organs con-
tained in the thorax will lead us to estimate the
danger arising from wounds which penetrate suf-
ficiently deep to reach  them.  Wounds of the
lungs we know are not  necessarily fatal, though
for the most part they are exceedingly  dangerous,
from the size and number of the blood-vessels by
which  they  are traversed.   These  organs are
sometimes  seriously injured although no external
wound be present.  This arises from the fractured
 portion  of a broken  rib being driven into  their
 substance,  of which injury hemorrhage, emphyse-
 ma, and inflammation, are the consequences most
 to be  dreaded.  Nevertheless, although  injuries
 of these organs  are of a very serious nature, and
 not unfrequently terminate fatally, we  find  occa-
 sionally tbat they  support most extensive injury.
 This is  familiar to many military and naval sur-
 geons who during  the late  war had opportunity
 of observing the powers of nature in repairing
 extensive injuries of these organs ;  and we before
 alluded to  the case of a gentleman who recovered
 after having both sides of his thorax transfixed by
 the shaft of a gig.  It is quite true that  penetrat-
 ing wounds of the  heart are, generally speaking,
 mortal;  but there  are so many cases on record of
 individuals who survived, some of them  for days,
 others entirely,  after wounds of  this  organ, that
 we cannot agree with those authors who maintain
 that such  injuries  are necessarily and  instantly
mortal.   At  the battle of Corunna a soldier re-
ceived a shot in the chest and fell insensible.  He
was found  by a comrade with signs of  life, who
carried him off the field, and he was immediately
embarked  with  the troops  and brought to Ply-
mouth,  where he died fourteen days after the re-
ceipt of the wound.  Mr. Fuge, who records the
case, (Edin. Med. Surg. Jour, v.xiv.p. 129,)  states
that, on examining the body, two quarts of blood
were found in the left side of the thorax, the lung
of that  side  being compressed towards the  spine.
A transverse opening  an inch long was observed
in the right ventricle of the  heart near the  origin
of the pulmonary artery, and  the ball was  lying
in  the  pericardium.   To the same  paper is  ap-
pended  an account of a suicide who lived  forty-
four hours  after discharging a  pistol  into  his
breast, and in whom the right ventricle was  found
wounded, and  the ball in the pericardium.   Du-
puytren, in his  " Le9ons  Orales," expresses  his
opinion that wounds of the heart are oftener cured
than is generally imagined.  He founds his  belief
on  the  instances of animals killed in the  chase,
in whom balls and the cicatrices of former wounds
have been found, and also on similar instances in
the human subject.   Many individuals have pre-
sented all the symptoms of  wound 'of the  heart,
and yet recovered ;  and he alludes particularly to
the case of a soldier, in whom, six years after the
healing of a wound  of the chest, a musket-ball
was found in the right ventricle of the heart, near
its apex.  From these circumstances  we think we
are justified in stating that wounds of all parts of
the heart, provided  they are  narrow, are not  ne-
cessarily immediately fatal.  Acupuncture of this
organ  has been  practised at Warsaw  with  im-
punity.  If, however, the wound  be considerable,
some lines for  example, death is usually instan-
taneous, from  the great deluge of blood that is
poured into the pericardium  and chest.    Under a
wound  of less  dimensions  the  individual may
survive for some days.  Thus, in  one of the cases
mentioned by Dupuytren,  a  man thirty-four years
of age  received two  stabs of a knife, one  in the
belly, the other in the chest,  of six and seven lines
in length.  He  lived for eight days, and  then died
with symptoms of diseased brain,  having been af-
fected with tetanic convulsions for two days  before
his death.  The  stomach  was  found perforated,
and there were  four  ounces of blood in the left
side of the chest, which had  come from one  of the
intercostal arteries  opened by the wounding in-
strument.  In the pericardium was observed a per-
foration three lines and a half long, and a wound
of the same extent in the  middle  of  the  left ven-
tricle.   In  another individual,  who died  mad,
after attempting suicide by amputating the  penis,
several small wounds of  the heart  were  found,
which must have been inflicted  several days be-
fore with a small round instrument  found  in  his
possession.  Another man, aged forty years, lived
seventy-two hours with three wounds penetrating
the  left ventricle,  inflicted  by  himself with  a
sharpened file.  In the thesis of M. Sanson  nu-
merous instances are mentioned of persons surviv-
ing wounds of both ventricles, some of them for
twenty days.  The late Due de Berri,  whose in-
stance has already been alluded to, lived  for eight
hours, although stabbed through and through the
left ventricle with a long  round instrument used
by  saddlers in  piercing leather.   All  these  in-
stances go to prove that wounds of this  organ are
not necessarily instantaneously  fatal,—a very  im
portant fact in legal medicine, for it sanctions the
possibility of  an individual removing  to a con-
siderable  distance after the receipt of a  mortal
wound, and being found dead some hours or da>s
after.   As an illustration of this fact, involving u
question of life or death, we may adduce the fol
lowing case mentioned by Dr. Dunlop, (Beck, by
Darwall, p. 335,) as having been tried in Glasgow
in the year 1819.
   The keeper of a house of bad fame in Greenock,
was indicted for the murder of a sa'lor by shooting 
DEAD, (PERSONS  FOUND)
576
him through the chest.  It appeared from the evi-
dence of the medical witnesses, that the auricles
and part of the aorta next the heart were shattered
to atoms by the  slugs and brass nails with which
the piece was  charged, and  in their opinion he
must have  dropped down dead  the  moment he
received the shot;  therefore,  as the body  was
found in the street, and the door of the house was
eighteen feet up an  entry, it  followed that the
prisoner must have run after him into the street,
and there  shot him.  For the  prisoner,  it  was
urged and  proved  that he had  shot  him through
the door of his own house, which he was attempt-
ing to  enter by force.  And besides  direct testi-
mony to this effect from those within the house,
and from a lad  who was along with the deceased
at the time, it came out in evidence that there was
a stream of blood  from the door of the house to
the spot where  the body was found, which could
not have run from the body towards the house, as
the threshold of the door was on a higher level
than the pavement of the street.  On this evidence
the prisoner was acquitted.  In judging of  wounds
of  this  organ, the size and  shape of the  instru-
ment, and the  depth and direction of  the wound,
are to be considered.   The extent of  the  wound,
as  we  have already  stated, makes a great differ-
ence in the chance of recovery.   But there is one
circumstance which is not  very  easily explained,
I hat is, how so large a wound  as a musket-ball
must make, permits  life to be carried on for  an
instant.  It is generally admitted that wounds  of
 the aorta  and  vena  cava are  mortal; but this
must be taken with limitation, for  very small
 punctured  wounds  may  certainly  be   inflicted
 without  involving  the  life of  the  individual.
 What  the  extent of a wound  necessary  to cause
 death  is, we  cannot precisely say;  but  we can
 conceive the possibility  of these  vessels  being
 pierced with an  acupuncture needle with impunity.
   The thoracic duct, from the  important function
 it  performs, can  scarcely  be  wounded  without
 inducing fatal consequences.   This arises as well
 from the  extravasation  of its  contents  into the
 thorax, as from the interruption  to the supply  of
 nutriment to the body.  Wounds  of the diaphragm
 have been generally divided into those of its ten-
■ dinous and of its  muscular portions;  but the dis-
 tinction is  useless, for it is not ascertained that
 injuries of one  portion are less serious than those
 of the other; and it is certain that both are highly
 dangerous.  There is  a source of  danger con-
 nected  with wounds of this muscle, which it is
 well to bear in mind, and  that is, the possibility
 of some  of the abdominal viscera being  pushed
 through the opening, and there being strangulated.
 Dr. Gordon Smith (Principles  of Forensic Medi-
 cine, p. 279) relates a case of this sort. A sharp-
 pointd  weapon  had passed through the diaphragm,
 notwithstanding which the  patient  made a rapid
  nnd perfect recovery to all  appearance.   At  the
  end of about three months, he died from  strangu-
  lated  hernia of the  stomach,  which had passed
  through  the wound of the diaphragm  into  the
  thorax.
    Wounds of  the abdomen, however slight, pro-
  vided they penetrate its cavity, must be considered
  dangerous, from the great  tendency of its lining
  membrane tc  take  on inflammatory action, and
the rapidity with which  inflammation runs over
its surface when once established.   Penetrating
wounds may also strike one or more of the viscera
contained in  the abdomen,  in which case the
danger arises  both from  the  lesion of the organ
itself involving  derangement  of  structure  and
function,  and  from the  effusion of  its  content*
into  the abdominal cavity.
   Wounds  of the stomach are  to  be deemed
highly dangerous, although there has been  great
diversity  of opinion concerning their mortality.
Dr. Beck takes notice of the  declared opinions of
some of the German colleges upon this point.  A
wound  of the stomach was  declared only acci-
dentally  mortal by the  faculty of Giessen, and
absolutely mortal by  the college at Frankfort;
while, in  another case, a wound was considered
mortal by the faculty  at  Leipsic, and not so by
that of Helmstadt and Wirtemburg.   The fact is,
that  very extraordinary  escapes  have  followed
wounds of this viscus.   The writer recollects the
case of a  pauper in the house of industry in Dub-
lin,  about the year  1814, who had received a
wound  of the stomach  some years  previously,
from which he recovered, with a fistulous opening
in the side, of considerable  size, communicating
with the  stomach.  He kept this plugged with a
tent of lint or  tow, and, to gratify  visitors, he
would, for the reward of a few pence, take a large
drink of milk or other fluid, and withdrawing the
plug, suffer it to flow out through   the  external
opening.  This and similar instances tend to show
tbat wounds of the stomach inflicted from without,
although highly dangerous,  are  not absolutely
mortal.   But  we can scarcely say the  same of
rupture of the stomach caused  by a  blow or con-
tusion on the  part, inasmuch as the contents have
then no chance of an external outlet, and must be
poured into the peritoneal cavity.   While upon
this subject, we may remark that rupture of the
stomach may  take place without external violence,
and it then commonly causes death after a train
of symptoms  that closely resemble the effects of
the  irritant poisons.  This accident usually occurs
from the efforts to discharge,  by vomiting, the
contents  of an over-filled stomach.   When the
organ is in this condition, it is carried forward,
and makes an abrupt turn  on the  lower end of
the  oesophagus, which acts as a valve, and opposes
the  exit  of the contained matters.   A striking
case of  this  kind is  related by Dr. Lallemand.
 (Inaug.  Dis. Paris, 1818.  Christison on Poisons,
first edition, p. 88.)  A woman convalescent from
a long  attack  of  dyspepsia,  being  desirous  to
 make amends for her long  privations as to diet,
 ate  one day to satiety.  Ere long she was  seized
 with a sense  of weight  in the stomach, nausea,
 and fruitless  efforts to  vomit.  Then she  all at
 once uttered a piercing shriek, and exclaimed that
 she felt her stomach tearing open; afterwards she
 ceased to make efforts  to  vomit,  soon became
 insensible, and in the  course  of the night she
 expired.   In  the fore part of the  stomach there
 was a laceration five inches long, and a great deal
 of half-digested  food  had escaped into the  cavity
 of the  abdomen.  Professor Barzelotti (Medicina
 legale, ii. p. 22) notices a case in which the rup-
 ture was caused, not by  the accumulation of food,
 but by  the accumulation of gases  arising frora 
DEAD,  (PERS
ONS  FOUND)
577
depraved digestion, similar to what arises in cows
which  have  eaten largely of clover.   In  these
cases the  train of symptoms  would  lead one to
suspect  the  administration of an  irritant poison,
but sometimes death is instantaneous.  Dr. Chris-
tison (loc. cit.) mentions the  case of a coal-
heaver in  London, who, while attempting to raise
a heavy weight, suddenly cried out, clapped  his
hands over his stomach, drew two  deep sighs, and
died on  the spot.   On dissection, a lacerated hole
was found in the stomach, big enough  to admit
the thumb, and the stomach did not contain any
food.  These cases show  the great danger arising
from simple rupture of the  stomach; but the danger
is still  more  increased  when the  laceration is
effected  by external violence ; for then, besides  the
injury done to the organ  itself, the solar  plexus
and semi-lunar ganglion are implicated  in  its
effects.  These parts  are  so  essential to life, that
injuries to them  are  sometimes followed by  the
most  rapid  and  perfect  death, the entire vital
power appearing to be at  once extinguished.
   Persons suffering laceration of the  intestines
from blows or contusions  are likewise exposed to
the greatest  danger;  but perforated wounds  do
not appear  of the same  mortal  character ; and
when proper treatment is  pursued, very surprising
recoveries  have taken place.   Wounds of  the
small intestines are said to be more dangerous
than those of the larger, in consequence  of  the
more  important functions they perform, and  of
their being  supplied  with a greater number  of
nerves; but we cannot perceive the value of this
distinction, as the principal dangers, extravasation
and inflammation,  are not influenced by  either of
these circumstances.
   Individuals  may be killed  by wounds  of  the
liver; although small  superficial  wounds, if  the
sufferer  escapes inflammation, may  not be attended
by serious consequences ;  but more extensive and
deeper injuries may cause a fatal hemorrhage, by
opening some of the  numerous and  large  blood-
vessels by which that viscus  is traversed.  Lace-
ration of  the liver  by falls is not an uncommon
occurrence; and when it happens, it most com-
monly causes the death of the patient.   Besides
the injury to the liver  itself, its great reservoir,  the
gall-bladder, is exposed to perforation and rupture;
and this is an accident of  the most  fatal character,
from the  effusion  of  bile into the  peritoneum.
This secretion and  the urine are the most irritating
of all the fluids of the body,  and  never fail  to
cause death when suffered  to escape into the belly.
Wounds of the urinary bladder, therefore, except
at the  part uncovered by the peritoneum,  are  of
the most fatal kind.
   Before  we leave this part of our subject,  we
wish to  make some remark" upon a form of acci-
dent which has been  long known and described,
but about which very vague and unphilosophical
notions  were entertained; — we  allude  to  what
have been termed  wind-contusions.  It is not rare
to find upon a field of battle dead bodies preserving
their form and the integrity of their surface, and
not presenting externally any lesion by  which
death can  be accounted for;  but  if the body be
opened,  some of  the viscera  of  the thorax  or
abdomen are  found bruised and ruptured, and  an
extravasation of 1 lack fluid blood or of  the con-
  Vol. I.—73                         2y
tents of the stomach  and intestines.   When the
nature and extent of these  internal lesions are
considered, it is evident that death must have been
instantaneous, and the vital powers so quickly and
completely destroyed, that there has not been time
sufficient to allow of the infiltration of blood into
the cutaneous tissue, so as to  produce  ecchymosis.
As this kind of injury has been  observed particu-
larly after battles, it was imagined  that death was
caused by  the wind  of cannon-balls, that is, by
the compression of the  air caused  by the passage
of the shot in the vicinity of  the individual.  But
when we consider the fluidity and elasticity of the
atmosphere, and the  little resistance  it makes  to
the passage of bodies  through it,  we must perceive
that this explanation is untenable; for the uncon-
fined  air never can be compressed to such a point
as to become a mass capable  of contusing or even
giving a severe shock to our bodies.  It  is now
generally  believed that these lesions are caused
by the contact  of the  cannon-shot  itself, when
towards  the close of  its trajet.   For the  first
moment of projection, when  tbe force is greatest,
it pierces, tears, and  carries off all  that occurs  in
the line of its direction ;  but when it approaches
the end of  its course, and its  velocity is considera-
bly diminished, it  loses  the  power of producing
these  effects, and as the skin  is supple and exten-
sible,  and the parietes of the  thorax and abdomen
are flexible and elastic,  and protected  by clothing,
they yield to the impetus without tearing,  and
resume their original form as soon as the com-
pressing force ceases to act.   But the parts which
lie deeper than the parietes,  and whose tissue  is
less flexible, and supported  by  bone, experience
necessarily  the  whole  force  of  the compression,
and are thus contused, bruised, or, in some in-
stances, reduced to a  complete pulp.  Any doubt
of the validity of this  explanation is removed by a
reference to reports of cases of injuries not depen-
dent on fire-arms, in which  the same laceration
and contusion of the viscera  of  the abdomen and
thorax have' been found without any appearance
of external injury.   Chaussier relates the  case of
a  strong  man,  thirty years  of age,  who, while
driving a cart heavily  laden with  stones, attempted
to get on the back of one of the horses, and falling
in the endeavour, the wheel passed  slowly over
his left shoulder,  crossing the  clavicle near the
sternum, and continuing its course obliquely over
the entire left side of the thorax.  The body  was
found  the  following  morning on the road, lying
on the back with the  track of the wheel marked
on the clothes by a broad streak  of mud.  Never-
theless, on  stripping  the body, there  was  no ap-
pearance on its exterior  that  could lead to a
knowledge of the cause of death.  However, after
removing  the integuments  and muscles  of the
thorax, it was  found that the  clavicle was torn
from the sternum,  and all the ribs of  the left side
were fractured, but there was  no ecchymosis under
the skin or round the fractures.   The  first  rib was
broken in one place near the  sternum, but all the
rest in two, about  three  inches  apart, which cor-
responded with the breadth of the  wheel.   These
fractures were  not complete, but were limited  to
the inner surface.  On  opening the thorax, the
pericardium was found distended with coagulatec
blood,  and  a large rent was discovered in  the left 
578
DEAD,  (PERSONS  FOUND)
auricle of the heart.   From this it is evident that
pressure  by the passage of a heavy body may
cause bruising  or  rupture  of the  internal parts,
without leaving any appearance of its action  on
the exterior;  and in like manner those great con-
tusions and sudden deaths, without external mark
of violence, observed  after  actions, are to  be  as-
cribed to the size and weight of cannon-shot strik-
ing the body with diminished velocity.
   We do  not  deem it necessary to dwell  upon
wounds of the extremities, as the danger of speedy
death in these  cases depends  upon the escape of
blood from some of the great blood-vessels im-
plicated  in the injury, a complication which is
easily detected by dissection.  But there is a form
of injury connected with this part of our subject
on which it is  necessary to make a few  observa-
tions.  We allude to wounds of the external parts
of generation in the female, which may prove fatal
by excessive  hemorrhage ;  the peculiar structure
of the parts, consisting of erectile tissue,  which is
very vascular, giving  rise to a continued, steady,
though not very rapid flow  of blood.  In illustra-
tion of this point we may refer to  two cases  re-
lated by  Mr. Watson.  The  first is that of a
woman who resided  near Edinburgh, whose hus-
band was tried  and convicted of having murdered
her  in the year  1826.  "The body," says Mr.
Watson, " of this unfortunate person was inspect-
ed by Mr. Newbigging and myself.   We were in-
formed of her having died suddenly.  She seemed
to be about fifty years of  age, of stout  form, of
very low rank,  having lived in a small, dirty, ill-
furnished  house, having only some shavings and
straw upon the  floor, covered with a rug for a bed.
The clothes in  contact with the private parts were
stained with  blood.   No  appearance of injury
could be perceived on any part of the body exter-
nally ; but upon separating the labia pudendi, a
wound about an inch and a quarter in length was
observed upon the inner side of the right  nympha.
This wound was evidently recent, its surface being
covered with coagulated blood. Externally it con-
sisted of a remarkably clean, straight incision  pa-
rallel with the nympha.   Internally  the finger
could be introduced  in four different directions to
the depth of  about two  and a quarter inches in
each :  upwards and  backwards towards the divi-
sion of the iliac artery ; backwards towards  the
tuberosity  of the ischium; laterally towards  the
hip-joint;  and  upwards towards the mons veneris.
In each direction the wound  was of nearly  the
same diameter, which readily admitted the finger,
and had distinctly an obtuse termination.  By in-
jecting warm  water  into   the large vessels,  we
found that none of them had been wounded, and
the  penetrating instrument seemed to have been
forced only through the cellular tissue.  The wea-
pon had passed up to the peritoneum at  the right
side of the pelvis, under which there was a con-
siderable effusion of blood, but had not penetrated
it.  Another very small, but  also very clean  ex-
ternal incision  was  observed at the side of that
above  described.   The cavities of the  cranium,
thorax, and  abdomen, were each  examined, and
their contents found to be quite healthy and natu-
ral. The  hemorrhage, therefore, which had taken
place from the wound  was the only cause which
w* could assign for her death, and  this we knew
from  the  nature  and  st ucture (erectile spongy
tissue) of  the parts cut, must have been profuse."
It was proved on the trial that the wound was in-
flicted by  a razor.
  The second case is very similar to that first de-
scribed :  it occurred in  the person  of a woman
who lived in Edinburgh, and whose sudden death
was occasioned by a wound received on the morn-
ing of the 1st of January, 1831.  This  case was
examined by  Mr. Mitchelhill  and Mr.  Watson,
They found the body dressed in the ordinary day-
clothes, which they removed carefully,  and ob-
served no wound  or tear on them, but the lower
parts were drenched  with blood.  They  then dis-
covered that the hemorrhage had proceeded from
a wound  of the  left labium pudendi, consisting
of a very clean incision about three quarters of an
inch  in length, parallel witii the margin of the
labium.   When the finger was introduced  into
this wound, it entered a bloody cavity sufficient to
have  contained a  small  hen's egg, and  from this
cavity the finger could be passed upwards towards
the symphisis pubis, downwards towards the peri-
neum, and backwards  by the side of the vagina
and rectum.   Its  greatest depth at  any of these
places was between two and three inches. When
the internal part of the wound was laid open, the
divided orifices of  several pretty large arteries and
veins were seen, and particularly the divided ex-
tremities of the large artery going to the clitoris.
By the evidence adduced at the trial of two young
men, brothers, for the  murder of this woman, it
was obvious she had received a wound at the first
floor of a common stair, almost immediately after
which she was precipitated headlong to the bottom
of the stair. In reference to these cases Mr. Wat-
son remarks, " In both, this part of the body seems
to  have been  selected by the murderers  to effect
their design secretly ; for in both, but particularly
in  the first, the wound was concealed to a super-
ficial observer ; and  they may have  had  an idea,
from the  frequency  of flooding  in  females,  that
their death might have been supposed to have
happened either from this cause or by accidentally
injuring  themselves by  sitting down upon some
sharp body.   For it is a curious fact that in  both
cases  the probable murderers were the first to go
for medical aid to the deceased.
    Circumstances affecting the medico-legal  cha-
racter of wounds. — So far we have considered
wounds according to  the consequences  that usu-
ally attend them; but  the  medical  jurist should
ever bear in mind the fact, that injuries,  naturally
belonging to  the class of slight wounds, may ac-
quire  the character of severe, dangerous, or  mor-
tal, from  the  co-operation of circumstances more
or less extraneous, and, therefore, relieving the in-
flictor more or less from responsibility.   We  have
already alluded to the memorable aphorism of Mr,
Hobbs, that there never was a wound but it might
prove mortal.   Let us now inquire into  those cir-
cumstances that are thus capable of altering the
medico-legal character of wounds :.  these are age,
sex,  constitutional peculiarities, previous injury
or  disease, subsequent  injury or disease ; malum
regimen.
   Of age, it may be said that adult age is on the
whole the most favourable to recovery from  inju-
ries : of this we have a very striking example  in 
                           DEAD,  (PERS

the case of burns, the effects of whicb are much
more severely felt by young subjects, and the mor-
tality attending them is greater in this class than
in persons who have reached adult age.  Frac-
tures may, perhaps, form  an exception to this, as
it is observed that  this species  of injury is less
fatal in children.
   Sex is a circumstance of aggravation in the case
of blows on  the breast of a female.   This organ
being in early life endowed with peculiar sensibi-
lity,  and in later years being prone to  take on
cancerous action when excited by injury, is natu-
rally a very vulnerable part, and a comparatively
trifling blow in this situation, may be followed by
the severest effects.  In like  manner, an injury
on the abdomen of a  pregnant  woman  must be
regarded as a more dangerous accident than the
same force applied  under different circumstances.
   Constitutional peculiarities do not form a good
exculpatory  plea unless  the  wound  be  slight.
They are  of two kinds, constitutional infirmities
and  malformation.   Slight  wounds  may be ren-
dered dangerous, and  even mortal,  from an ex-
treme irritability of the nervous system.  We see
this  in  the different effects  produced on different
patients by surgical operations, some  bearing with
fortitude what  others unaccountably sink under.
The scrofulous diathesis and venereal taint influ-
ence the  result of  wounds, and diseases of the
bones and joints have succeeded in such constitu-
tions to injuries whicb would have  been of little
consequence  in sound  ones.   The hemorrheal
diathesis is one calculated to  increase  the danger
of slight wounds in a remarkable manner, some
striking examples   of  which have been  already
mentioned.   Original or accidental malformation
may likewise contribute  to  the  fatal effects of a
slight injury.  Thus transposition of the viscera
may bring an organ within reach of a wound that
might have been otherwise harmless.   A very re-
markable  instance  of  such  malformation is  pre-
served  in the museum of the Dublin College of
Surgeons.  The subject was a woman advanced
in life, who  died in one of the hospitals of the
House of Industry, and who had never given any
indication  during life  of her  peculiar formation.
On examination of the body  after death, all the
viscera of the thorax  and  abdomen were found
transposed.  The heart was at the right  side, the
liver at the left, the stomach and spleen  at the
right, the  coecum in the left  iliac fossa, and the
sigmoid flexure of  the colon in  the  right, and all
the blood-vessels were transposed to correspond.
But  besides  such  a general  transposition,  there
may be a  partial malposition.   Thus, an artery,
usually deeply-seated may take a superficial course,
and  prove a  source of danger in case of a slight
wound inflicted in that situation.  A case in which
death occurred  in consequence of malposition of
an artery,  happened in the hands of one of the
most experienced surgeons in  Dublin some years
ago.   A fish-bone stuck in  the throat of an indi-
vidual, who applied to the gentleman  alluded  to
for relief.   A probang  was passed down  the oeso-
phagus, when suddenly an immense gush of blood
took place from the mouth of  the patient, and he
dropped dead in his hands.   On  examining the
body to ascertain  the cause of this unexpected
ONS   FOUND)                        579

fatality, it was found  that the arteria innominata,
instead of following its usual course in front of
the trachea, had dipped down between it and the
oesophagus, just at the spot where the fish-bone
had lodged, the point of which had been  forced
by  the  probang through the oesophagus into thf,
artery, and  thus caused the death of the patient
Besides these congenital malformations, there may
be accidental displacement of a viscus, as in  her-
nia, by which a blow in certain situations will be
made more dangerous.
   Previous injury or disease is a plea sometime*
set up in extenuation of guilt, but it is a  feeble
one, and  in fact untenable  if the injury is of a
usually dangerous  character, or has  manifestly
accelerated the death of the  individual.  It may,
however,  be used  with advantage if  the  injury
was slight; but the degree of weight that, should
be  allowed to it in law is  sometimes very difficult
of decision.  The chief questions on the subject
are, 1st, Was the  new injury adequate to cause
serious mischief in ordinary cases ? 2d, Whether
did the injury, or the previous disease or accident,
occasion death ?  3d, Did the  alleged previous
harm  really exist,  or was  it the consequence of
the injury ?  Chaussier relates the case of  a boy
who was killed by a very gentle stroke of a switch
upon the head, which in ordinary cases  would
have caused no mischief,  but proved fatal in this
in consequence of previous absorption of the skull
at the  particular part struck. An interesting illus-
tration of  the  second question  has already been
quoted from the same author, in which death was
produced by the bursting of an internal aneurism.
Cases  that  come under our third  head are very
common; we will  content ourselves  by quoting
one by Dr. Klapp of Philadelphia.   (Americai
Medical Recorder, v. i. p.  156, and  Beck, by Dar
wall, p. 352.)  An individual in that city, vvhf>
was in habits  of  intemperance,  engaged in  a
brawl,  received an injury, and  died thirty-eight
hours  after the affray. He walked and  spoke after
receiving  the  injury, and  even drank part  of  a
pint of spirits, but  was shortly seized with  insen-
sibility, dilated pupils, oppressed breathing, and
died without any return of sense.   The bone and
the brain beneath the injured part were examined
and found  natural.  The  mucous membrane of
the cardia and the upper part of the stomach were
greatly inflamed ;  the other parts  were not dis-
eased.  Before  the court, Drs. Hartshorn  and
Klapp gave it as their opinion that the injury to
the head had  not  been the cause  of  death, and
that there was no appearance  of  a blow on or
near the  region of the stomach.  A  verdict of
acquittal was the result. But supposing the  injury
to be of such  a kind as would alone prove fatal,
then the second question arises, Whether did the
injury or the previous disease cause death ?  There
are circumstances which may render this a  nice
question to answer : thus,  for instance,  the disease
and the injury may cause the same symptoms and
appearances, as in the case of apoplexy and extra-
vasation of blood from a blow.  In cases of this
kind confusion and difficulty are sure to  occur,
when  the  investigation is made  according to the
Continental system ; but  in these countries the
animus with which the injury was  inflicted being 
580
DEAD,  (PERSONS  FOUND)
Ihe chief object sought after,  the medical witness
is saved from the nice distinctions laid  down in
foreign authors.
  Subsequent injury or disease  may also  alter
the medico-legal  character of injuries.   It  may
happen  that  a disease totally unconnected  with
the effects of an injury, may invade a person who
has received a wound, and carry  him off.   This
is a case that sometimes creates great difficulty.
Thus, a  typhous fever  may  attack an individual
labouring under a wound of the head, or sponta-
neous pleurisy may occur after injury to the chest;
in both of which cases it is evident that  great ob-
scurity must exist.  We recollect the case of a boy
who was admitted into the Richmond  Hospital,
Dublin,  labouring under a  wound of  the  head
with a small depressed fracture of the right parietal
bone.  He went  on well  for some  days, when
headach  came on, flushed  countenance, fast and
hard pulse, dry and burning skin, and thirst  with
sickness  of stomach.  It was at  once  supposed
that inflammation  of the  brain had  set in,  and
preparations  were making  for trephining  him,
when attention  was  accidentally  turned  to his
right arm,  from which he  had been bled on the
day of his admission, and in it, in the neighbour-
hood of the puncture and spreading  up the arm
under the fascia, a large collection of  matter was
discovered, on the liberation of which, all the bad
symptoms  gradually  disappeared, and  the  boy
recovered well without any operation.   This was
a case in which a subsequent disease put on the
appearance of the worst consequences of the in-
jury, and was at first mistaken for them.
  Zacchias relates an instance illustrative of the
difficulty that may occur in these cases.   During
a period  in which the plague raged  at  Rome,  a
man received a  wound on the head, which de-
nuded the bone, but left no fracture.  The wound
appeared favourable for the first three days; but
at the termination of that period a fever  came on,
accompanied with bilious  vomiting  and violent
inflammation of the wounded part. On the fourth
day  the  wound  was  gangrenous, petechia?  and
buboes occurred,  and he  died on the sixth.  It
appeared  afterwards  that  he had been  visited
during the first two days of his illness by a friend,
who had died of the plague on  the  fourth day
after communicating  the disease to the wounded
person.   Tetanus  is  a consequence  of wounds
which must occur to every one as likely to  alter
tLeir medico-legal  character.  A  case occurred a
few years ago in England, in which the super-
vention of tbis disease upon a slight injury had a
great influence upon the fate of  a prisoner.  A
gentleman fired a gun, loaded with small shot, at
a boy whom  he  found trespassing on his ground.
He wounded him slightly in the leg, and the boy
appeared  going  on well  until he was  attacked
with tetanus, of which disease  he  died.   The
gentleman was tried, found guilty of murder, and
executed.  This case forms  a good  example of
what has just been stated respecting the English
practice in such cases ; for if the wound  had  been
inflicted with a stick or whip, or other implement,
it is almost certain that a verdict of murder would
not have been returned  against the prisoner; but
a gun having been  used,  made it appear that the
mtenl was to do some grievous bodily harm, and
the heaviest penalty of the law was accordingly
inflicted.
   Malum regimen, or improper treatment,  often
constitutes a very strong exculpatory plea, as by
it  the  character of wounds may  be materially
altered for the worse.  Accidental  or inevitable
want of skilful  attendance is not  a valid plea;
but if  the  omission was intentional or avoidable,
it takes off the responsibility of the inflictor in a
great degree.   If a patient  should  refuse to sub-
mit to proper treatment,  or should persevere in
the use of forbidden  articles of food, or should
expose himself to  cold  or a vitiated  atmosphere,
it is plain that he must  contribute to place  him-
self in a more unfavourable position, the result
of which  can  only be charged on  himself.   On
the part of the medical attendant, misgovernment
may  arise either from negligence or bad treatment,
by either of which the danger of  a wounded per-
son may be greatly aggravated.   " In general,"
says  Dr. Beck, " wben a dissection proves that no
wound mortal in  its nature has  been received,
and  when none  of  the  circumstances   already
enumerated can be urged  as causing its fatality,
the death of the patient  should be attributed to
the surgical attendant rather than  to the author
of the  wound, provided it can be proved that he
neglected the sick  person,  or maltreated  him by
leaving foreign bodies in the wound  which might
have been taken away; by  not suppressing he-
morrhage ; by not evacuating collections of pus
when necessary ; by employing tents unnecessa-
rily ; by neglecting or hurrying operations; or by
not causing the proper regimen to be observed."
(Med. Jur. by Darwall, p. 327,  [or  Amer. edit. ii.
235 : Philad. 1838.]
  In  cases where bodies  are  found dead  from
wounds or bruises,  a  very important question
arises which the medical jurist is frequently called
upon to solve,—that is, are the  wounds the result
of suicide, of accident, or of  murder ?   In the
greater number of  cases in which  our assistance
is required, the circumstances of the case are so
well  known,  or  can be so  proved  by witnesses,
that there can  be no doubt of the  cause of injury
or of the true author of it.  But there are  cases in
which, to fulfil the objects of justice,  it is neces-
sary  to determine  wbether  the wounds  inflicted
on an individual were by himself or  others.  The
solution of this question is always delicate,  often
embarrassing,  and very  difficult.   The  circum-
stances  to be  attended to in this inquiry are,—
first,  the  seat of  the  wounds;  secondly,  their
direction;  thirdly,  the  probable  weapon  used.
There  are  few wounds  tbat one  person  can in-
flict upon another that may not be  accomplished
by an individual  on himself.  Some, however,
form an  exception  on account of  their  extreme
difficulty.  For  instance,  it would  be  hard to
believe that a wound with a sharp-pointed instru-
ment in the  spinal marrow was  inflicted by the
individual himself; and in  death from fire-arms,
wounds  inflicted  from  behind can  scarcely be
supposed  to have  been  voluntarily  effected.  In-
cised wounds are seldom inflicted  except on  the
throat, for the purpose of suicide ;  but instances
have occurred  where individuals have resorted to
wounds of the extremities and amputation of the
penis for this purpose.  A case occurred recently 
DEAD,  (PERSONS FOUND)
581
within our own knowledge, where  the suicide,
having failed, as often happens, to destroy him-
self by cutting  his  throat,  deliberately bared  his
left arm,  and cut it  across to the bone,  above  the
elbow, dividing the brachial artery, from which
he bled to death.  The circumstance of fire-arms
being discharged in  the mouth of an individual is
sufficient  to warrant  the belief that it was  not
done by the hand of another.  Thus, attention to
the seat of the wound will  often determine whe-
ther it is the result of accident, suicide, or  homi-
cide, and will throw light upon the evidence of
witnesses as  to the circumstances under which
the injury was inflicted.   The  direction  of  the
wound will often likewise  determine the intent,
and the question of suicide  or homicide. When a
wound does not pass through the body, there  will
be little difficulty in ascertaining the direction in
which it came and in whicb it passes.   In  a case
of supposed suicide  by means of a  knife or  pistol,
the course of the  wound  should  be  examined,
whether it be  upwards  or downwards, and  the
 length of the arm  should  be compared with the
 situation and direction of the  injury.   It should
 be ascertained whether the right or left hand has
 been  used ; and as  the  former is that  most com-
 monly employed, the direction should correspond
 with  it; but if the  direction corresponds witb the
 left, it should be inquired  whether the deceased
 were left-handed.   When a wound is  alleged to
 have been inflicted by accident, we  may inquire
 into the probability  of the statement by comparing
 the stature of the body with that of the inflictor,
 and the relative position of the two at the moment
 the wound was received.  In fact, a stab given by
 an individual of small stature to one  of greater
 size  is naturally directed  from below upwards,
 and the contrary if it is the larger of the two who
 has inflicted iti  An example  of this occurred
 some years ago at Marseilles, (Med. Leg. t. iii. p.
 195,) in two men of  different  height, who fougbt
 a duel with swords on a public walk.  The weapon
 of each of the combatants reached the heart of the
 other at the same moment,  and  they fell dead to-
 gether.  Their bodies being  examined,  it  was
 found that the wound  given  by the small man
 was  directed from  below upwards,  and that by
 the larger from above downwards.   The situation
 and mode in which  a  wound is inflicted will often
 point out the intention of the perpetrator. Fodere
 (Med. Leg. t. iii. p. 196)  relates  a  case illustra-
 tive of this point.   A miller was assassinated at
 his own  door by a butcher, who  pretended  that
 he had no intention of killing him, but had only
 threatened him with his knife in consequence of
 some maltreatment  which  he  had received ;  that
 the miller renewed  the attack, and in  attempting
 to pursue him, made  a  false step  and had fallen
 on the weapon. A single external wound, which
 led downwards to two wounds of the left ventricle
 of the heart, separated from each other by an in-
 terval of two lines, showed that the accused had
employed  the same method to destroy his victim
 as that used by butchers  in that country to kill
cattle;  that is, after having driven the knife into
the heart, they withdraw  it some distance,  and
replunge  it,  so  as  to  make  a second internal
wound.   Thus the direction of the wound com-
pared with the respective statures of the two ad-
                                      2t *
versaries,  (the butcher being much smaller than
the miller,)  proved that  the blow had been  in-
flicted obliquely from  above downwards,  that is,
whilst the miller was sitting at his door, and  not
by a fall after getting  on his feet, in which case
tbe wound must have taken an  opposite direc-
tion.
  In the case of wounds from  fire-arms perforat-
ing the body, different opinions have been formed
as to whether this circumstance should determine
the distance at which the shot was fired ; and at
first we might be led  to  suppose  that if a pistol-
bullet passed through, the instrument from which
it was discharged must have been very near. But
this is found to depend so much upon the strength
of the  charge, the direction of tbe  ball, and  the
resistance offered by the parts of the body, that we
cannot venture to draw any conclusion  from it.
It is, however, of importance to be able to discri-
minate between the entrance and exit wound, as
a means of ascertaining the direction of the shot.
That made on entering is smaller than the other,
and has its edges inverted and depressed, while
the latter is much larger, with ragged,  everted,
and uneven edges, — a circumstance  depending
upon the direction in which the  force is applied
to the skin, as well as upon the diminished velo-
city of the ball.   When flat bones are perforated
by balls, the same difference in the size  and  ap-
pearance of the two  openings  is  to be observed.
A trial, in which the defence rested upon the dif-
ference between the  wounds,  took place a  few
years ago in Kent, and is recorded by Dr. Gordon
Smith.  (Principles of Forensic Medicine, p. 290.)
An officer in the preventive service was  indicted
for the murder of a man who was shot in the night,
under circumstances of a suspicious nature as to
his pursuit at the time.  There was no doubt that
he was in company with a party of smugglers, and
came by his death accidentally.   He was retreat-
ing before the  prisoner, who tripped, and in the
fall his gun went off.   It seems that, on the other
hand, several shots were fired  on the part of the
smugglers in their retreat, and  that the deceased
was killed by one  of them.  This appeared from
the testimony of a navy surgeon of considerable
experience, who examined the body.  He found
the wound in the upper part of the groin  much
smaller than that in the lower part of the  buttock,
which was  twice  or  three times the size of the
former, and was ragged and uneven.  Fragments
of the  bone were likewise felt at the hinder open-
ing, but none in the cavity of the pelvis.  From
these appearances he gave his opinion  that the
ball had entered in  front,  and  had consequently
come from his own party.
   The probable weapon with which a wound  Waa
inflicted will often assist  in disclosing  the  true
nature of the accident.   The singularity  of shape
that some wounds present, and  the  comparison
that may be made between them and that of dif-
ferent instruments, has sometimes served to  illu-
minate obscure  cases.  Such  is the case related
by Desgranges, and quoted by  Fodere, of an indi-
vidual, who, having got drunk in a pot-house, left
it to return home at eleven o'clock  at night, the
ground being covered with snow.  He was found
dead the  following morning, beside  a ditch near
his own house.   Desgranges examined the body, 
582               DEAD,  (PERSONS F O UN D) — DE LIRIU M.
which at first offered no trace of wound, bruise,
or violence; but on turning the head from left to
right, an oblique wound was discovered, scarcely
three quarters of an  inch  in extent,, under the
base of the lower jaw, and about the height of the
larynx.  The little  finger  introduced  into this
wound showed it to be wider and  more extensive
within than appeared from the external incision.
The clothes of the deceased were  stained  with
blood, and there was a large quantity poured out
on the snow.  It appeared  that  this wound had
been inflicted with  an auger, which  the  deceased
had carried out of the pot-house  under his  arm,
with the  point foremost, and upon which he, being
drunk  and hardly able to walk, had fallen.   This
instrument was found  lying  beside him covered
with  dry blood, having  been extricated  by the
deceased  from the wound, but not before it had
wounded the left carotid artery.
   While upon this  point, we think  it well to in-
sert the declaration of Sir Everard Home, relative
to the remarkable  case of  the death of Sellis, a
servant of the Duke  of  Cumberland,  and  the
simultaneous injury received by his Royal High-
ness.  Sir Everard's declaration seems to indicate
that Sellis had committed suicide after attempting
the life of the duke.  " I  visited the duke,"  he
says, " upon  his being wounded, and found my
way from the  great hall to his apartment by the
traces  of blood which were  left on  the passage
and staircase.  I found him  on the bed, still bleed-
ing, his shirt deluged with blood, and the drapery
above  the  pillow sprinkled  with blood from  a
wounded  artery, which puts  on  an appearance
that  cannot be mistaken by those  who  have seen
it.  This could not  have happened  had not the
head  been lying  on  the  pillow  when  it,was
wounded.  The night-riband, which was wadded,
the cap, scalp, and skull, were obliquely divided,
so that the pulsations of the arteries of the brain
could be  distinguished."  " While dressing these
wounds,  a report came that Sellis was  dead.   I
went to his apartment, found  the body  lying on
its side on the bed, without  the coat and neck-
cloth, the throat cut so effectually that  he could
not have survived a minute or two.   The length
and direction of the wound were such as  left no
doubt of its being  given  by his own hand ; any
struggle would have made it irregular.   He had
not even changed his position : his  hands lay as
they do  in a  person  who has fainted.   They
had no marks  of violence upon them.   His  coat
hung upon a chair out of the reach of blood  from
the bed ;  the sleeve from the wrist to the shoulder
was  sprinkled with  blood,  quite  dry, evidently
from a wounded artery, and  from such kind  of
sprinkling  the assassin of the duke could  not
escape."   (Edin. Ann. Regist. v. vi. pt. ii. p. 19,
and Beck by Darwall, p. 308, [or Amer. edit. ii.
li3: Philad. 1838.])
   Some light may  be thrown upon cases of death
from  fire-arms by attention to collateral circum-
stances.  Thus, in some  instances the crime has
been brought home to an individual by means  of
the wadding employed.  A case of this kind oc-
curred in France in 1818, and a similar one more
recently in England;  in both  of which the wad-
Jing was examined, and discovered  to have  been
torn from paper found in  the possession of^he
 murderer.  If the ball is discovered, a comparison
 of it with the gun or pistol from which it is sup-
 posed to have been  fired may  assist in the in-
 quiry.   Thus, in a  case  of  alleged suicide, in
 which a pistol was found beside tbe body, on com-
 paring the ball with the barrel of it,  it was found
 too large to have  entered it, and so  the question
 of suicide  was set at  rest,  and  attention was
 directed to  detect the murderer.  If a flint pistol
 have been employed for the purpose  of suicide, it
 has been imagined that the  discoloration of the
 fingers from tbe combustion of the priming would
 confirm the case as one of suicide ; but this mark,
 besides  being capable of  imitation  by a  crafty
 assassin, is becoming every day of less  value, in
 consequence of the general application of detonat-
 ing locks to all kinds of fire-arms.
    [In the Life of Sir Astley Cooper, by his Ne-
 phew, (Lond. 1843,)  it is  mentioned as an evi-
 dence of the accuracy of observation  of that emi-
 nent surgeon, that  when called  to see  a Mr.
 Blight,  of Deptford,  who had been  mortally
 wounded by  a pistol-shot  in  the year 1806, he
 inferred from an examination of the localities that
 the shot must have  been  fired  by a left-handed
 man.    A  friend of the deceased, a Mr.  Patch,
 then unsuspected, was the only left-handed man
 about the premises.  He was afterwards tried and
 convicted  of the  crime,  and  confessed  his guilt
 before execution.  (See, on all this subject,  the
 excellent work of Mr. Taylor, entitled A Manual
 of Medical Jurisprudence: Lond. 1844.)  The
 means of identifying spots  of blood found on  the
 body itself, on tbe soil, furniture, or clothes, or on
 the instrument with which death  has been  in-
 flicted, have been investigated by MM. Lassaigne,
 Chevallier,  Orfila, Barruel, and  others.  For  the
 results of these investigations the reader is referred
 to the works of Devergie, Guy, and Taylor,  al-
 ready cited.]
     J       J                 T. E.  Beatty.
    [DEATH, Apparent.—(See Dead, Pleso>s
 FOUND.)]
    DEATH,  Sudden. — (See  Dead, Persons
 found.)
   DELIRIUM. — The term  delirium has either
 been employed without design in a vague and in-
 definite  manner, or it has been purposely used in
 a very comprehensive sense, and made to include
 every  mode and  degree of mental  disturbance,
 from the slight and difficultly-traced aberrations of
 the argumentative and almost rational monoma-
 niac, to the  muttering and dreamy stupor of a
 patient labouring under the delirium of typhoid
 fever.   All the phases and  varieties of mental
 alienation,  whether  degrees   of melancholy or
 violent madness, the wild ravings of the drunkard
 nnd the intense reveries of the opium-eater, as well
 as the peculiar symptoms resulting from that op-
 pressed and disturbed condition  of the sensorium
 which  exists  in  severe  febrile complaints,  are
 alike comprehended under the designation of de-
 lirium when thus extensively applied.  But there
 are few common characters belonging to all these
 phenomena, and for the sake of distinct  and  ac-
 curate description they must be separated.  Those
 which  are  associated  with  madness  form a par-
j ticular group, and they may all be set apart under
I that head.  (See Insanity)   Under delirium or 
DELIRIUM.
583
febrile delirium we shall here survey the disor-
dered states of the sensorium and intellect which
occur  principally in  fever and  inflammatory dis-
eases,  and in some disorders affecting primarily
the brain itself or its investing membranes ;  and
we shall point out  the characters  which distin-
guish  these from the other phenomena, frequently
though improperly included with  them under the
same term.
   Phenomena. — Delirium supervenes on fever
during any part  of  its  course.  It  occurs in the
hot stage of some intermittents, but rarely makes
its appearance in typhoid or continued fever until
the disease has  reached its height, or  until the
period of strong  febrile action is established.   It
sometimes occurs suddenly, and without  any pre-
vious sign of disease affecting the head; but much
more  frequently it is preceded by headach, throb-
bing of the temples, heat of the scalp, a flushed
and oppressed countenance.  Occasionally a slight
hemorrhage from the nostrils is the harbinger of
a severe attack or exacerbation  of delirium.   The
patient  is at first delirious  during the  short and
imperfect periods of sleep, or immediately after he
 is roused, becoming, when fully  awakened, more
 clear  and comparatively collected ; by degrees this
 lucid interval is  less to be perceived ; the indi-
 vidual becomes more and more  incapable of re-
 flection and mental exertion, and gradually loses
 the power of recognizing the persons and objects
 which surround him.
   The phenomena  of  delirium, as  they appear to
 the observer and  are remembered by the patient,
 are like those of a feverish and incoherent dream.
 When, in a state of health, all voluntary control
 over the course of the  thoughts is withdrawn and
 the mind given up to reverie, there  is still, during
 our waking hours, a continual restraint exercised
 imperceptibly over the  wanderings of the fancy by
 the lively consciousness of external circumstances
 and relations.   This controlling influence is with-
 drawn  in health by sleep, and in  disease by the
 impaired state of the sensitive power whicb ushers
 in delirium, and  which goes on increasing as that
 affection advances, until it terminates in coma or
 complete stupor.  Delirium, then, appears to hold
 a relation to sleep and to the dreaming state which
 accompanies sleep,  or to be itself but a species of
 dreaming more intense and profound.
   Accordingly phenomena are recorded in many
 cases of delirium, bearing  a remarkable  analogy
 to some  of  the most  striking  peculiarities  of
 dreams.   In dreams the mind is carried back with
 vivid  intensity of feeling to scenes long  past, and
recals, with greater accuracy than  in the waking
 moment, minute incidents and circumstances.  In
delirium, when the  sensitive power is nearly ob-
literated, the memory is occasionally, under certain
modifications, surprisingly powerful  and active.
There are accounts on record, for example, from
which it appears that persons labouring under the
delirium attendant on fever, or succeeding injuries
of the head, have been heard to talk in languages
which they had been accustomed to speak in very
early  childhood, but had  for  a long course  of
years disused and totally forgotten.  The case of
a  Welshman has been mentioned,  who lay ill for
some  time in  St. Thomas's Hospital, after an in-
jury of the head.  During the course of his ill-
ness he was  heard to talk  Welsh  very fluently,
but could not utter a word of English : when be
recovered, it  was  ascertained  that  he had been
absent from Wales upwards of thirty years, and
had entirely forgotten his native dialect, the know-t
ledge of which was  thus revived by his disease.
This  statement, which was first  given  by  Mr.
Tupper, has been  confirmed to the writer of this
article by a personal  witness.  A parallel  case  is
that of a  French  countess,  born in Britany,  who
had learned the Bas Bretagne or Armorican idiom
during her infancy ;  many  years  after she  had
forgotten it, during the delirium of a severe fever,
she was heard to talk incoherently in a dialect
which to the  astonishment of everybody, a Welsh
servant understood  and interpreted.  Dr. Rush,
of Philadelphia, used to state that some of the old
Swedish settlers in  Pennsylvania, who, attaining
a period of great  longevity, had survived till his
time, were heard  in  many instances during their
last  hours, in  the almost incoherent mutterings
which preceded dissolution,  to talk in their native
language, which, during by far the greater portion
of their lives, had  been entirely disused  by them
and forgotten.
   This restoration of old and effete impressions
is accompanied by another phenomenon.   When
the  mind  is thus withdrawn within itself, if we
may use such an expression, and goes back to the
inmost recesses in which are laid up the stores  of
long-concealed, but,  as  it seems, never to  be ob-
literated reminiscence, it not only becomes uncon-
scious of external circumstances, or indisposed to
the  perception of surrounding objects, but  even
loses the recent impressions of memory.  Newly
acquired ideas  are effaced, like the immediate im-
pressions  of sensation.   The knowledge of some
language  but lately  acquired has been thus lost.
A  foreigner, mentioned by Mr. Abernethy, met
with an injury of  the head  when he was twenty-
seven years of age.  During the delirium which
ensued on this accident he  could only answer
questions in French, though  he  had previously
spoken English perfectly well.  He said that he
was but sixteen years old, the age at which  he
left his own country :  it is probable that the im-
pressions  received during eleven years had  been
effaced from his  mind.  After accidents which
have occasioned concussion of the brain  and con-
sequent delirium,  persons have lost all recollec-
tion  of events which occurred  during a certain
period antecedent  to the injury.  Two gentlemen,
intimately known  to the writer of this article, met
with accidents which occasioned to both  of them
severe injuries of the head.   In both, concussion
of the brain was  followed  by stupor, and after-
wards by delirium, which continued some weeks.
Both  of  these  persons recovered  their  faculties
perfectly, but each of them  had permanently lost
all recollection  of objects and incidents which had
occupied  his mind  for a considerable time pre-
viously to the accident.
   During the state of unconsciousness as *n ex
ternal impressions, there  is, together with  excite-
ment of memory, sometimes a considerable degree
of mental activity: the mind is exercised even in
forming new combinations.   Many persons  havii 
5S4
DELIRIUM.
been known to compose verses and speeches, and
to hold conversations on abstract subjects with in-
dividuals whom they imagined to be present.
   Persons  labouring  under delirium are at times
capable of being roused by external impressions,
and, when  once excited, they display unexpected
muscular energy, which is  followed by exhaustion,
but not in  every instance  by a relapse  into deli-
rium.  Van Swieten has twice mentioned the case
of a man who, under severe delirium, was roused
by hearing the noises  occasioned by a fire which
had  brokon out in a  neighbouring house.  His
incoherent  muttering, which  had  continued  for
some days, ceased,  and  he inquired  anxiously
into  the  cause of the alarm: bis delirium was
cured from that time.  A  patient lying  ill with
fever some years ago, in  tbe Bristol Infirmary,
was  suddenly roused  by a loud  peal  of thunder.
He started  from his bed, and in  a  moment leaped
over the beds of the patients who lay  in  a row
opposite  to him,  and  before  anybody  could  lay
hands on him, although in the middle of the day,
when all were  awake, he  climbed  up to an open
window,  twelve feet in elevation from the ground
of the ward, and almost accomplished his design
of throwing himself out of it.  He would inevita-
bly have been dashed to pieces if his foot had  not
providentially fixed upon a projecting ridge below
the sill of tbe window, by  which, as well as by
one  hand  grasping the  window-frame, he was
supported until ladders were placed on the outside
of the building, by  which he  was taken  down
without injury.  This man afterwards  recovered.
   When delirium terminates fatally, it passes into
coma. Sensibility becomes more  and  more  im-
paired, until all conscious  feeling seems  to be lost.
Inarticulate moaning succeeds to  delirious inco-
herence;  the patient loses in a great measure sight
and hearing; the pupils become  scarcely contrac-
tile, and the evacuations escape without conscious-
ness.  Patients have  recovered after remaining
for some time in this state, and this has happened
not unfrequently in  the case of young subjects.
But the symptoms above  detailed are more gene-
rally followed by others, whicb are the  sure har-
bingers of  death.  These  are  flocci volitantes,
picking the bed-clothes, convulsions, coma, with
subsultus tendinum, the eyes being turned up with
a failing  lower eye-lid.  One  of these symptoms
alone denotes great danger, but the aggregate an-
nounces the speedy approach of dissolution.
   Diagnosis.—The diagnosis between delirium
and insanity is, in practice, for the most part at-
tended witb little or no difficulty.   The presence
of inflammatory or typhoid fever  in the  former
case, and its  absence  in the latter, is in general  a
sufficient indication.   Mad persons have many of
their functions unimpaired ; they walk about, eat,
drink, talk.  The state of a  delirious  person is
quite different.  " The insane,"  says M. Georget,
" have frequently the  external  senses and  the
power of voluntary  motion  in  a  healthy state;
they see, hear, taste ;  intelligence  is in very few
abolished ;  often  the  mental disorder is confined
to a  single  faculty, or to a limited number of acts
dependent  on a single faculty; and in those cases
in which it appears to be the most extended, in
intense maniacal affections for example,  the facul-
ties appear to be perverted, or  insulated, and with-
out the bond of association, but are yet far from
being  extinguished:  the  most  irrational maniac
talks, reasons, wills, and is not always  absurd in
his reasonings  and actions.   In the delirious, on
the contrary, all the cerebral functions are severely
affected; tbere are no correct sensations, connect-
ed ideas, or passions; no regular voluntary  mo-
tions; little or no intelligence or recollection: the
patient is almost a stranger to  every  thing that
surrounds him as well as to himself."  We may
on the  other hand observe that most insane  per-
sons have the digestive or nutritive functions  in a
sound state, and that they display the external
appearances of health, especially after the few first
days  from the commencement  of their insanity,
and before they have shown signs of the  secondary
disease which  is destined to bring them to their
end :  in delirious persons these same functions
are always more or less in  a state of disorder.  We
should  in fact incur  no danger of contradiction
from persons who are in the habit of seeing cases
of insanity, if we were to venture on the assertion
that a  great number of  lunatics bear infinitely
greater resemblance  to  individuals in  perfect
health than to patients labouring under  febrile
delirium.
   It is of great importance not to confound these
two species  of mental disorder.   The cerebral af-
fection  which is connected  with delirium is in
general severe and of short  duration; it must be
combated by  a vigorous  method of practice in
order to prevent a fatal  termination : madness is
of long duration, and seldom  or never attended
with  danger  to  existence.  The  latter  disease
seems to  pursue its  victims even after their re-
covery, by the mistrust which they inspire as well
for the present as for the future;  a mistrust which
even  extends  itself to their posterity.   A patient
who  recovers  from this state  is often painfully
affected at finding  himself in  a inad-house.  It
would be unfortunate, on account  of these con-
siderations, to take a  patient labouring  under de-
lirium for a lunatic; and in doubtful  cases the
physician should only  describe  the state  of the
intellectual  faculties  by the  terms ' delirium' or
'disorder  of the brain' until he has  clearly re-
cognised  and  is satisfied  of  the  existence of
madness.
   The leading criterion between delirium and in-
sanity is  afforded  by the  state  of the sensitive
power or of the faculties of sensation and percep-
tion.   Insane persons have  the faculty of sensa-
tion generally unimpaired  ; and if they apprehend
external objects to be different from what they
really are, the error  lies not in any disordered
state  of the perceptive power itself, but  in the
perverted judgment or false conviction of the un-
derstanding, which  is so deeply rooted as even to
resist the evidence  afforded  by the senses.  An
insane woman is convinced that her husband is
dead; and when he  actually comes to  visit  her,
and to dispossess her  of this hallucination, she in-
sists that  the  devil has assumed the form of her
deceased husband in order to impose  upon her.
A delirious  person  cannot distinguish  one indi-
vidual  from another, and  sometimes  does not
know  the nurse who  constantly attends him.
There are, however, cases of delirium  approach-
ing somewhat  to mania,  in which  the sensitive 
                                       DELI

power  is but  little impaired,  and some of  the
peculiarities of insanity  show themselves.   We
have witnessed the display of cunning and stra-
tagem by patients slightly delirious; artful plans
laid, in order  to get rid of annoyances and  to
gratify inclinations; a strong impression  mani-
fested by the patient that he is where he is not;
a concealed suspicion that it is intended  to carry
him off and put him into confinement.  We have
known instances in which traits of this descrip-
tion have excited great alarm, lest what had been
regarded as temporary febrile delirium might prove
to be a permanent loss of reason. These fears have
proved groundless. The faculties are fully restored
after having been obscured under febrile delirium,
with  very  rare  exceptions.   The  restoration to
mental vigour is, however, in  some instances slow,
and occupies  several weeks, and  even  months.
Facts, indeed, have occurred within our  know-
ledge which have  seemed to indicate that the in-
tellectual faculties have  been in some  instances
even brighter and more vigorous than ever,  or at
least  have  been exercised with greater activity,
and more displayed after a recovery from  febrile
delirium;  and a parallel  observation  has been
made by  some of the older medical writers.
   Pathology. — Many  practical writers have
been led by observation to conclude that  there are
 two different states of the system accompanied by
delirium, in one of which  the brain is not  the
 actual seat of disease, at least to any great extent,
its functions being disturbed in consequence of
 disease, for the most part of intense degree, exist-
 ing in some distant  organ;  while  in the  other
 form of delirium the brain or its enveloping mem-
 branes is the  seat of inflammation.  It is very
 important,  in  a  practical point of view, to  dis-
 tinguish these two affections, which may be termed
sympathetic and idiopathic delirium.
   1.  The first-mentioned species of delirium was
 indistinctly described by Dr. G. Fordyce,  in  his
 minute detail of the symptoms of fever.   Fordyce
was of opinion that this form of delirium ought
to be treated with slight anodynes and restoratives.
M. Dupuytren has given  to this species of disease
the designation of nervous delirium :  he has de-
scribed it in the « Annuaire  Medico-Chirurgical
des Hopitaux." He remarks " that it is frequently
observed  in highly susceptible or nervous indi-
viduals, who have received severe wounds, or have
undergone  painful operations; in those who have
suffered greatly from the apprehension of under-
going  operation, and in  others who have made
efforts beyond their physical strength to display
fortitude and courage in bearing pain heroically ;
and, lastly, in persons who have made an attempt
to commit  suicide."   According to M. Dupuy-
tren's  observation,  cases of  this  description  are
never cured or alleviated by  antiphlogistic reme-
dies, but yield easily to the administration of nar-
cotic injections.  In the brain no traces of disease
have been discovered  by  M. Dupuytren when  he
has had opportunities of  investigating the morbid
appearances in cases of nervous delirium.  To this
form of delirium, as M. Georget has observed, we
must refer the various degrees of mental and sen-
sorial disturbance which occur  at  the  close  of
chronic, and even of acute diseases.  Compara-
tively few persons die in the  full possession  of
   Vol. I___74
IUM.                                    585
their  faculties.   But  it  may  be observed  that
chronic affections do not in general excite  deli-
rium  and febrile symptoms without passing into
a certain degree of acuteness.  May we not  refer
to the same head, as arising from a cause nearly
analogous, the  wanderings  experienced by pa-
tients reduced  to an extreme degree of weakness
on  sitting up or rising from bed, as well as the
delirium which  ensues  on excessive evacuations
of blood ?  Is  there not in either case a defect of
sanguineous stimulation, giving  rise to the dis-
order in the intellectual  processes ?  If we adopt
the opinion of  M. Broussais on the frequent ex-
istence  of gastritis, and on  the  primitive or se-
condary causes of febrile action, «the stomacb
may be the organ which of all  others  exercises
the greatest influence on the brain, and is gene-
rally, if not always,  the cause  of  sympathetic
delirium :  but  this opinion cannot be regarded as
established."
   The  opinion  that defective vascular  action or
vascular exinanition is a frequent cause of disor-
der in the functions of  the brain, is a-conjecture
not peculiar to M. Georget.   But the  physiology
of the brain is  not sufficiently known to enable
us to follow this conjecture  with any thing like
a legitimate theory.   We only know the fact that
long-continued irritation in the system, when the
powers of life  are giving way, frequently, if not
generally, induces, previously to dissolution,  more
or less of disorder in the sensorial and intellectual
functions.  This  is not  the case exclusively in
disorders  affecting the stomach, or even  more fre-
quently than in complaints  situated in  other or-
gans.   Inflammations of  the chest, phthisis, chro-
nic ulcerations  in  the  bowels occurring  as the
sequelae of fever, and  a variety  of  other disor-
ders,  often give rise to the kind of delirium  here
spoken  of.
   This species of disease has often been compar-
ed to delirium  tremens.  Its phenomena have but
little resemblance to the symptoms of that com-
plaint, whatever analogy may subsist between the
unknown causes of both.  They are alike in one
respect, viz., as  to the inutility of antiphlogistic
remedies.  It cannot  be  said that anodynes are
equally serviceable in either; they are, however,
in some instances of both diseases to be preferred
to all other remedies.
   2.  Idiopathic delirium is  a disease  of  greater
importance than  the  secondary  or  sympathetic
species, inasmuch as  it denotes a specific condi-
tion of  the brain, which requires  a particular class
of remedies,  and which, unless  removed by the
timely and vigorous administration of such reme-
dies,  will  speedily extinguish life.  It is more
marked in its symptoms, and more readily traced
to  its  exciting  causes :  there is, therefore, not
much difficulty  in general in ascertaining  its ex-
istence.   This form of delirium, likewise, some-
times leaves behind it vestiges which may be dis-
covered on dissection.   Such are  all the various
phenomena produced by inflammatory  action in
the meninges  and in some parts of the brain.
These  morbid  changes  are, however, seldom  of
great extent.   They  consist chiefly in vascular
injection  of the  surface  of the  brain,  increased
hardness in its substance, effusion of fluid in the
ventricles, injection of the vessels in the pia ma- 
586
DELIRIUM.
ter, serous infiltration of the  same membrane : a
similar condition of the arachnoid has  been, as
M. Georget  observes, less  frequently discovered.
More important lesions than these have been traced
in cases which combined paralytic or  convulsive
affections of the muscular system with delirium ;
but the latter cannot  be considered as belonging
to the disorder now under consideration.
  To the idiopathic form of the disease belong,
  a. Delirium following  injuries of  the  head,
fractures, concussions, wounds, and lesions of va-
rious kinds, which produce  inflammation  either
immediately or after  the first effects  have sub-
sided.
   6. Delirium accompanying inflammation  of the
brain or its  membranes, brought on by exposure
to heat or cold.  The effects of insolation, and of
exposure to heat in furnaces  or heated workshops,
come under this division.
   c. Delirium the result of intoxication, or  of ex-
cessive doses  of  opium  or other narcotics.   We
allude here, not to the staie of intoxication  itself,
but to a more severe disease  which  is often the
sequel of intoxication.   Of this cases frequently
occur in practice.  A  theatrical performer  came
home to his wife in a state of intoxication.   Dur-
ing the whole night and a part of the next day
he was supposed to be merely drunk, and no  alarm
was taken.  As he continued to be delirious on
the following day, medical assistance was requir-
ed.  He was still in a state much resembling that
of intoxication:  his  head  hot, face flushed, eyes
red, mind confused, but without coma or paraly-
sis.   His head was shaved, and the jugular veins
opened.  He  expired in the  course of the day,
and the  surface  of the  brain was found highly
injected, the  white  substance itself  presenting
abundantly  bloody points.   A man drank by mis-
take a poppy-head  fomentation.  He  was  seized
with violent phrenzy,  but speedily  relieved and
cured by means  of bleeding  and  powerful  anti-
phlogistic remedies.
   d. Delirium occurring in  erysipelas  affecting
the head is plainly of tbis kind.  We have re-
peatedly seen  the  morbid phenomena denoting
inflammation  strikingly displayed  on opening the
head in cases  of this description.  The metastasis
of dropsy, of rheumatism, and of various  other
diseases, when apoplexy is not the consequence,
gives rise to delirium, which may be termed idio-
pathic, whatever organ had  been  affected  before
the disease was transferred to the brain.
   e. Delirium attending continued fever is of this
kind, when  the head is the actual seat of the most
intense diseased action.  When  the fever has
been of that kind which some writers  have term-
ed cephalic, when the ordinary signs of determi-
nation to the  head,  or  of  increased  vascular ful-
ness have preceded and accompanied  it, delirium
may be considered in cases of fever as an inflam-
matory complaint.   The  practical consideration
of this  subject will  be entered upon  more fully
under the head of Fever.   We now proceed to
make some observations on the treatment of deli-
rium.
   Treatment.—The  treatment  of febrile deli-
rium may be reduced  to very  simple principles,
and these are such  as  are very generally under-
stood.
  Shaving the bead, the  application of cold wa-
ter, with  the  admission  of free air,  are  means
often adequate to  the  removal  of delirium as it
occurs in  typhoid fever.   We  have seen many
patients brought from  close and foul  apartments
with typhoid symptoms and labouring under deli-
rium, who, after  undergoing these  simple reme-
dies, and passing a single  night in  a cool, well-
ventilated ward,  have  been found  on  the next
morning so much improved, and so collected and
free from mental disturbance, as to require no par-
ticular remedy directed to the state  of the head.
   Topical bleedings, viz.  either by opening the
temporal  artery, by  cupping on the head, or on
the nape of tbe  neck, or by the application of
leeches to the head or round  the  neck, are well
known to be among the most important remedies
for febrile delirium.
   Cold applications, by iced water or merely wet-
ted cloths, by a stream of  water passed by means
of a funnel over  the vertex, by ice  pounded and
put into a bladder or  oiled skin, or by evaporat-
ing lotions, are next  in  point  of importance to
bleeding.
   Blisters to  the  nape of the  neck are often of
great service.   When the heat of the scalp is not
great, or has been reduced, and especially when
there  is much stupor, or  a tendency  to coma,
blisters are beneficially applied  to the vertex.
   Incisions in the scalp,  made in  the  direction
and over the  sagittal suture, are of great service
in cases of delirium combined with stupor, whe-
ther occurring in the course of fevers, or in affec-
tions of the head  otherwise brought on.  The in-
cision  should reach from the vertex to the anterior
part of the hairy  scalp, and be made down to the
pericranium.   The  effect of this remedy is often
an immediate relief by the bleeding which takes
place.   The subsequent inflammation  and suppu-
ration, the incision being kept open, are much
more productive of benefit than the ordinary super-
ficial inflammation excited by blisters, or the se-
rous discharge from the surface of the cutis.
   The writer  of this article has now  a patient who
is making progress towards recovery, and is al-
ready  almost  convalescent.    His  improvement
appears to have resulted from  the means last de-
scribed.   He  laboured under severe  delirium with
stupor, and had occasional fits of convulsion. His
disorder was brought on by exposure  to heat, his
occupation being that of supplying with  coal, and
attending to  the  boiling  apparatus of  a  steam-
engine.
   Purging is  of great benefit in  cases of idiopathic
delirium, and is often  sufficient alone to tbe re-
moval of the disease. We shall not proceed further
at present in the consideration of remedies required
for the treatment of delirium.   The morbid state
of the brain,  from which delirium  arises, seldom
forms a distinct and entire disease. When it occurs
in fevers, the  remedial treatment belongs to the
therapeutics of fever:  when it  proceeds from in-
juries of the  head, it comes under concussion of
the brain, or fracture or wounds of the scalp, &c
To articles on these several subjects  in the pre-
sent work, or to  distinct  treatises, we must refei
our readers for more particular details.

                            J.  C. Prichard 
DELIRIUM  TREMENS.
587
  DELIRIUM TREMENS.  Amongst the nu-
merous maladies which  are the results of vicious
indulgence, those of which the foundation is laid
in the abuse of ardent spirits, and other diffusible
stimuli, form  a long and frightful catalogue :  in-
flammation of the brain and its  membranes; of
the  pleura ; of the stomach ; of the liver; jaun-
dice; dropsy ; diabetes ; gout; mania ; dyspepsia,
with its manifold miseries—these are among  the
diseases induced  by habitual intemperance ; and
several more  might be added to the appalling re-
cital.
  Place this  catalogue before the man who is be-
ginning to acquire  a taste for inebriating liquors,
and he will feel alarmed ; he will  probably express
his astonishment at the infatuation of the drunk-
ard, and his  determination to halt at once in his
destructive career.   Happy is it  for such an  one
if his  conviction of danger be  abiding as it is
powerful:  unfortunately,  however,  it is  in  too
many  instances  speedily  effaced.   Temptation
 again and again offers itself, and triumphs  over
 repeated sober resolves, till, in the sequel, the  vic-
 tim persuades himself  that it is  absurd to forego
 a positive pleasure  through fear of remote  and
 contingent evils ; of maladies which  hundreds,
 more intemperate than himself, escape atltogether ;
 from many of which recovery is  not uncommon ;
 and to the visitation of which even  the ascetic is
 liable.  For  some  time, perhaps, he  is guilty of
 excess only on  extraordinary occasions ; but, by
 insensible  degrees,  he  slides into  the habit of
 drinking deep in all companies, and, at last, of
 indulging even in private, and at all hours.  From
 what is termed a pleasant companion, he degene-
 rates into a hard drinker, and ends a complete sot.
    Still he is attacked by none of the formidable
 diseases above enumerated,  excepting dyspepsia,
 which he  is very unwilling  to ascribe to its true
 cause;  or respecting the real source of which he
 is perhaps actually  deceived, owing to the tempo-
 rary relief which the application of fresh stimuli
 constantly affords him.  His bane and antidote
 are one and the same.  But he who abandons
 himself to incessant or immoderate potations should
 know, that if he escapes those diseases which
 once created such  alarm in his mind, he is yet
 obnoxious to one not less formidable, which some-
 times manifests itself rather suddenly, and speedily
 destroys the  patient; sometimes creeping  on by
 slow and almost imperceptible degrees, though  it
 may not  prove immediately fatal, may still leave
 him in a lamentable state of debility both of body
 and mind, and  materially abridge the term of his
 existence.
   This disease has  received a variety of appella-
 tions.   It has  been called brain fever, a peculiar
 disorder of drunkards, delirium et mania e potu,
 [cenomania,  mania  e  temulentia,  delirium po-
 tatorum, d.  tremifaciens,]  delirium ebriositatis,
 erethismus ebriosorum, encephalopathie  crapu-
 Imse, [folie des  ivrognes,] delirium  tremens.
 The latter designation is here adopted, not as being
 altogether appropriate, for it is confessedly  open
 to  more than one  objection.  It is not perhaps
 quite correct to speak of a delirium as trembling;
 and the term is yet more faulty, inasmuch as tre-
 mor is not an invariable, though  it be a very usual
 symptom.   But the designation first employed by
Dr. Sutton is that under which  tbe  disease has
been commonly recognized since  the  publication
of his valuable essay.  That essay, though it was
not the first distinct notice on our present subject,
was the first which seemed to attract the attention
of the profession in general to a subject previously
little known.  The  earlier labours of Drs. Pear-
son and Armstrong, important as they  certainly
were, excited less interest.  It  has been  observed
by Dr. Blake, that traces of this affection may be
discovered in the writings of ancient authors, even
as far back  as  those  of  Hippocrates; and  it is
true that, under the heads of phrenitis, mania, &c.
cases are recorded by them of which the symp-
toms  bear an intimate resemblance  to  those of
delirium tremens ; but that  those cases differed
materially from others  of true phrenitis or mania,
seems not to have entered  into the minds of the
venerable fathers of medicine.  Their successors,
from age to age, overlooked the peculiar character
of the disease.   Not many years ago the most
distinguished lecturers offered nothing,  or, at all
events, nothing precise upon  the subject—except-
ing Dr. William Saunders.  (See Sutton's Essay,
p. 4—note.)   Systematic writers were silent con-
cerning it.  The first distinct account of delirium
tremens  was from the pen of Dr. Pearson, who,
it would  seem, derived his information  from Dr.
Young, of Newcastle-upon-Tyne.  Dr. Armstrong
next  published a paper or two upon  the subject,
and he was  followed  by  Dr. Sutton.  Since the
appearance  of his essay, the  disease has again
been treated  of by Dr. Armstrong, in  his lectures,
and by several other  authors of reputation, both
of our own and  of  foreign countries  : it has ob-
tained a place in the works of Good  and of  Gre-
gory, though unfortunately they  differ  as to its
classification; the former placing it undet nervous,
the  latter  under  inflammatory affections.   It is
now fully recognised as a peculiar disease, requiring
peculiar treatment, and  therefore  one which it is
of  the utmost moment we should be able to dis-
tinguish from certain  others to which it bears no
inconsiderable  resemblance,  and  with which it
often has been, and  probably often is, confounded,
to the great detriment  of the patient, as well  as to
the discredit and mortification of  the  practitioner.
   In describing  the phenomena  of delirium tre-
mens, we  shall  adopt  Dr. Blake's division of the
disease into three stages, not merely as conve-
nient, but as founded  upon a philosophic view of
the subject.  The advantages of considering deli-
rium tremens under separate  stages have not been
overlooked  by  other  authors;  but  Dr. Blake's
arrangement seems, upon the whole, best calcu-
lated  to  obviate  the  obscurity and confusion in
which its history was formerly involved, and to
direct us as to our mode of treatment.
   The approach of the first  stage is announced
by symptoms  of general debility ;  the  patient's
appearance and  manner undergo a certain change;
his countenance is dejected  and anxious; his
spirits  are depressed ;  there is frequent sighing,
and oppression of the  prscordia.   All around him
perceive that he is indisposed, though  his  most
intimate friends  may  be altogether in the dark as
to the nature of his malady, or its cause.  If tho
invalid be  himself questioned, he will  probably
maintain that nothing ails him •  or,  if he admin 
583                           DELIRIUM

that he does not feel quite well, he will not be able
to explain  what  is the matter with him.   Upon
more particular inquiry it will be discovered that
his nights are restless, that his slumbers are short,
and disturbed by harassing dreams ;  that he rises
in the morning unrefreshed and languid; that his
appetite is impaired, or even that he loathes food;
that he  is  annoyed  by  nausea and continual
vomiting;  that  he suffers  from cramps of the
extremities.  Vertigo  and  confusion  of ideas are
usually present.  Pain of head has been reckoned
among the symptoms; but it is certainly neither a
common  nor a leading one.  The tongue is some-
times furred, but moist; often, but not in all cases,
tremulous.   The bowels are generally open.  The
pulse, according to Dr. Blake, whose opportunities
of observing the disease  at its commencement
have undoubtedly been ample, is invariably slow;
and although other writers do not mention this
remarkable slowness  of pulse, they all concur  in
representing the pulse as by no means frequent.
It is, moreover, soft and compressible; often feeble
and unsteady.  The temperature  of the  body
generally is not  increased, while that of  the ex-
tremities is considerably  below the standard of
health.  The hands and feet are cold and clammy;
the sensation they convey to the touch resembles
that observed in persons  labouring under enteric
inflammation.  Tremors of the  hands occur  in
most  instances.   Such are the  principal  features
of the first stage of delirium tremens, and beyond
this stage the disease may not proceed: by timely
and judicious treatment its further progress may be
arrested,  and by subsequent prudence on the part
of the patient its recurrence may be prevented.
   Generally, however,  it  is  succeeded, after a
shorter or longer period, according to the constitu-
tion, age, and previous habits of the patient, by
the second stage, or that of delirium.  In young
and robust subjects, whose excesses have not been
of long standing, the  stage of re-action or excite-
ment will  come on much more rapidly  than  in
persons  advanced  in  years, and  whose constitu-
tions  have been broken down by long intemper-
ance.  It is during  this stage  that the  medical
attendant is most liable to fall into error.  The
symptoms, many of them, are so similar  to those
of inflammation of the brain  or its membranes,
that, if he is not especially upon his guard, if he
allows the  pathognomonic signs of the disease to
escape him, his diagnosis will be incorrect and  his
practice unsuccessful.  When the second stage is
coming on, the vertigo and confusion of  head are
more marked; there is more decided aberration of
mind ; the countenance gradually assumes a wild
aspect;  the patient is incessantly restless;  there
is apparent an  anxiety to  perform immediately
whatever is desired of him; he even anticipates
your  wishes,  or what he  supposes  to  be your
wishes ;  he is peculiarly sedulous in the  perform-
ance of his ordinary duties, which he goes  about
in  a  hurried immethodical manner; he  is very
jealous of the least interference, either by advice
or otherwise, as to matters pertaining to his  voca-
tion,  exerting himself painfully to  prove  he  is
quite well, yet  evidently  mistrusting   himself.
Thus, if his occupation is that of a butler, he will
betiav a strange solicitude about mere matter of
,  outine; ne will be in a perpetual bustle; he will
TREMENS.

commit perpetual blunders, at the expense  fre-
quently of his master and  his guests:  his altered
countenance, uncertain step, and trembling hands,
will sufficiently evince his unfitness for the duties
of his situation ; yet he will pertinaciously repel
the proffered aid of his fellow-servants; his whole
manner will much resemble that of a person on
the verge of intoxication,  who  is excessively
anxious to  appear quite sober.   By ordinary ob-
servers he will probably be pronounced more than
half drunk, and they will  recommend  his being
sent to his bed, under the  notion  that sleep will
effectually restore him.  But such a patient cannot
sleep  off his malady.   He  is restless; his mind
wanders; he rises worse than he was before, with
more  symptoms of high nervous irritation.   By
degrees mental alienation is fully established ;  the
patient is in a constant worry  about some affairs
which he fancies  of  great  importance;  some
business,  generally private business, which must
be  attended  to.   He makes violent and repeated
efforts to liberate  himself  from restraint, lhat he
may apply himself to these affairs;  but he is not,
like tbe  decided maniac,  or the  man labouring
under the immediate excitement of an over-dose
of  strong liquor, disposed to be mischievous ;  his
exertions, though vehement, are not characterized
by  malignity or ill  nature;  he  quickly  forgets
what is past, and, if judiciously managed, is, upon
the whole, sufficiently  tractable.   He  will gene-
rally take the medicines offered him without much
difficulty, and, when exhorted  to  endeavour to
keep quiet, will manifest, for a short time, a desire
to  acquiesce.  He will now and then recognize
those of his family and friends who are near him,
and will  return a rational  answer to a few ques-
tions  ; but he very speedily relapses into his erro-
neous train of tbought.   At  this period  of the
disease the circulation is quickened, the heat of
the surface becomes greater, yet  still the pulse
remains  small, and  there  is a marked difference
between the temperature of the extremities and
that of the rest of  the body, the former continuing
damp and  cold.   If the  symptoms above-men-
tioned be not soon ameliorated, a sweat bursts out,
copious and clammy, and  occasionally, it is said,
of  an offensive  odour.  The mind becomes still
more distressed ; objects of the  most appalling
description  sometimes  present themselves to the
patient's  imagination ; he will be possessed with
the idea that he is persecuted by  evil spirits, who
are upon  the point of carrying him away, or are
preparing to destroy him ; or he may  fancy he is
surrounded by assassins ; and  cases are recorded
where the unfortunate sufferers  actually expired
while exerting themselves  to the utmost to ward
off the violence they supposed was intended them.
Catastrophes so  lamentable are not, however, of
frequent occurrence.  Various other hallucinations
less frightful, though still  very distressing, might
be  mentioned ; it may, however, be sufficient to
observe in a general way, that  the  mental  bias is
mostly of the melancholic kind.   Sometimes the
most  whimsical notions arise :  thus a patient will
imagine  that rats or mice, or  other troublesome
vermin are running over him, or near  him ; that
he  is employed in drawing ribands from the ends
of  his fingers, with numberless extravagancies of
a similar  nature. 
DELIRIUM  TREMENS.
589
  When delirium is completely established, there
is obstinate pervigilium, and tbis is a very impor-
tant, indeed it has  been regarded  as a pathogno-
monic symptom of the second stage of the disease.
At this  period, too, the countenance assumes an
aspect of extreme anxiety; the tremor of the hands
and  tongue is greater ; the latter  is more furred,
but still moist;  the pulse  is not  only small but
frequent, and  also  indistinct, partly  perhaps in
consequence of the tremor and unceasing work-
ings of the tendons of the wrists ; the  urine is
scanty and pale ; the bowels are usually confined ;
the dejections dark coloured ; the  pupils are con-
tracted,  but without intolerance  of light.   Still
there is no indication of local pain, and when the
patient is asked how he feels, he will often reply
that he is quite well.  These symptoms either in-
crease in violence, and others supervening, which
 very nearly resemble those  of the last stage of
 typhus, the patient dies  suddenly in a convulsion ;
 or  the  long-continued  delirium,  with  subsultus
 tendinum, picking of the bed-clothes, &c, is suc-
 ceeded by a short interval of quietude, and he ex-
 pires without  a struggle ;  or, after two  or three
 days, or it mayjDe  a week, yawning and drowsi-
 ness come on, and sleep follows,  which is gene-
 rally profound and  of long duration, lasting  from
 six to twelve or eighteen hours; the patient wakes
 collected, and  greatly refreshed, and his recovery
 may be looked upon as almost certain.
   Such are the general symptoms of the three
 stages of delirium tremens, which if they be at-
 tentively considered, and viewed as a whole, will
 enable the medical  student to perceive wherein it
 differs from certain other  affections  to which it
 bears a real or an apparent affinity.   When he
 comes to the bedside, he will  be in  a good measure
 prepared  to discriminate between a case of deli-
 rium tremens and one of phrenitis, mania, hypo-
 chondriasis, or typhus  fever.  If  he be so fortu-
 nate as  to be consulted early, during the first stage
 of the disease, he will  scarcely be at a loss as to
 diagnosis.  But it will more  often  happen that he
 is not summoned till the second stage is approach-
 ing, or until it is fully established ;  and then there
 will be  more difficulty in recognizing the affection.
 There may be certain cognate diseases where ac-
 curacy of diagnosis is not practically essential, but
 in very many instances it is  of the utmost impor-
 tance, and on no occasion perhaps  more important
 than when we are consulted  in a case of delirium
 tremens.  The previous habits of the patient may
 be unknown to the medical man ;  his friends may
 be imperfectly acquainted  with them, or may en-
 deavour to conceal  them ;  to the superficial or the
 unskilful observer he may appear to be labouring
 under phrenitis or mania; from himself, of course,
 no information can  be expected.  Whenever, there-
 fore, we are called  to such a case, we should in-
 stitute  the most careful inquiry   into the  early
 symptoms of the complaint,  we should endeavour
 to elicit  from  the family of  the patient what has
 been his state, both physical and  moral, for some
 time previous to the accession of delirium, and at-
 tentively view the  previous history, so  far as  it
 may be furnished us, in connection with existing
 phenomena—the pulse, the countenance, the tem-
 perature of the skin,  especially  of the extremi-
 ties, its dryness or moisture; the appearance of
tbe tongue;  the degree and  kind of alienation,
whether the delirium be accompanied with pain
of tbe head or any other part,  with indications of
increased arterial action, or of venous congestion,
or otherwise ;  whether it be characterized  by in-
tractable violence, or be of a more mild and man-
ageable nature ;  whether there be tremors of the
hands and tongue, whicb almost always accom-
pany delirium tremens  from the first, and do not
indicate extraordinary danger, while in phrenitis
they are scarcely ever present until the last stage,
and  are then of  most unfavourable omen.
   Having thus detailed the symptoms of  the dis-
ease, we proceed to say a few words respecting its
causes.   Now the principal features which mark
its first stage  so commonly exhibit themselves in
intemperate subjects early in  the day, when they
are in the state of exhaustion which  is the usual
consequence of a debauch, and have so frequently
been observed to arise in soldiers and others, when
for a time  deprived  of their  daily quantity of
liquor; that the sudden subtraction of accustomed
stimuli has  been regarded, by respectable  authori-
ties,  as invariably the  immediate cause  of the
disease.   The habitual and excessive indulgence
in strong liquors, or in other diffusible stimuli, has
been considered  as the predisposing, and the pri-
vation of them as the occasional or exciting cause
of the affection.
   To a somewhat whimsical theory of M. Le-
vielle, (Memoires de  l'Academie Royale de Med.
torn. i.   Sur la  Folie des Ivrognes, ou sur la De-
lire  Tremblante,) that  delirium  tremens  consists
in exaltation of the vital powers of the brain, ex-
cited by alcoholic  molecules absorbed from the
surface of the stomach and  bowels, and  carried
into  the current of the  circulation, it is  objected
by Dr. Blake, that  he never saw  an individual at-
tacked with delirium  tremens so  long as he con-
tinued to indulge in  his accustomed alcoholic po-
tations ; but that it invariably came on when old
drunkards ceased for  a given time (either from the
effects of an excessive debauch, or from any other
cause whatever, such as a wound, a fracture, or a
fever,)  to  take  their usual inebriating draughts.
To overthrow M. Levielle's theory would perhaps
cost little labour, but we do not consider that it is
in the  least degree shaken by the objection just
stated; for that delirium  tremens may manifest
itself in individuals who have never been deprived
of their accustomed  stimuli, even for an  hour, is
most certain ; as, for example, in publicans, who
live in an  atmosphere  charged  with alcohol,—
who, though seldom absolutely intoxicated,  are
always more or less under the influence of intox-
icating liquors—who are sipping from morning to
night.  Instances  of well-marked  delirium tre
mens occurring in such persons have fallen under
our  observation.  Interesting cases might be cited.
where, upon  the patient's being at once removed
beyond the  sphere of temptation, recovery was
rapid and complete ;  and others might be adduced
in evidence that the  habitual stimuli being obsti-
nately persisted  in, or, after  a certain interval of
abstinence, foolishly resumed, the disease will pro-
ceed to a fatal termination.
   The delirium which  comes on in persons ad-
dicted to hard  drinking, several days subsequent
to a wound or fracture, the traumatic delirium  of 
590
DELIRIUM
TREMENS.
M. Dupuytren, the symptomatic delirium tremens
of M. Barkhausen of Bremen, and which is re-
lieved by ardent spirits or strong liquors of one
kind or other,  though it be doubtless very nearly
allied to the affection which is the subject of our
present inquiry, does not seem to be identical with
It.  In such cases the system  receives a sudden
and violent shock ;  an individual, previously per-
haps in the enjoyment of robust health, accus-
tomed to strong exercise, engaged in  a laborious
occupation,  requiring  much  support,  is at once
confined  to his bed ; his  habits are in a moment
broken off; and no wonder  that, in  a few days,
he falls into a state greatly  resembling that of a
patient in  typhus—a state  which absolutely re-
quires the stimuli to which he used to resort  pre-
viously to the reception  of the injury.   But in
delirium  tremens, unconnected with other disease
or injury, we  recognise no such immediate and
overwhelming shock.  The general health is first
perceived  to fail ; it becomes more and more im-
paired ;  then  come on the  characteristic symp-
toms of the affection ;  and, if the habitual stimuli
be continued,  those symptoms progressively in-
crease.  From the first the patient passes into the
second stage, from that into the third  stage of the
disease, and he dies.   Upon  the whole, it would
appear that the predisposing cause of the delirium
which  in intemperate persons supervenes to a
wound, a fracture, a fever, &c. is habitual indul-
gence in strong liquors, or certain other diffusible
stimuli, while  the sudden  abstraction of such sti-
muli is its immediate cause.   But  in  delirium
tremens, unconnected with specific disease or ac-
cidental injury,  the predisposing cause  is to be
sought in peculiarity of temperament, combined
with other circumstances,  such as mental anxiety,
great and continued fatigue, &c. while habitual
intemperance must  be  regarded as the immediate
or exciting cause.
  We have stated that delirium tremens is caused
by the intemperate  use of strong liquors, or of
certain other diffusible stimuli.  Of these latter,
opium, either alone  or in its various combinations,
is the chief.  The long-continued and free use of
opium may certainly induce true delirium tremens.
We  have known it to be so produced, and this
fact  is sufficient  to  overthrow the theory of M.
Levielle,  before  referred  to,  which would make
the absorption of alcoholic molecules the exciting
cause of the disease.  It  has also  been asserted
that  the  poison  of  lead,  that malaria, that long
fasting, will produce it;  but we  think, with Dr.
Blake, that where  delirium tremens follows ema-
nations from lead, malaria, hunger, &c. it is only
in subjects  in whose constitutions the ebriositatic
diathesis has  been established  by frequent ex-
cesses.  When delirium from such causes occurs
in persons of temperate habits, it will not present
the other pathognomonic symptoms of the disease
of which we are speaking.
  We now arrive at an important question, one
which we would gladly dispose of in a satisfactory
manner, but which, we fear, must be  left in ob-
scurity—What is the  pathology  of delirium tre-
mens ?  Dr. Armstrong,   in  his  lectures, fairly
confessed he could  not satisfactorily answer the
question.   The affection, he said, appears to de-
fend principally upon some condition  of the ner-
vous system with the nature of which we are un
acquainted; and so he  left the subject.  By Dr
Gregory it is  dismissed  in terms sufficiently ex-
pressive of his doubts respecting it.  " It appears,"
he says, " to have for its proximate cause a pecu-
liarly excited  state of the  nervous system ; but
the occurrence of such symptoms in cases of ex-
treme inanition would lead to the belief that ex-
haustion of nervous power expresses, perhaps,
more accurately its  intimate  nature."  It  were
easy, in this  place,  to descant learnedly upon
cerebral irritation and disorganization; we might
throw additional darkness  over  what  is already
obscure; we  might pretend to  explain what is
unknown, by something completely unintelligible,
In  the  absence, however,  of just  information,
either  by means of examination after death, or
from  any other source, we prefer acknowledging
that we are very ignorant as to the pathology of
delirium tremens :  we  do not know  in what its
intimate nature consists ; but we do know enough
to direct us as to practice ; to enable us to  state
that in delirium  tremens,  uncomplicated  with
other serious  disease, such as  inflammation of
some important part,  unless circumstances are
peculiarly unfavourable, unless the patient's con-
stitution is extremely shattered, or he is very ill-
managed, he   will  recover  from the immediate
attack.   In simple delirium tremens,  occurring in
a subject neither far advanced in years, nor com-
pletely  broken down by  excess,  our prognosis
would be favourable.
   We  may now proceed to the  treatment  of the
disease. And here we would once more strongly
insist upon the importance of minute attention to
its several stages;  since, as each stage presents
some difference with respect to  symptoms,  each
will require modification as to the plan of treating
it.  It may be assumed tbat the  disease is one of
debility. Bloodletting, as a general remedy, is no
longer thought of.  In its first stage, of which the
symptoms are entirely those of diminished energy,
no practitioner would dream of bleeding, either
general or topical.  In  this  stage, (we speak, be
it remembered, of delirium tremens uncomplicated
with other accidental affection,) there  is absolutely
nothing but what would contra-indicate abstrac-
tion of  blood.  The employment of laxative me
dicines  will however be needed.  The bowels may
not be,  and indeed  they  usually  are not,  con-
stipated, yet the stomacb  and collatitious viscera
may fail in the due performance of their respective
offices ;  the alvine  evacuations, though not  defi-
cient, may be unhealthy.  In so disordered a state
of the  nervous system, as Dr. Gregory observes,
the secretions  will  probably be vitiated.   Miiu
purgatives will commonly suffice; but if, as some-
times happens, the bowels are actually constipated,
recourse must be  had  to  more  active remedies,
and amongst  these croton  oil perhaps is entitled
to  especial  regard, since, beyond its purgative
quality, it appears to exercise a peculiar influence
upon the nervous system.
  While in this stage of the disease we deprecate
bloodletting, and would, under ordinary circum-
stances,  employ only mild laxatives, we  would
not, on   the other  hand, advocate a  highly sti-
mulant  plan of treatment.  Under such treatment
patients may now and  then recover; but, genr- 
DELIRIUM
TREMENS.
591
rally speaking, the liberal exhibition of accustomed
stimuli will  be  likely to  render the supervention
of the second stage more certain, to induce more
violent re-action, and to place the patient in ex-
treme jeopardy.   The accustomed stimuli should
be witbdrawn without hesitation.  Neither wine,
nor spirits,  nor  strong  malt  liquors,  should  be
allowed at all;  or  at all events  they  should  be
administered only  in very  moderate  quantities.
Opium should  be regarded as our chief remedy;
but at this  period  it  is  not  to be given in full
doses, but in small ones, repeated at short inter-
vals.  If nausea ia present, with disposition  to
vomiting, or actually vomiting,  about ten drops
of laudanum, or of Battley's solution, may  be
given every other hour in an effervescing draught;
and anodyne enemata, should the stomach be very
irritable,  may be employed.  If the stomach is re-
tentive, and there be  no nausea, the above-men-
tioned quantity  of  the opiate, with  a few drops
of Hoffmann's ether, or (should ether disagree, as
it sometimes will,  producing  a  distressing sense
of coldness  in  the  stomach,)  a few drops of the
aromatic spirit ammonia, in  camphor  mixture or
some other  grateful vehicle, will  be found  more
advantageous than  any  of the stimuli to which
the  patient has been accustomed.   The warm
bath or  tepid affusion should not be  neglected.
Even cold affusion has been recommended  upon
highly respectable authority ; but, when we reflect
upon the train of symptoms which manifest them-
selves in the first stage of the disease, we should
scarcely, even  in a young and  healthy  subject,
venture  upon the adoption of so bold a practice.
Anodyne frictions  may be employed to the epi-
gastrium ; the head may be shaved, and the scalp
stimulated by  strong volatile  liniment; and a
blister be applied to the nape of the neck.  Eme-
tics  have been recommended  by American  phy-
sicians;  but, as  they do  not  appear  to recognize
the several  stages  of tbe affection, they leave us
in ignorance as to  the exact period when emetics
should be given: they  can scarcely be  deemed
applicable during its first stage ; and in the second
they would  seem to be a doubtful remedy.
   [By Dr.  Joseph  Klapp,  of Philadelphia, the
treatment of delirium tremens was made to con-
sist  almost  exclusively  in  the  employment  of
emetics.   On  them at least tbe main dependence
was placed.  When the patient  is first seen by
the physician, it may be advisable, in many cases,
to evacuate  tbe contents of the stomach ; and at a
subsequent  period,  the  equalizing and revellent
action of an emetic  may be employed with advan-
tage ; but it is vezy questionable, whether much
good can arise from the repeated administration
of agents whose  action may exhaust;  and under
such feelings, with  the  absence  of any markedly
beneficial results from their use in many cases,
they are  by no  means  generally prescribed  by
practitioners.]
   By the judicious  employment of the means just
pointed out; by the  adoption of what  may  be
termed a stimulo-narcotic plan of treatment, mo-
dified according to  the intensity  of the symptoms,
and the age, constitution, &c. of  the patient;  the
second stage may be averted ; the depressed ner-
vous power  being gently raised,  the  necessity for
a great remedial effort of nature, for violent re-ac-
tion, may be superseded ;  sleep  may be induced,
and the patient awake free from  complaint.
  While  upon the subject  of treatment  in this
stage of the disease, we have not touched upon
diet, and  for this plain reason,  that the state  of
the stomach is  usually such  as  not to admit  of
anything beyond  what is essential  in  the way  of
medicine.   Should, however, this stage be pro-
tracted, and the patient seem to require, or express
a wish for food, any mild nourishment,  such  as
arrow-root, sago, or broth, may be allowed him.
  Should  the second stage come on,  depletion is,
for the most  part, still to be  avoided ; it is a  re-
medy not  to be  employed but  with  the  utmost
caution.   In young and  vigorous  subjects, and
where  there  exists evidence of local determina-
tion, a single moderate bleeding from the  arm, or
the application  of leeches to the temples or behind
the ears,  may  prove  useful;  but the bleeding
should never be large, and very seldom will it be
proper to  repeat it; while, generally speaking, it
should be rejected  as a practice which has too
often  done  mischief,  and has not unfrequently
destroyed  the patient.  Opium is, at  this period,
our sheet-anchor, opium in full doses; all other
remedies are of inferior importance.   The object
is to get down, and that speedily, what experience
has proved to be  generally effectual.   We would
recommend laudanum,  say  sixty  minims, every
hour or two; such a quantity of liquid may almost
always be given without  difficulty, while  opium
in substance may be refused, or  its  tincture in
combination with other medicines may be obsti-
nately  rejected.
  The medical attendant should watch by his pa-
tient during the exhibition of opium, and steadily
persevere  for several hours,—not so much regard-
ing quantity, as the effect produced. While, how-
ever, we thus strongly insist upon the bold and
free employment  of opium in the second stage of
delirium tremens, we  would not be understood as
advocating its excessive or indiscriminate exhibi-
tion.   Should the remedy, after some hours, fail
to produce  the  desired effect, we must  proceed
with caution, lest by pushing it too far we add to
the intellectual disturbance,  and to the danger of
our patient.  The probability, however, is, that in
a few hours there will be a remission of symptoms;
that tranquillity  will succeed gradually to high
excitement, and  there will  be  a disposition  to
sleep.  This disposition will sometimes be attend-
ed with slight rigors, which  may alarm those who
are unaware of  their  nature and consequences.
We should then  be more sparing in our adminis-
tration of  opiates, and allow some time to intervene
between the doses. The inclination to sleep should
be promoted by every  means in our power; every-
thing  calculated  to excite,  as light,  noise, &c,
should of course be  studiously  guarded against.
The first  slumber may perhaps be interrupted by
startings,  and the patient may soon awake aiarme-'
and distressed ; but a moderate dose oi  opium,
with some warm stimulating drink,  and  a kind
encouraging manner on the part of the attendants,
will generally be followed by a sleep more pro-
found  and of long duration,  from which the pa-
tient will  awake perfectly  collected.
   Anxious not to divert the attention of the prac
titioner, at this so important a period of the dis- 
592
DELIRIUM TREMENS.
ease, from the one great and principal remedy,
we have hitherto said  nothing of other curative
means;  of calomel with the  compound  ipcc.
powder,  in the  proportions of two grains of the
former to six of the latter, every two hours,  till
the system is affected or the disease yields ; of the
warm bath; of cold applications to the head; of
purgatives ; among  which we may once more no-
tice croton oil,  either  given internally, or used in
the way of friction  to  the abdomen.   These are
not to  be  overlooked ;  they are valuable auxilia-
ries ;  and should opium, after a fair trial, fail us,
as it occasionally will, camphor, musk, ether, am-
monia,  with hyoscyamus, are  succedanea not to
be neglected.   The cautious administration, too,
of alcoholic liquors, may, in such cases, be of
service.
   During  this stage we must pay particular at-
tention to the moral management  of the patient.
We  must strive to obtain his confidence, to gain
an  ascendency over  his  mind without having
recourse  to coercive  measures.  As patients in
delirium  tremens  are  not usually  disposed to
be mischievous or  malignant, physical restraint
should  be generally avoided : if a man is very
uneasy and unquiet in bed, he may be permitted
to get  up ; and if he  is very importunate  to go
over his house,  or is possessed with the idea that
he must absolutely examine  letters or  papers, it
will  be tbe patt of prudence to yield to his wishes,
at least to a  certain extent,  for by  so doing we
shall be most likely to gain an empire over  his
mind;  and the satisfaction of his  desires, when
they are not clearly improper, will probably  ob-
viate a long and painful scene of impatience and
contention, and  will  favour  the return  of tran-
quillity, and the accession of that sleep so much
to be wished for. On no account, however, should
the patient be left for a moment without an expe-
rienced attendant;  and it should be remembered,
that although the delirium in this  disease is not
generally characterised by intemperate  violence,
instances sometimes occur where  it very closely
resembles  true  mania.*   Where  the  unhappy
patient  manifests  a  strong  disposition  to offer
violence to himself, or to those about him, every
offensive weapon should  be  removed,  and two
male attendants be employed to keep the patient
within  bounds.   We say two attendants, because
thus  the strait-waistcoat  may be avoided, which,
as Dr. Armstrong has observed, should  never be
resorted to but at the last extremity.
   In one word, the treatment of patients in deli-
rium tremens should  be according to Pinel's
directions in other cases of mental  alienation.
   To cut short the disease at this period is beyond
our  power ; our efforts must be steadily directed
towards  the  mitigation  of  urgent  symptoms.
Nature is now actively engaged in the work of
restoration, and it is the part of the sound physi-
cian to be her discreet minister.   He may direct
her efforts, but he must not pretend to " give them
pause."   If  left to herself,  her operations  will
probably be fearfully energetic: we should endea-
vour to regulate the efforts she is making towards
a good end.

  * A medical  friend of the writer very nearly lost his
 ife by the violence of a patient labouring under deli-
tium ireuien*
  It may, however, happen that all our exertions
during the second stage of the disease will prove
unavailing ; that the third stage, tbat of tranquil-
lity and sleep, will not be induced  by any of out
remedies ; and that all  the untoward  symptoms
formerly enumerated  will supervene.  How are
we  then to act ?   We must persist in the same
general mode  of  treatment.   We  may  shave
the head, and apply  blisters or antimonial  oint-
ment; we  may apply blisters,  or  mustard  cata-
plasms  to the  extremities;  we may employ mer-
curial frictions;  we may give powerful stimulants.
It is incumbent upon us not to omit these reme-
dies, though there exists little chance of  their
proving efficacious.  The last symptoms are those
of effjision into the ventricles, or  on  the  surface
of the brain ;  and such effusion to  any considera-
ble extent is almost always the forerunner of death.
   When the  event is  more fortunate, when the
immediate danger is  averted, we should support
the strength by moderate and frequent supplies of
mild nourishment, and the judicious exhibition of
diffusible stimuli, gradually diminishing the latter,
and after a short time subtracting them wholly.
   Having thus far conducted the patient,—having
placed him in present safety,—the  merely profes-
sional duty of the physician may be considered as
terminated.  Something, however, yet remains for
him to do if he would  be deemed  the neighbour
of the individual whom he  has just succeeded in
rescuing  from  extreme  peril.  The  physician
should not lose sight of the convalescent until he
has seriously advised him  as to future conduct.
He  should  avail  himself of the mollia tempore
fandi;—gratitude, confidence in the talent of his
medical attendant, a vivid sense of the danger he
has escaped,  a present  conviction  that  he  has
nearly perished through his own folly, will proba-
bly  incline  the patient  to  listen  attentively to
counsel earnestly and forcibly urged, yet without
the semblance of harshness or the tone of reproach.
What the  nature of this counsel  should  be, the
medical man need not be informed ;  the prophy-
laxis in the disease before  us is sufficiently obvious.
The  complete abandonment of previous habits
must be  inculcated; but  to  produce a  lasting
impression, the adviser must speak  from the heart.
He must, to adopt the language of one who was
truly an ornament to his  profession, " evince  a
genuine love of virtue, accompanied by a sincere
interest in the welfare of the person to whom his
counsels are addressed."   Such honest counsels
may  be productive of an  indelible impression;
they may conduct to the happiest results, to moral
as well as physical restoration;  or  should  they be
offered  in vain, the physician  will  retire with at
least the pleasing reflection that  he has to the
best of his ability fulfilled his duty.

                            H. W. Carter.

   [The plan of treating delirium tremens pursued
by the writer, as stated  elsewhere (Practice of
Medicine, 2d edit. i. 277, Philad.  1844), has
been entirely eclectic, and, in many cases, expec-
tant, and the results  have been such as to satisfy
him.  Under the view which he entertains of the
nature of the affection,—that  the  irregularity of
nervous action  is induced  by  the  withdrawal of
an accustomed stimulus, and that the recuperative 
DELIRIUM  TREMENS.
593
powers are, generally, entirely sufficient to bring
about the necessary equalization,—he has treated
the mass of the  cases which have fallen  under
his care, without either excitants  proper, or opiates.
In the first instance, an emetic  has been given at
times, for the reasons above stated ;  and, after-
wards, the  patient  has been kept in a state  of
tranquillity in his chamber—the intrusion of too
much light  and noise  being  prevented — and,
where the  stomach would retain it, gently nutri-
tious and easily digestible diet has been prescribed;
tije bowels have been kept open  by gentle cathar-
tics ;  and this has comprised the essential part of
the treatment.   In time,  the hallucinations have
disappeared, sleep has returned, and entire resto-
ration supervened.
   Under the idea, so generally prevalent, tbat the
patient will sink unless stimulants or opium are
 given, if the attack be severe, the physician is apt
 to become  alarmed, and  to  fly to those agents;
but, should he persevere, he will find that his fears
 are groundless, and  he will  be  encouraged in his
 course,  when he reflects that,  by administering
 either brandy or opium, he  cannot  infuse fresh
 vitality  into  his  patient, and can  only act on the
 excitability tbat  is  already present in the  tissues.
 In the female lunatic asylum of the Philadelphia
 Hospital, the course here recommended  has been
 advised, during  the  author's term of attendance
 as one of the physicians to the establishment, and
 where it has been  carried out, the general result
 has been satisfactory, in more  respects  than one.
 It has, in the first place, restored the individual to
 health—not, perhaps, as rapidly as either brandy
 or opium,  but  more permanently.  The term
 "restoration to health"  is hardly,  indeed, applica-
 ble to the change effected by the former remedy :
 the  patient is merely placed in the  condition  in
 which he was before the stimulus was withdrawn;
 and, as he was restored  by the  brandy, he  is apt
 —as before remarked—to regard it as indispensa-
 ble to his healthy condition.   In the  " total absti-
 nence"  plan, however,  the  habit of  drinking  is
 broken  in  upon,  and even if it should  require a
 short time  longer to restore  the individual, there
 is the consolatory reflection,  that delay is not use-
 less ;  as every  day's  privation  of the  wonted
 stimulus diminishes  the  feeling of necessity, and
 the desire for it.  One evidence of the good effect
 of the  course is,  that  they who are  dismissed
 cured, rarely, or  never, return to the wards.  This
 is an observation that has been made at the Phila-
 delphia Hospital, and as  it concerns paupers, it is
 probable, that the cures  are real and permanent,
 for were it otherwise, they  would, on subsequent
 attacks, be compelled, in  their destitution, to seek
 the  wards  of the same excellent charity.
   Under this eclectic course, it may be  advisable,
 however, in certain cases, to  administer both exci-
 tants and   opiates.   Where a  person  has been
 accustomed  for  years to the  daily  use of large
 quantities of alcohol, the  nutritive functions totter
 under the irregular innervation, and the recupera
 tive p-wers seem to be insufficient to restore the
 balance  of  nervous  action.   These  cases  are,
 however, uncommon.   In   like  manner,  where
 sleep has  not recurred,  after  a  continuance for
 some days of the plan above devised, a full dose
 of opium,—two  or three grains, in the form  of a
   Vol. I. — 75                       2 * *
soft pill,—frequently forms an excellent adjuvant.
There are cases, too, in which the irritability of
the stomach is so great, that no food or medicine
can be retained, and the patient becomes exhausted
by the irritation.   A blister, applied over the pit
of the stomach, and the blistered surface sprinkled
with sulphate  or acetate of morphia,  (two to four
grains at  a time,) may allay  the  vomiting,  after
which such internal management may be adopted
as the case may seem to demand.
   Dr. M.  Hall remarks, that " it becomes a serious
question, whether any  stimuli should  be allowed"
in delirium tremens.   Our observation and reflec-
tion are, in the main,  in favour of the negative;
and the remark is  applicable to the various  exci-
tant antispasmodics that are wholly trusted to by
some, because the  disease  is characterized by
tremors.  All  these  "antispasmodics"—assafce-
tida, castor, &c.—are, like capsicum,  mere stimu-
lants.   They  are  not  possessed  of  any specific
power over the disease, and are  never employed
by the writer, unless  he is desirous of exciting a
new nervous impression on the gustatory nerves,
and on the nerves distributed to the  lining mem-
brane of  the stomach.  The same may be said of
the  cold  shower-bath, or douche.   The  shock, or
new impression, made by it, is at times salutary,
but some  discrimination is needed in regard  to its
application to those  whose powers  are greatly
prostrated.
   Admitting, then, that there may be cases which
demand  something more  than the expectant or
eclectic treatment, these cases are certainly small
in  number ; and a careful classification, by  sepa-
rating those who are considered to require impe-
riously the use of stimulants  from those who do
not, cannot fail to lead to results in the highest
degree  satisfactory to  the philanthropist: first of
all, by preventing the indiscriminate  treatment by
alcohol adopted by  many ;  and secondly,—as a
consequence of this,—by leading to a more exten-
sive reformation in the patients themselves.    One
of the writer's  colleagues  in the  Philadelphia
Hospital, Dr.  Gerhard, is an  energetic supporter
of the method of  treating  the generality of  cases
by the free exhibition of alcoholic liquors, and, in
support of it, cites the results  observed in the
men's wards  under his care, from October  12th,
 1839, to  October 12th, 1840.   Of 162 cases of
decided delirium tremens, 87 were admitted in the
first  stage ; 73 in the  second ; and two in the
third :  160 cases  recovered,  and  one  remained
convalescent,  who is  since  well.   " One,  only,
proved fatal;  the patient was  admitted in tbe
third stage of the disease, and  died in a few hours
after his   entrance:  he  had  been  treated  with
opium; and a box of pills, which he was taking,
was  sent to the  hospital with him.  Of course,"
adds Dr. Gerhard, " this apparent exception con-
firms the general conclusion, that the disease ter-
 minates favourably in every instance when treated
according to  the method recommended."   Any
inference, however, from a single years  observa-
 tion, may be  fallacious ; and  especially may it be
 questioned, when the results of a similar treatment
 adopted by the same  observer and by others had
been previously less markedly  favourable.  It is a
 well-known fact, that  in certain seasons and years
diseases  are more severe than in others ; and the 
594
DELIRIUM  TREMENS —DENGUE
circumstance, that of the 162  cases of delirium
tremens, referred to by Dr. Gerhard as having been
admitted in the year ending October, 1840, only
two are classed in the third  stage, sufficiently ex-
hibits, that the disease must  have been unusually
mild.   The writer has now before him a statisti-
cal account  of the Women's Lunatic Asylum, at
tbe Philadelphia Hospital, for the years 1840 and
1841, which is  under the author's charge during
the  six  months, commencing  on the  first  of
November, and ending on the  first of  May ;  and
was, at  that time, under his colleague, Dr. Pen-
nock, for the other  part of the year.   It may be
proper to add,  that from November  1st,  1841,
to May 1st, 1842, not a  drop  of  alcoholic  liquor
was used in the treatment of delirium tremens in
the Women's Asylum, although some severe cases
in the third stage occurred, which, notwithstand-
ing, terminated most satisfactorily.
  Patients treated during the years 1840-41.
                Cases admitted.       Cured.       Died.
Intoxication........44.......44.......0
Delirium tremens—
           1st stage, 55.......55.......0
           2d stage, 19.......19.......0
           3d stage, 10.......  9.......1
  The  fatal case was not  seen  by the  author.
The  patient died the morning after her admission,
and had been treated in the  city for nearly a week
previously.  It cannot consequently be considered,
that  the value of the treatment has been settled
" upon  a more definite basis  than has yet been
done."   The investigations  ought to be  con-
tinued through a succession of years;  the differ-
ent methods of treatment be compared extensively,
and  under circumstances as nearly identical as
possible, before any such conclusion can be con-
sidered  established.   Moreover,  the  results ob-
tained by Dr. Gerhard,—successful as  they were,
—are not more so than those recorded by an ob-
server already cited, who places great reliance on
the treatment by emetics.   In a  report, made by
Dr. Klapp, he states, that of 51 cases, all but one
were  cured without the use of a grain of opium,
or a drop of alcoholic drink of any description;—
the unsuccessful case died of epilepsy.
                      Robley Dunglison.]
  [DENGUE.   This singular  name  for  a  dis-
ease,— according to Dr. Dickson, of Charleston,
whose essay (on Dengue, Bell's  Med. Library,
for  1839)  has  furnished the  main  material for
every thing since written  on  the subject,—was de-
rived from  the English negroes of the Island of
St.  Thomas, where the disease  prevailed, who
called it the " Dandy Fever," owing to the stiff,
affected gait induced in those labouring under it.
When  the  disease  occurred in  Cuba, the word
" Dandy" was  corrupted in Spanish pronuncia-
tion  into  " Dunga," or  " Dengue," by which  it
was known in the southern  states. It first made
its appearance in the Caribbean Islands in 1827,
whence it  spread over the  West Indies,  and in
the following year  to the  southern coast of the
United  States.   It  prevailed in  New  Orleans in
May and June ; and in July and August affected
very severely the inhabitants of Charleston ; reach-
ing  Savannah .in September and October.  At
the close of the year, it became gradually extinct
and has never since recurred.  " In its brief dura-
tion," as remarked by Dr. Dickson, (op. cit. p. 6,)
« in the suddenness of its appearance, in the rapi-
dity of its spread, and in its total  subsequent  ex-
tinction,  offering a  striking resemblance  to  the
Black  Death of the fourteenth  century, and  the
Sweating Sickness of the  sixteenth, and several
other shapes of pestilence, which have at different
points  of time  arisen  and  died  away,  scattering
among the nations horror and affrigbt."  » Hap-
pily, however," he adds, " as the record will show,
it was much unlike these plagues  in proportional
mortality ;  bringing in its  train  infinitely less of
danger and of death than of mere suffering."
  Diagnosis.—The disease was generally ush-
ered in  by febrile symptoms of  an inflammatory
character, accompanied by a painful  affection of
the joints and  muscles.   On the  second or third
day, the  fever declined, and with  it the articulai
pain,—the attack terminating in a copious perspi-
ration, occasionally attended with a rash or miliary
eruption, which was esteemed,  however, as only
an incidental symptom.   On the third or fourth
day, the  fever having  in the meantime intermit-
ted, more or less gastric disorder appeared, and on
the fifth or sixth, a cutaneous eruption, which re-
sembled  scarlatina  more than measles, but was
less confluent than  either of those affections,  and
consisted of  minute  florid  red  papulae, slightly
elevated, and  distributed  in  irregularly  shaped
patches, appearing first upon the face and  trunk,
and spreading to the extremities.   On the full de-
velopment of the eruption, a second  febrile exa-
cerbation, with severe arthritic and muscular pains
occurred.  After two or three days' duration, the
eruption  gradually  disappeared,  with  some  de-
squamation of  the  cuticle.   In  some cases,  the
lymphatic ganglions of the neck, groins, and axilla
remained swelled for a long period.
  Of all the symptoms the affection of the joints
was most tenacious and troublesome, adhering for
weeks to some, and constituting  a sort of perma-
nent lameness.  A  sore mouth  was  a frequent
symptom, and in one or  two instances there was
pretty severe glossitis.
  In regard  to the  pathology  of Dengue, there
has been difference  of sentiment.  Dr. Dickson,
(op. cit. p. 8,) classes it among the exanthemata;
whilst the union of an eruptive  fever with an in-
flammatory affection of the joints gave occasion
to its names, scarlatina rheumatica,  exanthesis
arthrosia, and  eruptive  articular or  rheumatic
fever.
  Causes.—Opinions have varied on this matter.
Dr. Dickson is disposed to regard it as contagious.
Drs. Osgood  and Lehman, who saw it in Cuba,
seem disposed to regard  it as the ordinary fevei
of that  region, under certain peculiarities of cir-
cumstances not well explained ;  and  Dr. Waring,
of Savannah, dwells upon  its close analogy with
the break-bone fever of  1826, and the epidemic
bilious remittent fever of 1827 in that city.  Still
closer, according to Dr. Dickson, (op. cit. p. 11,)
are the  points of similarity which may be found
in the history of the break-bone fever or remittent
described by Dr. Rush as prevailing in Philadel-
phia, in the summer and  autumn of 1780,  and
the epidemic of Calcutta and Berhampore, pour-
trayed  by Dr. Mellis in 1824-5.
  The prognosis was exceedingly favourable.  Per-
haps no form of disease is known, in which  the 
DENTITION.
595
proportion of deaths was so small  compared with
the numbers  attacked.  The aged were  most se-
verely handled,—remaining frequently infirm and
debilitated, with languor and emaciation.  In the
intemperate it served to usher in  formidable pa-
roxysms of delirium tremens.  When it did prove
fatal, it appeared to be owing to complications.
   Treatment.—The lancet was generally found
necessary  during the inflammatory  period, with
cathartics  and antiphlogistics.   Anodynes  were
likewise needed to relieve the violence of the pain.
                      Robley Dunglison.]

   DENTITION,  Disorders or.   Under this
head  we  shall endeavour  to  collect, not all the
affections  which  hereditary errors  and  popular
prejudice  have marshalled  under it, but such  as
careful  and  unbiassed observation  has  demon-
strated to  be  occasionally induced by the process
of cutting the teeth.  By adhering to this resolu-
tion,  a subject, once  of interminable length and
exaggerated importance, may be brought within
comparatively narrow bounds, and  if it be cur-
tailed somewhat of its mysterious interest, it will
not, we trust, lose in respect of practical  utility.
   The operations of nature are usually conducted
in so skilful and complete a manner  as should in-
spire all reasonable minds with large confidence
in her powers, and lead them strongly  to  doubt
all those hypotheses which  would make disease a
necessary adjunct  to the evolution of our corpo-
real frame.   That artificial modes of life, on  the
other hand,  together  with injudicious  manage-
ment, an excess of nutriment, with deficient exer-
cise, impure  air, and the other causes which tend
to derange  the  general health, must greatly  in-
crease the difficulty and danger of the process  of
dentition, is  indubitable; but that the  mortality
fairly traceable  to  it should,  under any  circum-
stances, have been rated so  high as one-tenth and
even one-sixth of all the children who undergo it,
cannot fail to excite our surprise.
   Children, as well as adults, are liable to nume-
rous diseases of  the three great  cavities; but the
difficulty of accurately recognizing them in early
infancy too frequently causes  their true nature to
be overlooked, and  disorders which are really idio-
pathic to  be considered merely sympathetic affec-
tions depending on the process of teething.
   Dentition, though often difficult and painful, is
not in itself, properly speaking, a disease ; yet the
excitement which it produces  is favourable to the
development of such complaints as there exists a
tendency tc- at this time of  life.   It is indeed  the
most critical  period of childhood, and the super-
vention of any serious disease, as small-pox, mea-
sles, &c, during its progress, is, from the increas-
ed sensibility of the whole  system, attended with
more than ordinary danger.
   The  first Dentition. — The rapidity with
which the first set of teeth  is developed  necessa-
rily causes a considerable determination  of blood
to the head,  a circumstance which  assists  us  in
explaining many of the morbid tendencies which
at this time occur.  The  rapid evolution which
the brain, also, is at this period undergoing, con-
curs in  a  still more powerful  degree to  heighten
the nervous  susceptibility.   This stage  of exist-
ence is,  indeed, remarkably characterized  by a ten-
dency to cerebral affections ;  and diseases of the
chest, abdomen, and  other parts, often become
complicated with them, or towards their termina-
tion merge into them.  The irritable constitution
and extensive sympathies which distinguish in-
fancy, help us to account for the  severity of the
symptoms which sometimes occur  from teething.
As the child grows older, though the local affec-
tion may be equally violent, the intensity of the
constitutional effects is generally much  diminish-
ed, and accordingly we  find  that the cutting of
the large double teeth occasionally gives rise to
much less  disturbance than that  of the smaller
teeth which preceded  them.
   Any  unusual obstacle to the coming forward
of the teeth, such as may be caused  by a dispro-
portion between their rate  of development  and
that of  the jaw; or even their too rapid progress
and the consequent appearance of several of them
simultaneously, must greatly augment the dis-
turbance produced by tbis process.
   The rudiments of the teeth are visible in the
foetus about the second or third month.   As they
increase in size, they are found to  consist of a
double membranous sac, from the bottom of which
rises a pulp composed of a vascular  and nervous
substance,  and  surrounded  by a colourless fluid
of  a  mucilaginous consistence.  This fluid  is
gradually absorbed as the pulp  enlarges, and  os-
sific matter becomes visible on the summit of the
latter about the  end  of the third  month.  The
enamel is  subsequently formed, but whether by
deposition  from tbe fluid, or by secretion from the
inner and vascular membrane of the sac, is a dis-
puted  point.  The jaw  at  first presents only a
channel along its edge; but by the growth of
transverse bony septa, this is subdivided into cells.
and the alveoli are thus  formed.  The  germs of
most of  the permanent teeth are visible even in
the foetus, and are situated behind and below the
milk teeth.
   At the period of birth the ossification  of the
teeth is already far advanced, the crowns  of the
incisors being usually completed, and a consider-
able part of those of the  double  teeth formed.
The ossification of their roots  is  a subsequent
process, and in proportion as  it  advances, and as
the alveoli  become developed, the  crown  of the
teeth is propelled towards the surface of the gum,
and by  the gradual absorption of this, and  of the
apex of its own enveloping sac, at length makes
its appearance externally.   The pressure on the
membrane and gums, and  the consequent irrita
tion which accompanies  this stage of the process,
give rise to the painful symptoms of dentition.
   The  milk teeth are  twenty in  number: they
usually appear in pairs, and those  of  the lower
jaw generally precede the corresponding ones of
the upper.  Tbey succeed  each other  commonly
in the following order :  first, the middle incisors ;
next, the lateral incisors; then either the canine
teeth or the anterior molars,—perhaps  more fre-
quently the latter,—(but not  invariably so, as M,
Serres would have us believe;) and lastly the pos-
terior molars.
   The first incisor is  generally cut about the sixth
or seventh month, although occasionally not  for
many months later; the canine teeth  commonly
appear about the fifteenth month: and  the postG 
596
DENTITION,
 ior molars at various periods from  the twentieth
to the thirtieth.  Thus, the whole period occupied
by the first dentition may be estimated at  from a
year and a half  to two years.
   Such is the usual process of dentition ; but it
varies  considerably in  different individuals, both
as to its whole duration,  and  as to the  periods
and  order  in which the  teeth make  their  ap-
pearance.  In scrofulous  children,  according  to
Gardien, the first  incisors are occasionally  cut
so early as the third or  fourth  month ; but such
teeth are apt to  decay and  soon  drop out.   Un-
derwood, on the other hand, has known weakly
and rachitic children to be still without  a  tooth
at twenty-two months old ; and in  such subjects
analogy  would  certainly lead  us to  expect  the
ossification of the teeth to  be tardy and imperfect.
The premature and rapid development of the teeth
has occasionally appeared to Guersent  to be,  not
the effect, but the  exciting cause of rachitis and
tubercles:  and, in general, it may be  stated that
the greater the number of teeth  coming forward
simultaneously,  the  greater the  danger:  those
who have them late usually suffer least.
   Numerous instances are on  record of children
who were born with some of their teeth  already
cut; of which Richard III., Louis XIV., and Mi-
rabeau, were notable examples.  In the case of
Louis it was brought forward,  but fallaciously, as
an argument to  establish his legitimacy, on which
the lateness of his posthumous  birth had  thrown
suspicion.   Such  premature dentition  is  neither
a proof of protracted  pregnancy, nor yet of a
strong constitution in the  infant, as it has been
observed that such children are often unusually
small,  and most frequently die early.   Indubita-
ble instances are mentioned by autbors, of indi-
viduals who  never had any teeth:  Borelli knew
a woman of sixty years of age in  this predica-
ment : certain diseases  of the  jaw  affecting  the
germs  of the teeth may be occasionally the cause
of this singular phenomenon.   Soemmering and
Fox each saw a case where several of the  teeth
were consolidated  into one mass ;  and we have
met with a similar instance in the Museum at
Leipzig, of two incisors  grown together by their
crowns, whilst the roots are separate.*   Such  ab-
normal appearances depend, no doubt,  on  the de-
ficient evolution of the alveolar septa.
  The natural symptoms of dentition in its mild-
est form are an increased flow of saliva, with
swelling and heat  of the  gums, and occasionally
flushing  of the  cheeks.   The child  frequently
thrusts its fingers, or any thing within its grasp,
into its mouth.  Its thirst  seems  to be  increased,
for it takes the  breast more frequently, though,
from the  tender state of the gums, for  shorter pe-
riods than usual.  It is more fretful and restless,
and sudden fits  of crying and  occasional starting
from sleep,  with a  slight  tendency to vomiting
and diarrhoea, are not uncommon.  Many of these
symptoms  often precede  the  appearance of  the

  * In the same museum, which is  very rich in prepara-
>.i«ms illustrating malformation and diseases of the tf-eth,
th»;re are examples of anchylosis of the teeth with the
jaw, occurring in rachitic subjects ; and others exempli-
fying the fragility of these organs  in individuals of a
■imilar constitution, and explaining their consequent
liability to break in extraction.
tooth by several weeks, and indicate an increased
activity in the process of ossification and develop-
ment,  or what in  common  language  is called
breeding the teeth.  In such cases the symptoms
subside in  a few days, to  recur again when  the
tooth approaches the surface of  the gum.  In the
first period the pressure of corals and other hard
substances  on tbe gum seems to be  agreeable, by
numbing the sensibility and dulling the  pain.  A
better form  than that of the ordinary coral is an
ivory ring,  as it obviates the danger  of its being
thrust into  the  eyes or  nose.   Rousseau, in  hi?
Emilius, objects to the use of hard substances fa
this purpose, and refers us to the instinct of  thf
young of other animals, which leads them to  ex
ercise their budding teeth,  not on bone or stones
but on softer substances, on which they can mak»
some impression.  In accordance with this view a
stick of marsh-mallows or of liquorice root, a piec«
of wax-candle or a crust of bread, have  been  re-
commended  instead of the coral; and in France
they often dip them  into honey or a sweet decoc-
tion of barley, in order to render them more agree-
able to the  child, and more relaxant to the gums.
In some parts of Germany we frequently see  in-
fants sucking a small bag containing a mixture
of sugar and spices, which is given to them when-
ever they are fretful or uneasy.  It re-acts suffi-
ciently on the gums, and certainly seems a very
successful expedient for occupying the child  and
keeping  it  quiet:  it thus  saves  the  nurse some
trouble;  but the injury which  the  constant use
of these  sweet and stimulant ingredients must do
the stomach, renders their employment  very ob-
jectionable.
   Gentle friction of the gums by the finger of the
nurse is pleasing to the infant, and seems to have
some effect  in allaying irritation and altering the
mode of the sensibility.
   Pain  appears to be the chief cause of all the
morbid  sympathies accompanying dentition, and
is  attributable partly to pressure on the membra-
nous sac and on the gum, and partly, or, as some
think,  principally, to the  pressure made by the
root of the  tooth on the dental nerves.
   In  feeble  and  delicate children dentition  is
usually, as we should naturally expect, more tedi-
ous  and difficult than in the healthy and robust;
but to this there are numerous exceptions ; and it
is  certain that when disorder does  occur in  the
latter, they  suffer  much more  severely, and  are
more apt to be cut off suddenly by superinduced
inflammatory affections, as was long ago remarked
by Hippocrates.  Puny infants, on the contrary,
are more prone to  a wasting diarrhoea and maras-
mus ; and  those reared in a crowded city gene-
rally suffer much more than those who have been
brought up in the healthy air of the country.  In
a word,  the two extremes of  debility and high
health, or rather that  appearance of it which is
induced  by over-feeding,  are  both exposed, and
nearly in an equal  degree, to danger;—the former
from a low wasting fever and  bowel complaints;
the latter from acute fever, determination of blood
to  the head, and convulsions.   Those who have
asserted that robust  children always suffer most,
have perhaps been  mislead  by external appear-
ances, forgetting that every the  slightest change 
DENTITION.
597
of condition in the fat and florid  child will be
more obvious and striking to the eye, than in one
which was already pallid and thin.
  The management of infants during teething,
when the process is going on in a  favourable
manner,  is very simple, and rarely calls  for the
interference  of the physician.   The child should
be much in the open  air, and well exercised, and
the bowels kept  free.   The employment  of the
cold-bath or cold sponging daily, followed by gen-
tle friction  over the surface of the  body, is very
useful;  and all means  should be taken to support
the tone  of the system at a just medium.   The
breast should be given to it often,.but not long at
a time,  and  thus  the attendant  thirst will be
quenched, and the gums kept  moist and relaxed,
and their irritation  soothed, without the stomach
being overloaded.  The  health and diet  of the
nurse should at this period be particularly attend-
ed to, and all stimulant food and drinks avoided.
   Dr. John Clarke, in his Commentaries on the
 Diseases of Children, ascribes  most of the disor-
ders which  accompany dentition to over-feeding
 and consequent plethora; to improper kinds of
 food, which produce irritation;  and to keeping the
 head too warm.  He  asserts that coolness  of the
 head, and washing it daily with cold water, ren-
 ders children much less  liable to illness during
 this period. Spontaneous salivation and moderately
 lax bowels are always to be considered favourable,
 as they  tend materially to diminish irritation; and
 when absent, their place should be supplied by
 gentle aperients, especially in the case of plethoric
 children, or those with cutaneous eruptions.
   [It has been a question, whether, during the
 irritation of teething, when the child is desirous
 of conveying everything to the mouth, hard sub-
 stances  should be  permitted to press  upon the
 gums.  It is a common custom to allow the child
 the  use of a piece of coral, or  of sealing-wax,  or
 what is preferable — inasmuch as it  cannot be
 forced into the mouth and injure the soft parts of
 that cavity—an ivory ring.  Some of the French
 writers  discard all such substances, but without
 much propriety.   If the gums be very tender, the
 child will  not use them ;  and,  if  pressing the
 gums upon them should afford relief, there appears
 to be no good reason why their  use should be
 forbidden, as the pressure cannot fail to aid the
 absorption  of the gum.   It has been suggested,
 as a good plan, to allow the  child the use of a
 small wax candle, a  stick of liquorice  root, or  a
 crust of  bread.   The  first of these  may be unob-
 jectionable ;  but  the liquorice  root may load the
 stomach with mucilaginous saccharine matter, if
 allowed  too freely; and  the crust of bread may
 excite alarm, by the softened portions getting into
 the glottis, and producing symptoms of strangling.
 The physician, however, is not  often consulted on
 these points; the whole  matter being generally
 regulated by the parent or nurse. (See the writer's
 Practice of Medicine, 2d edit.  i. 41.)]
   When dentition is difficult and tedious, the
treatment is  more complicated, and consists  in
allaying  local irritation, moderating urgent  symp-
tomatic affections, and when protracted and pro-
ductive  of much  exhaustion,  in supporting the
general  strength.   But,  in order to treat  of this
oart of our subject more satisfactorily, we shall
divide  the  phenomena of difficult dentition into
the idiopathic or local, and  the sympathetic or
secondary.   These latter might again be divided
either  according to their  nature, into spasmodic
and  inflammatory ; or according to  the organ or
texture which they affect; as this latter subdivi-
sion appears more conducive to accurate diagnosis,
we mean to adopt it.
   Of the local symptoms, or those occurring in or
near the mouth, painful  inflammation and swell-
ing of the  gum, which is hotter, of a deeper red
than natural, and intolerant of the slightest pres-
sure, are the most usual, and the cause of all the
rest.   There is often great determination of blood
to the head, the cheeks being red, hot, and swollen,
the eyes irritable and watery, the salivation  pro-
fuse, and the salivary glands occasionally enlarged
and painful.  Aphthae sometimes occupy the mouth
and fauces, and abscesses have, in some rare cases,
been observed  at the root of  the  tongue.   The
symptomatic fever is often great, and is remarka-
ble for its sudden rise and declension, intermitting
and recurring frequently in  the  course of a few
hours.  The thirst is extreme, and the child is at
one time restless  and irritable,  and  at  another
heavy and oppressed:  The sleep is  broken, and
the infant  frequently awakens  suddenly and in a
fright  from its short slumbers.   The urinary se-
cretion is usually much diminished, though cases
do sometimes occur, as  has been mentioned by
Whytt, when it is increased, and in  such the ac-
companying symptoms will generally be found to
be more of a nervous than an inflammatory char-
acter.
   As all these symptoms are  induced by the pain-
ful tension of the gum, the most rational mode of
attempting  their relief is by freely  lancing  the
swollen part.  Of the practical utility and perfect
safety of this operation, notwithstanding tbe pre-
judices which exist against it in some other coun-
tries, we have ample proof in  its daily performancu
with impunity, and  in the instant relief which  it
often affords to all the symptoms.  To give it  a
chance of success it must be done effectually, and
both the gum  and the capsule of  the tooth laid
fairly open.  An assistant holds the head of the
infant firm, whilst the operator, witb a gum lan-
cet or a narrow bistoury having three-fourths of
its blade guarded, separates the jaws, and keeping
the  tongue and cheek  out of  the  way with  the
fingers of his  left-hand,  cuts  down firmly in  a
longitudinal direction on the inflamed and swollen
gum ;  and  if it be a double tooth which is coming
forward, he  should  convert the incision  into  a
crucial one.  In Paris  they often dissect out the
flaps, but this seems to be an unnecessary addi-
tion to the  pain  of the operation.   The slight
bleeding which occurs is highly beneficial, acting
as a local depletion, and thus conspiring to take
off tension.  The fears of an excessive or debili-
tating loss of blood from this source,  may be con-
sidered,  as to all practical purposes, unfounded
and chimerical.   We do not usually recommend
the performance of this operation till the tooth be
already so  far advanced that we can be pretty sure
of succeeding in  laying  open  the  capsule :  foi
slight scarifications of the gum can afford no effec
tual or permanent relief.  Cases may. howevei,
occur, where even the temporary ease which su- 
598                                  DENTI
TION
perficial  scarifications are capable  of affording
should not be renounced ; but here we must take
care to explain to the child's  friends the object of
their performance, else  the  speedy return  of the
symptoms and the non-appearance of the expected
tooth may tend  to bring the  operation of lancing
the gums, or our own skill, into disrepute.  The
old apprehension that the scars which ensue, op-
pose, by  their hardness, the  subsequent progress
of the  tooth, though repeated in one of the latest
French works on the diseases of children, is quite
groundless;  for cicatrices, like all other new-form-
ed  parts, are, as Hunter long since pointed out,
much more easily absorbed than the original struc-
ture.  Slight ulcerations of the gum have in some
rare instances succeeded to the incisions; but this
is a very unusual  occurrence, and  may be gene-
rally prevented  by taking care to have our lancets
perfectly clean ; they are, besides,  of very little
consequence, as they readily heal under slightly
astringent applications.  Both Underwood and Ha-
milton enumerate ulceration of the gums amongst
the occasional effects of teething, and the  former
thinks they occur even  more frequently in cases
where  lancing has not been performed.
   When  the pain, determination of blood to the
head, and fever, persist  after the  gums have been
freely lanced, laxatives, mild diaphoretics, the warm
bath, and slightly stimulating pediluvia must be
employed, and if these be insufficient, one  or two
leeches should be applied behind the ears.   When
by the above means  the fever has been in some
degree reduced,  the bowels continuing free, if the
pain be still very severe, the  cautious use of ano-
dynes, as a drop or two of tincture of opium, or
minute doses of hyoscyamus, may be tried.  But
perhaps as a general rule, seeing that infants are
so very susceptible  of the influence of narcotics,
their external use, in the  form of anodyne fric-
tions to the  spine, is preferable.  When very rest-
less at night, the infant should be frequently taken
up and carried about in an airy room : by the cool
air and the  nearly erect  posture, the feverishness
will be alleviated, and  the  tendency of blood to
the head counteracted.
   Such  are the measures which modern expe-
rience  has found the most effectual in moderating
the  pains of dentition.  Very different  was the
practice of our forefathers, who,  misled probably
by the fanciful doctrine  of signatures, were in the
habit of  applying to the gums specific ointments
made of the brains of hares, or of the combs of
cocks,  which, as old Hartman would have us be-
lieve,  "cause  the  production  of  teeth without
difficulty and free from  accidents."  Whilst we
smile at the credulity of former generations, we
must not forget  that the anodyne necklaces and
other charms still in use  in our own day are in no
wise more trustworthy or less absurd.
   With regard to the affections  of  distant  organs
occurring during  teething,  we  must not forget
that they may originate  as primary or idiopathic
iliseases  at  this period  as well  as at any other.
Still, after making every allowance on this score,
certain disorders manifest themselves so  much
more frequently during  this process, and  often
subside so rapidly on the appearance of  a tooth,
as to leave us no doubt  with  regard to their occa-
sional  connection with the business of dentition.
  Of the disorders which  may be thus called into
action by the irritation of teething, very formidable
lists have been made out by authors.  The follow-
ing is a specimen  of these, and  of the  confused
manner in which symptoms and diseases are often
jumbled together: vomiting, anorexia, diarrhoea,
cholera, costiveness, increased or diminished urine,
urethral or vaginal discharge, with  painful mictu-
rition ; dry cough, dyspnoea, catarrh,  pneumonia,
spasmodic  affections  of the face,  limbs, glottis,
&c.;  insomnia, agitation and  fright on  awaking,
epilepsy,  somnolence,  stertor, coma,  transient
palsy of the arms and  legs ; ophthalmia, hydro-
cepbalus,  marasmus; eruptions,  especially about
the head  and  face,  swellings  of the  hands and
feet, enlargement  of the  cervical, femoral,  and
mesenteric glands, and  other scrofulous affections,
  From  this  enumeration it  appears  that the
chylopoietic and respiratory organs, the brain and
nervous system, the skin  and the lymphatics, arc
the chief scats of the sympathetic affections occa-
sionally induced by dentition.
  Of these secondary affections, those of the mu-
cous membranes are the most frequent, and they
may be either  inflammatory or not.  Inflammation
of the conjunctiva, of  the mucous membrane of
the air-passages and lungs, or of the stomach and
intestines,  will be  characterized by the usual
symptoms, and require the same kind of treatment
as  idiopathic  inflammation  of the  same parts,
though it will rarely be necessary to  push  it so
far.  Incision of the inflamed gums should always
be premised, and will sometimes,  without the em-
ployment of almost any other measures, be follow-
ed by the  speedy resolution of the disease.
  Far the  greater  number,  however,  of these
affections  are  not truly inflammatory, but depend
on  a peculiar  state of irritation kept  up in these
remote  organs by sympathy   with the  inflamed
gum.  Such,  usually, is the nature of the accom-
panying cough, vomiting,  or  diarrhoea. When
the vomiting  and  purging are not attended with
pain on pressure,  redness of the  tongue, loss of
appetite, or great oppression  and fever, we have
no  reason to believe in the existence of inflamma-
tion, either in the stomach or intestines.  Such
symptomatic vomiting may usually be restrained
by diminishing the quantity or  varying the quality
of the child's  milk or other food ; and if there be
evidence of excessive  determination  of blood to
the head,  by the application of one or two leeches
behind  the ears.  Should it prove very obstinate,
and debility, and  loathing of food  be induced by
it, narcotic frictions and fomentations of the abdo-
men, and a small blister applied  for three or four
hours  to  the  epigastrium or to the upper part of
the spine, may be  requisite.
  In  severe and protracted diarrhoea interfering
with the sleep and nutrition, and accompanied by
debility, emaciation, pallid skin,  a  dull  eye, and
sunken expression of countenance, in addition to
some of the above measures, tonic and  alterative
aperients are called for, such as rhubarb combined
with  ipecacuanha  or   hydrargyrum  cum cretd.
Absorbents  will be necessary  if  there be acidity
in the prima? viae,  which  is a  frequent  symptom
in the derangement of the digestive organs in-
duced  by  teething, and is  evidenced by griping
and by green and sour-smelling stools.   If the dis- 
DENTITION.
599
charges are of a bad quality, being fetid, blackish,
or very  pale, an occasional  dose of calomel  to
modify the intestinal secretion should be exhibited.
In very obstinate cases the cautious use of Dover's
powder, opiates  alone,  or in  combination with
minute doses of calomel, and given at short in-
tervals, or opiate enemata may be indispensable.
But in the latter mode of exhibiting  opium, espe-
cially in the case of children,  we must  never
forget that its action is sometimes,  as  has been
pointed  out by Dupuytren,  even  more energetic
than when given by  the mouth.  The diet must
be particularly attended to, the nurse changed if
her milk seem to disagree, and the strength sup-
ported by beef-tea, rice-milk,  arrow-root, &c.   In
many of these cases, quinine in  small doses will
be found a  very useful  auxiliary.   We are not
advocates for the premature use of medicine  in
this  affection ^  as on  the  one  hand  neglected
diarrhoea is a frequent cause of death in dentition,
and as on the other a lax state of the bowels has
a great  influence in  moderating  the dangers  of
this period,  it requires a very nice discrimination
on the part of tbe practitioner to know when to
interfere.  Perhaps no attempt should be made to
check the intestinal  secretion  so long as the ap-
petite, sleep, and strength continue unaffected.  It
is certain that bowel  complaints,  which would be
thought  very alarming  at  any  other  time,  are
often well  borne when they depend  merely  on
the irritation of teething. We should  therefore,
in most  cases, content ourselves with watching
their  progress as long  as they  keep within  the
limits stated above.
   Vomiting  and purging often  co-exist, and  in
their  combination frequently  constitute  a very
formidable affection.  M. Cruveilhier has described,
under the  title Maladie gastro-intestinale  des
enfans avec desorganization gelatiniforme, a very
violent and fatal disease of the stomach  and intes-
tines of this kind, which is characterized by ex-
cessive thirst, urgent vomiting, and frequent, very
fetid, green  stools, like chopped  spinach.   After
repeated  vomiting the  child  becomes  cold, and
falls occasionally into a state approaching to syn-
cope.  The pulse is slow and irregular;  the intel-
lectual faculties continue clear to the end.   The
infant is extremely irritable and cries incessantly,
except whilst being carried about in the nurse's
arms. A state of drowsiness and oppression soor,
supervenes, the face assumes a cadaverous appear-
ance, and the eyes are half closed and turned up.
The coldness of the  body, and  especially of the
extremities, goes on rapidly increasing, and  in the
course of twenty-four or forty-eight hours, a state
of extreme prostration and fatal collapse are some-
times induced.   By a superficial  observer this dis-
ease might be mistaken for  a cerebral affection,
as there is somnolence and screaming, with slow-
ness and inequality of pulse  in both ; but  in  the
peculiar disorder under consideration the somno-
lence is  interrupted  by the  slightest  touch,  the
sensibility of the skin is morbidly increased,  the
intellectual faculties are entire to  the last moment,
and the respiration is not unequal, as in disease
of the brain.  On dissection,  the mucous  mem-
brane of the stomach,  and  generally that of the
small and great intestines, is  found in a state  of
softening, being reduced to a soft  and disorganized
pulp,  but without any appearance indicative of
inflammation.  Cruveilhier's treatment consisted
in confining the diet entirely to  milk, and  giving
even that in the very smallest quantities, together
with baths and fractional doses of opium admin-
istered at short intervals, both by the mouth and
in enemata.   The chief causes  of  the disease
seem  to be  improper food,  premature weaning,
and dentition.  It may run on for many days, or
even weeks, and  when it  proves fatal, terminates
at last  either by an  acute  attack or  by gradual
sinking.  It  is evidently closely allied to cholera
morbus, and  is  in  no degree  an inflammatory
affection.
   M. Guersent, physician to the Children's Hos
pital at Paris, has given a description of the above
disease, differing in  some  respects from  that  of
Cruveilhier's. He remarks that this peculiar com-
bination of vomiting  and purging occurs only in
young infants from three or four months old to
the end of the  period of dentition, and is most
common when they  are getting the canine and
double teeth.   The diarrhoea is extremely abund-
ant, and the  stools are sometimes yellow, but of-
tener green, like flocculi of confervae floating in a
transparent serous fluid. Vomiting is soon super-
added, first of a serous fluid, and at a later period
of a porraceous matter.  A dry cough and irreg-
ular febrile exacerbations  usually occur in this
affection :  the prostration of strength and emacia-
tion are extreme.  Towards the close, slight con-
vulsive  motions  are  observed, chiefly about the
face  and eyes.   The voice  becomes excessively
feeble, the  features become relaxed, and  the child
sinks at length either in a state of agitation or of
extreme exhaustion,  whilst the consciousness to
surrounding  objects continues unimpaired to the
last.   There  are  some varieties of the disease :
thus the diarrhoea may precede the vomiting many
days;  or they may both commence nearly at the
same  moment, and the child then dies with symp-
toms of cholera in the space of three or four days,
or occasionally even within twenty-four hours.
The affection sometimes, however, assumes a more
chronic  form,  lasting thirty  or  forty days ; but
here there  are frequent suspensions and renewals
of the  symptoms.  On dissection,  the  mucous
membrane of the stomach and intestines has usu-
ally been found pale, colourless, and almost trans-
parent, as if  it had been macerated in water, and
the mucous  follicles  are in  their natural state.
In some rare  cases slight redness has been evi-
dent in the coecum and colon, but this so seldom,
that it could only be  considered as a casual com-
plication ;  and the same may, according to  Guer-
sent, who is  here at  variance with Cruveilhier, be
said of the softening of the mucous membrane of
the stomach  and intestines,  which forms no essen-
tial or constant part  of the  disease.   The treat-
ment which  he has found to succeed  best in this
peculiar affection, as  well as its  morbid anatomy,
tends to prove that it is much more nearly allied
to cholera  than to gastro-enteritis : this treatment
consisted in the  very lowest diet, mucilaginous
drinks, emollient injections, fomentations and nar-
cotic cataplasms,  j-ieeches are almost always use-
less or injurious.  As the disease advances, baths
and  the very cautious use  of opiate  enemata
are proper;   and when  the prostration  is  ex 
GOO
DENTITION.
treme, sinapisms and blisters should be applied to
the limbs, nucha, or abdomen.  Tonics and stim-
ulants have usually seemed to do harm.   In the
acute or cholera  form it mostly proves  fatal in
spite of all kinds of  treatment.  It is  here  from
opiates  internally that we can alone expect  any
benefit.
   Dr. Parrish, of Philadelphia,  has described a
spasmodic affection of the intestines, or a species
of flatulent colic, which he thinks is often depend-
ent on the irritation of teething.  The belly swells
up rapidly and becomes  extremely  tender to the
touch, the child cries much, the muscles of the
face and limbs are spasmodically contracted, and
the stools are  suspended.  The only thing which
gives relief is the expulsion of flatus,  and the
consequent  reduction of the  tympanitic  state.
The appropriate remedies, after lancing the gums,
seem to be draughts  or enemata, containing a few
grains of assafcetida, and two or three drops of
laudanum, friction of the abdomen and spine with
an anodyne liniment, and the induction of a free
state of the bowels by some gentle  aperient, or a
soap suppository.  Mr. Parrish has recommended,
as an immediate mode of relief, the extraction of
the air  from the rectum by means of a syringe.
   Having already alluded to disorders of the chest,
we shall here only  add that a susceptibility to
catarrhal,  and  even  peripneumonic  affections,
seems to be  occasionally  induced  by teething.
When the presence  of inflammation is indicated
by fits  of  coughing  so  painful as  to make the
child cry, and by soreness of the chest, dyspnoea,
anorexia, and  feverishness, after lancing the gums,
repeated purgatives,  emetics, and diaphoretics will
often afford   much  relief;  but in  severe  cases
leeches and blisters must never be omitted.
   The  dry nervous  cough  of irritation  is,  how-
ever, by far the most frequent species, and  may
occasionally be  much alleviated by anodyne fric-
tions of the spine and  abdomen, though it often
resists all treatment  till after the tooth  is cut, and
then cases spontaneously.  Cough at this period
seems sometimes to  depend on  an intermediate
derangement of the  digestive organs,  as  is indi-
cated by the  state of the tongue,  tension of the
abdomen, unnatural stools,  and the absence of
fever :  here emetics  and purgatives are the appro-
priate remedies.
   Affections of the brain and nervous system may
occur in every degree from  a slight and passing
determination of blood to those organs, up to the
most violent irritation, congestion, or even inflam-
mation. The pain in the gums keeps the nervous
system in a  state of constant excitement, which
is  favourable to the development of spasmodic
affections.
   When there exists considerable plethora and
drowsiness, the  use of purgatives and  leeches,
 with blisters to the nape of  the neck, is indispen-
sable.  On the other hand,  a state  of insomnia is
occasionally induced ; Or the sleep is much in-
terrupted,  and  the  infant often awakes with  a
start, frightened and crying.  This  should  never
be overlooked by the physician,  as it  indicates  a
condition in which the  occurrence of  epilepsy or
convulsions is by no means  improbable.  It seems
sometimes to  depend on cerebral congestion  and
sometimes on  derangement of the digestive organs,
though occasionally it is purely nervous;  and ac-
cording to whichever of these may be its cause, it
will require the use either of leeches and purga-
tives,  or of antispasmodics and warm baths.
  Where much fever accompanies dentition, con
vulsions often occur, especially if the bowels be in
a constipated state.  Neither feeble and  irritable,
nor large and fine infants are  exempt  from  their
attacks:  but  the latter are the most apt to be cut
off suddenly  by them.   It is with  the protrusion
of the anterior molars, or of the canine teeth, that
they most frequently come on ;  and they are oc-
casionally  preceded  by  grinding  of  the teeth,
trembling of the lips, and other premonitory symp-
toms.  They are not always so dangerous  as is
commonly imagined, and are  least so when con-
fined  to spasmodic motions of  the eyes, face, and
arms.  But if, on the other hand, the fits are very
general and violent, and succeed each other rapidly,
they are  then always very alarming.  They occa-
sionally terminate in  apoplexy or  paralysis.  As
very formidable convulsions have been known to
cease immediately on the gums being lanced, this
operation should never be neglected where they
appear swollen and painful. Tepid baths, leeches,
purgatives, narcotics, and antispasmodics, are se-
verally useful in  different states of the system.
Thus, if pain  be the predominant symptom, we
should avail  ourselves  of the soothing influence
of tepid  baths; if the sleep be lost, the cautious
use of narcotics will be  justifiable, provided there
be no fever;  otherwise,  and especially if the  child
be plethoric,  purgatives and leeches must be pre-
mised.  In weakly children, assafcetida and some
other medicines of the  antispasmodic  class  have
been  occasionally found useful.   Sprinkling cold
water in  the child's face while in the bath will
often cut short the fit;  and when  the recurrence
of the disease  is very frequent, an issue at the
back  of the neck, or the production of an artificial
eruption,  is to  be recommended.   (See Convul-
sions, Infantile.)    Underwood  speaks  of  a
transient palsy of tbe arms and legs occurring as
each  tooth is coming out, and which does not re-
quire any particular treatment  beyond attention
to the gums and to the bowels.   The  paralysis
after  convulsions is often permanent and hopeless:
leeches and counter-irritation to the spine should,
however, have a trial in such cases.
   Of the convulsive affections  occurring during
dentition, one  of the most formidable is spasm
of the glottis,  sometimes, but improperly, termed
spasmodic or  chronic  croup.  Dr.  John Clarke
has  described  it under the title of " a peculiar
 Convulsion  of Infant  Children,-" and it has
also been noticed by Dr. Hamilton, of Edinburgh,
and  Dr.  Cheyne, of  Dublin.  Dr. Monro has
alluded to it where he speaks of a peculiar species
of  hydrocephalus, attended with  spasm of the
glottis.  It has been written on  by Mr. Pretty, in
the  Medical  and Physical Journal,  under the
name of cerebral croup, and  has  been described,
in France, by M. Guersent, under the title Pseudo-
croup nerveux, and  still better by Gardien, under
that of Spasme du thorax et de la glotte ,• and by
Richter, Raimann, Schmalz,  Wichmann, &c. in
Germany.  But the latest, and much the  most
satisfactory account of  this disease is that by Dr.
Marsh, in his paper in the Dublin Hospital Re 
DENTITION. —DERI\ ATION.
601
ports, vol. v. to  which, and also to the article
Glottis, Spasm of, in the  present work, the
reader is referred.
  A peculiar swelling of the hands  and feet has
been mentioned  by Underwood as an occasional
symptom of painful dentition.   It was considered
by him as in itself, if not decidedly beneficial, like
a slight diarrhoea,  at  least unimportant,  as he
found it to  cease  spontaneously when  the  tooth
came up.  If any feverishness co-existed, he at-
tributed it not so much to  those  tumours,  as to
the  casual  coincidence of derangement in the
bowels or some other organ.
   Dr. Kellie,  of Leith, who  has described this
singular affection more at large, asserts that though
it be sometimes thus slight and  transient, yet in
many cases  it has appeared to constitute  a part
of a disease  of a more striking and serious nature.
The swelling, which is situated  on  the back of
the  hand and on  the  dorsum of the foot, has  a
considerable degree of  roundness and  elevation,
such as might be produced  by a blow.   It seems
to arise  suddenly, and is of a mottled,  somewhat
 livid, or purplish colour, feeling  rather cold, and
 exhibiting no sign of  inflammation  or increased
 sensibility.  It is  firm, and does  not pit on pres-
 sure.  It will occasionally continue for weeks,
 gradually becoming softer or assuming  somewhat
 of a leucophlegmatic hue, to which occasionally,
 but  very rarely, cedema of the whole  limb has
 been known to supervene.   Usually, however,  it
 disappears more suddenly,  without  passing into
 the  leucophlegmatic stage.   It is generally con-
 nected  with a  symptom  of  a more  formidable
 character than itself, viz., the spastic contraction
 of the flexors of the thumb and toes.  The thumb
 is rigidly contracted and permanently bent down-
 wards, and  laid flat upon  the palm  of  the hand ;
 and in like  manner the  toes are bent down to the
 plantar aspect of  the  foot.  The carpus is also
 sometimes drawn down by its flexors, so as to in-
 crease  the  sphericity  of  the metacarpal  bones.
 The child is  peevish and restless,  but does not
 seem to suffer  much pain  in  the affected  parts.
 In some cases only there  is pyrexia towards the
 evening; the bowels are commonly torpid, and
 the  stools procured by  laxatives  are fetid, clayey,
 green, sour, and slimy.  Its  duration  is from  a
 few days to several weeks, and  its termination
 usually  favourable.  General convulsions  have,
 however, sometimes supervened  ; in one  of Dr.
 Kellie's  cases fever made its appearance, and two
 others died with what Dr.  Armstrong calls symp-
 toms of " hectic teething."  It is a disease of the
 epoch of dentition, and  as the symptoms have oc-
 casionally ceased immediately after the  cutting of
 a tooth,  we may  conclude that teething  is, at
 times at least, its exciting cause.   The treatment
 recommended by Dr. Kellie consists in  scarifying
 the  gums, removing plethora if it exist, restrain-
 ing  vascular excitement and local determination,
 and regulating the alvine discharges.
   Of the cutaneous eruptions connected with den-
tition little  need be said,  as  they seem, by their
derivative action, like a lax state  of the  bowels, to
be rather useful than  otherwise.  The principal
varieties are, an erythematous efflorescence behind
the ears (intertrigo) ; crusta lactea ; the different
varieties of strophulus (the red gum  or  tooth-rash
   Vol. I. — 76
3a
of the vulgar) ; small phlyctence, like those of a
burn, and evanescent red  spots appearing upon
the face and other  parts.  But  as  most of these
may occur also quite independently of dentition,
we can be certain of the connexion  in those cases
only when they make their appearance, or undergo
an exacerbation, just before the cutting of a tooth,
and  become milder or disappear after it.   Should
they run to  such an extent as to become trouble-
some, laxatives are the best means of keeping them
down.   During their existence  exposure to cold
should always be avoided.
   Disease of  the lymphatic system is  an occa-
sional  result  of  the debility often induced  by
teething, and is manifested in the enlargement of
the cervical, inguinal, and mesenteric glands, &c.
In these, as in all other scrofulous  affections, our
chief attention should be turned towards the im-
provement of  the general health by good air, nu-
tritive food, regular exercise, attention to the diges-
tive  organs,  and other measures to which, we have
alluded in a preceding paragraph.
   The  Second Dentition. — The  milk-teeth
generally begin to fall out about the seventh year,
or somewhat earlier, and are replaced in the course
of five or six years  by the permanent teeth, which
usually come up with little or no pain.   Cases do,
however,  occasionally occur in which  there is
considerable local irritation, and consequent  en-
largement of the glands about the  jaw  and neck,
ophthalmia, cutaneous eruptions, &c.   The wis-
dom-teeth, which are cut about the twenty-seventh
year, or occasionally much later, are often produc-
tive of considerable uneasiness and swelling. The
pain being  sometimes  periodically intermittent,
has  been mistaken for  an aguish  or rheumatic
affection,  and treated with  bark  and similar medi-
cines.   Cases are mentioned where, from the  im-
perfect development of the jaw, there has not been
room enough  for the dentes sapientis  to  come
easily forward ; and hence much pain and swell-
ing  of the face, together with violent headach, in-
flammation  of the eyes, pain in the ear, and  ab-
scess near  the angle of the jaw,  have  resulted.
Free incision of the gum, or even extraction of a
tooth, may,  in  some of these  cases, be necessary,
along with leeches, fomentations, and poultices to
the  external swelling.
   The  second set of teeth occasionally  come up
before the first have fallen out, and we have then'
the  singular appearance of a double row  of teeth :
on the other hand,  there are instances on record
of individuals who did not begin to  get the second
set till they  were forty or fifty years of age.  The
cases in which veiy old persons have cut a third
set  of teeth (See Ed.  Med.  Comment, vol. iii.)
are  so extremely rare, that  we only  allude to them
because their development has been sometimes ac-
companied with excruciating pain  and  other  ch
cumstances, which  might  be extremely puzzling
to the practitioner if not aware of the possibility
of such an  occurrence.          .,,, „  T
                                W. B. Joy.
   DERIVATION  (from  derivare).  This term
may be received in  two acceptations :  it may  ap-
ply  to an effect produced on any morbid condition
of parts by  an artificial irritation or determination
elsewhere, which removes  or diminishes the pn
mary one ;  or to the removal or diminution of $ 
602
DERIVATION.
morbid  condition,  consequent on  the  occurrence
of a new irritation or excitation of action not ar-
tificially produced.   Thus when a blister is ap-
plied  in a  case of pneumonia, with relief of the
pulmonary disease, we have  an example of the
first acceptation ;  and when a disease of the lungs
subsides on the occurrence of a cutaneous erup-
tion, or of a diarrhoea, we have an instance of the
second.  In either case the principal pathological
phenomenon is the change of the seat of irritation
or excitement.
   The  term revulsion is one better adapted to ex-
press this phenomenon, but it matters  little which
phrase we  adopt.  The older authors entered into
many arguments respecting the difference between
revulsion  and  derivation, but as their  ideas  on
these subjects were founded on false physiological
views, we shall pass them by  here.
   The  circumstances  under which  derivation, as
taken in its first acceptation,  is observed, may be
thus enumerated.
   First, the application of agents to the  two great
surfaces of relation, namely, the skin and mucous
membranes,  calculated to irritate  or  merely in-
crease  the normal action of these tissues; and
secondly, the use of stimulants calculated to ex-
cite the secretions of various of the parenchyma-
tous organs.  Under these heads may be enume-
rated  all   the  irritating  applications  which we
make to the  skin, such as cantharides, ammonia,
tartar emetic, &c, and also the use of friction and
heat.   When  we  employ purgatives to  cure  a
dropsy, or  a  disease of the skin or of parenchy-
matous organs, when  we use diaphoretics to  re-
lieve a mucous inflammation, or diuretics to  re-
move serous effusions, we act on the derivative or
revulsive system, and the remedies are'in all cases
derivatives or revulsives.   In some of these cases,
we cure or alleviate the original  disease by the
production of a new inflammation in the part act-
ed on,  as in  the case of blistering; in others, the
part acted on is not made the seat of a  new in-
flammation, but its normal secretion is excited and
increased,  as in the case of  warm bathing pro-
ducing diaphoresis.
   The second example of artificial derivation  is
the production of irritation in  tissues deeper
seated  than the skin, but still exterior to the vis-
cera.   Of this, the use of setons and  issues is an
example.
   But, as  we  have already shown, derivation or
revulsion is  often found to occur independently
of any artificial excitation, and the consideration
of this subject comes to be of the highest interest
in medicine.  As, however, it is more immediately
connected  with metastasis, we shall in this place
merely sketch  the leading physiological  facts con-
nected with this species of derivation.   One of
the most interesting of these is, that this revulsion
often occurs between analogous tissues; thus, in
cases of inflammation of the synovial  membranes,
 tbe sudden subsidence of the disease is commonly
followed by inflammation of some of the  serous
 membranes, such as the pericardium, peritoneum,
pleura, or  arachnoid.   Again, a patient  has diar-
 'hoea;  this suddenly subsides and is succeeded by
 violent Dronchitis; he has a disease of the skin,
 whicn  is  repressed, and  the  mucous  membranes
 become engaged, or vice  versa.   But  this rule  is
 by no means so general as to form a law in  pa-
 thology, for we find very many instances of ex-
 ception ;  for example, the occurrence  0f ascites
 after suppression of the perspiration, hemorrhage
 from the  kidneys after the desquamation  of mea-
 sles ;  the alternation of catarrh  and hemiplegia;
 of gout  and  gastro-enteritis,  or bronchitis; of
 mania and cedema of the  lower extremities.
   We shall not here examine the relation  of cause
 and effect in these examples of conversion of dis-
 ease ; it  may suffice to remark, that in some cases
 the  subsequent or  secondary disease  appears  to
 arise from the cause so well illustrated  by Brous-
 sais, namely, the predominance of the sympathetic
 over the primary  irritation ;  while in others it
 seems to  result from  a morbid  condition of the
 whole system, consequent on the subsidence  or
 removal  of some local  irritation, which, from its
I chronic  duration,  has apparently become neces-
I sary for the proper balance of the constitution.
|   Two modes of revulsion are used in medicine.
| In the first, we endeavour to change  the  seat of
I irritation or excitement from the viscera to  the
j surface ;  in the  second, we  change it from one
 viscus to another.   The  first may be  called the
 exterior or  peripheral  revulsion ; the second, the
 interior or visceral.  To the first of these  we shall
\ in this article principally direct our attention,
   The modus operandi and therapeutic  applica-
 tion of the exterior  derivatives  are  questions of
 great interest in  medicine.  In  some  cases the
 application of a blister to the surface is followed
 by great relief of the internal  disease, while in
 others the reverse occurs.  To determine the cases
 in which the  favourable  or  unfavourable results
 may be reasonably expected, comes to be  a great
 desideratum.   Here experience is our chief guide.
 It has been long known that blisters will relieve
 local  inflammation of  the  internal  parts under
 three circumstances; first, where the disease is of
 the acute character, but modified in its intensity
 by  active  antiphlogistic  measures;  secondly,
 where it  is acute, as respects the time, but occur-
 ring in cases where the powers of life are low, as
 in typhoid inflammations  ; and, lastly, in chronic
 diseases.  In  all these cases, the activity of the
 capillary circulation in the diseased  part  is weak,
 and revulsion taking place with  ease, a rapid re-
 moval of the local disease is  often  the effect of
 our treatment.   On  the injurious effects of exter-
 nal revulsives in  acute inflammations, before de-
 pletion is used, most authors arc agreed.  Rostan,
 in his Clinical Medicine, says,  " Revulsions are
 generally contra-indicated in the early stage ol
 acute diseases when there is fever and the subject
 is young and strong."  The same author, in  an-
 other place, says that although a derivative effect
 is often obtained, yet that in  many cases excita-
 tion will follow the use of revulsives, and  an effect
 directly contrary to  that expected will be produc-
 ed.  Mr. Porter, in his  " Smgical Observations
 on  the  Diseases  of the  Larynx and  Trachea,"
 expresses himself  strongly against the use of blis-
 ters in acute laryngitis, particularly when applied
 to the neighbourhood of the part.  He says, they
 cannot be resorted to at an  early period  without
 considerable  risk of doing  mischief.   A  case is
 related, where, in  acute pneumonia, the  applica-
; tion of a blister was  followed by an aggravation 
DERIVATION.
603
of the symptoms and  death.   On dissection,  a
portion of the surface of the lung, exactly corre-
sponding to the size and shape of the blister, was
found in a  more advanced  stage  of inflammation
than  the remaining pulmonary  tissue.   Many
other authors might be quoted to the same effect.
Our own experience is decidedly  in  favour  of
these views.   We have often seen a distinct exa-
cerbation follow the application of a blister in the
acute pneumonia,  bronchitis,  or  gastro-enteritis
of children, in cases where bloodletting was not
used ; and  many medical  friends  have informed
us  of similar occurrences  in their  own practice.
Even in a  few chronic cases we have observed the
same effect where local bleeding has not been pre-
mised.
   We must, then,  admit that external  derivatives
have two modes  of action;  the one derivative, the
 other directly stimulant on the diseased part.  We
 find them, as we stated before, generally useful in
 three sets  of cases, namely, acute  inflammations
 where  general  and local  bloodletting has been
 premised, typhoid inflammations, and chronic dis-
 eases :  and it becomes probable  thai a part  at
 least of their utility is owing to the direct stimulus
 conveyed to the  capillaries of the diseased tissue.
 A  state of these vessels,  analogous to  Andral's
 asthenic hyperxmia, in all probability exists, and
 we know that stimulation  is often the best mode
 of removing this  morbid  condition.  This will
 account for the injurious effects of external revul-
 sives in acute cases before depletion has been used,
 and is  not inconsistent with  their good effects in
 cases of a different description.   They are all es-
 sentially stimulants.  If the irritability of the sys-
 tem  is  great, an increase of fever will be the result
 of the  sympathetic irritation of a blister, and in
  this way the local inflammation will be  aggravated.
  Whether  the  increase  of the  local  disease  be
  always owing to  this cause, or whether it  may
  occur  without   the  intervention  of  sympathetic
  fever, are  questions of difficulty, but bappily not
  of great practical importance.
    We often find, in cases  of intense irritation of
  internal organs,  that blisters will not vesicate the
  skin, but  that,  as. soon as the  disease has been
  modified,  they  will produce their usual effect.
  Can this be explained by supposing, that in con-
  sequence of the  intense inward determination, the
  surface has lost a portion of its vitality ?   In such
  cases,  the vesication of the surface is often not the
  cause,  but the consequence of the diminution of
  diseased action.
    The means generally employed to produce ex-
  ternal  revulsions  are the  application of blisters,
  sinapisms, or the tartar emetic ointment; and the
  use  of setons, issues, the moxa,  heat, and friction.
  In this country the most common mode is the
  application of blisters, either immediately over the
  diseased organ, or at some distance from  it.  Un-
  pleasant consequences often follow even this sim-
  ple  proceeding; of which the principal are the
  infliction  of great pain, the production of a  too
  violent inflammation, and the occurrence of stran-
  gury.   All these bad effects appear frequently to
  arise from the practice which  commonly prevails
  of allowing the blister to remain on for twelve
  or even twenty-four hours; a mode of proceeding
  totally useless, and constantly injurious.
  Dr. Leahy, the learned Professor of the  Prac-
tice of Medicine in the School  of Physic in Ire-
land,  has long  inveighed against this practice.
His mode is to remove the blister as soon  as de-
cided pain  is produced, although the part be  no*
vesicated.  Simple  dressings are  then applied ;
and  free vesication subsequently  occurs; and in
the majority of cases none of the distressing effects
alluded to are produced.  We can speak from our
own  experience  of the  superior  efficacy  of  this
mode, and feel  strongly  disposed to believe that
were it  more constantly pursued, we would see
fewer cases of the aggravation of internal disease
from the use of blisters.
   These views  are also  much  insisted on by M.
Bretonneau, in his Traite de la Diphtherite.  His
mode of using blisters is peculiarly elegant, being
founded on  the  experiments of Robiquet, which
show that the vesicating principle is soluble in
fatty substances.  A piece of extremely thin paper
is inserted between the blister and skin, through
which  of course  the  oily  solution  penetrates,
Many of the inconveniences of the common mode
of blistering are avoided, such as  the long-con-
tinued irritation  that portions of the cantharides
produce by  sticking to  the  part;  the unsightly
marks which blisters leave, &c. :  and  M. Breton-
 neau states that during six years' practice  in  his
 hospital, there did not occur a single case of ischu-
 ria after blistering  performed in this way.
   Some  practitioners, particularly on the  Conti-
 nent, prefer  applying blisters always  at some dis-
 tance from the  seat  of disease ;  in this way, ac-
 cording to  their opinion, avoiding the danger of
 direct  stimulation.  Facts   are  still wanting to
 enable us  finally  to  determine  on  the  relative
 merits of these two modes of proceeding; but if
 the use of a blister over a part affected with acute
 inflammation is avoided until  its capillary irrita-
 tion has been   modified by antiphlogistic treat-
 ment, we believe that the practice will generally be
 found safe.
   The use  of the tartar emetic  ointment, as re-
 commended by Jenner, has now  become  very
 common.   In some  cases, however, it is produc-
 tive of great distress, in  consequence of the forma-
 tion of large and angry pustules ; a circumstance
 in most cases arising from the use of too great a
 quantity of the salt in forming the ointment.  A
 drachm to the  ounce of lard is the  usual  propor-
 tion ; but if we employ a  diminished  quantity,
 the  remedy will act  much  better, and frequently
 with little or no distress to the patient.   From a
 scruple to half  a  drachm  of the salt, finely pul-
 verised, is generally sufficient;  and in this  way an
 extensive eruption of  minute pustules  will  be
 produced, from which we have never seen any un-
 pleasant consequences  to follow.  An extraordi-
 nary effect of this mode of counter-irritation has
 been several times observed, namely, the super-
 vention  of  violent irritation about the parts of
 generation.   At first it was  supposed that the ir-
 ritating  substance was  directly  conveyed to the
 parts by means of the patient's  hands;  but  this
 opinion is untenable, as the eruption has occurred
 in  cases where  the  greatest caution was used to
 prevent any direct conveyance of the ointment to
 the  genitals.  This  circumstance is noted by Dr.
 Mackintosh, in  his Practice  of Physic  vid both 
004
DERIVATION.
Dr. Graves and the^writer of this article have had
frequent opportunities of observing it in the Meath
Hospital.   In a case which occurred in private
practice, the inflammation about the genitals in a
young female was  so severe as to  threaten morti-
fication.   Another unpleasant result of this  mode
of counter-irritation  is the occurrence of violent
and  obstinate vomiting, particularly where  the
ointment has been rubbed over the epigastric re-
gion.
  We shall  now proceed to  consider the use of
external revulsion  in cases of visceral  disease.
Authors appear to  agree as  to the impropriety of
using revulsives in  cases of disease of the brain
when it is acute, and particularly  where bloodlet-
ting has not been  premised ; tbus  fully bearing
out the doctrine which we  have endeavoured to
support in this article.
  In diseases of the brain and spinal marrow, all
the different modes of revulsion have been prac-
tised with great success.   Indeed, with the excep-
tion of the first  stage  of acute  irritations, it may
be said that revulsives are of the highest utility in
all cerebral diseases, whether functional or organic:
where coma supervenes, and in chronic affections,
the best results often follow this practice.   Thus
in all the  forms of paralysis depending on disease
of  the brain and  spinal  marrow,  the various
revulsives  have long  been  recognized as among
our  best  remedies ;  and they may be  often  em-
ployed as prophylactics, as in cases where an apo-
plectic disposition decidedly exists, and where the
life of the patient may be  prolonged  by the timely
use of a seton in the neck.
   Dr. Jenner, in his  letter on  the  influence of
artificial eruptions, speaks in the highest terms of
the  utility of the  tartar emetic ointment in the
cure  of insanity, declaring  that in  all  his cases
(eighteen in number)  this treatment succeeded in
removing  the disease.  Dr. Burrows, however, is
by no means so  sanguine ; but states that in cases
where insanity has ensued on the  subsidence of a
cutaneous eruption, or is connected with gastric
irritation, this treatment will ameliorate the symp-
toms.   He prefers the use of  the  tartar emetic
ointment  to that of blisters.
   In Lallemand's " Lettres sur l'Encephale,"  a
• ase  is recorded highly illustrative of the effects
of powerful revulsion under  the most unfavourable
circumstance.  A  patient, upwards of sixty years
of age, became  affected with symptoms of ence-
phalitis, in consequence of an injury of the head.
The  prominent symptoms  were stupor, paralysis
with convulsions of the right arm, embarrassment
of  speech,  and loss of memory.   The circum-
stance  of the injury of the head  being unknown
to his medical attendants, the case was considered
as an example of  idiopathic fever, until the tenth
day, when the patient was seen by M. Lallemand
for the first time.   The patient  had then frequent
and long-continued  fainting fits;  the limbs on the
  ight side were contracted, with complete paralysis
of sensation ; the eyelids closed,  the eyes  diver-
gent and  insensible to light;  there was complete
 loss of hearing and intelligence; the  body  was
covered with a cold sweat; the respiration frequent
and stertorous ; and the pulse imperceptible.  In
 this  desperate  state,  Lallemand  applied boiling
 water to the legs of the patient.  The first appli-
cation  produced a  sudden  motion  of the whole
body ;  the left arm was agitated, the eyelids  were
raised, and  the  pulse became perceptible in the
arm.   In the  course  of  half an hour  the boiling
water was applied  to the thighs with still  more
remarkable  effects : the  face became red, and the
pulse full and frequent.   Ice  was now applied to
the head, and in two hours the sensibility was so
so much restored that the patient  frequently at-
tempted  to  remove the  cold application.  Under
this treatment, with the  occasional application of
a few leeches  to  the  head, the patient was nearly
restored  in  the course of eight days ;  and in two
months all paralysis had disappeared. The eschars
produced by the boiling water were very deep, and
suppurated  abundantly, seven  weeks  elapsing
before  cicatrization took  place.  Dr. Mackintosh,
in his  Practice of Physic, details a case of severe
cerebral  affection in fever, where  the  best results
followed a similar practice. In this case, however,
neither paralysis nor coma had taken place.
   In the employment of revulsives  in diseases of
the brain, it appears most proper  to select for the
place  of stimulation  some  part  remote from the
cranium.  In this way the action  of the revulsive
can be powerfully assisted by the application of
cold to the  head, as by the use of ice, or, what is
still better,  the cold affusion,  used in  the manner
directed  by  Dr. Abercrombie.
   We may here notice  the practice  of counter-
irritation along the spinal column, as proposed by
Mr. Teale for the cure of hysteric affections;  and
which, according to him, has been followed by the
best effects.  It would  appear, however, that as
yet a sufficient  number  of observations  has not
been made  to establish  the pathological views on
which this practice is founded.   Doubtless, cases
of spinal irritation do occur where  the use of re-
vulsion may be  followed by the best results. In
veterinary practice we have  known good effects
obtained, in cases of tetanus, by the use of severe
counter-irritation along the spinal column.
   In diseases of the  respiratory  organs, whether
of the mucous membrane, parenchyma, or serous
investment, revulsions have long been  employed
by physicians.  The same principles which guide
us in the use of revulsives in  diseases  of the brain
are found  to  apply here :—improper in the acute
stage,  and even  dangerous when the irritation has
not been reduced by antiphlogistic measures, they
are found generally of the highest utility in cases
where the  lancet  has been used, and where the
inflammation is of an asthenic or chronic character.
In simple acute laryngitis, the best  authors agree
as to tbe impropriety of using blisters  to the  ante-
rior portion of  the neck.  Guersent and Porter
express  themselves most strongly  on this subject;
the former, however, admitting that they may be
useful in the  asthenic croup,- but he prefers em-
ploying  them at a distance from the affected part.
Indeed,  there are  few  diseases  where so much
caution  should be used  in any mode of treatment
which would have a chance  of increasing irrita-
tion ;  as we know that a momentary spasm of the
glottis may suddenly extinguish  life.   In an irri-
table patient, then, we must be extremely cautious
in the employment of the  revulsive mode.   But
in chronic laryngitis we find  the best  effects from
counter-irritation in the neighbourhood of the part; 
DERIVATION.
605
repeated blistering, frictions with the tartar emetic
ointment, and the use of the seton, being among
our most successful modes of treatment in this
obstinate disease.
  The good effects  of severe counter-irritation in
a case of chronic laryngitis of long standing, and
which  threatened  the  life of the  patient,  were
strikingly exemplified some time ago in tbe Meath
Hospital.   The symptoms were extremely urgent,
and were not  alleviated by local bleeding.  Two
blisters, of about two inches  wide and five  in
length, were  applied  along the  course of  the
sterno-mastoid muscles, and the vesicated surface
sprinkled with finely powdered tartar emetic.   A
most severe counter-irritation was thus produced ;
the patient suffered  extremely ; but the laryngitis
was completely removed, and we  believe the cure
was permanent.
   In diseases of the lungs we find the same gene-
ral principles equally  to apply.  We have seen
many  instances where the  symptoms  of  acute
pneumonia or pleuritis were clearly  aggravated
by  the empirical use of blisters; but in tbe second
state of acute bronchitis, in most of the forms of
chronic catarrh,  in hooping-cough, in hepatiza-
tions, or  passive congestions of the lung, and in
the advanced stages of pleurisy,  the  revulsive
practice  is almost  always followed by the best
effects.   The utility of the same practice in cases
of chronic phthisis is so well known that we need
not comment on it here.
   One of  the most distressing circumstances in
the progress of a case of hypertrophy of the  heart,
is the occasional increase of palpitations  and prae-
cordial distress:  this is frequently relieved by the
application of a blister;  a circumstance which,
combined with our knowledge  of the  efficacy of
local bleeding in similar cases, adds greatly to the
probable correctness of Andral's  opinion, that in
 many such cases the cause of these symptoms is
an irritation of the internal membrane of the  heart.
   In the examination of the effect of external re-
vulsion in diseases  of the  digestive system, we
must consider its employment in  affections  of the
mucous  and  serous membranes.   Broussais, in
his Phlegmasies Chroniques, endeavours to esta-
blish that in inflammations of the mucous  mem-
brane, both acute and chronic, such  practice is
always improper, and  that those cases of altered
function  which are relieved  by vesication of the
surface, are not  in  reality examples of inflamma-
tion of the mucous membrane.  This assertion,
however, appears too general; both analogy  and
experience lead  to  the conclusion that  in  acute
gastro-enteritis the use of revulsives to the surface
will be probably followed  by bad  consequences,
but this is  far from applying to the chronic affec-
tions, where  we know that this  practice is con-
stantly productive of the best effects.   In  schir-
rhus of  the  stomach,  in chronic  diarrhoea, or
dysentery,  in tabes  mesenterica, the great  utility
of external revulsives  has long been established ;
so that, as  far as the affections of the gastro-intes-
tinal mucous membrane  are concerned, the gene-
ral principle  which  we have been endeavouring to
establish is  also borne  out.   In  point of fact,
Broussais does not.  seem lo  be sufficiently  aware
of the utility of stimulation in the internal as well
as the  external chronic inflammations.
                                      3a*
  The same conclusions are to be drawn in the
case of peritonitis.  In the violent acute disease,
and particularly before general and local bleeding
has  been  freely  premised, a blister  often  aggra-
vates the  symptoms ;  but in the chronic and as-
thenic forms of the disease, as in the low puerpe-
ral  peritonitis described  by Dr. Cusack and  Dr.
Gooch, it  is found that blistering the abdomen is
often followed by the  happiest results.
  We are indebted to Mr. Crampton for the par-
ticulars of a remarkable  case of chronic obdomi-
nal  disease, where a  powerful and  extensive re-
vulsion  was followed by the  greatest relief of
symptoms.   A  lady, who had  laboured   under
ovarian disease, with  severe symptoms of chronic
inflammation of the mucous membrane of the in-
testines, as  evinced by  diarrhoea, bloody  stools,
tenderness of the  abdomen, and emaciation, was
severely  burned  in consequence  of her  clothes
taking fire ; the neck, arms, and throat were the
seats of the injury.   On recovering from this ac-
cident, the  greatest improvement became  mani-
fest in her general health ; the bowels became re-
gular, nutrition went  on, the ovarian enlargement
subsided greatly, and the patient has since enjoyed
a state of good health  which could never  have
been anticipated.
  For information  on the employment of revul-
sives in diseases of  the urinary  organs,  and in
affections  of the generative system, we beg to refer
to the articles on these subjects. We shall  merely
remark that many practitioners avoid the applica-
tion of a blister to the loins in acute irritations of
the  kidney, such  as  nephritis or renal calculus,
fearing  that strangury   would be certainly pro-
duced.  We believe  that this  fear  is  quite  un-
founded, and that the application of a blister to
the loins may be  constantly had recourse to with
the best  effect  in these  cases.  There is no  evi-
dence to show that strangury is more liable to be
produced  by a blister to  the  loins  than  to  any
other part; but it is almost certain that in the
majority of cases  the strangury is owing to the
mismanagement of the blister.
  The last class of affections in which we shall
examine the utility of revulsives is that of fevers.
Louis has investigated this subject with his usual
precision, by comparing  the effects  of  blisters in
cases of typhoid fever which have proved fatal, and
in those where recovery took place.   In the first
class, he found that the mean duration of the dis-
ease was not altered by  the practice; that no
effect,  either upon the temperature of the body,
or the state of the circulation, could be connected
with the  action  of the blister;  that in two-thirds
of the cases the cerebral functions underwent no
alteration ;  and that in the remaining third but  a
very small proportion   presented alleviation of
symptoms.   The  examination of  the digestive
functions showed the  same results, so that he con-
cludes that in his cases the action of blisters pro-
duced no  effect, either on the duration of the dis-
ease or the progress  of  its symptoms.   In those
cases where recovery took  place, he  concludes
that blisters had  no appreciable effect on the dis-
ease, and that they perhaps but slightly retarded
the convalescence: so  that, in connecting thesn
facts with the inconvenience of blisters, he holdir 
606
DERIVATION
— DIABETES.
that they should be banished from the  treatment
.if typhoid fever.
   It is  to  be remarked, however, that in  these
cases  the  blisters were  applied,  not  over  the
splanchnic cavities,  but to  the extremities;  the
conclusions therefore only apply to this particular
mode, and  afford no  reason for  banishing the  use
of blisters  from the treatment of  typhoid fever.
We know, indeed, from experience, that in cer-
tain cases their utility is most remarkable. In  the
majority of cases of fever the attention of the phy-
sician is principally directed to  remove inflamma-
tion or congestions in some of  the  great cavities,
and revulsion is often the only mode left to him
of accomplishing his  object.  Thus  in certain
cases of coma occurring at an advanced stage of
the disease, the greatest advantage is derived from
the application of a  blister  to the  head.  In  ca-
tarrhal fever, when copious  secretion sets in, and
the powers of life are low, we have found, in  the
Meath Hospital, the most striking advantage from
free blistering on the chest, and have  never seen
any unpleasant result.   So, also, where pneumo-
nia occurs in the course of a  typhoid  fever,  the
application of a blister, after depletory measures
have been used, or where the skin is cool and  the
powers of re-action are slight, has been frequently
successful in ameliorating or removing the  dis-
ease.   Our  experience  in  the Meath  Hospital
leads us to  the conclusion that, as far as the utility
of blisters in  fever is  concerned, we may use them
for the  relief  of the  secondary  inflammations
which  occur, with great benefit;  always,  how-
ever,  acting  on the  principles which we  have
maintained in this article. [See the article Coun-
ter-Irritation for much  information  on this
  DERIVATIVES.   See Derivation.
  DIABETES.—Some of the earlier writers on
medicine have given different  names  to  the dis-
ease which forms the subject of the present  arti-
cle.   Thus it has been styled  diarrhxa urinosa,
hydrops ad malulam, hyderus, dipsacus, morbus
silibimdus, fluxus urinx, nimia urinx profusio,
polyuria.
  Owing to the excessive secretion and  frequent
evacuation of urine in this affection, it has also
been named diabetes, from the Greek word iiaflaivw,
which signifies  to pass through : and from the
circumstance of the urine having generally a smell
of honey, and a sweetish taste, the adjective melli-
tus has been employed to  denote  this character.
M. Renauldin, in an able article on diabetes in the
Dictionnaire  des Sciences  Medicales,  and after-
wards Dr. Prout, insist upon defining diabetes to
be " a disease in which a saccharine  state of the
urine is the characteristic symptom," although the
etymological  import of the word extends to any
affection  accompanied  with an immoderate dis-
charge of the urinary secretion.  It is not the best
logic, however,  to found a definition upon an
hypothesis ;  and as there are several instances on
lecord of patients dying  under all the symptoms
of diabetes, yet without the slightest indication
of sugar in tbe urine, we cannot fairly dispose of
these by assuming its presence in the latent state;
lor  it may be  latent in  the most incidental  case
of hysterical  enuresis, and then how could  Drs.
Renauldin and Prout refuse the name of diabetes
to this fortuitous symptom ?   We  make no un-
fair extension of tbeir hypothesis ;  and to  speak
truth,  chemists have as yet discovered no  good
test of either sugar or urea when in small quan-
tities, nor, were they perfect, ought medical men
to take their  results as defining  disease.   Dia-
betes,  like every other  malady, must not be de-
fined  by symptom  a or symptom b, but by the
aggregate and concatenation of the leading symp-
toms.  Of these, immoderate  excretion  of urine
and cachectic  emaciation  seem much more cha-
racteristic  than sweetness,  however general, and
which it  must be  allowed is  at  times undistin-
guishable.   All  the  modes  of analysis hitherto
devised for indicating  the vegetable and animal
oxides are extremely  imperfect, especially  when
these  are intermingled with other oxides ; and the
most delicate of them  seem to consist, not in de-
monstrating the  presence  of these  oxides them-
selves, but in generating new bodies, which are
supposed to result  from the re-union of the pri-
mary  elements into which the former  had been
supposed  to  be reduced by their operation.   In
every  genuine  case  of diabetes,  however,  Dr.
Prout contends  that a  careful  analysis of  the
urine will  detect more  or less  saccharine matter,
even when the sensible qualities of this fluid  fail
to point out the least  saccharine  impregnation;
for, as Dr. Watt  has  observed, sugar may be pre-
sent, but so covered with other substances that it
cannot be at all detected by the taste.
   Hippocrates seems to have been  altogether ig-
norant of this affection, for we  find no allusion to
it in  any  of  his writings;  but  Celsus, Galen,
Aretaeus, and Alexander Trallianus, have left us
histories of diabetes.  The description of it given
by  Aretaeus is  particularly  clear  and  minute.
These writers,  however, looked upon  the disease
simply as  an increased  flow of urine, and as pro-
ceeding from renal  irritation.  Galen thought that
this affection bore the same relation to the kidneys
and bladder as the lientary does to the stomach
and intestines.   Aretaeus Considered it a colliqua-
tion of the flesh  and limbs into urine.   He  has
observed, "that it has  the usual  urinary course,
namely, the kidneys and bladder, for the patients
never cease voiding their  urine, but as from the
openings of the water-ducts, the  stream is perpe-
tual."  Trallianus  adopted much the same view
of the complaint.  No further light seems to hav.e
been thrown upon the nature of diabetes until the
time of Willis, who first pointed out the saccha-
rine  taste  of diabetic  urine.   "The subjects of
this affection," that  able  writer  has  remarked,
" pass more  urine  than the whole  quantity of
fluids taken  into the body; they have besides a
constant  thirst, and a slow kind  of hectic  fever
always on  them.  It is very far  from  true, as some
authors affirm, of the drink being again discharged
with  little or no alteration, for the  urine in all
that I have seen,  (and I believe it will universally
be the case,) differed not only  from their drink,
and from  every other fluid in  the animal body,
but was like as if it had been  mixed with honey
or with sugar, and had a wonderfully sweet taste."
Willis has ably investigated the principal pheno-
mena  of the complaint, and endeavoured to  point
out its seat ; but be  confesses his  ignorance of 
DIABETES.
607
its causes and true nature.   He  has enumerated
a variety of  remedies adapted to  the removal of
the disease, but he admits the difficulty of ascer-
taining what are the true purposes which ought
to be kept in view in its cure. At the commence-
ment of the  diabetic tendency, he  found a cure by
no means difficult;  but in the advanced stage of
the disease,  such a result very seldom occurred.
This he supposed was owing to the crasis of the
blood  being  only a little loosened, and thus rea-
dily brought back again into  its former state ; but
when so much  dissolved  as  to have most of its
parts  separated from each other,  it could seldom,
if ever, be restored.   The treatise of Willis upon
diabetes has been translated  by Dr. Latham, and
published in his » Facts and Opinions" concern-
ing that affection.
   Sydenham,  who  lived  for several years after
Willis, and  was  cotemporary with him, has not
alluded to the  sweetness of the urine in diabetes,
though he has left an extremely accurate descrip-
tion of its causes and the indications of its cure.
We shall not attempt to account for this  silence
of Sydenham, by supposing, with  Dr. Latham,
that it arose from any other cause than mere inad-
vertency. Experiment was then but a new branch
of science;  and  the practice  of tasting the urine
of a diabetic patient was probably first adopted by
Willis, of all men, from the  beginning of time ;
nor would the practical mind of Sydenham con-
sider the announcement of more  importance than
if he had been told that the urine of hydrophobia
was bitter ;  for what, in his time, was to be learnt
from  either ?  After Sydenham, we  meet with
notices of this affection in the writings of  Cullen
and  Heberden;  and  since their  time many at-
tempts have been made to elucidate its real nature,
and to establish  a successful  mode  of cure.  Dr.
Rollo, however,  strongly roused  the attention of
th« profession to the subject by  the publication
and extended  circulation of Captain Meredith's
case, in which he proposed a new and important
plan of treatment.  To that  author every praise
is due for having enabled us  to form more correct
notions of the nature and cure of this complaint.
The names of Cruikshank,  Girdlestone,  Fother-
gill, Dobson, Latham, Baillie, Lubbock, Bostock,
Wollaston, Warren, Henry,  Bardsley, Watt, Sat-
terley, Prout, and Marsh,  [Christison, M'Gregor,
Bouchardat, Dezeimeris, R. Willis,] may be men-
tioned as those  of valuable contributors  to  the
■general fund of information which we now possess
concerning this formidable malady.
   It has been supposed that diabetes is a disease
of more  common occurrence at  the present time
than formerly, because we meet  with so  few .no-
tices of the complaint in the writings of  authors
from Willis  to Rollo, compared with the numerous
authentic records of diabetic cases since the valua-
ble publication of the  latter  physician. The fact
seems to be  that the disease  is now better under-
stood,  and  its   symptoms  are  more generally
known, so that not a few cases which would for-
merly have been  classed under the head of phthisis
or tabes, are now ascertained  to be genuine exam-
ples of  diabetes.  Dr. Storer,   of  Nottingham,
states,  in a  letter to  Dr. Rollo, that  he had not
seen a single instance of diabetes during  sixteen
years in which he had the cane  of  an infirmary,
containing upon an annual  average  fifty-two in-
patients, and three hundred out-patients.  In the
Manchester Infirmary, diabetic patients not unfre-
quently present  themselves  for admission, and  it
generally falls to the lot  of each  of the medical
officers of that institution  to receive  several  cases
under his care during the year.   On inquiry, we
have found that the  same holds true with  other
extensive public hospitals.  In  private practice,
too, instances of this disease are by no means un-
common ; for  we believe there  are  few medical
men who have a fair share of professional employ-
ment, to whom cases  of diabetes have not some-
what frequently occurred.  Diabetes occurs  in
early as well as in advanced life.  Heberden erro-
neously supposed that it exclusively attacked the
aged and  infirm.   We have  witnessed two in-
stances of  this disease in children under six  years
of age ;  and Dr. Venables has also recorded  seve-
ral  marked cases of infantile  diabetes.   A very
distinct  example connected with the  process of
dentition, and in which the urine was sweet, is
related by  Morton.   More than half of the  cases
seen by Dr. Watt,—and he  believed  the same ob-
servation would hold with regard to  all that have
been published,—occurred between  the  ages of
thirty  and forty-five; and  of the  other half a
greater number  were  below the former  of  these
ages than  above the latter.  " Of the whole," he
says, " the best  marked and most rapid  in their
progress have occurred in the very  prime of life,
and  when  the constitution was supposed to  be  in
its full vigour.  There is, perhaps,  no period of
life completely  secure from the disease,  though
few instances  have been  recorded under the age
of puberty.  I have  met  with  one instance in a
boy of three years of age.   It was most distinctly
marked ; the urine amounted to six or seven pints
daily ;  the voracious  appetite, urgent thirst, and
arid  skin  were  very remarkable.   He had also
phymosis,  and  afterwards suppression of urine.
The disease terminated in a fatal dropsy."
  This  disease  not  unfrequently  makes  its ap-
proach insidiously; and it unfortunately happens
that the  first symptoms are often disregarded, and
the complaint is allowed to advance  for some time
uncontrolled by  medicine.  The  increased  flow
of urine is merely regarded as the necessary  effect
of the thirst, and tho discovery of the saccharine
condition of this fluid is  also mostly accidental;
but  when  hectic, emaciation, and debility  have
supervened, a  more strict inquiry  into the symp-
toms is generally instituted, and the real nature
of the  complaint becomes  fully ascertained.  The
almost  constant desire to  make water, and the
insatiable thirst, particularly during the night, are
two  most distressing symptoms; the  patient  being
obliged  to be supplied with a large quantity of
fluid near his bed-side,  and having  to rise six  or
seven  times  or  oftener to evacuate the bladder.
The urine has a slight straw colour,  and sweetish
taste,  and yields  on evaporation  a considerable
quantity of saccharine extract.  The amount of
this  secretion passed during the twenty-four hours
is sometimes very considerable.  It has exceeded,
in more  than  one instance, seventy pounds.   In
the case of Smith,  detailed  in the  writer's "Hos-
pital  Facts  and Observations," thirty-six  pints
of urine  were voided in the  course of twenty-fou' 
GOS                                   DIA B
hours; and in that of Johnson, thirty-two pints.
The discharge,  generally speaking, is  less than
the liquid ingesta; but it has been found in one
or two cases, that the liquid  egesta have consi-
derably exceeded the whole amount both of the
solid and liquid ingesta. This  fact, though denied
by some writers, has been satisfactorily established
by Dr. Bardsley, who has  shown that the excess
of the former cannot be. accounted for solely on
the supposition of its being derived from a general
wasting and diminution of the  solid and fluid parts
of the system ; for in two or three instances during
the period in which the register clearly pointed out
almost a regular daily excess in the amount of the
urine compared with that of the liquids and solids
taken, the patients  had  gained an accession to
their weight of many pounds.   " To what law or
process of the animal economy,"  the  author just
named observes, " is the  supply of this  supera-
bundant quantity of urine to be attributed ?  Is it
derived from cuticular or pulmonary absorption,
or from a colliquation of the humours of the body  ?
Each of these modes has been  insisted on by
different writers."   We receive the fact without
framing any hypothesis to account for it.  The
researches  of  modern  physiologists, particularly
those of Klapp and Dangerfield, do however render
it  extremely probable that  this superabundant
quantity of  fluid is  absorbed  by the lungs  from
the moisture of the  atmosphere.  Numerous ob-
servations demonstrate that almost every kind of
matter in the state of fluid  or  vapour, introduced
into the  cells  of the lungs,  is rapidly absorbed
from  thence into the circulation, and,  generally
speaking,  presents itself at  the kidneys ; thus the
oil  of turpentine  manifests itself  in  the urine
within a few minutes ; and the amount of these
facts goes to prove that there  is a free  and rapid
absorption  always taking place on the surface of
the lungs.  On the other hand  absorption through
the cuticle,  if it exists at all, cannot be demon-
strated ; while it is admitted by almost every one,
that nine-tenths of the copious exhalation of the
pulmonary surface, which, according to propor-
tion, must at least be ten times as great as that by
the skin, or twenty pounds daily, is constantly in
the act of being re-absorbed  by  the pulmonary
surface :  and since the avidity of the absorbents
is known to be greatly augmented, as in dropsy,
by  an increased  diuresis,  while  the  pulmonary
exhalation  must be  proportionally diminished, it
is easy to conceive that the  absorption of the fluid
excreted  from  the  bronchi will be considerably
increased, and thus augment the quantity of fluid
egesta above the ingesta.   There  will,  moreover,
be absorption of part of  the  residual air  in the
lungs, and  this will  again supply itself from the
now moister air brought in from the atmosphere
by  inspiration,  to  what extent it is not easy to
compute ;  nor can we reasonably expect that any
such  computation will correspond  very exactly
with  the weights  of the  ingesta  and body at
different times,  the  means of taking which are
often  much  more fallacious  than is  generally be-
lieved.
  The mouth is mostly dry and parched, the taste
Is peiverted, and the secretion of saliva altered.
[Mr. M'Gregor found that it fermented briskly in
a  diabetic patient, when  yeast was added to it,
TES.
and complaints are often made of a constant sweet
mawkish taste in the mouth,  and a feeling  as if
the  teeth  were set on  edge.]   A  tough  viscid
phlegm  occupies  the  fauces ; the tongue  has  a
brownish fur on its centre, with florid edges ; the
gums are soft, spongy, and bleed on the slightest
pressure of the tongue against them, being mostly
ulcerated about the roots of the teeth ; the appetite
is usually keen, and sometimes ravenous ; uneasi-
ness about the stomach and bowels is experienced,
chiefly after eating, and the contents of the former
are not  unfrequently discharged in an acid and
undigested state;  the skin is  rough, dry, and un-
perspirable; the bowels are generally costive; there
is frequent pain and  a constant sense of aching
and weakness across the region of the kidneys,
particularly on  the least  exertion ;  itching and
excoriation, with phymosis of the prepuce, occurs
in males, and an  uneasiness about the meatus
urinarius in females;  the semen is  discharged
involuntarily,  chiefly  after voiding urine;  and
there is a  total loss  of the  sexual propensities.
Headach, impaired hearing, giddiness, and indis-
tinct vision, are mostly  present.  When  these
symptoms  continue only for  a short time,  they
are followed by serious disturbance in the genera]
health,  such  as  extreme  debility, languor, and
great emaciation.   The pulse,  which  is at first
quicker  than  natural, becomes slow and feeble.
The legs and  ankles swell; and a tickling cough,
with shooting pains in the chest, mostly harasses
the unfortunate patient  in the  last stage of his
disorder.  The mind  is extremely peevish, irrita-
ble, and  somewhat suspicious; tbe spirits are low
and depressed.
   By attention to the above symptoms, it is not,
we conceive, difficult  to distinguish diabetes from
every other disease.  There  may be a preterna-
tural  discharge of urine in other affections; but
in this only is a  saccharine condition of that se-
cretion present.   Most of the more severe symp-
toms  of  this disease  are  attributable  to the im-
mense amount of solid matter  which is constantly
draining off from the  body ;  and  indeed  some
diabetic patients seem to sink  merely from the de-
bility occasioned by the continued secretion of an
unnatural quantity of urine containing so large a
proportion of animal extractive matter.  The ap-
petite, though voracious, is inadequate to the sup-
ply of nourishment sufficient  to balance  the im-
mense and rapid waste which is daily taking place.
" The loss of so much matter,"  Dr. Elliotson ob-
serves, " from  the system, sufficiently  explains
the hunger, the feeling of emptiness and  sinking
in the stomach, the emaciation, debility, anaphro-
disia, coldness of the legs, pain both of them and
of the loins, the depression of  spirits, &c. without
attributing  the disease  to  the  stomach or the kid-
neys exclusively.  The excessive escape of fluid,
or when  this does not take place, the feverishness,
equally explains  the  thirst and dryness of the
skin."
   It will be shown, when we come to the consi-
deration  of  the pathology of  diabetes, that  it  is
mostly complicated with disease in  some impor-
tant organs.   Dr. Willan observed that he never
met with a  confirmed case of this disease in which
there was not some considerable  disorder of the
constitution, or a defect in some organ essentia 
DIABETES.
609
to life.   Our experience leads us to bold this  re-
mark as not far removed from truth ;  although it
may be  said that the constitutional affections  are
more frequently the effects of the progress of dia-
betes, than the  concomitants of its  commence-
ment.  Pulmonic affections,  we  know,  not un-
frequently precede or accompany diabetes.  Dr.
Bardsley remarks  that he  scarcely recollects  an
instance of the disease where a slight  affection of
the chest did not more or less prevail.   In several
instances, too, on  record, a connection  between
phthisis  pulmonalis and  diabetes is strikingly
marked.   The phthisical symptoms existing pre-
viously  to  the  attack of the  latter disorder  are
often suspended by its influence ; but on the par-
tial removal of the diabetic complaint, the tuber-
cles pass rapidly through their several stages, and
the patient's  sufferings  are  terminated  by death.
A similar suspension of the progress of disease in
the lungs is  sometimes noticed in females who
become pregnant whilst labouring under the symp-
toms of confirmed phthisis.   The  cough, expec-
toration, and hectic  fever,  almost entirely disap-
pear, pregnancy  advances,  and  labour ensues;
when in the course of a  few weeks  (sometimes
days) the pulmonary symptoms return with  ag-
gravated severity,  the  strength  rapidly  declines,
and  life is soon extinct.  In  the  more confirmed
cases of this disease which have fallen under  our
notice, there has been generally present a teazing
tickling cough, sometimes attended with purulent
expectoration, and mostly  with  dyspnoea, and
shooting pains in the chest.
   The most common exciting causes have been,
 according to our experience, frequent exposure of
the body to sudden alternations of heat  and cold,
 and  an indulgence in  copious draughts  of cold
fluid when the system has  been over-heated  by
 labour or exercise.  In twelve  cases  that have
come under our observation, the patients have at-
 tributed  their ailment  to one of  these  causes;
 hence,  we have  observed  this  affection  chiefly
 amongst that class of artisans whose  occupations
expose  them to sudden changes of temperature,
 or who reside in damp and  low situations.  The
intemperate use of spirituous liquors,  poor living,
and  distress of mind,  not unfrequently operate,
too,  in  the production of this disorder.  It is a
curious analogous fact, that dogs and rabbits  fed
upon rye-meal, or on decoctions of wheaten flour,
have a species of diabetes produced ;  as has been
ascertained by the experiments of Dr. Krimer of
Halle.   The secretion of urine becomes much in-
creased : the urea and  uric  acid  almost or alto-
gether disappear; the animal becomes emaciated ;
and  in  place of sugar, the urine  is found loaded
with albumen  and  mucus.   The  origin  of  the
complaint has been traced  by some patients to
sleeping out  the whole of the night  in  the open
air, in  a state of intoxication.  The subjects of
this  disease have  been mostly  liable to profuse
sweating upon any ordinary exertion,  and at such
times have  been accustomed to  abate thirst by
drinking freely of cold  liquids, or  by eating  im-
moderately of acid fruits, thus suddenly checking
perspiration.  The  state of  the  mind  seems lo
have a  more intimate connection with this affec-
tion than  has been generally  supposed.   In seve-
ral cases on  record, mental anxiety and  distress
  Vol. I. — 77
have been assigned as its chief cause.   Indeed, a
temporary  diabetes insipidus  is a very  ordinary
effect of such a  state, and the despondency of
mind throughout the disease is distinctly-alluded
to by Aretieus, and by many other eminent writers.
  We have not observed the characteristic odour,
compared to that  of hay, from the persons  of dia-
betic patients, to  which Dr. Latham has particu-
larly alluded.  It  has  been  supposed that the phy-
mosis  before noticed  as a symptom  of diabetes,
proceeds from  the extreme sensibility  of the ure-
thra, which subjects it to the general irritation of
the system so frequently present in the complaint,
and thus renders  it morbidly sensible to the stimu-
lus of  the  urinous fluid.
  With respect  to the emaciation, it  may be re-
marked that Dr. Lubbock considered  it  a leading
circumstance in  this  affection: for  in his expe-
rience  it came on slowly, the subject  of  it  not
perceiving much  deviation from health.  " I have
at this time,"  he  observes, " two  patients who,
excepting a slight and very gradual wasting of the
body, some increase of thirst, with occasional un-
easy sensations about the stomach\ to which may
be  added,  feebleness  of sight at times, and an
habitual tendency to phymosis, possess that degree
of apparent health and strength that would mis-
lead a  common observer."  He conceived that the
emaciation claimed the first attention of the phy-
sician  ; as without the removal of this symptom,
neither the reduction of the urine, the  alteration
of its  quality, nor the appearance of considerable
remaining muscular  power, could  prove that the
disease had yielded to any curative process.
  Diabetes frequently  occurs  in  the  scrofulous
habit,  but is not confined to it alone.   Some  au-
thors are of opinion that the disease  may  be  he-
reditary ;  thus  Dr.  Prout observes,  he  cannot
doubt  but that a predisposition or tendency to this
affection exists in  some families, as he bas wit-
nessed four distinct instances  of such a circum-
stance.  The first was that  of  a young man
whose mother and uncle had died of  the disease;
the second was that of a lady about fifty years of
age, whose brother or sister had  sunk under the
complaint; the third was that of a girl  about ten
years of age, whose father two or three years be-
fore had died of the same affection ; tbe  fourth
instance was that of  a gentleman, aged fifty-four,
who died of this  affection, and whose father  had
laboured under the same disease for several years.
Dr.  Storer has noticed the occurrence of three
cases of diabetes  in one family, in the persons of
a brother,  sister,  and  her  daughter.   The father
of the two elder died  of  that affection.   In  an-
other  instance, related  by Mr.  Leigh  Thomas,
three brothers in  one  family laboured  under dia
betes.   Morton has also alluded to the hereditary
nature of the disease.  We believe that a tendency
to it is occasionally inherited ; but further expe-
rience and a more extended inquiry on this point
are necessary, before  diabetes can be correctly ar-
ranged like  scrofula,  phthisis, mania, and apo-
plexy, under tbe  head of family diseases; for in
not  a  few  instances no  hereditary origin  can be
traced.  Yet, it must be observed, that even of
these diseases, no two have exactly the same here-
ditary  influence, nor are any two  of them  modi-
fied exactly in the flame degree by ircumstances 
010
DIABETES.
while all of them are seen to spring up every day
in cases where no hereditary taint can be suspect-
ed ; so that, if a comparatively rare disease like
diabetes has been found  by Dr. Prout hereditary
in four times out of twenty, it  seems fair to ad-
mit, that, as in the case of a  great  many  other
diseases,  its supervention is often greatly favoured,
if not determined, by  hereditary conformation;
and little more can  be  said even  of scrofula  or
mania.
   Various  opinions have been formed concerning
the proximate  cause of diabetes.   Thus  some
authors  of eminence, like  Mead, have supposed
that it depends on a " morbid state  of the liver
and bile;" some, as Dobson, Home,  Cullen, and
Rollo, believed that it proceeds  from  a defect  in
the assimilatory  organs ;  whilst others, as Dupuy-
tren  and Thenard, have attributed the principal
phenomena of the disease to a " morbid action  of
the kidneys."   Dr. Baillie also thought it proba-
ble that diabetes was owing to  a deranged  action
of the secretory structure of the kidneys, by which
the blood there is disposed to new combinations ;
and that  the effect of these combinations was the
production of a saccharine matter.  He at the
same  time imagined  that the  chyle might  be  so
imperfectly  formed  as to cause the  blood  to  be
more  readily changed into a saccharine substance
by the action of the kidneys.   The ingenious au-
thor of the Zoonomia conceived that diabetes was
produced by a retrograde motion of the absorbent
vessels, owing to which chyle  passed from the
lacteals into the lymphatics  of the kidneys  or
bladder.  Cawley thought that in this disease the
tubuli uriniferi were enlarged or relaxed, by which
the chyle escaped into the urine.  Willis conclud-
ed that diabetes  depended upon a dyscrasy or in-
temperament of the blood, resulting from a mor-
bid action of the assimilating powers.  " Thus,"
he observes, « diabetes is rather and more imme-
diately an affection of the blood than  of the kid-
neys,  and it thence  has its  origin, inasmuch  as
the mass of blood becomes, as it were, melted
down, and  is too copiously dissolved into a state
of serosity,  which indeed  is very manifest from
the quantity of urine  so immensely increased,
which cannot arise  from  any other  cause than
from  this  solution  and waste  of  the blood:
whence also the blood, which is left in the  body,
the serum being thus copiously abstracted from it,
becomes  much thicker and more apt to coagulate,
as we may infer from  the quick  and laborious
pulse ; for on that  account  the  heart  acts with
more  rapidity, that the blood, which it thus agi-
tates  more  than  is usual, may be preserved from
coagulating."   The   two  hypotheses, however,
which refer the seat  of the disease to  a morbid
action of the stomach, and a morbid condition  of
the kidneys, have been most  generally adopted.
" Were I to give a theory,"  says Dr. Home, " to
explain the nature and symptoms of this wonder-
ful disease, I would say  that it arises from  a de-
fect  of the  animal   or  assimilatory  process,  by
which the aliment is converted into the nature  of
our body."
   Dr. Home considered the excess or defect  of
this   process as the  source of many disorders.
Rollo, too, observes that the  immediate cause  of
diabetes  mellitus is a morbid condition of the sto-
mach,  forming or evolving from  vegetable  sub-
stances saccharine matter, which is quickly sepa-
rated as a foreign body by the kidneys.   » But, to
be more particular," he continues,  " we allege that
this disease consists in an increased morbid action
of the  stomach, with too great a secretion, and an
alteration in the quality of the  gastric fluid, pro-
ducing saccharine matter  by a  decomposition of
the vegetable substances taken  in  with the food,
which  remains unchanged."   It has  been urged,
and  with  reason,  as  a very serious objection to the
theory of Dr. Rollo, that  no sugar bas  been de-
tected  in the  blood  of diabetic patients; a fact
which  we shall shortly show to  be established by
the interesting experiments of Wollaston, Marcet,
Nicholas, Gueudeville, Themard,   Bostock, Vau-
quelin, Segalas, and other able chemists.
   In several instances of the disease which havt
come under our own examination, there certainly
has  been ample  evidence of preceding stomach
derangement;  but admitting that the stomach  ia
generally in a state of morbid activity, as may be
inferred from the  increased and almost insatiable
appetite which accompanies  the disease, still we
are  ignorant  of  the particular condition of the
primae  viae which leads them to favour the extrac-
tion of sugar.  Dr.  Henry thinks  that the theory
must be  modified by assuming  that the blood
which  reaches  the kidneys contains the  elements
of sugar, and  is  deficient in those of urea.  He
supposes, however, that it is necessary to a just
pathology of the  disease that some morbid condi-
tion of the kidneys should be admitted, though of
a kind which  has not yet been  explained by ana-
tomical investigation.
   Dr.  Mason  Good  conceived that a morbid and
highly irritable state of the kidneys was sufficient
to account for every  other derangement that marks
the progress of the disease.   He saw no necessity
for supposing an  idiopathic affection  of any other
part, whether  the stomach   or the  nerves, the
digestive or the assimilating  powers ; but decides,
from the attention which he has paid  to the nature
of diabetes, both  in  theory and  practice, that the
whole  of its phenomena may be  traced to renal
mischief,  and   consequently  that  it is a  far less
complicated affection than has hitherto been sup-
posed.  That the kidneys are frequently in a state
of irritation  is evident from the pain, heat, and
weakness, experienced  in those organs,  and the
augmented urinary secretion.
   Dr.  Lubbock seems to have noticed the coinci-
dence  of the  parched and dry skin with the sac-
charine quality of the urine, from which he was
induced  to believe that in this  affection the want
of perspiration or excretion from the  surface  is
connected with sweetness of the  urinary fluid;
and this belief was  supported by  an examination
of the nature of  the perspirable fluids, and of the
component parts  of saccharine matter.   On this
view he has formed a theory  of diabetes.   " It has
been proved,"  he observes, " that  sugar is, for the
most  part, composed  of carbon,  oxygen, and
hydrogen, united  in a certain  ratio; and it ap-
pears,  by  the  experiments  of Cruikshank and
Abernethy, that,  besides  the occasional  aqueous
fluid discharged daily from the surface of the body,
about  three gallons of carbonic acid are also lost
to the system by the perspirable matter.  Now 
DIABETES.                                    611
supposing, as happens in diabetes, this perspirable
excretion,  or  carbonic  acid, is suppressed  and
retained in the system, it is probable that the car-
bon and oxygen of the acid so retained, by enter-
ing into a due combination with some portion of
the hydrogen of the animal body, may tend to the
production of the saccharine matter of the urine;
and as the carbonic acid is the general product of
the vegetable world, it would follow that its reten-
tion in the animal body may produce the pheno-
mena of the defective animalization, characterising
diabetes as exhibited in the formation of sugar."
   Dr. Latham  has broached a very fanciful hypo-
thesis concerning the proximate cause of diabetes,
founded chiefly on the dyscrasy of Willis, and the
selecting power of the kidney.  As it is impossible
to condense it, we shall be  satisfied with merely
mentioning that  it is quite as  untenable as  some
of its ancient  predecessors.  Dr. Ferriar has also
given a very vague opinion in explanation of the
phenomena of this disease.  He supposes that if
the extreme vessels should from any cause take on
a morbid action, and, instead of supplying nutri-
tious matter, should form a substance which cannot
be applied to renew the waste of the system, the
diseased secretion must either accumulate in the
intermediate passages of the circulation, where it
would produce hectic fever, (by absorption,) and
subsequently death ; or it must be carried off by
some of the emunctories, to which its stimulus
must cause an increased determination of fluids.
This he conceives to be precisely the case in dia-
betes.   He afterwards refers the secretion of sac-
charine matter in the kidneys  to  metastasis, and
supposes it to arrive there by  the circuit of anas-
tomosing branches.
   In a reply to some strictures of the reviewer in
the  Medical and Physical Journal, on a case of
diabetes  related  in the sixth volume of the Edin-
burgh Medical and  Surgical  Journal,  the editor
observes that  the  discharge in diabetes may be a
diversion of a profuse  secretion from the skin to
the kidneys ;  that besides being morbidly profuse,
it is, like other secretions, susceptible of a change,
 and may become stimulating even  to the  skin
itself, and consequently much  more so to the kid-
ney, where it then must certainly act as a foreign
body exciting  the organ to  extraordinary action ;
and that in the enlarged and excited state of the
vessels of the  kidney, time is not allowed for the
secretion of urine to be  perfect, and  that  chyle
 mry pass off with it, or it may be called the urine
of dijtstion or of the chyle, which in the healthy
state u passed two or three  hours after a meal,
and cannot be considered a natural secretion.  M.
Dezeimcris supposes that the proximate cause or
essence of diabetes  consists in irritation of tbe
kidneys ;  that this  irritation is rarely primitive,
being  mostly the result of  chronic  gastritis.   In
the course of the latter affection there  is  extreme
thirst;  the patient drinks freely,  and the urine is
in proportion : this state is prolonged ; the activity
of the kidneys increases every day at the expense
of that of the other excretory organs ; they remove
from the body those fluids which require constant
renewal, and  thus again contribute to augment
the thirst.
   Such are only a  few of the hypotheses which
have been framed to explain the nature  of diabe-
tes ;  but they are sufficiently numerous  to  show
how little  is  really  known respecting  it.   One
great cause of this diversity of opinion  is,  as we
shall hereafter show, the defective aid afforded by
pathological  investigation.  « Pathological anato-
my," as the late celebrated Laennec justly re-
marked, " is  incontestibly the  surest guide of the
physician,  either in  the recognition of  maladies,
or in the cure of those which  are  susceptible of
cure."    We have no theory of our own to pro-
pose; but  from all the  attention which we have
been able  to pay to  the subject, and from what
we have seen of the disease itself, it appears to us
proper to admit that the natural and healthy  action
of both  the stomach and kidneys is materially dis-
turbed ; the  former  perhaps  primarily,  and the
latter secondarily; and that the dry and unper-
spirable condition  of the skin is much more in-
timately connected  with  its  production than is
generally supposed: thus  diabetes is an affection
not proceeding from a morbid  action of one par-
ticular  part, but of  several  important organs.
This statement is sanctioned by facts, and  seems
to derive  confirmation  from  the symptoms, the
remote  causes, the effects, and  analogy with other
diseases.  We  have used  the word perhaps in
the above allusion to the primary derangement of
the  stomach, because in several diabetic  cases on
record  the increased secretion  of urine  preceded
every other symptom.   So constant is the sympa-
thy  between the kidneys and  the stomach, that
Sydenham himself has declared there is no other
mean   of  distinguishing between  nephritis and
lumbago than the expression of this sympathy in
the  former case by  vomiting.   It is possible that
increased  action of the  kidney may very  early,
though not primarily, call the  stomach into sym-
pathy.   In a communication from our friend Dr.
Milligan of  Edinburgh, he remarks that  the fa-
mous Peter Petit asks, in his  Commentary upon
Aretaeus, if the  excess of sugar is furnished by an
error of tbe digestive process, why does  it not
pass off by  the bowels, the lungs,  or the skin, as
well as by the kidney ?  " But this very profound
and philosophical question  is very easily answer-
ed by the  practical observation, that we know, as
a matter of experience, that  any excess of fluid
introduced  into  the  circulation  does  not readily
pass off by  the  skin,  lungs, or bowels, but seems
naturally and designedly in almost every instance
to be carried away by the route of the kidneys and
urinary passages ; and that, therefore, we have a
right to expect that it  will be  so here.   But  it
does not follow from this that  the first  profusion
of urine in diabetes is saccharine, nor yet that the
initial steps  of the malady are to be traced to er-
rors in  the action of the stomach or the skin: nay.
so great is the number of persons who at all times
labour  under disease of the two latter organs, that
on diabetes  commencing we  should require very
strong  proofs that some aggravation of the mor-
bid condition of these parts, unconnected with aiij*
suddenly interposed cause, took place  at the time,
before  we  admitted that they were instrumental in
producing diabetes."
   [For some other  views on  the nature of Dia
betes, see page  617.]
   We  must next  allude  to tbe prognosis lo be
 generally  formed in  this  malady.  It  has been 
612
DIABETES.
•atisfactorily proved that a saccharine condition
of the urine may exist during several years with-
out the general health being materially affected,
or the  powers of  the  stomach  much  impaired.
Diabetic patients, whose mode  of living has been
on the wbole temperate, have been known, in not
a few instances, to reach advanced age.  It is in
those cases, chiefly, where the  constitution has
been  previously injured by long-continued  and
frequent irregularities that  the disease  under con-
sideration proves rapidly fatal.   Whilst the diges-
tive  organs continue  to perform their functions
with  tolerable  vigour,  the supply  of  nutritious
matter will  be  found nearly adequate to  balance
the waste which is daily  taking place from the
increased  quantity of the urinary secretion.   We
have  at this time  two diabetic patients, who, ex-
cepting some  increase  of  thirst  and urinary dis-
charge, and occasional  disturbance  of  the  diges-
tive organs, enjoy  a fair share of apparent health
and  strength, and are fully equal to the various
exertions  that devolve upon them in the ordinary
intercourse  of  life.  The disease, however, ought
to be  viewed with  much concern, for it is too apt
to pursue its fatal  progress  in defiance of all the
resources  of our art.   It is difficult to establish a
perfect cure when  the characteristic  symptoms of
the affection have been once fairly developed.  We
find that even Aretaeus  alluded to its fatal nature.
He has remarked,  " that the disease  is chronic,
and generated by length of time ; but short is the
life of man when  its establishment  is fully com-
pleted."   The  perfect recovery of the patient de-
pends upon the removal, not merely of one, but
of the whole of the symptoms; for one  may be
relieved by the aggravation of another.   Though
there may be a  considerable reduction in the  quan-
tity of the urine, still if there be no alteration in
its quality, and the saccharine impregnation con-
tinues, the disease  cannot  witb  propriety  be said
to have yielded to  any curative process.  It is by
close  attention  to, and  an  early discovery of the
premonitory symptoms that we must hope to pre-
vent  a  fatal termination.   The  disease unques-
tionably may be controlled  at its commencement
by the employment of the  means hereafter  to be
pointed out; but  it unfortunately happens that
the malady has in  most instances made consider-
able  progress  before  the patient's attention  has
been  called  to  its  real nature.   Rollo, Beddoes,
Cleghom, Watt, Bardsley, and others have related
cases  of diabetes in which  a cure has been effect-
ed ; but this happy result is by no means  of com-
mon occurrence.  When the disease is complicated
with phthisis, scirrhus, or other organic mischief
in any important organ, all hope at once disappears.
  With regard  to the perfect cure of diabetes, it
is certainly  necessary to speak  with much  cau-
tion ;  for, like some other  formidable diseases, it
is for  the most  part only capable of being relieved,
and not of being  effectually removed.   "  Within
the last six  or seven  years,"  says Dr. Prout,
" nearly twenty cases  of diabetes have  fallen  un-
der my observation ;  and  among these,  I  have
never but  in one instance, and in that for a very
short  lime only, seen  the urine of a diabetic pa-
tient rendered quite natural."   Dr. Lubbock, too
never saw this disease yield to any curative mea-
sures  ; the emaciation continued  to increase more
and more, until after  a lingering and protracted
state of suffering,  the unhappy subjects of it at
last gradually sunk.   Of twenty-nine diabetic pa-
tients who have been  under our care, sixteen have
eventually died, strongly evincing  the fatality of
the disease;  eight  out of the  remaining thirteen
have perfectly recovered ;  and of the other five
we have received  no  account.   The  chances of
restoration to health are frequently diminished by
the  irregularities  of the patients  themselves, in
deviating from the  prescribed modes of treatment,
notwithstanding  the strongest promises on their
part to  comply strictly with  tbe wishes  of the
practitioner.
   Previously to enumerating the morbid changes
which have been observed after death in diabetes,
it may be well to inquire what light has been
thrown upon the pathology of this disease by che-
mical analysis of the urine and blood of diabetic
patients.
   Sensible Properties and Chemical  Anal-
ysis of the Urine  in Diabetes Dlellitus.—
Several  distinguished  chemists  (amongst whom
may be mentioned the  highly respectable  names
of Cruikshank, Fourcroy,  Nicolas  and Gueude-
ville, Thenard, Vauquelin  and  Segalas,  Dalton,
Bostock, Henry, and  Prout) have  sedulously oc-
cupied themselves in investigating  the properties
of diabetic urine,  and have performed  a variety
of interesting  experiments, with the view of de-
termining the precise nature of that morbid  secre-
tion.  The sweet  taste of diabetic  urine  seems,
as before observed, to  have been first distinctly
pointed out by our countryman Dr. Willis.  Since
his time, the existence of sugar  in  the fluid has
been satisfactorily  determined.   It  is worthy of
remark,  however, that the saccharine impregna-
tion of diabetic urine is not at  all times discover-
able by  the  taste ; for  that secretion has been
found  to vary at  different intervals  during  the
twenty-four hours.   In the case of a young lady,
related  by Mr. Shirreff, the urine voided  at one
o'clock was free from sweetness  and perfectly in-
sipid ; some  time  after it  appeared natural, but
two hours after  dinner was  sweet, and in  the
evening  again perfectly  natural.  The urine in
this disease has, it has  been already said, a pale-
straw colour.  It is mostly clear when  first voided,
but on standing some  time  in the vessel, not un-
frequently  deposits a white flaky precipitate.  Its
smell at  first strongly resembles that of new hay,
but in the course of a short time a faintish acid
odour may be perceived.   It has been stated that
the temperature of diabetic urine, when recently
voided, is lower than that of the healthy secretion;
but this is a point which we have examined with
much care, and we have found  that  no  marked
difference exists  between  them.  An  important
circumstance connected with the consideration of
the peculiar character of diabetic urine is its spe-
cific gravity.  The profession is unlcr obligations
to Dr. Henry  for having satisfactorily  shown that
the specific gravity of  the urine in diabetes  melli-
tus is  higher than  in  healthy urine; a circum-
stance which had been overlooked by some  of the
most eminent writers on the chemical history of
that disease.   In ten  cases  of diabetes where he
had an opportunity of determining this property,
it never  fell short  of  1028 nor  exceeded 1040; 
                                       DIAB]

1000  parts of water  at 60° Fahrenheit  being
taken  as the standard ; whereas in healthy urine
he never found the specific gravity, under any cir-
cumstances, to exceed 1020.   Dr. Henry has re-
cently informed us that subsequent  trials of the
specific gravity of the first  morning's  urine of
healthy persons lead  him to  believe  that  this  is
understated, though perhaps a fair average for the
whole day.  Dr. Henry  considers  the specific
gravity as a most useful test  of the existence of
diabetes in doubtful cases, and, when taken along
with the actual quantity discharged, as furnishing
a  tolerably correct idea of  the degree of morbid
action.  " It  may  be objected, perhaps, (he ob-
serves,) to  the employment  of this  test, tbat  it
requires more familiarity with the method of tak-
ing specific gravities than falls to  the lot of the
greater part of medical practitioners.   By means,
however, of an hydrometer, which is well known
to practical chemists, and which may be readily
procured  at a small expense, the specific gravity
of the urine  may be  taken  in a  few  moments,
and with  the greatest  accuracy, by  a person
wholly unaccustomed to experiments of this kind."
Deeming  it  desirable to establish  a connection
between the quantity  of extractive  matter and the
more  certain character  of specific  gravity, Dr.
Henry engaged in a series of carefully-conducted
experiments, and from them  constructed the fol-
lowing  table, which exhibits at  one  view the
quantity of solid matter in diabetic  urine of dif-
ferent specific gravities between 1050 and 1020.
The scale may be extended, however, by the rule
of proportion, to any case in which  the  urine
may be found to have a specific gravity  above the
former or below the latter of  those two  numbers.
In the experiments  which  furnished the above
data of the table, the  urine  was evaporated by a
steam heat till it ceased to lose weigbt,  and  till it
left an extract which became quite solid in cooling.
pecific gravity of	Quantity of solid	Quantity	of solid
urine compared	extract in a wine	extract in a wine	
with 1000 parts	pint, in grains	pint, in	
of water at 60°.	and tenths	oz. qr.	scr. gr.
1020	382.4	0 6	1 2
1021	401.6	0 6	2 1
1022	420.8	0 7	0 0
1023	440.	0 7	1 0
1024	459.2	0 7	1 19
1025	478.4	0 7	2 18
1026	497.6	1 0	0 17
1027	516.8 *	1 0	1 16
1028	536.	1 0	2 16
1029	555.2	1 1	0 15
1030	574.4	1 1	1 14
1031	593.6	1 1	2 13
1032	612.8	1 2	0 12
1033	632.	1 2	1 12
1034	651.2	1 2	2 11
1035	670.4	1 3	0 10
1036	689.6	1 3	1 9
1037	708.8	1 3	2 8
1038	728.	1 4	0 8
1039	747.2	1 4	1 7
1040	766.4	1 4	2 6
1042	804.8	1 5	1 4
1044	843.2	1 6	0 3
1046	881.6	1 6	2 1
1048	920.	1 7	1 0
1050	958.4	1 7	2 18 <3 „
3n
                                          613

  By referring to this table, we can readily ascer
tain the quantity of solid  matter voided by a dia-
betic patient in a given time.  Thus, as Dr. Prout
has noticed, suppose ten pints are passed in twen-
ty-four hours, of the average specific gravity 1040,
it is evident that this will contain 10X 1- .4..2..6
= 15..7..2, or upwards of a pound and a quarter
of solid extract.
  The quantity of extractive matter obtained from
diabetic urine  is liable to considerable variation :
but it is for the most part  in proportion to the vio-
lence and severity  of the disease, especially when
the patient is  not confined  to any rules of diet.
It has amounted in a few instances to more than
two ounces from one  pint (wine measure) of  the
fluid;  but the  medium quantity in even very  ag-
gravated cases  of diabetes  mellitus may be fairly
estimated at  not more than ten drachms of solid
extract.   The  specific gravity,  too,  sometimes
changes  in a very remarkable nianner.  In  the
case of a  patient lately  under out care, it was re
duced in  the course  of two days  from 1033 to
1022, and very shortly afterwards it reached 1042.
In another instance, alluded  to by Dr. Prout,  the
specific gravity was reduced  in about sixty hours
after the patient had commenced  with  the use of
opium, from 1038 to 1.1074.   The  saccharine
matter had apparently disappeared, and was after-
wards superseded  by  urea, the quantity of which
had become excessive.
   The able author just mentioned has shown that
an excess of urea  frequently precedes the appear-
ance of saccharine matter in the urine.   " Now it
is a remarkable fact," he  adds, " that in diabetes,
in proportion as the saccharine matter diminishes
under the above plan, that of urea generally in-
creases ; and  in such instances  the presence of
the former principle cannot only be no longer  dis-
tinguished by the sensible properties of the urine,
but scarcely be demonstrated by the utmost skill
of the most experienced chemist, though the spe-
cific gravity of the urine may at the same time be
nearly 1040."  Sometimes sugar is wholly want-
ing in diabetic  urine even when the urea has al-
together disappeared.  Dr. Young met with an
instance of this kind.  After evaporating the fluid
in a gentle heat, a brown  substance was dissolved
in abundance  in alcohol, and afforded a stiff  ex-
tract, which contained the lactic acid with a little
trace of lactate and muriate of ammonia, but con-
sisted almost entirely of the animal extract which
accompanied the lactates,  was precipitated by tan-
nin, and left after combustion a  little  muriate of
soda, which showed a slight trace of uncombined
alkali.
   It has  been matter of  dispute whether urea is
contained, in any  proportion whatsoever, in  dia-
betic  urine.  Whilst  Cruikshank,  Dalton, Four-
croy, Nicolas and Gueudeville, Thenard and Bos-
tock contend for the non-existence of urea in  tho
urine of patients labouring under diabetes, Henry
and  Prout maintain that, although the quantity
of that substance  be very much  diminished, still
it is never entirely absent.  Dr. Bostock published
a highly valuable paper on diabetes in the 6th  vo-
lume of Memoirs of the Medical Society of Lon-
don, in which he  stated  that he  had  procured
nitrate of urea in  abundance, along with oxalic
acid, from  the extract of diabetic urine,   lie was
TES. 
614
DIABETES.
afterwards induced to repeat his  experiments at
the request of Dr. Bardsley,  who  sent to him
several  pure specimens of saccharine  extract for
examination, having himself failed in  several in-
stances  to detect  any urea  in diabetic extracts.
The result was, that  Dr. Bostock found his  for-
mer inference to be erroneous, and with a candour
very honourable to himself, acknowledged that we
have no evidence of the  existence of urea in dia-
betic extract.
   In  the  experiments of the  seven first named
chemists,  the test employed to  detect the presence
of urea was the addition of  nitric acid to the ex-
tract  of urine  dissolved  in  a small quantity of
water.  On  treating  extracts  obtained by slow
evaporation from  healthy urine in this  manner,
they found  that a copious precipitation of nitrate
of  urea always ensued  ; whereas in  their trials
with diabetic extract  they seem to have failed to
discover any traces of urea.  Dr. Henry, however,
has satisfactorily  shown by several experiments
conducted for the  purpose, that the action of nitric
acid on the urea may be  prevented  by its agency
on the  greater  proportional mass  of  sugar.  He
has stated that urea cannot be made apparent by
nitric acid in the extract from  any  mixture of dia-
betic and natural  urine, when the former exceeds
the latter in a greater proportion than that of six
to one ; or when  the solid  urea is less than one-
twentieth of the weight of mixed  extract.  It is
on the  ammonia  which comes over early in the
distillation of diabetic urine, that Dr. Henry seems
disposed chiefly to insist, as establishing the  pre-
sence of urea,  because  there is no other animal
substance which  can give origin  to  the volatile
alkali under such  circumstances. " Another proof
(Dr. Henry observes)  of the existence of some
portion of urea in diabetic  urine, may, in many
instances, be obtained by a careful observation of
the phenomena attending its spontaneous decom-
position.   At a temperature exceeding 60° Fah-
renheit, diabetic urine passes rapidly to the acetous
state.   But if  the succession of changes be care-
fully watched, it will be found  that there is a point
at which, before  it becomes acid, it  exhibits,  to
sufficiently delicate tests, distinctly alkaline  pro-
perties."   " The deficiency of urea in diabetes,"
he adds,  " may be stated as being very considera-
ble.  In those cases where I  have attempted  to
estimate it, from the quantity of ammonia evolved
by the destructive distillation of the urine,  the
urea has not appeared  to  exceed from l-40th to
 l-60th the quantity contained in an  equal mea-
 sure of concocted healthy urine.   One specimen
 of diabetic extract, with which I was  favoured by
 Dr. Bardsley, approached so near to perfect white-
 ness, that there  appeared  to  me little reason to
 expect  any evidence  of  its  containing urea.  Yet
 even in the product of  the distillation of this ex-
 tract,  after being rectified with  the  addition of
 potash, ammonia  was found.   On distilling, also,
 a portion of the urine itself, the condensed liquor
 gave manifest  traces of carbonate of ammonia.
 This urine, however, contained a far less propor-
 tion of urea than I  had ever before  ascertained;
 not  exceeding, as  nearly  as I  could  estimate,
 l-80th of  the  natural  quantity.   Making every
 allowance, then, on account of the increased flow
 ■>f urine, it will  appear that the quantity of urea
discharged by persons labouring  under diabetes,
in any  diurnal  interval,  falls considerably short
of the quantity voided in a state of health."   We
have repeated these experiments  with great  care
on an extensive scale, and arc satisfied with their
accuracy.  Dr. Prout  also considers the absence
of urea  as by no means characteristic  of diabetes,
He admits that in this, and  some other affections
of the urine, very little urea is sometimes present:
but the  same be shows to hold with respect to the
other principles, many of which  are  deficient in
such urine as well as urea.  He never met with a
specimen in which it was entirely  absent.  It may
in fine be correctly stated  that there exists a defi-
ciency,  though  not a total want  of the urea, in
the  urine  discharged in  well-marked  cases  of
diabetes mellitus.
   [It would  appear, however, from the observa-
tions of Messrs. Christison,  M'Gregor, and Bon-
chardat, that urea is generally contained in  dia-
betic urine in larger  relative  proportion than in
health,  but that it is masked by  the presence of
sugar, and cannot be discovered by the addition
of nitric acid, except by peculiar  management.]
   It may be proper to notice the  effects produced
by certain re-agents, and  by  evaporation,  on
diabetic and healthy urine, according to the expe-
riments of MM.  Nicolas and Gueudeville.  1,
Tincture of turnsol  added  to diabetic urine re-
ceived a reddish violet tinge; with healthy urine
it assumed a deep red.  2.  Nitrate of silver occa-
sioned  in  diabetic urine a  curdy precipitate, of
which the colour, at first white, soon changed to
violet, and the liquor became limpid with a slight
tinge  of yellow; it  was  altogether  inodorous.
With healthy urine the same re-agent afforded an
abundant precipitate of a deeper violet colour, and
the liquor preserved a yellowish  red  colour,  and
emitted a strong urinous odour.  Each precipitate
consisted of nitrate and  phosphate of silver.  3.
Lime-water produced a milkiness in diabetic urine,
immediately rendering it  turbid,  and affording a
faint ammoniacal  odour.   After some time  a floc-
culent  precipitate occurred, of which a part re-
mained on the surface of the liquor, which became
as limpid as water: this precipitate was phosphate
of lime.   The  same  test also rendered healthy
urine opaque,  and the precipitate was white and
extremely buoyant; but  the  liquid  preserved a
fine lemon-colour; the precipitate,  a phosphate
of lime, was also  more abundant  by one-half.  4.
Concentrated sulphuric  acid added  to diabetic
urine afforded a beautiful  rose-colour, occasioning
at first  a slight effervescence.  The surface of the
fluid became covered with  a light  froth,  which
remained for a long time, and there was scarcely
any precipitate :  the  liquor was   inodorous.  At
the instant of mixing sulphuric acid with healthy
urine,  the effervescence  was scarcely perceptible
 and the foam was slight.   The liquor assumed  a
reddish brown colour, and preserved the odour of
 urine :  at the bottom of the vessel was observed  a
small  quantity  of a  darkish red precipitate.   Dr.
 Henry has mentioned to  us that on adding nitric
acid, moderately  diluted, to  diabetic urine,  he has
often observed a change of colour to a red, resem-
bling that of a  weak acidulated  infusion of  rose-
 leaves, and  an immediate  and very sensible in-
 cr- i-:;-  of the saccharine odour.   5. Muriate of 
DIABETES.
615
barytes rendered diabetic urine somewhat turbid ;
and in a short time a slight precipitation  took
place  of  a white  salt,  which  was  sulphate  of
barytes. The same re-agent produced a like effect
upon  healthy  urine :  but  the precipitate was
rather more abundant, and of a brownish red co-
lour.  G.  Oxalic acid afforded with diabetic urine
a  light rose-coloured  flocculent  precipitate,  of
which a considerable part  was held in suspension
in the liquor.   The same acid threw down a pre-
cipitate with  healthy urine,  but  it  was heavier
and of a deeper colour.  7.  Sulphate of mercury
rendered  diabetic  urine slightly turbid, and  gave
it the appearance  of a white  salt.   A precipitate
of a reddish  tinge  gradually occurred, one-half
of which remained suspended in the liquor. Treat-
ed by the same re-agent, healthy urine assumed a
brownish red  tinge : the  precipitate resembled a
lilac-coloured salt, and was  wholly  deposited at
the bottom of the vessel.   It was the phosphate
 of mercury.   8.  Pure potass  rendered  diabetic
 urine turbid, and afforded a small portion of am-
 monia;  a white  precipitate  was  afterwards  pro-
 cured in small quantity.  The precipitate afforded
 by the same re-agent with healthy urine was on
 the  contrary  abundant, and the disengagement
 of ammonia  very considerable.  9. Muriate of
 lead communicated  to morbid  urine a milky co-
 lour ;  the precipitate which  ensued was that  of a
 white salt, slightly tinged  with red ;  it was a
 phosphate of lead : the liquor  remained transpa-
 rent.  Muriate of lead imparted to healthy urine
 a violet  colour, and produced  a  red precipitate;
 the  liquor remaining of  a  brownish red colour.
 10.  Diabetic urine precipitated  nitrate of mercury
 of a rose colour , and the  liquor became as limpid
 as water.  The precipitate of nitrate of mercury
 by healthy urine  was also of a rose colour,  but
 more abundant; and the liquor preserved a brown
 tinge.
   Analysis by Evaporation.— 1. After exposure
 to the air during six  weeks, (from 10° to 12°
 Reaumur, 54° to 59°  Fahr.,)  diabetic  urine be-
 came turbid within the first  six days, and gradu-
 ally deposited a white flocculent substance, which
 was found to be albumen.  The liquor afterwards
 became  limpid and slightly coloured, having a
 sour odour and acid taste exactly resembling vine-
 gar made  with  milk.   Healthy urine, after like
 exposure to the  air during the  same period,  soon
 exchanged its natural odour  for one  that was
 strongly ammoniacal; its colour became brown,
 and in the end it putrefied, affording a very fetid
 and offensive smell.  The precipitate was pulve-
 rulent, and composed of phosphate of lime, soda,
 and muriate  of soda.  2. Diabetic urine became
 acid, and  turned blue vegetable tinctures  red;
 whereas, healthy urine,  when putrid,  rendered
 the  same tinctures  green.   3. This  acid  urine
 combined perfectly with carbonate of potass in so-
 lution, without marked effervescence ; the liquor,
 after filtration and evaporation, furnished acetate
 of potash, mixed with a  small quantity of phos-
 phate of potash;  the  precipitate  obtained was
 scanty, of a white colour, and composed of lime
 and a small portion of magnesia. 4. Four pounds
 of diabetic urine afforded, on evaporation carefully
 conducted, four  ounces and a half of extract, of
'he  consistence of honey, of a brown colour, like
to treacle, and  having the odour of burnt sugar;
whereas  only three ounces  six  drachms  of an
extract of  tbe  consistence of honey, of a very
brown colour and  urinous odour, were  obtained
from four pounds of healthy urine.   5. Ten parts
of diabetic extract were mixed with four  of muri-
ate of lead  and  one of powdered  charcoal, and
after being dried they were submitted to distilla-
tion in  a  retort.   Little or no ammonia  was
afforded, but carburetted hydrogen  and a  black
fetid  oil.   The residue in the retort, on being
subjected to  an intense heat, gave  no traces of
phosphorus.  The extract of healthy urine, treated
in  the same manner, furnished  ammonia  and  a
fetid oil; the residue contained some muriate of
ammonia, and when  thrown upon  ignited char-
coal, emitted the  odour of phosphorus.  6.  One
ounce and two drachms of diabetic extract  being
treated with  four ounces of alcohol, at 35° Reau-
mur,  afforded a yellow fluid  resembling Spanish
wine ; the solution of the matter was nearly com-
plete, and  the  liquor  deposited,  in  the  space of
twenty-four  hours, a  light, flocculent, grey sub-
stance,  which, when washed and dried, weighed
only  twenty grains;  its taste  was  saline and
slightly sweet.   Lime-water, added  to  one por-
tion of  the  residue, afforded  a feeble ammoniacal
odour;  sulphuric acid, applied  to the other por-
tion,  changed it to a black colour, and  produced
the odour of sulphurous acid gas, indicating the
presence of albumen.   An equal quantity of the
extract of healthy urine, treated with alcohol,
afforded an abundant precipitate, composed of the
phosphates of magnesia, lime, soda, and ammonia,
uric acid, benzoic acid, and albumen.  Urea and the
muriates of ammonia and soda were held in solution
in  the liquor.  In order to obtain these different
substances separately, the fluid was evaporated,
and the residue being  dissolved in  water, nitric
acid was added to it, which occasioned  a copious
precipitate.  This precipitate was  found to be a
nitrate of urea.   7. On submitting diabetic extract
to  distillation with nitric acid, nitrous vapour was
disengaged ; the  residue being  dissolved  in dis-
tilled water  afforded,  on evaporation, oxalic acid,
and a small  portion of phosphoric acid.  8.  Four
 ounces and a half of diabetic extract, of the con-
 sistence of  honey, being dissolved in a pound of
distilled water, with half an  ounce of yeast added
 to it, and exposed to  a temperature of 15° Reau-
 mur  during  twenty-four hours, readily fermented,
 and  afforded a considerable  quantity of carbonic
 acid  gas.  After the fermentation was  over, the
 whole being submitted to distillation yielded ten
 ounces  of a spirituous  liquid.   Such  were the
 chief methods  employed by  MM.  Nicolas  and
 Gueudeville, with the view of establishing the
 peculiar nature  of diabetic  urine.   Dr. Bostock
 also  submitted portions of diabetic  urine to the
 action of different re-agents.   His experiments,  as
 well as those of Cruikshank,  Nicolas, and Gueude-
 ville, satisfactorily prove that  the  different salts
 exist in diabetic urine, nearly in tbe same  propor
 tion  to each other as in the healthy state of the
 fluid, but that they  amount only to about one-
 third of the absolute quantity.  Sometimes dia-
 betic urine has been found to contain a small por-
 tion  of blood, (as in the case  of Stevenson, related
 by Dr. Watt,) and  occasionally a  white milky 
616
DIABETES.
like fluid resembling chyle.  Having thus noticed
the principal circumstances  connected with  the
urine in diabetes, it may be proper to allude to
the state of the blood in that disease.
  Analysis of the Blood in Diabetes.—Nico-
las and Gueudeville, Wollaston, Marcet, Henry,
and some other eminent chemists, have performed
many experiments to determine the existence or
non-existence of sugar in the blood  of  persons
labouring under diabetes  mellitus.   Dr. Rollo
stated (in the case of Captain Meredith) that the
patient was bled, and the blood was kept for seve-
ral months without  undergoing  any  putrefactive
process; while a portion of healthy blood, taken
at the  same  time and  placed  in the  same room,
exhibited evident marks of considerable putrefac-
tion in four days, and was obliged to be thrown
away on the seventh.   Nicolas and  Gueudeville
ascertained  that  the blood of diabetic patients
afforded some serum, a small  quantity of fibrine,
and was less animalized than  that of persons in
good  health, but that it contained  no saccharine
matter.   Having satisfied himself how the albu-
minous part of healthy serum could be most com-
pletely coagulated, and by what  appearances  the
presence of sugar that had been added to it would
be most easily discerned, Dr.  Wollaston added
half a drachm of muriatic acid, previously diluted
with one drachm and a half of water,  to  six
drachms of serum, and immersed the phial  con-
taining them in boiling water during four minutes.
In the course  of a few hours  a  drachm or more
of water exuded from the  serum  that had been so
coagulated.   A drop of this water being  evapo-
rated, the salts which  it contained were  found to
crystallize, so that the  forms of the crystals could
be  easily distinguished; they were principally
common salt.   If any  portion of saccharine mat-
ter were added to the serum previous to coagula-
tion, the crystallization of the  salt was impeded,
or wholly prevented, according to tbe quantity of
sugar present.   By the addition  of ten grains to
the ounce, the  crystallization of the salts was en-
tirely prevented,, and the degree of blackness  and
disposition to deliquesce was of course more mani-
fest than with smaller quantities.   As a further
test of the absence or presence  of sugar, Dr. Wol-
laston added a little nitric acid to  the salts  that
remained after  crystallization  of the drop.   He
found that when the serum had been successfully
coagulated without  any addition of sugar,  the
nitric  acid merely  converted  the  muriatic  salts
into nitrates, and nitrate of soda was seen to crys-
tallize  without  foam or blackness.   But when
sugar had been added, a white foam rose round
the margin  of  the drop, and if further heat were
applied it became black, in proportion to the quan-
tity  of sugar present.  On  applying the above
tests to diabetic blood  and serum, Dr. Wollaston
failed to detect any traces of sugar.   Dr. Henry
performed some interesting experiments  on  dia-
betic blood, as noticed  by Dr. Ferriar, which  con-
firm the results of Dr. Wollaston's analysis.   Dr.
Prout has also  made a comparative examination
of the blood of a person labouring under  con-
firmed diabetes, with healthy blood.  He states  that
he was induced to undertake it with the intention
principally of determining whether the  quantity
of izote was the  same in  each.  The  diabetic
blood presented the usual appearances of healthy
blood.   The following were the results of his ex-
periments:—
Specific gravity of the serum of diabetic
                 blood..............   1029.5
---------------of the urine of the same
                 person, voided  at the
                 same time...........   1044-8
One hundred grains  of  the  diabetic serum, eva-
  porated and dried to the standard formerly men-
  tioned,  left ten grains of solid matters, which
  upon analysis were found to consist of albu-
  men ...............................  8-7
Lactates and animal matters usually existing
  in the blood........................   -6
Salts................................   -7

                                          10-

" Which very  nearly coincide," says Dr. Prout,
" with the proportions ascertained  by Dr.  Marcet
and  Berzelius  to  exist in the serum of  healthy
blood.   One  hundred grains of the diabetic urine,
evaporated and dried as before, left 11-7  grains,
nearly the whole of which was sugar.  Portions
of albumen from the serum  of this diabetic blood,
dried and analysed as before, yielded precisely the
same results  as albumen from the serum of healthy
blood."—" To  ascertain," Dr.  Prout continues,
" the relative proportions of  azote present in the
diabetic urinous extract and the  extract from
healthy urine, portions  of them were burnt with
the oxide  of copper.  The  results were, that one
hundred parts of the  diabetic extract (abstracting
alkaline and earthy salts) yielded only 6-5 parts
of azote, while the same quantity of extract from
healthy urine yielded from thirty-five to forty parts
of the same principle.   To obviate the objection
that the saccharine  matter of the urine might be
formed from  the other principles of the blood and
not from the  serum, comparative experiments were
made with the cruor of healthy  and of  diabetic
blood.   The results were precisely similar as to
the quantity of azote in both, and at  the same
time the quantity of azote  did not differ much
from that found to exist  in the serum above men-
tioned."  From these experiments of Dr.  Prout's,
it may be safely inferred  that the blood of  diabetic
patients contains an equal quantity of azote with
that of healthy persons.
  We  may  observe here,  that  Dr. Wollaston
thought that, in order to account for the presence
of sugar in  the urine, we must  either suppose a
power in the kidneys of  forming this new product
by secretion, or—if we admit  that the sugar is
formed  in the  stomach by a process of imperfect
assimilation, — must then allow the existence of
some channel of conveyance from the stomach to
the bladder without passing through the general
system  of  blood-vessels.  He conceived,  that if
prussiate of potass could be taken with safety, its
presence would be discerned by a solution  of iron
in as  small  a proportion as almost any  known
chemical test.   Finding that a  solution  of this
substance might be taken without the least incon-
venience, and  that in less  than one hour and  a
half the urine became  perceptibly  impregnated
with it, although the quantity employed  had not
amounted to more than three grains *f the salt, 
DIABETES.
611
he administered to a healthy person, about thirty-
four  years  of age, a dose corresponding to three
grains  and a half of the dry salt, and repeated it
every hour to the third time.   The urine being
examined every half hour, was found in two hours
to be tinged, and  to  afford a deep blue colour at
the end of four hours.   Blood was then taken
from the  arm, and the coagulum, after  it had
formed, was allowed to contract so that the serum
might  be  fully separated.  He then endeavoured
to ascertain the presence of the prussiate by means
of a solution of iron,  but  without  effect.  Dr.
Marcet also performed several  interesting  experi-
ments  at  the request of Dr. Wollaston on this
point.  In one experiment  he administered five
grains  of prussiate of  potash dissolved in water, to
a young  woman labouring under diabetes melli-
tus ; and  the proportion was repeated every hour
till she had taken thirteen or fourteen such doses.
After the fifth dose, her urine, by the addition of
a drop or  two of a solution of sulphate  of iron,
turned blue instantly.   At' this period of the  ex-
periment, a blister  was  applied to her  stomach,
and after a few hours, whilst still taking the prus-
 siate of potash, and whilst the urine strongly indi-
 cated  its  presence, the  blister was cut and  the
 serum collected.  This serous  fluid being, in the
 same manner as the urine, subjected to  the action
 of a solution of sulphate of iron, did  not suffer
 any change of colour in the least indicative of the
 presence  of  prussic  acid.  Yet  the urine still
 remained capable of imparting a blue colour to
 solution of iron, fifteen hours after taking  the last
 dose of  the prussiate  of  potash.  Dr.  Marcet
 afterwards repeated Dr. Wollaston's experiments
 on the serum itself, and with a similar result.  He
 also found that the susceptibility of the passage
 by which prussiate of potash is transmitted to the
 bladder seems  to vary  in different  individuals ;
 for  in five trials  he failed to discover any vestige
 of that salt in the urine of persons who  had taken
 it in quantities sufficient to produce its appearance
 in others.
   These  experiments,  though highly interesting
 and ingenious, still fail to  establish the fact of a
 direct communication between the digestive organs
 and the kidneys or bladder, by which sugar may
 be conveyed from the former to the latter without
 its entering the general circulation.  It is known
 that other substances  are also met with in the
 urine, such as urea  and lithic acid, which have
 never been detected  in the blood or other fluids
 of the body.  We have ourselves also carefully
 analysed  the blood  taken  from  several  diabetic
 patients, but never could detect the existence of
 sugar in it, nor indeed any marked difference in
 its chemical composition from blood in the healthy
 state.  Hence, it may be concluded that saccharine
 matter does not exist ready formed  in the serum
 of diabetic blood ; unless, indeed, we suppose with
 some modern Continental writers, that  sugar, like
 mercury, upon entering the blood, unites itself in-
 timately with the albumen, and constitutes a new
 compound of unknown properties, and which con-
 sequently sets our tests at defiance, although easily
 decomposed  by the glands, of which organs  this
 species of separation seems the natural office.   It
 is not more difficult to conceive  how a kidney
strongly excited by a redundant efflux of blood to
its tissue, should convert part of the elements of
the latter into  sugar, than  that the  mammary
glands of a  woman should be found to perform
the same thing in the sugar of the  milk which it
secretes upon  a similarly  sudden  determination
of blood to it after parturition.
   [This  negative evidence has been suffered to
prevail with the  generality  of  pathologists, al-
though it had been observed that the fluid of trans-
piration was sweet.   Recently, too, as before ob-
served, saccharine matter  has been  detected  in
the saliva.  It is clear,  therefore, that  the  blood
whence these secretions  are formed must contain
sugar or  the elements whence it was formed.  Of
late, however, respectable chemists  have affirmed,
that they have  unequivocally  discovered  saccha-
rine matter in the  blood.   To obtain  diabetic
sugar, the serum was coagulated by Mr. M'Gre-
gor, and  carefully dried by heat.  The solid mass
being divided  as  minutely as possible  by a pair
of scissors, was boiled in water, and the decoction
having been filtered  through  paper was  evapo-
rated to  a certain  extent.    The concentrated
liquid, on the addition of yeast, fermented strongly
for several hours.  Not satisfied with these re-
sults, and desirous of tracing the presence of sac-
charine matter still farther back,  Mr.  M'Gregor
instituted several experiments, from which he is
led to infer, that the stomach in  diabetes, forms
a preternatural  proportion of sugar, and  that the
admission of the saccharine matter into the chyli-
ferous vessels,  and the  consequent presence of a
material  in the blood,  which  is  foreign to  its
healthy composition, is the cause of the different
morbid phenomena of diabetes;—the kidney merely
separating—as the great  depuratory organ—the
foreign  material conveyed to  it  from  the  blood.
   Pathology of Diabetes. — It is matter  of
regret, that hitherto the most careful anatomical
research has afforded no satisfactory information
concerning  the origin of this complicated  malady.
Various  morbid changes have been detected or
the post-mortem examinations of diabetic patients,
but these, in not a few instances, may more pro-
perly be  considered  as  the effects than  as the
causes of the disease.  The kidneys are more fre-
quently met with in  a morbid state than  any of
the other abdominal viscera;  their size  is occa-
sionally  much  augmented.   In  four  fatal cases
under our own observation in immediate succes-
sion, these organs were  greatly enlarged, and the
ureters were  considerably  dilated. Dr.  Duncan
has related a case of diabetes in  the Edinburgh
Clinical Reports, in which the kidneys were much
larger than common ;   and Dr. Rutherford  and
other pathologists have noticed an unnatural in
crease of their  size.  The texture  of the  kidneys
in some instances is firmer, in others more flaccid
than usual;  their vessels are also  occasionally
preternaturally  enlarged;  and their surrounding
cellular membrane has more than once been found
filled with  a  gelatinous substance.  In the  case
of Robinson,  mentioned by  Dr. Rutherford, the
kidneys  were much augmented  in bulk, soft, and
their surfaces painted with numerous vessels; tne
vessels were uncommonly  dilated.  The emulgenl
vein of the right side was not under three-fourths
Vol. I. — 78
3b 
618
DIABETES.
i.f an inch in diameter, as it appeared distended
with blood.   The  ureters also were considerably
dilated ;  the  bladder seemed  capacious, its coats
thickened, and it was half filled with liquid.   In
the dissection, too, of Ann Laidlow, given by the
same author, the kidneys were  found somewhat
enlarged,  and on  cutting into  them the  tubuli
uriniferi were more  distinct than  usual, and the
pelvis  of each  was  also considerably increased;
but no other  morbid change of structure was per-
ceived.   Mr. [Sir  B.] Brodie, on  examining the
kidneys of a  patient of Dr. Warren's, who died of
diabetes, found them to possess an unusually firm
and grisly texture.  In order to ascertain the state
of the blood-vessels, he injected one of the  kid-
neys with  size and  vermilion previously to exa-
mination ; the other was allowed to remain in its
natural state.  On cutting into the substance of
the  injected  kidney, the  cortical part appeared
unusually red,  and the cryptae were seen more
numerous, larger,  and more distinct than  ever
occurs under circumstances of the most fortunate
injection.  The blood-vessels of the cortical  sub-
stance of the kidney which had not been injected
were unusually turgid;   the  ureters,  emulgent
artery,  and  vein,  were of natural dimensions;
the renal capsules were firmer and harder in their
texture than usual, and seemed  to partake of the
grisly structure  of the kidneys :  the bladdder was
sound.  M. Dezeimeris  noticed the increased bulk
of the  kidneys in three cases of  diabetes, which
occurred at the  Hotel Dieu in one year.   " In all
the cases  the volume of the kidneys was much
enlarged;  all their vessels were considerably de-
veloped, and their tissue, which was gorged with
blood, and of  a deep  red colour, could be  torn
with the greatest facility."  It appears from an
interesting and  extremely minute  examination of
a case of diabetes conducted by Dr. Monro, that
all the glands of the absorbent system were either
enlarged or morbidly altered  in  structure.  Upon
dividing the right kidney into two equal portions
by a longitudinal  incision, it seemed  as if it had
been very  successfully injected.   Many  blood-
vessels, both in the cortical  and  medullary part,
were filled with florid blood, owing  to which the
distinction between these parts was  not well de-
fined.   A transparent yellow-coloured substance
was found effused on tbe outer  side of  the pelvis
and infundibula.
   Dr. Beer met with a very remarkable degenera-
 tion of both  kidneys in the body of a young man,
 who had for a long time laboured under diabetes.
 They  were  extended by hydatids, contained in
 their interior substance, to such an enormous size
 that each was  one foot  long   and  seven inches
 broad,  and  the ureters were of  the size of the
 thumb.
   The ureters  and bladder  are sometimes  con-
 siderably dilated.   In  one instance, Dr. Duncan
 found  the  bladder capable  of  containing  five
 pounds  of urine, and  he states  that about that
 quantity remained  in  it after death.   It  had  its
 natural form, and its parietes were rather  thinner
 than usual,  although the  muscular fasciculi were
 very well marked.  Its inner coat presented a per-
 fectly healthy appearance, and tbe  ureters  were
 about one-fourth of an inch in diameter : the sym-
 pathetic and splanchnic nerves were also enlarged
to nearly three or four times their usual size.   In
the dissection  of a diabetic patient of Dr.  Pear-
son's, mentioned in Dr. Rollo's work, the kidneys
were found to be  in  a perfectly  sound state, and
so were the ureters;  but the urinary bladder was
much thickened, and  the  urethra was  dilated  to
three or four  times its usual width ; in  another,
related by Dr. Marshall, the kidneys had assumed
a  chocolate colour, were  large,  and the texture
soft and flaccid, particularly that of the portion
comprehending the tubuli uriniferi : the bladder
exhibited nothing unusual.  In the case of Oliver
Ormrod, detailed  by Dr. Clark,  the  ureters were
very much dilated, and through their whole course
measured full half an inch in diameter.  In two
cases, we have found the bladder much contracted
and thickened.  In one instance the capacity  of
this viscus was so much diminished  as not to ad-
mit more  than a  small  egg; in the  other,  the
parietes of the bladder were even more thickened.
   As post-mortem examinations  in cases of death
from this disease are  always interesting,  we shall
detail  the  following one which recently occurred
in our own  practice.  The external  cutaneous
veins were distended with  fluid blood.  On de-
taching  the scalp, some  ounces  of  blood issued
from the cut surface ; the  pericranium was redder
than usual.   The encephalon, and its containing
membranes, appeared free  from disease.   On rais-
ing the  sternum from the pleura, there were ex-
hibited no traces of recent inflammation, but exu-
dations of coagulable lymph appeared on the sur-
face of the pleura pulmonalis, which had formed
pretty strong  bands  or partial  adhesions to the
pleura  costalis, particularly on  the right  side.
Lungs  sound.  Nine ounces of fluid were found
in the right cavity of the thorax, and eight ounces
in the  left; the quantity  of liquor pericardii was
about half an ounce.  Gall-bladder distended with
bile.   Liver larger than  usual,  and of  a  firmer
 consistence.  Spleen of natural size, though rather
 denser than common. The urinary bladder was
full.   The left kidney had undergone a remark-
 able diminution in bulk, being not more than one-
 third of its usual size.  After the removal of fat,
 &c. it weighed ten drachms (troy weight) ;  it was
 otherwise  healthy, with  the exception  of some
 small hydatids on its surface.   The right kidney
 weighed five  ounces  six drachms (troy weight);
 its surface was a little irregular.  The stomach
 was inflamed on its posterior side and  next the
 cardia ;  the inflammation only affected  the inner
 membrane, which was also slightly corroded by
 the gastric juice.   It contained five ounces of half
 digested  cream-like  fluid.  In this  instance,  the
 diminished size of the left kidney formed the most
 singular feature in the dissection.
    MM. Dupuytren and Thenard, on the examina-
 tion  of a  diabetic patient, met with the stomach
 in a very much  enlarged state: its vessels were
 greatly  dilated, and forming upon the internal
 membrane of the organ a red net-work.  It also
 contained a considerable quantity of uninflamma-
 ble gas. and a small  portion of a greyish liquid, in
 which -vere floating seven or eight small, yellow
 ish, round, fatty substances.  The duodenum, and
 upper part of the jejunum and ileum, were some-
 what reddpr and thicker than natural; no appear-
 ance of disease was  discoverable in any other part 
DIABETES.
619
of the  intestinal  canal.   The  liver,  spleen, and
pancreas were  sound.   The   gall-bladder  was
moderately  filled with healthy bile.   The kidneys
were at least  one-third larger  than usual;  their
structure was  soft and of a grey colour, but in
every other respect  natural.  The other  organs
connected with the urinary  apparatus were free
from disease, though  the  bladder was very small.
The abdominal  lymphatic system, and the  tho-
racic duct,  were  more than ordinarily developed.
The arterial and venous  systems  had undergone
no morbid  alteration.   The lungs adhered to the
sides of the chest by loose cellular tissue.  In the
right lung there were  some small vomicae contain-
ing pus; in the left, several cysts completely  filled
with an elastic fluid.   The muscles were pale and
flaccid, but otherwise  in  structure quite healthy.
   Dr. Baillie has also left an account of the post-
mortem examination  of a person who  had  been
long affected with diabetes, and had been a patient
under his  care in  St. George's Hospital.  The
state of the  kidneys  is  very  minutely noticed.
" Both were of the ordinary size and shape. When
the proper capsule was removed from each, the
veins on the  surface were  much  fuller of blood
than usual, and  had  an  arborescent appearance.
When the  substance of both kidneys was cut into,
it was  observed  to be every where much  more
crowded with  blood-vessels tban in a natural state,
so as in some parts to approach to  the appearance
of inflammation.  Both  kidneys  had  the  same
degree of firmness to tbe touch as when healthy,
but they were  hardly so firm as kidneys usually
are the vessels of which  are so much filled with
blood.   A  very small quantity of whitish  fluid, a
 good deal resembling  pus, was  squeezed out from
 one or two of  the infundibula in both kidneys, but
 there was  no  appearance of ulceration in either.
 The artery and vein  passing into the cavity of
 each kidney presented exactly the natural appear-
 ance.  After separating, a good deal, the cellular
 membrane  which joins together the blood-vessels,
 was discovered a lymphatic passing  from  one  of
 the  kidneys :  it was  of the usual size, had the
 common valvular appearance,  and  was  empty.
 There were doubtless  several others belonging to
 both kidneys,  but they were so small as not  to be
 distinguishable.   The nerves of the kidneys were
 of the usual size, and the  ureters of both were per-
 fectly natural.   The renal capsules appeared  quite
 healthy.  The structure  of the  liver, stomach,
 spleen,  pancreas, intestines, and urinary bladder,
 was perfectly  natural, but one or two of the me-
 senteric glands contained a considerable quantity
of earthy matter."
   Organic changes are sometimes discovered in
 the internal structure of the kidneys  in diabetes.
 We may state as a pathological fact of some im-
portance,  that in three instances  of this disease
 we have detected the peculiar granulated or mot-
  led condition  of these organs,  so well  described
ny Dr. Bright as occurring in dropsical affections
accompanied with albuminous urine.  The cortical
part had lost all appearance  of  its natural struc-
ture, and presented a tolerably uniform  yellowish
colour with many yellowish-grey spots.  The me-
senteric glands in two cases were  much enlarged
and indurated ; and  in the other,  several  vomicae
were detected in the right lung.  There  was no
 evidence of organic disease in the liver or in any
 of the  other  abdominal viscera in the latter in-
 stance.
   Besides these morbid conditions of the kidneys
 and their appendages, a diseased state of  the sto-
 mach and lungs  has also been noticed  in this
 affection.  The former organ has  been found to
 exhibit marks of inflammation, and the latter have
 been studded  with tubercles in different stages of
 their progress.  In a fatal case of diabetes, which
 occurred in the Manchester hospital a few months
 since, both lungs were tuberculated ; and except
 dilatation of the pelvis of the kidneys and of the
 ureters, there was no  perceptible disease of the
 urinary organs.   The pulmonary affection was
 subsequent to the diabetes, therefore it cannot be
 said tbat this affection was excited by the former.
 In most of the dissections on record,  the mesen-
 teric glands have  afforded evidence of structural
 derangement; and from  our own observation we
 should say, that  next to the enlarged and flaccid
 state of the  kidneys,  this  is the most  uniform
 morbid appearance in  diabetes.   We not unfre-
 quently meet with similar  disease of structure,
 however, in  diseases very different both  in  their
 nature and symptoms from the  one under consi-
 deration ;  hence,  it  is not singular that such an
 infinity of hypotheses should have been advanced
 to account for the phenomena of this malady.  In
 some examinations of diabetic patients  no trace
 of organic disease has been discoverable.   An in-
 telligent practitioner informed us during the lasl
 year, that  he  had  recently examined the body of a
 young man,  twenty-one  years of age, who  had
 died  of this disease, without being  able  to detect
 the least deviation from healthy structure in  any
 of the  cavities.*   The different morbid appear-
 ances in the stomach, liver, and  lungs, noticed
 above,  are undoubtedly in some instances merely
 accidental  attendants; and indeed  the  diseased
 state of the kidneys themselves is, we conceive,
 mostly the consequence of long-continued morbid
 action.  The ureters, too, become dilated, and the
 bladder contracted  and thickened, from the con-
 stant passage of  such an increased quantity of
 urine.  From these observations, it is evident that
 the information regarding the nature of diabetes
 derived from  dissection is very unsatisfactory, and
 that  up to the present period we are ignorant of
 the essential pathology of the disease.   With so
 defective a pathology, the treatment must neces-
 sarily be vague, and  in a great measure empirical.
    The Treatment of  diabetes inellitus comes
 now under consideration.  The statements respect-
 ing the cure  of diabetes  furnished by the ancient
 writers on this disease are altogether unsatisfac-
 tory.   This cannot be matter of surprise when it
 is considered  that they regarded only the unnatural
 quantity of the urinary discharge, being entirely
 ignorant of any morbid alteration in its qualities.
 As it would  answer no  useful purpose  either to
 enter into an  examination of the comparative value
 of the whole  of the modes of treatment that have
I been proposed, or to dwell at any length upon the

   * In a dissection  of  a diabetic patient  of Dr. Forbes.
 no morbid lesion could be detected except slight enlarge
 ment of the kidneys, and a remarkably hypertrophic^
 state of the  duodenum. It was simply hypertrophy
 without any mark of inflammation or alteration cT
 tissue. 
020
DIABETES.
particular remedies which have been recommend-
ed, on various authority, for its removal, we shall
first merely notice the four branches of cure, ani-
mal  diet, venesection,  opium, and astringents,
which  of late years  have been chiefly  adopted ;
and then point out those principles of  treatment
which  seem  to us to be best calculated to arrest
the progress  and remove  the  symptoms of the
complaint. Dr. Home first suggested the employ-
ment of animal diet and  alkalies, with a  view  to
their specific  operation as septics ;  but  Dr.  Rollo
is entitled to  the  high  merit of having put into
practice the rigid use of an animal regimen as the
most effectual mode of curing diabetes.  The em-
ployment of  this plan is founded  on the principle
of preventing the introduction of  the materials of
which  sugar is formed into the  system, and of
thus destroying the  saccharine impregnation of
the urine.  Dr. Rollo also combined with an entire
abstinence from vegetable food the exhibition of
the hepatized ammonia, and the occasional inter-
position of narcotics and emetics.  Dr. Rollo's
practice has long since  enjoyed a fair trial in the
hands  of many  distinguished  practitioners, and
consequently sufficient  time has  been allowed to
admit of a correct inference being drawn  respect-
ing its real claims to the high character bestowed
upon it by so able an advocate. Without  particu-
larising individual cases in support of the efficacy
of a strict adherence to animal food in removing
some of the more formidable symptoms of diabetes,
it may be stated that its power of  abating thirst,
diminishing the unnatural quantity of the urinary
secretion and  rendering  it more animalized,  of
relaxing the  skin, and of increasing the bulk and
strength of the body, rests on the incontrovertible
evidence  of  facts and  experience.   Its influence
upon the urine is in general speedy and favourable,
and though perhaps when employed singly it may
prove on some occasions inadequate to the perfect
cure of the disease, still, under almost all circum-
stances, it will  be  found  to act  as a powerful
auxiliary to   venesection, 'opi<un,  or  tbe  other
means  which may be  adopted.  Dupuytren and
Thenard have contended that diabetes  may be as
readily subdued by animal diet as an intermittent
by the  use of the cinchona bark.  Dr.  Baillie, in
alluding  to  Dr.  Rollo's method  of practice, ob-
serves that it has been much more successful than
any other hitherto  adopted.  Dr. Bardsley has
also shown the advantages derived from confining
diabetic patients to  animal food.  Several of his
cases  strongly  exemplify the reduction in  the
quantity of the urinary secretion, and  the  disap-
pearance  of its saccharine  properties,  which
speedily followed the  use of this  regimen.   Dr.
Willan states that this  disease has been relieved,
and the saccharine quality of the urine removed,
by animal diet and the general plan recommended
by Dr. Rollo.  Were it necessary,  other respectable
authorities might be adduced in support of the
curative value of the  same method.   We have
adopted the animal regimen in several instances
witb the most  marked and unequivocal benefit,
and have known patients, who have had sufficient
means  and resolution  to persevere in  its use for
some length  of time, not  merely to recover their
 wonted health, but overcome the tendency  to the
 disease.  Owing to  the high price of  meat,  but
few of the poorer classes of persons who have the
misfortune to  labour  under  this complaint are
capable of a strict compliance with this plan of
treatment, for the amount of their daily labour is
mostly insufficient to procure  such a  supply as
the appetite demands.   This is not the only ob-
stacle  to  the employment  of animal  food  as a
remedy in diabetes; for there is often considerable
difficulty in keeping the patients for  any length
of time exclusively confined to such  a regimen;
and  many failures with  this method of treatment
may be attributed to a secret indulgence in variety
of aliment.   In some  instances there is an insu-
perable disgust at the taste, smell, and even sight
of animal food.   With the ordinary class of hos-
pital patients it is extremely difficult to prevent a
deviation from the prescribed plan of diet.   Dr.
Rollo himself laments that the mode of cure which
he proposed is so contrary to  the inclinations of
the sick. " Though perfectly aware," he observes,
" of the efficacy  of the regimen, and  the impro-
priety of deviations, they commonly trespass, con-
cealing what they feel as a transgression to them-
selves.  They express  a regret  that a  medicine
could  not be discovered, however  nauseous and
distasteful, which would supersede  the  necessity
of any restriction of diet."   This aversion, how-
ever, to the animal regimen is by no means  gene-
ral, for in some instances it has been adopted with
little or no inconvenience, and even been continued
by the patients from choice, when a certain allow-
ance of vegetable food has been permitted by the
physician. Dr. Marsh rather overrates the loathing
of animal  food on the  part of diabetic patients,
when he asserts that  the adoption  of  the animal
regimen,  during even  fourteen  days, is, in his
opinion, more than questionable.  In some of the
cases published by Dr. Bardsley, the exclusive use
of animal  food was continued for more than two
months.  We occasionally visit a  lady who has
laboured under diabetic symptoms for more than
nine years, and  during tbe greater part of that
time she has adhered,  with scrupulous exactness,
to the use of animal food.
   It must be recollected, however, that there is a
certain period at which it is necessary to combine
vegetable with animal diet.  When the more ur-
gent and  characteristic  symptoms  of  the disease
are subdued, and at the same time the strength
and bulk rather diminished than increased,  and
the appetite is feeble and impaired, it is proper to
allow a small proportion of vegetable  food.   The
salutary effects of this change are  soon rendered
visible in the improvement  of the appetite, and
the acquisition of flesh, strength, and spirits.  It
has been  remarked, also, that whenever a return
to vegetable diet is allowed not  only  with  impu-
nity but advantage, it forms  the surest criterion
of the restoration of the assimilating powers of
the  system, and  consequently of the  removal of
the disease.   It is necessary, however, to caution
patients against indulging too freely at first in
the use of vegetable  diet  after a long  and rigid
adherence to animal food, as they are apt, from
the agreeable nature of  the change, to relinquish
the latter regimen altogether, and  thus favour a
reproduction  of  the disease.   At this stage, the
state of the digestive organs  requires  particular
attention in order to establish  on a firm footing 
DIABETES.
621
the benefit obtained ;  for if the stomach and bow-
els are permitted  to become  deranged by irregu-
larities in  diet, the danger  of a relapse  may be
apprehended.  Bitter tonics, mild aperients, chiefly
rbubarb  and magnesia, and  sea air, prove  emi-
nently useful in promoting  the tone of the sys-
tem.   It is by no means intended to recommend
animal diet as the only mode  of subduing this
obstinate disease, but to show that no other, with-
 out its aid, will have the same influence in arrest-
 ing the progress of the diabetic symptoms.
   Previously to commencing with  the  sole  use
 of animal food, it is  of the  first importance to
iiave the  stomach  and  bowels  brought  into as
 natural a state as the character  of the  complaint
 will allow. Costiveness must be obviated by the
 regular use of mild aperients, and for this purpose
 castor oil is preferable to the saline  class of pur-
 gatives.   The  first effects of this plan  of treat-
 ment  should be  very carefully watched, as there
 is considerable risk of the sudden occurrence of
 acute  inflammation of the thoracic  or abdominal
 viscera when it is adopted shortly after an entire
 abstinence from vegetable food!  We have more
 than once been obliged to modify the practice on
 this account.   The liability to inflammation under
 the animal regimen  is  strikingly exemplified in
 the case of James Ridens, aged 26,  who was ad-
 mitted into the Manchester hospital  on the 2d of
 August, 1824, labouring under the ordinary symp-
 toms of diabetes.   The quantity of urine passed
 in the twenty-four hours  amounted  to nearly two
 gallons.   One pint yielded, on  evaporation, 1 oz.
 4 drs. and 8 grs. of a thick sweet syrup.  He had
 lost all venereal appetite, and his semen  was  in-
 voluntarily discharged.  Animal diet was  pre-
 scribed, and the nitric acid  mixture was ordered
 for common beverage.  His bowels were  opened
 by the aid of castor oil.  On  the 5th  the urine
 was diminished more  than four pints, and the pa-
 tient said  that it  was somewhat less sweet to the
 taste.   He had no aversion to animal food.  Early
 on the 8th he was suddenly seized with a severe
 pain in  the  epigastric region, which  was much
 aggravated under the pressure of the hand.   The
 stomach rejected every substance received into it.
 The pulse was small and frequent, and the coun-
 tenance  indicated  great  uneasiness.   Twenty
 leeches  were instantly applied to the epigastrium,
 sixteen  ounces of blood were removed  from the
 arm, and a purgative enema was injected.  In the
 evening the patient seemed somewhat relieved by
 the bleeding, but the pain of the epigastrium was
 still present.  A copious evacuation followed the
 enema.   The serum of the blood was milky, and
 the crassamentum firm.  Pulse 120, and weak.
 A vein  was again opened, and eighteen ounces
 of blood  were  abstracted; twelve  leeches  were
 applied  to the epigastrium,  and a  pill with two
• grains of  calomel, and two of extract of hyoscy-
 amus, was directed to be taken  every third  hour.
 The pulse after  the  bleeding was  106.  On  the
 morning of the 9th,  we found the  patient much
 worse, and evidently sinking  very rapidly.   He
 could with difficulty reply to the questions put to
 him.  The pain of epigastrium was  diminished,
 but the  pulse was tremulous and intermitting, and
 his extremities were  cold.  His bowels  had been
 moved twice during the night.   Anodyne fomen-
tations were  applied to the  epigastrium, weak
wine and water was  administered, and  bottles  of
hot water were applied to the feet.  He expired
in the  course of the  afternoon.  His friends,
though urged by frequent solicitations, obstinately
refused to allow an inspection of the body.  From
the above reports, however, it is  highly probable
that Ridens died of inflammation of the stomach,
induced by an unlimited use of animal food.   At
first, it was imagined that the sudden attack which
proved fatal might have been owing to over-reple-
tion ;  but he  had retired to rest as well as  usual,
and even complained of severe  pain  of epigas-
trium before breakfast, which  was generally with
him a very hearty meal. In the case, too, of John
M'Lean, related by  Dr.  Cleghorn, it appears that,
although his  diabetic symptoms were  much  re-
lieved by the use of animal food, still the  pneu-
monia which destroyed  him was induced by strict
adherence to  this regimen.
   It may be remarked here, that M. Rochoux pre-
scribed urea to a diabetic  patient,  (whose blood
was analyzed by MM. Vauquelin and Segalas
without finding in it any trace of sugar,) and it
was continued for several  days ; but  the  urine,
which was increased in  quantity, afforded,  on
careful chemical examination, no urea.
   Very opposite  to  the  above plan of treatment
recommended by Dr. Rollo, is that of depletion,
by copious and  repeated  bleedings.   Dr. Watt
was first led to try venesection from the circum-
stance of  his patient expectorating  blood,  and
from  having in mind the case of Captain Mere-
dith,  (related  by Dr. Rollo,) who, on the evening
after  bloodletting, " felt lighter, cooler, and  more
cheerful, and had less pain about  the kidneys."
On the following day Dr. Watt's patient seemed
much relieved, the  quantity of urine had dimin-
ished, the crassamentum of the  blood  was black,
and void of tenacity.   Finding so much relief
from  the first  bleeding, he  resolved on  a second,
and eighteen ounces were accordingly  taken from
the arm ; an animal diet was enjoined, and  car-
bonate of ammonia  prescribed to obviate acidity.
By repeated bleedings and a similar diet and medi-
cines, in about four  months this patient was  re-
stored to health.   The  following is the statement
of Dr. Watt's mode of treatment.  " The treat-
ment according to my plan is to reduce the quan-
tity of blood  already in the system,  to diminish
the supply of new materials, and to afford a cer-
tain proportion  of stimuli.   The  first  is accom-
plished  by venesection;  the second, by absti-
nence ; the third, by blistering, mercury, &c.  The
effect of this treatment on the system is increased
re-action, indicated  by some degree of fever, and
terminating in  the  restoration  of all  the secre-
tions."  It is to be  regretted that the same result
has not attended the employment  of bleeding in
cases of diabetes occurring to other practitioners.
   Dr. Watt  appears to have tried  venesection in
 one or  two instances under  the most untoward
 circumstances, the  pulse being slow  and feeble,
 the strength  reduced, and  the  lower  extremities
 oedematous;  and  still  with  benefit.   Even  the
 first bleeding sometimes produced an evident  im-
 provement in the symptoms.  In the case of Ste^
 venson,  the  fifth bleeding acted like  a charm.
 " The recovery after this was instantaneous and 
622
DIABETES.
striking.   The painful  sensation  in his bowels
left him; the  power  of virility  returned ;   the
gums became sound;  the skin soft and  perspira-
ble ; the  saliva, the urine, and the alvine discharge
natural;  in  six  days  he returned to  his work :
in two months  he was restored  to his  original
health."
   Dr. Watt found that the blood first drawn in
diabetes was thin and destitute of  buffy coat;  the
coagulum being  so soft and weak that it could  not
support its  own weight.  As the operation was
repeated, the blood assumed more and  more an
inflammatory character, and often  exhibited ulti-
mately a thick buffy coat, and a strong, firm, and
tenacious crassamentum. "The improved texture
of the blood," he observes, " as venesection was
-epeated, the increased hilarity of mind, and gene-
ral renovation of the living functions, warrant the
conclusion, that, however weakening it may be in
particular circumstances, bloodletting is a most
important mean of disburdening the system, and
of preparing the way for the final re-establishment
of  health and  vigour."  Mr.  Murray  has  also
related a case in the eighth volume of the Edin-
burgh Medical and Surgical Journal, in which the
blood improved simultaneously with  the health.
Some other instances have  been recorded, illustra-
tive of the salutary change produced in the con-
stitution  of the  blood itself by  repeated venesec-
tions.  Dr.  Ayre  found bleeding  useful in  one
example  of this disease. The appearances of the
blood strongly resembled  those observed by  Dr.
Watt;  and  indeed, so close  was the  relation
betwixt  the  state  of  the  blood  and  the relief
afforded, that  the  amount of the one was almost
determinable by a view  of the other.   It  is  men-
tioned that during the first month  the  patient  lost
eighty-eighc  ounces of blood, and took  at least
only  half the  usual  food,  yet  he gained  nine
pounds in weight, and acquired sufficient strength
to follow a laborious employment.  The marked
good  effects of venesection in two cases of diabetes
have  been ably shown by  Dr. Satterly.   His ex-
perience  fully confirms  the  safety  and efficacy of
the practice in some species of that complaint.
   We are enabled to  speak of the real value of
venesection  in  diabetes from a careful and  fair
trial of its influence upon the symptoms on several
occasions.   It is a remedy  of the first  importance
during the  acute stage of the disease, for it  has
the  power  of abating  the thirst, reducing  the
quantity  of the  urinary discharge, and  restoring
the natural secretion of the skin.  Under no other
circumstances ha\e we employed venesection with
advantage, though blood has been  abstracted from
the system at regular intervals and to a considera-
ble amount.   The practice, indeed, on the contrary,
has been iittended with a  diminution  of the  pa-
tient's strength without relief to the  diabetic
symptoms.  Taking Dr. Watt for our guide, we
have followed his plan  of treatment with scrupu-
lous exactness,  with  a  view of determining its
true claims  to confidence, but we have  had  too
often  to  lament the want  of success  which has
followed  its  adoption.   The  experience of  the
profession at  large would  seem  to confirm  the
statement just made ;  for the practice of venesec-
tion,  so  generally employed   shortly  after  Dr.
Watt's publication, is now, comparatively speak-
ing, only  partially pursued.   We venture to re-
commend the employment of bloodletting during
the early stages of  the  disease  in  persons of
somewhat plethoric habit;  and where the strength
is  not much reduced, and  particularly when pul-
monary irritation,  as indicated by  difficulty of
breathing, slight cough, and shooting pains in the
chest, may be present. The propriety of repeating
the operation, and the frequency of the repetition,
will be best determined by the effects  produced
upon the symptoms;  for in some instances it may
not be  prudent to open a vein more  than once,
whereas in  others no such restraint is necessary.
There is  sometimes  an objection on  the part of.
the patients to allow a fair trial of  venesection, for
feeling  great debility and  lassitude  on  the  least
exertion, they  complain more of the want  of a
supply  than of a superabundance of blood, and
thus cannot be convinced  of  the benefit likely to
accrue from such practice.
   When  general bleeding cannot with  safety be
adopted, the local abstraction  of blood may occa-
sionally be  substituted with  advantage.   It has
been our uniform'custom in cases  of this disease,
to direct the application of leeches  to the loins,
when much pain and uneasiness have been expe-
rienced in the region of the kidneys,  and always
with good effect; and we  have also found,  with
Dr. Marsh, that leeches on the epigastrium have
been highly useful  in removing the feeling of in-
ternal heat and tenderness so much complained of
in that part.  Indeed, patients have  requested the
repetition of leeches  to the epigastrium  on more
than one occasion, being  fully convinced  of the
benefit derived from  them.   This local  bleeding
has  not materially  reduced  the  strength, even
when employed more than once.  It should never
be  omitted  under the circumstances we have
pointed out, for though possessed of no curative
efficacy, it  is valuable in relieving  painful and
unpleasant  symptoms, and is seldom, if ever,
attended with  harm, which  is  more  than can be
truly said of some other remedies proposed in this
disease.
   In  a case of diabetes,  under the  care  of Dr.
Forbes, the  first application of leeches to the epi-
gastrium was  immediately followed by a change
in the urine to the healthy appearance.  It was
also much diminished in quantity.  But the benefit
was temporary, and although the same effect fol-
lowed subsequent leechings, but in  a  less degree,
the general  result did not seem very  beneficial.
   Cupping  is  preferable  to leeches  when  it is
desirable to  fix the  precise quantity of blood to be
removed, on account of the weakened  state of the
patient.  Great benefit sometimes attends the ap-
plication of  blisters to the  loins in  cases  of this
disease.  We have preferred the frequent repeti-
tion of  blisters, to keeping  the excoriated surfaces
open by means of irritating dressings.
   With the view of diminishing the nervous irri-
tability  of the system so generally present in this
disease, the  narcotic power of opium has  been
freely tried,  and in many instances  much  benefit
has attended its exhibition.  It has also been pre-
scribed with the intention of opening the  skin, and
exerting an astringent effect  upon  the  kidneys,
similar to that which it usually induces  on the
intestinal canal.   Dr.  Warren published two cases 
DIABETES.
623
of diabetes mellitus treated with opium, in  tbe
fourth volume of the Medical Transactions, which
afford satisfactory evidence of the  influence of
that valuable drug in restraining the quantity, and
moderating or  removing  the  saccharine quality
of the  urine.   In one of the patients this desira-
ble effect was produced after gradually increasing
the proportion  of opium  to  six  grains  twice  a
day; the sweetness of the urine  returned on  the
diminution of the dose, but was again removed by
increasing  it.   The other patient died, (although
the original  disease  was  subdued,) of phthisis
pulmonalis.  The dose was gradually  augment-
ed to five grains of  solid opium four times a day.
Dr. Elliotson has since exhibited opium in four
cases of diabetes, in which the good effects of this
remedy were satisfactorily established.   He  has
administered it in large doses, but it appears more
advisable  not to push the quantity to any great
extent.  Dr. Prout  also  found opium useful in
 this affection.  " All the beneficial effects," he ob-
 serves,  " to be really expected from opium, may
 in most instances be obtained by moderate doses
 only ;  and when thus judiciously exhibited,  and
 when no peculiarity of constitution forbids its use,
 I believe  that  it will be  found  one of  the most
 powerful remedies that we possess in this disease."
 Dr. Marsh, too, considers,  that amongst the reme-
 dies hitherto employed, opium in very large doses
 ranks  highest, for it possesses  the property of
 checking  and  restraining  the flow of urine,  and
 depriving it of many of its morbid qualities.   Our
 experience accords with that  of the above named
 authors, but we have rarely found  it necessary to
 administer more than six grains in the day, though
 on some occasions  this proportion has been con-
 siderably exceeded; and wben continued, during
 any length of time, in rather large quantities, this
 drug has produced  alarming and pernicious ef-
 fects.  We are decidedly of opinion, that it proves
 most beneficial in moderate  doses.  Of late we
 have given the  preference to the acetate of mor-
 phia, as it appears  to exert  an  equally powerful
 influence upon the disease, without occasioning
 the pain of head and constipation which almost
 invariably accompany the free exhibition of opium.
 On the whole,  opium is unquestionably entitled to
 be considered as a remedy of much value in  dia-
 betes, for it not merely diminishes the quantity of
 the  urinary  secretion, but also  proves  useful in
 removing uneasy sensations  and .calming mental
 agitation.  Astringents constitute another line of
 practice which is very ancient, and is still resorted
 to by  a considerable number  of  practitioners.
 They  are recommended by Celsus, and from their
 natural tendency to correct every excess in secre-
 tion,  have  obtained considerable notice in the
 writings of almost  every  author since  his  time.
 That  they  prove beneficial  by constricting the
 relaxed extreme  vessels through which  the urine
 filters  into the papillae of the kidney in diabetes,
 is the  general opinion;  but they  may probably
 act also by an  inherent sedative power, on which
 their astringent  virtue seems almost entirely  to
 depend.  It  is sufficiently proved by observation
 that they lessen the quantity of urine thrown off
 by the diabetic patient, up to a certain limit; but
this they seldom can  be made to pass ;  and  they
scarcely ever diminish the saccharine impregnation
of the urine.  By acting as tonics, however; and
by lessening the  sensibility of the  stomach, they
become useful auxiliaries in several modifications
of the disease, and are chiefly objectionable when
they are found to increase constipation.   Celsus,
however, trusted chiefly to a constipating diet, and
strong rough wines.   Sydenham used the rind of
the pomegranate; Morton rhubarb,  which  was
afterwards repeated by  Professor Rutherford with
advantage.  Lime water, decoction of oak  bark,
infusions  of kino and catechu, uva ursi, and di-
osma crenata, with many  others, have lately been
employed with the same  intention as the above :
but it may be fairly questioned whether alum, the
vitriols, or indeed any astringent  that ultimately
stimulates, can safely be put in action for the cure
of diabetes.  Dr. Grahame, of Dalkeith,  has lately
published an  ingenious method of directing the
sulphate of zinc  to the kidneys, by combining it
with  turpentine  in the form of a pill; but  even
this mild preparation should be tried with caution.
   Thus it appears that each of the four modes of
cure  mentioned above has strong  claims to  confi-
dence and adoption, in certain forms and stages
of diabetes.   Before laying down what appear to
be  the correct principles of treatment,  it may be
proper very briefly to enumerate some of the in-
dividual remedies that have been employed for
the removal of this disease.  The phosphoric acid
and its salts, as recommended by Dr.  Latham, the
phosphate of iron as used  by  Dr. Venables, in
doses of one or two grains, gradually increased to
a scruple or half a drachm, three  or  four times a
day ;  the phosphate of soda, on the  authority of
Dr. Sharkey, who has published two  cases of cure
attending its exhibition ; ammonia; calcined mag
nesia ; tonics, such as the mineral  acids, cinchona,
myrrh, &c.;  various bitters; mercury  pushed to
the extent of inducing salivation; chalybeates ;
cold bathing ; and the colchicum autumnale, have
been  severally used  in diabetic  cases, and  with
various success.   We have been informed  by an
intelligent medical friend, that he has of late ex-
hibited the meadow saffron in  two  instances of
this disease, and  with a highly satisfactory result;
but further evidence of its efficacy is required be
fore it can be entitled to rank as a remedy in dia
betes. Dr. Ferriar has detailed three  cases of con
firmed diabetes, in which a  cure  is said to  have
been effected  by  a combination of  Peruvian  bark,
uva ursi, and opium, in the proportion of one scru
pie of each of the  former to balf a  grain of the
latter, administered four times daily,  with the use
of lime water for common drink.  He treated this
disease as one of debility.  A case has also been
related by Dr. Bateman, where the same practice
was successfully adopted : but the disease return
ed after discontinuing the medicine, and did not
so speedily yield to  a repetition of it.   In  other
 hands this treatment has altogether failed.  Dr.
 Shee has. published  a case, in the progress of
 which, after the ineffectual  administration  of as-
 tringents and opium, paralysis with convulsions
 of the whole of the  right side  supervened.  In
 the course of ten days the patient  was restored
 to health, (the diabetic  symptoms yielded first,
 and  afterwards  the paralysis and spasm,)  by  a
 combination of camphor, kino, and oxide of zinc
 with  tonic infusions.   Dr. Alley  effected a cur? 
:24
DIAB
ETES.
of diabetes by animal diet and cinchona; and Dr.
Fraser mentions an  instance in which the urine
lost its saccharine property in  a month after com-
mencing the use of animal diet and the sulphate
of iron.
   Of late the aid of iodine has been sought in the
treatment of this affection ; and it has been stated
to us, on highly respectable authority, that it is a
remedy of superior efficacy to any of the numerous
substances that have been  proposed  for the  re-
moval of the diabetic symptoms.   The experience
of the profession, however, is as yet required  to
establish its real remedial virtues in diabetes.
   The nitric acid diluted with water,  (in the pro-
portion of about three drams of acid to three pints
of water,) is generally productive of benefit, miti-
gating the thirst and heat, and thereby diminish-
ing the quantity of the urinary secretion.  In the
majority of diabetic cases it  may be  taken with
advantage ;  but when there is  any tendency  to
diarrhoea it ought to be omitted, as the bowels are
apt to be  disturbed  by its use.  Under these cir-
cumstances,  lime water, or soda  water, will  be
found excellent substitutes, as they are  palatable
to the taste, and quench  the thirst.
   The Bristol water was considered by Dr. Baillie
as the best kind of  drink in diabetic  affections ;
indeed it has long been  celebrated  in  such com-
plaints.   Dr. Marsh  states that he  has known a
patient,  labouring under  confirmed diabetes, drink
very largely of the  Leamington  saline waters
without increasing the quantity of his urine, and
even apparently with some advantage to his gene-
ral health.
   It has been shown that animal diet, opium, and
venesection  may be adopted singly with advan-
tage in  some instances  of  this disease;  but we
have found from experience that the conjoint em-
ployment of the two former remedies, with the
occasional aid of the latter, is attended with much
greater benefit.   Animal diet forms the first  and
most important part  of the  treatment; for it pos-
sesses by far the most  powerful influence upon
the urinary secretion ;  and until  the unnatural
quantity of that fluid be considerably reduced, it is
in vain  to  hope for  any material change or im-
provement in its quality.  Unless the  disease be
first  of  all much changed by perseverance in the
animal  regimen, very  little benefit is to be ex-
pected  from any otber remedy whatever.  It  is
proper during its adoption  to bear in mind the
probable occurrence of inflammation  in  some or-
gan or part of the body, and to be prepared to meet
it  early by antiphlogistic measures.   Opium  is
also  extremely  serviceable  in allaying  nervous
irritability, and in  restraining the  urinary  dis-
charge.   Indeed, few cases of this disease occur,
in which the use of this valuable narcotic is not
indicated,  or can even  be omitted without disad-
vantage.   It does not interfere  with  the animal
regimen, but proves  a powerful auxiliary in the
removal of the complaint. Venesection, too, when
employed  with  vigour during the early and acute
stages of the disease, before the constitution has
become  seriously affected  or much  debilitated,
occasionally arrests  the  progress of the diabetic
symptoms, and  sometimes completely subdues the
malady.
   Thus it is obviously improper to trust the cure
of diabetes to any one remedy.  In the selection
of remedies, the symptoms form the  safest guide.
In  obscure  diseases, of the known varieties  of
treatment, that is to be held the best from which
most benefit has been obtained; a principle which
by no  means precludes the trial of new remedies.
Having ascertained the individual effects of seve-
ral, it is  often desirable to employ them together,
as by their combined operation they prove more
powerful  in  promoting  restoration  to health.
Though much advantage often attends the united
employment of animal diet, opium, and venesec-
tion, still we believe that the warm bath will
generally be found  more useful  than the latter
mode  of cure.  This opinion has been confirmed
by the experience of several respectable practition-
ers.   Warm bathing is generally agreeable to the
patients  themselves,  and when aided by flannel
clothing proves serviceable in removing the harsh,
dry, and shrivelled  state of the skin which ac-
companies almost every genuine case of diabetes.
It may be correctly affirmed, that in every instance
of this disease it is of the first importance to em-
ploy such means as are best calculated to restore
the natural functions of the skin.  Our experience
entirely coincides with that of Dr. Marsh on this
part of the treatment.   As early as 1765 " a case
of incontinency of urine complicated with diabe-
tes" was published  in  the  third volume of the
Medical  Observations and Inquiries, by Dr.  A.
Fothergill,  of Northampton,  illustrative of the
good effects  of  antimonial sudorifics assisted  by
the warm pediluvium.  Under this treatment  all
the  symptoms improved ; the patient's strength
and appetite  gradually  increased ; his skin be-
came moist; and his urine was less in quantity
than his drink.  His recovery  was at length per-
fect.   Dr. Marsh, however, has the merit of hav-
ing  enjoined a more  minute attention to the im-
provement of the state of the skin  in diabetes.
" Medical assistance," as Dr. Watt has justly re-
marked,  " is seldom  required where it is not more
or less affected, and we have  no  security of the
disease being removed,  though apparently local,
till the skin  assume  a  healthy appearance.  An
excess or deficiency in  the  cuticular discharge
never fails  to  produce some derangement in the
rest of the system."   When the functions of the
skin are restored, and. a free and equable perspira-
tion is re-established, a favourable change in the
more urgent symptoms  soon becomes manifest;
the distressing thirst and sensation of internal heat
are mitigated,  and the  quantity  of  the  urinary
discharge rapidly decreases.   In diabetes, with
the exception of the kidney, there is indeed, (as
Dr. Bostock  observes,)  no obvious exit by which
the contents of the  stomach can  be evacuated;
the perspiration is checked,  the alvine discharge
is in general not increased, and the weight of tbe
body is daily diminishing; hence the necessity  of
directing remedies to the relaxation  of the skin.
With a view of producing a more direct action  on
the skin, Dr. Marsh was induced  to employ the
vapour bath  in a well  marked case of diabetes
placed under his care, and the impression made
upon the disease by the frequent use  of  this re-
medy  surpassed his  expectations.   Its salutary
effects in promoting diaphoresis were immediately
perceptible.   He also kept up the perspiration  by 
DIABETES.
625
 means  of  warm clothing and  continued bodily
 exercise;  and with  daily improvement  to the
 patient, who was dismissed from the hospital in a
 convalescent state.  « The warm bath  has  been
 used," (says the author just named,)  « but it has
 been used  only occasionally:  it has been employ-
 ed as  a secondary remedy, as one  of minor im-
 portance, and not  as  one which, if properly  man-
 aged, is  of itself sufficient to effect a cure. Its
 daily employment for weeks, nay months, may be
 requisite to bring about  that relaxed and  freely
 perspiring  state of the skin, without which, what-
 ever temporary  abatement in  the symptoms, or
 diminution in the flow of urine, may  have taken
 place,  not  one step has in reality been  made to-
 ward the accomplishment of a  cure."  We are
 satisfied, with Dr.  Watt, that it is upon  the skin
 the first impression of disease is generally made,
 and that we have no  security  of the system being
 fully restored till it becomes natural in its appear-
 ance, and resumes its functions.   In the case  of
 Gosling, already before the public, and in two
 other instances of subsequent occurrence, we have
 employed  the sulphur in preference to the warm
 bath, as it  possesses  the power of stimulating the
 cutaneous  vessels  more forcibly than the  mere
 vapour of  water.  The result on  each occasion
 has been the re-establishment of a healthy cutane-
 ous discharge with an amelioration  of the symp-
 toms of the complaint.  Owing to the great debility
 and frequent pulmonary irritation present in the
 disease, much muscular exertion is  not  practica-
 ble, though it is particularly  desirable to obtain
 moderate exercise without inducing fatigue. In
 conjunction with the warm and sulphur baths, the
 pediluvium, bodily exercise, friction,  as recom-
 mended by Celsus, and flannel clothing,  remedies
 which  act  directly upon  the skin, diaphoretics
 may be exhibited internally with  great advantage.
 The pulvis ipecacuanha? compositus, in  the pro-
 portion of eight grains every five hours, often suc-
 ceeds  in promoting  free  perspiration,  and also
 proves useful in  allaying nervous irritability.  It
 is certainly entitled to rank very high as a remedy
 in diabetes.  In  cases of  a chronic  kind, and ac-
 companied  by much debility and nervous irritation,
 Dr.  Prout  says that  he  has seen  the very  best
 effects  from a combination of the  pulv. ipecac.
 comp.,  and  full doses of carbonate of iron, exhibit-
 ed  in  the  form  of an electuary made with the
 albumen ovi.  The  tartarized  antimony, in the
 dose of a sixth of  a grain every three  hours, also
 determines  freely to the skin, and  at the  same
 time keeps  up a slight degree of nausea,  which is
 rather desirable than  otherwise.  When the salt
 acts upon the bowels, the  proportion must be di-
 minished.  Having succeeded  by these means in
 re-producing cutaneous secretion, it is indispensa-
 bly necessary, in order to  insure  the good effects
 of the  amendment, to avoid sudden changes of
 temperature, and  to endeavour to maintain healthy
 perspiration  by the aid  of warm  clothing  and
 daily gentle exercise.   We are enabled to speak
 from our own experience  of the  efficacy of what
 may be called the diaphoretic plan of  treatment.
 In some instances,  where every other means have
proved  unsuccessful, it has operated  in a manner
most decidedly beneficial.   The patients  have re-
gained  both flesh  and  strength, and  recovered
  Voi,.  I. _ 79                        3 c
 their  wonted  spirits and  activity.   We  have
 found  it  most  advantageous  in the  incipient
 state  of the  disease ;  but it  has also been  of
 service where the complaint has  been long con-
 tinued, and the patient's constitution much de-
 bilitated.
   We are led  to  draw the following inferences
 from the preceding  facts and observations.— 1st.
 That no satisfactory explanation of the real nature
 of diabetes has, as yet, been presented to the pro-
 fession ; hence,  its proximate  cause is  still in-
 volved in obscurity.   2d. That it is probable that
 in most instances the stomach is primarily de-
 ranged, and that the kidneys are rendered mor-
 bidly active by the percolation of saccharine mat-
 ter.  3d.  That  the employment of an exclusively
 animal diet proves chiefly useful by cutting off
 the supply of those  materials whicb  lead to the
 formation  of sugar ; and thus, if persevered in for
 a time, a favourable change mostly occurs in the
 assimilation.   4th. That  the  animal regimen,
 opium, diaphoretics,  and  the  warm bath, con-
 stitute the most effectual means of arresting the
 progress of the diabetic symptoms, and of  effectu-
 ally removing the complaint;  and that cupping
 and blistering the region of the kidneys, venesec-
 tion in recent cases of an acute  character, lime-
 water,  or  nitric acid for  common drink, prove
 useful auxiliaries to the preceding remedies.  5th.
 That  no  individual  remedy or method of treat-
 ment  is applicable to every case of  the disease:
 for in some instances an entire  abstinence from
 vegetable food is highly useful; whilst in others,
 venesection, opium, or  diaphoretics are found
 most beneficial.   6th.  In  commencing with any
 plan of treatment  in  this disease, it is proper to
 ascertain the quantity of solids  and liquids daily-
 taken, in order to be enabled to  institute a com-
 parison with  the urine and its  contents after-
 wards. A  chemical examination of that secretion
 ought  never to be omitted before the trial  of any
 remedial measures, and during the progress of the
 complaint; as it enables the practitioner to deter-
 mine with  accuracy one most important point,
 namely, the quantity of saccharine matter it con-
 tains, and  to  ascertain the gradual advances to-
 wards recovery.  The urine may assume  nearly
 a natural colour, and lose  all its diabetic proper-
 ties to the taste and smell, when, on being eva-
 porated, its residuum is found to afford a saccha-
 rine impregnation, showing that the disease is
 not  completely  subdued.   From inattention  to
 the evaporation  and analysis of this fluid, medical
 men occasionally overlook the real nature  of the
 disease.  The specific gravity of the  urine ought
 also to be  very  carefully ascertained, for it is im-
 possible to  pronounce with any degree of accuracy
 respecting  the removal of this disease, or the bene-
 ficial change  produced by  any curative method
 upon the urinary secretion,  without raaking occa-
 sional  examination of the specific gravity of that
 discharge.   So long as the specific gravity of the
 urine remains beyond the natural standard, the
 cure cannot be  considered  perfect, although the
 patient may be capable of resuming the ordinary
 duties  of life.          _       T   _
                     JAMES Li.  Bardsley.
   DIAGNOSIS.  Tbis  term is derived from Sti
and yivuoicw, to know, and signifies distinction in 
626
DIAPHORETICS.
general ; in  medicine it is employed to designate
the distinction of diseases.
   It is necessary,  before giving a detailed  view
of the  diagnostic arrangement of diseases, to  enter
upon the general consideration of symptoms, as
the principal source on which the distinction of
diseases depends;  and as symptomatology, or the
doctrine of symptoms, cannot properly  be  con-
sidered under diagnosis, we propose  to  treat of
the symptoms and  diagnosis of diseases under the
term Stxptomatology.
                         Marshall Hall.

   DIAPHORETICS, (SiaqjopvriKci QdapaKa,  from
$ia<popiw, dffero, discutio, from Sid, per, and  <pipu>,
fero, porto,) are  medicines that augment the
function of perspiration.  In order to understand
the mode  in which they operate,  we  ought to
possess an accurate idea of  the manner in which
the cuticular function  is performed in a state of
health.
   The importance of perspiration  for the pre-
servation of health is well understood, but the
laws to which it is  subjected are still  imperfectly
determined.  It is a function of the whole of the
skin ; but whether it is possessed equally by every
part of it,  has not  been  ascertained  : it is,  how-
ever, probable that some parts perspire more freely
than other parts. The perspiral matter passes off
either  in  the form  of a thin, invisible vapour, as
insensible perspiration ,•  or  in  a liquid  form, as
sweat.  Various attempts  have  been  made  to
ascertain the quantity of the cuticular discharge.
From the time of Sanctorius, who first endeavour-
ed to determine  it experimentally, to  that of La-
voisier  and  Seguin, little  confidence could be
placed on the results of the experiments,  as the
amount of the pulmonary exhalation  was not de-
ducted  in  calculating  the loss which the  body
sustained in a given time.  Lavoisier and Seguin
overcame this difficulty, by inclosing the whole
body in  a  silk  bag, varnished with  caoutchouc,
having a small opening carefully cemented round
the mouth, which permitted the person to breathe.
The quantity of the cuticular discharge was  thus
determined to be one pound fourteen ounces in
twenty-four hours;  (Memoires de l'Academie des
Sciences,  1790, p.  610.) and,  as this  was the
result of repeated trials, we  may regard it as the
average quantity in a state of health.
  Many circumstances  tend  to vary  the  loss by
perspiration, not only in different individuals, but
in the same person  at different times,  and under
a diversity  of circumstances ; as, for instance, the
vigour of the frame, the nature and  quantity of
the ingesta,  the temperature of the atmospbere,
and many external  relations.   Thus  perspiration
is  diminished immediately after a meal, but  aug-
mented during the process of digestion :  it is also
promoted during sleep; in a dry state of the at-
mosphere ;   in  a current of  air;  and  under a
diminished barometrical pressure.  But these cir-
cumstances are  supposed to promote perspiration
independent of vitality; and therefore Dr. Edwards
has divided perspiration into that which results
from ordinary physical influences, and that which
is dependent on  vitality or secretion ;  or  into ex-
halation and secretion.  Both are  liable to be
«ffected by external agents.   In  low  tempera-
tures,  the loss  by evaporation  exceeds  that by
secretion, because cold suppresses secretion more
than it impedes evaporation.  It may, indeed, be
maintained that even  in a low temperature  the
cutaneous capillaries are still stimulated ; and,
consequently, that the portion  of  the insensible
perspiration, which  is  the  result of vital  energy,
must still be supplied : but it is in  the ratio only
of  the stimulus which  excites  the vessels that
furnish it: whilst the evaporation is less diminish-
ed, because the air  being heated by contact with
the body, is enabled to hold more moisture in  so-
lution than the air farther removed from the body;
and thence evaporation is favoured.
   One evident intention  of perspiration is to pre-
vent the temperature  of the body from rising
above that degree which  a state of health requires,
and to operate as a balance  to the heating  in-
fluence of increased arterial  action.   It also coun-
terbalances other secretions ; as  for  instance that
of the  kidneys., which is diminished as  the per-
spiration is increased, and augmented when it is
checked — a physiological fact of much practical
value.
   Many experiments have been made to ascertain
the chemical nature of the perspired  matter. From
all  that is known,  it may  be concluded  that it
consists chiefly of aqueous fluid, containing  in
solution some free  lactic acid,  lactate, muriate,
and phosphate of soda, and  an oleaginous princi-
ple : but there is also reason to believe that gase-
ous fluids are perspired by the skin  with bases  of
nitrogen,*  carbon,j-  and  hydrogen ;\  and  to the
presence of the latter, variously modified  by the
accession of other constituents, some physiologists
attribute the odour of perspiration.   This odour,
however, seems rather to  depend  on  the secretions
of the mucous follicles mingling with the  perspi-
ration,  than  to  be a  quality  of this fluid, as it
differs in different parts of the body.
  Contemplating  the nature of the perspiratory
function, we may conclude that  it is intended  to
answer two purposes :—1. to convey caloric from
the body, and thereby  to moderate and regulate
its temperature ; 2.  to  carry off  a large quantity
of carbon and hydrogen from the  circulating mass.
  Disease is frequently the consequence of a sud-
den  check to the perspiratory function;  means,
therefore, have been sought  for to restore it; and
substances which have the power of effecting this
are  termed diaphoretics.  Let us now inquire  in
what manner they produce their  effects.
  [The writer  has elsewhere  attempted to show
(General Therapeutics and Materia Medica,  i.
308 : Philad. 1843), that  in any  mode of viewing
the subject, it does not appear that we can  ascribe
any  extensive  series  of  morbid phenomena  to
simple obstruction of perspiration ; and that, con-
sequently, the indication  of restoring suppressed
perspiration, if it  be  admitted at all, must exist
much less frequently  than has been imagined.]

  *  Vide Tngenhouz's Experiments;  Experiences sur  les
Vegetaux, torn. i. p. 152; and those of Trousset, Annalea
de Chimie, torn. xlv. p. 7.1.
  f Vide Experiments of Count de  Millv: Histoirc  de
1 Acadeune Royale des Sciences et Belles Lettres de Ber-
lin, 1777, p. 3.5.
  t. Experiments on Insensible  Perspiration, by W.
Cruickshanks; Jurine's  Experiments, llistoire de la S*
eiete Roya.e de Medecine, torn  x.; and  those of Aber-
nethy, detailed in his Surgical and Physiological Essays. 
DIAPHORETICS.
627
   Diaphoretics may operate in two  ways:__1st,
 by stimulating generally, and so augmenting the
 force of circulation as to propel the blood forcibly
 through  the minute  vessels  of the corium, by
 which both the secreting  power of the skin, and
 the  excretory function of the  exhalents, is in-
 creased ; 2dly, by the absorption of the diaphore-
 tic substances  taken  into  the stomach, and the
 direct application of these  to the cutaneous capil-
 laries.
   In the healthy state of the system, perspiration
 is, probably,  always  the  result  of stimulating,
 either directly or indirectly, the cutaneous exha-
 lents ; and  sweating follows increased vascular
 action, whether this arise from muscular exertion,
 or from substances  taken into the stomach.   But
 in disease, when the temperature of the body  is
 augmented, the pulse is often frequent, indicating
 increased excitement  of the  general  circulation,
 yet the skin remains dry.   In  this state there  is
 evidently diminished action of the exhalents, whilst
 the  cutaneous  capillaries   have  their  secreting
 power impeded;  and, therefore,  this  condition
 must be overcome before diaphoresis can be  pro-
 duced.   Those substances which augment the
 force of the  general circulation, whilst at the  same
 time they  excite  the cutaneous  exhalents,  will
 effect this desired change ;  few substances produce
 this double effect, alone,  but it is readily induced
 by some combinations.
   Those diaphoretics which operate by augment-
 ing the force of the vascular system, increase the
 frequency and the power of the pulse, and  raise
 the temperature of  the body, previous to the flow
 of perspiration : on the  other hand,  those which
 act by stimulating the cutaneous exhalents without
 augmenting the force of tbe general circulation,
 exert a primary influence  on the nervous energy
 of the stomach, and the skin responds by that in-
 explicable connection to which the term sympathy
 has  been applied.
   As the primary  effect  of diaphoretics  is the
 evacuation of a large  portion of the aqueous part
 of the blood, it might be supposed that this vital
 fluid would  in consequence become thicker; but
 various circumstances  concur to prevent such  a
 result.  Amongst others, thirst  always accompa-
 nies sweating; and as this  forces us to take fluids
 into the stomach, the waste of the aqueous matter
 thrown off by the skin is rapidly  supplied.  At
 this  time, also, other  fluid  secretions  are  dimin-
 ished, the urine, for instance; so that the watery
 matters which would  be  carried off by them are
 diverted to the surface,  and  several substances,
 which naturally find other outlets, are expelled by
 the skin.   This is clearly demonstrated in some
 diseases.   Thus, in cases of ischuria renalis, the
 perspiration  has been  found to  contain  uric acid
 and other traces of urine.   Dr. Percival relates  a
 case  in which the perspired matter was so satu-
 rated with the salts of the refluent urine,  as to
 crystallize on the surface  of the body, in the form
 of a white powder.  Such  a condition of circum-
 stances is, indeed, not  surprising, when  we  con-
 sider that the suppression of one secretion induces
an unusual  action in the  vessels of some  other
organ, and a changed condition of the secretion.
  One unquestionably beneficial effect of diapho-
retics is the determination  of the blood  from the
 interior  to  the  surface, thereby relieving conges-
 tions, and maintaining that due balance of the cir-
 culation which  appears to be essential to the pre
 servation of health.   Their salutary influence  is
 also displayed in the increased power which they
 bestow on the absorbents, and in their relaxation of
 the surface  in  febrile  affections.   The  relaxing
 effect of diaphoretics is indeed the most important
 property they possess as remedial  agents, as it is
 on this  power  that their utility in inflammatory
 affections depends.   Were it,  however, attempted
 to  induce diaphoresis  in  inflammatory or  febrile
 affections by stimulating diaphoretics,  the desired
 effect would not only  be prevented from  taking
 place, but the hazardous symptoms would  be ag-
 gravated.   Several circumstances, therefore, are
 requisite to be  attended to, in the  administration
 of this order of medicines : we shall mention those
 most important in a practical point of view.
   1. Whenever diaphoretics  are   indicated, the
 patient should be confined to  bed,  but not over-
 loaded with bed-clothes.  If the pulse be full, hard,
 and quick, and  the skin hot, bloodletting, if not
 contra-indicated by some peculiar  circumstance,
 should preface  the use of the diaphoretics; and
 the bowels should also be freely opened.   It is a
 correct opinion, that free perspiration is not con-
 sonant with  a quick, hard pulse, and a tempera-
 ture  of the skin exceeding  102° of Fahrenheit:
 in this state, if  sweating occur, it is generally par-
 tial, and rather injurious than  salutary.  Even
 after the reduction of the  phlogistic diathesis, the
 diaphoretics to be selected are those which nau-
 seate and relax  the surface.
   2.  The free use of diluents  is necessary during
 the operation of diaphoretics, unless the  stomach
 be in a highly irritable state.   If antimonial  dia-
 phoretics, however, be employed, acidulated fluids
 should not be taken soon after the dose  of the
 antimonial, as vomiting would  be induced. When
 the temperature of the  surface is high, the dilu-
 ents should be  cold ;  but when it is  moderate,
 they should be  tepid.  So important,  indeed, is
 dilution in promoting  the action of diaphoretics,
 that the  mere introduction of cold or tepid fluids
 into the  stomach during  the  hot stage of fever,
 often produces diaphoresis.
   3.  During  the operation of diaphoretics, it is
 essential to use  bad conductors of caloric as cover-
 ings :  both the  body-clothes and the bed-clothes
 of the patient should be flannel, which, being of
 a light spongy texture,  not only preserves an uni-
 form  temperature, but also absorbs the moisture
 as the perspiration flows.  When  linen is  em-
 ployed, the moisture accumulates in it,  and aiding
 its conducting power, carries off the heat too ra-
 pidly from the body, and chills the  surface.   At-
 tention to this circumstance  is most essential, if
 it be requisite to keep up the sweating  for ten or
 twelve hours  longer, and especially if sleep be-
 come necessary  during the  continuance of the
 sweating.  The older practitioners  invariably re-
 sorted to the use of flannel during diaphoresis; a
 custom which has been too hastily condemned by
 modern practitioners, who recommend,  instead of
flannel, frequent changes  of  well-aired  linen, as
serting that this  is more refreshing to the patient,
that, from its comfortable feel,  it has a tendency
to allay irritation, consequently lo aid  in *ubdu 
$29
DIAPHORETICS.
ing the restlessness and inquietude of fever;  and
that it is essential for  carrying  off the fomes of
the disease.   The last part only of this  opinion
is  well  founded; and few  practitioners would
place a patient labouring under an infectious fever
in   flannel :  indeed, under such circumstances,
perspiration  to the extent which requires  the  use
of flannel is neither necessary nor desirable.
  4. Attention must be paid  to the  state of the
bowels and kidneys.   If perspiration be requisite
in  a low stage of fever,  purging must be studiously
avoided,  and should be checked  if it  occur spon-
taneously whilst the sweat is flowing; as it is al-
most certain to stop the sweating and to aggravate
the disease, by diverting the blood to the  interior,
and exposing  the  patient  to  cold.   The  utmost
caution, indeed, is requisite to prevent the admis-
sion of cold air to the  surface ;  and  no  cold li-
quids should be taken into the stomach whilst the
sweat is flowing,  and for some time  after it  has
ceased.  During the administration of diaphoret-
ics, every thing which  has a tendency to promote
the secretion  of the kidneys  should be  avoided.
The avoiding a  frequent  change of linen is in
conformity with this rule, as, in  affecting these
changes, the surface must  be necessarily exposed.
  5. The morning, directly after sleep, is the  best
period of the  day for administering diaphoretics,
as  the  system  is then easily excited, and the  sur-
face is relaxed :  experience has demonstrated  that
many  persons in whom  perspiration cannot be
induced at any other  period  of the  day, may be
readily made to sweat  at that time.   When  per-
spiration  accompanies  diseases,  it generally hap-
pens in the morning ;  there is then,  also, a natu-
ral decline of  febrile excitement; thence it is the
most favourable time for the action of diaphoret-
ics : and  besides, as the administration of diluents
is  necessary to maintain  the  diaphoresis, this is
the more  convenient period for  their administra-
tion.
   6.  When sweating  is to be checked, the skin
should be dried with  soft  warm towels; the pa-
tient should be carefully moved  into dry flannels,
and the  coverings gradually lessened, allowing
the arms to be cautiously exposed  to the air.  By
these  means,  the injurious consequences, which
might  follow a sudden  revulsion, are avoided.
   Before entering upon the examination of those
substances and means which  are usually  employ-
ed  to  promote diaphoresis, it may be proper to
state why we  arrange  them under the two follow-
ing heads :—
   1. Diaphoretics, which cause  a copious watery,
cutaneous excretion, or flow of svjeat.
   2.  Diaphoretics, which only augment the ordi-
nary perspiration.
   The first set excite the cutaneous  capillaries
and exhalents to  a degree sufficient  to  increase
both the secretory and the excretory  functions of
the skin beyond that point at  whicb the perspired
matter is carried  off'  in the  insensible  form;
thence it appears  as  sweat,  and  the substances
inducing it ought to be distinguished from other
diaphoretics.  They are properly  termed sudorifics.
The second set operate in  the same  manner, but
so moderately that they merely augment the ordi-
nary insensible perspiration.  It is true that both
these  results  may be  obtained by modifying the
dose of the substances employed, and the circum-
stances under which they are administered ; but
nevertheless  there are  substances  which, all cir-
cumstances being equal, produce a more powerful
diaphoretic effect than otbers ; and, therefore, this
division is useful.
   1. Sweating may be produced  in two ways:
by  substances  taken into the stomach ; and by
applications to  the surface.
  a. The substances capable  of  producing sweat-
ing when taken into the stomach — sudorifics—
belong  both  to the organic  and  the inorganic
kingdom  of nature.  Among the  first, ipecacu-
anha,  the root of  the  cephaelis ipecacuanha,
which  has been long known as  a  valuable  sudo-
rific, owes its  properties to  a peculiar  alkaline
principle,  discovered by M.  Pelletier,  in  1817,
named emetia.*  Separate  from the ipecacuanha,
emetia has not yet  been introduced into general
practice  in Great Britain,  although  it is  much
employed  on  the  continent.   Ipecacuanha  in
moderate doses, one grain or less, is  well calcu-
lated to produce sudorific effects ; but it is seldom
administered alone  for this purpose, being gene-
rally combined  with opium, the narcotic influence
of which it moderates, whilst its own diaphoretic
powers are augmented  by  the  combination.  It
exists  in  this state  in  the  compound powder of
ipecacuanha  of the  British  Pharmacopoeia?, ten
grains  of which, a full dose for  an adult, contain
one grain  of ipecacuanha and the same quantity
of opium.   In  prescribing this powder, or ipeca-
cuanha itself, or its  infusion  in wine, although it
may be advantageously combined  with camphor
or with nitrate of potassa, yet it ought not  to be
prescribed  in conjunction with astringent decoc-
tions or infusions,  as the tannin unites with the
emetia, forming an insoluble tannate,  which is
inert.  Its sudorific effects,  when once  begun,
should  be maintained  by copious dilution  with
tepid fluids; but tepid drink should never be taken
immediately after tbe powder, otherwise it may be
rejected  by vomiting.  It should,  also, be  recol-
lected  that the  diluents should not be acidulated,
as the  combination  of vegetable  acid  with emetia
is more  likely  to run off by the bowels than to
exert a diaphoretic  influence ; at the same  time,
as it is  advisable  to add something  to the  tepid
water to prevent  the nausea  extending to vomit-
ing, lemon-peel may be infused in toast-water for
that purpose.
   Mezereon, the inner bark of the roots of daphne
mezereum, is also supposed  to  owe its sudorific
property  to  an alkaline  principle,  duphnina,\
which  was first procured by  Vauquelin from the
daphne alpina ; but this is  uncertain.  Mezereon
is a stimulant  sudorific, exciting, powerfully, the
  * The emetia, in its separate state and pure, is white,
pulverulent, and unalterable in the  air,  of a slightly
flitter taste, inodorous, sparingly soluble in cold water,
hut soluble in hot water and in alcohol and ether, llis
seldom obtained in this state, but is usually of a reddish-
brown colour and deliquescent.  One hundred grains of
good  ipecacuanha  contain  sixteen of emetia.  MM.
Magendie and Pelletier suppose that it is taken into the
circulation, and exerls a specific effect on the lungs, and
on the mucous membrane of the intestinal canal.
  t Daplinina. when pure,  is a colourless, inodorous
alkaline salt, which crystallizes in transpaient  brilliant
crystals, soluble in water, alcohol, and elher. The alka-
lies, lime water,  and barytic water, tinge ils solution of
a golden hue; nitric acid converts it into oxalic acid. 
DIAPHORETICS.
629
heart and whole arterial system: it is apt to cause
vomiting and  purging.  It  has been found very
useful in chronic rheumatism, and, in conjunction
with the liquor  arsenicalis, in obstinate cases of
lepra, and some other chronic cutaneous affections.
It is probably to its sudorific property that we are
to ascribe its beneficial influence as an ingredient
in  the  compound  decoction  of sarsaparilla, in
secondafy  syphilis  and  many chronic diseases.
We are aware that  Mr. John Pearson states, that
he had  " very  seldom found it possessed of  medi-
cinal virtue, either in syphilis or in the sequela?
of that disease, in scrofula or in cutaneous  affec-
tions."* Our experience  prevents us from accord-
ing with this opinion.  Its  sudorific powers may
be  secured by administering  an infusion,  made
with two drachms of the bark in a quart of hot
water, in doses of f.^n- every four hours.
   Guaiacum,  the concrete juice of the guaiacum
officinale, was known as  a diaphoretic so early as
 1508, and was used by the natives of St. Domingo
as  a specific  in syphilis;  but although,  when
administered alone,  it possesses no influence over
lues venerea,  yet  it  is  a powerfully  stimulant
sudorific, and proves useful in impetigo and some
other cutaneous eruptions; in ozoena, and in scro-
fulous affections of the membranes and ligaments.
Its  utility in these cases may depend on its power
of augmenting the  energy of tbe  absorbents and
the cutaneous capillaries, thereby  improving the
state of the cuticular  function.   In cbronic  rheu-
matism, a solution of  guaiacum in aromatic spirit
of ammonia, the tinctura guaiaci ammoniata,  given
in doses of from f.gss. to  f.gii. at bed-time, and its
sudorific powers aided in the morning by copious
dilution with tepid fluids, has been productive of
much benefit; and  it is equally serviceable in
atonic  gout: but its boasted efficacy as  a gout
medicine has  never been realised; and  even in
chronic rheumatism the  remark of Dr. Ferriar,
that although  in some forms  of  the disease  it
proves serviceable, in  others  it produces no  effect
whatsoever, is no doubt  correct.  Dr. Chapman
makes  the following  remarks on the efficacy of
guaiacum  in  a morbid affection  of the  eye : —
" There is a morbid affection of the eye of gastric
origin,  hitherto  not sufficiently  noticed, where,
although no external inflammation exists,  or so
slightly  as hardly to be perceived, there  is  great
intolerance of  light;  sometimes very acute lanci-
nating  pains  through the  ball,  although  more
generally the sensation is that  of a  dull obtuse
ache, attended  with  much heat and aridity of sur-
face, which, whatever may be its  nature, is very
successfully treated  by the guaiacum."  (Chap-
man's Materia  Medica.)  Dr. Chapman appeals to
his  own experience  of the efficacy of this medi-
cine, and affirms that  he never saw  the  disease
cured by any other—[yet the affection appears to
be unknown to every  other pathologist and thera-
peutist.]
  As a sudorific, guaiacum acts freely only when
the  surface  is  kept  warm;  otherwise, it  excites
the  urinary discharge. The more  minutely the
guaiacum is divided, the  more certain is its sudo-
rific power;  and, therefore, the tincture, decom-
  * Pearson's Observations  on  the Effects of various
Articles of  the  Materia Medica, in the cure of Lues
Venerea. Lond. 1600, p. 49.
                                      3c
 posed by water, if the precipitated guaiacum be
 rubbed  up with  mucilage to suspend  it in the
 liquid vehicle whatever it may be, is the best form
 in which it can be prescribed. The dose of either
 of the tinctures is from f.^ss. to f.^iii.  The am-
 moniated  tincture is  to  be preferred  in atonic
 gout.
   It is unnecessary to enter into  any details re-
 specting those sudorifics which owe their powers
 to volatile oil.  They are all  too  stimulant to be
 employed as sudorifics, except in diseases of dimi-
 nished energy.  In the low and sinking stage of
 typhus, serpentaria often proves  beneficial; when,
 although the dry  hot  skin indicates the necessity
 of a sudorific, yet the nauseating and relaxing
 diaphoretics would prove injurious.  It has  also
 been found useful in dyspeptic affections accom-
 panied with a  dry skin, and is an excellent adjunct
 to cinchona or its salts in protracted cases of in-
 termittents, and in atonic gout.
   The  only inorganic  substances of value as
 sudorifics are the  preparations of antimony.  All
 of them may be so managed as to produce sudorific
 effects, but the most manageable and  certain  is
 the tartrate of antimony and  potassa ; and, in
 small doses, of from one-sixth to one-fourth of a
 grain, it seldom fails to procure  copious sweating.
 The experiments  of Dr. Elliotson have completely
 demonstrated the  inert character of the pulvis an
 timonialis of the London Pharmacopoeia; and the
 writer of this  article  has satisfied bimself, by an
 experimental investigation, that it bears no resem-
 blance to the true James's powder, the place of
 which it is intended to supply.  The antimony in
 James's powder is in the  state of  a soluble pro-
 toxide ,- in  the pulvis antimonialis it is usually^ in
 that of an  insoluble peroxide ,•  and as it is un-
 doubted that the more soluble the salts of antimony
 are, the more certain and powerful is their sudorific
 influence, it is easy to explain the general ineffi-
 cacy of the antimonial  powder,  130 grains of
 which have been given, three times a day, without
 producing  even nausea.   (London Medical  Ga-
 zette, December 1831, p. 463.)  But,  at the same
 time, it must be   admitted that  no medicines are
 so much modified in their effects by idiosyncrasy
 as antimonials: in one  person, small doses of
 tartar emetic will  induce only moderate sweating ;
 in another, the same dose will cause alarming
 vomiting  and  purging,  extreme  depression  of
 bodily strength, and  excite a degree  of nausea
 which cannot  be  allayed.
   The influence of antimonials is much augment-
 ed by combination with other substances, as cam-
 phor, calomel, and opium ; but,  in  prescribing
 tartar emetic,  it  should  be  recollected  that it is
 decomposed by alkaline carbonates, by the medi-
 cinal soluble  salts of zinc,  lead, bismuth,  and
 mercury ; and that an insoluble  tannate is formed
with the protoxide of antimony, when tartar emetic
is added to any of the astringent vegetable infu-
sions or decoctions, with  the exception of those
of oak-bark.   The tannate thus formed is inert,
on which account decoction  of  yellow  cinchona
  t We say usually, because  no preparation used as a
remedial agent is so variable in  its nature. In a few
specimens we have found a small proportion of the pro.
toxide :  but in far the greater number of the specimen*
examined, the antimonial is in the state of a peroxide. 
630
DIAPHORETICS.
is the antidote of tartar emetic.  In acute rheuma-
tism and other  inflammatory affections, a combi-
nation of one  grain of calomel, one-fourth of a
grain of tartar emetic, and from one to two grains
of opium, administered every fourth or fifth hour,
produces everything that can be expected from a
sudorific: indeed,  when the intention is to deter-
mine powerfully to  the surface, the  tartrate of
antimony and  potassa,  in  small- doses, repeated
at proper intervals,  and  aided  by warmth  and
diluents, is, as we have already said,  more  ma-
nageable and certain in  its  effects than any other
of this order of remedial agents.
   b.  Those agents which,  applied to the surface,
produce sweating by directly stimulating the cuta-
neous capillaries, are warm and hot baths, vapour-
baths, hot air-baths, and the cold affusion.  For
the modus operandi, and manner of administering
these, we must refer to the article Bathing.
   2.  The diaphoretics which merely augment the
ordinary perspiration produce their effect in three
ways:—1. through the  medium of the stomach ;
2. by entering  the circulation, and acting directly
on the skin ; 3. by application to the surface.
   Among the substances of this division of dia-
phoretics which operate through the  medium of
the stomach, we think it unnecessary  to say any-
thing either of musk or of castor.  With respect
to dulcamara,  (the  twigs  of the solanum dulca-
mara,) which owes its efficacy to a peculiar alka-
loid, named solania, either diaphoresis or diuresis
may be produced  by it, according to the extent
of the dose or the manner in which the surface
of the body is managed during its administration.
It generally produces nausea, and not improbably
much of its diaphoretic influence depends on this
circumstance ;  and on this account the dose should
be  gradually increased  during its administration.
Two fluidounces of the decoction, made with !|i.
of the bruised twigs boiled  in a- pint and a half of
water down to  a pint, given three times  a day,
seldom fail  to induce  and maintain  a  gentle
breathing perspiration.   Camphor certainly pro-
duces a tendency to diaphoresis, without increasing
the velocity of the pulse; and, therefore, it forms
a  useful adjunct  to more  decided diaphoretics ;
but with respect to sarsaparilla, even this is doubt-
ful ; and we are disposed to think that the diapho-
resis which it is supposed to produce is due to the
tepid diluent regimen which is generally prescribed
during a course of it.
   Among  the  inorganic substances belonging to
this division of diaphoretics, we find the carbonate
and citrate  of  ammonia, citrate of potassa, and
acetate  of ammonia.   The first  stimulates  the
nervous  energy, and produces diaphoresis when
aided by external warmth and plentiful tepid dilu-
tion ; it is indicated in the sinking stage of typhoid
fevers, and  other  debilitated conditions in which
diaphoresis is still  desired ; but otherwise its place
can  be much better supplied by many other sub-
stances.   In  combination  with  guaiacum  and
opium, considerable advantage has been obtained
from it in obstinate cases of chronic  rheumatism.
To produce  its diaphoretic effect the dose should
not  be less than  twelve grains, nor more than
twenty: the best  vehicle for administering it is
the almond emulsion.   The citrate of ammonia,
which is generally prepared at the moment of its
administration  by saturating recent lemon-juice
with carbonate of ammonia, possesses very mode-
rate diaphoretic powers;  but it  is less nauseous
than the acetate, and  forms an  excellent vehicle
for tincture of  opium, when it is desirable to pro-
mote its diaphoretic influence.  The same remarks
apply to the citrate of potassa, which is more fre-
quently employed  than  the former  preparation,
especially when the stomacb is in a highly irrita-
ble  state.   The old  method of administering the
saline draught — first swallowing the solution of
the alkali, and  immediately afterwards the lemon-
juice,  although now  seldom recommended, yet
bad its advantages.   The alkaline solution allays
the irritability of the stomach, whilst the close ap-
plication of  the  carbonic acid, extricated in the
stomach, to  the  nerves  of that viscus, affords a
certain degree of tone without interfering with the
diaphoretic operation  of the neutral salt  formed
by the union of the two  bases.  The best of the
neutral salts, however, for inducing diaphoresis is
the acetate of ammonia in solution, the old spiri-
tus Mindereri.   The common solution of this salt,
the liquor ammonia?  acetatis, is generally very
carelessly prepared, and  little pains taken to pro-
duce a strictly  neutral solution:  when the alkali
predominates, the solution of tartar emetic, occa-
sionally prescribed with  it, is decomposed ;  when
the vinegar is in excess, the usual dose of the an-
timonial excites vomiting.  The crystallized salt,
formed by saturating  strong acetic acid with am-
monia, being always neutral, should  be employed
in solution in preference to the usual preparation.
When perfectly neutral,  the solution is an excel-
lent vehicle  for soluble  antimonials  and opium,
aiding considerably the effect of both  on the skin;
it is also easily retained on the stomach, and fre-
quently allays the irritability of that  organ when
administered in doses of f.giii. to f.gxii. in any
bland fluid.
  The last of the substances necessary to be no-
ticed in this section of the second division of dia-
phoretics is water.  The greater part of the fluid
perspired by  the skin is water ;  and if the surface
be kept warm, so as  to  check the action of the
kidneys, the  proportion  is  generally  in the  ratio
of the quantity of fluid  taken into the stomacb.
But besides this cause of the diaphoretic influence
of water, it is  also well known  that the sudden
impression of a draught  of cold water upon the
nerves of the stomach acts  most  forcibly in pro-
moting diaphoresis.  A person who awakes in the
night  with the tongue  feverish and parched, a
quick pulse,  and a dry, hot skin, finds  immediate
relief from swallowing  a large  draught of cold
water: the cutaneous capillaries immediately con-
sent with  the  stomach, and copious  perspiration
often  ensues.  By imitating this practice in fevers
a similar result is occasionally obtained.  When
water  is to be employed  as a diaphoretic, much
depends on the management of the patient during
its administration.  If the surface be kept warm,
and the body surrounded with bad conductors of
caloric, a moderate quantity of water will produce
the effect required.   Under these circumstances,
cold water is  to be preferred to warm ; but it must
be kept in remembrance that in delicate constitu-
tions, even in  fever when the excitement is  high,
a sudden reduction of temperature is hazardous, 
DIAPHORETICS.—DIARRHOEA.
631
and,  therefore, tepid drinks are necessary ;  and
small quantities of aromatics may be added to the
aqueous fluid to moderate the nausea which tepid
water always produces.
  Besides being  diaphoretic itself,  water is the
general  auxiliary of all  other  diaphoretics ; nor
can the influence of the best of them be main-
tained without ample dilution.   In this  case the
fluid employed should always be tepid, at least of
a temperature not under 65°  Fahrenheit.   The
same rule, indeed, is necessary for the administra-
tion of diluents as  for the external employment
of water ; when the temperature  of the body is
under  96°,  cold  drink  should not be ordered.
Nature  points out  the best indications  for using
water, both as to its administration at first and its
continued employment, by the  sensation of thirst
which  accompanies every state of febrile action :
when this is present, we  cannot err in  prescribing
water,  the temperature being determined by that
 of the  body and the state of the skin.
   Among those substances which enter the circu-
lation  and operate  as diaphoretics by  their direct
influence on the skin, the first  whicb we have to
notice is sulphur.   When this  substance is taken
 into the stomach, it passes off through  the cuta-
 neous  exhalents  united  with  hydrogen ; a fact
 demonstrated by  silver, worn in the  pockets of
 those taking it, assuming the same dark hue as if
 it had been exposed  to  a stream of sulphuretted
 hydrogen  gas;  and  as it thus passes off, it excites
 diaphoresis.   As  a diophoretic,  sulphur is em-
 ployed  in cases of  chronic rheumatism and some
 other skin diseases; and in combination with oil,
 the  oleum sulphuratum of the  London  Pharma-
 copoeia, in chronic catarrh: but this is  an acrid,
 nauseous  preparation,  and consequently seldom
 administered.   In combination  with  potassium,
 sulphur forms a solid preparation, hepar sulphuris,
 which  by solution  in water  is converted into a
 hydro-sulphuret of  potassa.  Both of these pre-
 parations  have been employed as diaphoretics in
 chronic affections of the chest,  and in  several cu-
 taneous diseases.
   The  action of the  salts  of mercury upon the
 capillary system  has been long known ; and  in
 having the cuticular discharge promoted by them,
 it is probable that the skin only  shares,  as a secret-
 ing  organ, in the general  influence which  they
 exert on the glandular system ; but although their
 influence  on the cutaneous  function is demon-
 strated  by daily  experience, yet they  are  only
 employed as auxiliaries in promoting diaphoresis.
 Calomel, the protochloride of mercury, is the pre-
 paration usually selected for  obtaining the effect
 of mercury  on the  cuticular exhalents; and it is
 generally conjoined with tartar emetic or James's
 powder, ipecacuanha,  guaiacum,  or  opium;  to
 which  it imparts  additional  sudorific power.  In
 these combinations, calomel  is  given  with  ad-
vantage in all inflammatory diseases ;  and, in the
form of Plummer's pill, in cutaneous  eruptions
and  in  chronic rheumatism.  In this  pill the an-
timonial is  the antimonii sulphuretum prajcipita-
tum of the London College, a preparation pos-
sessing more certain sudorific properties than the
pulvis antimonialis  : whether an influence can be
ascribed to  the  guaiacum, considering  its small
proportion  to  the more  active ingredients in this
pill,  seems doubtful.   As a diaphoretic, the dose
of calomel should not exceed one grain, frequently
repeated.
  c.  Whether sweating or mere  diaphoresis be
produced, the cause of both, as far as they are the
result of the substances to which we have already
referred, is  the  augmented action of the whole
vascular system ;  but  diaphoresis may be  pro-
cured by the excitement merely of the cutaneous
capillaries.  The natural insensible perspiration is,
indeed,  apparently the effect solely of the cuticular
system of vessels ;  and although  means exist by
which this  may be  carried to sweating, yet still
the cause is confined solely to the cuticular ves-
sels.  Friction  operates in this way, acting on
the surface, in a manner equivalent  to muscular
exertion on  the whole  habit, in augmenting dia-
phoresis.  The tepid bath produces its effects on
the same principle, although both the degree and
the nature of tbe stimulus be different.   When
the tepid bath is employed, it  is necessary to con-
tinue the application for a considerable  time to
produce the desired effect.   The first result of its
application is emollient, the second diaphoretic.
   In remarking  on the practical employment of
diaphoretics, we should say  that  they  must be
selected according  to  the  nature  of tbe  disease,
and  the object to be accomplished.  Those that
operate by augmenting the force of the general
circulation are well adapted for relieving internal
congestions ;  those which produce nausea  and
unload  the  oppressed  capillaries,  are adapted for
diminishing febrile  action, and reducing the mor-
bid temperature of the body.
   With respect  to the diseases in which diapho-
retics are beneficial, we must refer to the various
articles  which are devoted to their consideration.
   [It may, however, be doubted whether we have
any internal remedies that are capable of acting
as direct  diaphoretics,—that  is, by virtue of spe-
cific properties which they possess over the glan-
dular or diapnogenous apparatus of  the skin.  In
every case in which the skin is hot and dry,  and
the indication appears to be to establish  diapho-
resis, the cause of this condition of the cutaneous
exhalents must  be inquired into, and if possible
removed.    Hence  it is, that the well-instructed
practitioner employs indirect diaphoretics rather
than such as are esteemed  direct.    Thus, dimin-
ished sensible  exhalation  takes place from  the
skin during the existence of fever  or inflamma-
tion, but tbe physician does not have recourse to
any  reputed diaphoretic, which acts by exciting
the sanguiferous system.  He adapts his antiphlo-
gistic remedies  so  as  to  reduce the already too
much excited condition of the blood-vessels, to the
healthy standard; and he finds, when he has re-
moved  the  internal inflammation, the heat  and
dryness of the skin subside, and diaphoresis satis-
factorily established. Under similar circumstances,
a full dose of opium is  attended with a similar re-
sult.   Opium in a  full dose is a  sedative ;  and
hence morphia,  in large doses, is often so power-
fully diaphoretic.  Nauseants are most effective
diaphoretics in  diseases of excitement; and they
are powerful sedatives.  On  the  whole,  even in
febrile and inflammatory affections, the use of tne
ordinary internal diaphoretics is  uncertain,  and
generally of no avail;  and many of them are do 
332                                  DIA R R H CE A.
cidedly injurious by their excitant properties; yet,
in many  such cases, advantage may be derived
from the equalizing influence of the warm-bath ;
and  in minor inflammations, especially  of  the
gastro-pulmonary mucous membrane,—as catarrh,
—warm diluents, aided  by the warmth  and qui-
etude of bed,  produce an equalizing effect, which
is often most salutary.
  In almost  all cases in which th.) employment
of diaphoretics appears to be  indicated,  the class
of sedatives, (q. v.)  or refrigerants, (q. v.) or both,
will be found infinitely more advantageous. (Ge-
neral Therapeutics, &c, i. 312.)]

                           A. T. Thomson.
  DIARRHCGA, (Aidpfioia, from Stasia, perfluo,
primarily from Sid, per, and j>iu>,fluo) ; looseness,
flux, lax.  This is a very common and well-known
disease, characterised  by frequent and imperative
calls to go  to stool, the evacuations being more
liquid than the usual  healthy discharges  from the
bowels.  Pain or griping  is  occasionally an at-
tendant, but not necessarily so.  This disorder is
frequently a matter of trifling importance  ; at other
times it is productive  of serious consequences.
  Causes. — Diarrhoea  may originate  in very
various causes.   One of the most common is  the
direct application of stimulants  to the interior of
the digestive tube.  Errors in diet, either  in quan-
tity or quality, will  often act in this way.  When
a great mixture  of different  kinds  of food and
drink is taken at  the same meal, a sudden attack
of diarrhoea  is no  uncommon  occurrence,  and
need not be matter of surprise.  In some  constitu-
tions a draught of cold water, beer, milk, &c. im-
mediately affects the  bowels, especially  if  the
individual  is  heated  at  the time;  and  ices  are
often  productive  of the  same effect.  Unwhole-
some articles of diet operate in a similar manner
on many individuals.  Of this  kind are, animal
food  approaching to a putrid state, raw vegetables,
cucumbers,  melons, mushrooms,  certain salads,
&c*   Diarrhoea is also a  very common occur-
rence in infants when the nurse's milk disagrees,
or when other food  is  given too  stimulant  for
their digestive powers, or in too  great quantity.
  Diarrhoea occurs as a sympathetic disorder in
many diseases, as in  the dentition  of children;
and there are many affections of a  more general
kind where it is a  frequent attendant.   Measles,
scarlatina, and other exanthemata, afford examples
of this.  In such cases there is little doubt that an
excited or hyperemic  state  of the mucous mem-
brane takes place :  some have even supposed that
an eruption analogous to that on the surface may
be present.   In  gastric  and enteric fevers, also,
diarrhoea is a frequent symptom.  It is often  the
initiatory state in cholera and  dysentery  ; and in
some  diseases, as  fevers,  it occasionally  shbws
itself as a critical discharge. The diarrhoea which
attends the latter stages of phthisis,  and other
  * We have the personal testimony of  no less a man
than Cicero, that the substances last mentioned are pro-
ductive of this complaint.—Dum volunt  isti lauti terra
nata, quae lege excepta sunt, in honorem  adducere, fun-
gus, helvellas, herbas omnesita condiunt.ut nihil possit
esse suavius.  In eas quum incidissem in  ca;na augurali
apud Lenlulum, tanta me Sidfipota  arripuit,  ut  hodie
primum  videar consistere.  Ita ego, qui me  ostreis et
r.iureuis facile abstineham, a beta etiam et a malva de-
.:eotus sum.—Epist. Fam. lib. vii.  127.
forms of hectic  and  atrophic affections, is  uni-
versally known.
   Many  causes  give  rise to diarrhoea  in  a  less
direct manner, such as exposure to cold, cold and
wet feet, an atmosphere simply cold and  damp,
or impregnated with putrid exhalations, &c. With
some  persons exposure to warm and damp air is
productive of the same consequences ;  and alter-
nations of temperature are often equally effective,
as in the case of a hot day being succeeded by a
chilly evening.  Suppressed evacuations, as inter-
rupted sweat, checked menstruation, the  disap-
pearance of abscesses,  retrocession of the eruption
of smallpox, measles,  or scarlatina, are  occasion-
ally succeeded by diarrhoea.  Many persons of a
nervous temperament are subject to similar attacks
on  the least agitation of mind, anxiety, or  sur-
prise ; and when such mental states  are present,
the  slightest  errors of diet  will be followed by
liquid discharges from the bowels, although  the
same  persons are exempt from any such attacks
when no such disturbing causes are in operation,
even when they indulge in a great variety of food.
Morbid secretions from the liver and other glands
that open into the intestinal canal,  as  well as  irri-
tating secretions from the mucous membrane itself,
are  also  causes  of diarrhoea.  So  likewise  are
worms generated there ; but less frequently than
might be expected.
  Gout in many instances appears to maintain a
tendency to loose discharges from the  bowels,  and
to expend itself by  this outlet.  We have known
several cases of persons who were  accustomed to
have three  or four loose motions  daily while in
health; and  when  the least interruption to  thi?
ordinary habit took place,  a fit of regular gout
came on, the  diarrhoea  re-appearing when  the
gouty  attack had subsided.   One  gentleman  had
his  first attack of gout  on giving a check  to a loose
state  of  the bowels which he considered trouble-
some ; and  for many  years  afterwards  diarrhoea
and  gout  constantly   alternated.   Tbis is  the
diarrhoea arthritica of Sauvages, and is noticed
by many practical writers, as Sydenham, Baglivi,
Musgrave, &c.  Many persons  are  liable to diar-
rhoea on visiting certain cities, as London,  Paris,
Cork,  Limerick, Galway, &c.   The waters of
such places are  commonly accused  as producing
the complaint, but there are probably other causes.
Diarrhoea often prevails epidemically without  our
being able to trace the precise cause; but in such
cases it  is commonly  accompanied by  catarrhal
affections of other mucous membranes.
  Symptoms and different forms of Dlar-
hcea.—An attack of diarrhoea is, in most instan-
ces, from whatever cause it may proceed, preceded
by feelings of indigestion, nausea, flatulence,  &c.
It is usually attended by more or less pain or un-
easiness  in different parts of the abdomen, more
especially before the bowels are called upon  to  act.
In the more severe forms, the abdomen is often
swelled,  hot, and  painful to the touch, and  the
discharges are announced by searching  pains of
various degrees, sometimes slight, sometimes very
severe, and attended occasionally by fainting,  and
frequently by nausea, or even  vomiting.   The
pain seems to follow the transit of the alimentary
mass, and to be connected with the peristaltic con-
tractions of the muscular coat  of  the intestines. 
DIARRHCEA.
633
The discharges take place without effort, and in
some instances are involuntary.  The patient feels
weaker  after each evacuation, yet  experiences
some relief from  the  pain, tension, and flatulent
working in the bowels.
  The number of stools is very uncertain ;  they
may amount to ten, fifteen, twenty, or even twice
that number, in the twenty-four hours.  In the
commencement of the attack they are abundant in
quantity ;  afterwards  they become more scanty,
and, whatever may have  been their original con-
dition, consist chiefly  of a serous fluid mixed with
fibrous threads.   The discharges are more fetid in
proportion  to  the quantity of proper excrementi-
tious  matter contained in them.   Paleness  and
wasting of  the body accompany  the severer at-
tacks ; likewise a sense of chilliness, dry skin, a
loaded tongue, and a diminution  of the urinary
secretion.  The patient becomes often so enfeebled
 as to  be forced to keep his room  or even his bed.
   The nature of  the  evacuations in diarrhoea has
 of course  attracted the attention of physicians in
 a very particular  manner, and in  most  cases they
 have  been  considered as constituting the very es-
 sence of the  disease.   The  discharges vary ex-
 tremely in colour, consistence, and other physical
 characters; and although this variety is often ob-
 servable in individual cases, either at one and the
 same instant, or at different periods of the attack,
 still,  generally speaking, different cases  commonly
 preserve throughout their course one  predominant
 character  of the  evacuations.   On this fact has
 been  founded the  most  common  classification of
 diarrhoea which we possess, and which, variously
 modified, has  obtained from the earliest times up
 to the  present period.   This  classification is, no
 doubt, as we have just observed,  founded in na-
 ture; still  it must be strongly impressed on the
 mind of the student and young practitioner, that
 the nature of  the stools alone cannot be admitted
 as affording a true indication of the  pathological
 condition  of the parts which constitute the seat of
 the disease, and much less as a guide in  practice.
 Constant  attention  to  their  character, however,
 can never be dispensed with on  the part of the
 practitioner.
   For a full account of all the appearances of the
 discharges  which have  been  considered as cha-
 racterising  different species  or varieties of diar-
 rhoea, we must refer to nosologists and systematic
 writers.   We can only notice a few of the most
 remarkable.
   Feculent diarrhoea. — The evacuations in this
 variety are of the ordinary faecal character, but
 more liquid and more frequent than natural. This
 may  be said to be present in the  commencement
 of all the  other forms, inasmuch as the faecal con-
 tents of the bowels must be evacuated either before
 the morbid secretions take place, or in  conjunc-
 tion  with  them.   What,  however,  has  been
 usually termed feculent diarrhoea, is that in which
 the evacuations  retain this character through the
 greater part of their course.   This is the D. ster-
 corea of Sauvages, the D. crapulosa  of Cullen,
 and the D. fusa of Good.   It is apt to occur to
 those who  have  large  appetites,  and  who have
 overloaded the stomach with a variety of food.  It
 often comes on without warning and without pain.
 It is  sometimes  attended with dyspeptic  symp-
   Vol. I. — 80
toms, but sometimes not.   It generally ceases of
its own  accord; and though it leaves the patient
somewhat debilitated, the healthy functions of the
bowels are soon restored, provided the patient or
his attendants are not too anxious prematurely to
arrest the  discharges, or again  to overload  the
stomach  with improper food.
   Bilious diarrhcea.—This is not a very uncom-
mon form of bowel disorder, yet  we believe it is
often said  to  be present when  the  affection is
merely that last described.   In the  proper bilious
diarrhcea, the stools, at first faecal, are loaded with
a  morbid proportion of bile, and  are, in conse-
quence, of a bright yellow or greenish colour.  It
is  supposed to arise from  an excited condition of
the liver producing a superabundant secretion of
bile, or bile of a morbid character, which acts on the
mucous membrane of the bowels as a stimulant.
This state of the liver is frequently produced, we
believe, by a primary affection of the duodenum,
of an inflammatory  kind,  which  either simply
excites the gland to increased action, by  what has
been termed continuous sympathy,  or produces in
it  a like  condition  with itself.   In either case  the
result is  an augmented flow,  and probably a  de-
praved state of the bile.  This species of diarrhoea
is  often met with in those who live intemperately,
or whose hepatic organs  have suffered  in  warm
climates.  Intense moral emotions, such as  a  vio-
lent fit  of anger  in sanguine  temperaments, or
grief and  disappointment in melancholies, have
been observed to give rise  suddenly to  it.   The
connection between the manifestation  of the pas-
sions of the mind and  the secretion of bile, so
familiar  to our classical readers in the writings of
the ancient physicians as well as poets, is founded
in accurate observation, and no  doubt originated
in the supervention of the form  of diarrhoea now
under consideration, to  strong mental emotions.
All our nosologists agree in  terming this variety
D. biliosa.
   Mucous diarrhcea.—In  the true  mucous diai
rhoea, the stools contain little or no proper faecal
matter, but consist chiefly of mucous or watery
fluids, the former being predominant.  The stools
sometimes consist entirely  of mucus,  which  is
passed either in large continuous  masses, or in
separate flakes, intermixed with  more liquid mat-
ters ; it  is often found, particularly^ in  the com-
 mencement of an acute attack, or rather, after this
 has lasted  a few  days, quite transparent, and of
 the  consistence of jelly; at other times  it lies at
 the  bottom of the pan like semi-transparent  mu-
 cilage.   The stools  are of very various colours,
 depending  chiefly on the  degree  of admixture
 with bile, but tbe characteristic features of the
 variety are to be sought for rather in the consist-
 ence and tenacity than in the colour.   This form
 of diarrhoea is usually  acute,  and often reigns
 epidemically in conjunction  with  mucous  fevers
 and catarrhal affections of the other mucous mem-
 branes, with some of which it occasionally alter-
 nates. It is often  unaccompanied with fever, even
 when of considerable severity ;  sometimes, how-
 ever, there is a very marked febrile state.  It some-
 times assumes a more chronic or sluggish coursii
 in old delicate valetudinarians, who  suffer from
 dyspeptic, hypochondriac, and other chronic ail
 ments.  In  such  cases,  both the  stomach  anj 
h£4
DIARRHCEA.
towels are often loaded with depraved mucus se-
creted in great quantity, and wbich appears to be
tbe cause of the diarrhoea.  In cases of this kind
the mucous membrane is sometimes found thick-
ened and  congested, and the mucous follicles are
erected and patulous ;  and unless a suitable treat-
ment is  adopted, the disease  degenerates into a
permanently chronic state, probably  with  atrophy
or dropsy.  This is the D. mucosa of Cullen and
Good, the Cosliaca mucosa of Sauvages.
   Serous diarrhxa.—In this form the discharges
are quite  serous or watery, and hence it has been
termed diarrhxa aquosa by many authors.  The
stools may be coloured variously, or they may be
nearly colourless ;  they may be almost  limpid or
intermixed with minute flakes or shreds.   Some-
times they are intermixed  with mucus, but  their
characteristic  feature is  their being  copious and
watery.   In some cases the quantity of fluid pass-
ed  is very great,  and  speedily induces  extreme
debility.   It is not always easy to distinguish this
variety from cholera.
   Serous diarrhcea may be produced under the
same circumstances as the mucous variety,  and
then it must be considered as an  acute  disease,
and as being, in many cases at  least, dependent
on  an excited or inflamed state of the  mucous
membrane of  the bowels. At other times it would
appear as if the serous discharge originated in an
opposite  condition of this part, the exhalents pour-
ing out their  contents  rather from  loss  of  tone,
and passively, than by an active  organic  process.
It sometimes succeeds profuse perspirations sud-
denly repressed, or the imprudent use of acids and
cold drinks when  the  body has been heated.  It
is sometimes the mode  in  which nature  relieves
herself from other diseases, as in dropsy, which
has been known entirely to disappear on  the su-
pervention of  a profuse diarrhcea  of this kind.  In
very severe cases  the discharges are so copious,
and the emaciation and exhaustion  so great, that
it would  appear as if almost the entire  contents
of  the exhalent  system were  thrown  upon the
intestines.  A marked form of this species is the
diarrhoea  of infants,  termed  watery gripes, in
which the stools are often purely serous.   This
is the D. serosa of Sauvages and Good : it is in-
cluded under  the  last  variety (mucosa)  by Dr.
Cullen.
  There is a variety of diarrhoea termed tubularis
by Dr. Good,  and which may be more  properly
named flaky or membranaceous.  It is more  enti-
tled to notice as throwing some light on  the pa-
thology of the disease  than as a distinct species
of diarrhoea.   In this variety there is a discharge
of coagulable  lymph,  generally  in  the  form  of
shreds or  bands of more or less extent, and some-
times retaining the tubular shape  of the  bowel,
whence Dr. Good derived his  specific  epithet.
Such discharges are certainly met with in relaxed
states of  the bowels, but they are still more gene-
rally, perhaps, observed  in  cases where constipa-
tion is the habitual state.   The  fact is, that the
peculiar inflammation of the mucous membrane,
which gives rise to this morbid secretion, may pro-
duce either constipation or diarrhoea ;  and  it is
probable  that  when the former state exists, the
seat of the disease is in the small intestines, and
wuen tne latter, in the large intestines.  We have
frequently observed these fibrinous  discharges in
cases  of  temporary  diarrhoea  supervening to a
long-continued state of constipation, whether ex-
cited by improper diet, purgative  medicines, or
occurring without any obvious cause. Such cases
are, in fact, examples of chronic enteritis, and not
of diarrhcea.
   The chylous or milky diarrhcea of authors, and
that termed gypseous or chalky by  Dr. Good, arc
both denominated from false notions of their na-
ture.  We believe that the whiteness in the ono
case is no more owing  to  the presence of chyle,
than in the other it is  produced by lime, as Dr.
Good  supposed.   The  chief cause of the white
colour in  both  these varieties  is, no doubt, the
absence of bile of the natural character or quan-
tity ; but as this may occur in very different states,
and when the discharges are in other respects very
different,  there is no sufficient reason for establish-
ing  any distinct form of disease on these grounds.
It is proper to observe,  however, that in chronic
cases when the stools are of this colour, and more
particularly if they resemble an admixture of chalk
and water, as described by Dr. Baillie (Med. Trans.
vol. v.), they for the most part indicate a disease
of a serious, often of a dangerous character.
   The variety termed  lientery,  in which undi-
gested aliment appears in the stools, has no claim
to be considered  as a distinct form of diarrhoea, as
the  circumstance supposed to characterise it may
occur in every  species of the complaint.
   Nature of the Disease*—The foregoing ac-
count  of the principal phenomena and more mark-
ed varieties of diarrhcea has necessarily anticipated
much  that  might be said under this head.  We
shall therefore content ourselves with a few addi-
tional observations.   " It is with  difficulty," says
Dr.  Cullen, " that I have arranged  this genus, as
it is not very consistent with our  plan to let it
stand in our nosology.   Diarrhcea  is universally
symptomatic of a great variety of diseases,  man)
of which are different from one another; so that 9
genus  formed from all these is a very complicated
one, and comprehends many dissimilar affections
and diseases."   (First Lines, Dr. Thomson's edi-
tion, vol. ii. p. 470.)   This  observation of Dr
Cullen is  very just; but he might have gone even
further, and stated that in a perfectly philosophical
system of medicine,  what  is  commonly termed
diarrhoea would be regarded merely as a symptom
of different pathological  states,  and  would,  there-
fore, be banished  from the  list  of individual dis-
eases.  We are, however, far from having attained
to this perfection of pathology even in theory,
and  it  is more than questionable  if the  adoption
of such a view of the case in practice would ever
be beneficial.  The safer plan to follow is to con-
sider the flux,  termed diarrhcea, as  a distinct dis-
ease, but to regard it as the consequence of various
morbid states  in  different, cases ;  the practitioner
only taking care,  before he  applies his remedies,
to ascertain the particular state which exists  in
the individual case before him, as far as his obser-
vation  and pathological  knowledge enable  him to
do so.  If he does not do this, but regards the flux
only, without  reference  to  its cause, he will  be
liable to commit grievous errors in his treatment
  As a general  rule, we may consider diarrhoea
as having its seat in the intestinal mucous  mem- 
DIARRHCEA.
G35
brane; and it is the state of this membrane,  and
not the  discharge, which is to be regarded as the
great object of attention to the pathologist  and
practitioner.  The only exceptions to this rule are
the cases where  the disease is excited by fluids
poured into the intestinal tube from the annexed
glands,  or  by irritants  of  a temporary kind, as
food or  medicines, applied  directly to the mem-
brane. Even  in these cases the secondary affection
of the membrane is often of much more importance
than the cause producing it.
   In the class of cases just mentioned, the mucous
membrane of the bowels can scarcely be said to be
diseased;  and the  functional disturbance speedily
subsides on the  removal of the offending cause.
But in the great majority of the cases of diarrhcea
the  membrane is  affected  in a more permanent
manner, although  the degree  of this varies ex-
tremely.                    ,
   In the mildest form of the affection there seems
to exist merely a morbid degree of irritability, or
a morbid sensibility,  in the mucous membrane,
which scarcely exhibits any indication of  disease,
except when  excited  by something applied to it.
 What,  however, in a sound state would produce
only the proper and natural degree of peristaltic
action,  now produces a morbid degree of action
incompatible with perfect health.  In another form
 of the affection there exists, perhaps in conjunc-
tion with the foregoing state, a morbid degree of
excitement or of increased action in the membrane,
 considered as a secreting  and exhaling  organ,
 whereby it throws out its fluids in a morbid state
 or in a  morbid quantity, or both.  In a third class
 of cases it is  supposed by some that the exhalents,
 in place of being excited to increased action, are
 in a state of atonic relaxation,  and thereby allow
 their fluids to escape  in a  condition  no less de-
 viating  from that of health.
   But  in a  still  more numerous class of cases
 there exists a more permanent deviation from the
 healthy  condition  of  the  mucous  membrane,
 namely, some form or degree of that pathological
 state to which we give the name of inflammation.
 In diarrhoea this state  may exist in every degree,
 from the  slightest shade of congestive irritation
 up to well-defined  alteration of the normal struc-
 ture of  the membrane: it  may be confined  to  a
 small portion of the intestinal tube, or it may ex-
 tend over a large portion. In this form of diarrhoea,
 the evacuations deviate greatly from the character
 of health, and consist principally of fluids secreted
 by the  inflamed  membrane,  being  mucous or
 serous,  or flaky from  admixture of  coagulable
lymph,  and very variously  coloured  according  to
the condition of the liver,  the ingestion  of food,
the previous treatment, &c.  In almost all cases
the inflammation  is confined to the large intes-
tines ;  but in some it extends to the small, and  it
may even originate there.
   The form of diarrhoea just  noticed, and which
may almost alway s be regarded as present in recent
cases of much severity, and in which the stools
are not  faecal, can  be  considered as differing from
the  disease  termed  dysentery only  in  degree.
When  the inflammation is strongly marked, no
doubt there supervene some peculiar symptoms—
particularly the intermixture  of blood with  the
mucous discharges, and fever—which do not exist
in diarrhcea; but still the essence of both diseases
is the same.  Both are inflammations of the mu-
cous membrane of the large intestines; but in the
one the affection is slight, in the other it is severe.
There is  the  same difference between  them as
there is between a mild pulmonary catarrh and
bronchitis, but no  more.
  The diarrhoea whicb almost always attends the
latter stage of phthisis  depends on ulceration of
the mucous membrane.  The  ulcers in  this case
are often  extremely numerous, being spread over
the whole extent of the bowels, but they  are most
common near the  extremity of the ileum.  Many
other organic affections  of  the mucous membrane
of the bowels, for the most part  the consequence
of inflammation, give rise to diarrhcea; but cases
of this  kind do  not come  properly within the
scope of the present article.
   The  state of the mucous membrane found on
dissection  in simple diarrhcea, varies greatly  in
different cases.  In recent examples, not connected
with other diseases, opportunities for examination
after death will  rarely occur, as  almost all such
cases are cured.   When opportunities of examina-
tion  have been found,  the membrane, in recent
cases, has been observed more or less red and con-
gested,  or extremely pale and anaemic, the redness
being disposed in patches or in continuous stripes,
leaving the intervening portions  very  pale.  In
cases of more severity and long standing, although
still short of the degree  constituting the dysentery
of nosologists, a  great  variety of  morbid appear-
ances have been found.  In these the membrane
presents every variety of colour,  from  the most
intense red, purple, or brown, to  the blanched or
anaemic state above mentioned, in which there is
nothing to be  seen in  the vessels but colourless
fluids.  In other cases  there  is an enlarged and
patulous condition of the mouths of the mucous
follicles, which look erected, and  sometimes in-
flamed, and as if excoriated.  The whole mucous
membrane is also found thickened and oedematous,
as in certain forms of dropsy, and is often greatly
softened.   The intestinal tube is  frequently much
contracted in its caliber.  In some cases coagula-
ble lymph is found adherent to the inflamed spots;
but this is not of frequent  occurrence: very tena-
cious mucus of an  inspissated character is com-
mon. In many instances dissection detects scarcely
any deviation from the  state of health;  and then
we  may  reasonably suppose that the  exhalents
and  mucous glands merely afford a rapidly in-
creased supply.
   The  termination of diarrhoea, when unattended
by other, and especially  visceral diseases,  is for the
most part favourable. But when the inflammatory
state of the membrane  becomes considerable, the
disease then, under  the  name of  dysentery, may
lead to very serious results, ulceration taking place
in the different tissues of the intestine, sometimes
followed  by perforation and  fatal  peritonitis.  In
some cases the inflammation of the mucous  mem-
brane extends or is transferred to the serous coat,
giving  rise to ascites.  In  this way diarrhcea and
dropsy  have been  observed to alternate, according
as the morbid action chiefly occupied''the internal
or external tunic of the  bowel. When it assumes
the chronic  form, diarrhoea  is sometimes a most
obstinate  disease,  resist.ng  in many cases  for 
636
DIARR
HCE A.
months  or  years,  every variety of  treatment.
When, however, it is not immediately dependent
on great organic changes in  the bowels or con-
nected viscera, the general health is often much
less affected, even in severe cases, than might be
expected. We have known chronic diarrhoeas of
considerable severity continue  through  the greater
part of a long life.
  Treatment. — In undertaking the cure of  a
case  of diarrhoea, it is  often  of  as much  conse-
quence to consider its degree of severity and its
duration as its precise nature.  Slight cases of
every kind are in general easily removed; and in
recent cases, even when severe, the mode of treat-
ment  is almost always simple, and generally suc-
cessful.
  Acute or recent diarrhxa.—1. in the common
form  of  feculent  diarrhcea recently produced by
some  known cause of irritation, as from improper
food  or  otherwise,  it is  seldom that  any other
treatment is  necessary  except  abstinence from
food,  with rest, and simple  dilution.  In such
cases   the  offending matter is commonly itself
speedily  evacuated,  and  occasions at the same
time a complete discharge of the  whole faecal con-
tents  of the  bowels.  When  this is effected, the
morbid action usually subsides of its own accord,
and health is at once restored.  Sometimes, how-
ever, the offending matter is either not thrown off,
or only  partially,  and a degree of excitement is
kept up  sufficient  to irritate the bowels without
unloading  them ;  the  stools,  partly faecal, partly
mucous or serous, are scanty, and  are accompanied
with  more  or less  of  griping.  The  indication
here evidently is to unload the bowels thoroughly;
and it is best  fulfilled  by an active but not irri-
tating purge, such as castor oil, rhubarb and mag-
nesia, or the common senna draught of a moderate
degree of strength.   When the  evacuations  are
free  and complete, the  irritation  is commonly at
an end.  But sometimes, in place of being insuf-
ficient, the evacuations are  too copious; the irri-
tating matter has acted like a drastic purge ; or
the ineffectual efforts produced  by  the primary
cause  have been raised beyond the healthy degree
by the purgative, and the same result of hyperca-
tharsis ensues.  In cases of this  kind the obvious
and  appropriate remedy  is an opiate ; and few
cases will resist the effect of this when combined
with quiet, a warm bed,  and abstinence.
  In  feculent  diarrhoea  coming  on  without any
very obvious exciting cause, in persons who  are
great eaters, or whose bowels  are generally in  a
confined state,  it will likewise be proper in most
cases to  administer a purgative, as the probability
is tbat the cause of the diarrhoea is some irritating
matter lodged in the bowels, and  not any primary
source of irritation in the intestinal  membranes ;
and it may be stated, as a general rule, that in re-
cent cases, if the motions are foecal, this practice
will   always  be  safe, and generally  beneficial.
Even  in cases where  the stools are  altogether
without proper faeces,—mucous or serous,—if there
exist  any  reason  to expect an accumulation of
faeces in the bowels, a purgative  will  still be pro-
per.    The previous  health of the patient, his  ha-
bits as to eating and alvine exoneration, the nature
»f the stools  at the very commencement of  the
attack, and the degree of tension  and hardness of
the bowels, will, if duly weighed, in  most cases
lead to a just conclusion as to the  point in ques-
tion.   Where there remains any doubt, the safest
plan will  be to give a moderate dose of a mild
purgative,  particularly  castor oil, and be  guided
by its effects.   If by its operation faecal stools are
brought away,  and  the irritation still continues, a
repetition of the dose  or a still more  active form
of medicine  will be proper.   In persons whose
bowels have been costive for some time before the
attack, and also in those who are large feeders, and
particularly if they  lead sedentary lives, a dose of
colocynth  with calomel and  antimonial powder
may be proper, followed up after a few hours by
the saline senna draught; the after treatment be-
ing the same as before.
   2. If the feculent diarrhoea is complicated  or
caused by a superabundant secretion of  bile, it
will  be necessary \p restore the liver as well  as
the bowels to its healthy functions.  The unload-
ing the bowels by purgatives  may be  at first ne-
cessary ; but when this is effected, the treatment
of the hepatic  affection may be  a  work of some
time.  It is obvious that the consideration  of this
subject belongs rather  to  another place,  (see He-
patitis, and Liveh, Diseases of) ; but we may
be allowed to say a few words on  it in reference
to diarrhcea.   If the augmented flow of bile or its
depravation has been produced by  a mere  tempo-
rary excitement, little  specific treatment will be
requisite, as the disorder of function will in most
cases be removed  on  the removal of the cause.
What is more  commonly called bilious  diarrhoea
is, however, in general,  an affection  of a more
fixed character, depending, as we had  occasion
formerly  to remark, either on  an inflammatory
state of the liver itself, or an excited condition of
this gland  transmitted through its  ducts from an
inflamed duodenum.  In both cases the disease
is usually of  an  acute character, and  requires
nearly the same treatment.  If the inflammatory
state  is considerable,  or  is attended with fever,
venesection will be proper; but this will not often
be the case  in any state which can  be classed
under the head of diarrhoea.  Local bleeding with
leeches, or cupping in  the hepatic and precordial
region, will, however, always be proper, and must
be carried to such an extent as the urgency of the
symptoms may seem to require.   The repetition
of this measure several times, after the interval of
one or two days, may  be requisite; and its effects
will  be greatly promoted by the frequent  use of
warm fomentations to the same parts.  Mild mer-
curial  preparations, the best  of  which  is  the
hydrargyrum cum  cretsi, will  also be proper  in
cases of this kind, more especially if the affection
of the liver is primary;  they should be  given  in
small doses at bed-time,  and  followed  up  next
morning by a moderate dose of castor oil or other
mild purgatives; but care must be  taken that the
inflammatory  condition of the  duodenum (if it
exist)  be  removed, or  at least mitigated  by other
means, before  the  administration  of  purgatives.
Calomel will then  have a much more beneficial
effect in  restoring  the healthy condition of the
liver.   Cooling, saline,  and demulcent  ptisans
constitute the best  general remedies  in  this kind
of diarrhoea, and commonly suffice, in conjunction
witb  the means  above mentioned and  a proper 
DIARRHC3A  [CHRONIC]                          637
diet, to restore the patient to health.  The proper
diet in these and other  cases will  be mentioned
hereafter.
  3.  In the acute or recent diarrhcea, distinguished
by the discharges being chiefly mucous or serous,
with little  or  no admixture of proper faeces,  all
these having been previously  evacuated either by
the natural efforts or by purgatives administered
with this intent, we  are  no longer  to look for re-
lief from the employment of cathartics, but  from
means calculated to allay the  irritation which
exists in the mucous membrane, and which con-
stitutes the disease.  These means consist of a
proper diet, or the abstinence from  all food, the
internal  use of refrigerants, diluents, demulcents,
diaphoretics, and opiates, the local detraction of
blood, warm  baths  or  fomentations,  and  other
 measures of analogous tendency.   The treatment
• will vary considerably according as the attack is
 slight  or severe, and also according to the nature
 of the exciting cause.   In very mild cases,  keep-
 ing the patient in bed, and restraining him from
 the use of all kinds of food, with the exception of
 barley-water,—in small  quantities, and this only
 if there is thirst,—will very often  put an end to
 the  attack  in  twenty-four hours, without any
 other  means.   If the attack appears to have ori-
 ginated  in cold or obstructed perspiration, it will
 be proper to apply the general means found most
 useful in catarrhal  affections, of which the most
 effective are confinement to bed, in a warm  room,
 and mild saline diaphoretics.  If the case is  some-
 what  more severe, the application of warm fomen-
 tations to the abdomen,  by  means  of flannel bags
 filled  with bran and dipped in hot water, will  be
 proper, (they will indeed  be  proper, though per-
 haps not absolutely  necessary, in the very mildest
 cases,)  together with small  doses  of  mucilage,
 with  or  without nitre  or  the  liquor  ammonia?
 acetatis, and an equally rigid system of diet.   If
 the diarrhoea does not speedily yield to these mild
 measures, or if it be accompanied with much grip-
 ing or painful tenesmus, a small dose  or two  of
 laudanum,  or  of the  pulv. ipec. comp. in  chalk
 mixture, will be proper  ; or a glyster may  be ad-
 ministered, consisting of not more than a couple
 of ounces of starch mucilage, and  a proportion of
 opium varying according to the severity of the case.
    When irritation is  not very considerable, these
 means will almost  invariably put an  end  to the
 attack in a very short time.  But  should  they not
 do so, or should the severity  of  the symptoms  at
 the commencement announce the invasion of a
 more formidable disease, previously to the use of
 opiates, six, eight, ten, or twelve  leeches, accord-
 ing to the violence of the attack, should be applied
 to the anus, and the glyster be  afterwards  given.
 The leeches may be applied  a second  or even a
 third  time, if the complaint proves obstinate.  In
 some cases general bloodletting may be proper;
 but this is a measure rarely necessary while the
 disease rem tins of  such moderate severity as still
 to justify the application to  it  of the  term diar-
 rhoea.
   The  interval remedies  we are accustomed  to
 employ in the cases where opiates are improper
 or unnecessary, or in conjunction with these, con-
 sist almost entirely of the blandest fluids given in
 small quantities, such as  the mucilage of acacia
or tragacanth and water, with  or  without nitre ;
the chalk mixture with the same substances, small
doses of the liquor  ammoniae  acet., and  the  like.
Indeed, were it not that it is often necessary, for
the satisfaction of the patient or his friends, to ad-
minister some medicine internally, the case would
often be better left to nature, after the employment
of the more active remedies ; but  if medicines are
given, they should be such as are  at least harm-
less.   We will venture to assure the  inexperi-
enced that they will find such means  infinitely
more conducive to the recovery of the patient, in
the  cases now  under  consideration, than either
purgatives, or astringents, or opiates, which we
regret to say are so  often lavished by those  who
in their pride of bold practice, as  it is termed, are
accustomed to regard with  scorn the  treatment
we are now  recommending.   When  the disease
is prolonged  beyond the space of twenty-four or
forty-eight hours, or even during this period, if
desire for food is urgent, more nutriment  may be
allowed ; but this must be in very small quantity,
and either liquid or of the softest deliquescent solids.
Of this kind are barley-water, rice-water, aiiow-root,
sago, weak tea with milk, rice-gruel, weak chicken
or veal broth thickened with rice  or barley, &c.
   In the variety of mucous  diarrhoea which occurs
in certain epidemic constitutions, and in  persons
of a sluggish phlegmatic habit, and in which the
intestinal tube is rather irritated secondarily  by its
own morbid  secretions than primarily, a different
kind  of treatment  is  necessary.   Both  emetics
and  purgatives  are here indicated ;  the first  to
evacuate the contents of the stomach and to stim-
 ulate its coats to more healthy action ; the last to
produce a similar effect on the bowels.  Ipecacuan
is the best  emetic in  such cases, and  the  same
 medicine, in small quantity, will  be very properly
 combined with rhubarb as a purgative.   A useful
 purgative will also be found in small doses of cas-
 tor  oil combined with a few drops of the ol. tere-
 binth.   When  by these means  the  bowels  are
 unloaded of their morbid secretions, and the mem-
 brane  stimulated to more  healthy action,  if the
 diarrhcea still continues  it must be  checked by
 mild astringents and tonics, or by small doses  of
 opium. In these cases catechu and kino are found
 useful; but when such means are necessary, the
 disease will  come  under the head  of chronic di-
 arrhcea, the  treatment of which we shall now
 notice.
    Chronic Diahkhcsa.—This form of diarrhcea
 is that which the practitioner is  most  frequently
 called upon to treat, and which he  finds  by far
 the most difficult to cure.  In addition  to the in-
 trinsic  severity of the disease,  sufficiently evi-
 denced by its long duration, and  perhaps in spite
 of  proper treatment, he has  probably to contend
 against many obstacles to recovery which did not
 exist, or existed  in a much  less  degree, in the
 acute  disease.   The patient  may  have probably
 an excellent appetite, and cannot or  will not re-
 frain from food calculated  to  keep up his com-
 plaint ; neither can he be restricted in many other
 particulars which obstruct recovery, but which the
 violence of the acute disease either forced him
  to  attend to, or its brevity rendered but little  irk
  some.
    Chronic diarrhcea may assume all the  forms ol 
R38
DIA R R H CE A
tbe acute variety as far as regards the nature of
the evacuations, and most  of them may succes-
sively appear in the same case ; although, gene-
rally speaking, the motions preserve one predomi-
nating character, as in  the  acute disease.  It is
chiefly in the chronic form, however, that the food
appears undigested  in the stools ;  a circumstance
readily accounted for both by the  nature  of th"
two cases and the diet respectively used in  them.
In  many cases of diarrhcea which are  chronic
both as to time and the moderate severity of tbe
symptoms,  the disease is found, on close examina-
tion, to consist rather of a frequent return of slight
attacks of the acute kind, than to be strictly chro-
nic, in the  usual sense of that term.  This is an
important distinction, and deserves the best atten-
tion of the practitioner.
   In respect  to the treatment of chronic diarrhcea,
it may be stated generally, that  when the symp-
toms assume the general  character of any of the
forms  of the  acute disease formerly noticed, the
treatment to be had recourse to must be similar in
kind, but modified  by the degree  of severity and
other circumstances of the particular case.  Other
modes of treatment will, however, be often neces-
sary, and which would  have proved injurious in
the acute affection.   It is here  where the  medi-
cines properly termed astringents, and  also tonics,
are applicable, and which are so seldom proper in
any of the acute forms.  In numerous  cases of
the chronic  disease such remedies are likewise
very improper, and we believe that the great art
of treating chronic diarrhoea successfully, consists
principally in the practitioner having the skill to
discriminate  such cases as are benefited by purga-
tives and astringents, from the very large propor-
tion which are injured by them.
   We think it will not be disputed by any prac-
titioner of experience, who has been accustomed
to consider diseases more according  to their pa-
thological  relations than as mere subjects of em-
pirical prescription, that  the greater number even
of chronic diarrhoeas depend not so much on any
foreign matter applied  to the intestinal  mucous
membrane, as on  some  intrinsic irritation of this
membrane itself; and, consequently, that the treat-
ment in all such cases is  founded  not on the indi-
cation of evacuating irritating matters, but on that
of allaying organic irritation.   In a certain  pro-
portion of cases, no doubt, such irritating matters
are'present, and their evacuation is essential to the
cure of the disease.  Great mischief, however, has
arisen  from  the false notion entertained  by many
practitioners in this country, that most diarrhoeas
are occasioned by such extraneous sources of irri-
tation, and which can only be relieved by  purga-
tives.   We cannot too strongly enter our protest
against such a principle as a general rule of prac-
tice.   The circumstances under which purgatives
may be used in recent or acute cases were formerly
pointed out; and when similar circumstances exist
in the chronic stage, the same treatment will be
 proper. The accumulation  of faeces in the bow-
 els in conjunction  with diarrhoea, will always in-
 dicate the propriety of purgatives, and they may,
 in a general way, be considered  as not likely to be
 injurious as long  as the stools are feculent.   The
 same  observation  is equally applicable to  those
 »ases  in which there appears to be a morbid accu-
[CHRONIC]

mulation of mucus or other secretions  in  the  in-
testinal tube.
   We do  not mean to deny that even when the
disease consists essentially in  an irritation of the
membrane, a  purgative  may not lessen or relieve
it; indeed, we know by experienrc that this is  ac-
tually the case, and  it is only what might be ex-
pected from the  known effect of stimulant appli-
cations to chronic inflammations of other  mucous
membranes;  but we wish the young practitioner
to understand  that this practice is to be considered
as the exception, not as the rule in the treatment
of diarrhoea, and  that even when a purgative has
relieved  the symptoms, it is  not to be hastily or
often repeated.  The  repetition of purgatives in
all bowel complaints requires  much judgment and
discretion.  Aperients may be considered  as fairly
applicable in cases in which the irritation  is of an
inactive kind, or where the disease has proved  re-
bellious to rei?..edies of a different class.  In such
cases rhubarb is perhaps the best purgative.
   Another notion, no  less false, and perhaps even
still more prevalent  among practitioners, is, that a
great  proportion of  chronic diarrhoeas  depend  on
debility or  loss of tone of the intestinal  membrane,
and are only to be relieved or removed by astrin-
gents, tonics,  &c.  Such a state may undoubtedly
exist; but we are well  assured  that the  number
of chronic diarrhoeas which originate in this cause
is extremely small compared with the cases which
depend on an irritated or inflamed  state of the
membrane.
   On the whole,  we wish the young practitioner
to understand that  he is  to  proceed to the treat-
ment  of chronic  diarrhcea on  the only  rational
principle of endeavouring to  ascertain  the precise
nature of each individual case before he prescribes
for  it; that he is to  give emetics or purgatives
where there is evidence  that the bowels are op-
pressed  or irritated by faecal accumulations  or
morbid secretions;  that he is to give  astringents
and tonics where the flux seems to be the conse-
quence of a  debilitated and  relaxed  state of the
mucous membrane; that he is to soothe excessive
irritability  by opiates ;  and that he is to remove
congestive  irritation  and  inflammation  by the
means best calculated to effect this object  in other
parts  of the   system,  namely,  by removing  all
causes calculated to keep  up irritation, and by the
employment of such means as have the power of
directly diminishing the local disease.  Our limits
will  not permit  us  to enter into the consideration
of the characteristic features  of each of these dif-
ferent kinds of diarrhoea ; but their discovery will
not  be  very   difficult  to any  one who  is well
grounded  in  the general  principles of pathology,
and who will take pains to investigate with atten-
tion the history and  phenomena of the different
cases that come  before him.
   [Attention has been drawn by Dr. Stokes (Lec-
tures on the  Theory and Practice of  Physic, 1st
 Amer. edit.  p. 87: Philad.  1837,)  to a chronic
form of diarrhcea, depending upon ulcerations of
the rectum,  at  a short distance  from the  anus.
 which may be seen with the  aid of the speculum.
 They occur chiefly  in  those of broken-down con-
 stitutions, and in such  as have taken a great deai
 of mercury.   The symptoms  are—irritation  of the
colon, tenesmus, tormina, frequent  evacuations 
DIARRHCEA  [CHRONIC]                           639
and generally, during the straining, a little blood
is passed.  Dr.  Stokes advises,  that  the  rectum
should always be examined, when  diarrhcea has
been of long standing, has resisted a great variety
of treatment, has  been  combined with tenesmus,
and a desire to remain on the night-chair after an
evacuation,—which shows irritability of the lower
part of the tube ;  and when the health does not
appear to be so  much affected  as it naturally
should be where  there has  been long-continued
disease of a large portion  of the great intestine.
Since the writer's attention  has  been directed to
this pathological  cause of chronic diarrhcea, he
has  met  with  several  cases,  which  have  been
treated successfully by touching them,  where prac-
ticable, with lunar caustic, or by a strong solution
of nitrate of silver—from four to  twenty grains
 to the fluidounce of water.]
   We shall conclude this  article by some further
observations  on  the  principal remedies  used in
diarrhoea.
   Diet.—In all  the  forms of diarrhoea, acute or
 chronic, and  whatever be the other kind of reme-
 dies which are proper, there is one mode of treat-
 ment which  is universally applicable, and which
 is the most  important of all : this is  a proper
 system of diet.   This is so  important a  part of
 the treatment, that we have no hesitation in stating
 that the majority of cases of diarrhoea, both acute
 and chronic,  that are curable, may be cured  by it
 alone.  In all cases of acute diarrhcea, and in  the
 large class of chronic cases which depend on irri-
 tation of the mucous membrane, the  food should
 be very sparing in quantity, of the mildest quality,
 and such as to leave, after the process of digestion,
 as little  excrementitious matter  as  possible.  In
recent attacks of  the acute  diarrhcea, it  is  often
 proper to take  no food for  the first day,  or only
 mild drinks, containing a small quantity of  unir-
ritating nutriment, such as barley-water or arrow-
root.  During the subsequent days, the same gen-
eral kind  of  diet must  be continued,  but  may be
given in  larger  quantity or of greater  strength.
 When the irritation  is somewhat allayed, on  the
third or fourth day perhaps, but not  earlier, broths
may be allowed,  but no solid food of any  kind,
and, least of  all, solid animal  food  is to be  per-
mitted, until  the disease is removed or greatly al-
layed.
   The following  may  be  stated as the order in
which the articles of diet will  generally be found
most  proper  in  such cases : barley-water, arrow-
root made with water, sago or tapioca, rice-gruel,
oatmeal-gruel carefully strained, light broths, with
some of  the preceding  ingredients.    In  some
cases, more  especially the chronic  kind,  a  drier
diet is found more suitable, — the liquid food  ap-
pearing to keep up the diarrhcea; but in all  cases
the ingesta must  be of  the mildest quality.  Rice
is one of the most valuable articles of diet in such
cases. It should be well boiled and merely moisten-
ed with a little broth. While it is extremely mild
and unirritating, rice  scarcely leaves any remains
to be transmitted  along  the intestines, and this is
the reason why it is generally regarded as astrin-
gent.  As soon  as it can be borne,  a  small pro-
portion  of the lightest animal  food  may be taken
with the rice.    Tender chicken is the  best to
begin  with; then  white game boiled; and  then
roast mutton.   The  meat  of young  animals, as
lamb and veal,  should  be avoided.   Beef is too
stimulant, and fish is bad on account of the  large
quantity of excrementitious matter it leaves in the
bowels.  Animal jellies are generally allowable in
the case where meat is  found to agree; but they
often are more  irritating to  the bowels  than the
muscular flesh of  animals.
   In chronic diarrhoea  attention to diet is no less
necessary, and in general it will be found that the
same kind  of  food is alone proper.  It constantly
occurs  to us to meet with cases  of diarrhcea of
many months'  standing,  or which  have lasted
even for years,  and which are  speedily removed
by the  substitution of a mild unirritating diet for
the  ordinary food  of healthy persons.  We will
here  give  the  outlines  of a recent  case of this
kind, extracted from the out-patients' journal of a
public institution to which the writer is  attached,
and we introduce it the rather because it is not an
uncommon case.
   May 4,  1821.  J. G., gardener,  aet. 35.  Has,
been affected for two years with his present  com-
plaints, which  constitute  that form  of diarrhoea
commonly termed lientery.  During the whole of
the above-mentioned period he has had five or six
loose stools daily.   He has a good, often a craving
appetite, but  unless  he  is very  particular  as to
what he takes, he  suffers  pain, sometimes severe
pain, shortly after eating, and  a relaxed  motion
speedily follows.  The stools are in general liquid,
slimy, dark, and offensive, and frequently contain
masses of undigested food.  All sorts of hard oi
solid food disagree, such as tough meats of every
kind, pork, cheese, &c, and when taken, appear
unchanged  in  the  subsequent  motions.    More
fluid  food  agrees, such  as arrow-root, gruel, rice,
broth if not fat, &c.  He is much  troubled with
flatulence, but is never sick  at  stomach so  as to
vomit, nor is he  thirsty.   The tongue  is white,
with considerable tenderness on pressure, and also
distension  of the  epigastrium ;  the urine is clear.
There  is no particular  dryness of  skin, and he
perspires easily  on exertion.   He has occasional
headach, giddiness, and slight palpitation, and the
feet  are often cold especially at night.  He sleeps
well, except when  pain  is present in  the bowels.
He has lost eighteen pounds in weight during the
last  twelve months.  Notwithstanding the avow-
ed inconvenience produced by certain  kinds of
food, he does not usually debar himself from them.
He also drinks beer, about two pints daily.
   This man was directed to alter his diet entirely;
to give up  all kinds of solid food, and to live  on
broth, jellies, light puddings, rice, and liquid fari-
naceous food ; to  give  up drinking beer; and, in
a  word, to take nothing which he  knew to have
the effect of irritating his bowels.  He was direct-
ed to put his feet in  warm water every night.
The only remedies prescribed were, ten leeches to
the pit of the stomach, and a powder consisting of
pulv. tragacanth c. gij,  potassa?  nit. Qj, to be dis-
solved in half a  pint of cold water, and taken  daily
in divided portions.
   The effect of  this change of regimen, (to which
the  man adhered faithfully) was, that  the  diar-
rhoea ceased within three days,  and never return-
ed.   He was  not,  however, discharged  fro"i \he
books of the infirmary  until the end of July, al 
640                         DIARRHCEA [CHRONIC]
though he had for some time returned to the use
of animal food  without suffering  any  inconve-
nience : indeed, he said his bowels were  then  in
a better state than he  ever remembered them  to
have  been.   This  man   continued  well many
months after his discharge.
  In  some  cases  of chronic diarrhcea, however,
particularly  those  in which astringent  medicines
are found useful, a solid diet of a more stimulat-
ing quality, with a moderate proportion of wine,
is found much more  useful than the bland unirri-
tating food above mentioned.   In  such cases  the
dry and tonic diet has  the effect of producing mo-
tions  of  a more solid  kind ; while  at  the same
time it tends at once to  restore the lost  tone  of
the bowels and the general strength.  In practical
medicine we must  never follow our  pathological
principles so far as  to be blind to the  results  of
experience; and in  diarrhcea,  as in every other
disease, however we may allow to science the ini-
tiatory in prescription, it is the observation of a
favourable result  alone that can justify persever-
ance  in any kind of regimen  or medicinal treat-
ment.
   Leeches.—In the case  above detailed we  are
disposed to  attribute nearly all  the good effects to
the change  of diet;  but the application of leeches,
even  for  a  single time, was probably  of benefit.
 We judge  so  from the marked benefit we con-
stantly  find from  their  use  in  this  complaint,
whether in  the acute or chronic form.  When  the
diarrhoea is evidently  complicated with a state of
irritation or slight  inflammation  of the mucous
membrane of the stomach and small intestines,  the
treatment should begin with  the  application of
leeches to the  epigastrium.  If this and the  ap-
propriate diet fail, then leeches must be applied to
 the anus, or to  this  part  in the first place, if  the
 diarrhoea is uncomplicated  with gastric irritation.
 For the  relief of the inflammatory irritation of the
 large intestines, there can be no doubt that leeches
 applied to the anus  are greatly more efficient than
 when placed  on  the abdomen.  This  remedy is
 indeed possessed of  remarkable powers in the dis-
 ease, often working,  according  to  the  common
 expression, " like a  charm," even in cases of very
 long standing and of different  external characters.
 Combined  with proper  diet, indeed, we are  per-
 suaded that the greater number of diarrhoeas, both
 acute and chronic, will yield to this method, with
 little or  no  aid from other medicine.  We  have
 repeatedly  known  a diarrhoea of long standing,
 more particularly in the case of infants, cured by
 a single application of two or  three leeches only;
 and in more obstinate cases it will be found that
 an instantaneous and marked  remission of  the
 symptoms follows every repetition of the remedy.
 Although, in our own practice, we  always  com-
 bine with the  use of  leeches,  in the cases where
 they are indicated, a proper diet, yet we have had
 ample  evidence  of their  unassisted  powers  in
 checking or removing diarrhoeas of great severity
 and  obstinacy.   We  would  add  one  caution,
 which may be useful to those  not  in the habit of
 making much  use of this  remedy :—to ensure the
 lull effect, the  leeches should be applied immedi-
 ately to the anus, that is, as  close to the mucous
 membrane  of the qxtremity of the rectum as pos-
 sible.   Unless  accurate   directions  are  given,
nurses will  be apt to mistake our  meaning.  It
has frequently happened to us to find the prescrip-
tion of hirudines ano carried into  effect  by their
being applied  to  the buttock, perineum, or even
sacrum.
  Bathing. — In most  of the cases in which an
unirritating diet and  the local detraction of blood
are beneficial, the employment of some  form of
the tepid or warm bath will be useful.  Although
the general  bath is often indicated, and is the best
form  of the application, yet in the  majority of
cases we find that  the frequent use of  warm
fomentations to the  bowels by means of flannel
bags  of bran, with  the foot-bath  at bed-time,
answers completely in promoting the removal of
the intestinal irritation.   (See Bathing.)*
   Opiates.—Of the  means calculated to .assist in
the cure by affording temporary relief from  pain,
as well  as by directly allaying the irritated condi-
tion of the  bowels, no remedy equals the use  of
opiate injections.   In  all cases where there is
tenesmus with pain and  frequent  stools, this
remedy is  to  be  had recourse to as a means  of
temporary relief, whatever other plan may be pur-
sued  for the permanent cure of the disease.   Solid
opium, or extract of poppy, carefully rubbed down
into mucilage, or the pulvis opii, Battley's liquor,
or the common tincture, may all be used.  Perhaps
the pulvis opii is, on the whole, the most conve-
nient form; of which one, two, or three grains
may  be administered in a  couple  of ounces  of
starch mucilage.   This may be repeated according
to the urgency of the case ;  but  the student is to
be  earnestly cautioned not  to be seduced by the
relief often produced by this application, into the
neglect of means of  more permanent efficacy.
   Astringents.—It will not, we trust, be imagined,
from the manner in which we have recommended
the use  of  the foregoing remedies, that we con-
sider the treatment  of diarrhoea by the  use  of
astringent medicines, properly so called, as  gene-
rally either  useless or improper.  On the contrary,
we know that cases of this disease are every now
and  then  met with, that can only be cured  by
such medicines;  and  that they are very  often
necessary,  at least as  palliatives,  in the chronic
form of diarrhcea. Sometimes nothing else affords
relief.  All that we labour to impress on the mind
of the  young  practitioner,  or on those who have
 unfortunately  been  taught  to  treat diseases as
 mere collections of  symptoms, without reference
 to  pathology, is, that there are many kinds of
diarrhoea wbich can be best treated without astrin-
gents and without purgatives; and that the pre-
sence of frequent fluid dejections does no more
 necessarily indicate the use of such remedies, than
 any  other single  symptom necessarily indicates  a
 peculiar treatment, without reference to the  whole
 disease of which  it is but a part.
   In all cases, before we have recourse to astrin-
 gents, the state of the  patient must be  carefully
 examined into, the nature of the evacuations, the
 state of the abdomen, &c.;  lest some inflamma-
 tory  affection should still remain and keep up the
   * Riverius gives his own case in testimony of the effi
 cacy of the warm  bath in  diarrhcea.  " Corrcptus  sum
 diarrhoea biliosa, tauta acrimonia prxdita ut annul ero-
 deret, ardoremque urinae concilaret. Dysenleria  erat in
 procinctu.  Ingressus semicupium tepidum, illico libera-
 tus sum.—River. Op. Univ. p. 509. 
DIARRHCEA  [CHRONIC]
641
the diarrhcea.  Astringents are a class of remedies
which seldom fail to do mischief when they do not
do good.   They are  indicated in the cases where
the  diarrhoea appears  to be kept up  by loss of
tone, or by a morbid  degree of  irritability, not
dependent on vascular orgasm or inflammation, in-
the  mucous  membrane of the. bowels ;  and  they
are  properly used in  all chronic cases which  have
resisted  the means  calculated to  relieve active
irritation, or other known pathological conditions,
as noticed above.
  For  the particular forms  of astringents  most
useful in such cases  we must refer to writers  on
Materia Medica, and to the article Astringents
in the present work.  We can only afford space
here for a few observations.
  The astringent substances from  the vegetable
kingdom that have been  used in alvine fluxes are
extremely  numerous ;  and  it  is  probable  that
some of those  not  now included  in our pharma-
copoeias, or, if included, not  much employed, are
not the least useful.   Catechu and kino are now
in most  common use, probably not so much be-
cause  they  are  in  reality the best remedies, as
because they are the strongest astringents.  They
are, however, often  very useful  in  the cases of
diarrhoea wherein remedies of this  class are in-
dicated.   Both  these  substances  may be  given
separately, or in combination with opium or  other
astringents.  One of the most usual forms of pre-
scription is the tincture of catechu in chalk mix-
ture, combined with  equal parts of the tincture of
cinnamon.  In other cases the watery infusion of
catechu answers better, in the form  of  the  infus.
 catechu comp., and may be given in doses of one
 or two ounces after every loose motion.
   Dr. Pemberton had an idea that kino had  some
 peculiar virtues as an astringent;  that  it did not
 act -as such except  diarrhoea were  present.   He
 therefore gave it the preference to other astringents.
 His mode of administration was in  doses of a
 scruple made into a  bolus with opiate  confection.
 (Treatise on  Diseases  of Abdom. Vise. pp. 112
 and 149.)   More recently an extensive series of
 experiments  on  the effect of kino  in  diarrhcea,
 were made in  the hospital of La Pitie, in Paris,
 by  M. Bally.    In   chronic  diarrhcea,  unaccom-
 panied by fever or marks of inflammation in the
 mucous membrane, the continued use  of the re-
 medy, even for  a short  time, was found almost
 invariably effectual in stopping the diarrhoea.  In
 one case 0f three years' standing it  effected a
 cure.  But the most remarkable result of M. Bal-
 ly's experiments is the alleged fact—that the kino,
 given  in  doses  of twelve or fourteen  grains  for
 several days in  succession,  succeeded  in curing
diarrhoeas attended  by febrile and  inflammatory
symptoms.   (Med. Gazette,  vol.  v. p. 700.)   We
confess we are surprised at such a result.
   Logwood, tormentil, and bistort were more em-
ployed  formerly  than  at present as astringents.
We believe the  former to be a valuable remedy :
the best form of  using it is decoction, which may
likewise be made the vehicle for  more active re-
medies. The plantain (plantago) was much used
by  the older authors;  and it  and  many  other
vegetables were taken boiled  in broths and demul-
cent ptisans-a form of medicinal administration
too much fallen into disuse in this country.^  Un-
  Yol. I. —81                       3d
ripe medlars were formerly famous for their occa-
sional effects in diarrhoea ;  but we apprehend the
cases are  few in  which  they  can  be recom-
mended.*
  Among  the mineral astringents,  lime and its
carbonate  deserve  attention,  as being  in  most
common use, and as  being perhaps not  the less
useful because they  are possessed of only moderate
astringency.   In  certain mild forms of diarrhcea,
particularly after the  use of purgatives,  the pulv.
cretae comp., with or without opium  according  to
circumstances,  is a very mild  and valuable re-
medy ;  and the mistura cretae, it need hardly be
said, is the common and one of the  best vehicles
for other more powerful astringents.   In  the more
chronic forms of diarrhoea lime-water has been
found occasional useful, taken in large quantities
as a  beverage ; and it is very properly combined
in such  cases with gum,  and often with milk.
Equal  parts of lime-water  and  milk, with acacia
or tragacanth, is a favourite  remedy with  many
old practitioners.   Alum is a medicine given fre-
quently in a somewhat  similar  form, under the
name of alum whey, which  is made by adding
two  drachms of  the alum to  a pint of boiling
milk :  of this whey  a glassful or three or four
ounces  may be taken as a dose.  Alum is also
given in a solid form, in bolus or pill, combined
with  kino, catechu,  or opium.  The  stronger
mineral astringents, the  acetate of lead  and sul-
phates of copper and  zinc, are occasionally useful,
particularly the sulphate of copper; but this re-
medy is chiefly applicat le in a form of the disease
which  does not come properly under our notice
in this article, the diarrhcea of phthisis.
  [The  solution of persesquinitrate  of  iron and
the tincture of chloride of iron are  said  to have
succeeded  when other remedies had  failed.   (See
the writer's New Remedies, 4th edit. p. 294: Phi-
lad.  1843, in regard to the former.)   The artemi-
sia vulgaris, carbo animalis, and ferri ferro-cyanu-
retum have been recommended of late years ;  but
there is no reason for believing that they  are supe-
rior  to other vegetable and mineral tonics.
  Of late, a mixture called Hope's Mixture, from
its proposer, which consists of nitrous  acid and
opium, forming a  nitrate of morphia, has  been
highly extolled, in  the United States more espe-
cially ; but it has not  succeeded more frequently
with the writer than  other remedies suggested by
the nature of the case. It is composed as follows :
R.  Acid,  nitros. f.gi; Aquae  camphor,  f.^viij ;
Tinct. opii gtt. xl.—M. Dose, a fourth part, every
three or four hours.
  The balsams and turpentines have been much
prescribed.  Of these the copaiba and the oleum
terebinthinae are  alone employed at the present
day.   Nux vomica and its active principle have,
  * Forestus relates a case of diarrhoea which seems to
have been most particularly obstinate, since he informs
us that the poor  patient "omnem suam substantiam
frustra in medicorum  ope consumpsernt, consilii causa,
ut ab hoc malo liberari posset," but which he (Forestus)
cured  in a few days by giving him a great quantity of
unripe medlars to eat.  The same author tells us of a
patient of Spirinchius, who was cured of an equally ob-
stinate diarrhoea by the same  means; but Spirinchius
was more fortunate in a richer patient, "qui modico
trecentos aureos pro sola mespilorum prascriptione  till
meravit."  Forest. Op. torn. iii. p. 47. 
642
DIARRHCEA
[ADIPOUS.]
   likewise, been  used,  and occasionally with great
   advantage.]
     In this and other forms of diarrhoea depending
   on disorganization of the bowels, opiate clysters
   are  commonly found most effectual.  A simple
   form of injection  recommended by Van  Swieten
   is also found occasionally beneficial in this  dis-
   tressing complaint: it consists simply of an ounce
   of treacle  or juniper-rob in three or four ounces
   of warm milk.   (Comment, vol. ii. p. 394.  Diar-
   rhxa  Febrilis.)
     In every form of chronic diarrhoea, warm cloth-
   ing  with flannel next the skin, and an  additional
   quantity on the abdomen, in the form of a belt or
   swathe, is highly  useful.  In  many cases,  also,
   warm galbanum plasters and other warm external
   applications  to the abdomen are very beneficial.
   This  mode of treatment was much  used by the
   older authors.  (See  Forestus passim.)*
     It is hardly necessary in all such cases to dwell
   on the propriety of the  patient  being lodged in a
   dry  well-ventilated chamber ; or of the advantages
   of a mild and dry  climate.   Chronic diarrhcea is,
   indeed, one of  the diseases in which a change to
   a warmer  and  drier  climate than  ours is found
   most  beneficial, (see Climate) ; and  this leads
   us to notice the fact well known to travellers, and
   to physicians who have had  much to do  with
   travelling invalids, that a journey is almost specific
   in arresting diarrhoea.
                            John Crampton.
                            John Forbes.

     Adipous DiAitRHrjEA molten grease, the gras
   fondure of the French, is characterized by a dis-
   charge of fatty  matter from the bowels, sometimes
   in a fluid state, at  others  in  the form  of  fatty
   concretions.   Many  cases  of  the  latter are re-
   corded ; and, of late years, attention  has  been
   especially  directed to the former.   In  one  case
   related by Sir Everard Home, the fatty discharges
   might be  accounted for  by the patient's habit of
   taking castor oil regularly ; but in other cases, the
   adipous discharges are  evidently at  the expense
   of the system.
     At times, the discharge is in  the form of oil, or
   semi-concrete matter  floating on  the top of the
   faeces,  and possessed of a fetid odour.   The quan-
   tity evacuated differs greatly.  In one case, which
•   occurred  to  Dr. J.  B.  Jackson,  of Boston, it
   amounted on the  average, in twenty-four hours,
   to about  eight  ounces  during more  than  four
   months.
     Some fatty concretions, analyzed by Lassaigne
   and  L. Gmelin, had  the following constituents :
   seventy-four  parts  of an acid  fatty matter,  in
   which stearin predominated, elain  and  a peculiar
   acid  ;  twenty-one parts  of a substance analogous
   to fibrin ;  four parts of phosphate of lime and one
   part  of chloride of sodium.  In another case, there
   were, in one hundred parts, sixty of  matter simi-
   lar to  spermaceti ;  thirty of phosphate  of lime ;
   eight of animal matter,  and two of loss.
     In many of the  cases of fatty discharge, there
   was  concomitant disease of the  liver, pancreas or
   duodenum; so  that it was imagined the anomal-
    * Qiiibus adjungenda sunt topica, olea, unguenta, lini-
   senta  et fotus, ungnenta  et irrigationes, ex oleo om-
   9hac. ros.iceo,  myrteo, cotoneorum  cum vino adstrin-
   gente. cerata. ii.'.   Forest, vol. iii. p. 58.              i
ous secretion might be the product of the pancreas
or the liver.   On the other hand, in  some  of the
cases on  record, the  ducts of the liver and pan-
creas have  been so obstructed as to preclude the
idea of its being the product of either of these vis-
cera ; and moreover it has been  seen in cases in
which there was no reason to believe in the exist-
ence of serious disease of those  organs.  At the
age  of three  years, a  little girl  was observed to
discharge something from the bowels as she walk-
ed across the  room;  this, when examined, was
found to be fat in  a liquid state,  which concreted
when cold.   " Ever since that time to the pre-
sent," (a  period  of eighteen months,) " she has
voided,"  says  Dr.  Babington, — the respectable
narrator of the case,—" at intervals of ten or four-
teen days, the  quantity   of  from one to three
ounces, sometimes  pure, at others mixed with the
freces: when voided,  it has  an unusually  yellow
tinge, and is quite  fluid, like oil.   Her appetite is
good, as well as her spirits, and her flesh firm, her
belly rather tumid  but not hard."   In other cases,
the disease appears to have occurred during phthi-
sis, hysteria, and other affections; in some  instan-
ces, oil was discharged from the  bladder likewise,
and  fatty concretions have been  taken  from the
vagina.   One of these  was examined chemically
by Dr. Martius, jr., and found to be composed of
fat with some traces of salts.
  These  facts sufficiently establish, that  under
certain  circumstances,  and, doubtless,  under the
influence  of particular diseases of the neighbour-
ing organs, the gastro-enteric and other mucous
membranes may secrete fat from  the blood, as the
physeter macrocephalus occasionally secretes an
enormous quantity  of fat  under the form of am-
bergris :—as much, it is asserted,  as one hundred
and  eighty-two pounds have been found  in the
body of one of these animals.
  Treatment. — Where organic disease exists,
the efforts of the practitioner may be fruitless; but
where the affection consists of a vicarious secre-
tion  from the mucous membrane  of the  intestines,
it may admit of cure.  The best mode of manage-
ment would seem to be, to attempt a thorough re-
volution in the whole system of nutrition by change
of diet, and an entire mutation  of all  the atmo-
spheric and other influences surrounding the pa-
tient.  Mercurials and  other agents belonging to
the class  of eutrophics,—iodine,  and its various
preparations, for example,—may be serviceable in
this view ; and we may be able  to comprehend,
that new impressions made on the nerves by the
various remedies  recommended in hysteria, may
put an  end to the  adipous secretion in hysteric
individuals,  by removing  the  irregularity  of the
nervous and other functions, which constitute that
protean malady.       _        ^
                      Kobley Dunglison.]
  DIETETICS. — An organised body, whether
of the animal  or vegetable kingdom, cannot sus-
tain the functions of life without  a certain expen-
diture, or  consumption  of the  materials of which
it consists ;  and it is evident, therefore, that every
living being, in order  to  continue its  existence,
must possess the means of receiving and assimilat-
ing to itself  foreign matter  for the repair of its
diurnal waste.  It is upon this necessity that the
want of food is founded;  its judicious administra- 
                                      DIETE

lion must be directed upon principles the know-
ledge  of  which can  be alone  derived  from tbe
sources of physiology and chemistry.
  The possession of a receiving canal, or internal
cavity of  some  kind, would appear to be exclu-
sively characteristic of  the  animal creation;  and
Cuvier has distinctly  stated that he knows  of no
animal unprovided with such  an apparatus.   In
plants, on the  contrary, which never contain any
organ analogous to an internal stomach, the fluid
supplies are  absorbed by pores on their surfaces ;
and although some physiologists have questioned
the propriety  of  so  sweeping  a generalization,
minute investigation  has shown,  that so far from
being real, the instances adduced by them in sup-
port of  their objection are only apparent excep-
tions  to  this general law  of nature.   To enter
upon this wide field of inquiry would be altogether
foreign to the practical objects of the present arti-
cle; nor  can we undertake to examine the  great
diversity  of means which Nature employs  in the
different  orders of animals for the conversion of
food  into nourishment  or  into  blood ; we  shall
only observe that with  such  nicety  are the  pro-
cesses of waste and supply adjusted, that whatever
may  be  the quantity of food taken, or however
the circumstances under  which  it is consumed
may vary, the same individual, after having aug-
mented  in  weight in proportion to  the quantity
of ingesta, will return in the space of twenty-four
hours to nearly the  same standard, provided  the
development of growth, or the existence of disor-
dered function, does  not interfere with the result.
During this  period, the food has been decomposed,
and re-combined into   compounds  analogous to
those which constitute the organs to which  it is
carried ;  and this would appear to take place, how-
ever remote  its composition may be from that of
the structures with which it is assimilated.   It is,
however, important to notice  that the extent of
the digestive cavity bears a relation to the nature
of the food it is destined to receive, and  by which
the animal is  designed  to  be  nourished; for the
more dissimilar its composition to that of the body
it is to recruit, the longer must it remain in its
alimentary cavity, and the more complicated must
be the changes which are to perfect  its transmu-
tation.  We  thus find  that carnivorous animals
have  generally less  capacious and  complicated
organs than  the herbivorous  tribes;  and  that
amongst  the latter, those that feed upon seeds or
fruits, with the exception of the ruminantia, have
them less so than those  which live upon leaves or
the entire vegetable.   The digestive canal of man
is less capacious and complex than that of  other
mammalia which live entirely on flesh ; whence
we may infer that in a state of nature he may be
capable of subsisting  either on animal or vegetable
food, and that he is  not only qualified for every
diversity  but for every admixture  of it.  Thus do
we see that, while many savage tribes exist almost
entirely on fruits  and roots, others are  as exclu-
sively fed on raw animal flesh.  The Hindoos, for
instance,  live  upon  rice; the Lombard peasants
upon  maize ; the West Indian negroes fatten upon
sugar, those  of Senegal upon gum ; while the Es-
quimaux  gluts himself with  the blubber of  the
seai.  It  would  appear,  however, that although
man may subsist upon almost every variety of
TICS.                                  643

food, he cannot bear with impunity a sudden tran-
sition from one species to another.  This circum-
stance was well exemplified in the eastern part of
France in the year 1817, where the failure of the
crops occasioned such  a famine that the poor
were  compelled to feed upon whatever vegetable
productions could be found :  the consequences are
stated to have been general anasarca, interruption
of the menstrual discharge, a  diminution  of the
ordinary number of conceptions  by at least one
half, and a permanent injury  to the health.  Even
the sudden return to the use of barley bread, after
the continuance of this  miserable regimen  for
three months,  M. Gaspard informs us, was not
unattended with danger.  Spallanzani  has satis-
factorily shown that animals  may be  brought  to
live  on food  of the most opposite kind, provided
the change from their usual diet be gradually ac-
complished,— such,  for example,  as a pigeon on
flesh, an eagle  on bread, &c.  We know  that in
certain  maritime districts of the  East, horses  are
not unfrequently fed upon fish, while on the coast
of Coromandel they are fattened upon balls of
boiled flesh mixed with grain  ;  and it is on record
that a lamb kept on ship-board was fed with flesh
until it refused the grass when afterwards turned
into a meadow.  Such  facts  have induced some
physiologists, amongst  whom  we may mention
the distinguished name of Dr. Bostock, to consider
it probable that all the anatomical varieties in  the
structure of the stomachs of different animals may
be resolved into their mechanical effects upon  the
aliments  submitted  to their  action;  and that,
whatever may be the chemical composition of  the
food, provided  it  be sufficiently  comminuted  or
triturated,  it  will  be equally  acted upon  by  the
gastric juice.   We might bere ask whether  the
nature of the  digestive solvent itself may not at
the same time  vary with that  of the food which
excites its secretion, and whether in  this way
Nature,  if not abruptly  called  upon, may not
adapt her measures to her necessities  ?
   Although it  is not our intention to discuss, at
any length,  the question as to  whether Nature
originally intended that we should feed on  animal
or vegetable food, nor to follow the train of those
speculative  authors  who have  endeavoured  to
prove  that animal food was  not  eaten before  the
deluge, but was introduced in consequence of  the
deterioration  which the herbage sustained on that
occasion,—there are, nevertheless, several points
connected with the first of these  questions which
we consider as  deserving some  notice.  Reasoning
from the data afforded us by the researches of the
comparative  anatomist, we  are undoubtedly au-
thorised in pronouncing man to be an omnivorous
animal, and this is perhaps the only generalisation
of which the subject is susceptible;  Broussonet,
however, has ventured so far  to  refine upon this
proposition  as  to decide upon  his  being more
herbivorous than carnivorous in his nature; and,
from the proportion which the different teeth bear
to each other,  he  concludes  that  his mixed diet
should consist of animal and vegetable food in tho
proportion  of twenty to twelve.  It is, howevei,
quite clear that no rule of this  kind can possibly
be established.   We have only  to consider the
different effects produced upon the body by these
two species of  food,  to  perceive that the circum 
644
DIETETICS.
stances of climate, season, exercise, habit, age,
and  individual peculiarity must at once oppose
such an admission.
  As every description of food is converted into
blood, and since the flesh and blood of carnivorous
and herbivorous animals do not differ very  mate-
rially from each other, it may be inferred that the
ultimate effect of all  aliments must  be virtually
the same;  and that  the several  species can only
differ from each other in the quantity of nutriment
they afford, in the comparative degree of stimulus
they impart  to the organs through  which  they
pass,  and in the proportion of vital  energy they
require for their assimilation.   Now were the de-
gree of excitement which attends the digestion of
a meal commensurate with  the labour imposed
upon the organs which perform it, it is quite clear
tbat less  irritation and  heat would attend  the
digestion of animal than of vegetable food ;  for in
the one case  the aliment already possesses a com-
position analogous to that of the  recipient, and
requires little more than  division and  depuration ;
whereas in the other  a  complicated series of de-
compositions and recompositions must be effected
before the matter can  be animalised, or assimilated
to the body.  But the digestive fever, (if we may
be allowed to  apply such an expression to a healthy
process,)  and  the complexity of the alimentary
changes, would appear in every case to  bear an
inverse relation to each other.  This must depend
upon the fact  of animal food affording  a  more
highly animalised chyle, or  a greater proportion
of that principle which is essentially nutritive, as
well as upon the immediate  stimulus  which the
nerves receive from its contact.  In hot  countries,
therefore, during the  heat of summer, we are, as
it were, instinctively led to prefer vegetable  food ;
and we accordingly find that the inhabitants  of
tropical climates select a diet  of this  description.
The Brahmins in India, and  the  people of the
Canary Islands, Brazils,  &c, live almost entirely
on herbage, grains, and  roots, while those of the
north use little beside animal  food.  On account
of the superior nutritive power of animal matter,
it is equally  evident  that  the degree  of bodily
exertion, or  exercise, sustained by an individual,
must  not be overlooked in an  attempt to adjust
the proportion in which animal and vegetable food
should be mixed. Persons  of sedentary  habits are
oppressed,  and ultimately become diseased,  from
the excess of nutriment which a full animal diet
will occasion ;  such a condition, by some process
not well understood,  is best corrected  by acescent
vegetables.   It is well known that artisans and
labourers, in  the confined manufactories of  large
towns, suffer prodigiously  in  their health when-
ever a  failure  occurs in the crops  of common
fruits.   This fact was remarkably striking in the
years  1804  and 1805.   Young  children*  and
growing youths generally thrive upon a generous
diet of animal food ; the excess of nutritive matter
is consumed  in the development of tbe  body, and
if properly digested imparts strength without re-
pletion.  Adult and  old persons  comparatively
require but a small proportion of aliment, unless
  * The aliment of almost every animal, in its first stage
of life, is composed of animal matter; even the gramini-
vorous birds are nourished  by the yolk of the egg for
Hivera! days after being hatched.
the nutritive movement be accelerated by violent
exercise and hard labour.
   Those  who advocate the  exclusive  value  of
animal food, and deny the utility of its admixture
with vegetable matter, adduce in support of theii
system  the rude health and  Herculean strength
of our hardy ancestors.   The British aborigines,
when first visited by the  Romans, certainly do not
appear to have been conversant with the cultiva-
tion of the ground,  and according  to  the early
writers,  Caesar,  Strabo, Diodorus  Siculus, and
others,  their  principal subsistence  was on  flesh
and milk;  but before any  valid conclusion can
be deduced from this circumstance,  the habits of
the people must be compared  with  those of  their
descendants.  The history of later times will fur-
nish us  with a satisfactory answer to those who
deny the necessity of vegetable aliment.  We
learn from the London bills, that scurvy raged to
such an  excess  in  the seventeenth  century as to
have occasioned a very considerable mortality : at
that period the art of gardening had not long been
introduced.   It appears  that the most common
articles of the kitchen-garden, such as cabbages,
were not cultivated in England until the reign  of
Catharine of  Arragon; indeed, we  are  told that
this queen could not  procure a salad until  a gar-
dener was sent for from the Netherlands to raise
it.  Since the change  thus happily introduced into
our diet, the ravages of scurvy have been less se-
verely experienced.
   It follows,  then, that in our climate  a diet  of
animal food cannot with safety be exclusively em-
ployed.   It is too  highly stimulant;  the springs
of life are urged on too  fast;  and  disease is the
necessary consequence.  There may, nevertheless,
exist certain  states of the  system which require
such a stimulus, and there  may also exist a con-
dition of the digestive organs  which renders them
incapable of assimilating vegetable food ; the phy-
sician,  therefore, may occasionally confine his pa-
tient to an animal regimen with as much propriety
as he would  prescribe opium or any other power-
ful remedy.  By a parity of reasoning, the exclu-
sive use of vegetable food  may be  shown  to  be
inconsistent with the acknowledged  principles  of
dietetics, and to be incapable of conveying a nour-
ishment sufficiently stimulating for the active ex-
ertions which belong to our present  civilized  con-
dition.   At the  same time, it must  be allowed
that an adherence  to  a  vegetable diet  is usually
productive of far less evil in sedentary habits  than
that which follows the use of an exclusively ani-
mal regimen.
   A very curious chapter might be written upon
the adverse  opinions which  the physicians of dif-
ferent ages  have maintained as to the importance
of dietetic observances  for the  preservation  of
health and the cure of disease.  Hippocrates was
the first who  attempted  to establish any general
principles upon the subject of dietetics ; but ac-
curate  as he  was in all his  observations of the
phenomena of disease, and  admirable as are his
precepts  for its  management, so watped were his
notions with regard to the nature of aliments,  by
an absurd and predominating  theory, that, instead
of gathering from the stores of his experience any
useful information, we find nothing but a mass of
the most  extraordinary  conceits.   Assuming  as 
DIETETICS.
645
the directing principle of all his researches, that
living bodies contain two elements,  differing in
power but agreeing in purpose, viz. fire and water,
which, with their consequences, heat and dryness,
moisture and cold, he considers  as necessary and
sufficient for the maintenance of all the functions,
— the water nourishing and  the fire setting in
motion,— he proceeds, after showing that disease
arises from  the deficiency of  one or the other of
these elements, to enumerate the different articles
of diet  which, from  their heating, drying, moist-
ening, and cooling tendencies, are best calculated
to counteract such morbid states.  He tells us, for
instance, that fowls  of every kind are drier  than
quadrupeds,  because they have  no  bladder, and
neither  secrete urine nor saliva;  thereby showing
that the heat of the body dries  up  its moisture.
Their eggs,  he says, are strong, nourishing, and
 inflating ; strong, because they  contain the germ
 of an animal,—nourishing, because they nurse it,
 as it were, with milk,—and inflating, because they
 become dilated from a tiny particle to a large size.
 But it was not to be expected that, anterior to the
 discovery of the circulation of the blood, or to the
 existence of chemistry as a science, any rational
 views could be entertained upon a subject so en-
 tirely dependent  upon such knowledge for its ex-
 planation.   There exists, however, a connection
 between a class of phenomena which the ancient
 physicians  recognised, and whicb  the moderns
 appear to have too hastily disclaimed,—we allude
 to what they termed non-naturals; so called from
 their not being  essential to  the mere nature or
 constitution of living animals, and which, besides
 the different aliments, included air, exercise, sleep,
 the excretions, and the passions of the mind.  In
 the second  part of  this article, it will be the en-
 deavour of  the writer to point out and  enforce
 upon the mind of  the practitioner, the very im-
 portant relations which obtain between the differ-
 ent stages of digestion and  the non-naturals above
 enumerated.
   In modern  times, the multiplied  resources of
 pharmacy,  and the discovery  of new chemical
 agents, have naturally enougb led practitioners to
 depend upon such remedies for the cure of chronic
 disease rather than  upon a modified plan of diet;
 while,  in the circle  of the profession, a certain de-
 gree of distrust, or we might even add of oppro-
 brium, has  fallen upon such  practitioners as have
 insisted upon its  paramount importance.  This
 circumstance easily admits  of explanation.   In
 physic a remedy or a practice has never been dis-
 carded by the regular practitioner but  it has im-
 mediately  found  a patron in  the  empiric, who
 seizes  upon it with avidity, in order to convert it
 to  his own advantage, just  as  the rabble dress
 themselves in the  cast-off clothes  of their supe-
 riors.
    The minor writers who have swarmed within
 the last half century have greatly contributed to
 throw  discredit upon the subject.   Nothing cher-
 ishes the  public scepticism, with  regard to the
 efficacy of  the  medical art, so much as the publi-
 cation  of the adverse  and contradictory opinions
 of its professors upon points so apparently simple
 and obvious, that every superficially informed per-
 son constitutes  himself a judge of their merits.
 If a leader is informed by  one class of authors
that a weak stomach  is unable  to convert liquid
food into aliment, and  by another that solid  food
is  injurious to feeble stomachs, he at once infers
that the question is one  of perfect  indifference ;
and ultimately arrives, by a very simple process
of reasoning, at the sweeping conclusion that the
stomach, ever kind  and accommodating, indiscri-
minately converts every species  of food into nour-
ishment, and that he has therefore only to consult
his own inclination in its selection.  On  the va-
letudinarian, incapable of healthy reflection, and
ever seeking for causes of fear and anxiety when
they do not choose to come uncalled, sucb works
may have  a contrary  tendency, and  lead  him to
suspect  the seeds of  disease in every  dish, and
poison in every cup.
   It appears to us  that authors have in  general
laid far too great stress  upon  the quality of the
different  species of  food, and  have condemned
particular aliments for those  effects which should
be attributed to their quantity, and still more per-
haps  to the circumstances under which they were
taken ; their dietetic precepts have  therefore fre-
quently assumed the air  of ascetic austerities, and
they have thus represented the cure far more formi-
dable than the disease.   It has  been sarcastically
observed by a popular writer, more remarkable for
the playfulness of his style than for the sound-
ness of his logic, that there exists a more intimate
connection between the doctrine of Tertullian and
 that of many a dietetic practitioner,  than is  gene-
 rally supposed; that he is the  ascetic intrenched
 in gallipots and blisters, preaching against beef
 and porter; terrifying his audience with fire and
 brimstone in  one age, and in the other with gout
 and apoplexy.  Now, while we must  all deeply
 lament that the severity of this sarcasm should
 have  been in some  measure  sanctioned  by the
 theoretical absurdities of many of  our  writers, it
 is impossible that any reasonable person can seri-
 ously contend that numerous diseases do not arise
 from an improper management of diet;  much less
 that  a judicious regulation of it cannot be render-
 ed subservient to their cure.  To those, however,
 if such there be, who do question the importance
 of dietetics, we have only to  observe  tbat they
 may as well deny the  utility  of the medical art
 altogether, and assert that, in all disorders of func-
 tion, Nature is sufficiently powerful to rectify and
 cure them, without the intervention of  art.  Un-
 less this be granted, it is absurd to  say  that bene
 ficial impressions may not be made as well through
 the medium of the materia alimentaria as through
 that of the materia medica;  or,  to borrow the
 language of Dr. Arbuthnot, that  what  we take
 daily by pounds must riot be, at least, as import-
 ant as what we  take seldom, and  only by  grains
 or tea-spoonsful.
    To  get rid of such a  difficulty, a class of  phi
 losophers admit the salutary influence of particu-
 lar aliments in rectifying  disorders of function,
 but  deny the necessity  of reason  or  philosophy
 for the selection or management of them, since
 they consider that Nature  has implanted  in us
 instincts sufficiently strong and intelligible  to di-
 rect us, under all  circumstances, to  what is salu-
 tary, and to  warn us from such food  as may be
 injurious.  We may observe  in reply, that man
 has so long forsaken the simple  laws which  Na 
646
DIETETICS.
ture had instituted for  his direction, that  it is  to
be feared she has abandoned her  charge, and left
him under the  control  of  that  faithless guide
and usurper,  to which  civilization has given birth.
Appetite, which expresses the true wants of the
system, can no longer be distinguished from  that
feeling which induces us to  prefer one species  of
food to another, and which is the offspring  of
habit,  and  the consequence of artificial  associa-
tions.   Nor must  it be forgotten that, during dis-
ease, the senses frequently lose their tact, and the
invalid  experiences  an  appetite  for  things  that
would be  prejudicial.
   That the  natural relations which  subsist be-
tween the  qualities  of food and  the impressions
made by them on the senses, are changed or de-
stroyed by the  refinements of artificial life,  is a
fact supported  by  many  powerful  arguments.
How many kinds  of aliment, originally disagree-
able, become pleasant  by habit 1  and how many
substances, naturally agreeable, become disgusting
from the creation of certain prejudices]   We are
acquainted with a  lady who is always made  sick
by eating a green oyster ; the cause of which may
be traced to an erroneous impression  she received
with respect  to the nature of the colouring mat-
ter.  Dr. Fordyce  has  urged a still  more serious
and conclusive objection to that hackneyed maxim,
" that we ought to  live  naturally, and on such
food as is  presented to  us  by nature," viz., that
man has no natural food.   It is decreed  that  he
shall earn his bread  by the sweat of his brow ;  or,
in other words, that  he shall by his industry dis-
cover substances from which he is to procure sub-
sistence ; and that,  if he cannot find such,  he
must cultivate and  alter them from their natural
state.   There is scarcely  a vegetable which we  at
present employ that  can  be  found growing natu-
rally.   Buffon states that our wheat is a factitious
production, raised  to its present condition by the
art of agriculture.  Rice,  rye, barley, or even oats,
are not to be found wild, that is  to  say, growing
naturally, in  any part  of the earth, but have been
altered, by the industry of mankind, from plants
not now resembling  them in such a degree even
as to enable us to  recognise their relations.  The
acrid and disagreeable  apium graveolens has been
thus transformed into celery ; and the colewort, a
plant of scanty leaves,  not  weighing altogether
half an ounce, has been improved into  cabbage,
whose leaves alone weigh many pounds ;  or  into
a  cauliflower of considerable  dimensions, being
only the embryo of a few  buds, which,  in their
natural state,  would  not   have  weighed many
grains.   The potato again, whose introduction
has added  so many millions  to  our  population,
derives its origin  from  a small  and  bitter root,
which grows wild in Chili  and at Monte Video.
If any of our readers, in the face  of such facts,
still remain sceptical upon  the subject  of these
metamorphoses, let them visit the fairy bowers  of
horticulture,  and they will there perceive that her
wand has not only converted the tough,  coriace-
ous covering of the  almond  into the soft and melt-
ing flesh of the peach, but that, by her spells, the
 our sloe has ripened into the delicious plum, and
 he austere crab of our  woods into  the golden
pippin ; that this again has  been made to  sport  in
almost endless  variety,  emulating  in beauty  of
form and colour,  in  exuberance of fertility, and
in richness of flavour, the  rarer productions  of
warmer regions and more propitious climates.  If
cultivation can ever be said to have left the trans-
formation of vegetables imperfect, the genius  of
cookery is certainly entitled to  the  merit of  hav-
ing completed it;  for whatever traces of natural
qualities may have remained,  they are  undoubt-
edly obliterated during their passage through her
potent alembic.
   After all, then, experience can alone supply the
want of instinct, and form the  basis of a rational
system of dietetics.  Experience, dearly bought
experience, has taught us that headach, flatulency,
hypochondriasis,  and  a thousand  nameless ills,
have  arisen  from the too  prevailing  fashion  of
loading our  tables with a host of entremets and
hors d'xuvres, which have too  frequently usurped
the roast  beef of old  England.  The theorist,  in
the true spirit of refinement, laughs at our terrors:
he  admits, to be sure,  that the  man who  eats
round  the table, " ab ovo usque ad  mala,"  is a
terrific glutton, but that, after all, he has only eaten
words,- for, eat as he may, he can only eat animal
matter, vegetable  matter,  and  condiment, either
cooked by the heat of water or by that of fire,—
figure  or disfigure, serve, arrange, flavour, or adorn
them as you  please.  There is  not a physician of
any practical knowledge  who  cannot,  at once,
refute  such  a doctrine by a reference  to facts;
every old  nurse  knows  from experience, that cer-
tain mixtures produce deleterious compounds  in
the stomach, although the chemist may, perhaps,
fail in explaining their  nature, or  the theory of
their  formation.   What would such  a  reasoner
say, if he were invited to a repast, and were pre-
sented only with charcoal and water ?  Would he
be reconciled to  his  fare by being told that his
discontent was founded on a mere delusion,—that
the difference between them and the richest vege-
table viands was merely ideal,—an affair of words,
—as, in either case, he would  only swallow oxy-
gen, hydrogen, and carbon ?  And yet we will
venture to assert  that the presumption in such a
case would not be more violent, nor more opposed
to the just principles of physiology and chemistry,
than  is  the  argument  by which the sciolist
attempts to defend a practice which converts our
refreshments  into  burdens, and  our food  into
poison.
   I. Materia Alimentaria.
   Those bodies which have possessed life can alone
be strictly considered as affording aliment to  ani-
mals;  and yet there exist a certain number of inor-
ganic substances, such as water, common salt, lime,
&c. which, although  incapable by  themselves of
nourishing, appear, when administered in conjunc-
tion with the former, to contribute essentially to nu-
trition.  The consideration, therefore, of the mate-
ria alimentaria  necessarily embraces,  not  only
the substantive agents above stated,but those acces-
sories  which  from their modus operandi might
properly enough be entitled alimentary adjectives.
Under the former division will be arranged all the
varieties of animal and vegetable food; under the
latter,  the class  of condiments  will  merit oui
attention.
   The arrangements which different authors  have
proposed for  the classification  of alimentary sub- 
DIETETICS.
647
stances will be found to vary according to the
particular  theory by which each may  have  been
influenced.  The chemist investigates the compo-
sition of an aliment, and arranges it either accord-
ing to the ultimate  elements of which he supposes
it to consist, or according to the proximate princi-
ples which he  considers  to  predominate in  its
composition.  The naturalist, on the  other hand,
merely inquires to what division in his zoological
system each article of diet belongs, and assigns to
it a corresponding place in his arrangement; while
the experienced practitioner is disposed to distri-
bute the nutrientia in an  order which answers to
his notions of their relative  nutritive  value,  or to
the supposed facility  with which they  are dis-
solved  in  the stomach : thus, for example, as he
finds from experience that  the darkest coloured
flesh generally contains more nourishment, while
it stimulates the system more powerfully than the
whiter kinds, he distributes venison, beef, mutton,
hare, &c.  into one group, while lamb, veal, and
the white meats, such as that of turkey, partridge,
pheasant, chicken, &c. he considers as constituting
a different class.
   Chemists have been ever anxious to reduce all
nutritious  substances  to some  one or more proxi-
mate principles. Haller attempted to resolve  them
into one elementary jelly.  Cullen  was of opinion
that the matter of nutrition is, in all  cases, either
oily or saccharine, or what seems to be a combina-
tion of both these principles.  Fordyce reduced
all  nutritious matter  to mucilage; but since he
admits of  a farinaceous mucilage, a saccharine
mucilage, &c, Dr. Bostock  very justly  remarks
that the inaccuracy with which he may be charged
is  but of  a  verbal  description.   Richerand at-
tempted to show that  the  nutritive principle is in
all cases either gummy, mucilaginous, or saccha-
rine.   Dumas is disposed to regard "mucus" as
the principe eminemment nutritif," by which he
probably means albumen, since he observes that it
forms the basis of our organs.   Dr. Prout, whose
researches in organic chemistry claim  our highest
attention and respect, has stated that he considers
that there  exist  three great natural  classes or
groups, which essentially  constitute the  ground-
work of all organized beings, which  he denomi-
nates  the  saccharine, the oleaginous and the
albuminous.
  [The classification  of Dr. Prout has been taken
by  Dr. Pereira  (A Treatise on Food and  Diet,
Amer. edit, by Dr.  C. A. Lee, p. 38,  New York,
1843)  as  the basis of his own, which includes
twelve  divisions :—the aqueous,-  mucilaginous,
or  gummy,-  saccharine,  amylaceous,  ligneous,
pectinaceous,  acidulous, alcoholic, oily or fatty,
proteinaceous, gelatinous and saline.  By the
combination of these alimentary principles  and
simple  aliments, our  ordinary articles of food, or
compound  aliments, are formed.]
  M. Magendie has distributed the nutrientia into
nine classes, according to the  predominance  of
one or more of those  proximate principles,  upon
the presence of which modern science has assumed
that the nutritive qualities of substances nVainly
depend.
 The following is his arrangement:
 I. Fibrinous  Aliments. —Comprehending
the flesh and blood of various  animals, especially
such as have arrived at puberty ; — venison, beef,
mutton, hare.
   II.  Albuminous. — Eggs,  &c.
   III.  Gelatinous.—The flesh  of  young  ani-
mals;  veal, chickens, calf's foot, certain fishes.
   IV.  Fatty  and  oilt---Animal fats,  oils,
butter, cacoa, &c.; ducks, pork,  geese, eels, &c.
   V.  Caseous. — The different kinds of  milk,
cheese, &c.
   VI.  Farinaceous.—Wheat, barley, oats, rice,
rye, potato, sago, arrow-root, &c.
   VII. Mucilaginous.— Carrots, turnips,  aspa-
ragus,  cabbage, &c.
   VIII.  Saccharine.—The different kinds of
sugar,  figs, dates, &c. ; carrots.
   IX.  Acidulous.— Oranges, apples, and  other
acescent fruits.
   If there be any truth in our dietetic experience,
and any natural  affinity between  the  objects of
our classification, the  theory of their arrangement
will be unimportant; for,  however  greatly  the
roads of our pursuit may  vary, we must all  ulti-
mately arrive  at  the  same end.   The  danger of
relying upon  chemistry alone as our guide arises
from the uncertainty in which the elementary na-
ture of matter is involved. There can be but little
doubt that the supplies by which the bodily waste
is recruited are solely derived from the food, for
experiments of  the  most  refined nature  bave
shown that no part  of the air we breathe is ab-
sorbed by the lungs [1] ;  but  it is more  than
doubtful whether those substances which are con-
sidered as the ultimate, or even  the proximate,
principles  of  our frame,  are supplied to  them
ready formed by the aliments;  or in other words,
whether the powers  of life do not analyse  the
matter submitted  to them, and by recombining its
elements,  With which  we  are probably as yet un-
acquainted, produce those compounds which  the
chemist has been induced to suppose have been
merely transferred from the ingesta, in order  to be
incorporated with the living structure.  This is
not only a  highly curious, but a  very important
question in dietetics.  If the views of the chemist
be true, we have only to ascertain what principles
may be excessive or defective in any state of dis-
ease, and  at once to adopt a diet that may restore
the healthy balance:  but plausible and encouiag-
ing as such a theory may appear, an appeal to
experience will zX once prove it to be a delusion.
The emaciated invalid can no more be restored to
his plump contour by oleaginous ingesta,  than
the rickety child can be cured of a mottities ossium
by the administration  of phosphate of lime.  " Na-
ture," says  Dr. Prout, " will not  permit the che-
mist to officiate as  her journeyman, even  in the
most trifling degree ; or in other words, he is as
little able to remedy  or supply, in a direct man-
ner, what is amiss or  wanting in organic action,
as he is to remedy or  supply an injured nerve oi
muscle ;  and the  only way in which, for the  most
part, he can hope to influence her operations, is
through  the indirect  agency  of  those circum-
stances which  naturally  possess  the  power of
influencing them, and the management and con-
trol of which  are, to  a certain extent, within his
power."   (Gulstonian Lecture, 1831.)   This ad
mission, however, by no  means invalidates the
utility  of  chemical  inquiries with regard  to the 
ETICS.
645                                  DIE TI

nature of tbe different articles of diet;  for as long
as the composition of our diet possesses the power
of influencing the constitution of our bodies, it is
essential that we should be  acquainted  with its
most minute details.
   Amongst the numerous chemico-physiological
questions which have  arisen in connexion with
the subject  of dietetics, the late  speculations of
M. Magendie  are not the  least curious.  It has
been  asserted by this  distinguished physiologist
that the azote or  nitrogen  of all the  different
tissues of the animal body can only be  supplied
by our food, and, consequently, that no substance
which does not contain this principle can support
life.  In order to acquire some more exact notions
on  this  subject,  he submitted several  animals,
during a necessary period, to the use of food of
whicb the  chemical composition was  accurately
ascertained.  We shall present our  readers with
a short abstract of these  experiments, and then
explain the different, but not less important, con-
clusions which we are prepared to deduce  from
their results.  He took a dog of three years old,
fat, and in good health, and put it  to  feed  upon
sugar alone, and gave  it distilled water to drink :
no restrictions were imposed as to  quantity.   It
appeared very well  in  this way of living for the
first seven or eight days; it was brisk, active, ate
eagerly, and drank in its usual manner.  It began
to get thin in the second week, although its ap-
petite continued  good, and it took about six or
eight  ounces of sugar in twenty-four  hours.  Its
alvine excretions were neither frequent nor co-
pious ; that  of urine was very abundant.   In the
third  week  its leanness increased,  its  strength
diminished,  the animal lost its liveliness, and its
appetite declined.  At this period there was deve-
loped, first  upon one eye, and then on  the other,
a small ulceration on the centre of the transparent
cornea ;  it increased very quickly, and in a few
days was more than a line in diameter; its depth
increased in the same proportion ; the cornea was
very soon  entirely  perforated,  and  the humours
of the eye ran out.  This singular phenomenon
was accompanied with an  abundant secretion of
the glands of the  eyelids.  The dog, however, be-
came  weaker and  weaker;  and, though  it ate
from three to four ounces of sugar per  day, it be-
came  so weak that it could neither  chew nor
swallow; for the same reason every other motion
was impossible.   It expired the thirty-second day
of the  experiment.   M. Magendie opened the
animal with every suitable precaution.  He found
a total want of fat; the muscles were  reduced to
less than five-sixths of their ordinary size; the
stomach and intestines were also much diminished
in volume,  and  strongly contracted.  The  gall
and urinary bladders were distended by their pro-
per fluids, which M. Chevreul was called upon to
examine.   That  distinguished  chemist found in
them  nearly all the characters which  belong to
the urine and bile of herbivorous animals; that is,
that the urine, instead of being acid as it  is in
carnivorous animals, was sensibly  alkaline, and
did not present any trace of uric acid, nor  of phos-
phate.  The bile contained a considerable portion
of picromel, a character considered as peculiar to
(he bile  of the ox, and in general to that of her-
uivorous animals.  The excrements were also
examined by M.  Chevreul, and  were found to
contain very  little azote,  whereas  they usually
furnish a considerable quantity.    M. Magendie
considered that such results required to be veri-
fied by new experiments; he accordingly repeated
them on  other  dogs, but  always with the same
conclusions.   He  therefore considered it proved,
that sugar  by itself is  incapable of supporting
dogs.  This want  of the  nutritive  quality, how-
ever,  might  possibly be  peculiar  to  sugar; he
therefore proceeded to inquire whether other sub-
stances, non-azotised, but generally  considered as
nutritive,  would be attended with the same con-
sequences.  He fed two  dogs  with olive oil and
distilled water, upon which they appeared to live
well for about fifteen days ; but they afterwards
underwent the same series of accidents, and  died
on  the thirty-sixth day of the experiment.  In
these cases,  however, the ulceration  of the cornea
did not occur.   Gum is another substance that is
said not to contain  azote, but which is considered
as nutritive.   To ascertain whether it acted like
sugar  and oil, several dogs were fed  exclusively
upon it, and the phenomena did not  sensibly differ
from those above described.  An experiment was
then instituted with butter, an animal substance
which, like  the preceding, is  considered  as not
possessing any azote in its composition.  The dog
was  supported by  it very well  at  first;  out in
about  fifteen  days  it began to lose flesh  and to
become weak: it  died  on  the thirty-sixth day,
although on  the thirty-fourth he gave it as much
flesh as it would eat, a considerable quantity of
which  it  took for two  days.   The  right eye of
this animal presented the ulcerations of the cor-
nea. The opening  of the body exhibited the same
modifications of the bile and urine.
  In order to  make the evidence furnished by the
above experiments  as complete as possible, after
having given  to  dogs separately, oil, sugar, or
gum, he opened them, and ascertained that these
substances were each  reduced  to  a particular
chyme in the  stomach,  and that they afterwards
furnished  an abundant chyle ;  whence he  argues
that, if these different substances are not nourish-
ing,  it cannot be attributed to  the want of diges-
tion.
  We are anxious to give all due credit to the
accuracy with which these experiments were per-
formed, but we deny the conclusions  which this
eminent physiologist has  deduced from their re-
sults.  We  meet him at  once, by questioning the
truth of his very first proposition,  that sugar, oil,
and gum cannot furnish azote.  Is there a chemist
of the present day who does not believe, although
he is unable to prove it by direct experiment, that
azote is a  compound ?  The sugar therefore may
furnish its elements,  although  we cannot detect
azote during its decomposition in our laboratories.
But let us waive this objection ; we are quite pre-
pared to impugn his conclusion on other grounds.
What  do bis  experiments prove ?  In  the first
place, the  fact which we have before stated,—that
an animal cannot bear a sudden  and  permanent
change in its diet without injury; and in  the next
place,  that  a highly concentrated diet, or food
which  does not contain  an intermixture of innu-
tritive parts, is always injurious.
  M. Magendie has himself, by  subsequent ex- 
DIETETICS.
649
 periments,  furnished evidence  against  his  own
 theory; for  a dog confined on a diet  of white
 bread, the gluten of which contains an abundance
 of azote, perished like those fed  on sugar or gum.
 Animals, moreover, which were  kept upon cheese,
 and even upon hard  boiled eggs, became  diseased,
 and  yet casein is  a  highly azotised principle,
 while albumen is considered by Berzelius  as the
 peculiar source of  all the animal secretions.*
   [That the effects were not owing to the priva-
 tion of azote, Magendie has  of late been still more
 amply satisfied.  (Comptes Rendus, Aotit,  1841.)
 In the name of a  committee appointed to inquire
 into the nutritive properties  of gelatin, he report-
 ed, as chairman, that gelatin, albumen, and fibrin
 — all of which  are  highly  azoted — when taken
 separately, nourish animals  for a very  limited pe-
 riod only, and in an  imperfect manner.  They
 generally  soon excite  such  insurmountable dis-
 gust,  that the animals die rather than  partake of
 them.  These experiments  have  led  to the  too
 hasty conclusion, that  the gelatinous  tissues are
 incapable of conversion  into blood.  " The gelatin-
 ous substance," says Liebig,  (Animal Chemistry,
 Amer. edit, by Webster,  p. 124, Cambridge 1842,)
 11 is not a compound of protein: it contains  no
 sulphur, no  phosphorus, and  it contains  more
 nitrogen or less carbon  than protein.  The com-
 pounds of protein,  under the influence  of the vital
 energy of the organs  which form  the blood, assume
 a new form, but are not altered in composition;
 whilst  these  organs, as  far as our  experience
 reaches, do not  possess the power of producing
 compounds of protein, by virtue of any influence,
 out of substances which contain  no protein. Ani-
 mals, which were fed exclusively on gelatin,  the
 most  highly nitrogenized element of the food  of
 carnivora, died with  the symptoms of starvation."
 " In short,"  he adds, «tbe  gelatinous  tissues are
 incapable of conversion  into blood."  Yet, it has
 been shown above, that  fibrin and albumen—both
 compounds of protein — when exhibited alone to
 animals, nourished them as imperfectly as gelatin.
  The experiments of Magendie show the neces-
 sity.for variety of food for prolonged animal health
 and existence.  Much, doubtless, depends on the
 habits of the  particular  animal or individual, and
 on the morbid effects excited by  completely modi-
 fying  the function  of assimilation, as it has been
 ordinarily  practised.   It has been  long known,
 that if a person, previously habituated  to both
 animal and vegetable diet, be restricted to one or
 other  exclusively,  he will fall  off,  and become
 scorbutic ; and yet he is capable of subsisting upon
 either, provided he be  restricted to it  from early
 infancy.
  Of  late, great light has been  thrown on  this
 subject by the researches of  the  organic  chemist.
 These have shown, that the  chief proximate prin-
 ciples  of animal tissues,  and  those that have been
 regarded as highly  nutritious amongst vegetables,
 have  almost  identically  the same composition.
(Liebig,  op. cit., p.  100.)  They all contain nitro-
gen, or are " nitrogenized."  The following  tables
 * The ingenious experiments  of Mr. Hatchett  also
show that albumen is the parent fluid from which other
principles may be formed ; he found, for instance, that it
Was convertible into gelatine and fibrine.— Phil. Irons.
1800.
Vol. I. —82
3e
from Liebig exhibit this similarity of constitution
in a striking manner :—
 Animal Proximate Principles, according  to
                   Mulder.
	Albumen.	Fibrin.	Casein.
Carbon,.....	. .. 54.84 . .	.. 54.5 G . .	. 54.96
Hydrogen, ...	... 7.09 . .	.. 6.90 . .	. 7.15
Nitrogen, .. .	... 15.83 ..	.. 15.72 ..	. 15.80
Oxygen,	... 21.23 ..	.. 22.13 . .	. 21.73
Sulphur,	.. . 0.68 . .	.. 0.33 ..	. 0.36
Phosphorus, .	. .. 0.33 . .	.. 0.30	
100.00
100.00
100.00
Vegetable Proximate  Principles,  according  to
              Scherer and Jones.
	Albumen, from wheat.	Fibrin.	Casein or Legumin.
Carbon, ...	.. 55.01 ..	. 54.603 .	.. 54.138
Hydrogen, .	. . 7.23 . . .	. 7.302 .	. .. 7.156
Nitrogen, ..	.. 15.92 ...	. 15.809 .	... 15.672
Oxygen,			
Sulphur,	> 21.84 ...	. 22.286 .	.. 23.034
Phosphorus,			
100.00
100.000
100.000
   It has been maintained by Liebig and by others,
 that  nitrogenized  or  azoted aliments are alone
 capable of forming organized tissues. These, con-
 sequently, have been classed by Liebig as plastic
 elements  of nutrition,- whilst non-nitrogenized
 aliments being, in  his opinion, inservient only to
 respiration, are termed by him elements of respi-
 ration.  All this, however,  requires proof,  and is
 combated by  what we observe in chylification.
 In the small chyliferous vessels, more  fat,  which
 is non-nitrogenized, is  contained  than can  be  ac-
 counted  for by the fat in the food ;  and as  the
 chyle proceeds, the proportion of fat becomes less
 and less, whilst that of the nitrogenized elements
 increases ; hence, nitrogen must be obtained, and
 a conversion,  doubtless, takes place of non-nitro-
 genized into nitrogenized elements.]
  We have said that  a certain volume or bulk
 seems to  be a necessary condition of wholesome
 food ; — does  not  the  capacity of the digestive
 organs  sufficiently show that Nature never  in-
 tended them for the reception of highly-concen-
 trated food ? This truth is still further exemplified
 by the very sparing manner in which she produces
 concentrated aliment;  the  saccharine  matter  of
 esculent fruits is generally blended with acidulous
 and mucilaginous ingredients, and the oleaginous
 matter is thus combined with the  farinaceous, in
 seeds,  kernels, and  ther substances of this de-
 scription.  The evils arising from the use of a too
 concentrated diet are well known to the physician;
 and, if we extend our observations to the domestic
 animals under our care, we  shall derive further
 evidence of this important fact. A great number
 of our horses are fed with  oats and beans, the
 nutriment  of  which is condensed into a much
 smaller space than it could generally be in natural
 provender;  and  these animals, when  supported
 on  such food,  are  consequently liable to various
 ailments originating from diseased action in the
stomach, or from general  plethora;  in short, it
need scarcely be remarked that horses so fed, and
 unnaturally confined in stables, require to be bled
and purged to preserve their lives.   The ani,nai 
650
DIETETICS.
 thus abused evidently suffers from acidity,  as we
 find  him frequently eating absorbent earths with
 avidity.*  Tbe extraordinary exertions  often  re-
 quired of horses  render  it necessary  that they
 should be better fed than when  existing in a more
 natural state ;  and  since  they do  not  travel so
 well  with a full stomach,  it is also necessary to
 adopt  the use  of  food in which the nutriment is
 reduced into the smallest  compass.  Post-horses
 and others, whose motion must be rapid,  are there-
 fore chiefly fed with corn alone ; but what  is  the
 effect ?—fermentation instead of digestion ;  as  the
 intolerable  odour which  assails us  in the stable,
 under  such  circumstances, and  the decomposed
 glass of its windows from the sulphuretted hydro-
 gen acting upon the lead contained in  it,  suffi-
 ciently testify.   Did it never occur to the physio-
 logist,  that  had Nature  intended animals to feed
 only upon the concentrated aliment of gramineous
 and leguminous vegetables, she would have sup-
 plied them with an apparatus by which they might
 separate the chaff  and straw from the grain ?
   These remarks  may be applied  to man :  we
 shall have occasion to show hereafter that the use
 of chocolate, butter, cream, sugar, and rich sauces,
 without a due  admixture of bread,  potatoes, and
 other less concentrated aliment, is  invariably at-
 tended with  disordered  digestion.   Unless  the
 taste be vitiated, there exists an  instinctive  aver-
 sion to such food—
    -------------------" the prudent taste
    Rejects, like bane, such loathsome lusciousness."
 The Kamtschatdales are  frequently compelled to
 live on fish-oil, but they judiciously form it  into a
 paste with saw-dust, or the rasped fibres of indi-
 genous plants.
   Bfwtritivencss and Digestibility of differ-
 ent kinds of Food.—Before we attempt to ap-
 preciate the value of the different articles of the ma-
 teria alimentaria, it will be necessary  to caution the
 reader  against the  popular error  of regarding the
 terms digestible and  nutritive as synonymous and
 convertible.   A  substance may be  highly  nutri-
 tive and yet be digested with difficulty ;  that is to
 say, it may require all the powers of the digestive
 organs to convert it  into chyle, and  yet, when so
 converted, it may  afford  a principle  of highly  re-
 storative energy :  this is the case with  the  fatty
 and oily elements.j-   On the contrary,  there  are
 substances which  apparently pass out of the sto-
 mach with sufficient readiness, but afford but little
 comparative support to the body.
   Writers on dietetics have descanted very  learn-
 edly  upon what they please to term  the perspira-
 bility and alkalescency of certain aliments.   To
 the former we are  quite unable to attach any pre-
 cise meaning ; with respect to the latter, we appre-
 hend that it is intended to express a highly  nutri-
 tive quality, with  a certain degree of indigestibi-
 lity.    Heavy  and light, as applied  to  food,  arc
 terms  equally vague and indefinite, and  ought
 never to be introduced  into writings which  aspire
 to the character of philosophical  precision.   The
 observation may be extended to the epithet bilious.
   It is only necessary to reflect upon the chemi-
 lal and mechanical  processes  by which chymi-
   * The habit of crib-biting may perhaps be  attributed
 to such a source.
1   t It has been calculated that an ounce  of fat meat af.
 fords nutriment equal to four ounces of lean.
 fication is performed in tbe stomach, to  perceive
 that the digestibility of a substance  may depend
 upon other circumstances than that of its chemi-
 cal composition.   Its mechanical state with regard
 to texture and consistence, is of the highest im-
 portance ; and if we attempt  to deduce  any law
 upon this subject, from the known  solubility of a
 substance out of the body, we shall fall into seve-
 ral fatal errors.   It will be necessary to investigate
 this question with  some attention, for it not only
 explains the relative digestibility of aliments, but
 furnishes the only true basis for a system of skil-
 ful cookery.
    The healthy stomach disposes most readily and
 effectually of  solid  food, of a  certain specific de-
 gree of density, which may be  termed its digestive
 texture,-  if it exceed this, it will require a greater
 length of time and more active  powers  to com-
 plete its chymification; and if it approaches too
 nearly to a gelatinous condition, the stomach will
 be equally impeded  in  its operations.   It is, per-
 haps, not possible to appreciate or express the ex-
 act degree of firmness which will confer the high-
 est order  of digestibility upon  food ;t indeed this
 point may vary in  different individuals;  but we
 are taught  by experience that no meat is so di-
 gestible as tender mutton : when well-conditioned,
 its fibre appears to possess that degree of  consist-
 ence which is most congenial to the stomach ; and
 in  this country  it  is  perhaps more  universally
 used than any other animal food.   Wedder mut-
 ton, or the flesh of the  castrated animal, is in  per-
 fection  at five years, and is by far the sweetest
 and most digestible.  Ewe mutton  is best at two
 years  old.  Beef appears to  be not so easy of
 digestion  ; its  texture  is firmer, but it is  equally
 nutritive;  much, however, will depend upon the
 period which  has elapsed since the death of the
 animal, and more upon the method of cookery ; in
 short, it would be worse  than useless to  attempt
 the construction of any  scale to  represent  the
 nutritive  and  digestive qualities of the different
 species of food :  the observations here introduced
 are merely noticed for the sake  of illustrating those
 general principles  whose application  can alone
 afford us any rational theory of diet.
    It will not be difficult to understand why a  cer-
 tain texture and  coherence of  the aliment should
 confer upon it digestibility or otherwise.  Its con-
 version into chyme is effected  by  the  solvent
 power of the gastric juice, aided by  the churning
 which it undergoes by the motions of the stomach;
 and  unless the substance  introduced  possesses a
 suitable degree of firmness, it will  not yield to
 such  motions : this  is  the case with soups  and
 other liquid aliments ;  in  such cases, therefore,
 nature removes the watery  part before digestion
 can be carried forward.  It is on this account  that
 oils are digested  with so much difficulty ; and it
 is probable that jellies and other glutinous matters,
 although containing  the elements of nourishment
 in  the  highest state  of  concentration, ate  not
 digested without  considerable difficulty; in the
 first ulace, on account  of their evading the grap-
 pling powers of the stomach, and, in  the next, in
!   X Some experiments were  introduced for this purpna.
 bv Gosse, of Geneva ;  but  inn conclusions deduced from
 them are by no means  satisfactory.  He confounds  solu-
 bility with digestibility, which iii  itself is suiiicienl W
| vitiate his  reasoning. 
DIETETICS.
651
consequence of their tenacity opposing tbe absorp-
tion of their more fluid parts.   For these reasons
the addition of isinglass and other glutinous mat-
ter to animal  broths, with  a view to render them
more  nutritive to invalids, is  a questionable cus-
tom.
   The texture of animal food is greatly influenced
by the age, sex, habits, condition, diet, and descrip-
tion  of death  of the  animal  which furnishes it.
In proportion  generally to the  age,  its flesh is
coarser  and more firm in texture, as every  one
must have noticed in eating  birds.   If the flesh
of mutton and  lamb, beef and  veal, are compared,
they will be found of a different texture ; the  two
young meats  are  of  a more  stringy, indivisible
nature than the others, which  makes them harder
of digestion.    It has  been also justly  observed
that young animals differ from  old  ones  in  the
distribution of the fat, which in the latter is chiefly
collected in masses or layers, external to  the mus-
cles ; whereas in the former it  is more interspersed
among  the muscular fibres,  giving the flesh  a
marbled  appearance, which is always a desirable
property of butchers' meat.  The texture of food
will also vary according to the wild  or domesti-
cated state of the animal; that of the  former is
more dense, although highly nutritive.  The  sex
also modifies  the quality of the flesh, that of the
female being always more delicate and finer-grain-
ed than that of the entire male, whose  fibres are
denser.  The influence of the  genital organs upon
this  occasion is very extraordinary ; it is  generally
believed that  the flavour of the female is even im-
proved by removing the ovaries, or spaying them,
as it is called.  Every day the  testes are permitted
to remain, even though  totally  inactive  with re-
gard to their proper functions, injures the delicacy
of the veal of the bull calf; and an animal which
is not castrated  until  after puberty always retains
much of the coarseness of the entire male.   The
mode of killing an animal has been  considered,
from the remotest ages, as capable of affecting the
quality of its meat. The flesh of hunted animals
is characterized by peculiar tenderness :  the same
effect is  produced by any  lingering death.  This
fact probably  explains the policy  of those old mu-
nicipal laws which ordained that no butcher should
offer or expose any bull-beef for  sale unless it  had
previously been baited ;  and it  is upon  the same
principle only that the quality of pig's flesh could
be improved  by the  horrid cruelty  of whipping
them to death, as said to be practised by the Ger-
mans.  The action  of vinegar, administered to an
animal some hours before killing it, is also known
to be capable  of rendering its  flesh less tough. It
is a  common  practice in  the country to  give  a
spoonful of this acid to poultry, when  they  are
intended for the immediate service of the table.
   Nothing, however,  tends more  effectually to
ameliorate the  rigidity  of  the animal fibre than
incipient putrefaction.  The length of time that
me.it ought to be kept after it is killed will neces-
sarily depend  worn its  tendency to undergo  the
putrid fermentation, and the prevalence of those
circumstances which are inclined to favour it.
   The circumstances  which have been just enu-
merated, as being capable of influencing  the tex-
ture of our food, and consequently its degree of
digestibility, are, however, unimportant when com-
pared with the modifying powers of cookery, which
we shall now proceed to examine.
   Cookery.—By cookery, alimentary substances
undergo a two-fold  change; their principles are
chemically modified, and  their textures mechani-
cally changed.  The extent and nature, however,
of these changes will  greatly  depend  upon  the
manner in which heat has been applied to them ;
and if we inquire into the culinary history of dif-
ferent countries, we  shall trace its connection with
the fuel most  accessible to them.  This fact readi-
ly explains the prevalence of the  peculiar species
of cookery which distinguishes  the French table,
and which has  no  reference, as some have  ima-
gined, to the dietetic theory or superior refinement
of the inhabitants.
   By the operation  of boiling, the principles not
properly soluble are rendered softer, more pulpy,
and, consequently,   easier  of digestion ;  but tbe
meat, at the same time, is deprived of some of its
nutritive properties  by the removal of a portion of
its soluble constituents: the albumen and gelatin
are also acted upon; the former being solidified,
and the latter  converted  into a  gelatinous  sub-
stance.   If, therefore, our meat be boiled  too long
or too  fast, we  shall obtain, where the  albumen
predominates, as in  beef, a  hard and indigestible
mass, like an over-boiled egg; or where the gelatin
predominates, as in young meats, such as veal, a
gelatinous substance equally injurious to the diges-
tive organs.  Young and viscid  food, therefore, as
veal, chickens,  &c, is more  wholesome when
roasted  than when   boiled, and  is easier digested.
Dr. Prout has very justly remarked that the boil-
ing  temperature is  too high for a great many of
the  processes  of cooking, and that a lower  tem-
perature and a greater time, or a species of infu-
sion, are better adapted for most of them.   This
is notorious with substances intended to be stew-
ed, which, even in cookery-books, are directed to
be boiled slowly, (that is, not  at  all,) and for a
considerable time.*   The ignorance and prejudice
existing on these  points  is very great, and com-
bated with difficulty ; yet, when we take into ac-
count their importance, and how  intimately they
are connected with  health, they will  be  found to
deserve no small share of our attention.   The loss
occasioned by boiling  partly  depends upon  the
melting of the fat,  but chiefly from the  solution
of the  gelatin  and  osmazone ;  mutton generally
loses about  one-fifth, and  beef  about one-fourth,
of its original weight.   Boiling is  particularly ap-
plicable to vegetables, rendering them more solu-
ble in the stomach,  and depriving them of a con-
siderable  quantity of air, so  injurious  to weak
stomachs.  But, even  in  this case, the operation
may be carried to an injurious extent; thus pota-
toes are frequently boiled to the  state of a dry in-
sipid powder, instead of being preserved  in  that
state in which the parts of which they are com
posed are rendered  soft and gelatinous, so as to
retain their shape, and yet be very easily separated.
On the other hand, the cabbage tribe and carrots
are frequently not boiled  long  enough, in which
state they are  highly indigestible.  In conducting
this  process it is necessary to pay some attention

  * Hence it is that beef-tea and mutton-tpa are mucli
more calculated for invalids than  the broths  of thea«
meats. 
652
DIETETICS.
 to the quality of the water employed; thus, mut-
 ton boiled in hard water is more tender and juicy
 than  when soft water is  used ; while vegetables,
 on the contrary, are rendered harder and less di-
 gestible when boiled in hard water.
   By the process of roasting, the fibrine is  corru-
 gated, the albumen  coagulated, the fat liquefied,
 and the water evaporated.  As the operation pro-
 ceeds, the surface becomes  first brown, and then
 scorched, and the tendinous parts  are  rendered
 softer and gluey.  Care should always be  taken
 that the meat should not be  over-done, nor  ought
 it to be under-dressed; for although in this latter
 state  it may contain  more nutriment, yet it will be
 less  digestible, on account  of the density  of its
 texture.   This fact has been  satisfactorily proved
 by the experiments of Spallanzani; (Spallanzani
 on Digestion,  vol. i. p. 277 ;)  and Mr.  Hunter
 observes that " boiled, and ro.asted,  and even pu-
 trid meat, is easier of digestion than that which is
 raw." (Hunter on the Animal Economy, p. 220.)
 Animal  matter loses more  by roasting than by
 boiling;  it has been  stated above,  that  by this
 latter  process mutton loses  one-fifth,  and beef
 one-fourth;  but by  roasting, these meats lose
 about one-third  of their weight.  In roasting, the
 loss arises from the melting out of the fat, and the
 evaporation of  the water; but the nutritious mat-
 ter remains condensed in the cooked  solid ; where-
 as, in boiling,  the  gelatine  is partly  abstracted.
 Roasted  are, therefore, more nutritive than  boiled
 meats.*
   The  process  of frying is, perhaps, the most
 objectionable of all the culinary operations.   The
 heat is applied  through the medium  of boiling oil,
 or fat, which is  thus rendered empyreumatic, and
 therefore  extremely liable to disagree with  the
 stomach.
   By broiling, the  sudden  browning  or harden-
 ing of the surface prevents the evaporation of the
 juices of the meat, which imparts a peculiar ten-
 derness to it.  It is the form selected, as the most
 eligible, by those who seek to  invigorate them-
 selves by the art of training.
   The peculiarity of the process of baking de-
 pends upon the  substance being heated in a con-
 fined  space, which does not permit the escape of
 the fumes  arising from  it; the meat is therefore,
 from  the retention of its juices, rendered  more
 sapid  and  tender.   But  baked meats are not so
 easily digested, on account of the greater retention
 of their oils, which are, moreover, in an empyreu-
 matic state.  Such dishes accordingly require the
 stimulus   of various condiments to  increase the
digesting powers of the stomach.
   [Solid] Articles  of Diet. —  Were we to
 follow the steps of preceding writers on dietetics,
 we should present a catalogue of the  nutrientia,
and introduce under each article a  history  of its
composition and qualities; but the utility of  gene-
ral principles is to abbreviate labour,  and to  class
under distinct heads  those remarks  which  were
previously scattered and unconnected.
   Wc nave seen that the nutritive qualities of a
substance depend upon its composition; but that
its digestibility may be influenced by various me-
  * It has been computed that,  from the  dissipation of
 Ihe nutritive juices by boiling, one pound  of roasted con
 Ujiis as much nourishment as two of boiled meat.
 chanical causes.  It is by such tests that we have
 now to examine the several classes of food, and to
 assign to the individual bodies which they em-
 brace their relative value as articles of diet.
   Milk is the only nutritive fluid  with which na-
 ture has  presented us; but if we  examine its
 chemical composition, we shall soon discover that
 it possesses an ingredient which is instantly coa-
 gulated  in the stomach : so that, in fact, it must
 be regarded as a mixture of solid  and liquid ali-
 ment ; the latter, however, considerably exceeding
 the former in quantity, and thereby demonstrating
 the necessity of a greater portion of fluid than of
 solid matter, on which the necessity of alimentary
 supplies is founded.
   Although recent  milk appears  as a homogene-
 ous liquid, it may be resolved, partly by standing,
 and partly by agents that do not  essentially alter
 the nature of its components, into three proximate
 ingredients, the cream, curd, 'and  whey.
    1. The cream rises  to the surface of the milk,
 after it has stood for some hours,  and  may be
 skimmed off, and thus separated from it.   It ap-
 pears to possess many of the  properties of oil, is
 smooth and  unctuous  to the touch, and  stains
 cloth in the same manner as other unctuous sub-
 stances.   By standing for some days it  becomes
 gradually thicker, and at length forms a soft solid,
 in which the flavour of cream is  no longer per-
 ceived, and that of cheese  is substituted  in its
 place. According to the experiments of Berzelius,
 cream is  a compound body, consisting of butter,
 4-5 ; cheese,  3-5 ; and whey, 92 parts ; but since
 the whey holds certain salts in solution, we may
 consider the whole  of the solid matter contained
 in cream  as amounting to 12-5 per cent.   When
 cream is agitated, as is done by the common pro-
 cess of churning, it is  separated into two parts; a
 thick animal oil, well  known by the name of but-
 ter, and a fluid which possesses exactly the same
 properties  as  milk that  has been deprived  of its
 cream.  This change has  been supposed  to be
 owing to the  combination of the  cream with the
 oxygen of the  atmosphere ; but  it takes place,
 though perhaps not equally well,  in vessels  from
 which tbe air has been excluded.
   2. When milk, either deprived or not of its
 cream, is mixed with certain substances, or allowed
 to stand till it becomes sour, it undergoes a change
 which is called coagulation, consisting of its sepa-
 ration into a solid substance termed curd, and a
 fluid called whey.  This change may be  effected
 by several  agents, such  as  alcohol, gelatine, and
 all  astringent vegetables;  by acids  and many
 neutral salts; by  gum, sugar, and  more  particu-
 larly by the gastric juice.  The effect is supposed
 to arise from the affinity of the coagulating  sub-
 stance for water, the curd, being principally albu-
 men, having very  little affinity for the same ,- but
 this theory can  hardly explain the operation of
 the gastric juice :  the infusion of a piece of calf's
 stomach, not larger than a half crown, will coagu-
 late  a quantity  of milk sufficient  for making a
cheese of  sixty  pounds  weight,  although the
quantity of coagulating matter cannot in this case
exceed a few grains.
  3. "Whey,  or  the liquid  which  remains  after
the separation  of the  curd, is  a thin and almost
transparent fluid, of a yellowish-green colour, and 
DIETETICS.
653
a pleasant sweetish taste.   It still contains, gene-
rally, a portion  both of curd and of butter;  the
former  of which may  be separated by a boiling
heat, in  the form of coagulum.   The  buttery
matter  also  separates  by  heat, especially if  the
whey  be  previously  allowed  to  become  sour.
Whey contains, indeed, in its  recent state, some
acetic acid.   When whey, which  has been  de-
prived as much as  possible of the butter and curd,
is  slowly  evaporated, it  yields the  peculiar sub-
stance  termed " sugar of milk,"  which  may be
obtained, by clarification with the whites of eggs,
in  the form of crystals.   The presence  of  the
saccharine matter held  in solution in whey enables
 that fluid to undergo the vinous  fermentation ;
 and it is  accordingly employed by the Tartars for
 making a sort of wine, which  is called Koumiss.
 For this purpose  mare's milk is selected,  as con-
 taining a larger portion of sugar than that of the
 cow.   Whey also contains several  saline bodies,
 viz., muriate of potass, phosphates of lime and of
 iron,  and sulphate of potasss ,■  and a  peculiar
 animal matter, which gives  a  precipitate with
 infusion  of  galls, and affords carbonate of ammo-
 nia by distillation.
   Although nature has  presented us with  this
 compound fluid for the purposes of nourishment,
 and although it is evident that its  several ingre-
 dients are wholesome, and designed for the various
 objects of aliment, yet, when separated  by art,
 they  are  frequently unwelcome to  the stomach ;
 that viscus  would appear to dislike the  interfe-
 rence of the cook, in the  performance of an ana-
 lysis which its own powers are so  well calculated
 to effect.   We are well assured that the first  pro-
 cess  which  takes  place  in  the stomach  for the
 chymification of milk, is  its separation  into curd
 and whey; and  yet  the  former of these  sub-
 stances, when  obtained by art, frequently proves
 highly oppressive  to the  stomach,  and sometimes
 occasions obstructions in the bowels.  Cheese,
 again, which is nothing  more than the coagulum
 of milk,  pressed,  salted,  and partly dried, with a
 portion of butter,  which, having been enveloped
 in the curd, is  not afterwards separable, is one  of
 the least digestible of our aliments, and  is  only
 adapted  to  strong stomachs, and to such persons
 as use great and constant  exercise.  When toasted,
 it is still more injurious, from acquiring a tenacity
 of texture highly hostile to the digestive functions
 of the stomach.   Butter, from its oily  nature, is
 apt to disagree with delicate stomachs, and when
 rendered  empyreumatic  by heat,  produces heart-
 burn  and  other  distressing   symptoms.   Whey
 differs considerably in its dietetic value, according
 to the method employed  for its separation. When
 this is effected by  rennet, it always holds a portion
 of cream and  curd suspended in  it, besides  its
 quantity of sugar.  It is, therefore, considerably
 nutritive ; but it  is, at the same time, more  ace-
 scent than milk, and hence it is liable to produce
 flatulence in those whose stomachs are disposed to
 encourage  fermentation.   Whey  that has  been
 produced by spontaneous coagulation always  con-
 tains  less nutritive matter, is more acid, and  con-
 sequently more objectionable, unless, perhaps, as a
 drink in  certain states of fever.
   From  this account of the composition of milk,
 several properties  of the entire fluid may be under-
stood.   By boiling  it, its  albuminous part is not
coagulated into a mass  like the white of an egg,
on account of the large quantity of water through
which it is diffused ; but a thin pellicle forms on
the surface,  which, if  removed, is immediately
replaced by another; and  thus the whole of the
albumen may be  separated in successive portions.
The effect of  this process is therefore to diminish
the nutritive  quality of the milk; but it may at
the same time render  it  more easily  digestible.
We have known many invalids who could take
boiled milk, but were unable to bear that fluid in
its natural state.
   Milk, in its dietetic relations, may be  considered
as  intermediate  between  animal and  vegetable
food; it is easily assimilated, and therefore affords
a quick supply of aliment to the system, while it
does  not excite  that  degree  of vascular  action
which is produced  by  other animal matters.   Its
nutritive  powers  may  be  increased  by various
additions, which have also, on some occasions, the
effect of correcting its natural tendency to acidity,
and on  others, that of obviating the costiveness
which  it is  liable  to occasion;  such objects are
sometimes fulfilled by  adding  oatmeal  gruel to it.
In certain states of organic disease, we have found
that milk, impregnated with  the fatty  matter of
mutton-suet,  is a valuable article  of  diet: such a
repast is best prepared by inserting the suet in a
muslin bag, and  tben simmering it with the milk.
   Before quitting  this  subject, it is  necessary to
observe that  there exists  some difference in the
composition   of  the milk  of different animals.
That of the  human subject is  much  thinner than
cow's milk ;  is  of a bluer colour, and contains
much more  saccharine matter.   It also yields h
larger proportion of cream, but from  which the
butter cannot be separated by agitation.  It depo-
sits a part of its curd by mere repose.  Asses'
milk bears a stronger resemblance to human milk
than to any  other; it  contains  more  sugar than
that of the cow,  and the proportion of curd is so
considerable  as  even  to separate  on standing,
before the milk becomes sour.  Goat's milk yields
a remarkably thick and  unctuous  cream,  and
abounds also in curd.
   Eggs, in point  of nutriment  and  digestibility,
may be classed next to milk ;  but their qualities
will  greatly  depend upon the manner in  which
they have been  cooked.   When raw, they  are
certainly not so  easily digested as when lightly
boiled, so as  slightly to coagulate their albumin
ous principle : but if this process be carried  too
far, they are  converted into a hard  mass, which
requires a long period for their digestion : but this
is  much accelerated by the use of vinegar as a
condiment.   They are  distinguished  by the pecu-
 liar quality of singularly affecting some stomachs,
even in the smallest quantity ; while they do not
 produce any  uneasy impressions on others.   We
 are acquainted with a person who constantly finds
 an egg to produce  uneasiness  when  his stomach
 is in the least deranged, but who can  eat  them
 with impunity at all other times.   It is a notori-
 ous fact that eggs, when raw, are laxative, and
 when cooked are apt to produce costiveness.
   Fish has been generally considered  as holding
 a middle rank between the flesh of warm-blooded
 animals  and vegetable food   It  is certainly Ipr* 
054
DIETETICS.
nutritive than mutton or beef; but the health and
vigour of the inhabitants of fishing-towns evidently
prove that it is  sufficiently nourishing for all  the
purposes of active life :  but in order to satisfy the
appetite, a  large  quantity is requisite; and  the
appetite returns  at  shorter intervals than  those
which occur during  a  diet  of meat.   Nor does
this species of food produce the  same stimulus to
the body ; the pulse is not strengthened as after a
repast of flesh ;  and that febrile excitement which
attends the digestion of the more nutritive viands
is  not experienced.   Hence fish affords  a most
valuable article of diet to invalids labouring  under
particular disorders; for it furnishes a chyle mode-
rately nutritive, but at the same time, not highly
stimulant.  From the nature of its texture, it does
not require a laborious operation of the stomach ;
although it is sufficiently  solid to  rescue  it from
those objections which  have been  urged against
liquid or gelatinous food.   From the observations
just offered upon  the nutritive powers of fish, it
must follow that such a diet is not  calculated to
restore power to habits  debilitated by disease, and
should never be directed under such circumstances,
but from the conviction that the digestive powers
are unable to convert stronger aliment into  chyle.
The jockeys who waste themselves  at Newmarket
in order to reduce their weight, are never allowed
meat when fish can be obtained.   On account of
the  low stimulant power of fish, it  requires the
assistance of condiment; and on this account salt
appears to be an essential accompaniment.
   Fish have been arranged under three divisions,
viz., fresh-water fish, salt-water fish,  and  shell-
fish ; but,  since  the value  of tbese  animals as
articles of food has an intimate relation to  the
colour and  texture of their muscles, and to their
gelatinous or oily qualities, it will be expedient to
consider their  several varieties with reference to
such conditions.  Turbot, cod, whiting, haddock,
flounder, and  sole, are the  least  heating  of the
more nutritive  species; and the flakiness  of the
fish, and its opaque appearance after being cooked,
may be considered as true indications of its good-
ness ; for when the muscles remain semi-transpa-
rent and  bluish, after sufficient boiling,  we may
reject it as inferior  in value, or  not  in season.
Whe« the fish is in high perfection, there is  also
a layer of white curdy  matter, resembling coagu-
lated albumen, interposed between its flakes. The
whiting is well adapted to weak  stomachs,  on ac-
count of the little viscidity  which it possesses ; it
is, at the same  time, tender, white, and  delicate,
and  conveys  sufficient nutriment  with but little
stimulus to the system.  The haddock much  re-
 sembles it, but  is firmer  in  texture.   Cod  has  a
 more dense fibre  than  the  two former, and con-
 tains also more glutinous matter: it is an  excel-
 lent aliment, but upon  the whole is not  quite  so
 digestible as whiting or haddock.   It is generally
 preferred when large ;  but such fish are frequently
 coarse.  The haddock  is certainly  better  when  it
 does not exceed  a  middling size.   Turbot is an
 excellent article of food ; but it is usually render-
 ed difficult of  digestion By  the quantity of  lobster
 sauce with which it is  eaten.  Sole is  tender, and
 yet sufficiently firm ; it is therefore easy  of diges-
 tion, and affords proper nutriment to delicate sta-
 unchs   It is necessary to  state that every part
of the same fish is not  equally digestible ; and it
unfortunately happens that those which are  con-
sidered the most  delicate are, at the  same time,
the  most exceptionable :  the  pulpy,  gelatinous
skin of the turbot, and  the  glutinous  parts about
the head of the cod, are very apt to disagree with
invalids.   Salmon  may,  perhaps,  he considered
the most nutritive of our fish ;  but it is heating
and  oily, and not very digestible  : and  persons,
even with strong stomachs, are frequently under
the necessity of taking  some stimulant to assist
its digestion.  The addition of lobster sauce  ren-
ders it still  more unwholesome: the  best condi-
ment that can be used is vinegar.   As connected
with  the  time of spawning, the  season of the
year  has the most decided influence upon the
quality of salmon.  It is in the highest perfection,
or in season, as it is  termed, some time previous
to its spawning ; the flesh is then  firm and  deli-
cious ; whereas,  after this event,  it is for some
time unfit for food.   Salmon trout is not so rich
and  oily  as  the salmon ;  although, therefore, it is
less  nutritive, it is at the  same  time less heating
and  more  digestible.   Eels are extremely objec-
tionable, on account of the large proportion of oil
which they contain.   From these observations,
the  value  of fish may be appreciated, and  the
qualities which entitle them to election easily un-
derstood.  Firmness of texture,  whiteness of mus-
cle, and the absence  of oiliness and viscidity are
the circumstances which render them acceptable
to weak  stomachs.
   Shell-fish have been greatly extolled by some
physicians as nutritive and easily  digestible  arti-
cles of food.  It will be necessary  to examine this
question by the application of those principles
which we have  endeavoured to establish.  Oys-
ters  would  appear  to  enjoy a reputation which
they do  not deserve ; when eaten cold they are
frequently distressing to  weak  stomachs, and  re-
quire the aid  of pepper as a stimulant;  and since
they are usually swallowed without mastication,
the  stomach  has an additional labour to perform,
in order to reduce them into chyme.  When cook-
ed they  are still  less digestible, on account of the
change produced upon their albuminous principle.
It is,  however, certain that they are nourishing,
and contain  a considerable quantity of  nutritive
matter in  a  small compass.  It is equally  clear
that oysters have occasionally produced injurious
effects, (Medical  Transactions  of the College of
Physicians, vol.  v.) ; these have been attributed to
their having lain on  coppery beds, but this idea is
entirely  unfounded,  and  arose merely from  the
green colour which  they  often acquire, the cause
of which is now generally understood, being some-
times an operation of nature, but  more generally
produced by art, by placing them in  a  situation
where there is a great deposit from the sea, con-
sisting of the vegetable germs of marine conferva,
and fuci,  and which  impart their colour to  the
oyster.  For this object  the Dutch formerly car-
ried  oysters  from  our coasts, and deposited them
 on  their own.   Native oysters, transported  into
the Colchester beds, soon  assume a green colour.
 Where this food has produced  a fit of indigestion,
 it has evidently arisen from the indigestible nature
 of the oyster, and the state  of  the individual's
stomach at  the  time; and had such a person in- 
DIETETICS.
655
dulged to  the same amount in any equally indi-
gestible aliment, there can  be no doubt  but  that
he would have experienced similar  effects.  Oys-
ters cast their spawn, which the dredgers  call  the
spat, in the month of May, after which  they are
sick and unfit for food ; but in June and July they
begin to mend, and in August they are  perfectly
well.  We therefore see the  cause  of their going
out of season, and discover the  origin of the old
maxim, that an oyster is never good except when
there is an r in the month.   Lobsters are  certainly
nutritive;  but they are exposed to the same ob-
jection on the ground of indigestibility ; and such
has been  their effect upon certain stomachs, as to
have excited a suspicion of their containing some
poisonous principle :  they have  been known to
occasion pain in the throat, and, besides eruptions
upon the skin, to extend their morbid influence to
the production of pain in the stomach, and affec-
tion of the joints.  As found in the London mar-
ket, they are generally underboiled, with a view
to their better keeping; and  in that case they are
highly indigestible.  The same observations apply
to the crab.   Shrimps are  a species of  sea crab,
which vary in their colour and  size, and are con-
sidered easier of digestion than the preceding arti-
cles.  The mussel is a species of bivalve which is
more solid, and quite as indigestible as any animal
of the same tribe.  The common people consider
them as poisonous, and, in eating them, take out
a part in  which they suppose the  poison princi-
pally  to reside.  This is a dark part, which is the
heart, and is quite innocuous:  the fact, however,
is sufficient to prove that this species of bivalve
has been known  to  kill; but probably not more
frequently than any other indigestible substance.
Our annals  abound with  instances of the delete-
rious  properties of melon, cucumbers, &c. and yet
no one will  contend  that  any poison, properly so
called, resides in  such vegetables.  The peculiar
cutaneous efflorescence wbich is produced by the
imperfect digestion of shell-fish, has been  observed
to occur more frequently in cases where  the  fish
has been stale or tainted, although it also happens
where no such error can be suspected.
   It has been usual to attribute all the cutaneous
affections which follow the liberal  use of fish as
depending upon the sympathy of the skin with the
stomach.  This, we believe, is in  general the true
explanation, since the effect is merely temporary ;
and when the  process of  digestion is finished, it
departs.  Its departure may even be hastened by
the operation of an emetic removing the  noxious
aliment.  At the same time the fact must not be
overlooked, that the oily principle upon which de-
pends the odour of certain fish, is  absorbed from
the alimentary canal, and  carried into the blood ;
this is evident from the  peculiar  flavour of the
flesh of certain birds which live upon fish.  It is
also well known that persons confined  for  any
length of time to  a diet of fish secrete a  sweat of
a rancid  smell.  It  is not, therefore, improbable
that certain cutaneous diseases may be produced,
or at  least  aggravated, by such diet; and in  hot
climates this effect may be less questionable.  The
priests of Egypt may therefore  have been  pro-
hibited from  e'ating fish  upon just principles, in
order that  the leprosy might be averted ;  and the
great  legislator of the Jews was. no doubt,  influ-
enced by some such  belief, when he framed  his
celebrated prohibition. (Leviticus, xi. 9—12.)
  It is  usual to  add various  condiments to fish,
and many kinds of fish are doubtless thus rendered
more digestible, by a necessary stimulus being af-
forded  to  the stomacb;  but rich  sauces are ever
to be avoided by the valetudinarian.  Vinegar and
salt, perhaps, form the best additions.
  The  mode of cooking fish  is  another circum-
stance of some importance.  Frying them in lard
or oil is an objectionable process:  in general, the
process  of  boiling is best  adapted for rendering
them wholesome.  Stewed  fish, with all the  usual
additions of glutinous and stimulant  materials, are
extremely injurious to dyspeptics.
  Birds.:—There exists a great variety in  the
qualities of the food which  is furnished by this
class of animals,  with regard to nourishment, sti-
mulus, and digestibility : the whiter meat of do-
mesticated  birds,  as  the wings  and  breasts of
chickens, contains less nutriment, and is less di-
gestible than that which is furnished  by wild birds,
as the partridge, &c.;  but the former is, at  the
same time, less stimulant  and heating  than the
latter.   These  are the circumstances which  are to
direct the medical practitioner in  his opinion.  No
general rule for the  choice of either species  can
be established; it must be  determined  by the par-
ticular  condition of  the patient, and  the  effect
which the  aliment is intended to produce.   The
same observation will apply to the  flesh of quadru-
peds ; that which is dark-coloured and contains  a
large proportion of fibrin, as venison, &c. is  easily
disposed of by the stomach, and  a large quantity
of highly stimulating chyle  is produced from it.
The whiter meats are, on  the contrary, detained
longer in  the stomach, and furnish  a less  stimu-
lant chyle.   The former, therefore,  will be more
easily digested  by weak  persons, while the  latter
will frequently run into a state  of acetous  fer-
mentation ; but they may, nevertheless, be pre-
ferable on  many  occasions, inasmuch as they im-
part less stimulus  to the  general system.   We
see, therefore, the folly into which many popular
writers have  fallen, of stating such or such an arti-
cle  as  being  wholesome  or otherwise; as  the
wholesomeness of an aliment must  depend upon
its  fitness to produce the  particular effect which
the case in question may require.  Van Swieten
has justly  said,  that " to assert a thing  to bo
wholesome, without a knowledge of the condition
of the person  for whom it is  intended, is like  a
sailor pronouncing the wind to  be fair, without
knowing to what port the vessel is bound."
  Farinaceous Aliments.—The flour of wheat
contains three distinct substances ; a mucilaginous
saccharine matter, starch, and  a peculiar sub-
stance, possessing many of the properties of ani
mal matter, termed gluten.  It is to the quantity
of this latter ingredient that wheat flour  possesses
so decided a superiority over that of barley, rye,
or  oats, for  from these latter grains  much less
gluten can be  extracted.   It furnishes by far the
best ingredient for making  that important  article
of diet, bread,- although it may also be made of
all  the various sorts of grain, as well as of  ches
nuts, of several  roots, and of the  potato.   We
shall first describe the nature  of wheaten breao,
and then  compare it with  that  produced  from 
656
DIETETICS.
other substances.  The first process for rendering
farinaceous seeds esculent, is  to  grind them into
powder between mill-stones :  the meal thus  pro-
duced  is purified from the  husk of the seed, or
bran, by the operation of sifting or bolting ;  and
it is  then denominated flour.  This, when mixed
with water  or milk, undoubtedly  possesses  the
power  of nourishing  the  body ;  but in this  raw
state it would not be sufficiently  digestible; it
would  clog the stomach,  and oppose those actions
which  are essential to chymification.   The appli-
cation,  however, of heat renders the compound
more easy to  masticate  as well as  to  digest;
whence we find in  the earliest history a reference
to some process instituted for  the purpose of pro-
ducing this change, although the discovery of the
manufacture of bread, simple as it may appear to
us, was probably the work  of ages.   It  has  been
just stated that wheaten flour is  the best adapted
for making bread, that is to say,  loaf bread ;  this
depends upon  the greater quantity of  gluten
which it contains, and which  operates in a man-
ner to be presently explained.   The first stage of
this  process of panification  consists in mixing
the  flour with  water, in order to form a paste,
the average proportion of which is  two parts of
the water to three of the flour ; but this will neces-
sarily  vary with the age and quality of the flour :
in general, the older and the better  the flour, the
greater will  be the  quantity of water  required.
This  paste may be  regarded as merely  a viscid
and clastic tissue  of gluten, the  interstices  of
which are filled with starch, albumen and sugar.
If, then, it be allowed to remain for some time, its
ingredients gradually re-act upon each other, the
gluten probably performing an important part; by
its action on the sweet principle, a fermentation
is established, and  alcohol,  carbonic acid,  and
lastly  acetic  acid,  are evolved.  If the paste be
now baked, it forms a loaf full of eyes, like our
bread, but of a taste so  sour  and unpleasant that
it cannot be eaten.   If a portion  of tbis old paste,
or leaven, as it is called, be  mixed with new-made
paste, the fermentation  commences  more imme-
 diately, a quantity of carbonic acid is  given off,
 but the gluten resists its  disengagement, expands
 like a membrane,  and forms  a multitude of little
 cavities, which give lightness and  sponginess to
 the  mass.   We  easily,  therefore,  perceive why
 flour,  deficient in the tenacity which gluten im-
 parts  to it, is incapable of making raised  bread,
 notwithstanding the greatest  activity  may be
 given to the fermentative process by artificial ad-
 ditions.  Where, however, leaven  has  been em-
 ployed, the bread will be apt to be sour, in  con-
 sequence of the great difficulty of so adjusting its
 proportion, that it shall not by its  excess impart
 an  unpleasant flavour, nor by its  deficiency ren-
 der the bread too  compact and  heavy.   It is for
 such  reasons that in this country  we  employ
 barm; a ferment which collects on  the surface of
 fermenting beer.   It appears  that we  are indebted
 to the ancient Gauls for this practice.  In Paris it was
 i utrod uced about the end of the seventeenth century;
 the Faculty of Medicine, however, declared it to be
 prejudicial  to health, and it was long before the
 bakers could convince the public that bread baked
 with  barm was superior to that of leaven.  A great
 question arose among chemists as to the nature
of this barm that could produce such effects, and
elaborate analyses  were made, and  theories de-
duced from  their results ; but all these ingenious
speculations fell to the ground, when  it was found
that barm, dried and made into balls, would an-
swer every purpose; the bakers imported it in such
a form from  Picardy and Flanders, and  when
again moistened, it fermented bread as well  as the
recent substance.  The presence, therefore,  of
carbonic acid,  water,  acetic  acid, and  alcohol,
could not be essential, for these  ingredients were
separated by the process of its preparation.   At
length it was  discovered that  gluten, mixed with
a vegetable acid, produced all the desired effects;
and such is the nature of leaven, and such is the
compound to which barm is indebted for  its value
as  a panary ferment.  After the dough has suffi-
ciently fermented, and is properly raised,  it is put
into the oven previously heated, and allowed to
remain till it is baked.   The mean heat, as ascer-
tained by Mr. Tillet, is 448°.   When the bread
is removed, it will  be found  to have  lost about
one-fifth of its weight, owing  to  the evaporation
of  water; but  this proportion will be varied  by
the  occurrence of numerous circumstances  which
it is not easy to appreciate.   Newly-baked bread
has a peculiar odour as well as taste, which are
lost by keeping : this shows that some  peculiar
substance must have been formed during the ope-
ration, the nature  of which  is not understood.
Bread differs very  completely from  the  flour of
which it is made,  for none of the ingredients of
the  latter can  be discovered in it; it  is much
more  miscible with water than dough; and  on
this circumstance its good qualities, most probably,
in a great measure  depend.   It is not easy to ex-
plain the chemical changes which have taken place.
It appears certain that a quantity of water, or its ele-
ments, is consolidated and combined with the flour;
the gluten, too, would seem to form a union with the
starch and water, and thus to give rise to a compound
upon which the nutritive qualities of bread depend.
   Unleavened bread consists of a mixture of meal
 and water, formed into  a firm  and tough cake,
 made as thin as possible, to favour its drying, and
 sometimes  with the addition  of butter, to  render
 it more soluble, friable, and porous; but it renders
 it sourer, and  more apt to produce acidity  on the
 stomach.  Of the unleavened sorts  of bread, bis-
 cuit is by far the best; and in  all cases  where
 leavened or fermented  bread does not agree, its
 use cannot be too strongly advocated.
   The  different  sorts of bread  to  be met with
 in this  country may  be considered  under three
 classes :  viz.  white, wheaten,  and household.  In
 the first, all the bran  is separated ; in the second,
 only the coarser; in the third,  none at all: so
 that fine  bread is made  only of flour,  wheaten
 bread of flour and a mixture of the  finer bran,
 and household  of the  whole substance  of  the
 grain, without taking out  either the coarse bran
 or fine flour.   It is necessary for the  medical prac-
 titioner to understand  these distinctions; for it
 will be proved  that an important dietetic fact is
 connected with them.  The  tendency of  starch
 upon the bowels is astringent.  Bread,  therefore,
 which is  made of the whitest flour is apt  to ren-
 der them costive ; but this is counteracted by the
 presence of bran, the scales  of which appear to 
DIETETICS.
657
exert a mechanical influence upon the intestines,
and thus to excite them into action.
  The French  have many varieties of bread,  in
which eggs, milk, and butter enter as ingredients.
They are also in the habit of adding ammonia  to
the dough;  which, during  its evaporation in the
oven, raises it, and thus adds to its sponginess.
   Barley-bread has a sweetish  but  not an un-
pleasant taste; it is, however, rather viscid, and
is less nutritive,  as  well as  less  digestible, than
wheaten bread.   It  is common to mix peas-meal
with  the barley, which certainly improves  the
bread.  Rye-bread is of a dark brown colour, and
is apt to lie heavy on  the stomach ; it  is also
liable to create  acescency and purging; but it ap-
pears to be highly nutritive.  In some of  the in-
terior counties of England, where  their bread is
often manufactured from oatmeal, there is a mode
 of preparing the meal by making it sour; the
 bread, instead of being hard, is thus rendered of
 a soft texture, and  from its moderate acidity is
 wholesome to strong persons : but invalids  should,
 if possible, avoid it.  In bread, however, this grain
 is more usually in  an  unfermented state, or it is
 made  into  flat, thin cakes, which  are baked or
 roasted. It is evident, from the health and vigour
 of the  people  who  use  this grain as a principal
 article of diet, that it must be very nutritive; but
 the stomach will require some discipline before it
 can digest  it.   In  those  unaccustomed to such
 food, it produces heartburn; and it is said to oc-
 casion, even in those with whom it agrees, cuta-
 neous affections.  In times of scarcity, potatoes
 have been made into bread ; but they contain too
 much mucilage  in  proportion to their starch to
 afford a good article : the bread thus produced is
 heavy, and apt to  crumble  into powder;  effects
 which are obviated  by mixing a certain quantity
 of wheat-flour with the potatoes.  Rice will also
 serve the  purpose  of making very  good  bread;
 but, like the potato, it  requires the  addition of
 some flour.  It is  said by some that bread made
 of different kinds  of grain is   more  wholesome
 than that made of only one  sort, as their qualities
 serve to correct  one another.  This is certainly
  the case with  that which is  commonly called
 brown bread, and which is made of  a mixture of
 wheat and rye flour ;  the  former, being of a more
 starchy nature,  and apt to produce  costiveness,
 while the latter often proves too laxative: a due
 proportion  of each, therefore, must furnish a de-
 sirable compound.
    The importance of bread, as an article  of diet,
  will be easily deduced from the principles upon
 which  the digestion of food in the stomach is ex-
 plained.   In addition to its nutritive qualities, it
 performs a mechanical  duty of some importance.
 It serves to divide  the  food, and to impart a suit-
 able bulk and consistence  to it;  it  is, therefore,
  more necessary to conjoin it with articles contain-
 ing much  aliment  in a  small  space, than where
  the food is both bulky and nutritive.  The con-
 centrated cookery of the French is rendered much
 more wholesome from the large quantity of bread
 which  that people  use  at their  meals.   Bread
 should never be eaten  new ; in such a  state, it
 swells  like a sponge in the stomach, and proves
 very indigestible.   Care should  also  be  taken to
 obtain  bread that has  been duly baked.   Unless
    Vol. I. —83
all its  parts are intimately mixed, and the fixed
air expelled, it will be apt, in very small quanti-
ties, to produce acescency and indigestion.
  After stating the advantages of bread, it is  ne-
cessary to make a few observations upon the evils
which  it  may  occasionally produce.  In certain
diseases it evidently produces a tendency to acidi-
ty ; we have daily instances of this fact  in chil-
dren, in whom acidity and much alimentary  dis-
turbance follow its use.   Shebbeare goes so far as
to say  that the rickets are so common in France
only because the quantity of bread given to chil-
dren is excessive;  which, by its acidity, destroys
the calcareous substance of the  bones, and reduces
them to a state of cartilage.   This is mere  idle
speculation, which is in direct variance with the
received  opinions  upon  this  subject.   Where
acidity occurs,  the bread should  be toasted, or
well-prepared biscuit substituted.
  Much has been said and written upon the sub-
ject of the adulteration of bread ; but we are in-
clined to  believe that the evils arising from such
a practice have  been greatly exaggerated.  Jt is
certain that  the inferior  kinds of flour will  not
make  bread  of sufficient whiteness to please the
eye  of the fastidious citizen without the addition
of a proportion of alum.  It has been also found
that unless this salt be introduced into the flour,
the loaves stick together in the oven, and will not
afterwards  separate  from each other with  that
smooth surface which distinguishes the loaf of the
baker.  This circumstance is  probably owing to
the action of the alum upon the mucilage  of the
flour,  which it  coagulates.   It has been said that
the smallest quantity that can  be  employed for
these purposes is from three to four ounces  to two
hundred  and forty pounds of flour.   It cannot be
denied that the introduction of a portion of alum
into the  human stomach, however small, may be
prejudicial to the exercise of its functions, and par-
 ticularly  in dyspeptic invalids.  It was found by
 Mr. E. Davy, of Cork, that bad flour may be made
into tolerable bread by adding  to each pound  from
 twenty to forty grains  of the  common  carbonate
 of  magnesia.
   Besides  bread,  several other  preparations are
 made  by  the solidification of flour, such as pud-
 ding,  pancake, &c.  The most digestible pudding
 is that made with bread or biscuit and boiled flour:
 batter pudding is not so  easily digested; and suet
 pudding  is to be considered as the most mischiev-
 ous to invalids  in the whole catalogue.  Pancake
 is objectionable on account of the process  of fry-
 ing imparting a greasiness to which the dyspeptic
 stomach  is  not often reconciled.  All  pastry is
 also   objectionable :  we  believe that one  half at
 least of the cases of  indigestion which occur  after
 dinner-parties may be traced to this cause.
   Many  persons entertain a strange  prejudice  in
 favour of pudding, and appear as  if they  con-
 sidered it to possess a balsamic virtue, or  some
 property by which the digestion  of other aliment
 is  expedited.   If ever such a  diet has served the
 valetudinarian, it  must have  been by excluding
 less stimulating food, and  not by any virtue ad-
  herent in the pudding itself.
    Amongst the  farinaceous aliments, the potato
 holds  a  distinguished rank ;  but its digestibility
  greatly depends upon its kind, and the nature cf 
558                                   DIETETICS.
the cookery to which it is subjected.   The species
which  is  known  by the name of waxy potato
should be  shunned  by the dyspeptic, for it is so
indigestible as to pass through the intestines in an
unaltered  state. ' The same  objection applies to
the young  or new  potato.  The mealy kind more
readily yields to the  powers of the stomach,  and
affords a healthy nutriment: but to the dyspeptic,
we have generally found this vegetable,  in all its
states, to be  injurious; if  ever  allowed to such
patients, it is worthy of  remark that roasting is
preferable to  every other form of  cookery.   The
process  of mashing certainly does not contribute
to its digestibility.   If boiled, care  should be taken
that it is not over-done; for in  such a  case  it is
deprived of its nutritious qualities.
   Rice is  the general aliment of the people of the
East, with  whom it answers the same purposes as
bread does with us.   As it is  not  much disposed
either to acescency or fermentation in the stomach,
it furnishes  a  wholesome  aliment  when  mixed
with other food ; but if taken in  large quantities
by itself, from its low degree of stimulant proper-
ties, it is apt to remain for a length of time in the
stomach: this effect is  greatly increased by  pro-
tracted boiling.  Where  the stomach is in a state
of relaxation  and debility, it ought not to be taken
without condiment; it  is,  for this reason, found
necessary   in the  warmer  climates to conjoin it
with  a  considerable quantity of warm  spices.
There formerly existed a  prejudice against its  use,
from a  belief that it had a tendency to produce
blindness.  It is scarcely necessary to state   that
such an idea has  no foundation  in truth.  It is
generally considered as astringent, and  is, there-
fore, a popular  remedy  for  diarrhoea; no astrin-
gent principle, however, has yet been discovered
in its composition, and it is probable that it owes
its virtues on such occasions to the mild and bland
mucilage, with  which it  abounds, shielding  the
intestines from acrimonious humours.
   There are various other  aliments  in  domestic
use which  owe  their qualities to  starch, such as
sago, tapioca, arrow-root, &c.   From the mucila-
ginous form  in which they are usually  adminis-
tered to invalids, they are not so  digestible as is
generally  supposed; but where the stomacb re-
jects more substantial  food,  they are  useful in
themselves, as well as proper vehicles for the  ad-
ministration of vinous stimulants.
   The leguminous productions, or pulses, may be
considered  as constituting the second division of
farinaceous aliment.  They  differ  little  from
grains, except in affording a more unctuous flour,
which  forms a milky solution with water, owing
to the presence of  an oily matter.   Although they
are highly  nutritive, they are certainly more indi-
gestible  than seeds, and  the bread they afford is
apt to occasion flatulence, and to lie  heavy on the
stomach    The use,  therefore, of  this species of
food is more circumscribed  than that of the  fari-
naceous seeds;  it  is principally confined  to  the
lower classes,  and  to  those  possessing  strong
powers  of  digestion.  In dyspeptic  habits they
ought on no account to be allowed; the symptoms
of uneasiness which they produce  in sucb persons
are often alarming :  flatulence and co'ic are  the
common consequences  of their  action.  Pulses
a^e employed  in two very different states; in  an
| early stage of their growth, when they are succu-
 lent ;  and when all their parts  have reached ma-
 turity : in the former condition they are frequently
 acceptable to the stomach ; but in the latter they
 are only  calculated  for  those  who  have strong
 digestive powers.
    Peas form a wholesome and  light food when
 green and young, but when  full grown and dry
 they are very  indigestible: in this latter state they
 contribute, in a remarkable degree, to the genera-
 tion of gas  in  the intestines.   In the form of
 pudding they are, if possible, still more objection-
 able ; for, to the  bad qualities which  depend upon
 their  composition,  are  thus  added  those which
 arise  from tenacity of texture.  Beans, like peas,
 are comparatively wholesome in  their immature
 state.   The  kidney-bean,  being  eaten  with  its
 pod, is not so flatulent as other pulse : when well
 boiled, it is easy of digestion, but not very nutri-
 tive.
    Nuts are generally supposed to have constituted
 the earliest food of mankind; and  they still  fur-
 nish,  in some countries, a considerable source of
 food.   In this country they are principally known
 as  an article of the dessert, although  on some
 occasions they are eaten  with  our  food.   With
 regard to composition, the chestnut may perhaps
 be  considered as more nearly allied  to the pulse
 than to the nut tribe, since it affords no oil by ex-
 pression, and  from its farinaceous qualities it may
 even be made into bread, although it is heavy and
 indigestible.   Its nutritive power must  be  con-
 siderable, since it forms the chief food of the lower
 orders of the plains  in Lombardy ;  and  it  has
 been  conjectured that  it  was the acorn  so  fre-
 quently mentioned in ancient history and tradi-
 tion.   When eaten after  dinner, an indulgence
 which can only be conceded to the most robust, it
 ought to be previously roasted ; ils digestibility is
 also increased by being kept for some time after it
 has been gathered.   It  is  at the  same time thus
 rendered more palatable by the greater evolution
 of its saccharine  principle.
    The evils which may arise from the use of the
 chestnut are  still more likely to occur after  the
 ingestion of nuts, for they are more  oily, as well
 as  more viscid and  glutinous :  when e.iten, they
 should always be accompanied with  salt; but it
 would be wise to banish them  entirely from our
 tables.
    Esculent Roots.—These are of two  kinds;
 those used as food, and  those which principally
 answer the purposes of condiment or seasoning.
 Under the first division may be classed turnips,
 carrots, parsnips, Jerusalem artichokes, rudishes,
 &c, many of which, it will be  seen, are  seldom
 used solely for aliment, but are  rather brought to
 our tables to qualify our animal food.  Under the'
 second division may  be arranged onions,  garlic,
 horse-radish, &c.  It will be necessary  to offer a
 few observations  upon the qualities of these seve-
 ral roots.
    The  carrot, from  the quantity of saccharine
 matter which it  contains,  is very  nutritive  and
 slightly laxative; but it also possesses a large pro-
 portion of fibrous matter, which in some  stomachs
 prevents the  digestion of the root, and it passes
 through the  bowels  with but  little change : to
| obviate this effect, it ought to be very thoroughly 
DIETETICS.
659
boiled, and it  should be eaten when young.  It
appears  to have been introduced by the Flemings,
in the reign of Elizabeth.   The turnip is a very
excellent vegetable, and, although it has the cha-
racter of being flatulent, it is less liable to disagree
with the stomach than the carrot; it ought, how-
ever, to  be well boiled, and the  watery part sepa-
rated by pressure.   Lord Townshend, secretary to
Charles I., was the person  who introduced its use
into England; but it  appears  that the ancient
Romans, in the best period of their republic, lived
much upon this root.   The parsnip is nutritive
and digestible, although many persons dislike it
on account of its sweet flavour.   The Jerusalem
artichoke  is agreeable, but watery and flatulent;
it ought,  therefore,  never  to  be eaten without a
proper  accompaniment of salt and  pepper.  All
the varieties of radishes have  a pungent and acrid
taste, in consequence  of  a  peculiar  stimulating
matter,  which resides  in the  cortical part of  the
root.  They may be said to contain little else than
water, woody fibre, and acrid  matter, and cannot,
therefore,  be very  nutritive;  they  may act as a
stimulant, and thus  prove  useful, but they ought
never to  be eaten  when  old, as the quantity of
inert matter in such a condition is apt to disagree
with  the  stomach.  From the  consideration of
radishes, we pass, by an easy  transition, to that of
onions,  &c, for they appear to form the connect-
ing link between alimentary  roots and those used
principally as  condiment.  The  onion, however,
although  classed under this  latter  division,  and
must be considered as valuable on account of its
stimulating matter, certainly contains a considera-
ble proportion of  nourishment.  This  appears
evident  in its boiled state, by which process its
acrimony  is exhaled, and a sweet mucilage sepa-
rated.   Sir John Sinclair  says  that it is  a well-
known  fact that a  Highlander, with a few  raw
onions in  his pocket, and a crust of bread, or some
oat-cake, can travel almost  to an incredible extent,
for two  or three  days together, without any other
sort of food.   The French are fully aware of  the
quantity of nourishment this plan affords;  hence
the soup a I'oignon is considered by them as  the
best of all  restoratives.  As  a stimulant to the
stomach and bowels, the onion, in a raw state, is
certainly of value, and  this is much enhanced by
its diuretic qualities.  The leek, garliek, shallot,
are of the same species, and  possess qualities of
the same  nature.   Horse-radish is  a warm  and
pungent root, and  is highly  valuable to the dys-
peptic as  a stimulant; it is, perhaps, the best of
all condiments for the prevention of flatulence.
   Esculent Herbs.—In  this class are arranged
the leaves and  stalks  of such vegetables as  are
eaten  at table in the form of " greens and salads."
Herbs eaten in a raw state are far less digestible
than when cooked.  During the heats of summer
they are refreshing, and are well calculated to as-
suage that febrile  state which full meals of ani-
mal food  are known  to occasion.  Of all these
herbs the water-cress is the most beneficial; for,
by operating  in  some degree as  an aromatic, it
promotes digestion, and corrects  that tendency to
flatulency which other  raw vegetables  are apt to
produce.  According to Xenophon, the ancient
Persians lived upon  water-cresses, which  they
considered the most wholesome  of vegetable pro-
ductions.   The  lettuce is generally eaten with
other herbs, in the form of a salad, dressed with
oil and vinegar.   Some difference of opinion has
arisen with respect to the  propriety of such addi-
tions.  Gosse, of Geneva, found that vinegar re-
tarded  its  solution in  the stomach,  and oil ha*s
been stated by others to render  it less digestible.
We have generally found  such condiments useful,
and that dressed lettuce is less likely to ferment in
the stomach than that which is eaten without them.
Oil is known to have such an effect  in  checking
fermentation, and the vinegar is not found to pro-
mote it.  The lettuce contains a narcotic* princi-
ple ;  and the effect of this is, in a great measure,
obviated  by a vegetable acid :  those persons, there-
fore, who eat lettuce with a view  to obtain such
effects, ought to  take it  without vinegar.  The
digestibility of celery is greatly  increased by ma-
ceration  in vinegar.   Cucumbers are by far  the
most  unwholesome  of all  raw vegetables, and
should be avoided as poison by dyspeptics.
   The vegetables which require to be boiled  are
the different species and varieties  of  colewort ;
the value of which does not depend so much upon
their nutritive quality as  the tenderness of their
texture.  On  this account,  the cauliflower and
brocoli are the species to be preferred, particularly
the younger sprigs of the former.  Of  the kinds
where the leaves only are employed, the Savoy is
of a  sweeter and more tender  texture  than  the
others, particularly its  central and upper leaves.
The  cabbage tribe  appear to contain a peculiar
essential oil, whence tbe unpleasant odour of cab-
bage-water ; this matter is liable to produce offen-
sive effects on the stomach :  the vegetable should
therefore be boiled  in  two successive waters,  in
order to free  it entirely from the  noxious ingre-
dient, and  at the same time to  render its texture
soft and  digestible.  Asparagus is  quickly dis-
solved in the stomach, and, when sufficiently boil-
ed, is not disposed to create flatulence or acidity :
along with its mucilage  it  frequently  contains
some sweetness, which affords a proof of its nu-
tritive quality.  From  the peculiar  odour which
it imparts to the urine of  those who  eat it, it  ap-
pears to possess some active matter  distinct from
its mucilage ;  and it is  generally considered diu-
retic.   Asparagus is only  wholesome when in an
intermediate state between root and plant.  When
older than  this, it is  remarkably  acrid.
   Fruits.—These are  generally regarded as  ar-
ticles rather  of luxury  than of food ;  and were
we to form our opinion  of their  value from their
abuse, we should certainly be rather disposed  to
class them  under  the head of poisons than of ali-
ments.   Nothing can be more mischievous to the
invalid than large quantities of apples, pears, and
plums, in the form  of dessert, after the stomach
has been already loaded.  But, when taken under
other circumstances,  they  contribute to health, and
appear to be providentially sent  at a season when
the body requires that cooling and antiseptic ali-
ment which they  are so well calculated to afford.
   Fruits may be arranged under the  following
heads : stone fruits,  the apple species, small-seed-
ed fruits, small berries, and farinaceous fruits.

  * We are told that Galen in the decline of life, suffer-
ed mucli from morbid vigilance, until he had recourse to
eating a lettuce every evening, which cured him. 
660
DIETETICS.
  The stone fruits have been denounced  as  the
 east digestible  species by  popular acclamation,
but much of the mischief that has been attributed
to their use  has arisen from the unripe state in
which  they were eaten.  They are, however,  cer-
tainly less digestible than other species, and more
liable to undergo fermentation  in the  stomach.
The hard pulp of certain plums  remains also in
the alimentary canal for a long time, and  is  fre-
quently passed  without having  been materially
changed.  The ripe peach is  the  most delicious,
as well as one of the most digestible  of the stone
fruits ;  the apricot is equally wholesome, but  the
nectarine is liable to disagree with some stomachs.
Cherries are far less  digestible;  their pulpy  tex-
ture and skins are  not easily disposed of by the
stomach; and  as the  sweetest species contain  a
considerable excess  of acid, they may be objec-
tionable in  some cases, and desirable in  others.
The apple species are not so dilute and watery as
the foregoing fruits,  and is less apt to pass into  a
state of noxious fermentation; but its texture is
firmer, and on  that account it is  retained  longer
in  the  stomach, and often proves  indigestible.
The same observations apply to pears, except that,
their texture being  in general less firm, they are
less objectionable.   The  orange,  when  perfectly
ripe, may be allowed to  the  most fastidious  dys-
peptic  ; but the white, or inner  skin should be
scrupulously rejected, for it is not more digestible
than leather.   The small-seeded fruits are by far
the  most wholesome.   Of these the ripe  straw-
berry and raspberry deserve the first  rank.  The
grape is also cooling and antiseptic, but the husks
and seeds should be rejected.  The gooseberry is
less wholesome on account of the indigestibility
of the  skin, which  is  too frequently swallowed.
The fruits to be classed under the head of small
berries are the cranberry, the bilberry, and  the red
whortleberry.    These  are  rarely  eaten,  except
when baked, and in that state their acescency  sel-
dom proves injurious.  The farinaceous fruits are
 universally  unwholesome.  The melon,  which is
the principal  one,  is  very apt  to disagree with
weak stomachs, and should never be  eaten after
dinner, even by persons in health, without a plen-
tiful supply of salt and pepper.
   By cookery, fruit, otherwise unwholesome, may
be converted into a safe and  useful aliment.   Ap-
ples, when  baked,  afford a  pleasant  repast,  and
from their laxative properties, are well adapted to
certain forms  of dyspepsia.  Dried  fruits, from
the quantity of sugar which generally enters  into
their composition, are very much disposed  to  fer-
ment and occasion heartburn.
   [The following table exhibits the time required
for the stomachal digestion of different alimentary
substances, in a well-known case, which fell under
the care of Dr. Beaumont, and  which the writer
had an opportunity of seeing.  The  table is co-
pied from  another  work, (the writer's Elements
°f Hygiene, 2d edit.  Philad. 1844.)  The most
digestible substances are taken as the standard,
which has been arbitrarily fixed at 1000; and ac-
cordingly, as aponeurosis, the first article  in  the
 table, required three hours, whilst, pigs' feet soused,
rice, &c. required but one, its digestibility compared
with that of these aliments, is  as 333 to 1000 ;
 and so of the others.  It need scarcely be said,
that all such tabular results apply in  strictness to
the individual  concerned  only; yet they  afford
useful comparative views, which, with exceptions
depending upon  individual peculiarities, may be
regarded as approximations applicable to mankind
in general.
ALIMENTS.
Aponeurosis..........
Apples, mellow.......
  Do.   sour, hard.....
  Do.   sweet, mellow ..
Barley..............
Bass, striped, fresh ....
Beans, pod...........
  Do.  and green corn ..
Beef, fresh, lean, rare...
 Do.   do.  do.  dry  .. .
 Do.   do. steak......
 Do.  with salt only ....
 Do.  with mustard, &c.
 Do................
 Do.  old, hard salted...
Beets...............
Brains, animal........
Bread, corn..........
  Do.  wheat, fresh ....
Butterf..............
Cabbage,  head........
  . Do.    with vinegar. .
   Do..............
Cake, corn...........
 Do. sponge.........
Carrot,  orange........
Cartilage............
Catfish, fresh.........
Cheese, old, strong.....
Chicken, full grown.. ..
Codfish, cured dry.....
Corn, (green) and beans
Custard.............
Duck, domesticated ....
 Do.  wild. .*.........
Dumpling, apple......
Eirgs, fresh...........
 Do.  do............
       do............
       do............
       do............
       do............
Flounder, fresh.......
Fowls, domestic.......
 Do.     do........
Gelatin..............
Goose, wild..........
Heart, animal.........
Lamb, fresh.........
Do.
Do.
Do.
Do.
boiled
raw
 do.
 do.
boiled
broiled
boiled
 do.
roasted
  do.
broiled
boiled
 do.
fried
boiled
 do.
 do.
baked
baked
melted
raw
 do.
boiled
baked
 do.
boiled
 do.
fried
raw
fricasseed
boiled
 do.
baked
roasted
  do.
boiled
hard boiled
soft boiled
fried
roasted
raw
whipped
fried
boiled
roasted
boiled
roasted
fried
boiled
equir'd
30
  * [Pigs' feet soused, rice, and tripe soused,being the
most digestible articles in the table, are estimated at

  t [In the case of oils, and other substances of similar
nature, which undergo little digestion  in the stomach,
the time merely indicates the period that elapses before
they are sent into the duodenum ] 
DIETETICS.
661
ALIMENTS.
Liver, beef's, fresh.....
Marrow, animal, spinal .
Meat and vegetables....
Milk................
 Do.................
Mutton, fresh.........
  Do.   do..........
  Do.   do..........
Oysters, fresh.........
  Do.   do..........
  Do.   do..........
Parsnips.............
Pig, sucking..........
Pigs' feet, soused......
Pork, fat and lean......
 Do. recently salted
 Do.       do.......
 Do.       do.......
 Do.       do.......
 Do.       do.  .......
Potatoes, Irish........
   Do.   do.........
   Do.   do.........
Rice................
Form of prepa-ration.	i Time requir'd for slo-machal diges-tion.
	h. m.
boiled	2
do.	2 40
hashed	2 30
boiled	2
raw	2 15
roasted	3 15
broiled	3
boiled	3
raw	2 55
roasted	3 15
stewed	3 30
boiled	2 30
roasted	2 30
boiled	1
roasted	5 15
boiled	4 30
fried	4 15
broiled	3 15
raw	3
stewed	3
digesti-
 bility
compar-
ed with
the most
digesti-
ble arti-
cles in
the table
Do.
Do.
Do.
sago................
Salmon, salted........
Sausage, fresh........
Soup, barley..........
 Do. bean...........
 Do. beef, vegetables, &
       bread.........
 Do. chicken........
     marrow bones....
     mutton.........
     oyster..........
Suet, beef, fresh.......
 Do. mutton.........
Tapioca.............
Tendon, boiled........
Tripe, soused.........
Trout, salmon, fresh....
 Do.    do.........
Turkey, domestic......
  Do.    do.......
  Do.    wild.........
Turnips, flat.........
Veal, fresh...........
 Do.  do............
Vegetables  and  meat,
    hashed ..........
Venison, steak........
boiled
roasted
baked
boiled
 do.
 do.
broiled
boiled
 do.

 do.
 do.
 do.
 do.
 do.
 do.
 do.
 do.
 do.
boiled
 do.
fried
roasted
boiled
roasted
boiled
broiled
fried

warmed
broiled
3	
3	30
2	30
3	20
1	
1	45
4	
3	20
1	30
3	
4	
3	
4	15
3	30
3	30
5	30
4	30
2	
5	30
1	
1	30
1	30
2	30
2	25
2	18
3	30
4	
4	30
2	30
1	35
 500
 375
 400
 500
 444
 307
 333
 333
 342
 307
 2S5
 400
 400
1000
 190
 222
 235
 302
 333
 333
 285
 400
 400
1000
 571
 250
 300
 666
 333

 250
 333
 235
 285
 285
 181
 222
 500
 181
1000
 666
 666
 400
 511
 435
 285
 250
 222

 400
 631]
  Of  Drinks, or Liaum Aliments.—As the
introduction of solid  aliment into the stomach  is
for the purpose of furnishing materials for the re-
pair of the different  textures, so is a supply of
liquid  matter essentially necessary to replace the
fluids which are constantly ejected from the body,
uuring the exercise of its numerous functions.  In
this point of view, therefore, the drinks ought to
be considered as real aliments.  The chyme and
                                    3r
the chyle may also require the assistance of some
liquid medium to increase the fluidity of the mass,
or to favour the  absorption of its finer and more
nutritive parts.   In every point of view, therefore,
dilution is an essential operation ; and an animal
will not only endure the sensation of hunger with
more tranquillity than that of thirst, but  he will
survive longer  under the privation of solid than
of liquid aliment.
   Before we enter upon this part of the  subject,
it will  be necessary that we should offer a few re-
marks  upon the nature  of the changes which
liquids undergo when introduced into the stomach,
and which would appear to be determined  by the
nature of their composition.  The subject teems
with curious facts, and is one of much importance
to the physician, as  it will enable him to appre-
ciate the utility  of liquid diet, and to understand
the circumstances which should decide its  prefer-
ence.
   It was  long  supposed  that liquids, like solids,
passed through the pylorus into the intestines, and
were absorbed together with the chyle, or rejected
with the excrement.   It is not asserted that this
never occurs; but it is evident beyond  contradic-
tion that there must exist another passage, although
its nature remains obscure, by which liquids can
be  conveyed to the  circulation ; for  it has been
.shown that, if a ligature be applied round the py-
loric orifice, in such a manner as to obliterate tbe
passage into the duodenum, the disappearance of
the liquid  from the cavity of the stomach is  not
so  much  even as retarded.  In order to discovei
whether drinks are absorbed along with the chyle,
M. Magendie made a dog swallow a certain quan
tity of diluted  spirit during the digestion of his
food;  in  half an hour afterwards the  chyle was
extracted and examined : it exhibited no  trace of
spirit,  but  the blood  exhaled a strong odour of it,
and by distillation yielded a sensible quantity.
   If a liquid, holding nutritive matter in solution,
be introduced into the stomach, it is either coagu-
lated by the gastric  juice, or its watery  paTt is
absorbed, and  the solid matter  deposited in the
stomach ; in either  case the solid product is con-
verted into  chyme.  Milk,  as we formerly observed,
appears to  be the only liquid  aliment which Na-
ture has  prepared  for  our nourishment; but it
seems that  she has, at the same time, provided an
agent  for rendering  a certain portion  of  it solid,
and hence  we are led to infer that this form is an
indispensable condition of bodies which are des-
tined  to undergo the processes  of chymification
and chylification; and that, unless some provision
had existed for  the removal of fluids from the
stomach, the digestive functions could not have
been properly performed.  When the  broth of
meat is introduced  into the stomach,  the watery
part is carried off, and  the gelatine, albumen, and
fat are then converted into chyme.   Wine and
fermented liquors undergo a similar change; the
alcohol which  they contain coagulates a portion
of the gastric juice, and this residue, together with
the extractive matter, gum, resin, and other prin
ciples  which the liquid  may  contain,  is  then
digested.    Under  certain circumstances  these
liquids may observe a different law of decomposi-
tion, which will, perhaps, in some measure explain
the different effects  which  such potations will 
662
DIETETICS.
produce; for example, the spirit  may undergo a
partial change in the stomach, and be even digest-
ed with the solid matter, or, on  some occasions,
be converted into  an acid by a fermentative pro-
cess ; this will be more likely to occur in vinous
liquors, which contain ingredients favourable to
ihe production of such a change, and hence the
deleterious property  of fermented liquors does not
bear an  unvarying relation to the absolute quan-
tity of their alcohol.   Oil, though possessing the
fluid form, does not appear  to observe  the  law
which  governs the disposal of such  bodies;  it is
not  absorbed, hut is entirely transformed  into
chyme by the stomach.   To effect this  change,
however, it  seems  essential  that  the stomach
should be in a state of high  energy,  or the  fluid
will undergo  chemical decomposition; nor  will
the stomach, unless it be educated,  as it  were, to
this duty, like those of some northern  nations,
digest  any considerable quantity of it; and since it
cannot be absorbed, it must find its exit  through
the  alimentary  canal, and  consequently prove
laxative.
  In classing the different species of drinks, we
may, as  with  solids, arrange them  according to
their chemical composition, thus—
  I. Water.—Spring, river, well-water, &c.
  II. The juices and infusioss  of  animal
and  vegetable  substances. — Whey,   tea,
coffee, &c.
  III.  Fermented liq.ltors.— Wine, beer,  &c.
  IV.  The alcoholic liquors,  or spirits___
Alcohol, brandy, rum, &c.
  Water. — The qualities of water differ essen-
tially according  to the source from which it has
been  obtained ;  and  those  accustomed  to  this
beverage are sensible to differences which wholly
escape the observation of less experienced judges.
How far  the existence of foreign matter  injures
its salubrity has been  a  subject of much  contro-
versy.  That the presence of very minute quantities
of earthy matter can become a source  of  disease
sounds strangely to the ears of the  philosopher;
and yet we have known patients, after drinking a
glass of water, from a sense of weight and oppres-
sion at the stomach, at once pronounce the exist-
ence of foreign ingredients. Animals would appear
to be generally more sensible of such  impurities
than man.  Horses,  by an  instinctive sagacity,
always prefer soft* water ; and when,  by necessity
or inattention, they are confined to the use of that
which  is  hard,  their coats become rough  and ill-
conditioned, and they are frequently attacked with
gripes.   Pigeons are also known to refuse hard,
after they have  been  accustomed to  soft water.
We are informed by Cleghorn that on  the eastern
side of the island of Minorca,  the sheep,  on  ac-

  * An  important practical distinction has been founded
upon (he  fact, that the water of some springs will dis-
solve soap, while that of others decomposes and curdles
n ; the farmer lias been denominated soft, the latter hard
wat.-r.  Sulphate of lime is generally the salt which im-
->arts this quality of  hardness: and it  appears  that the
proportion of five  grains to the pint is sufficient for the
purpose.  Suit water is a more powerful solvent of ail
vtg.'tiible  matters, and is consequently to be preferred
fm  domestic as well as medicinal use.  The brewer
knows well, from  experience, how much  more readily
and copiously soft, water will dissolve the extractive
matter of  his malt ;  and the housewife requires not the
dinniM tr inform her  that hard water is incapable of
4>akiLg good tea.
count of the hardness of the water, are subject to
a disease in the spleen.   But the most dangerous
sources of impurity exist in the animal and vege-
table kingdoms;  putrescent  matter poisons our
beverage, and becomes the secret cause of numer-
ous complaints.   The usual varieties of common
water were classed and defined  by Celsus, and
modern chemists  have  not found any reason  to
reject the  arrangement.  " Aqua  levissima plu-
vialis est,- dein fontana, turn ex flumine, turn
ex puteo ; post kxc ex nive  aut glacie, gravior
his ex lacd, gravissima ex palude."
   We may remark of river water, that, as it  is
derived from the conflux of numerous springs and
rain water, the proportion of its saline constituents
ought to be  small,  since  various  precipitations
must necessarily  take  place  from the  union of
different solutions.  It is, however, liable to hold
in  suspension particles of earthy matter  which
impair its transparency, and  not unfrequently its
salubrity.  It may also, in  the vicinity of a large
town, hold dissolved, as well as suspended, a con-
siderable portion of animal  and vegetable matter:
this is unquestionably the case in  the water sup-
plied from  the Thames by the  Grand Junction
Water-Company.
   For the purification and preservation  of  water,
numerous  ingenious methods have been adopted.
The mechanical impurities  may be easily enough
removed by filtration, a process which is suggested
by  Nature herself, for all springs arising through
sand, gravel, &c. must undergo such an operation;
but it will  not remove a particle of that matter
which is held in solution, and hence  the filter is
only of partial utility.   As that peculiar property
which constitutes  what is termed hardness gener-
ally depends upon sulphate of lime in solution, it
cannot be removed by filtration, but the addition
of an alkaline carbonate, in the proportion of from
ten  to fifteen  grains, to every pint, twenty-four
hours before it is used, will be found to soften it;
or,  if it should be found to depend upon super-
carbonate of lime, which is sometimes the case,
long  ebullition, without any addition,  will be
found sufficient for its  cure.   Another mode of
improving water, and one which has been lately
adopted by  Mr. Robins in his patent filters, is by
the  application of charcoal,  a substance which
possesses  in an eminent degree the property of
preserving water from corruption, and of purifying
it after it has been corrupted;  hence the filtration
of water  through alternate layers of sand and
charcoal offers the readiest  and most effectual
mode of abstracting its impurities with which we
are acquainted.j-   Where we  have reason, how-
ever, to  suspect much  injurious  contamination,
the process of boiling should  never be omitted;
after which  it  may be strained and  filtered, and
lastly agitated in contact with  the atmosphere, in
order to restore to  it its natural proportion of air.
In China, water is never drunk until it has been
boiled.  The mischievous effects of impure water,
where it cannot  be  corrected by any  chemical
process, are said to be best counteracted by some
bitter vegetable. Virey supposes that tbis circum-

  ♦ The  grpat desideratum has  ever  been to remove
soluble mailers from water; it is by no means impossible
that  a simple voltaic apparatus will hereafter  be cob-
trived for such a purpose. 
DIETE
TICS.
663
stance first induced the Chinese to  infuse  the
leaves of the tea-plant.
  Water is unquestionably the natural beverage
of man; but  any  objection against the use of
other fluids founded on their artificial origin, may
be at once met by the same argument which  has
been adduced in defence of cookery.   We are to
consider man as he is, not as he might have been
had he  never  forsaken  the rude path of nature.
VvTe are ready to admit that the more simply  life
is supported, and the less stimulants we use,  the
better; and that he is happy who considers water
the best drink, and salt the best sauce; but how
rarely does a physician  find that his patient  has
regulated his life by such a  maxim !   He is gene-
rally  called-, upon  to  reform  stomachs  already
vitiated by  bad habits, and  which cannot, without
much discipline,  be reconciled  to   simple  and
wholesome aliment.  Under such circumstances,
nothing can be more injudicious than abruptly to
withdraw the accustomed stimulants, unless it  can
be clearly shown that they are absolutely injuri-
ous,—a question which it will be our duty to  in-
vestigate.
   The juices and  infusions of  vegetable and ani-
mal matter constitute  the second   division  of
drinks.
   Toast-Water.—By impregnating water with
the soluble parts of toasted bread, we shall obtain
a liquid which will frequently agree with those
stomachs which  rebel against the use of the more
simple fluid.  It is thus  also rendered  slightly
nutritive, holding  a certain portion  of gum  and
starch in  solution.  Sir A. Carlisle  recommends
that it should be  prepared with hard biscuit, re-
duced by  fire  to a coffee colour.  " This drink,"
says he, « being free from yeast, is a most agree-
able beverage.   Much depends upon the water,
employed for  its preparation,  being  at a boiling
temperature, and it ought to be drunk as soon as
it has sufficiently cooled;  for,  by being  kept, it
acquires a mawkish and  unpleasant flavour.   In-
fusions  of other kinds  of bread, especially those
of toasted oat-cakes, and dried  or toasted oatmeal,
have  been recommended; but the taste of such
infusions would  not be  palatable to any one who
has not been accustomed to oat-bread.
   Barley-Water.—The  decoction  of barley is
a very ancient beverage; it is recommended by
Hippocrates, and preferred by him to every other
aliment in  acute  diseases.  Barley  has  the  ad-
vantage over other grains, in affording less viscid
potations.  The invention  of  pearl barley  has
greatly  increased  the value of this  grain ; it is
prepared by the removal of its husk or cuticle,
and afterwards  by being  rounded and polished
in a mill.   These well-known granules  consist
chiefly of fecula, with portions of mucilage, gluten,
and sugar, which  water extracts by decoction;
but the  solution soon passes into the acetous  fer-
mentation.  The bran of barley contains an acrid
resin, and it is to  get rid  of such an ingredient
that it is deprived of its cuticle.  The addition of
lemon-juice and sugar-candy greatly improves the
flavour of this drink.
   Gruel—Oats, when  freed  from  their cuticle,
are called groats; in which state, as well as when
ground into meal, they yield to water, by coction,
the fecula they contain, and  form  a  nutritious
gruel, which has also the property of being slightly
aperient.  It should never  be  kept longer than
forty-eight hours, as it becomes acescent,after that
period.   Gruel may be made of a different degree
of consistence, according to  the object of its pota-
tion.  If it be used as a demulcent drink, it should
be thin ;  and  may  be made,  as Dr. Kitchener,
our culinary censor, informs us, by mixing well
together, by degrees, in a  pint basin, one  table-
spoonful of oatmeal with three of cold water, and
then  adding carefully  a  pint  of boiling  water,
which is to be boiled for five minutes, stirring it
all the time, to prevent the  oatmeal from burning
at the bottom of the stewpan ; then strain through
a hair sieve, to separate the undissolved parts of
the meal from the gruel.   If  a  more substantial
repast is  required, double the  above quantity of
oatmeal must be treated in  a similar manner. To
increase the nutritive quality of this aliment, broth
or milk may be substituted for water.  Some per-
sons  are  in  the  habit  of introducing a piece of
butter into gruel; but the propriety of  this prac-
tice  is  questionable, where  the stomach  is sup-
posed to generate acidity.
  Sage Tea.—The virtues of sage have been so
extravagantly praised, that,  like many of our re-
medies, the plant is  fallen  into  disuse from the
disgust which its panegyrists have excited.  We
are convinced, however, that in  the form  of in
fusion  it  possesses  some power in allaying the
irritability of the  stomach,  (it  is frequently used
by the  Chinese as a tonic for debility of the  sto-
mach,)  and that, on  many  occasions, it will
furnish a salutary beverage. The  same observa-
tion will apply to the infusions of balm and rose
mary.  A drink extremely agreeable  to the sto
mach of invalids may  also  be made by infusing
lemon-peel in  boiling water, and adding a small
quantity of sugar.
  Tea.—There is no subject that has occasioned
a greater controversy amongst dietetic writers thar
that of tea.  By one party  it is decried as  a poi-
son ; by another it is extolled as a medicine,  and
a valuable addition to our food ;  while some refei
all  its  beneficial effects to  the water  thus intro-
duced into the system, and  its evil  consequences
to the high temperature at which it is drunk. I>.
order to understand  the value of the different ar-
guments which have been adduced in support, or
to the disparagement, of this beverage, it -//ill be
necessary to inquire into its composition.   Two
kinds of tea  are imported  into this country, dis-
tinguished by the epithets black and green.  Both
contain astringent and narcotic principles,  but in
very  different  proportions;  the  latter  producing
by far  the most powerful influence upon the ner-
vous system.   As the primary  operation of every
narcotic stimulant, tea is found to exhilarate and
refresh us, although there  exist individuals who
are  so  morbidly sensible to the action  of  certain
bodies  of this class, that feelings of depression,
accompanied with various nervous sensations and
an  unnatural vigilance, follow the potation of  a
single cup of strong tea ; while others experience,
from the same  cause, symptoms indicative of
derangement of  the digestive  organs: but thesu
are exceptions* from which no general rule ought
  * The Teader is referred to a pamphlet entitled -1 Ov
servations  on  the Medicinal and Dietetic Properties qj 
664
DIETETICS.
 to be deduced.   The salubrity of the infusion to
 the general mass of the community is established
 by sufficient testimony to outweigb any argument
 founded on  individual cases.   It must, however,
 oc admitted, that  if this  beverage be taken too
 soon after dinner, the digestion of the meal  may
 be disturbed by the distension it will occasion, as
 well as by its influence as a diluent;  the narcotic
 and astringent  principles  may also  operate  in
 arresting chymification ; but  when a  physician
 gives it his sanction, it is with the understanding
 that it shall be taken in moderate quantities, and
 at appointed seasons.   In  enumerating the  ad-
 vantages of  tea, it must not be forgotten that it
 has introduced  and cherished a spirit of sobriety ;
 and it must have been remarked by every phy-
 sician of general practice,  that those persons who
 dislike tea,  frequently supply its  place  by spirit
 and water.   Tbe  addition  of milk  certainly di-
 minishes the astringency  of tea ;  that  of sugar
 may please the palate, but cannot modify the vir-
 tues of the infusion.
   Coffee. — The hostility which has been mani-
 fested against the use of tea has been extended,
 with  equal rancour,  against that  of  coffee,  and,
 probably,  with  equal  injustice.   The  principle
 upon which  its qualities depend is more stimulant
 than  that  of tea, and  certainly  exerts a different
 species of action upon the nervous system, al-
 though it is very difficult to  define the nature of
 this difference.  If taken immediately after a meal,
 it is not found  to create  that disturbance in its
 digestion which has been noticed as the occasional
 consequence of tea ; on the contrary, it accelerates
 the operations of the stomach,  and will frequently
 enable the dyspeptic to digest  substances, such as
 fat and  oily aliment, which would  otherwise  oc-
 casion much disturbance.  The custom of taking
 coffee  immediately after dinner,  so  universally
 practised by the French, no doubt must counteract
 the evil effects  which the  peculiar  form of their
 diet  is  calculated  to produce.  Coffee,  like  tea,
 has certainly  an antisoporific effect on many indi-
 viduals ; it imparts an activity  to the mind which
 is incompatible with sleep ; but this will  rarely
 occur if the  beverage be taken for several  hours
 before our accustomed period of repose.   It seems
 to be  generally admitted  that it possesses the
 power of counteracting  the  effects  of narcotics;
 •ind hence it  is used by the Turks with much ad-
 vantage, in abating the influence of the inordinate
 quantities of opium they are accustomed to swal-
 low.  When  our object is to  administer it as a
 promoter of digestion, it should be carefully made
 by infusion ;  decoction dissipates its aroma.  The
addition of milk is one of questionable propriety ;
that  of sugar, or rather sugar-candy, may be  al-
lowed.  Some persons can  never take this  be-
verage without  suffering  from  acidity in  the
stomach: where this  happens, the practice must
be abandoned.
 Green Tea," by W. Newnham,  Esq.   There is a great
deal of sound sense in this little production.  The author
 refers the different effects produced by green tea to the
different states  of the system in which it is taken.   He
maintains that in a state of what he calls sthenic eicite-
 ment of the brain  and nervous system, as that produced
 by alcoholic stimulants, or by  intense  and long-con-
 tinued application of the mind to any particular object
of literary search, green tea will act as a salutary re-
medy; whereas, on the contrary, in states of diminished
excitement, morbid vigilance and  nervous disturbance
 will foi'nw its potation.
    [It appears from recent investigations of organic
 chemists, that  Theinc, the peculiar principle of
 tea, and  Caffeine, the principle of coffee, are iden-
 tical.  " We shall never certainly," says Liebig,
 (Animal Chemistry, edit. cit. p. 169,) "be able
 to discover  how  men  were  led to  the  use of
 the hot infusion of the  leaves of a certain shrub
 (tea),  or of a decoction  of certain roasted  seeds
 (coffee).   Some  cause  there must  be,  which
 would explain bow the practice has become a ne-
 cessary of life to whole nations.   But it is surely
 still  more  remarkable,  that  the  beneficial  effects
 of both plants on the health  must be  ascribed to
 one  and  the same  substance, the  presence  of
 which in two vegetables, belonging  to different
 natural families, and the produce of different quar-
 ters of the globe, could hardly have presented itself
 to the boldest imagination.  Yet recent researches
 have shown, in  such a manner as to  exclude all
 doubt, that caffeine, the  peculiar principle of cof-
 fee, and  theine, that of tea,  are, in all respects,
 identical."  And  he  adds (p. 170) :  " Without
 entering  minutely  into the medicinal action of caf-
 feine (theine), it will  surely appear a most striking
 fact,  even if we were  to  deny its influence on the
 process of secretion, that this substance, with the
 addition  of oxygen and the elements of water, can
 yield taurine, the nitrogenized compound peculiar
 to bile."]
    Chocolate. —  In  consequence  of the large
 quantity  of nutritive matter which this liquid con-
 tains, it  should  be regarded  rather as food  than
 drink.  It is prepared by reducing the cocoa-nut
 into  paste, with sugar, milk, or eggs : it  is also
 frequently  mixed  with  different aromatics, the
 most common of which is the vanilla, a substance
 very  liable to disagree with  the  stomach, and to
 produce a train of  nervous symptoms.   As a com-
 mon  beverage, chocolate is highly objectionable;
 it contains an oil which is  difficult of assimila-
 tion ;  it  therefore  oppresses  the stomach: this
 effect is of course  increased by the  application of
 too much heat in its preparation.  Another ob-
 jection against its  use is to be found in the obser-
 vations which we  have  already offered upon the
 subject of too great concentration.
   Cocoa  is usually considered as a substitute for
 chocolate.  As it contains less nutritive matter, it
 is  not  so objectionable; and, as the oily matter
 exists only in small quantities, it is less likely to
 disagree with the stomach.
   There  are certain saline solutions which are fre-
 quently employed  as drinks, and  deserve  some
 attention  in this place : such are  imperial and
 soda water.   Imperial is a solution of cream of
 tartar flavoured with lemon-peel.   It ought never
 to be  used except as a medicine.  If employed as
 an ordinary drink, it is apt to  retard digestion.  If
 ever useful as an  article  of diet, it will be under
 circumstances of robust health, and where a large
 quantity  of animal food has  been  taken.  The
 modern custom of drinking soda water during, or
 immediately after  dinner, has been  a pregnant
 source of  dyspepsia.   By inflating the  stomach at
 such a period, we inevitably counteract those mus-
 cular  contractions which are essential to chymifi-
cation.  The  quantity of soda thus  introduced
scarcely deserves notice : with the exception of
the carbonic  acid gas, it may  be regarded as
water, more mischievous  only in consequence of 
                                      DIETE

the exhilarating quality inducing us to take it at
a period at which we should not require the more
simple fluid.
  Fermented Liquors. — Volumes have been
written to prove that spirit, in  every form, is  not
only unnecessary  to those who are in health,  but
that  it has been  the  prolific  source of the most
painful and fatal diseases to which man is subject;
in short,  that Epimetheus  himself did not,  by
opening the box of Pandora, commit a  greater act
of hostility against our nature than the discoverer
of fermented liquors.  This is a striking specimen
of the fallacy of reasoning against the use of a
custom from its abuse.  There exists no evidence
to prove that a temperate use of good wine, when
taken at seasonable hours, has ever  proved inju-
rious to healthy adults.   In youth, and still more
in infancy, the stimulus which it imparts to  the
stomach  is undoubtedly injurious ; but there are
exceptions even to this  general rule.   The occa-
sional use of diluted wine has improved the health
of a child, by imparting vigour to a torpid stomach:
we ought, however, to consider it rather as a me-
dicine than as a luxury.
   Without entering further  into  the  discussion
11 a question which has called so many opponents
into the  field, it  may be  observed that whatever
opinion we may have formed as to the evils or
advantages  consequent upon  the  invention  of
wine, we  are not called upon, as physicians, to
 Mend it; our object  is to direct remedies for  the
 cure of those diseases which assail man as we find
 nim in the habits  of society. And as these  habits,
 jays Dr.  W.  Philip, are such that more  or less
alcohol is necessary to  support the  usual  vigour
of the greater number of people even  in  health,
nothing could be more injudicious than  wholly
to deprive them of it when they are already weak-
ened  by disease, unless it could be shown that
even a moderate use of it essentially adds to their
disease, which, in dyspeptics, is by no  means  the
case.   Our own experience coincides  with that
opinion.  In cases where the vinous stimulant  has
been withdrawn, we have generally witnessed an
aggravation of the dyspeptic symptoms, accompa-
nied with  severe depression of spirits.
   The term wine is more strictly and especially
applied to express the fermented  juice  of  the
grape,- although  in common language it is used
to denote that of any sub-acid fruit.  The presence
of tartar  is perhaps the circumstance by which
the grape is more  strongly distinguished from all
the other sub-acid fruits that have been applied to
the art of  wine-making.  Its juice, besides, con-
tains within itself all  the principles essential to
vinification,  in  such  a  proportion  and state of
balance as to  enable it at once to undergo a regu-
lar and complete fermentation; whereas, the juices
of other fruits require artificial  additions for this
purpose:  and the scientific  application and due
adjustment of these means constitute  the  art of
making domestic wines.*  It has been remarked
that all those  wines which contain an  excess of
malic acid are of a bad quality : hence the grand

 * For an  account of which, the reader is referred to a
most ingenious and interesting essay by Dr.  Macculloch
entitled " Remarks on the Art of making Wine ; with
Suggestions for the Application of its-Principles to the
Improvement of Domestic Wines."
  Vol. I__84                        3f*
TICS.                                   665

defect that is necessarily inherent in the wines of
this country, and which leads them to partake of
the properties  of cider; for in the place of the
tartaric, the malic acid always predominates in
our native fruits.
   The  characteristic ingredient of all wines is
alcohol; and the quantity of this, and the condi-
tion or state of combination in  which it exists, are
the circumstances that include  the more interest-
ing points of inquiry,  and explain the  relative
effects which different  wines  produce upon the
system ;  we  shall therefore  proceed to investigate
the various species, with reference to such condi-
tions.
   Wines may be at once resolved into two great
divisions;  into those which  are coloured, and
commonly called red wines, and into those which
have  a  yellow tinge, more  or  less deep, termed
white wines.   This colouring matter is  not de-
rived  from the juice, but from the husk of the
grapes.   If, therefore, the fermentation be not per-
mitted to  take  place in contact with the  hulls,
and sometimes even with the stalks of the fruit, a
white wine is in all cases produced. This colour-
ing matter is highly astringent, and consequently
the red wines differ from the white in their effects
upon  the stomach; and yet it is difficult to ex-
plain  the well-known extent of this  operation by
the presence  of so  small a proportion of active
matter.   It must, however, be remembered that
irritable  stomachs  are  frequently impatient of
astringent  matter.  Many  persons are incapable
of drinking port wine in consequence of the heart-
burn it occasions; while others, on the contrary,
appear to  derive advantage from  the  tonic influ-
ence of its astringency.  This  is  a  circumstance
of idiosyncrasy which  no  theory can explain.
Every physician must be practically aware of the
caprice which the stomach displays in its morbid
conditions  ; but as a general rule, it may be stated
that white deserve  a  preference over  red wines,
because the latter, being pressed, and subjected to
a stronger  fermentation  to extract the colouring
principle  from  the  husk, are  necessarily  more
loaded with extractive and astringent matter ; and
as this  remains in the stomach after the liquid
portion of the wine  is absorbed, it will  be liable to
occasion disturbance.
   The odour, or bouquet, and  flavour which dis-
tinguish one wine from  another, evidently depend
upon  some volatile and fugacious principle not
hitherto investigated by the chemist : this, in sweet
and half-fermented wines, is immediately  derived
from the fruit,  as in those from the Frontignan
and  Muscat  grapes;  but  in  the more  perfect
wines, as in  Claret, Hermitage, Rivesaltes, and
Burgundy, it bears no  resemblance to the natural
flavour of the fruit,  but is altogether the  product
of the vinous process. Some wines are artificially
flavoured  by the introduction  of foreign ingre-
dients, as  by almonds in Madeira wines,  as well
as in  those of Xeres and St. Lucar ;  and hence
their well-known nutty flavour.  Among  the an
cients, and in modern Greece, it is at this  day the
fashion  to  give a resinous  flavour,  by the intro-
duction  of turpentine into the casks.  These wines
were supposed to assist  digestion, to restrain moi-
bid discharges, to promote urine, and to strengthen
the bowels; but Dioscorides informs us that  thev 
666
DIETETICS.
were known to produce vertigo, pain in the head,
and many evils not incidental to the potations of
the same vinous liquor when free  from such ad-
mixtures.
  The quantity of acid contained  in  wines has
been supposed capable of diminishing their salu-
brity, and in some cases of rendering  them emi-
nently noxious.  There can  be  no doubt that
where there exists a considerable excess  of gallic
or malic acids, or where  acetic acid has been gene-
rated during a protracted fermentation, such wine
will  be obnoxious to the stomach;  but where the
acid  arises  from the nature of the  fruit, it surely
cannot merit  the  odium  which popular  opinion
would assign to  it.  What, for  instance, is the
acid  contained in  Madeira, and against which  so
many objections have been urged ? an atom merely
of tartar !   And yet  the person who fancies that
his digestion can be deranged  by its action, will
swallow  twenty times  the  quantity of the same
ingredient in some other shape witb pe.fect indif-
ference and impunity.
   Before we quit tbe subject  of vinous  acidity,
we must add a few words upon its supposed influ-
ence in exciting paroxysms of gout.  That such
attacks have followed  particular potations we  do
not  mean  to deny;  but a slight  excess  of any
kind, whether in diet or in exercise, will excite the
disease  in  those  predisposed to it.  Where this
predisposition exists, an additional  glass  of claret
may excite the disease ; but in all such cases any
other exciting cause would have a  similar  effect.
  It has  been alrealy stated that the characteristic
ingredient  of all wines is alcohol; and  that  its
quantity, and the condition or state of combination
in which it exists, are the circumstances in which
the  medical   inquirer  is  principally  interested.
The late experiments of Mr. Brande have thrown
considerable light upon  this subject; although,  as
in most instances of  discovery, they have raised
up new doubts and difficulties.  Daily experience
convinces us  that  the  same  quantity of  alcohol
applied  to  the stomach under  the  form  of wine,
and  in a state of mixture with water, will produce
very different effects  upon  the body,  and  to  an
extent which it is difficult to understand.   It has,
for instance, been demonstrated beyond the reach
of doubt, that port, madeira, and  sherry contain
from one-fourth to one-fifth of their bulk of alco-
hol ;  so that a person  who takes a bottle  of any
one of them will thus take nearly half a pint  of
alcohol, or  almost a pint of pure  brandy !   And,
moreover, that different wines, although containing
the  same absolute proportion  of  spirit, will  be
found to vary very considerably in their  intoxi-
cating powers.  No wonder, then,  that such
results should have staggered the philosopher, who
is naturally unwilling to accept any tests  of dif-
ference from the nervous system, which elude the
ordinary resources of analytical chemistry.  The
conclusion  was therefore drawn, that alcohol must
necessarily exist in wine in a far different condi-
tion  from that  in which we know it in a separate
Btate; or, in other words, that  its  elements only
could exist in the vinous liquor, and that their
union was  determined, and, consequently, alcohol
produced, by the act of distillation. That it was
the product, and not the educt of distillation, was
■n opinion  which  originated  with Rouelle, who
asserted that alcohol was not  completely formed
until  the  temperature was raised  to tbe  point of
distillation.   More  lately, the  same doctrine was
revived  and promulgated by  Fabbroni, in the
Memoirs of the Florentine Academy.   Gay Lus-
sac has, however,  silenced the partisans of this
theory,  by separating the  alcohol  by distillation,
at the temperature  of 66° Fahrenheit; and,  by
the aid of a vacuum, it has since  been effected a!
56°.  And to complete  the  demonstration, Mr.
Brande has shown that, by precipitating  the
colouring matter, and some other elements of the
wine, by the sub-acetate of lead,  and then  satu-
rating the clear liquor with sub-carbonate of potass,
the alcohol may be separated  without any eleva-
tion of  temperature; and he has  accordingly,  by
this ingenious expedient, been enabled  to construct
a table, exhibiting the proportions of spirit which
exist  in the several kinds of  wine.  No doubt,
therefore, can any longer be entertained upon the
subject; and  the fact  of the  difference  of effect
produced  by the same bulk of  alcohol, when pre-
sented to the stomach in different states, is to  be
explained  on the supposition  that, in wine, it is
not only  more intimately mixed  with water, but
that it  exists in combination  with  its extractive
matter; in consequence of which it is incapable
of exerting its full effects before it  becomes altered
in  its properties, or,  in  other words,  partially
digested;  and this view of the  subject  may  be
fairly urged  in explanation of the  fact,  that the
intoxicating effects of the same wine are liable to
vary  in degree in  the same individual, from the
peculiar state of his digestive  organs at  the time
of its potation.
   We have hitherto only considered alcohol as it
exists in a combined  state  in wine  ; but  it  is
essential to state that the stronger wines of Spain,
Portugal,  and  Sicily, are rendered marketable  in
this country by the addition of brandy, and  must
consequently  contain more or less uncombined
spirit; but the proportion of which  will not bear
a  ratio  to  the quantity added,  because, at the
period of  its admixture, a renewed fermentation is
produced  by the scientific vintner, which will assi-
milate and combine a certain portion of the foreign
spirit with tbe wine : this  manipulation,  in  tech-
nical  language, is called "fretting  in."   It is to
the quantity  of free,  not to  that  of combined
spirit, that the injurious effects of such wines are
to be attributed!  "It  is well  known,"  observes
Dr. Macculloch, " that diseases of the liver are
the most  common  and the  most formidable  of
those produced by the use of ardent spirits."  It
is equally certain that no such disorders follow the
intemperate  use of pure  wine,  however  long
indulged in : to the concealed  and unwitting con-
sumption  of spirit, therefore, as contained in the
wines generally drunk in this country,  is to  be
attributed the excessive prevalence of  those hepa-
tic affections, which are comparatively little known
to our continental neighbours.
   Much has been said about  the effects of new
wine  upon the stomach, compared with those pro-
duced by  that which has been  long  kept.  It will
be necessary to consider the changes produced in
this liquor by being kept.  In  the first place, red
wine  gradually deposits a quantity of cream  of
tartar, in combination with extracti"«>  an  1 colour- 
DIETETICS.
667
 ing matter, forming what is commonly called  the
 crust; so that a considerable portion of that mat-
 ter which is likely to  disagree with the stomach
 is thus removed ;  but  when kept in a cask, in  ad-
 dition to this change, a quantity of water is evapo-
 rated, and the wine becomes comparatively strong-
 er.  The custom  of exposing Madeira to motion,
 and a certain elevation of temperature, by send-
 ing it a voyage to the  East Indies, unquestionably
 improves the flavour, and produces  some internal
 change in the composition of the wine, which  the
 chemist is unable  to explain.
   hi a dietetic point  of view, wines may be  ar-
 ranged into four classes ; viz. 1,  sweet wines ; 2.
 sparkling or effervescing,- 3. dry and  light;  4.
 dry and strong.
   1. Sweet tuines contain the greatest  proportion
 of extractive and saccharine matter, and generally
 the least ardent spirit, though it  is often  rather
 disguised than absent.   Since a proportion of  su-
 gar has remained  unchanged in these wines dur-
 ing the process of vinification, they must be con-
 sidered as the results of an imperfecWfermentation,
 and are, in fact, mixtures of wine and sugar;  ac-
 cordingly,  whatever arrests the  progress  of fer-
 mentation  must   have a tendency to  produce a
 sweet wine.   Thus, boiling the must, or  drying
 the  fruit, will, by partially separating the natural
 leaven, and dissipating the water, occasion such
 a result as is exemplified by the manufacture  of
 the  wines of Cyprus, the Vino Cotto of the Ital-
 ians, and the Vinum   Coctum  of the  ancients ;
 by that of Frontignac, the rich and luscious wines
 Df Canary,  the  celebrated  Tokay, Vino  Tinto
 (Tent of Hungary),  the Italian  Montefiascone,
 the  Persian Schiraz, the Malmsey wines of Can-
 dia, Chio, Lesbos, and Tenedos, and those of the
 other islands of the Archipelago.   On account of
 the sugar contained in such wines, they are liable
 to become acescent on  weak stomachs ;  but where
 this is not the case, they are, in small quantities,
 frequently beneficial to invalids.
   2. Sparkling or effervescing wines. — These
 are indebted for their characteristic properties  to
 the presence  of carbonic acid ; they rapidly intox-
 icate, in consequence of the alcohol which  is sus-
 pended in, or more probably, in chemical combi-
 nation with the gas, being thus applied  in  a sud-
 den  and very divided  state to a large  extent  of
 nervous surface : for the same reason their effects
 are generally as  transitory as they are sudden.
 Independently of the  alcohol thus  held in solu-
 tion  in the carbonic acid, it is probable that some
 active aromatic matter is volatilised together with
 it, and which may  account for the peculiar effects
 produced on some  persons by champagne.
   3. Dry and light wines___These are exempli-
 fied by the more esteemed German wines, as hock,
 rhenish, mayne, moselle, neckar, and elsass; and
 those highly-flavoured  wines,  burgundy,  claret,
 hermitage, &c.  The former of these wines com-
 bine the effect of an acid with that  of the spirit.
 They do  not contain  any uncombined alcohol,
 and on that account  are to  be greatly  preferred.
 Genuine claret must be considered  as  the  most
beneficial of all our vinous liquors ;  it is well fer-
mented ; and on account of the  small proportion
°f spirit, as well as of extractive, which it con- j
tains, it is more salubrious than port.  It has been
 already observed  that  burgundy appears  to  hold
 dissolved some unknown principle of great activ-
 ity ; upon no other supposition can we  explain
 its stimulant  properties.  A few  glasses  of this
 wine will produce heat and  headach, which the
 relative quantity of alcohol in its composition will
 not account for.
    4. Dry  and strong wines, as madeira,  port,
 sherry, &c.   The name sec,  corruptly  written
 sack, signifies dry.  The sec  wine,  prepared  at
 Xeres, in Spain, is called, according to our ortho-
 graphy,  sherris  or sherry.   In the  manufacture
 of this wine, lime is added to  the grapes; a cir-
 cumstance, observes Dr. Macculloch, apparently
 conducive  to  its  well-known  dry  quality,  and
 which, probably, acts by neutralizing a portion of
 malic  or tartaric acid.
    It is a fact not easily explained,  that the sto-
 mach  is frequently outraged  by a wine to which
 it has  not been accustomed ;  and it is equally true
 that  a mixture of different wines  is a common
 source  of  indigestion.  The  custom of mixing
 wine with  water has its advantages as well as its
 evils.  By  dilution it frequently proves too  little
 stimulant to the stomach, and runs into  a  state
 of acescency.   An invalid  is also thus liable to
 deceive himself, by taking  more wine than  may
 be consistent with his  welfare.  Much, however,
 depends upon  the quality of the wine taken; the
 lighter wines cannot require  dilution, while  port
 is certainly rendered less injurious by the  admix-
 ture.
   Home-made or domestic  wines may be gene-
 rally considered as injurious to delicate stomachs ;
 they  are apt to ferment and produce  indigestion.
 Cider and perry are grateful  drinks  in  hot wea-
 ther ; but as they do not contain a sufficient quan-
 tity of  spirit to prevent their passing into the ace-
 tous  fermentation in the stomach of an invalid,
 they  should be avoided by those who have  any
 predisposition  to indigestion.
   Beer.—This is an article of beverage in almost
 every country.  The Chinese prepare it from  rice,
 and the Americans from maize.  Wre are also in-
 formed by  Herodotus, that, in very early history,
 the art  of making a fermented liquor from barley
 was  discovered by  the Egyptians.  As the cli-
 mate of England is not congenial  to  the growth
 of  the  vine, this species of liquor is perhaps more
 universal than in any other country ; and it  has
 therefore been  denominated vinum Britannicum.
 In  the higher walks of society, it has, indeed, of
 late years,  been  nearly  excluded: but whether
 this revolution has been attended with advantage,
 we shall presently have occasion to inquire. Malt
 liquors  differ from wines in several essential points:
 they contain a  much larger proportion of nutritive
 matter,  and a less proportion of spirit; while they
 contain a peculiar bitter and narcotic principle
 derived  from the hop.   It would appear that  the
 extractive matter furnished by the malt is  highly
 nutritive ; and  we accordingly find that persons
 addicted to  such  potations are in general  fat.
 Where, however, they are indulged in to any  ex-
 tent, without a corresponding  degree  of exercise,
 they induce a plethoric  state of the body, and  all
the diseases consequent upon such a condition.
In order to understand the process by which they
furnish  nourishment, we must once more refer 
668
DIETETICS.
the reader to the observations  which are offered
on the important subject of the digestion  of li-
quids ; from which it will appear that highly-con-
centrated extract will be left in the stomach after
the removal of its  watery part.   This extract  is,
for  reasons already stated, not  very digestible ;
and will therefore require the presence of less in-
spissated food to promote its chymification.   Ale,
therefore, when  taken without such precautions,
is liable to  disturb the digestive organs.   The ad-
dition of the hop increases the value of the liquor,
by the grateful stimulus which it imparts, and in
some measure redeems  it from  those vices with
which it might otherwise be  charged.   To those
therefore whose diet is not very nutritive, ale may
be considered not only  as  an innocent but  as a
salubrious  article;   and happy  is that country
whose labouring classes prefer such a beverage to
the mischievous potations of  ardent spirit.  These
remarks cannot, however, apply to  the classes  of
the  community who " fare  sumptuously  every
day."  They will not require a nutritive potation
of such a character;  and light wines have accord-
ingly, in these days of luxury, very properly su-
perseded its use : but we are not disposed  to ex-
tend this remark to its  more  humble companion,
" table beer."   We regard its dismissal from the
tables of the great as a  matter of regret; its slight
but invigorating bitter is much better adapted to
promote digestion than  its  more costly substitutes.
But it should be soft and  mild ; for  when  stale
and hard it is likely to disturb  the  bowels, and
occasion effects  the  very opposite  to those  it is
intended to produce.  Nor ought it to have too
great a proportion of hops, but should be thorough-
ly  fermented and  purified.   Sydenham always
took a glass  of  small beer at his  meals, and  he
considered  it as a preservative against gravel.
   The great division of malt liquors is into small
beer,  ale, and porter.
  The liquor called Ale was originally made  of
barley, malt, and yeast alone.  There existed for
a long time a strong prejudice against hops, which
were  considered as " pernicious weeds ;" but it is
now generally admitted that  they  constitute the
most  valuable ingredient in  malt liquors.   Inde-
pendently of the flavour and  tonic virtues which
they communicate, they precipitate, by means of
their  astringent  principle, the vegetable mucilage,
and thus remove from the  beer the active  princi-
ple of its fermentation  : without hops, therefore,
we must either drink  our malt  liquors  new and
ropy, or old and sour. There are several varieties
of ale, distinguishable by their colour :  when the
mall is slenderly dried,  the ale  is pale ,-  or brown
when the malt is more roasted or high dried.
  Porter.—This is  made  from  high-dried  malt,
and differs  from other malt liquors in the propor-
tions  of its ingredients, and by the  peculiar man-
ner in which it is manufactured.  Much  has been
said upon the fraudulent adulteration of  this arti-
cle ; but we are inclined to  believe that these state-
ments have been exaggerated.
  Ardent Spirits.—The art of extracting alco-
holic liquors by distillation from vinous liquors, must
be  regarded  as  the  greatest  curse ever inflicted
'ipon human  nature.   The fatal effects of  dram-
drinking have been vividly depicted by numerous
writers; and  the awful truth has been  too fre-
quently illustrated to render any remarks  in  this
place necessary.  In a medical  point of view,
however, spirit may  be considered as occasionally
useful.   Where it is taken in  a diluted state, the
mixture should  always be made twelve hours be-
fore  it is used.  Spirit  and water do  not easily
combine ; and much of the force of the former is
blunted by intimate  incorporation with the latter,
as we have  already observed under the  history
of wine.  We throw out this hint to  those who
are in the habit of drinking weak brandy and
water at their meals: although the propriety of
such a practice is questionable.  There are cases
of dyspepsia in which wine and beer equally dis-
agree with  the stomach, producing acidity and
other distressing  symptoms: very  weak spirit
may, perhaps, in such cases, be taken with  ad-
vantage ; but its strength should be uniform, and
no circumstances should induce the patient to in-
crease the proportion of the spirit.   The habit of
drinking liqueurs cannot be too much reprobated:
many of these cordials are impregnated with nar-
cotic  substances, which  add to  the noxious qua-
lities of the spirit.
  Of Condiments.—These may be defined sub-
stances  which are,  in themselves, incapable of
nourishing the  body, but which, in concert with
our food, heighten its flavour, promote its diges-
tion, dr correct some of its deleterious  properties,
The existence and  necessity of such agents  are
more general and important than is generally sup-
posed, and  a philosophical examination of their
modus  operandi would disclose views of great
and  novel  interest to the physician.  The bitter
principle which exists  in the  composition  of
grasses and  of other plants, appears to be essen-
tial to the digestive process of herbivorous animals,
for  when deprived  of it  they become diseased;
and yet we  are  assured, by repeated experiment,
that it passes through the alimentary canal without
undergoing the least change ; it can therefore only
act as a stimulant in transitu, and affords an excel-
lent example of a natural condiment.  We are our-
selves conscious of the invigorating  effects of slight
bitters upon our stomach, although  civilization
has,  to a great degree, destroyed our natural taste
for them, while, by improving our vegetable food,
it has probably rendered such  a stimulus unne-
cessary.  The Swiss peasant  cheers himself amid
the frigid solitude of his  glaciers with a spirit dis-
tilled from  gentian, the extreme bitterness  of
which is relished with a glee that is quite unintel-
ligible to those who  are not accustomed to it.
  From the  different nature of condiment, it  has
been  usually divided  into  three classes, viz.  the
saline, the spicy or aromatic, and the oily.
  Salt appears  to be a  necessary  and  universal
stimulus to animated beings;  and its effects upon
the vegetable as well as animal  kingdom have
furnished objects of the  most interesting inquiry
to the physiologist, the chemist, the physician, and
the agriculturist. It appears to be a natural stimu-
lant  to the digestive organs of all warm-blooded
animals, and they are instinctively led to immense
distances in pursuit  of it.   This is strikingly ex-
emplified in  the avidity with which animals in a
wild state seek the  salt-pans  of Africa and Ame-
rica, and in the difficulties they will encounter to
reach them : this  cannot arise from accident ei 
DIETETICS.
669
caprice,  but  from a  powerful  instinct,  which,
beyond control, compels them to seek at all risks
that which is  salubrious.   We are all sensible of
the  effect of salt on the human body ;  we know
how unpalatable  fresh meat and  most vegetables
are without it.  One of the ill effects produced by
an unsalted diet is the generation of worms.  In
Ireland, where from the  bad quality of the food
the  lower classes are greatly infested with worms,
a draught of salt and  water is a popular and effi-
cacious  anthelmintic.   Lord S0,nerville, in  his
Address to  the  Board  of Agriculture, gave  an
interesting account of  the  effects of a punishment
which formerly existed in Holland.  " The ancient
laws of the country ordained men to be  kept on
bread  alone, unmixed with salt, as the  severest
punishment that could be  inflicted upon  them in
their  moist  climate.   The  effect was  horrible ;
these wretched criminals  are  said  to  have been
devoured by worms engendered  in their own sto-
machs."  The wholesomeness and digestibility of
our bread are undoubtedly much promoted by  the
addition of the  salt  which it  so  universally  re-
ceives.*
  If the utility of salt be  thus established, it may
be asked how it can happen that salted provisions
should ever produce  those diseases which  expe-
rience has shown to arise  from their use.   In  ex-
plaining the operation of salting meat, and in  ap-
preciating the effects of such meat as food, it will
be  necessary  to  advert to a chemical fact, which
has not hitberto attracted  the attention which its
importance merits.  The salt thus combined with
the animal fibre ought no  longer to be  considered
as condiment; a chemical combination has  taken
place; and although  it is difficult  to explain  the
nature of the affinities which  have been  brought
into action, or  that of the compound  to which
they  have  given  origin, it is  sufficiently evident
that the texture of the fibre is so changed as to be
less nutritive as well as less digestible.   If we  are
called upon to produce any chemical evidence in
support of  such an assertion, we  need  only relate
the experiment of M. Eller, who found, that if
salt and water  be boiled  in a copper vessel,  the
solution will contain a notable  quantity of that
metal;  whereas if, instead of heating a simple
solution, the  salt be  previously mixed with beef,
bacon, or fish, the fluid resulting from it  will  not
contain an atom  of copper.   Does not this prove
that the process of  salting meat is  something
more  than the mere saturation of the animal fibre
with muriate of soda  ?
   Vinegar, in small quantities, is a grateful and
wholesome stimulant;  it will  often  check  the
chemical fermentation of certain substances in  the
stomach, and prevent  vegetable  matter in its raw
state from inducing flatulence; but its use requires
caution, and in some morbid states of the system
it is obviously  improper.  Fatty  and gelatinous
substances  frequently appear to be rendered more
digestible in the  stomach  by the addition  of vine-
gar, although it is difficult to offer either a chemi-
cal  or physiological explanation of the fact.  The
native vegetabfe  acids may also be occasionally

  * A  pound oTs^lTis generally added to each  bushel of
flour  Tnceit rnav be8 presumed, that every adult con-
sumes  two ounces of salt per week, or s.x pounds and a
half per annum, in bread only.
substituted : the addition of lemon-juice to  rich
and  glutinous soups renders them  less liable to
disagree  with the stomach; and the  custom of
eating apple-sauce  with pork  is,  undoubtedly,
indebted  for its origin  to the same cause.   We
shall take this opportunity to observe that vinegar,
if taken  in  considerable quantities, as is not un-
frequently the case with young persons, to prevent
the accumulation of fat, is highly injurious to the
digestive organs;  and, if the habit  be long  con-
tinued, produces fatal marasmus.
   The aromatic condiments comprise  the foreign
spices, as pepper, cayenne pepper, cinnamon, nut-
meg, cloves, ginger; and the  indigenous herbs
and  roots, such as  parsley, thyme, sage, garlic,
leek, onion,  horse-radish,  mustard,   &c.   The
former of these were not intended by nature for
the  inhabitants of  temperate  climes: they arn
heating and highly stimulant.   We are, however,
not anxious to give more weight to this objection
than it deserves.   Man  is  no longer the child of
nature, or the passive inhabitant of any particular
region :  he ranges over every  part of the globe,
and  elicits nourishment from the productions of
every climate.  It may be therefore necessary that
he  should accompany  the  ingestion  of foreign
aliment with foreign condiment.  If we go to the
East for tea, there is no reason why we should
not  go to the West for sugar.  The dyspeptic
invalid, however, should be cautious in their use;
they may afford temporary benefit at the expense
of permanent mischief.   It has been well said that
the  best quality  of spices  is  to  stimulate the
appetite, and  their worst to  destroy by insensible
degrees  the tone of the stomach.   The intrinsic
goodness of meats  should  always be suspected
when they require spicy seasoning to  compensate
for their natural want of sapidity.   But, mischiev-
ous  as the abuse of aromatic condiments may be,
it  is innocent in comparison with  the  custom of
swallowing a quantity  of brandy  or an increased
libation of wine to  counteract  the distress which
supervenes on a too copious  meal.
   Oil. — This, with  butter,  constitutes what are
called the  oleaginous condiments.   Melted butter
is, perhaps, the most injurious  of all  the inven-
tions of cookery:  oil,  when used  in extremely
small quantities, as  a seasoning to salads, appears
to prevent their running  into  fermentation, and
consequently obviates flatulency.
   II. On the periods best adapted fou meals,
     AND  ON  THE  INTERVALS WHICH SHOULD
     ELAPSE BETWEEN EACH.
   Having offered  a history of alimentary  sub-
stances,  and pointed out the  general characters by
which each species may be distinguished, we  shall,
in the next place, proceed to inquire into the vari-
ous  circumstances which may be capable of modi-
fying the effects of food upon the human body, so
as to promote, retard, or altogether to suspend the
digestion of it; and first, with  regard to the peri-
ods  best adapted for meals.   It is not extraordi-
nary that a discrepancy of  opinion should  exist
upon a question which  involves so man.v fluctuat-
ing  circumstances.   Controversy  upon  *his, as
upon many other subjects of diet, has engendered
a disbelief in its importance, and this scepticism
has given a plausible  pretext  for  indulgence on
the  one  hand, and protracted fasting on tie other. 
C7U
DIETETICS.
as the wishes or habits of mankind may have ren-
dered most agreeable.  We  have been told that
the best time for dining is, "far a rich man, when
he can get an appetite, and for a poor man, when
he can get food"  But appetite in health is regu-
lated by  habit,  and in disease it acts but  as an
imperfect monitor.  Certain  general  principles,
therefore, deduced from  observation and experi-
ence, must be  laid down for our guidance, and
these again in  their application must be modified
and adapted to  the circumstances of every particu-
lar case ; but before we enter  upon this part of our
subject, we must  offer  a few remarks upon the
phenomena of hunger and thirst.
   To account  for the well-known  sensation of
hunger,  various  hypotheses  have  been  framed,
which it is not our present purpose to examine.
The physiologists of the present day would ap-
pear to incline  to the  belief that it arises from the
stimulant action of  the  gastric juice upon the
nerves of  the  stomach;  and  to  support this
opinion,  Dr.  Wilson Philip relates the following
experiment.  A person in good health was pre-
vailed upon  to abstain from eating for more than
twenty-four hours, and during that interval to in-
crease the  appetite by more  than ordinary exer-
cise.  At the end of this time he was extremely
hungry ; but, instead  of  eating,  he excited vomit-
ing  by  drinking warm water and  irritating the
fauces.   The water returned mixed only with  a
ropy fluid,  such as the gastric juice is described to
be.  After this operation, not only all  desire  to
eat was removed, but a degree of disgust was ex-
cited by seeing  others eat.   He,  however, was
prevailed upon to  take  a little bread  and milk,
which in a very short time  ran into the acetous
fermentation, as indicated by flatulence and eruc-
tation.   Now,  if this  experiment proves anything,
it merely shows that disturbance of the  stomach,
or of the nervous arrangements which are subser-
vient to  it, will destroy appetite for food ; the ex-
istence of nausea, short of vomiting, will produce
the same effect, and yet in this latter case the gas-
tric juice is  not removed : so, again, if a narcotic
be applied  to the nerves, their power is paralyzed,
and the sensation of hunger ceases.   Such an
effect is  produced by the juice of tobacco, although
by long  habit the stomach may become indifferent
to its  operation.  Whenever the Indians of Asia
and America undertake  a long journey, and are
likely to be  destitute of provisions, they mix the
juice of tobacco with powdered shells  in the form
of small balls, which they retain in their mouths,
the gradual solution of which serves to counteract
the cravings of hunger.  Sir  Walter Scott tells us
that " General Monk, not being able to procure
any supper  at Coltstream,  was  fain  to have re-
course to chewing tobacco to appease his hunger."
In like manner we may explain the operation  of
spirit in taking away the appetite  of those who
are not accustomed to it; while those who indulge
the habit receive its stimulant without its narcotic
 impression.  Lord Byron entertained a great dread
 of becoming corpulent, and  on that account fre-
 quently  abstained from food for several days toge-
 ther, appeasing bis hunger by a wafer and a glass
 uf br.indy.
   Ahhough we do not  mean  to  deny  that the
 presence of a portion of gastric juice does not con-
tribute to tbe sensation of hunger, it is quite evi-
dent that the phenomenon is intimately connected
with an energetic  state of the  nerves, occasioned
by an  interval  of  inactivity, during  which, when
the organs  are in a healthy condition, the vital
powers may be supposed  to  accumulate.  We
might even  venture to question the agency of the
stomach so  far  as (o contend  that  the sensation
of hunger is seated in the ganglionic system ;  for
we know from  actual experiment that nausea  is
wholly independent  of  the stomach, since that
sensation, as well  as the spasm of retching, may
be produced by  the injection of tartar emetic into
the veins of an animal, from which the stomach
has been  previously removed.   Nausea, then, al-
though, like hunger, it be referred to the stomach,
is evidently independent of  it; and if nausea can
exist,  why  may not the  opposite  sensation of
hunger, even tbough the animal should have lost
its stomach by excision 1
   Natural appetite, which is only the first degree
of hunger,  never  appears  to recur  until  the ali-
ment previously introduced  has been duly assimi
lated.   It cannot, therefore, strictly speaking, be
said to have an immediate reference to the state of
the  stomach;  for although all the  chyme may
have  long before passed  out of that  organ, if any
delay  or  embarrassment  occur  in its  ulterior
changes, appetite  will not  return, since the ner-
vous  energy being  engaged in their completion
cannot accumulate in the  stomach; on the con-
trary,  in certain diseases, as in tabes mesenterica,
notwithstanding the presence of alimentary matter
in the stomach, the appetite is never pacified, the
subsequent  processes being imperfect. These views
are not introduced in this place for the purpose of
encouraging fruitless speculation, but in  order to
establish a proposition of the highest importance
in its  relations to  the theory of diet; viz. that the
several processes by which  food is converted into
blood cannot be simultaneously performed with-
out such an expenditure of vital energy as weak
persons are unable to sustain without mischief.
Thus, chylification  would  appear to require the
quiescence  of  the stomach, and  sanguification to
be still more incompatible with the  act of chymi-
fication.  If, therefore, the stomach be set to work
during the  latter stages of digestion,  the processes
will in weak persons be much disturbed,  if not
entirely suspended.   Certain circumstances cause
hunger to  return  at nearer  intervals by accelerat-
ing the nutritive process;  while others, by pro-
ducing an opposite tendency, lengthen such inter-
vals.
   It  is a well-known fact that if a  person be in-
terrupted in his meal for a quarter of an hour, he
finds  on resuming it that his appetite is gone, al-
though he  may not have eaten half the quantity
which he required ; this probably arises from the
food  having entered upon  those  ulterior changes
which are  incompatible with the energy  of the
stomach.
   The feeling of  thirst  announces  to tbe indivi-
dual the necessity of introducing a certain quantity
of liquid  into  the system,  in order  to repair the
waste which the body has  sustained in the exer-
cise of its functions, or  to impart  a  due degree of
solubility to the aliments which have been taken.
 We  accordingly find that  excessive perspiration 
DIETETICS.
671
increases the demand for it, and  tbat  dry food is
followed  by tbe same effect.  The sensation is
usually referred to  the  throat  and fauces,  but its
intensity does not bear any relation to the dryness
of those parts; for in  some cases,  where  the
tongue,  to  its very root, is covered with a thick
and dry  crust,  there is  little thirst; while, on the
other band, it is  frequently intolerable  at the very
time the mouth  is  surcharged with saliva.  We
are inclined to refer the  sensation  to the  cardiac
or splenic portion of the stomach.*  Dr. Gardner
has  remarked  that, in  the  case of a person who
had cut through the oesophagus, several buckets-
full of water were  swallowed  daily, and discharg-
ed  through the wound, without  quenching the
thirst, which was afterwards found to abate by the
injection of diluted spirits into the stomach.
   All physicians advocate the necessity of regu-
 larity, both  as regards the number of meals, and
 the periods at which they are taken.   Those who
 have weak stomachs will,  by such a  system, not
 only digest  more  food,  but will  be less  liable  to
 those affections which arise from its imperfect as-
 similation ;  because, as Dr.  Darwin  bas justly
 observed, they have in such a case both the stimu-
 lus of  the  aliment they take, and the  periodical
 habit to assist the process.  The periods  of hun-
 ger and thirst  are undoubtedly  catenated with
 certain  portions of time, or degrees of exhaustion,
 or other diurnal habits of life ; and if the pain of
 hunger be not removed by taking food  at the usual
 time, it is liable to cease until the  next period of
 time or other habits recur.   As these periods must
 vary according  to  circumstances in  each indivi-
 dual, it frequently becomes necessary in  civilized
 life to  have  recourse  to  intermediate meals,  or
 luncheons ; but to the dyspeptic  patient  such in-
 dulgences  are rarely to be permitted.   It is  the
 more necessary to impress this precept upon  the
 minds  of invalids, as  the  anxiety of friends and
 the popular errors which  exist upon the subject
 are too apt to  establish the  mischievous though
 specious aphorism  of  Sir William Temple, that
 " the stomach  of an invalid is like  a schoolboy,
 always  at mischief unless it be employed."  By
 such a  system  the natural  process  of  digestion
 must, if our preceding  views be correct, be con-
 stantly disturbed, and the healthy action of the
 stomach, as evinced  by the  return  of  moderate
 appetite, entirely prevented.    But though the ad-
 vantage of regular meals at stated periods is desi-
 rable, it has been  much disputed how many ought
 to be allowed in the day : some physicians have
 considered  one, others two,  three,  or even  five
 necessary.  It is, perhaps, impossible to lay down
 a general rule that shall apply to  every particular
 case.   In  some persons the  food rarely remains
 longer than three hours in the stomach ;  in others
 four, five, or even six hours.  It is evident, then,
 * Although the stomach is a single bag, it may be con-
sidered, with respect to its functions, as divisible into
two distinct cavities; and these portions are, during the
activity of the stomach, separated from each other by a
peculiar muscular contraction. Thesechambers evident-
ly appear to  perform different offices in the process of
digestion.  The  splenic portion would seem to separate
from the  food the  superabundant water, and then to
transmit the former to the pyloric division, where it un-
dersoesits first great change.  In the horse the: nitons
membranes of the two extremities of the stomach present
even a striking difference of structure.
that the repetition of the meals ought to be regu-
lated by this circumstance ; always avoiding the
extreme  of long fasting  and repletion.   Celsus
recommends the healthy to take food rather twice
than once in the  day, and  Sanctorius says, " that
the body becomes  more heavy  and  uneasy after
six pounds taken at once than after eight taken at
three meals," and  that  he who makes but  one
meal in the day, let him eat much or little, is pur-
suing a  system that must ultimately injure him.
When Plato returned that memorable answer to
the  philosophers who  inquired  whether he  had
seen  any  thing  remarkable in Trinacria, " vidi
monstrum in natura, hominem bis saturatum in
die,'" he referred rather  to  the  quantity  than to
the  repetition  of the meal of Dionysius.  In our
opinion, where the individual takes moderate ex-
ercise, three frugal meals  may be  allowed.   It is
reported that,  when Alexander  the Great turned
away his cooks on proceeding  upon a march, he
observed that he had no further occasion for such
assistants, as he carried with him superior cooks
—a long morning's journey to create an  appetite
for his dinner, and a frugal dinner to give a relish
to his supper.
   Breakfast is, perhaps, the most natural and
not the least  important of our meals :  for, since
many hours must have intervened since the pre-
ceding repast, the stomach ought to be in a con-
dition to  receive a fresh supply of aliment.   As
 all  the  food in  the body  has  during the  night
been digested, we might presume that a person in
 the morning ought to feel an appetite on rising ;
 this, however, is not always the fact : the energies
 of the  stomach, althougb  invigorated by repose,
 are not immediately called into action, especially
 in debilitated habits;  it  is  therefore  frequently
 advisable  to allow an interval  to pass before the
 meal.   A question of some interest has arisen as
 to the propriety of taking a solid or liquid break-
 fast. We seem to have greatly departed  from the
 custom  of our hardy ancestors in this respect.  A
 maid of honour in the court of Elizabeth break-
 fasted upon beef and drank ale after it; while the
 sportsman and even the day-labourer of  the pre-
 sent day  frequently  breakfasts  upon  tea.   The
 periods of their meals, however, were so generally
 different from those of modern times, that we can-
 not establish any useful comparison between them
 without taking  into consideration  the  collateral
 circumstances which must have influenced their
 operation.  It will not be difficult to show that
 liquids  at this meal are essentially  necessary. To
 say nothing of the instinctive  desire  we all feel
 for them, it is evident that there is a certain acri-
 mony and rankness in  all our  secretions at that
 time;  the breath has frequently a peculiar taint
 in the morning, which is  not  perceptible at sub-
 sequent periods of the day.  The fluids  of the
 body must have sustained a loss by perspiration,
 which  experiments  have shown to be double
 during  sleep,  a fact which in itself shows the pro-
 priety of a liquid breakfast.
    Dinner.—Among the Romans this was rathei
 considered as a  refreshment  to  prevent  faintne&s,
 than as a meal to convey much nourishment; but
 in modern  times we need scarcely say that it is
 regarded  as the principal meal,  at which every
 species of luxurious gratification is indulged  m. 
672
DIETE
TICS.
With regard to the proper period at which  inva-
lids  should dine, physicians  entertain but  one
opinion.   This period is the  middle of the day,
or at about two or three o'clock, in order to afford
a timely replenishment before the evening waning
of the vital powers, and which naturally precedes
the hour of rest.   The exact period, however, of
dinner must  in some  measure  be  directed with
reference to the  necessary habits of the patient,
the nature  and time of his breakfast,  and, above
all, to the rapidity or slowness of his digestion.
   Ouqht we to  take liquids at our dinner ?—
This question has been a fruitful source of con-
troversy ; but it  appears to us  to  be  very easily
settled.   By drinking before a meal, we place  the
stomach  in a very unfit condition for  the  duties
it has  to perforin.  By drinking during a meal,
we shall  assist digestion if  the solid matter be of
a nature  to require it, and  impede it if the quan-
tity taken renders the mass too  liquid.  It is evi-
dent that if the stomach be distended with fluid,
the digestion  of its solid contents must meet with
impediment; its bulk will stimulate the muscular
fibres to  contract too rapidly, and thus to expel
the food before it has undergone  the  necessary
changes ; while at the same  time, if the solid
matter be  diffused through a large quantity of
liquid, it cannot be so easily acted upon  by  the
gastric juice ; nor can it be readily converted into
that pultaceous  mass which appears to be a pre-
liminary  step to its digestion.  On the other band,
if the food be too hard or dry, its  necessary change
by the churning of the stomach cannot be accom-
plished.  It therefore  follows that different ali-
ments will  require different quantities of liquid to
assist their chymification.  Animal food will  de-
mand,  of course, a greater quantity than vegetable
food ; roasted  than boiled  meat, &c.  The best,
and perhaps the only test of the necessity of liquid
during dinner is to be found in  the sensations of
the individual,  which  ought  never to be  disre-
garded because  they appear in opposition to some
preconceived  theory.   If our food  possess that
degree of succulence which characterises digestible
aliment,  there will seldom  be any occasion  for
drink ; but, on the contrary, where the mass is
too dry, the stomach will give us  notice of it by
the creation of thirst.   But,  under any circum-
stances, the quantity taken should be small; it is
during the intervals of our solid  meals that the
liquid necessary for the repair of our fluids should
be taken  : and this brings us to  the consideration
of the next repast.
  Tea.—Theory and experience both conform in
demonstrating  the advantage which  attends a
liquid repast  a few hours after dinner.  At this
period  the  chyle has entered its proper vessels,
and is flowing into the blood, in  order to undergo
its final  changes.   Then it is that the stomach,
having disposed of its charge,  receives the whole-
some draught with the greatest  advantage ; then
it is that the blood, impregnated with new ma-
terials, requires  the assistance of  a diluent to com-
I'letp  their sanguification,  and  to  carry off the
superfluous matter; and it  is then  that the kid-
neys and the skin will require  the aid of addi-
nonal  water  to assist  the  performance  of their
i'mctions.
  Knpper.—In  the time  of  Elizabeth, the no-
bility and  gentry were accustomed  to  dine at
eleven, to sup between five and six, and to retire
to rest at ten.   It is therefore  evident  that  any
argument in favour of this  meal, founded upon
the  healthy  condition  of  our  ancestors,  cannot
avail.  By supper, in modern times, we mean  a
meal just before bed-time ;  but as sleep is  not
favourable  to  every stage of  digestion, it is very
questionable whether retiring to rest with  a  full
stomach  can,  under any circumstances, be salu-
tary.  During the first part of the process, or  that
of chymification, a person  so situated  may per-
haps sleep  quietly, unless, indeed, the  morbid  dis-
tension of  the stomach should impede respiration,
and  occasion distress; but when the food has pass-
ed out of the stomach, and the processes of chy-
lification and sanguification have been established,
the natural propensity of the  body is for activity,
and  the invalid awakes at this period, and remains
in a feverish state for some  hours.   Upon  this
general principle, then,  suppers, that is to say,
hearty suppers,  are  to  be avoided.  The same
objection cannot be urged  against a light repast,
which is often useful to dyspeptics;  and it  has
been truly  and facetiously observed, that some in-
valids need not put on their night-cap if they do
not first bribe  their stomachs to good behaviour.
   On the quantity of Food that ought to
he taken at different meals. — Nothing can
be more absurd than to establish a rule of weight
and  measure  upon such occasions.  Individuals
differ from  each other so widely in their capacities
for food, that to attempt  the construction of a
universal standard would be little less absurd than
the practice of the philosophical tailors of Laputa,
who, the reader will remember, wrought by mathe-
matical calculation,  and  entertained  a supreme
contempt for those humble and illiterate fashioners
who went  to work  by measuring the person of
their customer ;  but Gulliver  tells us  that  the
worst clothes he  ever wore were constructed on
abstract principles.   How then, it may be  asked,
shall we be able to  fix the proportion of food
which it may be proper for  an  invalid to take ?
By desiring the patient to attend carefully to  the
first  feeling of satiety.  There is a moment when
the relish given  by the  appetite  ceases ; a single
mouthful taken after  this oppresses a weak sto-
mach.  If  he eats slowly, and carefully attends to
this  feeling, he will never overload the stomach;
but,  that such indication may not deceive him, let
him  remember to eat slowly and  to masticate tho-
roughly.   This  is  an  important condition;  for
when we eat too fast, we introduce  a greater
quantity of food into  the  stomach  than the gas-
tric juice can  at once  combine with ;  the  conse-
quence of which will be, that appetite may con-
tinue after  the stomach has received more than it
can well digest.
  On the  conduct to he  pursued previous
and subsequent to Meals ; and on the re-
lations of Diet to  the Non-naturals.__We
do not intend to assert that Nature ever contem-
plated the necessity of confining men to a certain
routine of habits ; nor did she ever contemplate,
as far as we can learn, the existence of those  dis-
eases which may render such discipline necessary.
We  have in this place  only to  inquire into  the
habits which are most favourable or hostile to the 
DIF.TETICS.
 process of digestion, and then to form a code for
 the direction of those who may  stand in need  of
 such artificial assistance.   We have therefore to
 consider the influences of air, exercise, sleep, and
 the passions of the mind.
    Exercise in the  open air is essential to the well-
 being of every one; but its degree must be regu-
 lated  by circumstances.   The  interval between
 breakfast and dinner is  the period for active exer-
 tion, and the enjoyment of it, when not attended
 with severe fatigue, will strengthen and invigorate
 all the functions of the body ; but it is important
 to remark that the  valetudinarian and dyspeptic
 should never take his principal meal in a  state
 of fatigue.- and yet what habit is more general ?
 Every body is impressed with the belief that after
 the sedentary occupation of the morning, to take
 a long and  fatiguing walk will sharpen the  appe-
 tite and invigorate  the digestion : the consequence
 is obvious ; instead of curing, such  a practice is
 calculated to perpetuate and even to aggravate  a
 dyspeptic  malady  ; for the powers of digestion
 will be thus summoned at a period when the vital
 energy of the body is exhausted.   We are  anx-
 ious to be clearly understood upon this point: let
 it  not, therefore, be supposed that we decry the
 use of moderate  exercise before dinner; it is onlv
 the abuse of it we  are so anxious to prevent. No
 person should sit down to a full meal unless he
 has previously inhaled the open  air, and taken a
 quantity of exercise proportionate  to his power
 of sustaining it without fatigue.
    If exercise be necessary previous to a meal,
 there is also a certain period after it at which the
 accomplishment of the last stage of digestion will
 be accelerated by it.
    When the chyle enters the blood, the body be-
 comes enlivened; while  the  stomach  and small
 intestines, having been liberated from their  bur-
 then, oppose no obstacle to the free indulgence of
 that desire for activity which Nature has thus in-
 stinctively excited for our benefit. Then it is that
 animals are roused  from that  repose into which
 they had subsided during the earlier stages of di-
 gestion, and betake themselves to action; then  it
 is that civilized man feels an aptness for exertion,
 although he mistakes the nature  and object of the
 impulse, and is inclined to  regard it  as  nothing
 more than a  healthy sensation,  by which  he is
 summoned to that occupation to which inclination
 or  duty may prompt him.  Thus, instead of be-
 ing bodily active, the studious man receives it as
 a summons to mental exertion ; the indolent man,
 perhaps, merely to  sit up and enjoy himself; the
 libertine to commence his libations ;  and the vo-
 tary of fashion to attend the  crowded  circles of
 gaiety and dissipation.   In  short, this feeling of
 renovated energy  is used or abused in a thousand
 ways by different individuals, without  their  ever
 dreaming that  bodily exercise, and that alone, is
 implied by it.  The result of this mistake is, that
 imperfect assimilation and all its train of evils fol-
 low. In  this  respect  our  ancestors  enjoyed a
 great advantage from  their early hours;  they
 were enabled  by them to  take  exercise at  the
 most advantageous   periods  of  the  day;  even
 the ball-room, which in  our days  might be term-
ed Death's  ante-chamber, was not injurious ;—
with them the dance commenced  at  six and  ter-
 Vol.  I. _ 85                        3 a
673
  minated at eleven; with  us  it begins at eleven
  and ends at six !
    If exercise be useful during the period of san-
  guification, pure air is not less so ; and we may
  take this  opportunity of  protesting against the
  custom of frequenting crowded and ill-ventilated
  apartments at the very hour when the body requires
  the purest air for the sanguification of the aliment
  which has been recently taken into it.
    Sleeping after dinner is  a practice of very ques-
  tionable propriety : it is true that the inhabitants
  of many southern climates indulge in it with im-
  punity ; but it  does  not appear essential  in  this
  country, where  animal food is  used in such con-
  siderable quantities.  Its effect is to hurry  on the
  different stages of digestion;  and hence the fever
  and state of excitement in which the  person not
  unfrequently awakes.  In states of disease, it may
  occasionally be useful, and the recumbent posture
  may expedite the passage  of the aliment  out of
  the  stomach ; but we should recommend those
  who indulge in such a habit to remove all ligatures
  from the body.
    Passions of the mind, such as fear, anxiety, and
  rage, are well known  to affect the nervous system,
  and, through that medium, the stomach and func-
  tions of the digestive  organs ;  and so immediately
  are their consequences experienced, that a  person
 receiving unpleasant  intelligence at the hour of
  repast  is incapable of eating a morsel, whatever
 might have been the appetite before such commu-
 nication.
               " Read o'er this;
        And after this; and then to breakfast
        With what appetite you may."

   Iri directing our attention to the excretions, we
 must not overlook the sympathy subsisting  be-
 tween the  skin  and stomach.   If the cutaneous
 vessels  be universally excited, and  this excitation
 be long continued, they will at length fall  into a
 state of  indirect  debility, whence a sense of faint'
 ness, loss of appetite,  and the inability of digest-
 ing solid food will be  experienced.   This fact ex-
 plains the  diminished  appetite of which persons
 complain in hot weather, and that universal cus-
 tom  in  tropical  climates of combining the food
 with large quantities of aromatic stimulants. One
 of the most striking instances indicative of this
 consent  between  the  skin  and the  stomach is to
 be found in cases where cold or wet has been ap-
 plied to  the lower extremities.  The following is
 an extract from a letter received by the  writer of
 this article, from Dr. John Badeley, of Chelms-
 ford :—" A  gentleman who  consulted my father,
 complained that on getting out of bed in the morn-
 ing, and putting on his leather breeches, he con-
 stantly vomited, from  the sensation  of cold thus
 occasioned.   My father recommended him to take
 a glassful of cold water before he  commenced
 dressing, and it was found effectual.   The gentle-
 man  never  afterwards vomited upon these  occa
 sions."
   But it is  necessary to conclude this essay.  We
have  endeavoured, in the shortest possible com-
pass, to develope  the philosophy of the subject  of
dietetics, and, as far as our present knowledge ex-
tends, to point out the chemical and physical va
rieties of structure and composition which confei
upon  different articles  of nourishment their rel* 
674
DISEASE.
tive, nutritive,  and  digestible qualities.  In the
article  Regimen we shall endeavour to  apply this
knowledge to the treatment of individual diseases.
No general rule can be given for the guidance of
the physician in such cases.  Every such attempt
must  be a failure: it may foster quackery, and
perpetuate popular error, but it can never advance
the progress of that pure and simple science which
it is the object of these pages to inculcate.
                               J. A.  Paris.
  DILATATION OF BRONCHI.—See Bno.x-
CHITIS, Chuonic.
  [DILATATION OF  THE  HEART.—See
Heart, Dilatation of the.]
  DISEASE.   Disease  is disordered  action of
any part of the  machinery of the body, [or it is,
an  altered condition  of structure, or  function, or
 >oth, in some part of the organism.]   Its primary
effects, or perhaps we would say, its primary pal-
pable phenomena, are impeded or disordered func-
tions ;  and of these the  results  are alterations of
structure,  and various symptoms or signs indicative
of functional and of structural changes.
  There is a state of the different systems of which
the body is composed, in which  all the functions
of life are performed with comfort and ease, and  a
sense of well-being.  This is the state  of health.
Whenever any bodily or  mental function is  not
performed thus  harmoniously, there  is an  inter-
ruption of this  state, however  slight the departure
from the  condition of health  may be.  The first
symptom  of this slight disease,  for such it is, is
mere discomfort.  As the disorder proceeds, if it
does proceed, from  this slight beginning, the dis-
comfort is succeeded  by  pain and various other
circumstances, which are all consequently so many
symptoms of disease. Thus  the slightest  disor-
dered action may produce only inconvenience ; as
nausea, vertigo, pruritus :  and increased  disordered
action  will produce increased inconvenience ;  vo-
miting, loss  of sense, cutaneous  inflammation,
with the  additional  symptoms of pain.   On this
aggravated state changes of structure supervene.
It occasionally happens that  functional disorders,
because they in such cases affect parts of a low
degree  of sensibility,  proceed far, even to  struc-
tural alteration, with nothing more than  symptoms
 of  occasional discomfort;  but these instances are
not frequent.
   Compatible with the state  of health, also, are
considerable varieties  in  the  performance of cer-
tain functions.   They do not interrupt  health so
far as to produce even discomfort.  The pulse of
some individuals is never beyond 50, and of others
never below 110.   In some the  function of diges-
tion is more rapidly and  actively performed  than
in others  : and  the intellectual alacrity of different
persons is well  known to be widely different, yet
without disease.  But when  the food  is not di-
gested without discomfort or pain, or the circula-
tion not carried  on, or the mental movements not
made, without similar results; when  the appe-
tite is lost, when there  is fainting,  when there
is privation or other affection of any of the sensa-
tions or mental faculties ; then there  is  disease.
   The  least consideration shows us  that man is
f tposed to various circumstances capable of dis-
ordering his functions, and all these circumstances
are so  many causes of disease.   They are  found
in the elements by which he is surrounded; in
the food on  which he subsists; in excess or defect
of voluntary exercise ;  and  in  the nature  of his
mind,  sensations,  and affections, which  subjects
him to various kinds of risk by prompting various
actions and  enterprises, and which is susceptible
of impressions as well  as capable of originating
such actions.  Man is also  liable to connate and
inherited defects, and to diseases resulting  from the
natural decay of his bodily frame.
   The element  to which man is  chiefly and at
all times exposed, is the air.  Its variable tempe-
rature, dryness,  and moisture;  its alternations of
calmness and commotion ; and  probably, also, its
variable  electrical states; not only  immediately
affect the surface and  the respiratory organs, but
through the latter the blood, and through that fluid
the energy of all parts of the  system.  Some of
the variations seem to have  a direct  influence on
the nervous system ;  and there are  presumable
properties in the air, yet unknown save  in their
destructive effects, which are largely concerned in
the production of our common  continued fevers,
the yellow fever, the  plague, the intermittents of
fenny  countries, cholera, and what is called in-
fluenza.   No doubt can be entertained of the
agency of such atmospherical influences in  the
production of the common eruptive disorders; and
of one at least  of ftie disorders characterised by
irritation  of a particular portion of  the  nervous
system (the respiratory), and by spasm,—circum-
stances exemplified by the hooping-cough.   The
direct  influence  of the air on the nervous system
is not  easily proved; but to this, or to  some  effect
produced  on  the fluids  or solids of the body, to-
gether or separately,  must be  ascribed the  varia-
tions of feeling and spirits experienced by so  many
individuals  in variable  states of the weather, and
the suicidal despondency which medical travellers
have  found to be induced  by  the  sirocco.   (Br.
J. Johnson.)  The condition of certain structures
of the body, and perhaps of their  nerves, is seen
in the course of the  seasons to  be materially af-
fected by certain• states of the  atmosphere: the
effects being sometimes, apparently, merely the
result of temperature, as in the  catarrhs,  and dis-
orders of the respiratory and circulating appara-
tus in the cold weather of severe winters ;  but at
other times more obscure, as in the irritability of
the mucous membrane of the stomach and intes-
tines  in  the summer and autumn, of which the
consequences are  periodical  dyspepsia, gastric
fevers, diarrhcea, dysentery, and cholera.  Of dis-
eases thus obscurely arising, some, peculiar to par-
ticular localities, are  called  endemic;  others, ap-
pearing  and  disappearing  at  particular  seasons
with  some  regularity,  are called  epidemic, and
many  of the latter become under certain  circum-
stances communicable from one  individual  to an-
other.
   Several of the occupations of man in  civilised
countries are carried on  in  confined and  ill-venti-
lated  places, where the mere assemblage of many
persons  deteriorates  the  quality of  the  air: the
effect of breathing this is very injurious to health,
and a very  common cause of disease.   The influ-
ence of a high temperature, combined with  exces-
sive moisture, has been abundantly experienced ir 
DISEASE.
675
 the diseases incidental to tropical climates.  There
 are also occupations in the course of which light
 particles of foreign matter  are  mingled with the
 air and inspired ; as needle-pointing, grinding of
 corn, and mason's work ; and these particles cause
 irritation and disease.
   In the  quality and  in the quantity of food are
 found also the causes of disease.  Some kinds of
 food produce disorder by their stimulating proper-
 tics, and some  by otherwise inducing departures
 from healthy processes, as  in the example of cal-
 culous formations in the kidneys.  Man is equally
 disordered by excess and defect  of nutrition.
   Excess or defect of voluntary exercise and rest
 affects him no less.  It is the rule of nature that
 voluntary  muscular action  cannot be neglected
 with impunity ; and its excess produces direct ex-
 haustion.
   Many  familiar facts,  not uninteresting  to the
 medical  observer, illustrate  the effects of certain
 species and measures  of diet, and peculiar kinds
 and degrees of  exercise, upon  the human body.
 The  corpulence and  fatness of  coachmen  and
 farmers, and the thinness of students and of foot-
 soldiers, may  afford him instruction.    But the
 effects of what is termed  training, both in increas-
 ing and  decreasing the  bulk and  strength  of the
 body, and the vigour of the mind, are more espe-
 cially deserving of attention.  By  the administra-
 tion of dry and  very nutritious food ; by a certain
 degree of exercise in the open air; by allowing a
 moderate portion of sleep ; and  by avoiding every
 kind of excess; assisted, however, it  should  be
 said, by great attention to the state of the surface,
 and by a  little preparatory  purgative  medicine;
 the athletae of old, and  the prize-fighters of modern
 times, have been accustomed to  attain such a cor-
 poreal condition in the  course of  six or eight weeks
 as to  endure great fatigue, to breathe  freely and
 fully under extreme exertion, to bear violent blows
 on the head without  giddiness,  and to incur se-
 vere  wounds without  danger or long inconveni-
 ence.  The appetite, after such  a system  of train-
 ing, becomes great;  the skin becomes of a better
 colour; and the shape of. the body improves.  A
 man thus disciplined can not only run  twenty or
 thirty miles with ease, or walk a bundred, but can
 face dangers which would  before have appalled
 him ; and wrestle or contend advantageously with
 an assailant by whose strength he would  previ-
 ously  have been overpowered.   It is said, too,
 that the perceptions become more  acute, and the
 mental faculties more active;  but such conse-
 quences are of course not always observed among
 those who are commonly the subjects of training,
 although in their gaming devices they not  unfre-
 quently show great acuteness and power of calcu-
 lation.  These  effects  of training  are commonly
 very transient, and repeated or excessive  training
 seems  to  shorten human life.   It  is a question,
 however, how far this  supposed  hurtful effect of
 training is to be  ascribed to the intemperate habits
 of the persons  usually submitting  to  training.
 Race-horses and game-cocks, which are also sub-
 jected to particular training, are not  found to be
 shorter-lived than other animals  of the same spe-
 cies.
  By methods entirely opposite, the reduction of
strength and of bulk  may  be effected  in a very
short  space  of  time.   The  boys employed  as
jockeys  at Doncaster and Newmarket are some-
times reduced twelve or sixteen pounds in weight
in the course of ten days, in order to ride a par
ticular race.  They are  not allowed during this
preparation to have meat, or wine, or ale; but live
on fish, and puddings, and bread and butter: they
have tea at night,  but  nothing  to  eat with  it.
With this slender diet is conjoined strong exercise
in thick and heavy clothing.  After the race is
run, the jockey is allowed to indulge himself; and
it is said that as much as nine pounds  in weight
have been regained in eighteen hours. The effects
of this reduction  of weight and strength  on the
brain, as exemplified in the  intellectual manifesta-
tions, have  not been noticed ; but it is said  that
the  constitution  is often ruined  by these vicissi-
tudes.  Many  jockeys  may  be  observed  to  be
stunted in growth, and to have, even in the prime
of life, the dry and  withered  appearance of pre-
mature old age.
   It is worthy to be remarked,  that not only  do
excess in diet and extreme abstinence, too much
rest  and excessive fatigue,  extremes  of heat and
extremes of cold, disorder the body; but that they
all seem, when carried to the utmost,  to affect the
body in  the  same, or  nearly the same manner.
All  (perhaps by impairing the functions  of the
nervous  and  vascular systems) eventually induce
those  disturbed actions  which constitute  febrile
disorder.  In fact, what  is called re-action, under
most circumstances,  consists of the establishment
of actions tending to febrile or inflammatory pro-
cesses ; and  probably the converse, namely, that
inflammations and fevers are  commonly intended
to rid the body of some  inconvenience, is not far
from the truth.
   The great gift of the mind, also, by which man
is so greatly  raised above the  lower animals—by
which he inquires, improves, records his improve-
ments, and looks beyond this life—is a gift  that
his  imperfect  nature  cannot  bear  without the
tribute of occasional inconveniences, from which
the less privileged animals  are exempt.   Its inor-
dinate exertion, and the vehement impressions of
which it is  susceptible, exhaust  the  nervous
energy, or impair the nervous actions, or alter the
actual  condition of the nerve  ; and thus deprive
the physical part of the system  of some of its
power, increase its susceptibility, disturb the pro-
cesses which should  be performed in the different
bodily  organs, and bring on disease, or gradually
enfeeble the whole system.   From such causes we
perceive,  in  different  cases,  various  irregular
actions, chiefly exemplified in the muscles,—agi-
tation, tremor, faltering voice, unsteady gait, spasm,
hysteria,  epilepsy ;—or exemplifications of dimin-
ished power,  as in the various  shades of paralysis.
   By sloth and negligence, or by irregularity and
prodigality  of application, the powers of the mind
itself are equally impaired in some cases, and in
others .disturbed.   Sudden  and excessive joy ex-
hausts the mental and nervous  power at once; and
sudden and overwhelming sorrow oppresses both
beyond recovery, producing a state which is some-
times followed  by that deep sleep which restores
the capacity of endurance, and sometimes by that
sleep which ends all  worldly suffering. '
  The influence of sudden mental impressions os 
676
DISE
ASE.
the circulation, in whatever way this is exerted, is
evident enough  in  numerous  instances.  Their
power in the production of that unequal distribu-
tion of blood called determination is conspicuously
seen in the simple act of blushing.  Violent anger,
or a sense of shame, causes the smaller vessels of
the face and neck to be instantaneously injected
with blood.   By  similar, but more violent effects,
anger  has  led  to apoplexy; and this passion is
seen to render  the face red  in  some  individuals
and  pale  in others.  Fear  commonly  produces
paleness, and  extreme  fear  may induce  death.
The functions of the lungs may  be affected, or at
least the respiratory exertions  are  quickened, by
surprise or other  emotion ;  and simultaneous pal-
pitations show that the heart  responds to  the same
influences;  or  its sympathy may  produce  some
suspension of its actions, and syncope  ensue : the
faltering speech and the trembling limbs on some
occasions, and  the  increased speed  and  strength
exhibited  on others, equally  show how much the
muscular energy  may be influenced by temporary
states  of  the mind.   The gushing of  tears in
states of sorrow ; the diarrhoea and copious  renal
secretion under the .action of fear or vexation;  the
sudden appearance  of  gout and  of cutaneous
eruptions  in circumstances  productive  of  great
mental disturbance; the profuse perspirations, and
the altered  colour of the hair sometimes induced ;
are all illustrations of the  operation of the same
class of causes.
   Long-continued depression of mind,  or long
anxiety,  produces effects which are deeper  and
less immediately  visible.  The nervous  and  the
vascular system seem equally to suffer; and habi-
tual disorder of some of the  functions, going on
to the structural alteration  of some organ, is  the
consequence. Chronic determination to the vessels
of the stomach  or lungs ; or to the liver,  or intes-
tines ;  or to the heart,  or to  the  brain itself,  are
common results.  Obstinate dyspepsia, attacks of
asthma, permanent mischief to the hepatic and
intestinal  functions, or  some variety  of mental
disorder, are among the modes in which  such
results are manifested:  as  is also a slow increase
in tho size,  or change  in some part of the struc-
ture, of the  heart itself;  curiously according with
that strong  and  melancholy  expression,  that  the
person thus destroyed has  "died  of a broken
heart."
   On the other hand, need any  one be informed
of the  happy effects of a tranquil state of mind,
or of the  improved  health which is brought by
complete relief from heavy  anxiety ? The amend-
ed appetite,  the better sleep, the improved  com-
plexion, the increased nutrition, which follow in
the train of  cheerfulness, must be familiar to  the
most superficial observation.
   The diseases produced by a disordered imagina-
tion require oniy  to be  mentioned.
   There is a principle  in the human body which
enables it,  when not  previously disordered, to
support and resist the influences of  all  the agents
of disease up to a certain point. By this principle,
which  has been called the conservative principle,
it  is enabled to  endure great  and  even sudden
changes of temperature, and is secured for a time
against noxious  atmospheric  influences.  Great
variety of food can  not only be borne  without
inconvenience, but appears  to  be salutary;  anj
occasional imprudences,  as  regards both excess
and fasting, will, in a state of perfect health, pro-
duce no permanent uneasiness.   So also exercise
may be taken, even to the production of extreme
fatigue, or we may devote ourselves  to long-con-
tinued sedentary study, and  yet remain well for a
time ; and  it is familiarly seen  that neglect of
proper rest often  passes  unpunished.   It is the
same with respect to the mind.   When we are in
perfect  health, the various trials  met with in the
world ; the joys, the sorrows, the anxieties, which
by turns  affect us, are met with steadiness  and
fortitude, and pass away without disturbing the
equanimity of that part of the  system on which
they make their transient impression.  Leisure or
complete idleness may also  be interchanged with
severe or varied mental application, and the health
of the mind still be maintained.
   But when,  by the prolonged  or inordinate im-
pression of some of  the causes of disease already
enumerated, or by other  causes of disease which
remain  to be mentioned, the  vital power is impair-
ed in any one organ ; when,  for  instance, the
gastric, pulmonary, or cutaneous functions, or the
faculties of the mind, begin to show a little inter-
ruption of vigour and regularity, even the ordinary
objects with which the especial function is habi-
tually concerned become  exciting causes of dis-
ease.  Not only extremes and  sudden  varieties,
but the common air,  the  ordinary kind and mea
sure  of food  and  drink,  the customary  exercise,
and the daily excitements  and  depressions of
social life, become so many sources  of irritation :
all those things which have occasionally been de-
fined the sources of vital motion, — all  external
stimuli, all ideas of the mind, and volition,—then
become causes of actual disease.
   Besides the causes of disease to which man is
by his position constantly exposed, there are others
incidental to his frame itself.  A  heart naturally
feeble, or disproportionately small, is inconsistent
with health.  In every part of the globe,  although
more in some parts than in  others,  the species is
subject to occasional deformities, some of which,
as a contracted cranium or thorax, interfere with
the most important  functions, and  impede their
just performance.  Very serious diseases arise also,
in the course  of life,  from disordered actions, of
which the causes are  often entirely  unknown;
such are those departures  from healthy deposition
denominated cancer, tubercle, fungus haematodes;
as well  as the production of parasitic animals in
certain structures.
   It is also very often seen that one disease will
produce  a second, not unfrequently more severe
and dangerous.  In this way some of the morbid
formations just spoken of are occasionally induced;
as that of pulmonary tubercle after a severe attack
of catarrh, or after hooping-cough, or fever, or the
measles.   There is so close a connection between
the different functions of the body,  and  between
these and the  mind,  that  no  function can be long
or very severely disordered without  involving the
disorder of another.  This is particularly observa-
ble in affections of the respiratory and circulating
systems,  but is  existent,  in  a greater or less de-
gree, with  respect to all  the rest.   As fever is  a
disease which most deeply affects all  the functions 
DISEASE,
67'
of the body,  it more than any other leaves a dis-
position to various forms of disease ;  sometimes
to disease in the organs of locomotion, sometimes
to disease of the lungs, and very often  to diseases
dependent on serious impairment of the nervous
system, as paralysis or  fatuity.  The most numer-
ous instances, however,  of disease  following dis-
ease, are furnished by irritations, various in kind
and in degree, of the intestinal mucous membrane ;
which  are  so largely concerned in fevers as by
some  pathologists to be considered as their sole
cause, and  which doubtless  induce every variety
of irritation in the vascular apparatus of different
tissues, from simple determination  to common or
to specific  inflammation ; aggravating also, and
often alone producing,  all the varieties  of nervous
and spasmodic affections ; and being most widely
concerned in the establishment of local disorders
of every description, from a simple papular erup-
tion to erysipelas, or to  ulceration  and deep de-
struction of  parts.  The sympathies subsisting
between the  liver and  the brain,  and, more re-
markably, between the uterus and the  whole ner-
vous system, produce phenomena from which the
list of illustrations might be greatly swelled.
   Some diseases, chiefly such as exclusively affect
glands,  will  in  succession attack  various parts.
When tubercles exist in the lungs, they often also
exist in several  other situations, as in  the mesen-
teric glands, in the glands of the intestines, in the
uterus, in  the liver, in  the kidneys, even in  the
heart.  The  term malignant  has  been, although
with no very settled meaning, applied  to such af-
fections, and most frequently to cancer and fungus
hsmatodes, which, when once existing  in any
part, are imagined by some pathologists to spread
to other parts, and especially  to other  glands, by
absorption.   It is at least certain  that such dis-
eases  seem to  extend  themselves  in  succession
from the structure  first attacked.   The cause is
not so clear as the fact is certain. It may be, that
a general predisposition existing to a specific form
of disease, the  absorption, which unquestionably
takes  place, of diseased  matter, acts only by ap-
plying an irritant or exciting  cause  to other parts,
as sufficient as other irritants,  but not  more suffi-
cient  than they, to disorder  the glands through
which it passes;  and which glands,  when irritated
and disordered, run into the disease  to which they
are by original constitution predisposed.   Or  the
disease may be  simultaneous  in many parts, al-
though  unequally  advanced.   With  respect  to
tubercles, however, when they exist in  other parts
of the  body than the lungs,  it may, we believe,
be always predicated that they will  also be found
in the lungs themselves, and in a more advanced
state.
  It is not to  be forgotten,  moreover,  that  the
means employed to cure diseases are not always
guiltless of producing others.   Nearly  every kind
of medicine induces a  temporary state which is
really a  state of disease, of whicb the intention
and effect  is to relieve diseases more serious or
less controllable.   The excessive employment,
therefore,  of any kind  of medicine may induce
peimanent  or  at least  serious disease.   Thus
drastic purgatives  will  bring on  hemorrhoids;
mercury will hasten the progress of phthisis ; al-
kalies will irritate  the digestive mucous mem-
                                     3o»
brane;  and  all the  narcotics will obtund  the
sensations and cloud the intellect.   There  is the
strongest  reason  to  believe that  many nervous
affections are exasperated I y the habitual employ-
ment of mercurial purgatives; iodine  has  some-
times caused more obvious nervous irritations;
the nitrate of silver produces a permanent disease
of the skin, limited, however, to  an affection of
its colour.
   Old  age,  naturally impairing  the  vigour of
every function,  necessarily exposes every function
to disorder from common causes.  In  the  best
constructed body, the failure of the human frame
must begin somewhere. Even in those rare cases
in which extreme old age seems to be borne with-
out disease, there is  commonly particular impair-
ment of some  function or other for  some time
before all the functions cease.  Long before death,
the diminution of muscular power generally be-
comes evident.   A marked failure in the powers
of the stomach is still more  common.  The in-
conveniences of this time  of  life  have, however,
been eloquently enumerated in the article Age.
   The  terms applied to all these different causes
of disease, and  the arrangement of them, have oc-
casioned much very useless dispute.   It is time
that such scholastic  trifling should be abandoned.
What was defined, we believe  first by Gaubius, as
the proximate  cause, which  when  present con-
stituted the disease, when taken away removed it,
and,  when changed,  changed it,  either means
nothing, or means  the first of the effects  of the
cause of disease.
   Two things  are plainly necessary for the  pro-
duction of disease ;  a cause which acts  on some
organ, and a disposition in the organ  to be acted
upon.   Two kinds of causes, then, and two only,
are plainly concerned in  the  production of  dis-
ease ; a cause  which predisposes, and  a cause
which excites.   This may be illustrated by the
single instance of typhous fever.  One man  is
affected with typhous fever, and his  neighbours
escape.   The exciting cause of the fever is  sup-
posed to be  something peculiar in the air.   But
his neighbours have  been  exposed  to the same
peculiarity, and are not affected with fever.   We
explain this  by saying that his  health  was  not
previously good ; that he  was not  in a state to
resist the influence of the cause.  This presumed
disorder of his health was in  this instance, then,
the cause which predisposed him to the influence
of the exciting cause of the  fever.  In the same
way we  see, of half a dozen  persons  simultane-
ously exposed to cold and moisture, one  becomes
affected with sore throat, one  with pleurisy,  and
one with rheumatism ; and the rest may continue
well.   The exciting cause was present to all, but
a  predisposing  cause existed  only in  some,  and
was different in  each of those in whom  it did
exist.
   If we retain the term proximate cause, it  sig-
nifies, in these cases, the pathological condition
of the throat, the pleura, or the  joints ; but we
think the term may be advantageously  banisheu
from medicine.
   The chances and  the characters of  disease are
always  in  proportion to the force of the exciting
cause, and to the degree  of the susceptibility to
its operation.   Of several persons suffering from 
678                                    DISEASE.
what is called determination of blood to the head,
one may have vertigo, another pain ;  one  may
have a fit of epilepsy, and  one  die apoplectic.
The difference in the effect may be occasioned by
a difference in the power of the exciting cause, or
in the violence of the determination ; or, the de-
termination being equally violent  in  all, the dif-
ferent effect  may depend on the peculiar suscep-
tibility of each.
  There are certain cases in which disease appears
to be  produced  simply by the application of an
exciting  cause, without the existence of a cause
predisposing.  There are others in which an ex-
citing  cause  often seems to  be wanting.  These
inconsistent phenomena, however, are to  be as-
cribed to our imperfect knowledge of some of the
causes.  A violent  burn, a wound, or other  acci-
dent, will produce inflammation of various tissues,
with no other predisposing cause than the nature
of the  human constitution.  A child, in a particu-
lar condition of atmosphere, will become affected
with hooping-cough  or measles ; and the predispo-
sition is here also inherent in the constitution of
the body.  When the predisposition is removed,
as in  ordinary cases it  is, by the  occurrence of
these disorders, the child  may be  exposed to the
exciting  cause, the peculiar condition of the air,
with  complete impunity.  The cases  in  which
disease seems to  arise without an exciting cause,
are  chiefly those  of  morbid formations, in which
such cause exists in  the  supervention of  certain
actions not yet understood.
  Forms of Disease.—Diseases, however various
or complicated, or whatever are their terminations,
admit of  a division into two great primary classes;
the first comprehending all disorders of function;
the second all morbid products.
  Disorders of Function.—The view taken of
this  class by the general pathologist is one which
is continually enlarging with the progressive im-
provement of physiology.  Its leading features
may be spoken of in  connection with the two most
important symptoms of the body, the vascular and
the  nervous. Nearly every disordered action which
can be conceived  to exist, must be intimately con-
nected with some irregularity in  one or both of
these systems.
  1. In  the vascular system we observe, a.  local
determinations  or local accumulations of blood,
productive of an excess of supply, with excitement
of the  part supplied in excess; or congestion, with
oppression of the part congested,   b. Local defec-
tive  supply of blood, producing or contributing
to  produce, defective  secretions, defective energy,
external  discoloration, and  a tendency  to  otber
disordered  actions.   Of these may he mentioned
as  examples, defective  supply to the breasts or
uterus lr. feeble women ; to  the  hair in  old or
sickly  persons; to the brain  and other organs in
those convalescent from fever; and to the feet in
diseased or aged persons, with a tendency to  mor-
tification,  c. General excess of blood, or plethora ;
the results of which are very various : e.g. increase
of natural  secretions, exhalations,  and the vigour
of different functions ; irregular actions ; excessive
growths ; and, perhaps, other  morbid formations.
d. General defect of  blood, or anremia.  e.  The
mate of the olood-vessels in inflammation, whether
romnion  or specific, as in croup, &c.  f. The  state
or actions of the blood-vessels in misplaced  and
new formations,  including  altered conditions of
the blood contained in them.
   2. In  the nervous system  we equally observe
excess,  defect, and  irregularity of  distribution,
a. Local excess of nervous power; a state often
accompanied with excessive sanguineous supply,
but not  invariably.   To this  excess  of nervoua
power we cannot but attribute some of the in-
stances of increased sensations and increased mus-
cular actions in maniacal and hysterical persons.
In the cases of increased secretions, increased ab-
sorption, increased nutrition, and increased evacu-
ations ; comprising  the  unusual flow of tears, or
bile, or urine ; the sudden disappearance of dropsi-
cal accumulations ; hypertrophy of organs ; diar-
rhoea, and excessive  perspiration ; a mixed expla-
nation must be admitted :  and in most of these
circumstances, or perhaps in all except that  of in-
creased absorption, there appears to be a simulta-
neous  excitement of the nerves  and the blood-
vessels,  b. So, also, the general excess of nervous
power, or general nervous excitement, is  not often
seen distinct from excitement of the vascular sys-
tem.  Either, first existing, seems  to  induce  the
other.   The  nervous excitement may,  however,
exist first, and therefore separately,   c. The gene-
ral defect of nervous power is shown in the weary
and  exhausted, and in  some  forms  of  incipient
paralysis. It is observed in  many other instances,
but generally co-existing with defective power of
the vascular system,  d. Local defect of nervous
power is seen in persons  affected with  tremors,
chorea, and  partial paralysis ; in  idiots and  luna-
tics, whose intellectual actions are weak,  impeded,
or disordered, whilst their  digestive powers  are
often unimpaired  or even increased.   It is observ-
able also in  the sick, the feeble, and the aged, and
is one of the most ordinary precursors  of death.
The instances of deficient secretions, deficient  nu-
trition, and deficient evacuations, are, as the reader
will suppose after what has already been said, to
be viewed generally as the  consequences of a
simultaneous defect  in  the  nervous and vascular
actions.  If it be admitted  that the  action of  the
absorbents  depends  on the  nerves, deficient  ab-
sorption would in  some instances appear to depend
on defective nervous supply to the absorbent ves-
sels.  It is highly probable that some of the dis-
orders of the  function  of respiration  depend on
deficient actions  in  the  respiratory  nerves.  In
some of the instances  of chorea, as in  tetanus,
and in  hydrophobic convulsions, the disorder of
the nervous  system probably consists of excess, or
of irregularity, rather than of defect,   e. There is,
apparently, a morbid condition of  the nerves in
all inflammations, and  evidently in some,  as in
gout.   f. There  are  probably disordered  nervous
actions, in no degree yet understood, concerned in
misplaced and in new formations, including altered
states of the blood itself.
  One very  important example of general  disor-
dered action has been left out of this enumeration,
namely, fever.  Its place must depend on the yet
undecided question  of its  actual  nature.  The
vascular and the nervous depression, and  the sub-
sequent excitement of both the blood-vessels  and
nerves, are sufficiently evident.   But not only ia
the order of these phenomena yet undetermined, 
DISEASE.
  but their relation to a primary impairment of the
  vitality of the blood at least not disproved   For
  this reason we pass on to the second great  class
  of diseases, or morbid products.
    Morbid Products—These may exist in the
  solid or in Ine fluid components of the body.  They
  probably seldom arise from disorder of one of the
  great systems without coexisting disorder of the
  other.  In their characters they vary exceedingly,
  as will be made apparent by  the following, which
  is still an imperfect enumeration of them.
    a. The effects of simple determination of blood,
  or local  excess, which seems  to  be not only in
  many cases an increase of natural discharges, but
  alterations in  their properties.  These have not
  been very closely investigated.  The sudden, pro-
  fuse, and watery discharge from the mucous mem-
  brane of  the nostrils incidental  to  some indivi-
  duals from slight causes, and distinct from common
  coryza, affords an example of this class;  and sud-
  den evacuations from the skin, or bowels, may  be
  also mentioned.  The redundant  growth, or hy-
  pertrophy of organs, demands,  for one of its ac-
  companiments, or rather one  of its  causes, this
  increased determination of sanguineous material ;
  but such departures from  the natural state should
  perhaps be classed in another division (c). Active
  hemorrhages are another consequence of increased
  determination to particular parts.
    b. The effects of inflammation ;—serum, lymph,
  false membranes on serous surfaces, pus, thicken-
  ings of parts by intestinal depositions, gouty  con-
  cretions,  the diphtheritic  formations  on mucous
  membranes, as in croup, and in inflammation of
  the mucous lining of the  intestines or the vagina ;
  and the peculiar matter found  in scrofulous glands.
    c.  Natural  secretions or formations misplaced;
  —bone in soft parts, as in the  membranes of the
  brain, in the heart, in the blood-vessels; fat about
  the heart, or in the substance of the liver;  mis-
  placed fibrous tissue, cartilage, cellular tissue, hair,
  nails,  serous tissue  (in certain  tumous, Bichat,)
  mucous tissue  (in  fistula, Hunter,) enamel (in
  some diseases of the joints),  synovial membrane
  (in false articulations), arteries,  veins, and nerves
  (in some tumours).  These misplaced productions
  are often, imperfect.  They do not necessarily en-
  danger life, although they are often inconvenient,
  and sometimes  dangerous,  in consequence of their
  situation or the  size to which  they attain.  In
  certain cases they are formed  for the preservation
 of life; as in the case of the fibrous masses formed
 in aneurism, and of the  cysts  or boundaries of
 abscesses.
   d. Altered secretions,- — soft  or  fragile bone;
 acnd bile;  the disorders of the urine accompany-
 ing calculous formations.
   e. New formations, not  the product of inflam-
 mation.  In this  class may be placed the various
 tumours—common, adipose, pancreatic, mammary,
 and tuberculated sarcoma ; and  encysted and  os-
 seous  tumours ;  all of  which  are of a local char-
 acter,  and  many  of which coexist in  some  in-
 stances, as in certain enlargements  of the ovaria.
 To these must be added the  more serious forma-
 tions connected with some taint or fault in  the
constitution ; as scirrhus, tubercles, scrofulous en-
largements, encephaloid tumours or fungus haema-
'odes. and melanosis.  Hydatids, worms, diseased
679
  exhalations, (as ascites, in disorder of the liver,*)
  and changes in the nature of the blood itself, be-
  long also to this class;  and also the calcareous
  productions found  in  the  lungs and  bronchial
  glands.   Many of the products under  this head
  are dangerous to life.   Reacting on the imperfect
  constitution in which  they  have originated, they
  occasion  fever, various functional  irregularities,
  emaciation, and  death.   They  are frequently ac-
  companied by inflammation, the supervention of
  which appears to accelerate their progress;  but in
  their origin, in their first symptoms, and in the
  wide difference existing  between  them  and the
  ordinary  products of any of the forms of inflam-
  mation which are  the results of accidents, or can
  be excited  by artificial means,  we have so many
  reasons for ascribing them to processes quite dis-
  tinct from the inflammatory  process.
    Theories of Disease. —These  observations
  bring us  immediately to the  great question of the
  origin of these important departures from health ;
  not only  as regards the new products of disease,
  but the misplacements and excess and depravation
  of some of the natural  products ; the solution of
  which cannot precede the determination of some
  unsettled  questions in physiology.   When  the
  laws  and  processes of secretion are clearly demon-
  strated, the next step will be an  accurate know-
  ledge of the diseased actions in which morbid pro-
  ducts originate.
    The alterations occurring in  the fluid parts of
  the body,  but particularly in the blood, which once
  attracted  so  much  attention  as to be the general
  basis  of a  pathological system, have recently, after
  experiencing the capricious neglect to which many
 doctrines  containing much truth have at different
 periods been subjected, again  drawn towards them
 the anxious attention of philosophical physicians.
 (See  the  article Blood.)   The  vital  and,  as it
 were, independent properties of the blood are no
 longer overlooked, and  the important  office per-
 formed by this fluid in  relation to the secretions,
 an office extending  beyond the  mere supply of a
 material for their formation, directs the inquiries
 of the pathologist towards those  intimate changes
 which, taking place  within the arteries, or even in
 organs contributing to the unexplained  function
 of the hsematosis, are the real causes of the sin-
 gular and  abnormal  products presented  by various
 diseases.   Thus we may in the present time per-
 ceive the dawn of a new humoral pathology, more
 correct, and at the same time less exclusive,  than
 that which from the age of Hippocrates down to
 nearly the end of the seventeenth century pre-
 vailed throughout all the schools and doctrines of
 medicine.   Without reverting to the  dreams  of
 the mathematical physicians, the doctrine which
 ascribed  so many of the phenomena of disease to
 the moving powers, will not be discarded ; and
 even the first changes traceable in the blood itself
 may be acknowledged to depend  upon irregulari-
 ties in actions of which  the very existence is vet
 in the  utmost degree obscure,
   When it is considered  that five-sixths of the
 materials of the body are fluid; that all  the mate
rials even  of the solid parts  primarily exist in a

  * In a case of hypertrophy of the heart, the patient'*
perspiration  tinged hig linen, and the lining of hig hat
of a red colour. 
680
DISE
ASE.
fluid state, and are again reduced to fluidity before
their ultimate removal; it is quite in vain to deny
the importance  of paying attention  to  diseased
states of the fluids.  But physiology  teaches us
that the formation of the fluids depends, no less
than that of the solids, on  certain preceding ac-
tions, and that the disturbance of these actions is
often known to  be, and may -probably  always be,
antecedent to  the diseased condition of  the fluid
parts.
  In some circumstances the blood  is seen to be
so suddenly deprived of its  vitality, that the pri-
mary impairment of that vitality in other cases
where there is a  long series of morbid phenomena,
becomes exceedingly probable.   When  death is
occasioned by lightning, by a violent blow, or by
the poison of a  rattle-snake, and sometimes even
by the unknown poison which produces  a sudden
and violent attack of fever, in which  the patient
dies without re-action; the most palpable disorder
is effected in the blood itself, which is found to be
deprived of its natural and vital properties.   The
change in these cases is so instantaneous, that
even if we admit  an  antecedent change  in  the
nervous  actions, we admit what we are at  least
unable to demonstrate.  Recent observations have
made it highly probable that in a severe  attack of
the spasmodic cholera, the serum and some of the
saline  constituents of the blood are forcibly sepa-
rated from the red globules.
  In the instance of melanosis, some pathologists
have considered  the black formation to be a depo-
sit  from the blood, which has previously  under-
gone  some  peculiar change.   The growth of po-
lypi may perhaps be attributed to some change by
wbich the fibrine is separated from the blood.
  In other cases, where the duration  of less vio-
lent phenomena is more prolonged, as  in the case
of eruptive fevers, we  have every proof of the
action of the first cause of the disease  upon the
fluids.   In the small-pox we are enabled to com-
municate the disease directly through the blood to
the whole system.
  The great respectability of the authorities which
might be ranged on one hand as supporters of the
doctrine of fever being produced by an atmo-
spheric poison acting upon the blood ;—and, on
tbe  other  hand,  as  supporters  of the  doctrine
which,  admitting the sanguineous  changes and
their consequences, assert the  primary action of
the febrile poison on the  nervous system;—very
forcibly  shows  the  difficulty of determining  the
question by observation, and in the present state
of physiology, of unravelling the intricate impli-
cations of the nervous and vascular systems in the
performance of  healthy,  and consequently  of dis-
eased  actions.  Any one acquainted  with  the
present state of  medical science, and possessed of
some share of ingenuity, might construct a plau-
sible theory by attaching  himself to either one or
the other of these great systems.  The more pal-
pable indications of disorder, although that disor-
der is often but re-action, would probably cause
the number of those espousing the vascular theory
lo be the most considerable ; whilst the undefined
limits  of nervous  influence would give  to the
nervous theory all  the advantages to  be derived
from bold and  unrestrained conjecture.  In the
mean time, a true and permanent doctrine would
still  be  eventually  found  to  lie between these
extremes, and to be founded on the triple basis of
cotemporaneous disorders of both the  groat sys-
tems, and on the occasional primary affection of
either one or the other.
  At no period since the first cultivation of medi-
cine have physicians  ever been  so free  from any
predominant and absorbing theory of diseases as
at the present time.  So great, indeed, has been
the zeal with which facts  and cases have been
collected, that the age  is somewhat  open  to  the
reproach of having reasoned upon them too little,
Yet, when  it  is  considered  how indispensable
to a correct system of pathology is a previous
enlargement of certain  parts  of  physiological
science, it ought to be matter of praise rather than
of censure that the physicians of  the present day
so  much  abstain  from  premature  conclusions.
When the physiologist can  explain the formation
of the several secretions  from  the blood, and  the
workings of the  fine apparatus  by which these
formations are effected, and new parts formed,
while old parts are carried away;—when the rela-
tive dependences of  the nervous and the vascular
systems are determined, and the chemistry of  the
animal fluids in disease as well known  as  is that
of their normal state, then, and  then only, will  the
doctrine of the intimate nature of diseases become
exact.
   One or two of the general theories of disease,
however, which have  been prevalent since  the
commencement even of the present century, may
be alluded to.  A great majority  of the patholo-
gists of this country, who ascribe disease to disor-
dered actions, for a time adopted the views of  the
late Dr. Parry, of  Bath.  He was a physician of
great talents  and  great  industry.   Amidst  the
fatigues  of  a  large  practice, and  many interrup-
tions from ill health, he found  time to  make  ob-
servations upon almost every form in which disease
presents itself; and he proceeded a considerable
way towards  forming  these observations  into a
great system.   Perceiving the  error of  the older
practitioners, who, in  their attention to nervous
phenomena, overlooked their frequent dependence
on vascular disturbance, he rejected, most certainly
in terms too positive and unqualified, all idea of a
nervous theory, and looked for the origin of almost
all  diseases to some irregularity in the powers
which move the blood.   This theory was actually
applicable to so many and such severe affections,
not a few of which had been previously misunder-
stood and very erroneously  treated in practice,—
and  it was moreover so specious and so  conve-
nient, that it promised  fair  at one time to be uni-
versally adopted.   There were few forms of disor-
der in which it  seemed  very  difficult  to  admit,
either that the impetus of the blood in the  organs
chiefly affected was morbidly increased, or, without
general disturbance of the circulation, the tonicity
of the  arteries  proceeding  to  such  organs was
diminished, their elasticity preponderant, and their
resistance to the usual momentum  of  the current
of blood morbidly decreased.   In either of these
cases, one of which was often capable of demon-
stration, whilst the other always admitted of sup-
position, and not unfrequently existed, the  morbid
phenomena present  in  each case were ascribed to
undue determination of blood. 
DISEASE.
6S1
  Of many diseases the first palpable phenomena
are  affections  of  the vascular system.  But that
there are morbid actions in  which, even  when
visibly increased or disordered vascular action is
present, it is but an accompaniment, however in-
convenient  and even  hurtful, is  sufficiently evi-
dent.   The  mere disorder in  the  circulation will
not account for the  various morbid processes inci-
dental to the  scrofulous constitution, or for many
of the affections of the digestive, respiratory, men-
tal, and other functions.   With all our respect for
Dr. Parry, and there  are few authors for whom
we entertain a respect more sincere, it is impossi-
ble to go along with him, when, as if to show his
theory in the most advantageous point  of view
imaginable, he speaks of » that increased determi-
nation of blood to the lower extremities which
constitutes  gout."  (Elements of Pathology  and
Therapeutics, cccclvi.)
   We cannot, in short, possibly exclude the idea
 of a peculiar constitution of nervous substance, or
 modification of nervous action, although such con-
 stitution and  modification  are only perceived by
 certain  effects for which  no other  satisfactory
 cause can be assigned.   If such a pathology be
 still imperfect, it is only so  because physiology is
 circumscribed.  When  the nature of that nervous
 power or influence is  understood, which in  one
 part of the nervous substance effects motions in
 other structures, in another part permits sensation,
 in  another volition, in another the internal sense
 which governs some of the most important animal
 processes, and in  another all  that we  call intelli-
 gence, then may the  pathologist presume to hold
 a bolder language, for he will then advance to facts
 with which he is at present quite unfurnished and
 unaided.
    In the mean time, the  pathological connection
 between the two great systems, of which illustra-
 tions have  been  already given, are even now not
 neglected in practice.   The relief of some nervous
 disorders is  attempted,  and often effected, by
 means acting primarily  on the vascular ; as in the
 case  of hysteria, in which venesection is so  fre-
 quently more serviceable than any  of the  means
 which  are considered  to act  immediately on the
 nerves.  There are cases of inflammatory disorder
 in which the  best auxiliaries  of blood-letting  are
 sedatives, which  seem  simultaneously  to  allay
 nervous and  vascular  irritation.   Attempts  are
 alternately made to check the progress of morbid
 formations, as of scirrhus, by  lessening the supply
 of blood to  the part affected,  and by soothing the
 nervous system.   In phthisis pulmonalis, we  en-
 deavour to decrease the general momentum of the
 blood, or the  irritability of  the heart and arteries,
 without repeatedly lessening the general  quantity
 of the  blood; and the  means employed,  as, foT
 instance, the digitalis  or the hydrocyanic acid,
 seem to act on the whole vascular system by first
 acting on the whole nervous  system.   These  are
 so  many exemplifications of a liberal and philoso-
 phical  theory of diseases,  which, without being
 formally avowed, appears to us to have been acted
 upon for many years  past, in this country, in a
 variety of disorders.   It is  not unpleising to  ob-
 serve with  how  little pomp  such  a system has
 gradually spread its rational influence over British
 practice; its  unpretending  character arising ap-
   Vol. 1. — 86
parently from its being little  more than a refleo-
tion of undeniable facts.
  The strong disposition  of the human  mind  to
rest and generalize  after the fatigue of acquiring
or observing a limited  number of facts, has even
divided into at least two  sects those wno ascribe
disease to disordered actions ;  and these, adopting
a nervous or a vascular theory, are  only distin-
guished by the particular position they  have  se-
lected, by the particular facts or  phenomena on
which they take their stand,  and  which  they be-
lieve in every case  of disease  to  precede all  the
rest.  A few, and but a few, of the distinguished
teachers on the continent yet cling to the  assertion
that all disordered  actions  must  be preceded by
organic or structural change;  an assertion imply-
ing too complete a reversal of the  order of observ-
able phenomena to  require  any discussion.  But
a much larger sect  is composed of those who as-
cribe all morbid phenomena, all disease,  all struc-
tural change or new formation,  all disordered
action, to some shade or other of inflammation;
rather, it is to be apprehended, from a  misapplica-
tion of language, and the too  licentious extension
of the term  inflammation, than from  a  real and
unqualified proselytism to  so sweeping and un-
philosopbical a generalization.  Another sect, the
followers of M. Broussais, whose talents, unbound-
ed confidence in himself, and vehement eloquence,
have attracted some and  scared others  to swell the
number  of his disciples, acknowledge  no other
origin of the most remote diseases than disordered
action, irritation, or sub-inflammation  of the mu-
cous lining  of the intestinal canal;  a  plausible
doctrine, resting  on numerous facts,  and largely
intermingled with truth, but which becomes use-
less or unsafe when it is made universal.
   But whilst almost all  the  schools  of Europe,
and we may add of America, have  been distin-
guished by a calm  and philosophical spirit, averse
to mere hypothesis, and  little addicted to implicit
adoption of the tenets of any  single master—nul-
lius addictus jurare in  verba magistri,—a  sect
has arisen in Germany, chiefly consisting of men
whose enthusiasm  far outruns their powers either
of observation  or of reasoning, and embodied un-
der the appellation of Homceopathists.  To omit
all notice of this sect might be considered impro-
per in so general an article as the present; yet to
speak of  their opinions and practice without de-
parting from the ordinary style of medical discus-
sipn is somewhat difficult.
   Not without the  credit of  having pointed out
some unnoticed circumstances connected with the
administration and effects of  medicines, and even
deserving of some  praise for having enforced a
few salutary maxims of diet and  of regimen ; the
 founder of this sect, Dr. Samuel Hahnemann, sur-
passes  all the heads of all  the  sects  that ever
flourished,  or that have  been forgotten, in the
boldness  of his  assertions, the  carebss extrava-
gance of his deductions, and the scorn with which
he regards all whom he fails to persuade.
   According to the doctrine thus presented to the
hitherto deluded followers  of physic, the art of
curing diseases consists of the employment of me
dicines in each case, which, in a person in  good
health, would produce a similar disease.  There is,
we think, an ancient proverb  which comprehend* 
682
DISEASE,
 the grand principle  of homoopatbie, " what will
 cause a fever will cure a fever ;" a doctrine which
 appears, at first sight, hardly more reasonable than
 if one were to say, what will make a man drunk
 will  make a man sober ;  or, what  will break a
 man's  leg will  set it.  Although, as is  the case
 with any assumed general principle, a few specious
 facts may be  quoted in support of it, or  its truth
 may be admitted in a very limited number of in-
 stances, no one who  reflects on  the methods now,
 by universal consent, adopted in the  treatment of
 the large and  important classes of febrile and acute
 inflammatory disorders, can fail  to perceive that a
 principle from which these and all  surgical dis-
 eases must be excluded, has no claim to be looked
 upon as general.   It can be no  matter of surprise
 that  a  mind  which can  calmly entertain such a
 delusion, should believe that medicines daily used
 with the effects desired in  using them would be
 more useful,  nay, more energetic, if  employed in
 doses a million, a trillion, or  a decillion times
 more minute.  Even of  this extraordinary dimi-
 nution  of  dose, and of its good  effects, some ex-
 amples  may be adduced,  which all must admit—
 that of mineral waters, for instance,  although we
 are not sure that Hahnemann has availed himself
 of it.   But, in  this case, small doses  are  useful
 where larger dosies of the ingredients  of the water
 would be positively hurtful;  and there is  some-
 thing, too, in  the chemistry of nature not yet per-
 fectly imitated by art.  In many of the cases ap-
 pealed to by the homoopathist, (mercury, henbane,
 &c. being employed,) larger doses are given daily
 and with the  best consequences, and  in the same
 description of cases  in which  the  followers  of
 Hahnemann would divide a single dose into por-
 tions sufficiently numerous  for all the patients in
 all the  hospitals in the world.   Still the narrow
 principle is again  admitted, as  universal, unde-
 niable, and now first revealed to mankind.   Pre-
 cisely  the same kind of  reasoning pervades the
 homoopatbie  doctrine of  chronic  diseases, all of
 which are ascribed to syphilitic  taints or  to some
 form of cutaneous disorder: thus adding  another
 to a thousand previous  instances, that in  the cir-
 cle of diseased actions  any separate portion may
 be fixed on as the universal beginning by those
 whose defective sight is confined to that portion.
   The reception of such doctrines, even by a few
 individuals, in any country where the  reasoning
 powers  are not utterly neglected, can but be re-
 garded,  to use an  expression which the late Dr.
 James Gregory used to apply to such  follies, as a
 pitiable proof of the  ignorance  and credulity of
 mankind.  No one will think such  censure un-
 justly applied  to H imoopathists, if he  recollects,
 that without  disputing  concerning the examples
 which they bring to support their great principle
 of curing by resemblances, its absolute admission
 would dictate  that ardent  spirits  should be given
 in phrenitis, in gastritis, and  in  cystitis ; opium
 in lethargy and coma;  turpentine  in irritable
 states of the urethra, and  aloes in painful  hemor-
 rhoids ;  and that  the only  defence to be made
 against the accusation of merciless and even fatal
practice in such cases, rests on the tenfold  greater,
although less dangerous, folly of giving the ardent
■pints in doses of five  hundred  parts of  a drop,
 and the turpentine and aloes in doses of the mil-
 lionth part of a grain.
    Relations and Conversions or Diseases.
 —Dismissing the sulject of general theories of
 disease, it belongs to the general view of the laws
 which govern morbid actions, to notice the singular
 relations which exist between  affections  of differ-
 ent parts of the body, and also the conversions of
 diseases which are sometimes found to occur.
    These may be viewed in connection  with the
 vascular or the  nervous  system.   The  relation
 and conversion of diseases dependent on a state of
 plethora are so commonly observed as to be known
 to all practitioners.  Such a condition not only
 disposes  to  all inflammatory disorders,  but may
 induce the  especial embarrassment of any single
 organ without inflammation ;  as,  in the lungs,
 asthma or pulmonary  apoplexy ;  in  the brain, le-
 thargy  or cerebral apoplexy.  Combined with  a
 predisposition or susceptibility of the nervous sys-
 tem, it may  concur to  the production  of gout or
 of mania.
    As regards the relation of affections of the ner-
 vous system, we see whole families—every mem-
 ber exhibiting the family susceptibility,  but each
 in a different manner,  either  from different por-
 tions of the nervous system in each being inade-
 quate to healthy actions, or peculiarly affected by
 the circulating system.  Eccentricity, excessive
 shyness or  timidity leading  to  seclusion, chorea,
 epilepsy, amaurosis, mania,  and  other  nervous
 affections, are very commonly observed thus asso-
 ciated by the bonds of  relationship, giving as dis-
 tinct a  character to large families as the most
 peculiar external  features of resemblance trans-
 mitted by inheritance.
   New directions given to certain portions of the
 blood, together, probably,  with a transference of
 morbid actions in the nerves, may cause not only
 the conversion of gout to mania, already mention-
 ed, but of erysipelas of  the scalp to phrenitis, or
 of erysipelas of the trunk  to sub-inflammation of
 the intestinal coat with diarrhoea.   The  sudden
 repulsion of some of the disorders of the  scalp in
 children, as  of porrigo, is not unfrequently follow-
 ed by meningitis.   The sudden  recession of the
 cutaneous efflorescence  and  inflammation in ru-
 beola, scarlatina, or variola, is commonly followed
 by inflammation of the  lungs,  or the bowels, or
 the brain.  The supervention of an affection of a
 new organ, or the  subsidence of a similar disorder
 of an organ primarily affected, is usually  termed
 metustatis,-   among  the most  familiar examples
 which may be mentioned,  is that of rheumatism,
 in which the articular affection, when it suddenly
 ceases, is not unfrequently  followed by inflamma-
 tion of the  pericardium, and even  of the heart
 itself.
   Irritations  of the nervous system, of which the
 actual nature is very obscure, but the effects arc
 very serious,  may  now  and then  be observed to
 succeed each other either by natural conversion,
or in consequence  of means employed for the cure
of that  which first existed.  The  most striking
case of this kind  which we  ourselves  have wit-
nessed was  that  of a lady,  who  had been foi
several years affected  with melancholia without
any discoverable cause.  When all the resources 
DISEASE.
683
of ordinary means and medicirte  had been  un-
availingly  exhausted, she was persuaded  to try
the prescriptions of an irregular practitioner.  By
bis advice  she persevered for some  time in the use
of the corrosive sublimate, together with large
doses of the sulphuric acid.   The  mental depres-
sion gave way whilst she was taking these medi-
cines, somewhat, as may be supposed, to the dis-
comfiture  of those who had vainly attempted to
produce the same  good effect.  In a very short
time the same patient began to complain of pain
referred to the back and loins,  of a burning cha-
racter, at first occasional and not very severe,  but
which gradually became heightened to the extreme
of human  agony.  Medical and surgical skill were
fruitlessly  exerted even  to give  temporary relief,
and no means  seemed  for a moment to suspend
the malady, or to give the faintest hope even that
the principle of transition or conversion could be
brought into operation for the patient's benefit.
Her sufferings were unintermitting, except during
short and broken intervals of sleep, for nearly two
years : the lower extremities  became powerless,
then  contracted, then inflamed  by contact; and
these complicated afflictions only ended in  death.
   The most singular transitions of nervous irrita-
tion are exhibited  in hysteria,  in  the course of
which the  most severe inflammatory affections are
sometimes simulated in succession.
   The inconveniences  following the removal or
cure of chronic diseases are often such as to make
the propriety of endeavouring to put an end to
them somewhat doubtful.  After the cure of  a
chronic diarrhoea by metallic astringents, we have
noticed the re-appearance of scrofulous ulceration
of the skin ; and in a case in  which this had oc-
curred, and the ulceration was healed by a despe-
rate quack, symptoms  indicative  of pulmonary
tubercles immediately appeared, and death ensued.
The same  phenomena  have often been known to
follow measures calculated  to repel enlargements
of  the cervical  glands.   We  have  many  times
observed  the  supervention of various  inconve-
niences on the disappearance of chronic or habitual
coughs. The cessation  of gout, or the suspension
of hemorrhoids, has often been followed by epilepsy
or by asthma.   These accidents, of which a long
list might be given, prompt a very important indi-
cation to be observed in the treatment of all such
affections,  which will be dwelt  upon in the article
Medicine, Practical, Principles of.
   Occasionally there is  a translation of diseased
exhalations or effusions.  Anasarca will subside,
and oedema of the lungs will follow. Hydrothorax
or ascites are sometimes  much relieved by dropsical
swellings occurring in the extremities.  General
dropsy has come on after the  cure of ephidrosis,
both affections seeming  frequently to be meant for
the relief of plethora.
  Some affections are suspended during pregnancy,
apparently  in consequence of a converted determi-
nation from the part disordered to the uterus. The
instance of phthisis has  frequently been observed;
and we have noticed remarkable examples of it in
obstinate and  extensive  psoriasis.   It is curious
'hat  the determination   to  the mammae during
lactation does  not prolong the benefit;  a fact
which common  observation confirms as  regards
consumption, and which we have equally noticed
in the example of cutaneous disease.  The object
of the law of nature here exemplified seems to be
the preservation of the species, which after partu-
rition may be vicariously performed.
   Modification of disease  by temperament.
— Other modifications of disease arise from what
are called  temperaments.-  they  modify  the pre-
disposition  to  receive disease from  the  several
causes  which  have  been  mentioned; and they
modify the  course of disease  when it is  excited
by any cause.  The term temperament, however,
founded on an  ancient doctrine  of  four humours
supposed to temper each other, but long employed
without reference to the  theory in which it arose,
and often with  a vague and unsettled signification,
is among  the inconveniences of medical nomen-
clature, which  so many have prided themselves
on deforming by new additions of barbaric jargon,
and so few have attempted  to  purify and improve.
The sanguine temperament  (indicative  of the
predominance  of the  sanguineous  system), the
choleric (or bilious), the phlegmatic (or pituitous),
and the melancholic (or  atrabilarious), are desig-
nations which,  however  frequently  and familiarly
employed, convey little precise meaning, and that
little not always correct.  The sanguine tempera-
ment is supposed to be characterized by a full habit,
a soft skin, a  ruddy complexion, red or  auburn
hair  (the flavus  of the  Romans, and what the
Scotch still call yellow-haired),  a frequent pulse,
large  veins, and vivid sensations.   The  melan-
cholic, on the contrary, is described as existing in
a firmer frame, and  thinner,  with  a dark skin,
black hair,  and a slow  circulation: the  nervous
system is less  easily moved ;  the  disposition is
grave  and meditative  (meditabundus,  Gregory,
in Conspect. cap. xxiii.), and the  affections are
fervent and steady.   Intermediate between these
is the choleric.   But  the phlegmatic differs from
all in the laxity of the skin, the paleness  of the
face, the lighter colour of the hair, and the greater
sluggishness of the faculties of the mind.
  It is  unquestionable that this  ancient  division
must have been the product of extensive and deli-
cate  observation.  It  is  even  possible that when
the varieties of  men were less  mixed, the temper-
aments, some of which continue  the characteris-
tics of nations, were less  blended.  At  present,
all attempts to limit the inexhaustible varieties of
temperament, compounded, it  may be, of so few
and such  simple  elements,  is  as  unsuccessful as
to comprehend  within the bounds of a few de-
scriptions  all the variety produced by the different
associations of the  few  features of  the  human
face.   However interesting, therefore, a recollec-
tion  of the  temperaments  may  be to hiin whe
speculates on the varieties of human character, it
now affords little help to  the practitioner of medi-
cine, and  a  consideration of their divisions may
advantageously  give place to one which  has the
recommendation of being at once  more  simple,
not less comprehensive, and more easily admitting
every  diversity.
  There is an evident difference in the suscepti-
bility of different individuals to external  and in-
ternal, to bodily and mental impressions; and this
susceptibility, to the expression  of which we would
in medical language limit the word  temperament
may  be,  and doubtless  avnuuumes is, uniform 
684
DISEASE.
throughout the whole  individual  frame of body
and mind.  But it is so often irregularly disturbed,
and so often variously limited  in  different indivi-
duals, so liable also to transitory and  permanent
increase  or diminution  from  various  accidental
causes, that it requires, for any useful  pathologi-
cal or therapeutic end, to be regarded with little
jr no reference to an arbitrary division admitting
only of complete individual varieties.   From  the
original or constitutional excess or defect of sus-
ceptibility to one or more, or  all  the impressions
which the mental and bodily frame is intended to
feel, arise various diseases, and the diseases affect,
for the same reason,  a  particular course.   The
susceptibility may be  so increased, that common
light, common air, common sounds, common food,
common occurrences, cannot be tolerated :  it may
be so diminished that these circumstances do  not
affect the senses on which  they  are intended to
act.   But  the susceptibility  may be partial; in-
creased at one time, diminished  at  another—in-
creased in one organ, and not in  others ;  dimin-
ished in some organs, and in others increased.
   To this kind of susceptibility the practitioner
is required to pay much  attention, in order to dis-
cover the tendency in his patients  to particular
forms of disease, and  the consequent propriety of
pursuing particular methods of cure.  The occur-
rence of disease in any organ commonly, for  a
time, increases or  diminishes  its susceptibility to
ordinary impressions.   Thus, after fever, the brain
and  the intestinal  canal occasionally remain for
some time irritable  and  intolerant of  all impres-
sions, and in other  cases for a long time inert and
torpid.  The  disease  of some  organs induces or
is connected with peculiar states  of susceptibility
in others.   During the  progress  of tubercles in
the lungs, the irritability of the heart is very con-
spicuous, and that of the bowels is  not  unfre-
quently fatal.  In morbid states of the brain  the
stomach is sometimes irritable, and vomiting is  a
symptom ; and sometimes in a state so completely
opposite that powerful emetics will  not rouse it,
and  food is obstinately refused. In the same indi-
vidual we  may see tbe mind  excited, or exhibit-
ing, if we revert to the old terms, the peculiarities
of the sanguine temperament, and  tbe stomach,
bowels, and skin   decidedly  phlegmatic; and to
such cases no general term can  correctly  be ap-
plied.   All these varieties of susceptibility under-
go modification by climate, by diet, by excessive
evacuations, by the neglect of exercise, by exclu-
sion from pure air, by mistaken habits  as regards
clothing,  and by other causes of which the  im-
portance is fully shown in the article Education,
Physical, to which  the reader is referred for
many particulars which could  not properly be here
introduced.  Modifications,  both  as respects the
whole body and particular parts,  are  effected by
age, and are noticed in the article under that head
already referred to.
   Generally speaking, there  exists in women  a
greater degree of susceptibility to impressions than
in men ; and this  is very often observed  in  that
degree of excess which constitutes what Dr. Cul-
len called mobility, and which is the affliction of
the greater number of those who  are termed  ner-
vous patients.  These are the individuals who
 fcel  all the impressions of sense with almost pain-
ful acuteness :  they long retain, and vividly recal,
the impressions of music  and of painting, except
when new objects excite them, and therefore long-
est in the dark ;  and they are prone to hysterical
affections, as various as the sensations and actions
can be which may be associated witb morbid con-
ditions of all the various parts of the nervous sys-
tem.  (See Hysteria.)  The importance of be-
ing acquainted with the modifications of disease
in a  temperament of this kind  is very great in-
deed.  Such patients are not only more readily
affected by disease,  hut by remedies, than other
patients.  Soon  reduced  to apparent weakness,
the same facility  of being acted upon by various
stimuli occasions their recoveries to be often equal-
ly sudden, and to the  inexperienced  practitioner
surprising. Both the prognosis and  the treatment
must be regulated by these  circumstances.   Vio-
lent  medicines will do the patient harm and him
discredit.   The pale,  languid, feverish, irritable,
complaining  patient of to-day may before to-mor-
row  be converted, by the unexpected visit  of a
friend, into a patient no longer submissive to phy-
sic, or mindful of slight ailments, but anxious to
return to all  the amusements  of a dissipated life.
In proportion as  there is in  the male  sex an ap-
proach to this  mutable susceptibility, the practi-
tioner must expect the  same results, and observe
the same caution.
   Vis medicatrix.—The signification and value
of the different symptoms and signs of diseases
are  treated  of in  the articles Prognosis  and
Symptomatology.   There is, however, one view
of symptoms in  general which especially belongs
to the general subject of disease;  namely, their
frequent indication of tbat power in the system to
which has been given  the appellation of a via
medicatrix naturx.  This curative  power or pro-
perty, although the idea of it may have been push-
ed  needlessly  far,  and rendered somewhat  too
material, is an undoubtedly existing  property of
the  living animal  body.  It is  this  which  Van
Helmont personified  as the archseus, or grand re-
gulator, whose throne was  the stomach.   It is
what Wepfer called the president of the  nervous
system : and we do  not  see  that Stahl went be-
yond them when he referred the government of
the  body  " directly and  entirely to the rational
soul," diffused, however, over the whole body.*
   The truth is, that we have daily proofs of there
being a power in the constitution to repair injuries
and  restore  lost parts; and  that several actions
which we call disease are instituted to get rid of
the  causes  producing  them.  Nor is there any
necessary extravagance in the supposition thatth*
possible intention of all may be so.   The law  may,
perhaps, be  said to  be analogous with, or  con-
formable to, the law of which  natural philosopher.!
have gained a knowledge by  induction from vari
ous  phenomena ; that all action is followed by re-
action, equal to, but different from, the  primary
action.
   If a  bone is broken, if a  muscle or tendon, 01
even a nerve is divided, the divided ends  are re-
united.   If a portion of substance, as of the skin
and cellular  membrane and muscle, is lost, or cut

  * See Hoffman, Commentarius de differentia inter Hofl-
manni doctrinam medico-mechanicam et G. E. Stahl '
medico-organicam. 
DISEASE.
685
out, the deficiency is repaired, and the cavity built
up by granulations from  the bottom, and at last
covered in by  new  skin.   If  a part removed  is
without mucb delay re-applied — a  tooth, the tip
of the ear, a finger, a part of the nose—it becomes
firmly united in its original situation.  So anxious,
if we may so speak, is  nature  to preserve the life
she has given,  that wounds of the most important
organs will cicatrise ; wounds  of the lungs, of the
heart, of the intestines,  of the bladder, of the ute-
rus, even of the brain.
  Dr. Parry enumerates among salutary processes,
re-action, shivering, convulsions, bodily  exercise,
tears, sighing,  gout, dyspepsia, formicatio, vertigo,
coruscations, fever, loss of appetite, and wasting.
The propriety  of including some of these may ap-
pear questionable; but illustrations of the salutary
effects of the  greater number will so  readily pre-
sent themselves to those familiar with pathological
phenomena as to require no further observation.
Many cases of conversion of disease are, of course,
to be referred  to the same  head.*   Viewing the
principle in its widest extent, it may be  said to be
first exemplified  in the convulsions  of  infancy;
and it is  exhibited for  the last time, and ineffec-
tually, in the convulsions so  often preceding death.
   There  is a kind of consolation, not unattended
with a hope of the final extension of medicine far
beyond its present powers, to be derived from ob-
serving that even diseases of a  most fatal character
evince a conformity, as  it were, to the same great
curative  and preservative law.   The whole series
of changes in the tubercle are but so many efforts
to dislodge  and eliminate it from the lungs; the
process  is attended with irritation, and  by  long
continuance, or  rather by  constant repetition, it
generally ends in death.  A similar process  pre-
vails in cancer, and is sometimes, although rarely,
more happily  effected.   Calculi in  the bladder
occasionally  become enveloped in pouches of the
lining membrane, and irritate the patient no more ;
and sometimes escape  by ulceration into the rec-
tum or vagina, or through the abdominal integu-
ments.
   There can be no difficulty  in admitting  these
indications  of  the vis medicatrix naturae, without
referring them  to  anything more than an internal
sense, which the preservation of existence did not
require to be of the same nature as what are called
the external  senses.  It would be hardly necessary
to allude to the more material character  given  to
this power, if  the physicians who were most dis-
posed to invest  it  with  personal  properties and
dignity, had not, as a natural  consequence, be-
come too scrupulous about opposing it, even to the
extent of curing all diseases by what the French
have called expectation.
   The  proper  advantage  of acknowledging such a
power is, that  it prevents indiscriminate  and offi-
cious meddling—that medicina perturbatrix which
incessantly  contradicts  even  the best efforts to-
wards a natural cure.   In the modern practice  of
medicine and  surgerv, the vis medicatrix naturae
is seldom disregarded  ;  but  its suggestions are
not followed without discretion. Seeing the in-
tention of its working, it is yet  often seen by the

  'See  Parry,  Elements of Pathology"andI  Therapeu-
lies, vol. i. Par.  dccclui  to dccclxvi.  Second edition,
1825.                                    .,
                                        3h
practitioner to work  in  a dangerous manner, and
too much by a general rule; sometimes  too  ab-
ruptly, and sometimes after  too lingering  a man-
ner.  The object of art is  to adapt  the  rule  to
particular instances ; and the greatest wisdom  of
the practitioner is shown in determining when  to
wait upon nature, when to rouse her  to exertion,
when to  moderate  those exertions, and when  to
put an absolute stop to them.
   When a bone is broken, the body being pre-
viously in full health, the vis medicatrix naturse is
soon in full activity; the whole restorative force
is  called out.   Tbe vascularity,  the  heat,  the
vitality of the surrounding parts is increased; and
inflammation ensues. But it is often necessary to
moderate this  zeal and  haste of nature; to lessen
the  superfluous  excitement,  leaving  only  that
degree of it without which the repair cannot pro-
ceed.  Among savages  the natural power of heal-
ing  is so perfectly exercised, that it is said the
most frightful wounds  will  heal without  surgical
aid.  On the other hand,  a  patient of infirm con-
stitution  or disordered health becomes  subject to
some local  congestion; or some  accidental  and
trifling injury  brings a part of the  integuments
into a state of chronic and  inactive disease ;  and
the vis medicatrix naturae is not exerted until the
obstacle  to its exertion, the disordered state, per-
haps, of  the digestive organs, is removed by alter-
ative medicines : but that  done, and a wound or
abrasion, which  had  remained   stationary   for
weeks, instantly puts on  a  new character; secre-
tory and absorbent  processes  are at once com-
menced,  and the cure is soon completed.
   We see, too, in the case of a patient alarmingly
lowered  by an attack of fever, the nervous energy
sunk,  the power of the  heart  diminished, the
digestive function almost  annihilated, the respira-
tion laborious  and feeble.  Nature, unassisted, will
undoubtedly try to make this patient  rally: but if
the  trial  is successful, it can  only be so in the
course of many  weeks, perhaps  many months ;
and the body and the mind will long continue to
suffer, or perhaps never wholly recover.   Often,
after a succession of attempts, the patient sinks at
last.   But we know that by stimulants and tonics
judiciously administered, we can rouse the powers
of digestion, and re-animate the whole frame, in
less than half the time  and with less than half the
danger.
   Whilst, however, we  seriously consider the
design of nature in any malady,—whether she is
working, and  how she is working, and  how the
machinery will endure  the process she has set up
—we should still, having to treat  diseases as they
occur in civilized life,  never trust entirely to  the
vis  medicatrix naturae, except in  the case of  the
most  trifling  injuries,  where  a  process  of very
small extent is all that  is  required for the cure.
   The natural powers of  healing and recovery are
in many cases strongly  influenced by  peculiar
mental states.  The same  emotions and  passions
which redden  or blanch  the cheek, which affect
the ci't'aneous and renal functions, or those of the
stomach  and  bowels, can also promote or retard
the activity of the vis medicatrix naturae.   Confi-
dence of recovery often conduces to recovery; and
extreme despondency concerning the tendency of
a  disease sometimes leads to a fatal result.  Thic 
686
DISEASE.
is  very conspicuous  in some  affections, as in
fevers;  and has often been asserted to prevail in
malignant  disorders, particularly in cancer: and
some  practitioners  are  consequently inclined to
place implicit reliance on the prognostics in which
their patients are disposed to indulge.   But the
example of phthisis, which is in that respect not
singular among chronic disorders, may serve to
show  that  confidence may be even a part of the
disease, arising from a  morbid condition of the
sensorium : and  we  have  attended patients in
lingering forms of fever, which ended happily, yet
throughout the whole course of which it was im-
possible to excite a  ray of hope in the mind of the
patient.  In some cases the cessation of the fever
induces a  deep but  temporary despondency of
recovery.   Even with these exceptions, the influ-
ence of the mind  over  disease should never be
overlooked  by  the  practitioner;  nor should he
forget to inculcate that this influence of the mind,
like all the mental actions, may by firm endea-
vours be to a great  extent subjected to the will.
   Acute and  Chronic Diseases.—The differ-
ent period required by different disorders,  unas-
sisted by medicine,  for the production of a natural
cure, or, in fatal cases, for the destruction of life,
has long been  the  occasion of a general  division
of diseases  into acute  and chronic.   Acute dis-
eases   are  commonly attended  with severe and
obvious symptoms ; whilst chronic disorders are
usually less marked, and attended  with less suf-
fering.  To these distinctions there are, however,
exceptions.  Diseases  of short  duration, and in
their  effects destructive, are sometimes attended
with  few  symptoms of the  mischief they  are
effecting in the brain, in the  lungs,  or in  the
intestines; and diseases slow in their progress are
often accompanied with sufferings  of a very severe
kind.
   In  acute  disorders there is, except  in  rare
instances, warning  sufficient to guide  the  prac-
titioner ; but in chronic diseases the  most exten-
sive injury sometimes proceeds undiscovered until
the discovery is useless.   Acute inflammation, for
instance, can seldom  be overlooked ; but chronic
inflammation is frequently unnoticed until some
of its worst effects on structure have been wrought
by long continuance.  It is no less essential to the
physicians than to the  surgeon to be  especially
mindful, in all obstinate maladies, of the possibility
of serious  disorder.
   Periodicity and  Crises  of Disease.—But
there   are  also diseases, acute  as regards  their
severity, and chronic  as regards  their duration,
which are what is called remittent and intermit-
tent.  The symptoms arise and decline in a certain
series and  in a certain time ; then disappear, and
after a  certain  interval are renewed.  The  class
of fevers remarkably exhibits all the peculiarities
of remission and intermission;  and these will be
described  under  the head of  Fever.  In this
general view it may be  sufficient to mention, that
in our common continued fevers there is generally
once, and sometimes twice, in the space of twenty-
four hours, an observable  remission or  marked
alleviation of the febrile symptoms.  It is, however
in many cases  not very striking; and it is always
less striking in this  country than in those fevers
af warmer climates to which the  observers have
agreed to give the name of remittents.  In  one
class  of fevers, sufficiently  familiar to the prac-
tioners of marshy countries, the remission is so
marked and of such continuance as to be denomi-
nated  an intermission.   Each paroxysm  of an
intermitting fever or ague has a precise beginning,
middle, and end, with an unquestionable cessation
for a  time,  after which a new  paroxysm is com-
menced.  The intermission  is never of less length
than some hours ; it is often twenty-four, and not
unfrequently forty-eight.
   Not, however, in fevers alone have these well-
known but unexplained  circumstances of inter-
mission  and  remission  been  observed ; diurnal
remissions  are distinguishable  in every  attack of
inflammation.  There are periods  of the day or
night in which the symptoms are less severe, and
other periods in which there is an exacerbation.
Even some inflammatory affections are intermit-
tent, of which, perhaps,  rheumatism  is  the most
frequent  example; although  pleuritic  and other
inflammations have been described as assuming
the same character.
   An intermittent form of attack may very com-
monly be observed in many of the disorders usu-
ally called nervous or spasmodic; as in hysteria,
epilepsy, and nervous asthma.   Close observation
will  occasionally detect regularity in the attacks
of epilepsy, where slight inquiry would not cause
it to be suspected.  We have sometimes found the
alternate fits corresponding  in  point of time, and
the paroxysms very nearly observing two distinct
periods;  so as to be  somewhat analogous, only
with much longer intermissions, to what is called
a double tertian.  The same  intermission, more
or less regular, and often  with  considerable inter-
vals, prevails in a great number of cases of mani-
acal  affection.
   The intermissions in  tbese  instances appear
sometimes to be associated with periodical changes,
not appreciable except in  their effects, in the ner-
vous  system  itself.   At  other times there is a
manifest periodical excitement  of the vascular sys-
tem ;  but whether  a  primary excitement or not,
the  progress  of  physiological  and  pathological
knowledge will alone discover.   The ancient cul-
tivators of  medicine attached considerable impor-
tance to the periodicity of inflammatory affections,
even  of the slightest  kind ;  believing that what-
ever measures were employed, they would run a
certain course, mitigated perhaps, but not.prema-
turely brought to a termination.  Both with respect
to these and to the febrile disorders,  certain days
were  believed more favourable  to a termination of
the malady than others, or even to its amelioration.
These were called  critical days.  If the disorder
did not begin to decline, or altogether decline, on
one of those days, the hope of the practitioner was
transferred to a future critical day, overleaping one
or two days,  and sometimes a greater number.
Unfavourable changes were alleged  to  occur on
the same days in bad cases.  For a belief sanc-
tioned by the acute observation of the Greeks,  and
more or less cherished by almost every sect up to
the present day, it must at least be said that there
must be some strong  foundation.   Yet on  few
points are  modern authorities more  at variance;
some retaining the  old faith pure and  unmixed1
some admitting it  with reservations;  and some 
DISEASE,
  regarding it as a venerable but a groundless pre-
  judice.  We are not afraid to confess that our in-
  dividual observation inclines us to rank among the
  believers ; although at the same time we acknow-
  ledge  the insufficiency of individual  observation
  on a question of this nature.
    There is  some analogy between these periodic
  movements  of disease, and the periodical perform-
  ance of certain of the healthy functions, although,
  as regards  several of the latter, the effect is com-
  monly ascribed to habit.  The desire for food, how-
  ever, and that for sleep, which may be looked upon
  as indications  of an approach  to a state of  ex-
  haustion in  some part of the system, are found to
p  recur within a certain period in all; whilst in the
  instance of the uterine  functions in  the female,
  and in the  frequent examples of inconveniences
  resulting from a  plethoric state of the blood-ves-
  sels, there  is a certain effect produced within a
  given  and  exact time, and with which  habit can
  have nothing to do.  Again, in almost all slight
  but not very transient disorders, there is an alter-
  nation of excitement and depression, " a good day
  and a bad day ;" and, during convalescence, par-
  ticularly from  fever, we  have often noticed  the
  great distinctness of this intermittent or periodical
  character.
    As  from  the earliest cultivation of medicine it
  was observed that some peculiar  circumstance or
  state  of the body accompanied  the solution of
  many  diseases, or preceded  and,  as it  were, an-
  nounced their  favourable issue, or, on  the other
  hand,  their  termination  in  death ;  these circum-
  stances or states came to  be spoken of  as consti-
  tuting what was called a crisis, (from Kptai;, judg-
  ment,) and  the days on  which  they were  most
  generally found to take place were termed critical
  days.   This language still prevails, even among
  those who are less inclined than ourselves to credit
  the ordinary restriction of such occurrences to dis-
  tinct periods.
    Certain changes, often  noticed  as  preceding
  death,  more especially in chronic  diseases,—hic-
  cup for instance,—and which are  therefore consi-
  dered and called critical, do also, if any faith may
  be reposed in popular observation, sometimes recur,
  increase, or alternate with other critical changes,
  at periods answering to that  when the first warn-
  ing of that  kind appeared.  If physicians place
  no reliance  on such testimony, we are inclined
  partly  to attribute it to their being seldom  long
  engaged  in  watching maladies at the bed-side,
  where  the senses and thoughts naturally become
  concentrated on the events of the sick chamber
  alone.   Our own observation in  the  course  of
  c-ountry practice, and in cases where circumstances
  have occasioned our  attendance  to be close and
  protracted, has, we must candidly own, gone some
  way to corroborate  the popular evidence on these
  points,  which are  certainly not of a nature to be
  made familiar to those whose chief knowledge of
  disease is acquired in formal consultations, or in
  daily visits  to the  wards of public institutions.
  No harm can  arise, at all events, from directing
 the practitioner's attention to a subject which can
 only be investigated by a close attention to all the
 phenomena of ordinary sickness.
   In the progress of a fever, the  recovery or the
 fatal termination  is doubtless often preceded  by
687
 some  new action exemplified  in  the  state of the
 bowels or of the skin.  The sweating stage of an
 intermittent will occur to every reader as an ex-
 ample ;  but analogous phenomena often  charac-
 terise  those fevers which are denominated con-
 tinued.   Some  are also distinguished by critical
 eruptions, of which  the  appearance  relieves the
 febrile state.  Certain conditions of the cutaneous
 or  respiratory functions, productive of a peculiar
 odour of the breath or perspiration, are  well known
 to  practitioners  as indicative of an  aggravated
 malady.
   Inflammatory disorders sometimes suddenly and
 happily terminate on the supervention of cathar-
 sis ; whilst the common termination of inflamma-
 tion in abscess is itself often spoken of as critical;
 so  that to this day  we hear of  crude abscesses, of
 the digestion of the pus, and, among  the older
 members of the profession, of the coction of the
 matter.   Nervous  affections, dependent probably
 in  such cases on a plethoric state of  portions of
 the nervous system, often for a time disappear im-
 mediately after an attack of epistaxis, or, in fe-
 males, on the appearance  of the  catamenia after
 suppression.  The  accession and the departure of
 a paroxysm of hysteria or of asthma is sometimes
 marked by  a copious flow of limpid urine; and a
 very free excretion of  mucus from the  bronchial
 membrane forms the common and true crisis of
 the asthmatic fit.  Countless  illustrations might
 be  accumulated, but  no one conversant with  dis-
 ease can have failed to  remark  them.
   According to doctrines now very little regarded,
 these and numerous other phenomena  acquired an
 additional importance  from being  considered in-
 dicative of the successful or unsuccessful results
 of  a supposed struggle  in  the  system  for the  ex-
 pulsion of a morbific matter; a  supposition which,
 in many cases, is so far from being in  any degree
 unphilosophical,  that it rests  on  facts  too plain
 and of too  frequent  occurrence to  admit of  the
 least dispute.   The terms  crudity, digestion,  and
 coction, have however been conveniently laid aside,
 as communicative of  a sense which was  not suffi-
 ciently exact.
  The days on which the critical events are to be
 expected, have been variously named by different
 observers.   This discrepancy,  and, indeed,  the
 chief difficulty  in ascertaining, by actual observa-
 tion at the bed-side, the truth or incorrectness of
 the  ancient belief,  arise  from the  same  cause,
 namely, the uncertainty so often existing respecting
 the day on which any given disease actually com-
 menced.   In fevers, the first day is sometimes suf-
 ficiently marked, but not uncommonly it is  impos-
 sible to determine when the  general disorder was
 really  advanced  to the febrile condition.  We
 should ourselves venture to direct the attention of
 those anxious to investigate tbis  curious subject,
 to  the third, fifth,  seventh, eleventh,  fourteenth,
 and twentieth days of our common fevers; and
 we  think their attention will not  go quite unre-
warded.
  The physician will, perhaps,  find that in a con-
siderable proportion of cases of continued fever,
his  services are first deemed necessary on the third
day of fever, in consequence of symptoms indica-
tive of a serious disorder then first becoming  ob-
servable to  the friends of the patient.   Judicioun 
688
DISEASE.
 treatment will often  assist in bringing about  a
 favourable change  on the fifth or seventh;  or  a
 decided improvement will occur between the  elev-
 enth  and the  fourteenth day: or be postponed
 until  about the twentieth.  Without affecting rigid
 exactness in respect  to  these  days, or attaching
 extravagant importance to them, we have certainly
 thought  ourselves justified in these conclusions
 respecting them, by observations made in circum-
 stances not unfavourable  to  precise and  undis-
 turbed observation.   The principle assumed is one
 which in numerous cases  of  disease is  perfectly
 undeniable—that certain morbid processes  are for
 the most part effected in definite periods  of time.
   It  is not the object of the present work  to col-
 lect the curiosities of medical  literature; and we
 have  therefore briefly dismissed this, among other
 subjects, on which  it would be easy  to prolong
 ingenious discussion.  The practical  application
 of the doctrine of a crisis is obvious.  Its observa-
 tion may conduce to exact prognosis; an art  so
 difficult and deceptious, that  all  prudent  physi-
 cians advise that the prognostic should  be guard-
 ed with a care  that may, in all cases, cause it " to
 quadrate with the event;" but at the same  time
 an  art in which the  observant practitioner won-
 derfully excels those whose notice of the turns and
 changes  of  maladies  is less diligent.  Moreover,
 if a disease  ordinarily terminates in some specific
 way,  or in some  specific crisis, the induction of
 that particular crisis becomes a wise indication for
 the guidance of the  practitioner, although  it will
 often  be found that art  cannot accomplish more
 than an ineffectual imitation of those critical  evo-
 lutions which nature wants the power to perform.
   Besides the property inherent in the body which
 may be assumed in many instances of periodicity
 to be  the  primary cause, there is an evident pe-
 riodical influence exerted over  many maladies by
 certain combinations  of temperature, moisture,
 electricity, and other atmospherical properties, at
 different seasons  of the  year.   There are indivi-
 duals  who  in  the  spring  of  each year become
 maniacal; others in whom the heat of the sum-
 mer seems to produce the  same unhappy effect,
 and who are well in the winter.   A tendency to
 vernal fever is very common in delicate women ;
 and an aggravated dyspepsia, arising from gastric
 and intestinal irritation, is the  frequent precursor,
 and apparently the exciting cause of many of the
 fevers of autumn, which  are so commonly termed
 bilious; and with which some individuals arc re-
 gularly attacked every year.
  The influence  of  the  heavenly bodies on the
 corporeal  actions of  the beings inhabiting  this
planet, the lunar and sol-lunar influences, once
so reverently regarded, have been for some time
 past so often the subject of ridicule, as to make
almost any  allusion  to  them  liable to the same
 reception. It would, however,  be difficult to show,
in the first place,  any very good reason why  ani-
 mal bodies should be exempted from the operation
 of masses capable of acting on large portions, or
•<n the whole  of the  globe on which  they live;
 and abundant testimony, although not always, it
 must  be confessed, very conclusive, might be col-
Ivicted  in  favour of views which have been  too
entirely discarded.   That a lunatic should be un-
der lunar influences,  is an  opinion  now seldom
 mentioned but to afford an opportunity for com-
 placently contrasting the wisdom  of the  present
 time with the credulity of the past,   let of those
 who have the  charge  of lunatics  we  have,  we
 think, found the majority disposed  to believe as
 their forefathers did.   The  determination of all
 questions of this kind requires such long and pa-
 tient observation;  there  are so many collateral
 sources of deception, and the exceptions appear
 to be so frequent;  that it is to be feared mankind
 will  long  continue to content  themselves with
 unweighed assertions on the one hand, and indo-
 lent and contemptuous incredulity on the other.
   Nosology. — It was our intention to conclude
 this article with a view of the different arrange-
 ments of diseases which  had been  made by suc-
 cessive physicians  since Araeteus  first divided
 them into acute and chronic,  unless,  as is some-
 times stated, Asclepiades is to be  considered as
 having been the first deviser of nosology,  many
 of his definitions being retained by  Csslius Aure-
 lianus.  Galen,  however, mentions Mnesitheus,
 who lived after Hippocrates, as having  distin-
 guished himself by the classification of maladies.
   Conceding that the use of all nosological studies
 is really limited  to the schools,  and  that  to the
 practitioner they afford no immediate aid, it is yet
 not  uninteresting to see the way in which some
 of the greatest  men who  have  ever cultivated
 physic have  attempted to reduce the innumerable
 diversities of disease into something like  order.
 Not to dwell on their divisions into those  of the
 solids and fluids ; into internal and external; into
 idiopathic and sympathetic;  into protopathic and
 deuteropathic ;  into hereditary,  congenital, and
 acquired ; into those of infancy, childhood, adult,
 and  old age ;  into those attacking men and wo-
 men ; into the salutary,  the benign, the malignant,
 and  the  pernicious :  and without insisting vehe-
 mently on the  importance  of the divisions into
 curable, incurable,  and fatal;  or, with regard to
 the seasons, into the vernal, those of summer, the
 autumnal,  and those of winter;  or  into the spo-
 radic and popular; or into febrile and non-febrile;
 or sthenic, or asthenic;  or general and local : and
 passing over  many other refinements of a like
 kind, too often  based on erroneous theories; — it
 would be most  unjust  to forget the eminent ser-
 vices of Sauvages, the first of the modern nosolo-
 gists,  (1731,)  and the  frequent  references  to
 whose writings in this work sufficiently show the
 estimation in which he is yet held.  The celebrated
 Linnaeus also, in 1763, endeavoured  to arrange
 diseases with  the same regularity with which he
 classed the objects of botany,  but with less suc-
 cess.  Among the classes of Sauvages were anhe-
 lations, weakness, pains,  and  discharges,  all of
 which are usually but the effects of disease.  In
 the arrangement of Linnaeus,  fevers and syphilis
 are placed together, on  the  ground that both are
 contagious.
  In  the  more  complete  attempt of Dr. Cullen,
praised, and  justly praised, as an estimable work
 by his successor, Dr. Gregory, catarrh and dysen-
tery  are  placed  together,  because both  are  pro-
fluvia, or discharges.   Dr.  Cullen's nosological
arrangement  was succeeded by that of M. Pinel,
which became as general in the French schools
as that of Cullen had  been in  England.   The 
DISEASE.
689
arrangements of Sagar,  Macbride,  Bang, Daniel,
J. P. Frank, Sprengel, Hufeland, and many others,
in  whatever estimation  they were once held, or
whatever merit they possess, are now seldom re-
ferred to except by the curious.  Even Cullen's
nosology is  almost  unknown  in  the  schools of
London ; and Swediaur, who tried to improve it,
is no better remembered. Among the nosologists
who have pushed  the science to extremes, Vitet is
sometimes alluded to, as placing in his sixth class,
or diseases of evacuation,  and in its fourth order,
of organised bodies, accouchement, avortement—
making pregnancy a disease, "beginning in con-
ception, and ending in delivery."
   The  name of the celebrated John Brown de-
mands,  at least, a passing attention.  Dividing all
disorders into sthenic and asthenic, he established
on that  bold foundation a superstructure of physic
so ingenious, that, great as its defects were,  and
great the practical errors  into  which  they  led,
they long attracted the regards and admiration of
many of the most famous schools of Europe.
   With more attention  to the natural phenomena
of the human body, with more practical experience
and wisdom, but  at  the same time with  a freer
indulgence  of fancy, Darwin  attempted  a  new
arrangement of diseases in the Zoonomia; a work
in which, amidst  a great variety of matter  of very
various  value, the student will find many practi-
cal observations indicative of the penetration and
genius of its distinguished author.
   Dr. Bartholomew Parr, the author of the Lon-
don Medical Dictionary, a work of great  merit,
and full of  practical  information, attempted to
improve the nosology of Cullen, but  little  was
gained by the attempt.  Inflammations  constitute
his second class,  and in it we find phthisis.   In
the profluvia we meet with cholera and diabetes.
In  the  suppressorii,  or  suppressed functions, we
find constipation, and asthma, and jaundice, and
thirst.
   These obvious  inconveniences of artificial clas-
sification, which so many able persons  have been
so little  able to  avoid, show in  an unanswerable
manner  the  inutility of such  divisions.   If we
were disposed to ridicule the science of nosology
altogether, we might dwell on the nosology of Dr.
Parkinson, who divided all diseases into hyperbio-
lis and  catobiosis, and  hoped " to  obliterate the
term fever  from  nosological language;"  or we
might turn to the chemical nosology of M. Baumes,
of Montpellier, who classified maladies as calorin-
ised, oxygenised, hydrogenised,  azotinised,  and
phosphorenised.   But  any  further consideration
of the subject would be of little use to readers of
any class.
  If any arrangement is likely to be useful  in  a
practical point of  view, it would seem to be either
that of  diseases  according  to the parts, or the
functions which they  respectively  most  affect.
The former  is the arrangement followed  by the
present professor of the  practice of physic in the
London University ;  and the latter was followed
by the writer of  this article in the same chair.
By observing either of these methods, the  stu-
dent's practical knowledge  seems most likely to
become conveniently and usefully arranged, so as
to  be retained  with the greatest certainty,  and
referred  to with  the greatest  facility ;^ the  first
  Vol. I. —87
inquiry of a practitioner who is investigating the
case of a patient, being  concerning the part or
function  affected.  Some affections, as fever, being
of a general character, are conveniently placed in
a distinct class.  The specious exactness of an
arrangement proposed  by Dr. Young, the learned
author of the Introduction  to Medical  Literature,
never sufficed to bring into general notice a system
which was seen, at the first glance, to be without
any practical utility ;  and the same general objec-
tion may well excuse our dwelling upon or detail-
ing  any particular system  in a work  like the
present.   The functional arrangement adopted by
Dr. Mason Good might deserve particular notice,
on  account of the reputation of its author, were
it not that his incredible prodigality of barbarous
medical  terms has made his nosological arrange-
ment, if  not quite confused  and unintelligible, at
least  such as to  defy the efforts of the  strongest
and most retentive memory.  Having  ourselves
attempted a plan much less ambitious, and, as we
believe, much more useful, it affords us  no  small
gratification  to  find  that  the principle of that
which is followed by a teacher of so high and
deserved a reputation as Dr. Elliotson, is  as nearly
as  possible  the  same.  The only  object of any
consequence which it was  ever  pretended that
nosology could effect, is the accurate  discrimina-
tion of diseases.   This cannot be taught by short
definitions, but  by full, and  careful, and collated
descriptions : and in order that such descriptions
may be readily made  and remembered, we believe
that arrangement of diseases to be the best which
causes those which affect  the  same  organ  to  be
brought  close together.  Their resemblances may
thus  be  best compared, and  their differences best
observed ; of which the result will be, that facility
and accuracy of  diagnosis  which  so  greatly con-
tribute   to  distinguish  one  practitioner  from
another ; and, indeed, without  which, no man, be
his learning or his science what they  may, can
ever practise physic with success or satisfaction.
                               J. Conolly.

   [DISINFECTANT;  from dis  and  infect.
This term  has been  restricted by some writers
(Dr. A. T. Thomson, Elements of Materia Medica
and Therapeutics, 2d edit. Lond. 1835) to those
agents that are  capable of  neutralizing morbific
effluvia.   It  is so employed by the author of the
article Disinfection, in this work.   The writer
has always  used it, however, to include antisep-
tics.  These will be considered here;—the reader
being referred to the next  article for information
in regard to the others.
   Antiseptics, as the writer has defined them
elsewhere  (General  Therapeutics and Materia
Medica,  ii. 373, Philad : 1843), are "Substances
that  are  capable of  removing  any  incipient  or
fully formed septic condition of the  living  body,
or of any part of it."  If we  grant, that  such a
septic tendency  may exist  in the organism,  under
particular circumstances, we  can  conceive that
antiseptics may be needed  in two contingencies :
first, to obviate such tendency, and secondly, to
correct the offensive character of any of the tissneH
or secretions that may have become  putrid, and
thus prevent them from re-acnng on  the system.
Generally, the  acceptation of antiseptics include*
3h 
90                  DISINFECTANTS —DISINFECTION.
 nly agents that  are  employed  when signo of
putrescency have already  manifested  themselves,
and when the  object is both to destroy the offen-
sive character  of the tissues or secretions, and to
arouse the vital energies, so as to  enable the  func-
tions of nutrition to take fresh activity, and throw
off the morbiil and morbific  degeneration.  With
this  view,  the  different  vegetable  tonics,  and
especially cinchona,  with the mineral acids, are
commonly  exhibited, in order to induce a  new
action  in  the function  of innervation, — and,
through the improved  haematosis, to  enrich the
vital fluid, so that, when it reaches the capillaries,
—under the amelioration occasioned by these com-
bined  changes, — the  organs of nutrition   may
assume fresh  activity ; and  if a portion of the
organism has become dead, and consequently extra-
neous, a separation of the dead  from the  living
portions  may  be more readily accomplished.  In
this way, probably, most internal antiseptics  act;
whilst, by  passing into  the mass  of  blood, and
being exhaled through the different  emunctories,
they may,  at  the same  time, correct any septic
condition or tendency which the  different tissues
or fluids  have acquired.   The  action  of  some
antiseptics  cannot, however, be explained in this
manner.   This can obviously  only be  the modus
operandi of  such as  enter the  blood-vessels,—
wholly or in part.   Charcoal  probably exerts its
efficacy altogether on  the  first passages,  and,
through them, on the rest of the  economy.   It is
difficult to conceive, that it can  act through the
medium of the circulation ; whilst the chlorinated
preparations, creasote,  &c, produce their effect in
the  compound  mode  above  described.   In like
manner, when these and other agents  are applied
externally to gangrenous or gangrenoid parts, their
operation is equally complex.  They  first of all
disinfect, by acting chemically on the parts  with
which they come in  contact, and, as a general
rule, stimulate the vital energies of the tissues,
until these  assume a new action, and throw off the
morbid condition  and  degeneration.   With this
view, antiseptics are employed in gangrene,  spha-
celus, foul  ulcers, &c.  Some of them would seem
to act merely  as  disinfectants: such is  probably
the case with charcoal;  it merely  destroys the
putrid emanations, and  thus prevents  them from
acting injuriously  on the system.
  Of the special disinfectants of the living  body,
the most important are the following :
  Sulphate of Alumina.—The power, possessed
by  the aluminous  salts, of  preserving animal
matter has only  been appieciated  of late years,
and  chiefly through the  labours  of M. Gannal;
(History of Embalming &c. translated by Dr.
Harlan:  Philad.  1840.)   M.  Gannal  prefers the
simple sulphate  of alumina, made  by the direct
combination of alumina and  sulphuric acid.  It
has  been chiefly  to prevent  putrefaction in the
dead body, that  the  palts of alumina  have been
employed.  They  have,  however, at the writer's
suggestion, been used in the Philadelphia Hospital
as antiseptics and  detergents to  foul,  indolent
ulcers, and  with decided benefit;  (New Remedies,
4th edit.  p. 56 . Philad. 1843, and Medical Exa-
miner.- Philad. 1843.)
   Chlorine, in vapour, has been  inhaled in gan-
grene of the lungs, in which it has been found to
correct  the fetor of the breath and expectoration,
and to be, therefore, calculated to obviate not only
the local but the constitutional symptoms. (Stokes,
Dublin  Hospital Reports, vol. 5.)
  The  aqua  chlorini has been  given in variou*
cases as an antiseptic — as  in typhus, scarlatina
maligna, cancrum oris, gangrene of the lungs, &c.
It has also been used, properly diluted,  as a wash
to foul ulcers—as a gargle in putrid sore throat, &c.
   Chlorinated Lime and Chlorinated Soda have
been used in  like cases.
  The  Muriatic Acid  and Empyreumatie Ace-
tic or  Pyroligneous Acid  have  also  been pre-
scribed,  both  internally and externally, as anti-
septics.   The latter owes  its main properties to
the creasote  which it  contains.    This last  is
rarely given internally :  it is sometimes  applied to
foul, indolent ulcers, to  prevent or correct the
putrefaction of secreted  matters, and to stimulate
the parts to a better action.  It is also used as a
wash in gangrenous stomatitis ; and as a  collu-
tory, when a  fetid breath originates in the decom-
position of matters in the mouth.
   Charcoal is occasionally  given internally, in
septic conditions; but it is most frequently applied
topically,  as  in  dentifrices,  and foul ulcers.  All
the different   tonics,  too,  have  been prescribed
internally, as  well as applied  externally, in similar
conditions.   A poultice  of powdered  cinchona
is a  common application to foul ulcers, and to
gangrenous parts ; and  a decoction of  cinchona,
with muriatic acid, is frequently used as a gargle
in ulcerated sore throat.
                      Robley Dunglison.]

  DISINFECTION.—This word, being in some
degree new to our language, is here  used to ex-
press the operations by  which we attempt to clear
the air  and other bodies from the  contamination
of certain minute  particles,  some perceivable  by
the sense of smell, others not to be  thus  recog-
nised, but all producing deleterious effects on the
human  system.  Of those perceptible to the  sense
of smell the chemical qualities are in general more
or less known to us ; of those too, which are not
to be thus perceived, we possess some  chemical
knowledge; but of others we know  nothing ex-
cepting  their  deleterious effects on the human sys-
tem, and occasionally on that of inferior animals.
(See Infection.)
   However various the  sources of contamination,
the means which have  been  resorted to for their
correction are reducible to three heads: first, di-
luting, with pure  air, the atmosphere of the  in-
fected apartment or place;  secondly, the admix-
ture  of  certain gaseous  matters with  such  an  at-
mosphere, in  order to decompose the infecting par-
ticles :  or attempting to divest the atmosphere of
them by  substances  which have  an  absorbing
power;  thirdly,  clearing, by washing,  cleansing,
and exposure to the air  and  to disinfecting agents,
the solid matters, such  as  bed  and  body clothes,
the walls  of apartments, &c, of the noxious mat-
ters with which  they might infect the atmosphere
by slowly giving them out to it.
   1. Diluting with  pure air (for the  means of
accomplishing which see Ventilation)  is  the 
DISINFECTION.
691
measure which, in all cases admitting of correc-
tion, merits  the  most  confidence, and without
which all other means are nugatory.   It  is the
sole proceeding resorted to in cases in  which the
atmosphere of any place  is rendered  deleterious
to life by the  admixture of considerable quantities
of noxious gases, as  of carbonic acid produced by
vinous fermentation,  the combustion of charcoal,
or the decomposition of vegetable matters in a
close  place ;  or of carburetted hydrogen,  which
is occasionally so copiously evolved in coal-mines ;
or where the  wholesomeness of the air is impair-
ed  simply by the  destruction of its  oxygen, as
occurs in the  acid  fermentation ; or  where great
numbers of persons are assembled in a place com-
paratively small.
  2. The decomposition of the infecting particles
has been attempted from an early  period.   Large
fires were  formerly  kindled  in the streets of a
town  where pestilence was prevailing, with this
view ;  but it  seems more than  questionable whe-
ther they can in  such a  situation produce  any
beneficial effect whatever,  and by enlightened peo-
ple they  are now  entirely  abandoned.  In a limit-
ed quantity of air, however, as in an  apartment,
or the hold of a vessel, they may be  useful, not
by  acting chemically on miasmata, but as a venti-
lating process, by causing a current of air in such
situations ; the heated and consequently light air
ascending through the  chimney or  any aperture
which may exist, and being replaced by a portion
of that from  the exterior.   The firing of gun-
powder in the open air, which has been occasion-
ally resorted  to, seems destitute of any effect, for
we cannot expect any beneficial  chemical action
from  the azote, carbonic  acid, sulphate and sul-
phuret of potash, which are its products ; neither
can there be  hoped from it any movement of the
atmosphere sufficiently general to be  of service ;
but in a limited  space, by expanding the air, it
may certainly cause  it to be replaced by a portion
of the cooler and more condensed  external air.
Fumigations  with certain  aromatic substances, as
camphor, benzoin, &c, have  enjoyed a degree of
reputation probably unmerited, and founded solely
on  their  property of disguising unpleasant odours ;
but they are  now superseded  by measures deemed
more  scientific, whicb we shall proceed  to  con-
sider.
    Quick-lime.— This   substance,  besides  its
well-known property of absorbing carbonic acid,
which is copiously evolved from putrefying masses,
appears, too,  to absorb other gases which  are  the
result of putrefaction ; at least it has  the quality
of correcting offensive odours.  From its power
in this way, and probably from a supposition that
it decomposes or absorbs miasmata, it  is usual  to
pour it into privies or drains which emit offensive
odours;  and  when  pestilential  diseases are pre-
vailing to an  extent  to cause  great mortality, it is
customary to throw a thick bed of this substance
over the corpses in the grave or trench in which
they may be  deposited.  It is applied, too, in the
form of whitewash to the walls of apartments, in
which  persons ill of febrile  disorders have lain,
as a security against  any contagious matter which
may have adhered to them.
  Charcoal.--This  substance, as is well known
to chemists,  possesses tne property of absorbing
gases, and might, on this  account, be advantage-
ously employed to rid a limited portion of air of
hydrogen or other offensive matters with which
it is impregnated.  It has not, however, been em-
ployed in this way ; but the  utility of charcoal
filters in divesting water of any gases, the products
of animal or vegetable decomposition, with which
it is contaminated, has long been recognised.
  Acids. — These have long  been  supposed to
have the power of decomposing contagious  mat
ter, or in some mode depriving it of its virulence.
The well-known  thieves' vinegar owed its popu-
larity to this  supposed property ; and it is still
the custom to  dip into vinegar letters  and papers
which arrive from places where pestilence is pre-
vailing.  Clothes and goods of all kinds,  coming
from lazarettos, are exposed to  the vapours pro-
duced by the slow combustion of sulphur (sulphu-
rous acid).  But the former  being  thought  too
feeble, and the latter  having been found  exceed-
ingly irritating to the lungs, they are rarely em-
ployed  for  general  disinfecting purposes;  and
when acids  are used, either the muriatic, the oxy-
muriatic (chlorine), or the nitrous is  resorted to,
though  the employment of any of them in an
inhabited apartment  is not unattended with seri-
ous inconvenience to patients and attendants.
   Muriatic  acid  was first employed  by Guyton
Morveau, in 1773, to disinfect tbe principal church
of Dijon, the air  of which had  become so contam-
inated by the  emanations from  the vaults below,
from which, on account of their too crowded state,
the bodies had been  removed, that it was utterly
unfit for divine worship.  Vinegar, aromatics, and
the deflagration  of nitre had  been tried without
effect; but the vapour arising from the decompo-
sition of six pounds  of common salt by  two of
concentrated  sulphuric  acid deprived the  air in
one day of  all unpleasant odour, and  in four days
afterwards worship was  performed.   This distin-
guished  philosopher,  towards  the close of  the
same year, used fumigations of muriatic acid with
complete success for disinfecting the prison  of Di-
jon, whither fever had been imported from  other
gaols, of so malignant a nature that thirty-one
prisoners  had perished  from  it in  a very short
space of time.
   The proportions recommended are  twelve parts
of sulphuric acid of the specific gravity 17- to fif-
teen  parts of muriate of soda, which should be
slightly moistened before the acid is poured upon
it.   If employed for disinfecting an  uninhabited
place, flat earthen dishes, containing the mixture,
may be placed on a  sand-bath, and the whole of
the acid may be added at once.   If in one  occu-
pied by patients or others, all  heat  should be dis-
pensed with, and the acid should be added gradu-
ally.   The  latter rules  should  be considered  im-
perative in all cases where acids  are employed to
disinfect inhabited places.
   Nitrous acid  fumigations were first employed
in this country ;  and a liberal parliamentary grant
was bestowed  on Dr. Carmichael Smyth for their
application  to disinfecting  purposes,  which was
regarded as a  discovery.  A prior claim was sub-
sequently set up  for  Dr. Johnstone, of Worcester
The  fumigations were  successfully employed by
Dr. Smyth in  1780,  for checking the  progress of
a fever which  prevailed among the Spanish  pri 
692                                DISINFECTION
soners at Winchester, of whom  it had destroyed
a seventh  part  in  three months.  Several other
examples of their utility in disinfecting ships and
hospitals might readily  be quoted.  Nitre  and
sulphuric acid are the substances employed in this
mode of fumigation, and equal parts of both in-
gredients are found  to  be the best proportions.
The combination of  the salts producing a  consid-
erable evolution of heat, none should be employed
to aid the  decomposition.   It is calculated  that
half an ounce  of each ingredient will suffice to
disinfect an apartment of ten feet in each dimen-
sion, comprising of course a thousand cubic feet;
and it is advised, in case of our having to apply
the method to larger apartments, that we  should
multiply the cups or saucers which contain the
ingredients, ratber than introduce a larger quan-
tity than that  mentioned  into one  vessel, as the
red fumes disengaged might seriously incommode
the operator.
   Oxygenated muriatic acid (chlorine) was  first
proposed as a disinfecting agent  by Fourcroy, in
1791. It  was soon after employed by  Cruick-
shank, of  Woolwich, and by Guyton Morveau,
who thought it  preferable to all other acids ; and
it has since united  most  suffrages in its  favour.
There is an excellent and concise account, in the
eighteenth volume of the  Journal of Science and
the Arts, of the disinfection of the Milbank Peni-
tentiary by Mr. Faraday.   To this  the reader is
referred, as it comprises all that is necessary to be
known of  the mode of applying fumigations of
chlorine to uninhabited places.   The following
are the material points of the  process adopted by
Mr. Faraday.   He found  that one part by weight
of common salt, and one part of oxyde of manga-
nese, when acted  upon  by two parts of oil of
vitriol, previously mixed with one part by weight
of  water,  produced  the  best  results.   The salt
was bruised down with a  mallet previously to be-
ing mixed with the  manganese; and the acid and
water were mixed in a wooden tub, and  allowed
to stand for some hours,  that the heat produced
 by their combination  might be  dissipated before
they  were  poured on the other ingredients. Com-
mon  red  pans,  of a flat form, were used for the
funiigation. The evolution of chlorine commenced
a few minutes after the ingredients  were mixed in
the pan, and continued for four days, no extrane-
ous heat being  employed in the  operation.   The
 quantity of material used was 7001b. of salt, 7001b.
of  oxyde of manganese, and 14001b. of sulphuric
acid;  whilst   the   space requiring  fumigation
amounted  to nearly  2,000,000 cubic feet,  and the
surface of the  walls, floors, and ceilings was about
 J ,200,000 square feet.  The able arranger of the
process is  of  opinion  that from  one-half to one-
fourth of  the chlorine, and consequently of the
ingredients employed for its production, would be
quite sufficient  in a building of  the same extent,
for any of the usual cases where  fumigation is re-
quired.  The proportions recommended by Guy-
ton Morveau  differ from  those employed  by Mr.
Faraday.   The former philosopher advised that
two parts of powdered oxyde of manganese should
be mixed with ten parts of muriate of soda, and that
the mixture should be acted upon by six parts of sul-
phuric acid previously diluted with four of water;
 und in an uninhabited room, forty feet by twenty, he
thought two ounces of oxyde of manganese, ten
ounces of muriate of soda, six ounces of sulphuric
acid, and  four ounces of water, sufficient for per-
fect disinfection ;  the  doors and windows  being
closed for ten or twelve hours.
  Chlorine is so powerful an irritant to the  bron
chial lining, that its rapid evolution in  the pro-
cesses described above  is quite inapplicable  to in-
habited  apartments or wards, unless the quantities
of the ingredients  employed  are so small in pro-
portion  to the space to be disinfected that we can-
not expect any beneficial result from them.  Guy-
ton Morveau endeavoured  to surmount this diffi-
culty by means of his permanent apparatus of dis-
infection, which consisted of a glass vessel encased
in wood, having its mouth very accurately closed
by means of a  ground glass stopper, acted on by
a vice.   A  slight  turn of the vice allowed the
vapours, by their expansive force, to raise the stop-
per and mingle with the atmosphere.  One-third
of the  apparatus was  occupied  by four  parts of
oxyde of manganese, finely powdered  and  sifted,
ten parts of nitric  acid of sp. gr. 1.40,  and ten of
muriatic acid of sp. gr. 1.134.   From this combi-
nation  the  chlorine  is  disengaged much  more
slowly than by the action of sulphuric acid on a
mixture of muriate of soda and manganese; and
by means of the vice  the issues of gas are  regu-
lated  at pleasure, whilst the lightness and  close-
ness of the apparatus enable us to remove it rea-
dily from one place to another.  The disinfecting
bottle,  arranged in  the manner described, may be
opened  twice a day, and still retain its disinfecting
power for three or  four months.   However  inge-
nious the plan of  M. Guyton  Morveau,  this, and
perhaps all disinfecting processes—certainly all
for occupied wards  or apartments—are  superseded
by  the  agents  more  recently introduced by M.
Labarraque.  This gentleman, an apothecary in
Paris, was the  first to suggest the  employment of
chlorine in a liquid form for disinfecting purposes.
He recommends two solutions.   One, the chloride
of lime  (a solution of bleaching powder,) is pre-
pared by passing  chlorine gas over hydrate of
lime : this, when dissolved in water, forms Labar-
raque's liquid  ;  or the  liquid may  be formed
directly by passing  the gas into water which  holds
lime in suspension.   Two methods  are recom-
mended for forming chloride of soda,  one by M.
Labarraque, and the other by M. Pay en.   The
former  passes chlorine gas into a  solution of car-
bonate  of soda  ; the latter decomposes  chloride of
lime by the carbonate.  Both  processes  are easy,
the latter the most so ; and it has been so arranged
by M.  Pay en  as to make the resulting compound
identical with that prepared by the former method.
No carbonic acid is expelled on passing  the chlo-
rine into  the solution of  carbonate  of soda ; the
solution has  a faint  smell of chlorine;  when
heated, scarcely any chlorine  is evolved ; it first
acts as an  alkali  on  turmeric  paper,  and  then
bleaches it; on the addition of acid, chlorine and
carbonic acid are expelled.
   Chemists do not seem  fully agreed as to the
precise nature  of these compounds,  but in a prac-
tical work we do not feel called upon to enter into
controversies  on  this point.   (See Granville  in
Journal of Science, &c. vol. xxiii. and R. Phillips
in Philosophical Magazine, vol. i. of New Series.) 
DISINFECTION.
693
 [t is material to know that they are most powerful
 disinfecting agents, and that since their introduc-
 tion by  Labarraque  they have  been applied to
 every kind of case in which the operation of such
 agents is requisite, by innumerable scientific per-
 sons of various nations, whose,, testimony is loud
 in their favour.  They appear to  act, as the expe-
 riments of Gaultier  de Claubry tend to prove, by
 the evolution of chlorine, from the action of the
 carbonic acid contained in the atmosphere on the
 compounds, so that a gradual fumigation by chlo-
 rine takes  place; and where atmospheric impuri-
 ties abound, the proportion of carbonic acid being
 generally  greater, the  fumigation will  be  more
 rapid.   The following is an abstract of  these ex-
 periments :
   Well saturated chloride of lime being dissolved
 in water was submitted to the action of carbonic
 acid gas;  chlorine  was quickly  disengaged, and
 by continuing the operation a sufficient length of
 time, the whole was  expelled, the liquor no longer
 possessing bleaching powers,  and carbonate  of
 lime having been precipitated.
   Air, passed slowly tbrough a saturated solution
 of caustic  potash, to deprive it of carbonic acid,
 was then made to traverse a solution of the chlo-
 ride of lime ;  no chlorine was liberated, no effect
 of any kind produced.
   The chloride of soda is equally decomposed by
 carbonic acid, only more  slowly,  in  consequence
 of the solidity of the salt produced.
   A filtered  solution of the  chloride of lime was
 exposed  to the air on the  13th of August; on the
 10th of October it  no longer contained chlorine ;
 did not affect  litmus; and the precipitate from it
 proved to be carbonate of lime.  A stronger solu-
 tion of the same chloride, exposed  to the air on
 the 16th of August, was  found in the same state
 as the last  on the 10th of October.
   Air was passed through blood, which had been
 left to putrefy for eight days;  being then passed
 through  a  solution of the chloride of lime, carbo-
 nate of lime was deposited, and the  air was ren-
 dered inodorous and completely  purified.   In a
 second similar experiment the fetid air was passed
 through a saturated solution of caustic potash be-
 fore it arrived at the solution of the chloride; the
 latter then  had no effect  upon it, and the air re-
 tained  its  insupportable odour.   Another experi-
 ment was  made with air left  twenty-four  hours
 over putrescent blood ; the  portion  of  it which
 was passed directly  through the chloride was per-
 fectly purified, but when  previously  freed  from
 carbonic  acid, the chloride bad no effect upon  it.
 (Annales de  Chimie, xxxiii. 171, and Journal of
 Science, vol. xxiii.)
   These experiments of Gaultier de Claubry seem
 very conclusive, yet a fact is mentioned by Labar-
 raque and  Parton, in their report to the Council
 of Health  of Paris,  on  the  removal, from the
 church of St. Eustache, of the bodies which  were
 deposited there during " the three days" of July,
 1830, which  tends  to show that carbonic acid is
not uniformly the agent  which  decomposes the
chlorides and calls  into  action  the disinfecting
power of the chlorine.  These individuals found
this process go on very rapidly indeed, though a
bed of lime thickly spread over  the  floor must
necessarily  have absorbed the carbonic acid; and
hence were led  to conclude  that an exact theory
of the phenomenon still remains to be discovered.
(See Report, &c. or  abstracts of it in the Medical
Gazette for January 1, 1831, which also merits
perusal  as  showing the mode of applying  the dis-
infecting liquid on a large scale.)
   The chloride of lime is  the  preparation which
M. Labarraque recommends for disinfecting apart-
ments, while that of soda is  especially employed,
in topical and external applications, to foul  wounds
and  ulcers, &c.   It were  needless  to enlarge on
what is so  familiarly known,  their power of delay-
ing the  occurrence of putrefaction,  of arresting it
when it has already  commenced, and of purifying
the  tainted air  of hospitals, prisons, lazarettos,
ships, sick-chambers,  sewers, drains, and manu-
factories in which animal substances in a  state of
putrefaction are  used, and their consequent utility
to the anatomist, physician, and, we may  say too,
police-officers and magistrates.
   If an uninhabited  place  is to  be disinfected,
troughs or pans, whicb, expose a considerable sur-
face to the air, and containing the chloride  of lime,
are  placed in various  parts of the  building;  the
same liquid  is poured over  the floor, and sheets
wet  with it  are suspended in various situations.
If an inhabited  ward or apartment is to  be kept
clear of impurity, the floor must be  frequently and
freely sprinkled with it,  and  portions of linen
moistened  with  it should be attached to the bed-
curtains, window-hangings, &c.  If a  putrefying
body is  to be preserved, it should be kept wrapped
in a cloth steeped in it; or, if one is  to be  ex-
humed, the same plan should  be adopted, with a
copious affusion of the liquid into the vault  the
moment it is opened.  It  may be poured freely
into  drains, privies, or  night-chairs which  emit an
offensive odour; and foul sores may be frequently
washed  with the liquid chloride of soda,  diluted,
if necessary, with rose-water.   The only incon
venience connected with their use is the  unplea-
santness of the smell of  chlorine, which some
patients declare to be worse than that which it is
employed to correct; but they should be reminded
that  tbere is nothing pernicious to life in the smell
of the disinfecting liquid, whilst the bad smell of
the apartment betokens unwholesomeness.
   The subject would be left imperfect did we not
inquire into the extent of the  power and the mode
of action of acid fumigations, in which class  we
include chlorine, either directly applied or furnished
by the chlorides,  though not ignorant that  the title
of chlorine to be considered an acid is disputed by
chemists, and though there may be still some doubt
as to the mode in which the cblorides affect atmo-
spheric impurities.
  It  will be at once  understood that these agents
can  produce  a beneficial effect  only on  a  limited
quantity of air, and  that no epidemic constitution
existing in the atmosphere of a district or country
can  be  corrected by them.   If  they are to havt'
any beneficial effect  in checking the propagation
of febrile diseases, the  miasmata which  engendei
such diseases must be existing in a limited space ;
for if the air which  will necessarily replace that
which has  been  disinfected  partah* of a  general
contamination, it is  manifest that  their employ
ment can be attended with no good effect but thai
of correcting obvious nuisances,  such  as bad 
694
DISINFECTION.
smells.  Hence, when these vapours have  been
employed  to prevent the diffusion of a widely-
spreading epidemic malady, they have uniformly
proved inefficacious, as was shown by M. Nysten
and Professor Arejula regarding yellow fever, when
it was prevailing in the south of Spain during the
years 1800, 1801, 1803, and 1804.   Cabanellas,
it  is true, who was sent by the Spanish govern-
ment into  Andalusia to  employ  them, thought
favourably of their merits, but the weight of testi-
mony is against him ;  and, besides, he did not
employ  them till the month of November, when
the heat having abated, the intensity of the epi-
demic must, according to  its known laws, have
been  diminishing.  That, employed in  a limited
atmosphere, they have some effect in checking the
spread of typhus, appears to  rest  on  competent
authority.   Ignorant as we  are of the nature of
contagion, we are of course ignorant of any spe-
cific chemical power they possess of acting  upon
or decomposing it.  All the stronger acids, as we
know, possess  the property of corroding the ani-
mal texture ; and their power of acting on conta-
gious matter which  is of animal origin, may de-
pend on this  property, or on  their quality of ab-
sorbing or decomposing the noxious gases, which
are probably powerful vehicles of contagion, as it
is  ever found to be least active in the purest atmo-
sphere.   That in some way they act on the con-
tagion of typhus rests on  the testimony of Guyton
Morveau, Carmichael Smyth, and  a bost  of per-
sons of note and character; but the feeling of the
profession at large, and  we believe that  feeling to
be  a correct one, is that their power over it  is
limited, and does not supersede the necessity of
avoiding needless approximation to the sick, and
of adopting every measure of ventilation and clean-
liness which art can supply.
   That, in  a  limited atmosphere, they promptly
destroy  bad  odours, is well ascertained, and of all
modes  of fumigation that with  chlorine is the
most efficacious in this  way :  but on what this
property depends does not seem very well under-
stood in tiie case of  all of them.   Chlorine  com-
bines readily with hydrogen, and  combines with
or decomposes its compound gases; it decomposes,
too, ammoniacal gas, and hence there is not much
difficulty in understanding how an agent  which
acts promptly on those gases, the result of putre-
faction, and affecting strongly .the  sense of smell,
should be powerful in correcting the more obvious
nuisances of infected apartments.   But it is not
so  clear  how certain  of the other  disinfected
agents,  muriatic acid for instance, the affinity of
which for septic gases is  less general than that of
chlorine, remedy  such nuisances, though  the ex-
perience of Guyton and many others places the
fact that they  do  so beyond all question.
   3. It is  obvious  that  the solid  matters which
are  in  the infected  apartment will receive the
beneficial influence of the fumigations  employed
to purify the air.   In addition to this, they should
De  washed  with  soap and water, or an alkaline
ley ; the walls should be  white-washed, and air be
freely admitted for some time previously to the
room's  being again inhabited.   All body and bed-
clothes  withdrawn from  patients labouring under
fever should be thrown at once into hot water, and
»*:-r remaining there for some time, should be
 thoroughly washed with  soap or an alkaline ley.
 They should  then be hung  up in the air for a
 considerable length of time, and they may be oc-
 casionally sprinkled with the  chloride of lime.
   The ordinary mode of preparing  the liquid chlo-
 ride of lime is as follows :—Introduce into a com-
 mon retort fourteen parts of black  oxyde of man-
 ganese, six parts of muriate of soda, the same  pro-
 portion of  sulphuric acid, and twelve parts of
 water.   The  chlorine gas  will rise without the
 application  of heat, (though, if it  is thought de-
 sirable  to accelerate  the  operation, heat may be
 employed,)  and should be transmitted through a
 tube attached to the  neck of  the retort  to the  bot-
 tom of a vessel filled with a saturated solution of
 lime.   When this is saturated with chlorine, the
 test of  which is the cessation of the evolution of
 gas from the materials  in the  retort, it contains
 about twenty per one hundred of this principle,
 and may be diluted  with forty  parts of water for
 ordinary disinfecting purposes.   It is desirable to
 add the water shortly before  employing it, as  an
 extrication  of gas commences  rather rapidly  im-
 mediately on  the water being added.
   The liquid chloride of soda is prepared in  the
 same manner, a solution of one part of subcarbo-
 nate of soda  in twenty parts water being substi-
 tuted for the saturated lime-water.  The absorbing
 power of this  solution over the chlorine is less than
 that of the lime-water : hence, when used for  dis-
 infecting purposes,  the  liquid chloride  of soda
 should be diluted with only  thirty  parts of water.
   The materials  employed for  impregnating  one
 or the other of these  liquids with chlorine, may be
 frequently made to evolve  more of this principle
 by the  addition of more sulphuric acid, and thus
 successive quantities of the chlorides may be formed
 from the same ingredients.
   Dr. Henry, of Manchester,  has recently per-
 formed  a series, of experiments, which seem to
 prove that the fomites, or materials impregnated
 with the infectious  principles  of  various conta-
 gious diseases,  may be  rendered totally inert by
 exposure to  elevated temperatures.  Dr. Henry
 first ascertained  that raw  cotton, and  various
 kinds of piece-goods manufactured from  that or
 other materials  for clothing, are injured neither in
 texture nor colour by exposure for several hours
 to a dry temperature of nearly 212°, or even "50°,
 Fahrenheit.  He next ascertained experimentally,
 that vaccine matter, though capable of communi-
 cating  the disease after exposure to 120°  Fahren-
 heit, is rendered inert by a temperature of 140°.
 In the  third place, he found  that  a flannel shirt,
 which  had  been worn by a patient  in well-marked
 typhus between the tenth  and eleventh days of
 the disease, was,  after exposure for an hour  and
 three quarters to a temperature of 204° Fahren-
 heit, incapable of communicating the disease  to a
 person, below  whose nostrils  it was  placed  for
 two hours; that a second flannel waistcoat worn
 on  the night between the eleventh and  twelfth
 days,  and heated in  the same manner, and worn
 for  two  hours  by the same individual, did  not
 communicate the disease;  and that a third worn
 by the patient on the night  between  the  twelfth
 and thirteenth  days, after exposure to  heat  and
| seclusion in  an  air-tight canister  for twenty-six
I days,  was  equally  incapable of communicating 
DISINFECTION. —DIURETICS.
695
fever.  In the fourth place, he found that a series
of eight  flannel waistcoats worn for several hours
by patients  in  distinctly marked  scarlet  fever,
afterwards exposed to heat varying  from  200° to
204°,  and eventually worn for several hours by
children  not  having had scarlet fever,  did not
communicate the disease  to these  children.
  Dr.  Henry  expresses himself with a degree of
caution  respecting a  positive  conclusion  being
deduced  from his experiments on the contagious
principle of typhus ;  but thinks his experiments
sufficiently numerous to prove, that by exposure
to a temperature not below 200°,  during at least
one hour, the contagious matter  of scarlatina  is
either dissipated  or destroyed.  He is more in-
clined, however,  to  the latter than the former
supposition,   because  cow-pock  matter, though
completely deprived of its volatile  portion at 120°,
is not rendered  inert by temperatures much below
 140°.
   As a  disinfectant of articles which are capable
 of imbibing  and  retaining contagion,  heat, the
 author suggests, is greatly superior  to the vapours
 or gases used for the same purpose; inasmuch as
 the transmission of the latter may be stopped by a
 few folds of compressed materials;  while heat, if
 time enough be allowed,  finds its  way  in spite of
 all obstacles.  He limits the application  of  the
 method  to  the  destruction of contagion existing
 in substances technically  called  " susceptible ;"
 for instance, to  infected clothing of every descrip-
 tion ;  to infected bedding and bed-furniture of
 every kind  that would be spoiled in washing ;  to
 trunks and other packages brought by travellers
 from  infected places, and  to  merchandise when-
 ever it can be shown or rendered  highly probable
 that such merchandise has been in tbe way of
 imbibing contagious matter.  The apparatus re-
 commended by Dr. Henry is  simple, and  seems
 well calculated for the object  he has in view.   It
 consists principally of two vessels  of copper,  or
 tinned iron, between which steam,  the agent em-
 ployed for transmitting heat to the infected mate-
 rials,  is introduced : but for a full  description of
 the apparatus,  and for the plate  in which it is
 represented,  we must refer to the Philosophical
 Magazine and Annals of Philosophy for January,
 1832.
   In  a  matter  of so  much importance, and, we
 would add too, of such extreme difficulty, it  ap-
 pears desirable that a more ample series  of expe-
 riments should be performed on the  contagious
 principles of typhus  and scarlatina ; and that we
 ought not to rely on  mere analogy as a reason for
 extending to other contagions the procedure re-
 commended,  but  that  these ought likewise to be
 made the objects of experiment.
                           Joseph Brown.

   DIURETICS, (Diurelica,  <Pdppaica SiovpvriKa,
from Sid and  oipeio, meio:  Th. olpov, urina,) me-
dicines  which  augment  the urinary discharge.
This definition might be considered defective, as
being too general, but it is the only one that can
be admitted ; for the excretion of urine, under the
influence of diuretics,  does not always arise from
a direct  application of the  diuretic  substances to
the kidneys , but, frequently, from circumstances
connected with the state of the stomach, and other
organs,  under which  the kidneys act  only u  se-
condary part.
  Diuretics are supposed to operate in four dis-
tinct ways:  1, by  passing  into  the circulation,
and, being conveyed  to the kidneys without un-
dergoing any decomposition in  transitu,  acting
directly as  stimulants  on the urinary organs ;  2,
by suffering decomposition in transitu, and  act-
ing on the  kidneys  by one or more of their con-
stituents ; 3, by acting primarily  on  the  stomach
and primae  viae, communicating thpir action to the
kidneys by sympathy  ;  and, 4, by stimulating the
disordered  capillary system to more healthy ac-
tion,— thereby preventing the undue  effusion of
fluids into  the serous  cavities,  and permitting the
absorbents  to convey those already effused  into
the circulation, to be discharged by their natural
excretories the kidneys.*
   1. In the healthy and ordinary condition of the
body, the  blood which is sent to the kidneys is
divided into innumerable streams, each of  wbich,
entering the  glandular glomerules of which these
organs  are  principally composed,  supplies  the
pabulum from which  the urine is secreted ; what-
ever, therefore, is conveyed to the kidneys through
the medium  of the blood must, more or less, affect
the natural function of these organs. Thence the
inquiry, in what manner is  this effected ?
   If we analyse the urine, we find that it consists
of water ;  urea, a peculiar compound of nitrogen,
oxygen, carbon, and hydrogen ; small proportions
of sulphates  of soda  and potassa ;  phosphates of
lime, soda, and  ammonia ;  muriates of soda  and
ammonia;  lactate of  ammonia and fluate of lime.
Knowing that these are the components of urine,
it is not difficult to ascertain what substances  have
passed  through the kidney's,  and  whether these
have undergone decomposition.  Thus,  if  free
potassa or nitrate  of potassa  be taken into the
stomach in moderate  doses,  and be afterwards de-
tected  in the urine,  we may conclude that  they
have been conveyed  to the kidneys through the
blood, as they could not otherwise be found in the
excretion of these  organs.  The excretion, how-
ever, of these salts does not take place without the
kidneys experiencing the influence of their stimu-
lating   qualities,  and consequently  having  their
natural action so much augmented that a larger
than usual supply of urine  is  the result.  On the
knowledge of this  truth, the first division of the
preceding  arrangement may be said to be consti-
tuted.   It  is nevertheless a curious fact that, al-
though these substances can  be readily detected
in the urine, yet they cannot be  discovered in the
blood ;  neither  can colouring matters, which are
easily  displayed in  the urine, be  rendered  evi-
dent, either  in the  blood  or  in tne chyle.  A
doubt was suggested as to the  medium througi
which  such  matters are conveyed to ihe kidneys
by Sir  Everard Home, who imagined that  they
found their way through the spleen ; but be after
wards properly abandoned this opinion, on finding
that, after removing  the spleen, and tying the
thoracic duct, the colouring matter of rhubarb in
  *  This plan of the mode in which diuretics operate n
a modification of that of Dr. Paris, (Pharmacologia, vol
i. p. 167,) which in its turn is a modification of that sug.
gested by Dr. John Murray, (Materia Medica, vol. i. n
36G-R) 
696
DIURETICS.
jected into the stomach of a dog could be detected
in the  urine.   It  is sufficient,  however, for our
purpose, to know  that substances taken  into the
ttomach are conveyed  to the kidneys ;* and  that,
if they  are of a nature to stimulate these organs,
provided the stimulus be short of that necessary
for exciting inflammation, an increased  secretion
of urine must follow.   It is  indeed perfectly ob-
vious that the  stimulant  influence of diuretics
must be  within a certain  limit;  for were the
excitement of the  kidney sufficient to induce in-
flammatory action, the  urine,  instead  of being
augmented in quantity, would  be scanty, high-
coloured, and acrid ;  a fact of great practical im-
portance.
  It may not be improper to remark, in this place,
that the chief intention of the renal secretion is,
probably, the excretion of urea.  When both kid-
neys are taken  away from a dog, the animal dies
before  the ninth day ; but, previous to death, the
serosity of the other secreting organs affords traces
of the  presence of urine  in  it.  In  reply to this
mode of reasoning, it  is stated that, in a healthy
condition of the body with the kidneys entire, urea
has  been  detected in  the perspiration ;  and that
there are  instances of persons having passed  no
urine for many years together, and who yet have
suffered no inconvenience ;-j- but these are excep-
tions to a  general  rule.
  Much of the fluid  ingesta passes off by the
kidneys, and  the quantity of  urine excreted  is
generally  proportionate to  the  quantity  of fluid
taken into the stomach ;  thence the necessity of
dilution to promote  the operation  of  diuretics.
None of the substances possessing diuretic pro-
perties require the aid of dilution so much as tbose
in the first division of our arrangement.  Without
this they  would scarcely be conveyed to the kid-
ney, and,  if they were, the over-excitement which
would be induced would check rather than promote
the increase of the urinary secretion.
  The action of diuretics is, also, much modified
by the function of the skin.   When a diuretic  is
administered, the surface should be kept cool; for
if the cutaneous exhalents be stimulated  by heat,
the medicine determines to the surface, by that law
of the system which regulates the balance between
the skin and the kidneys as excretories, and sweat-
ing  supervenes  with a diminished discharge of
urine;  just as in the healthy state, in cold weather,
when the surface is chilled, the urine is abundant
and pale, whilst in warm  weather, when perspira-
tion flows freely,  it  is  scanty and high-coloured.
On  this account  the  season of the year, and all
circumstances influencing the function of the skin,
modify  the operation of direct diuretics.
  2. Many vegetable bodies and some salts which
operate as  direct diuretics, undergo digestion, to a
certain  extent, and only one or more of their con-
stituents reach the kidneys.  It is a curious fact,
  * Alkalies are detected in the urine by testing it with
tumeric paper; nitre by dipping a piece of bibulous paper
into it, then  drying the  paper,  and applying it to the
tiame of a candle; if it deflagrate, nitre is present.  The
odour of asparagus, garlic, turpentine, cubebs, and many
other substances, is detected in the urine an hour or two
after these substances have been swallowed.
  t Dr. Richardson, in a paper published in the Philoso-
phical Transactions of 1713, mentions a lad of seventeen,
vrho had never made any urine.
however,  that  the saline  bodies which  undergo
decomposition  in transitu  are  those into which
the vegetable acids enter as components.  The
acid, which is  separated, is decomposed  and  re-
solved into its primary elements as if it had been
swallowed in its  free state ;  and the alkali being
taken  into the circulation, is conveyed undecom-
posed to the  kidney, and excites that action in it
which promotes the secretion and excretion of  the
urine.  This remark, however, as we shall after-
wards prove, is  not generally  correct; for some
salts,  compounds of vegetable acids with alkalies,
bitartrate of potassa, for instance, operate in a man-
ner which cannot be explained  upon the supposi-
tion that its alkali only is conveyed to the kidneys.
The neutral  salts containing the mineral acids  are
not decomposed, but operate as  direct diuretics, as
has been  already described.  Dr. Paris seems  in-
clined to  believe  that the bitter principle is the
active ingredient of the vegetable diuretics, which
are decomposed by the digestive organs :  we are
not prepared to deny the accuracy of this opinion;
but, if we may reason from  analogy, we  should
be disposed to  ascribe the  effect to some alkaline
principle, whicb it is probable  all  of them con-
tain.   That  other  principles  of vegetable bodies
are separated during digestion,  and carried to the
kidneys, is evident  from  the odour which garlic,
turpentine, asparagus, and some other vegetable
matters impart  to the urine ; and as these are diu-
retics, it is not improbable that they possess this   '
quality from the principle, whatever it is, which
is combined with or constitutes the odorous matter.
  Salts containing vegetable matter in excess, are
more  diuretic than those which contain the same
acids  in proportions only to neutralize the alkaline
bases with which  they are united, in proportion
as they are  more susceptible of decomposition.
Thus, whilst bitartrate of potassa is diuretic, the
neutral tartrate is purgative, and exerts no action   i
on  the kidney.  Something, however, is  due  to
the extent of the dose in which the salt is  admin-
istered ;  many substances in small and moderate
doses operating as diuretics, which, in large doses,
operate as cathartics.  This is the case with bitar-
trate of potassa.  Oil of turpentine in doses of ten
or fifteen minims  up to a fluidrachm, stimulates
the kidneys  so  powerfully  as   to  cause  bloody
urine, yet a  fluidounce purges and  produces  no
perceptible effect  on the urinary organs;  and  in
the same manner, when nitrate of potassa has
been taken in large doses by mistake for sulphate   i
of magnesia, the symptoms  do not indicate any
affection of the kidneys.
  3.  With regard to the third description  of diu-
retics, those  which augment the flow of urine,
without acting  directly on tbe  kidneys, we find
that they are substances which, augmenting the
nervous  energy, give an  impulse to the  general
vigour of the babit, and produce tone.  In a weak-
ened state of body the fluids in  the serous  cavities
and cellular  texture accumulate; and when the
cutaneous system  shares in the general debility,
anasarca  also is the consequence.   In such con-
ditions of the  body, by  augmenting the  general
tone,  the urinary organs also acquire additional
vigour; and thence  diuresis and  the absorption
of effused fluids follow the administration of vege-
table  bitters and other tonics. 
DIURETICS.
697
  4. The fourth division of diuretics is one of
great importance, and  contains, besides  mercury,
many diuretics, the action of which has been erro-
neously supposed to depend on their influence on
the absorbent  system.   We shall  examine  this
subject in detail, when we have occasion to speak
of the substances that  are arranged under this di-
vision.
   Diuretics, from the increased discharge of urine
which  they induce, operate as evacuants ; but, at
the same time, they also  exert a stimulant influ-
ence.  As evacuants, they remove the general ple-
thoric  state of the system, and diminish excite-
 ment without  inducing much debility ; for, as the
abstraction of fluid from  the  circulating mass is
slowly effected, the vessels contract and gradually
 accommodate themselves to the lessened  quantity
 of their contents.  As  evacuants also, diuretics are
 supposed to carry off acrimonious matters contain-
 ed in the blood ;  but the existence of such matters
 in the circulating mass is very doubtful. As sti-
 mulants, diuretics act both on the general and the
 capillary systems, even when they exert a direct
 influence on the  kidneys.   As far as their effects
 depend  on their  stimulant properties,  they are
 contra-indicated in all inflammatory states of the
 kidneys; in which states, and where much irrita-
 bility is present, the simple diluent diuretics are
 to be preferred.   Water is the best of these;  how
 far it acts a part in all diuretics is not accurately
 known, but it has undoubtedly an influence in
 modifying their effects.  There is no doubt that
 copious draughts  of  water, or any mild aqueous
 fluids, if  not determined  to the skin by external
 warmth, pass  freely off by the kidneys,  and thus
 produce an increased discharge" of urine.
    Among the diuretics which  act primarily on the
 kidneys,  without undergoing decomposition  in
 transitu, we find ?ime volatile oils.  The oil of
 turpentine, -ne of  these, in  whatever manner
 it may be tak«m into the habit, rapidly displays its
 presence in the urine by  the  odour of violets,
 which  it lommunicates to that secretion.  Its ef-
 fects,  however,  as we have  already stated, are
 greatly influenced by  the extent of  the  dose.   In
 some idiosyncrasies it  causes a cutaneous eruption
 closely resembling eczema, in which case it ought
 not to be  prescribed.  During  its  employment
 neither wine nor spirits should be indulged in, and
 the ordinary quantity  of food should be  diminish-
 ed. Cajeput oil, and that of  cubcbs and of
 juniper, operate in  every respect  in  the same
 manner.   They are all employed to excite the ac-
 tion of the kidneys in hydropic diseases; but in
 effecting this, it is probable that they also influ-
 ence, generally, the capillary system.  The oil of
 turpentine is the most useful of the three ; thence
 the reason why good English  gin is a superior
 diuretic to Hollands, being rectified on oil of tur-
 pentine instead  of juniper berries.  These volatile
 oils may be combined with sugar as an oleo-sac-
 charum^ and given in any bland fluid, the best of
 which is the bitter almond  emulsion.
    Among the inorganic substances  belonging to
 this section of the direct diuretics, iodine stands
 foremost.   The alcoholic  solution or tincture is
 the form of the medicine most commonly employ-
 ed. When administered internally in doses of
 from  ten to  thirty minims of the  tincture, m a
    Vol. I. —88
glass of water, twice or three times a day, iodine
stimulates powerfully the whole of the glandulai
system, and, in a special manner,  the  kidneys.
The diuretic effects of iodine, in combination with
its general influence on the glandular system, ren-
ders it a most useful remedy in ascites connected
with diseased states of the liver and the mesente-
ric glands.  Like foxglove, it does not act benefi-
cially when the abdomen is tense; but after tap-
ping and reducing the excitement by a judicious
employment of the lancet, it rapidly displays its
influence on the kidneys.  It seems to be the only
decided  agent  which  we possess for stimulating
the absorbents, and this extends even  to their in-
fluence over healthy glands : both  the  mammae
and the testicle free from disease have in several
instances nearly disappeared  during its adminis-
tration.  The writer of this article bas had  occa-
sion to remark  its powerful influence on the ab-
sorbents most satisfactorily demonstrated  in a case
of  diseased ovarium, which, after tapping,  and a
course  of alteratives with tincture of  iodine, car-
ried to  the extent  of sixty minims for a dose three
times  a day, was completely cured.  In this in-
stance, it is probable 'that the  great advantage
arose from  the rapidity with whicb the iodine was
thrown into the habit after the tapping, and whilst
the flaccid  sac  remained  as a kind of extraneous
body in the abdomen.   It has never proved useful
in  similar  cases  when administered during the
turgidity of the  ovarian  tumor, the growth of
which seems to be little connected with the gene-
ral system, and to depend solely on the  local ac-
tion of its own vessels; the state of tension, there-
fore, being  its natural state, it may be regarded in
this condition  beyond the  sphere of action of
agents  affecting the  general  system,—a circum-
stance, however, which is set aside as soon  as the
fluid is discharged, and thence it is  brought with-
in  the sphere of the influence of the iodine.
   Some inconveniences  arise from the employ-
ment of iodine in irritable habits.  It causes fe-
brile excitement, which is often accompanied with
nausea, vertigo, and  headach, and, occasionally,
 with dysenteric symptoms, and, at other  times,
symptoms  resembling  those of paralysis agitans.
 It, also,  in some instances excites perspirations
 and gripings.   Under such circumstances the use
 of the medicine must be suspended.
   A milder diuretic than either pure iodine o. its
tincture is  the  hydriodate of potassa [iodide of
potassium.]   Owing to its  solubility, it is ad-
 ministered  in  a saturated solution, in  doses of
 mxx. to foji.   It is  incompatible  with  salts of
 copper, of lead, mercury, or silver.
   The only oxide which has a direct diuretic in-
 fluence is potassa.  In the form  of  the liquor po-
 tassae of the British pharmacopoeiae, it may  be ad-
 ministered  in  very large doses in  bland, demul-
 cent fluids. Its primary influence  is exerted on
 the stomach : if any  acid be present, it is neutral-
 ized ; but if the alkali predominate, or no acid be
 present, it  first acts as a sedative, allaying the
 morbid irritability of the stomach, and then enter-
 ing the circulation,  is carried  undecomposed  to
 the kidney, upon which it acts, and  can be readily
 detected in the urine.*   As a diuretic, potassa in
   * It is detected by testing the urine with infusion u'
 rhubarb or turmeric.
3l 
698                                   DIUR
not extensively p^scribed, owing to an erroneous
opinion that it is  injurious in large doses.  The
writer of this article, by gradually increasing the
dose, has given one  hundred minims of the solu-
tion of the London College three times a day, for
several successive weeks.   In these large doses its
power  in  curing the most obstinate cases of pso-
riasis  is very striking, and although its beneficial
effects are not  evident until  it displays its influ-
ence on  the kidneys, yet it has on  no occasion
produced any injurious effects.  It is not much to
be depended on in dropsical affections.
   Among the neutral salts  operating  as  direct
diuretics,  nitrate  of potassa has long held a
place.  It passes unchanged  to  the kidneys, sti-
mulating tbem to increased action, and augment-
ing rapidly the quantity of the urinary discharge.
It can be readily detected unchanged in the urine,
on which account  it ought not to be administered
in inflammatory affections of the urinary organs ;
but none of tbe diuretics can be  less depended
upon in dropsical  effusions ; even after the phlo-
gistic diathesis has been subdued.  It operates in
doses of from gr.  xv.  to gss, and requires to be
largely diluted.  The  chlorate of potassa ope-
rates nearly in the  same manner as  the nitrate,
but it is seldom prescribed as a diuretic.  There
is some uncertainty  with regard to the manner in
which borax (sodae sub-boras) operates as a diu-
retic ; but, from the  smallness of the dose (gr. x.
to ^ss) required to act on the kidneys,  we are dis-
posed to think that it passes entire to these organs.
It is readily decomposed by all the mineral acids,
common  salt, muriate of baryta,  and  nitrate  of
silver, all  of which,  therefore, are to  be regarded
as incompatible with it in prescriptions.
   Those  diuretics which undergo  decomposition
in transitu, and operate directly on the kidneys by
one or  more of their constituents,  comprehend
substances from the three kingdoms of nature.
   The only animal diuretic  is canthariden,*
[or cantharidin,]  as contained in the blistering
beetle, cantharis officinalis, and the milabris varia-
bilis, which  has lately been introduced from China.
The canthariden has  not yet been employed in
its sepaiate  state as a diuretic, but  the influence
of the blistering beetle on the urinary organs has
been long known.  Hippocrates employed  it in
dropsies, and a celebrated diuretic of Tulpius con-
sisted of the tincture of Spanish flies, cardamoms,
and f>weet spirit of nitre.  The internal  use of
cantharides, however, requires the utmost caution,
and when thus employed, whether in the form of
powder or of tincture,  the freest use of diluents of
a demulcent kind is absolutely necessary.  In the
form of powder, cantharides, in doses not exceed-
ing two grains, stimulate the kidneys, and cause
an increased flow of urine;  and it  is  singular
lhat neither heat in  the region of the  kidney nor
strangury is experienced in this case.   They have
been found beneficial in ascites, in old worn-out
constitutions.  When accidentally over-dosed and
  * Canthariden, in  its separate state, is  a white sub-
stance, in minute micaceous scales, insoluble in water
and cold alcohol, but soluble in  boiling alcohol, ether,
«Dd oil.  The knowledge of its solubility in oil is a fact
of much practical importance in cases of poisoning by
canthariden, in which  the administration of oil, by dis-
solving the canthariden, lends to diffuse the acrid influ-
ence of the poison, and consequently ou->iit never to be
resorted to
TICS.
 inflammation  of the  kidneys  supervenes,  with
 bloody urine, insupportable pains in the abdomen,
 strangury,  vomitings, or convulsions,  the  lancet
 must be freely employed, with copious dilution,
 and  an enema of warm  water, containing  from
 mxx. to f.^i. of tincture of opium.   The employ-
 ment of oil must be avoided.
   The balsam  of copaiba, cnbebs, and the
 fruit of the juniper, owe their diuretic properties
 solely to the volatile  oil which they contain, and
 which, separated from their other components dur-
 ing the process of digestion, is carried  to the kid-
 neys, and  augments  their natural  function;  it
 may be readily perceived by their  odour  in the
 urine.  Copaiba in an over-dose causes inflamma-
 tion of the kidneys ;  consequently,  it ought to be
 carefully avoided when there is the least tendency
 to ulceration of these organs.  It may be adminis-
 tered either in a fluid or a solid form.  In the first
 it is given,  combined with mucilage and any bland
 fluid, in doses  of from twelve to thirty minims;
 or the volatile oil, separated from the resin by dis-
 tillation, may be rubbed  up  with sugar, and ad-
 ministered  in bland fluids, as  an oleo-saccharum,
 in doses of from ten to twenty minims.  The so-
 lidification  of the copaiba is best effected by mag-
 nesia, in which state it may be formed into pills ;}■
 or, for the  same purpose, it may be  formed into a
 soap, as the union of the alkali does not, in  any
 degree, diminish  the  efficacy  of the balsam.  In
 moderate doses, from gr. x. to ^ss. of the powder,
 cubebs are  diuretic;  in larger doses  they are pur-
 gative.  It is probable that  some  of the benefit
 derived from their employment in gonorrhoea may
 be ascribed to the diuretic influence  of the volatile
 oil so much increasing the urinary discharge as to
 enable it to wash out tbe virulent matter in the
 urethra.  We  are not aware  that they have been
 employed in dropsical effusions.
[   In  the  same manner as the digestive organs
 separate  the volatile oil  of cubebs  and juniper-
 berries, they separate veratria, the  active principle
 of the colcliicum  autumnale,  and scillitina,
 that of the scilla maritima, from the  powder
 of the dried bulbs of these plants.   Although col-
[ chicum, in  full doses, acts powerfully on  the ei-
i cretory ducts of the  liver  and the pancreas in the
 duodenum, and brings down a  large quantity of
 bile  into the intestinal canal, yet in small doses
 the  veratria is separated, taken into the circulation,
 and  stimulates the kidney.  As a diuretic, how-
 ever, it is less powerful than the squill, a circum-
 stance altogether depending  on its disposition to
 run off by  the bowels.  For diuretic purposes the
 tincture is  the  best preparation of the colchicum,
 as the alcohol takes up the gallate of veratria,
 which is less liable to pass the pylorus undecom-
 posed than the acetate, which  is  always formed
 when either vinegar or wine is employed  as the
 vehicle for taking up the  active principle of the
 plant, and  which passing the pylorus, and bring-
 ing down  a large quantity of bile from the  liver,
 almost invariably purges.  Both  the petals  and
 the  seeds of the  colchicum yield the same  active

   t This is effected by mixing the balsam with one-third
 of its wtight of magnesia, spreading the mixture u|x>n a
 plate, and exposing it to the action of the air for ten o»
 twelve days. It then hicomes plastic, and may be readi-
 ly formed into pills.  The activity of the copaiba is not
 diminished by its union with themayneaia. 
DIURETICS.
69b
principle to alcohol, wine, or vinegar, as tbe bulb.
The  dose of the dried bulb, in powder, is from
five grains to twelve grains, that of the tincture
or the  wine  from mxx. to mix., and that of the
vinegar from f.^ss.  to f.^i.   Upon the  whole,
however, the preparations of colchicum are much
less to be confided in, where morbid  accumula-
tions of  fluid are required  to  be lessened, than
those of the squill; and it only  proves  useful as a
diuretic when it exerts  little  influence  on  the in-
testinal canal.  It, nevertheless, cures dropsies by
its  stimulant influence on  the capillary system,
and  by its  evacuant  properties,  when given in
larger  doses than those mentioned as fitted to se-
cure its diuretic influence.   Squill is given in
substance to  secure its diuretic effect; but it is
generally prescribed  in combination with calomel
or the blue pill, or bitartrate  of potassa.  As a full
dose given at first is apt to induce vomiting, it is
preferable to  commence witb doses of a grain of
the  powder,  gradually increasing the quantity  to
 six  grains,  repeated  every  fifth or sixth  hour.
 Cullen recommends the bichloride  (oxymuriate)
 of mercury  instead  of calomel, as an  adjunct to
 squill; but every intention is sufficiently answered
 by the calomel, and  it  is much less Ukely to irri-
 tate the bowels.  If the combination of squill and
 a mercurial  act on the bowels, the latter must be
 discontinued, and the  mercury introduced  by the
 surface.   In some habits, owing  to idiosyncrasy,
 squill  excites an eruption on the skin  not unlike
 nettle-rash, accompanied with severe gripings, cold
 sweats, and  occasionally convulsions; in which
 case the use of the remedy should be discontinued,
 and cordials with opium administered.  Squill is
 most useful as a diuretic, in doses not  exceeding
 eight grains of the dried bulb :  it is incompatible
 with the  alkaline carbonates, astringent vegetable
 infusions, and solutions of the sulphate of iron.
   A decoction of the twigs of the common broom,
 spartinm  scoparinm, has been employed as a
 diuretic from lime immemorial: although nothing
 is known respecting its active principle, yet what-
 ever it is, the decoction seldom fails  to excite the
 action of the kidneys.   As little is known  respect-
 ing the  active principle of  sarsaparilla,  but it
 certainly affects the  kidneys; the alterative  influ-
 ence, however, of this  root, can  scarcely depend
 on its diuretic properties ; and amidst so  many
 better diuretics, it might  be rejected from the list
 without any inconvenience being experienced by
 its removal.
   Amongst the inorganic diuretics which undergo
 decomposition in transitu,  are salts of potassa
 and soda, the alkalies of which only are  trans-
 mitted to the kidneys.  The  carbonate and the
 bicarbonate of potassa, although  the one contains
 double the quantity of carbonic acid of the other,*
 both operate nearly  in  the same manner as diure-
 tics; a circumstance owing to the reduction of the
   * Carbonate of potassa.
      Potassa, 1 propor............= 48 or 68-57
      Carbonic acid, 1 propor.......= 2-2—31-43
                     Equivalent....70  10000

    Bicarbonate of potassa.
      Potassa, 1 propor.............= « or 47-M
     Carbonic acid, 2 propor.......= 4-1 — 4J so
      Wat?r,l propor.............."ZJ^I..--
                     Equivalent.... 101  IQO'OO
latter to the state of the carbonate, during  its
decomposition in the  stomach.  The dose of the
carbonate is from ten  grains to gss, hut it may be
augmented  to  three  drachms;  the bicarbonate
may be given in double that quantity.  The pro-
perties of either, as diuretics,  are not lessened by
administering them in  the state of effervescence
with  lemon-juice or  citric acid ; this acid being
separated during the digestive process in the same
manner as the carbonic ;  and if any febrile heat
be present, this  is the best method of administer-
ing these carbonates.   The same opinion may be
given of the carbonate and  bicarbonate  of soda,
which, owing to their taste being less  disgusting
than that of the carbonates of potassa, are more
generally employed as diuretics.
   The acetate of potassa has considerable claims
to attention as a diuretic, if it be not over-dosed,
for in doses exceeding  gi. it operates as a purga-
tive.   In small  doses it  may be  conjoined with
infusion of gentian, or that of any light bitter: it
operates with more  certainty in small doses fre-
quently repeated, than in full doses  taken at long
intervals. We have seen it ordered in conjunction
with bitartrate of potassa; but in this combination
the diuretic influence of both salts  is destroyed,
and a tartrate of potassa is formed  by the decom-
position of  the acetate, and the abstraction of the
superabundant  tartaric acid  from  the bitartrate,
which purges.  The bitartrate in small doses, from
gr. x. to ^i, is a much more useful and certain
diuretic than any of  the other neutral salts in this
division of  this  order of medicines.   We are by
no means  satisfied that the influence of this salt
depends on its  alkali finding its  way to the kid-
neys ; for, when we  reflect that Qi of the bitar-
trate contains gr. v. only of potassa, and  that
twenty minims  of the  liquor potassae contain gr.
vii. of potassa, and that the  diuretic effect of the
J)i of bitartrate is much greater than that of mxx.
of the  liquor potassae, there appears undoubtedly
some difficulty in assenting to the accuracy of the
theory which has been stated.  The influence of
the bitartrate in ascites is well authenticated, and
every  day's experience confirms the  confidence
which  has been placed in  its  diuretic  powers.
The emaciation wbich the bitartrate causes when
taken as ordinary beverage, however, depends on
its operation on the intestinal canal.  Bitartrate of
potassa  is  beneficially conjoined with squill or
colchicum, or with bitter infusions;  or, if the salt,
when administered  alone,  have weakened  the
digestive organs, in  combination with tartarized
iron.  In cases  connected with glandular obstruc-
tions,  we  have  given  it  at  the same time  that
iodine was  externally applied in the form of an
ointment, and always with benefit:   and  here the
dose of  the  bitartrate may be the same as if the
iodine  were  not employed.  The  soluble  salt,
formed  by  the  union  of the sub-borate  of  soda
with the bitartrate of potassa, operates, also, pow-
erfully as a diuretic.
   Some very active  agents are found capable of
producing  a diuretic  effect  on  the system by
stimulating the capillaries to  more healthy action.
and thus enabling the absorbents to take up fluids
already effused  in the serous cavities and cellular
membrane, and  to throw them upon the kidneys,
their natural excretories.  Tobacco is one of these - 
700
DIURETICS.
it was  introduced  to the notice of the profession
by Dr.  Fowler, for  this purpose; and when admin-
istered  in small doses, either in the form of infusion
i-r of wine, so as not  to  nauseate, it has been
■riven successfully in dropsy.  No diuretic, how-
ever, requires  so much caution in  its administra-
tion  under  the  most  favourable  circumstances;
and, therefore, it has been less employed than it
deserves to be.
  Much of the  efficacy of foxglove depends on
the period of the growth of the plant at which the
leaves  are collected, and the manner of drying and
preserving  them.   In  the months  of July  and
August they are in the  best state: they should be
then gathered, and dried between  colourless bibu-
lous paper, in  a warm room, and under a moderate
pressure.   This may appear  to be an unnecessary
degree of care and trouble, but for the preparation
of a medicine of so much activity, and which is
administered  in grain  doses, too  much attention
cannot be bestowed to preserve all  its medicinal
powers in  the  only  way  in which  they  can be
obtained.    When the dried pulverized leaves lose
their green colour,  some chemical change has
taken  place in them which deprives them of their
native  properties.  In  employing  foxglove  as a
diuretic, it should be recollected that its influence
on the  capillaries  is not obtained in states of  the
habit exceeding the  limits  of the healthy standard
of tone.  In states below  that point, it stimulates
the capillaries, and diminishes the force and fre-
quency of the pulse, and  operates  as a diuretic;
for in  dropsical  effusions, whether those of ascites
or hydrothorax, no benefit can be expected  from
the  employment  of foxglove, as long as any ten-
sion of the vascular  system exists.  It  is  after
tapping and  a  reduction  of arterial action,  that
decisive advantages  are obtained from prescribing
foxglove in hydropic affections.  It is on the  same
principle  that it is most useful in lax, pale, leuco-
phlegmatic habits; and, if the disease be anasarca,
in those cases in which pitting is left on pressure
 of the affected parts :  thence, when this state does
 not exist, the system must  be lowered by blood-
 letting and purging, before  any advantage can be
 expected   from foxglove  as a diuretic.  It  has
 been  found useful to combine it with mercurials,
 especially  the  blue  pill;  and pushing this far
 enough to affect very slightly the salivary  glands:
 but in cases of either anasarca or ascites,  the best
 adjuncts  are bitartrate of potassa, acetate of ammo-
 nia, or colchicum ;  and in   constitutions broken
 down by protracted courses  of mercury, the nitric
 acid.
   When foxglove is administered in the form of
 powder,  the  dose may be  gr. i.  repeated for the
 first two  days  at intervals  of eight hours;  after
 which the  intervals should be lengthened accord-
 ing to the  effects produced.  An infusion  made
 by macerating  one drachm of the dried leaves in
  f.^viii. of boiling distilled water,  and  f.^i.  of
 cinnamon  water, for four  hours, speedily produces
 the diuretic  effects of the  plant, when  given in
 doses of  f.^i. repeated at  intervals  of five hours.
 The dose of  the  tincture  should not at first ex-
 ceed  ten  minims;  but it  may be  gradually in-
 creased until its  diuretic  influence  be  perceived.
 Thf. symptoms of an overdose are nausea, vomit-
  Jig vertigo,  pulsation in the temples, a sensation
of heat throughout the body, sweating, sometimes
diarrhcea, and  occasionally salivation.  One re-
markable symptom sometimes occurs, a suppres-
sion of urine.   The best antidotes, under such
circumstances,  are, ammonia,  brandy and  water,
opium, and the stimulus of a blister applied over
the pubis.   One circumstance is particularly ne-
cessary to be noticed in prescribing  digitalis—its
power of accumulating in the  system, like mer-
cury,  and  suddenly  exerting  its  specific  effects
when  not expected.  No medicine, therefore,  re-
quires to be more closely watched, whether it be
given  in moderate doses, long-continued, with the
view of obtaining  diuresis;  or administered  in
gradually augmented doses, to lull delirium  and
procure sleep in mania.  Whenever nausea is felt,
it must be noticed  and suppressed;  for vomiting
arrests the diuretic influence of the remedy.
   Little requires to be said  of lactucarium as
a diuretic.  It  has been found useful in hydrotho-
rax, and some  other  cases of dropsical  effusions,
by the German physicians;  but in  this country
its place is much better supplied by foxglove.
   All bitter tonics possess, more or less, diuretic
effects ;  but the seneka  root is  perhaps better
adapted for this purpose than any other:  its in-
fluence is  particularly felt in those cases in which
the serous accumulations are the effect of  general
debility; as for example, those  cases of asthenic
ascites which sometimes follow acute diseases.  In
such cases, also, much benefit is obtained from the
ferrum, tartarizatum, which,  besides operat-
ing as a tonic, has a direct diuretic influence, and
has been found peculiarly serviceable in cases of
anasarca connected with affections of the  heart;
but in these cases its employment must  be  pre-
ceded by purgatives and mercurials.  With respect
to the employment of mercurials, much benefit
is derived  from their aid in promoting the opera-
tion of other diuretics.  Thus the diuretic effects
of squill are rendered more certain when combin-
ed  with calomel; and those  of digitalis when
 united with the blue pill.   In both instances the
 stimulant influence of the mercurials on the capil-
 lary system aids that  of the active principle of
 the other diuretics, and more benefit seems to re-
 sult from such combinations  than when either is
 administered alone.
    From the view which we have  given of the
 substances most commonly employed as diuretics,
 the practical  employment  of them as remedial
 agents may be very briefly stated.   In  febrile af-
 fections much must  be done before prescribing
 diuretics; but in  long-protracted fevers, whether
 intermittents  or  continued fevers, if oedematous
 swellings  occur, their use is indicated  and must
 not be delayed.  If they be prescribed during con-
 tinued fever, it should be recollected that  one  of
 the most distressing occurrences in that disease is
 retention  of urine;  and, therefore, in prescribing
 diuretics,  it is highly requisite  to examine daily
 the state of the bladder.  Most fevers in their ter-
 mination  display  critical changes either  in  the
 quality or the quantity of the urinary discharge :
  under such circumstances, it  becomes a question
 —how  far are diuretics likely  to  favour  such a
 crisis ?   At the commencement of fevers the urine
 is generally pale ; it becomes afterwards  high-co-
[ loured ; and at the termination of a paroxysm, if 
DIURETICS —DROPSY.
701
the fever be intermittent or remittent, or, when it
begins to decline, if it  be  of the continued type,
a sediment either lateritious or of a pale pink co-
lour is deposited, and has  been regarded  as criti-
cal.  But this sediment is to be regarded rather
as the  result of a certain catenation  of actions,
than as  the  excretion  of any thing injurious to
the habit; and,  were diuretics able to promote it,
they would  be of no  avail.  Upon the  whole,
therefore,  even as simple  evacuants, diuretics are
of little value, either  in  idiopathic fevers, or in
acute diseases in which fever is a symptom.  They
have been advantageously administered  in  many
chronic affections, especially those accompanied
 with eruptions on the  skin ;  but the chronic affec-
 tions in which  their influence  is truly  beneficial
 are dropsies.  This  class of diseases  depend on
 such an  atony  of the capillary system, that in-
 stead of the capillaries carrying forward  the fluids
 they contain, they pour them out into the serous
 cavities, and thence the balance between the exha-
 lation and absorption which  exists in health being
 broken, the effused  matter  is  accumulated to a
 degree which overpowers the absorbents.  Diure-
 tics are prescribed to cure dropsies in nearly every
 form ; and do so by stimulating the capillary sys-
 tem, so that no fresh  effusion  taking  place, the
 absorbents  are  enabled  to  take up the already
 effused fluid, and  to throw it upon the  kidneys,
 its natural emunctory. When success attends the
 administration of diuretics in dropsy, one advan-
 tage resulting from their  employment over drastic
 purgatives and some  other remedies is, the little
 debility which they occasion.   If diuretics,  how-
 ever, be given alone,  they are  uncertain in their
 effects, and  seldom in  that case  deserve more than
 the title of palliatives; but, as  adjuncts to  other
 means, they aid materially the  evacuation  of the
 effused fluid, and have  thus frequently effected
 the  removal  of general  dropsy.  Their success,
 however, is very precarious ;  and  so  many cir-
 cumstances interfere with their operation, that it
 is difficult to form a prognosis  of their  expected
 effects.   Sometimes they operate freely, increas-
 ing greatly the  discharge  of urine, and yet  the
 dropsical swellings continue.  In this  case some
 organic mischief must be looked for; and  unless
 this can be removed,  no  great  advantage can be
 expected from the evacuation of the effused fluid.
   The kinds of dropsies  in  which  direct diuretics
 have proved most  beneficial  are  anasarca and
 ascites ; whilst those  which operate by diminish-
 ing arterial  action,  and  augmenting that of the
 capillaries,  are  the best adapted for hydrothorax.
 But even in any case the  influence of diuretics
 hinges upon so many accidents, that all of them
 are precarious in their effects.   In encysted drop-
 sies they are utterly useless, unless preceded by
 reducing the sac to  the state  of an extraneous
 body.
   Diuretics have been much prescribed in calcu-
 lous diseases; and most of the substances called
 lithontriptics are diuretics.  We have ample proofs
 that none of them act  chemically in  dissolving
 calculi; nor, indeed, can  they be said to be capable
 of effecting  any change  on the kidneys sufficient
 to prevent the formation  of calculous matter.  It
 is probable that the  benefit accruing  from  their
 employment  is wholly due  to  their influence on
the digestive organs;  and by their aiding in the
formation of a  better gastric juice, the digestive
process being rendered more complete, all the se-
cretions, and consequently all the excretions, must
necessarily become more healthy, and  cease to
deposit the  uric  and other acids in the pelvis of
the kidney.
   In  conclusion, we would say that  the  efficacy
of this order of remedies depends more on the tact
of the prescriber, and  his intimate acquaintance
with the changes, both structural and functional,
which disease produces on the system, than  any
other.   The operation of no other order of medi-
cines is so much modified by circumstances ;  and
no other medicines require so much attention as
these  for insuring their beneficial effects.  The
following rules  ought always  to be  strictly ob-
served during the administration of diuretics.
   1.  The surface of the body must be kept cool.
   2.  The use of diluents is essential, and ought
always to be  urged,  more  especially when the
saline diuretics are employed.
   3.  The patient  should, if  possible, be  out of
bed during  their operation.
   4.  The diuretic should be administered in the
day-time.
   5.  After  the  accumulated  fluid has  been  re-
moved from the  serous  cavities, and the use of
the diuretics suspended or  discontinued,  tonics
should be prescribed.
   G.  Little  advantage can be  anticipated from the
employment of diuretics in those dropsies which
originate from  organic  affections of the liver or
the chylopoietic viscera,  and  still less in encysted
dropsy.   It is only in those cases connected with
debility  and deranged action of the capillary sys-
tem,  that diuretics can be  regarded as certain
remedial agents.            A  T Th0MS0N.

   DROPSY.   (From the Greek, vSpu>^ — Latin;
hydrops:—Th. vSmp, water, and ut/', the look oi
aspect.)  Dropsy  is a  common term signifying
effusion into the cellular tissue, or into any of the
natural  cavities of the  body.   With the addition
of the epithet encysted, it has  likewise  been em-
 ployed  to  designate  a  very  different series of
 affections, viz.,  those  collections of serous  fluids
 which are  contained  in factitious  sacs,  and of
 which the  ovary  is more peculiarly  the  subject.
 These, as having neither the  same origin, nor ad-
 mitting the same treatment, will be spoken of in a
 separate article.
    Even  real dropsies  differ  so much from  each
 other,  in consequence of the  organs in  whose
 neighbourhood or in whose  substance they form,
 that they cannot all be comprehended in one arti-
 cle.   Thus hydrocephalus,  though  agreeing  in
 having as one of its terminations an effusion of
 serum into  the  ventricles of the brain, can by no
 means be regarded in the same light with effusion
 into the larger cavities of the body.   Its progress
 is more rapid, its origin more decidedly inflamma-
 tory,  and,  when it assumes  a chronic form, it
 never gives rise to anasarca, which  almost con-
 stantly  attends  hydrothorax  or ascites.   Hence,
 therefore, under  the common head of dropsy, we
 can only consider this and other local dropsies, so
 far as the  same theoretical explanations of their
 phenomena agree with each other; and our chief 
702
DRO
PSY.
attention must be paid to the form, origin, and
treatment of what is commonly denominated ge-
neral dropsy.  For the  peculiar symptoms by
which hydrocephalus,  hydrothorax,  and hydrops
pericardii are indicated, we  refer to the articles
under which  these affections are treated.
  The ancients appear  to  have had  very  crude
notions of the cause of dropsy, and any approach
to a rational theory of the disease is of very mo-
dem origin.  Hippocrates explained its occurrence
by the corruption and  softening of the flesh, and
its conversion into water.  Celsus states that the
common cause of dropsies is too great an  abun-
dance of humours.  Galen,  attempting greater
refinement, referred it to refrigeration of the liver,
which he  assumed might happen either from an
affection of that  organ itself, or from sympathy
with other organs; and with  little modification
this theory of Galen was received in the schools
till  after  the discovery  of the lymphatics by Asel-
lius.
  Forestus, who  wrote in tbe latter part of the
sixteenth century, adopts the opinion of Celsus,
and explains it by the theory of Galen.  He as-
sumes that in consequence of the refrigeration of
the  liver,  the veins  also  become  refrigerated:
hence a more serous state of the blood  and greater
abundance of water; and hence, according as the
affection is local or general, anasarca or ascites is
produced.
  Fernelius,  apparently seeing the insufficiency
of this theory, referred  anasarca to refrigeration
of the liver, and ascites to a rupture of the vessels
which contained  the humours.   By these,  how-
ever, it is  scarcely possible  that  he  could intend
the  lymphatic vessels,  as he wrote before the dis-
coveries of Asellius had  been published, and long
before these vessels were supposed to be so general
as it is now known that  they are.
  Sennertus, following Fernelius, made  a some-
what nearer  approach to a  rational theory ;  for
while he adopted the old doctrine with regard to
anasarca, he attributed the occurrence of ascites
to obstruction of the liver and  spleen, by which
means the  vessels were distended with fluid, their
extreme  mouths dilated, and an  escape of serum
permitted into the  cavity of the abdomen.  The
discoveries of Asellius  gave  rise to  a  different
theory, and dropsy was referred to a rupture of
the  lymphatics.   Judging from the language of
Lower,  it  might  be supposed  that  this doctrine
had obtained considerable support, when the well-
known experiments of this physiologist laid  the
foundation  for a more rational explanation of  the
phenomena of effusion  than any which  had  yet
been given.  By tying first the inferior cava, and
afterwards  the jugular veins, he  did much  more
than any of his predecessors—he proved that ef-
fusion might be caused by obstruction in the veins.
Neither Sydenham, nor Mead, nor Willis appear
to have concerned  themselves much  with the the-
ory of dropsical effusions, but were  content with
simply inculcating  particular modes of  practice.
Soon after  Mead, or even while he was yet living,
Haller was laying the foundation for more rational
i.xplanations  of the phenomena  of dropsy.   He
adapted the then general theory of absorption by
the  veins,  and lays down distinctly that dropsy
may ensue, .lot only when the veins are obstruct-
ed, but when the course of the blood through the
veins is retarded  by debility, whatever may be its
source.*
   Haller did not acknowledge the absorbing office
of the lymphatics, but even when, in consequence
of  Dr. Hunter's doctrines, absorption was entirely
referred  to  those vessels, it made no difference in
the theory  of  dropsical effusions.  It was  only
necessary to change  " veins" into " lymphatics,"
and it was  supposed that a sufficient explanation
had been given.
   Such  is  a short outline of the attempts which
have  been  made  to  explain  the phenomena  of
dropsy ;  and at the beginning of the present cen-
tury the general opinion seems to have been that
the disease depended upon defective  absorption,
and that it was  essentially a disease of debility.
The  investigations  of  various  writers  into  the
causes and  treatment  of hydrocephalus,  which
served clearly to prove that this disorder had very
frequently an inflammatory origin, naturally tended
to  re-open  the general  question ; and Blackall,
Abercrombie, and many others were led to teach
that both anasarca and  ascites are often attended
with  and dependent upon inflammation.  Former
writers had indeed given examples of dropsies
successfully treated by bloodletting; but these for
the most part were single cases; and  no attempt
to lay down any general plan had been made till
the time of the writers  just referred  to.  Multi-
plied  experience has now determined the question
of  treatment; and  that  in many cases an anti-
phlogistic plan is  requisite, is no longer a matter
of  doubt.   But whetber dropsy depends upon in-
creased exhalation or diminished  absorption,  is
yet undecided ; nor do we feel that the facts are
sufficiently  numerous to determine the dispute.
We shall shortly give the principal arguments for
either theory.
  That dropsy proceeds  from deficient absorption
is argued, because, whether we consider the  veins
or  lymphatics  the  instruments of this function,
pressure  upon their trunks is followed  by an effu-
sion of serum into the parts farthest removed from
the heart.   This, indeed, till some  late experi-
ments by Magendie, was the only real fact which
could be adduced in favour of diminished absorp-
tion.   This physiologist, by inducing an artificial
plethora, and tben  showing that the function in
question  was less actively exercised than in  those
cases where no such plethora existed, has certainly
given additional  probability to  the theory, and,
under any circumstances, has  proved what before
was purely  hypothetical—that absorption is  capa-
ble of being diminished.   On the other hand, that
increased exhalation is  the cause, is argued from
the circumstance that absorption actually proceeds
in dropsy,  that the fat  is taken away, and that
emaciation advances pari passu with the effusion;
that this  function is always the last to yield, and
that it appears to become more energetic in pro-
portion to the general debility of the system;  that
the exhalents are capable of pouring out very dif-

  * Sed etiam absque ejusmodi causis hydrops nasci vi-
detur,  quoties debilitas aliqua, iindecufique nata, itei
venosum tardat.  Facile enini intelligitur, in universum
diutius sanguinis per artrrias nmtum superesse, queni
cor  proximum terget, priorein vero inotum venarum qui-
eseere. Ergo  si arteria? exhalare pergant, vena; resorbera
cessant, collectus vapor in hydropem abibit. 
DROPSY.
703
ferent quantities of fluid, as is seen in the secre-
tion of tears, the sudden increase of perspiration,
&c.;  and, lastly, that the fluids effused are differ-
ent from the natural secretions of the parts, con-
taining  a  much greater quantity of serum ;  and
that this difference would not exist if dropsy were
the simple result of diminished absorption.
   A far more important question, however, to the
practical physician, is the condition of the system
under which effusion takes place—whether it be
a  sthenic  or asthenic  state.  Whether we adopt
increased  exhalation or diminished absorption as
the source of effusion, this question will admit of
the same decision.   Effusion  may clearly  take
place in a state of debility and in a state of undue
activity of the  system, or of plethora.   With re-
gard  to absorption, the experiments of Magendie
 have clearly proved that  plethora is unfavourable
to this function ; and  that  it is favourable to in-
creased exhalation, the profuse perspirations of
persons having a  full habit clearly  evince.  If
such individuals are bled, the tendency  to per-
 spiration either yields entirely or is greatly dimin-
 ished.
   We have therefore to investigate carefully, in
 every case of dropsical effusion, the general state
 of the  system  by which  it  is accompanied, for
 what may be proper for one  state will most un-
 doubtedly be injurious to the other.
   The only points, then, that  we can  assert as
 proved in  tbe  theory  of dropsy,  are—first, that
 the balance between exhalation and absorption is
 broken, in  consequence  of which more  fluid is
 poured out  than is taken  away ; and, secondly,
 that  this may take place from over-activity or from
 debility of the general  system.
   Something may attacb also to the condition of
 the blood, but  upon this point we  have very little
 satisfactory information.   That hemorrhages in-
 crease the serous portion of the  blood, and that
 profuse hemorrhage gives  rise to  dropsy, is cer-
 tain ; and that  in  dropsies, more  especially those
 accompanied with extreme debility, the blood often
 exhibits a remarkable difference in the proportions
 of serum and  fibrine, in its  coagulability and in
 its colour, is likewise certain ; but we have yet no
 data by which to connect these phenomena with
 dropsy as cause and effect.
   Almost the  only information, till the  late ad-
 vancement  of  chemistry, which had been obtained
 respecting the nature  of the fluids effused in drop-
 sy, regarded the colour and  taste, although in  a
 few  instances  the consistency and  coagulability
 had  been noticed.  They have been described as
 a yellowish serum, as being of the colour of urine,
 orange-coloured,  saponaceous, purulent,  bloody;
 and, in one instance, Morgagni observed  the fluid
 to coagulate without heat.   For a more particular
 account of  these fluids we  are  indebted to Marcet.
 He examined them in hydrocephalus, ascites, hy-
 drothorax,  and in most other dropsies;  and he
 has given a detailed account of the  result in the
 second volume of the  Medico-Chirurgical Trans-
 actions.  According to this statement, the prevail-
 ing animal  substance  is albumen, which  is con-
 tained  in very different  proportions.  There  is
also  a peculiar  animal substance  which Dr. Mar-
cet names muco-extractive matter, from its being
(incoagulable, but soluble in  water and other men-
strua.  Gelatine was not discovered in any ol these
fluids.
  In the  fluids  of ascites, hydrothorax, hydrops
pericardii, hydrocele, and that which is sometimes
effused in the thyroid  gland, the albumen is so
considerable as to render them  coagulable;  while
in that of spina bifida  and hydrocephalus, it is so
small in quantity as scarcely to be rendered visi-
ble by heat or acids.   The specific gravity is  ex-
ceedingly various both in different d'opsies,  and
in the same dropsy at different periods.
   These differences, however,  are found to affect
principally, if not exclusively,  the  animal matter
only of dropsical fluids; the saline matters being
by  no means subject to similar variations.
   The particular saline ingredients of all these
fluids  are  muriates of soda  and potash, sulphate
of  potash, soda and phosphate of  lime, iron,  and
magnesia.  A hundred grains appear to  consist
of  about  seventy-two  grains of muriate of soda,
mixed with  a little muriate of potash; between
eighteen  and twenty  grains of soda, brought to
the state of subcarbonate; and a mixture of eight
or  ten grains of sulphate of potash, phosphate of
lime, phosphate of iron, and  phosphate of mag-
nesia.
   The caustic alkali contained in these fluids, Dr.
Marcet proceeds to say, appears to be  combined
with the animal matter in a manner not well  un-
derstood, and the proportion  of the uncombined
alkali to the other salts is greater  as  the  specific
gravity is more considerable.  To this account of
the animal fluids  Dr. Marcet  has  subjoined  the
following table, to show the proportions of saline
and animal matter in  various  dropsical  or  serous
fluids, and in the serum of the blood.
Fluid of spina bifida
Hydrocephalus.......
Ascites..............
Ovarian dropsy......
Hydrothorax.........
Hydrops pericardii...
Hydrocele...........
Blister...............
Serum of blood.......
	-'■is o co o	C sis ill 3
Sp. Gr.	Grains.	Grains.
1007	14.4	2.2
1006 7	9.2	1.12
101.5	33.5	25.1
1020.2		
1012.1	26 6	18.8
1014.3	33	25.5
1020.3	80	71.5
1024.1		
1029.5	100	90.8
<3
Grains.
  9.2
  8.08
  8.4
  8.0
  7.8
  7.5
  8.5
  8.1
  9.2
  The specific gravity here stated is an average.
  I. Dropsies may  be acute or chronic, idiopathic
or symptomatic, primary or secondary, general  or
local, inflammatory, sthenic, asthenic, &c.  These
varieties occur in every cavity in which dropsy
itself takes place, but the different forms are more
common in one  cavity than  in another.   Thus,
the  brain is most frequently the subject  of acute
dropsy ; the pleura? and pericardium  hold the next
place in this liability to  acute effusions, and  the
peritoneum the last.  The cellular texture is per-
haps on an equality in this respect with the pleura
and pericardium, but it is seldom affected without
some organ suffering at the same  time, in  whose
action it participates.   Dropsy of the sthenic cha-
racter is for the most part an acute, but not always
an inflammatory disease.   It chiefly assumes  the
form of anasarca.  (See Anasarca.)  Sometimes
it appears to be purely idiopathic, and unattended
by  disease or affection  of any  particular  organ 
704
DROPSY,
In this case the anasarca takes place very suddenly,
the whole cellular  tissue sometimes becoming in
a few hours enormously distended with fluid ;  and
there is  considerable heat of skin, with a full and
hard pulse, furred tongue, and much thirst.   Not
unfrequently the patient complains of tenderness
over almost the whole surface of the  body, espe-
cially if strong pressure  be made, so that we might
be induced to  believe that the cellular tissue under
these circumstances is in a state of-inflammation.
The bowels are generally costive;  the urine coag-
ulates on boiling, the precipitate thus formed be-
ing very various in quantity,—sometimes scarcely
rendering the  urine at all muddy, at others form-
ing almost a solid  mass.   This state of the urine,
it has been inferred, is conclusive of disease in the
kidney ;*  but  we shall in the course of this  arti-
cle afford reason for questioning this inference : it
certainly indicates  a disordered function of this
organ, and not unfrequently accompanies structu-
ral disease of  it.
   Much more frequently acute dropsy is accom-
panied  by  inflammation of the lungs or pleura,
and sometimes of both.  The  pulmonary symp-
toms, however, are not always very prominent,
and they sometimes  nearly disappear when the
effusion has taken place.   In sucb cases, inquiry
into the history of the patients  generally shows
that they had suffered  for several days, or occa-
sionally several weeks, from cough and  dyspnoea,
and that about the period at which these symptoms
diminished in severity,  the  face was  perceived to
swell in the morning and  the  legs at night, and
the  abdomen, without  being  very  perceptibly
enlarged, would  not allow the  clothes to be  but-
toned or laced so tight as usual.  From this time
the swellings increase rapidly ;  the whole cellular
tissue becomes affected, and the countenance is
very  leucophlegmatic in  appearance.   At other
times the pulmonary symptoms and effusion  pro-
ceed pari passu, or the former precedes the dropsy
only by a few hours,  but is not relieved by the
occurrence of effusion.  '
   The progress  now described  is generally exhi-
bited in the acute anasarca, from whatever source
it may have derived its origin; but not very seldom
effusion takes  place to a considerable  extent  into
the abdomen  at the same  time, and the ascites
quickly  becomes equally marked, if not the more
prominent  symptom.
   Ascites is much less frequently an acute disease
than anasarca, and in most cases is the result of
previous inflammation.   In the article Ascites
we have described  several  instances of this kind.
   The exciting causes of acute dropsy are,—the
repression  of  eruptions, the  sudden  suppression
of perspiration, suspension  of  the  catamenia, or
of any other customary evacuation, inflammation
of the lungs  and  pleura,  exposure to cold, &c.
It  also  succeeds scarlet fever,  when this disease
has run its regular course ;  sometimes it has suc-
ceeded  parturition, coming  on  suddenly  and
without any pain.   In this last case, ascites alone
is  often observed ;  but at other  times it is accom-
panied  by  excessive anasarca.   The  ascites  suc-
ceeding parturition is also at times very manifestly
dependent upon peritoneal inflammation, and  is
    T)r. Bright, however, to whom  this notion  owes its
origin, by no means carries this doctrine so far.
attended with  fever, quick, small, wiry pulse, and
excessive tenderness of the abdomen, &c.  These
symptoms precede the effusion, and the tenderness
diminishes, but does not  entirely disappear upon
its occurrence.  In some of these cases, when the
abdomen has  been emptied, we have discovered
an  enlarged  ovarium,  and  we  are inclined  to
believe that  it is to the irritation produced by dis-
ease of this organ, with  the additional  stimulus
of the puerperal state, that the effusion is owing.
The  termination  of  such  cases  is various:  in
some, after the disappearance  of the dropsy, the
tumour remains quiescent, and is not attended by
any inconvenience; in others the  ascites, indeed,
is removed, but the ovary continues to enlarge,
and we have at length encysted  substituted for
peritoneal dropsy.
  Dropsy may be acute as  to  the  rapidity of its
formation, and  yet be  the  very  reverse  of an
inflammatory  disease.   This variety  is, however,
much more  rare  than  the preceding species, but,
like it, assumes the form of  anasarca or of ascites
alone, or of both together.  It comes on in general
very rapidly, and  is unattended by  fever or  any
symptom of increased arterial action.  In the arti-
cle  Anasarca an instance  has been mentioned,
taken from Dr. Bateman's reports of Diseases in
London, where it came on after excessive fright,
and was removed  by  the administration of  cin-
chona.  In  the form of ascites we have several
times seen it follow parturition ; the patient being,
within a few  days of  delivery, as  large or even
larger than at the period  of  labour.  In these
instances the  only striking  symptom is debility;
there is neither  thirst,  nor  heat  of skin,  not
quickened pulse ; and the patient appears to suffer
no  other inconvenience from  the  effusion  than
what proceeds from the increase of her bulk.  The
progress of  such cases  towards recovery is very
slow, and is always impeded by violent depleting
remedies.   The most  successful plan of treating
this affection is generally by slight tonics, frictions
over the bowels, and bandaging.   It ought, how-
ever,  to be  remembered  that  such  patients are
liable to become the subject of sub-acute inflam-
mation ; and unless great watchfulness be prac-
tised, the  disease from  this cause  may become
incurable.
  Of the same asthenic character are those forms
of effusion  which  are  the  consequence of  any
excessive discharge, and  more  especially  hemor-
rhage.  We have mentioned one instance  in the
article Anasarca in which the hemorrhage was
the consequence of diseased uterus; and the ana-
sarca (the form such dropsies  generally assume)
appeared and disappeared, as the hemorrhage pre-
vailed or was  suspended.   Any other debilitating
discharge  will unquestionably lead to  similar
results.
  II. We shall now proceed to notice those spe-
cies of effusion whicb are  always  the result of
some organic disease,  and which  may therefore
be  termed  symptomatic  or secondary  dropsies.
They  are  usually chronic  in their course,  are
seldom attended  with acute  inflammation,  hut
very  frequently accompanied with aub-acute in-
flammation.
    Dropsy from Disease of the Heart.—
[Cardiac Dropsy.] — This species  of effusion ix 
DROPSY.
705
usually preceded by tbe common symptoms of
disease of this  organ,  and such disease may pre-
cede, and often does  precede, the occurrence of
dropsy for months,  and even for years.
  The first symptom of dropsy arising from dis-
ease of the heart is usually observed  in the face,
the eyelids being puffed in the morning, and an
unusual difficulty of opening  them  being  expe-
rienced.  This  single symptom frequently endures
for a  very  considerable time  before  any farther
progress is observed.    Next, the feet swell  at
ni<mt, and the upper  extremities  become  very
quickly the site of effusion, and the left arm  earlier
and more, frequently than the right.
   The anasarcous swelling,  which  is peculiarly
pellucid, usually long precedes the occurrence of
ascites; effusion taking place in the peritoneal
cavity late  in  the disease and very slowly.   Fre-
quently, indeed, patients are examined, in whom
anasarca has been the  consequence  of cardiac
disease, without a single  ounce of fluid   being
found in the abdomen ;  and sometimes, although
 more rarely, not even in the cavities of the pleurae.
 The pulse is not always characteristic of disease
 of the heart;  and of course the same difficulty
 must naturally occur in  detecting such disease,
 whether accompanied  or not  accompanied by
 dropsy.  When, however, effusion   begins  after
 long  disease, and  without pulmonary symptoms,
 in the face and upper extremities, we may always
 suspect the heart to be the source of the effusion.
 In many patients, and particularly in women, this
 first symptom  appears  to  be  followed  by partial
 effusion into the chest, and for some weeks before
 any farther progress is made, the patient is unable
 to lie down.   At first this difficulty  of preserving
 a reclining posture is  very slight, and only an ad-
 ditional pillow is required, the patient at this time
 being scarcely sensible that the inability of lying
 down is the consequence  of disease.  Gradually,
 however,  the effusion  increases,  progressively in-
 volving every  part of the system — the cellular
 texture and the cavities of the brain, pleura, and
 peritoneum.
   The urine in some of these cases at a very early
 period affords  a very slight deposit of albumen
 upon boiling,  and  this albuminous  secretion be-
 comes more and more  abundant in  the progress
 of the disease.  Its quantity varies considerably.
 In a patient who died in the Birmingham Hospi-
 tal during the present year at  a very early stage
 of the effusion, two  months  before his death the*
 urine was barely rendered turbid, but the evening
 he died it was rendered nearly  solid, by boiling.
 On dissection, the heart was found enormously
 enlarged, and the  aorta very much diseased. The
 kidneys were  perfectly sound.  The urine,  how-
 ever, does not coagulate  in every case of dropsy
 arising from  disease of the  heart,  nor is it very
 easy to say what is the precise state of the system
 in which this phenomenon does occur.
   None of the species of dropsy is more frequently
 relieved, or we may  say for  a  time even cured,
 than this ; but it very frequently recurs, and at
 length, favoured by the exhaustion  from long dis-
 ease, and sometimes perhaps  even by the remed.es
 that  have been necessarily employed, a very co-
 pious effusion takes  place  into the chest  and
 death often at last occurs very  suddenly,   bome-
   Vol.  I. — 89
times,  and  this is no  unusual occurrence, the
anasarca permanently disappears for some time
before death, or remains  but in a very, slight de-
gree.   The  oppression of the chest, however,  is
not diminished, and occasionally a greater deter-
mination of blood takes place to the  lungs,  or
these organs become congested, especially if much
obstruction  occurs in the valvular structure of the
left side of the  heart.  At this period haemoptysis,
acute pneumonia,  and pleurisy, are very liable to
ensue,  and require the most decided antiphlogistic
treatment.   Even this treatment  does no more
than afford temporary relief,  and inflammation
occurs again and again, till the means of the phy-
sician are exhausted.  To stimulate increases  tbe
inflammation,  and farther  depletion is rendered
impossible by the extreme debility of the patient.
   The course now described is not peculiar to any
one affection of the heart; the symptoms are, more
or less, the same under every malady of that organ.
Some  difference  nevertheless exists according as
the heart is the subject  of what Corvisart calls
active  or passive aneurism ; congestion  and in-
flammation  being' more  common  in  the former
affection than in the latter.  Often, indeed, when
passive aneurism exists, advantage is derived from
the lighter tonics united with diuretics, but active
depletion is neither  called for  nor admissible : it
reduces  the patient without benefiting  him as  re-
gards the disease.
    Dropsy from Disease of tbe tilings. —
Under the head of Anasarca we have given se-
veral instances of this affection, when arising from
or connected with inflammation of the lungs.  For
the phenomena attending it under  such circum-
stances, we refer therefore to that  article.  It is
not, however, only after inflammation of the paren-
chymatous  structure of these organs that effusion
occurs; it  arises also after chronic  bronchitis;
after chronic pleurisy ;  and  frequently,  perhaps
 generally, in a greater or less degree, in the latter
 stages of tubercular phthisis.
   The phenomena  of dropsy, when arising from
 chronic bronchitis, do not materially differ, except-
 ing as to the rapidity of its progress, from a simi-
 lar affection after inflammation of the lungs.  The
 face and upper extremities are in both cases the first
 to become  oedematous.  Sometimes this cedema is
 so slight, that it produces only slight stiffness at
 first waking in the  morning, and is scarcely—oc-
 casionally not at all—recognised by the patient rs
 the consequence of any swelling of the eyelids.
 At a shorter or later period after this,  the ankles
 swell,  and the affection  in this stage may remain
 nearly stationary for  months  and  even for years.
 As, however,  chronic bronchitis is liable to pass
 at particular periods into  a sub-acute, sometimes
 even  into  an  acute form, there is usually at the
 same time  an  increase in  the  effusion, which will
 thus be found to increase and subside  with every
 aggravation or alleviation of the  original malady.
 We have  in  this  manner  known an individual
 pass seven or eight  years  without  any  material
 alteration ; in the  summer  enjoying  a tolerable
 state of health,  in  the  winter threatened with a
 fatal  termination from  fresh attacks.   It ought
 also to be observed, that each attack leaves the
 individual  in  a less favourable state than before.
 At length  the dropsical effusion begins to increase 
706
DROPSY.
more rapidly; the whole cellular texture becomes
anasarcous; fluid is poured  out into the cavities
of the peritoneum, the  chest,  and the brain, and
death ensues from the affection of one of these
latter cavities.  Sometimes the pleura?, the peri-
cardium, and  the cellular texture  of the lungs
become so dropsical, that the patient is unable to
lie down,  and at last appears to die  from suffoca-
tion ;  and not  unfrequently death takes  place
very suddenly under such circumstances. Another
termination  is in  effusion into  the  ventricles of
the brain, and the patient dies with the common
symptoms of apoplexy, or falls into a doze, and
imperceptibly passes from a state of sleep to actual
death.
  To tbis general description of the course which
dropsy from chronic bronchitis  pursues, is  to  be
added,  the supervention of fresh symptoms as ad-
ditional organs become involved.  Thus  palpita-
tion of the heart supervenes  with  the effusion of
fluid into the pericardium ; the dyspnoea increases
with the increase of effusion into  the pleurae or
the cellular tissue of the lungs; the digestive or-
gans become more disturbed  as their functions are
interfered with by the pressure of fluid within the
cavity  of the peritoneum; and if  the brain is in-
volved in the general disposition  to dropsy, stupor,
paralysis, or apoplexy, may and not unfrequently
does ensue.
  Dropsy likewise takes place in the latter stages
of chronic pleurisy and tubercular phthisis, but it
is not  often a very prominent affection,  and is
chiefly confined  to the lower extremities.   Some-
times,  however,  the body  becomes universally
anasarcous,  especially in phthisis,—and very little
can  be effected for the effusion under such hope-
less circumstances.
  Dropsy from Disease of the Liiver,  [Hepa-
tic  Dropsy.]—This species of dropsy has been re-
cognized from the very earliest periods of medicine
of which any record remains, and  to this most of
the  older histories of  dropsy  refer.  The form
which  it assumes is chiefly  that of ascites; and
some peculiar symptoms attend its progress, which
deserve consideration  in  its  treatment.   Dropsy
takes  place in the latter stages of  most hepatic
diseases; nor are we  acquainted  with any mode
of detecting the  precise nature of  such diseases
during life,—whether  there is  nutmeg liver, or
simple enlargement of it, or  tubercular disease,—
excepting in the  last instance, when the  bulk of
the deltoid, become  the  seat of pain greatly re-
sembling rheumatism, and not unfrequently mis.
taken for it.  The urine is very red  and deposits
lithic acid, and  the  evacuations  are  usually, but
not invariably, clay-coloured.   In many instances
sickness also is  present, and a greater or less de-
gree of jaundice.   When  this last  symptom  is
united with those above enumerated, no doubt can
remain that the  liver is the seat of some important
disease.
   When the symptoms now mentioned have con-
tinued for  some time,  the ankles are  perceived to
swell at night a little,  and  the  abdomen becomes
somewhat fuller.  The urine at the same time di-
minishes in quantity,  the  skin  becomes dry and
harsh, and  tbe patient  suffers  from distressing
thirst.  The progress of the effusion from this pe-
riod  is very various;  in  some  cases  ascites  is
quickly formed,  and the lower extremities become
anasarcous throughout; in others the ascites  is
complete, while there is  scarcely  any  oedema pre-
sent ;  and  in a  third series of cases,  the progress
of both is  very  slow :  in these last the ankles re-
main  long slightly  oedematous without any in-
crease of effusion, and sometimes for two or three
weeks together  it entirely disappears, so that the
patient fancies that the dropsical tendency is gone;
again  however it returns, and the dropsy becomes
permanent.  The duration of the disease is like-
wise various ;  for while  in  most cases several
months elapse from the commencement of effu-
sion  till the death  of the patient, in others the
effusion  takes place only  a few days, or two or
three  weeks before  death ; and  we have some-
times  seen the  abdomen become excessively dis-
tended three or four days only preceding dissolu-
tion.
   As  in dropsy from disease of  the lungs, fresh
symptoms  are added as additional cavities become
the seat of effusion ; but neither  the chest nor the
ventricles of the brain  so readily  pour out fluid as
when  the dropsy commences with an affection of
the  heart or of the lungs.  The dyspnoea which
usually comes on in  the latter stages of hepatic
ascites, is chiefly to be referred to the protrusion
of the diaphragm into the cavity of the chest, and
it is seldom that any cerebral disturbance  exists
in  these  cases.   Generally, indeed, hepatic pa-
tients preserve their intellectual powers to the last
in a very extraordinary manner.   We have some-
times  however  seen delirium come  on in a few
the oruan has so far increased that a tolerably cor-" hours, or a day or two before death ; but this is so
rect opinion may be formed by external examina
tion.
  Disease  of  the liver .usually exists for a long
time before effusion takes place, and its earliest
symptoms  are  little  more  than those of simple
functional  dyspepsia.  There is flatulence, unea-
siness at the stomach after eating, and often some
pain and tenderness  in the right hypochondrium ;
and occasionally at a very early period  the lower
edge of this organ may be perceived harder, larger,
and  lower in the abdomen than is usual.   There
is a short dry  cough occurring at  times through-
out the day, but more particularly on first rising
in the mornii.g, ana the  sputa are  blackish and
occasionally dotted with blood.  The pain passes
sometimes backwards under the blade-bone ;  at
>»iher times the muscles covering this  bone, with
usual in the closing scene of all chronic  diseases,
that it cannot  be regarded as an  essential part
of the affection we are now describing.  Under
these circumstances  the  patient gradually wastes
away ; and death seems the natural result of a de-
bility that had been continually increasing till the
moment of dissolution.
   Dropsy from Disease  of the Spleen and
Pancreas.—There  are  no general symptoms by
which we can  readily recognise  these organs as
the  sources  of effusion.   With regard to the
spleen, its enlargement usually long rrecedes the
occurrence of dropsy; and tbe diagnosis, conse-
quently, when the patient is seen early, can sel-
dom be difficult.  Dropsy from  this cause  often
disappears;  and we have known  in one instance
the effusion and the  tumour vanish together, after 
DROPSY.
707
the  latter had existed for  many months.  The
pancreas has not been much observed  in dropsy,
and we are not acquainted with any case of effu-
sion that could be attributed to an affection of this
organ.
  Dropsy  from  Disease  of  the  Kidneys
[Renal Dropsy]---Many affections of these or-
gans are capable of inducing effusion, and this  is
a common  consequence when from any  cause
they are extensively diseased.  The kidney is oc-
casionally converted into a scrofulous mass; and
we  have met with cases, and several  others are
recorded, in  which under such circumstances  it
formed a prominent tumour in the abdomen.   A
much less degree of disease is, however, sufficient
to produce  effusion.   The  form of dropsy under
these circumstances is anasarca, and ascites does
not  usually  take place till  later in the disease.
The cedema commences in the lower extremities,
and in some instances which have come under our
notice, the limb  corresponding with the diseased
kidney, where only one was affected, has swelled
most; so that we are induced to believe that cede-
ma in such cases is sometimes the consequence
of pressure upon the ascending cava, or at least is
aggravated by this pressure.
   Dr. Bright has within these few years brought
to the consideration of the medical world a pecu-
liar change in the  structure of the kidney, which
he  regards  as the cause of dropsy, and the  ten-
dency to which change, or its actual occurrence,
is indicated  by the coagulability of the urine—
[Albuminuria.   (See  Kidney,  Diseases   of
the)].  In these views he is joined by Drs. Chris-
tison and Gregory, the latter of whom  has  how-
ever shown that the peculiar alterations alluded to
by  Dr. Bright, and  the presence of  coagulable
urine, often  occur without dropsy.  The peculiar
nature of this change we shall intimate when we
describe the morbid anatomy of dropsy.
   Three forms of dropsy connected with disease
of  the kidney may be  particularly traced in  the
cases recorded by the above-mentioned physicians:
— the first  commencing evidently with the respi-
ratory or  circulating organs, and  united, either
from the beginning  or as  the effusion proceeds,
 with disease of the kidney ;  the second, commenc-
ing with disease of the kidney, and secondarily
affecting respiration  and circulation; and a third
in  which the kidney is the only organ  affected
throughout.  The first species differs little from
that which we have already spoken of under the
head of dropsy from disease of the lungs, except-
ing in the  supervention of symptoms indicative
of renal disease.   These symptoms are sickness,
vomiting, purging, pain  in  the loins, often united
with coagulable urine ;  but this last may exist in
a very great degree, and for a very  long time,
without any appreciable alteration in the structure
of  the kidney.  The former  symptoms exist  in
very various  degrees, either alone or united, and
are sometimes altogether absent.
  The second form  begins with anasarca only,
which quickly becomes universal, and in a longer
or  shorter  time,  commonly within a  few  days,
symptoms of inflammation  of the lungs or pleurae,
or of both, supervene ;  and though this may be
removed by appropriate treatment, it returns again,
each time increasing the disorganization of these
organs, and sometimes also extending to tbe peri-
cardium, and giving rise to adhesions between its
surfaces.   The dropsy also is, at the commence-
ment of the  disease,  often easily  removable, but
still it returns, till at  length a few weeks or days
before death  it disappears altogether.  In  these
cases, it is frequently only the anasarca and ascites
that  disappear, and the cavities of the  chest are
found after death to  be full of effused fluid.  In
this  as  in anasarca from  other causes, effusion
may take place in the brain;  and knowing the
sympathy between the kidney and this  organ, it
is by no  means surprising that this is no unusual
occurrence.
  The third  is a much rarer occurrence than the
two  former.   Dr. Bright has  given one instance
of this, in which no  other symptom was present
than extensive anasarca  with  coagulable urine,
containing a considerable quantity of the red par-
ticles of  the blood.   The  anasarca disappeared
under the treatment  which was adopted, but the
patient died suddenly  from inflammation and oede-
ma  of the glottis.  Dissection appears to have
proved that in this instance the kidney was in  a
state of excessive congestion, if we may not go so
far as to call it inflammation.
   A peculiarity in patients  suffering under this
dropsy is their extreme liability to be affected by
calomel.   Dr. Bright  and Dr. Gregory  have re-
lated instances illustrative of  their proneness  to
severe salivation from very small quantities of
mercury, and we have ourselves witnessed cases
of the same  kind.
   Much importance is attached by Dr. Bright and
the Edinburgh physicians  to  the coagulability of
the  urine, as indicating extensive  change in the
structure of the kidney,—much more, indeed, than
it appears to us the evidence  afforded is able  to
sustain.   Dr. Wells has long ago shown that this
symptom appeared and disappeared under circum-
stances in which it could not fairly be regarded as
the  consequence of organic  disease.  He  saw  it
suddenly induced by  the exhibition of mercury :
he knew an  individual in whom it appeared pro-
bable that the coagulability of the urine had ex-
isted for nine years:  he  also  pointed out the fre-
quency of its occurrence in that form  of dropsy
which succeeds scarlatina;  and showed, likewise,
that with the disappearance of the dropsy the kid-
neys ceased  to pour out serum.  Dr. Bright him-
self contends  only for functional  disease  in the
first instance, leading secondarily as in other cases
to organic disease ; although it must be confessed,
from the great stress which he lays upon this one
symptom, a  cursory  reader might easily mistake
his  meaning.  Dr. Elliotson,  also, is reported  to
maintain that the urine may  strongly  coagulate
for a time without any change in the structure of
the  kidney.
   We  are, however,  disposed  to go even farther
than this;  and without denying  that  in  some
instances coagulable urine is  the consequence of
serious primary disease in the kidney, nevertheless
to maintain,—that in many instances it is merely
a symptom very remotely connected with organic
alteration in the kidneys.   As  a secreting  organ,
the  kidney is especially bable to be affected by tho
pabulum afforded it;  and should the blood reach
it in an imperfect state, whether in consequence 
708                                      DROPSY.
 of indigestion, imperfect change in the lungs, or
 inordinate action of the heart, or insufficient ner-
 vous influence, we  may expect  that  its function
 will be impaired.   Accordingly we see it deposit
 yellowish sediments in indigestion, lateritious sedi-
 ments in  febrile  diseases, and phosphates after
 injury of the spine.   Now in  very many of the
 cases, perhaps  in  the majority, of dropsy with
 coagulable  urine,  the effusion is preceded   by
 inflammatory symptoms of the organs of respira-
 tion ; and in many there is disease of the heart.
 Considering the important changes that take place
 in the blood during its passage through the lungs,
 we can hardly be surprised that an  affection  of
 these  organs  should  influence  the secretion  of
 urine;  and  again, while  apoplexy is  distinctly
 traceable to hypertrophy of the heart in some cases,
 it surely is not extraordinary that by this organ
 also the secretion of the urine should be modified.
 But we are not left only to theory on this point:
 the numerous cases in which  the urine coagulates,
 already refened to, and in which organic disease
 cannot fairly  be presumed to exist, confirm to a
 certain extent this view of the subject, while mor-
 bid  anatomy still farther corroborates it.   In two
 instances winch we have lately had an opportunity
 of examining, where the urine had strongly coagu-
 lated during life, no disease whatever was observa-
 ble in the kidney.  To one of these we have already
 referred.  The other occurred in a lady who had been
 suffering from pulmonary symptoms, and symp-
 toms of disease of the heart, for nine months, when
 we first saw her.  At  this time the urine coagu-
 lated strongly, and  continued  to  do so  till the
 period of her death, three months afterwards. Yet,
 while the left lung, the pleura, and the heart, ex-
 hibited serious disease of long standing, and while
 the liver was  also diseased, though in a slighter
 degree, — there was  no appreciable change what-
 ever in the substance  of  the kidneys.   A small
 cyst containing a colourless  fluid  was seated  on
 the superior convex portion of the left kidney, but
 did  not in the slightest degree interfere with  its
 structure.  In this case there  had never been any
 pain in the back.
   The view we now contend for is by no means
 unimportant as a guide to practice; for the plan
 of treatment must necessarily  be different, accord-
 ing as we consider the kidney primarily or seconda-
 rily  affected.   Should  we  find reason to believe
 that  the  respiratory organs are the earliest  and
principal  sufferers, our chief attention  must  be
 paid to them.   As a guide also to  a correct prog-
nosis, this view is most important; because, if the
kidney is to be regarded as organically diseased  in
every case of  coagulable  urine,  all  such cases
 would be evidently hopeless,  and little would  re-
main for the physician but to  smooth  the path  to
a fatal termination.
  The next question  which  presents itself con-
nected with this state of the urine, is the condition
of the system in  which  it exists.  Dr. Blackall
regarded  it  as inflammatory;  Dr. Prout regarded
it rather as proceeding from irritation than inflam-
 mation, (Prout on the Urinary Organs, first edit
 p. 48); and other authors appear to have paid
scarcely any attention to this  part of the subject,
excepting so far as  stating that it could not be
 relied upon as a guide in practice.   That it  is  at |
times connected with an inflammatoiy btate of the
kidneys, the following case, which occurred in our
practice several years ago, abundantly proves.
   A girl, twenty-three years of age, applied on the
11th of July, 1823, complaining of severe pain
across the back, in the region of the kidneys, with
shivering and frequent sickness.   A short time
before, the right foot had swelled; but at the time
of her application  this had subsided.   Her urine
was of a dark brown colour, depositing a thick
precipitate upon the addition of tartarized antimony,
and becoming of the consistency of melted butter
by boiling.   She made water very frequently, but
very little at a time.  She complained of pain  in
the  pudenda.  The catamenia were scanty, but
regular to the period.   She  had had scarlet fever
six months  before,  and her urine  had been of the
dark colour, now mentioned, ever since, but occa-
sionally becoming a little clearer.  This case was
regarded  as  inflammation  of  the  kidneys, and
treated  accordingly, and on  the  21st of July, she
was convalescent;  the urine had then returned  to
a healthy state, being lighter in colour, and afford-
ing  no  coagulum upon boiling.   On the other
hand Dr. Blackall has given a case of dropsy after
scarlatina, in which the urine remained coagulable
after the effusion had disappeared, and regained a
healthy state under the administration of cinchona.
At the present time we have a case of dropsy with
coagulable urine, in which the quantity of serum
greatly  diminished  for a few days after taking sul-
phate of quinine.*   Dr. Bright also remarks that
occasionally we find anasarca even with coagula-
ble urine so  marked by debility that  tonics and
steel give decided relief.
  Dr. Wells had seen the urine become coagula-
ble after the  exhibition of  mercury, and this  is
now a well-known effect  of mercury.  Dr. Bos-
tock observes  that in a great majority of cases of
persons in apparent health, serum may be detected
in the urine by the appropriate tests, and  that in
his own person he  had observed  it to be increased
to a  considerable amount by the  slightest causes.
In a patient  of the Birmingham Hospital, who
had  had anasarca connected  with bronchitis, after
both diseases had disappeared, and the urine, which
had  originally  been coagulable, had  recovered its
healthy condition, it was found  one day immedi-
ately after dinner to be rendered  almost solid by
heat, and  the next morning the  same means did
not detect a single particle.
  These few facts abundantly confirm the opinion
of Dr.  Prout, that  taken alone "as a symptom,
the albuminous urine does not, in the present state
  *The patient here alluded to was in the Birmingham
Hospital, and died soon after the ahove was written.
The body was examined, but there was no alteration in
the structure of the kidneys.  The cortical part was paler
than usual, but retained its natural structure, and the
tubuli were perfectly distinct.  The kidneys were exhi-
bited to several of the  medical officers of the establish-
ment, who all agreed that there was no change whatever
of structure. The  liver in this case  was, if Anything,
smaller than natural, and externally hai'  exactly the
appearance of lung ; internally it appeared as if it were
pervaded  by inspissated bile, and was firmer than na-
tural.  The  peritoneal coat had contracted numerous
adhesions with the diaphragm.  The heart was remarka-
bly small, the walls of the right  cavity were very thin,
while those  of the left compared with  the  right were
enormously thick.  These were the only unusual appear-
ances about the body.  This  man had  been a spirit-
drinker. 
DROPSY.
709
of our knowledge, indicate the use of any parti-
cular remedy or  mode  of treatment; but  that,
nevertheless, it is  a symptom of which we ought
always  to  be aware,  since, taken in conjunction
with the others, it may  be occasionally useful in
directing us to form  a more correct judgment of
the general nature of the disease."
  Albuminous urine appears  to be much  more
ultimately  connected  with  anasarca  than with as-
cites.  Dr. Wells  found it, in twenty-four cases
out of thirty-seven, connected  with anasarca; in
fourteen cases of ascites  previous to anasarca,
there was  no serum  in  the urine; and in  eight
cases of anasarca  subsequent  to  ascites, the urine
in all contained serum, and in one it was rendered
solid by heat.  Of the seven cases related  by Dr.
Christison, anasarca  was  tbe principal form of
dropsy  in  six, and in the seventh  only was the
ascites  a prominent  symptom.  Much the  same
proportion  is observable in  Dr. Gregory's cases;
and in  the twenty-three  cases  recorded  by Dr.
Bright, anasarca was the form of effusion in all.
   We  cannot dismiss  this part of  the  subject
without some observations on the composition of
coagulable  urine.   Dr.  Bright believed that the
dark brown colour was frequently owing  to the
presence of the red globules of the blood, and in
this opinion he is  supported by Dr. Gregory.  The
case of inflammation  which we have already given
strongly supports this view, and  there are few
physicians probably who will doubt the possibility
of its occurrence.   This point therefore we may
now leave : a much more  important part remains,
viz. to afford our readers the best means of inves-
tigating some of these points themselves.
   All the writers referred to  (and in numerous
instances we have confirmed the fact  by our own
experience) state that coagulable  urine bas a much
less specific gravity than healthy urine ;  and Dr.
 Gregory has given two tables containing the result
 of an equal number of trials with coagulable and
 with healthy urine.   The  average specific  gravity
in fifty cases was in healthy urine 1022-46, the
highest being 1033,  and the  lowest 1005; while
in the  coagulable urine, the highest was  1023-5,
and the lowest 1006-5.
   With regard to the best means of detecting al-
bumen when it exists in  urine, we may  observe
that heat, while  it is of readiest application, will
generally be found sufficient.   It is often  advisa-
ble, however, to make  use of re-agents,  and of
these corrosive sublimate is the most delicate.  The
nitric and  muriatic acids  are also  employed for
the same purpose, as is  also the  ferro-prussiate of
potash, and alcohol.   With respect to the effects
of these latter re-agents,  Drs. Gregory and Bos-
tock are somewhat  at  issue.  The  former  says
 hat he never knew  a case in which  they caused
i precipitate when heat had no effect, while Dr.
Bostock observes, " I  have  also  found  certain
states of the  urine where  heat had no effect, but
where muriatic acid threw down  a precipitate, and
again where muriatic acid  had  no effect, but where
the albumen was detected by the bichloride of
mercury, or 4he  ferro-prussiate of potash."  All,
therefore,  that can be deduced  is, that all these
re-agents  should  be employed  in  succession in
suspected  urine,  when  the first fails to discover
"Ib'imen.
                                    3k
  Dropsy from Disease of the Uterus  and
Ovaries.—Many of the affections of the uterus,
after they have existed long, give rise to dropsical
effusions into the lower extremities.   Sometimes
this appears to be the result of pressure only  upon
the great vessels, when the uterus is  either en-
larged  itself or contains a tumour of considerable
size.  At other times the effusion appears to be
the result of  the hemorrhage to which, under cer-
tain forms of disease, the uterus is peculiarly lia.
ble.  This therefore is not fairly to be referred for
its  origin to organic disease  of the uterus  ; the
dropsy is simply the consequence of the hemor-
rhage,  and hemorrhage from any  other organ
would  give rise to similar results.   With regard
to the ovaries, we know that they are  themselves
the seat of those  affections which are called en
cysted  dropsies, and  in  this light they do not  at
present demand our consideration.  But affections
of the  ovaries appear sometimes to  produce real
ascites, while they still present only the character
of nearly solid tumours, and at the same time the
lower extremities become oedematous.   We have
already mentioned  our suspicion that ascites  is
sometimes a consequence of ovarian disease, sub-
sequent  to parturition, and  we have met  with
cases of  bronchitis  in  which  ascites  has  taken
place earlier than probably it would have  done,
had not ovarian disease existed previously.
   Morbid Anatomy. — This naturally divides
itself into two parts :—first, the morbid  anatomy
of the serous membranes and cellular tissue, which
are the immediate  sources of the  effusion ; and,
secondly, the morbid changes of the various vis-
cera, in consequence of which  the serous mem-
branes and the cellular tissue assume  a  dropsical
disposition.
   1. The most ordinary appearance  in the serous
membranes is thickening and opacity, which are
more or less  manifest in every serous membrane
of the body.  Thus in hydrocephalus, the lining
of the  ventricles, though seldom separable as a
membrane, is evidently firmer and more condensed
than natural;  but the changes referred to  are
much more easily seen in  the pleura, pericardium,
and peritoneum.  All these membranes become
opaque or thickened ; coagulable lymph is thrown
out; and we not unfrequently find large  layers of
lymph converted into factitious membranes.   Ta-
cheron (Recherches Anatomico-Pathologiques, vol.
iii. p.  196)  says, "The  pleura has been found
thickened and covered witb a layer of villous mat-
ter, oily  to the touch, whitish, and  similar to the
intestines of the cow when converted  into tripe."
The same author has given  an example of both
pleura and the peritoneum becoming tuberculated.
Dr. Ayre has related a case of ascites in which he
found  the peritoneum thickened and opaque, quite
white, and having nearly the thickness of chamois
leather.    In the Quarterly  Review  of Foreign
Medicine, a case is given of a woman who became
dropsical after being brutally kicked by her hus-
band : in thirteen years she was tapped 665 times,
and on dissection the peritoneum was found car-
tilaginous and three lines thick.
   So far as the serous membranes themselves are
concerned, these appear to be the principal changes.
With respect to tbe cellular tissue, Portal tells  -»
that in dropsy it is more  or less thickened, that 
10
DROPSY.
the cells are dilated, and many converted into one,
and that he had  seen the intermuscular cellular
tissue put on a  cartilaginous appearance  under
such circumstances.  (Portal, Des  Hydropisies,
torn. ii. p. 12.)
   Morgagni relates  a case of anasarca in  which
the tissue was  thickened,  and,  as  he  says,
the fluid, from  the  frequent  intervention  of
the cellular layers, assumed the likeness  of  ge-
latine.   Bichat observes that in prolonged cases
of leucophlegmasla, the  subcutaneous fluid is by
degrees infiltrated through the prolongation of the
areola? of the skin, separates their fibres, and some-
times penetrates to tbe epidermis, which it bursts
in different places, and the  fluid escapes through
the apertures  which are thus  made.   (Bichat,
Anatomie Generale, p. 689.)  In the  case above
referred to, from  Morgagni, the  cuticle had been
thus raised, but not burst, so as to form immense
bladders,  which  were filled with water.  (Mor-
gagni, Ep. xxxviii. c. xxvi.)  The cellular tissue
itself is in such cases remarkably bleached.
   This perhaps  is the  proper place for noticing
the changes which  occur in the absorbent  vessels
and veins.  It has been often assumed that  the
former may be dilated and burst, but we know no
cases which afford confirmation to such an opin-
ion.  That the absorbent vessels are more easily
detected in dropsical  bodies is true,  but this  pro-
bably is  chiefly owing to the  removal of the adi-
pose substance of the system.  Dr. Hodgkin, how-
ever, has lately  rendered  it probable that these
vessels are in some way connected with effusion.
He has related several cases of dropsy in which
the absorbent glands, and  especially  those  sur-
rounding the great vessels, were enlarged and in-
durated.  (Medical Gazette, January  21,  1832.)
This enlargement appears to consist  throughout
of an uniform texture, rather the consequence of
a general increase of the whole gland, than a new
structure displacing the original  one.  It is  simply
an hypertrophy therefore of the glandular system.
In illustration of this morbid growth, five cases
are given, two in children, one nine and one  ten
years old; one in a man aged thirty,  and  two in
persons of fifty  years of age.   In  four of these
cases  the spleen  was enlarged ;  and a fifth case
of enlarged spleen with general  induration of the
absorbent glands  is referred  to, drawings of which
were made by Dr. Carswell, and are contained in
his collection.
   In  local anasarca  the veins frequently exhibit
peculiar appearances. Sometimes their cavities are
completely obstructed by  fibrinous  clots,  which
nave evidently formed during life. In other cases
the internal membrane is thickened, red, and co-
vered with coagulable lymph.   Occasionally  pus
is found in their  cavities.
   Diseases of the arteries are often found in dropsy,
and particularly  aneurisms of the aorta.  The  late
Mr. Freer believed that inflammation of the lining
membrane was common. We are not aware that
this observation  has been confirmed, but we have
seldom opened a patient dying with general  dropsy
who did  not exhibit some  disease  of this mem-
inane.   This generally  consists  of scrofulous or
oony deposits, with frequent ulceration ; and we
once saw the descending aorta  beset with  nume-
rous incipient aneurisms, from  this cause, a few
of them being larger than a good sized pea.
  2. The  lungs are frequently found with the
appearances consequent to bronchitis.  The bron-
chial membrane is inflamed, and its texture thick*
ened, sometimes even ulcerated.  The cavities of
the bronchi and air-cells are filled with a frothy
fluid, and  sometimes with pus.  At  other times
we find the common results  of pneumonia, con-
gestion of  the lungs, serous infiltration, hepatiza-
tion, purulent infiltration, &c.   When dropsy of
the pleura  has existed long, the  lung  is often so
much compressed as to form a solid body,  wholly
or in part impervious to air.
   Tubercles are not unusually discovered in drop-
sical patients, although  no suspicion of tubercular
phthisis may have existed during life.
  The various organic alterations of the heart are
also frequent in tbis disease,  and may, doubtless,
be regarded as the original cause of effusion. For
a more minute account of these morbid  changes
we refer the reader to the articles on the diseases
of this organ.
   The  liver  exhibits an  immense variety of ap-
pearances  in  dropsy.   It is  sometimes hard and
scirrhous,  many instances of which are given by
Morgagni.  (Epist.  xxxviii.)  Dr.  Baillie says in
many cases of ascites the liver  is diseased,  being
hard and tuberculated;  and  in  another place he
has  particularly described the  kind  of  change
which is here meant.  The tubercles which are
formed in  this disease occupy the whole mass of
the liver, are placed very near each other, and are
of a roundish shape.   They give  an appearance
everywhere of irregularity to its surface.   When
cut into, they are found to consist  of a brownish
or yellowish-white solid matter.  They are some-
times of a  very  small size, so as not to be larger
than the heads of large  pins ; but most frequently
they are as large as small hard nuts, and some-
times larger.  When the liver is thus tuberculated,
it feels much harder to the touch than natural,
and not uncommonly its lower edge is bent a little
forwards.  Its size, however, is not generally larger
than in a healthy state,  and sometimes Dr. Baillie
thought it  was smaller.   If a section of the liver
be  made in this state,  its vessels seem to have a
smaller diameter than they have naturally  ; and it
frequently  happens  that the  liver is of a  yellow
colour from tbe  bile being accumulated in its sub-
stance.  The gall-bladder is generally  contracted,
and of a white colour, from its being empty.  Dr.
Baillie also mentions a peculiarly hard liver, which
exhibits, when cut into, no peculiar structure, and
is also  accompanied by incipient  ascites.  This
state of the liver has frequently fallen under oh
notice,  and we  have found it still only unusually
firm when  the ascites has been  very considerable.
  Dr.  Bright  has described an appearance of the
|i*er, probably the more advanced stage of the last
morbid structure, and which seems really to de-
serve the name of scirrhus.  The substance of the
liver is hardened throughout, and bands of thick-
ened cellular membrane, like ligamentous matter,
pervade every part: in some  parts* of the  liver
from which this description  is  drawn, it  formed
one-third of the whole structure. Although, when
seen  externally, the liver appeared  tuberculous 
DROPSY.
711
and knotty, yet when examined internally there
were no tubercles.   The  liver is also sometimes
etudded with large white tubercles ;  and we have
§een the structure of the organ so completely ob-
scured by their accumulation, that it could scarcely
be recognised.   This disease, however, seldom
gives rise to effusion  till it has made very exten-
sive progress.   The weight of the liver in such
cases is often very great: in a patient whom we
examined last year, it amounted to eleven pounds.
  The changes now enumerated form indeed but
a small part of the  modifications  to  which this
organ is liable,  and which  are found  to give rise
to effusion. The observation of Dr. Bright, how-
ever, that  those changes in the structure of the
liver by which the branches of the vena portae are
compressed more frequently give rise to dropsy
than any of the circumscribed changes, (as tuber-
cles of various kinds,  and hydatids occurring im-
bedded in their substance,)  is perfectly accordant
with our own  experience;  and the  observation
we have just made  respecting the period of effu-
sion in tubercular disease of the organ, drawn as
that observation  is  from numerous  facts which
have  fallen under  our notice,  is an additional
confirmation.
   The colour of even what  is called a healthy
liver  is  exceedingly various, and  hence,  from
colour alone, it  is  not easy to draw any positive
conclusions.  Sometimes, however, the variation
is so decided that we cannot hesitate to pronounce
the structure diseased.  The  most remarkable of
these  changes is that which has been termed the
nutmeg liver, and  this term more completely ex-
plains the appearance than any lengthened descrip-
tion can do.  Sometimes the whole liver is much
lighter than usual; at others it is yellow, and ap-
pears  to be filled  with inspissated bile; and Dr.
Bostock has rendered it  probable that this is ac-
tually the case, for in a liver of this kind submitted
to his examination,  he inferred from numerous
experiments  that it  contained  cholesterine,  the
substance which forms the basis of biliary calculi.
In  a  liver which we examined within these  few
days,  the colour externally was that of hepatized
lung,  and it might easily  have been mistaken for
this organ so far as  tbe colour was concerned.
The interior was very dark, yet we could scarcely
say that the structure was diseased.  [See Liver,
Diseases  of the.]
   The spleen is also frequently found in a diseased
state in dropsy.  It is sometimes much harder than
natural,  and at the  same time  considerably en-
larged.  It will  occasionally attain  an enormous
bulk,  forming  a very prominent tumour in the
abdomen, and after continuing some time, giving
rise to effusion, by which the tumid spleen is sub-
sequently concealed.  The structure of the spleen
does not in such cases appear altered, but is only
firmer and more compact, still retaining its natural
eolour and granulated  appearance.  Sometimes
this organ  is covered with small white cartilagin-
ous bodies, probably tubercles, as we once found
'hem  in a man whose lungs were studded with
•imilar particles ; and Dr. Hodgkin has related a
ewe in which  they  seem to have  pervaded the
"ubstance of the organ. In this instance the spleen
was at least nine inches long, five broad, and pro-
portionably thick :  its  structure consisted  of an
almost infinite number of small white globules,
which appeared to  arise from deposits  in the
cellular tissue of the organ.
  The pancreas is seldom diseased in dropsy; we
have  sometimes  thought it much  harder than
natural, but on cutting into it it has invariably
exhibited a natural structure.
  The kidneys are subject to various diseases, and
very different morbid structures are exhibited  in
them  in cases of dropsy.  Dr. Bright thinks that
his  investigations  will authorise three  varieties
generally attended by albuminous urine; — « In
the first a state of degeneracy exists, which, from
its appearance, might be regarded as marking little
more  than simple debility of the organ" (ansemia).
" In this case the kidney loses  its usual firmness,
becomes of a yellow  mottled  appearance  exter-
nally  ; and  when  a section  is made, nearly  the
same  yellow colour, tinged with  grey, is  seen to
pervade the  whole of the cortical part, and  the
tubular portions are of a lighter colour than natu-
ral.   The  size of  the  kidney is not materially
altered, nor is there any obvious morbid deposit."
This  state of the kidney is well known as  the
consequence of dram-drinking, but  it certainly is
not confined to the victims of intemperance.  It
is frequently found in patients who  have  suffered
from  tedious and  exhausting  disease ;  and  Dr.
Bright himself states that he had observed it in a
case  of  diarrhcea  and phthisis, and  of  ovarian
tumour.   We have observed it in a woman who
died from disease of the heart, and in whose lungs
there were softened tubercles, none of which had
been  discharged.   In this instance  the urine did
not afford  the slightest coagulation by heat.   In
the most advanced stage of this disease Dr. Bright
thinks that there  is a more decided alteration of
structure, and that some portions are consolidated
so  as to  admit  of very partial  circulation ;  in
which state the surface has a somewhat tubercu-
lated  appearance, the projections being paler than
the rest, and at this period the urine  is coagulable.
  The  second form is  one in which the  whole
cortical part is converted into a  granulated tex-
ture,  and where there appears  to  be a  copious
morbid interstitial deposit  of an opaque  white
substance.   In its earliest stage this only produces
externally  an  increase  of  the  natural  mottled
appearance, or sometimes that of fine  sand sprin-
kled more  abundantly on some parts than others.
The same appearance is slightly observable inter-
nally on  making  a longitudinal  section.  After
the disease has continued some time, the deposited
matter becomes more abundant, and innumerable
specks of no definite form  are  observed on  its
surface.   The cortical part exhibits, on being cut
into,  a similar appearance.  Later in  the disease,
the granulated state begins to show itself exter-
nally in frequent slight uneven projections on its
surface, and  the  kidney  is  rather larger than
natural.
  In  the third form the kidney is quite rough and
scabrous to  the  touch  externally,  and rises  in
numerous small projections, yellow, red, and dui-
plish. The organ is often inclined to be lobulateu,
and on making an incision, the texture is  found
approaching to cartilaginous hardness. The tubu
lar portions are observed to be drawn nearer to the
surface, and it appears like a contraction of every 
,12
DROPSY.
part of tbe  organ, with  less interstitial deposit
than in the last variety.
  Dr. Bright also mentions two other conditions
of the  kidneys, in which coagulation of the urine
is sometimes observable.   One  of these consists
in a preternatural softness of the organ ; the other
in the  blocking up of the tubular structure by
small portions  of a  white deposit, bearing  the
appearance of small concretions.   In the former,
a corresponding loss of firmness has been observ-
able in the heart, liver, and spleen ; and  in  the
latter, the cortical portion has been firmer than
usual,  and the  tubuli  have  assumed a  waved
direction.
  These are  by no  means the only diseases of the
kidney that give rise to or are  attended by dropsy.
It is sometimes scrofulous.  We have seen it con-
verted  into a  steatomatous tumour so large that it
formed a prominent tumour in the abdomen.  In
another case the right kidney was five or six times
its natural size, soft, and divided into lobules.  On
opening it, it was found full of scrofulous  matter,
which  occupied the whole of the cortical part and
the interstices of the tubuli, which were scarcely
at  all  traceable.   The left kidney equalled  the
right in size,  but was less diseased.  The cortical
substance  was changed into  a  granulated fatty
substance, presenting much the appearance of the
liver under some circumstances.   The tubuli were
in this instance quite distinct.  In this case, which
is copied from notes taken in 1826, the urine had
come away stillatim, and the patient had suffered
very much from excoriation of the pudenda.  She
never complained of  any particular pain  till  six
weeks before her death, when  she became anasar-
cous.  The symptoms then agreed with those of
Dr. Bright's  and  Dr. Gregory's cases.   From the
urine during  the whole period coming away stilla-
tim, this secretion was not particularly examined.
We have particularly mentioned this case because
it illustrates the remark of Dr.  Gregory, that the
persons in whom he found the morbid alterations
of the kidney,  were  either those who  had  led
irregular lives, or who presented the usual charac-
ter  of  the strumous diathesis.  Again, in a case
which  we  examined a few days ago, the left kid-
ney contained several calculi; and its structure,
though much wasted, was remarkably healthy in
appearance, while the right kidney was pale, and
the tubuli were very indistinct in consequence of
an interstitial deposit  of a whitish substance.
  These,  probably,  are only a few of the devia-
tions from health which occur in the kidney, and
vvhich  give rise to or accompany dropsy.   With
regard to any of these changes  being  necessarily
connected  with  albuminous  urine, enough  has
Deen shown  above  to prove that at present  the
subject requires  additional  investigation.  We
have found albuminous urine  to a very considera-
Dle extent, without any corresponding alteration in
the structure  of the kidney; and we have related
one instance  of Dr. Bright's first variety, in which
the urine  did not coagulate.  It cannot, however,
De considered improbable that this phenomenon is
connected  with some pecuhar  condition  of  the
organ, and that, when long continued,  it will lead
to  some pecuUar morbid alteration of structure.
But what this condition or this alteration may be,
must still be  regarued sub judice; and we  should
mislead our readers in no slight degree if we called
upon them to believe that anything further in this
matter has yet been discovered, than  a more fre-
quent coincidence between  coagulable  urine and
disease  of the  kidney than  had been  previously
suspected.   This  coincidence, though frequent, is
not invariable; nor are the symptoms which are
reported to indicate it more to be  relied upon.
[See Kidnet, Diseases or the].
   Prognosis. — The prognosis in  dropsy must
naturally  vary  much according to its  origin, its
combination with organic disease, its duration, and
the debility of the individuals who are the subjects
of it.
   Acute dropsies, cseteris paribus, are more curable
than chronic, and idiopathic are more  curable than
secondary dropsies.  With  regard  to acute drop-
sies  our judgment must  be greatly guided by the
concomitant circumstances.   If there be any vital
organ seriously affected,  as the lungs  or the heart,
our  chance  of  removing  the effusion  will  be
governed greatly by the control we may be able to
obtain over the original disease.  Thus, if anasarca
succeed bronchitis, a permanent recovery from the
dropsy cannot be expected without the  disappear-
ance of the bronchitis.  It will indeed  sometimes
happen, as we  have mentioned in a previous part
of this article, that effusion will disappear a short
time before death; but this clearly is no  cure of
the  secondary  disease.   In healthy constitutions,
which have been uninjured by irregular habits of
living, the acute dropsy will, under proper treat-
ment, usually terminate  favourably;  but in those
who have been  weakened  by drinking or other
irregularities, or who  are originally of  debilitated
constitutions, we  can  seldom  venture  to predict
recovery.
   Witb regard to secondary dropsy, we may state
that those arising from disease of tbe heart usually
admit  of  removal, but the disappearance of the
effusion is seldom permanent. Nevertheless, longer
or shorter intervals of  ease are afforded; and,
under cautious treatment, months, and even years
may elapse between the first occurrence  of effusion
and  the fatal termination.  The same remark to a
certain degree holds good of that species of dropsy
which accompanies disease  of the lungs, but it  is
certainly less curable than the former species. The
effusion which succeeds hepatic disorders is almost
always fatal, and by no means affords a chance of
cure in an equal degree with the two  former modi-
fications.   There  are, however,  some  cases of
ascites connected with enlargement of the liver, in
which the effusion will disappear repeatedly under
the  use of diuretics, and in a few  instances we
have known a considerable time elapse before it
has  returned.   That which succeeds or is accom-
panied with extensive disease of the kidney seems
absolutely  incurable when  the renal disturbance
has  produced any extensive  change  of structure;
but the symptoms of this change are  by no means
at present satisfactorily ascertained.
   Treatment.— In the treatment  of dropsy, as
in every other disease which falls  under the care
of the physician,  certain  general principles are first
to be considered;  and, secondly, the circumstances
by which these principles are more or less modified.
   It has  already been  stated that  dropsies are
sthenic or asthenic, or in different periods of their 
DROPSY.                                     713
-TOgress tbat they partake of both conditions—at
one time the sthenic, at another the asthenic  pre-
dominating.  To tbis  point, then, attention must
first be paid, and  an antiphlogistic or a contrary
regimen pursued accordingly.
  Should  the  effusion have arisen suddenly,  and
should local inflammation be present, whether of
the lungs  or any other organ, bleeding must by
all means be recurred to; and it must be  carried
far enough to affect the system, to reduce the
pulse, produce  faintness, or relieve the immediate
inflammatory symptoms.
  The  bleeding may be  repeated  should  the in-
flammation continue, and should  the strength of
the patient permit.   But  even when this is much
reduced, and venesection  can scarcely be justified,
local bleeding  may be  advantageously employed,
and in  all such cases cupping is much more effica-
cious than leeches.  The  glasses should be applied
as near as may be possible  to the affected organ,
and to  the part of the organ which is most impli-
cated.  Accordingly, in disorders  of the lungs, the
blood should be drawn  from the region  of the
chest;  and if, which  will frequently occur, one
part of the organ is particularly affected, the glasses
should be applied opposite to it. The same remark
holds equally good in  dropsy connected with in-
flammation of  the pleura.  In this case the chest
should always be examined without covering, for
by its dilatation, contraction,  &c, much additional
assistance is afforded  to  the diagnosis.   Next to
 bleeding, counter-irritants are indicated in all those
 cases in which there  are  local  affections, and it
 may be necessary to continue these for a considera-
 ble time.  Indeed,  in all chronic  disorders,  if
 counter-irritation be advisable at all, it is advisable
 to persist  in it, either till the disease for which it
 is employed has disappeared, or till the strength of
 the patient seems to suffer from its effects.   Who-
 ever has  examined a dropsical patient when pleu-
 ritis has been present, must have remarked the
 presence of factitious membranes  of very different
 ages, and in comparing  them with the previous
 symptoms be will usually be able to fix upon pre-
 cise  periods at which some of  them were  first
 firmed.  A little  further reflection will lead  him
 to the conclusion that at no time bad the tendency
 to pleuritic inflammation  been  completely over-
 come,, and although, at particular stages, evident
 and very severe exacerbations had taken place, yet
 that through the whole  disease the  inflammatory
 action  had more or less persisted.   Under  such
circumstances, reason clearly points out one course,
 viz., to continue  the  remedy while  the slightest
trace of  inflammation  remains.   In inflammation
of the pleura, (perhaps of serous membranes gene-
rally,)  this is  particularly necessary, for it is not
always  painful, and  may proceed  a great  way
without exciting surprise.  And  it is this point
that appears to us  most important in that species
of dropsy to which Dr.  Bright  has assigned the
morbid  state of the kidney for  its origin.  We
have abeady expressed  our doubts whether in the
majority  of such  cases  the inflammation of the
serous  membrane be not the primary disease ; at
any rate  it is frequently concomitant, and in no
slight degree accelerates a fatal termination. Under
such circumstances it is to the local inflammation
and not the effusion that attention must belaid;
   Vol. I. — 90                      3 K *
if the former continue, the  disappearance  of the
latter will be of no avail.  Bleeding  is not  only
called  for  in  dropsy  when local  inflammatory
symptoms are present;  a general state of plethora
equally demands  it.   Our  chief dependence for
an accurate diagnosis in this case is the full  hard
pulse, and in great measure also the history of
the patient.  We cannot,  however, too strongly
inculcate the necessity of care  in bleeding  indi-
viduals of irregular habits, and who have indulged
excessively in drinking, especially spirit-drinking,
or in any other debilitating  vice.  Whatever may
be their appearance,  or however hard  and firm
their pulse, such  persons ill bear extensive san-
guineous depletion ; they sink rapidly afterwards
into a low typhoid state, without the possibility
of rousing the system to  healthy  and  energetic
action.
   Of the two principal modes of overcoming in-
flammation,  bleeding  and  counter-irritation, we
have perhaps for this place said enough.   Of in-
ternal  remedies, the two most  powerful unques-
tionably are the antimonium  tartarizatum,  and
calomel in combination with opium.  The  former,
to be really serviceable, should be administered in
the doses recommended by  the Italian physicians,
and thus  given,  its  efficacy in inflammation  is
most extraordinary.  Nor is its effect* merely felt
in  depressing  the inflammatory action;  it  acts
upon the bowels and upon the skin, and thus, not
unfrequently, by promoting the functions of these
organs, but especially  of the last, it favours even
directly the removal of the effusion.   The princi-
pal inconvenience which is experienced  from this
medicine is the nausea and sickness which it in-
duces, particularly after the first few dotes.  This,
however, in most cases soon disappears, and the
patient is able  to take from one to  three or even
four grains at a dose without the slightest  nausea.
It will indeed  occasionally happen that an indi-
vidual cannot obtain what has  been  well  termed
the  tolerance  of the medicine; this,  however, is
so rare a case that it does not contradict the gene-
ral position.  Calomel and opium have been long
known as peculiarly useful  in those inflammations
which throw out plastic lymph, such as  iritis, cy-
nanche  laryngea, &c.  These, however,  are by
no means the only forms of inflammation in which
calomel and opium may be advantageously sub-
stituted  for venesection or any other  mode of
bloodletting.   Whenever the strength of the pa-
tient is too much reduced to admit of farther san-
 guineous depletion, while  still the inflammatory
symptoms continue unsubdued, this  combination
may be usefully employed.   It should be given  as
frequently as every three hours, and  according  to
the  age of the patient the dose may be proportion-
ed from two to four grains  of  calomel, with from
 half a grain to two grains of opium, every time.
 It may be continued till the mouth becomes slight-
 ly affected, but it will be seldom advisable  to carry
 it farther than this.   What  has been  now said
 merely refers to the subduing of any inflammation
 which may be present, which  may give rise to  or
 accompany the dropsical effusion.   But to these
 we  may often  add diuretics or purgatives.   Of the
 different articles which are employed for this pur-
 pose we shall  speak more particularly in a subse
| quent part of this  article.  We here only inti 
714
DROPSY.
 mate that in addition to the  plan for overcoming
 any local inflammation or general plethora, we are
 also called  upon to attempt  the removal of the
 effusion by stimulating the secretions of the bow-
 els and kidneys.
   While on the one hand we frequently find drop-
 sical effusion united with inflammation, so on the
 other  the  system is  sometimes, though  perhaps
 more  rarely, in  a  state  of general debility.  In
 this last condition  a very opposite practice  must
 be adopted, and the most powerful tonics, such as
 quinine  and the different  preparations of  steel,
 may  be not only  safely administered,  but  may
 even  be  demanded.   We must  not, however, for-
 get that mere weakness will not justify the use
 of these  remedies, because this may and frequently
 does  occur when local inflammation is  present.
 A greater object will therefore  be to  distinguish
 these  different  states;  for what will be useful to
 the one will unquestionably be injurious to the
 other.  For the diagnosis we must refer to the
 histories of dropsies as we have  laid them  down
 in the present  article,  and under Ascites  and
 Anasarca.  When, after  proper investigation,
 we are fully satisfied that the system is in  a state
 of great general debility, the sulphate  of quinine
 and  the different  preparations  of steel  may be
 given.   It will, however,  often happen that a de-
 bilitated  patient cannot bear such powerful tonics,
 and that their stimulating power  produces fever-
 ishness and general irritation.   In this  case we
 may have recourse  to the vegetable bitters, and if
 the patient is very feeble, the Iceland moss will
 be found to be  one of the most useful remedies
 which the Materia Medica affords.
   Between these two plans,  however, we may be
 called  upon to take a middle course, and alternate-
 ly to depress and support the strength  of the sys-
 tem, accordingly as  inflammatory symptoms or
 the reverse predominate.  Here reliance must be
 placed upon the judgment of the medical atten-
 dant.   Under such circumstances local depletion
 will generally be much  preferable to general,  and
 the peculiar symptoms will generally point to the
 affected organ.   We have already stated that cup-
 ping,  when  it can be effected, is to be preferred to
 leeches, as the quantity of blood taken is  more
 easily  ascertained, and far less fatigue induced to
 the patient.
   The remarks now made equally apply  to every
 form  of  effusion, but some modification of treat-
 ment  is  peculiarly called  for according to the or-
 gans from which the drop=y derives its origin.   It
 is  to  these points, therefore, that we  now  more
 particularly call the attention of our readers.
   Treatment of Dropsy connected with Disease
of the  Heart.—Next to  the general considerations
which  have already been  mentioned, we have to
recollect that any obstruction in the flow of blood
from the right to the left side of the heart will be
 very likely  to produce  congestion in  the  lungs,
 and for the relief of this symptom we may be call-
 ed upon  merely to  diminish  the general mass of
 blood  in  the system.  And again, should the size
of the heart be greatly increased, even  though no
 very  material disease should  exist in the valvular
 stiucture of the organ, the lungs may be so com-
 pressed that they may be  unable  to receive, with-
 out inconvenience,  even their usual complement
 of blood ;  and  for this cause also depletion may
 be necessary.   These  observations may not ap-
 pear to bear immediately upon the treatment of
 dropsical effusions, but without a reference to the
 organs upon which such effusions depend, it will
 be impossible  in any  case  to  conduct them to a
 successful termination.  Our first attention then
 is due to the condition of the heart and its influ-
 ence upon the lungs; our second must be direct-
 ed to the dropsy itself.
   In  the first place, we must consider whether
 there  exists a sthenic or  asthenic state of the ge-
 neral  system.   If the former  prevails, recourse
 may be had to drastic purgatives, particularly to
 elaterium  and  croton-oil, with or without pre-
 vious  bloodletting, according to circumstances;
 and in few  cases does more good effect follow the
 exhibition of remedies.  They must  be repeated
 every  two or three  days till the effusion entirely
 disappears.   By this means we must  not, how-
 ever, expect that the dropsy will be prevented from
 returning;  but considerable  intervals of ease will
 be afforded, and the patient may be enabled  to
 live comfortably for several years, the dropsy oc-
 casionally recurring and being restrained by treat-
 ment.
   Some patients, however, ill bear excessive purg-
 ing, and we are then compelled to use other means,
 and chiefly  diuretics.   Of these the digitalis pur-
purea, or common fox-glove, is one of the most
 efficacious in the effusion which depends  upon
 disease of the heart, and which is connected with
 some  degree of debility.  In this respect our ex-
 perience corroborates the opinions of  Drs. With-
 ering and Blackall, that it is most successful where
 the debility is completely marked, the countenance
 pale, the pulse  weak,  and  the muscular energy
 lessened.  We  have usually preferred  the  infu-
 sion, and have administered it in half-ounce doses
 two  or three times a day, till it has increased the
 urine,  had a decided effect upon the pulse, or pro-
duced  some other of its peculiar consequences.
   The propriety of giving digitalis in cases of de-
bility naturally suggests its  use in those cases in
which  it is  necessary to commence the treatment
by bleeding; and accordingly this  plan was re-
commended by Dr. Withering, and has been con-
firmed by Dr. Blackall,  as probably by most phy-
sicians  who have paid  much attention to the ac-
tion  of this drug.  Dr. Blackall has mentioned
one  symptom which  is decidedly opposed to the
exhibition of digitalis, viz. "a membranous  ten-
sive  pain in the head,  sometimes over  one  eye,
with a sort of disturbance of the brain, which oc-
casionally attends an overdose  before  any bad
signs have appeared ; if  neglected, it is followed
by convulsions."  The same physician also re-
marks, very correctly, that when the urine is de-
cidedly increased, the digitalis  ought to be  sus-
pended, as its debilitating effects are then apt to
become greater than the system can bear with im-
punity.  The diuretic effect  of  digitalis is some-
times greatly increased by its combination with
opium, as indeed  is the  case with many other diu-
retics.
   Sometimes the dropsy consequent to disease of
the heart occurs in such a state  of general debili-
ty, that somewhat of a tonic  plan  is  required.
We  have repeatedly  seen such a state occur in 
DRO
PSY.
715
 "emales, in whom there has been either a misera-
 ble hysterical state, or positive and decided hypo-
 chondriacism.  Active  stimulants, it  is evident,
 must be as injurious to such patients as depleting
 measures; both,  though  from  different  causes,
 will increase the turbulent action of the heart and
 the distress of the patient.   Under these circum-
 stances we have found great  benefit from the fer-
 rum tartarizatum, either in combination with a
 tonic or with a diuretic, such as the infusum ge-
 nista? or the infusum  taraxaci;  these appear  to
 strengthen the  system generally,  while  they act
 powerfully upon the kidneys.
   In the latter, or rather the last stage of this spe-
 cies of dropsy, the anxiety, or we might say the
 anguish of the patient, is inconceivably painful to
 witness.   Often  the mind remains  unclouded,
 and all the natural  feelings  of affection for rela-
 tives, and attachment to life for their sake, re-
 main unimpaired.   When the disease has attain-
 ed this point, it  is  only in our power to afford
 temporary and very  imperfect relief by means of
 opium and  ether.   These must be given in fre-
 quent  doses, and  large enough to ensure  their
 specific effect.   Fortunately,  painful  as is the
 stage we  are now  considering, it does not last
 long;  the patient shortly falls into a state of stu-
 por, and sleeps, as it were, to  death, or dies in-
 stantaneously, and  very unexpectedly to the at-
 tendants.
   Treatment of Dropsy connected with Disease
 of the  Lungs.—On  this form of dropsy we have
 not much to add  to the remarks which we have
 just made with regard  to the effusion  when con-
 nected with disease of  the heart.   Bleeding,  gen-
 eral and local, may be and frequently is necessary;
 and, in addition  to  this, counter-irritation, espe-
 cially by means of the tartrate of antimony, ought
 strictly to  be enforced.   With respect to medicine
 more immediately calculated  to remove the effu-
 sion in this as in the preceding form of dropsy,
 we  are chiefly  dependent  upon purgatives  and
 diuretics.   With regard to the former, they ought
 never to be exhibited while we suspect the lungs
 to be the  subject of inflammation.  It is, we be-
 lieve, a remark of Sydenham, that violent purga-
 tives are injurious in  pneumonia, and we have
 had frequent occasion  to  confirm the  opinion.
 When, however, effusion is present in the chest
 or in the lungs, without any sensible inflammatory
 state, the drastic purgatives frequently afford the
 most remarkable relief, and sometimes suffice alone
 for the entire removal of the dropsy.  As a diu-
 retic, diritalis appears  less serviceable in dropsy
 consequent to disease  of the lungs, than  where
 the heart is the original seat of  disorder.  Squills,
 however, in combination with laudanum  and the
 neutral salts, particularly the sulphate of  magne-
 sia, act very powerfully  upon the kidneys, and in
 some instances  speedily and  entirely remove the
 effusinn.   It  is in  this form of dropsy  that the
 superlartrate of potash deserves  the greatest  con-
 fidence, as it  keeps  up a constant  flow from the
 kidneys and the bowels together, without inducing
 that debility which drastic  purgatives or digitalis
 are so apt  to occasion.
   Treatment of Dropsy connected with Disease
of the Liver.—This  is probably the most difficult
of any suedes of droosv to treat  successfully, in
consequence partly of the  broken-down constitu-
tion in which it generally occurs, and partly from
the  obscurity in which  the  different diseases to
which the liver is liable are involved.  When we
can satisfy ourselves that this organ  is the subject
of inflammation, without any remarkable change
in  its structure, local bleeding and counter-irrita-
tion are required in the first instance; and, in the
second place, those internal  medicines  which are
known more  particularly to  act upon the biliary
secretions, such  as the  different preparations  of
mercury, and the nitro-muriatic acid.   Mercurial
frictions  may also be had recourse to with advan-
tage in very  many  cases.  The mercury should
be persisted in till the mouth is affected, and bene-
fit  has sometimes been  derived from keeping up
salivation for a considerable time.   In addition to
placing the system  under the influence  of  mer-
cury, some medicines are required more immedi-
diately to act upon the kidneys, and  through  their
increased action to carry  off the effused  fluids.  In
the article Ascites we have mentioned  the utility
of combining many diuretics  together; and in the
form of dropsy that we are now considering  this
practice is more particularly  demanded.  Among
the most efficacious under tbese circumstances are
squill, colchicum, liquor ammonias  acetatis, and
the spiritus  aUheris nitrici, given in combination
of two or more,  and  administered every  three or
four hours.   WThen,  however, the  colchicum is
given, much attention is  necessary that it  does
not induce its peculiar symptoms, which are pre-
cisely those of cholera.   This  may  take place in
peculiar constitutions after a  single dose only, but
more commonly, like digitalis, it accumulates in
the system,  and  its effects are not developed  till
after the  medicine has been continued for several
days.  Digitalis  is  not often applicable to dropsy
connected with  extensive  hepatic disease, as  its
debilitating effects are greater than patients so  af-
fected can bear.   Dr. Fowler  made very  numerous
and satisfactory experiments upon the  nicotiana
tabacum, and why this medicine should  so com-
pletely have fallen into desuetude it  is difficult to
determine.  It is certainly one of the most pow-
erful diuretics which the  Materia Medica contains,
and we have never seen any evil effects resulting
from its  use.   It has appeared to us particularly
useful  in dropsy  connected with  enlargement  of
the  liver and spleen, but little to be relied upon
when the principal disease is situated in  the chest.
The reports of Dr. Fowler are unfortunately not
full enough  to enable  us to  draw any very accu-
rate conclusions as to the nature of the diseases
in which he found it most beneficial; but five of
the successful cases in which he used it were the
consequence  of  agues ;  and  enlargement of  the
spleen is well known to be a common consequence
of this disorder.  The form we have used is  the
infusum  nicotianae of Dr. Fowler, which is made
by pouring a pint of boiling water upon  an ounce
of tobacco.   This is  suffered to  macerate for an
hour in  a covered vessel, and fourteen  ounces
only are strained off, to which two ounces of rec-
tified spirits of wine are  added to make it keep.
Thirty drops are given at first three times a day
in water, and the dose is gradually increased, till
it  augments  the  flow of urine, or produces  sick-
ness and  giddiness.   The  dose has  been earned. 
716
DROPSx*.
by Dr. Fowler, as high as one hundred and eighty
drops at night, and one hundred in the morning.
   With the exception of abstaining from mercury,
it does not seem necessary to lay down any other
plan than what  has now been referred  to, when
the disease of  the  liver  amounts to change of
structure.   It ought, however, to be  always kept
in mind, that when the liver is tuberculous, or we
have reason to believe that it is affected with hy-
datids, mercury may weaken the patient,  but can
have no effect upon the disease.  How far under
such  circumstances it may  be advisable to  try
iodine, or  the muriate of lime, may  be  very pro-
perly a subject  of  consideration.  In a  case of
apparent simple enlargement of the liver, in a girl
of twelve  years  of age,  but  unconnected  with
dropsy, we certainly derived great advantage from
employing the  former, and under similar  circum-
stances, connected  with  effusion, we should cer-
tainly be inclined to afford it a trial.
   Treatment of Dropsy  connected with  Disease
of the Kidney. — Dr.  Bright, who has most at-
tended to  this subject, appears to lay  the principal
stress upon the  supertartrate  of potash ; but in
this, as in every other   modification  of  dropsy,
reference  must first be had to general principles.
We  have  already  stated our  opinions  at  some
length respecting the signs by which the affections
of these  organs may be  ascertained.   When,
therefore,  we  feel convinced that the kidneys  are
diseased, the same rules which have been  laid
down for  the treatment of other  local disorders
will apply here, and local depletion with counter-
irritation must be as proper in the one case as in
the other.   At  the  same time we confess that on
this point we have  not experience for our guide,
so far as this particular organ is concerned.   We
may, however, mention a fact that has been related
to us on  good authority  connected with  diabetes
mellitus, and which has  some  analogy with  the
disease  now  under consideration.  The  medical
man to whom a patient with this disease  applied,
and  from  whose urine he had collected a conside-
rable  quantity of sugar by evaporation, rubbed in
the unguentum antimonium tartarizatum over the
loins ; and while the irritation was  kept up, the
sugar entirely disappeared from the urine.  Other
symptoms, however, supervened, which compelled
him to suspend the ointment, and  the sugar was
again found in this fluid.  The supertartrate of
potash has the same effect in this dropsy as when
disease of the  lungs or  pleura is present.   We
are sorry  to say that we  have little  more to add
on this subject, as  it is  one to which at  present
little  attention has been  paid, and  respecting
which our actual  knowledge is any thing  but pre-
cise.   We would, therefore, most strongly incul-
cate the observance of general principles in its
treatment, till  farther investigations shall  have
clearly demonstrated those peculiar modifications
of practice which may be demanded by the  par-
ticular organ.
   [Observers have  differed  in regard to  the pro-
priety of  administering  diuretics  in the dropsy
occasioned by the disease of the kidney, described
by Dr. Bright.   By most, they have been con-
sidered unadvisable, especially in the early periods;
but they  are advised by  M. Rayer, who prefers
eochlearia armoracia.  Notwithstanding the argu-
ment of Dr. Christison (On Granular Degeneration
of the Kidneys.Edinb. 1839, and Philad. 1839, and
art. Granular Diseases of the Kidney, in Tweedie's
Library of Practical Medicine,  Amer. edit. iii.
271: Philad. 1842) that an agent which increases
the secretion of an organ may not add to existing
disease in that organ, diuretics must be considered
equivocal remedies ;  and, upon  the  whole, Dr.
Christison is desirous of so regarding them in the
disease under consideration ;  but he is of opinion,
that the "dread of an  evil influence  from them
over the primary disease has  led several estimable
authorities to forbid their employment  likewise in
all  secondary affections, in  some of which no
other remedies are so promptly efficacious."]
  We may  here very properly terminate our con-
sideration of particular forms of dropsy.   They,
however, by no means exhaust the subject;  and
careful  observation would probably find signs no
less marked in effusion occurring after the disease
of other organs, and a  consequent propriety of
modifying the treatment.   What we have already
said will, we trust, afford a somewhat clearer view
of the principles upon  which dropsy ought to be
treated, than has yet been published. It will show
that certain  general principles  apply  to all, but
that these are more or less modified according to
particular circumstances, and the  organs  which
give rise to effusion in the first instance, or become
involved in the  course of the disease.  There is
nothing empirical or irrational  in this treatment.
Dropsy is not (as  it is too often regarded by men
even  highly intelligent  and much engaged in
practice) the consequence either of debility alone
or  inflammation alone ;  it is  neither always  a
sthenic nor  asthenic state of the system in which
it occurs ; it may be  one or the other, or the one
may alternate with the other.  Since we find  that
different organs  are the original causes  of effusion,
the treatment of the local diseases is not to be
neglected in the  great  anxiety  to remove  the
dropsy.  Neither is effusion to be neglected; but
we  are to use different remedies  according to the
organs  which are  affected.  Some of these we
have  endeavoured to point out;  in doing so we
do not pretend  to be free from error ; but the road
is opened for others, to pursue a  similar line of
observation.  If this  is  carefully followed, we do
not question but that a  few years will add a mass
of information  respecting tbe peculiar power of
medicines in  this disease, which  may go far to
diminish  its present ill repute,  as one of the
opprobria medicinae.
   Of  the  particular  remedies  employed in
Dropsy.—We  should not consider that we com-
pleted the subject  of the treatment of dropsy, did
we  not offer a more complete record than we have
yet done of the various medicines which have
been  proposed  as  specifics in this disease.   We
may comprehend these under the various heads of
purgatives,  diuretics, emetics,  sudorifics, tonics,
frictions, scarification, acupuncturation,  paracen-
tesis.   The operation of some of  these we have
already discussed, and here, therefore, we shall do
no more than enumerate them.
  Purgatives. — The principal of these are the
croton tiglium,  from which the croton oil is ex-
pressed, and in which form  alone we know the
remedy in this  country.  The  dose  is a single 
DRCFSY.
717
drop, and  this  will  operate  in many  instances
most violently,  producing  within  half an  hour
sickness, vomiting, and profuse alvine discharges.
Dr. Good recommends  the  alcoholic solution first
proposed by Dr. Nimmo, but we have never found
the oil do any real mischief. There are individuals
upon whom it will not act at all, or who require
four or five drops to ensure the operation.  With
such idiosyncrasies the  oil must of course be given
in the larger dose.
   Elaterium is  also given with the  same intent.
We have mentioned under the article Anasarca,
the form  we prefer,  viz.  two  grains  of elate-
rium (or half a grain  of elatin) combined with
a  scruple  of  the extract of gentian, and  divided
into four pills, one to be given every hour till free
evacuations are procured.
   The common elder and the dwarf elder (sam-
bucus  nigra,  sambucus ebulus)  have formerly
enjoyed a high reputation as hydragogues; and
the former is particularly recommended by Syden-
ham.   Every part of these  plants  is emetic and
purgative, but the  most potent is  the inner bark,
which  may be taken in powder or infusion.   The
dose of the former is said by Dr. A. T. Thomson
to vary from five  grains  to  half  a drachm; we
have, however,  no personal experience upon  the
subject, nor can we say to whicb species of dropsy
it is most applicable.  If the remark of  Sydenham
be correct, that it  acts equally upon the kidneys
and bowels, we should  expect it to be particularly
serviceable in effusion  connected with disease of
the liver, when  it  is thought advisable to unload
 the system quickly, as  experience  seems to prove
that ascites  (and  this  is the  form  which usually
accompanies hepatic disorder) usually yields more
completely to diuretics  than to purgatives.
   Rhamnus catharticus, or  common  buckthorn,
is another hydragogue  highly praised  by Syden-
ham, but which, like the elder bark, has gone out
of fashion.   Sydenham employed it in  syrup, and
states that it removes the effusion without disturb-
ing the circulation, or rendering the urine higher
coloured, as other purgatives are accustomed to
do; but that it has the  inconvenience of inducing
excessive  thirst.  The dose of the recent berries
is one  scruple, that of the dried berries  a drachm.
The dose of the syrup prepared  according to the
London Pharmacopoeia is from half an ounce to
an ounce, the patient drinking freely at the  same
time of demulcent  fluids.
   Helleborus niger, or black hellebore, has also
been used as a hvdragogue;  and  Avicenna,—no
mean authority so far as the  mere action of reme-
dies is concerned, — observes that  he had  seen
more wonderful effects from it than from any other
remedy — "but it will not always  equally work
wonders."  The dose as a hydragogue is from ten
grains  to a scruple.  In the employment of  black
hellebore much care is necessary that the extract
be fresh, for, by keeping, it appears very soon to
lose its medicinal qualities.  The dose above-men-
tioned may be repeated  at the end of six or eight
hours if no operation  shall have ensued ; but in
practice the utmost caution is necessary that the
peculiar poisonous effects do  not follow.  In some
individuals the  smallest dose induces inconceiva-
ble anxiety.   In the few instances where this has
occurred  in  our own experience, the  individuals
were known to be incapable of bearing the mildest
narcotic  medicines, from  the  intolerable  distress
which always followed their exhibition.
   Many other purgatives, as gamboge, jalap, scam-
mony, neutral salts, have at various times been in
vogue for the cure of dropsy, but it scarcely seems
necessary to speak of them here more particularly.
They all in great measure act in a similar manner,
viz. by producing free watery discharges, and thus
stimulating  the  absorbent function.   The super-
tartrate  of potash is rather a mild aperient than a
purgative, and occasionally acts  also most power-
fully  as  a diuretic.  It is  remarked, however, by
Dr. Ferriar, that it sometimes " neither increases
urine nor stool, yet  it cures."  Its use  in dropsy
was, we believe, first particularly pointed out in
this  country by Dr.  Home, and  in his  reports he
has related twenty cases in which it was  employed.
We  collect  generally from them that it was most
beneficial where there was an inflammatory action
present in the system, and where there  was no
actual organic disease.  At the same time  it  ap-
pears in some  instances to have been serviceable
where the liver was deranged.  Its action is chiefly
that of an aperient, producing profuse watery eva-
cuations, without exciting thirst or feverishness.
Dr. Thomson states  the dose  as  a hydragogue to
be from  four drachms to six drachms, in an elec-
tuary.   Dr. Mason Good says  that in order to
ensure  its aperient  action, it ought never  to be
given in less than ounce doses; but our experi-
ence  by no  means  corresponds  with  this.   We
have  frequently succeeded by giving only drachm
doses three  or four times a day :  after the second
day  profuse watery  evacuations often  follow to
such  an extent that we are obliged to suspend the
medicine.   In the intervals the milder tonics may
be advantageously employed.  (See Cathartics).
   Diuretics. — Digitalis holds the first place, in
modern  times, in this  class of medicines; but as,
in the course of this  article, we have already men-
tioned the  circumstances  which  render  it most
appropriate  in  dropsy, we shall only  refer  the
reader for a more particular account of this drug
to the article Diuretics.
   The squill is certainly a very powerful  diuretic,
but its  powers are much increased  by  uniting it
with  otber diuretics, particularly  the neutral salts.
In some cases, where the  inflammatory action is
at all high, its operation  is greatly favoured by
small doses  of  blue pill  administered  in such  a
manner  as slightly to affect the mouth.   Dr. Black-
all observes, that it is much to be depended upon,
when, with an oppression of the chest, the urine
is scanty, high-coloured, and without serum. How
far this  last remark  is perfectly correct may be
questioned ; but that it is highly serviceable when
the urine is high coloured, is  perfectly  in accord-
ance  with our own experience.
   The  attention of British practitioners was  first
called to the diuretic properties of the pyrola um-
bellata  by  Dr. W. Somerville,  and they are so
well attested, that we cannot but regret that more
attention has not been paid to it.  It is  a native
of  North America,  and  belongs to the natural
family of Ericea?.  The latest account  is that of
Dr.  Bigelow, professor  of Materia Medica  and
Botany  in  Harvard University,  in  the United
States.   " In a number of dropsical cases," savs 
718
DRO
PSY.
this  gentleman, as quoted  by Messrs. Churchill
and Stephenson, " wben first given, it made a dis-
tinct and evident impression on the disease, com-
municating  an increased  activity to  the  absorb-
ents, followed by  a great augmentation of the ex-
cretion from the  kidneys.   The benefit, however,
with me, has been in  most instances temporary,
and it was found  better to omit the medicine for a
time, and to resume it afresh, than to continue it
until the system  had become  insensible to its sti-
mulus.   After  suspending it  for a week  or  two,
the same distinct operation  took place on return-
ing to its use, as had been manifested in the first
instance.  It proved in almost every instance an
acceptable  medicine to the patient, and was pre-
ferred, both  for its sensible qualities and its effects
on the stomach, to other  diuretics and alteratives
which had  been  prescribed."  The paper of Dr.
Somerville, which is contained in the  fifth volume
of the Medico-Chirurgical Transactions, is valua-
ble from the post-mortem examination of Sir James
Craig, to whom the plant had afforded  very im-
portant benefit.  In this  instance the liver was
studded  with innumerable tubercles, the  perito-
neum  throughout was thickened, and the  intes-
tines were glued together with coagulable lymph.*
The lungs  on the left side were  sound, but com-
pressed an  the right side  by three pints of water.
The pericardium  contained  six ounces of water,
and  the  heart  was somewhat larger  than usual.
The history of this case  abundantly proves that
the original malady was in the liver.   According
to Dr. Somerville, the  virtues of this plant do not
reside in any volatile principle, and he found con-
sequently that a decoction acted much more ener-
getically than an  infusion.  In order to make this
decoction, an ounce of the dried plant, including
the root, stalks, and leaves, is cut into small pieces,
and  macerated twelve hours in two pints of cold
water, and then boiled till  it yields one  pint of
strained  liquor.  Mr. Carter found that thirty-four
pounds avoirdupois of the recent herb produced
four pounds of extract, which had the same  pro-
perties with the decoction.  Five scruples of this
extract in  pills  or in solution  may  be given  in
twenty-four hours.
   The  spartium  scoparium or common broom,
the leontodon taraxacum  or dandelion, the apium
petroselinum or  common parsley, the juniperus
communis,  and  the  colchicum  autumnale, all
possess considerable diuretic powers, and may fre-
quently be united with some of those above men-
tioned, with much advantage.  The meadow-saf-
fron is perhaps the most powerful of all these, and
we have succeeded with it  in conjunction with
mercurials, in acting upon the kidneys in hepatic
disease when no other remedy  had any effect.
The spiritus colchici  ammoniatus of  the London
Pharmacopoeia is the  preparation which we have
chiefly relied upon, given in half-drachm  doses
three times  a  day, with a  blue  pill night and
morning, and sometimes  mercurial frictions over
the abdomen being added.
   In the 57th  number of the Journal Hebdoma-
daire, for October, 1831, M. Lemasson has given
a detailed account of  the employment of the bark

  * As. however, he had been frequently tapped, this last
appearance was  probably a consequence of the opera-
"nn  and not  a part of the original disease.
of the root of the chiococca racemosa auguifuga, or
snow-berry tree, belonging to the natural family of
the Rubiacese.   This bark furnishes a bitter prin-
ciple, crystallizable  in delicate needles,  without
smell, of a bitter and  rather an astringent taste,
soluble  in water, very soluble in alcohol, espe-
cially when warm, and reddening the tincture of
turnsole;  in this principle all the peculiar medical
properties reside.  This remedy is said by M.  Le-
masson to he chiefly applicable to atonic dropsies.
A decoction  of  the  bark  is made by macerating
two drachms of  the bark in eight ounces of water,
then boiling for ten minutes,  and straining  the
liquor off, which is  divided into  two doses,  and
the second dose is taken  two hours after the first.
The cases related by  M. Lemasson  are  all con-
nected with great general debility of the system.
One was  a case of chronic bronchitis with  slight
dilatation of the heart, and in this patient the  fee-
bleness  was  very considerable.   Two were  the
consequence of  syphilis and mercurial courses, to
which universal anasarca succeeded, but  without
any particular visceral disease.   In one patient
affected with dilatation of the right cavities of the
heart, the exhibition of the bark was preceded by
bleeding.   The  effect in all was an improvement
of  the appetite,  and  a great increase in the flow
of urine.  The medicine is administered as above-
mentioned in two four-ounce doses, with an  inter-
val of two  hours between  the first and second
dose ; when this affects the kidneys, they continue
their action for several  days, and the medicine is
not again exhibited  till the urine diminishes.  In
the first case which  was  related, it was given on
the 18th of June, on the 20th of the same month,
and not again till the 5th of July, after which it
was not repeated.  In  the second case it was only
given twice.  On the  22d of May, and on  the
29th, both terminated  successfully, and the medi-
cine had a similar effect of increasing the appetite
and the flow of  urine together.
   Emetics.—These  have been recommended  by
some authors, and cases have been given, in which
they have succeeded when  other remedies had
failed.   We have ourselves no  experience of their
effect in this disease, and they appear to be ban-
ished from modern  practice.   We shall  content
ourselves therefore with this intimation.
   Sudorifics.—These are unquestionably in  some
cases highly  useful,  more  particularly however
when disease of the lungs is present. The vapour-
bath has  occasionally  been  successful in  such
cases.   The celebrated  Dampier cured himself by
covering himself all over witb sand, heated by  the
sun, in  California, for an  hour, after which " he
was carried  to  his  bed and  well covered  with
clothes,  where he  fell  into a profuse sweat, after
which he recovered daily."   The compound ipe-
cacuanha powder has in this way been successful,
and we  have seen ascites  attended with liver  dis-
ease removed by it, though the  patient died soon
after, from the original malady.
   Tonics.—Every species of dropsy may in some
part of its course require the  exhibition of tonics,
for a state of debility  easily  follows  depletion,
however necessary it may have been ; and  it  has
not unfrequently happened that a patient has been
cured of dropsy,  and died of the weakness induced
by  the  remedies.   To obviate this,  appears to 
DROPSY.
719
have been  the objet.t of the celebrated electuary
of Dover, which is  a combination of scammony,
sulphuret of iron, and crude  mercury.  Of this
formula  Dr. Blackall  says, that »it has certainly
performed  many cures, and there is so much de-
bility in  the disease, that the addition of tonics to
purgatives,  never indifferent, is particularly desi-
rable here,  where it can  be  made  with safety."
Steel and  bark are  the principal tonic remedies
that have  been used  in dropsy, and we  consider
the ferrum tartarizatum to be the best preparation
of the former, as it unites  a diuretic with its tonic
properties.  We have usually given it  in combi-
nation  with infusum calumbae,  and  particularly
in those asthenic dropsies in which tbe  heart or
lungs are diseased.   In the asthenic dropsy con-
sequent to chronic  bronchitis, united with coun-
ter-irritation of the chest,  it will sometimes alone
remove  the effusion.   The sulphate of quinine is
given with the  same  intention, and  in weak and
scrofulous habits it seems  preferable  to the prepa-
 rations of steel.  Dr. Blackall prefers bark also in
 the debility consequent to dropsy after an  acute
 disease.  In the exhibition of these tonics the ut-
 most care is necessary that they are not  given in
 an inflammatory state of the system, nor while the
 tendency to inflammation remains ;  but when by
 bleeding, digitalis, and other evacuants,  the  effu-
 sion has nearly disappeared,  and the urine reco-
 vered its natural state and quantity, tonics will
 complete the  cure, and secure the patient from  a
 relapse.
   The  action of the  remedies just  mentioned is
 more distinctly known than that of the tonic pills
 of  Bacher, and which we have noticed under the
 article Ascites.  More like cream  of tartar than
 common tonics, these pills seem sometimes to be
 merely  anti-hydropic, removing the effusion with-
 out inducing any increase in the urine or alvine
 evacuations.   The  dropsies  in which  we  have
 found them most useful are those which occur  in
 girls about the age  of puberty, without manifest
 derangement of any particular organ, and we have
 observed them  to be more useful in ascites than
 anasarca.   The younger  Bacher, in  speaking of
 Hack hellebore, says that it is not applicable to
 cases in which the solids  are firm, nor  when the
 fibre is  greatly relaxed and weakened, but when,
 with  some degree  of debility, the  circulation  is
 irregular, and determined  to some particular organ.
 We may observe, however, that in  many  of the
 cases he has related, no such determination is in-
 dicated  by the  symptoms  enumerated, and  in our
 own practice they have seldom been of use, when
 there has  been evidence of organic disease.  The
 action of  these pills, as we have already mention-
 ed, is often imperceptible, but at other times they
 procure copious evacuations from the kidneys and
 bowels, and sometimes, according to Bacher, they
 cause profuse perspiration.  The following is the
 formula of Bacher, as published by his son :—
     R Extracti hellebori nigri,
        Myrrhae solutae, aa, ^i.
        Cardui benedict,  pulv. guty. M.s.a.
   Fiat  massa aere sicco exsiccanda, donee forman-
     dis pilulis apta sit. Singula* ad grana sex.
   Ten  of these pills were given  three times  a

  3We have  repeatedly cautioned medical  practi-
tioners against the danger which may ensue from
the poisonous properties  of the black hellebore,
and  here  therefore we  shall only  inculcate ex-
treme watchfulness whenever this remedy is ex-
hibited.
   It is probable that many other of the common
mineral and vegetable tonics may be employed in
asthenic dropsy, and it  will always be advisable
that the practitioner should, as far  as  possible, be
provided with substitutes, as, from  particular idio-
syncrasies, individuals are sometimes incapable of
taking what may in other respects be the most
appropriate remedy.
   [Methodical compression, where it  can  be em-
ployed, is often of decided service in promoting
absorption ; at other times, it is employed only as
a support when  the integuments are  largely dis-
tended with the fluid of dropsy.  Frequently, the
benefits from compression are more apparent than
real—the fluid being simply forced from  the cel-
lular membrane pressed upon by the bandage, and
returning to its former position when  the pressure
is withdrawn.]
   Friction. — Under the head of Ascites,  we
have referred to a case in the 49th volume of the
Philosophical Transactions, in which friction with
oil effected a cure in an old case of ascites.  We
are  unacquainted with  the' particular symptoms
which more particularly indicate this remedy, but
there certainly can be  no objection to it in any
case in which the abdomen is free from tender-
ness.
   Blisters.—These sometimes  afford great  relief
and we have often had  recourse to them in oui
own practice.   They  are not,  however, alway
unattended with  danger, and whenever they are
applied, the surgeon ought to be requested  to at-
tend to their progress.    We have  more than once
seen death hastened by the  blistered surface be-
coming inflamed, and mortification ensuing.
   Scarifications.—These are indeed the opprobria
medicinae.  They afford  relief from  the  pressure
and weight of the effused fluid, but  too  often at
the same time give rise  to inflammation, gangrene,
and death.  Yet there may be cases in which the
distension is so  great and the distress so intense,
 that the operation may not only be  justified, but
 may be demanded.  Upon this head we would
 briefly remark,  that in old  and  very debilitated
 persons they should seldom, perhaps we  might
 more  properly say, they should never be practised,
 and that in young persons in  whom the repara-
 tive process is more readily set up, great attention
 should be paid to their  appearance and  progress.
 The mere presence of dropsy will make no differ-
 ence  as  to  the  proper  manner  of  treating  the
 wounds ;  but if  inflammation be  present, or gan-
 grene, the same local and general  remedies must
 be recurred to, as if no effusion had  existed; nor
 indeed is this  only useful  to  the wounds; fre-
 quently when the fluid has escaped, the  tonic and
 stimulating  remedies  which  the  surgical treat.
 ment  has required, have prevented the return  of
 the effusion.
    Acupuncture.—This is only a  milder mannei
 than  scarification, of  effecting  the mechanical
 escape of the fluid; and the remarks made upon
 the former are equally  applicable  to the presen<
 remedy.   Evil consequences are perhaps less fit 
720
DYSEN
TERY.
quent, but  still they  do not unfrequently occur.
(See Acupunctciik.)
  Paracentesis.—Of this operation we have spoken
under the head of Ascites, nor does it appear to
us necessary to add to the remarks whicb we have
there made.
  Diet___The only point that remains to be no-
I iced is that of diet, but upon this head, we do not
feci called upon  to  make many remarks,  nor
should we indeed have  mentioned it at all, had it
not been for the vulgar opinion which formerly
prevailed, that fluids  ought not to be allowed to
dropsical patients.  Even  this notice is  perhaps
quite  unnecessary, as the error  is, so far as we
know, completely exploded.  Sir Francis Milman
first examined the question, and gave the most
satisfactory  evidence  that the   restriction from
fluids was not only  not  beneficial,  but was in
many cases even injurious; and since his time, so
much additional evidence has been obtained to the
same  purpose, that to allow dropsical  patients as
much fluid as they wish to drink, is becoming an
axiom in the treatment of disease.   It  has been
well ascertained that many diuretics only stimulate
the kidneys in proportion to the quantity of bquid
in which they are given.
   With  respect to the nicer question of food, it
seems unnecessary to make any remark:   this
must  be varied with the nature of the dropsy,  and
the symptoms by which it is attended; and who-
ever understands the meaning of a phlogistic  and
antiphlogistic  regimen  will know bow  to apply
either of these, or to vary from one  to the other,
in the disease of which we have been treating, as
circumstances may require.
                           John Darwall.

  DYSENTERY.—This word  is  derived from
the Greek word Svccvrepia, which  is compounded
of Sic (difficile, xgre, male,) and  ivrtpov  (intesti-
num), and signifies that the intestines are mor-
bidly  affected.  By Celsus the disease is named
tormina, from one of its leading  symptoms;  and
ly Caelius Aurelianus rheumatismus intestinorum
cum ulcere'.  Dr. Ballingall applies to it  the  not
inappropriate appellation of colonitis.   By certain
French writers it is called colitis (colite), and in
common language it is named flux or bloody flux,
according as the intestinal discharges are free from
blood  or sanguinolent.  It is placed as a genus in
the class pyrexiae, and order profluvia of  Dr.
Cullen ; in the class fluxus, and order alvifluxus,
of Sauvages; and, very correctly, in the class  hx-
matica, and order phlogotica, of Dr. Mason Good.
  Division of the  Disease. — Dysentery  con-
sists, in its early and acute stage, of inflammation
of the mucous  membrane  of the intestines, espe-
cially  of the colon  and rectum.  This inflamma-
tion, by implicating the  other coats of the bowel,
and by generating  ulcers, may produce extensive
and very  intractaUo disorganization, giving rise to
symptoms less acute than those of the early stage,
but bearing a considerable resemblance to them.
Hence it appears that there is  a  natural  division
of the disease into an acute and chronic form;  the
lirst consisting of inflammation, the second of its
occasional  effects, supervening on attacks of the
acute disease, which bave been imperfectly treated,
O' which our art has proved too feeble to subdue.
  Various writers have proposed divisions of the
acute stage  into  species, and complex arrange-
ments of this kind are to be  found in systematic
works.  From what has been stated respecting the
nature of  the disease, it will be manifest that any
distinction between cases of uncomplicated dysen-
tery must be  principally founded  either on  the
degree of  inflammation, or the extent of intestine
affected by it.   The  former circumstance unques-
tionably gives rise to various shades of discrepancy
between different cases, but  admits of no precise
line of demarcation by which any  assemblage of
cases can be contradistinguished from others.  The
extent of bowel implicated in the  disease  consti-
tutes a  somewhat more important  ground of dis-
tinction, for it is supposed that in the warmer re-
gions a larger portion  of intestine is affected with
inflammation tban in temperate climates; and that
this circumstance, coupled with certain effects pro-
duced on the constitution by a high temperature,
invests the disorder named by recent writers tropi-
cal dysentery,  and by Savages, dysenteria xqui-
noctialis, with  a peculiarity  of character meriting
special notice.   It will hence  appear that uncom-
plicated dysentery may be considered under two
heads, the first  comprising that form of the disease
most frequently  observed in temperate  climates,
whilst tropical  dysentery is  discussed under the
second.  It  should  be remarked,  however, that
though  the distinction between  the extremes of
these varieties may be very manifest, intermediate
degrees will be found,  and such it  has not unfre-
quently occurred to the writer of this article to
observe in the south of Europe, which might be
referred with almost equal propriety to either the
one form or the other.  Besides these varieties in
the  character  of simple dysentery, its  complica-
tions with other diseases require attention.
   The following definition of dysentery will per-
haps be  found  sufficiently  precise: — Frequent
mucous or muco-sanguinolent stools, pain  in the
abdomen,  griping, and tenesmus, generally accom-
panied with pyrexia.
   The uncomplicated dysentery  of temperate cli-
mates.—Premising that many degrees of intensity
are found  in this affection, from the  slight sporadic
case in which the general health is but  little de-
ranged and  no  danger threatens life, to the wide-
wasting epidemic which has  proved the scourge
of fleets and armies, we shall present a sketch of
as mild a form as the disease is almost  ever
observed to wear.  A case of this description may
commence with  feculent and liquid stools, and
they may become subsequently mucous, with occa-
sionally a slight admixture of blood; or, they may
be  of  the latter character  from  the  beginning.
There is little  if any fixed pain in the  abdomen;
but considerable griping previously to the patient's
rising to the night-chair, with a peculiar sense of
working or commotion in the bowels, often referred
to the situation  of the sigmoid flexure of the colon;
there is generally some heat at the anus, but the
sensation extending thence up the, rectum  is one
rather of irksomeness than of  heat, and it induces
very distressing straining, constituting the affection
called tenesmus,- the dejections do not  exceed
seven or  eight  in the day,  and after  they have
acquired  the mucous or sanguinolent  character,
traces of feculent matter are occasionally percepti- 
DYSENTERY.
m
ble in them.   Dysury is rarely observed, dyspnoea
never, though both of these morbid states are very
general  attendants of  more severe cases of  the
disease; the appetite is generally impaired;  the
thirst is considerable; the  tongue is sometimes
furred, occasionally natural, and the pulse is little,
if at all, quickened or affected with respect  to its
force.  The mean  duration of this slight form of
the disease is from seven  to eight days; it may be
said to be  never fatal, but it not unfrequently lays
the  foundation of chronic  dysentery, and often
leaves such a tenderness of the bowels as renders
them more prone  than  before to morbid action
from cold or other causes.  We  should presume
that the inflammation  in  such a case as this was
slight in degree, and  limited to  the  rectum and
inferior portion of the colon.
   A more intense  form of the  disease than that
which  has just been described, will be found of
frequent occurrence when dysentery is prevailing
epidemically.  This  more severe disease may be
preceded by diarrhoea, which we have observed to
be a very  general precursor of dysentery in  what-
ever cbmate  we  have witnessed it; or it may
 occur without this premonitory symptom.  Occa-
sionally a well-marked rigor, followed speedily by
febrile heat,  introduces  the disease ; whilst, in
other  cases,  the  first symptom is  pain  in  the
bowels, to which  the mucous stools characteristic
of  dysentery in a short  time succeed.   In  many
instances some slight derangement of the stomach
and bowels, indicated  by flatulency,  costiveness,
inappetency,  nausea,  and occasionally Vomiting,
is experienced for some  days  before the attack.
 When the disease  is fully formed, the characteris-
tic mucous or muco-sanguinolent stools are passed
 very frequently, with great pain, an extreme  de-
gree of straining,  and a feeling as if the viscera
themselves were about to be discharged. Feculent
stools  occasionally intervene between the dysen-
teric discharges,  and  pure blood  is sometimes
voided in considerable quantity, especially in an
advanced  stage of the disease.   After the disorder
has subsisted some days,  it is not unusual for the
patient to void portions of a substance resembling
suet, tallow, or flesh.   A sense of heat, or, as the
patients express it, burning  at  the anus,  extend-
ing  thence up the rectum,  and which becomes
excessive when there is a call to empty the bowels,
is much complained of. When  fever has occurred
from the commencement of the disease, it of course
subsists throughout its progress;  and in cases in
which it has not existed from the first, it usually
arises when  the intestinal disorder has become so
fully formed as we are now describing  it to be.
There  is a warm skin; a hard,  generally frequent
and small pulse;  the tongue is either  covered
with a white  mucous coat, or it is dark and dry ;
there is great prostration of strength, and the urine
is scanty,  high-coloured,  and is passed with pain
and difficulty.  The griping which precedes each
evacuation is  very distressing throughout the  dis-
ease ; but only in an  advanced  stage,  and in a
case which has held  its course uninfluenced, at
least beneficially,  by treatment, is there much if
any permanent pain in the abdomen.   When it
occurs, it  is generally situated in the hypogastric
region, and is  increased by pressure.  Its presence,
especially  if it is accompanied by fulness and ten-
  Vol. I___91                         '3l
sion of the abdomen, may be generally considered
as a bad omen, as indicating that the inflammation
has extended to the exterior tunic  of the bowel.
Dyspnoea is  frequently observed to co-exist with
the symptoms, denoting that the peritoneal surface
of the intestines is affected.   Throughout the dis-
ease there is  loathing of  all solid  food, and the
thirst is great, sometimes intense; and it is attend-
ed with this distressing circumstance to the patient,
that in many cases everything which is taken to
allay it produces  tormina, and an  instantaneous
and irresistible impulse  to go to stool.
   Should  no relief be  afforded by the  remedies
employed,  the prostration  of  strength  becomes
great;  the pulse feeble, with coldness of the ex-
tremities ;  the tongue either furred  and brown, or
glazed,  red,  and  aphthous; the  discharges from
the intestines are dark and offensive; the mind is
low and desponding;  hiccough is  an occasional
symptom,  and death  sometimes  takes place in a
period varying from  a fortnight to three  weeks
from the commencement of the attack. But much
more frequently,  even in  bad cases, some mitiga-
tion at least of symptoms is obtained, and the dis-
ease degenerates into a chronic form.
   Restoration to health may  be expected when
there is diminution  of pain in the abdomen, of
tenesmus,  and of the frequency of the discharges,
and especially if,  instead of the mucous or muco-
sanguinolent dejections, the stools become natural.
An abatement of the febrile symptoms and thirst,
and a return of appetite, are favourable signs ; but
all favourable symptoms  are to a  certain  extent
fallacious,  for after a truce of a few days we may
discover that we  have  that insidious and slowly-
wasting disease, chronic dysentery, to combat.
   This description, which  comprises the two ex-
tremes of the disease as it has  fallen  to our lot to
observe it in  Europe,  is drawn from  personal ob-
servation.  For an  account of dysentery  as it
occurs between the tropics,  we  must  be indebted
to the  able men  who have witnessed  its ravages
in those regions.
   Tropical Dysentery. — The  following is Sir G.
Ballingall's description  of tropical  dysentery, or,
as he very properly terms it, colonitis.
   " The  form of flux  now under consideration
commences in general with much of the appear-
ance of a common diarrhcea; frequent and unsea-
sonable calls to stool, with an  irresistible inclina-
tion to strain over it. The evacuations are generally
copious, of a fluid consistence,  without any pecu-
liar foetor ; sometimes streaked  with blood, and at
other times a small quantity of blood is voided in
a separate  form, unmixed with the faecal matter.
The pulse, in this stage of  the disease, is seldom
altered ; the  heat of the  skin  is not  perceptibly
increased,  and the tongue  is frequently but little
changed in its appearance.  There  is always  a
great prostration  of  strength and  depression of
spirits; the former symptom being always strongly
dwelt upon by the patient;  the appetite is  indif-
ferent, and the thirst urgent. To these symptoms
succeed a fixed pain in the hypogastrium, more or
less acute; the pain extending to,  and peculiarly
urgent  in, one or both ileac regions, and some-
times to be traced along the whole  course  of the
colon, with a sense of fulness,  tension,  and  ten
derness upon pressure; and on  applying the nana 
722
DYSENTERY.
 to the surface of the abdomen, a preternatural de-
 gree of heat is frequently perceptible in  the inte-
 guments.   The  evacuations  now become  more
 frequent and less copious ; they consist chiefly of
 blood and mucus, or are composed of a peculiar
 bloody  serum, which  has been very aptly  com-
 pared to water in which beef  has been washed or
 macerated.  A suppression of urine and distressing
 tenesmus now  become urgent symptoms; the in-
 difference to solid food increases, while there is an
 uncontrollable  desire for liquids, particularly cold
 water, which the patient prefers to any drink that
 may be offered to  him,  and  from wbich he ex-
 presses his inability to refrain, though prepossessed
 with the idea of its being injurious.   The tongue
 is now generally white  and  furred; sometimes,
 however,  exhibiting a florid, smooth, and glassy
 appearance, with a tremulous  motion when thrust
 out; the skin  is either parching hot,  so as to ren-
 der it even  painful  to retain the hand in contact
 with it, or covered with profuse perspiration,  inso-
 much  that  it  may  often  be observed standing in
 large drops  on  the surface ;  the pulse is  still fre-
 quently but little affected ; sometimes, however, it
 assumes a  febrile  quickness,  without any other
 remarkable  feature ; at other times it will be  found
 without  any  increase of velocity,  but  full and
 bounding, with a peculiar thrilling sensation under
 the fingers.   This state of the pulse, whenever it
 takes place, always denotes extreme danger, and
 shows that the disease is rapidly hurrying on to
 the final stage, in which  the  lassitude and dejec-
 tion so conspicuous throughout its course are now
 converted into the utmost degree of anxiety, de-
 pression, and fear of death. The patient generally
 shows an  inclination  to dwell upon symptoms
 which to a spectator would  appear of minor im-
 portance.   He evinces  the  greatest reluctance to
 part with his medical attendant, though fully sen-
 sible how unavailing the  efforts of  medicine are
 likely to prove.   The discharges by  stool, which
 are frequently involuntary, are now accompanied
 with  the  most intolerable foetor;  they  are fre-
 quently mixed with shreds  of membrane,  and
 quantities of purulent matter ;  a protrusion of the
 gut, forming a complete procidentia ani,  takes
 place; and cases are not wanting where a portion
 of the inner coat of the  intestines  amounting  to
 some inches has been  thrown  off in a  state of
 mortification."   (Observations on  Dysentery,  p.
 49.)  It is  needless to  say  what must be the re-
 sult of such a case as this, unless it is efficiently
 succoured in an early stage.
  Diagnosis.—The only diseases with which
 dysentery can possibly be confounded are cholera,
 hemorrhoidal flux, and diarrhoea.
  The rapidity of the march of cholera, compared
 with the long duration of dysentery,  is alone an
important ground of distinction between them.
 Cholera occasionally ceases in  twenty-four hours,
and perhaps never  lasts beyond a week ; whilst
the mean duration of dysentery is probably about
a fortnight,  and many cases endure  for  months.
Vomiting  is a uniform  attendant of cholera,  and
is  seldom observed  in  dysentery;  the purging,
during a considerable part'of the course of dysen-
tery, is mucous or  muco-sanguinolent, whilst its
 prevailing character in cholera is bilious.  Tenes-
 mus is a most distressing  symptom of dysentery,
 but in cholera it is generally absent.  In  cholera
 the alvine discharges are copious, and are passed
 with violence; the very reverse is the case in
 dysentery, and the former disease is attended with
 spasms of the extremities, which are not perceived
 in the latter.
   The tumours  at the  margin  of the anus; the
 blood flowing from the commencement of the dis-
 ease  unmixed with mucus;  the comparative ab-
 sence of tenesmus ; the  freedom from abdominal
 pain; and  the  solid  nature of the feculent dis-
 charges, which  are observed in hemorrhoids,  will
 secure  us  from confounding this  disease with
 dysentery.
   The distinction between dysentery and diarrhoea
 is easily drawn, in the more  advanced stage of the
 former disease, from the mucous and sanguinolent
 condition of the alvine discharges; but the testi-
 mony of the writer must be added to that  of Sir
 James M'Grigor and many others in proof of its
 extreme difficulty, in  many cases,  in  an early
 stage.  If it is then to be found at all, it must be
 sought in the character of the prevailing epidemic
 rather than in that  of any individual  case sub-
 mitted to our observation.   We believe that  the
 pathological condition in dysentery, and in cases
 of severe diarrhcea, is in its nature the same;  but
 that the  inflammation of the lining of the digestive
 canal is  more intense and enduring  in the  former
 than  in the latter disease.  In both cases, the first
 effect of this  inflammation is the rapid expulsion
 of the ordinary contents  of  the  intestinal  canal;
 but the inflammation existing in dysentery remains
 after  the canal is entirely emptied, and gives rise
 to  those  secretions from the  lining membrane
 which constitute the discharges characteristic of
 the disease.  In  certain cases,  those unpreceded
 by diarrhoea, the site  of the inflammation in  the
 lower part of the bowels seems to have the effect
 of retaining the natural contents of the canal, and
 of causing, from the first, evacuations consisting
 merely of matters secreted from the bowels.
   From  the description given of epidemic choleric
 fever, (see Cholera,) it will  be manifest that from
 the moment the choleric stage is fully formed, no
 confusion can arise between  this disease and dys-
 entery.   The spasms, serous  discharges, and early
 collapse of the former disease, are extremely'dis-
 tinctive.   But  in the  incipient stage of the  two
 disorders, some difficulty might be experienced,
 which would,  however, be dispelled by a reference
 to the character of the prevailing epidemic.
   In  this view of the diagnosis of intestinal affec-
 tions  attended with increased discharge,  it  is im-
 possible not to be struck with the strong relation
 which in their  rudimental  stage they generally
 bear to each other—a  relation which cannot  but
 lead to the suspicion, that, however widely differ-
ent in character and danger they may be when
fully  formed, the primary pathological condition
is, in all, if not identical, certainly closely ana-
 logous.
   Chronic Dysentery.—This  may be considered
as almost a more distressing termination  of  the
acute  form than death  itself,  for recoveries from it
 are rare, and it is fatal  after an amount of pro-
tracted suffering which  is extreme.  The fever
 which attended the acute form  subsides,  and a
temporary recruiting of strength and  appetite is 
                                      DYSEN

experienced, but  tbis truce from distress proves
deceptive.   The patient  occasionally feels sharp
pains of tbe bowels, with  frequent stools, consist-
ing of food apparently little changed by the  pro-
cess of digestion, mixed  with  slight streaks of
blood :  these symptoms may subside, and continue
to recur at intervals, either from  some manifest
imprudence in regimen, or without any assignable
cause, until extensive  disorganization of the in-
testine  takes place.   The stools are then mucous
and bloody, sometimes mixed with  purulent mat-
ter;  or such dejections  as  these  alternate with
discharges  of sanies, or  of offensive, ill-digested
fieces, the  number  of evacuations  varying from
three or four to seven or  eight  in  the day.   The
abdomen  at the  same time feels  full and  hard,
without being very painful on pressure ;  the urine
is high-coloured,  and is  passed with pain.   The
patient, when  in  bed,  lies on  his  side, with  the
body much curved,  and  the lower limbs  in  the
position of extreme  flexion on the abdomen, so as
to relax its muscles as much  as  possible.   The
pulse is feeble, intermitting, and  generally slow,
excepting towards evening, when some degree of
fever  occurs.   The  tongue is  often bright  and
glossy; the skin  is  cold, sallow, dry and rough;
the lips appear exanguious; emaciation proceeds
rapidly ;  the feet and legs become oedematous,
and  ascites occasionally  takes  place; the patient
sometimes becomes jaundiced ; and  finally, after
the lapse of weeks or months, he sinks  from  irri-
tation and exhaustion.
   The odour of persons  suffering under this dis-
ease is peculiar, and  the same may be occasionally
observed  in  the  acute  disease :  no description
could convey an  idea of it  to  one who had  not
experienced it, but  if once  recognized, it cannot
be forgotten ; it is very offensive, and at the same
time acid.   It is  independent of that of the mat-
ter ejected from the bowels.
   Acute dysentery occasionally leaves the bowels
in a condition less decidedly morbid than that just
described, and  one  from which the patient gene-
rally recovers,  but  after  a  considerable lapse of
time, perhaps  of years.   This condition is indi-
cated by  attacks of diarrhcea,  commonly  of the
lienteric character, recurring at intervals of three
or four weeks, and lasting for a few days; during
the attacks the  dysenteric odour  is  perceptible
about the  person  of the patient.
   Complications of Dysentery.—This disease  is
found combined with fevers, that is, instead of the
pyrexia symptomatic of  the local  affection, some
form of idiopathic fever exists in conjunction with
dysentery ;  and if the fever is a contagious one,
the two may be communicable together.  Know-
ing as we do the  proclivity of fevers  to affect the
intestinal  lining,  it cannot be matter of surprise
that the large intestines should  be occasionally the
seat of such affection.  There are other diseases,
too,  with which it is occasionally  found com-
bined.
   The complication with typhus occurs under the
operation of debilitating  causes, such as want of
food;  and where  numbers of persons being accu-
mulated in  a  space proportionately small  proper
ventilation and cleanliness are  impracticable.
   From these causes it has frequently proved more
fatal  to the garrisons of  besieged  towns than the
TERY.                                 723

assaults of the enemy.   It is characterized by a
remarkable stupor, resembling that of a drunken
man;  by headach,  vertigo,  and  delirium;  the
eyes are dull and very sensible of the  impression
of light;  on some day between the fourth and the
sixth day, a miliary  or  petechial  eruption often
appears on the neck, breast, and arms; the tongue,
teeth, and gums are covered with dark sordes, and
the pulse is frequent and small, or, when  the dan-
ger is imminent, intermitting.  The dejections are
frequent, scanty, composed of mucus mixed with
dark-coloured blood, and  of  an extreme  foetor;
the  urine  is  high-coloured,  as if  stained with
blood; nasal hemorrhage is not unfrequent, but it
does  not  prove  critical; the usual colic  pains of
dysentery are severe during the first four  or five
days; then they abate,  and  are again increased
about the ninth or eleventh day, when  a diarrhceal
discharge comes on which frequently destroys the
patient rapidly.  When the case  is fatal, death
generally occurs  from the ninth to the thirteenth
day, but  sometimes  as early as from the third to
the seventh.
   Dysentery  occasionally  complicates the early
stage of intermittent fever, and in this stage it
may be found  either during  the paroxysm only,
or, which is much more frequently the case, as a
permanent disease associated with  the  ague.  But
its existence at the commencement of intermittents
is very rare in comparison with its occurrence  at
a more advanced period, when disorganization of
the liver and other abdominal viscera has resulted
from the long  continuance  of the disease.  Its
supervention  in the  advanced stage of ague con-
stitutes a melancholy complication, and is  very
frequently accompanied or followed  by general
dropsy;  the  patient  lingering in much  suffering
until released  by death.  (See Intermittent
Fever.)
   Pathological researches have proved the  compli-
cation with disease  of the liver to be much less
frequent  than was supposed;  yet there seems no
doubt that, in a form  of dysentery occasionally
met with in warm climates, there is such  a com-
plication.  The affection of the bowels commences
in the form of diarrhoea; the  stools are  variously
coloured, black, green,  or  deep yellow;  they are
preceded  by considerable griping, felt principally
about the umbilicus;  they are frothy, accompanied
by much flatus, and cause considerable scalding or
excoriation about the anus. After a few days they
become white and mucous, with an occasional ad-
mixture of imperfectly digested aliment. Through-
out the disease, there is inappetency, with nausea,
intense thirst, a yellow  fur on the  tongue, great
oppression in the epigastrium, and a frequent pulse.
It is a slow disease, lasting for weeks  or months;
and in its progress  great emaciation, hiccup, and
bilious vomiting, are superadded to the other symp-
toms.  This form of dysentery, which  is some-
times called hepatic flux, may terminate in  health,
in incurable disease of the bowels, or in abscess of
the liver.
   The following graphic sketch of a form  of dysen-
tery more intense than the foregoing is drawn by
an  experienced  observer of the diseases  of warm
climates.   According to the views of the  writer,
which are most  probably  accurate, it should b«
referred  to  the compbeation of dysentery with 
724
DYSENTERY.
hepatic  affection which  we  are at  present  de-
scribing.
  '• The patient is at first languid, and loses at the
same  time  his  appetite and hilarity  of  mind.
Sometimes he complains  of pain in tbe region of
the liver,  increased by pressure, and in some de-
gree rebeved by the expulsion of flatus from  the
stomach;  but this pain is very trifling, or at least
much more stight than might be expected from the
condition  of the  bver as discovered  after death.
The presence  of this symptom  denotes the  true
character of the disease; but in many cases it is
entirely wanting, and hence the  greater obscurity.
In many cases the most acute observer can disco-
ver no sign  of bad health, but a  white tongue and
a pulse  more frequent than usual.
  " Matters remain in this state during a period
varying from four to eight days,  and the inexperi-
enced practitioner apprehends little danger; but in
this respect he is deceived; for an insidious fever
depresses the patient by  almost  imperceptible  de-
grees,  till  the  actual symptoms   of  dysentery,
namely, tenesmus and  very  frequent  alvine dis-
charges, display  themselves  with  great violence.
These symptoms  are accompanied by ardent fever,
delirium,  oleaginous  sweat,  febrile anxiety,  and
urgent thirst, whilst the  tongue  is covered with a
yellow fur, which is converted towards the close
of the disease  into a permanent dark crust.  A
large  quantity of green, bilious, and sanguineous
matter flows from the bowels,  and finally convinces
the medical attendant that the  morbid condition
of the liver and bile  is  the exciting cause of the
flux.  There is not much  pain  in  the bowels in
this stage of the disease;  but  the tenesmus is most
distressing,  and occasionally protrudes a  portion
of the rectum from the anus.  Subsultus tendinum,
hiccup,  and cold sweats take place;  and, unless
relief is afforded before  the  disease reaches this
stage, death speedily ensues." (De Dysenteria Re-
gion umCalidarum. Archibaldo Robertson Auctore.
Edin. 1817).
   Pathological Appearances.—These vary ac-
cording to the period of death and the nature of
the case.  If dysentery prove  fatal in an early
stage, the appearances are  those of inflammation
simply, or of inflammation and gangrene of the
mucous membrane of the large intestines, with few
or no traces of ulceration.  If at a more advanced
period, the other coats of the bowels are found to
participate in the disease,  and  numerous and exten-
sive ulcers are discovered.   In  inflammation, the
external appearance of the bowel is healthy;  but,
on opening it, portions  of its mucous membrane
throughout  the whole extent  of  the colon  and
rectum, and occasionally some  part of the small
intestines, are found of a  bright red or brownish
colour, and sensibly elevated above the  level of the
more healthy parts which are interposed between
them.   These  inflamed  portions  are  sometimes
covered with a puriform, sanguineous, or sanious
secretion,  which  gives  them the   appearance of
ulceration; but if this is scraped off with the back
at a scalpel, and  the part is washed, the surface is
found unbroken.   False membrane is sometimes
found deposited on the mucous coat. Dr. O'Brien
describes  it as occurring both  in  the large and
small intestines, but  as  being most frequent and
remarkable  in  the colon and rectum.  In some
cases, he informs us, it occurred in patches, but in
others the mucous membrane was  covered  by a
uniform layer of white lymph.  (Transactions of
King and  Queen's Colleges, vol. v.)   Gangrene
is  denoted by  blackness  or lividity, and morbid
softness of the membrane, the muscular coat occa-
sionally partaking of the softness;  and in some
instances by vesicles full of a fetid fluid.
   In cases which have terminated fatally in a more
chronic stage, there is thickening of  the tunics of
the intestine, and the bowel is < mtracted in diame-
ter and ulcerated.  The ulcers are diffuse or  folli-
cular.  The former may be of the size of a sixpence
or a shilling, or an extensive portion of the mem-
brane  may be  in  a state  of almost  continued
ulceration, the  diseased  surface  being varied by
portions in a stfte of red fungous elevation, running
irregularly over it, and  separating  the ulcerated
spaces from each other.   The follicular ulcers are
of the size of spbt peas; their concavity is lined
with  pus, and  their edge is surrounded by a red
circle.   The follicles are occasionally found  in a
state of inflammation, having a tubercular appear-
ance,  compared  to  small-pox.  The  ulceration
occasionally perforates the coats of the intestine so
as to  allow its  contents to  escape into the cavity
of the abdomen.  This accident and  its  conse-
quences  deserve  separate  consideration.   (See
Perforation.)  Adhesions of the peritoneal sur-
face to the adjacent viscera, and serous effusion
into the cavity of the abdomen from  the extension
of inflammation to the exterior tunic of the intes-
tines, are not unusual occurrences.
   Other viscera, beside  the  bowels,  are occasion-
ally found  to show  traces of disease.  The  me-
senteric glands  are  sometimes enlarged and in-
flamed, and the omentum is described by Dr. Jack-
son as being in some cases dry and  shrivelled, in
others gangrenous,  and occasionally  forming a
new and fleshy-looking  substance, which confines
the intestine in such a manner as to obstruct its
canal.  (A Sketch of Febrile  Diseases, by Robert
Jackson, M. D., Stockton and London, 1817, p.
439.)  The liver has been supposed to be gene-
rally affected in  dysentery, and it is occasionally
found small and indurated or enlarged, and at the
same  time of a firmer  consistence  than natural,
or an abscess has been found in it  in  that form
of the disease called hepatic flux; but pathologi-
cal researches have  proved  that changes  in its
structure are much less frequent than was ima-
gined, and by no means essential  to dysentery.
Even in cases of this disease in which this organ
is  functionally  affected  during life,  or in  which
researches after death show  that its structure  has
undergone a change,  (and  the  instances where
this  latter  occurrence is  discovered bear a  very
small proportion indeed to the whole amount of
examples of fatal dysentery  ;) there  is great  rea-
son to think that the irritation is rather propagated
from the intestinal canal to the liver, than that the
reverse order of causation takes place.  There is
no organ  of the  body of which the influence in
generating disease has  been so  much oveirated
by medical men as the liver, occasionally perhaps
from mere carelessness, but too often, we appre-
hend, from a not very creditable wish to run with 
DYSEN
TERY.
725
the current of popular opinion, which throughout
Great Britain  and her dependences is strangely
favourable to hepatic and bilious doctrines.
  Causes—Dysentery is generally most preva-
lent during the latter end of summer and autumn,
when the alterations of temperature are  sudden,
and especially when there  is a considerable dis-
crepancy between the heat of the day and night;
but there is no season of the year in which  it is
not found occasionally to make its attacks, pro-
vided the body be exposed to the cause peculiarly
favourable  to  its production,  cold  or chill  after
comparative warmth.   It is much more prevalent
in the warmer  latitudes than in temperate cli-
mates ; probably in some degree from the circum-
stance, that in the former situation the heat of the
day is followed by great comparative cold at night,
the chilling effect of which  is aided by the heavy
dews which are so general in the warmer regions
of the earth.  The operation  of the same cause
is manifested in the case of soldiers, who are fre-
quently attacked in numbers after a night-encamp-
ment or bivouac on damp ground.
   Unwholesome food,  the abuse  of spirituous
liquors, and the drinking of bad wine, bring  on
attacks of the disease in climates and situations
where it prevails ; but indulgence in fruit, which
is often assigned as its cause, does not appear to
have such an effect.
   Malaria is supposed to be a cause of dysentery,
and there is reason to think the supposition cor-
rect.   The disease  occurs in  the  climates, situa-
tions, and seasons favourable to the production of
periodic fevers ;  it is  occasionally combined with
them, and appears to succeed  or supplant them,
as though it were owing to  a continuance of the
operation of the febrific cause, modified in its na-
ture or influenced in its effect by extrinsic circum-
stances.   The analogy between dysentery and
other forms of bowel  complaints and such fevers
has struck the eye of observers from Sydenham
to Jackson.   It is difficult to assign to the  first-
mentioned causes, cold and bad diet, and to mala-
ria, their respective share in the production of the
disease.  It is probable  that  sporadic cases are
frequently owing to the former exclusively, and
that they may co-operate in producing attacks  of
the disease  when it  is prevailing  epidemically;
for instance,  malaria  having been  applied, expo-
sure to cold or  dietetic errors  may immediately
bring on an attack.
  The discrepancy of testimony as to the conta-
gious nature of  this disease is extreme ;  but were
the  question  one which  the  preponderance  of
great names could decide, it  would  probably be
answered in the affirmative.  So general was the
belief in its contagious nature  some  years  ago,
that contagious  pyrexia  is inserted  among the
characteristics of the  disease in Cullen's  Nosolo-
gy, as if it were an acknowledged incontroverti-
ble doctrine.   But in the present day we  believe
there is scarcely a medical  man of much  experi-
ence in the disease who believes it  to be conta-
gious; and  the  writer  has never  seen  a single
case which he had the least reason  to  attribute to
such a cause.   The  conflict  of opinion  on this
point is perhaps to be  explained by certain au-
thors having seen many cases  of dysentery  com-
plicated with typhus, and by their having  ascribed
to the disease, generally, that which is true only
of one of its complications.
  Treatment of Acute Dysentery.—The na
ture of the disease being ascertained, the practice
to  be  pursued  becomes   sufficiently  obvious.
Bloodletting  naturally  presents  itself  as  one
means of subduing the inflammation;  and if the
constitution sympathises with the  local affection,
so that  there is general fever, with  a warm skin
and a frequent and  sharp pulse, blood should be
taken freely from the arm.   We  should  not rely
upon general bleeding as the sole mode of deple-
tion in the disease,  for experience teaches us that
the inflammation of mucous membranes  is less
amenable to this remedy  than that of most tissues;
but it should be followed  by local bleeding  by
means  of leeches ; and in the milder order  of
cases this may altogether supersede general deple-
tion.   Twenty or thirty  leeches should be applied
along the course of the colon, or to any point of
the abdomen where pain is felt, the parts being
subsequently covered with  a hot  poultice.  The
repetition of leeches must of course depend upon
the intensity and duration  of the disease, and the
degree  of relief afforded by the first application.
Should griping,  purging,  and particularly fixed
abdominal pain  continue, they may be  repeated
on  the following day, or each succeeding day,  to
the third  or fourth time, if the circumstances men-
tioned indicate  the propriety  of the  repetition ,
their number in the later applications being regu
lated  by the necessity of the case and the strength
of  the patient.  It  should be remarked, however,
that the  first application,  if vigorous, frequently
affords so much relief, that, by the aid of internal
medicine,  the   disorder proceeds  thenceforward
very steadily to  recovery.  Hot fomentations and
the warm bath will be found serviceable  after the
bleeding,  and subsequently the abdomen  may be
blistered with benefit.
   Purgatives  are  generally administered; and,
during a considerable  period when  the retention
of feculent  matter  in the  cells of the colon was
erroneously supposed to constitute the very essence
of  the  disease,  they were  principally  depended
upon by some  practitioners  for  its  cure;  and
though the  more correct views at present enter-
tained  may  seem  to forbid  their  employment,
experience teaches  us that to unload the bowels,
when requisite, with gentle laxatives, is not only
safe but  beneficial.  Were the writer to digress
into a question  of  general  therapeutics, but one
connected with  the  present  subject, he  woulc
remark that though laxatives are found prejudicial
in  neuralgic irritation of the intestinal canal, he
has never observed injurious  effects  from their
moderate and judicious employment in inflamma-
tion  of  its  mucous  lining;  and  that  he  has
detected the most extensive lesions  of this mem-
brane, where the practitioner had rigidly abstained
from  them.  It  is  desirable, however,  that the
abuses which heretofore existed, regarding their
employment in dysentery, should not be  resusci-
tated, and on this account  it appears advisable  to
specify the sole  circumstances  under which they
should  be administered  in this disease, and the
precautions this  administration requires.
  In  every  case  of dysentery, the first  remedial)
measure should be directed to subduing the essen 
726
DYSENTERY.
tial disease, the intestinal  inflammation ; the pri-
mary and paramount means, therefore, are the
general or local bleeding,  or both, as the circum-
stances of the case may require.  In that form of
the disease  which is un preceded  by diarrhcea, a
dose of castor-oil, sufficient  to expel  the  matters
lodged in the intestines, may be given after a little
respite from suffering has  been obtained by bleed-
ing ;  and should  its  operation be tardy,  it may be
accelerated by a mild emollient enema.   In that
more frequent form of the disease which has diar-
rhoea as a precursory symptom, purgatives  should
by no means be employed early ; but in any form
of dysentery, should a considerable  period have
elapsed without a feculent discharge, a mild laxa-
tive will  be  advisable, for  the retained matters are
generally in  a morbid condition, and can scarcely
fail  to be a greater source of irritation  to the in-
flamed membrane than the  operation of a gentle
laxative.  The repetition  of medicine of this kind
will of course depend on the circumstances of the
case ; should the alvine discharges become fecu-
lent  and copious, it need not  be repeated.  No
more  proper  laxative can  be  selected than the
oleum ricini, aided   in its  operation by a mild,
tepid, and emollient enema.  Some practitioners
think favourably of a solution of  neutral salts
with which a proportion of  tartarized antimony is
combined ;  but it seems doubtful whether the irri-
tating effect  of the  salt  on the intestines  would
not counterbalance  the  benefit likely  to  accrue
from the diaphoretic action  of the antimony.
   Mercury is so powerful a subsidiary  of general
and  local  bleeding  in the  cure of inflammation,
that  we  should naturally  expect benefit from it in
this  disease ; and experience proves its  prudent
employment  to be of great service.  It might be
 objected to on the same ground as purgatives, the
 dread of an  irritating  effect from it on the in-
 flamed intestine ; but the  result of its employment,
 our only safe guide, shows the apprehension to be
 erroneous,  provided the  medicine   be properly
 administered.  It is a remedy more  generally ap-
 plicable  to dysentery in  warm latitudes  than in
 this country ; but if employed with prudence, and
 merely as subsidiary to the general or local bleed-
 ing, or  both, advantage  will be derived from  it
 wheresoever  the disease  may  be prevailing.  A
 grain or a  grain and a half of calomel, combined
 with from five to ten grains of Dover's  powder, or
 half a grain of opium; or  five  grains  of  hydrar-
 gyrus cum  creta,  likewise combined with the
 opiate ;  may in  this country be  administered at
 intervals of four hours, the period being  length-
 ened when  the  symptoms  begin  to abate.  It is
 not necessary to excite ptyalism, although this  is
 a contingency from which  no evil result  need be
 apprehended, provided the  medical attendant be
 sufficiently watchful of the effect of the  remedy
 to prevent its being  excessive. In warmer climates,
 the same dose of mercury, combined  with a smaller
 proportion of Dover's powder, or a grain  of ipe-
 cacuanha, may be  given every hour or two  till
 some effect is produced on  the disease or the sys-
 tem. In our Indian  settlements the  practice is
 much bolder than this, calomel being administered
 in doses of a scruple.  Mr. Annesley gives such a
 dose nightly, followed by an oily or a saline pur-
 gative in the morning, till  the  dejections become
natural and healthy, (Sketches of the Diseases of
India, p.  417 ;)  and calomel in such  doses is a
familiar remedy with British physicians in tropical
climates.
  Diaphoretic medicines are employed by many
medical men  in dysentery.   The ceratcd glass of
antimony, which was a favourite remedy with Sir
John  Pringle and others,  probably  owed great
part of its  influence over the disease to its power
of exciting  perspiration;  and  the combination
which has  already been mentioned, that of a mer-
curial preparation with Dover's powder,  perhaps
derives part of its very great utility  from tbe same
property.  Ipecacuanha alone is a valuable medi-
cine of this class.   It may  be given in large doses
in the form of pills without exciting vomiting, as
in the manner recommended  by Mr. Twining in
the Calcutta  Transactions.  By  combining it with
extract  of gentian he  exhibits as much as six
grains, which he repeats at intervals; and, as he
assures us, with an excellent effect.  A decoction
of three  drachms of the root, boiled in a quart of
water down to a pint, administered in portions of
three  or four ounces, as an enema, and  repeated
once  or twice in the day,  we  have often found to
have  the effect of allaying irritation and tenesmus,
and to be  generally beneficial.   The  same  medi-
cine is frequently combined with calomel, or other
mercurial preparations, with considerable improve-
ment of  the efficacy of both.  Emetics are favour-
ites with some practitioners, but the benefit to be
derived from them  is  much  more certainly  and
easily attained by  nauseating  or diaphoretic doses
of ipecacuanha.
   Tenesmus is  frequently a distressing symptom.
Of course effectual relief can  be afforded only by
the general process for subduing the disease; but
it may be  allayed  by anodyne enemata, of  which
a solution of three or four grains of opium in a
small quantity, not  more  than two  ounces, of
starch mucilage,  constitutes  a very good one.
Dr. Abercrombie recommends injections  of lime-
water, at first diluted with milk  or  thin arrow-
root,  with  the addition of an opiate.  It should be
impressed  on the  minds  of junior practitioners
that enemata administered witb the view  of allay-
ing tenesmus should be small, for this affection is
aggravated by distending the lower portion of the
intestinal canal  with bulky fluids.   Mild emollient
clysters  have already been recommended  as adju-
vants to the  oleum ricini when there  is retention
of  feculent matter in the intestines ; but it should
be understood  that their  employment  in these
cases is  admissible only when the irritation of the
inferior  portion  of the canal is not extreme.  We
have met with instances in which even the intro-
duction  of the pipe could  not be borne.   In such
cases as these, tenesmus  and  irritation may be
allayed  by opium, Dover's powder, a dose of lau-
danum,  or by opiates combined with  infusion of
 cusparia or  balsam  of  copaiba, administered by
 the mouth.
   Dr. Cheyne,  whose practice in the dysentery
 of this  country has been very extensive, thinks
 highly of the power of opium in its cure, and
 gives the following summary of his experience of
i its efficacy and  that of other remedies.  The mode
 of treatment he found most generally useful was
 bloodletting, followed by calomel and opium, and 
DYSENTERY.
72
this by balsam  of copaiba  and farinaceous diet;
and he says, « were the same cases again  to be
placed  under my care, I would  not hesitate  to
give opium in doses of four or five grains, as it
was the opium chiefly that seemed to arrest  the
progress of the  inflammation ; and whatever  in
such a case  procured  respite  to the patient from
agony, sometimes proved of permanent  benefit."
(Dublin Hospital Reports,  vol. iii.)  This testi-
mony, proceeding from  such a  quarter,  should
have great weight.  The concluding clause con-
tains a truth of much importance, and one appli-
cable to many diseases besides dysentery.
   [Dr. Christison expresses the  belief,  that  the
cure of epidemic dysentery may often be effected
by opium alone, begun early and  given  boldly.
In one epidemic, it was prescribed  at once in the
dose of one, two, or three  grains  every  six, four,
or three hours,  according  to  the  urgency of the
 symptoms, until signs of its narcotic action began
 to display themselves; and in  this way sometimes
 twenty and  even thirty grains were given in  the
 first twenty-four hours.  In several cases, where
 the treatment was commenced not later than the
 close of the second day, the  force of the disease
 was at once completely broken, and the only reme-
 dies needed afterwards were  the  continuance of
 the opium in diminished doses, and restricting the
 patient to pulpy solids as  diet.   The writer  has
 often seen the excellent effects of opium  in  this
 as well as  in other inflammations, given in seda-
 tive doses ; but caution has to be used that it be
 not pushed too far.]
   Swathing the abdomen with flannel, so  applied
 as not to press painfully, is useful  as a  means of
 keeping the temperature uniform.   Should abdo-
 minal pain require relief, hot fomentations may be
 frequently and freely resorted  to.   If the anus be
 inflamed or excoriated, it  should  be bathed with
 goulard water ;  and it may be protected from the
 acrimony of the discharges by being anointed with
 unguentum cetacei, or wax and oil.
   The diet throughout the disease should be mild
 and light, consisting  of arrow-root, milk, simply,
 or witb gum acacia dissolved  in it, rice  or barley-
 water, and mucilaginous and bland matters of this
 description ; they should be given  in small quan-
 tities at a time, and the whole amount of what is
 taken should be small.
   Treatment  of Chronic Dysentery. — Our
 indications  here are  much more perplexed,  and
 our difficulties  much greater, than in  the acute
 form of the disease.  That intestinal ulcers occa-
 sionally  heal  has  been  proved  by Dr.  Troilet,
 (Journal  General  de Medecine) ;  and Dr.  La-
 tham, in his account of the disease which prevailed
 in the Penitentiary at Milbank, has given  an ex-
 cellent description of intestinal ulcers in the pro-
 gress of reparation :  hence we should not utterly
 despair of success in  this very intractable malady.
 As in most diseases which  are but little  amenable
 to our art, the remedies proposed are very various.
 Those which deserve the most confidence are small
 doses of hydrargyrum cum creta*  or calomel with
 Dover's powder, or the same mercurial prepara-
 tions with  opium and ipecacuan; lime-water;
 vegetable astringents  and bitters, as kino, catechu,
 cusparia, quassia and logwood ;  nitric acid ;  opi-
 um , balsam of copaiba or  tolu; or various comb.-
nations of these remedies, as a strong decoction
of cusparia with nitric acid and laudanum, recom-
mended by Dr. Abercrombie.  The late Dr. Jack-
son, whose experience of this form of disease was
very extensive, placed  much  reliance on  small
general bleedings, repeated at intervals of a week ;
but in  a disease attended with so much debility as
this, very moderate local bleeding from the integu-
ments  of the abdomen, and the  application of blis-
ters to the same parts, appear to be safer methods
of accomplishing the object to be attained.   Mo-
derately  stimulating and  oleaginous frictions  of
the abdomen, the part being subsequently swathed
with flannel, are occasionally  found useful; and
the warm salt-water bath is soothing to  the pa-
tient, and generally beneficial to the disease.  Pow-
dered  charcoal, combined with powder of ipeca-
cuan and rhubarb, has been found advantageous ;
and Dr. Abercrombie speaks favourably of a com-
bination of the same substance with Dover's pow-
der.  The writer has found considerable temporary
benefit in this distressing affection from  the sul-
phate  of  copper, administered  in the manner  re-
commended  by Dr. Granville  in  various chronic
affections of the bowels.  It is given  in doses  of
half a grain with an equal quantity of opium ; and
is gradually increased, if  necessary, sometimes tc
the extent  of  three grains, with half-a-grain or a
grain of opium three times  a day.   Where there
is  reason  to suppose  that  the lower part of the
intestinal  canal is the  seat of ulceration, various
injections are employed with advantage.  A weak
solution of acetate of lead or white  vitriol has the
effect  of allaying  irritation ; whilst a solution of
blue vitriol, or one of corrosive sublimate in lime-
water, excites foul and  sluggish  ulcers to healthy
action, and  in  some  cases has  appeared to  aid
materially in effecting a permanent  cure.   These
injections should not consist of more than two or
three  ounces of fluid, for great  irritation is pro-
duced under the circumstances mentioned by dis-
tending the canal by large enemata.
    [The various remedies recommended  lu  diar-
 rhoea (q. v.) are equally appropriate in the  affec-
 tion under consideration.]
    The diet, throughout  the disease, should con-
 sist of the  mildest and  most bland farinaceous
 food,  taken  in small quantity, solid animal food
 and all stimulating matters being rigidly forbidden.
 Solid  food, in any considerable quantity, must be
 injurious  as a more mechanical irritant  in that
 condition of the intestines which beyond a doubt
 exists in chronic dysentery ; whilst liquid freely
 taken excites griping, passes rapidly through the
 bowels, and must tend to disturb that reparatory
 process which it should be our object to encourage.
 If  the disease have commenced in a district where
 dysentery is endemic, change  of air is a  remedy
 of first importance, and one  without which  al.
 other  means will often  prove nugatory.   A sea
 voyage has  frequently proved  very  advantageous.
    The  treatment  to  be  adopted in  dysentery,
 complicated with  idiopathic fevers,  will be ga-
 thered from the rules contained in this article, and
 in  the articles on continued  and periodic fever.
 The combination with liver disease, the hepatic flux
 of Ballingall, and others, requires mercurial  treat-
 ment  by means of  blue-pill, calomel  and  opium,
 or  inunction, till  ptyalism  is induced ; and this 
728
DYSMENORRHEA.
unless the exhausta .1 of the patient forbid it, is to
be  kept up  till the discharges assume a healthy
appearance.  Laxatives are occasionally requisite,
and of these castor-oil is the most proper.   The
warm-bath,  sudorifics, blisters, and bandaging the
abdomen  with  flannel, are as important as in the
treatment of the  uncomplicated  disease;  and
should the tenesmus be  distressing, it may be al-
layed  by  any of the forms of anodyne enemata
recommended in  that disorder.
                            Joseph Brown.
   DYSMENORRHEA, (from Si,s, xgre,- rfvcc,
menses,-  piu, fluo,-) painful or difficult  men-
struation.—This disease  is  important  from its
occasional extreme obstinacy ; from the great suf-
fering which it produces, and from the contrariety
of opinion which prevails as to its nature, and the
treatment required for its relief.   In  healthy men-
struation  there is often  no warning whatever of
the period;  more generally there  is some degree
of discomfort, consisting of a sensation of weight
and fulness  about the pelvis, with a bearing down
and aching of the thighs, but usually the suffering
is so slight as not to call for medical aid; in dys-
menorrhoea, however, the menstrual period is ac-
companied with  such  acute pain and suffering,
and is looked forward to  with  such apprehension,
that the patient is eagerly inclined to seek for re-
lief, and is but too often  driven from one remedy
to another with but trifling advantage.
   The time at which the pain comes on varies in
different cases.   In many the  pain  precedes the
discharge, or else  the  discharge  is  exceedingly
scanty as  long as the pain lasts ; but as the quan-
tity increases to  a  full  flow, a subsidence of the
suffering takes place ; in these cases the pain will
last only  a  few  hours.   In other instances the
discharge  is more profuse than  natural during the
whole continuance of the  pain, is apparently ex-
pelled in gushes,  and  is  then usually mixed  with
coagulated blood.  In  a few more rare cases the
pain will  only occur in the latter part of the men-
strual  period, accompanied either with  a diminu-
tion or an increase of the flow, and ceasing  only
after every vestige of the discharge has passed off.
  All  these  varieties will be found in practice,
though in the histories of this disease some have
been often omitted,  and most authors have de-
scribed the  pain  as occurring only  at the  onset,
and ceasing when the  full and  free evacuation
takes place.
  The pain often resembles the grinding pains of
the first stage  of labour, and is  similarly in pa-
roxysms of short duration and  frequent recur-
rence.   There is  also, in the intervals, a constant
aching pain  down the legs, with  a dragging sen-
sation  in the back and loins ;  there is sometimes,
also, a sensation of bearing down in the pelvis,
with even an actual lowering of the uterus.   All
these pains will vary in degree ; for in some severe
cases the paroxysms have been so violent that the
patient has  rolled on the  bed  or  the floor  with
agony, and,  in  a  few instances, the writer of this
article has noticed severe convulsions of the cha-
racter of tetanus, even amounting to  regular  opis-
thotonos.  The expulsion of  a membranous  sub-
stance has been  observed in dysmenorrhtea by
Morgagni, (Epist. 48, art. 12,) who described it
 as generally consisting of a small bag, containing
 a fluid, on which account it was usually mistaken
 at that time for a very early abortion.   More par-
 ticular notice was  attracted to this  peculiarity in
 modern days by the  late Dr.  Denman, who satis-
 factorily established the fact  that the membrane
 was expelled at least as frequently in  single as in
 married women, and that it  had the  appearance
 of a  triangular cast  of the cavity of  the  uterus,
 having an  exact  resemblance to the membrana
 decidua.  It would seem that where  a  bag con-
 taining a fluid was really discovered, it must have
 been an  ovum, at  an early period of  conception,
 particularly  as such  women  are very  liable  to
 miscarry.   Dr. Denman was  of opinion that this
 membrane, although often  not noticed, was ex-
 pelled in every case of dysmenorrhoea.  That he
 was wrong in this conjecture  is now well known,
 as, though occasionally met with, it is  by no
 means common, although  there  are  often sub-
 stances perceived which at  first sight resemble it,
 but which consist merely of coagula  of blood, with
 the colouring  matter separated.   From the sup-
 position that the membrane  is always  expelled,
 and that  it consists of coagulable lymph exuded
 from  the lining of the uterus,  necessarily resulting
 from  inflammatory action, has arisen a very faulty
 opinion of the nature of the  disease, and  a most
 mistaken  and pernicious mode of treatment, when
 universally applied.
   Dysmenorrhoea may arise at  any period of life
 at which  the menstrual function is performed.  It
 will sometimes exist from the  time of puberty and
 cease  upon marriage; in other  instances the first
 attack is immediately after marriage, and lasts till
 the patient becomes pregnant; in some it does not
 appear until after child-birth.  It has  been often
 stated that no woman can become pregnant whilst
 this disposition to dysmenorrhoea exists; but this
 is far  from  being correct; the eitor arising from
 the fact that such  patients are particularly liable
 to abortion at a very early period, which abortions
 have been supposed to be merely unusually aggra-
 vated  attacks of the  complaint.   Nor again, as
 has been generally considered,  is pregnancy a cure
 for a previously existing dysmenorrhoea, unless by
 great care and management the first two or three
 months are  safely passed over.
  It would appear that the  immediate  cause of
 this  distressing disease  is extreme  irritability of
 the uterus; and as  it is well known that great
 irritation is but a step removed from inflammation,
 it is  very probable that in  some cases,  where  a
 membrane is expelled, inflammation of a peculiar
 character  may be excited.  It  does not follow as a
 certainty  that the  separation  of a cast of  fibrine
 from a mucous surface is the result of decided in-
 flammatory action.  Some pathologists have gone
 so far as to dispute the possibility of pure inflam-
 mation arising in a membrane  where no  blood-
 vessels are to be found, although they ramify pro-
 fusely in the sub-mucous tissue. The tubular casts
 of lymph from the lining of the intestines are often
 brought on by irritation alone, as by  the improper
 and excessive administration  of calomel; and in
 croup, the fibrinous tube, which is occasionally
formed in severe cases, is not found adherent by
vascular union to the surface  on which  it is de-
posited.  Although he does not exactly agree in 
DYSMENORRHEA.
729
these views, it certainly appears to the writer that
the pain of dysmenorrhoea is no proof of inflam-
mation, any more than the pain of labour; and it
may be stated that generally there is no other sign
of inflammation present but pain; that the pulse
is merely quickened during  the  immediate  par-
oxysm, at which time alone the skin is hot or the
face flushed ;  frequently indeed the skin is damp
and cold, and the face pallid.   On two occasions,
where blood was  drawm from the arm during the
painful period, no buffy coat or contracted cupped
surface was found to exist.   Although the writer
does not deny the occasional  existence of inflam-
mation, particularly in plethoric  and robust con-
stitutions, yet he believes  that in by far the ma-
jority of cases acute irritation alone exists.   The
women  most liable to this  complaint are  those
possessing great susceptibility of frame,  who are
subject  to  hysterical affections,  and  who have
strong passions  and ardent temperaments.  Dys-
menorrhoea will often occur only at those periods
of life when there is great constitutional disturb-
ance, or much  mental excitement, as at the early
years of menstruation, or  shortly after marriage.
  [It is affirmed by Dr. Ferguson (Tweedie's
 Library of Medicine, Amer. edit. iii. 305) that
sexual intercourse,  immediately  previous  to the
expected menstrual  flux, has  excited the  severest
forms of the disease.]
  Treatment.—This has varied  according to the
view taken of the nature of the  disease.   Those
 who consider it to be  universally  of an inflamma-
 tory character, have  of course  recommended blood-
 letting, local and  general, frequent depleting me-
 dicines, and a spare diet.   Where the deciduous
 membrane has been certainly and habitually ex-
 pelled, it is  not improbable but that benefit may
 be derived by local bloodletting to a moderate ex-
 tent ; but as a general rule, such treatment is not
 required, and in many instances it has done con-
 siderable mischief by the  extent  to which it has
 been carried.  By the character  of the  constitu-
 tions usually affected, by the  spasmodic nature of
 the pain, and by the success of a very opposite
class of remedies, it  would appear that the disease
 is rarely inflammatory, perhaps never purely so,
 but that it arises from a peculiarly irritable condi-
 tion of the uterine organs.  On this principle the
 treatment is twofold : 1.  to relieve the immediate
 pain during the menstrual period ; 2. to regulate
 the general health in the  intervals.  For the first
purpose opium is the best remedy, where it can  be
borne, and  particularly when combined with ipe-
cacuanha, and with camphor in  doses of four to
ten grains.  Immediately before  the expected at-
tack, the bowels should be opened by a mild ne-
gative or a  warm-water  injection ;  the  patient
might also put the feet in warm water, or sit in a
warm hip-bath.   At  this time  should  the pulse
be full and  frequent, the countenance flushed, and
geperal  plethora  prevail,  the local abstraction  of
blood by cupping on the loins,  or  by leeches to
the pudenda or  groins, might be advisable.*  At
the onset of the pain, opium (or any of  the other

  * In the writer's opinion it is  only in such  cmm that
bloodletting is desirable ; but it is fair to state that many
eminent practitioners lay  great stress on fee   d  «-
peated removal of blood in nearly all cases of d>sinenor-
rheea.from  the belief that the pain  necessarily denotes
inflammation.
  Vol. I. —92
narcotics, if more  suitable,) may be given in full
doses, combined as before mentioned, and repeat-
ed every hour or two according to the effect.  Bel-
ladonna  plasters may be applied to the  sacrum;
injections of warm mucilage, containing belladon-
na or opium, may be frequently thrown into the
vagina;  and, in addition, we may direct supposi-
tories of clysters,  containing  from  one to two
grains of opium.   Hot fomentations to the pubes,
loins, and perineum  are also frequently of great
service.   Ether, assafcetida, and ammonia may be
taken at intervals.   Hot gin-and-water is a very
popular  remedy, and will  often subdue the pain.
These  medicines, however, should be cautiously
administered, should  there be much  heat of skin
and feverish excitement.
  In the intervals of the periods the general health
is to be regulated,  and  the constitution  to  be
strengthened so as to be rendered less irritable.
It would be advisable, should the patieni be mar-
ried, that intercourse should be avoided  for about
a week  before  the expected attack.   In the ma-
jority of cases  the  preparations of iron are the
best remedies which can be given, combined so as
not to produce too great excitement of the  circu-
lation.   Equal parts of vinum ferri and the com-
pound spirit of  sulphuric ether (gss  to  gi) may
be given two or three times a day, or the mistura
or pilula ferri composita of the London Pharma-
copoeia  may also be tried.   A useful combination
is the  sulphate  of iron, the  compound extract of
colocynth, and the soap and opium pill, two grains
of each.  The natural chalybeate waters seem on
the whole to be more serviceable than any artifi-
cial preparations.  Where  iron disagrees, some of
the other metallic tonics  may be of advantage,
particularly the  zinc. The vegetable tonics do not
appear to be of  much use; we must  except, how-
ever, the senega, which Dr. Chapman,  of  Phila-
delphia, has confidently recommended, especially
in those cases where a membrane has been habitu-
ally expelled.  He was induced  to try this  medi-
cine from a supposed analogy between  this form
of the disease and croup, as regards the formation
of fibrine from a mucous surface; he advises four
ounces of the decoction to  be taken daily. [Expe-
rience  has  not, however, confirmed  this view in
either  one  disease  or  the other.]   In obstinate
cases a  course  of mercury  has been  round the
means  of cure, particularly when  combined with
sarsaparilla.  Repeated blisters or caustic issues to
the  sacrum have also been tried, and in  some
instances successfully.  The bowels should  be
kept open, but not too much so, and the purga-
tives should not  possess an irritating character.
Moderate exercise is advisable,  but all violent
exertions are to be avoided.   The diet should be
nutritious, but not stimulating.   Cold hip-bathing
will be  found of use, and  much benefit will ariot
from the regular employment, night and morning
of cold-water injections into the vagina, especially
if combined with the superacetate of lead.   In a
few cases there  has been a remarkable connection
between the existence  of  this  disease  and  rheu-
matism  in  the  same person, and the medicines,
such as guaiacum and colchicum, given to relievo
the rheumatic symptoms,  have at the  same time
cured the dysmenorrhoea.  This was accidentally
noticed  in a case, some years ago, by Dr. Goorij, 
730
DYSMENORRHEA — DYSPHAGIA.
with regard to guaiacum, and he consequently
was induced to try that medicine where the pain-
ful menstruation existed without the rheumatism,
and sometimes with success.   Further trials, by
the writer  of this  article, have  confirmed  this
observation in several instances, and it is remarka-
ble  (since  Dr. Gooch's observations  were never
published) that the same remedy has been highly
spoken of by Dr. Dewees, of America, in a recent
publication.
  [Mechanical Dysmenorrhxa is a variety which
has been ascribed to the small size of the os uteri,
or to a narrowness  or  stricture in  some part of
the canal of the cervix.  To remove this condi-
tion, it has been proposed to introduce a common
metallic bougie, of which there are various sizes,
from that of the  metallic probe upwards.  When
Dr. Mackintosh published the 4th edition  of his
Principles of Pathology and Practice of Physic,
he had  treated  twenty cases  by dilating the os
uteri, and had permanently cured eighteen.  After
that period he bad other successful cases ; for Dr.
Churchill (Diseases of Females, 2d Amer. edit. p.
80:  Philad.  1843) states  that he  had employed
dilatation in  27 cases,  and cured 24,  of whom 11
had since borne children.   The operation may be
performed—the patient lying on the left side—by
introducing the index finger of the left hand until
it reaches the os uteri, for the purpose of directing
the  instrument  to  the  part: it  is  then to be
gently insinuated, by  a  rotatory motion, until it
attains  the fundus  of the uterus.   Much force
ought not to be employed—and little or no  pain
is said to attend the operation.  That dysmenor-
rhoea—as the writer has  said elsewhere (Practice
of Medicine, 2d edit. ii. 395:  Philad. 1844)—may
be induced by this cause, can  scarcely be denied;
yet it is, doubtless, rare, inasmuch as such a condi-
tion of the organ would prevent the flow of the
menses   altogether :  and  yet, in many  cases of
dysmenorrhoea the discharge is more copious  than
usual.  It  has  been  properly suggested by Dr.
Ferguson (loc.  cit.), that the employment  of  a
bougie may operate beneficially by  inducing a new
action in the parts with which it came in contact,
and that this  may be the  salutary agency—not the
mere mechanical dilatation.!      ~,  T
                          J      C  Locock.
   DYSPEPSIA.  (See Lxoigestion.)
   DYSPHAGIA,  derived from  5«r, difficultly,
and ipdyta, to  swallow.   This term is applied to
express a difficulty or impossibility of swallowing.
When the extent and compound  nature of the
apparatus for deglutition is considered, it becomes
obvious  that this is a  symptom which may  arise
from  many and essentially different causes.  Thus,
all affections  of the mouth, tongue, and  pharynx,
all lesions of nutrition, circulation, or innervation
of the oesophagus, the  pressure of tumours on this
tube, &c.  will  give rise to  this distressing and
often fatal symptom.
   In the common acceptation of  the word, how-
ever, it is used  to express affections of the  oeso-
phagus  itself, either the result of  some morbid
condition of  the  part,  or of pressure  from  neigh-
bouring  tumours.  To these we shall principally
diiect our attention in this article;  first enume-
rating the principal causes of dysphagia that  have
hitherto been described.   These are
  1. Congenital  malformations  of the  mouth,
tongue, soft palate, pharynx, and  oesophagus.
  2. Disease of the mouth, tongue, and pharynx.
  3. Disease of the oesophagus.
  4. External and internal tumours pressing on
the oesophagus.
  5. Disease of the cardiac orifice.
  6. Affections of the larynx and epiglottis.
  The congenital malformations of the  mouth,
pharynx, and oesophagus, which would act in pro-
ducing  dysphagia,  are  principally  the  extreme
smallness of the tongue, the microglossia  of An-
dral, a state, according to this author, owing to an
arrest of development, and the consequent exist-
ence  of  the  hyoid portion only  of the  tongue.
Under these circumstances deglutition becomes
extremely  difficult,  and  several  individuals  so
affected have been obliged to introduce the fingers
in order to assist the process  by pushing the food
into the pharyx.   We are not aware of any case
of the opposite state (macroglossia) being known
to produce dysphagia.
   Adhesions of the tongue, either to the lower lip,
or to the inferior part  of the  mouth,  have been
sometimes observed ; indeed Andral considers that
state called tongue-tied,  to be merely a lesser de-
gree of this malformation.
   The  last  congenital  malformation connected
with the mouth is the  absence of its anterior ori-
fice ;  this is also to be looked on as an arrest of
development; for it  is  the  normal state  of the
mouth in the early periods of foetal life.
   The pharynx is occasionally irregularly deve-
loped, terminating in  a cul-de-sac, and presenting
partial dilatations and herniae of the internal mem-
brane  through the muscular fibres.  The exam-
ples of absence of the part, or its duplication, have
only occurred in monsters.
   The malformations of the oesophagus are stated
to be somewhat more numerous than those of the
pharynx. Thus, in some cases, the upper portion
terminates by a cul-de-sac, between which and the
stomach there is nothing but cellular membrane.
In other cases this is reversed,  the tube proceed-
ing  upwards  from the cardiac orifice for a few
inches, and there terminating.  In  a few instances
the oesophagus has been found reduced to a mere
cord, while in others the obliteration did not take
place till within a short distance from the cardiac
orifice.  (Andral.)  Other malformations are de-
scribed,  such  as its  division  into  two  canals;
(Blaes,  Obs.  Med. rarior; see  also Billard and
Michel;) its  obliteration  above  and  persistence
below forming a communication with the trachea,
(Martin,  Observateur  des  Sciences  Medicules,
1825.)
   In cases of congenital obliteration of the oeso-
phagus,  the  symptoms,  as observed in new-born
children,  are sudden  vomiting when any fluid is
attempted to be swallowed ; this vomiting  occur-
ring without effort, and  the ingesta  being thrown
up unaltered.   In a case of absence of the oesopha-
gus, (Journal Comp. D.'ct. des Sciences Med.)  thu
drink was ejected through  the nose ; and it would
appear that in some cases, as in stricture, a tumour
m;sy be observed in the neck previous to vomiting,
The children of course die of inanition.   In  the
case published  by Sir Astley Cooper, the infant
lived for eight days;  in  that  recorded  by Van 
                                     DYSPI

Cuych three days ; and in the example of oblite-
rature first alluded to, the child  lived eight days,
during which time the stools and  urine continued!
It is scarcely necessary to remark,  that in these
melancholy cases  we can do nothing but appease
the cravings of hunger by nutritive injections and
baths.
  This is not the place to describe  the various
fiffections of the  mouth and  pharynx, attended
with dysphagia, although they constitute the most
common  causes of dysphagia.   For information
on these subjects,  the reader is referred to the se-
veral articles in which  the  individual diseases of
the  Mouth, Phaiuxx, &c. are  particularly spo-
ken of
  The sources of  dysphagia arising from a morbid
condition of the oesophagus are, its acute or chro-
nic  inflammation,  the growth of fungous or
cancerous tumours from its  interior, spasm,  and
paralysis.
  Acute  inflammation of the oesophagus does not
seem  to be a common  disease in  the adult, the
tube at this period of life being but little excitable ;
but in the infant, according to  Billard, (Traite
des Maladies des  Enfans,)  it  is more frequently
met with, which perhaps is  owing to the state of
congestion in which  the mucous membranes are
often found after birth.  In fact,  oesophagitis may
be an intra-uterine  disease, as is  proved  by the
occurrence of follicular  ulceration  in the part, in
still-born children.  The prominent symptom of
this disease  in the new-born child is an imme-
diate vomiting when an attempt is made to swallow
fluids : this vomiting  is constant,  often  without
any apparent effort;  the milk  is thrown up un-
changed, and in several cases the usual symptoms
of gastric inflammation have not  been observed.
A remarkable case of this disease  is recorded by
Dr. Abercrombie,  in his work  on the Pathology
of the Digestive  System.   The  symptoms  were
fever and difficulty of swallowing;  the attempt to
swallow sometimes excited cough, and frequently
vomiting, with ejection of a soft membranous
substance.  This  disease we have never seen but
in one  case,  where  the  patient  died  of acute
phthisis,  and where there was difficulty of swal-
lowing and vomiting. Here, however, the pharynx
was affected.
  Much has been written on stricture of the oeso-
phagus, but the true pathology of the disease has
not as yet  been  sufficiently recognized.  There
can be little doubt that in  the great  majority of
cases it is the result of a chronic inflammation of
the whole or part of the tube, producing an hyper-
trophy of its different tunics, but  principally of the
sub-mucous cellular  tissue.  The  most  perfect
analogy exists  between it and the disease called
scirrhus of  the  pylorus and cardia, which is now
admitted  by the best pathologists to be the result
of a chronic inflammatory process.   The exciting
causes, and  the history of  the  various cases of
stricture of the oesophagus,  tend strongly to esta-
blish this opinion. Admitting this to  be the case,
we may hope to  relieve the disease in its  early
period, and at all  events we have a key to its
physiological  treatment even  in  its advanced
stages.
  The thickening is  sometimes general, but more
commonly  partial, and varies from  that which
AGIA.                                  731
 would slightly narrow the tube, to its  complete
 obliteration.  It is almost always progressive, but
 Dr. Good mentions a case where the morbid pro-
 cess appeared to have been arrested, after having
 produced such a narrowing of the tube, as to pre-
 vent voluntary deglutition :  this state continued
 for  twenty years, during which the  patient was
 supported by means of food introduced by a silver
 canula into the stomach.  But this is a very rare
 case ; almost every patient afflicted with this dis-
 ease must die a slow and painful death.  In  some
 instances ulcerations  have been met with  above
 or below the stricture, (Baillie,-) and in a few the
 semi-cartilaginous cellular tissue has become bony,
 as we see in other cases of  chronic  irritation  of
 this structure.   A dilatation often occurs imme-
 diately above the  obstruction, which is sometimes
 visible when the  patient attempts  to  swallow
 (Odier, Edin. Med. Comment, iii.)
   Vegetations and other morbid  growths  have
 been met with in  the oesophagus, where they pro-
 duce a great and  commonly fatal obstruction.  A
 remarkable case of this kind is detailed by Dr.
 Monro, in which, whenever  the patient retched, a
 large fleshy excrescence was thrown up into the
 mouth, reaching to the teeth.   On dissection this
 was found to  be a  polypus,  extending nearly
 through the whole course of the oesophagus.
   We have before stated that dysphagia arising
 from  a  morbid condition  of the oesophagus may
 generally  be  referred  to  chronic  inflammation,
 spasm, or paralysis; let us, before speaking  of the
 treatment of stricture, contrast  the symptoms ol
 these  different affections.
   1.  Chronic  Inflammation  or  Organij
 Stricture.—Invasion slow, the  obstruction at
 first slight, but gradually increasing.   Attempts to
 swallow often exciting great  pain along the course
 of the tube to the  base of the skull.  Fluids more
 easily swallowed than solids in the advanced stages.
 Salivation, cough, hectic, and ejection of purulent
 matter—duration  of the disease considerable.  Ex-
 citing causes—irritations of  mucous membranes.
   2. Active  Neurosis, or Spasmodic Stric-
 ture.— Invasion  sudden, accompanied with a
 sense of constriction in the throat,  and pain, even
 when  the patient does not attempt  to swallow.
 Disappearance often sudden—occasional relaxation
 by the use of the probang;  relief  from antispas-
 modic medicines; absence of hectic and signs of
 ulceration ; exciting cause often  mental emotion ;
 occurring in nervous, irritable, hysteric, and melan-
 choly persons.
   3. Passive Neurosis, or Paralysis of the
 (Esophagus, may arise from disease of thu cerc-
 bro-spinal axis, or occur independently of it.   Sud-
 den loss of the power of swallowing without the
 symptoms  of spasm.   No  obstruction  found  by
 tbe probang.   Cure by electricity.
   Before speaking of the treatment of these spe-
 cies of dysphagia, we must remark that the  spas-
 modic stricture may, from its violence or frequent
 occurrence, cause organic disease of  the tube, by
 the injury done to the circu ation and innervation
 of the part.  In  this way a  spasmodic may pass
 into an organic  affection, as ileus  may  pass into
 enteritis. This fact must always be borne in  mind
 in the treatment of a case of spasmodic dvsphagia.
I   The  treatment  of  organic stricture  lias  been 
732
DYSPHAGI A—DYSPNCE A,
hitherto nearly empirical.  In its early stage, when
any chance exists of effecting a cure, time is often
lost by the  exhibition of useless  nostrums; and
great injury done by using bougies, when the part
is in a state  of acute irritation.  In  such a case,
every thing that can irritate or excite the  part
should  be  most carefully  avoided;  the  lancet
should be used, and leeches  boldly and repeatedly
applied to the neck.  These means should be fol-
lowed by counter-irritation;  and it is possible also
that the use of mercury might assist in the re-
moval  of the disease.  Indeed, we have a decided
example of its efficacy in a case related  by Dr.
Munkley, (Medical Transactions, vol. i.) where
in a very unpromising case, a  perfect cure was
effected by the use of this  medicine.  (See also
Rush, Inquiries and Observations: Dobson, Medi-
cal Observations and Inquiries, vol. vi.)
   In the advanced  cases,  advantage  has occasion-
ally been obtained from the  use of the bougie, and
the exhibition of hemlock.  In such cases a seton
would  probably be useful,  and the  diet  of the
patient must be spare and unirritating.
   The treatment  of the  second species must be
"that of spasmodic affections  generally.  It is often
connected with deranged bowels, in which cases
the judicious use of purgatives, followed by nervous
and tonic remedies, will be advantageous. During
the spasm antispasmodics  may be given.  A patient
thus affected should  avoid  all debilitating causes,
tbe use of  very  hot or cold  drinks, and sudden
changes of temperature.   Constant exercise in the
open air seems to be the best preventive.
   It is obvious that the treatment of the passive
neurosis, or paralysis of the tube, will depend on
the presence or absence of  organic disease in the
brain  or spinal marrow.  If such should  not  be
present, the best remedy  appears to  be electricity,
of the good effects  of which several examples are
recorded in Dr. Monro's learned  work.  In one
case the patient could only swallow when seated
on the electric stool.  This  affection seems gene-
rally to be curable.
   The pressure of tumours exterior to the  oeso-
phagus is not an unfrequent cause of dysphagia.
They  may be  enumerated  as  follows:  1. Aneu-
risms of the aorta.   2.  Enlargement of the bron-
chial glands.  3. Encephaloid  tumours growing
from the posterior mediastinum.  4.  Enlargement
of the cervical vertebra.  5. Abscess in the neck.
And, 6. Bronchocele.  The diagnosis of most of
these affections is difficult.  In the case of aneu-
rism of the aorta, the disease has more than once
been mistaken for stricture of the oesophagus; and
in one  instance the tumour was ruptured by the
incautious use of  the probang.   (Abercrombie.)
A very remarkable case  of encephaloid tumour,
producing dysphagia and  symptoms of phthisis, is
detailed in  the Dub. Hos. Reports, vol. v., in the
report of the Meath Hospital.
   The last  cause  of dysphagia which we  shall
notice, is the existence of disease in the larynx and
epiglottis.   On this subject  much useful informa-
tion may be obtained  from the work of Louis,
(Recherches sur la Phthisic)  It  is  obvious that
any state of the larynx  which causes pain or diffi-
culty in its  movements  during deglutition, must
 oe a cause of dysphagia, and there are cases where
 'liis is the  prominent  symptom.  Destruction of
the epiglottis, or its tumefaction from  cedema, will
give rise  to the  same  symptom  from different
causes.   Of the last source of dysphagia, two most
interesting examples have occurred lately  to our-
selves.  In both patients  there was great  cedema
of the neck, and in the cellular membrane  in  the
neighbourhood of the parotids,  and the epiglottis
was so swollen as  to form a large tumour prevent-
ing deglutition.  In such  cases tbe drink is dis-
charged through the nose.   Free puncturing with
a lancet might prove serviceable in this affection,

                          William Stokes.

   DYSPNCE A.  Difficult or disordered  breath-
ing.  This term,  which  is  generally applied  to
those derangements  of the respiratory function
which interfere  in a sensible manner  with  its per-
formance,  would  not be  inapplicable  to  all  in-
stances of defect in this important process.  Al-
though in many instances only a symptom, dys-
pnoea  is  one of such  importance, that it often
becomes  a principal  object  of  treatment, as it
constitutes the  chief danger of  the disease.  For
this reason it is  important to examine more  closely
into its  nature, and to distinguish  between its
several causes.
   The muscular act of inspiration is excited by a
sensation arising from the presence of black blood
in  the lungs.   This act, in the natural state of
the function, removes the  sensation by supplying
air, which converts the venous into arterial blood.
But a variety  of causes,  presently  to be consi-
dered, may impede or  interrupt this conversion,
and then the sensation becomes more or less per-
ceptible and painful, and excites exertions of the
respiratory forces,  increased  in  extent and fre-
quency,  to relieve it.  These may prove  so  far
effectual as to supply the  defect and remove the
sensation of oppression ;  then there  is  hurried
breathing rather than actual dyspnoea;  but when,
as is frequently the case, these supplementary ex-
ertions are insufficient  to  effect the due arteriali-
zation of the blood, it accumulates in  the branches
of the pulmonary artery and  veins, and occasions
the most oppressive and distressing sensations.  A
person suffering from them complains of  an op-
pression on  his chest,  and cannot bear even the
weight of  the bed-clothes  .- he feels the room too
small, and begs to have the windows opened ; he
is restless, and endeavours to find relief by sitting
up; however great his courage, he  is depressed
and becomes alarmed by  a feeling of impending
suffocation.  The semi-erect posture, by  permit-
ting a more extensive dilatation of the chest, often
gives some relief;  and to this degree of dyspnoea,
obliging the patient to sit up, the term orlhopnxa
has been applied.
   As the elements or principal parts concerned in
the function  of  respiration are three, namely, the
blood, the respiratory machine, and the  air,  the
causes of  dyspnoea may arise  from changes  in
any of these.   As the  peculiar condition  of the
blood which is called  venous is  the  immediate
cause of the sensation  of  dyspnoea, so the blood
being (if we  may use the expression) more  venous
than  usual, may give rise to the feeling of dys-
pnoea, without any derangement of the respiratory
apparatus.  Of this nature is the dyspnoea  arising
from violent exercise, which ceases as soon as tbe 
DYSPNCE A.
733
 flow of venous blood to the lungs becomes mode-
 rated by rest.   Whether other processes, such as
 increased secretions, the  digestion  of blood, &c.
 be capable of  producing the like effect, that is, of
 so changing the  blood, that although the respira-
 tion be healthy,  this fluid  is not arterialized with
 sufficient rapidity to prevent  the feeling of dys-
 pnoea, is uncertain ;  but the  stethoscope teaches
 us that the function of respiration is more active
 in some  individuals  than in others, and that there
 is also a difference in the  same individual at dif-
 ferent times.   Laennec ascribed certain cases of
 habitual dyspnoea, in which the sound of respira-
 tion was even more  distinct than  usual, to an in-
 creased  necessity of breathing,  (besoin  de re-
 spirer;) and  although we should  scarcely admit
 his  instances  (chronic bronchitis) to be cases in
 point, we think such a cause of dyspnoea to be in
 accordance with  the pathological  view which we
 have given.  It seldom happens that persons with
 lungs in  healthy action can exhibit such a state,
 the  relative power  of the organs  being  greater
 than the  supposed increased  demand :  but those
 whose lungs are defective in  consequence of dis-
 ease, although not usually suffering from the de-
 fect, do certainly  experience dyspnoea after taking
 food, and at other times, in a  manner  that will
 well admit of  this explanation.  It is through the
 blood, rather than in any other way, that diseases
 of the heart sometimes give rise to dyspnoea ; any
 impediment to the pulmonary circulation causing
 an imperfection in the oxygenating  process.
   The  following are the derangements of the re-
 spiratory function that may occasion dyspnoea :—
 1. derangements that interfere with the respiratory
 movements ; 2. derangements  that obstruct the
 passage of air to  and from the pulmonary cells;
 3. derangements in the pulmonary tissue that ob-
 struct the action of the air on the blood.
   1. The first of these, namely, those that inter-
 fere with the respiratory movements, are  of two
 kinds; a. derangements of the  mechanism of re-
 spiration, including spasm, paralysis, weakness or
 pain of the intercostal  muscles, diaphragm,  and
 other muscles concerned  in respiration  ; rigidity
 or ossification  of the cartilages or  ligaments of
 the  ribs, pain or rigidity of the pleura, and dis-
 tortions of  the spine or ribs : b.  derangements
 external to the respiratory machine, but interfering
 with its movements, as pregnancy, abdominal tu-
 mours, and acute pain of the peritoneal  coverings.
 Of these causes, spasm and paralysis of the respi-
 ratory muscles are the most important.  In tetanus,
 and  in paralysis resulting from  severe injuries of
 the brain and  spinal marrow,  or  from narcotic
 poisons, the dyspnoea thus produced is  generally
 the immediate cause of death.   In typhus fevers
 and  other  complaints of  the  extreme  adynamic
 kind, dyspnoea  arises from absolute weakness of
 the respiratory muscles;  and hence the utility of
 stimulants.  In other instances of fever,  in which
 the brain is severely affected, the breathing is often
 hurried—in  such cases the affection of the respi-
 ration depends on the condition  of the brain and
 nervous system.  Acute pain,  whether in the tho-
 rax or abdomen, frequently produces an  apparent
dyspnoea,  by rendering the full exercise  of  the
organs of respiration intolerable. This especially
occurs in pleurodyne, and in some cases of pleu-
ritis and  diaphragmitis.   Ossification, rigidity, or
distortion of the thoracic parietes, and the pres-
sure of abdominal  tumours, do not often occur to
a degree sufficient  in themselves to produce dys-
pnoea ; but by curtailing the sphere of the func-
tion, their presence may convert any trivial attack
on  it,  by  bronchitis or  other cause, into one of a
serious nature.
   2. The second division of this class of causes
of dyspnoea, those that obstruct the  passage  of
air to and from  the pulmonary cells, may properly
be divided into, a. obstructions of the air-tubes,
and, b. compression  of the  lung.  Obstructions
of the air-tubes may proceed from the state of the
lining  of the tubes themselves, from matters effused
in them,  or from  tumours  pressing upon them.
Tumefaction of the mucous membrane of the tra-
chea  and  bronchi, whether proceeding from in-
flammation, congestion, or oedema, and spasmodic
constriction of the muscular fibres  of the glottis
and bronchi,  are the derangements of the tubes
themselves which not unfrequently occasion dys-
pnoea.   Effusions in the air-tubes are the causes
of dyspnoea in  many diseases; and they may be
either  a redundancy of the  ordinary secretion  of
mucus, as  in  slight inflammation, or of  a  new
character,  as coagulable lymph in plastic inflam-
mation ; pus,  serum, and pituita in  the various
degrees of bronchitis and catarrh;  blood in bron-
chial hemorrhage and  pulmonary  apoplexy ; tu-
bercular and other  matters from  phthisical exca-
vations, &c.  Compression  of the lung, by  effu-
sion into  the sacs of the pleura? and pericardium,
whether of air,  as in pneumothorax ; or of liquid,
as  in  pleurisy, hydrothorax, and  dropsy  of the
pericardium;  and  by "tumours in the thorax; is
the  other  cause of dyspnoea which operates by
obstructing the passage of air to and from the pul-
monary cells.
   3. The last class of derangements of the respi-
ratory  function  that become  causes of dyspnoea,
are diseases in  the pulmonary tissue  itself, ob-
structing  the due action of the air  on the blood.
Such are, a. the obliteration  and filling up  of the
cells by effusion,  of lymph,  serum,  and  pus in
peripneumony ; of blood in pulmonary apoplexy;
of serum  in pulmonary cedema;  and of tubercu-
lar matter in phthisis : b. an alteration in the con-
dition  of  the membranes forming and lining these
cells or vesicles; such as, the thickening and in-
creased rigidity of the tunics of enlarged cells in
pulmonary emphysema; and we  conceive that an
altered state  of the  lining  mucus, the  natural .
function of which  when healthy is  to facilitate
the transfer of  oxygen to  the blood, is another
cause  which  may  give  rise to  dyspnoea.  We
have before noticed an excessive quantity of this
mucus  as  a cause  of obstruction to the passage
of the  air to and fro in the air-tubes, but we here
suppose such  a change  in its chemical qualify
as would  deprive  the  function of its  aid.  Thu
bronchial  secretion  has been proved by late expe-
riments to be  much under  the influence  of the
nervous system, and those cases of what is called
nervous dyspnoea,  in  which signs  of bronchial
spasm  are absent, and  the  sound  tf respiration
distinct and even  puerile, are probably referable
to the last-named cause.
  Besides in the blood, and in the organs  of  res 
734
DYSPNCEA —DYSURIA
piration, dyspnoea may sometimes have its  cause
in the  third element  of the  respiratory  process,
the air.  A deficiency  of oxygen is, perhaps, the
only state  of the air that can  directly occasion
the feeling of dyspnoea ; for carbonic acid, carbu-
retted hydrogen,  and other noxious gases, when
in considerable quantity, do so rather by  exciting
spasm or some other derangement of the respira-
tory apparatus.  The stertorous breathing of those
who have been exposed  to the fumes  of  burning
charcoal is also  an  indirect  effect,  and proceeds
from the poisonous  agency of the evolved gases
on the  nervous system.  Although  a defective
proportion of oxygen in the air may contribute to
the oppression  which some persons  of low  respi-
ratory powers experience in crowded rooms, other
causes, such as heat, noxious  animal effluvia, &c,
have at least an equal  share in  exciting it.  The
dyspnoea felt at  great  altitudes, where the atmo-
sphere  is  exceedingly rare, may with  more fair-
ness be attributed to the cause in question.
   When  a case of dyspnoea  presents  itself, it
must be of great  importance  to  discover from
which  of  these  several causes  it  arises;  which
we can never do with certainty without an exam-
ination  of the  physical  signs.   These will sup-
ply tbe desired information by positive indications
in the  case of organic disease  within the  chest,
whether effecting the  bronchi or the pulmonary
tissue; and in  the  other cases  enumerated, aus-
cultation will give such negative signs, as will in
the  greater number of instances, in conjunction
with the general symptoms, lead to  an estimation
 of the  true nature of the cause.   For the charac-
 teristic signs of  the diseases mentioned as  causes
 of dyspnoea, we refer  to  their several articles  re-
 spectively.
   We have cited, however,  one instance  of  the
 production of dyspnoea, in   which, if it be  not
 idiopathic, the  symptom is  not referable to  any
 distinct disease.  We allude to  the  case  of in-
 creased want  of breath,—" besoin de respirer,"
 as Laennec has termed it,—and which  we have
 referred to the venous condition  of  the blood  in-
 creased beyond its natural standard. Such a dys-
 pnoea can be detected  only by the absence  of  the
 signs of every other  cause: where,  therefore, a
 dyspnoea occurs, whilst pure  air is found to pene-
 trate freely into  every part of the lungs, and  the
 diseases which modify the state of the bronchial
 membrane and its secretion have not  existed, the
 disorder must  be necessarily referred  to  an unu-
. sually  venous or carbonized state  of the blood.
 If we  attempt to rise one link higher in the chain
 of causes, we shall find that physiology  reveals
 to us only one probable mode in which this state
 is itself produced ; and that is, by an excessive
 formation of those  secretions which are, in rela-
 tion to the blood, defective  in  carbon.  Such is
 urea, a predominant principle in the urine. From
 its  formation, principally, the  carbonic  acid  ex-
 haled from the lungs is supplied, and if  we as-
 sume  the possibility of deviation from the healthy
 proportion of this supply, we enter  on ground less
 sanctioned by experience than by analogy.   We
 conclude  this subject with the remark, that the
 medicines which Laennec commended as capable
 of  diminishing  the " besoin de respirer,"  (bella-
 donna, stramonium, conium, &c.,)  if they act as
narcotics, deadening  tbe sensation of dyspnoea,
would not be eligible; but  if they act, as is not
improbable, by  diminishing  the secretions which
render the blood venous, then  they really would
relieve the  function, and not  merely stifle the
symptom.               Q  j  R  WlLLUMg

   DYSURIA  (from  Sis, xgre,  and olpov, urina.)
Dysuria, or difficulty in voiding  the  urine, is a
symptom of many different diseases, and  arises
under a variety of circumstance.  Although only
a  symptom, it  well merits  careful consideration,
from the suffering which  it occasions, and the
serious consequences to which it often speedily
leads.
   Dysuria exists in every degree,  from the slight-
est to the most intense, when the  difficulty termi-
nates in a total inability to expel the urine.  The
consideration  of  the subject  in  this  extended
sense will  lead us to treat of retention of urine,
which, though peculiarly the province of the sur-
geon, is  an object of  deep interest to the practical
physician.
   Dysury is often attended with  smarting pain;
sometimes the  pain is lancinating or shooting, at
other times it is accompanied by the most distress-
ing efforts to  expel  tbe contents of the  bladder,
such as have been described in  the article Calcu-
lus.  Pain, however, is not a necessary  accom-
paniment of dysury ; thus, the imperfection  with
which men  advancing  in life  discharge  the last
drops of urine, although wholly unattended  with
pain, is  a true dysury, though  in  almost all those
cases where the expulsion of the urine is prevented
by a deficient  power in  the muscular coat of the
bladder, there  is no pain.  In  such  instances, as
the difficulty of discharging the  contents of that
organ increases, no urine escaping, or only a small
quantity constantly dribbling away, the urine gra-
dually accumulates and  produces distension of the
bladder.  If the progress of the disease has been
slow, and  the  patient is not of an inflammatory
habit, the bladder sometimes acquires a size al
most  incredible.   It expands  in all  directions,
pressing  downwards, backwards, and laterally,
filling all the pelvis not  occupied by fixed viscera,
and forcing behind  and above it those  that are
moveable.  Under such  circumstances the bladder
has risen to the umbilicus, or even higher, push-
ing up the adjacent  organs  upon  the diaphragm,
and  thus impeding respiration.  Such enormous
distension has  occurred chiefly in females, in whom
the bladder is  much less irritable than in  men;
and  the quantity  of urine  evacuated  by  the ca-
 theter in these cases  has sometimes amounted to
 twelve quarts.  Instances,  indeed, are recorded
 where it is said to have  been more than five times
 as great; but  in all probability  many of these ex-
 traordinary histories  have originated in mistake or
 exaggeration.  Frank relates a case in which forty
 quarts of urine  were found  in the  bladder after
 death.  (J. P. Frank, De curand. hom. morb. Re-
 tentio urinae.)  To allow of such expansion  of the
 bladder, its coats must be healthy and pliant, which
 in many instances of urinary disease  is far from
 being the case.  When this organ is indurated
 and contracted,  a  comparatively small accumula
 tion of urine may prove fatal.
    The fluid descendirg through the ureters find- 
DYSURIA.
735
ing a resistance to its entrance into the bladder,
fills and dilates those tubes, and at length produces
the  same effect on the cavities of the  kidneys.
The pressure thus caused on them diminishes or
wholly arrests their secretion, while the absorbent
vessels carry a part of the urine into the circulat-
ing mass.  The perspiration, which now becomes
profuse,  has a  strongly urinous  smell,  and  the
taste of urine has  even been perceived in  the
rRouth. (Heberden, Comment, de Morbis.)  Under
such circumstances inflammation of the distended
viscera speedily takes place ; and  if no relief be
obtained, the urine escapes by a gangrenous aper-
ture in the bladder or urethra,  into the surround-
ing cellular substance, or into the peritoneal cavity.
The extent to which the urine is diffused in  tbe
cellular  membrane is often  extraordinary, some-
times reaching as high as the  soft parts covering
the chest.  When the urethra has given way be-
hind a  stricture,  the  scrotum  is usually swollen
enormously by the acrid fluid,  which strikes with
gangrene whatever it  touches:  at other times, the
only visible  indication of what has happened  is a
dark sphacelated  ring surrounding  the orifice of
the urethra.
   Retention of urine, when accompanied by  in-
flammation,  is always productive of great consti-
 tutional disturbance : the skin is  hot; the pulse
rapid;  the thirst  urgent;  the tongue speedily  co-
vered by a dark crust, and great anxiety and rest-
lessness prevail.  Vomiting, hiccup, and extreme
tenderness of the abdomen  indicate the  commu-
nication of disease to  the peritoneum;  low deli-
rium comes  on, and the patient dies comatose or
convulsed.
   We can in general depend on the report of the
patient as to the existence of difficulty in expelling
the urine; but it  often requires a very careful ex-
amination, before  we can ascertain the true state
of the bladder.  The urine may flow with pain,
or dribble away insensibly, or the patient may feel
not the slightest  inclination to discharge it;  yet
under all these circumstances the bladder may  be-
come disturbed to such a  degree that  the most
dangerous consequences result  from neglecting to
relieve it.   Distension of the bladder can seldom
be mistaken, if the finger be applied to  its lower
fundus  through the  rectum or vagina, while  the
other hand  is  laid upon the  hypogastrium ; in
general  a distinct undulation of the  fluid may be
produced by this method.  All  doubt,  however,
will be  removed  by calling in surgical  aid,  and
having  the  catheter  introduced.  Some striking
instances are  recorded, where the  bladder in a
state of excessive distension has  been  mistaken
for a collection of purulent  matter, or  for abdomi-
nal dropsy,  or ovarian  tumour; and  proposals
have been made for the evacuation of  the fluid by
tapping.
  Causes.—The circumstances which  interfere
with a due  performance  of the excretion of  the
urine are very numerous.   Dysury may arise from
the acrimony of the urine irritating the  passages
through which it is  forced, and increasing their
natural sensibility; thus, both  alkaline urine  and
that which contains  an excess of acid, have  this
effect.   Difficulty in  voiding  the urine is  also
occasioned by an  irritated or inflamed condition of
the urinary organs, or of the  adjacent and asso-
ciated  parts;  by  which  the healthy  sympathy
between  the muscles  which retain,  and  those
which  expel the urine, is disturbed or destroyed.
Thus, dysury exists in gonorrhoea;  with inflamed
prostate gland;  with urinary calculus  in any of
the tubes or cavities, provided it occasion irrita-
tion ;  it also exists in cystitis; in inflamed ureter;
in nephritis; and with inflamed hemorrhoids; in-
flammation  of the rectum, and irritation of it from
worms, or from the tenesmus of dysentery.   The
dysuria which  accompanies  this  last disease is
often productive of great  distress, and has in  our
own experience  sometimes occasioned retention,
requiring the warm bath, and even the catheter.
Dysuria also occurs  in the painter's colic, from a
sympathy between  the bladder and the intestines
in their state of spasmodic irritation.  The irrita-
tions  and inflamed conditions  of the vagina  and
uterus produce dysuria: thus it is met with in the
newly-married;  in cases of gonorrhoea in females;
in the early period of pregnancy, and as a warning
symptom in  approaching abortion.   Dysuria  is
likewise a principal symptom of the warty excres-
cence which occasionally forms at the orifice of the
female urethra.  ( Clarke,  Diseases of Females.)
   A frequent cause of dysury, and  of its more ag-
gravated form, strangury, is the internal  exhibi-
tion of cantharides, and their external application
in  the form of  blisters and  issues: we have  also
known vesication from scalding water  produce the
same symptom; but this sympathetic effect is of
rare occurrence.  Other substances, of a  much
milder nature than cantharides, are productive ol
irritation  of the urinary organs when taken in
excess: thus Rhenish  wine and new beer have
been  known to  occasion dysuria;  and the latter
is considered by continental  writers as no  unfre-
quent cause of puriform discharge from the urethra.
Increased secretion of urine, as in diabetes, and
from the operation of diuretics, is  often attended
with  pain and  difficulty in voiding it.  In some
individuals asparagus is productive of much urinary
irritation; but we have never observed this effect
from  gooseberries, which are  more  powerfully
diuretic than many drugs referred  to this class in
the Materia Medica.
   Dysuria  sometimes  exists, as a mere nervous
affection, in connection with hysteria;  and  some-
times it arises from neuralgia of the bladder.  The
influence of dentition, which is so often manifested
in  disorder  of the digestive organs, is occasionally
extended to the urinary apparatus.  This affection
is also produced by everything which mechanically
obstructs the discharge of urine:  thus, strictures
of the urethra or prepuce;  enlargement of the
prostate gland; varicose veins at the neck ot the
bladder; polypous or fungous growths of its inter-
nal lining;  introsusception of the bladder, (Aubin,
Pathologia  Externa, t. ii.)  the  intestines falling
into the cavity so produced;  projecting folds of the
mucous membrane — are all occasional causes of
dysury.   It may also originate from calculi in any
of the urinary  passages, from the kidney down-
wards ; from hydatids; coagula  of blood; inspis-
sated  mucus;  false membranes  or  laminae  of
coagulated  albumen plugging the ureter or urethra.
Morgagni (De Sedibus, &c.   Epist. 41, sect.  13.)
and others have given accounts  of  such mem-
branes, found in the bladder  or urethra, or expelled 
736
DYSURIA.
with the urine; but cases are also .ecorded which
serve to support the idea that part of the internal
surface of the bladder is sometimes thrown off and
discharged by  the urethra.*
  Through the kindness of  Dr. Weir, a remarka-
ble  case of this nature  fell  under our observation
some years ago.  A  female,  who was delivered by
the forceps, after the head of  the child had  been
arrested  for twelve  hours,  had, two days after-
wards, an  inflammatory attack  with pain  in the
hypogastrium.   Incontinence  of urine followed;
several  small  sloughs  came  away, and one was
extracted  from the  meatus.  About three weeks
from delivery, retention  of  urine took place, and,
after many hours, a  large slough was forced  off
suddenly  with a gush of urine, which continued
to flow  to the extent of two quarts.   On carefully
examining the slough, it was found to consist of a
thin membrane without any perforation, six inches
in length by four in breadth.   One of its surfaces
was granulated, rough with earthy particles, and
stained with blood of a brown colour; the  other
presented  the  appearance  of cellular membrane,
with small flattened masses of what looked like
adipose  tissue.  It  was very extensible, and on
minute inspection an appearance of muscular fibres
could be traced within  its  substance. That  the
bladder had in this case Fuffered a very  severe
injury was obvious: for the  urine, for some time
before  and for a considerable time after the dis-
charge  of the  slough, was  mixed  with blood, and
deposited  much purulent mucus:  there was also
at  one period a phosphatic deposit  from the urine,
and two minute spongy calculi were voided.   No
 opening could be detected between the vagina and
 bladder;  and after the slough  had been discharged,
 six or seven ounces of urine were  from time to
 time voided in a stream.
    The obstruction  producing  dysuria is  some-
 times  dependent on a change in  the position of
 the bladder, as in hernia of that organ, and in pro-
 lapsus  of tbe  rectum or uterus.
    Ruysch gives a very curious case of complete
 prolapsus of the uterus, accompanied by the most
 excruciating  urinary sufferings, in which he cut
 into the  front of the prolapsed tumour, and ex-
 tracted  several calculi with a  successful  result.
 (Obserb. Anat. Chirurg. Ob. 1.)
    On other occasions the  cause of obstruction to
 the flow  of the urine lies exterior to the bladder
 and urethra;  as when it arises from ligatures round
 the penis, swelling of the prepuce,  aneurism of
 the corpora cavernosa, abscesses  in the vicinity,
 carcinomatous indurations,  tumours  within  tbe
 pelvis, the gravid uterus,  retroverted uterus, the
 menstrual fluid collected  behind  an  imperforate
 hymen, fmces or other hard  substances lodged in
 the rectum.
    Inability to void the urine sometimes arises from
 rupture of the bladder, which may either be com-
 plete, or involve only the  mucous  and muscular
  * Rohaut,  Memoires  Acad.  Roy. des Sciences, 1714
(The membrane  had  distinct blood-vessels — a  male.)
Koch, Haller Disjmtal. Medic, t. i v. (A female after abor-
tion )  Ruysrh, Adversar. Anat. Dec. ii. n. 9.  (A female
after parturition.)  IVillis, De Urinis, cap. v.  (A female
suffering under calculus.)  Fahner, Beytrage zur practis
ch"n unci ucrichilichi'ii arzney kiinde, b. i. n. v. Guisard.
ditique de Chirurgie.
tunics.  The sudden occurrence of pain in the re-
gion of the bladder, and incapacity to expel the
urine after the reception of an injury, the absence
of tumour of the bladder when examined  through
the rectum or vagina, and the scanty discharge of
jets of bloody urine by the catheter, will  in gene-
ral  point out the real nature of the accident.  It is
to be observed in relation to the diagnosis, that
although the bladder have been  ruptured, there js
often circumscribed tumour in the hypogastric re-
gion.  In an instance of ruptured bladder which
occurred in our practice some years ago, a urinary
abscess which pointed in the hypogastrium was
punctured on the twelfth day after the accident,
and the  patient survived till the twentieth.  On
inspection, the small  intestines were found glued
together, and to the abdominal peritoneum, by an
albumineus exudation; and thus a partition was
formed between the upper and  lower portions of
the abdominal cavity, which  stretched across in an
arched form a little below the navel.  The lower
cavity, which was of great extent, and communi-
cated  under the left  Poupart's  ligament with  a
sinus  passing  for several inches down the thigh,
was more than half filled with  putrid urine, pus,
flakes of albumen, and  liquid fseces; for the intes-
tines had given way in several places.  The blad-
der was seen  lying collapsed in its natural situa-
tion, and presented posteriorly, on the left side of
its upper  fundus, a rounded opening  about  two
inches in diameter.   The peritoneal coat was ex-
tensively separated at  this  point, and  its edges
hung loose in  flocculent shreds.  It is  probable
that in this case only the mucous and  muscular
tunics were at first ruptured, and its long duration
afforded some slender hope  of a favourable termi-
nation : the only chance of success was from an
early puncture of the hypogastric tumour, which
we proposed in the second  day after the  accident,
 but it was overruled in  consultation.
    Dysury often originates  in a want of power in
the muscles which expel the urine.  The muscu-
 lar fibres of the bladder, if long kept on the stretch,
 gradually  lose more and more of their contractile
 force, and at length become  wholly  paralysed. In-
 stances of this description are of daily occurrence,
 when individuals have been prevented from empty-
 ing the bladder by delicacy, or by the absorbing
 engagements of business or pleasure.  The pres-
 sure of the child's head in the latter  stages of
 parturition often keeps the urine pent  up, and
 thus induces inability to expel it after the obstacle
 is  removed.  The same loss of power in the fibres
 of the bladder,  though in a much more dangerous
 form, arises from affections of the brain and spinal
 cord, and from pressure and disorganization of the
 nerves which  supply  the  bladder : in  this  way
 difficulty of voiding the urine occurs in  fevers, in
 extravasations  and effusions within the cranium,
 in pressure from fractures of the bones, and in in-
 juries and chronic diseases  of the spinal  cord.
    Among the causes  of dysuria, there is none
 more familiar to common observation than the ex-
 posure of the body to cold.  It acts by producing
 a  contraction of the urethra, more especially in
 men, disturbs and destroys the natural consent of
 parts, and in the end induces a  torpor of the blad-
 der.  Wherever a predisposition to dysury exists
 from mechanical obstruction  or otherwise, the 
DYSURIA.
737
action  of cold  becomes an  immediate exciting
cause.
  Treatment.—In attempting the treatment of
cases of difficulty or inability of voiding the urine,
our first object ought to be to ascertain the cause
from which  it proceeds, and,  if possible, to  re-
move that which has occasioned the symptom : if
we succeed in accomplishing  this, the dysury in a
great majority of cases will cease.   In every  in-
stance  of this affection it is of especial importance
to discover  how far it is connected with  an  in-
flammatory or plethoric condition of the body, or
of the  urinary organs in particular;  and should it
be so,  to have speedy recourse to bloodletting and
leeches.  When dysury occurs during pregnancy,
or  is  symptomatic of approaching  abortion,  tbe
adoption of this practice will generally be required.
   When the affection is of a  spasmodic character,
or  accompanied by pain or  irritation, the warm-
bath,  warm  applications  of various  kinds,  and
opiates by the mouth, friction, or enema, will be
found  of the  greatest utility.  The last of these
remedies is particularly serviceable in that form of
dysury which is caused by the  application  of can-
tharides.  In  many cases of dysury, even where it
depends  on a  certain degree of mechanical ob-
struction, the operation of  a  smart  purgative has
produced immediate relief; and in every instance
it is a  safe rule to  unload  the  bowels as speedily
as possible, for by this means we relieve the neck
of  the bladder  from pressure, and  promote the
healthy sympathy  of the  parts.  In dysury  and
retention of urine  of a spasmodic  character, the
tincture of the muriate of iron, in small repeated
doses,  has proved a valuable remedy in the hands
of the  late Mr. Cline and  many others.  The sud-
den effusion of cold water  on the genitals  and
neighbouring parts has sometimes procured a flow
of urine when all other methods have failed, partly,
perhaps,  by causing a relaxation of  spasm, but
chiefly by rousing  the contractile powers of the
bladder.  But  when the vigour of  this organ is
actually impaired, we must have recourse to sti-
muli of far more effective and  permanent opera-
tion.   Blisters to the loins and sacrum, the forma-
tion of eschars  by  moxa  or potassa, and the cau-
tious exhibition of cantharides, are  the remedies
which  will be found of most avail.
  When dysuria appears to be connected with the
scanty  secretion or  acrimonious quality  of the
urine,  diluents are  to be given freely, along with
such mild diuretics as the  spiritus anheris nitrici,
spirit of juniper, decoction  of the fibrous roots of
the leek, liquor potassae  with hyoscyamus, bicar-
bonate  of soda, or Seltzer water. Stronger diuretics
are in  severe cases  given with advantage, such as
the parsley breakstone (alchemilla arvensis), seeds
of the  wild carrot (daucus sylvestris), and the oil
of turpentine.   Dysury from alkaline urine must
be treated on the plan  already laid  down in the
article  Calculus.
  Should inability to void  the urine have arisen
from long  voluntary retention of it,  the  patient
ought  to immerse  his  feet in  warm water, and,
placing the  penis  in a basin of the  same, make
gentle  pressure  on  the hypogastrium, and endea-
vour to evacuate the bladder, when he will often
succeed without any farther assistance.  The im-
mersion of the penis in warm water rarely  fails to
  Vol. I. —93
give great relief in the  painful micturition which
attends gonorrhoea.  When difficulty  of  voiding
the urine occurs, as it very often  does, after partu-
rition, the simple expedient of making pressure on
the hypogastrium  with a warm  sponge will not
unfrequently save the  patient from the necessity
of having  the urine drawn off by the catheter.
But to this instrument  we must  have recourse in
very many cases of retention of urine ; and it is
fortunate that the  surgeon  possesses  in it  the
means of removing a symptom which  is  at once
most distressing and dangerous.  The catheter,
however, is  not  always successfully employed,
even by  surgeons of acknowledged eminence and
dexterity; and it then becomes a question how the
danger can best be averted.  If the symptoms are
not urgent, a little delay may still be  allowed, to
give a farther trial to tbe most  important of the
remedies already enumerated, and to  the well-
directed  employment of sounds  and catgut bou-
gies ; but we must on no account wait so long as
to incur  the  slightest risk of gangrene or rupture
of the bladder.   The only means  now remaining
by which the life of the patient can be saved, is,
to  puncture  the bladder,  or open  the  urethra
behind the obstruction,  should such be the nature
of the case.  This, however, is in the province of
the surgeon, and therefore foreign to <he nature
of our work.
W.  Cumin.
   [EAR, DISEASES OF THE.  (See Otalgia
and Otitis.)]
   ECTHYMA, (from Ik, ex, and §<iuv, fervere,) a
disease of the skin, characterised  by an eruption
of phlyzacious  pustules,  neither  contagious  nor
infectious.
   Synonymes.—Tippivdoc vel OiputvBos,* et imwic-
ris,-f (Grxcorum ;)  therebinthus, (Latinorum;)
albotin vel  albotes,^  schera et  botsor,§ (Arabo-
rum;) terminthus, (Wiseman,  Turner, Lorry,
Plenck;) epincytis, (Sauvages,-)  psoride crusta-
cee,  (Alibert,-)  Erbsenblattern,  (Teutonice  sec
Plenck,-) eiternde Flechte,  (sec. Sprengel;)  pa
pulous scall,- ulcerated tetter.
   By the term with which Willan chose to desig
  * " Some will have the denomination from the likeness
of the pustule to the fruit of the tercbinthus. Others,
with more reason, read it  epi6tv0o^, ciccr,  which  it
somewhat  resembles."   Turner.  Vide Hipp.  Epidem.
lib. ii.  sect. 11;  De Humor, xi. 1;  Galen,  in  Exeg.
diet. Hipp, item Comment. 3, De Humor, et Comment.
4, in  lib. vi. Epidem.; Mg\x\. I. iv. c. 4; ^Etii. lib. ii. ta?-
trab. iv. c. 03; Foes. CEc.  p. 015, 016; M. Aurel.  Sev.
1. de Epinyctid. part. ii. contr. 3; Dioscorides Alexand.
vide Gorrai defin. Med.; Oribas. lib. vii. Syncop. exxxvi.
 f From lr,i and vv^, so called, according to some, because
the eruption  first appeared, or only appeared, by  night,
and, according  to others, because it was most trouble-
some at night.  But whatever be the reason of the  ety-
mology, it is plain, from the description of this eruption
left us by the best authorities, that it consisted of phly-
zacious pustules.  Vide  Hipp. Prorrhet  2, De Intern.
Affect.; Celsus, lib. v. c.28, sect. 15;  Paul. jEsrin. lib. iv.
cap. 9; Oribas. Synops. lib.  vii. c. 37. The  Arabians
translated  the term by sera  or schera, and  sometimes
botsor, (Avicenn. lib. iv. fen. vii. torn. iii. c. I.) which  last
being of the same etymology, restored it  to its natural
connection with terminthus.   Actuarius, as it appears to
us with little show of reason, insists on a distinction
between epinyctis and terminthus, (Meth.  Med. lib. ii. r-
11, 12.)   Some authors, bearing entirely upon the deri-
vation of epinyctis, have been"led into the ...,.-,ike of
considering it the same  as the  urticaria tnberosa— an
error which Pennertus verv properly corrects.
  J Fallop. I. de Morb. Gall. c. 5, torn. i. p. 086
 § Avicenn. lib. iv. fen. 3. t. i. and f. 7, t. iii. c 1, Her
sler de Herpete, p. 30; Eoussel de Herpete, § 99.
3m 
733
ECTHYMA.
nate this disease he lost hold of the thread which
led us to the knowledge which the ancients  had
concerning it.  In the synonymy we have endea-
voured to recover it, thus to connect ancient expe-
rience with modern observation, the only substan-
tial use of learning.
   The eruption in this  disease consists  of large
round pustules  generally  distinct  and sparingly
scattered, each having a hard, red,  elevated base,
terminating   in a  thick,  hard, greenish or dark-
coloured scab, which, falling off, leaves generally a
livid red spot of longer or shorter duration, some-
times a superficial cicatrix, more rarely an ulcer,
seldom a tubercle.
   This eruption is frequently confined to the ex-
tremities, appearing most  commonly on the legs,
on the outer  side of the thighs, arms, and forearm,
frequently on the abdomen, nates,  lumbar region,
neck, and  front part  of the chest, rarely on the
face or scalp, and  very seldom occupies tbe whole
body.
   The  pustules sometimes break out together in
successive crops ;  but generally  they appear, go
through their progress,  and terminate, indepen-
dently of each other, some being on the decline
whilst others are appearing.
   This eruption is sometimes, but not generally,
accompanied with fever;  it  is  more  frequently
attended with restlessness, a state of general  irri-
tation or erethism, and sleepless nights.  Morbid
phenomena  produced by gastric  and intestinal
irritation, as  anorexia, &c, almost  always appear
during  the  course of the eruption.  Sometimes
fever, anxiety, great  general distress, and pains
of the limbs precede the eruption, which subside
on its appearance.   If the pustules be abundant,
thickly  set, violently inflamed, and acquire a great
size, considerable symptomatic febrile action  may
be present; and if they ulcerate, are slow in their
progress, and  of  long continuance,  emaciation,
debility, and regular  paroxysms of hectic fever
supervene.
   Each  pustule generally commences in a circum-
scribed  red  inflamed  point, which  becomes  gra-
dually  raised,  and in the course  of a few days
acquires a size varying from that of a lentil to that
of a sixpence; their apex is soon observed to point
with pus, whilst the base continues hard, circum-
scribed,  and  of a bright red colour; at the end of
three or four days the pus dries,  and scabs, more
or less thick, are formed,  which, when they  fall,
leave spots of a dark  red  colour.   The pustules
vary  in size,  from that of a small pea to that  of a
sixpence or  larger.   They are generally distinct,
but sometimes they form irregular clusters. Their
development is frequently  accompanied with very
acute stinging pains, similar  to what precedes
erysipelas, or the  herpes zoster.
   From this their usual course considerable de-
viation  is sometimes observed.   Their progress is
sometimes tediously slow and imperfect.  Suppu-
ration in some cases is established rapidly, and in
others it is only effectual after many days; some-
times the pus is in very small quantity, occupying
only  the apex of the pustule, the base remaining
broad, hard,  and inflamed ; sometimes, more espe-
cially on the hands and  feet,  the  pus raises the
cuticle over all the extent of the pustule, giving it
 be appearance of a bleb or bulla.    Some of the
pustules are  occasionally resolved,  thin,  white
scabs forming successively  over  their surface;
sometimes ulcerations, more or less deep, succeed
the pustules, especially those  seated on the lower
extremities,  or such as follow scarlatina or small-
pox, and sometimes slight indurations succeed to
the scabs.   The pustules are  not always distinct,
but sometimes as it were confluent,  and though
generally accompanied with a burning, itching or
stinging pain,  they  are also  sometimes  entirely
free from any painful sensation.
  It has been doubted whether  the term pustule
was properly applied to the eruption  of ecthyma
which  supposes an active inflammation and sur
purative action to constitute  the  essence  of the
disease,—a supposition inconsistent with the state
of system existing in all cases as the predisponent
cause of this disease ;  and  it has been asserted
that a minute examination does actually disclose
a state of vessels differing materially from such an
action ; that,  instead,  a  lesion  of some minute
vessel takes  place in each spot of ecthyma,  and a
kind of petechias are  thus produced.  But  from
some cause, depending  either on  a minor degree
of debility of the system to that in which the
petechia? remain quiescent, or on a greater degree
of irritability of the skin, attempts are made to
repair the mischief by  the vessels of the part, and
inflammatory action  takes  place.  The  minute
vessel thus ruptured has its extravasated contents
mixed  with  the coagulable lymph poured out by
the vessels labouring to  repair the mischief, and
the mixed  fluids,  drying on  the  spot, form the
minuter scabs.  But the constitution being  un-
equal to carrying through the process in a healthy
manner, irregular attempts  at  suppuration  take
place, and  the bulk of  the scab  is  usually sur-
rounded by  and partly mixed with a  minute por-
tion  of ill-formed  pus, which, drying, increases
the bulk of the scab.  Many of the  minute vessels
concerned in this process being too relaxed,  their
secretion is   mixed with and  deeply  coloured by
red globules, which escape  under the increased
action.   The scab now becomes a cause of irrita-
tion to the surface on  which  its basis  rests; the
bloody purulent secretion increases,  becomes in-
spissated, and  attached  to the  mass;  ulceration
gradually destroys the  surrounding cutis, and the
margin of sound skin becomes elevated and thick-
ened.   The  scab, by the continuance of this pro-
cess, is  gradually elevated and rapidly enlarges, a
fresher  and  broader ring of gcowth being added to
its basis every three  or four days.   (Plumbe, on
Diseases of  the Skin.)
  This ingenious account of the process of the
eruption of ecthyma is not  in  strict accordance
with the phenomena,  but, on the  contrary, is in
many respects at variance with them :  it rests in its
chief points  upon suppositions purely gratuitous,
for  it has yet  to be ascertained,  and we are in-
clined to deny it, that even petechias are nothing
more than ruptures of minute vessels; and it is
directly contradicted by other observers who have
examined attentively the structure of the pustules
of ecthyma at the different stages of their progress.
According to them, in their first state of red ele-
vations, there exists only a vascular injection with
a round circumscribed tumefaction of the  skin;
that, in  their second state,  a certain quantity of 
ECTHYMA.
739
purulent serosity is deposited, under the epidermis,
at their summit, more rarely over all their surface ;
that, in their third state, a substance of the nature
of a false membrane is deposited in the centre of
the elevation, which is evidently perforated; that,
in the fourth state,  after this  substance has been
extracted and the epidermis removed,  the  pustule
appears in the form of a little cup surrounded with
a hard  broad border; and  that, in their last and
fifth state, the border, during  the following days,
gradually  disappears, whilst  a  small  cicatrix  is
formed under the scab, the centre of which is sunk
into the point where the perforation has been ob-
served.*
   The phlyzacious pustules of ecthyma  may be
developed in the healthiest body by the local ap-
plication of certain  irritating  substances.  Thus
tartar emetic, in  powder or in ointment, after the
manner of Autenrieth, is capable of giving rise to
them ;  and the same has been observed of certain
pulverulent matters, as metallic powders, sugar,
and lime, which accounts for its being frequently
seen in  masons  and grocers.   But  it is  more
commonly met with  as a symptom and effect of a
general disordered state of body, or a sympathetic
consequence of irritation or inflammation  of some
internal organ.    Hence it has been  observed  to
supervene upon unusual  fatigue,  long-continued
exertion, much night-watching, great  mental anx-
iety, and strong  moral affections : and it has been
most frequently observed in persons who have in-
jured their constitutions by previous excesses, by
the abuse of spirituous liquors;  or who have suf-
fered in consequence of deficient nourishment, or
unwholesome food, or surfeits ; whose health has
been impaired by dwelling in dark,  damp, cold,
and close habitations; or by habits of sloth and
uncleanness ; or  whose constitutions  have  been
debilitated by the effects of malignant fevers,  as
small-pox, measles, and scarlatina.   Hence it is
favoured by a moist  and cold atmosphere, though
it occurs  most frequently in spring and summer,
and is met with  frequently in infants, in  the  de-
cline of life, and in women, more especially during
pregnancy, or whilst suckling, or coexisting with
amenorrhoea; and is frequent in large cities, hos-
pitals,  prisons,  garrisons,  work-shops, and  man-
ufactories.  For the  same reason it is so often ac-
companied with  symptoms of gastric and intesti-
nal  disorders, with loss of appetite, pain in the
epigastrium, irregularity of tbe  bowels, lassitude,
headach, &c.; and has been observed frequently
coexisting with  chronic inflammation of the mu-
cous membrane  of the stomach and intestines,
with such concomitant symptoms as inflammation
of the conjunctiva, and of  the mucous membrane
of the pharynx ;  and has  sometimes been observ-
ed to be critical in acute gastro-enteritis.   In pre-
disposed  habits,  trifling local  irritation will  pro-
duce it, as leech-bites, and even the friction of the
clothes; so that  some authors have remarked the
pustules to be frequently  seated under the wrist-
bands and collar of the shirt, the waistband of the
breeches,  and at the gartering place above the
knee.
  Though the eruption of ecthyma  preserves its

  * Fcthuma  Dictionnaire de Medecine  et Chirurgie
Pratique -Ch. Ed. Jsselin Essa. sur PEcthy.na,  Pans,
1827.
character with comparative constancy, and is one
of those cutaneous affections the least convertible
and  disposed to pass into others, it sometimes de-
velopes itself in the exacerbations of other inflam-
mations of the skin, as in lichen, prurigo, scabies,
and  variola,  but shows, in general, a closer con-
nection with furunculi.
   Though such is the general appearance, course,
and  causes of this disease, they admit, as we have
noticed, of considerable diversity, sufficient, in a
practical point of view, to justify a division of the
genus into several species; and though we prefer
the specification of Willan and Bateman to that
of Alibert, (psoris Crustacea  acuta  and psoris
crastacea chronica,) as being more true, precise,
and  practical,  we  shall  venture  upon  a slight
alteration of the name of one species,  so as to
make  them all more distinct and consistent;  and
shall add to  the genus the syphilitic form of the
disease.   The following  will therefore be  our
arrangement.
   1. Ecthyma vulgare.
   2. Ecthyma infantile.
   3. Ecthyma luridum.
   4. Ecthyma febrile.
   5. Ecthyma syphiliticum.
   1. Ecthyma -vulgare.—Syn. Epinyctis vul-
garis (Sauvages); Psoris Crustacea  acuta  (Ali-
bert) -, Ecthyma aigu (Rayer) ; die gewbhnliche
eiternde flechte (Teutonice).
   In this species of ecthyma, generally after some
days of languor  and general  oppression, of loss
of strength and appetite, of derangement of the
digestive  functions,  of headach, of pains in the
bowels or of the limbs, and after less refreshing
nights, with, more rarely, redness  and inflamma-
tion of the conjunctiva, and sore throat from ery-
sipelatous inflammation of the  pharynx,  an erup-
tion, accompanied  with sharp stinging  pains, ap-
pears  on  some part of the  extremities, or on the
neck, shoulders, or breast.   This eruption, which
is usually completed in three  or four days, con-
sists ^jf small red circumscribed elevations of the
skin, not  yielding or  disappearing on  pressure;
for three  or  four days they continue to enlarge,
becoming  surrounded with  an inflamed areola,
which is hard and circular, and in young subjects
of a bright red colour; having suppurated at  their
apex,  which  is distinguished  by  a small  dark
point, after a day  or  two they break, discharging
first pus  and  afterwards a  thinner fluid, which
quickly  concretes  into dark-brown or  greenish
scabs.  The constitutional derangement which pre-
ceded  the eruption is now abated ;  the  inflamed
areola extends itself, becoming gradually paler as
it enlarges ;  in about a week, all the pain, sore-
ness, and  inflammation subside,  and the  scabs
soon after fall off, leaving  no  mark behind.  If
they continue adherent to the skin for  a longer
time, which sometimes happens, they leave, when
detached, a dark red spot, or, more seldom, a su-
ficial cicatrix, in  size resembling those of small-
pox, but less deep.   If the  pustules be situated
in the neighbourbood of  lymphatic  glands, these
latter become sometimes swollen and inflamed.
   The whole process of this eruption, in general.
occupies from  seven to fourteen  days, and one
eruption frequently completes the disease.
   This species is most commonly  met with v 
740
ECTHYMA.
spring and summer; it affects principally young
people and adults, and is occasionally observed in
women during  gestation.   It frequently follows
excessive  fatigue,  severe  or prolonged  exertion,
night-watching,  nurse-tending, anxiety, vexation,
and  other  emotions of mind, errors of  diet, and
indulgence at table.  It  appears to be very much
connected with the state of the digestive organs,
but seems  to depend upon something  more than
their  mere derangement.   It  has been  well  ex-
pressed by Bateman, by a state of distress of the
constitution.   It is  also  sometimes observed  as
critical of acute  gastro-enteritis.
   In  general, this species does not stand much in
need  of the interference of art.   Gentle, cooling,
and  saline purgatives, as senna, manna, and  tar-
tarised soda  or  potass ; acidulous diluent drinks,
as whey ;  and  light,  cooling diet,  afford  ample
means of cure.   In robust, sanguine, or plethoric
subjects, a small bloodletting  accelerates the pro-
gress  of the eruption, and renders these  means
more efficacious.  If much irritation and restless-
ness  be  present, and  much local uneasiness, the
tepid bath  is  the surest means of affording relief.
If the alvine evacuations are unhealthy, five grains
of the pulv. hydrargyr. cumcreta may be taken at
bed-time, with a  few  grains of Dover's powder,
but  even this is  seldom necessary.   The diluted
sulphuric acid, simple or aromatic, is a good tonic
as the disease declines.  If the  local affection de-
mands any treatment, an emollient poultice is the
best.
   2.  Ecthyma  Infantile.— Syn.  Terminthi
neonatorum—Schiilblasen,  Teutonice (Plenck.)
   In infants of a constitution naturally weak, or
disordered by bad or insufficient suckling, or  by
being brought up by hand  upon  food not suited
to tbe powers  >f their digestion, an eruption  of
phlyzacious pustules is a common occurrence.
   In  this  species, as  the  former, the  eruption is
partial, chiefly affecting one particular part of the
body, and, as in the former also, several pustules
may appear together; but more commonly the
disease consists of a successive eruption of indi-
vidual pustules, by which  its  duration  is some-
times extended  to several months.  The pustules
are first observed  near the groins, on the abdomen
near the umbilicus, near the axillae, and on the
thighs or nates ; sometimes they  are not confined
to the trunk and extremities, but  also occupy the
face and scalp.   The  course and progress of each
individual pustule  is the  same as that  of the
ecthyma  vulgare, but they are in  general more
irregular in  their size,  a large being frequently
observed by the side  of a very small one ; their
form  is circular,  but  they vary  more in colour,
being sometimes of a bright red, sometimes of an
amaranthine, and sometimes of a livid colour, ac-
cording to the strength or weakness of the infant.
The pustules of this species are more disposed to
suppurate extensively, and more  apt to  terminate
 in ulcerations, which in weakly infants  heal im-
 perfectly, being covered by a thin, filmy cicatrix,
easily re-opening or abraded, marked by  a peculiar
 puckering of the  surrounding skin.   In some se-
 vere cases, generally  only  to be found amongst
 tbe most  indigent,  gangrenous eschars  and deep
 sloughing ulcers, similar to those of erysipelas in-
 fantile, are not  uncommon  terminations of the
pustules of this species.   Occasionally, also, after
threatening suppuration, the pustules gradually
diminish and terminate by a succession of desqua-
mations.
   The process by which an improper nourishment
developes this disease  appears to consist  not only
in a deranged state of digestion and assimilation,
but also in the  production of inflammatory affec-
tions  of the alimentary canal; for chronic inflam-
mations of the digestive organs are frequently ob-
served in  connection with this eruption.  But  all
the chronic derangements of the abdominal organs
of infants are  capable of inducing this eruption,
and  hence  phlyzacious pustules   are   common
symptoms of the marasmus which depends upon
obstruction of the mesenteric glands.  Cold and
moisture  appear frequently to furnish the exciting
causes of this eruption.   According  to Plenck, it
has sometimes prevailed epidemically.
   The treatment of tbis species consists in chang-
ing the nurse or in altering her milk by diet or
medicines, or in adapting the diet of the child to
the powers of its digestion.  For this last  purpose,
asses' milk,  goats' milk,  and whey afford very
useful resources.  The  air, exercise, and clothing
of the patient  also deserve  attention.   In mild
aperients, as castor-oil, manna, and  magnesia,
with  mild mercurial alteratives and  soda, and, if
there  be   any feverishness  or fretfulness, small
doses of nitrate of  potass and the  tepid bath, the
medical treatment consists.  As soon as it can be
borne,  the ferrum tartarizatum, given in small
doses, affords  a convenient alterative  and tonic.
The  chloruret of potass  and the pyroligneous acid,
both  in small doses, are said to have been found
particularly serviceable  in this eruption, as, also,
the Peruvian balsam and sulphate of quinia. Nor
is the local treatment of the pustules, if large, un-
important.  If  there be much pain  or irritation,
fomentations of the decoction of poppy-heads fre-
quently afford  relief; in  superficial ulcers, with
profuse acrimonious discharge and  itching, weak
solutions of chlorine or chlorate of lime  are most
useful applications.
   3.  Ecthyma Luridum.—Syn. Terminthus
(Auctor.  Var.) ; Psoride  crustacee sordide (Ali-
bert); ecthyma chronique (Rayer).
   An eruption of large phlyzacious pustules, some-
times acquiring a  very considerable size, having
their base hard, elevated, of a dark  livid red co-
lour, and  continuing  highly  inflamed, even after
scabbing  takes place; slow in their progress, ex-
tensively  distributed over the body, and sienerally
connected with a slate of cachexy ; these circum-
stances afford the  distinguishing features  of this
species of ecthyma, which,  though in  different
stages, is accurately represented  in Plate xliii.
of Bateman's  Delineations, and in  Plate liii. of
Alibert.
   The pustule of  this  species is more analogous
1 to an ill-conditioned boil, being more extensive and
 prominent than is usual in ecthyma.  Suppuration
 is seldom completed in less than eight or ten days,
 when the pustules break  and discharge a curdy,
 sanious,  or bloody  fluid, which is soon converted
 into  hard dark  scabs, and these are encircled with
 a hard violet  or livid red-coloured  areola.  The
 surface covered by the  scabs is slow  in  healing,
 and the ulceration  sometimes extends bevond the 
ECTHYMA.
 limits of the pustule ; but the ulcerated cavity is
 soon  filed  up with hard  dark-coloured  scabs
 firmly attached, seldom separating for many weeks
 sometimes  not for months.   Though the  ulcera-
 tion  extends, it is always surrounded by a deep-
 seated  hardness and by a dark inflamed  border,
 and, when  not covered  by a scab, which  some-
 times happens if they have been removed by vio-
 lence, tedious ulcers, with callous edges, discharg-
 ing  a  sanious pus,  are often the consequence.
 When the scabs fall off, dark red-coloured patches,
 or cicatrices of a violet  red  colour, remain for a
 considerable time  over the parts which have been
 occupied by the pustules.  Sometimes the pustules
 are long stationary, and do not proceed to  suppu-
 ration, but are followed by tubercles of  a violet
 colour; these may,  however, ultimately proceed
 to suppuration and  ulceration, and  thus leave
 irregular cicatrices in the  skin.   In  this  species
 the pustules are more entirely independent of each
 other's progress, and may continue to succeed one
 another without any order for several months.
 They are  often attended with extreme  pain and
 soreness, generally without fever ; but sometimes
 considerable constitutional irritation is present, and
 in protracted cases hectic fever : in some cases the
 respiration is remarkably affected.
    Ecthyma  luridum  is  always  a symptomatic
 affection, a consequence of cachectic disorder of
 the habit.   For this reason, it prevails most during
 the winter season, and  is most  commonly met
 with amongst persons advanced in  life, or amongst
 those whose constitutions have been broken down
 by misfortunes or imprudence. Hence  the indi-
 gent who inhabit  dark, damp, and narrow streets
 and cellars, whose means and habits seldom allow
 them the comforts of cleanliness;  prisoners con-
 fined to dark and dreary dungeons, filthy, squalid,
 and ill-fed; those who have been exposed to great
 hardships  and hard  labour;  or those who have
 been compelled  to live  upon unwholesome food,
 particularly such  as  is  hard, dry, smoked, and
 salted ; and such as  have abused  their health by
 an irregular life, particularly those  addicted to the
 use of  ardent spirits,  are  most frequently the sub-
 jects of this disease.   The state  of body  which
 prepares for this disease may also be produced  by
 previous diseases, as in febrile affections, when the
 cure or the crisis has  been imperfect;  and in this
 way it occurs very frequently  as a sequel of scar-
 latina, measles, and small-pox.
   The  essential point in the  treatment  of the
 ecthyma luridum consists in correcting the faulty
 state  of habit  upon which this disease depends,
 and this object, the cure of the cachexy, is  not to
 be attained  by any one  simple method  of treat-
 ment, but by the combination of several,—neither
 by depuratives, nor alteratives, nor tonics, but  by
 a happy adaptation and  adjustment of them all.
 The experienced physician  knows, that  to renew
 and  regenerate  the   organizing and organizable
 fluids of the body, before  proffering a supply it is
 necessary to  excite a demand,  and that to give
 vigour and activity to the function of nutrition, it
 is useful to diminish the volume of the  nutritive
 fluid; that, whilst  in this way activity is given to
 the process of nutrition, care  should be taken  to
modify,  by the proper  use  of alteratives, the action
of  the  organs, by  whose united  functions the
741
 nutritive fluid is  created ;  and that these actions
 may be performed satisfactorily and effectually, it
 is necessary by stimulants or tonics to support the
 action of the nervous system, until the new, fresh,
 and healthy blood is of itself capable of doing so.
 In these three intentions,  the indications  of the
 cure of cachexy  consist.   Therefore, in the com-
 mencement of the disease, mild cooling purgatives,
 or very small repeated  bloodlettings, (from two to
 four ounces,) and light nutritious diluting drinks,
 are good  preparatory measures; whilst  any dis-
 tressing irritation may be relieved by opiates, the
 action  of any organ  which is deficient may be
 solicited  or modified  by its appropriate specific
 stimulus, and the vigour of all may be increased
 by exalting artificially that  of the nervous system.
 From this view the practitioner will readily under-
 stand the application of such remedies as sarsapa-
 rilla, guaiacum, and taraxacum ; of saline mineral
 waters ; of antimony  and  mercury, either alone
 or as they are more conveniently united in  Plum-
 mer's  pill;  of  vegetable and mineral  acids, of
 decoction of cinchona, of sulphate of quinia, and
 chalybeates ; of the fresh and sea-water tepid bath
 and cold sea-bathing; of whey, asses' milk, milk
 diet; of food, light, nutritive, and  easy  of diges-
 tion ; of wine in small  quantities;  of gentle exer-
 cise in open dry  air; of warm clothing; and, as
 much as may be possible, of quiet  and repose of
 mind.
   The  local treatment, when the state of the pus-
 tules demands it, consists in emollient applications
 and softening plasters to favour a benign suppu-
 rative process; but when they show any malig-
 nant appearance or disposition to  gangrene, it  is
 best arrested by nitrate of  silver in solution, the
 butter of antimony, or caustic potash.
   4. Ecthyma Febrile. — Syn.  Ecthyma ca-
 checticum  (Bateman);  Psoris  Crustacea  acuta
 (Alibert);  Ecthyma aigu (Rayer).
   After febrile  symptoms of two  or  three days'
 continuance,  accompanied  by headach,  pains of
 the limbs, loss  of appetite,  disordered digestion,
 irregularity of the bowels, great restlessness,  and
 sometimes delirium, there appears an eruption of
 numerous and scattered phlyzacious pustules, ge-
 nerally  smaller than in the other  species.   The
 pustules are commonly first observed upon  the
 extremities, to which, either dispersed or clustered
 together in  irregular patches, they  are sometimes
 confined ;  but they also frequently  appear first
 upon the breast, in other cases on  the forehead ;
 and sometimes  extend  over the whole trunk, the
 face, and the scalp.  The eruption of the pustules
 is accompanied with a burning stinging sensation,
 or with itching  or tingling,  and a great  desire to
 relieve it by scratching.  After the first eruption
 fresh pustules continue  to  break out daily, until
 the skin is thickly studded with them ; and as the
 successive   pustules go through  their  different
 stages of inflammation, suppuration, and desqua-
 mation, at similar periods after they  arise, they
 are necessarily seen under all these conditions at
 the same time; the rising pustules exhibiting a
 bright red hue at  the  base, which  changes to a
purple or chocolate tinge as the inflammation  de-
clines,  whilst little laminated  scabs  are  formed
upon their tops : when  these fall off, a dark stain
is  left, which remains  for some time.  The pus 
742
ECTHYMA.
tules whicb occupy the breast and abdomen  are
generally less prominent  than those  on the face
and arms, contain less matter, and terminate rather
in  scales than scabs.  Pustules may continue to
succeed each other, in the manner just described,
for several weeks, the average duration of the dis-
ease being from two  to four months.  The best
representation of this species of ecthyma is that
in Bateman's Delineations, Plate xliv.
   On the  appearance of the eruption the febrile
symptoms are diminished, but not removed, for a
state of  constitutional irritation, of erethism,  or
hectic, continues during the progress of the dis-
ease, which  is invariably accompanied by  great
languor,  and by much depression both of  the spi-
rits and  muscular  strength.   The pulse is  gene-
rally quick and small; the  skin hot, dry, and
harsh ; the tongue dry, red, and glazed; the  gums
tender, swollen, and bleeding easily, sometimes to
a considerable extent; and  there is generally an
inflammatory state  of the  fauces and  pharynx, in
which  superficial  ulcerations may be  observed ;
this inflammatory  state sometimes extends to the
Schneiderian  membrane and conjunctivce.   The
legs and  feet are occasionally oedematous.
   The ecthyma febrile is  always a  symptomatic
disease depending  upon an inflammatory  state of
the mucous membrane of the stomach, and con-
nected  with a digestive state of the abdominal cir-
culation, corresponding to that  disorder of body
described by writers under the term of scorbutic
cachexy.   In  persons of  this state of  body this
eruption  declares itself at the change of season,
in spring and autumn, from exposure to inclemen-
cies of weather.  It occurs  most frequently after
the body has arrived at full maturity, particularly
in those  debilitated by a long series of  excesses ;
and it  is occasionally  seen in the crude convales-
cence of  gastritis imperfectly cured.
   The nature of the ecthyma febrile affords  satis-
factory indications  for its cure.   If the eruption
be extensive, the local inflammation severe, or if
it be attended with  much fever, depletion by  small
venesections, by leeches to the anus, epigastrium,
or  hypochondriac   regions, or by cooling saline
purgatives, is a necessary measure; whilst the
secretion of the liver  is to  be solicited by mild
mercurial alteratives, taking care to prevent their
affecting  the constitution,—a circumstance,  how-
ever, liable to occur in this disease, even  from very
small doses.   The mercurial alterative may be
combined with antimonials, as the James's  pow-
der, or with  Dover's powder.  These, with the
tepid  bath if there be much irritation, diluting
acidulous drinks  and light  diet,  constitute the
means  of cure.  In milder  cases, cooling saline
purgatives and acidulated drinks will, in the  com-
mencement, be found sufficient; and when the
febrile symptoms have abated, the Plummer's pill
combined with a course of taraxacum affords an
alterative treatment of great value.
  These  remedies   may be succeeded by  the  di-
luted sulphuric acid and preparations of cinchona,
as soon as the state of the stomach  admits them.
Tbe warm alkaline or salt-water baths are very
useful subsidiary means, and  the diet  throughout
should  be mild, light, easy of digestion and nutri- j
bo.is.                                          i
  When the pustules are  the seat of much  pain, |
 of itching, or uneasiness, local applications are of
 considerable use.  Of these a solution of chlorate
 of soda  is one of the best.   Dr. A. T. Thomson
 found great advantage from the following :
           R Plumbi acetatis, £ss.
              Acid, hydrocyan, f.^iii.
              Unguenti cetacei, 5 iii.
   M.  fiat unguentum partibus cutis nudis appli-
 candum.
   The ecthyma febrile  has only been accurately
 described by  Bateman,  Alibert,  Hewson  (North
 American Medical and Surgical Journal, January,
 182G), and  Dr. A. T. Thomson (Bateman's Sy-
 nopsis, 7th edit. 1829").
   5. Ecthyma Syphiliticum.— Sqn. Syphi-
 lide pustuleuse  phlyzacree (Rayer, Biett);  Pus-
 tular venereal disease (Carmichael).
   Under the influence of the venereal virus, modi-
 fied no doubt by some peculiarity of constitution,
 natural or acquired, an eruption of phlyzacious
 pustules  is frequently observed;  and which, in a
 classification  founded entirely on  the  external
 characters of disease, we are  justified in placing
 under the genus ecthyma.
   The pustules of the ecthyma syphiliticum suc-
 ceed each other,  are generally sparingly scattered
 and distinct, and seldom very  numerous, and have
 been by  Lagneau, on account of their large size,
 compared to  those  of small-pox ;  they  are most
 frequently seated upon the limbs,  and especially
 upon the legs; but they  have  been observed upon
 every part of the body.  They first  appear under
 the form  of a livid spot, in breadth somewhat less
 than that of a shilling, but also sometimes larger;
 throughout a considerable  extent of  this spot, the
 epidermis becomes raised and  gradually distended
 by a greyish sero-purulent fluid, whilst the tume-
 faction slowly increases, and  is  surrounded by a
 broad areola,  invariably  of a  livid copper colour,
 one  of the characteristic distinctions of this species
 of ecthyma.   After a few  days the pustule opens
 and  discharges a liquid, which concreting forms a
 very hard blackish  or brownish-black scab; the
 scab becomes by degrees very  thick, furrowed
 circularly, and  is  generally  of a regular round
 form. The progress of the pustule most commonly
 takes place without any symptoms of local inflam-
 mation ;   there is little increase of heat;  the sur-
 rounding parts are free from pain ; a slight smart-
 ing  is all that the patient feels.  The scabs are
 strongly  adherent,  and they  may remain unde-
 tached for an indefinite time;  but when  they fall
 off, either spontaneously  or by means of emollient
 applications,  they expose round ulcerations, most
 commonly deep, having  their  edges  abruptly pre-
 cipitous, formed of a  hard violet-coloured tissue,
 and  their  bottom of a greyish, pale,  unhealthy
 aspect.  These ulcerations  seldom extend, but the
 scab gradually forms again,  and  is successively
 detached ; until  at last, by means of appropriate
 treatment, the new  scabs  are formed  less thick,
 the ulcerated  surfaces become healthy, and are
 succeeded by a  permanent round cicatrix, of a
 copper colour.  (Cazenave et Schedel,  Abrege
 Pratique,  &c.  Paris, 1828.)
   Infants born infected with  the  syphilitic virus
 present most commonly this form of  eruption.  In
 this  case  the pustules are  very numerous, broad,
flat,  superficial,  and of an oval form.   They be- 
                               ECTHYMA

come  covered with  blackish scabs, of no  grea7
thickness, which are followed by small ulcerations.
A  very  characteristic general appearance of  the
countenance, which  it would be difficult to  de-
scribe, attends this complaint.   The skin is foul,
the features are drawn,  and the whole body is
emaciated,  wan, and, as it were, etiolated ;  the
countenance is wrinkled, giving the appearance
of extreme  old  age, and  a peculiarly  diseased
odour is exhaled.   (Cazenave  et  Schedel,  Op.
cit.)
   The pustules of the ecthyma syphiliticum  are
distinguished  from those of the other species by
being surrounded by an areola less broad, but of a
dark copper  or  violet colour;  by  their thicker
scabs, furrowed  circularly ; by  being succeeded
by ulcers round  and  deep, witb precipitous edges,
and being  invariably followed  by a depressed in-
delible cicatrix,  and by being generally attended
by some concomitant constitutional  symptoms,
such  as  inflammation and  superficial ulcerations
of the fauces, pains of the bones, sometimes iritis,
whilst the history of the  case affords the evidence
of some primary affection.
   Mr. Carmichael, who is peculiar in his opinions
in limiting  the true syphilitic disease to  one form
of eruption,  does not consider the phlyzacious
pustules to be of that nature.  He considers them
as consecutive of a peculiar primary ulcer, which
he describes as characterized by a reddish-brown
surface, bordering  closely on the phagedenic cha-
racter, having its  edges  raised and well defined,
not excavated, but either on a level with the sur-
rounding skin or considerably raised above it, ap-
pearing at  its commencement  in  the form  of  a
small pustule, attended with itchiness. According
to his observation  the secondary eruption is pre-
ceded by fever.   (Carmichael on Venereal  Dis-
eases, 1825.)
   The view which Mr. Carmichael  entertains of
this eruption  leads him  to consider mercury as
unnecessary for its  cure; he therefore depends
upon antimonials,  sarsaparilla,  and guaiacum for
the constitutional remedies ; zinc lotions and rest
in the primary affection ; sulphur fumigations, or
equal parts of tar and sulphur ointment as  the
local remedies in the secondary eruption. But as
this method of treatment has not met with general
sanction, the greatest number of practitioners think
it safest to have recourse to the specific cure.  This
has been already described at length under Acne
Syphiliticum.   (See Acxe.)
   [This form of ecthyma,  as well as that which
attacks chiefly the legs'of old  and cachectic per-
sons who have lived  intemperately, is well treated
by the iodides, especially the iodide of iron.]
   When an infant at the  breast is  the subject of
this eruption, the remedy  should  be introduced
through the system of the nurse,  either  by admi-
nistering to her the liquor oxymuriatis hydrargyr.,
or by the friction of mercurial  ointment; and if
the health  of the nurse  does  not  allow of  this
manner of introducing mercury, the same may be
effected  by  giving  the infant the milk  of a  goat
which has been  submitted  to the  friction of mer-
curial ointnent.   These methods have been used
at the Hospital of St. Louis at Paris, and followed
with the most complete success. But the mercury,
if necessary, may be also directly given to the m-
-ECZEMA.                            743

fant ; either small doses of the hydrargyrum cum
cretii, or minute doses of the oxymuriate of mer-
cury  in  decoction  of elm  bark or  emulsion of
bitter almonds, as  recommended by  Dr. A. T.
Thomson.  (Bateman's Synopsis, 7th edit.)
                                T. J. Todd.

   ECZEMA, (from tK%cw, effervesco,) is a disease
of the skin, characterized at its commencement by
the existence of minute vesicles, which are usually
closely crowded together,  and  terminate either in
the absorption of their contained fluid,  or  in its
effusion and subsequent concretion into thin scales.
It is accompanied with a burning heat and tingling
of tbe inflamed portions of the  skin.  The disease
is not contagious, is usually unattended with fever,
and may, for the most part, be traced to some irri-
tating cause, either acting directly on the cutaneous
surface,  or internally  through  the medium  of the
constitution.
   Willan and Bateman, who have always endea-
voured  to seize on  the earliest  appearances pre-
sented by cutaneous diseases,  as being  the most
constant and  characteristic, have placed eczema in
their sixth order, vesiculx; whilst Alibert,  whose
classification  is  usually founded  on the   more
obvious, though less distinctive, phenomena  occur-
ing in the  advanced period  of these affections, a
period when several species which were originally
dissimilar often become confounded in their exter-
nal  features, though still unlike  as to their even-
tual progress, and  as to their appropriate  modes
of cure, has placed it in  his order "dartre squam-
meuse."  Thus he has grouped it along with some
of the true scaly diseases, and along with some of the
papular ones.  Struck, however, by the  abundant
serous secretion by which it  is usually moistened,
(and which should have led him to a knowledge
of its essentially distinct nature, by turning his
attention to its primitive vesicular form, the source
of this moisture,) he adds the characteristic epithet
" humide."
   M. Biett,  who,  to an  intimate  acquaintance
with the labours of his own  countrymen in this
department of pathology, adds  an extensive know-
ledge of the  works which have appeared on the
subject  in England and Germany, usually mani-
fests a decided preference for the classification and
general views of Willan and  Bateman.  But in
respect  to eczema, he thinks these  authors have
too  many subdivisions  of the disease, and have
spoken  in too sweeping a manner of the absence
of inflammation around the vesicles, and of fever;
as  the former almost always  exists to a certain
extent, and if the local affection occupies  much
space, some fever usually results.  The latter fact,
however, we think is very plainly hinted at, if not
expressly  stated,  by  Bateman  himself.  If the
cutaneous affection  be very severe and extensive,
we often also find  inflammation of the mucous
membranes to coexist.
   Rayer, a more recent  writer, whose views often
manifest  a somewhat singular coincidence with
those which Biett has been  in the  habit of pub-
licly teaching for many years past, emits  the same
opinion as to the unnecessary  subdivision of thib
affection  in  the  English classification, and pro-
poses to  substitute  a  two-fold division,  viz. into
acute and chronic,  as  more practical and useful 
744                                      E C Z 1

than the triple one  into  eczema  solare,  eczema
impetiginodes, and   eczema  rubrum;  against
which, in addition to the want of uniformity in
the grounds on which it  is  formed, it may be
objected that the first and third are really the same
'lisease, differing only in respect to their cause, or
<he degree of attending inflammation; and against
'be second, that it is really a complication of two
•Jiseases, and  not a  distinct, well characterized,
rimple species.  Averse, however, to interfere with
an arrangement  so universally adopted in these
countries as that of Willan and Bateman, we
sh«U  not here deviate from it, convinced that in
pathology as  well as  in pharmacy,  the  modern
taste for uniformity and  simplification of nomen-
clature,  whenever it has  deprived us of  terms
recalling well-marked sensible characters, effects
or causes, has tended to do injury to a science so
strictly practical as  that  of  medicine.  Names
that make a strong impression on the memory are
here often much more desirable than those whose
only  merit is their  consistency  with a purely
scientific but unimpressive uniformity.
   Eczema most frequently  appears  simply as  a
local disease, preferring, unlike the true scaly dis-
eases, those situations where the sebaceous follicles
abound, as the ears, axillae, groins, upper and inner
part of the  thighs, scrotum, margin of the anus,
and in women, moreover,  the external parts of
generation, the nipples, and adjacent portions of
the breast; or it selects those parts  which are
much exposed to external influences, as  the hands,
arms, and  face.  At  times, however, it is a much
more extensive disease, and occupies successively
nearly the whole cutaneous surface; and this  is
especially the case when it originates  in the use
of mercury, or in some other cause acting through
the medium of the constitution.
   1.  Eczema Solare chiefly occurs in persons of
a delicate skin, after long exposure to the rays of a
summer sun.  Sportsmen, and  those  who take
very  long walks  in  this season, mowers, harvest-
 labourers, and others whose business exposes them
 to the above cause, are its most frequent subjects.
 It is occasionally preceded by a slight feeling of
 general indisposition; and some degree of tension,
 together with heat and tingling, is felt  in the por-
 tion of skin whicb is to be the seat  of the erup-
 tion.   This is most commonly the backs  of the
 hands  and fingers, and the face, neck, and arms,
 especially in women, or those who happen to have
 them long  uncovered whilst in  the  sun.   The
 skin is usually pale, and is crowded with thick-set
 microscopical vesicles, so closely  approximated  as
 to leave no interstices  of  redness.  Occasionally,
 however, there is a slight blush round each vesi-
 cle ;  and this species occurs usually, as Bateman
 mentions, in  the upper part of the arms or on the
 breast, particularly  in  females, and is  commonly
 called heat spots.  In men of a sanguineous  tem-
 perament who use violent exercise in hot weather,
 phlyzacious pustules, or painful and slowly suppu-
 rating tubercles not unfrequently make  their ap-
 pearance in the midst of the eczematous eruptions.
   The vesicles  are  very  small and acuminated,
 and  contain  a limpid  fluid, which soon becomes
 milky and is  absorbed; or after sbghtly increasing
 in size, they burst and  ell'use their contents, which
 concrete and form minute brownish yellow scales
3 M A.

 or scabs, and the whole disease, if not very exten-
 sive, finally terminates in desquamation within one
 or  two  weeks from its   commencement.   The
 larger the surface at first attacked, and the greater
 the  irritation, the more likely is the  affection to
 spread successively  to new and extensive portions
 of  the cutaneous  superficies.  Some  precursory
 indisposition, as we bave  just stated,  may occur,
 but much more frequently  it is absent, the eruption
 coming  out almost immediately after exposure to
 the sun's rays.  It usually begins and terminates
 in an  acute form, but at  times  it  passes  almost
 immediately into a chronic inflammation, with an
 abundant exudation  of  a  viscid  fluid,  which
 rapidly concretes  in the form of thin  scales, and
 is attended with tenderness, redness, and excoria-
 tion  of the  affected skin.  In  these  prolonged
 cases, as Bateman remarks, the effused fluid seems
 to be of an acrid nature, inducing inflammation,
 and occasionally superficial ulceration of the part3
 with which it  comes in contact, and  the disease
 assumes somewhat  of the form of impetigo.  The
 duration of this affection  seems to be little under
 the influence of medicine, and  usually requires
 little more than the protection of the part from the
 exciting cause, and the frequent employment of
 tepid ablutions.
   2. Eczema impetiginodes  is preceded and
 accompanied  by  a painful  tension,  formication,
 and pruritus, and is distinguished from the other
 varieties by the occasional intermixture  of  pus-
 tules, into which its vesicles, which  are  deeply
 imbedded in the skin, become themselves not un-
 frequently converted.   All this gives it a conside-
 rable resemblance to some of the forms of impe-
 tigo, to which  it is  also allied in  the similarity,  or
 rather the identity, of its causes, which for the
 most part consist in the habitual contact of  vari-
 ous  irritating  matters.   Thus  the  irritation in-
 duced by the repeated application of lime, sugar,
 alkalies, &c, to the hands, gives rise to eruptions,
  (bricklayer's itch, grocer's itch,  &c.,) which are
 vesicular  in  some individuals  and  pustular  in
 others, and are apt to assume a chronic form when
 the exciting cause long continues to  be  applied.
 Thus, also, either a vesicular or a pustular inflam-
 mation may be induced by the irritation  of sul-
 phur or sulphurated alkalies, used for  the cure of
 common itch, and be mistaken for the continuance
  of this disorder.
    Similar eruptions may be caused by a blister,
  a mercurial plaster, Indian varnish, valerian  root,
  diachylon, frictions with  croton oil, opodeldoc, or
  ammoniacal liniments, and many other stimulat-
  ing external applications.  Exposure  to the heat
  of a forge or a strong fire has sometimes  excited
  it, as has likewise the internal use of  various me-
  dicinal  substances, as opium, antimony,  copaiba,
  &c.  Irregularities in diet and excessive drinking
  are also reckoned amongst its occasional causes.
  When  the skin is very delicate, this eruption has
  been known to manifest itself within three or four
  hours after the application  of a Burgundy  pitch
  plaster,  and to be productive  of much  distress.
  We have known an  individual  in whom almost
  every species of plaster, even the mildest and least
  irritating, has  given rise to this affection, and have
  seen it ensue in another after the employment of
  the common linseed poultice.   The  mixed  erup- 
ECZEMA.
745
tion of vesicles, pustules,  and boils occasionally
induced  by a  blister  or  other irritating  plaster,
often extends to a considerable distance from the
centre of irritation, overrunning a considerable por-
tion of the chest,  back,  abdomen, &c, inducing
much pain  and feverishness, and persisting  occa-
sionally, as Bateman  remarks, for a fortnight or
upwards, but without  any eventual injury.
   The eczema impetiginodes,  if its extent be not
great, may  run through its course in from one to
three weeks.  Occasionally,  however, it passes
into an obstinate  pustular or scaly disease, and
this we have seen  it do within a fortnight after its
commencement.   In its ordinary course, the vesi-
cles break and discharge an  acrid fluid that irri-
tates the adjacent  skin, which becomes inflamed,
thickened, fissured, and excoriated in  streaks, as
if torn  by  the nails.   At this  period its resem-
 blance to impetigo is  still more striking  than  at
 an earlier stage.
   In the treatment of this  affection,  in  addition
 to the removal  of the irritating causes, and tbe
 use of the  antiphlogistic and local  soothing mea-
 sures to be detailed at the end of this article, we
 must at the same time endeavour to remove tbat
 morbid state of the system of which the prone-
 ness to these  eruptions  from  slightly  irritating
 causes is an evidence ; and  it is in this part of the
 treatment of cutaneous disorders that  the French
 practitioners, who have anticipated and excelled
 us so much in  the employment of the  antiphlo-
 gistic and soothing measures  just  alluded to, ap-
 pear to have fallen short; the proper attention to
 the regulation  of  the functions of the  digestive
 organs being too often overlooked by them.  The
 most remarkable instances of this  extreme  irrita-
 bility of the skin which we have met with, have
 been in individuals  labouring  under  dyspeptic
 symptoms  of an old date; but we do  not by any
 means  wish to insinuate  that this is universally
 the case.   Eczema impetiginodes, as well as im-
 petigo itself, seems to fall under the head of dar-
 tre squammeuse  cruslacee in  Abbert's  arrange-
 ment.
    3. Eczema rubrum is the most severe and
 most inflammatory variety  of this affection, and
 is, like the others, preceded by a feeling of stiff-
 ness, heat, and tingling.  It  takes its specific name
 from the diffuse or erythematous redness on which
 the vesicles  make tbeir  appearance.   At first  it
 has  somewhat of the appearance of erysipelas,
 but may be easily distinguished  from  it by the
 'oughness which   it  presents to the touch, and
 which, on minute  examination with  a  lens in a
 favourable light, is found to  depend  on  the pre-
 sence of innumerable small and crowded transpa-
 rent vesicles.  These in two  or three days become
 opalescent, and in size about equal to a pin's head,
 after which thev  usually  burst and pour forth
 their contained fluid, which inflames  and excori-
 ates  the parts with  which  it  comes in contact.
 The disease successively invades  new portions of
 the skin, and is accompanied as it proceeds with
 swelling of the true  skin and cellular membrane.
 The discharge  from the vesicles  is  often very
 abundant,  has a peculiarly  heavy odour, and con-
 cretes rapidly into yellowish incrustations.  Hard-
 ening on the patient's linen also, it causes much
   Vol. I.-94
3n
pain,  by coming  in  contact with  the  excoriated
surface, which in some, cases is so extensive as to
occupy the greater portion of the body.  When
so widely spread  and severe, it  causes  much suf-
fering, and a certain degree of febrile  excitement
is necessarily the consequence.
  It usually makes its first appearance about the
scrotum or inner part of the thighs or  groins, but.
this is not constant.   Its duration is indefinite.  If
limited in extent, it may run through its course
within a fortnight;  but if it has occupied the
greater part of the surface of the body, it may last
for a couple  of months  or even  longer, when at
length the encrusted secretion drops off.   But the
morbid cuticle continues to exfoliate  for a consi-
derable time after, and this is occasionally attended
with the loss of the hair and nails.   Of this affec-
tion, mercury is one of the most frequent causes.
The  mercurial eczema (sometimes miscalled ery-
thema) seems to have been first clearly noticed by
Benjamin Bell,  in his treatise  on Gonorrhoea and
Lues Venerea, and  was subsequently more  fully
investigated by  Dr.  Moriarty, Dr.  Spens, and Dr.
M'Mullen, and by Mr. Alley and Mr.  Pearson.
   Dr. M'Mullin's description of it, in the second
volume of the Edinburgh Medical and  Surgical
Journal,  represents  it as a much more serious
 affection than Bateman and most succeeding writ-
 ers have done.   According to  Dr. M'Mullen, it is
 ushered in with a well-marked febrile paroxysm,
 and is accompanied by dry cough, difficult respi-
 ration, and sense of tightness across the pracordia
 —the skin being remarkably hot and the seat of
 an itching and prickly sensation.   On the first or
 second  day,  a   diffused  redness   and numerous
 crowded papula? (vesicles) make their  appearance,
 generally  on  the   scrotum, thighs,   or  forearms
 first, or on those parts where  mercurial  frictions
 have been made. The cuticle  soon exfoliates, and
 the  fauces and  eyes become somewhat inflamed.
 The  above  symptoms,  which, according to  Dr.
 M'Mullin, characterize the first stage, last for one
 or two weeks,  and if  the disease be in a  mild
 form, recovery  may ensue immediately  after the
 desquamation;  but  if severe, a second and  much
 more serious stage ensues, in which  the skin is
 studded  with innumerable  vesicles,  which soon
 discharge an irritating fluid of a nauseous  odour.
 This, by concreting into  large incrustations of a
 reddish or dark colour, constitutes the third  stage.
 The inflammation of the fauces, eyes,  and eye-lids
 now becomes exasperated, and the face is deformed
 by  a mask  of  encrustations fissured in various
 directions.   The affection occupies successively a
 large surface of the body, which in its excoriated
 state is the seat of great irritation, and the pain is
 exasperated by  the weight of the body in lying, a*.
  well  as by  tbe  contact  of the concreted matter.
 The latter is liable  to crack or be torn across on
 the slightest change of posture, and thus new raw
 surfaces are continually  becoming exposed.  \
 fever of the typhoid type accompanies these ex
  treme cases ; yet, which is singular,  the appetite
 continues unimpaired throughout.   The catarrhal
 symptoms generally undergo  an  exacerbation to-
  wards the conclusion, as is manifested by the in-
 creased anxiety and pain in the chest, the cough,
  and bloody expectoration.   The  pulse becomes 
74G
ECZEMA.
frequent, feeble, and  irregular, the tongue  black
and parched, and diarrhcea, delirium, convulsions,
gangrene of the skin,  and death close the scene.
  In the above description we scarcely recognize
the comparatively mild disease described by  Bate-
man, whose account certainly agrees  much more
closely  with the affection usually met with  in
practice.
  In mercurial eczema, in addition to the  catar-
rhal affection of the air-passages, a tendency to in-
flammation in the mucous membrane of the  intes-
tines often coexists, as is manifested by the facility
with which  diarrhcea is induced.   Dysury  too is
an occasional but much rarer symptom.  The ca-
tarrhal  affection is not mentioned by  Bateman ;
and by  some other writers, who speak of it, it is
considered  to be merely  a casual complication.
Dr. Gregory thought that both the affection  of the
skin and that of the mucous  membrane were the
effect of cold caught whilst under  mercurial influ-
ence; but Mr. Pearson's experience does not con-
firm this opinion.   Rayer strangely intimates that
the occurrence of eczema mercuriale may be obvi-
ated by taking the precaution of shaving the part
to which mercurial frictions are to be made.  When
we recollect, however, that it may be induced  by
almost every form of mercurial medicine, and that
too whether internally or externally administered,
we cannot place much confidence  in this mode of
prevention.  That inflammation of the skin should
result from the internal exhibition of mercury, is
in no respect more  wonderful  than that severe and
even fatal enteritis should originate in its external
employment, as in the  instances  recorded by Dr.
Crampton.
   Those cases of eczema rubrum  which originate
in the use of mercury, are  generally the most ex-
tensive. Local examples of  it on exposed parts
seem to be sometimes induced by the influence of
very hot weather, and a succession of red patches
generally make  their appearance  in such a man-
ner as  to prolong  the  disease to several weeks,
without, however, any evident derangement  of the
general  health.  Amongst  its occasional  causes
have been  reckoned,  a  stimulating diet, the con-
stant use of shell or sea-fish, &c.  Some  indivi-
duals  are  subject  from  slight or  inappreciable
causes  to a very frequent recurrence of tbis affec-
tion about the ears,  face, and back of the  neck,
accompanied with swelling  and  redness  of the
face, and a considerable putiiness  about the eye-
lids ;  which  obtain for it in popular language, but
very  improperly, the appellation of  erysipelas,
from  which  it differs both in its duration and the
degree of danger attending  it, as  also in the pre-
sence of vesicles in place of bullae.  Occasionally
minute pustules are intermixed with the vesicles,
and make the eruption approximate more closely
to the  description of the impetiginous variety of
eczema.
   Eczema in its chronic form, which often  proves
a very  intractable disease, (its removal, especially
in elderly persons,  being attended  with great diffi-
culty, and its relapses frequent,) has  perhaps not
 oeen sufficiently attended to by Bateman.
   According to Rayer, who has given an excellent
description of it, it may occur as the sequel  to any
 3f the  acute varieties above described.   In  it  the
 inflammation often pxtends deep >nto the true skin
 ■>nd cellular membrane, giving rise  to  a thicken
 ing, roughness,  and  inequality  of the  surface,
 wbich becomes fissured and excoriated, and is not
 unlike  a part which  has  been  lately  blistered;
 being raw and moist in some points, and present-
 ing a scurfy appearance from adherent  cuticle or
 dry and foliated secretions in others.  It is in this
 advanced stage of eczema that its identity with the
 dartre  squammeuse humide of  Alibert is most
 obvious.  The secretion of acrid lymph is uninter-
 rupted, and the  itching  so intolerable, that  the
 unfortunate patient cannot abstain from  tearing
 the surface with  his nails, and thus aggravating
 and perpetuating the disease.
   This state may continue with little variation for
 months or even years;  the  cuticle, which assumes
 a yellowish tinge from the contact of the discharge,
 being   at  frequent  intervals  exfoliated in  large
 patches.   The inflammation  is liable to frequent
 exacerbations; and occasionally, after appearing
 to  be almost subdued, it bursts out with increased
 violence, either on the  same place, or in some dis-
 tant part of the body.
   One of the most frequent seats of chronic eczema
 is about the external ears, and from thence it not
 seldom extends into the  meatus  auditorius exter-
 nus, and thus sometimes  induces  deafness.   In
 like manner, when  it  exists on the face, it may
 spread  from the external surface of the nose to  the
 nostrils;  and  in both this and  the preceding case
 it  proves  peculiarly obstinate.  When seated  on
 the lips, they occasionally become considerably
 swollen, and  we have seen it in this state present
 an appearance which might  in  young persons
 have been mistaken  for a scrofulous  affection.
 When  it attacks the scalp, it is not unfrequently
 confounded with tinea.  There is  great itching.
 The  hair  is   at  first  matted  together with  the
 abundant discharge, but this, gradually  diminish-
 ing, is succeeded  by a  constant furfuraceous
 desquamation, beneath  which the skin on examina-
 tion is  found to be red, shining, and tender.
   In its chronic form, eczema frequently manifests
 itself idso  on the  upper and  inner part  of  the
 thighs; the scrotum  and  prepuce in men,  and
 about the external organs  of generation and  the
 breasts in females;  anil in  all these situations  the
 itching is most intolerable.
    The circumference of the anus is also very  fre-
 quently attacked with  it, simultaneously or alter-
 nately with other parts  of the body.  It often occurs
 here  by  an  extension of the disease from  the
 scrotum or thighs;  but in some of the most obsti-
 nate examples it is a strictly insulated affection,
 confined to the verge  of  the anus, perineum, and
 cleft of the buttock; in which  situations a serous
 secretion  concreting into  thin, laminated, semi-
 transparent scales, like  exfoliated  cuticle, takes
 place at intervals.   In these  cases  it seems often
 to be   connected with  dyspepsia and ;in  irregular
 state of the bowels, the siools being unnatural,  «nd
 affording evidence of vitiated intestinal and biliary
 secretion, inasmuch as they are  often  peculiarly
 fetid, black, and  tenacious, and expelled  with so
I much  difficulty,  as  to give  rise  to the belief in the
 existence of  a stricture of the  rectum.   But  ihis
I difficulty seems to depend  merely on a spasmodic
 stale of the sphincter, induced by the chronic  irri-
| tation  in  the skin  and contiguous portion of the 
ECZE
jbucous membrane of the rectum ; for the patient
is at times able to evacuate the bowels freely.  The
empirical use of  bougies in such cases cannot fail
greatly to aggravate the patient's sufferings and
perpetuate the evil, by the forcible extension of the
excoriated parts.   The sensation  of  burning heat
and itching becomes greatly aggravated on getting
warm in  bed, demanding all the resolution which
the individual can summon up to avoid scratching
and exasperating it with his  nails,  an operation
which  in his sleep almost inevitably takes place.
The exacerbations to which  this affection is liable
sometimes  alternate  and sometimes coincide  with
those of  the dyspeptic affection.  It is one of the
many examples of the  intimate sympathy which
subsists between the external outlets of  mucous
membranes and the more internal and distant parts
of  their  surface.  Ascarides   sometimes coexist
with this disease, and  though there is no reason
to suppose  them capable of producing  it,  save
when a  peculiar predisposition exists, they must
doubtless tend  much to exasperate the irritation
and prolong its existence.  We have known  this
affection  alternate with small  patches of lichen,
psoriasis, or eczema  on the arms or neck.   Se-
dentary habits, too free a mode of living, especially
in regard to the use of wine and malt liquors, and
costiveness, are sure to aggravate it.   With regard
to the treatment  of it, little can be expected  from
local  applications;  frequent ablution with  cold
water affords  a  momentary relief;   but it is to
great temperance, steady and active exercise, a due
regulation of the bowels, and a correction of the
vitiated  and irritating nature of the alvine.  dis-
charges,  that we can  alone look for permanent
benefit.
   The diagnosis of eczema is occasionally at-
tended with considerable difficulty,  as cases not
unfrequently present themselves  where  papula?
and  pustules  coexist with  the true  eczematous
disease;  thus allying  the case at once to lichen,
impetigo, and eczema, and  making  us wish that
the idea of Burns had been acted on, in establish-
ing as an appendix to our present classification  a
set of composite genera to which those specimens
of cutaneous disease which are of a mixed charac-
ter, and display an affinity to two or more of the
simpler forms, might be referred.  For the conso-
lation of  the student in this  department of patho-
logy, we may mention that we have seen the  most
practised  eye puzzled by such  combinations ; and
individuals,  who had made  cutaneous disorders
their peculiar study for years, confess themselves
unable to dispose satisfactorily of such examples
in any part of our present arrangements^
  In the  first stage of the affection, when it exists
in its simple form, the  only diseases with which
we are liable to confound it  are some of those of
the papular kind, and scabies.   From the former
it may be satisfactorily distinguished  by the colour
of the minute vesicles,  or more certainly  still by
puncturing them with a needle, and thus  demon-
strating the fluid nature of their contents.  Their
subsequent  progress, too,  is  dissimilar.  From
scabies, or common itch, the diagnosis, especially
of the  impetiginous  form  of eczema, notwith-
standing  what is asserted by professed writers on
the  subject, we  have often  found  by no means
easv.  Its  presence for those situations where
IMA.                                     747

 the sebaceous  follicles  abound—a  knowledge  of
 the preceding  causes, such as exposure to great
 heat  or  other  local irritants — the closeness and
 uniformity with which its minute and acuminated
 vesicles are distributed,—the accompanying tume-
 faction— the tingling  and smarting rather than
 itching which  attends them — will, it is said, ena-
 ble us to distinguish it  from the  scabies, in which
 the vesicles are more apart—larger and more un-
 equal in size—less transparent,  or of a duller  co-
 lour,  and without any inflammation at their base,
 —intermingled with minute ulcerations and small
 dark  scabs—attended with a sensation of  simple
 itching—and, finally, occupying chiefly the inter-
 vals of the  fingers, the  wrists, and  the flexures of
 the articulations generally.
   The presence or absence of a contagious quality,
 and the effects of treatment, which are  usually
 dwelt on  as points  of distinction, are  not very
 creditable grounds on which to form our diagnosis.
 To discover the  nature of a  disease when  it has
 been  already cured, or when it has  spread to other
 persons  in  consequence of our incompetence to
 decide on its true nature, is not satisfactory to any
 of the parties concerned.
   A  complication  of itch  and eczema  is  not an
 impossible occurrence, and of course must present
 much difficulty.  Indeed,  we have heard of such
 cases by which the medical attendants were greatly
 embarrassed, till in the frequent  handling and  ex-
 amination  of the parts  they have themselves con-
 tracted scabies, and thus  become fully convinced
 of the existence of at  least  one part of the dis-
 order.
   The miliary eruption may be easily distinguish-
 ed by the constitutional symptoms which  precede
 or accompany it;  and  simple  erythema, by  the
 absence  of  all  feeling of roughness such as char-
 acterizes eczema rubrum  even  in  its early stage,
 and depends on  the elevation  of the nascent vesi-
 cles.   Inattention  to  this circumstance has  led
 some  writers improperly  to  describe the  eczema
 mercuriale as a species  of  erythema.  Impetigo is
 sometimes distinguishable  with difficulty, if at  all,
 from   that  species of eczema in which pustules
 present  themselves.  The existence of pustules
 from   the very commencement, and the  greater
 thickness and  prominence of the  crusts, belong
 more  especially to the former.  In a  practical
 point of view, however, their diagnosis is not very
 important.  It  is often far from easy to distinguish
 psoriasis of the scrotum and  penis from  eczema
 of the same parts when in its advanced and scaly
 stage : the greater  thickening and hardness of the
 integuments in the former, and the fact of vesicles
 or humidity never having  been  present, will aid
 our diagnosis.   When  eczema has existed  a con-
 siderable time,  its red, chopped, and scaly  surface
 approximates closely to the appearance of  lichen
 agrius.  But even  when vesicles no longer exist,
 as is  the  case in  the  more  advanced  and  drier
 stages of eczema, minute disseminated scaly points
 will  frequently show their former seat, and dis-
 close  the true  nature of the disease.  Eczema  of
 the breast and  nipple in its scaly stage,  which it
 has generally attained to before  we are consulted,
 presents  to the eye merely  a collection of thin and
 generally yellowish crusts, and is accompanied
 with  a burning itchiness;  at  this period we «hal' 
T48
ECZEMA.
in vain  search  for vesicles.   Chronic eczema, in-
deed, in its later periods, when it has passed into
a scaly state with  numerous erosions and ulcera-
tions, is scarcely recognizable at first sight, even
by the most experienced eye.  It is to the history
9f the case that we must here  look for decisive
information.
   In what we  have said of the diagnosis of this
very frequent and very distressing cutaneous af-
fection, we have been actuated  by a desire to re-
present it  in all its true difficulties; as we know
that the most  zealous students often turn with
disgust from the  investigation  of diseases  of the
skin, upon finding these difficulties  so infinitely
greater than they are represented in books, and
begin  in  despair  to suspect  that they want the
tact necessary  for their successful study.   When
made  aware of the obscurity  which they often
present even to the most experienced, this cause
of discouragement will  in  some degree be done
away with.
   The prognosis of the acuter forms of the dis-
ease, especially when they depend on some obvious
cause  of  local  irritation, is generally favourable.
In those cases where the mercurial eczema has as-
sumed  its most formidable aspect, the danger has
been attributable probably not so much to this af-
fection in itself as to the  cachectic habit  of the
patient, exhausted  by  previous  and co-existent
disease as well as by tbe profuseness of the dis-
charge.  In the majority of those instances where
chronic eczema is very obstinate, and where the
most carefully  adapted local treatment has proved
 unavailing, we should be led to suspect that there
 is something materially  wrong with the state of
 the general health.   We  have seen such cases
 which had existed for years, and resisted for nearly
 as long a time the most judicious and energetic
 topical measures.  In  the aged it is peculiarly un-
 manageable, and a cure often almost hopeless.
 Alibert speaks of the dartre squammeuse humide,
 in its  aggravated  form, as one of the most obsti-
 nate and insufferable  diseases to which humanity
 is liable; the irritation which it keeps up, and the
 despondency which innumerable relapses tend  to
 generate, having  in some  instances, according  to
 him, led the unfortunate  patient to the commission
 of suicide.
   Treatment.—The introduction of the sooth-
 ing plan of treatment constitutes the most remark-
 able improvement which has taken place in regard
 to the management of  the  cutaneous diseases  in
 these latter times.  In mild cases, if we can suc-
 ceed in subduing for a time the irritation which
 exists, nature will often do the rest, and  re-esta-
 blish the natural actions of the part.  In no class
 of these diseases are soothing measures more called
 for than  in  the vesicular forms, in which  the in-
 flammation  is usually characterized by considera-
 ble acuteness  and a high  degree  of irritation.
 This  is peculiarly the  case with some of  the va-
 rieties of eczema.
    Great relief may usually be afforded by frequent
 ablution  with  tepid water or mucilaginous decoc-
 tions,  as  those of bran, marsh-mallows,  poppy-
 heads, or of gruel or milk  and water; by mild
 poultices, with or without the addition of goulard,
 and by local and general tepid baths.  Mr. Plumbe
 condemns in  strong  terms the use of ointments,
and recommends the employment of the common
spirit-wash in incipient cases.   Lotions containing
prussic acid have been found to have much influ-
ence in  allaying the pruritus.   When the patient
is young and of a sanguineous temperament or
plethoric habit, venesection should not be neglect-
ed, and leeches and cupping in the vicinity of the
disease  are most important  auxiliaries.   The diet
should  be light and very sparing.   Bateman re-
commends the use of bark and serpentaria, but on
no very clear indications.  Mild diluents, gentle
laxatives, and the use of the vegetable or mineral
acids, are generally all  the  internal medicine ne-
cessary, especially in the acuter and more rapid
forms of the affection.  As  to the propriety of the
employment of  acids, so usually recommended in
cutaneous disorders, we might, if guided by theory
alone, have some doubts; for in certain habits, as
has  been  remarked by Sir A. Carlisle,  they of
themselves occasionally excite much irritation in
the  skin.   Thus many people are affected with
pimples shortly after taking  them, together with
burning  heat in  the  face  and  itching over the
whole body. Yet here, as elsewhere, preconceived
notions with regard to the propriety of  a thera-
peutic agent in  disease, derived from a knowledge
of its influence in a state of  health, must not be
put in  competition with the  practical  results of
experience, and we have certainly  seen very trou-
blesome cases of eczema yield rapidly whilst acid
drinks were used.  The  mineral acids (sulphuric
and nitric) seem, indeed, to have considerable in-
fluence  in  the  later periods  in diminishing both
the exudation and the itching of the affected parts;
whilst in the earliest and most inflammatory stage
those of the vegetable kind, on account of their
cooling properties, perhaps  deserve the preference.
   In the mercurial eczema, if its attack be violent,
 Biett, we believe, never omits  the precaution of
 taking  blood from the arm,  as the best means of
 obviating or moderating those symptoms  of irrita-
 tion  in the mucous membranes of the respiratory
 and digestive  organs which  occasionally compli-
 cate  it.  Pearson recommends the use of diapho-
 retics ; but  the irritable state of the stomach and
 bowels frequently renders them improper: and in
 those  very  rare cases where typhoid symptoms
 supervene, the employment of bark will often, for
 the same reason, be found  inadmissible.   Opiates
 have very usually been recommended  by way of
 allaying irritation and  procuring  sleep, but their
 exhibition requires much circumspection, as opium
 has occasionally been  known, in  this as well as
 in the healthy  state of the skin, to induce severe
 itching : and Dr. Moriarty met with one case in
 which  it* apparently was the cause  of a relapse.
 The daily use  of the tepid  bath usually affords
 much relief by removing the secretion and keeping
 the surface pliant.   Where, however, the excoria-
 tions  are very extensive, even the tepid bath can-
 not well be borne, and the effort of getting in and
 out of it causes much suffering.  The heat of the
 bath must be carefully regulated, for if of too high
 a temperature, it will inevitably aggravate  the
 inflammatory tendency in  the  cutaneous surface.
 The pain caused by the rigidity and contact of
 the incrustations may be in some degree  alleviated
 by the application of the linimeutum calcis.  Re-
 peated changes of tbe linen are indispensable, and 
ECZE
will sometimes, from the abundance of the secreted
matter, be necessary as often as three or four times
in the course of one day.  The return to mercury
in these  cases is to be avoided if possible; as even
its mildest preparations have occasionally induced
a recurrence of the disease, an effect which took
place  in a case recorded  by Dr. Crawford, from
the incautious application of citrine  ointment to
the still morbid skin.  In some urgent cases, how-
ever, mercury has been again  exhibited, and with
impunity.
  When eczema has become chronic, the local
treatment should still in almost every case be of
the soothing kind.   Hence  a steady perseverance
in the use  of tepid  mucilaginous decoctions, of
lotions containing the acetate of lead, of local  and
general  baths, continues, as  in  tbe first stage, to
be proper.   General  and  local bloodletting  and
other antiphlogistic measures will still often afford
us most valuable assistance in subduing this ob-
stinate affection ; the  propriety of their employ-
ment and repetition being  of course determined
by a joint consideration of the state of the consti-
tution and of the local inflammation in each indi-
vidual case.   We cannot, however, help thinking
that,  in this country at least, the utility of these
measures has, till within  these very few  years,
 been  greatly overlooked, and that their  employ-
ment, even at the present  moment,  is  quite too
infrequent.  This  may perhaps in a great degree
be attributed to their never once being alluded to
by Bateman, whose bias seems to have been alto-
gether towards the opposite mode of treatment, or
the frequent exhibition of tonics.  His preposses-
sion,  too, against the use  of aperients in eczema
is not justified by the experience of others, as they
are often found to be highly  beneficial.  We have
known  very severe  cases yield  to the combined
employment of baths, mineral acids, and laxatives.
 When these and the other measures detailed above
disappoint  us after having been fairly tried for at
least  three  or four  months, recourse may be  had
to the  cautious use  of Fowler's solution, or of
 tincture of cantharides.  Amongst Biett's nume-
rous cases under the influence of those powerful
 medicines, we do not recollect to have seen them
ever do mischief;  and  hence we participate fully
in the  sentiment  with which he frequently  pre-
faces their prescription, namely, that no medicine,
however active, is  dangerous in  prudent hands.
Mucilaginous and diluent drinks enter largely  into
all his plans of treatment, and  must tend materi-
ally to obviate the danger of gastric irritation  dur-
ing the use of energetic internal medicines.  Whe-
ther the beneficial  influence which arsenic  and
cantharides often display depends on tbsir  imme-
diate action on the skin,  or whether it is attribu-
table- to their effecting a species of counter-irrita-
tion  on  the mucous membrane,  and  a consequent
equalization of the  circulation  in the cutaneous
and mucous surfaces, is utterly unknown.  Their
great power as modifiers of the actions of the  skin
is, however, indisputable.   The  exhibition of frac-
tional doses of the corrosive sublimate also, given
in a decoction of dulcamara, occasionally effects a
cure where other measures have failed.
  Caustic applications, as  the nitrate of silver or
diluted  muriatic acid, have sometimes been used,
as is  mentioned by  Rayer, with a view to chang-
                                     3n  *
IMA.                                     749

ing the mode of irritation in the  part;  but they
are not unattended with risk, and  violent exacer-
bations and deep  cicatrices have resulted  from
their employment.  In the advanced scaly stage
stimulant applications have sometimes been of use,
by exciting a more active inflammation, and thus
subverting the existing morbid action.  Ointments
containing the red precipitate or  tartrate of anti-
mony, and blisters have occasionally been had re-
course  to with this view, and with  success; but
the practice is rather empirical, and the result du-
bious.  In  an indolent and scaly state,  alkaline   V
and sulphur baths  may perhaps sometimes be use-
ful ; but if too early employed, they are sure to
aggravate the inflammation, and in the great ma-
 jority of cases the vapour bath is to be preferred
to them.
   When there exists  any obvious  derangement
of the general health, little  improvement  need
be expected till this state be  first counteracted.
 Country air and  a careful regulation of the diet
 are  here points of the first importance ;  alterative
doses  of calomel or blue pill, with the  decoction
 of sarsaparilla,  will  sometimes also be of great
 service.  In those cases  where there is a marked
inflammatory diathesis, indicated  by a full pulse,
 heat of skin,  thirst,  headach, drowsiness, &c,
 Dr. Elliotson has found much benefit from mercu-
rial medicines,  given  so  as slightly to  affect  the
 mouth,  in  conjunction with  venesection and a
 low diet.   Such a mode of employing mercury,
 in a disease of which it  is itself an occasional
cause, will, however, demand great circumspection.
   The use of water-dressings, in  preference to all
 ointments and greasy  applications, has long been
 zealously advocated by Dr. Macartney, who has
 directed much of his attention to the study of dis-
 eases  of the skin.  Indeed the beneficial  effects
 which may be produced  in this and several other
 cutaneous inflammations, merely by keeping  the
inflamed part  constantly moist by  means of lint
wetted either with cold water or a weak solution
 of the acetate of lead, and enveloped in oiled silk,
 are  unquestionable and  striking.   We do  not,
 however, think that the employment of ointments
 is in  all cases  injurious, having known  eczema
 of the ears  and face,  though attended with  ex-
 treme irritation, receive immediate relief, and  get
 speedily well under the  use of an ointment com
 posed of cold cream and the liquor plumbi acetatis
 in the  proportion of two  or  three  drops  to  the
 ounce, in  conjunction  with the repeated applica-
 tion  of a  cooling  lotion, consisting of the acetate
 of ammonia, accurately neutralized, largely dilu-
 ted, and holding a minute portion  of the acetate
 of lead in  solution.
   If the disease have  existed  about the face for a
 considerable time, an issue or  perpetual blister to
 the nape of the neck or the arm effects a useful
 counter-irritation,  and  will  thus  often tend both
 to accelerate the  cure  and  to prevent a relapse.
 A free state of the bowels and a frequent use of
 the bath  seem also to have  much influence in
 guarding against a recurrence of  the affection.
   The  propriety  of a cooling and  sparing  diet
 throughout every stage of the disorder, and even
 for  a  considerable time  after its disappearance
 cannot be too strongly  insisted on.
                                 W. B. Joy 
750
EDUCATION,  (PHYSICAL)
  EDUCATION,  PHYSICAL.   Education, in
the ordinary acceptation of the term, refers only
to intellectual and moral cultivation.  Mr. Locke,
however, has taken a wider and juster  view  of
the subject, and in his excellent Treatise incul-
cates strenuously the attentions necessary for pre-
serving and strengthening the bodily constitution.
This branch has been denominated physical edu-
cation.
  If medical science effect something more than
the mere  adaptation  of remedies  to  a  few spe-
cial  diseases;  if it embrace  the  more  enlarged
and comprehensive purpose of promoting general
health, and  preserving the bodily frame in the full
and  vigorous exercise of all its functions, then is
the subject of physical education entitled to a pro-
minent place in every work which  professes to
treat of the  science, or to display its most useful
applications.  No applications of its principles can
be more useful  than those  which regulate the
physical management of the young; for even in
infancy, and still more when childhood passes on-
ward to adolescence and  puberty, are  errors of
ignorance  and prejudice daily committed, which
sow deeply the seeds of disease, consigning many
a sufferer to an early grave, or entailing miseries
which render life a burden rather than a blessing.
However difficult it  may be to correct the mani-
fold errors by which, in early life, health and hap-
piness are sacrificed, it must  at least be right to
point out  to those who wish to  learn, what are
the principles  by which the first of earthly bless-
ings, a sound mind  in a sound body, can  be best
insured.   With bodily health, mental is here as-
sociated, for the connection  is intimate :  if  the
body languishes, the  mental powers, which  act
only  through  bodily  organization, must fall  far
short of that energy and  activity of which they
would otherwise be capable; while the irritability
of  mind  to which weakness  and ill health  are
prone, is sure to act unfavourably on  all  the moral
feelings.   In the present article  the design is to
lay down principles rather than rules; for  the lat-
ter never can be so framed as to admit of univer-
sal application, and when indiscriminately used,
they  either, through necessary  variableness of
effect, fail  to inspire confidence  and in time  fall
into disuse, or the good  which they do accomplish
is sure to be balanced by a portion also of  evil.
To lay down  principles is the  safer and better
course, for though  pbysiological truths are what
few even  among the most intellectual classes of
society are prepared to comprehend, their educa-
tion unhappily leaving them utterly unacquainted
with  the  structure  and functions of their  own
frames, still the dissemination of these truths, es-
 pecially in connection with a subject of such deep
 and universal interest, may not be wholly unavail-
ing, but may rather  prove  the means of exciting
enquiry, and of dispelling that ignorance to which
so much of the ill health of every period  of life
 may be distinctly traced.
   Man, in his relation to external objects, is  sub-
 jected  by nature to certain laws; in other words,
 there  exist between man and the external world
 certain definite and immutable relations, as obliga-
 tory as a  positive  ordinance.  If the relation be
 disregarded, the law violated, the  penalty ensues
 with a certainty tha  cannot be evaded.  It is well,
then, as all are subjected to these laws, are capable
of acting in conformity with them, and sure to
suffer when betrayed, whether  by ignorance or
wilfulness, into infringing them, that some con-
sideration should  be bestowed on them, in order
that errors  of  ignorance  at  least may have some
chance of being avoided.
   The natural laws which connect man with the
objects around him have been appropriately classed
under three heads; namely,  the physical, organic,
and moral.   Vitality confers no exemption  from
the  laws of matter  and motion.   To  these the
human body is subject equally  as  if it were not
endued with life.  It is true  that, while  animated,
it possesses to a certain extent powers capable of
modifying their operation ; still  it never ceases to
be under their  influence, and it  is liable to suffer
whenever that influence  is  overlooked or miscal-
culated.  The body gravitates, and when deprived
of support  falls to  the  ground, equally as if it
were inanimate.  Physical  laws,  therefore,  are
worthy of consideration,  in  order  that no injury
may accrue from  their violation. . But  animated
bodies are subjected to laws peculiar to themselves;
and as life is always  connected with organization,
these laws are called organic. It is with them that
we are more immediately concerned on the present
occasion. Man, however, is not only an  organized
and animated being, but also a moral and intellec-
tual one; and is, in consequence, subject to further
laws in relation to this part of his nature, namely,
the  moral.  As his moral and intellectual powers,
however  derived  essentially from his  spiritual
nature, are dependent on  organization  for  their
exercise and manifestation ;  as the several powers
act interchangeably on each  other ;  and  as a close
analogy resulting from  this connection subsists
between the organic and moral  laws, it will be
necessary to take  some notice of the latter in the
following pages.
   The organic laws may be subdivided according
as they regard respectively the preservation of the
species  and of the  individual.   The former of
these may here be passed over as not essential to
the present purpose, the  preservation  of the indi-
vidual being that  which chiefly claims attention in
discussing the principles  of  physical education.
   The animal body is connected  more immediately
with the external world  by  digestion and respira-
tion, it being through  these   processes that  it
derives the elements  by  which it subsists.  Food
and air are indispensable so long as life endures ;
and if either be withheld, or depraved in quality,
or too scantily  supplied, the animal languishes and
prematurely dies.   Other elements are  most  pro-
bably combined ; there  being  reason  to believe
 that the electric conditions of the atmosphere
 exert an influence on the animal economy neither
 slight nor  unimportant.   We  know  too  little,
 however, on this  subject to make it the ground-
 work of any  reasoning.
    On the regulation of  diet much of the health
 of the body depends.  All animals are destined by
 nature to feed on  particular  aliments, for digesting
 and assimilating which they are furnished with an
 appropriate organization.   Some are herbivorous,
 some graminivorous, some carnivorous. Man being
 by  nature omnivorous, a mixed diet of animal and
 vegetable food is  best fitted for his adequate nutri- 
EDUCATION,  (PHYSICAL)
751
tion, being most accordant with his organization ;
and this fact o.ught to serve as a sufficient reply to
all  those  who  decry either  animal  or  vegetable
diet.  The proportions  best suited for supporting
perfect health  must  ever vary in individual in-
stances, being  dependent  on  age, temperament,
habits  of  life, state  of  health, climate, season of
year, and  other  incidental circumstances.  The
general principle  being clear, sufficient  ground
should be  specially shown whenever it is deemed
necessary to depart from it, or to modify its appli-
cation.   To display the properties of the several
artii-lcs of food, both animal and vegetable, is the
province of dietetics.   (See Dietetics.)
   The quantity of  food  deserves as much con-
sideration  as  its quality.   It  should be such  as
the stomach can  easily digest, and  sufficient  to
repair the waste whicb the body continually un-
dergoes.   In the young, too, it should provide for
 the growth of the body, which in them is, up to a
 certain age, progressive.  Deficiency of sustenance
 [eaves the body imperfectly nourished, checks  its
 natural growth, and begets various diseases mark-
 ed by  debility.   Excess,  on the contrary,  pro-
 motes  inordinate nutrition,  induces corpulence,
 oppresses all the functions of life, and through the
 various efforts  made by the constitution to dispose
 of or to get rid  of it,  lays the foundation of  by
 far the greater portion of human  maladies.   In
 the functions more immediately essential  to mere
 animal existence,  nature  influences by  feelings
 antecedently to any exercise  of reason, and,  with
 respect to the nutrition  of man, has given him
 appetite both to incite him to take food, and to
 assign a  limit  to his use  of it.   A  healthy sto-
 mach, supplied with simple diet, will, if the  inti-
 mations of appetite be  heeded, be rarely guilty of
 excess.  But though the stomach is thus satisfied,
 and the natural appetite ceases, it is still capable
 of taking more food,  and  even of digesting  it.
 Viands tempting to the palate will incite a fresh
 appetite,  under which the quantity of food requir-
 ed for health, and which consistently with health
 ought not to be exceeded, is often more than dou-
 bled.   Pampered with  luxuries, and rather living
 to eat than eating to live, numbers become slaves
 to a sensual gratification of the lowest  kind.
    Excess is the vice rather of adults than of the
 young, who are rarely either gourmands or epi-
 cures, unless through the fault of those who rear
 them.  The law of temperance, however, is com-
 mon to all, and, however it may be disregarded by
 the inconsiderate or the sensual, cannot be viola-
 ted with  impunity.
    Co-ordinate with nutrition, in  its being essen-
 tial to animal life, is respiration.   It differs in one
 respect, that while food is  required only at inter-
 vals, appetite  being the  natural incitement  and
 measure  of quantity,  air  is  necessary  every mo-
 ment ; and as  the process goes on uninterruptedly,
 no incitement  of appetite is  needed  for inhalation
 of air. The capacity of the lungs, too, being defi-
nite, no intemperance can be practised;  and with
 regard to this  function it is quality rather  than
 quantity  that requires  to  be  attended  to.  This,
 however,  is of the very first importance; for if
 pure air be not  breathed, health cannot be pre-
served.  Of injury from impure air the young are
peculiarly susceptible,  and  this requires to  be
attended to in many parts of their ordinary man-
agement.
  Next in importance to food and air, as a means
of maintaining  health and vigour,  is  exercise,
whicb is to be considered not merely as it regards
locomotion, but as applying to all the actions  of
the animal frame whicb minister to existence, and
by which the several functions are sustained.  The
actions immediately essential to existence are,
happily, independent of  the will, and are thus  se-
cured against the effects  of indolence or caprice.
Respiration,  though not wholly an involuntary
process, is so far independent of the  will for  its
ordinary exercise as to continue uninterruptedly,
througb the  whole period  of life, without  effort
and almost without consciousness. Thus circum-
stanced, and  secured  as  its  organs  are  by their
compact and admirably constructed mechanism, it
might be  conceived that this process at least might
escape the evil influences of heedlessness or error;
yet  no function of the  frame has suffered  more
from the pernicious effects of folly  and fashion,
effects the reality of which it would be-difficult to
credit,  were  it  not attested  by woful experience
and daily observation.   Circulation,  too, is  inde-
pendent of the will, its organs being  excited suffi-
ciently to ensure the regular continuance of their
actions, by the fluid which digestion  supplies and
which  respiration vitalizes.  Yet here, also, though
nature has provided for the regularity of this func-
tion, and rendered  it independent of direct  inter-
ference, man contrives indirectly to disturb  it by
over-excitement through excess of nutritive mat-
ter and abuse of various stimulants.   So  far is
the  body  ensured against the neglect or  impru-
dence  of the individual, that what  is absolutely
necessary for existence is carried on  by the mere
incitement of appetite,   and through actions  in
which the will has  no share.   But  though mere
existence is  thus capable of being maintained for
 a while with little  effort, voluntary exertion is still
necessary for giving even  to these independent
functions  the activity necessary for  healthful vi-
 gour.  Unless exercise,  in  its ordinary sense, be
 taken, neither respiration nor circulation can fully
 accomplish the purposes which they  are intended
 to serve ;  and proportional decline of health and
 strength must ever ensue.   Exercise conduces to
 healthful  digestion,  perfect respiration, and effi-
 cient circulation.   Neglect of exercise weakens
 the stomach, inducing  changes in  the digestive
 processes  unfavourable to the formation  of health-
 ful  chyle; it tends to reduce  the capacity of  the
 chest, and thus to  render  the  respiratory process
 less effective; and it diminishes the actions  of the
 heart and arteries  to the  extent of suppressing
 some of  the most  important  functions  to which
 they are  subservient, namely, those which take
 place  in  the capillary  system.  For propelling
 blood duly into all the capillary vessels, a certain
 portion of exercise is indispensable.  If this  be
 not taken, some or other of those vessels  will  be
 inadequately supplied ;   and in proportion must
 their  functions  decline, while  the  blood  which
 ought  to  pervade  them  is  thrown back  on  the
 larger trunks, overloading and oppressing the gen-
 eral system.
   Life subsists  through  a series of motions, and
 all these  should be  maintained in regular and ade- 
752
EDUCATION, (PHYSICAL)
quate exercise.  If any become suspended, or de-
cline  beneath the activity necessary for the due
performance of their respective functions, the or-
gans shrink, and  more or  less impression on the
general health ensues, according to the importance
of the parts consigned to quiescence.   If there be
total suspension, the organ then undergoes changes
wholly subversive of  its character and  functions.
A vessel which ceases to  convey its  proper  fluid
becomes soon  changed into a solid cord.   Muscu-
lar fibres, if consigned to inactivity, waste  pro-
gressively, with proportional  loss of  power, until
at length they approach the state of simple mem-
brane.  The laws of muscular action require that
the muscle, in order to retain even its natural
structure, must be continued in the adequate ex-
ercise of its natural functions, else it declines both
in volume and power, and all the  functions  to
which its actions  are subservient, become impeded
in consequence.
   The foregoing  sketch, though brief and imper-
fect, may suffice to show what is meant by re-
ferring  to the  natural laws.   The subject, how-
ever,  is not yet sufficiently matured for an ele-
mentary exposition of the whole  of them, and
at all events the writer of the present  article is
unprepared  to attempt it.   Whatever  remain,
therefore, applicable to the present purpose, must
be left for the occasions which in  the  course  of
this essay may call for their introduction.
   In pursuing the subject of physical education,
the period  of life  to which  it applies may  be
divided into  the  consecutive  stages  of Infancy,
Childhood, Adolescence, and  Puberty.  The dis-
tinctions are sufficiently  intelligible  without as-
signing exact limits to each.   To do so  by a  divi-
sion of years would conduce  but  little  to preci-
sion, for individuals differ  so  much,  that similar
ages do not necessarily  indicate corresponding
stages of development either in bodily or mental
powers.
   Infancy. — The  management  of  infants has
been much improved in modern times, and many
hurtful prejudices have been utterly extinguished.
None, at least  in this country, even of the most
ignorant, deem it necessary at the present day to
swathe the infant's body so as to deprive its limbs
and head of all free motion, as was long the uni-
versal  practice, and in some  countries, even  of
Europe,  continues to be so.   The  infant is  now
suffered to  enjoy  the  unrestrained exercise of  its
muscular energies so  far  as its limited powers  of
exerting them permit.  This was a great eman-
cipation, and conducive not only to physical but
also to  moral improvement.   The  exercise  of
every natural power is accompanied witb pleasu-
rable feeling, and, without resorting to  metaphy-
sical refinements, it  may,  from a  close  analogy,
be averred that the infant  is sensible of pleasure
from the free  exercise of  its  motive powers, and
suffers pain  from their restriction.  These sensa-
tions excite moral emotions, and without any great
stretch of imagination, it is possible to detect the
dawning of  an irritable temper at a period of life
when a  moral feeling  is scarcely  supposed  to
exist, and to trace its development to irritations
which enlightened caution might prevent.  Even
at this early period the moral  laws are  not to  be
disregarded.  These laws  pronounce that moral
feelings no less than the physical powers acquire
force by  exercise, and  that  the «urest  way  of
weakening those which, when tending to excess,
lead to evil, is to consign them as much as possi-
ble to quiescence.  Great  care is therefore neces-
sary not to arouse angry passions, and especially
in infancy, when the otber moral feelings, and the
intellectual  powers  by  which they  are  in  later
years controllable, are too imperfectly developed
to  be  of avail.   The principle  is  applicable  to
every period of  life, and  the interesting stage now
under discussion should  have the full benefit of it.
   The present  occasion does not call for minute
details of the management of infants, which are
so  familiarly known and so much under the guid-
ance of  competent advisers, being  for the  most
part regulated by enlightened medical attendants,
that a  few  general  remarks  may here suffice.
They may be comprised under the heads of cloth-
ing, food, state of bowels, air, temperature, clean-
liness, exercise, moral discipline, and habits.
   Clothing.—The clothing of infants should be
soft in  texture,  so as  not to irritate their tender
skin.  It should be made  so as to give free  play
to  all the limbs, no  part being subjected to con-
striction  or undue pressure, and should also  be  so
simple as to admit of being quickly adjusted.  The
process of being dressed is irksome to most in-
fants, causing them  to cry, and exciting as much
mental  irritation as they are capable of feeling.
It should, therefore, be rendered as brief as is com-
patible with the ablutions  required, and with the
necessary adaptation of the  garments  to   their
several purposes.  By a  very little ingenuity  they
may be so constructed as to be put  on  and re-
moved with little delay.  It would be well if pins
could be wholly  dispensed with, their use being
hazardous through the carelessness  and stupidity
of nurses, and even through  the  ordinary move-
ments of the infant itself.   Soft tapes, loops, and
buttons, hooks and eyes, or other such fastenings,
might be beneficially substituted.
   Food.—That the infant should derive its ear-
liest sustenance from the mother's breast was so
obviously designed by nature, that  the  abstract
propriety of mothers  suckling  their offspring ad-
mits of no dispute.   The question, however, whe-
ther all mothers should discharge this duty is not
thus determined, the condition of the mother and
her capability of performing it requiring to be
taken into account,  as well as  the  wants of the
child.   When a mother is young,  healthy, and
sufficiently robust, it is  her  bounden duty,  as it
ought to be her  dearest  pleasure, to foster in her
bosom the being which  she has brought  into ex-
istence, and to nourish it with  the food expressly
provided by nature for its use.   Every considera-
tion, both physical and moral, pleads for this exer-
cise of maternal  function. By it the  bodily health
of both mother and child is promoted, while it ex-
cites in both the purest emotions of the heart.
   All mothers, however, are not  capable of per-
forming this duty ; and, unfortunately, among the
higher and middle classes of society, a considera-
ble portion, through  errors of physical education,
and the  debilitating  effects of  various pernicious
practices proceeding  from fashion,  luxury, and
dissipation, are  incapacitated  for  undertaking  it
Thus error  perpetuates  itself, and in  its  natural 
EDUCATION, (PHYSICAL)
753
consequences comes to act in a circle.  The dis-
sipated mother neglects  her child, and this child,
if a female, commences life under disadvantages
which, by weakening her frame, tend to unfit her
for eventually acting as  a mother.   Extreme deli-
cacy of constitution, diseased condition  of the
frame, defective secretion of milk, may forbid the
mother to suckle  her child.  Unless she can per-
form the  duty with safety to herself and benefit to
her infant, she ought not to attempt  it.   In this
case a young  and healthy wet-nurse  is the best
substitute.   But even this resource is not always
attainable, and then it is consolatory to reflect that
children  may be reared without material prejudice
to health, by  what  is  termed feeding by hand,
though extreme care is requisite to make the sub-
stitution  effectual.   In  this case  the  process  of
nature should  be  emulated as far  as possible, and
food should  be imbibed by suction from a nurs-
ing-bottle, rather  than swallowed from  a spoon.
Much  injury results from  giving  infants food too
gross for their digestive  powers.   If  nursing by
hand, as it is termed, be  resorted  to, the  food, for
the early months at least, should approach as nearly
as possible to human milk.  Milk  and water, with
a little sugar, is quite  enough for  the  first two
 months.   After  which  some farinaceous matter
may be combined.   Thick  gruel,  panada, biscuit-
food, and such matters, are much too  solid, at
 least in  very early infancy.  They overload  the
 stomach, causing indigestion,  flatulency, and grip-
 ing.  These create a necessity for purgative medi-
 cines and carminatives, which again weaken diges-
 tion, and by  the unnatural irritation perpetuate
 the  evils which  render them necessary.  Thus
 many infants are kept  in a continual  round of
 repletion, indigestion, and purging, with  the  ad-
 ministration of cordials and narcotics, who, if their
 diet were in quantity and  quality suited  to their
 digestive powers, would need no  aid  from physic
 or physicians.
   The frequency with  which  medical aid is re-
 quired for infants under gastric and intestinal dis-
 turbance, and  the  numerous infantile  maladies
 which spring from this  source, are sufficient proof
 that their ordinary diet is not as rational as it might
 be rendered. From errors of diet are the digestive
 functions of infants chiefly, if not solely,  liable to
 be impaired, and, when these become so, correction
 of diet, rather  than the exhibition of drugs, should
 be relied on for remedying the evil.   We are far
 from inculcating  that on such occasions  medical
 advice should  not be resorted to ;  on the contrary,
 our persuasion is, that,  when  such  disturbance
 arises, medical counsel is absolutely necessary, as
 the medical  adviser is more likely to  see  the real
 nature of the  evil, and  adopt rational means for
 its correction, than  they  whose  injudicious pro-
ceedings occasioned  it.  But we would strenuously
advise the medical  attendant to be sparing of his
drugs, unless he see adequate cause for exhibiting
them.  We are well aware that,  even in  infancy,
the bowels  may  become loaded,  and  their lining
membrane coated with redundant mucus, and that
purges, even of calomel and antimony,  with rhu-
barb  or  scammony,  may be  required to cleanse
them,  and  restore  healthy secretion.  But such
remedies should  not be prescribed on  every trivial
occasion, and  at  all events a  succession  of such
   Vol. I. — 95
drastic purges can very rarely be  needed.   The
stools, if rightly understood, will furnish a suffi-
ciently certain guide.  If there be  evidence  of
redundant and vitiated secretion, and if the removal
of this by purgatives relieve pain and  restore tran-
quil feelings, no doubt can attach to the means by
which these effects are obtained. But it sometimes
happens that some tinge in  the faeces, some inci-
dental pain, misleads the practitioner,  inducing
him to believe that more purging is needed, when
the prevailing distress may be owing to the irrita-
tion caused  by  the  purgatives already too  freely
administered.  In  tbis case  he will do well to
pause, and, by abstaining from interference, suffer
the bowels to recover  the  tranquillity which  his
remedies serve to disturb.   It is  a valuable part
of medical science to  know when to resolve on
doing  nothing, and an excellent  result  of moral
courage  to dare to  act on that resolution.   On
such occasions it  is not true that medical skill is
at fault or  in abeyance.  It only evinces the saga-
city to perceive that nature  is competent  to  her
own work, and that she ought not to be interrupted
in completing it.
   In judging of the intestinal secretions of infants,
there is a source of fallacy which  deserves to be
noticed.   Mucus accumulates on the lining mem-
brane  of the stomach  and  bowels,  and becomes
morbid, inducing disease. The irritation of purga-
tives, too freely given, will also cause an increased
secretion of mucus manifested in the stools.   The
matters discharged, however, are very different in
their nature, and can hardly deceive an experienced
eye.  In the former case, the mucus  is  opake,
dense, ropy, or  membranous ; in  the latter,  it is
limpid  and fluid.  Purgatives relieve the  former
condition ; they exasperate the latter.
   Infants  naturally have free bowels, and,  if pro-
perly fed, they need no medicine.  Even in purg-
ing off  the meconium, art is often  superfluously
resorted to, or at least prematurely employed.  The
first milk  of the mother's  breast is the natural
purge, and oftentimes even this is  not required. A
too early exhibition  of castor-oil,  as is very gene-
rally  practised, is  unwise.   A little manna  is  less
irritating,  and will in general suffice.  Simple sup-
positories were formerly much in use, and perhaps
they have been  too much laid aside.   When  dis-
tress, however, arises from distension or  flatulency
under retention of the meconium, some aperient is
needed,  and, for  certainty  of effect, castor-oil is
perhaps most to be relied on. With  respect to the
general management of the bowels of infants, the
principle is  that they should be kept free, and by
the mildest  and least  irritating means.  This is
all that health requires.   It may be finally re-
 marked, however, that no  course of proceeding
can be more prejudicial than, having first over-
 loaded the stomach and then administered  purga-
tives, followed by carminatives and narcotics, to
return  to  the dietetic  errors which  created  the
necessity for all this discipline.
    Air.—It  is of importance that  children  should
 breathe a pure atmosphere.   During the day this
 is  in general sufficiently attended to; but at night
 they are very apt to be  placed under circumstances
 unfavourable to a free circulation of the air around
 them.  Apprehension of cold causes them to ie
 then  more closely enveloped with clothing, esrvi 
754                        EDUCATION,  (PHYSICAL)
ciallv about the head; curtains are drawn in order
to exclude cold air;  nay, through extreme care, a
thin covering is not unfrequently thrown over the
face of a  sleeping infant, confining the respired
air, and impeding the access of fresh air required.
All these practices are bad, and ought to be avoid-
ed.  The head should not be muffled, curtains are
objectionable, and the face should  not  be covered
during  sleep.   Pure air is  Heeded, and a supply
of this  should  be ensured without giving way to
undue apprehension of  cold, of which the danger
is very slight, unless great imprudence be prac-
tised.  Infants  should  be guarded  from cold, but
much heat is prejudicial.   On this as well as on
several other accounts, the child should not lie in
the bed with the  nurse.   After having  sucked, it
should  be  placed in a  cradle with just so  much
covering as is necessary for preserving the natural
temperature.
   Cleanliness.—Cleanliness  is essential  to the
health of  infants, the functions of the skin  being
of high importance, and requiring to  be  kept in
due activity.  The  body should  be washed  all
over once  a  day at  least, and impurities should
never be suffered to remain for any time in con-
tact with the skin.  At  first  the water used should
be tepid, but after a frw months the temperature
should  be  gradually lowered,  until cold  be em-
ployed, unless there be such extreme delicacy and
deficient re-action  as  to  render this  hazardous.
Children  bear well  the transient application  of
cold, which is  in general succeeded by a  genial
glow,  both refreshing  and  invigorating.   Many
weakly children  are renovated  in  health and
strength by means of  a daily plunge  in a cold
bath.
   Exercise.—Infants,  for the first month or two,
sleep so much that  there can be no exercise, save
that of being carried about in the nurse's  arms.
After this  time it is advisable to sutler them to
exercise their limbs freely, by laying  them  fre-
quently on a bed,  sofa, or  carpet, and allowing
them to roll and kick at their good pleasure.  The
delight  which this  affords  evinces how grateful
such freedom is to their animal feelings.
   There is one very common  mode of exercising
infants, which, we think, deserves  particular  no-
tice—we mean  the practice  of hoisting or raising
them aloft in the air.  This  practice is of such
venerable antiquity, and so universal, that it would
be vain to impugn  it.   The pleasure, too, which
most children evince under it,  seems to show that
it cannot be so objectionable as a cursory observer
would  be  disposed to  consider.   Still  there are
hazards which ought not to  be wholly overlooked.
The risk  of accident  is  one  of some amount :
children have slipped from the hands, and sus-
tained  serious injury.   Some  people are so ener-
getic as to  throw  up children and  catch them  in
descending.  This rashness there can be no hesi-
tation  in  reprobating, for however confident  the
person may be of not  missing hold, there must
ever be risk of injury from the concussion suffered
in  the descent, and even  from the firmness  of
grasp necessary  for  recovering and maintaining
the hold.   The motion of  the  body, too, has a
direct tendency to induce vertigo;  and  when the
liability of the infant brain  to congestion and  its
consequences is  considered, when  the frequency
of hydrocephalus in infants is borne in mind, an
exercise which impels blood to the brain will not
be regarded as wholly insignificant.  There is one
more objection which seems not to have attracted
attention.  The hold taken of a child in  the act
of hoisting it is  by the hand  grasping the chest
The fingers and thumb placed  on each side of the
sternum, compress the ribs, and any one with the
hand so placed will at once perceive that if the
pressure were strong, and  the  resistance from the
elasticity of the ribs weak, the impression on the
chest resulting would  correspond  exactly  with
the deformity named chicken-breast.   That any
force is ever used  capable of inducing speedily
such a change  is in the highest degree improba-
ble ; but that reiterated pressure of this kind, how-
ever slight, would in a weakly child have power
to impress  and distort the chest, few, we imagine,
will doubt.
   Rocking was formerly in  almost universal use
with infants, though not meant precisely as exer-
cise.  Every cradle  had its  rocker,  by means of
which it was put in vibratory motion whenever
the infant was  to be set asleep.   The expedient
answered its  purpose; but  the  propriety of in-
ducing sleep by such means is very  questionable,
or rather must  be utterly disallowed.  Sleep  here
ensues because the  motion promotes a congestive
state of the vessels of the brain inducing a degree
of vertigo.  For the reasons already assigned when
discussing  the exercise of hoisting, this cannot be
salutary, and must be scarcely  safe in  the delicate
brains of infants.
   Moral Management.—To notice the moral
discipline of infancy may excite a smile;  and yet
it  is a subject of no slight  moment.  From the
hour of birth the infant is a moral being, and  sub-
ject to the  moral laws;  and it  is the duty of those
who are responsible  for its culture  to  see  that
these laws  be  not infringed.   Bodily  health, too,
being more or less affected by  mental excitement,
a treatise on physical education would be incom-
plete if this source of disturbance were disregarded.
Infants possess several  propensities  and passions
of great  activity ;  and as neither the countervail-
ing sentiments, nor the intellectual  powers by
which they are to be controlled in after-life, are at
this age equally developed, it is the more incum-
bent on  those  who  govern  them  to  regulate, on
sound principles, the dispositions which they dis-
play.  Good dispositions are capable of being cul-
tivated, and evil of  being restrained, even  in the
cradle.  But they who undertake the task  should
look well  after the  government of  their  own
minds;  for if in pursuing  it they yield to the im-
pulse of feelings, unrestrained  by  the  higher sen-
timents and unguided  by the intellect, their mea-
sures will be ill adapted to the ends desired, and
little likely to attain them.   An irritable nurse is
unfit for the care of a fretful child.   The fretful-
ness may be owing  partly to natural disposition;
it often arises from impaired  health, or from slight
sufferings occasioned by some injudicious manage-
ment.  Rendered uneasy  by overloaded  bowels,
constriction from the clothing, misplaced  pins, or
other source of disquietude, the infant has no re-
source but  to cry ; and  if the cause of distress be
not removed, habitual fretfulness and irritability
of temper may become established.  In a child of 
EDUCATION,  (PHYSICAL)
755
natural good temper, when the distress is relieved,
calmness returns; but if the  temper be naturally
irritable,  this becomes aroused  by the pains en-
dured, and especially if under  its sufferings the
child be harshly or unkindly treated:  so that even
when the bodily distress  ceases,  equanimity is not
restored.  Children cry from  pain ;  they cry also
from  passion ;  and no tones can be more distinct
than those which express the respective feelings.
The one should be promptly quieted by removing
the cause of pain ;  the other  is  less speedily cor-
rigible, requiring both time and  a system of sound
moral discipline, to  prevent habits  of irritability
acquiring strength by reiterated excitement. When
the natural temper is irritable, causes of irritation
should be carefully avoided ; the irritability should
be calmly but  steadily repressed ; other faculties
of the mind, too, should be called forth, as indi-
rectly suspending the exercise of the irritable feel-
ings ; and according as the  mental  powers be-
come progressively developed,  the  higher senti-
ments and  intellectual  faculties should  be  so
cultivated as to ensure  them that predominance
over  the animal propensities which the  Creator
has  allotted to them, and on the maintenance of
which all virtue and  happiness  depend.   To ex-
ercise this controlling power in due  time  is the
greatest good which the  infant can experience;  it
lays the foundation of  all moral improvement,
and cannot be too early commenced.  No error
can  be  more pernicious in its consequences than
to be reckless  of exciting  the  passions  of chil-
dren, without considering how  they  are to be al-
layed. Some have been so misguided as wantonly
to excite  such passions in order to habituate the
parties to self-control;  but this error  is so mis-
chievous,  and  so  irreconcilable with  all  sound
principle, that it  must  be of rare  occurrence.
Even carelessness, however, in this respect  is in-
excusable ; and no child should  be  subjected to
any  irritation that can be avoided.   Frequent ex-
citement will, in the naturally irritable, confirm ill
 emper.  while it will endanger  the establishment
of it, even in those who are naturally more calm.
Irritability  of temper in children should  be re-
garded rather in the light of a disease to be reme-
died, than of a fault  to  be punished.  They are
as nature made them, and no  more accountable
for irritability of temper than for a weak digestion
or other  bodily infirmity.   The possession of an
irritable  temper is a  misfortune rather than  a
fault, and the being so  unhappily circumstanced
merits pity rather than  reproof.  All  the assist-
ance which kindness and sympathy  can  render
should be given in support of the struggles  which
such  a  being  has  to  maintain within his own
breast. Imperturbable calmness  is required  in the
government of children, who readily distinguish
whether reproof or punishment  proceed from ex-
cited passion, or are resorted to  solely for their
correction or improvement.  This discussion, how-
ever, must terminate  here.  Enough has been said
to  m irk the close connection that subsists between
moral discipline and physical  welfare.  Tranquil-
lity of mind is essential to good health, and the
government of  the passions is important towards
attaining the ends of  physical education.
   In rearing children it is necessary  to bear in
mind the force  of habit,  by  which, in many parts
of the animal economy, regularity is maintained
with a precision which the dictates of reason could
never command.  Many  of the bodily functions
are signally under its influence ; and on the prin-
ciple  that  activity gives vigour, while quiescence
leads to abatement of energy, much of  moral dis-
cipline may b«. founded on the formation of habits
during those early years when the self-controlling
powers of  the individual  are yet  but imperfectly
developed.  In  respect of food,  of sleep, of the
alvine discharges, a disposition to periodic recur-
rence is clearly  discernible ;  and by attending to
it, regularity of the respective functions may be
sensibly promoted.   Fixed periods  for taking food
are desirable,  and they should be frequent.  It is
unwise to  load the stomach with fresh  food until
the previous  meal  has been digested and passed
onward to the  intestines.   From this error the
gastric and intestinal irritations of infancy often-
times proceed.  Regular habits of  evacuating the
bowels, if duly established,  have  much effect in
superseding the use of medicine.   So prone are
the bowels to make  at certain periods  efforts for
their own relief, that if from any cause the periodic
impulse be resisted,  the effort ceases, and is not
again  actively renewed until the next revolving
period arrives; accumulations, productive both of
inconvenience and  injury, going  on  during the
interval.   It seems  needless to pursue further the
consideration  of infancy.   What  has  been said
furnishes   sufficient  guidance for  conducting the
ordinary management of health, and for guarding
against the errors  to which  this  stage of life is
exposed.   So  many  of the principles inculcated in
the foregoing inquiry apply to the next stage, or
that of childhood, that this may  be more briefly
discussed.   [See a  Treatise on the Physiological
and Moral Treatment of  Infancy,  by  A. Combe,
M. D., Amer. edit, by Dr. J. Bell:  Philad. 1840.]
   Childhood.—In  considering the stage of child-
hood, we shall,  for the sake of method,  pursue the
same arrangement  that was followed  in  treating
of infancy, without deeming it  necessary, how-
ever, to dwell more circumstantially on any point
than its merits may  specially require.
   The clothing of cbildhood should possess the
same properties as  that  of infancy.   It  should
afford due  warmth, be of such materials as do not
irritate the skin, and  so  made as to occasion no
unnatural  constriction.
   On the feeding of children their health is much
dependent; and in  this  respect  injury is often
done from  regulating their diet according to some
preconceived  system  founded on partial expe-
rience or  imperfect observation.    Children,  to
support their natural growth, require ample suste-
nance, and this admitted  truth is with many a
sufficient reason for  overloading their  stomachs,
and with food of too  nutritious a  kind.  Others
again,  from having  seen  healthy children reared
on a low diet, and, also from having occasionally
witnessed disease brought on by excess of animai
food, unaware, too, of the hazard of generalising
from insufficient facts, hastily conclude that low
diet is wholesome,  and animal food prejudicial.
No exclusive system can in this respect be right,
nor can any precise  rule of diet be possibly laid
down, as this requires to be adapted in every case
to the  particular constitution concerned.   It has 
756                        EDUCATION, (PHYSICAL)
been already shown that a mixed  diet of animal
and vegetable food is that which  nature has de-
signed for human beings ; their organization being
fitted  for its use.   The  period, too, when animal
food may begin to be used seems also indicated
by nature, and some portion of it seems fairly ad-
missible as soon as teeth appear  sufficient to mas-
ticate it.  These, however, are but general  truths,
which require  continually to be modified in their
application by special circumstances.  The con-
stitution of the child, and the  effects of particular
diets,  will in  general indicate sufficiently  how it
may be best sustained.  If of a sound constitution,
free  from fever or evidences  of  plethora, with
healthy bowels, a cool skin and clear tongue, the
diet may be liberal, and some animal food may be
conjoined.   It is not wise to stint  the  growth of
children by a too low diet, for, however it may for
a while appear to agree, it induces a state of body
deficient in vigour and  unfit for maintaining full
health.   Children so reared are  prone to scrofula,
and to several other diseases marked by impaired
energy of frame.  Yet neither should children be
pampered; for this leads to evils no less formida-
ble, though of a different character.  Large meals
oppress the stomach, cause indigestion, and by
overloading the bowels, obstruct one of the most
important  excretions.   Too  much  animal  food
supplies blood in excess, begetting a proneness to
fever  and inflammation  ; and every one is  aware
how large a portion of the diseases of children is
thus characterised.  So  long as the general health
is unimpaired, the body and mind active, and no
evidence present to mark excess of  nutriment, that
food may be allowed which natural  appetite  calls
for, and which appears to yield adequate nutrition;
and in such case a mixed diet of animal and vege-
table  food will be  found the best for this purpose.
But if languor at  any time ensues, and febrile in-
dications become manifested,—if the pulse become
frequent, the skin  hotter than  natural,  the tongue
white  and furred, the  bowels irregular, — then,
though these several symptoms  should be only in
slight  degree, and unattended with any specific
derangement  amounting to what is  considered
disease, not only should the diet be  lowered, and
its animal part for a time withdrawn,  but measures
should be  taken to  correct the  state of repletion
which has been suffered to arise.  For some  time
after its removal, too, care should be  taken to keep
the diet under that which  occasioned the consti-
tutional disturbance.
   These observations apply to children of sound
constitutions and  robust  health, and attention to
them may be the means of averting much disease.
In such the plethora so induced is positive; that
is, the blood generated exceeds what the constitu-
tion in its most healthful state could need  or dis-
pose of.  But  there is  another, and a numerous
class  of constitutions in the management of which
further principles are needed.  These are by nature
less robust, and, possessing less powers of resist-
ing slight influences, their healtb becomes more
or less impaired.   The weakness induced disin-
clines to exercise ; and  thus  a  further source of
derangement is superadded.  Under  these circum-
stances,  the nutritive matter  introduced into the
system, though not exceeding what the same con-
stitution in  a state  of  health and vigour would
require, is redundant under its altered condition.
The enfeebled powers  cannot dispose of it; and
hence arises a state of relative plethora, producing
all the evils of the positive, while, from the partial
weaknesses that co-exist, it is capable of inflicting
still more  injury on the frame.  It is the plethora
ad vires of the older writers ;  and the febrile state
which  it  induces  is,  like  that of the  positive
plethora, relievable by evacuations and abstinence.
But for the  restoration of  perfect health, some-
thing more is needed than  merely getting rid of
the febrile excitement.  Suitable treatment will
abate the  plethora,  remove the fever, and correct
the incidental derangements, so as  to bring back
the constitution to the  point from which the  oc-
currence of relative plethora had  caused  it to de-
viate, and increased caution  in diet may prevent
the plethora recurring.  But by adhering to this
caution, the  food  required for full health may be
withheld,  and feebleness  of habit becomes esta-
blished.   In  this  state, while it is  necessary to
limit the  diet so long  as  evidences of renewed
plethora are prone to occur, the necessity of im-
proving the habit,  so as to enable it to bear more
adequate  nutrition, should  be borne  in mind.
Moderating by cautious depletion the circulation
when overcharged, preserving a free state of ex-
cretions, increasing the exercise, restoring tone by
cold ablution or  the   shower-bath, with  other
alterations contributary to the same end, will, if
judiciously  applied and  steadily persevered  in,
restore many such constitutions to a state of vigour
capable of bearing  the diet  of full health, and
exempting the parties  from manifold diseases to
which  they would otherwise be exposed.  It will
be perceived that the measures here enjoined  are
partly remedial, partly restorative ; and it is of the
first importance that the right order of their em-
ployment  be  not reversed.   If, while the remedial
measures  are needed, the fear of debility or other
prejudice  lead to the premature use  of  restorative
means, the whole  corrective process is disturbed
and  rendered impracticable, and  disease more or
less formidable is sure to result.
  Regulation of the bowels  is one of the most
important attentions by which the health of child-
hood is preserved.   Children of sound health, who
are properly fed and have sufficient exercise, will
rarely need aperient physic.  Nature is fully equal
to her own work, and  if not obstructed will effec-
tually  perform it.   Still the  bowels of  children
will occasionally get deranged, and their incidental
irregularities cannot be  too soon rectified; for, in-
dependently  of the local  distress  which  a  disor-
dered state of bowels  occasions, so long as this
continues, a most  important function of health is
suspended, and part of its duties becomes trans-
ferred  to  other  organs unfitted  for discharging
them.   Various  irritations,  too,  resulting from
nervous sympathy,  ensue.   To restore a healthy
state of bowels whenever these become deranged,
is an important part of the physical management
of childhood.  For this, simple means should be
preferred  ; but if  they  fail  to  re-establish regular
evacuations  with  healthy secretions, more  active
remedies must then be resorted to, the direction of
which belongs not to this  place.
   Children should breathe a pure atmosphere both
by  day and night.   By day they should be much 
EDUCATION,
(PHYSICAL)
757
in the  open air,  and  allowed to exercise their
limbs freely, short of fatigue.  Long  walks are
objectionable, and a single over-exertion  of this
kind is capable of doing permanent injury.  In
treating of exercise we  wish to give  one caution
applicable  to  that period when  the  child  first
attempts  to walk.   Its  early  efforts are  viewed
with so much delight  that they  are  apt to be
encouraged and prolonged without regard  to the
mischief which  they may occasion.   The bones
of  infants  have  little  resistance, and  time  is
required ere those  of the legs are capable of sus-
taining the weight of the body.   If prematurely
subjected  to it, they actually  bend  and become
curved; and many an inconsiderate mother has  to
mourn over the deformity which she has  herself
created.  In the upper classes of society this result
perhaps  is  not frequent.  It  occurs  chiefly  to
young mothers who have weakly children, and for
obvious reasons the first child  is most exposed  to
it  Among the poor  it is very common, though
their indiscretion springs from  somewhat different
feelings.  With them it is less  the indulgence of
maternal emotions, gratified by  the child's exhibi-
tion of strength, that leads to this distortion, than
the necessity of confiding  very young children  to
the care of otheis but a few years older.   This
distortion, if timely noticed, is capable  of correc-
tion, even after  sensible curvature has taken place.
Such children are  in general feeble; and renova-
tion of strength with  the  regular action of the
several muscles of the limb may  counteract the
injury sustained, and cause the deformity to dis-
appear.  But to produce this  effect the original
cause  of distortion must be sedulously  avoided,
until  firmness  of  bone and  strength  of muscle
remove all hazard of perpetuating or renewing the
evil.  In addition to other means  of establishing
the necessary vigour of frame  in such  cases, a
daily plunge in a cold bath is of signal efficacy.
   It is hardly necessary to enter further  into the
physical discipline of childhood; nor is it required
in this stage of existence to make any distinction
between males and females.   Happily for the lat-
ter, they are, during childhood  at  least, strangers
to those restrictions and injurious  practices from
which  in later years they are doomed to suffer so
severely.  From   this  period  on  to puberty  a
marked difference  prevails in the management of
boys and girls,  greatly to the prejudice  of the lat-
ter; and it is to the errors thus  committed, and
the calamitous  evils which they inflict,  that atten-
tion will be chiefly directed in the following pages.
   Adolescence. — Boys,  though  oftentimes too
much confined by the prevailing systems of school
discipline, have on the whole considerable liberty,
and they  avail themselves  of it  so as to  exert
freely and  actively their muscular energies.  By
such exercise  their  growth  is  promoted,  their
vigour  improved,  their health maintained, and a
robustness of  frame  acquired  exceeding that of
girls to a  degree far beyond what mere difference
of sex  would account for.  Very different  is the
fate of  female  childhood as  it passes onwards to
adolescence.  When this latter stage is approached,
the trammels of error, prejudice, and false system
begin to be imposed, restraining the free exercise
of body and mind, and conforming  both, not to
what reason and right feelings enjoin, but to what J
                              3o
fashion and vanity dictate.  The body, instead of
being suffered to attain  its just  proportions unin-
fluenced by interference  of art, is to be trained
into those forms which  the  caprice of the  day
admires, however unnatural, or however  unbe-
coming  in  the eye  of  unvitiated  taste.   The
limbs,  formed  for activity, and requiring free exer-
cise for the development of their structure and the
maintenance of their powers, as well as for the
preservation of general  health, are to be restricted
to those movements to which a fancied graceful-
ness attaches, even though the  best powers both
of  body and  mind  wither  under the blighting
influence of the vicious system.  The mind fares
no  better; for instead of  the cultivation of those
intellectual powers and  moral feelings which con-
duce  to utility, happiness, and virtue, the  best
years of life are wasted on vain accomplishments,
which, even when  attained, are too dearly pur-
chased, yielding but a very inadequate recompense
for the time and toil bestowed on them, and  which
in  a large  proportion  of instances, from  being
forced  against nature, and without the talents that
would  justify such assiduous cultivation, are never
acquired to  the extent of  answering a single good
purpose, being sure to be abandoned as soon as
the parties become free  agents, and released from
the control of their unrelenting taskmasters.  Each
of  these  subjects will  require to be considered
more in detail;  and above all, attention must be
forcibly drawn to those horrible ravages in female
health that result from  the visceral lesions  which
the tyranny of fashion occasions.  To any one
impressed with the  reality and extent of the evils
here deprecated, it is difficult to think or write on
them with perfect calmness.  We shall  endeavour
as much as possible to confine ourselves to a plain
exposition of  the evils  deplored, and of these we
shall  adduce  only  such  evidences  as admit of
unequivocal demonstration.
   Of boys it  is unnecessary to say much, as the
principles already inculcated apply to them equally
as to infants and children.  To them the advance
from childhood brings  but greater freedom;  and
if the  confinement of school exceed  what  sound
reason and the philosophy of nature would sanc-
tion, they redeem the mischief by the active unre-
strained gambols in  which they indulge  when
school-hours are over.   They pass much  time in
the open air, exercise freely, take food with  appe-
tite, and digest it thoroughly;  whence the  sto-
mach and bowels are seldom disordered, and their
sleep is sound and refreshing.  Their clothes, too,
make no injurious pressure ; all their muscles are
at liberty to act, and the free  exercise of these
promotes both their growth and  activity, ensuring
thus the regularity and efficiency of the several
functions to which these muscles are subservient.
   With girls, the ordinary modes of proceeding
are much less  healthful. It is not that their health
is less  an object of regard, or less carefully tended,
but other considerations than those of health  ob-
tain an  undue  share of attention, and  various
practices subversive of health are pursued in igno-
rance of the extensive  mischiefs to which  they
lead.   After childhood, education formally com-
mences, and from this period certain objects of
maternal solicitude are pursued  with a zeal and
earnestness  which, if  vrell  direited, would ^p 
758
EDUCATION,  (PHYSICAL)
worthy of all praise.  As it is, that of good inten-
tions can only be  awarded; for the  tendency of
much that occurs at the periods of life now under
consideration is  to  render valueless  all the cares
lavished, by breaking down the constitution.
  The first error is  that of restraining the free mo-
tions of the body and limbs, so natural at this pe-
riod of life, and  in which the young of both sexes
so much delight.  The young lady is now to cul-
tivate manners,  to  practise  a certain demureness
supposed to be becoming, to attend to her carriage,
keeping her head erect, and her shoulders drawn
back; and if from inability to continue the mus-
cular efforts necessary for this end, she fail  to  do
what nature does not empower her to accomplish,
negligence  or obstinacy  is imputed, reproach is
cast, which, being felt as  unjust, irritates the mo-
ral  feelings;  and thus a slight error in physical
discipline becomes  a fruitful source not only of
bodily injury but of  moral depravation.  It is a
well-established  fact with respect to  muscular en-
ergy, that the contractions of muscular  fibres  on
which  their actions depend, require intervals  of
relaxation ;  that, if the contractions be prolonged
without this relief, they in a certain time fail, so
that no effort of the will can continue them.   In
other words, the muscles tire, and an interval  of
7epose is necessary  to fit them for  renewed effort.
This is  familiarly instanced by the experiment of
holding the  arm extended, wben, even though  no
weight be held in  the hand, the  continued mus-
cular action required for  maintaining this position
cannot  be sustained  for many minutes.   If this
be true of the firm  and robust muscles of adults,
how much  more forcibly does the  principle apply
to the tender and immature muscles of early life!
To preserve a good carriage, to keep the head and
shoulders continually in  that position which the
dancing-master  approves,  require   considerable
muscular powers, such as  no girl  can exercise
without long, painful, and  injurious training, nor
even by this, unless other measures to be hereafter
noticed, be resorted to in aid of her  dbect  endea-
vours.   We would not here be understood as un-
dervaluing  a good carriage, which  is  not  only
pleasing to  the  eye, but  is, when natural, abso-
lutely conducive itself to health, as resulting  from
that relative'position of the several parts connect-
ed exteriorly with the chest, which allows greatest
freedom to the internal organs. To ensure a good
carriage, the only rational way is to  give  the ne-
cessary power, especially in the muscles chiefly
concerned;  and  this is to be done, not by weary-
ing those muscles  by continual  and unrelieved
exertion, but by  invigorating the frame  generally,
and more especially by strengthening the particu-
lar  muscles  through  varied  exercise alternated
with due repose.   Attention  to  general health,
suitable diet, regular bowels, moderate but regular
exercise, not of particular  muscles  only, but  of
tn.' whule frame, cold bathing when  needed, and
other such me tsures, will maintain a good carriage
by giving that power which  the more direct means
so generally practised served but to exhaust   All
this may appear  trivial and  of slight importance,
yet the principle inculcated  is far from being so;
and it applies to this early sta.-e of life as forcibly
os lo those  rure advanced.   Nay, more so; it is
at this sta^e that its observance is  of greatest mo-
ment ; for  if it be  here disregarded, effects may
result, which,  though  not immediately  obvious,
are capable of laying the foundation of evils that
cannot  afterwards  be  redeemed.   It  is  po>sible
that the principle might be more clearly illustrated,
more forcibly inculcated in connection with those
later periods of life when the consequences  of
disregarding it  are  more prominent; but we pre-
fer dwelling on it in its  earliest and simplest ap-
plications,  as a clear conception of these  will ma-
terially  assist in unravelling and  comprehending
the more complex conditions which are hereafter
to be noticed.   The  evils produced  by errors  in
physical education  oftentimes beget actual disease,
and the nature of this will ever be more  intelligi-
ble in proportion as we ascend to the causes which
primarily induce it.  It has been  shown  that  di-
rect endeavours to  enforce what is called a  good
carriage necessarily fail of their  effect, and that
instead  of strengthening they enfeeble the muscu-
lar powers necessary for  maintaining it.   This
fact soon becomes perceptible; weakness is no-
ticed, and  instead of correcting this by the  only
rational mode, that of invigorating the weakened
muscles, mechanical  aid is called in  to support
them, and  laced waistcoats are resorted to. These
undoubtedly give support,—nay,  they may be  so
used as almost wholly to supersede the musculai
efforts, with the advantage of not tiring,  howevei
long or continuously employed.   Improvement of
carriage is  manifested, the  child is sensible of re-
lief from a painful  exertion, the mother is pleased
with  the  success  of her  management, and this
success  appears to  superficial observation fully to
confirm the judgment which superintends it.   In
the present ignorance that prevails on all points
of animal physiology, it would  be quite impossi-
ble to convince any mother so impressed  that she
was doing otherwise than ministering to her child's
welfare.  Yet what are  the consequences to which
her measures tend,  and which such measures arc
daily and hourly producing ?   It has been shown
in the foregoing pages,  when noticing  the organic
laws, that  a muscle  consigned to  inactivity not
only loses  power,  but  becomes  attenuated and
wasted,  its  nutrition failing from want of  that en-
ergy which due exercise alone can confer.   The
fact  is  notorious,  the  principle  unquestionable,
although its application to the case under consid-
eration has been little heeded.   The  muscles  of
the back and chest, restrained in their  natural and
healthful exercise  by the  waistcoats called in  to
aid them,  and  more  signally in  after-life by the
tightly-laced stays  or corsets, become  attenuated,
and  still further enfeebled, until  at length  they
are wholly  dependent on the mechanical aid, be-
ing quite incapable of dispensing  with it for anj
continuance.
   At first,  laced waistcoats are used rather for the
convenience of suspending other parts  of the dresi
than with  any view  of giving  support  to weak
muscles, or of influencing the shape; and confined
to such  use they would be perfectly harmless.   In
time, when weakness becomes inferred, not  from
any evidences of actual debility, but merely from
tbe girl's not being  able to  maintain the unnatural
and constrained posture which  fashion and  false
taste  enjoin, the advantage of compressing the
chest by means of the waistcoat, so as to give sup- 
EDUCATION, (PHYSICAL)
759
port to the muscles of the back, becomes discovered,
and the mechanical power supplied  by the lace
affords but too  effective means of accomplishing
this compression.   The effect pleases  the mother,
promoting, as it does, her dearly-prized object—a
good carriage ;  it is endured by  the  girl  as  the
lesser of two evils, for though at  first irksome, it
releases her from the pain of  endeavours which
she has not power to  continue to the extent re-
quired.  As years advance, various causes combine
to render this practice more inveterate  and more
pernicious;  and still the  potent  instrument,  the
lace, extends its ready and effectual  aid.  The
extent to  which this  practice prevails, and  the
degree to which it is carried, are  too  notorious to
need being dwelt on.  Extreme cases  we wish not
to state, lest they should  appear exaggerations;
but daily observation displays to all who walk our
 streets, and  still more signally to those who  fre-
 quent our assemblies of fashion, the many  victims
 who, through tight lacing, sacrifice health, and too
 often life, at the shrine of empty  vanity.
   It is time now to scrutinize  the further injuries
 which this  unnatural practice  inflicts.   The  first
 evil is already suffered in the dorsal weakness oc-
 casioned by mechanical support having superseded
 muscular   energy.   The  muscles   are  become
 enfeebled  and attenuated; their physical condition
 unfits them now for doing  that for which  nature
 designed them  ; the stays  are become indispensa-
 ble, and, so strong  is tbe faith in their necessity,
 that a proposition to discard  them  would be
 accounted monstrous.  A  conception  that they
 could be laid aside would be regarded as quite too
 improbable  to be for a moment entertained.  But
 now a taper waist becomes an object  of ambition,
 and the stays are to be laced more closely.  This
 is still done gradually, and, at  first, imperceptibly
 to the parties.   The effect, however,  though slow,
 is sure, and the powers of endurance thus exer-
 cised come  in time to bear almost unconsciously
 what, if suddenly or quickly attempted, no  heroism
 could possibly  sustain.
   The derangements to which tbis increased pres-
 sure gives rise  must now be considered.  The first
 is the obvious  impediment to  the motions of tbe
 ribs which  this constriction of the chest occasions.
 For perfect respiration tbese motions should be
 free and  unrestrained, and, as has  been  already
 noticed, perfect respiration is necessary to those
 changes in the blood which fit it for  nutrition and
 the other purposes af the  animal frame.   In  pro-
 portion as respiration is impeded, is the blood im-
 perfectly  vitalized ;  and in the same  ratio are the
 nutrient  and  other functions dependent  on the
 blood inadequately performed.   Here, then, is one
 source of debility which affects  the  whole frame,
 reducing every part below the standard of health-
 ful  vigour.   According, also,  as each inspiration
 of  air becomes less full, the wants of the system
 require, as a  compensation, increased  frequency ;
 and thus quickened  respiration commences  dis-
 turbing the lungs, and creating in them a tendency
to inflammatory action
The heart, too, becomes
excited, the pulse accelerated, and palpitation is in
time superadded.   All ^.^^31
resulting from mere constriction of the chest, they
become  fearfully  aggravated  when  at:  .  more
advanced stace, as will be more fully shown in the
sequel,  additional sources of  irritation arise  in
flexure  of the spine, and in derangements  of the
stomach, liver, and other  organs subservient  to
digestion.  The foregoing disturbances  are formi-
dable  enough,  and  sufficiently  destructive  of
health, yet they are not the only lesions  which
tight lacing induces.   The  pressure, whicb  is
chiefly made on the lower part of the  chest, and
to which this part most readily yields, extends  its
malign influence to the abdominal viscera also. By
it the stomach and liver are  compressed, and, in
time, partially detruded from the concavity of the
diaphragm, to the great disturbance of  their  func-
tions; and  being pressed  downwards, too,  tbese
trespass on  that space which the  other abdominal
viscera require, superinducing still further derange-
ments.   Thus, almost every function of the body
becomes more or less depraved.   Nothing  could
have prevented the source of all this mischief and
misery from being fully detected and  universally
understood, but the slow and insidious  process  by
which the aberration from sound principle  effects
its ravages ; and on this  account it is that we  lay
so  much stress on the remoter evils when con-
sidering the primary errors, for it is only by tracing
those to their source, and by connecting the several
visceral lesions which ultimately take  place with
the incipient and apparently harmless errors which
form the earlier links  in the chain  of causation,
 that any hope  can be entertained of  those evils
being clearly understood or effectually  rectified.
    It must  be seen that the same principles apply
 to  every stage of this destructive system, and that,
 however insignificant the effects  of the early waist-
 coats may appear when compared with  those of
 the tight-laced  corset, the same false  principle is
 manifested  throughout.   The girl's waistcoat, ii
 used  otherwise  than as a support for the other
 articles of dress, is improper.  When tightened
 in  order to support the  back,  instead of giving
 strength, it produces  real weakness by the effect
 on the dorsal  muscles  already  described;  and
 when  further  straitened, so  as to  diminish  the
 waist, it then  commences that  suicidal  process
 which years of suffering  and  ill health are after-
 wards to complete.
    But  there are further  evils yet to  be  noticed.
 The mere  weakness of back, so often adverted to,
 becomes in its turn an aggravating cause of visce-
 ral lesion.   The body cannot be always cased in
  tightly-laced stays; their pressure may be endured
  to any extent under the excitement of  the evening
  display, but during the day some relaxation must
  take place.   Under it,  the  muscles of the back,
  deprived of their accustomed support, and incapa-
  ble of themselves to sustain the incumbent weight,
  yield, and the column of the spine bends, at  first
  anteriorly, causing round shoulders  and an arch-
  ed back ; but eventually  inclines to one or other
  side, giving rise to  the  well-known and  too  fre-
  quently occurring state of lateral curvature. This
  last change most frequently  commences  in  the
  sitting posture,  such females being, through gene
  ral debility, much disposed  to sedentary  habits
  As soon  as  lateral  curvature  commences,  the
  lungs and heart become still more disturbed;  an-
  helation from  slight exertion, short  cough,  and
  palpitation ensue; and at this time, chiefly in con
  sequence of the pulmonary derangement,  alarm 
760                        EDUCATION,  (PHYSICAL)
oegins to be  entertained,  and  the  approach of
phthisis apprehended.  Medical aid is now sought,
and  as  the  more  obvious  malady  is  within  the
chest, and  from the excitement which prevails
presents an acute character, blood  is drawn, and
other means are resorted to suited for arresting
inflammatory action.  And to a certain extent the
practice is necessary and right, for  in this state
there is often so much inflammation and  conges-
tion as fully to justify depletory treatment. Should
the disease, however, be misconceived as primary
inflammation  of the  thoracic contents, the relief,
however signal at  the  time, must  be transient,
and, unless attention be given  to  those  causes
from  which the perpetual  derangements  spring,
enduring health has but little chance of being re-
stored.  Removal of the spinal flexure by using a
recumbent instead of a sitting posture;  alternating
this with regular and proper exercise so as to call
into  renewed  action the weakened and  wasted
muscles;  invigorating these still further by cold
sponging and  stimulant frictions ; and finally, re-
novating the general  health by regulation of bow-
els, suitable diet, the cold  shower-bath, and such
tonic medicines as  the constitution may need, are
the appropriate and only effectual means by which
this state of health  can be permanently improved.
   The  views  of spinal curvature here presented
will  be found  more fully stated in a paper in the
5th volume of the  Midland Medical and Surgical
Reporter,  to which the reader is referred.
   We have already  mentioned the injury which
constriction of the chest inflicts on the liver and
stomach.  Either  or both  of  these organs  may
under  this disturbance  display the  ordinary evi-
dences  of local inflammation or congestion, and
to these will apply all that has been already stated
respecting the heart  and  lungs.   The  local in-
flammation or congestion may be real, and require
depletion  together with other active  remedies, but
they are liable to recur  if the  original disturbing
causes be not  rectified.   They are sensibly aggra-
vated as soon as the spine begins to yield, for ac-
cording as the body bends forward, the lower ribs
in connection with  the sternum are forced in-
wards, increasing the pressure  made on the liver
and stomach,  and  further  irritating these if al-
ready brought into  a state of excitement.
   But all the  evils  produced by the vicious course
so long and so obstinately persisted in  are not yet
enumeiated, an important train of  consequences
being yet to be noticed in the derangements of the
uterine  system.  When the age of puberty is ap-
proached, the  organization  distinctive  of sex be-
comes more fully developed, and in  the  female
constitution certain changes take place  the sup-
pression or  retardation  of which is fraught with
injury lo health.   Of these changes  one of the
most important, and  that which is most liable to
be effected by contingent influences, is menstrua-
tion.   This function we mean here to  consider
only so far as  it is prejudiced by the causes of ill
health now under consideration.  For menstrua-
tion  to commence at  the proper age and to con-
tinue regular  and perfect, it is  requisite that the
whole frame be in a healthful state  and  every
function adequately performed ; consequently, the
general depravation  of  habit lately described is
eminently unfavourable to the establishment of this
natural process.  There is also required a certain
vigour of the constitution capable of  propelling
blood with sufficient energy into the capillary ves-
sels, which vigour habits enfeebled  in  the  way
lately noticed do not possess.  It is further neces-
sary that the larger trunks leading to these capil-
laries be  not  overcharged,  else congestion takes
place,  which  further  debilitates  the overloaded
vessels, rendering them still less  capable of pro-
pelling their contents into  the capillaries by the
secerning functions  of which they would be re-
lieved.   Yet this congestion is  prevented by the
impeded circulation  arising  from constriction of
chest,  and by  the disturbance of the  abdominal
viscera  lately explained.  It is necessary, also, to
take into account the  various  coincident efforts
made by the constitution towards preparing for
the signal revolution in the system whicb incipient
menstruation  indicates.   When  these efforts  are
defeated by menstruation not commencing at the
proper period of life, much additional derangement
of bealth ensues, and  blood  which  ought to be
disposed of by the uterine vessels becomes either
congested in the surrounding tissues,  or determin-
ed to other  parts, so as to cause vicarious hemor-
rhages of various kinds.  Thus the regularity and
efficiency of the  uterine functions, so essential to
female bealth, become  impeded and  impaired by
the injudicious measures which, when first resort-
ed to in  childhood, are little suspected of exerting
any such influence.
  Although so much has been attributed to con-
striction  of  chest in impairing general health, and
occasioning special  derangements, and assuredly
not more than strict truth  warrants, many other
errors of physical education  lend  their aid to pro-
duce that feebleness  of constitution  and delicacy
of health of which  so many females are the vic-
tims.  These shall be  now considered  under the
same arrangement which was followed with respect
to the earlier stages.
  Clothing.—The clothing of young  females is
far from being what reason would.sanction.  It is
oftentimes deficient in  the necessary warmth, the
materials being  too  slight  to  yield  protection
against the vicissitudes of a variable  climate, and
too much  of the person being  wholly exposed.
Errors of this kind, however, are much more com-
mon and carried  to  much greater lengths at  the
period when education, in its usual sense, may be
said to be  completed; that is,  when the young
lady passes  from  the restraints of  the school-room
to the dissipations of fashionable life.  As, how-
ever, this cbange usually takes  place before  the
body has attained its  full  vigour, the following
remarks  on the dress and conduct of females, on
first leaving school, belong properly to our subject
If the errors of dress are less signal in the attire
worn by  day, they  reach their acme  when  the
evening rout or midnight ball is  to  be  attended.
At these seasons the  tightly-laced stays, exposed
chest, and thin draperies, furnish a  combination
of influences, the continued effects of  which no
constitution could withstand; while to these is yet
to be added that of respiring for hours a heated
and vitiated atmosphere, and, after this, of passing,
when relaxed and exhausted, into the cold currents
of a frosty night air.   So far from wondering that
many suffer from  tbese egregious imprudences, our 
EDUCATION,
(PHYSICAL)
761
surprise should be that any escape;  and instead
of the  inherent delicacy so  often imputed  to  the
constitution of females  as  explanatory of their
peculiar ailments, we have ample proof, in their
powers of resisting such  noxious influences, that
they possess conservative  energies not  inferior to
those of the most robust male.   Were  men to be
so laced, so imperfectly exercised, so inadequately
clothed, so suffocated, so exposed, their superiority
of bodily vigour would soon cease to  have any
existence.
   Defect of clothing, though most  signal  in  the
chest and shoulders, is  not confined to  the upper
part of the body.   The  feet require warmth, which
subservience  to  fashion prevents.  They cannot
be compressed but  at the  cost of much suffering,
some distortion,  and  the infliction  of positive
disease.   Fashion  also permits  the  legs  to  be
covered with only the  thinnest  materials.   Thus
the capillary circulation of the feet, rendered suffi-
ciently languid by the general weakness, becomes
further impeded by the pressure of tight  shoes,  and
the debilitating effects of cold.  The crippled state,
too, thus  occasioned, is a further obstacle to  effi-
cient exercise, and so adds to the general debility.
   Food.—The food of the  young of both sexes,
as  indeed of  every age, should be suited  to  the
particular  constitution.   The  general  principles
for regulating it have been already laid  down.  It
should, for reasons already assigned,  be  rather
nutritious than spare.  The effects of casual reple-
tion are less prejudicial, and more easily corrected
Ann those of inanition;  still the bounds of tem-
perance should never be exceeded.  There  should
be a due admixture of animal food, but  wine  and
stimulants are needless  and improper.   It is to be
hoped that no caution is needed  at the present  day
against a practice, not unknown  in the last cen-
tury, of females inclining  to corpulency reducing
themselves by abuse of acids. The effect was pro-
duced  by destroying the  tone  and injuring  the
structure of the digestive organs, and from the evils
which resulted, we would fain hope that  a practice
so pernicious has been for ever abolished.
   At the ages under consideration the state of the
bowels requires to be attended to; and here again,
girls suffer in  a  much  greater degree than boys.
The abdominal congestions to which their whole
course of discipline subjects  them, have  no means
of relief save  the increase of  alvine excretions.
There  is, therefore, even  more  to be carried  off
through this outlet than  a state  of health would
supply.  Yet from the general  debility and defi-
cient exercise the alvine discharges are very prone
to  be  irregular and inadequate.  Much disease
would at. this age be averted, and the conservative
powers of the constitution would have a far better
chance of being effectively exercised, if a regular
and healthful  state  of bowels  was  maintained.
For this there should be not only daily evacuation
in sufficient quantity, but, wl at is  still more  im-
portant,  the  matter  discharged  should be  of a
healthy character.  And  here we would  caution
medical men against being misled by false delicacy
so as to trust to  reports, which are  never to be
relied on.  Ocular inspection furnishes  an indica-
tion  of  the highest value, both in exhibiting  and
withholding medicines; and so  assured  are we of
its absolute necessity as a guide to  medical^udg-
  Vol. I.-96                         °
ment, that we cannot understand how a medical
practitioner can  conscientiously perform his duty
who disregards it.  As it is the duty of the medi-
cal practitioner to avail himself of this source cf
information when attending patients under disease,
it is equally so to  point  out to convalescents the
importance of it to  the  maintenance  of general
health.   Were  the  state  of  bowels  in young
females more attended to, ample evidence would
be furnished  of the necessity of some evacuant or
corrective discipline, long before the accession of
actual disease; and, what is of more importance,
much accumulated and too often intractable disease
might thus be altogether  averted.
   Exercise.—What has been  already stated with
respect to air and temperature  in  infancy  and
childhood can   be  so  readily  applied  to  the
more advanced ages, that they need not here be
further discussed.   Exercise,  however,  demands
some additional  notice.  Boys enjoy this  freely,
and of the best  kind, in the  unrestrained indul-
gence of their youthful sports.  By means of these
every muscle of  the frame  comes in for its share
of  active  exercise, and free growth, vigour,  and
health are the result.  It would be happy for  girls
if some portion of such  latitude were  allowed to
them also.   But it is far  otherwise.  Even under
the more  favourable circumstances of country life,
they are too  much restricted from the free exercise
which  health requires.   Their  very dress unfits
them from taking it, and the alleged  indecorum
of  those  active movements to which  youth and
spirits  instinctively incite,  is  a  bar to even  tke
attempt being made.   At their age the  measured,
slow-paced, daily walk is quite  insufficient even
for the  muscles  specially engaged, while it leaves
many others wholly  unexercised.  If this be true
of  the  more hale  and robust inhabitants  of the
country, how much more forcibly does it apply tc
the delicate and attenuated residents of towns, and
especially to the inmates of female schools.   Of
these establishments the systems and habits re-
quire much  revision, and until some effective re-
formation takes place, of which there  is yet but
little prospect, they  will not  fail to excite  our
sympathy and  regret  for  the blanched aspects,
shadowy  forms,  and sickly constitutions so  con-
tinually presented, and which  it is so  painful to
witness.   Such beings are as little  fitted for en-
countering the toils or fulfilling  the duties of'life,
as are plants  of a hothouse for being transferred to
the open  borders.*
  * The amount of exercise, or rather the extent to which
the want of exercise is carried, in many boarding-schools,
will appear incredible to those  who have not personally
investigated the subject.  The following is the carte of a
young ladies' boarding-school, drawn upon the spot, a few
years since, from the report of several of its  inmates:—
At    G in  the morning the girls are called, and rise.
From 6  to 8,  learning or saying lessons, in school.
      8  to Si, at breakfast.
      8| to 9,  preparing lessons out of school, (some of the
              girls permitted to do so in the garden )
      9  to 1,  at various tasks, in school.
      I  to 1J, out of school,  but must not go ,/ut ol
        doors; reading or working, and preparing for
        dinner.
      1£ to 2,  at dinner.
      2  to 5,  in school, various tasks.
      5  to5J, tea.
      5| to 6,  preparing to go out; dressing, or reading,
        or playing in school.
      (5  to 7,  walking, generally arm-in-arm,  on the
        high-road, many with their books in their hands,
        and reading. 
762
EDUCATION,  (PHYSICAL)
  By the foregoing statements we do not mean to !
cast the  slightest  reflection on  those  by  whom
these seminaries  are superintended.   We have
ever found them most solicitous for the health of
their  pupils, sedulous to  preserve it,  and when
disease  arose, unremitting  in devoted  attentions.
But the system is faulty, and for this they are not
accountable.  By  the  influences and  prejudices
which uphold that system, they, like  others, are
chained ;  and  until the  system  itself  yield  to
increasing knowledge, juster views of the animal
economy, a more correct conception  of mental
energies and of the  injuries  wbich their over-
citement  occasions both to themselves  and to the
bodily frame, and a firm resolution not to barter
health for vain accomplishments;—in other words,
until both mental and physical education undergo

  Two days in the week they do not walk in  the even-
ing at  all, being kept in  for dancing; but, by way of
amends, they go out on  two other days, from 12 to 1, and
then they miss writing.  It is to be remarked that they
never go out unless the weather is quite fine at the particu-
lar hours allotted for walking. They go to church, all the
year round, twice every Sunday, on which day no other
exercise is taken.
From 7  to 8, for the older girls,  reading  or working
               in school, (this is optional,') and then
               prayers; for the younger, play in school,
               and prayers.
  At 8, the younger go to bed.
From K  to 9,  the older, reading or working, as before.
     9,  to bed.
  The twenty-four hours are, therefore, thus disposed
of:—
                                             Hours.
In bed, (the older 9, the younger 10,)................9
In school, at  their studies  and tasks...............9
In school, or in the house, the older at optional stu-
  dies or work, the younger at play................ 3J-*
At  mea Is......................................... 1±
Exercise in the open air .......................... 1
                                             H
  The above account was  taken from a second or third-
ra4e school, and applies more particularly to the season
most favourable for  exercise,—summer.  It is to be re-
marked  that  the confinement is generally greater  in
these than in schools of a higher order.  That the prac-
tical results of such  an astounding regimen are by no
means overdrawn in the preceding pages is sufficiently
evinced  by the following fact, a  fact which we will ven-
ture to say may be verified by inspection of  thousands
of boarding schools in this country.  We lately visited,
in a large town, a boarding-school containing  forty girls;
and we learnt, on close and accurate inquiry,  that there
was not one of Ihe girls who had been at the school two
years (and the majority had been as long) that was not
more or less crooked! Our patient was in this predica-
ment; and we could perceive (what all may perceive
who meet that most melancholy of all processions—a
boarding-school of young  ladies in their walk; that  all
her companions were pallid,  sallow, and listless.  We
can assert, on the same authority of personal observa-
tion, and on  an extensive scale, that scarcely a single
girl, (more especially  of  the middle classes,) that has
been at  a hoarding-school for i wo or three years, returns
home with unimpaired healtii; and, for the truth of the
assertion, we may appeal  to every candid father whose
daughters have been placed in  this situation.  Happily,
a portion of  the ill health  produced at school is in many
cases only temporary, and vanishes after the return from
it.  In the schools in which the vacations are frequent
or long, much mischief is often warded off by the perio-
dical returns to the ordinary habits of healthful life; and
some happy constitutions, unquestionably,  bid defiance
to  all the systematic efTorts made to undermine them.
No further proof is needed  of the enormous evil produced
by  the present system of school discipline than the fact,
well known  to all medical  men, that the greater propor-
tion of women in the middle and upper ranks of life do
not enjoy even a moderate  share of health ; and persons,
not of the medical profession, may have sufficient evi-
dence of the  truth,  by comparing the relative powers
of  the young men and young women  of any family in
taking  bodily exercise, more  particularly  in walking.
The difference is altogether inexplicable on the ground
of»e* only.—J. F. Editor.
        * Younger only two hours and .. talf.
considerable reformation and be founded on more
rational principles, the evils must exist to an extent
which no superintendent of a seminary  can con-
trol.   We  are  sorry  to  be  compelled by truth to
add that we have often  found the  same pernicious.
regimen carried to as great a height, although on
a smaller scale, in private families, under the  eye
of a  fashionable  governess and a fond but injudi-
cious mother.
   Hurried  breathing,  short  cough, palpitation,
constitute a state of indisposition ere actual disease
is considered to exist.   Weak back, with incipient
curvature of spine, in time aggravate these devia-
tions from  health.   Irregular bowels attend,  im-
pairing still further the  general health, and giving
rise also to special ravages of the  most formidable
kind.  . A hard  and  tumid  abdomen  follows,  the
precursor and eventually the index  of mesenteric
derangement, which,  next to phthisis, is  perhaps
the most intractable malady of youth with which
the physician has to contend.  Other evils, refera-
ble to the  erroneous system and to the debility
occasioned  by  it, may   also be  seen.  Of these,
chilblains are very common, and, when they occur,
add greatly to suffering and  to the further decline
of health.   They arise  from failure of circulation,
and,  locally considered, are  analogous  to frost-
bitten parts; being in fact so many partial mortifi-
cations resulting  from loss of vitality in the capil-
lary vessels.  The  surgical treatment which they
receive  is  not  always  judicious.  Regarded  too
much as local sores, and the irritability which they
display being too much heeded, rest is enjoined,
and thus even the insignificant exercise previously
taken is suspended.   Far better would it be, when
this evidence of impaired vigour presents itself, to
disregard the local ailment, and look solely to the
constitutional state in which the local malady  has
its origin.
   It  is a prevalent opinion with  teachers and pa-
rents that  it is more  conducive to the progress of
education to keep a child at school when in infirm
health, where the studies may still be continued, at
least  in some degree, than to interrupt them entirely
by a removal to the parental roof.   This is a great ,
and often a fatal mistake.  By such delay nothing is
lost that can under such circumstances be accom-
plished : feebleness of body is little  favourable to
the  full  exercise of mental   energies.  Mental
faculties depend  for their manifestation and exer-
cise on  bodily  organs,  and in  proportion as  the
organs are  weakened, does the vigour of the facul-
ties decline.  By suffering both organs and facul-
ties  therefore to  acquire renewed vigour, power!'.
of effective exertion  are recoverable to an extent
fully  capable of compensating for the temporary
inactivity.   It is  a great mistake  to  conceive  that
education   advances  in proportion  to the  lime
devoted to  it, or to the  earnestness with which it
is pursued.  Mental powers are capable of a  cer-
tain exertion only, and  if they be oveistrained, or
too assiduously employed, they weary and decline,
accomplishing  much less than, with unimpaired
vigour and more moderate  exertion, they would
be capable of doing  in much less time.  Every
student i6 conscious of  the inequality of his men-
tal powers  under different states  of  bodily health
and  different  degrees  of mental  weariness,  and
fully sensible how little  progress he makes when a 
EDUCATION,  (PHYSICAL)
763
forced effort is required.  The mind, too, requires
variety of exercise in order to employ and gratify
ihe various faculties of which it consists, and if it
be chained down to a few objects, and  especially
if these be little  congenial to its prevailing tastes
and capabilities, the labour turns to little account.
Under the  systems  of education  which  prevail,
years are wasted  in pursuits  which ought not to
occupy a tenth  part of  the  time,  if their value
were rightly estimated, and the real powers of the
mind properly directed.   And this  leads us  to
consider, what has  hitherto been but too  little
attended  to in conducting  education,  the direct
influence which the exercise of the mental powers
has on the bodily health.
   In the few  following remarks  on  this subject
we shall  draw freely from an admirable paper pub-
 lished in the  sixth  volume  of the Phrenological
Journal,  entitled  " On  Mental  Exercise,  as a
 Means of  Health."   The  principles  inculcated
 are of the highest importance, and though  ema-
 nating in this instance from phrenological views,
 they have also so sure a basis in established phy-
 siology, that they may be beneficially applied even
 by those who  still close  their eyes to  the truths
 of a science  in which the writer  of this article
 has no hesitation  to  avow his firm belief; and
 which, justly estimated, has  more power of con-
 tributing to the welfare and happiness of mankind
 than any other with which we are acquainted.
   The importance of muscular exercise as a means
 of preserving  and improving health  is generally
 admitted.  It  ministers to the health  of the body,
 and, as the brain has its  due share of this advan-
 tage, mental  energies are  also  promoted   by it.
 "But there is great  reason to believe that exercise
 of mind, regular active employment both of  intel-
 lect and of moral  feeling, of which the various
 parts of  the nervous system  are the  organic me-
 dia, contributes so essentially to the well-being of
 the whole system, that it cannot be neglected  with-
 out inflicting  positive  injury; and that, independ-
 ently of its mental  advantages, it is  necessary to
 the enjoyment of full physical health."  It  is es-
 sential to health that tbe functions of the nervous
 system be well performed.   But the  intellectual
 powers,  with  the affective and moral feelings, form
 a part of these functions, and so intimately con-
 nected are the physical and mental energies that
 they mutually influence  each other; so that, in
 proportion as nervous stimulus is unduly expend-
 ed on the one, it  becomes  withdrawn from  the
 other.   Deficient or irregular exercise  of nervous
 functions gives rise  to much suffering, and  in no
 class of  beings more signally than in that to which
 so much of this essay has been  devoted, namely,
 of young females of the upper and middle  ranks,
 more especially those " of a delicate and nervous
 constitution, who, without  any existing disease,
 without  even  having undergone any  severe  indis-
 position  sufficient  to debilitate the system,  are
 nevertheless  habitual invalids, and can scarcely
 venture  beyond the limits of the drawing-room,
 or withdraw themselves  from the  rays of the sun,
 without  some evil, real or  imaginary, instantly
 overtaking them, and forcing them  back to their
 rctrcit"
   Some of the sources  of this extreme  delicacy,
 uiJ the  means  of remedying it,  it has been  the
object of the foregoing pages to explain. "Young
men of the same  rank suffer  infinitely less,  be-
cause the constantly recurring  calls  of business
and public life operate upon them as stimuli, and,
in spite of themselves, exercise the feelings and
employ the  intellect on  objects  of some  perma-
nent value and importance,  and thus keep up  a
stir of life and excitement of the system whicb is
favourable to the health of all  the  functions, and
to which unhappily  many of the opposite  sex re-
main, especially in their youthful years, altogether
strangers."
   " The three grand sources of vitality, failure or
weakness of which may induce infirm health  and
delicacy of  constitution, are  the  digestive,  the
sanguiferous, and  the nervous apparatuses; and,
accordingly, whenever great  debility is observed
to exist without any marked local disease, its true
cause will almost to a certainty be found in weak-
ness  or  deficiency affecting one or other of the
three great systems  of  organs  just named.   If
digestion,  for instance,  be radically feeble, then
the chyle or nutritive material will fail,  and weak-
ness follow.   If the lungs and  circulating system
be weak, the respiration will be imperfect, and the
blood being inadequately acted on by air, its com-
position will be impaired, and, sent in this state
through the blood-vessels, it will no longer afford
the usual stimulus and support to  any of the  or-
gans,  and  hence  again  constitutional delicacy.
And, lastly, if the nervous  functions be defective,
not only will the mind suffer, but all the functions
of the  body will participate with  it in  languor,
because all of them will receive a diminished and
vitiated supply of nervous  stimulus, a due share
of which is essential to their healthy action."
   The  digestive,  respiratory,  and  sanguiferous
functions have been already noticed